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Sexual Precocity in a 16-Month-Old2 T7 Z6 l- r1 o* P
Boy Induced by Indirect Topical
6 [: G! S; |! \$ U# y/ i: DExposure to Testosterone
. |& p( h# C( h1 _* w/ lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, }3 z1 G5 z% ?- E  Dand Kenneth R. Rettig, MD17 I% F, d7 @( j8 t0 M* ]2 ^
Clinical Pediatrics! |! Z6 o, u8 \& q$ ]1 ~
Volume 46 Number 6
! F& @$ u: }4 ?July 2007 540-543
; b; Q0 I# X' e2 Y© 2007 Sage Publications' K% g. N0 I% n8 ]
10.1177/0009922806296651) Y. q1 O3 |$ y
http://clp.sagepub.com$ \5 H7 Q1 o3 T! K2 L: J& {
hosted at+ ~8 c- S0 F. @4 k6 B9 T
http://online.sagepub.com+ h' e/ V* }$ c
Precocious puberty in boys, central or peripheral,2 j3 r; R4 e- H
is a significant concern for physicians. Central8 `) C7 @% \1 o7 t5 P+ G
precocious puberty (CPP), which is mediated' ~. z7 {2 a# ?+ x' L: E8 Y9 D
through the hypothalamic pituitary gonadal axis, has% m* A) B% H3 f
a higher incidence of organic central nervous system
3 B3 y& k" L9 T2 \" ]: olesions in boys.1,2 Virilization in boys, as manifested
; w7 {4 F$ L2 Z) cby enlargement of the penis, development of pubic8 w" K9 l) M  o- G$ e9 i
hair, and facial acne without enlargement of testi-: r$ A: i4 D) n" G
cles, suggests peripheral or pseudopuberty.1-3 We7 J4 {/ u- \2 P+ [% u/ s
report a 16-month-old boy who presented with the* l3 C) l8 k, {& z: h
enlargement of the phallus and pubic hair develop-# N+ U: Z7 |5 U3 \, ?$ i' L: N, Z
ment without testicular enlargement, which was due
' u& `& ]) w3 \- o! n; D/ nto the unintentional exposure to androgen gel used by) v% x: d( C5 `. h
the father. The family initially concealed this infor-
% j% Q0 g) x4 ?! N4 [mation, resulting in an extensive work-up for this
- p! w9 G8 N8 ^' Q/ F' v+ }child. Given the widespread and easy availability of  h' e7 L: h. V1 f+ m) w
testosterone gel and cream, we believe this is proba-
8 H) A6 }* r! Zbly more common than the rare case report in the; X9 B" x, E# d) J1 ^
literature.4
3 Q! m, ^) M6 R# U6 yPatient Report" |$ y5 P8 J( ~; |  ~
A 16-month-old white child was referred to the
7 }0 u3 h% L: X, M# j: B% G& I8 s& Kendocrine clinic by his pediatrician with the concern
7 B- P2 ]7 [+ A' d6 _of early sexual development. His mother noticed
( L7 ]+ x7 N4 q: U* N* o. @light colored pubic hair development when he was
8 E; O( X" S/ a; ^: _8 zFrom the 1Division of Pediatric Endocrinology, 2University of  ^4 q4 ~" \! k; L. W# I; Q7 E/ ~
South Alabama Medical Center, Mobile, Alabama.! K' A3 s6 ?/ e; e, i% s/ W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& h4 W! u# a5 m% ~4 mProfessor of Pediatrics, University of South Alabama, College of; O& e7 Q  z. b( R" H  a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" C! ~; Q, N: `( Z) |2 }
e-mail: [email protected].
  \  R/ v0 Q: F8 f  ?6 X9 Habout 6 to 7 months old, which progressively became
7 f8 r# b, u4 h3 cdarker. She was also concerned about the enlarge-' [. l) n* m5 P/ O8 {- C+ D$ M
ment of his penis and frequent erections. The child1 N- B, g, D2 e+ ]8 J
was the product of a full-term normal delivery, with
5 `6 t/ b1 X9 Ia birth weight of 7 lb 14 oz, and birth length of
3 u5 |$ k$ _3 Y, }; [- p20 inches. He was breast-fed throughout the first year
' h( k5 S! {& Z' w$ Y: m3 t# fof life and was still receiving breast milk along with2 ~& U$ u7 n8 l* K
solid food. He had no hospitalizations or surgery,
0 w( r2 X% }  F9 ?% \and his psychosocial and psychomotor development/ C( ^- d% F7 {
was age appropriate.
6 _5 i2 t/ W1 ?( SThe family history was remarkable for the father,
$ y+ ?6 r& t6 P: V) L2 c" b! Swho was diagnosed with hypothyroidism at age 16,
, a, U) a0 c7 Vwhich was treated with thyroxine. The father’s0 t- W' o- d9 R/ H& D
height was 6 feet, and he went through a somewhat
( z5 H- h, F" ]early puberty and had stopped growing by age 14.3 V( e' V: `( [) C6 j
The father denied taking any other medication. The
0 a  d/ b1 l7 f5 M2 Fchild’s mother was in good health. Her menarche* Y7 {( p- W' p$ Z
was at 11 years of age, and her height was at 5 feet8 ~; D+ ~1 m/ V9 _$ [
5 inches. There was no other family history of pre-/ y+ z- S) ]! A  V, c  n
cocious sexual development in the first-degree rela-
) A# V8 Q4 J  M' ?7 ?6 m% ytives. There were no siblings.
" L0 V* b3 i% N. zPhysical Examination8 n, D+ o& o/ V6 m( O
The physical examination revealed a very active,
# I# B7 ~1 o2 Z( Dplayful, and healthy boy. The vital signs documented
; f0 t2 @+ Z9 V" F2 z* u; {a blood pressure of 85/50 mm Hg, his length was
2 \$ k, A) T$ ]  G; x90 cm (>97th percentile), and his weight was 14.4 kg
8 O. Q3 W9 X  R6 `' d/ W  i' l6 |(also >97th percentile). The observed yearly growth
7 |+ S5 d) e+ }" Z% @( m3 k# G0 {velocity was 30 cm (12 inches). The examination of# W. c1 Y! k) E
the neck revealed no thyroid enlargement./ x& _8 k( n/ z, w
The genitourinary examination was remarkable for
; p! X' Y1 L: h6 k: F. lenlargement of the penis, with a stretched length of1 \3 ~* Z/ L$ j; k9 Q$ v6 C
8 cm and a width of 2 cm. The glans penis was very well0 c5 i4 ]  [$ E4 U& R* [# e0 U
developed. The pubic hair was Tanner II, mostly around" N' X$ [- X6 f0 ~
540
- U$ T3 S3 o0 U- m1 ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' F( K* {! L7 v1 cthe base of the phallus and was dark and curled. The
/ J5 A  Q6 G/ p6 ftesticular volume was prepubertal at 2 mL each./ [) L0 r9 @& u. L
The skin was moist and smooth and somewhat
- H+ G) v" s+ [; |1 M* koily. No axillary hair was noted. There were no" L/ N$ d" H8 s/ h, ~3 ~
abnormal skin pigmentations or café-au-lait spots.
