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Sexual Precocity in a 16-Month-Old+ ]4 ^% r& q( T7 c% G/ h; c
Boy Induced by Indirect Topical
  u4 `0 w, S7 m1 a/ vExposure to Testosterone0 ~8 F- P. k, [# R
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% E7 T4 x1 _" R! E9 rand Kenneth R. Rettig, MD1
1 H- o" J+ I# tClinical Pediatrics
* i. u6 E1 D  _# a+ i2 `Volume 46 Number 6
: g5 H' p% H8 K. H' O3 fJuly 2007 540-543' m; c# D4 g. A+ E* c( o
© 2007 Sage Publications6 d+ p3 u7 Z/ f2 ~6 y) i. {8 b$ ]
10.1177/0009922806296651
$ ~/ q, b5 E8 j; }+ \, @9 Mhttp://clp.sagepub.com$ ~% b5 f9 Q4 v
hosted at1 F) z) `. m( \
http://online.sagepub.com% |, t0 m9 x' v* t5 b7 l
Precocious puberty in boys, central or peripheral,
3 F: h# ~4 l! {# J! ^/ r: J/ d# sis a significant concern for physicians. Central
* T1 \" O/ K; y; [1 Qprecocious puberty (CPP), which is mediated& ?! F2 s, j0 n" v% D8 p+ T& s3 I2 S
through the hypothalamic pituitary gonadal axis, has
6 z9 t) t; L& \6 [6 p( Na higher incidence of organic central nervous system( J' z. G$ X# q( R8 ~2 J
lesions in boys.1,2 Virilization in boys, as manifested; D7 P: D8 f! Q1 F6 ]! s
by enlargement of the penis, development of pubic3 G7 R' H7 i" [% m% _
hair, and facial acne without enlargement of testi-
! L1 H; I% q) b( }' M5 Z; icles, suggests peripheral or pseudopuberty.1-3 We
6 N/ X( O6 H+ G0 Zreport a 16-month-old boy who presented with the
5 Z2 V8 z( o; E1 n0 ?( Q" m1 |enlargement of the phallus and pubic hair develop-
, k! J; A  g$ w- n" S% @2 Y# Ument without testicular enlargement, which was due) E2 X8 U. @* E: M
to the unintentional exposure to androgen gel used by
# r0 W1 M/ a7 K: jthe father. The family initially concealed this infor-
$ {  n( Q# w( @mation, resulting in an extensive work-up for this% f/ T! T) @" _$ O) Z9 {
child. Given the widespread and easy availability of
8 e- H9 m0 l/ n  O5 I# ]5 gtestosterone gel and cream, we believe this is proba-
6 Q0 z/ w" Q& [. [& r, ~5 \bly more common than the rare case report in the4 W0 m& X" D9 i; U) |2 A
literature.4/ h6 J+ O! i& V$ }2 v
Patient Report
1 P/ Y5 N' O& e2 H7 kA 16-month-old white child was referred to the
. E/ v0 e# x  P4 u( Gendocrine clinic by his pediatrician with the concern
! p- o* S9 u! }$ W! N1 hof early sexual development. His mother noticed
. C) [6 M6 Y+ z! d$ T3 x2 vlight colored pubic hair development when he was9 k) u! p& }7 @( x/ ^
From the 1Division of Pediatric Endocrinology, 2University of
: ]2 |/ R' j3 a' ~South Alabama Medical Center, Mobile, Alabama.9 I1 R: e% f/ M  q
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 A0 m% B+ n2 N6 l3 T! ]) |) ]
Professor of Pediatrics, University of South Alabama, College of9 T: i2 z2 I2 r+ E/ l, f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 O) `, e$ x1 @  n
e-mail: [email protected].  e4 c: U. p  |; t, U/ f. s* C
about 6 to 7 months old, which progressively became
* K7 f' r% w0 B' Tdarker. She was also concerned about the enlarge-
2 j* _' s: k3 w$ o& W) x8 iment of his penis and frequent erections. The child
4 \$ y3 |$ ~+ ]% T9 i  D! Kwas the product of a full-term normal delivery, with
& D8 k9 m) r$ p" E5 Z4 ga birth weight of 7 lb 14 oz, and birth length of! A1 Q$ s' O  I7 b; i) y% M4 v2 ^
20 inches. He was breast-fed throughout the first year
$ Z$ n) c: x, \6 G+ }* U$ Gof life and was still receiving breast milk along with
6 l& }8 H, V* n. J# y& Hsolid food. He had no hospitalizations or surgery,
( W0 m$ U, [4 U0 j; p% y2 Wand his psychosocial and psychomotor development
5 G! A& R. |( k4 Lwas age appropriate.( N! N* L" Y3 h( k
The family history was remarkable for the father," L: X. \" i9 H. x7 o( L  j
who was diagnosed with hypothyroidism at age 16,
6 }5 V- R4 X0 q/ a( B) m% Rwhich was treated with thyroxine. The father’s
" M# s7 d9 t2 V+ f/ c, R. g2 Aheight was 6 feet, and he went through a somewhat4 F7 [- ?. N& N% c9 C9 i( B
early puberty and had stopped growing by age 14.  `3 H! J! k& r9 E+ q5 z( K
The father denied taking any other medication. The
1 Z1 u  C5 j  C7 U) Uchild’s mother was in good health. Her menarche/ L( \6 C! t$ B. G& l
was at 11 years of age, and her height was at 5 feet
* E6 {% z. R7 M) r/ U6 Q) ]5 inches. There was no other family history of pre-) k4 Y. J+ C7 j7 V
cocious sexual development in the first-degree rela-
" v( p0 z  d4 V1 }8 k/ b. ^! e3 {$ Htives. There were no siblings.
