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Sexual Precocity in a 16-Month-Old5 W) w8 D- w1 y/ \) b
Boy Induced by Indirect Topical
) w0 e8 T  W  B" q* M. V5 O+ DExposure to Testosterone
% w6 o9 H/ p) L/ Q( Y3 I( KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 b! M( r+ ]2 I; ]) U3 yand Kenneth R. Rettig, MD1
: h. f, P3 @0 j# t/ f% BClinical Pediatrics# D" z( K5 P& U3 ^" ~8 {
Volume 46 Number 6
1 L8 e- R1 A% KJuly 2007 540-543
% n/ W% b: L& j, ]$ E© 2007 Sage Publications
+ k8 @: G' U  y4 u' q, @) \10.1177/0009922806296651. d0 H5 h1 b6 q( p  p
http://clp.sagepub.com7 U* [' F+ y. ^* }7 U; _
hosted at
+ z7 @* y" ]/ X& g7 p5 Q* Zhttp://online.sagepub.com. C5 r' A  L# d4 q( V4 @
Precocious puberty in boys, central or peripheral,0 u: P8 k6 O: [' r
is a significant concern for physicians. Central8 w; u/ e% k  I/ k  R% E+ f
precocious puberty (CPP), which is mediated7 e! \! M3 @' [/ {
through the hypothalamic pituitary gonadal axis, has6 h& i# v/ M0 F2 e5 P3 _- Q
a higher incidence of organic central nervous system& \( [: ~+ g+ ]7 E
lesions in boys.1,2 Virilization in boys, as manifested
& X: A/ X' ?& }' o" }$ {0 ?by enlargement of the penis, development of pubic
; R/ a+ X; s1 S, i# c/ n- h. Thair, and facial acne without enlargement of testi-
- @; P4 q' c! m$ N& Mcles, suggests peripheral or pseudopuberty.1-3 We
. f+ I, [" ?; ]0 z# u3 Ureport a 16-month-old boy who presented with the) l0 q, y, w- J3 I6 Y: H2 U+ S8 e9 ?
enlargement of the phallus and pubic hair develop-/ H. h! D0 ]3 G6 A
ment without testicular enlargement, which was due7 G$ d# y! Y& X! ~3 J
to the unintentional exposure to androgen gel used by9 r4 L2 Z  v/ b. ^$ p
the father. The family initially concealed this infor-6 o9 [6 o2 ?- P) F9 ?/ u
mation, resulting in an extensive work-up for this
! o8 w! x( T; l1 c2 A5 R& Lchild. Given the widespread and easy availability of- Q# Y, w" o' C$ M* ]
testosterone gel and cream, we believe this is proba-
6 [0 f: x1 ^$ pbly more common than the rare case report in the' X' L4 n5 }6 r# p) F. n
literature.40 ?5 Q# r. @. }) P* J7 P
Patient Report' w, i0 n7 Y9 r7 j/ d1 d
A 16-month-old white child was referred to the: u5 `+ \! g  i6 u* D
endocrine clinic by his pediatrician with the concern3 k1 B) x5 n* f
of early sexual development. His mother noticed9 H9 b2 [  S7 T% ^3 b% `1 N
light colored pubic hair development when he was
  }3 S8 }0 t; vFrom the 1Division of Pediatric Endocrinology, 2University of5 Z$ k* W5 }( N5 i3 e2 y
South Alabama Medical Center, Mobile, Alabama.: \" u' ~' \. i. \- R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* m) A# h3 a% w8 o: T) @3 DProfessor of Pediatrics, University of South Alabama, College of
' v' y2 i. a1 r$ p7 F1 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ I+ B3 z3 j; ?  K8 F
e-mail: [email protected].
/ I9 W; G! K* M' T1 f5 v2 n# O3 Habout 6 to 7 months old, which progressively became
3 B9 t% U' @" a5 u9 v2 D  k& `darker. She was also concerned about the enlarge-/ ~; `& b. s3 h: }) F3 w# B/ R, l
ment of his penis and frequent erections. The child$ o! V# T: H. k) O/ ?) `" Z
was the product of a full-term normal delivery, with
6 F& ?( d. i4 M, c6 g9 M, w  za birth weight of 7 lb 14 oz, and birth length of  C+ @: p5 O+ [7 _
20 inches. He was breast-fed throughout the first year0 ?- B7 }% _# O% \# |' R8 v7 x9 I5 Y
of life and was still receiving breast milk along with
/ z5 K2 R3 g8 P% ~, b# Rsolid food. He had no hospitalizations or surgery,$ N8 B% n) H( f* G" ?* K
and his psychosocial and psychomotor development
/ \# ^$ k- ~: B  p: nwas age appropriate.& h* C6 {  l& ~7 v& Z
The family history was remarkable for the father,5 m+ D2 R6 |* b7 `6 G
who was diagnosed with hypothyroidism at age 16,* m. }: n! W; |. O
which was treated with thyroxine. The father’s( b! s" b& @0 ^6 l  q
height was 6 feet, and he went through a somewhat& J! h: y& C: u5 d( x! J
early puberty and had stopped growing by age 14.
& u5 X) w" U7 c- N. `The father denied taking any other medication. The
4 G' Q% O9 X+ _4 h, j( j3 z0 r7 cchild’s mother was in good health. Her menarche
6 |) {- P, }8 Q( ?# U( d4 K: @was at 11 years of age, and her height was at 5 feet* i1 c! k% Q- _7 l
5 inches. There was no other family history of pre-% u! T2 x9 @$ A# e* D1 j
cocious sexual development in the first-degree rela-
* q9 @( b! A, g* T4 x  X* Atives. There were no siblings.7 ]9 G' }5 ^) I* b
Physical Examination
" O( p2 q& J$ \+ J$ @; t& ^% VThe physical examination revealed a very active,9 d2 @- I" B' X4 y1 F
playful, and healthy boy. The vital signs documented
7 t/ \( \& s/ I' g% n- Ba blood pressure of 85/50 mm Hg, his length was
" H0 i% L. w2 l  ?# X. i8 }2 C+ y90 cm (>97th percentile), and his weight was 14.4 kg# z& i* |1 X9 Y" f( }; \1 x: Q
(also >97th percentile). The observed yearly growth
- N: N' z: p' c" t$ Tvelocity was 30 cm (12 inches). The examination of! ^' O  H2 ?: F, ]+ L, f& Z3 {
the neck revealed no thyroid enlargement.