& i0 p; U" U) l- Z, H: k7 V1 P+ UNeurologic evaluation showed deep tendon reflex 2+! ^% w' {2 d- F, f
bilateral and symmetrical. There was no suggestion- @, r" m/ s2 C3 [  [
of papilledema.; U2 M. o/ }" u7 |; g
Laboratory Evaluation% b+ G6 `6 f" a
The bone age was consistent with 28 months by
4 Z2 ?0 [  B. p! {using the standard of Greulich and Pyle at a chrono-
' w; {) N+ f. s1 ?1 j3 N# slogic age of 16 months (advanced).5 Chromosomal2 k6 A- H: G. c* F1 @. l- z# G
karyotype was 46XY. The thyroid function test) K8 n5 C* U+ V. `- B8 r
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" U% k+ @$ H  E& h* Y; wlating hormone level was 1.3 µIU/mL (both normal).0 d/ g; D: r$ d" g# V/ A
The concentrations of serum electrolytes, blood% X  N) o  ~- @6 `" H
urea nitrogen, creatinine, and calcium all were  O% e) {" q  g+ \7 V2 T
within normal range for his age. The concentration1 F5 }* n7 f6 Q
of serum 17-hydroxyprogesterone was 16 ng/dL
5 t+ V* I& b) q( A, [8 a$ Z(normal, 3 to 90 ng/dL), androstenedione was 20
2 x6 c- P! n1 O4 d& o6 `ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ F4 I9 q* u' p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" X" P6 w/ e& X8 I( adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
; ^. V5 m; b  a) L1 o49ng/dL), 11-desoxycortisol (specific compound S)6 C) C1 B$ y: p0 |6 o+ N$ a% b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" U4 h$ V# @8 E. P+ Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& x2 W, O* r% W  m* x! i8 B, m
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% R9 u6 f6 {/ y+ ~3 g2 eand β-human chorionic gonadotropin was less than
+ v6 D- i5 ^9 G( H5 mIU/mL (normal <5 mIU/mL). Serum follicular
% g/ [# V) d8 X2 S/ Wstimulating hormone and leuteinizing hormone
5 h5 ~8 ~" @( Z8 Q4 y# Cconcentrations were less than 0.05 mIU/mL* x& f" t( w3 G
(prepubertal).
  d" r) B* F6 f9 Q4 ^The parents were notified about the laboratory
" Y2 o& `5 S" cresults and were informed that all of the tests were# R  M2 j& h! r# _- D! d
normal except the testosterone level was high. The
5 s0 }% j) N6 Y8 v; |0 S( e  y, Hfollow-up visit was arranged within a few weeks to
, G  U( z2 O% H! q8 Eobtain testicular and abdominal sonograms; how-
0 v0 p: }3 s+ J5 `8 f+ yever, the family did not return for 4 months.) u( w  p, i! c: H" h( l
Physical examination at this time revealed that the  D% ]! e4 ?! T
child had grown 2.5 cm in 4 months and had gained
" Y9 J& D& w; F5 v2 kg of weight. Physical examination remained% T5 x8 N. v2 m# j: A( v
unchanged. Surprisingly, the pubic hair almost com-$ }1 ?; k* e2 P2 g8 k/ L$ |
pletely disappeared except for a few vellous hairs at
1 I( `/ q( ]/ }' X  ]/ K2 ?the base of the phallus. Testicular volume was still 2
8 j, }8 F# t% R) n% W4 L. fmL, and the size of the penis remained unchanged.* F0 F% ^: }& g6 B
The mother also said that the boy was no longer hav-1 Z3 y3 Q$ z, Z6 @0 _3 i1 _: ?
ing frequent erections.7 Q* U: a0 Z5 @5 x# l7 U
Both parents were again questioned about use of+ z6 M7 A3 I- f6 k
any ointment/creams that they may have applied to
1 H  D, J; Z: K% {the child’s skin. This time the father admitted the
, _, I% N' S+ m! d' c7 P3 }0 }Topical Testosterone Exposure / Bhowmick et al 541
6 n' H3 l" X6 Y- T% C; C/ v9 R. Iuse of testosterone gel twice daily that he was apply-
, Y3 g0 \, W6 j5 |4 Sing over his own shoulders, chest, and back area for  m; V( v; P; B6 \$ e; ]' r, o
a year. The father also revealed he was embarrassed
' `/ e- }0 F  U9 E( x! b, y, `to disclose that he was using a testosterone gel pre-4 O+ t. H2 W; d- \; y+ e
scribed by his family physician for decreased libido1 X* H8 }. L. ]; }4 p4 P$ Y
secondary to depression.2 O0 ~2 S# g& G7 u- F
The child slept in the same bed with parents.& b: [. C. X4 b: h
The father would hug the baby and hold him on his: |) b, V6 I$ g0 C# r& R4 x
chest for a considerable period of time, causing sig-; e. E7 v: `6 `* H; d
nificant bare skin contact between baby and father.+ W: Z6 Q7 r  R4 c2 f
The father also admitted that after the phone call,# n9 I. P8 Z9 f: Q8 s
when he learned the testosterone level in the baby
. x% n8 G* H! b8 Iwas high, he then read the product information
# J+ o8 G  U) X% g  Jpacket and concluded that it was most likely the rea-
, S2 f- ]4 c) u) S) zson for the child’s virilization. At that time, they+ W, W- O# C% m' ~/ Z  U0 I
decided to put the baby in a separate bed, and the7 }6 v" g: J# U) i
father was not hugging him with bare skin and had% h; e) S3 M* i- Y7 Y
been using protective clothing. A repeat testosterone
  W7 e2 g4 ]. E8 k) u2 Stest was ordered, but the family did not go to the. c. d% ^# Q, K9 W5 G) J* W5 j
laboratory to obtain the test.$ d& J% w2 r: g+ A1 N0 U
Discussion" r/ Z2 Y  X, ^8 _' X- N
