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Sexual Precocity in a 16-Month-Old5 B% e# Q) v, y
Boy Induced by Indirect Topical6 s" a8 _3 @( O4 o; J
Exposure to Testosterone
" I+ U+ x; `  Z, d, x. Z4 d+ [# p. mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 N" k& y5 }- N# M! n
and Kenneth R. Rettig, MD1
$ @; M# I; H5 j% p6 RClinical Pediatrics0 `, a9 Y* p4 T% }
Volume 46 Number 6# Z7 ^. h5 O& Y
July 2007 540-5431 Z+ J/ x5 G4 r/ u. o' O% V
© 2007 Sage Publications
; T9 @, s8 t4 ~1 R/ u+ g# ]* r* v10.1177/0009922806296651$ f6 b- l; b- z4 Z
http://clp.sagepub.com4 n. q9 |3 k' i2 Q* T+ F2 R
hosted at/ Z( i! }" a8 {3 `
http://online.sagepub.com
4 f, _9 h# H1 I* y: a7 m$ m. ZPrecocious puberty in boys, central or peripheral,5 c; A, y* B: @6 W
is a significant concern for physicians. Central2 j* [5 C! Z5 D. o6 @1 Q9 B+ O
precocious puberty (CPP), which is mediated6 W# _1 W  Q) J7 S# w* L3 g( m6 g! K$ `
through the hypothalamic pituitary gonadal axis, has
+ V# m5 \$ j% W9 X2 v* |# ?a higher incidence of organic central nervous system
% d% S: P3 c: u: _+ ulesions in boys.1,2 Virilization in boys, as manifested
8 s" E. n: G' U4 e2 r3 }1 vby enlargement of the penis, development of pubic
# N3 L6 R3 X! t+ p  J) R+ ?3 shair, and facial acne without enlargement of testi-+ o1 e8 k6 L1 s. l3 g7 S
cles, suggests peripheral or pseudopuberty.1-3 We
/ T, t! r1 D) i+ z: u& V5 preport a 16-month-old boy who presented with the
, i! X3 j% n* u4 }enlargement of the phallus and pubic hair develop-
, F+ \2 h* ]/ z5 F0 {ment without testicular enlargement, which was due% }& W* {% f  x! q- C+ C+ U
to the unintentional exposure to androgen gel used by
- K# y1 N6 k( D0 U% i" z+ `# P/ e3 gthe father. The family initially concealed this infor-* V$ I- w' M  D, W8 X( M
mation, resulting in an extensive work-up for this
% n; g9 a9 C  O8 l  b8 V8 gchild. Given the widespread and easy availability of% R/ u4 a7 @% l6 |/ s9 H& B
testosterone gel and cream, we believe this is proba-
6 \/ f6 F( C7 nbly more common than the rare case report in the
% ?6 S& o# W; a5 T2 f( r6 Nliterature.4' i4 n: c$ E7 |& C
Patient Report
' J& x* _& p$ A3 ~2 @* c  R) eA 16-month-old white child was referred to the% G5 W9 U" @. Z  T% h! r- N- i
endocrine clinic by his pediatrician with the concern- R/ q5 e9 |5 p3 M& N" ?4 c& B# }4 E+ w
of early sexual development. His mother noticed' j: O+ A$ \0 C# E8 P# E# d+ \
light colored pubic hair development when he was* x. J- [! Y4 w6 j+ @
From the 1Division of Pediatric Endocrinology, 2University of
! k8 ]" B4 Q2 s; u- LSouth Alabama Medical Center, Mobile, Alabama.% F! o! y6 H& t5 H; N5 q2 x' j
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ {8 {1 g/ L+ \3 f4 jProfessor of Pediatrics, University of South Alabama, College of. y  Y+ C. B* n! m* h' V4 n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 ?) Z! X3 P  a
e-mail: [email protected].9 _" t% H  V0 F5 g$ F$ \
about 6 to 7 months old, which progressively became
$ T! `$ y. M5 ?- M! \darker. She was also concerned about the enlarge-
/ f4 B" e) k; \7 pment of his penis and frequent erections. The child2 w4 q9 h3 F# v, B1 {" G4 Z
was the product of a full-term normal delivery, with/ ~; W! K* z3 W# m" f9 y
a birth weight of 7 lb 14 oz, and birth length of. B$ Z3 w8 p) z; j
20 inches. He was breast-fed throughout the first year
: ]5 v7 [  o7 H7 q2 wof life and was still receiving breast milk along with; K* v8 p$ A  _) \) [! `7 i& w5 X
solid food. He had no hospitalizations or surgery,
8 e* N. z1 o# U6 Q, G. C( i' g$ A& ~and his psychosocial and psychomotor development9 _. e& |( M- Y: C# h
was age appropriate.3 g0 u; L) \# z9 w
The family history was remarkable for the father,& e5 m( q, R& ^( l$ s' `( ~# I- P
who was diagnosed with hypothyroidism at age 16,
5 D" k- p) ~0 a! G- Dwhich was treated with thyroxine. The father’s& W) [) e  v0 @- r' s
height was 6 feet, and he went through a somewhat
. O% o( b# z  e. F, G. Aearly puberty and had stopped growing by age 14.
6 V8 Q+ v7 q# E8 x4 \6 r! XThe father denied taking any other medication. The) }# Z( @  p  F9 ]/ T: x% e$ a0 d
child’s mother was in good health. Her menarche
% w( |4 M; C. w- swas at 11 years of age, and her height was at 5 feet
1 C% r- `) P2 h# j8 j5 inches. There was no other family history of pre-6 z2 S0 t$ s2 W0 L0 w- W
cocious sexual development in the first-degree rela-9 A7 @  z. ~2 }* `" e: |, |
tives. There were no siblings.
+ a* ?! e# ~: {& z# Z6 |0 oPhysical Examination3 C7 J% E5 l' T3 q) M- ^
The physical examination revealed a very active,
6 J7 W% q( S2 J' }playful, and healthy boy. The vital signs documented; ~$ A! N0 \% B0 S* |. M/ G
a blood pressure of 85/50 mm Hg, his length was
# X" Q" J. z' X( J5 w# n  s90 cm (>97th percentile), and his weight was 14.4 kg
+ e: }5 \0 h3 p/ u(also >97th percentile). The observed yearly growth
7 s' p. \% Z) v6 k9 fvelocity was 30 cm (12 inches). The examination of
  [# x- Z! m, b, V- i, [the neck revealed no thyroid enlargement.
