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Sexual Precocity in a 16-Month-Old4 M! [3 n8 B6 p" E! M
Boy Induced by Indirect Topical
2 ?* P; P8 F4 m6 L: G& fExposure to Testosterone& @# \* Y! m9 O8 A  [( J
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ f$ j! ?! {" y, G7 r
and Kenneth R. Rettig, MD14 Q5 z9 w. M) `2 \% J/ c: I
Clinical Pediatrics
) H+ R& A: Y( m; F4 e& q" XVolume 46 Number 6
5 b. `: M( g! |) M  SJuly 2007 540-543
+ M4 A& L: x4 t9 v) [% R© 2007 Sage Publications& ~- L2 d' x7 w
10.1177/0009922806296651+ H2 {/ q# q) z: k
http://clp.sagepub.com
5 j* b( S# a8 H1 n2 khosted at$ u$ l& M7 |0 c* v3 ~( r9 u0 f
http://online.sagepub.com
  F& F  a) j! C& o* |  X! vPrecocious puberty in boys, central or peripheral,
7 O% V$ z% Q; ~- Vis a significant concern for physicians. Central$ h/ z; b# E5 M
precocious puberty (CPP), which is mediated6 e: b. G3 z1 N6 P/ l
through the hypothalamic pituitary gonadal axis, has
$ ^+ J  [# J& L; Q$ N9 C9 S: m  N" ?a higher incidence of organic central nervous system
3 G( V6 L& Q) n) |+ p& Nlesions in boys.1,2 Virilization in boys, as manifested4 Q* Z: C/ W5 n$ z) m7 n
by enlargement of the penis, development of pubic
2 O( ~% s2 d' d' `4 E! ~hair, and facial acne without enlargement of testi-
1 f; r1 _9 a, U! I3 ycles, suggests peripheral or pseudopuberty.1-3 We
1 d% s4 I1 F  m% J; A8 u. Creport a 16-month-old boy who presented with the1 b. l" s' Q7 W* g$ m
enlargement of the phallus and pubic hair develop-$ o2 g' f, U8 y2 z
ment without testicular enlargement, which was due
9 H$ B3 ^4 W8 l/ ~6 P/ G* b) W8 Lto the unintentional exposure to androgen gel used by9 v. f- [3 D7 V5 S
the father. The family initially concealed this infor-
% H; H. Y  [$ nmation, resulting in an extensive work-up for this/ u9 y# `1 q5 s  y
child. Given the widespread and easy availability of
3 B( J/ h0 z/ l  utestosterone gel and cream, we believe this is proba-, `1 H. x) R3 r! e
bly more common than the rare case report in the
9 z) O% c  j! F3 @literature.4: T1 I. e$ q4 S$ T% O! M9 z$ w  _9 E
Patient Report7 u1 `- c. g+ d; @$ k
A 16-month-old white child was referred to the
$ C3 [: e# {1 x5 U: m# K, v& Pendocrine clinic by his pediatrician with the concern0 D0 r: u$ `6 u
of early sexual development. His mother noticed
2 W5 r! @9 K: _" U: `6 B8 ?light colored pubic hair development when he was5 A4 `. S6 p$ m$ z
From the 1Division of Pediatric Endocrinology, 2University of
. v5 `1 y& _1 d' Z# P: C3 ^+ kSouth Alabama Medical Center, Mobile, Alabama.  B4 q; u! K$ ^- m! f) V% O* a
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 }7 h0 [0 n# `
Professor of Pediatrics, University of South Alabama, College of
' l& L# b9 d$ v/ A  ]: HMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& Z& P; r# f1 M- Y
e-mail: [email protected]., r# x! C! Z, P" r
about 6 to 7 months old, which progressively became' Z7 D0 [, B- o5 Q- W+ N6 U( t
darker. She was also concerned about the enlarge-
  D- e- x. j& B2 z& hment of his penis and frequent erections. The child
. O0 i) y0 x" c# r4 B) Qwas the product of a full-term normal delivery, with! I$ M! ~# S# o  ^/ d1 u# {# }
a birth weight of 7 lb 14 oz, and birth length of$ F) N1 q! b* Q. _
20 inches. He was breast-fed throughout the first year
3 L+ M9 W' M; c# ^' J) cof life and was still receiving breast milk along with
( P8 H: q* b$ W( psolid food. He had no hospitalizations or surgery,
4 Z( y" B1 ?6 ?and his psychosocial and psychomotor development
" w4 F% k- R2 |3 W1 L7 M( h1 ewas age appropriate.
* r; @' ^8 r- Z4 G) OThe family history was remarkable for the father,
8 `: D" h+ P2 v* t: r1 b- Fwho was diagnosed with hypothyroidism at age 16,
4 C! R" O& [: ~which was treated with thyroxine. The father’s4 n. \9 ?! S1 p- _% }
height was 6 feet, and he went through a somewhat" r1 e2 _% U2 q, m0 r. G' Y
early puberty and had stopped growing by age 14.
1 W/ ~8 s" ~0 A: Y* U) OThe father denied taking any other medication. The. R% u" }" A% F) n1 W
child’s mother was in good health. Her menarche
) N6 h9 ^2 A. S- Ywas at 11 years of age, and her height was at 5 feet
# u; b2 H! Y7 w1 Q) O. h5 inches. There was no other family history of pre-  t7 G: D& I$ n8 Z. d5 l
cocious sexual development in the first-degree rela-/ C  i+ @8 v9 l* m7 N! S
tives. There were no siblings.
6 v" I( N/ m$ c5 B7 u' }3 nPhysical Examination! y5 @& o, ]+ Q" B: j' s2 n
The physical examination revealed a very active,- J9 @9 K0 e9 J$ L) B
playful, and healthy boy. The vital signs documented
. Q- C7 u( C0 Z# s+ O- I- d  fa blood pressure of 85/50 mm Hg, his length was+ I( S! N  \4 n$ S# ?  a" C" P
90 cm (>97th percentile), and his weight was 14.4 kg
# }; u: {4 m, X6 Z- `(also >97th percentile). The observed yearly growth, l# [: c! ?* W. L
velocity was 30 cm (12 inches). The examination of8 p$ s. C. ]6 r; M; f
the neck revealed no thyroid enlargement.
