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Sexual Precocity in a 16-Month-Old
; R# A0 w) Q: u: QBoy Induced by Indirect Topical! E+ D4 q3 [: C2 M" i+ q
Exposure to Testosterone& D: @5 D+ L! F: C
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 o8 Q4 J' f. i1 U8 x  Hand Kenneth R. Rettig, MD1
) _5 g. a! _# K0 y( c  H* q+ S+ g2 [4 @Clinical Pediatrics
- E0 t7 s' \' q, ]Volume 46 Number 6- c% r- x; |- F
July 2007 540-543
- p( S' b; K* y, [© 2007 Sage Publications% a& H' n+ }5 A4 d
10.1177/0009922806296651" i& j; m" ]0 ~- _- }
http://clp.sagepub.com7 p3 T. J$ {0 Y' O0 I% P
hosted at
' @! z$ A& @7 ]% m/ v& t8 Rhttp://online.sagepub.com) s  S% x# I3 K; a( G- H
Precocious puberty in boys, central or peripheral,6 m1 p0 _% P. V. z/ I8 `/ b/ L0 x
is a significant concern for physicians. Central- w: P: y( I3 L( @( Z+ N+ X
precocious puberty (CPP), which is mediated- G+ N/ U. A3 z  z. x- b- C
through the hypothalamic pituitary gonadal axis, has
/ G9 v+ \2 g$ y6 h0 s' |a higher incidence of organic central nervous system' J- ?/ d. m7 f% s' \1 |5 x- W
lesions in boys.1,2 Virilization in boys, as manifested' j  P6 i$ L. @: M6 w" u! a/ {
by enlargement of the penis, development of pubic
! y$ A* k8 g! N( v8 A$ A) jhair, and facial acne without enlargement of testi-. t- c$ Z; a" d1 q0 n( A
cles, suggests peripheral or pseudopuberty.1-3 We
, _7 J! {+ b8 ~2 {6 v* Hreport a 16-month-old boy who presented with the
! M  C! K3 t1 B" ienlargement of the phallus and pubic hair develop-, y% b. q2 d: A0 w( a4 {- u7 @
ment without testicular enlargement, which was due( [$ N) N2 D' P: h6 h
to the unintentional exposure to androgen gel used by
5 p/ P* w6 D4 R) F/ P" N) M! Athe father. The family initially concealed this infor-' D6 c' ~. A, J. D$ B4 Q
mation, resulting in an extensive work-up for this6 q* w8 Q' e3 [$ ?
child. Given the widespread and easy availability of7 I$ Z/ @6 w3 H1 S7 k) ~
testosterone gel and cream, we believe this is proba-
* x8 J1 R. g& T, _- e: c* ]3 w! x# `bly more common than the rare case report in the& Q* R# V( F8 n- U: W! D+ e4 g; C
literature.4
/ M; M' q9 b5 ^( M2 i( YPatient Report" ~8 v* x3 J9 P! M: Z+ }! }
A 16-month-old white child was referred to the
2 @$ R4 \" N3 @/ c. e6 Q- t0 tendocrine clinic by his pediatrician with the concern
) q7 \! W* M1 j  G! K" Jof early sexual development. His mother noticed5 u' j5 x. T- E. _8 N7 s* A' g3 W
light colored pubic hair development when he was
' J6 d) v& w- c: jFrom the 1Division of Pediatric Endocrinology, 2University of
( [! a% r, Z3 G2 p. r2 @. x& XSouth Alabama Medical Center, Mobile, Alabama.
& `, M3 U) ~; I5 {Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 k! b8 W6 W2 @% X+ m2 HProfessor of Pediatrics, University of South Alabama, College of% V8 Y3 p; a0 P! D0 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. a) F2 ~# E: k* P" G7 G% ne-mail: [email protected].$ B5 x6 C3 \  d/ ~
about 6 to 7 months old, which progressively became
* K6 P& m9 n* \9 g/ }darker. She was also concerned about the enlarge-/ D3 \' q1 I' F8 t, Q, i
ment of his penis and frequent erections. The child# l# H  X+ n0 s8 {
was the product of a full-term normal delivery, with0 t0 m# o* b: ?8 ?2 ~
a birth weight of 7 lb 14 oz, and birth length of
# M4 V: P' l# \8 y; r20 inches. He was breast-fed throughout the first year/ s& ^! F, s4 }  L2 E& L+ s0 s& V
of life and was still receiving breast milk along with1 T/ v5 t; M, u
solid food. He had no hospitalizations or surgery,
- x  G* x- U: T6 V2 Sand his psychosocial and psychomotor development! m& @- U) ]0 Y5 Q
was age appropriate.$ I( h0 m7 Y/ t4 n8 z
The family history was remarkable for the father,
. N1 m; N, n: x8 m! \0 X: _4 gwho was diagnosed with hypothyroidism at age 16,, g8 o( K& P0 j2 |1 a9 I: w
which was treated with thyroxine. The father’s
: I, v$ ]1 h0 Lheight was 6 feet, and he went through a somewhat
- Z9 n+ A: j2 `/ dearly puberty and had stopped growing by age 14.7 J3 Q: Q6 X9 e, F1 Z
The father denied taking any other medication. The
% p2 ]% B3 z5 E, Fchild’s mother was in good health. Her menarche9 E6 k; b' J3 V
was at 11 years of age, and her height was at 5 feet
6 T/ z8 e0 y+ K9 ]( ~5 inches. There was no other family history of pre-
8 e$ R. H0 P9 Wcocious sexual development in the first-degree rela-$ b( i0 \  }# g
tives. There were no siblings.3 c& ^9 c2 c5 v! L- |
Physical Examination
1 d- c( ~$ Q2 ]; `7 a4 V- lThe physical examination revealed a very active,! T! I( i8 y3 v
playful, and healthy boy. The vital signs documented
0 X- X' V0 Q0 A7 R/ H$ z, l7 m$ G( wa blood pressure of 85/50 mm Hg, his length was# U) U) U" L+ z, Q
90 cm (>97th percentile), and his weight was 14.4 kg
4 Q. O: \. E  f$ P- E' L& u: Y' F(also >97th percentile). The observed yearly growth
" c, L3 K8 N5 J5 x% s" h/ Mvelocity was 30 cm (12 inches). The examination of; k3 v7 @; ^3 I3 U1 d+ W/ s- m
the neck revealed no thyroid enlargement.
