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Sexual Precocity in a 16-Month-Old; ^5 i, a( x) Y+ g# y0 D
Boy Induced by Indirect Topical8 Y% Z& Y+ \0 g2 @
Exposure to Testosterone
/ p, t- J8 m! R; A7 tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 g* ~) |; h# n5 T/ `4 land Kenneth R. Rettig, MD1
* @5 N9 V: q6 P& ]8 M3 xClinical Pediatrics: z$ k; U- g& d  N( K
Volume 46 Number 6
& _* G" S! a; W* m9 z1 hJuly 2007 540-543
4 a, S; Q- o0 c( C- L* Q5 i© 2007 Sage Publications* C3 N* C( i# H- K. M6 f# T
10.1177/0009922806296651
, [# Z3 }: w6 ~3 z% Hhttp://clp.sagepub.com4 s" j0 b: ?0 a( y' k
hosted at
, d9 \/ K7 f$ U# Y& k0 v# Xhttp://online.sagepub.com; x  Y, ^& t4 i% Y7 _# T5 X" p% i' \. b
Precocious puberty in boys, central or peripheral,2 @. n* V: R% m& ~
is a significant concern for physicians. Central' y- H1 L: L" ^6 V3 N. M
precocious puberty (CPP), which is mediated  f8 V" E) @* ^' E
through the hypothalamic pituitary gonadal axis, has& B+ I$ N" C& _4 M  a) z3 k4 A
a higher incidence of organic central nervous system1 @  K1 E4 F5 [' j4 i
lesions in boys.1,2 Virilization in boys, as manifested( y8 y- V5 K5 Q6 d
by enlargement of the penis, development of pubic+ m) T+ Q" N- |' c
hair, and facial acne without enlargement of testi-3 ^9 c* k) o7 g. w
cles, suggests peripheral or pseudopuberty.1-3 We% m/ Y* |: H- H. n
report a 16-month-old boy who presented with the0 p4 I2 B% Q: @! m& k
enlargement of the phallus and pubic hair develop-* h- q6 F1 ~. J/ p
ment without testicular enlargement, which was due
% C' T0 [4 ]. I/ g9 `to the unintentional exposure to androgen gel used by
8 Y* Y+ C/ Z; ?8 H/ Y  K/ n0 Nthe father. The family initially concealed this infor-
: M6 Y5 q. b6 }. A& y3 i/ f* ^* Kmation, resulting in an extensive work-up for this
# D; W) I* `- [: {- w9 Mchild. Given the widespread and easy availability of- m" {0 N- u2 q8 A1 ]
testosterone gel and cream, we believe this is proba-9 B, J: d- y5 L# Z' g& L
bly more common than the rare case report in the( {3 G) i, i5 w3 @. ~# D
literature.4& S2 R+ j7 k% b5 B7 q1 f& R1 n- z
Patient Report
+ y. H7 d1 v7 ~* H# R0 \A 16-month-old white child was referred to the9 A7 \' I. u6 `- U
endocrine clinic by his pediatrician with the concern# n' q9 P7 q! @4 ^: X6 I
of early sexual development. His mother noticed) s6 e, s$ _9 O- E% ~- C' H; F
light colored pubic hair development when he was
6 E# _" \; R' f% u  ~3 U6 yFrom the 1Division of Pediatric Endocrinology, 2University of
0 y7 d# E( W. ?  M* m7 Q2 C8 W2 A6 n0 zSouth Alabama Medical Center, Mobile, Alabama.7 V: U6 r) j. j; {# ?1 }
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' |5 K5 ~4 B! h( uProfessor of Pediatrics, University of South Alabama, College of4 ?; D) Z) e1 h0 j( |9 `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! @+ @4 U. H6 N8 T6 ]
e-mail: [email protected].
( H5 ~3 ~/ i  L( B- w4 r! v" g/ `about 6 to 7 months old, which progressively became8 p8 @  T- `  ]5 e! D9 v
darker. She was also concerned about the enlarge-
0 c0 v9 `8 z3 r0 l) m8 Qment of his penis and frequent erections. The child
' ?* S  G& F9 E0 u8 Z  Cwas the product of a full-term normal delivery, with3 q( ^, ?( q, Z: l! }
a birth weight of 7 lb 14 oz, and birth length of
  v% m# d7 }2 v$ p( y20 inches. He was breast-fed throughout the first year) Q5 F; L9 v9 j2 @
of life and was still receiving breast milk along with8 \  P  ^6 G1 \: x( Y0 [2 Z
solid food. He had no hospitalizations or surgery,- n* ?* E1 k. }- n
and his psychosocial and psychomotor development; }* h/ p( ?* y. g- W1 H
was age appropriate./ E# S" M7 T$ O* R+ |/ g
The family history was remarkable for the father,
, I5 S$ L6 b5 `, p3 Gwho was diagnosed with hypothyroidism at age 16,, V; L6 v% L3 _) u9 E
which was treated with thyroxine. The father’s
) {2 g) x- n9 c% Eheight was 6 feet, and he went through a somewhat
1 d8 a" H2 T7 s' v1 a9 U5 g9 ], Y1 W5 Vearly puberty and had stopped growing by age 14.% ^8 |0 J9 i8 E3 e3 n9 F3 W+ d: J" R
The father denied taking any other medication. The+ P0 [2 m, u! h! q' j
child’s mother was in good health. Her menarche
3 ?& @8 B/ `& f! pwas at 11 years of age, and her height was at 5 feet
% Y8 ^% S9 h3 A& C% E5 inches. There was no other family history of pre-
7 v7 ?. n" Z3 @% k+ t& Vcocious sexual development in the first-degree rela-# B# ^2 Y9 P- a4 b
tives. There were no siblings.
$ F! ?, [$ A$ @4 JPhysical Examination
0 N# a( k+ v1 j: OThe physical examination revealed a very active,
  Q  K+ y6 x0 Q  Q; n# ?/ Pplayful, and healthy boy. The vital signs documented7 {5 g8 A7 r3 B+ E: \' W
a blood pressure of 85/50 mm Hg, his length was% n/ g: [( F4 s% e; e* V# n, Q
90 cm (>97th percentile), and his weight was 14.4 kg
2 Y. \" n& g& X& k7 Y(also >97th percentile). The observed yearly growth; P' b; S; L$ W
velocity was 30 cm (12 inches). The examination of- \6 E8 V- D* M  Y
the neck revealed no thyroid enlargement.
