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Sexual Precocity in a 16-Month-Old
1 B" A" ?' M& N+ NBoy Induced by Indirect Topical/ {+ A5 l$ @# d0 q& `& `+ p$ ?
Exposure to Testosterone9 i% U8 V! ~1 G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' t8 L  T( @0 g1 l& H, X! I# W; ]
and Kenneth R. Rettig, MD1
/ `& F0 k; I. P8 kClinical Pediatrics) K) k+ B9 h% U+ g9 y! I' \4 s
Volume 46 Number 6
2 s: l  `7 E5 c# ?/ K' e- sJuly 2007 540-543# W0 `9 T5 w0 w) I  N
© 2007 Sage Publications
/ X8 K6 z8 x8 l* P3 X10.1177/0009922806296651
/ v3 @5 z1 z9 U8 b9 `http://clp.sagepub.com
& _: M7 K( k' h, s: d; J% m3 ^6 J. H8 chosted at8 U  _# X. F* o/ r& Y
http://online.sagepub.com
7 l& H$ r$ o" c1 Z; l* u+ u  H! BPrecocious puberty in boys, central or peripheral,
: W; R& T: e* H; w) pis a significant concern for physicians. Central9 i' j' A  f1 K8 Z
precocious puberty (CPP), which is mediated
3 e6 N0 O: R7 ?1 H8 w/ J) qthrough the hypothalamic pituitary gonadal axis, has. z0 {5 _4 v3 d$ t. E
a higher incidence of organic central nervous system, g% w: l. R  D
lesions in boys.1,2 Virilization in boys, as manifested  v9 q3 o7 G; [: L
by enlargement of the penis, development of pubic8 x! |8 g: u( G  T- `( E2 ~
hair, and facial acne without enlargement of testi-
  O, }8 V1 u* u6 Z5 R4 ~) ycles, suggests peripheral or pseudopuberty.1-3 We% a9 r& a' E* _7 z& ?3 [
report a 16-month-old boy who presented with the" }& \( ]+ R- ~4 |: X- c0 d
enlargement of the phallus and pubic hair develop-
% _/ {7 Y# O  }ment without testicular enlargement, which was due0 ^* S: C3 I% u" ]2 e+ _/ Q
to the unintentional exposure to androgen gel used by
5 v! ~" e- r7 C6 G6 u, Mthe father. The family initially concealed this infor-0 t; |; o4 Q. d) x" B. x
mation, resulting in an extensive work-up for this
  h- f7 Y, M+ l  b, F; `child. Given the widespread and easy availability of/ a' ^& n2 v* x( K$ Z
testosterone gel and cream, we believe this is proba-
- G( @6 W  h/ d7 G: `bly more common than the rare case report in the
0 a& ~& Q( w- U2 l; r' sliterature.4  ?3 U, o5 Y/ `
Patient Report  ~1 a7 R. w+ ^# k9 d1 }
A 16-month-old white child was referred to the! J: ~1 ]" {4 e  G  B6 r+ Q, F
endocrine clinic by his pediatrician with the concern3 o7 B5 B3 @, W/ I
of early sexual development. His mother noticed7 ^$ b* H- R7 `% A1 Z% M: n
light colored pubic hair development when he was% a* d" b/ D0 r! b1 m8 H
From the 1Division of Pediatric Endocrinology, 2University of0 t3 S/ o/ ~8 m9 o7 j* y9 @
South Alabama Medical Center, Mobile, Alabama.
4 x; l: U, M) u6 r4 pAddress correspondence to: Samar K. Bhowmick, MD, FACE,
% }; }6 B% f! \8 ?Professor of Pediatrics, University of South Alabama, College of! r% H3 \0 c( ?9 M
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 q8 t4 R- c9 P. a6 S0 t6 he-mail: [email protected].3 Q, }. {! O4 ^6 K' o
about 6 to 7 months old, which progressively became; ^6 Z" b% I" @8 V2 j2 D/ E" x) O
darker. She was also concerned about the enlarge-( v/ {/ j# x3 {0 C4 V: P" u; N
ment of his penis and frequent erections. The child0 ?! V6 v, y" a) [
was the product of a full-term normal delivery, with
* `# N3 s8 O) v" Sa birth weight of 7 lb 14 oz, and birth length of& X. [: \2 @( _9 e+ {) \
20 inches. He was breast-fed throughout the first year$ t; h) d' l* k) S) C
of life and was still receiving breast milk along with" J: H: m% q) u& _2 G5 r) R
solid food. He had no hospitalizations or surgery,! ?+ C, D8 a( z. j* {6 G
and his psychosocial and psychomotor development
# R7 P7 S8 `5 k0 B5 t0 T( V. @7 |was age appropriate.  }+ ~+ L: n+ L& q# }; r
The family history was remarkable for the father,
* T: c* U4 N) ]6 ~9 c0 xwho was diagnosed with hypothyroidism at age 16,! C' Q; h) z8 K. y1 ]* |
which was treated with thyroxine. The father’s8 W) s- |3 h2 W9 n% p  F
height was 6 feet, and he went through a somewhat" \+ O  m0 f2 T$ i
early puberty and had stopped growing by age 14.
! G6 h) F1 z; ~% oThe father denied taking any other medication. The
$ k6 j- Y* T+ d3 c' R6 a9 e" ?% Lchild’s mother was in good health. Her menarche
+ X3 t: ]/ o. C1 t" K1 b. ywas at 11 years of age, and her height was at 5 feet( I: F$ e' Y6 L4 F4 E( r3 _
5 inches. There was no other family history of pre-
( J' S5 _  _+ X% j2 J- ?cocious sexual development in the first-degree rela-
7 T5 [! I1 [, Z+ Z- _' atives. There were no siblings., ^1 M; `, V/ Y7 F( s! L3 s
Physical Examination
" G6 e5 ]# Q& Y9 j" HThe physical examination revealed a very active,
, ^8 n  A3 p: y4 p* p7 Zplayful, and healthy boy. The vital signs documented
' h& y- e: D, ^9 s7 _, E; \) qa blood pressure of 85/50 mm Hg, his length was
0 i: z: W: a  I: ]. {- ^90 cm (>97th percentile), and his weight was 14.4 kg. w7 D- r9 J2 J& N0 [5 V
(also >97th percentile). The observed yearly growth
9 _) W2 c' l7 r. |velocity was 30 cm (12 inches). The examination of7 y9 c& ]4 `+ {" I/ l
the neck revealed no thyroid enlargement.& F9 P. D3 W4 W3 ?6 F5 i; U
The genitourinary examination was remarkable for
$ k" [+ P8 N% u2 Aenlargement of the penis, with a stretched length of" @% U& T; J( K/ X9 o
8 cm and a width of 2 cm. The glans penis was very well+ `+ S# Y8 p+ [, D: Z7 }$ ?
