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Sexual Precocity in a 16-Month-Old
3 U# z, Q1 y* A: e8 bBoy Induced by Indirect Topical
4 u$ d# I' Z3 ^Exposure to Testosterone
7 e! R6 D( {; i6 fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% q  _! `8 i( H2 `' S$ ?and Kenneth R. Rettig, MD14 [- J3 s! E& h1 u
Clinical Pediatrics4 p$ F$ o" I) A' k$ V4 M) B0 Z9 w
Volume 46 Number 6
6 h+ Q7 u  A6 ]3 s" ^8 nJuly 2007 540-543
3 M5 O/ _4 H/ N6 x© 2007 Sage Publications
3 S2 S, q& n6 n6 x10.1177/0009922806296651
, C: g, \9 h. C$ n* qhttp://clp.sagepub.com: \: O. r' I2 w, j) j' H) M4 F
hosted at) a, j' l1 T+ x+ l# r
http://online.sagepub.com2 j3 b, z: P  U+ u
Precocious puberty in boys, central or peripheral,
$ B% i, O% p+ ?; a. e: u& J+ F$ yis a significant concern for physicians. Central
8 _6 }7 H; m2 F- @. Q: K/ sprecocious puberty (CPP), which is mediated
. ~5 v$ g$ C9 _) [& I9 _through the hypothalamic pituitary gonadal axis, has/ z  M- T1 `3 U% N5 T8 Y* k
a higher incidence of organic central nervous system$ |! }* U# b$ S9 T- m$ d
lesions in boys.1,2 Virilization in boys, as manifested' G) Z" I0 r% w9 g. u& U1 w" u1 b
by enlargement of the penis, development of pubic
! o& `( Q9 Q6 {4 K. f- ~hair, and facial acne without enlargement of testi-; U" R0 \6 O  \( |; P
cles, suggests peripheral or pseudopuberty.1-3 We
) a1 `  X% y, A# z1 }# l! K% V  N3 sreport a 16-month-old boy who presented with the
/ s2 e* z6 t# ?8 s$ denlargement of the phallus and pubic hair develop-
6 A0 H3 A! E, H1 G' U# O+ }ment without testicular enlargement, which was due
0 @* g" a2 M- c8 ]! Bto the unintentional exposure to androgen gel used by
* P  m* H& W. R6 ^. Z7 c1 Zthe father. The family initially concealed this infor-
) Z( U: t0 l7 ymation, resulting in an extensive work-up for this. K# l& K$ y* E* E& a
child. Given the widespread and easy availability of
$ r: _4 s' C" {0 \testosterone gel and cream, we believe this is proba-* M7 Q7 H  G5 Y: a
bly more common than the rare case report in the" ~, [2 a1 U" b% k, z
literature.4
2 P/ R9 P- e9 S  M2 R- iPatient Report
& N. v" @% \# R! R' N5 a7 ~3 yA 16-month-old white child was referred to the
" P) v$ Q( a. e% ~6 D* W! tendocrine clinic by his pediatrician with the concern# a# Y) t% f6 b7 f) S% g) M9 P/ [
of early sexual development. His mother noticed/ ^8 K4 P/ [1 g$ B9 Q, P) ^( B2 @
light colored pubic hair development when he was# h, j  j) \" |5 G6 P
From the 1Division of Pediatric Endocrinology, 2University of+ ~! U  U4 a+ c
South Alabama Medical Center, Mobile, Alabama.; p1 d% y+ a) R/ S/ d% `- R! ~: w
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; v% @9 m1 r" S) }Professor of Pediatrics, University of South Alabama, College of0 r  C1 T' G4 R6 W  B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: `8 @; m5 `4 s: w6 Q% `
e-mail: [email protected].2 Q' u* B. h& G+ `: I
about 6 to 7 months old, which progressively became; ^3 j$ x6 p) g% \7 g# B5 R
darker. She was also concerned about the enlarge-
% v7 ]3 W3 S' Ument of his penis and frequent erections. The child% y6 T' H1 x' t8 u+ s6 [
was the product of a full-term normal delivery, with
3 j+ `6 q/ B$ D5 qa birth weight of 7 lb 14 oz, and birth length of. y2 s( ], _# A
20 inches. He was breast-fed throughout the first year& U5 R: P& p: P8 c& j( Q4 K
of life and was still receiving breast milk along with
0 Z+ I* X5 c9 H6 }solid food. He had no hospitalizations or surgery,
: i# T# k, }, u7 ^; Q8 A- uand his psychosocial and psychomotor development
& ~2 k8 Z" R! o7 a8 d, U! z7 |was age appropriate." Q: }% Q# d! w" B
The family history was remarkable for the father,- n" u5 C+ ~0 d/ ?+ ]
who was diagnosed with hypothyroidism at age 16,) R) x7 v8 T- J$ d
which was treated with thyroxine. The father’s# ]# ^+ a7 K; ?# ^  |# T
height was 6 feet, and he went through a somewhat
% T4 p8 n+ C5 B; K' f2 \/ Wearly puberty and had stopped growing by age 14.6 ]/ F2 Y# D9 Y# P  f! B2 o: _
The father denied taking any other medication. The
- b3 O  @% l& Z: ichild’s mother was in good health. Her menarche
/ X, j; d" R7 S; q5 M8 Zwas at 11 years of age, and her height was at 5 feet) E# k; m. Z% r& [$ G' l9 }% F+ T
5 inches. There was no other family history of pre-. i% P1 R2 A$ Z/ @: `6 d2 h% V* ]
cocious sexual development in the first-degree rela-
/ B5 G% c& |* B4 w4 |tives. There were no siblings.
/ \1 @' l5 B* f& FPhysical Examination
- P7 ~! |5 I) D7 p8 a1 gThe physical examination revealed a very active,. W+ n. ~/ f  f$ F9 e: A0 y
playful, and healthy boy. The vital signs documented1 Z6 L% y5 `' L1 S# V' @
a blood pressure of 85/50 mm Hg, his length was
3 z( f$ h5 m  Z" }2 p; C90 cm (>97th percentile), and his weight was 14.4 kg( h4 x% b5 i' t
(also >97th percentile). The observed yearly growth$ ~0 E7 M, f3 W  r
velocity was 30 cm (12 inches). The examination of+ W/ V5 S* m* T3 d5 t
the neck revealed no thyroid enlargement.6 H: M6 |9 m  X' F* n3 x4 c( d
The genitourinary examination was remarkable for
! m1 [1 N; o  nenlargement of the penis, with a stretched length of. z( C# c- \4 U$ ]1 u) q
8 cm and a width of 2 cm. The glans penis was very well6 i' x$ u8 y8 S) R& G9 w# A
developed. The pubic hair was Tanner II, mostly around
8 ^  K& b% Z. W540
6 A+ j8 g9 a7 x( hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 c2 c; f. q6 S+ |( cthe base of the phallus and was dark and curled. The
$ _( e) W' [$ V2 S* l2 E; O/ [# o$ Ctesticular volume was prepubertal at 2 mL each.
