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Sexual Precocity in a 16-Month-Old' v6 T0 {, B  |. i; Y0 ^" N1 X5 i
Boy Induced by Indirect Topical. w- C3 N6 r& A- R$ U
Exposure to Testosterone
0 i1 B  P& n+ C2 H/ M: {9 LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 X' P  A: P) s+ Y% j. H! i8 b1 q6 Wand Kenneth R. Rettig, MD1
- }2 u& k& C2 a8 V$ D& w; r0 q% zClinical Pediatrics
' K: m5 Q% j7 I) Y# ~4 P, ]4 vVolume 46 Number 6) `' X7 _! T3 Q- c- m2 O
July 2007 540-543, Q" V1 a$ K9 |: i: E% N
© 2007 Sage Publications* S- X" L. V2 N* E
10.1177/0009922806296651
3 M6 j  x# w: K0 uhttp://clp.sagepub.com
; B6 q6 I. h9 ~* thosted at6 O2 O6 ]$ _- n. y
http://online.sagepub.com
6 ^8 D* ]6 x; E! ^) O0 v0 gPrecocious puberty in boys, central or peripheral,  J3 Z% {" P* X+ h) Z. R
is a significant concern for physicians. Central
. ^1 i; @! y' S) Mprecocious puberty (CPP), which is mediated0 `9 J# D' X/ }% ~+ v7 l1 h5 s
through the hypothalamic pituitary gonadal axis, has+ [! Y1 I% {( H1 V6 M" V
a higher incidence of organic central nervous system0 f* E- \, m  [& c) a- N
lesions in boys.1,2 Virilization in boys, as manifested5 m' O+ i* q% O6 {! T
by enlargement of the penis, development of pubic1 T9 m% u6 ^; @- u
hair, and facial acne without enlargement of testi-
* i" W% Z4 C* ?cles, suggests peripheral or pseudopuberty.1-3 We
& f( x: p: a+ r" N. C7 X& W3 _# Qreport a 16-month-old boy who presented with the
: C9 r9 _/ X* @, z! L1 P2 venlargement of the phallus and pubic hair develop-
4 m; z5 E0 L) A. C, F, pment without testicular enlargement, which was due$ L- o: A) |0 w0 M6 H; @3 x9 s
to the unintentional exposure to androgen gel used by
5 d; c# }1 M- p5 n- p  U/ C, Lthe father. The family initially concealed this infor-
- a& {( P8 r2 b1 y+ v( Mmation, resulting in an extensive work-up for this
, U" i) V3 e( B$ l% Ychild. Given the widespread and easy availability of
: |5 u0 }8 e* C' P- _testosterone gel and cream, we believe this is proba-: U$ s" i+ e* }
bly more common than the rare case report in the
% `: [7 J  ]+ @9 Aliterature.4
4 ^- E) i  ]( m' @; g  fPatient Report
8 e' `9 K8 }# _! _% T" d: E" g4 _3 b5 pA 16-month-old white child was referred to the! i: z8 D- m# K: t4 X+ p
endocrine clinic by his pediatrician with the concern" i, h7 ~0 M1 u
of early sexual development. His mother noticed
4 F9 ~* m# _# U  Q7 ?- ylight colored pubic hair development when he was: f: u' R9 N& P) E
From the 1Division of Pediatric Endocrinology, 2University of; k3 T# M8 {8 ?; {2 ]
South Alabama Medical Center, Mobile, Alabama.( K/ |) f" `, J: d4 [- h& p" q
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ k* Q+ c! ?+ i  `5 K9 l1 ]# \
Professor of Pediatrics, University of South Alabama, College of
. _8 G4 v, c' w. I, |Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- d  g: s- C9 L" Y0 ^& L5 l
e-mail: [email protected].
3 a0 t* R* a" g# Labout 6 to 7 months old, which progressively became* S1 \4 Z0 ^  T
darker. She was also concerned about the enlarge-7 I* i9 [# N8 q% o$ a' u
ment of his penis and frequent erections. The child+ T" l0 i- j$ e
was the product of a full-term normal delivery, with) F: @2 F* B! q* l5 @
a birth weight of 7 lb 14 oz, and birth length of
+ v5 j+ L& N( M' k, S: M20 inches. He was breast-fed throughout the first year4 i2 {2 z$ M7 z, |* I
of life and was still receiving breast milk along with
2 M/ ~# D4 t: s5 a  Rsolid food. He had no hospitalizations or surgery,
* A( S2 W2 F. J& {' r9 pand his psychosocial and psychomotor development
, J2 b& [/ P( }% s( n3 ?3 ?was age appropriate.
3 }$ G5 e/ o( B6 T* G; QThe family history was remarkable for the father,9 Q6 M/ g" C8 U+ f0 f4 ]! G' Q6 i
who was diagnosed with hypothyroidism at age 16,( G) A; F% c8 P4 @# F" z
which was treated with thyroxine. The father’s
7 @  X" n& q& A3 ^$ t) L% {height was 6 feet, and he went through a somewhat
. C9 A; \/ I2 X2 t& Pearly puberty and had stopped growing by age 14.# n4 l" ?6 p& E% j' X' A
The father denied taking any other medication. The* |/ R3 n9 d: Y! C
child’s mother was in good health. Her menarche, b* w/ }2 i* w" Q% A1 i. J  M
was at 11 years of age, and her height was at 5 feet
9 V% y7 a5 K& t; y: t5 inches. There was no other family history of pre-
* f/ b8 Y( h: {5 n% Q7 Vcocious sexual development in the first-degree rela-' S- `0 E+ f# G$ g' i
tives. There were no siblings.
