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Sexual Precocity in a 16-Month-Old1 ~4 o4 D$ L# i
Boy Induced by Indirect Topical
! t( Y, U# P6 I: Q0 N! P3 fExposure to Testosterone
, j, \" P" ^- V5 e. [8 s: `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! n, |* f! ^: o' h- ]1 q8 y1 b* y, |
and Kenneth R. Rettig, MD10 E( o8 M) L3 @) p, E
Clinical Pediatrics/ q3 z3 Z% A* ^7 v: ^6 n, _9 }
Volume 46 Number 6; x/ _1 g7 o  y' f$ G7 N+ w
July 2007 540-543: L. L: k7 U* q4 {* I, B6 d
© 2007 Sage Publications+ o% d! Y) o# ~+ J
10.1177/0009922806296651& y/ U: F, F. {' w. W
http://clp.sagepub.com; m9 a. M9 {3 M
hosted at4 i& J7 [7 |% x9 O; Y! ?+ k* U
http://online.sagepub.com
& x( L3 C2 q1 b4 I) UPrecocious puberty in boys, central or peripheral,
5 s$ Q6 t  x1 e. w. U$ B1 [is a significant concern for physicians. Central+ _) C7 t  j) m1 c  S- C+ I( U9 T. D
precocious puberty (CPP), which is mediated3 j$ i' ]+ x* z: f$ u9 H
through the hypothalamic pituitary gonadal axis, has# j( S, e3 T$ `9 a! @% m0 Q
a higher incidence of organic central nervous system! t* g% q9 I8 i1 N2 [2 Y
lesions in boys.1,2 Virilization in boys, as manifested
8 U- C" q* B0 ~$ Lby enlargement of the penis, development of pubic6 ?9 l7 ^; w5 C+ ~# `5 s9 s
hair, and facial acne without enlargement of testi-3 r0 Z1 F5 `* S5 \3 I- d% J
cles, suggests peripheral or pseudopuberty.1-3 We
% z- G& E* e  c3 o7 zreport a 16-month-old boy who presented with the4 Q9 A& c! j- E! A, V8 G( o4 k$ H) i# Q
enlargement of the phallus and pubic hair develop-
; M2 y4 Q6 c# {: x6 ]/ Fment without testicular enlargement, which was due  C% v, O3 [& h& W+ i
to the unintentional exposure to androgen gel used by/ E  j# D+ g2 p" F9 v
the father. The family initially concealed this infor-) P! c( Q  F) U3 m, g
mation, resulting in an extensive work-up for this
% R8 v! U# V% g( `child. Given the widespread and easy availability of
5 o4 l. U9 u# ?+ d* Jtestosterone gel and cream, we believe this is proba-7 i! c, o) M+ r& {. S) w
bly more common than the rare case report in the
% H  G) L, @& s/ Q# U# g( ~; rliterature.43 e8 V( f6 U9 }, y0 u5 O
Patient Report
' N5 V5 m9 \& J3 `  vA 16-month-old white child was referred to the
! Q% L, V" H: I" R, `( uendocrine clinic by his pediatrician with the concern. |: v! \. |; D" N. r' Q3 v! x, |
of early sexual development. His mother noticed
+ f) u& ?5 E3 |$ llight colored pubic hair development when he was
) Y" \# k8 {2 b6 [4 l2 ^) iFrom the 1Division of Pediatric Endocrinology, 2University of
  P" u9 v5 X% R5 OSouth Alabama Medical Center, Mobile, Alabama.! ?/ m# I1 z0 F0 ?& \% S8 X
Address correspondence to: Samar K. Bhowmick, MD, FACE,; }( N) L  i- O" G
Professor of Pediatrics, University of South Alabama, College of; T9 C! c+ ^3 _  `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ b4 b4 f  o. [! L  w) y1 h0 Te-mail: [email protected].  h' M& W0 ^3 i6 G% _
about 6 to 7 months old, which progressively became
6 F6 {, r( h6 tdarker. She was also concerned about the enlarge-
5 A" A9 M2 T$ Rment of his penis and frequent erections. The child
1 d$ k1 ]& |  Q: w) \was the product of a full-term normal delivery, with) D+ o: T# |7 }( T
a birth weight of 7 lb 14 oz, and birth length of1 l9 `. `0 U# N, I
20 inches. He was breast-fed throughout the first year7 }: j. l" _" V& R8 _6 C
of life and was still receiving breast milk along with% e$ w$ P) `0 a3 a+ E: Z1 V% K; W9 {
solid food. He had no hospitalizations or surgery,3 u5 ]7 X% {& ]* E) m/ t
and his psychosocial and psychomotor development
4 |$ U9 j7 F( `2 ~5 f5 qwas age appropriate.
1 `9 T% Z! u$ }6 h+ W# O; Y6 ?The family history was remarkable for the father,5 X+ R5 e. S$ T. R+ h0 e/ X
who was diagnosed with hypothyroidism at age 16,
+ D& v/ H! C% _9 P" kwhich was treated with thyroxine. The father’s
3 q8 A1 f+ S- D  x( [* B1 o& Sheight was 6 feet, and he went through a somewhat
* m8 S6 R/ ?7 }3 f" o7 ]5 Nearly puberty and had stopped growing by age 14.
. R5 W- N/ E5 [! IThe father denied taking any other medication. The: Q4 }; O, E1 @& S# p
child’s mother was in good health. Her menarche
9 `# i" c% M4 z3 L  p0 e; kwas at 11 years of age, and her height was at 5 feet
0 I4 K, W- m5 x1 F, F2 s/ Z5 inches. There was no other family history of pre-8 E3 B# p- ]$ ]
cocious sexual development in the first-degree rela-
0 M% F! z* i* Z2 C: ~tives. There were no siblings.
: H1 K" V# n' j6 |! lPhysical Examination
& w$ B' n. t4 U$ T, [The physical examination revealed a very active,  _+ D% p8 O) ~
playful, and healthy boy. The vital signs documented
' b$ \* ]; ~2 V# ?a blood pressure of 85/50 mm Hg, his length was4 v" R- q/ P" B7 H
90 cm (>97th percentile), and his weight was 14.4 kg: i  _' k& q& A2 L1 U8 y7 w# t
(also >97th percentile). The observed yearly growth
, J, ?! W; h  h1 n7 R/ B9 D5 qvelocity was 30 cm (12 inches). The examination of
/ }: @0 Q, j( O0 V( T7 C4 R# Uthe neck revealed no thyroid enlargement.