9 n. y& d; y) m2 LPhysical Examination2 a0 x" {  U+ N! F0 x
The physical examination revealed a very active,- P- [0 ~* O# z) V  ^/ M$ E) M5 M
playful, and healthy boy. The vital signs documented5 q5 ]3 k( V' ?& v- r# P
a blood pressure of 85/50 mm Hg, his length was9 a) F( J. U1 _# k  t& C/ W
90 cm (>97th percentile), and his weight was 14.4 kg9 F' {5 a+ h; c3 t
(also >97th percentile). The observed yearly growth: i  x' F6 {" E+ W. x5 e
velocity was 30 cm (12 inches). The examination of
& S0 u$ Q. F6 [% S/ u( y# i1 G. b7 Ethe neck revealed no thyroid enlargement.3 z% {/ T2 k9 O  {+ n4 c! T
The genitourinary examination was remarkable for
5 d/ U9 X4 i( \  J& [enlargement of the penis, with a stretched length of
' Y* X0 }' r- ]' P8 cm and a width of 2 cm. The glans penis was very well
+ y5 A+ k* d* B, t' pdeveloped. The pubic hair was Tanner II, mostly around
+ m( M$ `7 u% \540" k) J1 \' u" b7 i. B2 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ C' Y2 b& U$ {; I9 N. s) i
the base of the phallus and was dark and curled. The) p7 X5 _6 A$ N+ d5 ~" A, f0 J4 x
testicular volume was prepubertal at 2 mL each.
) h: N. C; C! {! K! ^- qThe skin was moist and smooth and somewhat# v6 H8 O3 y# N( z4 Z
oily. No axillary hair was noted. There were no6 F3 {$ @, Z( I
abnormal skin pigmentations or café-au-lait spots.9 R& ^3 I! f8 V
Neurologic evaluation showed deep tendon reflex 2+
  U. ^7 h+ s; K. C3 Z2 U4 G/ H. Obilateral and symmetrical. There was no suggestion% l6 t! g5 _6 R. z  R
of papilledema.
% v# {7 p* m; f1 NLaboratory Evaluation0 O% \2 ]! S% W4 k8 h1 s- b
The bone age was consistent with 28 months by
0 A. g' w# s0 Z: k2 U; uusing the standard of Greulich and Pyle at a chrono-
- @9 P2 f! J* V  Mlogic age of 16 months (advanced).5 Chromosomal: [# T6 Y, w' y# \) E6 G
karyotype was 46XY. The thyroid function test+ u5 M2 u% o) Z8 ~7 S; c9 z# G7 p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' ~5 T/ y$ ~, b  u# ?" ^
lating hormone level was 1.3 µIU/mL (both normal).1 _& P1 k6 D0 a* d
The concentrations of serum electrolytes, blood
  X, e' l! z) Burea nitrogen, creatinine, and calcium all were2 }8 A% s8 _+ {$ ^4 z, F/ b0 B
within normal range for his age. The concentration
2 p$ K0 I7 B- ?1 d" N! }" B8 f% iof serum 17-hydroxyprogesterone was 16 ng/dL
# O  u4 D9 P$ H5 r( f6 y7 O(normal, 3 to 90 ng/dL), androstenedione was 20( W' E4 y- q" F3 h6 D  K5 _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  B' |# m7 _/ z, a9 }( o/ L
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" X, k" z& _+ m, O8 R+ Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
' z& _8 t& M  z. q. k/ H49ng/dL), 11-desoxycortisol (specific compound S)2 \5 C0 @( n7 p+ c
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) @6 d5 Z- J. k
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' b! T6 y8 B: g- P" Q& ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. w1 g) E1 C" H1 g1 x( m0 q
and β-human chorionic gonadotropin was less than
- S3 s8 d2 m  i' E9 k5 mIU/mL (normal <5 mIU/mL). Serum follicular
( E, D) z) x/ Dstimulating hormone and leuteinizing hormone* q" E0 W! G4 c9 o+ }5 x0 h$ Y
concentrations were less than 0.05 mIU/mL: R; d2 i5 ~0 f& K  H0 {
(prepubertal).
* c/ G; ?9 C& {$ Q  I# D8 jThe parents were notified about the laboratory
% d# M, K8 @- lresults and were informed that all of the tests were
: [3 D4 A/ k; Gnormal except the testosterone level was high. The2 a! I, B( ~6 J- B" F; T" ?, {
follow-up visit was arranged within a few weeks to3 u# |7 s2 }  m2 u+ {
obtain testicular and abdominal sonograms; how-0 u( a4 i9 P7 }
ever, the family did not return for 4 months.3 a' o0 W% M% M, N7 a/ j
Physical examination at this time revealed that the
" ]8 X5 a4 G8 K4 G% @5 G; o0 vchild had grown 2.5 cm in 4 months and had gained! T0 W% B/ l/ _7 K* |2 X
2 kg of weight. Physical examination remained
1 a; {- q: Y: a- Wunchanged. Surprisingly, the pubic hair almost com-
5 c8 v) \  U3 t$ i; ?' opletely disappeared except for a few vellous hairs at4 n5 \1 h; H3 {4 N+ M
the base of the phallus. Testicular volume was still 2# M* v# D) Q+ I; f) U5 L
mL, and the size of the penis remained unchanged.0 c6 T  e( q" @4 S9 N
The mother also said that the boy was no longer hav-
  P2 ~/ V+ ?* \* A1 eing frequent erections.
* s  q7 J0 v5 aBoth parents were again questioned about use of9 Q) C+ e+ _0 G/ z  P3 @; U
any ointment/creams that they may have applied to
8 j  e% f, z# Q, ~8 j/ `the child’s skin. This time the father admitted the
7 a) a; b# |6 i/ Y3 qTopical Testosterone Exposure / Bhowmick et al 541
) \' |; l* G4 U3 x( K  Juse of testosterone gel twice daily that he was apply-. `, Y% A' s+ `& l! m& h
ing over his own shoulders, chest, and back area for, d# H5 }2 H- z/ l
a year. The father also revealed he was embarrassed9 W4 [  X" \, F0 N* o. |! Z. ~
to disclose that he was using a testosterone gel pre-
2 Z1 g* ]% Z) cscribed by his family physician for decreased libido
# M+ y5 K) p# \, H; T) w4 l1 ?secondary to depression.( q3 ?! }% b3 a. z7 D& z" s
The child slept in the same bed with parents.
