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Sexual Precocity in a 16-Month-Old
" m" i: U6 c! N: ?6 m* C$ DBoy Induced by Indirect Topical
1 ~8 _& ~1 y  b9 VExposure to Testosterone
3 u9 f  v4 b! ~0 d4 K3 ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" P$ m3 R# u" p# x5 U
and Kenneth R. Rettig, MD1! u5 F1 _. m% j! L  M" i
Clinical Pediatrics
3 U* I& G. w1 K# x* E- WVolume 46 Number 6
3 O3 i+ U% C5 [7 J7 HJuly 2007 540-543
# \/ X0 G. w' ?8 h6 \© 2007 Sage Publications
+ B+ k* u" a) P7 r1 Q10.1177/0009922806296651
# o9 D; j2 ]3 _8 h  Uhttp://clp.sagepub.com( ?4 c/ Z, R% U# [! L
hosted at$ s" {- [3 X2 D4 p
http://online.sagepub.com3 G! B$ f. K3 u
Precocious puberty in boys, central or peripheral,
4 ^, i3 G  z$ |# Fis a significant concern for physicians. Central
( n6 C* ?5 f- S. G( E6 zprecocious puberty (CPP), which is mediated" i! X! x+ r& M' v: r
through the hypothalamic pituitary gonadal axis, has
- L* G1 ]# ]5 b/ j5 e; Sa higher incidence of organic central nervous system( |% F# q! Q# H4 N
lesions in boys.1,2 Virilization in boys, as manifested
- D+ Z& e! R! q' U/ P$ ^, w' vby enlargement of the penis, development of pubic4 J2 M* Y! `) q. |+ [; _# s
hair, and facial acne without enlargement of testi-
1 h. E+ d8 k- @# J, Xcles, suggests peripheral or pseudopuberty.1-3 We3 d+ C6 G% {9 z7 W+ f
report a 16-month-old boy who presented with the
! q/ n4 e1 c5 Denlargement of the phallus and pubic hair develop-
. _2 G4 i& e* ^: P' yment without testicular enlargement, which was due/ Q  G; y) e5 t( V
to the unintentional exposure to androgen gel used by! m& N" _' _; M. @# \" [; P8 [* |
the father. The family initially concealed this infor-1 a+ K- Z6 |+ i
mation, resulting in an extensive work-up for this
& W; t, i. h. X/ Cchild. Given the widespread and easy availability of+ t2 y  x; a# t8 J1 B4 |
testosterone gel and cream, we believe this is proba-" [' d/ c5 I# A3 t8 V1 Y" z
bly more common than the rare case report in the
2 C9 b# |5 H9 x. x% C5 J1 H" lliterature.4
; l2 u- Z+ [( ?) O4 W; k3 PPatient Report( c2 d( a& c/ a  }( O) U
A 16-month-old white child was referred to the
! @1 N8 [( h5 E+ F) cendocrine clinic by his pediatrician with the concern
7 b$ [. t" W! g. A8 N/ Nof early sexual development. His mother noticed
  p* N+ S) G. G& P% o3 X. c$ L8 flight colored pubic hair development when he was
7 d7 w; {1 m' A, e& \/ G# eFrom the 1Division of Pediatric Endocrinology, 2University of7 W, U5 W/ V. K& [& L0 T
South Alabama Medical Center, Mobile, Alabama.7 `1 s1 b0 z  ~1 R, x
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ ]0 B8 P" }. `: J% T, k0 K& n9 MProfessor of Pediatrics, University of South Alabama, College of
7 M' N9 L# S; _  l- n% XMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 M# X! B# S: d/ q% M9 r- J; n  w
e-mail: [email protected]., k: v7 ?% G* G! h
about 6 to 7 months old, which progressively became  j. T  h8 y+ Z: K! {! {8 [) M
darker. She was also concerned about the enlarge-3 \* O2 h( S& X3 ]* j! y% [
ment of his penis and frequent erections. The child3 W7 e% M0 m' f# v. c
was the product of a full-term normal delivery, with) ]* p- ?9 F( o' \# H; M
a birth weight of 7 lb 14 oz, and birth length of
) H1 I3 X# T! N: u7 S* S; x20 inches. He was breast-fed throughout the first year4 O; C; F+ @* G" _% J7 w* @; p! o
of life and was still receiving breast milk along with  |+ R. v$ \; e
solid food. He had no hospitalizations or surgery,5 n' d- N! f+ r
and his psychosocial and psychomotor development
9 _- h7 i" ?0 x. @# s1 S; nwas age appropriate.
$ |- x- U  x  g+ OThe family history was remarkable for the father,: ~# ]& {2 j5 n' e* h( z
who was diagnosed with hypothyroidism at age 16,
: h# c/ X' T1 Z( Ewhich was treated with thyroxine. The father’s
4 B1 l/ s5 b  z- K, w9 b3 ]height was 6 feet, and he went through a somewhat
- Y: [8 C% U6 Mearly puberty and had stopped growing by age 14.  k+ k6 D# t3 C. H
The father denied taking any other medication. The
) r2 u9 g+ O; b! ochild’s mother was in good health. Her menarche# \3 M8 l7 C+ a( Z4 V- B
was at 11 years of age, and her height was at 5 feet
9 e% u7 _+ w: f6 B$ Y( r5 r5 inches. There was no other family history of pre-
! ^; l. z2 t( q7 O" e: c& Z5 vcocious sexual development in the first-degree rela-, ]8 c; b) A, I
tives. There were no siblings.
' ^8 q1 K3 b0 f) _1 {3 `) i" B; sPhysical Examination
7 A3 H. l6 U1 o: M' ]# b$ FThe physical examination revealed a very active,
: f2 ]8 n0 a6 y) iplayful, and healthy boy. The vital signs documented
! W. {8 D1 m4 a2 X; da blood pressure of 85/50 mm Hg, his length was
# k( @( R0 D* ]- s" V; @90 cm (>97th percentile), and his weight was 14.4 kg
5 ^* j( |( }9 ^! R(also >97th percentile). The observed yearly growth
' O9 F1 j/ |  }9 m. cvelocity was 30 cm (12 inches). The examination of
7 H0 ^7 L9 t9 [) j# S  rthe neck revealed no thyroid enlargement.
! n& V4 ?5 H! W9 ?1 [) }The genitourinary examination was remarkable for' I" u+ w, B/ J, F/ ?
enlargement of the penis, with a stretched length of# e3 w% L% B4 [, ]. M1 x$ m
8 cm and a width of 2 cm. The glans penis was very well3 ?+ i* U7 t8 K  r9 m( q/ `& _" B! a
developed. The pubic hair was Tanner II, mostly around
, U% Y# T, H2 @8 u8 E540' q; U1 H4 r# A' k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 y2 I4 A( ]( t1 u+ z  k/ z1 M- }the base of the phallus and was dark and curled. The
/ Q: k+ h( J0 ^1 v3 E5 z, M8 ltesticular volume was prepubertal at 2 mL each.
