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Sexual Precocity in a 16-Month-Old
" B! a  z0 _! J* \0 ~" v1 cBoy Induced by Indirect Topical" a) M  j. D, Y; B* a4 U
Exposure to Testosterone
4 e1 u, H! G8 ]) O0 ?Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' ~" V7 ^! L5 S  b# }# A' C$ \8 J0 D$ @
and Kenneth R. Rettig, MD1% A: t/ d) t9 o2 m9 E
Clinical Pediatrics
0 i. N0 A9 u/ w9 U2 f, o2 g! IVolume 46 Number 6
$ q/ M6 O+ X0 j/ WJuly 2007 540-543
, V" b: q" N8 x; u" U/ {© 2007 Sage Publications! ~+ l. t: [& v6 w/ B7 `- H/ J% [
10.1177/0009922806296651
& Q( F) c% r* b0 q0 Fhttp://clp.sagepub.com
( O) y! a" c. Qhosted at5 d0 }" d9 X+ ]
http://online.sagepub.com
: J6 l# d2 M/ k9 b( f) E4 fPrecocious puberty in boys, central or peripheral,$ _+ M+ f  l4 t" r3 R& W  \# E
is a significant concern for physicians. Central# }7 a0 S$ r+ e1 A. A, b. q. N
precocious puberty (CPP), which is mediated
7 S6 ]: S1 A0 j, r3 wthrough the hypothalamic pituitary gonadal axis, has; |3 o( \3 E& y2 A% g' Q, p  a( D
a higher incidence of organic central nervous system
$ @+ ?8 G  p6 tlesions in boys.1,2 Virilization in boys, as manifested1 K4 |5 J5 c% b  ]+ d
by enlargement of the penis, development of pubic
- k$ X* d' z! V* bhair, and facial acne without enlargement of testi-5 I* Q  s- e' a( `2 V( [: X% N. ?# b
cles, suggests peripheral or pseudopuberty.1-3 We
4 ]8 L, U, h2 t6 i7 I5 R! sreport a 16-month-old boy who presented with the
  ?) {: U- W: A; |enlargement of the phallus and pubic hair develop-
: G* i8 ^' ^5 z  r0 `6 b% q0 }0 fment without testicular enlargement, which was due/ K7 H; P$ E, h& t  ]- g% H
to the unintentional exposure to androgen gel used by  \5 ]" d9 `  U+ A  u* z, g
the father. The family initially concealed this infor-2 q, n! e/ ]: a+ ?: c% D
mation, resulting in an extensive work-up for this
: @, ]+ @) k4 a8 Rchild. Given the widespread and easy availability of
8 T" p( Z" j/ o- p3 @4 ^testosterone gel and cream, we believe this is proba-! u( a% m# V! M* Y1 A
bly more common than the rare case report in the
6 X  q0 G) c* n1 e) Bliterature.4' k6 O! w' i( d  Y* h. v" c, j* X
Patient Report4 L2 n1 @9 K1 `) Q
A 16-month-old white child was referred to the
# m0 i& G0 M! C9 X9 ?endocrine clinic by his pediatrician with the concern
3 j7 X( J9 @* p; B, qof early sexual development. His mother noticed
4 c$ d" ^1 G7 O- E( g1 ^light colored pubic hair development when he was+ N3 j3 {7 k3 ^9 {. J, B8 B
From the 1Division of Pediatric Endocrinology, 2University of
) z1 Z1 `5 S) J5 f: w. GSouth Alabama Medical Center, Mobile, Alabama.' j- `. j1 |' j+ J
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 d) W; i" J$ e3 {3 OProfessor of Pediatrics, University of South Alabama, College of
+ H5 o2 E: q! w4 Y+ Y5 L3 |Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 @# [; r7 P' d7 O, }
e-mail: [email protected].
2 W( c/ e% v' n7 Labout 6 to 7 months old, which progressively became% m) q+ \; @$ f8 `; @- j
darker. She was also concerned about the enlarge-
) O) P' V2 ~% s; g2 D7 fment of his penis and frequent erections. The child
3 J4 i! ?2 n; g% q$ X" bwas the product of a full-term normal delivery, with- P" W0 B4 H# R) o! y
a birth weight of 7 lb 14 oz, and birth length of3 v4 L. k( z7 C1 v4 y
20 inches. He was breast-fed throughout the first year% J- g+ p4 Z) f7 w) b' o
of life and was still receiving breast milk along with4 Y% u/ g. o# @
solid food. He had no hospitalizations or surgery,
5 U! w( I- H; u# Dand his psychosocial and psychomotor development3 {5 L1 U' Z; Z; `8 S9 m9 x
was age appropriate.( }: Y& x3 E8 n5 {: f8 T' i
The family history was remarkable for the father,
* }( k- h! l9 q, V- [: O0 Awho was diagnosed with hypothyroidism at age 16,9 @% x3 ~" c! }! u6 S2 [
which was treated with thyroxine. The father’s) X' M1 N1 ?+ P$ s
height was 6 feet, and he went through a somewhat7 b2 n4 [2 V% W+ N2 e6 @) J8 ^3 O
early puberty and had stopped growing by age 14.
% P9 B! j2 {! l1 f" kThe father denied taking any other medication. The  d6 [& R- h2 J8 |# P. R
child’s mother was in good health. Her menarche+ X7 w8 I6 r' y! q6 e( w
was at 11 years of age, and her height was at 5 feet
  E  L8 x! K) z5 inches. There was no other family history of pre-
! s: A: k. U+ w4 i  f& Dcocious sexual development in the first-degree rela-
% ^) W- |1 `4 P3 K& N/ Etives. There were no siblings.7 ~% q& j1 Q& W% U1 q
Physical Examination
  p, c6 ]! B: j/ j1 L+ P% CThe physical examination revealed a very active,% B; G. y  n, P, U4 e1 g
playful, and healthy boy. The vital signs documented
- q' }! N% `. Q" b( qa blood pressure of 85/50 mm Hg, his length was
0 Q/ `8 M* A- y# n! I6 e! ^; a90 cm (>97th percentile), and his weight was 14.4 kg
+ i6 u6 x( ?% q, B* w+ z(also >97th percentile). The observed yearly growth8 H! ]' k* W( I2 P8 ]" X# q
velocity was 30 cm (12 inches). The examination of
$ H7 ]& e8 i$ Othe neck revealed no thyroid enlargement.