2 x$ g! D3 k6 [& e7 i! sThe genitourinary examination was remarkable for- U  X3 `6 Z! N! I+ G+ h) Q
enlargement of the penis, with a stretched length of7 Z# }7 F. j* o' O; d6 p' n  K; R
8 cm and a width of 2 cm. The glans penis was very well
( y) E' O( o( e5 g$ L8 qdeveloped. The pubic hair was Tanner II, mostly around+ i8 d9 q( _3 K( u5 K# W$ V8 D
540
: _5 [; C/ i. _0 Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 a5 O: Z1 F! X) z" L' |the base of the phallus and was dark and curled. The. a& U" `# @4 B; S2 m* V* K7 s; f
testicular volume was prepubertal at 2 mL each.0 ^* Z& W" ]6 m+ O6 j
The skin was moist and smooth and somewhat: h, }3 l. A& w" e2 l/ ]  M: J. Z; q
oily. No axillary hair was noted. There were no
* @" N1 H8 R, P: y8 dabnormal skin pigmentations or café-au-lait spots.9 x( W- d! S  O+ ~' O
Neurologic evaluation showed deep tendon reflex 2+
' S6 F+ ^; Z( l* u( Fbilateral and symmetrical. There was no suggestion
( q# C: b; O! `3 e; uof papilledema., C0 M9 |0 s2 V9 G- F/ I4 L
Laboratory Evaluation
0 W9 ]5 Q2 j$ j' H1 K1 }" G; UThe bone age was consistent with 28 months by! Q2 P* W) G, z) |2 G5 [* K
using the standard of Greulich and Pyle at a chrono-2 ~9 m. S  s6 j2 j9 ?
logic age of 16 months (advanced).5 Chromosomal
2 C9 T3 C1 z7 a0 N! w$ Vkaryotype was 46XY. The thyroid function test: H, y* _6 c. v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: ?4 `) s% c6 z% A4 plating hormone level was 1.3 µIU/mL (both normal).6 b1 s- D, ]4 U8 o5 j8 o
The concentrations of serum electrolytes, blood
, U" i- Q; i& O" i/ lurea nitrogen, creatinine, and calcium all were
& ?6 E' q7 p6 G9 p; {within normal range for his age. The concentration! }8 L/ d7 v2 s7 R3 U
of serum 17-hydroxyprogesterone was 16 ng/dL9 U' K; R" [: P( V( {" y
(normal, 3 to 90 ng/dL), androstenedione was 20
" o7 N# E, k( \8 F9 o) p, wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% k# k. c7 E# x+ R# nterone was 38 ng/dL (normal, 50 to 760 ng/dL),- w4 i2 j, o: u
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ P; r7 m, }$ V% s+ f  W/ a49ng/dL), 11-desoxycortisol (specific compound S)
7 q! n/ G3 x  u' ]! f" j! pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; b0 [  x0 a6 ]0 X* H+ R4 }, atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# z9 K1 E9 p9 w0 Wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 c0 i/ i/ v5 u$ {and β-human chorionic gonadotropin was less than  t6 W" b3 _6 {4 q
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 i  Q2 N8 s8 i" f" G
stimulating hormone and leuteinizing hormone+ J- J" x) f0 G# G9 @9 v
concentrations were less than 0.05 mIU/mL1 P8 _) q# s7 y0 }$ R' a
(prepubertal).2 B5 m$ C" O4 x  C0 F* O4 r# A
The parents were notified about the laboratory' m' O6 J0 q- I/ r1 q' z- ?
results and were informed that all of the tests were
) q- y) S4 g2 y0 x) N9 E. |normal except the testosterone level was high. The- H" d% q- y1 i
follow-up visit was arranged within a few weeks to
1 `) x5 u! a) ?" o/ Fobtain testicular and abdominal sonograms; how-- Y* \6 @/ f0 J- f" u
ever, the family did not return for 4 months.% h- z, W$ T) w" w) [+ ~
Physical examination at this time revealed that the
; R  m* v$ H3 h+ P6 w4 qchild had grown 2.5 cm in 4 months and had gained9 I+ ]8 q5 x) G
2 kg of weight. Physical examination remained
. c5 P5 A+ F- J" z# B" Hunchanged. Surprisingly, the pubic hair almost com-
6 B) c; _; j2 c" v9 upletely disappeared except for a few vellous hairs at
( ]+ P9 l, Z% I; A# rthe base of the phallus. Testicular volume was still 2  w0 W- Q. Y9 Q0 c7 H
mL, and the size of the penis remained unchanged.
# N. l, A: ~, t- _: J5 o* uThe mother also said that the boy was no longer hav-% S" @- j# j( }7 a0 n$ @8 ~" j" @$ A
ing frequent erections.' ?9 a# k- e3 F6 p& o2 H
Both parents were again questioned about use of( w$ \( A; {" Y# ]$ ^7 M9 S2 ]
any ointment/creams that they may have applied to
, ~& ^+ I! ?! y% v4 Ithe child’s skin. This time the father admitted the
0 d2 K8 a0 i: D. K; j2 H& MTopical Testosterone Exposure / Bhowmick et al 5414 A' F! g" F. [5 ^) N( N9 q6 k
use of testosterone gel twice daily that he was apply-" |# K+ `; x  K7 D3 `
ing over his own shoulders, chest, and back area for
3 p; |: S- i6 W3 [$ P9 pa year. The father also revealed he was embarrassed2 M6 D+ G9 l8 I9 ~6 T
to disclose that he was using a testosterone gel pre-
, Q9 n7 O, K. w  o% t' e. B8 Xscribed by his family physician for decreased libido
+ l8 b2 G0 e* v/ l6 D0 J: xsecondary to depression.# A( G( a0 u0 I- }
The child slept in the same bed with parents.
