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Sexual Precocity in a 16-Month-Old. ~& s9 K# K- d+ D- _$ ?. c
Boy Induced by Indirect Topical
) S4 d( w+ ~# a* A- fExposure to Testosterone* ?  e( G9 f' A, N6 O$ Y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 R- C/ s. k- h) v  t2 O& h
and Kenneth R. Rettig, MD1! j$ u; I/ }! j% u0 B: F0 R
Clinical Pediatrics
% [& H' z( B; T0 u7 H1 ^* c6 ]Volume 46 Number 62 x4 r3 M/ q+ [7 B5 G1 c) e2 |4 z* ^
July 2007 540-5432 B, c& N1 M1 H/ ~
© 2007 Sage Publications
  J4 i  t; y$ K3 D5 a10.1177/0009922806296651, Z. o$ |) R8 c, j1 Q' h
http://clp.sagepub.com" N1 [" q8 C2 Z. ]4 I
hosted at) Z- E, G) q+ i( h
http://online.sagepub.com
4 \/ x1 e4 A/ XPrecocious puberty in boys, central or peripheral,
  f3 s. O( X9 q% V5 S3 e2 t4 Zis a significant concern for physicians. Central" R% a7 f% Q0 F  K) s0 A& x/ D
precocious puberty (CPP), which is mediated+ \2 ]2 c2 \7 G& I; d7 t# F
through the hypothalamic pituitary gonadal axis, has
4 o5 `* V( p* Ra higher incidence of organic central nervous system6 d  ^' s7 R" K
lesions in boys.1,2 Virilization in boys, as manifested
* S2 Y1 p) B1 c# Fby enlargement of the penis, development of pubic  i9 m* @+ n1 `! z: [
hair, and facial acne without enlargement of testi-
0 t% {8 u: h6 ?6 y1 {cles, suggests peripheral or pseudopuberty.1-3 We
1 @( @% O. b2 U: C# ~1 J: rreport a 16-month-old boy who presented with the3 L+ M, x( Q" k2 J, g, E
enlargement of the phallus and pubic hair develop-
" h! p  G  E: L' m( j: B6 Gment without testicular enlargement, which was due7 V- q5 ^" F' j: S* N0 R+ P" a
to the unintentional exposure to androgen gel used by; p8 p3 e6 a5 S) B4 L/ i
the father. The family initially concealed this infor-- }5 ^8 O" y. |2 r0 a
mation, resulting in an extensive work-up for this6 t4 g" w7 J- B- p5 `+ u; i% N$ {
child. Given the widespread and easy availability of/ F, y% M: `" Q. [! f1 k! B9 V
testosterone gel and cream, we believe this is proba-
/ K2 U; o( ^) R+ w2 A* Ebly more common than the rare case report in the. x1 q! ^; n" a
literature.4
/ m4 W5 n! @# b/ X/ G. cPatient Report: n1 U( T" j( o0 k4 }$ u0 w4 ~5 y7 j
A 16-month-old white child was referred to the/ P6 S# {$ o' e$ v' C
endocrine clinic by his pediatrician with the concern
; T0 k! J- c7 N1 {  a6 pof early sexual development. His mother noticed
5 u" y0 C" K) Z5 o; _- Elight colored pubic hair development when he was
' l0 m6 g& t! `From the 1Division of Pediatric Endocrinology, 2University of
/ e8 G- g) i/ |8 M1 ~South Alabama Medical Center, Mobile, Alabama.. O4 S+ L# b) D4 b/ `! T5 K; v" n
Address correspondence to: Samar K. Bhowmick, MD, FACE,$ _, [" k! B8 U: C! X9 Z- r; i: R
Professor of Pediatrics, University of South Alabama, College of5 @! e+ x+ k* o+ n/ p0 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  p$ ]' ]% Q$ T; T. O2 R
e-mail: [email protected].. o$ K, X0 F0 |) J+ a! n, A0 G* u
about 6 to 7 months old, which progressively became: F4 C' `  _# n1 O$ y
darker. She was also concerned about the enlarge-2 {3 h' y* O( {' J) T
ment of his penis and frequent erections. The child
  r* l' K# R1 h+ uwas the product of a full-term normal delivery, with
/ ?) g0 v2 w, Sa birth weight of 7 lb 14 oz, and birth length of
9 K2 ?, z* Z5 }4 _$ e20 inches. He was breast-fed throughout the first year
( L- h- d7 b! ?" e, mof life and was still receiving breast milk along with
4 W# P* n; |) `2 d0 Qsolid food. He had no hospitalizations or surgery,
! k2 e) d* s( X8 p* Uand his psychosocial and psychomotor development
, v: U+ f/ T& \was age appropriate.
+ ?9 W3 a9 W' Y8 Z2 ]+ CThe family history was remarkable for the father,
9 |1 [" W# v1 W6 f: uwho was diagnosed with hypothyroidism at age 16,
% L- H1 ^& F+ J' C, P9 p5 Ywhich was treated with thyroxine. The father’s
1 {; B- g% y) A; S8 Jheight was 6 feet, and he went through a somewhat( q  ~8 r3 b8 Z
early puberty and had stopped growing by age 14.5 i2 C7 b7 U+ @2 Z, Y" d
The father denied taking any other medication. The2 p2 }6 Q; ^! q$ q2 O/ a6 @# A
child’s mother was in good health. Her menarche
+ r7 e1 m: o" P: h$ X# f$ G/ Vwas at 11 years of age, and her height was at 5 feet
4 k3 C3 X5 j% w& @+ \5 inches. There was no other family history of pre-
) O0 D5 z8 W8 P( |- h+ @cocious sexual development in the first-degree rela-
* ~4 n* ^! e, dtives. There were no siblings.9 [7 L! p* I& {6 Z
Physical Examination. x" K2 U! g+ l3 m! F
The physical examination revealed a very active," K/ g% u, [( t0 ]* b: G0 b6 m6 n
playful, and healthy boy. The vital signs documented
' M) V; O% y! `; t( h, Na blood pressure of 85/50 mm Hg, his length was& w7 _: n- A2 u7 a' G: a8 K
90 cm (>97th percentile), and his weight was 14.4 kg
, ?& Y$ A7 i2 M+ I6 X' r(also >97th percentile). The observed yearly growth" S: i0 }0 D! c9 L6 V; r
velocity was 30 cm (12 inches). The examination of$ @7 f, ^& D" i2 {/ l4 d
the neck revealed no thyroid enlargement.