2 N; F! |* ?! Z! W1 mThe skin was moist and smooth and somewhat
. n' Q1 b/ c/ B: [; w+ }; aoily. No axillary hair was noted. There were no( `6 p+ |$ Z' V
abnormal skin pigmentations or café-au-lait spots.0 z9 z6 P; Y- X8 f8 t' A
Neurologic evaluation showed deep tendon reflex 2+( q# H8 u8 }  B# I5 a0 H( n+ Y
bilateral and symmetrical. There was no suggestion2 l5 K2 u  G+ f
of papilledema./ V' h: _0 F: d( k& r/ E1 t- }
Laboratory Evaluation
5 k$ V7 [; }; E) ]The bone age was consistent with 28 months by3 U7 I3 ?" Q/ ?& ^- V
using the standard of Greulich and Pyle at a chrono-
( v5 U4 [) W9 Z) ^+ qlogic age of 16 months (advanced).5 Chromosomal' J. T7 c  B' w- l7 X0 E- {
karyotype was 46XY. The thyroid function test! ]( `3 M) J8 ]' D9 |' w
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ K( l* ~9 m* N
lating hormone level was 1.3 µIU/mL (both normal).
/ h2 m* {7 Y! D- l. H2 ~! h! G/ M4 GThe concentrations of serum electrolytes, blood
, m! p: s( K  M  D% @5 x! ]$ s! R% T' burea nitrogen, creatinine, and calcium all were
( b9 V  P: W/ y) Iwithin normal range for his age. The concentration. c# u; E9 w% d# Q/ [+ Z
of serum 17-hydroxyprogesterone was 16 ng/dL
! e! ?6 f: y7 e! R(normal, 3 to 90 ng/dL), androstenedione was 20( |6 N( C5 g: n$ p0 A6 E" S9 s
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 B2 B5 p  }/ O4 T" Wterone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 X. o" p' O. b0 B4 T0 T# f% A8 wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to& @6 b! ?1 B# o
49ng/dL), 11-desoxycortisol (specific compound S)
5 b% W+ D- D" ?$ C) Y% ~4 V  {was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 G! N, M' H6 @" t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 i1 J- k6 I0 S+ ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" B" H; o# S1 c+ A! {and β-human chorionic gonadotropin was less than/ K: c$ r& B  n3 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 Q4 Z! Y0 _8 \( Y; v$ F5 [) tstimulating hormone and leuteinizing hormone( U7 k! p/ X+ p" o6 C
concentrations were less than 0.05 mIU/mL
4 N! V6 E( B8 z9 ?' F6 b# L0 d* a(prepubertal).
- I8 \! b2 h0 d1 f; SThe parents were notified about the laboratory3 L2 [) @7 J9 F6 n7 I9 a
results and were informed that all of the tests were
- g! S0 s8 A- Y4 p- bnormal except the testosterone level was high. The1 r+ x4 [0 Z, C: u' F
follow-up visit was arranged within a few weeks to+ {9 }/ F7 k1 k1 [' u! |: R* C/ g
obtain testicular and abdominal sonograms; how-
6 E5 I. c* E/ q, y) kever, the family did not return for 4 months.; H) n. b3 @% c. b7 F7 U
Physical examination at this time revealed that the) w4 @1 g1 i: \! e
child had grown 2.5 cm in 4 months and had gained
* P1 s: E7 e* t: B. m- z/ p: x2 kg of weight. Physical examination remained
, T( z- _; U9 _2 x. w- Eunchanged. Surprisingly, the pubic hair almost com-
, m9 ?6 u& q1 [. s9 y4 mpletely disappeared except for a few vellous hairs at7 C) R5 B2 C" w. h/ n0 l
the base of the phallus. Testicular volume was still 2
3 L3 ~( J8 v' B7 E/ b7 lmL, and the size of the penis remained unchanged.
6 i2 z* ]9 @: Z7 R8 J  ]8 F# HThe mother also said that the boy was no longer hav-/ _& Q1 @6 V" a9 [# G, ]) q
ing frequent erections.- i% |: ?' o9 S
Both parents were again questioned about use of
' C  H) H3 u) j$ N7 t' Zany ointment/creams that they may have applied to
$ r1 v" Y/ u  d: qthe child’s skin. This time the father admitted the
( m/ x, G3 z6 I: n, {) q& D, e3 nTopical Testosterone Exposure / Bhowmick et al 541
  E& P6 z+ [1 J* b  {use of testosterone gel twice daily that he was apply-
- H( T% M7 _' [# M' ^& Ring over his own shoulders, chest, and back area for
3 G2 n0 c' t$ p+ U3 qa year. The father also revealed he was embarrassed
$ `; a, g7 ]' Y5 ato disclose that he was using a testosterone gel pre-/ i7 @8 x+ O* C9 i4 ]
scribed by his family physician for decreased libido
8 [) g; v# `* p1 ?& q# usecondary to depression.
; Q& s% L  r, f/ u* [; [. y2 FThe child slept in the same bed with parents.
