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Sexual Precocity in a 16-Month-Old2 ^8 x, H6 K! F- R( U3 H
Boy Induced by Indirect Topical
4 _; n+ v, [) n7 N1 I5 `0 b  E, cExposure to Testosterone
5 G" h! R6 C/ V( W, ^) oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: h7 i* n9 F" D9 }: n- o( `, oand Kenneth R. Rettig, MD13 ?$ P7 {& l7 f+ y5 d
Clinical Pediatrics; Z. E( c  x# d0 C8 o2 \% P
Volume 46 Number 60 f# s. o& {  w& y4 i7 Z1 V& K
July 2007 540-543
  O& {/ o4 N; A3 g1 E  u' z4 P© 2007 Sage Publications
0 |  x: O' E7 k5 |; ]10.1177/0009922806296651
7 [' C, o$ c4 ^, x) Mhttp://clp.sagepub.com) h+ g  R5 n" F8 u
hosted at
# l2 b$ C/ u& h( ]) h- o( Whttp://online.sagepub.com
& k" C2 n, Z0 A( d& c$ VPrecocious puberty in boys, central or peripheral,& |+ {; s* |4 |' G4 e
is a significant concern for physicians. Central% w/ r; {% a( ^5 i& g' Y7 w5 D
precocious puberty (CPP), which is mediated
! u) ~) ], K$ I5 H3 I' j$ Qthrough the hypothalamic pituitary gonadal axis, has
" }3 k3 T( D3 \a higher incidence of organic central nervous system
2 m# Q5 V4 L& }- S# Klesions in boys.1,2 Virilization in boys, as manifested
$ h* X7 Y% m3 J( L; e# ]: j  T6 X2 hby enlargement of the penis, development of pubic
8 k6 n! ], c" }6 W" K! {( s3 [4 h1 {hair, and facial acne without enlargement of testi-
  @( B9 d, O5 O! l& B- ccles, suggests peripheral or pseudopuberty.1-3 We0 W) p) ~$ w1 v" p- u) D, ^+ g; W
report a 16-month-old boy who presented with the
* o' h3 v7 ^& g$ o$ T% c  lenlargement of the phallus and pubic hair develop-
7 {" {! Z  K9 g! h4 c9 A( d% Zment without testicular enlargement, which was due3 e# c' Y+ B9 v: Y2 T$ i9 f
to the unintentional exposure to androgen gel used by0 m( g! Y1 v/ t1 n  T+ t1 f0 q0 ?
the father. The family initially concealed this infor-7 R* p( J5 h, w
mation, resulting in an extensive work-up for this
6 v1 V3 _- y( N/ k3 kchild. Given the widespread and easy availability of
9 q/ e: y3 n' t, D( F! Ytestosterone gel and cream, we believe this is proba-
/ m, [; ~6 S: q6 C. G" Bbly more common than the rare case report in the/ D" P6 @( o' E& r, R
literature.42 @/ X9 `& C8 Z7 @1 e  S
Patient Report
$ ~; g- F: l  N' F) [A 16-month-old white child was referred to the) ?" A1 M& Z5 u
endocrine clinic by his pediatrician with the concern; S# }  i9 }7 b: x' \$ c* o& |
of early sexual development. His mother noticed
$ F' V1 M- o& K* W3 rlight colored pubic hair development when he was
3 D% `9 d% V" Z, f& \From the 1Division of Pediatric Endocrinology, 2University of+ c1 s; N7 L( A3 x# J1 k9 T9 [( Z
South Alabama Medical Center, Mobile, Alabama.# m) c6 q/ U; N
Address correspondence to: Samar K. Bhowmick, MD, FACE,& h$ \" O7 @+ A* T  K5 |: G0 B
Professor of Pediatrics, University of South Alabama, College of  X7 ^9 m8 J$ {7 N! Q; d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 K/ ~# p% u, I6 s- R" He-mail: [email protected].
  H$ [6 N1 Z3 xabout 6 to 7 months old, which progressively became
+ m% v& x  b+ }1 B- K( ]+ m0 y/ Odarker. She was also concerned about the enlarge-
2 `& M7 f1 P* o, Oment of his penis and frequent erections. The child
6 Z" k6 p4 a; l6 \; ~; Nwas the product of a full-term normal delivery, with
8 i; o) b- ]( g8 [" @! p' xa birth weight of 7 lb 14 oz, and birth length of' O4 B1 B# ?) v* C( ^
20 inches. He was breast-fed throughout the first year6 c5 _* K" B8 Z
of life and was still receiving breast milk along with' A$ u* T( Y+ q/ Z
solid food. He had no hospitalizations or surgery,
2 a1 L6 F$ _& A9 D! N) {and his psychosocial and psychomotor development# F- L8 U0 A+ E% p2 u
was age appropriate.1 a8 u. x- }: H  ?2 N5 z- a8 {
The family history was remarkable for the father,
8 u  @7 S9 Z( g+ m1 `: Mwho was diagnosed with hypothyroidism at age 16,
  H: d) ?% w6 twhich was treated with thyroxine. The father’s
6 }2 Z: C0 K+ x" b" S; y$ Nheight was 6 feet, and he went through a somewhat, p: H% z) D1 d( t
early puberty and had stopped growing by age 14.( G. d' L+ c. ]# i9 M; f
The father denied taking any other medication. The2 w2 P+ L: C' a6 s$ ]
child’s mother was in good health. Her menarche
1 s( Z+ ]+ I7 a; T; J0 hwas at 11 years of age, and her height was at 5 feet
2 V( L. c, n$ }+ O0 D5 inches. There was no other family history of pre-
" V) P1 N& T) A8 F- G# l9 Gcocious sexual development in the first-degree rela-& N% w' [9 Y, m6 @
tives. There were no siblings.
