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Sexual Precocity in a 16-Month-Old
- T" m+ |$ w+ I& ~/ s. qBoy Induced by Indirect Topical2 Q7 b. c# U8 \, Z4 a4 i
Exposure to Testosterone
( T! A5 ~1 s7 ~* k0 ?" ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 |- B3 j1 i% ~9 o, b( r7 t* |! [and Kenneth R. Rettig, MD1( P4 m6 Z9 D4 G
Clinical Pediatrics0 b3 a' L) F" K: X1 Q
Volume 46 Number 6. x& I$ R  z' G, j
July 2007 540-543- k! f2 y* `/ }1 a4 [, N
© 2007 Sage Publications
* g1 ^' ]! W  K" t4 A$ d10.1177/00099228062966511 Y2 z" o: o' T* n! m* X  E1 ^
http://clp.sagepub.com
) Q7 N( I0 v8 V9 x4 K" i' X3 i  Qhosted at9 G6 g2 g9 |# u4 D3 L
http://online.sagepub.com' W+ [5 N$ I* B( W7 b3 @
Precocious puberty in boys, central or peripheral,' K) \. d/ E! _: O, a( }0 I1 g
is a significant concern for physicians. Central  P( x* c! A: Y% v* P  O$ u& e9 c
precocious puberty (CPP), which is mediated- x* a- r  n9 h$ N  I
through the hypothalamic pituitary gonadal axis, has7 H8 @, ]6 b5 p, V7 t$ N
a higher incidence of organic central nervous system
0 ^2 n  J) T  C9 M& N! tlesions in boys.1,2 Virilization in boys, as manifested
9 p6 S; E8 w* m% {2 nby enlargement of the penis, development of pubic
5 H5 Q) I0 k! x' Khair, and facial acne without enlargement of testi-
- \3 {/ C0 N* v8 }cles, suggests peripheral or pseudopuberty.1-3 We
+ w  A- U$ g+ c, I1 \$ Wreport a 16-month-old boy who presented with the
* O$ L+ Z& {1 e( d3 uenlargement of the phallus and pubic hair develop-
$ l6 ~! `6 C* [6 g# F3 X) Xment without testicular enlargement, which was due
; v3 u  p  e8 S' x, mto the unintentional exposure to androgen gel used by
+ t+ ~/ B# q. t0 pthe father. The family initially concealed this infor-0 A! C$ n2 {2 {$ X* I- L2 b
mation, resulting in an extensive work-up for this2 @5 N$ o% A' ?. g* o3 U
child. Given the widespread and easy availability of) S! W: I5 X/ S: ?' ^4 ~
testosterone gel and cream, we believe this is proba-9 Q  L3 @6 }2 S6 I# q$ f- Q5 J
bly more common than the rare case report in the
) o- N5 x3 p: mliterature.4
/ S. }# |( p' p$ L# x  j5 {( KPatient Report  E6 p1 L+ [' R9 L! C/ J
A 16-month-old white child was referred to the, c( j9 E  U8 W2 Z  v1 I3 A
endocrine clinic by his pediatrician with the concern9 |: O5 P+ s0 X+ d* t, D
of early sexual development. His mother noticed
) _1 t; s$ J# ^. a( clight colored pubic hair development when he was
- ]( E5 ^! {- z6 ?7 b3 rFrom the 1Division of Pediatric Endocrinology, 2University of
: Y, x4 L# a. i. dSouth Alabama Medical Center, Mobile, Alabama.5 [' {- b- O1 M1 Y: x6 ~6 ]5 P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ `0 c: w- E& y+ sProfessor of Pediatrics, University of South Alabama, College of
1 ?) `- Q" ~7 A* Q: I/ M2 }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 q7 ?4 G! r9 O% o* U5 w% B
e-mail: [email protected].
5 X* J* V; S3 ~% h; z; N8 Habout 6 to 7 months old, which progressively became
- v( p# X* v, {: y, xdarker. She was also concerned about the enlarge-
/ L7 n8 v. `/ O7 j2 y3 }- z5 ?ment of his penis and frequent erections. The child& _6 T. Y2 m: A1 {" |
was the product of a full-term normal delivery, with. L: X* j7 V3 j8 F" n
a birth weight of 7 lb 14 oz, and birth length of% j9 g7 X, v2 w0 ?- ~6 z: ^' C
20 inches. He was breast-fed throughout the first year
/ `/ E$ O" A0 y% `) O6 }1 ~# hof life and was still receiving breast milk along with! y1 Y; T; J4 Z5 H% p: ~! [7 Q
solid food. He had no hospitalizations or surgery,8 G; {8 t) s1 l
and his psychosocial and psychomotor development, f) z, i, y8 |# N% t- s  f) H
was age appropriate.
# f5 A* a0 g* D2 FThe family history was remarkable for the father,2 q# c2 Q- i: m% S
who was diagnosed with hypothyroidism at age 16,
; z% X& J1 Y! Y6 D+ `7 C8 ]which was treated with thyroxine. The father’s/ p4 f; f; t: r
height was 6 feet, and he went through a somewhat
2 M, w# }/ V- b# x+ iearly puberty and had stopped growing by age 14.
0 [6 j4 T' b3 ~/ ~2 f' B. bThe father denied taking any other medication. The# {$ K" A( W/ ~. h& m4 z
child’s mother was in good health. Her menarche
! P1 R& s: d/ r+ o* J8 d5 }was at 11 years of age, and her height was at 5 feet8 d' z7 A+ ?+ b
5 inches. There was no other family history of pre-
) ]% g& J8 t+ ]cocious sexual development in the first-degree rela-
  z1 d! U  a! A3 Ltives. There were no siblings.
7 O' i, x# l  t( fPhysical Examination
4 I4 o' b% [# D9 b. z3 D) M8 T; [The physical examination revealed a very active,% n* ?# `9 f, _5 [
playful, and healthy boy. The vital signs documented
5 h- D0 U- o5 f& ba blood pressure of 85/50 mm Hg, his length was& b9 ?; g' C) j% r
90 cm (>97th percentile), and his weight was 14.4 kg
9 B3 x3 e) W) f: l, Q7 x(also >97th percentile). The observed yearly growth8 U$ O/ Q% x+ K4 V# s5 ]
velocity was 30 cm (12 inches). The examination of
8 z, t/ F8 z1 z5 gthe neck revealed no thyroid enlargement.