developed. The pubic hair was Tanner II, mostly around7 ^! u8 N0 W& L. k- W
540
) p9 }: ?2 D5 q3 Q" J/ Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 B2 ]; N, J0 K& k+ w
the base of the phallus and was dark and curled. The
7 i7 g- O/ [& vtesticular volume was prepubertal at 2 mL each.# u  l& n9 ]; B0 Z7 w4 W
The skin was moist and smooth and somewhat
5 A  t6 F) f0 \1 e# t4 `oily. No axillary hair was noted. There were no
$ I4 Q0 L) C5 wabnormal skin pigmentations or café-au-lait spots.
1 c5 n, m! h9 g0 d6 `2 M1 u' yNeurologic evaluation showed deep tendon reflex 2+5 K% {, b5 |9 z  r0 h8 h: x/ L
bilateral and symmetrical. There was no suggestion
9 X2 B( m8 ?$ ?3 k. hof papilledema.
6 q. ?& |7 @1 ^5 ^) A4 E3 k0 \5 C6 uLaboratory Evaluation9 @3 n6 I+ f' u7 y
The bone age was consistent with 28 months by, \0 `. c+ Q3 |
using the standard of Greulich and Pyle at a chrono-) R* `' O4 H2 P  x8 G: j1 L
logic age of 16 months (advanced).5 Chromosomal
2 ~/ B" L5 D0 L; M% okaryotype was 46XY. The thyroid function test
8 d6 z/ O) u6 |showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ C7 d: l0 R+ g) [; O! ]
lating hormone level was 1.3 µIU/mL (both normal)., D7 P4 K5 F: F& h: {3 i, T
The concentrations of serum electrolytes, blood
+ l9 v: r8 J1 Q, U7 Ourea nitrogen, creatinine, and calcium all were
% b: d- R1 K7 g- Ewithin normal range for his age. The concentration
$ d; \5 _: h- B5 aof serum 17-hydroxyprogesterone was 16 ng/dL
2 A! G% z& `% v. `1 X" H(normal, 3 to 90 ng/dL), androstenedione was 208 G4 P/ P) ~+ D' H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# h2 s) L7 i& [  R3 G& wterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 Z1 v% J: o9 T" T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# f3 L0 C& I2 p: g7 f# f  m7 _49ng/dL), 11-desoxycortisol (specific compound S); Q+ ?! y9 s8 I  z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ Z( y! X5 P" ^: V) [! F" {tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, _  @, S& v7 L. p  O% I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' p' M2 l# F2 Band β-human chorionic gonadotropin was less than! p$ `: C5 N" q' i2 u' |( M0 H
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 I$ u, H. |1 ?& U. Y4 hstimulating hormone and leuteinizing hormone* [  d$ z2 O# N; v& H) D
concentrations were less than 0.05 mIU/mL# `7 S8 C+ V5 L3 e
(prepubertal).
* \: ]# k. N/ k) C# dThe parents were notified about the laboratory* U! Z& m' ~0 R8 P( Q: X4 v7 N' T: d
results and were informed that all of the tests were
# F/ A, {3 y2 Jnormal except the testosterone level was high. The
; J* I! \- f; k# @  Y7 W  \' Bfollow-up visit was arranged within a few weeks to' D% s2 c* J3 t2 e
obtain testicular and abdominal sonograms; how-3 ]" b/ I0 {/ ^3 t# v7 j
ever, the family did not return for 4 months.( f5 \( b: o& p' l
Physical examination at this time revealed that the
8 l# M6 l, J! f" G4 n# D! Ochild had grown 2.5 cm in 4 months and had gained# A- Y) q6 s: D5 }
2 kg of weight. Physical examination remained6 @# m! M- d- s$ O% _6 ^
unchanged. Surprisingly, the pubic hair almost com-
5 j9 l) N3 `: J; J9 S1 ]  E# Cpletely disappeared except for a few vellous hairs at% X& Q! W+ ]6 r) P: W
the base of the phallus. Testicular volume was still 2
' v' {" S- }; k5 ?# y% @9 i# O* ymL, and the size of the penis remained unchanged.
8 t/ j7 {$ C3 fThe mother also said that the boy was no longer hav-
* ^" d; J6 n+ G# O  g- jing frequent erections.: x: z- L8 @% v2 c3 x7 ~
Both parents were again questioned about use of5 a/ I& W3 {6 N+ O+ n' @6 j
any ointment/creams that they may have applied to7 `. ^" E7 ]; C  A; w$ f
the child’s skin. This time the father admitted the% A0 A; Y0 N0 z; L* I0 n2 f4 w
Topical Testosterone Exposure / Bhowmick et al 541
8 v$ i0 o* @/ puse of testosterone gel twice daily that he was apply-# _& M% F; B# W6 ~
ing over his own shoulders, chest, and back area for
; m& `( h$ a6 J; p4 n+ X2 ~a year. The father also revealed he was embarrassed/ k& X# G$ @! \) x! j& q
to disclose that he was using a testosterone gel pre-
# ^7 m$ {* p5 ~scribed by his family physician for decreased libido& S3 K) F/ @& ?4 K# |3 _
secondary to depression.' g) ^  V4 v- K3 ?
