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Sexual Precocity in a 16-Month-Old$ ^% I6 z( `0 k/ u
Boy Induced by Indirect Topical! m( R0 r% E5 u% k) I
Exposure to Testosterone
! v- ^1 Q: Z, V; J7 g: GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 i; }0 u0 g3 u' H/ X7 Y5 t9 d4 F9 ?and Kenneth R. Rettig, MD1
/ Y: t, Z& T7 T8 V3 lClinical Pediatrics
, O0 H$ b/ ?, i3 }) oVolume 46 Number 6
, g# ~: y9 t% n2 @  M: dJuly 2007 540-543
) `" ]- }+ b) `. O% a3 ?& G& d© 2007 Sage Publications0 g7 M7 |/ s; Z5 O% ^6 C5 Z
10.1177/0009922806296651
, d! O. F7 I  l- _, C* Nhttp://clp.sagepub.com
; Z5 \6 e4 ^+ G4 u( m8 Shosted at6 A& v% {- M+ Y8 z. Y0 l# h9 G) Z5 X
http://online.sagepub.com# i1 g  M* M. _. z2 l' I( b+ E; F
Precocious puberty in boys, central or peripheral,
/ M: Q6 }" u+ U7 n/ h8 z* h, a& ~is a significant concern for physicians. Central5 X+ v1 a/ t' y+ o5 K' q) Q
precocious puberty (CPP), which is mediated
' f0 Y- @! |' O! Fthrough the hypothalamic pituitary gonadal axis, has, ?7 i' |; V9 [* o+ M% t; U6 t/ }8 F
a higher incidence of organic central nervous system
/ v) q/ x: F6 D8 Y; flesions in boys.1,2 Virilization in boys, as manifested0 h* X; M8 v9 l( B
by enlargement of the penis, development of pubic
0 y$ Q) ?* |3 b8 C3 H( v! U0 qhair, and facial acne without enlargement of testi-6 z2 \/ Q* I$ s4 Y2 e" c' f
cles, suggests peripheral or pseudopuberty.1-3 We2 h+ G6 h9 J0 I9 c
report a 16-month-old boy who presented with the5 M7 y1 o4 T; j+ ^% u2 F
enlargement of the phallus and pubic hair develop-
! e" @- o6 W: _8 |0 s# Vment without testicular enlargement, which was due
; k$ n3 J  Q# z2 ]! n, O8 {to the unintentional exposure to androgen gel used by( c; a" P! e$ q/ b" x
the father. The family initially concealed this infor-4 \1 y6 J9 \! o* S. F9 K
mation, resulting in an extensive work-up for this$ F$ Y" s9 q$ n% A" l  A
child. Given the widespread and easy availability of# p# V* T$ n6 ^" M; f+ s& q/ d# Y
testosterone gel and cream, we believe this is proba-
& y5 u$ ?4 m6 {6 N. s2 U9 Bbly more common than the rare case report in the+ u! ?5 l: r; T, I
literature.4! |" t2 m8 _/ e& W# D, O6 L
Patient Report/ `- w+ ]# C. h6 T
A 16-month-old white child was referred to the
1 p( K7 P4 K+ e" V; ~+ V* F9 zendocrine clinic by his pediatrician with the concern) z& [2 }3 q( w, B
of early sexual development. His mother noticed
- L7 G* j/ E0 Llight colored pubic hair development when he was  n1 [8 h- l. ^2 A
From the 1Division of Pediatric Endocrinology, 2University of
6 H+ w7 P* f3 D( WSouth Alabama Medical Center, Mobile, Alabama.
* ^8 @1 h% w- J1 F1 k! e$ f9 |Address correspondence to: Samar K. Bhowmick, MD, FACE,
: V* [+ Y: g0 n6 ?  r& ?) Y. l& AProfessor of Pediatrics, University of South Alabama, College of/ b. j* y5 Z1 o& A! X
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  T9 F0 g( d8 ~- U4 F" G
e-mail: [email protected].
6 y6 e' M( w* V6 S# b. l) [; dabout 6 to 7 months old, which progressively became; n1 {2 q) O6 _
darker. She was also concerned about the enlarge-( M+ O+ W# j2 [8 ?+ r5 m
ment of his penis and frequent erections. The child. v# ^6 Z/ h5 b9 I: h' j0 Z& F2 e
was the product of a full-term normal delivery, with
  I6 t1 q6 @4 _4 ^a birth weight of 7 lb 14 oz, and birth length of6 ^$ L, `$ u: @: }4 k! u1 w9 G
20 inches. He was breast-fed throughout the first year' |2 z" A' ~0 D; M; Y
of life and was still receiving breast milk along with' @8 o% o  f  R* I3 i* }* |, |3 r1 U
solid food. He had no hospitalizations or surgery,- t. `+ U9 t7 y  \) i
and his psychosocial and psychomotor development
: u( t, U2 O( \* q, T7 K7 f; Twas age appropriate.
! N. d' p) _% J; u5 zThe family history was remarkable for the father,/ [: a7 t/ n2 F0 Y
who was diagnosed with hypothyroidism at age 16,+ I. D0 Z% f! Y. r* t% k% p( V# m
which was treated with thyroxine. The father’s3 i4 f) g5 G; P& j; Y+ z, k4 M8 \
height was 6 feet, and he went through a somewhat
- S' h; |; W* V7 learly puberty and had stopped growing by age 14.& q# y4 P: H9 [0 b  e& Q2 Q- l
The father denied taking any other medication. The. }3 U( N% {3 T, q$ Q
child’s mother was in good health. Her menarche& }8 q# x2 r( H( g) z8 h3 ]
was at 11 years of age, and her height was at 5 feet4 L/ x- t$ j& C. i' s# L8 B
5 inches. There was no other family history of pre-5 `6 ~- l* ]! ?' e0 d
cocious sexual development in the first-degree rela-. z0 N" C  c) _' T! b$ s8 R
tives. There were no siblings./ j7 ?# `6 r0 Q) }3 o# _5 @
Physical Examination, [4 c* W6 n3 y: Z4 d
The physical examination revealed a very active,
# j, K3 {- ^) ~( K7 l; ?) Eplayful, and healthy boy. The vital signs documented
% e, g" z% ?2 e0 za blood pressure of 85/50 mm Hg, his length was# S( g1 Y* G: A+ e4 z1 B! j+ r
90 cm (>97th percentile), and his weight was 14.4 kg
0 o: B7 }3 Y9 `% U- E(also >97th percentile). The observed yearly growth# b2 q0 u- c- U: e
velocity was 30 cm (12 inches). The examination of1 l, U/ q! Z) n0 ~3 |; I
the neck revealed no thyroid enlargement.