4 l1 r3 M- Y* b3 K6 N& Z4 W% CPhysical Examination
: O$ \# `2 Y/ s( ]* e+ X- dThe physical examination revealed a very active,
5 m" R$ y- n# [3 gplayful, and healthy boy. The vital signs documented
: M8 N5 f) ]* S" G6 ma blood pressure of 85/50 mm Hg, his length was
/ z1 O% {" e  o( U2 n90 cm (>97th percentile), and his weight was 14.4 kg
1 i0 l" m8 U" l/ g% l) Q(also >97th percentile). The observed yearly growth6 O1 q4 l2 a. }8 V+ _
velocity was 30 cm (12 inches). The examination of
: H' `) O. C7 q" C/ Hthe neck revealed no thyroid enlargement.+ h% u2 P& n5 m" D) z9 x' G
The genitourinary examination was remarkable for3 H) L* h5 B4 ]4 F2 A( Y$ T
enlargement of the penis, with a stretched length of1 R2 a- y2 q1 Y+ A+ v9 c
8 cm and a width of 2 cm. The glans penis was very well5 V+ {$ i5 d2 b1 i% n! U  Q
developed. The pubic hair was Tanner II, mostly around6 L. J. u# p; I( u( a- _3 d& \
540
( D# U  v# m/ aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ @8 o9 y, u$ g- O& Wthe base of the phallus and was dark and curled. The
! H6 I# ]% j/ M# L* I( M4 utesticular volume was prepubertal at 2 mL each./ t6 C: f+ c% Z! f( ?5 X
The skin was moist and smooth and somewhat) N% D* j. a# D( S. j( W1 ~8 O
oily. No axillary hair was noted. There were no
! f2 `  `1 T/ j' ?% F& z! s7 k" R3 Xabnormal skin pigmentations or café-au-lait spots.5 f8 }% _# O: n  O
Neurologic evaluation showed deep tendon reflex 2+
# o: [, o( W- [bilateral and symmetrical. There was no suggestion
  _5 ]9 ~7 W0 X  k5 `of papilledema.- k/ s, q! a* \) S& \  C
Laboratory Evaluation
) w' h" u$ B4 e' x, U5 T" ?The bone age was consistent with 28 months by
# {4 g9 E0 v; f5 o% h. X; dusing the standard of Greulich and Pyle at a chrono-, R' W0 m# q2 V0 y  N
logic age of 16 months (advanced).5 Chromosomal! n1 ^/ n8 u, Z9 T: ^4 r8 S
karyotype was 46XY. The thyroid function test+ t& N% w+ c- r( h5 G0 ?
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& |& `, g% y3 u; M. L2 E! c5 N
lating hormone level was 1.3 µIU/mL (both normal).
/ g% H- w- Y+ C$ RThe concentrations of serum electrolytes, blood
9 j6 h% u$ S) r: C; K3 k' ^urea nitrogen, creatinine, and calcium all were7 M5 P) G6 O  J( E5 a0 L# e% ~
within normal range for his age. The concentration
& c, u" U3 t# ~% v! }; N9 mof serum 17-hydroxyprogesterone was 16 ng/dL. m0 _0 z  X0 r3 S  b9 [2 j; h: [
(normal, 3 to 90 ng/dL), androstenedione was 20
/ e4 X5 U2 Y' V2 e, O! hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ A, M5 Z- W3 X6 ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),% M( S% Y9 v  X% Z" x9 m; i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to% v* n3 P6 ^: b) Q
49ng/dL), 11-desoxycortisol (specific compound S)
6 B6 s! g" \* R5 u$ Y1 e0 swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 Y" i8 \! I. z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  c" `% ?8 Q8 }, c* A8 `3 ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 q$ {9 y/ N7 W; U+ s# T* b
and β-human chorionic gonadotropin was less than4 R8 b/ r* S1 n$ u) W& n( E
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 v7 Y1 W: ?. I' K. {; u- Xstimulating hormone and leuteinizing hormone
7 a0 Z7 {: A2 Fconcentrations were less than 0.05 mIU/mL
6 N# A' ^. }. m: |1 U(prepubertal).
( a) b1 V; F+ k% Z4 mThe parents were notified about the laboratory
3 f- T% W$ k- J, e+ K! t* L& q1 O+ _' Presults and were informed that all of the tests were  I1 N2 N, J) b! X6 l. T' T% h4 x
normal except the testosterone level was high. The4 [  X0 V& w& z/ M
follow-up visit was arranged within a few weeks to8 I# ^" R- q) J; P- }
obtain testicular and abdominal sonograms; how-& J4 K# q7 r5 a* m1 ?( `, Q
ever, the family did not return for 4 months.
" g) L' y- W8 ]% P- a% @7 E% w/ a6 E- a! dPhysical examination at this time revealed that the: P' a# i, i, F0 W2 A  g2 `5 `3 ^
child had grown 2.5 cm in 4 months and had gained, w$ v& P5 h: n, D  }5 S
2 kg of weight. Physical examination remained; Q0 m8 W/ F" V. H# P( m2 M
unchanged. Surprisingly, the pubic hair almost com-& P( d  X3 B$ p
pletely disappeared except for a few vellous hairs at
. [) P1 t! w! E$ ^& F7 G$ h7 ?, Wthe base of the phallus. Testicular volume was still 2
. v# v6 P+ R/ X% l+ g2 e0 {3 z% NmL, and the size of the penis remained unchanged.
' ~- X, w; v' jThe mother also said that the boy was no longer hav-
3 y3 l+ m5 k- m* g3 J; Q/ @  ning frequent erections.. |0 `; X) w3 h  J1 i4 h
Both parents were again questioned about use of
" c  s. F4 v/ Eany ointment/creams that they may have applied to8 n7 K- W+ ^% M. @
the child’s skin. This time the father admitted the
( b! ~0 U' F5 ~- Q7 m$ C4 S! lTopical Testosterone Exposure / Bhowmick et al 541
$ N6 s) d, [% g4 q; Luse of testosterone gel twice daily that he was apply-- c* ^! K. i4 X" T2 h; [" M3 S
ing over his own shoulders, chest, and back area for& z5 D* U9 m# |0 f5 s& O) r
a year. The father also revealed he was embarrassed
- \% ?2 c. C4 Z: k$ A1 N3 Mto disclose that he was using a testosterone gel pre-
* T. n/ X$ z! x' ?# l( qscribed by his family physician for decreased libido: j* X+ R9 r% i! K2 w2 e( O$ C  w" E
secondary to depression.2 g3 D) j4 g; r  r8 G- M; O0 _
The child slept in the same bed with parents.
