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Sexual Precocity in a 16-Month-Old8 v6 I& c, p, y2 L
Boy Induced by Indirect Topical" w; E  M  G* i9 L3 U$ w2 n1 v" X
Exposure to Testosterone/ e4 C! h* z: I+ T) s
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- D( O$ H+ |; S  e( M) v% G$ C
and Kenneth R. Rettig, MD1
9 T/ ?5 ~0 g7 J1 x, g- x' bClinical Pediatrics( e, `( X7 {/ Q/ F: V( b( s% Z; H
Volume 46 Number 6. ~" n) [: s4 J+ f+ h9 v
July 2007 540-5434 l1 W5 L1 {2 ~, ?
© 2007 Sage Publications
/ l- S. _3 P# j6 \$ B. f9 I10.1177/0009922806296651, J+ j& g. J9 a" ^$ {7 l+ u
http://clp.sagepub.com. K3 i! G- Y. r+ X$ W. E0 L
hosted at2 o6 w" ~1 [" `8 L4 z
http://online.sagepub.com* B1 O8 V: ]: X: F$ w* U
Precocious puberty in boys, central or peripheral,
1 Z* G/ |% d, {# R9 C) X$ y, d; Eis a significant concern for physicians. Central/ }) q8 A3 w' G/ y  _/ Y
precocious puberty (CPP), which is mediated
: Z3 @+ o6 P( M% ?2 }4 u1 d, t  Vthrough the hypothalamic pituitary gonadal axis, has
0 m& X6 y! G( w! i0 k  {a higher incidence of organic central nervous system
$ `9 g( a" X( j3 q! zlesions in boys.1,2 Virilization in boys, as manifested
1 V! \1 h( E8 B) V/ ]by enlargement of the penis, development of pubic% @) o  `) P- q5 D  ~! u
hair, and facial acne without enlargement of testi-9 W' V/ v3 U7 |5 A
cles, suggests peripheral or pseudopuberty.1-3 We% [7 I6 q) _) B! W( ]1 H
report a 16-month-old boy who presented with the
' w" P7 O; Q# @, {/ g9 [/ eenlargement of the phallus and pubic hair develop-
9 Z3 [8 ~8 J1 C* |# a& `, `ment without testicular enlargement, which was due
9 I0 R# y3 I$ Q8 }. [/ P5 b. nto the unintentional exposure to androgen gel used by
: z9 m# r; [: ~+ Z6 n: wthe father. The family initially concealed this infor-# R/ y- O: X: u
mation, resulting in an extensive work-up for this
) `% h/ q4 m1 j+ ]child. Given the widespread and easy availability of* x. t, M* |! ~& S' Q
testosterone gel and cream, we believe this is proba-
; G7 \% s  P3 D9 o( U8 mbly more common than the rare case report in the. [; @3 c6 K" N6 i' {
literature.4
& X5 Y/ ^  G- b  I5 N, v( IPatient Report+ Z9 R! _) |1 N9 D7 z! |
A 16-month-old white child was referred to the1 q; U: e) Y& b) l0 |
endocrine clinic by his pediatrician with the concern( Z  e1 o9 M1 {: r! d( c
of early sexual development. His mother noticed
" S5 T) z* k( M! A! zlight colored pubic hair development when he was4 a' w/ Q7 f; V1 O
From the 1Division of Pediatric Endocrinology, 2University of
& {" O2 L; }# F1 R" R5 XSouth Alabama Medical Center, Mobile, Alabama.: U0 K) G. B- [( u* H4 k; V
Address correspondence to: Samar K. Bhowmick, MD, FACE,* \- c4 x- `, ^& U. |# b8 |0 m* Z
Professor of Pediatrics, University of South Alabama, College of3 h2 d$ X. d+ p
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! _# }( k$ w9 u4 {- d
e-mail: [email protected].
+ B6 H' x. V- |about 6 to 7 months old, which progressively became
+ A/ Y+ K. `' s+ {darker. She was also concerned about the enlarge-
1 @/ _6 U- C* [ment of his penis and frequent erections. The child
$ l% [8 l7 `/ b- n7 E5 qwas the product of a full-term normal delivery, with
. N$ H, {" U) D8 na birth weight of 7 lb 14 oz, and birth length of
; u& ^1 S$ T3 A* _2 j/ @7 A- s20 inches. He was breast-fed throughout the first year
0 {, l6 s8 w' {* O+ n" Dof life and was still receiving breast milk along with
5 t# a& A1 r2 B- _solid food. He had no hospitalizations or surgery,
; W# L3 v, L0 \+ l3 i$ s2 land his psychosocial and psychomotor development9 R* ]$ @0 J) V2 ?9 b  u6 z. G
was age appropriate.- k# W. H- L0 G' a% g
The family history was remarkable for the father,+ y1 S3 \; v2 ]/ |! G/ |
who was diagnosed with hypothyroidism at age 16,
' W- Y& h. H& P3 Swhich was treated with thyroxine. The father’s7 @9 P. j9 |/ M+ @
height was 6 feet, and he went through a somewhat
) h5 W5 D. \0 q- i# O2 l' {* ^early puberty and had stopped growing by age 14.* y& c$ N1 P3 H, i5 @
The father denied taking any other medication. The. J7 c; ^. s, |* g
child’s mother was in good health. Her menarche
3 |$ @; M. O' \2 X: p  A; _was at 11 years of age, and her height was at 5 feet
  s2 W' W: Y& r0 `8 w3 A; c) ^: c  i5 inches. There was no other family history of pre-
( \* B& s; j1 icocious sexual development in the first-degree rela-
! i# y" `- F7 f% Stives. There were no siblings.
' m) [$ R: S( A9 @Physical Examination
0 h7 B- C' S9 R# uThe physical examination revealed a very active,
: G! m3 P6 Y4 `$ Kplayful, and healthy boy. The vital signs documented
1 Z, j* ~' a1 T& w. ja blood pressure of 85/50 mm Hg, his length was1 H/ E. s* Q$ {; R5 }$ W
90 cm (>97th percentile), and his weight was 14.4 kg+ }' j8 ^- I" P% E, o
(also >97th percentile). The observed yearly growth
7 ]: X+ u- f7 n* u; p1 avelocity was 30 cm (12 inches). The examination of. e5 L  W* ~5 a( Y0 }" @
the neck revealed no thyroid enlargement.
