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Sexual Precocity in a 16-Month-Old3 x! G. r3 v9 [  ]4 s0 V& `, _
Boy Induced by Indirect Topical; N5 \2 k9 ~, |" Y
Exposure to Testosterone( g; w6 R( p0 w* C% ]+ `
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' V( I1 N) G. E+ m, ]2 |and Kenneth R. Rettig, MD1' c9 E8 I7 }% X
Clinical Pediatrics" T" r; U  v! B
Volume 46 Number 6
* L5 Z. H* w  _5 Z+ d% EJuly 2007 540-5434 n& \' I5 E8 z8 [/ {
© 2007 Sage Publications( k% y, c' I% K4 X
10.1177/0009922806296651) w& s% i: f/ P# u  t2 x+ `2 r
http://clp.sagepub.com
2 g- D5 w2 \' S; Y% C4 V. ]$ K" Zhosted at  ~$ z: v9 H9 s0 z* C* g
http://online.sagepub.com
0 v  O, S5 s* W. |& N. IPrecocious puberty in boys, central or peripheral,, `7 b/ B/ y' V) `6 K, n; N
is a significant concern for physicians. Central& k1 b( l9 {: b
precocious puberty (CPP), which is mediated% z+ J* _: o7 ~2 i; b8 Z% N) D
through the hypothalamic pituitary gonadal axis, has
* m4 c0 X& M7 w; ~* ~! ca higher incidence of organic central nervous system# z9 c1 m" F! U' p" H$ V. C3 ^
lesions in boys.1,2 Virilization in boys, as manifested
6 M1 c) t; `- q  y9 k( m& F+ [" P+ G2 qby enlargement of the penis, development of pubic! s, q$ {* G  B& N+ K+ S% R
hair, and facial acne without enlargement of testi-4 F5 ]0 _' _+ _: S, @
cles, suggests peripheral or pseudopuberty.1-3 We
9 R( n" H, C! K( o$ yreport a 16-month-old boy who presented with the
  ^  J" K- a( K( u+ o9 x& Kenlargement of the phallus and pubic hair develop-
# n$ [0 V& T" v$ y+ Zment without testicular enlargement, which was due6 S  g* D. z! R- ?- h$ e! Z& x
to the unintentional exposure to androgen gel used by! p* H3 m0 B9 h0 Z4 r& Y8 r
the father. The family initially concealed this infor-. k. \1 }/ L3 J' g& N
mation, resulting in an extensive work-up for this, N4 p$ v. B7 D8 U
child. Given the widespread and easy availability of# H. h$ }- b  q% A" \: T0 z2 \
testosterone gel and cream, we believe this is proba-
: j+ ^; r0 W2 r, d: _! W& p! ~7 Sbly more common than the rare case report in the& N0 H8 j+ r8 o
literature.4
+ z# h7 \' m: e' gPatient Report
$ z* o- }" h  m' v& zA 16-month-old white child was referred to the' _! _8 {: _/ }3 m5 |& l
endocrine clinic by his pediatrician with the concern
5 Q# D8 P5 s! M4 T; N6 [of early sexual development. His mother noticed1 i4 f! O+ u. {$ _, u/ V
light colored pubic hair development when he was
$ r7 v# {7 \/ e5 ^From the 1Division of Pediatric Endocrinology, 2University of# K( r- {9 S" B% H1 }
South Alabama Medical Center, Mobile, Alabama.
5 o7 x2 K( Z% @% c; E% U& p. TAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. a3 K3 ?3 ]& E) k$ XProfessor of Pediatrics, University of South Alabama, College of+ E0 c1 S8 h6 ^- d% y+ L& d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ q2 H' H0 c2 {3 ^  a, y, s7 K
e-mail: [email protected].
6 x% m9 X$ h6 `. ^8 f: F2 X4 uabout 6 to 7 months old, which progressively became+ X+ ^* [( b8 d' g! d
darker. She was also concerned about the enlarge-' p5 N9 P7 l* u! {
ment of his penis and frequent erections. The child0 d4 e% F6 u5 M* G$ X
was the product of a full-term normal delivery, with
7 }' |# P: M1 O' Y: Z- T- u  W% Za birth weight of 7 lb 14 oz, and birth length of
3 S, O, u" E8 r4 @( u20 inches. He was breast-fed throughout the first year% D' b5 z: C$ t- s
of life and was still receiving breast milk along with
+ I+ i) U2 j/ A7 N" M/ Tsolid food. He had no hospitalizations or surgery,
' h0 K/ U) J7 D  a: X/ Mand his psychosocial and psychomotor development
3 U- J5 x1 {, w+ _was age appropriate.
' n( F% q3 D( j8 q9 g8 W6 w7 WThe family history was remarkable for the father,
/ y: e9 x+ e# ?# M" Q$ ~6 u( Awho was diagnosed with hypothyroidism at age 16,
! Y: @/ g" s5 j9 e8 Vwhich was treated with thyroxine. The father’s7 }+ ?& W! `  M6 W2 u2 e$ F/ C
height was 6 feet, and he went through a somewhat
8 Q3 Y- r, z, O* Hearly puberty and had stopped growing by age 14.
- a, l- ]& e( _# `9 ?9 x% Q! xThe father denied taking any other medication. The
1 L' p, }* p* w, Q0 g0 bchild’s mother was in good health. Her menarche. k: @5 f& I& F8 w: e7 F/ ^8 k% v  Z
was at 11 years of age, and her height was at 5 feet
# e: R+ ?/ u! n5 z; l5 inches. There was no other family history of pre-
, J4 Y! H% ]# q5 Jcocious sexual development in the first-degree rela-, ]. K) E" U* i) w* t+ d
tives. There were no siblings.' u" v% _$ n2 L" [
Physical Examination
9 x' g/ O: }: f1 l. j" h5 _  N1 h" WThe physical examination revealed a very active,
% q0 r. H. v- ~$ f+ f" Splayful, and healthy boy. The vital signs documented2 }) C: t, e' j: Z
a blood pressure of 85/50 mm Hg, his length was! h9 f& ^/ b: c8 z" c
90 cm (>97th percentile), and his weight was 14.4 kg& L; g3 e  `0 f- r; F& ^& O* }
(also >97th percentile). The observed yearly growth
8 h# a! G% Z4 ^+ O1 ?+ N, ^) d1 Ovelocity was 30 cm (12 inches). The examination of$ _/ C; Y3 H" \: o5 e4 h
the neck revealed no thyroid enlargement.3 F  K: n/ E: o5 ]; Z, C
The genitourinary examination was remarkable for- U4 a: R3 S+ l
enlargement of the penis, with a stretched length of- [) O$ k2 D+ J3 \. h* l
8 cm and a width of 2 cm. The glans penis was very well
8 r' Q% o& l! w$ i5 [; mdeveloped. The pubic hair was Tanner II, mostly around/ l( }# z( t& Z& b) l- N6 M
540
( g, y: G3 \4 f4 _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 Q; H0 v' L1 a( N
the base of the phallus and was dark and curled. The
% o9 f( j: L+ e3 D9 i0 gtesticular volume was prepubertal at 2 mL each.