; b# t2 u' U+ T8 N1 B& m% JThe genitourinary examination was remarkable for" N9 P- M  N$ `1 r: p
enlargement of the penis, with a stretched length of5 _: u9 ]% `# E8 l+ C+ B
8 cm and a width of 2 cm. The glans penis was very well/ I& K3 I" e& B& M% i, f0 r; [
developed. The pubic hair was Tanner II, mostly around! D5 `3 X7 ~, y7 t* H7 G3 j9 ]
5400 t2 n+ z$ G2 A/ E1 z
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the base of the phallus and was dark and curled. The0 F1 R3 g. l: D! T
testicular volume was prepubertal at 2 mL each.% y$ m4 \- s6 k8 ^" R' n
The skin was moist and smooth and somewhat1 v; M% p- m& E# l
oily. No axillary hair was noted. There were no
, i' t& i( X% E9 |- |, eabnormal skin pigmentations or café-au-lait spots.! g- O& T6 p/ ]
Neurologic evaluation showed deep tendon reflex 2+6 M3 z6 x! z; R' j% {+ m
bilateral and symmetrical. There was no suggestion
: W# T2 r5 d5 G0 V0 F# qof papilledema.
7 O. Y# O9 @+ U* f( NLaboratory Evaluation& z  y$ i- p; g+ k0 j- y) k0 N* r  n7 H
The bone age was consistent with 28 months by
4 O" V2 C% W' D' [( Cusing the standard of Greulich and Pyle at a chrono-9 D+ \# w% H) Z
logic age of 16 months (advanced).5 Chromosomal' j& L. i) M0 Q" a7 b
karyotype was 46XY. The thyroid function test$ a  Z5 @& U. F$ \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% {' _! Q# v! A  clating hormone level was 1.3 µIU/mL (both normal).
- U/ W$ v* \8 {9 wThe concentrations of serum electrolytes, blood
  Z$ u0 c8 r6 Durea nitrogen, creatinine, and calcium all were; a& y+ X+ F$ _: |% D
within normal range for his age. The concentration
1 ^8 T, |1 O6 k+ c7 fof serum 17-hydroxyprogesterone was 16 ng/dL( U, R% Q; a# \
(normal, 3 to 90 ng/dL), androstenedione was 20
9 v$ a  l) F) ^# o) sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& a6 o& |6 V$ e4 [8 N/ Aterone was 38 ng/dL (normal, 50 to 760 ng/dL),# F* ^6 X" L$ C0 w$ c4 \/ q0 w
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 B# ]5 `0 J3 X49ng/dL), 11-desoxycortisol (specific compound S)
& Z7 C2 r" @% y3 rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 K3 L- C9 ?  M  s" utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) U. B- N( Y6 p- |4 U. C: atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( l, d6 X* d. _" n1 X" jand β-human chorionic gonadotropin was less than
+ M7 U$ H# h  A& _) F6 d5 mIU/mL (normal <5 mIU/mL). Serum follicular3 D0 _; ^) A7 s
stimulating hormone and leuteinizing hormone
' x# c% y# {. e% x/ Zconcentrations were less than 0.05 mIU/mL* Y( [6 F: F* a( y- `6 E4 g
(prepubertal).- _& C9 c% W" E0 C8 b4 x( u0 O
The parents were notified about the laboratory; E% ], Z! R3 I% b$ D
results and were informed that all of the tests were
( u5 v. G# u% \3 D) bnormal except the testosterone level was high. The
; C! V" }' g# E) vfollow-up visit was arranged within a few weeks to
! t, y+ W( \: u4 v1 Mobtain testicular and abdominal sonograms; how-1 v6 h+ f3 v; l4 M+ u( d( ~! d
ever, the family did not return for 4 months.4 H7 m5 s/ D, _& v# @7 R
Physical examination at this time revealed that the/ W* d$ k& P, P1 A
child had grown 2.5 cm in 4 months and had gained% f1 J' `+ q; Z% x
2 kg of weight. Physical examination remained( n. Q' \' d1 @/ L. {
unchanged. Surprisingly, the pubic hair almost com-
- @- f0 \  y/ S. j+ L4 gpletely disappeared except for a few vellous hairs at
9 {0 G. D: f) q3 Rthe base of the phallus. Testicular volume was still 2
; L  S, Z& P4 z5 ?$ }! m9 \mL, and the size of the penis remained unchanged.5 U2 K1 x8 M. z  D3 B
The mother also said that the boy was no longer hav-% K1 z2 N9 J* A) o! I% O( i0 k) ^7 w
ing frequent erections.' \- B* M; C; [: [- f1 r/ f
Both parents were again questioned about use of
+ X2 J" k9 E8 S! U9 ]0 Cany ointment/creams that they may have applied to0 \! O- _9 A+ V6 h, T. T# o; N, `
the child’s skin. This time the father admitted the" z2 Q; @4 u7 |- [
Topical Testosterone Exposure / Bhowmick et al 541
; T1 k2 E2 R& M- nuse of testosterone gel twice daily that he was apply-
# w) p2 s9 T4 c/ u* w3 \ing over his own shoulders, chest, and back area for
; @% K4 @' y% y0 Ba year. The father also revealed he was embarrassed. ]' ?* d/ i! p& c& s
to disclose that he was using a testosterone gel pre-
( O1 X3 b6 a/ G+ Q  Iscribed by his family physician for decreased libido
& t  g, @; R" _# isecondary to depression.
, k5 N: Q$ q- u( Z% BThe child slept in the same bed with parents.