/ M2 ]+ S( n9 Q7 qThe genitourinary examination was remarkable for+ Y# A  W2 r, {: d/ w. ^
enlargement of the penis, with a stretched length of5 B: O/ _2 u. L# g* c, q
8 cm and a width of 2 cm. The glans penis was very well
8 U% I6 G) I" T2 V% g5 Odeveloped. The pubic hair was Tanner II, mostly around/ A, h' r& M! h9 z
540
9 y+ T8 u% e/ n" B9 t1 Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 c! \. Z* p! x% f4 O) Z2 Hthe base of the phallus and was dark and curled. The, {) E' Z$ U  a* P% M' n
testicular volume was prepubertal at 2 mL each.' T2 E/ Q4 x% y; g) F
The skin was moist and smooth and somewhat1 G0 P* s* ^5 B5 ~4 \
oily. No axillary hair was noted. There were no
( `: g' N4 T6 ^1 R  o, q+ L0 Oabnormal skin pigmentations or café-au-lait spots.
$ n! ~" O( _0 I  T2 cNeurologic evaluation showed deep tendon reflex 2+* ]# m3 O; q& q" T
bilateral and symmetrical. There was no suggestion
5 b5 J# [$ V) r4 F. {of papilledema.
" C3 g* Z9 C" X6 v5 s$ r$ [+ aLaboratory Evaluation
, r, m* `1 t8 G# ?+ E+ G$ aThe bone age was consistent with 28 months by
7 f. Z2 N# i/ E; R3 ?) F5 Cusing the standard of Greulich and Pyle at a chrono-7 R8 d6 y4 l. h- |7 ]9 l4 W
logic age of 16 months (advanced).5 Chromosomal
8 \# s" D; h- f- t1 Ykaryotype was 46XY. The thyroid function test  j- ^6 a: m4 B* U! C2 a1 d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ d1 d3 i+ S+ P1 \1 b* a
lating hormone level was 1.3 µIU/mL (both normal)." L. N& p4 ?/ H8 q* |
The concentrations of serum electrolytes, blood
1 W5 F2 e. @( ourea nitrogen, creatinine, and calcium all were
' r, W4 C  X& Q1 q' j, }- @within normal range for his age. The concentration4 U+ k& y& ]6 ]# N; ^
of serum 17-hydroxyprogesterone was 16 ng/dL* q8 }$ i, |0 U0 n; \. }8 c9 ]
(normal, 3 to 90 ng/dL), androstenedione was 20
+ b  K4 }/ u6 C- F% x$ {9 bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, ]% [, s: Y* B, B5 Uterone was 38 ng/dL (normal, 50 to 760 ng/dL),/ T& w; d0 h2 j5 L6 a  j) J4 A; N4 v9 p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# L6 e" X; n) _, g: [- E% q49ng/dL), 11-desoxycortisol (specific compound S)
! B, P+ f, `$ f, m& u0 Q& Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 Y( J8 e# K7 E/ J! A. U4 d( b2 A0 G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 r& D2 t0 a9 G/ ^3 V: xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" S( H$ O# C6 H" g3 X# G# {% Y( s, Iand β-human chorionic gonadotropin was less than
, v9 B* O1 O; E5 mIU/mL (normal <5 mIU/mL). Serum follicular
) }: T- ?& K) W8 G  W/ E: I4 ]8 xstimulating hormone and leuteinizing hormone9 `2 n3 I9 a% `4 a
concentrations were less than 0.05 mIU/mL
# \+ F; v% ~4 J' O5 |0 r(prepubertal).
! {' Q: |5 B! ^3 U0 OThe parents were notified about the laboratory% m4 h' _; Y; X, x# d
results and were informed that all of the tests were
% n$ E# y# [, G5 d# X$ ?normal except the testosterone level was high. The
7 Q: V- P$ y" R  N8 y8 M; G2 Ofollow-up visit was arranged within a few weeks to; g2 D, l! Q2 z) `! K' B
obtain testicular and abdominal sonograms; how-
  l% i* U3 e6 m# L- u/ {7 U, Qever, the family did not return for 4 months.6 ?5 _8 z3 o6 E
Physical examination at this time revealed that the
: ~" H- _( E5 Y* ]* uchild had grown 2.5 cm in 4 months and had gained; b$ Q, L( U7 n& H! S* V4 T& j
2 kg of weight. Physical examination remained
; k2 K& Q; _* \$ u( Punchanged. Surprisingly, the pubic hair almost com-  d7 C$ l5 t) o& q& ?- [# s. s
pletely disappeared except for a few vellous hairs at: D$ b0 O! Y: u  x3 J2 V! C
the base of the phallus. Testicular volume was still 2! q3 J. S: ^) i; S3 w
mL, and the size of the penis remained unchanged.
$ I5 s, O6 X! q5 P( ]0 TThe mother also said that the boy was no longer hav-/ i' W5 w8 v. X5 X; X, D
ing frequent erections.
# ]2 \  I) p3 H; A2 ^+ B/ yBoth parents were again questioned about use of
7 F. X: A& G7 W( V- f$ _any ointment/creams that they may have applied to
5 D+ F$ e$ `: C& rthe child’s skin. This time the father admitted the: X# L: s8 o* i( W
Topical Testosterone Exposure / Bhowmick et al 541
/ W* y2 ], z" K0 Euse of testosterone gel twice daily that he was apply-  e1 B1 o0 g( L; S2 ^" F# U
ing over his own shoulders, chest, and back area for
) b# Z0 V! k* fa year. The father also revealed he was embarrassed' e6 J0 b, t" o) n9 Z$ L
to disclose that he was using a testosterone gel pre-
$ ?+ ?* `% ?8 m1 d- W7 Vscribed by his family physician for decreased libido
9 e! a* H% v0 l# L8 V' `+ `secondary to depression.
5 `7 m$ w% x1 j5 G1 AThe child slept in the same bed with parents.