3 R9 q# ]/ {7 d- x  }  xThe genitourinary examination was remarkable for. l- ]2 _4 D4 W0 H9 K& D3 K1 A
enlargement of the penis, with a stretched length of' Q5 `5 C3 T9 ^
8 cm and a width of 2 cm. The glans penis was very well! y# f7 l( ]# E; X. P; L6 }
developed. The pubic hair was Tanner II, mostly around
: d) a' N) J# _  O540
( ~( p  `5 \3 a/ Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. w1 E7 s/ v* w4 v
the base of the phallus and was dark and curled. The
: B, }! y7 X9 G' ~8 I" qtesticular volume was prepubertal at 2 mL each.; Q7 i% f+ x6 q' X
The skin was moist and smooth and somewhat
, `; o! t: q, E1 goily. No axillary hair was noted. There were no  w. D4 q, e* N2 K) [
abnormal skin pigmentations or café-au-lait spots.
; V0 ]6 i/ L& @1 ?* c2 @Neurologic evaluation showed deep tendon reflex 2+% q2 j) b0 k2 ~
bilateral and symmetrical. There was no suggestion+ `5 e6 V. u/ F3 j. v
of papilledema.
8 H. g) z" g: u- m6 j& fLaboratory Evaluation8 o" b0 p7 K5 |& i
The bone age was consistent with 28 months by$ Q1 `4 y+ G1 j' n" _. C
using the standard of Greulich and Pyle at a chrono-1 |: `: t  M9 j9 w6 e+ y( g, \2 Z
logic age of 16 months (advanced).5 Chromosomal& m" F' V% @' t3 o* O! i
karyotype was 46XY. The thyroid function test& {+ @0 ?, N# H2 O! ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, X3 [/ [! F! G* h! Y# j; N) clating hormone level was 1.3 µIU/mL (both normal).
% m3 [% i$ }% ?) o  Z/ J; KThe concentrations of serum electrolytes, blood+ I# c: }# K& Y6 p. t: T7 ~' D
urea nitrogen, creatinine, and calcium all were8 S! z4 ?& ^( o* T4 q
within normal range for his age. The concentration
1 l) L( B( P7 i3 hof serum 17-hydroxyprogesterone was 16 ng/dL( ~4 h* y* I4 R3 \; z; x* K% n0 O
(normal, 3 to 90 ng/dL), androstenedione was 20
/ _+ b, v3 A, \9 b* x7 H5 Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* n# G+ Z6 q) E9 t% h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 g, _; ~( M+ D+ J# jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
) n3 O) T4 F1 t; n1 s49ng/dL), 11-desoxycortisol (specific compound S)
4 k& U/ [3 s7 o+ j; @0 @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# d9 c9 U; p) a8 ~" v) [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# h) m/ ^4 v5 d8 f: z& P4 Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- k4 z" ?# A9 G3 [0 iand β-human chorionic gonadotropin was less than
- H! ?. w$ I; ]7 g; Q4 U5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ h8 w) J  o2 V8 D+ `' \stimulating hormone and leuteinizing hormone3 c* f! y5 u9 r; O0 n6 _- E
concentrations were less than 0.05 mIU/mL! s8 |  q6 }% f% |
(prepubertal).2 \8 G8 J; v/ _# G6 Y' a
The parents were notified about the laboratory
0 |7 n# a: z' N; i: vresults and were informed that all of the tests were8 p! B( M. h$ M+ F0 A
normal except the testosterone level was high. The
3 {, R( Y2 c8 W" ]( w2 X1 u8 wfollow-up visit was arranged within a few weeks to9 u: j$ O# n3 p7 ~
obtain testicular and abdominal sonograms; how-% i4 k' h# S7 ^. o6 z$ u# u3 m2 _
ever, the family did not return for 4 months.
3 c! h' p) z$ i  f" y1 k0 YPhysical examination at this time revealed that the' \$ R  k/ i5 h0 H
child had grown 2.5 cm in 4 months and had gained. f, R0 {% b! e
2 kg of weight. Physical examination remained
5 L4 U$ U. B* u+ M9 p/ ^unchanged. Surprisingly, the pubic hair almost com-, |! `9 m* y& ]$ G2 D7 D: ^
pletely disappeared except for a few vellous hairs at! W7 H7 |8 v  U* J  w" ^2 U
the base of the phallus. Testicular volume was still 2
  x6 d' c4 t, z; @' r) GmL, and the size of the penis remained unchanged.9 Q# `" A+ |% P" q
The mother also said that the boy was no longer hav-
0 Z  X7 T& D8 y1 X3 L# [3 }ing frequent erections.3 Y, o) V+ l5 d
Both parents were again questioned about use of+ ?3 j1 R3 `2 \* G/ _
any ointment/creams that they may have applied to
! t% T8 C* Y  sthe child’s skin. This time the father admitted the0 v' x/ p( u' o( }1 Y. p0 e" M  h  f8 ^
Topical Testosterone Exposure / Bhowmick et al 541
  c1 G3 N6 E. C0 v2 ?use of testosterone gel twice daily that he was apply-
" D( H* ^* X/ R+ S* D; ^) bing over his own shoulders, chest, and back area for
( L6 o- z& k2 l4 ca year. The father also revealed he was embarrassed
4 d+ d/ K6 f9 w' q/ Q5 z% \$ Tto disclose that he was using a testosterone gel pre-/ n$ _" M: Y1 G) m( ~2 g; K: j
scribed by his family physician for decreased libido
3 H( ^# h" b) i! Qsecondary to depression.
- [% v% K; q5 Y( G# h6 B8 }The child slept in the same bed with parents.
* j5 a+ f9 c4 p9 I1 H6 c* ]/ XThe father would hug the baby and hold him on his, I  M$ K: b9 ]( k
chest for a considerable period of time, causing sig-
" ^! G3 R' q( ?, `nificant bare skin contact between baby and father.
