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Sexual Precocity in a 16-Month-Old
" F; w4 G1 Z; T; x7 WBoy Induced by Indirect Topical
9 H" {5 h, E9 a7 ^' d+ zExposure to Testosterone
: _4 v! {% a6 `2 b# XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; M7 N4 N( I: c1 A) ^and Kenneth R. Rettig, MD1
2 h& ?* y( e' K' n" iClinical Pediatrics( M, g) z6 o" u# v/ y4 p
Volume 46 Number 6, E& N, h: B$ c2 V8 R( }3 K
July 2007 540-543
0 h. C4 O, J! c6 v0 X© 2007 Sage Publications
5 T- Y" K; c, I4 Q10.1177/0009922806296651: c3 a, Y! o# F/ X1 u  \$ Z
http://clp.sagepub.com
2 T' |7 Y; ]7 O+ U" Q1 G3 E7 ^7 Hhosted at
) V" @7 ?3 x0 H# j: Ohttp://online.sagepub.com: u1 M3 Q. r2 f
Precocious puberty in boys, central or peripheral,/ `/ Y& B( j1 Z
is a significant concern for physicians. Central# }, C; o' t. d1 v' S! x% ]
precocious puberty (CPP), which is mediated" B& z0 V$ e! x+ e/ `
through the hypothalamic pituitary gonadal axis, has
: |+ ^4 I4 ]' f) d" M/ r  Ta higher incidence of organic central nervous system& Y8 p- n7 v3 E) B! i
lesions in boys.1,2 Virilization in boys, as manifested/ }, x* U( T& g5 a
by enlargement of the penis, development of pubic. Q8 q8 Z. K' Q  K
hair, and facial acne without enlargement of testi-
0 |! r8 ~1 M( x  F+ @cles, suggests peripheral or pseudopuberty.1-3 We
+ I2 m: ]" j2 O" O' W& I. b! ureport a 16-month-old boy who presented with the
4 `8 E2 _0 M6 b8 o& C8 }enlargement of the phallus and pubic hair develop-1 c  n. C" Z- a6 P- h# A1 _" ]
ment without testicular enlargement, which was due
  d9 E% H3 T- B$ u( {to the unintentional exposure to androgen gel used by
) j7 U7 Y3 N, `3 G3 J) kthe father. The family initially concealed this infor-: k. Q- s4 ^5 s3 b8 @: X( [1 S
mation, resulting in an extensive work-up for this
! ~# b( `, J- Vchild. Given the widespread and easy availability of' l( C1 e) N9 W" G* l1 V2 k
testosterone gel and cream, we believe this is proba-
* s6 c- i8 Y# p2 X% k: q4 {* N0 fbly more common than the rare case report in the
. z0 `% Z9 U$ m5 v( \% x& l! Rliterature.4' R  b' h: B) g* R! ^' o0 ~
Patient Report) _, t' M  E' O/ z, P: M4 s/ ~
A 16-month-old white child was referred to the
9 v* `+ g" V; L* @, ]4 W. }endocrine clinic by his pediatrician with the concern( \2 u& S5 X% \3 A
of early sexual development. His mother noticed1 D$ M# f/ U. _, \$ [
light colored pubic hair development when he was) X, T$ ~0 m9 o# e0 u
From the 1Division of Pediatric Endocrinology, 2University of2 K9 b/ T! {; x" [1 b- R9 l- r
South Alabama Medical Center, Mobile, Alabama.! _8 H) g- c: S! a% ^! G) H: H0 s
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# L; X- {# w  [+ [9 n( cProfessor of Pediatrics, University of South Alabama, College of
+ i& L. w/ s* ^+ q  v# eMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- a- ]! B0 m+ |. Y6 P7 ve-mail: [email protected].! ]5 s) ^" {: H0 V
about 6 to 7 months old, which progressively became, _/ v& u( U4 S" R6 D4 C
darker. She was also concerned about the enlarge-3 q4 y! R( L9 c6 H, L& r; e
ment of his penis and frequent erections. The child
. M* I( C: m/ w, |: {& L$ z4 b$ P6 Nwas the product of a full-term normal delivery, with
7 X9 Q5 h: f; _8 Ja birth weight of 7 lb 14 oz, and birth length of+ d1 \, e, R+ }9 _
20 inches. He was breast-fed throughout the first year
7 K: q; T6 ?3 h3 a; L2 P+ Zof life and was still receiving breast milk along with( y1 u  ?% v# n) N
solid food. He had no hospitalizations or surgery,: ^: U3 g- r* }9 u* ^+ j; g
and his psychosocial and psychomotor development/ k; z5 ?7 L8 _( ^
was age appropriate.9 W% z' C2 e: K; c" n, S
The family history was remarkable for the father,5 o5 c5 L5 {: _/ H4 J: h9 z
who was diagnosed with hypothyroidism at age 16,
5 t% z0 x' L* a) zwhich was treated with thyroxine. The father’s
  F5 B) t7 A/ Bheight was 6 feet, and he went through a somewhat4 c# a( J( x3 x! P$ y2 ~0 H
early puberty and had stopped growing by age 14.0 z7 D# x  j/ N0 N$ r
The father denied taking any other medication. The
( I4 y6 ~* z  w- N; q! t: kchild’s mother was in good health. Her menarche
/ [+ W/ O' B5 h2 {- i4 swas at 11 years of age, and her height was at 5 feet
6 M; H2 E6 b/ W& I$ e5 n$ u5 inches. There was no other family history of pre-3 B4 K! g# ]* `- K. K1 }+ ^. G
cocious sexual development in the first-degree rela-. N5 J) i0 r" v8 Z: s3 _; P
tives. There were no siblings.% K8 Q- k- X+ T1 p6 P, ]
Physical Examination
* W1 Z1 l, a7 g' C5 V% F7 H) hThe physical examination revealed a very active,5 l( b+ G( B7 n5 F+ G- ~3 h5 P
playful, and healthy boy. The vital signs documented
$ o# B: E, d4 Z4 v* b4 ba blood pressure of 85/50 mm Hg, his length was, S& `* E# g6 A* ?) D- Y5 o
90 cm (>97th percentile), and his weight was 14.4 kg* \- I( y( |5 M5 Q! o! I  R
(also >97th percentile). The observed yearly growth8 S9 C8 \. t0 _9 o* \3 {6 \0 z" c
velocity was 30 cm (12 inches). The examination of. w% ]$ N5 ^2 T5 y2 m8 I& J$ x
the neck revealed no thyroid enlargement.