% r  v9 k; ~2 j* j% NThe genitourinary examination was remarkable for5 ]* C9 J: {: {* r' d6 @
enlargement of the penis, with a stretched length of
) _  E: Q# g% i" u# P" H8 cm and a width of 2 cm. The glans penis was very well
9 D9 F, Z0 k2 ideveloped. The pubic hair was Tanner II, mostly around
) j& c1 ^7 \; t! s% l8 `540
/ g+ t9 G( f% b6 K! }) l* k; Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% O* \- s6 b0 P! L: c- Cthe base of the phallus and was dark and curled. The0 O; M. W( e2 V$ J$ |
testicular volume was prepubertal at 2 mL each.0 w0 N$ X7 O! f& E5 U( q  f8 A5 P( r
The skin was moist and smooth and somewhat
- ?# D+ [. N; M, J* roily. No axillary hair was noted. There were no
) ~9 O+ R( D+ y' Y  w( W7 r. k4 {- Wabnormal skin pigmentations or café-au-lait spots.0 D! |+ e  n" |+ ^1 e
Neurologic evaluation showed deep tendon reflex 2+
$ L; D9 }' U% m/ V& T' |bilateral and symmetrical. There was no suggestion4 ?  w  H5 @( h- S$ d. o& D! v
of papilledema.
, h; [$ n; ^" q( w5 e* oLaboratory Evaluation
; o- W) ?1 F2 n& D; tThe bone age was consistent with 28 months by
5 u( ?+ z' C$ D; I  lusing the standard of Greulich and Pyle at a chrono-" H- W6 J7 p0 i% E8 t& D4 m/ M
logic age of 16 months (advanced).5 Chromosomal- i+ O+ I' q( N2 @6 w
karyotype was 46XY. The thyroid function test3 t) R/ O3 i% Y4 O' N$ f
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. ]! K4 V' I' t+ a& _8 o4 K: ^
lating hormone level was 1.3 µIU/mL (both normal).
! b9 {* O4 s4 J3 FThe concentrations of serum electrolytes, blood( k. c1 b' {- a8 i8 \
urea nitrogen, creatinine, and calcium all were: a0 e5 V. h4 f
within normal range for his age. The concentration0 i1 @1 I7 [9 z/ k' s! D3 a
of serum 17-hydroxyprogesterone was 16 ng/dL5 V" K) }0 }$ F
(normal, 3 to 90 ng/dL), androstenedione was 20% J7 d$ o/ H7 [' J( R' ~6 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" w. `; d# B* S. C- p; e5 ^' i" U0 T% yterone was 38 ng/dL (normal, 50 to 760 ng/dL),0 b+ B' q7 t. H) m/ e5 S
desoxycorticosterone was 4.3 ng/dL (normal, 7 to3 ~6 e) o0 z5 y4 a3 \' `) s$ T
49ng/dL), 11-desoxycortisol (specific compound S)
, U, ^1 v9 C- n. _/ D7 z; n; jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) O  l2 n6 r) }. M# i5 v( xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 \/ }- c# q. P, y* Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; T3 V9 |, X) g! Cand β-human chorionic gonadotropin was less than. j: L& f4 c8 l8 |
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 m6 @# P- s8 W
stimulating hormone and leuteinizing hormone
8 z8 a/ f. D  I( ~4 n9 yconcentrations were less than 0.05 mIU/mL
; w( }2 r% I8 m# l/ x2 b(prepubertal).% Y$ F, D) p8 K
The parents were notified about the laboratory8 R8 {6 f3 _& P1 ], @, ~* B& |
results and were informed that all of the tests were
- K4 D+ J% Z) P: C( G2 L2 Pnormal except the testosterone level was high. The
3 E6 x. \6 P4 E2 i/ Qfollow-up visit was arranged within a few weeks to
2 R3 F5 u6 x9 `obtain testicular and abdominal sonograms; how-
, W$ L& m/ z( |# I) C" pever, the family did not return for 4 months.7 K* e2 M6 v1 a% d3 v* @
Physical examination at this time revealed that the
7 x/ A5 v9 O* V& m& T/ wchild had grown 2.5 cm in 4 months and had gained8 Z) b6 o% v. Y7 g* K8 d
2 kg of weight. Physical examination remained
- e* n' J& m' c* T" L' yunchanged. Surprisingly, the pubic hair almost com-0 J* c' r6 d* G3 t
pletely disappeared except for a few vellous hairs at  c' M2 p6 _9 y- y0 n3 E8 _% l! N
the base of the phallus. Testicular volume was still 2; }- A0 U) I) d8 @
mL, and the size of the penis remained unchanged.6 l% z$ b8 O! u4 d" J
The mother also said that the boy was no longer hav-
- M6 ^# `( F8 K+ |; m: w  w# f. qing frequent erections.
) r# O/ \9 h8 \6 {Both parents were again questioned about use of
8 Z7 z' o  a) t+ w3 r* [" q! ~7 u7 e% tany ointment/creams that they may have applied to2 A4 _% Q5 ^& V# S. T1 B- k4 Z
the child’s skin. This time the father admitted the
4 x/ g- r  t! d( F! [Topical Testosterone Exposure / Bhowmick et al 541
5 U* }5 L/ q: z, O" G7 R/ {6 guse of testosterone gel twice daily that he was apply-
% ^. U8 o) ?5 f8 |& ^ing over his own shoulders, chest, and back area for% ?6 q' ^( P( ?. m  s  q+ a
a year. The father also revealed he was embarrassed* I; R& r, m5 t4 A
to disclose that he was using a testosterone gel pre-
; I% Z/ S/ g# d: G1 E  ^2 dscribed by his family physician for decreased libido% J1 i6 C' p" z# m' W& C
secondary to depression.
. c7 t2 [. s; i$ ~- B  u! W$ CThe child slept in the same bed with parents.