4 L0 D9 u0 c- F- q* X' d6 j* ~3 RThe genitourinary examination was remarkable for0 d, i- O( k* O! ], K" |$ w
enlargement of the penis, with a stretched length of
# w: y. v$ \" ?& O  s6 O8 cm and a width of 2 cm. The glans penis was very well+ ^/ y5 k1 z4 O% h- u
developed. The pubic hair was Tanner II, mostly around
) g4 G; U4 R2 L6 B$ o4 o540
$ n* t7 u' ]6 Z8 ~7 R2 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 d2 m' M) [3 [2 c/ Y
the base of the phallus and was dark and curled. The# j4 ^( j. |/ _( G* X! `
testicular volume was prepubertal at 2 mL each.. G. M, ^- e3 u: B" ^+ n( {4 V% C
The skin was moist and smooth and somewhat
* A% i8 F, ?- |3 T1 ^$ Zoily. No axillary hair was noted. There were no
+ n% D4 _0 }7 A+ N/ h; `abnormal skin pigmentations or café-au-lait spots.; u1 {( C- K2 ^( y- w# W: |9 \; Z
Neurologic evaluation showed deep tendon reflex 2+) S. y4 b" N- y+ g9 X
bilateral and symmetrical. There was no suggestion4 N: y! Z4 Q% F' i
of papilledema.
$ K% c; c# L! |2 ILaboratory Evaluation
0 C: R8 h$ A: Q4 Y' G- ~6 u& LThe bone age was consistent with 28 months by$ j. {8 m6 M( z! f  q
using the standard of Greulich and Pyle at a chrono-
/ A' e5 d- d- e: q3 Klogic age of 16 months (advanced).5 Chromosomal
- t- R% l; x. a3 _3 T9 v0 f+ n. mkaryotype was 46XY. The thyroid function test1 [: m' D: F% M4 _+ |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 N, o% v5 B& f8 a
lating hormone level was 1.3 µIU/mL (both normal).
) ^& B0 G" Z, w# w4 SThe concentrations of serum electrolytes, blood
8 l% k! p/ F2 a+ Turea nitrogen, creatinine, and calcium all were
/ B. v$ ^: e* ^: cwithin normal range for his age. The concentration
" H; e% F0 R* d. t2 I$ V" Cof serum 17-hydroxyprogesterone was 16 ng/dL
) I  }, T: B1 R( R(normal, 3 to 90 ng/dL), androstenedione was 20/ c; r& }) g4 \  h$ @. U4 h
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ J& x% w- P, {' \7 k* _$ Y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),  g) g% D2 E6 H+ T) K9 ]2 o
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' f9 T) k' P' g7 b49ng/dL), 11-desoxycortisol (specific compound S)
) z8 Y* p! Z2 z+ g) W, Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; C8 r; I* s0 x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; c' ~' ]9 V! u2 Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! M. y& ]+ i9 Zand β-human chorionic gonadotropin was less than
/ s0 ^( H/ {- A3 M/ k2 L7 A5 mIU/mL (normal <5 mIU/mL). Serum follicular
& H; Y3 o4 A7 q( L' R$ estimulating hormone and leuteinizing hormone
! P# _( m  i; ]/ qconcentrations were less than 0.05 mIU/mL* M; L# ]$ v6 L9 ]6 m; R& S
(prepubertal)./ [" N6 E6 \/ G4 v4 a- h$ {
The parents were notified about the laboratory) p( g  m2 R) F: D
results and were informed that all of the tests were
" u& l: W" z1 ]) Nnormal except the testosterone level was high. The; j( |/ W% V# C! _3 u
follow-up visit was arranged within a few weeks to: V* Q, M: ?  k3 d" L9 _9 P+ z
obtain testicular and abdominal sonograms; how-# O0 D, p; q) X+ e9 V
ever, the family did not return for 4 months.
, j/ Z8 B9 o/ m6 @  Z+ \  S2 JPhysical examination at this time revealed that the& X! j  Z8 g& N" |
child had grown 2.5 cm in 4 months and had gained$ @9 h4 k( Z) I
2 kg of weight. Physical examination remained
3 m, ]4 F( [5 v4 \; J$ K% N6 @unchanged. Surprisingly, the pubic hair almost com-
+ _$ t+ }5 m0 c3 Opletely disappeared except for a few vellous hairs at
" K8 S. k* l0 Y1 C7 Jthe base of the phallus. Testicular volume was still 2
0 b1 k- g+ y+ _7 e; dmL, and the size of the penis remained unchanged.
( Z" C2 {  H# x5 C, B  oThe mother also said that the boy was no longer hav-
& @+ a, H) ~9 [) t6 I- m4 Y# Eing frequent erections.6 G3 w9 h+ B: |& ]& b- A: d& Q
Both parents were again questioned about use of- I, \* _2 `7 P+ b0 p3 O  y
any ointment/creams that they may have applied to& F& ^; `$ x  l* {6 U" d: V
the child’s skin. This time the father admitted the; X/ F9 S5 p' y& y! f0 L
Topical Testosterone Exposure / Bhowmick et al 541/ N2 d5 X( z  R  ~( Q1 R
use of testosterone gel twice daily that he was apply-
( L/ P1 ?! M- [& l! a: C8 n: `, j# Q( Cing over his own shoulders, chest, and back area for8 A: r# {+ V$ L
a year. The father also revealed he was embarrassed
# l8 x% u( S" z5 b0 A5 G  R. L- i, {7 Qto disclose that he was using a testosterone gel pre-
+ l2 p# N1 Y1 p: j0 J# ]scribed by his family physician for decreased libido) [1 ^8 Z; Y3 @0 t8 H) G4 b/ l
secondary to depression.
+ \* X$ }  ?2 e/ H  P# V1 l, s" K& KThe child slept in the same bed with parents.
' i8 k- a5 H( I) zThe father would hug the baby and hold him on his
! ^3 I! t1 G! ]+ Q+ B. j; hchest for a considerable period of time, causing sig-1 J% [4 W# T  F$ B# o% `* O$ S
nificant bare skin contact between baby and father.