# @7 _0 |) |" @The genitourinary examination was remarkable for
2 A, M* g( K8 |# G# _! Cenlargement of the penis, with a stretched length of
5 L0 T7 P& e3 w# Q8 _7 K8 cm and a width of 2 cm. The glans penis was very well. s4 t, Y. h/ ~9 p/ l2 N8 v
developed. The pubic hair was Tanner II, mostly around% E8 F& p3 Y8 I
540
6 h! k& d3 \3 v, U9 a  ^- cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 I2 t# ]3 g! q; g& Zthe base of the phallus and was dark and curled. The
. q# A1 I# Y: V! u8 itesticular volume was prepubertal at 2 mL each.
( [, C. ?: |9 a8 J# o3 g" J) hThe skin was moist and smooth and somewhat9 f8 K0 A8 h) @% U  t
oily. No axillary hair was noted. There were no
0 M$ g7 D$ d1 m8 j( R- Fabnormal skin pigmentations or café-au-lait spots.
% l0 |2 J* ^: z& O: B4 ^Neurologic evaluation showed deep tendon reflex 2+$ \, d# W+ O" \8 G0 ^3 g: ^: A3 `
bilateral and symmetrical. There was no suggestion1 H, G# F9 C$ N7 ~
of papilledema.
  U0 }6 c' N2 q; i% f8 yLaboratory Evaluation; V1 e1 v5 O; s  N  p0 g
The bone age was consistent with 28 months by
) y/ e. e" g# M6 S, a5 ]  H4 Kusing the standard of Greulich and Pyle at a chrono-2 }& X& R" ]5 G- Q" s3 y' s
logic age of 16 months (advanced).5 Chromosomal/ ]4 r4 r$ t6 J, A" w. P
karyotype was 46XY. The thyroid function test) W  `; v+ n0 k3 C; R  d( S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, s  M2 U+ L  W& Y: v* m+ D
lating hormone level was 1.3 µIU/mL (both normal).$ {1 |' Q, V' e: |/ g# u! A
The concentrations of serum electrolytes, blood
6 e. S& o1 z% A! Xurea nitrogen, creatinine, and calcium all were
3 T6 K  R5 `0 F% l; owithin normal range for his age. The concentration1 e5 J* {" I" }  @- r5 {& C8 ]" G: Y7 e
of serum 17-hydroxyprogesterone was 16 ng/dL7 S: _* `! Q8 }  K, D
(normal, 3 to 90 ng/dL), androstenedione was 20
+ L6 m1 B* }/ M- |9 yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- e4 @8 `. m$ i7 M9 ~; o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* D# C$ i/ s/ O" ?& k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 ]4 g: Y# J6 [$ w; P/ B/ e% Z0 ~49ng/dL), 11-desoxycortisol (specific compound S)9 i( h0 q$ f( ]* e2 `. b" o9 A) T* x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* e' y8 U$ o5 X) X4 y' v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& J# r/ ~) c& k, a4 X1 z3 `
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ O# s0 |6 Y4 @$ l
and β-human chorionic gonadotropin was less than  p' T/ M( v0 F: t! M
5 mIU/mL (normal <5 mIU/mL). Serum follicular
& g( s9 J' B& l+ n+ ostimulating hormone and leuteinizing hormone
/ k" P8 a6 g3 i0 F2 Bconcentrations were less than 0.05 mIU/mL% x# N1 b5 q* L6 p, D7 }
(prepubertal).
2 p& X# s2 K) GThe parents were notified about the laboratory
) c5 y3 A! q2 A/ xresults and were informed that all of the tests were7 }8 k) m1 `- @7 ^
normal except the testosterone level was high. The8 |8 x0 w1 m4 f+ D1 D; o
follow-up visit was arranged within a few weeks to4 R) S, a5 n. N' b. o: D6 t# H
obtain testicular and abdominal sonograms; how-
( y$ S  }5 M/ n% T/ c) iever, the family did not return for 4 months.( Z- S+ E& ~1 ?; }, m7 x( K$ f
Physical examination at this time revealed that the
/ t8 j  |7 B" t) S. A" {2 F/ d+ ?child had grown 2.5 cm in 4 months and had gained8 t  X* w9 t2 Z
2 kg of weight. Physical examination remained0 @- J3 }$ B, A
unchanged. Surprisingly, the pubic hair almost com-
- A! i- N7 g, Z) S, R. T% \pletely disappeared except for a few vellous hairs at
1 N+ O8 S* V; |0 d' }8 n. N; `4 {/ bthe base of the phallus. Testicular volume was still 2! e4 q; N2 j) W
mL, and the size of the penis remained unchanged.1 o3 x, I$ p( f8 C  A
The mother also said that the boy was no longer hav-
$ X/ X4 u, m/ W8 S5 g, K# {ing frequent erections.! {8 O- X2 Y% h  A: b
Both parents were again questioned about use of0 ^# B9 H! f7 x0 ]% x& l) S& ]/ C
any ointment/creams that they may have applied to
1 z0 K( c* V3 f0 \the child’s skin. This time the father admitted the* N- K! {& l1 d- d' E: X' t0 y
Topical Testosterone Exposure / Bhowmick et al 541
5 Q  p4 t5 F9 Kuse of testosterone gel twice daily that he was apply-! o0 X1 ]1 o4 Q/ m; e
ing over his own shoulders, chest, and back area for
1 _- n+ g/ ?" H1 o5 X4 w  Q- \) Ua year. The father also revealed he was embarrassed) T, [; ^: p& Z! G
to disclose that he was using a testosterone gel pre-
( Q" j& R; F- ~: H& Cscribed by his family physician for decreased libido) P% c1 h0 E! J* s+ U6 u; F0 o
secondary to depression.
