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Sexual Precocity in a 16-Month-Old8 }6 m& c; Q  D' e" y
Boy Induced by Indirect Topical' B% v0 U1 g% N; U
Exposure to Testosterone5 Y0 H: D  p- {% l6 h7 ^
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 H# d2 i$ F4 F& F
and Kenneth R. Rettig, MD1
, Y% u0 [- I7 S+ ZClinical Pediatrics0 F0 [) `" p4 ~/ G7 _) }: v1 L& c
Volume 46 Number 6
0 q( @+ H" D; a+ I( ?4 n  ?5 BJuly 2007 540-543
! W# Y: `2 l3 k1 `8 ]( a© 2007 Sage Publications
% j& P& h" s1 @: `; Z" \9 @7 G) R; c10.1177/0009922806296651
" R: L- w7 J0 v& m1 w4 d; qhttp://clp.sagepub.com
) O2 y8 m. p  x; p% F0 Khosted at
, {1 m/ Y7 {0 d+ A$ ihttp://online.sagepub.com
+ C) I/ {3 p/ NPrecocious puberty in boys, central or peripheral,; k4 \* I, |8 R: E/ ?) p
is a significant concern for physicians. Central
( K0 q* _8 z. fprecocious puberty (CPP), which is mediated
& N+ n6 k0 p$ Athrough the hypothalamic pituitary gonadal axis, has$ h; q5 A; s7 I
a higher incidence of organic central nervous system# k6 ?9 m7 h: g  X- q
lesions in boys.1,2 Virilization in boys, as manifested
- V+ q& R# [( {' ^/ Oby enlargement of the penis, development of pubic/ n- R' Z' K: d, R
hair, and facial acne without enlargement of testi-
/ \+ w9 B! d; Q; U/ Ocles, suggests peripheral or pseudopuberty.1-3 We0 \1 p( i3 ]% v/ w8 f$ [
report a 16-month-old boy who presented with the% Q! f, z" g' U8 |7 Z; _
enlargement of the phallus and pubic hair develop-9 j6 e$ k0 ?, f; P, i& t
ment without testicular enlargement, which was due
5 A5 z3 I2 A; Fto the unintentional exposure to androgen gel used by. |* N. J. @0 j9 E
the father. The family initially concealed this infor-. v9 I. x2 c9 o0 h2 S
mation, resulting in an extensive work-up for this
: c, k1 m$ q* e* x" X& kchild. Given the widespread and easy availability of* Q" c4 p$ d- E
testosterone gel and cream, we believe this is proba-
- R8 T4 ^2 T6 tbly more common than the rare case report in the! ?$ l, s9 G' i- z! I2 N
literature.49 x) U) m  [( ?+ b6 x/ d
Patient Report0 Q- R* h1 {& ?6 k% x- o1 f
A 16-month-old white child was referred to the2 v5 Z$ ?  f0 a( W/ V3 P
endocrine clinic by his pediatrician with the concern9 b. v  l, t1 Y" I1 H# N  g
of early sexual development. His mother noticed$ u1 X1 a; b. U8 _
light colored pubic hair development when he was& ~5 \* A% s4 ?& s0 m2 x
From the 1Division of Pediatric Endocrinology, 2University of
9 c/ a, E$ I# H( ^; c& p3 ISouth Alabama Medical Center, Mobile, Alabama.
) ^- d, @8 K/ n% nAddress correspondence to: Samar K. Bhowmick, MD, FACE,) ^- a  Y0 P4 V* I  S
Professor of Pediatrics, University of South Alabama, College of
! x  ~/ z4 M1 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ x9 n7 w! I- L1 ]! T$ H
e-mail: [email protected].% B& A8 D  i& d
about 6 to 7 months old, which progressively became
% {* G1 [  v, I" F) [$ e! \& kdarker. She was also concerned about the enlarge-- s1 k! B9 S. m: _" ]4 p7 P% J% y
ment of his penis and frequent erections. The child
, ?) e* i1 p/ B% X9 x: l, @was the product of a full-term normal delivery, with
' {, j6 R- J1 v8 ~$ ba birth weight of 7 lb 14 oz, and birth length of# k/ Q2 m" `+ F2 r% ?2 C# g+ M- V, O
20 inches. He was breast-fed throughout the first year$ R3 }0 b$ B2 d" q' L# ]  @, E8 I
of life and was still receiving breast milk along with$ D6 k9 [6 ]) e
solid food. He had no hospitalizations or surgery,
1 c& \9 ~# a) j' Land his psychosocial and psychomotor development$ ?! d3 K3 R- o
was age appropriate.
; X" c+ x# }9 eThe family history was remarkable for the father,
; \) N: o) ~7 A; A* @) u4 Gwho was diagnosed with hypothyroidism at age 16,: D2 A: {0 d) T  Z5 I. o
which was treated with thyroxine. The father’s
4 `1 l4 R1 j8 `1 j* K4 W2 k  fheight was 6 feet, and he went through a somewhat
! X, T, j9 V& g* q/ i/ l* D  Q+ ~early puberty and had stopped growing by age 14.
' {: F8 L2 Z" J# y. L" IThe father denied taking any other medication. The0 ^, z) i! w: p2 i# N1 h% }
child’s mother was in good health. Her menarche% [* l" x7 Y# E  g; x; a! l
was at 11 years of age, and her height was at 5 feet
9 R5 u1 x, D( W' l8 R5 inches. There was no other family history of pre-* M$ ?3 n6 M- u
cocious sexual development in the first-degree rela-
" V  a, O: T/ A0 J  ~. rtives. There were no siblings.7 O, z6 S. [, |! t$ |3 P
Physical Examination0 \; n( \: |+ b4 b
The physical examination revealed a very active,3 E# `* r* h% q6 T5 K* ?& a* p
playful, and healthy boy. The vital signs documented; A" k( y4 D! h! }# B/ M
a blood pressure of 85/50 mm Hg, his length was
: V6 p+ _3 g# d4 g90 cm (>97th percentile), and his weight was 14.4 kg2 G  ~$ X$ `9 X$ v5 O
(also >97th percentile). The observed yearly growth
+ z6 }/ y8 W  k5 S1 K: a- Ivelocity was 30 cm (12 inches). The examination of2 O2 D1 T& |$ V, g
the neck revealed no thyroid enlargement.