) D* ?% J% k4 z& X/ w' DThe father also admitted that after the phone call,9 n/ N# p8 L9 F9 g. r  X
when he learned the testosterone level in the baby
8 e( G4 O: l" w) u! d" awas high, he then read the product information
# O& }& `0 A. y  ~- epacket and concluded that it was most likely the rea-& E1 P# r' j) ]( v8 i% P: M% ?
son for the child’s virilization. At that time, they. d1 r* ^0 U. S" x2 g
decided to put the baby in a separate bed, and the
8 t; D/ ~# X& T/ @( N: Xfather was not hugging him with bare skin and had6 C) f/ D) ?  \& K) H/ |
been using protective clothing. A repeat testosterone: U6 Z0 y4 u. ?; L7 ]8 t+ p$ k
test was ordered, but the family did not go to the* L; }3 c" K' Q4 A, ?$ J1 e
laboratory to obtain the test.& r( @, ?7 h: d
Discussion) r& `. q4 B! x; w! o
Precocious puberty in boys is defined as secondary/ B7 U% v; q! ?* g
sexual development before 9 years of age.1,4  r: D& {& w* G- Q
Precocious puberty is termed as central (true) when6 W1 _4 i- k/ L* H% a+ ]  ]
it is caused by the premature activation of hypo-
; z* N$ m% {( H2 h+ V- U2 Dthalamic pituitary gonadal axis. CPP is more com-# \6 W& s9 b- D' Q$ \$ i6 O3 f. k) {
mon in girls than in boys.1,3 Most boys with CPP- H) X+ L& m" @& w
may have a central nervous system lesion that is) f% L0 E0 w$ a' \2 x8 H6 d" v3 X
responsible for the early activation of the hypothal-
. A+ F1 Q. H! O1 v% {! W& {amic pituitary gonadal axis.1-3 Thus, greater empha-
) f' d( ^& f8 J2 b" w% D  b, W+ F! Esis has been given to neuroradiologic imaging in
( ~  \" \  l3 }/ d# S4 `! E! Eboys with precocious puberty. In addition to viril-/ P% H% J2 C, q3 w
ization, the clinical hallmark of CPP is the symmet-9 ^/ I5 w; s6 j" g0 s; O* C
rical testicular growth secondary to stimulation by
; W6 I5 G# y7 U' [; Fgonadotropins.1,3
6 z$ ?0 B$ V' f% W5 P6 e# `$ pGonadotropin-independent peripheral preco-
3 e; [! d: q1 A. I4 Jcious puberty in boys also results from inappropriate
2 t- w1 y) U' r, randrogenic stimulation from either endogenous or
# d! g! X9 s, P: G+ Lexogenous sources, nonpituitary gonadotropin stim-
( R3 N4 c' |: k" Sulation, and rare activating mutations.3 Virilizing. D6 _& s% J* e$ A4 M5 P
congenital adrenal hyperplasia producing excessive
. y/ Y( L+ [1 ]. C6 yadrenal androgens is a common cause of precocious
- y' R; q% S7 T0 w6 c4 t$ w% d2 Qpuberty in boys.3,4' H/ `) Q9 {" ~* @8 \
The most common form of congenital adrenal: A& w1 U; ~: }! |2 ^
hyperplasia is the 21-hydroxylase enzyme deficiency.+ ], q$ {) J% e$ h) {$ t& z5 u1 q
The 11-β hydroxylase deficiency may also result in
! m7 P+ R- z- [excessive adrenal androgen production, and rarely,
0 z- h! F! J! Pan adrenal tumor may also cause adrenal androgen
* }6 M. C# \0 {) U4 ]excess.1,3
1 }3 k+ n& @7 O, x& b( e* a$ j. x  t/ Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. b. Q+ F2 G0 r: U; `542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 R( ~) z1 S9 z6 x# VA unique entity of male-limited gonadotropin-0 M0 ~7 ~9 g/ X: d* F% {
independent precocious puberty, which is also known: N9 U7 W$ A7 y2 _
as testotoxicosis, may cause precocious puberty at a9 x& ~; v, h5 [' ^3 ]
very young age. The physical findings in these boys+ ~  {: K7 L; M* V$ P: N
with this disorder are full pubertal development,, c' p' g, _1 b* E# g
including bilateral testicular growth, similar to boys
& A( d% {- t( s+ c+ Twith CPP. The gonadotropin levels in this disorder6 X! R1 ?% v1 Z% p# s" d
are suppressed to prepubertal levels and do not show4 \1 Z  y9 ]6 j$ j3 u
pubertal response of gonadotropin after gonadotropin-
3 u) e6 L' L) T' Vreleasing hormone stimulation. This is a sex-linked! W: j% E! `- h3 @
autosomal dominant disorder that affects only
1 }; C* z' D; u/ @males; therefore, other male members of the family2 ^! b( `0 Z1 Z  S' [8 h+ [
may have similar precocious puberty.36 o7 N' O! F  s- \: t7 z( H8 S: h: ?
In our patient, physical examination was incon-7 o. R; Z0 {! e7 F! t: d
sistent with true precocious puberty since his testi-; L* Q0 X4 x* y6 W3 @
cles were prepubertal in size. However, testotoxicosis( w" X8 o! b% @2 }4 Q; W# @( c
was in the differential diagnosis because his father
* w2 q! T8 D3 g/ c9 Vstarted puberty somewhat early, and occasionally,7 ~/ M/ [) [) N/ D
testicular enlargement is not that evident in the" P: w/ H" G+ \& c
beginning of this process.1 In the absence of a neg-
" j8 C3 p) s/ L+ Q  Native initial history of androgen exposure, our5 t& h- e$ a0 G& o, |
biggest concern was virilizing adrenal hyperplasia,
- z1 X7 ?  t" D3 |6 seither 21-hydroxylase deficiency or 11-β hydroxylase
4 t. ?5 {5 `# y7 m8 K* Ldeficiency. Those diagnoses were excluded by find-
% Y0 ?) G; i+ m  Wing the normal level of adrenal steroids.2 k& p( R. Q% |
The diagnosis of exogenous androgens was strongly. F& [" w' p# o* c$ `0 H+ K
suspected in a follow-up visit after 4 months because
1 h: U8 c9 L9 w7 C- r; Zthe physical examination revealed the complete disap-
  z- P7 {' [1 g: mpearance of pubic hair, normal growth velocity, and0 X3 y. d0 q/ L  T9 @% L
decreased erections. The father admitted using a testos-
$ S. A6 K5 Q1 U# tterone gel, which he concealed at first visit. He was2 X$ E* J/ I! P) [
using it rather frequently, twice a day. The Physicians’
: T4 F" g, q( Y$ |( |Desk Reference, or package insert of this product, gel or
# P* C9 Y# L& scream, cautions about dermal testosterone transfer to
6 G  F2 x3 ~1 p; T; _unprotected females through direct skin exposure.
* _. V6 V0 Y  E4 t. `' }Serum testosterone level was found to be 2 times the
6 v$ \& c) C) C; g/ sbaseline value in those females who were exposed to7 v3 P0 x- m# P
even 15 minutes of direct skin contact with their male0 T3 K- l. p& ]3 f% \2 T6 c" H
partners.6 However, when a shirt covered the applica-( ?% f  U9 E+ v6 @( t" ]. o* Z
tion site, this testosterone transfer was prevented.