2 `* D6 \) P, i/ t$ M& |6 A6 DThe skin was moist and smooth and somewhat
0 F4 k5 E# i# R, x. ?7 R4 noily. No axillary hair was noted. There were no5 X! n. G% r' Y# e/ i6 D
abnormal skin pigmentations or café-au-lait spots.- V" b; u0 U. U7 e/ V* @
Neurologic evaluation showed deep tendon reflex 2+
7 G# i) v3 d; V& a! e8 abilateral and symmetrical. There was no suggestion
4 d( r# g. {. ~2 \0 Zof papilledema.
6 J* M1 z- G$ B$ `6 w, h) gLaboratory Evaluation
& u7 d+ R/ d& i! DThe bone age was consistent with 28 months by  k. n4 b! N8 p
using the standard of Greulich and Pyle at a chrono-
( E' I' M; A* l2 p) Nlogic age of 16 months (advanced).5 Chromosomal
2 u5 N5 b. A: r2 t4 M( jkaryotype was 46XY. The thyroid function test
4 _  X& X( t6 ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) _8 s+ T3 X6 G( v2 \, wlating hormone level was 1.3 µIU/mL (both normal).
. P* i+ ^/ ?- O( A/ |( BThe concentrations of serum electrolytes, blood6 K( @' _. S: x2 f  B3 f; m
urea nitrogen, creatinine, and calcium all were
+ P1 U5 I8 S4 X6 Cwithin normal range for his age. The concentration4 {. [; d; M  f: \$ b
of serum 17-hydroxyprogesterone was 16 ng/dL2 n0 Q/ k* o' s
(normal, 3 to 90 ng/dL), androstenedione was 20
/ Q% u+ L8 v3 ]) v4 A8 s4 |) }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 i! F6 t, i9 K: ?4 [( Aterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' v3 ?; D$ D( e- Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to; M) Z0 O# d) C; K
49ng/dL), 11-desoxycortisol (specific compound S)
8 T  [0 t% v$ V7 w/ V* E! E/ Kwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- ^/ r+ L* N3 t% ?9 r: }% j7 qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% W* s2 O  W/ Y( e  K  ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 W7 d7 {) ]$ u) ~7 Zand β-human chorionic gonadotropin was less than- s8 C4 o( d5 n" y2 Z- Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular# T5 b  ?* m# U/ [$ w& ]! M
stimulating hormone and leuteinizing hormone: I: l3 z6 J5 F$ Z- ?' [
concentrations were less than 0.05 mIU/mL
' J+ f8 P& @, p8 I(prepubertal).
! c( i8 \0 ^) z8 [4 x! DThe parents were notified about the laboratory, L2 |! z3 f; `- @/ I. q9 L
results and were informed that all of the tests were+ O: k' q  S8 a; k
normal except the testosterone level was high. The( a& A  K* U3 M5 R
follow-up visit was arranged within a few weeks to
" |) d/ y. a8 e% }obtain testicular and abdominal sonograms; how-  H  a% J! H0 X; t1 W$ u
ever, the family did not return for 4 months.
8 j9 ~0 x: ~7 {: q* p+ J1 n* O2 E0 `Physical examination at this time revealed that the- L: h1 M) w& D, W/ M: ^
child had grown 2.5 cm in 4 months and had gained) g: l  `4 V1 X( p; S- Z" {: Y
2 kg of weight. Physical examination remained  W7 g/ B+ W3 o6 h! }
unchanged. Surprisingly, the pubic hair almost com-6 m( ^  j7 _! O9 M: K9 q
pletely disappeared except for a few vellous hairs at7 F1 P% ~% X: _, M
the base of the phallus. Testicular volume was still 23 b( [( n, S( Z' {! v
mL, and the size of the penis remained unchanged.
* v$ @- F% u  d9 p( k7 G$ ZThe mother also said that the boy was no longer hav-
# ~" k: E6 g4 X2 e, king frequent erections.7 q8 \7 g( `  K& d! \3 x: w
Both parents were again questioned about use of
0 m; ^' J: J, i0 I& k. B# ^any ointment/creams that they may have applied to
% F1 R  }: N0 j+ `) D# E6 t$ Gthe child’s skin. This time the father admitted the
8 K3 d9 e8 N" B0 r1 f' WTopical Testosterone Exposure / Bhowmick et al 541
, p  S  A! D9 p3 m$ M! K  f! wuse of testosterone gel twice daily that he was apply-/ C/ K% M' T% E! T% z9 j% y
ing over his own shoulders, chest, and back area for
- B' x; x3 U3 O1 ~a year. The father also revealed he was embarrassed( z6 m8 j- o+ y
to disclose that he was using a testosterone gel pre-  J% l* G3 |; u; K6 s
scribed by his family physician for decreased libido+ h: m6 p4 s" o7 u
secondary to depression.) x/ x$ ^6 U' k
The child slept in the same bed with parents.
