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Sexual Precocity in a 16-Month-Old4 t+ z( L. h1 \- A; d* B
Boy Induced by Indirect Topical) _# G1 s3 g* h
Exposure to Testosterone8 a. I( F2 s5 e7 V- h. H: z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 E! r* f! F# w
and Kenneth R. Rettig, MD1: `, O5 G! a9 Q5 H* f
Clinical Pediatrics
; B3 V# @; z7 l% p' w# Y+ iVolume 46 Number 6
0 E( S1 w7 M- ?5 a% JJuly 2007 540-5435 R' }" Z2 y! k( x7 v% ]
© 2007 Sage Publications  G) d2 w3 e4 b
10.1177/0009922806296651
9 l. ^/ p8 z4 \5 Q* G) Lhttp://clp.sagepub.com
) K& n$ ~8 `+ G! W5 dhosted at
- k6 y; G) l, {0 ^6 Mhttp://online.sagepub.com
- O* W5 N# f  D. D! j) zPrecocious puberty in boys, central or peripheral,
5 [4 c5 T' k# Iis a significant concern for physicians. Central
1 U* i( [0 d& q9 H$ E  k" fprecocious puberty (CPP), which is mediated
' ~: i4 o. R9 A+ L3 |. kthrough the hypothalamic pituitary gonadal axis, has" l, B2 [- J! F7 |3 K' F- ?% @4 i
a higher incidence of organic central nervous system/ a/ e9 [: B6 Y; v5 B
lesions in boys.1,2 Virilization in boys, as manifested
3 b3 q6 E2 R& [3 Q. M3 j4 n( Z$ Cby enlargement of the penis, development of pubic6 i1 S- [7 o# F, _; X
hair, and facial acne without enlargement of testi-1 _% R. l1 z7 q
cles, suggests peripheral or pseudopuberty.1-3 We8 Y# B% n  p6 H5 ]
report a 16-month-old boy who presented with the2 O2 l" L9 P: n; ^
enlargement of the phallus and pubic hair develop-* [; N* N; l1 ^6 o
ment without testicular enlargement, which was due
: J' u7 B( _$ I' W$ d2 {# {) ]to the unintentional exposure to androgen gel used by/ v% q0 }# H- e4 s' ^9 ]" q
the father. The family initially concealed this infor-
* E0 T  {( U+ E/ I, |; o+ m' {mation, resulting in an extensive work-up for this  _* H/ R) U) r. \0 f( T& M
child. Given the widespread and easy availability of
; Y! p, l3 ~& Wtestosterone gel and cream, we believe this is proba-
- ?+ }! g7 Z4 n/ Q) x, t  i; Jbly more common than the rare case report in the
3 S# a7 X6 d; r6 Hliterature.41 R% U; ]; {5 P) W* O/ _
Patient Report! Z2 x; f+ j# R% z' ]
A 16-month-old white child was referred to the  V  j+ Z* y" q1 c) c  J
endocrine clinic by his pediatrician with the concern$ {% R- G" I0 Y% {
of early sexual development. His mother noticed* R! S. X" h( J2 I5 C' X( \, o
light colored pubic hair development when he was
$ O' L' A. Z* i# g) [4 J" U3 m! kFrom the 1Division of Pediatric Endocrinology, 2University of
+ p6 L$ v; i5 V2 S. ASouth Alabama Medical Center, Mobile, Alabama.
: t2 }+ V1 O6 e8 {0 NAddress correspondence to: Samar K. Bhowmick, MD, FACE,/ q9 e3 [: \2 M2 c
Professor of Pediatrics, University of South Alabama, College of
! H! o  Z; z; F5 \! T6 f5 eMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: g6 Z7 }9 c5 u9 ]) _: _2 \& Oe-mail: [email protected].$ d5 M- O3 T! }6 a
about 6 to 7 months old, which progressively became2 f) F6 s$ ?- @9 C7 X+ a2 A2 }( m
darker. She was also concerned about the enlarge-
4 i9 H: m" L" X# v& {, H: O0 B/ T" i0 V  ~ment of his penis and frequent erections. The child. o- p+ I" W+ [# ?) i. Y  w7 {
was the product of a full-term normal delivery, with
& ]8 B6 ]/ `5 i/ o5 l# n- `) Ea birth weight of 7 lb 14 oz, and birth length of
4 T8 k: w( v" u( R. \: u20 inches. He was breast-fed throughout the first year
  Y: F$ U1 B% _1 ~of life and was still receiving breast milk along with
* _& e$ }6 W, y' e6 ~; Msolid food. He had no hospitalizations or surgery,, x. N: f  x& {- r8 w0 F/ b$ ~
and his psychosocial and psychomotor development: D' A+ M6 x+ B
was age appropriate.( o( Z( L( u$ w+ U6 _7 o: I
The family history was remarkable for the father,
" K1 Y0 m, ?! C3 K6 E1 h. k' k: rwho was diagnosed with hypothyroidism at age 16,, [. O: ~) b( F  I1 t
which was treated with thyroxine. The father’s
. z" |* U# U, @/ ]" e  C* _8 Pheight was 6 feet, and he went through a somewhat
) C7 n2 O" g4 t& E; Nearly puberty and had stopped growing by age 14.