, b! K: R( x2 _. X0 R( XThe father would hug the baby and hold him on his
  V9 L% s$ @$ wchest for a considerable period of time, causing sig-% [" H$ m' l% |8 R/ Z
nificant bare skin contact between baby and father.  y" m5 T% h: q% h1 x  j; o8 o
The father also admitted that after the phone call,
6 f" `9 y) h3 L# F7 Xwhen he learned the testosterone level in the baby
: D& T, }- [9 |( M7 w  i( f' W+ N8 }was high, he then read the product information
/ ~( \7 t5 D" o4 D' zpacket and concluded that it was most likely the rea-
  [- J% h# p# V, F8 q0 Lson for the child’s virilization. At that time, they, s% J2 @7 c5 [8 \6 r$ J
decided to put the baby in a separate bed, and the
; F" P  n; ^1 z% M1 w( l3 cfather was not hugging him with bare skin and had
0 _% }% W, G' ?( j9 F0 J7 Xbeen using protective clothing. A repeat testosterone
: {  c' K# I$ F4 m! wtest was ordered, but the family did not go to the
1 ?- W8 e% G' V' @; O# B+ alaboratory to obtain the test.- o! Y0 [+ T, `" s' N, p( H
Discussion
5 x8 j3 T/ Y3 D$ P+ i, k" j2 yPrecocious puberty in boys is defined as secondary$ q) G5 J# m4 u1 k4 ]/ T: Y6 W
sexual development before 9 years of age.1,4
- U2 I! d* c$ \% IPrecocious puberty is termed as central (true) when2 d" p5 I0 h8 \1 n' S1 }* c
it is caused by the premature activation of hypo-+ K0 j# c0 f  O6 S! f
thalamic pituitary gonadal axis. CPP is more com-4 Y, T8 D( a6 d- ~  y
mon in girls than in boys.1,3 Most boys with CPP+ o: x; |& l* O! _& y  _1 X
may have a central nervous system lesion that is
" u2 @5 D8 x/ \6 `; Zresponsible for the early activation of the hypothal-* S& d; z% {6 D& c
amic pituitary gonadal axis.1-3 Thus, greater empha-
: d& @% c( V# x0 [  Usis has been given to neuroradiologic imaging in
2 u+ n/ [8 m6 ]( lboys with precocious puberty. In addition to viril-
& h. l1 M# u- i  k1 p" ?5 rization, the clinical hallmark of CPP is the symmet-0 J4 a! u( {: j% m9 l1 p$ e- v
rical testicular growth secondary to stimulation by
6 ?$ ]; N2 |" B6 D7 d7 ^gonadotropins.1,3# |4 w- ]! ~0 J5 J7 [# |& T- W
Gonadotropin-independent peripheral preco-
9 R2 M3 s0 g( r% z- J( ^2 m7 Acious puberty in boys also results from inappropriate( w, z4 W6 q3 W5 v! ?3 L
androgenic stimulation from either endogenous or7 p/ P! d! l% R9 h% w3 m1 Z
exogenous sources, nonpituitary gonadotropin stim-  f$ x6 k7 d! U$ Q) x4 c! L
ulation, and rare activating mutations.3 Virilizing
2 P- i9 w: S! b" s* ]congenital adrenal hyperplasia producing excessive2 o& |3 _: i; s: ~; `
adrenal androgens is a common cause of precocious) J7 L2 |$ ~" E- V5 ]
puberty in boys.3,4' v! Z/ Q' q1 v  |; ~" ?& M
The most common form of congenital adrenal6 j+ O% Z- ^& d# x( c
hyperplasia is the 21-hydroxylase enzyme deficiency.( C; d$ S, I6 }/ J- B
The 11-β hydroxylase deficiency may also result in
4 v' i8 g, ]$ W$ ~  g2 m9 zexcessive adrenal androgen production, and rarely,& n' Y; r! J/ X  k& I/ y, V
an adrenal tumor may also cause adrenal androgen) i: O. W1 T) g" k7 |$ W5 N9 O
excess.1,3
5 d8 ?+ m; r0 \. Z& i& Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 V' `) P. J0 P0 w542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 }- D  E4 ]1 l, A
A unique entity of male-limited gonadotropin-8 d1 [5 X+ R- ~; d' J- e& D3 R
independent precocious puberty, which is also known: R9 w+ K0 P  s8 \* Y) h
as testotoxicosis, may cause precocious puberty at a
5 L- A. Q/ p- I6 d" n9 a# vvery young age. The physical findings in these boys/ c- c& T! c& _4 n' h
with this disorder are full pubertal development,  w' G1 {) Z& y" p6 h
including bilateral testicular growth, similar to boys9 h) b7 e$ v" o) x8 t
with CPP. The gonadotropin levels in this disorder
/ N) n: S" Y; Z( Ware suppressed to prepubertal levels and do not show
7 k2 [* ?' ~6 m+ _3 K0 p1 fpubertal response of gonadotropin after gonadotropin-; T3 g6 l; E% P/ ?+ |
releasing hormone stimulation. This is a sex-linked
2 T4 g( U5 L0 M+ X+ u" H+ Aautosomal dominant disorder that affects only: ~8 o3 P* O& i5 l/ L
males; therefore, other male members of the family
- |- x9 ~3 |- vmay have similar precocious puberty.34 v% ?; z0 w' O2 a, i+ |7 ^
In our patient, physical examination was incon-- }4 c1 S. Q) k/ e  v3 L9 S
sistent with true precocious puberty since his testi-# L7 B8 E4 W# Y* a
cles were prepubertal in size. However, testotoxicosis/ B( u/ X5 f8 m( O2 y- y% U
was in the differential diagnosis because his father/ n; T5 p( y4 D2 z$ \
started puberty somewhat early, and occasionally,. Q! ~3 x) ?1 C* D  i
testicular enlargement is not that evident in the; b& v# }- f/ O6 d
beginning of this process.1 In the absence of a neg-
" \) o- g# L$ _% U: f0 pative initial history of androgen exposure, our
2 K$ s3 N% m( Y2 P/ Mbiggest concern was virilizing adrenal hyperplasia,
% @4 Z) L& c( {% h3 u0 P' ]- d: W% Beither 21-hydroxylase deficiency or 11-β hydroxylase
) ]7 o4 {5 R, f& c+ h3 Ydeficiency. Those diagnoses were excluded by find-
* o+ a! v# |4 ^4 J" Hing the normal level of adrenal steroids.
