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Sexual Precocity in a 16-Month-Old- v& U. @% Q0 I# Q; ]& ?" Q
Boy Induced by Indirect Topical
9 S: j% q/ G0 s% K8 _Exposure to Testosterone
1 Z0 w( y" g7 k- F( y3 Q; lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; o! C) h3 M# V1 j5 ~5 N, vand Kenneth R. Rettig, MD1. a1 e: N9 m# r) J" d0 Y6 v
Clinical Pediatrics
6 F) t0 E* j# i2 w/ L5 l& L) NVolume 46 Number 68 K& b, q& s9 j. e* ?  G2 i3 P
July 2007 540-5430 ~4 Z1 `8 x) u0 l9 j
© 2007 Sage Publications
* l& [; J$ Y& A( C5 R6 _- O8 O10.1177/0009922806296651/ @1 R- _) x9 G, O* t! _& u
http://clp.sagepub.com
. F3 N! R: z* _; n, `6 e  ?& G$ Jhosted at- ~6 j# p9 k, j
http://online.sagepub.com
  X8 x( E" q, r! y4 l1 uPrecocious puberty in boys, central or peripheral,/ O0 L# i% i( E0 [; j- j
is a significant concern for physicians. Central9 k, H. C5 E1 Z/ ^; V
precocious puberty (CPP), which is mediated
8 W2 ]: b# f) \" C0 Q! ithrough the hypothalamic pituitary gonadal axis, has# e% v5 m, Q# N- j: I0 K5 d2 x
a higher incidence of organic central nervous system
: a! M$ \# L* S8 l+ ]lesions in boys.1,2 Virilization in boys, as manifested: m3 C1 d( Q; Y2 m6 i' G  {$ y
by enlargement of the penis, development of pubic
2 `1 o8 {! x  J/ ^hair, and facial acne without enlargement of testi-
8 W" s( V' a) ?/ Ocles, suggests peripheral or pseudopuberty.1-3 We) W' j- a: ^3 R+ o5 \) }
report a 16-month-old boy who presented with the; e) z  Y# a! P; m) m9 P1 k! `( }2 {* V
enlargement of the phallus and pubic hair develop-
  V: I7 G0 o7 Xment without testicular enlargement, which was due  h  q: V) U6 V1 k
to the unintentional exposure to androgen gel used by( v( {2 W2 N0 ^# |1 y: d. ]
the father. The family initially concealed this infor-
& E/ B+ a( X3 V: b5 Ymation, resulting in an extensive work-up for this
  a7 t, A9 ~$ a7 z; \child. Given the widespread and easy availability of
/ `( P0 D4 K$ {; gtestosterone gel and cream, we believe this is proba-
/ w8 ^5 p2 D7 h+ q: ybly more common than the rare case report in the
0 U. L3 D. H- Aliterature.4# h; Z, N, ]( ]- l8 \* j
Patient Report
; ]! A3 D9 `7 n& F( @: g! k2 {" nA 16-month-old white child was referred to the$ u- O% G& e+ B) Z/ Q
endocrine clinic by his pediatrician with the concern
6 E' k  q( }7 `. u; @' gof early sexual development. His mother noticed) A4 v8 }, N: ?( f
light colored pubic hair development when he was+ q7 g$ N! v3 F( G# F
From the 1Division of Pediatric Endocrinology, 2University of
  K4 ?, w- |; U2 iSouth Alabama Medical Center, Mobile, Alabama.2 d( B3 u' D+ {! m  y; j
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ I. T7 r4 c% @- W; ]Professor of Pediatrics, University of South Alabama, College of+ ~. s/ ?3 F- S$ p7 V) y, c; |' D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 s; m: C* _) i1 U) O( x: pe-mail: [email protected].  \) l* z8 Q. y, r" e+ D
about 6 to 7 months old, which progressively became
1 P6 ]7 k9 q* a# z' A- Q5 M5 sdarker. She was also concerned about the enlarge-
7 I' ]1 }5 n2 v8 rment of his penis and frequent erections. The child+ n* O* U' z4 _8 K* |6 n  Y3 {4 }
was the product of a full-term normal delivery, with/ F9 G" N- G! d# D5 a8 Y
a birth weight of 7 lb 14 oz, and birth length of
6 g9 @3 B1 n3 V3 x" [  j20 inches. He was breast-fed throughout the first year' D8 N! _& j/ [8 {
of life and was still receiving breast milk along with
) N( d8 Z7 H) a* {( jsolid food. He had no hospitalizations or surgery,
/ r$ i5 O& r  B% u8 P3 `. qand his psychosocial and psychomotor development' }% a1 G/ Q. ~" u, a1 i( b
was age appropriate.
* x1 e, k1 H4 k" j. R, X( ^The family history was remarkable for the father,
  T; R8 k9 e3 y$ a& Pwho was diagnosed with hypothyroidism at age 16,
$ ]( n) k# e( w8 Y# pwhich was treated with thyroxine. The father’s
7 s5 a& B+ B% I$ S. t  X/ _height was 6 feet, and he went through a somewhat$ q* j9 z4 Z8 R( G' [
early puberty and had stopped growing by age 14.6 K6 `- D; M. P0 ^& i8 g
The father denied taking any other medication. The
, ~7 \' ]0 D' _% ^child’s mother was in good health. Her menarche) i( t" L! B( }
was at 11 years of age, and her height was at 5 feet0 B* W5 O, \# J. j+ d6 N
5 inches. There was no other family history of pre-2 ~, I8 V  b) _: l1 ?6 {
cocious sexual development in the first-degree rela-# d/ u. G2 }; x6 `
tives. There were no siblings.5 _2 s2 H* ]1 F
Physical Examination
8 D! ?! B3 t% _  X% h6 n* K: pThe physical examination revealed a very active,2 ^4 C* J- v  z/ o
playful, and healthy boy. The vital signs documented
0 H1 v+ e7 ], z0 t/ u1 o: va blood pressure of 85/50 mm Hg, his length was
  y9 T0 G; q/ z. {. ~5 K  w- ~& V/ |90 cm (>97th percentile), and his weight was 14.4 kg
; y1 Q1 g' e; `* m(also >97th percentile). The observed yearly growth
, U% N, @. @; _' T8 Dvelocity was 30 cm (12 inches). The examination of
* b, \* \8 s* Sthe neck revealed no thyroid enlargement.