3 Y  G$ x5 E0 e2 \% GOur patient’s testosterone level was 60 ng/mL,( l/ x$ E  O0 [# E, N/ l
which was clearly high. Some studies suggest that
5 ]: W6 v5 V8 Q- \% U! u5 M0 qdermal conversion of testosterone to dihydrotestos-
4 v- _- A- t2 e) [terone, which is a more potent metabolite, is more$ L6 @4 V. P) c8 t
active in young children exposed to testosterone0 j  @" k2 Y( R
exogenously7; however, we did not measure a dihy-
9 i  q+ _/ b3 P: t) \drotestosterone level in our patient. In addition to4 \$ Y8 C0 u2 U: V, h3 t4 S% p
virilization, exposure to exogenous testosterone in
- i6 o6 _& E6 `children results in an increase in growth velocity and
* B1 P. S6 u, b. U! M& K0 @advanced bone age, as seen in our patient./ f/ P8 B" h+ n* n1 w  S* ^* f& C
The long-term effect of androgen exposure during& m# Z- s" x( K! n/ V
early childhood on pubertal development and final9 C* h5 y- M6 n. Z  k3 y- U
adult height are not fully known and always remain; |/ E* v/ b' b4 ^7 g" z( d
a concern. Children treated with short-term testos-
) c( {  y! E8 ?- p4 }terone injection or topical androgen may exhibit some# U7 m% _, T# Y& @- |% _7 J
acceleration of the skeletal maturation; however, after
* f/ E# f) B) o, j$ G# tcessation of treatment, the rate of bone maturation
1 U1 ~) C5 `3 G/ h- wdecelerates and gradually returns to normal.8,9
+ ], N4 [, f( i4 z; nThere are conflicting reports and controversy. F5 u+ D( T2 w+ P$ P$ ]1 r! f* O$ e  \
over the effect of early androgen exposure on adult% M; N( |3 x6 O2 W. j1 E  k9 Z
penile length.10,11 Some reports suggest subnormal8 d' A1 I* S, V1 B1 J
adult penile length, apparently because of downreg-
7 x) h, s/ v2 I# h1 aulation of androgen receptor number.10,12 However,% L$ R1 n# g; @7 K5 w2 {$ X) h
Sutherland et al13 did not find a correlation between; c" E7 ]( m2 d
childhood testosterone exposure and reduced adult* |& [9 @3 c( M1 u7 m- J
penile length in clinical studies.
4 k! A: G! o9 H9 W" c2 P, K# \Nonetheless, we do not believe our patient is+ l# N# e2 S1 `# D: M& K  r7 K
going to experience any of the untoward effects from
6 j% I& h* o& ~- R/ [testosterone exposure as mentioned earlier because
; a# Q) q$ m) J- y7 uthe exposure was not for a prolonged period of time.
8 F. \& Q- w2 C& _& c" OAlthough the bone age was advanced at the time of
* }3 m# o- |  [% w: b0 g  T1 xdiagnosis, the child had a normal growth velocity at) a: t! d6 V8 o. y& d" Z9 ?
the follow-up visit. It is hoped that his final adult5 Y0 B, m' q9 ?7 s& G, |; j
height will not be affected.- G. F3 z' P8 A1 e7 Z
Although rarely reported, the widespread avail-
1 n5 `/ u. X" u2 w! nability of androgen products in our society may# a" N  ?+ Y  \4 m, @/ `" y. a
indeed cause more virilization in male or female# M+ ?. w" `, B- c9 |2 ?# [6 i, \- \; \
children than one would realize. Exposure to andro-: g4 o1 u) E* J6 l
gen products must be considered and specific ques-% ~8 V( J3 M$ U( J1 Y9 q& L
tioning about the use of a testosterone product or5 `, V' k2 I9 X/ z3 n
gel should be asked of the family members during
8 ~' d/ W" H2 h+ T1 h, E  fthe evaluation of any children who present with vir-
6 c1 [$ `% \0 G! j- o& T( pilization or peripheral precocious puberty. The diag-  q$ _2 B' u, H( i* V+ N  ^
nosis can be established by just a few tests and by6 D" H0 C  i/ d. ^
appropriate history. The inability to obtain such a4 A2 v: U. \" Q3 G2 U4 {
history, or failure to ask the specific questions, may
$ }1 U/ ?8 a, j0 X. u: jresult in extensive, unnecessary, and expensive  H4 v* q2 W: P; K3 w) V. M, q$ C
investigation. The primary care physician should be; m1 a" j) q* ?" |
aware of this fact, because most of these children6 |( \) z' P2 D3 s7 \# i
may initially present in their practice. The Physicians’
4 y8 H0 _7 M3 L% c7 P6 X6 J1 N, zDesk Reference and package insert should also put a- |9 b$ {" l  z' \* U$ h$ T
warning about the virilizing effect on a male or
( I; E4 q2 e- d( G0 L+ A' B+ Cfemale child who might come in contact with some-
3 l# D% V1 s. G. ~5 qone using any of these products.
0 K  P' w* c+ o$ L- M  nReferences' f% j! T3 V2 S
1. Styne DM. The testes: disorder of sexual differentiation
( H. z3 E$ ~/ v3 \. wand puberty in the male. In: Sperling MA, ed. Pediatric5 ~3 I! F9 A5 u
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 ]! M* v4 b: l) X# B
2002: 565-628.0 N$ U. X, F$ ]: A; M3 b. |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 {+ W4 F( Z$ w( S, Q( o: V3 ?
