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Sexual Precocity in a 16-Month-Old
& a5 [% D. K& xBoy Induced by Indirect Topical& h8 Z/ g9 f% p' V- M
Exposure to Testosterone
6 Z& R+ I; X( Z9 f  `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" Z2 u* E$ ^7 Q$ [
and Kenneth R. Rettig, MD1* k# n3 @5 m: B6 {) `: p
Clinical Pediatrics
8 I* \* }7 j5 p. u+ }' T& g. PVolume 46 Number 60 c: b# G( {/ N' _: R6 e
July 2007 540-543
& h4 p1 S4 j% z+ k© 2007 Sage Publications
& X7 y7 y9 o- `9 {7 c4 |10.1177/0009922806296651
, S' Q8 F4 r( L1 U; u' lhttp://clp.sagepub.com4 T( G. p3 B- X
hosted at- E; W1 k% G4 H. N) K% x3 \5 [
http://online.sagepub.com: x& ?. u7 Q' m/ V* ~
Precocious puberty in boys, central or peripheral,
* u9 a: ^8 X$ j$ b4 m+ Fis a significant concern for physicians. Central7 Q3 i( b% M; z/ V2 r9 j- f2 B1 ?
precocious puberty (CPP), which is mediated
8 r$ ^! _/ S, _; t* u/ i. a; ?through the hypothalamic pituitary gonadal axis, has
7 h1 I- p1 q$ p: u* ^a higher incidence of organic central nervous system
; k# o* U' _/ B1 ]7 Tlesions in boys.1,2 Virilization in boys, as manifested* X: n: I) X7 F
by enlargement of the penis, development of pubic( {" h7 R* ~1 R0 A  I
hair, and facial acne without enlargement of testi-
4 I! q7 }& ]5 y5 a% h; h. ocles, suggests peripheral or pseudopuberty.1-3 We6 p. J" E& p8 R! h2 W- P7 H" ?1 }
report a 16-month-old boy who presented with the
2 V, B% e( d& Menlargement of the phallus and pubic hair develop-9 h. G# K: \: u2 b; I
ment without testicular enlargement, which was due
. ~( P1 P: z- Q+ s8 Bto the unintentional exposure to androgen gel used by; W4 j& D( Y4 H8 i5 P
the father. The family initially concealed this infor-; ^- U; t* S8 u/ v
mation, resulting in an extensive work-up for this
4 E6 _) N5 V" @. A% c1 |- P  f# gchild. Given the widespread and easy availability of
, |# A7 ~# ?! l- I. ?0 I; ?0 Ktestosterone gel and cream, we believe this is proba-& Z: _$ j3 @$ [+ h  M+ ~
bly more common than the rare case report in the) \' S, X: K8 z8 Z1 Z: O% T- D
literature.4
7 Q7 F' S1 o: T) P8 p# \, M5 w# QPatient Report
6 k# J* E0 ~+ o: ]9 A" K( g% GA 16-month-old white child was referred to the5 s$ k) U( a3 R# O0 F' D1 S$ z
endocrine clinic by his pediatrician with the concern
3 Z, q' l! G8 D% l, S) Y) wof early sexual development. His mother noticed" I4 M' x; O2 Z$ r2 J3 b* z
light colored pubic hair development when he was  k- q6 a) u' T) Y2 F3 r' |
From the 1Division of Pediatric Endocrinology, 2University of' C) `0 @& u$ g7 y
South Alabama Medical Center, Mobile, Alabama.
$ N2 `" s! \" n0 ?5 f, k( @* t7 GAddress correspondence to: Samar K. Bhowmick, MD, FACE,* W: a) B8 L9 L6 [1 h7 z7 H; [8 w
Professor of Pediatrics, University of South Alabama, College of, k1 l- ~" K; @( s" s" [# h0 `8 w
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- D% M1 i- O  t  ]; O; `
e-mail: [email protected].
( M1 b0 x" N2 ]* R7 h3 dabout 6 to 7 months old, which progressively became
# l* d% i% ]( _) Vdarker. She was also concerned about the enlarge-
" N8 `+ I, [5 D' r. L  Iment of his penis and frequent erections. The child
5 K6 l* Q( Y7 ?! awas the product of a full-term normal delivery, with8 |. R) U9 m8 H3 Q% ]
a birth weight of 7 lb 14 oz, and birth length of6 T) ~2 n% h+ _4 \  {  k3 T) m: \
20 inches. He was breast-fed throughout the first year
6 @1 o/ f) N! n5 Vof life and was still receiving breast milk along with! P/ i. B8 a9 X; I3 U9 G
solid food. He had no hospitalizations or surgery,9 Q9 N' x# m' T) P4 @* e5 w2 C
and his psychosocial and psychomotor development( ], n7 D! L# {3 ?+ c# ~( ]- l7 D
was age appropriate.
6 n- s) z9 L1 S6 O$ TThe family history was remarkable for the father,* P  B! ?! [- U. Z
who was diagnosed with hypothyroidism at age 16,
& [; g! {2 M2 hwhich was treated with thyroxine. The father’s
. S* l5 O* d+ a0 Vheight was 6 feet, and he went through a somewhat
# W! t  m( f. c) ?early puberty and had stopped growing by age 14.+ ]% \( R* R, S0 B1 F
The father denied taking any other medication. The* l: |3 G4 ~# H1 b0 s& B* S
child’s mother was in good health. Her menarche
2 [$ j" x- J* l5 [7 M5 S7 hwas at 11 years of age, and her height was at 5 feet, H* b; _4 u) i3 X. y0 d) Q8 D
5 inches. There was no other family history of pre-
  x' w  ~6 A2 [  S5 pcocious sexual development in the first-degree rela-' r9 t0 ]# R7 E8 H# r
tives. There were no siblings.% u5 m, W& d5 B7 F  {' L& y
Physical Examination; G9 N( B. x- A0 n0 B% N8 f- I
The physical examination revealed a very active,; K# Y! e7 E1 w8 g* K* X0 q( u
playful, and healthy boy. The vital signs documented
0 V/ `+ k$ q  Y9 la blood pressure of 85/50 mm Hg, his length was
2 c: S" T( V. l0 D! ~90 cm (>97th percentile), and his weight was 14.4 kg
3 C" E( _6 P7 T4 X% y+ Y(also >97th percentile). The observed yearly growth( l0 l& A. O5 z- U! r% P% K
velocity was 30 cm (12 inches). The examination of
5 R1 ?4 d" H  d* q; _& jthe neck revealed no thyroid enlargement.. E& Y  g# E' j
The genitourinary examination was remarkable for$ a6 `! H5 }1 U8 ^0 o1 h& t6 v# }; N
enlargement of the penis, with a stretched length of
0 O! `! n1 m! _4 @3 i- g) d8 cm and a width of 2 cm. The glans penis was very well
. h, v* t# V: M$ rdeveloped. The pubic hair was Tanner II, mostly around$ I# m- @' P) Q% \% A( N
540
4 v9 h( Y) h' W# Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: Y6 E( \5 T/ w
the base of the phallus and was dark and curled. The
9 q9 Z/ [4 [* }, Ctesticular volume was prepubertal at 2 mL each.
