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Sexual Precocity in a 16-Month-Old
5 f1 O. {, `0 q* `, {& |Boy Induced by Indirect Topical
, D6 t& r# q) \Exposure to Testosterone8 v# j$ T" u5 j9 e" I. g4 F2 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ D/ c# S% S/ a7 w+ o* I9 u
and Kenneth R. Rettig, MD1
+ W4 E/ y" {- E; A( q0 h6 H/ cClinical Pediatrics
& O1 @$ ^1 I$ b0 c# _Volume 46 Number 68 c; `& n# O8 E! l
July 2007 540-5433 W3 x3 U5 D  X( n0 l
© 2007 Sage Publications
% \2 n! }6 L$ J10.1177/0009922806296651
% S9 i. o; R  k. e4 w$ Lhttp://clp.sagepub.com
7 C4 T  \- B, e9 h2 T8 khosted at
8 u. r! C! h7 I# Vhttp://online.sagepub.com( R: _' y1 w& W# h" s: ~3 U" q
Precocious puberty in boys, central or peripheral,
+ q5 ?' l2 s, Yis a significant concern for physicians. Central1 b4 Z7 n' x1 \/ Z* s/ H
precocious puberty (CPP), which is mediated4 L3 H: K+ {" }& m/ X- m% T% r  x* v
through the hypothalamic pituitary gonadal axis, has
5 l" Z$ P2 U" d$ G8 Na higher incidence of organic central nervous system3 ^( a9 b( h. I7 d# M% K0 Y; }
lesions in boys.1,2 Virilization in boys, as manifested
$ C4 n6 K" N+ _% Dby enlargement of the penis, development of pubic
# d3 n  M  g5 A5 X& D# chair, and facial acne without enlargement of testi-6 X* O) K" R: V  `/ w* W
cles, suggests peripheral or pseudopuberty.1-3 We
; ]2 R  v0 {$ d8 o$ j& ~6 wreport a 16-month-old boy who presented with the
# e2 K$ n9 K, G3 w& t/ W6 N+ uenlargement of the phallus and pubic hair develop-  E6 B9 @8 X4 B5 h& [# c: J% d
ment without testicular enlargement, which was due
- c! U! F( _; ]5 Kto the unintentional exposure to androgen gel used by! [. i- ^4 E6 z. ~- d- Y6 v
the father. The family initially concealed this infor-
  a4 V# a5 d% s5 M$ Dmation, resulting in an extensive work-up for this' m* ~* e$ B: h, N3 ~. ~3 Q
child. Given the widespread and easy availability of
6 q# d, o* X1 e9 Etestosterone gel and cream, we believe this is proba-# ?/ }, j" a2 B
bly more common than the rare case report in the
2 r; v) e2 }4 |" Aliterature.4
4 ~4 e! n' ]- ?2 B. NPatient Report
; \' u, a6 V2 O- xA 16-month-old white child was referred to the# B- `0 j: I4 j2 T$ ]
endocrine clinic by his pediatrician with the concern
: l8 P! n9 {9 p& hof early sexual development. His mother noticed
! }5 L# ^8 T4 K- u" U, b* K" Hlight colored pubic hair development when he was2 P" C6 U3 e0 ]  P8 H# w
From the 1Division of Pediatric Endocrinology, 2University of, X5 O( \1 P7 l# D9 q
South Alabama Medical Center, Mobile, Alabama.
: B8 j) q, P* r8 V# g  H$ [. k! iAddress correspondence to: Samar K. Bhowmick, MD, FACE,' c, U' ^, c( N, p: U
Professor of Pediatrics, University of South Alabama, College of
' q% K! E6 D, [/ Q7 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ J8 X' M3 _# x- r/ _
e-mail: [email protected].$ R5 F4 Y  F- i0 n% E! {
about 6 to 7 months old, which progressively became
! `+ _* e2 H5 E8 A$ p0 J  udarker. She was also concerned about the enlarge-
; j6 U. |8 l4 R4 ?ment of his penis and frequent erections. The child
1 z, u5 \* A$ ]3 y; r$ ~was the product of a full-term normal delivery, with
0 N% ~0 D. w0 P* H6 wa birth weight of 7 lb 14 oz, and birth length of
- E8 c% P: ~4 y/ q1 i$ @% {20 inches. He was breast-fed throughout the first year  \: R8 i$ s5 i1 U2 p9 d; R
of life and was still receiving breast milk along with
! _$ @6 t& V- Bsolid food. He had no hospitalizations or surgery,9 R7 e- o; d6 J$ X/ K9 i+ ]2 O
and his psychosocial and psychomotor development
% X3 X4 A, G/ u; L. @5 Iwas age appropriate.) L$ n; E4 S# \6 K: R
The family history was remarkable for the father,4 C: V0 h% a, C( ~# X
who was diagnosed with hypothyroidism at age 16,% u, l% e1 f3 `! x+ f0 s* q4 A
which was treated with thyroxine. The father’s
. A8 D% j& s/ h. C- r" Wheight was 6 feet, and he went through a somewhat' a# v( _6 P4 I$ d/ T% I8 F
early puberty and had stopped growing by age 14.
7 S# k+ ^/ ]( z( c. x( E! k4 HThe father denied taking any other medication. The
& f! s0 S) N, |5 ^9 y. `1 \" z, tchild’s mother was in good health. Her menarche
* t% k7 }* h8 T  Q& v9 ?! ?' Fwas at 11 years of age, and her height was at 5 feet
9 r- S% ?4 q# W; U  _, ?5 inches. There was no other family history of pre-+ L9 ?6 \" n0 _' K
cocious sexual development in the first-degree rela-
% T  \& ~4 V) M2 ?tives. There were no siblings.; M7 W) O! Y/ N
Physical Examination
1 z% q; ]0 v6 U3 Q  w5 S3 A' TThe physical examination revealed a very active,
2 ^, ~1 C, o  w' M; _5 `( k2 Aplayful, and healthy boy. The vital signs documented
2 [) p9 _* r, Z$ ?9 G2 U: \4 N  Ta blood pressure of 85/50 mm Hg, his length was% Q" n; D. o) q+ B6 A6 J1 R2 v# i6 B
90 cm (>97th percentile), and his weight was 14.4 kg
1 C0 ?+ Y' Y4 d4 U6 D0 w, J& h(also >97th percentile). The observed yearly growth
! \% q) }! L: Kvelocity was 30 cm (12 inches). The examination of
1 s5 \# v- [* B0 pthe neck revealed no thyroid enlargement.. m1 w8 C& {; Q
The genitourinary examination was remarkable for
  ]# Z- [/ z+ ~6 V0 c/ e; nenlargement of the penis, with a stretched length of
6 c8 g% H& ^0 U4 c" m8 cm and a width of 2 cm. The glans penis was very well( s5 j9 u$ `9 {% q2 @7 }
developed. The pubic hair was Tanner II, mostly around' k4 ~2 ^4 }- L. B
540
2 r8 u' v" w  b9 m8 n7 dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; e4 y! X" f4 J$ G; rthe base of the phallus and was dark and curled. The+ ^" z5 y0 A. _; M3 w$ I0 w
testicular volume was prepubertal at 2 mL each.