0 G# |  y  a; {  i. Q/ yThe genitourinary examination was remarkable for
& E" Z& B0 g3 S6 s: ~enlargement of the penis, with a stretched length of/ Q6 }$ ]+ y7 x9 I, q& q, @
8 cm and a width of 2 cm. The glans penis was very well
+ [/ ?% i( d% M& ^) o6 Cdeveloped. The pubic hair was Tanner II, mostly around
4 |4 e9 [( L  P$ [" w) P540
' _, v3 z+ }/ I! F5 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) j  a' e" m, r
the base of the phallus and was dark and curled. The
* ]* k5 K7 q: h! itesticular volume was prepubertal at 2 mL each.
: ]: U' Z0 M7 R1 ?The skin was moist and smooth and somewhat
9 f; l' `: L* W* _  q# g9 c5 ]; loily. No axillary hair was noted. There were no3 b5 C2 R& i/ K0 n8 h1 j
abnormal skin pigmentations or café-au-lait spots.9 i/ S/ D' M: p: E! Z( b
Neurologic evaluation showed deep tendon reflex 2+
  v# a* R1 X+ B' [bilateral and symmetrical. There was no suggestion
6 V$ i# k9 J  P3 P; O2 c6 J# ~8 lof papilledema./ ?) X* G1 S$ d2 x
Laboratory Evaluation
) }' G$ q! S) q$ a( F- F+ gThe bone age was consistent with 28 months by* i1 W0 O, S1 T
using the standard of Greulich and Pyle at a chrono-
; Y6 U$ }% p  H0 G3 b/ Ologic age of 16 months (advanced).5 Chromosomal+ q& Z8 u& A# d
karyotype was 46XY. The thyroid function test
  N, S! x, a0 L- [: cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
* l2 J; {, h+ L% W0 C2 X4 Rlating hormone level was 1.3 µIU/mL (both normal).
6 t* D- P" F! a+ W# j4 G' J$ FThe concentrations of serum electrolytes, blood) k# \9 P% U$ [: U9 w5 L+ u0 ?
urea nitrogen, creatinine, and calcium all were
" s5 T+ \$ H8 Z9 O# Xwithin normal range for his age. The concentration
: ]$ F3 z$ n) g$ Y( m  i* @# Lof serum 17-hydroxyprogesterone was 16 ng/dL4 i2 M1 a% n  A$ h
(normal, 3 to 90 ng/dL), androstenedione was 20
; ]3 d. H* ?/ @, F/ Q/ jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: e- C/ R8 {0 t/ K, E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 f: x7 C# Y. |, _, A, U" p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to! }; z7 s) z4 K) R! E+ I
49ng/dL), 11-desoxycortisol (specific compound S)8 w) b% w8 D0 z, k: c' t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ ]% H( f3 F  t# O% etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# p! Z" m4 d1 t9 N7 {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ A. m! y5 [' {/ K2 Q# C" band β-human chorionic gonadotropin was less than
4 p/ ^6 U5 S& O9 q4 ~2 n5 mIU/mL (normal <5 mIU/mL). Serum follicular
# i; E; w; n% ]+ ~6 wstimulating hormone and leuteinizing hormone! L, D1 z6 d6 x
concentrations were less than 0.05 mIU/mL
" D! ]1 ]% W; w3 W(prepubertal).3 a9 W: U1 O# {1 b, O) w% v
The parents were notified about the laboratory1 x9 W/ W6 X% i
results and were informed that all of the tests were& n. c" Q) g) z  D" V/ Y7 O, N
normal except the testosterone level was high. The
* K/ }" U: d- F/ A+ Sfollow-up visit was arranged within a few weeks to' X$ ~) Z! A4 d- Z
obtain testicular and abdominal sonograms; how-
8 H0 [/ j' g3 D; e4 B$ }/ Vever, the family did not return for 4 months.- A( @, O0 U8 u  Y. I9 W* H( S! X9 |
Physical examination at this time revealed that the$ e9 I  k3 p+ S0 B
child had grown 2.5 cm in 4 months and had gained  c! M: [! o" Q
2 kg of weight. Physical examination remained5 I# L* R- _! C/ c; P
unchanged. Surprisingly, the pubic hair almost com-
# d# V& a2 c& h* Q7 @6 W" ]; Ipletely disappeared except for a few vellous hairs at
9 D; X* u- v6 G& Z* wthe base of the phallus. Testicular volume was still 2+ g* z# N/ j9 K) I; I; |
mL, and the size of the penis remained unchanged.) \  x' Q4 |2 {1 |
The mother also said that the boy was no longer hav-/ r7 j: }" e: U" K
ing frequent erections.
% W! v4 h) U  uBoth parents were again questioned about use of
; I8 j* @# T  T7 L' T% Fany ointment/creams that they may have applied to+ f% E2 b3 f# ^! y7 l, \- j
the child’s skin. This time the father admitted the
2 \3 o5 v$ k( e0 g+ x# oTopical Testosterone Exposure / Bhowmick et al 5411 j9 }) N: _" o
use of testosterone gel twice daily that he was apply-0 N( H' z! q! g! F0 I- F0 n& o
ing over his own shoulders, chest, and back area for
$ n& P- k! x4 f* B# h0 {3 Qa year. The father also revealed he was embarrassed1 a) M$ \2 D: P% k8 C$ z
to disclose that he was using a testosterone gel pre-6 t3 c0 s9 h; w' b$ q. E
scribed by his family physician for decreased libido3 R& ]: _& l- ?' ?6 S+ Z4 |. v% N7 O
secondary to depression.
- ?! x6 t; ?8 ^5 UThe child slept in the same bed with parents., i/ ?4 w* k  y* O+ n) \5 v8 K
The father would hug the baby and hold him on his
! ?9 U& e: c; \6 Wchest for a considerable period of time, causing sig-8 N$ @1 T/ j3 e$ b7 b7 ?; m$ T, c- [  n) S
nificant bare skin contact between baby and father.; `' Y7 o  D/ p& C
The father also admitted that after the phone call,
5 {+ n9 D( Q$ }2 k& ywhen he learned the testosterone level in the baby
* K6 a8 E' s" N% bwas high, he then read the product information4 w7 ]- `* @- ^2 K% u# N% G0 _
packet and concluded that it was most likely the rea-
( `8 \! K3 l1 c1 Mson for the child’s virilization. At that time, they
8 w% V4 K! e) _9 ydecided to put the baby in a separate bed, and the
0 h9 s  x9 j* I/ C5 [* ~father was not hugging him with bare skin and had
, K3 {6 I, |$ P% ybeen using protective clothing. A repeat testosterone; O' a! {( g% G7 |4 z; n
test was ordered, but the family did not go to the7 e* [; T8 Q" n  v6 F3 u1 i
laboratory to obtain the test.
