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Sexual Precocity in a 16-Month-Old: W3 S$ A/ D0 Y  a% X: c% j6 W
Boy Induced by Indirect Topical
! W9 d" }. `! \; ^! X: @6 a/ \Exposure to Testosterone9 x0 ]/ b! f; G5 _4 w
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: m; W' q6 w! k' z
and Kenneth R. Rettig, MD1) q9 T2 O/ v9 V* {
Clinical Pediatrics
  X0 a" V) }0 ], W( o% kVolume 46 Number 6
% J% f& ]% ^, _5 s1 U  y3 B' hJuly 2007 540-543
+ ^; g3 z. u, K( Z" {8 [© 2007 Sage Publications4 J: T* v' w: r0 n
10.1177/0009922806296651
" b8 ]) G: Y- Thttp://clp.sagepub.com
; [8 h0 B% k- \+ v5 fhosted at3 z" @( k, R$ ?" j3 n3 K: b+ ]3 e
http://online.sagepub.com) ^& N/ x) `. w' K( |/ {% b0 J
Precocious puberty in boys, central or peripheral,
% H* W- o' [) n! P$ z9 gis a significant concern for physicians. Central4 N" q% A! Z! ~/ Q, q
precocious puberty (CPP), which is mediated6 \! j6 l( ]+ d7 ~9 a& `5 e
through the hypothalamic pituitary gonadal axis, has
& l2 _; ^' V8 a1 C. Ha higher incidence of organic central nervous system
# f& [( p: Z7 t) I  j4 ^/ w. E  elesions in boys.1,2 Virilization in boys, as manifested
( ~3 Y  n, _, \) s$ X3 ^0 `  V9 Mby enlargement of the penis, development of pubic
: Y* u5 z- A0 }) Z3 H9 V- fhair, and facial acne without enlargement of testi-/ t- Y# b- N1 h' ~& u- [
cles, suggests peripheral or pseudopuberty.1-3 We6 y  t9 t  J9 c: R0 @0 h6 ^1 u
report a 16-month-old boy who presented with the0 A; `; q5 s- |. p- @' l1 x; g
enlargement of the phallus and pubic hair develop-0 ~1 Y4 C& `& C: v  j
ment without testicular enlargement, which was due3 G' G9 j) `  L: \! `% I6 G0 e
to the unintentional exposure to androgen gel used by5 V* e* P( ?$ g0 C
the father. The family initially concealed this infor-) L7 x1 W* |/ Q- e- {! u
mation, resulting in an extensive work-up for this
: d# {- ~# p- T! Vchild. Given the widespread and easy availability of
" P- {4 g# g' J( R3 p8 F, \5 a6 c5 Jtestosterone gel and cream, we believe this is proba-+ P; u0 ~# f7 B5 F' X7 _; D
bly more common than the rare case report in the
3 Z; Y! S8 Q+ W( ?; Jliterature.40 r# d0 k' p  |8 V; v
Patient Report/ Q6 _1 r) O7 }: z4 s$ j+ ~- k
A 16-month-old white child was referred to the) L. g0 s  u5 b' \
endocrine clinic by his pediatrician with the concern
' _7 F6 O4 f$ e' tof early sexual development. His mother noticed
, A! ]& C, j. P' r1 Vlight colored pubic hair development when he was* I/ z) u) E1 k# W
From the 1Division of Pediatric Endocrinology, 2University of
9 v5 Q% a3 S/ g- U. `South Alabama Medical Center, Mobile, Alabama.
+ \7 x% K& K9 u9 y/ ?Address correspondence to: Samar K. Bhowmick, MD, FACE,2 R0 M) q  S2 h4 a
Professor of Pediatrics, University of South Alabama, College of
* K, u/ [( W, q7 MMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! X1 o" J7 [1 Ie-mail: [email protected].
* X! |7 z8 S6 i% c4 n' d$ ?about 6 to 7 months old, which progressively became# O6 z  p, t$ x; e; J
darker. She was also concerned about the enlarge-$ m8 _, @8 c, ?: G: z
ment of his penis and frequent erections. The child; U3 ?; [6 Y! y% l9 {4 V
was the product of a full-term normal delivery, with
$ Z8 D* p- |8 u( {$ @% {; j+ [a birth weight of 7 lb 14 oz, and birth length of( ?! K# H1 ?. P+ P! d3 M  T
20 inches. He was breast-fed throughout the first year
( A6 e# J; y, G1 ~of life and was still receiving breast milk along with; V! x. Y+ `; Q! t7 V5 i' s
solid food. He had no hospitalizations or surgery,% N* y2 y/ |( H& ~% ]  _
and his psychosocial and psychomotor development- b2 v+ d, X+ \& t
was age appropriate.( m' w2 I9 R6 D; Z
The family history was remarkable for the father,* K, \+ C  R( q. ~2 y$ ?
who was diagnosed with hypothyroidism at age 16,2 C2 B1 T6 f7 a! G7 h& e2 Q
which was treated with thyroxine. The father’s
. n- p" B8 M6 z% C1 \height was 6 feet, and he went through a somewhat
& P/ W6 t6 ~( Z; bearly puberty and had stopped growing by age 14.# o  a- v4 q$ J
The father denied taking any other medication. The
# Z' M) U7 E$ t* ~+ \# xchild’s mother was in good health. Her menarche$ M0 ]& o6 j" A4 N0 U1 B: B- u4 L
was at 11 years of age, and her height was at 5 feet
: X$ {3 N1 y* [- K1 A5 inches. There was no other family history of pre-
6 ?# @4 d! J: A7 N1 Ecocious sexual development in the first-degree rela-
$ \9 R8 c( s7 K5 i* a+ ~5 Vtives. There were no siblings.
6 A) W- t% v) M+ W7 @2 ?Physical Examination
0 ]1 W+ ~) r: ~; k- KThe physical examination revealed a very active,
: _7 h% M& t1 M3 {' K: O  O: fplayful, and healthy boy. The vital signs documented' \7 A! G( K/ ^2 G7 _8 X
a blood pressure of 85/50 mm Hg, his length was
* w* {$ G+ ~, }' F7 _; ]90 cm (>97th percentile), and his weight was 14.4 kg- N9 O$ U; z5 [2 t; ]) O
(also >97th percentile). The observed yearly growth* @4 X5 `7 D) f1 A$ ]
velocity was 30 cm (12 inches). The examination of. ^( H6 p9 e- r1 w$ S0 d$ L+ `
the neck revealed no thyroid enlargement.
