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Sexual Precocity in a 16-Month-Old
/ U. J) p% Y( A. ]6 ABoy Induced by Indirect Topical
& K" F1 T1 `4 KExposure to Testosterone. [- G$ P! Q3 `- b5 X0 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! \4 k& L+ _8 O1 I* o+ H% E
and Kenneth R. Rettig, MD1/ r  ?' b4 }4 B. `8 ^: y/ O3 }
Clinical Pediatrics
1 p0 ?1 a$ K0 I' j7 Z/ ~1 WVolume 46 Number 6. u1 E$ ?, E+ Y0 y- o3 g6 A
July 2007 540-543
# z- `+ Q) P3 v; b  ^& o© 2007 Sage Publications
( K) U) V: O# W8 ?10.1177/0009922806296651
4 H$ D( |/ r1 E; @+ chttp://clp.sagepub.com
7 V) |, H+ ?- {* \; S$ Ihosted at
: q6 N0 B- x- x: M3 Khttp://online.sagepub.com
: o6 ?5 `# ?+ N/ W, }2 U6 {Precocious puberty in boys, central or peripheral,3 B- F. }' s3 l5 u) o
is a significant concern for physicians. Central6 N8 k, R( y" L
precocious puberty (CPP), which is mediated
0 Q( w1 Z# n1 t8 w' L3 pthrough the hypothalamic pituitary gonadal axis, has( p! ^( o9 E% A( O: n  E
a higher incidence of organic central nervous system7 a; A3 n: n  S9 x* q8 V
lesions in boys.1,2 Virilization in boys, as manifested2 c' r: U) |( U4 [8 ]
by enlargement of the penis, development of pubic. `  G; q3 x& M/ J* z
hair, and facial acne without enlargement of testi-* P+ u/ ~; T8 \) o/ R+ S3 h
cles, suggests peripheral or pseudopuberty.1-3 We. p* V* q/ k+ D& W
report a 16-month-old boy who presented with the
, s0 [( ^# g  g' H8 zenlargement of the phallus and pubic hair develop-
9 m9 W0 [( Z' Q: H. Xment without testicular enlargement, which was due
. m4 X- O0 n. kto the unintentional exposure to androgen gel used by
: G: u& J. W# b* w3 B7 C/ mthe father. The family initially concealed this infor-
' I  ~& z6 S9 d$ j: Y7 d3 |: ?! @mation, resulting in an extensive work-up for this# o0 v( v2 ^4 G7 X5 D" [
child. Given the widespread and easy availability of
& W$ f. B- i2 ~testosterone gel and cream, we believe this is proba-
; C1 Q+ Q1 T4 Y# c0 Ebly more common than the rare case report in the
9 E; Y1 h! ~8 Y$ T3 J" I3 pliterature.4- J3 f1 h; O4 x4 y1 A
Patient Report
3 G, q% N4 B( E( `A 16-month-old white child was referred to the* x  ?. |! O7 k2 g- b# L. a! g9 ]5 d4 ~
endocrine clinic by his pediatrician with the concern
6 t( T2 s7 j6 V, t5 t6 A: m# pof early sexual development. His mother noticed& X. @" I. J% m8 M, `
light colored pubic hair development when he was! Y+ `0 e3 d1 P, P4 X1 i0 B
From the 1Division of Pediatric Endocrinology, 2University of
- u$ T7 p) z4 n' GSouth Alabama Medical Center, Mobile, Alabama.0 O. C' Y+ S/ o
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 Z) J, v9 s: w2 ~+ B' m* I
Professor of Pediatrics, University of South Alabama, College of; N- {" n" k% i( c0 g
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; Z6 p% W9 {8 Z9 h7 `' |e-mail: [email protected].
0 H, {' z( u- N% Oabout 6 to 7 months old, which progressively became% E+ ?( ?/ c1 a
darker. She was also concerned about the enlarge-4 [3 [3 \) h& h$ F4 V- `! j
ment of his penis and frequent erections. The child
- `5 M- }% \7 H# _; X2 Iwas the product of a full-term normal delivery, with$ z* U7 A' A, L) f9 U( w
a birth weight of 7 lb 14 oz, and birth length of1 @! \- B9 R7 [: D" \  S
20 inches. He was breast-fed throughout the first year, Y) U8 @% l2 w; r: n" x# ~7 f6 C
of life and was still receiving breast milk along with
# v1 s# `  _+ N8 ^solid food. He had no hospitalizations or surgery,
) ?, K0 [$ x  f* d  L2 _and his psychosocial and psychomotor development
! s7 H/ b* B: G" Zwas age appropriate.; M5 s# A& [" \1 Z
The family history was remarkable for the father,8 P, p. k- e7 ]" b
who was diagnosed with hypothyroidism at age 16,
  n( m/ N$ ?' S6 A- c! `which was treated with thyroxine. The father’s1 L; e- O) f2 v' d6 ]
height was 6 feet, and he went through a somewhat! g# l* V! {7 e: Q" D, L3 e4 G8 Z
early puberty and had stopped growing by age 14.
( J( }+ M, t$ i0 NThe father denied taking any other medication. The- s$ ^: o! x. u- T
child’s mother was in good health. Her menarche. S9 }: Y6 r& K% n6 d3 ]+ [
was at 11 years of age, and her height was at 5 feet
& L& A+ y/ Q/ b5 u* {5 inches. There was no other family history of pre-
/ t: }' q  O( k. D% a3 c) j; @! m0 `* pcocious sexual development in the first-degree rela-8 c7 F3 j# m) @9 l5 z
tives. There were no siblings.
! ^! n. v& F4 u6 ?6 X  wPhysical Examination
' p. F# j: k! _+ y1 K% v) U/ NThe physical examination revealed a very active,
! X; o3 T5 ?0 Wplayful, and healthy boy. The vital signs documented
4 R, i7 S8 L4 W7 @* r3 W, ba blood pressure of 85/50 mm Hg, his length was- z) @! h) p* G
90 cm (>97th percentile), and his weight was 14.4 kg
2 C0 X& i- |) M% g+ k. \(also >97th percentile). The observed yearly growth
& y* a4 R. a! I% W5 A* ovelocity was 30 cm (12 inches). The examination of
3 q" m) F( y" H$ ythe neck revealed no thyroid enlargement.
