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Sexual Precocity in a 16-Month-Old/ s* L# ~) N( X( {# I; n
Boy Induced by Indirect Topical- }. w& l9 G% e5 W; l
Exposure to Testosterone" b  U+ R' z. e- p0 m3 ~. ~$ w
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" W# t5 w2 S8 F) V9 R2 l! l! _and Kenneth R. Rettig, MD1
, e2 @3 u+ }; b2 a7 w8 A3 ^Clinical Pediatrics! ~, g- r" t  q. [; E: ~$ [
Volume 46 Number 6
* c( l* b; [9 g2 m: GJuly 2007 540-5434 o8 K: f1 Y/ P$ R" Z
© 2007 Sage Publications
+ I1 |3 ^" W$ d, s, z10.1177/0009922806296651( o. |& g9 D, Q; j# Q
http://clp.sagepub.com5 g( M. P" D9 e+ i  P+ G
hosted at
. |' L! A$ t+ ]http://online.sagepub.com& G4 x( O0 T7 K; o
Precocious puberty in boys, central or peripheral,
: l+ ^8 V% T2 S) O3 Ois a significant concern for physicians. Central8 o, R. \9 _; G' I$ Q8 V" F0 U
precocious puberty (CPP), which is mediated
7 Y. T3 g! L: h& L. ythrough the hypothalamic pituitary gonadal axis, has
, d! T6 L6 Z( b' xa higher incidence of organic central nervous system
* R. R# c+ o- Y4 k  blesions in boys.1,2 Virilization in boys, as manifested1 {6 l$ a. F( C1 q
by enlargement of the penis, development of pubic
- f% L8 I# j  _! S- mhair, and facial acne without enlargement of testi-
  r5 N. K, N% U& L+ K- R  s. Ccles, suggests peripheral or pseudopuberty.1-3 We
2 v# Z' e% `" ~9 Freport a 16-month-old boy who presented with the
3 Z# o& t9 j4 fenlargement of the phallus and pubic hair develop-4 p, R7 G# O( {) z
ment without testicular enlargement, which was due
$ ^7 e/ e( r4 v2 p( S/ Fto the unintentional exposure to androgen gel used by9 M. N. D- S7 P0 f5 u9 ]8 Z
the father. The family initially concealed this infor-: X6 p, A& _9 b$ e* D
mation, resulting in an extensive work-up for this
: m( Q/ S% `* A9 \3 Z$ Qchild. Given the widespread and easy availability of4 v5 c7 \$ \# {4 K3 j- r8 O$ j
testosterone gel and cream, we believe this is proba-
* V: p2 R7 P7 R* P9 Lbly more common than the rare case report in the) n( b5 f) O" h
literature.4/ m6 b& X# t* R& I* {& A. [
Patient Report
- N/ _! c( k7 q' z# kA 16-month-old white child was referred to the
+ o# B8 U3 d8 i) E! ?: fendocrine clinic by his pediatrician with the concern
- f. b. X7 u2 y/ X5 D3 Gof early sexual development. His mother noticed9 ?5 v) S$ a8 N% x; m* H% P8 y
light colored pubic hair development when he was* O) F# r/ r) U; n& \
From the 1Division of Pediatric Endocrinology, 2University of5 ~9 l& s, m, q; P% E6 A% K
South Alabama Medical Center, Mobile, Alabama.
. I, T, r; D# u- y) |/ p8 t% zAddress correspondence to: Samar K. Bhowmick, MD, FACE,# F' a; L8 H# R: a
Professor of Pediatrics, University of South Alabama, College of
; z( k* l3 Q/ Z2 L3 s. G4 T7 b- UMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ k5 T# V2 ]& n3 J1 De-mail: [email protected].
1 Z0 [* j6 k- z( ]) |2 [6 X8 Mabout 6 to 7 months old, which progressively became1 I' C6 U) H, \/ t- [7 J9 i7 Q: g
darker. She was also concerned about the enlarge-
' v9 d! p% Q2 H# k2 ^2 Yment of his penis and frequent erections. The child
! i/ {3 Y; g# awas the product of a full-term normal delivery, with
5 Q# t) y" a9 t3 t, O% xa birth weight of 7 lb 14 oz, and birth length of
; M; K; v5 W# E$ y20 inches. He was breast-fed throughout the first year! A, P  Y$ y5 @2 O; `
of life and was still receiving breast milk along with
4 S3 ?6 H( p6 r* R1 e/ Bsolid food. He had no hospitalizations or surgery,5 S8 f0 j6 Z; P: E+ L
and his psychosocial and psychomotor development: b$ a# t0 n5 H; |" s9 W
was age appropriate.
! P8 [  S4 _: RThe family history was remarkable for the father,( [0 N. X$ {# l" O
who was diagnosed with hypothyroidism at age 16,
. B8 N+ M7 x1 J6 e* i  e2 Jwhich was treated with thyroxine. The father’s) W3 d1 Q1 }  [8 U* x
height was 6 feet, and he went through a somewhat5 |" }0 d+ e. [5 J5 V
early puberty and had stopped growing by age 14.
/ A9 `$ Q% ^- E9 B" Y/ ?) LThe father denied taking any other medication. The
3 O2 C" Z' _( n1 Zchild’s mother was in good health. Her menarche
, K# Q" V  u1 [# ?! Y" r% h; pwas at 11 years of age, and her height was at 5 feet
6 D6 t' V7 j& {: d9 G6 m5 inches. There was no other family history of pre-
6 d) O7 C. t" _0 v0 f: J9 E$ @' ococious sexual development in the first-degree rela-: h+ Z$ e- [9 g
tives. There were no siblings.3 w' n# ^" ]3 a* o
Physical Examination0 c8 ?2 S  Z2 r) p
The physical examination revealed a very active,* T& Z* G& a  R1 L: {* t
playful, and healthy boy. The vital signs documented
/ Q8 k" r  j: ba blood pressure of 85/50 mm Hg, his length was2 `; ]3 E  }' k% a! R6 A
90 cm (>97th percentile), and his weight was 14.4 kg' x: p8 a- C3 L5 w% ~
(also >97th percentile). The observed yearly growth
% ?, C/ E- ?3 I8 ?( |% @, Uvelocity was 30 cm (12 inches). The examination of# p% P; N; t1 n! r( T! T) w$ V
the neck revealed no thyroid enlargement.