3 H" q8 `* c8 ?! _; p, [( D1 Y: y2 WPhysical Examination6 @) @' }" `" q: m3 w8 i0 o
The physical examination revealed a very active,$ S8 p! o0 w# Q- f
playful, and healthy boy. The vital signs documented5 c0 n. [! }: y/ e8 s
a blood pressure of 85/50 mm Hg, his length was
2 i+ t) _+ G+ u5 z/ v# {8 [90 cm (>97th percentile), and his weight was 14.4 kg8 J+ H  W) f4 z$ j( u$ q" j
(also >97th percentile). The observed yearly growth
& ^, D; H; Y: P, S( {velocity was 30 cm (12 inches). The examination of: H2 `. L+ f. g- c
the neck revealed no thyroid enlargement.8 D  S5 W& Z* K% j  u; I3 P+ U5 R
The genitourinary examination was remarkable for3 {( r/ ~2 C/ f+ z. O
enlargement of the penis, with a stretched length of6 D3 B/ }& s2 k
8 cm and a width of 2 cm. The glans penis was very well
4 ?' l6 b0 ^- {1 E# d3 Q$ X9 s: \developed. The pubic hair was Tanner II, mostly around" K* s' P& I0 U8 m" Z9 Y/ e
540: S7 Q% e" Q) N& I8 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 f8 x0 R7 J- bthe base of the phallus and was dark and curled. The" V3 ~1 P8 c1 r) |: G5 i# q+ m% M
testicular volume was prepubertal at 2 mL each.8 j9 d" C% y8 R( V# `% x
The skin was moist and smooth and somewhat
6 W" l1 @( K% J2 k% m* s. x$ xoily. No axillary hair was noted. There were no; R4 H9 d8 d; b
abnormal skin pigmentations or café-au-lait spots.7 e. L/ a  }9 Y* S7 t, E
Neurologic evaluation showed deep tendon reflex 2+
  ^6 J( u, T$ z: z' Ibilateral and symmetrical. There was no suggestion
9 P# _& S( z* `% C6 ~: N) D- V8 m4 Qof papilledema.
" c5 A* f1 i  zLaboratory Evaluation
0 Z9 e# k% O. U+ lThe bone age was consistent with 28 months by1 n- _7 l* E- [  p* c0 R
using the standard of Greulich and Pyle at a chrono-
6 R! t# n0 s5 N1 \& Ylogic age of 16 months (advanced).5 Chromosomal$ d$ u, O! j4 v: ?; M5 @% f5 l
karyotype was 46XY. The thyroid function test; H3 R% W# n- g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' N0 B" T3 B( e1 W- F! i
lating hormone level was 1.3 µIU/mL (both normal).' h7 _; E' x5 u$ X3 C
The concentrations of serum electrolytes, blood& |) ]4 b" Y* S  I  `
urea nitrogen, creatinine, and calcium all were$ ?% d: S( Q9 d  @* F3 ^
within normal range for his age. The concentration
, @3 h, g9 Q9 P5 o* z6 d8 Tof serum 17-hydroxyprogesterone was 16 ng/dL
4 P4 F: y. j  p5 M9 j3 c% a(normal, 3 to 90 ng/dL), androstenedione was 20" M' {  a4 m/ v1 O' _4 E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& q( M6 ]; E& u3 v# Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),1 T# Y. D/ b" D
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 d" u5 ]/ H7 n2 ]7 ~7 a
49ng/dL), 11-desoxycortisol (specific compound S)
* v# J2 ^6 m2 U9 N$ z1 jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- w0 L% K( Q3 x, \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 f+ z$ {9 Q, G5 `0 E) `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 V1 i9 N. @4 K" ]
and β-human chorionic gonadotropin was less than# L! O2 o' h- D* z) p4 k% q
5 mIU/mL (normal <5 mIU/mL). Serum follicular
' s; ?7 |1 G- jstimulating hormone and leuteinizing hormone5 Q* z9 @/ r- X9 A
concentrations were less than 0.05 mIU/mL. V8 n. p, |- h
(prepubertal).
  P$ E! i/ i# m. R1 M8 HThe parents were notified about the laboratory( l; _$ z7 k0 {3 v5 q7 f6 K5 P
results and were informed that all of the tests were
, E3 M- M: h1 N0 d; Lnormal except the testosterone level was high. The& S. M9 h# B$ X
follow-up visit was arranged within a few weeks to
4 ?: ~% W9 T/ _) E5 [" g# |; `obtain testicular and abdominal sonograms; how-) S% l3 F/ a8 q% x
ever, the family did not return for 4 months.
7 F: z- X) g+ W7 J! I4 H" CPhysical examination at this time revealed that the+ P) G0 V3 L4 M# P: t
child had grown 2.5 cm in 4 months and had gained# v% T  G1 j2 R* H( r2 X
2 kg of weight. Physical examination remained. G  D2 v: T4 ^
unchanged. Surprisingly, the pubic hair almost com-, o+ o8 m# ~  i/ `8 \. V
pletely disappeared except for a few vellous hairs at8 P$ o5 c  i$ g0 \$ d( E, ]& x0 E  R) ~
the base of the phallus. Testicular volume was still 2
6 J5 W+ _  I0 h' U# JmL, and the size of the penis remained unchanged.
! O; c4 N. l' DThe mother also said that the boy was no longer hav-( X  p! p1 v1 J$ c$ q% o
ing frequent erections.* u/ p2 h. w% {
Both parents were again questioned about use of7 \* X9 X- i8 A3 ?  C. p% E' ]
any ointment/creams that they may have applied to: e; b5 ^3 g; ]
the child’s skin. This time the father admitted the
) p; T, _6 x( [8 {Topical Testosterone Exposure / Bhowmick et al 541; k% g5 t3 {' i' f6 u
use of testosterone gel twice daily that he was apply-$ [6 r" U& u6 j. w+ r
ing over his own shoulders, chest, and back area for& r3 x, ~- ]3 C5 h
a year. The father also revealed he was embarrassed4 n  l' q, m# w' h9 {
to disclose that he was using a testosterone gel pre-
' W1 J) F/ a7 Jscribed by his family physician for decreased libido# R. O- b, Z. ~5 q+ S# v+ D
secondary to depression.- e  G; K, S' l; F# \3 I) B
The child slept in the same bed with parents.