Precocious puberty in boys is defined as secondary
  r8 b& L9 l; f6 ?+ Esexual development before 9 years of age.1,4/ x' [) N1 z2 C0 m* i$ R4 ?- L0 T' x
Precocious puberty is termed as central (true) when
5 w( i! N, L6 [8 F; r4 dit is caused by the premature activation of hypo-
2 \: I8 I  ?3 H: n! nthalamic pituitary gonadal axis. CPP is more com-; r4 T3 O- W8 b! ]$ ?  t5 W
mon in girls than in boys.1,3 Most boys with CPP
( O/ z5 Q9 P3 D% omay have a central nervous system lesion that is
0 M) i7 U$ v6 A+ X% a, p  lresponsible for the early activation of the hypothal-8 I0 M! ]5 e5 c5 c) {+ I: l
amic pituitary gonadal axis.1-3 Thus, greater empha-
) L$ M, f6 u7 o8 e$ ]0 Zsis has been given to neuroradiologic imaging in# ~/ ]! C  m' ^$ R3 E
boys with precocious puberty. In addition to viril-& b5 g0 r5 T4 P+ z
ization, the clinical hallmark of CPP is the symmet-
6 P% I! }) ^# J' ~9 u! {rical testicular growth secondary to stimulation by, l" ~3 O7 O  ]* X0 {" H
gonadotropins.1,3
- L$ Q: ?# H" a) Y8 HGonadotropin-independent peripheral preco-
9 `( X' R: X; b8 h4 T) D& z  \cious puberty in boys also results from inappropriate7 a$ s- H: ~7 w; |
androgenic stimulation from either endogenous or5 X" x2 ]( q; c- b) p. S1 j) Q9 e
exogenous sources, nonpituitary gonadotropin stim-( l5 Q* d& A- _
ulation, and rare activating mutations.3 Virilizing
( @4 s* u( e% y, B& Z2 Y7 Y0 ?9 M. ^congenital adrenal hyperplasia producing excessive: ~8 D0 v8 u6 L+ E6 n4 s
adrenal androgens is a common cause of precocious
# m, x2 ]# v3 ?puberty in boys.3,4
% k) Y% m& ^  t5 lThe most common form of congenital adrenal0 I( O4 D1 v% w" m
hyperplasia is the 21-hydroxylase enzyme deficiency.6 B' {4 i2 x) P& D% J
The 11-β hydroxylase deficiency may also result in
+ g3 D. H9 f  F' ^" Pexcessive adrenal androgen production, and rarely,% h% [/ j3 |) ?' H0 B& m
an adrenal tumor may also cause adrenal androgen" S- X6 `2 b# r3 }  h% Y; z) G+ e
excess.1,3: u+ B  q) @6 m7 I5 L8 {8 z" X/ q; U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 j- }) e$ J' n2 @
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 b: ]0 D' Y1 M5 m2 L9 r  F
A unique entity of male-limited gonadotropin-
, p. z, I0 y2 W; Uindependent precocious puberty, which is also known7 i& \: o4 M  w  r$ [( B2 \) l6 @
as testotoxicosis, may cause precocious puberty at a
& l. \  Y. N8 Overy young age. The physical findings in these boys6 [6 X8 @8 N& E/ Y
with this disorder are full pubertal development,
3 {) }5 e2 m# S, ~1 ~7 ^0 l3 nincluding bilateral testicular growth, similar to boys
( w/ y3 r8 E9 n, i4 j6 Iwith CPP. The gonadotropin levels in this disorder
( S7 d9 u/ h' V/ f) Fare suppressed to prepubertal levels and do not show
8 Q: ^5 ~; Y& B' }! \pubertal response of gonadotropin after gonadotropin-
3 Y' ?* B, z2 u! Areleasing hormone stimulation. This is a sex-linked8 O- b# d9 a+ d0 N/ R6 B& {* D
autosomal dominant disorder that affects only& j. x0 Z" G( ]: I0 J7 q" B
males; therefore, other male members of the family- b0 p8 Q2 O" G" K$ o+ ~/ D' o
may have similar precocious puberty.3
, v: y) Y9 @+ XIn our patient, physical examination was incon-
% u- X! I3 v8 [; |0 @sistent with true precocious puberty since his testi-5 J% u4 w/ I# o, Z' ?) A  l
cles were prepubertal in size. However, testotoxicosis! U& D7 L4 p5 n* u3 C1 ^
was in the differential diagnosis because his father. D4 D0 y' J# j. z' I, ?
started puberty somewhat early, and occasionally,
" L2 Y% B0 Q2 F/ @  [testicular enlargement is not that evident in the# f6 C8 h, \* p! ]; G
beginning of this process.1 In the absence of a neg-# Z* e" `: p; T0 x  C8 d( o7 \; _
ative initial history of androgen exposure, our, h/ b2 `6 b& t' j
biggest concern was virilizing adrenal hyperplasia,
. Z0 E/ T8 C: ~# P+ Jeither 21-hydroxylase deficiency or 11-β hydroxylase0 d, o6 w! v  V
deficiency. Those diagnoses were excluded by find-8 n6 q$ q' E' \2 [' e1 x
ing the normal level of adrenal steroids.
" b1 E1 S. J) l* z1 I9 ?The diagnosis of exogenous androgens was strongly
7 g& w  u/ C/ Hsuspected in a follow-up visit after 4 months because9 T% y5 Y  e/ v, j4 t7 X5 y
the physical examination revealed the complete disap-3 q9 u) j1 ]0 B0 P, ?! H
pearance of pubic hair, normal growth velocity, and5 ?. P  n2 ]0 V+ p
decreased erections. The father admitted using a testos-
1 D, ~1 t: {4 `% {- s# ?' [1 wterone gel, which he concealed at first visit. He was
$ p9 H8 E1 Y, T$ c; M. }( `using it rather frequently, twice a day. The Physicians’
! l/ y: m& S% l5 b. }. ~1 uDesk Reference, or package insert of this product, gel or" x9 U: q! i2 ]
cream, cautions about dermal testosterone transfer to
8 j" D7 w; F! _' {; |, x( \unprotected females through direct skin exposure.