( g& K& p. I8 _2 D, h: SThe father would hug the baby and hold him on his
, A5 y9 M+ j% U% F5 v7 k4 Echest for a considerable period of time, causing sig-
/ z( i: g, W  E9 `nificant bare skin contact between baby and father.( c2 `' F! m; G% o
The father also admitted that after the phone call,
* G( p& v$ W: {) P! j) E0 H2 C) swhen he learned the testosterone level in the baby
4 D. p  B' Z/ u. dwas high, he then read the product information$ O8 I* U) h' U
packet and concluded that it was most likely the rea-
7 ]1 C8 J- ]* y6 c7 E: \: Zson for the child’s virilization. At that time, they3 o2 T! E: p$ ]5 e& q9 _
decided to put the baby in a separate bed, and the
0 R' ~$ B7 V6 Y! `1 R8 `9 sfather was not hugging him with bare skin and had; Z9 x# Z% G; O8 ?8 p  d2 [
been using protective clothing. A repeat testosterone$ i' t$ q3 E, s! D  a
test was ordered, but the family did not go to the  Y* {* a8 v" N
laboratory to obtain the test.
3 U9 P" `; U% Q+ R$ u/ FDiscussion! D8 _- o9 F( G. N
Precocious puberty in boys is defined as secondary
) H% ~/ U( o0 i- ~9 ]1 Q% Xsexual development before 9 years of age.1,4- ]. v" s1 F2 X& O
Precocious puberty is termed as central (true) when( `/ w1 h; i3 H& C# o
it is caused by the premature activation of hypo-
" A$ t" \  `* l+ @4 Athalamic pituitary gonadal axis. CPP is more com-
# f& H, k' J8 Y8 q9 P( j) Y3 cmon in girls than in boys.1,3 Most boys with CPP
7 N/ @, @4 m5 i4 R% ymay have a central nervous system lesion that is
0 N7 t+ ^: `4 A, Aresponsible for the early activation of the hypothal-3 k7 f: N' h, Z' N
amic pituitary gonadal axis.1-3 Thus, greater empha-% J- K& p* a5 A" Q' @
sis has been given to neuroradiologic imaging in
  b9 Y% X' b/ K$ m0 yboys with precocious puberty. In addition to viril-9 _4 k" i& h! U$ x8 w5 Y- F/ Y
ization, the clinical hallmark of CPP is the symmet-4 I9 k& ?# S1 l% r- x1 d0 [  Y
rical testicular growth secondary to stimulation by
2 Z' e( M  H& Ngonadotropins.1,3
: }7 V& V& M# z5 ]0 B& t/ X2 jGonadotropin-independent peripheral preco-
4 y+ D5 K+ P9 b! h6 z5 T& qcious puberty in boys also results from inappropriate
4 u0 ]  N0 R$ u' g& @androgenic stimulation from either endogenous or! Q9 z+ D. R% e4 o: q
exogenous sources, nonpituitary gonadotropin stim-
2 v5 C7 M$ z0 X# Oulation, and rare activating mutations.3 Virilizing7 c/ B: ~8 b6 V
congenital adrenal hyperplasia producing excessive1 m6 R$ q5 w4 [) ?/ K
adrenal androgens is a common cause of precocious% x+ t, ]; w! }/ _) ]; A
puberty in boys.3,4
$ l% o+ M0 q4 S: c  EThe most common form of congenital adrenal
( m# g/ L. ~  ]! Zhyperplasia is the 21-hydroxylase enzyme deficiency.3 t7 |  f/ n1 h& _& \/ U
The 11-β hydroxylase deficiency may also result in
3 G' ^% }1 Y( _6 W# n! oexcessive adrenal androgen production, and rarely,: X% r# F  H) P% f6 Z
an adrenal tumor may also cause adrenal androgen
3 t* ]6 O3 |: x, pexcess.1,3/ }/ n: |, P3 w* {8 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 s! D8 ]0 |: w$ c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ U- ]( B' I1 N1 \
A unique entity of male-limited gonadotropin-
8 g  D7 k  B: F$ windependent precocious puberty, which is also known3 d9 }! S' K( q0 S
as testotoxicosis, may cause precocious puberty at a* i  _1 e; Z; O3 j
very young age. The physical findings in these boys1 t; F- ?- a6 N* j4 [: H
with this disorder are full pubertal development,7 _3 o6 `8 F9 E1 ]8 K7 {
including bilateral testicular growth, similar to boys
( w" k; d/ U" t" [with CPP. The gonadotropin levels in this disorder
7 l$ c: J# }3 Eare suppressed to prepubertal levels and do not show
: r9 I" C& ]4 _, u* ~pubertal response of gonadotropin after gonadotropin-3 x0 G# {; [3 d; l- n% m
releasing hormone stimulation. This is a sex-linked9 c! F% z* F" q, {# L. \7 ]3 _& m) M
autosomal dominant disorder that affects only: i6 B/ W3 }! W  H: M% O* a6 u
males; therefore, other male members of the family
$ P9 P$ u* \7 g7 @! G6 h, L" H, S4 `$ rmay have similar precocious puberty.3
3 W! ]* ~- M) f; aIn our patient, physical examination was incon-! `8 `- \9 J! _! S4 g/ C+ ^
sistent with true precocious puberty since his testi-0 c5 h0 C3 n0 J1 O
cles were prepubertal in size. However, testotoxicosis! \2 Q& q: n: x  h) {( e
was in the differential diagnosis because his father
* J" X, ^, h6 l+ F9 t7 Bstarted puberty somewhat early, and occasionally,
7 J% X% |2 [' c6 A3 g6 X, c- x0 `testicular enlargement is not that evident in the
3 ?  j: k  j5 ]  Mbeginning of this process.1 In the absence of a neg-
6 Y4 z. c+ I& |, Oative initial history of androgen exposure, our
5 w' C- D" b5 g+ w. r! Ybiggest concern was virilizing adrenal hyperplasia,+ ^! F& ~6 s- x; T  G( E4 n) K6 P
either 21-hydroxylase deficiency or 11-β hydroxylase
  j8 X% o) X9 x3 j2 N# T0 @deficiency. Those diagnoses were excluded by find-" x: n- I9 p! q0 U. p
ing the normal level of adrenal steroids.