. _, p4 x+ i3 Q- P% R# uThe child slept in the same bed with parents.. B9 B2 _+ {. c
The father would hug the baby and hold him on his
& g: X) n+ q( T, r" |chest for a considerable period of time, causing sig-
' S. N1 x0 ], N: x! Anificant bare skin contact between baby and father.
  n) u( g& S# ]. J$ [The father also admitted that after the phone call,
- i: Z' [+ Z6 l( l- I% x1 }when he learned the testosterone level in the baby; O6 W. @- ~+ H, M3 q5 _: ~- K6 T% v2 W
was high, he then read the product information6 l) i% {4 j) F4 u1 e4 [) B
packet and concluded that it was most likely the rea-/ }9 f8 D/ O* [4 `
son for the child’s virilization. At that time, they) O7 |7 g3 c% Q# e; e) B
decided to put the baby in a separate bed, and the8 y7 N; B0 _1 N3 k6 `
father was not hugging him with bare skin and had+ p2 t& H3 k* s( _+ A' C
been using protective clothing. A repeat testosterone
6 c- K* |2 ]; W: I6 r! jtest was ordered, but the family did not go to the+ B8 F# U' Y9 k
laboratory to obtain the test.) }/ `. w8 `+ p- E; A; K
Discussion
1 p9 B: ?: D: E3 iPrecocious puberty in boys is defined as secondary& d0 k! N7 h& c+ |+ s$ v
sexual development before 9 years of age.1,42 y3 h/ T( W; T& j" N, |
Precocious puberty is termed as central (true) when
) O$ R9 s+ R9 g/ iit is caused by the premature activation of hypo-
5 Q# ~; j1 v+ B8 `# a; n4 C4 M. ~- othalamic pituitary gonadal axis. CPP is more com-
* V: e: Y4 U: F3 amon in girls than in boys.1,3 Most boys with CPP
  q+ @, E; ?: f; J" h+ ]may have a central nervous system lesion that is: x7 ?6 B6 D6 @4 P* O8 d6 w) N
responsible for the early activation of the hypothal-$ H- C4 {' j# j4 V, Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
0 r& n5 s& k! K5 `sis has been given to neuroradiologic imaging in3 Z9 S' R5 A/ c' I9 X4 I8 a. G  g
boys with precocious puberty. In addition to viril-
3 F  D$ [  x, l; ]ization, the clinical hallmark of CPP is the symmet-
& f" ]5 S! S$ q3 J% |7 Xrical testicular growth secondary to stimulation by: o( B. W! ~3 }9 I  Z- K; z
gonadotropins.1,3
- i$ m$ A$ ^6 |% c) ^$ ?& X- gGonadotropin-independent peripheral preco-
/ K% @4 M: j  w, k: |8 bcious puberty in boys also results from inappropriate3 h$ i( W; z2 v$ ~" w
androgenic stimulation from either endogenous or
3 C: V1 {' x* n+ t- r, Gexogenous sources, nonpituitary gonadotropin stim-
  e+ k( Z5 h& F  nulation, and rare activating mutations.3 Virilizing, q* B& J/ q. x3 D& `( f
congenital adrenal hyperplasia producing excessive1 f4 }. @0 ]8 S( _$ J4 N( `) A
adrenal androgens is a common cause of precocious- m! B* ^9 I$ ]+ S0 c; {5 }
puberty in boys.3,4
3 L9 V: g7 @$ G  _8 ?9 n+ tThe most common form of congenital adrenal$ u5 k1 c; Y& ^, Z
hyperplasia is the 21-hydroxylase enzyme deficiency.+ P+ o/ y1 u- u+ ?7 Z
The 11-β hydroxylase deficiency may also result in( t9 B, k2 N& {" R4 K6 V3 B
excessive adrenal androgen production, and rarely,
4 b- i) q- n  n0 u. O7 o5 X4 Man adrenal tumor may also cause adrenal androgen* w5 e" d6 a- U8 F% E
excess.1,3; F5 w5 z) x; C; [0 K3 f. S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. g% j* e; |9 w- C' d0 K
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. j( T% ]- S4 k6 |, d; V
A unique entity of male-limited gonadotropin-$ V! x0 h! e, j9 J
independent precocious puberty, which is also known
# ^5 I- g8 ]5 J1 \0 Q4 G1 ?: U2 ras testotoxicosis, may cause precocious puberty at a3 U% v1 `! i  s& g, j* D% g
very young age. The physical findings in these boys
9 u& _3 U' c# _with this disorder are full pubertal development,
/ u$ ^  R- m/ u& a( J% K/ u! b7 v; Lincluding bilateral testicular growth, similar to boys! ~9 |1 i, {% C, }6 n2 g
with CPP. The gonadotropin levels in this disorder
2 P9 m9 u5 N% d" C  n# E6 ~7 k+ tare suppressed to prepubertal levels and do not show
- I1 x, O& V; m0 U8 ~pubertal response of gonadotropin after gonadotropin-
1 H. B- }+ q+ ]; I% Areleasing hormone stimulation. This is a sex-linked0 F) l  x1 u; i% D, K% x* u
autosomal dominant disorder that affects only2 }0 t4 `$ h4 L8 ]1 t
males; therefore, other male members of the family
8 N: U- o$ v. n9 W% P% @! Umay have similar precocious puberty.3
% {, m+ V7 l& R& E0 ?2 bIn our patient, physical examination was incon-
* t/ d) O4 }/ x; g; Ssistent with true precocious puberty since his testi-2 Y0 ]* t( Q' F& ]0 U$ B! r
cles were prepubertal in size. However, testotoxicosis- ~, G5 T0 P1 W9 b$ p+ B- W+ {
was in the differential diagnosis because his father
3 |* j" Y' v# e; W7 Tstarted puberty somewhat early, and occasionally,1 R& G, O" Q4 ^8 m4 [4 _* ]- F: E
testicular enlargement is not that evident in the
5 \2 W/ x- p2 gbeginning of this process.1 In the absence of a neg-
8 v' O' M1 c* E4 O5 U  o2 T( ^& O; Rative initial history of androgen exposure, our- S9 J7 V  a0 n  k! M. k0 {7 y
biggest concern was virilizing adrenal hyperplasia,' M% e% f( t9 [! ^2 C
either 21-hydroxylase deficiency or 11-β hydroxylase
5 U# [% q) Q0 B! O. C7 jdeficiency. Those diagnoses were excluded by find-2 `  d: E! g$ I/ E' j) X+ c
ing the normal level of adrenal steroids.; r8 w' S8 y: e0 I  y7 n; q0 Y
The diagnosis of exogenous androgens was strongly1 |; m4 {- I4 p0 v' }1 @
suspected in a follow-up visit after 4 months because% R3 g' [0 C2 A; O6 O5 {
the physical examination revealed the complete disap-/ y6 X" o- s8 \
pearance of pubic hair, normal growth velocity, and3 m( l6 ]( [$ L. C" \, J
decreased erections. The father admitted using a testos-
4 z# k) |5 R; D, ^" C7 V) `0 D# Dterone gel, which he concealed at first visit. He was' M* q/ L9 e4 h! c% S
using it rather frequently, twice a day. The Physicians’9 \, B' _# q) e' m3 K
Desk Reference, or package insert of this product, gel or* @. E6 P1 o7 v8 c, s
cream, cautions about dermal testosterone transfer to7 p% W) P8 N9 @8 i- c
unprotected females through direct skin exposure.