4 ~: r. v/ {8 V% N0 ^The genitourinary examination was remarkable for3 @9 w( }1 _. T; g2 M  D- [
enlargement of the penis, with a stretched length of
  @2 T% P: N% f6 d; ^: K: P: j8 cm and a width of 2 cm. The glans penis was very well) @+ h. Q) ^1 W6 ~* R: H, q
developed. The pubic hair was Tanner II, mostly around
1 K5 ]& J3 a' S- a540
$ H# H1 e' f/ `* Z# R! qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 Q& u! i; u. g2 F' C8 b$ `/ A1 o$ Lthe base of the phallus and was dark and curled. The
$ w$ ?$ `) K) g3 M6 Gtesticular volume was prepubertal at 2 mL each./ }9 H( R! e  P9 U; V, x' u$ s5 P
The skin was moist and smooth and somewhat/ R: i  O/ F+ p1 A9 o
oily. No axillary hair was noted. There were no" u. P8 F0 F! y
abnormal skin pigmentations or café-au-lait spots.
1 e, I2 f; i! y" N: INeurologic evaluation showed deep tendon reflex 2+# l) n1 |( ]) Z: r1 j/ }
bilateral and symmetrical. There was no suggestion* s  Q9 L8 {9 {* q4 n  M& ~: Z
of papilledema.4 ^$ T+ U5 Q" @1 ~4 h$ h
Laboratory Evaluation
1 ~) m# |6 s- rThe bone age was consistent with 28 months by
1 c4 r) J* }5 B9 ^  d0 musing the standard of Greulich and Pyle at a chrono-
3 p4 Q( z2 T  \/ _% `logic age of 16 months (advanced).5 Chromosomal- S' O. ]9 V2 g0 l
karyotype was 46XY. The thyroid function test6 d% e/ F& f3 m! v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' Y! w3 |/ E0 m: K. D/ u
lating hormone level was 1.3 µIU/mL (both normal).
, n1 @7 U9 N2 v5 r& w( VThe concentrations of serum electrolytes, blood2 Y) D3 \+ s+ u2 u3 `6 i
urea nitrogen, creatinine, and calcium all were
, k0 o9 S! o6 |8 |3 Owithin normal range for his age. The concentration' k' `4 R, w% V! G9 j
of serum 17-hydroxyprogesterone was 16 ng/dL
% N* `' }6 A7 J4 O6 B/ ](normal, 3 to 90 ng/dL), androstenedione was 206 V5 `! d; Q. ]: G% @0 `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" w8 L/ B8 Z  c! Sterone was 38 ng/dL (normal, 50 to 760 ng/dL),( l  R* x2 P! s
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 D+ k8 _+ \% r
49ng/dL), 11-desoxycortisol (specific compound S)( _' Q8 n7 e% N% l! l2 ^8 |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( J8 O$ G# D& w# r. ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* m0 s: r3 J% y2 w: i* m0 u
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 J+ O" R- s6 c- @. ]! H$ Uand β-human chorionic gonadotropin was less than
0 S  Q# m  U6 a  f/ C& y( a% o' F5 mIU/mL (normal <5 mIU/mL). Serum follicular  C9 j" V/ k: K" }5 O# g+ _
stimulating hormone and leuteinizing hormone
6 E/ e# Z" S+ n7 L" K9 ~concentrations were less than 0.05 mIU/mL
( v( G8 ?3 o1 O7 @2 Y(prepubertal).
% b. T/ s& ]2 k2 T+ eThe parents were notified about the laboratory5 s% L+ ]6 T+ C6 D- i$ x
results and were informed that all of the tests were' b. l' Y4 s) D8 e# V
normal except the testosterone level was high. The
$ s9 K. p" j! R/ R9 y0 a9 Yfollow-up visit was arranged within a few weeks to
7 j7 y/ Y% o+ j+ B1 }! ]2 b) |obtain testicular and abdominal sonograms; how-
. r( c/ _; c7 Yever, the family did not return for 4 months.+ F* D' u" I6 |  i6 E# D* m' m
Physical examination at this time revealed that the
/ Y$ A& ~* I$ ]$ q, h2 e4 I- b) E+ ~child had grown 2.5 cm in 4 months and had gained
# Z/ K3 B' K4 ^# n) z2 kg of weight. Physical examination remained
' |7 F- u1 t5 m$ ?0 Ounchanged. Surprisingly, the pubic hair almost com-
) K7 h: {+ ~" ~pletely disappeared except for a few vellous hairs at7 _& [6 e. [9 U2 ^. s
the base of the phallus. Testicular volume was still 2  }, R. R5 o3 e& D) k
mL, and the size of the penis remained unchanged.9 w% J5 R0 S$ m+ Z2 G% |: J
The mother also said that the boy was no longer hav-
* u3 `) L/ X' \0 r' W# ting frequent erections.2 g. G2 d1 Y8 m" I; D: s
Both parents were again questioned about use of( @& c6 r4 k$ \8 f) g
any ointment/creams that they may have applied to3 {/ L' j# ]  e0 B- y$ ?
the child’s skin. This time the father admitted the( A% @& J5 y4 [( n1 Y
Topical Testosterone Exposure / Bhowmick et al 5413 h/ f8 E# s# v2 E! p0 G& b
use of testosterone gel twice daily that he was apply-' p; d8 I$ ~, X: l9 t, ~  L% m
ing over his own shoulders, chest, and back area for
6 P5 y4 d  @" F  Ja year. The father also revealed he was embarrassed
5 h- X2 H9 ]1 mto disclose that he was using a testosterone gel pre-, a2 n7 F! H' _/ g
scribed by his family physician for decreased libido+ _! a+ A- z& x9 Y( {/ C
secondary to depression.
1 T- }1 u) u2 E+ q4 PThe child slept in the same bed with parents.
9 S. I/ i; k6 t' n& F8 v: ^$ ~The father would hug the baby and hold him on his6 c% n" U3 k/ O" ]& ?( g( R: _  v
chest for a considerable period of time, causing sig-
# c( a% F3 M2 m$ Cnificant bare skin contact between baby and father.
" Q) a! M9 c" ?; I0 E9 YThe father also admitted that after the phone call,
* }) ?  s# O% ]0 W. awhen he learned the testosterone level in the baby" ]' B, Y4 D- t  A. M8 Q7 d/ t
was high, he then read the product information
  Y4 n& B2 T. v# z, f8 G4 R+ apacket and concluded that it was most likely the rea-; y" {/ g/ Q3 e; m
son for the child’s virilization. At that time, they) e3 a7 r9 h6 N& F  B" x
decided to put the baby in a separate bed, and the
  S* i3 D8 ^6 Y% G; i* u: [father was not hugging him with bare skin and had3 S9 y5 b/ ~  m9 a. J. b
been using protective clothing. A repeat testosterone0 G! u  }* {1 {" y2 C
test was ordered, but the family did not go to the. ]( g( f+ j( \1 c" q+ q5 c1 W8 q
laboratory to obtain the test.
