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Sexual Precocity in a 16-Month-Old3 U5 N' b9 N0 o; d' h  I: \' ]
Boy Induced by Indirect Topical# @% l$ R1 t" F( X, @* A
Exposure to Testosterone6 z9 O2 n; X, q6 P
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. z9 M3 m; `* l; }and Kenneth R. Rettig, MD1% S+ Y' c1 n0 g: e0 P1 @
Clinical Pediatrics
; E1 S8 H, a. t  Q. y4 ~( aVolume 46 Number 6
6 O% x+ [! I6 A" O, ?July 2007 540-543
# P, \2 H0 Q* f, }; C© 2007 Sage Publications* O* w! W1 m' g8 D9 V
10.1177/00099228062966511 L' `, A2 s9 m$ n, W$ S" D
http://clp.sagepub.com, [! x" I8 Q6 N1 o" S
hosted at
& q1 T. ^4 T7 n, m4 U. _. Q0 M- Whttp://online.sagepub.com0 ?# ]6 Q6 H7 {
Precocious puberty in boys, central or peripheral,
5 }. _  _$ v6 ^" f/ `! cis a significant concern for physicians. Central
* b/ K/ l/ r, G# h* Y2 Pprecocious puberty (CPP), which is mediated, A+ n  T. K. z' h
through the hypothalamic pituitary gonadal axis, has
2 m, ~: J( U. {5 y8 ?+ ^/ A' \# ha higher incidence of organic central nervous system* V; h  r4 ?3 h/ _& O. C
lesions in boys.1,2 Virilization in boys, as manifested
  z& w) I* L/ V0 K/ Aby enlargement of the penis, development of pubic
% @- x+ z$ [7 [# X' z* [hair, and facial acne without enlargement of testi-
9 @% ?7 d7 _+ i- Zcles, suggests peripheral or pseudopuberty.1-3 We
' G. Q. q4 h+ }& i5 l8 Q  y4 Jreport a 16-month-old boy who presented with the  i2 H3 s; @1 T0 b% D& O
enlargement of the phallus and pubic hair develop-
! D3 L8 L0 T2 @6 `ment without testicular enlargement, which was due
7 t8 R" I6 p3 v5 cto the unintentional exposure to androgen gel used by
2 }1 R' y! f  z1 ^the father. The family initially concealed this infor-- w& |" z  `6 _- z
mation, resulting in an extensive work-up for this
8 z2 M' d+ s6 r7 D" r- Pchild. Given the widespread and easy availability of  W7 i) ]) s& C6 X
testosterone gel and cream, we believe this is proba-
5 a% r' q" s% i1 B+ T; L% B! a- Gbly more common than the rare case report in the
% h* h+ r( \. x3 Q0 O/ cliterature.4) ?* k. X7 b0 y# }/ A  Z
Patient Report+ G; k, K" [) n: t  J4 m
A 16-month-old white child was referred to the! s1 h4 ?1 A! |5 ?: t
endocrine clinic by his pediatrician with the concern" @4 M# ^% ?, g2 v
of early sexual development. His mother noticed
$ L* e  T3 c) X( C. Q* n- |; y. vlight colored pubic hair development when he was# f% |. ~; @, o! n
From the 1Division of Pediatric Endocrinology, 2University of8 Q! a7 O& o8 n% k
South Alabama Medical Center, Mobile, Alabama.
8 z% ^  A! w! \5 W2 u" r4 B: ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,- n- O  v  w+ ~5 {) C8 l. a
Professor of Pediatrics, University of South Alabama, College of! V: M7 F' d# v- H7 u6 s, ]
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ J9 w" X' a  ^e-mail: [email protected].( V' q4 C3 l" x- ?; H+ o
about 6 to 7 months old, which progressively became
* N; M. y. k. X4 ]* ^' rdarker. She was also concerned about the enlarge-
3 W  [( o; q, |" w3 o! z: c& Mment of his penis and frequent erections. The child3 b+ o' r" H' _# v4 [( V
was the product of a full-term normal delivery, with
' L. l- H3 F6 e5 L3 Pa birth weight of 7 lb 14 oz, and birth length of
! h: J2 n8 u, R, K20 inches. He was breast-fed throughout the first year% _3 O7 S0 I# J
of life and was still receiving breast milk along with5 A: p4 o; R' Q1 h* |& v' L
solid food. He had no hospitalizations or surgery,
& e( ]3 V- t/ t. F! \( l6 e! Pand his psychosocial and psychomotor development
7 R. x7 y) u8 h* _% }0 owas age appropriate.& j: V1 w$ c* I  n
The family history was remarkable for the father,& y& b0 \6 d5 G( k; [
who was diagnosed with hypothyroidism at age 16,
( ^" V7 w7 e6 Z* e$ c- twhich was treated with thyroxine. The father’s
& P* z  L% l4 ?3 q: }# i: `2 vheight was 6 feet, and he went through a somewhat
; ^& {+ {$ [" E1 [* J0 dearly puberty and had stopped growing by age 14.9 n+ n# a$ z- n- P
The father denied taking any other medication. The
, j7 [2 h  [. I' Kchild’s mother was in good health. Her menarche
2 A+ c* E1 ^. m8 Q! owas at 11 years of age, and her height was at 5 feet" B5 D2 |0 Q, _
5 inches. There was no other family history of pre-( F# }0 f  g: M; J' X( \
cocious sexual development in the first-degree rela-# |% F, r- f! ?- I$ b3 @) i
tives. There were no siblings.: j* S1 y3 K" U: F
Physical Examination+ J5 l, \: Z: v
The physical examination revealed a very active,
3 B& \& H9 i" R7 L& ~, E3 T% bplayful, and healthy boy. The vital signs documented8 H; _0 Q6 @+ c. l# p% _% K# \, m
a blood pressure of 85/50 mm Hg, his length was, v1 s( Z. |" J! f. O* \8 U- j
90 cm (>97th percentile), and his weight was 14.4 kg5 z1 D5 ~# T9 ~2 Z; n3 p' C! ?
(also >97th percentile). The observed yearly growth
6 B' p4 Q* \% a) Lvelocity was 30 cm (12 inches). The examination of
" U/ i5 |$ V, ^9 ~" P# L4 A$ K1 cthe neck revealed no thyroid enlargement.
