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Sexual Precocity in a 16-Month-Old
5 j) A. t( k2 P% N) DBoy Induced by Indirect Topical
6 b3 V# x& {8 u; y0 \5 h+ ^Exposure to Testosterone
  J0 v) v6 l' _; j: C4 f/ X8 s) RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( ^6 V% T' N$ S9 @) ^and Kenneth R. Rettig, MD1
; i" J' Z/ I& J2 L9 |( p+ K5 rClinical Pediatrics2 A' T) z! w* {) |5 c5 g
Volume 46 Number 6
% d2 V) U& G, f$ ]6 XJuly 2007 540-543
/ r& E4 ]7 p& o0 c' q* {2 _  D© 2007 Sage Publications( Z% r+ I: [+ ?
10.1177/0009922806296651
0 x1 p% w# X8 @# j. Vhttp://clp.sagepub.com
6 l2 i& J" N2 f( ~% ~# {- qhosted at( E& p) O5 {  t- ~1 u
http://online.sagepub.com0 o' e: Y* H) ^' Q+ t  ~2 L
Precocious puberty in boys, central or peripheral,
/ O: t9 }* f. s! o4 D4 E+ d( }is a significant concern for physicians. Central
; e) e8 Q9 P4 ~& @5 jprecocious puberty (CPP), which is mediated
" C# G, b; E! t$ @+ rthrough the hypothalamic pituitary gonadal axis, has. a2 U2 T1 {, e" j/ h' J3 v* v$ }
a higher incidence of organic central nervous system% j+ d. j/ k% `5 C5 N, J. |  c0 s; t" {
lesions in boys.1,2 Virilization in boys, as manifested# I! p% c4 T+ k: P+ n9 c
by enlargement of the penis, development of pubic7 u. {7 ?* W( G2 e+ g  T
hair, and facial acne without enlargement of testi-
: r7 ^+ S4 V! q8 G- Fcles, suggests peripheral or pseudopuberty.1-3 We% d9 y& \, J6 m7 W) w+ I% c
report a 16-month-old boy who presented with the$ l$ C. j4 ~+ X, R3 n- f
enlargement of the phallus and pubic hair develop-
& ?! L  v) j8 f# X/ R. zment without testicular enlargement, which was due
1 F  Q2 \, d/ c0 Vto the unintentional exposure to androgen gel used by: ~; a) W' Z, n/ l; x
the father. The family initially concealed this infor-% i3 ]; C  r( E" N" h/ q
mation, resulting in an extensive work-up for this
/ a) `- w# N, [0 b/ T0 x  Z! ?child. Given the widespread and easy availability of" I) ~9 W' O' P+ W
testosterone gel and cream, we believe this is proba-  T0 y1 ^# [3 d* e! d& p# n5 g" v( n
bly more common than the rare case report in the
$ N$ m0 n' u% }literature.4  y1 T3 l  Q/ h7 ]6 u4 v
Patient Report, T$ U/ w% |1 s5 I
A 16-month-old white child was referred to the
1 |1 R+ |$ V! H  u( L; pendocrine clinic by his pediatrician with the concern
! i6 y$ n+ i+ c7 u& \of early sexual development. His mother noticed$ _5 k* U, ?9 Y% f9 l+ c
light colored pubic hair development when he was
6 B- d4 p' Y# I( G; x" KFrom the 1Division of Pediatric Endocrinology, 2University of
$ h+ ?8 ?2 M5 `: \South Alabama Medical Center, Mobile, Alabama.
6 H& |0 \  ]& S' i- A; C1 @Address correspondence to: Samar K. Bhowmick, MD, FACE,% j8 ?7 r' _( o; r
Professor of Pediatrics, University of South Alabama, College of2 m* _$ \# h' s6 c0 d. U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  @, Q  |4 t& z3 T. f( e8 he-mail: [email protected]./ K$ s( C4 J$ g* `
about 6 to 7 months old, which progressively became
  F- n' ?! Q! x6 edarker. She was also concerned about the enlarge-
/ S; n3 L: ?; ^2 ~# Z' D+ c1 Vment of his penis and frequent erections. The child, T6 k" _7 u" p8 t% h& p) N- U9 x. i
was the product of a full-term normal delivery, with
" a# O- R5 ^! p6 e9 sa birth weight of 7 lb 14 oz, and birth length of
$ q- |$ V" z) p7 X20 inches. He was breast-fed throughout the first year
3 d2 ~9 `* \+ H# d8 ^' e6 nof life and was still receiving breast milk along with3 z% q& R/ Z! {1 z
solid food. He had no hospitalizations or surgery,
* u, W  Z) N( `) h" k& t0 h9 Vand his psychosocial and psychomotor development
$ R2 Q/ u; ~0 Pwas age appropriate.  p4 z- A6 m! K1 N9 P
The family history was remarkable for the father,5 j5 Z  p8 j: O& j
who was diagnosed with hypothyroidism at age 16,+ c! A! s, P! p% h
which was treated with thyroxine. The father’s
; z6 x1 C3 S0 \4 p4 A7 z, mheight was 6 feet, and he went through a somewhat8 R1 B* g' Y) U. Q
early puberty and had stopped growing by age 14.0 Y5 S5 W, ~; x7 W! ^' Y! o7 e* q
The father denied taking any other medication. The
0 U, i6 s% l! B8 X1 @- rchild’s mother was in good health. Her menarche2 L* e2 C, `+ L& X
was at 11 years of age, and her height was at 5 feet
" r& a: b9 t7 W  V% ]4 x/ t1 M& Q5 inches. There was no other family history of pre-
+ a  v; A# K2 r5 ^  u' ncocious sexual development in the first-degree rela-; m. a6 `" t+ ?
tives. There were no siblings.