6 p# d" n  C) H. dThe genitourinary examination was remarkable for+ k5 `; s/ f4 S! _' l1 a& u. H
enlargement of the penis, with a stretched length of
  G# ]' P: }( A/ b8 cm and a width of 2 cm. The glans penis was very well/ r, ^4 Q+ v- ]+ f: m/ G
developed. The pubic hair was Tanner II, mostly around
  X  i; x9 _7 C540
+ o: U! W2 ?3 ^% p4 o$ _$ ?5 gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, k" E3 P6 y% I: D
the base of the phallus and was dark and curled. The
$ _- |2 Q2 @* ^3 ~$ n8 o+ ?# q8 ktesticular volume was prepubertal at 2 mL each.
  g; y, e# r! c3 \The skin was moist and smooth and somewhat7 v. ]+ {) O( o! P
oily. No axillary hair was noted. There were no
$ g, t0 t) Q; Fabnormal skin pigmentations or café-au-lait spots.7 x0 J( l& L. j1 J- ?, z8 c! m
Neurologic evaluation showed deep tendon reflex 2+8 r2 C1 J- D/ \+ ?0 A
bilateral and symmetrical. There was no suggestion
' O: ~! i& ~' ~4 E* wof papilledema.3 |% c5 ~% L; ?! n
Laboratory Evaluation
  K7 \) ^3 ]$ [. M) |The bone age was consistent with 28 months by5 M! ?' m: S9 [/ K8 ]
using the standard of Greulich and Pyle at a chrono-$ Q! k+ `# M' ^# N( f/ U* G
logic age of 16 months (advanced).5 Chromosomal
2 c  I/ y9 A5 d1 @: ?0 |karyotype was 46XY. The thyroid function test
  c2 i- s: K# s! |6 x+ K1 Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-. A( \% r, F! x4 M" ~0 D* U
lating hormone level was 1.3 µIU/mL (both normal).
, ?& q" T9 ?, n# b3 h3 n* ]2 Z& ~The concentrations of serum electrolytes, blood; ~) C& P' t$ l1 i* ]/ M9 n; Z
urea nitrogen, creatinine, and calcium all were
" R1 n# Y0 V$ |" Bwithin normal range for his age. The concentration* \4 V# P2 C2 t2 n% \( Q# h$ B  L2 y
of serum 17-hydroxyprogesterone was 16 ng/dL
% ]) K9 W5 E( `/ k, F(normal, 3 to 90 ng/dL), androstenedione was 20" N5 ]; z* G" Y' q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 l0 B. }: d0 q$ J! pterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 b( c' K- U/ T& V& y3 q! r1 |1 F
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# E* S, t, {9 b/ m: M3 t* Y- F0 b: E+ E. [
49ng/dL), 11-desoxycortisol (specific compound S)
# _. [( w2 b" Y  z) nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) J3 r# _# M! v9 j% M! M+ ?
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* T4 N# [- j( E9 Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" W8 _" ^( T1 R1 a! Nand β-human chorionic gonadotropin was less than# v7 e8 m, E& [, {' [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; K* L/ S- P7 e+ l0 pstimulating hormone and leuteinizing hormone3 T$ g# C* g3 Q' S2 g- q! B4 U& b
concentrations were less than 0.05 mIU/mL
# P3 X1 R; \# k; m$ W(prepubertal).% ~, T9 N& Q& v% m$ |. z
The parents were notified about the laboratory
4 v6 L4 k5 l" V0 x5 K7 e: }* [results and were informed that all of the tests were5 L- A/ v* ^( T% u7 o4 \9 F/ f2 P( s
normal except the testosterone level was high. The
! U  W: J% I* L1 x; q  d, Xfollow-up visit was arranged within a few weeks to
4 T, `0 G& x0 I) ]% gobtain testicular and abdominal sonograms; how-' r! V9 a+ h8 V: j; d
ever, the family did not return for 4 months.7 o* a+ z. t' P5 ^! @
Physical examination at this time revealed that the
5 b- |2 h( ]9 f7 S" [6 R# Pchild had grown 2.5 cm in 4 months and had gained6 s1 p% J* |$ M1 Y
2 kg of weight. Physical examination remained
4 n  `$ v; S3 Z  V  cunchanged. Surprisingly, the pubic hair almost com-
6 q1 n% e' n$ M) b! t4 ]pletely disappeared except for a few vellous hairs at
4 J  O8 g! f4 c1 S% O9 ?the base of the phallus. Testicular volume was still 2* c! r% R8 |" ]' @2 R8 T
mL, and the size of the penis remained unchanged.
% d0 N' p1 B4 Z5 |6 M  aThe mother also said that the boy was no longer hav-$ M, r" J, I/ z% L
ing frequent erections.
3 p) B6 \- G3 l3 u, C, k1 R- _Both parents were again questioned about use of
( r/ y) E* m! u2 V  n+ Eany ointment/creams that they may have applied to. P/ r5 o2 j  u4 B5 z2 K
the child’s skin. This time the father admitted the. a+ n/ v% T6 U. q5 A
Topical Testosterone Exposure / Bhowmick et al 541
9 {: ]+ v1 m3 R. M$ l3 U1 quse of testosterone gel twice daily that he was apply-
, N* [& T3 J$ }ing over his own shoulders, chest, and back area for) _1 f  I" R/ z8 t* a, y& Y
a year. The father also revealed he was embarrassed
9 m6 X  N" Y7 _, U  Y8 T0 R9 Z# R/ t! yto disclose that he was using a testosterone gel pre-
' s( `, M% O" l6 s8 Qscribed by his family physician for decreased libido
; h) [) u# [9 e- w6 l7 ~secondary to depression.% U! J% |2 Y) v1 Y/ I
The child slept in the same bed with parents.