$ }+ n- ?9 y1 ?8 ^; L4 ^The skin was moist and smooth and somewhat; R& V1 o6 \1 r( R) e7 y( G$ g
oily. No axillary hair was noted. There were no# F5 L: x& |. s* n* Q
abnormal skin pigmentations or café-au-lait spots.
; k, x8 X% r, V( T' QNeurologic evaluation showed deep tendon reflex 2+( \) H" x8 s' a* [
bilateral and symmetrical. There was no suggestion
1 j0 q6 }3 c" P# c9 u3 ?: g- nof papilledema.; S4 M: C$ t' n% T( b6 w/ W
Laboratory Evaluation' P7 W% k. t0 D" J" h9 j& {
The bone age was consistent with 28 months by9 k% b' h9 a0 Q1 H0 L
using the standard of Greulich and Pyle at a chrono-
1 G: ~8 E8 \, I( H7 vlogic age of 16 months (advanced).5 Chromosomal" r) e2 W5 K* Q4 w7 k4 V( X
karyotype was 46XY. The thyroid function test. g8 Z8 {) t9 W- ?0 [  N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, H+ a& S, `# {8 olating hormone level was 1.3 µIU/mL (both normal).7 k/ X9 \7 y1 T1 E
The concentrations of serum electrolytes, blood6 h/ A& z' m8 w1 t* A
urea nitrogen, creatinine, and calcium all were4 E, W; B7 V- p1 M3 _; u. j" |
within normal range for his age. The concentration
, z8 q; N, C6 qof serum 17-hydroxyprogesterone was 16 ng/dL0 z  y) w& A+ _+ f4 a
(normal, 3 to 90 ng/dL), androstenedione was 20
1 b! G# T5 @' {6 m' b5 m) Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 [' {0 U/ U& x5 z& T. }7 ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; N  Q  q5 o7 {0 e- W! Z( E, Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ y/ I) F) y) Y+ T% G0 U- f+ U# ~
49ng/dL), 11-desoxycortisol (specific compound S)
( R* E, N+ K- p7 N. qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ [9 m1 P2 i; M: s- j$ L" u* d) Dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 A; A) H' a1 c. vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),# W2 I% Y. R$ p5 k1 D% z" X
and β-human chorionic gonadotropin was less than) J0 G6 h* w- i; I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
. m- ?1 i" m! ostimulating hormone and leuteinizing hormone. W) y# U5 B5 Y* z; M
concentrations were less than 0.05 mIU/mL
0 |! q  G* e7 ~3 u/ d(prepubertal).; [+ j6 B# m& G' r' E9 I" g
The parents were notified about the laboratory
( H: V  l: _' ]: ~results and were informed that all of the tests were
$ ?+ _5 P) _$ B. F. J6 a" O9 k) a+ knormal except the testosterone level was high. The+ t. `1 ~; y3 n0 W; O7 T$ E
follow-up visit was arranged within a few weeks to. D+ x, |  x8 ]2 W* H
obtain testicular and abdominal sonograms; how-
/ g% G5 B' E! x8 j, never, the family did not return for 4 months.
, W/ L! y1 m% C5 tPhysical examination at this time revealed that the8 |# k1 n: w) S' k7 |4 Q
child had grown 2.5 cm in 4 months and had gained
; p  M& k. k! i% y1 y2 kg of weight. Physical examination remained. V) C9 c- n- ]8 Q6 B! A
unchanged. Surprisingly, the pubic hair almost com-  m1 Q- g8 o# t0 ~! y0 n0 e
pletely disappeared except for a few vellous hairs at& T' c, c$ n% C" V! \* k, j
the base of the phallus. Testicular volume was still 2, c8 a' R5 w; [# t
mL, and the size of the penis remained unchanged.
4 E& ^7 |% z6 t$ @8 \0 sThe mother also said that the boy was no longer hav-% t6 Z, P" Z$ n! L6 N
ing frequent erections.
: E) r: O9 h1 Q, H# f- @1 RBoth parents were again questioned about use of
) Q1 ]7 G$ S6 ?2 q- `" ]& a% B2 i3 gany ointment/creams that they may have applied to; ?6 x# }4 G5 o3 f+ N2 K9 `; H7 R
the child’s skin. This time the father admitted the( x$ Y& K# r8 e; i3 @+ |
Topical Testosterone Exposure / Bhowmick et al 541' u5 q2 s1 Y1 j
use of testosterone gel twice daily that he was apply-
; f4 {, m9 D) Eing over his own shoulders, chest, and back area for
1 m" U* [" j- ?0 c# Ha year. The father also revealed he was embarrassed
$ u% k9 ^% z0 Zto disclose that he was using a testosterone gel pre-
5 R7 M. H0 F  D" J# i" pscribed by his family physician for decreased libido
  A; N% L- B0 d4 O- t4 ^0 psecondary to depression.
* r4 x/ y  Q6 |" c6 h& FThe child slept in the same bed with parents.
" Y1 R3 k& n/ R0 h( j/ [# K2 f8 _- `The father would hug the baby and hold him on his
8 s! h$ \4 c9 M9 [( q& P2 i& ichest for a considerable period of time, causing sig-
/ J, U( E' [( E$ c, a4 inificant bare skin contact between baby and father.+ Q: o' a: O) t6 ?8 y1 M0 V
The father also admitted that after the phone call,
1 {# V5 \& `( {2 y4 j6 fwhen he learned the testosterone level in the baby' i! Z6 {- T6 ?8 C+ d
was high, he then read the product information
" Y- V" k! {5 x8 m+ Ypacket and concluded that it was most likely the rea-
- A# J' |5 S' V8 Yson for the child’s virilization. At that time, they# R+ M$ f& X; G3 c; Z5 w
decided to put the baby in a separate bed, and the
; ~$ G4 }3 n( Hfather was not hugging him with bare skin and had( b5 {( B$ Q( k$ {6 z% g1 c- u
been using protective clothing. A repeat testosterone
, D2 _  N$ J9 ztest was ordered, but the family did not go to the: V9 I6 _; o5 i8 h" v( A
laboratory to obtain the test.
