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Sexual Precocity in a 16-Month-Old
9 X8 M+ d/ s: `6 NBoy Induced by Indirect Topical
# H' N, g, Y, |) ~: I  e; j7 QExposure to Testosterone
& q# T' i" j9 z  HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% p3 H& @# J6 _and Kenneth R. Rettig, MD1  g2 S, C- X; M% E" g* k8 T
Clinical Pediatrics
2 ~2 M. Q) s0 h6 A, ~Volume 46 Number 6
% Y7 M6 I3 Z7 X6 w( `, l9 HJuly 2007 540-543
9 l" ~9 F; t+ m; n1 \© 2007 Sage Publications/ L9 q) w+ a6 _" Y6 t
10.1177/00099228062966518 B. |: j/ Y* S% Q* I9 L) X
http://clp.sagepub.com5 k) b& S3 [' |
hosted at- Z! D9 e/ I: V% e5 N' w7 |
http://online.sagepub.com
0 s  Q4 m9 v7 WPrecocious puberty in boys, central or peripheral,& _/ z- Q0 l: ]; _# d  j5 Z- d5 N
is a significant concern for physicians. Central
; W% w1 Q8 N8 F2 S1 `precocious puberty (CPP), which is mediated
% I6 Z* k$ u- f* U9 ^( Othrough the hypothalamic pituitary gonadal axis, has
! l4 |/ P( A7 w6 |/ b# Ia higher incidence of organic central nervous system
, l: N. W/ j! A. e" Y" Qlesions in boys.1,2 Virilization in boys, as manifested
( v  A# [) i, W/ `3 V8 @by enlargement of the penis, development of pubic2 f6 D# o# F, H; o- ]7 y
hair, and facial acne without enlargement of testi-
  J+ C$ E6 q% z( f1 ~7 Z5 \cles, suggests peripheral or pseudopuberty.1-3 We
% w" w$ `: F$ h3 X; @5 w6 o2 Jreport a 16-month-old boy who presented with the. p! E* P+ F5 G% n1 V- M; f
enlargement of the phallus and pubic hair develop-
. W! G2 z9 W4 `" N- R2 Ument without testicular enlargement, which was due
- Q$ D* X  G( l7 S& G! D1 `to the unintentional exposure to androgen gel used by
$ d+ @5 d0 s! }* Z. z& M0 s. jthe father. The family initially concealed this infor-
$ i1 E* \; C5 J! O9 T6 tmation, resulting in an extensive work-up for this
# ^5 o5 y% t8 n5 x" nchild. Given the widespread and easy availability of
) u  E& J6 t/ e& k8 Ctestosterone gel and cream, we believe this is proba-
  F2 f$ k/ E- d! y9 S, z4 Zbly more common than the rare case report in the# e1 s/ @/ Q8 Y# p- I
literature.4: ]6 Z( k- C5 f2 Z: V, c4 z4 {3 q
Patient Report% W! h) m- p( b
A 16-month-old white child was referred to the
6 m, o/ [2 K' ]. N! Y  T3 `  qendocrine clinic by his pediatrician with the concern2 F6 P4 a4 V; m2 o9 j
of early sexual development. His mother noticed" K, l* X5 L- O- o
light colored pubic hair development when he was
3 {3 a" `  R' j. \5 K" T, bFrom the 1Division of Pediatric Endocrinology, 2University of
9 F! z9 q& X& Q# R% PSouth Alabama Medical Center, Mobile, Alabama.( x/ h* B3 g+ C- y7 h# n
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 z" K! J/ o+ a( [0 R2 iProfessor of Pediatrics, University of South Alabama, College of; \. F+ y9 T* x, N0 ]8 `8 j, ]( x# I7 f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) q$ }7 ]: A& e5 Q: He-mail: [email protected].) f2 s4 c, _" x' m5 C& _& @
about 6 to 7 months old, which progressively became+ g5 C, g$ o3 y8 R
darker. She was also concerned about the enlarge-
( Y8 x1 H& u2 L2 e: V- l" w4 Dment of his penis and frequent erections. The child
( E' L# ]! g0 W' [! L8 Nwas the product of a full-term normal delivery, with
$ F4 Z& }' Y6 |8 F8 W) G& Ta birth weight of 7 lb 14 oz, and birth length of
( F" J' g$ }3 S+ N0 j! c20 inches. He was breast-fed throughout the first year; j  h6 \" {  S* V2 {
of life and was still receiving breast milk along with
5 W5 ^; F& Y9 g. z/ h4 \/ Xsolid food. He had no hospitalizations or surgery,
# H! H' q& y5 ?and his psychosocial and psychomotor development7 K1 ~+ K! q" X1 W
was age appropriate.: u8 G, b2 x# `) z0 D8 f7 `3 b: j5 Q
The family history was remarkable for the father,8 D) O! w# w; n1 D
who was diagnosed with hypothyroidism at age 16,( d9 l1 v2 y" v- k
which was treated with thyroxine. The father’s9 ]+ Q8 v, O& k
height was 6 feet, and he went through a somewhat  B+ {4 n4 A; _+ z( K& n
early puberty and had stopped growing by age 14.6 w- h2 s7 ?; L' {2 m3 L
The father denied taking any other medication. The( \" P, d9 H! _
child’s mother was in good health. Her menarche0 f; N+ Y6 N) X% U% ^' |7 K5 M
was at 11 years of age, and her height was at 5 feet
4 j2 Y  G; z2 ?% g4 b& O5 inches. There was no other family history of pre-  l0 `3 J/ F$ |, }( }) |
cocious sexual development in the first-degree rela-
2 S6 g+ k7 N2 b2 wtives. There were no siblings.1 Z+ p6 a0 Y' O8 H, W! @5 P
Physical Examination0 D- A; j, o) e8 R, y8 w
The physical examination revealed a very active,& k& I6 k" W0 K# l) G
playful, and healthy boy. The vital signs documented
) T# |  K5 d: ^1 Ha blood pressure of 85/50 mm Hg, his length was7 X1 w2 M' m, P- C
90 cm (>97th percentile), and his weight was 14.4 kg
& E( `! p/ _- a+ I* |8 P(also >97th percentile). The observed yearly growth+ z# U* d1 q6 y- i' N7 G1 v
velocity was 30 cm (12 inches). The examination of3 Z( m) K2 x" j
the neck revealed no thyroid enlargement.