2 `4 H) C' [1 k' v# lThe father would hug the baby and hold him on his# r" S4 |! J- `7 u8 ]0 g2 ~
chest for a considerable period of time, causing sig-  j& j- X# m, e
nificant bare skin contact between baby and father.$ o( p* g- K4 Q, r  c8 m4 g
The father also admitted that after the phone call,. O+ P! ^! r% O0 s9 g9 C
when he learned the testosterone level in the baby
9 @; x8 S- p* ^; H9 q# I; kwas high, he then read the product information& _0 ^- `) e( T4 E
packet and concluded that it was most likely the rea-
, d8 C: r, D* V! U3 dson for the child’s virilization. At that time, they
7 R8 v. w0 r* Gdecided to put the baby in a separate bed, and the& O) H$ Y% f* l
father was not hugging him with bare skin and had
8 @" u1 B/ T. a+ Sbeen using protective clothing. A repeat testosterone
$ m9 J! H4 C6 y) R  r1 n6 F) L$ ytest was ordered, but the family did not go to the
2 h7 ^& H1 B- U' m. i6 m* Plaboratory to obtain the test.
" E% c; i9 O! r6 v, z: ?* _Discussion
8 \( B0 r$ P% x$ j, R0 a& z4 ?4 hPrecocious puberty in boys is defined as secondary
1 f2 n' Z! ~# a  c* n, m* tsexual development before 9 years of age.1,4# Y/ ^# D$ o$ F0 `( @4 {$ }
Precocious puberty is termed as central (true) when
7 q  g4 y3 u3 i% ?6 Q, t2 Hit is caused by the premature activation of hypo-
  F' r( h7 U: t' `thalamic pituitary gonadal axis. CPP is more com-9 p- ]  k- I  E. K4 T+ P0 V
mon in girls than in boys.1,3 Most boys with CPP. `" c5 o& l5 E5 o! C
may have a central nervous system lesion that is
6 X/ j1 D$ Y5 S7 e, A+ yresponsible for the early activation of the hypothal-
# O4 |5 ^8 R; W$ a1 B! D: V& Zamic pituitary gonadal axis.1-3 Thus, greater empha-
" v. t( U6 s! ^! }% o# X+ m0 M" isis has been given to neuroradiologic imaging in0 k% a3 ~& k* h" O
boys with precocious puberty. In addition to viril-# m: `7 v8 M. H) m0 G( \
ization, the clinical hallmark of CPP is the symmet-% V; i( I. `6 G3 r- Z( t/ a9 O
rical testicular growth secondary to stimulation by
& U9 v! t2 `, D% Bgonadotropins.1,3
  P8 H' e/ U6 X7 `Gonadotropin-independent peripheral preco-9 p) u: L: K- u7 I- x
cious puberty in boys also results from inappropriate
( i. B- o1 o$ V  W- }- |: \8 W' Uandrogenic stimulation from either endogenous or, i1 g) ?' Z8 x
exogenous sources, nonpituitary gonadotropin stim-
* i- ^4 Q6 E: p) @+ Tulation, and rare activating mutations.3 Virilizing
7 a% |  _5 P) B5 j3 ]1 Xcongenital adrenal hyperplasia producing excessive
0 h% l) d( A, I9 `9 Eadrenal androgens is a common cause of precocious
# {! g, S# Z% S( [3 ~! `$ x# c* [puberty in boys.3,46 p4 \  e8 p* H4 b  S# w& h
The most common form of congenital adrenal4 }0 _' H6 Y0 b/ K8 V& J6 I
hyperplasia is the 21-hydroxylase enzyme deficiency., [- b, g7 F+ W9 M, f9 t
The 11-β hydroxylase deficiency may also result in6 i7 `3 R  p4 M3 \$ J+ F5 v
excessive adrenal androgen production, and rarely,
" E1 Q$ f& r1 r: Man adrenal tumor may also cause adrenal androgen& B: ~' P+ l4 j2 a* r4 k
excess.1,3
* e+ R* Z8 q6 B2 S4 {' Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* B; e. T( @+ L5 u4 N* N7 z+ ?
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* H" c! K$ o' c, n
A unique entity of male-limited gonadotropin-
7 e5 C6 L: P6 A2 xindependent precocious puberty, which is also known
# ^6 U. g$ r8 k# H3 N; ias testotoxicosis, may cause precocious puberty at a% c; t3 g$ M! e/ Z3 @
very young age. The physical findings in these boys
. s" E/ N5 a4 R9 U7 j2 P$ owith this disorder are full pubertal development,$ o+ P$ w" d) m* i
including bilateral testicular growth, similar to boys
; b, m, c  j6 l; q/ u( F$ Lwith CPP. The gonadotropin levels in this disorder
9 Q0 @. B: X9 I: n4 Uare suppressed to prepubertal levels and do not show! z! d0 I/ x9 r" f5 i: {4 }
pubertal response of gonadotropin after gonadotropin-. {7 s3 c8 N2 R
releasing hormone stimulation. This is a sex-linked
6 d: `& y! C  V' l0 ?" fautosomal dominant disorder that affects only; t; v7 S* m; Q* W" l$ j, j6 R
males; therefore, other male members of the family
" X. K! A( Y$ s' l, t/ g, Bmay have similar precocious puberty.3* u3 f! Z: {4 V/ q
In our patient, physical examination was incon-% P& D- L# O! p, o* B( _8 H, W2 V
sistent with true precocious puberty since his testi-! W- W" O/ X+ [* Z! n! o
cles were prepubertal in size. However, testotoxicosis# X5 S3 E1 u$ S! Y! Y3 L9 \* v3 }, o
was in the differential diagnosis because his father
( E/ o% t1 ~; n3 k1 Q2 D  Xstarted puberty somewhat early, and occasionally,
" M7 B# I6 w/ Y" ?: B; @/ k7 g- g' ]! Ytesticular enlargement is not that evident in the3 z0 s: ^* Q7 l" w$ ?0 p7 B
beginning of this process.1 In the absence of a neg-
! _% Y! _0 k" jative initial history of androgen exposure, our- ^2 T8 R& {) N0 u% g* Z! N
biggest concern was virilizing adrenal hyperplasia,
( P/ G- ]+ v$ k5 m( Q  Keither 21-hydroxylase deficiency or 11-β hydroxylase  c% `) T; ^5 W4 ^
deficiency. Those diagnoses were excluded by find-
. T6 L$ M2 S2 t. y8 sing the normal level of adrenal steroids.