2 D( g: O7 z0 ]" X, OThe genitourinary examination was remarkable for
( a. z2 P7 S0 E. n" o7 _enlargement of the penis, with a stretched length of
* k4 y# \+ _* L. s% j. D! Z8 cm and a width of 2 cm. The glans penis was very well
% p9 B/ @8 n/ W# N' H! ddeveloped. The pubic hair was Tanner II, mostly around
$ Q+ ]; Z  E1 E. @; Q+ Y/ n5401 f: n* X8 C+ i" g+ W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. o. r. y  H4 {the base of the phallus and was dark and curled. The
' o% g  {) p8 D+ s% \4 F: _testicular volume was prepubertal at 2 mL each.6 e3 |& C# D1 Q9 C" J! m+ A1 b
The skin was moist and smooth and somewhat/ a; j6 Y. ~4 l# p; ^+ Y8 U4 O! X( _
oily. No axillary hair was noted. There were no, i* ^' C1 g& N9 C$ ~" ~  j
abnormal skin pigmentations or café-au-lait spots.+ ~. g0 F' i! _4 w
Neurologic evaluation showed deep tendon reflex 2+
6 |: ], K4 }" N' fbilateral and symmetrical. There was no suggestion$ l. [& K/ V, `! x* X' [3 }4 B
of papilledema.. [. r5 y& ^' f2 j7 f
Laboratory Evaluation6 j1 }/ K$ O7 e* J, E; ?5 _  s
The bone age was consistent with 28 months by7 q- S4 ^& s" I
using the standard of Greulich and Pyle at a chrono-
3 @& ?2 R% |9 N% Z+ flogic age of 16 months (advanced).5 Chromosomal
$ D+ a- G4 i9 z: Kkaryotype was 46XY. The thyroid function test) Y, m8 M7 |) N+ A4 W
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 P2 Y7 C# r+ t0 a; Jlating hormone level was 1.3 µIU/mL (both normal).
, R5 ]4 D) c, D* x! y' H3 j! }; nThe concentrations of serum electrolytes, blood5 g( o5 `# L$ s- p$ U' `
urea nitrogen, creatinine, and calcium all were& s$ b" o1 G9 h9 \# i( V
within normal range for his age. The concentration6 |& j9 U) b" j* T
of serum 17-hydroxyprogesterone was 16 ng/dL
" I3 w- J4 l0 t1 c' Q* Y, b( R- {(normal, 3 to 90 ng/dL), androstenedione was 20
- e  A& _. `2 L9 hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 S$ w/ e5 l9 P  O6 f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 X( P8 f9 F0 ]: F. E
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 q7 w6 S+ |7 {1 A( M. {5 G3 E49ng/dL), 11-desoxycortisol (specific compound S)
! Q% b9 l: j' p: q0 W/ nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ X; w8 e) K, D% @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 Q: h4 R: C3 ?& Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),, G5 _8 d) ^" G5 d1 }9 N
and β-human chorionic gonadotropin was less than: i7 A2 ?1 X" j9 c# b, {- Y" T
5 mIU/mL (normal <5 mIU/mL). Serum follicular1 Q4 q3 V; u( m7 D4 O" B
stimulating hormone and leuteinizing hormone+ t  h& @3 _  v( ~3 N' d
concentrations were less than 0.05 mIU/mL, r4 I7 d6 [& o7 D6 N
(prepubertal)., ]' E7 D, g! M9 @( y8 M0 N5 v
The parents were notified about the laboratory) u  z8 ^& w" Y. @+ w: t% V
results and were informed that all of the tests were. |- q) P  K. W* x
normal except the testosterone level was high. The  k$ O# \. ~$ e( L- [2 n
follow-up visit was arranged within a few weeks to
6 J% U7 i4 A" B, Y# G) Bobtain testicular and abdominal sonograms; how-
" o- |/ |. |# Qever, the family did not return for 4 months.
( y3 j% x: ^5 O4 o4 L+ l5 dPhysical examination at this time revealed that the
0 J% Z) H7 U( D8 \; f5 c; Ichild had grown 2.5 cm in 4 months and had gained
4 d* a' T) }3 Z. {. U# J4 {2 kg of weight. Physical examination remained
/ y' q) {9 O2 vunchanged. Surprisingly, the pubic hair almost com-" k+ `3 b" X7 n" V
pletely disappeared except for a few vellous hairs at* P" V5 X* E! ^
the base of the phallus. Testicular volume was still 26 b$ Z# \7 P( |- u; ]/ U; I
mL, and the size of the penis remained unchanged.
/ v; d( J# p2 t8 \4 r3 p4 SThe mother also said that the boy was no longer hav-7 h6 V2 E# E6 b' Y
ing frequent erections.
7 W: ]+ H- v& K1 l6 z; uBoth parents were again questioned about use of
/ S( C% e+ g/ \8 rany ointment/creams that they may have applied to5 _- v: m+ h: u! ^6 A
the child’s skin. This time the father admitted the8 z5 Z, T: a" ]6 _2 |" I) T
Topical Testosterone Exposure / Bhowmick et al 5414 Z( N" ?& {* S  y' Y  U, v5 T
use of testosterone gel twice daily that he was apply-
9 P/ u& b" c2 {& B% `8 M' R7 wing over his own shoulders, chest, and back area for
8 J( ^. M# l' j5 O% _a year. The father also revealed he was embarrassed* b0 B: c) |7 Z6 X/ t
to disclose that he was using a testosterone gel pre-9 r# g* |" h' Q; k
scribed by his family physician for decreased libido
7 z& I7 h' ?! D. f2 fsecondary to depression.1 i. K$ |. A7 x
The child slept in the same bed with parents.* f8 Z) {+ x. g+ C( v
The father would hug the baby and hold him on his
* f9 w. @0 a# l5 v4 ?2 y' f5 J; Ichest for a considerable period of time, causing sig-
# Y/ C6 L) ]0 i- dnificant bare skin contact between baby and father.: N" H/ p! h0 W2 f0 ~8 v% m
The father also admitted that after the phone call,: _/ A" ]; j- ^
when he learned the testosterone level in the baby5 I0 N, q1 R& O+ E
was high, he then read the product information
& J  @/ ~' k1 w7 O- xpacket and concluded that it was most likely the rea-
/ p. w$ E6 q7 }$ gson for the child’s virilization. At that time, they) ?% K2 [, @, ~' B* D
decided to put the baby in a separate bed, and the) d1 V/ W0 h& r- _
father was not hugging him with bare skin and had9 ^& n  k' j" @; C
been using protective clothing. A repeat testosterone2 H6 C% y  z& t7 l# L
test was ordered, but the family did not go to the# @% {; l- p, w4 s' k' I" S2 T5 M
laboratory to obtain the test.