- |3 ^/ E5 z/ L1 O/ tThe father would hug the baby and hold him on his, X5 ^' d, x, x7 k
chest for a considerable period of time, causing sig-
. c% u  d3 r% h( D: d# W: _nificant bare skin contact between baby and father., N- T: ~0 |. z& q2 ~4 n
The father also admitted that after the phone call,
% \+ X  _! k0 B$ q5 K. qwhen he learned the testosterone level in the baby
4 E! A/ C; I. r& I5 Q0 k1 ewas high, he then read the product information% z, M# y$ Z. j: ?" H
packet and concluded that it was most likely the rea-
" W, y/ x& S' ~* ^9 s9 `son for the child’s virilization. At that time, they% D0 F/ \' }) [9 N
decided to put the baby in a separate bed, and the$ t! Y7 @  J* t1 \- x: ^( A% k( d
father was not hugging him with bare skin and had
) Y0 X8 q% F/ j, I* L2 sbeen using protective clothing. A repeat testosterone
; B7 K1 ?# n$ A4 R! F6 Wtest was ordered, but the family did not go to the
# k6 J" y' v* D0 X# |' _1 B5 `. A! Elaboratory to obtain the test.
# Y. @* h1 K  q0 b( dDiscussion
* l8 y5 l6 D% W8 n8 i5 W) f% _Precocious puberty in boys is defined as secondary
( i$ T) l/ P4 v0 p9 ]# D2 Usexual development before 9 years of age.1,4
3 m8 v5 s$ M- |8 g& p+ k+ tPrecocious puberty is termed as central (true) when$ z$ O5 }6 e3 B: `. w, e9 k+ s6 }9 B2 w
it is caused by the premature activation of hypo-% i/ J9 X! a$ e2 B
thalamic pituitary gonadal axis. CPP is more com-. `) M; ~: d: _4 y
mon in girls than in boys.1,3 Most boys with CPP2 O! |; d' d5 K. B, F
may have a central nervous system lesion that is/ j% r' t  `7 b7 g5 h( v
responsible for the early activation of the hypothal-
+ z; E1 B; `' d7 v* n6 N, kamic pituitary gonadal axis.1-3 Thus, greater empha-
  H3 i2 b' w9 f6 E% o) t& u1 rsis has been given to neuroradiologic imaging in- w/ Z# Z3 b" Y8 m
boys with precocious puberty. In addition to viril-) V6 o+ w& g; X: h" N& ]
ization, the clinical hallmark of CPP is the symmet-
# |3 ~* @# u# _) T5 d9 Arical testicular growth secondary to stimulation by
/ z$ @) b% E. g: g! hgonadotropins.1,3
/ `9 X! f) Y) U, F- {. cGonadotropin-independent peripheral preco-2 W; {" g; [" S; q0 I
cious puberty in boys also results from inappropriate! d! t' E9 O; y, n  ^4 ^2 O& |# [
androgenic stimulation from either endogenous or1 [# K& ?0 o( t- _
exogenous sources, nonpituitary gonadotropin stim-( I# @. R: z3 \- \1 m( q, v- |
ulation, and rare activating mutations.3 Virilizing  X" d9 O8 F" W* V
congenital adrenal hyperplasia producing excessive
, {5 w, H. L  |, |; Yadrenal androgens is a common cause of precocious* o6 q7 C; s6 s, O; O
puberty in boys.3,4: _0 u: z2 V3 ?
The most common form of congenital adrenal
4 p) z$ b2 C1 m. M2 Chyperplasia is the 21-hydroxylase enzyme deficiency." P6 A+ z2 _& E$ v' K7 q5 e$ }
The 11-β hydroxylase deficiency may also result in# c5 ^* \- g5 e
excessive adrenal androgen production, and rarely,8 |. c" o. o; Q" B* _
an adrenal tumor may also cause adrenal androgen* Y! p  p8 J- N3 w
excess.1,3
  y+ y( a7 G+ C/ c" A3 a* Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; _  F" M! q1 @0 `* Q1 K542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 D6 y5 F4 ?, [9 o& E
A unique entity of male-limited gonadotropin-
4 {1 e' O% q; I8 s6 Xindependent precocious puberty, which is also known, e0 J; C8 {5 O2 L8 W! |+ T
as testotoxicosis, may cause precocious puberty at a
# Q& m/ E9 B0 }2 n1 s% Cvery young age. The physical findings in these boys
: H  ^; y8 Q' Q& s+ M& u% cwith this disorder are full pubertal development," N. L; x4 \3 X/ u
including bilateral testicular growth, similar to boys' P$ f5 i8 U+ D$ E# r4 s" {
with CPP. The gonadotropin levels in this disorder
" z2 b$ ]( A" L- e6 p9 J" Q" Gare suppressed to prepubertal levels and do not show
* N* R- H( _8 L$ g, Q2 npubertal response of gonadotropin after gonadotropin-% P  t: u0 U$ _! q; E  {
releasing hormone stimulation. This is a sex-linked
, }6 S) j4 ?2 r1 j4 Oautosomal dominant disorder that affects only7 T  j; b1 L6 O+ H  x
males; therefore, other male members of the family
$ N. k# W) q' b+ mmay have similar precocious puberty.3
% c5 @( K7 J- `' Z, q2 f( I9 `In our patient, physical examination was incon-
# \4 x/ X/ r; A, I  Zsistent with true precocious puberty since his testi-
: e# j" h& I3 p, ^. j! B; s1 f9 lcles were prepubertal in size. However, testotoxicosis: K1 c- U) `( [  U
was in the differential diagnosis because his father+ W4 P7 w' B1 b4 O9 p( E
started puberty somewhat early, and occasionally,
, _2 B3 a: O0 r9 e$ mtesticular enlargement is not that evident in the
8 l. \1 a5 q. L4 ], J9 c/ u, T) ~beginning of this process.1 In the absence of a neg-3 e; w$ t% f6 n% G" U4 j3 i
ative initial history of androgen exposure, our
- i2 ?: c+ `# I1 x# j6 L& obiggest concern was virilizing adrenal hyperplasia,
6 p6 d6 |) L! b+ q. Deither 21-hydroxylase deficiency or 11-β hydroxylase/ m( f4 o0 o( H8 U
deficiency. Those diagnoses were excluded by find-
' F2 n6 X1 ~' C9 jing the normal level of adrenal steroids.$ O5 {7 q2 S" Y8 c
The diagnosis of exogenous androgens was strongly3 E' g" R- [) H( K