- T* n3 O: m& I/ UThe skin was moist and smooth and somewhat* |# x; |5 s: v& s+ n4 g
oily. No axillary hair was noted. There were no
: y! t5 M9 _' E9 ~  labnormal skin pigmentations or café-au-lait spots.
0 \: e4 N! w) d8 ONeurologic evaluation showed deep tendon reflex 2+. ?- K; n% g9 `' b9 R! U- k0 o
bilateral and symmetrical. There was no suggestion" M4 B3 s6 h$ r
of papilledema.
( R7 R& }% \1 D& M& n4 YLaboratory Evaluation. J9 O! j9 q6 d# t9 {
The bone age was consistent with 28 months by, f# V1 m9 R* l, B! h) @2 u
using the standard of Greulich and Pyle at a chrono-
6 `, b! r* ^" ^! ~2 q: Zlogic age of 16 months (advanced).5 Chromosomal9 y0 O  n7 K: N  {9 b4 w' S
karyotype was 46XY. The thyroid function test- L% ~. z" p) ~. [! d) Q& Z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 ~+ i7 D8 `! W% H9 R( ?lating hormone level was 1.3 µIU/mL (both normal).8 X2 ~9 \. F' x! u/ ~4 A
The concentrations of serum electrolytes, blood
+ G: ~5 \9 x+ S1 Y5 burea nitrogen, creatinine, and calcium all were+ v: _, z/ r$ k( r6 k! c
within normal range for his age. The concentration
$ ^1 Q0 _8 }- _* `  w6 |" `of serum 17-hydroxyprogesterone was 16 ng/dL7 ]+ M4 s) x$ Z8 v2 U( p
(normal, 3 to 90 ng/dL), androstenedione was 204 n1 L% U6 a& m1 ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 g; k8 V( C& A( r9 @/ b, w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ ~5 `9 K* h8 x2 }. D. mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( P1 V" Z( C5 b1 P; s3 x) [  y49ng/dL), 11-desoxycortisol (specific compound S)
: g  \/ L" T9 C% bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, I( i$ e/ G/ k# I) E* S0 o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 T, M( C# t& z- M0 jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; z' E# Y( w7 K% M8 Cand β-human chorionic gonadotropin was less than9 q% O( C- F7 _' E# b8 ^9 d! X, B6 l
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 Z6 U' c4 a. ?
stimulating hormone and leuteinizing hormone
* ^2 V, P, \3 Q' S1 Zconcentrations were less than 0.05 mIU/mL
! T, K6 F% p* \* P( G7 k% ^* s(prepubertal).
8 O  {. Q8 H8 J+ }3 {The parents were notified about the laboratory' P, Q2 B$ m6 y5 m' L
results and were informed that all of the tests were, Y- P8 S$ W0 g9 p+ N
normal except the testosterone level was high. The: b; ]* s4 a8 k1 z- s5 L6 w  q
follow-up visit was arranged within a few weeks to% |- e! q! O/ q4 p3 g
obtain testicular and abdominal sonograms; how-* L% ]/ B' }$ }
ever, the family did not return for 4 months.8 h8 g; N- i' H6 F; }% }1 o8 n4 y
Physical examination at this time revealed that the
8 ^5 T2 d. }2 y9 A2 rchild had grown 2.5 cm in 4 months and had gained) r# d1 q" p" N$ k5 P4 c$ h
2 kg of weight. Physical examination remained
/ u4 B6 p; x7 e# j  k3 runchanged. Surprisingly, the pubic hair almost com-
, L8 G  F5 O# `6 M3 Dpletely disappeared except for a few vellous hairs at
* j, p& H# {, l* c, F: \2 ~the base of the phallus. Testicular volume was still 2
* @/ L7 I! X+ q" x2 F* R% MmL, and the size of the penis remained unchanged.
- l: y3 G. A0 ?4 XThe mother also said that the boy was no longer hav-3 U* H) `* I' A$ g3 H) O6 y: N, s
ing frequent erections.
% M3 L2 {8 I# L* nBoth parents were again questioned about use of0 i/ ]' b: U  M  n
any ointment/creams that they may have applied to
- C% H* R9 r8 t7 ?* Gthe child’s skin. This time the father admitted the
* B2 Q, a: Z7 O+ z1 dTopical Testosterone Exposure / Bhowmick et al 541
- V; N6 p$ K2 Luse of testosterone gel twice daily that he was apply-4 V' K+ i+ K5 b( e2 l
ing over his own shoulders, chest, and back area for
  _4 O: L9 ^* _+ y& `  }a year. The father also revealed he was embarrassed
3 `- B/ v0 l. X, ]- F, Oto disclose that he was using a testosterone gel pre-; U1 d3 P& N" c" p' P0 T
scribed by his family physician for decreased libido
4 u( @& Y  k9 |, n2 r; ?secondary to depression.! ]) G1 O; W9 k; G1 v  @
The child slept in the same bed with parents.
7 C) h) t1 g7 l' @( ]% VThe father would hug the baby and hold him on his
1 s. u; q4 K3 a# L8 A/ ]chest for a considerable period of time, causing sig-
) q. ~7 ~$ L% x& Q- n+ @nificant bare skin contact between baby and father.