5 _7 ?0 @% ~# n6 A- I" JDiscussion
" x1 V% [# N+ b& g1 {Precocious puberty in boys is defined as secondary3 ^4 c( ?5 N5 Q
sexual development before 9 years of age.1,4) L* C2 q- u6 L; K" R1 M
Precocious puberty is termed as central (true) when
5 n5 f8 u' u# ?; U* W0 m2 t+ Rit is caused by the premature activation of hypo-
" Y5 Q( v. B/ c* f0 C+ L. h& `/ Wthalamic pituitary gonadal axis. CPP is more com-
3 n3 p* i* C2 `; }8 hmon in girls than in boys.1,3 Most boys with CPP
8 ~- @. e; r& z' N# h, Imay have a central nervous system lesion that is
* ?8 S# r$ E  A+ L& D+ Q* Dresponsible for the early activation of the hypothal-8 T' D1 v' v) b3 y/ ^
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 C4 u; \+ P% Q6 c$ J, w9 Ysis has been given to neuroradiologic imaging in
1 Y" M( g" f/ k) kboys with precocious puberty. In addition to viril-
8 q4 e3 K7 Y% z! [ization, the clinical hallmark of CPP is the symmet-9 C' F; d0 k4 g. P
rical testicular growth secondary to stimulation by
$ y; j7 W: l, d. u9 J: I0 h4 Igonadotropins.1,3
) s& {# d9 n1 h4 n" E' s/ bGonadotropin-independent peripheral preco-9 ?( Q% q& k6 Z1 K
cious puberty in boys also results from inappropriate) K, W' e! W7 l" D& n$ W7 Q
androgenic stimulation from either endogenous or8 Y3 `! p5 n& H! a
exogenous sources, nonpituitary gonadotropin stim-
. [/ X' \0 ], Y2 [ulation, and rare activating mutations.3 Virilizing
/ y$ U/ P% o& qcongenital adrenal hyperplasia producing excessive
2 @0 \* s6 k; |" [+ y; ]# ~& qadrenal androgens is a common cause of precocious$ }- B+ O' I3 D* C. W8 z, S* _# ]
puberty in boys.3,4. l" X- h0 g7 S8 |- Z
The most common form of congenital adrenal
5 z& u! {1 y# I. Ghyperplasia is the 21-hydroxylase enzyme deficiency.) W! u9 ^( o9 o3 M( O% ]
The 11-β hydroxylase deficiency may also result in- t6 T! P; F. T: I9 h+ P! ]/ S6 ~
excessive adrenal androgen production, and rarely,
, n5 g2 X5 [! s4 E( San adrenal tumor may also cause adrenal androgen2 p. {3 P0 P) ]( g1 t6 n0 p5 C
excess.1,3
6 C1 O9 X/ Q7 I& k- Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) d5 `! R. n7 B6 Q4 f) f. B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% N  w* T! I+ U) s4 N' I+ {* z
A unique entity of male-limited gonadotropin-
' F% B  f% U) E+ @9 M: I' S  k$ _7 Xindependent precocious puberty, which is also known# O4 J3 w' C3 k* y$ e
as testotoxicosis, may cause precocious puberty at a
( R% k1 u, j+ p  P9 Tvery young age. The physical findings in these boys2 \2 ?, ^9 j2 ?& p2 k7 L1 u" W
with this disorder are full pubertal development,& U0 ~* N# b5 F, @; I3 z
including bilateral testicular growth, similar to boys8 P) h! p* r$ B: u' q: A6 {
with CPP. The gonadotropin levels in this disorder3 |& i# @9 N1 E7 a' D
are suppressed to prepubertal levels and do not show
& E7 ^+ R/ E4 Gpubertal response of gonadotropin after gonadotropin-
4 z, c" }- E' J' V; Sreleasing hormone stimulation. This is a sex-linked
. V4 [. \6 O1 }autosomal dominant disorder that affects only
0 F1 T4 R+ G; z1 c4 H" c! Hmales; therefore, other male members of the family
3 b2 k. I  s8 \. `+ j8 Wmay have similar precocious puberty.3  q, n% U* g9 ~' r9 g
In our patient, physical examination was incon-
4 R6 L& w( G+ f! N: esistent with true precocious puberty since his testi-
8 M% J0 Q" Z. Y  [, scles were prepubertal in size. However, testotoxicosis: o' c1 P* f8 g6 C# j3 N
was in the differential diagnosis because his father/ H/ t% C0 U: A6 ]" Y5 p# O8 x
started puberty somewhat early, and occasionally,
5 b, {  n, y0 y( i4 H  Atesticular enlargement is not that evident in the
5 _& P1 x4 Y3 K7 D, U1 k+ |8 g. Lbeginning of this process.1 In the absence of a neg-  v& [: O7 ]% b( }  {$ t8 \% \
ative initial history of androgen exposure, our4 l- Y/ k( l9 m% Y  j9 U7 }$ w0 g
biggest concern was virilizing adrenal hyperplasia,  r  h1 q6 y4 c) e1 t. B
either 21-hydroxylase deficiency or 11-β hydroxylase
# p# P2 ?7 J  f7 H, o& b0 V1 Edeficiency. Those diagnoses were excluded by find-/ ~1 A! |" R4 Q; S* s
ing the normal level of adrenal steroids.6 ^: Z9 p" a0 e$ ^
The diagnosis of exogenous androgens was strongly
9 }# ?0 x6 H& R) y3 ^, G' v5 `% ysuspected in a follow-up visit after 4 months because1 j7 Q( [3 j0 s7 P( K7 n* G
the physical examination revealed the complete disap-
# I* r6 x2 B  ^/ ]pearance of pubic hair, normal growth velocity, and
- d2 U& l  H$ F! Y5 Rdecreased erections. The father admitted using a testos-
1 R4 E; r. ]: S1 j) F* G/ G$ ?terone gel, which he concealed at first visit. He was+ T/ T6 h+ b( W2 [' \# _: E' b5 D
using it rather frequently, twice a day. The Physicians’# Z+ C; E0 E1 k. l1 }( ~5 v
Desk Reference, or package insert of this product, gel or
( d2 B/ B/ Y, v" e7 ]cream, cautions about dermal testosterone transfer to& M: p# k) i. ]. \2 i, v$ e
unprotected females through direct skin exposure.' j" B* k! h8 q8 u/ ^
Serum testosterone level was found to be 2 times the7 h" V  ^* W% F; ^. H( s- S
baseline value in those females who were exposed to  U. u3 H$ n6 F0 A  r
even 15 minutes of direct skin contact with their male6 u( `7 X! B5 c, Q6 q  y/ e: E
partners.6 However, when a shirt covered the applica-5 G: |5 v3 P- U6 v
tion site, this testosterone transfer was prevented.