, b, B( A9 n5 A' x( b* s0 \* rDiscussion: P. \# B" h4 u" W8 j5 `
Precocious puberty in boys is defined as secondary) `) F5 f. q% c! J, g! u5 Z5 i* n
sexual development before 9 years of age.1,4
* s+ c0 s. m5 x! `Precocious puberty is termed as central (true) when
: ]5 f- M  k" T3 @6 Q6 y' T+ U, ait is caused by the premature activation of hypo-' E: P% ~: Z- p, T& s
thalamic pituitary gonadal axis. CPP is more com-
. A2 X; T+ f+ P# s+ r' m8 `mon in girls than in boys.1,3 Most boys with CPP7 ]* _+ x: h, R+ |7 ]/ d
may have a central nervous system lesion that is0 C, \- g  U2 l4 d3 b7 ~' k, p
responsible for the early activation of the hypothal-
& q3 b, A" m6 t4 P$ W( H& ~) V" @amic pituitary gonadal axis.1-3 Thus, greater empha-
) B- m# ~& ~3 H. t' j  `sis has been given to neuroradiologic imaging in
  a* ^0 S, V& C1 @: \; w% g! d7 P: aboys with precocious puberty. In addition to viril-7 [3 ]1 e  M* x+ A) ?
ization, the clinical hallmark of CPP is the symmet-0 c0 d) |' I  f) x4 I' f
rical testicular growth secondary to stimulation by
% m" h! E; v$ Cgonadotropins.1,3
' o& o" f) J1 |/ uGonadotropin-independent peripheral preco-# X- e+ i& N. G/ K: I% A# s
cious puberty in boys also results from inappropriate
# |2 @  g3 r. mandrogenic stimulation from either endogenous or& M/ R2 q% [, G
exogenous sources, nonpituitary gonadotropin stim-% b; E; r# [/ S$ D' D
ulation, and rare activating mutations.3 Virilizing
1 y. \+ j: }) {2 f  P1 bcongenital adrenal hyperplasia producing excessive
' g  h& t, d8 y" u. [adrenal androgens is a common cause of precocious
8 n, B7 U4 D6 opuberty in boys.3,41 A: m6 d+ ?! G( v9 X
The most common form of congenital adrenal
; l& a5 Y4 ?! {: e! Mhyperplasia is the 21-hydroxylase enzyme deficiency.
; g0 G% Q1 V4 hThe 11-β hydroxylase deficiency may also result in; ]3 b2 V( f5 i# y* T" }6 e
excessive adrenal androgen production, and rarely,
8 f9 f  v- h* Q$ lan adrenal tumor may also cause adrenal androgen
" S5 O% X3 e! U1 |% Dexcess.1,30 j& ~/ p+ \: z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& s3 c# H1 Y/ w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- @; E( K+ i2 e: e5 \$ g: T
A unique entity of male-limited gonadotropin-
0 Z* v. w+ |7 ~" Findependent precocious puberty, which is also known# C4 N. v5 ]# R' J
as testotoxicosis, may cause precocious puberty at a& F& M. A$ H. Q8 U2 X& a1 T4 A
very young age. The physical findings in these boys
: q# [5 u  Z9 s/ `with this disorder are full pubertal development,0 ]0 ~& E2 V. D
including bilateral testicular growth, similar to boys6 H0 p* y$ |1 ]3 }3 c
with CPP. The gonadotropin levels in this disorder
' U% g: G8 W# b+ }0 r6 Xare suppressed to prepubertal levels and do not show9 b; S8 F: W/ t; s7 N! p
pubertal response of gonadotropin after gonadotropin-
, \1 e1 O6 q! ?: B4 sreleasing hormone stimulation. This is a sex-linked# V7 V+ ^; u6 @4 v* P1 b( H
autosomal dominant disorder that affects only
! v- v/ S/ M1 y  u, R7 a8 o2 x& Wmales; therefore, other male members of the family% c) b1 M; [4 V8 ~" z
may have similar precocious puberty.3
5 m) J+ X! [) _% u" rIn our patient, physical examination was incon-
- k5 Q4 q8 L2 o7 J' M, Zsistent with true precocious puberty since his testi-
8 L+ A/ B' q  n4 |6 X9 ecles were prepubertal in size. However, testotoxicosis7 p6 n/ H1 ~) q" B& C/ ?/ [
was in the differential diagnosis because his father
" F5 U! P5 Q& ostarted puberty somewhat early, and occasionally,
3 S4 s4 A5 F( T5 j; o2 W5 n8 j9 }testicular enlargement is not that evident in the
; D3 C! e+ T1 k% r& Hbeginning of this process.1 In the absence of a neg-/ I8 F3 \5 N+ q* o; U. R  z& e( q
ative initial history of androgen exposure, our7 t+ [. _; h# U& u3 @; l
biggest concern was virilizing adrenal hyperplasia,9 v/ q1 I" w+ X0 x5 m' \& d
either 21-hydroxylase deficiency or 11-β hydroxylase
6 }% K6 e: E- F4 e( U: Qdeficiency. Those diagnoses were excluded by find-6 q6 }* @! J. C' w
ing the normal level of adrenal steroids.! p: Q3 t9 u* e
The diagnosis of exogenous androgens was strongly
$ j+ Y3 x( `! x" Csuspected in a follow-up visit after 4 months because) D( `7 K+ F' p
the physical examination revealed the complete disap-
4 r6 D3 l! j6 opearance of pubic hair, normal growth velocity, and! B& @( W* q; v6 k* n
decreased erections. The father admitted using a testos-5 o4 ~* A  T# W; M2 T# H
terone gel, which he concealed at first visit. He was2 Z1 S% S. Y/ R- P) q6 @$ }
using it rather frequently, twice a day. The Physicians’9 S  z5 }9 i+ N1 H
Desk Reference, or package insert of this product, gel or8 w7 Z9 ]9 `/ k$ X5 Z1 o( o
cream, cautions about dermal testosterone transfer to8 ^' W0 x4 W. f- i+ N( d; Z5 q
unprotected females through direct skin exposure.