% ]8 V" x# R' k( iThe genitourinary examination was remarkable for. a  ^: P$ d# T/ ]* z: h: y* Y
enlargement of the penis, with a stretched length of8 J) a. _) {  O: P0 \. n, D( s
8 cm and a width of 2 cm. The glans penis was very well% \1 @$ }& y. ~8 L: F
developed. The pubic hair was Tanner II, mostly around
6 f; d/ {) f( Z% B" C. p540
, l% v" l' Z; T5 }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 T( U( m7 ?) g* fthe base of the phallus and was dark and curled. The
# N) P4 d! @5 _4 a1 t' z4 D3 |8 T0 xtesticular volume was prepubertal at 2 mL each.9 U2 z* r' u" Y. Y4 r/ W: `5 h6 |) z
The skin was moist and smooth and somewhat
, h5 u1 ]: p/ c9 y8 X( |oily. No axillary hair was noted. There were no  H. E4 Q1 |. q8 {7 ]6 Q% u
abnormal skin pigmentations or café-au-lait spots.0 u" F* R; s& I9 S6 S
Neurologic evaluation showed deep tendon reflex 2+- q% I/ M# l3 k* \) ~- M/ t
bilateral and symmetrical. There was no suggestion
' k# Q  [# o# H9 }- N' xof papilledema.
7 I$ {2 b1 l: K! B/ jLaboratory Evaluation) N* i0 u( F/ t! n# w
The bone age was consistent with 28 months by+ O( @9 Y* D* N7 I
using the standard of Greulich and Pyle at a chrono-
! |; z7 e3 g5 ^; @logic age of 16 months (advanced).5 Chromosomal  f2 ^3 D- @: Y: U% y$ _% U
karyotype was 46XY. The thyroid function test
# Z" q5 S- v$ _" U0 A# Q* b  Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
; F0 z5 w  C7 P* o. o3 J3 a/ z" vlating hormone level was 1.3 µIU/mL (both normal).; J8 O4 G# ?' H0 l+ v0 I% [3 c
The concentrations of serum electrolytes, blood2 v. s0 D+ ?, ^6 t
urea nitrogen, creatinine, and calcium all were9 O$ Z% b0 d6 G6 X9 M
within normal range for his age. The concentration! Y& X' ~. }9 [# q5 M
of serum 17-hydroxyprogesterone was 16 ng/dL
, z% k, X; ~3 M8 C(normal, 3 to 90 ng/dL), androstenedione was 20( ?" I6 ^3 K. @7 _- a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: c+ s( `+ M! Y3 oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 P3 B/ w: F6 ~4 Q1 B' _& ^8 R% h$ I+ T7 ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ n1 T0 i% x) c/ e2 ]5 T49ng/dL), 11-desoxycortisol (specific compound S)
% s0 E( F- U( ^% Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 H- z) o: |  e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. G: @- ~3 e5 J" ^3 F% E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 Z5 }0 V) j/ l* T, T' aand β-human chorionic gonadotropin was less than( ^8 m! l0 a' z2 O! K: B: e
5 mIU/mL (normal <5 mIU/mL). Serum follicular5 x/ }$ a8 F- q9 h$ \! ~
stimulating hormone and leuteinizing hormone9 e0 `9 A9 z' Q% d
concentrations were less than 0.05 mIU/mL, d; r4 X  o, w9 {- I9 I
(prepubertal).
/ D( @  ^5 E4 N4 rThe parents were notified about the laboratory
5 f, u2 N! \: Dresults and were informed that all of the tests were+ F# I. N: M" z% |# U) M5 d
normal except the testosterone level was high. The5 c; K2 D$ s! |7 r
follow-up visit was arranged within a few weeks to
1 ]4 {1 }3 U6 R& J# i' G" j) Zobtain testicular and abdominal sonograms; how-
6 W9 ?9 P0 j# I, b% }" J2 _ever, the family did not return for 4 months.
5 Q7 ~9 V- P% y2 j6 [1 i  SPhysical examination at this time revealed that the
: e7 N% x0 q- B* N+ qchild had grown 2.5 cm in 4 months and had gained
  n' c( R- ~& v! D8 S, H2 kg of weight. Physical examination remained! k% T0 N0 r4 r# A' `
unchanged. Surprisingly, the pubic hair almost com-8 O" L  Q# P6 [5 V
pletely disappeared except for a few vellous hairs at
) {/ M% \% i- C, hthe base of the phallus. Testicular volume was still 22 z# {: E: Z5 E2 }# {
mL, and the size of the penis remained unchanged.
& K" |* u5 t" |1 B2 ~# nThe mother also said that the boy was no longer hav-) @" ~0 }- ^7 z- C
ing frequent erections.
7 r! L0 [4 h0 D' m- x9 W$ a# ]Both parents were again questioned about use of
. ?% Q8 K) C! d$ S8 ?/ v; ]# Many ointment/creams that they may have applied to" O7 p* S* B+ f1 R0 ]4 `1 q
the child’s skin. This time the father admitted the4 p+ U; Q6 ]. Q( k7 Q
Topical Testosterone Exposure / Bhowmick et al 5410 n' O+ d2 ~) j% g: ]
use of testosterone gel twice daily that he was apply-
8 e% f" {/ u" R7 Ning over his own shoulders, chest, and back area for  |0 l5 K0 M5 v, t' u
a year. The father also revealed he was embarrassed9 o2 w$ H9 h& v* S
to disclose that he was using a testosterone gel pre-0 u7 v; J+ x6 D5 _7 m
scribed by his family physician for decreased libido7 p' N' T  S& t8 C* M- I9 w5 v
secondary to depression.
9 h! \" D0 j. X1 x# y% a" N7 aThe child slept in the same bed with parents.
1 ?& w# K; A3 w! Z& M. e5 g: r, mThe father would hug the baby and hold him on his7 J. c: g" A% [
chest for a considerable period of time, causing sig-( e& @( _: E9 {; g1 \* H
nificant bare skin contact between baby and father.