/ Q  H6 Q* Y9 {; ]The father also admitted that after the phone call,
2 m* c" C8 |9 e$ E* l* b# xwhen he learned the testosterone level in the baby4 R, M: J$ K$ f9 C' ?
was high, he then read the product information
% {' o5 e1 A& y7 i( Rpacket and concluded that it was most likely the rea-
  t4 p+ v7 S" t7 q8 ^son for the child’s virilization. At that time, they/ \) ?8 ^# y( X# d1 x
decided to put the baby in a separate bed, and the
6 c$ C' d! ~: ffather was not hugging him with bare skin and had; V0 a" _/ k" ^6 j6 q' H
been using protective clothing. A repeat testosterone+ ]% d; _3 V1 W7 ]
test was ordered, but the family did not go to the. i/ F9 l8 h9 `" G  H5 E% g2 `- y
laboratory to obtain the test.
! n% `* e& b) u9 T4 E4 j7 B: kDiscussion! z" n) o. B& `
Precocious puberty in boys is defined as secondary
+ I# h* q; K# g9 H+ a8 bsexual development before 9 years of age.1,4
( u& j% _2 G4 [1 Y: e3 U6 vPrecocious puberty is termed as central (true) when
0 u9 s3 ~9 \& `, u4 eit is caused by the premature activation of hypo-
7 a4 Y  v" I/ U! z' R7 Zthalamic pituitary gonadal axis. CPP is more com-2 A1 q) k: }( h' L+ ~* B
mon in girls than in boys.1,3 Most boys with CPP& L8 _! A( n! L) a4 V# D) ^+ g
may have a central nervous system lesion that is+ f7 n4 ^0 w7 B+ Y+ g
responsible for the early activation of the hypothal-
8 P# v1 D$ a* o3 K: n% Y" mamic pituitary gonadal axis.1-3 Thus, greater empha-
% N& V0 G% ]) W* ssis has been given to neuroradiologic imaging in
6 S, W+ q8 ^# ^( F9 |( B+ i  Q1 oboys with precocious puberty. In addition to viril-
* ]* ^$ J7 s0 ?1 q( g4 l8 }/ Gization, the clinical hallmark of CPP is the symmet-$ L& w: T$ h  H* ?3 f" W
rical testicular growth secondary to stimulation by
  c* ^/ g, x5 N' [& [$ C# h/ p# pgonadotropins.1,3
2 T, n+ y4 D- D  h# sGonadotropin-independent peripheral preco-5 Q' U+ r# {* z% k4 F/ \
cious puberty in boys also results from inappropriate& B! E: m5 S  N
androgenic stimulation from either endogenous or% g7 P1 P7 y, P
exogenous sources, nonpituitary gonadotropin stim-
6 m  J# R  i+ gulation, and rare activating mutations.3 Virilizing- b+ ]6 z+ z) v1 e; N, F
congenital adrenal hyperplasia producing excessive" E$ {% \0 L  e8 q) n8 d
adrenal androgens is a common cause of precocious4 d( j0 K. P- c# {/ J% R
puberty in boys.3,4
' n2 J: ^- z/ T" Y4 XThe most common form of congenital adrenal+ F# J/ `. [- {
hyperplasia is the 21-hydroxylase enzyme deficiency.1 g$ s7 Y6 c0 i0 s
The 11-β hydroxylase deficiency may also result in" B% a8 r$ E1 K- y% s& ^
excessive adrenal androgen production, and rarely,
, g8 M8 O: R0 Q# Ean adrenal tumor may also cause adrenal androgen
2 A. x# O0 x" k8 Vexcess.1,3
2 z% \/ m$ g" pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# _2 U, ?9 n2 I2 c) s& w
542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 l" e6 d8 V; r' u# Z, |7 D, m! _
A unique entity of male-limited gonadotropin-
) D  |" Z4 i/ @$ Vindependent precocious puberty, which is also known. B% N9 B$ i5 c2 j8 b% t
as testotoxicosis, may cause precocious puberty at a* V* F- ~8 F3 k3 t5 ]  k, b
very young age. The physical findings in these boys
$ F0 N0 L: ~* Zwith this disorder are full pubertal development,$ l. ]  q0 g7 V% r& {: P+ d) r: D
including bilateral testicular growth, similar to boys
, Z' v* Q# {7 f+ g6 qwith CPP. The gonadotropin levels in this disorder, f$ ~' b9 u+ k1 [" o* C) o' a
are suppressed to prepubertal levels and do not show
. q2 N1 H" m! O* Y, o8 T" a& e+ lpubertal response of gonadotropin after gonadotropin-0 V: s' j8 |/ q- j, A. G
releasing hormone stimulation. This is a sex-linked
( g2 X0 M* A" d; A0 Xautosomal dominant disorder that affects only& ?7 B+ Q8 G0 E8 a% Q- t6 G" N
males; therefore, other male members of the family
8 B( p" ?0 D6 h7 Pmay have similar precocious puberty.3/ e2 h2 U! f, G8 P: |: U
In our patient, physical examination was incon-
8 L  \1 U! S! Z2 Y! b; w, T6 dsistent with true precocious puberty since his testi-& H" a4 B$ @2 K$ d  R; Y2 b
cles were prepubertal in size. However, testotoxicosis
: {# D+ |3 |8 I$ K* zwas in the differential diagnosis because his father
/ X, n6 t8 U6 k7 e8 H+ z8 V' v5 _started puberty somewhat early, and occasionally,
8 T, v: d$ n% p  z$ T1 gtesticular enlargement is not that evident in the
* x) x% N! ~( l! O0 |1 Tbeginning of this process.1 In the absence of a neg-
& W3 s, ~2 ^2 ?2 oative initial history of androgen exposure, our
; G4 `( I( U. ~0 _: |! k3 o& W* Zbiggest concern was virilizing adrenal hyperplasia," J1 O' t, B, Z, \
either 21-hydroxylase deficiency or 11-β hydroxylase2 ~3 K" K9 c# p0 Z! Y
deficiency. Those diagnoses were excluded by find-
2 E! q0 \3 u4 d% B4 T. oing the normal level of adrenal steroids.
, g2 T5 L' G+ s' d4 a+ w2 W4 H6 ?The diagnosis of exogenous androgens was strongly
: x  x' y! [: E% ~+ e! G& Z  Tsuspected in a follow-up visit after 4 months because
+ m/ p, ]5 P4 ]7 W% s6 `# fthe physical examination revealed the complete disap-2 p! y) l- P5 {
pearance of pubic hair, normal growth velocity, and6 ~# v+ z5 e( l  p+ _9 R( i+ G
decreased erections. The father admitted using a testos-1 B5 c0 t! u0 G: o0 u4 [' r
terone gel, which he concealed at first visit. He was
! [* t$ @( @+ \# vusing it rather frequently, twice a day. The Physicians’- J$ b: n- A) i  g- L' B2 H0 `  ?