" J8 R# V6 W2 t: p+ @: fThe father would hug the baby and hold him on his1 \! [7 q& v. p8 m
chest for a considerable period of time, causing sig-; @/ f0 y& l+ V# G+ {
nificant bare skin contact between baby and father." X9 k' P+ d, V( d* {- E2 [+ K. D/ `
The father also admitted that after the phone call,
' |0 F& ?' D* D; X- k$ dwhen he learned the testosterone level in the baby
/ c4 o2 |: ^/ o8 f6 rwas high, he then read the product information
8 ?4 P- ^- q% T) q& ypacket and concluded that it was most likely the rea-! Q( S7 M0 Z) y1 n2 ?+ L3 J
son for the child’s virilization. At that time, they
/ D- p* M  w. W+ e# I% Jdecided to put the baby in a separate bed, and the7 H$ ?& |" o3 r: ?* Z
father was not hugging him with bare skin and had7 k6 s6 T! R3 I: E
been using protective clothing. A repeat testosterone4 Z2 |" A% M9 |+ C
test was ordered, but the family did not go to the" u& }3 v) u$ F$ ]: T# Y
laboratory to obtain the test.
, w1 \. s! a+ b( N8 ~0 k0 |Discussion
8 b3 l9 f2 o" U' vPrecocious puberty in boys is defined as secondary
! a* A& q8 a; I2 F1 asexual development before 9 years of age.1,4" U; u7 k9 g7 O0 P& Q( ]
Precocious puberty is termed as central (true) when0 j/ ?' x( |, d
it is caused by the premature activation of hypo-3 j5 @) U; N* \: J; q* T+ w+ [7 m
thalamic pituitary gonadal axis. CPP is more com-: Z( L- Y  C) ]* l( B5 X
mon in girls than in boys.1,3 Most boys with CPP
: P0 f* d( E! Q6 F- rmay have a central nervous system lesion that is( ]# g, S9 x" o" ^$ X
responsible for the early activation of the hypothal-
  V& ]! c' T2 L# A: oamic pituitary gonadal axis.1-3 Thus, greater empha-6 l  m# E' w5 P4 P/ I
sis has been given to neuroradiologic imaging in$ T/ u  o* I" u/ }7 Z8 J/ U
boys with precocious puberty. In addition to viril-* {4 _+ X* w# W# I) X
ization, the clinical hallmark of CPP is the symmet-
4 u, D) `" j' {: S/ trical testicular growth secondary to stimulation by; t- K& p. }/ ?
gonadotropins.1,31 b7 o9 y2 Z, ?$ Z
Gonadotropin-independent peripheral preco-
2 d3 {5 y4 A0 q2 B& ocious puberty in boys also results from inappropriate% ^. M; N; z' z/ M# {( D
androgenic stimulation from either endogenous or
, R5 a- {( N( h( \2 Oexogenous sources, nonpituitary gonadotropin stim-" ^4 e/ }* V: W+ L
ulation, and rare activating mutations.3 Virilizing* q  R: g* C: p: U0 \
congenital adrenal hyperplasia producing excessive6 X% y, ^0 j* S( q" v  h
adrenal androgens is a common cause of precocious
8 v; I6 h! w/ ^4 [* f! d& fpuberty in boys.3,4
1 F3 K* O7 v6 Q, F7 jThe most common form of congenital adrenal* }; g/ W+ {4 @5 W" m& r) ~
hyperplasia is the 21-hydroxylase enzyme deficiency., M3 j$ q2 n# a# F+ h: C
The 11-β hydroxylase deficiency may also result in
5 K7 y# _5 }7 I5 X7 C1 y& B) Yexcessive adrenal androgen production, and rarely,
" [/ ?! p* \8 a* l1 {an adrenal tumor may also cause adrenal androgen% z' L6 H; V1 d) t, e# w' u( H
excess.1,30 g$ C9 D" O/ R  _; Y# c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 \# \" E( r& p/ G8 X* L542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ e6 Z/ V. R8 mA unique entity of male-limited gonadotropin-
6 l% }  l. z. ^+ c) eindependent precocious puberty, which is also known
; ^1 y4 g  s6 m( P( ?; gas testotoxicosis, may cause precocious puberty at a0 A/ M; P5 x$ d  Q+ [$ X  V6 C
very young age. The physical findings in these boys! V5 E: _; a  X
with this disorder are full pubertal development,
) Q  X6 V! c; `' d3 m! iincluding bilateral testicular growth, similar to boys7 K- r: S+ l9 u' N- t( V3 a  @
with CPP. The gonadotropin levels in this disorder
0 `' H$ t3 s5 l" q/ oare suppressed to prepubertal levels and do not show
7 A$ d6 g0 C1 J6 i2 X$ Epubertal response of gonadotropin after gonadotropin-
. O$ O# l# W( c( [; W  q5 }releasing hormone stimulation. This is a sex-linked
# E, }( x' W! o9 D. aautosomal dominant disorder that affects only
1 s( |( o: K5 z! ^; Ymales; therefore, other male members of the family( m" l& y6 O# b0 i$ m! S, I
may have similar precocious puberty.3- h8 ]- y) a1 O; y; h5 s0 C8 h2 n
In our patient, physical examination was incon-
$ B$ m0 A" p( f8 ]" P) Nsistent with true precocious puberty since his testi-* h4 }/ U$ a# {& S. }7 O
cles were prepubertal in size. However, testotoxicosis
8 K* Y5 M( m% c& ~$ B  Awas in the differential diagnosis because his father1 y* h2 _% P4 j. F( X. N3 }# F
started puberty somewhat early, and occasionally,0 k+ ]" m4 ]. d* h. v+ v" x
testicular enlargement is not that evident in the3 @  M7 b2 t9 ~" x4 J
beginning of this process.1 In the absence of a neg-7 `. ^  B9 @+ m& e0 i
ative initial history of androgen exposure, our. o4 ^, N! P0 i6 u0 d! I
biggest concern was virilizing adrenal hyperplasia,0 @' q- p. z% n% \) e
either 21-hydroxylase deficiency or 11-β hydroxylase; A+ ]! S  u, H* A% @
deficiency. Those diagnoses were excluded by find-. b9 i( s) N* }' E6 m9 J0 [
ing the normal level of adrenal steroids.- r  S1 D4 d+ {1 ~; O. w: @4 i' ?