. \. C2 r5 R4 |4 ?Discussion
  Z, I4 i6 M5 B0 c4 FPrecocious puberty in boys is defined as secondary
# N0 h0 }+ j6 `8 N% C- a, Y6 gsexual development before 9 years of age.1,40 r2 b+ I$ a! A  J# c7 G* v; g* ~) y$ I7 t
Precocious puberty is termed as central (true) when
- R6 y4 N2 @. t* e6 m+ Kit is caused by the premature activation of hypo-/ Q6 J  B  P2 t
thalamic pituitary gonadal axis. CPP is more com-
% n8 t4 X) r7 K5 Hmon in girls than in boys.1,3 Most boys with CPP' h. ]! ^  N( K$ B
may have a central nervous system lesion that is/ }- [1 ~$ P1 V4 h8 i0 {0 j. q
responsible for the early activation of the hypothal-
4 O5 i& f9 E6 V4 O# H1 Uamic pituitary gonadal axis.1-3 Thus, greater empha-
3 y/ j! ?, n5 C$ X+ dsis has been given to neuroradiologic imaging in& G1 p3 ^1 M& z
boys with precocious puberty. In addition to viril-
( q" z5 D! H* U6 `$ i- Lization, the clinical hallmark of CPP is the symmet-
9 d9 |- R" v# g7 ^rical testicular growth secondary to stimulation by
$ Q0 c, `- q: I  h' @( rgonadotropins.1,3
: v: J1 C1 r8 TGonadotropin-independent peripheral preco-
* g, X4 n, t1 H: `: Fcious puberty in boys also results from inappropriate) l" z/ x" o! d& Z8 A' p$ P6 B0 D
androgenic stimulation from either endogenous or
$ N- i, G5 E& f/ gexogenous sources, nonpituitary gonadotropin stim-
: f5 \+ @8 g" nulation, and rare activating mutations.3 Virilizing
3 e' n# R# n# ]: z. icongenital adrenal hyperplasia producing excessive  z( v. p. W; E0 M) \. `" X
adrenal androgens is a common cause of precocious7 v$ N" r" y! v$ {+ L5 s2 I% S
puberty in boys.3,4+ @: P) _9 o+ y& @3 t
The most common form of congenital adrenal
8 ?/ t/ h( L( q! N+ chyperplasia is the 21-hydroxylase enzyme deficiency.. R1 E9 X# g2 r% m# m# h% ]
The 11-β hydroxylase deficiency may also result in, G8 x  p) a/ Q* p  Z
excessive adrenal androgen production, and rarely,/ L: M" c5 U) |7 f
an adrenal tumor may also cause adrenal androgen& l" g- O  [& L' r
excess.1,3. ?( i  U' T: g& _1 l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" X2 [  j: u- O0 d7 Z6 O
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 O  O( r3 k; b5 b% f! i# p
A unique entity of male-limited gonadotropin-, c) E) V5 R6 j8 T7 F" u3 l
independent precocious puberty, which is also known
% L. I7 H. l1 ias testotoxicosis, may cause precocious puberty at a, d9 |9 r, q0 q) U$ @0 x8 x; y$ W
very young age. The physical findings in these boys
; \" ?5 ~4 B2 B6 @3 I  q+ R# ]; iwith this disorder are full pubertal development,
' L5 ]9 P/ v4 I! k9 ]including bilateral testicular growth, similar to boys) i) o( M) d4 O3 j
with CPP. The gonadotropin levels in this disorder3 G/ ?7 ]0 ~6 a* ?9 `4 h2 F
are suppressed to prepubertal levels and do not show
' b% R  p3 H4 ?& w% }* Cpubertal response of gonadotropin after gonadotropin-
  }  `) j! y* Y$ x& P/ G0 L) Zreleasing hormone stimulation. This is a sex-linked' }* f" z" K8 |) q* z% i9 W
autosomal dominant disorder that affects only
4 _6 M1 e! {8 emales; therefore, other male members of the family
3 E! T! I& T% i5 ]. dmay have similar precocious puberty.3
- R' ~) _6 D, W) ]$ L, y: vIn our patient, physical examination was incon-
4 |4 v0 J8 e# y( }& _3 ssistent with true precocious puberty since his testi-0 T/ [% Y0 C+ G/ A1 h
cles were prepubertal in size. However, testotoxicosis
( R+ h- r  A. P2 P, Hwas in the differential diagnosis because his father
; r% l, g8 x; @7 u- ostarted puberty somewhat early, and occasionally,
. v; J1 ]. n' b4 c1 U$ s* z( Stesticular enlargement is not that evident in the
' [0 H) a* D7 u" I# d1 Ibeginning of this process.1 In the absence of a neg-
5 ?$ h: F2 C+ M, n' iative initial history of androgen exposure, our
% A6 x- H3 i/ I! Cbiggest concern was virilizing adrenal hyperplasia,
; Q: j  U3 ~5 ^% R$ _either 21-hydroxylase deficiency or 11-β hydroxylase
) p7 U! y$ k* d2 u1 I- E' b$ G( Q. |) Qdeficiency. Those diagnoses were excluded by find-/ h) h# J$ g5 t3 t2 c
ing the normal level of adrenal steroids.