0 R) C+ e" b1 X) |7 f1 ?$ n2 BThe genitourinary examination was remarkable for
) x) E# w7 K( ~" v+ [! ?6 uenlargement of the penis, with a stretched length of
2 o7 V( h. ~; e! @* a& M8 cm and a width of 2 cm. The glans penis was very well0 c6 Q- X8 Z) I4 u
developed. The pubic hair was Tanner II, mostly around0 N+ D, _$ v. k% I6 u/ `
540
" M) B' N# m$ q/ W% {# w# tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 H9 A, k) @0 ?0 J
the base of the phallus and was dark and curled. The
( r! Z1 J* u$ H, g! g0 itesticular volume was prepubertal at 2 mL each.
2 S2 ~% c; J( D  z4 q+ v2 l5 mThe skin was moist and smooth and somewhat
- t; L( X7 p. l, Y3 h2 _oily. No axillary hair was noted. There were no
6 W, }; _2 x/ G- @, k% |abnormal skin pigmentations or café-au-lait spots.
& [/ }6 D" z$ ]: N  E  v5 q& `Neurologic evaluation showed deep tendon reflex 2+) I* q% O3 {# H) O, t- h( Z
bilateral and symmetrical. There was no suggestion9 f. ^# @& Y* X3 |, [# S+ X
of papilledema.
# [( P- g) G, J) Q1 B+ pLaboratory Evaluation; J9 y6 T7 g1 z* p& B- M
The bone age was consistent with 28 months by
$ h+ i1 ?0 A: i  Zusing the standard of Greulich and Pyle at a chrono-
) n( n0 g* _4 ^# t! Z; \- Mlogic age of 16 months (advanced).5 Chromosomal0 \) U2 `- \& ?8 `6 x& Y7 R
karyotype was 46XY. The thyroid function test" s: f$ t& y0 C+ ?
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. ~3 E% t' g9 l1 Y& X4 Mlating hormone level was 1.3 µIU/mL (both normal).
4 W) E6 _( X6 y# Y! eThe concentrations of serum electrolytes, blood2 Y" F" P% ?# N; u6 n
urea nitrogen, creatinine, and calcium all were
7 a& T, C0 q% k5 f9 Mwithin normal range for his age. The concentration
( K) m, W/ _3 C1 G* yof serum 17-hydroxyprogesterone was 16 ng/dL% V& r( g9 e3 t
(normal, 3 to 90 ng/dL), androstenedione was 20
2 O% \, \3 K8 l! @; y6 \0 ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 ~! M4 N& z5 \5 c+ ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
' q* f% A2 H! Z; h! s8 T7 X8 K3 a0 Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" o7 z. B8 F1 y7 [
49ng/dL), 11-desoxycortisol (specific compound S), \4 O% G  J' t8 R5 ?8 k9 g! R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ w/ H+ k# L* i) }: ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 r1 z+ h: d. G7 q3 h% M5 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 D; x+ y2 \' R' Z) u0 t, p) Z* Eand β-human chorionic gonadotropin was less than
7 C) T, ?2 x& T5 l" A5 mIU/mL (normal <5 mIU/mL). Serum follicular* |: [+ w, Y8 C7 G
stimulating hormone and leuteinizing hormone' d  X; K; O) V) m7 {* t7 Q
concentrations were less than 0.05 mIU/mL9 s2 Y% w- I& J, J& e! ~, _
(prepubertal).' c4 M: ?3 a. u- N7 i% f
The parents were notified about the laboratory1 }$ Y, c% X! c  g5 L( ~
results and were informed that all of the tests were6 d6 Z1 g% i8 |/ @
normal except the testosterone level was high. The
" V3 B8 x7 m0 s  n3 S+ yfollow-up visit was arranged within a few weeks to
/ P. Z# y% R/ v# c, Cobtain testicular and abdominal sonograms; how-
; o' }4 q2 Y0 _3 E: rever, the family did not return for 4 months.
8 k' [1 }' J8 o1 ^% z* h  N8 K! `% _Physical examination at this time revealed that the& S1 L  _7 Z+ T5 a# G2 j1 C
child had grown 2.5 cm in 4 months and had gained$ r5 \* C/ w/ G( [* d" i
2 kg of weight. Physical examination remained
$ [  k% X! q" g& k, A- junchanged. Surprisingly, the pubic hair almost com-
- W, d3 }5 o( u4 n' I* P* Hpletely disappeared except for a few vellous hairs at; s( a5 }9 ^7 Y, O- B$ I/ A: P
the base of the phallus. Testicular volume was still 2
6 r) {' c8 z% LmL, and the size of the penis remained unchanged./ U" j, o& Y9 H; j7 }/ I0 ]
The mother also said that the boy was no longer hav-
6 ?! U+ g, ?( V4 U% uing frequent erections.
1 [: R# \0 ^& i6 CBoth parents were again questioned about use of
1 W) i: Z/ b- c3 eany ointment/creams that they may have applied to5 w% W* e/ m! i% F3 \
the child’s skin. This time the father admitted the
; ]2 }7 \& V$ K9 Z8 S4 T5 DTopical Testosterone Exposure / Bhowmick et al 541
' O3 M3 ?) e( m$ duse of testosterone gel twice daily that he was apply-
1 F6 U) F6 `4 w2 Ding over his own shoulders, chest, and back area for
" o3 Z( ?/ z& Z9 va year. The father also revealed he was embarrassed+ I6 S5 j* c9 Z
to disclose that he was using a testosterone gel pre-; s0 Y) y7 ]. j
scribed by his family physician for decreased libido' J7 ^. g1 ~% d( @% _4 z4 Q" k: g
secondary to depression.
. O- c" ]5 ~1 D  eThe child slept in the same bed with parents.. I: n9 S/ C$ H/ H" w5 E
The father would hug the baby and hold him on his
. Q" y0 b$ [2 |# N" q: W" jchest for a considerable period of time, causing sig-. D2 k$ K9 Z% n3 ]5 v2 P- \- {# a6 S
nificant bare skin contact between baby and father.
