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Sexual Precocity in a 16-Month-Old
0 o$ H( N, j$ A& @* M# w4 _Boy Induced by Indirect Topical$ ]/ s, n8 z: z8 t
Exposure to Testosterone- D2 z; m4 M5 }% o: D9 q; h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ `  _0 S1 H, U; c$ z4 mand Kenneth R. Rettig, MD1
7 A; b5 m# [( D" Q; GClinical Pediatrics9 X7 z0 L# w* o$ P( V
Volume 46 Number 6
* d1 o# D9 g( GJuly 2007 540-543
4 c) }1 W! m8 T( u© 2007 Sage Publications
0 |- i- G- B6 ~10.1177/0009922806296651. T2 b( _0 s8 m. {1 K! @* |: `6 c6 A
http://clp.sagepub.com9 m& y5 ^5 x! ^# `, @" S
hosted at" J; s* K  t( l" F9 l
http://online.sagepub.com
8 k* ], |( n: V: V$ Q0 j$ wPrecocious puberty in boys, central or peripheral,9 @  D# F" R8 {& ~6 x  u, b0 \
is a significant concern for physicians. Central( u9 n; d6 W5 n: _$ g
precocious puberty (CPP), which is mediated
; ^6 j& I8 e% E/ E: U- nthrough the hypothalamic pituitary gonadal axis, has; N. x* H! a! |
a higher incidence of organic central nervous system/ F/ N# o7 _9 ], t* F9 C1 H7 ~3 v
lesions in boys.1,2 Virilization in boys, as manifested
8 y  ?, |5 T" H. `* gby enlargement of the penis, development of pubic. z- w4 C/ @. c$ Z7 ?6 ~
hair, and facial acne without enlargement of testi-
. ?% n! x6 Y9 }cles, suggests peripheral or pseudopuberty.1-3 We/ t) c, R/ w5 B) x# D  f* _) C
report a 16-month-old boy who presented with the% y9 r& g, b5 V3 f  C* `+ j, K
enlargement of the phallus and pubic hair develop-
0 d- `+ i$ d  T) hment without testicular enlargement, which was due
& L0 h! [' _; i% e3 _to the unintentional exposure to androgen gel used by
5 c( p0 a1 i! Y+ r9 t% A; n( r0 Cthe father. The family initially concealed this infor-0 r, i& i0 n' z  P% B* L; ^
mation, resulting in an extensive work-up for this
& u- y" N5 J0 P$ m; S- @: F4 Fchild. Given the widespread and easy availability of
8 ?3 T9 {( K2 U+ }  k1 q* ^/ S; d- v* ztestosterone gel and cream, we believe this is proba-( T$ k/ @) A9 l4 f
bly more common than the rare case report in the
2 e$ q6 D: z  [* Tliterature.4
# D: K1 v4 M$ o$ g* r+ qPatient Report$ X# g( m. e0 O! G+ f% Y7 s4 S' ]
A 16-month-old white child was referred to the: E0 x/ l' M8 z" O! e* n
endocrine clinic by his pediatrician with the concern
! n1 l6 S1 ?  u9 `& a) n: Zof early sexual development. His mother noticed
8 ]: c) |: R* N- y/ k' K" elight colored pubic hair development when he was: h$ e2 a' t% W- U) N+ A
From the 1Division of Pediatric Endocrinology, 2University of
3 `( F7 [* K8 X. C* ]/ q1 f( ], JSouth Alabama Medical Center, Mobile, Alabama.# p2 E+ c. c6 }: T# j: s: ]
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 y5 S3 @5 \6 {3 l& n' C& CProfessor of Pediatrics, University of South Alabama, College of
/ A6 p0 |  l+ Q' QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 x) a8 }) F& n* K$ c7 _( o: p
e-mail: [email protected].+ ~4 R3 A0 O- \+ Z2 l
about 6 to 7 months old, which progressively became
. n0 c5 V7 M/ {8 L: e; g3 r: v3 gdarker. She was also concerned about the enlarge-
% Q& u" Z1 C/ A* Z  e& |( Ument of his penis and frequent erections. The child
& I/ z! B; F  L* W+ O5 r- Owas the product of a full-term normal delivery, with
2 v; Y& R* s' }/ Za birth weight of 7 lb 14 oz, and birth length of
% L$ O9 `9 Z% ]' x$ s. g20 inches. He was breast-fed throughout the first year
: S8 O( x' t! |, |2 c# pof life and was still receiving breast milk along with1 b) M- j: a, c% a0 N7 G3 K$ H
solid food. He had no hospitalizations or surgery,- x( [/ g* L# b, D* |4 i8 b
and his psychosocial and psychomotor development: w: d4 Y  z. }1 a2 {2 {1 L
was age appropriate./ p4 \# X9 a4 Q+ ^# G! _3 ?6 _8 U8 z
The family history was remarkable for the father,
5 E4 a! M' s( W& u$ Swho was diagnosed with hypothyroidism at age 16,! T5 X& f4 w# |# u% B6 h
which was treated with thyroxine. The father’s
  f! p! P& ^$ o% eheight was 6 feet, and he went through a somewhat
$ h: v; ]- _8 f: X! Learly puberty and had stopped growing by age 14.  A% x0 X8 G% ]4 @' l) r6 \
The father denied taking any other medication. The; D# B0 J8 m1 V
child’s mother was in good health. Her menarche/ m1 e) ]- g' G9 N2 w
was at 11 years of age, and her height was at 5 feet6 r8 g' U! a$ g& a1 a
5 inches. There was no other family history of pre-0 E5 e9 k& M3 {8 Z1 b
cocious sexual development in the first-degree rela-4 J4 R0 d+ o7 {% F7 ~9 I) a
tives. There were no siblings.
, G2 B) b- i) n+ zPhysical Examination
9 M/ {7 Y' F: L1 O+ CThe physical examination revealed a very active,
5 z4 g- B* l& O$ K5 Y% aplayful, and healthy boy. The vital signs documented
& o& m, `  m- S/ g- V, ?( {4 la blood pressure of 85/50 mm Hg, his length was; H' |  t. w  z* b
90 cm (>97th percentile), and his weight was 14.4 kg
# @1 @* N) B6 D! X& U(also >97th percentile). The observed yearly growth
5 L4 R- c; a- Mvelocity was 30 cm (12 inches). The examination of: Z; g) Z# j: J
the neck revealed no thyroid enlargement.