  V3 U. x, c, u. a7 tThe diagnosis of exogenous androgens was strongly
  b5 b2 j' z( K1 {. [1 tsuspected in a follow-up visit after 4 months because3 @$ R' D" B: B$ d1 ]6 B
the physical examination revealed the complete disap-
7 @3 M/ M% |  I; W* l9 |pearance of pubic hair, normal growth velocity, and
; k5 k. c4 E$ V7 odecreased erections. The father admitted using a testos-
) _/ {6 Q# F. P2 N6 H' w9 C$ _4 R5 oterone gel, which he concealed at first visit. He was- X5 j+ K  J" }1 B8 d
using it rather frequently, twice a day. The Physicians’0 B2 @  w/ [' G# K$ h* F4 r
Desk Reference, or package insert of this product, gel or9 D" ], f7 K9 ]) _* R; K
cream, cautions about dermal testosterone transfer to- Y/ K1 G( b; l6 f. o2 T& \
unprotected females through direct skin exposure.: {. |1 C) A9 X
Serum testosterone level was found to be 2 times the
; D' C" x- M* b$ Ebaseline value in those females who were exposed to1 f% }( J8 E* u) G) o
even 15 minutes of direct skin contact with their male
4 ]& O# N1 p3 kpartners.6 However, when a shirt covered the applica-: x0 l( h/ h0 _5 S; S0 A- H
tion site, this testosterone transfer was prevented." Z% M# [0 o, m% g2 G
Our patient’s testosterone level was 60 ng/mL,
( _: o' g6 k' {1 i  @. A8 {3 swhich was clearly high. Some studies suggest that
- B9 f2 e# s+ w# ~' p# fdermal conversion of testosterone to dihydrotestos-5 X- }1 c  ^& @. x  R( s
terone, which is a more potent metabolite, is more8 ~* z. Z1 W' i  S2 F, a) B2 @
active in young children exposed to testosterone
) N9 ], V5 n2 T+ K/ ]/ ~1 G6 Uexogenously7; however, we did not measure a dihy-7 m* `! Q+ n) ~0 u9 l: J) j
drotestosterone level in our patient. In addition to, z4 U8 N$ _9 B8 L6 q- [
virilization, exposure to exogenous testosterone in( p3 Z/ U- S' e* [6 }2 |$ ^
children results in an increase in growth velocity and
3 k/ ?; l+ h# A$ \advanced bone age, as seen in our patient.+ u6 R) Y+ e8 C0 P0 c! q1 u
The long-term effect of androgen exposure during! z/ D( r+ [- I  y! E* N
early childhood on pubertal development and final7 g: D2 Z7 a# }$ I
adult height are not fully known and always remain
+ O8 b7 h3 o$ |3 C% M! w9 ya concern. Children treated with short-term testos-
1 V& Z6 c" M/ q4 |' d/ Jterone injection or topical androgen may exhibit some% T( @, ^) W3 A" q$ F: _# |
acceleration of the skeletal maturation; however, after+ g) V. O. r$ u$ P
cessation of treatment, the rate of bone maturation
4 ?( J6 i( X; c: D8 s9 A; N; ^decelerates and gradually returns to normal.8,9) q5 _: d6 K. `, s
There are conflicting reports and controversy
$ P" n1 r( h8 S' `4 gover the effect of early androgen exposure on adult
+ R/ {0 B2 S' E5 q  y0 zpenile length.10,11 Some reports suggest subnormal5 V% Z$ y' \- u" O
adult penile length, apparently because of downreg-
% n( F8 u  @* }ulation of androgen receptor number.10,12 However,
3 f7 e9 r0 k5 M& R2 ]7 J* E8 N5 iSutherland et al13 did not find a correlation between) y9 Q. c& L$ I8 L4 A. D' ~
childhood testosterone exposure and reduced adult2 I5 Y  X% G: D1 y- k) I
penile length in clinical studies.
& a7 g: Y) m' k# B& A  Q- GNonetheless, we do not believe our patient is: t. Q0 g( J7 q! d
going to experience any of the untoward effects from/ K/ _1 b! ?8 x1 s
testosterone exposure as mentioned earlier because
" X- h6 g! S5 j' \  Z* s% a3 g( j1 Bthe exposure was not for a prolonged period of time.2 I$ t5 r5 l4 p/ R
Although the bone age was advanced at the time of7 b) l+ V& @  F2 {- ~/ ?
diagnosis, the child had a normal growth velocity at
; e: t7 P7 Q$ e, r) j3 D9 n: i- athe follow-up visit. It is hoped that his final adult, e& c3 y! r5 n* ?5 _
height will not be affected.
1 |# a" k( W3 ^0 e# j" ^: uAlthough rarely reported, the widespread avail-
; B1 X9 S& S; N, `. g# Hability of androgen products in our society may3 F; }( h8 ^$ O5 v* T1 b
indeed cause more virilization in male or female6 z% e. X1 Z$ W. q9 D5 |
children than one would realize. Exposure to andro-
% V! ]) t( Z# }; D, y: \- }gen products must be considered and specific ques-3 _- a# [  |! N2 C) B5 H
tioning about the use of a testosterone product or4 c/ ^0 p2 ?( y6 o
gel should be asked of the family members during+ m, `  l( N: w
the evaluation of any children who present with vir-7 ^; F6 A7 ^* A8 L
ilization or peripheral precocious puberty. The diag-
% x: A5 H+ H# Snosis can be established by just a few tests and by
- B/ [$ }7 D! u) T- S5 T: l0 C( z2 bappropriate history. The inability to obtain such a9 Q/ K0 ~, W- W, }" R* X& A
history, or failure to ask the specific questions, may
- O. X0 T/ h0 a- M2 z9 Lresult in extensive, unnecessary, and expensive
" r7 u+ r# G6 b2 Q- F( zinvestigation. The primary care physician should be) V8 P% Q3 |. f/ K( S4 U) F
aware of this fact, because most of these children
4 Y4 E: _1 C, W, W  Kmay initially present in their practice. The Physicians’6 f* z1 N" ]0 k0 O
Desk Reference and package insert should also put a
1 B2 a! {. _+ Q4 Mwarning about the virilizing effect on a male or! `9 p( t5 ]1 ]+ a$ U
female child who might come in contact with some-/ E4 s, h: R/ O& R  z
one using any of these products.
5 M& i8 C0 Z2 H0 ?% YReferences& d; q2 m0 A- G4 x& S( r
1. Styne DM. The testes: disorder of sexual differentiation
, O. d& n; e9 n! E- I- @and puberty in the male. In: Sperling MA, ed. Pediatric' A, l* g8 T% s/ H, @3 {1 p9 s0 A8 g9 o; Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 u: }+ Y& f+ o2002: 565-628.