; D$ z1 G* O/ @Serum testosterone level was found to be 2 times the
: s/ d# b& D+ z8 L- Pbaseline value in those females who were exposed to
& H9 l: N6 Q: i5 [' ^even 15 minutes of direct skin contact with their male+ L; V) b7 b( @
partners.6 However, when a shirt covered the applica-% ~7 j0 Z3 \1 D( }
tion site, this testosterone transfer was prevented.5 U- V" x) V+ N8 j3 T
Our patient’s testosterone level was 60 ng/mL,
: Q+ u5 ~) o; ^5 Ewhich was clearly high. Some studies suggest that! o1 O: c2 X1 L/ a
dermal conversion of testosterone to dihydrotestos-$ [5 k+ c* k) @1 T. \) X, E
terone, which is a more potent metabolite, is more( G: u5 }% c: z# f" c$ t. V
active in young children exposed to testosterone
/ G  l2 \# Y9 d; h9 U2 h* S3 ~exogenously7; however, we did not measure a dihy-
4 y2 A" X- i5 i2 y% Jdrotestosterone level in our patient. In addition to% }' m8 ~8 Y5 c( l1 E2 z* S$ F
virilization, exposure to exogenous testosterone in
; T$ |9 o4 ~$ Z5 M+ e. ?children results in an increase in growth velocity and9 u  _1 x0 M; V) }& o1 [
advanced bone age, as seen in our patient.5 P! c) ]# v- F& R+ P0 M4 [
The long-term effect of androgen exposure during; \0 Q# X/ f+ X0 l5 H
early childhood on pubertal development and final! V/ l! O$ n! J4 m& i
adult height are not fully known and always remain
5 T$ e% N3 R: {& }% Va concern. Children treated with short-term testos-
+ [& n# h% ^8 [/ h( Kterone injection or topical androgen may exhibit some. k7 S7 a/ E% g4 c5 D$ D+ M1 k
acceleration of the skeletal maturation; however, after% m+ D4 ]( J$ ~# e1 q: I6 [8 o
cessation of treatment, the rate of bone maturation
" M% l% }0 [- p( g. K  |decelerates and gradually returns to normal.8,9
, T4 c* @  Z/ q8 E4 KThere are conflicting reports and controversy+ X" z! j/ N7 y- H- G, s+ g. i7 t
over the effect of early androgen exposure on adult. V( b( l9 I  d3 {- [0 x  y% v6 s4 Z
penile length.10,11 Some reports suggest subnormal
- A) _0 _9 h9 \' R# |adult penile length, apparently because of downreg-) h% h7 g  B# S( U; [( |
ulation of androgen receptor number.10,12 However,
8 F8 U9 k: }9 T+ PSutherland et al13 did not find a correlation between% ]) Y+ r  G0 l' Y
childhood testosterone exposure and reduced adult' g" f# `, O5 Z& q3 A5 T4 U! b
penile length in clinical studies., ~& O/ _9 _. ]* b- r: L
Nonetheless, we do not believe our patient is+ d# M. `1 S7 R0 R
going to experience any of the untoward effects from
9 i$ z7 T. {$ |+ P1 {testosterone exposure as mentioned earlier because) U, `1 R5 s6 V
the exposure was not for a prolonged period of time." g7 w& ]& }7 k  }+ }% ?% X/ L( Z
Although the bone age was advanced at the time of8 Z9 j; r( D3 W  h; s; c- p7 w
diagnosis, the child had a normal growth velocity at9 ]; Y6 c' {  @+ r( S) b6 Y
the follow-up visit. It is hoped that his final adult5 e7 b. F) k+ J' J* M$ Z& G9 X
height will not be affected.9 L0 ]: R0 D9 V$ ~% _6 V# Y+ k
Although rarely reported, the widespread avail-0 |# D4 O% n; Z( t+ t% d
ability of androgen products in our society may& W* W7 g; V# w
indeed cause more virilization in male or female8 H3 ^* s1 d5 b. K
children than one would realize. Exposure to andro-' w( f5 K% t! z3 Y
gen products must be considered and specific ques-
  J! n$ j7 s% Itioning about the use of a testosterone product or
, {  h# N8 F) Hgel should be asked of the family members during% g, ~# T; c( y1 B/ p8 A
the evaluation of any children who present with vir-
8 k( z. W! |- J/ j9 m( E0 z/ Jilization or peripheral precocious puberty. The diag-
: ^- T/ ^7 v+ E* ?nosis can be established by just a few tests and by
- [% e3 n6 C* N' Fappropriate history. The inability to obtain such a
+ F8 ?" h0 r" C) ?5 [3 r: ^history, or failure to ask the specific questions, may
- E4 g0 }" G/ @) f3 L# Presult in extensive, unnecessary, and expensive
" Y: J) E+ ?' m( Tinvestigation. The primary care physician should be
- m1 x: q# j2 u/ taware of this fact, because most of these children
+ M% f: T2 [, rmay initially present in their practice. The Physicians’
  @" g0 M+ v! v8 a& h. U* mDesk Reference and package insert should also put a
& f3 ]% ?$ m/ |# E& T3 ]6 z, e$ Uwarning about the virilizing effect on a male or" O' t& L! P' E
female child who might come in contact with some-
- }& P  \% T( rone using any of these products.0 a" h5 _: ]; Z) D$ \/ ?
References5 c- M5 f+ i5 o
1. Styne DM. The testes: disorder of sexual differentiation' R( v2 b8 k0 P6 |" D
and puberty in the male. In: Sperling MA, ed. Pediatric
) F- ]  q: K# t6 ~$ y5 ]$ \/ TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% S% [! m1 V- ]
2002: 565-628.