* ~% B% p' B) U3 M& s- J- |Discussion
9 C3 M$ I) p! ~$ [0 yPrecocious puberty in boys is defined as secondary% C$ U; K/ P4 |$ U: [
sexual development before 9 years of age.1,48 h. p3 \. U2 N% f% _5 l. m. `
Precocious puberty is termed as central (true) when! _9 ?7 v$ i9 Y
it is caused by the premature activation of hypo-
9 x* v+ i! B& V2 z: K% _) Othalamic pituitary gonadal axis. CPP is more com-
3 z- @3 q) }  _7 b! Q* Vmon in girls than in boys.1,3 Most boys with CPP, i/ ^: _6 T* A- B
may have a central nervous system lesion that is/ ?! a) ^( [6 b5 \7 L# H
responsible for the early activation of the hypothal-' P1 B/ k$ G9 s; d- i  H
amic pituitary gonadal axis.1-3 Thus, greater empha-& p8 ]8 Z4 Y7 G
sis has been given to neuroradiologic imaging in
' F8 [4 X8 f8 \) y) z, Zboys with precocious puberty. In addition to viril-
& ?) i- n( |# }2 J' kization, the clinical hallmark of CPP is the symmet-
1 S5 S5 Z4 B' wrical testicular growth secondary to stimulation by
2 N. d! R7 H0 |4 Q7 u" vgonadotropins.1,37 Y7 o" O+ l2 F: U6 q
Gonadotropin-independent peripheral preco-5 f: g, j% D4 D1 ?/ F$ Q8 ~+ t
cious puberty in boys also results from inappropriate
8 @. B. L" B4 ]/ C% `androgenic stimulation from either endogenous or) l& \7 A- N, b+ S  D
exogenous sources, nonpituitary gonadotropin stim-
8 G$ O0 {/ E) g) F, @ulation, and rare activating mutations.3 Virilizing
( ^( v6 a5 z1 w* U" jcongenital adrenal hyperplasia producing excessive
: z. c) ~" h% S* W2 e3 u7 U6 u, B. yadrenal androgens is a common cause of precocious
$ [- h) u9 m" M* ypuberty in boys.3,4
, A- z7 n! ?. j8 |$ V) x( e3 k7 SThe most common form of congenital adrenal
* F) y) u& r- G- \7 Zhyperplasia is the 21-hydroxylase enzyme deficiency.) P. b, J6 U/ T7 y# R/ v- t
The 11-β hydroxylase deficiency may also result in
. M7 _. E0 B2 E( S4 T- |/ o) xexcessive adrenal androgen production, and rarely,
. v6 u/ x1 f6 y, r7 Tan adrenal tumor may also cause adrenal androgen
$ g. c0 d, f8 [0 G& kexcess.1,3! L, s! N: i( N) ?% o; T: d, ^8 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 B/ m9 g  V1 c8 e5 [
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' H& m# j; t; x+ jA unique entity of male-limited gonadotropin-* s9 Y  |) D0 Q3 I- D: k; N
independent precocious puberty, which is also known" S% O& m" Q/ n0 S: N! ?2 g1 b7 L
as testotoxicosis, may cause precocious puberty at a& z1 Q5 h$ ]+ o5 ]3 m( S9 v- T
very young age. The physical findings in these boys% ^! E, z$ R/ @$ {
with this disorder are full pubertal development,+ P0 l! m9 A3 n" H* C
including bilateral testicular growth, similar to boys
/ x! D1 h; u/ t/ c+ Rwith CPP. The gonadotropin levels in this disorder
" G2 y: M9 j7 Q8 dare suppressed to prepubertal levels and do not show
; K/ s& L# E- L& Ipubertal response of gonadotropin after gonadotropin-) N# j, z9 G; Q& t
releasing hormone stimulation. This is a sex-linked
& Q/ v/ X! D0 S* \autosomal dominant disorder that affects only* M# `5 Z7 d7 f  h
males; therefore, other male members of the family* r% n- _5 q9 D% P+ W& Q
may have similar precocious puberty.3
4 s! D4 U# J& o7 Q- Z" DIn our patient, physical examination was incon-
/ R  Z- N/ m' N! @/ f2 z6 ~sistent with true precocious puberty since his testi-6 \+ @5 e( _( d# O3 c8 Z4 }2 }
cles were prepubertal in size. However, testotoxicosis
$ Q  J$ q  ~& i& A) |5 Q& u8 awas in the differential diagnosis because his father* M# s$ k1 b% H( _1 \! n2 K% ~
started puberty somewhat early, and occasionally,7 s8 g/ M4 o- W* m2 x7 R
testicular enlargement is not that evident in the
. z+ F; v* j2 `2 Abeginning of this process.1 In the absence of a neg-
5 n9 Z/ F$ _  z% w2 I* r9 c# Bative initial history of androgen exposure, our, `8 ]; w' P6 S4 R& X% O
biggest concern was virilizing adrenal hyperplasia,
+ c: |' E0 [, s0 M+ f3 P6 veither 21-hydroxylase deficiency or 11-β hydroxylase: y$ B/ H& b  u$ k! R4 R
deficiency. Those diagnoses were excluded by find-
3 I9 V) I2 o0 ^3 c% W1 cing the normal level of adrenal steroids.
3 [" y! [5 s: U3 Y4 gThe diagnosis of exogenous androgens was strongly( D7 R$ }& T$ J- `+ ^  N
suspected in a follow-up visit after 4 months because( M$ u7 ]4 t( G% I4 K
the physical examination revealed the complete disap-
; D5 W/ N! Y/ W* k5 O3 v- R1 epearance of pubic hair, normal growth velocity, and- A" ^' H- v  y
decreased erections. The father admitted using a testos-
% R2 q+ u- K/ X% y9 t$ bterone gel, which he concealed at first visit. He was
6 C9 R: e; e" g9 Z* U' eusing it rather frequently, twice a day. The Physicians’
  A7 P2 e  ]1 }# G. rDesk Reference, or package insert of this product, gel or" g. l8 n: |& N- @. `! l! W
cream, cautions about dermal testosterone transfer to; L( L3 O  j2 L( A" |) {# \
unprotected females through direct skin exposure.