) h5 B& o; g4 T8 y* a  j+ oThe genitourinary examination was remarkable for4 m) R( w; V% G7 \8 Q/ U
enlargement of the penis, with a stretched length of- Z0 p% z6 a8 @8 V4 W4 l
8 cm and a width of 2 cm. The glans penis was very well5 g; i1 Z4 X! Z! L7 y$ s3 C; |
developed. The pubic hair was Tanner II, mostly around
3 K& Z" y+ W9 @540% D+ s# T( U& D' p+ ?  D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. D/ S* l, L! @. R# Z. h% z2 E
the base of the phallus and was dark and curled. The7 o3 v+ Z  L+ Z3 a3 Z0 c  t2 v
testicular volume was prepubertal at 2 mL each.  B5 a. H3 J7 P; h9 n- N7 c
The skin was moist and smooth and somewhat
: Q/ z, T, q5 c9 C, E# y7 Boily. No axillary hair was noted. There were no6 a* m# R- x4 M
abnormal skin pigmentations or café-au-lait spots.
7 ^' U* y6 H% ?$ W" V- cNeurologic evaluation showed deep tendon reflex 2+
8 P1 u. P3 D$ b$ `0 i/ Rbilateral and symmetrical. There was no suggestion
& \: ~2 ]7 K( S+ r6 }9 Zof papilledema.1 k; ^7 i! F3 l
Laboratory Evaluation
6 d7 u. Z+ n4 S  d+ D/ [9 {) S/ oThe bone age was consistent with 28 months by6 e" S) q& M  K* R& P+ }' _
using the standard of Greulich and Pyle at a chrono-
" M9 R% P  Q% K7 ~& slogic age of 16 months (advanced).5 Chromosomal# b6 x% H+ G& N$ J4 T
karyotype was 46XY. The thyroid function test0 t" d6 u/ w. h( i3 g  f# _8 j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 b# [$ i* E6 k  `0 ]" p6 E. u! [
lating hormone level was 1.3 µIU/mL (both normal).4 I! o  Q0 O( \: w" [" {. {' a7 O4 c
The concentrations of serum electrolytes, blood9 B! k' w7 \. ?2 R
urea nitrogen, creatinine, and calcium all were+ F% i4 g1 _1 b2 F; `6 Z! L
within normal range for his age. The concentration
4 s+ \" m$ z  |5 u: cof serum 17-hydroxyprogesterone was 16 ng/dL
) D# Z5 f* u" P. s% w% t(normal, 3 to 90 ng/dL), androstenedione was 20  v1 X& C: e4 O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) G, j+ m) W+ e& nterone was 38 ng/dL (normal, 50 to 760 ng/dL),8 Q. A* F- h, `" Z2 @3 e7 Q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( M7 w0 F+ U/ c: G  f49ng/dL), 11-desoxycortisol (specific compound S)# w6 h4 K! Q3 M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* e, y  l2 [3 u: [3 c
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; c& I  M0 d1 q- B  h& K# T$ d* W1 u+ Ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),  D5 E% H+ q9 ~8 O
and β-human chorionic gonadotropin was less than' }: R7 O. m$ G9 f) G' [5 @: _8 |1 j
5 mIU/mL (normal <5 mIU/mL). Serum follicular% n: J  i) R: l; A
stimulating hormone and leuteinizing hormone( f7 n/ s" P6 M# u" a2 Z* N
concentrations were less than 0.05 mIU/mL
, l1 M3 K/ W7 l3 z(prepubertal).8 c: [/ p5 k1 p) m3 ^
The parents were notified about the laboratory
, L8 J% _# A* n7 ]2 Y/ ^+ T8 \results and were informed that all of the tests were) i% U7 J* ^- A; A( l
normal except the testosterone level was high. The/ R4 i( Z$ [+ H) I7 P4 Z5 \3 ?
follow-up visit was arranged within a few weeks to2 H7 k+ s; y- f: C; R9 d0 F: u0 P  \
obtain testicular and abdominal sonograms; how-
2 e& L! `1 b& n" q( M% Iever, the family did not return for 4 months.: K, g0 O* [& @. T" c0 \9 P! D
Physical examination at this time revealed that the6 C- {4 q( Z* W" ?3 g& X' [
child had grown 2.5 cm in 4 months and had gained) ~- Z9 H: C  Z, k2 y# P* B! Z' J% j8 d
2 kg of weight. Physical examination remained
8 x, s% O$ \5 i9 p5 Lunchanged. Surprisingly, the pubic hair almost com-
! N) u/ ^* E( q4 ~3 u% ypletely disappeared except for a few vellous hairs at5 B3 e$ f% J% m* }9 m, F! h7 m
the base of the phallus. Testicular volume was still 2" ~4 C( O2 G; t; J9 w  h) z: {6 T
mL, and the size of the penis remained unchanged.7 u8 }$ E, B' F& c! V  o. q
The mother also said that the boy was no longer hav-
1 v# e. Z0 o/ r) v: K! wing frequent erections., x& P; v$ I7 c- {+ [# X
Both parents were again questioned about use of
3 E3 D# E& @8 ~any ointment/creams that they may have applied to9 C- N7 B0 e+ G& H1 {  N4 `
the child’s skin. This time the father admitted the2 U/ D; H* _0 Q( i( o7 A
Topical Testosterone Exposure / Bhowmick et al 541
, R5 x( {( a0 G/ w# }8 wuse of testosterone gel twice daily that he was apply-
( Z7 U: h9 Q$ _; ~ing over his own shoulders, chest, and back area for& |3 c+ u0 U; Z6 i& O' x2 }, T1 b
a year. The father also revealed he was embarrassed
4 U1 e/ l( h3 Pto disclose that he was using a testosterone gel pre-
  c; Z) g9 ?4 dscribed by his family physician for decreased libido
& d1 c: `3 u, W8 o' z% P$ j4 gsecondary to depression.
( r' a" X1 h, a4 HThe child slept in the same bed with parents.# G' l/ |. t9 H* ^$ ?