The child slept in the same bed with parents.% |$ @" C2 H/ e/ m( n- L8 {
The father would hug the baby and hold him on his( ]: {9 e9 C) S& n- x# ?4 z
chest for a considerable period of time, causing sig-
' \; ?2 z6 P! X3 Mnificant bare skin contact between baby and father./ P4 p: k2 P6 I, }3 ^* c5 [: w
The father also admitted that after the phone call," D* k' w4 A, ^. M4 i! I
when he learned the testosterone level in the baby
. D# R0 p: z) |5 l9 {" Y( ^1 r2 Gwas high, he then read the product information6 b: Y) f* E- h2 R! I5 i. z+ r; X6 F
packet and concluded that it was most likely the rea-/ C' M6 W$ v* r- ^; E1 x  c
son for the child’s virilization. At that time, they
5 I' w- y. |8 v8 x$ V) Ndecided to put the baby in a separate bed, and the) {, P0 B+ L; J- v+ `
father was not hugging him with bare skin and had
+ ~# Z9 N/ L1 C) e2 K) obeen using protective clothing. A repeat testosterone
8 R& H1 n6 a3 B% T$ R* @test was ordered, but the family did not go to the
9 k9 x' x& \6 s  P% A8 S3 f5 ]  t0 |laboratory to obtain the test.1 @- a& X; w- l" \% i( {
Discussion
5 o9 l6 n& s, B7 ?, |. k" o/ q) xPrecocious puberty in boys is defined as secondary
, }: I/ h- Q+ E2 l3 _sexual development before 9 years of age.1,4
) `& p; l# w  z/ m' B# i+ jPrecocious puberty is termed as central (true) when
, q) r; w* h1 j7 \; M4 U* S: ~it is caused by the premature activation of hypo-/ }: l, [6 B, f9 n: f0 E
thalamic pituitary gonadal axis. CPP is more com-; H. @% F# B0 G" C  c8 n, C
mon in girls than in boys.1,3 Most boys with CPP
0 V) X; i2 T1 ?2 Mmay have a central nervous system lesion that is$ H" `5 u* q7 b4 v
responsible for the early activation of the hypothal-
  X! q. U% l4 B! Z* hamic pituitary gonadal axis.1-3 Thus, greater empha-
! A0 N9 l$ L7 b! z& Y* x2 tsis has been given to neuroradiologic imaging in6 H  `9 `! t7 L) _
boys with precocious puberty. In addition to viril-
" r" B7 u# c( x! D8 \2 eization, the clinical hallmark of CPP is the symmet-/ ?  w4 ]5 e$ }, z, o" U* [
rical testicular growth secondary to stimulation by
: F( C5 O8 [4 s* ~4 jgonadotropins.1,3+ A! u8 m) l; ~7 p5 _$ w
Gonadotropin-independent peripheral preco-- }0 C/ C8 Z' e
cious puberty in boys also results from inappropriate1 ~' T- R* {5 f% Y' Q4 r; D  e3 F
androgenic stimulation from either endogenous or
* t. O3 j9 b, y+ `9 Yexogenous sources, nonpituitary gonadotropin stim-
: B, v2 }/ }$ x; l. Pulation, and rare activating mutations.3 Virilizing
( I9 v; ~8 l2 k& ?congenital adrenal hyperplasia producing excessive' W) Z9 L5 [  R" q% r6 O
adrenal androgens is a common cause of precocious
: k6 L; I% O; M, i" L6 e: f6 b8 Gpuberty in boys.3,4
6 C. Z$ Q/ f& s; e4 I5 s8 o# aThe most common form of congenital adrenal; Q; m# l. C8 C5 l/ ?8 y. B
hyperplasia is the 21-hydroxylase enzyme deficiency.
" ^6 `$ u8 \4 E  ^9 BThe 11-β hydroxylase deficiency may also result in
4 c* L9 U- k- c. P0 kexcessive adrenal androgen production, and rarely,+ c+ E- z$ v3 l- l: F
an adrenal tumor may also cause adrenal androgen
0 r1 f$ V; x: t8 O$ A6 o; p( iexcess.1,39 j! h7 ?) }0 @4 U9 j8 |: t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) E5 N! V( g+ \. o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 E6 _  m# n/ u( @! f% a" E" aA unique entity of male-limited gonadotropin-
  n0 k( y; T2 a* c3 I4 ~9 qindependent precocious puberty, which is also known! B( n: `: f; e$ P. X: f
as testotoxicosis, may cause precocious puberty at a
3 t, v" A5 l7 ]" R$ w8 {very young age. The physical findings in these boys
% Y3 Y' u1 r9 X, awith this disorder are full pubertal development,! V: U& Z, q! B
including bilateral testicular growth, similar to boys3 e* K$ ^. b8 ^$ |+ ^
with CPP. The gonadotropin levels in this disorder; T/ n! e( L; ~8 W; b& r6 p
are suppressed to prepubertal levels and do not show
1 {# f0 x: p- ]6 z6 Opubertal response of gonadotropin after gonadotropin-
6 ~6 S0 Z+ T3 @4 kreleasing hormone stimulation. This is a sex-linked/ B; y3 A/ W+ P% F
autosomal dominant disorder that affects only- F% z' I/ a1 [5 ^
males; therefore, other male members of the family
9 \  L* k& f3 v3 t3 a6 y/ ~9 nmay have similar precocious puberty.3& z: W; K  z8 H' u$ o" j( A
In our patient, physical examination was incon-
5 A& @; _- B) _+ ^1 jsistent with true precocious puberty since his testi-& t5 _: H2 L5 x9 d* y  J
cles were prepubertal in size. However, testotoxicosis
( I; |. ~5 u+ D3 x) W+ v/ C6 owas in the differential diagnosis because his father  H, Q4 p6 ~- Y" B
started puberty somewhat early, and occasionally,( l8 V9 n2 j3 `& S; O: U' n, K
testicular enlargement is not that evident in the" U8 J: Z+ ]& l/ s+ p! J( u
beginning of this process.1 In the absence of a neg-
. g2 a9 t6 O8 D! P/ S6 @ative initial history of androgen exposure, our4 _: _! z5 @8 S% Z& s8 P
biggest concern was virilizing adrenal hyperplasia,+ z5 t, j  g" d# X+ _6 n) x2 C! A& \
either 21-hydroxylase deficiency or 11-β hydroxylase- E7 O7 |6 E2 I+ ]/ {0 q; }1 w% U  t
deficiency. Those diagnoses were excluded by find-* c$ v1 e( K2 c+ c  P
ing the normal level of adrenal steroids.