3 Z4 q- e9 v0 q; i- KSerum testosterone level was found to be 2 times the8 R# I2 K5 w% G5 u$ m: a
baseline value in those females who were exposed to
9 |8 T( P" D' A& k3 _* jeven 15 minutes of direct skin contact with their male: e/ y6 J6 H$ g5 A/ U! g
partners.6 However, when a shirt covered the applica-
/ n1 F" \; N2 C: B) |tion site, this testosterone transfer was prevented.! Y7 a/ t8 W5 Q$ }8 G: H  T0 M. a% @
Our patient’s testosterone level was 60 ng/mL,
+ @7 S' X) ?! fwhich was clearly high. Some studies suggest that. a1 t2 j3 D! @( n7 s1 Y' F
dermal conversion of testosterone to dihydrotestos-
+ G0 o, N! ^: s! b( g4 }terone, which is a more potent metabolite, is more$ T; s0 s/ \" d. S8 r" {
active in young children exposed to testosterone3 O: p4 m! h4 @# s) C9 Y; q6 t
exogenously7; however, we did not measure a dihy-) ~6 W& e6 A. _* f" A
drotestosterone level in our patient. In addition to
4 z( `$ D0 |) X# U/ C) Rvirilization, exposure to exogenous testosterone in
. J; ^) T! ?9 E  d, @/ Y. Cchildren results in an increase in growth velocity and
% z5 i% _5 E( Gadvanced bone age, as seen in our patient.
  ~  D8 A6 Q7 _, k/ eThe long-term effect of androgen exposure during. J' b$ F7 r0 x3 e
early childhood on pubertal development and final  Y( g) f8 C+ ~" I( Q) U8 q7 M
adult height are not fully known and always remain
- O# e( ^; S* S8 S: |' Xa concern. Children treated with short-term testos-
5 l' T1 N: r+ y' L# k9 mterone injection or topical androgen may exhibit some
/ P1 r' h: A: @2 j7 iacceleration of the skeletal maturation; however, after' l4 y5 z  t. p$ g- H& j& b6 a# r
cessation of treatment, the rate of bone maturation
  a& C/ b6 U$ a' I5 ^) M; f  A5 F3 y; Idecelerates and gradually returns to normal.8,9
1 I; O& R: y) g  p4 N6 OThere are conflicting reports and controversy
; ]; T3 Q. K7 x& F5 h  E. zover the effect of early androgen exposure on adult4 p2 X" e% `8 p* g& P* a7 x" z# z8 ^
penile length.10,11 Some reports suggest subnormal7 Z, y( ~5 v% d9 {& C) B
adult penile length, apparently because of downreg-, v) I3 ]. p5 U) Q% N2 V
ulation of androgen receptor number.10,12 However,$ t" }# e1 P& @1 x
Sutherland et al13 did not find a correlation between+ H  K! f7 W4 F7 ?
childhood testosterone exposure and reduced adult! K- [/ h9 [/ Y
penile length in clinical studies.
( m% v7 n; p" ?: e) h5 PNonetheless, we do not believe our patient is5 H' N4 ^, @5 |
going to experience any of the untoward effects from
+ f; y6 u4 P+ M4 K. M! j2 `testosterone exposure as mentioned earlier because) [* p2 }3 G2 X% K5 t) J/ @7 h
the exposure was not for a prolonged period of time.
# T0 L+ ~/ ^2 C3 e2 bAlthough the bone age was advanced at the time of" T. o2 M) _6 E( O
diagnosis, the child had a normal growth velocity at
2 q6 i  K0 X* C% ^7 [( |the follow-up visit. It is hoped that his final adult
; {. T. n! b, g# d* V# z% \2 ?0 Eheight will not be affected.: p$ R7 q5 y8 |  J. ~3 l
Although rarely reported, the widespread avail-
' A& d& q- u- dability of androgen products in our society may
: g; h8 L- s3 |% D2 H5 t2 Findeed cause more virilization in male or female) A3 n& Z, K* m/ L6 j2 T7 b
children than one would realize. Exposure to andro-/ k+ W7 n; |  ^  H0 @
gen products must be considered and specific ques-5 M8 T+ f" i6 f5 R! W
tioning about the use of a testosterone product or5 z/ t4 a5 ]$ D( ^6 K
gel should be asked of the family members during
& n5 i6 c4 W, Ethe evaluation of any children who present with vir-( g3 {; h  ~8 r% E! U& G. ]2 D6 s
ilization or peripheral precocious puberty. The diag-- Q; Y# `3 i' k3 F: V  @; Q
nosis can be established by just a few tests and by
% S4 Y+ J& E- T# p) c( c8 ?appropriate history. The inability to obtain such a
$ T/ p" X. ^* r0 Nhistory, or failure to ask the specific questions, may
0 r+ Z" W6 C5 K, G6 A; t; X% c( Iresult in extensive, unnecessary, and expensive
4 Q1 n4 _4 ?( p) Vinvestigation. The primary care physician should be
9 {+ j! d! x7 {" A+ E5 B8 _3 S8 b( raware of this fact, because most of these children
3 X! r* N+ H0 g  q5 y% n& rmay initially present in their practice. The Physicians’5 I/ J+ B3 f3 Y' _6 Z
Desk Reference and package insert should also put a
! Z" S1 K$ M8 I9 }warning about the virilizing effect on a male or, u+ I8 u4 ~3 Z7 X# J9 x9 Z0 O
female child who might come in contact with some-: {- t% O7 C8 c4 A1 E
one using any of these products.
- @% L( T# L. }$ E$ {5 P! ~# ?5 L/ ?References
% o; y+ J3 R0 J6 M7 g4 h' f  }1. Styne DM. The testes: disorder of sexual differentiation! R) d7 y8 Q. `9 O( f2 R
and puberty in the male. In: Sperling MA, ed. Pediatric
% j4 K3 A0 a; N7 U: t/ k( j- t) yEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' b4 K$ t# t) M8 }: [
2002: 565-628.