: T1 K/ O/ O6 b+ uThe father denied taking any other medication. The
/ i( w- V7 e* b/ Z2 S/ Achild’s mother was in good health. Her menarche
$ f/ o6 U5 S! J* G! s1 k+ [" _was at 11 years of age, and her height was at 5 feet/ o6 K. r% X7 G5 k) G/ l5 ]/ b
5 inches. There was no other family history of pre-
- b# e+ [2 ]8 C5 icocious sexual development in the first-degree rela-$ F; H6 H6 J7 S
tives. There were no siblings.9 H- B2 c2 q8 l, b
Physical Examination1 F" k% a( Y; P! X
The physical examination revealed a very active,
) N3 E, B) y' M! B8 \7 Vplayful, and healthy boy. The vital signs documented0 O; T0 w2 [7 D% Q, B& ]
a blood pressure of 85/50 mm Hg, his length was
6 O& n6 l8 _& S/ f90 cm (>97th percentile), and his weight was 14.4 kg1 K3 W) O: A3 x
(also >97th percentile). The observed yearly growth& D: P7 Y( m8 A" |. N. _# j
velocity was 30 cm (12 inches). The examination of# a1 ]! K9 j' D  R( O* c  w) W
the neck revealed no thyroid enlargement.5 |/ M" b- \8 J( Z9 E
The genitourinary examination was remarkable for& n# u- P6 u- @3 i2 B6 O$ a- z5 y
enlargement of the penis, with a stretched length of: H. u% N0 |/ t
8 cm and a width of 2 cm. The glans penis was very well
% W: V4 c5 B3 wdeveloped. The pubic hair was Tanner II, mostly around0 U  q1 x" O4 g/ O( g
540: M0 D2 W' L; M7 E6 v3 j  N; E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 R4 h, \  m4 S1 x" Z& }
the base of the phallus and was dark and curled. The' j; z  s) x+ a1 {" V
testicular volume was prepubertal at 2 mL each.5 ^6 m; U4 B' @& l0 H- e3 f
The skin was moist and smooth and somewhat
0 i! G8 y. E' |% C, G' \  E1 soily. No axillary hair was noted. There were no: ~& S! e3 p# j
abnormal skin pigmentations or café-au-lait spots.. D* j2 y: I: |- r
Neurologic evaluation showed deep tendon reflex 2+
6 J: u8 C5 z) Hbilateral and symmetrical. There was no suggestion  W0 |& {" @" P9 V" d
of papilledema.
- y! X5 N# U* j$ wLaboratory Evaluation
& Y3 x6 W( y9 L/ K) mThe bone age was consistent with 28 months by
4 I/ l; |8 L0 y. m% l4 p+ E1 jusing the standard of Greulich and Pyle at a chrono-% m4 w. I- a, k& [: b9 g
logic age of 16 months (advanced).5 Chromosomal
, _4 {% o# l& }7 L( b9 Pkaryotype was 46XY. The thyroid function test
2 R0 F+ e; {7 d- h) Rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-. y' {& |# u+ q& o* u7 y
lating hormone level was 1.3 µIU/mL (both normal).
0 C' z( C5 n8 @8 CThe concentrations of serum electrolytes, blood
1 W: i: W# g4 durea nitrogen, creatinine, and calcium all were. z2 K  H& b( W! d
within normal range for his age. The concentration
3 h' Q* ~& X1 a! U# g7 bof serum 17-hydroxyprogesterone was 16 ng/dL& x/ x2 A9 X$ B7 j/ n3 J! z+ o
(normal, 3 to 90 ng/dL), androstenedione was 20
5 p* J! d* b  Y) g4 V8 K# x, {$ nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' \) v+ L' Y( h0 J3 h" Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 U5 ?7 l, {! \5 W, X" q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 c6 p1 Q7 [. n9 n1 S6 y49ng/dL), 11-desoxycortisol (specific compound S)# W. d, {9 M$ F- C1 T
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 D1 V$ t; \# L1 f8 l
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, a7 ~7 }' X9 }3 \testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 G, w; h" D2 R1 y& D8 Z6 _* ]
and β-human chorionic gonadotropin was less than
( ?8 i2 R- G$ K' c! l! K. p5 mIU/mL (normal <5 mIU/mL). Serum follicular
# ^0 A( t& M( C. e  V5 M$ V7 L5 bstimulating hormone and leuteinizing hormone
" d0 c8 g6 I" m) xconcentrations were less than 0.05 mIU/mL- I% Q9 E3 ?% H: K; M
(prepubertal).
+ L, M% W& D  V' D) u6 M1 BThe parents were notified about the laboratory% h3 M! u! ~* f; O+ E+ H& g/ X6 C
results and were informed that all of the tests were) J5 D8 C* w( _* ^) {0 Y  G
normal except the testosterone level was high. The3 W  }* V- \! p$ K9 Q
follow-up visit was arranged within a few weeks to, G5 `! c4 O7 c) S
obtain testicular and abdominal sonograms; how-4 A+ e! q% i! }/ R4 ^1 j0 j
ever, the family did not return for 4 months.0 F9 n) H$ y( l5 U7 S
Physical examination at this time revealed that the1 @0 L4 n  p3 J! t5 F% ^8 H
child had grown 2.5 cm in 4 months and had gained: W0 ?. l) g5 \$ [0 |6 c, i8 M
2 kg of weight. Physical examination remained
) I8 I8 u- X1 g$ R9 X# ]6 i5 @unchanged. Surprisingly, the pubic hair almost com-
* ^! {3 ^5 t3 opletely disappeared except for a few vellous hairs at
* _1 U  ~* u  w# O8 N, _+ @$ U9 Bthe base of the phallus. Testicular volume was still 2
; j( m8 Q! |& ]mL, and the size of the penis remained unchanged.. [0 Z5 m7 ?+ P+ X
The mother also said that the boy was no longer hav-
6 s  |' S5 d3 u( `2 {ing frequent erections.( _, t8 \3 w; R7 h5 X
Both parents were again questioned about use of
% d4 X, K2 |: t3 P' k( H4 Uany ointment/creams that they may have applied to; C* @& g4 t( ~
the child’s skin. This time the father admitted the
4 u  z9 k( ~4 z4 }2 O) sTopical Testosterone Exposure / Bhowmick et al 541
0 e. g3 U+ _& B; t+ g, ouse of testosterone gel twice daily that he was apply-
! e: e) W6 A* R* F+ w* O5 fing over his own shoulders, chest, and back area for3 c: d; Q0 U% o
a year. The father also revealed he was embarrassed6 }4 [5 I* v9 }; r& R: l" T7 }
to disclose that he was using a testosterone gel pre-) P! j4 `* k! b3 S$ x  D" X5 G' K+ R+ J
scribed by his family physician for decreased libido3 ]3 V$ h& d- o1 Y! m" H
secondary to depression.% f- f- U; n* {7 J! ^9 Z/ S% G. F
The child slept in the same bed with parents.* R3 n- u' _  u2 ]2 H4 |
The father would hug the baby and hold him on his# M+ s6 ~: a% E& f6 M
chest for a considerable period of time, causing sig-
0 x6 @7 o! t; Z" n- e% Qnificant bare skin contact between baby and father." e3 x0 R2 p6 O  Z9 `
The father also admitted that after the phone call,5 N; d" C" A% r% N6 P
when he learned the testosterone level in the baby% K, \0 G5 T: k5 I' d( ]
was high, he then read the product information/ O- S# ^$ i4 q; V( C9 a4 q
packet and concluded that it was most likely the rea-$ I. _' m' m' m! O& _$ {
son for the child’s virilization. At that time, they6 l: e! b( A- ^, H3 k
decided to put the baby in a separate bed, and the
% D% p, |. b1 H$ t$ J7 ^father was not hugging him with bare skin and had
& i- ]7 C  v6 I8 ]been using protective clothing. A repeat testosterone
3 g* E1 A3 W# N( ]3 D" d4 n3 otest was ordered, but the family did not go to the
. e- k- O( `+ ]( ^$ Ulaboratory to obtain the test.