- b0 s/ A( M' j: M% m0 B3 kThe father would hug the baby and hold him on his: X" O8 g0 r! f
chest for a considerable period of time, causing sig-
/ N. b% l( f5 h" j' s3 \+ ^3 gnificant bare skin contact between baby and father.' U2 q4 j: e7 @/ _3 S* C" L* _
The father also admitted that after the phone call,# f% F/ Z9 \1 F9 Q7 G
when he learned the testosterone level in the baby
: r) h0 I4 P7 [was high, he then read the product information
( l: R2 Y) ~: g' m$ Fpacket and concluded that it was most likely the rea-
/ t7 p$ y* Q1 f: s9 [" gson for the child’s virilization. At that time, they0 h+ n" d5 Q3 m0 o& y' _
decided to put the baby in a separate bed, and the/ k' k0 N- ?& Z0 N$ }
father was not hugging him with bare skin and had
1 {8 a/ v; l; t; l; mbeen using protective clothing. A repeat testosterone/ F) ]9 z. Z2 b
test was ordered, but the family did not go to the( @6 ~# S- W6 V& T
laboratory to obtain the test.6 g0 c9 v- Q: Q. i- h& n
Discussion
/ d4 K: S# F, w" M3 E8 L. HPrecocious puberty in boys is defined as secondary* U6 I0 F! q1 N8 i/ N/ Z
sexual development before 9 years of age.1,4
) u( C1 z4 m$ t( F$ ?Precocious puberty is termed as central (true) when  x9 b+ C5 H; n
it is caused by the premature activation of hypo-# \* C" x  \0 p6 j7 q  _4 w
thalamic pituitary gonadal axis. CPP is more com-8 }- R& W0 p8 o$ N( b% }$ g- Y7 w
mon in girls than in boys.1,3 Most boys with CPP
0 u; F! \" z  r4 Q8 T" umay have a central nervous system lesion that is
- a3 i7 J" i* z" [$ D: nresponsible for the early activation of the hypothal-
% y; f( M. O% v! b; R3 n6 ~amic pituitary gonadal axis.1-3 Thus, greater empha-0 Z# r7 n9 U0 O. V  |! _- z
sis has been given to neuroradiologic imaging in
& B+ N' y7 U) s: `% U  u# mboys with precocious puberty. In addition to viril-/ T, |- }5 q7 y  }3 u- \, m  v: ^5 s
ization, the clinical hallmark of CPP is the symmet-' s2 M. X3 H  j& R- `) n9 e
rical testicular growth secondary to stimulation by! J* L5 A% B; h, o+ g
gonadotropins.1,3
5 Z; l# m: Q( t. l$ v0 `  S7 l& aGonadotropin-independent peripheral preco-
2 b7 C! h1 N. j3 e' \. b' `cious puberty in boys also results from inappropriate% m2 H1 G* E1 E
androgenic stimulation from either endogenous or* U; Z9 s+ D5 q1 b! {
exogenous sources, nonpituitary gonadotropin stim-
: |% G: ]" C0 ]% t8 U2 ~! R, r0 j& Iulation, and rare activating mutations.3 Virilizing% q8 y" P$ D  y3 ~+ \9 m! S2 J
congenital adrenal hyperplasia producing excessive
2 s5 T+ V) V5 R5 |; madrenal androgens is a common cause of precocious/ v) v1 r( c5 s  y7 t
puberty in boys.3,4
% f: [  ]6 N0 A. UThe most common form of congenital adrenal: ]- \3 \2 x3 \6 P! K! f# u2 k9 V$ Y
hyperplasia is the 21-hydroxylase enzyme deficiency.1 K- P" b+ B/ ?* s0 m$ h8 ^
The 11-β hydroxylase deficiency may also result in: Q, m- v9 _' l; N! ]% G. F* a+ I
excessive adrenal androgen production, and rarely,
' Y! @$ H0 c5 |! Ian adrenal tumor may also cause adrenal androgen
# A  j2 M9 R" @, U. K% x' Vexcess.1,3
" G: ^! \; p. F7 u; w* H4 V* tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( H7 ^7 d  b" ?542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# I, v; Y9 `( J. t. q  K
A unique entity of male-limited gonadotropin-
, i* b( `( Y$ Z& i9 V) R+ W  w) Tindependent precocious puberty, which is also known* F5 Z  Y& o/ j# `2 z1 g' y, j
as testotoxicosis, may cause precocious puberty at a  u3 E  K0 h; _: R/ n; d
very young age. The physical findings in these boys! Z0 D2 ^' w- H8 U3 \8 J  a/ O
with this disorder are full pubertal development,  {# F% A5 `4 C: W- h0 z" P
including bilateral testicular growth, similar to boys
" p, v- v# ?! Q; K  S1 a' @) Bwith CPP. The gonadotropin levels in this disorder0 _& @' I# ]' \% W! s
are suppressed to prepubertal levels and do not show7 M0 M2 w: z) _, G
pubertal response of gonadotropin after gonadotropin-6 k! A/ l" O, c* U+ W
releasing hormone stimulation. This is a sex-linked. |' c, p* O% M0 r% R  i9 m
autosomal dominant disorder that affects only
" \4 @5 Z+ g0 |4 T$ C# v9 h5 f0 Pmales; therefore, other male members of the family; s/ ~2 I, |% [+ v( \
may have similar precocious puberty.3% \" r7 D$ ^" Q# q
In our patient, physical examination was incon-
+ f" d1 U# ]" @( r) q- B; esistent with true precocious puberty since his testi-
; |4 `# X6 K( A: \. Mcles were prepubertal in size. However, testotoxicosis9 y* Y5 J- i9 g( V% V
was in the differential diagnosis because his father
/ U/ A2 ?& U3 ?' p+ Istarted puberty somewhat early, and occasionally,
& [* t9 c1 E" Q8 W4 s. [( Y2 i/ Mtesticular enlargement is not that evident in the: l# e: Z+ s, g8 p* h* r; O& e1 @
beginning of this process.1 In the absence of a neg-
$ Z. \* F+ G  S' Y6 Pative initial history of androgen exposure, our
* r7 K5 ?* n' dbiggest concern was virilizing adrenal hyperplasia,
. {- S6 Q  H: q% ?either 21-hydroxylase deficiency or 11-β hydroxylase" W! u. `  V& R
deficiency. Those diagnoses were excluded by find-
  C  t' l+ T7 _' k* {ing the normal level of adrenal steroids.
5 A, s( v6 b5 ^0 T4 c; UThe diagnosis of exogenous androgens was strongly
( x3 ~4 x8 C2 ?* F; m6 p, }' ususpected in a follow-up visit after 4 months because
% m/ T5 v, D% v+ J9 O+ Cthe physical examination revealed the complete disap-, b7 W2 q1 X: \( H/ S) g% G
pearance of pubic hair, normal growth velocity, and! H! D' h+ d3 v* s: B  A) M- |
decreased erections. The father admitted using a testos-
" ~: g! N% N  M/ w9 K: _; @( kterone gel, which he concealed at first visit. He was
7 G* ?6 R- W5 l4 h7 Ousing it rather frequently, twice a day. The Physicians’' G# s" H: Y/ q" |5 P7 |
Desk Reference, or package insert of this product, gel or
5 `# A1 R, N/ w% m9 fcream, cautions about dermal testosterone transfer to$ o! u9 H& ?7 T# Q% U# I5 j* U' ~0 e/ v
unprotected females through direct skin exposure.