& ?) ~: d  q! X% |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 |) V1 B7 h, t: c: i$ x* n. E
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
5 d" S5 n0 \/ rBoy Induced by Indirect Topical9 H2 P% w% P6 q6 y: {' f2 `
Exposure to Testosterone* P4 d0 k& N5 S! Z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 F, i) r- v( L) S0 ~( oand Kenneth R. Rettig, MD17 w9 A. S/ Q; s$ Y/ B5 L9 {
Clinical Pediatrics
! c  s% X$ H' b- h; `Volume 46 Number 69 }) y' W! \. t; ~& l# c
July 2007 540-5433 b$ P! Z6 I% N1 q- ^
© 2007 Sage Publications% r) P: ?, {' A" h: K6 b
10.1177/0009922806296651! [4 q6 q" o& M# c( j" r% d
http://clp.sagepub.com
; Y! l: _+ m9 @" P5 f8 O0 R( phosted at
8 Y. C* d& W0 m4 T$ B; p- X6 ^http://online.sagepub.com/ u' N4 E3 O1 y; m
Precocious puberty in boys, central or peripheral,
# f. [& H& [1 P% W7 e& Dis a significant concern for physicians. Central
7 E8 B- a9 C8 y9 e" k9 z. A5 qprecocious puberty (CPP), which is mediated
& M- s* G! x, o) _& Wthrough the hypothalamic pituitary gonadal axis, has
- W+ n) S6 V- Ma higher incidence of organic central nervous system
7 x% F; c0 S/ V6 wlesions in boys.1,2 Virilization in boys, as manifested
; g" X- P& E+ f# u, ?by enlargement of the penis, development of pubic
+ `. D  a+ t4 i/ Z/ f7 ohair, and facial acne without enlargement of testi-
1 H% [9 @  C) ~& \- s, jcles, suggests peripheral or pseudopuberty.1-3 We
# b  z7 A9 S' H# Wreport a 16-month-old boy who presented with the
: B5 x) }7 q# P3 x' Jenlargement of the phallus and pubic hair develop-
$ Q9 @/ L8 x2 {9 f* [( m: x4 Kment without testicular enlargement, which was due
4 I9 V2 ~2 x% y0 K/ n' N4 eto the unintentional exposure to androgen gel used by
) D# k# ^6 _$ D0 gthe father. The family initially concealed this infor-! \5 v  ?" D* D  Y2 M
mation, resulting in an extensive work-up for this
5 |% _' R# U% k8 G0 s1 cchild. Given the widespread and easy availability of
: w. @  T3 h( s: ?7 Ntestosterone gel and cream, we believe this is proba-8 g+ d+ O: B; y% @
bly more common than the rare case report in the
# [! S* A- N( _8 {' l: Nliterature.4
( _$ b2 k& [, E; T# N& [; nPatient Report
6 r. T  i0 W$ b* \) ?A 16-month-old white child was referred to the3 |; f7 X  a4 V
endocrine clinic by his pediatrician with the concern
1 X4 \/ ?) c  Rof early sexual development. His mother noticed
% u  U6 }6 E+ @# D6 q2 X2 nlight colored pubic hair development when he was( _) T& p# N/ ]: u
From the 1Division of Pediatric Endocrinology, 2University of" x% ^) \' X( j* V  ]8 B( l. N1 j3 t
South Alabama Medical Center, Mobile, Alabama.& p0 Q% C/ r. U+ }1 m; g
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( y( s  [2 C! u& q4 G- w% vProfessor of Pediatrics, University of South Alabama, College of( V4 X4 o( O! _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' P; F. ~# L# ]8 [8 g9 F, K
e-mail: [email protected].
5 _% A' I8 g6 `about 6 to 7 months old, which progressively became* M4 s8 x7 c* f* H: ^( r0 E( X* e
darker. She was also concerned about the enlarge-
  ]/ ?( f+ u  \ment of his penis and frequent erections. The child3 v# s8 o, ~+ o
was the product of a full-term normal delivery, with
; n" x9 B7 ~; l  X; f% ha birth weight of 7 lb 14 oz, and birth length of( [3 [# r& |3 S" f7 Z7 a: P' k. {& o
20 inches. He was breast-fed throughout the first year- p: T' ]8 D5 l0 |
of life and was still receiving breast milk along with
2 j7 S  V/ ^% n- Q+ Q1 G( t( d$ Jsolid food. He had no hospitalizations or surgery,) F( p" l# _8 U
and his psychosocial and psychomotor development$ h2 z) G$ w" O4 A6 Z/ \# D" X; r
was age appropriate.9 w/ @& v1 T4 ~6 G: u
The family history was remarkable for the father,
# V; F/ F# Y* |1 N( n9 V0 ywho was diagnosed with hypothyroidism at age 16,
( U0 y/ A% X) ~which was treated with thyroxine. The father’s$ h" p1 d! F( z, q; x' n
height was 6 feet, and he went through a somewhat
9 s2 }, g4 b" g# mearly puberty and had stopped growing by age 14.0 ~' O5 d7 N7 Y) r2 m
The father denied taking any other medication. The
, {, H; f# Z. rchild’s mother was in good health. Her menarche. ?7 N2 r3 y  I' Z5 o* t; {8 e
was at 11 years of age, and her height was at 5 feet6 E0 g( v+ L) h9 W
5 inches. There was no other family history of pre-4 n/ c! l4 d0 P4 J4 l# a
cocious sexual development in the first-degree rela-7 \" ]6 Q' c$ }7 m* t$ D# k
tives. There were no siblings.# Q1 @- X7 Z, F  ?  W. v
Physical Examination7 v9 m5 h6 P$ \2 o' v5 T
The physical examination revealed a very active,- ~* t/ M+ p, s% T6 W
playful, and healthy boy. The vital signs documented5 T( @3 D" l: v1 s
a blood pressure of 85/50 mm Hg, his length was
% [% W4 ^( x- l8 }90 cm (>97th percentile), and his weight was 14.4 kg
# V4 j+ s+ M' M% g' k9 @(also >97th percentile). The observed yearly growth- s" Z! R5 ]3 n3 q' @) V. o
velocity was 30 cm (12 inches). The examination of5 l5 g; v' i  M# h$ e
the neck revealed no thyroid enlargement.8 Z* L# [4 Z3 |5 j) j0 h
The genitourinary examination was remarkable for
( @1 `0 D4 w/ w, Z; o5 Penlargement of the penis, with a stretched length of8 ~) I3 @( f3 G5 {' g
8 cm and a width of 2 cm. The glans penis was very well
8 M# ^  l. [& i" O. tdeveloped. The pubic hair was Tanner II, mostly around
3 M( m" d- R: H# Q, N: S) C, E540
; l7 @. w0 `' I+ _6 W' a2 h2 \  Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, {  O; [% Q3 n" m. D
the base of the phallus and was dark and curled. The
8 u; ]& L/ M' {6 R4 x+ ttesticular volume was prepubertal at 2 mL each.