" V- k/ I/ M7 a( c1 k. z; }+ |8 WSerum testosterone level was found to be 2 times the1 N3 s! g# m7 `0 r% `
baseline value in those females who were exposed to# \/ e, `* i* p3 ?% R8 g0 j9 h$ Y
even 15 minutes of direct skin contact with their male
+ j3 x0 _1 c! ]  E: [  {partners.6 However, when a shirt covered the applica-
. k/ Y* M! v. [6 F5 ytion site, this testosterone transfer was prevented.9 ~% q, ]8 e8 u- n, e8 M3 V# f
Our patient’s testosterone level was 60 ng/mL,4 z/ T2 V3 V  n$ l# f& w; i
which was clearly high. Some studies suggest that
$ {1 m2 I% z$ f0 x# d9 a, {$ Udermal conversion of testosterone to dihydrotestos-! U# q9 A) u9 u8 u9 g
terone, which is a more potent metabolite, is more
! b7 `  _9 y, e' E& n: ^4 uactive in young children exposed to testosterone& ~+ E9 y1 \( N3 O& n
exogenously7; however, we did not measure a dihy-
  r- C# n4 y/ d4 C5 V/ g' M) }drotestosterone level in our patient. In addition to) J/ p$ u' K" V) t- v) V$ g
virilization, exposure to exogenous testosterone in" J9 n% X. u& B# p( K& y" e$ ~1 h- t
children results in an increase in growth velocity and8 y  w+ B6 y: y, [9 B
advanced bone age, as seen in our patient.7 B7 c5 s  @( i" t; K# P
The long-term effect of androgen exposure during: X. d: F  ^6 H! R0 N0 Q( P) _( |
early childhood on pubertal development and final( v, _+ s' H) P( v
adult height are not fully known and always remain
( Z7 n" O6 I  x- z" Sa concern. Children treated with short-term testos-) l8 f- u9 a" T! u8 R9 G
terone injection or topical androgen may exhibit some$ m& t& M) @' y; D: i& I. d' L
acceleration of the skeletal maturation; however, after
& s& B& W- u( P8 W! v1 hcessation of treatment, the rate of bone maturation
' @2 h% x4 a" A+ n4 Kdecelerates and gradually returns to normal.8,9
8 e, p# w' A; K5 Q, I0 b5 vThere are conflicting reports and controversy
9 ~9 L# w# k. x2 {7 yover the effect of early androgen exposure on adult
* j4 A* c' w9 Tpenile length.10,11 Some reports suggest subnormal
' x7 o# d5 }! ~' T$ z9 X( e, G& Tadult penile length, apparently because of downreg-
% c8 y* @5 J: |8 k7 fulation of androgen receptor number.10,12 However,7 E6 ^0 ^7 e0 u- Z
Sutherland et al13 did not find a correlation between+ b7 ]* @8 I8 D4 j
childhood testosterone exposure and reduced adult
) w, y6 t$ E! @; l: a1 j; x& u$ Ypenile length in clinical studies.
) F, i6 [8 `! K2 K% `. O8 WNonetheless, we do not believe our patient is
  m$ `- Y$ a& a9 R3 h% O& `/ Qgoing to experience any of the untoward effects from% }% u" N4 o8 p/ I) g
testosterone exposure as mentioned earlier because9 l: Z, `0 S3 U( k9 D. g0 I: u
the exposure was not for a prolonged period of time.
' h) @% V1 o8 A( s/ x% }; @Although the bone age was advanced at the time of
. L- g9 }, t5 z% J0 x  D  Wdiagnosis, the child had a normal growth velocity at( g. d: A& r- P
the follow-up visit. It is hoped that his final adult
: }  d: @: }/ \/ t% w0 y8 Vheight will not be affected.5 E5 t6 g. p8 q' H( h
Although rarely reported, the widespread avail-
, y: [2 A2 H: Y3 Lability of androgen products in our society may& E$ B& P# U. l) M& r
indeed cause more virilization in male or female
  c; p- N0 K# h+ W* ^4 o* ~children than one would realize. Exposure to andro-! }/ L# v$ m0 ?, L8 n0 g& a
gen products must be considered and specific ques-
+ C# C+ W  S% |! d: f+ t5 y& L$ Jtioning about the use of a testosterone product or
: m) Y& @# \# x7 u; Dgel should be asked of the family members during" E% u; D' P+ o9 |) o* J5 T2 B* ?- ^
the evaluation of any children who present with vir-
$ W# L) A- ?; d5 Y, b1 eilization or peripheral precocious puberty. The diag-
6 G% \% j: ^1 W  _, Enosis can be established by just a few tests and by
7 F, Y4 O( ~$ w8 l8 P' F/ r% \appropriate history. The inability to obtain such a* b8 F5 H( Z+ k/ ^: M) {5 u& ?2 i
history, or failure to ask the specific questions, may
1 W; L3 Z  J) Z" M# K4 [result in extensive, unnecessary, and expensive
, J) [  z1 E. Z3 u6 p. U2 R; w. ginvestigation. The primary care physician should be
* l3 Q( M4 C6 N& T3 K# b' \aware of this fact, because most of these children. [5 G1 `7 V- @8 k7 w# D& A
may initially present in their practice. The Physicians’