, i" E5 M3 o; _7 ]3 P. oThe skin was moist and smooth and somewhat
8 A1 X0 I# ^; Foily. No axillary hair was noted. There were no
9 |0 T# ]) s  J+ w: cabnormal skin pigmentations or café-au-lait spots.
" x4 x. u; I& L& E/ aNeurologic evaluation showed deep tendon reflex 2+
4 w' N: T# U+ ^- Wbilateral and symmetrical. There was no suggestion  b: H$ U" r7 R9 R' b' @
of papilledema.
4 f5 A9 _! A+ d) t7 g' C: bLaboratory Evaluation
# Q) g1 N- _' Q7 T# ^9 QThe bone age was consistent with 28 months by( d2 s5 a# M, \$ p- H+ e+ J8 s4 `
using the standard of Greulich and Pyle at a chrono-* ^; B" a) k. }. N6 V- U8 O4 b+ x
logic age of 16 months (advanced).5 Chromosomal! O* M- t; O2 Z! _  \  m( ?
karyotype was 46XY. The thyroid function test" x; c* b$ I: e7 e5 g& [* d& ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-) v* T. v) f' _1 i! A7 ]- i. U
lating hormone level was 1.3 µIU/mL (both normal).
3 i& x' [( q1 H9 y2 V3 @3 CThe concentrations of serum electrolytes, blood5 P5 O5 f# P+ Q2 @% v# U! }4 E+ |1 U
urea nitrogen, creatinine, and calcium all were
1 Y! f. z; S7 C3 X. Bwithin normal range for his age. The concentration
) H' e+ b# E8 E! h  Z2 h; ^: Pof serum 17-hydroxyprogesterone was 16 ng/dL; A1 t6 R' f) w2 C# P- O
(normal, 3 to 90 ng/dL), androstenedione was 20
, z3 h  e- j( T$ J2 I- Y! h  dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
9 s5 ^2 K; k1 R: L3 @# A+ K( j* Z0 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' l  U$ q0 `% t8 }' cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. q  j& E3 @% J# w' E: R0 M
49ng/dL), 11-desoxycortisol (specific compound S)
- S  n$ T) b$ Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 i+ V% ?+ t1 O" R( @+ v$ Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: d0 D  u: r9 B- q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( e% b5 t# m7 H" y8 P% V4 g
and β-human chorionic gonadotropin was less than
! G; ?6 C- M% s; W1 F/ h5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 q7 I: `" s! W* X6 t3 @, Hstimulating hormone and leuteinizing hormone
& n3 ]* k( u; d! J2 I0 b* tconcentrations were less than 0.05 mIU/mL+ P6 F/ B& s8 K& h8 R
(prepubertal).
8 c: P, d4 V' s: n7 t' T. CThe parents were notified about the laboratory6 ^/ b- ^7 {' S7 V: r' f
results and were informed that all of the tests were
6 E: l, o- N7 S" b# dnormal except the testosterone level was high. The& \, G& [% B0 b' o( A; r
follow-up visit was arranged within a few weeks to$ j! ]- W8 U! x# }
obtain testicular and abdominal sonograms; how-
1 y9 _) t2 `3 Q) m2 Q$ m0 c; A  lever, the family did not return for 4 months.
: g9 s) @; F% hPhysical examination at this time revealed that the
9 f) T1 U4 z: G( n& `# lchild had grown 2.5 cm in 4 months and had gained
9 W1 S1 P, m0 m2 kg of weight. Physical examination remained& U1 p( l! D7 c
unchanged. Surprisingly, the pubic hair almost com-5 s! Z" Z5 N2 g6 h! w
pletely disappeared except for a few vellous hairs at
9 V3 t1 ^. }  m6 E( dthe base of the phallus. Testicular volume was still 2
4 h2 U4 r/ i9 I0 q" w9 fmL, and the size of the penis remained unchanged.
# }* `0 ^$ [' \' N+ ^* Z- E/ JThe mother also said that the boy was no longer hav-
5 l7 o5 l0 m  v' T( j+ ging frequent erections." e: X9 D, x3 I6 L8 v
Both parents were again questioned about use of
. d( |) E* y5 Z$ S2 nany ointment/creams that they may have applied to: A/ m- R" {. V! y/ \
the child’s skin. This time the father admitted the" A: k# ^( O5 \6 Y
Topical Testosterone Exposure / Bhowmick et al 5418 R8 d# C+ w+ B) ?