* |9 T' c- q/ W1 ^. N0 v- bThe genitourinary examination was remarkable for
2 [+ [# O& W1 O* {enlargement of the penis, with a stretched length of
/ _( J9 c; |% Z0 i' W6 q8 cm and a width of 2 cm. The glans penis was very well$ l  s2 `: _' k9 L( k
developed. The pubic hair was Tanner II, mostly around
# E8 R4 x8 e2 P% @) F# ^+ [; K540  _) z% c) ]  T9 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& Z0 O4 q0 s8 ^) {5 c; t$ ]0 u+ R- l+ t
the base of the phallus and was dark and curled. The
) I) E/ P- \% i8 S; x7 ntesticular volume was prepubertal at 2 mL each.
5 F5 j- B# B  |+ u6 xThe skin was moist and smooth and somewhat
7 {8 L- ?& |/ y' ioily. No axillary hair was noted. There were no
/ C- _3 G. s6 ], Q' P1 V4 N0 d4 Zabnormal skin pigmentations or café-au-lait spots.& P1 I* }0 G  A  T
Neurologic evaluation showed deep tendon reflex 2+
  ?  v3 A( j1 {' b5 Obilateral and symmetrical. There was no suggestion. c# m" f/ ?, y8 Q0 ~. j9 b4 i
of papilledema.
# r& M  Y: E  M: e% C& lLaboratory Evaluation; @) o7 f8 u0 Z) F" R1 [
The bone age was consistent with 28 months by1 B/ ?/ x; C$ j# l7 D
using the standard of Greulich and Pyle at a chrono-5 c. p7 S; k+ M8 H
logic age of 16 months (advanced).5 Chromosomal
( L2 n% e3 s/ vkaryotype was 46XY. The thyroid function test
1 E# n( [0 y- H# D; ]1 ~* }9 Ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-
. Z% V# Q3 ]' e8 ?! i2 Qlating hormone level was 1.3 µIU/mL (both normal).
! {' g( ^6 }# f' L! C6 A4 i! _The concentrations of serum electrolytes, blood
( H/ a) }$ H: Y5 W1 {urea nitrogen, creatinine, and calcium all were# F) E& n4 z& I; p0 ?0 E
within normal range for his age. The concentration
3 a7 B, m0 E/ T* dof serum 17-hydroxyprogesterone was 16 ng/dL
9 D/ S1 S+ F- x4 Z* H2 ^/ C(normal, 3 to 90 ng/dL), androstenedione was 20
9 k9 n* \# A5 C' v# Q& Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 ]4 R5 J1 H* C0 |( v8 K8 K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ `3 w- G+ [' @" F6 l2 N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to  s# H2 ~8 C# f8 `
49ng/dL), 11-desoxycortisol (specific compound S)+ b5 w) H4 l8 Z* }; Z, M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; b* X7 ?- o) @& J' jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* r9 n! N+ A* D, _; p  U1 }7 \2 [testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 w/ y' q$ G- ?  E" jand β-human chorionic gonadotropin was less than
% F8 [$ @: ]+ q( m6 d+ g$ f, t5 mIU/mL (normal <5 mIU/mL). Serum follicular3 m) C# @( S! }" {  n% n
stimulating hormone and leuteinizing hormone4 q: |. ^. ]6 A1 G6 o. {" x+ W2 k
concentrations were less than 0.05 mIU/mL1 K1 j* C1 C, X+ N8 N# J
(prepubertal).3 B; J- b1 O! `0 \* U
The parents were notified about the laboratory" o: D6 b6 f  S! M+ B* f* y) X8 W- k
results and were informed that all of the tests were9 H: b$ h- V$ ~: H! M
normal except the testosterone level was high. The+ w8 T4 N: \1 F. T
follow-up visit was arranged within a few weeks to
. d2 y1 X# S+ z+ d' F- \6 Robtain testicular and abdominal sonograms; how-$ R! h" m7 n! ?. s
ever, the family did not return for 4 months.
$ V; m) T; _7 `' r5 o; S& FPhysical examination at this time revealed that the# y3 k0 B( p! q! I/ G0 r5 M
child had grown 2.5 cm in 4 months and had gained
2 u( L6 G) W% v( q2 ^7 D2 kg of weight. Physical examination remained2 }- K! j6 O9 ?) ^' r( f
unchanged. Surprisingly, the pubic hair almost com-$ i* q* J' R" S. _! _4 e6 Q
pletely disappeared except for a few vellous hairs at- T* X" Z' F0 g) p5 s
the base of the phallus. Testicular volume was still 2
+ X' c. f$ n% P" v# J, i% [4 W/ ?mL, and the size of the penis remained unchanged.
6 A' u- P( b5 C  X+ x) B: tThe mother also said that the boy was no longer hav-
9 x0 |' g4 L7 V) S3 Xing frequent erections.
( M% z% f, E" D5 ZBoth parents were again questioned about use of: W* M) B% e' B- p/ V7 C) U$ [
any ointment/creams that they may have applied to
& i2 V/ H, m- w  l# Q; F' v7 x' ethe child’s skin. This time the father admitted the
7 R2 A4 a: c. t% z( ^Topical Testosterone Exposure / Bhowmick et al 5416 G' w% }" V4 _" E
use of testosterone gel twice daily that he was apply-
, i# l. [4 J5 M* o7 fing over his own shoulders, chest, and back area for2 D; ^& N- N+ K, }+ ?4 b" L
a year. The father also revealed he was embarrassed
( q  {6 u; U- J- n, v/ K' I) gto disclose that he was using a testosterone gel pre-4 H' G( v$ I( H" o# ~* `1 l
scribed by his family physician for decreased libido
5 K" w4 {1 L0 @; E8 N! wsecondary to depression.
" N; g2 v& v( M! f9 MThe child slept in the same bed with parents.