4 M. G5 X" j% k1 d: ?7 QSerum testosterone level was found to be 2 times the
3 z; O9 P  J; |- [baseline value in those females who were exposed to& e& B, r' r, o+ H/ ~  w5 c. v
even 15 minutes of direct skin contact with their male0 y9 p" m6 E8 N# e
partners.6 However, when a shirt covered the applica-, J$ S2 t' b6 N  |5 H9 `+ l
tion site, this testosterone transfer was prevented.
# X. @8 T- }/ AOur patient’s testosterone level was 60 ng/mL,
) x- V, L/ {6 Ewhich was clearly high. Some studies suggest that- H# S  a, n0 X
dermal conversion of testosterone to dihydrotestos-
& H3 k" e" ]: g( \terone, which is a more potent metabolite, is more
$ q7 H+ ?  q6 L7 p2 Oactive in young children exposed to testosterone
% }- v- M  K0 F7 ^9 Sexogenously7; however, we did not measure a dihy-; Z2 @& r) S) g5 N
drotestosterone level in our patient. In addition to
7 [, P, l3 \/ rvirilization, exposure to exogenous testosterone in
9 l8 p5 C- D  J9 ?children results in an increase in growth velocity and
+ N: b5 ?4 D3 M: E7 madvanced bone age, as seen in our patient.; [. k  n5 e! w/ x* n8 Q5 u
The long-term effect of androgen exposure during
* G) p+ `2 ?0 _( W! Fearly childhood on pubertal development and final
8 g% R  A: ^7 l4 |8 Iadult height are not fully known and always remain  A. g. D; H* w4 }' l
a concern. Children treated with short-term testos-
/ s4 i1 Y) N0 ?/ [- qterone injection or topical androgen may exhibit some  @9 ^3 X7 C8 b4 w* v/ i3 X" k3 ?
acceleration of the skeletal maturation; however, after
8 R3 D" W9 _( G" Mcessation of treatment, the rate of bone maturation
9 n1 l; Z/ j+ i1 e  [/ v0 |7 x! sdecelerates and gradually returns to normal.8,9
9 Y9 V- E! \  V' Z7 gThere are conflicting reports and controversy
# n" y- Y  l( Bover the effect of early androgen exposure on adult
1 B% n" z) `- i. L/ gpenile length.10,11 Some reports suggest subnormal+ g; T2 {4 _7 _
adult penile length, apparently because of downreg-/ @' z; z5 X5 `- u4 g9 h
ulation of androgen receptor number.10,12 However,
3 n' ^# \. o* j, _6 t- hSutherland et al13 did not find a correlation between
: X" ]  G- }, K4 x4 qchildhood testosterone exposure and reduced adult
9 w  g" @: W' C0 G1 L5 N, I! E( vpenile length in clinical studies.6 s; Q" a& z! V; `- D% m$ @
Nonetheless, we do not believe our patient is
6 V# t$ w$ D: G6 O  kgoing to experience any of the untoward effects from& ~3 G: b; X7 a- ~# z( \& h7 J
testosterone exposure as mentioned earlier because9 h/ B) y1 z0 D8 n5 [( k
the exposure was not for a prolonged period of time.2 x0 u9 x8 H; ]( Y
Although the bone age was advanced at the time of
) t4 X) v# d3 N7 F* q6 Y1 R5 u( M8 rdiagnosis, the child had a normal growth velocity at- u, Z# I( _& C
the follow-up visit. It is hoped that his final adult8 t7 v4 L9 L% H0 @/ y5 w& ?; k- m
height will not be affected.
8 Z5 Z5 d* A  I. x) NAlthough rarely reported, the widespread avail-
/ s& m6 `/ [! dability of androgen products in our society may  _1 s, {  p) k
indeed cause more virilization in male or female8 ]/ g6 |1 z+ Z: |  r, C
children than one would realize. Exposure to andro-0 q) c" [* B8 r0 O8 V* q& h) e
gen products must be considered and specific ques-
. f! u) p7 d; {, {& T+ j& Itioning about the use of a testosterone product or  `- B0 ?0 h& v, P, k
gel should be asked of the family members during
: S. W: Y. w0 p6 U; f% vthe evaluation of any children who present with vir-
2 K8 u5 M* ?! `) t1 B1 D, ailization or peripheral precocious puberty. The diag-
4 C) v! U: y* F8 l) r3 N# h- Lnosis can be established by just a few tests and by
5 H5 I& [8 ^6 aappropriate history. The inability to obtain such a
& v# H& c. `: a2 ?history, or failure to ask the specific questions, may
$ @$ U0 F' p2 h3 o, }/ ~result in extensive, unnecessary, and expensive
# g1 u$ V, A5 L( E! sinvestigation. The primary care physician should be
8 ^  L6 Y* N% ]6 i) m; W+ U0 Oaware of this fact, because most of these children
% z$ r6 b/ m( g+ h2 E7 F2 w4 D- l) Mmay initially present in their practice. The Physicians’" @& E9 O( [* E) z  H9 g0 @' M
Desk Reference and package insert should also put a
) i8 {4 |+ Q! M7 ?/ |/ M8 @8 H/ Dwarning about the virilizing effect on a male or
& e- j" i( f3 I" |  E" rfemale child who might come in contact with some-
% D6 g7 i; r5 a1 o1 r+ `one using any of these products.