3 `: O/ K' p  p' w6 P4 ~+ J- b2 lThe father also admitted that after the phone call,) f; T+ V# R. G$ t% {
when he learned the testosterone level in the baby! i+ M$ q2 A& N  D. d8 Q% _1 N
was high, he then read the product information
" Q. I6 d+ e" R3 [; opacket and concluded that it was most likely the rea-
* h0 {6 \! ^5 N% d" Hson for the child’s virilization. At that time, they
* x3 ^: Q' I& F: R4 @. y: y4 Sdecided to put the baby in a separate bed, and the
" L; _! u5 V0 T5 jfather was not hugging him with bare skin and had
- j+ p9 \2 G2 F6 wbeen using protective clothing. A repeat testosterone8 U1 z: W$ l+ m8 t$ I  `. Y
test was ordered, but the family did not go to the# I1 p0 L* i5 H- }) U% \7 W- v; m
laboratory to obtain the test.6 h7 U  O3 ^1 g5 [3 h; T3 N6 d
Discussion
1 A2 D. N' I3 G. K6 u$ aPrecocious puberty in boys is defined as secondary* c6 z& t* T3 k" q" d1 y
sexual development before 9 years of age.1,45 o7 q. w: k* z1 p
Precocious puberty is termed as central (true) when* M/ D! c8 s* R' F; V, r
it is caused by the premature activation of hypo-
$ ]* Q; c4 c" {! \* m; jthalamic pituitary gonadal axis. CPP is more com-
  j6 [$ {/ P/ L; fmon in girls than in boys.1,3 Most boys with CPP2 \4 g  b% [- i/ Q
may have a central nervous system lesion that is  y2 p9 U' H' l7 }
responsible for the early activation of the hypothal-$ w! {/ d2 \' B( a
amic pituitary gonadal axis.1-3 Thus, greater empha-
5 i- _- Z: y3 B0 c! [" U! n2 |* S: {sis has been given to neuroradiologic imaging in: }' |( R& y1 l; b4 J$ q( W
boys with precocious puberty. In addition to viril-9 i2 P& `5 p( s! x; u* V
ization, the clinical hallmark of CPP is the symmet-( Q+ m5 R3 O& R+ @6 j
rical testicular growth secondary to stimulation by2 r# [3 w2 J, T9 K7 y. f8 x
gonadotropins.1,3
& y. l, J# Y# j  @( w& z6 ?Gonadotropin-independent peripheral preco-0 t3 S$ O! [/ P7 y7 f0 D
cious puberty in boys also results from inappropriate
; F9 m2 G3 r. u  ]% Nandrogenic stimulation from either endogenous or9 @) d4 N7 i: s9 @7 T! M% I+ |9 a
exogenous sources, nonpituitary gonadotropin stim-& L5 e/ W7 r) v
ulation, and rare activating mutations.3 Virilizing/ R5 e# l; W! ]3 n- l5 [
congenital adrenal hyperplasia producing excessive
3 a) H. Q1 ?1 yadrenal androgens is a common cause of precocious! k8 J- J# ?  G7 G
puberty in boys.3,4$ C$ ]7 {- k2 P) X& h2 O
The most common form of congenital adrenal
( }2 o4 f0 E. @5 \( j. |9 ahyperplasia is the 21-hydroxylase enzyme deficiency., ^# m- ^+ a7 [/ d$ j3 P% @
The 11-β hydroxylase deficiency may also result in' e0 _( e) k2 j$ I% ]4 Y2 c  ~" {* q; U
excessive adrenal androgen production, and rarely,
) P+ S( M$ x' E  ?& @3 e- xan adrenal tumor may also cause adrenal androgen
2 a" p4 X9 {- D; c7 dexcess.1,3
$ h, a8 D; v2 k8 Q! _% m2 Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  A" U/ r4 P- _) r8 A8 v+ @
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: N. g; _: C3 w
A unique entity of male-limited gonadotropin-
9 B% c+ V  E$ N$ y- V) l% O6 E7 kindependent precocious puberty, which is also known
" V$ j. V+ u4 z; N3 }as testotoxicosis, may cause precocious puberty at a% M7 Z% E5 _7 _- D  q7 D4 B
very young age. The physical findings in these boys
% k/ U' Z5 |$ i% N! uwith this disorder are full pubertal development,. g) Y) |' H4 e0 ]
including bilateral testicular growth, similar to boys% b7 i" K; v* G
with CPP. The gonadotropin levels in this disorder
$ c2 ^& R, y( S: S9 `are suppressed to prepubertal levels and do not show
4 m' Q: w' f$ Ypubertal response of gonadotropin after gonadotropin-7 G: ~) V3 c" A
releasing hormone stimulation. This is a sex-linked
# F! l) z- j2 N6 Qautosomal dominant disorder that affects only
% E7 n4 |* N. m/ ], c7 ^8 H. a- Cmales; therefore, other male members of the family
& D, s* T% J5 k! y3 W* `0 [may have similar precocious puberty.37 p$ O$ ?( n9 w* B  e4 b5 T0 _
In our patient, physical examination was incon-
3 l$ f( h: d7 N9 fsistent with true precocious puberty since his testi-
' O9 m5 T' Q# p3 y% }$ b3 c  @5 tcles were prepubertal in size. However, testotoxicosis( j" n8 m& Y3 Q7 @7 i5 N4 D0 R/ u
was in the differential diagnosis because his father3 s( C: d  N- E5 Z+ m1 u
started puberty somewhat early, and occasionally,# S* h" T7 Y! q" b" N2 _
testicular enlargement is not that evident in the- y. {5 k: k) w  C; v
beginning of this process.1 In the absence of a neg-
, q) d0 X; H& Pative initial history of androgen exposure, our7 z) P, l2 m/ c& T1 j2 d8 k4 P8 K
biggest concern was virilizing adrenal hyperplasia,/ z; J; s5 B, n+ x9 w
either 21-hydroxylase deficiency or 11-β hydroxylase
, n8 T! z7 I* b& D5 t7 l5 ydeficiency. Those diagnoses were excluded by find-
  m# u8 U2 W+ T4 H* Oing the normal level of adrenal steroids.9 `) e) B4 `' h" G
The diagnosis of exogenous androgens was strongly, t9 f/ Y1 b8 s' A7 |9 d0 w% @
suspected in a follow-up visit after 4 months because
; K" u, f* T4 m! I7 d% Nthe physical examination revealed the complete disap-6 I7 M' f% z! H' e
pearance of pubic hair, normal growth velocity, and6 U. J/ f) I6 z& l2 `$ o2 n# R
decreased erections. The father admitted using a testos-
6 M. z+ Q$ }# V# Z9 Cterone gel, which he concealed at first visit. He was% n  [" {; o+ G5 V! h* u, [  d" o! @4 q
using it rather frequently, twice a day. The Physicians’6 O; b" y. {8 x( ]9 ]1 [1 X- ?