; {5 k: y8 S4 _7 b0 t) R5 T: O" |Discussion2 d4 a2 K( O4 C/ Q2 n. z( \6 x2 }
Precocious puberty in boys is defined as secondary
# Q1 u+ h4 P: r0 t! o8 y6 o7 K' }sexual development before 9 years of age.1,4
% i7 `3 s4 M  A0 a3 U$ v7 X1 uPrecocious puberty is termed as central (true) when/ e' x$ a" g! a+ P. b* D" F
it is caused by the premature activation of hypo-. t! r6 [; x/ @" T; Y
thalamic pituitary gonadal axis. CPP is more com-
$ t* `/ b. J3 g% z3 r. Qmon in girls than in boys.1,3 Most boys with CPP
9 D2 y7 W+ }% |+ D  ?. V' k0 p6 Gmay have a central nervous system lesion that is
4 i  d& ^8 c# e7 f% _/ E) e$ s+ I6 Fresponsible for the early activation of the hypothal-
& l6 ?% h7 N! Z2 ^; samic pituitary gonadal axis.1-3 Thus, greater empha-/ ?$ L& ]5 C# y  M5 ~' h8 S
sis has been given to neuroradiologic imaging in1 f" P$ H  K/ B
boys with precocious puberty. In addition to viril-$ Z! T8 a. z0 v/ d, Y& n8 y
ization, the clinical hallmark of CPP is the symmet-
  t4 }. M4 M' |( p% nrical testicular growth secondary to stimulation by0 H; A. V. i3 v  Y$ x+ R% S
gonadotropins.1,3
. W6 }; V: J7 _# g+ N% P, i; U/ TGonadotropin-independent peripheral preco-
% A7 i7 `4 _  e# B- C2 ncious puberty in boys also results from inappropriate
( e4 I( F; ]0 H3 [: W. Oandrogenic stimulation from either endogenous or+ H" T4 e. S  X/ N' v, T: n4 y( \: _0 Y
exogenous sources, nonpituitary gonadotropin stim-
$ T- l" I" `7 \ulation, and rare activating mutations.3 Virilizing8 c) n, R  Y* `, M/ ?. p
congenital adrenal hyperplasia producing excessive/ c% y5 O% V8 U' t8 _" X
adrenal androgens is a common cause of precocious
% w8 W7 G" I- t) o2 ^, r+ \puberty in boys.3,44 \% V; ?, r4 w3 D: k! z8 _
The most common form of congenital adrenal
% Z# M; T3 M" Q; ?hyperplasia is the 21-hydroxylase enzyme deficiency.
' k; I+ H. G6 ~: ?4 X& cThe 11-β hydroxylase deficiency may also result in
9 J- }6 A; `' N! y+ g5 bexcessive adrenal androgen production, and rarely,) ?) x/ R2 `: Z% r- t
an adrenal tumor may also cause adrenal androgen
" o6 r+ T3 z% K2 Q  Z, [4 f* P' s3 |2 D6 \excess.1,3  u* l, ]0 b6 S* C! q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! I, D3 D" W$ y+ p
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, f# w2 h+ C+ t* r9 Q3 J9 L
A unique entity of male-limited gonadotropin-
" K1 g' o, M$ y" |( ~5 \independent precocious puberty, which is also known
% I2 f: r, p/ n: Mas testotoxicosis, may cause precocious puberty at a6 Q4 S. Y, d: t( V: |
very young age. The physical findings in these boys
+ Z$ z( ?% B. X9 P4 \with this disorder are full pubertal development,( a- |0 x, L& k6 X
including bilateral testicular growth, similar to boys
5 _) ~' @% t4 }& l( Ewith CPP. The gonadotropin levels in this disorder: }" C  H$ b* [5 v0 L
are suppressed to prepubertal levels and do not show$ M: x, q' O/ W% u0 c
pubertal response of gonadotropin after gonadotropin-. g' U" ?/ C1 h/ Z
releasing hormone stimulation. This is a sex-linked6 r* V3 x1 L' Y1 ~% y
autosomal dominant disorder that affects only
4 J# l0 y8 i# _% i+ [males; therefore, other male members of the family0 n: ?5 G6 B  V: z3 `
may have similar precocious puberty.3
. C* N$ y( O, h- w2 Z3 G9 `; qIn our patient, physical examination was incon-+ p; r7 L. b6 W" U0 X7 `
sistent with true precocious puberty since his testi-$ c5 Q# _2 M: |6 B# X$ H
cles were prepubertal in size. However, testotoxicosis
% {; N- R! d7 i( A. B" g& Iwas in the differential diagnosis because his father8 h; |3 y9 L+ I+ u- K3 P7 x) R
started puberty somewhat early, and occasionally,
, ], e0 R: y9 j) o6 K6 V/ K) X, Ftesticular enlargement is not that evident in the
4 g  U- j' K7 _: m5 _; \+ Vbeginning of this process.1 In the absence of a neg-
5 D8 z. }" r* w" e. U# kative initial history of androgen exposure, our
# \- ^5 K' N# d& c8 bbiggest concern was virilizing adrenal hyperplasia,. y/ g& [, j' H' C/ a9 _4 U
either 21-hydroxylase deficiency or 11-β hydroxylase
. h6 n- j% g4 P' n2 J& ^deficiency. Those diagnoses were excluded by find-9 b, h9 A5 H" U, s% W8 E9 y* o
ing the normal level of adrenal steroids.# @" I/ R) y1 b1 q) e1 `
The diagnosis of exogenous androgens was strongly8 X& G2 X, ]1 @4 s- B
suspected in a follow-up visit after 4 months because$ V8 {$ G; U; H9 C
the physical examination revealed the complete disap-5 S- E7 @# J* }: L0 q% q
pearance of pubic hair, normal growth velocity, and8 w; |( N) X2 i: y& B
decreased erections. The father admitted using a testos-
! {5 N$ y7 u: E5 h2 ?+ qterone gel, which he concealed at first visit. He was& A. ]% P5 ?5 t! s1 w4 Y
using it rather frequently, twice a day. The Physicians’