7 w8 q; [& V9 `, Q4 Z  rThe genitourinary examination was remarkable for
* x  z2 ?; r8 ~9 M  cenlargement of the penis, with a stretched length of
2 c2 {: v4 n% b" Y. z/ g; x/ F" k8 cm and a width of 2 cm. The glans penis was very well
" w, T0 A) y# Z/ H. Rdeveloped. The pubic hair was Tanner II, mostly around! v( `2 l7 I: |  G
540
! ^* S) h2 r: I4 O( K- hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 Q: j- Z7 q0 e6 d  z7 K# G, I
the base of the phallus and was dark and curled. The5 J2 x1 l) W3 D: k
testicular volume was prepubertal at 2 mL each.& e: T2 p* {9 i- k) O
The skin was moist and smooth and somewhat
9 T8 |5 R. d! I- noily. No axillary hair was noted. There were no) g- v8 ]3 V$ H% I0 {- T
abnormal skin pigmentations or café-au-lait spots.
5 G& B/ o$ m5 d/ |  tNeurologic evaluation showed deep tendon reflex 2+" d8 m# C5 t8 M: X7 Y
bilateral and symmetrical. There was no suggestion
6 n. `3 U* U; R: ~of papilledema.
# S$ P* S* V1 {# OLaboratory Evaluation
% i9 J( ~4 B; ?' _The bone age was consistent with 28 months by
7 u- y0 A* d2 k' U1 `) R6 Y" busing the standard of Greulich and Pyle at a chrono-
) |1 l. N, k3 r, ^7 `logic age of 16 months (advanced).5 Chromosomal
; ]9 \7 N9 Y) w) S% z; c) X$ l7 t& Gkaryotype was 46XY. The thyroid function test
  r8 Q  ?8 Y+ K2 v# ]& Eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 m- R! q: J, \$ z) \  f' N; olating hormone level was 1.3 µIU/mL (both normal).8 `9 Z! z7 m3 U- O- f2 M8 `& g) t
The concentrations of serum electrolytes, blood
$ Q' C# k+ `" f8 eurea nitrogen, creatinine, and calcium all were4 K9 o  K6 Y- a/ N2 l
within normal range for his age. The concentration
; Y8 r2 o3 r1 U* G9 oof serum 17-hydroxyprogesterone was 16 ng/dL
8 o& U* b2 Z6 y(normal, 3 to 90 ng/dL), androstenedione was 20. y$ O' ?7 X& O  b: l, @
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. @/ {1 z0 P4 L3 x1 ]  Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),' S1 }) G: z. @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; J) C4 A* u$ M3 l2 s- s, \7 n
49ng/dL), 11-desoxycortisol (specific compound S)7 v9 {3 R' V5 y' R; P1 w& M8 @( S
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 A/ ^* x6 p2 |9 @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 q/ \4 m4 w( r9 M" B% m0 r
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 K; H2 C) j0 @$ A6 W) {  P3 O0 {
and β-human chorionic gonadotropin was less than( v6 O  u0 \' |- r# a
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% b4 t# p" s" c# e: z% o; ]stimulating hormone and leuteinizing hormone
' Z3 ~; I! {. j& x+ Q, a2 bconcentrations were less than 0.05 mIU/mL- u7 D& o+ z4 E  V; J
(prepubertal).
- \/ g% C6 x# m6 `& t, p7 |  pThe parents were notified about the laboratory
# `. z$ j, \1 u1 T4 s% X/ m, ~results and were informed that all of the tests were
, b9 Y$ t0 {. a! R- K; `6 ]normal except the testosterone level was high. The  x& q/ j$ `4 [. G% G4 o
follow-up visit was arranged within a few weeks to
0 |+ s- x7 z& G0 [! f$ T& fobtain testicular and abdominal sonograms; how-* F( ]1 P. w6 d; m# d0 H8 \: d9 _
ever, the family did not return for 4 months.
% z) H8 Q% Z. @" Q: PPhysical examination at this time revealed that the  D( E7 R$ R$ m4 Y( B
child had grown 2.5 cm in 4 months and had gained+ X$ r- B- P' T) @5 ?
2 kg of weight. Physical examination remained
8 R' ^" H8 h% L* `unchanged. Surprisingly, the pubic hair almost com-
- t: f/ v$ z) C' j& J! R3 \pletely disappeared except for a few vellous hairs at
; z1 ~  [: |; p, T( \! U+ C2 `' }2 _4 O. zthe base of the phallus. Testicular volume was still 2( X# F) C+ X$ @7 u/ @' `( j
mL, and the size of the penis remained unchanged.
: c3 g0 U1 R6 Q( c& ^9 V# SThe mother also said that the boy was no longer hav-
8 A$ C+ |' z, t* N4 Z. {ing frequent erections.% {  G1 h+ T( F/ L  i% P* Z: C/ c
Both parents were again questioned about use of& n9 E0 Z9 U) R. `1 P+ y2 h' X
any ointment/creams that they may have applied to
$ ]8 i( q$ e7 S5 L* V* Z" W& Qthe child’s skin. This time the father admitted the  h  V+ j7 e0 d" g
Topical Testosterone Exposure / Bhowmick et al 5412 E5 |; \% B/ r6 g8 X- P) C
use of testosterone gel twice daily that he was apply-
* s4 n# v# _; ting over his own shoulders, chest, and back area for& Z0 a0 r% @8 R1 I6 F$ u! h
a year. The father also revealed he was embarrassed
  u3 C8 Z, O# {" _0 J- G. ]; gto disclose that he was using a testosterone gel pre-1 r9 F  t6 s' D! F
scribed by his family physician for decreased libido( g- l" h+ \# i8 F3 x4 h) n: \
secondary to depression.
, o; a4 H# J3 ?+ ^. fThe child slept in the same bed with parents.# r# e" |! T- \
The father would hug the baby and hold him on his
# ^* T, D' R2 h& }: Xchest for a considerable period of time, causing sig-
- _9 E& i. F  w4 n. f1 d4 E, S4 cnificant bare skin contact between baby and father.