Desk Reference, or package insert of this product, gel or- L  F* ]4 M4 ]5 ~
cream, cautions about dermal testosterone transfer to
: z5 r9 R8 N) d/ E) Dunprotected females through direct skin exposure.* o% q1 L% J0 \3 `& b. i6 n
Serum testosterone level was found to be 2 times the/ o4 z. D% A' c' K- ]2 _9 U
baseline value in those females who were exposed to5 P% H7 g6 R3 T1 _: f& R, e
even 15 minutes of direct skin contact with their male* u+ @+ b3 W. `
partners.6 However, when a shirt covered the applica-
/ F7 M! k% h& `# ~8 Stion site, this testosterone transfer was prevented.# m, z9 d, G; ]4 c6 m: J
Our patient’s testosterone level was 60 ng/mL,
1 o+ g$ q9 n( i- A4 F' Wwhich was clearly high. Some studies suggest that
" \( @( T- u9 }% Vdermal conversion of testosterone to dihydrotestos-
% O/ i& R* m$ z  V  u/ F+ d$ c# hterone, which is a more potent metabolite, is more
8 R/ c4 V" Z/ `: B" M. K  z; gactive in young children exposed to testosterone& |( e# N6 o+ a: X- ~2 V( L
exogenously7; however, we did not measure a dihy-
8 ?" I9 a- _' C* E# }drotestosterone level in our patient. In addition to& o+ X+ J  ^2 S- t( J. R2 T( v' o
virilization, exposure to exogenous testosterone in' u) @$ O- g5 [+ d4 f
children results in an increase in growth velocity and" A0 h5 B8 Q" Y4 e. d9 x# z4 A
advanced bone age, as seen in our patient.) V  A% m& _" o! C6 v% g/ o$ s
The long-term effect of androgen exposure during
* ?. C* _8 w3 \  k+ J, ^8 \early childhood on pubertal development and final0 i1 Z3 N6 j) F
adult height are not fully known and always remain+ }- e, I6 P; y& N% W
a concern. Children treated with short-term testos-. H  T' S* h, s1 D1 \' B
terone injection or topical androgen may exhibit some
' _6 R7 s& f5 z. t6 G8 ^$ Y1 kacceleration of the skeletal maturation; however, after
  c5 [# I9 ]3 h3 rcessation of treatment, the rate of bone maturation
" q2 _1 B, U! ]decelerates and gradually returns to normal.8,9
6 _" N) r# r6 U0 m1 wThere are conflicting reports and controversy0 I! I+ g' y  c% _. k* U* o
over the effect of early androgen exposure on adult1 p+ b# G8 m7 c
penile length.10,11 Some reports suggest subnormal0 T  Y2 e5 N: V
adult penile length, apparently because of downreg-+ Y3 w& E/ O- J) k0 q, G
ulation of androgen receptor number.10,12 However,
' u" R3 q# g  z/ i" ]* A4 pSutherland et al13 did not find a correlation between
9 k! l' T+ p4 @  m3 s/ B" J& }& ]childhood testosterone exposure and reduced adult
+ N( {4 T8 J: C7 S1 Ipenile length in clinical studies.
$ a/ u3 @5 l* WNonetheless, we do not believe our patient is
- i9 y: t8 f% i1 K" |4 W, R1 B$ Ygoing to experience any of the untoward effects from
: y/ G' S8 u. G7 G. A  Y' r: }testosterone exposure as mentioned earlier because0 J$ s1 L6 Q9 Q* O* Q0 J" n; l
the exposure was not for a prolonged period of time., b) y" T5 c# v$ d$ X  a8 D/ w7 P
Although the bone age was advanced at the time of/ V! Z. m' F% Q8 f; @0 C
diagnosis, the child had a normal growth velocity at7 d5 [6 B0 A+ E. d) C2 w$ k: G& Z0 E/ k
the follow-up visit. It is hoped that his final adult
# t6 D8 {7 ]  j+ \1 yheight will not be affected.- T% _& Q- [  h9 o& w' i7 o
Although rarely reported, the widespread avail-
3 W0 `6 d: _' e( Xability of androgen products in our society may
' J! Q1 B6 r; C* Vindeed cause more virilization in male or female" H7 O/ [; h# N( b& l7 V9 X: h
children than one would realize. Exposure to andro-
; K0 {: K5 F% ]( I, Sgen products must be considered and specific ques-( H5 F, l  a& X3 ?; a
tioning about the use of a testosterone product or
/ m8 U) a# K3 q6 K$ lgel should be asked of the family members during
/ ^" x7 W' _- ^( L6 k1 M9 }the evaluation of any children who present with vir-9 h% E# l( D" a& F# {1 p4 _5 b7 `% x
ilization or peripheral precocious puberty. The diag-
4 P: {" j: ]7 ^+ wnosis can be established by just a few tests and by
1 o) r' N4 y: Kappropriate history. The inability to obtain such a
1 F( r9 j* H) @* X8 _: ?, a. ?8 b7 V. hhistory, or failure to ask the specific questions, may
, H& |. U4 p3 L0 N6 ~result in extensive, unnecessary, and expensive
' N9 P1 Q" d$ Xinvestigation. The primary care physician should be
9 M# I0 z. U6 t" b- d$ b& _aware of this fact, because most of these children; @8 l5 u8 t# e0 h7 Y; o; c% ]
may initially present in their practice. The Physicians’3 P: ]" A* a' h+ X1 [
Desk Reference and package insert should also put a
! W6 a% ^% Y: Mwarning about the virilizing effect on a male or
! N# r" j( t/ M( n7 y7 r- Y; rfemale child who might come in contact with some-+ T* I; R- K! Y; r5 c0 h
one using any of these products.3 c8 P; |  K3 Y' i
References6 p, t" D) \9 T0 ]$ h5 f" s1 X
1. Styne DM. The testes: disorder of sexual differentiation
. x' D( \# _1 i; Z: Pand puberty in the male. In: Sperling MA, ed. Pediatric
: W0 W, e/ [) Y, E% L: x2 sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- U8 b2 c: Q) Z! _& o' V
2002: 565-628.