1 n* M$ T( ~- k# u  ODesk Reference and package insert should also put a
1 i, F& P4 c: C% A+ N' n1 uwarning about the virilizing effect on a male or
% T+ f/ u* m9 A: T2 j: V/ Zfemale child who might come in contact with some-
4 L4 m8 |8 Y2 y4 y: q% D) _one using any of these products.
* n# j: a" V( A+ bReferences# P. `/ ]% ?- M* m- n5 @
1. Styne DM. The testes: disorder of sexual differentiation0 ~* q- p/ ]! \* Y) h
and puberty in the male. In: Sperling MA, ed. Pediatric) z: [& x9 t) D" T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 i# }$ b& v4 `4 z  |( z2002: 565-628.; h6 G) E' r5 o; X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( T% y/ O5 Q  u3 M5 n9 q- N# zpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 Q0 D: a1 l( HBoy Induced by Indirect Topical1 W$ k! ]4 F( P* M- R2 ?0 r- I
Exposure to Testosterone5 ~* x2 H# M  L# d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 S; J% q( |$ q8 p, p9 [and Kenneth R. Rettig, MD1
- u. B* l/ j) e" ^Clinical Pediatrics7 Q$ W' E: R' M& A' |
Volume 46 Number 6
/ ^+ w& d# P8 Z! A/ W9 T! b0 c( b0 pJuly 2007 540-543
: _6 ?* x) B& s* v$ F3 X© 2007 Sage Publications
6 H5 D- y; j" J1 k3 |6 r2 [% I10.1177/0009922806296651# g# O8 E" t3 u
http://clp.sagepub.com# t3 v# B1 B  s
hosted at
+ k! _8 Q# n& {( V1 F' bhttp://online.sagepub.com) w8 _2 [) K& {2 C" ^( q. Z
Precocious puberty in boys, central or peripheral,
" E1 `0 Y7 d. l, o9 t7 o1 g; Xis a significant concern for physicians. Central) w7 p3 a. H7 l) x1 O4 r
precocious puberty (CPP), which is mediated
; F% D& [  q% |, d2 kthrough the hypothalamic pituitary gonadal axis, has! G  v  A& N& R+ ]. \0 a; {3 @
a higher incidence of organic central nervous system/ y" R3 L3 J0 C' r* w) t
lesions in boys.1,2 Virilization in boys, as manifested
0 ]0 S2 W) b  l& Vby enlargement of the penis, development of pubic
9 P7 a/ k6 z( U) Thair, and facial acne without enlargement of testi-
+ F! W! p( \$ h' y; Ccles, suggests peripheral or pseudopuberty.1-3 We0 D- H8 ?& |1 o
report a 16-month-old boy who presented with the
) w. v8 \, H9 T  ienlargement of the phallus and pubic hair develop-
7 ^; U2 W4 C  k, `3 {5 |ment without testicular enlargement, which was due
" s0 ~5 x0 O4 f3 u2 @0 A, tto the unintentional exposure to androgen gel used by
' v* s' x* y- X9 k' u% Tthe father. The family initially concealed this infor-' m( f8 T9 Y- a1 h7 A
mation, resulting in an extensive work-up for this3 e8 N) A! b3 q  H' a
child. Given the widespread and easy availability of0 `; @7 Z' g4 E% u
testosterone gel and cream, we believe this is proba-
: E2 U' {- q) h% H$ O, pbly more common than the rare case report in the% l4 H9 v# \6 B/ I
literature.4
; E! I  f% Q7 vPatient Report
# p: }! P6 c6 [" s' W  Y' xA 16-month-old white child was referred to the
9 K$ _" _3 a# O9 i2 Y! ~endocrine clinic by his pediatrician with the concern
! A- C, l8 r! W7 X) {of early sexual development. His mother noticed
; @8 \4 P3 D: X3 E8 j4 p8 j3 y* P1 clight colored pubic hair development when he was3 W! G: J5 ], O0 Y( z2 s& @8 W- U
From the 1Division of Pediatric Endocrinology, 2University of2 {9 ]; i) M2 R3 p5 A
South Alabama Medical Center, Mobile, Alabama.
! [+ Q6 K* N* `( eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; h% G# s* q" H/ |+ uProfessor of Pediatrics, University of South Alabama, College of
( Y4 U! ~( V; y+ {2 Q9 g1 cMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: g9 I: U1 D3 `" L$ [, _6 r5 S; y
e-mail: [email protected].1 \( Q, r2 U7 X3 g% z! q; R
about 6 to 7 months old, which progressively became3 V5 m$ ]/ T0 o2 A( E1 f% T5 |
darker. She was also concerned about the enlarge-8 K& J/ ~* _! N+ u& S3 F
ment of his penis and frequent erections. The child
9 Z/ H/ u0 z8 C! n8 kwas the product of a full-term normal delivery, with# O+ K( z0 J6 p0 C6 t0 S
a birth weight of 7 lb 14 oz, and birth length of( M& }! K: m  {9 }
20 inches. He was breast-fed throughout the first year, P  h0 g4 K8 {7 p
of life and was still receiving breast milk along with
# q$ ~: z  ^  [% ^; S! h+ Dsolid food. He had no hospitalizations or surgery,* f8 I" a# X5 P) m& K; d2 E
and his psychosocial and psychomotor development' X; b8 T& j, q, N" Q/ n# w1 O+ Z
was age appropriate.
! T& i9 P  O* GThe family history was remarkable for the father,4 t' X  k# K/ ?( v
who was diagnosed with hypothyroidism at age 16,
' i/ M1 J* _6 L: j3 T) a, [' kwhich was treated with thyroxine. The father’s" r% ]8 P7 [' w
height was 6 feet, and he went through a somewhat
- C; x9 Y5 ?2 p0 f( k% ~early puberty and had stopped growing by age 14.
2 _5 e3 G  v" b6 g/ uThe father denied taking any other medication. The9 @& s& c) p7 o
child’s mother was in good health. Her menarche3 Q0 B: g) Z9 f3 \; `3 Q2 W
was at 11 years of age, and her height was at 5 feet7 v0 T( P- Q3 j! x+ E
5 inches. There was no other family history of pre-
$ ^5 U; h; U2 g, z/ a' i3 j6 Wcocious sexual development in the first-degree rela-+ |2 G2 j% V& j7 Z: T& j/ T
tives. There were no siblings.