$ I' o) p) Y; nThe father also admitted that after the phone call,
: a0 [# e$ Q9 U6 Xwhen he learned the testosterone level in the baby
1 q4 `5 F% S8 I9 P$ C, M( Twas high, he then read the product information6 S, g- p0 [- V  t% K
packet and concluded that it was most likely the rea-
! N& z( e5 H" l( j7 H' ~% C$ Json for the child’s virilization. At that time, they
2 |# F& N7 w# R6 ?2 sdecided to put the baby in a separate bed, and the
+ Q2 |. d5 L' I' k! M4 O8 ]father was not hugging him with bare skin and had0 F( {2 z) M  C: c) E8 q
been using protective clothing. A repeat testosterone
7 d+ F7 s; O' c2 _' utest was ordered, but the family did not go to the. j7 X1 B4 z1 q* p% n) w6 w, [) c
laboratory to obtain the test.
3 X8 ~1 n6 ?1 B2 i5 y( R% BDiscussion, {0 b0 a" U7 e8 ]2 _* i( U7 g" k
Precocious puberty in boys is defined as secondary; s6 o4 X( m( J" n4 h; _
sexual development before 9 years of age.1,4' @8 d/ x( A6 N- u2 `
Precocious puberty is termed as central (true) when
- N0 {1 q3 w8 ~2 T! Q7 Uit is caused by the premature activation of hypo-
2 j3 H# \' Z) O7 f$ W9 T: Gthalamic pituitary gonadal axis. CPP is more com-
# [8 R! R& G8 [/ H8 P' Emon in girls than in boys.1,3 Most boys with CPP4 D5 t; ]6 V& ^8 ^/ a" s( G
may have a central nervous system lesion that is& N) t  |: k+ v! }, P% C
responsible for the early activation of the hypothal-
+ J1 K8 w1 J: camic pituitary gonadal axis.1-3 Thus, greater empha-
2 w" `2 l2 f' ?- e/ ?4 s* `0 o+ y2 @sis has been given to neuroradiologic imaging in8 [; U, F( ?" u8 O2 t) u/ y
boys with precocious puberty. In addition to viril-
8 p/ V9 e# @' f; d" w( fization, the clinical hallmark of CPP is the symmet-
( Y* u8 z" \2 x( U" h2 X) s  ^rical testicular growth secondary to stimulation by8 F5 @2 ]* O9 r  o- z% l3 f) {
gonadotropins.1,3& o$ v" |. U, j8 @4 G  [' p
Gonadotropin-independent peripheral preco-2 {8 ?( Q% R  P, \
cious puberty in boys also results from inappropriate! q) O4 K: p. p) o
androgenic stimulation from either endogenous or
: {1 W/ o; F! b3 w7 k0 z. hexogenous sources, nonpituitary gonadotropin stim-% v2 d3 b0 r! k8 {1 ]
ulation, and rare activating mutations.3 Virilizing4 t" u& G2 B( l. F5 }
congenital adrenal hyperplasia producing excessive! {3 [. ]6 ~1 p) E2 d$ q. z
adrenal androgens is a common cause of precocious
- V' L8 n  }. ~- z1 ?/ w+ mpuberty in boys.3,4* T4 Z& D. m5 s' o9 X$ r) V6 b' ]
The most common form of congenital adrenal3 a: J- A* S0 j/ m
hyperplasia is the 21-hydroxylase enzyme deficiency.& F" M' ^+ {$ \; E3 e) E
The 11-β hydroxylase deficiency may also result in
0 s9 f: A* d+ _8 O8 ]2 z  uexcessive adrenal androgen production, and rarely,
" m# t* U9 Z! U: m6 B6 w5 f! xan adrenal tumor may also cause adrenal androgen
8 N# n; i4 X0 a) f( z' \3 }; Kexcess.1,3
* J1 ]$ n4 w* q. L4 Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 W# ?4 r: {- s  Z% O0 Q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% F" f0 }  Q, `0 }$ i6 G6 OA unique entity of male-limited gonadotropin-0 r3 H; q' m4 r7 p# {
independent precocious puberty, which is also known
8 s" r8 s* N" i7 P% ]3 h# Las testotoxicosis, may cause precocious puberty at a
8 o# {" Y, `$ S9 L& p" Nvery young age. The physical findings in these boys+ N2 G1 ]* e* f5 j
with this disorder are full pubertal development,
" }7 `8 o) E/ h' f' W2 `including bilateral testicular growth, similar to boys& Q, R+ g3 z! A! A
with CPP. The gonadotropin levels in this disorder- g. I! k( u. t2 m  d  ~
are suppressed to prepubertal levels and do not show
) [3 n3 Z' g7 Y/ h* F! m  Ipubertal response of gonadotropin after gonadotropin-
; h  \# Z/ h  f5 M1 Freleasing hormone stimulation. This is a sex-linked
9 L& m( I8 I5 h$ _/ hautosomal dominant disorder that affects only( N4 R1 p$ _9 p$ u6 h7 ^) I, V+ W
males; therefore, other male members of the family; O3 ]- G3 O* N4 o
may have similar precocious puberty.3
3 j0 d; c+ u" n) n" L3 p; qIn our patient, physical examination was incon-: i; [: i, _6 }% Z# W
sistent with true precocious puberty since his testi-- a4 V  v+ n4 ?$ K- M
cles were prepubertal in size. However, testotoxicosis7 R( K2 {( l( x  Q  t
was in the differential diagnosis because his father/ b9 S5 y& Z' ?
started puberty somewhat early, and occasionally,% ]0 B1 r5 T- S8 Q8 w' A" T
testicular enlargement is not that evident in the) z4 v. l$ B; `; L5 O3 ~( \
beginning of this process.1 In the absence of a neg-
& U. P+ v4 u7 J0 j6 vative initial history of androgen exposure, our; _5 t' X5 t0 d$ r
biggest concern was virilizing adrenal hyperplasia,% h( U7 |5 V1 L2 z
either 21-hydroxylase deficiency or 11-β hydroxylase( R. J/ {& d! K1 j5 k6 V2 p
deficiency. Those diagnoses were excluded by find-
6 ]2 k) c1 ]1 h, y( N  Uing the normal level of adrenal steroids.