1 m; M1 p6 _7 {The genitourinary examination was remarkable for
3 f5 l8 Z) g; W* [7 l6 oenlargement of the penis, with a stretched length of
: n8 }( m0 R$ z8 cm and a width of 2 cm. The glans penis was very well/ l4 ~+ v' a5 A1 d& b( A4 s7 L1 t
developed. The pubic hair was Tanner II, mostly around. b, q) K0 X7 _: ~/ l$ M
5407 a, Q0 j6 b) Q. ~' I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; k- q# M0 b0 t* {$ w( I3 J. X5 e/ athe base of the phallus and was dark and curled. The
) |, l( R. B% |) M- i) i, T* n6 dtesticular volume was prepubertal at 2 mL each.4 Y" k. e+ C; M1 E
The skin was moist and smooth and somewhat
  }  |+ J2 [2 o& u1 R& x, Yoily. No axillary hair was noted. There were no; b$ o$ E" A; r. F  M6 c' ^
abnormal skin pigmentations or café-au-lait spots.
# x! |- D6 q4 F1 fNeurologic evaluation showed deep tendon reflex 2+
+ Q! l! G( R. r. ~: O( o3 ybilateral and symmetrical. There was no suggestion
& o/ p# x1 e+ v' vof papilledema.( Q) D1 [! x- V8 a+ k& e/ N! J% I
Laboratory Evaluation, f0 }0 ]. q, ?9 ^2 }& Z. o$ N" k
The bone age was consistent with 28 months by; h: g1 m( M: \& g9 A0 J& V
using the standard of Greulich and Pyle at a chrono-) B% P0 ]4 R8 m  f7 p0 a  Z* h3 o
logic age of 16 months (advanced).5 Chromosomal- l# }. v8 N) B9 `& l6 Q
karyotype was 46XY. The thyroid function test
7 W+ O: [2 Y6 }) {showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( Y* f6 m: a3 Y/ [lating hormone level was 1.3 µIU/mL (both normal).
' H5 ]1 q- A% M* i# mThe concentrations of serum electrolytes, blood  {) j0 b& O0 ]/ i" u
urea nitrogen, creatinine, and calcium all were5 {' x" a" S" R  q! X
within normal range for his age. The concentration# Z0 E2 M$ ?. j+ V
of serum 17-hydroxyprogesterone was 16 ng/dL( T  z% a5 }8 [) N- ~' C, _5 p
(normal, 3 to 90 ng/dL), androstenedione was 208 a9 }% {  c4 S, v: @9 R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' @% Q6 t! I9 Z6 [. k2 h: Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 }4 ?! k0 s( [4 f3 _/ N1 Z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- U" V! ^- |% n9 J* e1 O  I3 Q
49ng/dL), 11-desoxycortisol (specific compound S), m8 ^8 P9 r( y) }/ C3 x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 q; u( D0 S& x: u8 itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 ^8 W+ y& D7 Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' p+ J9 V) r5 v! H$ z' G5 u6 q+ J$ \
and β-human chorionic gonadotropin was less than
$ G6 p- }" i0 a- |, ]1 L7 B5 n- R5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 ~. u) N# w1 @/ |4 s$ d+ Zstimulating hormone and leuteinizing hormone
9 V0 u% n% S6 D  j0 Q. ^% Cconcentrations were less than 0.05 mIU/mL
1 W8 u3 t" T- a# N9 ?(prepubertal).5 m+ k5 f* X7 p' n& X9 h5 y' Z
The parents were notified about the laboratory
8 k4 m) i0 M) ]  Q' cresults and were informed that all of the tests were
. t1 w+ y6 S0 R7 d: z$ K8 hnormal except the testosterone level was high. The
( d4 `2 b1 x) Y: Y3 v1 F4 xfollow-up visit was arranged within a few weeks to7 ^9 a" S- W. e# |* L1 |5 y3 ]
obtain testicular and abdominal sonograms; how-
- q# s) M7 ?/ _) E) N) Z0 t! A* Eever, the family did not return for 4 months.
2 {- Z) R4 L3 f6 \  n+ ~4 \2 `Physical examination at this time revealed that the) {2 n9 m9 @5 x. o- j3 @" y& k
child had grown 2.5 cm in 4 months and had gained  u5 X  S3 K, e8 j
2 kg of weight. Physical examination remained
' |  X- P0 m" Hunchanged. Surprisingly, the pubic hair almost com-4 a; Q2 U5 Q& W) I" i( `
pletely disappeared except for a few vellous hairs at- n# C2 t' B1 M* x: ^
the base of the phallus. Testicular volume was still 2
% P% [. ]& Z# |. emL, and the size of the penis remained unchanged.+ H3 j7 |8 I) ?6 e
The mother also said that the boy was no longer hav-2 s+ C/ u0 _9 `% B) @! k8 a9 O
ing frequent erections.