1 H! |. G) B" B& f' J! R0 DSerum testosterone level was found to be 2 times the
# {- D0 h: k8 S% G# Fbaseline value in those females who were exposed to$ h5 I' S# I# w4 @6 V# h
even 15 minutes of direct skin contact with their male2 c" v+ f/ T6 Z8 T) O- u- I$ i
partners.6 However, when a shirt covered the applica-$ s6 D' u1 E* P/ J% c
tion site, this testosterone transfer was prevented.
0 E& t0 c6 P* D( `2 p5 W  b3 N" X5 WOur patient’s testosterone level was 60 ng/mL,
6 Y; z' G/ X" X: e! ]which was clearly high. Some studies suggest that( S, x9 }4 M6 T5 J6 D) F3 n
dermal conversion of testosterone to dihydrotestos-6 B6 ]. B" b+ T4 K3 g+ R- S( R
terone, which is a more potent metabolite, is more2 ?& b" y0 T3 u/ F/ M
active in young children exposed to testosterone
' p( M9 Y6 ]! c, J8 U$ T: fexogenously7; however, we did not measure a dihy-
  A% f/ Z5 J- Q- ?+ _# cdrotestosterone level in our patient. In addition to
: x4 u& s, _7 A) f, C+ n6 wvirilization, exposure to exogenous testosterone in3 Q" p0 m# Y5 w! s
children results in an increase in growth velocity and5 p+ v2 k* _3 G% P( U/ u5 a; W
advanced bone age, as seen in our patient.* C6 @- L5 \+ D4 I' K
The long-term effect of androgen exposure during4 s. F" C, s$ n8 i0 P2 Q$ P$ F% [
early childhood on pubertal development and final
$ b! A/ Z+ h, u: g: w$ Cadult height are not fully known and always remain# @  L; m: i/ J. z# I
a concern. Children treated with short-term testos-
$ C& l; @1 c: x; w0 \- `terone injection or topical androgen may exhibit some
4 k' K- a8 v' H2 r1 Vacceleration of the skeletal maturation; however, after
" y4 V" \; P% \. ]' p* h( Fcessation of treatment, the rate of bone maturation  A( W. a5 N$ B: q" j2 v) e
decelerates and gradually returns to normal.8,9
9 {5 f& ^$ N, h+ WThere are conflicting reports and controversy% H7 M2 b) o9 K& }# Z; `
over the effect of early androgen exposure on adult
3 L  v7 s+ Q! ]7 Q+ S* l# {penile length.10,11 Some reports suggest subnormal
- F0 ^5 ]  B& C% t3 q' ]' ]+ N: ?, Wadult penile length, apparently because of downreg-) }0 r; a# x3 m! z% \- H5 a  N: d# X; l4 n
ulation of androgen receptor number.10,12 However,
5 q  r+ h& U; }5 h0 mSutherland et al13 did not find a correlation between
; L5 l  y. V( O  k6 {childhood testosterone exposure and reduced adult7 q8 U( ^3 `! ^9 m+ v1 ?
penile length in clinical studies.) X6 b/ ]% S0 X
Nonetheless, we do not believe our patient is+ D0 Y: Q. n, z9 S" s( |0 c5 x( n
going to experience any of the untoward effects from, S1 W0 r/ ]- F2 R. k  E7 j+ x4 k& V
testosterone exposure as mentioned earlier because
# x6 Z% D- _. ~" p2 b+ othe exposure was not for a prolonged period of time.2 T2 B6 A0 b, E& _- n& j# Z4 s
Although the bone age was advanced at the time of5 S( ]! g! w( J, ~3 w* v4 d+ |# w1 j
diagnosis, the child had a normal growth velocity at
9 D4 T' x3 e/ t* U7 pthe follow-up visit. It is hoped that his final adult" l7 I5 R1 w/ v6 D: E% i" M* c
height will not be affected.5 K+ b/ V" F6 I; j, a6 l* W& @8 j6 _3 n
Although rarely reported, the widespread avail-
$ R- I0 {* r  q3 q7 U+ y; Y' wability of androgen products in our society may' a$ k, S  l6 b0 e4 I
indeed cause more virilization in male or female0 g3 y/ a- N1 f0 m% N7 k- @
children than one would realize. Exposure to andro-0 @3 [# |, J  Y6 c' t
gen products must be considered and specific ques-$ ?/ e) C0 a/ |5 Y
tioning about the use of a testosterone product or. K: ?, [3 ?: D! ?: S
gel should be asked of the family members during5 h* |! ~3 ~9 q" w3 x0 Z9 c
the evaluation of any children who present with vir-
9 X9 d6 I2 Q+ F1 J' d" e: r% Rilization or peripheral precocious puberty. The diag-8 h& @: G% [3 _; R" [1 T% l
nosis can be established by just a few tests and by. g8 B* W- [1 t# ?' Y' j
appropriate history. The inability to obtain such a" h, E6 E; U+ V' h# A) H
history, or failure to ask the specific questions, may
  F  i& R7 U6 Q2 `result in extensive, unnecessary, and expensive
2 J- f; z1 Z0 p. |/ ~/ y& binvestigation. The primary care physician should be
& `2 s; v7 J6 A- Zaware of this fact, because most of these children
. V+ a& R: V! }0 ?; ^( Tmay initially present in their practice. The Physicians’
6 G1 k& {0 s+ N' dDesk Reference and package insert should also put a  z& k3 W, f: B( h# Q7 E$ Y+ O6 k
warning about the virilizing effect on a male or+ M/ k4 V7 _9 m8 J& M! i) H: A
female child who might come in contact with some-
5 R. P5 k2 t$ ~one using any of these products.
! w& \! `" m6 M0 XReferences
! C5 E! `$ Q4 s) x0 |% I" _1. Styne DM. The testes: disorder of sexual differentiation! \) Y3 w" S3 t9 K