7 ~9 L  a* f$ g) _9 N+ CThe diagnosis of exogenous androgens was strongly
* |. Z  W- B! Asuspected in a follow-up visit after 4 months because
0 y1 t. _6 g3 l0 u1 M1 tthe physical examination revealed the complete disap-- b( _8 p7 p# Y" e
pearance of pubic hair, normal growth velocity, and
! w: ?4 Y' J9 ndecreased erections. The father admitted using a testos-( a% q, z/ A" _! {. P: K, l5 T
terone gel, which he concealed at first visit. He was
3 d. ]# s& a) N. H' H) M) _using it rather frequently, twice a day. The Physicians’' t. H; @, k# C2 u; T6 F2 T( j
Desk Reference, or package insert of this product, gel or" t) R& P& l4 ^  A1 z- B3 H% a- Y
cream, cautions about dermal testosterone transfer to  n: L+ ]% Q; |
unprotected females through direct skin exposure.  U) a; n& _7 f3 A9 ^  H
Serum testosterone level was found to be 2 times the
6 h# ^* t$ ~  ]7 P( o) cbaseline value in those females who were exposed to
8 J& P% l7 M% c  n, f, M5 p3 |% f9 [6 Yeven 15 minutes of direct skin contact with their male: G* A9 N- T& p3 g! x
partners.6 However, when a shirt covered the applica-
$ u& h: A  \) ?& Q: u% }tion site, this testosterone transfer was prevented.1 o8 i- D# _: p. e& {  H
Our patient’s testosterone level was 60 ng/mL,! [0 j6 E) ]8 O
which was clearly high. Some studies suggest that/ w# B& p# S3 G1 z+ A
dermal conversion of testosterone to dihydrotestos-# q  W! D3 q2 q# z
terone, which is a more potent metabolite, is more+ m% l: m  j, n) ^/ D$ B
active in young children exposed to testosterone
- w7 g2 a+ _, a( g9 S- \5 D# Xexogenously7; however, we did not measure a dihy-1 f# H9 ^0 J' M- Q$ I" e% o1 M  l
drotestosterone level in our patient. In addition to9 ^' B# T6 z; f4 n: @7 h
virilization, exposure to exogenous testosterone in
$ Z1 k  s- y  h8 @6 l  \  z3 i9 {$ N& schildren results in an increase in growth velocity and, F, D4 t3 A0 Q- |' w/ D2 m
advanced bone age, as seen in our patient.( |, I9 m; [7 u
The long-term effect of androgen exposure during4 X) l* M& d& a+ F# b
early childhood on pubertal development and final8 Y6 B6 u3 y2 K4 U: T, t% H7 {
adult height are not fully known and always remain
3 D# c( o# e8 x8 r3 ?a concern. Children treated with short-term testos-
; p, d# i0 b, F4 o) iterone injection or topical androgen may exhibit some
+ S% y+ h: C) i2 }acceleration of the skeletal maturation; however, after" D3 I" V6 g  {# B$ J, T/ K
cessation of treatment, the rate of bone maturation
# y# N) z& u  y* Vdecelerates and gradually returns to normal.8,9$ @! f  ]6 h  ]7 v% g
There are conflicting reports and controversy
* ~/ f; U5 i/ h, H/ l( \over the effect of early androgen exposure on adult% E0 [9 K9 m: g  j; I
penile length.10,11 Some reports suggest subnormal: P4 b, K% ~" M  K: m
adult penile length, apparently because of downreg-) u" K% C5 S9 ^" n  t9 @7 P# s) v: @
ulation of androgen receptor number.10,12 However,0 o/ D, Z; W" n* Z* l% ^/ B, S* w
Sutherland et al13 did not find a correlation between
( w- ^! h3 v2 i" d- Fchildhood testosterone exposure and reduced adult
& u! z. [; f1 l- F) m. D* [, dpenile length in clinical studies.
' N3 R# t$ S$ hNonetheless, we do not believe our patient is
& v& S$ H( ]' I+ Z1 bgoing to experience any of the untoward effects from
# w6 {* Q; |' x$ V* j" stestosterone exposure as mentioned earlier because. f: R. m/ f6 n  I* {$ [3 Q
the exposure was not for a prolonged period of time.
2 L3 ]) M9 g/ w! \7 r. bAlthough the bone age was advanced at the time of  L3 W( c3 ?+ V
diagnosis, the child had a normal growth velocity at7 J2 [4 e  v0 _- D* g
the follow-up visit. It is hoped that his final adult6 L( ~  O6 u. }# P% `. m
height will not be affected.
4 l( O1 T" x0 h+ o# l5 d) N* m( ~% pAlthough rarely reported, the widespread avail-
  t! M2 n  A9 E; h8 Kability of androgen products in our society may
# |' f3 V5 K) j0 E- |indeed cause more virilization in male or female
1 T" Q4 \$ m- W/ Y4 Uchildren than one would realize. Exposure to andro-
3 ?7 D- k# n# q7 u& ~2 Egen products must be considered and specific ques-
- l& W! H% M+ Y2 |1 l( c& ttioning about the use of a testosterone product or
3 G3 Q( y4 C( O* Ngel should be asked of the family members during& e2 O# J2 g+ c2 I( O7 f3 o- E
the evaluation of any children who present with vir-3 M1 g$ C& f$ V2 N, Z  U! T9 _. l
ilization or peripheral precocious puberty. The diag-+ W  Z4 c9 J2 F* E5 R
nosis can be established by just a few tests and by# T# k1 D/ Q. q* G+ j
appropriate history. The inability to obtain such a
( h$ g% w4 m6 Shistory, or failure to ask the specific questions, may+ q& S  @7 e; m* O) m9 S- T7 [
result in extensive, unnecessary, and expensive) T! @0 m! M2 Y
investigation. The primary care physician should be
9 ]! O  s/ {" ?2 D3 k0 m) Caware of this fact, because most of these children
) Q8 m5 L& c) imay initially present in their practice. The Physicians’
) l" x" W" t  \* Q+ b3 J; u& HDesk Reference and package insert should also put a6 M; V& q% n, X
warning about the virilizing effect on a male or
" d9 V3 p3 h7 r. Efemale child who might come in contact with some-1 V4 N2 T. L. A* e2 F* O; ]7 s
one using any of these products.
  q/ P) P! |  S: K' s  p, F) XReferences4 v2 m8 e1 N9 K9 ]; c' V
1. Styne DM. The testes: disorder of sexual differentiation
6 ?. I3 C5 J  R- a5 L, J  M! dand puberty in the male. In: Sperling MA, ed. Pediatric8 f# @- m, j: X% b& l& j
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
/ c) H; l4 ~% v& J4 i! p2002: 565-628.
