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Sexual Precocity in a 16-Month-Old
) U5 O3 b' E1 c9 z- @Boy Induced by Indirect Topical
) A- f9 {% ~9 |Exposure to Testosterone- q! F. B) C9 a/ D# d" E
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" {  J, M$ W6 b' V
and Kenneth R. Rettig, MD1
' `) d: ^+ e' V$ P2 ^: l6 UClinical Pediatrics
8 S1 y5 v; Z& ^Volume 46 Number 6
/ a' O  R8 O( H5 @3 ?* cJuly 2007 540-543
& x$ i( O; u7 X7 l" h- G$ J9 q. M© 2007 Sage Publications
- }: n# K/ B' f0 w4 R6 D) M! z10.1177/0009922806296651
: J# X( R/ O1 @http://clp.sagepub.com
, ?9 x, l7 u, G! m4 H1 _3 ]% Phosted at
8 k; {7 s! R/ ^2 A- J" shttp://online.sagepub.com$ \" g# B* m3 A1 B0 H! E  ^
Precocious puberty in boys, central or peripheral,& ^- E  q! r( w4 [
is a significant concern for physicians. Central
, R/ w" d& {5 d0 Z& \precocious puberty (CPP), which is mediated8 X) w& X) {4 t; e
through the hypothalamic pituitary gonadal axis, has- k" F! Y- `5 A! B" P* y
a higher incidence of organic central nervous system- I  u+ P( D. _
lesions in boys.1,2 Virilization in boys, as manifested+ y4 s' u: |, P$ o
by enlargement of the penis, development of pubic
9 T2 H8 k9 X/ \5 ]7 [  Fhair, and facial acne without enlargement of testi-
6 |& A8 e' _4 ccles, suggests peripheral or pseudopuberty.1-3 We
1 H+ h0 |% n% y+ D: ]8 W/ A# {report a 16-month-old boy who presented with the
1 W  h4 b7 `. t% u1 d# ^% Zenlargement of the phallus and pubic hair develop-9 H+ M- X7 i, K7 W6 \$ H
ment without testicular enlargement, which was due
2 L0 b7 M5 J$ q( j2 ^( {to the unintentional exposure to androgen gel used by& T/ h) N# y0 O6 i
the father. The family initially concealed this infor-: p$ o9 w& E3 B& `8 N
mation, resulting in an extensive work-up for this( I8 S* O, e& h# a& B( g. N
child. Given the widespread and easy availability of
; [! X) O3 i) z9 D! Ltestosterone gel and cream, we believe this is proba-6 R9 Y8 ~7 Q3 G  E
bly more common than the rare case report in the
2 e  ]" c! d2 R/ q1 [; gliterature.4
' Y8 N" |2 V4 H! I+ uPatient Report
) ]+ {% F: ?8 PA 16-month-old white child was referred to the( f6 P* S  B% X9 O6 E( ~9 E! {9 @
endocrine clinic by his pediatrician with the concern( @0 w- D3 j0 w' q1 z8 h- M
of early sexual development. His mother noticed2 N$ s4 J& \! C  w, G- N- P
light colored pubic hair development when he was
* A6 ]- n- ]8 H) x8 U- Z  B# CFrom the 1Division of Pediatric Endocrinology, 2University of3 j3 b6 W! X6 s! [% p: h
South Alabama Medical Center, Mobile, Alabama.5 u* c+ V7 @; U
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 N; I- b: i7 R* r0 `) o
Professor of Pediatrics, University of South Alabama, College of8 @$ z7 S1 v: |, W) P' t" M
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. {& m7 H2 m: O! I! X0 ]: g6 R
e-mail: [email protected].
! c5 f- k* ~0 P7 z3 f, e* Cabout 6 to 7 months old, which progressively became
5 x4 T& M/ }! t  A. S3 odarker. She was also concerned about the enlarge-
8 {- y2 j. o! e; ~ment of his penis and frequent erections. The child
8 Q! X- i( c! b* W) uwas the product of a full-term normal delivery, with
9 m" A8 W: f6 S* V5 R) e2 X$ Fa birth weight of 7 lb 14 oz, and birth length of/ z" f' m$ L& Z3 U- s
20 inches. He was breast-fed throughout the first year( O: E. r% E/ F( H0 N
of life and was still receiving breast milk along with
% q4 {" R, g4 K7 Usolid food. He had no hospitalizations or surgery,% o1 D- v5 U; V  X6 _- |, ^2 d
and his psychosocial and psychomotor development
; X2 p9 t* W/ W# ]6 Q' F+ S6 Bwas age appropriate.
  f: Q5 q. T0 M! I% Q- nThe family history was remarkable for the father,  N9 W4 `5 ?# G$ {
who was diagnosed with hypothyroidism at age 16,3 B1 A- q. B5 T- b
which was treated with thyroxine. The father’s. ?3 X( H0 p, `& C
height was 6 feet, and he went through a somewhat
5 d4 G, U* J. f+ kearly puberty and had stopped growing by age 14.
. A) @) W# I  rThe father denied taking any other medication. The
. A2 v2 P) ]3 E. t( Vchild’s mother was in good health. Her menarche0 _* B0 n' r* Q6 D# V6 ~/ a
was at 11 years of age, and her height was at 5 feet
1 Q7 N, \4 U% ^; I/ P, A5 inches. There was no other family history of pre-
0 h8 Q& P8 o6 e/ r+ Y1 ncocious sexual development in the first-degree rela-( c3 s) {9 n. W+ B; r; z
tives. There were no siblings.