and puberty in the male. In: Sperling MA, ed. Pediatric
# ^( X9 A; Z7 ]  A: [% |# m9 q$ mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 H/ U" L5 B* X2002: 565-628.
1 R% }+ d5 h3 `/ p' A: \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- c$ n6 w- h7 S7 W2 V
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
0 M" c5 I, v6 B9 N, g( PBoy Induced by Indirect Topical( l( c% h8 @( j, ~  S
Exposure to Testosterone
5 A& |, {* d5 _" h7 p' a- {( tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& Q/ ^5 T5 `2 H" F
and Kenneth R. Rettig, MD1* k: d  ], _+ t; L4 d3 S
Clinical Pediatrics
. D9 T2 T0 m4 S2 tVolume 46 Number 6( y# [% L( S8 I) {. C5 i
July 2007 540-543
" w" z7 ?7 G0 U8 n2 D* `© 2007 Sage Publications4 p2 `: i7 r) J* e0 q5 p
10.1177/0009922806296651( _  [  _" T9 W4 C* ?- E: A5 ^
http://clp.sagepub.com
; x& `$ U* `8 z2 Yhosted at( u8 p' \4 b5 ?8 Y
http://online.sagepub.com
- i1 E) _8 _  n8 }Precocious puberty in boys, central or peripheral,
4 O0 R1 z3 u0 X# a0 h" g9 R+ @is a significant concern for physicians. Central* m" v; c8 n7 Y9 `: d* M: c, B
precocious puberty (CPP), which is mediated4 _* T1 S, y9 f: g3 ~) i+ g) x" s
through the hypothalamic pituitary gonadal axis, has! J/ V/ d) c. `' ?
a higher incidence of organic central nervous system5 P. f$ r; S) ^, o, A$ x9 _6 R" n
lesions in boys.1,2 Virilization in boys, as manifested- K' D+ s+ o5 P4 L+ |
by enlargement of the penis, development of pubic
. ^+ i3 d) O# C* Whair, and facial acne without enlargement of testi-4 l9 y) e5 m/ c$ N1 Q: [
cles, suggests peripheral or pseudopuberty.1-3 We! I; K1 W' v6 _0 b
report a 16-month-old boy who presented with the
/ Q/ d* t& S( C1 |% Genlargement of the phallus and pubic hair develop-
# q1 M. P9 w) ^( Qment without testicular enlargement, which was due
8 @- i, l+ L; h- Dto the unintentional exposure to androgen gel used by
. t% A- t# m5 r/ o$ L! w) K5 rthe father. The family initially concealed this infor-2 o& L( x) a* E5 K3 R
mation, resulting in an extensive work-up for this
4 ~7 g9 T. d, j9 v4 D, ochild. Given the widespread and easy availability of$ U! ~  b8 c! Q" v" k- [" [& d' J
testosterone gel and cream, we believe this is proba-
3 @7 M5 W3 J6 L: n6 `8 ^bly more common than the rare case report in the
' T! a6 L- D4 A5 sliterature.4
; Z4 N& M# Z" LPatient Report* k  Q4 E0 D  ^. l
A 16-month-old white child was referred to the0 u! ]. N  C9 O% O
endocrine clinic by his pediatrician with the concern
$ a0 l0 \3 D4 o& |4 Mof early sexual development. His mother noticed
7 w% N( h; O. i+ alight colored pubic hair development when he was3 V3 q3 q# W( p
From the 1Division of Pediatric Endocrinology, 2University of
4 z; ]1 |) D; J8 u+ SSouth Alabama Medical Center, Mobile, Alabama.1 E- r" M6 m$ P! N& I5 Y2 S$ J* ]
Address correspondence to: Samar K. Bhowmick, MD, FACE,! @! c) C5 }# ]( q! j6 N
Professor of Pediatrics, University of South Alabama, College of) O4 q8 {- o- S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 t  U& I' z$ X4 k! m* de-mail: [email protected].
1 M6 f( q/ o% ]about 6 to 7 months old, which progressively became! r( |% o6 }0 e+ b
darker. She was also concerned about the enlarge-
' M! X# W5 @" e( o: J! c  Qment of his penis and frequent erections. The child
+ R+ _+ {4 W# |+ c+ cwas the product of a full-term normal delivery, with# `7 y- L* B9 Q6 I, T/ l
a birth weight of 7 lb 14 oz, and birth length of7 A3 _# U* W2 x4 E
20 inches. He was breast-fed throughout the first year7 Q4 d" S, i# x$ F7 j2 Y
of life and was still receiving breast milk along with
& i6 h; k/ ]% X4 G1 msolid food. He had no hospitalizations or surgery,
# a  f7 A( e# W3 `( M! Aand his psychosocial and psychomotor development
) x" k' N5 u; E1 l7 l! ?was age appropriate.8 A7 C9 u( r; `4 x$ W% \
The family history was remarkable for the father,8 `7 a+ t1 P+ x! ^0 C8 ^: ~  [
who was diagnosed with hypothyroidism at age 16,
2 X; A% r  {! b. \which was treated with thyroxine. The father’s/ j0 o# h$ `/ K& b* W+ W9 d
height was 6 feet, and he went through a somewhat+ u; z  ~( m, m  k$ L( X; y
early puberty and had stopped growing by age 14.
, L. R& V% j% a# o, C; [5 FThe father denied taking any other medication. The  P: r% b! c, w7 z; u, G
child’s mother was in good health. Her menarche$ @7 f' l8 X& E1 I9 \$ E- ]/ S# [
was at 11 years of age, and her height was at 5 feet) ]0 @6 N; a* |3 Y" G  L
5 inches. There was no other family history of pre-
( Y, {/ b/ h$ s& M3 Y# z3 tcocious sexual development in the first-degree rela-6 T$ M  F" K0 T) ~2 d
tives. There were no siblings.* Q# j: a) p1 y( L
Physical Examination
3 l/ G5 O/ G  d+ x5 n4 VThe physical examination revealed a very active,
2 d+ L5 X6 R) y% ?% Jplayful, and healthy boy. The vital signs documented! u5 ?: E& `) ~  y# h1 N
a blood pressure of 85/50 mm Hg, his length was
3 U/ V: X1 x0 p( ~% U" e90 cm (>97th percentile), and his weight was 14.4 kg$ J$ r+ T( l; |
(also >97th percentile). The observed yearly growth  d9 d  A. f) j# M6 q8 A2 A( C* M
velocity was 30 cm (12 inches). The examination of
. ^. X, Z+ E% ~" r; l" K9 |5 xthe neck revealed no thyroid enlargement.  |2 S, j. u5 f; k
The genitourinary examination was remarkable for+ X/ Q: h) R) M# z0 h1 t! h
enlargement of the penis, with a stretched length of
$ a8 f$ `1 x; ], t' c9 D8 cm and a width of 2 cm. The glans penis was very well
7 o: i; \$ E, h" p! Hdeveloped. The pubic hair was Tanner II, mostly around
4 B& {+ v7 h) x2 X540
* H, G0 ~- ^( G* Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& _# c- f1 h4 v, l
the base of the phallus and was dark and curled. The
# X$ ]& Q# L4 ?; h6 |1 |$ itesticular volume was prepubertal at 2 mL each.
, O7 c' O" i- E1 Z* p) l8 lThe skin was moist and smooth and somewhat. Q0 b% L) \, E% c7 W% e4 x
oily. No axillary hair was noted. There were no6 f+ M) U/ S. @* H- ~
abnormal skin pigmentations or café-au-lait spots.