1 U9 A3 X7 u2 e. D$ {Both parents were again questioned about use of! O: k, S2 Z* D, i
any ointment/creams that they may have applied to
' Q/ n% ]7 e" @/ l) q# athe child’s skin. This time the father admitted the0 W: q/ ^9 E2 D+ L, D
Topical Testosterone Exposure / Bhowmick et al 541
% K! u- K) g! q, h/ n1 suse of testosterone gel twice daily that he was apply-
8 Z" P* |+ K. Y& ging over his own shoulders, chest, and back area for
9 K7 P2 w) [  f5 f+ e6 Va year. The father also revealed he was embarrassed8 H# F$ |2 q$ V8 w; X. L( N
to disclose that he was using a testosterone gel pre-
/ R9 p2 O$ z: F8 b8 b( x, U0 ascribed by his family physician for decreased libido
- a. ]% T0 _$ \7 x; x* Fsecondary to depression.* N9 k" ~& K, L2 c
The child slept in the same bed with parents.- Z3 m" P2 q) z; q
The father would hug the baby and hold him on his
: [3 n. C$ s4 u1 y/ hchest for a considerable period of time, causing sig-6 ?" m9 o5 z3 }7 A
nificant bare skin contact between baby and father.4 J- c# Y" R8 }: b# D! u4 S! V2 W6 ]
The father also admitted that after the phone call,) w7 Y% `: N: j+ }9 t2 O
when he learned the testosterone level in the baby# J. ]  m& O9 I5 g9 b
was high, he then read the product information3 t7 ~3 O% \# H  {$ x6 _# T* z
packet and concluded that it was most likely the rea-
+ g3 z* M( z' {! o0 ison for the child’s virilization. At that time, they
4 w2 p3 o, ^0 Y8 G2 Fdecided to put the baby in a separate bed, and the
+ W  y" S0 _, F, rfather was not hugging him with bare skin and had) \) ?8 l! B$ Y; K& g/ h3 n) ]
been using protective clothing. A repeat testosterone( w6 y* T8 [3 D, F
test was ordered, but the family did not go to the; V( h7 z+ v: Z4 R; g" C
laboratory to obtain the test.9 o1 A9 E1 O4 p& h. d( r% e1 ]
Discussion& L7 w; e, N$ G, j" `
Precocious puberty in boys is defined as secondary
/ V6 x$ \/ C5 T% Psexual development before 9 years of age.1,4
7 w/ @& b" a; x9 R# dPrecocious puberty is termed as central (true) when+ Q+ e7 T. z. c+ e( G9 ~. }& N
it is caused by the premature activation of hypo-1 U7 P* ~2 N3 G: {  V  d3 Y5 Q" j* |# O
thalamic pituitary gonadal axis. CPP is more com-6 j1 a& k0 \  |6 x7 C( w
mon in girls than in boys.1,3 Most boys with CPP0 {6 v: r2 x* K
may have a central nervous system lesion that is
2 z/ C: q1 q- E8 K& Zresponsible for the early activation of the hypothal-
; |' J( ?9 j1 O+ Qamic pituitary gonadal axis.1-3 Thus, greater empha-
* E; I+ l+ n3 f8 asis has been given to neuroradiologic imaging in+ j: Z( g" y" ^
boys with precocious puberty. In addition to viril-& t' \; w! Q& R$ b/ B( t, L* _
ization, the clinical hallmark of CPP is the symmet-5 Q" z7 n- L5 N; D& a% V# ^# g
rical testicular growth secondary to stimulation by; p& d* f1 O- c
gonadotropins.1,3
; S$ D3 D/ T& F7 r) [Gonadotropin-independent peripheral preco-
9 M3 N, n& M! F) c' C) U3 Ocious puberty in boys also results from inappropriate7 p4 c9 m' i- j3 A+ T
androgenic stimulation from either endogenous or
3 G( v7 v9 e  \5 ]; E$ k) Zexogenous sources, nonpituitary gonadotropin stim-* y7 b! k& N" C0 G
ulation, and rare activating mutations.3 Virilizing' F3 Z( G( U+ k' k0 T+ |
congenital adrenal hyperplasia producing excessive
0 r' F/ F4 G4 Z6 [" F+ w' ^adrenal androgens is a common cause of precocious% i2 ?, @" Y, F; w0 A
puberty in boys.3,4
& [5 I# R' L% d- A( w6 z; PThe most common form of congenital adrenal
! T4 S% }. |6 o' D2 Chyperplasia is the 21-hydroxylase enzyme deficiency.5 Q! Q( j7 o1 h" I7 p9 p+ K. E
The 11-β hydroxylase deficiency may also result in6 r* W/ z( b) b; a7 a3 A5 ]' l
excessive adrenal androgen production, and rarely,
% l# b2 }& r$ X( K/ Aan adrenal tumor may also cause adrenal androgen
& w/ s# z  F+ `( C0 _excess.1,3/ G: K- H7 Q5 O" g/ {: u. v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: e/ O2 V. ]: v3 Y) C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  ], O9 T0 E; z' k! R; n" H
A unique entity of male-limited gonadotropin-: ^6 q; O" E' R) j7 r5 j
independent precocious puberty, which is also known
. x# M5 K( ^) Z3 N' Cas testotoxicosis, may cause precocious puberty at a
' g5 F% T0 u+ S. y2 j+ ]* l! gvery young age. The physical findings in these boys: n  F4 j+ M7 w/ `1 V4 [* Y0 t, x- a
with this disorder are full pubertal development,  p9 u. a$ F% s
including bilateral testicular growth, similar to boys
0 w1 M  p" {: A4 Q6 ^; ?2 {5 \, jwith CPP. The gonadotropin levels in this disorder
7 v3 Z; k* k- B8 g: a; ~1 ]7 Zare suppressed to prepubertal levels and do not show: ?6 V4 l, F: o% ?/ N% Y0 [1 Z
pubertal response of gonadotropin after gonadotropin-6 [# T( v& \# |8 s  W
releasing hormone stimulation. This is a sex-linked
1 o6 c! r! ]" Y3 K' b/ `; mautosomal dominant disorder that affects only& \2 C( Z. g5 s" K7 d3 `: c
males; therefore, other male members of the family
' Q2 C4 B, f* n& M% K, Gmay have similar precocious puberty.3
2 _& p7 {# v# c/ J5 Q0 wIn our patient, physical examination was incon-
. ^1 @; M3 O' V& q# P( jsistent with true precocious puberty since his testi-$ A0 }0 J0 A+ o3 ^/ H
cles were prepubertal in size. However, testotoxicosis
. r0 q2 y9 K" n  g) I# gwas in the differential diagnosis because his father
3 {8 j- c1 D, D; Lstarted puberty somewhat early, and occasionally,
) w0 G2 x9 M/ W* gtesticular enlargement is not that evident in the% s( a% O2 A/ V# a
beginning of this process.1 In the absence of a neg-- L3 c- C6 {/ d; l0 ]0 m/ \
ative initial history of androgen exposure, our# k3 h& g4 C- {6 ~8 Q6 @
biggest concern was virilizing adrenal hyperplasia,7 ~" t( D' I6 Q$ b0 v
either 21-hydroxylase deficiency or 11-β hydroxylase% G: l* d: e0 i3 g  J$ ]$ \
deficiency. Those diagnoses were excluded by find-
5 z+ ]" E! C1 E( H0 ~ing the normal level of adrenal steroids.
