S.A.

17 October 1970

MEDICAL

terminal phalanges. The skin lesions are characteristically

red-brown nodules or plaques, which can occur anywhere,
but are most characteristically seen at the inner canthi of
the eyes. Biopsy of the skin lesions helps in the diagnosis.

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JOURNAL
SUMMARY

Examination of the skin can give clues as to the diagnosis of

a rheumatic or arthritic disorder. A particular plea is made
for the search for lesions of psoriasis before initiating
corticosteroid therapy.

PRECOCIOUS SEXUAL DEVELOPMENT FOLLOWING TUBERCULOUS MENINGITIS:

A CASE REPORT*
A. aLl SKY, t M.B., B.CH., DIP. PAED. (RA D), F.C.P. (S.A.), Department of Paediatrics. Coronation Hospital.
Johannesburg

Neurological sequelae are the most common complications of tuberculous meningitis. Endocrine disturbancesalthough rare-do occur, the most frequently described
being abnormalities in sexual development, diabetes insipidus, obesity and stunted growth. Aberrations in sexual
development may be either precocity or hypogonadism.
Whereas sexual precocity has been described as an isolated
finding following tuberculous meningitis, hypogonadism is
usually associated with obesity and stunted growth. The
following report is of a Coloured female child who, in
addition to severe neurological damage, developed sexual
precocity at 3 years of age as a complication of tuberculous meningitis.

optic atrophy and impairment of hearing. Her weight was

21 lb (9,5 kg). Her height was 375 inches (95'3 cm), with
a head-symphysis measurement of 215 inches (54'6 cm).
The arm span measured 345 inches (87,6 cm) and the
circumference of her head was 195 inches (49,5 cm).

CASE REPORT

A l-year-old Coloured female infant was admitted to

Coronation Hospital with a history of cough and fever
of 1 week's duration. Left-sided convulsions had occurred
the day before admission. Birth history and development
during the first year of life had been normal. The family
history was non-contributory. On examination the child
was semi-comatose and pyrexial, with clinical evidence
of meningitis. Examination of the chest showed signs of
right upper lobe consolidation.
Special Investigations
The cerebrospinal fluid was slightly turbid and contained 185 polymorphonuclear cells and 90 lymphocytes/
mm'. Chemical examination of the fluid showed a raised
protein of 336 mg/loo ml, a low sugar content of 12 mg/
100 ml and a low chloride level of 103 mEqflitre. No
organism was seen on direct examination but culture was
positive for tubercle bacillus. Full blood count, urea and
electrolyte estimations were within normal limits. X-ray
of the chest showed a homogenous loss of translucency
in the right upper zone with cavity formation and a patchy
loss of translucency in both lower lobes (Fig. I). The
tuberculin skin test (Hea) was strongly positive. Treatment
consisting of isoniazid 20 mg/kg/day, streptomycin 40 mg/
kg/day and prednisone 1 mg/kg/day was instituted.

The patient remained in hospital for 2 months, during

which time there was very little change in her neurological
state. She was then transferred to a hospital for the treatment of tuberculous patients. At 30 months of age breast
development and pubic hair growth were noted. Vaginal
bleeding had also been observed. At tills stage she was
transferred back to Coronation Hospital for further investigation. On readmission the clllld was found to have severe
neurological damage with spastic quadriplegia, bilateral
'Date received: 22 June 1970.
t Present address: Department
Johannesburg.

of

Medicine,

Baragwanath

Hospital,

1. Chest X-rayon admission showing loss of translucency of right upper lobe with cavity formation.

Fig.

Breast development was present as well as marked pubic

0 masses were palpable on abhair growth (Fig. 2).
0 ovarian mas es were felt on
dominal examination.
rectal examination, but the uterus was thought to be
slightly enlarged.
Repeated Special Investigations
Full blood count, urea and electrolyte as well as the
glucose-tolerance curve were within normal limits. Reassessment of the cerebrospinal fluid showed a slightly
raised protein of 60 mg/100 m!. Con iderable improve0 radiological
ment was seen on X-ray of the chest.
abnormality of the skull was found and air-encephalogram
examination wa norma!. The protein-bound iodine

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MEDIESE

measured 60 p.g{lOO m!. Urinary gonadotrophin excretion

measured on two occasions showed an elevated FSH level
of 12 - 24 mouse units, while the 17-ketosteroid excretion
was 12 mg{24 hours and the 17-hydroxycorticosteroid
level was 23 mg{24 hours. While being investigated vaginal
bleeding was observed, lasting I - 2 days and occurring at
29 - 31-day intervals. A vaginal smear demonstrated oestrogenic activity.