3 y% T, W* \3 H/ H  CThe father would hug the baby and hold him on his1 t$ b0 k- ?* K
chest for a considerable period of time, causing sig-
/ J0 Q5 @! m0 L3 }7 enificant bare skin contact between baby and father.' W8 V% K6 [2 d4 }* n* Q, M& {1 h
The father also admitted that after the phone call,
3 v, M% W( F5 g$ i* dwhen he learned the testosterone level in the baby
9 k6 w& ?0 K4 Ywas high, he then read the product information
* M7 p% v- |& n2 M2 M! Rpacket and concluded that it was most likely the rea-- O0 |& h5 l2 o3 a" h
son for the child’s virilization. At that time, they
; b2 p; W! b. Ndecided to put the baby in a separate bed, and the
! {8 O( f9 M# Z8 c, qfather was not hugging him with bare skin and had. R5 g/ F( c0 P0 g' j  l. z8 t! Y
been using protective clothing. A repeat testosterone
. {  \2 d5 m: ^1 G$ M: Vtest was ordered, but the family did not go to the
1 s* F# y: w9 j! I- u, F/ vlaboratory to obtain the test.% L* |+ ^* s3 D- f9 l' t4 h
Discussion6 H. R# U4 ~/ c7 t
Precocious puberty in boys is defined as secondary' H  U) ^" f' U" \6 |0 ~$ V$ R. T
sexual development before 9 years of age.1,4
$ ~6 v3 T" z: A0 X2 A, oPrecocious puberty is termed as central (true) when
4 ?- W( u- X6 pit is caused by the premature activation of hypo-
) B) \) o0 D; h: nthalamic pituitary gonadal axis. CPP is more com-4 y  u) d- V9 W4 n
mon in girls than in boys.1,3 Most boys with CPP; P; H- @/ J: p
may have a central nervous system lesion that is
( I/ s; x, D: b5 }) o" cresponsible for the early activation of the hypothal-/ I& V# ]6 O2 X9 G, ^
amic pituitary gonadal axis.1-3 Thus, greater empha-
  o+ Q( b0 o- U# B- f* ?sis has been given to neuroradiologic imaging in3 ?0 h& h  o. L. c& |" O! V
boys with precocious puberty. In addition to viril-' A' ?+ E# m. `
ization, the clinical hallmark of CPP is the symmet-
  S: s/ Z5 J9 t7 |6 T/ l: P9 Frical testicular growth secondary to stimulation by
$ N7 O  U. b$ Egonadotropins.1,34 p, b) ]8 p1 P+ V9 O+ r; l  l1 J
Gonadotropin-independent peripheral preco-) S* J7 D; c1 J. S
cious puberty in boys also results from inappropriate
8 k: @' H3 I/ r/ V& U4 randrogenic stimulation from either endogenous or
8 [0 r4 U! q. d# O% rexogenous sources, nonpituitary gonadotropin stim-
' W4 o0 K5 A4 F# D2 I- f  Mulation, and rare activating mutations.3 Virilizing
* u7 e8 U6 `2 Ocongenital adrenal hyperplasia producing excessive
* a1 O" }9 b% B$ o* }  radrenal androgens is a common cause of precocious
! n7 e" a0 v/ @: z# \" w8 fpuberty in boys.3,41 [+ U5 ~6 |0 M5 m* Q1 Y
The most common form of congenital adrenal
; E- ?, U  y- e9 z2 khyperplasia is the 21-hydroxylase enzyme deficiency.
( B& ]6 {2 L# l/ }The 11-β hydroxylase deficiency may also result in0 H' v# M/ E0 {# y% Z5 ?9 C0 n0 L
excessive adrenal androgen production, and rarely,% W) b3 [+ g9 J" U& l* J6 M& A
an adrenal tumor may also cause adrenal androgen( n- w2 r% _! r( S# ?: |1 t
excess.1,3
8 v( K% b' X" M* A# w. B% k& z  }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: R4 `# Z, q" A& q& h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 v7 |) w6 h! f2 v' @- V! HA unique entity of male-limited gonadotropin-
- J/ I! D! d  l, m" Z$ g7 gindependent precocious puberty, which is also known
- i; S) S5 w, ~/ f2 }# H, y$ F1 C% zas testotoxicosis, may cause precocious puberty at a$ A# p8 F# H8 V) @: q. n
very young age. The physical findings in these boys
% e+ U; ?% x9 C  y" |with this disorder are full pubertal development,
" p) A" i2 h0 Jincluding bilateral testicular growth, similar to boys# T- z' v( N- f% E, c, `& g6 n
with CPP. The gonadotropin levels in this disorder8 g: r7 i; F8 K/ y, [2 ]) }; `, I; X
are suppressed to prepubertal levels and do not show
+ V  v( {8 ]) Opubertal response of gonadotropin after gonadotropin-
* O0 ^7 s2 @$ ^/ |releasing hormone stimulation. This is a sex-linked5 o4 F* z3 |3 u1 h+ h" x# H9 u8 V
autosomal dominant disorder that affects only: s# M9 \1 q# p' V9 n
males; therefore, other male members of the family
4 v3 C9 ~- `3 i2 s5 Q0 Dmay have similar precocious puberty.3
( R, J1 A0 W% A3 hIn our patient, physical examination was incon-( W4 p/ O/ C2 g( h
sistent with true precocious puberty since his testi-
: w6 U* P& i3 L) ncles were prepubertal in size. However, testotoxicosis3 ~  x* R, g1 P! \  [3 v4 p
was in the differential diagnosis because his father- O! X9 Q* r& i/ T
started puberty somewhat early, and occasionally,# C/ \/ I& t" N. i$ j
testicular enlargement is not that evident in the0 Q& B: Z3 }! }9 u, X9 H/ @
beginning of this process.1 In the absence of a neg-
& t8 Q( B2 ]4 l. t/ ]; V3 eative initial history of androgen exposure, our
" Y8 i( Y5 |+ u/ I) Kbiggest concern was virilizing adrenal hyperplasia,: l; u1 h2 K3 f) R" H0 w: t
either 21-hydroxylase deficiency or 11-β hydroxylase
( m9 g8 B3 I+ s' ]/ V6 ~* hdeficiency. Those diagnoses were excluded by find-! A! O+ B8 O1 E+ a6 W
ing the normal level of adrenal steroids.
! p" `. s( ?/ xThe diagnosis of exogenous androgens was strongly% [, Z* j9 q! i# Z
suspected in a follow-up visit after 4 months because# b# m! A, n- s6 E$ a2 o3 G7 N
the physical examination revealed the complete disap-% @4 c. a6 z8 N/ Y! w& I6 b
pearance of pubic hair, normal growth velocity, and7 r  S7 _0 V4 {
decreased erections. The father admitted using a testos-
  a. I4 X- D# ]* t* dterone gel, which he concealed at first visit. He was; e. x2 w6 M7 N2 ]2 O# h% `8 I
using it rather frequently, twice a day. The Physicians’
6 L" N$ x2 B3 a/ tDesk Reference, or package insert of this product, gel or* s$ d9 L9 K5 D6 ~- Y
cream, cautions about dermal testosterone transfer to1 Q9 J: n1 X* V( l9 U& g
unprotected females through direct skin exposure.
