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Sexual Precocity in a 16-Month-Old$ m5 j( Q5 b$ n# F0 r
Boy Induced by Indirect Topical
/ n. N1 o" i2 Q3 U7 p/ n# rExposure to Testosterone+ f  g  U; P' w# P8 m
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; S1 L( Q& {& T* E& e4 A. Uand Kenneth R. Rettig, MD1" |, e# I/ N3 f0 B
Clinical Pediatrics
" a3 ?9 p/ i. w* f3 ^  H- c+ rVolume 46 Number 6) m) f. m9 K) u0 v4 S0 B8 k
July 2007 540-543
! o) z  k/ |$ ^. q© 2007 Sage Publications
( ]# P2 r5 i/ v) V10.1177/0009922806296651# u6 K7 V* \) ~# |. G
http://clp.sagepub.com$ q; ]# Y, Y  ]" w/ z
hosted at
4 C( T9 D( k. N) W2 w" P* i+ Q8 L! bhttp://online.sagepub.com
( A3 t  ]8 W' }4 R/ |Precocious puberty in boys, central or peripheral,3 n+ l8 q1 u: _* D9 {- P. n8 i
is a significant concern for physicians. Central6 s0 E4 h5 K0 u# q7 b! m
precocious puberty (CPP), which is mediated
+ R# d* w7 M9 \& `* Y& J, j6 w# Hthrough the hypothalamic pituitary gonadal axis, has  a4 w0 b  |6 S) D7 O5 Q! |
a higher incidence of organic central nervous system
7 A$ r( M; Q8 k9 F6 J4 k  W8 Xlesions in boys.1,2 Virilization in boys, as manifested
/ I+ [* Y; u: M8 W3 I4 zby enlargement of the penis, development of pubic
3 a! h" ^( k4 n. V- \2 G* k% jhair, and facial acne without enlargement of testi-: H) w  X! v( R9 Z% y* V% v
cles, suggests peripheral or pseudopuberty.1-3 We
9 v" q) m! x' s& O- N1 O- `report a 16-month-old boy who presented with the
8 C. E' [( p. _' o. n5 menlargement of the phallus and pubic hair develop-
: b' G0 S. M5 O# i. Tment without testicular enlargement, which was due: [4 j0 c7 ]. Q7 Z! u4 {9 b
to the unintentional exposure to androgen gel used by) i" m" s# d0 T9 q. W# \% A
the father. The family initially concealed this infor-
, I/ C4 W0 h' G) {mation, resulting in an extensive work-up for this
6 P2 e& ^8 q/ T& V8 [child. Given the widespread and easy availability of
$ v  `% A3 ~0 {' s1 `# e' B4 Ztestosterone gel and cream, we believe this is proba-
: t+ Z! {1 u# W9 h' w' h2 pbly more common than the rare case report in the
$ K; F  q/ H* |& A+ o! u" i4 uliterature.4; e$ h7 O+ I& O1 [$ N
Patient Report
$ v, V+ E3 \2 ^1 h) L9 SA 16-month-old white child was referred to the
1 U) N" K: u* i7 G2 iendocrine clinic by his pediatrician with the concern
& H+ Q  @# o. W( k1 `of early sexual development. His mother noticed( Z% u$ i4 I3 o, X- b& r: D. J
light colored pubic hair development when he was
9 G; j1 g' _* B5 w8 [/ tFrom the 1Division of Pediatric Endocrinology, 2University of
/ d# ]+ d* u- j3 c/ h/ m: t7 |South Alabama Medical Center, Mobile, Alabama.% l6 O5 J8 e/ O: h. f
Address correspondence to: Samar K. Bhowmick, MD, FACE,( d$ \" s) k3 E# ^. c
Professor of Pediatrics, University of South Alabama, College of
$ x! E# |, h8 `Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 u4 M, T2 K( he-mail: [email protected].( s0 Q3 v( u9 @3 b* q) v; }
about 6 to 7 months old, which progressively became$ n$ K2 v" ~5 Y$ U8 [. e
darker. She was also concerned about the enlarge-# W2 Y+ s" s, d. ]3 p
ment of his penis and frequent erections. The child9 W- |1 B- f4 I+ s. L
was the product of a full-term normal delivery, with1 W6 e* F% V9 g1 V8 \; b1 B4 \5 u+ w
a birth weight of 7 lb 14 oz, and birth length of
7 C# ?1 ^# V' m& s- l$ C% W6 T1 Z2 v4 f20 inches. He was breast-fed throughout the first year, T: ^7 `4 X9 ^7 a0 H5 k
of life and was still receiving breast milk along with
" V9 F8 W7 e1 g- ]$ _5 \8 ~: {# Hsolid food. He had no hospitalizations or surgery,! r& S3 z3 N0 y. u! f
and his psychosocial and psychomotor development
1 B* d" K$ Q1 Q& u# k' jwas age appropriate.
  h, P, w& [1 l: C5 eThe family history was remarkable for the father,& t- f2 B# \% s9 N. x
who was diagnosed with hypothyroidism at age 16,
% H4 j' }6 Q* c8 G7 E! q0 K* T3 }which was treated with thyroxine. The father’s
9 b) F- [; R+ W' m; P: Theight was 6 feet, and he went through a somewhat
- K; {+ i  a: `7 Nearly puberty and had stopped growing by age 14./ F. ~8 ?8 ^% b" ^
The father denied taking any other medication. The7 P( ~, e/ n4 `3 J' d/ O% q( i
child’s mother was in good health. Her menarche$ Y4 W, O  u" C) ^+ X6 i; j* @
was at 11 years of age, and her height was at 5 feet
! t) [- B1 d3 B/ M5 inches. There was no other family history of pre-
7 A& a9 d& O& V0 F# mcocious sexual development in the first-degree rela-
* q. J  j* F9 X& O( btives. There were no siblings.
: {# P, S* R7 V4 uPhysical Examination
8 R; @3 s" A4 n. x7 p- D; V8 ?The physical examination revealed a very active,
! o+ |  u5 h' ?8 Nplayful, and healthy boy. The vital signs documented3 A/ l" J* |9 o7 J
a blood pressure of 85/50 mm Hg, his length was' N/ h% v5 m7 z4 K# _+ l2 T
90 cm (>97th percentile), and his weight was 14.4 kg0 ?7 h8 |4 u5 d* B0 }
(also >97th percentile). The observed yearly growth0 i) G; i- \& a" T
velocity was 30 cm (12 inches). The examination of3 U, j) P/ r/ {: B9 }5 B9 a& v
the neck revealed no thyroid enlargement.