; B) N$ U" m) N+ A! _The diagnosis of exogenous androgens was strongly# b$ z5 O: t' h, A
suspected in a follow-up visit after 4 months because1 q& q$ @: z+ C; e/ A
the physical examination revealed the complete disap-
, h. h" h- P! N# b7 ?2 B& Fpearance of pubic hair, normal growth velocity, and. d- d  n$ Z5 }9 `$ K* I
decreased erections. The father admitted using a testos-# J5 J4 ^2 O; V* s5 c. s) t2 D" k
terone gel, which he concealed at first visit. He was
& F- A  ?+ W& musing it rather frequently, twice a day. The Physicians’' e6 Q/ m! T0 c0 b
Desk Reference, or package insert of this product, gel or
% o4 f7 b5 s- p3 [, lcream, cautions about dermal testosterone transfer to
, |5 f& H6 h$ d- sunprotected females through direct skin exposure.
' J$ L* F6 c$ o$ sSerum testosterone level was found to be 2 times the
1 I. y& H" A( b) ~, ?8 b5 ^9 H& s7 `  ubaseline value in those females who were exposed to
0 |4 U- e% `  e6 \, I7 aeven 15 minutes of direct skin contact with their male1 \$ _% S) A3 `
partners.6 However, when a shirt covered the applica-5 D4 O, K" Q1 a2 C+ H; H7 U
tion site, this testosterone transfer was prevented.1 c: k# t5 i2 n$ ]5 T, p9 H; [
Our patient’s testosterone level was 60 ng/mL,, M, j" C1 ~: D9 \0 C* _, \: N3 B
which was clearly high. Some studies suggest that
( t" q5 P0 m+ q% I7 |0 sdermal conversion of testosterone to dihydrotestos-# Q, _- S4 z" H0 [' ?
terone, which is a more potent metabolite, is more
4 J: C1 O2 G% Wactive in young children exposed to testosterone, h. O6 ^; X4 J, H4 X4 Q* X1 u
exogenously7; however, we did not measure a dihy-" v0 t% p1 o9 W" U* c' E% Y
drotestosterone level in our patient. In addition to0 l: u  R- W* m; |4 G) e
virilization, exposure to exogenous testosterone in
1 G/ Y( \$ `" s. \' tchildren results in an increase in growth velocity and, J6 i# O& Z: _7 v
advanced bone age, as seen in our patient.  Z- ]% Y* H6 m$ o! j- e1 }
The long-term effect of androgen exposure during
7 y* q2 q9 i, jearly childhood on pubertal development and final
8 @8 c3 ^1 q) m' o0 zadult height are not fully known and always remain, ?0 _! |' b9 P, F  V4 t
a concern. Children treated with short-term testos-& p7 L9 P( E2 U, a* G
terone injection or topical androgen may exhibit some
. G- H( [! \% _& J; }( @acceleration of the skeletal maturation; however, after
) q3 z! S8 a$ M- g  x. c5 P, O5 d. g6 kcessation of treatment, the rate of bone maturation
- e% l% a( T/ Y- ^* X5 kdecelerates and gradually returns to normal.8,9
' k( V9 N! `" ]; C+ V$ dThere are conflicting reports and controversy6 @/ ~3 r  W+ r: P' E
over the effect of early androgen exposure on adult6 v8 R5 Z3 x1 q1 h7 A/ C7 I
penile length.10,11 Some reports suggest subnormal* s# b8 k  k5 D* |0 h8 F
adult penile length, apparently because of downreg-1 ?. n& d% D! f# ?3 r2 m
ulation of androgen receptor number.10,12 However,
* [5 h' W8 _  F  |2 ~2 b5 BSutherland et al13 did not find a correlation between
6 W: [3 K5 ^! x$ @" jchildhood testosterone exposure and reduced adult. {2 j2 z* D, K6 Z
penile length in clinical studies.( y) [/ Y5 A7 K3 J4 O& J
Nonetheless, we do not believe our patient is
7 N( t; z) Y- R; A4 d: l( @going to experience any of the untoward effects from
# e- P+ H. m/ S! i* B. Q  Otestosterone exposure as mentioned earlier because: I' y* @' ]; \0 s
the exposure was not for a prolonged period of time.! W( K) q) j4 ]$ r7 M) N% \+ a
Although the bone age was advanced at the time of
0 M- p4 Z& ]5 ?* c8 Kdiagnosis, the child had a normal growth velocity at) ]. L: W6 h# y% u* ?
the follow-up visit. It is hoped that his final adult# ]+ o( O/ _1 V
height will not be affected.
( q3 D; e* K: |7 h3 |: WAlthough rarely reported, the widespread avail-$ D4 P* h1 h9 |7 v9 O
ability of androgen products in our society may
2 A: i& S% S3 d) Aindeed cause more virilization in male or female9 m% f3 A3 d% Q2 P
children than one would realize. Exposure to andro-
! ^6 D1 y) Y+ W. b% y/ R" i3 a( o+ agen products must be considered and specific ques-; @& v' V2 M6 a
tioning about the use of a testosterone product or
0 j2 `/ n0 I4 ~( l# U$ ]gel should be asked of the family members during4 P! X0 ^2 _% N1 t
the evaluation of any children who present with vir-
- \4 ]' _# S5 hilization or peripheral precocious puberty. The diag-# a" w# |; A8 g$ {6 T& |
nosis can be established by just a few tests and by- B* P8 d+ Q. {  V0 T
appropriate history. The inability to obtain such a6 _/ ~9 a# t- t) {0 o2 p! y
history, or failure to ask the specific questions, may
3 X' j3 H) h! {: f2 q8 ^result in extensive, unnecessary, and expensive  ?% E% S  g. \9 B( l7 I0 B" y! v
investigation. The primary care physician should be, [3 n- I; D! b" P) s, p2 e
aware of this fact, because most of these children" }/ v  `7 d2 Q
may initially present in their practice. The Physicians’
. B' u4 H, P$ b2 G1 ^6 n+ SDesk Reference and package insert should also put a% C- Y1 @# `7 W7 t- d