% N, ~, t# u$ b* j* R$ SThe diagnosis of exogenous androgens was strongly7 {# r8 o7 h2 p7 ]
suspected in a follow-up visit after 4 months because4 V. S) k2 ^) A5 M  E" l$ A6 ^
the physical examination revealed the complete disap-2 O+ Y% L* i  V' h  E+ C! z; R
pearance of pubic hair, normal growth velocity, and
- x$ t6 }; g, Rdecreased erections. The father admitted using a testos-6 {$ U* p2 i3 q# Z: B3 E  }' v
terone gel, which he concealed at first visit. He was
. W6 F8 E& G7 p/ `  ?% iusing it rather frequently, twice a day. The Physicians’
( Z6 X& O3 N9 O, F/ }Desk Reference, or package insert of this product, gel or, ?4 \% b2 E* |7 i$ F
cream, cautions about dermal testosterone transfer to- D' k. h9 G1 M+ Q; t
unprotected females through direct skin exposure.2 F. j1 n/ @4 \2 X% O- P% Z
Serum testosterone level was found to be 2 times the
- W: N! _7 C  c# V) \1 lbaseline value in those females who were exposed to1 q! z, [  W2 O3 O: ^% \
even 15 minutes of direct skin contact with their male# l4 w+ Q% K& W2 o9 c0 @7 H
partners.6 However, when a shirt covered the applica-
4 ^) x8 E5 g# s; E" xtion site, this testosterone transfer was prevented.8 P! F) x/ x+ m" v: ^5 F
Our patient’s testosterone level was 60 ng/mL,
6 y" L4 l/ @% \1 ]which was clearly high. Some studies suggest that
0 P- L: t9 T! W) I( wdermal conversion of testosterone to dihydrotestos-6 O7 {, E& U" s0 Z( W
terone, which is a more potent metabolite, is more2 r# {+ `8 d6 P: p3 e
active in young children exposed to testosterone
, w* k2 i0 P) f0 H/ O9 S+ Dexogenously7; however, we did not measure a dihy-
/ k" r: {& g4 u6 x4 |/ Ndrotestosterone level in our patient. In addition to% i# s# f# z. A8 M: f& ~7 z
virilization, exposure to exogenous testosterone in
2 R! D% F" c2 C* V6 ]5 Ichildren results in an increase in growth velocity and9 u6 A0 [0 E" C
advanced bone age, as seen in our patient.
. g: c& R0 F( x" A. s; wThe long-term effect of androgen exposure during
: O+ I* E% P! dearly childhood on pubertal development and final4 J* C: w8 u: s
adult height are not fully known and always remain
* r* n- D5 {# k% r+ m- _a concern. Children treated with short-term testos-
, {: z+ W4 X( w5 T5 n7 Rterone injection or topical androgen may exhibit some
5 [- V: n4 Z! d* a" @acceleration of the skeletal maturation; however, after# E6 {! H" ?4 k0 S2 W" p1 u
cessation of treatment, the rate of bone maturation
/ g4 v7 h3 e- t/ w8 Y9 ydecelerates and gradually returns to normal.8,9
" q/ m& d. Q) l% B# W- k8 X6 ?There are conflicting reports and controversy3 B( W. z/ h; ^( Y; E! i
over the effect of early androgen exposure on adult
# g5 x& h) G7 L* Tpenile length.10,11 Some reports suggest subnormal
# j5 M" A; U! p8 f. S+ Ladult penile length, apparently because of downreg-, b. k( k$ K5 R  R2 y5 S
ulation of androgen receptor number.10,12 However,( _& n4 d, M8 m3 ]/ K  A
Sutherland et al13 did not find a correlation between2 Y( z* w& {6 M# P6 u5 w
childhood testosterone exposure and reduced adult' s5 z4 T# S! p% d0 o
penile length in clinical studies.
  O$ Y8 d7 r* o5 d  a9 CNonetheless, we do not believe our patient is
$ O# x0 T$ D0 p- T% i) ]3 ?! ?) pgoing to experience any of the untoward effects from4 v9 @( C7 c' A$ P3 S
testosterone exposure as mentioned earlier because9 b; G5 k4 ^7 b5 C2 [. s2 ]' K
the exposure was not for a prolonged period of time.3 g) o1 ~# p' C' {/ o% _
Although the bone age was advanced at the time of6 S4 F; K$ \9 F! w
diagnosis, the child had a normal growth velocity at% D4 z9 W0 |# Y, L
the follow-up visit. It is hoped that his final adult* [7 ]1 \! H. n; W& k2 T0 B; I
height will not be affected.3 u+ d/ g! w% h
Although rarely reported, the widespread avail-
: o7 N% _$ A( @" w/ ~7 O3 _3 J  T0 C: s5 Mability of androgen products in our society may
/ S" v0 C, R% n, L1 c0 iindeed cause more virilization in male or female
1 U1 Q! J& ^# K% |' b: c# W& vchildren than one would realize. Exposure to andro-
' q+ g; g2 [, C* \; _! Wgen products must be considered and specific ques-
) P0 H9 G  }+ L0 K; E# Etioning about the use of a testosterone product or
, b3 o3 E  ~6 e7 L* h; agel should be asked of the family members during: C- K' d7 W+ C$ m
the evaluation of any children who present with vir-
/ S7 {! Q8 _, i+ U( Zilization or peripheral precocious puberty. The diag-' N4 A) ~( o) y
nosis can be established by just a few tests and by0 G/ j: g6 C3 a( \6 P
appropriate history. The inability to obtain such a" Q1 }1 q& R0 E$ d3 p
history, or failure to ask the specific questions, may: M" r3 Y& u- e. }3 A
result in extensive, unnecessary, and expensive
, H- X/ D3 n0 `; V0 y! ^1 rinvestigation. The primary care physician should be
% R/ j5 h1 F  q* @" s$ n$ u' R* daware of this fact, because most of these children6 Z; f# n1 j! F4 N. E+ ~! J' z
may initially present in their practice. The Physicians’
% w' v% K6 L" X# Z5 y& ~, M4 jDesk Reference and package insert should also put a
; c9 D9 Z2 }9 _3 g/ Q/ c6 T( @2 Ywarning about the virilizing effect on a male or
/ E* `, e5 n3 ]* `female child who might come in contact with some-/ d4 _# O5 N( @! z( ], _
one using any of these products.
: C2 c2 U7 v& U2 cReferences
4 x5 a, T8 J/ Q; X+ M- d1. Styne DM. The testes: disorder of sexual differentiation
. H$ k- T9 G9 G% y8 T% S, T7 W8 _and puberty in the male. In: Sperling MA, ed. Pediatric! [4 b  s* ^3 I& V5 f' h  N, i' i6 ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' T8 S' u' l4 O0 v' P/ i
2002: 565-628.