7 B) [3 y! n; r: J/ rSerum testosterone level was found to be 2 times the
# ]) V$ V5 ]4 q( l8 Wbaseline value in those females who were exposed to
/ O8 }' I5 ~: e5 ]5 Meven 15 minutes of direct skin contact with their male  V; F: z6 s3 s, Y9 {/ I1 ]- Q
partners.6 However, when a shirt covered the applica-
/ `5 `- Q* n  i- t6 t% I: wtion site, this testosterone transfer was prevented.# M0 s7 o' ~8 |" |( S; |7 i; d
Our patient’s testosterone level was 60 ng/mL,
9 s0 m% S) E/ Y; owhich was clearly high. Some studies suggest that
2 L8 n9 v4 f3 b1 b' y$ mdermal conversion of testosterone to dihydrotestos-" }8 p  y7 A, R, b% _& g
terone, which is a more potent metabolite, is more
' k  o' M7 [2 U1 e. Q7 s! ~# |! Yactive in young children exposed to testosterone
, P0 @1 P" M" G' n( J4 w. q  rexogenously7; however, we did not measure a dihy-
5 L" s! g2 B$ z! v1 adrotestosterone level in our patient. In addition to
9 w  n- i" j1 s5 j( Pvirilization, exposure to exogenous testosterone in0 g+ X/ u' }8 k$ j
children results in an increase in growth velocity and
4 x/ d6 w4 q$ a" Z9 Gadvanced bone age, as seen in our patient.
: p0 J( T) r) F) T' Y3 X6 QThe long-term effect of androgen exposure during9 p! s# ]- ]% p$ k' r( r" o
early childhood on pubertal development and final
5 P) j& a0 t" ]3 L; k+ |: C' \adult height are not fully known and always remain! s- O5 T# k) j- q( _* y7 T
a concern. Children treated with short-term testos-
/ A* n; Z7 |( C& I# I& Y* Lterone injection or topical androgen may exhibit some
- H  H' l- T/ y$ T4 U( J: zacceleration of the skeletal maturation; however, after) Q3 ^& t& A# R" q
cessation of treatment, the rate of bone maturation
5 l- J# e  c1 M% s; |7 Zdecelerates and gradually returns to normal.8,9! \. K- Z3 Q. G2 \! A, }4 c; F& ^
There are conflicting reports and controversy
! V0 C& f+ A1 n  dover the effect of early androgen exposure on adult3 ]8 w: o3 A" R7 Q
penile length.10,11 Some reports suggest subnormal: @( R! [4 q- r( k* s
adult penile length, apparently because of downreg-
# p! H/ {' N$ l- n5 Pulation of androgen receptor number.10,12 However,
7 h7 {# w' x$ ~. e' B. uSutherland et al13 did not find a correlation between3 e, v- a; J" ^/ @1 P
childhood testosterone exposure and reduced adult
, E9 K# v- \2 A4 f. fpenile length in clinical studies.. ]2 S. i9 c  H8 b4 n! [$ O
Nonetheless, we do not believe our patient is6 e# v' N4 r3 F  q4 G
going to experience any of the untoward effects from
8 X* _. }+ M* E; [testosterone exposure as mentioned earlier because
# k/ X, r5 Y8 W* p& ithe exposure was not for a prolonged period of time.! L$ d* V6 V8 f4 p& S8 U4 e; u  q
Although the bone age was advanced at the time of. t5 I  `; ?, z2 W! E2 A
diagnosis, the child had a normal growth velocity at; ~2 `4 ^  o$ G) s# t- e
the follow-up visit. It is hoped that his final adult" p: y2 a7 E: ^' `2 ^2 a
height will not be affected./ n' H! ^2 S3 q, O' Z2 ~
Although rarely reported, the widespread avail-3 e+ G1 M$ \2 L! ?% S) ?
ability of androgen products in our society may
: r! E7 ]; ]: windeed cause more virilization in male or female* L& n6 y6 P6 D8 Y
children than one would realize. Exposure to andro-
6 d* T  a& w' G% g$ r" k) Egen products must be considered and specific ques-
6 P0 u* p/ S6 e# B4 k+ ptioning about the use of a testosterone product or
1 K" I2 g' D/ i3 {: w) V. [2 j: bgel should be asked of the family members during6 O7 Z0 n; ]% q: S- N% y3 M3 y
the evaluation of any children who present with vir-1 j  S+ M, M3 P* A- g
ilization or peripheral precocious puberty. The diag-
! I& F8 s( r4 W5 ^, j5 lnosis can be established by just a few tests and by
" R. M- _9 ]7 `1 G* |" L( Aappropriate history. The inability to obtain such a
; F1 y7 E2 y( o+ p) l5 l7 chistory, or failure to ask the specific questions, may9 ]# L8 B4 o8 `
result in extensive, unnecessary, and expensive. o6 F1 L  v, I4 ~! p& T0 V8 ]! F
investigation. The primary care physician should be$ \% u* }" S) u6 i
aware of this fact, because most of these children
, a2 P: q6 l- Z6 Jmay initially present in their practice. The Physicians’/ b3 J2 f4 X, j3 O  j; k
Desk Reference and package insert should also put a/ Q! [/ |- P, n# x  a0 B' N# ~$ [
warning about the virilizing effect on a male or
* C4 S+ X( p; g  `' U* ~% ~female child who might come in contact with some-
) s( T0 }- c4 j0 E' }one using any of these products.) q2 J5 f$ U  [2 W" h
References
* ?# F1 C- H! I, ^1. Styne DM. The testes: disorder of sexual differentiation