/ u% D1 U- c% _0 Y3 nThe genitourinary examination was remarkable for2 e) }; F  W+ _% U- Q
enlargement of the penis, with a stretched length of1 p' _* y7 C" Z; w: O
8 cm and a width of 2 cm. The glans penis was very well
) w; C8 j- o) z" X/ Udeveloped. The pubic hair was Tanner II, mostly around
. \+ f3 {5 i5 e2 [540
: x) ]7 j1 ]$ ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 E# P8 I6 n9 w( othe base of the phallus and was dark and curled. The
8 k7 N# e0 A* G9 Wtesticular volume was prepubertal at 2 mL each.
- P/ q( [- Y% o  M  d$ S* c: T1 qThe skin was moist and smooth and somewhat
/ N0 K& W+ T7 s+ M5 S( r3 s! e7 uoily. No axillary hair was noted. There were no
/ W* s% k4 m# \+ p* Sabnormal skin pigmentations or café-au-lait spots.
. Q8 G- _. K' o: nNeurologic evaluation showed deep tendon reflex 2+9 @) n" j  l( _& v+ e$ w1 A$ a, R
bilateral and symmetrical. There was no suggestion& C. z6 Q/ _- `
of papilledema.
7 v3 x4 M6 G# x0 {/ x: wLaboratory Evaluation7 d; C9 [8 p! V# I
The bone age was consistent with 28 months by
+ U7 C- V& D. g3 m2 Dusing the standard of Greulich and Pyle at a chrono-
3 A/ \$ V) i* ^, f' o% a( flogic age of 16 months (advanced).5 Chromosomal
% t+ O1 D; r) Ukaryotype was 46XY. The thyroid function test
4 f9 V" O  I) W- s( Q) Rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
- H. V3 L- J, W: L$ Ilating hormone level was 1.3 µIU/mL (both normal).1 @+ U4 |3 E; G
The concentrations of serum electrolytes, blood
' U  ?: ?4 _; ]8 Qurea nitrogen, creatinine, and calcium all were' {2 c) F' B. t0 s! O
within normal range for his age. The concentration
( d7 d  b! `- h! ^" y# c1 A# G& l* g6 tof serum 17-hydroxyprogesterone was 16 ng/dL
) j. C9 z9 {8 n, h6 ](normal, 3 to 90 ng/dL), androstenedione was 203 u7 M: _: A7 N5 M2 G; G& {9 u
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 b. O' d: R8 k; N# S1 K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),8 G5 t' R' E2 V9 z2 v& V8 ]& [5 P; h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 b0 p3 |9 o( U* K* g49ng/dL), 11-desoxycortisol (specific compound S)8 j2 H$ o: D5 V8 E5 d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 n0 J3 d$ V* \4 @9 ?
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) }) m( y9 o6 T) Y# U2 _* h
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ L: P5 _1 z$ \( j) B4 Xand β-human chorionic gonadotropin was less than
( \  i4 M' u1 q# n5 mIU/mL (normal <5 mIU/mL). Serum follicular" i# i8 E1 v( F# O' Q  N
stimulating hormone and leuteinizing hormone" x3 e0 m) y+ Q* D1 _
concentrations were less than 0.05 mIU/mL# n: G! _8 z5 m
(prepubertal).
, X/ s0 U* [) v) S# k) cThe parents were notified about the laboratory
2 A) O8 v% o  Nresults and were informed that all of the tests were" j+ Z6 ^( }& _$ m( s
normal except the testosterone level was high. The
$ \& f7 `- v5 ?follow-up visit was arranged within a few weeks to
! |! e1 ~" J& v5 ]5 ^obtain testicular and abdominal sonograms; how-+ L) C  P6 `4 d( t, i$ c* Z
ever, the family did not return for 4 months.( l" d0 [# ]0 K; ]' G
Physical examination at this time revealed that the6 L6 |& G- {# R1 `! P; K" W
child had grown 2.5 cm in 4 months and had gained
4 f  M" M% A  W9 A* u; h8 n$ S2 kg of weight. Physical examination remained( K! N+ n- H! ~+ `; K' a) n
unchanged. Surprisingly, the pubic hair almost com-
* V4 _; t: X3 I( L6 i' Cpletely disappeared except for a few vellous hairs at% [1 N. R# ^0 Q+ O& ^3 s, j
the base of the phallus. Testicular volume was still 21 \0 y+ H3 C, T
mL, and the size of the penis remained unchanged.
$ {, ^$ B, y* B4 SThe mother also said that the boy was no longer hav-
* `2 v( ]$ @4 {* D& @9 E5 Q, jing frequent erections.
2 M  s4 e4 Z- m; ?6 f; C: n3 GBoth parents were again questioned about use of! v" Q! H  e- N% _# w  S3 H
any ointment/creams that they may have applied to
0 k6 i0 W: O3 \/ _* V1 A' zthe child’s skin. This time the father admitted the
5 x# C' ^6 m9 {' F/ y+ |5 fTopical Testosterone Exposure / Bhowmick et al 541. K* }$ u( D+ {* r5 _$ r
use of testosterone gel twice daily that he was apply-% C2 }% A6 j" V) {% G7 d, ^
ing over his own shoulders, chest, and back area for
  x" q+ \, B- @4 qa year. The father also revealed he was embarrassed
9 Z# I+ y% r$ v) l4 j' v4 D. lto disclose that he was using a testosterone gel pre-
8 p0 M  f, c. s2 W) j: Uscribed by his family physician for decreased libido/ I/ s+ A/ l% f. c
secondary to depression.