! L/ k: p5 A# A( \The father would hug the baby and hold him on his2 [: Z( A4 N1 N: u3 k1 m, H3 @; S+ o
chest for a considerable period of time, causing sig-
6 p3 d! y$ v9 f4 _% rnificant bare skin contact between baby and father." T: Y# ~9 n5 Y( z3 f4 _" \4 N
The father also admitted that after the phone call,/ e3 ~/ @& V( A7 c+ u2 d$ A
when he learned the testosterone level in the baby. U7 g- \. H- O8 ]
was high, he then read the product information: M! O5 T, B/ _7 ?) q, D, H
packet and concluded that it was most likely the rea-
& ]7 U7 y, R( cson for the child’s virilization. At that time, they
7 `2 L- Z- h) B' u& w; U# r% T) N; tdecided to put the baby in a separate bed, and the! q  f4 H/ X8 m" {6 N9 i
father was not hugging him with bare skin and had6 E  M2 ], T* i( _" ~$ o& t
been using protective clothing. A repeat testosterone
0 h7 H, \) u( E% `( a0 w1 Ytest was ordered, but the family did not go to the
& M- u$ K: p6 F( n( M8 jlaboratory to obtain the test.5 q' y+ Y! Q. \( o; N5 X9 z; m
Discussion. |1 h! e1 _9 @9 @/ X* h
Precocious puberty in boys is defined as secondary( r) X: t: U# w
sexual development before 9 years of age.1,4" F# L$ n9 f2 }" G
Precocious puberty is termed as central (true) when8 `3 N1 S  u; f6 _( s
it is caused by the premature activation of hypo-' e( y9 N% o8 @  x' O
thalamic pituitary gonadal axis. CPP is more com-
, t8 M( i0 _7 Lmon in girls than in boys.1,3 Most boys with CPP. ^% g- D) g& O# m/ I) j
may have a central nervous system lesion that is2 D4 P: w8 n8 Y% x, J. I7 R
responsible for the early activation of the hypothal-" N9 g8 p* F' v, h: j" x* p
amic pituitary gonadal axis.1-3 Thus, greater empha-
% |3 v7 Y! c* E9 Qsis has been given to neuroradiologic imaging in- S, B* ^8 j6 M7 v
boys with precocious puberty. In addition to viril-1 a" n+ v! S( {% Y: I2 T
ization, the clinical hallmark of CPP is the symmet-
3 E/ v% W/ h  zrical testicular growth secondary to stimulation by
5 X! H: u& A% Y2 j/ Rgonadotropins.1,36 Y3 S' q. u# o2 o+ K, n4 ~
Gonadotropin-independent peripheral preco-! Q- D7 B- P- Z1 F) d& |" Q
cious puberty in boys also results from inappropriate' ~/ m; {' R7 C! y
androgenic stimulation from either endogenous or! ^/ c" }* Z  \7 E& ~, q1 x
exogenous sources, nonpituitary gonadotropin stim-+ A% O# H; {/ g4 b) s9 c
ulation, and rare activating mutations.3 Virilizing
+ i, |( p; z  S- {8 p0 kcongenital adrenal hyperplasia producing excessive/ G7 u0 l+ t/ ~$ I; G3 I  p4 r) D8 X
adrenal androgens is a common cause of precocious  d5 L; F6 d2 l; Y0 y4 {7 C+ B4 J. o
puberty in boys.3,4, }+ U: U# _+ T- w
The most common form of congenital adrenal( Y0 n" C7 v; {; I2 H$ R3 {
hyperplasia is the 21-hydroxylase enzyme deficiency.5 `) Y' g% D; M3 T6 i0 s% O
The 11-β hydroxylase deficiency may also result in) G4 m* P: I! l, w. _# s3 O, g
excessive adrenal androgen production, and rarely,
6 A0 J0 J  C! Z/ x4 z) can adrenal tumor may also cause adrenal androgen0 d8 H! @  Z3 P- z) x) @9 X
excess.1,3
. J7 K6 n+ z2 R: A; fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# b; A: t- g  [2 }542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 J, N" U/ ?) u* _! b2 g5 kA unique entity of male-limited gonadotropin-, r" E0 k6 h! d8 j
independent precocious puberty, which is also known
( L9 {- U) C! E% Xas testotoxicosis, may cause precocious puberty at a1 L& ]& g1 P0 W% C
very young age. The physical findings in these boys
7 f6 i* ~3 a2 e3 ?" y% |* h# i3 pwith this disorder are full pubertal development,
  f  t3 B$ z$ Y2 ~( A/ l0 dincluding bilateral testicular growth, similar to boys
, J" P" _1 R8 q, W5 O9 Rwith CPP. The gonadotropin levels in this disorder' }1 Q3 ~% c6 ^5 c9 I
are suppressed to prepubertal levels and do not show% @5 r1 E: L8 j) m2 H# J
pubertal response of gonadotropin after gonadotropin-( t! g: ]/ }5 L7 N6 A' U9 _: @/ {7 }2 K
releasing hormone stimulation. This is a sex-linked/ x# J/ u2 O/ s: y# R) X
autosomal dominant disorder that affects only& f) N  M( O2 ~4 G
males; therefore, other male members of the family
* [' D7 q7 D8 Z0 v- A" Z1 Hmay have similar precocious puberty.3
: _1 g3 F$ r& q8 W9 i' p% FIn our patient, physical examination was incon-3 y7 \1 x3 O" U( R- H! o
sistent with true precocious puberty since his testi-$ T, @' j2 D- ]
cles were prepubertal in size. However, testotoxicosis
# c2 M" W6 m7 ?+ h: y- pwas in the differential diagnosis because his father6 u* Q; Y0 g' P/ J) g! T' s' W
started puberty somewhat early, and occasionally,; ?: A0 M, D: {6 N
testicular enlargement is not that evident in the6 b5 |' n1 V) D! }% @" E7 q
beginning of this process.1 In the absence of a neg-
( Q3 v( m/ ^. O+ _1 ?ative initial history of androgen exposure, our
( q9 O3 ^  y4 K* C, Rbiggest concern was virilizing adrenal hyperplasia,  w3 w0 n1 W8 o; J
either 21-hydroxylase deficiency or 11-β hydroxylase
- \3 H) l. a' |# Sdeficiency. Those diagnoses were excluded by find-0 n/ c0 W+ [7 D$ M* D) ~% l& L' Z
ing the normal level of adrenal steroids.8 k; f; S5 t. o# k( f% B6 Z4 y
The diagnosis of exogenous androgens was strongly! C) R- G6 M) z: L
suspected in a follow-up visit after 4 months because# i) |, ]5 L6 {' d# X" {
the physical examination revealed the complete disap-2 z% a% B/ B6 W2 g1 T$ Z( p0 B
pearance of pubic hair, normal growth velocity, and
4 |& V" o$ m, ~' K  V& c  |decreased erections. The father admitted using a testos-
/ W' u) W+ W3 p4 A1 Qterone gel, which he concealed at first visit. He was
/ F5 X4 d7 g1 Z7 O5 i3 r0 vusing it rather frequently, twice a day. The Physicians’5 Q. V6 D$ T+ ^9 @# Q
Desk Reference, or package insert of this product, gel or
( ]2 v' i% o5 F9 g( ^! W' G6 Ccream, cautions about dermal testosterone transfer to
, q5 k4 z* E6 }4 ^* L8 R. W7 s/ Punprotected females through direct skin exposure.! @# d, T: ?5 Y+ |! ?& R" ^% _
Serum testosterone level was found to be 2 times the* S; j) `; d. R% u7 b
baseline value in those females who were exposed to, R# L7 @! O/ _6 h) K9 o
even 15 minutes of direct skin contact with their male* g( ~. p3 |; `! V
partners.6 However, when a shirt covered the applica-
% k8 e" ]6 Z' ction site, this testosterone transfer was prevented.