. X$ T6 \; X  O) A- eThe father would hug the baby and hold him on his
( ~( U9 f+ n, h' F( E8 c) [' \chest for a considerable period of time, causing sig-
8 W7 o2 e' a; B: U2 z- p+ Onificant bare skin contact between baby and father.
! l5 E1 |/ W0 W3 C& Y: m" Z( YThe father also admitted that after the phone call,
- k# C/ I5 ^) ]" L+ `5 Fwhen he learned the testosterone level in the baby
. r* G8 X; p: u: V+ B: fwas high, he then read the product information
/ G9 V. d$ O- A1 T, ppacket and concluded that it was most likely the rea-5 v4 a  v% v6 j& E5 o
son for the child’s virilization. At that time, they% c, T) {+ Z; B  F. ?& E% Y
decided to put the baby in a separate bed, and the0 |( v/ b1 `; y. o8 y+ ]  h( z' o. }
father was not hugging him with bare skin and had
  B: V2 G# t, u. ~* Xbeen using protective clothing. A repeat testosterone4 y; v5 M( J1 R# P  ~
test was ordered, but the family did not go to the
. d4 f* ~1 x* F/ v+ |laboratory to obtain the test.; T  {0 d6 I# \* l" a7 e5 [
Discussion
' R, C2 J+ e& H: h& a# nPrecocious puberty in boys is defined as secondary0 R1 W( v$ J$ ~
sexual development before 9 years of age.1,4
, P; z; l: B$ a$ p4 \9 RPrecocious puberty is termed as central (true) when
* Q8 C! e$ l7 V* s- nit is caused by the premature activation of hypo-# ?, i( T: Y4 U- ]$ t* r( {* v
thalamic pituitary gonadal axis. CPP is more com-' d3 O/ X, i% s3 W6 }* u
mon in girls than in boys.1,3 Most boys with CPP6 T% J% z' c4 z% p0 O! y! u0 H
may have a central nervous system lesion that is
7 _, G' I0 _& `+ N9 c' H# V# Bresponsible for the early activation of the hypothal-" F5 q3 R- u& q9 N! w3 g5 W9 Z+ j) P' m
amic pituitary gonadal axis.1-3 Thus, greater empha-
* i4 ~& \  C8 u2 |( gsis has been given to neuroradiologic imaging in
$ T: S( ~3 \2 gboys with precocious puberty. In addition to viril-
3 t% A6 a/ e( _/ i8 ^) }9 i8 p( ~ization, the clinical hallmark of CPP is the symmet-
6 n$ s3 R: x/ |4 srical testicular growth secondary to stimulation by5 }, j2 A; T5 _+ M& G
gonadotropins.1,3% X! ^: a- H- o7 Z8 z
Gonadotropin-independent peripheral preco-
$ v- f* U2 W' {cious puberty in boys also results from inappropriate" Z; ?' q1 U% I4 I. M$ T
androgenic stimulation from either endogenous or
. k, g4 |5 t& t# ~0 j$ Oexogenous sources, nonpituitary gonadotropin stim-
$ x1 \  m- f* v, {. ~2 iulation, and rare activating mutations.3 Virilizing# I& C# J6 y( J
congenital adrenal hyperplasia producing excessive: n* t2 i% o( y* {9 a/ p
adrenal androgens is a common cause of precocious
  j4 m# ^7 p% n4 T3 k/ K  `2 Bpuberty in boys.3,4# }) y0 x) X( @" e
The most common form of congenital adrenal
5 s* s# K% S" Q- \6 }  }hyperplasia is the 21-hydroxylase enzyme deficiency.- r! I5 }6 l$ Q
The 11-β hydroxylase deficiency may also result in
' v0 c: A5 F$ m( G$ u& Mexcessive adrenal androgen production, and rarely,
$ C! O- W, p9 T$ _/ g% Z+ Ban adrenal tumor may also cause adrenal androgen
) Q' y- Y* z% c4 Uexcess.1,32 Y; B( j$ c* Q: u  h$ z9 t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! v  |; b) E7 \: X: k3 W5 K/ G542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 H/ O) Z( K5 c9 R" q
A unique entity of male-limited gonadotropin-
  V2 o( k+ _+ _) c1 |independent precocious puberty, which is also known8 l( C  f. N7 Q; V7 A2 [
as testotoxicosis, may cause precocious puberty at a
, O3 a) X1 r, a9 v) Xvery young age. The physical findings in these boys1 H' D6 a8 s( N. ]& g+ I% Z5 p
with this disorder are full pubertal development,& @5 z* F0 u- y# ]8 q3 O8 v( `
including bilateral testicular growth, similar to boys9 |/ p2 x& A) H2 j
with CPP. The gonadotropin levels in this disorder& `/ A5 ^4 S; t& H4 a+ q
are suppressed to prepubertal levels and do not show
" V2 }! h& _" c# ^7 B; [1 G: Tpubertal response of gonadotropin after gonadotropin-
! i/ Z. ^1 K, g5 m% ]7 Preleasing hormone stimulation. This is a sex-linked* h1 A! X3 `( }& l9 \* Z9 a6 I
autosomal dominant disorder that affects only
# V/ b8 Q9 ], k  j# ~: \! ^males; therefore, other male members of the family3 l+ D9 J9 J* {3 U
may have similar precocious puberty.3& `+ U5 u  O, R* k
In our patient, physical examination was incon-
* G$ t3 A' q2 _6 g" Gsistent with true precocious puberty since his testi-
; O. E' B. Y: _8 b' u: tcles were prepubertal in size. However, testotoxicosis; ~, r8 N# R$ p  u5 _
was in the differential diagnosis because his father
3 M8 I/ Y- [2 U* {started puberty somewhat early, and occasionally,
' U1 X, w/ }( A+ t1 }% |) q0 Utesticular enlargement is not that evident in the) g: S" W" S3 X* s2 @
beginning of this process.1 In the absence of a neg-- J5 X4 k! \7 P4 s9 X4 X
ative initial history of androgen exposure, our
$ ]3 M% G" a; f* x: c& Cbiggest concern was virilizing adrenal hyperplasia,  T0 C+ o* ]- r6 b5 a/ S1 x) ]
either 21-hydroxylase deficiency or 11-β hydroxylase
5 C, f4 U8 S% ?0 U+ U0 edeficiency. Those diagnoses were excluded by find-; l8 [7 ?- e; E; I: j+ \
ing the normal level of adrenal steroids.