Desk Reference, or package insert of this product, gel or- A2 F. ^$ T+ ^6 a
cream, cautions about dermal testosterone transfer to. E9 G7 Q0 k# }4 L+ q9 _
unprotected females through direct skin exposure.. _4 i/ x8 D$ C7 p
Serum testosterone level was found to be 2 times the
) ?4 k0 V% g; e' ]  Ubaseline value in those females who were exposed to
# Q( Q, e4 C! k  Y5 c9 X5 p. veven 15 minutes of direct skin contact with their male2 c) X$ q3 M& c, M+ p) Q- O
partners.6 However, when a shirt covered the applica-
( y2 d1 L( ?0 rtion site, this testosterone transfer was prevented.
* t- Y# ?& T$ e6 b: |Our patient’s testosterone level was 60 ng/mL,
! k8 ]7 f" y( Z( t- bwhich was clearly high. Some studies suggest that3 Q  |" q5 l& Y  Y  l
dermal conversion of testosterone to dihydrotestos-
& q; B3 O: [) L- ?terone, which is a more potent metabolite, is more8 ^( i9 j6 @# X7 L) a+ w: ]
active in young children exposed to testosterone6 }) R% c4 U4 f2 p+ x9 r
exogenously7; however, we did not measure a dihy-
/ w$ T* S. p1 i$ k( k* I3 ndrotestosterone level in our patient. In addition to! ~% q% e2 [) U  V' o4 \
virilization, exposure to exogenous testosterone in
; j" a4 X3 R% o: m6 L. W2 G' Tchildren results in an increase in growth velocity and
( T4 \# H( M" a* P: P  Hadvanced bone age, as seen in our patient.6 r5 b) L8 y- ~* P6 S
The long-term effect of androgen exposure during
* B6 W; G3 p# g# x: e# `early childhood on pubertal development and final5 v. |0 h5 a/ c4 i8 z  m
adult height are not fully known and always remain
) R3 k- q/ D+ l# A# ]; Z) k" ^a concern. Children treated with short-term testos-
$ m% D1 P! e# ^: sterone injection or topical androgen may exhibit some$ {+ G8 i" [& R# ~; ~1 M, ]& V
acceleration of the skeletal maturation; however, after
( s/ u0 R9 m$ W5 v. y. ?8 w! dcessation of treatment, the rate of bone maturation
8 r" Q0 I) F' {" O1 x5 qdecelerates and gradually returns to normal.8,9# ^5 x0 _8 Y# p; X- U
There are conflicting reports and controversy* I! C* t& Z! J0 w+ }
over the effect of early androgen exposure on adult3 w5 i0 m1 `7 C; Q7 {
penile length.10,11 Some reports suggest subnormal4 \/ l- x: m; p6 w2 S' R
adult penile length, apparently because of downreg-: D( F$ Z& N' H
ulation of androgen receptor number.10,12 However,0 u* G, j- [/ X. p' [
Sutherland et al13 did not find a correlation between" m( a" R/ e' M  `1 j( g
childhood testosterone exposure and reduced adult: N! O  D! n5 ~
penile length in clinical studies.
! l! P1 X2 ?  s3 Q0 ZNonetheless, we do not believe our patient is
8 `: i1 \* q4 F/ pgoing to experience any of the untoward effects from
* \. [& P0 H9 D' ^( C. X6 @testosterone exposure as mentioned earlier because* f5 `3 I# _+ i' ]! V6 T" i9 u
the exposure was not for a prolonged period of time.
) l2 D2 {) X, zAlthough the bone age was advanced at the time of
1 Z1 y" ~. w5 q. y( @1 jdiagnosis, the child had a normal growth velocity at/ X) S& z" w: `" u2 a7 R
the follow-up visit. It is hoped that his final adult. D+ C$ o9 Z% ~. C  ]/ G/ O
height will not be affected.
& O/ a- I0 j1 e! V/ H8 b8 L2 k9 B; q; D' ]Although rarely reported, the widespread avail-. ~0 y4 j+ t9 k; I
ability of androgen products in our society may; |  c: m3 H, N* J
indeed cause more virilization in male or female
( y$ v7 t& z9 k7 ichildren than one would realize. Exposure to andro-
: o% L* D5 U" E. O' U4 Ugen products must be considered and specific ques-0 Q# B: o& c( `/ d5 {! c
tioning about the use of a testosterone product or- M6 X1 b# N" m3 r; |
gel should be asked of the family members during
: ~, W2 c: S% Q7 G/ |the evaluation of any children who present with vir-$ W7 z! O7 }/ m% H5 c1 c6 I7 n
ilization or peripheral precocious puberty. The diag-
8 p% h  Q# |2 b3 P+ Ynosis can be established by just a few tests and by
6 b" G! Y  k6 ?( vappropriate history. The inability to obtain such a
2 \( r& s8 |/ Z& |9 E. Z5 ]' ]history, or failure to ask the specific questions, may
5 C+ q4 k* U: y5 Q+ jresult in extensive, unnecessary, and expensive1 R7 r% X. g# _: V
investigation. The primary care physician should be6 h* e) E5 l& `
aware of this fact, because most of these children- U8 R' L: g4 }! e2 m0 w4 J
may initially present in their practice. The Physicians’1 B& Y9 Y6 {7 R
Desk Reference and package insert should also put a
- R6 J7 s5 U) {3 s. g- Cwarning about the virilizing effect on a male or3 L" {' \5 F- Z. ?) @9 S" B
female child who might come in contact with some-
9 v! v5 F2 N) @. r+ Y6 }  B2 kone using any of these products.