8 `. @' t0 f- y7 U* xThe father also admitted that after the phone call,8 [. w6 X2 w# [; J5 O% T2 X8 B& Z: R
when he learned the testosterone level in the baby# h4 ~( L9 r' ^; C- Y6 F6 H
was high, he then read the product information
; w) @0 R  `+ S! Apacket and concluded that it was most likely the rea-
! y& _, z7 A$ G8 g4 w# p3 yson for the child’s virilization. At that time, they
+ a1 l& h/ l; e6 udecided to put the baby in a separate bed, and the- x; c! S: K4 x1 y  u+ V
father was not hugging him with bare skin and had
  \8 u8 x1 V- tbeen using protective clothing. A repeat testosterone& O: U" K0 \% p! g
test was ordered, but the family did not go to the
3 U0 F6 S; f/ d  K/ Slaboratory to obtain the test.
/ f# `; {0 K: N2 C1 ?4 n* n7 G% UDiscussion
2 C$ _' A$ v+ q9 p5 IPrecocious puberty in boys is defined as secondary
; O* ]1 @4 }) Bsexual development before 9 years of age.1,4# w4 d- s( E- f. t% B7 h
Precocious puberty is termed as central (true) when
; Q3 U4 Y- i0 q7 q9 M* D: {% E4 Tit is caused by the premature activation of hypo-" z4 A% _6 P; l  I: l8 [( U7 ?. Z$ [, L
thalamic pituitary gonadal axis. CPP is more com-
, e- `  ?1 ]4 M) i* c6 Amon in girls than in boys.1,3 Most boys with CPP
* \) e$ Z" V; K& h5 \$ t% jmay have a central nervous system lesion that is
- x; s3 h% k$ ~+ U7 ]8 cresponsible for the early activation of the hypothal-  N4 I) w& f/ R' Q# u& ?4 ?
amic pituitary gonadal axis.1-3 Thus, greater empha-
- @' _6 a* [9 tsis has been given to neuroradiologic imaging in
% ^1 E# t* \/ Vboys with precocious puberty. In addition to viril-
# h! s; I+ {1 ]5 K2 S4 H8 l* Sization, the clinical hallmark of CPP is the symmet-
% O- E2 K6 @: |0 arical testicular growth secondary to stimulation by$ N: p" v+ b& m
gonadotropins.1,3# L. b; G' w1 M
Gonadotropin-independent peripheral preco-. }; l" y# S6 ]. a0 x! W" Z& s
cious puberty in boys also results from inappropriate9 Z+ ^8 j$ w) O" J
androgenic stimulation from either endogenous or
, C" Z7 h" E9 u& {5 l: ^) ~. Iexogenous sources, nonpituitary gonadotropin stim-
- b0 e, x8 r& e" D: a3 y7 ?# Xulation, and rare activating mutations.3 Virilizing- h6 ?# c8 Q" b2 K( K
congenital adrenal hyperplasia producing excessive0 S6 u. ^8 x" U% z7 m
adrenal androgens is a common cause of precocious* G( V9 ?% L$ B% m
puberty in boys.3,4
4 f" U, k9 W7 H/ NThe most common form of congenital adrenal
+ G& x& A0 C  B' ~4 l9 s4 phyperplasia is the 21-hydroxylase enzyme deficiency.4 r6 ]5 t  k+ Q+ C  z% U4 s1 s
The 11-β hydroxylase deficiency may also result in8 r( I4 y! y* j9 F5 l6 i
excessive adrenal androgen production, and rarely,
# g# Y6 g, Y; I% O2 G3 Q" m0 Aan adrenal tumor may also cause adrenal androgen( h1 k+ Q% G/ p2 _5 I. i% T
excess.1,3. H% n- o7 E4 G  K3 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- V! }* B1 S! O% N; y$ R: Q! R4 K  j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ [: a+ C- B) o0 B% m6 r. wA unique entity of male-limited gonadotropin-
+ Y' D9 `0 F7 a7 K  r+ ?independent precocious puberty, which is also known
1 x6 t5 O9 h0 X, t3 P# `as testotoxicosis, may cause precocious puberty at a
& y/ y- P& y$ C  Wvery young age. The physical findings in these boys9 }9 Q+ {1 z+ e( R/ |
with this disorder are full pubertal development,
7 Q, R5 R% t8 j4 C3 n' X8 Eincluding bilateral testicular growth, similar to boys, ]! L; e" T& k4 [# K1 S0 y1 P
with CPP. The gonadotropin levels in this disorder
5 S/ V+ c2 u$ e! p: |9 _; }5 iare suppressed to prepubertal levels and do not show
1 J( `! U6 N0 N" T  Wpubertal response of gonadotropin after gonadotropin-
6 W# n9 y* H' m) Xreleasing hormone stimulation. This is a sex-linked
' _, Y8 l, ^8 [, k2 P/ j7 M7 _: _' ?autosomal dominant disorder that affects only
2 t3 E, z- c, a+ Fmales; therefore, other male members of the family& m- Q3 Q) }$ L! z2 y- U/ D
may have similar precocious puberty.3
7 N+ i; h! z$ R; PIn our patient, physical examination was incon-# [2 {: z9 e, w
sistent with true precocious puberty since his testi-. v, z9 t* k0 {; b
cles were prepubertal in size. However, testotoxicosis3 B! n+ M1 L) U: L" z
was in the differential diagnosis because his father
7 Z1 X& v3 p( estarted puberty somewhat early, and occasionally,2 g% L" B  @; G8 ~5 L: }
testicular enlargement is not that evident in the) o% c, F0 F) H1 |5 E
beginning of this process.1 In the absence of a neg-. S$ R1 i6 b) O: x2 r0 W
ative initial history of androgen exposure, our9 b9 _1 q. O- x6 k
biggest concern was virilizing adrenal hyperplasia,
% ~9 L+ I: ]: J; e2 T! N  Peither 21-hydroxylase deficiency or 11-β hydroxylase
7 u: e5 k# N8 `3 |4 x- s' ~deficiency. Those diagnoses were excluded by find-2 d7 `! R$ \3 }6 @
ing the normal level of adrenal steroids.# }+ l0 {( v& A9 l4 j- n) Q* B
The diagnosis of exogenous androgens was strongly
) }7 O* y1 M) k' h) _+ q# V2 Fsuspected in a follow-up visit after 4 months because- k( `) ~0 ~/ q7 g- s( V
the physical examination revealed the complete disap-
9 X$ s/ m; S9 K3 L7 p8 n0 h3 {pearance of pubic hair, normal growth velocity, and
% f" Q4 _6 ~- p6 ~/ s7 ydecreased erections. The father admitted using a testos-
$ y  n: }2 A# V: ^7 p  Y4 h: qterone gel, which he concealed at first visit. He was
4 W! c; D  I. f8 Husing it rather frequently, twice a day. The Physicians’# j" \: z, P) Q7 F) {% w! f) o
Desk Reference, or package insert of this product, gel or
4 y+ g% q( z, B" I& g* icream, cautions about dermal testosterone transfer to
4 f" n- _+ V1 ounprotected females through direct skin exposure.