5 M: c3 n* `! |9 {; Z( h3 [) fThe child slept in the same bed with parents.
9 r2 W. q& `! u+ S% m" h0 OThe father would hug the baby and hold him on his9 [: O( z: W2 k" L7 r; x
chest for a considerable period of time, causing sig-
  E0 q9 x  i7 M6 e: Dnificant bare skin contact between baby and father.* L: P- S  s" r% ?0 r5 G- |
The father also admitted that after the phone call,4 T% o2 G$ x8 R' k7 f4 C4 R
when he learned the testosterone level in the baby9 c5 X; [% n+ Y: _/ v3 ]0 x
was high, he then read the product information
9 S! s5 Z% Q8 _3 l- e. g! Npacket and concluded that it was most likely the rea-+ P2 K; p1 m, N6 ?  X7 m7 h& X0 D
son for the child’s virilization. At that time, they1 i9 C! p% h$ u4 D/ r
decided to put the baby in a separate bed, and the
; v# \& C/ \* B6 X' sfather was not hugging him with bare skin and had
9 ]6 F( n( D; {$ f$ {been using protective clothing. A repeat testosterone
/ j9 s6 B0 w# ptest was ordered, but the family did not go to the
7 G% ^' ?5 a: e3 A) W8 H+ n2 N7 _laboratory to obtain the test.5 B, U; O; K$ B$ }
Discussion
0 D' v- V+ I0 s' ^0 f8 {  `Precocious puberty in boys is defined as secondary6 k% i9 c6 H' W
sexual development before 9 years of age.1,47 K. b+ j4 Y8 e
Precocious puberty is termed as central (true) when3 `, z- Z$ t. |% B: _; @
it is caused by the premature activation of hypo-
+ ?+ S" L; y+ `* ithalamic pituitary gonadal axis. CPP is more com-0 N# Y7 M- }) ^
mon in girls than in boys.1,3 Most boys with CPP) U: E  @& z7 g1 K
may have a central nervous system lesion that is
, I' @/ {3 r- T- q7 Z: nresponsible for the early activation of the hypothal-
7 u& m4 v3 J+ h! A' E  ]. oamic pituitary gonadal axis.1-3 Thus, greater empha-4 F2 K, F. o9 D% c. q6 T4 k; l
sis has been given to neuroradiologic imaging in0 L4 d, u* w" _9 J
boys with precocious puberty. In addition to viril-2 Q( `( L/ ^9 }8 p! L& C6 c
ization, the clinical hallmark of CPP is the symmet-
; D) n0 c, r* B/ m) @: i# I0 H7 k" z5 c8 Crical testicular growth secondary to stimulation by) Q6 @! P$ ~4 h8 N- ~5 p1 h8 h: Y
gonadotropins.1,3
( j" z8 U# Q6 @4 ~Gonadotropin-independent peripheral preco-( q/ e0 w, [  u$ ~
cious puberty in boys also results from inappropriate5 t' w3 y( n8 e8 m; o) P( K
androgenic stimulation from either endogenous or4 f0 `1 b/ C+ h4 W: ]
exogenous sources, nonpituitary gonadotropin stim-
( ]: l$ p+ p% F  e. fulation, and rare activating mutations.3 Virilizing' i0 I/ g) `, L' P4 s
congenital adrenal hyperplasia producing excessive0 Y2 B; S) ^" \+ w
adrenal androgens is a common cause of precocious' ?* F* G7 ^7 F
puberty in boys.3,4
, l3 R- }' g, x2 nThe most common form of congenital adrenal6 s) k6 D* s: M2 T& e  X- W
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ F' L( J9 M* u: l4 {: s+ ^4 [/ G3 ZThe 11-β hydroxylase deficiency may also result in
7 q4 M' C: o; A- B3 aexcessive adrenal androgen production, and rarely,2 x; s9 H4 `/ u; v4 {, Z9 _
an adrenal tumor may also cause adrenal androgen
+ ^' e# }- R+ F' k3 ?excess.1,39 [9 B# q  S" ~: ^* i) k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( s( V* w5 l6 a6 K$ b0 s542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 n* Y* I( a/ r/ @/ j7 Y. }
A unique entity of male-limited gonadotropin-- D4 V4 z* o9 k& [
independent precocious puberty, which is also known# C- N" V" R/ b6 E+ C  E
as testotoxicosis, may cause precocious puberty at a
7 \+ h. O  _* G2 I9 q& d. J0 mvery young age. The physical findings in these boys4 N4 A7 X# n) @: S5 H7 n
with this disorder are full pubertal development,
# @. j) n8 c; Y/ A3 d" Cincluding bilateral testicular growth, similar to boys( @2 w) s" A7 h0 L9 ^  s4 Y% V
with CPP. The gonadotropin levels in this disorder
7 q- f, s& A* P# k% f0 vare suppressed to prepubertal levels and do not show
) E! \) \2 M. q& N' W% V/ M/ w  ~pubertal response of gonadotropin after gonadotropin-0 h, _7 J0 I% c3 Q7 }, Z& @
releasing hormone stimulation. This is a sex-linked2 R9 o! P% o9 U" `- z0 N' Q: E, B
autosomal dominant disorder that affects only
5 M; {" \3 f9 h9 zmales; therefore, other male members of the family, d( k3 I& s: E* n
may have similar precocious puberty.3
0 ^8 C, w; T# a- X$ u  b* oIn our patient, physical examination was incon-
4 v# K0 U2 O* @* s* f& L$ I0 isistent with true precocious puberty since his testi-
- ]1 g2 H9 |: X" ]. k5 Jcles were prepubertal in size. However, testotoxicosis3 `; b. r! T, c0 _4 T1 r% q# x
was in the differential diagnosis because his father
! }, k$ B: T# M7 qstarted puberty somewhat early, and occasionally,
  Z/ b6 l( D( `1 o1 ltesticular enlargement is not that evident in the
) E# k) U# c% V( q; u1 s" j  n+ Abeginning of this process.1 In the absence of a neg-: F0 I( g& u* t
ative initial history of androgen exposure, our
) o% j  l6 P) P; Q% z& ], _  sbiggest concern was virilizing adrenal hyperplasia,: n  n3 C% Y; z: ^8 Y2 a7 A
either 21-hydroxylase deficiency or 11-β hydroxylase$ ^7 I" t: E* w4 L- z! l2 V
deficiency. Those diagnoses were excluded by find-
, Y$ e, I% p5 ?8 w! r& Zing the normal level of adrenal steroids.