5 U8 M) b$ i  D- b2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 a; G! A- |* u4 k0 ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old; u2 G1 ?( E# w+ c
Boy Induced by Indirect Topical: y- D% G& ?  P' @) x4 v- h
Exposure to Testosterone2 M9 p3 y9 n& j' S: c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# Z0 Y3 z' q" \2 P) P0 }  X: S0 f
and Kenneth R. Rettig, MD1
! v# V2 S; `2 T/ R9 r5 {! HClinical Pediatrics3 `' N9 v1 K5 I) l; E+ s
Volume 46 Number 6: u& R: X. \+ e; m6 s
July 2007 540-543- a1 e0 q1 J6 M) Y7 t% {  C; A
© 2007 Sage Publications
) B- A" a6 `# \6 }3 h5 P10.1177/0009922806296651
6 z/ c0 j' r" S9 A, @http://clp.sagepub.com
' q3 r7 O9 o; D6 I% Q3 jhosted at' |5 }% ?7 s5 }# b$ \- w6 q
http://online.sagepub.com
& D8 A' S; b9 jPrecocious puberty in boys, central or peripheral,
5 }/ u, T5 A: [* Qis a significant concern for physicians. Central
5 k+ n5 |  N( b4 _) b" pprecocious puberty (CPP), which is mediated# r& F6 h, L, H% D+ J* |- J
through the hypothalamic pituitary gonadal axis, has
; [6 s7 H6 p$ H% A5 X9 Q& M, I; |  ]: Pa higher incidence of organic central nervous system
0 a" `2 p( u  ~8 T% c6 ?lesions in boys.1,2 Virilization in boys, as manifested/ p* Q% _9 Z0 A; t0 z/ ^6 j
by enlargement of the penis, development of pubic, I+ q- Z/ I: N, b3 x0 a( J
hair, and facial acne without enlargement of testi-
9 A/ M. e! X) m. D5 j8 zcles, suggests peripheral or pseudopuberty.1-3 We: y% j4 Y# h) D
report a 16-month-old boy who presented with the0 L* E' `- K5 d% H3 ^
enlargement of the phallus and pubic hair develop-
: ~# m7 P7 s$ E8 w& p4 R6 C4 Mment without testicular enlargement, which was due
) Q; R3 ^$ Y  h, ~to the unintentional exposure to androgen gel used by
4 t1 o. X% R1 cthe father. The family initially concealed this infor-
, [: @% j4 M! \" I# u  l5 W8 A+ fmation, resulting in an extensive work-up for this
, t; t. J# R) E" t5 H4 zchild. Given the widespread and easy availability of
1 w7 n" k# |6 J- H4 k" f0 Ptestosterone gel and cream, we believe this is proba-# t6 C, c6 m, v) a# |1 s. ?
bly more common than the rare case report in the: Z3 o7 y1 l+ ]4 M5 J6 P
literature.4! ]1 O4 p" A+ C
Patient Report
) Q5 @6 c! p0 B: RA 16-month-old white child was referred to the
: i' X: X& _+ V3 W. E% c6 z7 F0 vendocrine clinic by his pediatrician with the concern
& P. t( |! L7 Q' K$ T6 _6 ~- C% fof early sexual development. His mother noticed
: X: t3 e7 C$ t8 k: ^light colored pubic hair development when he was  b, Z) g# Z* i0 t+ A; s2 D4 t
From the 1Division of Pediatric Endocrinology, 2University of2 \9 p2 a- t/ N- Z+ G+ }* N
South Alabama Medical Center, Mobile, Alabama.
# i/ p! F' u+ R+ w0 \Address correspondence to: Samar K. Bhowmick, MD, FACE,
% A/ W+ G/ J5 eProfessor of Pediatrics, University of South Alabama, College of# S, X# [# R5 _, P- G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 {8 h: E6 c' @6 W' H9 w
e-mail: [email protected].
0 ~8 u% }# [+ H8 F# ?3 Eabout 6 to 7 months old, which progressively became
7 H3 G% k1 v# R# g/ s' i# f; Q( Ldarker. She was also concerned about the enlarge-
- U# F; k9 _; l% B2 |( {5 {ment of his penis and frequent erections. The child* @" s6 U) t) ~, b  j6 _
was the product of a full-term normal delivery, with6 j" f1 J4 t; E% q3 n3 u
a birth weight of 7 lb 14 oz, and birth length of7 J) |8 n( e7 q7 v' H, s9 C
20 inches. He was breast-fed throughout the first year& P: A4 ]0 M: s( X: G, F$ u3 r
of life and was still receiving breast milk along with- a  j& P; \* J1 [9 J) f% E
solid food. He had no hospitalizations or surgery,* g/ A" `, }7 M0 V
and his psychosocial and psychomotor development
3 }/ X" m0 ~! y* X( w, Bwas age appropriate.
4 i8 F# S2 ^0 [6 ~9 u/ m1 m( }The family history was remarkable for the father,  W/ }) ^2 R" X5 O: [' T0 \. v
who was diagnosed with hypothyroidism at age 16,
" B* A% `/ s7 n4 x! n% [4 F( @which was treated with thyroxine. The father’s
/ C7 Y' p+ Z. T7 g; Iheight was 6 feet, and he went through a somewhat) X& p6 P. {9 t9 U: s9 q
early puberty and had stopped growing by age 14.
  d' G2 E# ]: K( p, b) [The father denied taking any other medication. The& ~  T+ e  H/ o0 w( [5 r
child’s mother was in good health. Her menarche) v0 }6 K4 o% h6 h9 @: u
was at 11 years of age, and her height was at 5 feet, s5 d1 Y2 k+ ?
