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Sexual Precocity in a 16-Month-Old
5 v, O1 b7 A8 J6 X. W! {% `Boy Induced by Indirect Topical
* i8 p: a. G' L0 A5 KExposure to Testosterone1 R0 r3 W9 P* T, _5 A  W7 k
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 H8 p7 U$ `8 S% b2 \8 hand Kenneth R. Rettig, MD1
& I7 I) w8 w! Z" AClinical Pediatrics, N9 g( V# Z8 \
Volume 46 Number 63 ^* e: U7 a$ P, j
July 2007 540-5439 T5 p" K; F7 x( u; u1 e* l8 p! h
© 2007 Sage Publications
! z, Z7 P3 y$ `, Q3 j1 Y6 v10.1177/0009922806296651/ R/ K0 }9 a' ?/ W
http://clp.sagepub.com. V- ~  F: X- ^- N- [
hosted at6 L, ?! C4 a" U. z+ C) E5 k5 I, G
http://online.sagepub.com# w6 I) Y+ n% y$ m6 O
Precocious puberty in boys, central or peripheral,
# k! a2 r* S! j7 d# Y+ `4 iis a significant concern for physicians. Central, N6 Z/ ^: a* `9 x- q- k
precocious puberty (CPP), which is mediated! D. r6 [' R* @/ B+ D$ \, x; V
through the hypothalamic pituitary gonadal axis, has7 z$ m5 E# a) |* p' y
a higher incidence of organic central nervous system- M: l. ?* `( G1 B  w
lesions in boys.1,2 Virilization in boys, as manifested4 ~$ k' |! |& U; n
by enlargement of the penis, development of pubic
& {' _* D1 }; V1 e" t% Chair, and facial acne without enlargement of testi-9 g/ Y7 j* N! n1 z; c+ G0 N
cles, suggests peripheral or pseudopuberty.1-3 We% `. E  V( P( j" O
report a 16-month-old boy who presented with the
3 y& h3 R' g$ f) i" ]' d( x% denlargement of the phallus and pubic hair develop-3 a2 J2 o9 C) `7 u) {
ment without testicular enlargement, which was due. r6 {" `4 R8 R6 Q$ n( t
to the unintentional exposure to androgen gel used by
) A( e/ A* X5 m2 H% ^* I3 K( hthe father. The family initially concealed this infor-3 j4 m5 X6 ?1 m9 l1 A3 k. O
mation, resulting in an extensive work-up for this
4 |3 g" L7 d/ \% d! {) e2 w& ~child. Given the widespread and easy availability of; h: w/ F- X. p. O' y# v
testosterone gel and cream, we believe this is proba-
0 W5 V( y  u8 N& z1 L. mbly more common than the rare case report in the
( M; v" c6 o+ d" G8 W7 cliterature.4
# @5 p( C, u4 J0 M1 R- M. w: WPatient Report7 d; e3 T1 i. r6 R. U4 c# e
A 16-month-old white child was referred to the
8 ^$ `2 A0 {7 A# `- \endocrine clinic by his pediatrician with the concern( V+ s% u4 }% h5 J  @& c
of early sexual development. His mother noticed% x1 A- Q/ O! ^% l
light colored pubic hair development when he was
' e: ~9 e) y- n. VFrom the 1Division of Pediatric Endocrinology, 2University of4 V( L  k) `) G( y
South Alabama Medical Center, Mobile, Alabama." h( s; m+ T0 A3 S& B: X
Address correspondence to: Samar K. Bhowmick, MD, FACE," u& A6 _: F& G1 Y
Professor of Pediatrics, University of South Alabama, College of
' L: l. m: U( V. a5 O% fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 p1 |& L0 K: }) ~7 J0 V+ H1 a
e-mail: [email protected].. r% X; J4 n  _1 U: l
about 6 to 7 months old, which progressively became
0 T) f8 }. I7 |darker. She was also concerned about the enlarge-9 v5 f  g6 Y- n; F( B3 a
ment of his penis and frequent erections. The child
1 d- m' K3 Y( A( Kwas the product of a full-term normal delivery, with/ A- K4 \, [' u- ?' E1 y  V1 E
a birth weight of 7 lb 14 oz, and birth length of8 X/ t9 ?& Q0 \5 u: M/ k2 j+ {
20 inches. He was breast-fed throughout the first year
4 y: E3 n8 Q, Pof life and was still receiving breast milk along with1 H+ z2 V& {: |8 r+ K3 ]  {) p
solid food. He had no hospitalizations or surgery,- s. C4 j" [# c; k6 i1 c/ M
and his psychosocial and psychomotor development
4 i; g; X5 P, c" S; F/ {0 awas age appropriate.* m( L$ f* K+ u. I6 B" P, T
The family history was remarkable for the father,4 ^( D& |) |- I  B" e7 j: R# j+ n- H
who was diagnosed with hypothyroidism at age 16,# ]4 K% U: A) s
which was treated with thyroxine. The father’s8 c1 a1 j+ b4 `5 n
height was 6 feet, and he went through a somewhat5 L- }* W+ Z  m* Y
early puberty and had stopped growing by age 14.