1 |2 T. D4 a; q: wThe diagnosis of exogenous androgens was strongly4 ^( t, `# ^0 k+ }- o. H4 S
suspected in a follow-up visit after 4 months because
3 H7 _* T' K$ |+ w2 p7 X6 D7 Ithe physical examination revealed the complete disap-
/ q: }; B: M% n* Y, M/ `4 Zpearance of pubic hair, normal growth velocity, and
+ W. I, s8 t4 Z, ?decreased erections. The father admitted using a testos-
. P! U. D6 s& E& Yterone gel, which he concealed at first visit. He was* o. @3 F- {4 }0 k* L- u
using it rather frequently, twice a day. The Physicians’
% p, [7 [! n$ ?3 WDesk Reference, or package insert of this product, gel or- C+ x! ~- C; O  e3 ]- z/ y
cream, cautions about dermal testosterone transfer to; r, M9 d% |2 W6 e( T: P
unprotected females through direct skin exposure.8 h+ }5 R8 ?6 t" p: J
Serum testosterone level was found to be 2 times the
* h) h2 |, H# ]. mbaseline value in those females who were exposed to
% j- L' f" q' xeven 15 minutes of direct skin contact with their male
- K" d, s' Y7 }; s& y9 N& [partners.6 However, when a shirt covered the applica-5 w' D* P" P: e/ i7 H( I" b% I
tion site, this testosterone transfer was prevented." l' E* z5 e0 k9 U) H
Our patient’s testosterone level was 60 ng/mL,9 M, w7 f8 w0 S# w' L1 h! L
which was clearly high. Some studies suggest that
6 l- Y. O( ~/ T% G1 b. k" xdermal conversion of testosterone to dihydrotestos-) s- }- Z. E0 L5 ]# ?, A$ [: v
terone, which is a more potent metabolite, is more6 O) w% p0 {" w" ]7 {
active in young children exposed to testosterone
4 f: [8 |; H4 t+ N7 eexogenously7; however, we did not measure a dihy-
7 U; c+ m* ?8 M+ K7 u9 x% B6 {drotestosterone level in our patient. In addition to1 R! H% D& _$ r+ V# ~% U9 Y5 U
virilization, exposure to exogenous testosterone in4 B. P4 Q9 I( p9 ]# o
children results in an increase in growth velocity and% m' T3 @- O3 f6 Q8 N9 H
advanced bone age, as seen in our patient.' J( ]" E5 n" O" D
The long-term effect of androgen exposure during/ a) \0 u. q/ Q4 f
early childhood on pubertal development and final
9 F( v; e. {) {' ?; m6 s- D' u( ^adult height are not fully known and always remain
+ B2 U- t, D$ z  E. Y9 Ya concern. Children treated with short-term testos-  I) D, n7 l6 l3 |# |, o0 p8 B$ n
terone injection or topical androgen may exhibit some7 r/ _3 |& h- y9 p+ x2 j
acceleration of the skeletal maturation; however, after/ f; r, ]. A, }6 K$ `
cessation of treatment, the rate of bone maturation
; S6 k$ m" j' Edecelerates and gradually returns to normal.8,9
* `$ r3 F3 m/ r0 P5 ZThere are conflicting reports and controversy
! X2 W! }2 v6 R+ V" X# @2 H7 ?) d/ {: kover the effect of early androgen exposure on adult
' d' r1 L# E; B6 gpenile length.10,11 Some reports suggest subnormal4 B- M" r( k3 @& D' M
adult penile length, apparently because of downreg-
, ]& }2 |4 d# O4 A0 x) fulation of androgen receptor number.10,12 However,
1 ?( R. r6 h0 J: u! A' BSutherland et al13 did not find a correlation between, C; M' w. u- b6 @) }6 c1 z! ], U8 Z/ d
childhood testosterone exposure and reduced adult
; |6 E) Y4 ]5 r7 g' L# Mpenile length in clinical studies.
* Z4 X* V! p7 z, eNonetheless, we do not believe our patient is
6 Y7 }& ]3 j* @. o4 Igoing to experience any of the untoward effects from* r1 O4 F. C8 ~$ T  q
testosterone exposure as mentioned earlier because
8 B) j% @  t4 \, Ithe exposure was not for a prolonged period of time.
: J- o2 ^/ D4 L5 p* A8 G7 ZAlthough the bone age was advanced at the time of
/ }, u- H+ E7 q, c) o. t9 C0 {6 `diagnosis, the child had a normal growth velocity at# l* q  [; l; a" }! B5 N( {
the follow-up visit. It is hoped that his final adult
8 g7 I" `% y/ d9 y, Dheight will not be affected.0 o3 x4 a6 V4 u7 y' ~6 |6 v
Although rarely reported, the widespread avail-
( G9 u" W+ b6 Jability of androgen products in our society may5 ~" {3 ^4 T, w9 P" L
indeed cause more virilization in male or female& w' f+ z/ p0 D( c0 k. L$ U0 K
children than one would realize. Exposure to andro-3 I! s6 i% s- {; y6 |$ O
gen products must be considered and specific ques-
% e, r. ]8 ~- ]/ w  ftioning about the use of a testosterone product or$ r8 u9 I: _8 v2 @2 y
gel should be asked of the family members during: Z- r1 g3 a% l8 j* |: q/ N1 N* B
the evaluation of any children who present with vir-% W! R; g& ?9 Z3 M0 [' P' H) s1 L
ilization or peripheral precocious puberty. The diag-! K. |) E1 R8 V, ~9 f0 b$ r
nosis can be established by just a few tests and by4 a' O$ ~( W: A
appropriate history. The inability to obtain such a' G4 S7 f+ ]5 j1 l4 P
history, or failure to ask the specific questions, may
: W: T* c. o+ tresult in extensive, unnecessary, and expensive
# D" D( N0 P$ l, V- E' X& qinvestigation. The primary care physician should be
* _$ y" t+ E7 w1 I7 Qaware of this fact, because most of these children& J: L- V# c4 W# _5 c
may initially present in their practice. The Physicians’& i5 N4 Y1 N' ?7 |" n" ^1 n
Desk Reference and package insert should also put a
* o* b. w- u8 ^% hwarning about the virilizing effect on a male or
6 b8 L7 q/ U: ]/ N, d, H4 C6 q* u9 Vfemale child who might come in contact with some-
+ W- k2 R0 F' J4 J* H2 ~/ oone using any of these products.; G' u4 x* t7 k% Y: R
References; S* Q3 U8 Z4 Y
1. Styne DM. The testes: disorder of sexual differentiation6 C5 v. l: J) l6 f
and puberty in the male. In: Sperling MA, ed. Pediatric
; g1 v4 }7 X, @3 lEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 o# V) V2 ~3 F1 R. X- S. n2002: 565-628.