* ^* b* H; f. s/ S7 r% k; t1 {Physical Examination
$ C* r9 O3 L4 I0 b5 qThe physical examination revealed a very active,
1 W7 g# v% \  O% ]9 Aplayful, and healthy boy. The vital signs documented
& @" U3 ]5 H! k6 F- X' Xa blood pressure of 85/50 mm Hg, his length was: H1 |& Z+ [: P* S/ x# t! i
90 cm (>97th percentile), and his weight was 14.4 kg1 D' Q; Q0 E' l3 x( {4 k* i
(also >97th percentile). The observed yearly growth) Z2 R9 j+ g% D% _# J$ E
velocity was 30 cm (12 inches). The examination of. r/ N/ y& s3 G/ T% N8 _0 h% {0 E
the neck revealed no thyroid enlargement./ Y! z. ^5 D$ @5 M: C- u
The genitourinary examination was remarkable for( }8 d: N" c. L& A# q3 C
enlargement of the penis, with a stretched length of, N- H& ?7 q! X9 L2 C+ N* S' j1 D
8 cm and a width of 2 cm. The glans penis was very well( G, ^' J) y% n1 s9 z* j9 M1 B3 \6 }
developed. The pubic hair was Tanner II, mostly around) l7 I" p" N+ T
540
2 ?8 z* l1 g' X' L+ J+ oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( W  a- @+ Z# W" h2 f5 w1 r$ Q* q9 Uthe base of the phallus and was dark and curled. The0 P! K$ w( \: I- X
testicular volume was prepubertal at 2 mL each.  F' a" D8 @' m$ L3 E# F4 p* M
The skin was moist and smooth and somewhat
& T9 f9 N4 Y' u8 T& J4 {, Ioily. No axillary hair was noted. There were no& r8 d+ q; J3 I
abnormal skin pigmentations or café-au-lait spots.
6 J, Q( T5 Y! yNeurologic evaluation showed deep tendon reflex 2+  }& o7 w+ u0 W9 g+ T7 _) i1 C
bilateral and symmetrical. There was no suggestion! ]9 u6 q% l8 K: c' F
of papilledema.  d3 z" Z$ U/ w& T  p. r
Laboratory Evaluation
) s1 J7 B7 K/ l: U! H6 JThe bone age was consistent with 28 months by
3 `7 N+ q2 G  q( B, j; V" Nusing the standard of Greulich and Pyle at a chrono-! E' \+ |  z0 q0 C
logic age of 16 months (advanced).5 Chromosomal
9 k6 k3 Z% u6 Ekaryotype was 46XY. The thyroid function test
4 T3 b2 f8 @5 ?; L5 p9 jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 h  s0 I9 g! {2 e
lating hormone level was 1.3 µIU/mL (both normal)." B/ X3 \1 H; g9 V  ^4 y
The concentrations of serum electrolytes, blood7 f# w7 x# D, R% X( T3 x8 Z3 }
urea nitrogen, creatinine, and calcium all were
8 |4 i. D* c  h+ Z9 Awithin normal range for his age. The concentration0 F. B* M1 D6 |! G5 w
of serum 17-hydroxyprogesterone was 16 ng/dL' c# E& R, F- N8 w/ Y5 f
(normal, 3 to 90 ng/dL), androstenedione was 20, a) Q7 T* d$ q9 |9 \% ]# K; k
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- J0 j% M0 i# i) o' U& L/ c
terone was 38 ng/dL (normal, 50 to 760 ng/dL),- R4 g7 X5 `( S6 t/ g( e$ x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 E& a. D" p: p% S0 H
49ng/dL), 11-desoxycortisol (specific compound S)
5 Z- ]. y& o9 F2 @0 ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- h0 w$ T- @% |9 q+ A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 n9 q4 h/ [: j
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 L! U4 ~, v) P! sand β-human chorionic gonadotropin was less than& A# x; S+ h5 h# A. O) ~
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 }. ]! O5 a, E% _4 bstimulating hormone and leuteinizing hormone% z9 a; ~0 ^) G4 A, X5 b
concentrations were less than 0.05 mIU/mL0 ]! P- @$ w- }0 Z$ Q
(prepubertal).
* h8 C3 ?6 ?6 N9 ~3 {0 K1 u/ CThe parents were notified about the laboratory
, j7 f+ a$ R( A" {* oresults and were informed that all of the tests were
3 t* t' x5 I7 ~# \4 W9 tnormal except the testosterone level was high. The
; V! b) e5 [! r- sfollow-up visit was arranged within a few weeks to$ h0 v) n$ i1 V9 D* n8 G
obtain testicular and abdominal sonograms; how-2 B& n. g- p9 U. L- }
ever, the family did not return for 4 months., B) o$ W( C, t2 O* c" v
Physical examination at this time revealed that the
- N& J2 ?6 c0 _8 g' `child had grown 2.5 cm in 4 months and had gained
7 \0 \1 t5 M# m; @9 t+ m2 kg of weight. Physical examination remained
$ h  V& c4 J; G" {unchanged. Surprisingly, the pubic hair almost com-- i+ A( k/ N2 s: U6 ~
pletely disappeared except for a few vellous hairs at
$ D" y7 h2 S$ f  A& @& E+ }the base of the phallus. Testicular volume was still 22 q% `' B! I6 b7 A' ?
mL, and the size of the penis remained unchanged.
* I! I4 g* o+ W  LThe mother also said that the boy was no longer hav-0 i+ O/ _" @. E" h- ^5 n  c
ing frequent erections.
5 X& U$ C. l& h3 T" v* q& T9 tBoth parents were again questioned about use of
0 c* e! B; ~; |, i- g- g9 rany ointment/creams that they may have applied to& n( Q* F; ~7 w! c
the child’s skin. This time the father admitted the
# L) A3 _% `' B6 R1 s* s4 }Topical Testosterone Exposure / Bhowmick et al 541
! h9 ~- K- P2 N# ]; kuse of testosterone gel twice daily that he was apply-% [' `  Q& u  a: f% C3 ^" Z
ing over his own shoulders, chest, and back area for* Q* g0 S# D5 B* M
a year. The father also revealed he was embarrassed
4 `" G) A; x2 J, Ato disclose that he was using a testosterone gel pre-* k3 U9 f4 @  R8 |' Z5 \& w. Z# w
scribed by his family physician for decreased libido& w4 D: C& ?' g) J6 ~
secondary to depression.
& W  K" L/ d) f$ E0 lThe child slept in the same bed with parents.