2 U1 p* n% [: c7 G" d; DThe diagnosis of exogenous androgens was strongly
. R# \+ H+ b$ Q2 y1 S1 Jsuspected in a follow-up visit after 4 months because6 P+ x4 d. G, P0 J0 _1 Q3 e) p/ f4 A
the physical examination revealed the complete disap-
( a: b: H9 k" e% ~+ I- p5 N% G7 fpearance of pubic hair, normal growth velocity, and/ R) ~- c) V0 K+ @% Z% b7 S6 E$ ?
decreased erections. The father admitted using a testos-
# O: {9 }4 L* g! M) Tterone gel, which he concealed at first visit. He was# Z7 S5 b+ c" D; c* R. m
using it rather frequently, twice a day. The Physicians’6 N! k- r3 K$ h8 F2 W
Desk Reference, or package insert of this product, gel or
6 |1 j  O6 a% @cream, cautions about dermal testosterone transfer to- B, P) B, I* W. ^
unprotected females through direct skin exposure.
' K! q3 o( F5 ^5 _Serum testosterone level was found to be 2 times the2 k  o9 x* g/ Y, f; m7 \- n; t
baseline value in those females who were exposed to
8 g, F- V' K8 G& E( xeven 15 minutes of direct skin contact with their male) a5 R( y6 V6 I" A: J2 S. F# U
partners.6 However, when a shirt covered the applica-1 D9 J% {- p  L7 j; f. v
tion site, this testosterone transfer was prevented.5 }" ~# v4 x- {$ b* R  i# J
Our patient’s testosterone level was 60 ng/mL,
: T% {( q6 x5 Mwhich was clearly high. Some studies suggest that
9 ^, i# b( s& \$ L, e( y$ cdermal conversion of testosterone to dihydrotestos-
! K- M% u" B5 C% Cterone, which is a more potent metabolite, is more4 ^  n; V$ N/ [: H0 }* c
active in young children exposed to testosterone2 H0 M6 F! s& u4 B: l8 ?# a6 l
exogenously7; however, we did not measure a dihy-
2 U. \4 w1 b* s; G8 }( {drotestosterone level in our patient. In addition to
2 Q8 F. p5 h6 L+ N& ]% Wvirilization, exposure to exogenous testosterone in
) a5 r7 U/ L' B4 ^7 |children results in an increase in growth velocity and
6 f6 p' h: _; r* ^advanced bone age, as seen in our patient.7 j+ `  n8 ^7 o: B  B
The long-term effect of androgen exposure during; P- R' U3 \/ Y" ^. l: m8 p1 J
early childhood on pubertal development and final7 L$ v: H5 D2 I" d. k
adult height are not fully known and always remain
# e* K0 {6 {6 f. A, h1 Ga concern. Children treated with short-term testos-
0 `/ f& ^1 }+ R; Sterone injection or topical androgen may exhibit some5 K. A2 x2 X# I0 k" N. a3 V
acceleration of the skeletal maturation; however, after8 v' K1 c+ X9 \9 ~
cessation of treatment, the rate of bone maturation3 t* c3 h0 d9 E+ ?
decelerates and gradually returns to normal.8,9
  u! D  U. {' i4 O/ |' W# OThere are conflicting reports and controversy
& G6 J: Y9 D, Aover the effect of early androgen exposure on adult
& ]2 y2 b- O& P( X( {penile length.10,11 Some reports suggest subnormal
) p2 d( n2 o/ H1 ^, t* }( iadult penile length, apparently because of downreg-! y* M$ i, ^) F  y$ Z
ulation of androgen receptor number.10,12 However,
7 ?6 d% k, }' k6 ?+ t9 eSutherland et al13 did not find a correlation between# q9 c" m  e6 L$ a0 p4 a
childhood testosterone exposure and reduced adult! u* q( ~- t9 s* W3 I% C" B8 `0 u. b
penile length in clinical studies.9 i! O' @+ s5 q1 g! X
Nonetheless, we do not believe our patient is3 y' C1 G: y" j1 i
going to experience any of the untoward effects from
8 W& X! C; D, u0 L! ytestosterone exposure as mentioned earlier because- w. k' Q) M9 U6 W. V! i
the exposure was not for a prolonged period of time.
- p/ \' z+ o6 D/ O/ MAlthough the bone age was advanced at the time of/ J2 l# v. Z& q2 N- o5 E! I$ N" y" `
diagnosis, the child had a normal growth velocity at! t" A* d5 s$ p  w: T' \3 L* }' B
the follow-up visit. It is hoped that his final adult
( _( ?* u5 {+ l/ _4 xheight will not be affected.2 W0 \7 L1 j* G  H! o
Although rarely reported, the widespread avail-3 S% W- l0 L- U, `7 C
ability of androgen products in our society may& G8 H+ `% d9 M- a' K; x
indeed cause more virilization in male or female
/ J5 @' v3 m  t- W/ Wchildren than one would realize. Exposure to andro-
- G: N. d& L. o4 `+ agen products must be considered and specific ques-, s  Z6 ^0 X, u4 g' T% i
tioning about the use of a testosterone product or
2 C+ r8 m* `1 h2 c) D  Ngel should be asked of the family members during8 K& l- Z; L/ j' H( A- ?: ^; U
the evaluation of any children who present with vir-
& L  r) ?: L6 T# o# filization or peripheral precocious puberty. The diag-+ p" j* |4 k0 k% J# ^' l0 m
nosis can be established by just a few tests and by  @8 T" m6 C2 {' O6 h% L7 u' m
appropriate history. The inability to obtain such a2 t  T, X7 t4 e: d- K
history, or failure to ask the specific questions, may
8 q" Q9 x3 t1 \% m# E' P) sresult in extensive, unnecessary, and expensive
4 T/ _  [. n. U( w/ G0 }; O2 C/ Binvestigation. The primary care physician should be
; `- m2 _' ~# y2 e/ ~' s; L1 vaware of this fact, because most of these children
8 O7 f; e' a' Umay initially present in their practice. The Physicians’, E# i0 B3 K) e( b0 a$ t1 |
Desk Reference and package insert should also put a
; Q. }* F% H9 n, pwarning about the virilizing effect on a male or
; A0 ]- W# a0 b0 L: Y4 ]: Lfemale child who might come in contact with some-
: ~. s8 W- {1 l7 g) `" rone using any of these products.2 p$ B) c; O2 ?$ X
References
3 R& p7 p. q6 b1. Styne DM. The testes: disorder of sexual differentiation8 V% ]3 S; E. n. e
and puberty in the male. In: Sperling MA, ed. Pediatric
4 d" ~; U/ X9 c/ ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 x9 `$ g; n! r- ?2002: 565-628.