7 Z2 H3 C. M+ NDesk Reference, or package insert of this product, gel or( a' s' v/ V( z' s& G
cream, cautions about dermal testosterone transfer to
. s' d+ D# l: o. H7 J2 Q5 n- Q. Uunprotected females through direct skin exposure.) W9 N, F; f: S
Serum testosterone level was found to be 2 times the  a: a8 k7 k( K+ u
baseline value in those females who were exposed to
7 j) {+ R6 p% Q/ Keven 15 minutes of direct skin contact with their male0 w; ?/ Z- [2 K7 v) W5 P( m
partners.6 However, when a shirt covered the applica-: o4 ]' d( R9 v
tion site, this testosterone transfer was prevented.3 j4 n4 ^) w$ e/ ^6 W. P+ S9 `
Our patient’s testosterone level was 60 ng/mL,# A7 i: m. _! B& _
which was clearly high. Some studies suggest that
5 S. B/ _. A$ |* ]$ fdermal conversion of testosterone to dihydrotestos-
1 p# p% d6 ^) `4 N- fterone, which is a more potent metabolite, is more+ B" |: _6 p# J0 `4 V
active in young children exposed to testosterone' \! M# u% {2 r6 s
exogenously7; however, we did not measure a dihy-- R) `# D; `; i2 y# O
drotestosterone level in our patient. In addition to! x8 N1 L! k$ F/ w
virilization, exposure to exogenous testosterone in- m8 a4 F) X8 Z7 a! }& o8 T) w- b
children results in an increase in growth velocity and
* F- @. r9 r! V3 L1 E- b. F: k7 jadvanced bone age, as seen in our patient.
0 }6 Z/ ^0 q8 p; r( g6 \The long-term effect of androgen exposure during3 g5 ^; e, c9 q4 e5 x
early childhood on pubertal development and final
' `2 y4 M0 a" ]- I' m) V  Eadult height are not fully known and always remain5 u/ J, T+ g) p8 V
a concern. Children treated with short-term testos-$ C' M' g" L7 Y: \- C& q+ N7 n: W
terone injection or topical androgen may exhibit some
% |5 G+ I# i7 J1 \, K% `# ?5 Oacceleration of the skeletal maturation; however, after# V: h. D1 J- y
cessation of treatment, the rate of bone maturation
! J+ o, M6 K7 N1 qdecelerates and gradually returns to normal.8,9; E+ M9 G9 X% ~( r5 a: D9 H
There are conflicting reports and controversy
! G# q9 j0 U! z9 o2 Vover the effect of early androgen exposure on adult4 f: i; C& X1 y7 Y' s9 i7 {) s- w
penile length.10,11 Some reports suggest subnormal( I+ G; @- Q! d( z# R3 C
adult penile length, apparently because of downreg-
9 n4 N% S" Z0 o" c" Rulation of androgen receptor number.10,12 However,5 Y9 `" c. q) e% o7 o$ q( ]
Sutherland et al13 did not find a correlation between
1 v. n8 ]4 R7 T$ U. echildhood testosterone exposure and reduced adult
. N* ~; n: D4 j6 O4 X2 u& ]2 Vpenile length in clinical studies.
3 r8 r- S/ ~+ p0 ]' q! p; x$ ?& l0 b5 WNonetheless, we do not believe our patient is: W: i$ c+ R# q6 U% f
going to experience any of the untoward effects from2 \8 v4 L* d+ I1 W
testosterone exposure as mentioned earlier because
0 D) u' U6 w4 y+ Tthe exposure was not for a prolonged period of time.+ Q7 H% K( I# J/ R4 ^( h
Although the bone age was advanced at the time of
' }8 d. ?, J" v  u- r) p% ~/ ?diagnosis, the child had a normal growth velocity at+ M$ S  U9 _! `* O- l
the follow-up visit. It is hoped that his final adult, k' N1 z- L; B9 q( a- C. A: ]
height will not be affected.
" T# _) ?0 f! |6 o1 J$ c4 tAlthough rarely reported, the widespread avail-
5 t1 v0 W* w7 N0 }; K7 @0 w( lability of androgen products in our society may+ B* c4 y1 W, z" Z
indeed cause more virilization in male or female2 h3 C! \) a6 |% v8 G
children than one would realize. Exposure to andro-
4 i0 U& `$ R5 T7 D2 Y$ j" ]gen products must be considered and specific ques-
, d6 [# e  r6 M# D# ^tioning about the use of a testosterone product or" E# H3 d# R) O. r5 f
gel should be asked of the family members during
' `; i- X% c* J$ t& M: V/ dthe evaluation of any children who present with vir-% L6 Z, y! C/ s) f: R8 y- u' r3 ]- F
ilization or peripheral precocious puberty. The diag-
- _/ e) }) K6 Q0 ]& A% Dnosis can be established by just a few tests and by
, E+ V" C8 q/ H% Q- W) Nappropriate history. The inability to obtain such a
: b4 T) h, ~0 z2 e  r* S1 c0 ahistory, or failure to ask the specific questions, may1 `& c4 A& U0 {- U2 i& l- y( s0 [
result in extensive, unnecessary, and expensive
" @+ u0 W7 q: s9 jinvestigation. The primary care physician should be) ^& J& w" x1 ^9 B" N8 i4 K
aware of this fact, because most of these children
+ Y! R! B  C5 `& Hmay initially present in their practice. The Physicians’. c% m: k$ F, E
Desk Reference and package insert should also put a
' Z# l9 I+ Z0 V& w2 s. `warning about the virilizing effect on a male or  b! U4 j1 K% D  Y- W- h
female child who might come in contact with some-+ J  `+ c/ q# V! \& ]' j; I+ y, \
one using any of these products.* L, {9 _# {+ E( }1 p. [# h
References. C7 Z8 i" P5 f2 u: D/ [3 z% }0 ?