$ S- G0 F+ m9 l, \6 R- `2 h6 iThe diagnosis of exogenous androgens was strongly/ d* w8 s3 p5 E
suspected in a follow-up visit after 4 months because; i5 s5 x# ^7 B  @
the physical examination revealed the complete disap-7 k4 N( B" O2 I) C. ^$ G  Z8 I
pearance of pubic hair, normal growth velocity, and: H2 `7 u% Y* v5 G0 B; a
decreased erections. The father admitted using a testos-
; Q: L( \% @) o  u) g: Qterone gel, which he concealed at first visit. He was2 V5 E8 S& t3 ^
using it rather frequently, twice a day. The Physicians’0 f, k# `! C# t& v- _
Desk Reference, or package insert of this product, gel or
0 ~6 ~1 n9 S+ qcream, cautions about dermal testosterone transfer to8 T3 ]; I- D( N# C. ^4 P
unprotected females through direct skin exposure.& t! K, S) T% `- n% I
Serum testosterone level was found to be 2 times the1 x* h  K' M8 N& R* l
baseline value in those females who were exposed to  L2 W# t8 p1 }; Z  @4 D& W
even 15 minutes of direct skin contact with their male
9 i% h* i8 A0 m( v/ Fpartners.6 However, when a shirt covered the applica-0 Q, ?8 F: w, N3 O' g$ X
tion site, this testosterone transfer was prevented.
( X3 t4 o; t7 n3 m$ ROur patient’s testosterone level was 60 ng/mL,$ B, W  U- V- E9 q/ r$ n, C
which was clearly high. Some studies suggest that
; y$ Z+ i8 K+ N# I- Idermal conversion of testosterone to dihydrotestos-
3 O5 q! ^2 @" J% t$ t. |terone, which is a more potent metabolite, is more
, {* T5 u  ^" ?% Y1 v5 zactive in young children exposed to testosterone
' l$ h- V; j" o* Oexogenously7; however, we did not measure a dihy-2 W: H% v2 n' x
drotestosterone level in our patient. In addition to) R' X% [0 A( N
virilization, exposure to exogenous testosterone in
4 Z6 R: L+ Y/ ^! Z: R: }. C; hchildren results in an increase in growth velocity and+ y$ o3 b; f- K3 J
advanced bone age, as seen in our patient.
" o, ~  {' T0 XThe long-term effect of androgen exposure during% `! {' i8 e* c5 V
early childhood on pubertal development and final! j& N. Y0 K5 w3 R; M7 f
adult height are not fully known and always remain2 U( o, {/ K" C# t$ e- S. Q' i
a concern. Children treated with short-term testos-
1 k/ z, U9 U+ b% ]8 Eterone injection or topical androgen may exhibit some
( O5 S' S3 g: J6 l% M4 M/ uacceleration of the skeletal maturation; however, after& T. V. i/ q$ |' g  n1 S7 D
cessation of treatment, the rate of bone maturation
, Y% d, j1 ~+ r( D. J$ wdecelerates and gradually returns to normal.8,9$ a/ W* n9 [' `, Z
There are conflicting reports and controversy
" |9 |% Y; [& k" Q- ~over the effect of early androgen exposure on adult
6 t" [0 V# p9 C- g8 l% lpenile length.10,11 Some reports suggest subnormal: o' b, A$ ^. e  D
adult penile length, apparently because of downreg-
- V9 X7 s% q# _2 B) u& Hulation of androgen receptor number.10,12 However,
" k& n0 _! _& G. ^& v. P- K! P2 RSutherland et al13 did not find a correlation between# l4 I. e! y) v+ x) `6 G, G8 w
childhood testosterone exposure and reduced adult
  i' j+ w2 k7 ]% g& ~penile length in clinical studies.
2 D0 W2 A' A9 a: ?Nonetheless, we do not believe our patient is
' f9 F3 J" ~, d6 i- Qgoing to experience any of the untoward effects from
+ n  ?7 c& Q6 |# A2 Rtestosterone exposure as mentioned earlier because
$ c5 ^/ E% U. Ethe exposure was not for a prolonged period of time.
% T6 i; D+ u- R0 W9 rAlthough the bone age was advanced at the time of
1 |. p: d5 e/ L1 X% A# _: Y4 xdiagnosis, the child had a normal growth velocity at
2 ^& p7 ]( D; f1 g) R) G$ j; h: C1 G4 jthe follow-up visit. It is hoped that his final adult8 U- t2 t8 y+ J9 c! h
height will not be affected.
. A/ M( F; }1 G' {Although rarely reported, the widespread avail-6 {$ E& N4 f* [& K) d0 N
ability of androgen products in our society may
# H# |* C. C- q2 ~' P" }indeed cause more virilization in male or female5 H' u! J1 ^% A9 y7 w$ J8 o
children than one would realize. Exposure to andro-! z0 c! U0 d, B1 Y: `9 `6 E. B% ^. q
gen products must be considered and specific ques-9 W& u* @6 o  g9 X* V
tioning about the use of a testosterone product or* Q' W/ q' A/ p" Q
gel should be asked of the family members during6 _: E4 ~* w; S  M5 h
the evaluation of any children who present with vir-2 s- `4 M2 m1 v5 C( H
ilization or peripheral precocious puberty. The diag-
: B$ D: j$ g! U% g. F2 pnosis can be established by just a few tests and by" b% Y  K6 V! C- d/ g
appropriate history. The inability to obtain such a: {8 t  J/ A- E& [$ P- ]2 F7 [! C
history, or failure to ask the specific questions, may& F, O8 x) S5 o9 |" `
result in extensive, unnecessary, and expensive
% {% j, |* q; T3 X4 w4 q/ Ainvestigation. The primary care physician should be
+ ~. `3 V7 w' Q+ M# \aware of this fact, because most of these children& d, r9 x8 h0 |+ P
may initially present in their practice. The Physicians’- n* T' e' j2 F9 s
Desk Reference and package insert should also put a
/ D0 _% Q- r! Xwarning about the virilizing effect on a male or# x9 @, r# F+ n4 P$ Q' A
female child who might come in contact with some-4 k: }+ G0 c# y8 O  |
one using any of these products.! e$ ]/ C$ n. f2 U' |& l7 n5 {+ [
References
  U& Z, S& }4 q3 H% k, b8 W. l2 g1. Styne DM. The testes: disorder of sexual differentiation$ d3 ?$ E% }2 H* t  L1 S1 M$ t+ B
and puberty in the male. In: Sperling MA, ed. Pediatric
' _, }, B: k: Z# BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) x* L$ R# {. C6 r3 i3 c  o
2002: 565-628.