5 inches. There was no other family history of pre-
  ~5 u% d) u9 icocious sexual development in the first-degree rela-" G2 D, N9 F% M0 T# r: t  K9 \
tives. There were no siblings.8 l) \3 f& y) A/ `8 j
Physical Examination
' w, w4 p& C2 t; k6 ^- zThe physical examination revealed a very active,+ v$ H5 v  p' |0 G3 n# H
playful, and healthy boy. The vital signs documented
+ x: p/ s" A% \( z. e% l8 V9 Xa blood pressure of 85/50 mm Hg, his length was* f% n; d: K% x1 v
90 cm (>97th percentile), and his weight was 14.4 kg; i$ ~/ s9 c( m- U/ Y5 |  L
(also >97th percentile). The observed yearly growth
$ l  J) p# T' Yvelocity was 30 cm (12 inches). The examination of
& Y" x; H5 w4 R; Y: ^the neck revealed no thyroid enlargement.7 I3 N8 U8 n, P. Z- F9 N, y) z
The genitourinary examination was remarkable for. \. l6 C. m, @) G' B& o  r1 `
enlargement of the penis, with a stretched length of" x2 c4 {6 E+ U0 g& \- F* o: C
8 cm and a width of 2 cm. The glans penis was very well; J/ {% n7 O/ J
developed. The pubic hair was Tanner II, mostly around5 g! |  }! I. w
540
2 c8 c% m( ]$ @+ q9 ]0 Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: Y4 p: t' \2 R# s3 }
the base of the phallus and was dark and curled. The
" @/ C! K+ ]& q- M: c& F( Ztesticular volume was prepubertal at 2 mL each., m& ~$ c! r! ]
The skin was moist and smooth and somewhat! i0 |6 K9 H3 `. J9 q
oily. No axillary hair was noted. There were no, S* Q. j' u& s; q" g% A! _
abnormal skin pigmentations or café-au-lait spots.
8 q1 [# N; M( x, m3 k. t: H, GNeurologic evaluation showed deep tendon reflex 2+
% t! w( p2 z  _2 ~/ Ybilateral and symmetrical. There was no suggestion
& x$ @2 W. ]/ m/ P( Qof papilledema.  q* u5 k& n# X- m
Laboratory Evaluation  z% U) _: Y/ \8 S6 ^
The bone age was consistent with 28 months by
2 c9 k/ O6 }: T) L" R4 u) o, Lusing the standard of Greulich and Pyle at a chrono-
( p) |! A# D* J9 J+ |) o7 `logic age of 16 months (advanced).5 Chromosomal" M& g1 s3 l4 [* m. O
karyotype was 46XY. The thyroid function test  u  o/ p% m' T% {% I  ]) Z, W. ?
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: b' d7 z; M! M( c9 h' c
lating hormone level was 1.3 µIU/mL (both normal).% e1 _! a) \8 H( U( D" Z2 E2 \
The concentrations of serum electrolytes, blood- }1 @7 H5 r$ `+ F
urea nitrogen, creatinine, and calcium all were
5 z3 d! `! x5 zwithin normal range for his age. The concentration
5 c+ L3 h- a* c$ eof serum 17-hydroxyprogesterone was 16 ng/dL
$ g$ j# M* ^3 P$ u(normal, 3 to 90 ng/dL), androstenedione was 20
/ q4 H2 o( D* C: \- z  Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 L( n1 ?* W% [8 f/ q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 G6 o2 \! d: k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ s4 }2 z* C6 B7 }/ {# g% U5 P
49ng/dL), 11-desoxycortisol (specific compound S)) d- I; B4 ~# j/ a4 E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- N" k" B$ K8 K7 D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# o( @! d2 P" C+ }- R: @
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 u; N1 e7 P: gand β-human chorionic gonadotropin was less than
6 x& X0 W$ k8 O: J5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 T* e+ C! j4 \8 {# |& i- q6 Mstimulating hormone and leuteinizing hormone
3 S$ V6 l7 G$ U! ?  Z9 N) Aconcentrations were less than 0.05 mIU/mL; t# V3 Q/ f& N. k' ]3 H# h
(prepubertal).
& t- K! ?* ]$ D& _! _0 l, DThe parents were notified about the laboratory1 z  |" V. D$ @! r/ Z0 \; s: t
results and were informed that all of the tests were* k2 Z- j; P& p
normal except the testosterone level was high. The+ L9 k! s; x/ ]- V8 x6 |) r
follow-up visit was arranged within a few weeks to
1 S4 K! m* j4 v7 T. r( F8 O4 aobtain testicular and abdominal sonograms; how-
& k2 ^. V* W% aever, the family did not return for 4 months.
$ U6 t0 E2 P+ K6 ?# ~Physical examination at this time revealed that the# t2 o0 J+ n" |8 T$ m
child had grown 2.5 cm in 4 months and had gained
: B, a% G- g: Q6 l+ u2 kg of weight. Physical examination remained
: U: `* ]- N8 }1 @. @' I5 Sunchanged. Surprisingly, the pubic hair almost com-
8 `! W$ ^5 `6 X9 A& O- tpletely disappeared except for a few vellous hairs at/ N( _" @9 ~% L' J; r
the base of the phallus. Testicular volume was still 2+ E- E2 ~6 L$ t) D" x: Y+ i
mL, and the size of the penis remained unchanged.
; H. _* y2 B$ H: h& k" {* ZThe mother also said that the boy was no longer hav-
" l  E- K1 p7 R& v/ b' Z3 T  eing frequent erections.
& P  @0 M" `# g5 f- WBoth parents were again questioned about use of
# A- l5 [  K9 Z: }9 G. {( Cany ointment/creams that they may have applied to
5 ]: k& y. J) z. N# q1 h$ P4 i4 {the child’s skin. This time the father admitted the
4 x1 C3 b' Y+ c8 b% wTopical Testosterone Exposure / Bhowmick et al 541
4 s3 C( }  a* O9 Y) e, |9 L- I( Ause of testosterone gel twice daily that he was apply-! S! U+ F9 h8 ]! i8 x" E* u
ing over his own shoulders, chest, and back area for  a( M5 g' N/ U$ g4 S; \' j% b, V
a year. The father also revealed he was embarrassed! ^: O$ e( r* h( P
to disclose that he was using a testosterone gel pre-
9 M7 B  {0 l2 q. Hscribed by his family physician for decreased libido
  B. E' q2 g% e7 R, d  vsecondary to depression.
/ S5 T$ b3 A4 H: H. wThe child slept in the same bed with parents.
3 v; x+ q6 A/ x; L; qThe father would hug the baby and hold him on his
% ]& \' x  h: z: n  P. s% ?4 Q" W* {chest for a considerable period of time, causing sig-
1 ~2 _. |4 P: z! U- ^6 W3 enificant bare skin contact between baby and father.
