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Turner Syndrome: Differential Diagnoses & Workup

Author: Daniel C Postellon, MD, Clinical Associate Professor, College of Human Medicine, Pediatrics and Human Development, Michigan State University; Consulting Staff, Pediatric Endocrine Clinic, DeVos Children's Hospital
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Noonan Syndrome

Other Problems to Be Considered

Autoimmune thyroiditis
Gonadal dysgenesis
Lymphedema
XY gonadal agenesis syndrome

Workup

Laboratory Studies

  • Diagnosis
    • Karyotyping is required for diagnosis of Turner syndrome. Diagnosis is confirmed by the presence of a 45,X cell line or a cell line with deletion of the short arm of the X chromosome (Xp deletion).
    • The buccal smear for Barr bodies is obsolete.
  • Y chromosome
    • Patients should be tested for the presence of Y chromosomal material using a Y-centromeric probe.4
    • Patients with 45,X/46,XY mosaicism may have mixed gonadal dysgenesis and are at a high risk for gonadoblastoma. These patients may require a prophylactic gonadectomy to prevent death from malignancy.
    • Patients with ring chromosomes or fragments of chromosomes should be examined for Y chromosomal material for the same reason.
  • Gonadotrophins
    • Both LH and FSH may be elevated in untreated patients younger than 4 years. Gonadotropins are later suppressed to normal or near-normal levels, only to rise to menopausal levels after age 10 years.
    • Assess both LH and FSH levels prior to initiating estrogen replacement therapy.
  • Thyroid function tests
    • Because of the high prevalence of hypothyroidism in Turner syndrome,8 obtain thyroid function tests at diagnosis.
    • Thyroid-stimulating hormone (TSH) measurements should be repeated every 1-2 years or if symptoms develop because patients may develop hypothyroidism at a later age.
  • Glucose metabolism
    • Abnormalities of glucose metabolism, including overt diabetes mellitus, are more common than in unaffected children.
    • Glucose tolerance tests should not be used as a screening test. Obesity should be avoided.
    • Screening for diabetes mellitus is best performed by obtaining a hemoglobin A1c or fasting glucose level.
    • Urinalysis for glucose should be performed at each follow-up visit with patients taking oxandrolone or human growth hormone.
  • Continuing care: As routine health maintenance, patients with Turner syndrome should have BUN, creatinine, fasting blood sugar (FBS), fasting lipids, liver enzymes, free thyroxine (T4), and TSH levels measured annually after childhood.
  • Virilization: Signs of excess androgens are generally absent. If virilization occurs, a search for Y chromosomal material by fluorescent in situ hybridization (FISH) or polymerase chain reaction (PCR) is necessary as part of an evaluation for possible gonadoblastoma.

Imaging Studies

  • Renal
    • At diagnosis, perform ultrasonography of the kidneys and renal collecting system.
    • Annual urine cultures and measurement of BUN and creatinine levels are recommended for those patients with abnormalities of the renal collecting system that predispose to obstruction.
  • Cardiovascular
    • Perform echocardiography, MRI examination of the heart, or both upon diagnosis. Evaluate 4-limb blood pressures secondary to the high incidence of coarctation of the aorta.
    • A cardiologist should monitor abnormalities.
    • Because of the risk of aortic dissection, cardiovascular examinations should be repeated every 5 years during adulthood and prior to assisted reproduction.
    • A complete cardiovascular evaluation should be completed prior to attempting assisted reproduction.
  • Bone age
    • Bone age is usually normal prior to adolescence but is delayed afterward because of the lack of estrogens.
    • Obtain bone age before starting growth hormone or estrogen therapy. Growth hormone does not increase height if the epiphyses are fused.
  • Bone density
    • Osteoporosis is common but may be overdiagnosed in short individuals.
    • Measure bone density initially in adults and 3 years later.

Other Tests

Audiology is indicated in patients with Turner syndrome.

  • Infants diagnosed at birth should have a hearing assessment in the nursery. Otherwise, formal hearing assessment is recommended at age 1 year and before entering school. Formal re-evaluation every 5 years has been recommended.
  • More frequent testing is needed in children with repeated otitis media.
  • Adults should also have a hearing evaluation at least once with further testing later if hearing loss is suspected.

More on Turner Syndrome

Overview: Turner Syndrome
Differential Diagnoses & Workup: Turner Syndrome
Treatment & Medication: Turner Syndrome
Follow-up: Turner Syndrome
Multimedia: Turner Syndrome
References
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References

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Further Reading

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Keywords

Turner syndrome, Turner's syndrome, 45,X karyotype, Bonnevie-Ullrich syndrome, gonadal dysgenesis, monosomy X, XO syndrome, short stature, Leri-Weill dyschondrosteosis, coarctation of the aorta, aortic dissection, diabetes mellitus, treatment, diagnosis

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Contributor Information and Disclosures

Author

Daniel C Postellon, MD, Clinical Associate Professor, College of Human Medicine, Pediatrics and Human Development, Michigan State University; Consulting Staff, Pediatric Endocrine Clinic, DeVos Children's Hospital
Daniel C Postellon, MD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Medical Editor

Ian Krantz, MD, Department of Pediatrics, Assistant Professor, University of Pennsylvania and Children's Hospital of Philadelphia
Ian Krantz, MD is a member of the following medical societies: American Society of Human Genetics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert Anthony Saul, MD, Clinical Professor, Department of Pediatrics, University of South Carolina; Senior Clinical Geneticist, Greenwood Genetic Center
Robert Anthony Saul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Medical Genetics, and American College of Physician Executives
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Bruce Buehler, MD, Professor, Department of Pediatrics, Pathology and Microbiology, Executive Director, Hattie B Munroe Center for Human Genetics, University of Nebraska Medical Center
Bruce Buehler, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Pediatrics, American Association on Mental Retardation, American College of Medical Genetics, American College of Physician Executives, American Medical Association, and Nebraska Medical Association
Disclosure: Nothing to disclose.

 
 
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