use of testosterone gel twice daily that he was apply-6 U, }: p+ Q, B9 i4 i1 y+ h
ing over his own shoulders, chest, and back area for) ^% I' @. z$ L3 G
a year. The father also revealed he was embarrassed
# ?" ?4 ?2 j- O& J/ U! w! p- \) Q# Uto disclose that he was using a testosterone gel pre-( j  {3 }! c( [2 }& J
scribed by his family physician for decreased libido
1 U/ k9 I% e3 g1 @: i8 P5 rsecondary to depression.& K+ ^, i2 r9 V) C+ m/ \2 ^" D
The child slept in the same bed with parents.9 v; T- j: v( z
The father would hug the baby and hold him on his3 h. `/ W% I- N: _5 K+ `: H7 c
chest for a considerable period of time, causing sig-+ O% n* O- X. `! s
nificant bare skin contact between baby and father.0 ?' Q0 c3 K  k! v! m0 H+ w. g
The father also admitted that after the phone call,4 n1 X- B$ F2 ~- ]- j, X! p3 ^- W
when he learned the testosterone level in the baby/ x5 }5 [6 \0 q2 K1 s3 ]1 h& [( |
was high, he then read the product information' I' O! S! B( `; u% `3 k8 j
packet and concluded that it was most likely the rea-
; ~( F, {7 t9 @$ \5 cson for the child’s virilization. At that time, they
1 D% a' ~/ Y/ g! }! d, m9 Qdecided to put the baby in a separate bed, and the
3 E% f& n- {. b7 `( q$ Bfather was not hugging him with bare skin and had% b) v4 B6 P) W
been using protective clothing. A repeat testosterone/ C; h2 a& X, B
test was ordered, but the family did not go to the
! J  i4 k  M5 X1 F1 @$ k0 Elaboratory to obtain the test.. {# k7 Z8 o9 K, e# k6 x/ y4 C9 p
Discussion
$ B5 y) ]" X" P% R7 |* F7 TPrecocious puberty in boys is defined as secondary
% d$ F  \) t+ x( bsexual development before 9 years of age.1,4
2 f+ d, _2 T0 j# CPrecocious puberty is termed as central (true) when
" |' J" t8 c* n7 @/ K" hit is caused by the premature activation of hypo-9 w& t% }' m6 u( {) R2 B
thalamic pituitary gonadal axis. CPP is more com-5 u9 b" V) a3 _. v  S
mon in girls than in boys.1,3 Most boys with CPP7 ]  ?+ n% u; G. d$ q
may have a central nervous system lesion that is
4 [( Q! ~  S* T6 ^responsible for the early activation of the hypothal-/ l6 f0 g0 J1 }3 m% u0 E$ g
amic pituitary gonadal axis.1-3 Thus, greater empha-2 L' b  U: l+ c! V  M
sis has been given to neuroradiologic imaging in
/ t! A4 e8 o; v4 `0 ~% hboys with precocious puberty. In addition to viril-- D* A' Q. B( G8 m( n
ization, the clinical hallmark of CPP is the symmet-- c+ U3 N/ u( R
rical testicular growth secondary to stimulation by" V. H9 Y0 f3 Q7 Q2 i+ D
gonadotropins.1,3
; s+ K4 u, y8 Y! f4 \) LGonadotropin-independent peripheral preco-
$ q+ _" i5 P6 u- ~# |" Jcious puberty in boys also results from inappropriate
+ w' f) c" ^6 h# k1 Qandrogenic stimulation from either endogenous or5 N, L( d# T& I2 K
exogenous sources, nonpituitary gonadotropin stim-* Q' V  l" @& Y: ~9 T, p2 p4 H
ulation, and rare activating mutations.3 Virilizing0 A& S5 e  e3 `
congenital adrenal hyperplasia producing excessive% _$ a7 h0 w; Z6 y/ P# X
adrenal androgens is a common cause of precocious/ ^  b# h2 `+ R. A3 ~
puberty in boys.3,44 T8 C! X2 k, |8 m4 t6 `6 r
The most common form of congenital adrenal
/ t+ c$ p7 \( W3 c) yhyperplasia is the 21-hydroxylase enzyme deficiency.6 h4 _9 O( A! Q' B3 K
The 11-β hydroxylase deficiency may also result in( v/ I. z* c( d* F
excessive adrenal androgen production, and rarely,
" N9 f3 S! b; T4 m; {7 W0 Tan adrenal tumor may also cause adrenal androgen
5 e% ~$ C1 C" S& g) g* T0 h) A) mexcess.1,3
4 @6 F/ w7 Y% P" D- [8 f) @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 F. P" q* n7 {8 h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, Q4 N! t  Y4 m! `/ u' l( OA unique entity of male-limited gonadotropin-
  ?' s' _$ R2 Z* l5 E' Windependent precocious puberty, which is also known
" l2 S! h6 z+ q# b* l1 las testotoxicosis, may cause precocious puberty at a
* V, d% Y! W- V! b% ^. y! |2 cvery young age. The physical findings in these boys+ q% ^! ~. \  _2 y% M; c
with this disorder are full pubertal development,
9 s# V& q9 f. M$ B- h2 y" l# ^/ Lincluding bilateral testicular growth, similar to boys
( j% k% p- V1 f) bwith CPP. The gonadotropin levels in this disorder
. W) v3 a- i& \( care suppressed to prepubertal levels and do not show; N: j! G$ o* ?. ~8 V
pubertal response of gonadotropin after gonadotropin-5 S; L# I$ |. P. g2 ~1 o8 ?: S" W
releasing hormone stimulation. This is a sex-linked
# B) s& J0 L* J4 v' v7 ?' xautosomal dominant disorder that affects only6 E. O" a- L" {$ ?$ }7 C
males; therefore, other male members of the family7 K* T: T! X& W# R+ j9 w% d; M
may have similar precocious puberty.36 X8 n' a) _7 a+ F) K: u6 ^
In our patient, physical examination was incon-
0 k9 X$ d! @# q* J( isistent with true precocious puberty since his testi-
  W; c7 Y" {, i' T, Qcles were prepubertal in size. However, testotoxicosis
) C4 Q' F9 K  q# O8 ?was in the differential diagnosis because his father) [7 S9 }8 K/ m6 }! N% ^8 a
started puberty somewhat early, and occasionally,
4 P; H, @# }) E( g8 E( otesticular enlargement is not that evident in the) P% j# q8 N: ^
beginning of this process.1 In the absence of a neg-. p/ h2 W0 F$ w+ D. Y$ h, ?+ i
ative initial history of androgen exposure, our2 q# h; c# U3 ?7 n2 }: B! A0 h0 ?