8 V; a% o; Y$ V! TThe father would hug the baby and hold him on his
8 S+ G, p% |8 V! p& S' I7 K( c+ kchest for a considerable period of time, causing sig-
4 Q$ K; ]7 |9 S2 J" cnificant bare skin contact between baby and father.' F9 u2 o. f9 s! x4 _; Z3 J
The father also admitted that after the phone call,5 N! D% {1 n+ c+ w* ~$ h3 t2 h+ x
when he learned the testosterone level in the baby$ N+ V* C* M+ ~! p
was high, he then read the product information2 B5 {0 b; ^: Z, b
packet and concluded that it was most likely the rea-2 ?! Z1 F; l* m5 A; r4 H
son for the child’s virilization. At that time, they& Q* e4 I9 r2 C
decided to put the baby in a separate bed, and the! h# e! O& y2 m% x
father was not hugging him with bare skin and had
% @& l7 W4 m8 x/ J* W1 W* ^) R1 mbeen using protective clothing. A repeat testosterone
1 H, X- K2 ~) R5 Vtest was ordered, but the family did not go to the
6 U( [) n; H0 v3 U7 `# d% \  @laboratory to obtain the test.
4 p4 C# `4 g3 A" e1 {Discussion: }: p% @' F# ]  Y- b. A4 n* ?7 T
Precocious puberty in boys is defined as secondary
# R3 P% T# W; q+ L: S+ jsexual development before 9 years of age.1,4
( ^. e& V6 ^# }Precocious puberty is termed as central (true) when4 W! ?1 l! M5 s# R4 J' b8 K) E) c6 D
it is caused by the premature activation of hypo-. ~# {; m) n, e) G8 I0 i
thalamic pituitary gonadal axis. CPP is more com-
+ l2 L  ^# s  B3 d+ |mon in girls than in boys.1,3 Most boys with CPP/ k6 b$ S1 \3 W. _) j1 p9 w
may have a central nervous system lesion that is
$ C8 X; b  d3 p0 r; t, @/ l) Iresponsible for the early activation of the hypothal-
/ b; J. S% E  A/ L9 |5 ?* e- }amic pituitary gonadal axis.1-3 Thus, greater empha-4 h4 ^, j# S- ?) F  n) k
sis has been given to neuroradiologic imaging in3 d$ i# ?; k8 |2 R, V# i
boys with precocious puberty. In addition to viril-. D' W, @. Q4 I' O
ization, the clinical hallmark of CPP is the symmet-
9 R: c& _0 s+ B& b* d" s; z& Y0 urical testicular growth secondary to stimulation by
. y$ h; f/ k9 c( E9 }' n' V; `gonadotropins.1,3  w# [+ Z: ^# u0 J3 b
Gonadotropin-independent peripheral preco-
/ i% Y5 Q! o: o; ^9 u- p% ocious puberty in boys also results from inappropriate
3 w7 ~7 |7 x/ a& Oandrogenic stimulation from either endogenous or
6 E4 _0 O4 }+ F. n# Gexogenous sources, nonpituitary gonadotropin stim-+ O7 J6 a, I2 G$ v' b6 E9 [' Q
ulation, and rare activating mutations.3 Virilizing
9 A; ]' }0 m5 k, Rcongenital adrenal hyperplasia producing excessive& V" d8 h2 A9 K
adrenal androgens is a common cause of precocious
: n6 ]2 b( N7 O0 I* X9 E4 ypuberty in boys.3,4+ y& k: u2 X3 K  V
The most common form of congenital adrenal7 W% }) B1 Y' g- ^
hyperplasia is the 21-hydroxylase enzyme deficiency.& j7 |  Q3 O- f% r8 j1 h1 N
The 11-β hydroxylase deficiency may also result in
4 a0 n: F  _9 v9 j& l$ p6 gexcessive adrenal androgen production, and rarely,
) n% a2 G$ q6 D5 S. Aan adrenal tumor may also cause adrenal androgen& y  a4 V) ~/ u. s2 p, e9 U
excess.1,3) V/ d1 h1 X, q/ @- g  m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# }& O5 @+ I/ N% y* m
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: x6 s' ^5 E; c5 }1 ^6 w7 h. @
A unique entity of male-limited gonadotropin-* Y' W- q& Y5 u' u& E1 s2 M
independent precocious puberty, which is also known, W/ A. e9 X4 x6 ^* B
as testotoxicosis, may cause precocious puberty at a/ v- A/ N/ D; X: ]* f- B
very young age. The physical findings in these boys
  {6 h3 X4 F' v7 ?; iwith this disorder are full pubertal development,
5 l& d2 c7 K4 |6 w" rincluding bilateral testicular growth, similar to boys
2 f1 U1 S1 L: ?6 E1 L1 f! ?  S! j. m# Bwith CPP. The gonadotropin levels in this disorder) B) [+ I& N3 y: c4 B2 R% p) {
are suppressed to prepubertal levels and do not show
+ o; a/ Q( t! m5 Lpubertal response of gonadotropin after gonadotropin-
( g" G1 g/ m* c. vreleasing hormone stimulation. This is a sex-linked( L, J  t, h* l7 }: a! ~$ y* K3 l! s. f
autosomal dominant disorder that affects only
# @9 n# Q  r8 {* M" I1 Ymales; therefore, other male members of the family
) J/ n, O/ T' ~. `& lmay have similar precocious puberty.3! _) d, }* R' d* [% O& y
In our patient, physical examination was incon-  T/ T3 m7 u  x& b$ f
sistent with true precocious puberty since his testi-
% n- y! x/ Z2 P/ z0 p9 zcles were prepubertal in size. However, testotoxicosis
) F* {9 v% ~2 M3 ~was in the differential diagnosis because his father6 L& ~. e, s4 r6 A4 W& k$ |: H9 @
started puberty somewhat early, and occasionally,
7 t! W* x  `$ e: ]testicular enlargement is not that evident in the
* B0 U* U8 {& Y4 T, g0 nbeginning of this process.1 In the absence of a neg-2 m$ c1 O7 v5 [! `
ative initial history of androgen exposure, our* n' F& p: Q" S  M! `" ~
biggest concern was virilizing adrenal hyperplasia,8 z4 \& g* z) p" f
either 21-hydroxylase deficiency or 11-β hydroxylase
/ y$ U1 B& D2 I; J& {- ideficiency. Those diagnoses were excluded by find-
& T. I" Y1 s  _8 q8 q3 ?  Sing the normal level of adrenal steroids.
0 s# c2 Y/ m3 w- V3 \' W1 SThe diagnosis of exogenous androgens was strongly+ M9 \9 [0 Q3 `1 I/ g" K
suspected in a follow-up visit after 4 months because
  L6 Y' Q# u8 N8 m+ Othe physical examination revealed the complete disap-" E' h; A) R1 I
pearance of pubic hair, normal growth velocity, and; ]; |% O# q4 M' I' b, ^$ Q
decreased erections. The father admitted using a testos-8 H# X( D& U1 ?$ ]
terone gel, which he concealed at first visit. He was( i3 J+ B' P4 i2 a- v" Z
using it rather frequently, twice a day. The Physicians’
0 h7 C( ^: @. g5 P' |$ TDesk Reference, or package insert of this product, gel or
" V; I# X4 X* ]" {1 k' Hcream, cautions about dermal testosterone transfer to" f: R7 a1 U5 G/ `! e! j
unprotected females through direct skin exposure.