0 i- \! e: r5 R* \% lPhysical Examination
9 c9 Q6 \7 m  G, O* C3 O# u. p) ~The physical examination revealed a very active,6 a* f. m1 {6 c/ u
playful, and healthy boy. The vital signs documented
8 i* R+ ], _( o% I" [/ K  Va blood pressure of 85/50 mm Hg, his length was
. p: @% l( h8 x% I2 ~9 R7 T90 cm (>97th percentile), and his weight was 14.4 kg+ T5 G4 R7 G  `3 S/ e* [
(also >97th percentile). The observed yearly growth
% M# g% N% x; o* k  F3 h% Qvelocity was 30 cm (12 inches). The examination of
( H- T9 E  H% k! d6 g8 N$ Uthe neck revealed no thyroid enlargement.. D/ K3 q  f0 v+ s; Z: g
The genitourinary examination was remarkable for  [6 {2 x6 U6 B- W7 O6 T
enlargement of the penis, with a stretched length of
; s: N; }4 z+ B  X% Z& T: X/ \4 ^* ^2 {8 cm and a width of 2 cm. The glans penis was very well
- a$ b: {8 ~( t8 w6 B& I+ w- Rdeveloped. The pubic hair was Tanner II, mostly around
1 V2 h3 V1 _  d6 H8 f( ?540
7 y0 f4 }8 V. t" i( M6 B2 h% kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! U, G" D5 p# G9 J% nthe base of the phallus and was dark and curled. The. D" L  L0 W" y; ^5 E, S" J0 g
testicular volume was prepubertal at 2 mL each.8 b2 f! A% S0 W( D  e  p7 d2 X& r
The skin was moist and smooth and somewhat2 W" w+ n  I+ J. e
oily. No axillary hair was noted. There were no# K4 }7 Q! k4 H) F, G( Q, z# b: g
abnormal skin pigmentations or café-au-lait spots.6 \( O2 y; ~: k: z- i8 h+ w
Neurologic evaluation showed deep tendon reflex 2+
2 E  [4 Y( {" C* O) lbilateral and symmetrical. There was no suggestion
' q) o* i/ m! D/ Z% E6 yof papilledema.
5 [  d: H% N+ x' JLaboratory Evaluation" e; \7 N# U  S  R) u
The bone age was consistent with 28 months by8 [3 v+ C7 i$ }+ a2 }
using the standard of Greulich and Pyle at a chrono-
8 \9 F( h6 P# B& q+ C3 Z& F) g. Qlogic age of 16 months (advanced).5 Chromosomal
5 |# w% t$ `' x- G2 Fkaryotype was 46XY. The thyroid function test
) u' J7 ?3 ~& ?  d* Tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-' a& V) F1 u' d. i5 D
lating hormone level was 1.3 µIU/mL (both normal).
% G, {: n2 _* }3 Y0 FThe concentrations of serum electrolytes, blood4 M3 w2 }$ I( m, C- S" o" P) S" z
urea nitrogen, creatinine, and calcium all were- J& w8 T- Z+ ?+ m
within normal range for his age. The concentration4 ?# [) ^0 c+ p: |$ K
of serum 17-hydroxyprogesterone was 16 ng/dL
0 }' g4 r% G: R9 g5 m(normal, 3 to 90 ng/dL), androstenedione was 20, g; s0 `; \/ q: Y0 ^5 o' @: ^
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  T# Z6 q/ h' e' e0 C* S) ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ C# V! w/ u! w$ X  k9 F/ pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to, Z  u$ G: P6 h* |& \6 Z
49ng/dL), 11-desoxycortisol (specific compound S)
4 x9 E4 M9 N0 _4 s0 mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 _6 V' i! w, V/ e* R, G% d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& Z* M7 q- o$ y3 o$ j/ B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) t# `- d! P1 q( ?9 D7 [
and β-human chorionic gonadotropin was less than& w- J! x' H$ ^. k* g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# A4 F; z3 \8 H& \stimulating hormone and leuteinizing hormone
( r( m  G7 ~6 b0 M, h9 M% ?/ tconcentrations were less than 0.05 mIU/mL" K# V! d1 }0 t# F! A
(prepubertal).
1 f. p5 x) z% @% h) Q4 D' yThe parents were notified about the laboratory
6 B! n/ \! O! g: M7 {$ Presults and were informed that all of the tests were
) t  h3 m$ M! |8 m" g3 N6 b/ \normal except the testosterone level was high. The
9 T) f. z! M$ ~) {+ ffollow-up visit was arranged within a few weeks to
8 d1 r/ c: P$ Z1 j/ e, `' Q- j8 \9 W1 Oobtain testicular and abdominal sonograms; how-1 v: U# ^; B2 k
ever, the family did not return for 4 months.6 [5 F( P$ @; U7 s
Physical examination at this time revealed that the& J: a8 {4 i, \: b9 p' c! U& [
child had grown 2.5 cm in 4 months and had gained
# {3 w1 O' z2 b1 R2 kg of weight. Physical examination remained* l" R$ s9 x  ^9 l- A( _! S
unchanged. Surprisingly, the pubic hair almost com-( Q" x. d. c+ z& J% N8 d( T
pletely disappeared except for a few vellous hairs at  o( f; a* J- k
the base of the phallus. Testicular volume was still 28 G. U' _2 d  J2 f1 g
mL, and the size of the penis remained unchanged.: ?0 t4 j8 d# q) Q
The mother also said that the boy was no longer hav-
$ y6 ^  A0 S# a$ U  [. Ting frequent erections.
. n3 U9 {$ b, k4 ?Both parents were again questioned about use of
1 C! _& m0 s" p; P! }: ~any ointment/creams that they may have applied to( V9 I1 _: ^. s6 p9 D7 c1 }
the child’s skin. This time the father admitted the
/ Z7 h9 N- h- z( R  [  uTopical Testosterone Exposure / Bhowmick et al 541
, G6 \  v5 h  M0 V9 g  muse of testosterone gel twice daily that he was apply-: G7 e( e* E3 S) I; G
ing over his own shoulders, chest, and back area for
5 {) J3 k# w& G1 q; q8 l/ S- La year. The father also revealed he was embarrassed
+ v" }! @5 X% y0 Q1 a+ @4 h# X6 eto disclose that he was using a testosterone gel pre-
+ u7 d# c: R  q2 wscribed by his family physician for decreased libido) ?  u1 r3 r# c0 v
secondary to depression.  h# }# ^% ?( P* q' s/ B0 }, ~" C
The child slept in the same bed with parents.4 \/ S( p2 Q. h
The father would hug the baby and hold him on his
$ r$ p; r: T* l3 p* ^. n  gchest for a considerable period of time, causing sig-
1 {% g' |8 P( T+ C  _$ a3 s4 t1 ^nificant bare skin contact between baby and father.