biggest concern was virilizing adrenal hyperplasia,
! r  p4 o2 O+ h- s7 y* Seither 21-hydroxylase deficiency or 11-β hydroxylase( O  [& `3 ~# w  G: W6 v
deficiency. Those diagnoses were excluded by find-" n2 `2 }1 N! V$ {7 q
ing the normal level of adrenal steroids.: ^4 t* Q: D3 C& S; r3 c# s# x( h; {
The diagnosis of exogenous androgens was strongly0 ~& W- K& B; G) q1 T2 y0 [" \% c
suspected in a follow-up visit after 4 months because! M( Y7 R9 R) S! g4 B6 r" m' O5 _
the physical examination revealed the complete disap-
4 d- [6 P7 N6 _9 O7 k( N- apearance of pubic hair, normal growth velocity, and3 \) |1 b% n( M1 Q; o$ i  g
decreased erections. The father admitted using a testos-6 }6 ~) E. a4 H; a2 X
terone gel, which he concealed at first visit. He was
! K  c6 s4 a/ Z/ K" Busing it rather frequently, twice a day. The Physicians’
, y; h" o9 s* hDesk Reference, or package insert of this product, gel or1 }' |4 q" n7 p
cream, cautions about dermal testosterone transfer to2 d; h" v' ~& M- D* k- t
unprotected females through direct skin exposure.; G( T, k1 O: u
Serum testosterone level was found to be 2 times the
! ~: f. z4 a' Y& W- f  R2 fbaseline value in those females who were exposed to: f1 ~/ V1 q( h, V8 }3 m! P
even 15 minutes of direct skin contact with their male
2 v" b" b+ {$ D6 N- R+ Lpartners.6 However, when a shirt covered the applica-
) k- f5 F+ i# y8 ]6 |' ttion site, this testosterone transfer was prevented.
4 N! {" W% a6 [% R" r, `* |$ dOur patient’s testosterone level was 60 ng/mL,4 y1 F/ C5 R0 Z2 \! [" q
which was clearly high. Some studies suggest that
$ P5 w9 r2 |8 q4 X9 Wdermal conversion of testosterone to dihydrotestos-$ p+ d& k9 J, p) |( a4 h5 z! Q; u
terone, which is a more potent metabolite, is more8 e7 v: f& e# u7 W( `9 ?+ h0 p! e$ A
active in young children exposed to testosterone
: D1 y1 T; r: n! Pexogenously7; however, we did not measure a dihy-
8 n2 {9 V* z2 R. Gdrotestosterone level in our patient. In addition to5 f8 |" E5 Y8 u4 }
virilization, exposure to exogenous testosterone in: A4 J) C5 |. t' a
children results in an increase in growth velocity and7 b- r, S7 N/ O/ }
advanced bone age, as seen in our patient., m. p9 N0 c2 P/ {6 l, D6 [
The long-term effect of androgen exposure during
9 x0 S4 `# w# ]2 f# rearly childhood on pubertal development and final7 g' z1 h% {1 W& y- |) C6 L: V2 U
adult height are not fully known and always remain" ]8 b' U+ s8 c$ o% _1 Z' y
a concern. Children treated with short-term testos-
- F8 C, b! i- V( o3 gterone injection or topical androgen may exhibit some
& e9 K+ h- q  X* ?5 u5 o6 [acceleration of the skeletal maturation; however, after+ q( C9 T" T* t) I: x
cessation of treatment, the rate of bone maturation
8 R+ Z# E" `3 b, E2 ?/ Qdecelerates and gradually returns to normal.8,9
" k" d2 A) D! K9 M# T7 ?0 w1 eThere are conflicting reports and controversy  c4 v0 H+ B  \
over the effect of early androgen exposure on adult
* T2 B% g' R1 J* Lpenile length.10,11 Some reports suggest subnormal0 d6 E5 ?0 e; c. B! n$ S' O* B
adult penile length, apparently because of downreg-' ~6 g4 c. X( i  ~, w) y6 [0 a' L9 Y
ulation of androgen receptor number.10,12 However,
6 z+ H2 ?! c* R, L6 G  KSutherland et al13 did not find a correlation between
* p, `# T* u% b$ f, a6 J" E- h" `% Z5 achildhood testosterone exposure and reduced adult3 ^& D8 a' u+ O: j$ V
penile length in clinical studies.2 \5 C0 L% m$ d% [  T  R
Nonetheless, we do not believe our patient is  r2 N: D+ R/ P  L- \$ M
going to experience any of the untoward effects from* W# D3 w0 g& |1 U# E$ h
testosterone exposure as mentioned earlier because
* ^! [% D' {; `8 k4 q( |+ ^! x- mthe exposure was not for a prolonged period of time.$ T* `4 y& [# v4 t; u& a
Although the bone age was advanced at the time of+ E% B& u2 U) p) Q: }
diagnosis, the child had a normal growth velocity at5 c7 z1 L6 ]! l+ X5 S3 |, `
the follow-up visit. It is hoped that his final adult7 G, o% X2 F% Q3 w, F
height will not be affected.
4 B/ @/ G+ |* l6 t/ [Although rarely reported, the widespread avail-4 k4 o2 Q" T3 l) ^
ability of androgen products in our society may' q/ \" R% n  T! u4 S
indeed cause more virilization in male or female
2 |# x, ]8 ^0 }' `children than one would realize. Exposure to andro-
" K/ ?8 [2 A7 l9 k% g" }4 H7 Xgen products must be considered and specific ques-# o/ _4 j/ V- f! o4 Y- R
tioning about the use of a testosterone product or
1 j- f2 ]+ G8 i: T! Xgel should be asked of the family members during
# O- n, o5 `0 `. {1 n& T; Pthe evaluation of any children who present with vir-. b# J0 P4 r: f, F1 w
ilization or peripheral precocious puberty. The diag-
) P/ X7 S4 p- E& w6 d# A! d& p$ Unosis can be established by just a few tests and by
9 O+ w- @% l# s$ f' Q$ U  iappropriate history. The inability to obtain such a) q% {' n" J( }1 N3 @
history, or failure to ask the specific questions, may4 d" H: S1 f( C% j1 g) }
result in extensive, unnecessary, and expensive
( {8 i( ^5 s+ ^  Kinvestigation. The primary care physician should be. H% d' N! X$ \
aware of this fact, because most of these children) E" u6 y6 I/ P0 W5 T
may initially present in their practice. The Physicians’; V$ g/ z" Y7 ]5 s! `8 j
Desk Reference and package insert should also put a  U$ m4 O, d3 }5 M
warning about the virilizing effect on a male or0 G! A; v& n$ T. h( l8 J
female child who might come in contact with some-
+ i* J% `, D  t; {one using any of these products.- Q6 e9 V0 A. H( x
References7 [, Q) b) q* ?2 T, w  h
1. Styne DM. The testes: disorder of sexual differentiation/ J( ^* R, s6 f$ z2 @
and puberty in the male. In: Sperling MA, ed. Pediatric# S  V9 w" f, j' _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) d9 U' g% w6 f1 U. `0 e1 j, e, r
2002: 565-628.5 s# }- |9 A. h1 N. {" T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) V5 @! Y6 [' F3 P* Wpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
9 {, z! ]. N, n# GBoy Induced by Indirect Topical
2 F  B! A: M0 d* K1 KExposure to Testosterone/ z. p1 X& ~; f3 D8 N' W
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" g, ]1 Q- F7 ]$ Dand Kenneth R. Rettig, MD1
6 H- C: s3 d4 ~( s2 D+ x3 L* zClinical Pediatrics
0 A8 u% d' y* v4 h$ y( NVolume 46 Number 65 Q6 Q' a& F$ u( T
July 2007 540-543
! d+ s" x. B9 T& a2 z. u; j© 2007 Sage Publications
2 h! w# H0 N+ c+ Z; {* o10.1177/0009922806296651
$ |/ T" Z6 W( @" i! h/ }: Ahttp://clp.sagepub.com+ v! C, Y! Z6 N# j& z& Z
hosted at
: b' t4 d" c2 D0 |http://online.sagepub.com" e5 X9 J. `. q- Y# r% P
Precocious puberty in boys, central or peripheral,
3 {  S( t5 `" n" W# ]is a significant concern for physicians. Central
) c* _) I9 \5 G7 B) e- Iprecocious puberty (CPP), which is mediated# @) h/ [5 T# G  p7 O; x9 [0 a
through the hypothalamic pituitary gonadal axis, has9 X3 M9 B' s8 T
a higher incidence of organic central nervous system; \: P' d* U% V5 s: z) ?
