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Sexual Precocity in a 16-Month-Old0 ], E& a, _3 w9 I+ r: z5 C# f7 e5 b
Boy Induced by Indirect Topical' D& z" J; v! @2 x4 u! G/ g& g/ J
Exposure to Testosterone
, k& S/ p) W2 E9 JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 i9 b  z# Z' O7 z$ W3 G
and Kenneth R. Rettig, MD1
& C* b& ~) R& t0 W6 sClinical Pediatrics% `; j( M6 t% W% h7 J
Volume 46 Number 6
- t9 h) I5 V9 xJuly 2007 540-543+ A8 Z* _7 E% `
© 2007 Sage Publications
( k& M3 W. d5 z$ ~10.1177/0009922806296651: f/ c4 [3 [! ~# d2 \& Y  u) L$ e9 @  F
http://clp.sagepub.com4 V! t4 a& J6 }/ s3 n, @; x  ~) ~  }
hosted at+ P6 j# k- |# T/ f6 e
http://online.sagepub.com% [- @$ q$ d7 v2 S/ Y
Precocious puberty in boys, central or peripheral,
  t. x0 c6 \- R) dis a significant concern for physicians. Central
, F4 h2 p' d4 u4 Q/ q% J8 m% Wprecocious puberty (CPP), which is mediated
4 G+ X' e! d' q9 r" ^through the hypothalamic pituitary gonadal axis, has/ Z' q4 U# T. n' B3 G1 M
a higher incidence of organic central nervous system9 Y) B% ]! A$ z7 g& F- S( v1 i
lesions in boys.1,2 Virilization in boys, as manifested
- N) H  d: k0 p4 W# Q; k# L$ ~! p$ lby enlargement of the penis, development of pubic
" u8 I; J  o- s- m3 W! j3 yhair, and facial acne without enlargement of testi-
# N! {2 `2 M) d6 ?' D8 Q2 R6 Ncles, suggests peripheral or pseudopuberty.1-3 We
( z* V( P8 _7 rreport a 16-month-old boy who presented with the2 l4 i. ]9 W& c: G* U9 B
enlargement of the phallus and pubic hair develop-) U+ w) \3 t4 N0 `1 F  O
ment without testicular enlargement, which was due7 C' J& s7 B. b4 p6 I
to the unintentional exposure to androgen gel used by
0 y  D6 }$ V  Y- Sthe father. The family initially concealed this infor-
  i. I% l. j7 q& B2 Q. v+ x. rmation, resulting in an extensive work-up for this
! x' I* S5 S6 Fchild. Given the widespread and easy availability of3 M+ ?0 ~+ z. J/ ^6 Z8 G
testosterone gel and cream, we believe this is proba-4 c& L' e: m8 r. h6 j
bly more common than the rare case report in the
" n, p+ B$ [6 H1 j/ g. k9 |; Hliterature.4
) e$ w' H3 ], u2 |7 APatient Report
$ ], N( x! }; q6 F; f4 D8 nA 16-month-old white child was referred to the. M& `7 y% F; Y( U6 I! X) M
endocrine clinic by his pediatrician with the concern$ |. d4 [7 d- v" c
of early sexual development. His mother noticed
# I  u' g+ T! K$ a9 _. u( Dlight colored pubic hair development when he was
- ]- C, [, O9 p. e, j) WFrom the 1Division of Pediatric Endocrinology, 2University of  l7 |9 n; C) c, J+ D
South Alabama Medical Center, Mobile, Alabama.
3 \# M0 \! T9 H! W8 F7 N0 R2 H) WAddress correspondence to: Samar K. Bhowmick, MD, FACE,# o) n. a+ R. s# r8 e9 o' }" z
Professor of Pediatrics, University of South Alabama, College of
6 u, }' e) V' w: h% @- x, NMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 r# e  @  ]/ _& ]e-mail: [email protected].: c& T  m+ q# ?! z7 P5 X
about 6 to 7 months old, which progressively became
% K' p( w  y/ `  `darker. She was also concerned about the enlarge-
: D  ~. {; _6 G% m3 @% F1 kment of his penis and frequent erections. The child% m% v* i1 E: g' d
was the product of a full-term normal delivery, with
# |$ D" {( `) u  ], Z" na birth weight of 7 lb 14 oz, and birth length of2 f' v- Q6 y& s, B  Q& j! R4 v
20 inches. He was breast-fed throughout the first year+ a. v! c2 p6 ]! q+ R2 g4 a
of life and was still receiving breast milk along with
, O8 B+ G9 n; K+ K& X( c1 [solid food. He had no hospitalizations or surgery,4 O( J. `! s2 ]3 m5 Q: \2 R& }
and his psychosocial and psychomotor development
7 c/ }# ]$ ~7 C5 V4 q( Y5 t" f/ Bwas age appropriate.
; m$ m% c% R/ r, N+ WThe family history was remarkable for the father,
+ J) n' T# g; _, Vwho was diagnosed with hypothyroidism at age 16,
2 [8 \2 K* L3 s  s+ }: H3 pwhich was treated with thyroxine. The father’s
# g0 w5 @9 Z8 x. f) f7 a1 M- K! ^height was 6 feet, and he went through a somewhat
, k9 R& u+ P7 f* J, n) iearly puberty and had stopped growing by age 14.- f" Q2 B2 l. {6 ]4 [
The father denied taking any other medication. The
! W; m" v8 F6 Fchild’s mother was in good health. Her menarche
( Y$ [% H: S( hwas at 11 years of age, and her height was at 5 feet
% E8 [/ H2 h0 h0 J( j5 inches. There was no other family history of pre-; [2 E9 e" {* r! y) a
cocious sexual development in the first-degree rela-5 {& g$ B) v  |$ ]2 V% `( j
tives. There were no siblings.
( K7 L5 G' a% H% G- V. FPhysical Examination% v# s- t4 f' j& U3 _) F
The physical examination revealed a very active,; v5 F- ]6 ?  b: Y& R
playful, and healthy boy. The vital signs documented) Y- r- _0 \9 D
a blood pressure of 85/50 mm Hg, his length was0 m% r  u$ h  u" N# t& v
90 cm (>97th percentile), and his weight was 14.4 kg5 j0 _  V1 N0 i4 z1 A) }
(also >97th percentile). The observed yearly growth
4 w" l$ X6 L5 {3 h, T6 Mvelocity was 30 cm (12 inches). The examination of7 R4 s- x& N* X8 O4 Z1 {& l
the neck revealed no thyroid enlargement.