; P1 ~% q: Y! E1 v: `- dPhysical Examination! Z/ F" [4 j9 u$ A1 e( L' _% {
The physical examination revealed a very active,1 Z5 w$ c5 j" ^) _" S7 n7 V+ u( V
playful, and healthy boy. The vital signs documented
; O! Z, ~, R3 I0 h5 h7 Da blood pressure of 85/50 mm Hg, his length was" x" M$ d+ C9 [, S
90 cm (>97th percentile), and his weight was 14.4 kg- W2 [( x; _2 F! k% }' U  i& J
(also >97th percentile). The observed yearly growth5 ?5 ~! `( @9 o6 M6 M6 B0 M
velocity was 30 cm (12 inches). The examination of8 U7 h. B8 l0 E3 [+ P% ]! K1 `" W5 z
the neck revealed no thyroid enlargement./ I) `8 g" v# F) Q, k7 c+ E
The genitourinary examination was remarkable for8 M  G# ?# U/ g, S
enlargement of the penis, with a stretched length of
+ e, C4 x# v$ j& m8 cm and a width of 2 cm. The glans penis was very well) J% Q; ]  g+ @3 |) S
developed. The pubic hair was Tanner II, mostly around0 _8 k) D- b% H5 T$ r
540( W( C! l9 A$ h) d$ F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  i1 g) V. `% G2 ^5 |the base of the phallus and was dark and curled. The
& r+ P! K1 B& z# t( p) Rtesticular volume was prepubertal at 2 mL each.5 F) Z4 W' P' ~0 a3 n3 J
The skin was moist and smooth and somewhat
5 `  S2 S1 T% H9 E' r, Coily. No axillary hair was noted. There were no1 a7 a) E" ~! r4 \8 Y, T- l
abnormal skin pigmentations or café-au-lait spots.
" u* H. H( r" A2 Z$ CNeurologic evaluation showed deep tendon reflex 2+
8 h$ S5 k9 t4 @, i' U% ?. Lbilateral and symmetrical. There was no suggestion
7 Y  D, K/ x# E0 D  s' N9 Sof papilledema.' R; g2 S; i4 b  g
Laboratory Evaluation
5 O' G- |1 G) M! P9 G' yThe bone age was consistent with 28 months by
4 J% F% f( b* t% ^# e* P$ X6 Ausing the standard of Greulich and Pyle at a chrono-
3 Y2 v, T, V+ U, O( e& \logic age of 16 months (advanced).5 Chromosomal
& V2 {  N% X( ~5 j+ B$ skaryotype was 46XY. The thyroid function test) y, L0 V3 m: F& q$ \. q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& M* {. {/ i0 N$ ]# y- v' n; o3 o
lating hormone level was 1.3 µIU/mL (both normal).
! B0 Y3 c& g4 J' H0 p% @/ hThe concentrations of serum electrolytes, blood
" a  x7 f# e& f  f. ^urea nitrogen, creatinine, and calcium all were
- `2 w/ O: z  Y( T7 R( u. Ewithin normal range for his age. The concentration% k& i8 Z0 w7 S2 Y
of serum 17-hydroxyprogesterone was 16 ng/dL
6 N' S- N3 O8 o0 {% X4 K4 x(normal, 3 to 90 ng/dL), androstenedione was 20: F' x0 R; A( b8 ?* @( r4 l; Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; K8 i2 d: V5 H) Q7 i5 wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
" D7 g  v0 ^0 V! A7 b2 ^. B5 adesoxycorticosterone was 4.3 ng/dL (normal, 7 to* l3 \9 [* h/ }7 x3 N2 n' b( v
49ng/dL), 11-desoxycortisol (specific compound S)
( p/ F2 r& H4 h" a1 B/ v8 T  Dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( f2 L2 y- [, I8 Q% Q  h5 j- ]# `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! F$ O' `  w# f3 T& h# b$ ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 L9 {$ Y6 S9 S# m( K$ eand β-human chorionic gonadotropin was less than
0 u+ e/ a2 F- n+ _* ^6 Z5 mIU/mL (normal <5 mIU/mL). Serum follicular
! A2 j/ B8 Z7 D+ F+ H/ k8 y4 V6 rstimulating hormone and leuteinizing hormone
. `  l5 `9 v3 I6 \3 n7 pconcentrations were less than 0.05 mIU/mL' T; _/ c8 ^" g; Z
(prepubertal).
1 k: A" }% r" k9 O- tThe parents were notified about the laboratory
1 G0 r( r; _; H7 Cresults and were informed that all of the tests were# d9 N6 s# l- J: s  }8 b9 [
normal except the testosterone level was high. The; t' `- T3 q' s: L* ~
follow-up visit was arranged within a few weeks to
2 p- d4 c* _' D. C; c3 g; T& Qobtain testicular and abdominal sonograms; how-* k8 M7 u% [- y0 P" w& k
ever, the family did not return for 4 months.
9 l0 g4 X! ]. ?$ Y0 k: Y( GPhysical examination at this time revealed that the
: ~4 Y5 x# h$ ~9 M7 Kchild had grown 2.5 cm in 4 months and had gained$ z# ?: ?9 B# T: g
2 kg of weight. Physical examination remained
' Y; E- ~* U/ K/ n" ?unchanged. Surprisingly, the pubic hair almost com-
) k8 x4 a! z' f5 Q2 ?' `pletely disappeared except for a few vellous hairs at
( {$ E  X4 _  _the base of the phallus. Testicular volume was still 2
6 P- j4 k/ w0 N) UmL, and the size of the penis remained unchanged.# E& \& ], S# R: |5 o4 ?; l
The mother also said that the boy was no longer hav-% S2 ~9 Z2 X: P1 W# D8 O( H
ing frequent erections.2 i) V8 |" `9 R7 w& L4 Q- ?8 }
Both parents were again questioned about use of
  s1 e8 p" s- N! [any ointment/creams that they may have applied to
( @8 j( k$ b% l2 M7 [; r7 \the child’s skin. This time the father admitted the
4 x) h6 }4 x2 W4 WTopical Testosterone Exposure / Bhowmick et al 541
) G( ~% c( y9 p$ n  G/ kuse of testosterone gel twice daily that he was apply-, z' f* \: ^0 e) H! p4 }
ing over his own shoulders, chest, and back area for
' E: ^- |* Z1 G: Ka year. The father also revealed he was embarrassed
/ u8 `: b- i6 ]+ uto disclose that he was using a testosterone gel pre-
& Q* [; v: [1 R2 Y( s$ qscribed by his family physician for decreased libido
7 X8 ^. B* K" V; O  L0 }secondary to depression.% I! i3 K+ Q, }- J
The child slept in the same bed with parents.' L' O& E" k8 }0 u3 i; `. d
The father would hug the baby and hold him on his
- {& K; H4 n# J9 schest for a considerable period of time, causing sig-. O. W& C/ c% w. p6 G
nificant bare skin contact between baby and father.; x! R* A; U3 l/ |' i- d3 S1 M
The father also admitted that after the phone call,
7 o, O5 i2 Q6 v2 `: Twhen he learned the testosterone level in the baby
% H2 V0 J" c, j0 z* ?9 ?2 Kwas high, he then read the product information
! j9 ?) u0 m! L, [8 w1 Mpacket and concluded that it was most likely the rea-7 C& c% y' e# ^* X. I" J
son for the child’s virilization. At that time, they
" z; G/ I- @! }+ c4 M# Cdecided to put the baby in a separate bed, and the
2 G. z: B7 M2 H. ^& }# E) pfather was not hugging him with bare skin and had
* v& k; u5 l& |: {9 bbeen using protective clothing. A repeat testosterone( b4 o" m: r% ]5 [
test was ordered, but the family did not go to the6 t' K( c9 h7 s9 v1 K' M8 I) A
laboratory to obtain the test.