Fig. 2. The patient aged 30 months. Note pubic hair

growth and breast development.

It is felt that the presentation and subsequent progress
in this child would fit a picture of true sexual precocity
complicating tuberculous meningitis.
DISCUSSION

Precocious sexual development may be divided into 2

groups,' viz. true precocious puberty and precocious pseudopuberty. In the first group the development is always
isosexual and is due to gonadotrophin secretion. It indicates
not only precocity of the secondary sexual characteristics
but also an increase in size of the gonads with premature
production of mature sperm or ova. In precocious pseudopuberty the development may be either heterosexual or
isosexuaI. Here only the secondary sex characteristics
appear and the gonads do not mature; this is due to sex
hormone secretion or administration. True sexual precocity
is divided into primary and secondary groups. In the
primary or idiopathic group the aetiology is not known,
whereas the secondary group comprises the neurogenic

17 ()ktober 1970

TYDSKRIF

category, gonadotrophin-secreting tumours, and the

McCune-Albright syndrome. The majority of the cases in the
secondary group are due to neurogenic disorders. Primary
or idiopathic sexual precocity is more common in females,
whereas the secondary causes are found more frequently
in males. Sigurjonsdoiter and Hayles' reviewed 96 cases of
true sexual precocity and found that 54 of the 72 girls
fell into the primary group. On the other hand 15 of the
24 boys were classified under the neurogenic category.
Various neurological disorders causing true sexual precocity
have been described, including hypothalamic hamartomas,
tuberous scleroses, pineal tumours, astrocytomas, measles
encephalitis, hydrocephalus and tuberculous meningitis.
Sexual precocity complicating tuberculous meningitis
is not common. Lorber' in 1961 reported on the long-term
follow-up of 100 children who recovered from tuberculous
meningitis, and found 3 cases of sexual precocity, all in
girls. Donner and Wasz-Hockert: in discussing the late
neurological sequelae of tuberculous meningitis in 191
cases, found only I case of sexual precocity. In 1964
McLaren-Todd and Neville' reviewed 194 cases of tuberculous meningitis. There were 118 deaths and of the
remaining 76 they were able to trace 65 cases. The only
endocrine abnormality noted was delay in onset of
puberty in 2 cases. Asherson et al." from Cape Town
described 2 cases of obesity and hypogonadism and 1 case
with precocious sexual development complicating tuberculous meningitis. An interesting feature of their cases
was the presence of intracerebral calcification in the
suprasellar region. This finding has been described by
other authors. It was not noted in the present case.
In tuberculous meningitis the site of maximal infection
and the most dense exudate is in the basal cisterns. This
may lead to obstruction of the cerebrospinal-fluid pathways. Calcification of this exudate occurs in a significant
proportion of children who recover from the disease. These
lesions are in close proximity to the pituitary gland and
hypo thalamus. In addition to vascular damage, the hypothalamic nuclei may suffer as a consequence of the variable
degree of hydrocephalus that may occur. Tubercles in the
hypothalamus are also described. In view of these pathological findings it would be reasonable to expect disturbances in hypothalamic-pituitary function to be common,
but this is not so.
SUMMARY

True sexual precocity complicating tuberculous meningitis is

an infrequent finding. A case occurring in a 3-year-old Coloured
girl is described who at the age of I year developed tuberculous
meningitis and in whom breast development, pubic hair growth
and vaginal bleeding were subsequently noted. The literature
is briefly reviewed.
I wish to thank Dr G. Elliot, Medical Superintendent of
Coronation Hospital, for permission to publish this report;
and Dr H. Cohen, under whose care the patient was admitted.
REFERENCES
I. Nelson, W. E. (1964): Textbook of Pediatrics. 8th ed., p. 1260.
Philadelphia: W. B. Saunders.
2. Sigurjonsdoiter, T. J. and Hayles, A. B. (1968): Amer. J. Dis. Child.,
llS, 309.
3. Lorber, J. (1961): Pediatrics, 28, 778.
4. Donner, M. and Wasz-Hockert, O. (1963): Acta paedia!. (Dppsala),
suppl. 141, 34.
5. McLaren-Todd, R. and NeviUe, J. G. (1964): Arch. Dis. Childh., 39,

213.
6. Asherson, R. A., Jackson, W. P. U. and Lewis, B. (1965): Brit. Med.
J., 2, 839.