/ a" r5 i4 x6 \$ n6 ~5 ?The diagnosis of exogenous androgens was strongly9 K; ^# f" n, Q) w( Z
suspected in a follow-up visit after 4 months because1 Z7 V$ T4 Q2 |! N
the physical examination revealed the complete disap-
: t$ r- N' g2 }# u' ypearance of pubic hair, normal growth velocity, and3 f* c" {, A7 V2 Q" h+ f
decreased erections. The father admitted using a testos-
) |+ P4 V+ ?& J2 yterone gel, which he concealed at first visit. He was
% F8 E5 ]2 Y/ ^) E9 Musing it rather frequently, twice a day. The Physicians’
: |4 E  ?5 |+ `5 {. {1 Y( h, MDesk Reference, or package insert of this product, gel or
) A  Z: Z5 Y6 W4 ?" Q. Tcream, cautions about dermal testosterone transfer to
3 @& t9 B2 _% C4 O7 ~unprotected females through direct skin exposure./ S/ o: V) q# P. o9 C: Q) B( X
Serum testosterone level was found to be 2 times the2 |: {" j9 A  o
baseline value in those females who were exposed to: R( O3 x4 Z) D! t
even 15 minutes of direct skin contact with their male5 n! B9 Z9 T6 y  y
partners.6 However, when a shirt covered the applica-% c7 B% ]5 G( e0 c4 R  C
tion site, this testosterone transfer was prevented.4 X: L7 y/ z' l2 x7 j2 z2 J7 W. m  P
Our patient’s testosterone level was 60 ng/mL,
$ q' c, S, w" J* ^. hwhich was clearly high. Some studies suggest that
' W$ a  a3 A, ]8 w' P% O0 xdermal conversion of testosterone to dihydrotestos-
5 s3 b5 j" Q& x" X- M! Z5 x, b; vterone, which is a more potent metabolite, is more
. {& J- b) I' M. t% s/ eactive in young children exposed to testosterone
6 i% ~2 I5 E; T6 n; z% M0 wexogenously7; however, we did not measure a dihy-( J* J4 r" X: Z, E" ?$ m, O
drotestosterone level in our patient. In addition to
) u$ \( W' C7 q/ K" t1 Wvirilization, exposure to exogenous testosterone in
' t, m) j4 {+ R$ a, mchildren results in an increase in growth velocity and
, x% q  j6 F; y; [& y: M  Kadvanced bone age, as seen in our patient." E2 j3 F, D9 G7 {
The long-term effect of androgen exposure during/ }- ~8 ^+ j' P& U: s; |
early childhood on pubertal development and final9 A7 c: P2 p8 d5 T" K. I
adult height are not fully known and always remain
! q& I  q7 k  }. m  ?4 qa concern. Children treated with short-term testos-
" X. \# n  v( ?- y* Z( Qterone injection or topical androgen may exhibit some* [" J5 C+ \2 m+ o4 ^
acceleration of the skeletal maturation; however, after
5 m  p7 r6 }8 Z1 hcessation of treatment, the rate of bone maturation
9 ^  l5 S0 i; i3 Udecelerates and gradually returns to normal.8,9
3 b/ [; X) |& }There are conflicting reports and controversy
" P0 v/ r/ Z# G- q8 ]# V- Vover the effect of early androgen exposure on adult
+ g1 V5 @$ v8 Q5 y6 t( wpenile length.10,11 Some reports suggest subnormal
4 n' I! i) A6 F9 |' padult penile length, apparently because of downreg-
$ F& @# O( D- y# n8 R' i8 {) ^" ~ulation of androgen receptor number.10,12 However,
, M  M0 ~! x8 Y: q! O- I: @2 ISutherland et al13 did not find a correlation between
  K3 }" b7 I8 l0 pchildhood testosterone exposure and reduced adult! O/ n0 V. p# G# g2 t+ |
penile length in clinical studies.3 G! M  l  Z8 Z& l, b4 [9 z0 O
Nonetheless, we do not believe our patient is: M2 |/ a" K, H- C; p3 J
going to experience any of the untoward effects from6 m. \4 k9 O1 ^4 X" F1 l
testosterone exposure as mentioned earlier because+ t& _2 t7 Z  u7 s
the exposure was not for a prolonged period of time.
8 y2 {8 T# ?7 }: KAlthough the bone age was advanced at the time of, `  n9 p" ^; o: x- ]& u. q
diagnosis, the child had a normal growth velocity at
# F2 h* [2 o! ]' c; e  U8 S5 kthe follow-up visit. It is hoped that his final adult( S$ D$ o8 m3 G5 O, P0 K8 l
height will not be affected.
; H. H# f: _% X, G" Y. z2 K0 RAlthough rarely reported, the widespread avail-- s% u8 }# x& s: T& X) O1 `
ability of androgen products in our society may8 w, o9 d3 ?6 @
indeed cause more virilization in male or female
4 r5 [# `7 G9 ~8 pchildren than one would realize. Exposure to andro-
2 c( l1 |7 S/ C9 dgen products must be considered and specific ques-
8 i* D& D3 O! x8 y7 G5 etioning about the use of a testosterone product or
7 N8 e9 H" J; dgel should be asked of the family members during
2 a4 {5 |0 }5 q1 C, y1 hthe evaluation of any children who present with vir-
) r9 T0 z8 b5 M& H% ~: f2 m6 l" Y' Silization or peripheral precocious puberty. The diag-) \- r; }4 Y4 e/ ~
nosis can be established by just a few tests and by
  F' Y3 {/ u& S7 aappropriate history. The inability to obtain such a
! `6 U7 M3 E, Y' j5 p3 q& M% o- Bhistory, or failure to ask the specific questions, may2 a( G4 \; B6 O& i
result in extensive, unnecessary, and expensive
1 `+ B) W: L0 V! M( Q! i+ Y) v0 Rinvestigation. The primary care physician should be
  c6 G" _3 h- r  ~8 a1 eaware of this fact, because most of these children# v4 u* n4 ~! l" _, `
may initially present in their practice. The Physicians’
, ]) E( J: h3 C& jDesk Reference and package insert should also put a
) p& s; ^3 S- o! [! ?warning about the virilizing effect on a male or2 L5 x! Q" ?# k1 Y6 d) ]- y) U* \
female child who might come in contact with some-# b2 b& [" N! G
one using any of these products.* j5 H' U: z$ R- a8 M2 Z7 j
References
# q, s2 z) Q; d6 W  k- c* y1. Styne DM. The testes: disorder of sexual differentiation
" W  @: ^3 ?; ^8 \! |5 q* T# land puberty in the male. In: Sperling MA, ed. Pediatric
* f$ z+ h5 C* FEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 j4 K! C1 C6 J6 C0 w4 O2002: 565-628.