" y  ?  [- G5 e! X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ L7 f, @! U3 Lpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old+ m$ b* V8 x7 l$ T3 |9 W
Boy Induced by Indirect Topical
* K2 x* N! _: L' `Exposure to Testosterone
( o% d; Z2 l; WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( n; t9 G+ A% o( |3 dand Kenneth R. Rettig, MD1# p/ I6 A( _1 e0 g1 Y
Clinical Pediatrics, v1 l3 f' F: R/ X  g
Volume 46 Number 65 H1 p# o( {$ H+ z
July 2007 540-543
  C3 ^. `) O7 V# u1 L: c2 }8 |6 G! o© 2007 Sage Publications4 S2 P: J# _0 [. Q5 T& W7 Q, M' k
10.1177/0009922806296651$ e, `* ~+ X* `* ~; m8 W4 X
http://clp.sagepub.com
4 H) `' i8 u0 H: ehosted at
2 j9 B; a9 t% W$ xhttp://online.sagepub.com: a: n4 H1 B  o5 K* h( n+ J
Precocious puberty in boys, central or peripheral,
: |7 Z* y0 u! qis a significant concern for physicians. Central
$ m0 |6 U( b* c% Qprecocious puberty (CPP), which is mediated
  |! U, G% K% ythrough the hypothalamic pituitary gonadal axis, has, `0 V1 P2 N7 Q" h' u/ C7 ^. B, s: p
a higher incidence of organic central nervous system
7 {- t8 m: s& h  K" i; R% Nlesions in boys.1,2 Virilization in boys, as manifested) Y: t9 l1 T% @" B: d- Z
by enlargement of the penis, development of pubic
( g! p' ]" Q; B, {$ _% A1 g4 Fhair, and facial acne without enlargement of testi-
; n, z. h* F8 e8 k/ P' ^2 t) {cles, suggests peripheral or pseudopuberty.1-3 We5 y4 Z2 I9 k) R4 x6 m6 k  r
report a 16-month-old boy who presented with the
; ?1 K. k, c) M) @/ Uenlargement of the phallus and pubic hair develop-
: M, P; l) a6 T7 J! @ment without testicular enlargement, which was due) |% O% }. o% @1 `9 E( q
to the unintentional exposure to androgen gel used by" g: F9 Z; k* T/ ~% K/ t) q/ q* v
the father. The family initially concealed this infor-, h2 s/ V6 E) Z/ r+ X
mation, resulting in an extensive work-up for this/ S7 A# K9 ]: P! o5 S- G- W! q
child. Given the widespread and easy availability of9 A- g" b5 x, m) N5 Q0 z' `
testosterone gel and cream, we believe this is proba-
$ \' m/ D: Q- ]1 a/ jbly more common than the rare case report in the
1 V6 h8 m9 p3 V" f3 dliterature.4' }6 l0 {# o+ w$ V' j
Patient Report
6 h7 Z2 U9 i& a' ?0 ~A 16-month-old white child was referred to the# F/ B' \. `2 z8 G; k! h, l; A
endocrine clinic by his pediatrician with the concern+ J! E1 \. V' P/ I
of early sexual development. His mother noticed
6 H- N2 L/ J* R( f. `light colored pubic hair development when he was8 v5 l9 _+ N+ [- ]) _
From the 1Division of Pediatric Endocrinology, 2University of
+ y* M' e9 z) R- t/ c( D) YSouth Alabama Medical Center, Mobile, Alabama.! u' X  w4 y' l$ R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; b5 e* h8 D, l) r# gProfessor of Pediatrics, University of South Alabama, College of
$ [; K! |: U6 q+ m8 B2 aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- i3 r% @* d- c# I% W: @; N
e-mail: [email protected].0 L! k% c$ e+ V0 U" ~+ s
about 6 to 7 months old, which progressively became
5 I/ `7 n8 @4 H1 x3 wdarker. She was also concerned about the enlarge-
0 h! I8 Z* P( O. q* V- R% _7 mment of his penis and frequent erections. The child
8 `1 M) z1 w8 ]4 g! u8 twas the product of a full-term normal delivery, with4 D6 G* Q( q% W) [( m; s
a birth weight of 7 lb 14 oz, and birth length of: X# f8 l& }  W+ j, t. J. Q0 x/ F5 B+ I
20 inches. He was breast-fed throughout the first year0 M5 B& K7 q% r# y) [" g6 ^1 C
of life and was still receiving breast milk along with& x2 }* y; [# C0 O' F% l
solid food. He had no hospitalizations or surgery,
2 w/ i1 s! m" q. |, {( R4 @and his psychosocial and psychomotor development
' e# L: I$ J! ewas age appropriate.$ ~- {, j- _1 @( a
The family history was remarkable for the father,
; d4 h' x/ X2 q$ c+ fwho was diagnosed with hypothyroidism at age 16,/ w' Z7 t8 b- P: u! \
which was treated with thyroxine. The father’s) v+ n3 z& i; g* D4 M: p
height was 6 feet, and he went through a somewhat& }- U  y1 w* A
early puberty and had stopped growing by age 14.; Y" T; l7 d" h( Y" B/ F/ s7 ?" @
The father denied taking any other medication. The  A! e& h* C+ Q! ]
child’s mother was in good health. Her menarche: g$ z" K0 t) P4 `
was at 11 years of age, and her height was at 5 feet
7 S# x; f5 w+ c9 L& f5 inches. There was no other family history of pre-
# c, K  Y/ |5 j# P9 Scocious sexual development in the first-degree rela-
3 K4 a0 P+ Q' gtives. There were no siblings.
+ R6 ^5 r- ~9 Y& _; Q+ r- g" KPhysical Examination
7 ?; q6 ]) f! p7 S! K: ~The physical examination revealed a very active,2 D6 }4 d4 k2 V5 |
playful, and healthy boy. The vital signs documented
; S8 A% R3 A' [8 B: h+ ?a blood pressure of 85/50 mm Hg, his length was
' x8 Q2 w. B9 S2 p( Y90 cm (>97th percentile), and his weight was 14.4 kg
9 N0 ~' N4 F" [* E, `( @7 G* d(also >97th percentile). The observed yearly growth) W8 s* t) r& ], [; l- ?
velocity was 30 cm (12 inches). The examination of
0 {2 Z, a4 ^+ A3 I8 @7 P! a  lthe neck revealed no thyroid enlargement.  q0 e4 ]' h/ k3 b: _
The genitourinary examination was remarkable for( ?6 f# v, f$ S* h! n  |  Q
enlargement of the penis, with a stretched length of* b8 Y6 W3 ~7 r6 Z1 _! s" b: e
8 cm and a width of 2 cm. The glans penis was very well
( m$ v4 L  _2 }3 |. k4 L* x0 Pdeveloped. The pubic hair was Tanner II, mostly around
$ @9 B$ o' |/ f0 x, ?9 R3 h. a. ?540
/ S6 c0 \9 N, s. ~& `( \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- o2 t& i: i& U3 q. j% }, a* Jthe base of the phallus and was dark and curled. The; ]  F' ~; o1 l# T# y6 o
testicular volume was prepubertal at 2 mL each.