suspected in a follow-up visit after 4 months because
5 ?; E2 \* V6 Vthe physical examination revealed the complete disap-
9 B6 ~5 l% y! s: I0 R! o  mpearance of pubic hair, normal growth velocity, and8 t7 e. K" `3 W- r+ w
decreased erections. The father admitted using a testos-$ u/ E# _' e& T0 e
terone gel, which he concealed at first visit. He was
# c" M: p1 u1 m& Uusing it rather frequently, twice a day. The Physicians’% s) H, x+ }; F& G$ Q
Desk Reference, or package insert of this product, gel or8 K9 b4 d3 e4 e9 v
cream, cautions about dermal testosterone transfer to
: |7 U( V2 u3 o1 A# V7 Runprotected females through direct skin exposure.2 x$ L# n1 t8 ~5 e* h
Serum testosterone level was found to be 2 times the; j3 P4 x. K. A. O; J
baseline value in those females who were exposed to7 J/ N; W9 G( }
even 15 minutes of direct skin contact with their male; d$ O3 X4 C' E" A' w0 b" ~
partners.6 However, when a shirt covered the applica-$ @' ^2 i5 c1 Z2 W7 u! o6 f
tion site, this testosterone transfer was prevented.: \9 N* w: o' }. H; Z9 }+ t
Our patient’s testosterone level was 60 ng/mL,
/ y  L# O9 I: [( Y. U7 bwhich was clearly high. Some studies suggest that% g( I! V- W+ L' _' U" [- X
dermal conversion of testosterone to dihydrotestos-
2 {9 C  T/ N+ [# I4 @  gterone, which is a more potent metabolite, is more. u5 i, x; E5 X: C5 W
active in young children exposed to testosterone
; T1 x* O" [/ G! b7 _% Zexogenously7; however, we did not measure a dihy-' u! Y4 c& |. X- J7 T7 B1 c
drotestosterone level in our patient. In addition to7 q) u8 |2 r8 l( U8 i6 I
virilization, exposure to exogenous testosterone in; i% ~. r3 w7 |% Q2 I  W
children results in an increase in growth velocity and8 p# L: Q# X, ^" |7 E# M8 e; Y; t. c3 \
advanced bone age, as seen in our patient.$ O4 d. O$ P) f$ b3 J& R0 `
The long-term effect of androgen exposure during
, l# r. w/ n; ^  pearly childhood on pubertal development and final: o- V3 }0 q; t. ?4 D1 C7 ?+ p3 `
adult height are not fully known and always remain
3 `7 y  D) S& R5 _9 ra concern. Children treated with short-term testos-6 _) z5 Q: t9 j$ ]# U
terone injection or topical androgen may exhibit some  ~1 y1 C2 ?+ g6 \- X& Z6 ~
acceleration of the skeletal maturation; however, after
; I' `- q- f$ `cessation of treatment, the rate of bone maturation
9 m9 a5 m6 W0 b* X9 r+ bdecelerates and gradually returns to normal.8,9* t& n% \; y8 Q" M) W
There are conflicting reports and controversy
2 }% W% A0 M4 E) b, H. Qover the effect of early androgen exposure on adult
: K) z& ]; _3 m: Q8 M2 H) z0 rpenile length.10,11 Some reports suggest subnormal- L0 v. A" H: H* ^8 G/ y9 K: g
adult penile length, apparently because of downreg-
: W9 c7 b5 W7 A6 \1 p2 Yulation of androgen receptor number.10,12 However,- t+ j& C7 `4 O4 {
Sutherland et al13 did not find a correlation between
/ w" T/ R% W3 V0 _# K* C" @8 S# Qchildhood testosterone exposure and reduced adult
5 y- _$ Q( p- P; t9 [' |penile length in clinical studies.
4 Q- l3 x$ p4 t2 v# ANonetheless, we do not believe our patient is: I4 C6 ^; m6 M0 X
going to experience any of the untoward effects from
% g- }& T) A0 \' R0 itestosterone exposure as mentioned earlier because
. w% p1 A0 _" J- b% W. n- n0 n; Lthe exposure was not for a prolonged period of time.
- X4 P/ R9 s  _, r' J, tAlthough the bone age was advanced at the time of
) S7 J* ~! o6 Sdiagnosis, the child had a normal growth velocity at) Q8 a" F% D6 I0 `" B4 G
the follow-up visit. It is hoped that his final adult
- ~& x" Q) C4 T2 C1 Pheight will not be affected.
& Z  N+ F2 K- s/ ~# {Although rarely reported, the widespread avail-
( n2 a. O. l5 \5 I( u4 H& fability of androgen products in our society may! m( T; x% j5 J5 v8 B
indeed cause more virilization in male or female8 |0 ?9 r- C5 J! ]
children than one would realize. Exposure to andro-7 P7 i( \5 {( X) \2 ?( O% l4 b: n  M5 ?
gen products must be considered and specific ques-0 l# b1 O9 N! x" w
tioning about the use of a testosterone product or2 L8 D( Y# P1 U5 g. c3 o' M
gel should be asked of the family members during
" r+ `$ ]' m! E) fthe evaluation of any children who present with vir-
: v4 G5 T. @' P' t* i/ {4 e( Cilization or peripheral precocious puberty. The diag-
) {2 B( h' G) j/ Pnosis can be established by just a few tests and by
9 y$ q8 Y2 j6 P; G- \7 p5 Pappropriate history. The inability to obtain such a
$ ~3 \3 W5 I/ y, E+ |history, or failure to ask the specific questions, may
6 F# _* y. R8 h- F/ Sresult in extensive, unnecessary, and expensive
  W2 Z# T8 Z, @  S& [$ T* Ainvestigation. The primary care physician should be. n& e$ O5 g  i0 c1 ?
aware of this fact, because most of these children9 q7 a. {3 ?! O4 g5 y6 E) n
may initially present in their practice. The Physicians’6 [! k8 f  t/ M- i# H+ b0 p
Desk Reference and package insert should also put a% O  l; ^. w. \! u' L& K7 @
warning about the virilizing effect on a male or
% m% @9 E! O0 {  N3 M0 w. w+ rfemale child who might come in contact with some-4 i1 R5 A$ L" u8 \7 r! _3 i6 x& |
one using any of these products.