! v& b# Z; Q7 v$ N9 Q2 rOur patient’s testosterone level was 60 ng/mL,
  [/ `# }( v0 z8 jwhich was clearly high. Some studies suggest that9 [: M9 |# l+ }& D, E3 b0 p
dermal conversion of testosterone to dihydrotestos-
' R& ~) ?: \$ u# Sterone, which is a more potent metabolite, is more4 D( m9 z* H3 O2 L3 f! W/ n6 ?: Y. b6 f1 t
active in young children exposed to testosterone
* Y, D, H& `0 o: a% D& B7 qexogenously7; however, we did not measure a dihy-
3 `4 m1 [7 c' q. Ydrotestosterone level in our patient. In addition to0 _( x3 w- Q6 h& K
virilization, exposure to exogenous testosterone in
* t7 k; M- ?; j: [children results in an increase in growth velocity and* O: I8 L6 O% |* X! T& Y
advanced bone age, as seen in our patient.1 ~, t, s# e& B) x, ~
The long-term effect of androgen exposure during  U5 C" n' J; ]! j% X
early childhood on pubertal development and final" m8 a  {9 `# M1 M) A* b' ?% X/ F
adult height are not fully known and always remain# S6 o8 L, V8 t0 C
a concern. Children treated with short-term testos-1 }# x, @2 M7 U0 ?
terone injection or topical androgen may exhibit some
5 s7 e$ Q1 ^1 uacceleration of the skeletal maturation; however, after
3 [' R5 e2 c+ F! c+ Zcessation of treatment, the rate of bone maturation5 v" h+ o8 y& q) h# u
decelerates and gradually returns to normal.8,9! U" a) [' s! D: A) o$ S  u- I
There are conflicting reports and controversy* ^6 ^6 r& B. L- U; i
over the effect of early androgen exposure on adult
  u6 w/ y8 R' ?5 \1 d& M; wpenile length.10,11 Some reports suggest subnormal' _6 G7 H5 Z9 T* S3 @
adult penile length, apparently because of downreg-* M' n1 v9 F6 P4 m. |
ulation of androgen receptor number.10,12 However,
+ J) R2 v3 [- X. r) D3 Z6 aSutherland et al13 did not find a correlation between' z, W& A9 q2 e2 [+ x
childhood testosterone exposure and reduced adult
- E3 |, F7 ~! i' Qpenile length in clinical studies.
* n/ p- S6 ^" `5 }; i$ oNonetheless, we do not believe our patient is0 W" D+ _' d1 Y1 S
going to experience any of the untoward effects from. R' @0 _1 y( ^/ x# C
testosterone exposure as mentioned earlier because
) x3 k2 D1 U6 z* |. k( J1 z( ?1 _the exposure was not for a prolonged period of time.% `8 P/ {) s. w# a5 Z5 t6 t; k
Although the bone age was advanced at the time of
) a' O; [$ w$ Y% ]& W# J& N) _diagnosis, the child had a normal growth velocity at5 }' m! c; l( E3 p4 e2 d7 x
the follow-up visit. It is hoped that his final adult1 A% q8 X9 X$ W; F' `* f
height will not be affected.
7 s" x3 f% [& C* U8 tAlthough rarely reported, the widespread avail-% N1 Z$ C  Y& p" H; x& J5 e& R
ability of androgen products in our society may
0 C( n4 e7 o& [2 o! Vindeed cause more virilization in male or female$ c# ?: x+ L1 j% _5 O+ }
children than one would realize. Exposure to andro-
% p, N7 N( n" x. h4 Cgen products must be considered and specific ques-
8 X: |: y9 y. Z( k7 G* Stioning about the use of a testosterone product or
2 {0 N; I% v* Z  j8 sgel should be asked of the family members during
- ]& ]/ ^5 d# f. @1 u4 Hthe evaluation of any children who present with vir-
* x8 q1 K# x; p4 x, ]ilization or peripheral precocious puberty. The diag-
! L6 H. p- P, I& Y$ m  Rnosis can be established by just a few tests and by
2 y/ k0 Z* i" y+ `* [  t% E0 C  qappropriate history. The inability to obtain such a6 N1 {& a# h$ g5 Z" ]! D
history, or failure to ask the specific questions, may: I3 ~; v7 G$ F- b& C+ f+ o' p4 w
result in extensive, unnecessary, and expensive
- j# p3 H, g. J. E( c7 X7 r6 \investigation. The primary care physician should be# D5 v  y# I% v7 t3 w
aware of this fact, because most of these children; G- z; @* D" ?% o6 r' I
may initially present in their practice. The Physicians’
3 |+ M! I$ S0 U2 f. Z  @' cDesk Reference and package insert should also put a% {1 v' h  ^2 J
warning about the virilizing effect on a male or
0 N9 e( w: f2 \6 ^4 o: T$ Q) Sfemale child who might come in contact with some-( U' @, T+ W7 v0 S/ k9 u+ }" A
one using any of these products.