( {( h- Y# F# d7 t$ iThe genitourinary examination was remarkable for0 n6 l( y. ?! a% m: R
enlargement of the penis, with a stretched length of$ {# a; ^8 H5 j8 H0 a4 U5 L
8 cm and a width of 2 cm. The glans penis was very well8 f1 y( J% Z6 e) X, V" n9 t
developed. The pubic hair was Tanner II, mostly around9 w' x" q+ u& J. j; ]( K
5406 u, R. P. e2 g5 N6 L" j+ ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ c' j3 y1 D# e; ^, H+ w
the base of the phallus and was dark and curled. The: R6 k. f6 Y# a
testicular volume was prepubertal at 2 mL each.! c0 n  W( G5 W, E2 {, h
The skin was moist and smooth and somewhat" Y( S, u0 y- D( F. Q2 D( Q" U
oily. No axillary hair was noted. There were no( c2 D$ Y% ?. r, r; r* m1 _' Z
abnormal skin pigmentations or café-au-lait spots.. t) g# T) `: v
Neurologic evaluation showed deep tendon reflex 2+
) n8 E. m0 T: ?; a" i+ u! ebilateral and symmetrical. There was no suggestion
' ?4 q2 I+ O. L6 Q% u" U  Oof papilledema.  A9 p( H! s2 I1 ?# [% {/ w
Laboratory Evaluation
1 E* V  n; i/ f4 nThe bone age was consistent with 28 months by& H& Y6 h4 R, c( f) d" }
using the standard of Greulich and Pyle at a chrono-
" ]1 R* W8 G! m4 P8 n+ h$ qlogic age of 16 months (advanced).5 Chromosomal
! \/ Z- b- z! A* M+ h5 I' Okaryotype was 46XY. The thyroid function test
) x* l! }4 o# g0 `showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 V) }& e$ T1 T7 M9 a. n: g
lating hormone level was 1.3 µIU/mL (both normal).
9 p; Y' I: s; a9 x* \# SThe concentrations of serum electrolytes, blood; W; Z3 k/ `, M+ `/ N
urea nitrogen, creatinine, and calcium all were* v$ z8 P( q  ?; Q" ^6 u' |
within normal range for his age. The concentration. o. P- e4 B) p) M
of serum 17-hydroxyprogesterone was 16 ng/dL
4 }3 u. q% x  u: f(normal, 3 to 90 ng/dL), androstenedione was 20
% Z# C0 W& T$ Z! ~4 e; Kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 V) g$ g6 A: I5 I: s; Sterone was 38 ng/dL (normal, 50 to 760 ng/dL),
  Z* d( v( t9 ~& sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 t% \! R& t& U2 y& c4 Q% x
49ng/dL), 11-desoxycortisol (specific compound S)
/ G9 |1 Q, R4 N: twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 e( \' f6 Q9 B- e3 s/ |tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 r0 p" v/ a& b0 U+ Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),: s: I; F4 _( A. L. {; @0 X  j; j( O
and β-human chorionic gonadotropin was less than* b3 m3 h8 g/ \3 U) m
5 mIU/mL (normal <5 mIU/mL). Serum follicular  i4 U* |# S' F5 i: c% T3 p
stimulating hormone and leuteinizing hormone
7 i0 s) Z; x9 lconcentrations were less than 0.05 mIU/mL
4 L* y- Q1 I. C( D- y& a* r% q! ^$ M(prepubertal).
" `7 p  r. c- m9 K+ `7 H1 ]' M& ]The parents were notified about the laboratory
& v* C5 I" I: Presults and were informed that all of the tests were2 k$ j8 j, v0 I, S/ ^4 R( T
normal except the testosterone level was high. The9 _" u- T( [+ G3 x' ~/ G0 N4 L
follow-up visit was arranged within a few weeks to
. u$ R6 y/ i* `4 `/ Pobtain testicular and abdominal sonograms; how-
# Z2 p* r$ x8 W! Zever, the family did not return for 4 months.
# u9 {" v  R$ {9 |+ F: aPhysical examination at this time revealed that the
* D5 G$ b# H( Q& Z# [8 |9 _child had grown 2.5 cm in 4 months and had gained6 Q$ d1 t4 S: m
2 kg of weight. Physical examination remained* S$ E/ g7 S1 v* o( K
unchanged. Surprisingly, the pubic hair almost com-
( B; C) T' q( V  J7 u2 c5 V2 Q, ipletely disappeared except for a few vellous hairs at
  N$ f/ c9 W5 O# H  x, q" vthe base of the phallus. Testicular volume was still 2
- j; `2 k; c: ~& x, }mL, and the size of the penis remained unchanged.
, R; _8 Y& K* W' h3 u  z* t& p3 \The mother also said that the boy was no longer hav-0 g% s/ T- f  d. v
ing frequent erections.
" N, d' L% j- m$ r4 qBoth parents were again questioned about use of
# e5 D9 b% j9 O% |) g( ^$ J& ~* {9 {any ointment/creams that they may have applied to& h: D9 H2 j( f4 h5 B% v3 Q# J
the child’s skin. This time the father admitted the4 Q) y% G+ l& J3 d0 P* h
Topical Testosterone Exposure / Bhowmick et al 541& a: f: `+ O/ w( b# x
use of testosterone gel twice daily that he was apply-
% }1 ?* n+ u# k0 d- hing over his own shoulders, chest, and back area for  ?& f) s3 X0 o" B& E' v7 B$ C6 @1 F
a year. The father also revealed he was embarrassed, W$ e7 Z1 z5 m7 ]3 `
to disclose that he was using a testosterone gel pre-  G" j' N" Z! S  e! A2 |% D; X9 F
scribed by his family physician for decreased libido
: N/ k5 ]2 @" t$ u1 W3 ksecondary to depression.+ [0 S4 y2 U5 A5 S
The child slept in the same bed with parents.
6 C3 P3 R+ ^2 r1 t' hThe father would hug the baby and hold him on his! g3 |3 I" ]- y% S
chest for a considerable period of time, causing sig-
8 u  M% a6 I( Knificant bare skin contact between baby and father.