The father would hug the baby and hold him on his1 i% W0 k! Y- u- p; P7 z5 g4 J! Z
chest for a considerable period of time, causing sig-
3 _* O5 t9 f6 h; dnificant bare skin contact between baby and father.) _( t; P2 X) J) H. r+ s; d
The father also admitted that after the phone call,
* m( i9 X; @2 awhen he learned the testosterone level in the baby
' @7 I- T( o' E: v3 Z* W2 ewas high, he then read the product information* H  Z, K! U2 s) E" w- {% k5 U7 O( _1 B
packet and concluded that it was most likely the rea-$ a) \2 N( C0 N; n8 U3 _
son for the child’s virilization. At that time, they
7 O# o* s1 M( q5 ldecided to put the baby in a separate bed, and the
9 W. j1 o! r; e. J! lfather was not hugging him with bare skin and had) s8 {, Q# N! m9 C) q
been using protective clothing. A repeat testosterone
0 x2 Z" Y" j7 K0 N) ]# e" K& Xtest was ordered, but the family did not go to the4 ?9 D1 {. \: t3 F3 u: t& b+ _
laboratory to obtain the test./ k0 ~3 H' W- M) _
Discussion3 n0 z8 ?- }* U, n. D
Precocious puberty in boys is defined as secondary6 N+ d8 D9 S" r0 f2 K
sexual development before 9 years of age.1,4
  G6 T; L6 m+ d# HPrecocious puberty is termed as central (true) when
' V, `% z2 b5 {it is caused by the premature activation of hypo-
2 x, h3 L% R0 J2 W/ Lthalamic pituitary gonadal axis. CPP is more com-: j- O2 i7 M) j2 U# B
mon in girls than in boys.1,3 Most boys with CPP
/ ~$ F$ L' E2 |  P: s+ R& h) rmay have a central nervous system lesion that is5 S8 ^0 B" ^( D  K
responsible for the early activation of the hypothal-6 T6 K) u* F4 P8 E# J4 s: z
amic pituitary gonadal axis.1-3 Thus, greater empha-
) c: O. t; x; O- I4 Hsis has been given to neuroradiologic imaging in
5 [9 n- Z4 }+ p* m, W, R" ]boys with precocious puberty. In addition to viril-
4 N" v7 k9 n0 w) {% _" Y! I  j! D4 Z, C9 nization, the clinical hallmark of CPP is the symmet-; ]. Y' w( `- P$ m& [
rical testicular growth secondary to stimulation by% k7 ^1 q8 m" z! H% b/ V+ {
gonadotropins.1,3
4 u& X0 M5 k  I) sGonadotropin-independent peripheral preco-& |7 x6 ?) u$ ]" o
cious puberty in boys also results from inappropriate
+ g+ O( ^' g/ }% d( ]4 G2 E$ uandrogenic stimulation from either endogenous or) M' L6 n9 Y4 Q! V% R! E5 {, Q
exogenous sources, nonpituitary gonadotropin stim-+ K$ Z: J  U/ k! g
ulation, and rare activating mutations.3 Virilizing5 d# O' a0 j3 T
congenital adrenal hyperplasia producing excessive
* t+ |+ L9 L* H7 t1 L# J% {4 ]( oadrenal androgens is a common cause of precocious
+ q7 \4 }. Q8 d0 v$ }- \puberty in boys.3,4
, f) |% C1 f* J+ x3 V* dThe most common form of congenital adrenal
2 z/ M: w* r1 x7 Zhyperplasia is the 21-hydroxylase enzyme deficiency.+ t) a, a& v7 D$ u4 z
The 11-β hydroxylase deficiency may also result in
4 n# E8 D0 ]* l! t: zexcessive adrenal androgen production, and rarely,/ y; e, m) Z7 j; h* Q3 T
an adrenal tumor may also cause adrenal androgen% A7 R* @5 J/ @8 R8 V- ?+ {  L0 |
excess.1,3
$ m+ d; R8 @; Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& `; Z0 r  _4 A9 K. C9 ]542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" Z  C) n, Y1 R; w, }A unique entity of male-limited gonadotropin-6 \& Y: h5 X/ m/ g  |
independent precocious puberty, which is also known" l5 E3 s# @7 v3 Q6 h6 e8 r# o) U
as testotoxicosis, may cause precocious puberty at a4 ]% i, q8 R" a6 D% ]4 L
very young age. The physical findings in these boys
, J6 c6 p: M3 j5 E8 Z& swith this disorder are full pubertal development,( k+ V7 H1 A$ q- F( n
including bilateral testicular growth, similar to boys! x) J( C9 ~8 D2 S+ k
with CPP. The gonadotropin levels in this disorder) g& V: K) h7 ?3 ]6 o, w; L7 U  p+ }7 D
are suppressed to prepubertal levels and do not show
5 \2 Z1 x. l* m3 z* M9 O# kpubertal response of gonadotropin after gonadotropin-% X2 h/ c. k+ }/ N8 T( ~0 r* `
releasing hormone stimulation. This is a sex-linked* q0 n7 c+ z' r7 X( j: m0 Y9 a
autosomal dominant disorder that affects only
$ o; R$ ~; e* F) v0 vmales; therefore, other male members of the family4 P% j( l- N7 ]8 [3 p$ _' L
may have similar precocious puberty.3
) W9 n, k' r( }# e1 qIn our patient, physical examination was incon-
& Z4 ~% X1 z- K, U8 }* Isistent with true precocious puberty since his testi-+ e9 k& ]& G& ^- L# t
cles were prepubertal in size. However, testotoxicosis) d) ]* u5 j9 ~" C( m& ?