: j( X8 i, X! HReferences
% \$ u- o4 ], b0 @1. Styne DM. The testes: disorder of sexual differentiation9 b  ]+ `) o7 n" e5 L' V
and puberty in the male. In: Sperling MA, ed. Pediatric- r* R) a7 h: y: _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 r7 v. d5 g2 M; E2002: 565-628.2 a1 X5 F7 _9 c* A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. |; W! X. r; P! g$ s* W, g* o
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' K+ {9 v: U, L  zBoy Induced by Indirect Topical/ C5 ], P7 a5 G6 g' @( D
Exposure to Testosterone* t" D6 Z9 H# E- J& k
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 f, L7 T8 o' z6 {) mand Kenneth R. Rettig, MD10 m9 B( O! _# E9 z4 O; F
Clinical Pediatrics
  A% t, n% E$ b" p7 J5 VVolume 46 Number 6
; v/ ?. T- a9 [' b4 W2 ZJuly 2007 540-5430 v# ^! j6 e3 Y% j
© 2007 Sage Publications9 e6 G) i; L/ [4 U( Z
10.1177/00099228062966511 b8 G9 W8 l7 g- ?. h
http://clp.sagepub.com
! B. j) x- h" Z* I+ j/ q7 ihosted at
9 L8 M0 a3 l$ {( R. k# dhttp://online.sagepub.com9 ?& U9 c2 n4 y0 C# d; m: n2 `
Precocious puberty in boys, central or peripheral,
" _& K7 p& R& l9 E  T+ }9 e# wis a significant concern for physicians. Central
* }6 t9 L& }% C/ X* {* s( q, Mprecocious puberty (CPP), which is mediated8 B' y1 L1 O& f8 w; n& q+ I
through the hypothalamic pituitary gonadal axis, has
$ o$ p1 }6 D% \: \" R& Ha higher incidence of organic central nervous system% ]$ K  b$ [4 `; T5 F' j: i
lesions in boys.1,2 Virilization in boys, as manifested0 O. m6 Y3 ~: _1 `8 E( B
by enlargement of the penis, development of pubic
9 S' R3 l* C% k# yhair, and facial acne without enlargement of testi-
- t' m4 @2 _4 U6 h, {cles, suggests peripheral or pseudopuberty.1-3 We
& a5 J( p( m& c) B' Z6 Q; T7 K8 Treport a 16-month-old boy who presented with the1 d8 I  d/ ?) T' [! }) }
enlargement of the phallus and pubic hair develop-. {' u, H# X3 h4 H" c& N
ment without testicular enlargement, which was due* Z* ^: W( J7 `! U: {5 b% m, t
to the unintentional exposure to androgen gel used by' |" _' m. N9 `; [5 J& v
the father. The family initially concealed this infor-8 |8 w* o, w  Z9 x- n  F
mation, resulting in an extensive work-up for this
6 v: V1 N! M' ^2 |) wchild. Given the widespread and easy availability of8 f, \" P" ?+ a1 ^
testosterone gel and cream, we believe this is proba-8 q7 Y: I8 N2 B/ H& `
bly more common than the rare case report in the4 q8 e: N' o  h' s! ^1 Y
literature.4
8 N" K4 J, L& G* b% a, vPatient Report
0 u8 R; ?1 o4 s  o7 Z, c! A" pA 16-month-old white child was referred to the
: c+ o; w$ J- g! [endocrine clinic by his pediatrician with the concern
+ Q; ~) @' Y: v. mof early sexual development. His mother noticed
: P; V1 v8 M, k% r) j" }light colored pubic hair development when he was* ]" j# i% S9 q1 P) y8 {. q+ z
From the 1Division of Pediatric Endocrinology, 2University of. F& V, }7 y" C( E7 w
South Alabama Medical Center, Mobile, Alabama.
# D; C( d" ~# B) K. T# yAddress correspondence to: Samar K. Bhowmick, MD, FACE,
: Y/ ^4 h% Z' n! ~3 I( yProfessor of Pediatrics, University of South Alabama, College of+ T5 e8 g0 n4 G8 o4 ?7 w3 A
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! {# ~! p. k" C! q8 z1 Ae-mail: [email protected].
, J4 U+ h! i- h0 i. s) _4 R$ M  Labout 6 to 7 months old, which progressively became
% K+ O! W5 c3 T$ hdarker. She was also concerned about the enlarge-* o, V5 C' V  n1 d* y# `
ment of his penis and frequent erections. The child
$ J. ~0 Y$ S0 V& R5 Vwas the product of a full-term normal delivery, with2 o. z, A: A3 F6 _& E* q; B
a birth weight of 7 lb 14 oz, and birth length of
! N( y6 K! q* i; s+ E  d20 inches. He was breast-fed throughout the first year( o/ g1 |( ]  |3 ~$ i8 X( ^
of life and was still receiving breast milk along with
1 \6 U2 l% {3 [6 V3 m9 M) }7 m) csolid food. He had no hospitalizations or surgery,9 X' m& O9 }- O
and his psychosocial and psychomotor development3 f- `- f: G( f/ q: C$ r6 p* G
was age appropriate.
% x6 i2 T" Z2 r' v9 aThe family history was remarkable for the father,( t" p& n$ C* l- {7 n% l: F0 ?
who was diagnosed with hypothyroidism at age 16,
( }' J6 k& F, p1 vwhich was treated with thyroxine. The father’s4 \. P8 M- l# ?% U  V% |* o
height was 6 feet, and he went through a somewhat
) J# g( E9 w$ j' A2 eearly puberty and had stopped growing by age 14.- W$ e0 W" c/ N) n0 d
The father denied taking any other medication. The( T3 G: R  Y: \1 r3 y
child’s mother was in good health. Her menarche
1 u7 `1 g2 {: I4 R5 [/ T/ `was at 11 years of age, and her height was at 5 feet1 B' l0 X: I+ C. c8 o
5 inches. There was no other family history of pre-: V- \! }2 H1 K3 ?4 y1 S
cocious sexual development in the first-degree rela-
. Q1 [" R8 W0 M- q8 w4 L- j/ {5 Vtives. There were no siblings.
5 X! _6 @+ t! P& `1 r) D. u- \. qPhysical Examination1 K0 U, u& |9 z) U4 U; a1 T) V! L
The physical examination revealed a very active,0 g& j( d  z$ L1 c
playful, and healthy boy. The vital signs documented
2 O9 g* n' E# c& Ma blood pressure of 85/50 mm Hg, his length was
4 }9 W4 c/ ]$ o/ K, u5 m, O: L1 ~90 cm (>97th percentile), and his weight was 14.4 kg
6 ~: b% F% h% U! `5 |(also >97th percentile). The observed yearly growth) H5 T9 O; @0 c8 J# d0 r; Z/ R, g
velocity was 30 cm (12 inches). The examination of
, f; c. z! [- ~5 w7 lthe neck revealed no thyroid enlargement.