- m5 r4 H7 U7 C% hThe genitourinary examination was remarkable for  C3 E7 ]3 S! A0 B
enlargement of the penis, with a stretched length of
4 O) \3 `/ h" p9 ^% A: L8 cm and a width of 2 cm. The glans penis was very well
& k( F$ A& C4 y1 O2 K7 o& Kdeveloped. The pubic hair was Tanner II, mostly around! k' I0 m1 E7 j, \
540* f7 w! i1 J7 \' {3 T0 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 |/ J* }4 X+ ]. U# e; \9 t% b
the base of the phallus and was dark and curled. The
% w* }' l9 l0 {4 Wtesticular volume was prepubertal at 2 mL each.
: A8 A2 s$ ]/ M4 kThe skin was moist and smooth and somewhat) H9 U5 K; P' E  v2 Z" \
oily. No axillary hair was noted. There were no
9 R9 q% W! v6 f" `9 o7 X- }2 Dabnormal skin pigmentations or café-au-lait spots.8 I# G, e0 o/ i' S3 z2 r: r( u
Neurologic evaluation showed deep tendon reflex 2+; y- u/ U9 W; p* C( s1 |" P
bilateral and symmetrical. There was no suggestion- G1 \0 s- T/ ]# s; ^
of papilledema.
: }) `: M8 Z; z0 c0 ~' @- d! d. FLaboratory Evaluation
! _; Q- W2 J8 fThe bone age was consistent with 28 months by( s4 u& L  ^- ~% i
using the standard of Greulich and Pyle at a chrono-
6 ^2 `4 g* J# l' z/ G" Alogic age of 16 months (advanced).5 Chromosomal
) D# C' Q- g4 Hkaryotype was 46XY. The thyroid function test
7 ?% W6 Y7 L; j; C) r5 wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 ~# o6 w( u9 R& E: E4 s: R+ Plating hormone level was 1.3 µIU/mL (both normal).
& t1 d4 X2 Y7 O  v, U  q  W& [8 |' t, eThe concentrations of serum electrolytes, blood# P7 n! o7 s% ]  B# `, ^
urea nitrogen, creatinine, and calcium all were
, A, Y7 ~9 i3 i+ iwithin normal range for his age. The concentration
4 P* |7 i$ [5 c6 Nof serum 17-hydroxyprogesterone was 16 ng/dL
- C# Y9 |0 g  R(normal, 3 to 90 ng/dL), androstenedione was 209 j( g! e" a- q# ^7 q9 I6 Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: [4 c$ h) j& d5 _/ X0 Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),- j; {: {7 n3 T- O0 c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; P& s# O2 t0 M$ l, L  ^49ng/dL), 11-desoxycortisol (specific compound S)6 l' i' ~. p7 ?. q+ ]; d0 |/ ~" }
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# D- p; _2 \" v2 @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 h( S' s! P' ^4 ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) q2 _8 J8 S+ t* N, e0 nand β-human chorionic gonadotropin was less than
7 Y+ b, b. N; O" }5 mIU/mL (normal <5 mIU/mL). Serum follicular
# ^. u5 P! [* B( A: o6 P9 a% nstimulating hormone and leuteinizing hormone
$ n! @- n: o9 _3 v) cconcentrations were less than 0.05 mIU/mL
: d( E3 j- E$ K1 J" r7 m(prepubertal).
1 a+ K1 j1 p5 {% @3 aThe parents were notified about the laboratory
7 x$ d8 X* k% E7 Oresults and were informed that all of the tests were
" R1 b  |$ x) l5 H( ~# n  B2 Gnormal except the testosterone level was high. The
: q, n7 t& a# ^. N' lfollow-up visit was arranged within a few weeks to3 E2 p" j  h( v7 D
obtain testicular and abdominal sonograms; how-
8 ?& T. v: p' C0 Zever, the family did not return for 4 months.3 [) c. a0 z6 I$ s9 e& l
Physical examination at this time revealed that the
# D+ |# I/ s5 d+ I0 T2 Uchild had grown 2.5 cm in 4 months and had gained
+ ~! |& r. k8 o  Y$ D! c5 k2 kg of weight. Physical examination remained
" n0 A  a) \- x0 a$ aunchanged. Surprisingly, the pubic hair almost com-1 [) S  x3 E5 d( Q0 e
pletely disappeared except for a few vellous hairs at
: b) V& s$ ?, K- s' @% kthe base of the phallus. Testicular volume was still 2: i9 p7 ]2 n) t: [0 s
mL, and the size of the penis remained unchanged.& b4 K9 \) v) |# m
The mother also said that the boy was no longer hav-$ v$ O3 N$ h& r" }1 E, G+ x
ing frequent erections.
7 t+ \( s  T3 x! ]$ @% _Both parents were again questioned about use of
- T- Q6 Y3 `8 a  Z/ gany ointment/creams that they may have applied to
8 ]5 r0 D8 P2 Y" ithe child’s skin. This time the father admitted the! N3 E3 P" [7 s+ Q8 T9 D5 a. v
Topical Testosterone Exposure / Bhowmick et al 541
2 p3 j; B- f- _$ Y) Puse of testosterone gel twice daily that he was apply-& i; z$ ^9 l! R% u6 B
ing over his own shoulders, chest, and back area for
) C! P' v; v- I* O8 t% u! @a year. The father also revealed he was embarrassed
( [8 i2 N+ w* z( wto disclose that he was using a testosterone gel pre-+ U) u! @2 g8 E3 E
scribed by his family physician for decreased libido
5 P7 r2 }' Y7 G/ p( F8 }secondary to depression.
3 G+ Y- m! y0 ?, L% nThe child slept in the same bed with parents.5 U7 k; t4 m& ]0 k
The father would hug the baby and hold him on his
/ I) \3 L) R% m) |chest for a considerable period of time, causing sig-
+ l! T( _4 L/ C" x. pnificant bare skin contact between baby and father.3 I# T+ b' Z3 d) N, h  M  o/ V
The father also admitted that after the phone call,
0 R: p. l3 J+ u$ N# R. S+ z: Ewhen he learned the testosterone level in the baby
) r' a0 z, g$ bwas high, he then read the product information
7 v+ |) l& }0 `: \6 [! lpacket and concluded that it was most likely the rea-6 w* w2 }+ w" i' y
son for the child’s virilization. At that time, they1 Y; c8 r3 B1 o4 h0 V1 P: B. K8 R4 K
decided to put the baby in a separate bed, and the
) u1 K! b5 X/ u( p% M% Hfather was not hugging him with bare skin and had) t; p) u4 V2 K, p# V" F# Z8 l
been using protective clothing. A repeat testosterone# G% g$ \, Q% Q5 J3 f
test was ordered, but the family did not go to the
' k, E) p- t) U! {; H/ Dlaboratory to obtain the test.