was in the differential diagnosis because his father
1 H, E$ u# e6 t, D8 a1 d. R" Pstarted puberty somewhat early, and occasionally,) g5 `% s8 E) U
testicular enlargement is not that evident in the
0 ^& U% b; x' `: v/ Qbeginning of this process.1 In the absence of a neg-
) d6 j! ~" V$ M' Z. c( M8 s4 k" Mative initial history of androgen exposure, our. i5 ~* o0 z8 ^* D( Z5 q6 @( P# z
biggest concern was virilizing adrenal hyperplasia,( Y6 X/ I* v* k+ _
either 21-hydroxylase deficiency or 11-β hydroxylase
4 ]8 j# |; F& u0 t1 R+ sdeficiency. Those diagnoses were excluded by find-
) B  B0 \  U) ]ing the normal level of adrenal steroids.  T6 D( D7 z) B5 r+ }
The diagnosis of exogenous androgens was strongly+ O! D/ u- u/ A  }
suspected in a follow-up visit after 4 months because
' ?- n6 q' Z# q" v$ qthe physical examination revealed the complete disap-' m0 ~" W3 |9 x, p1 x2 k7 d2 `6 z
pearance of pubic hair, normal growth velocity, and
6 r- t! X! e  E/ Odecreased erections. The father admitted using a testos-
  g) g: ]! P6 |# jterone gel, which he concealed at first visit. He was/ i% w; y0 m6 E+ v3 J' X$ A
using it rather frequently, twice a day. The Physicians’
  N" i4 o, {) a) t+ Q- tDesk Reference, or package insert of this product, gel or" j& y4 X3 e# U9 v
cream, cautions about dermal testosterone transfer to
- h% l& m$ \5 q: ?unprotected females through direct skin exposure.# L- F) r" d2 G$ X) B. L
Serum testosterone level was found to be 2 times the# e1 U1 U& Q* y' t# v& P. S9 k
baseline value in those females who were exposed to
; ?2 M2 {  E2 s% {  [, v- o9 U. l" Eeven 15 minutes of direct skin contact with their male2 A: R$ W, ]( T
partners.6 However, when a shirt covered the applica-6 @' X8 o& U' Q/ L4 y/ N
tion site, this testosterone transfer was prevented.- G: a4 |. s. N3 o0 F
Our patient’s testosterone level was 60 ng/mL,
9 k8 t3 j3 |! q$ S  m, ]which was clearly high. Some studies suggest that. s) `8 a8 f( R) Q
dermal conversion of testosterone to dihydrotestos-2 S' b6 t+ C6 O' G# ~
terone, which is a more potent metabolite, is more
8 R& S% H: A" dactive in young children exposed to testosterone
2 b* u. @5 e2 eexogenously7; however, we did not measure a dihy-' ~8 Q4 |5 ~% @0 \1 n: E% _9 [* c
drotestosterone level in our patient. In addition to1 q+ O; [5 E: a7 o$ V9 I7 O
virilization, exposure to exogenous testosterone in9 G# ^$ M+ {% S
children results in an increase in growth velocity and# Z1 H; u/ E, u$ t' |
advanced bone age, as seen in our patient.
1 j. B, S7 N9 V( NThe long-term effect of androgen exposure during& j/ r0 k4 x6 H, b! R4 ~
early childhood on pubertal development and final. h- C+ p$ H9 F5 V8 _/ b# `
adult height are not fully known and always remain% _: W) }3 c9 I, _+ E1 c
a concern. Children treated with short-term testos-
" X' W6 b% z9 m5 m0 S+ Fterone injection or topical androgen may exhibit some
( W( v) @$ \  g- }4 m6 tacceleration of the skeletal maturation; however, after7 _6 C) H  b+ ~3 I0 h2 W! z- O# u, Z
cessation of treatment, the rate of bone maturation  L/ H1 T+ h9 `% ^
decelerates and gradually returns to normal.8,9
- \( P: {! M, x. ^4 b5 j3 t3 q' \There are conflicting reports and controversy  o: t+ F. E* p; N1 J/ X7 @4 i
over the effect of early androgen exposure on adult
( w6 H$ a0 r4 d) x5 ?# U; upenile length.10,11 Some reports suggest subnormal6 \9 k( h# Z) f4 P3 a
adult penile length, apparently because of downreg-/ [% x9 p% _% p) P# ~
ulation of androgen receptor number.10,12 However,) D! P$ X( C) n
Sutherland et al13 did not find a correlation between
- }9 q7 F) a; e' m. Dchildhood testosterone exposure and reduced adult
% u1 Y2 Z4 P" @: E$ n0 }penile length in clinical studies.
! v2 A3 p, b3 K: cNonetheless, we do not believe our patient is. a8 [3 y0 r3 h' H
going to experience any of the untoward effects from3 ?( j/ _( m+ g
testosterone exposure as mentioned earlier because( }, A- J$ c* F8 k, t4 T
the exposure was not for a prolonged period of time.+ n7 T" L- [1 {' M
Although the bone age was advanced at the time of' A  y  A% V$ a3 ~2 R4 J. F
diagnosis, the child had a normal growth velocity at
6 B0 J8 M8 F1 N% g! Jthe follow-up visit. It is hoped that his final adult
+ z2 T* U9 _' C& j' q7 m" B4 Aheight will not be affected.
+ L$ Q( I+ Z2 `' Z2 \% e+ D+ NAlthough rarely reported, the widespread avail-
2 T6 m! J1 t  K) N8 w. hability of androgen products in our society may
6 ?' d2 o. @6 Z# c; g8 K# lindeed cause more virilization in male or female* U0 {8 {0 G$ y# k
children than one would realize. Exposure to andro-# S! _( ^* D9 }: Y+ o, R7 S7 W
gen products must be considered and specific ques-, {0 r6 I9 M/ c0 k( g0 k5 ?