  a6 I) m$ H/ r" NDiscussion
  d/ C  _6 m' P) NPrecocious puberty in boys is defined as secondary& Z: g  i/ a. E8 K1 S. C  x
sexual development before 9 years of age.1,46 g1 P2 X6 A( W
Precocious puberty is termed as central (true) when4 w/ n3 Z) F6 y. F) n/ k3 E3 D
it is caused by the premature activation of hypo-: ^% d, r, J* A
thalamic pituitary gonadal axis. CPP is more com-
/ |) f* f0 A' C2 A. O0 Pmon in girls than in boys.1,3 Most boys with CPP
, C) |, I5 H. Y0 K  w8 Zmay have a central nervous system lesion that is
! N0 f6 H, h( {responsible for the early activation of the hypothal-* o- U. F1 ^& I3 }; M, X
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 ]* \- {. j/ s5 E6 Rsis has been given to neuroradiologic imaging in
) D$ a' w# E% a6 s) [2 h( Dboys with precocious puberty. In addition to viril-
5 \/ M: ]0 {) v8 fization, the clinical hallmark of CPP is the symmet-
" c% Y9 F4 R: T0 @  V9 Y2 ^0 frical testicular growth secondary to stimulation by* p2 N; |  a9 S$ X
gonadotropins.1,3- d) Y5 j/ m4 S
Gonadotropin-independent peripheral preco-
' [: O1 x$ }& J: b1 ?5 `- F3 q8 ~4 rcious puberty in boys also results from inappropriate0 G) A8 [+ _; `& ^7 b% V
androgenic stimulation from either endogenous or3 X$ R  T6 q3 f- m3 K$ ^* ^
exogenous sources, nonpituitary gonadotropin stim-5 G6 K! Q; p) x  h7 r$ m
ulation, and rare activating mutations.3 Virilizing
$ E8 y4 X) G# T  v" W! F- e0 n% Zcongenital adrenal hyperplasia producing excessive' l- o* `, d, J/ t4 w% t  u7 v0 S
adrenal androgens is a common cause of precocious/ v+ w4 w- [) t; G7 {9 l& b2 w
puberty in boys.3,4
; K/ Z. @! ~: O* ?The most common form of congenital adrenal
" l, q1 E8 M5 s7 {hyperplasia is the 21-hydroxylase enzyme deficiency.* c" a- q) y0 D* O) x! p! t
The 11-β hydroxylase deficiency may also result in& ?6 M( s/ S- D; }2 H
excessive adrenal androgen production, and rarely,& w) P1 z  \  w5 j
an adrenal tumor may also cause adrenal androgen9 }% K$ Z7 {. t, [+ G' A$ Y  ?
excess.1,35 B% Q9 k1 G/ g2 `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! A9 ]: y; U1 C- q0 Z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- A! o2 w. V1 I4 C  E+ Z2 D6 dA unique entity of male-limited gonadotropin-
+ I" m, u3 m2 L5 _independent precocious puberty, which is also known
" Q6 e0 H. d2 H' R4 x9 K9 S9 }as testotoxicosis, may cause precocious puberty at a
; j) W' k6 C. Y# j; X+ n( s- Y+ J5 {very young age. The physical findings in these boys
8 s4 x2 A* I1 j& [3 Uwith this disorder are full pubertal development,+ C+ y1 B" W3 ~! x( E$ P
including bilateral testicular growth, similar to boys' G, i* j5 e7 T% v$ x
with CPP. The gonadotropin levels in this disorder
4 y' [8 }6 c! b8 ~0 mare suppressed to prepubertal levels and do not show
$ y- t3 Q+ i! x- p& r/ Fpubertal response of gonadotropin after gonadotropin-% ~& `: `5 R5 c3 G! x* r& \: p* T
releasing hormone stimulation. This is a sex-linked% a5 _7 W! g6 Q8 W8 m; l
autosomal dominant disorder that affects only
* |7 g' N, b* ~' ^( ~3 z1 w7 }males; therefore, other male members of the family
( R5 P4 _" C$ ^7 G9 \* \, O- ~0 l# ymay have similar precocious puberty.3
0 J7 T+ M( {8 C$ B: nIn our patient, physical examination was incon-
( B) Z( A6 t, D" E0 ]8 y9 O$ ssistent with true precocious puberty since his testi-
. l/ X# Q' V4 T& [, zcles were prepubertal in size. However, testotoxicosis
! B: H' c% D# _) c3 ^was in the differential diagnosis because his father
. Z- D+ Z& V' T$ {! kstarted puberty somewhat early, and occasionally,
2 L2 D% L! w  l4 Y, Otesticular enlargement is not that evident in the5 ]7 I) q6 C3 r- }7 [' b, Q- s0 R1 R2 j
beginning of this process.1 In the absence of a neg-1 X. }3 Y% ?! |7 ~! v
ative initial history of androgen exposure, our; {1 |- v/ W/ i9 x( [8 g+ l
biggest concern was virilizing adrenal hyperplasia,
- K3 h: O4 R: u% k" i+ heither 21-hydroxylase deficiency or 11-β hydroxylase! }0 i4 s* Q; y+ |- L7 J6 j
deficiency. Those diagnoses were excluded by find-
0 Z/ U3 `& i- K% `& Fing the normal level of adrenal steroids.
: h' r9 T$ K9 x7 [* dThe diagnosis of exogenous androgens was strongly
0 t4 g/ D" u* N3 d; |+ fsuspected in a follow-up visit after 4 months because
1 Y2 E4 S2 D+ Z# kthe physical examination revealed the complete disap-
1 ?6 S  w$ D2 e/ ~pearance of pubic hair, normal growth velocity, and/ A8 Z' w/ f% g+ I0 V6 X
decreased erections. The father admitted using a testos-- F5 [2 {1 E' `8 p: r
terone gel, which he concealed at first visit. He was9 d3 X0 q, `  O; M" V8 B
using it rather frequently, twice a day. The Physicians’9 z; c: ?; W, G6 _8 ]$ F
Desk Reference, or package insert of this product, gel or' {$ @6 H# `( E' `1 T. R: u
cream, cautions about dermal testosterone transfer to
: r/ q3 @* _$ `unprotected females through direct skin exposure.