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: t0 t4 D- r" Y
Boy Induced by Indirect Topical8 u+ {% P5 _5 b
Exposure to Testosterone
! E% b- |/ b2 t1 k+ x" C& X- G3 HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" C$ p) T9 B# j1 \/ V% L3 q
and Kenneth R. Rettig, MD1
4 A4 P" G! s* l$ fClinical Pediatrics
* v4 A- ~1 i  N/ m, XVolume 46 Number 6
" u  V: _1 |1 w; yJuly 2007 540-543) O* \: Q7 S; U5 N
© 2007 Sage Publications
2 Y, m; I" `4 b" y! z10.1177/0009922806296651
% q' A2 B) O1 ^: `, q  D+ G* ~9 `) e3 hhttp://clp.sagepub.com$ X) n# l# J5 k' f6 ?8 ?2 Q' e: l. U
hosted at
. r5 q5 r3 P$ N! r0 }2 Uhttp://online.sagepub.com0 H8 B6 y' U4 [+ P7 ]8 q/ Z
Precocious puberty in boys, central or peripheral,$ e  F0 w$ E5 }5 K( p6 e
is a significant concern for physicians. Central
! H& V. V* c/ Z" w) l9 Y* dprecocious puberty (CPP), which is mediated2 g/ Z4 b: b' \& S, K
through the hypothalamic pituitary gonadal axis, has
4 x* z# Q: c  h3 A9 [a higher incidence of organic central nervous system1 W, P% R0 D1 J  N
lesions in boys.1,2 Virilization in boys, as manifested2 w/ A! x8 B) l" Z' s" v
by enlargement of the penis, development of pubic- T+ H, |9 P8 P6 Z
hair, and facial acne without enlargement of testi-
0 z1 Y* e7 r3 x8 @cles, suggests peripheral or pseudopuberty.1-3 We
, ?# D8 w" q( V% X9 {report a 16-month-old boy who presented with the" L3 f. Q  K# ~) w% V. m
enlargement of the phallus and pubic hair develop-7 X- S5 n. g* a: L# E8 b
ment without testicular enlargement, which was due* C# T4 K! u7 e+ C" r4 v* r3 M5 d" O
to the unintentional exposure to androgen gel used by
9 O$ E1 ?% ?5 v0 `the father. The family initially concealed this infor-
8 l  w1 c4 @6 S6 u" B0 [6 mmation, resulting in an extensive work-up for this
1 g; z8 s- R; A% X& K" t7 _child. Given the widespread and easy availability of
. v: S% V! A9 V; etestosterone gel and cream, we believe this is proba-1 d$ R% J6 z; B* G6 f+ y4 X: i
bly more common than the rare case report in the9 X& O, U; E* u' J& V) d: ^
literature.4
3 }$ H5 I- j! T* i& v1 {3 i* LPatient Report
) x1 J5 d$ O; k& d+ ?5 S9 pA 16-month-old white child was referred to the( ^; [8 D5 i; A9 }, X. B2 K' g
endocrine clinic by his pediatrician with the concern1 H8 A  H- A/ g9 u) ]# H! Z- a
of early sexual development. His mother noticed
1 y# {) k$ T- }2 w! S6 `light colored pubic hair development when he was
! B& j# {% \7 i( TFrom the 1Division of Pediatric Endocrinology, 2University of8 O- f& O/ n+ a! l
South Alabama Medical Center, Mobile, Alabama.9 y& C2 X" _9 o8 ^0 t
Address correspondence to: Samar K. Bhowmick, MD, FACE,( `  L8 \/ b% b3 D0 p+ D
Professor of Pediatrics, University of South Alabama, College of
& x0 Q( g3 P/ m# z) R7 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ `  f  u  q9 e# M" c
e-mail: [email protected]./ |$ ^. w; G$ ^6 q! f. ~
about 6 to 7 months old, which progressively became
% f. k- q+ B) r$ M9 `& f/ Ldarker. She was also concerned about the enlarge-. d( i* S- c  y% E) O
ment of his penis and frequent erections. The child3 N0 x& V# ]/ ^. F
was the product of a full-term normal delivery, with
6 i7 S$ G1 x; y* {" C+ D/ B+ E6 C& Z9 Fa birth weight of 7 lb 14 oz, and birth length of
+ X4 z7 a# z5 Z, F: P. w20 inches. He was breast-fed throughout the first year
, m7 i9 B* {* I& jof life and was still receiving breast milk along with- b. |3 _$ X# r9 [4 f2 s1 j
solid food. He had no hospitalizations or surgery,8 K+ n3 Z3 c  _% ^0 E
and his psychosocial and psychomotor development
- I: g3 _& x: h3 y- _; mwas age appropriate.
( k4 ]  X+ s8 k; m9 OThe family history was remarkable for the father," p0 b0 E$ b: c, }
who was diagnosed with hypothyroidism at age 16,7 h" e7 m) h- s$ {" I; Q
which was treated with thyroxine. The father’s& j6 I( l+ A3 o  f3 a
height was 6 feet, and he went through a somewhat
$ |/ {; x# e! {" X0 c0 I4 P7 Qearly puberty and had stopped growing by age 14.- J. R: |6 |8 Y) z  I
The father denied taking any other medication. The
$ o5 ]: {2 f0 Bchild’s mother was in good health. Her menarche
( e2 H' z$ Y7 u) s( _5 N, s. U) Gwas at 11 years of age, and her height was at 5 feet
* a# M' p; J, W8 l5 c; \8 o5 inches. There was no other family history of pre-
) |( ]; n7 u: H& V2 Vcocious sexual development in the first-degree rela-  b9 q8 \0 n. W/ h+ V
tives. There were no siblings.
! q/ u' a( h8 ^/ ePhysical Examination
0 y# s! y  U- R5 y. F* zThe physical examination revealed a very active,5 U! Z  Q  b! C% A
playful, and healthy boy. The vital signs documented* z: k6 A$ n+ |; J/ F/ U
a blood pressure of 85/50 mm Hg, his length was
/ U( q$ E3 T6 P" u6 ~$ L90 cm (>97th percentile), and his weight was 14.4 kg
0 M9 h: L- o# j3 V(also >97th percentile). The observed yearly growth
" I! E1 @6 w! o% V- Lvelocity was 30 cm (12 inches). The examination of
1 v& J3 k" B7 w' l% A7 j2 S- ?the neck revealed no thyroid enlargement.