! U. O6 d) V. Y- j" U( cOur patient’s testosterone level was 60 ng/mL,; v$ {' m0 v: {# X$ m" W- A5 S! A) O, U
which was clearly high. Some studies suggest that( g$ G" }8 o7 Z1 o( }6 ]) t
dermal conversion of testosterone to dihydrotestos-( M0 N* X) S8 C! K
terone, which is a more potent metabolite, is more9 W. R. X( v0 T: G
active in young children exposed to testosterone
( ?' s) q/ k' {exogenously7; however, we did not measure a dihy-
* Z6 ~5 o# o5 D( s' O4 h$ _2 v: t* {drotestosterone level in our patient. In addition to: }" d8 N2 X4 I: V1 I7 A
virilization, exposure to exogenous testosterone in1 t: a. r! V& y! W" a% |$ k
children results in an increase in growth velocity and% Y9 g7 L( U& q( N
advanced bone age, as seen in our patient.' R! {+ ^! r% ^1 f( H% ]3 |& W
The long-term effect of androgen exposure during
; ^4 f+ y0 q& o) Y; @4 xearly childhood on pubertal development and final
% V. H8 X8 `) D, i+ a: d" @2 iadult height are not fully known and always remain
6 d; t$ S% ]- \0 r( _a concern. Children treated with short-term testos-
! ^) M& j4 Y1 X; Wterone injection or topical androgen may exhibit some& v. B& G1 ], u7 p
acceleration of the skeletal maturation; however, after
. I8 I  @* @8 Qcessation of treatment, the rate of bone maturation
, X( F) m- I8 g: s2 Gdecelerates and gradually returns to normal.8,9+ g9 \1 g$ `7 l% v* f
There are conflicting reports and controversy8 _# w5 S9 |. z" X
over the effect of early androgen exposure on adult; ]- S& _, o# F: S2 i5 ~( O0 y5 L
penile length.10,11 Some reports suggest subnormal( r/ H6 V$ ]- J( h( ?$ Q6 j  O* s
adult penile length, apparently because of downreg-- G: B6 D3 S, a' r8 f
ulation of androgen receptor number.10,12 However,9 x; r, n- E4 O7 z4 \/ e
Sutherland et al13 did not find a correlation between
$ `  p* D  b" c# K, U, _3 Pchildhood testosterone exposure and reduced adult
! m/ P& G  P! F6 h6 A4 ?0 w  Tpenile length in clinical studies.
4 U# i: L, s6 I: @" X* R+ M# s6 r" RNonetheless, we do not believe our patient is% I: A2 K4 j7 R- B/ F/ E, y
going to experience any of the untoward effects from
7 l7 d- @6 h) ttestosterone exposure as mentioned earlier because
8 M4 i! Q$ T$ i8 x& }& h4 R  L0 ithe exposure was not for a prolonged period of time.
/ d2 B7 h8 v1 }1 y$ b$ G' K: V; q7 YAlthough the bone age was advanced at the time of5 C& D: \) i; I6 p
diagnosis, the child had a normal growth velocity at1 h- \: u1 ^0 ^- N: P. e$ U
the follow-up visit. It is hoped that his final adult
$ X) L3 f( P$ L" u- O6 ^height will not be affected.3 ~7 w! f. l2 W, f7 e
Although rarely reported, the widespread avail-5 t0 s$ P4 m$ T/ J$ I/ `
ability of androgen products in our society may9 j8 W7 I1 }0 k# X" \
indeed cause more virilization in male or female
" }: t. C% u! `+ C; q0 Fchildren than one would realize. Exposure to andro-
" g4 Y7 D  ~" }1 g& W% qgen products must be considered and specific ques-
% j% T7 g7 r% b# g& S1 E) s2 A' ationing about the use of a testosterone product or
  d( u. @7 n8 Z  C& Fgel should be asked of the family members during
2 f' q( R7 N$ u" p& lthe evaluation of any children who present with vir-
5 a8 g4 S% S$ U# a' Xilization or peripheral precocious puberty. The diag-: i9 [2 z1 B( U8 B4 g1 h# u! x
nosis can be established by just a few tests and by2 a$ w, r. G4 w7 i6 A) p
appropriate history. The inability to obtain such a
2 `! z  A. s5 ihistory, or failure to ask the specific questions, may
, y- x( W& {0 @+ sresult in extensive, unnecessary, and expensive
' ]9 X0 i6 C# Z) f2 ^; c! yinvestigation. The primary care physician should be6 c' @8 |' i6 Y8 |& ]6 c
aware of this fact, because most of these children
; l0 U$ w$ e8 @! amay initially present in their practice. The Physicians’
- h$ ~9 j( \% J( nDesk Reference and package insert should also put a
8 H# l: }7 }8 }2 a; r4 R' hwarning about the virilizing effect on a male or
4 Q) V" l  B) |' Y: x( R4 @  tfemale child who might come in contact with some-
7 x# `' ]. ~- P1 b) l$ a2 G  Qone using any of these products.