' u, V* N  r+ C' x( j2 _- e" z3 T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  z8 M6 g/ R" Y* Ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
- I: g! o* D" }( J. ABoy Induced by Indirect Topical$ D6 g$ d: Y, Y0 Q
Exposure to Testosterone
9 O) |1 Z) m9 oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  `0 M7 P) z6 \8 u, U) [
and Kenneth R. Rettig, MD1
) G* _2 s7 @; z1 d- h; ZClinical Pediatrics
/ _& j, g/ u( P8 p( O: }( eVolume 46 Number 6; n0 w3 z( \+ e7 N
July 2007 540-543+ E. y( y- B( ?: R8 g/ Q
© 2007 Sage Publications- y; B: @+ A, N6 `  ]
10.1177/0009922806296651  J' z; j& H4 A2 w1 G
http://clp.sagepub.com
) x$ L# F/ ~0 L1 N. @" q! j' \hosted at1 Z9 h3 k/ s0 g' z  D4 X+ K# o3 ~# s; G
http://online.sagepub.com3 G8 p0 I  z- `/ h- Q: L
Precocious puberty in boys, central or peripheral,
" o! @# f- S1 D+ d; U) Sis a significant concern for physicians. Central* l1 W( J+ {. R* o
precocious puberty (CPP), which is mediated0 b! b4 k/ K8 S. h- O# x' z! O5 l0 N
through the hypothalamic pituitary gonadal axis, has
! o9 c4 P' a5 l$ ra higher incidence of organic central nervous system
6 L& ]) M& }5 ~6 hlesions in boys.1,2 Virilization in boys, as manifested
' D; l  K+ U& ?0 f2 Bby enlargement of the penis, development of pubic$ l$ x2 a/ _5 I: {3 e. Q
hair, and facial acne without enlargement of testi-/ u: ]% N+ a- R' u' W$ v
cles, suggests peripheral or pseudopuberty.1-3 We0 m' C7 E* q2 G
report a 16-month-old boy who presented with the
' S5 j3 Y9 y+ P- K. \enlargement of the phallus and pubic hair develop-# n9 [: B  O$ x* O/ l
ment without testicular enlargement, which was due6 @8 {2 \" t. F0 C
to the unintentional exposure to androgen gel used by
# Y3 }; B; X4 Pthe father. The family initially concealed this infor-
1 T5 H( K' [% y; l5 B) z6 w5 {mation, resulting in an extensive work-up for this8 g3 n# T1 ?9 j
child. Given the widespread and easy availability of; ?- a) y, ^2 o( D, ]% k! t% K
testosterone gel and cream, we believe this is proba-
5 J4 _& i5 i  X) I4 p) J  i& Qbly more common than the rare case report in the
( s- b: i0 f8 K/ Zliterature.4
  Z/ Z# F9 t9 T) x( Q9 f4 M: bPatient Report! s# Q5 r6 [; w" R+ b
A 16-month-old white child was referred to the
, c' l7 @. v) r  ^* Y0 i5 s' H+ Qendocrine clinic by his pediatrician with the concern; S9 f& j. F9 S9 A: |
of early sexual development. His mother noticed
1 N; N/ _3 j/ X8 O# rlight colored pubic hair development when he was3 w! L: D; k2 q) s" V/ c! _  M
From the 1Division of Pediatric Endocrinology, 2University of
8 v- F7 C% l$ k" d) e* `0 S; }8 \South Alabama Medical Center, Mobile, Alabama.
" h; V2 }5 C+ ]5 V7 S0 [2 h$ XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
# P9 [2 v  i/ w" `1 w8 Y$ aProfessor of Pediatrics, University of South Alabama, College of
: ~1 n. P) ?9 Y8 s- q. o+ @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 ]' [) h3 ^' fe-mail: [email protected]., a% K6 x: N" i  g& ~/ Y
about 6 to 7 months old, which progressively became
) Y$ Y6 K+ Z" }: p* wdarker. She was also concerned about the enlarge-
6 _4 u  }* z$ N$ B3 X" c5 Qment of his penis and frequent erections. The child
0 k0 }: \. w, i% z* _was the product of a full-term normal delivery, with
- m5 [% A* T) m% a. B, R( q5 J6 m1 Da birth weight of 7 lb 14 oz, and birth length of
0 A+ Z+ }  Q& R) o6 I20 inches. He was breast-fed throughout the first year. ]( [( ~$ f9 {2 Y' S
of life and was still receiving breast milk along with! e! `* \1 }, \1 K2 D& Q" s+ y
solid food. He had no hospitalizations or surgery,
9 u; q6 x# i8 K, C6 uand his psychosocial and psychomotor development
# e: S) C/ E3 _- G8 A# Z$ [was age appropriate.2 ]- ^, s: [& A
The family history was remarkable for the father,
# f. z1 ^2 \) I, K2 N% Ywho was diagnosed with hypothyroidism at age 16,2 h# J$ D4 ^  g/ k0 o' B/ F$ t
which was treated with thyroxine. The father’s( v" D, x9 L! o2 W
height was 6 feet, and he went through a somewhat
* M5 v! d5 X% w6 R& h2 r$ c/ Tearly puberty and had stopped growing by age 14.
5 l9 B, B3 k- ?5 V2 g& sThe father denied taking any other medication. The
- T% ~2 D4 b" c5 q- Tchild’s mother was in good health. Her menarche) d  l8 e" T( V$ G2 C
was at 11 years of age, and her height was at 5 feet4 Z/ q" j1 n! o2 N& X
5 inches. There was no other family history of pre-' ^" N: t8 }5 A6 |% @; d
cocious sexual development in the first-degree rela-
- N2 A# ^4 A! d1 k" d) [tives. There were no siblings.7 h, q6 j: R  t3 ?3 Q
Physical Examination
; u$ {# r* E; {& WThe physical examination revealed a very active,4 @, t; J- L$ ~- ^& c
playful, and healthy boy. The vital signs documented+ R7 Q" B$ h4 |# c1 s% z( U( [3 N+ ?
a blood pressure of 85/50 mm Hg, his length was
1 O0 |3 h) I) h0 d+ v" ^! U7 L90 cm (>97th percentile), and his weight was 14.4 kg1 Y& h/ o/ W* R) |; z9 I6 z
(also >97th percentile). The observed yearly growth
/ W+ [% X; u, |, N/ Z7 vvelocity was 30 cm (12 inches). The examination of
* ?. e# O( ^' G! bthe neck revealed no thyroid enlargement.