  ^: c9 l, {3 H1 D3 c4 mNeurologic evaluation showed deep tendon reflex 2+
+ u8 x$ A8 `. m7 |: A! `: d$ ybilateral and symmetrical. There was no suggestion
- t  P1 w0 {% w, c8 Z3 gof papilledema.+ y7 j, K! G/ X( \4 y' k
Laboratory Evaluation8 `: J1 n! W5 t- W8 P* {( j  |
The bone age was consistent with 28 months by
4 s9 d. v3 g: G' A; h: Ousing the standard of Greulich and Pyle at a chrono-. }8 O; B; d' k; f6 ^% x
logic age of 16 months (advanced).5 Chromosomal. m, X( T' i( a# K
karyotype was 46XY. The thyroid function test/ w+ j7 ~2 p" Z2 t( M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 h" d# i8 ~0 q8 [4 zlating hormone level was 1.3 µIU/mL (both normal).
( Z& V! w' u; p4 f! dThe concentrations of serum electrolytes, blood
7 U& u! d" `* m: W2 q, k( lurea nitrogen, creatinine, and calcium all were
9 n; a" s; ]. t0 n4 k% dwithin normal range for his age. The concentration
5 W3 t! O( t( Q6 X- R1 Kof serum 17-hydroxyprogesterone was 16 ng/dL- r, b) m+ \7 n- Y) |# H4 W
(normal, 3 to 90 ng/dL), androstenedione was 20  ?  _9 n5 Q$ m" Z, x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 K" t( U4 D/ g* rterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ t, ]/ C7 O8 a3 r  {5 s( U( Q$ }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) B' r5 j$ [. d4 J8 w% V49ng/dL), 11-desoxycortisol (specific compound S)
  q2 ^& H& b2 s4 F7 c/ |* Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# M3 X. a" s# w& o( ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ x# l+ {9 e# Z4 z% G8 u$ ?: N/ |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& @" F* k. ]5 T- jand β-human chorionic gonadotropin was less than
1 j  ], K1 R( q% i; k) g5 mIU/mL (normal <5 mIU/mL). Serum follicular( N$ A: {  c6 c3 \, f' ]" P
stimulating hormone and leuteinizing hormone* o( y8 Z! [# b/ I/ a; u5 C
concentrations were less than 0.05 mIU/mL
! u9 I# `# R' d9 j# [# ]/ Z(prepubertal).* s  K( \$ |6 E. A9 y
The parents were notified about the laboratory6 d& q: f" d0 |$ B# t" j7 a& k6 {
results and were informed that all of the tests were5 n' q* ~. i8 S5 _. d
normal except the testosterone level was high. The) A2 {0 h7 O' H
follow-up visit was arranged within a few weeks to
7 G, u0 w  \# a; y7 P2 c5 J+ Tobtain testicular and abdominal sonograms; how-
6 |6 @* D5 c. X  {ever, the family did not return for 4 months.
6 z6 M! G" N& K1 I; H1 v# C! FPhysical examination at this time revealed that the
: I0 i1 l" W8 K7 kchild had grown 2.5 cm in 4 months and had gained; P. @5 y: o$ G. N
2 kg of weight. Physical examination remained
7 |2 L9 U2 u% a3 {2 y* f, V& Dunchanged. Surprisingly, the pubic hair almost com-
( w4 I- e6 r6 |! R& g) ~' fpletely disappeared except for a few vellous hairs at* ^0 d+ v* A1 K8 D5 o
the base of the phallus. Testicular volume was still 2# j3 B( S: E8 O6 |! B% C
mL, and the size of the penis remained unchanged.
4 J( H2 C. ^2 _5 vThe mother also said that the boy was no longer hav-
% e( m7 ]( X% L5 H5 M" C/ Q" S+ Iing frequent erections.5 g. C  l) `3 I/ Q. w
Both parents were again questioned about use of  v) G+ ^1 o' M: J. N' q
any ointment/creams that they may have applied to# w2 p8 \- {8 d0 Z6 }7 K6 Y, }
the child’s skin. This time the father admitted the
9 z% O+ G* A6 M! v9 I9 Q/ ]Topical Testosterone Exposure / Bhowmick et al 5412 O, h: K: e. J3 q7 t+ Q1 k
use of testosterone gel twice daily that he was apply-
# [& V, k  N! E) Q- |! iing over his own shoulders, chest, and back area for
3 s& K# |2 t' e5 Y) ka year. The father also revealed he was embarrassed
$ \  \  G% P" R- w& Dto disclose that he was using a testosterone gel pre-
2 E0 W, I/ c  E$ f( Fscribed by his family physician for decreased libido
% a4 C6 B1 a" x% ]7 Asecondary to depression.  ^2 y, b; {1 x1 f' |/ a
The child slept in the same bed with parents.
5 l0 X4 B2 _1 S" fThe father would hug the baby and hold him on his) t3 O( S$ D. u
chest for a considerable period of time, causing sig-/ `7 R! T3 o& o! E
nificant bare skin contact between baby and father.
+ l/ }* b8 [% E" L( rThe father also admitted that after the phone call,
* q4 Z  F( r$ @7 u) \8 Qwhen he learned the testosterone level in the baby
3 M+ x2 _1 ^# }. y0 G9 ^! M6 y, |was high, he then read the product information. U: Z3 }8 H, i4 m$ z* O
packet and concluded that it was most likely the rea-9 H9 g( O. z( K2 q; l1 Z
son for the child’s virilization. At that time, they4 _* l5 \% l. d
decided to put the baby in a separate bed, and the
9 S. F6 `+ a& k; [father was not hugging him with bare skin and had1 ?, k4 L* R( H* {1 d: e
been using protective clothing. A repeat testosterone
; o5 u, n! A- w; f; Btest was ordered, but the family did not go to the
+ g0 X( b$ P0 N  u% M6 m1 rlaboratory to obtain the test.