! M# g( v, V7 K) ]5 Y; e- t/ pand puberty in the male. In: Sperling MA, ed. Pediatric6 s8 v* l. U0 F( r+ S, m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) w3 L% {! X' A2002: 565-628.8 u. ?, X. l7 R1 C3 q& t$ |6 U
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( J7 U6 D$ Q  |8 O8 D  R
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old  R# J* p7 s# b5 d. s) s' B! c( D
Boy Induced by Indirect Topical
9 b2 \% ^' H6 U7 EExposure to Testosterone) E& t7 V$ m, h# O2 S4 j& o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" w7 c1 d6 [! S, C6 g5 xand Kenneth R. Rettig, MD1
) [% X. ^( x! Z* e& O' M  N5 }Clinical Pediatrics
4 ^# |0 N4 H1 }Volume 46 Number 6
- c1 B* B6 m$ q% l7 C2 P8 x: K; A1 ^July 2007 540-543& p! r. z% t. \$ \
© 2007 Sage Publications
: I% r7 i4 c' e! @, q10.1177/0009922806296651" J4 @7 M4 n( ~! W! j
http://clp.sagepub.com
  B5 m4 M; G3 \4 Z5 Khosted at
$ D3 `7 W/ t. X: o$ c+ Hhttp://online.sagepub.com2 s9 R' _9 p3 n" j7 b: e
Precocious puberty in boys, central or peripheral,7 u+ C( f( k! J2 `# M
is a significant concern for physicians. Central6 n5 y5 k! g& X2 r+ C5 d
precocious puberty (CPP), which is mediated7 J' t5 d" D5 o; V0 T
through the hypothalamic pituitary gonadal axis, has
+ |. e7 X4 y8 O) W: ?* f' D" N; Ga higher incidence of organic central nervous system7 |0 Z8 R$ a. a
lesions in boys.1,2 Virilization in boys, as manifested8 Y, F. `- L( y1 x  P( `( h: d
by enlargement of the penis, development of pubic
3 A; U$ Z% A; Nhair, and facial acne without enlargement of testi-
% H& Y3 Z5 ]+ Z: w/ r' j& acles, suggests peripheral or pseudopuberty.1-3 We
" l+ Z, G: K5 L) w4 oreport a 16-month-old boy who presented with the
+ c# \' m) s$ P0 v9 N) W( kenlargement of the phallus and pubic hair develop-9 M3 t: q$ D4 o- y+ X3 E
ment without testicular enlargement, which was due. P, J; F& v7 X3 y: y1 v" f
to the unintentional exposure to androgen gel used by
( a. V+ [* r. s1 Q" @" u0 r9 K9 zthe father. The family initially concealed this infor-
( j  Z5 z" T; G+ zmation, resulting in an extensive work-up for this
: U! Z0 z# @0 t' [! E6 Xchild. Given the widespread and easy availability of/ \; [/ m2 l6 L* Y2 N# d* ]) f
testosterone gel and cream, we believe this is proba-
1 P5 f6 Z( }. n+ qbly more common than the rare case report in the$ ?% M5 z2 k5 K& k
literature.45 y9 x/ T6 {7 B/ f
Patient Report; R' V' e! ~5 T# w: q9 E/ Z
A 16-month-old white child was referred to the
0 e2 ^0 ~( e9 b" g* Bendocrine clinic by his pediatrician with the concern+ H% P- j! _# R7 _0 T
of early sexual development. His mother noticed, A3 ], E5 N8 Z- e, L8 @: j8 G3 ~
light colored pubic hair development when he was
" A" |2 K2 s1 s3 j  \7 A+ l+ iFrom the 1Division of Pediatric Endocrinology, 2University of
8 E/ y# R# z& FSouth Alabama Medical Center, Mobile, Alabama.4 [' S) N% ?+ I- J  a, a; _* P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ M) [$ V9 }! J+ N1 N& wProfessor of Pediatrics, University of South Alabama, College of9 [1 q7 ?" C6 r) I: V" s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) C5 ]9 \" C. W" |, N3 he-mail: [email protected].% z' ]5 J8 q9 x$ Y, J! l
about 6 to 7 months old, which progressively became
9 ?  g, o: q4 ]darker. She was also concerned about the enlarge-
! {" O6 x( d2 N; b, Ament of his penis and frequent erections. The child
3 {1 k. a& g" i, A, a/ ]was the product of a full-term normal delivery, with
; ^1 q& F: S& n8 ?4 i; |8 e4 {) _! ua birth weight of 7 lb 14 oz, and birth length of. x& f+ k& z6 F9 y+ b* u" w
20 inches. He was breast-fed throughout the first year2 _5 K, T4 a$ `# e
of life and was still receiving breast milk along with2 w, T4 y# S+ T/ P1 i1 i, G4 ?
solid food. He had no hospitalizations or surgery,( u. V  W0 R' ?5 J/ }6 q
and his psychosocial and psychomotor development7 e1 a5 x* r, [" |
was age appropriate.7 D2 ~+ M6 h1 g. s4 }
The family history was remarkable for the father,: T; K& \0 ]5 N2 ^! q/ P* c% |
who was diagnosed with hypothyroidism at age 16,/ [. \( i2 V: |8 k7 |$ t$ u) F
which was treated with thyroxine. The father’s
$ D/ t5 f; K' g% D$ kheight was 6 feet, and he went through a somewhat' i( \& T9 I0 u. M( E3 d, u2 a
early puberty and had stopped growing by age 14.
1 ^* _* E) j/ T" C: fThe father denied taking any other medication. The
; ?; d3 m5 W; I) E6 Uchild’s mother was in good health. Her menarche% d, ^) t1 b2 F9 O, ~
was at 11 years of age, and her height was at 5 feet/ U7 B0 @  s$ T. h  ]9 v# a
5 inches. There was no other family history of pre-: l7 P" O- W6 N, E
cocious sexual development in the first-degree rela-
; \: n, h% }) R6 X/ btives. There were no siblings.