: i* m6 p5 ~) H" z7 e1 OReferences
  y0 b0 q  I. k1. Styne DM. The testes: disorder of sexual differentiation1 Q: ?% w7 N  M! i3 t* W* M
and puberty in the male. In: Sperling MA, ed. Pediatric; o9 A, M, m5 x2 q- x
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) ]; y& w) x! l4 R
2002: 565-628.$ o$ d* B  q& F1 y8 g& R4 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ D& P9 R" |! o. w# s9 S- ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
6 ^/ m/ ]% v' y. ^2 J* OBoy Induced by Indirect Topical1 q9 f  k3 v, i: S/ Y! p6 b" u
Exposure to Testosterone: E1 Q% p( z8 ~5 e* @; c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ |3 X9 M2 U+ C/ v4 vand Kenneth R. Rettig, MD1
: }( q" e% E+ o8 P7 H# ~Clinical Pediatrics2 X- K0 r9 ^( E  L0 v8 d
Volume 46 Number 62 z/ u% Q( p% K5 Z' n  a" a5 S
July 2007 540-543
( M# ^# o. j  B" W9 S* F5 t  ]© 2007 Sage Publications
: ?, \: d/ I/ N2 o10.1177/0009922806296651; z4 J$ c8 C. _
http://clp.sagepub.com
& P" G6 i1 f2 n1 ^0 {hosted at* X, R( a3 [& R) i' d
http://online.sagepub.com
/ R% @% q9 p# M4 \Precocious puberty in boys, central or peripheral,& E5 \% t4 g% N, y6 S4 ]) ^
is a significant concern for physicians. Central9 ]# |- L7 C2 `
precocious puberty (CPP), which is mediated' g- k+ i- e5 b
through the hypothalamic pituitary gonadal axis, has) Y4 ~/ T$ ]  b
a higher incidence of organic central nervous system' y4 }$ |+ o: v4 u7 v# [2 }/ ?
lesions in boys.1,2 Virilization in boys, as manifested
+ A+ K9 [4 m2 fby enlargement of the penis, development of pubic& |& b6 n" r6 D, l
hair, and facial acne without enlargement of testi-
& X% d6 r5 q, G4 g" L, L; I. \cles, suggests peripheral or pseudopuberty.1-3 We( J! ]$ ?- v1 G, [0 d  K4 E
report a 16-month-old boy who presented with the$ c$ y. i( _" x/ r+ ]& U: I
enlargement of the phallus and pubic hair develop-
1 S! U; P1 d1 X' y4 m9 Tment without testicular enlargement, which was due
9 }* }( A2 N' v; ^! L  P; ?to the unintentional exposure to androgen gel used by
+ y* O# x8 v. I6 T; S1 Fthe father. The family initially concealed this infor-% {. q( Z' A6 a( W0 w/ t, c
mation, resulting in an extensive work-up for this' B2 H1 s! `5 }7 P& Y" S' z
child. Given the widespread and easy availability of0 V% z3 `1 G/ X+ T+ U, w  w5 B4 i# y" s
testosterone gel and cream, we believe this is proba-; `) k( e) p3 A0 w5 A# V9 q
bly more common than the rare case report in the& B: K& I6 a" J( b
literature.4) f0 \. h7 _: \# _9 U: D! T
Patient Report
, i- |- Z! _3 X4 p0 e9 O+ fA 16-month-old white child was referred to the) s- }) k0 o3 [1 M* `
endocrine clinic by his pediatrician with the concern6 M$ G6 F( U9 g% u# p- M6 W3 V8 k
of early sexual development. His mother noticed
$ M4 M3 g/ s' w4 Xlight colored pubic hair development when he was6 c+ d! C6 F/ P2 V, Y) U
From the 1Division of Pediatric Endocrinology, 2University of
) O# G, c  o. H% I6 n" i( Y) ?  ?South Alabama Medical Center, Mobile, Alabama.
9 Y- i. h" I* E$ P6 m& HAddress correspondence to: Samar K. Bhowmick, MD, FACE,% r2 Y3 }# ^% M" k8 R6 j( }
Professor of Pediatrics, University of South Alabama, College of
$ T. b% L  Z- \+ QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. `) [/ [5 |3 D. \- Ee-mail: [email protected].
/ w8 x+ H) {3 A2 @+ c3 K0 a/ k; fabout 6 to 7 months old, which progressively became8 V- [% J5 X) h: Y" R" ~! @& w
darker. She was also concerned about the enlarge-6 w3 ~% P) U2 g: |2 G
ment of his penis and frequent erections. The child
+ ?# f9 S+ ~* G* ywas the product of a full-term normal delivery, with
" R: v2 o: G% A7 za birth weight of 7 lb 14 oz, and birth length of  e6 q" j: V5 T7 q0 [5 e8 Q
20 inches. He was breast-fed throughout the first year6 d3 V9 k. z0 `
of life and was still receiving breast milk along with3 y! k; P0 w% b7 f
solid food. He had no hospitalizations or surgery,. i  y/ k1 J& q/ Q
and his psychosocial and psychomotor development/ X! O# k* H  v/ O0 Q5 G5 @; G  f
was age appropriate.
8 k: d7 k+ G9 T/ |3 zThe family history was remarkable for the father,
' N. Y: ?7 ]4 B0 a% Rwho was diagnosed with hypothyroidism at age 16,
6 z$ }4 a: m: H( v3 Pwhich was treated with thyroxine. The father’s/ i$ b- ?) _  v" J% o% X3 u5 u
height was 6 feet, and he went through a somewhat1 `' a) Q3 [, `: i8 S. p% v
early puberty and had stopped growing by age 14.
2 s  E; u8 U6 ]* ?3 `; u! D9 gThe father denied taking any other medication. The  r% u4 M0 {7 Z+ H( V1 r# V
child’s mother was in good health. Her menarche
4 C! _2 E2 |+ W& \, Nwas at 11 years of age, and her height was at 5 feet
2 d% L( F1 r, u, k2 r, F  w& \5 inches. There was no other family history of pre-
( P. K* k. ^0 R5 K" b* v! X9 U' _cocious sexual development in the first-degree rela-+ P5 ~9 |% N6 l
tives. There were no siblings.
7 g" X+ `3 B) t4 u; A: CPhysical Examination& I; Y2 {  M' K! L
The physical examination revealed a very active," q& v6 i# f& T9 m8 ~
playful, and healthy boy. The vital signs documented0 Y! ?+ _2 y. Y- i; e3 ~
a blood pressure of 85/50 mm Hg, his length was  f+ I' i4 n* T( T. Y; _- W( T
90 cm (>97th percentile), and his weight was 14.4 kg- k; o; Q/ U' I  a7 G0 I
(also >97th percentile). The observed yearly growth9 J. ?4 M' e- S- a
velocity was 30 cm (12 inches). The examination of" O7 L8 }7 C! M3 w+ y6 ~
the neck revealed no thyroid enlargement.