4 U& M- I8 g+ J4 }# cThe father would hug the baby and hold him on his
6 s4 n, w, I5 d8 q9 Mchest for a considerable period of time, causing sig-9 G% |- l* m  d7 [% \9 r
nificant bare skin contact between baby and father.9 F. w# ?2 m7 u+ K# j
The father also admitted that after the phone call,
5 `  \7 i( `  j7 i& L4 \7 iwhen he learned the testosterone level in the baby, v; T# J/ P1 ?4 l
was high, he then read the product information
. O- `6 C$ a' s* @% b0 w( `packet and concluded that it was most likely the rea-, y0 p* |2 t6 c8 M2 }7 X
son for the child’s virilization. At that time, they  J3 ^5 L8 I6 _2 L9 U- ^
decided to put the baby in a separate bed, and the
9 a4 l8 t8 X2 I2 Ffather was not hugging him with bare skin and had
0 z; o: Z" _! Xbeen using protective clothing. A repeat testosterone
7 T$ n3 m; ^' h) {  T, ztest was ordered, but the family did not go to the
. D8 f7 [( ~3 g  u- W5 |* M; ^  _( R' xlaboratory to obtain the test.6 o- C0 ?/ k! h( b; x& [1 D
Discussion
6 H( `% q8 e: L+ xPrecocious puberty in boys is defined as secondary
2 w5 h  ?; M) s% \sexual development before 9 years of age.1,43 d& ?$ X/ B/ L# L% R
Precocious puberty is termed as central (true) when7 e! ~4 p; a8 I0 n' a
it is caused by the premature activation of hypo-
. b. t3 R! }+ B) u( Ythalamic pituitary gonadal axis. CPP is more com-+ A5 l: \- q& T" Y* R. w% m
mon in girls than in boys.1,3 Most boys with CPP6 R& e% r( Y- G" D' d% ]; m. F
may have a central nervous system lesion that is3 I- i5 ?5 J0 ]$ ~/ E# r, x# H
responsible for the early activation of the hypothal-
' h& k# {0 g3 J) s2 b' |+ h/ qamic pituitary gonadal axis.1-3 Thus, greater empha-
1 C& H2 [; _! n) O2 @  Y) d( gsis has been given to neuroradiologic imaging in1 Z% N; M5 I4 u* K, b" b$ A- \
boys with precocious puberty. In addition to viril-
7 Z7 w( N, L& ?) sization, the clinical hallmark of CPP is the symmet-0 \; L# T. U9 h/ I7 ]7 J: v
rical testicular growth secondary to stimulation by
# Z& N: f# o9 @$ {gonadotropins.1,3
" ~4 ]- P1 J. V" _Gonadotropin-independent peripheral preco-
9 N! a, q: {' N3 D& P; R7 Mcious puberty in boys also results from inappropriate) Y' ~! o0 G. Q1 Q9 _4 O
androgenic stimulation from either endogenous or* @- W( K. W9 Q! F" E) r
exogenous sources, nonpituitary gonadotropin stim-9 Y8 j8 _" w% H( ^* M6 |. C
ulation, and rare activating mutations.3 Virilizing: j# l  `- @4 }% L% @% g
congenital adrenal hyperplasia producing excessive  ?8 ~* }  K2 C; `) L& U$ j, N
adrenal androgens is a common cause of precocious. i. a$ t& O( Q; d; |) J% _
puberty in boys.3,4
1 e7 i7 z8 }6 L/ T, _) c% BThe most common form of congenital adrenal
2 N& q5 _. I  u' G8 Ehyperplasia is the 21-hydroxylase enzyme deficiency.
1 T5 x6 r. ^  Q2 e) V* F/ j$ S1 ?The 11-β hydroxylase deficiency may also result in' e+ N3 [3 P+ I
excessive adrenal androgen production, and rarely,
5 v6 d  i4 a! W& p  @. }2 R3 ban adrenal tumor may also cause adrenal androgen+ X- h5 k. S0 V( G
excess.1,3
" O4 V" H& H7 W! ], `( k2 U% k" Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 W  Z& ~& o2 R. X7 A, m. n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! n5 h8 A0 d: N3 P. IA unique entity of male-limited gonadotropin-4 Y% k0 r# A9 ]) q4 r, S1 u4 d6 q
independent precocious puberty, which is also known  _3 m- M& E7 \5 p
as testotoxicosis, may cause precocious puberty at a$ [: n5 j4 M. ~# t0 c
very young age. The physical findings in these boys9 }# t, ~6 _2 p! ^! y
with this disorder are full pubertal development,. K7 h# ]7 S3 s3 \2 W' N: F) s% ~
including bilateral testicular growth, similar to boys! [( g9 Z  }4 K0 h
with CPP. The gonadotropin levels in this disorder
! ^& f; u- m4 n7 H3 ?are suppressed to prepubertal levels and do not show! y. t" f* d' i% E
pubertal response of gonadotropin after gonadotropin-
2 m& n" X5 o+ C, K5 ereleasing hormone stimulation. This is a sex-linked2 ?2 B: M+ T) @! H# E
autosomal dominant disorder that affects only
9 Z$ z0 v4 o% a( b: P+ P( Dmales; therefore, other male members of the family
3 f) y* C# t7 |: r0 Qmay have similar precocious puberty.3
5 W3 i/ z; U# X# NIn our patient, physical examination was incon-
! K  a. H/ X9 L& k0 V- |! |/ c9 W# osistent with true precocious puberty since his testi-1 x! z9 f' A, j' F- {: U% n  e
cles were prepubertal in size. However, testotoxicosis6 I8 n! }+ E$ d. e
was in the differential diagnosis because his father+ f4 @* z3 n) w5 r: h; k1 G# y
started puberty somewhat early, and occasionally,
- v# E7 R) i$ e7 \  u3 S0 K- otesticular enlargement is not that evident in the
0 D1 w; P' \5 C: Q5 }beginning of this process.1 In the absence of a neg-
9 n: C' p6 `; t& p" u6 I: r- z* y1 @ative initial history of androgen exposure, our
, G2 G* N! t. o& V2 vbiggest concern was virilizing adrenal hyperplasia,4 J7 q8 g/ H2 y
either 21-hydroxylase deficiency or 11-β hydroxylase
! Q- q# [5 x% L5 {- `( G4 z1 ddeficiency. Those diagnoses were excluded by find-' _) X5 i8 j( I# R7 {
ing the normal level of adrenal steroids.
