A 13-year-old boy is brought to the office for a well-child visit. The patient is concerned that he is the shortest boy in his class. He is in 7th grade and participates in soccer and baseball. The patient is a picky eater whose diet consists primarily of cereal, fruit, pasta, and pizza. He has seasonal allergies and takes cetirizine and a daily multivitamin. His mother is 165 cm (65 in), and his father is 178 cm (70 in). Height is 140 cm (55 in) and weight is 39 kg (86 lb). The patient's sexual maturity rating (Tanner stage) is 1. The remainder of the examination is unremarkable. A radiograph of the left wrist reveals a bone age of 10 years. His growth chart is shown below. Which of the following is the most likely diagnosis in this patient?

Question

A 13-year-old boy is brought to the office for a well-child visit.  The patient is concerned that he is the shortest boy in his class.  He is in 7th grade and participates in soccer and baseball.  The patient is a picky eater whose diet consists primarily of cereal, fruit, pasta, and pizza.  He has seasonal allergies and takes cetirizine and a daily multivitamin.  His mother is 165 cm (65 in), and his father is 178 cm (70 in).  Height is 140 cm (55 in) and weight is 39 kg (86 lb).  The patient's sexual maturity rating (Tanner stage) is 1.  The remainder of the examination is unremarkable.  A radiograph of the left wrist reveals a bone age of 10 years.  His growth chart is shown below.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d667_da88_bc81_d743ccb6c984_MD0003_00 This patient has short stature, defined as height at the ≤2nd percentile for sex and age. Short stature is most commonly a normal variant of growth due to constitutional growth delay or familial short stature. Constitutional growth delay can be recognized based on a delayed bone age, with a linear growth velocity starting at age ≥3. Affected patients typically have a normal birth weight and height but show a slowed linear growth velocity between age 6 months to 3 years. This results in height at the ≤2nd percentile. They subsequently (eg, age ≥3) grow at a normal rate (ie, normal growth velocity), so their growth curve remains below but parallel to the lowest percentile line (ie, linear growth curve). Their puberty (including the adolescent growth spurt) is delayed, and bone age (ie, skeletal maturation) is delayed compared to the chronological age. However, they eventually have a normal growth spurt and reach a normal adult height. Management includes reassurance and monitoring of linear velocity. In contrast to constitutional growth delay, patients with familial short stature have a bone age that correlates with chronologic age, and puberty is not delayed. Although these patients have normal linear growth velocity (eg, stable percentile) similar to constitutional growth delay, one or both parents also have short stature (unlike in this patient) (Choice C). An affected patient's adult height remains low. (Choice A) Celiac disease can present with short stature and result in delayed bone age; however, patients typically also have weight loss and gastrointestinal symptoms (eg, diarrhea, abdominal distension). This patient has appropriate weight gain and is otherwise asymptomatic. (Choice D) Patients with growth hormone deficiency have short stature, delayed puberty, and delayed bone age. However, linear growth velocity is slowed, typically presenting as declining height percentiles crossing 2 major percentiles (ie, 50th, 25th). This patient's height percentile is stable, indicating a normal linear growth velocity. (Choice E) Hypogonadism leading to testosterone deficiency can be congenital (eg, Klinefelter syndrome) or acquired (eg, testicular trauma or infection). Although delayed puberty is common, bone age would be normal. In addition, most patients have gynecomastia (not seen here) due to negative feedback, causing increased LH, FSH, and estradiol. (Choice F) Hypothyroidism can cause declining linear growth velocity and pubertal delay. In contrast, this patient's linear growth velocity is normal. In addition, he has no clinical symptoms of hypothyroidism, such as fatigue, constipation, or cold intolerance. Educational objective: Constitutional growth delay is characterized by short stature (height at the ≤2nd percentile) and normal linear growth velocity after age 3. Puberty and bone age are delayed, and adult height is typically normal. References: Constitutional growth delay. (http://www.ncbi.nlm.nih.gov/pubmed/30969602)

A 13-Year-Old Boy Is Brought to the Office for a Well-Child