# m* K' m' X7 b0 ISerum testosterone level was found to be 2 times the+ Y2 d7 |5 q: \9 u  h1 H0 w
baseline value in those females who were exposed to; P2 J! A5 b/ x9 p/ D# e+ n- H
even 15 minutes of direct skin contact with their male. j+ B- P2 C% |/ m) ?
partners.6 However, when a shirt covered the applica-
% ?, \& m/ f' V! N! ^1 z9 p3 z6 f) Z' ?tion site, this testosterone transfer was prevented.$ R8 c  F! L  ?8 C
Our patient’s testosterone level was 60 ng/mL,
2 Z0 Z: l) H" L& {) R. S8 m  H' @: @3 Mwhich was clearly high. Some studies suggest that
6 x0 ^: y0 h3 u# Vdermal conversion of testosterone to dihydrotestos-/ ^0 r3 T9 h; h0 d8 z4 u
terone, which is a more potent metabolite, is more
) f1 i' T, K. Zactive in young children exposed to testosterone
. A4 m6 Y) ]7 j' v& oexogenously7; however, we did not measure a dihy-
+ B3 u" b4 r; }* {4 N7 F! A* tdrotestosterone level in our patient. In addition to% n4 F$ f/ Z* [4 ~# w" r
virilization, exposure to exogenous testosterone in
/ v0 E$ z: e0 H0 t3 b2 b& E5 zchildren results in an increase in growth velocity and( G5 X7 r% L. U4 |' f" r! {
advanced bone age, as seen in our patient.. y6 \- c" m" Q  O, n
The long-term effect of androgen exposure during
( W6 \+ o0 m5 b8 }. s; \; C) {early childhood on pubertal development and final0 t' m+ L2 t$ \( t* H3 s  B" E
adult height are not fully known and always remain! F; y. O' t3 l+ }- T) e
a concern. Children treated with short-term testos-
" ]; y) }/ {2 X4 C0 A, cterone injection or topical androgen may exhibit some0 A% e5 u: w6 s# y
acceleration of the skeletal maturation; however, after
. |: {4 R! i4 U8 z0 [% ocessation of treatment, the rate of bone maturation6 B% i/ c) M" u1 o* e: e
decelerates and gradually returns to normal.8,9
8 h9 x( U1 Q& I9 ?7 M. QThere are conflicting reports and controversy8 H! _% W/ N' t0 m, @: b. Z
over the effect of early androgen exposure on adult
0 j# U9 Y1 N& u9 L( w; E, E' }  Z5 Lpenile length.10,11 Some reports suggest subnormal
- r4 J% A2 r2 m( r6 ?. t# Madult penile length, apparently because of downreg-" Y7 p/ K# i% ]1 A2 ~) n% D8 e: N
ulation of androgen receptor number.10,12 However,
; w; U2 W& Q. G+ sSutherland et al13 did not find a correlation between
# z9 v; Q% h, o5 ^" I5 `childhood testosterone exposure and reduced adult/ c: y6 g; w2 H
penile length in clinical studies.
# Y4 z1 \0 n3 y0 h7 ~3 G2 `/ FNonetheless, we do not believe our patient is; a4 K( b  o: c2 {
going to experience any of the untoward effects from
: w4 _9 E7 P" q' U6 B0 T2 Btestosterone exposure as mentioned earlier because
; _* u! x2 C$ e- {# J7 bthe exposure was not for a prolonged period of time.8 L8 e" ^7 a4 a2 v% H# R3 J* S
Although the bone age was advanced at the time of
+ }4 f2 }- M* {- Y' Wdiagnosis, the child had a normal growth velocity at8 R8 u+ P& ^  D' P1 b
the follow-up visit. It is hoped that his final adult
7 S9 E' V' L9 }. u' C( l- theight will not be affected.
/ I6 e/ E, G- t* W8 z; u$ PAlthough rarely reported, the widespread avail-
7 ^/ t2 }) w2 }+ d) pability of androgen products in our society may8 `" y" X7 ~, F" D6 {2 \7 @
indeed cause more virilization in male or female
& q* D1 q+ M4 g7 N! L" }children than one would realize. Exposure to andro-
! c: `1 @& D. e" H3 tgen products must be considered and specific ques-
8 H# _, l* A- ?) H4 g2 a9 Htioning about the use of a testosterone product or: c, i: X1 f( Y9 Q
gel should be asked of the family members during5 |- |  Q3 N- H; `
the evaluation of any children who present with vir-7 N6 \3 r7 }' U4 e: j
ilization or peripheral precocious puberty. The diag-; c* i7 C6 J. p! D/ O. ?, ]
nosis can be established by just a few tests and by
- L7 |; M' V7 G% O: f2 bappropriate history. The inability to obtain such a
& s) j* h5 }) R! khistory, or failure to ask the specific questions, may( _$ i9 M# [# b' U
result in extensive, unnecessary, and expensive
/ x2 C, c$ x, n; @$ M) jinvestigation. The primary care physician should be
3 \; e( j; j% Y' Q4 B- Yaware of this fact, because most of these children2 M- Q2 S. v) ^6 X
may initially present in their practice. The Physicians’
" ^' t( |4 c& ?; G- t/ YDesk Reference and package insert should also put a! e, M! N4 W( W7 e$ U
warning about the virilizing effect on a male or
+ L5 i5 G& Q: x4 u3 U& J5 P' gfemale child who might come in contact with some-
# r% ?  @# Z1 _8 I# Y3 Zone using any of these products.
# h& T, T, {+ S7 f5 IReferences
) r0 c" Q, s! I1. Styne DM. The testes: disorder of sexual differentiation0 P) Q* F7 U  t
and puberty in the male. In: Sperling MA, ed. Pediatric7 L$ O/ W7 w* ^) [# a) v
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& B% O' E/ S0 S2002: 565-628.
6 @% |1 L" [4 _8 s" L, `: y8 `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 c% P3 h5 z( @8 ~' Upuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 q8 m0 N# Q8 }% ?