- j( {" }; J4 z) {7 }/ c4 bThe genitourinary examination was remarkable for
+ w. g1 N$ L8 R4 X$ a. ?& ^2 Henlargement of the penis, with a stretched length of/ N" N. |1 f/ h' s2 k/ U
8 cm and a width of 2 cm. The glans penis was very well- I( U) l# O* K0 z/ s5 g
developed. The pubic hair was Tanner II, mostly around
4 _# E4 J8 }9 y5 r$ x# v540( N3 o+ \7 x. g) ?& A( \8 [: Z# ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 M+ o- u, T! H" ]( e2 r
the base of the phallus and was dark and curled. The% }( q& t5 q. c/ R: \& O: T
testicular volume was prepubertal at 2 mL each.
. j" W9 d% H5 Y. d' JThe skin was moist and smooth and somewhat% ]1 R/ {% _! x( ^; x2 z4 R5 t
oily. No axillary hair was noted. There were no% O/ V/ h7 s% \9 l" K7 _
abnormal skin pigmentations or café-au-lait spots.
$ x3 Z2 B- O2 E6 j0 }7 dNeurologic evaluation showed deep tendon reflex 2+( k% t- H, z# ^3 v/ ^* l/ u! d
bilateral and symmetrical. There was no suggestion9 d) l  Q7 `' w3 m5 @+ V  K
of papilledema.4 T0 T% q1 _. b) T
Laboratory Evaluation9 D& k6 I$ }4 S2 ^/ d+ ^
The bone age was consistent with 28 months by
8 u4 ]4 V+ M/ ~% U; p0 f6 nusing the standard of Greulich and Pyle at a chrono-# O  L( d* d# \
logic age of 16 months (advanced).5 Chromosomal
3 }9 Z" ^, |6 [* r8 Vkaryotype was 46XY. The thyroid function test
& h, ]( k% x! n1 I" a1 cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 S# ]: L3 Z* Y. f2 \6 P/ n
lating hormone level was 1.3 µIU/mL (both normal).
8 R6 t0 D8 S2 y8 s# i" DThe concentrations of serum electrolytes, blood
8 K! k" k  U1 \5 S! murea nitrogen, creatinine, and calcium all were+ S9 F0 }' W8 k! S
within normal range for his age. The concentration2 v( v9 O! `8 o6 E; f- d8 B/ `+ w
of serum 17-hydroxyprogesterone was 16 ng/dL$ j. o7 i- ?7 B; X# _, O
(normal, 3 to 90 ng/dL), androstenedione was 20& H# Y7 O$ L# z. s5 a: u! j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* d) g6 o1 H5 t* o) zterone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ i6 X3 c# j9 ]' N9 G3 I& J, Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 F: R4 e( u- c% B& R49ng/dL), 11-desoxycortisol (specific compound S)% D, [" u( h1 H" i7 d: J
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ ]/ @% a0 X0 P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: ?- @5 x1 D" ~( A8 Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 [3 V, g, U9 k. u& d  {  m5 m
and β-human chorionic gonadotropin was less than& Q3 y. h' w; S2 _4 n( L$ R5 S6 h1 S
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: o0 q; b8 Y) sstimulating hormone and leuteinizing hormone
5 b" \0 U: I- P- H" L* gconcentrations were less than 0.05 mIU/mL
# C& ^/ C- R! B(prepubertal).: Q! |% w9 Q* D  U" J
The parents were notified about the laboratory
1 t3 }+ k: _+ L9 D2 q; [results and were informed that all of the tests were: I2 g1 i2 e3 R/ b! j2 S- a
normal except the testosterone level was high. The2 Z! W7 H8 i5 w. d! @$ P0 @
follow-up visit was arranged within a few weeks to
6 V% {2 m7 g! s# p" [4 B3 Aobtain testicular and abdominal sonograms; how-
2 T+ i4 \5 ]! o7 C% uever, the family did not return for 4 months.
2 D, u) M* }0 W5 VPhysical examination at this time revealed that the
7 t# a) t3 {( @  A7 pchild had grown 2.5 cm in 4 months and had gained
: C$ J3 N+ X' i3 E3 _" F2 kg of weight. Physical examination remained  i; C7 l/ i2 v7 @+ q
unchanged. Surprisingly, the pubic hair almost com-6 y8 {7 f5 K1 R2 |# h7 b4 j4 U2 Q# D
pletely disappeared except for a few vellous hairs at# B4 N3 T8 W, e: {) @( h
the base of the phallus. Testicular volume was still 2; C5 A/ w; O; Q) j$ K: J
mL, and the size of the penis remained unchanged.* L8 A$ _. ]+ Y+ b. H& U! p" j' z
The mother also said that the boy was no longer hav-
1 M) B8 ~+ U8 oing frequent erections.$ j- o  L- x+ a$ r& G
Both parents were again questioned about use of
- p9 c, b- Y' G2 R8 \/ e8 Lany ointment/creams that they may have applied to
# J* J4 K* S1 v8 wthe child’s skin. This time the father admitted the& ^+ f* ?2 O# |7 d: }' K
Topical Testosterone Exposure / Bhowmick et al 541
* R, E9 w$ ?0 P8 |/ ^8 Puse of testosterone gel twice daily that he was apply-3 i3 l5 s0 F* r, D
ing over his own shoulders, chest, and back area for
. j) ^* ], C0 A$ ja year. The father also revealed he was embarrassed
  y; l+ M8 x0 E, W) o9 Pto disclose that he was using a testosterone gel pre-$ o" o4 }3 \& O# r3 p/ q- I# l- J
scribed by his family physician for decreased libido
# Z( ~+ s1 e4 j5 Z7 B& }secondary to depression.9 r" b/ g6 I2 J9 b, {: H& _
The child slept in the same bed with parents.
1 w1 ~8 ~- c+ }The father would hug the baby and hold him on his: Z4 G& _- C$ d: Z
chest for a considerable period of time, causing sig-
9 w/ J; g$ M1 l: p, |& ]nificant bare skin contact between baby and father.