: h2 Z9 ^! ]. J4 ^. Y/ a# UThe father also admitted that after the phone call,
1 O1 H2 j& U- f( p! Uwhen he learned the testosterone level in the baby5 ^' [) t1 J# K, u' P7 L' a
was high, he then read the product information
4 c! L# u! g4 I% {- A4 Ypacket and concluded that it was most likely the rea-
. a, G2 e  R5 T" U% @; e/ }# nson for the child’s virilization. At that time, they: x8 g& `4 S1 Y& _8 w9 N/ l
decided to put the baby in a separate bed, and the2 h2 F0 @7 L2 H" |% b# D3 `; g; G/ ~) `
father was not hugging him with bare skin and had
. s1 ]1 J( \+ K1 m8 {been using protective clothing. A repeat testosterone% m6 i* |0 c) \4 I
test was ordered, but the family did not go to the
& T. Z( ^' B9 e* R/ ylaboratory to obtain the test.. s- D. F! T* Z0 J! i
Discussion3 I( V5 M9 ~/ J$ z" F: u9 E7 ^
Precocious puberty in boys is defined as secondary
+ C  i( i9 d7 R1 Q3 ^7 Z: ksexual development before 9 years of age.1,47 x# N: `% ]2 H* j. w9 T# G
Precocious puberty is termed as central (true) when
6 z2 v; _  f; H5 ^7 _" Q  H- dit is caused by the premature activation of hypo-" G  i" K, G2 m& s0 M1 z7 O. J, B" n
thalamic pituitary gonadal axis. CPP is more com-
/ c( d% @4 a2 @; H' L9 S: gmon in girls than in boys.1,3 Most boys with CPP
, e" ^" D2 Q' s- V3 Ymay have a central nervous system lesion that is- _: x; e& K, E2 ?7 z( }% a
responsible for the early activation of the hypothal-
) g: [% R2 o7 ?) z' E7 y( Gamic pituitary gonadal axis.1-3 Thus, greater empha-# u) U# F+ F2 h$ J- P& w0 J
sis has been given to neuroradiologic imaging in
( B6 F5 j7 s/ t5 M! qboys with precocious puberty. In addition to viril-
+ x+ R1 p$ w+ n  \ization, the clinical hallmark of CPP is the symmet-
! l4 Q* v& ^2 n  N+ Y: jrical testicular growth secondary to stimulation by
  Z! }$ C& q6 ]# c2 pgonadotropins.1,3
0 r1 D7 O, z, c+ j% p: Q' B2 KGonadotropin-independent peripheral preco-
6 m, ~7 k% n( G! \2 p1 Ccious puberty in boys also results from inappropriate
2 @. f: m$ \; |androgenic stimulation from either endogenous or5 R) G. d& R' P- j1 u
exogenous sources, nonpituitary gonadotropin stim-
$ X* g7 a2 ^0 g2 hulation, and rare activating mutations.3 Virilizing9 i; ~% ?7 y' u! p3 z  [( z9 r) ^
congenital adrenal hyperplasia producing excessive* Q: Y2 S8 _1 x1 S/ t( L
adrenal androgens is a common cause of precocious% ~' G7 u# K, Q6 a, i4 M
puberty in boys.3,4' {; R/ Y; Q$ W4 z' H8 d# a
The most common form of congenital adrenal
" T% e9 \  ]) T# L" H) ?9 S8 d8 |hyperplasia is the 21-hydroxylase enzyme deficiency.2 Z3 z0 ?0 Q& u6 h# o1 b6 {# h+ T
The 11-β hydroxylase deficiency may also result in
& a, ~( \5 p! e  {; F; k/ kexcessive adrenal androgen production, and rarely,
2 \, B+ e8 f) `0 S# ^- z8 Wan adrenal tumor may also cause adrenal androgen
) ^  U  y/ E1 \4 b7 x: Kexcess.1,3
$ _  e; E* b3 a1 E& Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& Y$ s8 P; p& l" }/ b2 k542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- S3 g% C1 E: Z6 ?8 Z9 s( Y1 N' y8 B, {A unique entity of male-limited gonadotropin-; Y" V  p9 Y- V
independent precocious puberty, which is also known
# u5 t* v) J! c  J! H( y4 ias testotoxicosis, may cause precocious puberty at a
$ E3 J" d6 b  x, |very young age. The physical findings in these boys
+ y2 W. S7 [) i' u* L& C- pwith this disorder are full pubertal development,
, r1 h2 ]: g0 kincluding bilateral testicular growth, similar to boys5 G% [) W; f/ p$ S
with CPP. The gonadotropin levels in this disorder
2 ]7 y$ S7 A8 N, ^' n! V, p$ iare suppressed to prepubertal levels and do not show
* u% D7 |- `) ~+ d6 ?/ V, Opubertal response of gonadotropin after gonadotropin-6 r% `) y  s: Y: e- p5 Z# v
releasing hormone stimulation. This is a sex-linked$ m# i  R: A3 K. m+ g- i
autosomal dominant disorder that affects only9 ^( t: ~- S- T/ G7 J3 o+ Y
males; therefore, other male members of the family9 R" m; l' \. _& _, u: N2 M* N
may have similar precocious puberty.3
& `; q# V9 g( M( jIn our patient, physical examination was incon-# A) x# ~, S+ ^# y$ q9 v( B6 m* k
sistent with true precocious puberty since his testi-) f) y) t5 H5 }2 u% Z6 C. O& Y
cles were prepubertal in size. However, testotoxicosis, f3 {5 L$ J  Y1 T
was in the differential diagnosis because his father- ?9 T! @- P! ?( f$ V
started puberty somewhat early, and occasionally,
8 N+ X7 z+ h' ]testicular enlargement is not that evident in the" o# c  v+ Z7 I2 L% L
beginning of this process.1 In the absence of a neg-4 o) i0 ~' f0 f3 r7 I% d) j3 `
ative initial history of androgen exposure, our6 V( P! D5 G! S
biggest concern was virilizing adrenal hyperplasia,
$ N# A& C7 k: i* ?; P3 H( Ieither 21-hydroxylase deficiency or 11-β hydroxylase
: L. f" R; K! Q0 l* jdeficiency. Those diagnoses were excluded by find-5 _. _& [" |& V) K4 N5 ^
ing the normal level of adrenal steroids.' C6 E' C: p+ H8 W# B+ l
The diagnosis of exogenous androgens was strongly7 i- l! \( P1 n% {
suspected in a follow-up visit after 4 months because
) Y/ ?4 l3 B3 Y. e! w3 U4 {the physical examination revealed the complete disap-
/ V$ m/ Z' L# {2 Ipearance of pubic hair, normal growth velocity, and3 O: t2 f  f8 c2 M, [- v+ A
decreased erections. The father admitted using a testos-5 N& J7 y( V% J6 ^
terone gel, which he concealed at first visit. He was) ?4 B! X8 j% i5 L
using it rather frequently, twice a day. The Physicians’% y! t, U0 T1 ~' t
Desk Reference, or package insert of this product, gel or
9 x6 }9 k4 Z' D$ d% Q! w* J1 x' K' @cream, cautions about dermal testosterone transfer to" A2 S9 t1 `$ a; `
unprotected females through direct skin exposure.