: {1 S0 i+ W  ]; M9 R1 y+ |& A! z$ V, cThe father also admitted that after the phone call,
$ Q1 k% w/ {% x9 D* V  U, B1 ywhen he learned the testosterone level in the baby1 F, c1 j' p7 `0 \; a
was high, he then read the product information! y) P. A6 u7 S! T2 S9 H, m
packet and concluded that it was most likely the rea-) N) Q0 d5 ^* ^" v
son for the child’s virilization. At that time, they% Y* U$ A$ ?3 i3 B8 R
decided to put the baby in a separate bed, and the* H# u( w8 p" ~% v2 h1 e5 I
father was not hugging him with bare skin and had" p; f7 a* ?1 w! v0 T, d7 R/ ?6 _. V
been using protective clothing. A repeat testosterone, i6 p: y+ t3 i1 v
test was ordered, but the family did not go to the' u9 |  }# u# A! C  o
laboratory to obtain the test.
' |7 k$ {4 L1 ^" Q& SDiscussion  a* h. L- A4 s
Precocious puberty in boys is defined as secondary' L# E; A" R- N: |
sexual development before 9 years of age.1,43 D/ P' t$ `  N% j5 K) e4 b
Precocious puberty is termed as central (true) when/ r, j6 S, f% \$ A( k) K. G" |
it is caused by the premature activation of hypo-
; v4 ]' I0 b5 O. R) F+ e) uthalamic pituitary gonadal axis. CPP is more com-$ x; Y5 q" f% t3 @
mon in girls than in boys.1,3 Most boys with CPP  V. e$ i# L% E
may have a central nervous system lesion that is
' z7 D9 l, o% F% H  Z( gresponsible for the early activation of the hypothal-( c) K0 E$ j% b+ o' C
amic pituitary gonadal axis.1-3 Thus, greater empha-
# Z3 Y& y' n5 u* Q3 F) u2 c- Isis has been given to neuroradiologic imaging in
( }# H+ V( E3 I$ }boys with precocious puberty. In addition to viril-
! W/ f  w1 R  fization, the clinical hallmark of CPP is the symmet-( A& S2 ^( R! c; I* {; X. R. G8 g! j
rical testicular growth secondary to stimulation by- t  H. s5 p; x9 O' D8 q4 S  {
gonadotropins.1,3) X; U- _% S0 w
Gonadotropin-independent peripheral preco-6 R; q. F' S. s
cious puberty in boys also results from inappropriate
) h4 x( p1 _4 {1 a! |+ handrogenic stimulation from either endogenous or
: g* l3 |' j( Hexogenous sources, nonpituitary gonadotropin stim-) L; |- Y6 m+ `" \- i: X# v
ulation, and rare activating mutations.3 Virilizing: u$ v& X, y# ^  Y
congenital adrenal hyperplasia producing excessive) H- u' e: U( s5 E
adrenal androgens is a common cause of precocious
) q* A( X' B; r5 \puberty in boys.3,4
/ v. k3 j9 c+ ]) @' z! _$ A' Z( AThe most common form of congenital adrenal* B. w: P' K0 K5 |
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ w; K$ v( Q2 X4 s1 v1 O. ~The 11-β hydroxylase deficiency may also result in
9 _( c: F0 H' x- @( ^( H( T" Bexcessive adrenal androgen production, and rarely,# X8 F+ g9 f7 k) U
an adrenal tumor may also cause adrenal androgen
0 j' x+ Z8 b) k; v) Mexcess.1,3
" l' A" G7 L. y) ?+ K6 Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" E" I+ Q0 b9 k; U) s) ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  \3 l# r9 f, a; T- q! e# \# E
A unique entity of male-limited gonadotropin-
7 k1 f! [" x! y6 j7 {- |independent precocious puberty, which is also known3 w$ q' c/ a: Q" f
as testotoxicosis, may cause precocious puberty at a. M4 K7 n8 |: u- k8 \
very young age. The physical findings in these boys
. w# I9 o& ]" H; q4 Owith this disorder are full pubertal development,
( ?$ u6 i' y" Z  P7 Q2 Q* lincluding bilateral testicular growth, similar to boys
4 }$ K. Q3 m7 G/ {4 e0 T% Z, Mwith CPP. The gonadotropin levels in this disorder& }; D; r0 Q. M6 z4 z
are suppressed to prepubertal levels and do not show2 w4 R0 r: w1 C7 Z$ V6 O7 ^4 q8 x
pubertal response of gonadotropin after gonadotropin-/ m  v+ `7 ?$ o% f; ?
releasing hormone stimulation. This is a sex-linked
6 T2 A/ h. ?9 c' _# _+ w; wautosomal dominant disorder that affects only4 m( B' T2 v3 J( T! o0 L! P
males; therefore, other male members of the family
5 i7 Y. h& T+ h  B- U, L2 vmay have similar precocious puberty.3" Q9 y9 b9 d4 L( v" b' O! |5 V
In our patient, physical examination was incon-: u6 E6 q0 Q' k: T3 ]" g: s
sistent with true precocious puberty since his testi-; C1 \% b7 ^& p7 A
cles were prepubertal in size. However, testotoxicosis- d$ r0 P7 Z* |: \  j1 z! \7 S
was in the differential diagnosis because his father
' R( X4 e6 o  ~2 a: k8 W, G2 Gstarted puberty somewhat early, and occasionally,
3 K' {& u: A3 F  [9 S5 W8 \6 A2 F  G! `testicular enlargement is not that evident in the, R) ~. n# l. T5 Y. I
beginning of this process.1 In the absence of a neg-9 p0 q: p, Y* _3 c8 y0 t1 ?
ative initial history of androgen exposure, our
* h+ B- f' N+ J2 t* F9 h4 Obiggest concern was virilizing adrenal hyperplasia,
5 }8 J; |1 W+ [/ Teither 21-hydroxylase deficiency or 11-β hydroxylase! I) w& q4 C4 S( C! [7 U5 F8 E
deficiency. Those diagnoses were excluded by find-
6 E  ~$ ^$ s* G, a" jing the normal level of adrenal steroids.
6 l7 ?. d# I' y, ^The diagnosis of exogenous androgens was strongly8 F0 w: q1 T6 Q$ T# E' U) o" E4 K
suspected in a follow-up visit after 4 months because
% B% m8 i9 O" j8 X: [7 l7 j# i' J8 Ythe physical examination revealed the complete disap-% t4 Z: T' z0 t1 t- N7 C  N" \7 e
pearance of pubic hair, normal growth velocity, and
; ~- x- K( L8 B& Z$ ?decreased erections. The father admitted using a testos-
0 i; i8 e+ _3 R( [& l" H  a8 A. Hterone gel, which he concealed at first visit. He was
& f& ]6 D, ?5 k; R- o$ susing it rather frequently, twice a day. The Physicians’
5 I3 o. a1 T% [0 nDesk Reference, or package insert of this product, gel or& e2 ]7 m4 i; V( }: a8 _9 x
cream, cautions about dermal testosterone transfer to8 Z' n7 V3 M. H0 o
unprotected females through direct skin exposure.