The diagnosis of exogenous androgens was strongly
) e& B6 f! X- i3 |: t) Msuspected in a follow-up visit after 4 months because0 S& d* [9 Z  o0 ]8 R/ N* q
the physical examination revealed the complete disap-
1 q& g7 P  J! R/ F- \pearance of pubic hair, normal growth velocity, and8 ]+ d( @' m3 @7 Y
decreased erections. The father admitted using a testos-
' s- v0 o: E' Y& O. q6 `terone gel, which he concealed at first visit. He was* x* H$ g* f/ H9 }1 a
using it rather frequently, twice a day. The Physicians’. ?& |/ E9 k0 n% r6 F
Desk Reference, or package insert of this product, gel or
) X, F! Q9 _9 {! d  ccream, cautions about dermal testosterone transfer to: w# u- g: y* [6 ?5 x3 ~* @
unprotected females through direct skin exposure.
5 y; g, _4 T: ?) K, vSerum testosterone level was found to be 2 times the6 e4 Q/ B# Q; I
baseline value in those females who were exposed to
- Z! Q  N; [& c9 Veven 15 minutes of direct skin contact with their male2 k$ p' e- a# o0 o* y# {
partners.6 However, when a shirt covered the applica-
0 d8 ~# b7 F9 D# E3 f$ ition site, this testosterone transfer was prevented.
( i$ t" f5 O4 Z5 c- yOur patient’s testosterone level was 60 ng/mL,
6 ]$ }# w% D( L4 A' D4 Bwhich was clearly high. Some studies suggest that% B) a" a# }6 w9 }
dermal conversion of testosterone to dihydrotestos-
7 W" O1 u/ X. c- C) S( {: `9 y0 Wterone, which is a more potent metabolite, is more
+ t% h( I6 L% x) ~. _7 u* Tactive in young children exposed to testosterone% O7 T3 r6 [% n1 G
exogenously7; however, we did not measure a dihy-
6 a. r: W, S( H0 a8 E$ S" @3 l( \drotestosterone level in our patient. In addition to
6 T- o# d5 l* M* jvirilization, exposure to exogenous testosterone in
$ ]! e* s3 s* b# Pchildren results in an increase in growth velocity and
  v+ c' G/ E# Z+ [2 Radvanced bone age, as seen in our patient.
$ b- C  p- N* b) g7 x( t0 l4 m- ^8 CThe long-term effect of androgen exposure during( `0 F# y, ^/ t, T% q
early childhood on pubertal development and final
$ y4 ]: n" M1 G! j5 v, O8 Nadult height are not fully known and always remain5 s9 N& X' X! R- a5 |
a concern. Children treated with short-term testos-) C- ?# {& W0 Y" [3 a7 K1 p+ I
terone injection or topical androgen may exhibit some5 F% I. \) D4 _
acceleration of the skeletal maturation; however, after
) B# K# i2 c* v" g1 Xcessation of treatment, the rate of bone maturation7 h# `3 v' Y6 L) f: m3 j
decelerates and gradually returns to normal.8,91 o# ?7 z/ ^4 S) o% e2 ]
There are conflicting reports and controversy
. |$ ?; Q5 ?2 ]6 R! o' G: s$ |% |0 Eover the effect of early androgen exposure on adult
+ l& b3 P; M  W/ G1 Rpenile length.10,11 Some reports suggest subnormal- I6 Z# d) h( H! n$ t
adult penile length, apparently because of downreg-; W3 l3 Y: q/ T1 g4 k
ulation of androgen receptor number.10,12 However,; i; r$ E5 K- ?# [  Y; m& u7 k
Sutherland et al13 did not find a correlation between
: l" h: _  S& p0 achildhood testosterone exposure and reduced adult& G' @1 B2 N2 A0 Y. j% @2 b
penile length in clinical studies.
9 {, w. A: v# F/ cNonetheless, we do not believe our patient is
9 k5 }7 n, [# |$ u; Hgoing to experience any of the untoward effects from
, ~; l$ n0 `* k9 q+ n0 Mtestosterone exposure as mentioned earlier because( e4 D4 [. G9 D. H! E
the exposure was not for a prolonged period of time.
1 E; U0 I9 e  H# NAlthough the bone age was advanced at the time of
: c% J, e$ D2 N- x. gdiagnosis, the child had a normal growth velocity at
9 g: s% ^* e9 x' I3 o! ~2 tthe follow-up visit. It is hoped that his final adult, _$ I, w& e$ X+ _% N
height will not be affected.
$ b5 p7 w6 Z4 c( ^' q# @Although rarely reported, the widespread avail-4 x, M1 u6 Y" T! `# r  A: I
ability of androgen products in our society may
; k/ D; W0 ^6 s# [6 d# Z: zindeed cause more virilization in male or female! J) B/ a$ h1 G% t
children than one would realize. Exposure to andro-
; U' T. K6 r- H; z3 t" M+ C: Vgen products must be considered and specific ques-! q1 w5 S8 S0 c% [# d6 ~
tioning about the use of a testosterone product or
. W1 V6 Z3 o6 g9 g6 bgel should be asked of the family members during
8 R  a, M2 I# n- ~4 Ithe evaluation of any children who present with vir-
1 e  O( a; I: T8 s4 y8 iilization or peripheral precocious puberty. The diag-' f5 i& j9 }4 R; P. E8 t
nosis can be established by just a few tests and by
9 _8 ]$ y  J  j  `appropriate history. The inability to obtain such a
* V7 }' X# C( G: D/ |history, or failure to ask the specific questions, may
6 D/ w. u& T6 V3 {. ]! x& fresult in extensive, unnecessary, and expensive
1 t/ R1 C$ }, R. Q0 ~8 minvestigation. The primary care physician should be) K! o3 M4 Y2 H8 B4 }! S# t
aware of this fact, because most of these children
8 ?" i8 t: F1 S+ amay initially present in their practice. The Physicians’
9 [/ T. B7 ?4 O* \+ K5 G7 l7 tDesk Reference and package insert should also put a* ?6 \/ y) E( \2 _' Z% R- x
warning about the virilizing effect on a male or9 D3 Y* {( n6 @. @" n; f
female child who might come in contact with some-
1 H7 m: N& ?  Y: W- Y5 _, v8 kone using any of these products., l- x; E! ^1 A$ |3 k) q8 J
References% ^. H0 n1 o% p! _; y" Q8 D
1. Styne DM. The testes: disorder of sexual differentiation: o! p4 j6 J* Z6 x2 `
and puberty in the male. In: Sperling MA, ed. Pediatric5 e. B7 Z9 p' x5 y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ Q4 I/ p( a4 V$ i" H2002: 565-628.: C+ q0 d$ Y; I4 B, F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 c3 n: a) I9 C) `
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old1 h  f# e4 e3 V! E0 J/ @2 ~% |
Boy Induced by Indirect Topical
9 Y: K8 H( P6 n* ?/ U2 p) AExposure to Testosterone" H0 m1 E+ C" V' y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 Y: z3 l$ V+ R$ Z3 F
and Kenneth R. Rettig, MD1
9 C  I9 F, f. ?9 b( G/ h8 uClinical Pediatrics
$ R9 e/ b0 ^! Q/ U. @; `Volume 46 Number 6: _2 U& _  n! j' ?