  K: c4 o- v4 }9 U2 I' cThe genitourinary examination was remarkable for
. u0 q, Y5 X0 t; A0 D  v2 Zenlargement of the penis, with a stretched length of& `( O, n3 ?1 R# Y$ ?; u% s0 }
8 cm and a width of 2 cm. The glans penis was very well
5 }# k6 }, }, d  y1 v9 O5 Cdeveloped. The pubic hair was Tanner II, mostly around
5 _- ^: u+ P" @4 c1 |. O* q( g540' s, Y6 Q1 D; U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  n$ g. p) P- z' D% ~7 g- E9 c
the base of the phallus and was dark and curled. The, T4 ?+ `: \# r, p( L! d# r
testicular volume was prepubertal at 2 mL each.
% Q4 m- ~' ^: _8 oThe skin was moist and smooth and somewhat
, ?+ j& Z0 H8 @; n" qoily. No axillary hair was noted. There were no
% K! o3 b. U9 v$ |- B# b' j9 Uabnormal skin pigmentations or café-au-lait spots.0 g6 _+ x6 o( O" p
Neurologic evaluation showed deep tendon reflex 2+
; N) @2 U1 }) l7 [& abilateral and symmetrical. There was no suggestion
, {. u  k4 V6 yof papilledema.
" Y' l* R$ j9 p8 QLaboratory Evaluation: t0 N9 i% J* x0 {& |0 h
The bone age was consistent with 28 months by& d( V& a3 H& i- o  q% L! {1 n
using the standard of Greulich and Pyle at a chrono-/ W. I6 q0 |" a$ _5 ?; Z! X) O% r
logic age of 16 months (advanced).5 Chromosomal* V4 f4 o, p6 v
karyotype was 46XY. The thyroid function test7 ]1 m5 M$ I& b4 x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
- a9 O0 p, C/ `+ F8 wlating hormone level was 1.3 µIU/mL (both normal).
0 Z: @+ A7 K3 Y' J5 t( `0 Y( RThe concentrations of serum electrolytes, blood* a4 Y" }$ O) j
urea nitrogen, creatinine, and calcium all were
' ^) c+ J% B5 Rwithin normal range for his age. The concentration5 N3 e2 z$ `! R' T* `* `6 X
of serum 17-hydroxyprogesterone was 16 ng/dL
" v7 t: O- V1 K& P' {. x(normal, 3 to 90 ng/dL), androstenedione was 20
9 ?7 ~2 T, n# @% p9 Ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% D. Y5 ]$ g! \6 e' B  E1 o3 Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( y, N, O; p8 @8 p- Z0 X6 qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ W8 Q" G* n  V- D9 R49ng/dL), 11-desoxycortisol (specific compound S)5 g0 o) o9 ~, V9 ?; g! P8 a/ Q6 X2 B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# F, f) {9 l% n- f- I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' J4 v( V$ M6 _4 i5 Y  G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, L0 a3 }, A' B& z# W: ^/ @
and β-human chorionic gonadotropin was less than  I. K/ t6 L( l# A, J
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; j1 }* q7 N1 v8 \% g0 O' t# vstimulating hormone and leuteinizing hormone6 y% U& o7 U$ I& {& W+ F
concentrations were less than 0.05 mIU/mL
% Q7 F5 [# Y( W/ m2 P& I# F(prepubertal).
& D) c. B) t9 j0 t& R2 S7 m1 p5 gThe parents were notified about the laboratory
. Q4 A. k# _4 t9 l5 }8 V5 ^results and were informed that all of the tests were
$ B! K# ]9 G/ inormal except the testosterone level was high. The
: {. N) H0 H" O/ r3 a/ T( kfollow-up visit was arranged within a few weeks to
  X" G! S5 s. fobtain testicular and abdominal sonograms; how-; Q5 ?5 L) ?3 G. Q% @
ever, the family did not return for 4 months.+ N2 o  E  T6 S% d7 O/ F" N
Physical examination at this time revealed that the& h6 N4 P( f/ w1 [& p' G
child had grown 2.5 cm in 4 months and had gained
% K' z. M1 T" u. _) i1 j+ A! P2 kg of weight. Physical examination remained# k6 n# m: M- e2 [
unchanged. Surprisingly, the pubic hair almost com-1 ~: r8 H7 _1 i, e+ L
pletely disappeared except for a few vellous hairs at, F  n$ L0 Y6 P. d6 j5 R
the base of the phallus. Testicular volume was still 2
; J8 s" e: p& \) f# dmL, and the size of the penis remained unchanged.
' [5 i4 F2 c* p4 Q' T& M) fThe mother also said that the boy was no longer hav-- a* |# D8 \  U2 w
ing frequent erections.
* R# y* p4 I) i2 d6 Y4 r, [6 K) vBoth parents were again questioned about use of* B% }4 H, ]1 J6 P# M9 h
any ointment/creams that they may have applied to' E5 ?, G  A4 ?