4 o2 \! |0 k6 U6 Q$ P2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, g: F5 B: |1 Y. K) J
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' C4 R0 \5 t7 J1 {2 pBoy Induced by Indirect Topical& O3 F7 P/ \1 v' {1 `% n
Exposure to Testosterone3 ?% S$ h  p3 ]) v& W1 A* |, p9 U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* n# g; w: ^: d+ L% o5 i1 y+ T
and Kenneth R. Rettig, MD1- h8 M$ Y2 z9 u1 O' n6 p
Clinical Pediatrics* g! \$ |* ]# ~" w
Volume 46 Number 6
8 a* v6 |* i) ?/ r, O* U8 LJuly 2007 540-543* T8 x9 i3 C$ U" u
© 2007 Sage Publications
6 b- {3 ]6 A+ `/ H1 ?  g( f4 N10.1177/0009922806296651
) p- n! n! j7 M  E7 Qhttp://clp.sagepub.com: b% H. y% r% ~5 _1 I
hosted at$ k, l; z& Q- T3 Z* f
http://online.sagepub.com
8 i" Z9 x: j$ o4 {Precocious puberty in boys, central or peripheral,+ ^7 ?" P2 A5 B# X# L
is a significant concern for physicians. Central
0 n1 j& e6 r- T! ^precocious puberty (CPP), which is mediated
* Y" Y! G; a; ]through the hypothalamic pituitary gonadal axis, has
. }9 L4 I2 Y# I/ \, u. q+ b& ?" Pa higher incidence of organic central nervous system( B& E: ~5 l4 S4 ~- k
lesions in boys.1,2 Virilization in boys, as manifested; k8 f: [) z7 s! p3 d8 u
by enlargement of the penis, development of pubic
( C: V) S8 e- H' d3 S! e, jhair, and facial acne without enlargement of testi-
1 R) M: J- t+ ]cles, suggests peripheral or pseudopuberty.1-3 We9 Y$ C. r" H7 L( y
report a 16-month-old boy who presented with the
; C& ]2 D4 ?. y9 j7 Venlargement of the phallus and pubic hair develop-
3 p7 d6 _- k* A* F5 Iment without testicular enlargement, which was due
' i9 {( q+ O6 N  q6 @to the unintentional exposure to androgen gel used by) a& r. W) u" s, z# i8 P
the father. The family initially concealed this infor-: I: g9 o- K* V6 \# l: d7 P- E& H
mation, resulting in an extensive work-up for this# H& H; w& U! G( A# ^8 o
child. Given the widespread and easy availability of
" n: [7 d# k( [/ I+ ~3 w) itestosterone gel and cream, we believe this is proba-' U0 ?$ i/ D! e
bly more common than the rare case report in the# z4 j" h+ A8 \8 v2 X3 Z2 P9 U
literature.42 t6 L+ r" l, K8 @& E
Patient Report
: {2 |# J2 H% a3 zA 16-month-old white child was referred to the; _& g/ w2 K5 m& o7 P; }
endocrine clinic by his pediatrician with the concern+ ]  ?6 ~! F" q! \( q
of early sexual development. His mother noticed- |/ ?, F6 [$ w1 Q% ~
light colored pubic hair development when he was1 J& U4 b! P/ H( h1 X, l' n9 p0 k
From the 1Division of Pediatric Endocrinology, 2University of" e* K( G; S6 G7 C9 D
South Alabama Medical Center, Mobile, Alabama.
" I& y/ ^* D% o1 j, Q3 @Address correspondence to: Samar K. Bhowmick, MD, FACE,
* s+ E: M' d0 X- K& v0 x" |/ Q* f! rProfessor of Pediatrics, University of South Alabama, College of
- |- p$ k4 j0 A* C3 q* L, iMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% a; [3 r6 l. e  P
e-mail: [email protected].
4 S8 q# t$ u2 l! V8 d; dabout 6 to 7 months old, which progressively became  s. o' S$ B( x( W$ u- o/ W+ C
darker. She was also concerned about the enlarge-
. g8 b2 Q/ J$ E+ m/ r3 ^* kment of his penis and frequent erections. The child
7 m; t* A, K2 S% t2 ~was the product of a full-term normal delivery, with2 L) g2 L! ?* D8 w% c9 }7 G& F
a birth weight of 7 lb 14 oz, and birth length of/ R% l; B3 r& }8 o
20 inches. He was breast-fed throughout the first year
; k: h  [- b  |; ]+ E9 ^# Oof life and was still receiving breast milk along with7 n/ `7 J; D* q7 u3 E& N/ Q
solid food. He had no hospitalizations or surgery,$ T8 s. a, n: t/ \# r
and his psychosocial and psychomotor development8 o! _  ?! i& m
was age appropriate.  ]) O) t" F# D+ l$ v$ I" a
The family history was remarkable for the father,
. L/ `2 k" {' Zwho was diagnosed with hypothyroidism at age 16,
+ z+ b' w; Q! O5 z' Hwhich was treated with thyroxine. The father’s5 o+ _6 e/ P; d8 n7 y7 G* R1 [
height was 6 feet, and he went through a somewhat, Q7 h4 k7 C- _- F
early puberty and had stopped growing by age 14./ J4 M6 U- a# _$ Z' o& v* M
The father denied taking any other medication. The
# i2 e' E( ^' }child’s mother was in good health. Her menarche
/ O( ^. r" E) Ewas at 11 years of age, and her height was at 5 feet
, n6 m3 I& H+ h5 inches. There was no other family history of pre-
2 M- e5 ?) l  T3 ^& D9 N& Acocious sexual development in the first-degree rela-
! f+ q2 ]5 O( \& M# `tives. There were no siblings." ^: J* C, D0 C/ d/ l
Physical Examination; f; u, ~. k( p* L
The physical examination revealed a very active,) J( N: k" c) x; q6 h
playful, and healthy boy. The vital signs documented! ~5 i6 U( U8 f2 V: W& j* y
a blood pressure of 85/50 mm Hg, his length was2 E' q+ C/ s8 B" C! T
90 cm (>97th percentile), and his weight was 14.4 kg9 j" j5 t1 _. `* T8 S# q6 f
(also >97th percentile). The observed yearly growth
2 D1 \8 J) D- S0 Q5 Y' D( q6 k8 P% Bvelocity was 30 cm (12 inches). The examination of- b0 @* T/ z& E7 T( g/ q3 G0 U
the neck revealed no thyroid enlargement.