. l' _5 T0 ?8 y& X$ S- d. eThe genitourinary examination was remarkable for
" `4 Y5 c* d2 }- ~enlargement of the penis, with a stretched length of  b9 H0 X1 t2 I& a- G5 I/ ?6 K
8 cm and a width of 2 cm. The glans penis was very well( r( o: p5 G+ |3 q+ z
developed. The pubic hair was Tanner II, mostly around# |& T1 `7 W* W
540
/ a0 g! [8 J6 u+ lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 a% K7 x6 R+ v
the base of the phallus and was dark and curled. The3 y4 F6 u4 |  c' Z
testicular volume was prepubertal at 2 mL each.
5 `, t7 X4 H  ]0 A8 kThe skin was moist and smooth and somewhat
$ K5 v& {6 h8 M- c$ Joily. No axillary hair was noted. There were no
! W  |  r4 y/ A. K" ~abnormal skin pigmentations or café-au-lait spots.. a0 b  o1 j; }. V# ]( t
Neurologic evaluation showed deep tendon reflex 2++ g( N: x6 `: j  u+ s% I) K
bilateral and symmetrical. There was no suggestion
( {6 w$ B4 ]& T- ?5 P) G! Oof papilledema.- M# y3 O& I6 J6 E# Y
Laboratory Evaluation& j0 [, X9 \5 l& \" y  s& s
The bone age was consistent with 28 months by$ O- Q4 _# v  I8 [3 M( `: W. i
using the standard of Greulich and Pyle at a chrono-
+ r% K8 s/ A# E. _" {! q  u4 J, y( K$ Zlogic age of 16 months (advanced).5 Chromosomal9 G9 \. Z3 C# C" \3 {
karyotype was 46XY. The thyroid function test* V: m) Q. R5 C( P/ k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 G( N: `8 l. n5 k: Z2 N, n$ q, L/ Nlating hormone level was 1.3 µIU/mL (both normal).: Y/ L/ D0 A- b/ X6 A) M
The concentrations of serum electrolytes, blood  A/ \/ ?! \7 p' o) r6 V
urea nitrogen, creatinine, and calcium all were
- F) H& ~' S' t5 ]6 Kwithin normal range for his age. The concentration
4 F2 W, R( Y4 ?' B3 H" D, Nof serum 17-hydroxyprogesterone was 16 ng/dL
, @1 t- Q( v; d) V8 y: t1 H5 B(normal, 3 to 90 ng/dL), androstenedione was 203 {( i: R" j6 I
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ c* f8 t) H1 ]5 {
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( ?1 ^) p& j+ B( C! @) C& _1 J% Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to* R6 f8 V1 q5 T* d- b
49ng/dL), 11-desoxycortisol (specific compound S)
. G0 U& n6 S* a/ O, s( Q+ lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ f  _- c5 H. S  B+ g7 U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) x" `. ~$ Q, W' M, h  Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 g7 C* G' w2 b! [1 r5 fand β-human chorionic gonadotropin was less than/ E1 S' L) [$ Y4 L# X
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# A: l2 O/ [$ ustimulating hormone and leuteinizing hormone7 B3 K: h8 W# Z1 i
concentrations were less than 0.05 mIU/mL
$ b' P' y1 Y& `! X: H3 N(prepubertal).
. ^) R  n& \  r% P" eThe parents were notified about the laboratory9 c4 J4 W- G" ]& |" j, f
results and were informed that all of the tests were# C7 k/ ]  F* Q# n, U: o1 p
normal except the testosterone level was high. The5 U1 Y, C6 I" T: B" a# j
follow-up visit was arranged within a few weeks to- b  O! G/ u$ E! D
obtain testicular and abdominal sonograms; how-
5 b8 j9 `' C4 h" o) d7 \ever, the family did not return for 4 months.4 N# T/ D* V6 a0 l3 x. b
Physical examination at this time revealed that the. \3 |/ r. H# l& ^% S
child had grown 2.5 cm in 4 months and had gained" {4 N+ I9 c2 U# Z" Q' W8 v$ X
2 kg of weight. Physical examination remained
5 H2 k* P; h3 h! ]7 i) a" G& e; Vunchanged. Surprisingly, the pubic hair almost com-" }$ O9 i; _( o* J9 `3 X
pletely disappeared except for a few vellous hairs at
( U$ I# a7 F* y6 `! u4 Othe base of the phallus. Testicular volume was still 2
* L1 A: y" t$ h; m, T: HmL, and the size of the penis remained unchanged.
; Y  x  s4 Q, V! aThe mother also said that the boy was no longer hav-
& i% g! X' d# S5 P/ }$ y: Ding frequent erections.
9 r1 J$ P* l  d2 ^Both parents were again questioned about use of
# J) ]1 H& G: Many ointment/creams that they may have applied to3 y; o8 A2 b; Y" w
the child’s skin. This time the father admitted the
+ o9 Q, E: m; ^& J7 xTopical Testosterone Exposure / Bhowmick et al 5413 e) A' C) `- Y6 j
use of testosterone gel twice daily that he was apply-
6 P3 o6 e( [! aing over his own shoulders, chest, and back area for! g9 }! H6 p( j* p4 v4 o
a year. The father also revealed he was embarrassed5 e9 Y. p6 c+ B+ a( ^6 e
to disclose that he was using a testosterone gel pre-. g% N8 p$ ^: R0 T
scribed by his family physician for decreased libido
  _9 E/ i" O- s( ~! d7 asecondary to depression.
5 e1 C8 @5 L9 l) ZThe child slept in the same bed with parents.
( v6 ?: e  n' G, IThe father would hug the baby and hold him on his6 E% Z5 a) B; B7 W2 r
chest for a considerable period of time, causing sig-& u9 b$ W% p  P$ R$ U
nificant bare skin contact between baby and father.