! I2 T1 P- G4 C/ }The father would hug the baby and hold him on his9 Y9 Y1 z+ g4 x  R& i
chest for a considerable period of time, causing sig-6 y( d8 U# l! j
nificant bare skin contact between baby and father.) Y) c! w0 v' S
The father also admitted that after the phone call,% P. `% R0 r; B2 `+ A) k) C
when he learned the testosterone level in the baby
$ G* w# Q1 p) W, Q( }  V  P) owas high, he then read the product information) b: O4 e9 ~5 y3 S4 G$ q2 \
packet and concluded that it was most likely the rea-$ ~8 I5 a, m5 d; e: i2 {4 u6 P! ]1 Y
son for the child’s virilization. At that time, they* U3 d! v. I, [" K: i) B
decided to put the baby in a separate bed, and the* Z4 |3 \+ _+ X
father was not hugging him with bare skin and had2 C/ N2 s8 B" R. f6 i+ O
been using protective clothing. A repeat testosterone6 {: S$ N# M1 f, N
test was ordered, but the family did not go to the
7 X& z/ y. Y! h6 O* blaboratory to obtain the test.: |( [8 m: P9 f
Discussion
# E4 Q  L/ M6 ?Precocious puberty in boys is defined as secondary
" w# F- h! W6 G  @sexual development before 9 years of age.1,4
- l+ n9 \- x( w; N  Q5 n* mPrecocious puberty is termed as central (true) when
+ G" K1 [! F# S6 _it is caused by the premature activation of hypo-
' V3 k0 O% J9 d. q+ q" ithalamic pituitary gonadal axis. CPP is more com-
& Y! c  V- w6 X: e7 Umon in girls than in boys.1,3 Most boys with CPP5 t9 o) l  N; v
may have a central nervous system lesion that is, b4 A$ G* |7 i" Y# f* ~% I
responsible for the early activation of the hypothal-
% x6 F+ j( V; A6 `2 d; x' Jamic pituitary gonadal axis.1-3 Thus, greater empha-
) i7 U8 y( b" f# dsis has been given to neuroradiologic imaging in7 B2 J. A$ ]* d! [4 V- b) }1 B- o. Z
boys with precocious puberty. In addition to viril-$ ]/ h, i  j& z+ M% B9 A
ization, the clinical hallmark of CPP is the symmet-
9 Z9 U* `0 B9 G6 grical testicular growth secondary to stimulation by! h' O7 U) g( k& O( t. z1 Y9 T
gonadotropins.1,38 j9 z; i2 Q# {. T# B/ v' F* M
Gonadotropin-independent peripheral preco-
+ D& i* D. v2 {" u$ j9 ycious puberty in boys also results from inappropriate
$ z, U3 }6 d$ |" R9 kandrogenic stimulation from either endogenous or
5 T6 _. k1 S2 s( ^) |; Rexogenous sources, nonpituitary gonadotropin stim-
0 q5 e# E' X2 c. gulation, and rare activating mutations.3 Virilizing9 _: k" N% [/ T" ?3 M
congenital adrenal hyperplasia producing excessive
& ]1 ?* z0 Y6 c4 O  C* Ladrenal androgens is a common cause of precocious
3 W- g2 |/ t- c, r+ t1 o/ {2 G5 mpuberty in boys.3,4
! }0 E" k, Y; s# N+ R/ kThe most common form of congenital adrenal/ j0 h- \7 O: `& _$ Y
hyperplasia is the 21-hydroxylase enzyme deficiency.* a9 X% x/ [% N4 r
The 11-β hydroxylase deficiency may also result in
' T1 g7 Y4 b; k! O7 j5 U2 Bexcessive adrenal androgen production, and rarely,( q1 Q* t- G. r3 n
an adrenal tumor may also cause adrenal androgen; Q9 \' L8 u) W3 h' T
excess.1,3% ~; M2 e. }0 h1 E* |% `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ F/ e. H; V, q  q: @
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 H3 |& I  c; ]# bA unique entity of male-limited gonadotropin-1 R0 ]( J/ K2 g! t9 x
independent precocious puberty, which is also known
0 e9 @: }/ j" C+ C3 D4 Has testotoxicosis, may cause precocious puberty at a
% X9 C! r% u3 @% _2 Ivery young age. The physical findings in these boys6 k% w" ~. `# ~6 G7 J) U
with this disorder are full pubertal development,2 m# d& Y, U4 I( F2 q# D
including bilateral testicular growth, similar to boys) J( d- M% ]$ g, o" W
with CPP. The gonadotropin levels in this disorder
( |# t# K+ O* ~5 ware suppressed to prepubertal levels and do not show
/ z1 `1 F% y! D2 I' x. Bpubertal response of gonadotropin after gonadotropin-
* H8 Y- v! R& N: ]' i# X) @9 jreleasing hormone stimulation. This is a sex-linked5 |6 R) X2 s, @" g
autosomal dominant disorder that affects only' U/ C3 [+ G; \4 |) C. v7 |; p
males; therefore, other male members of the family+ m: `2 x$ s- ^4 b& c6 o) P8 W
may have similar precocious puberty.3
3 f  V! A3 x+ [+ z9 K3 |7 PIn our patient, physical examination was incon-
0 M4 R% ]1 W6 c& i$ Ysistent with true precocious puberty since his testi-& L. u, S  m& g5 E2 z5 Q
cles were prepubertal in size. However, testotoxicosis# |( V; V4 V+ K3 c. ^' T& ?: B
was in the differential diagnosis because his father# p& A+ j/ R5 i3 g( H5 c
started puberty somewhat early, and occasionally,: v! N* e+ H, q( F
testicular enlargement is not that evident in the
$ y) ?$ w+ M6 Z4 j3 Y% n. fbeginning of this process.1 In the absence of a neg-
( E- t  m& `% c  c7 Y& h) jative initial history of androgen exposure, our
% |& v) ?* t) w% O. P7 I  N9 xbiggest concern was virilizing adrenal hyperplasia,
: t+ C6 h. ]# q, R0 g6 Yeither 21-hydroxylase deficiency or 11-β hydroxylase
' Z% ^) b5 p1 I: sdeficiency. Those diagnoses were excluded by find-
7 f  K: J; C) k0 E6 k$ m. z5 V% a- ting the normal level of adrenal steroids.( Z7 C4 l. u, x' c3 F
The diagnosis of exogenous androgens was strongly
  X, Q- M8 N. D6 w$ t% h  W6 k/ \9 j( E! Ssuspected in a follow-up visit after 4 months because. A/ _0 M" m: \0 q: r5 H  s$ ^
the physical examination revealed the complete disap-
8 m, o" T$ ]- Y! n/ E! f6 [; C5 hpearance of pubic hair, normal growth velocity, and
9 n8 p( L; a& E9 |) A: I5 Idecreased erections. The father admitted using a testos-
8 J) e. r5 Y( H. oterone gel, which he concealed at first visit. He was
0 [/ Q7 U, f; `1 m" p  vusing it rather frequently, twice a day. The Physicians’$ d0 v* r' ]+ p+ K4 c8 M; o
Desk Reference, or package insert of this product, gel or
6 o( L5 U8 h. a! J0 o' C, @cream, cautions about dermal testosterone transfer to8 N; ^1 n- `# r9 q/ E" h
unprotected females through direct skin exposure.