( N5 J: x% d" D6 S& A. I: ^% XThe genitourinary examination was remarkable for
( a& v' Q% s) Y3 V; C) Venlargement of the penis, with a stretched length of
( }5 f* s  b' ~# S  Y$ X8 cm and a width of 2 cm. The glans penis was very well
# H- X( R8 i; s9 Pdeveloped. The pubic hair was Tanner II, mostly around
+ c8 [  T: s1 [540* ]/ I" i* }$ j! ~3 E' e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 w1 ?5 V# n, R! Ythe base of the phallus and was dark and curled. The" c4 j" v) P9 h/ H
testicular volume was prepubertal at 2 mL each.: p, m+ B1 v. j7 ~
The skin was moist and smooth and somewhat! i, R4 m$ ?: ]5 Z. W2 b0 [/ f
oily. No axillary hair was noted. There were no! z2 G9 @5 {. c8 `% b
abnormal skin pigmentations or café-au-lait spots.
6 M: T" D3 Q, z1 b5 lNeurologic evaluation showed deep tendon reflex 2+- ?) N% w* {" V9 y5 h. L& x  i
bilateral and symmetrical. There was no suggestion
" D* E; {' r3 F2 Jof papilledema.
. R- O" I: m0 Z* I" S9 \8 \Laboratory Evaluation/ p: T, x7 Y* g5 c* [  G$ _
The bone age was consistent with 28 months by
% ]( a* u, @4 j! Tusing the standard of Greulich and Pyle at a chrono-
, i& q: r0 e  O; ^* \logic age of 16 months (advanced).5 Chromosomal4 x" I) }! o, f8 q0 o' k4 G" d
karyotype was 46XY. The thyroid function test
" J4 S% T- \+ R  {, R2 F& Z) vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( k; m( L8 z, G' z2 slating hormone level was 1.3 µIU/mL (both normal).0 X2 e: Y- S( q9 }! ?
The concentrations of serum electrolytes, blood
4 e2 y; Y8 P  a1 L; b/ turea nitrogen, creatinine, and calcium all were
7 Y, K3 U; {. n  L' pwithin normal range for his age. The concentration" N# G+ r6 l) u) k/ U
of serum 17-hydroxyprogesterone was 16 ng/dL& V+ F6 Y1 S3 X6 Y
(normal, 3 to 90 ng/dL), androstenedione was 20
, G- D7 Y$ p% I2 V) c* Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 u% |6 p$ I, p" x" \" cterone was 38 ng/dL (normal, 50 to 760 ng/dL),: e$ F  G9 X/ y% q5 c0 \8 A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' b+ d: p- v/ W2 c  F% V; D49ng/dL), 11-desoxycortisol (specific compound S)3 [# N; ?: n6 e
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% f$ o7 Q$ Y& D( m6 Ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; [) T) y. e; `$ c$ `% Q# G4 j5 M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% R1 r0 C4 ~% W1 @0 B4 Q  D
and β-human chorionic gonadotropin was less than' Y9 k" `9 R: T2 y
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 D6 R1 }. Y/ f. a/ u! C0 f
stimulating hormone and leuteinizing hormone% P. D5 q4 T$ P% C* k( g  J  j7 i9 |
concentrations were less than 0.05 mIU/mL
5 m! s+ E; N! z0 b(prepubertal).9 B: W$ B. `2 D
The parents were notified about the laboratory0 @* F+ v" d2 x: Y' }
results and were informed that all of the tests were
. O: ~" B/ J+ A) _2 w2 h  Z- znormal except the testosterone level was high. The
2 Y: |# [+ U  X( N. n) R- Ifollow-up visit was arranged within a few weeks to
! L% W1 i1 Y! n" H$ a7 j1 K3 Zobtain testicular and abdominal sonograms; how-: Z( c0 h% S, ?# k6 h/ q
ever, the family did not return for 4 months.
4 f; d. w. H3 j$ n; U# t, q) jPhysical examination at this time revealed that the
, g, V7 _: ]1 d; |. K+ @4 a. E8 Wchild had grown 2.5 cm in 4 months and had gained
8 P" J( E0 T  Z$ U! S" \2 kg of weight. Physical examination remained3 v+ X. O9 x: n9 X, v) y) |
unchanged. Surprisingly, the pubic hair almost com-
- k' A  X. U0 _' z! s. @! \+ qpletely disappeared except for a few vellous hairs at3 h) X8 C, W. m3 t  i4 b5 V
the base of the phallus. Testicular volume was still 2. y3 \" S3 M3 Z2 w
mL, and the size of the penis remained unchanged.( S& k( ~" `( Z/ D9 R' Z4 A
The mother also said that the boy was no longer hav-
4 T" U  ~# {4 o/ H1 g# bing frequent erections.. J' `9 h! l) f" A2 ~5 f
Both parents were again questioned about use of
  s5 P% H$ u, ]5 @- m% vany ointment/creams that they may have applied to1 R: X3 z5 r* I/ ?! Q1 ~- B
the child’s skin. This time the father admitted the3 D4 S( P; e( q. O9 ~
Topical Testosterone Exposure / Bhowmick et al 541
( k6 {# i+ v" G( xuse of testosterone gel twice daily that he was apply-
, Q1 g/ T8 s5 y# uing over his own shoulders, chest, and back area for
# {5 X  E) R; n; H6 T' O1 _4 Sa year. The father also revealed he was embarrassed7 ~) Q7 n. \# k+ _: }, b5 u. m) ]
to disclose that he was using a testosterone gel pre-
- p, d: _' N9 m# j* e& K- s2 n$ {4 Nscribed by his family physician for decreased libido  S/ T/ N1 W' \- r
secondary to depression.
3 Q9 t% H, P4 j5 U* L$ H4 H+ VThe child slept in the same bed with parents.# X% Q. p7 d$ {. Y: W
The father would hug the baby and hold him on his) K: o0 X6 E5 i6 a4 m
chest for a considerable period of time, causing sig-
2 m8 g1 l6 V9 q$ f: Unificant bare skin contact between baby and father.