tioning about the use of a testosterone product or4 R9 i" M; b% i5 f* e
gel should be asked of the family members during
- c6 @# e5 J. j0 U& r  Y9 Q# cthe evaluation of any children who present with vir-
6 c0 t2 {4 N6 z% M, F. N: ?ilization or peripheral precocious puberty. The diag-9 I4 v( J+ x6 y% D% ?% _
nosis can be established by just a few tests and by5 U1 I# L$ A+ w/ F) v% v- O# ]
appropriate history. The inability to obtain such a; ?2 N  X/ E# F2 B% O- U/ z7 i
history, or failure to ask the specific questions, may
2 B/ q9 W  A7 ?. }result in extensive, unnecessary, and expensive. ]" O& X" P  D3 h
investigation. The primary care physician should be
) {: r; t" g; o; R6 N0 c. @aware of this fact, because most of these children
4 i* I3 U- f# O$ ~  y' smay initially present in their practice. The Physicians’
0 _7 V( F  K% }3 H2 n& ~1 LDesk Reference and package insert should also put a' y3 i( C7 b  @0 C
warning about the virilizing effect on a male or9 s, M4 ?/ y; v# c
female child who might come in contact with some-
8 ?9 n- ]' i7 C; ?2 `2 uone using any of these products.) o! Q! D* D8 E2 ~* ^
References
6 K* Z- m5 V/ ~) J0 v1. Styne DM. The testes: disorder of sexual differentiation
" |. q0 Q8 {5 u* V/ ]; pand puberty in the male. In: Sperling MA, ed. Pediatric: D/ T& S/ G0 Y- E, \/ O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 F% b4 F4 X: G2002: 565-628.3 k) V" L$ d0 ?, F$ p% N1 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ j" j- B2 d7 a# _2 Ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old5 e5 q2 R- C% I4 h8 |- R
Boy Induced by Indirect Topical/ k3 R% z3 Q2 n6 Y( |$ R4 j! V
Exposure to Testosterone
+ x# m8 G* y  N' V8 u  d) jSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ G3 I8 [" g! X
and Kenneth R. Rettig, MD12 }  y9 \0 Q2 A% x+ \0 R4 ]
Clinical Pediatrics: U# S: u* ?" b# l; K5 H5 ]
Volume 46 Number 6* v* ?1 x% l) a5 {& R% x7 [" x9 n+ C
July 2007 540-543, H1 R& x* ^3 C! D
© 2007 Sage Publications, P+ T! h' b9 K% c% b& O
10.1177/0009922806296651
: D; _$ b0 \& a' @. fhttp://clp.sagepub.com
5 E/ i9 X: y5 C. ^hosted at0 r( Q% y, b1 }7 ]1 s6 T
http://online.sagepub.com
7 o4 D0 T6 C+ O1 qPrecocious puberty in boys, central or peripheral,0 E0 F% N7 T% u, W0 \1 N  I" B, ~+ i
is a significant concern for physicians. Central# u3 M; k+ s/ X% [* s6 c1 u
precocious puberty (CPP), which is mediated! |1 F. ?, L) B( P+ S8 H
through the hypothalamic pituitary gonadal axis, has$ \1 y9 @0 ]1 \$ c$ V$ B
a higher incidence of organic central nervous system
* v' r* H8 b. j. G. Elesions in boys.1,2 Virilization in boys, as manifested' U5 v" l* \4 V3 _6 ], k( h
by enlargement of the penis, development of pubic; f- N, e; p- o5 x4 `: l( W6 P+ x8 h
hair, and facial acne without enlargement of testi-
8 ]+ J8 Z! Z9 I4 d+ D7 m! Ecles, suggests peripheral or pseudopuberty.1-3 We
* `* L1 Z9 t  ~. @  U6 Ereport a 16-month-old boy who presented with the2 i  C% P% d8 U, Y$ \% j
enlargement of the phallus and pubic hair develop-
5 G5 k' H! h. M3 y# b- h* hment without testicular enlargement, which was due: f* X( N3 J4 Y9 X' `
to the unintentional exposure to androgen gel used by
2 w+ g$ a2 u  s1 X- Q. cthe father. The family initially concealed this infor-# ^- M3 v9 `( e2 H/ z
mation, resulting in an extensive work-up for this. H7 S* D: R. z' G; X% u
child. Given the widespread and easy availability of5 u, n+ r' s  m* {2 B" k' R% Q
testosterone gel and cream, we believe this is proba-5 J7 \) ]* o) m+ X1 P
bly more common than the rare case report in the8 j$ a3 q; P$ M8 k- U5 p
literature.4
/ M% V0 v% A4 A5 ?" |5 wPatient Report
3 C' r2 C' y& M' q) qA 16-month-old white child was referred to the$ F4 Z; h. \* E& L; d! I6 a0 S2 a1 w
endocrine clinic by his pediatrician with the concern
0 c5 f. D1 r: H+ \: ?! @9 Sof early sexual development. His mother noticed- T8 L) y. k7 f! `' T0 R8 e
light colored pubic hair development when he was
6 c- }1 b+ T) u( pFrom the 1Division of Pediatric Endocrinology, 2University of. Y$ l% l" O, W. E8 u" Z3 p; ^( b
South Alabama Medical Center, Mobile, Alabama.7 i" V+ s) m9 p, P
Address correspondence to: Samar K. Bhowmick, MD, FACE,& V( f! L% p, K( a& j( B
Professor of Pediatrics, University of South Alabama, College of2 Z6 J2 |& b- d5 q% [/ D  d1 I7 K
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% K- L( g) I9 Q
e-mail: [email protected].
( S! P" _7 H$ q0 r7 |0 {; |about 6 to 7 months old, which progressively became
0 M% c9 p6 d+ Udarker. She was also concerned about the enlarge-6 N% I$ _% y* l' L0 ^
ment of his penis and frequent erections. The child
8 u2 D7 M' `( {/ B0 n6 d  owas the product of a full-term normal delivery, with0 O0 {2 D' m& Z* U$ a$ c  Z7 |
a birth weight of 7 lb 14 oz, and birth length of+ t* x) `5 I) P  E+ Y& c
20 inches. He was breast-fed throughout the first year0 z) Z0 T7 }. ?! B% `& }2 ^
of life and was still receiving breast milk along with
3 P; A" r& X' A' Q! [: c8 msolid food. He had no hospitalizations or surgery,
$ @1 E7 T7 U4 L( b) e3 C0 K/ W( Qand his psychosocial and psychomotor development
% v+ y: t- G4 }1 {& _+ z8 Xwas age appropriate.2 ]0 n% S% G8 }8 a. a5 v
The family history was remarkable for the father,
/ h6 }+ A0 [/ ^9 |who was diagnosed with hypothyroidism at age 16,. X# v8 o% @- z2 M8 q" x- |
which was treated with thyroxine. The father’s
$ ]# _0 f2 @! V8 I) h# ]- Fheight was 6 feet, and he went through a somewhat
0 T* B7 p8 x4 G" B- nearly puberty and had stopped growing by age 14.. R' V, _: L6 D! G5 j
The father denied taking any other medication. The( i; Z- F0 Y. V: r
child’s mother was in good health. Her menarche
5 v, N' h/ M) ~2 y4 pwas at 11 years of age, and her height was at 5 feet
( f0 Y+ Z5 R* }  _  f- B3 |5 inches. There was no other family history of pre-
, F2 R5 G6 G3 T3 l. u! @7 Mcocious sexual development in the first-degree rela-
. W# k- ?& I) t1 ]tives. There were no siblings.$ j0 ~7 o' g' l( r" ^
Physical Examination7 S+ m) N) C5 @( s4 U
The physical examination revealed a very active,
$ ?- x- U5 h5 `# dplayful, and healthy boy. The vital signs documented
8 U/ v) r( w  ?6 Ja blood pressure of 85/50 mm Hg, his length was$ ]6 l* E# f4 j3 }
90 cm (>97th percentile), and his weight was 14.4 kg: q( U" v! C, W( p6 t
(also >97th percentile). The observed yearly growth
6 _- m. H; r4 r# v( nvelocity was 30 cm (12 inches). The examination of* L" W" A8 F; }5 ^$ q) x0 X
the neck revealed no thyroid enlargement.