, n0 t9 w7 W* ~+ R' ]0 eReferences' ^& e& O  k& ]. h, X$ m
1. Styne DM. The testes: disorder of sexual differentiation- W9 j0 W4 ]; L4 @
and puberty in the male. In: Sperling MA, ed. Pediatric
! v: s8 R) I7 w( V1 C$ ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 b5 [( ?& O/ j2 h
2002: 565-628.' ^3 q1 Q- L/ @7 `: I1 K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 ~- m/ H4 {" J3 r9 \7 W: \% U
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
7 J7 K5 Q+ d: S1 |, L, Y3 PBoy Induced by Indirect Topical
. m3 \/ Y9 a; k/ Q. l" XExposure to Testosterone
6 j7 t0 _! T& v) O* C8 _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; [2 x. }& y' \  X7 k: aand Kenneth R. Rettig, MD12 |, K: J8 b( C/ T
Clinical Pediatrics
- X( B/ U+ `' }, b. P# A8 PVolume 46 Number 62 O) A* Z' T/ q0 `  ^6 g
July 2007 540-543. \! l( O' E" f9 {" Z% K
© 2007 Sage Publications
$ m5 f& I) }$ F4 T8 U) ?10.1177/0009922806296651
8 R% t4 v4 y; F* m3 }3 j) mhttp://clp.sagepub.com
! o% ?' K5 ]9 m2 x+ i5 I6 H1 Y) d. ?# ahosted at1 ?; F) O" y$ j5 d
http://online.sagepub.com
7 c, s3 q) X5 MPrecocious puberty in boys, central or peripheral,! V) X; S1 q0 ?5 F0 S, f1 o" X
is a significant concern for physicians. Central& x4 H1 A$ V! b3 T
precocious puberty (CPP), which is mediated, A" d2 k) n; V/ t$ H2 j/ M
through the hypothalamic pituitary gonadal axis, has' ?4 @  x, R) c8 A" O+ q8 p  j
a higher incidence of organic central nervous system4 N; K4 w+ E; d7 L2 x) ]
lesions in boys.1,2 Virilization in boys, as manifested
1 Y  o: w* z# }. I( lby enlargement of the penis, development of pubic
# i% j9 i9 T& X7 G$ Ehair, and facial acne without enlargement of testi-
1 U2 D* P, m8 ^3 O* x$ Gcles, suggests peripheral or pseudopuberty.1-3 We( I3 G, i) t- v1 x
report a 16-month-old boy who presented with the. J/ S# U' c7 E+ @8 Y' c- S; A
enlargement of the phallus and pubic hair develop-# g# w6 O* N9 E5 j$ P' Y4 U
ment without testicular enlargement, which was due9 m: e  t1 B8 f( \* Q% q9 z
to the unintentional exposure to androgen gel used by
3 M& V$ }1 \4 Ythe father. The family initially concealed this infor-
2 u  a! ^; v7 A: l" {* \1 {mation, resulting in an extensive work-up for this8 D; b/ m1 L5 R3 {
child. Given the widespread and easy availability of
0 T- l, I/ v5 s0 {# z7 ]: Gtestosterone gel and cream, we believe this is proba-1 L: p4 Y- g6 G1 K
bly more common than the rare case report in the
& o% y/ j8 ~' Xliterature.4
. I, @9 Y7 m9 Q3 ]7 l7 z$ F! K( [Patient Report
  f& v# e+ }& }: Y$ o- sA 16-month-old white child was referred to the
; C. L2 p; J) j) X3 Cendocrine clinic by his pediatrician with the concern3 l+ w6 L2 q/ z/ u
of early sexual development. His mother noticed) L: x% D5 K" t* D9 A: x: g1 E
light colored pubic hair development when he was
& V( v$ l2 h, b0 ?: P. X0 `$ bFrom the 1Division of Pediatric Endocrinology, 2University of- P/ X5 K& x& j$ ]$ Q* ?3 A- S$ U
South Alabama Medical Center, Mobile, Alabama.
8 a/ ?4 Y9 Y; v* FAddress correspondence to: Samar K. Bhowmick, MD, FACE,; \4 J. F- V* t/ K( T  ?+ b
Professor of Pediatrics, University of South Alabama, College of7 ~. ]# B5 |2 d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' ?! {9 N. x, P2 `' A+ Xe-mail: [email protected].
, O3 {" O0 M; _, ]1 z8 l. wabout 6 to 7 months old, which progressively became
# ?5 S! ]( N' Z. L0 [9 v  odarker. She was also concerned about the enlarge-4 W. u) P+ J5 Y& V% O2 G
ment of his penis and frequent erections. The child
# X3 G' U# v  x$ S/ ?was the product of a full-term normal delivery, with/ P9 x2 F! ~' q( r7 w
a birth weight of 7 lb 14 oz, and birth length of4 d  C. m0 d- L6 I2 ]& n
20 inches. He was breast-fed throughout the first year
* s1 ~- ]6 e7 b# q6 Z6 ?of life and was still receiving breast milk along with
/ I4 E& k2 c9 `  K0 ksolid food. He had no hospitalizations or surgery," P( S0 A, A3 P! l# K
and his psychosocial and psychomotor development
/ E8 @% M  ^' r5 F$ r: [4 i, Cwas age appropriate.
3 ~3 I) E; u# z& OThe family history was remarkable for the father,
% u: F4 H% E# P9 E& q+ G* zwho was diagnosed with hypothyroidism at age 16,- Q- M& U  ]4 B! q1 _! Z+ J
which was treated with thyroxine. The father’s
# W) L( z% ~  j& m& ]! dheight was 6 feet, and he went through a somewhat
9 q, R8 K- }5 c$ r- {; [3 u+ Zearly puberty and had stopped growing by age 14.3 S/ H* N" A9 u
The father denied taking any other medication. The
$ y7 J5 M7 r, Y- Lchild’s mother was in good health. Her menarche! I2 B* x8 G8 G$ p8 B+ R
was at 11 years of age, and her height was at 5 feet
' `  d& P+ S7 z" [8 }5 inches. There was no other family history of pre-
. n% e& Z5 @, gcocious sexual development in the first-degree rela-5 \+ |5 L4 X3 B3 g/ s
tives. There were no siblings.* x9 c. p3 e9 Y* j9 T6 l) a+ F
Physical Examination
4 v* r* I- j: s9 uThe physical examination revealed a very active,
/ m  }- Y- H7 L3 m* o4 i& Oplayful, and healthy boy. The vital signs documented1 Y# T$ M& X- Y3 ^- u" Y
a blood pressure of 85/50 mm Hg, his length was2 x  W) x. j3 t; F
90 cm (>97th percentile), and his weight was 14.4 kg
, L" v6 h2 P, W  T(also >97th percentile). The observed yearly growth
3 A! A" l5 f2 j# n6 pvelocity was 30 cm (12 inches). The examination of
) j" P! F# B) y8 b$ g! Hthe neck revealed no thyroid enlargement.