) a& p3 w( Z: c0 b  ZThe skin was moist and smooth and somewhat; r* @$ }  l3 l' ^
oily. No axillary hair was noted. There were no9 K+ l0 S" L4 n4 M1 X; M2 i
abnormal skin pigmentations or café-au-lait spots.6 R9 p/ |3 h7 Z4 h& M
Neurologic evaluation showed deep tendon reflex 2+
2 t% _1 {! d8 l9 W% o4 ^0 S0 pbilateral and symmetrical. There was no suggestion/ O% w1 s; _% M+ d- C; s
of papilledema.6 i! Y& D+ r& L9 r6 S
Laboratory Evaluation
: y7 z( j8 @5 q! N: \The bone age was consistent with 28 months by
- W; C6 z& _9 S. s$ H: R* j0 musing the standard of Greulich and Pyle at a chrono-
" C+ o; U% S; R. Tlogic age of 16 months (advanced).5 Chromosomal' U( Z) C7 S: l0 w3 V
karyotype was 46XY. The thyroid function test0 _* N2 l3 m7 Z5 m0 W0 S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 ?7 j1 N5 ^2 d* b+ O) M! n- U; _
lating hormone level was 1.3 µIU/mL (both normal).( w) l. m$ n3 L" F
The concentrations of serum electrolytes, blood1 x+ H9 d! A6 A( a/ }8 B) e5 v
urea nitrogen, creatinine, and calcium all were
" p1 q5 T2 p# F0 m/ V' k+ Cwithin normal range for his age. The concentration. M) A/ T  p$ X# `
of serum 17-hydroxyprogesterone was 16 ng/dL
# x9 `* N; J* ~! T+ t* i4 {(normal, 3 to 90 ng/dL), androstenedione was 20
' F' G/ R& |* F$ T6 J# ]/ }- Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% k! i2 n* Q# A, ~; f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
) E' j9 Z7 i2 X/ C  [desoxycorticosterone was 4.3 ng/dL (normal, 7 to, [# E( Q% x9 [7 f% `! B' L: B2 U  l
49ng/dL), 11-desoxycortisol (specific compound S)
$ `3 A. }/ @0 ^. fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 Z2 b& [% }+ L! \% N% |
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! g. v5 S0 N6 r; Q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 a; Y- I% v+ t1 T3 O9 c, b
and β-human chorionic gonadotropin was less than# g" ]1 O2 c" X
5 mIU/mL (normal <5 mIU/mL). Serum follicular/ e, v8 U) v1 N' T8 ]# P
stimulating hormone and leuteinizing hormone7 {3 D4 w( `1 U
concentrations were less than 0.05 mIU/mL
9 n: h) m9 b  h6 S(prepubertal).
9 W' m& ]2 Z' E, V7 d4 CThe parents were notified about the laboratory
$ x) ]1 H/ A7 Sresults and were informed that all of the tests were
$ y/ i. f# {$ a" Jnormal except the testosterone level was high. The+ w& v3 P2 N& G$ n
follow-up visit was arranged within a few weeks to
" ?9 ^6 ~" Q8 U/ O8 H( H) robtain testicular and abdominal sonograms; how-! S* {9 l' a" w( L7 v4 d
ever, the family did not return for 4 months.0 y% [5 v. P% ?8 X  v: g% P  z+ L
Physical examination at this time revealed that the9 }/ H0 p2 D6 D
child had grown 2.5 cm in 4 months and had gained4 N' j/ J: V" b
2 kg of weight. Physical examination remained
0 Z/ P4 U5 N" D8 q& o8 Munchanged. Surprisingly, the pubic hair almost com-
) J/ I# A5 I! ~; D9 t4 Epletely disappeared except for a few vellous hairs at
2 ]/ W4 P( `" S2 e) O6 L5 Othe base of the phallus. Testicular volume was still 2
4 Z8 ^& n. r8 I9 v; kmL, and the size of the penis remained unchanged.; Y- i; H" @9 v5 N
The mother also said that the boy was no longer hav-) n) V. _2 r% u9 [( T* z- `$ M
ing frequent erections.
+ a$ \$ k1 N: }( \/ L, uBoth parents were again questioned about use of5 V& J5 D, s7 d: x* c
any ointment/creams that they may have applied to; T: j, Z  o# D5 v, L
the child’s skin. This time the father admitted the( C$ t9 o6 f+ \6 R0 }& Q
Topical Testosterone Exposure / Bhowmick et al 541% y6 z+ g" R1 S' s0 w8 t% f( L8 r7 [
use of testosterone gel twice daily that he was apply-: k8 A0 {1 U8 s9 ~
ing over his own shoulders, chest, and back area for
7 _! s/ g& y/ g4 G: a9 [a year. The father also revealed he was embarrassed. |3 x+ d7 q# E+ I; F- D
to disclose that he was using a testosterone gel pre-7 l6 H, T9 {1 H3 q
scribed by his family physician for decreased libido2 k; O* w) k$ f, e( y& f- D. _
secondary to depression.* C  s; c9 u0 j+ L# @# C" @* Y3 q
The child slept in the same bed with parents.
  ~1 L: B' l+ l# X- f- m* TThe father would hug the baby and hold him on his
3 C9 `. X" f/ M: Z5 c7 Q. Y; kchest for a considerable period of time, causing sig-
) ]! a0 w9 s1 xnificant bare skin contact between baby and father.# {$ y: G/ G4 G$ p. a: \
The father also admitted that after the phone call,6 X6 ?/ Q# g6 a" k* X
when he learned the testosterone level in the baby
5 \! f' h+ ~4 x% ~7 s# mwas high, he then read the product information
5 t- x; m, z% P$ b% spacket and concluded that it was most likely the rea-
5 R9 `3 e9 q7 v/ Y1 O* o5 json for the child’s virilization. At that time, they
7 l' Q( T- K! e% Y. l% J' p% R6 wdecided to put the baby in a separate bed, and the
5 E7 n6 `: A: e/ ~) ofather was not hugging him with bare skin and had
9 h$ u7 ], \4 Wbeen using protective clothing. A repeat testosterone
! ^9 ]( l# }: Ntest was ordered, but the family did not go to the; W' j! D  s8 i: Q+ E7 {/ ]! J) x
laboratory to obtain the test.