0 H; r5 c% n, A3 T3 I0 w9 j0 K* EThe father also admitted that after the phone call,
/ ^$ r! G) S/ [; z( q' C! ?) Kwhen he learned the testosterone level in the baby' ?, W0 e5 l! W% H( k. C4 e
was high, he then read the product information$ g: P0 W1 R3 y' A/ `" n
packet and concluded that it was most likely the rea-+ Z1 F) a; K/ G& ~6 k2 n* R
son for the child’s virilization. At that time, they
, m) k7 A& B6 u1 g  Sdecided to put the baby in a separate bed, and the6 k* Q- v" G  {- K/ s! P4 a
father was not hugging him with bare skin and had
; o) m- i6 |$ D/ z8 S; l6 g) [( v$ vbeen using protective clothing. A repeat testosterone
3 u" B- [5 U0 w9 }( h, qtest was ordered, but the family did not go to the" N' a+ {4 Q7 b: C
laboratory to obtain the test.
7 V: J* G8 U! DDiscussion
4 q% H+ t& E. k5 V0 oPrecocious puberty in boys is defined as secondary
0 h7 t' @) x. X( k) @0 `% m: y; Vsexual development before 9 years of age.1,4
9 p* V; C7 k( `. `; X, R2 p$ s! DPrecocious puberty is termed as central (true) when
3 t# ]* e$ X1 F5 t! U( f, t' I  bit is caused by the premature activation of hypo-, B, r" [  b; R* `
thalamic pituitary gonadal axis. CPP is more com-
# x4 F5 G9 Y( Nmon in girls than in boys.1,3 Most boys with CPP8 @! u+ K5 W$ k6 F) f6 P
may have a central nervous system lesion that is
: a. K7 B9 Y6 {$ n* Dresponsible for the early activation of the hypothal-* T; j- r( L: f
amic pituitary gonadal axis.1-3 Thus, greater empha-; H4 ~* ?7 ^3 n  B
sis has been given to neuroradiologic imaging in9 z9 Y* ~, z. d
boys with precocious puberty. In addition to viril-9 N0 g6 S1 }3 M" g
ization, the clinical hallmark of CPP is the symmet-$ `( r8 `8 D& s; s  g9 D
rical testicular growth secondary to stimulation by
8 K& n5 i1 N! L4 Fgonadotropins.1,3' |" X8 P5 C6 e3 t6 C5 a
Gonadotropin-independent peripheral preco-
& x. c$ Y5 I5 D6 w  j$ Xcious puberty in boys also results from inappropriate' }& V, U' G: \0 C4 L
androgenic stimulation from either endogenous or
+ _9 @* k& r& Y: N. `$ n9 Lexogenous sources, nonpituitary gonadotropin stim-
2 J$ A/ \$ R  B" t# a8 rulation, and rare activating mutations.3 Virilizing- o! R8 l. Q# k3 k& Y4 j; q6 L
congenital adrenal hyperplasia producing excessive
$ Y5 y5 V; ~! p  p7 v; t9 k) Eadrenal androgens is a common cause of precocious
, v) r: E  O7 l5 l3 O! K: Y+ apuberty in boys.3,4* x7 v9 }, J6 s3 d
The most common form of congenital adrenal) p- c7 A2 S) E% F  N) b
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 j" a# y( {5 V, c# ]5 gThe 11-β hydroxylase deficiency may also result in0 I" b  s: m( v5 _4 W% Q) ]
excessive adrenal androgen production, and rarely,
& i- v. a( K% R1 W! Fan adrenal tumor may also cause adrenal androgen0 Q3 i# P0 c$ D2 _3 `; y7 J3 h
excess.1,3
6 r5 X! i7 i6 ]4 n: }; B- Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: |$ L4 |. v0 y1 v; g, C8 Q542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 x; B/ g* }- i6 I- R' E5 s  j" L
A unique entity of male-limited gonadotropin-4 u" ]: K8 B7 r& y9 c
independent precocious puberty, which is also known
6 a9 ^  e$ E( f0 N* V( }as testotoxicosis, may cause precocious puberty at a
0 o) r) p0 m8 n9 B2 Z7 b6 }/ R3 Nvery young age. The physical findings in these boys
/ R9 A% e, c* m8 X) F1 ?with this disorder are full pubertal development,
+ W9 L* k! s  M8 M+ n" T2 O# W* cincluding bilateral testicular growth, similar to boys
: x* }1 _1 N' T1 D! l& Pwith CPP. The gonadotropin levels in this disorder
& p# }+ \: g3 u& d: N( {are suppressed to prepubertal levels and do not show
# U3 F0 c8 g5 r4 J1 Tpubertal response of gonadotropin after gonadotropin-" H: {. o7 I6 S7 c) ~& I  S
releasing hormone stimulation. This is a sex-linked
" {2 k7 J$ \' S5 ^, u/ kautosomal dominant disorder that affects only" k, ~2 z: K8 ^; R
males; therefore, other male members of the family- b. K" G  ^: K8 L
may have similar precocious puberty.3. P- }7 ?7 Z& v% m" J/ I
In our patient, physical examination was incon-
) {+ ^9 a' z. i0 `1 T8 q, D# Q% Q: X9 Ssistent with true precocious puberty since his testi-
% `$ v1 h& N4 t0 T5 \  ocles were prepubertal in size. However, testotoxicosis+ j6 e/ B  T" f" x" @) r& v
was in the differential diagnosis because his father
% F2 L- k, w. N3 e0 Qstarted puberty somewhat early, and occasionally,  |7 U2 |3 W9 N& M: M
testicular enlargement is not that evident in the7 K9 x; X! }$ ~0 ^7 q/ Z. N2 Z
beginning of this process.1 In the absence of a neg-4 ?1 `8 t0 S: D* P* i, x/ s) x
ative initial history of androgen exposure, our; C0 ?3 e0 p  J+ ?: P% D
biggest concern was virilizing adrenal hyperplasia,  F) S0 j8 `3 [6 p) I
either 21-hydroxylase deficiency or 11-β hydroxylase1 w% Q) y4 Z! u9 X# Q8 j
deficiency. Those diagnoses were excluded by find-
% r+ f! w& n! E6 }& xing the normal level of adrenal steroids.