, T9 N5 z$ I8 @. E( G) {The genitourinary examination was remarkable for
4 Q6 K" K; `6 x- r' r9 Denlargement of the penis, with a stretched length of
' p+ ~# t" ?6 T$ I8 cm and a width of 2 cm. The glans penis was very well
3 \' N/ Y# |* _9 H( ?0 L( Mdeveloped. The pubic hair was Tanner II, mostly around
7 r; ^8 f" w* |540/ u! t# ~( ?  Y/ B/ b. T' j% }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ L1 K1 [* {. l; L& Hthe base of the phallus and was dark and curled. The
4 y0 R2 v& _' Otesticular volume was prepubertal at 2 mL each.* Q4 }0 F$ a9 }% M4 y! Q/ q* a
The skin was moist and smooth and somewhat
* Y- {' l# u% p- {; [, R% xoily. No axillary hair was noted. There were no& v( I/ o7 c$ @+ u
abnormal skin pigmentations or café-au-lait spots.& [( z9 A4 Z. C0 }  T
Neurologic evaluation showed deep tendon reflex 2+
# z4 P- k- {1 m  Zbilateral and symmetrical. There was no suggestion
& _4 ~; h* l7 V, p( m3 M7 q7 m* b. j7 Oof papilledema.. _& K* |. C, A+ k
Laboratory Evaluation
( A$ V$ S- Q9 B+ j5 i; d% I1 oThe bone age was consistent with 28 months by
# `) [& b, A, Y4 l/ `9 [using the standard of Greulich and Pyle at a chrono-! w% o# N5 i( M, K) k
logic age of 16 months (advanced).5 Chromosomal/ @* l+ u5 B- Y7 R0 g# ~
karyotype was 46XY. The thyroid function test
) X) j' t0 _8 t2 s' f! ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-8 T9 I0 V1 R( [6 R
lating hormone level was 1.3 µIU/mL (both normal).3 b- C3 T$ l3 D3 a6 ^3 D& L! I
The concentrations of serum electrolytes, blood0 T3 N; Z2 x1 \+ N2 m
urea nitrogen, creatinine, and calcium all were
: U& k* D" N$ m" _) w. F6 @8 Mwithin normal range for his age. The concentration
! J9 S3 t( ~7 ~# n, s0 z% ?of serum 17-hydroxyprogesterone was 16 ng/dL
) d6 f& L+ @" Z& B(normal, 3 to 90 ng/dL), androstenedione was 205 E! E! W) ]) ~* A$ y1 q4 u% w  J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 P  E0 F7 G7 Iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 {& o8 B. a/ L2 O9 k9 xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to& j9 |5 }8 f5 q; A: E
49ng/dL), 11-desoxycortisol (specific compound S)5 S9 f' V( ?" K# {; m' e: ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 Y' `  D+ w0 ~# x! Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( y- o) `- |3 ?5 Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* |* b  ]1 o* D5 _) B
and β-human chorionic gonadotropin was less than
5 Z+ ^; N# _+ z2 ]; @6 o/ Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
* B1 X3 Y7 a. |stimulating hormone and leuteinizing hormone
+ H4 ?+ W# y( T" O2 uconcentrations were less than 0.05 mIU/mL
( r# C$ a  s, V& Q(prepubertal).
  J  v# E* d& W& T1 v; Y* K+ qThe parents were notified about the laboratory
$ s& Y: X' a6 a+ g0 Oresults and were informed that all of the tests were# f- x/ b# g) v( z. h- {) K
normal except the testosterone level was high. The0 ^8 }" f$ i- [! {+ D1 L
follow-up visit was arranged within a few weeks to
* \- i# Q, a, T. O0 {obtain testicular and abdominal sonograms; how-) x2 U9 L2 V0 n$ N6 n' X
ever, the family did not return for 4 months.2 a* [4 q# W  m2 B3 k" e* f* y9 C
Physical examination at this time revealed that the6 ^& g* x' Z! z9 {  B6 e
child had grown 2.5 cm in 4 months and had gained
" L7 p3 Y& {/ h/ [: }2 kg of weight. Physical examination remained
  C0 m6 a) i8 S% i5 @unchanged. Surprisingly, the pubic hair almost com-4 S* f/ F- ]% E" D0 R" R' l; |
pletely disappeared except for a few vellous hairs at
9 U, N4 |$ _2 r! d6 Pthe base of the phallus. Testicular volume was still 2
+ L  q5 q9 j) e1 a( BmL, and the size of the penis remained unchanged./ K1 b; ?4 L8 |- c# U( n$ }/ l- g
The mother also said that the boy was no longer hav-
/ B+ P7 D4 N1 Y) }$ B+ w5 Ling frequent erections.% ^) ~' C, S& e9 w& J
Both parents were again questioned about use of
, P& {0 t; {4 u% i4 g0 q- Z  Lany ointment/creams that they may have applied to
, p7 X- N$ h  Y+ g7 |the child’s skin. This time the father admitted the
3 e- I5 C5 _, q! ~2 O; u+ X3 xTopical Testosterone Exposure / Bhowmick et al 541
: }% v8 Y5 u" X5 v' J* Fuse of testosterone gel twice daily that he was apply-) Z6 ]- Y& G7 P
ing over his own shoulders, chest, and back area for2 j0 @' Z/ A0 z$ ^7 r: E
a year. The father also revealed he was embarrassed& v/ N; o5 y+ g1 A9 f+ M. Z9 p
to disclose that he was using a testosterone gel pre-
8 j$ U( |) v2 j  T& Jscribed by his family physician for decreased libido6 m& a) H+ I" L( }6 o
secondary to depression.
+ F. t) E( H! y8 ]The child slept in the same bed with parents.
$ Q, o5 w7 Q- K/ x  a* lThe father would hug the baby and hold him on his
% X9 v! g# n# w7 {! f4 k# S. _/ }: A( vchest for a considerable period of time, causing sig-+ T! K: Q4 [: Y( B  [  m
nificant bare skin contact between baby and father.