' y9 x" T( |8 t+ k( L- d/ FThe father also admitted that after the phone call,8 d& n$ z( S/ q
when he learned the testosterone level in the baby. E: p' K: k1 e. e0 Q0 ]
was high, he then read the product information
6 y  S2 Y' B# y7 h; Rpacket and concluded that it was most likely the rea-6 j& H+ b6 G9 Y$ M/ |5 z
son for the child’s virilization. At that time, they
9 Q- r0 \7 [1 X+ g  Ydecided to put the baby in a separate bed, and the- d/ I3 u2 |3 P7 k1 g" ?: J! E
father was not hugging him with bare skin and had+ G, ]" ?9 i  W9 \
been using protective clothing. A repeat testosterone8 |+ C9 K: z: A7 A( @; R; L! @& n
test was ordered, but the family did not go to the7 \3 F# ]7 w. Y  @3 q& F+ Q
laboratory to obtain the test.* n( Y+ ?3 g" F2 B
Discussion; ^' Y- m  c8 p
Precocious puberty in boys is defined as secondary
. X: J2 o6 x8 j# R- \: t6 x- qsexual development before 9 years of age.1,4( y9 G$ o+ P& @7 _# k( |
Precocious puberty is termed as central (true) when8 X2 W2 W3 {2 b3 T: }" q
it is caused by the premature activation of hypo-% }  d3 L- a4 H5 @
thalamic pituitary gonadal axis. CPP is more com-& m! b" r- W0 w* J4 W/ ~% I
mon in girls than in boys.1,3 Most boys with CPP
7 j0 h4 \* R7 \" M$ _may have a central nervous system lesion that is
4 ~5 @0 x. S& o. I6 p/ {0 eresponsible for the early activation of the hypothal-0 e7 O7 Z5 G1 }# H
amic pituitary gonadal axis.1-3 Thus, greater empha-7 v$ ?' U& i* x$ {; G& h  R: C0 y
sis has been given to neuroradiologic imaging in
9 p. t3 e( E: W& [" lboys with precocious puberty. In addition to viril-  Y! z, b% t' Y& w
ization, the clinical hallmark of CPP is the symmet-! X6 d9 G  O# `& _
rical testicular growth secondary to stimulation by; l6 S3 P% p9 ]& }2 w) z4 v; u$ A
gonadotropins.1,3% F1 q- A- N$ Z
Gonadotropin-independent peripheral preco-' o/ \# t, Z, p- }6 i
cious puberty in boys also results from inappropriate
- O  c9 ]1 r! Y5 T% @. l# s8 ~androgenic stimulation from either endogenous or
0 A# m3 ?- q+ W& o4 q5 r/ yexogenous sources, nonpituitary gonadotropin stim-8 d( j2 ?3 F/ w0 A" T) v+ p' A9 Y+ N
ulation, and rare activating mutations.3 Virilizing; {! J! M3 D9 \
congenital adrenal hyperplasia producing excessive& b, i: A. ~, E) B1 V( b
adrenal androgens is a common cause of precocious
0 S! }2 Z, j/ a* }5 ^2 {- Qpuberty in boys.3,4
  P/ J2 @5 z0 y) h) i4 D5 x$ ~The most common form of congenital adrenal8 r( [+ J$ y) m5 H; h" }* G, h* ?: x
hyperplasia is the 21-hydroxylase enzyme deficiency.. F7 d. W  @7 d) A, u
The 11-β hydroxylase deficiency may also result in
+ B+ d" E6 J( V" J* h' N4 q* X9 Iexcessive adrenal androgen production, and rarely,- \1 U2 S6 ?' J
an adrenal tumor may also cause adrenal androgen9 h: W4 r: s, T, h- X3 G5 d
excess.1,35 f/ ]& P  L" N" \. B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( D! e, \! T$ Q( T+ x  b3 J5 M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* x) K& H  \1 n
A unique entity of male-limited gonadotropin-) Y/ k' X2 k/ y0 i8 X
independent precocious puberty, which is also known( A# K' X  G! F
as testotoxicosis, may cause precocious puberty at a( x7 _& |  }8 E! V# ?
very young age. The physical findings in these boys3 z; [8 ?/ I4 W
with this disorder are full pubertal development,: x8 b# P7 a3 W+ d5 D% ^, ]9 Y; e2 q
including bilateral testicular growth, similar to boys$ B( n6 u6 \4 r$ Q) C
with CPP. The gonadotropin levels in this disorder
4 c+ p9 i0 M% b) F9 W8 F; T: e, yare suppressed to prepubertal levels and do not show) V) s/ t; m" j- h. H- ^
pubertal response of gonadotropin after gonadotropin-4 l) @0 p+ Q5 D$ C
releasing hormone stimulation. This is a sex-linked
7 K  T# _8 z, o! u  B* m- B6 Q8 [autosomal dominant disorder that affects only4 {& N) N! l; D- z
males; therefore, other male members of the family
% \! K$ X# X2 A) X; L( S$ T! Y9 smay have similar precocious puberty.3
$ R9 @6 u5 r" b7 Y6 @, A/ eIn our patient, physical examination was incon-
, G" k! O( v. F2 R$ y$ Bsistent with true precocious puberty since his testi-) [. |' @/ A+ C& c: `* `6 a
cles were prepubertal in size. However, testotoxicosis, ^9 N. H) J1 i4 S
was in the differential diagnosis because his father1 ~( C- q: ^: t- F4 t0 W
started puberty somewhat early, and occasionally,
+ n3 S2 r+ M2 c9 C; Wtesticular enlargement is not that evident in the3 D) q- ^: E& k$ s
beginning of this process.1 In the absence of a neg-
, n$ {2 @0 Y4 Q" P0 o( _ative initial history of androgen exposure, our
9 u: H, A9 W' E% g2 D4 }biggest concern was virilizing adrenal hyperplasia,& ^4 ~$ v  O2 a% H7 P# P
either 21-hydroxylase deficiency or 11-β hydroxylase7 `9 X, i0 j7 g! P$ G& C) D4 d+ u
deficiency. Those diagnoses were excluded by find-
" G, S& O0 {/ |ing the normal level of adrenal steroids.6 [" q) ~; |5 F# u: x
The diagnosis of exogenous androgens was strongly. |' W9 d, ~! Y  P4 g' B
suspected in a follow-up visit after 4 months because
& D: z3 W! y" X% V: L6 A7 ?the physical examination revealed the complete disap-- P4 M7 ~4 z1 w$ [
pearance of pubic hair, normal growth velocity, and/ z1 d* i$ l6 a9 v& g* O. V* w8 K. w
decreased erections. The father admitted using a testos-5 ~1 R/ W1 s2 k; K) L0 n4 C$ D
terone gel, which he concealed at first visit. He was  p/ ?7 f: w# Z8 E$ n/ {# r
using it rather frequently, twice a day. The Physicians’
; w* z0 h  w/ X$ IDesk Reference, or package insert of this product, gel or
# V! @, x9 E' pcream, cautions about dermal testosterone transfer to4 B8 e' h) j" n; [; u6 p+ u
unprotected females through direct skin exposure.