5 k( _8 i6 s: R( N; I/ dPhysical Examination
: b9 E& D3 M& h) lThe physical examination revealed a very active,5 x+ V2 h" t# M3 H; v8 a
playful, and healthy boy. The vital signs documented
% N" Y: _) A0 y4 Q4 s' [a blood pressure of 85/50 mm Hg, his length was9 z8 t4 C9 b, P+ _9 p2 l" c
90 cm (>97th percentile), and his weight was 14.4 kg, [& [9 u0 Z7 @! s5 s1 @4 M9 `
(also >97th percentile). The observed yearly growth
4 B0 e0 H5 @6 W6 D1 l& ~velocity was 30 cm (12 inches). The examination of( Y6 Q4 k6 u- B; H
the neck revealed no thyroid enlargement.& i& G. [$ g9 S/ s! N$ o# }" d
The genitourinary examination was remarkable for
! u# B# m/ @5 b! a7 C6 v( `: v2 z  uenlargement of the penis, with a stretched length of
/ p( I- }3 w) I, }, T6 a8 cm and a width of 2 cm. The glans penis was very well0 C: N. ?! E8 Y1 l6 b3 n
developed. The pubic hair was Tanner II, mostly around
6 J3 Z& n( `, E" n; n) L; h540
7 p+ b- M' v6 M2 |7 Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# L- Y& W( ?7 r" ^6 ^) X- t
the base of the phallus and was dark and curled. The
4 l- z. C7 y) Z# j( P. I* P5 otesticular volume was prepubertal at 2 mL each.2 ^& c  h& O1 O) `( ]7 `
The skin was moist and smooth and somewhat
7 T" l% x  C& W0 Q! `& s8 soily. No axillary hair was noted. There were no
# D: q7 @/ f/ x, ]9 Vabnormal skin pigmentations or café-au-lait spots.
( L# b5 d. t5 U) _  p1 |2 {Neurologic evaluation showed deep tendon reflex 2+; e& b- `/ ~" v  A8 E* }% T
bilateral and symmetrical. There was no suggestion
$ x4 P: Z. x5 r4 b1 Bof papilledema.' a0 ?( l- j& N3 z/ d  k
Laboratory Evaluation
. H- u$ \$ H% F# C' PThe bone age was consistent with 28 months by
- F4 W% T! x# N# t3 {( m- Iusing the standard of Greulich and Pyle at a chrono-
4 v0 x1 Y$ Y# n6 W0 K5 Elogic age of 16 months (advanced).5 Chromosomal# i& X* f0 a5 J0 i8 Q
karyotype was 46XY. The thyroid function test$ N2 q; h1 o: M/ S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# L* d. h, I8 h( T  N7 m: o
lating hormone level was 1.3 µIU/mL (both normal).3 b! g" _0 X4 o+ I
The concentrations of serum electrolytes, blood4 o  d3 _/ L% [1 ]4 ^
urea nitrogen, creatinine, and calcium all were
( C7 Z; y, w- Twithin normal range for his age. The concentration6 W, \  o" e/ I: |& d
of serum 17-hydroxyprogesterone was 16 ng/dL% R5 v6 Y; E6 ?) P
(normal, 3 to 90 ng/dL), androstenedione was 20
9 `1 O. n4 h* |, cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 l2 |. V" [0 {5 A  xterone was 38 ng/dL (normal, 50 to 760 ng/dL),* ]. Y  e# l; g! s$ p. a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 Q. f' _) J5 @2 h  _
49ng/dL), 11-desoxycortisol (specific compound S)8 O# N$ |/ p9 C' x4 N) g& f$ }& t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 K" L: W* s; b/ `( k  [6 X# z: D+ btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 w) {- |) z% {3 mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 e/ k# i# I0 G  J$ x
and β-human chorionic gonadotropin was less than
6 N* ^5 ?0 N, A4 T; K7 D5 mIU/mL (normal <5 mIU/mL). Serum follicular
# n( P' M) P6 |, J/ M1 K' R8 f% Q! {stimulating hormone and leuteinizing hormone
6 W7 e( t* u7 `: \- a* K1 _* nconcentrations were less than 0.05 mIU/mL5 S! b" z) r7 t
(prepubertal).2 Z1 ]7 n- ?) i6 q: o8 d+ V
The parents were notified about the laboratory
( F0 x) M: m  O$ Nresults and were informed that all of the tests were- G8 W3 E4 N9 T- H/ N2 m
normal except the testosterone level was high. The9 G8 ]8 k3 N% d3 K$ s8 d7 `, T
follow-up visit was arranged within a few weeks to
. X2 U+ l8 m  d3 c8 S8 Z" cobtain testicular and abdominal sonograms; how-
  ?' _& v# P# I; r  X% c% {ever, the family did not return for 4 months.
* \7 z1 g( L2 O3 }- n3 iPhysical examination at this time revealed that the9 {2 `1 o$ Z( R: l6 S1 ]
child had grown 2.5 cm in 4 months and had gained
$ [8 r$ R/ m$ ]4 K5 \' c2 kg of weight. Physical examination remained
2 t: ^, D* H- m& Vunchanged. Surprisingly, the pubic hair almost com-# p9 x3 h% S  W
pletely disappeared except for a few vellous hairs at4 F/ `0 R5 y, D8 u1 [
the base of the phallus. Testicular volume was still 2
' a7 A# H2 o$ XmL, and the size of the penis remained unchanged.
7 ?/ Q, h- _9 ^The mother also said that the boy was no longer hav-
! n7 q: C+ q" j& g+ o* A% ^ing frequent erections.
0 M( V% P3 f+ p# nBoth parents were again questioned about use of. O* f! Q% {3 _6 h% ~  T9 g
any ointment/creams that they may have applied to
, N2 Z$ l0 w* ?' Tthe child’s skin. This time the father admitted the
% o+ s3 R* \9 Y3 Z3 OTopical Testosterone Exposure / Bhowmick et al 5410 q% |' Q# }0 U, ^7 g
use of testosterone gel twice daily that he was apply-
. A% ]3 A- P# g4 {5 B" Ping over his own shoulders, chest, and back area for: L8 O: a. }, C* M5 T, s
a year. The father also revealed he was embarrassed( ]1 a- j0 [4 A& K/ \
to disclose that he was using a testosterone gel pre-% ?8 ~2 _5 s* {3 q: Z
scribed by his family physician for decreased libido! f) T2 c! Q  Q5 s
secondary to depression.