warning about the virilizing effect on a male or
; l% b1 r& f/ Z3 Sfemale child who might come in contact with some-
8 I8 b- c  Z6 e% `one using any of these products.
- F' y5 J! P, W+ |0 |References, I; r3 s6 m1 m, n
1. Styne DM. The testes: disorder of sexual differentiation' Z1 B7 Q) ?+ K% n0 y
and puberty in the male. In: Sperling MA, ed. Pediatric
9 I3 g! T8 d& P4 s- P: dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 i2 H( D8 Z( u6 R. z/ h5 j2002: 565-628.; i% O3 u  f5 q/ d! F( Y9 b. a
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  f! p2 l2 _8 H& ~, l3 Npuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
6 z! ^2 P3 \( R' A' M2 W( P  oBoy Induced by Indirect Topical+ t* Q& b( S( z5 V4 E# q+ N
Exposure to Testosterone- T9 E4 K- }) X" ]- I4 I# h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 h: Q+ t# Z0 z' @5 S/ Q
and Kenneth R. Rettig, MD1
7 w' @  {% j" a* w5 AClinical Pediatrics" [3 [1 Z8 a7 Q: C! ]. w, g
Volume 46 Number 6
5 S; i' o$ |0 \% P& \8 vJuly 2007 540-5431 Q, _# k+ u( S6 M; w
© 2007 Sage Publications
: O# Y8 J7 ^9 T4 U10.1177/0009922806296651& D3 `  u# M3 a4 e$ l  m5 _
http://clp.sagepub.com
6 N! a" |: o. thosted at
6 P7 k& V4 m: Dhttp://online.sagepub.com! {' L; l& C  l+ p& Q- T
Precocious puberty in boys, central or peripheral,7 Q, ~. ]% X* X) v' \9 t. e
is a significant concern for physicians. Central
, A& x( B! [& s' s0 ?5 `8 v2 Gprecocious puberty (CPP), which is mediated
( n; }: d3 A; W7 X) jthrough the hypothalamic pituitary gonadal axis, has
$ d) {# q! H% x/ S% `1 A) r" N7 qa higher incidence of organic central nervous system
: t7 C; m2 J$ W9 h' nlesions in boys.1,2 Virilization in boys, as manifested
! S8 f. y. n) w  J  R. Jby enlargement of the penis, development of pubic
" y5 S' Q- p- A, X; ^2 U6 s, Uhair, and facial acne without enlargement of testi-
7 m! @. T) x9 A$ w# }3 o& k& T( gcles, suggests peripheral or pseudopuberty.1-3 We
2 [* ~" j' X6 |report a 16-month-old boy who presented with the5 x! I# E, E7 j' n
enlargement of the phallus and pubic hair develop-! ^8 B, J! t' {! V
ment without testicular enlargement, which was due
! |4 h  c5 O9 sto the unintentional exposure to androgen gel used by% q: d% ^9 ]0 `) C6 c4 s8 I: K
the father. The family initially concealed this infor-
# @, S! c; p# W9 X  A( p+ c6 Xmation, resulting in an extensive work-up for this: j. u( }0 l0 e: {1 l& R% k, E" Q0 U
child. Given the widespread and easy availability of7 c, p% D9 J0 ]+ E6 h/ u- W  j
testosterone gel and cream, we believe this is proba-4 ?4 o  m+ h  M9 G
bly more common than the rare case report in the9 Y1 v$ x1 W3 g+ b0 c" @# {$ ?
literature.4
  P& P& t# u+ p1 h2 _Patient Report7 A/ [& V8 p. M
A 16-month-old white child was referred to the
: A5 d) q& y0 t+ uendocrine clinic by his pediatrician with the concern: S" Q2 W7 {9 f/ f% Y9 v
of early sexual development. His mother noticed- z! y6 Y& ^9 T8 J
light colored pubic hair development when he was& A1 k$ K3 n$ Z- b
From the 1Division of Pediatric Endocrinology, 2University of
( k% p7 ^& G* G( R5 H5 vSouth Alabama Medical Center, Mobile, Alabama.
$ ~3 v4 o4 F: o9 Z# E6 l+ Q3 c2 q6 oAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 s) X# H5 t  E7 M
Professor of Pediatrics, University of South Alabama, College of
4 c6 L& [8 H) ?! _" f5 EMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 U' Z, Y1 O: U5 J, U& {
e-mail: [email protected].
' ?+ Y  W& e) t$ O- d0 Yabout 6 to 7 months old, which progressively became' G% T0 k' k$ Y  X
darker. She was also concerned about the enlarge-& l7 w, @0 n( z! L7 s" a1 B& t  z$ `
ment of his penis and frequent erections. The child
- f' G5 h' t2 n3 b* G+ m8 \was the product of a full-term normal delivery, with
& x) B9 y1 i2 T* g: sa birth weight of 7 lb 14 oz, and birth length of6 A0 d  ^. b! W- G3 \
20 inches. He was breast-fed throughout the first year
3 E- [) S) Q" h$ G5 `6 F/ A' D, rof life and was still receiving breast milk along with
3 z* P. W% E# _( W1 L) |solid food. He had no hospitalizations or surgery,6 l1 {) N; Z0 j& n" d- e0 c6 l' w
and his psychosocial and psychomotor development
5 s. N) I# M5 j( Q. A  zwas age appropriate.- N8 @' D. [9 |+ H! l3 ^
The family history was remarkable for the father,
! z* }9 j+ L  k5 r/ r5 mwho was diagnosed with hypothyroidism at age 16,. g+ l0 |0 k9 I, u  f% A  J2 T+ B
which was treated with thyroxine. The father’s. e# R0 N# ~: X, k' {. f% I: @3 w, z5 o* k
height was 6 feet, and he went through a somewhat+ o. P! Z% k* K! U- _) _! }' U* V
early puberty and had stopped growing by age 14.$ }6 l" c' y# S% B
The father denied taking any other medication. The
# J& I) b. v3 X2 wchild’s mother was in good health. Her menarche3 |* s( V* E$ I1 {) X- e
was at 11 years of age, and her height was at 5 feet2 t( N' y6 s% o7 ~; p5 S
5 inches. There was no other family history of pre-" d$ K' K0 k4 g- Y# q3 W: l
cocious sexual development in the first-degree rela-( ^  `8 u) K, K# r) o& m2 Y/ p
tives. There were no siblings.( B  r: B5 Z2 C$ B9 a" Y- Q
Physical Examination
: N* Z/ K% y$ o; jThe physical examination revealed a very active,
& t& W  P& P0 p; xplayful, and healthy boy. The vital signs documented
/ c3 K, }& J& d) g" q# c' h/ X# Da blood pressure of 85/50 mm Hg, his length was6 s! C& Y! ]% q6 D  N& R3 F- p
90 cm (>97th percentile), and his weight was 14.4 kg7 A5 ^# T: ^0 P: C; _1 ?! g
(also >97th percentile). The observed yearly growth
1 i4 Q6 B% m  R. z/ y7 d! Zvelocity was 30 cm (12 inches). The examination of
4 m, f5 L; u; S5 p/ x/ Zthe neck revealed no thyroid enlargement.