July 2007 540-5434 S1 |& h3 B+ `* Z# h
© 2007 Sage Publications
. ]9 A4 O# V2 ?5 x( s. ^1 ?' B10.1177/0009922806296651
/ N8 k) z# n% @, j# zhttp://clp.sagepub.com6 `! Y; k3 X9 g. c- M
hosted at8 V+ S! W# p+ \1 p$ S% r; g
http://online.sagepub.com% q1 R$ \2 V- K$ s& R, P
Precocious puberty in boys, central or peripheral,
& e( p: J* \( mis a significant concern for physicians. Central, d( V$ s. l% z  D8 d) ]6 n/ W7 W
precocious puberty (CPP), which is mediated
) ?7 M6 b, ?1 J( B3 h7 c9 _through the hypothalamic pituitary gonadal axis, has3 C# O& `5 z+ d" [" }
a higher incidence of organic central nervous system7 P/ d  ?" J  o6 H' L- o2 f
lesions in boys.1,2 Virilization in boys, as manifested
9 I( n* H% e1 D2 sby enlargement of the penis, development of pubic
0 k; c" P" p+ B5 u' y3 V* v# e+ j/ \hair, and facial acne without enlargement of testi-) H2 H! y) d0 T6 K1 B- @
cles, suggests peripheral or pseudopuberty.1-3 We
4 R* u4 `4 g! E1 x# \% oreport a 16-month-old boy who presented with the4 i- T3 j9 K- c! B1 z& m- U
enlargement of the phallus and pubic hair develop-
% u6 Z* z% y4 D& Pment without testicular enlargement, which was due% B6 K% s% `! j! T  U% ~
to the unintentional exposure to androgen gel used by
. F; d5 L" ^: g; j7 F& r$ n( Cthe father. The family initially concealed this infor-$ Y( a% ~# T" o. U2 Y  y6 {. |2 m
mation, resulting in an extensive work-up for this
6 ?  `1 l5 Q8 z" j3 }3 G& E  pchild. Given the widespread and easy availability of2 ?/ V( }0 a% x8 n: `4 m# H3 Z
testosterone gel and cream, we believe this is proba-
4 p: Q7 w' V1 y4 C/ Y' |bly more common than the rare case report in the
- I& ?: c. F7 W! ?9 `& ~literature.4' D$ @, `' ?3 T% u8 U2 a4 s1 m* x
Patient Report) K# L3 z( w" ^4 t0 j4 Q# Y
A 16-month-old white child was referred to the
8 f8 M% u5 Y# R1 k3 cendocrine clinic by his pediatrician with the concern
+ a- M+ P3 m9 {+ uof early sexual development. His mother noticed
) X5 ^  K7 z' M! `# ]2 ulight colored pubic hair development when he was
5 E) F8 V4 a2 N. N0 j4 y: d: IFrom the 1Division of Pediatric Endocrinology, 2University of& M/ S8 r+ w4 F% F) D% i- y: s
South Alabama Medical Center, Mobile, Alabama.; y8 o5 O* o0 W9 c9 s: S% B- o( D9 g
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 D$ c1 H2 H, e- J0 s4 bProfessor of Pediatrics, University of South Alabama, College of
4 Y+ j! G, u: nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 {& H6 _4 K( Z7 B" T5 G
e-mail: [email protected].
/ `1 o4 M" D! @about 6 to 7 months old, which progressively became" g$ k# o% D! Q( Z: u
darker. She was also concerned about the enlarge-' L* y0 \: E6 L6 I1 I1 t
ment of his penis and frequent erections. The child9 {/ y. l9 D( v* I8 Y9 L' W, @
was the product of a full-term normal delivery, with& y, p9 N* V: s" Z% a
a birth weight of 7 lb 14 oz, and birth length of2 Q( X( [8 B) w" d9 \& y5 l
20 inches. He was breast-fed throughout the first year: m) M$ H, g( @
of life and was still receiving breast milk along with
3 K# V3 \$ e4 L+ }% w/ d  w6 m- Dsolid food. He had no hospitalizations or surgery,1 B, O% G; w" K
and his psychosocial and psychomotor development9 }8 L4 K+ L( M# P9 l$ U
was age appropriate.3 K( P6 C6 T, l  A0 ]" @
The family history was remarkable for the father,
5 G# m& D* H6 ^: A9 ^who was diagnosed with hypothyroidism at age 16,+ x# v3 ]. e# Z
which was treated with thyroxine. The father’s2 G4 T, O5 h% D- b; |, a
height was 6 feet, and he went through a somewhat
) `% w" K. E2 u8 r( I) Nearly puberty and had stopped growing by age 14.
/ f+ ?! D. ]2 h' L  X/ L! C9 Z) MThe father denied taking any other medication. The6 M1 p! k2 _7 V# t9 Q. C% L5 n
child’s mother was in good health. Her menarche
  b) e3 M& w5 ?: @was at 11 years of age, and her height was at 5 feet
' y, k+ A9 a4 S  C5 inches. There was no other family history of pre-; L" D) ^% [2 u$ h. Z
cocious sexual development in the first-degree rela-
2 J: d' ^0 D: Q0 q4 xtives. There were no siblings." v' Q: ^' r0 m; _
Physical Examination) w1 p+ F7 O! M% O$ z' C" q
The physical examination revealed a very active,1 j; a2 E5 Q; X* \2 t, ^! b; U
playful, and healthy boy. The vital signs documented- u/ e/ T# ~+ U' B5 B8 k0 M
a blood pressure of 85/50 mm Hg, his length was
5 J; E. j/ Y. X+ I4 p6 e. c90 cm (>97th percentile), and his weight was 14.4 kg" \$ R2 L; i1 z) J
(also >97th percentile). The observed yearly growth8 u$ Z  I$ a+ N8 A8 s& U8 u  f
velocity was 30 cm (12 inches). The examination of( _: q5 @+ J1 q/ k' s
the neck revealed no thyroid enlargement.