9 W- u0 c# Y: s% q- d9 ~6 \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: B) p: C) p) X  }9 c) Q, x; ?  J# L1 e
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ e- T' d5 f3 UBoy Induced by Indirect Topical
2 n& b. E. }$ `: h( aExposure to Testosterone
/ k3 f/ J( o" _& r& ?1 rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 ^( o+ f% J# Z. Y' O% {4 G0 ~and Kenneth R. Rettig, MD1
: s7 ?; g* ^8 FClinical Pediatrics
% I7 I' C& ^1 N; B' FVolume 46 Number 66 M8 W( q3 J: \  X- h
July 2007 540-543+ p4 U% m" C1 K+ \4 Y' t/ z3 l0 D
© 2007 Sage Publications
  V( n0 @  |5 N10.1177/0009922806296651
3 b8 ~: z2 T: G6 M1 H% I$ Chttp://clp.sagepub.com
: n* i1 s6 [; @; @, n. Q: ], Zhosted at
; L6 U. @. F( V" |http://online.sagepub.com# k/ `* D) V5 J1 x  h; V
Precocious puberty in boys, central or peripheral,  h! A7 J8 k0 G
is a significant concern for physicians. Central$ a. s1 u6 N7 _4 [9 z; V5 `
precocious puberty (CPP), which is mediated
; X8 E3 j  I: C+ n' ^' Gthrough the hypothalamic pituitary gonadal axis, has8 O$ N% |$ F1 P: P, ^6 u2 F
a higher incidence of organic central nervous system8 V& K- z7 B: K1 I# e2 X# x" ^  M
lesions in boys.1,2 Virilization in boys, as manifested
3 M; N+ l7 j1 @0 y# Z6 ?; l- o' Hby enlargement of the penis, development of pubic
$ Y8 A# ~3 A  R3 \3 b0 L, vhair, and facial acne without enlargement of testi-
; o5 y! K2 ~' Vcles, suggests peripheral or pseudopuberty.1-3 We
- E: r! H8 G6 g& X5 U" P3 ^; }  Oreport a 16-month-old boy who presented with the. l  b, V4 Z# g
enlargement of the phallus and pubic hair develop-2 O4 ?) J. r6 I) p7 k8 C
ment without testicular enlargement, which was due
7 ~( ^$ W* J2 I: c. Q/ ~to the unintentional exposure to androgen gel used by: H4 O# e$ ?6 `( p8 t
the father. The family initially concealed this infor-
' b1 q) E- D0 s8 Q4 r) r9 jmation, resulting in an extensive work-up for this2 |3 t8 P! M1 s( [7 K& G8 _
child. Given the widespread and easy availability of7 V8 g1 S5 ]8 i& a7 p
testosterone gel and cream, we believe this is proba-* b6 Z, C) G  L; W& T
bly more common than the rare case report in the+ k/ n6 _( o/ \. ^3 O& A, h! L  c
literature.4
) U( n* ~, ], @1 Z. [Patient Report
% j5 G3 T: x6 r5 a1 z1 r% IA 16-month-old white child was referred to the- e. ]. q/ \* H( X6 W* L
endocrine clinic by his pediatrician with the concern8 d- c* L8 j+ w5 M. u" Q
of early sexual development. His mother noticed, o8 o. i8 e0 U: g7 F
light colored pubic hair development when he was# n# r  _8 e: v& n
From the 1Division of Pediatric Endocrinology, 2University of' g, l' L- u; ~
South Alabama Medical Center, Mobile, Alabama.% @- r: d0 ]( S
Address correspondence to: Samar K. Bhowmick, MD, FACE,7 ?4 Y* ?( G3 H4 ~, C
Professor of Pediatrics, University of South Alabama, College of( N2 j4 i/ _  ~' b* ?! t, P6 ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- j  O$ X- G5 Se-mail: [email protected].
7 v; n4 q# y4 k; f6 |about 6 to 7 months old, which progressively became
+ }3 v1 N4 \- G+ Pdarker. She was also concerned about the enlarge-
7 X& c; h) J$ j/ U0 f* k" Yment of his penis and frequent erections. The child
1 p3 u9 o- {1 j) }was the product of a full-term normal delivery, with
+ \' D& t. o' \4 _( l0 ]0 c! Ra birth weight of 7 lb 14 oz, and birth length of+ A/ v' M! Z, b6 a! ^* b
20 inches. He was breast-fed throughout the first year
) N5 x8 w' B6 rof life and was still receiving breast milk along with9 q5 E( ^* S: Z6 U) T
solid food. He had no hospitalizations or surgery,
1 _3 ]7 K1 ~  G, Pand his psychosocial and psychomotor development
0 g# W* i# l$ Q6 }' H0 ^was age appropriate./ x8 J8 n6 p, x8 g+ s8 z3 Q
The family history was remarkable for the father,
. C, `/ a9 B/ M' O: k- C/ u$ Dwho was diagnosed with hypothyroidism at age 16,) g4 u6 G2 O( ?+ a/ Q
which was treated with thyroxine. The father’s
3 ]0 B. y: v2 S( W" T. Iheight was 6 feet, and he went through a somewhat
+ Z3 |5 q4 A8 ]2 D( X1 v$ learly puberty and had stopped growing by age 14.
3 E$ K* R, R& t  M% W6 OThe father denied taking any other medication. The
1 x* D0 s* o6 z6 |* r; M3 V% M7 zchild’s mother was in good health. Her menarche
1 S- B9 S" ?8 Z' pwas at 11 years of age, and her height was at 5 feet
9 Q# H! S; T8 b2 Y3 }4 ?5 inches. There was no other family history of pre-
" j. R$ \/ }( o1 {cocious sexual development in the first-degree rela-' @9 a6 t' R; _
tives. There were no siblings.