the child’s skin. This time the father admitted the6 Q) Q7 ?5 w8 ^# v
Topical Testosterone Exposure / Bhowmick et al 541
7 P6 B$ M3 k$ e& fuse of testosterone gel twice daily that he was apply-" k. b( n9 [3 J2 c
ing over his own shoulders, chest, and back area for; C9 f# g/ ^/ J8 U! E, W
a year. The father also revealed he was embarrassed
- a# ]* I- y# H) D! mto disclose that he was using a testosterone gel pre-
+ {3 N2 u/ J  h: ]: [5 P( Escribed by his family physician for decreased libido/ b1 L$ c3 M. |7 E6 F/ F
secondary to depression.1 e! u. s' v) s3 ?/ a
The child slept in the same bed with parents.! o: w3 R: I( ?/ Q0 u/ j
The father would hug the baby and hold him on his# N6 ]/ g4 t# [& B
chest for a considerable period of time, causing sig-
/ W1 i9 g* T" k' Q0 z4 }% Z* _nificant bare skin contact between baby and father.+ S  [* Y& V! h- j1 d" X  G' ]: x
The father also admitted that after the phone call,, [3 s. E# N1 R6 y5 w
when he learned the testosterone level in the baby
# e/ X7 o# }6 y7 U# Q6 N5 \was high, he then read the product information3 K" D) w# J5 @
packet and concluded that it was most likely the rea-0 E' V- b& o: }. W0 ~! Z# e% w
son for the child’s virilization. At that time, they
5 ^0 I+ j& O" h3 {, P0 Bdecided to put the baby in a separate bed, and the
; g7 Z: Q$ }0 v$ S+ r. hfather was not hugging him with bare skin and had* v! r2 @8 z. D* a5 Y7 K( c
been using protective clothing. A repeat testosterone" y) g2 A2 Q! Y
test was ordered, but the family did not go to the
: @7 r" ]" J. b: w1 y! d8 Xlaboratory to obtain the test.- x! e9 P9 `3 ^4 K9 G
Discussion
% B$ a  Q8 {4 a0 G# TPrecocious puberty in boys is defined as secondary) U3 B4 E* Z! i9 X9 z+ b8 |
sexual development before 9 years of age.1,4& {  R& W" b5 b
Precocious puberty is termed as central (true) when0 V6 X/ F7 ~; b2 G; O2 @  H
it is caused by the premature activation of hypo-
" I3 ]4 N7 B  P7 l. W+ Jthalamic pituitary gonadal axis. CPP is more com-2 A* w9 x$ q5 N  @
mon in girls than in boys.1,3 Most boys with CPP
0 A1 K- J6 I3 S; D" N! M' Pmay have a central nervous system lesion that is& t4 t' `5 J; |' ^5 D/ J$ P4 d1 j' u: F
responsible for the early activation of the hypothal-
& L% O" d) `/ D7 Gamic pituitary gonadal axis.1-3 Thus, greater empha-' f7 m, q6 p  o0 k( P8 s
sis has been given to neuroradiologic imaging in
4 \4 t8 T9 ^/ b! kboys with precocious puberty. In addition to viril-8 s, H3 a1 S8 ~5 m9 z8 e* @
ization, the clinical hallmark of CPP is the symmet-
6 d$ C' Y0 C/ G  ^" xrical testicular growth secondary to stimulation by* N; A' t# ~7 G# z/ j, n! f
gonadotropins.1,3# }4 M, ~: q+ p( {
Gonadotropin-independent peripheral preco-
' c+ z* l# v9 `0 `cious puberty in boys also results from inappropriate( I& {5 i! g  T1 b! j% w5 T
androgenic stimulation from either endogenous or: _  n7 l6 x/ ^* D1 B
exogenous sources, nonpituitary gonadotropin stim-
- L9 K6 B8 ~  F+ s! ?4 p/ |* Lulation, and rare activating mutations.3 Virilizing8 C, g/ D- E; o' o" y2 t
congenital adrenal hyperplasia producing excessive
) ]; W1 b2 T$ A) F5 Sadrenal androgens is a common cause of precocious1 w4 I( [3 _+ i. o9 }4 ~
puberty in boys.3,4
; Q0 v! r) ^% x# a; FThe most common form of congenital adrenal$ L9 E4 t& \0 m; }
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 I% H# j2 J7 Y! G% Z. z& oThe 11-β hydroxylase deficiency may also result in
% \' e/ ]/ a& N8 Q) E! ]# A6 Mexcessive adrenal androgen production, and rarely,1 s  c/ t5 B; x$ ~3 n1 J
an adrenal tumor may also cause adrenal androgen
9 v7 n. H& ]$ s1 zexcess.1,3  O$ m$ C6 K1 t" A7 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ y7 d5 T: v8 j- n1 S2 F( n. t' B542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; \6 P6 ]* o& C  Y. EA unique entity of male-limited gonadotropin-: t; J0 S( I7 h1 n# k3 ~
independent precocious puberty, which is also known; F7 @7 d* V9 r- K0 J3 A/ Z+ J
as testotoxicosis, may cause precocious puberty at a
+ Z2 D! q+ D3 Z* ?0 y. h& l5 Wvery young age. The physical findings in these boys( _6 m& {* R0 x$ }1 S: o! r( e
with this disorder are full pubertal development,
1 X* Q% T& R7 T: d! b$ r# y+ jincluding bilateral testicular growth, similar to boys* Y  |% k5 J# ]2 z6 v
with CPP. The gonadotropin levels in this disorder/ K% S: s0 `/ t) f1 u
are suppressed to prepubertal levels and do not show8 A1 F) t3 P! x1 M6 Q
pubertal response of gonadotropin after gonadotropin-" k3 H5 T! h% f9 Z6 D* [
releasing hormone stimulation. This is a sex-linked
! J( R2 Q0 W6 o  L" u! zautosomal dominant disorder that affects only
8 o5 w9 D9 q* ~; N1 A. z' m  cmales; therefore, other male members of the family# U: b! W2 _, l, ]7 Z) w  H" I, H) p4 t
may have similar precocious puberty.3
; D! m: n6 S1 d( P& U  Z" ?In our patient, physical examination was incon-0 ?5 d# P, P& _5 j- r$ O3 B
sistent with true precocious puberty since his testi-0 T1 H5 V2 ~* `5 T! ^; U
cles were prepubertal in size. However, testotoxicosis0 U( O1 t5 h! n/ j9 b4 g
was in the differential diagnosis because his father9 y% F0 @) E) R$ G' x
started puberty somewhat early, and occasionally,* c* E& O; ~2 {6 K9 l( l) R
testicular enlargement is not that evident in the
) T6 z6 E3 v7 o5 zbeginning of this process.1 In the absence of a neg-
, v" ?* C1 ~4 S  y% j6 B/ zative initial history of androgen exposure, our
2 f# Y) t- f# N) Nbiggest concern was virilizing adrenal hyperplasia,
$ X+ ^$ a" ?, ieither 21-hydroxylase deficiency or 11-β hydroxylase
' |& e* M' v; U0 {& l# Jdeficiency. Those diagnoses were excluded by find-
: P& N+ g0 o  ^; H0 q; P5 |ing the normal level of adrenal steroids.