9 {+ k* T3 k  f( kThe genitourinary examination was remarkable for9 \  J- M4 X1 ^7 w; m1 a
enlargement of the penis, with a stretched length of- T0 a' [! D0 X! i8 m) J
8 cm and a width of 2 cm. The glans penis was very well
# B7 {! x( L" t" ?8 C: c/ ^developed. The pubic hair was Tanner II, mostly around4 \1 o" h6 |7 s3 r* _3 m$ a
540
  E3 }; x; p3 [$ W' z; q% Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ D: ]6 X$ M! d
the base of the phallus and was dark and curled. The
" |& `' l0 S7 |) wtesticular volume was prepubertal at 2 mL each.
6 U7 h" i" j8 E- [! x% cThe skin was moist and smooth and somewhat$ |; ~, H* h1 {7 y9 y
oily. No axillary hair was noted. There were no4 b3 S  n9 f$ M; \& G. H
abnormal skin pigmentations or café-au-lait spots.: ~& W: h* }9 u+ g: ?1 S  N' F. \
Neurologic evaluation showed deep tendon reflex 2+8 v7 s( ^" V9 B9 }8 x, Z; E0 X* N
bilateral and symmetrical. There was no suggestion/ d: K* O# ^( m  W
of papilledema.
: w* O0 p5 _6 I$ @% V: O/ g# }7 ZLaboratory Evaluation6 W) ^5 m8 s! v7 \3 `# Y) P6 ]2 e
The bone age was consistent with 28 months by
/ m& o( I9 u( Y1 T/ uusing the standard of Greulich and Pyle at a chrono-
5 g( A1 ?& H& clogic age of 16 months (advanced).5 Chromosomal1 b1 o/ |6 z" t1 P6 J! d
karyotype was 46XY. The thyroid function test( e% b: E. L4 n) H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. q/ ~7 N  f$ |9 T# Ylating hormone level was 1.3 µIU/mL (both normal)." ?/ }! ]. x  T2 h
The concentrations of serum electrolytes, blood( G9 X. v/ b( r* x
urea nitrogen, creatinine, and calcium all were% a) H6 M3 V: B9 O* w/ a% E
within normal range for his age. The concentration
; m6 Y# f' z# v6 L1 N& x$ e% Bof serum 17-hydroxyprogesterone was 16 ng/dL
2 B) W: e- ]; @9 C! L5 g- J* p; I(normal, 3 to 90 ng/dL), androstenedione was 20
8 N! q- G4 w2 S$ I, Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 q* @9 G8 J4 ]( zterone was 38 ng/dL (normal, 50 to 760 ng/dL),( u0 N, D) [7 I) u8 P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- h5 V+ l/ K3 v49ng/dL), 11-desoxycortisol (specific compound S)
- S! J4 I5 O- e! M2 I) wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 ?' b) ^* m! ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 P0 p: R: Z3 t) U& ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ G0 _! K9 C1 c$ ~; Qand β-human chorionic gonadotropin was less than+ Z9 Q9 r  t* d7 I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) \1 Y/ l9 Q! a& t2 Dstimulating hormone and leuteinizing hormone- i0 `3 ]" C8 ]& N0 i+ z8 h5 U
concentrations were less than 0.05 mIU/mL. F0 ~/ o. b5 ^" @& `' Y
(prepubertal).
& j. i% C6 i0 M' T* w: QThe parents were notified about the laboratory5 n& @4 Q3 [; r; T# W
results and were informed that all of the tests were5 t# O0 y9 }% \* b& g* M
normal except the testosterone level was high. The
0 h9 u- d6 J" W7 ~' Qfollow-up visit was arranged within a few weeks to# z; h7 z) `/ |% z4 J
obtain testicular and abdominal sonograms; how-5 c- w, Y# X) Y# v; E
ever, the family did not return for 4 months.
; ~4 g- ]" G5 f9 [9 qPhysical examination at this time revealed that the
! ?, B% Y) {' zchild had grown 2.5 cm in 4 months and had gained
0 |7 u- c6 W7 q& N3 \6 }2 kg of weight. Physical examination remained" H' I1 e( r5 W) Z
unchanged. Surprisingly, the pubic hair almost com-: }/ ^7 Y* P( m7 w- L
pletely disappeared except for a few vellous hairs at
, C2 r' a0 k! q3 V$ E3 L- w1 m, n; xthe base of the phallus. Testicular volume was still 2, r) ], ^( J2 K* t  X
mL, and the size of the penis remained unchanged.
0 y: k% |7 H; rThe mother also said that the boy was no longer hav-
# \, W+ Y6 p$ i, M& Uing frequent erections.
- f, k1 ?& G; RBoth parents were again questioned about use of5 U/ A7 I/ i7 i5 p5 }" W
any ointment/creams that they may have applied to
0 b) \4 X4 {. W4 ~/ T+ @4 R1 Y. Vthe child’s skin. This time the father admitted the1 V/ a2 |  k% A$ h, ]
Topical Testosterone Exposure / Bhowmick et al 541& X) T1 ?- s9 d  c
use of testosterone gel twice daily that he was apply-
1 @' p0 H$ z4 p0 T, bing over his own shoulders, chest, and back area for
& }5 R; b+ B( K& f) R; V+ Ua year. The father also revealed he was embarrassed- l! j! L3 Y# B4 c7 C
to disclose that he was using a testosterone gel pre-# A! S1 s8 }9 h, J5 M: ?; A( g
scribed by his family physician for decreased libido
' k" |! c! z4 I& R* k% ksecondary to depression.
& @$ g" `4 J" i: t" gThe child slept in the same bed with parents.