7 u; Q, G2 X! z3 A# |Serum testosterone level was found to be 2 times the6 P+ z1 ~) i. y8 U$ _  v5 ~
baseline value in those females who were exposed to
. r* z6 B4 T  N$ yeven 15 minutes of direct skin contact with their male
" E# D* o& r( J0 ]) R/ Lpartners.6 However, when a shirt covered the applica-
- E* O+ ?9 ]( Q6 W: s  rtion site, this testosterone transfer was prevented.
' {) m0 t1 c5 [8 p: V* R( s6 nOur patient’s testosterone level was 60 ng/mL,% t6 F0 v# Y5 ?& W/ a
which was clearly high. Some studies suggest that: ^" Z, O3 I* g" n, y2 \/ W
dermal conversion of testosterone to dihydrotestos-) h! s- K& C8 ~7 o
terone, which is a more potent metabolite, is more
: v9 z- a3 Y6 V1 f  a9 pactive in young children exposed to testosterone
% G6 X8 S$ q$ W  _: Q& z" w2 _/ ?' y4 T; _exogenously7; however, we did not measure a dihy-; O: D* m# i$ i2 y, x; \1 c
drotestosterone level in our patient. In addition to
; w& {9 Z8 o2 {- xvirilization, exposure to exogenous testosterone in6 O/ I; N& x7 Z
children results in an increase in growth velocity and8 H% c( P% O: ~6 c* j7 l! f
advanced bone age, as seen in our patient.) |, Z/ D& ?+ f' ^" L7 C
The long-term effect of androgen exposure during
5 ?. f' Z& r" X' P& qearly childhood on pubertal development and final5 k  f6 H9 k8 o) i' P. q
adult height are not fully known and always remain
0 P# c! b3 B# [a concern. Children treated with short-term testos-
& f( M3 i% h/ Q' w7 H9 @0 q& M/ T8 u- wterone injection or topical androgen may exhibit some
5 B; W/ F% z0 H) N1 f1 jacceleration of the skeletal maturation; however, after
' f! J1 y* i" J( T7 @4 q5 \  E- bcessation of treatment, the rate of bone maturation
$ {7 p/ `8 n" r7 edecelerates and gradually returns to normal.8,9* `8 S8 Z3 A- ~( Q: _
There are conflicting reports and controversy$ r% y: H  X8 n/ t5 [) ^
over the effect of early androgen exposure on adult
2 I2 T+ |, \- |5 @  e# O8 `3 ipenile length.10,11 Some reports suggest subnormal) L& L4 S9 D1 r5 b8 U
adult penile length, apparently because of downreg-
  F5 J- V8 j! ?7 m% T! q: i2 m0 b  Uulation of androgen receptor number.10,12 However,3 h' ?. x9 @2 V( a" J
Sutherland et al13 did not find a correlation between
3 |! M: [  n% n* F+ y$ Bchildhood testosterone exposure and reduced adult% q" B) f# K/ @- b9 q
penile length in clinical studies.0 m/ G6 O2 C) K4 v1 j' S, s9 v
Nonetheless, we do not believe our patient is9 G& x0 e; c! j5 B2 v) U
going to experience any of the untoward effects from) @8 E) ?, i" Q" O/ r
testosterone exposure as mentioned earlier because8 P1 X4 D& {# S8 {/ @7 |$ _) B! S3 B
the exposure was not for a prolonged period of time.
+ Q. w2 P% G$ tAlthough the bone age was advanced at the time of& `/ n0 ]9 o, |; Z: l* C
diagnosis, the child had a normal growth velocity at9 D! a8 k* Y' K. g
the follow-up visit. It is hoped that his final adult3 |  L, l1 l& m* W$ ?
height will not be affected.
' L" }' r- X, `! U" E& uAlthough rarely reported, the widespread avail-9 p) {- v/ v4 r+ }# o  H# @3 y, Y
ability of androgen products in our society may1 K7 D. a! h, U& E, D4 P9 r
indeed cause more virilization in male or female
* L- W: y& j6 V' Y, I+ [) k2 q3 Hchildren than one would realize. Exposure to andro-
6 t% C5 Y/ X, I. hgen products must be considered and specific ques-$ w5 [0 s# D: F7 ~' M$ r
tioning about the use of a testosterone product or
; H. A8 \/ R* L/ Z( S, ~gel should be asked of the family members during
5 ]# S- n, {/ n6 j4 ]; athe evaluation of any children who present with vir-* h) N  c- Y% t5 g
ilization or peripheral precocious puberty. The diag-; ^- T! ~! O( }' h8 O
nosis can be established by just a few tests and by/ H7 ^* P# W, u& V6 J. t9 a
appropriate history. The inability to obtain such a
) H) }; ]! T/ c4 E) Xhistory, or failure to ask the specific questions, may- D8 P/ Q& H+ j, \
result in extensive, unnecessary, and expensive* s9 k, z- V5 f6 `4 ~6 i
investigation. The primary care physician should be
9 c( L9 _  [# E$ {. eaware of this fact, because most of these children* s9 W; ~4 ?* b2 e
may initially present in their practice. The Physicians’% p6 X+ x! L3 }3 x
Desk Reference and package insert should also put a! q7 H% o  p) p5 @$ d$ p& ]
warning about the virilizing effect on a male or
0 B: t0 l. Y5 \! R2 f! Pfemale child who might come in contact with some-" i4 D$ ^0 K# A$ d, @6 R/ {
one using any of these products.
. b0 Z7 \" x: A7 CReferences4 A# N  K  @8 C/ X3 X% l9 b
1. Styne DM. The testes: disorder of sexual differentiation2 o7 J1 V! P2 }1 a
and puberty in the male. In: Sperling MA, ed. Pediatric( ~4 G% \7 z+ M' M2 K  n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- ]  n( K' w  u5 z2 p8 I" l
2002: 565-628.