1 w) T$ E# I' eThe diagnosis of exogenous androgens was strongly# @  W; J1 w7 O3 Q5 W, N
suspected in a follow-up visit after 4 months because
$ ]- I  i0 P& z, n, |the physical examination revealed the complete disap-
) X: i1 ~0 k; O' Cpearance of pubic hair, normal growth velocity, and6 s) j6 ?6 N# ?- W* r9 Y
decreased erections. The father admitted using a testos-
2 D2 o9 x6 g% ]. Vterone gel, which he concealed at first visit. He was4 Z) W; W3 }0 t1 M3 E4 o
using it rather frequently, twice a day. The Physicians’$ g4 F9 h8 y; F  Z2 e4 M
Desk Reference, or package insert of this product, gel or7 N2 A) O2 Q9 h$ b
cream, cautions about dermal testosterone transfer to
) u2 U$ E5 v* H  P' H# bunprotected females through direct skin exposure./ v3 Y5 a" Y" S$ ?9 A) F
Serum testosterone level was found to be 2 times the
+ ^' a% R1 y( d. h4 p2 _2 jbaseline value in those females who were exposed to
6 o0 k3 m& V+ y, Y& [even 15 minutes of direct skin contact with their male; ?7 D3 c0 _( t! Z; ?; j, r/ Y' [4 ~
partners.6 However, when a shirt covered the applica-' c) T3 a( {: p9 z4 M, o# D4 `' }
tion site, this testosterone transfer was prevented.) g% y% x4 N* ^
Our patient’s testosterone level was 60 ng/mL,6 w& W" L- E; c1 G
which was clearly high. Some studies suggest that
( I) m% A+ W) \" C- jdermal conversion of testosterone to dihydrotestos-' a$ |  [( n& u# s
terone, which is a more potent metabolite, is more' c# s% [/ V% N0 _0 W, P
active in young children exposed to testosterone/ E* {! O) F6 \* f' d% p! S& _* z
exogenously7; however, we did not measure a dihy-9 B0 A, T$ Y8 ^8 y* `, B
drotestosterone level in our patient. In addition to  S+ b2 m0 a, T% `# `5 a9 m6 K) c9 e
virilization, exposure to exogenous testosterone in
5 i, x4 b$ V5 W$ dchildren results in an increase in growth velocity and% U( M9 U; Z( H  b7 J; B. S% Q
advanced bone age, as seen in our patient.# }- F: E" }- h: J' ^, P
The long-term effect of androgen exposure during
" N/ K2 |' B( o, V: F# a5 [early childhood on pubertal development and final- S7 Y- S* i0 k8 G
adult height are not fully known and always remain; X3 ]( E6 O6 j( M! x5 T$ n+ c, d
a concern. Children treated with short-term testos-  B4 S7 L+ M8 e  v
terone injection or topical androgen may exhibit some
) p) H1 R! O% u) n) e7 e2 T# yacceleration of the skeletal maturation; however, after' J' p/ r+ K# p9 N; `) l
cessation of treatment, the rate of bone maturation
2 T  I6 V/ h% ^3 ldecelerates and gradually returns to normal.8,98 ]3 L* C2 J9 j" R
There are conflicting reports and controversy
* F* k0 W, H$ J5 d# W) l" _over the effect of early androgen exposure on adult
8 h6 g5 {3 b* M9 openile length.10,11 Some reports suggest subnormal
5 D5 D! y5 \0 Ladult penile length, apparently because of downreg-
! {9 }2 N) q, J4 S$ U# Culation of androgen receptor number.10,12 However,( J9 i) f& v, Y2 X6 Z  b
Sutherland et al13 did not find a correlation between
" t% h+ ]+ U8 ]- mchildhood testosterone exposure and reduced adult
, D) d# {; l, d- ypenile length in clinical studies.1 s( g" z5 g  b
Nonetheless, we do not believe our patient is
0 H3 C7 e: Z. Q; N/ O1 egoing to experience any of the untoward effects from
- j1 O- c3 R6 k+ c* Ntestosterone exposure as mentioned earlier because8 {; K9 f* [* O9 f2 ^# M) @# w0 ]
the exposure was not for a prolonged period of time.
3 Q( E* g  x; @1 L. P5 z& i# }Although the bone age was advanced at the time of4 t+ b8 e: l6 I& b+ J5 D9 x( W
diagnosis, the child had a normal growth velocity at
9 \; s* ~! v) G" B+ g3 zthe follow-up visit. It is hoped that his final adult
# o7 R8 h, q  c) ]( ]) Q. s2 fheight will not be affected.4 k$ A  z: _0 @: S& ?+ E
Although rarely reported, the widespread avail-  z7 P' f& {( d0 u" b& k( f
ability of androgen products in our society may
1 T: Y) y# X9 j/ A- m, xindeed cause more virilization in male or female
5 J6 K: [' p$ K# Z  q7 L& A9 @0 \children than one would realize. Exposure to andro-
+ x3 K' W2 A8 W! Y. ~gen products must be considered and specific ques-
! O: W" v( l9 _tioning about the use of a testosterone product or5 c/ _( Y: D* x  D" e6 z
gel should be asked of the family members during
$ R: T) |/ _; H% A( @6 |the evaluation of any children who present with vir-, v6 X0 b$ o, s- ^' t& ~  ~
ilization or peripheral precocious puberty. The diag-" U( Q2 T$ w, k+ K  y
nosis can be established by just a few tests and by
+ ~  B6 T; ]# I, Aappropriate history. The inability to obtain such a
  t4 A2 H1 X  j& B' @: ohistory, or failure to ask the specific questions, may
. g3 }% `; x1 ^, ^result in extensive, unnecessary, and expensive
, S, L) ]: x, S7 ^; ~6 H- {investigation. The primary care physician should be
6 H/ q7 w3 E+ l2 Saware of this fact, because most of these children
; ~7 e( a; V# J& s3 Rmay initially present in their practice. The Physicians’+ k6 t( j6 q; F( Q* g( q& [) W0 U
Desk Reference and package insert should also put a6 K" _& e* [  }4 f" ^+ j
warning about the virilizing effect on a male or
6 f$ t5 U: _( x& d3 V# Afemale child who might come in contact with some-. c. _5 o$ }3 q5 `6 E! ]+ B
one using any of these products.