7 ^; A6 k) s+ [. `+ K% ySerum testosterone level was found to be 2 times the  {! [# F# ~$ I9 t
baseline value in those females who were exposed to
  g" g  `$ K' Q' O, q. weven 15 minutes of direct skin contact with their male
4 j8 X$ J/ g( ?* Qpartners.6 However, when a shirt covered the applica-5 l# D# J' }3 p( D, D
tion site, this testosterone transfer was prevented.
! f  z; B" V6 hOur patient’s testosterone level was 60 ng/mL,
3 m: y. z6 G1 m6 H) H2 \7 M" Ewhich was clearly high. Some studies suggest that! h1 G9 }  H7 S( _* @; F
dermal conversion of testosterone to dihydrotestos-
3 A, c' X9 w$ ]: L& v7 L) yterone, which is a more potent metabolite, is more9 ^9 z1 P( l) D8 Z& I3 {
active in young children exposed to testosterone
; \: S2 M( Q1 @exogenously7; however, we did not measure a dihy-: L- Z' U& j$ r7 i1 h$ |
drotestosterone level in our patient. In addition to  a/ I' D% `3 a+ R; M% j# B: H1 f- f
virilization, exposure to exogenous testosterone in
9 t  Q, [5 R! @. t& Jchildren results in an increase in growth velocity and4 I1 R* j1 r$ u0 O
advanced bone age, as seen in our patient." H: a8 ]; C0 x
The long-term effect of androgen exposure during
. F6 d+ t( H- J0 ?! w8 Oearly childhood on pubertal development and final
- j' ]$ M4 e/ F: Fadult height are not fully known and always remain: [) A& v: l" l. X, M
a concern. Children treated with short-term testos-1 {' f8 l/ @5 {1 {3 d9 n- n
terone injection or topical androgen may exhibit some# h! W7 n- g* v1 g8 R6 s/ ?$ C% n
acceleration of the skeletal maturation; however, after
/ J! p* `1 \0 P! b- Ocessation of treatment, the rate of bone maturation& Q% m. h0 e" V  r) \: I1 J
decelerates and gradually returns to normal.8,9
; d  ~/ b3 f+ L/ M3 uThere are conflicting reports and controversy7 J' o  J% g9 j3 S. O" F" _) G
over the effect of early androgen exposure on adult$ p8 Y7 ?6 C* R1 t7 Y' v  E6 r( @: g
penile length.10,11 Some reports suggest subnormal: h, P/ j$ u; y# R+ b3 V% l4 o- t3 d
adult penile length, apparently because of downreg-  X" U  A1 c' G  R- x0 k. ?
ulation of androgen receptor number.10,12 However,
2 w# |/ ]5 f% g& y% s) ]  ySutherland et al13 did not find a correlation between0 S1 @( ^0 A! v! w. i* N) W
childhood testosterone exposure and reduced adult
! h& K" @$ {# openile length in clinical studies.
* a6 z9 Z  D5 b& y" D- {* b+ A) _9 u: INonetheless, we do not believe our patient is5 F! x3 ?9 ~, d$ Y$ h* c
going to experience any of the untoward effects from
& L9 E' z3 Z! Y9 @6 E' Ytestosterone exposure as mentioned earlier because
' w; J/ e* M4 B* p, Rthe exposure was not for a prolonged period of time.
8 a: c1 _- A1 ~4 vAlthough the bone age was advanced at the time of; S  }% d# `: f8 ]7 e/ K
diagnosis, the child had a normal growth velocity at* q& I" u6 A' M" |# d; x+ o0 `
the follow-up visit. It is hoped that his final adult
3 u, w, s+ L$ m7 q( ]4 x0 a8 @height will not be affected.
" a5 V9 q% i: u& ^4 a" J% ?Although rarely reported, the widespread avail-
& {' }  P) y+ ^/ [% }0 q9 R0 t# ]ability of androgen products in our society may4 |& k; f  O/ x5 G0 Q
indeed cause more virilization in male or female
# W; i+ }; b- `1 h5 u+ ~  [children than one would realize. Exposure to andro-
7 M2 T! {1 e: V7 Vgen products must be considered and specific ques-
% b) T/ j8 h0 n; V; @. y7 Z, C" Itioning about the use of a testosterone product or' i2 R' x  i4 }, L" h( t
gel should be asked of the family members during* o( V: q  Z6 ~( a1 Z& s
the evaluation of any children who present with vir-
4 n+ f( z. R" o' Zilization or peripheral precocious puberty. The diag-$ t4 M% y, T9 l" ~
nosis can be established by just a few tests and by
$ s$ d2 o) v& `2 u  Rappropriate history. The inability to obtain such a8 b( u8 X/ F1 c; G8 C  V
history, or failure to ask the specific questions, may7 Z8 M& U: H: P# z0 O
result in extensive, unnecessary, and expensive
/ ^5 @4 ^5 B  W% P% ~: }investigation. The primary care physician should be
% U2 n& f  f9 o4 h+ t( N& n- iaware of this fact, because most of these children- A* `8 K% [4 _) n" ?5 J; k7 ~