7 K6 |8 a8 n! l! e# b, h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. f4 Y: a" Y0 C6 @- upuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old$ K, Z' B9 H2 W: T( H5 J! }3 J
Boy Induced by Indirect Topical
$ Q: N1 F+ P8 `9 M4 X; }) dExposure to Testosterone
' s/ G+ A" G  G2 u8 GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. m2 k. S( k* k. r
and Kenneth R. Rettig, MD1
# ^4 Z' T/ I3 L' Y( PClinical Pediatrics
% I' r5 _# }, ^Volume 46 Number 6; m9 X5 r4 r+ q9 b" N  g3 [% n& ^0 G2 j
July 2007 540-543
3 e: m- V0 B& }/ M0 l. [3 D7 U© 2007 Sage Publications3 O# }, n' T1 U; C& {" j# M
10.1177/0009922806296651+ F& T1 }8 x- t& s6 C* O! h
http://clp.sagepub.com
5 @1 G, ?7 U# W  r8 b* i0 ehosted at
5 Q4 J# }3 b. I: f; E+ v5 Hhttp://online.sagepub.com
2 w7 y' D7 Q2 D  \: V6 U& g6 GPrecocious puberty in boys, central or peripheral,8 D" v1 b3 B$ h4 C
is a significant concern for physicians. Central
: z' B: n4 |. c2 pprecocious puberty (CPP), which is mediated
3 [! G( T0 \8 Q3 v6 V7 ethrough the hypothalamic pituitary gonadal axis, has
% l& w* P: P) [* [+ F' K, ra higher incidence of organic central nervous system
5 D$ C7 R4 ]# }9 c% R- Z& S) vlesions in boys.1,2 Virilization in boys, as manifested
. i: {% E; H) Q  T" o) J5 @by enlargement of the penis, development of pubic
4 i1 i8 J4 b! ~7 x) _" \1 Mhair, and facial acne without enlargement of testi-: n* F6 V4 P+ m/ _: {5 X  f* ?
cles, suggests peripheral or pseudopuberty.1-3 We! g3 y$ G( ^0 _, N- N; g
report a 16-month-old boy who presented with the
  j# S/ {! a3 denlargement of the phallus and pubic hair develop-, F( t/ ^; n( ^
ment without testicular enlargement, which was due
% E0 @8 j# v. ^. O& z/ Yto the unintentional exposure to androgen gel used by& }1 k. }) A: k6 k: B
the father. The family initially concealed this infor-
/ `) Q& m/ T0 p, J* `) ^mation, resulting in an extensive work-up for this
* E0 H! D$ o# K1 G! {* f% P& X" Ochild. Given the widespread and easy availability of
1 F" U- l& l) M3 h$ `- X% G  s4 Vtestosterone gel and cream, we believe this is proba-4 e/ X* b  E% p  ?! ^& [3 M
bly more common than the rare case report in the
1 m1 m( K9 }' O# ^( q2 ~1 F4 xliterature.45 a# {+ A  |0 e& s( l
Patient Report
& B1 j1 r: S( ^8 o! ~, yA 16-month-old white child was referred to the) {6 `" q. R# w6 W1 E4 _$ h9 c
endocrine clinic by his pediatrician with the concern4 H4 N0 u; N* q3 p+ u/ d1 q
of early sexual development. His mother noticed
. H1 J2 b: e3 V2 flight colored pubic hair development when he was
" L' e$ B8 q4 A$ l; rFrom the 1Division of Pediatric Endocrinology, 2University of8 D8 C8 u1 C- g' ]0 |7 s6 W+ [
South Alabama Medical Center, Mobile, Alabama.. O2 y  \. C- Q* P: `9 g
Address correspondence to: Samar K. Bhowmick, MD, FACE,( L8 S+ |* |- Z) R& K
Professor of Pediatrics, University of South Alabama, College of* W& Y+ P+ {8 x8 o
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% w$ }* S/ [) Ve-mail: [email protected].8 C. A% c8 s/ {. d
about 6 to 7 months old, which progressively became' @/ d: r( d* y) G
darker. She was also concerned about the enlarge-
. t, s/ G2 t7 M( W& zment of his penis and frequent erections. The child6 q" R- G- e! V7 ^; w2 E+ o+ Q; m8 P
was the product of a full-term normal delivery, with
6 \# x- Q+ V# C9 V/ [2 x8 Y( G5 Ya birth weight of 7 lb 14 oz, and birth length of5 x. d1 U3 ^% k+ t
20 inches. He was breast-fed throughout the first year
1 z) C! H; W% g+ K0 R  ?8 E* m. a' _; e% yof life and was still receiving breast milk along with1 T. i9 y' P% T0 |
solid food. He had no hospitalizations or surgery,1 ]' R# j7 Q8 G% m
and his psychosocial and psychomotor development/ L$ z. \% |7 E( f7 }
was age appropriate.
6 L9 D( \5 Z, k, [% [& tThe family history was remarkable for the father,+ ]% p8 m) T8 ^2 z3 d7 v( i6 E, u
who was diagnosed with hypothyroidism at age 16,
1 C3 D( y6 \# M8 l, ?: c( O9 Jwhich was treated with thyroxine. The father’s$ T0 v) H: e7 D# k* P: p/ c: x
height was 6 feet, and he went through a somewhat
: g1 a" O3 U8 r( \, q( [7 x# Bearly puberty and had stopped growing by age 14.
; |0 I, y9 h6 x' a3 s6 KThe father denied taking any other medication. The
% J6 {  n  O  @4 Q- @+ S" Schild’s mother was in good health. Her menarche7 q  ]: p: b4 |: J3 v$ H9 ^. u
was at 11 years of age, and her height was at 5 feet  z  g0 b) q5 I
5 inches. There was no other family history of pre-" [* \1 `+ m5 q  {8 J
cocious sexual development in the first-degree rela-
) _5 i" W: J' X' K3 ]tives. There were no siblings.
8 A; |! b( |1 O" iPhysical Examination
4 A+ B% w  w" r$ {! _The physical examination revealed a very active,6 z+ U+ y& o, G4 Z* U1 t& G
playful, and healthy boy. The vital signs documented
0 b1 @6 n  D. y0 [: ]6 i* Da blood pressure of 85/50 mm Hg, his length was
8 W' C5 P8 [4 q" Z* Q90 cm (>97th percentile), and his weight was 14.4 kg
. t  c. z# B" u: H: e+ h(also >97th percentile). The observed yearly growth! Q  p4 I2 I9 m. v$ B; ]
velocity was 30 cm (12 inches). The examination of! e5 b' J# `0 t! s
the neck revealed no thyroid enlargement." |) q- J9 d3 v( d4 W5 G
The genitourinary examination was remarkable for
8 H, I9 D: o6 Xenlargement of the penis, with a stretched length of
) }3 j5 |7 h" I6 X9 W, j) X! `8 cm and a width of 2 cm. The glans penis was very well
6 p6 z) Z1 }( e, A+ _" c. x, L2 r$ r9 xdeveloped. The pubic hair was Tanner II, mostly around
$ i2 }$ k* b% k& b- }540# q( T1 P$ j  ?8 l+ A# Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) u8 |7 i6 B2 h. H* ithe base of the phallus and was dark and curled. The7 h: L9 k" K% |- D, t6 `4 |3 N" k
testicular volume was prepubertal at 2 mL each.