- n' h( B9 j6 {3 {$ gThe father also admitted that after the phone call,( d% J) a9 n9 m
when he learned the testosterone level in the baby( H6 a% p6 t( f4 X3 x  I4 A
was high, he then read the product information, w8 S/ p: e/ `/ N& I3 C- }& a5 o
packet and concluded that it was most likely the rea-+ ^. ^, z. E/ Y3 _& l$ s! k2 p
son for the child’s virilization. At that time, they
* N5 Q) D# a) g+ gdecided to put the baby in a separate bed, and the
- u$ S% X" F! y1 L+ Ffather was not hugging him with bare skin and had
8 y* }! v* b2 f$ fbeen using protective clothing. A repeat testosterone! ^8 [2 Z$ V* ^, q
test was ordered, but the family did not go to the
. m% Q$ u; G5 n/ f7 s7 R( Vlaboratory to obtain the test.9 _( q. `4 ~/ s' J# A7 m: V
Discussion& ~2 Z3 a, e# {% s& I. t! R
Precocious puberty in boys is defined as secondary$ e3 V, ?2 M: k. i6 a3 J
sexual development before 9 years of age.1,44 i' ?5 \; M+ x. X% w; L
Precocious puberty is termed as central (true) when
+ b  l; F( A! T/ Dit is caused by the premature activation of hypo-
' s6 J8 o9 |( x' K1 Kthalamic pituitary gonadal axis. CPP is more com-$ G8 p# R; B2 N! V7 w
mon in girls than in boys.1,3 Most boys with CPP
/ n+ j4 y- O5 @, r  wmay have a central nervous system lesion that is
  K8 b8 y1 i; G/ V0 o# k) L- Sresponsible for the early activation of the hypothal-9 i9 E4 R, h3 ^- y2 \8 p- c
amic pituitary gonadal axis.1-3 Thus, greater empha-$ b. k( \2 z: X8 k* ^! q" @
sis has been given to neuroradiologic imaging in6 H1 r1 ?: d* j# E/ V+ `! G! O  f
boys with precocious puberty. In addition to viril-. w" M; a7 x" M# H3 w# e6 o
ization, the clinical hallmark of CPP is the symmet-
8 T* q9 l8 u8 G( x0 r; F5 g6 xrical testicular growth secondary to stimulation by$ b& L6 V2 L$ b2 F& \; \; I& U& m) V
gonadotropins.1,35 P9 t4 Y( _  {: ~) e( I% `
Gonadotropin-independent peripheral preco-6 E: L, ]2 }0 l% @1 c$ a9 f- @
cious puberty in boys also results from inappropriate( N+ p6 o# q: S- t
androgenic stimulation from either endogenous or
8 _( N9 l! L) a# v5 h0 [( eexogenous sources, nonpituitary gonadotropin stim-
& C# N( y$ c) g% T; Lulation, and rare activating mutations.3 Virilizing
) Q) O7 Z9 r% Xcongenital adrenal hyperplasia producing excessive' f. T+ l: U# M% ~* a! b" |0 `- E9 c2 t
adrenal androgens is a common cause of precocious
. d* t: T9 s& s; f6 T  [puberty in boys.3,4
7 u# _- J& [6 W; yThe most common form of congenital adrenal
9 \9 n9 V0 Z$ k% R( ehyperplasia is the 21-hydroxylase enzyme deficiency.
% W- z% G) C' C! \The 11-β hydroxylase deficiency may also result in
5 T, O! ?" w7 A9 mexcessive adrenal androgen production, and rarely,
; }  s" @( X+ Z; ?! O( J9 Tan adrenal tumor may also cause adrenal androgen
5 R# {# ?# _" d' W2 }+ e, H) h2 xexcess.1,3
; P  c4 Z$ f9 o- B1 p3 k# h! C7 Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) W7 p2 J+ i+ M, j2 e9 k, d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- m6 H" Z% R4 j* Z' U
A unique entity of male-limited gonadotropin-
; F# d: _1 ?$ ~, k6 ]$ `# Lindependent precocious puberty, which is also known; K1 ]( s& Y& C% R3 Z
as testotoxicosis, may cause precocious puberty at a# R' ~0 g3 y0 P1 j
very young age. The physical findings in these boys3 T7 d) M3 l8 ^, S- F* E$ ^3 v
with this disorder are full pubertal development,
8 E/ D5 f+ n5 dincluding bilateral testicular growth, similar to boys
' t! n+ }5 Q5 q" t7 ~2 X4 cwith CPP. The gonadotropin levels in this disorder' h& L+ B7 A( v4 g. {
are suppressed to prepubertal levels and do not show7 I" B  }0 P9 ^& c/ K, D5 W9 J% B
pubertal response of gonadotropin after gonadotropin-
8 }7 P4 W* S! D, Qreleasing hormone stimulation. This is a sex-linked
$ L: [% |$ c6 w, M0 b3 H% y! |) hautosomal dominant disorder that affects only  |2 m: f" t  [7 l6 E# H5 H
males; therefore, other male members of the family
* Y2 e2 L& O% k" R2 imay have similar precocious puberty.3
2 I4 t6 h( ]' t& S- G* m( X( IIn our patient, physical examination was incon-6 f- O. U3 C+ c" t& o7 I5 L
sistent with true precocious puberty since his testi-+ Y  y6 l* s4 v  [# F8 q+ H6 S
cles were prepubertal in size. However, testotoxicosis
! r: t* e- @' I& c7 zwas in the differential diagnosis because his father! V& a8 Y6 y0 F7 V% O0 G
started puberty somewhat early, and occasionally,( f- {+ ?- }' z. d. l
testicular enlargement is not that evident in the! B/ o9 L( m: m) L% p4 b5 F
beginning of this process.1 In the absence of a neg-
9 x5 ~( }& h) L9 j* T: n% z9 cative initial history of androgen exposure, our/ B3 ~- K9 O0 Q; `6 j# v
biggest concern was virilizing adrenal hyperplasia,
; P1 e+ G7 F  n+ keither 21-hydroxylase deficiency or 11-β hydroxylase1 D0 H9 b' `% m2 m  t
deficiency. Those diagnoses were excluded by find-
  R' j+ W6 Y$ q/ m9 ?0 S) s* `ing the normal level of adrenal steroids.; ?5 q, |5 o  W( {5 N
The diagnosis of exogenous androgens was strongly
8 Z' Y* ^- a$ H7 Isuspected in a follow-up visit after 4 months because7 R; a/ _. r) g
the physical examination revealed the complete disap-
& ]1 [" g. Q4 e2 Jpearance of pubic hair, normal growth velocity, and
: C4 F; o! ]) w/ g% A' ~decreased erections. The father admitted using a testos-+ [; u4 ?9 T: [
terone gel, which he concealed at first visit. He was
0 Y- l; Z8 J7 O: kusing it rather frequently, twice a day. The Physicians’
! k5 m8 q3 A) L" P! h3 ADesk Reference, or package insert of this product, gel or# c# U- k* y1 N8 c% O  v- O! r
cream, cautions about dermal testosterone transfer to
+ ]& v4 }2 u) X+ ]- w* dunprotected females through direct skin exposure.! c2 ^3 C; v; ?: N
Serum testosterone level was found to be 2 times the8 v0 l) @- d  l- ^! m% P: r
baseline value in those females who were exposed to/ u# N8 J' h) e8 U. z
even 15 minutes of direct skin contact with their male- X) w4 g. A/ i" d, W# c/ B  ?