0 l8 k$ W- d+ LPhysical Examination
% Z! w8 h" ?+ r) `! UThe physical examination revealed a very active,4 x8 I( P' n, k0 Z
playful, and healthy boy. The vital signs documented7 t: u: H+ J; H& K* w& O2 E1 }1 b
a blood pressure of 85/50 mm Hg, his length was3 p6 X2 B+ s% i* c9 d1 a/ J
90 cm (>97th percentile), and his weight was 14.4 kg
' \0 e. k( k2 O2 \% E) N# Z4 l% x(also >97th percentile). The observed yearly growth
) `6 d8 a3 w* V1 ~+ ivelocity was 30 cm (12 inches). The examination of
5 O9 i% n5 M5 Q- kthe neck revealed no thyroid enlargement.7 N  N: G$ \% S1 u% n
The genitourinary examination was remarkable for
" t1 |' w" o4 Nenlargement of the penis, with a stretched length of$ j7 G# j6 j0 Z' g/ d
8 cm and a width of 2 cm. The glans penis was very well
' d$ S6 u! t2 W& S0 \% ddeveloped. The pubic hair was Tanner II, mostly around
/ F2 m( n9 u! `2 I2 P4 m, u6 Q" V$ e540
. D+ C& i6 ?9 [% `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( O' I1 m# s- @* g) f
the base of the phallus and was dark and curled. The
/ k& F( o6 b9 m  J! Itesticular volume was prepubertal at 2 mL each.2 Z: h- D9 p. S
The skin was moist and smooth and somewhat
& S) b6 R$ }3 loily. No axillary hair was noted. There were no- n) \1 `" Y, J3 }' c! e+ j; Q
abnormal skin pigmentations or café-au-lait spots.7 N0 _9 _% n: G9 v2 K0 k0 H0 `
Neurologic evaluation showed deep tendon reflex 2+3 D# V2 T0 ?, ~
bilateral and symmetrical. There was no suggestion
4 t1 j2 P0 P; I$ E1 J/ tof papilledema.
2 s& u+ u! c0 B/ V! S4 h: k$ U7 wLaboratory Evaluation9 Q+ W: g$ P# N# t# B
The bone age was consistent with 28 months by
( ?: B4 r5 x4 @  M% Iusing the standard of Greulich and Pyle at a chrono-
9 R1 {/ X. l; Z. J7 C& I8 r) ilogic age of 16 months (advanced).5 Chromosomal
4 V6 Q; y' p2 x6 y" ?% h0 akaryotype was 46XY. The thyroid function test
' N7 q4 o' {2 {. s" ~, c$ b3 Cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-# W/ w: l4 [0 U, E# O* O
lating hormone level was 1.3 µIU/mL (both normal).
( M( r$ N+ ?' i. l+ l8 r) S2 C% uThe concentrations of serum electrolytes, blood/ r# ?+ F2 ?8 q" p9 {
urea nitrogen, creatinine, and calcium all were
) |' R1 b& H8 _. U! swithin normal range for his age. The concentration: Y  A- R* D1 c$ p
of serum 17-hydroxyprogesterone was 16 ng/dL. e5 \# t, Z# X* r
(normal, 3 to 90 ng/dL), androstenedione was 20. e4 A2 t' ]9 W0 ]" ]; S0 U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& y8 T2 Z$ Y2 s9 X  p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),+ Q, [4 B8 @+ @5 ?5 u: P5 P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* S' E: f5 t; d/ k$ B- K9 T
49ng/dL), 11-desoxycortisol (specific compound S)9 k) g  W* b7 D6 f" d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; q' I' D+ U. f: l3 K( _# d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ q! }6 t1 e) k/ H! ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 E+ k) X5 P( x6 r; y# |1 l, a5 M
and β-human chorionic gonadotropin was less than2 v- E# v' Q- o0 A  J
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ G& x: L- c" i: f3 Z. I: p
stimulating hormone and leuteinizing hormone
: m7 F2 G  L& w& x: }5 \concentrations were less than 0.05 mIU/mL
0 b' U1 S0 A, H0 d7 U9 r(prepubertal).
/ `' e: M1 f6 ?4 ^' N3 L8 QThe parents were notified about the laboratory, d- q9 h( l0 L( ?* ^
results and were informed that all of the tests were" x& \" q: H) I
normal except the testosterone level was high. The$ ~. {1 m9 {+ A- Z% A- T  Y/ }
follow-up visit was arranged within a few weeks to
2 w2 J! H% M& m0 |3 U2 p3 z4 ]" fobtain testicular and abdominal sonograms; how-
3 u# j" n: j" n/ h) j- wever, the family did not return for 4 months.. p! z* v( x/ P1 I; Z0 X* c5 e. X
Physical examination at this time revealed that the
) h- Y9 V: ~- _# j$ l4 Z2 `/ Achild had grown 2.5 cm in 4 months and had gained; y# E5 g- t4 j0 l% g) V4 p, Y; \
2 kg of weight. Physical examination remained
0 e) [- Q1 f6 C# Eunchanged. Surprisingly, the pubic hair almost com-
# ^8 S1 z1 ?! C5 Zpletely disappeared except for a few vellous hairs at  M5 M; ?3 I3 u7 ?% R
the base of the phallus. Testicular volume was still 2
3 `, F! B0 c  f' M$ umL, and the size of the penis remained unchanged.
: F' U0 v( `1 q% TThe mother also said that the boy was no longer hav-7 q( F1 q- \* X: U% e6 L
ing frequent erections.
" {" Q. v; I0 c0 G+ {Both parents were again questioned about use of$ X$ Z3 }" R6 N1 O* f9 Y& S  D% f8 X
any ointment/creams that they may have applied to
' X: k, w$ d( a0 b6 E; {% Rthe child’s skin. This time the father admitted the& q1 w. r8 s- {3 _( m% P
Topical Testosterone Exposure / Bhowmick et al 541
! l! i8 U7 v. D- Q1 Kuse of testosterone gel twice daily that he was apply-
6 L: N! y$ N5 R4 a( a5 K* aing over his own shoulders, chest, and back area for7 \' W( `+ d& ]/ M% x
a year. The father also revealed he was embarrassed7 P+ Q) U6 Q+ P- k
to disclose that he was using a testosterone gel pre-" N0 @% t6 a0 U0 E( \
scribed by his family physician for decreased libido  k7 w- W2 V* C0 K+ h: g
secondary to depression.; J0 _& x9 Q7 _! W, ?& a6 t6 B+ X( g
The child slept in the same bed with parents.- M- o; G2 A* m: A
The father would hug the baby and hold him on his/ b! D! V( V9 W! {  H* g" _% y% J
chest for a considerable period of time, causing sig-
6 X& b1 M9 l1 K2 V4 E( i5 Jnificant bare skin contact between baby and father.( o: `2 J, v6 X3 m$ M7 X* a% G
The father also admitted that after the phone call,0 {* l  A9 m0 u4 C
when he learned the testosterone level in the baby# G+ \1 T  f3 `, J
was high, he then read the product information3 [" g/ S0 |) j) [' b, \
packet and concluded that it was most likely the rea-
* e1 D# k2 p4 o6 J# Q2 ?6 ]son for the child’s virilization. At that time, they0 t0 |7 n; v# d- ~
decided to put the baby in a separate bed, and the4 q+ a# R5 Q# z! W) A4 S
father was not hugging him with bare skin and had
- Z$ Y3 P: X  X  k! R* ]5 Rbeen using protective clothing. A repeat testosterone
  z+ l! {1 p% J; ltest was ordered, but the family did not go to the
5 ]; j$ k, _  Y+ ]: Rlaboratory to obtain the test.
