Endo Case Challenge: Pubic Hair and Violent Behavior in a Strong 19-Month-Old Girl

Sasigarn A. Bowden, MD; Brian K. Bowden, MD


October 25, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 19-month-old female toddler is brought in by her mother owing to the development of pubic hair, which was first noticed approximately 1 month earlier. The amount of pubic hair has progressively increased. Her mother reports that the child has no history of acne, axillary or facial hair, breast development, or vaginal discharge.

She is also concerned about her daughter's aggressive behavior, which has been increasing in the past month. The girl has been irritable and hits her mother or other family members when she is upset. She is very strong, with the muscle strength of an older child. For example, she is able to push a large chair and move other pieces of furniture and objects that are typically too heavy for children her age. Her arms and legs have become muscular. She also seems to be growing taller. Her mother reports that she has a good appetite, with no history of abnormal weight gain or loss.

Her birth history reveals that she was born at 25 weeks' gestation to a 17-year-old gravida 1 mother. Premature birth was precipitated by maternal cervical incompetence. Her birth weight was 800 g (28.22 oz); birth length, 34 cm (13.39 in); and head circumference, 23 cm (9.06 in). She was on mechanical ventilation in the neonatal intensive care unit (NICU) for 3 weeks and was discharged after a 3-month stay in the NICU. She is not taking any medications.

Her mother had normal puberty, with her first period at age 12 years. The family history does not include early puberty or any instances of sudden infant death syndrome. The mother and maternal aunt have mild hirsutism (facial hair). No one in the family uses testosterone gel or patches or any androgen hormone products.


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