1. Styne DM. The testes: disorder of sexual differentiation
% d7 A) O4 x' Aand puberty in the male. In: Sperling MA, ed. Pediatric
8 @5 k# N" Z. u5 @( e3 KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) I/ G  ~$ g  G  H6 U' V8 s: `* E$ T
2002: 565-628.# a: I! P! m8 d5 i1 u. }2 h
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ `0 z7 j- c  Spuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 f# C8 z8 g% Y" X+ z; WBoy Induced by Indirect Topical" }, ]% H0 l) x: |
Exposure to Testosterone
1 D5 z6 P5 g' }( DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 ~) u9 d# r% U1 Hand Kenneth R. Rettig, MD12 b  l2 q, `8 D+ Q* }) b1 ]7 L- p
Clinical Pediatrics0 v" U* F) R, G7 ~$ q
Volume 46 Number 6
5 Y* Z4 P" ~' k' BJuly 2007 540-543; u# {) ?& P8 m! d
© 2007 Sage Publications4 c# c9 M7 C8 v
10.1177/0009922806296651
* f  X  w/ @7 L. _6 whttp://clp.sagepub.com
% y! o7 e1 B/ ~; o% |hosted at
# r& j; Z$ B  b% x0 _3 u: v4 l" Shttp://online.sagepub.com
# h( i  Q- R& Y% l: X& c4 f$ nPrecocious puberty in boys, central or peripheral,3 |1 q. k1 N" u4 y
is a significant concern for physicians. Central+ d8 w) }, d( ?6 _2 s; k
precocious puberty (CPP), which is mediated, }( n! g, ^) U  l7 G! c
through the hypothalamic pituitary gonadal axis, has
$ ?$ o! t/ c6 Y4 {a higher incidence of organic central nervous system
/ l+ p1 ~! F6 Hlesions in boys.1,2 Virilization in boys, as manifested
7 X5 |* f* h2 a! Eby enlargement of the penis, development of pubic
6 M; w8 B: ~* `, ?' }2 Bhair, and facial acne without enlargement of testi-# v4 g7 b" y7 Q! z# M
cles, suggests peripheral or pseudopuberty.1-3 We' T. K9 r! ^& M; J: v* r- c9 l
report a 16-month-old boy who presented with the& v# b* c/ o8 V. t, t
enlargement of the phallus and pubic hair develop-' G3 o2 E6 \1 {9 [9 N  c* y
ment without testicular enlargement, which was due
% ^$ S, ?% i- @, ?; ?4 Fto the unintentional exposure to androgen gel used by
# o: c2 E: V! e# V, Ythe father. The family initially concealed this infor-
2 A8 w8 k$ `' v( M( v2 `mation, resulting in an extensive work-up for this
' h+ Y( p  Z! M7 tchild. Given the widespread and easy availability of  f% q5 H$ z3 [: A; L$ H4 }( i
testosterone gel and cream, we believe this is proba-
6 v& C* P% M% hbly more common than the rare case report in the
* D/ [, A1 c4 O, Z0 ^0 iliterature.4" _* M$ z- r3 R
Patient Report
; h; ]' C& f7 OA 16-month-old white child was referred to the
! w, p% j# G1 zendocrine clinic by his pediatrician with the concern
# I4 o5 u! L/ u" zof early sexual development. His mother noticed
# H$ V3 o0 j% Q  m( P0 I  \4 ]light colored pubic hair development when he was
8 I7 j3 |0 E) g# Q) jFrom the 1Division of Pediatric Endocrinology, 2University of
/ j) C$ b: `  V( Z9 p+ Z) n+ J$ cSouth Alabama Medical Center, Mobile, Alabama." h, U* q) c9 A0 {" t
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! E2 o" C* C" }4 [Professor of Pediatrics, University of South Alabama, College of
& t+ E8 S7 g  N9 E( FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, A! b! u3 l6 E4 we-mail: [email protected].
8 e1 U. s! u1 `- o! Q1 Babout 6 to 7 months old, which progressively became
5 ~: i5 [, o0 s3 F, d. K0 k$ I" Gdarker. She was also concerned about the enlarge-4 W* m1 [5 z% @& ?7 W& M
ment of his penis and frequent erections. The child% M# T6 r6 [5 e% [" t3 t
was the product of a full-term normal delivery, with$ X6 n, C' [, o3 y
a birth weight of 7 lb 14 oz, and birth length of2 n- y$ E: K; t# O$ T3 L2 f
20 inches. He was breast-fed throughout the first year
3 |/ R: ]1 A5 f# G# V; Cof life and was still receiving breast milk along with
  Y0 P/ o4 ~) O3 f8 Vsolid food. He had no hospitalizations or surgery,
/ A0 c! m0 k9 T1 @. Land his psychosocial and psychomotor development5 z7 v. E0 ~/ b% y# i: u- f. Q
was age appropriate.% `6 X: ]+ k) s* N& V
The family history was remarkable for the father,
& k1 X5 c' K: hwho was diagnosed with hypothyroidism at age 16,$ r1 |/ K' ^, M
which was treated with thyroxine. The father’s' Y2 m0 q$ }0 k) t8 u
height was 6 feet, and he went through a somewhat9 N: V/ H  E' v5 a4 T
early puberty and had stopped growing by age 14./ @$ u' _. @/ v
The father denied taking any other medication. The# ]4 V' e5 T! u- `, u
child’s mother was in good health. Her menarche9 L6 g  N. h' J4 X$ }+ Y' w
was at 11 years of age, and her height was at 5 feet
5 k: I" E. b8 J$ P2 J" {5 inches. There was no other family history of pre-8 b/ e$ V5 R' x, Z
cocious sexual development in the first-degree rela-
+ [' _: t( V- \# f5 C, X# Mtives. There were no siblings.. c$ L2 z3 B9 w7 G: z1 E+ f+ x
Physical Examination
; o) b8 ?3 ^2 U2 i! AThe physical examination revealed a very active,9 k7 A8 T) t. L" r- }! s
playful, and healthy boy. The vital signs documented* Y  y0 k  H  F0 z5 a
a blood pressure of 85/50 mm Hg, his length was2 H# h2 V2 r. h) B8 R9 k- K. p
90 cm (>97th percentile), and his weight was 14.4 kg) k7 P5 L0 J8 H6 A4 _/ s9 H' e
(also >97th percentile). The observed yearly growth/ t- b* e* a  z! m3 P4 n8 X
velocity was 30 cm (12 inches). The examination of% X6 D% {" G* m7 \: |. `
the neck revealed no thyroid enlargement.' _+ h4 Z; |, w9 P0 ~
The genitourinary examination was remarkable for
7 Q$ r6 X: i# H3 M0 e3 Menlargement of the penis, with a stretched length of+ w$ J: }- {, F  L9 }
8 cm and a width of 2 cm. The glans penis was very well
3 I- E) a' B- |8 `: \# Fdeveloped. The pubic hair was Tanner II, mostly around
/ [# `! e2 s9 ]; i# {. t- U540
8 N9 C, O8 Y, e. [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( U3 i8 }2 X, t$ d
the base of the phallus and was dark and curled. The
4 j" P% T* N" N4 ~testicular volume was prepubertal at 2 mL each.* m, T0 B; l; F# n" ?9 |3 E
The skin was moist and smooth and somewhat
& y) F: r# _, @. {  _( xoily. No axillary hair was noted. There were no% C5 @4 s3 P6 L  X: z
abnormal skin pigmentations or café-au-lait spots.5 T) ^5 b# {* ?# T: k5 ~
Neurologic evaluation showed deep tendon reflex 2+3 T& n. G4 {+ S( n! \$ @2 I* x
bilateral and symmetrical. There was no suggestion
  ]5 q4 H) P" [. w( k8 Bof papilledema.