. E( ^% N$ U; J( TThe father also admitted that after the phone call,! J  i# p  X7 F2 d
when he learned the testosterone level in the baby5 b- S2 o$ \2 n
was high, he then read the product information! s0 g5 A6 C; g
packet and concluded that it was most likely the rea-
' m  g# N+ M/ [9 Json for the child’s virilization. At that time, they1 [) m9 c/ _0 `3 d
decided to put the baby in a separate bed, and the
( x- ~: P0 B6 Pfather was not hugging him with bare skin and had
0 [' m: o0 B6 E& abeen using protective clothing. A repeat testosterone
+ s: S* u5 N* Ktest was ordered, but the family did not go to the
) j7 y. e6 Q  v, K8 Z8 i: u" T( ]laboratory to obtain the test.5 Z0 `; E/ \+ d- p# A; }1 e
Discussion' I7 T' |. G% ?2 v0 s- |* K1 |
Precocious puberty in boys is defined as secondary
0 H  q1 f2 r' j. W9 ^5 xsexual development before 9 years of age.1,4
- G$ N- ^9 ~2 l. X+ @Precocious puberty is termed as central (true) when
; f0 `/ b/ }& e/ `it is caused by the premature activation of hypo-
4 ~4 ~8 O: j6 \thalamic pituitary gonadal axis. CPP is more com-4 P* O$ P; }  Q+ h! D, o3 }# O+ {& L
mon in girls than in boys.1,3 Most boys with CPP
! g) Y3 y( I2 G+ D: g' U# h( T5 `may have a central nervous system lesion that is
- F" x4 R1 x  `. x% M8 ~: tresponsible for the early activation of the hypothal-: b6 b# _  ]+ I4 E
amic pituitary gonadal axis.1-3 Thus, greater empha-
& x5 o( m& S$ e) w, l8 A% `! p: c0 lsis has been given to neuroradiologic imaging in
  p3 q" K( B4 vboys with precocious puberty. In addition to viril-4 Q" _# A$ q% v+ z+ v
ization, the clinical hallmark of CPP is the symmet-
: z7 E# z1 O# q' y- k- mrical testicular growth secondary to stimulation by& {: j" h2 {$ w
gonadotropins.1,3% h% c& S/ u; t5 P" R7 k+ d9 T
Gonadotropin-independent peripheral preco-
" E& Q! [5 u% [. X) Qcious puberty in boys also results from inappropriate4 ~/ z4 P, O1 S
androgenic stimulation from either endogenous or
" `) X# X2 W4 L" d1 |+ uexogenous sources, nonpituitary gonadotropin stim-
3 L  g$ p1 I0 g4 H2 ?# h  Bulation, and rare activating mutations.3 Virilizing
; ]$ x6 ]% G: S0 |! Rcongenital adrenal hyperplasia producing excessive0 h8 k2 ~. z9 U8 d0 T
adrenal androgens is a common cause of precocious
: r$ C- c8 h' v7 \puberty in boys.3,44 A/ X/ M1 I* P5 l6 t, t! i
The most common form of congenital adrenal5 D+ |# R( e. b! @
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 [  g/ ?8 r5 F8 J8 Q) @The 11-β hydroxylase deficiency may also result in
8 a* a/ N0 N, z6 z- J2 Fexcessive adrenal androgen production, and rarely,3 E0 G3 B3 s. q# v8 s% \! v
an adrenal tumor may also cause adrenal androgen
  K3 W  c" s* ~# xexcess.1,3
1 [9 [' U! ]& O' Z) xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 k& r, e' t# V- k+ ^9 l" X2 D/ P542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 c( j8 v; S* I, G& r
A unique entity of male-limited gonadotropin-( j# b. P& x) E$ i( {) x
independent precocious puberty, which is also known
' E9 E$ |% S$ P" f" e0 \! G, H- `as testotoxicosis, may cause precocious puberty at a1 g& @, w; X' ~% \
very young age. The physical findings in these boys
* ]2 F- @8 U: i- T% p, [4 j5 Bwith this disorder are full pubertal development,
9 Z" B7 A7 U: R; w+ z) ~% H8 Zincluding bilateral testicular growth, similar to boys
* T( d( K  {% Z: Uwith CPP. The gonadotropin levels in this disorder
2 P8 L( u3 z* ?2 d0 Q0 k( O. Q+ {are suppressed to prepubertal levels and do not show' s5 Y" S! F' R4 _; ?/ H
pubertal response of gonadotropin after gonadotropin-
( d1 c* y% V- N: v* B$ h/ nreleasing hormone stimulation. This is a sex-linked
3 q, o; F  j! N: v' Tautosomal dominant disorder that affects only7 |, P$ r0 x. y$ ]
males; therefore, other male members of the family7 V* A* |6 d8 C5 ^
may have similar precocious puberty.36 v( \) b" K# T9 ~* @: u7 ^9 A/ N
In our patient, physical examination was incon-
1 l+ D: u* v* f* e' o9 T" K) Ysistent with true precocious puberty since his testi-
: i" ^$ `$ I- B5 V: Y( e) U& ccles were prepubertal in size. However, testotoxicosis8 p8 h* T* O+ k4 P+ ~% ]# k
was in the differential diagnosis because his father" S7 ]9 |: J5 u  j
started puberty somewhat early, and occasionally,4 ]  i0 E* L9 x
testicular enlargement is not that evident in the
$ c4 f6 U0 r$ M! Nbeginning of this process.1 In the absence of a neg-
5 ?6 X, }8 p' K" y% ?6 Vative initial history of androgen exposure, our" V# X& K7 M0 Z& A* S. ?
biggest concern was virilizing adrenal hyperplasia,# {6 T" A* n% _# `5 _7 o7 {
either 21-hydroxylase deficiency or 11-β hydroxylase
) Q* z) Q- O% qdeficiency. Those diagnoses were excluded by find-. R" C4 o0 \4 z0 U0 H2 {9 K
ing the normal level of adrenal steroids.4 p6 k# l5 Q) n% T' y
The diagnosis of exogenous androgens was strongly" D1 T' q. B6 o. `: w2 {
suspected in a follow-up visit after 4 months because  h  u+ e/ T! I# `$ f
the physical examination revealed the complete disap-
/ q' ~) x7 o6 c, lpearance of pubic hair, normal growth velocity, and
8 E# R+ h$ `; T- M/ ?decreased erections. The father admitted using a testos-" z- B' K3 T: a8 y/ W; G9 c% B$ ]" f( ~, k
terone gel, which he concealed at first visit. He was" t. F. o. o# F9 j! f9 t8 m
using it rather frequently, twice a day. The Physicians’4 J: I$ V4 x4 p( V- C) l7 @  A; U
Desk Reference, or package insert of this product, gel or& d6 U/ L# a6 f% x! g! m
cream, cautions about dermal testosterone transfer to* y  z5 N0 G+ U) ^9 ]7 j) {) l# G7 ?
unprotected females through direct skin exposure.