8 `6 I- G$ A: h& j7 i) L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 ^1 J) J8 N# \3 s3 s* V
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
  |6 E9 {' \2 L: pBoy Induced by Indirect Topical' j  C% b8 Y8 O
Exposure to Testosterone
- G& v1 G+ N0 r9 c0 w* vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ q2 k+ S% |( n, Fand Kenneth R. Rettig, MD1
( k! S/ ]& E! L. P5 kClinical Pediatrics
4 F9 B+ K6 j! c3 b) n7 z1 _Volume 46 Number 6
# i6 \$ S' B! _) _! v. |9 QJuly 2007 540-543) G6 s6 s6 r" Z* D1 C  w; _5 z9 i
© 2007 Sage Publications8 T. M5 f% V, A! I- T) P; o
10.1177/0009922806296651
4 t0 k" ~* }$ r! Ahttp://clp.sagepub.com
8 L6 i0 E& O1 B' ^3 t  P% Chosted at
! Q$ e: p- k0 \3 h5 y" H4 @7 Nhttp://online.sagepub.com' X6 \$ W- Z2 \' P7 f  |
Precocious puberty in boys, central or peripheral,
/ ]. y7 ?' I( w) i* b3 mis a significant concern for physicians. Central
3 n7 l5 h( y* a& j9 Iprecocious puberty (CPP), which is mediated' r$ Z3 _8 ~1 S3 ?4 t1 o9 O4 o
through the hypothalamic pituitary gonadal axis, has1 N5 Y0 ?# [2 C  ?# e6 f
a higher incidence of organic central nervous system( k5 c2 p2 R2 H
lesions in boys.1,2 Virilization in boys, as manifested- m6 G3 h5 O: b0 I, |8 }$ F
by enlargement of the penis, development of pubic
% L" w# ]+ @3 N1 b/ _8 {/ Phair, and facial acne without enlargement of testi-
. v1 k, K& m, d. R5 H6 \' lcles, suggests peripheral or pseudopuberty.1-3 We/ h6 N8 ]* K  Z( H0 \
report a 16-month-old boy who presented with the$ S* E; m, `, n1 L; ?
enlargement of the phallus and pubic hair develop-5 }3 G! C: R, J# ?$ h: P
ment without testicular enlargement, which was due
# V/ q4 q( D. U2 a) m& Ato the unintentional exposure to androgen gel used by/ ]9 Y; I3 A3 P' M5 r3 b5 a- I
the father. The family initially concealed this infor-* }% {* d$ v+ D& o
mation, resulting in an extensive work-up for this
( q0 W6 q- o5 |6 ~* G$ vchild. Given the widespread and easy availability of* t# B& Q: W9 m& v1 g# h* `! Y% `
testosterone gel and cream, we believe this is proba-# c% W: T8 D: {/ @2 ]/ {5 \
bly more common than the rare case report in the* n+ \! h- p' l% J/ t) [
literature.49 w# x2 {- w" |7 X( _
Patient Report7 c' U3 F- v% [. Y
A 16-month-old white child was referred to the6 O% N8 W4 x/ z* }* ^; E. [
endocrine clinic by his pediatrician with the concern
$ @5 |- K6 a) Tof early sexual development. His mother noticed0 D+ c  z% r% A& \
light colored pubic hair development when he was
* Y9 O. U0 t" M1 hFrom the 1Division of Pediatric Endocrinology, 2University of: Z& v$ K. W' q$ D# y
South Alabama Medical Center, Mobile, Alabama.
! M/ n: {, d; e% xAddress correspondence to: Samar K. Bhowmick, MD, FACE,3 z9 d( N: L: Y/ T- W$ B: R
Professor of Pediatrics, University of South Alabama, College of7 `1 w5 p. K2 C; A1 o
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 P. n+ g" Q( P
e-mail: [email protected].9 w$ V& q2 d  Q8 e" k
about 6 to 7 months old, which progressively became7 h9 n; q$ X- M# y
darker. She was also concerned about the enlarge-
' G" n- ?2 S: M/ j" fment of his penis and frequent erections. The child3 h5 j2 B# [1 i  b- q2 v
was the product of a full-term normal delivery, with
- j' j# `& V: K) \% Y2 R( j% M+ Ha birth weight of 7 lb 14 oz, and birth length of
, C: A6 Q2 H+ @% a20 inches. He was breast-fed throughout the first year& B6 f2 H) ^/ v8 F
of life and was still receiving breast milk along with9 ]3 `7 K# @& w4 B
solid food. He had no hospitalizations or surgery,0 K( s. v9 L# R" Y- k! ]0 W+ |
and his psychosocial and psychomotor development
7 \& B6 Z* M& E3 _% K: L; @was age appropriate./ d7 P5 i6 F8 a7 l2 k0 @
The family history was remarkable for the father,5 ~/ w: v4 |* p" \1 l
who was diagnosed with hypothyroidism at age 16,) c( d# {- _. u, m
which was treated with thyroxine. The father’s
9 k6 b& u2 Q  l7 J" H- I2 C! Q( Jheight was 6 feet, and he went through a somewhat/ d, h4 b, b3 {3 a" I3 v9 ]
early puberty and had stopped growing by age 14.
) \& w. B( a( p' B% T" sThe father denied taking any other medication. The" X0 M% o2 G! e7 z
child’s mother was in good health. Her menarche* B+ M/ n( j4 a1 }$ Y$ D1 }
was at 11 years of age, and her height was at 5 feet$ a- S1 P6 r. }* L8 m' R6 U# R9 X2 ?! w
5 inches. There was no other family history of pre-
$ M2 |$ D+ I/ d" q1 _% e; zcocious sexual development in the first-degree rela-$ q- b9 F1 E! T/ i
tives. There were no siblings.# U+ f8 Y8 M' {+ P# d
Physical Examination  y4 u7 U( R1 i; W' ^, z7 E7 m6 d. B
The physical examination revealed a very active,3 a4 h' T* B1 ?# b! p. H; l
playful, and healthy boy. The vital signs documented
, _( z  _/ L2 ]5 l$ Ca blood pressure of 85/50 mm Hg, his length was  P0 U! R. _1 @$ r
90 cm (>97th percentile), and his weight was 14.4 kg; G+ l9 G( v; m0 r. n
(also >97th percentile). The observed yearly growth
( Z9 z+ s5 q% k4 O$ U% {! g8 @- bvelocity was 30 cm (12 inches). The examination of
% u9 Y- a/ r6 D# t) Bthe neck revealed no thyroid enlargement.5 N6 f0 U6 Z/ i
The genitourinary examination was remarkable for
! O- u6 {* P- `% O  kenlargement of the penis, with a stretched length of
8 Y) K! L* A/ }& ?1 l( A. _7 S8 cm and a width of 2 cm. The glans penis was very well
; d, }% Q& t! Z$ k1 D( Gdeveloped. The pubic hair was Tanner II, mostly around
# B2 B! r* Y; ~. L540: s+ O" X8 [; E  T8 Z* M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; G7 c0 Q; a/ J) L# o' P0 kthe base of the phallus and was dark and curled. The
; s6 u% {9 @* S5 A& I6 Mtesticular volume was prepubertal at 2 mL each.5 d' `* a( o! C8 Y0 H4 s  l& r
The skin was moist and smooth and somewhat2 v# z5 G. y5 T4 ?. f% Z6 e
oily. No axillary hair was noted. There were no
, T; S6 n6 Z9 T7 ]* Jabnormal skin pigmentations or café-au-lait spots.