* h% [8 s7 e* _, {Discussion
8 U, c/ T/ a8 l% }3 jPrecocious puberty in boys is defined as secondary
5 D# s- Q9 |) |& w3 @. Dsexual development before 9 years of age.1,4
$ D$ W# W& g3 P+ M4 KPrecocious puberty is termed as central (true) when8 w6 k- d8 W' z$ a
it is caused by the premature activation of hypo-, z- |  T7 r) o. A: q, F8 F2 n
thalamic pituitary gonadal axis. CPP is more com-% N6 v! \$ p; T% G5 V
mon in girls than in boys.1,3 Most boys with CPP; Q$ w; ]" y* Z- Q6 |! L( }
may have a central nervous system lesion that is
* g$ Q# J6 O/ m1 _1 ]responsible for the early activation of the hypothal-
9 w  J$ f9 i: zamic pituitary gonadal axis.1-3 Thus, greater empha-& b  _4 i9 ~4 S  _
sis has been given to neuroradiologic imaging in, j3 `1 M, @2 N/ f5 G0 Q) c& x
boys with precocious puberty. In addition to viril-
7 }4 n0 F/ W0 h! o: B. k* O3 K+ @ization, the clinical hallmark of CPP is the symmet-; O* F" n1 v1 ^# h' a& r* M  R# I2 A+ w
rical testicular growth secondary to stimulation by( P" d! y/ }  P8 F% m5 c
gonadotropins.1,3
+ b8 I' u. K& d- `Gonadotropin-independent peripheral preco-
- d" T2 F% y6 o0 V/ h$ `cious puberty in boys also results from inappropriate
' A- S* u& S3 L/ n) W5 s) V7 fandrogenic stimulation from either endogenous or
9 L( G) k) e6 \# E- qexogenous sources, nonpituitary gonadotropin stim-
- ?/ S5 R) F6 j2 a  Eulation, and rare activating mutations.3 Virilizing
: \1 k6 t4 ^" t0 k( u! Ncongenital adrenal hyperplasia producing excessive
$ H& h! H& o' sadrenal androgens is a common cause of precocious. x$ P* W4 ?! _$ I
puberty in boys.3,4- l! L0 s, T+ K1 Y  d
The most common form of congenital adrenal. `$ ~+ g  q) d! \( K* Z% {
hyperplasia is the 21-hydroxylase enzyme deficiency.
' y; a3 O* g6 _The 11-β hydroxylase deficiency may also result in2 y5 y3 q6 v0 h% `' H& g" Z( E" f
excessive adrenal androgen production, and rarely,
! K7 J9 v  O( D- N4 [an adrenal tumor may also cause adrenal androgen
# j  x, [; ^0 ^3 V$ Q5 p& O/ hexcess.1,3
" @' q# w. G! N( Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: O# g8 U- j6 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% x+ }& y" F* l# d) KA unique entity of male-limited gonadotropin-
1 }/ S) @4 p9 R) A* Rindependent precocious puberty, which is also known% w  K$ l( S' u' G8 b
as testotoxicosis, may cause precocious puberty at a/ j6 Y4 ^3 U( |, q
very young age. The physical findings in these boys
* G( u: w% H- \1 Xwith this disorder are full pubertal development,2 Q% a2 B) R! E% A2 z; d9 l
including bilateral testicular growth, similar to boys
$ m& k1 A" L2 z' _! Xwith CPP. The gonadotropin levels in this disorder$ ?+ t+ p, q! N% D# a+ J
are suppressed to prepubertal levels and do not show
* c  {: i# z% M9 qpubertal response of gonadotropin after gonadotropin-5 X4 S! Q) S! P8 s* O: q
releasing hormone stimulation. This is a sex-linked" m; n2 `, U1 M: u' W
autosomal dominant disorder that affects only2 |5 H$ |/ v) y" z8 }# Z
males; therefore, other male members of the family$ q! m' s3 O( k8 C" p8 {6 A. p  }
may have similar precocious puberty.3; H/ G! @! J+ ~
In our patient, physical examination was incon-$ y/ X" h/ ^$ ]: k( b1 b: y. [
sistent with true precocious puberty since his testi-
8 j3 x. \) L3 P% t, S+ i9 I) lcles were prepubertal in size. However, testotoxicosis8 ~) V3 J  p! x+ E6 h
was in the differential diagnosis because his father
! t( ?( ^" S" m) j) istarted puberty somewhat early, and occasionally,. w3 I7 g9 J# D- N
testicular enlargement is not that evident in the' g% r- s5 J6 k% d. m; v
beginning of this process.1 In the absence of a neg-
: u- w: \, H7 e( p7 aative initial history of androgen exposure, our8 {3 p8 I: z# [, D, D6 I# f
biggest concern was virilizing adrenal hyperplasia,2 h6 ?: M9 F. _& a
either 21-hydroxylase deficiency or 11-β hydroxylase+ c1 |  W& G3 e5 q
deficiency. Those diagnoses were excluded by find-+ ?' [# e" \/ d& G1 P: ~, s
ing the normal level of adrenal steroids.
" Y) q5 A' @. M7 m* W: t7 r6 i4 `The diagnosis of exogenous androgens was strongly; T3 W  Z3 L, H4 ?5 u/ b
suspected in a follow-up visit after 4 months because
  r, x$ I- b" L; S& Othe physical examination revealed the complete disap-3 X4 J+ ^, Z5 Y
pearance of pubic hair, normal growth velocity, and! m& X1 w. C$ i% c5 h9 n
decreased erections. The father admitted using a testos-
" G* n: }0 T: ~) vterone gel, which he concealed at first visit. He was
  ^) E9 }6 B1 u/ [5 susing it rather frequently, twice a day. The Physicians’4 _4 c- Y. |& H! _* N- ~
Desk Reference, or package insert of this product, gel or
9 S( O, Q& `" Z. {+ Y1 ^$ q) Qcream, cautions about dermal testosterone transfer to
. z5 B! o; p, R5 ]unprotected females through direct skin exposure.