- D3 v  v5 G* i6 q' r# hThe father denied taking any other medication. The- \# p' L8 V" l
child’s mother was in good health. Her menarche
+ v- c& T& a4 Swas at 11 years of age, and her height was at 5 feet1 D2 r7 X5 y. l0 z  z3 X3 w
5 inches. There was no other family history of pre-
  r! G; v9 ?% ]9 ]cocious sexual development in the first-degree rela-
! V: Y2 B# x6 V3 v3 ?3 x' y2 V% e1 f3 c/ jtives. There were no siblings.4 S8 g' U# D# r0 [% i! k$ L
Physical Examination) Q: g$ |" R# M  m
The physical examination revealed a very active,/ `5 p9 D2 v$ O. k  S0 D
playful, and healthy boy. The vital signs documented5 a" _- ?* X, j+ B! R
a blood pressure of 85/50 mm Hg, his length was
2 G& D5 Z2 O1 g' C90 cm (>97th percentile), and his weight was 14.4 kg
2 o$ e1 \1 ^3 a(also >97th percentile). The observed yearly growth+ i+ r1 |; q: e& o2 |
velocity was 30 cm (12 inches). The examination of9 Y; K& Y5 U4 ^: t! X& l
the neck revealed no thyroid enlargement.
7 ]/ _- q; F0 h0 kThe genitourinary examination was remarkable for% J- w: X* [7 ^
enlargement of the penis, with a stretched length of2 v( i1 w% m- m' M
8 cm and a width of 2 cm. The glans penis was very well1 z5 N! d9 f1 c
developed. The pubic hair was Tanner II, mostly around
1 e. I# j& I% J# G6 l7 e; ^6 E540
' ^( R1 J7 s2 V' F4 jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 F' l5 R& B" T/ ]the base of the phallus and was dark and curled. The
- ^( m/ R$ l; J* n" @  P4 N6 ^testicular volume was prepubertal at 2 mL each.
$ l' _* B, w# @% {, I, W. v9 LThe skin was moist and smooth and somewhat
: G0 D4 Z2 K1 v- Toily. No axillary hair was noted. There were no) c" V, h8 A6 @- f, H- y
abnormal skin pigmentations or café-au-lait spots.7 B) R: g: I% k( f
Neurologic evaluation showed deep tendon reflex 2+' L3 s) J6 R4 j  g5 k! J
bilateral and symmetrical. There was no suggestion& |# H5 L# [8 o, b' Q
of papilledema.
0 S, ?6 ?2 u" t6 aLaboratory Evaluation% ~- V3 ]2 u1 J2 n0 {
The bone age was consistent with 28 months by- v. X5 P( c* }( c0 {
using the standard of Greulich and Pyle at a chrono-
! l- h2 a% K( b9 x  wlogic age of 16 months (advanced).5 Chromosomal
* ~. y$ \% l0 c1 R" ]: t) Xkaryotype was 46XY. The thyroid function test
. }0 f7 @8 t$ X7 R' F- Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-8 q0 |: ^) k# V& b9 A& [
lating hormone level was 1.3 µIU/mL (both normal).
! [! P* j5 a! d$ C* SThe concentrations of serum electrolytes, blood
5 k; r7 g9 l# r. n; f5 \! V5 xurea nitrogen, creatinine, and calcium all were, i+ C) c; g6 a2 G. V9 r/ a) G
within normal range for his age. The concentration
0 s4 ^* _( e% [6 N: ^, Lof serum 17-hydroxyprogesterone was 16 ng/dL$ R+ M$ w# ~+ H
(normal, 3 to 90 ng/dL), androstenedione was 20
) F: ?# w& k! c' c, _) J# n' Lng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, }6 V  X+ I3 F5 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& {, B5 B4 u* z" Y: u1 y( R0 i  adesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 T2 X2 ?( ]; O( G, E+ G
49ng/dL), 11-desoxycortisol (specific compound S)
) s- g. u& B0 H. Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 c' r5 _9 w- j3 E2 E% _! [1 htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; l3 w- a! K0 t- P, ]# {4 N5 T( E* {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ w% I( m9 k. E& |, {and β-human chorionic gonadotropin was less than: W* x7 G+ g' R2 |9 S0 n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 H9 r( i0 W( f6 Q+ ^) G. ystimulating hormone and leuteinizing hormone
" L* ?9 z. }: T- v- y. econcentrations were less than 0.05 mIU/mL
( E) i  s1 b6 b4 `- E8 ?$ Y. m, ](prepubertal).