9 w. H0 O! [. w1 YReferences+ A1 j, R. O9 g
1. Styne DM. The testes: disorder of sexual differentiation
3 B; E4 d7 F" N9 m* i3 U) oand puberty in the male. In: Sperling MA, ed. Pediatric5 X; M3 q, }: x+ d* R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' l3 O+ G* i) {% E& a2002: 565-628.8 K0 u. G! o0 T! E
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 g! f( U& z8 p' T2 O! p& F
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old( `" L8 J' j/ T, N' A$ b1 u
Boy Induced by Indirect Topical, `# `5 D/ ?- F" i+ g
Exposure to Testosterone8 h! \* t3 z/ t9 G/ |" n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( A+ ?" d8 D, s1 F0 x8 s6 X1 G& Kand Kenneth R. Rettig, MD19 P4 v4 g% [6 f& I
Clinical Pediatrics6 {3 f, {( ]$ A! {  B
Volume 46 Number 6
6 L  |* ~0 ]. `( P$ k2 gJuly 2007 540-543, I9 [$ z4 ^6 b- D% ]9 B( S
© 2007 Sage Publications& R! H% G5 s5 @' |% c; w
10.1177/0009922806296651& K4 l1 o3 m4 Y9 l* e/ F% W2 d
http://clp.sagepub.com
# q4 o+ ]/ p' s& Y7 E, Khosted at6 ?9 ~" o+ V. z* B8 L) P% h) K( p
http://online.sagepub.com4 z. T- b2 w: p0 x2 d7 ?# C1 s6 c
Precocious puberty in boys, central or peripheral,' Y8 C# y2 s& {, e
is a significant concern for physicians. Central
! s) I( i, K& o5 o- I  s3 J$ a' @$ Qprecocious puberty (CPP), which is mediated* h- _3 }; p* c% k* |' `* L
through the hypothalamic pituitary gonadal axis, has9 p3 l& |( j' o3 j6 ^
a higher incidence of organic central nervous system
& G4 ^5 K' X! C3 M" ?$ Z4 tlesions in boys.1,2 Virilization in boys, as manifested
2 O7 K; ?1 [5 R/ V$ A7 pby enlargement of the penis, development of pubic
  O" t* a# h- {& [hair, and facial acne without enlargement of testi-, i! O( U+ @" {3 u; B4 V. j
cles, suggests peripheral or pseudopuberty.1-3 We( }# k) F" @+ g' w, Q
report a 16-month-old boy who presented with the4 D3 O, D3 @# t% b! G
enlargement of the phallus and pubic hair develop-* V- s- k9 k  A, [# F3 l
ment without testicular enlargement, which was due
: O) V( q* ]5 H% i7 Wto the unintentional exposure to androgen gel used by% A  k6 q' V6 v; {4 K/ ?$ Q$ i
the father. The family initially concealed this infor-3 K2 K4 y/ `: h
mation, resulting in an extensive work-up for this
. }0 y6 n6 p9 w2 D% W. schild. Given the widespread and easy availability of
  z4 Y; j$ h3 p2 F2 F1 }+ ftestosterone gel and cream, we believe this is proba-. k. ^6 a/ k3 @7 F
bly more common than the rare case report in the1 V. B/ J) @1 ^, t6 j5 R* w- C( C
literature.4+ a3 a; G0 {- U5 E$ g
Patient Report* V% q* [) u5 U. \2 @9 t
A 16-month-old white child was referred to the
  V1 r# l4 k& x' }endocrine clinic by his pediatrician with the concern
# ]0 b8 W6 V- ~8 h$ s/ A( gof early sexual development. His mother noticed
$ u0 ^# f" X/ R" z; Clight colored pubic hair development when he was2 T, A  w9 T" }. a7 j. B
From the 1Division of Pediatric Endocrinology, 2University of
0 t8 L' R8 J* U1 o5 ]South Alabama Medical Center, Mobile, Alabama.
7 g$ N! f' j" b9 C$ ]. TAddress correspondence to: Samar K. Bhowmick, MD, FACE,& P' `+ Z+ E6 D- ]4 C& T
Professor of Pediatrics, University of South Alabama, College of
, a3 |. Y* R- f/ [4 vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 \. ]: f; [0 ^- X; a/ Qe-mail: [email protected].% H1 y* h4 T! M; _( s; B: N9 `$ A
about 6 to 7 months old, which progressively became
' Y% ~' @7 c1 L. Xdarker. She was also concerned about the enlarge-" h8 [/ v1 k$ L9 ]" y- {
ment of his penis and frequent erections. The child
& U1 m& z0 M4 Z& n- |; Wwas the product of a full-term normal delivery, with
$ E! Z7 L# w# F! y! Xa birth weight of 7 lb 14 oz, and birth length of: [8 L- E0 O# n7 o9 s# A- ?
20 inches. He was breast-fed throughout the first year
; }6 O+ I, b2 ^1 f) a0 z! ?* |  Yof life and was still receiving breast milk along with+ V. U$ u2 A# |/ [: @" j/ [5 k
solid food. He had no hospitalizations or surgery,% s# J. E' T8 |& T7 E
and his psychosocial and psychomotor development2 g6 ^2 x5 X! y- R8 U, z, h
was age appropriate.
4 N1 n. \$ M! @. jThe family history was remarkable for the father,8 M2 ], c7 [; B; m6 F
who was diagnosed with hypothyroidism at age 16,0 e* K1 [( q- s* ~0 Z
which was treated with thyroxine. The father’s# L( N. s- Y" C
height was 6 feet, and he went through a somewhat8 Y1 Y: ^- n" ~- L1 v
early puberty and had stopped growing by age 14.
; `! [$ N" R0 {" L: b, tThe father denied taking any other medication. The
& A6 x9 G$ ~: r4 W4 Q" pchild’s mother was in good health. Her menarche5 E5 q6 f  v9 L' v9 \
was at 11 years of age, and her height was at 5 feet5 s6 @7 x, `1 o# `7 j
5 inches. There was no other family history of pre-
5 ^( c0 W' q3 Q" @1 a5 ]cocious sexual development in the first-degree rela-
" m; ]5 {; G9 a6 v" `tives. There were no siblings.
8 }7 w9 b" e% \8 j  u8 Y+ SPhysical Examination
9 k& B: {: w7 M. ^9 aThe physical examination revealed a very active,
* m- }; p% Q8 A# ?$ |: b) J4 uplayful, and healthy boy. The vital signs documented
' U8 h6 a( U# L- F' ?a blood pressure of 85/50 mm Hg, his length was; t8 }7 t: m5 A0 r
90 cm (>97th percentile), and his weight was 14.4 kg
# N9 R& [5 U/ ~2 y8 T0 B: ^(also >97th percentile). The observed yearly growth, V" M, q" E7 Y- i2 o8 [0 h  s
velocity was 30 cm (12 inches). The examination of4 K% S  N# t0 w* L0 s
the neck revealed no thyroid enlargement.