Boy Induced by Indirect Topical$ \3 K" l' K) M* g3 a8 g7 Y
Exposure to Testosterone4 _0 ^* [$ N, J: d3 b3 l( n+ m
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( }  c& A, u% X3 `
and Kenneth R. Rettig, MD1
5 ~7 \7 V* c, uClinical Pediatrics9 g9 ]) \9 W4 F+ ^3 C; H8 y8 G
Volume 46 Number 6
& P3 n) }  y! O% YJuly 2007 540-543, D, z/ M. S  f1 O5 R; `
© 2007 Sage Publications# z6 n! @4 Y8 Q4 u8 _
10.1177/00099228062966513 L1 i5 x( B0 K, H& x: m. {
http://clp.sagepub.com
  z& t8 Y5 b* M+ chosted at- ^7 L/ M3 D1 ^, L- @3 y- x/ x! f4 m
http://online.sagepub.com
- ?, m& {. b+ bPrecocious puberty in boys, central or peripheral,
+ u3 ]# r* V- A- r7 zis a significant concern for physicians. Central
, U" f8 E/ R* X: Z! Tprecocious puberty (CPP), which is mediated
" {6 [" {: ^& u: M. Cthrough the hypothalamic pituitary gonadal axis, has( Y- @( S5 j0 ~1 E3 K7 h
a higher incidence of organic central nervous system
1 ~8 m8 n, ~* G: i& H- v$ N% `# clesions in boys.1,2 Virilization in boys, as manifested
# b4 q" T' }- N0 v+ c6 jby enlargement of the penis, development of pubic; H. H( X4 t2 l& X( t
hair, and facial acne without enlargement of testi-
% M# a! I2 ~1 G% ycles, suggests peripheral or pseudopuberty.1-3 We6 D6 }" a% q- g
report a 16-month-old boy who presented with the
9 P6 ]2 `4 F$ `# R1 D" `/ \1 menlargement of the phallus and pubic hair develop-
% u) q8 x. Z$ m5 S' S8 X' z' ^ment without testicular enlargement, which was due  {% }1 }5 g8 U6 G* z0 `
to the unintentional exposure to androgen gel used by
# }, h1 S2 Y# Q4 \7 `the father. The family initially concealed this infor-
# ^$ }* F% S) b1 f( tmation, resulting in an extensive work-up for this
. d" E- W0 d6 n: c! Y/ V5 Ochild. Given the widespread and easy availability of
2 {) k' ]: u" a; s. D  ttestosterone gel and cream, we believe this is proba-9 G2 i7 q0 @& Q
bly more common than the rare case report in the1 M  e4 e" {+ S7 R; |7 ^
literature.46 y; M4 p! Q% a! `5 u" n
Patient Report# W& X2 o& G3 d4 V$ C6 f
A 16-month-old white child was referred to the* f( Z' w/ ?4 m# j4 H
endocrine clinic by his pediatrician with the concern
* r9 ^8 e+ I. L2 Q' ~of early sexual development. His mother noticed. W& X  q4 I( ?1 n
light colored pubic hair development when he was
& `: k, ]" Z1 ]( o* o7 H3 tFrom the 1Division of Pediatric Endocrinology, 2University of
/ v  t4 S7 C1 [& I0 B( QSouth Alabama Medical Center, Mobile, Alabama.7 V) C2 s* j0 Q" g% w. ?
Address correspondence to: Samar K. Bhowmick, MD, FACE," t* v9 c- d( E7 D% {
Professor of Pediatrics, University of South Alabama, College of
' v4 g8 p0 @$ W, L7 Y/ sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 k7 w$ a0 W. z( ye-mail: [email protected].
$ |8 ?# D! I8 D* H; w. F7 s1 k3 pabout 6 to 7 months old, which progressively became
1 u# s4 ?/ L, j* E$ G1 x5 ~9 F7 R3 x% _darker. She was also concerned about the enlarge-6 q* M6 W2 p7 [0 @/ c7 s' V
ment of his penis and frequent erections. The child
9 D9 Q* j' N% E9 S! Cwas the product of a full-term normal delivery, with' h2 p$ G* I" W( `
a birth weight of 7 lb 14 oz, and birth length of
- w- H- ]5 D, O20 inches. He was breast-fed throughout the first year
" c" P1 d  V6 F! ~of life and was still receiving breast milk along with
7 W: w" U' V2 m4 f! g4 y! fsolid food. He had no hospitalizations or surgery,
& b% z. }' G( l  c( D0 ~and his psychosocial and psychomotor development) Z9 r( s7 G  l" R: \. l3 a
was age appropriate.
0 U5 h$ V& J. RThe family history was remarkable for the father,
# {( q- r) H' F% ~" M( N/ o7 Nwho was diagnosed with hypothyroidism at age 16,% S+ S7 c4 v* V% M* A
which was treated with thyroxine. The father’s2 y6 Q3 f& C. e1 j) a
height was 6 feet, and he went through a somewhat% z) s4 S7 H" [% E5 p: @4 T
early puberty and had stopped growing by age 14.
7 I. u" I& ^: I+ y7 l9 RThe father denied taking any other medication. The
4 n! D& F0 p# K5 Z" K, o$ ichild’s mother was in good health. Her menarche) m% F. w2 ^; m! d4 H
was at 11 years of age, and her height was at 5 feet9 [8 s7 C4 ]0 M' D
5 inches. There was no other family history of pre-
1 n. B. S; V6 F- y; H- Vcocious sexual development in the first-degree rela-
: F$ J6 _* D1 x  E# r  L) X* \; I9 d6 m7 vtives. There were no siblings.
! R* ~6 h/ c7 c  x5 f6 vPhysical Examination
- S; e' A7 |; Q" u- x, t! kThe physical examination revealed a very active,9 _2 x$ G4 x; `6 F+ v
playful, and healthy boy. The vital signs documented
5 \( A, H+ s5 p% U6 Xa blood pressure of 85/50 mm Hg, his length was6 D, T. p; }! F+ s' W  N; t
90 cm (>97th percentile), and his weight was 14.4 kg
, d& |3 b' a1 a# _8 B(also >97th percentile). The observed yearly growth1 u8 v0 {" S& D. b7 [1 m) U
velocity was 30 cm (12 inches). The examination of
% A  j( M5 B! l! D3 O$ ^0 }the neck revealed no thyroid enlargement.7 d8 q) C# D/ L2 d8 ?( p, p8 v
The genitourinary examination was remarkable for
! {9 v6 v$ D# u4 g5 E# Menlargement of the penis, with a stretched length of
! f" P) b4 X/ u4 }# K, f8 cm and a width of 2 cm. The glans penis was very well- f9 E/ @2 |5 q7 V/ p& T9 M
developed. The pubic hair was Tanner II, mostly around
: T! c# e# o, ?& h- G3 q540
2 _9 _, x) s& @8 F! G9 N' Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 w1 {. ^/ [. qthe base of the phallus and was dark and curled. The" }/ l" z! g& `
testicular volume was prepubertal at 2 mL each.