) l, o# @2 ?3 O/ sThe father also admitted that after the phone call,8 }, i! e' D$ W) B! p( F: I
when he learned the testosterone level in the baby
* V  Y4 y! J. I1 M. U/ f9 Bwas high, he then read the product information  B- p8 \, S$ q$ r5 p
packet and concluded that it was most likely the rea-0 \* v% t: T$ s0 h, }: o% z: i
son for the child’s virilization. At that time, they" |  b9 c/ g& r# S0 b
decided to put the baby in a separate bed, and the* J% m$ G) y7 g+ l2 a1 ]+ [5 Q1 M
father was not hugging him with bare skin and had
. p) a$ W) e& S$ `5 ]been using protective clothing. A repeat testosterone- S: x8 `" u5 n5 _' O2 g3 ?
test was ordered, but the family did not go to the) b8 w2 j. `. A
laboratory to obtain the test.
4 a4 }3 _5 p$ @$ J. K4 h$ DDiscussion. Y8 {7 D" _) ]3 K8 _9 f6 d. I6 \
Precocious puberty in boys is defined as secondary
2 U* l+ Q. \9 I4 wsexual development before 9 years of age.1,4
5 T0 r% Z1 d5 ?Precocious puberty is termed as central (true) when
' o0 D. O/ H* f' W8 M1 vit is caused by the premature activation of hypo-1 ?) W- A& e6 A4 Y# l
thalamic pituitary gonadal axis. CPP is more com-
/ E2 m  L) z! r5 i* tmon in girls than in boys.1,3 Most boys with CPP- H9 X1 N3 R. X& `2 @1 m
may have a central nervous system lesion that is
. K. ?# Z$ E. Y+ ~responsible for the early activation of the hypothal-) A- p  U. M5 g+ f+ ~* H
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 f( W8 q6 I7 T7 Y1 ~1 P5 K# ]& Hsis has been given to neuroradiologic imaging in  \5 h8 R' q: a6 a
boys with precocious puberty. In addition to viril-! @9 R, N6 ]$ v, A/ X) G$ @- i
ization, the clinical hallmark of CPP is the symmet-
6 }& B. a5 p* q4 U  R& ^rical testicular growth secondary to stimulation by
0 f7 f5 j  r* G  s% j1 Ogonadotropins.1,3  u, c; `/ @0 \7 |
Gonadotropin-independent peripheral preco-
7 h3 O+ y: ]5 _; qcious puberty in boys also results from inappropriate& Y- F* x) Q4 l8 x6 Q& ]- @
androgenic stimulation from either endogenous or( W' Y8 G! c- _( q4 k" {
exogenous sources, nonpituitary gonadotropin stim-
: {" b6 ^7 y7 g+ q  culation, and rare activating mutations.3 Virilizing
9 J$ w8 o  r, |2 Hcongenital adrenal hyperplasia producing excessive
4 n9 A& T# ?6 h4 F% o1 gadrenal androgens is a common cause of precocious- `& C( a$ V- d) z! Z
puberty in boys.3,4
( n4 z: I% Q: j' {2 C9 P8 m7 j4 EThe most common form of congenital adrenal
6 ^% J) p6 u1 J) y* d. Z9 W& _hyperplasia is the 21-hydroxylase enzyme deficiency.' G* t) E; g" Y$ i4 n
The 11-β hydroxylase deficiency may also result in
% |) r% Q8 e$ K: u/ {excessive adrenal androgen production, and rarely,
( t) n% J/ ~  P5 b% ^5 }# @% Z* yan adrenal tumor may also cause adrenal androgen
* {- H: T& q& V* o/ ?8 Gexcess.1,3# B* e2 Q6 c! T/ d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: ?- @: V& Y& C& k6 R9 }3 N542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: C4 `& y) j; E/ Z; fA unique entity of male-limited gonadotropin-* h4 ~- L- o0 R' q9 T
independent precocious puberty, which is also known
. M) t" I& ?/ }) ^$ N# A4 eas testotoxicosis, may cause precocious puberty at a
3 G. r5 m; c* F  r8 `% Hvery young age. The physical findings in these boys: J# [) q4 e2 F2 G
with this disorder are full pubertal development,4 V) G. p8 o5 D1 j
including bilateral testicular growth, similar to boys3 U6 I5 e/ x% j) T
with CPP. The gonadotropin levels in this disorder
+ Q- k0 `8 i3 o6 Nare suppressed to prepubertal levels and do not show
( [: e$ h) N/ T+ T2 jpubertal response of gonadotropin after gonadotropin-) h. ~% u0 z& _7 |4 P
releasing hormone stimulation. This is a sex-linked
) X( H' R, M# O- }9 Xautosomal dominant disorder that affects only
* v6 r! e3 j+ l0 b7 n+ [7 wmales; therefore, other male members of the family1 X3 z& P9 A: I# r+ Z8 r
may have similar precocious puberty.3
8 E$ J) q% u7 ^1 I1 uIn our patient, physical examination was incon-& g! F4 u: o. Q3 R
sistent with true precocious puberty since his testi-
( Z6 d1 A" z1 ~5 y6 t- ~% Tcles were prepubertal in size. However, testotoxicosis
# V$ p# p. y8 Y" M' e/ z) c( x0 F. Iwas in the differential diagnosis because his father
. e/ p; Z/ L% N+ n# Y5 Qstarted puberty somewhat early, and occasionally,8 w4 m% K9 |. C; E' X. H! r' P9 t
testicular enlargement is not that evident in the1 I  u+ p- x- X  u4 g5 g' o3 r
beginning of this process.1 In the absence of a neg-
: u7 M& ~4 [' v& U+ `1 mative initial history of androgen exposure, our
: t) _5 ?1 @) N' {* E  R3 c# R! K1 Obiggest concern was virilizing adrenal hyperplasia,
3 J* b& H; ]3 F3 w, }) Peither 21-hydroxylase deficiency or 11-β hydroxylase
; |8 Q' N4 a; y6 n2 `( l, H' Sdeficiency. Those diagnoses were excluded by find-, X- N% @% u5 f3 |/ a5 N$ q
ing the normal level of adrenal steroids., [, c8 y" W& x+ u3 R
The diagnosis of exogenous androgens was strongly
  C. V" i4 `% C8 J+ ysuspected in a follow-up visit after 4 months because
0 N8 L4 o/ |+ E. ]8 l7 qthe physical examination revealed the complete disap-
" B- j, ]7 L* W1 J# M: l1 o) rpearance of pubic hair, normal growth velocity, and0 r) D8 h; W& C0 \
decreased erections. The father admitted using a testos-0 P$ ^7 n% z* ?0 X8 o) K9 {) d+ R3 F
terone gel, which he concealed at first visit. He was' \) r8 P* Z. e) H4 ?. k0 d