5 e! F) a' x3 c5 L$ V9 NThe skin was moist and smooth and somewhat4 [/ n& O# w% z8 s1 G4 V( v' G# Y
oily. No axillary hair was noted. There were no$ b3 ?+ n' H0 l5 J! s0 W" S
abnormal skin pigmentations or café-au-lait spots.
( \( _# u; B$ S0 S+ W9 G; fNeurologic evaluation showed deep tendon reflex 2+
$ J8 Y+ N$ @; Ibilateral and symmetrical. There was no suggestion8 r1 Y4 ?" k8 t6 R5 K2 [
of papilledema.
8 K8 k  F7 q! ?: KLaboratory Evaluation
/ H: u2 c0 h, U- zThe bone age was consistent with 28 months by: r4 i+ J& M- x! b8 b
using the standard of Greulich and Pyle at a chrono-
% C' q4 H1 e& l* Glogic age of 16 months (advanced).5 Chromosomal
% d8 i- {0 b& L' skaryotype was 46XY. The thyroid function test! M- @/ r+ i: J6 A' a: o0 I& `! k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" S/ F( p& T/ E. D, Qlating hormone level was 1.3 µIU/mL (both normal).
" h( g( C7 l# D/ [1 R* q+ eThe concentrations of serum electrolytes, blood! I5 g9 r5 |( p4 N
urea nitrogen, creatinine, and calcium all were* ^' ?& A7 _6 a7 Q8 R. S
within normal range for his age. The concentration6 B7 A7 E3 O& r/ R; v6 u% v7 G
of serum 17-hydroxyprogesterone was 16 ng/dL6 p( b6 u8 U3 S# j! S
(normal, 3 to 90 ng/dL), androstenedione was 20
( V$ F; ~: }& r6 v% }% ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( O' B* c) v$ F4 N
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 x& d3 [+ z* ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ ~/ N! Z8 ^4 Q8 I% R9 m; l$ [+ ^6 t49ng/dL), 11-desoxycortisol (specific compound S)7 M8 J! I$ k7 f% {# m
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  j; n5 e/ h) o& p3 @! Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, H+ x( k) p3 j. y. J0 ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL)," ]% m( R  T& j7 y7 M
and β-human chorionic gonadotropin was less than0 \  s) v7 a: ]( |
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" ]4 K% h) k$ F( O! Jstimulating hormone and leuteinizing hormone8 f  T. s, h* \+ w; S
concentrations were less than 0.05 mIU/mL0 P! |3 h% A5 q
(prepubertal).
* ?1 ?% F1 d( k2 S3 EThe parents were notified about the laboratory
7 G& z  \* T- oresults and were informed that all of the tests were: o* m( C3 E& J1 q- u
normal except the testosterone level was high. The
: f' _) n* \2 d( Xfollow-up visit was arranged within a few weeks to9 [9 k$ `. ?" ]6 y5 c
obtain testicular and abdominal sonograms; how-$ w" T& m4 A* N( v' S" D
ever, the family did not return for 4 months.2 f" G$ Q) u* P8 G' u% P  M/ c* V
Physical examination at this time revealed that the4 Z& n& I/ |' ?8 n3 E  U' \
child had grown 2.5 cm in 4 months and had gained, H# K( M6 x7 c; S5 y2 }3 Q+ k) h. u8 w
2 kg of weight. Physical examination remained, |2 }. T" q% e. \
unchanged. Surprisingly, the pubic hair almost com-! m. u8 @9 O7 W3 M# P
pletely disappeared except for a few vellous hairs at5 P5 P$ _! S4 c
the base of the phallus. Testicular volume was still 2- s2 |3 e. K) l6 ?$ ~6 n4 t2 C
mL, and the size of the penis remained unchanged.7 T0 e. h( s: S% H' C) p8 l3 S$ X: b
The mother also said that the boy was no longer hav-# s& B" w" D; F7 i( Z. s- t  r1 o
ing frequent erections.9 Y% G) Q6 [7 q* h0 A
Both parents were again questioned about use of# w4 E: X  x2 q* G. P
any ointment/creams that they may have applied to
; _% y, I2 r. j7 X7 ?& mthe child’s skin. This time the father admitted the
: j1 ?% V8 d- u  G1 b( a$ T" ^8 RTopical Testosterone Exposure / Bhowmick et al 5411 Y; J: Y$ F* x1 a& V5 j& F
use of testosterone gel twice daily that he was apply-4 h2 c1 N, i+ e7 M0 ~9 k- L# D7 i
ing over his own shoulders, chest, and back area for
6 ]* {8 V& i3 u; N5 \a year. The father also revealed he was embarrassed* |5 a" t. [- Y4 M1 P5 _* f* T! y
to disclose that he was using a testosterone gel pre-$ v, c9 V9 S' c0 t1 F5 L3 {: `
scribed by his family physician for decreased libido
2 [' x  F; A/ D2 `" f4 A; F1 ^7 L7 bsecondary to depression.) P: F0 A' I# x# h. k
The child slept in the same bed with parents.
6 o3 U% k% o6 s6 u% _+ mThe father would hug the baby and hold him on his/ j# S) F# M. k5 e7 u* [  g
chest for a considerable period of time, causing sig-; g$ h: }1 z% E( S. b" R
nificant bare skin contact between baby and father.