5 g1 G% u& t/ b6 b' FReferences
5 j0 k3 d. I7 h4 ~; `1. Styne DM. The testes: disorder of sexual differentiation( x/ F: J, E9 k, u
and puberty in the male. In: Sperling MA, ed. Pediatric* Z) ~- h2 a4 o+ D0 g: I- Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 Z! V5 x% ^) S2 E( K; _8 l2002: 565-628.$ ^9 Z6 n) P* b2 |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 s+ i: m; F( L8 ]! U9 t- G$ n8 p7 K
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old$ |8 h2 d, z  J
Boy Induced by Indirect Topical
2 n/ B* T* Z3 a3 U0 b* ^, N+ ~Exposure to Testosterone
2 x3 W2 i3 C; q. YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 W  w" f" B) M- o7 t& Jand Kenneth R. Rettig, MD15 Z3 Q+ a7 k8 ~7 x) R! P1 y" P( F& r' A
Clinical Pediatrics* m6 ~9 X# @7 S/ d! a/ y
Volume 46 Number 6
4 d) n; L# W$ ZJuly 2007 540-543/ u( @: S3 Y  o3 I1 l
© 2007 Sage Publications( S+ y: P# A- Q
10.1177/0009922806296651
7 Y8 Y' g1 j" q4 g' ^# _http://clp.sagepub.com) A& j6 K, B5 R- C5 \9 A
hosted at5 X* l& R5 n: t6 @1 h
http://online.sagepub.com: |; a+ z9 A2 L% \
Precocious puberty in boys, central or peripheral,
0 c) @+ Y0 ^; h/ S# X% Ais a significant concern for physicians. Central+ f; m8 Z/ u: P6 K0 ^: m5 X5 {
precocious puberty (CPP), which is mediated
- f& N5 B! o  ithrough the hypothalamic pituitary gonadal axis, has5 K( k2 v4 G* ?5 m
a higher incidence of organic central nervous system
( D  {1 r9 M' V- l9 tlesions in boys.1,2 Virilization in boys, as manifested
, G7 N/ Q1 I$ H+ Q1 F) Aby enlargement of the penis, development of pubic
2 J" x* i, b4 |$ Z" \hair, and facial acne without enlargement of testi-- R, [" i3 V1 `: ?% e4 K8 y
cles, suggests peripheral or pseudopuberty.1-3 We
6 z3 d5 O  A; areport a 16-month-old boy who presented with the1 N! s2 M/ i0 w0 d3 ?5 ?
enlargement of the phallus and pubic hair develop-
8 }1 S. z: t, g9 c9 X( `" t3 A$ |ment without testicular enlargement, which was due
# t+ \; p+ o% u# M" J8 {2 S- i+ Uto the unintentional exposure to androgen gel used by) P( Y( ]; j! d/ C/ W( H
the father. The family initially concealed this infor-
+ D( Y3 Z& L( b" f- y! x( ^# Kmation, resulting in an extensive work-up for this
! C  A$ R6 C7 m* ~. x8 hchild. Given the widespread and easy availability of
4 l) P( S6 c4 wtestosterone gel and cream, we believe this is proba-; Q' e( }, P. i
bly more common than the rare case report in the+ x; y7 J! S8 a0 F$ V) ^
literature.4, X5 O6 }- B2 s9 O; \% I3 k
Patient Report
" b% b5 J0 v0 x8 t1 F) TA 16-month-old white child was referred to the7 k& }& J' H3 h( j9 W
endocrine clinic by his pediatrician with the concern$ V; m) Q) J) [- b
of early sexual development. His mother noticed
, n- J! ?; a9 a' e. \; k$ O+ Alight colored pubic hair development when he was
$ i$ H1 U! V. C% l& J; M8 |From the 1Division of Pediatric Endocrinology, 2University of7 @. h/ v! e( n; r0 \- X
South Alabama Medical Center, Mobile, Alabama.) J$ n" M. g* _% ^) d
Address correspondence to: Samar K. Bhowmick, MD, FACE,& R, Y+ h% d2 c9 X6 U/ Z5 S2 a. B2 I
Professor of Pediatrics, University of South Alabama, College of
8 o$ w( Y. |0 G! X; n) S( G4 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* M* _2 B; u; }* y2 N. x8 m
e-mail: [email protected].
1 {  X! g# h. S$ L( `about 6 to 7 months old, which progressively became) o2 i" Q0 }7 z4 u2 T+ A/ |. q
darker. She was also concerned about the enlarge-5 `1 p2 f" j6 E/ H; j
ment of his penis and frequent erections. The child
8 Y" E$ j1 ^& f4 s" _7 _, K; {! cwas the product of a full-term normal delivery, with
! U+ C# p8 W) z  va birth weight of 7 lb 14 oz, and birth length of( e6 M8 M5 _7 f# b
20 inches. He was breast-fed throughout the first year9 `, J9 F6 [9 T
of life and was still receiving breast milk along with; u* `: E, e* E9 `. c+ b; t0 I
solid food. He had no hospitalizations or surgery,
1 l" `, ^3 }2 J9 nand his psychosocial and psychomotor development
7 S* ?) a0 a0 w( iwas age appropriate.
% c- \- v' M( l: HThe family history was remarkable for the father,
) U' B; V/ b* W+ X& Pwho was diagnosed with hypothyroidism at age 16,
; ~; {9 d% k' Y: Wwhich was treated with thyroxine. The father’s
6 K6 C+ X) P4 @. ]height was 6 feet, and he went through a somewhat
- f8 r. \  Q4 ^1 yearly puberty and had stopped growing by age 14.
" _# R. d% d, `The father denied taking any other medication. The
4 Q- z: F% a) j* E5 L* K8 D: F% achild’s mother was in good health. Her menarche
" U9 Y9 o! M8 l  a  ]% Z5 Ywas at 11 years of age, and her height was at 5 feet
6 T" F4 K* ^0 z! _' n5 inches. There was no other family history of pre-! Y7 d' \7 I, ]0 Q5 G' \. H
cocious sexual development in the first-degree rela-$ t+ r% E( o- h7 c4 P
tives. There were no siblings.