8 k# D( A+ U7 ?% }The diagnosis of exogenous androgens was strongly
4 X' Y' D  O* osuspected in a follow-up visit after 4 months because
9 ^0 t$ P' i: Othe physical examination revealed the complete disap-" w7 e! k. c: h3 A% A( R
pearance of pubic hair, normal growth velocity, and
% ]5 Q) p% ~4 n/ O6 ^6 ldecreased erections. The father admitted using a testos-
4 {3 r5 Q) a# ~% S  qterone gel, which he concealed at first visit. He was
, T8 O) @5 E+ K; {using it rather frequently, twice a day. The Physicians’
/ H& \, c/ W5 l4 kDesk Reference, or package insert of this product, gel or- s) B+ Y- C. B: q9 v$ Z4 y
cream, cautions about dermal testosterone transfer to7 ~$ Q- f7 f4 j& F
unprotected females through direct skin exposure.+ d% I# W3 d- O
Serum testosterone level was found to be 2 times the
) \7 z7 }3 m% `) Q8 F, M0 ^( h9 g( E" kbaseline value in those females who were exposed to
7 i7 h9 o, [1 Q7 @3 i6 seven 15 minutes of direct skin contact with their male$ ?" w; {& W( P# Y
partners.6 However, when a shirt covered the applica-
# ?; h* e7 U" C9 wtion site, this testosterone transfer was prevented.9 \3 h) F" i, b9 w9 F- L7 I7 K
Our patient’s testosterone level was 60 ng/mL,! t  A8 H5 ~1 d6 e
which was clearly high. Some studies suggest that
0 ^4 A1 g0 }8 n5 Adermal conversion of testosterone to dihydrotestos-( H  a( M7 k  |- Q
terone, which is a more potent metabolite, is more
. j0 m( B( I- _/ t+ G  p! Iactive in young children exposed to testosterone" E% C& m: a% g- N
exogenously7; however, we did not measure a dihy-
4 O) ~, ~. y1 ]0 odrotestosterone level in our patient. In addition to" C1 ~/ P7 v  `3 O- `5 b: B2 |3 o
virilization, exposure to exogenous testosterone in/ N  _0 @2 j( E
children results in an increase in growth velocity and
2 t; C' I/ S2 i/ M9 D+ Y7 iadvanced bone age, as seen in our patient.$ b& {' [$ T& K& B$ D
The long-term effect of androgen exposure during4 O8 n+ r2 r9 S2 z; \/ Y! I& L7 ^
early childhood on pubertal development and final# u) u2 I+ |# s0 z  u6 f( x$ P9 B; y
adult height are not fully known and always remain3 `, R6 n: S( h: J. a5 }
a concern. Children treated with short-term testos-7 B9 s: T& K, y) V; x6 P  z
terone injection or topical androgen may exhibit some  N  W( v* i1 L: \$ {% h
acceleration of the skeletal maturation; however, after& [) B! N! X+ e" Q1 G# e* }# |- f
cessation of treatment, the rate of bone maturation
) |8 X& W7 ~" S% G0 c% {decelerates and gradually returns to normal.8,9
3 \9 q' n  B8 d6 D0 `! Z, pThere are conflicting reports and controversy8 u& p6 `6 V* m" d/ L) ^/ B
over the effect of early androgen exposure on adult/ N3 {( j( f9 e- y# z5 S9 }
penile length.10,11 Some reports suggest subnormal
; M0 }7 ~0 `& W) G3 c! t) c# F* C, madult penile length, apparently because of downreg-) H% F) S6 j( c/ D/ q6 E$ `7 F
ulation of androgen receptor number.10,12 However,; q$ R% \( R: [* u
Sutherland et al13 did not find a correlation between+ F  s6 {/ ]9 R
childhood testosterone exposure and reduced adult
8 f) D" b/ \- n/ r4 d% O. [penile length in clinical studies.
. w! d( Z7 `  d9 `1 KNonetheless, we do not believe our patient is) A* z0 n* j& ]4 y0 _6 A
going to experience any of the untoward effects from9 d6 a' K5 U. [, _# {' X
testosterone exposure as mentioned earlier because
5 [# y7 m* @' othe exposure was not for a prolonged period of time.
/ {4 ^$ l2 r0 I1 a8 h) NAlthough the bone age was advanced at the time of6 Q* O2 F, v4 g; D/ ]4 s
diagnosis, the child had a normal growth velocity at2 D2 H' S0 \* `$ J
the follow-up visit. It is hoped that his final adult6 G0 W$ L, X/ F
height will not be affected.& l* u- `& b' z1 d! S' s
Although rarely reported, the widespread avail-
+ h3 }) C$ e7 |& {' {9 Lability of androgen products in our society may
2 C" \, _7 W. e+ b! Dindeed cause more virilization in male or female
9 q7 z5 g/ L6 k/ t5 kchildren than one would realize. Exposure to andro-: P% ^; \  c. v6 V
gen products must be considered and specific ques-
6 E" l  [* h1 m* \% n. jtioning about the use of a testosterone product or
, I" @3 w1 i3 g. ^) Egel should be asked of the family members during
# x' s% _' z  A! ]; k3 @5 h& Othe evaluation of any children who present with vir-1 F7 S1 ]+ j2 ?; N3 ~$ O
ilization or peripheral precocious puberty. The diag-
- g0 c; i3 ]5 c9 G$ S+ jnosis can be established by just a few tests and by; \1 i0 b! c1 r0 y# J
appropriate history. The inability to obtain such a5 n6 |5 n! `+ b% c, X% E
history, or failure to ask the specific questions, may
' M# r8 T6 M) K- `3 v. Q  }result in extensive, unnecessary, and expensive
1 g. _- I. C7 f" Uinvestigation. The primary care physician should be) a6 ?' ~2 x9 A$ I
aware of this fact, because most of these children
: K8 z2 ^6 o4 A1 r& Tmay initially present in their practice. The Physicians’
! W+ \8 o9 Q! ?- p1 J% |7 [Desk Reference and package insert should also put a
$ J" p/ }; {$ [4 R) U% w; E- Nwarning about the virilizing effect on a male or0 h* r& ~, y& l2 k: M" K6 H
female child who might come in contact with some-! ]- h# K% a# v$ F/ Z0 f
one using any of these products.