7 i  V3 p! O; ?" Z. _8 m5 NThe skin was moist and smooth and somewhat! X$ g8 q' N0 l
oily. No axillary hair was noted. There were no
  c4 z) X8 {: s5 Sabnormal skin pigmentations or café-au-lait spots.
9 D4 w3 J2 o& A2 Q8 g( UNeurologic evaluation showed deep tendon reflex 2+) s1 T1 }; r) E0 _
bilateral and symmetrical. There was no suggestion
  V' j% }; e* @8 z; oof papilledema.
6 W$ X0 a: L3 D. p0 T2 w2 BLaboratory Evaluation& S' o: s* M5 x+ _' \8 x8 y: }
The bone age was consistent with 28 months by8 b: F% F$ v0 V
using the standard of Greulich and Pyle at a chrono-
) f$ I+ i+ v- w% c4 G9 u+ `; n1 `logic age of 16 months (advanced).5 Chromosomal
7 w. {4 x( ~! v# T& E: s, X6 ]karyotype was 46XY. The thyroid function test
, D7 {  w' Z0 w4 g5 _& H9 A8 ?# qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 [7 |" {! V) y3 [$ A$ i% A. dlating hormone level was 1.3 µIU/mL (both normal).
3 q' i4 o9 ?! ~! E$ pThe concentrations of serum electrolytes, blood: N6 [! H$ d3 b# E( X' @9 f2 D
urea nitrogen, creatinine, and calcium all were
+ ]) a4 K2 L! `within normal range for his age. The concentration) W) M5 c; X7 Z
of serum 17-hydroxyprogesterone was 16 ng/dL  C% v9 G) ~/ i, x1 P. }- c2 v
(normal, 3 to 90 ng/dL), androstenedione was 20
: J& K  Z6 b9 {4 X; E( c! X& J+ fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* J2 ?8 @" {. X! Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 _8 c( K" j4 r1 ]$ }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 @7 u" d( Q; s) l
49ng/dL), 11-desoxycortisol (specific compound S)2 n2 Q  T' e. t. [& x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( m+ A6 H: Q4 f9 C  k  K7 G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 w: k) V1 e( l, m7 Q7 m5 }+ F& Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ a6 }0 A2 b2 S* z+ z; t* ?and β-human chorionic gonadotropin was less than
$ X9 ?% }8 s9 J5 h. ~- F5 mIU/mL (normal <5 mIU/mL). Serum follicular" p7 ~$ T' n; K" G/ o+ t7 W* n
stimulating hormone and leuteinizing hormone
8 {$ X) g0 T1 @concentrations were less than 0.05 mIU/mL
! w, w# H4 h2 @/ h. a7 H" `3 Y2 D(prepubertal).7 q4 h9 y7 n+ M* v5 m1 [' s4 \
The parents were notified about the laboratory
" F: r( h$ b0 T) G- B. u/ Cresults and were informed that all of the tests were( S! i0 O' A5 t7 X1 W. q! Q
normal except the testosterone level was high. The
# L0 Y$ H4 b. Z" D1 a" \+ o- W2 Q6 {follow-up visit was arranged within a few weeks to
9 z0 {/ Z* Z  i2 `$ T0 Q" ]obtain testicular and abdominal sonograms; how-
- S: q/ y! P+ G" ^0 w% C5 i& C' pever, the family did not return for 4 months.' _/ G7 u! c3 L. O, k0 J4 {. `
Physical examination at this time revealed that the
5 e+ Q! E: x7 M1 s$ X% A4 Dchild had grown 2.5 cm in 4 months and had gained
& e) C* d; q: E8 r% r, ?4 @3 r0 x9 v$ ^2 kg of weight. Physical examination remained
" K9 m+ a9 y; p: zunchanged. Surprisingly, the pubic hair almost com-
  v* J/ _! D* M( u/ `pletely disappeared except for a few vellous hairs at- D" [5 W0 x( \( s$ \$ r# K
the base of the phallus. Testicular volume was still 2
* S" c: ^0 ~) D$ S; EmL, and the size of the penis remained unchanged.
6 k5 k) d% V2 F: G$ yThe mother also said that the boy was no longer hav-
' V+ L; P" f+ c  ^- ning frequent erections.
  C8 j: c. K; q+ V( GBoth parents were again questioned about use of' e9 t/ l9 i  ?
any ointment/creams that they may have applied to1 k: L/ l% j- ?
the child’s skin. This time the father admitted the
7 e8 t) y2 s$ L8 k! p" d. ?Topical Testosterone Exposure / Bhowmick et al 541% B6 n. C$ A, r
use of testosterone gel twice daily that he was apply-
% o1 h! N+ W0 N: m" {- ~  y+ sing over his own shoulders, chest, and back area for) L2 g; E  Q) l( s9 F- y
a year. The father also revealed he was embarrassed
% o5 ]  A; Y6 y" s* K; f, b; Hto disclose that he was using a testosterone gel pre-
& W) F0 [1 [, `, K$ u: bscribed by his family physician for decreased libido
1 c' q- ~: _/ P* k+ Z+ }/ t& o3 L6 Esecondary to depression.