% U% e7 a# m' q# X, xThe genitourinary examination was remarkable for0 S" P( \$ W  `4 g
enlargement of the penis, with a stretched length of
1 @! b1 w0 |/ ?2 s% O; f6 D; A8 cm and a width of 2 cm. The glans penis was very well* w' j* }' j4 g# N+ k7 [5 M
developed. The pubic hair was Tanner II, mostly around
' d0 A: b! |; w6 y( v/ O  z! @540( C) g9 r5 x5 U6 G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. t( G4 ]; ]  {5 a6 athe base of the phallus and was dark and curled. The
0 L& Y$ j6 B6 x6 y8 }" itesticular volume was prepubertal at 2 mL each.
3 y% L" g3 f! bThe skin was moist and smooth and somewhat% Q: Q2 x, P( v5 ]( J$ P; y
oily. No axillary hair was noted. There were no
' u, F+ j- l7 Y2 p5 yabnormal skin pigmentations or café-au-lait spots.
- `; @  M4 @+ J" I+ xNeurologic evaluation showed deep tendon reflex 2+
, A& \6 }) T, Q7 r% M! O* gbilateral and symmetrical. There was no suggestion
: S# T/ p/ k  d7 b. b+ m: Jof papilledema.
; U& I" x  T4 G3 ^! MLaboratory Evaluation
1 d9 |7 q, F5 X) G( {% LThe bone age was consistent with 28 months by+ ^# _' _0 [% I! u% o9 h* z  \
using the standard of Greulich and Pyle at a chrono-
, {2 v2 V8 E+ z# Clogic age of 16 months (advanced).5 Chromosomal% Y' |* B% P# Y* v
karyotype was 46XY. The thyroid function test8 N* H( M; j. H/ f
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
; N! z1 M  H" K. v% h+ ylating hormone level was 1.3 µIU/mL (both normal).0 Y  K7 z" G- v5 ?8 W3 R! J5 f( \
The concentrations of serum electrolytes, blood' J! X9 z  b4 i: z" H5 `4 }2 S
urea nitrogen, creatinine, and calcium all were
7 V: @7 B- {/ D' k& ^within normal range for his age. The concentration
, p' x0 \$ P$ j2 g% t2 m; Tof serum 17-hydroxyprogesterone was 16 ng/dL# z! s, N7 n8 P/ F( U& p
(normal, 3 to 90 ng/dL), androstenedione was 20
8 S( s7 @1 u2 T8 j- t. f$ ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: t8 c  h( B& Y! E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 U7 e4 }; t0 m0 Q- udesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 {! ?% U3 P5 e
49ng/dL), 11-desoxycortisol (specific compound S)0 c3 n+ f6 h: u; [/ p! v3 [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ @  J( v8 e$ Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 r& O( U  a) e% v! f6 B8 g. s5 etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 V# f$ F. z1 t, }' xand β-human chorionic gonadotropin was less than
9 ?/ @" q2 L" B! h5 mIU/mL (normal <5 mIU/mL). Serum follicular! w1 g, @. u$ q  ?7 T% J# j
stimulating hormone and leuteinizing hormone4 N3 A& s$ L+ R9 r+ b- @' ^7 H* A
concentrations were less than 0.05 mIU/mL
! G# v* B3 T2 {! d* q! F9 c$ \2 G(prepubertal).
7 R5 R. G* a0 L% |The parents were notified about the laboratory
& G- I9 x: w$ A- Uresults and were informed that all of the tests were& u4 x. b. i7 u/ F  v- B7 U/ T
normal except the testosterone level was high. The6 J7 F/ v' o/ g
follow-up visit was arranged within a few weeks to; O' e4 e3 `3 l. l3 p; f. _7 u
obtain testicular and abdominal sonograms; how-
4 ]) Z" W" L' c$ J) g; k9 rever, the family did not return for 4 months.: V/ C: d+ z/ _9 Q# `% Q
Physical examination at this time revealed that the
+ S$ G; L/ U8 V  z2 w6 Q) j0 Q7 {child had grown 2.5 cm in 4 months and had gained
$ H" [, _- H& ^8 O: ^) y2 kg of weight. Physical examination remained
# m7 y# c7 |1 @8 [$ c- ?unchanged. Surprisingly, the pubic hair almost com-* O* P# `1 H5 A+ {
pletely disappeared except for a few vellous hairs at' o5 A( \% P3 s$ N, ~6 A4 Y5 T; j
the base of the phallus. Testicular volume was still 29 P" M/ C6 r# R! f+ M/ l
mL, and the size of the penis remained unchanged.
6 n+ N3 G, [5 H" g2 f$ y; s& cThe mother also said that the boy was no longer hav-7 k: A  d0 Z# m9 F
ing frequent erections.
7 X  p5 r- v5 r9 EBoth parents were again questioned about use of
* P. Y2 J4 D5 K9 O! vany ointment/creams that they may have applied to9 R. t5 c- k) T9 Y
the child’s skin. This time the father admitted the/ m* h; {& A/ }# K4 `+ Z. B: f- H, S
Topical Testosterone Exposure / Bhowmick et al 541
: O# ]0 E- m+ ?7 Huse of testosterone gel twice daily that he was apply-0 n0 C7 u, @% j( X" i
ing over his own shoulders, chest, and back area for
) l. x6 X, R; Z6 {# }7 ka year. The father also revealed he was embarrassed
6 ^- B3 {" }% G8 Cto disclose that he was using a testosterone gel pre-( b5 J, }/ w/ c7 ?
scribed by his family physician for decreased libido. `$ ?6 i% m( T/ B
secondary to depression.! i8 i& A; O/ c. D# I
The child slept in the same bed with parents.  ^9 C, y1 W& g% U4 R$ Q4 O
The father would hug the baby and hold him on his+ y+ `6 C! B) y. u
chest for a considerable period of time, causing sig-) r5 j" Y+ B/ H0 [8 i
nificant bare skin contact between baby and father.