3 C# y/ w9 T- m6 v" X$ M- ^The genitourinary examination was remarkable for1 E) l; a, x; i, S- G# u. a
enlargement of the penis, with a stretched length of* O7 o1 {* @4 a& a0 w0 q6 S0 X
8 cm and a width of 2 cm. The glans penis was very well
1 E- X1 t( L* ~) p4 U$ P7 C; Ddeveloped. The pubic hair was Tanner II, mostly around
, _' o6 {" k% \% t1 l/ j0 k540& Q% M6 K- }5 S. M- g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ u  n9 L- x, v, V- rthe base of the phallus and was dark and curled. The" D2 Z* ~4 L/ O/ b) |3 U- }
testicular volume was prepubertal at 2 mL each.1 ?0 i6 [- ~# {- j" b( `0 t$ s
The skin was moist and smooth and somewhat
3 W1 O& N  L4 O: [* ioily. No axillary hair was noted. There were no
3 _3 J0 J3 k6 F. p; Sabnormal skin pigmentations or café-au-lait spots.: \9 L* @  B; E9 R& ~) V" h" z; j
Neurologic evaluation showed deep tendon reflex 2+2 Z. X, @% U$ g5 l; K
bilateral and symmetrical. There was no suggestion
1 y* p$ }" a1 |* K( q: s# Rof papilledema.
$ ~! `- S( x; r1 JLaboratory Evaluation
9 i6 h3 t/ C' I* T; O$ X& i6 JThe bone age was consistent with 28 months by" B+ U6 W1 d1 [* z4 V4 H( c
using the standard of Greulich and Pyle at a chrono-$ m( q: S3 c% H( X4 E% {
logic age of 16 months (advanced).5 Chromosomal; P- `1 p; I0 t4 `
karyotype was 46XY. The thyroid function test
1 v$ K4 h: E# ~# C1 N7 pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: s/ n/ y% ?2 R1 }% _* elating hormone level was 1.3 µIU/mL (both normal).
! Y0 {, w  A3 Q7 F6 Y0 PThe concentrations of serum electrolytes, blood  ~' g7 B# ?0 s( c' R0 u9 Z
urea nitrogen, creatinine, and calcium all were
% T* C6 |) {7 W% e3 h7 awithin normal range for his age. The concentration
6 c% Y$ O4 Z2 f  z! G, N2 q9 }of serum 17-hydroxyprogesterone was 16 ng/dL" t( O+ ?9 ^. p( s2 b
(normal, 3 to 90 ng/dL), androstenedione was 20
' y! b$ d0 |) ^& }& qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. `0 ^2 _; ~& S% }3 d! w; A7 I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; q; c- V: t$ d# T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 `( C6 `9 X0 n' m9 y49ng/dL), 11-desoxycortisol (specific compound S)
. C4 B, [  G. Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ g: i/ K- }( O# B, g, I% ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' @, D' p* q7 ~6 C9 |6 y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% e3 Q9 Q; V9 j8 h/ g
and β-human chorionic gonadotropin was less than
2 `% z9 u8 E7 A9 ?- |5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 U" p8 M- M8 b. A) K( V$ a* C- Estimulating hormone and leuteinizing hormone" M4 E5 y+ ~, a6 f
concentrations were less than 0.05 mIU/mL" x, j& T6 f: K- m
(prepubertal).7 ^7 P  Y6 l/ f5 b) K7 G4 _" Z
The parents were notified about the laboratory4 j) c8 W1 v; `* z6 f4 k* S
results and were informed that all of the tests were
- s5 p$ V& g0 u$ i/ m8 {normal except the testosterone level was high. The
" ~# G) [3 C" X6 |follow-up visit was arranged within a few weeks to
9 P/ }* o" r$ T/ lobtain testicular and abdominal sonograms; how-
! O" Y3 x* ~3 S( T$ Fever, the family did not return for 4 months.- u+ V! |, i: v! _) C
Physical examination at this time revealed that the9 E2 x# E# Q  y2 _; V3 l
child had grown 2.5 cm in 4 months and had gained
& a* {" o( \& n2 g: C2 kg of weight. Physical examination remained" o: l3 [+ z6 d! A
unchanged. Surprisingly, the pubic hair almost com-+ \! ^8 u# I. {1 E4 s9 O$ W4 v( G- h
pletely disappeared except for a few vellous hairs at
$ H/ F, {( t% z/ T- z8 Dthe base of the phallus. Testicular volume was still 2
* ?+ K0 Y* `4 z; z/ CmL, and the size of the penis remained unchanged., F/ l# n4 e  |4 C
The mother also said that the boy was no longer hav-+ u) Q' H& e6 N& \8 O" m+ K/ p7 _
ing frequent erections.