( h7 N* B# z, k" BNeurologic evaluation showed deep tendon reflex 2+. L5 K1 @, o$ t0 R3 o5 @; {
bilateral and symmetrical. There was no suggestion* ]) O2 N6 i: j; B4 [
of papilledema.
& a  Q' s3 |# L: \- MLaboratory Evaluation
) j2 R% H' `- i! Y  J2 U' cThe bone age was consistent with 28 months by6 ]  E: H$ c6 p8 U4 v
using the standard of Greulich and Pyle at a chrono-
8 g3 ]6 a7 N4 G7 l3 R  Y( \) X) Dlogic age of 16 months (advanced).5 Chromosomal1 o/ _0 L8 O. H8 L2 |: a( J. Y7 ~$ x
karyotype was 46XY. The thyroid function test, S# ]! u# y3 o% ?" R' J/ l9 L6 X
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
& q# R, F5 s* O  ?' G- B; R, f( qlating hormone level was 1.3 µIU/mL (both normal).
9 i  D- z4 r: h$ d! o# l5 ^The concentrations of serum electrolytes, blood
+ c2 o) w( o  e  Furea nitrogen, creatinine, and calcium all were3 N: W" S; s/ K
within normal range for his age. The concentration
# ]8 k% D" D# l/ }- A' w. oof serum 17-hydroxyprogesterone was 16 ng/dL) t/ c% A5 `5 M; p8 V6 H8 B0 {* e
(normal, 3 to 90 ng/dL), androstenedione was 20
# c  c. D' q4 n. _  y6 M" F; dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: d2 ?6 d/ C& F1 [3 q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),  Z& p' C# r1 _- V& Z! V3 _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to7 k' b: {( r) O1 ^/ b7 X7 p" C
49ng/dL), 11-desoxycortisol (specific compound S)
% x) h( ]$ w7 r9 P8 T. ]4 A1 q5 Qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ N* M# N$ h% Ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, ]( l& k! w9 `: U/ k3 n* n0 c
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 ~7 _, T- h# z4 l" T
and β-human chorionic gonadotropin was less than" J: Z& }1 x5 ]6 F( u
5 mIU/mL (normal <5 mIU/mL). Serum follicular
, U( u) q# F) Mstimulating hormone and leuteinizing hormone, I# ?5 V& _  U3 ]: @
concentrations were less than 0.05 mIU/mL
  I! z1 p( x5 S$ x0 a. P; i(prepubertal).' E: q$ s6 L. h1 J' k5 n. D5 n
The parents were notified about the laboratory, t# o. P  {( A: ]
results and were informed that all of the tests were
# r: X6 v0 w$ ?: {8 q6 n6 Anormal except the testosterone level was high. The
& ~& f* r7 H1 Sfollow-up visit was arranged within a few weeks to
' i# Z" h2 V  n9 D; b4 yobtain testicular and abdominal sonograms; how-# F% E6 ^2 y+ k0 P7 i, o
ever, the family did not return for 4 months.
6 G; |0 p$ O5 |. l9 t; z- B9 A9 UPhysical examination at this time revealed that the
, H- l( [& a; s; Lchild had grown 2.5 cm in 4 months and had gained
8 }$ N; h' j4 M4 w7 L2 L2 kg of weight. Physical examination remained
- i! |6 \0 _4 zunchanged. Surprisingly, the pubic hair almost com-1 H8 o* {* }* v$ e" z, |, @
pletely disappeared except for a few vellous hairs at1 T) G7 ?4 s% d
the base of the phallus. Testicular volume was still 2: `/ ?9 R$ b3 o
mL, and the size of the penis remained unchanged.
% e6 M- v3 Y& ^7 W- i) o3 C/ O# }The mother also said that the boy was no longer hav-
9 p/ I7 P7 I& R5 [4 {% r0 Ming frequent erections.
# j" I. x9 p+ u; q7 O! ?Both parents were again questioned about use of
- c" k' |7 z5 s3 {0 dany ointment/creams that they may have applied to3 U: f% Q- p- s8 J; y
the child’s skin. This time the father admitted the8 b: Z2 {+ x$ @0 Q
Topical Testosterone Exposure / Bhowmick et al 5416 {* p& y( x8 R! ?: ~8 p
use of testosterone gel twice daily that he was apply-4 V/ ~/ j. T- W! I7 O5 \0 h4 |6 ?
ing over his own shoulders, chest, and back area for% w* x1 `' q$ }8 k+ n! D0 c2 T
a year. The father also revealed he was embarrassed# S+ @7 c9 u5 h9 R8 i
to disclose that he was using a testosterone gel pre-
* I: ^+ [$ ?' j9 R4 H1 I* n" T3 W& ]scribed by his family physician for decreased libido5 S2 d* N! z& [; \
secondary to depression.- X/ _+ T5 J/ z/ `' m
The child slept in the same bed with parents.