5 M, s- u0 w, S% i4 mThe father also admitted that after the phone call,6 f2 i6 F3 `* z( T
when he learned the testosterone level in the baby6 a& D2 _# R: _1 L
was high, he then read the product information& d; e/ _6 P5 ]. h
packet and concluded that it was most likely the rea-
4 y( `4 F6 x: W+ ^$ u3 W1 S. yson for the child’s virilization. At that time, they
+ E& S( j& q& Edecided to put the baby in a separate bed, and the
& }% t. ^3 a* Ofather was not hugging him with bare skin and had0 ^' }- X. c6 R+ M: x# a" R
been using protective clothing. A repeat testosterone# x6 P3 Z* F% g( s. {  ]5 _( h
test was ordered, but the family did not go to the3 \8 q. l, D1 O& r, P5 t
laboratory to obtain the test.% l. o7 O$ O  P* F) t2 z
Discussion5 D( z8 d: N. X) d. I
Precocious puberty in boys is defined as secondary; {! s( I, c3 G& p5 k5 A& O" |
sexual development before 9 years of age.1,4
9 b+ M+ |! M' @( h5 R! ^4 y. x4 XPrecocious puberty is termed as central (true) when$ v' t6 Y0 h, t: G! U# s
it is caused by the premature activation of hypo-
9 v( ^+ j' G9 m* Tthalamic pituitary gonadal axis. CPP is more com-1 a0 T4 c, f- i/ m
mon in girls than in boys.1,3 Most boys with CPP
& n5 E5 X' L' A, mmay have a central nervous system lesion that is* H. r) M5 g* B4 ?. W& ]
responsible for the early activation of the hypothal-( U- c4 ^/ f% g" {
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ u( l/ X6 q: s/ f" m/ Msis has been given to neuroradiologic imaging in
9 |- Q7 n9 x8 R+ ?# C: g) Oboys with precocious puberty. In addition to viril-
; z) b  r- D) }  iization, the clinical hallmark of CPP is the symmet-
& s2 i" v- u& Z+ v6 ?9 \rical testicular growth secondary to stimulation by7 w( i5 R9 @$ g) e: n
gonadotropins.1,3
1 X) a) K- m5 E, W7 LGonadotropin-independent peripheral preco-: Q. n% v# V2 k: x3 s4 T/ u5 m8 ~
cious puberty in boys also results from inappropriate. h% i- I8 `' B$ K" h2 ~- _5 I3 Z9 L7 [
androgenic stimulation from either endogenous or% K8 w( v5 e2 t" V
exogenous sources, nonpituitary gonadotropin stim-
! M1 w4 V$ {- k4 ^ulation, and rare activating mutations.3 Virilizing* N* \3 Z& S, z, [
congenital adrenal hyperplasia producing excessive( q! u& B2 Y" g$ Z% j1 Y
adrenal androgens is a common cause of precocious' L8 v- d: j7 R: ^6 s
puberty in boys.3,4
. q* P$ i( l& g1 L) T5 OThe most common form of congenital adrenal; t: M' R1 N: [: }! R5 M; j0 H2 I
hyperplasia is the 21-hydroxylase enzyme deficiency.& [5 Y( b% ~4 |$ C
The 11-β hydroxylase deficiency may also result in
& v4 F  N3 ]5 w$ O; @excessive adrenal androgen production, and rarely,
7 M! }; n/ V4 P! Q" E5 Yan adrenal tumor may also cause adrenal androgen7 n7 S6 i  c' M4 ?+ U5 ^
excess.1,3
9 e' G# _  I2 ~6 y2 y6 n6 \/ rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 j, a3 z4 i6 K' P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 z! P/ x) X) e; m5 O6 xA unique entity of male-limited gonadotropin-) Y$ `0 u6 o& a! t
independent precocious puberty, which is also known
, \! z8 T& T0 yas testotoxicosis, may cause precocious puberty at a9 v# }$ p. r. r( Q8 b
very young age. The physical findings in these boys
: Y3 F( ?4 d6 C" a: y5 d. o, dwith this disorder are full pubertal development,/ \$ i1 l. _( u4 E- _* l
including bilateral testicular growth, similar to boys. E, w2 B( m, d
with CPP. The gonadotropin levels in this disorder
" G& [( B# R2 Uare suppressed to prepubertal levels and do not show: r2 ^& v5 ?' }' i' D
pubertal response of gonadotropin after gonadotropin-
3 A% W3 D( a, M7 Z8 X$ _releasing hormone stimulation. This is a sex-linked. o1 w  s% ?, v) C
autosomal dominant disorder that affects only
. |$ W$ U8 a; r# _5 A% y, imales; therefore, other male members of the family
% d* p& H- ~0 h6 m  m. tmay have similar precocious puberty.3/ p( a" o% {* D/ ~( J
In our patient, physical examination was incon-' ~3 K* E* i4 _2 E  L9 S( h! W9 A
sistent with true precocious puberty since his testi-, B( W$ I' b7 @9 u1 x& y9 v/ G
cles were prepubertal in size. However, testotoxicosis. J1 i% E: ]% ~1 f) Y1 L
was in the differential diagnosis because his father2 |/ k+ S3 I; G9 w" O
started puberty somewhat early, and occasionally,
0 u) ?! E0 [% m% S$ N. H; Ltesticular enlargement is not that evident in the8 G% S: K, |9 z6 Y
beginning of this process.1 In the absence of a neg-
! L: ]* C" \$ l3 tative initial history of androgen exposure, our4 U' F- O/ K7 e# y
biggest concern was virilizing adrenal hyperplasia,
5 l7 _) @0 q$ Q; T- v: Deither 21-hydroxylase deficiency or 11-β hydroxylase
$ S6 T+ |/ k. J* f- ^. fdeficiency. Those diagnoses were excluded by find-
7 c2 _9 ?$ @$ R5 c) xing the normal level of adrenal steroids.