  k+ e& t( f  M) n3 @2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 D3 b* d7 q" n* ]7 {. o
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
, L* l- T4 B7 s; e: b! E7 `/ @: O/ ~Boy Induced by Indirect Topical2 c9 T7 O/ h* w: |2 G
Exposure to Testosterone* X5 a3 w3 L2 X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ s; h( y7 p# r: D4 Z$ U" C% T
and Kenneth R. Rettig, MD1
4 R( |! o( ^0 IClinical Pediatrics0 [. L+ h1 K5 q9 ]
Volume 46 Number 6
) L* w# u1 I4 C& |. c7 `July 2007 540-543
; P) x; x1 y( H2 j! V© 2007 Sage Publications
& S5 q. H! n: L9 w* ~10.1177/0009922806296651
2 e3 V/ s' o  b* v. \5 W" p) C! xhttp://clp.sagepub.com
' B) t5 E& c9 N7 k: u- Vhosted at
- A: y6 h3 p$ O6 t. t3 v" Rhttp://online.sagepub.com
( b( S& l. [/ B: V6 GPrecocious puberty in boys, central or peripheral,! D* }8 V9 h& p! R0 D( q' o1 ^
is a significant concern for physicians. Central
5 [: m$ [  g) R8 o1 Tprecocious puberty (CPP), which is mediated
6 a# O7 p0 T* ~9 f; Dthrough the hypothalamic pituitary gonadal axis, has8 V) T& \% R1 f' Y& P6 D8 n4 m' w
a higher incidence of organic central nervous system- Y: b1 Y. e% t! ~
lesions in boys.1,2 Virilization in boys, as manifested
, q& K/ ^( {& Zby enlargement of the penis, development of pubic
6 H! L. p6 \1 s8 H. Q1 A; Z& n9 Y- t* A1 Vhair, and facial acne without enlargement of testi-0 P) ~# g( ?4 u
cles, suggests peripheral or pseudopuberty.1-3 We1 e+ x: z$ x! X. d! v0 q+ `% V) g
report a 16-month-old boy who presented with the
! ?; \3 @- i% @enlargement of the phallus and pubic hair develop-7 p8 \+ v( O6 B6 R- L/ B
ment without testicular enlargement, which was due
' ~4 b7 o' y$ Z5 w  sto the unintentional exposure to androgen gel used by
" M% f2 K) T! u/ pthe father. The family initially concealed this infor-+ J  y' P# ^8 H* A. M. z1 V3 ~
mation, resulting in an extensive work-up for this
% |5 m2 j2 V8 o7 h) a, R5 k- mchild. Given the widespread and easy availability of
$ T! A, o+ s2 atestosterone gel and cream, we believe this is proba-
1 K  k4 g6 T8 b7 ?  \2 Tbly more common than the rare case report in the
- u& k0 n* m! E3 c' r) ^1 Hliterature.40 l3 Q$ y% I2 Z/ M( |) @
Patient Report
$ t( P6 a) o9 u" t6 [+ I; p/ \A 16-month-old white child was referred to the# L; y$ s* B# ]! Y4 o. v- W
endocrine clinic by his pediatrician with the concern5 \, ?2 L) O& N2 M" `
of early sexual development. His mother noticed* |3 _$ O: }, x* u* ]. W/ E( S& F/ L
light colored pubic hair development when he was
  X$ ?7 n! ]( \3 o1 @From the 1Division of Pediatric Endocrinology, 2University of
) T) i/ Z; j% E: jSouth Alabama Medical Center, Mobile, Alabama.% k, p2 a& W% a% F! A
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* m$ R/ x. O$ ^; |% J* c( sProfessor of Pediatrics, University of South Alabama, College of
' s1 ^7 f! @  S5 A# q9 ~: p8 d$ jMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ z4 d% H. p; h/ R" H6 ye-mail: [email protected]." ]/ o1 X# ~9 Q1 V+ c
about 6 to 7 months old, which progressively became
+ }6 o/ ^$ c8 o" v* u) cdarker. She was also concerned about the enlarge-
$ }  a; O) f& r7 Mment of his penis and frequent erections. The child$ F5 r# ]) t$ Q. f9 l
was the product of a full-term normal delivery, with
! s6 u1 u: z1 R9 ]+ q8 {# b) n( ha birth weight of 7 lb 14 oz, and birth length of
* f) c: y6 Q, p# u* }20 inches. He was breast-fed throughout the first year
# x( _$ ]3 Z, y8 f  N6 k  D+ p) Yof life and was still receiving breast milk along with  I3 m# ^! ]  [. g9 n% E
solid food. He had no hospitalizations or surgery,
8 Y# R( ~& P7 x1 Z) Fand his psychosocial and psychomotor development( f) h4 S( D2 G5 t" n& G! N9 h
was age appropriate.
# X& y7 Y2 E' {! X' nThe family history was remarkable for the father,, }8 g; y) y$ H$ x; q
who was diagnosed with hypothyroidism at age 16,
* Z1 [/ ~/ w. Q4 y2 D4 \which was treated with thyroxine. The father’s
8 K& D: m& N7 S( Gheight was 6 feet, and he went through a somewhat
5 ~/ T, z- Z6 d& t0 J5 fearly puberty and had stopped growing by age 14.% H- T7 l9 c( h: D  d8 `
The father denied taking any other medication. The
+ Y7 R$ K; e# M9 q. ~: V* r: ochild’s mother was in good health. Her menarche: I3 L2 f) v. c
was at 11 years of age, and her height was at 5 feet! B" W' K1 m# V, q7 H
5 inches. There was no other family history of pre-& _6 p+ g  ?0 B% ^$ e9 ~- N
cocious sexual development in the first-degree rela-& t+ U( L2 Y  [9 q- L, ~
tives. There were no siblings.9 P" {/ q4 O4 ~  U6 g( {2 v# |
Physical Examination
2 l. C/ W0 n/ I) ?5 vThe physical examination revealed a very active,  g* W  S$ B" K' M+ i# a
playful, and healthy boy. The vital signs documented* p0 q) k0 H' k& F! j
a blood pressure of 85/50 mm Hg, his length was; L7 I* K8 q$ y' u* y
90 cm (>97th percentile), and his weight was 14.4 kg
* \) Y8 l6 T  v4 u3 I3 b(also >97th percentile). The observed yearly growth
+ z3 l3 {1 I0 G4 R: xvelocity was 30 cm (12 inches). The examination of
  B  l- g! L4 Q4 q3 ithe neck revealed no thyroid enlargement.