, ^+ n4 }  K7 }: bThe diagnosis of exogenous androgens was strongly
3 l; K0 v2 {, ?6 ]  L- ?suspected in a follow-up visit after 4 months because" U( ~* X) g* b$ x& c
the physical examination revealed the complete disap-, S$ t' C1 n+ ~4 \: e+ u8 |
pearance of pubic hair, normal growth velocity, and* B. ~4 C3 Y, i2 ^! B. z% i, T6 N
decreased erections. The father admitted using a testos-
- ~2 B4 a6 A! g# v/ e8 ]; g, Wterone gel, which he concealed at first visit. He was
; U$ D  |/ R( u/ d+ ~1 Y% lusing it rather frequently, twice a day. The Physicians’+ \! y% [- L9 B( d+ Q
Desk Reference, or package insert of this product, gel or
4 Y9 \- i8 m8 \( Z/ q8 {cream, cautions about dermal testosterone transfer to
# f2 Z, u' ?" V7 A+ junprotected females through direct skin exposure." h) C8 B  ?+ \$ x/ W. a
Serum testosterone level was found to be 2 times the3 m  N; Q2 t) |# i5 j! l5 j( w
baseline value in those females who were exposed to
1 X4 e2 Z" g8 M1 O1 ceven 15 minutes of direct skin contact with their male
' W# S3 J2 }" w& t$ T0 _partners.6 However, when a shirt covered the applica-
) P0 H& f* N+ M! @8 \! Ztion site, this testosterone transfer was prevented.
: J. }2 ~+ G7 d+ z. EOur patient’s testosterone level was 60 ng/mL,
+ T3 Y! K8 S0 {, v  Qwhich was clearly high. Some studies suggest that
. L4 e/ Y: Z. t* C$ k' p1 S9 gdermal conversion of testosterone to dihydrotestos-5 B8 V, |9 T0 n+ Y9 \3 u
terone, which is a more potent metabolite, is more
" _- ]  w. l" p* Kactive in young children exposed to testosterone
, m, O; m# q0 c  r+ a$ Iexogenously7; however, we did not measure a dihy-/ G3 P9 C7 f5 q- Y
drotestosterone level in our patient. In addition to( A, {1 S+ w" Y8 ~0 A
virilization, exposure to exogenous testosterone in, O" Z% D) D3 v( I5 o, K
children results in an increase in growth velocity and
+ J! D0 P2 A, J5 h; l" tadvanced bone age, as seen in our patient.
5 d! _- V& z1 E4 Y4 {& SThe long-term effect of androgen exposure during
& c: `8 P; {: d; g2 eearly childhood on pubertal development and final: ?) N( V8 p- u4 E
adult height are not fully known and always remain" m+ W* V* N0 K/ R- U
a concern. Children treated with short-term testos-' q' `6 _; r% M2 W
terone injection or topical androgen may exhibit some4 P: G, `' ?' i6 t( Y7 R
acceleration of the skeletal maturation; however, after' v# \7 M5 F2 t! q! a7 g
cessation of treatment, the rate of bone maturation& H9 T8 ~3 d9 X. l) a3 @/ I
decelerates and gradually returns to normal.8,9" p  P" L* P$ [0 j) s6 N6 o
There are conflicting reports and controversy, _8 z& @0 d% v$ C7 T
over the effect of early androgen exposure on adult$ E, n$ B) f7 `
penile length.10,11 Some reports suggest subnormal
! W8 D& P6 b  {0 q9 G! |9 ^! cadult penile length, apparently because of downreg-
. v  p9 U4 E# Uulation of androgen receptor number.10,12 However,
+ i4 o3 v2 T" k+ H) qSutherland et al13 did not find a correlation between
/ o8 w/ v5 E  X, u, h' Achildhood testosterone exposure and reduced adult
! x, f; P9 P% W" V; V! Openile length in clinical studies.
( v0 K( U9 D8 w0 ~( t. O6 d" SNonetheless, we do not believe our patient is
$ f# H8 f; K( ]* j/ B' B& y/ j* pgoing to experience any of the untoward effects from
% f% ^4 {( f1 d1 d, W- M$ {4 G- X9 rtestosterone exposure as mentioned earlier because6 ^2 P' L" G; _) ~2 K' V
the exposure was not for a prolonged period of time.
; g" w) `0 d6 _5 Y* J$ C7 P/ PAlthough the bone age was advanced at the time of
/ F) ^4 s7 B! @1 [- o4 cdiagnosis, the child had a normal growth velocity at; W$ p8 G3 k4 G9 i5 f
the follow-up visit. It is hoped that his final adult5 r- r2 c1 e; b. H7 i7 a/ b
height will not be affected.
$ v( C! E2 N) C# WAlthough rarely reported, the widespread avail-
  [' F( i. U: d4 x% Lability of androgen products in our society may8 R( L2 ?) K8 o, T- h  g
indeed cause more virilization in male or female' j* J* n# c8 {" ?( q& u
children than one would realize. Exposure to andro-
4 }% b7 I0 W& I" h7 H, Vgen products must be considered and specific ques-4 _' L" n4 q# U( G* P. Z
tioning about the use of a testosterone product or
$ Y! p- y+ j8 m% G: ?gel should be asked of the family members during
0 a1 H  w) H" Y6 K5 vthe evaluation of any children who present with vir-
+ Y1 q& t3 I, n$ G' z5 X5 R9 `ilization or peripheral precocious puberty. The diag-/ i* h) `- H6 T
nosis can be established by just a few tests and by- n3 m1 |5 f: i3 g
appropriate history. The inability to obtain such a# F1 \6 `" z4 k* U* q$ e) m; V
history, or failure to ask the specific questions, may) M& t& w. J2 X6 ?9 E* V/ A: ]. S
result in extensive, unnecessary, and expensive
: U1 Q( ^4 u/ s! c1 j: T" q# A! k* Yinvestigation. The primary care physician should be" r8 x4 H, e/ c9 W
aware of this fact, because most of these children, R; Q$ x. I2 f! C$ I4 P2 \5 Q
may initially present in their practice. The Physicians’% q7 d% |/ u" u
Desk Reference and package insert should also put a+ n! ?+ z& s3 \: m. l; M% L$ l' R
warning about the virilizing effect on a male or
/ u& T  |% m6 y7 ?5 R9 Pfemale child who might come in contact with some-9 x% G' b( v$ ^9 N( v
one using any of these products.2 [$ W7 e/ W4 k: m" `' a
References
  A* Y: Z# \7 v1 i+ F1. Styne DM. The testes: disorder of sexual differentiation; I5 l4 y6 l3 d5 T3 {* X7 ]" @
and puberty in the male. In: Sperling MA, ed. Pediatric
+ s7 I6 q$ y6 p! U5 V/ g2 UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- U) `/ S$ h5 L( U
2002: 565-628.% w& k4 @7 ~9 G* m( L
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ U" G0 m  i8 |( G
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
# B$ a1 _; v- F1 L7 J. yBoy Induced by Indirect Topical% E( c/ n' [7 |3 G! H
Exposure to Testosterone
. C: W1 t& O, o) d2 m/ ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 g- z8 ?& G/ O
and Kenneth R. Rettig, MD1
( B* `& K7 I  h/ T4 EClinical Pediatrics
4 n# n& c) y4 w5 ]0 bVolume 46 Number 6
5 q8 Q" F+ k* J+ @" m2 y2 d  y  q+ Q6 |July 2007 540-543  W! C+ i( e( h) r6 y  J/ c. H
© 2007 Sage Publications$ c6 j# Z: Z. E8 d* y1 T4 w
10.1177/0009922806296651
. y0 x5 {# B! g9 o: ghttp://clp.sagepub.com
; j# n$ O; X$ M6 p, |& Uhosted at
  \  h8 ?9 }, V/ k- hhttp://online.sagepub.com  A7 l; c- v. Z' A- o: U
Precocious puberty in boys, central or peripheral,+ d( B3 M5 L' Z
is a significant concern for physicians. Central$ o3 U) O) d9 x) L: p
precocious puberty (CPP), which is mediated# Y) H6 c' S0 v. a; A, w# L
through the hypothalamic pituitary gonadal axis, has7 [' x( G  L2 z6 E; N8 ]
a higher incidence of organic central nervous system! x1 |7 C  ]( `5 I- d4 q
lesions in boys.1,2 Virilization in boys, as manifested1 H2 f) l* `: s* |" o3 `% B
by enlargement of the penis, development of pubic, L6 f. ^; Z8 c' |# y
hair, and facial acne without enlargement of testi-( z; M2 c6 p) h1 ?