lesions in boys.1,2 Virilization in boys, as manifested/ v7 G  k- ^2 `- a
by enlargement of the penis, development of pubic
, l1 `& q5 m  X3 A2 e$ Shair, and facial acne without enlargement of testi-" J# i- Z7 i3 {% H1 Z7 T0 k
cles, suggests peripheral or pseudopuberty.1-3 We! A- m, K9 X& w3 o" ]* @
report a 16-month-old boy who presented with the8 F; N& L' x0 I% o5 \! W
enlargement of the phallus and pubic hair develop-& v+ p- O. V; E5 u1 P7 K; M1 U- ~
ment without testicular enlargement, which was due5 n. y! k2 g3 P) \1 Z) D, t2 |
to the unintentional exposure to androgen gel used by& l* J6 u" _1 l8 }: ]( k
the father. The family initially concealed this infor-! j' F" Y. Y2 U7 p/ q7 y" b# k* I
mation, resulting in an extensive work-up for this+ r# X! d( n; N
child. Given the widespread and easy availability of! N. f9 I6 }0 j7 }8 x, i/ _
testosterone gel and cream, we believe this is proba-
0 {: r) a" W% [7 v' \& R/ v) ably more common than the rare case report in the
6 ]' w+ F9 y# Yliterature.4  w& H, L3 y- `9 c- x- g# X  N
Patient Report
7 Q8 p# ]( J+ v6 v0 P5 q2 uA 16-month-old white child was referred to the
3 P; Z3 l& S3 s' k5 d$ R; {endocrine clinic by his pediatrician with the concern
7 q1 s# s* X# Y, s% qof early sexual development. His mother noticed: _+ g0 d- ^/ ?$ j" f# L6 m
light colored pubic hair development when he was) B, n6 ]. D+ m/ ?/ ]
From the 1Division of Pediatric Endocrinology, 2University of
: K4 u$ X, s) Z4 x0 i! I$ GSouth Alabama Medical Center, Mobile, Alabama.
3 q. ^- M: p7 e5 p4 ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. Q) j/ @  n: p' B8 z. iProfessor of Pediatrics, University of South Alabama, College of% T' a5 G' u" p3 ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) U% |' A3 x; J# X/ |e-mail: [email protected].
+ T3 o" ^3 T% j) }! Gabout 6 to 7 months old, which progressively became! ~; L* O# Q. g( I; Z$ t
darker. She was also concerned about the enlarge-
7 e, A$ w  z9 F! O) Y% Sment of his penis and frequent erections. The child; D% _& j: {  z
was the product of a full-term normal delivery, with
; J4 F: c$ }! p' Fa birth weight of 7 lb 14 oz, and birth length of
- S' ?* D5 U# y1 {' \3 h7 E4 x20 inches. He was breast-fed throughout the first year" |) W# q5 C" M, n# H7 s
of life and was still receiving breast milk along with
1 I1 |( `* b2 Ksolid food. He had no hospitalizations or surgery,: n! k; m8 s, d- v; F8 }
and his psychosocial and psychomotor development
/ f! M0 \4 }$ k  r  J5 Qwas age appropriate.
9 k: ?  D; q, Y1 _9 m- n' c( c" g6 iThe family history was remarkable for the father,1 b6 L% l9 p9 e' f. N
who was diagnosed with hypothyroidism at age 16,4 e5 s: P$ p: s, I9 a  ^1 Z$ V
which was treated with thyroxine. The father’s
/ z  r  x, c6 M, m" bheight was 6 feet, and he went through a somewhat
! [/ N- ]2 Y4 o" G2 L* \early puberty and had stopped growing by age 14.
$ G5 R) P/ d4 \0 c7 F! NThe father denied taking any other medication. The# g+ E1 Z4 o9 K$ W0 a4 I4 l* y
child’s mother was in good health. Her menarche
# [5 x! ~1 Q9 kwas at 11 years of age, and her height was at 5 feet' K" g. T4 q6 w" L2 G
5 inches. There was no other family history of pre-
. r/ Z( T) `' y+ zcocious sexual development in the first-degree rela-/ ?1 r4 c3 C. W7 r2 T5 I
tives. There were no siblings.
# q# h1 w& s. a5 \, sPhysical Examination7 O; G; k$ |! e8 R# s7 p7 `$ h
The physical examination revealed a very active,
  ~9 O% ^9 C8 g2 eplayful, and healthy boy. The vital signs documented
) d1 F" J7 v& P4 K1 F! ea blood pressure of 85/50 mm Hg, his length was
1 I6 K' _) x/ H) z9 B90 cm (>97th percentile), and his weight was 14.4 kg7 O$ `# @% w. R
(also >97th percentile). The observed yearly growth# p) F, s" }0 e0 D0 h
velocity was 30 cm (12 inches). The examination of) p7 i: n& x* ]# k. n3 Z
the neck revealed no thyroid enlargement.