0 C( @. l, J  w% g) |' d0 F# BThe child slept in the same bed with parents.
( `+ o9 _+ T# Z" Y8 M: I0 u! @The father would hug the baby and hold him on his
7 [0 }+ \/ B6 h, c5 [7 P; T& |chest for a considerable period of time, causing sig-
2 J" f7 R( ^/ L+ a& c7 Lnificant bare skin contact between baby and father.2 y' k+ O) `" k: _/ {! i: u
The father also admitted that after the phone call,0 l0 ~- c6 F" _" ?4 S) s  ^; e
when he learned the testosterone level in the baby
1 ?1 o- m& b9 N$ Z' U! a* Dwas high, he then read the product information
# Y( A( o$ D: z; R( f* upacket and concluded that it was most likely the rea-
2 P+ K' X8 O: b8 t8 p. gson for the child’s virilization. At that time, they
0 S% I" m+ e5 x" `5 l2 Gdecided to put the baby in a separate bed, and the: J5 P5 [6 I$ g6 R  ~' ~4 s
father was not hugging him with bare skin and had7 b7 Q% ^3 W" C4 U( P. Q  w
been using protective clothing. A repeat testosterone
8 S7 K% p2 f6 I; l$ itest was ordered, but the family did not go to the5 ?# b: Z* z0 Z
laboratory to obtain the test.
  P( n; F2 [( d" {Discussion
- X  z  A. \, n4 w# ]Precocious puberty in boys is defined as secondary1 J  `3 M( X2 ~: X
sexual development before 9 years of age.1,4
3 l8 r# S# d# r: E, w; e) mPrecocious puberty is termed as central (true) when
$ t9 k  `5 X- o8 p0 sit is caused by the premature activation of hypo-
: h# N6 o6 n% }3 m& A# Xthalamic pituitary gonadal axis. CPP is more com-
5 M' A/ u9 z  x4 q1 nmon in girls than in boys.1,3 Most boys with CPP
% C6 m9 [' V9 ^% c! amay have a central nervous system lesion that is. I- y4 x: U6 _3 E5 T" s
responsible for the early activation of the hypothal-5 r! z' ?4 [. x( a; I+ z5 u9 }: q6 \
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ K0 b9 o& o5 E# e) _) _sis has been given to neuroradiologic imaging in. Y7 F% P4 t- o2 h9 t3 A
boys with precocious puberty. In addition to viril-2 h3 T5 ~9 R* K0 b; E2 t
ization, the clinical hallmark of CPP is the symmet-! g, o% _* K' q0 |: x" _
rical testicular growth secondary to stimulation by
5 z& H: m( T8 I4 v1 pgonadotropins.1,3( _% J; N9 k' T; ^' f2 r2 T7 W4 E
Gonadotropin-independent peripheral preco-
: J  G  ]1 U. o+ Ecious puberty in boys also results from inappropriate  F$ b0 \- F9 E9 C* J
androgenic stimulation from either endogenous or. u& T; e5 _; d$ H5 `' D
exogenous sources, nonpituitary gonadotropin stim-: `. Y( h9 e, v6 O- u4 K& `/ M
ulation, and rare activating mutations.3 Virilizing) b7 k* F/ d  }7 K( y
congenital adrenal hyperplasia producing excessive
' l3 S$ ]( M% \3 I0 Q" }adrenal androgens is a common cause of precocious
' H" Y7 h* {3 u, A6 Npuberty in boys.3,41 N5 I% S8 J6 }; S+ e* {2 f
The most common form of congenital adrenal0 [- m. y! K4 i( H4 Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ V2 z* p) P1 m7 ^3 F: m! PThe 11-β hydroxylase deficiency may also result in
8 c8 ^! H: f% n/ @% `4 mexcessive adrenal androgen production, and rarely,0 s7 g% ^8 r' P0 M  K
an adrenal tumor may also cause adrenal androgen
! n! V2 c4 _- H- S* Kexcess.1,3
3 o, n9 i: x# x* Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 c' t" Y- y: u1 i( n- O+ o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# h4 }, S: D# O# V4 ]% lA unique entity of male-limited gonadotropin-3 J8 C6 N& c& A! G, _* F7 \; f) @
independent precocious puberty, which is also known
* u" z' }8 c, k/ B& N% was testotoxicosis, may cause precocious puberty at a
% [# z, M% g9 ?: K  K& [! E( Xvery young age. The physical findings in these boys
6 o; Z1 ?; Q9 k1 Z1 f  mwith this disorder are full pubertal development,6 {7 g6 R; V+ y; s. [# B
including bilateral testicular growth, similar to boys8 H- ], k1 f7 u7 o
with CPP. The gonadotropin levels in this disorder
" a8 x" p4 G7 P* s8 lare suppressed to prepubertal levels and do not show$ n4 V% C: M% `- c$ `2 r, w5 |
pubertal response of gonadotropin after gonadotropin-
* |" B5 J8 g5 M6 q& W2 {; Areleasing hormone stimulation. This is a sex-linked/ Q1 s1 ]1 A; J5 p+ d4 R5 _: c
autosomal dominant disorder that affects only
& z, X4 W7 E% }  ?/ O7 O% g, W0 k0 wmales; therefore, other male members of the family
  F8 e9 A7 O1 G, T* bmay have similar precocious puberty.32 T  e1 ^5 Z) M% p2 h6 P' w( Q
In our patient, physical examination was incon-0 r. u, p2 f& R$ p
sistent with true precocious puberty since his testi-
% f& r4 v- O" S* E6 v) R* @cles were prepubertal in size. However, testotoxicosis3 X$ t, S+ m6 s5 q
was in the differential diagnosis because his father- k: ]; i0 A8 |) y# z2 _  F9 |
started puberty somewhat early, and occasionally,3 Z( E: o$ h- G+ k* Q
testicular enlargement is not that evident in the* m: H9 ], L3 b* G
beginning of this process.1 In the absence of a neg-+ k4 I2 {  C6 \3 _6 R
ative initial history of androgen exposure, our
. _0 r% J% R! p$ Gbiggest concern was virilizing adrenal hyperplasia,
/ a7 r( E  ]) B+ H! E( zeither 21-hydroxylase deficiency or 11-β hydroxylase1 V; a7 _0 a' k# V! q# j; L8 o' c