partners.6 However, when a shirt covered the applica-/ s9 }% k. ]& R, c
tion site, this testosterone transfer was prevented.5 e! x  l  D9 Z# M9 w0 N' @
Our patient’s testosterone level was 60 ng/mL,/ E3 O- m  j8 k1 x) Q3 U' c
which was clearly high. Some studies suggest that
3 E& k6 C* D5 U, q  a3 h7 `dermal conversion of testosterone to dihydrotestos-7 {3 L8 i  }0 `& T9 P4 p7 z& F
terone, which is a more potent metabolite, is more
8 q, E' Q6 G+ N8 R& e) @& D: H  [active in young children exposed to testosterone5 [* i: o6 E9 o% Y8 b, T) J/ o
exogenously7; however, we did not measure a dihy-: S% H( V9 t" ^4 Y' s7 a" o1 e6 u, `5 J5 h
drotestosterone level in our patient. In addition to
5 B% ^9 l" d  r6 y. xvirilization, exposure to exogenous testosterone in
8 s8 x- X/ \; W- r# Fchildren results in an increase in growth velocity and3 Z4 H& F0 ]4 x5 L7 l
advanced bone age, as seen in our patient.
5 h) O. i+ c3 x9 W9 c  L3 |3 NThe long-term effect of androgen exposure during# O5 Q3 c) \' _' k
early childhood on pubertal development and final; [! r* E3 w$ X+ t. y
adult height are not fully known and always remain4 I$ Y# f8 i7 l& D( \: {, N  d
a concern. Children treated with short-term testos-
+ s  t3 S1 ?  O6 i8 q8 v  Qterone injection or topical androgen may exhibit some
0 E9 u9 o; ^' \acceleration of the skeletal maturation; however, after
; Y& P) E5 @6 d% \8 b2 _cessation of treatment, the rate of bone maturation
  X# f1 B- z% t1 ]$ Y/ u8 Bdecelerates and gradually returns to normal.8,9
( z9 Y, N! `9 XThere are conflicting reports and controversy
3 e* O$ O2 d& kover the effect of early androgen exposure on adult
  w9 F  g# q2 ^+ E5 _: bpenile length.10,11 Some reports suggest subnormal
# X& A1 @+ G; H2 fadult penile length, apparently because of downreg-
4 h) p9 ?7 l/ j8 Q: vulation of androgen receptor number.10,12 However,/ s: B+ ~; r% F. E+ t# Q' z
Sutherland et al13 did not find a correlation between2 o$ d! w) ?* `7 v3 z' w$ f/ _
childhood testosterone exposure and reduced adult
) _- n" E: P3 X2 M2 D5 J. \penile length in clinical studies.
: p, w; k6 |1 ]+ q9 t" {+ WNonetheless, we do not believe our patient is$ G- |1 \/ G5 i2 `- L( m  p7 l
going to experience any of the untoward effects from
7 s6 }& d9 Y0 q+ X. g, x+ {, A5 s* r9 n& utestosterone exposure as mentioned earlier because
8 X( O* c! Y# Q. C/ p1 Lthe exposure was not for a prolonged period of time.- g. U& @, ~3 F* _- y4 n$ c8 |5 b1 O
Although the bone age was advanced at the time of
$ K! A& l. Y7 L  e8 ]1 ~diagnosis, the child had a normal growth velocity at( ^3 A; q1 Z8 T4 t/ \4 g
the follow-up visit. It is hoped that his final adult  c! S- C0 Q* n$ h+ q6 j. f' e) @
height will not be affected.
" S8 Q+ N8 J4 s8 N& uAlthough rarely reported, the widespread avail-& b' U, E3 y) K1 v
ability of androgen products in our society may  G2 Z; n4 M- L! f# k) [+ W
indeed cause more virilization in male or female+ n5 I3 N0 x. k* S
children than one would realize. Exposure to andro-
( b7 y- u; x- c. U4 y, V8 K: \gen products must be considered and specific ques-- l/ f4 S2 r, K+ l! k0 W
tioning about the use of a testosterone product or
4 E5 v+ _, C& i1 [2 ngel should be asked of the family members during
% i- A: [# C( s$ zthe evaluation of any children who present with vir-  h( M% ^& L+ w+ J2 ?
ilization or peripheral precocious puberty. The diag-
1 t4 K0 ]! U6 {/ b& onosis can be established by just a few tests and by
% W! E5 k+ U7 D* R0 ]appropriate history. The inability to obtain such a
# X$ w' V, Z, A: p* K) Ghistory, or failure to ask the specific questions, may9 N! P( o, `  K* X2 J  Q  H
result in extensive, unnecessary, and expensive  s- s% t5 q. Z1 g
investigation. The primary care physician should be& P" \" H6 i6 o9 }; }
aware of this fact, because most of these children
! b4 v, |; M( V8 Dmay initially present in their practice. The Physicians’- t1 ~+ ?. J& B: z
Desk Reference and package insert should also put a: I1 m4 b7 T6 V2 r* x7 X% i, g
warning about the virilizing effect on a male or3 [9 i6 Z! t7 e- ~* c. x
female child who might come in contact with some-
; P( A+ L; z/ d9 ?2 b4 fone using any of these products.
& D3 G3 \, i7 Y! x  p7 ]7 aReferences
% x1 p5 P$ G7 u, U- M2 d1. Styne DM. The testes: disorder of sexual differentiation
) D) K3 y- u9 y9 Q2 Jand puberty in the male. In: Sperling MA, ed. Pediatric
% i0 e% @. N! w; i/ `Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! B8 u: J4 i6 t3 {" ?, o8 ?/ }
2002: 565-628.5 s. k2 M% R1 K# ~3 u5 v" D$ C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. w# a$ ?& m; y9 P7 W; l. Gpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
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
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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

" ~0 n! C% f, s  _8 F; M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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