' v3 m. V4 H$ n6 p+ _2 \6 EThe diagnosis of exogenous androgens was strongly$ G; n% d- M: R- D9 g# A8 d
suspected in a follow-up visit after 4 months because: K( |0 z% F9 Y. n
the physical examination revealed the complete disap-
2 H3 M4 h6 B3 w+ R1 Hpearance of pubic hair, normal growth velocity, and. J1 s6 S+ v2 v+ o9 R/ T8 m
decreased erections. The father admitted using a testos-6 i4 ]+ {9 X0 `% t. B, ~
terone gel, which he concealed at first visit. He was  ~, y* Z; D* t% \. G
using it rather frequently, twice a day. The Physicians’
& a5 ^- m, X: i' L# @1 rDesk Reference, or package insert of this product, gel or& `: }+ r; X6 p) @7 J
cream, cautions about dermal testosterone transfer to
5 P, e- J" @% m& d- Junprotected females through direct skin exposure.
) @5 @+ ^* ~0 sSerum testosterone level was found to be 2 times the; R( N9 o$ H0 o
baseline value in those females who were exposed to8 n7 [" M- B  H% L' X8 E5 q
even 15 minutes of direct skin contact with their male8 d" R& {+ ?. c8 W
partners.6 However, when a shirt covered the applica-- c6 ~$ ]. m* s
tion site, this testosterone transfer was prevented.
! {& Y. g. t: j. s7 _Our patient’s testosterone level was 60 ng/mL,. r% R' Z1 R4 z. ~0 }% j, S: p; d3 L
which was clearly high. Some studies suggest that9 M7 N$ p$ p* O
dermal conversion of testosterone to dihydrotestos-
: J# I: F6 j7 R9 |& @terone, which is a more potent metabolite, is more: m7 T3 I# E+ i% t! q' Q! B
active in young children exposed to testosterone' m# v; x0 j$ s) q
exogenously7; however, we did not measure a dihy-
, ]- ~: J5 g4 S2 _+ Kdrotestosterone level in our patient. In addition to
3 K8 V5 |2 w6 e4 |, X% \virilization, exposure to exogenous testosterone in
1 x; @% p+ E, tchildren results in an increase in growth velocity and. V5 n! r4 {; f( c
advanced bone age, as seen in our patient.3 h, r# H: f7 w; W0 f, l& D! J1 A/ y
The long-term effect of androgen exposure during5 v' q4 q3 W& {# j$ |
early childhood on pubertal development and final- E# Q' U5 ^6 z/ I. S) l
adult height are not fully known and always remain
; [; \' q! Z3 Z  S8 Wa concern. Children treated with short-term testos-
$ H4 z; b7 v' Y* v% K* d7 Bterone injection or topical androgen may exhibit some
- K$ b" i* g- n7 Z7 k& Z5 Iacceleration of the skeletal maturation; however, after9 V$ [, s9 C$ `1 j4 w' c
cessation of treatment, the rate of bone maturation- |7 @# \4 `! t0 v" o% }) A
decelerates and gradually returns to normal.8,9- S/ W# g  Z. F9 {( \0 l5 g! w
There are conflicting reports and controversy
6 X2 M2 G5 O3 O9 M' {, d0 {5 _over the effect of early androgen exposure on adult
, q- ^! n2 U/ f9 F2 P: V. ^penile length.10,11 Some reports suggest subnormal
) z3 P$ X2 [; M7 p7 V* aadult penile length, apparently because of downreg-
0 F5 j7 K7 Y* ?6 b4 c# iulation of androgen receptor number.10,12 However,8 c. q7 L" L+ ^. R7 s: x9 Z+ v8 U
Sutherland et al13 did not find a correlation between3 b4 {; r: N/ ^  z
childhood testosterone exposure and reduced adult
' m3 O# y8 T6 K) y  P4 o- I# v5 S- {penile length in clinical studies." ?  g8 R8 a  f/ q" s# g
Nonetheless, we do not believe our patient is5 o9 ?' z% t+ c9 p# ^) _1 S
going to experience any of the untoward effects from
- p& J' L6 l1 Gtestosterone exposure as mentioned earlier because
* M! {1 c: Z6 l+ T$ \2 m6 {the exposure was not for a prolonged period of time.
# J4 q/ j8 m* F7 R# FAlthough the bone age was advanced at the time of( f# G0 [2 _0 g: T/ `7 O
diagnosis, the child had a normal growth velocity at
5 Z% A, }" O3 z$ wthe follow-up visit. It is hoped that his final adult
4 {3 k* v6 H0 K9 @0 v9 zheight will not be affected.
; H  `9 L3 \7 @9 t- ZAlthough rarely reported, the widespread avail-2 y. P8 }; B" Y$ q  \: v
ability of androgen products in our society may
0 V3 L" F% t6 F0 Nindeed cause more virilization in male or female& `3 U- f6 a; B( A2 `+ g* n) x' a
children than one would realize. Exposure to andro-  g- O; H& k$ ?1 T
gen products must be considered and specific ques-
. @) ?, Y0 a. ytioning about the use of a testosterone product or
& w) _$ i9 V, n0 G+ s4 k/ c* {$ igel should be asked of the family members during
% p' K9 j% h. R0 t$ ~- O6 E* ythe evaluation of any children who present with vir-' U# d( D) O, h8 ~/ Q' d9 D
ilization or peripheral precocious puberty. The diag-4 _+ I  j0 ^3 }, c
nosis can be established by just a few tests and by0 A- Z2 c; ?- f! ?+ n+ q" Y
appropriate history. The inability to obtain such a, |; z, E: K+ t. O6 n2 e/ k4 d" U; G
history, or failure to ask the specific questions, may
2 `- \8 L# P4 P0 q; Gresult in extensive, unnecessary, and expensive# r; G7 \. `" k% o# `
investigation. The primary care physician should be
! `* s. u; F! }1 P. ^aware of this fact, because most of these children
* |* t/ z$ Z9 c( d- ]may initially present in their practice. The Physicians’
9 `0 |- A% P# R/ |Desk Reference and package insert should also put a