- f& v# ^) h' [+ Z' N! _Serum testosterone level was found to be 2 times the" d) d# l" w/ R, m9 ?& k( ~7 j
baseline value in those females who were exposed to
  I( d9 T) W! p; C" Deven 15 minutes of direct skin contact with their male' P  u+ p) T3 O$ y  Y
partners.6 However, when a shirt covered the applica-# H, r. v  ^5 G3 X5 B# l
tion site, this testosterone transfer was prevented.4 |4 K) V" h+ T% @& X! E+ S9 w' P
Our patient’s testosterone level was 60 ng/mL,
  t+ d% `: v6 R* {1 C$ j$ a$ F1 wwhich was clearly high. Some studies suggest that9 ~. v' ^; H- z: |/ L
dermal conversion of testosterone to dihydrotestos-; I; e' ?6 {( ^  }# M5 P9 Q
terone, which is a more potent metabolite, is more* R+ R6 |, G* I6 [
active in young children exposed to testosterone0 o8 o0 K% j' V( t% f8 e% d# I$ s
exogenously7; however, we did not measure a dihy-  ?0 B+ l4 ^+ E
drotestosterone level in our patient. In addition to
4 O8 C, z/ ^9 ?0 _( r! M1 Kvirilization, exposure to exogenous testosterone in( y6 f7 E! `; b! L# X
children results in an increase in growth velocity and
; b, s- m. W# a4 i  c' Yadvanced bone age, as seen in our patient.
; [2 `$ Y1 W9 WThe long-term effect of androgen exposure during
" s4 Z8 M  {$ Nearly childhood on pubertal development and final
; p8 u! y$ {$ m& Nadult height are not fully known and always remain+ M* C& o; Q- E; J
a concern. Children treated with short-term testos-
0 c7 k8 F/ J$ }) y. V: o5 {7 zterone injection or topical androgen may exhibit some
% |" v0 m2 \4 m, d% l; {) H4 u- G% macceleration of the skeletal maturation; however, after
) i" E* f) `0 z& Ycessation of treatment, the rate of bone maturation
+ [9 k) X5 S: e$ N& M5 [6 f4 X, T) ]decelerates and gradually returns to normal.8,9* o; M# {2 j" n6 J  Q! t
There are conflicting reports and controversy0 f* H( g) m$ `2 Y9 Z" e4 L
over the effect of early androgen exposure on adult
5 |5 |2 v9 [# Cpenile length.10,11 Some reports suggest subnormal
, {7 I! o& |8 T8 b" j! P! jadult penile length, apparently because of downreg-! @' p+ z1 J* ~+ L, o+ ~
ulation of androgen receptor number.10,12 However,* C- R# z, N* T5 s2 Q9 ?$ w9 V
Sutherland et al13 did not find a correlation between& M; A( v% S3 ^* _/ v3 K
childhood testosterone exposure and reduced adult
  w% X. O" ?* {) w" C& xpenile length in clinical studies.
" G6 O* Q# t8 r% N) G. R/ C  `# X, yNonetheless, we do not believe our patient is5 K" ]9 p: X+ u# z" t7 X0 o( M
going to experience any of the untoward effects from
2 F' }9 U: _5 |6 t1 Jtestosterone exposure as mentioned earlier because. x  [8 h/ h) s( O
the exposure was not for a prolonged period of time.
+ p7 q, v3 G: ^. aAlthough the bone age was advanced at the time of' l& D" A4 u7 P$ S2 A$ f
diagnosis, the child had a normal growth velocity at3 B! A5 o; o" ^& G
the follow-up visit. It is hoped that his final adult6 \$ [. c' R3 k
height will not be affected.
6 M& ?/ p* u2 O6 H0 w+ LAlthough rarely reported, the widespread avail-% Y' D0 F( c; G# d! f; x9 v
ability of androgen products in our society may# L( j' G1 S$ ?& h% d
indeed cause more virilization in male or female
8 l5 x( T  \6 T. K. c$ k$ gchildren than one would realize. Exposure to andro-
) Q/ b) V9 l; m1 h$ _gen products must be considered and specific ques-! Y0 n( @; _2 t. x  m% x) G2 H6 o0 n
tioning about the use of a testosterone product or, u4 r5 C1 Q# J4 O0 ~7 S
gel should be asked of the family members during4 `( r$ }0 _& C4 X/ w& ~
the evaluation of any children who present with vir-
) m& ]* m) n0 e" Dilization or peripheral precocious puberty. The diag-) B" d2 z6 L8 i) r
nosis can be established by just a few tests and by* W3 l7 g7 m7 A' c( u6 A4 U
appropriate history. The inability to obtain such a# j( T# Z3 }" V. j; D+ B5 X$ M! R) K
history, or failure to ask the specific questions, may
9 Q2 e  n8 Q* i, b; zresult in extensive, unnecessary, and expensive
/ W" I- A2 n4 j% f" e# E- f' l# Minvestigation. The primary care physician should be; Z: F3 N7 R+ ~/ T1 u
aware of this fact, because most of these children
9 i; k: y  z* Z/ S, k+ F" l: Nmay initially present in their practice. The Physicians’7 S# g5 A: F! P. r1 h8 y
Desk Reference and package insert should also put a. {5 T, u3 K' @! D/ E* e8 _, O
warning about the virilizing effect on a male or' N, w! E$ ^1 g& I; g
female child who might come in contact with some-
/ T% A' S+ Q( W0 \6 e, y5 ?one using any of these products.
/ ?3 [; P9 N, }References7 d; x. a, M, k6 G$ R# s& e' D
1. Styne DM. The testes: disorder of sexual differentiation
- R4 X, Y; c, \: Z6 h# Aand puberty in the male. In: Sperling MA, ed. Pediatric2 v: r% b5 r" G& \" r, q$ D- r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 I! C4 ^1 ~8 [$ C$ V9 e, i" w2 S
2002: 565-628.