7 {) Q$ z8 R  k+ lSerum testosterone level was found to be 2 times the
; P  p$ N+ y! m7 zbaseline value in those females who were exposed to
* F* J! r9 g$ o6 T9 }even 15 minutes of direct skin contact with their male7 M( v, e; e5 b: ^
partners.6 However, when a shirt covered the applica-
* n' k4 L/ n6 n& [9 L. vtion site, this testosterone transfer was prevented.
* M+ G# b* t: V: v& T5 C. V, cOur patient’s testosterone level was 60 ng/mL,8 N: p5 M8 K, B6 p3 j& z
which was clearly high. Some studies suggest that% F9 g  {: J, h  D# S( t8 \! U; n
dermal conversion of testosterone to dihydrotestos-
4 [% K* q2 ~, s! _* d# Lterone, which is a more potent metabolite, is more' J1 j1 k! b! R) o0 n' n
active in young children exposed to testosterone
& r2 K  [- D) ?: E5 `1 _exogenously7; however, we did not measure a dihy-
1 `) s8 o; f1 ~, edrotestosterone level in our patient. In addition to: Y/ @( m, Z3 w; z
virilization, exposure to exogenous testosterone in2 ^7 \! e! |" A2 J6 T
children results in an increase in growth velocity and6 E2 ?! @4 E. |' a
advanced bone age, as seen in our patient.4 O4 r5 o% h: N
The long-term effect of androgen exposure during
5 B( R# [6 W% o* ^early childhood on pubertal development and final, V) c8 ?2 X& o: `2 M
adult height are not fully known and always remain
3 I% _( f+ r- s/ K+ n+ @  H$ Ja concern. Children treated with short-term testos-
4 C5 w( x9 N0 B" h5 L8 P0 C/ s" fterone injection or topical androgen may exhibit some
7 [, r! h* B6 G1 E4 {acceleration of the skeletal maturation; however, after
/ h( t  [/ `. `2 a. Qcessation of treatment, the rate of bone maturation" q5 L  z9 R$ Y/ D; H: s- q& [5 ~
decelerates and gradually returns to normal.8,9
6 S1 W- z) `4 L9 j3 eThere are conflicting reports and controversy
: G/ ]( C; t. J0 {9 v' \" [over the effect of early androgen exposure on adult; j& D1 d: s3 ]+ {
penile length.10,11 Some reports suggest subnormal/ }( k( d2 v2 ^) q/ k& b1 ?6 `
adult penile length, apparently because of downreg-  L: T. J% K4 b4 K* S
ulation of androgen receptor number.10,12 However,# B6 @! D/ d, y7 _, \
Sutherland et al13 did not find a correlation between# v2 }& m6 K0 ~2 c
childhood testosterone exposure and reduced adult
- I/ y1 _" v/ u: i9 i, hpenile length in clinical studies.
; U; H) z+ Q* ^+ r8 g2 dNonetheless, we do not believe our patient is
7 u6 u, U& I* y- d5 g0 Jgoing to experience any of the untoward effects from2 I; n( J8 |  o1 [- y1 g8 {
testosterone exposure as mentioned earlier because
1 t4 D' U2 U4 C, t( Vthe exposure was not for a prolonged period of time.
4 E5 J$ h+ Y1 V: E6 g7 y5 f! `6 H- w; pAlthough the bone age was advanced at the time of
. R) f, j4 [0 t+ o; E' W# Kdiagnosis, the child had a normal growth velocity at
% l- @' Y1 C& x3 sthe follow-up visit. It is hoped that his final adult
8 p+ L; }+ }4 o9 Pheight will not be affected.. h8 N  w, h( F5 Q
Although rarely reported, the widespread avail-
- V8 T4 d8 V1 P$ C3 [ability of androgen products in our society may
2 h4 L7 y8 N0 m2 l, E+ q% Mindeed cause more virilization in male or female
0 z+ N" D4 [# J  |children than one would realize. Exposure to andro-
3 N, a# y: ]7 a) I- _. mgen products must be considered and specific ques-
$ }0 |8 l# I) G( Ftioning about the use of a testosterone product or
2 q, K5 w* C; q9 |gel should be asked of the family members during
( c/ J" O# m$ r  v5 @& `; Ythe evaluation of any children who present with vir-
( r; \# G/ E6 _) ~. ^3 L  Filization or peripheral precocious puberty. The diag-& Q0 @, n5 x% c1 H/ j5 Z" [& B
nosis can be established by just a few tests and by& u3 J; f" \5 K
appropriate history. The inability to obtain such a+ k& p% S4 ?; m2 |, u
history, or failure to ask the specific questions, may: q2 s; U, K6 o- K$ X/ N. ?( ~  ^, m
result in extensive, unnecessary, and expensive
+ B: A3 c1 L' ]) Vinvestigation. The primary care physician should be
& q' j3 K" z6 a7 N7 Vaware of this fact, because most of these children
3 t  C) P2 b3 d# ~( u9 k7 w$ {may initially present in their practice. The Physicians’/ E$ v0 o) _( Y4 Y5 A4 V# l& R
Desk Reference and package insert should also put a
9 J; h; Y  L$ |# u6 J% w9 Jwarning about the virilizing effect on a male or1 n- x- h& A' h. Y  \: o
female child who might come in contact with some-
2 Y# U4 N) `9 e0 j' [one using any of these products.- P( d- g7 s1 F+ e
References
7 O$ w& q! B9 Y4 o$ l9 X7 `1. Styne DM. The testes: disorder of sexual differentiation
9 h, k( b! p: B; x# {/ l" @and puberty in the male. In: Sperling MA, ed. Pediatric% [" h9 W  X( v  J
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- U% S; l& O/ S. q5 ]2002: 565-628.