may initially present in their practice. The Physicians’  N, H  v* h: A' B
Desk Reference and package insert should also put a! p* ^5 u8 ?  {' s
warning about the virilizing effect on a male or) U  \0 j5 t/ B3 E8 j
female child who might come in contact with some-
6 O# I4 I4 x4 P# _! t8 [- Xone using any of these products.
1 V, R, E% o; cReferences
8 [& P7 S: J, O1. Styne DM. The testes: disorder of sexual differentiation
) B$ `) G% V" g3 u2 I. j7 gand puberty in the male. In: Sperling MA, ed. Pediatric
2 l5 v' O- |& S% p5 {( LEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) W) x/ c# }6 t6 a) l- Y- k2002: 565-628.3 L, i9 C5 t( g0 M- F3 M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, m& y8 l, o4 d8 p7 ~4 L7 a- |puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old8 W* A+ |) }. |9 F6 C5 F! z
Boy Induced by Indirect Topical
1 d0 l: x6 [  w7 y+ U) V& MExposure to Testosterone
! n6 B: U$ o0 r1 J# z2 i2 tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# c3 I+ N5 n. z+ C
and Kenneth R. Rettig, MD1
+ i8 S4 ~2 h3 }) G5 l( {Clinical Pediatrics) f& m6 K# x/ P* |
Volume 46 Number 6
# x& |- o. q5 g# r$ ]July 2007 540-543& b9 D8 `0 ?$ j/ L+ b
© 2007 Sage Publications2 C; S5 F1 O" [- ], h" k
10.1177/0009922806296651' t! L2 z6 Y& X1 E
http://clp.sagepub.com" O* L' J- b* n3 i/ c& E# H6 E. C$ e
hosted at* }) ]& |& D- }: a
http://online.sagepub.com/ r" z% ~; L% x, v& I
Precocious puberty in boys, central or peripheral,& ~  r5 x2 S5 D
is a significant concern for physicians. Central
, w. S" q, S$ l' {precocious puberty (CPP), which is mediated1 I7 |& j8 C2 `
through the hypothalamic pituitary gonadal axis, has- ?! h; n. V  Q, w2 V6 ]
a higher incidence of organic central nervous system
9 f$ K  B+ U. k+ q' o( N- Olesions in boys.1,2 Virilization in boys, as manifested
" ~  _6 S/ A* O4 y8 p+ _* ]+ _by enlargement of the penis, development of pubic
4 ~  A8 M2 y1 G7 T6 ~0 j! {hair, and facial acne without enlargement of testi-( T' p% E# [. y9 V5 X+ c8 U% @, K
cles, suggests peripheral or pseudopuberty.1-3 We
# o. @, }, v# Sreport a 16-month-old boy who presented with the+ g" P4 }2 M8 E5 q
enlargement of the phallus and pubic hair develop-
# b9 O+ _  ~* E' Oment without testicular enlargement, which was due; x6 v0 g6 C( K9 Y1 E
to the unintentional exposure to androgen gel used by/ {: R* O  g* F% @) i" O( \
the father. The family initially concealed this infor-; X( ]! X/ B2 Z1 L/ q7 \
mation, resulting in an extensive work-up for this. r  ]7 H$ o; N# b
child. Given the widespread and easy availability of
; R0 f: ~/ i9 otestosterone gel and cream, we believe this is proba-
/ B; ]; Q, O' L( }; T0 nbly more common than the rare case report in the
. D  Q( F5 F6 c; b$ x6 X  Sliterature.4
8 w+ a, H9 w; c4 e5 x# l6 x) P  bPatient Report1 h* e1 `% H% E1 X+ z( @
A 16-month-old white child was referred to the
, P: K! I! }: c9 u1 p* Oendocrine clinic by his pediatrician with the concern  }) w& C$ M# m& m8 B
of early sexual development. His mother noticed
  F9 @9 t) A0 W" r0 Xlight colored pubic hair development when he was
: Z- b8 e4 i# X, X8 }5 ^; VFrom the 1Division of Pediatric Endocrinology, 2University of" B* G, e9 K7 q8 s; t1 G, X
South Alabama Medical Center, Mobile, Alabama.. E" O4 J: ]: p5 C: N( \3 c
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 u# A2 j2 h) T- G
Professor of Pediatrics, University of South Alabama, College of
& z8 j$ \, x% [# r+ {2 G: ~' kMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& Q4 M. k% T% ~, q, U$ I. I
e-mail: [email protected].
) v( t: a7 M* z, n$ ]about 6 to 7 months old, which progressively became% ^& f' w+ d- x4 _& `- \6 N3 q
darker. She was also concerned about the enlarge-
& E( ~4 q, S. W# mment of his penis and frequent erections. The child! T5 j% A# v0 K4 e
was the product of a full-term normal delivery, with
+ w0 H) `9 T6 d. na birth weight of 7 lb 14 oz, and birth length of
+ b- M( Z/ b- e: m+ Q20 inches. He was breast-fed throughout the first year) z2 e0 y6 A- U; x3 }: u
of life and was still receiving breast milk along with
) m( S. p: A" B$ M2 W. _( }, gsolid food. He had no hospitalizations or surgery,' H9 i- h& Y, Q4 n* E
and his psychosocial and psychomotor development. N/ k; \+ G( Q' w; C0 A( ~
was age appropriate.
( f' v; N: c9 F. e9 sThe family history was remarkable for the father,- x! A' }& i  {# Q
who was diagnosed with hypothyroidism at age 16,
7 V, _7 y4 Q6 [9 E' }; ?2 Q6 `7 jwhich was treated with thyroxine. The father’s4 E: _& u% t5 ]7 y& D$ b  G7 ^& k
height was 6 feet, and he went through a somewhat9 M% @( h; i2 J- D
early puberty and had stopped growing by age 14.- u/ F* j( [* Z6 p7 }
The father denied taking any other medication. The/ j% Y1 Z1 k( ^7 I
child’s mother was in good health. Her menarche
' |3 Y* c: @$ R/ Ywas at 11 years of age, and her height was at 5 feet
7 T9 `; a! W0 `- ^# ~5 inches. There was no other family history of pre-
( e0 ]1 M4 S- i9 h3 c% W: e2 @% v6 ycocious sexual development in the first-degree rela-
3 a/ ]$ Y! i" g3 u# R# Utives. There were no siblings.