6 t* A! ?& M5 y" S# N2 f" Owarning about the virilizing effect on a male or, y  J" o& X8 k* @# t( f3 f
female child who might come in contact with some-: _' N/ |7 V2 v9 J# ^0 q" D
one using any of these products.7 G0 v' G+ R8 r: x( @
References
' p) K5 n6 q+ O5 e, C6 `! B1. Styne DM. The testes: disorder of sexual differentiation: c7 }6 f2 U* O7 ^. X
and puberty in the male. In: Sperling MA, ed. Pediatric
9 C% q) k( t% CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! X* a: g. D* a, M& [
2002: 565-628.  H7 N% X3 x  u, c$ O5 D& P' W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 z  x% S) s$ c# ^( epuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
0 E& |. F6 q% j2 J8 F, Y, qBoy Induced by Indirect Topical5 q) c# @& {3 W$ v; \
Exposure to Testosterone
8 W1 N& A+ Q6 @4 k, D$ ?$ fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# T) U' U3 m8 a7 Oand Kenneth R. Rettig, MD1
4 v- @5 X6 t2 p# j2 \Clinical Pediatrics
/ a/ k6 l/ C* E5 P! O8 BVolume 46 Number 6
3 M9 s" d& ?5 _4 Q1 VJuly 2007 540-543
! d9 K9 r7 Y! |0 ~) D8 S& |© 2007 Sage Publications
1 y8 j* \$ ]4 h9 L3 ?& q  ?4 ?10.1177/0009922806296651; p% N/ O: n6 h6 v& i) l
http://clp.sagepub.com0 K" a, X; w" T2 m- N$ I
hosted at' B: f' ^! V1 h% h2 v9 T2 D5 |  N
http://online.sagepub.com
/ b3 x% y* `1 C% W" [8 qPrecocious puberty in boys, central or peripheral,# A, {0 C; e4 O& v' l2 d
is a significant concern for physicians. Central/ x/ L; Y! l7 v
precocious puberty (CPP), which is mediated9 C& g: T- `% s$ a" A* C6 j
through the hypothalamic pituitary gonadal axis, has
0 L& L4 @" v6 g" v6 @* aa higher incidence of organic central nervous system9 \0 {; A; M' ]
lesions in boys.1,2 Virilization in boys, as manifested
) \3 i; ?$ `5 w; I% Iby enlargement of the penis, development of pubic9 c7 S( t' d5 F- M' }0 B& ~
hair, and facial acne without enlargement of testi-
1 o4 J, n: C: C) L1 Icles, suggests peripheral or pseudopuberty.1-3 We
  b: J) b9 e& dreport a 16-month-old boy who presented with the- x9 F1 [: t( T
enlargement of the phallus and pubic hair develop-
  T/ N+ O, D* y: ^/ U! U# J& P! n: |ment without testicular enlargement, which was due
* l; E" ~5 O# Sto the unintentional exposure to androgen gel used by
( b: W; Z2 |2 o2 T* U! Athe father. The family initially concealed this infor-
% n3 ^4 L4 x" b) M; Y0 G' kmation, resulting in an extensive work-up for this
; g0 {' z0 D; @- d5 w; pchild. Given the widespread and easy availability of
' \0 Y+ A0 k& l, o& j: Btestosterone gel and cream, we believe this is proba-
; @* d  e! e0 c4 w4 H' v( _4 E1 }+ vbly more common than the rare case report in the9 N; T- q- s; n3 ~, l2 w2 A
literature.4* B) m* T: B- E
Patient Report
3 c3 x5 }+ I* H9 m  a2 D+ BA 16-month-old white child was referred to the
( [% M* B0 u! l% t1 f9 l2 \7 Wendocrine clinic by his pediatrician with the concern6 V1 V  W- G8 l* B3 b- Y
of early sexual development. His mother noticed
  L  ^( N8 L1 r* P6 p* olight colored pubic hair development when he was: N) y! u/ @! T7 R  X
From the 1Division of Pediatric Endocrinology, 2University of, Y: {( `8 w+ \
South Alabama Medical Center, Mobile, Alabama.+ f: s$ T# R3 p0 ^$ }. Y: p6 k+ J
Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 `( N7 G/ b5 M) q0 ^3 ?5 FProfessor of Pediatrics, University of South Alabama, College of! ?- H, V- N7 [( M! s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 |+ j# j0 g/ p9 u& p. _e-mail: [email protected].
; P; k2 Z& J1 _  V6 h+ Jabout 6 to 7 months old, which progressively became$ V, N2 y6 G9 L
darker. She was also concerned about the enlarge-9 v3 o* e. }4 B( f; R
ment of his penis and frequent erections. The child
3 Z3 }' F& A; c+ J$ `. S$ Mwas the product of a full-term normal delivery, with4 V# _8 t7 m% P. ?
a birth weight of 7 lb 14 oz, and birth length of
, c* Z  V" @5 l4 A" _) A) T20 inches. He was breast-fed throughout the first year6 c4 k, v" b  T) [# [( B! p! l
of life and was still receiving breast milk along with
9 F6 ?; x. Q9 p3 Z# u: Ksolid food. He had no hospitalizations or surgery,7 T  |  g( v4 y# j* H
and his psychosocial and psychomotor development
9 N) C, X5 E8 e% jwas age appropriate.$ v) p/ w& u' `. E
The family history was remarkable for the father,
) h4 p: W% L! pwho was diagnosed with hypothyroidism at age 16,2 v( I6 X# H0 g. I; @3 y
which was treated with thyroxine. The father’s
7 }8 `# F8 ?2 ^. C! ^, eheight was 6 feet, and he went through a somewhat/ O, ?2 Y" s; r5 z9 i& L; e
early puberty and had stopped growing by age 14.
6 x2 G: z# s' K1 {' P8 FThe father denied taking any other medication. The+ r+ d7 D2 W/ t: q
child’s mother was in good health. Her menarche
* [6 h; J. |$ K4 z: xwas at 11 years of age, and her height was at 5 feet& p1 O! E6 r! d' ^+ b
5 inches. There was no other family history of pre-
" g4 A/ R" v+ n, @4 Rcocious sexual development in the first-degree rela-0 s6 Q+ ^8 m0 o. X$ O( d3 m' Z: E
tives. There were no siblings.