! ~' a+ t, B% FThe genitourinary examination was remarkable for
- P/ ~' `6 L& |, g& c! g# penlargement of the penis, with a stretched length of
6 P& v/ `2 K8 ?1 X* `: @+ Z8 cm and a width of 2 cm. The glans penis was very well& _* ^$ h8 B  e, R2 {' ^9 ]7 e
developed. The pubic hair was Tanner II, mostly around
3 d0 I5 M! S, P( ^$ j$ h! q) ?540( B3 g1 g% u" I6 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" y0 G8 K" }9 c) I( Sthe base of the phallus and was dark and curled. The
5 [+ P+ Z0 u# h& }% Ttesticular volume was prepubertal at 2 mL each.
& E1 h: q$ [( X* O+ ~# g- T! WThe skin was moist and smooth and somewhat
1 q5 Y( |9 c1 D( e0 B$ r4 @oily. No axillary hair was noted. There were no; O  v) s  e* z* }: }3 O4 F5 p- |
abnormal skin pigmentations or café-au-lait spots.
4 [$ P1 K% y; S; }5 `Neurologic evaluation showed deep tendon reflex 2+! ~& G8 {3 s, C0 ~
bilateral and symmetrical. There was no suggestion
7 ~$ X3 l4 q4 y, D3 Y) nof papilledema.
4 B% }: e% _& Q' v; KLaboratory Evaluation
7 Z9 x8 r% R4 m& mThe bone age was consistent with 28 months by
( b/ }, U2 A, Rusing the standard of Greulich and Pyle at a chrono-
' g$ t# f; S' ~: \8 m+ |' w- f( d+ Nlogic age of 16 months (advanced).5 Chromosomal' a2 P0 N- y: D
karyotype was 46XY. The thyroid function test) P' [, k! Z' s( R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 Z, T( s, H: t! C6 s" L# o0 H8 l% mlating hormone level was 1.3 µIU/mL (both normal).0 b' F! f) d' F8 G0 ^+ y6 w8 ]
The concentrations of serum electrolytes, blood
9 i: r3 i/ c( S$ m: X( g+ G% l. A' ?urea nitrogen, creatinine, and calcium all were
# F/ _& @4 I1 x; I: N, Uwithin normal range for his age. The concentration
  x/ t' A# J/ [. V# }of serum 17-hydroxyprogesterone was 16 ng/dL2 u; |5 \2 b$ H% E6 @# u
(normal, 3 to 90 ng/dL), androstenedione was 20! D8 r  K3 m1 o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! |9 ~1 Y; W+ C$ v- U" ?, z/ Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),
- m) \/ k5 `& Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to8 L  L/ |2 m  _; `
49ng/dL), 11-desoxycortisol (specific compound S)
- ~6 m! i& M7 t7 X! twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% Y+ X5 `% c+ L1 ^1 Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 |: q; e  x' T8 ]" m1 l8 btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 m  [9 u! o4 {, jand β-human chorionic gonadotropin was less than
; Q! v4 J! b  N1 V5 mIU/mL (normal <5 mIU/mL). Serum follicular% |/ O  H* y/ J) q
stimulating hormone and leuteinizing hormone
, [: x9 x' _& R' d& v$ s4 `- d+ t6 b1 Iconcentrations were less than 0.05 mIU/mL" l+ r! E  S% K! J5 U
(prepubertal).: N2 e" x* |% M
The parents were notified about the laboratory
2 H6 X7 W1 g3 z" c5 p4 Lresults and were informed that all of the tests were8 I3 j+ |# e5 ]' K" B
normal except the testosterone level was high. The
5 q: o* }# R  ^follow-up visit was arranged within a few weeks to
+ z8 S) Q  M9 E) f0 Z7 Yobtain testicular and abdominal sonograms; how-! R3 Y" t3 U- F- m
ever, the family did not return for 4 months.& B; p) e5 J  }) U, C. L  z4 u
Physical examination at this time revealed that the
' Y7 }. s  t) z8 Cchild had grown 2.5 cm in 4 months and had gained
% z# |7 d; P6 a, z* q; q/ R4 \9 E2 kg of weight. Physical examination remained  p( X; r7 a$ k+ m3 L" }
unchanged. Surprisingly, the pubic hair almost com-! t3 U9 z0 K9 ~! A$ f( f- Q
pletely disappeared except for a few vellous hairs at
/ p8 Z% U+ f: ?, w! Wthe base of the phallus. Testicular volume was still 2
. f5 b, L6 Q- G! N1 h( d7 T  |mL, and the size of the penis remained unchanged.
" I4 ]9 u3 s/ H, I  K* IThe mother also said that the boy was no longer hav-1 g. i' y/ w" X" J! t# P; }* x
ing frequent erections.
* l+ J) ^' q$ P0 B! aBoth parents were again questioned about use of
: q/ }4 k, s' l! l& Y' I3 xany ointment/creams that they may have applied to
0 p" C/ y- r  x2 L% k( `the child’s skin. This time the father admitted the, O* X* T$ r6 T
Topical Testosterone Exposure / Bhowmick et al 541
8 U# `6 l# `: Iuse of testosterone gel twice daily that he was apply-
3 C1 J! q9 X1 D& ring over his own shoulders, chest, and back area for/ z& h( M& m3 [1 u1 A" X, }; ?
a year. The father also revealed he was embarrassed8 S* y/ O& r' m6 O! [
to disclose that he was using a testosterone gel pre-8 Z7 W7 S2 }1 M+ k
scribed by his family physician for decreased libido0 C. T$ a) Y% f2 C4 V; T
secondary to depression.
- f: h- e/ @' U, r# E& XThe child slept in the same bed with parents.