7 @; u8 T  M& H- KThe genitourinary examination was remarkable for
, S$ g9 Z8 H  Z# eenlargement of the penis, with a stretched length of" ?3 a* c# |/ @7 }2 A4 r) q7 v) e
8 cm and a width of 2 cm. The glans penis was very well" R7 z) f8 X; d  ^! b* s
developed. The pubic hair was Tanner II, mostly around8 O3 t! H& B, A; t( e- N
540
# f. f! Y9 ~/ c: g0 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 ^+ M% z* j  c1 C6 M) k
the base of the phallus and was dark and curled. The( M: y# o- |$ v" f: P( l  Q# \
testicular volume was prepubertal at 2 mL each.
6 j3 h- R% H& ]. y2 h! d/ }The skin was moist and smooth and somewhat
' o8 ?6 y0 U/ i3 z# O% Ioily. No axillary hair was noted. There were no  G4 `% i% j$ N% W# H+ v' S& ~
abnormal skin pigmentations or café-au-lait spots.
) {( z8 M/ B0 k& dNeurologic evaluation showed deep tendon reflex 2+$ f) w; a; w0 W0 b
bilateral and symmetrical. There was no suggestion; e. m, G% v& T% p
of papilledema.& z* C; B& o2 X/ ~
Laboratory Evaluation2 h- j+ x" j2 T; e# j+ a$ N
The bone age was consistent with 28 months by& X  N9 Z4 W# }& x$ T9 S8 N) B' K
using the standard of Greulich and Pyle at a chrono-6 x  U  W- a. S0 n% [0 Q1 ~7 y
logic age of 16 months (advanced).5 Chromosomal
! \: R% \2 P3 |( ?) X4 Y" X( i6 Bkaryotype was 46XY. The thyroid function test8 m8 l6 v, d2 \  y) K7 N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( V0 \8 E6 U% E) V) K7 G9 p
lating hormone level was 1.3 µIU/mL (both normal).
& J. f6 P" q1 {% nThe concentrations of serum electrolytes, blood$ ~8 L  _' s4 k* l, f8 _: h  i
urea nitrogen, creatinine, and calcium all were
* O7 z+ a! G( swithin normal range for his age. The concentration+ b* ^$ C* a  v
of serum 17-hydroxyprogesterone was 16 ng/dL
4 C8 Q, E' h9 [  i. ~6 e: V(normal, 3 to 90 ng/dL), androstenedione was 20
3 ^' d6 P6 U2 B4 ]# x/ q" fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 m7 x$ ~8 G. z0 `. vterone was 38 ng/dL (normal, 50 to 760 ng/dL),; a/ B; ?" g! v5 I/ ~* |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 D' a+ J7 s9 v6 x+ ~6 k, M2 d
49ng/dL), 11-desoxycortisol (specific compound S)0 o2 d' P5 k: B! j/ h3 R$ }6 w, y% M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 {0 A( N8 c& e! Z" |% ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 j/ S" `2 M9 Y" X7 T  ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),) K6 L. A: K/ r0 a. {
and β-human chorionic gonadotropin was less than. d4 ]* x5 T. K$ \5 h
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  i4 U& F, X' a: Sstimulating hormone and leuteinizing hormone
4 u. d0 ^) z% e2 k0 }; J' ?concentrations were less than 0.05 mIU/mL
$ M) G9 F' r# K! N: W9 ?(prepubertal).( j; q5 ?3 f6 u) F4 I: |
The parents were notified about the laboratory
: I+ H! {1 F! Y$ {4 K6 @% O$ I8 tresults and were informed that all of the tests were
$ C( N% J# R' K' Tnormal except the testosterone level was high. The& L, r# J" l* E. m$ w& p% A2 p5 i! w
follow-up visit was arranged within a few weeks to
8 n" I$ Z5 ~: k, K+ a2 `6 _obtain testicular and abdominal sonograms; how-
( |2 k5 ?* ^8 Bever, the family did not return for 4 months.
0 S1 g  s2 ]  ^9 t* GPhysical examination at this time revealed that the
' D8 a# D7 j+ ^child had grown 2.5 cm in 4 months and had gained
9 U) p: s8 i, W2 kg of weight. Physical examination remained
0 G0 B$ ?+ o7 m$ Bunchanged. Surprisingly, the pubic hair almost com-6 q6 Y& _7 G) z. L. a& i, o6 P
pletely disappeared except for a few vellous hairs at. f4 v! ]& J+ B: d$ G0 x
the base of the phallus. Testicular volume was still 2/ Q! {9 ~! }- X9 F0 n
mL, and the size of the penis remained unchanged.% }5 R1 r7 n* J5 ~0 b! m
The mother also said that the boy was no longer hav-7 X! m% C) d' }2 j: ], R
ing frequent erections.
  u  }- ^1 Y1 |* ]1 y3 D, {. ZBoth parents were again questioned about use of
) _# Y* P3 b/ ~8 Uany ointment/creams that they may have applied to# B' |- @$ t, F- s
the child’s skin. This time the father admitted the1 M) i* R0 h( i) L* }) o
Topical Testosterone Exposure / Bhowmick et al 5414 Q" `% e5 s6 W9 Q6 N
use of testosterone gel twice daily that he was apply-: `. ?0 f+ j1 M
ing over his own shoulders, chest, and back area for$ R( L$ n  X- a
a year. The father also revealed he was embarrassed
+ q1 v7 v/ {  z) b9 n1 O; x+ Rto disclose that he was using a testosterone gel pre-
2 P  t1 L' ~8 cscribed by his family physician for decreased libido) Q( w) O5 K; ~5 r8 V8 I2 v
secondary to depression.
4 {) W6 `% h* q9 ^5 I: _* fThe child slept in the same bed with parents.