4 L& P4 @5 f: |  F! I$ o! o1 `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ c1 w2 _& _) Q1 D
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
9 \" f6 T5 O4 O! v; f- @; XBoy Induced by Indirect Topical
" H- r( d3 j& `Exposure to Testosterone
1 {8 @+ L, c# ^- T0 d/ _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 e" }; @( X4 f; Y: i4 g
and Kenneth R. Rettig, MD1
. \7 f/ E5 x3 `; D5 S* }1 lClinical Pediatrics
) v$ Q9 ~6 l9 s( S; ]' tVolume 46 Number 62 N% _- L" X0 `  @3 ?' z, G
July 2007 540-5431 I: w2 s1 M, H( G
© 2007 Sage Publications
. L1 h  X9 @2 k10.1177/0009922806296651
* N4 s* i/ h/ j- G0 C9 W+ {http://clp.sagepub.com
5 s: S- T3 K/ L6 {8 _% xhosted at
3 G- p/ G" _: l- jhttp://online.sagepub.com, s9 g5 X3 e' `" J" f. F% y! s
Precocious puberty in boys, central or peripheral,
3 B1 r6 ]: O& r0 ~) w* Fis a significant concern for physicians. Central/ P) k; y! f6 r, \8 {
precocious puberty (CPP), which is mediated5 W7 @' o8 d$ c2 c1 F
through the hypothalamic pituitary gonadal axis, has! q* y+ n; V# k3 I0 O- E6 u
a higher incidence of organic central nervous system! V% |( A7 o1 o8 f, @
lesions in boys.1,2 Virilization in boys, as manifested$ J5 ~' H. {/ O
by enlargement of the penis, development of pubic
! t/ x3 O1 b9 [" |; U# Khair, and facial acne without enlargement of testi-
( \7 N; `. ^# B" bcles, suggests peripheral or pseudopuberty.1-3 We
# N4 D4 i- e# O% j. mreport a 16-month-old boy who presented with the
  H9 d% p3 k% f" u+ x7 \7 x* yenlargement of the phallus and pubic hair develop-
9 _0 Z$ b2 R( K: e! pment without testicular enlargement, which was due8 }6 a2 I! N; o. s3 x5 I
to the unintentional exposure to androgen gel used by
, x1 B& T' d* B' Hthe father. The family initially concealed this infor-
  @" a% M$ _& [0 [mation, resulting in an extensive work-up for this$ J- B* w; j: i" }
child. Given the widespread and easy availability of
( y0 Y8 u: X7 C6 Ltestosterone gel and cream, we believe this is proba-4 P# {5 t) B) }8 S: B! h9 b" O
bly more common than the rare case report in the
( L* L! q8 N  w. k7 I8 R  Q  k7 @literature.4# h) }9 |9 ^$ @) `
Patient Report: s7 J, v* I. h
A 16-month-old white child was referred to the
* e7 x/ s0 d) `, G6 gendocrine clinic by his pediatrician with the concern
) @- v: v# k$ C6 Gof early sexual development. His mother noticed* V% ^8 ]9 {1 g9 W; H
light colored pubic hair development when he was# i: G% A8 T5 s& z; C# M0 O1 u; }
From the 1Division of Pediatric Endocrinology, 2University of9 V) b' y0 a; O: s, @! i0 L
South Alabama Medical Center, Mobile, Alabama.
6 J4 @4 [  U8 V7 a# x- s9 EAddress correspondence to: Samar K. Bhowmick, MD, FACE,
" Y1 Y9 F; O" q$ z# wProfessor of Pediatrics, University of South Alabama, College of
0 u$ n* {/ _+ o* WMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: @) W' w6 l; S6 ?: N6 e1 T  g
e-mail: [email protected].
. Q/ A/ D( [- K8 L' Z' Rabout 6 to 7 months old, which progressively became
3 o" |9 t. N+ Bdarker. She was also concerned about the enlarge-
, |  |/ I, }  X, D% l* l, x! x+ nment of his penis and frequent erections. The child) y/ s6 x% F$ D; V1 J! u
was the product of a full-term normal delivery, with9 V7 o+ o5 r6 I' f8 b) z  e( K
a birth weight of 7 lb 14 oz, and birth length of0 V9 H& ]9 b  i. N) s7 g5 q! G
20 inches. He was breast-fed throughout the first year  i4 m- C, i8 ^: D( K% K* ^
of life and was still receiving breast milk along with$ E0 p7 Y+ d& _. |2 c0 B, _( ^- v/ L
solid food. He had no hospitalizations or surgery,
! _7 |; @& R" [. c8 k- Wand his psychosocial and psychomotor development$ g' a: `4 t  q  b7 a
was age appropriate.
# L, m( ^& L+ h. R6 Z( wThe family history was remarkable for the father,
' `- w7 z* o3 x/ m1 l2 J7 Vwho was diagnosed with hypothyroidism at age 16,
/ G5 d5 G4 n9 a  J6 y$ t4 R) n+ I# l( Twhich was treated with thyroxine. The father’s; E( `$ F% _$ D& h2 B) p' c
height was 6 feet, and he went through a somewhat2 J; R$ @) j% z! b/ M
early puberty and had stopped growing by age 14.
) {9 b7 _! A) FThe father denied taking any other medication. The
: Z9 j9 M# A+ z7 C6 M6 G6 tchild’s mother was in good health. Her menarche* m7 P/ `* N3 b& i) y: Z( y
was at 11 years of age, and her height was at 5 feet
1 f! @! T/ X3 f: i8 u, Y5 inches. There was no other family history of pre-3 c6 k0 A  [0 t) v% _* I/ ~) u; i* m
cocious sexual development in the first-degree rela-
3 P+ E# D  T1 `tives. There were no siblings.
9 \% @% ?( X& qPhysical Examination
/ t, e" V& Z. s! XThe physical examination revealed a very active,
' g8 g% @+ A. \9 S' e2 d8 _playful, and healthy boy. The vital signs documented
  f9 z# Y. K5 O2 Ja blood pressure of 85/50 mm Hg, his length was
9 m5 ^2 C4 h; n90 cm (>97th percentile), and his weight was 14.4 kg* y1 T2 H, d1 q5 m
(also >97th percentile). The observed yearly growth
$ C! X) o3 O% D8 F  X1 Y2 G3 o$ Xvelocity was 30 cm (12 inches). The examination of1 P, k4 I7 i" ~8 l& L+ m
the neck revealed no thyroid enlargement.