: ?$ O, n0 v& j% |, i, @The genitourinary examination was remarkable for0 y9 }  m# N! [* y; v/ U& q4 r. W
enlargement of the penis, with a stretched length of' {$ n6 g% j( D' C8 _" k% k
8 cm and a width of 2 cm. The glans penis was very well2 P: s# l3 Y0 ?3 }
developed. The pubic hair was Tanner II, mostly around$ z  L+ }, O$ g
5405 T% P  [; w; l' ?: D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: Y  B  X4 O' B3 x. B" \, U% f
the base of the phallus and was dark and curled. The& n$ c! _* K& g& u! ^8 `$ Z
testicular volume was prepubertal at 2 mL each.
8 I3 N* e. ^8 s8 \- mThe skin was moist and smooth and somewhat
: d! ~9 f  t9 k  k$ |. G/ {oily. No axillary hair was noted. There were no
0 R. C7 m' y$ @abnormal skin pigmentations or café-au-lait spots.+ |7 D' s1 D1 J+ [: S4 W
Neurologic evaluation showed deep tendon reflex 2+4 o, R, o0 ]2 @4 i
bilateral and symmetrical. There was no suggestion) m# B0 N3 M8 _
of papilledema.% \: t% ?2 N0 j% n. y% E- s( ^
Laboratory Evaluation* t# w8 e# B+ s5 T- w" c& Q- L
The bone age was consistent with 28 months by
( [$ v5 F2 [3 d- L8 f' Jusing the standard of Greulich and Pyle at a chrono-% J9 F: m7 M; z9 h* [& E7 }! L
logic age of 16 months (advanced).5 Chromosomal: f. G1 H9 y+ Y) P( u, n
karyotype was 46XY. The thyroid function test5 t0 T6 i" A& b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 e& @& W1 W9 F/ [
lating hormone level was 1.3 µIU/mL (both normal).
1 z7 J) h& {3 E0 F8 lThe concentrations of serum electrolytes, blood& I0 f; x1 ]$ U* S$ [
urea nitrogen, creatinine, and calcium all were
6 S" Y. n/ p* D" D0 Mwithin normal range for his age. The concentration
6 Z2 {# w  d8 \: rof serum 17-hydroxyprogesterone was 16 ng/dL
' [$ y: Q# _+ g3 E+ i(normal, 3 to 90 ng/dL), androstenedione was 20
% H8 l1 O* a6 _  j# Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% d, d; I2 j8 r: t8 c5 K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, S2 p5 Z& c0 E& }desoxycorticosterone was 4.3 ng/dL (normal, 7 to" ~& ?  B: }! [% P
49ng/dL), 11-desoxycortisol (specific compound S)
: g' G2 B2 z) ~" Q7 d( X; ?( Mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 G4 `. _" B, c$ T" g/ W) @( W* w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, Y0 c. W  s1 O+ K0 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* _5 V3 ]* }* q( U$ q6 \4 \" L
and β-human chorionic gonadotropin was less than7 D& S, E" K$ Q, k& s9 t
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 q' ?! y8 q' R. _
stimulating hormone and leuteinizing hormone  P  j% l; }' D
concentrations were less than 0.05 mIU/mL
0 A( N" L' X' b0 c$ u(prepubertal).
5 W: j' Y7 U' S  jThe parents were notified about the laboratory8 i7 m( r, ^' s5 J( @& }' [
results and were informed that all of the tests were
3 z$ N( m6 b+ k* [normal except the testosterone level was high. The0 b+ ~; h4 x$ J; ]9 K4 Y: @
follow-up visit was arranged within a few weeks to- ~( _' d+ ^- J
obtain testicular and abdominal sonograms; how-
9 }9 u  n" F: [, Lever, the family did not return for 4 months.
! E" L3 s' p2 x; p# wPhysical examination at this time revealed that the
- Y) y/ A. `( _child had grown 2.5 cm in 4 months and had gained8 H& F4 w- ?0 z+ w2 I3 R( {2 f+ p
2 kg of weight. Physical examination remained
9 T6 M+ p2 |! c& h: U3 p' ^unchanged. Surprisingly, the pubic hair almost com-: t2 h4 Y0 @* @8 ~/ ~- z
pletely disappeared except for a few vellous hairs at. `/ s( @6 j; ~8 |" ~3 P! U7 ]0 a
the base of the phallus. Testicular volume was still 2
, N. i4 y5 \& d* j4 ^; {mL, and the size of the penis remained unchanged.
9 l- w( Y$ ]9 T+ O3 C/ h) UThe mother also said that the boy was no longer hav-- u; y( |8 n+ q3 J0 Y4 O
ing frequent erections.
3 j' u/ f6 a6 |( kBoth parents were again questioned about use of5 L# i: V# w+ Z# U
any ointment/creams that they may have applied to) r2 S% t! i2 s3 E7 P0 b. _+ E
the child’s skin. This time the father admitted the
# M) h5 M! y6 T' hTopical Testosterone Exposure / Bhowmick et al 5417 V$ \8 V% M/ R8 c% F
use of testosterone gel twice daily that he was apply-
  [  v8 _$ G3 ^7 bing over his own shoulders, chest, and back area for1 z" u0 Y+ @  z. K2 C
a year. The father also revealed he was embarrassed
: t- q" n" ?3 A4 G. p# N4 u& Mto disclose that he was using a testosterone gel pre-
4 F2 u: L& x- b  t/ c# ?scribed by his family physician for decreased libido
9 f! l( W% k3 f4 o  esecondary to depression.( F( o) _% {4 ~; N
The child slept in the same bed with parents.4 r3 o: K4 c) [2 y) s8 r
The father would hug the baby and hold him on his
- D) Q& q8 J- K, E7 tchest for a considerable period of time, causing sig-
  l4 M* y% X$ P% z1 Hnificant bare skin contact between baby and father.0 B7 e9 M( H4 l* P
The father also admitted that after the phone call,. D! {) \% G# Z8 I$ E0 I! G
when he learned the testosterone level in the baby1 r: [* I, F" y9 L3 w
was high, he then read the product information8 O0 N  f3 ^. o; i4 A
packet and concluded that it was most likely the rea-
& U4 M7 a/ ^( lson for the child’s virilization. At that time, they6 L4 Z1 u5 `; I# m! M" B6 \' h