! I8 @) o3 q0 v2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; t8 v2 W' d7 {7 [
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
6 j3 R: S7 ?8 J- MBoy Induced by Indirect Topical- s6 t0 i! L* e
Exposure to Testosterone3 e" q5 U3 o- P; e+ [3 \& j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ Y$ z9 f; ~" C* ]. Xand Kenneth R. Rettig, MD1
6 u- j: b: l! R/ R+ I" g# JClinical Pediatrics
, K3 N6 [2 G9 n. B' N8 ~Volume 46 Number 6  r9 D2 ^. {" Z; w) _+ [8 [
July 2007 540-543$ m. r' x- K( N2 |' L- {
© 2007 Sage Publications3 c. ^9 @! U) B3 L8 ]( |
10.1177/0009922806296651
7 F: n- W1 I4 K5 @# T! W7 ihttp://clp.sagepub.com8 |9 x4 \) r) c! `% s
hosted at
) v* f7 N2 U. _3 B( O/ `% K' phttp://online.sagepub.com% w! P" l" @: C' ~- X$ k
Precocious puberty in boys, central or peripheral,, g& d4 k' V5 L/ N  u: x4 h' K; c
is a significant concern for physicians. Central2 F6 P6 N1 ?+ q% q+ o9 m) a
precocious puberty (CPP), which is mediated
/ |5 G4 o  e  G6 Dthrough the hypothalamic pituitary gonadal axis, has) N3 z, h1 c5 t( I; P
a higher incidence of organic central nervous system
" O$ g9 A' v3 \3 H. J% X$ Ylesions in boys.1,2 Virilization in boys, as manifested6 w; s0 S2 e: R5 b4 X
by enlargement of the penis, development of pubic" X" H9 E1 a& O- N
hair, and facial acne without enlargement of testi-$ V5 `! Z# s, ?
cles, suggests peripheral or pseudopuberty.1-3 We
8 H% l8 g  {4 g  ]5 m2 Vreport a 16-month-old boy who presented with the
% n1 y. h5 ^! Cenlargement of the phallus and pubic hair develop-
! L  d$ s( e* [! @, Q+ V% a9 _' tment without testicular enlargement, which was due* [* j, V5 B' t! q
to the unintentional exposure to androgen gel used by7 r+ Y9 K" _: f, c% k
the father. The family initially concealed this infor-( }6 N: {9 a/ K7 ~8 ?% J2 Z' P
mation, resulting in an extensive work-up for this
  G/ w0 j# f; l8 V+ vchild. Given the widespread and easy availability of6 g+ c( T/ H  M" D: h
testosterone gel and cream, we believe this is proba-0 z" j' p* |9 R4 P6 B0 b
bly more common than the rare case report in the" `' P( m* L/ Y- A* Q
literature.48 a& |3 w  v. |' B3 b9 V# r
Patient Report
$ X7 s# b; ^: L2 @# MA 16-month-old white child was referred to the1 A/ E; z" s  L7 p) p- w; u4 _( P( T
endocrine clinic by his pediatrician with the concern& u( E8 r; Q& w9 ~* c. m9 x
of early sexual development. His mother noticed( `* z" W# u$ b$ j0 |0 j1 z
light colored pubic hair development when he was
7 I4 M7 V/ g$ k; s- U- J1 b: KFrom the 1Division of Pediatric Endocrinology, 2University of0 i7 f& T2 p6 v8 s+ h
South Alabama Medical Center, Mobile, Alabama.
/ i$ r% j6 Z" R  N$ {Address correspondence to: Samar K. Bhowmick, MD, FACE,. b' R. [! ?. ]. @( R& x
Professor of Pediatrics, University of South Alabama, College of' y0 r; L% i3 n1 {4 V, B7 P8 @# Q% b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, h+ t  D* e, W0 Ve-mail: [email protected].2 j8 J- s! x# [* z+ h& V3 z; C* M1 r
about 6 to 7 months old, which progressively became
5 n. A$ Y# M7 |1 n  z; w2 n* `- pdarker. She was also concerned about the enlarge-
: f- b" A/ e/ }9 ]1 Q" Jment of his penis and frequent erections. The child* S# x+ Q; {; g7 N  I* l( ^, R
was the product of a full-term normal delivery, with+ B. a4 T% G; i3 R7 j5 K
a birth weight of 7 lb 14 oz, and birth length of6 [. k! L* n$ H$ S0 R7 g
20 inches. He was breast-fed throughout the first year
* z% c: y, E) D% `2 L, W6 zof life and was still receiving breast milk along with
9 E  o( G5 `3 K" l( Osolid food. He had no hospitalizations or surgery,
3 I7 V* O% {  B/ @% i0 E& I6 w+ C; land his psychosocial and psychomotor development
3 G. ~) V- S5 n( h" hwas age appropriate.
% p; J7 X- S% E2 C: }$ h$ WThe family history was remarkable for the father,
5 w6 Y* h) t- s; swho was diagnosed with hypothyroidism at age 16,
( Z" L( t  Y& |( j1 iwhich was treated with thyroxine. The father’s
9 l4 s! `) C+ p% e, h1 H- F) y( fheight was 6 feet, and he went through a somewhat8 D* {1 y, j' `( W, P
early puberty and had stopped growing by age 14.4 C9 d9 O& @; [9 p$ w$ I
The father denied taking any other medication. The7 `6 J4 _5 W& i1 J
child’s mother was in good health. Her menarche
" w3 a( o7 g# ^8 C8 ]was at 11 years of age, and her height was at 5 feet2 d& `. m& j$ b4 T$ e
5 inches. There was no other family history of pre-
' {+ _$ U, |9 w+ C$ bcocious sexual development in the first-degree rela-
5 K8 W6 D, ]' K0 Etives. There were no siblings.
' c, J- G; k# w! h* f% J; ^  k; Z- ZPhysical Examination1 {+ Q3 j+ c1 x5 k% U. l: S
The physical examination revealed a very active,
: _! P  [7 `. s) z2 u) ?" |; }playful, and healthy boy. The vital signs documented' [' V8 D+ L7 ?' E* W. F. f
a blood pressure of 85/50 mm Hg, his length was
0 w( _: A: X# u4 p0 d/ Q/ G; D+ h90 cm (>97th percentile), and his weight was 14.4 kg
. B3 ~# z& _9 x7 u+ Y$ |(also >97th percentile). The observed yearly growth3 d* _% E# E5 F7 M; {) z! \( B+ Y
velocity was 30 cm (12 inches). The examination of
2 [! b6 y' O; W5 lthe neck revealed no thyroid enlargement.