. _; l* j# l# Q( l; h; z1 n* CThe genitourinary examination was remarkable for+ L1 ]/ i( m% Q% U: e
enlargement of the penis, with a stretched length of
1 {. K7 [0 z1 @$ n  k8 cm and a width of 2 cm. The glans penis was very well
( f$ `; ?2 `: Q' I: c* O, \0 W( H8 zdeveloped. The pubic hair was Tanner II, mostly around
5 T' K8 `& o! b/ |6 h+ V! U  [540
' x; u2 ^. ~0 }/ [( ?: s, N% d- iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 l. W* _% S, c6 l- y: b2 A5 R* C3 ithe base of the phallus and was dark and curled. The
' y# S! O4 h7 z1 R# L9 itesticular volume was prepubertal at 2 mL each.
8 N7 _$ x" h* \% _  RThe skin was moist and smooth and somewhat
$ O, P1 k7 {5 g5 _& G% Y: Loily. No axillary hair was noted. There were no7 E# D. V- q  Q  C) P& W. g
abnormal skin pigmentations or café-au-lait spots.
2 Z$ u: q2 Q+ N/ y# a, QNeurologic evaluation showed deep tendon reflex 2+
# C6 d  O0 D. M' {. _bilateral and symmetrical. There was no suggestion
: U& y. c3 u$ o4 P: {# _' Mof papilledema.
6 e+ X! v0 B% E# j3 Q8 e9 C9 \( NLaboratory Evaluation+ m4 e6 @. Q$ V5 t- h  N
The bone age was consistent with 28 months by) K/ a4 S) a! V! o/ B
using the standard of Greulich and Pyle at a chrono-$ c" g7 \, `! W9 n% }
logic age of 16 months (advanced).5 Chromosomal
  L3 k& z/ X6 b+ l2 M; W2 w# l  jkaryotype was 46XY. The thyroid function test
# Z& ?1 d/ g0 I) F$ Z- J8 E& Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 ]! M6 w/ D8 o$ ?/ M' F
lating hormone level was 1.3 µIU/mL (both normal)." s. n0 z6 H7 m4 u& ?# E+ b' K9 V
The concentrations of serum electrolytes, blood
! k: r  a8 K; J  Z+ k( {urea nitrogen, creatinine, and calcium all were
$ }5 \7 ?+ n/ s% Nwithin normal range for his age. The concentration. E* x+ J* T; b: J& v
of serum 17-hydroxyprogesterone was 16 ng/dL5 [4 R* r9 ~5 {: B2 @- A; X
(normal, 3 to 90 ng/dL), androstenedione was 20) c) i6 x3 r, Y' e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; ?3 \; p" E. T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 d8 ?/ V" I4 m6 E; p# I/ U
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ v+ C0 U* Y9 d1 ]
49ng/dL), 11-desoxycortisol (specific compound S)9 z) W' K* k/ ^+ h' }. _; D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; ?9 J2 w0 H7 Jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 f, ~' c) j1 \3 Q+ ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 b% s) V' P) P4 Wand β-human chorionic gonadotropin was less than
/ i+ W2 G2 t7 J6 Z5 J5 mIU/mL (normal <5 mIU/mL). Serum follicular$ ^( Q" [, j% v$ S( R  ~1 f
stimulating hormone and leuteinizing hormone
6 F% r- C: |& P: u  S2 _) }1 j4 Nconcentrations were less than 0.05 mIU/mL7 K; C7 ]/ R; |/ F9 l
(prepubertal).
7 w2 u* ]6 R. B$ sThe parents were notified about the laboratory3 H" N3 [$ F, f
results and were informed that all of the tests were
- l" V& S: N4 C& m- Inormal except the testosterone level was high. The
5 \' F1 o9 D+ [3 l0 X1 xfollow-up visit was arranged within a few weeks to. f( y1 H, a9 `0 Q) B$ G) c
obtain testicular and abdominal sonograms; how-$ ]0 D2 H7 {; ~* e# _- ?0 ^8 z
ever, the family did not return for 4 months.
  U$ v: t# F3 ~( b8 e; bPhysical examination at this time revealed that the
) K7 Z* [" S% _3 S9 Z! K% Ochild had grown 2.5 cm in 4 months and had gained
5 s) ^5 j% a9 f7 e" E- v2 kg of weight. Physical examination remained6 L. M5 r  k7 H6 n# V1 V. |, f
unchanged. Surprisingly, the pubic hair almost com-7 o0 l! b5 |% s* B5 x7 E# \+ O% q
pletely disappeared except for a few vellous hairs at8 H4 J1 i! g5 M6 u, d' ]( n
the base of the phallus. Testicular volume was still 2
9 W- z2 E# H" K, V  VmL, and the size of the penis remained unchanged.- y0 J; W& F; j) ]; U5 Z
The mother also said that the boy was no longer hav-
6 d* E! D* Q* N3 g' B- ?: Y* z6 eing frequent erections.
9 H5 a7 q. q7 U$ [Both parents were again questioned about use of
7 e" o( _' ]0 x) n* D" V& N, W/ l! \any ointment/creams that they may have applied to
7 V$ g% n/ a/ _the child’s skin. This time the father admitted the
0 H) _; V% e4 F9 KTopical Testosterone Exposure / Bhowmick et al 541% p$ V" K- A* A5 t, ^9 N
use of testosterone gel twice daily that he was apply-
3 B' a; s$ c" cing over his own shoulders, chest, and back area for$ ^$ C* X3 s0 m" r. @2 u0 |5 D/ d
a year. The father also revealed he was embarrassed2 \3 q) ^% ^% ?2 c& Q. F- b  _
to disclose that he was using a testosterone gel pre-# |' U9 r! M8 U9 ^7 {; G( [
scribed by his family physician for decreased libido7 S& e& u* {$ M
secondary to depression.