decided to put the baby in a separate bed, and the* ~7 d/ d( U4 i8 ?0 b% E
father was not hugging him with bare skin and had; L4 `/ k& j5 F+ r/ @
been using protective clothing. A repeat testosterone5 ?4 \9 {, X8 V6 s4 J
test was ordered, but the family did not go to the
2 P+ O2 ?" U& H2 V* {laboratory to obtain the test.
% `! k, e" e: QDiscussion; @6 N* \1 @6 @
Precocious puberty in boys is defined as secondary  `3 a" Y: q% ~. \1 f+ l
sexual development before 9 years of age.1,46 P9 N* H5 \* V& l6 t
Precocious puberty is termed as central (true) when
. f4 l7 X, @* w) Bit is caused by the premature activation of hypo-
- r) d" U9 |0 hthalamic pituitary gonadal axis. CPP is more com-
+ E+ Z) P: G4 smon in girls than in boys.1,3 Most boys with CPP0 [. K5 ?. W0 J4 y( L
may have a central nervous system lesion that is  j: _8 i8 q4 k% ~7 ~
responsible for the early activation of the hypothal-* \+ g3 V8 V, }4 _0 N* ]$ B2 {0 p" `
amic pituitary gonadal axis.1-3 Thus, greater empha-
- J* b* G1 _0 E" z4 G% H# A4 usis has been given to neuroradiologic imaging in7 P$ b' j$ D% A- E& D+ K# H3 O4 ?
boys with precocious puberty. In addition to viril-8 M3 q3 W/ r. c6 e, Q; @
ization, the clinical hallmark of CPP is the symmet-6 @# K+ X" _) [1 w2 a, A% g
rical testicular growth secondary to stimulation by/ K- @1 U) y; @
gonadotropins.1,3: M2 x( u$ P% O) h' d2 `% i
Gonadotropin-independent peripheral preco-
* |3 H, x$ T- V3 J9 @6 ccious puberty in boys also results from inappropriate
7 V0 w/ o$ j% d! M  v$ ]androgenic stimulation from either endogenous or
/ G" D# M3 v+ f2 _8 J0 Z. n( Texogenous sources, nonpituitary gonadotropin stim-
1 p+ N- _" ~, U" Iulation, and rare activating mutations.3 Virilizing. v6 x. `1 A+ S) Y+ `; L- E
congenital adrenal hyperplasia producing excessive) M# b. z3 D8 y' A1 _
adrenal androgens is a common cause of precocious) [- A- @3 D4 O: ]+ C/ W7 B
puberty in boys.3,4
2 H2 x9 z1 n9 @' v& LThe most common form of congenital adrenal' m! v% s, A$ w
hyperplasia is the 21-hydroxylase enzyme deficiency.
$ ?* F: e4 ~- y, A' x7 jThe 11-β hydroxylase deficiency may also result in( K' ?0 Z. n, k' n! R( ?
excessive adrenal androgen production, and rarely,: t3 @+ x9 J+ I' Y5 g( a
an adrenal tumor may also cause adrenal androgen
1 s  N2 p( Q; Y; Wexcess.1,3
% k2 [  `% Q. e" k$ H# _. O  ?4 Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- f( N, y/ [/ k* S) i1 S- J9 x  R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* [- v+ B+ d4 qA unique entity of male-limited gonadotropin-' |! I8 K* ^. D
independent precocious puberty, which is also known& q  I- F+ L5 P) e8 Z* E$ g
as testotoxicosis, may cause precocious puberty at a) u( a6 x  k+ @2 a
very young age. The physical findings in these boys
. O! ?% g0 |+ k8 G  b9 twith this disorder are full pubertal development,
$ U! B# _- l" a% ]- F* X( lincluding bilateral testicular growth, similar to boys1 k2 [. d0 h$ I6 a9 U  T- b
with CPP. The gonadotropin levels in this disorder8 m! ~! h' G. @" o* r9 q
are suppressed to prepubertal levels and do not show  U  ^) p/ E# r1 r; z
pubertal response of gonadotropin after gonadotropin-1 W1 W( r0 _8 |" Z- p* ]
releasing hormone stimulation. This is a sex-linked1 p6 k& E" }2 E6 R
autosomal dominant disorder that affects only0 @  r! Y$ P+ B" g, U' \
males; therefore, other male members of the family
8 d2 I& q; S' D( Omay have similar precocious puberty.3
/ T  _! V/ S5 B0 ^3 a. FIn our patient, physical examination was incon-7 }; w4 J) Z5 }4 h
sistent with true precocious puberty since his testi-7 }; E& ]3 @  g# ]( `
cles were prepubertal in size. However, testotoxicosis5 J  i; ?& `# D# T( x5 r. r
was in the differential diagnosis because his father
* O, o7 d4 }- o! w  ?: sstarted puberty somewhat early, and occasionally,& Z7 {7 U9 j( k3 z4 W4 i+ _% U- M8 Z
testicular enlargement is not that evident in the
% C; y! k3 X5 K; n9 x4 Tbeginning of this process.1 In the absence of a neg-+ r: p' f9 [3 X& A+ |( c
ative initial history of androgen exposure, our8 k# o* ^! O1 `4 }! z5 H, e
biggest concern was virilizing adrenal hyperplasia,
7 x0 _, g/ \; h/ W; meither 21-hydroxylase deficiency or 11-β hydroxylase
$ e( y. E/ ~( jdeficiency. Those diagnoses were excluded by find-
1 H4 e1 i4 ?1 s0 W- Z: U0 P* g3 Zing the normal level of adrenal steroids.
8 A7 Y$ ~8 k3 M& k" ZThe diagnosis of exogenous androgens was strongly6 f: K8 z2 m" `
suspected in a follow-up visit after 4 months because
- K7 D" q5 S4 I9 A2 I; mthe physical examination revealed the complete disap-
- p+ [$ g9 O0 M- m" X1 O, s; npearance of pubic hair, normal growth velocity, and
* ?7 V- o  {/ M& _. J$ Ydecreased erections. The father admitted using a testos-
! r, a% ?# d  Y& e4 I- M7 Y5 rterone gel, which he concealed at first visit. He was
  t/ S0 D$ |8 ^" F$ {3 ?using it rather frequently, twice a day. The Physicians’
/ e" }1 k* U  G# S0 H8 h4 sDesk Reference, or package insert of this product, gel or
' a) ]3 k. D+ _cream, cautions about dermal testosterone transfer to
: P* \# N) d3 S5 R# C7 Ounprotected females through direct skin exposure.% G: u; _! b* |5 `, H% Q2 I
Serum testosterone level was found to be 2 times the/ b# j' B' K5 H+ Q: w
baseline value in those females who were exposed to) U2 g, O/ O: Z3 F
even 15 minutes of direct skin contact with their male" r1 a8 O- i! i
partners.6 However, when a shirt covered the applica-
9 v; B" b  p+ `/ `% |$ W/ a; Ytion site, this testosterone transfer was prevented.