cles, suggests peripheral or pseudopuberty.1-3 We
3 `' j! A& c# T+ v- D( _  v2 greport a 16-month-old boy who presented with the
6 D; `( i4 s' D& Zenlargement of the phallus and pubic hair develop-
, \3 s8 M8 b# G, S9 j9 pment without testicular enlargement, which was due* s+ c0 S7 w; V1 Z! B* r
to the unintentional exposure to androgen gel used by
: W) N! y; t0 h4 Y' {! X1 o: p4 Nthe father. The family initially concealed this infor-
4 B0 G& f0 l6 }3 a, Omation, resulting in an extensive work-up for this4 l. L* u4 {+ T# O1 ]
child. Given the widespread and easy availability of
7 ~* O. r+ |+ p6 a1 {; ttestosterone gel and cream, we believe this is proba-
2 `: v! G4 R) D% d1 c* ~; y' Lbly more common than the rare case report in the1 E+ U! N; q+ S$ O0 g
literature.4' R7 ~- m, @" C$ K. d1 a; V2 x
Patient Report% ]; y+ z* l6 K' b2 d$ u& Z- r
A 16-month-old white child was referred to the- a. G9 i1 w0 v6 b
endocrine clinic by his pediatrician with the concern
- c. K  R' j  v$ w: ?of early sexual development. His mother noticed
- V$ T! F. o+ V+ wlight colored pubic hair development when he was
$ j8 T' Y4 u6 H+ x& GFrom the 1Division of Pediatric Endocrinology, 2University of/ j$ M! S, \0 N% W
South Alabama Medical Center, Mobile, Alabama.
: S0 ]  I& v, MAddress correspondence to: Samar K. Bhowmick, MD, FACE,- [- Q$ ^4 b  h# R& q
Professor of Pediatrics, University of South Alabama, College of
# c, [. a; Z& \7 p4 m0 r1 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 U- S" \# H0 T0 P' M2 G- I5 v% ne-mail: [email protected].
1 u9 G0 w* |! J$ kabout 6 to 7 months old, which progressively became
" _3 Z5 P& o7 R. F) [darker. She was also concerned about the enlarge-) e0 @  F2 B8 v
ment of his penis and frequent erections. The child/ z& r0 N8 P; O1 ^/ v+ F) M. ]
was the product of a full-term normal delivery, with9 i( K% F, _* \9 t/ x$ p
a birth weight of 7 lb 14 oz, and birth length of
: J9 k9 n' T4 ?9 G- T, C20 inches. He was breast-fed throughout the first year/ N% V) ~) c' V5 Y0 h
of life and was still receiving breast milk along with
' }/ i4 M6 p3 a, U, c# Z, b' Dsolid food. He had no hospitalizations or surgery,
/ g1 \3 G! b" |# Y7 V7 D1 Q' ?and his psychosocial and psychomotor development" h3 ?1 _" Y! k8 w1 [  Y# N
was age appropriate.# ^' s. {8 `: M4 s
The family history was remarkable for the father,
) D1 h3 W) B# Q0 @) r1 K' }+ }who was diagnosed with hypothyroidism at age 16,# N" x8 i4 R8 Q- s
which was treated with thyroxine. The father’s
9 _* k% T$ {$ {9 \6 Yheight was 6 feet, and he went through a somewhat4 O+ i" w. s: }2 {! |% f  Q( p
early puberty and had stopped growing by age 14.
# [# B' a" }* j* X# AThe father denied taking any other medication. The$ C. }( W6 [$ \/ {" d- t
child’s mother was in good health. Her menarche/ Q; a; R4 a6 i- E
was at 11 years of age, and her height was at 5 feet
" B* O* M# W, W9 u9 v5 inches. There was no other family history of pre-
: J" m, L! P6 b7 h# W4 `! G" _cocious sexual development in the first-degree rela-2 C/ \; j9 b- J0 J* _) `( y. J
tives. There were no siblings.