, i  Y5 e% N/ L) r* X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! r. k- g; y+ l7 A# N1 S+ S! }puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old1 P0 g1 O, S+ t1 {% \# L3 j
Boy Induced by Indirect Topical
9 \* z# w1 g7 |: h# h: KExposure to Testosterone
( M5 K) C+ U; ^, Q# JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' H( a: r; ?. s  T/ Hand Kenneth R. Rettig, MD1
3 G* `& T$ Y4 U2 GClinical Pediatrics
$ x0 ~9 s2 @0 v3 u: u" BVolume 46 Number 6
8 c  ]0 r) m' H) `' @( u/ E1 r: bJuly 2007 540-543$ y! n3 S) `2 k4 ^: Q
© 2007 Sage Publications
% e4 @8 j1 \3 c2 _; G' X10.1177/0009922806296651: h% ~: _. U9 i9 L9 z' S9 l! N' ~
http://clp.sagepub.com
1 z+ H3 E& U$ u: `- U3 fhosted at
( k6 k9 Y' m% Y4 phttp://online.sagepub.com
( X& `5 G" @$ h, dPrecocious puberty in boys, central or peripheral,
% [' M5 |% r, R& yis a significant concern for physicians. Central& @  d$ b8 ]. z3 r$ W) C4 U/ B* @' m
precocious puberty (CPP), which is mediated2 \8 T& J' v3 Z5 D1 u! D2 F, Y
through the hypothalamic pituitary gonadal axis, has* ~8 X; A0 ^* p- t: c- H
a higher incidence of organic central nervous system4 _0 N3 N" H3 n  U/ V8 X: w
lesions in boys.1,2 Virilization in boys, as manifested
# T  I. h' m/ F, f) }; [# b( Gby enlargement of the penis, development of pubic) f+ @5 [+ V6 ]1 |. k4 }
hair, and facial acne without enlargement of testi-
0 _/ L. J: f! A& j  T1 l7 zcles, suggests peripheral or pseudopuberty.1-3 We
( K  P, @7 k; e0 _% dreport a 16-month-old boy who presented with the
) G' h# `) E4 Jenlargement of the phallus and pubic hair develop-, I; o* H1 P1 B& i' M4 V
ment without testicular enlargement, which was due
% ^; }: ~6 o0 q5 H! v! `, \* v. Xto the unintentional exposure to androgen gel used by
* o+ s7 r$ H8 D' b2 ]( v' I7 S' A, Gthe father. The family initially concealed this infor-
! v/ X% b3 F9 @1 N3 z" ?4 i7 Amation, resulting in an extensive work-up for this) }+ s/ C6 Z9 u* s
child. Given the widespread and easy availability of2 s' Q5 G* L& @& q
testosterone gel and cream, we believe this is proba-
8 ~3 Z: T1 \* F- W/ j2 Fbly more common than the rare case report in the
5 S$ ]" ^9 s  P0 f8 N1 vliterature.4, T) q& j2 N9 b# ?% }4 W
Patient Report2 \/ K+ x5 `) ~" O* J/ I1 f; r2 u; z
A 16-month-old white child was referred to the
- T) b# e9 H0 b' H; A4 t9 Oendocrine clinic by his pediatrician with the concern. g, \7 y8 F: v+ M
of early sexual development. His mother noticed
+ p( S+ H% z$ E; n( r( c! Y+ ?light colored pubic hair development when he was9 W2 A+ G* ^7 W- o! _
From the 1Division of Pediatric Endocrinology, 2University of6 y% ^- B# c% w7 @
South Alabama Medical Center, Mobile, Alabama.7 O7 l' ~" w/ e. ?  J
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 _6 j0 q, E) `. W( I$ B
Professor of Pediatrics, University of South Alabama, College of9 X8 M% o8 H6 F& {3 F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, \- F/ j  h+ t( q
e-mail: [email protected].( O$ |: k: h. J; L) a" E/ i, o8 q
about 6 to 7 months old, which progressively became
, R. e* s& h" c( H2 m5 O9 r- H7 Adarker. She was also concerned about the enlarge-4 L* }/ T0 `# d! Y
ment of his penis and frequent erections. The child' h- D6 r2 `" t  G$ ]% N
was the product of a full-term normal delivery, with
7 w- i# S  P; ^( v" B0 u/ g7 Ca birth weight of 7 lb 14 oz, and birth length of
* `0 l3 p+ ^4 M20 inches. He was breast-fed throughout the first year; x6 D! n; _; `% k/ i! Z5 d0 s
of life and was still receiving breast milk along with1 W0 J- c( o1 j2 G, ^; ?" Y, D
solid food. He had no hospitalizations or surgery,1 G" d, r, b4 y4 K% t5 w) z' H
and his psychosocial and psychomotor development/ R  n& z. ^$ b) x6 i# ^- B
was age appropriate.- n$ O* k, l4 p: v* g0 U& ~  _
The family history was remarkable for the father,! m! C1 [9 o, U+ `% a% ^
who was diagnosed with hypothyroidism at age 16,  q7 f$ b, B0 ], }9 t
which was treated with thyroxine. The father’s6 M; o- _: L1 H8 Y4 z
height was 6 feet, and he went through a somewhat
" B; F" W  F" Searly puberty and had stopped growing by age 14.
& y/ l9 d1 e, F5 v# lThe father denied taking any other medication. The
$ e( B7 U0 u" n' k/ z9 A; fchild’s mother was in good health. Her menarche
, O! D9 `( e$ j% F# t& a' [9 twas at 11 years of age, and her height was at 5 feet$ \, R6 a2 l' `. w& }# S+ E* y
5 inches. There was no other family history of pre-
) k# {; L5 h! n! ^7 Y% g( V& Tcocious sexual development in the first-degree rela-1 q4 M5 U! v* j6 Y7 Z
tives. There were no siblings.; N; m# G6 e( \' T3 q% j3 b. i/ H
Physical Examination- n6 K/ k7 x1 v
The physical examination revealed a very active,/ {6 I3 b% P# k4 F, `4 ~# g
playful, and healthy boy. The vital signs documented
. Y& f( B) L% x/ t5 ya blood pressure of 85/50 mm Hg, his length was
2 x: l* S. \9 U6 u: A" F90 cm (>97th percentile), and his weight was 14.4 kg
; l3 _& A) \4 ]- [# R(also >97th percentile). The observed yearly growth3 X+ C7 b! x3 D3 B
velocity was 30 cm (12 inches). The examination of
/ |  J! B( T) q0 j8 O/ j8 \6 e" Nthe neck revealed no thyroid enlargement.1 }4 Y0 t8 p5 ?) h$ G3 t/ V3 G! N
The genitourinary examination was remarkable for5 I" s" G* U$ j
enlargement of the penis, with a stretched length of
3 |( ?$ W, J2 E, m8 cm and a width of 2 cm. The glans penis was very well
! E7 C8 J1 }! X* ~developed. The pubic hair was Tanner II, mostly around7 r4 U. m; l' r+ D# {
540
9 K0 q9 b7 Z/ S' P$ _, T1 ?( ?5 eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: S+ Z, s  G8 j' c
the base of the phallus and was dark and curled. The( F! n( E+ v1 C; i  B. R
testicular volume was prepubertal at 2 mL each.
