Vaginal Bleeding in a 3-year-old

1. Mohini Bollineni, MBBS* 2. Ruban Dhaliwal, MD, MPH* 3. Aditi Khokhar, MBBS† 1. *Division of Endocrinology, Department of Medicine, 2. †Division of Pediatric Endocrinology, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY A 3-year and 7-month-old girl presents to endocrine clinic with vaginal bleeding. She has had diffuse hyperpigmented flat lesions on the right half of her body since birth, breast enlargement for 2 weeks, and vaginal bleeding noted as bright red bloody discharge on urination for 3 days. Her birth length was at 75th percentile. She has been growing along 90th to 95th percentile since age 3 months. Her current height velocity is 9.3 cm per year. Her weight is at the 95th percentile. She does not have hearing or vision problems, bone pain, or headaches. There is no family history of early puberty. Mid-parental height is 67.4 in (89th percentile). On physical examination, her vital signs are normal for age. She has breast buds (Tanner 2 breast) bilaterally and Tanner 1 pubic hair. Large diffuse cafe-au-lait lesions are present on the right half of body including the right chest and trunk, extending inferiorly to the right upper leg and superiorly to the nape of neck. The lesions have irregular borders and are limited to the midline. There is no axillary freckling. She does not have any facial or skeletal deformities. The remainder of the physical examination is unremarkable. The laboratory values (listed in Table 1) reveal luteinizing hormone and follicle-stimulating hormone levels in prepubertal range with a low estradiol level. Growth hormone (GH) and insulin-like growth factor (IGF-1) levels are high for age. Serum prolactin …