# g" }% V. ]" B( n5 w3 tThe genitourinary examination was remarkable for' }! ]. A( u+ _* t+ G# w5 N
enlargement of the penis, with a stretched length of4 H5 U3 C# i7 d5 c4 z" L. S& x
8 cm and a width of 2 cm. The glans penis was very well
! o' q$ s* X0 cdeveloped. The pubic hair was Tanner II, mostly around/ u, y! A4 j9 q. l
540
/ @6 C" L# @5 |- j5 F" T/ p1 Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  _+ ?2 r% `; K; W( s
the base of the phallus and was dark and curled. The
- L/ o# T/ `' @. r4 A  V5 atesticular volume was prepubertal at 2 mL each.3 i, ]8 \/ h! w1 \2 r% Z  o3 l3 I! ]
The skin was moist and smooth and somewhat" R# l0 a% R) F* c( G
oily. No axillary hair was noted. There were no
3 i+ ^+ W& w) `! r' iabnormal skin pigmentations or café-au-lait spots.
, s0 h0 t6 R" L; G" R  jNeurologic evaluation showed deep tendon reflex 2+6 R+ t4 }3 w, P0 Z
bilateral and symmetrical. There was no suggestion
/ P; M/ x, e$ _/ c2 R: W# fof papilledema.1 |" p5 I8 H+ c( [0 n' F
Laboratory Evaluation
# l* z  O9 }# e! rThe bone age was consistent with 28 months by9 o2 h- ?* j: ?2 i% i4 p
using the standard of Greulich and Pyle at a chrono-0 O3 _* z( @$ L4 Z
logic age of 16 months (advanced).5 Chromosomal# L8 A4 r( G, O! j1 L) x
karyotype was 46XY. The thyroid function test! v$ b- r- r+ ~" |* c* v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-4 B! A: w5 b, A' v9 @
lating hormone level was 1.3 µIU/mL (both normal).8 a. E8 N) _* C
The concentrations of serum electrolytes, blood+ t% I: u+ x4 a' v7 b; Z1 v! c
urea nitrogen, creatinine, and calcium all were
+ R! _2 q- Y0 H3 H  }! nwithin normal range for his age. The concentration9 B. W7 Z/ F( c( ~* C9 ^2 K( K
of serum 17-hydroxyprogesterone was 16 ng/dL
5 U7 ]; [& c. d' B4 l& u5 E(normal, 3 to 90 ng/dL), androstenedione was 20$ f  m# R/ k- {! J1 P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 J1 \1 s+ O2 @2 W
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 y" V6 t7 e2 fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 v$ C4 L* E7 X+ @$ ?* z2 Z& O49ng/dL), 11-desoxycortisol (specific compound S)2 G, q9 T' i, t0 K' D6 |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, T! q& J9 T5 [. `+ r. h2 t* [3 p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& f  X* Z3 K# rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  R( K' H  {2 C7 fand β-human chorionic gonadotropin was less than
/ W: Q1 I2 [+ V0 {8 b; u+ t1 A5 mIU/mL (normal <5 mIU/mL). Serum follicular! ?* @; e; b  ?+ K9 S( M
stimulating hormone and leuteinizing hormone0 G/ Z$ p* B* R7 p" a# U; p5 z: @
concentrations were less than 0.05 mIU/mL$ n. w( D; _& L; l
(prepubertal).
# m7 n) o, }5 O1 `: S8 D# {" d5 `The parents were notified about the laboratory- O; [# k( O* H+ q- [
results and were informed that all of the tests were
1 H4 D( Z. v3 k8 y8 E6 i7 Znormal except the testosterone level was high. The& [6 i- \4 P4 j: g, K) V8 c( X8 z
follow-up visit was arranged within a few weeks to
  z0 A5 r& V; pobtain testicular and abdominal sonograms; how-6 l" ]7 s  T6 o
ever, the family did not return for 4 months.
8 }% J7 i+ N- MPhysical examination at this time revealed that the- |! J9 |4 d5 ~' W4 @7 }
child had grown 2.5 cm in 4 months and had gained
9 p- [5 O) \3 B. J( i4 o2 kg of weight. Physical examination remained
# Y: j! r7 H7 b* {( munchanged. Surprisingly, the pubic hair almost com-7 X: C* W# [( K6 |/ \. o
pletely disappeared except for a few vellous hairs at
* \9 i3 C1 X( V% D8 s' f: {the base of the phallus. Testicular volume was still 2! ]/ [5 o2 @4 W
mL, and the size of the penis remained unchanged.
' ?3 \, z, ~& L2 i4 f+ w( eThe mother also said that the boy was no longer hav-
/ x1 I: o8 t% k( k* Q  V- B% Ging frequent erections.3 f* @$ N+ e* \8 p. r' W  O7 |# `
Both parents were again questioned about use of
+ z: A, s7 I! m2 W/ N1 t$ xany ointment/creams that they may have applied to
$ j' l7 Y3 U2 ?3 d: F. X/ p) `7 uthe child’s skin. This time the father admitted the5 O7 Z( `$ y+ r4 s
Topical Testosterone Exposure / Bhowmick et al 541
' d. @' Y% B: Y2 H& w. R5 Tuse of testosterone gel twice daily that he was apply-! r  r" ^% O$ |$ i# }( t' E/ z
ing over his own shoulders, chest, and back area for
( C2 ]- b) P! G2 D1 S3 Wa year. The father also revealed he was embarrassed
9 E4 h' p9 C3 ^0 t8 ~. fto disclose that he was using a testosterone gel pre-
4 Q+ b0 P% O3 Cscribed by his family physician for decreased libido. C4 y1 a$ ~* p% _' j! ?. F: Q" ]( M
secondary to depression.