5 j1 F5 y# n  }5 ~! JThe skin was moist and smooth and somewhat; h  ~. ]8 E% M* T( Y& C
oily. No axillary hair was noted. There were no4 j$ v# }; H2 W& ~/ I
abnormal skin pigmentations or café-au-lait spots." `, R; Z3 a/ C0 U
Neurologic evaluation showed deep tendon reflex 2+
0 O/ l& @- l6 U0 tbilateral and symmetrical. There was no suggestion! L& Q7 \* S% ^  }( P& u
of papilledema.
- D6 [: N  ~" v' K1 YLaboratory Evaluation
9 W$ r3 L; z2 k' u2 i' c$ PThe bone age was consistent with 28 months by7 k* f( @9 [0 k& I& f. n
using the standard of Greulich and Pyle at a chrono-
) ]6 c" w' B# V" p2 U% k7 Llogic age of 16 months (advanced).5 Chromosomal6 N; Y6 V/ G/ m/ D0 }) m# H
karyotype was 46XY. The thyroid function test! N/ t( {0 n9 M) i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 a/ j8 U# u* q* y8 t: Flating hormone level was 1.3 µIU/mL (both normal).- f: G- I; N: P+ [
The concentrations of serum electrolytes, blood
9 K" q4 O+ [! t" L( D: N3 furea nitrogen, creatinine, and calcium all were
6 K- T5 B+ c6 G; Lwithin normal range for his age. The concentration& {4 D: O1 I1 U
of serum 17-hydroxyprogesterone was 16 ng/dL0 w1 @4 v3 c) }, y
(normal, 3 to 90 ng/dL), androstenedione was 20; P+ w6 [2 T" j6 T: v; e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! I/ a) G9 K3 z# E( u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ Q) c" Z, `6 `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( q5 w! l, Z8 r49ng/dL), 11-desoxycortisol (specific compound S); L8 l9 ~+ }* ]* g5 Y" E+ O; ?' ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 q0 m# o3 }& z6 P, `
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 n* R, C4 O2 U- Y1 q  S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ P3 O6 F) s9 X9 N( e/ Nand β-human chorionic gonadotropin was less than
/ G2 z5 @, ?- `" D4 `5 mIU/mL (normal <5 mIU/mL). Serum follicular0 U2 P$ v, ]9 h4 x
stimulating hormone and leuteinizing hormone
4 X2 x# Y7 `7 s! s/ Gconcentrations were less than 0.05 mIU/mL1 H, k( b+ U2 E
(prepubertal).( W' @1 n1 ?6 `$ U; b7 A
The parents were notified about the laboratory
" n5 M( b* g' J4 H3 E: Y) B! [results and were informed that all of the tests were) [6 \5 D- Z+ K1 b1 a; K; H
normal except the testosterone level was high. The1 [& u  Q0 Z" S- ^: b
follow-up visit was arranged within a few weeks to
( Q9 y3 v4 G, L0 C% x. r# Jobtain testicular and abdominal sonograms; how-0 h- ]4 A, m) X3 o8 H
ever, the family did not return for 4 months.3 Z6 e& B  J1 _2 Z+ Y5 d
Physical examination at this time revealed that the
& u6 k' B8 Q* L7 k4 jchild had grown 2.5 cm in 4 months and had gained( m: d+ M- I5 ?* q/ p9 n% z+ {
2 kg of weight. Physical examination remained6 |/ x3 S& F# t0 b! `1 u
unchanged. Surprisingly, the pubic hair almost com-
4 O! V0 w  C2 U9 d& }# xpletely disappeared except for a few vellous hairs at
2 [, H  g, {# h5 d$ W  c1 B' Xthe base of the phallus. Testicular volume was still 2
2 |% ]2 A6 q& R& g+ `6 M0 LmL, and the size of the penis remained unchanged.: I' Q' [5 e' f$ X
The mother also said that the boy was no longer hav-  L7 T, e3 S* q1 O5 G
ing frequent erections.! d& ~5 Y- {) e" T/ n9 Y
Both parents were again questioned about use of9 K) \# Y3 n  d4 B
any ointment/creams that they may have applied to
4 @4 A* d) I% ~, K/ qthe child’s skin. This time the father admitted the! L; G) y3 K9 m2 {8 n
Topical Testosterone Exposure / Bhowmick et al 5411 p& M; l! T" Z2 D/ O% x- M
use of testosterone gel twice daily that he was apply-
, E) A: V) a6 `1 G) ~% O2 uing over his own shoulders, chest, and back area for
6 c8 b& P" ?3 M: c7 y, }0 Sa year. The father also revealed he was embarrassed
5 H! }7 x2 d$ D1 p1 K9 hto disclose that he was using a testosterone gel pre-. `+ Y9 |! ?7 ~8 R. P4 Y2 D( E
scribed by his family physician for decreased libido
0 Y9 Q  t3 x5 ]0 O* Y" G0 vsecondary to depression.
3 C$ I) w: \$ j1 X5 C* X* b6 }2 M8 aThe child slept in the same bed with parents.
) P! U3 o1 l' C, nThe father would hug the baby and hold him on his
# M0 i5 C6 X: s  Z# bchest for a considerable period of time, causing sig-. m7 O7 x6 o! c0 t2 E7 }
nificant bare skin contact between baby and father.