1 h/ W, f' I. y( p  e8 T/ z7 OPhysical Examination
# e' x( y; {1 H; p# _! iThe physical examination revealed a very active,
) k/ {6 J& E, r; L; d, lplayful, and healthy boy. The vital signs documented
7 w3 J. m9 U$ q! U1 P3 y& ?, xa blood pressure of 85/50 mm Hg, his length was6 M( W9 m+ }" X& n* `
90 cm (>97th percentile), and his weight was 14.4 kg: S+ g& a$ y+ q+ v, g2 w0 i5 y
(also >97th percentile). The observed yearly growth
1 C# g2 R" v# F/ X) cvelocity was 30 cm (12 inches). The examination of+ }" H% n- Y5 u7 K7 F; l% |
the neck revealed no thyroid enlargement.1 ]1 P2 V1 }" n" Y6 ?+ c
The genitourinary examination was remarkable for4 S& ~6 x" V4 Q) D* S
enlargement of the penis, with a stretched length of6 ^% _6 [3 J$ m- u( Y: L3 B- N
8 cm and a width of 2 cm. The glans penis was very well+ T9 }7 F7 L/ i; ~0 L, N
developed. The pubic hair was Tanner II, mostly around* i4 G7 n; E4 Y$ P; C7 ]2 _" ^2 \0 r
540
6 |% Z  v2 P4 g. y7 h. Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 m* T, B' U' {the base of the phallus and was dark and curled. The6 y/ G- X7 O8 M
testicular volume was prepubertal at 2 mL each.6 W# x6 H4 b. Z0 q' @: v
The skin was moist and smooth and somewhat' h5 t( L8 v2 Y8 J: a' W
oily. No axillary hair was noted. There were no) A' x1 ^; A6 O( ~  q/ |( t+ U' ~
abnormal skin pigmentations or café-au-lait spots.2 j9 u8 ~! ^* U- M
Neurologic evaluation showed deep tendon reflex 2+
; E) F( T: W! Z( ~3 s, |- mbilateral and symmetrical. There was no suggestion  j7 n- Z; w( p8 F
of papilledema.
. ^/ {( ]0 I; @7 nLaboratory Evaluation/ K% x; b8 _* t% d! Z- C
The bone age was consistent with 28 months by2 B, n4 m: d/ x: B" _  ~* z& |5 h% N. B, B
using the standard of Greulich and Pyle at a chrono-: V) V5 Y! W4 F$ h5 L& K+ k, a
logic age of 16 months (advanced).5 Chromosomal, c( `, \8 ?6 ~/ M+ T
karyotype was 46XY. The thyroid function test
8 C8 T! n( Y1 T* s4 pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-# Z' D  C: k; e& r, y) ~
lating hormone level was 1.3 µIU/mL (both normal).2 C: b' {' \9 l) ^9 _+ H# g
The concentrations of serum electrolytes, blood$ K0 M$ {' @& |& N
urea nitrogen, creatinine, and calcium all were* D+ J* q; ~2 H7 g0 {
within normal range for his age. The concentration1 i# p% {: A" R
of serum 17-hydroxyprogesterone was 16 ng/dL
* ?4 Y, h6 ?8 z  L7 m. z8 q# K/ ](normal, 3 to 90 ng/dL), androstenedione was 20
" ~7 _0 d1 z; ^2 w  Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( w0 k2 j/ o) ^; F6 E9 r
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. O# `6 E2 ~0 D1 j9 I
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 K3 T: v" @& v7 D, J
49ng/dL), 11-desoxycortisol (specific compound S)
, D7 y1 b; _- X3 y* Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 }3 K' g. x( ?, Z" Y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% r' M6 Q9 S3 q6 V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ l9 `1 |) o! r6 S, pand β-human chorionic gonadotropin was less than1 X# X! x4 f4 R- a# [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ t* P% u0 n) B( g9 E: k6 hstimulating hormone and leuteinizing hormone7 u9 C" e. G% u9 S! _
concentrations were less than 0.05 mIU/mL
  J8 R2 ?- ]5 k% V# R(prepubertal).6 |. P7 }0 Z0 h( ]8 W# d% a
The parents were notified about the laboratory
; U! Q1 A# N0 Q' D6 Iresults and were informed that all of the tests were0 D0 J. f) X+ U7 T+ `- \
normal except the testosterone level was high. The
+ P& J: c* V+ x* ]# C0 s" ]* Afollow-up visit was arranged within a few weeks to
% v- K$ ~7 ^5 sobtain testicular and abdominal sonograms; how-" O( f9 B  |- H$ A$ M+ V
ever, the family did not return for 4 months.
: U4 t6 _0 o. Q+ fPhysical examination at this time revealed that the3 Y" x$ ], C- `, k$ }
child had grown 2.5 cm in 4 months and had gained: u5 s; y, G% [
2 kg of weight. Physical examination remained
7 h* g& t* F. _1 p6 dunchanged. Surprisingly, the pubic hair almost com-
( n. X* n9 ?/ a" Y8 b2 W, j2 Dpletely disappeared except for a few vellous hairs at
: j3 p: F5 ~1 o9 d" y8 G( G  Hthe base of the phallus. Testicular volume was still 2
! ?1 E5 F& t  GmL, and the size of the penis remained unchanged.$ U8 z2 j3 w5 G/ p0 t
The mother also said that the boy was no longer hav-
. @4 ^: n- J; M; R7 _. `ing frequent erections.* t2 z( ^& f1 {3 z5 ?
Both parents were again questioned about use of
7 a: f* K. j; Q9 w8 G1 c$ Kany ointment/creams that they may have applied to. \1 w& Y: v5 E, U7 R  u% i
the child’s skin. This time the father admitted the
5 e: v- W$ C# }Topical Testosterone Exposure / Bhowmick et al 541" @0 c( V' A# x- f
use of testosterone gel twice daily that he was apply-/ W, u8 g- }  k# q7 g# ]7 @' Z
ing over his own shoulders, chest, and back area for! m% E6 Z. D. w6 b% j. X
a year. The father also revealed he was embarrassed8 C/ s/ i9 Z6 Z4 `
to disclose that he was using a testosterone gel pre-
, [" Q" P- p8 [7 j: dscribed by his family physician for decreased libido
( G$ j: w7 h6 g! r: gsecondary to depression.8 n/ E" R) H* A% N: M& @% ^
The child slept in the same bed with parents.
4 C. x2 K0 w( m6 D" @The father would hug the baby and hold him on his
* L; G0 q5 N4 l1 e8 D+ Wchest for a considerable period of time, causing sig-
" c. T$ `7 n* S5 pnificant bare skin contact between baby and father.