3 g0 U) R5 Q9 q! h7 l$ _; L) gThe father would hug the baby and hold him on his$ @# m# [2 |1 g. ^
chest for a considerable period of time, causing sig-
4 d$ L3 G% c& J* @: Fnificant bare skin contact between baby and father.4 _3 \" e, N0 P% Z  |6 n( Z8 i
The father also admitted that after the phone call,
8 A3 O: M8 O5 H/ A; _* v& f# awhen he learned the testosterone level in the baby
" I+ d, l- m& r& W* l0 Y$ Rwas high, he then read the product information4 y4 @1 W9 `; K# j3 v; v: B% o# x6 @
packet and concluded that it was most likely the rea-# n3 t: u8 g* E% l$ L, l
son for the child’s virilization. At that time, they+ |; \8 J, o0 j- [9 C7 T$ T
decided to put the baby in a separate bed, and the
0 p3 \' a$ _, T$ ^6 X. Y4 [2 Vfather was not hugging him with bare skin and had
2 a, b: w4 O/ N/ Ibeen using protective clothing. A repeat testosterone
1 ?$ j, r  T. F+ Rtest was ordered, but the family did not go to the
6 R  u8 b# b; y: Olaboratory to obtain the test.$ C; B3 J' C, |7 r; Y. z7 W
Discussion
5 t) }! ^( [+ k1 T( g. O7 D+ xPrecocious puberty in boys is defined as secondary" m& {3 N2 N  r( p. z% n8 Z
sexual development before 9 years of age.1,4
7 I: Y. n) v7 d0 a, ZPrecocious puberty is termed as central (true) when' k* h0 L7 E, t; n; Y0 M
it is caused by the premature activation of hypo-0 d. J9 H8 c; {/ t( k" v
thalamic pituitary gonadal axis. CPP is more com-
+ t7 h, {/ O9 N$ v" bmon in girls than in boys.1,3 Most boys with CPP
7 {7 ^* m1 H7 X! r; @may have a central nervous system lesion that is
8 l2 V5 t' q6 Y1 v9 a$ yresponsible for the early activation of the hypothal-
  K' X8 T. @6 hamic pituitary gonadal axis.1-3 Thus, greater empha-
; X3 h$ _7 d5 h9 ]( y( nsis has been given to neuroradiologic imaging in3 a/ D) h- n; E9 q' D: K
boys with precocious puberty. In addition to viril-
( A9 ?, W, |4 E: i4 T) H) }ization, the clinical hallmark of CPP is the symmet-
( b5 g# ^, k, P: K3 hrical testicular growth secondary to stimulation by$ F) u2 T0 Q1 y; K3 l
gonadotropins.1,3
) y, c# D, a0 d' xGonadotropin-independent peripheral preco-6 g! ~/ p( C& H6 I2 P3 N% x
cious puberty in boys also results from inappropriate& e9 d5 D( B' O% \
androgenic stimulation from either endogenous or; O) n& l( ]) Y( H$ D
exogenous sources, nonpituitary gonadotropin stim-
3 u: a5 ~7 ~9 tulation, and rare activating mutations.3 Virilizing1 u5 n  R: x5 W% v
congenital adrenal hyperplasia producing excessive6 v3 T) ?) c. X& I$ D4 u+ [
adrenal androgens is a common cause of precocious, x" Z1 q6 `$ c* k/ M$ r
puberty in boys.3,4* P1 \$ V: l% J1 z5 t2 c! a( v
The most common form of congenital adrenal
6 U" v7 _; j- b  a/ W7 z2 xhyperplasia is the 21-hydroxylase enzyme deficiency.
( E  C1 r' ~9 f* `* e, t& L7 yThe 11-β hydroxylase deficiency may also result in
- w. k  O/ t6 u# yexcessive adrenal androgen production, and rarely,
$ a  ^7 ]/ J; R- y; L' @' }* g+ m( Man adrenal tumor may also cause adrenal androgen3 O& \) g' c% _- U* B& l! q
excess.1,3
$ f7 [5 ?+ |3 ^7 x; @9 d. Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' ?( o+ `) u: b4 N542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 ]2 I) w. w: w4 M* K! c2 ZA unique entity of male-limited gonadotropin-9 t4 G$ i& R8 _/ V- T1 D( o/ x* p
independent precocious puberty, which is also known
- \0 A$ T( ~- aas testotoxicosis, may cause precocious puberty at a0 s2 U* q$ Y) i! j
very young age. The physical findings in these boys/ o1 C& [; ]3 [5 b% ^
with this disorder are full pubertal development,& g" F  Y, ]/ P
including bilateral testicular growth, similar to boys
8 g* e' L" Y0 @2 X. P9 y8 zwith CPP. The gonadotropin levels in this disorder
* w. r* X; d: \- ~. qare suppressed to prepubertal levels and do not show2 D' z% w! Z- U5 S4 |5 c
pubertal response of gonadotropin after gonadotropin-
8 p$ e1 l" B7 O4 [3 ^releasing hormone stimulation. This is a sex-linked3 |/ t( J5 ^' i% W! g3 X
autosomal dominant disorder that affects only8 [: q8 g. m3 e. ^5 ~+ F4 j
males; therefore, other male members of the family
: S$ D- }; |4 ]may have similar precocious puberty.3+ `: l4 R' P$ g/ l1 n" U5 R0 s
In our patient, physical examination was incon-
0 D6 y/ O& D8 ^5 r, L4 y0 v, [! }sistent with true precocious puberty since his testi-" t  }5 H0 \- }* z) Q; \
cles were prepubertal in size. However, testotoxicosis. B6 ~/ B  p9 h* u
was in the differential diagnosis because his father
$ t/ O+ i! D/ N" V' V% h; pstarted puberty somewhat early, and occasionally,( {$ H5 i" R+ t6 T* [
testicular enlargement is not that evident in the) T  n+ S% z* W1 S8 \3 W
beginning of this process.1 In the absence of a neg-
6 \$ W* A8 K+ _* V: I- U. _1 rative initial history of androgen exposure, our5 x4 l% s/ y3 \  X7 [
biggest concern was virilizing adrenal hyperplasia,
* w4 i" L# {9 I7 L( {either 21-hydroxylase deficiency or 11-β hydroxylase) S) E# G) p" O. h7 Y- W
deficiency. Those diagnoses were excluded by find-
: ]+ n9 q2 N; T: d1 Ling the normal level of adrenal steroids.3 I. |, Z( u1 H8 b
The diagnosis of exogenous androgens was strongly( h. O7 T) J# [$ {. h
suspected in a follow-up visit after 4 months because
$ R* K- I7 q) d' T4 U/ Q. j, J2 ~the physical examination revealed the complete disap-
  }" ?7 b" A; Wpearance of pubic hair, normal growth velocity, and" H& c, Q9 y( g/ e, q* {/ E
decreased erections. The father admitted using a testos-
5 f( e" W& K* K# p  e+ G/ f9 uterone gel, which he concealed at first visit. He was
  c7 j/ u: q( Rusing it rather frequently, twice a day. The Physicians’; e! J( C& t5 ~; R7 V
Desk Reference, or package insert of this product, gel or
/ ?2 j. E" v6 Y  h7 `cream, cautions about dermal testosterone transfer to
) v" T) L* e" ^" y7 Ounprotected females through direct skin exposure.- q! Z9 V- v8 T4 t% m; H
Serum testosterone level was found to be 2 times the9 w4 C. }* g* g' s
baseline value in those females who were exposed to
. f. A" l7 E, e' P! \, ieven 15 minutes of direct skin contact with their male3 B0 x$ D/ t: w1 B4 G8 ]2 V! I7 p+ ?/ I
partners.6 However, when a shirt covered the applica-0 i% q1 F# k: w7 i
tion site, this testosterone transfer was prevented.