- F" L0 G* ?# ]$ x9 T. q4 K2 o0 b3 OSerum testosterone level was found to be 2 times the3 w% s6 D* I" y( v
baseline value in those females who were exposed to( {4 L4 h: U. j% O5 b& Z% p
even 15 minutes of direct skin contact with their male4 H$ j# J# t3 }1 k
partners.6 However, when a shirt covered the applica-- A. d4 g8 r1 m* I
tion site, this testosterone transfer was prevented.2 y. T: [- ^+ ~; H9 o3 W" Z
Our patient’s testosterone level was 60 ng/mL,; Y) N% e" S- u/ I7 ]1 O7 @1 z
which was clearly high. Some studies suggest that: {  D' H9 T% x
dermal conversion of testosterone to dihydrotestos-5 f0 F; u3 K6 W, }4 K8 A
terone, which is a more potent metabolite, is more
9 M. G4 [4 ]( Aactive in young children exposed to testosterone& ~- z8 C4 B: x+ Y" d  A
exogenously7; however, we did not measure a dihy-
+ l8 }/ ~9 K- e* g: L/ Rdrotestosterone level in our patient. In addition to
" @7 w0 h: n3 s: p2 g1 ?$ s& avirilization, exposure to exogenous testosterone in' Q( y8 r) V, D, H* o2 g
children results in an increase in growth velocity and! _8 u5 n- `1 f) Y& |+ g: m
advanced bone age, as seen in our patient.# @! z* |( F/ G8 `, z3 I6 `
The long-term effect of androgen exposure during1 `6 W6 [& C+ ~+ t& r  f
early childhood on pubertal development and final$ t9 S* A# v2 E" P. g" k: U
adult height are not fully known and always remain8 y( W) o% R; n+ }- ]
a concern. Children treated with short-term testos-
! B9 B0 J1 {0 Q3 `terone injection or topical androgen may exhibit some
9 d5 S, w! b0 \5 U' kacceleration of the skeletal maturation; however, after% P. y/ P& Z7 x
cessation of treatment, the rate of bone maturation; I" D0 O$ g: o+ ]& i+ Y, i
decelerates and gradually returns to normal.8,9  @* A- }. X7 z4 P
There are conflicting reports and controversy: @! m( @' d( @% C. T, ?$ O: N
over the effect of early androgen exposure on adult- q8 z: p. I! H% d$ y
penile length.10,11 Some reports suggest subnormal1 |- a7 k; t$ X: d+ t4 }5 T* s
adult penile length, apparently because of downreg-
/ `7 F  B7 @3 Dulation of androgen receptor number.10,12 However,9 N* }& r7 l( P! {$ A1 A0 j
Sutherland et al13 did not find a correlation between0 K* l0 ~7 X) O4 u3 w
childhood testosterone exposure and reduced adult
7 m6 N! Q4 D# Z! Q3 Apenile length in clinical studies.
  U; n- s4 p/ ]5 ~) GNonetheless, we do not believe our patient is
' w' `! z9 U% a2 y6 j$ }- jgoing to experience any of the untoward effects from
) m- H+ N+ J. y$ r) U) c9 [/ F0 ftestosterone exposure as mentioned earlier because
6 s, a" R; S& P' C3 |; ^- I0 tthe exposure was not for a prolonged period of time.- @2 o6 B1 f0 S, B- I
Although the bone age was advanced at the time of
9 N+ [4 n6 f9 {  {0 z: s% ndiagnosis, the child had a normal growth velocity at* V) e2 s6 [1 s! {7 q
the follow-up visit. It is hoped that his final adult
1 q$ e# o; y" Y% u& n0 Zheight will not be affected.
+ @# V& _# k: J! |Although rarely reported, the widespread avail-
9 N; E, V; z3 T: y! Gability of androgen products in our society may
: f- G3 f' D* sindeed cause more virilization in male or female4 {  B. S! Z' X6 g6 F$ @
children than one would realize. Exposure to andro-0 W9 N6 M& P' ?
gen products must be considered and specific ques-0 d2 t; Y( {% l8 c
tioning about the use of a testosterone product or
6 v% O  a( i2 H+ |gel should be asked of the family members during% {* p$ X/ r# b  W3 N0 s. \
the evaluation of any children who present with vir-- }' F+ x! [# f3 I
ilization or peripheral precocious puberty. The diag-
3 a3 ]) Z9 z* Unosis can be established by just a few tests and by
; H6 w) M! w( t. T) i7 p  Pappropriate history. The inability to obtain such a& l6 S! b$ Q; y7 a8 U$ J
history, or failure to ask the specific questions, may
1 i: s5 |8 |6 C) V8 Q" Dresult in extensive, unnecessary, and expensive# w0 V1 ^9 A, Y6 Q( u
investigation. The primary care physician should be+ X! f9 v+ r1 d, t% U: [1 ]
aware of this fact, because most of these children0 F2 j, ^$ Y5 K- A2 @1 @
may initially present in their practice. The Physicians’$ q( o2 b% Y, O& V
Desk Reference and package insert should also put a
$ d: G: C$ t% I* S+ W/ }+ iwarning about the virilizing effect on a male or0 I; T3 F, d" |! J" |; C
female child who might come in contact with some-
2 N8 K" I1 L6 i8 R; H& Z2 T  Bone using any of these products.
$ I+ K8 b5 h. i1 }References
) c( k, z5 r4 @  H2 m( Y5 H1. Styne DM. The testes: disorder of sexual differentiation
; ]* E" m& a; b# K  u) Band puberty in the male. In: Sperling MA, ed. Pediatric, l, z* m+ A5 r+ G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ U$ H6 R- j0 _% c2002: 565-628.3 A: r, ]! O- U5 }8 V
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" Z2 Q4 y: H. n& h9 s; f
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
' h! ?+ x6 l& Z" _" X& i4 l# T8 o5 A
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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