/ s$ q& M$ |  R' Q( k# F$ z# F9 _  \The father also admitted that after the phone call,
. u7 h; _: X. @) `, xwhen he learned the testosterone level in the baby, l; z3 ?! r* z. t6 h5 `: `
was high, he then read the product information
% ]* H# E3 w  P' r4 ?2 Wpacket and concluded that it was most likely the rea-
5 ]7 i$ E+ S4 q8 Z, Eson for the child’s virilization. At that time, they4 l9 R. d5 J3 \% w' E# n0 }
decided to put the baby in a separate bed, and the
- `: ^( L& E4 E" g# M6 f$ I* cfather was not hugging him with bare skin and had
$ ^6 B  }3 C3 B, z8 W. }been using protective clothing. A repeat testosterone' M$ l+ l2 V+ h6 b
test was ordered, but the family did not go to the
7 p* c! M5 q, w) W: b" Xlaboratory to obtain the test.
. Z9 Y7 z$ e3 B# G" TDiscussion
' S/ F% T0 q7 QPrecocious puberty in boys is defined as secondary
) ?5 ^( H5 ?% ]sexual development before 9 years of age.1,4* |! l4 o/ m+ s! O
Precocious puberty is termed as central (true) when
+ Q% T9 \+ s5 {1 N. v4 H7 Lit is caused by the premature activation of hypo-
' f2 A- N. C0 j* `. [thalamic pituitary gonadal axis. CPP is more com-
9 g7 ]0 V; _2 I- h) a( E! I9 Cmon in girls than in boys.1,3 Most boys with CPP
. }% l$ g8 Z  ?0 k7 [& qmay have a central nervous system lesion that is& H9 _. n* }( ^% Q  }
responsible for the early activation of the hypothal-5 w+ \" S) R4 F& }5 ]
amic pituitary gonadal axis.1-3 Thus, greater empha-& f; C1 p1 D6 u7 U
sis has been given to neuroradiologic imaging in8 r+ f  @9 b3 b: e' i
boys with precocious puberty. In addition to viril-) s8 k' W# v  [5 z9 H9 D0 z
ization, the clinical hallmark of CPP is the symmet-
7 s) s' f7 z: L8 v3 g. Irical testicular growth secondary to stimulation by% r3 \* t& m* L% T  B* m0 P
gonadotropins.1,3
/ H. U& A/ ]- d7 x, gGonadotropin-independent peripheral preco-
" B9 o8 Y' X1 R) G: y( n. Ecious puberty in boys also results from inappropriate
8 [* B$ j1 t' Z1 j/ ?3 sandrogenic stimulation from either endogenous or# h) n1 E2 A3 x
exogenous sources, nonpituitary gonadotropin stim-0 s5 X9 z8 l$ j9 Q
ulation, and rare activating mutations.3 Virilizing
5 j' }9 d1 c+ u3 ucongenital adrenal hyperplasia producing excessive
! q3 Z4 Y+ D8 ~$ x+ badrenal androgens is a common cause of precocious; Q2 E/ E% g6 Z) ~$ f9 P6 t
puberty in boys.3,4
$ U$ c0 c1 w* s& kThe most common form of congenital adrenal
6 Z- v5 L3 |, g$ N; t+ v* K2 _hyperplasia is the 21-hydroxylase enzyme deficiency.+ R" _' {% d2 d7 i
The 11-β hydroxylase deficiency may also result in  X5 [' t: E1 L# y
excessive adrenal androgen production, and rarely,
* t8 k, |" `) {/ x5 @# Xan adrenal tumor may also cause adrenal androgen
; M7 G5 D8 ?$ l$ Uexcess.1,3
/ _; W* q& e5 C4 C0 {  vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! ], u! F0 N6 A+ h! T  E9 e( [
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; |2 h5 H& o. G# v
A unique entity of male-limited gonadotropin-
. q8 E7 u2 d) r0 E# ^independent precocious puberty, which is also known+ Y+ _6 a0 F4 o, X8 S
as testotoxicosis, may cause precocious puberty at a9 \$ g* U% \& \+ C- d& Y
very young age. The physical findings in these boys6 Z: Y& }( P" s
with this disorder are full pubertal development,8 q+ `) Z3 R' h# v
including bilateral testicular growth, similar to boys
4 @& Z7 S  {& h& h8 [% dwith CPP. The gonadotropin levels in this disorder1 [4 V; y7 ]/ ^. P. ^8 X
are suppressed to prepubertal levels and do not show( H# t5 P- X8 q5 n3 c# S/ a, m
pubertal response of gonadotropin after gonadotropin-
" J3 J7 a' }6 Z: `* B5 ]releasing hormone stimulation. This is a sex-linked
3 V& R# y8 @5 s- t6 zautosomal dominant disorder that affects only+ Y+ c+ Q9 k/ p
males; therefore, other male members of the family
! ^* I8 ?" K- G/ _0 \9 h9 ~may have similar precocious puberty.3
8 s4 Y7 d8 O- G: h$ fIn our patient, physical examination was incon-
7 g4 S6 Q3 q7 n' h# R8 f# {; Fsistent with true precocious puberty since his testi-
$ H( ]2 T" n, Ecles were prepubertal in size. However, testotoxicosis
$ p/ t! w$ e9 U& h. H; l$ mwas in the differential diagnosis because his father
" M0 [9 T8 d& F! G9 pstarted puberty somewhat early, and occasionally,
: F$ ?+ V; b' g5 ztesticular enlargement is not that evident in the- ^; ^. b: C  Y; ~0 D  Q. j
beginning of this process.1 In the absence of a neg-
* ?/ W7 X$ A4 U9 W7 hative initial history of androgen exposure, our
' |/ V' Z9 j) p3 G6 X! e8 zbiggest concern was virilizing adrenal hyperplasia,4 t/ H6 \, D- _
either 21-hydroxylase deficiency or 11-β hydroxylase
6 V7 @7 I% Z8 Y  ?0 kdeficiency. Those diagnoses were excluded by find-
/ F  c# O: C, L  King the normal level of adrenal steroids.
1 k. d- k, H* z* p' M% `: iThe diagnosis of exogenous androgens was strongly
+ l( b7 ]8 C) |# b8 x; g) zsuspected in a follow-up visit after 4 months because8 e% W" @0 b6 t, C0 }
the physical examination revealed the complete disap-
- n7 L3 L: f# P; j) Dpearance of pubic hair, normal growth velocity, and
! n! [3 O- q; z/ g/ ?: |3 jdecreased erections. The father admitted using a testos-
2 k1 x6 ], f% V2 I) zterone gel, which he concealed at first visit. He was
0 r+ ?* s2 i: @6 _# Husing it rather frequently, twice a day. The Physicians’  ~( ~# F* B1 R0 w
Desk Reference, or package insert of this product, gel or- k2 C- _- G# i
cream, cautions about dermal testosterone transfer to( C4 i& P5 N6 B4 k2 e
unprotected females through direct skin exposure.