6 _/ g6 v" i& g4 f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. @# j& b; q/ r9 D1 |3 j4 {
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old' N7 Z+ \9 S' [  d8 I
Boy Induced by Indirect Topical! y/ C( U' [) J: c
Exposure to Testosterone3 O- J, q2 ^2 S: L8 {- V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% k4 ^7 k4 z1 y+ Z4 x0 m, F
and Kenneth R. Rettig, MD18 ~9 u/ p. h% q9 M7 V
Clinical Pediatrics
2 K4 H& ^" I; c) a) w3 m0 HVolume 46 Number 6
* @4 C" P' G  I$ y, DJuly 2007 540-543
# r. y+ a. C  R. h# }# _: p: O© 2007 Sage Publications
# _" o" h" j* p) X4 k$ E10.1177/0009922806296651
4 R  b; k0 a' r! @& m2 hhttp://clp.sagepub.com# s: U% r5 @0 `$ L; O
hosted at, Y! N3 p! w" `  K$ W$ v
http://online.sagepub.com! v2 a& e* v; j
Precocious puberty in boys, central or peripheral,
4 _; c# {5 p( _  ~' _is a significant concern for physicians. Central) o9 T& |  c2 g- c. v
precocious puberty (CPP), which is mediated
: N: X( Y  M8 e/ F+ `/ Z3 bthrough the hypothalamic pituitary gonadal axis, has# e& q( f8 S4 M0 Y4 {
a higher incidence of organic central nervous system
" w7 o8 b# \3 D* o: h, C! @lesions in boys.1,2 Virilization in boys, as manifested- s% g  [- `/ \; y6 \) P: R
by enlargement of the penis, development of pubic
8 |1 s; ]" Y- g* w; w# h0 [hair, and facial acne without enlargement of testi-( n7 F3 Y3 f0 j; O" x" [1 f
cles, suggests peripheral or pseudopuberty.1-3 We
8 f4 @- ]4 F" U+ l+ u5 sreport a 16-month-old boy who presented with the
4 q7 M7 @8 M, U% M! Penlargement of the phallus and pubic hair develop-
; r7 P) Z5 ]: n+ oment without testicular enlargement, which was due
* F6 F% X: j7 \2 }, c% Gto the unintentional exposure to androgen gel used by# d& a3 u& h% x2 a% S8 t8 k- S: Q
the father. The family initially concealed this infor-
% ?8 @5 Y$ S& rmation, resulting in an extensive work-up for this
8 A  M6 U- o, ?5 i7 `$ q3 m$ mchild. Given the widespread and easy availability of
' X- g5 v1 x3 E% h# m: ~testosterone gel and cream, we believe this is proba-
) \& W, L/ @) E# r2 @9 zbly more common than the rare case report in the
6 @; V& z6 o" ~- z0 d! o5 R0 ^literature.4
3 F6 e  S: ?0 [" zPatient Report
& m7 w7 _2 _( `  O; xA 16-month-old white child was referred to the
# c/ U5 R0 B9 y  S# X4 v! U# @endocrine clinic by his pediatrician with the concern% c6 Q2 I$ |6 K( _5 Q! f( i- s
of early sexual development. His mother noticed, l5 C) y# z; e' q
light colored pubic hair development when he was
0 A6 n( P' G: i' n  bFrom the 1Division of Pediatric Endocrinology, 2University of2 r7 R! P% R- ^* v
South Alabama Medical Center, Mobile, Alabama.
  [1 @5 I: V! Y/ }4 sAddress correspondence to: Samar K. Bhowmick, MD, FACE,, h2 Y8 m. n. U( u2 {$ D0 K
Professor of Pediatrics, University of South Alabama, College of
8 F8 b, X7 d0 P; RMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 g, Z$ x3 z- u$ K! _e-mail: [email protected].3 E2 I4 Z% Y  g5 ?4 a/ @
about 6 to 7 months old, which progressively became; t1 \0 W* q1 ~; s# p0 h
darker. She was also concerned about the enlarge-
" B7 S* q% ]: e/ `( d0 p, @ment of his penis and frequent erections. The child
2 g* P" X* p/ K: `) g# {was the product of a full-term normal delivery, with6 I# M9 x" ^, p" F% N
a birth weight of 7 lb 14 oz, and birth length of
- F0 n3 f' J" L, I* Y% d20 inches. He was breast-fed throughout the first year6 u* v% y4 g4 k  `
of life and was still receiving breast milk along with* c0 x7 U1 L1 B, i' z3 v1 K
solid food. He had no hospitalizations or surgery,. v6 A* t6 ^; I& x# A! x
and his psychosocial and psychomotor development/ Z- r. h! X$ S( Q
was age appropriate.
' Q( R( f6 [2 U5 L# Q2 M% XThe family history was remarkable for the father,# K2 g' N# a: ]/ Y; _
who was diagnosed with hypothyroidism at age 16,- S2 o8 T4 P3 Q) d. j3 Y
which was treated with thyroxine. The father’s
4 l+ S. j' ^) y0 v2 W0 }# ^height was 6 feet, and he went through a somewhat
; m: B* N0 c& L* W+ c. r2 w" Y! zearly puberty and had stopped growing by age 14.* N9 {% V9 W' s; F% r
The father denied taking any other medication. The
  a2 s+ r/ s" \) O+ A+ zchild’s mother was in good health. Her menarche- T% W' ]6 d+ [
was at 11 years of age, and her height was at 5 feet/ a- k9 a/ S2 k4 ?7 C
5 inches. There was no other family history of pre-
* c) y; o1 y- p/ O$ J1 b' Ecocious sexual development in the first-degree rela-+ _, l7 S3 ]% I) G5 f) p6 C
tives. There were no siblings.