/ w/ @) S/ ^; \+ ^2 j0 W4 r* [The father would hug the baby and hold him on his8 J* |; f) a1 [0 Y
chest for a considerable period of time, causing sig-
( X0 R5 y. q& knificant bare skin contact between baby and father., l$ Z$ p0 Q& {' B0 h6 W4 F
The father also admitted that after the phone call,' i, C# Y5 g0 l  K& g( p
when he learned the testosterone level in the baby% e$ B0 @8 G  u- z0 x3 u/ ~, ~' C
was high, he then read the product information
: H) U+ T: |; l1 z# e# Tpacket and concluded that it was most likely the rea-
+ O! r3 a+ f) C1 k5 B  lson for the child’s virilization. At that time, they. J# H) m; t8 ~- X7 i4 x0 @+ h8 E
decided to put the baby in a separate bed, and the
: _2 B. e% Q) |& Yfather was not hugging him with bare skin and had
' v9 _, y) A8 ^been using protective clothing. A repeat testosterone
. \  R# v/ m- S" w8 ]4 k) v5 ntest was ordered, but the family did not go to the
* m$ l5 j& t) O2 r5 O* _: y3 _laboratory to obtain the test.
' ~8 h: y2 R  E: v% u- z4 G, r' ~/ F; `/ xDiscussion
; H9 [; E# D$ rPrecocious puberty in boys is defined as secondary
2 }4 A* l, d) s; E' q& Hsexual development before 9 years of age.1,4
0 y( T8 u3 B7 a1 Q. n/ P8 S- Y+ L8 fPrecocious puberty is termed as central (true) when8 L- ~6 X5 j1 z0 C8 S; ~, ^5 Z! a% g: P
it is caused by the premature activation of hypo-; O- M- X9 B+ \' a6 S6 z& d
thalamic pituitary gonadal axis. CPP is more com-
* ^1 r/ x' u% W6 Rmon in girls than in boys.1,3 Most boys with CPP
5 i) a' m+ m) ?+ p8 S8 ?, amay have a central nervous system lesion that is$ ?% K( C6 W. f& w
responsible for the early activation of the hypothal-( C4 ?! I" x2 E3 z+ Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 k3 v! }8 z0 Z6 \7 l1 z- Z. w# osis has been given to neuroradiologic imaging in/ C+ O, K. S5 S" o
boys with precocious puberty. In addition to viril-# k4 q3 o5 L, S$ v# t
ization, the clinical hallmark of CPP is the symmet-
2 p# n/ ?- Y, }$ M( srical testicular growth secondary to stimulation by
* O+ e) e, u+ {9 W: `/ b* a. w6 @; _gonadotropins.1,3
* K6 [, d+ O' B, p: h$ ~Gonadotropin-independent peripheral preco-2 G7 d* a% U: k. N2 A
cious puberty in boys also results from inappropriate
! n) b7 G) V2 a; T/ M1 Bandrogenic stimulation from either endogenous or
8 d. _0 W7 t7 v; Mexogenous sources, nonpituitary gonadotropin stim-
" p: L5 M; G4 H* M( x9 Rulation, and rare activating mutations.3 Virilizing
& G7 P' h4 Y% M4 icongenital adrenal hyperplasia producing excessive
7 i2 z: y. n# K6 ?. e' I& tadrenal androgens is a common cause of precocious) c  |" B, [$ t  ~, `! @# A$ o
puberty in boys.3,4
: A5 w! S7 k0 e0 q9 r# g* ^$ ~5 cThe most common form of congenital adrenal
9 e1 d7 Y( t0 u/ o6 Q" O* ^hyperplasia is the 21-hydroxylase enzyme deficiency.( a7 `( Z$ N1 {0 w! w/ d$ u+ G
The 11-β hydroxylase deficiency may also result in, w; }* \7 h2 \4 S
excessive adrenal androgen production, and rarely,1 Q3 B0 d8 u4 R
an adrenal tumor may also cause adrenal androgen
" f, |5 ^% y, L, r) `7 U3 Yexcess.1,3: w, ~9 J% ~/ A$ {- v# V( [/ s: J/ Z" ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ V3 {$ u( r! q5 H! b; b
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 Y! ]+ ]" \! r' P! g0 z2 O, @: f
A unique entity of male-limited gonadotropin-
' u! c' \* m+ H6 windependent precocious puberty, which is also known' b4 W2 ^0 G. y: w2 }
as testotoxicosis, may cause precocious puberty at a
8 ~4 G3 u1 u3 \! N: vvery young age. The physical findings in these boys" |% K1 W/ L* T" W3 Q
with this disorder are full pubertal development,( g- }# g6 Z- P3 N
including bilateral testicular growth, similar to boys" e" U) y" u' I  N( i
with CPP. The gonadotropin levels in this disorder" ^+ I/ f6 N6 L. f$ x
are suppressed to prepubertal levels and do not show
& b8 w7 l' u3 x0 Spubertal response of gonadotropin after gonadotropin-$ v. f" H8 ^8 `8 D6 V. ^0 O$ a% Z
releasing hormone stimulation. This is a sex-linked
- g! A  a6 c1 T( M) A1 M5 qautosomal dominant disorder that affects only
- j. C. S% i& cmales; therefore, other male members of the family6 ?" f& u! x) c1 W. E% u* E
may have similar precocious puberty.3' I) r' f( M/ r
In our patient, physical examination was incon-" u* ]! f2 z6 _5 b& l# i' Z
sistent with true precocious puberty since his testi-
: S7 ?. b- J& K. B) `# icles were prepubertal in size. However, testotoxicosis7 o( S' e5 ^- ~" h/ w1 q
was in the differential diagnosis because his father9 }5 K( @6 h$ ?) h
started puberty somewhat early, and occasionally,
. H: E% z6 @9 W* \, |, t1 t; Ytesticular enlargement is not that evident in the, k1 n$ w4 k1 Y) c
beginning of this process.1 In the absence of a neg-
6 r& T& [  l- L5 M6 K# Uative initial history of androgen exposure, our
/ W- q+ ~! J" j, A: s! ]! Ybiggest concern was virilizing adrenal hyperplasia,
/ k# ]9 }/ x4 @either 21-hydroxylase deficiency or 11-β hydroxylase
0 m3 D3 B* T9 |! Q5 G0 G) e" vdeficiency. Those diagnoses were excluded by find-
" `) c: m, a# J! Ring the normal level of adrenal steroids., f3 b' |# R9 S: D
The diagnosis of exogenous androgens was strongly
* s1 z8 N/ ?- \$ ^( E) gsuspected in a follow-up visit after 4 months because
& c' v  E6 m8 s" ^3 I$ athe physical examination revealed the complete disap-; Z6 m6 q$ `* T' A4 s
pearance of pubic hair, normal growth velocity, and
% j4 `2 z  o& ^$ ^9 @decreased erections. The father admitted using a testos-0 x% S& m7 b1 u; ]- t" y- p+ K, J/ ^
terone gel, which he concealed at first visit. He was
5 u" k) }# B/ u0 J) @using it rather frequently, twice a day. The Physicians’% I# \9 B& z$ q- ^
Desk Reference, or package insert of this product, gel or
+ o. m, b' Q0 g5 A' M& Tcream, cautions about dermal testosterone transfer to
. F4 h+ L* z- K1 P' E4 ^) S! m# Q" bunprotected females through direct skin exposure.