8 J: h9 M# }( l# v) GDiscussion
; j- N! ~5 Y& l. |9 }; IPrecocious puberty in boys is defined as secondary  ?8 s0 g' P" r6 h% O
sexual development before 9 years of age.1,40 p# ]/ k0 f1 F5 {, n* K8 T
Precocious puberty is termed as central (true) when
; ?1 n! ~2 r/ n  x# \8 X  t. ^1 sit is caused by the premature activation of hypo-2 O* P) l2 }/ f! q2 T
thalamic pituitary gonadal axis. CPP is more com-
7 o2 l8 w9 q/ xmon in girls than in boys.1,3 Most boys with CPP$ }7 \5 u- P3 ^/ z
may have a central nervous system lesion that is
7 A$ }! v" ^1 v* b# iresponsible for the early activation of the hypothal-
% k8 ?5 N5 K# j# e6 ]0 e1 oamic pituitary gonadal axis.1-3 Thus, greater empha-% i& J1 ~8 v' L3 h5 J
sis has been given to neuroradiologic imaging in2 B! M1 Q5 p+ D" [, h
boys with precocious puberty. In addition to viril-- t( z& K! o+ H( L% s- U& b
ization, the clinical hallmark of CPP is the symmet-
3 a8 l% c( u, Yrical testicular growth secondary to stimulation by* Y# `. F5 }6 o* ]
gonadotropins.1,3
3 x; |( o- x  x0 w# QGonadotropin-independent peripheral preco-" t/ P, H$ m! g, W
cious puberty in boys also results from inappropriate9 O1 C1 u0 Q" [' D
androgenic stimulation from either endogenous or
! `8 x" M* H3 Q( Cexogenous sources, nonpituitary gonadotropin stim-5 r- J, X) J% E% ]$ \
ulation, and rare activating mutations.3 Virilizing
- @( C& Q1 y4 i+ B. D. fcongenital adrenal hyperplasia producing excessive
( J+ d6 s" Q9 o7 Vadrenal androgens is a common cause of precocious  F$ N, T. f& w# a/ l- k
puberty in boys.3,4
7 [9 L0 U2 a7 n4 nThe most common form of congenital adrenal( Z6 A* Y9 [( a/ r% Q( n
hyperplasia is the 21-hydroxylase enzyme deficiency.
" V! u9 d) A( m* G* N; H0 _- M  B% xThe 11-β hydroxylase deficiency may also result in
3 H. c' o8 q0 |! I$ N' bexcessive adrenal androgen production, and rarely,6 E* ?  \0 f/ i5 ?. }; p
an adrenal tumor may also cause adrenal androgen! {, P. @0 ~# m7 [5 W5 O2 H( i
excess.1,35 ]! v3 \1 o) K1 P  N! i( h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* t$ e! K4 ?9 \+ `) J9 B% t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& L- K8 O! A( ^# V
A unique entity of male-limited gonadotropin-
9 f! a9 i, [! L0 g  d9 _: X" i# J) Nindependent precocious puberty, which is also known9 |) [3 _/ w# e! g1 r5 ~3 J& w
as testotoxicosis, may cause precocious puberty at a
$ D+ M! r& C2 e8 p/ X" Avery young age. The physical findings in these boys
; E* A3 ^4 b" c4 L3 F( c( iwith this disorder are full pubertal development,4 t- N( E3 i8 x  \1 e/ G
including bilateral testicular growth, similar to boys
$ f0 Q) z! c. }; \7 {% a1 i  |with CPP. The gonadotropin levels in this disorder  ~. l" S4 q; d& A8 U% U
are suppressed to prepubertal levels and do not show
$ V# G  x, r9 r$ D8 R- i+ {pubertal response of gonadotropin after gonadotropin-, k/ [+ P7 G" g
releasing hormone stimulation. This is a sex-linked1 E2 t( ]/ T" U0 ^$ W
autosomal dominant disorder that affects only& B4 J; L, H0 m* T9 b
males; therefore, other male members of the family
6 Y8 O% F6 Z/ Z* B/ H* ^- |# smay have similar precocious puberty.3
# t; M* q' `6 l4 c+ }# mIn our patient, physical examination was incon-, z# s9 h9 l* l( }; i+ e
sistent with true precocious puberty since his testi-% K6 {. p& l' V1 J2 @/ O
cles were prepubertal in size. However, testotoxicosis
" y& H+ v: i) }was in the differential diagnosis because his father
. u5 h6 a  E/ O: }; z4 W7 J8 Rstarted puberty somewhat early, and occasionally,
* l  y" i( a* Ktesticular enlargement is not that evident in the/ N! F( r% _8 A1 I, G( C% `
beginning of this process.1 In the absence of a neg-
. q; O, A8 i9 n7 I2 }) B* Z, v$ mative initial history of androgen exposure, our
& \5 f6 E8 a. u( W  p( N1 Wbiggest concern was virilizing adrenal hyperplasia,
! p" T* Q7 m3 m  {either 21-hydroxylase deficiency or 11-β hydroxylase/ u  S  \. M% w2 \/ h5 S( i
deficiency. Those diagnoses were excluded by find-
# p( E7 M8 g3 W6 jing the normal level of adrenal steroids.. ~- ^2 M3 R1 P- f" X3 r5 P
The diagnosis of exogenous androgens was strongly* W9 F0 k9 F1 g( v
suspected in a follow-up visit after 4 months because
- k4 K) C( _0 D+ d9 Bthe physical examination revealed the complete disap-  X6 _' W/ ^& I6 G* k/ K- n
pearance of pubic hair, normal growth velocity, and
8 G7 {% U- }  C1 z% `- ?/ G& adecreased erections. The father admitted using a testos-
" e8 A* E0 s6 Z+ X5 vterone gel, which he concealed at first visit. He was
2 y" ?/ }' J8 _% musing it rather frequently, twice a day. The Physicians’
9 B& A# ?! G2 I5 t+ V2 L. N7 n; ~Desk Reference, or package insert of this product, gel or
0 c6 m% `! P, q& f9 u7 s8 gcream, cautions about dermal testosterone transfer to
/ r( l( y9 _6 _8 b0 Runprotected females through direct skin exposure.