% B9 A2 i3 y7 z( LThe father also admitted that after the phone call,! K- S5 u9 N4 {6 N. V/ ^: g( W# N
when he learned the testosterone level in the baby) i9 j5 p5 U7 s8 |/ B& r% \: V
was high, he then read the product information
) ~# z% P8 c& D8 c, Mpacket and concluded that it was most likely the rea-
5 C7 z7 E) H5 y- j' u  s) D, ~( }8 `son for the child’s virilization. At that time, they
. [5 s6 V8 X7 w- V& p, f* a9 pdecided to put the baby in a separate bed, and the. D( K# u* J' f% A
father was not hugging him with bare skin and had
, R; X- Q6 \1 M+ e3 Q1 }9 O: }0 ?been using protective clothing. A repeat testosterone
, n3 D" [- I8 w  l0 x0 _test was ordered, but the family did not go to the
  b8 h  |) z: o: ilaboratory to obtain the test.1 I$ Z, Y% z- o5 m9 n$ t0 w% ~+ x
Discussion
8 i# h# J# d  u: u9 `- TPrecocious puberty in boys is defined as secondary2 n5 O- p9 o. b
sexual development before 9 years of age.1,4" G' h  @9 Z) o) H
Precocious puberty is termed as central (true) when; s; B6 \- Z( C4 G
it is caused by the premature activation of hypo-
* T) M( d1 V+ g  }- X2 Lthalamic pituitary gonadal axis. CPP is more com-7 T2 Y6 F2 a3 c) r0 Y
mon in girls than in boys.1,3 Most boys with CPP
/ @- t# ^1 E# G$ {" mmay have a central nervous system lesion that is# ]. h3 q: Y2 P) Z
responsible for the early activation of the hypothal-
% y  V( ]0 u8 ^& Eamic pituitary gonadal axis.1-3 Thus, greater empha-: Q! ^: D5 Z1 d, s" U/ a
sis has been given to neuroradiologic imaging in, O/ g4 D" y: g* J3 Q/ I
boys with precocious puberty. In addition to viril-7 ?& }& q; v- l) V
ization, the clinical hallmark of CPP is the symmet-
; Q6 N% d& T) l% z% ^- Frical testicular growth secondary to stimulation by/ O& D0 b# T! r% v7 q
gonadotropins.1,3
9 V- [+ ~& p3 d3 S  ?Gonadotropin-independent peripheral preco-9 I8 z. t5 p3 n! X; q2 W
cious puberty in boys also results from inappropriate# o: \; m3 Q: r( {( J7 H' q9 D
androgenic stimulation from either endogenous or6 q3 u4 z: z- T3 ~' K6 [
exogenous sources, nonpituitary gonadotropin stim-3 K" N$ P8 ?; C  r3 x' Q6 [0 k
ulation, and rare activating mutations.3 Virilizing. I; s. l% q) A% b$ }  O& g) ]/ b9 ~' v7 s
congenital adrenal hyperplasia producing excessive: Z" r: I: F$ K$ ]' n1 {
adrenal androgens is a common cause of precocious
/ p+ ?1 w. c8 O0 S( E- w( spuberty in boys.3,4
4 s% V" z$ N4 X0 O+ T% vThe most common form of congenital adrenal, V8 H6 M5 a) a2 G6 c" }, a
hyperplasia is the 21-hydroxylase enzyme deficiency.
- L, K1 ^" v% V/ r. c$ z/ \The 11-β hydroxylase deficiency may also result in
" d$ `8 @6 U7 B: F( _excessive adrenal androgen production, and rarely,
+ \4 h  }2 q. Oan adrenal tumor may also cause adrenal androgen
; [/ ~5 Q. T% b6 h- e7 d: y; s# m2 O, iexcess.1,3; h/ w0 u0 V0 w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 @+ o: W, h9 _2 \8 ~6 _. w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; c0 L$ {' t9 s* }9 c3 h$ H2 vA unique entity of male-limited gonadotropin-6 x' J8 B1 S6 P: b2 c
independent precocious puberty, which is also known
0 t5 Y% ^7 k! M- p5 b, r6 N) K8 oas testotoxicosis, may cause precocious puberty at a
" r7 P% x' F, ?( J  ^very young age. The physical findings in these boys
  l8 k$ |* v2 E3 Y+ A# M0 Xwith this disorder are full pubertal development,0 @& ~- p! m+ H" F
including bilateral testicular growth, similar to boys. ^) D" l4 p3 |. s
with CPP. The gonadotropin levels in this disorder
0 g( s; C* u' N* Zare suppressed to prepubertal levels and do not show5 r; `; Q9 `) L4 [6 h7 b* W
pubertal response of gonadotropin after gonadotropin-
6 b' {- v4 V5 s0 r8 Qreleasing hormone stimulation. This is a sex-linked
6 m& _% A, y" E9 ]* \% o) gautosomal dominant disorder that affects only
8 o7 J" y; X0 G3 y# `6 `: K5 kmales; therefore, other male members of the family
' u3 ], K  E0 I" Y# _: Emay have similar precocious puberty.3% ]* M, o& `) p2 ?0 D
In our patient, physical examination was incon-  i$ l* ^3 {' [% r/ ~, h# x
sistent with true precocious puberty since his testi-
1 B* ?7 {0 A% t+ Q' Jcles were prepubertal in size. However, testotoxicosis
! ?: Y3 q6 }% l& _% hwas in the differential diagnosis because his father. U1 K5 G5 m: V) f3 m: d/ N7 k
started puberty somewhat early, and occasionally,3 |- O" [& \, L% B5 r
testicular enlargement is not that evident in the
! f9 v8 {: b; A& {6 s: i/ pbeginning of this process.1 In the absence of a neg-
( {6 d5 T8 A9 Mative initial history of androgen exposure, our: f( ^% V" ~- u
biggest concern was virilizing adrenal hyperplasia,
. O% A  c/ H, a4 z- j, D$ Xeither 21-hydroxylase deficiency or 11-β hydroxylase2 P( i* a7 j& @# X3 q
deficiency. Those diagnoses were excluded by find-
" ]2 \' ?( S( uing the normal level of adrenal steroids.
  E; v  }( L1 ]4 k: z3 K3 UThe diagnosis of exogenous androgens was strongly
0 w; Z/ D6 M" y7 {& @; k* v# rsuspected in a follow-up visit after 4 months because% \8 D' n8 C! Q3 j9 y( d7 ~# `
the physical examination revealed the complete disap-8 I9 O( H- D* f. T
pearance of pubic hair, normal growth velocity, and
3 i6 G) ^$ p3 @& j% \, H1 S3 Q! Rdecreased erections. The father admitted using a testos-% g5 O3 I# c% q% X6 v, w
terone gel, which he concealed at first visit. He was- `& x. x: E5 q9 }
using it rather frequently, twice a day. The Physicians’
. ?5 g% x- A* ]  h7 kDesk Reference, or package insert of this product, gel or; S3 n) a1 y- v0 F: ~
cream, cautions about dermal testosterone transfer to
% @, U3 n2 n8 g$ h- l) N# Z: [; f+ Hunprotected females through direct skin exposure.