. Q- ~) o; n0 `$ n) dDiscussion
" ~+ O" ]/ }  z, q8 r- J- DPrecocious puberty in boys is defined as secondary
+ A$ l" E& _6 Hsexual development before 9 years of age.1,4
) J, m% ~2 d7 u& A, F0 rPrecocious puberty is termed as central (true) when7 ^& ~- |" k4 l2 ^1 H
it is caused by the premature activation of hypo-
' I# v4 Z, ?5 z  g1 athalamic pituitary gonadal axis. CPP is more com-
2 a$ F* l" b; F# g/ \1 [mon in girls than in boys.1,3 Most boys with CPP
3 k% k3 B9 K% i7 C% Y6 E! J. emay have a central nervous system lesion that is
0 K5 _  U. |: R8 L9 [* r( O2 presponsible for the early activation of the hypothal-- b9 ?0 ?: `% m/ h( K' e
amic pituitary gonadal axis.1-3 Thus, greater empha-& L5 k, }, X2 B& c" i
sis has been given to neuroradiologic imaging in
( e# Q) S' y4 `boys with precocious puberty. In addition to viril-. Y: B  T! m  X3 ?
ization, the clinical hallmark of CPP is the symmet-
/ o& u3 X- @  M& _rical testicular growth secondary to stimulation by8 T* E! _- S/ [. Q+ j
gonadotropins.1,3
$ Z4 f+ D  f- A3 u0 J  NGonadotropin-independent peripheral preco-
; b6 m6 L) |3 Z7 h8 \cious puberty in boys also results from inappropriate
. t" Y0 H  {# }, Gandrogenic stimulation from either endogenous or
) ^8 u  V0 ?6 w4 _( c2 N# E3 nexogenous sources, nonpituitary gonadotropin stim-- }) D/ B- m/ A- g* [2 ^* H
ulation, and rare activating mutations.3 Virilizing  [- R& f! O3 _7 K- }, D
congenital adrenal hyperplasia producing excessive8 [! r2 K8 X: ^. G/ D5 r  W3 K9 K
adrenal androgens is a common cause of precocious
/ ~' \1 ^; p" P( m2 i( I# tpuberty in boys.3,4" Q- q2 |) J. p( _8 n
The most common form of congenital adrenal
/ U8 b7 t9 S/ p/ s9 R, _; vhyperplasia is the 21-hydroxylase enzyme deficiency.
& i' M* L3 o  ~+ g/ Q3 M, {The 11-β hydroxylase deficiency may also result in
+ s7 \: r$ E& x4 qexcessive adrenal androgen production, and rarely,( b9 ~- I/ A, F" C
an adrenal tumor may also cause adrenal androgen
8 r4 {- Y2 R- Pexcess.1,3
+ i& b0 C) Q& S. ?9 V0 P" Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  c8 V. k  g* L, q3 [$ \# o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 w. S7 z) a# A3 B& XA unique entity of male-limited gonadotropin-
( {  B( F& V: v! Z% l& U& Mindependent precocious puberty, which is also known
, U7 A: |% H: F# x& `as testotoxicosis, may cause precocious puberty at a% i1 k1 x# I+ [6 F1 r" s- S, K+ k
very young age. The physical findings in these boys1 J- b3 ]6 v, }
with this disorder are full pubertal development,
' p1 M8 n8 b6 `1 q! gincluding bilateral testicular growth, similar to boys
3 g) ]7 z) v7 J0 ]' |4 U3 u$ _with CPP. The gonadotropin levels in this disorder4 }  d1 v9 E% u+ G
are suppressed to prepubertal levels and do not show
, V5 M% q% q$ J! `pubertal response of gonadotropin after gonadotropin-5 s& N% \# V& j2 o" Q& m! q. ^! t; p
releasing hormone stimulation. This is a sex-linked
0 a' I0 _5 [2 Pautosomal dominant disorder that affects only
+ g( n3 S/ k/ i! T9 c: k. n) Lmales; therefore, other male members of the family
: C; e6 M2 e$ x* T# fmay have similar precocious puberty.36 e7 I6 ?8 T# `! |" t2 Y
In our patient, physical examination was incon-
4 J2 X/ t- }0 m9 \# I8 Ysistent with true precocious puberty since his testi-
: T( q- ?# e" p# Q8 e4 ]( ]cles were prepubertal in size. However, testotoxicosis
$ o$ m3 V: `1 ywas in the differential diagnosis because his father
0 m3 s5 M+ s6 T5 _8 zstarted puberty somewhat early, and occasionally,
3 [: b  m* R4 O' |testicular enlargement is not that evident in the
- f( D8 U# ?7 K+ F+ gbeginning of this process.1 In the absence of a neg-
4 [8 `1 V1 D" s; @4 E  }ative initial history of androgen exposure, our
0 t4 `* K9 s% _, p) i1 ~' E) kbiggest concern was virilizing adrenal hyperplasia,3 Q  T" J; G4 c5 D! {
either 21-hydroxylase deficiency or 11-β hydroxylase
; D" s. I3 ~9 T% M0 `deficiency. Those diagnoses were excluded by find-+ q* [/ G8 s- I& v# f9 O
ing the normal level of adrenal steroids.' g' z# a0 B7 c3 n/ i: V& W! ~4 I
The diagnosis of exogenous androgens was strongly
! ?, B* }3 n# C* Esuspected in a follow-up visit after 4 months because: ]- H3 K: n6 U+ x
the physical examination revealed the complete disap-. o7 j6 x8 v( N6 n
pearance of pubic hair, normal growth velocity, and* s) }9 {0 f2 \# W
decreased erections. The father admitted using a testos-0 T. P( p# w: {0 W- N# _
terone gel, which he concealed at first visit. He was& j% s0 Y2 A/ g0 P1 t
using it rather frequently, twice a day. The Physicians’! q  M+ A' T5 u# n& a+ q5 y) i
Desk Reference, or package insert of this product, gel or3 d- b1 J( z$ ^
cream, cautions about dermal testosterone transfer to, A0 V& U- ~4 j8 y! t  s1 S! j
unprotected females through direct skin exposure.9 H( v0 N: q/ }2 A. g  J
Serum testosterone level was found to be 2 times the8 ?9 F) t* O1 U  L3 h8 a  p- A
baseline value in those females who were exposed to8 t7 e* W7 Q( p4 b' d
even 15 minutes of direct skin contact with their male! R, t8 g9 [. S5 J: Y
partners.6 However, when a shirt covered the applica-" h  ^+ E- C9 y; G
tion site, this testosterone transfer was prevented.