- q' Q. N3 H8 e& d( K1 q+ I# o+ ]The father also admitted that after the phone call,5 _/ }4 X* M8 ^) M& S  k
when he learned the testosterone level in the baby
- R/ W, z* V4 D5 a. Y! awas high, he then read the product information
! P( a3 \3 g) h* E; }6 Dpacket and concluded that it was most likely the rea-/ L. C& J5 h" j1 M+ q
son for the child’s virilization. At that time, they
1 h( Z0 ?* K9 J, i7 v$ Vdecided to put the baby in a separate bed, and the" g7 c6 ~9 m' A
father was not hugging him with bare skin and had
. q/ p2 o% n: ?% G4 ~3 Bbeen using protective clothing. A repeat testosterone/ t$ D6 Q  S  q% N9 K- b/ m  v
test was ordered, but the family did not go to the/ a0 _# E8 ~" v9 |
laboratory to obtain the test." ?, @- K( `: D0 n7 E- A$ }: c+ b
Discussion. N3 J7 h" @! G, U: g
Precocious puberty in boys is defined as secondary2 N  U9 ?& f" f: Z
sexual development before 9 years of age.1,4
* G! T' @# M% C$ ]$ kPrecocious puberty is termed as central (true) when& v0 ~! Q! W+ d/ h: M
it is caused by the premature activation of hypo-: `: ]5 t( k+ d: o* v6 p( U
thalamic pituitary gonadal axis. CPP is more com-
4 l- Z4 i' k% T& Y% Omon in girls than in boys.1,3 Most boys with CPP
, W1 |8 H2 }6 {. t8 jmay have a central nervous system lesion that is
' ?6 i% g9 R+ j2 A! C! Fresponsible for the early activation of the hypothal-8 Q; K2 d. b) `$ u
amic pituitary gonadal axis.1-3 Thus, greater empha-
! A: K. ?- c+ a' `8 m2 w# L9 Y; gsis has been given to neuroradiologic imaging in
/ m( o1 L3 e5 G+ d2 H" N$ X: Dboys with precocious puberty. In addition to viril-
" C, e  T5 p: d( Nization, the clinical hallmark of CPP is the symmet-
" X+ G, d5 t% u5 c7 M' x. D% X: `rical testicular growth secondary to stimulation by+ H* W" |+ P$ G" X  p! @
gonadotropins.1,3# @$ l% u  B7 |8 E* e
Gonadotropin-independent peripheral preco-
4 }0 w+ V- q' N! _% i* Bcious puberty in boys also results from inappropriate
- B  m' H, R+ U: M4 c5 o' handrogenic stimulation from either endogenous or
3 Z/ ^; K7 G/ j3 x3 N9 aexogenous sources, nonpituitary gonadotropin stim-- Y; v9 ^& h6 |
ulation, and rare activating mutations.3 Virilizing4 V. c) y# v7 L! L
congenital adrenal hyperplasia producing excessive
2 _- q* |  d, j8 X# `& _, l: cadrenal androgens is a common cause of precocious! v( T, b$ y. ^2 U
puberty in boys.3,4% o! O6 S: [5 T0 r  i
The most common form of congenital adrenal
2 H* S6 `$ v  O3 khyperplasia is the 21-hydroxylase enzyme deficiency.0 S: T# ^+ O4 s$ _0 V& i: S
The 11-β hydroxylase deficiency may also result in
% ]% |7 r9 j( w2 i2 H6 h) Cexcessive adrenal androgen production, and rarely,
) v4 ]$ [/ s5 g- Yan adrenal tumor may also cause adrenal androgen
  f/ V3 x' j# W7 I& wexcess.1,3
/ z5 k4 X( d/ j, [7 a4 F" V0 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 c7 H7 f1 X! M. y2 O: d# G; C% u
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ w6 o* Q$ r4 x4 J6 s
A unique entity of male-limited gonadotropin-! _! d; T5 n8 ^4 p
independent precocious puberty, which is also known9 D+ M3 _1 d. m. R" E
as testotoxicosis, may cause precocious puberty at a
, Z9 k: H5 r- p8 wvery young age. The physical findings in these boys( I9 g+ a% B- k: y+ i
with this disorder are full pubertal development,/ _( }( C2 L9 W0 L. w
including bilateral testicular growth, similar to boys
/ E1 L; I" C* U$ k( [7 qwith CPP. The gonadotropin levels in this disorder$ F, v8 s. Z4 |' ^. U. p, ]
are suppressed to prepubertal levels and do not show
5 u# K8 t  }& l) r" [5 p7 A3 c& ipubertal response of gonadotropin after gonadotropin-
9 I+ _8 J/ r# `' Q/ }' ?releasing hormone stimulation. This is a sex-linked
. K" t" k% h0 `, \& bautosomal dominant disorder that affects only8 r( o& r  u" n' ]7 D
males; therefore, other male members of the family% ?, |  v7 }. S' x* w* p1 ~- l
may have similar precocious puberty.3
( b' P* `/ h# k4 F/ G1 x8 gIn our patient, physical examination was incon-5 m( |+ i& \8 n" W- `
sistent with true precocious puberty since his testi-! n! _- Y* Y! M
cles were prepubertal in size. However, testotoxicosis
! N/ I8 N% `  t& s4 M9 Qwas in the differential diagnosis because his father
: A' Q4 m, r! C$ v3 \started puberty somewhat early, and occasionally,
- y/ d, e( Q) r0 \6 ]testicular enlargement is not that evident in the! G7 \! E3 w: o) A' M
beginning of this process.1 In the absence of a neg-- \2 O7 w2 {$ f' @7 W8 D
ative initial history of androgen exposure, our& `. g: h: N1 l) m+ M( S9 L1 r
biggest concern was virilizing adrenal hyperplasia,3 s% Q4 {* l9 O2 ~* F
either 21-hydroxylase deficiency or 11-β hydroxylase; V! q8 H( W' Q# A6 Y9 w3 \9 z
deficiency. Those diagnoses were excluded by find-
" k' z: C/ j4 V( B2 B; ^( a4 aing the normal level of adrenal steroids.