+ Q* U( l1 [* |Serum testosterone level was found to be 2 times the
& r" @* o# x, X0 G( t, wbaseline value in those females who were exposed to& d( D0 R" t0 d1 j  O- n
even 15 minutes of direct skin contact with their male# w6 V" F2 F* v! R; N# P
partners.6 However, when a shirt covered the applica-: h" G6 z& h  B, c8 g
tion site, this testosterone transfer was prevented.
: z; ]1 ~5 Y5 m+ a1 NOur patient’s testosterone level was 60 ng/mL,# E6 G( I0 Y, ^
which was clearly high. Some studies suggest that5 ~, B" t' _2 \4 P8 y( c
dermal conversion of testosterone to dihydrotestos-
4 ^" e2 w/ {9 I' V6 {8 P7 T+ Q  V4 I+ R. cterone, which is a more potent metabolite, is more
: s, Z3 q/ c5 C6 Tactive in young children exposed to testosterone! V. f- C4 Z! M  s
exogenously7; however, we did not measure a dihy-
2 D( @7 K2 Y# r2 D$ ?3 Jdrotestosterone level in our patient. In addition to
* O$ \! D5 q+ M4 R2 {virilization, exposure to exogenous testosterone in
7 F8 {( e. g* W: h. v. echildren results in an increase in growth velocity and
, @- l2 L( E6 i9 zadvanced bone age, as seen in our patient.4 B7 _% Y( f9 m8 ?0 ^" N1 K
The long-term effect of androgen exposure during+ y8 q3 v) f5 o" _
early childhood on pubertal development and final. y) U( H% w* @* h& a2 C9 u* ^
adult height are not fully known and always remain; [: D' X0 T- ~  [
a concern. Children treated with short-term testos-
/ E. Y  H) o* e: H0 E0 Zterone injection or topical androgen may exhibit some" X5 i& F" b+ `" e0 S" @" k
acceleration of the skeletal maturation; however, after
7 k  G. o; \; V2 |cessation of treatment, the rate of bone maturation
  j2 Q6 X) Z  R4 ?decelerates and gradually returns to normal.8,9
% s. q) P1 W' ]$ t: ^+ M' \There are conflicting reports and controversy
# Y  [/ a# y- v1 \+ Bover the effect of early androgen exposure on adult& G0 P6 g+ G  j& H, ^4 H
penile length.10,11 Some reports suggest subnormal
, G; N4 o) r- j2 y1 vadult penile length, apparently because of downreg-
( S; h0 Y- L$ {ulation of androgen receptor number.10,12 However,# O; K  @, J8 t
Sutherland et al13 did not find a correlation between8 k* _9 y1 _4 t$ i2 A8 f4 i
childhood testosterone exposure and reduced adult
2 A, P4 O1 K# @0 q2 Z7 _penile length in clinical studies.' n  a  \" e+ X4 V7 @
Nonetheless, we do not believe our patient is
9 P& ?: T0 W$ p$ ~" sgoing to experience any of the untoward effects from
) e! A6 w- h4 p9 ftestosterone exposure as mentioned earlier because6 n& o7 N/ ~8 Y9 r$ x* F& W: n
the exposure was not for a prolonged period of time.% P/ v% V" p8 ~& x" X
Although the bone age was advanced at the time of+ p$ }5 y/ _6 p. }
diagnosis, the child had a normal growth velocity at) Y, r1 v, T7 J
the follow-up visit. It is hoped that his final adult
- ~& h4 A& v& fheight will not be affected.# z' r7 J3 X( U
Although rarely reported, the widespread avail-
* y5 ]9 r, ]' d" i- S& Uability of androgen products in our society may
3 v7 F3 g) i6 c/ N2 W. v! tindeed cause more virilization in male or female( S6 Q7 Y+ q/ v5 L
children than one would realize. Exposure to andro-+ C* w4 D- {, @, T/ S- k$ @
gen products must be considered and specific ques-& V$ f3 v. y/ e- O
tioning about the use of a testosterone product or
: i% b3 o% W" q6 g/ |$ t2 x- G- kgel should be asked of the family members during
5 ]; [! d2 d4 U) p  Vthe evaluation of any children who present with vir-
/ m  e: [; Y  g  T' K2 \ilization or peripheral precocious puberty. The diag-
! ^( b- B- ]# Ynosis can be established by just a few tests and by9 a  R" _  y' g" }
appropriate history. The inability to obtain such a, Q5 j# Y+ T7 V/ k
history, or failure to ask the specific questions, may
4 g+ L' \5 |* o% Mresult in extensive, unnecessary, and expensive
! |0 W) a. n' v/ x0 Finvestigation. The primary care physician should be- `+ d' g( U' m% X
aware of this fact, because most of these children7 y5 X# q  [, e$ K7 t1 u
may initially present in their practice. The Physicians’/ a8 \4 g1 e6 k5 W# r
Desk Reference and package insert should also put a) N1 O3 |+ a+ M1 M
warning about the virilizing effect on a male or
0 P& s! H! X' r' ^& G: Bfemale child who might come in contact with some-$ }' e; J# x* H% x4 _" E1 I9 d4 ?
one using any of these products.
; u  G( m7 s& }; L& o( qReferences
8 @% p2 I. \) ?3 z) x2 M1. Styne DM. The testes: disorder of sexual differentiation+ F0 ?1 I8 |. b
and puberty in the male. In: Sperling MA, ed. Pediatric
/ y0 t9 i! S4 B6 i7 _1 TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' {5 @8 l* n6 s2002: 565-628.
: }) B: C3 V) K$ Z+ i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. v( ~, U9 g4 ^. C& s
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
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
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

& J+ `( B; ]$ x& j- e" z5 v* x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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