$ S, w; c+ ?! q- |$ jThe genitourinary examination was remarkable for
: Q) O7 ^1 f6 v1 N/ Oenlargement of the penis, with a stretched length of
6 ^9 O* K" B, N- ^- O" Q$ W7 q7 o4 v8 cm and a width of 2 cm. The glans penis was very well' U( }' [5 a. q  K* @( u; U9 {
developed. The pubic hair was Tanner II, mostly around2 o( v, D2 p. c# @/ _4 _/ G+ g
540# d( D$ L: q( c( y1 }1 r/ i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% W. _  J8 O8 ?# d0 @6 D
the base of the phallus and was dark and curled. The
. @& l$ G% E  S$ |testicular volume was prepubertal at 2 mL each.  X% R% |; z$ T: m7 j
The skin was moist and smooth and somewhat
, ]; b1 `' J$ S% t" X/ Y9 ]oily. No axillary hair was noted. There were no
" `* `, v" v3 q1 Rabnormal skin pigmentations or café-au-lait spots.
/ Q# Y- i4 k5 f6 r( _1 `Neurologic evaluation showed deep tendon reflex 2+* i2 w) U8 i5 `
bilateral and symmetrical. There was no suggestion
$ R) e" N6 {% lof papilledema.
  U8 x+ ^) d" {- @9 F* o3 [Laboratory Evaluation2 f3 q% F! w, o7 B* N8 U& I
The bone age was consistent with 28 months by
+ ^$ A% K9 ]% [3 _' b, Tusing the standard of Greulich and Pyle at a chrono-
, P9 x4 U# i3 l+ V  C# flogic age of 16 months (advanced).5 Chromosomal
" n8 l* |+ U6 C/ Hkaryotype was 46XY. The thyroid function test4 _$ ]9 m3 k! r, I. v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ k7 e8 v8 N  Y7 I. |2 ?lating hormone level was 1.3 µIU/mL (both normal).
" c2 Z% z4 k+ v: mThe concentrations of serum electrolytes, blood7 t7 i2 W/ y4 a1 u
urea nitrogen, creatinine, and calcium all were% S, X* \8 F7 T3 N, @& V2 w) |) D+ M
within normal range for his age. The concentration
  F' H- l8 {- F/ e& h- mof serum 17-hydroxyprogesterone was 16 ng/dL6 l- W& C, i+ n8 Q5 P
(normal, 3 to 90 ng/dL), androstenedione was 20
, B! ]: s1 d" ~$ ^/ S- Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 e( R% f0 I/ }! V. v5 u5 U" `* h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) `2 O# B( i8 Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! a$ d9 s! ^$ C* K49ng/dL), 11-desoxycortisol (specific compound S)$ |% E! _) t: a7 D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 ]3 z* [1 k' h+ W! L4 o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 o' k  A; R+ ?- E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ D* `3 w1 S1 G9 U  V3 Land β-human chorionic gonadotropin was less than
0 q7 ~; T3 Z( g5 mIU/mL (normal <5 mIU/mL). Serum follicular6 ]0 K$ s  W* h) r% n# h8 ~: V
stimulating hormone and leuteinizing hormone) _- ^( ^. H' E& O- z
concentrations were less than 0.05 mIU/mL
1 p: W* d, H0 e# u1 ]1 U" r: q(prepubertal).2 c- g. Q6 E  e
The parents were notified about the laboratory* v7 S) {) p9 m  Q- X( E& R* U
results and were informed that all of the tests were, s3 ^/ G0 g- m5 D7 ~; ]- z- _4 F
normal except the testosterone level was high. The3 @. [7 y% _. T4 c% j9 t4 |& U1 E
follow-up visit was arranged within a few weeks to
" ~( V9 v$ J0 V. `- o: Zobtain testicular and abdominal sonograms; how-9 D. f: Y6 [4 g, z* z+ T5 X  N
ever, the family did not return for 4 months.2 p( i- a+ q( T2 G
Physical examination at this time revealed that the! t5 C0 @, c+ ^! n
child had grown 2.5 cm in 4 months and had gained
& N0 G+ I( c9 M' y) b2 kg of weight. Physical examination remained8 p" \' K9 q: D$ R/ ~6 S' Z
unchanged. Surprisingly, the pubic hair almost com-
, l/ P, h( k' b+ O( h# F, Vpletely disappeared except for a few vellous hairs at/ q, q/ O0 I9 r) a1 r
the base of the phallus. Testicular volume was still 2
4 X# i& v3 \5 B$ mmL, and the size of the penis remained unchanged.
1 d# o) i2 ?9 y  f& z) E4 D/ GThe mother also said that the boy was no longer hav-
& {& e$ Y" u4 m6 _ing frequent erections.: T+ _6 c" r1 a
Both parents were again questioned about use of( V1 U3 X1 q  v' R" M5 G( x9 ?4 c
any ointment/creams that they may have applied to( I* t+ b3 N0 o' H) Q' W$ G
the child’s skin. This time the father admitted the
: V1 @3 }: [+ R2 W5 A0 gTopical Testosterone Exposure / Bhowmick et al 541% Z  b  Y. F& D) ]) G
use of testosterone gel twice daily that he was apply-) @* R1 k( K3 i; t% L
ing over his own shoulders, chest, and back area for, e% U2 v; {2 w# `
a year. The father also revealed he was embarrassed: \  [, J1 c* H* |: ^
to disclose that he was using a testosterone gel pre-& v* C! v  p0 P. n% F8 l' q' j
scribed by his family physician for decreased libido
  G1 T4 O& |5 W7 I% wsecondary to depression.
9 ^4 _. ~) w- S! YThe child slept in the same bed with parents./ v2 S; G+ @0 Z
The father would hug the baby and hold him on his  c& k1 f  k7 I2 c3 U' J' f
chest for a considerable period of time, causing sig-# [: V0 t: R6 I+ Z' H& T) N6 j
nificant bare skin contact between baby and father.