, v  T7 o4 a' J; Z7 s& `/ F: fSerum testosterone level was found to be 2 times the
# u: O+ {  h& z* d/ c( mbaseline value in those females who were exposed to
2 \- Z: A& O. e( k) k" O+ \9 aeven 15 minutes of direct skin contact with their male
0 A$ W2 E  ?8 v1 D: t' Vpartners.6 However, when a shirt covered the applica-/ Y" p# @) F, Q3 ]9 Z. ?
tion site, this testosterone transfer was prevented.) O% V$ d; x7 ?" J) O1 x$ L+ ^& y
Our patient’s testosterone level was 60 ng/mL,
" P: c8 o1 m- Rwhich was clearly high. Some studies suggest that
2 m+ x" |6 C3 ^# W1 t+ s  N. `+ ?dermal conversion of testosterone to dihydrotestos-; v* A) |$ `. k% F: W( o; y/ T) {
terone, which is a more potent metabolite, is more' Q3 q- b0 {" q
active in young children exposed to testosterone
* f; e6 R$ d( l2 O2 h9 ~' Oexogenously7; however, we did not measure a dihy-7 Z9 x7 P/ _& Q
drotestosterone level in our patient. In addition to8 S* S. b8 R( A% V* b
virilization, exposure to exogenous testosterone in
$ E- C& Y/ f, Ychildren results in an increase in growth velocity and
- S( e' q* @& S' d% {% Q; dadvanced bone age, as seen in our patient.: o& i8 ?- T6 t/ ?( V1 O* U8 T6 w
The long-term effect of androgen exposure during
/ n1 j% q1 g. z# ~early childhood on pubertal development and final
* s* J) g7 \8 z$ qadult height are not fully known and always remain1 h9 A, [, g3 K' O
a concern. Children treated with short-term testos-
# t* n6 f+ ~! n1 Bterone injection or topical androgen may exhibit some1 c" _  Q" U# s
acceleration of the skeletal maturation; however, after
  m! {$ K) A4 z/ |5 Tcessation of treatment, the rate of bone maturation
2 C) `5 @. _* y$ _decelerates and gradually returns to normal.8,9
# _/ _( L$ j! {; y2 o% |There are conflicting reports and controversy8 a: S4 G, T3 h" p( t0 F
over the effect of early androgen exposure on adult) p& [" Z. q, h  V& j) Y) Q
penile length.10,11 Some reports suggest subnormal
6 P, ]8 R2 }! C: x; kadult penile length, apparently because of downreg-
# B( s4 h4 U* ^9 {8 @) Kulation of androgen receptor number.10,12 However,
4 t; X4 b: u$ Q) TSutherland et al13 did not find a correlation between. |6 m. p  W. ^6 W. [; }. g
childhood testosterone exposure and reduced adult- W: g  E0 T; \3 `, \% v' [: k
penile length in clinical studies.4 I& h) w% A* v( V" P% ~) q
Nonetheless, we do not believe our patient is' V% }+ H  g; q7 K" ^
going to experience any of the untoward effects from. W' u  |. }1 x& x0 w. ?
testosterone exposure as mentioned earlier because
) S9 Y: h$ q( I7 A  q) Nthe exposure was not for a prolonged period of time.
2 L% ~9 `6 ]- L# H6 ^  R9 A* _* {# HAlthough the bone age was advanced at the time of
6 n0 W- _/ c, P3 o7 k& p1 \diagnosis, the child had a normal growth velocity at* Q: L, [- D2 x6 B
the follow-up visit. It is hoped that his final adult
2 z. |! V5 p2 M; q+ kheight will not be affected.( e0 S* Z5 n' V& N% ]/ m$ d3 k
Although rarely reported, the widespread avail-
* \9 H6 [2 r# a! X6 ^/ g+ e0 Nability of androgen products in our society may
- {% m. s  g. y9 r. k# J) Nindeed cause more virilization in male or female' Q3 \5 Z$ u5 M2 L3 v1 c, K  u7 E
children than one would realize. Exposure to andro-
" \; l( O* I" K5 O- D$ X( Wgen products must be considered and specific ques-4 B3 H8 w( [  p
tioning about the use of a testosterone product or
9 G! d. w' @" b$ x7 @2 ogel should be asked of the family members during0 `/ i- r/ ?- |+ h! g7 f
the evaluation of any children who present with vir-$ I  z, `+ {' }! X: ?( V$ A
ilization or peripheral precocious puberty. The diag-: V- j$ s7 I0 x) |. m; `
nosis can be established by just a few tests and by0 G; m  W8 ?8 f5 C4 ]" c0 w
appropriate history. The inability to obtain such a
7 x% w8 b5 L( S4 [history, or failure to ask the specific questions, may% u5 N; Y2 A2 ]
result in extensive, unnecessary, and expensive4 O' c% H% s1 a4 c' }- s
investigation. The primary care physician should be1 g% J1 y& S: s( }  f
aware of this fact, because most of these children: z3 a& d5 F7 j) q! d; |+ ^
may initially present in their practice. The Physicians’
8 s, z% ^  I6 G: _/ EDesk Reference and package insert should also put a
, R2 u! G1 e( J6 g, k! l4 Mwarning about the virilizing effect on a male or9 m4 t, l( ]7 m$ m6 K* G
female child who might come in contact with some-2 c: g( H) x# T* ?
one using any of these products.* _  d; B$ a& d! Z
References  S$ L$ A" z- e, A  h, o
1. Styne DM. The testes: disorder of sexual differentiation$ V. I$ }! S; c8 V
and puberty in the male. In: Sperling MA, ed. Pediatric& J$ i. d6 b" A, w1 `& a: @
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! R. h2 s( [: @" v' M' s% h  Z2 g2002: 565-628.