0 U+ s8 J: [2 ]6 xLaboratory Evaluation
7 R/ u4 F$ {2 e3 S' D9 S8 BThe bone age was consistent with 28 months by) ?& {1 W6 \, I2 }
using the standard of Greulich and Pyle at a chrono-9 w9 j7 W; a" L: r
logic age of 16 months (advanced).5 Chromosomal1 g+ N+ F2 r' l+ p( w( l. K' }- T
karyotype was 46XY. The thyroid function test
8 U7 [9 a6 X4 X" X' T- e' Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 ]$ ]* l. ?, V& g. B" A  q
lating hormone level was 1.3 µIU/mL (both normal).7 v' }4 @4 O+ d- y$ W: i+ R
The concentrations of serum electrolytes, blood( B/ m) ^  T5 t- J. b
urea nitrogen, creatinine, and calcium all were9 U4 F& d/ i' ~& u. j
within normal range for his age. The concentration
, ]+ }! |3 r" c" fof serum 17-hydroxyprogesterone was 16 ng/dL& g7 K( x7 h4 X" \# b
(normal, 3 to 90 ng/dL), androstenedione was 20
; Q2 b9 v" ], x( \; J9 P$ F) Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" ?" k: S3 L% T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 p$ _# A/ A* i3 w) c9 [% E7 @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ Y! b  e' u' f1 [49ng/dL), 11-desoxycortisol (specific compound S)4 b& C0 I7 z# u& H
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& V: q: o$ T' q* `/ q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 N, h( V$ u* O3 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% B& ~& b; X7 B- {1 @7 S/ yand β-human chorionic gonadotropin was less than9 }- S5 @' n1 N, _% I9 Q' b/ V
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: @) |( x# C4 R) {stimulating hormone and leuteinizing hormone) x$ y8 @: h8 Y! \8 y4 u0 h
concentrations were less than 0.05 mIU/mL$ K9 r% q/ G% @+ {( O
(prepubertal).( r( Q* ]7 J6 q6 m9 B) c& y  x
The parents were notified about the laboratory9 a6 a# }. t0 t
results and were informed that all of the tests were
! i! ~+ C7 d% u4 ?3 F3 P8 znormal except the testosterone level was high. The+ K/ h$ t* E: U$ X
follow-up visit was arranged within a few weeks to
# r& G3 b! _& d5 Y  I  K, hobtain testicular and abdominal sonograms; how-5 j5 |7 G/ \+ e
ever, the family did not return for 4 months.8 k8 [7 W( E$ U# I
Physical examination at this time revealed that the
: o% y) A0 l. G6 ~0 S8 f. I& jchild had grown 2.5 cm in 4 months and had gained
) A- U0 \: r7 b: x+ e2 kg of weight. Physical examination remained+ v" {. e$ [& @6 l* D
unchanged. Surprisingly, the pubic hair almost com-
) Q) V5 m+ |: }- Npletely disappeared except for a few vellous hairs at
9 V8 p8 g3 H. n% Y: K3 Uthe base of the phallus. Testicular volume was still 21 r# F9 [. f/ K( }+ z  ~8 C  I
mL, and the size of the penis remained unchanged.
# a4 y) j, [. o1 h/ cThe mother also said that the boy was no longer hav-: R2 s5 U, R; H0 M) N  B( N
ing frequent erections.; Z# r8 y/ ~  K# R
Both parents were again questioned about use of
+ P! i2 I7 ?; zany ointment/creams that they may have applied to, Z7 n5 E! U% Y1 D9 `/ z. g
the child’s skin. This time the father admitted the
( h5 f5 K5 @  s6 ~& }Topical Testosterone Exposure / Bhowmick et al 541
2 e# t; w4 ]% n$ E0 j3 |use of testosterone gel twice daily that he was apply-
* N& F/ [: ]6 ^$ S" U& [' g/ zing over his own shoulders, chest, and back area for; d) ]; W4 K% f# ?* a9 \! q5 u5 r9 P0 Q
a year. The father also revealed he was embarrassed
# G; d+ O0 R/ `  u; v% K/ M9 pto disclose that he was using a testosterone gel pre-, w: m" d# b3 Z2 _9 L$ G% }" c* H
scribed by his family physician for decreased libido* m/ l) t& x' a+ S
secondary to depression.
; s# i8 ]- ^4 }; DThe child slept in the same bed with parents.; n9 p; j* u. T+ D6 D
The father would hug the baby and hold him on his! z, ^9 U) S- j' M* J! r
chest for a considerable period of time, causing sig-% s. b3 n, H& y8 h- a' g
nificant bare skin contact between baby and father.