8 n) ~- k7 B. c7 AThe child slept in the same bed with parents.* @' F% ?/ u. p9 w& n8 i
The father would hug the baby and hold him on his% n7 D5 g' J# e2 r" j: X( v4 V
chest for a considerable period of time, causing sig-7 D% P4 Y$ c* E
nificant bare skin contact between baby and father.+ r( M9 g  ^( M; H
The father also admitted that after the phone call," Z6 W: H3 i  ~( r: n. Z. U0 A  i
when he learned the testosterone level in the baby& z( C# R& v3 u! ?1 o, m3 Y! {
was high, he then read the product information# |/ C# B5 i, b4 W* f8 A" o7 E
packet and concluded that it was most likely the rea-
' M; V! C# l, v  `son for the child’s virilization. At that time, they
- ~. J4 D& c3 M, M; ?8 Wdecided to put the baby in a separate bed, and the
: S5 }# M. j. G' J, r) [( q$ Wfather was not hugging him with bare skin and had
$ ]# q% w( w: k. A* M% M- u1 T, fbeen using protective clothing. A repeat testosterone& t9 `, B/ g- n% _
test was ordered, but the family did not go to the
0 R# B. v. G, M' ]# {laboratory to obtain the test.
  V2 O" ?6 U& A. {Discussion
& L- s6 |1 G! i8 ^Precocious puberty in boys is defined as secondary8 ^& b9 m4 K) F7 O
sexual development before 9 years of age.1,4
9 n; R8 ~, ]% v$ Z8 Q* {( r( e& JPrecocious puberty is termed as central (true) when9 k8 d- Q/ l' L  P* p
it is caused by the premature activation of hypo-2 G( n2 x& ]& c! b, Z7 F
thalamic pituitary gonadal axis. CPP is more com-4 [  A3 y% W0 J3 F/ P% l; n
mon in girls than in boys.1,3 Most boys with CPP. B8 S1 z, H% H" W
may have a central nervous system lesion that is
4 n( t) L8 j2 a" T- f3 f$ r! G" i/ zresponsible for the early activation of the hypothal-) I1 Z% M7 y; S
amic pituitary gonadal axis.1-3 Thus, greater empha-
% B. X+ s. c' e! qsis has been given to neuroradiologic imaging in
  m! {3 f. |5 v% j& P8 m& b$ Gboys with precocious puberty. In addition to viril-. z1 ^, D/ o: N! s  ]! J
ization, the clinical hallmark of CPP is the symmet-) T8 J6 [+ D1 U; ^2 k
rical testicular growth secondary to stimulation by
" ~! D% a1 ?# \1 i# Jgonadotropins.1,3
, t$ `0 S& _* q' X7 KGonadotropin-independent peripheral preco-
5 |; J3 \' @) g1 qcious puberty in boys also results from inappropriate& {$ Z4 l8 t1 I
androgenic stimulation from either endogenous or8 }% b6 L; Q+ o3 S1 G
exogenous sources, nonpituitary gonadotropin stim-# ~0 A4 P7 a& Y2 Z) J
ulation, and rare activating mutations.3 Virilizing+ T+ Y; S4 u8 }4 V0 v
congenital adrenal hyperplasia producing excessive1 R( q1 T: q% ?% J7 X/ V
adrenal androgens is a common cause of precocious
9 t/ q& l, F1 ]5 Wpuberty in boys.3,4
4 o9 P; \: q' Z8 Y3 S9 jThe most common form of congenital adrenal* E; J7 `9 s0 h$ z# l& p0 z2 q
hyperplasia is the 21-hydroxylase enzyme deficiency.
, \  `6 P1 J7 s7 u% x5 C: H5 M7 m; PThe 11-β hydroxylase deficiency may also result in
7 j2 c, {6 P7 m+ aexcessive adrenal androgen production, and rarely,1 v4 z# }. n" I) o5 E& a* k0 Z
an adrenal tumor may also cause adrenal androgen
( E. K- O7 x, `! D( c: Cexcess.1,3! J. G9 V4 G, u7 ~/ {- j9 E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 F. K6 U; o4 A0 X6 w, I
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) x# W! T7 K% p- N% ~( V8 H% iA unique entity of male-limited gonadotropin-0 ]. {8 C0 a7 n+ i; ~: Q, |
independent precocious puberty, which is also known
% z; Q) Z7 c1 F! m! U7 H: Gas testotoxicosis, may cause precocious puberty at a7 o& J% {4 R) n, g+ W( O
very young age. The physical findings in these boys8 v; }( t0 X  l
with this disorder are full pubertal development,
9 N9 Q9 |: p+ {! Sincluding bilateral testicular growth, similar to boys
. d3 _3 |; o% s9 z3 z7 Z& J  q+ gwith CPP. The gonadotropin levels in this disorder& Y9 a6 ^; R3 _' T% q' Q0 E2 Z& A
are suppressed to prepubertal levels and do not show) n9 X: a- W+ F6 |( O
pubertal response of gonadotropin after gonadotropin-
2 c% @  X/ n- v5 [! ^; H7 H* jreleasing hormone stimulation. This is a sex-linked
" `2 [9 Q( n3 p% F% Sautosomal dominant disorder that affects only" u4 }9 E2 a; z- K
males; therefore, other male members of the family
: q& v6 M+ F: M4 ]8 E2 hmay have similar precocious puberty.3" I$ R1 G9 V* ?5 z3 p
In our patient, physical examination was incon-% b) m4 L  G. |) _& L3 g
sistent with true precocious puberty since his testi-
  E% q9 T  ]- `4 f6 @1 r' A0 Ycles were prepubertal in size. However, testotoxicosis: P+ D. t3 X! M" {+ \5 J
was in the differential diagnosis because his father
. d8 s2 Y3 j7 ~' Ustarted puberty somewhat early, and occasionally,
; W+ V8 ?, B9 c) ltesticular enlargement is not that evident in the
) R; c7 `, A: @9 `5 Ubeginning of this process.1 In the absence of a neg-
' v2 i( s+ \+ p; j2 T1 Dative initial history of androgen exposure, our
( i% ^' w; \- s5 m$ r/ Ibiggest concern was virilizing adrenal hyperplasia,2 {; \! R, W! @) l$ S) O) w+ O
either 21-hydroxylase deficiency or 11-β hydroxylase, @( M( _# t. X
deficiency. Those diagnoses were excluded by find-
8 X0 Z* i# `5 }  Fing the normal level of adrenal steroids.6 X" h0 [# G8 T- Z% r# t
The diagnosis of exogenous androgens was strongly2 ]$ u( R- H( P, z) c, G
suspected in a follow-up visit after 4 months because
. g6 `; h) l# v( t5 l; I% Sthe physical examination revealed the complete disap-7 v$ |8 d2 b1 v( a* o, ]% c- W
pearance of pubic hair, normal growth velocity, and( D9 B& A. E5 z  Y+ {