) |: q* E7 t9 i7 a0 z! P  L3 k# l# ~Serum testosterone level was found to be 2 times the6 \0 h) R7 H: V. I
baseline value in those females who were exposed to" E# k! E5 J8 d+ Z$ J5 A/ q3 B
even 15 minutes of direct skin contact with their male
1 k7 c0 m/ G# Cpartners.6 However, when a shirt covered the applica-- A! \2 A! K6 n9 @+ [. Y& h
tion site, this testosterone transfer was prevented.1 [% v# g) x1 ?+ c9 E3 |2 g
Our patient’s testosterone level was 60 ng/mL,* _, l" F) P  d% y4 l
which was clearly high. Some studies suggest that
; m9 F6 ?0 E* F+ Kdermal conversion of testosterone to dihydrotestos-5 \$ G* A4 V6 R
terone, which is a more potent metabolite, is more. u- f2 a" J8 h9 U1 R. a; i( e- ^) c
active in young children exposed to testosterone
3 s2 O! s$ s) [- r& y' H7 r; Hexogenously7; however, we did not measure a dihy-
1 E9 k" m( S) J# _  edrotestosterone level in our patient. In addition to, c9 n9 e, T' g
virilization, exposure to exogenous testosterone in
; {5 B# p, Z  U; z$ \  `7 ?children results in an increase in growth velocity and
3 _# V* |0 z/ f5 _advanced bone age, as seen in our patient.0 ]: c* T, s- Q
The long-term effect of androgen exposure during, a  x+ G" _) v
early childhood on pubertal development and final
0 g- M; C/ b0 D$ {$ {  Eadult height are not fully known and always remain
- z: E+ M; z) n7 Ha concern. Children treated with short-term testos-
9 r: q! O7 ~' }8 K0 r8 q8 \terone injection or topical androgen may exhibit some- }2 |0 ]$ r5 b; ^
acceleration of the skeletal maturation; however, after
5 I/ o( {! P$ _: p; Gcessation of treatment, the rate of bone maturation$ [4 r1 [- J( o' h5 z
decelerates and gradually returns to normal.8,93 r0 q9 H* N- ~$ z( L2 H/ @
There are conflicting reports and controversy, d0 H) V6 B0 B. f' M4 J/ K
over the effect of early androgen exposure on adult
0 V% L) a; @# X# S( f4 ^: Spenile length.10,11 Some reports suggest subnormal7 }- a0 d; }+ d
adult penile length, apparently because of downreg-8 G, O" n* }! a, c+ E, r' f* x
ulation of androgen receptor number.10,12 However,( B/ U4 X6 ~( ^. B* s: @
Sutherland et al13 did not find a correlation between
' w- q0 m2 @8 |) tchildhood testosterone exposure and reduced adult
8 Y6 |# ^( j9 I3 t3 N: X$ rpenile length in clinical studies.
+ A$ Y/ Y9 _: k8 e- `" I6 JNonetheless, we do not believe our patient is
* A! ]. h5 N  U; s, Z1 {, k; C% J+ F+ Vgoing to experience any of the untoward effects from! _( ?& O) Z* Y6 U
testosterone exposure as mentioned earlier because# C. ^5 j1 A* g5 P' }
the exposure was not for a prolonged period of time.7 ?" w9 P) K  I1 N7 T
Although the bone age was advanced at the time of+ @: C. W1 V+ j8 B. V
diagnosis, the child had a normal growth velocity at
" ]) x( t- R* {8 q  p' Mthe follow-up visit. It is hoped that his final adult7 C! d" U: e0 D8 C+ G1 b: F
height will not be affected.
- I4 C  b4 u7 v+ k$ DAlthough rarely reported, the widespread avail-
# b7 E: N$ [7 f9 q# uability of androgen products in our society may8 p6 m- ~: f% m
indeed cause more virilization in male or female( r) j9 D6 ^/ o# G8 b
children than one would realize. Exposure to andro-
2 Q3 x6 D: ~( w% Mgen products must be considered and specific ques-
" w2 M6 \8 F/ A! _1 ntioning about the use of a testosterone product or; i5 ]- v) O9 q, [7 Z  |: Q( b
gel should be asked of the family members during' Z+ F$ n$ c! ]5 z1 m" k
the evaluation of any children who present with vir-
- ?- @3 N1 |( R& pilization or peripheral precocious puberty. The diag-
- C1 h1 O  r% _' A; m& Q8 d3 F. |: X! Znosis can be established by just a few tests and by8 \- q7 t  D% Y$ w* u
appropriate history. The inability to obtain such a& M" \& q8 N2 }. }9 s, a
history, or failure to ask the specific questions, may
/ {6 }! z' C2 {: L" Fresult in extensive, unnecessary, and expensive
$ q0 l0 J$ @( H) N. t4 [- [( X' @investigation. The primary care physician should be
" i/ y4 l4 n) z9 u  ]3 Q  n1 Naware of this fact, because most of these children
$ F# Y" o$ S% pmay initially present in their practice. The Physicians’! A. a; d3 I7 \" C' z
Desk Reference and package insert should also put a7 k; d9 |3 Y# }$ E  g$ r" Y
warning about the virilizing effect on a male or
4 K) M! t) Q% b1 r# }, cfemale child who might come in contact with some-
  c* P0 t2 @" I5 Oone using any of these products.6 z2 N, N& ^- x4 {( L
References
# F+ Y0 \$ ]2 c1 @1 s/ C1 j4 J1. Styne DM. The testes: disorder of sexual differentiation( x2 L6 f* x9 h) X
and puberty in the male. In: Sperling MA, ed. Pediatric) Y2 E  m8 `+ _; Z# z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
/ [+ e3 e/ L2 r8 |$ G" c( ~  H2002: 565-628.
4 P6 a; ?# H1 j2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 B2 P# x4 P6 T, q0 T# ]puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
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

1 L8 D; l* w$ P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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