1 D; N' q$ W. b  t  A" IReferences1 v0 k$ l& I2 ~! I2 w
1. Styne DM. The testes: disorder of sexual differentiation
% ~" r8 m9 u4 h2 Z: h# X) uand puberty in the male. In: Sperling MA, ed. Pediatric
; ^( j, R9 h6 }* L2 \* _# ?; g& k: j2 {Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( Z" t: ]# ^* @: Y: B/ y2002: 565-628.9 F8 L8 U( p$ P3 k
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" E9 }$ c( ]9 _# w; t6 v  ^/ j) z& H
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* ~; s0 m) f3 a2 N
Boy Induced by Indirect Topical8 _$ S0 b3 z1 @: R3 P' s+ K3 T
Exposure to Testosterone1 r& S5 x# f* C8 k' \; l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& p! L/ V' B. e) q; qand Kenneth R. Rettig, MD1
" I3 u& \4 w- i; a  }Clinical Pediatrics5 ?6 n/ J" X& d3 e, b9 h8 D
Volume 46 Number 6$ w7 N: T5 r0 N& a) @, r* i% X
July 2007 540-543# o+ V2 W+ |9 B8 q; Y
© 2007 Sage Publications
: S4 Q6 [2 f, b) u10.1177/0009922806296651
) `! g$ r; P) O: f% u' A) Zhttp://clp.sagepub.com0 l0 H. C) u+ V) k; Z/ s+ u# o4 X
hosted at
, B& k: g+ Q% `4 ~5 P1 w) @http://online.sagepub.com; K! g  a+ K- c) D' D: e$ ?
Precocious puberty in boys, central or peripheral,
( |4 F  [$ K. B. U' xis a significant concern for physicians. Central+ F# w. B$ _, L% w6 K: n: Y
precocious puberty (CPP), which is mediated1 C1 V8 t1 V/ M7 k& F! ?( N
through the hypothalamic pituitary gonadal axis, has
; R; Q0 A8 G+ z& R7 Ia higher incidence of organic central nervous system
, L2 Y2 `7 [3 v8 N! A4 I3 Q4 p6 Ylesions in boys.1,2 Virilization in boys, as manifested2 Z/ Q/ ^& ~% M2 R' z8 C
by enlargement of the penis, development of pubic
1 V! O. {, ]/ _5 K5 t% E5 }* s/ lhair, and facial acne without enlargement of testi-
, X9 K3 D, I( c7 x" M  dcles, suggests peripheral or pseudopuberty.1-3 We9 Z, Z9 V: [0 f, d1 d( D
report a 16-month-old boy who presented with the$ _  k0 A# }; x1 N2 c8 }! e$ P5 N
enlargement of the phallus and pubic hair develop-% K1 u0 c( `# [2 p! k9 c
ment without testicular enlargement, which was due
* K, T" [: ]6 [to the unintentional exposure to androgen gel used by
. i0 H3 @# n5 c  ~6 t; m" d& b+ f  cthe father. The family initially concealed this infor-; B7 I# A8 ^# Z
mation, resulting in an extensive work-up for this
0 V& Z5 v. u0 T! `$ U( J8 ^' Y, v$ Hchild. Given the widespread and easy availability of
  B" W* p$ z6 o' R$ ptestosterone gel and cream, we believe this is proba-  d2 B' j2 U8 K1 U
bly more common than the rare case report in the
% O" D( T& n" b6 `$ S3 qliterature.4
% h9 Y1 F3 |0 L/ t* F! M9 nPatient Report
. }2 Q9 S: u7 O0 T, s2 UA 16-month-old white child was referred to the
' S  O6 c/ L6 n3 x$ q( R% P# sendocrine clinic by his pediatrician with the concern3 J+ T+ U3 X+ J1 ]1 L
of early sexual development. His mother noticed( i0 p! z& ~6 M' x- E) n+ n: k
light colored pubic hair development when he was
4 G3 J! w& s: _' F4 CFrom the 1Division of Pediatric Endocrinology, 2University of" K8 s  I3 D7 ?6 \3 H
South Alabama Medical Center, Mobile, Alabama.
" r9 h9 @1 R: v6 B, hAddress correspondence to: Samar K. Bhowmick, MD, FACE,
: ]( K& n8 }/ \3 WProfessor of Pediatrics, University of South Alabama, College of
7 e# p) ^1 i5 n1 E+ U$ X7 V+ jMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( C' V( R) _, J6 E8 n5 i7 c
e-mail: [email protected].
5 }" K) b  N, u$ E/ x" dabout 6 to 7 months old, which progressively became
9 @6 ~, A  Y2 ^! q  Adarker. She was also concerned about the enlarge-
# W7 h9 A3 O5 fment of his penis and frequent erections. The child
) I* c9 ~$ Q0 b( d/ _! _was the product of a full-term normal delivery, with
/ J2 a/ H) ^) P4 Y) d/ ^a birth weight of 7 lb 14 oz, and birth length of
: P4 z. L% s4 \20 inches. He was breast-fed throughout the first year
- w6 J( p( V" P  k2 a; n4 v9 iof life and was still receiving breast milk along with& E) X0 P! `* x. _" |
solid food. He had no hospitalizations or surgery,/ l9 @5 L( A7 ]4 G+ _9 B% V# J
and his psychosocial and psychomotor development: _, }' a4 ~  }9 k
was age appropriate.' S$ F8 U0 K# p, R. l% [
The family history was remarkable for the father,4 @( S: i  @' @) q2 Z, l
who was diagnosed with hypothyroidism at age 16,
, C* F# i$ T# q8 }! P7 j5 Iwhich was treated with thyroxine. The father’s
3 {. Q+ |) D' Q3 y1 z- Z  mheight was 6 feet, and he went through a somewhat( R* l3 t, b$ Y
early puberty and had stopped growing by age 14.( g( l" [( T8 N6 V+ J' q- b
The father denied taking any other medication. The5 q3 I" L" R; z+ J8 M1 A- _
child’s mother was in good health. Her menarche3 I  ^+ G  f4 T
was at 11 years of age, and her height was at 5 feet! Q0 A7 {! l5 m' f
5 inches. There was no other family history of pre-3 ?6 _+ c# F7 z0 n
cocious sexual development in the first-degree rela-
+ B: c* D  s# R  C- Atives. There were no siblings.4 M, w4 T# O1 s: f
Physical Examination# j6 [9 c# Z# `0 T) |5 G$ W0 `/ S4 E
The physical examination revealed a very active,7 x+ F# i# B! A( D; O( @
playful, and healthy boy. The vital signs documented
, I' V+ k) i. ka blood pressure of 85/50 mm Hg, his length was; m, B  }* g. ?1 e$ w/ s; q
90 cm (>97th percentile), and his weight was 14.4 kg
0 H3 i! z7 p2 g+ K1 @6 n(also >97th percentile). The observed yearly growth
" h2 m4 u. S" G: hvelocity was 30 cm (12 inches). The examination of+ p9 J1 I: p7 t/ H4 i
the neck revealed no thyroid enlargement.5 |5 \; y' T, T
The genitourinary examination was remarkable for' S. D3 Y" ?% g
enlargement of the penis, with a stretched length of
2 U% D8 g( {9 N2 d8 k8 cm and a width of 2 cm. The glans penis was very well
4 p* R3 R5 b8 B9 kdeveloped. The pubic hair was Tanner II, mostly around) B- f7 t5 p2 f9 N. N, L
540
: _5 o0 I; Q1 S$ t! C# a1 A2 E  k. iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% B2 w0 T+ _7 r
the base of the phallus and was dark and curled. The
6 J: u) Y' l6 G0 n: ]$ ^! ttesticular volume was prepubertal at 2 mL each.2 q; Y% b& P' b: g% w' Q
The skin was moist and smooth and somewhat
. H+ Y+ I9 u. L# f0 C# }2 hoily. No axillary hair was noted. There were no, C* O1 Z* s3 D4 s
abnormal skin pigmentations or café-au-lait spots." T3 l6 L* k! \. K% T
Neurologic evaluation showed deep tendon reflex 2+
9 F' K( ]; \  c/ y( P8 sbilateral and symmetrical. There was no suggestion4 I+ k) H# N" D1 H6 B
of papilledema.