4 F* x% H1 V( n4 p9 dThe child slept in the same bed with parents.
% \! C2 P  w8 I. _2 _& HThe father would hug the baby and hold him on his
# B! q1 m, c& d( n+ Vchest for a considerable period of time, causing sig-
9 ]$ s/ |* H* `nificant bare skin contact between baby and father.) E$ n* R0 c1 T4 g7 U# U
The father also admitted that after the phone call,
! J1 I' h* A6 o7 \4 G1 Zwhen he learned the testosterone level in the baby5 I+ [/ v  d/ z* T
was high, he then read the product information
7 o5 S+ y) v: ^packet and concluded that it was most likely the rea-- T/ N4 d- q& q/ Y. u
son for the child’s virilization. At that time, they
% g- N7 v- T* u" W+ _- i) v. ?decided to put the baby in a separate bed, and the
, J" \6 F1 Z8 E/ f( Q- Ffather was not hugging him with bare skin and had5 @. O. L, N9 X. x3 s$ d
been using protective clothing. A repeat testosterone
1 |; n* f( Z" v, |% z9 p# U! |& b& etest was ordered, but the family did not go to the3 m; D4 a7 v" t. y: @
laboratory to obtain the test.7 `  _/ P* P' {6 x. j
Discussion; ]; a2 l) B! l% X. a- {
Precocious puberty in boys is defined as secondary
& A( E/ W$ s7 C  ~; c& M$ _: Zsexual development before 9 years of age.1,4
2 L- B0 q$ s1 `2 `Precocious puberty is termed as central (true) when
1 }1 }& y) C4 ^2 w7 I2 K! Z8 _it is caused by the premature activation of hypo-
$ B* o) V+ T5 h* W& s0 g' h# u8 Y% Kthalamic pituitary gonadal axis. CPP is more com-
; H  k  c! R8 a2 ?mon in girls than in boys.1,3 Most boys with CPP7 ]: \, C0 v9 C  d8 b
may have a central nervous system lesion that is
. Q# V6 H! a/ X7 v. T8 x$ P1 T  Q6 ?2 Nresponsible for the early activation of the hypothal-
- K  t7 v  a3 Y* B# N( W1 Mamic pituitary gonadal axis.1-3 Thus, greater empha-
; L9 R- P& l( Msis has been given to neuroradiologic imaging in
" f! q  ~/ c+ s6 wboys with precocious puberty. In addition to viril-
9 q* b/ i; ~. M. b. |8 vization, the clinical hallmark of CPP is the symmet-2 l. W4 {- ?% d, L6 D" a5 V, w
rical testicular growth secondary to stimulation by
% V+ w/ b  a0 S7 J( J# Hgonadotropins.1,3. }, z. B6 B8 Z0 I* h8 F
Gonadotropin-independent peripheral preco-
" O$ A# a5 R- D" v0 A  acious puberty in boys also results from inappropriate
' z8 \$ M- n) q; T* ^androgenic stimulation from either endogenous or& p% L1 Q$ U% T; Y2 o
exogenous sources, nonpituitary gonadotropin stim-
  g' P! l& s( I5 ?6 Vulation, and rare activating mutations.3 Virilizing
+ g) k; x2 V2 Y0 ]congenital adrenal hyperplasia producing excessive! c: `, S: T- S! l0 L) w8 b
adrenal androgens is a common cause of precocious
  Z1 b: d2 @1 Z* o" R) {puberty in boys.3,4
7 y  M, ]" e' ]- T$ H3 }- ^0 KThe most common form of congenital adrenal
4 O+ }9 G" n- i- W* Z, C$ Shyperplasia is the 21-hydroxylase enzyme deficiency.! W. L* ^- s2 M9 Y+ A! U: R  w
The 11-β hydroxylase deficiency may also result in
7 i# D- Q3 a, m" r! Eexcessive adrenal androgen production, and rarely,
0 ^. s5 u4 ?& U& h/ j5 E4 @an adrenal tumor may also cause adrenal androgen
  c, B: {/ Q7 g- uexcess.1,3/ m8 A8 p& A& k0 u) n, h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ M3 Q% s% C7 w( N: Z* q' H$ u
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 A0 R7 w' D5 r; O7 V0 ?A unique entity of male-limited gonadotropin-6 Q! k  J: K; {5 Z& n% W
independent precocious puberty, which is also known
% _( `* W" [+ H; l0 l" E2 j- s$ uas testotoxicosis, may cause precocious puberty at a
" |. z( }/ P  t1 lvery young age. The physical findings in these boys" E* R1 d: Y* }/ z: f, C, O
with this disorder are full pubertal development,
$ ^+ a9 k2 x+ M9 mincluding bilateral testicular growth, similar to boys
2 O' R4 ^1 T2 U" l. dwith CPP. The gonadotropin levels in this disorder" ?" W% b( {0 [8 R
are suppressed to prepubertal levels and do not show8 T" L" @: I  c; Q
pubertal response of gonadotropin after gonadotropin-
. I, ]& e7 p+ i1 m6 }releasing hormone stimulation. This is a sex-linked5 A0 {3 W- p: F8 a3 ~( W( T- g
autosomal dominant disorder that affects only
) P3 S( a# P/ L6 n! a: b( Ymales; therefore, other male members of the family
9 ]+ N$ E  X: `" [  A4 cmay have similar precocious puberty.3& f6 u" h& Z& x8 _" \9 w9 J" u# z2 X
In our patient, physical examination was incon-
9 X0 w0 Y; C) O) vsistent with true precocious puberty since his testi-4 s6 {8 x( ~/ y$ T+ d) Z( e2 a
cles were prepubertal in size. However, testotoxicosis2 D8 I3 F( ~; ?- k6 t2 k
was in the differential diagnosis because his father# y5 ^* |4 r% Y5 d8 |* O3 q( b& x
started puberty somewhat early, and occasionally,
; a( x$ ]+ m) J2 ^5 ltesticular enlargement is not that evident in the
  W% M2 |# z1 s4 W; _6 _! B% Obeginning of this process.1 In the absence of a neg-5 z9 m. P5 P; e3 M8 D1 q7 P
ative initial history of androgen exposure, our
8 ~0 L0 g1 Y# h  M. tbiggest concern was virilizing adrenal hyperplasia,
. Q8 o1 p& M4 ^/ V; Xeither 21-hydroxylase deficiency or 11-β hydroxylase+ ~+ l0 x5 d! W6 L# \
deficiency. Those diagnoses were excluded by find-
; o, f' s# v! q- ting the normal level of adrenal steroids.& D. R- @& F. c8 h$ T, h! r" P
The diagnosis of exogenous androgens was strongly" |- a: E: A% a5 z' Q- T
suspected in a follow-up visit after 4 months because, N. H; d6 H  E# C
the physical examination revealed the complete disap-/ Y! ]& k. i% G2 j# B- T- m- q, [
pearance of pubic hair, normal growth velocity, and/ ^1 P8 J9 L7 R& l
decreased erections. The father admitted using a testos-
  c/ h- C4 W! Sterone gel, which he concealed at first visit. He was
% p5 v3 t. r( B1 Eusing it rather frequently, twice a day. The Physicians’
: u$ f! R( \+ h0 m- k  C3 D4 dDesk Reference, or package insert of this product, gel or$ ~9 d/ z& k/ o
cream, cautions about dermal testosterone transfer to; T/ p2 ?: m5 u0 G" w
unprotected females through direct skin exposure.