7 r" z3 s# G1 n( v, i. p- gDiscussion" |6 p1 `+ ]. o$ w( n% c% z+ d" T" P
Precocious puberty in boys is defined as secondary/ n. U5 }) J+ G' f' ^) f! a" A2 Y8 Y
sexual development before 9 years of age.1,4
5 |4 c/ b4 _1 Y, d% ^  fPrecocious puberty is termed as central (true) when5 d3 [+ y% D  R3 _% b7 S+ \
it is caused by the premature activation of hypo-( Z5 g' x, M' C2 t
thalamic pituitary gonadal axis. CPP is more com-. X) o8 m: Q3 B* W9 i9 z
mon in girls than in boys.1,3 Most boys with CPP
2 o1 c% e1 s/ X9 P2 Q7 d: Zmay have a central nervous system lesion that is5 i/ b, c/ ?5 a8 U  f
responsible for the early activation of the hypothal-
! N: v+ V5 L9 B$ bamic pituitary gonadal axis.1-3 Thus, greater empha-# k' ?0 |' X  z' N3 ?# ]" a- o
sis has been given to neuroradiologic imaging in
% d4 t5 O. \# q( O* \boys with precocious puberty. In addition to viril-
9 A) P0 o& i& |3 j+ d* f  wization, the clinical hallmark of CPP is the symmet-
# Y8 c, o# D# A  j2 Grical testicular growth secondary to stimulation by/ S' K3 P1 c: f  Z! l9 ~
gonadotropins.1,3% e+ i) I5 J8 _! f- v8 H
Gonadotropin-independent peripheral preco-
8 g5 p; D& o- G6 q" x% {# ~: I3 [cious puberty in boys also results from inappropriate
1 ~! r/ K* e- A, S3 y& L2 U4 h' Landrogenic stimulation from either endogenous or) m# {) J2 `0 X+ e* q! S
exogenous sources, nonpituitary gonadotropin stim-
4 a8 P$ o; `% Y( ?! o1 F4 Y. {ulation, and rare activating mutations.3 Virilizing. ]+ D! H& R: L
congenital adrenal hyperplasia producing excessive
( w3 r  E3 O* _! h  q4 H  eadrenal androgens is a common cause of precocious. b/ h1 {7 [! K
puberty in boys.3,4- X9 N/ ^& e; i0 ~' c' _
The most common form of congenital adrenal
, [- C/ Z# q0 a7 s  N* y& Chyperplasia is the 21-hydroxylase enzyme deficiency.  c! p6 @" V7 m8 U: |9 t
The 11-β hydroxylase deficiency may also result in0 T# N7 J: j" _; D  b
excessive adrenal androgen production, and rarely,
9 n: R1 e+ C+ o+ |8 H" ?an adrenal tumor may also cause adrenal androgen5 P: T3 A0 w" h) }: m
excess.1,3
. c& j, v4 M% ^; gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 ^. }+ g% D# \0 C: D5 s1 h) O542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ x  A8 |5 d% p" [% b. E; n
A unique entity of male-limited gonadotropin-3 O: D* ^+ n8 D3 b  @4 ?" v5 D
independent precocious puberty, which is also known
; q/ g3 T7 h7 L' B: x6 fas testotoxicosis, may cause precocious puberty at a
( T7 v( V1 }2 c% y) z. S6 i, Lvery young age. The physical findings in these boys' c/ U: I# Y$ @' Y; |
with this disorder are full pubertal development,
% t) t' }0 R9 W  ?9 qincluding bilateral testicular growth, similar to boys& I" [) Y8 r0 u" |
with CPP. The gonadotropin levels in this disorder
) Q9 t# }; f- Q; a; Kare suppressed to prepubertal levels and do not show
* U9 E0 w, ^( Fpubertal response of gonadotropin after gonadotropin-
# ?% F0 G7 N: i" H- a" Y0 l( Kreleasing hormone stimulation. This is a sex-linked
$ \8 N3 O4 A" i% N4 D# N( I# C3 mautosomal dominant disorder that affects only
- X7 t, C6 A1 K! n; _, Imales; therefore, other male members of the family: E7 ~2 r1 z+ T8 V9 k' ~
may have similar precocious puberty.3% N3 M. n: n3 U1 ?4 ?2 G
In our patient, physical examination was incon-) H( ^3 R& Y- m( M) x
sistent with true precocious puberty since his testi-8 a: r6 u, i8 i$ Y. ^" g
cles were prepubertal in size. However, testotoxicosis
! N5 h1 M; M( L2 ^' {was in the differential diagnosis because his father/ Y- v7 {" O' {0 V
started puberty somewhat early, and occasionally,
3 Z+ t; ]. u* q& Xtesticular enlargement is not that evident in the
9 d; b" D) f: ~& \. q/ r  q0 Y, y/ Pbeginning of this process.1 In the absence of a neg-
1 m6 D! e" c  Gative initial history of androgen exposure, our
+ U' l3 p* B! g) _9 O1 \: Obiggest concern was virilizing adrenal hyperplasia,; N9 V$ S" E: ?