. E; }0 d$ E0 t: X; q  t( {& g' s+ tOur patient’s testosterone level was 60 ng/mL,
4 n0 b6 x3 [( }: W  z' Jwhich was clearly high. Some studies suggest that
$ [' x  d  U6 ~5 s5 A7 ^9 Sdermal conversion of testosterone to dihydrotestos-
, Z! Z% [6 }+ L- _' N& `terone, which is a more potent metabolite, is more
& |6 G6 S" r% t) `+ y" Qactive in young children exposed to testosterone4 T# a9 a  k* ?# [7 Z" a5 X' O
exogenously7; however, we did not measure a dihy-
6 R; ^# s! [6 o6 `* r  \drotestosterone level in our patient. In addition to
/ j7 U. l" m2 L0 T( g! ^virilization, exposure to exogenous testosterone in
7 j* I) S' h- }- G( `children results in an increase in growth velocity and+ h# U( g  J; X
advanced bone age, as seen in our patient.
! m2 f. e( O; \% y1 U1 f. ]' j4 fThe long-term effect of androgen exposure during0 c  Z+ Y5 {# R1 p4 q
early childhood on pubertal development and final
4 u3 Q% k3 r7 |, w' oadult height are not fully known and always remain- n& u+ R* d/ l+ O% I" R) d6 A+ V6 n
a concern. Children treated with short-term testos-" g8 ?6 ~8 P$ w1 f8 q
terone injection or topical androgen may exhibit some7 I) A& c; n7 I( y  g' Y* [& H! @
acceleration of the skeletal maturation; however, after9 e, x; d) J! I  B0 t9 M* T
cessation of treatment, the rate of bone maturation
0 ~  Q( Y, @9 i* T7 Z, E' Adecelerates and gradually returns to normal.8,9
, Z3 a6 g- Y) A- _( eThere are conflicting reports and controversy
6 V+ C3 C: [# U8 eover the effect of early androgen exposure on adult* @2 b9 N* n5 S/ T9 C
penile length.10,11 Some reports suggest subnormal5 j4 _1 a! O# t" L9 L* M
adult penile length, apparently because of downreg-
, J$ V+ A4 U: u7 m$ w. bulation of androgen receptor number.10,12 However,) r' l2 A% P. X, n) X& d% e
Sutherland et al13 did not find a correlation between, o8 w1 d- N7 [/ p0 P- X
childhood testosterone exposure and reduced adult
% }, G6 U1 T2 Z- h( _9 jpenile length in clinical studies.
3 b4 S$ N* L4 M1 p! a6 ^Nonetheless, we do not believe our patient is
8 L6 e+ d$ U# ?2 c- l6 F  K" m) Rgoing to experience any of the untoward effects from9 K* ?6 J5 I$ \7 j$ _6 \% {
testosterone exposure as mentioned earlier because
; b! t3 N1 u4 A$ J: ]8 M5 }8 Bthe exposure was not for a prolonged period of time.- K- J. t8 P, Q1 ^1 ]5 z) E
Although the bone age was advanced at the time of! |) O) ?5 }* {) `; @8 H
diagnosis, the child had a normal growth velocity at
3 ]. ?# K( L7 lthe follow-up visit. It is hoped that his final adult
: @  t+ D0 T0 Q% I7 {height will not be affected.' s# l! \  I3 P
Although rarely reported, the widespread avail-
; D' K+ i: m, qability of androgen products in our society may
3 f( Z; I0 c2 c8 s. Jindeed cause more virilization in male or female' p) [$ R" ?+ P! ]
children than one would realize. Exposure to andro-
5 C, ~3 c6 f" _9 e- \gen products must be considered and specific ques-2 X* k  R+ z, G# e" J
tioning about the use of a testosterone product or
9 H* r8 ?# I5 S& agel should be asked of the family members during
0 b6 |9 Q$ k: P% v# H, t" e! gthe evaluation of any children who present with vir-
5 h8 j# S% \  ?ilization or peripheral precocious puberty. The diag-9 V: S, a/ M% ^: x
nosis can be established by just a few tests and by+ L" a9 F9 K: l6 Y* x
appropriate history. The inability to obtain such a
6 C4 K0 ~9 W' }  \' i% i* P; Fhistory, or failure to ask the specific questions, may" d( [6 a$ F, i/ ~& H% q1 ?0 q
result in extensive, unnecessary, and expensive8 A& O8 S& H* i8 }; o7 b
investigation. The primary care physician should be
8 u, ?& I3 |! E0 Aaware of this fact, because most of these children1 b' L5 Z. \3 x9 n
may initially present in their practice. The Physicians’
$ p4 T# t* }) p) t6 X  k% UDesk Reference and package insert should also put a
0 S" P  \, d/ p+ zwarning about the virilizing effect on a male or' R: `  b; D: H" n: z2 b) w
female child who might come in contact with some-+ `9 B/ y/ N# \/ t
one using any of these products.& b7 k# y& Z9 s" F
References7 m5 u' \* m7 @4 ~
1. Styne DM. The testes: disorder of sexual differentiation
; y6 ]4 |9 I. G# M$ wand puberty in the male. In: Sperling MA, ed. Pediatric/ g7 z4 P) ~1 L( {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 A' V! P% u6 H) P2002: 565-628./ F- Q+ M5 I, ~* K! \5 n
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 a' s2 V) Z/ m: w9 c, a
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
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

" G+ y) w# \, _1 L5 y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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