& N& L$ v" a! D3 m1 XThe diagnosis of exogenous androgens was strongly  e$ p! J# m. a5 A' D, V# L
suspected in a follow-up visit after 4 months because" A1 H) L! Q, }: y( E7 g; f
the physical examination revealed the complete disap-7 F  n8 `- p. D/ C: W& i
pearance of pubic hair, normal growth velocity, and
# m3 e' j' N; v' w1 g- |decreased erections. The father admitted using a testos-5 g. C. {. I: n  l
terone gel, which he concealed at first visit. He was9 C+ F; s8 E2 v
using it rather frequently, twice a day. The Physicians’2 P0 b1 L* |2 K; {
Desk Reference, or package insert of this product, gel or& F/ l& Q% j1 R
cream, cautions about dermal testosterone transfer to' z0 Y7 V: G( n# j! w( y
unprotected females through direct skin exposure.' \2 U5 c! b+ H' A: J7 x) ?0 U
Serum testosterone level was found to be 2 times the: L( E1 c& c% W& D) |% G! G5 @/ U7 k
baseline value in those females who were exposed to
: ~3 K$ g, s& keven 15 minutes of direct skin contact with their male/ O" m" L/ r# N
partners.6 However, when a shirt covered the applica-
* \$ K$ W: u# U. U5 \tion site, this testosterone transfer was prevented./ x7 I9 i  `, {) P( i
Our patient’s testosterone level was 60 ng/mL,
2 a8 e4 i/ S2 mwhich was clearly high. Some studies suggest that
: d* E' g7 i4 Z9 i# _5 j+ y2 idermal conversion of testosterone to dihydrotestos-2 \5 V, c4 q$ J% U0 E8 A  j
terone, which is a more potent metabolite, is more0 ?9 p% r6 F+ E1 K3 N' b% b
active in young children exposed to testosterone
# i& p3 U& k5 u/ ^- Q: z& kexogenously7; however, we did not measure a dihy-, o0 r8 ]5 _0 `; c+ ^+ G
drotestosterone level in our patient. In addition to
( R. M/ e6 I2 D9 x; K! Ivirilization, exposure to exogenous testosterone in
# O% @' w3 s* Y& ~* Echildren results in an increase in growth velocity and( v1 j2 }4 \# _
advanced bone age, as seen in our patient.. A8 v# e8 n# ~  T7 b
The long-term effect of androgen exposure during
, p/ P$ P/ `# Cearly childhood on pubertal development and final
% q+ q# H0 D8 }adult height are not fully known and always remain
9 C" L( {% f* g! ya concern. Children treated with short-term testos-* \) w/ f) Q" \5 ~; _
terone injection or topical androgen may exhibit some
' Y5 g$ ~* c( o9 n9 r% Q2 t. lacceleration of the skeletal maturation; however, after
9 \( ^% Q  t( i3 N# J3 Ccessation of treatment, the rate of bone maturation# V; B9 I& J: d3 d- Z: c7 |6 j& P& B
decelerates and gradually returns to normal.8,9# [6 [* l, G0 r
There are conflicting reports and controversy
1 o* d* _8 {+ j' v5 yover the effect of early androgen exposure on adult
; D  ^+ j2 A0 Z1 g, }penile length.10,11 Some reports suggest subnormal
) |1 c/ X: G+ V6 l) hadult penile length, apparently because of downreg-$ b; ^# Y, I! ^5 I7 F# j, t
ulation of androgen receptor number.10,12 However,3 D" X& l6 `2 E: r3 k( i: U! y
Sutherland et al13 did not find a correlation between
$ C7 m; d+ o7 e; k. B, qchildhood testosterone exposure and reduced adult/ j: u* r( q) m, p: Z
penile length in clinical studies./ p, [% K. s/ S$ u" C8 a* F" r
Nonetheless, we do not believe our patient is
3 [$ t9 ^+ c- A4 X2 s! }going to experience any of the untoward effects from4 c; C3 i. E: S' Z! Y4 \' g2 U# c
testosterone exposure as mentioned earlier because
6 }; _* T/ |  ^* b: othe exposure was not for a prolonged period of time.
9 L5 \$ Q8 Y; `$ U* ^Although the bone age was advanced at the time of' v5 E+ x4 v3 y2 t# ~
diagnosis, the child had a normal growth velocity at& o: g! J/ q# y" D; A" A$ K
the follow-up visit. It is hoped that his final adult5 W7 A! i$ [# @1 t# z5 G
height will not be affected.
2 S+ i/ U+ H! b8 ]. L" bAlthough rarely reported, the widespread avail-
2 E0 [/ ]! L  zability of androgen products in our society may# Y+ c2 P' a- X
indeed cause more virilization in male or female9 V- f* I+ Q0 }0 F
children than one would realize. Exposure to andro-% C# _, @; K4 p1 s. o
gen products must be considered and specific ques-2 N% m! ^. X0 e# _% G0 p
tioning about the use of a testosterone product or
  A9 M5 g2 ~# Y* M; ~4 j5 W8 n% ^0 Mgel should be asked of the family members during8 i; b9 c) D; v  d' r0 Y) T
the evaluation of any children who present with vir-
3 {' E" T. _  V' ~, n# Y3 W9 Silization or peripheral precocious puberty. The diag-) q9 t) I# m3 h4 w! \
nosis can be established by just a few tests and by
; b. ]( `& I- ]- `6 E$ vappropriate history. The inability to obtain such a3 ~& e5 A# H6 e9 S/ N+ z: V
history, or failure to ask the specific questions, may3 s; s  ^4 Y" i, F, S1 ~$ y
result in extensive, unnecessary, and expensive5 G+ U$ ^2 q/ u9 K! [( d% W
investigation. The primary care physician should be
- ?$ D& g3 C. d* }6 K: s8 Kaware of this fact, because most of these children; {5 R7 A: X6 f! ]! f
may initially present in their practice. The Physicians’. `; Q3 Q  T6 m  w
Desk Reference and package insert should also put a. B5 d1 ?- U: ]
warning about the virilizing effect on a male or1 _4 a$ s& F; k+ ?
female child who might come in contact with some-
1 I' j) A! c" _4 v# X% Cone using any of these products.% q2 E, V! L5 d+ {7 U8 A9 b2 f
References  L6 w4 ]" U& h6 ~6 i
1. Styne DM. The testes: disorder of sexual differentiation
" e$ T7 r; A) T( ]3 [# S& ^and puberty in the male. In: Sperling MA, ed. Pediatric
' _+ D' j' v' D: L  EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% o' r# T: S! K8 K: M2002: 565-628.
' @& a9 Y! q5 L" O2 ~2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: x% x9 v  Y: F4 opuberty 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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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

( H6 D) a( N8 X" ?8 Y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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