Challenges in the era of COVID-19: Starting from the clinical examination

ABSTRACT

Introduction: Physical examination remains the cornerstone of medical practice. However, its importance has been underestimated during COVID-19 pandemic because of concerns related to exposure risk and use of personal protective equipment. Solitary median maxillary central incisor (SMMCI) may be an isolated clinical trait or associated with other anomalies and endocrine pathologies including hypopituitarism, hypothyroidism, isolated growth hormone (GH) deficiency, precocious or delayed puberty, short stature without GH abnormalities. Aim(s) The aim of this case presentation is to underline the significance of clinical examination, as in SMMCI, an important clinical finding that may lead to an early diagnosis of hidden endocrine abnormalities. Material(s) and Method(s) A 78/12-year-old girl was hospitalised because of an episode of acute headache with walking instability. Her past medical history was uneventful except for premature adrenarche since the age of 56/12 years. A paediatric endocrinologist had estimated her 2 years before, at the onset of the COVID-19 pandemic and ordered hormone assays and a Synachten test. Because of her past medical history and the positive family history for type 2 diabetes, she underwent a detailed hormone laboratory evaluation including oral glucose tolerance test (OGTT) and LHRH test. Furthermore, because of the borderline response in 17-hydroxyprogesterone following ACTH stimulation, CYP21A2 gene analysis was performed. Result(s) Her clinical examination revealed excessive body mass index (18.9 kg/m2, 90th percentile) and B I and PH II-III Tanner stage with axillary hair and odor. OGTT revealed insulin resistance (HOMA-IR 3.38). Based on the increased LH response in GnRH test (LH at 30 min 3.8 IU/L) in association to the increased ovarian volume (3.25 and 5.3 ml with 6 and 9 follicles respectively), she was diagnosed with central precocious puberty (CPP). At the time of final clinical and laboratory overview by the Chief of the Unit, the girl was asked to put off her mask, unraveling a SMMCI, a finding not having been identified and correctly evaluated until then. Consequently, a pituitary gland magnetic resonance imaging (MRI) was mandatory, revealing ectopic posterior pituitary at the pituitary stalk with hypoplasia of anterior pituitary, possibly implicated in the CPP aetiology. The patient was prescribed triptorelin and is on regular endocrine follow-up. Conclusion(s) SMMCI, so easily diagnosed, may be the cardinal clinical feature guiding further physical, endocrine laboratory and imaging investigation and leading to early diagnosis of endocrine pathology. Clinical examination remains the key of paediatric endocrine evaluation, overcoming any potential risk in the era of COVID-19.