: h+ K+ D5 R' jPhysical Examination# K  V; h' k3 r1 `5 S
The physical examination revealed a very active,
* p5 g' A4 C% r/ u7 H3 Y8 k0 P9 vplayful, and healthy boy. The vital signs documented0 ~' w0 @( Q0 _) d' e7 K
a blood pressure of 85/50 mm Hg, his length was
; M( v. c4 D% M( b90 cm (>97th percentile), and his weight was 14.4 kg
6 T" S; n1 ~9 u6 y1 ?: N) ?(also >97th percentile). The observed yearly growth
9 [% B& V* ^) B1 i" {( C2 Tvelocity was 30 cm (12 inches). The examination of, C! \% L- K* M- V
the neck revealed no thyroid enlargement.7 b/ \( \' |+ a1 t
The genitourinary examination was remarkable for
  d& ]/ h' s! p1 G* v0 G; [  w# fenlargement of the penis, with a stretched length of( k" y% v/ v* `& F6 B
8 cm and a width of 2 cm. The glans penis was very well4 H5 N* E0 q( S, r# z
developed. The pubic hair was Tanner II, mostly around
/ R" F- m, o+ D, k/ d- q540
. m. X9 ~* a# E1 s+ k9 ]% qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 H9 K  h+ I8 |* ?the base of the phallus and was dark and curled. The
4 [2 Q) R7 T& u2 Gtesticular volume was prepubertal at 2 mL each.
4 }% i# M  F7 B" n2 k# YThe skin was moist and smooth and somewhat
" }# Z$ ~1 o+ h" f! Foily. No axillary hair was noted. There were no
+ K; H+ F# {7 {7 _+ I- Tabnormal skin pigmentations or café-au-lait spots.
3 \: {/ U! V; Q2 V' ^Neurologic evaluation showed deep tendon reflex 2+! }; t+ E3 E" _) m% t* k
bilateral and symmetrical. There was no suggestion
* W: Z2 ~, J( K- i9 [8 A" Pof papilledema.
" x" v; h$ L6 V7 ?Laboratory Evaluation5 ?* d' D# j2 f
The bone age was consistent with 28 months by
7 y4 {# Z/ V4 k4 s! f2 Y& G9 Musing the standard of Greulich and Pyle at a chrono-; h2 r7 X# _4 S; \
logic age of 16 months (advanced).5 Chromosomal# s! t/ s  J2 j' W1 e' P
karyotype was 46XY. The thyroid function test6 p$ x6 T' i. l) _, [; t/ R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 G% S) M0 y& S3 H
lating hormone level was 1.3 µIU/mL (both normal).( w2 u3 ^" C/ Z' |
The concentrations of serum electrolytes, blood
5 F% e* h2 F) a! Y2 l8 Yurea nitrogen, creatinine, and calcium all were
& a4 v# p4 w2 i4 Cwithin normal range for his age. The concentration
  r& e/ b4 \& t" L. a+ a/ t/ mof serum 17-hydroxyprogesterone was 16 ng/dL
5 T1 J& c9 \4 t) S" |(normal, 3 to 90 ng/dL), androstenedione was 20' K2 r5 }, p9 C; S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 D3 C% R) C0 M3 n; q7 P  D" pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
" O, l1 W* R, W0 u6 Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  s: D9 c+ F& u4 b' |" }. ?  H( `49ng/dL), 11-desoxycortisol (specific compound S)
, J6 \3 K, G9 d' bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 U( G9 O: Q8 ^7 K- Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ B" U( I5 k0 qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ q6 x+ U# @7 ?' F
and β-human chorionic gonadotropin was less than
8 q. S0 ^5 ^5 ~+ B& K/ V5 mIU/mL (normal <5 mIU/mL). Serum follicular% v2 X, b* L9 D. C( V! p) p
stimulating hormone and leuteinizing hormone
6 ~5 P* f5 F) M6 @  W* \3 hconcentrations were less than 0.05 mIU/mL
7 @4 ~; ^- V+ ~' O(prepubertal).
+ v& B4 h$ E& ]  @& Y. _5 `The parents were notified about the laboratory! E2 ~) y. j9 \. f: R# w
results and were informed that all of the tests were4 q' k- z) k: g; e4 o
normal except the testosterone level was high. The9 L/ ~/ b) J- Q0 @+ Z' M' K
follow-up visit was arranged within a few weeks to2 ~9 |: j8 {8 S4 Z
obtain testicular and abdominal sonograms; how-: Z/ {( F& t. P  s. O/ z/ i- A
ever, the family did not return for 4 months." O9 S' |$ c- g5 c6 F& @
Physical examination at this time revealed that the' L( }1 @5 B& s
child had grown 2.5 cm in 4 months and had gained3 a* T) J: D3 r- J8 h$ Q+ o
2 kg of weight. Physical examination remained
9 P% L- N. d# hunchanged. Surprisingly, the pubic hair almost com-0 x. A. [9 c4 n: f' q2 t) }' U3 ^( Q6 T
pletely disappeared except for a few vellous hairs at
0 G& a6 v5 |3 W7 G6 s6 [( othe base of the phallus. Testicular volume was still 2* M& A& p. t& }5 Y0 a
mL, and the size of the penis remained unchanged.
" f& j  L2 q. b$ d1 f0 ?5 PThe mother also said that the boy was no longer hav-  P& f* H. e% o( T% o
ing frequent erections.
2 v. m( Y/ V; H5 @( B( vBoth parents were again questioned about use of
- A  ]: K% v1 y& k7 w0 @- Eany ointment/creams that they may have applied to
( d2 c/ b! |1 c9 ^5 tthe child’s skin. This time the father admitted the' M5 a2 C# f' B; F1 T
Topical Testosterone Exposure / Bhowmick et al 541
; P5 C, k2 T  v5 \, E+ zuse of testosterone gel twice daily that he was apply-
, g6 I# f8 v# ]" c2 d  S) T3 Sing over his own shoulders, chest, and back area for
2 B7 o5 b7 X+ O1 {: R/ A! F. {2 }a year. The father also revealed he was embarrassed: x4 D  M. z3 {, S- p( U! C
to disclose that he was using a testosterone gel pre-
& |1 u% Z: m: H, u5 ]scribed by his family physician for decreased libido
$ b# N, g+ g) P! @' t: v2 Jsecondary to depression.% M# x, q( c& e* U; y
The child slept in the same bed with parents.
1 b! h" ?  L, s# p9 ~The father would hug the baby and hold him on his3 s( o; S* a& [9 a* ~
chest for a considerable period of time, causing sig-
" C7 w" u0 j5 a( h, P  Z) [5 Lnificant bare skin contact between baby and father.