/ b3 ?5 x4 }3 S3 i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 l3 G/ C9 Q! u1 h( {3 b
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
4 @9 A: I8 n) C" _Boy Induced by Indirect Topical
" S$ K; r; A' O0 Z' \7 vExposure to Testosterone
7 ^8 t* Y" b) F/ iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% Y# T6 z: ]4 b- ]5 \/ L) |, pand Kenneth R. Rettig, MD1
. f$ z+ G8 F2 S- D/ m9 bClinical Pediatrics- n" X3 I$ E* I0 `, c) t9 }
Volume 46 Number 6' B: ^& q+ H  h+ n8 A- y
July 2007 540-543% m1 h- B  U2 q3 n
© 2007 Sage Publications
9 T( K& T0 _( _  z7 l- Z( J, q0 y10.1177/0009922806296651% S7 K% T% e) a" }: O
http://clp.sagepub.com7 q' ~6 {* M1 _" P4 g
hosted at  _* f( u4 q4 r% N
http://online.sagepub.com
) N+ U; z% N6 X, c% SPrecocious puberty in boys, central or peripheral,' W- ^+ N) r' ~+ q8 x
is a significant concern for physicians. Central4 I1 F7 g; x" W* u: D3 H9 [, g
precocious puberty (CPP), which is mediated: k( P  |' K& P+ {- |
through the hypothalamic pituitary gonadal axis, has' B2 J  H" _9 _2 P8 k; {
a higher incidence of organic central nervous system8 H8 Y. m# o5 h. J: L+ h
lesions in boys.1,2 Virilization in boys, as manifested& T  J1 Y2 n) S4 M1 e" `8 R
by enlargement of the penis, development of pubic. O, {6 D1 ?* o% [9 \
hair, and facial acne without enlargement of testi-
6 j! v6 W) l' o0 T- \4 qcles, suggests peripheral or pseudopuberty.1-3 We
1 s6 ^1 c  a0 Preport a 16-month-old boy who presented with the
6 V/ S: n- A% h0 a) i4 S- ]  z  eenlargement of the phallus and pubic hair develop-
) q8 W3 W  C. L! {7 R# \ment without testicular enlargement, which was due1 p, J; m9 \+ s5 W; H
to the unintentional exposure to androgen gel used by' p' `1 s2 ^) v" h. r
the father. The family initially concealed this infor-
- [' r" _/ [9 b1 S2 t0 O/ c  \$ bmation, resulting in an extensive work-up for this8 j% i/ c6 K9 |/ f+ q9 P
child. Given the widespread and easy availability of
; X& q9 S6 R3 |/ r$ l/ e8 z3 g3 utestosterone gel and cream, we believe this is proba-3 Q3 K- _& a0 F
bly more common than the rare case report in the
0 ]  p+ z% {4 \6 Lliterature.4( l' Q9 H/ ^* ~; W7 S5 R' g
Patient Report
' B% d& x: [& Q7 Q0 a6 ]A 16-month-old white child was referred to the
/ Z8 w7 w) j) [" p6 R9 @endocrine clinic by his pediatrician with the concern
, I6 y$ c" D: G! K) o8 E% F! m$ Tof early sexual development. His mother noticed: H" p$ `9 {: X9 B, `6 \( e
light colored pubic hair development when he was$ I0 I! x8 l$ [+ x; |( B, F5 d
From the 1Division of Pediatric Endocrinology, 2University of+ x, ]9 @# W% c! `
South Alabama Medical Center, Mobile, Alabama.
2 K% A$ w9 s% O6 X4 W) wAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ _: S  M# M+ _, D# {; `Professor of Pediatrics, University of South Alabama, College of9 p0 g/ {. c1 E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' m6 C& D2 t$ p  k4 G5 ^e-mail: [email protected]./ W  d' B  u5 X# T5 ]: i
about 6 to 7 months old, which progressively became/ W$ S# I- U: i4 p3 E
darker. She was also concerned about the enlarge-
$ f5 i+ Q% r6 [$ Iment of his penis and frequent erections. The child; Y9 M3 l$ t& D/ }- U" Z. c
was the product of a full-term normal delivery, with
( [( r$ V  m2 h0 u$ ya birth weight of 7 lb 14 oz, and birth length of
8 ]" q6 t, F" j6 I9 Y20 inches. He was breast-fed throughout the first year
$ m& H$ Q2 N5 R% N3 @  @$ Qof life and was still receiving breast milk along with
: d; Z7 s& `8 D% {0 I9 X  d2 isolid food. He had no hospitalizations or surgery,
- K+ q. `- Y9 M% xand his psychosocial and psychomotor development
9 u$ R+ ]0 C7 v0 cwas age appropriate.
- N; b: H3 P1 xThe family history was remarkable for the father,
5 \9 h# N7 \- l, C1 Uwho was diagnosed with hypothyroidism at age 16,. U" V( l7 F; Q- a1 F; i
which was treated with thyroxine. The father’s
: j+ G+ ?9 \8 s2 w; b" S7 Qheight was 6 feet, and he went through a somewhat$ c7 t* G' E% ]: n& l
early puberty and had stopped growing by age 14.
, }* H, Y* t1 D  d6 Q1 j% AThe father denied taking any other medication. The
. t, b( C) m% w! \& B; {0 nchild’s mother was in good health. Her menarche1 k" N9 ]2 {1 [( ~- r' `
was at 11 years of age, and her height was at 5 feet) ~+ \! f8 d% o
5 inches. There was no other family history of pre-- m. ~( s0 M2 X. W+ x& p$ S
cocious sexual development in the first-degree rela-
6 A- W# |9 y% Mtives. There were no siblings.* C5 C  }- v( ]; |. r- T8 S
Physical Examination
3 z& T& p* S! M, h( [8 ^7 @The physical examination revealed a very active,% f( W1 X3 _* }: B4 n; y
playful, and healthy boy. The vital signs documented  D* {9 j4 t3 l, y6 ^8 R% T
a blood pressure of 85/50 mm Hg, his length was
4 p# G3 a. J# F' ?) J9 P5 D9 a) J/ P90 cm (>97th percentile), and his weight was 14.4 kg2 C' Y$ S1 K. Y/ n1 Y
(also >97th percentile). The observed yearly growth1 ~/ s, W4 N6 A) b
velocity was 30 cm (12 inches). The examination of
: W; E- J# c. J% A* nthe neck revealed no thyroid enlargement.$ N0 g& `/ S5 w; O; J9 A- `+ e7 Q0 @
The genitourinary examination was remarkable for3 U- o# o5 k  [' q
enlargement of the penis, with a stretched length of
7 p+ c% `3 v3 R6 K5 t$ g8 cm and a width of 2 cm. The glans penis was very well
7 R5 g  k, s+ x+ r' H  ldeveloped. The pubic hair was Tanner II, mostly around
8 e8 C5 e: M- l  I# S+ Y: N; G2 x5403 P* M, X& ]; U. d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 Q# I6 W9 _$ _2 O; X- |the base of the phallus and was dark and curled. The% \2 g; U, z3 M( D0 \: ]
testicular volume was prepubertal at 2 mL each.4 r. i1 H5 M7 P8 P
The skin was moist and smooth and somewhat5 n# ]) ~0 K! Z
oily. No axillary hair was noted. There were no  n$ m* A  y7 f4 |, {# y+ d1 y
abnormal skin pigmentations or café-au-lait spots.