2 N2 L0 I0 V' @5 UPhysical Examination- L( v9 t% {# \
The physical examination revealed a very active,
6 I& Q! K3 M9 x0 x+ A' o4 {0 x. ~playful, and healthy boy. The vital signs documented
, ?4 Y5 `1 ^9 |5 Qa blood pressure of 85/50 mm Hg, his length was/ r* ?3 p9 X* H! B9 U8 Q5 _
90 cm (>97th percentile), and his weight was 14.4 kg) A% l$ i, I- Y7 m% m* r
(also >97th percentile). The observed yearly growth3 b' E; w+ s# X/ d5 X8 `
velocity was 30 cm (12 inches). The examination of
$ ~3 h0 u% Z% E' _5 D8 J, y9 Fthe neck revealed no thyroid enlargement." K( Q1 F8 R# ]/ [9 O2 S( k
The genitourinary examination was remarkable for/ C8 D  m9 y) }
enlargement of the penis, with a stretched length of
( E7 P; O. H* R3 _$ L$ Q8 cm and a width of 2 cm. The glans penis was very well
  E! J) Z5 @; a4 G; K' G( Cdeveloped. The pubic hair was Tanner II, mostly around  n9 B  }0 f7 S6 P; F0 ^5 T
540
. z3 c/ P7 v6 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 ~/ i9 |# v0 E& @+ r% \& V: i. hthe base of the phallus and was dark and curled. The
; P2 }# D5 Y4 W( Stesticular volume was prepubertal at 2 mL each.
' ]1 o& w% p0 }  P4 TThe skin was moist and smooth and somewhat
) z+ Z. o- ], b" E4 _8 [6 w7 Hoily. No axillary hair was noted. There were no
# @, ]) k! ?2 ]abnormal skin pigmentations or café-au-lait spots.* O% S5 ]6 C9 F8 ~. F# k
Neurologic evaluation showed deep tendon reflex 2+8 j! I( a. A% h$ i8 g
bilateral and symmetrical. There was no suggestion. l. O! `3 |8 w9 C* _
of papilledema.- j5 u: p$ m0 r; E# N
Laboratory Evaluation( {3 d$ Y$ u  u4 p$ F0 S
The bone age was consistent with 28 months by
7 V! |. _! ?' qusing the standard of Greulich and Pyle at a chrono-
3 |9 N  q+ u# J+ u2 w1 F) N  @logic age of 16 months (advanced).5 Chromosomal
4 l" {, \& ?, \4 e. Skaryotype was 46XY. The thyroid function test
7 a  H8 I- E; h. ~; z2 W# Cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 S2 w3 [3 I1 K% i: b
lating hormone level was 1.3 µIU/mL (both normal).) @6 k: b+ `4 R1 T5 F+ d3 v
The concentrations of serum electrolytes, blood$ y( B/ Q; N7 y4 r
urea nitrogen, creatinine, and calcium all were! M% W: i8 z* C8 }$ W9 W, V
within normal range for his age. The concentration
7 p0 v( ]7 R/ l" ]! N1 f; k, ^+ Vof serum 17-hydroxyprogesterone was 16 ng/dL
5 `0 O9 K" |8 r2 b' Z" P(normal, 3 to 90 ng/dL), androstenedione was 209 w) _& O# r; q0 _; C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 ?, j2 m8 i% j+ k5 ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- _3 G0 m) P% F* I+ p3 l2 @( ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to6 {( i, A& t' M" `1 Z  w
49ng/dL), 11-desoxycortisol (specific compound S); A$ o7 v0 J" G$ o* Z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: z' {' L4 a3 W/ f/ F8 E" W) i/ Y6 ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 W4 f' m) d3 M1 r- G$ _% T% ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 Z3 }- \! j- m% g/ i; H0 `
and β-human chorionic gonadotropin was less than9 P. w* V" P/ S2 v6 }1 ^
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 q! g* u! l% S0 E
stimulating hormone and leuteinizing hormone9 k" [) u2 o& H2 q
concentrations were less than 0.05 mIU/mL
5 b7 ]$ e1 R& {0 A, b! O6 q! A(prepubertal).; ~4 i. x% H% a* u8 Z7 l
The parents were notified about the laboratory
, d, V- b7 }' R2 I: Lresults and were informed that all of the tests were
: O' h$ w" l! T' v( Ynormal except the testosterone level was high. The
* _1 [; c! A6 A+ h* j% Hfollow-up visit was arranged within a few weeks to: Q6 A+ R0 X3 K9 m3 |
obtain testicular and abdominal sonograms; how-. l- l5 ^' B1 D
ever, the family did not return for 4 months.
1 S; s& ]& _7 B! CPhysical examination at this time revealed that the
9 T0 A( F( I; @# Q4 Hchild had grown 2.5 cm in 4 months and had gained2 ~" m+ K$ g; L5 z6 w; |
2 kg of weight. Physical examination remained
& t1 J0 C' j# j% E- V8 Punchanged. Surprisingly, the pubic hair almost com-
) C* J/ l5 `- @7 ^pletely disappeared except for a few vellous hairs at  M# d5 Q" W( K
the base of the phallus. Testicular volume was still 2
( s( T; }: x- ~9 c, xmL, and the size of the penis remained unchanged.
/ [% z3 q8 V# z/ v* E, kThe mother also said that the boy was no longer hav-4 o8 W+ ?7 e4 _% K' |/ {
ing frequent erections.7 c+ ^6 @9 E: ?: b
Both parents were again questioned about use of% m+ ~0 D1 @$ P$ ]
any ointment/creams that they may have applied to
# V% s- Q) Q4 A6 Nthe child’s skin. This time the father admitted the
. q, B5 W: G$ A/ L& [Topical Testosterone Exposure / Bhowmick et al 541' I% b. m  Z' D% Y6 W
use of testosterone gel twice daily that he was apply-
+ K! D. Y* @1 R; G4 b0 Z$ J+ Qing over his own shoulders, chest, and back area for# _. m9 e+ T! B: Z# v
a year. The father also revealed he was embarrassed
% t, J5 t# Q2 n9 B; mto disclose that he was using a testosterone gel pre-2 ]+ O: y: a' X5 o4 j
scribed by his family physician for decreased libido
( P* F# f; ]8 c; A9 J' A3 zsecondary to depression.% F# `9 F$ n* B8 a
The child slept in the same bed with parents.* ~% D8 B0 p; F) j
The father would hug the baby and hold him on his' N- V+ i8 @' k, v# s, z9 G6 [  H" i: j
chest for a considerable period of time, causing sig-" n% i' [4 m! Y  r  |8 ^; ]# Q) u
nificant bare skin contact between baby and father./ x- I! x* G( H$ `
The father also admitted that after the phone call,
" _5 S& b9 k% J% d- x1 Ywhen he learned the testosterone level in the baby$ ~; ]  T+ N+ W1 a/ m
was high, he then read the product information
3 E9 O) Z/ F; ]$ z% B+ s, W& hpacket and concluded that it was most likely the rea-8 y1 m+ v3 K9 P! O' l( X
son for the child’s virilization. At that time, they1 J; k7 B6 g, _* l) J8 [1 e- U" V
decided to put the baby in a separate bed, and the' u/ z$ H9 b' b' G/ E8 e
father was not hugging him with bare skin and had
0 f. `" |( z2 w  i5 V. k2 zbeen using protective clothing. A repeat testosterone. N. ]1 g1 n1 y$ e% Z* z# H
test was ordered, but the family did not go to the
5 q2 z  V$ T8 C! D, V+ Q* W2 dlaboratory to obtain the test.