8 O6 J# b0 U/ [. B( zReferences
% A- p) f! [! [( y$ @! _$ c1. Styne DM. The testes: disorder of sexual differentiation- C2 }2 _  v  u" Y( w6 W0 }9 y
and puberty in the male. In: Sperling MA, ed. Pediatric
8 Y$ {, ^" G2 @5 b! t& J/ j: gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 |! Q3 o6 h6 w/ G2002: 565-628.) p) o5 S5 A2 K( _2 U
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. D& F) ?% c- Q: f7 h8 c
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ |$ z1 ]8 j. V8 y* `Boy Induced by Indirect Topical
, M* C9 c  `- s! e9 ZExposure to Testosterone
' b3 I0 E/ I6 G+ fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% Q' h" O3 s8 A: i$ Y4 ]and Kenneth R. Rettig, MD1. s- l, \: h2 J
Clinical Pediatrics
6 _' i) r8 A& D( u5 ]) H, D% S0 iVolume 46 Number 6
6 Y) _9 }) O0 q3 z( sJuly 2007 540-543
" p' W2 W8 k# P& D0 _7 m8 F' j© 2007 Sage Publications
9 u1 ~. z7 b5 C0 H* [10.1177/0009922806296651
( A  X$ }  W* w$ K$ P; k: ^http://clp.sagepub.com
! I' H; o( n7 e3 v: ^7 Nhosted at
; u! ?; R' f, m% S* vhttp://online.sagepub.com
5 ?% x' E1 T6 nPrecocious puberty in boys, central or peripheral,9 ^) ^, r& w" b2 z9 ?# ^5 ~
is a significant concern for physicians. Central1 ^7 Q# k8 A5 }" c' m* A
precocious puberty (CPP), which is mediated6 \2 `9 n  ^) V6 s# s+ U2 N
through the hypothalamic pituitary gonadal axis, has
2 u; }0 {+ p8 X- A; r; f9 }0 ua higher incidence of organic central nervous system& G4 U  r9 Y; u0 S5 M5 P6 \
lesions in boys.1,2 Virilization in boys, as manifested
; @! U0 A8 O1 q2 eby enlargement of the penis, development of pubic7 ?! Z9 x& u. E0 p
hair, and facial acne without enlargement of testi-
3 ]) w) R1 e. l7 B) c. d3 m. [$ h7 Hcles, suggests peripheral or pseudopuberty.1-3 We* E5 M. O) B* G$ u- v
report a 16-month-old boy who presented with the: L6 C! v9 n2 I, G
enlargement of the phallus and pubic hair develop-! d3 q; X/ N5 u1 U/ S7 S* c
ment without testicular enlargement, which was due( C% E- L; `" x& n3 r; x
to the unintentional exposure to androgen gel used by
# z! w; }. V5 u: m1 C) d% R8 ithe father. The family initially concealed this infor-
; n  ], z& F" r! @mation, resulting in an extensive work-up for this
+ _! n3 L' m5 \+ bchild. Given the widespread and easy availability of9 R+ x; J8 C5 q9 `" G
testosterone gel and cream, we believe this is proba-
8 R6 r1 t# x& jbly more common than the rare case report in the; y& I6 P4 r' R6 G& i  [
literature.4
3 F7 W3 s' K5 E7 O1 U  A7 ]7 n, ^Patient Report
! D6 J  t8 b. T3 {- r0 B1 XA 16-month-old white child was referred to the% N' D# \1 T6 p5 E
endocrine clinic by his pediatrician with the concern
) t8 R; ]$ Z+ q' S' uof early sexual development. His mother noticed4 f+ c4 o9 F/ \/ U& ]( ~# V: c
light colored pubic hair development when he was! D/ C0 }0 v/ Z& ~8 f- y: [) o9 g  r- v
From the 1Division of Pediatric Endocrinology, 2University of9 q. P* s; j+ Y
South Alabama Medical Center, Mobile, Alabama.
: E( ~! r' b! h# g$ W; OAddress correspondence to: Samar K. Bhowmick, MD, FACE,3 m% m; B) C) T  [3 E; p
Professor of Pediatrics, University of South Alabama, College of" z' [8 h* W; H1 y7 V6 \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) M" }) g4 Q) F% W
e-mail: [email protected].* C& u1 F9 _( z
about 6 to 7 months old, which progressively became' ^5 N) W& h  ?, h- R1 m6 j
darker. She was also concerned about the enlarge-
# c) [8 ~' T$ w1 ]ment of his penis and frequent erections. The child" i$ V4 y1 b, V7 [
was the product of a full-term normal delivery, with9 p. c: a3 o3 }/ B5 P
a birth weight of 7 lb 14 oz, and birth length of
: N3 M' x- y% y. n20 inches. He was breast-fed throughout the first year; v: L6 u* j5 o- _" r0 O( ], p
of life and was still receiving breast milk along with
6 w: R* f+ D" x/ \solid food. He had no hospitalizations or surgery,& K! `4 |7 x1 E  [) N: G- r) D& D
and his psychosocial and psychomotor development
/ k( i. k8 G' ]* f+ S. Vwas age appropriate.
/ R# S/ M) z+ p4 C8 ~The family history was remarkable for the father,0 ^3 u' b0 V, d. [8 v, n
who was diagnosed with hypothyroidism at age 16,& E; W/ C/ @- j& _  Q" n* h% M
which was treated with thyroxine. The father’s& ]) V% x- r0 Q: `7 ?6 D
height was 6 feet, and he went through a somewhat* x7 v0 {6 ~- P0 g' C
early puberty and had stopped growing by age 14.4 ]7 F1 d: f- d' m/ q; Q5 H
The father denied taking any other medication. The
9 H4 B( K) X0 _' cchild’s mother was in good health. Her menarche: `" K% s+ e+ b. Y$ U: r
was at 11 years of age, and her height was at 5 feet
/ F1 b/ C" @6 Z# y$ O, q' \5 inches. There was no other family history of pre-
" ?$ K1 |( t4 q% Qcocious sexual development in the first-degree rela-5 H" u+ M3 z; n
tives. There were no siblings./ C" h4 l( V0 b
Physical Examination
% n9 @3 U! M$ L9 KThe physical examination revealed a very active,. X2 Y( z0 R( N/ L' `$ [6 \6 N
playful, and healthy boy. The vital signs documented/ S& n* w9 J, ?5 m' {! p
a blood pressure of 85/50 mm Hg, his length was
* k+ n4 u; C( B0 x8 ?7 T( M: \90 cm (>97th percentile), and his weight was 14.4 kg9 u9 a6 G8 l! W' M/ A+ ^
(also >97th percentile). The observed yearly growth
' r6 P9 t  b. j2 g- }velocity was 30 cm (12 inches). The examination of% {$ g% B8 ]# P/ o
the neck revealed no thyroid enlargement.