6 D) [2 j  M2 N0 {. b6 n1 ]Serum testosterone level was found to be 2 times the  k* \: S( K7 ?* J+ D( \
baseline value in those females who were exposed to7 ~9 A( w" H9 T# N! I6 |9 _, @
even 15 minutes of direct skin contact with their male
  r( q+ `: C" N! v$ gpartners.6 However, when a shirt covered the applica-. Y5 d3 F/ V. D' `3 u5 ]
tion site, this testosterone transfer was prevented.
0 M) X* b2 g7 z/ ^: z1 s) K6 ~- mOur patient’s testosterone level was 60 ng/mL,
  S( K7 a1 s8 ~9 mwhich was clearly high. Some studies suggest that1 @( @- E& Q+ e8 T+ y* w: e1 _8 C
dermal conversion of testosterone to dihydrotestos-
+ G+ w# V$ r  H# X# j2 R9 @terone, which is a more potent metabolite, is more9 R# _0 y" V+ B3 L; M9 @
active in young children exposed to testosterone
5 b; P  N' A; Q6 \- ^0 Bexogenously7; however, we did not measure a dihy-
) x8 z' ?4 m+ x8 R  hdrotestosterone level in our patient. In addition to
8 K( S3 ~/ q8 }& h6 h' {7 \9 {virilization, exposure to exogenous testosterone in+ K  W2 m- I- G3 W9 C0 N' b
children results in an increase in growth velocity and
2 |" J) n* d1 h+ D) L3 [/ [$ Tadvanced bone age, as seen in our patient." a5 p" m/ F/ v. T* I) Y/ V. ~
The long-term effect of androgen exposure during# v' J6 C3 ~6 n0 j. q, q3 h/ x
early childhood on pubertal development and final
1 D8 p( n( j" m# _( f" Y% @adult height are not fully known and always remain
+ H2 t- \% B) Na concern. Children treated with short-term testos-
8 {/ J4 T. m. m( _6 e# qterone injection or topical androgen may exhibit some
* N0 ], J5 C  J7 Uacceleration of the skeletal maturation; however, after3 p! N* T& N/ d% I' R
cessation of treatment, the rate of bone maturation. Q* z8 _; Z0 F, m' y
decelerates and gradually returns to normal.8,9
$ W& o4 @! w6 jThere are conflicting reports and controversy4 Z* [6 z' A+ y2 }$ y
over the effect of early androgen exposure on adult
" y2 ~8 S: ?/ n# D4 o4 `3 gpenile length.10,11 Some reports suggest subnormal
" E$ q: n6 j1 ?; T  _adult penile length, apparently because of downreg-
8 D9 ]6 ^) o  ?1 lulation of androgen receptor number.10,12 However,
; ?, i1 X' ]  M8 L" x5 |6 \Sutherland et al13 did not find a correlation between
! L% {4 l  |: T  k2 o0 z) H% `childhood testosterone exposure and reduced adult% X( D1 _5 F5 D9 f) O/ E+ K
penile length in clinical studies.
* K$ x( Z8 }: V/ V6 Q4 b8 rNonetheless, we do not believe our patient is
" K& U, T8 }% n. @going to experience any of the untoward effects from
6 f& V$ w9 ^- {" xtestosterone exposure as mentioned earlier because
/ k- ^) `8 O3 o% `4 {* w6 [the exposure was not for a prolonged period of time.4 d5 k+ r8 X: u3 ?, V/ l5 x
Although the bone age was advanced at the time of, M0 T, t7 t' A, v7 ]% d
diagnosis, the child had a normal growth velocity at# Y$ `4 E! n* s. B$ B6 c
the follow-up visit. It is hoped that his final adult
: s. k* G! m8 |, |1 p8 dheight will not be affected.
  n7 K/ Y: H+ A8 r$ u/ r1 RAlthough rarely reported, the widespread avail-
- ?3 }0 {$ F% v0 Pability of androgen products in our society may0 V: E9 y$ i" p. P  l
indeed cause more virilization in male or female
6 Q' c6 C! z4 O# E% M  Vchildren than one would realize. Exposure to andro-
6 J( p* c6 ]' P, q( ?gen products must be considered and specific ques-- k9 v$ G: d, N' M7 q- s
tioning about the use of a testosterone product or
; ~( Q) E9 k- w4 Q/ X  @5 kgel should be asked of the family members during* |/ @! V2 ]  G9 q
the evaluation of any children who present with vir-1 K) h/ ~- ?  ^% ^/ P/ C" `
ilization or peripheral precocious puberty. The diag-( @! P. \$ m: S, M1 ~3 u, B' Z$ \
nosis can be established by just a few tests and by+ j7 ]6 ]) q8 X$ Q$ p/ E# G8 b( Q. z" O
appropriate history. The inability to obtain such a
+ U  f% e) ]7 a4 ?history, or failure to ask the specific questions, may
- z) ]' E9 c! u, Z8 cresult in extensive, unnecessary, and expensive
# B# Y% }" }8 C" [" p. |investigation. The primary care physician should be
- C( h9 @. J! M/ _1 s7 J9 q" R8 ]aware of this fact, because most of these children
# _9 F, @4 d( X  m1 \9 h  X8 x) }% bmay initially present in their practice. The Physicians’/ m; S; k' H& t' A8 R3 ?
Desk Reference and package insert should also put a
8 P9 q1 z1 b) Q5 Vwarning about the virilizing effect on a male or
3 C6 @; N; z$ M' J0 N  Nfemale child who might come in contact with some-
& N3 |5 g0 T% G5 hone using any of these products., i$ C% `6 Y' N/ D+ y2 x
References
4 C3 ]/ X1 a) s4 t# _! j1. Styne DM. The testes: disorder of sexual differentiation  B; A$ m0 ?) y0 S$ ?
and puberty in the male. In: Sperling MA, ed. Pediatric
+ s* N; @! W$ r' AEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) J. `& t" {1 E' i4 Y2002: 565-628.