1 F: }9 [; X7 u) N) r" ^6 F# PPhysical Examination8 g9 m4 c- k- Y2 ^: s
The physical examination revealed a very active,
3 C) o. F& P6 e: t- `playful, and healthy boy. The vital signs documented3 W) J' N9 a8 j& x
a blood pressure of 85/50 mm Hg, his length was' i% o, _' |" d
90 cm (>97th percentile), and his weight was 14.4 kg
/ O9 t2 E0 M- z  W$ b(also >97th percentile). The observed yearly growth
% g* M' I9 Y# D+ Xvelocity was 30 cm (12 inches). The examination of
6 m5 k, I, A5 B+ ?0 o( p# Sthe neck revealed no thyroid enlargement.* Z: d7 R: g" C
The genitourinary examination was remarkable for
& O2 y4 k, K' K$ ienlargement of the penis, with a stretched length of
; U! {, p; N6 }/ E1 x  `% U( _8 cm and a width of 2 cm. The glans penis was very well) g8 h) o9 ]0 O" J
developed. The pubic hair was Tanner II, mostly around  k' O- H! N0 j+ o+ e, v" ?
540
3 O) J$ `# c0 S6 o$ N' Y1 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% o; v/ l6 l6 b3 D7 k% }  d
the base of the phallus and was dark and curled. The
; H1 R. B( n# n$ U) {8 }; ltesticular volume was prepubertal at 2 mL each.
0 `4 U" s! O6 V1 S$ ?  iThe skin was moist and smooth and somewhat. q# z1 A* y! Y2 E6 a# S( {- x1 p
oily. No axillary hair was noted. There were no' O: E3 p8 K3 k( w
abnormal skin pigmentations or café-au-lait spots.
8 [) C# }0 }! K& D: L8 ZNeurologic evaluation showed deep tendon reflex 2+
  I  _1 Z9 J3 ybilateral and symmetrical. There was no suggestion
# v! D7 |# a: m0 H+ Yof papilledema.2 Z: \6 v7 k3 @! t& u9 {! R2 T
Laboratory Evaluation/ Z( }! D  h* ~. F( ^$ ?
The bone age was consistent with 28 months by+ R& P# F2 v$ K$ r
using the standard of Greulich and Pyle at a chrono-0 j8 N! H. M; q. T* T- K
logic age of 16 months (advanced).5 Chromosomal0 T; s0 u* S. ?7 O" T' N
karyotype was 46XY. The thyroid function test
' H" w9 T2 S" I# [: `5 i8 S8 `showed a free T4 of 1.69 ng/dL, and thyroid stimu-
! J' C! n' A: g: B. x5 ~3 |lating hormone level was 1.3 µIU/mL (both normal).  @( G7 @! E( {0 X! f
The concentrations of serum electrolytes, blood
) {8 F8 A% V' }4 S# h7 k6 aurea nitrogen, creatinine, and calcium all were
4 ?. ?# [4 i3 u7 B& }- Fwithin normal range for his age. The concentration
) p' ^0 k, ^; C2 {. O. i- h* qof serum 17-hydroxyprogesterone was 16 ng/dL. m' a) }/ {+ X4 P
(normal, 3 to 90 ng/dL), androstenedione was 20) t' f) a( g8 u/ K7 D4 w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ A2 Z$ Y6 q$ s9 G* S
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 q% h, D4 Q9 P+ X
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 N: i0 z( F0 [7 T7 T9 H, B49ng/dL), 11-desoxycortisol (specific compound S)
$ C# b1 B$ M6 S4 L0 i7 Xwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; W- ~) \% l  g1 e9 v" Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# i( ~2 r- L1 m* V. h- U9 ]: l: D
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' M/ l: @0 e- ~6 ?& S
and β-human chorionic gonadotropin was less than- u& [$ r# P& I& h4 q6 o& ~9 K/ c
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# j, \; G" E2 Y' G" C$ t  Dstimulating hormone and leuteinizing hormone
! T$ F' S, w+ E- C/ R5 ^7 ?- econcentrations were less than 0.05 mIU/mL5 I$ L, \9 k/ ~: o; c
(prepubertal).
9 U& ]! L# i1 z# cThe parents were notified about the laboratory! v. k' t5 d/ i% r9 a- c
results and were informed that all of the tests were. I1 I% A& n( M# Q
normal except the testosterone level was high. The
5 N: h1 F9 R+ x* F# ?follow-up visit was arranged within a few weeks to
5 |0 `6 z& ~4 o) E2 fobtain testicular and abdominal sonograms; how-
. ^( q( |6 `5 n& f: pever, the family did not return for 4 months.% D0 o4 I. m# X- K; U
Physical examination at this time revealed that the
" |6 a+ Y# a/ Y  uchild had grown 2.5 cm in 4 months and had gained
5 E2 a6 y' ^) p7 m2 E2 kg of weight. Physical examination remained7 M) {2 O* T( N
unchanged. Surprisingly, the pubic hair almost com-# u: `/ J& v& @& U  f! @
pletely disappeared except for a few vellous hairs at* E" p5 [, K, }: X5 f7 T
the base of the phallus. Testicular volume was still 26 k! ?* x9 d6 h8 |. n( K% V  y
mL, and the size of the penis remained unchanged.
1 s2 y7 w: `* q# ]: DThe mother also said that the boy was no longer hav-, w* c  b+ H7 p2 r1 I  q) b, a" ^( |( Y
ing frequent erections.( X3 t8 D1 j: e
Both parents were again questioned about use of
- f6 i5 L+ C& b2 e  A! ?any ointment/creams that they may have applied to0 \4 L$ D8 B5 }2 t& X# K
the child’s skin. This time the father admitted the) c) ?" M/ o( w$ P! L% N7 U7 g# s
Topical Testosterone Exposure / Bhowmick et al 541
% t! H+ ^- U4 z1 Nuse of testosterone gel twice daily that he was apply-( v6 r/ x5 i6 A: v4 V0 B
ing over his own shoulders, chest, and back area for% U' @5 }' e3 `! o; k. K* l4 _
a year. The father also revealed he was embarrassed4 o2 }( Z/ r1 J( [3 C7 ~
to disclose that he was using a testosterone gel pre-- y6 k7 ?, H! ~2 o8 [
scribed by his family physician for decreased libido, y3 p, d3 e; N, |3 p
secondary to depression.. b  S5 V# E- O* U, O) a  G- [' w0 T
The child slept in the same bed with parents.9 |) c" K% I5 R5 g4 ~
The father would hug the baby and hold him on his
$ ~/ _. m" H: K' V) D% q% I9 ochest for a considerable period of time, causing sig-" }# O; [6 |/ I# @) M
nificant bare skin contact between baby and father.