: W. u! K7 \1 ^. D. R) a- l5 c4 yDiscussion
: [( p/ u3 r) x% d( kPrecocious puberty in boys is defined as secondary
0 |: W) x/ |% ~sexual development before 9 years of age.1,4
+ n' p) T* @4 z$ l2 B: @' Z+ sPrecocious puberty is termed as central (true) when; Q& X3 }, c) N) g% m0 \
it is caused by the premature activation of hypo-
' L- a! @1 l( M6 cthalamic pituitary gonadal axis. CPP is more com-& |( e) h8 f( [
mon in girls than in boys.1,3 Most boys with CPP* A3 U4 P2 N" W  C# ^4 ]! h2 y$ H
may have a central nervous system lesion that is
2 q+ I+ O4 ^3 b% N& X! Wresponsible for the early activation of the hypothal-
* t3 D1 T+ u' b/ q1 [amic pituitary gonadal axis.1-3 Thus, greater empha-
+ P( i4 U3 Y+ I0 `; J1 v5 e* o* Isis has been given to neuroradiologic imaging in
5 G8 a  c7 H/ ~boys with precocious puberty. In addition to viril-% `2 Q2 o* P6 C; g$ l% |. a: R
ization, the clinical hallmark of CPP is the symmet-; J. f: J; P  u% v: h5 y
rical testicular growth secondary to stimulation by
; i- i1 R, y$ R* z+ s& a9 \* a: sgonadotropins.1,3
( M4 L( u2 ^; S$ z/ m* hGonadotropin-independent peripheral preco-
- |2 G5 |* G; P( lcious puberty in boys also results from inappropriate
  p+ P1 \- e* Bandrogenic stimulation from either endogenous or& F8 Q2 `1 }0 o" a3 H
exogenous sources, nonpituitary gonadotropin stim-: G6 M! j  o' P$ P# F7 U
ulation, and rare activating mutations.3 Virilizing
1 Y, A: c" @  r1 ]- t1 wcongenital adrenal hyperplasia producing excessive
2 t  b4 Z8 r* M& h% M  E5 kadrenal androgens is a common cause of precocious2 D% \: x, p' ~
puberty in boys.3,4  H, e# u. R3 E
The most common form of congenital adrenal
7 t, V1 E5 f" _( H0 [8 {# Qhyperplasia is the 21-hydroxylase enzyme deficiency.
: e5 M0 H2 d, m  A4 D8 d4 B7 ^  g! }The 11-β hydroxylase deficiency may also result in* M6 L* ^+ q# T- Y# m* b
excessive adrenal androgen production, and rarely,7 E3 N. [' M* q( Z) W: G1 n
an adrenal tumor may also cause adrenal androgen
5 K; D( N1 e  z9 ^0 W7 @/ Zexcess.1,3
$ i5 K  _8 R4 w* Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 c  r0 v5 O5 f. p' ?; l542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ q- x4 S! ^% F" \0 S7 tA unique entity of male-limited gonadotropin-9 N* K9 M( J% k$ q7 E7 X
independent precocious puberty, which is also known
! a" c2 h0 y, E  C2 v1 E9 h6 [as testotoxicosis, may cause precocious puberty at a: i5 F3 \( d5 M( e% T1 e" a, h6 Q
very young age. The physical findings in these boys- @( s# s( ^1 H( u) f0 G  ~' r8 r" ~
with this disorder are full pubertal development,# e/ D) `2 C& O" t
including bilateral testicular growth, similar to boys
8 a' _# [4 \  v/ lwith CPP. The gonadotropin levels in this disorder1 s) d& e; w0 R6 s0 p$ x) d& W
are suppressed to prepubertal levels and do not show9 @7 U9 Y% m1 h
pubertal response of gonadotropin after gonadotropin-0 f: {  F2 h+ S' p4 l9 V
releasing hormone stimulation. This is a sex-linked
7 ^8 N! b3 i2 P/ U' W) qautosomal dominant disorder that affects only" J, |7 i  C' p3 j- e& U
males; therefore, other male members of the family
0 ^0 E9 f# p, Y! bmay have similar precocious puberty.3
/ H; s& O( a/ G2 aIn our patient, physical examination was incon-3 N, i% w5 p( B+ c
sistent with true precocious puberty since his testi-/ r! m9 q0 W- [
cles were prepubertal in size. However, testotoxicosis
( S, J5 M! @2 Q) y7 ?% M7 swas in the differential diagnosis because his father7 @2 ~; R0 u8 D! B4 I
started puberty somewhat early, and occasionally,
% d# T. l/ A. ^" @- Etesticular enlargement is not that evident in the
9 R4 K) R% J$ ^) wbeginning of this process.1 In the absence of a neg-( ^/ Z2 @2 e) p% P3 [0 Y% N
ative initial history of androgen exposure, our
) b; k( B, i7 d' N4 vbiggest concern was virilizing adrenal hyperplasia,0 N' Z6 w# M* x
either 21-hydroxylase deficiency or 11-β hydroxylase4 ~9 Q& h5 ]! d4 H
deficiency. Those diagnoses were excluded by find-! V' K7 D2 @5 p* k
ing the normal level of adrenal steroids.' D9 c2 s* H" S
The diagnosis of exogenous androgens was strongly
1 w/ q: k! h0 [: hsuspected in a follow-up visit after 4 months because, v& ?  w0 X( \' k8 m. p( O8 \
the physical examination revealed the complete disap-7 q; W! i2 N$ a
pearance of pubic hair, normal growth velocity, and
6 @1 `' B, H7 k7 a- c& l/ t% y) ~decreased erections. The father admitted using a testos-
; C: i  y- j$ m$ I3 \6 u" lterone gel, which he concealed at first visit. He was
0 J5 `1 p8 k( [$ B2 W0 t( Eusing it rather frequently, twice a day. The Physicians’
& }# I) N/ o) q; gDesk Reference, or package insert of this product, gel or8 R. @, Q' X* k4 H# @# |, Y0 E
cream, cautions about dermal testosterone transfer to" T- P5 F; s4 B8 M$ H: j
unprotected females through direct skin exposure.6 l) U9 C( v6 J' K+ K0 k* ?- l
Serum testosterone level was found to be 2 times the
2 B4 N4 Z! [+ G9 [, {0 r/ dbaseline value in those females who were exposed to
( O) z  C8 ~+ G/ teven 15 minutes of direct skin contact with their male
4 s- S5 F- b3 u6 b* t1 M! |9 vpartners.6 However, when a shirt covered the applica-  @- R! Q. K" e' E$ W
tion site, this testosterone transfer was prevented.! l! j* V* M% M$ P  h
Our patient’s testosterone level was 60 ng/mL,
9 w( T  g8 [: j( J; n  Ywhich was clearly high. Some studies suggest that
! H6 O# u6 a$ u) Ydermal conversion of testosterone to dihydrotestos-  R0 h. M5 \# i3 y) l
terone, which is a more potent metabolite, is more
4 H4 f$ G3 [. d2 B' i- P# O7 i6 pactive in young children exposed to testosterone
1 l5 a$ |5 D: d' R3 aexogenously7; however, we did not measure a dihy-
/ z: @; \  q3 i( adrotestosterone level in our patient. In addition to
* x' ^) K2 ^2 s7 r3 b/ Fvirilization, exposure to exogenous testosterone in
& y+ V' U4 m9 l! L9 q; m# Achildren results in an increase in growth velocity and
! U# O, Y) d6 l1 nadvanced bone age, as seen in our patient.