  A9 T" ^0 ^% r/ ^& B# I/ p# gThe genitourinary examination was remarkable for
5 ^' _5 l4 }; H  W% p+ [enlargement of the penis, with a stretched length of6 o& s* ~; f5 H: Z; D( _) U! U) D+ E4 t
8 cm and a width of 2 cm. The glans penis was very well; ~8 }! X3 @. t, G% _! w& ^# r
developed. The pubic hair was Tanner II, mostly around
% m, K6 _2 R6 I8 o2 T8 w0 y! C540! O8 c8 r6 Y# J; ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' U! N6 K5 H9 T' m' H3 kthe base of the phallus and was dark and curled. The
' c2 Y: ^8 O; r3 }  ]testicular volume was prepubertal at 2 mL each.
" V/ s+ J6 t6 L: g4 y* E' vThe skin was moist and smooth and somewhat; |9 ]4 n8 r! p
oily. No axillary hair was noted. There were no
* b  n' _) a: z% [( x: l; O9 Q0 zabnormal skin pigmentations or café-au-lait spots.
- c7 D- b" t; n5 H* P/ wNeurologic evaluation showed deep tendon reflex 2+
+ ]! a: c0 C: E/ Dbilateral and symmetrical. There was no suggestion
5 v5 X" j0 v0 E: S  v! {+ ?0 bof papilledema.
  B  b# R1 l9 u& H3 KLaboratory Evaluation
8 z7 r* M6 _' t3 n% f8 j/ h+ P. B( EThe bone age was consistent with 28 months by: P$ J% d) ~) p& k; T* i3 m
using the standard of Greulich and Pyle at a chrono-
+ m: @/ F, [) |. j5 klogic age of 16 months (advanced).5 Chromosomal
* K8 P5 H" i, x  lkaryotype was 46XY. The thyroid function test
$ k; f/ h0 b# [showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 t3 d# S, B% V; {  N1 H6 Zlating hormone level was 1.3 µIU/mL (both normal).+ S0 ^+ K( }, d
The concentrations of serum electrolytes, blood/ ?5 c3 @8 U% |
urea nitrogen, creatinine, and calcium all were0 q3 ^* ~' u  m( f9 d
within normal range for his age. The concentration
8 g, T8 E2 K6 w- @8 G7 Hof serum 17-hydroxyprogesterone was 16 ng/dL0 M3 w' P7 m! N4 S/ O4 ]
(normal, 3 to 90 ng/dL), androstenedione was 20
- b# U( A2 _) ]9 u! j) N7 Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 _% N2 k9 l. G# y* b2 Z9 y& i' K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; F. x7 K1 i/ Y& Bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
' C$ Z: D5 s% k, e8 N2 b1 h5 `4 D9 d8 v49ng/dL), 11-desoxycortisol (specific compound S)- {8 W" l6 f) a: g( t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: Q3 x+ f0 t6 g4 {2 `/ ^/ m" U+ u) Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ Y% i6 T' @( }1 i% M1 Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ o8 h7 }$ C/ J) z3 k4 y3 V
and β-human chorionic gonadotropin was less than' n% p- p+ ~$ y8 {3 a8 O7 }
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 k+ o; \+ H5 u) Pstimulating hormone and leuteinizing hormone  {( T3 P; v  A, V" q: F1 G# b# P# y
concentrations were less than 0.05 mIU/mL( ~! d7 Y' I3 `. |
(prepubertal).
5 c; Z, S( r9 L" A4 e" \1 V+ v9 vThe parents were notified about the laboratory
* c: V0 W6 [8 l1 @results and were informed that all of the tests were; D6 F5 _, P; [) [; D& X% }
normal except the testosterone level was high. The* u$ S7 d$ q4 f5 s; q: a, Y# W
follow-up visit was arranged within a few weeks to+ P& |; Z" Y, B4 g8 S: e9 ]3 B: ^
obtain testicular and abdominal sonograms; how-
: W* V, _6 c. w7 r# j8 n1 Hever, the family did not return for 4 months.
; f/ Y; @/ o# LPhysical examination at this time revealed that the
! M8 g. x! Q& s( o) pchild had grown 2.5 cm in 4 months and had gained
+ Q" S8 @/ E4 [7 C2 kg of weight. Physical examination remained
1 t; j8 U# k  wunchanged. Surprisingly, the pubic hair almost com-& ^: T$ ?( o; E* A. M. g7 N/ O
pletely disappeared except for a few vellous hairs at7 P& W# W+ k2 j% y: G( G/ K% Q
the base of the phallus. Testicular volume was still 2; L5 D. {# \( I0 u5 K' a+ a& V4 \
mL, and the size of the penis remained unchanged.( g5 H! c/ f/ `
The mother also said that the boy was no longer hav-5 i: m4 r0 `4 g: G+ C9 v# [3 @$ M
ing frequent erections.
: L* @) Y# }! M* z% jBoth parents were again questioned about use of
* D: l8 }- ]# U( P# N" C, S" R% H) C( Uany ointment/creams that they may have applied to
1 X  w8 H; q, w0 a4 X4 mthe child’s skin. This time the father admitted the
$ ]9 E& C& |3 q/ r" Z/ _3 h0 h& jTopical Testosterone Exposure / Bhowmick et al 541
4 u1 C# F  [, p6 |use of testosterone gel twice daily that he was apply-& Q# J" m6 W, _! ?% W! A- ~
ing over his own shoulders, chest, and back area for: [7 i+ e& b6 W8 B! y& G" {
a year. The father also revealed he was embarrassed) Z5 N/ G: Z  _' L
to disclose that he was using a testosterone gel pre-
- n9 N3 g$ P* dscribed by his family physician for decreased libido  x2 b& W7 L' G5 |
secondary to depression.
. Z2 n( f7 P  a$ y3 U3 `! |4 zThe child slept in the same bed with parents.