: w+ S- L# z5 ?9 |9 T" w) KThe genitourinary examination was remarkable for+ u5 Q+ T% C; k7 m2 M
enlargement of the penis, with a stretched length of
/ I  i, V3 Z. n) T4 s8 cm and a width of 2 cm. The glans penis was very well
$ A8 U* M( W& F; w; k( F5 j4 q( m; ldeveloped. The pubic hair was Tanner II, mostly around1 Q  K/ E5 Q1 @4 S5 d
540) f' b- i9 ?/ o* Q1 `( J5 b& O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ s& p6 @$ K- |: ^: jthe base of the phallus and was dark and curled. The* L0 N. K, }' j
testicular volume was prepubertal at 2 mL each.
) D2 w" O4 T4 Z% u/ qThe skin was moist and smooth and somewhat
- _% R0 G0 N4 ]0 \, z9 Uoily. No axillary hair was noted. There were no
3 ~, A( j# P# w- I) \3 j5 N* l6 ~/ zabnormal skin pigmentations or café-au-lait spots.6 I% U1 u% ^$ l3 ]- \# z
Neurologic evaluation showed deep tendon reflex 2+
; H5 f! S8 {% H$ O0 ?$ r2 Z7 Gbilateral and symmetrical. There was no suggestion) G# S( ?) b4 a
of papilledema.
! \% a8 ?9 R6 r4 Q% @- T4 D+ XLaboratory Evaluation% K! H& [; f8 E0 E9 D* v1 r- c
The bone age was consistent with 28 months by; e( r2 K/ k4 M. a8 e3 n
using the standard of Greulich and Pyle at a chrono-
+ p' y( m1 o7 E$ Vlogic age of 16 months (advanced).5 Chromosomal
* u1 J1 |; n0 l% \& y$ x  @* okaryotype was 46XY. The thyroid function test
. d* E# g2 C) \5 ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-' t* a0 W; V* F# Q( s+ v
lating hormone level was 1.3 µIU/mL (both normal).
: m. K' T% t, ?' e* |- e: Y) SThe concentrations of serum electrolytes, blood
8 @' @! ?1 _5 L! |. p; zurea nitrogen, creatinine, and calcium all were0 S  s% ~- t5 K8 {- g4 _
within normal range for his age. The concentration. o" P/ B4 }: @7 \
of serum 17-hydroxyprogesterone was 16 ng/dL8 n5 @* j3 C, V9 [
(normal, 3 to 90 ng/dL), androstenedione was 20# s9 V+ e( e$ y, V' J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& F3 q8 y2 ^( t) y; t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( B5 P2 l! B: P; P2 U  O$ F3 Vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 N& `0 ]' B: ^. T$ y49ng/dL), 11-desoxycortisol (specific compound S)
" Y) h, z/ w2 Y) b2 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: V9 O, l% l* v  j# ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; r2 k( Y" v  \9 C" _1 utestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! }& e$ `3 A; l# [' s* G/ q2 l' [* k+ fand β-human chorionic gonadotropin was less than) @. r& W9 K' v) U, U+ ?' w
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 ]% O) Z: E. r: [
stimulating hormone and leuteinizing hormone+ ]$ |0 c8 F- f" K% ~
concentrations were less than 0.05 mIU/mL
0 R7 C0 l# q, A: H! \(prepubertal).
* J0 q4 W: Z. e+ V$ QThe parents were notified about the laboratory
/ v0 ?" P- p/ t  Z, R& v5 @& L. eresults and were informed that all of the tests were
" o( [- e6 w: p5 q! i5 q- i' ynormal except the testosterone level was high. The1 t0 [! i/ Y( l; E$ {
follow-up visit was arranged within a few weeks to" m1 U# {1 K  {3 _0 w
obtain testicular and abdominal sonograms; how-
- e" J$ z( Z- {& N/ V! G% cever, the family did not return for 4 months.
( |# f/ H1 ?5 J8 Q! @$ }Physical examination at this time revealed that the
( ]1 f. L; ?' L, |5 y, w& z) G! Cchild had grown 2.5 cm in 4 months and had gained
1 }' l0 m" T: p3 D( t# G8 c, o8 m# g2 kg of weight. Physical examination remained
- v3 a& M  L2 @, L, e, eunchanged. Surprisingly, the pubic hair almost com-$ T2 q% [/ n2 n# Z
pletely disappeared except for a few vellous hairs at
. @& C( ^/ O; ~# C. c  W  Qthe base of the phallus. Testicular volume was still 2
2 _, x% Y$ A. u" O+ Q2 tmL, and the size of the penis remained unchanged.
, ^" s; ?. a$ p1 K  ?. y" u2 vThe mother also said that the boy was no longer hav-& C1 |8 V, Q& \* ^1 Q
ing frequent erections.
* ^0 B/ B9 x8 ^- D) RBoth parents were again questioned about use of2 F. L  W+ b" s) z- t7 p/ U) {1 y
any ointment/creams that they may have applied to% R# e% W( O2 c7 w2 \: w
the child’s skin. This time the father admitted the- m) E% l8 P% C* M2 B  a. r
Topical Testosterone Exposure / Bhowmick et al 541' \" f& N; ^- d; Q8 f
use of testosterone gel twice daily that he was apply-
2 C" f/ _0 }9 V3 Eing over his own shoulders, chest, and back area for3 ]) P, i- b3 A! ?7 D
a year. The father also revealed he was embarrassed
' @' a" _6 h- eto disclose that he was using a testosterone gel pre-- V# e3 [8 }3 X/ A  }2 g
scribed by his family physician for decreased libido
' ]7 w' D! H8 o; Q1 M2 s1 E: h$ psecondary to depression.