) [0 g" i$ }; \0 w5 Z0 B. b/ H4 n5 [The father also admitted that after the phone call,
# j" J$ e: N& H+ owhen he learned the testosterone level in the baby  u- M) N- V$ A- E% Y: e
was high, he then read the product information
  T* r% J0 `7 I; I2 N# Tpacket and concluded that it was most likely the rea-
! t* y" m& |: Q* F1 ]son for the child’s virilization. At that time, they6 ~( g& k/ ?* C! m
decided to put the baby in a separate bed, and the7 ~6 x( d1 }9 G1 Y' ?; x& O
father was not hugging him with bare skin and had
' c! M; O+ ~, O1 b- C" j  b0 Vbeen using protective clothing. A repeat testosterone
7 n. q+ {1 h' F- z  [test was ordered, but the family did not go to the
' a% @- N: ^$ p/ Q7 xlaboratory to obtain the test.1 ~7 n- z0 n- [$ Q) D
Discussion& ?# l/ l- e5 G* c" p) A$ a
Precocious puberty in boys is defined as secondary
$ ^% x* e% f5 `# N- B7 r' n0 Rsexual development before 9 years of age.1,4& `0 h% _/ J( q* q; R
Precocious puberty is termed as central (true) when
  L$ z* \4 H# u' {# sit is caused by the premature activation of hypo-
" E$ J% A& \6 o( w' z8 qthalamic pituitary gonadal axis. CPP is more com-
. x$ @. H' M6 C( ~4 O7 amon in girls than in boys.1,3 Most boys with CPP% g9 x, ~# B  h' Q
may have a central nervous system lesion that is
1 j: F! V* T' L; Y- A0 qresponsible for the early activation of the hypothal-
% u' d* l& w2 X' u/ mamic pituitary gonadal axis.1-3 Thus, greater empha-6 ]5 n* l% ^; i  Q
sis has been given to neuroradiologic imaging in
3 h" E  f: z& F; }- x! ~& S, C6 Wboys with precocious puberty. In addition to viril-7 j0 R+ X) ?' t1 ]! c8 _+ ^
ization, the clinical hallmark of CPP is the symmet-
" o9 t+ d# {/ r2 Q( r) vrical testicular growth secondary to stimulation by8 B' x* b7 W/ ~; f, J: V/ @
gonadotropins.1,3
- u0 n" Q) T2 ]4 f9 m% u* k4 g, tGonadotropin-independent peripheral preco-) i: ], V6 T3 S) {" v% g
cious puberty in boys also results from inappropriate
8 H9 M, u$ t, d- M* Uandrogenic stimulation from either endogenous or4 {( f3 e2 r4 e: M. d3 Y  |" A
exogenous sources, nonpituitary gonadotropin stim-
# w3 E7 b" @) i* l! h/ u1 Zulation, and rare activating mutations.3 Virilizing
" W# I3 s9 h; ~  j- p  Ncongenital adrenal hyperplasia producing excessive
2 b4 Y  \' C1 i2 [! dadrenal androgens is a common cause of precocious$ W) k* l$ h  o, U4 C1 w
puberty in boys.3,43 r  `+ @( C; |) S
The most common form of congenital adrenal+ B5 n& ?, h1 _$ b( ]# b& z
hyperplasia is the 21-hydroxylase enzyme deficiency.  l% s" [3 v$ ]: {  |% i% R
The 11-β hydroxylase deficiency may also result in
& ?( n. r, s/ m# p$ o, ^excessive adrenal androgen production, and rarely,4 P2 n; `# B9 m1 V6 _% A4 h& d" d
an adrenal tumor may also cause adrenal androgen- q5 ~1 r: _/ f( w
excess.1,3
" E/ t6 H$ ]& `1 r5 Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ d! F4 A9 L4 Q! w9 x
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ s) D1 W) ?. U2 j$ ~" N$ J
A unique entity of male-limited gonadotropin-
6 x9 O  [+ g4 O$ {independent precocious puberty, which is also known
& D# C5 ?" q( Q  A" Ias testotoxicosis, may cause precocious puberty at a! S2 M3 m  P, G- d) ?$ H
very young age. The physical findings in these boys
6 z9 c# y1 s* n* F0 _with this disorder are full pubertal development,2 n! s' q) E( O5 Q5 i  B
including bilateral testicular growth, similar to boys
, U, u8 F. M" H  ^with CPP. The gonadotropin levels in this disorder: `% `2 Z0 j9 ~3 _5 b  u
are suppressed to prepubertal levels and do not show
! }& y/ d# ]  ipubertal response of gonadotropin after gonadotropin-. J! K! y4 l2 E
releasing hormone stimulation. This is a sex-linked
8 W) p, w! l( f; s$ hautosomal dominant disorder that affects only
+ N. v+ k6 a9 k8 Pmales; therefore, other male members of the family& P0 C4 c5 o% d; H* q. P
may have similar precocious puberty.30 X- J4 M% G7 d1 f" ]: c
In our patient, physical examination was incon-
1 C! G+ J; Y1 u% ~% X1 lsistent with true precocious puberty since his testi-+ ~& k% Q) ~; }) a3 p+ k; @
cles were prepubertal in size. However, testotoxicosis% X6 S6 D: g) v, O+ E: c0 ?
was in the differential diagnosis because his father! G! y, v" d5 R4 T& K
started puberty somewhat early, and occasionally,
: l1 Z: G. A- P' Y$ ^testicular enlargement is not that evident in the
' q! V3 i' i4 [6 ybeginning of this process.1 In the absence of a neg-
$ q9 r9 \# T0 |$ Mative initial history of androgen exposure, our4 o" b$ L8 R- x: A& W
biggest concern was virilizing adrenal hyperplasia,
3 l6 _3 D" N8 b: Q* \8 j3 N5 h8 R4 qeither 21-hydroxylase deficiency or 11-β hydroxylase' B/ h0 v. n+ H+ L  e1 L4 P  u
deficiency. Those diagnoses were excluded by find-
' X+ o% a; z- _  Q, u. ]! m' Eing the normal level of adrenal steroids.