2 V- o) k& [3 U) gThe father also admitted that after the phone call,
9 t) }0 ~0 Z$ x( y" c$ U7 Bwhen he learned the testosterone level in the baby
4 a( j" l  R5 z. H' Xwas high, he then read the product information% [, W' N4 Y) S: a6 f
packet and concluded that it was most likely the rea-$ t* a4 Q0 s5 R9 T; z  h. e  o/ x8 _
son for the child’s virilization. At that time, they! |% b, y9 O6 x1 P* V; Y( M4 k
decided to put the baby in a separate bed, and the
, ]1 o( T: K* c$ ^father was not hugging him with bare skin and had
7 H0 v7 M# a. e/ c2 D3 x" rbeen using protective clothing. A repeat testosterone* i) \2 j7 E9 F  O5 f, }' n, W
test was ordered, but the family did not go to the
, P& e* z3 C) e  ylaboratory to obtain the test.4 p3 F, U: ]) x- ?
Discussion
0 t' K5 E3 O' u: B; @  `# x$ g6 GPrecocious puberty in boys is defined as secondary$ r5 O3 d+ D  i! w  c! f
sexual development before 9 years of age.1,4* f5 @  u3 e/ G) J: J# @
Precocious puberty is termed as central (true) when. B7 j& j: D/ n6 g# c
it is caused by the premature activation of hypo-
3 ~& |0 I- S  L$ Uthalamic pituitary gonadal axis. CPP is more com-6 e; V& O5 R3 i& u
mon in girls than in boys.1,3 Most boys with CPP7 X. x$ W/ I* p! |; t6 c
may have a central nervous system lesion that is! ]. v( u& m) J9 v  I$ v; z
responsible for the early activation of the hypothal-* _2 |; E) E% z, t1 F" B$ f8 C
amic pituitary gonadal axis.1-3 Thus, greater empha-
" O0 E0 ?' T" O* `' Hsis has been given to neuroradiologic imaging in$ p7 M4 k' d( M2 {* L% D. L% ]. l4 |
boys with precocious puberty. In addition to viril-
( a( u  I0 E$ t6 k' wization, the clinical hallmark of CPP is the symmet-
. C5 F5 ~" P  F  `$ Y4 ?7 q9 mrical testicular growth secondary to stimulation by, G( E; I0 L) x8 {
gonadotropins.1,3) l$ ^1 v+ J$ b9 J. e: @
Gonadotropin-independent peripheral preco-9 e" i, ]9 r% g7 J7 h3 K- C
cious puberty in boys also results from inappropriate1 j( U0 x" n0 Q. k/ [% W- T8 ?
androgenic stimulation from either endogenous or- D  K' l# g' |% F+ z" W
exogenous sources, nonpituitary gonadotropin stim-9 r" n, v* ?" \# m8 n/ ]5 X; P
ulation, and rare activating mutations.3 Virilizing
# f, z9 S) W9 pcongenital adrenal hyperplasia producing excessive( k, C* k5 `, M5 T$ a9 g
adrenal androgens is a common cause of precocious$ ]" ?% {' ]. V: ~. E' N% h" P
puberty in boys.3,47 ^) \& r0 G: H# I* ~! U
The most common form of congenital adrenal2 v! E, s, l( |. O5 W7 n3 N
hyperplasia is the 21-hydroxylase enzyme deficiency.
# W9 j0 L" h. W3 M1 KThe 11-β hydroxylase deficiency may also result in( Z3 i: {1 ~7 H4 @1 R
excessive adrenal androgen production, and rarely,
8 [: A4 E7 O/ [, B8 z, Ran adrenal tumor may also cause adrenal androgen" b: L) d3 p# g- J3 X; _1 I* [+ d
excess.1,3
$ \  V% _( K: g2 @6 \) sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ W# g" Z$ o0 {* {4 j6 ?& s0 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 {$ P0 c' j6 }, |  u6 }4 JA unique entity of male-limited gonadotropin-
1 E9 L& ^+ b! Y! M. W- }/ Xindependent precocious puberty, which is also known
  E1 [) R+ l4 Gas testotoxicosis, may cause precocious puberty at a
. v& `/ y' z3 u( Hvery young age. The physical findings in these boys3 b+ p6 y% G3 M  f. d8 x4 n/ U3 W
with this disorder are full pubertal development,% a4 v% K) `% m5 T& Y5 Z3 M
including bilateral testicular growth, similar to boys
, [* H( V2 m3 \- u9 ?/ W1 K9 X6 Uwith CPP. The gonadotropin levels in this disorder# |1 m- B' j5 `0 c$ h6 m
are suppressed to prepubertal levels and do not show
9 R9 O* t. ^: s) Q0 j9 e; \pubertal response of gonadotropin after gonadotropin-# V% @! n0 ~, V6 N; L# E
releasing hormone stimulation. This is a sex-linked
* R* b$ {& N' s6 vautosomal dominant disorder that affects only
% X1 j/ N  F9 c* m- y' Vmales; therefore, other male members of the family, m( }+ T" L, w. B$ R
may have similar precocious puberty.3
4 n5 X; [& c8 e' CIn our patient, physical examination was incon-4 }9 ?4 N% L) A6 g
sistent with true precocious puberty since his testi-+ Z/ @- r) G8 Y$ B) j
cles were prepubertal in size. However, testotoxicosis1 F# |6 S0 x/ k! K" k& O+ U3 x# n
was in the differential diagnosis because his father1 `: q; r( U. Z2 O! i
started puberty somewhat early, and occasionally,
6 ]2 M: [/ l, s) C8 E7 S) Otesticular enlargement is not that evident in the
" G. [3 i" H0 S& gbeginning of this process.1 In the absence of a neg-& N% A! r5 \' _0 X6 X' U7 k
ative initial history of androgen exposure, our
4 \( g( @: z# n. e* x+ cbiggest concern was virilizing adrenal hyperplasia,- c* K: o$ {4 j1 J; K( N
either 21-hydroxylase deficiency or 11-β hydroxylase
8 C! o' W' t" W/ Ldeficiency. Those diagnoses were excluded by find-
, D" ?& w+ H! i! J4 Hing the normal level of adrenal steroids.% q. h+ l3 {* Z1 J
The diagnosis of exogenous androgens was strongly) m# P/ d7 k) y0 U! ~6 X
suspected in a follow-up visit after 4 months because' X, d: A0 ^" E7 l
the physical examination revealed the complete disap-+ ~/ q0 D4 ~% Q' R$ C1 _
pearance of pubic hair, normal growth velocity, and3 [8 b1 ~/ w" P7 T
decreased erections. The father admitted using a testos-
6 q1 T6 K# `. d- W& J7 O+ ?9 pterone gel, which he concealed at first visit. He was
6 U) T( `# u- wusing it rather frequently, twice a day. The Physicians’
! q4 R* r4 N" wDesk Reference, or package insert of this product, gel or
3 ?- f( R$ s+ i; |cream, cautions about dermal testosterone transfer to) S) O8 @9 O; X# y' N
unprotected females through direct skin exposure.