/ z  ?* R" W8 ~  oNeurologic evaluation showed deep tendon reflex 2+
- Z' e3 r! h0 b% ?bilateral and symmetrical. There was no suggestion
2 u0 V) L7 u6 l+ O1 ?( _+ h0 Oof papilledema.
5 q; O% f, E- k# m; x3 JLaboratory Evaluation) T! s. ?* M- `3 U
The bone age was consistent with 28 months by* H- ?! @) D! I! Z6 c
using the standard of Greulich and Pyle at a chrono-
. p* R, b5 `* s5 f/ p2 glogic age of 16 months (advanced).5 Chromosomal; F: l- a- J$ J" \7 t+ g" R
karyotype was 46XY. The thyroid function test" i1 c4 }# X; T- ?; y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 ^3 ?# x4 s+ J, Jlating hormone level was 1.3 µIU/mL (both normal).
' O% ~" M4 v0 j5 B' n9 S" n5 O- c& DThe concentrations of serum electrolytes, blood9 Q& w' `- S+ X1 U
urea nitrogen, creatinine, and calcium all were7 m$ E3 F8 u2 F/ _& n- s
within normal range for his age. The concentration3 [- e' Y& ^, G
of serum 17-hydroxyprogesterone was 16 ng/dL: i5 e3 d# [/ l& u: o/ o
(normal, 3 to 90 ng/dL), androstenedione was 20% ^3 J% F$ X* H  D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 J6 h  z) T4 Q# [! |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: }3 y; j3 x7 v% w& ^
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. h6 V2 k6 t& a
49ng/dL), 11-desoxycortisol (specific compound S)
7 f+ ~, u; @- Z9 j' e' pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ x1 o0 g) w: s; Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# U3 N8 e! m1 s2 {! [# a& J( ^. y$ V; _testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 j) n3 M5 h! S8 x1 x
and β-human chorionic gonadotropin was less than8 Y( N  y5 x" S# J
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ v8 `: ?- x: Rstimulating hormone and leuteinizing hormone
  W# N, y- @$ A( m& u# nconcentrations were less than 0.05 mIU/mL
$ H9 v$ W* I" ](prepubertal).( R% C2 l+ z& ~# w
The parents were notified about the laboratory6 a; N8 u, ~: V* ?
results and were informed that all of the tests were" D4 l. r- Y  P: ]8 t! s$ D( @* m
normal except the testosterone level was high. The
, \' v$ m6 e5 \6 Y% ifollow-up visit was arranged within a few weeks to
2 s0 I( R8 y& O, k' Tobtain testicular and abdominal sonograms; how-$ l  P# Q+ i3 r  a
ever, the family did not return for 4 months.4 s* K8 Y( |- H0 Q
Physical examination at this time revealed that the
; i+ k- b( N/ w6 lchild had grown 2.5 cm in 4 months and had gained
; G: l& I3 g$ o8 z& `5 ]( q2 kg of weight. Physical examination remained% l4 r& T7 [; C3 ^
unchanged. Surprisingly, the pubic hair almost com-  J8 F5 F1 F3 U3 c
pletely disappeared except for a few vellous hairs at- F. ^0 ]7 O# [
the base of the phallus. Testicular volume was still 2
) x% S/ _, \' q# b1 k# t2 j8 [mL, and the size of the penis remained unchanged.
  s0 D8 K+ v9 J6 c: B0 M+ @7 PThe mother also said that the boy was no longer hav-" l- K  O' B$ s# ?! k
ing frequent erections.
, k8 M/ u! l; j$ }% d. w( lBoth parents were again questioned about use of% x, b7 _1 Z! s9 g1 Y$ ^5 X/ N# s
any ointment/creams that they may have applied to
) {* Z, z7 X7 G+ G$ G# g+ k1 Ethe child’s skin. This time the father admitted the
* w% l8 C0 F4 h' ^Topical Testosterone Exposure / Bhowmick et al 541
$ D, F- p* S2 w7 T0 }. i* \use of testosterone gel twice daily that he was apply-. |* {/ j  n' U% o# A
ing over his own shoulders, chest, and back area for/ ?( u0 W: R& B) M
a year. The father also revealed he was embarrassed1 G  k1 P9 C" R* x
to disclose that he was using a testosterone gel pre-
) {- y% s* s8 d) y0 S; T, }scribed by his family physician for decreased libido( w% o/ A: q1 J  n! p9 z; G, J
secondary to depression.
+ w. \& V5 h& P5 A7 kThe child slept in the same bed with parents.
  ]! E9 }  I) M1 c! xThe father would hug the baby and hold him on his
7 M' i) n' m/ r9 ]chest for a considerable period of time, causing sig-5 r) T+ ~" Q3 i
nificant bare skin contact between baby and father.
0 D) f) F2 G- h- ~3 s# S. \The father also admitted that after the phone call,4 n# G+ ~; w, A4 z" Z# }  V0 [) G
when he learned the testosterone level in the baby: a3 E, m, `2 C, A8 S+ Q
was high, he then read the product information4 Z  `7 m, x* \6 L. h
packet and concluded that it was most likely the rea-
  P$ s& f0 X& N: J. o# G, d+ w0 Yson for the child’s virilization. At that time, they
9 L  N7 |3 q( z3 S  Y. }' Qdecided to put the baby in a separate bed, and the
; v% w5 K9 J& |% Vfather was not hugging him with bare skin and had
& i4 g; v& B$ v  Xbeen using protective clothing. A repeat testosterone
  k6 z- V. ^1 e+ ztest was ordered, but the family did not go to the$ c+ ]4 l' {! R/ k
laboratory to obtain the test.