) k' z/ W) Q7 w/ YOur patient’s testosterone level was 60 ng/mL,
  s1 D" v) v' S8 D" ?, e- Q& @which was clearly high. Some studies suggest that
! O" P% E/ z5 l7 k3 D) [" |& Y2 udermal conversion of testosterone to dihydrotestos-' C- z# t& M3 h: L; f7 X
terone, which is a more potent metabolite, is more
- o9 B6 T. Z% I5 n1 `7 ?6 P5 ]active in young children exposed to testosterone+ h; ?9 \( {9 G) d6 M
exogenously7; however, we did not measure a dihy-0 H: |+ l# P6 j3 K
drotestosterone level in our patient. In addition to
' n; s- H6 y9 tvirilization, exposure to exogenous testosterone in
# j" j3 g+ T3 qchildren results in an increase in growth velocity and$ L  ]. k6 ~/ N
advanced bone age, as seen in our patient.
) I: K& h  m6 e+ L1 r8 bThe long-term effect of androgen exposure during
9 u+ N) v  n% v; a6 i' Fearly childhood on pubertal development and final% N0 D( r7 ^3 Y! h4 U! m; [
adult height are not fully known and always remain
8 \, F2 U. V# _9 G$ ?a concern. Children treated with short-term testos-/ ~8 s$ w, d: R4 y" G& O5 K& d5 u
terone injection or topical androgen may exhibit some
0 ~% \2 k% l! d$ w, C, j+ [acceleration of the skeletal maturation; however, after3 D/ H& Q. F6 W$ E$ ?2 a) A
cessation of treatment, the rate of bone maturation+ z3 w/ @# A% D9 @
decelerates and gradually returns to normal.8,9- Q2 a( \2 p4 w8 A: j! P& X$ [5 D
There are conflicting reports and controversy
$ s7 n: \, c6 J6 c" B2 @over the effect of early androgen exposure on adult! I) S- S0 \! Z& u4 |4 n1 J! n7 m
penile length.10,11 Some reports suggest subnormal4 U( _+ F# _& A% k& `7 i6 G2 g
adult penile length, apparently because of downreg-9 [+ q! k' {8 W! r% T
ulation of androgen receptor number.10,12 However,
2 f: V2 J0 Q8 n# zSutherland et al13 did not find a correlation between( w; P9 z1 J" q
childhood testosterone exposure and reduced adult; w% f4 b9 h/ z- K7 H! U/ s- \! M
penile length in clinical studies.
" k* |0 v- M  I: s; `) nNonetheless, we do not believe our patient is
9 N3 V6 T! \, l) cgoing to experience any of the untoward effects from: ?; A4 _+ z: b% ~- v
testosterone exposure as mentioned earlier because
" o9 f) w4 h+ F- \3 W7 Zthe exposure was not for a prolonged period of time.+ E6 `9 F: P  n! x1 N+ I
Although the bone age was advanced at the time of
# V) K6 I- s' D6 g: N& b+ ?, `2 adiagnosis, the child had a normal growth velocity at
/ Y* d3 e! ?6 [( a+ ]% Ythe follow-up visit. It is hoped that his final adult3 ]1 G! V! G; q; k' a6 A7 s
height will not be affected.
% m) z- R5 X, \4 M  tAlthough rarely reported, the widespread avail-
' a0 o! t3 s& x6 N* b! b) a5 }ability of androgen products in our society may
" R$ y% r4 u& |indeed cause more virilization in male or female2 y6 ~+ V; L" g, E' y  P2 \, L
children than one would realize. Exposure to andro-
2 N) d1 c. S+ K$ w) _gen products must be considered and specific ques-
& |: [  P1 S2 r3 r0 b8 Y4 Gtioning about the use of a testosterone product or
" N' g. I$ D1 e9 \7 zgel should be asked of the family members during
9 E) n& B  T  q3 ~9 ithe evaluation of any children who present with vir-' U, u/ M, M9 d) o
ilization or peripheral precocious puberty. The diag-
3 ]2 L+ z$ d( R$ Q! J! [nosis can be established by just a few tests and by7 M7 o8 j9 ~! u+ G6 u) j
appropriate history. The inability to obtain such a
% J9 g0 {+ t  Y3 Hhistory, or failure to ask the specific questions, may
% \2 H2 W* {! x3 d; vresult in extensive, unnecessary, and expensive: X0 w, k1 u6 X% R( @
investigation. The primary care physician should be
4 |5 ^: Z9 `) y1 O; Uaware of this fact, because most of these children9 X$ H' \0 ^: a7 N1 ?
may initially present in their practice. The Physicians’
& R6 O7 ?& J# p$ ^# XDesk Reference and package insert should also put a
! ~: I! J5 J. {. S  {warning about the virilizing effect on a male or
: i7 a! R0 H1 `; H& rfemale child who might come in contact with some-
0 w( ]/ q9 Z# ^7 t" |one using any of these products.8 i* r: g) l7 O5 T
References
# a5 Z. o( a' D( ]& I9 r% q1. Styne DM. The testes: disorder of sexual differentiation
: p. _8 y9 q0 Y! j2 a) O0 K+ Zand puberty in the male. In: Sperling MA, ed. Pediatric2 x, n8 A; s; k% W
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) ^6 j2 r/ u) o( r4 g2002: 565-628.& r1 h& i  K& @
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, W! I# V) e/ d3 kpuberty 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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
) L6 ^, _% s) i& W2 Y
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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