$ i# t% l4 ?5 w5 Q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- J. M, L6 r$ r4 `+ ]* }5 j& \puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 s: g. _6 w  F1 q
Boy Induced by Indirect Topical
$ b  u. m8 g5 qExposure to Testosterone1 Y5 W. B9 Z7 S( |5 p$ h' G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 T" z& i$ h) a! C, zand Kenneth R. Rettig, MD1
4 ~6 v5 `1 ~% D& o" _& _% c% wClinical Pediatrics& ?8 e/ V( Z8 Z
Volume 46 Number 6
# V& D; c% B- m" s$ `5 n6 LJuly 2007 540-543
7 `% h$ o/ ^; W& U5 v8 O$ o© 2007 Sage Publications
- _1 o# t7 M9 O# O1 W# D% N" }. G10.1177/0009922806296651- c8 `' C2 R5 [
http://clp.sagepub.com
/ |5 O5 {4 q3 x5 ohosted at1 @$ V) z4 T) ]8 j0 C  p% D
http://online.sagepub.com
: \* \0 @% l3 Z7 i& A0 QPrecocious puberty in boys, central or peripheral,6 B9 d& u( e6 _# @/ `3 r* @: w
is a significant concern for physicians. Central
2 C' S1 @% @# z% P# Lprecocious puberty (CPP), which is mediated7 S( L& U% ^& [
through the hypothalamic pituitary gonadal axis, has5 t) B! d' L, a7 \& J3 X! y
a higher incidence of organic central nervous system
3 b; t  V9 l9 u. F& R) Y! p0 h# F( Xlesions in boys.1,2 Virilization in boys, as manifested. J1 |, |3 H$ S! q7 Z2 Q7 e( X) L
by enlargement of the penis, development of pubic1 U* [' ?5 Q8 r$ K& V
hair, and facial acne without enlargement of testi-* a8 R; w7 H5 I
cles, suggests peripheral or pseudopuberty.1-3 We
5 D( F- w/ x: c! y3 Ureport a 16-month-old boy who presented with the9 [' ~- ^9 n5 i# M7 [% v& \! r/ e  B
enlargement of the phallus and pubic hair develop-
4 k5 J# Y4 z# a2 C& ^( Xment without testicular enlargement, which was due- o9 P2 f: b; G4 c( t
to the unintentional exposure to androgen gel used by. ^! x9 X+ u7 U5 H1 p# D
the father. The family initially concealed this infor-6 \; l; N/ F$ e8 p) D: `/ @3 G( b
mation, resulting in an extensive work-up for this
% E8 d' [* W7 Dchild. Given the widespread and easy availability of
8 I7 M: t' f; H" ~3 e+ s) K6 K' ftestosterone gel and cream, we believe this is proba-: J3 L8 m* D0 ]
bly more common than the rare case report in the/ m' G: O* N% H& X% B
literature.4) N$ W5 A; O4 X5 f: x
Patient Report* x( H( T+ A4 }* r' _
A 16-month-old white child was referred to the8 Q1 s; p. w- R+ j$ R$ M
endocrine clinic by his pediatrician with the concern- y* S; Q3 I) F5 y8 P- ?
of early sexual development. His mother noticed( d" w; m6 L, S0 [9 M7 [
light colored pubic hair development when he was
& j" T4 _; y0 P  Y$ e0 P4 |( \From the 1Division of Pediatric Endocrinology, 2University of% e. s$ q- t0 P1 A
South Alabama Medical Center, Mobile, Alabama.
8 K( e4 f! L$ k0 y. f  o4 xAddress correspondence to: Samar K. Bhowmick, MD, FACE,. \1 A6 s! l& {( g- j- |8 u
Professor of Pediatrics, University of South Alabama, College of
, Y: R6 a5 L0 zMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. Y( V% B. {0 `% l3 ~4 P/ w& ~& y) He-mail: [email protected].4 }1 S1 W! j" l' F0 W9 z# t
about 6 to 7 months old, which progressively became
  x8 Z% J6 |3 g& |" U/ u6 odarker. She was also concerned about the enlarge-+ g( J; y6 Z- w* [
ment of his penis and frequent erections. The child+ M+ p% ~0 i$ M
was the product of a full-term normal delivery, with
( e' R; @2 y. {& @' D* K) sa birth weight of 7 lb 14 oz, and birth length of( \$ u) N$ K; o: L( j% f) `0 F0 O0 {
20 inches. He was breast-fed throughout the first year9 d6 F, W8 `& R6 f
of life and was still receiving breast milk along with
3 H7 Y  `" @* psolid food. He had no hospitalizations or surgery,  @5 F& [; [- g( [: k& S( ?% `
and his psychosocial and psychomotor development
. y6 C8 x5 R1 `7 ^9 O( c  rwas age appropriate.
0 X' M+ \8 x% j0 s5 _4 W3 j/ DThe family history was remarkable for the father,
! l$ `* j- k$ Z" k; awho was diagnosed with hypothyroidism at age 16,2 y4 v, J( c0 w- A
which was treated with thyroxine. The father’s
& Q$ Z1 R  y- ^* C: `8 r, L" E0 @height was 6 feet, and he went through a somewhat5 x: x6 ~* D: T1 F# J( o: T1 c
early puberty and had stopped growing by age 14.
/ W1 z2 `4 x# L& e( B3 w" iThe father denied taking any other medication. The' f* Z8 r' L  z; i* e" x# a2 J0 m, H! \
child’s mother was in good health. Her menarche
' T; p7 j7 \. V7 L# f5 C+ awas at 11 years of age, and her height was at 5 feet
) p7 X0 o( [9 o* z* G+ o5 inches. There was no other family history of pre-& I+ S3 X' x. \  t
cocious sexual development in the first-degree rela-
6 v" N6 R  ]. B; R4 Ntives. There were no siblings.
; V" b! X% E! R& F1 E- f) bPhysical Examination( U# R; x( v% @, z6 ?, K
The physical examination revealed a very active,
( m7 E* q* D7 i) Bplayful, and healthy boy. The vital signs documented
7 ^8 u* f3 l' Q2 d% T$ `a blood pressure of 85/50 mm Hg, his length was: @7 v/ X: |9 @
90 cm (>97th percentile), and his weight was 14.4 kg
% U) ?& i5 c- ~: c4 _7 |(also >97th percentile). The observed yearly growth% b5 z0 J* [0 n. S; N  c2 r# e7 w
velocity was 30 cm (12 inches). The examination of
7 }) M! h3 R9 W. X' Dthe neck revealed no thyroid enlargement.& l( b0 `" U9 T8 d- J
The genitourinary examination was remarkable for
0 z3 i$ Q/ Y' e  O! M4 cenlargement of the penis, with a stretched length of) Z* r7 M* v) r- T; q" h) g
8 cm and a width of 2 cm. The glans penis was very well0 l, v' o- ^! P
developed. The pubic hair was Tanner II, mostly around# X( P5 G9 y$ Y- r) z" ?