7 V( `  q' s/ Z$ F6 LThe genitourinary examination was remarkable for4 }! k0 c! S  p8 c
enlargement of the penis, with a stretched length of7 n  e5 a6 D1 W- W& G2 c
8 cm and a width of 2 cm. The glans penis was very well
" t) `" X! M* M( h8 Vdeveloped. The pubic hair was Tanner II, mostly around
. ^. ]+ G* m1 j7 F. i5 f7 s* k; ^540
- [1 t- ]6 o6 E) Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 B# d6 g, X" B1 s  G  X" _. U+ ?& I7 {
the base of the phallus and was dark and curled. The* ?! n) U3 D) W, }+ e  X5 Y1 _1 |
testicular volume was prepubertal at 2 mL each.
+ F' J7 j' |$ f% }, |; q/ IThe skin was moist and smooth and somewhat
7 q- l5 A. n+ B5 e6 V- c& Goily. No axillary hair was noted. There were no! ?1 i+ S2 T1 w) n: o2 o
abnormal skin pigmentations or café-au-lait spots./ L' s- r! g* J8 P8 D( W  g
Neurologic evaluation showed deep tendon reflex 2+! c+ P4 y7 X2 `) |  B" E: _% D) y; u
bilateral and symmetrical. There was no suggestion
# p; x7 ]2 {$ Yof papilledema., ^6 m0 O6 [  G, U3 O6 q
Laboratory Evaluation
( E! E5 M& H  fThe bone age was consistent with 28 months by6 t. K0 p; W) i  u
using the standard of Greulich and Pyle at a chrono-
/ i" q% u6 O. L" F7 s$ o9 xlogic age of 16 months (advanced).5 Chromosomal! k( N. z5 ]5 j  G6 T
karyotype was 46XY. The thyroid function test
) z# s! X$ ?4 N+ Hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- T. t7 E' R4 r' N, U% {
lating hormone level was 1.3 µIU/mL (both normal).
, j$ {6 r) R( ~2 e: Z% lThe concentrations of serum electrolytes, blood8 B- @! d4 _8 S' v; a- `; }. C" Y
urea nitrogen, creatinine, and calcium all were. w% s, e  C; a2 t# u3 B# c: L
within normal range for his age. The concentration
& g) ?# M) s! E5 a. P/ s. u# @of serum 17-hydroxyprogesterone was 16 ng/dL
2 ~/ ~4 b2 f' `- S/ ](normal, 3 to 90 ng/dL), androstenedione was 20
7 l# l* A1 ^. ~' eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& x0 b  x1 c% i& m% O) L7 z$ F% L2 b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 k4 W/ i7 c$ ^( [" o: [desoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 E: u4 [4 @& a  P  v8 Y49ng/dL), 11-desoxycortisol (specific compound S)
9 P6 T- |: c8 p  _was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% L- S7 i( V, }  t! Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 N4 V, T" q: \; `  j; o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, V5 c% J  I" Z; X2 Kand β-human chorionic gonadotropin was less than$ B5 a/ z* A+ P  D2 y+ b" V+ `
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( ]' c0 B3 j# ~8 r' n4 }8 ostimulating hormone and leuteinizing hormone
7 p1 x2 O. Y- ^9 ]! Lconcentrations were less than 0.05 mIU/mL2 W6 F6 ]; q7 l. P
(prepubertal).
3 Z1 h2 b( B/ s/ Y# O/ dThe parents were notified about the laboratory! J( J* F' `! S% r8 N$ ?% r
results and were informed that all of the tests were
7 `; f- V  p* W- e9 k1 }; Lnormal except the testosterone level was high. The
7 h4 C3 O7 K" T. x9 H6 \follow-up visit was arranged within a few weeks to4 B7 w4 O" P0 w) i& N
obtain testicular and abdominal sonograms; how-
( k4 Q. m9 `/ |! \' \ever, the family did not return for 4 months.
/ S- m6 v% \1 w- s* h, b) v" O: y" oPhysical examination at this time revealed that the  ]! \9 E0 L9 T, v
child had grown 2.5 cm in 4 months and had gained
1 x/ K3 h2 E6 i7 ?9 M2 kg of weight. Physical examination remained
8 y1 ?% f3 o3 I7 @' J) N9 lunchanged. Surprisingly, the pubic hair almost com-2 X  b$ b) B2 G7 I9 [
pletely disappeared except for a few vellous hairs at3 T9 K) c  D7 n+ y0 m9 B; o# O
the base of the phallus. Testicular volume was still 2
1 S! A& I8 p/ M  P* |" A7 K' emL, and the size of the penis remained unchanged.
9 @7 `$ m1 k) W9 `The mother also said that the boy was no longer hav-
, b* m+ I) l' u) s6 ging frequent erections.
( _$ z9 I9 U# {Both parents were again questioned about use of% \3 R5 r7 ]3 o+ j0 G, F
any ointment/creams that they may have applied to2 j) B% s# d9 v9 \
the child’s skin. This time the father admitted the+ f( O. H4 G, m6 ?
Topical Testosterone Exposure / Bhowmick et al 541
. |; A+ x; U/ @use of testosterone gel twice daily that he was apply-* U4 S) N- ~8 c2 N5 B1 p
ing over his own shoulders, chest, and back area for6 [7 w- L7 U* ~, A8 e/ o
a year. The father also revealed he was embarrassed( c" V* r. I) |5 O- Y
to disclose that he was using a testosterone gel pre-
& k& ?9 [( n/ y2 fscribed by his family physician for decreased libido
! {  _; q3 m4 X! Z, M$ K% ysecondary to depression.
2 s! D  m1 R% ]3 bThe child slept in the same bed with parents.6 x* j; C, \# ]9 \) p
The father would hug the baby and hold him on his
) k% Q/ J  u% r$ U& z8 jchest for a considerable period of time, causing sig-
: M4 h( i4 O) t- j# `nificant bare skin contact between baby and father.