! L% o! x3 t7 r5 _/ q3 |Discussion1 h0 |, G2 h% e9 p$ u- w
Precocious puberty in boys is defined as secondary  y, c: N$ p% H/ E* w) u3 H2 |
sexual development before 9 years of age.1,4
1 ~: n- `7 I$ a0 O! n/ |. K; SPrecocious puberty is termed as central (true) when
, m( R2 y+ Y& \; _0 [+ J; X1 eit is caused by the premature activation of hypo-- K5 a5 E  e. o- i
thalamic pituitary gonadal axis. CPP is more com-3 j1 y; S7 x4 q+ n& |
mon in girls than in boys.1,3 Most boys with CPP
6 S5 n* ?2 p! Emay have a central nervous system lesion that is/ @* R( N6 v: U! w, }- l! n* k' {
responsible for the early activation of the hypothal-& N, [9 u0 N/ E" P
amic pituitary gonadal axis.1-3 Thus, greater empha-
5 {- ~: v. C. }# i  ~* |" R* Lsis has been given to neuroradiologic imaging in7 t! F8 S5 K1 k( }9 L+ L
boys with precocious puberty. In addition to viril-
9 T2 S( u8 l- ^+ Qization, the clinical hallmark of CPP is the symmet-
' N& O* C, a) K% B: `! {) }1 D# |rical testicular growth secondary to stimulation by' ?, J" b7 e/ _; [- \- T
gonadotropins.1,3: t! V; B/ t+ t$ s
Gonadotropin-independent peripheral preco-
  b( x. r  ~8 i9 pcious puberty in boys also results from inappropriate
; A/ \# q5 j  [& \5 U+ kandrogenic stimulation from either endogenous or/ p( r% B- ~# h0 c
exogenous sources, nonpituitary gonadotropin stim-# ~5 H% g  F7 L: m
ulation, and rare activating mutations.3 Virilizing6 R# S  q0 L5 {3 Q
congenital adrenal hyperplasia producing excessive1 B$ x) D. v4 F4 _. f* h& A& x
adrenal androgens is a common cause of precocious" D1 f. f4 S5 e6 _% @' i
puberty in boys.3,4
& h0 H) {$ O$ Z& M6 r1 F* \The most common form of congenital adrenal, N$ S- g3 w+ Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
; w$ g: J9 [# B2 `% r- OThe 11-β hydroxylase deficiency may also result in
- O  y5 Z( k% x2 B0 N8 g, Eexcessive adrenal androgen production, and rarely,4 z; Q8 B, ^! O! f4 h5 I
an adrenal tumor may also cause adrenal androgen9 D( D" W% D8 q5 Q
excess.1,3$ c' f3 o, n- _+ N% l+ W: d/ Y8 b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 y* {2 ?1 U% h' ]/ N  F, \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 K: f$ @0 h; Z( E8 mA unique entity of male-limited gonadotropin-) v. O! `8 s  r0 p( R1 ?
independent precocious puberty, which is also known
3 T6 b- P/ \" [8 r5 B, U  f% I( N4 k% Yas testotoxicosis, may cause precocious puberty at a4 _0 X/ T* P# q
very young age. The physical findings in these boys/ C5 A: a2 E7 j9 n: G
with this disorder are full pubertal development,6 |) i; H: x0 J. w" D  J
including bilateral testicular growth, similar to boys
% c4 o; B# _! q+ }# D. _/ T. q+ \with CPP. The gonadotropin levels in this disorder9 ~, C. A+ x% E) a4 P) V
are suppressed to prepubertal levels and do not show
7 {1 ~6 [5 `) G* U+ O, Opubertal response of gonadotropin after gonadotropin-
& d+ w  |/ b  G. R4 Q3 c5 lreleasing hormone stimulation. This is a sex-linked
2 y' o; W' D6 f$ T, Iautosomal dominant disorder that affects only
  F, g4 f0 Y5 d) u+ \6 h8 }males; therefore, other male members of the family
* x3 C4 ]8 X, m6 N. B( N& T  `may have similar precocious puberty.3, ]+ @+ N. x/ t$ F0 n) X& [1 Q
In our patient, physical examination was incon-
- i0 z, @3 B3 n. `" ~5 o: Gsistent with true precocious puberty since his testi-; u9 N4 Z; R5 i; H
cles were prepubertal in size. However, testotoxicosis  p  Y0 B! Q( Y. a6 c4 u1 C
was in the differential diagnosis because his father
% Q$ Z) q5 t9 o0 `started puberty somewhat early, and occasionally," F' H# O4 [! K2 E
testicular enlargement is not that evident in the
& \6 {5 m8 ]+ ]% F# {5 q4 F0 K0 tbeginning of this process.1 In the absence of a neg-
: N5 U$ g! e( M$ S7 ~. Zative initial history of androgen exposure, our/ L7 o3 Q( M0 v& D( ~# }' ?
biggest concern was virilizing adrenal hyperplasia,7 v3 v, L& j! S5 j( O2 `
either 21-hydroxylase deficiency or 11-β hydroxylase
+ Y9 N' Z* a, k! zdeficiency. Those diagnoses were excluded by find-
, J2 x% `& P* N- @: }ing the normal level of adrenal steroids.2 w0 R% q5 |% s1 y; @
The diagnosis of exogenous androgens was strongly
5 U1 V( W  ~# ]) [9 X0 vsuspected in a follow-up visit after 4 months because$ b6 r" `; C- P$ h& J/ @/ V. B
the physical examination revealed the complete disap-; l) p: A2 r1 G$ L2 F. U1 A% w
pearance of pubic hair, normal growth velocity, and
# n# q+ U' d2 l6 \9 P9 Kdecreased erections. The father admitted using a testos-& u" m; }7 e& x4 B" j8 r
terone gel, which he concealed at first visit. He was# _( q* s  q- H" y' E+ V
using it rather frequently, twice a day. The Physicians’+ F( {/ V' E' G: q" T' d
Desk Reference, or package insert of this product, gel or' Q* v# o, p* u& `8 S6 k) Z
cream, cautions about dermal testosterone transfer to
( \  v3 b2 B) l: J* p  Runprotected females through direct skin exposure.8 n7 @# `3 Z' o- B1 r
Serum testosterone level was found to be 2 times the
1 u; d* |5 i% Qbaseline value in those females who were exposed to; F3 j: T: ~2 t; @3 Y$ g2 H
even 15 minutes of direct skin contact with their male
+ c. c& T; k5 z7 b5 j5 W- I1 s2 }- Y! ]partners.6 However, when a shirt covered the applica-
1 t# k; M& z" ]" b8 U) otion site, this testosterone transfer was prevented.