( u% [9 r6 H  `The father also admitted that after the phone call,
0 T3 d) p6 ^. H5 Y2 U# s$ swhen he learned the testosterone level in the baby
6 s! o  Q9 f! ~2 i5 Z. pwas high, he then read the product information9 k* n- f6 }9 F8 g
packet and concluded that it was most likely the rea-* B* r# ~2 i1 T5 m
son for the child’s virilization. At that time, they5 a, j9 p" B2 f4 F
decided to put the baby in a separate bed, and the, v/ I, G, Y6 n
father was not hugging him with bare skin and had
/ P, A2 N8 M* d' j# R5 A$ x6 d4 S" C- Abeen using protective clothing. A repeat testosterone
% ?, ^1 r: }1 B- }' |test was ordered, but the family did not go to the, w9 v" A& X* R! x% i9 l1 h8 e
laboratory to obtain the test.
+ g6 Y; ^* L! ^8 M4 o* _; D1 j$ fDiscussion
9 ?# a# {8 f; X; m/ O) {- u1 l9 CPrecocious puberty in boys is defined as secondary
) j4 w  @% a8 l8 p7 A! q) csexual development before 9 years of age.1,4
8 _/ g- g: m, |( L+ }Precocious puberty is termed as central (true) when
+ }- P% C) l; I9 d- P" ~it is caused by the premature activation of hypo-
* c2 O% r3 ~; S0 I7 wthalamic pituitary gonadal axis. CPP is more com-+ E2 C. m( C1 W+ m! ?
mon in girls than in boys.1,3 Most boys with CPP8 K" m; }/ p# q# y. X/ O) O
may have a central nervous system lesion that is
7 R- D& n6 E( U& `# Hresponsible for the early activation of the hypothal-
6 B+ r6 M3 X. d/ B' w6 camic pituitary gonadal axis.1-3 Thus, greater empha-
) c3 r$ b2 p+ d( n6 r8 H0 G/ zsis has been given to neuroradiologic imaging in
; G$ }$ w& d) ]! i" b3 Kboys with precocious puberty. In addition to viril-
2 v/ i; {( ?& `3 n' l4 U/ l: Iization, the clinical hallmark of CPP is the symmet-) E$ g- @4 U; O; |
rical testicular growth secondary to stimulation by
: y* A1 q, S( _1 Ggonadotropins.1,3
$ b" ^, ]0 D/ W8 f( CGonadotropin-independent peripheral preco-! c. ~2 R, F4 `& W8 H
cious puberty in boys also results from inappropriate
" d$ R, K! x, i. tandrogenic stimulation from either endogenous or
7 ?, {% b: e8 @- T* dexogenous sources, nonpituitary gonadotropin stim-
6 Q  K- k* W) U" r* E. D. Vulation, and rare activating mutations.3 Virilizing
# o. f1 u8 q* H  z4 j2 pcongenital adrenal hyperplasia producing excessive
& o8 Z5 v4 l: N7 W; d9 l: fadrenal androgens is a common cause of precocious
8 {! S, v2 Y: b: p, Wpuberty in boys.3,4
- Y5 ?! }$ i* I' b+ kThe most common form of congenital adrenal
: r7 I& Z( p. U7 K6 |hyperplasia is the 21-hydroxylase enzyme deficiency.
+ Z" H! @& S: N5 n8 YThe 11-β hydroxylase deficiency may also result in% o5 }, o# `1 q0 }- [' E
excessive adrenal androgen production, and rarely,
' F# z. R9 E6 |an adrenal tumor may also cause adrenal androgen
1 H2 r3 Y2 ?8 ]* d5 ]2 U1 {, W  W1 vexcess.1,3: }0 u6 @: U' x6 `1 w% t. _2 B7 T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- J; s6 E4 Z1 A! {4 w- a0 g
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, X2 t+ l: d% ?" ]. p5 Q8 B+ gA unique entity of male-limited gonadotropin-& P* l9 _9 S- o5 @& @+ z
independent precocious puberty, which is also known' h1 i6 i$ z; C% }( p3 {% d( M
as testotoxicosis, may cause precocious puberty at a
  |3 ]: I9 f/ y6 G4 j2 T! Cvery young age. The physical findings in these boys
: X- p( m  e. ~. s& J2 jwith this disorder are full pubertal development,
% ?0 n) z. W9 M$ v& ~including bilateral testicular growth, similar to boys
2 G0 c' v' _7 qwith CPP. The gonadotropin levels in this disorder
0 D( E( A0 r( h8 ^+ H! aare suppressed to prepubertal levels and do not show
" |8 `* a$ _0 T/ Q0 e  U1 jpubertal response of gonadotropin after gonadotropin-& J: h$ {! R, W) h- Y$ E
releasing hormone stimulation. This is a sex-linked
9 k* t, Q' b( F9 e- w9 E' ]5 n  oautosomal dominant disorder that affects only0 D7 e8 X# K+ @( a5 h
males; therefore, other male members of the family  d0 T) B6 }: @9 q- t
may have similar precocious puberty.3$ z% f& @/ C8 f( d
In our patient, physical examination was incon-
  u. W* G/ J- D6 \sistent with true precocious puberty since his testi-- ]% N$ |" H4 `/ z) Y9 Z
cles were prepubertal in size. However, testotoxicosis8 p, k/ z0 R9 F; }
was in the differential diagnosis because his father! I+ R% s9 d+ m3 q& V8 K% G" o. v
started puberty somewhat early, and occasionally,5 e' q$ z& _0 c& D  p
testicular enlargement is not that evident in the' Z6 k' {! f' {9 R2 k) k
beginning of this process.1 In the absence of a neg-) ?$ W0 ]5 D+ [& W! @
ative initial history of androgen exposure, our
2 p+ x5 ^" a4 G% f& s9 U' Z& e. }& Rbiggest concern was virilizing adrenal hyperplasia,/ D6 M1 e- a/ V3 ]: j; j1 B: i( F
either 21-hydroxylase deficiency or 11-β hydroxylase" A( \* K# E2 ~8 S" A( C& s- l% o
deficiency. Those diagnoses were excluded by find-
& ^1 w$ `4 S  C% Fing the normal level of adrenal steroids./ N1 d: P' N  J0 l7 [7 I, y
The diagnosis of exogenous androgens was strongly5 _1 ^. h4 F5 ]4 J" J( p) ~
suspected in a follow-up visit after 4 months because( J# H9 e+ f& E" p- A$ n  h" K& }$ x( ~
the physical examination revealed the complete disap-9 v" S9 @. I- V/ h9 y& D+ C
pearance of pubic hair, normal growth velocity, and
; N; l. [0 U4 A& w3 S- B9 H# p/ Bdecreased erections. The father admitted using a testos-: C7 P5 h' I) n# ~& g
terone gel, which he concealed at first visit. He was
8 K6 _5 E; j7 t) X/ S0 c" _% _using it rather frequently, twice a day. The Physicians’
7 X% Z2 g) s. b$ a1 Y3 q7 FDesk Reference, or package insert of this product, gel or
6 r) A: S, u8 Y- pcream, cautions about dermal testosterone transfer to
7 y8 Z& ]1 k" w) }6 @, lunprotected females through direct skin exposure.; X9 J4 k1 P/ P# `2 ~2 L
Serum testosterone level was found to be 2 times the
$ f3 [# T0 ~8 v! ^# Y' t9 gbaseline value in those females who were exposed to) ], k) ?3 s0 B% H
even 15 minutes of direct skin contact with their male
9 {5 o7 u8 \  j% m% C5 dpartners.6 However, when a shirt covered the applica-
8 l/ i3 Q7 W: y6 u; S0 C8 I: gtion site, this testosterone transfer was prevented.