/ `# r5 C% Q3 o/ Q2 oThe father also admitted that after the phone call,
- h- j  ~+ Z+ O3 l- N& [: _$ Wwhen he learned the testosterone level in the baby
  x- |9 p4 s9 K* i% E: m" Iwas high, he then read the product information
# `2 E; I9 U5 q/ Rpacket and concluded that it was most likely the rea-
8 n6 _0 L* k" W. Z" V. i, |son for the child’s virilization. At that time, they
4 j, E3 H, r3 |* rdecided to put the baby in a separate bed, and the$ [" O+ y0 o- c1 ~4 f( R
father was not hugging him with bare skin and had6 f% F2 d5 k7 z. ]0 o- [  W. P. Q
been using protective clothing. A repeat testosterone: c6 l$ j- ^* |
test was ordered, but the family did not go to the
6 X* t4 r) p5 u8 @# c5 i6 rlaboratory to obtain the test.' f6 K/ ^  r: e7 z6 K, q, @
Discussion$ l+ L3 u7 `% l/ Y7 F( z
Precocious puberty in boys is defined as secondary
) R! k* ~3 K, J% y- c) m1 h8 Osexual development before 9 years of age.1,4
  Y' D- J& p; C9 tPrecocious puberty is termed as central (true) when
3 Y  H& ]1 h6 s0 v9 Kit is caused by the premature activation of hypo-
; l) @. ?8 B0 gthalamic pituitary gonadal axis. CPP is more com-' j( t, c  P9 \7 M( K! z' ^
mon in girls than in boys.1,3 Most boys with CPP
& |# I( q/ ]; `1 j- Nmay have a central nervous system lesion that is0 S1 Q9 f3 r4 L$ ?* y& S
responsible for the early activation of the hypothal-8 V8 O4 j  n- o
amic pituitary gonadal axis.1-3 Thus, greater empha-
, P) J/ q2 C. ]# M/ N( rsis has been given to neuroradiologic imaging in
7 q  A* |0 Z, u: lboys with precocious puberty. In addition to viril-# D3 c4 a& j+ S+ j7 _! g1 T4 {# p
ization, the clinical hallmark of CPP is the symmet-
) o. p4 e/ p/ N7 J" y' jrical testicular growth secondary to stimulation by8 w+ J+ e2 k% e
gonadotropins.1,35 K6 y* T- Y7 l& f  y( R
Gonadotropin-independent peripheral preco-. a! d6 L. `) K
cious puberty in boys also results from inappropriate
4 |1 b6 ~; ^" m3 O$ ?androgenic stimulation from either endogenous or
, l5 b( n! V8 z" f# M4 i* v8 qexogenous sources, nonpituitary gonadotropin stim-
! g+ ^# c7 j8 m9 R/ dulation, and rare activating mutations.3 Virilizing
  N0 ~$ H- M! m. V" ]4 n; |6 bcongenital adrenal hyperplasia producing excessive
. ~! ]7 t, G2 w, E; ^1 o# nadrenal androgens is a common cause of precocious1 k- d$ ]/ B2 O
puberty in boys.3,4. b  g3 B( j0 y' J. o9 S
The most common form of congenital adrenal% G% h7 Z  B/ r
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 c# Y+ U# n1 _* ]% h1 `The 11-β hydroxylase deficiency may also result in/ \- O  O/ O2 Y( U
excessive adrenal androgen production, and rarely,  \8 C) N) ~1 u
an adrenal tumor may also cause adrenal androgen) T5 ?0 g3 J1 m/ j$ j
excess.1,3
8 E' z. E0 T$ V, Z6 fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 f2 y8 {" o2 Q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. _  U+ J5 ~- BA unique entity of male-limited gonadotropin-
- W, p" S7 e3 X  P6 s7 vindependent precocious puberty, which is also known. `/ R. ]; b+ }6 U. M, [
as testotoxicosis, may cause precocious puberty at a
- x1 B. V( {' o  U1 [$ lvery young age. The physical findings in these boys. y! Y- I. ^" R  O" h* a
with this disorder are full pubertal development,
/ J2 [8 s$ w# K  s, L. z. z3 o3 D! b' Nincluding bilateral testicular growth, similar to boys) o6 H, l* c1 k- u, q7 y1 @. X
with CPP. The gonadotropin levels in this disorder' {% `$ D% y! c1 X3 l5 l
are suppressed to prepubertal levels and do not show$ H& [' |' q/ C: R
pubertal response of gonadotropin after gonadotropin-. ]5 K2 J  [+ a' _: e; c
releasing hormone stimulation. This is a sex-linked9 z. a3 h3 u4 O) w
autosomal dominant disorder that affects only& k( o0 G, D; y' N+ p5 y; o
males; therefore, other male members of the family
% g8 m; M$ c( p( Jmay have similar precocious puberty.3
. L0 g) Y% [% V9 W  g  ?* P: QIn our patient, physical examination was incon-
( }( j0 L8 |. d. C/ P2 y/ Osistent with true precocious puberty since his testi-
7 A- n0 d1 o$ T1 zcles were prepubertal in size. However, testotoxicosis
0 J' Z  Y3 _, Cwas in the differential diagnosis because his father
! H1 ]7 I9 Y. e' {- h4 G# Istarted puberty somewhat early, and occasionally,
% M$ V$ T! V4 q# x6 |$ Ptesticular enlargement is not that evident in the
  e# r& Y: o6 ^; ^* U1 P2 v( ?beginning of this process.1 In the absence of a neg-& C% i4 T9 K4 E
ative initial history of androgen exposure, our6 P3 V( Y- ^$ Z, I# T
biggest concern was virilizing adrenal hyperplasia,1 m5 K- `+ \2 b. [. [% o
either 21-hydroxylase deficiency or 11-β hydroxylase) m) u+ B* Q  J; ~: C& E
deficiency. Those diagnoses were excluded by find-
/ T! j8 \$ J% V# Iing the normal level of adrenal steroids.
+ U! {8 z7 d: g$ ?0 d1 eThe diagnosis of exogenous androgens was strongly1 M5 X% T: E. ^7 }4 n, C
suspected in a follow-up visit after 4 months because
8 {+ [9 E& Z9 A6 X- N: ithe physical examination revealed the complete disap-
" R9 f6 V  G8 V& q$ R5 zpearance of pubic hair, normal growth velocity, and
+ n+ g% p" t! b" q  s1 Odecreased erections. The father admitted using a testos-
6 T9 g  g. C2 Tterone gel, which he concealed at first visit. He was* Z; o0 G$ b0 v" N" s. ]# F
using it rather frequently, twice a day. The Physicians’
9 R, U* R; L+ J  `' `Desk Reference, or package insert of this product, gel or
; w5 S% u/ a9 A# K! E! Pcream, cautions about dermal testosterone transfer to' F/ a8 G6 W# b; |, e) O9 y
unprotected females through direct skin exposure.