' u8 v8 p( H. g  l8 w- O% pPhysical Examination
0 o" H* k% E* y6 r  J. v& W9 ^! eThe physical examination revealed a very active,
1 c" @) _) Y) @playful, and healthy boy. The vital signs documented
3 h6 v* s( _! {8 h% ba blood pressure of 85/50 mm Hg, his length was
8 ~4 O7 ~- o, a" {9 i- ]/ R: O( L90 cm (>97th percentile), and his weight was 14.4 kg$ u! t" h3 H4 }2 ]% f' ~
(also >97th percentile). The observed yearly growth0 \$ Y4 ]6 c% t% Q# L
velocity was 30 cm (12 inches). The examination of0 F9 }. P: c3 q% B  U
the neck revealed no thyroid enlargement.7 c- F/ z& C6 a" t6 E) M2 b* f
The genitourinary examination was remarkable for, [1 L" F+ o  T* ]4 E, K
enlargement of the penis, with a stretched length of
  l: r2 G# l5 y2 U8 A8 cm and a width of 2 cm. The glans penis was very well
( n- ~% j- Y2 W/ u( t! ndeveloped. The pubic hair was Tanner II, mostly around% {. [; ~- o; k3 ~+ r
540( P+ I3 N$ w9 t$ h5 g/ _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* e' {( V: |# q9 e2 D
the base of the phallus and was dark and curled. The+ k  b: J0 r" `/ Q6 B! d" e
testicular volume was prepubertal at 2 mL each.6 w! G+ e6 ?, E% C# i& _; X: B
The skin was moist and smooth and somewhat3 g, j2 \5 i* I' L' h5 @
oily. No axillary hair was noted. There were no
+ v4 U+ W/ z, Q8 G) T8 d- u0 a- S, x# labnormal skin pigmentations or café-au-lait spots.
1 T3 d' z- V1 VNeurologic evaluation showed deep tendon reflex 2+7 Z$ S! q+ ]" b- g
bilateral and symmetrical. There was no suggestion
# g$ Y6 ~: l& e3 Q+ Dof papilledema.
8 ~# i; X$ X. X. O" A" zLaboratory Evaluation; }- D5 ~5 l  {! O" h* S
The bone age was consistent with 28 months by& H2 d; L+ R7 e  F; w/ P
using the standard of Greulich and Pyle at a chrono-! @) C4 l8 a4 p4 w
logic age of 16 months (advanced).5 Chromosomal
3 _5 H) R8 c! D0 ]- ^" U( E* akaryotype was 46XY. The thyroid function test6 x* T6 {3 J7 E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 O0 H: |' j- q+ Ulating hormone level was 1.3 µIU/mL (both normal).6 e" }0 X3 d& i
The concentrations of serum electrolytes, blood
0 b( f( ]' q0 E2 z/ Jurea nitrogen, creatinine, and calcium all were6 z/ O8 \* }& M/ c. G
within normal range for his age. The concentration
0 y0 L- M- r% z- e* Zof serum 17-hydroxyprogesterone was 16 ng/dL
6 E/ i! F1 K0 g, O(normal, 3 to 90 ng/dL), androstenedione was 20% ~0 z: V. R( Y/ n  f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ W# Q; b& I) c3 f# Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 ~5 C% F( h9 N- ~desoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 \2 y) m$ `/ k4 _9 `49ng/dL), 11-desoxycortisol (specific compound S)2 {" b- Y7 E' q- y( R8 o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 w+ x: j+ M6 F* y* t7 Dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. |, m: x* P0 B8 Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. T3 d# }5 M0 T7 C. D
and β-human chorionic gonadotropin was less than/ k# ?" U: t% E9 P7 y: w' u. n6 K& U
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 @- H& D2 l% b; c( O# l( S0 |stimulating hormone and leuteinizing hormone/ L7 x, }$ G6 e
concentrations were less than 0.05 mIU/mL9 i) w1 }: ?( {+ O
(prepubertal).
# ?+ y0 N7 n0 |* }& @/ @6 gThe parents were notified about the laboratory
9 ]! L6 M* |9 S$ Kresults and were informed that all of the tests were4 F- _1 v- I0 n3 j% l3 `
normal except the testosterone level was high. The+ J( F3 Y5 x1 Z2 i
follow-up visit was arranged within a few weeks to
+ [' Z$ H" u5 I, l1 p% B- Y# Tobtain testicular and abdominal sonograms; how-
8 h7 x" k1 B" s2 m0 Q6 J5 W$ n/ oever, the family did not return for 4 months.
7 B; \6 i; ^% g+ w) J- w( sPhysical examination at this time revealed that the
2 o$ S8 Q! ^, x8 Y! Y7 f4 |- R3 }child had grown 2.5 cm in 4 months and had gained$ `( H" Y1 e6 `
2 kg of weight. Physical examination remained* L2 Z. B* f5 h  Z6 t8 T
unchanged. Surprisingly, the pubic hair almost com-
' w. C# n( |, Z3 U5 xpletely disappeared except for a few vellous hairs at9 q8 v5 c+ x' x8 |
the base of the phallus. Testicular volume was still 2
% Y+ b5 X) i0 D# ~4 o- dmL, and the size of the penis remained unchanged.
0 o5 m' I, V/ R6 x" y/ ]) RThe mother also said that the boy was no longer hav-
- T' ~& q9 h4 ding frequent erections.
* n4 _" l0 o2 _9 D! C/ {Both parents were again questioned about use of
/ Q% u  g  N5 S7 I7 q& ^any ointment/creams that they may have applied to& a1 r8 j6 N: L, I; {; v1 H5 G
the child’s skin. This time the father admitted the
3 z- o  {+ [6 q" P* `Topical Testosterone Exposure / Bhowmick et al 5413 j2 D- @) Z0 c
use of testosterone gel twice daily that he was apply-" M4 k9 x1 f, s* E* Z
ing over his own shoulders, chest, and back area for  r# r3 q/ D/ N7 y
a year. The father also revealed he was embarrassed) Y* N* I! k2 X* R- Q/ X
to disclose that he was using a testosterone gel pre-
( ]7 n, l7 c6 H" |. ^, Y& \( J  Lscribed by his family physician for decreased libido
7 r6 v( ^0 B7 Esecondary to depression.