$ U4 V3 j8 c0 n+ H- RThe father also admitted that after the phone call,2 f# c( w# t! _
when he learned the testosterone level in the baby
* M: S( v. b; W. p/ vwas high, he then read the product information
* B, Z7 U- l# S- a# M7 L) ]packet and concluded that it was most likely the rea-
% T* s, A$ c$ @# }) e0 _son for the child’s virilization. At that time, they- b1 a7 \. s' p
decided to put the baby in a separate bed, and the% b2 T% l9 o$ m3 k: i
father was not hugging him with bare skin and had
' U: ~6 n+ y* ^been using protective clothing. A repeat testosterone
9 h  E5 ?( A/ v. T* T! btest was ordered, but the family did not go to the
; j$ \' N6 b6 y, R6 r  Jlaboratory to obtain the test.
8 R$ p$ V9 v" S; o) m. mDiscussion$ b, |& u& ^9 E7 l2 G
Precocious puberty in boys is defined as secondary  m( B2 M5 Z  X2 j  p
sexual development before 9 years of age.1,4/ W) T* p4 z0 A7 m
Precocious puberty is termed as central (true) when
/ N* P! W& A* q6 \3 \% bit is caused by the premature activation of hypo-
- R8 o& r/ o" pthalamic pituitary gonadal axis. CPP is more com-
5 B5 N0 G8 i! c4 Mmon in girls than in boys.1,3 Most boys with CPP
4 J$ h; M+ M& t4 X( R5 d: q1 zmay have a central nervous system lesion that is
' t$ Z5 ^& A% P- i( z0 p5 wresponsible for the early activation of the hypothal-
  Y) S( d8 k; a) d4 Z$ tamic pituitary gonadal axis.1-3 Thus, greater empha-* t7 v! n* E7 i- h; m+ E3 M
sis has been given to neuroradiologic imaging in
. Q- t% J: m, Jboys with precocious puberty. In addition to viril-0 q& G. O  j) C& D  \% W$ @
ization, the clinical hallmark of CPP is the symmet-4 B0 f: ^" U$ J" H2 n3 [
rical testicular growth secondary to stimulation by! V9 g  @, Y! p8 J( S; B5 Z
gonadotropins.1,3$ S7 T1 ^( B* O7 i, c# Q; y
Gonadotropin-independent peripheral preco-
" }7 E1 s; r% M4 f0 Y+ qcious puberty in boys also results from inappropriate
! J: i% d3 A! O; b6 s/ Eandrogenic stimulation from either endogenous or
1 O' y6 x. l  I- n% u7 w6 Vexogenous sources, nonpituitary gonadotropin stim-" H. G' v; u. E% O
ulation, and rare activating mutations.3 Virilizing! F( Y* t! Y; {% l. J/ U
congenital adrenal hyperplasia producing excessive& L  b) M& r) o
adrenal androgens is a common cause of precocious9 S" ~. \# {$ Q) I% G, Z+ Q; u
puberty in boys.3,4
( C3 W6 b2 o$ D) EThe most common form of congenital adrenal( z. ~* Y4 ~: u5 d# _
hyperplasia is the 21-hydroxylase enzyme deficiency.
. ~! H' S9 d7 fThe 11-β hydroxylase deficiency may also result in' I& F, _8 X2 h6 N4 o( m  C
excessive adrenal androgen production, and rarely,
  G3 a3 P0 N- Nan adrenal tumor may also cause adrenal androgen
- I1 x3 @$ E& z$ `excess.1,3
+ G6 _6 w$ Y: D& ]2 D% X- rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) j5 M* l: G- ^1 x# L542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 z& s3 H  _+ r% zA unique entity of male-limited gonadotropin-
3 Z1 G' T* Y8 A) r: U. `, a2 Tindependent precocious puberty, which is also known. Y5 @. F$ T. z0 k. ^
as testotoxicosis, may cause precocious puberty at a% w. l1 F4 h  ~6 z7 N
very young age. The physical findings in these boys
9 I7 K2 q0 N1 Z3 ywith this disorder are full pubertal development,# b$ g; q% |* b( _
including bilateral testicular growth, similar to boys
. Z# s0 N/ F2 s2 _9 {, [. pwith CPP. The gonadotropin levels in this disorder
' u& M  S5 h. N$ ^0 rare suppressed to prepubertal levels and do not show* P$ }6 Z7 F9 E1 G& d& d, k
pubertal response of gonadotropin after gonadotropin-
( h/ z+ m" y) i& s! Xreleasing hormone stimulation. This is a sex-linked
0 }4 O9 u% b* l( O! S7 Oautosomal dominant disorder that affects only( Y" Q- j7 w) q. B* J
males; therefore, other male members of the family2 ?5 N& i0 A5 S& t- k
may have similar precocious puberty.3+ u/ C+ h% p; L9 ^& J' B
In our patient, physical examination was incon-! i" V$ B  c7 {' B1 {/ R
sistent with true precocious puberty since his testi-& l8 Y- P/ U: C  p- q' ~7 [7 v
cles were prepubertal in size. However, testotoxicosis
0 K3 Q4 T! p( P  o7 w3 Kwas in the differential diagnosis because his father
2 B0 o. L* c; x0 [# t' n  p* R" jstarted puberty somewhat early, and occasionally,
8 Z) b* D7 J3 Ltesticular enlargement is not that evident in the
' [9 [1 t5 k  G- h  K) Obeginning of this process.1 In the absence of a neg-
0 O# y2 i/ q  ?% w' a# l7 S8 B/ Vative initial history of androgen exposure, our
0 y( l+ s! u9 Z+ h4 W5 Vbiggest concern was virilizing adrenal hyperplasia,
4 G" @6 Z& s; X4 k; Neither 21-hydroxylase deficiency or 11-β hydroxylase
9 t1 ^- O1 s# I& l2 W1 W3 Tdeficiency. Those diagnoses were excluded by find-6 [  I- v# O) x  t
ing the normal level of adrenal steroids.0 y6 i" g8 J1 M+ v( `( N5 Q
The diagnosis of exogenous androgens was strongly7 n- S/ z4 C7 n! ]+ W. ?$ w
suspected in a follow-up visit after 4 months because
. z* R; j. e6 ^. Othe physical examination revealed the complete disap-
2 v) {% x# C1 A, O! a; |% wpearance of pubic hair, normal growth velocity, and& M' k! G- n; O, z9 N
decreased erections. The father admitted using a testos-9 J& Y9 I- ]1 _9 L9 `
terone gel, which he concealed at first visit. He was6 _2 x" Q' P2 V, A* \# Q
using it rather frequently, twice a day. The Physicians’4 q+ y3 F3 ~0 `! d
Desk Reference, or package insert of this product, gel or2 F: h5 M- i) Q. h8 D# z. m
cream, cautions about dermal testosterone transfer to
. k. {: _' u( I1 N, _) [7 Eunprotected females through direct skin exposure.