decreased erections. The father admitted using a testos-
. x5 q$ L. r  C' sterone gel, which he concealed at first visit. He was
3 N, e0 m* t7 V' m' X6 q& i6 K2 |0 p" fusing it rather frequently, twice a day. The Physicians’; m3 j8 n8 _0 t$ }. q' ^# n, N
Desk Reference, or package insert of this product, gel or0 E5 ^: b- N" O1 k
cream, cautions about dermal testosterone transfer to- v$ @# w* u( K2 c7 o
unprotected females through direct skin exposure.0 h. D; e; Y+ k6 {# j4 l" H5 M
Serum testosterone level was found to be 2 times the
% Y' l; q. X) k  M$ m+ S% H( Qbaseline value in those females who were exposed to
9 ^; T% m3 x4 Y+ j) deven 15 minutes of direct skin contact with their male! C) R( _" e9 Q% w
partners.6 However, when a shirt covered the applica-" d- @8 T, X: d* B
tion site, this testosterone transfer was prevented.8 w! }2 p- b" ~2 O
Our patient’s testosterone level was 60 ng/mL,
: m& M" j$ w& y9 D" W; U9 q- Jwhich was clearly high. Some studies suggest that' a$ R2 z' I" d, {5 e5 w
dermal conversion of testosterone to dihydrotestos-& ~! x5 |% u2 l, V0 `9 R# e
terone, which is a more potent metabolite, is more
. @0 B1 V8 {* U' O# iactive in young children exposed to testosterone9 g$ D" g7 G3 |8 j7 f" {* n
exogenously7; however, we did not measure a dihy-9 x2 d! o" v6 W! z
drotestosterone level in our patient. In addition to3 a3 c/ F) M- O; g; U1 M
virilization, exposure to exogenous testosterone in
2 M/ ?5 H; }1 q. @  b" uchildren results in an increase in growth velocity and
7 u7 L: c- q6 D) Q6 v% P- cadvanced bone age, as seen in our patient.: T; T9 e+ L( }) {7 C
The long-term effect of androgen exposure during3 j9 u  C' ]+ t, M8 l
early childhood on pubertal development and final8 ^: @0 n0 R3 G' ]. Y
adult height are not fully known and always remain$ I* u& G: m+ Y/ k
a concern. Children treated with short-term testos-
$ U! E; x' ^9 U2 O+ B  Uterone injection or topical androgen may exhibit some
; z! G* a9 {+ z7 \acceleration of the skeletal maturation; however, after, [6 f) i1 b2 P6 J: o5 n# J
cessation of treatment, the rate of bone maturation* ^* l5 _5 j# `9 _4 Z6 m
decelerates and gradually returns to normal.8,99 W. D' I& k- W( h6 t$ a9 S4 w) u
There are conflicting reports and controversy0 X5 ~8 H4 w  s5 z$ V
over the effect of early androgen exposure on adult
: B% P6 Y6 Y% U% A9 H, Z- U' Npenile length.10,11 Some reports suggest subnormal7 M9 n/ d) z- L, `/ W
adult penile length, apparently because of downreg-7 h6 Z4 ~, x2 v
ulation of androgen receptor number.10,12 However,
* v/ }/ ^" ~) h9 sSutherland et al13 did not find a correlation between7 r( L8 L1 x8 [
childhood testosterone exposure and reduced adult
; G" Z% Y- }9 Dpenile length in clinical studies." ^1 r- {& \0 O9 D, V4 D% H
Nonetheless, we do not believe our patient is: `/ [& |/ }- V/ N2 U
going to experience any of the untoward effects from
- B: \) S) ?% J; e$ P+ x  N3 a& ^2 ktestosterone exposure as mentioned earlier because7 g( _. |7 W. K# J4 w
the exposure was not for a prolonged period of time.
4 ?" M" ]% f; J# p$ d3 o9 E4 mAlthough the bone age was advanced at the time of
* n# m# E8 A+ y; \5 q8 hdiagnosis, the child had a normal growth velocity at
: A# r! K; J9 T. B0 }$ Othe follow-up visit. It is hoped that his final adult
6 T" t+ o  t4 ]3 C; Gheight will not be affected.; l) `  q4 x4 h
Although rarely reported, the widespread avail-" _! Q, M8 x  `
ability of androgen products in our society may' C0 _1 f! I; Q4 F( J
indeed cause more virilization in male or female) F' M1 ^' v3 o4 c
children than one would realize. Exposure to andro-2 J! x" k, ?, J. U( l1 ^
gen products must be considered and specific ques-, ?- t) p, b' b8 D
tioning about the use of a testosterone product or
- G" E7 }/ q( J! V- O6 ]7 igel should be asked of the family members during$ Y6 G$ f  S) a% b8 L! q
the evaluation of any children who present with vir-! m8 H4 p9 w6 G6 N
ilization or peripheral precocious puberty. The diag-
' w  v/ N  K8 X% Knosis can be established by just a few tests and by
. t5 b$ C& C6 h# T. B$ d# ?/ ~appropriate history. The inability to obtain such a
$ i8 g5 H* f7 t/ _( Dhistory, or failure to ask the specific questions, may
/ B0 q; @. F/ }* J/ D& nresult in extensive, unnecessary, and expensive) k7 [4 b! d$ \. s5 n
investigation. The primary care physician should be
; N" d$ f: V/ P# Waware of this fact, because most of these children
, X2 Y2 l0 N, ]$ Q/ s6 y; rmay initially present in their practice. The Physicians’
& h+ z4 O7 L% GDesk Reference and package insert should also put a
4 ^! P' I$ j" o2 v& C2 h+ ~warning about the virilizing effect on a male or
$ l4 C9 d/ Z  u' C/ f7 C! d3 M1 qfemale child who might come in contact with some-
9 T. F/ _. O, W' ]2 ]8 l* yone using any of these products.1 Z/ j0 x4 G4 o5 H4 Z* b1 I
References
0 l: m& a2 d4 X1. Styne DM. The testes: disorder of sexual differentiation9 b, s% f3 v! ]5 v! D! U. m$ v
and puberty in the male. In: Sperling MA, ed. Pediatric
( A& M- d3 I* o, N' Z8 T( SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; W* \+ w' X# Y1 U2002: 565-628.; E0 V% o/ j+ N! |2 j6 ]3 Z' e. k
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* t0 Y+ p1 i" P1 Y8 ]/ E' mpuberty 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
4 Q3 K5 ^. H% ^. D+ {
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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