( g* ]7 L' W' M- ]Serum testosterone level was found to be 2 times the7 {" {% o+ p' R" C1 ^& q
baseline value in those females who were exposed to
3 r7 d- Y& |9 e; H0 Veven 15 minutes of direct skin contact with their male6 E! X% V& d/ O! P, o/ D
partners.6 However, when a shirt covered the applica-7 x' u6 D2 I& c' n- I0 j1 V: f9 O
tion site, this testosterone transfer was prevented.% K  W# c, g: W- @" T
Our patient’s testosterone level was 60 ng/mL,
. d2 T; p  L  P  d% |0 S7 e1 R8 zwhich was clearly high. Some studies suggest that
+ ?6 n! W0 {; V) T9 Q' }) vdermal conversion of testosterone to dihydrotestos-
4 [, T: l+ x, F3 [! g  H3 dterone, which is a more potent metabolite, is more
2 [. H7 B3 }1 x2 a# l1 R; K6 cactive in young children exposed to testosterone
7 D- n8 \: {( r, ]exogenously7; however, we did not measure a dihy-4 q4 U( X. C3 L! d0 s" X) C4 v
drotestosterone level in our patient. In addition to
- ~/ Z! s, g/ y& i2 E: R/ g2 Jvirilization, exposure to exogenous testosterone in
* `0 c5 J/ Z4 R) Jchildren results in an increase in growth velocity and
8 p, O; [+ @; R& madvanced bone age, as seen in our patient.
* D" q& y( @, n8 ^. g* TThe long-term effect of androgen exposure during' Z( ^5 y2 a- g' ?7 T
early childhood on pubertal development and final
. h. Q' b( m& |, iadult height are not fully known and always remain
" y7 P  p4 R& w4 k3 X! m* S  Wa concern. Children treated with short-term testos-
+ p; O* O, }. U, Zterone injection or topical androgen may exhibit some3 m. P  L5 ?- t$ H+ w
acceleration of the skeletal maturation; however, after
7 {4 B# \/ T+ M  r* ycessation of treatment, the rate of bone maturation! d( D8 m" [% [
decelerates and gradually returns to normal.8,9
+ N: q" s3 o% i: iThere are conflicting reports and controversy1 M/ T" Y, ~$ f
over the effect of early androgen exposure on adult
8 R( f$ i  W" t0 Z0 n, x4 P( v; ?penile length.10,11 Some reports suggest subnormal) {5 P: D& J) F1 s
adult penile length, apparently because of downreg-4 c# i% w4 A  v& [9 ?* |! {! y, ?8 G; B
ulation of androgen receptor number.10,12 However,
; p. @( K  e' j+ W; KSutherland et al13 did not find a correlation between
& j. H" m0 J( D# ^+ l, echildhood testosterone exposure and reduced adult& r. f4 G3 I6 ^4 C
penile length in clinical studies.% ^3 W8 a0 g, n4 _9 f, c
Nonetheless, we do not believe our patient is
5 x) f/ T* e) D/ V7 ngoing to experience any of the untoward effects from; `+ t2 T. r" g+ m9 v% _0 n  [, V
testosterone exposure as mentioned earlier because
8 v; A+ _& v* e* k; Ithe exposure was not for a prolonged period of time.
. U2 M9 ?/ v. l! M4 QAlthough the bone age was advanced at the time of
0 }( \: M5 x/ _$ ediagnosis, the child had a normal growth velocity at
% n. w% G! D8 x, zthe follow-up visit. It is hoped that his final adult. B; L( m# u6 B9 t: U: P9 w
height will not be affected.7 }: G+ y+ }9 o7 V  x  h7 ^
Although rarely reported, the widespread avail-/ X( N+ x7 d% K$ C0 N3 [2 a' G% o
ability of androgen products in our society may6 s" j- B0 _0 Z) Q
indeed cause more virilization in male or female8 K/ t" F) e7 l8 G  N" n" d. U' W5 u
children than one would realize. Exposure to andro-
  e2 C) |! n0 Qgen products must be considered and specific ques-
* Z; v( g- \' l8 [, M- x) wtioning about the use of a testosterone product or3 v7 X1 ?' g! S$ b- f
gel should be asked of the family members during( H, h( r/ k3 T+ M+ \8 A
the evaluation of any children who present with vir-1 h4 W; T/ E- I9 T/ C- [$ A2 c/ h) n$ [
ilization or peripheral precocious puberty. The diag-! O; g+ E6 }9 [0 G2 Z
nosis can be established by just a few tests and by
' N6 P5 k2 p* @$ `appropriate history. The inability to obtain such a, I# b3 @* K* X  I$ x4 X
history, or failure to ask the specific questions, may6 d0 d2 h1 Q7 G/ |2 d' R
result in extensive, unnecessary, and expensive
* w) v' I4 X3 `4 |7 N0 cinvestigation. The primary care physician should be
6 D# b1 y* f  b8 zaware of this fact, because most of these children' B! E, k  c$ s( y/ \" J
may initially present in their practice. The Physicians’
7 s5 J9 F$ \- |Desk Reference and package insert should also put a
: `! B+ U6 ~( D1 q0 Wwarning about the virilizing effect on a male or
# T, i$ b$ t7 j5 [female child who might come in contact with some-
* a! W5 c8 ?% i/ k" jone using any of these products.; L( T0 g' r; x, ~" H- N
References) G7 t# A" i5 ?7 Y
1. Styne DM. The testes: disorder of sexual differentiation' h' z6 k* D: k
and puberty in the male. In: Sperling MA, ed. Pediatric
; e% S* B' ?6 k$ P, i9 {Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, T* e: k7 O! E( [1 m( h# ^
2002: 565-628.
) w  X" j. {& r/ ^) w7 \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 `6 P7 T# R, [2 ]6 c' l
puberty in children with tumours of the suprasellar pineal
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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
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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
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

# _0 e# X7 [- }* F' o# H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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