0 T% C4 q) G) n. DThe father would hug the baby and hold him on his
4 ^6 X( u$ j* ~$ D7 c' r$ @chest for a considerable period of time, causing sig-$ T' t4 e- b+ i4 L9 ~: Q2 d+ @
nificant bare skin contact between baby and father.7 H; Q) f8 O" g0 c5 n9 E
The father also admitted that after the phone call,
( }( l* S& w2 U9 }; Rwhen he learned the testosterone level in the baby* |  [" q9 L9 W) D
was high, he then read the product information
! H' F4 Q; B- Z8 e6 [packet and concluded that it was most likely the rea-
5 c! H4 w  u# L- i0 |son for the child’s virilization. At that time, they$ q; m& \( P' T/ C
decided to put the baby in a separate bed, and the
( {1 y" f- J4 O' ]2 _. pfather was not hugging him with bare skin and had. G3 K" q7 a" L2 o& T" s$ q
been using protective clothing. A repeat testosterone
. A+ R  P4 ~: [test was ordered, but the family did not go to the# M' H8 y% U) y( s& `
laboratory to obtain the test.- l" K& F' q# y- t0 i6 o3 \
Discussion
& V/ F5 B; Z$ y1 n) IPrecocious puberty in boys is defined as secondary
! Z" P/ v8 C. R5 F$ ^0 ysexual development before 9 years of age.1,42 m% X% W+ D4 A1 Q5 h  P" i& w
Precocious puberty is termed as central (true) when
, }4 N) ^! U* T* G' I8 Tit is caused by the premature activation of hypo-: P$ h) R4 Z& F2 c/ d! e0 z
thalamic pituitary gonadal axis. CPP is more com-+ P% E4 d0 r. X/ {+ @
mon in girls than in boys.1,3 Most boys with CPP
( e, ^8 z$ i6 K/ {: N) X! m& Z2 vmay have a central nervous system lesion that is
3 G3 ^) [/ W- W  J- ?6 hresponsible for the early activation of the hypothal-
$ R* m7 X$ I. N& j4 ?, damic pituitary gonadal axis.1-3 Thus, greater empha-1 s0 g7 g4 O4 a% n& o! S  C
sis has been given to neuroradiologic imaging in
5 k0 C" }+ L+ D& D. M; E7 cboys with precocious puberty. In addition to viril-
; c: j5 ]+ U8 {0 |4 V: e( Z+ a0 nization, the clinical hallmark of CPP is the symmet-  p& v$ A/ q9 b& z
rical testicular growth secondary to stimulation by
8 G9 u, }3 p8 k. }, i* N) s8 r8 jgonadotropins.1,3
$ W' Q/ [% q- A4 X; q1 l! I* NGonadotropin-independent peripheral preco-- o! E. ?2 Z" s4 s% d& \9 T
cious puberty in boys also results from inappropriate
4 q2 P2 J4 d+ D; w- mandrogenic stimulation from either endogenous or! u9 Y0 j& V# J- `& V( X4 C6 z% |
exogenous sources, nonpituitary gonadotropin stim-4 M( [# Y: G5 H( Y# J1 M6 @" g
ulation, and rare activating mutations.3 Virilizing4 D, c: s+ _$ Q. W: b1 c
congenital adrenal hyperplasia producing excessive1 A2 _( T+ j6 [! U0 f6 b6 n3 n. m4 ]
adrenal androgens is a common cause of precocious
# W$ t) ?, C& a; {9 Epuberty in boys.3,4
. X7 \* a- ?3 p+ Y& p2 X, gThe most common form of congenital adrenal1 c" A: X; _0 u$ Q1 R, U
hyperplasia is the 21-hydroxylase enzyme deficiency.
! r1 r' _+ M# q) a+ A% BThe 11-β hydroxylase deficiency may also result in" x6 e$ I% b. M3 i. h; c+ y
excessive adrenal androgen production, and rarely,8 ]/ P4 [( I6 {! f' C
an adrenal tumor may also cause adrenal androgen
: K1 E  Y. @9 D/ J7 rexcess.1,3% ?: g+ y8 r: i1 T6 D' J/ U1 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* Q/ G/ x7 s' B3 t6 E9 ?542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 v' f" G, `3 Y
A unique entity of male-limited gonadotropin-8 W; z6 n$ B- T  d" O. C+ H6 s+ u
independent precocious puberty, which is also known: w# L! R! W8 ~" X7 h
as testotoxicosis, may cause precocious puberty at a& I, H5 y) u- s8 _
very young age. The physical findings in these boys
$ x: H' i& U  J% S/ ~2 a- Qwith this disorder are full pubertal development,
  n" |0 k6 ~9 [including bilateral testicular growth, similar to boys
- K1 V% j) m& P2 I. qwith CPP. The gonadotropin levels in this disorder( \+ g, G! l- E) `5 m6 b# Y
are suppressed to prepubertal levels and do not show
! G1 C' d' K, O2 n0 u- R- Jpubertal response of gonadotropin after gonadotropin-
0 j; z5 \8 b9 i! Y3 n! u: areleasing hormone stimulation. This is a sex-linked9 S, N# P# Q/ i, ~0 d. U# ?9 m
autosomal dominant disorder that affects only
  P- P9 H  D7 `! t/ Mmales; therefore, other male members of the family8 \) h0 \4 v, H8 K" U
may have similar precocious puberty.3
( R3 N) y& I* yIn our patient, physical examination was incon-
; R- F! b9 [+ U; C' ysistent with true precocious puberty since his testi-- S+ L( R, o$ Y/ \9 O. d/ N
cles were prepubertal in size. However, testotoxicosis+ u5 R3 r  C) b! v1 H
was in the differential diagnosis because his father" C! J- H" _( d
started puberty somewhat early, and occasionally,$ ]5 a- N2 H* m
testicular enlargement is not that evident in the. n/ l& F5 U- n  M9 i
beginning of this process.1 In the absence of a neg-
+ r: t: V) g5 a5 Native initial history of androgen exposure, our
9 f0 t/ U9 p& g  Gbiggest concern was virilizing adrenal hyperplasia,
" C8 ]; W9 S! G! q8 xeither 21-hydroxylase deficiency or 11-β hydroxylase; h( f, f2 t7 h  l$ e. p! a
deficiency. Those diagnoses were excluded by find-0 b% }& v' l3 {" s/ p
ing the normal level of adrenal steroids.
! c7 v! C/ [% |The diagnosis of exogenous androgens was strongly
% E3 ]2 n+ w4 t+ e  Y7 Zsuspected in a follow-up visit after 4 months because
/ y5 b. S, i+ H3 athe physical examination revealed the complete disap-
% \5 H9 `& q8 Q" zpearance of pubic hair, normal growth velocity, and. d: r, w7 b* J! p
decreased erections. The father admitted using a testos-
) b5 t/ Q1 T$ K" Z6 V/ h0 vterone gel, which he concealed at first visit. He was7 d" g! b7 g  \1 @3 ?. c
using it rather frequently, twice a day. The Physicians’6 W3 J( x( J* @8 j) z3 _
Desk Reference, or package insert of this product, gel or
8 h3 h/ M4 _! j# s, A2 ecream, cautions about dermal testosterone transfer to
% J7 m$ H6 }( p  H9 U/ s3 Sunprotected females through direct skin exposure.