. k1 k' L8 U' _3 `2 a! X# DThe father also admitted that after the phone call,
$ ]8 I1 V, g- c# m2 p/ Kwhen he learned the testosterone level in the baby
9 V1 ]& v! l! q4 j; }% H3 twas high, he then read the product information
& I9 ]" ]9 Z( Zpacket and concluded that it was most likely the rea-/ w' W- z; }( @6 g% @1 E
son for the child’s virilization. At that time, they
' C. R6 |! U$ S. r& T) _decided to put the baby in a separate bed, and the/ y& J$ e  w0 B: [
father was not hugging him with bare skin and had  U' N, o; Q/ R1 l8 @1 E- A5 r
been using protective clothing. A repeat testosterone) n/ m& I- p8 X
test was ordered, but the family did not go to the! \8 x+ X4 h& `! }! E  V  b
laboratory to obtain the test.6 E& n5 E" `& _
Discussion
) V( k' t% @; n! e) y& MPrecocious puberty in boys is defined as secondary
. ]0 L! m6 P& l# Nsexual development before 9 years of age.1,4$ Q; b& I9 Q7 v$ x' l, D. i  Y2 ^: a
Precocious puberty is termed as central (true) when
8 \7 h' E; v8 s( qit is caused by the premature activation of hypo-
( s) |- T) s% F8 Q+ r+ w7 kthalamic pituitary gonadal axis. CPP is more com-5 T' B$ G' X9 c/ h+ b5 |* K
mon in girls than in boys.1,3 Most boys with CPP
) H( C, v, f, X$ i; \+ gmay have a central nervous system lesion that is
- q6 a4 n' Y0 B% f# ^responsible for the early activation of the hypothal-
% s4 F- u( ~6 G; u# q3 oamic pituitary gonadal axis.1-3 Thus, greater empha-6 C. v. I! t- G1 D$ N
sis has been given to neuroradiologic imaging in. i9 f, m. h3 N; s7 D: E) h+ K
boys with precocious puberty. In addition to viril-
5 m/ e* ^  ~+ r* X4 dization, the clinical hallmark of CPP is the symmet-
& t& C. N  Z2 i8 u. W) Y1 r  Xrical testicular growth secondary to stimulation by
: C5 A# d1 {* K6 Z; agonadotropins.1,3) f6 o* ~9 }" m9 q- L
Gonadotropin-independent peripheral preco-
. O0 r9 N8 D8 {cious puberty in boys also results from inappropriate
5 n, U( _3 ?  `* r0 oandrogenic stimulation from either endogenous or
% [& O% @* }3 z$ Sexogenous sources, nonpituitary gonadotropin stim-7 v. d: _; D; b/ J5 o( m
ulation, and rare activating mutations.3 Virilizing* P3 ]. Y4 H# A5 _) o% z
congenital adrenal hyperplasia producing excessive
, Y" e# ?- x& P( f) k0 Iadrenal androgens is a common cause of precocious
2 K, @$ B" x! f2 t6 N9 cpuberty in boys.3,4
7 M. I: h- S3 dThe most common form of congenital adrenal8 T) ]4 D9 B" R7 y8 l
hyperplasia is the 21-hydroxylase enzyme deficiency.5 h8 Z" y2 E9 [4 O( N
The 11-β hydroxylase deficiency may also result in
* X# m# a) P( j. w6 P& [+ D/ cexcessive adrenal androgen production, and rarely,/ O+ S( _5 G; g" K
an adrenal tumor may also cause adrenal androgen2 p3 d' Y; v+ C
excess.1,3/ ~( v0 o2 p+ ~3 T# M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, w6 H: f7 G( C3 r
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! U: E( I4 ?5 h( |+ Y
A unique entity of male-limited gonadotropin-
5 e  P0 S, I, Z" {8 Rindependent precocious puberty, which is also known4 ]3 ?. x" f; G. z0 f1 e9 [
as testotoxicosis, may cause precocious puberty at a
2 j: k" @* S% @5 i; l8 R" ?very young age. The physical findings in these boys; N' K2 e' x% k, q
with this disorder are full pubertal development,+ @, d& R/ i4 X( R
including bilateral testicular growth, similar to boys
/ @) g0 l$ G# Y) O. Iwith CPP. The gonadotropin levels in this disorder0 a# ]* N& N& \7 Z1 {/ d+ y
are suppressed to prepubertal levels and do not show
4 a% i4 I6 [* E* H+ b7 bpubertal response of gonadotropin after gonadotropin-
3 C1 o6 ?9 Q: O2 z: L' _5 m1 Ireleasing hormone stimulation. This is a sex-linked
: M% S% K7 W& S- C/ Xautosomal dominant disorder that affects only
! d1 E3 d6 h9 e* Q: Smales; therefore, other male members of the family
0 l3 j8 Q" F; k3 b# t; g9 ]may have similar precocious puberty.3
8 S% S2 n5 K9 E4 ]In our patient, physical examination was incon-
  H5 Y3 Q  N0 Dsistent with true precocious puberty since his testi-$ D* I3 b5 i/ `! c' l( A, R
cles were prepubertal in size. However, testotoxicosis
0 S- W9 B* k! z) f1 Nwas in the differential diagnosis because his father/ @8 H" F' L$ z7 }# g
started puberty somewhat early, and occasionally,, g$ X. K7 P4 [# U
testicular enlargement is not that evident in the  }1 ?0 r: w/ O& b4 T. X
beginning of this process.1 In the absence of a neg-
5 B) r9 }2 e/ o9 Uative initial history of androgen exposure, our: z/ ?; t% [4 H1 T7 a, q2 c
biggest concern was virilizing adrenal hyperplasia,
( ~& Q' C8 O: ^9 _. |/ ^/ z, p, p2 Peither 21-hydroxylase deficiency or 11-β hydroxylase
+ _. ], @0 z. O' ?deficiency. Those diagnoses were excluded by find-
% X3 ^* T& K$ d$ x* \ing the normal level of adrenal steroids.
9 e' o, [. R! g! o- W* n! e: e- b( ^The diagnosis of exogenous androgens was strongly  u0 t# T. s7 r2 m
suspected in a follow-up visit after 4 months because
, U- i) U0 u+ f8 O, O* w. |the physical examination revealed the complete disap-; I: T5 z, e2 D5 N! C5 i4 |
pearance of pubic hair, normal growth velocity, and
+ a% K. y* C2 V# n; A/ vdecreased erections. The father admitted using a testos-
( Y6 n1 y' n" L5 u, l3 lterone gel, which he concealed at first visit. He was+ c+ I" h, z* H+ l3 v3 q
using it rather frequently, twice a day. The Physicians’* B- K! b  M6 c" _2 E1 w- d5 ~3 ?