/ T( l" I; @. P, dThe skin was moist and smooth and somewhat
$ z" J% Z4 `. h' E/ j* }oily. No axillary hair was noted. There were no8 W8 }; O3 V7 h' z
abnormal skin pigmentations or café-au-lait spots.
- z8 n7 M. j5 i  Z3 DNeurologic evaluation showed deep tendon reflex 2+
, H. @1 F: e! d& U: ^& W8 x* O! \bilateral and symmetrical. There was no suggestion, T2 ^( @, S+ W4 o, T" `! y
of papilledema.# _( |5 E+ {" X& R' s
Laboratory Evaluation3 ~/ ?' K0 \7 R/ i( m
The bone age was consistent with 28 months by8 \. Y0 a! E) S& e/ N1 l6 V
using the standard of Greulich and Pyle at a chrono-
, a" G' x/ x% @! Ilogic age of 16 months (advanced).5 Chromosomal
, E  J: E2 @, V9 ~karyotype was 46XY. The thyroid function test
$ s6 q6 ]5 D( E# r0 [" sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" G( n8 I4 s3 H9 U, L3 X4 p
lating hormone level was 1.3 µIU/mL (both normal).% ^+ G% l3 z+ j. F: T
The concentrations of serum electrolytes, blood
/ U' Z% }5 X0 V1 G  ]1 }/ M6 Z. lurea nitrogen, creatinine, and calcium all were
  V% o# t8 E8 F: Qwithin normal range for his age. The concentration, E) a* j4 u$ e/ D4 \3 u2 A) k* a8 {6 `
of serum 17-hydroxyprogesterone was 16 ng/dL
; V3 A7 q7 b1 Z# G! ?% o" N& k(normal, 3 to 90 ng/dL), androstenedione was 201 }* }4 q1 N/ k4 a* ]5 f3 O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 X& _4 r7 ]4 P( o8 Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),: T( F) n6 U3 {& ^+ H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ m9 R) s% S  W; ]8 X2 V
49ng/dL), 11-desoxycortisol (specific compound S)
! U( C  Z+ T9 L6 X3 Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! a% ]) J8 n# }# s- L. N" ?+ z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 V  w9 Y; s1 o2 U1 h% ]6 \6 ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% d7 Z! p. }$ `7 S; Sand β-human chorionic gonadotropin was less than# i( \1 h* p4 U3 [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 y% Z* V4 k2 |, V! Astimulating hormone and leuteinizing hormone4 y4 i+ |; W5 k' {$ I
concentrations were less than 0.05 mIU/mL
/ N7 }, l! A" k  G% h2 V(prepubertal).
: Y. o. O& H3 O3 c$ @The parents were notified about the laboratory
1 Z5 F( S$ l7 `- S7 i4 U" \0 |  lresults and were informed that all of the tests were2 q. Q" {' x# [( t  O2 d( D; F
normal except the testosterone level was high. The/ u+ l% \3 s9 u( b3 }6 \
follow-up visit was arranged within a few weeks to) {+ s! s3 e" z0 x
obtain testicular and abdominal sonograms; how-, I7 M9 A* E! W* M
ever, the family did not return for 4 months.  ~0 a5 N9 j9 n4 W% V3 [3 M
Physical examination at this time revealed that the
/ @0 C5 F$ D$ zchild had grown 2.5 cm in 4 months and had gained
7 F# O8 X' x% B2 kg of weight. Physical examination remained
! f! n9 |9 X, `" F5 X. w# qunchanged. Surprisingly, the pubic hair almost com-* g; c8 \0 P* n/ Z
pletely disappeared except for a few vellous hairs at$ I7 b+ U; t9 ^4 o3 \& ]: L5 H
the base of the phallus. Testicular volume was still 2% q$ b  \* i, Z6 s' l; G9 g  {
mL, and the size of the penis remained unchanged.
- x5 c7 R0 i8 Y2 i1 sThe mother also said that the boy was no longer hav-
6 M9 v2 N. W" |' y* M) V  B6 L% |ing frequent erections.1 [2 x5 G: e7 G# |
Both parents were again questioned about use of
* T5 b1 s* i( _0 T' E# b3 r8 Wany ointment/creams that they may have applied to
; O- p% o, |1 j6 }the child’s skin. This time the father admitted the- L) d, @4 N/ e2 @. W
Topical Testosterone Exposure / Bhowmick et al 541
( N% ~- x" B9 V" T3 ause of testosterone gel twice daily that he was apply-
1 ~4 }' P1 m- T" ]ing over his own shoulders, chest, and back area for
, _- U/ ^) t5 Ea year. The father also revealed he was embarrassed
! }: _2 E3 g+ G: A  Zto disclose that he was using a testosterone gel pre-' {$ l& y2 W7 W
scribed by his family physician for decreased libido
! f5 r4 P4 P9 ~secondary to depression.0 h  C. {: r$ r$ A9 V
The child slept in the same bed with parents./ i  {! v2 T4 n! a
The father would hug the baby and hold him on his7 z- G+ g/ C) X
chest for a considerable period of time, causing sig-& `  n- Y4 ^4 w8 l) M
nificant bare skin contact between baby and father.- r  m8 K" `. K4 S/ s) W; y
The father also admitted that after the phone call,! {6 V' ^" t: p$ j# p
when he learned the testosterone level in the baby
* l( x- x9 B0 k, dwas high, he then read the product information- i2 D, v: B8 @$ m( q& X" h
packet and concluded that it was most likely the rea-
: Z5 Y. ], S& c( f5 u. Pson for the child’s virilization. At that time, they( D& @( Z& M, I7 P$ e$ [7 |
decided to put the baby in a separate bed, and the% I5 a! U" m( d$ Y% Y2 c7 c
father was not hugging him with bare skin and had' U5 N# t/ k* g: ^' U2 ^% H) H% W
been using protective clothing. A repeat testosterone8 k' H$ _4 B5 u. n
test was ordered, but the family did not go to the
: Z; J0 ^% ?, {- A: C! {7 Nlaboratory to obtain the test.