$ g, O' O$ j; E4 F2 ]4 _+ ESerum testosterone level was found to be 2 times the2 s  ^' Q) P5 Q' j( r9 U( B
baseline value in those females who were exposed to  h- S' }" ]7 K4 j: v
even 15 minutes of direct skin contact with their male1 _& H) T5 |6 f# S" s) {! \! o
partners.6 However, when a shirt covered the applica-. l& W5 N) i. n; \# N$ a: @
tion site, this testosterone transfer was prevented.
3 ^1 F. M) k  m6 a( _. l- t7 l3 W, MOur patient’s testosterone level was 60 ng/mL,5 _$ f6 p3 F0 L; Q9 @+ [
which was clearly high. Some studies suggest that
4 G" Z2 u9 c3 J, i, {& P% Fdermal conversion of testosterone to dihydrotestos-
& y* r/ U5 ~0 Cterone, which is a more potent metabolite, is more% p( F6 d' B3 p( [( Q2 F1 i, K
active in young children exposed to testosterone
# ^7 u" a% x4 P# W$ [exogenously7; however, we did not measure a dihy-
7 j. P# X& k6 t" Rdrotestosterone level in our patient. In addition to% |  i& X# ^9 H; i+ J
virilization, exposure to exogenous testosterone in
  n1 o! ?3 W5 O% h' L3 jchildren results in an increase in growth velocity and& J$ X. a9 S) w& Y6 X$ ~: _
advanced bone age, as seen in our patient.' p. q1 `! P0 a' Z- F$ _
The long-term effect of androgen exposure during
' H( y+ Z2 f1 hearly childhood on pubertal development and final: r7 K: i$ f* p+ a
adult height are not fully known and always remain
. i) {; P2 V! U( J. t3 ga concern. Children treated with short-term testos-
- A* K- `: J# t8 y$ zterone injection or topical androgen may exhibit some
" c: q3 s6 z! w- [/ Facceleration of the skeletal maturation; however, after
+ {4 ?+ f" Y/ B4 Ycessation of treatment, the rate of bone maturation
; W) [0 a3 j0 y; H9 O6 T" vdecelerates and gradually returns to normal.8,9. q6 M% z7 W# l: k$ x
There are conflicting reports and controversy- C7 M" v9 _! m( m
over the effect of early androgen exposure on adult
, `4 Q9 m/ z  M/ U( ?# Ppenile length.10,11 Some reports suggest subnormal
0 s* d; S2 V" z9 P  Xadult penile length, apparently because of downreg-
. j. b# r6 }+ S0 _4 g0 yulation of androgen receptor number.10,12 However,! z2 e* ~1 e/ l
Sutherland et al13 did not find a correlation between
3 I/ L2 [8 R+ ~7 M1 x7 L+ ~) Cchildhood testosterone exposure and reduced adult" {# E: m7 F* |
penile length in clinical studies.) u% n' P. O) a3 p& F/ l
Nonetheless, we do not believe our patient is
: u+ k& R* K$ i2 {. ^! V7 s' m' p- Tgoing to experience any of the untoward effects from
! T- q8 V0 A  E8 s6 r' Vtestosterone exposure as mentioned earlier because- h. ]7 `8 \2 ]
the exposure was not for a prolonged period of time.) M; o) [4 A1 }6 x# b$ p% {- p- A
Although the bone age was advanced at the time of
! ~2 t/ A& v# {3 ~# Gdiagnosis, the child had a normal growth velocity at6 A+ B6 |/ X( W, b3 n( e. H- Z
the follow-up visit. It is hoped that his final adult
! T) ]( `/ _9 Q; [& v1 ^3 u7 Theight will not be affected.
: J7 k4 X2 x$ }. oAlthough rarely reported, the widespread avail-
. f4 v0 \$ m) E- Eability of androgen products in our society may- ^) d. X8 `; |* r2 {
indeed cause more virilization in male or female
4 ]# q# U' Y8 i  R) f# |+ ^) }children than one would realize. Exposure to andro-; v, P; x0 i8 s2 t5 N: G
gen products must be considered and specific ques-
' y0 f& O1 J4 O* ^* m5 v3 ationing about the use of a testosterone product or
7 A- H3 a+ g+ x$ b) Egel should be asked of the family members during
" P4 _1 W" ^/ N/ C6 L* s3 c4 Jthe evaluation of any children who present with vir-' y, d, O" e' o. Z
ilization or peripheral precocious puberty. The diag-) B- u, I, X+ v9 H
nosis can be established by just a few tests and by9 S3 u) s9 k( N1 M+ b3 r4 k5 Y
appropriate history. The inability to obtain such a
4 w; \& ^# K. U# `, z4 X7 [history, or failure to ask the specific questions, may
3 q2 F2 s+ C# H# u& wresult in extensive, unnecessary, and expensive
* V" a# A$ M4 h+ A5 t8 K5 n' ]investigation. The primary care physician should be* I" }- M9 U5 O
aware of this fact, because most of these children
! Y. f5 ]. I( r! umay initially present in their practice. The Physicians’& F+ T# b! T+ P2 ]  Y4 a
Desk Reference and package insert should also put a
. Q8 C+ M! u6 wwarning about the virilizing effect on a male or
! Q; Y2 D! u1 o; Kfemale child who might come in contact with some-
0 H/ l3 f; c# Q  y$ R, j: done using any of these products.
8 B% F- m" ^! G9 Q1 b" g# QReferences( B8 i, G2 V4 I. S
1. Styne DM. The testes: disorder of sexual differentiation
6 `9 u. l% y, j! j( a" yand puberty in the male. In: Sperling MA, ed. Pediatric
5 n+ L3 }! V" W+ e8 w' WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 p# _3 A6 d0 q1 u2002: 565-628.
  {( Y8 k7 i4 H2 m" A% ^0 T4 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; o: Y! O# e' E4 a( m: j" ?# r
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
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!
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
' Y# G' X- e" q# w
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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