; U/ a3 |5 P5 }- F/ ~: F) y. Y: }# x( {Serum testosterone level was found to be 2 times the' y1 R+ d* a. ?1 u9 y% S7 v
baseline value in those females who were exposed to
( R8 H2 m6 i' H* N1 G8 ~2 oeven 15 minutes of direct skin contact with their male& E' _1 o3 `( ]! B, f' |
partners.6 However, when a shirt covered the applica-) d: Z% M5 R( @9 o
tion site, this testosterone transfer was prevented.
9 e5 W9 r- z! Z; M4 `* ^Our patient’s testosterone level was 60 ng/mL,# P/ f1 ?% I5 W8 d
which was clearly high. Some studies suggest that. u9 J; d6 |: ^6 k6 j
dermal conversion of testosterone to dihydrotestos-
& _) w" M$ K( E  `- H, yterone, which is a more potent metabolite, is more
! I3 L7 I1 e# R4 o7 g0 Hactive in young children exposed to testosterone
0 B; a* ^  C; ^3 n& kexogenously7; however, we did not measure a dihy-" }; f6 ^  q5 z+ }9 u1 ?3 q
drotestosterone level in our patient. In addition to0 y! F$ N# C5 H) p
virilization, exposure to exogenous testosterone in
5 t# w% ?+ B& A  W/ j- Pchildren results in an increase in growth velocity and, F2 F; B* R: D: ]! |( A. t
advanced bone age, as seen in our patient.
5 b% x+ l# l8 f5 u. cThe long-term effect of androgen exposure during# K+ J: Q+ @- ]+ O% L; a0 y
early childhood on pubertal development and final8 [* k+ X: S; {  m4 q: Y; t4 y4 @
adult height are not fully known and always remain/ V0 O+ }: X" c- {. u  L$ I
a concern. Children treated with short-term testos-
) W1 s$ y+ [: g9 P/ K* [: dterone injection or topical androgen may exhibit some0 }; S' l1 b/ m( g9 R' A
acceleration of the skeletal maturation; however, after
. |+ r7 X6 [- X, Y! i: I9 fcessation of treatment, the rate of bone maturation) {; d2 G( q# ?/ p! @( F7 z
decelerates and gradually returns to normal.8,9! J6 ^% @: o- Y( h! t
There are conflicting reports and controversy% E+ |2 [* B3 \
over the effect of early androgen exposure on adult
8 F" i% u1 Z: e: I0 mpenile length.10,11 Some reports suggest subnormal
5 I5 i# L5 C( Ladult penile length, apparently because of downreg-
0 c9 z& D: y- A" m- Q% z/ m2 N, @ulation of androgen receptor number.10,12 However,( J  ~+ y" h$ q) I7 S* l) q; \8 S
Sutherland et al13 did not find a correlation between4 i9 P: R. z, R% A% n
childhood testosterone exposure and reduced adult, I6 d% B% \6 M) P- k' L
penile length in clinical studies.
/ C7 n# e9 v+ P) d9 X0 \+ C: u. ?Nonetheless, we do not believe our patient is
* R. y; j7 V0 r3 Xgoing to experience any of the untoward effects from1 t; w8 ^9 @( p- s9 b
testosterone exposure as mentioned earlier because& d  C0 h: \5 h. p
the exposure was not for a prolonged period of time.
7 A0 A/ l% N5 C2 {' hAlthough the bone age was advanced at the time of9 K- U7 Q: l' P. m" {# X: T6 b+ t
diagnosis, the child had a normal growth velocity at. G2 H6 D: n! [: N3 J3 _+ \
the follow-up visit. It is hoped that his final adult
7 w( C& S' j; _0 Hheight will not be affected.% j$ K, t* O% {: w; P
Although rarely reported, the widespread avail-& _2 `# A# m$ t; K3 u$ V
ability of androgen products in our society may
0 Z# o+ `  F# N5 f* b1 u& Pindeed cause more virilization in male or female
" Y+ l. Q( O; U5 Cchildren than one would realize. Exposure to andro-
* F6 l) x! V  F4 n. Jgen products must be considered and specific ques-- J5 c. i8 g- J$ `) ]/ o3 J
tioning about the use of a testosterone product or
1 b! w8 [4 ~' h! i+ Z5 Ngel should be asked of the family members during
) O( [( h3 V7 C5 }  zthe evaluation of any children who present with vir-1 \: u3 j$ o4 U) j) I) E4 E
ilization or peripheral precocious puberty. The diag-" B( z* U: \( I) ]- u3 `
nosis can be established by just a few tests and by% P+ Q  q6 t* D3 b" |% `3 u  d
appropriate history. The inability to obtain such a4 V5 ]7 H# c! }
history, or failure to ask the specific questions, may! D, d$ c. d7 O
result in extensive, unnecessary, and expensive
7 A4 b+ V) S0 vinvestigation. The primary care physician should be& ?1 @) }  V5 p0 ?0 V! F+ U/ s
aware of this fact, because most of these children3 d) M- l- h# U, d7 z, E
may initially present in their practice. The Physicians’: Z+ n! ~7 u% x
Desk Reference and package insert should also put a
4 p2 z1 O0 I; O0 n1 Jwarning about the virilizing effect on a male or
, Y% T0 }5 s. p7 b9 a. xfemale child who might come in contact with some-0 M) G. i6 a' B2 b  q' ^6 ?
one using any of these products.6 v- y( z5 v/ t" a7 C
References, G& _6 w# Q8 k. o9 g* A
1. Styne DM. The testes: disorder of sexual differentiation  F) |3 K. g9 `
and puberty in the male. In: Sperling MA, ed. Pediatric# M9 ~5 b4 f/ `& B) m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ o* C7 @' \# [+ `* Y. s5 L2002: 565-628.* W' K& |3 ?1 J1 A) L* e- |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& ~  x1 Y8 ]+ a3 B' x% o7 q! q2 spuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
, p7 i0 p, ]: l
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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