% h* P" i7 I, t' h8 S/ @4 kBoth parents were again questioned about use of& k' x) y- q( A1 D! i6 O, j
any ointment/creams that they may have applied to
2 r' M9 I5 P  \! P/ J' }2 g- rthe child’s skin. This time the father admitted the
8 b3 u" m+ n7 T$ xTopical Testosterone Exposure / Bhowmick et al 541' X* U1 _$ P2 Y6 @/ T% {" }& A
use of testosterone gel twice daily that he was apply-
7 T2 d- |4 f0 c3 M. f7 x( ~ing over his own shoulders, chest, and back area for
2 e, g  A* \  C8 Ca year. The father also revealed he was embarrassed: ?9 _" D3 Y* Q+ Z
to disclose that he was using a testosterone gel pre-
8 Z6 \, Q5 o" m5 wscribed by his family physician for decreased libido
# B- ?: u! N( Vsecondary to depression.8 p* F# f& V- R4 D% W
The child slept in the same bed with parents.4 q& y- N1 j$ s9 a6 b: M
The father would hug the baby and hold him on his
; }, ]: y3 E, e/ Mchest for a considerable period of time, causing sig-
  Y. m# J0 M4 e, r! ?7 Inificant bare skin contact between baby and father./ v# z- e$ H+ F$ P$ c, A4 p
The father also admitted that after the phone call,
1 l# q7 }& f; {4 ewhen he learned the testosterone level in the baby
; d7 P$ J& w3 O. Awas high, he then read the product information2 u9 |% V, C: f  t+ Q0 p! g
packet and concluded that it was most likely the rea-
0 V  k+ H1 q, F6 d% Uson for the child’s virilization. At that time, they! @1 K- T5 ~* i$ a- t# R
decided to put the baby in a separate bed, and the
' _; m3 r7 p9 L# t" H: pfather was not hugging him with bare skin and had
7 y$ E3 P) {& o6 f6 Jbeen using protective clothing. A repeat testosterone
, S3 `* d$ ^+ Ktest was ordered, but the family did not go to the
% n! Y/ p/ K5 Wlaboratory to obtain the test.& e& d% @9 o# {; |7 v9 _! S3 r
Discussion
) C: u, Y. R+ I0 c2 w: wPrecocious puberty in boys is defined as secondary
! ~( ~% n5 O+ F4 a$ n$ |sexual development before 9 years of age.1,4; |9 g% t/ M: z, E+ j2 L
Precocious puberty is termed as central (true) when/ k/ }0 H6 \" d3 I! V
it is caused by the premature activation of hypo-
3 J& \- [8 e6 ]% athalamic pituitary gonadal axis. CPP is more com-
5 {  i4 ~( l9 T( gmon in girls than in boys.1,3 Most boys with CPP$ u; R: ~; z' O" Z
may have a central nervous system lesion that is9 B# n- h% \. m# A, j. U) @: Y
responsible for the early activation of the hypothal-6 G& E* T: p- s
amic pituitary gonadal axis.1-3 Thus, greater empha-
0 t2 l+ W, m0 i$ P0 d5 @1 R) U" dsis has been given to neuroradiologic imaging in
' b7 u! y8 _/ m4 `- e8 R( ?. O! Aboys with precocious puberty. In addition to viril-
3 n! O/ O8 H) D( b( r$ r: rization, the clinical hallmark of CPP is the symmet-! f* |' Y0 i" O7 p/ a/ f
rical testicular growth secondary to stimulation by
4 H' w+ R+ ~9 L$ bgonadotropins.1,3
, y0 W/ d& C. c/ {9 GGonadotropin-independent peripheral preco-
3 D3 Z+ j6 L& ]  G# b5 Qcious puberty in boys also results from inappropriate
% V. U2 x% \) k. D4 ?- L1 fandrogenic stimulation from either endogenous or
6 `9 t8 }! \: D! w0 ]# @exogenous sources, nonpituitary gonadotropin stim-
4 z3 _# N7 B# ]: ]' G1 Aulation, and rare activating mutations.3 Virilizing) P- Q( p9 N) u; x: B
congenital adrenal hyperplasia producing excessive
% _; N7 K& M: M2 oadrenal androgens is a common cause of precocious0 B. G/ Z; X2 _0 A8 U/ T7 `/ l$ P
puberty in boys.3,42 Y1 \8 y, ^8 q' W8 L
The most common form of congenital adrenal
& @$ j# C8 H8 y9 l- nhyperplasia is the 21-hydroxylase enzyme deficiency.
' Q* ^+ S; z+ a7 i4 {6 `The 11-β hydroxylase deficiency may also result in. E/ l4 I# A8 N7 [5 k
excessive adrenal androgen production, and rarely,
1 }0 y7 o, e0 A/ xan adrenal tumor may also cause adrenal androgen+ R' Q( B1 |, X, g! v* X
excess.1,3
8 c0 d& P, G# L4 Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 O0 ]2 e: [3 M2 A$ n8 k' p# u* f0 F542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" |/ b. a9 F' q; t! m4 jA unique entity of male-limited gonadotropin-5 Q5 E- _  l( W7 O$ |+ ~0 u
independent precocious puberty, which is also known
) U1 a0 V5 `4 X  Aas testotoxicosis, may cause precocious puberty at a
% v9 E4 s- q0 d8 `) k5 r6 @& h; \very young age. The physical findings in these boys
8 N. s( n9 Z, \  {7 {with this disorder are full pubertal development,# H1 m' v. B6 P2 g0 q5 k
including bilateral testicular growth, similar to boys
: L1 N) a( _5 t& N, @with CPP. The gonadotropin levels in this disorder
. w+ ^* C+ q; ?are suppressed to prepubertal levels and do not show
8 s' N$ x  Z1 ?1 r/ k% ]  Kpubertal response of gonadotropin after gonadotropin-( A% ^  t+ C7 l: G% j2 E2 C" V. ?
releasing hormone stimulation. This is a sex-linked+ D& m# L( c, o
autosomal dominant disorder that affects only7 y" G, `# O. e  C
males; therefore, other male members of the family
4 \3 e% d' K: h3 I6 Bmay have similar precocious puberty.3
, y; E/ s8 x3 R% ^In our patient, physical examination was incon-+ ^. k/ o. h) K. L# U, X
sistent with true precocious puberty since his testi-
  _, g: [9 E9 v. I/ x( jcles were prepubertal in size. However, testotoxicosis0 ]9 v# J8 x0 F! M0 h- F6 m, f
was in the differential diagnosis because his father* _* g7 M+ `7 B7 [
started puberty somewhat early, and occasionally,9 M8 {/ W$ \! k
testicular enlargement is not that evident in the
9 W5 C7 z  K3 F; J# gbeginning of this process.1 In the absence of a neg-
' i* A( C7 s% @& |ative initial history of androgen exposure, our
# z8 D8 C' K7 Y; s. f$ N; k6 i  g* y/ ]biggest concern was virilizing adrenal hyperplasia,
( S' ]. Z2 |5 u' J. P( y: S1 e" @either 21-hydroxylase deficiency or 11-β hydroxylase
4 h" N0 @) }( u& b; [deficiency. Those diagnoses were excluded by find-, S" o- f. G; U; ?  f
ing the normal level of adrenal steroids.
' E* G' ]& F- E0 VThe diagnosis of exogenous androgens was strongly) {, {8 f6 Q$ q- t- p; R: R
suspected in a follow-up visit after 4 months because; P/ i& V# B$ n, W9 l( s2 Y# Q# d" M
the physical examination revealed the complete disap-
- x$ K( i: w5 P8 m" ?pearance of pubic hair, normal growth velocity, and: l4 L4 K$ R! d) g1 n& ]
decreased erections. The father admitted using a testos-
' k8 S9 q5 C/ |# g1 pterone gel, which he concealed at first visit. He was1 \8 c* r0 l" D1 q9 m+ [* H
using it rather frequently, twice a day. The Physicians’" h+ }5 v2 Y" Y& _9 u3 R# {/ S) p) q/ p
Desk Reference, or package insert of this product, gel or
! s) P8 T! n* m3 S( B1 Ucream, cautions about dermal testosterone transfer to* f' W. M! s1 q$ R5 a1 r& H9 N
unprotected females through direct skin exposure.
