ESPE Abstracts

Background: Growth hormone therapy can be indicated for children who are born small for gestation age (SGA) (either birth weight or birth height < -2 SDS) without catch-up growth (height < -2.5 SDS) at age 4 years. Growth hormone therapy is considered a safe treatment.

Case presentation: A 12-year-old girl was referred to the pediatric endocrinologist for short stature. She was born small for gestational age (birth weight SDS -2.2; height at birth SDS -0.5). Her medical history was uncomplicated. She was treated for migraine with prophylactic propranolol. She exercised regularly. SNP array showed a normal female chromosome pattern. She fulfilled the criteria for growth hormone therapy and started in August 2018. At physical examination in December 2019 showed Tanner M2. GnRH analogue treatment had been proposed but refused by the patient. She had regular checkups (every 3 months), and blood results (thyroid function and IGF1) were within normal ranges. One and a half years after growth hormone therapy had started, she was referred to a pediatric orthopedic surgeon for hip complaints on the left side. These complaints commenced six weeks before. There was no recent trauma, infection, or fever. Previously prescribed orthotics had no effect on the pain complaints. On physical examination a changed gait pattern was observed. A hip radiograph showed a discrete irregular aspect of the left acetabulum. Additionally, an MRI scan was performed that showed avascular necrosis of the left femoral head with limited cortical depression.

Discussion: Small for gestational age without catch-up growth in the first four years is a common indication for growth hormone therapy. During counseling, patients and parents that fulfill criteria for growth hormone therapy should be informed about advantages and disadvantages. Possible adverse effects are intracranial hypertension and slipped capital femoral epiphysis. Our patient developed avascular necrosis after 1.5 years of growth hormone therapy. This is a very rare complication, previously described in 7 cases in children with a combination of renal failure and growth hormone therapy.

Conclusion: We present a healthy SGA born girl, with normal renal function, that developed avascular necrosis due to growth hormone therapy. A lesson that can be learned from this case is to consider this rare complication in case of hip pain during growth hormone therapy and early referral to an orthopedic surgeon.