: c& d$ [6 K( K$ _, H- T- K. CSerum testosterone level was found to be 2 times the
2 O2 X- J$ o9 p( ?$ R7 X: Sbaseline value in those females who were exposed to6 V4 G6 }- K! a. o" |
even 15 minutes of direct skin contact with their male
5 g+ {3 N  y6 S: Cpartners.6 However, when a shirt covered the applica-6 P8 Z# Y: s7 d3 C3 t, K
tion site, this testosterone transfer was prevented.0 \$ T7 w- d" I* ^3 Q* ~8 t
Our patient’s testosterone level was 60 ng/mL,% D& @% L# o2 v4 c6 k
which was clearly high. Some studies suggest that
+ h8 C2 E7 d; ^dermal conversion of testosterone to dihydrotestos-. ?+ o% l/ p! D5 A
terone, which is a more potent metabolite, is more
: E) a1 D$ y( r7 ?active in young children exposed to testosterone
$ p+ A/ Q2 h; Jexogenously7; however, we did not measure a dihy-
* v( u  {" d7 m! Sdrotestosterone level in our patient. In addition to9 f' P$ v' a0 @8 f  V0 t/ w
virilization, exposure to exogenous testosterone in
5 g8 U$ I% C$ w3 w! l/ |' z' m; vchildren results in an increase in growth velocity and" D  A" q! j( |( f4 d; I3 y" H
advanced bone age, as seen in our patient.
- L# h/ }' R6 w- ~, ]# |The long-term effect of androgen exposure during
, p' b* G6 P5 [2 o/ Bearly childhood on pubertal development and final
+ N' _# l1 K8 ?1 J( U: ?adult height are not fully known and always remain- A. L+ O+ u' `4 K+ i1 @1 e' ?
a concern. Children treated with short-term testos-
9 g& z5 n! H& p% z( W9 ~9 Q0 u! zterone injection or topical androgen may exhibit some
8 Q+ p7 E: y1 a1 |6 X6 Xacceleration of the skeletal maturation; however, after+ ?# F5 N% f! J  j+ e. K- E) ?  k
cessation of treatment, the rate of bone maturation
+ {9 C8 I2 X1 e* |0 f9 p+ h% wdecelerates and gradually returns to normal.8,9, T) Q# n$ b  ~
There are conflicting reports and controversy
, A3 N1 u% R1 O. S8 k. S. ]over the effect of early androgen exposure on adult
- q& a- p0 \) s: b1 ?- Ipenile length.10,11 Some reports suggest subnormal# ]' e2 @! L+ k8 I. \: j; }$ h% _
adult penile length, apparently because of downreg-
8 i) k/ s* C1 Q3 L8 lulation of androgen receptor number.10,12 However,
7 E% Q1 r- O' R# wSutherland et al13 did not find a correlation between
! X8 E+ O* [$ V6 f8 mchildhood testosterone exposure and reduced adult$ \2 L9 u/ P$ y% K
penile length in clinical studies.! [' l% Q7 \* x7 }
Nonetheless, we do not believe our patient is4 |1 L6 D- ^- q4 K; X
going to experience any of the untoward effects from5 o$ W  W0 D2 U( D
testosterone exposure as mentioned earlier because
7 i% J$ U3 k3 Nthe exposure was not for a prolonged period of time.2 [5 w/ I4 R0 q& R
Although the bone age was advanced at the time of( L6 B8 R$ |4 _; N- `0 A1 [. W. r
diagnosis, the child had a normal growth velocity at
8 z, \; w, ]0 k& A% V2 ithe follow-up visit. It is hoped that his final adult
) P6 m4 `& B4 {4 p: `* j* mheight will not be affected.
' M+ E( t3 N* S9 ]Although rarely reported, the widespread avail-" H! f! V) S! I  v+ U
ability of androgen products in our society may- f, ]1 t1 p% f4 J
indeed cause more virilization in male or female
4 ]- L7 w5 b5 I& ^+ g* v0 B( m, wchildren than one would realize. Exposure to andro-- h+ Q" ?2 j0 G$ q
gen products must be considered and specific ques-
& G$ J9 |+ }  q5 c6 ]tioning about the use of a testosterone product or3 R' r+ A- Y; }) k- b
gel should be asked of the family members during
" c+ x2 o* [3 b1 }& t( p) Jthe evaluation of any children who present with vir-4 Z$ T+ J3 t( P- P, n
ilization or peripheral precocious puberty. The diag-+ H+ Y8 L% }: o) c3 ]4 o# s9 p
nosis can be established by just a few tests and by& [2 z1 s, F" v: X$ ?2 X
appropriate history. The inability to obtain such a
9 F: V. C( _! Rhistory, or failure to ask the specific questions, may5 y" E3 m( }( L/ P( n% t) j' h
result in extensive, unnecessary, and expensive
1 i7 v! G" m/ K9 N9 Yinvestigation. The primary care physician should be
+ V3 q* ~. ]- a* ]" Laware of this fact, because most of these children
; z% ?5 d1 H1 gmay initially present in their practice. The Physicians’  K4 n, n' [0 \3 X4 L
Desk Reference and package insert should also put a) n- I$ v# k, `" P8 ?
warning about the virilizing effect on a male or
  Y0 S; t+ f- w4 L& o. Kfemale child who might come in contact with some-
- l5 {2 n3 Y# ^3 fone using any of these products.' u5 ]5 e: t! Q0 V. v
References# u# {7 L/ q0 e# v) l
1. Styne DM. The testes: disorder of sexual differentiation/ z! F3 w2 p. X+ [1 v3 [2 ]
and puberty in the male. In: Sperling MA, ed. Pediatric
( e3 p4 Q% o! L; CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 \* @+ {) s4 T: K: [/ h/ ?
2002: 565-628.
4 ?, ~# ~& ?# n$ d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* r: t9 W- n/ T& ?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!

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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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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

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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

  B, d, K' R3 p/ h( q3 J. X( G精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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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