- d" P; B, |/ ]3 G; oSerum testosterone level was found to be 2 times the& Y) q# [1 l4 \  i3 I
baseline value in those females who were exposed to
7 K0 ~0 f1 m; C  `7 L- Weven 15 minutes of direct skin contact with their male# _. [! Z& X" \9 W+ Z% ]
partners.6 However, when a shirt covered the applica-; l9 [+ m/ L2 [4 H9 y+ [; o8 o
tion site, this testosterone transfer was prevented.7 M, G& Y6 C$ `+ N' S8 n& Q3 o
Our patient’s testosterone level was 60 ng/mL,) o; _1 m$ W0 ]" U0 u
which was clearly high. Some studies suggest that* @4 v' m+ c, N& i9 n. @- E
dermal conversion of testosterone to dihydrotestos-
9 ~5 \+ j4 z# r% nterone, which is a more potent metabolite, is more
) Q! d. ], l) h, F1 d! Yactive in young children exposed to testosterone
7 ^: I: j9 \0 Uexogenously7; however, we did not measure a dihy-
/ t. l6 c- }2 l% Y3 p' p1 Sdrotestosterone level in our patient. In addition to) a: m% |" \/ v" S# w) \0 i
virilization, exposure to exogenous testosterone in; \4 F/ x3 Y7 @- h8 @1 Q+ @$ p' p
children results in an increase in growth velocity and% o/ w8 w! H0 A' l0 g  c, y
advanced bone age, as seen in our patient.
2 y- E8 b: d5 s& bThe long-term effect of androgen exposure during
$ y* M8 [- T! Cearly childhood on pubertal development and final
9 D* V; w% L# r; ~% sadult height are not fully known and always remain3 `  q: ]% h4 I' I: w; a4 E/ x
a concern. Children treated with short-term testos-% N; k, J: d2 l5 ]7 c
terone injection or topical androgen may exhibit some1 l3 v( |: J: I4 d3 O/ L$ R
acceleration of the skeletal maturation; however, after
  e- t6 L) R) Q& b* Acessation of treatment, the rate of bone maturation
7 e; e( E( n0 fdecelerates and gradually returns to normal.8,93 v  }! z  ]4 o+ A) a- S
There are conflicting reports and controversy# Z8 E, D  e# r9 k5 h8 D& e
over the effect of early androgen exposure on adult
9 _' ]# p5 c( J8 e6 r" L) }penile length.10,11 Some reports suggest subnormal
4 m! j+ a5 ^: f' v1 M  d! i+ Yadult penile length, apparently because of downreg-- h" P# s& r, Z
ulation of androgen receptor number.10,12 However,3 j% _- \+ ?2 s5 A
Sutherland et al13 did not find a correlation between! y  A  C8 e8 w* l4 d& t
childhood testosterone exposure and reduced adult
' \( {' F+ y. X6 m- U( J5 Vpenile length in clinical studies., b5 t" e- [+ f! O
Nonetheless, we do not believe our patient is$ ]* t/ A- w2 w
going to experience any of the untoward effects from
6 y( e) u2 v$ e* }6 S# N& Utestosterone exposure as mentioned earlier because
, I5 T. t* P( \( [6 B1 h7 c8 Kthe exposure was not for a prolonged period of time.& M: N0 z: l0 k) t9 n& b
Although the bone age was advanced at the time of8 ~3 p  o$ g& I6 F. r5 ]& g
diagnosis, the child had a normal growth velocity at
6 {' r) l* Q* ^. d' Pthe follow-up visit. It is hoped that his final adult
) L  }4 J1 P, h4 Rheight will not be affected.
5 E# S6 _! V2 TAlthough rarely reported, the widespread avail-' L. t9 w& F& D
ability of androgen products in our society may
+ M7 @; f; _% n' Q3 R- A, qindeed cause more virilization in male or female( S5 k7 c- n) n/ B
children than one would realize. Exposure to andro-" ^2 _5 p* `/ Y3 U; A; {
gen products must be considered and specific ques-
2 b; }2 Z) T0 C) Ftioning about the use of a testosterone product or8 C/ ~5 h3 I+ n: I! G5 H4 L( q
gel should be asked of the family members during! @& X" H* t- ?8 p9 s7 @
the evaluation of any children who present with vir-" e7 u( O$ @6 Z  ]
ilization or peripheral precocious puberty. The diag-
* U, k. V3 L; [/ @/ O* Ynosis can be established by just a few tests and by
" }- Y2 _' O. f. o( z: @. m) nappropriate history. The inability to obtain such a, w) _  U9 s9 N9 I  t' {; T
history, or failure to ask the specific questions, may
6 j- |$ T; O/ yresult in extensive, unnecessary, and expensive
/ J  T, S+ ]  E% m/ sinvestigation. The primary care physician should be! R7 L) |" F- y9 x: v2 ^% x
aware of this fact, because most of these children( B0 F' G. G3 w8 U. V) v
may initially present in their practice. The Physicians’8 l% z' E9 B! A: c; l
Desk Reference and package insert should also put a
7 Z) R; H( z1 s- D0 N3 Cwarning about the virilizing effect on a male or  Q9 f4 O$ b7 m+ c
female child who might come in contact with some-
2 ]% x5 c- j3 b" i! o# z* Tone using any of these products.% V) M5 s5 u. y1 ?8 c5 F
References. s; F9 x( }0 W( O6 @) c
1. Styne DM. The testes: disorder of sexual differentiation* B! d/ [! R* \6 w1 R8 V# F
and puberty in the male. In: Sperling MA, ed. Pediatric. r! k9 Q( u. _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  d# D( j+ `5 \# h( I+ J2002: 565-628.
4 L2 X  g7 h, z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 o. }' h* C8 @; m5 y3 B0 s8 Hpuberty 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

" J3 q! f  `, D+ {% K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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