WOMANHOOD COMING TOO SOON

Jeruto* was a lively four-year old whom we were all trying really hard not to stare at. She was definitely in the wrong ward, carrying a diagnosis we all flocked to her bedside to see. We were literally gawking at the little one. Thankfully, she had no idea why she was suddenly so important but she loved the attention and the gifts it brought.

It is amazing what our patients put up with when they carry a rare diagnosis. Medical students are encouraged to see the patient as the opportunity is so rare, and the memory will serve them well in the future in the event that they come across a similar patient. Most times, seeing just one physical sign in a patient will trigger a buried memory that would go a long way in diagnosing the patient on your examination couch correctly.

Jeruto had finally come to the teaching hospital a whole year after her symptoms set in. At only three years of age, Jeruto developed unexplained vaginal bleeding. She had always been a chubby baby hence the mother had missed the fact that the breast enlargement that her baby was having was not just attributed to fat.

The traumatized mother was very scared. At first she thought her daughter had been defiled but after careful inspection, she found no other injuries. Her little girl was never out of her sight. She was her first born and being a stay-at-home mom, she was fully in charge of her care.

She put her daughter back in diapers and consulted her mother in law. The two lay women living in a rural village in Nandi, went through an array of possible reasons for her abnormal situation and became more and more convinced that a dark power was at play. Being extremely religious, Jeruto’s grandmother opted for the familiar path, which was to have Jeruto prayed for by her church priest.

For a while, the bleeding stopped and they presumed that the baby was fine. Three months later, the bleeding resumed. This time round, Jeruto’s father was home on leave from his work station in Mombasa. He would hear none of the prayer options and he sought medical help from a nearby health centre.

For months, Jeruto was treated for various medical conditions; urinary tract infection, dysentery and even bilharzia but the bleeding would not cease. Eventually, one of the health care providers seeing her noted a new development, Jeruto had developed an abdominal swelling that was growing rapidly. He referred her to the teaching hospital for further care.

Jeruto was diagnosed with precocious puberty, a condition so rare, it happens in 1 in 5,000 to 10,000 children. It is also five times more common in girls than boys. Whereas the more common type is where there is an abnormality in all the hormones responsible for reproduction, all the way from the brain level (hypothalamus and pituitary gland) to the ovary (in girls) or testes (in boys); Jeruto’s condition was even more rare.

Her condition was as a result of an ovarian tumour known as the granulosa cell tumour. Though commonly not cancerous when it occurs in children, it definitely leads to a lot of distress, both for the child and the parents. The developing swelling noted in Jeruto was the tumour growing. This tumour was producing the female sex hormone, oestrogen, which was causing all these puberty symptoms.

Jeruto, at a tender age of four, was being inadvertently turned into a woman in a little child’s body. As a child, she was saved the agony of having to understand the ramifications of the condition but her parents were distraught, coupled with the knowledge that she had a growth inside her.

In our set up, it is not uncommon for such rare conditions to go untreated for prolonged durations. It is almost taboo for a young child to have vaginal bleeding and conclusions to the supernatural occurrences are quickly drawn. Yet this is a definite sign of things going wrong that require immediate intervention for a proper diagnosis and treatment plan to be made.

It is normal for newborn baby girls to bleed vaginally or have a semblance of breast buds in the first few weeks of life. This is usually as a result of high levels of the mother’s oestrogen hormone in the baby. After birth, the baby ceases to receive these hormones and their levels will drop over time, leading to the disappearance of these symptoms.

However, new onset of growing breast tissue, vaginal bleeding and abnormally rapid growth in height requires a thorough review of the baby. Ovarian tumours, abnormality of the function of the adrenal glands or hypothyroidism could be causing mayhem. Reports have been made in babies as young as four months!

Thankfully for Jeruto, the able multidisciplinary team of specialists drawn from various key departments were up to the task. We thronged the operating room to gawk some more. She underwent successful surgery to remove the large offending  tumour. The surgical skill on display was one of a find considering the minute size of our patient.

The laboratory confirmed that the tumour was not cancerous amid celebratory cheer from all of us. We were all rooting for her. She went on to recover very well from surgery, further proving her resilience. She had to make do with losing one ovary but the remaining one would serve her well in future. The offending bleeding stopped and the breast tissue regressed somewhat. Her childhood had been redeemed!

While Jeruto has grown up with her scar, wearing is proudly as a badge of honour for what she survived, her mother definitely found peace. The question of how to use a sanitary pad on a pre-school child had been laid to rest. Her daughter could now happily ditch the diapers!