using it rather frequently, twice a day. The Physicians’( f, _( A8 Q1 I3 s3 c+ y% S
Desk Reference, or package insert of this product, gel or
9 Y- X- u  R" t6 n; acream, cautions about dermal testosterone transfer to
9 {- v) u5 o! K5 ~. X2 Sunprotected females through direct skin exposure.! L* g  s+ R" w. _3 j- C2 g$ A
Serum testosterone level was found to be 2 times the
8 @9 G& t9 M; W& Sbaseline value in those females who were exposed to" U8 R. p: O+ t0 m1 ?9 A
even 15 minutes of direct skin contact with their male2 {& X+ q1 W& K4 x( d
partners.6 However, when a shirt covered the applica-
- Y7 \2 v* K. d! P5 v0 ?tion site, this testosterone transfer was prevented.2 h5 s" `# L6 A& Z
Our patient’s testosterone level was 60 ng/mL,
1 m: f; E( U: qwhich was clearly high. Some studies suggest that
& S! y$ h# K" }( A3 `  Q/ sdermal conversion of testosterone to dihydrotestos-
4 Q5 Q2 R1 Y( x' e5 X  Kterone, which is a more potent metabolite, is more
. b, g; Y6 W, l& Q) f2 pactive in young children exposed to testosterone
. O5 d5 S2 P* v; H0 E; A2 S( M  Cexogenously7; however, we did not measure a dihy-+ G/ N: p! {+ W. J, C  n
drotestosterone level in our patient. In addition to" z, i  g* j5 o, N1 _$ U/ G
virilization, exposure to exogenous testosterone in
+ r' ?: E2 L( O0 @2 qchildren results in an increase in growth velocity and
/ S. F; G8 J& q7 m/ z( x% [0 Hadvanced bone age, as seen in our patient.; X& @- _8 z) ^" S
The long-term effect of androgen exposure during; G" X& I+ L) u5 M
early childhood on pubertal development and final/ J0 H* ^, R: y  C4 W
adult height are not fully known and always remain( [5 Q2 m1 B" ~8 C+ w
a concern. Children treated with short-term testos-0 M3 i: N- \" n3 B1 T
terone injection or topical androgen may exhibit some
' ^8 O+ P& O/ n* E4 o' }acceleration of the skeletal maturation; however, after
; t9 T4 `8 q1 K0 d& F, xcessation of treatment, the rate of bone maturation) m# X9 W8 m! s. A
decelerates and gradually returns to normal.8,9
+ N1 `  ^# P  x4 ]9 BThere are conflicting reports and controversy
! i1 U; U& v# m) u/ }$ ]7 \over the effect of early androgen exposure on adult
1 k/ L7 y) K; S+ c/ Y& cpenile length.10,11 Some reports suggest subnormal7 Q( ]7 [2 x& \% T- `- ~- @
adult penile length, apparently because of downreg-8 o3 y. y7 j( m. G. }
ulation of androgen receptor number.10,12 However,2 Z1 O/ d7 Z! o8 n- M
Sutherland et al13 did not find a correlation between
% o, T6 J! v$ k. G: t* k, A0 q% S8 \childhood testosterone exposure and reduced adult
6 q8 i: w7 {2 E; ^0 M2 ?: {penile length in clinical studies.
5 }8 Z% |: h! A+ ^/ `0 @Nonetheless, we do not believe our patient is
& J/ f$ `. ~8 m- r/ D# y/ [going to experience any of the untoward effects from
/ z- N" f! |. q1 ktestosterone exposure as mentioned earlier because
0 \6 ?9 i2 d; v6 H* B0 othe exposure was not for a prolonged period of time.
. s; H& p6 v* RAlthough the bone age was advanced at the time of
. k6 T' w- O, l! ?6 R% sdiagnosis, the child had a normal growth velocity at- K. a* H2 A' L2 e
the follow-up visit. It is hoped that his final adult! U& \6 c- C$ @/ Z0 C# z+ ^
height will not be affected.  p! I# n% K+ J
Although rarely reported, the widespread avail-
, M, u- X8 U& P* `! D5 @ability of androgen products in our society may
% ?8 R9 Z. k: J& G0 lindeed cause more virilization in male or female
  d5 P' V. u; i' a: i7 s& R# Cchildren than one would realize. Exposure to andro-! Y2 O) A0 L+ ^- q; Q: h: p
gen products must be considered and specific ques-7 R; E# Q  C" Y2 c) G  z
tioning about the use of a testosterone product or& b: a4 I! `) |, ]( `  B) s; c8 U
gel should be asked of the family members during  w  }) u  A2 z0 \2 w0 Z& z8 |7 y5 T* }
the evaluation of any children who present with vir-
2 b) P# n0 p% _. m$ H3 |  Wilization or peripheral precocious puberty. The diag-
2 M8 p. B1 A; G- Knosis can be established by just a few tests and by6 Q( T3 h$ V" v& p
appropriate history. The inability to obtain such a
% a8 n/ ]  _: c, L6 Q, g+ ohistory, or failure to ask the specific questions, may
- V% k6 ?( t9 x1 D& c1 @. i! J2 bresult in extensive, unnecessary, and expensive# s0 L8 W$ |. a, G4 ^! O7 t4 h
investigation. The primary care physician should be, Z1 t/ M# R4 S6 z( x2 C
aware of this fact, because most of these children
; U% O% m7 R1 n4 [3 ?; \  |" ]may initially present in their practice. The Physicians’4 J% y9 m* \* X
Desk Reference and package insert should also put a; \! t7 F9 C, U# x: M
warning about the virilizing effect on a male or- H5 Z0 a: W! f! G2 z# v: Y! X
female child who might come in contact with some-
' h" v) s4 n0 r! {7 c: aone using any of these products.8 j3 y& u& @0 a7 M* N$ {
References, U/ m  E' a# u
1. Styne DM. The testes: disorder of sexual differentiation
2 ?4 n3 B! P- k  j. G4 |: }5 Qand puberty in the male. In: Sperling MA, ed. Pediatric
8 V- g2 Y5 z  C0 W4 c' k9 ~/ hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' F: a9 \- M8 p3 F2002: 565-628.! @+ I& H& X; x2 s6 [9 ?7 E8 P3 j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 U" H4 b% @! q: ^  o$ |9 d
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

  j1 @  J/ k% X8 M$ 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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