either 21-hydroxylase deficiency or 11-β hydroxylase
8 \. k$ n( x4 Wdeficiency. Those diagnoses were excluded by find-
' @6 O- {' ]/ [. M4 V' ~( j# xing the normal level of adrenal steroids.: a4 b) c; j! F5 b+ P9 u# ]- {
The diagnosis of exogenous androgens was strongly4 v& `" `7 `3 L& p1 |' A2 y
suspected in a follow-up visit after 4 months because
' A8 B8 s6 b5 \, a* [  rthe physical examination revealed the complete disap-
3 Q6 M0 ~4 m* Y! \: Z  dpearance of pubic hair, normal growth velocity, and
1 t' `& ]- X+ k/ G' \0 J. }decreased erections. The father admitted using a testos-
2 \5 V+ [5 }; J) Qterone gel, which he concealed at first visit. He was
9 E5 ]/ q5 l( F1 J, y! [: [using it rather frequently, twice a day. The Physicians’
' s8 L* y; t, l5 B6 H& Y- U: fDesk Reference, or package insert of this product, gel or- A) @/ b$ \$ l8 o; H
cream, cautions about dermal testosterone transfer to+ [7 O3 c* ~9 n3 i0 G
unprotected females through direct skin exposure.8 Q2 i' T4 Y8 b
Serum testosterone level was found to be 2 times the
( Y/ z1 o" v* q, @& Qbaseline value in those females who were exposed to7 h0 Q  G, P6 K- M- b: p
even 15 minutes of direct skin contact with their male
% p1 h0 p5 n1 Wpartners.6 However, when a shirt covered the applica-
% I1 u0 t& e, ^0 i' \% a6 wtion site, this testosterone transfer was prevented.) o" }% p) [" M. l
Our patient’s testosterone level was 60 ng/mL,: u% q9 E7 ~/ e+ i' P: S8 w  y
which was clearly high. Some studies suggest that: M: h  K6 C; V& m
dermal conversion of testosterone to dihydrotestos-* G& A! W* c4 U
terone, which is a more potent metabolite, is more
8 u/ s( k, s4 a. ^, g6 @$ c$ }active in young children exposed to testosterone4 o8 d9 b6 ?; H  Y7 R* Y
exogenously7; however, we did not measure a dihy-# ~! V8 _. h8 R( z
drotestosterone level in our patient. In addition to1 y& R0 ?; u5 i$ a0 i) [
virilization, exposure to exogenous testosterone in
% e& g9 V. W: o  ^. P# H% z) P8 vchildren results in an increase in growth velocity and+ ~7 D2 \% m6 H. C0 T0 ?. A' n+ F4 D
advanced bone age, as seen in our patient.
  t% o3 z+ O, `/ I. f' H# o$ s6 H4 OThe long-term effect of androgen exposure during
; N  b$ G7 |$ G5 v' }: a- Bearly childhood on pubertal development and final
$ c4 T' O* c1 V3 S7 wadult height are not fully known and always remain) r, v' ?/ q/ \( ]
a concern. Children treated with short-term testos-' V- X( X2 G; A2 `: _# Z
terone injection or topical androgen may exhibit some
) |  m; K  g' N$ w3 \acceleration of the skeletal maturation; however, after: B0 _6 V7 \  Z, I
cessation of treatment, the rate of bone maturation
7 I+ ^8 {1 d" A2 }- f5 ?* p/ Fdecelerates and gradually returns to normal.8,9
. x3 f4 ^; ~0 W3 T: `1 k! u/ j( iThere are conflicting reports and controversy
, x  f6 a" V, l2 F7 Y1 U9 mover the effect of early androgen exposure on adult
+ L$ c! t; _. N" e0 p6 i  I, ?penile length.10,11 Some reports suggest subnormal
5 `- l* K+ Y' R. cadult penile length, apparently because of downreg-
1 e* m! p0 T, S0 J5 p$ m, b; x) Mulation of androgen receptor number.10,12 However,
* z! G) }* S, f& s5 j/ xSutherland et al13 did not find a correlation between9 T" N- h6 k" m; |. ]. `% G6 C1 }
childhood testosterone exposure and reduced adult
8 M1 a% E$ }' w% T; M+ A" ]. I+ Ppenile length in clinical studies.0 k$ n0 ]3 R' X
Nonetheless, we do not believe our patient is
4 ], u. d* q- v4 l) egoing to experience any of the untoward effects from
+ k- A1 B# x6 R) }0 ^+ e4 xtestosterone exposure as mentioned earlier because
! F2 Z# J  }2 T5 L8 Cthe exposure was not for a prolonged period of time.( a, f" b- L4 `9 Q4 P) X0 W
Although the bone age was advanced at the time of
; V& _9 j  _$ X8 B5 |diagnosis, the child had a normal growth velocity at. G$ a% T% v, }( U4 M* |
the follow-up visit. It is hoped that his final adult
) [, `# [, }, dheight will not be affected.
: x9 H/ D2 R% Y. ~4 i0 OAlthough rarely reported, the widespread avail-
# w& ?" g6 {) H6 E: a* \9 ]ability of androgen products in our society may* J9 Y' A1 _8 w8 u; T$ s) i5 C
indeed cause more virilization in male or female  Z/ l9 O5 T' e1 [$ K2 w9 e
children than one would realize. Exposure to andro-4 p1 N+ L  A4 ]  \3 \4 a
gen products must be considered and specific ques-. m: Y2 c" _+ `8 W7 ~; J
tioning about the use of a testosterone product or% U8 q0 S+ i+ m! D" @5 t
gel should be asked of the family members during- c* }# l$ v% J2 |
the evaluation of any children who present with vir-
% N" V7 K: t% k8 }ilization or peripheral precocious puberty. The diag-
9 w7 }4 h1 _* S* t4 L9 vnosis can be established by just a few tests and by% V2 m, ^2 l& F
appropriate history. The inability to obtain such a7 T) \' m" S% _4 b; k9 r5 E+ H
history, or failure to ask the specific questions, may2 a6 M$ x/ G5 b. ]" H+ F/ r; x) z2 I
result in extensive, unnecessary, and expensive  x% u* r- U- q& j- i' ?& Z
investigation. The primary care physician should be9 J1 B. ]+ Z  E4 f5 F! T0 l
aware of this fact, because most of these children- q/ a5 B9 A5 d2 h- M5 w4 r
may initially present in their practice. The Physicians’
5 ~" _1 G+ Y/ G- f, G4 Y) |Desk Reference and package insert should also put a
! ]  Z' I( `# z* Vwarning about the virilizing effect on a male or
0 g1 n/ M6 @6 G9 m; v0 l' Cfemale child who might come in contact with some-" B8 k* {. v/ S0 V* _( B, a8 r$ @( W
one using any of these products.
1 l& L" `. [- Z5 F6 zReferences  p# P& @$ K4 D! N2 k' `, x. a
1. Styne DM. The testes: disorder of sexual differentiation3 r, `8 V: Y/ f; G; F  X
and puberty in the male. In: Sperling MA, ed. Pediatric
0 b5 X0 D8 Y5 q" SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# h+ p$ ^- s# Z1 L7 K2002: 565-628.
( @( I* s/ _& x7 a& d$ {) |# g2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. S& p7 E1 }# w6 {% u
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
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精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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