% V/ P" `& R( M/ k: H9 n. bLaboratory Evaluation
  Q# p0 }" ~4 C- G1 s5 n) C2 \: qThe bone age was consistent with 28 months by
3 x' P* t. R' f& Wusing the standard of Greulich and Pyle at a chrono-) B% V' i/ L! T! c9 y
logic age of 16 months (advanced).5 Chromosomal
# C/ y; ?2 \# e; h4 {. N1 Y4 L; Ckaryotype was 46XY. The thyroid function test) N6 j0 C& X2 M) g( t2 `0 N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# i6 I" C/ q  h! Y/ m% f
lating hormone level was 1.3 µIU/mL (both normal).
( C( L/ Y5 l9 L9 D/ {* lThe concentrations of serum electrolytes, blood
" V; @& H5 v2 q9 ourea nitrogen, creatinine, and calcium all were
) K  s, D/ s" R6 bwithin normal range for his age. The concentration4 {% u- ^$ k# D" F
of serum 17-hydroxyprogesterone was 16 ng/dL8 G& j% z5 z8 \! P" t
(normal, 3 to 90 ng/dL), androstenedione was 20! L% @$ A, c% |6 K5 }$ ^
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: b- |  A/ X! t# D. A$ h) E0 p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; e# B- y. f9 v
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ t9 t  _# w& T; s
49ng/dL), 11-desoxycortisol (specific compound S)
6 ?3 C5 ]: o0 d: C" gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. g5 y( @6 W6 @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 G) _+ M& o: R) a6 z2 F* rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),# ~8 s# w. Z& \* {1 o
and β-human chorionic gonadotropin was less than
1 p% H8 D. N  H; `, E/ ?  c% C( v5 mIU/mL (normal <5 mIU/mL). Serum follicular& C. P5 ~4 Q0 d7 O4 l3 l* w2 o
stimulating hormone and leuteinizing hormone% f6 }9 H. R: Q' p5 ^
concentrations were less than 0.05 mIU/mL& g8 E/ _5 n$ O5 ^* [5 \  a
(prepubertal).
# D% |. f' j0 B' C9 K; CThe parents were notified about the laboratory% P& I# N; @# {
results and were informed that all of the tests were: j  h- o0 }9 G  o, K! T# v
normal except the testosterone level was high. The
0 h% z5 j8 l* efollow-up visit was arranged within a few weeks to
1 `1 y7 g$ a# Y( x* uobtain testicular and abdominal sonograms; how-
6 m  q% ^  G/ v7 T4 [ever, the family did not return for 4 months.
- I) F1 ~2 h3 ^' v, l, R; ?& |Physical examination at this time revealed that the
* p% N0 [% z# @9 k# U4 fchild had grown 2.5 cm in 4 months and had gained# a+ S' I( x: Q- ?9 i8 ~
2 kg of weight. Physical examination remained
7 }. o" j6 x: m$ X) t. o1 I3 dunchanged. Surprisingly, the pubic hair almost com-7 t7 R& f0 Q! O/ S# ^& m/ T
pletely disappeared except for a few vellous hairs at
2 F2 Q! I* m2 k! ithe base of the phallus. Testicular volume was still 2
4 R5 P, i% z  _4 ?# g2 TmL, and the size of the penis remained unchanged.
1 S9 ~9 D  G3 \) `( X6 O& BThe mother also said that the boy was no longer hav-4 J" u9 o& o0 F6 d, {
ing frequent erections.3 s6 b# n  K3 P( v' |, H0 w! y' v9 {
Both parents were again questioned about use of
6 q2 V+ K2 h5 [8 d  qany ointment/creams that they may have applied to
/ j& f9 d1 |4 Y, C4 Vthe child’s skin. This time the father admitted the
: d+ ?; q, [: DTopical Testosterone Exposure / Bhowmick et al 541
) N( n5 Q5 V7 W0 Kuse of testosterone gel twice daily that he was apply-4 m9 Y" W" `& {: |/ i  ]: t
ing over his own shoulders, chest, and back area for" T& y1 h$ S/ p( ~
a year. The father also revealed he was embarrassed
* n& f: d0 A' `to disclose that he was using a testosterone gel pre-( g6 X- C" i0 s6 v1 {
scribed by his family physician for decreased libido
/ |2 h/ g" ]- D+ D/ o; Zsecondary to depression.
1 B( h! J) B3 C% h) G) UThe child slept in the same bed with parents.
0 d: y4 \% V" n$ W' @The father would hug the baby and hold him on his
. j8 J; G' b% r) k( ochest for a considerable period of time, causing sig-
* A, W# U6 h  a! B7 H' ^# k& d+ c' lnificant bare skin contact between baby and father., G6 [  F9 M$ q3 h2 l
The father also admitted that after the phone call,( r- `+ Q6 S! \
when he learned the testosterone level in the baby+ c+ {3 [8 f: P0 [4 H1 @# L
was high, he then read the product information* B+ ]( b( z  }1 P
packet and concluded that it was most likely the rea-5 ?  \4 w' `; s8 ~( `$ G$ c2 m
son for the child’s virilization. At that time, they9 I* ?6 _; f$ \, g
decided to put the baby in a separate bed, and the
/ p3 A$ n7 r; C: Gfather was not hugging him with bare skin and had
- d+ q% {  H) d4 gbeen using protective clothing. A repeat testosterone4 Z% m' a0 l1 A4 `' z' `
test was ordered, but the family did not go to the9 z9 o& [$ X6 p9 Q# E  C
laboratory to obtain the test.
