Table 1 Timeline of case presentation

Before 2020

The family noticed bilateral breast enlargement, sought medical advice in different primary care facilities and had been reassured

First visit: 8 December 2020

Patient presented at the age of 4 years and 5 months with gradually progressive bilateral breast enlargement since the age of 9 months, with accelerated growth

Left wrist X-ray: bone age of 8 years

Hormonal tests and abdominal ultrasound requested

Second visit: 15 December 2020

Investigations and imaging results

Basal luteinizing hormone 3.1 mIU/L prestimulation. Increased to 8.8 mIU/L 45 minutes post-gonadotrophin-releasing hormone stimulation

Estradiol E2 29000 pg/mL (5–15 pg/mL)

Dehydroepiandrosterone sulfate 90 ng/mL (2.3 ng/mL). Early morning cortisol level 16 ng/mL (7–28 ng/ml)

Abdominal ultrasound showed a right-sided hypoechoic suprarenal mass

Abdominal CT scan requested.

Third visit 22 December 2020

Follow-up with abdominal CT scan result

Abdominal CT scan revealed a well-defined rounded focal lesion with a smooth outline at the level of the right adrenal gland with normal left adrenal gland and ovaries

Diagnosis of estrogen-secreting adrenocortical tumor and surgical referral

Fourth visit 12 January 2021

Postoperative evaluation, patient was clinically well

Normal cortisol and dehydroepiandrosterone sulfate. Estradiol E2 40 pg/mL consistent with central precocious puberty.

Patient started on gonadotrophin-releasing hormone agonist

Fifth visit 15 June 2021

Patient was well, compliant to monthly gonadotrophin agonist injections with partial regression of her secondary sexual characters and normal growth velocity (5 cm/year)

Abdominal CT scan was normal with no evidence of recurrence

To continue on gonadotrophin-releasing hormone agonist, with regular follow–up for the possibility of tumor recurrence