540& g/ w1 W5 f+ A1 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% l1 l; ~) m6 f% j0 O1 K
the base of the phallus and was dark and curled. The( j9 x' O0 \( e$ v5 c7 k; c/ _
testicular volume was prepubertal at 2 mL each.
; u9 E9 c, N% ?& hThe skin was moist and smooth and somewhat/ U6 K* A5 v9 o$ A
oily. No axillary hair was noted. There were no) O+ ]- I! h) G% H
abnormal skin pigmentations or café-au-lait spots.7 {6 o  L4 `. s+ @" Y0 M
Neurologic evaluation showed deep tendon reflex 2+
. s3 k4 X8 M, s+ O/ j" ?4 vbilateral and symmetrical. There was no suggestion* x6 S( h- N/ F6 Q2 R, @
of papilledema./ k/ O9 s% E  C) C# A: v
Laboratory Evaluation
+ D+ q. S/ |$ S4 g, NThe bone age was consistent with 28 months by
0 z4 B/ K( g$ ]; @8 {3 B- Q! yusing the standard of Greulich and Pyle at a chrono-
4 b! Q* j) q5 j- X3 C0 |logic age of 16 months (advanced).5 Chromosomal
" H% P. E. C$ l/ o( Gkaryotype was 46XY. The thyroid function test
% F, {5 c7 p% ^1 P- H3 @+ @% d* ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 P) {" V6 n: n/ e3 tlating hormone level was 1.3 µIU/mL (both normal).
7 j, M5 n$ o: IThe concentrations of serum electrolytes, blood
, D; P( c6 `1 u5 A; s* Wurea nitrogen, creatinine, and calcium all were9 \+ Q: Q2 b' @) g* t* g
within normal range for his age. The concentration" K( z0 p; p" q* z$ w( Z  Y) |  l
of serum 17-hydroxyprogesterone was 16 ng/dL
: |# n1 L+ k& Y- p) E) P, z6 ~(normal, 3 to 90 ng/dL), androstenedione was 20
' z8 Q7 k$ T! q9 `6 Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& w# f4 f) {7 `( L# m  h/ ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: o, o4 R* M& `7 B4 K3 L/ s% x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ c( M8 N) V, x, c2 T
49ng/dL), 11-desoxycortisol (specific compound S)
/ P* Z1 C8 v  s; x9 f: k+ y6 Qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" P. c; Z) G6 ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 E1 u/ d: h' ^4 C4 C. O& _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* @2 y+ t0 @) d9 h& T# g0 g/ [
and β-human chorionic gonadotropin was less than
4 V/ R4 j$ p; t/ h5 @5 mIU/mL (normal <5 mIU/mL). Serum follicular
* e' \, B4 Q. ^, nstimulating hormone and leuteinizing hormone) K$ m. G& \4 G) U  _% v0 Z
concentrations were less than 0.05 mIU/mL5 I, _( G  g  O0 |( q' a! w
(prepubertal).
' D2 i# P& [' D: z& {, F* uThe parents were notified about the laboratory
) g- P8 m0 E' Vresults and were informed that all of the tests were
" D+ z9 L3 e& `- a! s4 m  z$ nnormal except the testosterone level was high. The
/ G6 E6 e5 |& B, s, Z( H2 l7 b3 Cfollow-up visit was arranged within a few weeks to
3 t0 s% x, v5 R+ S# f) U- m6 uobtain testicular and abdominal sonograms; how-
8 z" r) r! N+ `5 Jever, the family did not return for 4 months.
) n! H$ s  x& b* {( M* [Physical examination at this time revealed that the+ H. T+ h5 N! v/ v; ]1 w
child had grown 2.5 cm in 4 months and had gained
$ ?; ?9 c: u- |2 kg of weight. Physical examination remained
! Y* q; p: m; J9 h9 ?4 Aunchanged. Surprisingly, the pubic hair almost com-  r! {' \' ]3 Q. L
pletely disappeared except for a few vellous hairs at9 K/ x" ?/ T( L: P8 u
the base of the phallus. Testicular volume was still 2
7 }& R+ {9 U5 K+ hmL, and the size of the penis remained unchanged.
  e& x9 U( |) O& m- P1 OThe mother also said that the boy was no longer hav-
- D- K- _7 x8 I. E/ b8 bing frequent erections.
& c5 c1 a' a7 F* a" |  qBoth parents were again questioned about use of
# j& y5 V, j- a  ?any ointment/creams that they may have applied to
( E- O- N7 F6 a# C9 ]% Athe child’s skin. This time the father admitted the
, G0 E% _$ u. C; h# cTopical Testosterone Exposure / Bhowmick et al 541. F, s8 `8 i+ |  A! ~% i
use of testosterone gel twice daily that he was apply-
3 r" V8 a( [% g, Ting over his own shoulders, chest, and back area for
) s6 P7 _$ Y6 V- R8 V6 p0 Ua year. The father also revealed he was embarrassed$ K, {, }0 l# x7 R6 a
to disclose that he was using a testosterone gel pre-
4 C4 `, A( G0 B0 r6 Kscribed by his family physician for decreased libido
) P2 N6 b) ~/ z4 |; [secondary to depression.
! a1 y( ^( @; x4 N8 ?# oThe child slept in the same bed with parents.! T3 Z$ J) y( D9 g- s9 M
The father would hug the baby and hold him on his2 s3 T! D- M1 M7 |. I$ A9 a
chest for a considerable period of time, causing sig-' C6 I5 J- u6 }) R3 R
nificant bare skin contact between baby and father.% G9 M$ H1 G* B$ x% y  Z
The father also admitted that after the phone call,! U! @5 D% [. d  I+ v
when he learned the testosterone level in the baby3 p9 ~, k% ^7 j6 }' ~) z
was high, he then read the product information; g* p7 H" y  E9 ]/ N5 [
packet and concluded that it was most likely the rea-8 v" x2 G1 a+ N2 j( B
son for the child’s virilization. At that time, they/ r4 t* [$ ^, H$ I
decided to put the baby in a separate bed, and the
6 X% ?- o0 |, V3 R/ q3 qfather was not hugging him with bare skin and had
- H& t, ^% C; C1 X0 D  _been using protective clothing. A repeat testosterone
! ]- h& H7 R+ l% K- j2 ktest was ordered, but the family did not go to the8 W4 D7 t5 f1 F  p5 h! X6 \
laboratory to obtain the test.