3 h- p5 B- C) U" _, CSerum testosterone level was found to be 2 times the
% I# j4 c% R$ J4 N" qbaseline value in those females who were exposed to3 U0 ^/ F1 ^% n. A
even 15 minutes of direct skin contact with their male8 @  @; d5 O1 M
partners.6 However, when a shirt covered the applica-
7 C. |. l6 [# ]  _* B* ction site, this testosterone transfer was prevented.
) h; |$ R  R- POur patient’s testosterone level was 60 ng/mL,+ l: g; w2 z1 G4 v% f+ P
which was clearly high. Some studies suggest that
# b; Q  \& F" n0 jdermal conversion of testosterone to dihydrotestos-
" a! a+ d: G8 hterone, which is a more potent metabolite, is more
. O* A" [4 T# _9 w9 A0 G2 G- |active in young children exposed to testosterone
( ]2 \: g4 F1 ~exogenously7; however, we did not measure a dihy-
" m* `. k5 P* y- x  a1 Ydrotestosterone level in our patient. In addition to
- C! b" [2 t2 K6 Y( ]  avirilization, exposure to exogenous testosterone in
1 E5 l" Q; S( qchildren results in an increase in growth velocity and
- o) x5 r7 z, `! Cadvanced bone age, as seen in our patient.8 O+ ?$ S' F2 x+ [# h; P
The long-term effect of androgen exposure during3 j) I3 K, k* ]3 V# `) D1 m3 N8 [
early childhood on pubertal development and final9 R5 R0 [/ Z' a3 e7 l5 \
adult height are not fully known and always remain
- d/ W1 I9 b( y9 `: R4 wa concern. Children treated with short-term testos-
! x/ M. `& I3 _4 V9 v. ~( B7 gterone injection or topical androgen may exhibit some
: C9 E% H6 b$ i1 f  U% Kacceleration of the skeletal maturation; however, after# T! Y9 W. ^. f- x+ S
cessation of treatment, the rate of bone maturation8 l2 p, I& d, l
decelerates and gradually returns to normal.8,9
( S+ F, L+ K8 G( p2 _& G+ {There are conflicting reports and controversy, A* R' f# \; w( y2 Q7 }# K2 Q0 c
over the effect of early androgen exposure on adult, r' x' G, [; ]7 r# y" d1 l5 _" D8 c
penile length.10,11 Some reports suggest subnormal
0 z4 M" M: b# j  Jadult penile length, apparently because of downreg-4 l. z% L$ R- R4 _+ n
ulation of androgen receptor number.10,12 However,
1 Q' v! M% ~) p! I+ d5 W- ?Sutherland et al13 did not find a correlation between
3 U. d- b; `  O$ L) Achildhood testosterone exposure and reduced adult
3 ]3 N8 V, T+ @9 h$ O- jpenile length in clinical studies.
1 o3 n8 N) ~3 d. o0 ^1 p$ }Nonetheless, we do not believe our patient is# v; M) {, m" u8 N' Z4 |" [' S9 @
going to experience any of the untoward effects from, I: i1 K- z' G( Y3 i& d) g
testosterone exposure as mentioned earlier because) U4 s: b5 \: x  E  }# H
the exposure was not for a prolonged period of time.7 s9 Q" i$ \, o  k) Y; Y
Although the bone age was advanced at the time of
7 z4 O' a% {8 ~9 Q3 A6 Bdiagnosis, the child had a normal growth velocity at
0 R- V% I: E. e! {- h( @/ ^the follow-up visit. It is hoped that his final adult2 X/ E+ ]" K* @- e5 F# t& |
height will not be affected.
! I# N7 J; M* P+ P( pAlthough rarely reported, the widespread avail-
1 P1 h. T4 ~/ q4 u9 s( e! o8 l* Oability of androgen products in our society may, ]2 ^7 a4 z4 F2 ~6 [
indeed cause more virilization in male or female
" Q: x4 _* g- |2 K( p8 `4 cchildren than one would realize. Exposure to andro-
' s: f7 Y1 c, Q7 V! d, @gen products must be considered and specific ques-( n; M; Y3 g1 S4 q7 D/ s1 \0 N5 U
tioning about the use of a testosterone product or6 x# [8 D- M6 H) H" A" @/ A
gel should be asked of the family members during9 x  q0 f6 }* l- ^3 L
the evaluation of any children who present with vir-
$ H. M% \' x/ u+ U. Q1 milization or peripheral precocious puberty. The diag-
; K/ n* K- b# L: n3 Unosis can be established by just a few tests and by  K5 d5 _7 m0 q  b# ?5 j) ?# ^
appropriate history. The inability to obtain such a% K4 d+ q2 s2 d4 [; ?' g5 H
history, or failure to ask the specific questions, may
( L2 @) o* S! W1 n. ^+ Mresult in extensive, unnecessary, and expensive
8 `9 v# y( {* q: s" T9 finvestigation. The primary care physician should be
4 f" s) y0 ?5 m7 Q5 M/ I* y6 xaware of this fact, because most of these children. X; Q' ?+ w- T) C+ T& V4 y
may initially present in their practice. The Physicians’
9 ~$ [& h$ Y& l: MDesk Reference and package insert should also put a* `" V: e7 L" \3 `
warning about the virilizing effect on a male or7 |" n( Y5 s  j" c
female child who might come in contact with some-
) W1 C6 }$ d3 V$ Lone using any of these products.
- y  D2 H1 X3 L6 K5 O( `References
) \2 X) ]* B8 A/ f# s" x! [1. Styne DM. The testes: disorder of sexual differentiation6 ]3 s5 ^! w4 L. O& e' y1 h* K
and puberty in the male. In: Sperling MA, ed. Pediatric
" J* ?5 j2 |, ]- A2 `* SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 O1 H. z+ c/ Q) f* C$ P
2002: 565-628.
" D% W1 ]4 [" Y  ?2 r0 ~8 r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 [0 d- V; a+ l0 |5 g$ H
puberty 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

5 X: S5 B' ?( s" T' Y4 v. |5 y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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