, w, @1 C7 K# d; Q" P; d. k6 {The child slept in the same bed with parents., y) J$ A# d5 f1 D8 p
The father would hug the baby and hold him on his
* r& |! ?! S+ H1 H' p7 Q* E" }chest for a considerable period of time, causing sig-& L' ~* U3 I" A& g- R1 o3 t. B
nificant bare skin contact between baby and father.
  y2 v5 {0 e, ~/ L* QThe father also admitted that after the phone call,3 y% o4 H( r4 C* A
when he learned the testosterone level in the baby6 ?9 K0 p9 ~. L- E
was high, he then read the product information
7 ?  P) i4 L7 M$ jpacket and concluded that it was most likely the rea-4 P9 Q2 P) m0 v
son for the child’s virilization. At that time, they
; h' r+ ^4 O( h! O+ ~' ]decided to put the baby in a separate bed, and the! @, G" L( R- k  f! [
father was not hugging him with bare skin and had: P3 G( G+ |; e3 q
been using protective clothing. A repeat testosterone$ w* c7 v8 e1 M7 f  f( O) I- c- D+ P
test was ordered, but the family did not go to the
# V2 l$ O* d  w0 Wlaboratory to obtain the test.
- K* B0 n% E- p% d8 HDiscussion
( R: j2 U; Z8 y8 u2 K5 `Precocious puberty in boys is defined as secondary% v, q& [! M+ P; I3 L. E
sexual development before 9 years of age.1,4) R2 n  ^2 v/ R* M* b& t5 ~
Precocious puberty is termed as central (true) when1 h3 n6 W7 p0 ^
it is caused by the premature activation of hypo-
; M$ V' D; f7 T, k. C. Athalamic pituitary gonadal axis. CPP is more com-
2 k' B4 k8 ~) [9 n9 Y( v3 {( Emon in girls than in boys.1,3 Most boys with CPP: ^$ F( [! Y$ ]* U; a. ]
may have a central nervous system lesion that is
  M+ r. y5 w8 gresponsible for the early activation of the hypothal-: ~: K* ~; R0 a7 y% l
amic pituitary gonadal axis.1-3 Thus, greater empha-
5 o. d' @9 s6 a. ?2 Xsis has been given to neuroradiologic imaging in- j2 `7 D( o7 ?. E# e% g! F
boys with precocious puberty. In addition to viril-
; u) Z8 `' I/ P9 f/ n1 G  oization, the clinical hallmark of CPP is the symmet-+ M7 J' B3 g$ M
rical testicular growth secondary to stimulation by
; m8 z$ [) A, T3 Sgonadotropins.1,3% B) j5 G6 D# C
Gonadotropin-independent peripheral preco-' b- X6 Z- x: M+ b% o* f- D+ G
cious puberty in boys also results from inappropriate" T0 j# ~) e9 o9 a
androgenic stimulation from either endogenous or% F8 y4 [1 t  }. ]- b  a5 X/ S
exogenous sources, nonpituitary gonadotropin stim-
8 j9 l( v& r5 p7 |8 O- N6 x, Iulation, and rare activating mutations.3 Virilizing
1 s$ {/ I% V1 Ycongenital adrenal hyperplasia producing excessive
. r1 E7 x2 t0 i' Qadrenal androgens is a common cause of precocious" @$ w" Z" }( k" R2 r* h
puberty in boys.3,4
4 w3 Z- N. q, QThe most common form of congenital adrenal
9 y6 H& ~; Y6 I: |hyperplasia is the 21-hydroxylase enzyme deficiency., _. @- @$ ~1 {  w* c( u( }3 k% _* s- t
The 11-β hydroxylase deficiency may also result in
0 b0 `5 g7 M  [4 C2 |excessive adrenal androgen production, and rarely,2 f4 s5 x! U4 `. `1 j; {' C
an adrenal tumor may also cause adrenal androgen
3 s+ I" e, ]) \. Pexcess.1,3
2 C0 S) Y; e1 iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 S$ q6 _/ \% w$ f/ E, N1 o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 |' W, X* X7 p# U2 e+ y+ LA unique entity of male-limited gonadotropin-
# e8 V9 [2 ]5 R' Jindependent precocious puberty, which is also known
8 h( N0 E4 r, I* r- i9 M6 |as testotoxicosis, may cause precocious puberty at a1 |( W; C3 K2 s+ h' u1 `. W
very young age. The physical findings in these boys
# T8 w; y8 {( vwith this disorder are full pubertal development,& t% N+ I% @" m+ x  A5 C# i* n& l
including bilateral testicular growth, similar to boys
! p* @; u5 k. T# P' J0 vwith CPP. The gonadotropin levels in this disorder2 ?# M: k& `8 w0 V6 w
are suppressed to prepubertal levels and do not show
2 |: o8 M7 m( _, b! h! G- `pubertal response of gonadotropin after gonadotropin-
4 d# G( b0 S/ j, w2 C% H# |4 r9 E+ Preleasing hormone stimulation. This is a sex-linked6 d* i: ~' B* T' E. l2 X& u( j
autosomal dominant disorder that affects only# n& X4 A! E/ b' A" l
males; therefore, other male members of the family
8 E, N! x% K) M9 U) n9 umay have similar precocious puberty.3
7 \! X) t5 d* F0 l6 z0 a5 ?) bIn our patient, physical examination was incon-
9 r2 m5 }7 m# R8 R; P" P; gsistent with true precocious puberty since his testi-
, W% ^# t& W5 M: A- h6 X, Dcles were prepubertal in size. However, testotoxicosis! Y2 X& `& r  Y% h7 Y* b+ p! T; h; T; t
was in the differential diagnosis because his father
* q# C9 \7 E  R5 @# Ostarted puberty somewhat early, and occasionally,
+ S/ f* z! _: q2 t. J8 O# o# Ztesticular enlargement is not that evident in the
8 T3 i& D4 @0 e- m, Gbeginning of this process.1 In the absence of a neg-
. G% k( m3 {) c- K, \: Oative initial history of androgen exposure, our
* f; q) ~( m2 P1 m' m* G: qbiggest concern was virilizing adrenal hyperplasia,* S  N- d1 G8 y6 i: ?# [% i& {+ V
either 21-hydroxylase deficiency or 11-β hydroxylase! W# i8 N" l2 A; h. |
deficiency. Those diagnoses were excluded by find-  ?/ x6 A' }: g$ a! x
ing the normal level of adrenal steroids.! J  A. L7 i7 v' l  G4 g  Z
The diagnosis of exogenous androgens was strongly
' D, m/ C4 Y8 D  r4 vsuspected in a follow-up visit after 4 months because
; m$ P! G9 E  s5 N+ t5 wthe physical examination revealed the complete disap-
( ?; L( F2 r  h7 m- Z9 ~pearance of pubic hair, normal growth velocity, and
/ l4 s* F4 K' H( g  E# N) A5 idecreased erections. The father admitted using a testos-' I- {* ^/ B5 c" p2 F2 W
terone gel, which he concealed at first visit. He was
1 L  ?  @6 C% y9 K- {using it rather frequently, twice a day. The Physicians’; q) O6 l. ^4 O5 [4 G
Desk Reference, or package insert of this product, gel or
7 M' V! h* I5 S* Icream, cautions about dermal testosterone transfer to
8 r! c& N/ T5 s5 wunprotected females through direct skin exposure.  g+ t- H5 n1 l& Z% T
Serum testosterone level was found to be 2 times the6 o6 V6 e4 q4 l6 c6 Z
baseline value in those females who were exposed to; P+ c- R. {5 g9 i
even 15 minutes of direct skin contact with their male$ r3 Y: }" j6 [4 S: z
partners.6 However, when a shirt covered the applica-
- |9 e4 q7 A+ t' |tion site, this testosterone transfer was prevented.