" D& ^, o" {# D( k1 BSerum testosterone level was found to be 2 times the
5 @3 B" C4 y( `! G# vbaseline value in those females who were exposed to7 c$ E/ h+ ^* N% m6 X5 K
even 15 minutes of direct skin contact with their male# U' U$ I( U8 f! ?' c0 W5 X, X
partners.6 However, when a shirt covered the applica-
" |0 g$ T  X, Stion site, this testosterone transfer was prevented.& J* W5 O6 N$ F/ Y* G
Our patient’s testosterone level was 60 ng/mL,9 I( v' i* @; R/ z
which was clearly high. Some studies suggest that
* E! S% H' i2 M0 c2 u9 Odermal conversion of testosterone to dihydrotestos-) p! [. ^& V6 }7 ?( |  U) X% e
terone, which is a more potent metabolite, is more' p! U1 @4 Z+ q/ c4 |/ L
active in young children exposed to testosterone
" k& U; v9 l7 Lexogenously7; however, we did not measure a dihy-! |1 Z* d. `! T' h- _2 Q) G* E/ ?
drotestosterone level in our patient. In addition to7 `' \, _# L' z
virilization, exposure to exogenous testosterone in
% V' J( W2 `8 T& echildren results in an increase in growth velocity and
$ s! |' \9 y* |9 G! ~0 Oadvanced bone age, as seen in our patient.
5 O! E7 V0 L" Z( w4 hThe long-term effect of androgen exposure during
% m; }6 I5 [% ?0 I: }( R) g5 o& Jearly childhood on pubertal development and final' D9 c# Q+ i* P5 I9 L
adult height are not fully known and always remain$ {% ?9 Z) t2 j  t0 I5 y3 \# {& b
a concern. Children treated with short-term testos-: g! ]5 z0 C4 t7 k+ L# G
terone injection or topical androgen may exhibit some: h# ~  p) S' p3 D
acceleration of the skeletal maturation; however, after
* y# A; n5 J0 y( D& ]cessation of treatment, the rate of bone maturation
3 J0 d: y( e& J+ o: D( L8 ydecelerates and gradually returns to normal.8,9
- R& {7 O/ L3 I/ k+ _' wThere are conflicting reports and controversy& R) |' G& t% ]% p  I8 h# }
over the effect of early androgen exposure on adult
4 ]/ o; u0 R- vpenile length.10,11 Some reports suggest subnormal
+ G: J, Y; p. E( _$ n, t; hadult penile length, apparently because of downreg-0 l/ q" O  V$ r6 x1 ?0 `  ]
ulation of androgen receptor number.10,12 However,
6 t& p: |6 l6 s$ r- USutherland et al13 did not find a correlation between6 I% @+ f0 |+ H; X: p8 h- E' l
childhood testosterone exposure and reduced adult3 x% z' S4 F; c  J1 w  W6 P
penile length in clinical studies.* i' O# d% {% {  a7 ~
Nonetheless, we do not believe our patient is: G( a9 X. Z) X! @
going to experience any of the untoward effects from
$ ?& M# \3 |: E  u; rtestosterone exposure as mentioned earlier because* P- ?- r$ I7 h& t2 C
the exposure was not for a prolonged period of time.: G# O  @! B; c5 R. d' c9 Y
Although the bone age was advanced at the time of
8 U1 N: u# Y0 S8 |diagnosis, the child had a normal growth velocity at
( J3 J  z! H8 @" ythe follow-up visit. It is hoped that his final adult
4 M+ l1 U& c. ]3 M" l# j: Wheight will not be affected.! l) o# z: B+ d+ X
Although rarely reported, the widespread avail-
9 }- F. r# s6 yability of androgen products in our society may, ?2 w" S$ g' u* m+ v/ @
indeed cause more virilization in male or female" g0 U8 _3 R* t
children than one would realize. Exposure to andro-6 ]+ O7 d" j' `) A: b& B% I1 m
gen products must be considered and specific ques-
3 _# i/ y9 Z# f# R/ I& n( Gtioning about the use of a testosterone product or- ~" p  v4 \4 [2 N, _$ Q4 E
gel should be asked of the family members during
5 }. U9 u, C8 M+ d/ dthe evaluation of any children who present with vir-  v2 N5 Q) |; V4 \( Y6 X- g
ilization or peripheral precocious puberty. The diag-
6 s+ b! F, Y3 ]' j, w! S4 Rnosis can be established by just a few tests and by
% N6 ~3 I% `. a0 Uappropriate history. The inability to obtain such a
3 |9 N: ~8 J3 X; w8 e' Ihistory, or failure to ask the specific questions, may- o' i+ @: H6 p% m0 Y1 I9 ~1 q2 c
result in extensive, unnecessary, and expensive
. B' M. t% T" Tinvestigation. The primary care physician should be
4 V! {4 O4 m& [, O* G3 R$ Gaware of this fact, because most of these children
# h) s7 ~4 N, m1 Lmay initially present in their practice. The Physicians’
8 _# t% a: m; a% {9 v+ B, @0 FDesk Reference and package insert should also put a9 K+ E* r5 R0 V4 B
warning about the virilizing effect on a male or3 Q5 M4 ?! C+ f! w9 U0 [9 \3 M
female child who might come in contact with some-+ w8 I5 z- G8 o3 D% z7 u
one using any of these products.8 p) T* |; y% L0 A. F+ y
References
: f8 s, r' c8 D: l: a" |  @1. Styne DM. The testes: disorder of sexual differentiation9 S$ R* ^4 x* `9 @1 d: N
and puberty in the male. In: Sperling MA, ed. Pediatric6 G; \- S9 f" @+ K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' Y* R1 ?6 B! }7 `* s7 a' G
2002: 565-628.* B- j* A" z" y9 [2 X6 G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 C: s" {9 D( B, O3 z. m! I
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

7 V+ X' D1 i' `$ `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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