# W( }+ c3 P% k. A6 }6 gOur patient’s testosterone level was 60 ng/mL,
$ X- v3 h6 |8 Z( r5 Ewhich was clearly high. Some studies suggest that# [4 a2 W* Y- P2 L8 w( G& u
dermal conversion of testosterone to dihydrotestos-+ E7 a- Z& e; G( f
terone, which is a more potent metabolite, is more; k! }- H/ K# h9 L4 @
active in young children exposed to testosterone
- C/ X) k7 b) M* I. I+ f9 g5 Texogenously7; however, we did not measure a dihy-
2 U1 {9 ]! S& |$ Z# x6 qdrotestosterone level in our patient. In addition to
# ?& d( c, O- b2 @+ J1 tvirilization, exposure to exogenous testosterone in
: H# e4 N; @: ~6 n/ ~# rchildren results in an increase in growth velocity and8 `9 y: x  Y$ i' c# R, f. h& a
advanced bone age, as seen in our patient.9 y1 ?( o9 h" F* c
The long-term effect of androgen exposure during
( W1 b3 U/ a; Y0 h0 Jearly childhood on pubertal development and final! z/ I8 D; f# j) d% W. X
adult height are not fully known and always remain. C7 N; ~- }+ A# v
a concern. Children treated with short-term testos-
; P) S6 [8 M6 E/ f* _9 X* jterone injection or topical androgen may exhibit some$ E* g& j4 W: R2 X( V( B
acceleration of the skeletal maturation; however, after8 m: F9 k6 _+ g* s
cessation of treatment, the rate of bone maturation& F$ [! M, }* ?+ S! A. Q/ |2 p
decelerates and gradually returns to normal.8,9
2 B0 U+ n2 f: L9 S' }There are conflicting reports and controversy
' }  J9 K7 M4 \& @* s& |. b0 Qover the effect of early androgen exposure on adult
' V9 o6 i" _' ?& X6 i! Xpenile length.10,11 Some reports suggest subnormal5 {" n  }3 N. z$ c8 D6 k
adult penile length, apparently because of downreg-
6 F( {" o7 c3 q( A3 P% C: H; P. l$ f, Oulation of androgen receptor number.10,12 However,8 H6 x, q  O: Q- q
Sutherland et al13 did not find a correlation between
$ r3 f8 Z' L5 y* `+ l9 ^childhood testosterone exposure and reduced adult
7 S* C, h- M4 N# N! ^& @penile length in clinical studies.
2 A3 m- h8 L/ B$ LNonetheless, we do not believe our patient is
; }; B# o+ A6 {+ Ngoing to experience any of the untoward effects from4 g4 ~* W  |' }( f
testosterone exposure as mentioned earlier because* C3 o( @1 x- f$ `$ {* G
the exposure was not for a prolonged period of time.! E4 g. `0 u. B( ?1 P5 k
Although the bone age was advanced at the time of0 r1 D2 M$ E2 h4 n. i
diagnosis, the child had a normal growth velocity at
# K$ s2 j& {/ \$ Q- d0 G3 Q- V' [the follow-up visit. It is hoped that his final adult
0 O: X/ W- L6 x7 A  ^height will not be affected., r7 q7 E$ f* ^" t& ^3 S  a
Although rarely reported, the widespread avail-
, D" z8 `- O1 F6 E/ @% @ability of androgen products in our society may
  X, u+ q, L: m- [2 w4 V7 L$ rindeed cause more virilization in male or female
- Z: j  n, Z8 b- lchildren than one would realize. Exposure to andro-
5 a+ l' A0 B  ?$ wgen products must be considered and specific ques-: S4 v; h" |3 R. p6 D
tioning about the use of a testosterone product or
9 T' v! j; k& ygel should be asked of the family members during4 H4 T2 s1 p- b! M/ C3 T
the evaluation of any children who present with vir-
4 @8 i1 n' `4 |ilization or peripheral precocious puberty. The diag-
( t% a7 J1 W$ {# R* A# Q; ?6 h; `& lnosis can be established by just a few tests and by
  ~/ P1 W/ u, n: w( cappropriate history. The inability to obtain such a
3 R4 }8 t- @9 o( m+ |history, or failure to ask the specific questions, may
; E9 N* y  H$ I% _/ i) }: `result in extensive, unnecessary, and expensive
1 L( ^' e( |4 ^investigation. The primary care physician should be
' d6 B$ C  T3 N, O. Q0 yaware of this fact, because most of these children0 \- m2 E5 m7 m) w0 F. ^. \* N+ J
may initially present in their practice. The Physicians’
* O+ W2 P' e7 vDesk Reference and package insert should also put a# [7 _$ v0 o" S0 O
warning about the virilizing effect on a male or
* n# ^* q1 r& afemale child who might come in contact with some-
9 [$ s4 K; d7 k  S3 v/ s2 I& L5 N/ h( cone using any of these products.
' V% q8 T3 M6 q3 J! Y4 A0 bReferences* v  b/ h- h8 r) t0 h- M
1. Styne DM. The testes: disorder of sexual differentiation
) r! q) R- V2 e( J3 P! B9 b+ i! zand puberty in the male. In: Sperling MA, ed. Pediatric
/ t, @* u" K* I8 ]2 dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ `! m+ k7 ]; P+ J
2002: 565-628.# k7 u8 u; A/ X; O4 U* p/ x9 i& Z8 ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. R6 _; G0 V5 S2 H) P
puberty in children with tumours of the suprasellar pineal
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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!

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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!
累計簽到:11 天
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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

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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

2 _- w+ C; I- P, U. M! C3 s精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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