6 V4 w: s2 k9 V( BOur patient’s testosterone level was 60 ng/mL,' y5 l7 f4 [$ b  u
which was clearly high. Some studies suggest that# M$ r9 |0 _# l$ ]
dermal conversion of testosterone to dihydrotestos-
) ^0 B- }1 ~, j* Cterone, which is a more potent metabolite, is more
. k5 k5 h" g' B/ e4 Dactive in young children exposed to testosterone
4 W3 C) w9 A! l  @% L: fexogenously7; however, we did not measure a dihy-: c% Z, F7 e7 E0 Z+ N9 j. E* d
drotestosterone level in our patient. In addition to/ P  b: a' K# ?; B( M
virilization, exposure to exogenous testosterone in6 r& Y5 @; F$ }  q& i. R
children results in an increase in growth velocity and' P% Q% _' E& b" o2 Y  d8 u$ e
advanced bone age, as seen in our patient.
9 C% _0 U4 \6 _" c  YThe long-term effect of androgen exposure during
! r1 q4 D5 Y7 Q. O+ M. Zearly childhood on pubertal development and final
. T8 r- g% t" s8 W% p9 w- H9 Radult height are not fully known and always remain2 u1 P+ |# g4 Y
a concern. Children treated with short-term testos-" Q1 M  z  N, o8 \
terone injection or topical androgen may exhibit some  w/ w' _; u+ Z" f
acceleration of the skeletal maturation; however, after
. x; e7 G, b' k( J" @1 F4 a7 S! k$ ?7 xcessation of treatment, the rate of bone maturation9 I4 n! ~1 j/ G; u, R
decelerates and gradually returns to normal.8,9
" f, y7 s, T) m" h0 a8 bThere are conflicting reports and controversy# q7 l' j% Z6 q; O" \( `' ^5 _: A. W! y
over the effect of early androgen exposure on adult
0 |3 s6 q, W0 |& s2 epenile length.10,11 Some reports suggest subnormal
9 Z% C( U  g4 w- `  Uadult penile length, apparently because of downreg-5 m5 P1 a) ]# z9 d1 e9 N# X
ulation of androgen receptor number.10,12 However,
% B- ^# F" R; i$ G, V' @4 nSutherland et al13 did not find a correlation between" B9 w! j4 p0 g% B2 n
childhood testosterone exposure and reduced adult
4 v  C; ^, B! z- i3 K% zpenile length in clinical studies.
5 l9 H: @: `( l" i* fNonetheless, we do not believe our patient is
: J: l: ?; a  s5 N( ]! @6 g- Zgoing to experience any of the untoward effects from
- W! V0 x8 R7 _3 ltestosterone exposure as mentioned earlier because
* e* H2 W: i$ v* c8 athe exposure was not for a prolonged period of time.
8 s/ F. k9 q: MAlthough the bone age was advanced at the time of
: R( T& R3 y- z- `: }diagnosis, the child had a normal growth velocity at4 ^  B; x; p: X" h  P& s
the follow-up visit. It is hoped that his final adult2 S. S5 A# {' m+ A- W$ g4 m
height will not be affected.+ x6 [7 ]0 Y; u0 C! S, C
Although rarely reported, the widespread avail-6 F/ Q  {" k% F3 U5 ]( \. d8 h
ability of androgen products in our society may5 \  Z$ H; |$ _5 q6 m' Y
indeed cause more virilization in male or female$ w, M1 [5 |1 d5 h# ^
children than one would realize. Exposure to andro-1 A) E: N  R/ W+ v5 ~% Z- f
gen products must be considered and specific ques-
: K) X& S! \0 o/ J' w; Dtioning about the use of a testosterone product or
# M' i* D% I  d! z+ hgel should be asked of the family members during+ j, X( ?, X% G7 \9 B
the evaluation of any children who present with vir-) l) U  J# r, z- C
ilization or peripheral precocious puberty. The diag-
6 B& _# u7 D$ A1 N0 ^/ [nosis can be established by just a few tests and by, z- v) T! P( A
appropriate history. The inability to obtain such a0 l  S4 `' X9 h8 O7 x" n$ h
history, or failure to ask the specific questions, may( Q/ f  p0 F& a
result in extensive, unnecessary, and expensive' G- N0 g, F  [+ W# l4 h: V
investigation. The primary care physician should be5 H/ `8 N! N" Y# \# d: ~2 ]
aware of this fact, because most of these children
8 H) q4 k9 a: h- }2 v8 \9 b) Y3 E0 Q3 q) |may initially present in their practice. The Physicians’
; C0 A4 c7 S6 S/ O- ~( }' N5 g, Y: PDesk Reference and package insert should also put a+ ?, e! ~; r+ i' g
warning about the virilizing effect on a male or
- v  @' i$ g- c, I5 @- cfemale child who might come in contact with some-
/ B$ w1 _1 h- |9 l5 ?6 R7 Q. {one using any of these products.
$ ~: H) K2 M& h5 ]  R; d* AReferences7 }: Y, g* N4 u* p0 a5 `. ?  k
1. Styne DM. The testes: disorder of sexual differentiation
0 G6 {9 p. c& [8 t; Q  z+ ^6 @+ rand puberty in the male. In: Sperling MA, ed. Pediatric
# y! X8 D# X8 O; xEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. O0 Z5 k8 T0 f8 e# o
2002: 565-628.
' P% ?8 H5 [6 o; j. E2 g* \3 t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 t* z& T, [  }3 }' l* K
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
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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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