% y& @& m. C" M# _: a* V7 lThe long-term effect of androgen exposure during4 z7 O& ]! j/ K$ o" l
early childhood on pubertal development and final; o( A4 [* _, Q1 _" o0 r1 C; a
adult height are not fully known and always remain
) R3 Z8 w4 T( L  p' G' J3 Wa concern. Children treated with short-term testos-
0 h/ Y  M, j+ Pterone injection or topical androgen may exhibit some4 |+ l0 u8 t9 v/ ~: F
acceleration of the skeletal maturation; however, after$ k: m2 |/ j) Q7 k9 v7 _
cessation of treatment, the rate of bone maturation. f, Y4 B, c% N; Z' q3 [
decelerates and gradually returns to normal.8,9
* E- c" c) c' p# i) NThere are conflicting reports and controversy
" a1 h/ t7 P' Zover the effect of early androgen exposure on adult
4 X/ r# \2 T# ~& B7 Qpenile length.10,11 Some reports suggest subnormal9 ?# J1 b; j, Y5 [) c6 K9 e
adult penile length, apparently because of downreg-) [8 |' v' U* v& r
ulation of androgen receptor number.10,12 However,9 ^9 [8 q' l* C; m) B
Sutherland et al13 did not find a correlation between
4 c& A$ p8 a1 x2 echildhood testosterone exposure and reduced adult0 l6 m6 x! I3 N
penile length in clinical studies.
3 Q; W3 y3 e, g$ yNonetheless, we do not believe our patient is
3 W' R8 A( u6 e3 [! F6 u7 |/ Bgoing to experience any of the untoward effects from
+ P0 e& b  _5 |' l- M( wtestosterone exposure as mentioned earlier because
, I# w- T6 |0 |( Jthe exposure was not for a prolonged period of time.
. j: `& v7 O, V* y/ M* a+ LAlthough the bone age was advanced at the time of
* \' w  F# U. _; [$ Q' v# w* e2 Fdiagnosis, the child had a normal growth velocity at3 m+ b  Q. o+ d' h
the follow-up visit. It is hoped that his final adult
3 O! C- ^1 `6 Lheight will not be affected.! ]7 B; v% R! V5 i6 @& x! p
Although rarely reported, the widespread avail-, M9 h5 E1 n6 G9 k- n. x
ability of androgen products in our society may
  t5 F6 ~* R  Q: N6 ?indeed cause more virilization in male or female
, q+ b5 r8 }$ q5 ^1 E, vchildren than one would realize. Exposure to andro-
* Y4 S& @4 ?. T! s/ g% M$ Ngen products must be considered and specific ques-, L. p0 a$ ^! N5 B! M
tioning about the use of a testosterone product or% G% I3 W3 a4 o3 F0 h8 D6 V
gel should be asked of the family members during
5 |" O; O! @9 c; v2 rthe evaluation of any children who present with vir-) l; s( \$ B" I; {0 a, @4 b
ilization or peripheral precocious puberty. The diag-. y$ g1 J4 A/ w" ^  n
nosis can be established by just a few tests and by' ]1 @! C- M4 T0 V7 L0 i' i: n
appropriate history. The inability to obtain such a
, }# b& I) A- |9 Z& Y* T3 m8 `( ^history, or failure to ask the specific questions, may
; \; |: k7 I2 t: T- Lresult in extensive, unnecessary, and expensive. A) P, d( t/ h4 p+ I
investigation. The primary care physician should be
; N0 ?$ k7 _$ t+ ]2 A( |aware of this fact, because most of these children8 B* M" L- B$ v' ^
may initially present in their practice. The Physicians’2 m4 D& v% c5 @% ?0 Z! Z; b3 J
Desk Reference and package insert should also put a3 S4 l2 w, E. a
warning about the virilizing effect on a male or
1 z* N- J( ?5 n& Zfemale child who might come in contact with some-
% s9 m4 [, R5 _0 h7 Jone using any of these products.
7 m) y$ _$ f9 `* s9 IReferences6 Y4 H1 |* n8 ?
1. Styne DM. The testes: disorder of sexual differentiation
0 O1 o& c( n7 u! x5 Rand puberty in the male. In: Sperling MA, ed. Pediatric  ]: q# N/ l% J" {2 n+ q) r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ ~* A, q+ t5 O, r& a1 ]7 c# Y# d
2002: 565-628.
: p# c3 ~6 E9 p* ]2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 I! S5 [5 Y" ?& ?
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

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發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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