# A+ e4 n4 r' `The child slept in the same bed with parents.
" {% K. L" Y- ]  KThe father would hug the baby and hold him on his
4 t5 l; h6 c1 k" g9 I3 t3 w# v( Jchest for a considerable period of time, causing sig-8 l# s1 e$ }) p4 k1 j/ a* U0 @5 J
nificant bare skin contact between baby and father.- n* Q+ ?, D5 R7 B
The father also admitted that after the phone call," M, Z$ ~/ j) I7 s
when he learned the testosterone level in the baby( y) p4 @  x) S! v" P
was high, he then read the product information- c. B7 r& n) {+ r! a3 Q+ y
packet and concluded that it was most likely the rea-
. \! \5 H* J9 v$ \& tson for the child’s virilization. At that time, they
; s; b$ N3 @/ u4 |+ X) S9 tdecided to put the baby in a separate bed, and the. M# W4 I. _% \& i
father was not hugging him with bare skin and had" U' S6 W. d, ]* h. w. Y3 k
been using protective clothing. A repeat testosterone
; O! h! X6 y8 {) X) Utest was ordered, but the family did not go to the$ S. w( w% h9 q# U: @# g& d2 f5 ]7 r
laboratory to obtain the test.
: n1 i" w6 W/ f% V1 m0 DDiscussion
; ?% O) [+ n$ e& XPrecocious puberty in boys is defined as secondary! D9 `! o) k5 t  `
sexual development before 9 years of age.1,4
5 U' |$ s8 V* E- z; _+ Y3 |" {Precocious puberty is termed as central (true) when" `! w) }9 @7 g
it is caused by the premature activation of hypo-
' S$ M. u2 N/ I) [* f* v2 Vthalamic pituitary gonadal axis. CPP is more com-
) `* v+ R" i. _8 Nmon in girls than in boys.1,3 Most boys with CPP
) E" z* }/ V8 Zmay have a central nervous system lesion that is
8 H1 ?8 V% h6 c4 x- Y! `responsible for the early activation of the hypothal-7 m* g! e/ [+ y. }4 ?' N" ?
amic pituitary gonadal axis.1-3 Thus, greater empha-
; m! O9 ^, V4 \+ w" B4 ?sis has been given to neuroradiologic imaging in0 I4 @2 N/ r& `. c) l0 A
boys with precocious puberty. In addition to viril-- W, F9 x7 f+ f
ization, the clinical hallmark of CPP is the symmet-/ C# m; A' j2 r. I/ r( a# E9 ^; Q
rical testicular growth secondary to stimulation by
9 R& _5 |  J9 h$ x6 Hgonadotropins.1,3
1 l. C2 P2 G: K8 }5 uGonadotropin-independent peripheral preco-# g- V. G) S$ ~, q
cious puberty in boys also results from inappropriate- E. F, W, F9 Y* I/ c3 Q4 j
androgenic stimulation from either endogenous or8 P8 Q) Z: N- Y/ ]' D5 B) [8 u
exogenous sources, nonpituitary gonadotropin stim-( m3 R% d' Q4 T- _
ulation, and rare activating mutations.3 Virilizing
+ t7 o# k( \3 u5 t; }9 @0 b" B6 `# {congenital adrenal hyperplasia producing excessive
1 a: n5 j5 _/ v1 [# fadrenal androgens is a common cause of precocious  ~; T. B' q& S) }% C) J5 A  y
puberty in boys.3,4
, q- r8 ?: W+ d) Z" F8 [" DThe most common form of congenital adrenal
1 w9 v  x8 i: {( q: ^! j1 @hyperplasia is the 21-hydroxylase enzyme deficiency.
  o0 M0 v& {( V5 fThe 11-β hydroxylase deficiency may also result in9 f; t+ a0 R4 n
excessive adrenal androgen production, and rarely,' A* V0 E' G) F( M
an adrenal tumor may also cause adrenal androgen
1 `. \& H0 w8 \/ Aexcess.1,3) }; T3 z. u$ [9 f$ n5 V! z  L+ Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ `8 W. Y; I2 L8 E: w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! x3 {+ h0 A. ]7 s# ~A unique entity of male-limited gonadotropin-4 x. e6 L3 g7 o. U
independent precocious puberty, which is also known* b) Q- i2 a( L, L- `
as testotoxicosis, may cause precocious puberty at a) {  }( U( v( C, m/ n# S" E
very young age. The physical findings in these boys
, }/ Z# D7 a; M) W' @! [: |with this disorder are full pubertal development,( G, v8 C3 g3 @! @0 B' }8 O/ H
including bilateral testicular growth, similar to boys
: Z" Q6 V" {/ [9 F5 c, Hwith CPP. The gonadotropin levels in this disorder
+ s5 c' s' S, w8 z1 v- a5 o- V+ ~are suppressed to prepubertal levels and do not show2 [# T, W' U* i& Z; T
pubertal response of gonadotropin after gonadotropin-
) ?, r& h* C6 Rreleasing hormone stimulation. This is a sex-linked. @6 n; t9 N$ o9 b
autosomal dominant disorder that affects only/ l; F" i2 [7 G3 W' U; M# C, y& h
males; therefore, other male members of the family
( a0 p' t* S1 ]) [% H0 Q2 T0 x! {+ Umay have similar precocious puberty.3( ~- F9 g* {  }( X- U3 r+ D1 Z
In our patient, physical examination was incon-
5 x& t  J5 T2 s2 n3 Psistent with true precocious puberty since his testi-6 E, E8 W- M" g1 C
cles were prepubertal in size. However, testotoxicosis" m& U6 x$ Z( k
was in the differential diagnosis because his father1 R) ]" i5 O( o
started puberty somewhat early, and occasionally,
# m) A! p9 I, ?+ U. e; Ntesticular enlargement is not that evident in the: _  z$ w, L! v' W: d4 ~! `
beginning of this process.1 In the absence of a neg-
/ p) s" v6 F* M6 E" yative initial history of androgen exposure, our
6 u0 E& f/ l# Q- Rbiggest concern was virilizing adrenal hyperplasia,
  z! L! n; W7 s8 q* V5 M8 ]: k0 Geither 21-hydroxylase deficiency or 11-β hydroxylase* l2 S0 P$ S% V' X
deficiency. Those diagnoses were excluded by find-
/ J) i, E- i% e% ^# ~) K4 Oing the normal level of adrenal steroids.+ c  p, R, G3 \
The diagnosis of exogenous androgens was strongly
+ ]% e4 `4 ^. Z( Hsuspected in a follow-up visit after 4 months because
' `& E+ }# p" L; y3 K  g4 ?0 ]5 nthe physical examination revealed the complete disap-
5 {2 p9 {4 P) W$ zpearance of pubic hair, normal growth velocity, and  C& f, m$ g& d4 [8 D* H
decreased erections. The father admitted using a testos-
, L/ ~/ {( K& ~. _6 dterone gel, which he concealed at first visit. He was/ Q7 t! \" H% L! P6 \& ~
using it rather frequently, twice a day. The Physicians’
. ~3 j6 t) e4 k2 ?( [$ JDesk Reference, or package insert of this product, gel or
* |" T% b3 ]1 N: x( A: \3 kcream, cautions about dermal testosterone transfer to# h- Z" T( g; i
unprotected females through direct skin exposure.