5 w9 ^5 R- H1 |' q5 G$ w, m8 g& M( ~Discussion( F7 @+ i1 `5 }% x* Y" q: p
Precocious puberty in boys is defined as secondary
7 c0 f' Q5 u% l- c7 csexual development before 9 years of age.1,4
5 p- c2 y3 b; p) sPrecocious puberty is termed as central (true) when- Z9 @6 U/ r. c& N2 i) a; M
it is caused by the premature activation of hypo-
2 D  g4 N9 B( m- [2 vthalamic pituitary gonadal axis. CPP is more com-
/ Y2 X1 {2 E+ r7 d- [4 B' nmon in girls than in boys.1,3 Most boys with CPP
" v0 x" D" Q) }may have a central nervous system lesion that is. [# P0 _5 L( a
responsible for the early activation of the hypothal-, m0 N, a) q- R& F$ D; U  D
amic pituitary gonadal axis.1-3 Thus, greater empha-2 V  g2 a. P! X# l. i1 W
sis has been given to neuroradiologic imaging in8 a1 u8 A' s+ o
boys with precocious puberty. In addition to viril-4 E6 c! |5 ?! {
ization, the clinical hallmark of CPP is the symmet-
$ r1 r+ M2 o8 U6 ^8 l: `' k+ n# xrical testicular growth secondary to stimulation by6 R2 V/ W6 l1 e9 F2 _+ E
gonadotropins.1,33 j3 o; ^8 g  j+ P
Gonadotropin-independent peripheral preco-
- r: T6 L# \) ocious puberty in boys also results from inappropriate6 [* y7 p( R/ ]
androgenic stimulation from either endogenous or& j! n- s8 W- j. E1 L) d
exogenous sources, nonpituitary gonadotropin stim-
, w$ `3 |1 Y2 ~* d6 `: W: qulation, and rare activating mutations.3 Virilizing; v5 }4 A  N: P4 L+ ?% R
congenital adrenal hyperplasia producing excessive7 {7 w4 h/ r* S
adrenal androgens is a common cause of precocious& N; @- G- D6 C6 ~+ h/ ]2 i, h9 i
puberty in boys.3,4
# F+ j/ e4 X( U% u% NThe most common form of congenital adrenal
/ p2 K! m% o4 X/ ~hyperplasia is the 21-hydroxylase enzyme deficiency.5 C5 q/ G, C* W5 N* p) M+ D
The 11-β hydroxylase deficiency may also result in
" O- p' g5 V: v& W9 Y" Uexcessive adrenal androgen production, and rarely,  j* S' H8 ~; T7 b% A
an adrenal tumor may also cause adrenal androgen
) \6 [2 d% U8 {+ o: b: A, B8 pexcess.1,3
' k, ~8 Z: |% q" c# i2 g- F8 r4 @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 x8 M& i* N9 u0 S" Y% O0 ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ }% s4 l3 A3 W: |" yA unique entity of male-limited gonadotropin-5 G# t5 x) i" N5 [( ]  @5 n
independent precocious puberty, which is also known1 W# T& H- H5 e5 ?* Z% s
as testotoxicosis, may cause precocious puberty at a
( k* z$ I( `: N8 m  Wvery young age. The physical findings in these boys$ w/ k* f( h( B* J1 m0 F3 p# b! F. N% }9 E% `
with this disorder are full pubertal development,% l3 }9 L2 h) b) ?  A4 T% r; o
including bilateral testicular growth, similar to boys% Z8 o0 r9 ?3 [1 u  S
with CPP. The gonadotropin levels in this disorder- X$ a/ N, Q9 w, F$ L+ M  F
are suppressed to prepubertal levels and do not show; a  h( q9 w3 H% d) M$ s7 C
pubertal response of gonadotropin after gonadotropin-
' B3 F' o$ i$ E  e7 ^* x$ wreleasing hormone stimulation. This is a sex-linked# C( b+ z# I- N; R" `' P
autosomal dominant disorder that affects only) u6 ^7 Y* I3 M
males; therefore, other male members of the family2 c! ~3 t) p7 q! d6 R( l
may have similar precocious puberty.3. O' Q$ w" R% P/ N" a0 O
In our patient, physical examination was incon-
7 b/ J2 H  d$ usistent with true precocious puberty since his testi-& u  ]( c) \5 i6 D- w( T
cles were prepubertal in size. However, testotoxicosis2 K3 B- y' W* q" }' n. B
was in the differential diagnosis because his father; v* g; u$ S. X
started puberty somewhat early, and occasionally,- l8 W2 U. W! c4 f4 \
testicular enlargement is not that evident in the: M! ~! w; B: h: X) q
beginning of this process.1 In the absence of a neg-
, }; m% C  ?% Z1 Q# hative initial history of androgen exposure, our
: \' R# I4 O  H. M6 `" Z! Q& u. qbiggest concern was virilizing adrenal hyperplasia,7 C3 R, l$ D" f- y2 X: ~. o' h5 p
either 21-hydroxylase deficiency or 11-β hydroxylase6 T- I6 N0 `1 D  H2 B: d- s
deficiency. Those diagnoses were excluded by find-
0 }7 j, a6 g8 {8 Y% p1 ]) ring the normal level of adrenal steroids.