( a/ N# v9 l! Z# H/ `1 _; XThe child slept in the same bed with parents.7 P4 W( b4 t: k! v  f4 h
The father would hug the baby and hold him on his
- c* e: Z+ ?- G2 i' L6 Echest for a considerable period of time, causing sig-3 i" K+ @( z% s
nificant bare skin contact between baby and father.7 F! C) i/ `% x+ g) j' ]
The father also admitted that after the phone call,5 w. n7 o2 C! Z4 I* `
when he learned the testosterone level in the baby
  Q4 A) t5 r6 l/ P. p; b( Y) w; S+ wwas high, he then read the product information2 z, O/ k9 I9 W( P+ [9 E
packet and concluded that it was most likely the rea-
, u; I6 K! y) d4 Oson for the child’s virilization. At that time, they* ?; _) ^$ @1 w- ^5 ?8 O
decided to put the baby in a separate bed, and the
# C5 p3 k6 Y# }' j. J( afather was not hugging him with bare skin and had6 E# Z2 V( {+ J
been using protective clothing. A repeat testosterone: D% H9 G. k, \+ Y' o4 x
test was ordered, but the family did not go to the
4 p, u& K* I( s) ]* z8 n6 Claboratory to obtain the test.* j$ n2 |6 T  A# @  D- t
Discussion
4 B# f) L" A5 d. `; Z$ b6 nPrecocious puberty in boys is defined as secondary
+ l! D$ L4 r( F5 Y* e( W6 f' ]9 F3 ?sexual development before 9 years of age.1,46 g0 A% `/ Z! s/ T( Q; V( M. Y# {
Precocious puberty is termed as central (true) when' j+ _- B  q+ s7 a9 y! O5 |
it is caused by the premature activation of hypo-
/ @( J& ?1 s: B  Y8 M% b& fthalamic pituitary gonadal axis. CPP is more com-. w0 o4 a! p' ^7 P, a
mon in girls than in boys.1,3 Most boys with CPP
6 x- e0 F# c; N/ v1 l: @, Wmay have a central nervous system lesion that is% p2 S* z: j( Z6 \0 N( [
responsible for the early activation of the hypothal-6 {9 M% p' d+ `! W
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 m: r. ^  i' X1 Vsis has been given to neuroradiologic imaging in! ]6 Y7 y6 Q1 P" f$ a& M) t
boys with precocious puberty. In addition to viril-
4 i2 [4 l# b4 ^9 ^3 G* w4 _ization, the clinical hallmark of CPP is the symmet-
; L* V% T& S" i2 U9 W# zrical testicular growth secondary to stimulation by: k: N+ X5 V! ]- w; r& G3 }
gonadotropins.1,3# L* b5 f$ k3 N" V% I5 U; j3 w4 ^
Gonadotropin-independent peripheral preco-
4 z5 C: L  s8 }" L- Y2 Qcious puberty in boys also results from inappropriate. ~2 {" F% y) @" i' V
androgenic stimulation from either endogenous or
* U8 T6 e4 |0 B$ n- b6 q' Uexogenous sources, nonpituitary gonadotropin stim-- j( t! t3 @/ z& n
ulation, and rare activating mutations.3 Virilizing* [' o2 D' {. K4 }) ^" C% s7 L
congenital adrenal hyperplasia producing excessive
0 f. R+ m' ?& F! Vadrenal androgens is a common cause of precocious
! x# D! Y& x8 e; r/ F, Npuberty in boys.3,4
6 f# n0 P) n+ o/ [0 ?2 O( u: _The most common form of congenital adrenal2 `9 Y# @8 F8 Z
hyperplasia is the 21-hydroxylase enzyme deficiency.! E0 t0 u# `2 n) e7 D7 z( j
The 11-β hydroxylase deficiency may also result in8 F2 W+ x+ R2 Y+ @2 ]* w' c
excessive adrenal androgen production, and rarely,6 M# |' @' g- w, \6 w3 A
an adrenal tumor may also cause adrenal androgen& p& B* s" n& [
excess.1,3' H, R6 Y  Y0 a2 I" a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 [. }: S8 S& t( t5 f: ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% [2 G; ~/ j- K2 R
A unique entity of male-limited gonadotropin-! t) P+ c5 z1 O4 O9 ^1 a
independent precocious puberty, which is also known
& _1 a  \4 c* A3 `- F  G3 k( qas testotoxicosis, may cause precocious puberty at a7 ?' L1 v- b- g- U
very young age. The physical findings in these boys: q) d% Z3 }3 f" W3 W; t
with this disorder are full pubertal development,
% P- N& @: ?% [including bilateral testicular growth, similar to boys* p+ |" N, g7 z8 a
with CPP. The gonadotropin levels in this disorder% d+ k3 v5 d) f  d& x1 f
are suppressed to prepubertal levels and do not show7 N8 E; k2 g& d, b# \
pubertal response of gonadotropin after gonadotropin-
! y9 {2 h+ W8 j: nreleasing hormone stimulation. This is a sex-linked$ j4 S6 A. t1 [  d- n4 P# N) W4 U
autosomal dominant disorder that affects only
0 s3 c9 g* p3 P5 {males; therefore, other male members of the family6 b) M: Z: ^* a
may have similar precocious puberty.3
( h' {2 h( @6 I: E1 Y/ xIn our patient, physical examination was incon-
2 b$ s  C' Z8 Q) |sistent with true precocious puberty since his testi-) ]" u. r! |2 B9 I6 e7 K- y
cles were prepubertal in size. However, testotoxicosis% {& g6 h- u  O
was in the differential diagnosis because his father* r: z6 p8 \& H1 c% w
started puberty somewhat early, and occasionally,
' w; x. Y0 R: i- e0 X5 d( _' A# }testicular enlargement is not that evident in the) ~5 u/ }! y+ n0 ]& a: C
beginning of this process.1 In the absence of a neg-/ s, w0 C5 o" r6 J* c  T$ j
ative initial history of androgen exposure, our6 V" Y: i, J  S% @: E# u( }8 c
biggest concern was virilizing adrenal hyperplasia,
9 V6 w( x5 T; T; P& m/ z4 V6 V) Aeither 21-hydroxylase deficiency or 11-β hydroxylase
7 f8 u& M0 _2 X- ^# q, N- kdeficiency. Those diagnoses were excluded by find-2 _3 j; C. s- ^1 R' b. \4 C( S6 M
ing the normal level of adrenal steroids.