( U% X/ p: @: P4 w$ J9 ]Discussion
$ N* `/ I$ W% E$ T% nPrecocious puberty in boys is defined as secondary
' v/ |# p$ F" i/ L2 p9 a1 r( Wsexual development before 9 years of age.1,4
0 p% m. C4 |$ fPrecocious puberty is termed as central (true) when7 ^. `' B& e: a. @& n: v
it is caused by the premature activation of hypo-2 n0 I8 n0 w+ E$ A, {& q1 ]# h( e
thalamic pituitary gonadal axis. CPP is more com-! v- v( e: A- W! ?+ W
mon in girls than in boys.1,3 Most boys with CPP" ?1 u/ K+ |# l) |* b% y- ^
may have a central nervous system lesion that is, }5 T" r8 _* d
responsible for the early activation of the hypothal-
9 {: G  d- C( }8 s8 @amic pituitary gonadal axis.1-3 Thus, greater empha-) R2 j: U6 V- K% g2 w7 F
sis has been given to neuroradiologic imaging in
+ ?  A# B& g) O6 n5 r; r% Lboys with precocious puberty. In addition to viril-% q  Y* p5 R0 D* t+ j
ization, the clinical hallmark of CPP is the symmet-5 F: `/ H' I% v6 s
rical testicular growth secondary to stimulation by# ?- A  F8 }  G8 a/ c
gonadotropins.1,3
/ a6 t1 r- f; q6 MGonadotropin-independent peripheral preco-
* I2 n8 ~( P# V  `" B" N: {' Ucious puberty in boys also results from inappropriate7 ~5 ^6 o8 x$ a1 B% D+ o
androgenic stimulation from either endogenous or1 _% h0 o1 `6 Z9 a9 B
exogenous sources, nonpituitary gonadotropin stim-
7 }( t+ M# l! sulation, and rare activating mutations.3 Virilizing) _7 C( Q8 J! j" V
congenital adrenal hyperplasia producing excessive
% L, S; q" Y3 S1 z$ ?adrenal androgens is a common cause of precocious9 z) X& S& w% C  t7 l0 Z9 v, a) V
puberty in boys.3,4
4 l  b! g" C0 |( @7 m$ BThe most common form of congenital adrenal. i, s1 D- p; ]1 q. O9 {8 R; M
hyperplasia is the 21-hydroxylase enzyme deficiency.
. C% `" r0 o( i8 T, h. HThe 11-β hydroxylase deficiency may also result in
3 f) |0 \" q+ E+ K) Jexcessive adrenal androgen production, and rarely,
4 M8 J. t# _# A# {  o$ V, Uan adrenal tumor may also cause adrenal androgen: P" w6 e( f  }- c
excess.1,3
9 V' }% ^& w% s% H% T- v5 Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, }; ^0 I% z) l5 m& L, h542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# u/ A5 w8 \4 V4 p' PA unique entity of male-limited gonadotropin-5 g. n' }6 f* L9 h
independent precocious puberty, which is also known
0 b2 S! U* Z8 x0 m% i+ [7 e3 W$ h8 Oas testotoxicosis, may cause precocious puberty at a
: V/ J" N8 I9 X, kvery young age. The physical findings in these boys6 E2 F7 ~* u8 N3 N3 M: Q( \
with this disorder are full pubertal development,
3 h4 L) Q/ Y, s: t  d) Lincluding bilateral testicular growth, similar to boys
' _7 y5 i* M8 _9 Awith CPP. The gonadotropin levels in this disorder# f! f. i7 n3 ^6 C
are suppressed to prepubertal levels and do not show
7 r+ l8 w! F& |$ M, Q7 B. @: \1 jpubertal response of gonadotropin after gonadotropin-
) a" ^) }5 E0 hreleasing hormone stimulation. This is a sex-linked
6 Y( T$ q4 _* h% }autosomal dominant disorder that affects only
* ]/ ~6 p! h) ~. p; \" f3 N7 q6 {males; therefore, other male members of the family
. r; ]3 ^! _2 k* r& Rmay have similar precocious puberty.3
  @8 `! r5 V( f: G  ?! HIn our patient, physical examination was incon-% l- k  K4 L0 l9 T' Z2 [7 q
sistent with true precocious puberty since his testi-+ v) h. E6 [* q% F& ]
cles were prepubertal in size. However, testotoxicosis( v( Y- h1 r- Y% l: h! J2 S$ s
was in the differential diagnosis because his father" y. t0 M9 K  x" f% N* M* |- i) D8 r
started puberty somewhat early, and occasionally,
  w$ l2 [  K% K! R* Otesticular enlargement is not that evident in the4 j* J2 z. m& T, Q
beginning of this process.1 In the absence of a neg-0 l' c% p+ ]+ O% o
ative initial history of androgen exposure, our
$ T& N5 b1 |' r3 c+ X5 w) Nbiggest concern was virilizing adrenal hyperplasia,5 w; j4 i3 ?7 n
either 21-hydroxylase deficiency or 11-β hydroxylase
5 d& t6 G6 q" ?$ D+ i# Z. Zdeficiency. Those diagnoses were excluded by find-8 S# N- \8 i* o: x- Q
ing the normal level of adrenal steroids.