" a8 S# e0 K  @& NSerum testosterone level was found to be 2 times the+ t: T1 J8 Z1 \+ }
baseline value in those females who were exposed to
0 k1 |! b% q7 w' @2 ^% Xeven 15 minutes of direct skin contact with their male
7 d$ y" ~) k4 W; O; cpartners.6 However, when a shirt covered the applica-, D( B) T5 m) w
tion site, this testosterone transfer was prevented.* A; Y& D9 P- p- _7 L+ H* h
Our patient’s testosterone level was 60 ng/mL,  W% s# U+ m0 ~+ ?0 A( L. m
which was clearly high. Some studies suggest that
7 j, N1 n7 h7 Z# z: w& D; `dermal conversion of testosterone to dihydrotestos-- O0 }3 E- p2 I- B
terone, which is a more potent metabolite, is more
" x3 c/ g7 K* F2 sactive in young children exposed to testosterone& |% g% K$ q" c& Y% `! i6 B1 h
exogenously7; however, we did not measure a dihy-
- U: b. T% N; Zdrotestosterone level in our patient. In addition to
5 [" x/ k3 e$ |  Lvirilization, exposure to exogenous testosterone in' Y7 c$ z; h8 m; ^7 K8 Z' P# E& F9 b
children results in an increase in growth velocity and+ H6 x- }+ c6 L3 V& E* x, r% }
advanced bone age, as seen in our patient.3 C  e8 {; ?5 O! N$ [5 E  y- a
The long-term effect of androgen exposure during9 p* Y/ Y& X. i+ ~5 f( [
early childhood on pubertal development and final
: S  }; U* ^+ X+ a* hadult height are not fully known and always remain
+ U2 j* M6 |4 B- {a concern. Children treated with short-term testos-
; X' f  g* B  m( _# N' Gterone injection or topical androgen may exhibit some4 H, V+ ]: B( G% M0 R1 f2 S
acceleration of the skeletal maturation; however, after
# s# G  x% ~0 k1 A1 d/ ocessation of treatment, the rate of bone maturation
' z6 ?( H" S, p* `1 H. F% U$ u- Jdecelerates and gradually returns to normal.8,9  K1 ~" ~  w' a
There are conflicting reports and controversy
  F* H3 U0 X2 D) C) c* Cover the effect of early androgen exposure on adult
2 N( Y8 l# p2 n9 d8 m7 O4 X: L1 Qpenile length.10,11 Some reports suggest subnormal
+ Y3 _# F# i- C) M1 \adult penile length, apparently because of downreg-& w1 j  r% M  h+ r- O- z! K" G" L
ulation of androgen receptor number.10,12 However,) T: c/ G9 ^8 ], u
Sutherland et al13 did not find a correlation between! V" g; U" Y* t0 v3 r
childhood testosterone exposure and reduced adult5 }, l$ d/ G" O& M1 B6 \2 V
penile length in clinical studies.& ~6 ~, @" D' H) s1 C: V( A
Nonetheless, we do not believe our patient is, I( ]# [( m" S
going to experience any of the untoward effects from
, j: F* M! o" C$ j/ ftestosterone exposure as mentioned earlier because5 P7 X; p- E5 Y
the exposure was not for a prolonged period of time.6 @  T8 ?6 y: i, r4 T  X
Although the bone age was advanced at the time of, ~! z3 q! I; V! Z* N- F+ E8 d# r
diagnosis, the child had a normal growth velocity at
4 j: F5 U( n0 }/ J$ P5 A7 ]- X: Athe follow-up visit. It is hoped that his final adult
5 A6 S' V" a6 g  q% E( Nheight will not be affected.2 K9 Y+ k3 E( i$ l6 U) N5 j7 l* ]1 k
Although rarely reported, the widespread avail-3 O9 B. v: K: c+ Q9 ^! O
ability of androgen products in our society may
2 x: F) l" m, f" t+ I5 Y7 gindeed cause more virilization in male or female
0 t/ g) ^# X2 achildren than one would realize. Exposure to andro-
: U1 n, C  G) y3 O' pgen products must be considered and specific ques-" s' ]" m& r! N7 Q5 T4 z
tioning about the use of a testosterone product or2 ^" ?' g% t! c0 e9 B
gel should be asked of the family members during  Q6 k1 w9 s& C0 ~8 F- V
the evaluation of any children who present with vir-
4 D) D& E- y7 \8 J9 I! C' Oilization or peripheral precocious puberty. The diag-8 k( \  [3 M7 l7 Y. q
nosis can be established by just a few tests and by
1 ?# l  n! x( B. m7 C! k+ Y' wappropriate history. The inability to obtain such a
; t( L+ w5 g+ Whistory, or failure to ask the specific questions, may
0 O0 ~2 H1 U& I: `- a* F* g* W& gresult in extensive, unnecessary, and expensive/ B( [5 a' ]: \3 ~. K2 ]
investigation. The primary care physician should be/ H' y& |! r6 r# a$ h
aware of this fact, because most of these children
" [# q1 L9 f% e0 `+ imay initially present in their practice. The Physicians’
, T2 \2 p2 ~. S( n: oDesk Reference and package insert should also put a+ G, B) }3 T. C3 y6 D
warning about the virilizing effect on a male or  [; _( J# K0 F* ]. e. j( i
female child who might come in contact with some-
# V2 A- |) K1 K) W0 oone using any of these products.
$ a, j, ^2 |$ x/ g2 oReferences" b' m" x% r- w! @0 Q/ B% G5 `
1. Styne DM. The testes: disorder of sexual differentiation% O/ z* O$ J( O% P% X
and puberty in the male. In: Sperling MA, ed. Pediatric' M' ]/ r: g$ d/ H
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% }/ ~+ d3 d* r, n2002: 565-628.
) r4 L" \- v# W8 f6 |8 D2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; i4 n. ^! u  U, u
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

4 G( D9 H; `1 W9 x/ _. w) x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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