1 W7 M  C/ p( \% O* }1 A& `The diagnosis of exogenous androgens was strongly0 D; [' Y  P5 R1 h7 E! V
suspected in a follow-up visit after 4 months because( J% A" G% L: g9 S
the physical examination revealed the complete disap-4 f5 s% d0 {5 C- b
pearance of pubic hair, normal growth velocity, and8 D$ s$ P5 B0 Y
decreased erections. The father admitted using a testos-( A' Y2 N, H4 I! o+ p
terone gel, which he concealed at first visit. He was
1 k" p( i$ c! B8 @4 ousing it rather frequently, twice a day. The Physicians’' m: V3 a. U2 q& \4 \, D, G
Desk Reference, or package insert of this product, gel or+ y3 N; A$ U; B2 H% C
cream, cautions about dermal testosterone transfer to" ^8 r5 h, b: a4 R
unprotected females through direct skin exposure.' C8 S) V" U( n# O8 O! u8 M9 e: D
Serum testosterone level was found to be 2 times the: @/ I" R2 k, s  m
baseline value in those females who were exposed to" C& ?" P/ s' x3 y4 K3 M; T+ y
even 15 minutes of direct skin contact with their male' ?$ i0 t4 R' r" {! u5 Q
partners.6 However, when a shirt covered the applica-
/ k* y# ]2 ?$ t% E9 p; U, @tion site, this testosterone transfer was prevented." P% {% O7 X) y! H' K
Our patient’s testosterone level was 60 ng/mL,
1 T4 Y, O1 C) \* O$ r$ Rwhich was clearly high. Some studies suggest that
8 ]9 p* Z) W: Jdermal conversion of testosterone to dihydrotestos-
6 M2 V, X' g& ^terone, which is a more potent metabolite, is more
) k" A3 j. l; P6 _, g1 i& Yactive in young children exposed to testosterone
# [! e+ Y% v  C+ M( C+ n7 \; yexogenously7; however, we did not measure a dihy-
) X' _3 I" T0 R, {# D; k9 D8 {  F8 edrotestosterone level in our patient. In addition to
2 e+ r; M0 y6 u$ t: P# y$ ^2 Dvirilization, exposure to exogenous testosterone in
7 n! w; d/ J0 ~- C+ ?2 z) Schildren results in an increase in growth velocity and1 ^" k& J  L' I1 ]  r" f+ t
advanced bone age, as seen in our patient.
- W$ P2 e1 ~/ r1 E& D; l( R  tThe long-term effect of androgen exposure during
, p3 _2 _" L# }early childhood on pubertal development and final
& y+ `. l6 A" Qadult height are not fully known and always remain: A; c! P) t- y! w1 x+ @( m
a concern. Children treated with short-term testos-
) ]$ d% e9 M0 E( t* ?0 Kterone injection or topical androgen may exhibit some- n5 A/ r9 l0 z4 S
acceleration of the skeletal maturation; however, after& M/ `$ B0 }, Y+ ~" r
cessation of treatment, the rate of bone maturation
5 S# Y1 y# l' idecelerates and gradually returns to normal.8,9
6 O$ M; T9 a7 S; L" P. F! VThere are conflicting reports and controversy0 b& Y; X1 p: {: E& }( A
over the effect of early androgen exposure on adult
) t3 t# ^/ g& C) d) ~3 rpenile length.10,11 Some reports suggest subnormal2 [6 d9 }* H( p8 L: r# v. l
adult penile length, apparently because of downreg-
- n9 [! c, H0 `. x3 b& x9 b2 \ulation of androgen receptor number.10,12 However,- Y& R) P7 X" y0 H
Sutherland et al13 did not find a correlation between
! T$ ~5 w' d  T: a& Zchildhood testosterone exposure and reduced adult
: R, f- B& a: Upenile length in clinical studies.8 v# Q# r+ I( h2 f" j; X
Nonetheless, we do not believe our patient is" U  `2 i$ B: ~4 f
going to experience any of the untoward effects from9 w$ k8 q" D. ]( ~& Y
testosterone exposure as mentioned earlier because. Y6 _* t. Q* N9 b2 D0 |$ u: M% ?
the exposure was not for a prolonged period of time., l  K1 v% d/ R( z0 ~
Although the bone age was advanced at the time of
# H. Q7 O6 f) w9 N& o' F& _diagnosis, the child had a normal growth velocity at3 R3 S+ h6 N& @9 r
the follow-up visit. It is hoped that his final adult) `  F2 e* D7 w' {* \2 d
height will not be affected.3 ^+ ?: _4 x, }8 @; u
Although rarely reported, the widespread avail-( `/ f" m" v* k& V/ u0 I$ z& c; u
ability of androgen products in our society may
" s4 n, T2 Y3 i4 \indeed cause more virilization in male or female" O1 R, k9 @) }6 [2 I# F9 Y
children than one would realize. Exposure to andro-
7 C! v/ d" x7 M: J( T; Kgen products must be considered and specific ques-9 I, t$ K+ v2 P) K- s2 m9 p
tioning about the use of a testosterone product or. V2 M* ]! d; {( Z% W; b& D
gel should be asked of the family members during" @  b: V' H$ l1 s' B$ q- A- H
the evaluation of any children who present with vir-
1 i$ ~7 j& a% r' ~: x/ @/ L, v4 [ilization or peripheral precocious puberty. The diag-) U; @" c' P, ?& O
nosis can be established by just a few tests and by- x" m# P; b, @# c9 F$ |$ R' I
appropriate history. The inability to obtain such a' K0 y, p9 o. g; K* W8 u
history, or failure to ask the specific questions, may6 z4 p8 ^, f9 U8 Q& \
result in extensive, unnecessary, and expensive
( ^, J5 K( L4 G/ M* O; g; pinvestigation. The primary care physician should be
# D! {" q3 k; n6 S  u+ Vaware of this fact, because most of these children
6 T+ \$ v! J% h- i7 U7 Ymay initially present in their practice. The Physicians’
8 q4 J( |# T4 h( p# ^Desk Reference and package insert should also put a
; G! L8 ?, \' _- gwarning about the virilizing effect on a male or; L6 E1 m& J* E1 l+ m
female child who might come in contact with some-! @6 s: a# b5 U
one using any of these products.# J- O- z) b& r6 `
References
% m  a3 S0 S$ q' T1 I, f1. Styne DM. The testes: disorder of sexual differentiation& M* e5 A' z) ~, S
and puberty in the male. In: Sperling MA, ed. Pediatric' V, Q; J, C& R/ [; a$ X; L0 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% C% |% ^7 t, h) s$ {- a7 L3 R
2002: 565-628.! X* I. j/ f, h* z7 Q% A, K9 k9 l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. e/ o9 b8 Z/ z8 y6 N* \. R. y
puberty in children with tumours of the suprasellar pineal
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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
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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

4 L  f! e! w- D: z# I# C6 S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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