' t: `1 l: L' \1 T$ Y- B9 XOur patient’s testosterone level was 60 ng/mL,
; i0 X  u" h% A3 z( a/ Lwhich was clearly high. Some studies suggest that" a) A; M$ D7 k6 p9 _
dermal conversion of testosterone to dihydrotestos-
1 ~% F! t8 t1 p( r6 Iterone, which is a more potent metabolite, is more# Y$ [8 V8 w* p+ j' ~* G
active in young children exposed to testosterone
8 a! B+ ^' {5 J, f' C( g# g5 iexogenously7; however, we did not measure a dihy-
3 r# v7 s+ C7 U# I2 fdrotestosterone level in our patient. In addition to0 {) {- g0 s; [3 w; H+ H# y
virilization, exposure to exogenous testosterone in6 B1 L- b  {% i+ |
children results in an increase in growth velocity and! w  l/ ?. ]: T- d( }
advanced bone age, as seen in our patient.* t% m+ O; q( l- ~
The long-term effect of androgen exposure during6 q( {1 l' P. n2 q2 ?- g- v  n
early childhood on pubertal development and final
, P7 ^8 O- D4 `: Xadult height are not fully known and always remain/ u! N8 x6 I" X: C) s6 M# s
a concern. Children treated with short-term testos-
9 z; s% Q* U$ g# \6 Kterone injection or topical androgen may exhibit some
% [* x8 F1 V& e4 u/ q# N0 facceleration of the skeletal maturation; however, after6 ?7 e/ V, _+ F8 }
cessation of treatment, the rate of bone maturation
; K2 a' v1 B% h0 `8 l5 @0 B5 Adecelerates and gradually returns to normal.8,9- `; g6 O, k% T
There are conflicting reports and controversy% W; y* E+ ?0 _) o' B) h; b8 X
over the effect of early androgen exposure on adult2 o4 a  q$ I+ q0 Y' I- m
penile length.10,11 Some reports suggest subnormal9 s9 F' `7 X# f, E9 P
adult penile length, apparently because of downreg-
: n& R  O8 \$ q: {8 X7 l% Yulation of androgen receptor number.10,12 However,
# C: h6 x- I3 k4 z  \5 V& S6 TSutherland et al13 did not find a correlation between# F4 W+ i/ B4 Z/ a* |  Z
childhood testosterone exposure and reduced adult- ?8 n- U! Y0 A
penile length in clinical studies.
/ J8 ]4 i' z$ gNonetheless, we do not believe our patient is
3 S$ C: P) k9 r, Rgoing to experience any of the untoward effects from7 A0 }8 S( [* @1 a" \1 z
testosterone exposure as mentioned earlier because/ n) j, }2 O5 |  z  Y
the exposure was not for a prolonged period of time.
, d8 a, X5 A9 ~3 \; H+ @Although the bone age was advanced at the time of
' m' {( A) s& S( s! _diagnosis, the child had a normal growth velocity at/ e% c: {, F3 E4 Y# R, L: M  R# B5 o
the follow-up visit. It is hoped that his final adult
- G4 T$ }: V$ U) @; ^  rheight will not be affected.
& A3 J/ u2 G* [/ r! ?+ z) ZAlthough rarely reported, the widespread avail-
8 n$ v/ {# x. K+ Lability of androgen products in our society may
) j9 B: V8 Q) q6 A# `6 m6 n1 mindeed cause more virilization in male or female: W- e1 i  B7 M& u3 `. _1 }. o" {
children than one would realize. Exposure to andro-( A: l# \) R% n+ _' e9 {
gen products must be considered and specific ques-7 ~1 {9 K4 V- A) `/ b
tioning about the use of a testosterone product or4 |2 @9 C) T$ s2 H$ b8 P; W7 C/ A
gel should be asked of the family members during6 ^, U. J; e, q& F+ r1 o
the evaluation of any children who present with vir-
5 W, o0 u& q  b2 X1 Rilization or peripheral precocious puberty. The diag-
- d' P; E) o+ u* q$ s' Inosis can be established by just a few tests and by
- s$ N6 ^% D8 E7 O2 E+ Y; iappropriate history. The inability to obtain such a
- J/ a% V! b. T4 z& [; `. C3 [history, or failure to ask the specific questions, may
- Y6 ^0 J2 M/ q$ T3 N6 t3 A8 l2 presult in extensive, unnecessary, and expensive4 c+ t/ q9 d4 S  f4 ~' _8 @
investigation. The primary care physician should be
! u0 y1 Z6 Q! \' yaware of this fact, because most of these children- \* L) v. `" F, n* z4 y1 e
may initially present in their practice. The Physicians’
8 k; T+ h7 Q1 x( ?+ F1 w# pDesk Reference and package insert should also put a
9 B& Q" C' _! y9 m4 v1 z% ~" i1 ~  Ywarning about the virilizing effect on a male or) S2 E* ]- e  @2 N3 R; P2 v  j
female child who might come in contact with some-% y; N4 `. E6 R7 i7 W& K
one using any of these products.
; E* R8 Y6 W6 c# b: N- e, u' eReferences
  i9 g! J8 C& m) T/ m1 \: _% B- h1. Styne DM. The testes: disorder of sexual differentiation! [, _; f: Y! l5 d9 d
and puberty in the male. In: Sperling MA, ed. Pediatric4 X" f% ]7 W* x; i, [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 |  q  l5 p& z5 O4 @2002: 565-628.
& H7 F' m5 B) D. {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& F/ U0 w* B3 ^6 W! tpuberty 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
* E& ~% _- I+ I0 I3 K% N! |
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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