- Y$ H0 J( y( j3 OThe father would hug the baby and hold him on his
+ C+ q5 c. S7 h% ~" echest for a considerable period of time, causing sig-: f, J: w: i; l( T! G; [8 _5 Q' E
nificant bare skin contact between baby and father.) \' Y7 x, w# b
The father also admitted that after the phone call,1 }0 H; a8 E: d; n2 G8 w% @
when he learned the testosterone level in the baby
9 A% Z$ w$ j1 Xwas high, he then read the product information
$ r8 e9 ~0 z/ u" F6 {packet and concluded that it was most likely the rea-: x& V" A! @! B
son for the child’s virilization. At that time, they
; y- `$ K# w! b4 c8 E7 U; f& odecided to put the baby in a separate bed, and the
( G6 x+ N( I. m6 afather was not hugging him with bare skin and had
# |$ S- t$ Z7 \( _been using protective clothing. A repeat testosterone
. n  E6 A% B( ^" t0 H/ Stest was ordered, but the family did not go to the9 r" O9 d0 `+ y2 r- V7 z
laboratory to obtain the test.! d; ?6 U, K! Q' Q1 R+ N
Discussion- ~. o! l( q+ a3 F# x
Precocious puberty in boys is defined as secondary$ ?: q4 i- B) c
sexual development before 9 years of age.1,4
, K2 x4 u/ c# @- r% uPrecocious puberty is termed as central (true) when8 `/ R" q: v: X1 I; p
it is caused by the premature activation of hypo-
3 [) q/ D# Y2 s& @thalamic pituitary gonadal axis. CPP is more com-$ Z# x" R5 s; q2 X
mon in girls than in boys.1,3 Most boys with CPP3 n& B9 I- [- O$ L; i
may have a central nervous system lesion that is
: M$ }  G, \6 Z. p- ~responsible for the early activation of the hypothal-9 i9 B' P! ]6 M  ^* V7 J
amic pituitary gonadal axis.1-3 Thus, greater empha-
& O3 z4 N" D& dsis has been given to neuroradiologic imaging in
2 @) K0 O/ \4 d! d' B4 u/ Bboys with precocious puberty. In addition to viril-
9 e; D8 j/ p6 _1 V! rization, the clinical hallmark of CPP is the symmet-. d. _$ o9 m. h* S9 m# q& G
rical testicular growth secondary to stimulation by
+ g6 m$ j* g. f2 F- q5 Sgonadotropins.1,3
; d2 I$ r; f9 a7 T3 Y+ MGonadotropin-independent peripheral preco-
+ c/ g" t$ p$ Hcious puberty in boys also results from inappropriate
  G' F8 }1 v/ d/ I8 y. M7 F5 qandrogenic stimulation from either endogenous or
! X6 }3 J) I- n7 L4 cexogenous sources, nonpituitary gonadotropin stim-
0 _) o$ m% O3 {( g8 nulation, and rare activating mutations.3 Virilizing
+ s9 E0 x  [4 V& \congenital adrenal hyperplasia producing excessive
5 z! @! @8 G# c, w2 j0 eadrenal androgens is a common cause of precocious
& v) x0 P( D- _puberty in boys.3,4
' l  ~: _8 s1 W2 VThe most common form of congenital adrenal
' Z& a1 o" f2 t8 ~( c" y: E" U6 uhyperplasia is the 21-hydroxylase enzyme deficiency.
/ ^5 S, E3 T% V2 h' }1 ZThe 11-β hydroxylase deficiency may also result in# X. @* \$ B: z8 }' b
excessive adrenal androgen production, and rarely,
; y, F# Z6 d* C5 k1 ]an adrenal tumor may also cause adrenal androgen  z2 m4 N( T. J
excess.1,3
* n* s+ |8 G9 {( X* ~9 s/ U' w/ z$ P2 jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 \" K2 R6 q) Z+ [6 H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ d6 x) P* p; c2 G
A unique entity of male-limited gonadotropin-6 _4 V# V6 S, u0 [* `5 u2 W
independent precocious puberty, which is also known- S1 Q1 Z; v* \  M5 s( Z& W
as testotoxicosis, may cause precocious puberty at a
" O; K# e2 |- r" avery young age. The physical findings in these boys
! x$ n- B# E5 \/ F$ W' Hwith this disorder are full pubertal development,7 L# h( ^4 f3 ~# r, {5 N+ G1 O
including bilateral testicular growth, similar to boys
: _* E" O9 W4 awith CPP. The gonadotropin levels in this disorder
% [9 o  ]  g% }; w2 yare suppressed to prepubertal levels and do not show
" }# V2 X: x& z7 ~pubertal response of gonadotropin after gonadotropin-
! w- z$ d/ l% S' @, rreleasing hormone stimulation. This is a sex-linked( M% t: n/ p/ P5 q) X
autosomal dominant disorder that affects only3 `5 G) c8 k5 M- ~6 N- q
males; therefore, other male members of the family
- ~* E* ?' n( e" lmay have similar precocious puberty.34 B& T- W1 B' g/ t5 S
In our patient, physical examination was incon-; S: q. |7 m( ?$ n
sistent with true precocious puberty since his testi-. q  d: I- U8 Z$ L2 G& ~- I( Q
cles were prepubertal in size. However, testotoxicosis: r' F3 }9 v0 k: {" ^4 G
was in the differential diagnosis because his father% ^1 p2 S: a5 \: W8 y
started puberty somewhat early, and occasionally,, w6 V1 I2 d' W# C7 d8 Q/ f; b
testicular enlargement is not that evident in the
' p2 U0 A4 O" q5 F) f: i1 E" ebeginning of this process.1 In the absence of a neg-
% @( d1 }+ r2 Yative initial history of androgen exposure, our
/ G0 o' M6 f4 sbiggest concern was virilizing adrenal hyperplasia,
3 B1 C/ C/ g6 ]5 u/ ?2 c! [7 `- _' qeither 21-hydroxylase deficiency or 11-β hydroxylase
4 ]7 ~# M5 Q  ]* Mdeficiency. Those diagnoses were excluded by find-/ ?/ ^  @1 K/ l' Q
ing the normal level of adrenal steroids.) L5 y& Y* K# B7 N4 t7 {/ g: T
The diagnosis of exogenous androgens was strongly' ~8 i  {( u  _2 ]' _  F
suspected in a follow-up visit after 4 months because) U7 ?, L4 B: b* M2 e% W
the physical examination revealed the complete disap-
& z3 i# P' R( n" Ipearance of pubic hair, normal growth velocity, and
4 R" A1 Y! A- D9 C) Jdecreased erections. The father admitted using a testos-8 x& W* A4 m' X8 P& X6 i: N
terone gel, which he concealed at first visit. He was1 {9 w, H! v$ D8 s
using it rather frequently, twice a day. The Physicians’$ n! h. `, j) [. D3 J" N* n
Desk Reference, or package insert of this product, gel or
3 c& `( ~7 |' ?* M! d. C( C# ucream, cautions about dermal testosterone transfer to
) M) e2 ~1 Q: r. `- xunprotected females through direct skin exposure.