( L/ p) ?8 R) w7 X" ^0 H  x$ \+ SThe diagnosis of exogenous androgens was strongly
6 w: z& @" j: j) f+ Vsuspected in a follow-up visit after 4 months because
. \, r: ~; l! tthe physical examination revealed the complete disap-; Y  j* M2 G, z4 c1 h5 v
pearance of pubic hair, normal growth velocity, and+ x$ H' S# W9 d/ v# ]) e+ z
decreased erections. The father admitted using a testos-+ e! ^3 W" w- |9 L0 g
terone gel, which he concealed at first visit. He was
1 L# g: i' {9 D! {5 [1 Jusing it rather frequently, twice a day. The Physicians’8 X( Y; r8 U; ]2 c$ M
Desk Reference, or package insert of this product, gel or/ P( u- B+ h8 I% {
cream, cautions about dermal testosterone transfer to
2 I# p; m4 l4 I: f; j( Y' a8 Aunprotected females through direct skin exposure.
. O1 C" y; Q" \" ]) WSerum testosterone level was found to be 2 times the2 G4 K1 U, l! j) l7 K3 h
baseline value in those females who were exposed to
" W2 S5 v0 _9 a! n8 x3 E3 }even 15 minutes of direct skin contact with their male
- m7 J* l3 A* `# R7 E8 V7 c' Mpartners.6 However, when a shirt covered the applica-
. Z2 q/ d2 X( z' P) b& N1 p" Ytion site, this testosterone transfer was prevented.
7 a/ J  ~6 s7 y" MOur patient’s testosterone level was 60 ng/mL,
/ r/ Q8 l5 v. K/ S/ Dwhich was clearly high. Some studies suggest that4 Y" i& T: ?+ D+ E. W
dermal conversion of testosterone to dihydrotestos-
" E: C% G1 o6 Rterone, which is a more potent metabolite, is more
. l: [9 `* g+ C& tactive in young children exposed to testosterone+ b! J. l4 @% u4 @8 G  K
exogenously7; however, we did not measure a dihy-
( b; s: L  {% y  _! E" Adrotestosterone level in our patient. In addition to0 j) y# _  ~: N  F
virilization, exposure to exogenous testosterone in$ B3 N* Y% H, _1 H
children results in an increase in growth velocity and
( K7 D5 F1 p: A9 P5 I$ Zadvanced bone age, as seen in our patient.
. n. ~( \: D7 Y# W/ bThe long-term effect of androgen exposure during* P2 x7 f6 j8 x, a$ `
early childhood on pubertal development and final. b* x' h# d7 d, H
adult height are not fully known and always remain: W* _% w8 m3 |8 v; g
a concern. Children treated with short-term testos-9 X. A  r6 \4 ]& P
terone injection or topical androgen may exhibit some; Q3 f0 k" \1 Z& M
acceleration of the skeletal maturation; however, after
' H% b8 u$ f, s% rcessation of treatment, the rate of bone maturation
" c" p7 O& @+ o7 p: }decelerates and gradually returns to normal.8,97 y' F# ]0 W' X' }( T  P* Z% T
There are conflicting reports and controversy
1 h9 g* I& {5 d5 Z8 I8 |- b' o4 mover the effect of early androgen exposure on adult
3 v  F$ b' w% ^6 z9 ]! G& [penile length.10,11 Some reports suggest subnormal# n5 V1 f9 m1 s% U6 Y5 y
adult penile length, apparently because of downreg-
/ u$ h: J/ }7 |6 c4 _* @3 g5 F5 Hulation of androgen receptor number.10,12 However,. s" m. I, D8 Q- s; `
Sutherland et al13 did not find a correlation between
, m! {  {# O+ G* m! |childhood testosterone exposure and reduced adult; G8 p9 i0 U6 O2 _
penile length in clinical studies.
" S- i1 d/ B4 X, Y/ M6 }, r$ P; l$ qNonetheless, we do not believe our patient is
1 h9 S& z! l6 \% r; z- r4 Tgoing to experience any of the untoward effects from
" Y3 l8 w4 }, n+ s/ `3 A: otestosterone exposure as mentioned earlier because. p2 j  g2 Z1 \  {8 X
the exposure was not for a prolonged period of time.
0 V( C, J* A8 U9 p' H' n0 W& DAlthough the bone age was advanced at the time of( E. N. S6 t' b7 p
diagnosis, the child had a normal growth velocity at. m. k6 q" Z" {; A
the follow-up visit. It is hoped that his final adult
) c! y; G! F( ~% v5 k5 iheight will not be affected.+ C! b0 o* A2 m$ Q; O3 {7 `
Although rarely reported, the widespread avail-5 O. T; z" h, z
ability of androgen products in our society may
- o- b; _+ `1 r0 R( Hindeed cause more virilization in male or female1 C$ ~0 W5 \9 d+ U2 @
children than one would realize. Exposure to andro-
8 v+ c; w; \  y) q: Agen products must be considered and specific ques-
1 n" n  i- W/ E: W# P, f- ptioning about the use of a testosterone product or$ |) I0 [. n' L+ H8 x1 Y
gel should be asked of the family members during
0 g" }0 k# ~, Q$ h/ S6 T9 O; L' Othe evaluation of any children who present with vir-6 k: w- b* ^7 \9 `9 z
ilization or peripheral precocious puberty. The diag-
  V: j: Y5 I# k" ]% l8 c5 ynosis can be established by just a few tests and by' M: ~: k5 q- T4 z0 _8 y$ P/ r
appropriate history. The inability to obtain such a
4 O7 n8 x0 s" Phistory, or failure to ask the specific questions, may' f* e1 ~5 k4 M& j, H8 ?5 z
result in extensive, unnecessary, and expensive2 V: H) k- e0 d
investigation. The primary care physician should be9 h& Q- b$ t7 \5 k- A4 m1 H! Q
aware of this fact, because most of these children( [# {4 `4 I) A9 t. r; F
may initially present in their practice. The Physicians’
+ V, B5 N2 A" X8 s9 JDesk Reference and package insert should also put a
, j- C2 Q7 k/ {" x: x2 Gwarning about the virilizing effect on a male or
/ L; m; L2 j& `1 E6 qfemale child who might come in contact with some-5 R. h! N7 X9 k' ?$ x
one using any of these products.5 S$ B0 {/ j6 m' q
References# @9 h* ]2 H3 a% S0 n" M
1. Styne DM. The testes: disorder of sexual differentiation
( i1 A* U5 j4 t9 [2 t. p+ M" Yand puberty in the male. In: Sperling MA, ed. Pediatric
- F8 p! M4 x; U, ^/ ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. t+ K3 [; f; T1 v4 z2002: 565-628.: n% F, T( c8 O) }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ y- ?. H  V; s1 n. p+ A6 c+ E
puberty in children with tumours of the suprasellar pineal
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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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

6 t. o' a9 R: o4 H1 P; D. `" |2 }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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