& h" x: \8 m# t2 s- o) J2 PSerum testosterone level was found to be 2 times the
" f7 @' h% _3 L( nbaseline value in those females who were exposed to
- j! k' a9 ?) @! z6 weven 15 minutes of direct skin contact with their male
' j; A. J  n$ Epartners.6 However, when a shirt covered the applica-, ?+ E! L$ ~1 [, o) l6 ]
tion site, this testosterone transfer was prevented.& N$ _' r4 c0 ?2 [9 |! e( s# n
Our patient’s testosterone level was 60 ng/mL,
3 T: M6 u1 `, |# a5 S9 o% k9 ^" a% u5 rwhich was clearly high. Some studies suggest that+ J* q( E0 ]) s/ x, E# W
dermal conversion of testosterone to dihydrotestos-
3 G/ e0 K5 E4 [7 S/ N! oterone, which is a more potent metabolite, is more/ ~) A$ N% Q- h0 f
active in young children exposed to testosterone
1 b. K0 s/ n, i" z/ x7 v9 S1 q8 @exogenously7; however, we did not measure a dihy-
  _" |2 Q& n4 M+ A9 F9 e5 hdrotestosterone level in our patient. In addition to, E+ W  R7 b# s# Y- B0 I
virilization, exposure to exogenous testosterone in
( f  E  Q" C1 ^0 l5 q: p$ y8 xchildren results in an increase in growth velocity and( d, h  ]5 S' p- X8 R$ c2 l# O
advanced bone age, as seen in our patient.
3 }- W) w8 U2 H+ t% hThe long-term effect of androgen exposure during
% m$ C; B- e6 t* c- Y: Yearly childhood on pubertal development and final% K5 N" C1 i) L$ V) p
adult height are not fully known and always remain
9 w; V: i! z- \% Z' ^3 y4 P8 Aa concern. Children treated with short-term testos-
/ c4 G9 @: D& Iterone injection or topical androgen may exhibit some$ Q% [7 n- ~0 A
acceleration of the skeletal maturation; however, after/ g, i& @" w3 Q3 ^
cessation of treatment, the rate of bone maturation
+ N! j* ^/ i4 o7 X; h4 Rdecelerates and gradually returns to normal.8,9
& f5 ]& i  ^/ B& ]7 zThere are conflicting reports and controversy
8 T. S+ L2 F( @over the effect of early androgen exposure on adult) @) S9 }  ~4 g- p7 B5 \7 I
penile length.10,11 Some reports suggest subnormal- o& ^& \% j) K: @8 ]
adult penile length, apparently because of downreg-5 s" C8 ]1 H2 j7 Z+ J/ S
ulation of androgen receptor number.10,12 However,
0 }: z( T+ y4 q7 o  L+ n9 q. sSutherland et al13 did not find a correlation between
) }+ G: @+ y9 i$ e7 R$ N/ Tchildhood testosterone exposure and reduced adult
2 O6 t( M/ \, V" f2 Spenile length in clinical studies.
6 D1 O7 G8 v2 I  b# m, GNonetheless, we do not believe our patient is7 _) e- B2 @5 I, H5 y: g0 u
going to experience any of the untoward effects from
& ~+ z# n7 [2 Itestosterone exposure as mentioned earlier because
% l1 C! X, |. z' f4 s, kthe exposure was not for a prolonged period of time.
2 ~5 @# x, Q& @6 l, B: k: ~# u8 V& oAlthough the bone age was advanced at the time of
3 M: j2 S. E  C! J- c% Z0 i5 R9 ddiagnosis, the child had a normal growth velocity at3 Y* d( y& q: H- d* q/ H
the follow-up visit. It is hoped that his final adult; h% U; T( m" H' L
height will not be affected.
, I. m; {# E% U# fAlthough rarely reported, the widespread avail-/ \/ M$ F3 Y* U
ability of androgen products in our society may
* M: f: F' c4 t; A. O) l  uindeed cause more virilization in male or female7 j' K0 Z* W! M: _2 ~
children than one would realize. Exposure to andro-& x* N+ E8 L/ ]8 v8 h! \
gen products must be considered and specific ques-
! w& B$ r7 B! n' v9 C% `" Utioning about the use of a testosterone product or0 L" l- G( w- ?/ W& |1 U
gel should be asked of the family members during- T# I0 t; K# P  p0 z6 z( K
the evaluation of any children who present with vir-* N3 M1 v) Y# p
ilization or peripheral precocious puberty. The diag-
6 E% O! ?. H& t! `$ |; {nosis can be established by just a few tests and by( ~- a# z6 f" f. i
appropriate history. The inability to obtain such a, q! T! B/ H8 X: l" S7 U4 C
history, or failure to ask the specific questions, may  M3 h+ M3 j2 p9 X! K2 B
result in extensive, unnecessary, and expensive! r6 }* u0 x8 p5 ^
investigation. The primary care physician should be
' E7 T' n$ R- saware of this fact, because most of these children
- h3 r& O0 s" t. ~may initially present in their practice. The Physicians’
+ o0 h6 F$ k! x0 eDesk Reference and package insert should also put a
, f4 R  [. I8 a9 ~8 E0 t9 |warning about the virilizing effect on a male or: `/ ?- z2 X. g
female child who might come in contact with some-
" i* ]' g  q' p. C5 m9 O1 ?one using any of these products.
8 e, h8 O) H3 }- }+ cReferences
# G9 f  u5 u* w- j3 J4 x1. Styne DM. The testes: disorder of sexual differentiation& W& R, _+ [, \# V8 _
and puberty in the male. In: Sperling MA, ed. Pediatric
! |+ t+ k# p, J$ {3 i5 MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ L; [$ R' M6 J9 l; X
2002: 565-628.
3 ~  `; v7 H# Z% o# n3 x  \  L: `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 k" L( i: S# I/ ?1 m5 s# V" N
puberty in children with tumours of the suprasellar pineal
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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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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

0 n- f: o! P. E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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