6 E, K  B1 \* }0 H( E& _# g6 t. {Serum testosterone level was found to be 2 times the  T' f- c- i1 I9 W  A- k- N
baseline value in those females who were exposed to
% }/ e. q! x! n& H4 `% g: n$ k! ^even 15 minutes of direct skin contact with their male# S, N" Q$ Q' Z9 v# x% l
partners.6 However, when a shirt covered the applica-* c" e1 T$ J6 B% F" R
tion site, this testosterone transfer was prevented.
  {2 v& N# ?& b+ H) dOur patient’s testosterone level was 60 ng/mL,* {. z; g! i; N1 i; [
which was clearly high. Some studies suggest that
8 N' z. C6 m- y4 Q, G" j# R! udermal conversion of testosterone to dihydrotestos-* s' `  s0 x& g7 h
terone, which is a more potent metabolite, is more
' }, I- U7 I2 G5 K2 E- nactive in young children exposed to testosterone; ^' G4 B$ Y8 L. k, t
exogenously7; however, we did not measure a dihy-& u! }: K0 ~, G2 O; f
drotestosterone level in our patient. In addition to) W  E* f. X3 u' \* @1 q
virilization, exposure to exogenous testosterone in; k5 Y/ ~/ [3 g! Q
children results in an increase in growth velocity and: ^# ^: D+ V: P& K9 U
advanced bone age, as seen in our patient.
7 x9 r5 L" q2 w4 S8 w6 dThe long-term effect of androgen exposure during
2 [% I! k1 f# D- Y+ o( o  Nearly childhood on pubertal development and final4 p; G) l4 R5 X. b
adult height are not fully known and always remain
- p1 d0 g# N* U# P3 B6 _a concern. Children treated with short-term testos-& g& E0 x0 t2 c  _3 A% T
terone injection or topical androgen may exhibit some5 K6 I, _( e8 Z2 O; ?
acceleration of the skeletal maturation; however, after, h% p" s/ r6 G- b! N" Z9 M0 D
cessation of treatment, the rate of bone maturation" I0 r, ?# V6 l+ |
decelerates and gradually returns to normal.8,97 M3 U) h& G+ |1 o
There are conflicting reports and controversy
, t  A* H7 F7 H$ H7 y) Oover the effect of early androgen exposure on adult7 t* k: L/ `' H  m) U
penile length.10,11 Some reports suggest subnormal7 Y1 e3 o0 v: f+ g/ h
adult penile length, apparently because of downreg-/ D& h2 ~5 r, H, l7 y0 f: t7 n
ulation of androgen receptor number.10,12 However,
( W/ N6 P. y, J3 M6 ?Sutherland et al13 did not find a correlation between, x+ u* O3 ?' G; @) k& `) v
childhood testosterone exposure and reduced adult3 l' E5 G6 D* `! ]3 K
penile length in clinical studies.; i, J$ R: X, q9 [8 E
Nonetheless, we do not believe our patient is) ~3 u1 p8 D! w* B
going to experience any of the untoward effects from6 s8 I7 _/ B' K( y# b9 m
testosterone exposure as mentioned earlier because  d' z% |' w9 }- r7 Y( U
the exposure was not for a prolonged period of time.2 H' w$ w0 G2 h' o
Although the bone age was advanced at the time of- K! Z( v# A# a) R
diagnosis, the child had a normal growth velocity at
! p0 T6 k# z( W- ]4 I4 ?the follow-up visit. It is hoped that his final adult
1 c, g6 i* g' |( ~) T, v! lheight will not be affected.
. R1 z4 _3 }, Y1 b  AAlthough rarely reported, the widespread avail-
  o1 }  r. {6 Q8 N/ B* bability of androgen products in our society may2 I" \3 l! [& L
indeed cause more virilization in male or female/ `& M8 W& [% Z! c. b
children than one would realize. Exposure to andro-' O1 i3 j3 Z. M3 [
gen products must be considered and specific ques-3 ~5 V- k. C6 G5 M7 h, g( e% \
tioning about the use of a testosterone product or
4 e! x) H( ]# f  ~: O8 g# P  q/ vgel should be asked of the family members during7 T2 d4 D  ^0 Q" S/ }* u4 e0 E
the evaluation of any children who present with vir-5 V" W9 i- |, d. D6 V
ilization or peripheral precocious puberty. The diag-
/ t$ v  J, Q" Y% z- }' y" {! ~nosis can be established by just a few tests and by! t) v  Q* \; y1 S  {( x
appropriate history. The inability to obtain such a% t. A' E- N) u/ O: s
history, or failure to ask the specific questions, may' Y, H) f4 S  Y: M6 I
result in extensive, unnecessary, and expensive
9 I: N; c3 G5 j  |7 winvestigation. The primary care physician should be, ]/ Z/ c1 @0 b: B2 u
aware of this fact, because most of these children
3 Y0 j& K3 P1 J0 b8 {9 Bmay initially present in their practice. The Physicians’5 S) D  j  C3 ^3 }7 O4 U0 C$ U
Desk Reference and package insert should also put a+ k/ ?( \; C! g/ q
warning about the virilizing effect on a male or, r; W1 D3 s6 R/ p+ ~% J6 J1 n
female child who might come in contact with some-0 b1 ~" u$ H  _* \1 W
one using any of these products.9 n2 o1 y& n" C$ M) m2 d
References% T) E# e$ q+ C% R" l
1. Styne DM. The testes: disorder of sexual differentiation) |# X. d( x3 ]
and puberty in the male. In: Sperling MA, ed. Pediatric
; Z* S9 O  C2 S. o8 I! `* O# VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 |* D# N, U3 d/ ]) ^2002: 565-628.
2 e9 J! H$ e* K; i( @0 @" w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. W/ O# X- D/ t' n4 ]  n
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

% f. @/ T3 p: `( }* |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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