Desk Reference, or package insert of this product, gel or1 P3 D) w; B, M
cream, cautions about dermal testosterone transfer to
8 c' n! Z) M+ c7 ounprotected females through direct skin exposure.
. t0 B  J) |7 zSerum testosterone level was found to be 2 times the
! [3 u+ n1 i" T1 u5 `. y1 k  Gbaseline value in those females who were exposed to
) C$ b* y; P& P* }( \even 15 minutes of direct skin contact with their male% v/ R: [) r) U7 n6 K/ s
partners.6 However, when a shirt covered the applica-
) K- b, k# a0 @9 N3 ftion site, this testosterone transfer was prevented.
* s" z; s! B$ O* xOur patient’s testosterone level was 60 ng/mL,9 s8 L+ J  b0 l
which was clearly high. Some studies suggest that
+ q/ m, I* l" T2 \1 Idermal conversion of testosterone to dihydrotestos-
9 i! U- Z2 {+ y+ ?terone, which is a more potent metabolite, is more
8 F# S1 e! T+ B6 @active in young children exposed to testosterone: P3 o' N- ]8 V# e' Q
exogenously7; however, we did not measure a dihy-' O' e  S9 _# @7 t9 s7 N' a9 S& }9 r5 ]
drotestosterone level in our patient. In addition to6 j, x. N; ~( _( R2 F
virilization, exposure to exogenous testosterone in
- H% t7 O4 ?  D4 Ychildren results in an increase in growth velocity and3 ~. x: J. S' ~$ ^
advanced bone age, as seen in our patient.( L2 n! D- I. ~+ g4 ~+ }" d3 @( k5 Y
The long-term effect of androgen exposure during
+ o8 I/ J; ?5 K- |. @9 |5 o, Q; ?early childhood on pubertal development and final* e  K2 i" h; M+ g1 v- K8 l
adult height are not fully known and always remain6 N, _. c6 T/ g% Z7 s4 V1 e( G
a concern. Children treated with short-term testos-
6 F- P& y! ]7 N! U# q2 jterone injection or topical androgen may exhibit some
5 R- v2 E; A& [' _acceleration of the skeletal maturation; however, after' d- N! `' D: [- N; p: L
cessation of treatment, the rate of bone maturation
3 T7 M$ f  V, o, \" N( b. a( m1 adecelerates and gradually returns to normal.8,9- A5 E! E6 z/ C8 i) x; b, s5 }, m
There are conflicting reports and controversy
+ r( V4 ^1 q8 k8 u) K" Wover the effect of early androgen exposure on adult- R9 X! o9 K% t+ ~5 d+ C7 l! i
penile length.10,11 Some reports suggest subnormal% K8 [& Q& x: S7 v
adult penile length, apparently because of downreg-% @. f0 L5 e( Y$ k" h9 r  @
ulation of androgen receptor number.10,12 However,
' f$ _8 P& A! h" M' R& Y% zSutherland et al13 did not find a correlation between
4 N" L, u" b3 h) R0 m0 echildhood testosterone exposure and reduced adult
* a+ B" O8 N% Y' tpenile length in clinical studies.* J5 c/ T) @/ b  P; |. C2 o
Nonetheless, we do not believe our patient is
1 z+ N! l+ J& q1 r2 S3 Z. f# D4 Fgoing to experience any of the untoward effects from
1 R  v4 O" M) M4 otestosterone exposure as mentioned earlier because
5 F4 J! A$ I5 G5 Q  vthe exposure was not for a prolonged period of time.
, G( [5 e& h/ o* q: eAlthough the bone age was advanced at the time of7 ]6 Q+ G" M8 A: W, U
diagnosis, the child had a normal growth velocity at$ c& J3 R# b3 Y* u5 Y/ z& [- z
the follow-up visit. It is hoped that his final adult8 }2 C9 V8 _& A# r1 W$ n
height will not be affected.4 J. n& P2 T( A* r( \. Y
Although rarely reported, the widespread avail-
1 I% N% V" L. zability of androgen products in our society may
! u# Q0 l/ W' D* a9 F) ?indeed cause more virilization in male or female
9 B8 _8 I3 b: P. x" t$ k# Uchildren than one would realize. Exposure to andro-$ Z4 W+ l5 G  j* C
gen products must be considered and specific ques-
& W! H4 ^; A: p/ L9 ytioning about the use of a testosterone product or
: }- H8 ^% U! b0 y7 O2 M, K6 k. Wgel should be asked of the family members during
! O% f( |& N$ O" f/ h; w- cthe evaluation of any children who present with vir-
, W/ _; S0 e$ H8 S) s4 kilization or peripheral precocious puberty. The diag-
& L% ^* B% _7 @: u4 x# ~nosis can be established by just a few tests and by- d+ Q4 I( J( o: G: k+ w
appropriate history. The inability to obtain such a* N+ M; S) e3 h: ?7 u( i
history, or failure to ask the specific questions, may
) q9 s5 ]) z6 O) W  m8 Presult in extensive, unnecessary, and expensive! A* T2 c3 f# x" p) C) M6 F
investigation. The primary care physician should be7 T$ M# P4 U+ v" K% V  ]
aware of this fact, because most of these children
) ~, Y8 J5 @$ W: x  e/ V5 }8 G6 p/ G) Cmay initially present in their practice. The Physicians’
+ Q" v0 Q0 J, a0 g2 P" A3 VDesk Reference and package insert should also put a& ]" D2 i# M! i% \
warning about the virilizing effect on a male or3 ~8 ~' r% W* u+ M- c" q! N
female child who might come in contact with some-+ i: e8 s4 j5 n+ ~" L5 g
one using any of these products.9 m% i  J4 T8 E. B; J$ q4 a6 W$ n
References: M# r7 S/ n2 d7 j
1. Styne DM. The testes: disorder of sexual differentiation
- _% H2 [8 K0 q2 `- Band puberty in the male. In: Sperling MA, ed. Pediatric
- r  F( y0 j' q' R, \6 ?2 HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. ^  j& o' ]& v: s2002: 565-628.! r7 X5 x7 t+ \
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 E  s! C& j8 \8 V3 D
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

. c5 B/ a) K( q" }: ^# {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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