  A4 L1 ]& A- kSerum testosterone level was found to be 2 times the
- {; P: T, b' Q. d/ Q1 U9 Hbaseline value in those females who were exposed to
, g. L" }$ D" u5 p6 O2 v) Qeven 15 minutes of direct skin contact with their male6 Q1 n# L+ X! i: w
partners.6 However, when a shirt covered the applica-
; k8 `; {- B9 htion site, this testosterone transfer was prevented.
$ L+ \) u3 T; W- q" H$ _Our patient’s testosterone level was 60 ng/mL," w/ l5 M  S3 k8 y, u/ s
which was clearly high. Some studies suggest that
$ T# A% l: L/ R' Gdermal conversion of testosterone to dihydrotestos-: }# g0 U$ }' n; b" R
terone, which is a more potent metabolite, is more. M$ W" |8 ~; ~% r; b
active in young children exposed to testosterone' e! R6 H/ z9 b5 J  p
exogenously7; however, we did not measure a dihy-8 u0 g- @) d# \! z5 J
drotestosterone level in our patient. In addition to  j5 H/ h0 l' ~" D; f$ ?
virilization, exposure to exogenous testosterone in" b+ ^. D1 Q7 p, ]( l* N
children results in an increase in growth velocity and
3 `3 N1 b% S  q$ ~1 o1 d1 Dadvanced bone age, as seen in our patient.
6 U# i6 }0 ~0 W2 JThe long-term effect of androgen exposure during
, u+ e3 _& ^. Mearly childhood on pubertal development and final1 D' |" U- \) g! D! A
adult height are not fully known and always remain
' T) I, x" k4 q6 C4 w8 _: Fa concern. Children treated with short-term testos-
5 J. k1 A" P7 ^6 B$ `# J" z5 yterone injection or topical androgen may exhibit some
' G  M  T8 w9 Yacceleration of the skeletal maturation; however, after1 H/ L3 |/ m  |- t
cessation of treatment, the rate of bone maturation
! i8 S' L# m, s. Z% Cdecelerates and gradually returns to normal.8,9! e/ c1 v# g0 q0 B; U1 S  p
There are conflicting reports and controversy
, V" r! v8 ?6 I& c) J  mover the effect of early androgen exposure on adult( [; u6 h$ W# R, }* L9 n
penile length.10,11 Some reports suggest subnormal
2 d  F% @; |! @4 E- H+ N5 Tadult penile length, apparently because of downreg-
( f0 R3 b/ d5 n; Kulation of androgen receptor number.10,12 However,
5 ?! R! S) j1 Q1 qSutherland et al13 did not find a correlation between
7 c8 @. o5 b" \/ L2 Pchildhood testosterone exposure and reduced adult; s, {: a& R" N
penile length in clinical studies.+ r9 U  y# H  ~. Z0 `
Nonetheless, we do not believe our patient is
* v& _- i5 B, n( agoing to experience any of the untoward effects from
+ a8 F6 _* C2 q, J8 Y: ltestosterone exposure as mentioned earlier because
$ V; W: ~- s) y6 w! p! xthe exposure was not for a prolonged period of time.
( a' _5 S9 a6 g% |5 ]5 hAlthough the bone age was advanced at the time of+ |, W! ?* h: T% A: @
diagnosis, the child had a normal growth velocity at
! a8 J* A# w) n5 ?7 s' t4 hthe follow-up visit. It is hoped that his final adult
4 {5 y) x% J: i( u6 kheight will not be affected.8 g8 E* a$ @4 I  _6 s
Although rarely reported, the widespread avail-
$ ?1 h6 n6 X% u( T* [ability of androgen products in our society may8 I7 P! ~, o* ]4 Z  H
indeed cause more virilization in male or female7 l: ]- {6 \' L8 b: \5 K4 M
children than one would realize. Exposure to andro-
  T$ V2 L. f7 k  k7 e2 kgen products must be considered and specific ques-
; n2 U" N! l! U9 v/ \5 L- `& n* V1 Ationing about the use of a testosterone product or
* f8 X/ `, y& E. E6 U3 Qgel should be asked of the family members during' O* z5 k6 b0 T. t( p' k2 m
the evaluation of any children who present with vir-- n- t: Q/ Z  x& P! ^
ilization or peripheral precocious puberty. The diag-
( k5 i- @5 R" K$ K% cnosis can be established by just a few tests and by
+ H. ^) J4 [7 l8 W) Z' Mappropriate history. The inability to obtain such a( C6 W* P( {) l  [: l$ X0 b
history, or failure to ask the specific questions, may# _* a/ M- Q7 }% {3 u7 u
result in extensive, unnecessary, and expensive
# F* Q- k: _2 f* f. _investigation. The primary care physician should be
2 U; s4 z+ S5 ~4 X& [8 L) ]. vaware of this fact, because most of these children2 q; b. ^* |& z
may initially present in their practice. The Physicians’9 p+ E# I+ C* q  y: Q& A
Desk Reference and package insert should also put a
; M0 r) s8 H. w7 }warning about the virilizing effect on a male or5 X" j6 X/ S: `7 m$ |6 c1 b8 B1 E
female child who might come in contact with some-
! E. U" V5 x, \% \* Eone using any of these products.4 {9 u+ n) j' f. y  @+ q% x
References
, z8 T, h, Y: C- J: M4 b1. Styne DM. The testes: disorder of sexual differentiation
) l8 U4 M) H8 ~$ L9 eand puberty in the male. In: Sperling MA, ed. Pediatric: N1 `8 o/ K6 |/ ~7 \
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 E6 S1 v' H$ g5 W8 r6 O+ S1 j
2002: 565-628.
5 M, U% A( A; N/ \" L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ ]! a/ ?& C% n1 apuberty in children with tumours of the suprasellar pineal
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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

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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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