7 E# e1 D( D1 J- o0 ^4 XThe father would hug the baby and hold him on his
7 Z7 G8 y! p5 ~6 p" |chest for a considerable period of time, causing sig-
9 R1 e2 c: h9 f2 knificant bare skin contact between baby and father.
# @) O6 i4 x. D* b1 A) F, }The father also admitted that after the phone call,8 t3 v4 J6 `' A/ r, e  |
when he learned the testosterone level in the baby
6 F$ \, b6 D/ h. O9 w6 k" Twas high, he then read the product information+ k" X% Y2 t3 h0 m) S
packet and concluded that it was most likely the rea-! x1 v8 u5 J. T! C6 B
son for the child’s virilization. At that time, they
: V: R7 [  Y. j; u2 p/ e2 K" {2 cdecided to put the baby in a separate bed, and the
$ c- E7 j8 n, R2 M7 Wfather was not hugging him with bare skin and had. S. q) u: |5 R. l  @
been using protective clothing. A repeat testosterone
$ {" J; n* \; M7 A" l: `test was ordered, but the family did not go to the
3 w6 ?$ w! D% Rlaboratory to obtain the test.
  o% P) ?3 a% S# QDiscussion4 c4 s! L7 A. x7 H
Precocious puberty in boys is defined as secondary/ P+ p! R8 |# {% R' Y/ u
sexual development before 9 years of age.1,4
8 e( o- S5 y7 B, ], C7 H+ e( _; iPrecocious puberty is termed as central (true) when
. K0 v$ P' N% r+ S" Dit is caused by the premature activation of hypo-+ S/ J' n9 I% k' D) v
thalamic pituitary gonadal axis. CPP is more com-$ D* T2 j0 P4 I, f
mon in girls than in boys.1,3 Most boys with CPP: [6 C5 W# W, H2 [( {  [8 L. m% X
may have a central nervous system lesion that is. S. q8 |$ D: V, ^# ~$ l
responsible for the early activation of the hypothal-
9 X/ O+ a/ m0 V' s7 ]+ Ramic pituitary gonadal axis.1-3 Thus, greater empha-+ }' F; {% J. J; g
sis has been given to neuroradiologic imaging in+ |5 \! R! M2 [8 I5 ?) L' `9 r
boys with precocious puberty. In addition to viril-
3 b+ i8 ~: R( V- f7 l3 ^0 ^* F1 j2 [4 sization, the clinical hallmark of CPP is the symmet-
) R8 L! q4 Q; z( N$ Grical testicular growth secondary to stimulation by* N* V  F; P8 ?( q7 B
gonadotropins.1,3
' g  j% e7 Z* V& U& G# H0 o0 PGonadotropin-independent peripheral preco-$ ]+ X% t& N# D, g5 U
cious puberty in boys also results from inappropriate
& }' }. _& k* f" k3 ]androgenic stimulation from either endogenous or
! F! ]  n) N+ Cexogenous sources, nonpituitary gonadotropin stim-* Q. f8 N, v6 v+ {+ Q- k, _; P
ulation, and rare activating mutations.3 Virilizing
8 z  m4 a3 A' B4 v: E/ hcongenital adrenal hyperplasia producing excessive
2 [# U8 v% s) G( I2 fadrenal androgens is a common cause of precocious6 \5 b" |0 |- h
puberty in boys.3,4
; ^7 p# N5 I# W! p* S5 d0 I+ mThe most common form of congenital adrenal& F- T/ r7 D( o5 h
hyperplasia is the 21-hydroxylase enzyme deficiency.& j9 u6 d( c% t1 t7 i. \3 F
The 11-β hydroxylase deficiency may also result in
# G. O# a3 q+ texcessive adrenal androgen production, and rarely,6 |+ O* C8 {) o2 G  O8 ~2 N
an adrenal tumor may also cause adrenal androgen
# }1 E  q# I/ Q# wexcess.1,3' ~* P1 U8 q% }" N: ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  i. i4 X/ f) j9 C5 Q/ D$ K0 c9 I
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! r. U+ t4 ]' K0 ]3 `
A unique entity of male-limited gonadotropin-' D! `+ c9 y. G4 _  T
independent precocious puberty, which is also known0 Y0 q+ ^: ?1 T: \9 X' P
as testotoxicosis, may cause precocious puberty at a
$ ^* ^9 c& b8 B  v! Zvery young age. The physical findings in these boys5 ^2 N# ?, {$ r! o7 o6 R
with this disorder are full pubertal development,+ h4 S" I  C; }0 _1 G
including bilateral testicular growth, similar to boys
) i% U6 t/ q0 n6 ?2 _) A' cwith CPP. The gonadotropin levels in this disorder2 Q7 n) n* W3 D" F) V) }
are suppressed to prepubertal levels and do not show8 {4 n8 S) X. H  N$ D0 q7 O
pubertal response of gonadotropin after gonadotropin-
' m) j; o7 F% Q% k* t0 P" [7 K: oreleasing hormone stimulation. This is a sex-linked
' b0 [0 L5 M: X& ^$ [8 ]autosomal dominant disorder that affects only& x/ O/ h) K: J9 r2 k8 T1 U
males; therefore, other male members of the family
: k$ O* Q8 A+ p. w) }! z" ?& I2 Umay have similar precocious puberty.3
! Q6 T; b  K) p6 P6 h1 }In our patient, physical examination was incon-. `. j1 L9 g3 H: |2 @( B
sistent with true precocious puberty since his testi-
* G% ~/ q7 Z7 Bcles were prepubertal in size. However, testotoxicosis& X2 L# O1 d+ }
was in the differential diagnosis because his father$ u: a1 [' _. u3 t6 U
started puberty somewhat early, and occasionally,
+ F7 g% m8 N/ ntesticular enlargement is not that evident in the. x% p# c' z! Y6 L3 Z
beginning of this process.1 In the absence of a neg-
; D7 @$ z7 B* }& V* k6 mative initial history of androgen exposure, our
. M2 L8 I) I" l5 c! Q5 p# v9 |biggest concern was virilizing adrenal hyperplasia,4 e/ k) W- f0 `2 Y  g
either 21-hydroxylase deficiency or 11-β hydroxylase
+ r( i# f* o5 F+ v* jdeficiency. Those diagnoses were excluded by find-
$ h9 W& C  t% q+ e5 A1 ~& Y+ u8 Iing the normal level of adrenal steroids.# T) e; l5 ~& V8 z% g; Q
The diagnosis of exogenous androgens was strongly
; n# J. V0 `# Esuspected in a follow-up visit after 4 months because
4 R3 X$ B: x' Ithe physical examination revealed the complete disap-
) J: t. _" R- o2 E7 Y( o" Dpearance of pubic hair, normal growth velocity, and8 V4 j7 d8 j# _, `# U5 Z
decreased erections. The father admitted using a testos-$ Z/ T% X9 x& B! t+ m0 y4 F
terone gel, which he concealed at first visit. He was$ A% H/ ^$ v" b1 v3 |: z
using it rather frequently, twice a day. The Physicians’( J* V% z0 K* k* q1 I( y% w
Desk Reference, or package insert of this product, gel or* @1 C. O: G. l2 o: f5 ^: g
cream, cautions about dermal testosterone transfer to3 r) q7 L1 F, m( ]9 g' f
unprotected females through direct skin exposure.