: G8 h! ~3 R+ z% _1 P/ u( LOur patient’s testosterone level was 60 ng/mL,
3 Q- L# o7 e7 d% Hwhich was clearly high. Some studies suggest that/ t- q$ Q! U* H
dermal conversion of testosterone to dihydrotestos-
1 d# o9 M) y0 U; aterone, which is a more potent metabolite, is more, R2 o* S& D" {5 i$ Y
active in young children exposed to testosterone6 a8 _8 k; H. b& ~, F% J
exogenously7; however, we did not measure a dihy-  Z; F) U2 K/ f
drotestosterone level in our patient. In addition to
+ k+ [! y9 L. K9 l6 T7 \virilization, exposure to exogenous testosterone in
2 i8 g- `' c; ~) o2 C# Echildren results in an increase in growth velocity and1 R+ G+ Y5 T8 C$ L7 a# H# I: \
advanced bone age, as seen in our patient.
$ z( ]6 {+ t: P) p8 q" OThe long-term effect of androgen exposure during& S5 D. n/ U- R8 f$ @
early childhood on pubertal development and final' G9 J8 a$ e6 O1 @- R% m% ^+ \
adult height are not fully known and always remain
/ {5 D- S  D/ n  t) u* j4 {a concern. Children treated with short-term testos-% U5 V6 [5 |  B4 X; e
terone injection or topical androgen may exhibit some
; @  Z! l) u/ G+ \! @4 a8 ?acceleration of the skeletal maturation; however, after% Q5 A6 h) r: f3 X3 @0 |
cessation of treatment, the rate of bone maturation$ ?3 c5 Q8 O" v! b
decelerates and gradually returns to normal.8,9, e, h" j5 N5 g& r! D! Y
There are conflicting reports and controversy
) l2 I! Y: |& [2 T0 }over the effect of early androgen exposure on adult
2 b- |6 v. l, o! r4 n9 Cpenile length.10,11 Some reports suggest subnormal
+ ~- @6 M; F; Z7 @) g) p9 Y% m& g7 uadult penile length, apparently because of downreg-  L, Z' p* d- U; y0 H
ulation of androgen receptor number.10,12 However,8 P, R$ X) g  f7 f5 P' C
Sutherland et al13 did not find a correlation between) X! c' x6 h, r9 G# C1 a
childhood testosterone exposure and reduced adult: O& g- q# _0 _* R
penile length in clinical studies.7 N' q( j5 y! B! `9 S0 f1 T) p
Nonetheless, we do not believe our patient is
; W' `5 t" b( p# Xgoing to experience any of the untoward effects from
5 c! b* F' J* ptestosterone exposure as mentioned earlier because% Y" g$ ]: {3 n! [$ T% j
the exposure was not for a prolonged period of time.
% [, ?" r9 T# U+ JAlthough the bone age was advanced at the time of' F0 A* W8 ^; m9 o6 T# V
diagnosis, the child had a normal growth velocity at
" e+ a  D5 x7 j& l; K7 L! N  Jthe follow-up visit. It is hoped that his final adult& B, t8 `$ e/ Q, E3 r* @! a* P% Q
height will not be affected.
- I( x" N/ C% u, U- L+ u( V' }' rAlthough rarely reported, the widespread avail-! j8 x! b5 w8 p, X/ `
ability of androgen products in our society may
# Y/ X; ?- h# ~! j* `indeed cause more virilization in male or female
4 Z  y! C9 n! s' a- i& p5 K9 n- uchildren than one would realize. Exposure to andro-
" Q4 w. a& r) R2 Ygen products must be considered and specific ques-
: b/ f; ?+ i+ s/ h6 h- _8 Y- qtioning about the use of a testosterone product or
3 y; y# P! f! X. v0 ^; X/ ~8 C( Fgel should be asked of the family members during5 @0 C) L9 T+ A8 M7 u, a( N
the evaluation of any children who present with vir-$ S% w3 b  H1 z. p. g$ _- e7 A
ilization or peripheral precocious puberty. The diag-
  F7 L- D. u$ qnosis can be established by just a few tests and by2 A( E# G! t6 i) Y. t5 P* s
appropriate history. The inability to obtain such a
, i0 v: T" r. P& ahistory, or failure to ask the specific questions, may8 ]5 X" h( _( n( l8 }. c
result in extensive, unnecessary, and expensive8 n3 A' x* @+ k" X
investigation. The primary care physician should be
# }! H" e1 w) S$ eaware of this fact, because most of these children0 t7 p* S& k' p  V
may initially present in their practice. The Physicians’
0 S$ h; P. t+ f3 T" K4 wDesk Reference and package insert should also put a, g" x5 d0 }0 \
warning about the virilizing effect on a male or
5 x$ n9 r+ W! O8 N) [# v* e% ffemale child who might come in contact with some-
/ Q3 f: w' t& g; I3 z# S7 Mone using any of these products.! F. R7 u' S4 M, v" R/ @
References
9 j6 J! }. [& Y/ j5 J2 t: E  x1. Styne DM. The testes: disorder of sexual differentiation
  y3 f2 t- K. a3 ?: Uand puberty in the male. In: Sperling MA, ed. Pediatric) a; Q# G% z0 m1 x' C2 }) s2 H
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ I4 b" q. o( z. Y
2002: 565-628./ j* K+ a/ v* C, b2 o6 J
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( N/ H. P$ R# V9 `puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
8 t3 ]$ \; A4 Y1 S- {: `
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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