) w2 ^8 B& i, p9 c; Y) dThe diagnosis of exogenous androgens was strongly: s3 f5 L! q6 g/ v. d0 _
suspected in a follow-up visit after 4 months because
# r6 J, P( `# X( o/ E0 \2 sthe physical examination revealed the complete disap-- r! ]' j9 D  h& i  I
pearance of pubic hair, normal growth velocity, and/ T2 n9 y$ f6 B* W5 L! |& y
decreased erections. The father admitted using a testos-
  {+ ~9 R3 t. X* Q: [& l. Dterone gel, which he concealed at first visit. He was
3 d: x- l# Q# H) T1 p) c9 [" ~" Tusing it rather frequently, twice a day. The Physicians’
- f& u4 i7 a  [1 U" [6 W$ yDesk Reference, or package insert of this product, gel or
7 w# c/ P% ~3 j7 N+ H# Scream, cautions about dermal testosterone transfer to; T" [& U, K  ~. v7 }  U; z7 s( H
unprotected females through direct skin exposure.& D0 t5 F) `6 R; q7 F* e9 I
Serum testosterone level was found to be 2 times the5 j( y, I4 ]& ]8 R9 Y" O
baseline value in those females who were exposed to! z8 o% F2 d5 x: `, h' T
even 15 minutes of direct skin contact with their male3 ~) X" D* K7 ]3 Z; ^0 s4 F# q
partners.6 However, when a shirt covered the applica-
' \4 r6 s$ I, I8 E$ Ftion site, this testosterone transfer was prevented.
) B  ]! W3 w7 {! X* xOur patient’s testosterone level was 60 ng/mL,( E0 l) n! v9 o  L3 \# r1 z, t
which was clearly high. Some studies suggest that4 c) b) I( u! T  ^! x. q  k" D
dermal conversion of testosterone to dihydrotestos-! [, b# _/ n. X; u9 D
terone, which is a more potent metabolite, is more" D: s$ C" x( S2 i
active in young children exposed to testosterone
  ?! d' N7 j4 X3 m4 a; r, B, }exogenously7; however, we did not measure a dihy-- W  t( n% [) M/ B) g5 f
drotestosterone level in our patient. In addition to
6 p1 s( G' L4 y0 i( m' a& C- ~virilization, exposure to exogenous testosterone in; w8 X. v  b1 p5 p! d( b3 i
children results in an increase in growth velocity and
' F2 Z  x3 k! R: h, Z2 |3 kadvanced bone age, as seen in our patient.
7 A7 ~& k0 w' `7 ?5 z& `+ N2 R2 xThe long-term effect of androgen exposure during" b0 Q: L5 v: [( F: ^
early childhood on pubertal development and final
# U$ k1 _" H! B' Vadult height are not fully known and always remain' ^) {8 R. i: I" y! K
a concern. Children treated with short-term testos-
) t+ S! i2 r6 i) U9 \9 ]7 @terone injection or topical androgen may exhibit some# q9 `/ p* H; {" Z3 c! h" c+ u- N
acceleration of the skeletal maturation; however, after
: Q" F4 G! N7 @  @( w0 D! X2 Q3 w, ~cessation of treatment, the rate of bone maturation
. r' ~/ A8 C4 J7 e% X: h8 pdecelerates and gradually returns to normal.8,9
; d3 ^. O: U3 w- q$ F5 m% \2 V+ RThere are conflicting reports and controversy
# y& [' E5 k' ~* I* aover the effect of early androgen exposure on adult* u; O& K/ q: P) Q! B. Z
penile length.10,11 Some reports suggest subnormal; z1 p+ `1 \3 M2 X
adult penile length, apparently because of downreg-
- N+ K- ]+ P- b6 V* |( ]% [ulation of androgen receptor number.10,12 However,+ Q  |- _, C3 L( c8 k8 n  E5 L* w# q
Sutherland et al13 did not find a correlation between
+ V, ]" j$ ^8 H' kchildhood testosterone exposure and reduced adult
& V& Y2 c8 `9 ]: e/ Ypenile length in clinical studies.6 T! Z/ a( q4 t% u! c. W+ n2 n$ i
Nonetheless, we do not believe our patient is7 i8 I# [, f5 b& Q. L
going to experience any of the untoward effects from
; R- _3 T7 k, c# I7 X' ptestosterone exposure as mentioned earlier because
! t$ L8 ]' o3 y! r: k# N3 Jthe exposure was not for a prolonged period of time.
6 @! j$ P- ~  o3 g& B( rAlthough the bone age was advanced at the time of( E. j0 A8 Q5 d
diagnosis, the child had a normal growth velocity at0 U$ L' G5 f. c/ E
the follow-up visit. It is hoped that his final adult: g0 ~+ k  U1 D' ^; B9 v2 S: E* j
height will not be affected.
* v# \/ O* j" }" A! C2 lAlthough rarely reported, the widespread avail-
- l6 d; U. g' c6 {ability of androgen products in our society may1 ~( p2 J$ a& R0 t& Y3 B7 Q# b
indeed cause more virilization in male or female5 H/ ?& @9 G2 w. H
children than one would realize. Exposure to andro-
4 R+ y- R2 E5 g' o% P: e  Q( t9 e3 T- Qgen products must be considered and specific ques-
: d0 G) S3 S2 H, g2 _# S5 rtioning about the use of a testosterone product or
; o  k# J' P2 ]+ u/ C. Ngel should be asked of the family members during
0 S7 J, I  A/ D" o1 }the evaluation of any children who present with vir-% `+ U1 G7 _) P* P
ilization or peripheral precocious puberty. The diag-
4 q7 u$ F% p& a) jnosis can be established by just a few tests and by
: x" C  k/ k( o( f  ]appropriate history. The inability to obtain such a
. e) N, |% G/ \0 ]2 g8 ahistory, or failure to ask the specific questions, may: g0 H- a, D7 R( R) l' Z9 A
result in extensive, unnecessary, and expensive
' y7 |) ~( W6 _6 s: D8 y) Finvestigation. The primary care physician should be- W0 {+ p( k5 H
aware of this fact, because most of these children5 }$ T5 _' H" k+ `; ^( |7 x. k( o
may initially present in their practice. The Physicians’
- I! {* H2 M$ x- QDesk Reference and package insert should also put a2 c' l- o0 P0 n# m
warning about the virilizing effect on a male or
; z7 n! K! w5 [! g5 zfemale child who might come in contact with some-
7 P# m1 F$ @' a1 Done using any of these products.
  q* [+ a5 Z# Y, s( ^References  v" N. o7 f+ ?: N( l, q
1. Styne DM. The testes: disorder of sexual differentiation
/ `$ p% \8 d& q7 Xand puberty in the male. In: Sperling MA, ed. Pediatric7 F) R' l2 f1 T0 \# }
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: ~& _: q8 |* ?3 W3 r4 N2002: 565-628.1 P7 T" h2 L) ~7 J' Q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 [, R9 h5 }' ]/ e, x$ npuberty 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

& ?% Y6 o% D: W, N4 m1 |' w8 H  r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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