) q3 s+ m1 d% q$ L9 `Discussion1 q) E' J5 J+ ?- b2 U+ o. w
Precocious puberty in boys is defined as secondary  `* i+ R4 S9 H
sexual development before 9 years of age.1,4
8 F* K  A$ m: f7 ^" M4 \+ Y, TPrecocious puberty is termed as central (true) when
( v& Q7 e- c/ \& E/ \3 Jit is caused by the premature activation of hypo-5 c2 O# J2 U8 R( z+ @2 O
thalamic pituitary gonadal axis. CPP is more com-! h9 p$ g, w/ B. t& X/ t8 G
mon in girls than in boys.1,3 Most boys with CPP6 }1 M% G4 |1 X+ ?' S3 f* A, x
may have a central nervous system lesion that is
$ o( M1 [0 m6 I8 z" h8 P. O0 X: aresponsible for the early activation of the hypothal-9 L" H8 I& X: L  z! ~4 L
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 V( Q8 W4 l! V* R% xsis has been given to neuroradiologic imaging in
& t( x, s9 Z5 Uboys with precocious puberty. In addition to viril-
( T- ~! g4 t. y! Q) F" @8 n% e7 Lization, the clinical hallmark of CPP is the symmet-' \, @: s* J& c% Z# `+ ]0 }
rical testicular growth secondary to stimulation by
. [8 Z3 c* o1 G! w9 qgonadotropins.1,3
1 a( c9 s8 M$ c+ }: i8 FGonadotropin-independent peripheral preco-" J4 l& b5 J- Q8 o! E: |' i
cious puberty in boys also results from inappropriate
- X$ [5 f  f$ o/ N/ b: dandrogenic stimulation from either endogenous or
" m$ m% ?5 H. Y2 F& rexogenous sources, nonpituitary gonadotropin stim-
4 J! F' L5 M# s& \. Q# W* y5 ?/ fulation, and rare activating mutations.3 Virilizing; ~1 [) N* |) B2 g! g: s
congenital adrenal hyperplasia producing excessive
! y6 d. F' u7 l: _+ R1 Kadrenal androgens is a common cause of precocious
& L4 b* B3 w2 @puberty in boys.3,4. u3 [4 w" e/ M' w3 n' x0 q6 w* o& {
The most common form of congenital adrenal' W* D" X5 K2 d7 z. x+ }: H) {
hyperplasia is the 21-hydroxylase enzyme deficiency.
& ~5 \9 o; D* v0 f4 t; d) EThe 11-β hydroxylase deficiency may also result in+ y7 ?+ u4 G+ _/ K  d
excessive adrenal androgen production, and rarely,
, u& m* K- s* A. |an adrenal tumor may also cause adrenal androgen" x% W7 J, t; A3 I
excess.1,3( [( M+ L& [, H1 q9 Q$ X7 d: X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 ?( p1 P- L$ D* G0 J2 M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" T. g5 R* H5 c- @
A unique entity of male-limited gonadotropin-- X: ]$ X2 d) @
independent precocious puberty, which is also known
  a/ r3 `4 [: R8 R7 ^% Bas testotoxicosis, may cause precocious puberty at a
0 w8 W% M( K' m; qvery young age. The physical findings in these boys
, W  k" ]3 ^4 d" b& T) @with this disorder are full pubertal development,% b1 |7 ^, p: b' S% L4 n
including bilateral testicular growth, similar to boys  u3 l/ T- T% O/ \* R) x
with CPP. The gonadotropin levels in this disorder
1 J# X& G* W6 d0 \3 M$ care suppressed to prepubertal levels and do not show) O2 o) m. h2 y6 `: V7 o
pubertal response of gonadotropin after gonadotropin-
8 d) x9 E  l: j5 @& l) i6 Ireleasing hormone stimulation. This is a sex-linked' _3 M0 O* h3 I( u. V& _) @
autosomal dominant disorder that affects only
, y5 l- \! M9 q) a8 y/ Tmales; therefore, other male members of the family
' L4 j7 B% w" [2 M" n6 hmay have similar precocious puberty.3# ]! c9 h$ W4 H- q6 ]
In our patient, physical examination was incon-3 h3 A- _' G& T. b
sistent with true precocious puberty since his testi-, i+ V, A6 Z  p8 u' g, B
cles were prepubertal in size. However, testotoxicosis
2 F8 k) H, q' a5 @  S! U* ~' Owas in the differential diagnosis because his father
( k0 c' \" l8 e; |, e/ [started puberty somewhat early, and occasionally,6 v, K3 C" ]# g) j
testicular enlargement is not that evident in the% q0 X4 D! z$ P/ I
beginning of this process.1 In the absence of a neg-" I7 r+ U5 e7 D4 Y8 \$ Y
ative initial history of androgen exposure, our
& q; d" h& ^8 U/ g9 g& M! ]9 s, Tbiggest concern was virilizing adrenal hyperplasia,% i* R# z- p' e
either 21-hydroxylase deficiency or 11-β hydroxylase
* R1 E( e( Q# j& Wdeficiency. Those diagnoses were excluded by find-
" I/ z6 G( M2 w: l/ ring the normal level of adrenal steroids.8 ?& S, }+ O& U' C6 i* l3 v
The diagnosis of exogenous androgens was strongly
1 }2 \& |- S- B9 @1 tsuspected in a follow-up visit after 4 months because
: h" C/ B" {0 W- h, \the physical examination revealed the complete disap-
' y# \' s  @7 w2 S; d! Y) h# bpearance of pubic hair, normal growth velocity, and# \* j. U/ J1 I1 \
decreased erections. The father admitted using a testos-
  o, _- I( C; Vterone gel, which he concealed at first visit. He was% i3 Y" N2 i' g- ]
using it rather frequently, twice a day. The Physicians’- ?( k8 ~, L% Y. g
Desk Reference, or package insert of this product, gel or
) ?  ^8 W; x% b+ r% X7 `3 lcream, cautions about dermal testosterone transfer to4 L" K' ]& L' d, }0 w
unprotected females through direct skin exposure.7 m. U* j/ c) [6 {8 {9 U* O- A. e
Serum testosterone level was found to be 2 times the; p7 T5 I0 A& p) U8 T