# y! A& E0 H5 |, HThe diagnosis of exogenous androgens was strongly& s0 v% {9 T$ C8 r. D8 d% f# K  b- e
suspected in a follow-up visit after 4 months because% O$ R4 d( T8 f. ?
the physical examination revealed the complete disap-; o$ w9 R! E8 e
pearance of pubic hair, normal growth velocity, and9 V  f# \! P- X2 \
decreased erections. The father admitted using a testos-
$ M& f2 L9 ~- F* \: @terone gel, which he concealed at first visit. He was5 B% ?5 h. f, j9 c9 ]# W: X4 }
using it rather frequently, twice a day. The Physicians’
- P' X1 h" b' iDesk Reference, or package insert of this product, gel or$ y" T) D+ s# [! x. F6 T- S6 n
cream, cautions about dermal testosterone transfer to, R, ]" F7 E$ I4 y  K6 Y* |" A( z
unprotected females through direct skin exposure.6 S6 @' o5 c' W. z1 M
Serum testosterone level was found to be 2 times the7 U: m. v' C$ ]# ?$ w2 q3 C
baseline value in those females who were exposed to
6 k' s: {# @" g0 p* a. beven 15 minutes of direct skin contact with their male3 A) E5 O" k  M: ~, g" e' L
partners.6 However, when a shirt covered the applica-
; E8 _+ A9 u0 U$ i/ _: W- ^! ption site, this testosterone transfer was prevented.
  P* w- v' T1 f2 U# k) N6 bOur patient’s testosterone level was 60 ng/mL,
6 }) f8 B" T* R2 Nwhich was clearly high. Some studies suggest that
, X9 k% b4 }. y6 \5 z6 Rdermal conversion of testosterone to dihydrotestos-" @3 L  S6 N0 g  C; I8 R8 H& i
terone, which is a more potent metabolite, is more# X! z# g) F- m0 a3 K
active in young children exposed to testosterone+ r3 _( Q7 v3 i" ]5 E
exogenously7; however, we did not measure a dihy-
$ T0 T+ a6 X& _. E. jdrotestosterone level in our patient. In addition to( b& h6 }; B' j  k, {! T8 [0 W
virilization, exposure to exogenous testosterone in% z$ N7 V. H- `  k8 ^, u: ^
children results in an increase in growth velocity and, s+ n; j9 o$ \; G
advanced bone age, as seen in our patient.
! r' K5 a# f3 F3 K, I2 Z' PThe long-term effect of androgen exposure during
" X  B2 h. p% g. F; V& cearly childhood on pubertal development and final  ~6 ?- s, x! d  [" u3 Z
adult height are not fully known and always remain4 E$ ]. z8 `7 i# B: k0 r9 f6 U
a concern. Children treated with short-term testos-
9 W4 l* w3 h5 K8 Fterone injection or topical androgen may exhibit some5 O! N" Z0 u" X/ T
acceleration of the skeletal maturation; however, after
9 U  q# n' N; ]0 Z/ D& u+ ncessation of treatment, the rate of bone maturation8 O  F- y3 ~9 q# z
decelerates and gradually returns to normal.8,93 h% P' v* Z! Q: S7 O
There are conflicting reports and controversy
9 Q' l: R3 g1 l# z( Jover the effect of early androgen exposure on adult6 a/ J0 |0 Z/ d" h% m, h* B0 V
penile length.10,11 Some reports suggest subnormal5 t  p. o% E0 b6 g
adult penile length, apparently because of downreg-6 j3 `1 T" {& T' y9 a6 z7 Q
ulation of androgen receptor number.10,12 However,; D6 `3 b3 C. W0 @4 y& U  o' a
Sutherland et al13 did not find a correlation between$ I+ g- h4 k; J! j
childhood testosterone exposure and reduced adult
0 z9 }- z  A' m7 A& q$ U3 x; ipenile length in clinical studies.. h. e% \$ f! W
Nonetheless, we do not believe our patient is! n4 m- s; a( ]! s) E7 ^9 \
going to experience any of the untoward effects from
6 X; S; x$ b1 ?( i& Y. ?testosterone exposure as mentioned earlier because7 Z# S: w5 {- n+ B( E
the exposure was not for a prolonged period of time.+ _, V  I8 [: ?4 A+ j
Although the bone age was advanced at the time of' t8 B3 k( [( G0 f
diagnosis, the child had a normal growth velocity at
0 G# }; @* X: Z, [/ Q  _( mthe follow-up visit. It is hoped that his final adult
2 b! P6 T0 q6 Y6 g) i; y- @8 _# }height will not be affected.
5 g9 J* t0 P& `8 L' l8 |Although rarely reported, the widespread avail-: ]- r1 ]8 u$ ]& Q' W8 p9 O" G" t
ability of androgen products in our society may
( P; d* l! I' x% m7 B5 Vindeed cause more virilization in male or female, r" f& h# Q; B) R$ Y  \# b
children than one would realize. Exposure to andro-5 f! }. j( I7 r! F' y9 E7 t
gen products must be considered and specific ques-8 j) E" ?+ o8 Z* S2 i. o% m
tioning about the use of a testosterone product or
* O% @; e/ d' O5 t; J! }gel should be asked of the family members during
  c4 f7 W. E9 f, H. d* B/ Hthe evaluation of any children who present with vir-# x9 A, V1 u% R) s- `
ilization or peripheral precocious puberty. The diag-" o8 f2 N9 ^  I9 e. G: ]
nosis can be established by just a few tests and by
* d3 F1 J0 w* C6 O4 D/ @appropriate history. The inability to obtain such a0 W, V' q1 c: \9 ^* Q8 x
history, or failure to ask the specific questions, may, I& c- X- o) M1 x- o# L
result in extensive, unnecessary, and expensive
( F) M' C0 r4 e. H1 a) Binvestigation. The primary care physician should be1 {  F+ C8 r; o$ G4 K! U
aware of this fact, because most of these children/ O  S) g- y# W/ B6 T! k5 {
may initially present in their practice. The Physicians’5 ]3 f  j, C3 o; r: ~
Desk Reference and package insert should also put a
3 f1 P: g8 O0 b  _+ Owarning about the virilizing effect on a male or
8 k4 U# n1 B) E7 A) J: Hfemale child who might come in contact with some-$ W/ z: b6 b6 b, A
one using any of these products.
2 f8 a0 R) l" }; Z; }# bReferences
' a' c3 y. f! g( ?; q' c" x1. Styne DM. The testes: disorder of sexual differentiation
5 z" {8 G) s% }0 Rand puberty in the male. In: Sperling MA, ed. Pediatric. V) Z/ u# g( B4 ~* _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! Y1 h, X; `- O2002: 565-628.' i6 y' m" f6 w: T: Q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 p1 s7 Q, k" s3 b4 P: vpuberty 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
9 R3 b9 x( N+ ]5 m) D8 U+ W# G* Z
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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