3 L' d* F3 j" J8 ~% W9 ESerum testosterone level was found to be 2 times the
4 o4 f2 k2 Q5 e2 O* j: D& ~" q* Z( Nbaseline value in those females who were exposed to
; ^0 A) y# D+ Qeven 15 minutes of direct skin contact with their male
% x' v' h7 |0 {, ~' opartners.6 However, when a shirt covered the applica-) p& _9 L) w3 n2 V7 u
tion site, this testosterone transfer was prevented.
7 _, c/ [3 f3 c+ FOur patient’s testosterone level was 60 ng/mL,
0 e2 N% ]2 e2 zwhich was clearly high. Some studies suggest that
; `0 c) d5 p, u( Gdermal conversion of testosterone to dihydrotestos-
" i; W" I% G1 J5 C8 Qterone, which is a more potent metabolite, is more
1 G  c8 _$ H0 ]' W& \active in young children exposed to testosterone) K9 i7 B# `# e) c2 t: g9 s
exogenously7; however, we did not measure a dihy-  i. e* O* |, J9 k) y" N' Q
drotestosterone level in our patient. In addition to' u( c6 n* x! u: b( e
virilization, exposure to exogenous testosterone in
4 w/ B1 v0 O+ x: schildren results in an increase in growth velocity and
7 a$ ]# G  B: `# N* k* Oadvanced bone age, as seen in our patient.1 Z  a0 i" S3 w( G8 C
The long-term effect of androgen exposure during1 P7 W: B9 ]1 a$ N+ K
early childhood on pubertal development and final
/ j4 x7 b  U- g5 yadult height are not fully known and always remain
0 {7 @( ~# Q3 i$ d1 R) f$ Ma concern. Children treated with short-term testos-
* L% _, s- k/ U, L# kterone injection or topical androgen may exhibit some
- f3 V" g4 Q$ ~  o7 f) ?acceleration of the skeletal maturation; however, after: U+ a9 j. ]  v6 O
cessation of treatment, the rate of bone maturation
) o9 _) ~7 D5 k6 ]6 xdecelerates and gradually returns to normal.8,9- k3 A: q' U9 ?) g
There are conflicting reports and controversy
5 d8 ?) M- h: D- z8 @, Q3 hover the effect of early androgen exposure on adult, P1 _' r- [( W" C$ K& j5 ~
penile length.10,11 Some reports suggest subnormal! Y- Y+ I  A4 q8 N. S) Q
adult penile length, apparently because of downreg-
9 R# w9 k# `/ C% u8 Y. Rulation of androgen receptor number.10,12 However," U% A9 @3 C& a
Sutherland et al13 did not find a correlation between# g" ^$ ?) T- \0 [: D
childhood testosterone exposure and reduced adult
: C1 b: o! }( Z3 r+ w5 S6 ^, mpenile length in clinical studies.$ U* A. e: v8 _8 z( [, e: r+ H
Nonetheless, we do not believe our patient is
8 f4 M0 E4 N! H! Z* z% x+ |going to experience any of the untoward effects from
. G1 T! r* Y$ n3 f% Stestosterone exposure as mentioned earlier because
) P! M- T( L8 M4 i4 Jthe exposure was not for a prolonged period of time.# }. g6 T7 R7 U8 ~0 l$ P' k
Although the bone age was advanced at the time of
3 m2 ^: H. e4 Z# cdiagnosis, the child had a normal growth velocity at
; P% Z* x! j9 o3 A8 wthe follow-up visit. It is hoped that his final adult
& b6 p  Y; \0 F* g( Uheight will not be affected.% t) F% Y4 C/ `
Although rarely reported, the widespread avail-
7 b! P3 m% r6 ?6 f6 g% vability of androgen products in our society may. E2 n. x' N2 ^6 ~6 l/ e% O3 j2 j0 q/ m; A# D
indeed cause more virilization in male or female
/ d7 {4 ?, s$ Q: _/ p" E! Y$ uchildren than one would realize. Exposure to andro-
( W+ z5 z) D. m8 k' Pgen products must be considered and specific ques-
/ @4 I' O( e8 [+ L% Vtioning about the use of a testosterone product or
- s( g- v3 o) `8 X8 E# Ngel should be asked of the family members during
* X3 v& s" _* b' c: o4 ^! W( ~the evaluation of any children who present with vir-
5 V% J$ ~7 |9 }ilization or peripheral precocious puberty. The diag-
  r# W8 |( P* t/ V: Q$ }% Xnosis can be established by just a few tests and by
8 L4 Y6 \6 [# X7 A. |; K/ Sappropriate history. The inability to obtain such a
. p7 v. \' {8 \2 mhistory, or failure to ask the specific questions, may
! T  \. Q4 l' v0 H" F1 l* a+ {- ^result in extensive, unnecessary, and expensive* Z4 ?3 J1 S' M0 `7 d& {) o
investigation. The primary care physician should be
# F8 R1 |9 T  P; I, Vaware of this fact, because most of these children
0 E1 J& H# z! o1 T( j$ T( Jmay initially present in their practice. The Physicians’
. Z8 \! |* l& hDesk Reference and package insert should also put a
& h8 a0 w- L  ^/ X/ [" f& Y+ Vwarning about the virilizing effect on a male or
9 P* o9 F+ ]$ o/ W0 g( tfemale child who might come in contact with some-
" O! N# G3 ?/ v* B  fone using any of these products., J; H" k8 ?. T* T4 T' q- }
References+ P' E, M) Q; h/ E
1. Styne DM. The testes: disorder of sexual differentiation3 ]) j3 q6 v% y" C
and puberty in the male. In: Sperling MA, ed. Pediatric
' p, g; r" E0 z% D- }6 e9 @Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 ]" d1 U, x* j8 t' P
2002: 565-628.
: s( \% H- \! y1 y  b! M/ D% ?2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 b, c: R! u- _+ [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 Y, V3 d# Y6 c! ?
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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