baseline value in those females who were exposed to, `8 X- p" q' ~! @; ]# f" \9 {# b
even 15 minutes of direct skin contact with their male
/ P: R/ u/ v, |) I  T- d) k" P0 vpartners.6 However, when a shirt covered the applica-
, C) w. u  ?2 [/ U/ ntion site, this testosterone transfer was prevented.. T* }0 Q0 [5 l+ z' C0 R3 U
Our patient’s testosterone level was 60 ng/mL,# Q' Y8 \) c6 Q- x/ I" {7 N
which was clearly high. Some studies suggest that
2 l# g5 m; q5 Tdermal conversion of testosterone to dihydrotestos-9 d2 D+ W3 X) G2 y8 @
terone, which is a more potent metabolite, is more! P8 N& b# @$ j# t, |8 l7 |
active in young children exposed to testosterone$ `, j2 R3 }1 I
exogenously7; however, we did not measure a dihy-4 t; S% o( p4 U" s5 S3 [" A9 R1 m8 C
drotestosterone level in our patient. In addition to
$ P0 J/ J+ U4 T4 C+ w, E* f, Nvirilization, exposure to exogenous testosterone in& Y* m* B& t5 J2 H" X  r
children results in an increase in growth velocity and
. M; E3 C; o1 `' ^advanced bone age, as seen in our patient.) B0 H! h8 E  C( M; M: ~' R" @
The long-term effect of androgen exposure during
  d8 `; t. s6 ^: H8 J' @% d/ zearly childhood on pubertal development and final: A4 O, k' |- @2 g) q- l2 o
adult height are not fully known and always remain! p# P; Z0 _5 h
a concern. Children treated with short-term testos-4 s+ j# U8 i$ S5 l* F
terone injection or topical androgen may exhibit some
' W, r- n3 o& @1 T8 J- @7 ^; gacceleration of the skeletal maturation; however, after, G8 L6 p' o5 _
cessation of treatment, the rate of bone maturation
8 W9 {6 c8 v* @, I- J+ Z9 Adecelerates and gradually returns to normal.8,9
' S7 x. F4 C4 K2 XThere are conflicting reports and controversy3 h% ?% D. V  |) l4 B
over the effect of early androgen exposure on adult
1 D# d/ n% O5 ~9 x+ |( q4 Bpenile length.10,11 Some reports suggest subnormal
- L6 _" h9 B, h" B+ \4 o( y1 ^$ yadult penile length, apparently because of downreg-
6 Q& u3 |$ X2 i# |ulation of androgen receptor number.10,12 However,
& c3 z$ p  A# O& d& a6 K* ?4 X/ nSutherland et al13 did not find a correlation between
1 t+ D: Y/ u! X9 o; y- Hchildhood testosterone exposure and reduced adult0 E( s' ~( x6 i- j. E3 E( i8 X
penile length in clinical studies.! H  M: B$ b- X6 W3 ^
Nonetheless, we do not believe our patient is
1 v3 l/ b- |# b% i. Q( cgoing to experience any of the untoward effects from9 w+ i$ x  `% G; `$ M8 g1 K
testosterone exposure as mentioned earlier because! z- I  X% n. h: E
the exposure was not for a prolonged period of time.
' ]9 [, h" s# e, u) YAlthough the bone age was advanced at the time of- r- V3 W% [" G0 o! ?4 ~
diagnosis, the child had a normal growth velocity at: x" M& y; E9 Y5 j2 ^
the follow-up visit. It is hoped that his final adult
# t* A( t$ f5 u# ~+ I; @height will not be affected.7 }3 T  U4 x, t' M  ^* r  T' n
Although rarely reported, the widespread avail-( f  l/ Z2 h: F3 l& F4 q+ O
ability of androgen products in our society may
. m2 Y; X6 k! j. p" L5 G" xindeed cause more virilization in male or female# ~* c) m% H* [
children than one would realize. Exposure to andro-" }% |6 ?1 z  u# q4 R5 \
gen products must be considered and specific ques-( d. J( A5 b/ T6 M5 v) ]
tioning about the use of a testosterone product or
. K3 O1 }5 T& z) |+ Mgel should be asked of the family members during
2 J' \5 g1 m1 |  I% H9 Pthe evaluation of any children who present with vir-; d, `/ ?$ D* O9 n
ilization or peripheral precocious puberty. The diag-
5 S# R. }' h5 R2 K! gnosis can be established by just a few tests and by
# n3 O4 Y; e/ G1 P) Z/ ^- xappropriate history. The inability to obtain such a
( A- X* g, q+ L7 s* _  q! Phistory, or failure to ask the specific questions, may
3 p$ v- x4 Y$ |  zresult in extensive, unnecessary, and expensive
/ Q, b! C, p. D7 D# minvestigation. The primary care physician should be
* I) \+ [9 T+ j, caware of this fact, because most of these children2 R$ s& Z8 e; J$ a2 Y1 C
may initially present in their practice. The Physicians’
  a: Z1 x1 s+ IDesk Reference and package insert should also put a: M. V+ {+ X( W7 H
warning about the virilizing effect on a male or" P  J) c1 v  m0 l. c
female child who might come in contact with some-8 \) i: Q* y3 }- w) u% ]! T
one using any of these products.  B9 r  _! f$ b* _' a! u3 Q
References
* Q6 h: j! x& v, W' |! w4 b, F1. Styne DM. The testes: disorder of sexual differentiation
) X: h5 k. U! p  ~and puberty in the male. In: Sperling MA, ed. Pediatric
1 k) {6 d4 T( H7 i+ s4 R8 p7 EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 A0 z. V/ S- @( t2 \+ x% f6 c( G2002: 565-628.: I1 B* [! C5 g9 u# h
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. y  [8 G  T9 x
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

$ p% d+ x. Y& P精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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