- f. K$ y) W! E6 G' }3 o" Z* aThe diagnosis of exogenous androgens was strongly
$ \9 s3 u- R/ Ksuspected in a follow-up visit after 4 months because' ?6 u8 u1 N: X& S0 u6 x
the physical examination revealed the complete disap-9 J1 M; i; w& M; M" Y
pearance of pubic hair, normal growth velocity, and
* U( M7 |7 }! @. Udecreased erections. The father admitted using a testos-
5 M( [3 A( b: I% mterone gel, which he concealed at first visit. He was
5 y% T' N( E" T8 O1 uusing it rather frequently, twice a day. The Physicians’4 h8 p3 X% }, G8 r# P
Desk Reference, or package insert of this product, gel or  F( p- C. w% W
cream, cautions about dermal testosterone transfer to0 c! K% I( T# ^7 @% Z3 Z% u( k
unprotected females through direct skin exposure.
1 n2 n+ z* s4 K# jSerum testosterone level was found to be 2 times the
9 ]/ _1 ?# w3 e6 ]( |baseline value in those females who were exposed to* z: i- h: @* a# K' c
even 15 minutes of direct skin contact with their male2 d3 t- A% }8 m( \
partners.6 However, when a shirt covered the applica-* P% l9 k; f. J" U2 T/ W! k7 H, `
tion site, this testosterone transfer was prevented.% j0 e1 [$ T( y" y. \* \
Our patient’s testosterone level was 60 ng/mL,3 s+ j; t0 r3 d
which was clearly high. Some studies suggest that0 i+ n/ K4 c' \
dermal conversion of testosterone to dihydrotestos-
2 u7 q% d% ^. _; Gterone, which is a more potent metabolite, is more/ h2 g& x* G2 a  N( k
active in young children exposed to testosterone
9 D8 V$ n  H% m6 O# t/ ^exogenously7; however, we did not measure a dihy-% u* |0 w, [: v# @( c% v
drotestosterone level in our patient. In addition to
& v3 n- j# d. z6 Ovirilization, exposure to exogenous testosterone in
: R/ l, h# P" h# d# x: ?children results in an increase in growth velocity and
2 l& d8 }3 }$ _0 Q0 [6 kadvanced bone age, as seen in our patient.
, ?) Y; \' k' X4 dThe long-term effect of androgen exposure during8 {. v( t! ~! K- j* ]5 v7 x2 }
early childhood on pubertal development and final+ [, |* m) D; D' r3 I( |
adult height are not fully known and always remain
) r& S8 b- I9 Q) ]. _: ?+ S5 a- z, Sa concern. Children treated with short-term testos-9 O9 p* E2 P' @5 @+ e
terone injection or topical androgen may exhibit some5 ]9 }/ W' Z, n/ N
acceleration of the skeletal maturation; however, after
! O: z# x' u7 H  vcessation of treatment, the rate of bone maturation) c/ F9 _4 y9 q1 Y/ o0 a
decelerates and gradually returns to normal.8,9
" N5 k( i6 i2 v% RThere are conflicting reports and controversy1 l5 J* u8 V  {+ S6 }) N
over the effect of early androgen exposure on adult
% j6 Z7 D' r+ jpenile length.10,11 Some reports suggest subnormal- b8 m' G1 K) W8 o9 A4 ~5 v& p8 b
adult penile length, apparently because of downreg-0 j$ `; z+ K+ w7 z% {
ulation of androgen receptor number.10,12 However,
& H. l1 Z/ S& {3 V, x1 wSutherland et al13 did not find a correlation between
  d! @/ Z( D3 ^0 jchildhood testosterone exposure and reduced adult
, v0 U+ G' ]% {* o3 {! fpenile length in clinical studies.
9 h3 Q8 p6 ^3 A4 d) y. XNonetheless, we do not believe our patient is
2 l$ K/ t, X" H6 M1 t! wgoing to experience any of the untoward effects from
: v& L+ q) K2 b1 q2 I5 Rtestosterone exposure as mentioned earlier because* {5 R6 |3 j+ y3 F
the exposure was not for a prolonged period of time.
  o! v$ E. i" h5 c' N! w- H  o' JAlthough the bone age was advanced at the time of
4 \8 R8 G- x, e$ ^diagnosis, the child had a normal growth velocity at
5 \( ^' q% \( D! G( O/ @" [! V  Xthe follow-up visit. It is hoped that his final adult
$ w) w+ |. p' T$ Y; v' d$ \height will not be affected.7 @4 z+ ?. r9 u+ h% W; I. W6 {
Although rarely reported, the widespread avail-
- p, l* b6 Z* M/ u5 S3 Lability of androgen products in our society may* k1 R( J1 d. k2 i* [( ~* u6 r% q5 _
indeed cause more virilization in male or female& R: G+ S9 p, D7 A3 n
children than one would realize. Exposure to andro-, l, I; ~# X% G; w
gen products must be considered and specific ques-
- U: ~7 t4 z: N3 l+ O% Z; n; E. itioning about the use of a testosterone product or
- [/ ?. X0 y" [, @6 I8 ]gel should be asked of the family members during, i( c! _) r+ D
the evaluation of any children who present with vir-, _; @: g( e% v# [! S% `, j+ v
ilization or peripheral precocious puberty. The diag-
1 y# V" l& E8 H6 T+ onosis can be established by just a few tests and by- L  a3 M. j6 f5 o) e8 J
appropriate history. The inability to obtain such a4 j0 z: O6 {' n" D2 }; K' V
history, or failure to ask the specific questions, may
) A+ T' b# c8 |- \' Wresult in extensive, unnecessary, and expensive
& i7 y/ X0 K! Tinvestigation. The primary care physician should be
7 f5 O) e, f- G1 m/ M4 ^; H3 U# s- ^aware of this fact, because most of these children2 c' L, C& Z. e
may initially present in their practice. The Physicians’" C/ z" V; ?. L4 A, E* }5 i6 |5 N
Desk Reference and package insert should also put a
$ F4 |, u4 {) Kwarning about the virilizing effect on a male or+ O+ i- ]2 ~& Z3 [
female child who might come in contact with some-
7 y4 X0 ]5 d& C( X6 C. U' pone using any of these products.! y1 U: b- X) G5 B/ H) g
References
( A2 A2 ]% O" k6 l$ V: I; }1. Styne DM. The testes: disorder of sexual differentiation
% k1 J) c# X; B) i( Tand puberty in the male. In: Sperling MA, ed. Pediatric/ C4 c' |3 N  V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 ^  _+ U/ m& L: Q/ b* P2002: 565-628.
$ I# a6 W+ K  g2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 N9 y  G0 x: l1 J, ]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

, @5 a) X" ], `( t5 c/ Q, v5 v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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