deficiency. Those diagnoses were excluded by find-
9 M$ U9 C2 t! ling the normal level of adrenal steroids.
, Z& C$ g0 h& W$ wThe diagnosis of exogenous androgens was strongly& A. W3 ?6 e: E+ a+ E7 T2 L; q
suspected in a follow-up visit after 4 months because3 h  W! q# c+ a: I" C
the physical examination revealed the complete disap-
/ m' h8 ^+ w5 F& o" q2 A5 |1 _pearance of pubic hair, normal growth velocity, and
+ p- `, q; n7 [6 E) Adecreased erections. The father admitted using a testos-
! z8 P- f& W3 H2 r9 p+ Wterone gel, which he concealed at first visit. He was5 ]0 M* z$ S5 c9 U- t
using it rather frequently, twice a day. The Physicians’2 t, V! k- P; E+ B1 _5 O) |, q
Desk Reference, or package insert of this product, gel or
1 `4 |) l* z" p' e7 s" |cream, cautions about dermal testosterone transfer to
2 i, y8 w( }4 dunprotected females through direct skin exposure.% p0 K8 ]1 k: h* e6 W. Y  E
Serum testosterone level was found to be 2 times the- S) K  P1 f) ]% A% [! |
baseline value in those females who were exposed to# C& H0 v0 _% B
even 15 minutes of direct skin contact with their male( s; [& c6 v, V7 A
partners.6 However, when a shirt covered the applica-
8 G. L9 v' v2 r. j% D1 r2 gtion site, this testosterone transfer was prevented.5 V2 R8 |+ U+ P* v
Our patient’s testosterone level was 60 ng/mL,6 {# Z4 |2 x) e1 W
which was clearly high. Some studies suggest that9 u: A& R; K8 ?6 w# @  X. ^0 b
dermal conversion of testosterone to dihydrotestos-4 k! z& N. k1 j' x+ E" j
terone, which is a more potent metabolite, is more( l5 j* ^, c8 {$ r" Q! l
active in young children exposed to testosterone: h( O4 I% F1 Z! p/ j, ~9 s
exogenously7; however, we did not measure a dihy-
3 I  T0 C) |: D& S3 J; n8 cdrotestosterone level in our patient. In addition to
% m' S8 m. Q# N4 ovirilization, exposure to exogenous testosterone in
$ x" P) ~- q1 Z% Xchildren results in an increase in growth velocity and, y: a0 M; F- b( C$ V0 T
advanced bone age, as seen in our patient.& N/ o0 K' k% L7 h
The long-term effect of androgen exposure during* p! d/ R3 V6 e- Z7 |. d
early childhood on pubertal development and final
9 m7 O6 d* E; B. badult height are not fully known and always remain
9 @5 }1 ?+ C* o9 m" @0 @# sa concern. Children treated with short-term testos-3 V3 ~; C7 f1 q/ b
terone injection or topical androgen may exhibit some
0 D3 T+ q' W3 z6 {acceleration of the skeletal maturation; however, after6 f1 h. ]- G3 [# K7 K
cessation of treatment, the rate of bone maturation
  D  |, c. `5 a: `: ldecelerates and gradually returns to normal.8,9
0 q" v; ]" ]: p" Z; JThere are conflicting reports and controversy
. J# ~, t. }, l# X5 p5 ^* \over the effect of early androgen exposure on adult8 ?; U, p0 L1 j; g8 Y" e" {0 G5 N
penile length.10,11 Some reports suggest subnormal$ B% p5 O" U/ e: ~' j9 X& L
adult penile length, apparently because of downreg-' D3 ?& v6 K9 j4 T: |) E( l: U2 k! D
ulation of androgen receptor number.10,12 However,/ f, ~3 R8 ?) R/ h: i3 ~& k
Sutherland et al13 did not find a correlation between
- F, D. @, E: K( ^childhood testosterone exposure and reduced adult6 i+ F, B0 u+ W5 r5 R& @+ i" h# O( n
penile length in clinical studies.$ n/ a3 q' u7 R9 \4 J8 u
Nonetheless, we do not believe our patient is
2 z1 F# w: f. p1 G% {+ hgoing to experience any of the untoward effects from
* p. z; T6 U- d6 ltestosterone exposure as mentioned earlier because( V8 U4 T& U' |3 t7 D+ x
the exposure was not for a prolonged period of time.% z. [. K0 y( P) Q( N, X3 M
Although the bone age was advanced at the time of" R4 c2 m. @3 A1 T
diagnosis, the child had a normal growth velocity at4 o8 B4 ~2 E0 i& r' F
the follow-up visit. It is hoped that his final adult
  r  P; `7 \5 ^" zheight will not be affected.
( h% n) C, ?0 d0 C# pAlthough rarely reported, the widespread avail-; c3 p. f0 F3 R/ s7 s2 N
ability of androgen products in our society may
7 p5 h" |$ F7 R9 f+ Kindeed cause more virilization in male or female  C. z8 t; m* K
children than one would realize. Exposure to andro-! u, ]& p2 U" M
gen products must be considered and specific ques-' y8 ?# t( e, j# f+ x. N
tioning about the use of a testosterone product or
# G& {1 ?7 p- Y+ I( z3 F+ }gel should be asked of the family members during3 N0 I9 D: I7 d4 ~1 j& x
the evaluation of any children who present with vir-4 P+ `7 {. `8 }1 U# H; h
ilization or peripheral precocious puberty. The diag-
9 o* V7 R& _" X1 }# S7 p2 _' X0 ~nosis can be established by just a few tests and by+ f% i. ^# M8 X$ c3 z6 Z; K4 |
appropriate history. The inability to obtain such a3 t6 C* R4 Z) |/ b
history, or failure to ask the specific questions, may
; q, T, h" R% ]8 Gresult in extensive, unnecessary, and expensive
: n5 T1 Q: Z! z1 k' I; J  \investigation. The primary care physician should be; B* ^3 {4 u' H& d! ?, O# |8 B
aware of this fact, because most of these children# v9 H$ N: C  \% w5 n4 Q9 k, p
may initially present in their practice. The Physicians’
6 n3 Y. g# z( O  C7 Q0 {Desk Reference and package insert should also put a
, p* ~8 y7 v; D  Y9 Zwarning about the virilizing effect on a male or
$ P( Z0 p4 ?+ Vfemale child who might come in contact with some-/ G! r3 Y5 s8 a6 M0 a
one using any of these products.
" @" a+ [; `* |7 K. Y0 c+ wReferences  C( y1 _8 _) h2 D5 c
1. Styne DM. The testes: disorder of sexual differentiation" h4 U  j: ?* _4 [4 z
and puberty in the male. In: Sperling MA, ed. Pediatric1 |0 F( r2 K5 u
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 X& W- t# q6 W9 `( L1 Y2002: 565-628./ N% o: ]6 N. H& S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# t6 Z8 K! `; spuberty 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

* g0 B3 {2 o. i& V4 ~, k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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