: g2 g5 \6 O) m2 UThe parents were notified about the laboratory
( O1 P; H% f% L0 Z, H" vresults and were informed that all of the tests were
; j8 b9 t3 X; a1 M9 s0 V) x; lnormal except the testosterone level was high. The
5 e1 h+ M" ?+ n$ h. kfollow-up visit was arranged within a few weeks to
" m: \% C* o1 L$ E6 Tobtain testicular and abdominal sonograms; how-
' j2 P! S7 B/ s  gever, the family did not return for 4 months.7 i8 N( X3 P( b/ l; Q
Physical examination at this time revealed that the
2 \; {: S) p+ {0 C1 `8 _" x' T" Fchild had grown 2.5 cm in 4 months and had gained. d0 e% i+ J$ E' L) ^
2 kg of weight. Physical examination remained3 Y9 V0 J% q! ^7 i" P) i! f
unchanged. Surprisingly, the pubic hair almost com-
$ s* {) @: L- L- s2 b! Ypletely disappeared except for a few vellous hairs at, W3 e/ Q. ^& o* ]% f
the base of the phallus. Testicular volume was still 2( i7 m8 `5 L5 ?2 Y4 y
mL, and the size of the penis remained unchanged.
, ~( G  Q7 \$ ^5 `5 z$ q' z$ x: y2 X$ RThe mother also said that the boy was no longer hav-* m% x- U9 N$ r, {- `
ing frequent erections.
- X% H' h) v1 e1 r  |Both parents were again questioned about use of
+ D* p' z9 c' z# L+ hany ointment/creams that they may have applied to9 @& I7 e3 w  N4 P
the child’s skin. This time the father admitted the
4 R: |5 y: w- m3 n  RTopical Testosterone Exposure / Bhowmick et al 541( }/ T2 C5 E2 Z6 S5 z# b& q
use of testosterone gel twice daily that he was apply-2 }2 i$ e6 K8 w& x# Z- D; F/ R/ b
ing over his own shoulders, chest, and back area for
1 Z9 n3 n1 T; a, H' A& q: B4 za year. The father also revealed he was embarrassed8 a- ^5 Q) }0 ~5 j$ q: A; A/ [- M
to disclose that he was using a testosterone gel pre-
( u0 S' ?6 p" u, E. m% V; cscribed by his family physician for decreased libido8 o& l. F# n" g- P" y) z- a) Y
secondary to depression.: U4 ^( q7 E0 a( C( `$ u; n7 w
The child slept in the same bed with parents.
5 Y6 H1 t' e8 K9 k/ cThe father would hug the baby and hold him on his/ s( Z" I! m9 f
chest for a considerable period of time, causing sig-; [. e8 Y1 C7 N8 X; W. b3 {& b% S
nificant bare skin contact between baby and father.. w% k' I$ y) n! \2 m
The father also admitted that after the phone call,
% h* H/ N& t& g! ?: K, z4 U$ k2 jwhen he learned the testosterone level in the baby
  q/ {3 p% I5 Xwas high, he then read the product information7 c9 J5 ~! `; [& n" ~$ F- D5 G
packet and concluded that it was most likely the rea-  d4 V+ F) G1 j& s% T, A. O# l
son for the child’s virilization. At that time, they
: |, c2 \9 O$ q* S6 }2 j7 b! G. I6 L/ @4 @decided to put the baby in a separate bed, and the
3 Y3 c5 z1 N$ j0 B$ V2 U" p9 _# }2 [father was not hugging him with bare skin and had& }1 E8 L+ s# d" R
been using protective clothing. A repeat testosterone8 V: R) x) P" u2 K; }3 a) T
test was ordered, but the family did not go to the
) D6 l4 Y" V8 I9 B7 hlaboratory to obtain the test.6 F0 U4 o  k: I+ Q6 M. S- d0 {
Discussion
) L! o4 f4 [# [+ _' l9 uPrecocious puberty in boys is defined as secondary
9 A: |) W9 t0 K. @sexual development before 9 years of age.1,4
* B' g1 O. U. b. r; uPrecocious puberty is termed as central (true) when
5 D  s9 |# B$ O% l+ m' a5 x/ kit is caused by the premature activation of hypo-
% h* o0 f8 ?! d$ p" f( {1 H! T  Q, Qthalamic pituitary gonadal axis. CPP is more com-
+ f# l4 U* A# ?4 ^, ]  V4 ]mon in girls than in boys.1,3 Most boys with CPP, z6 J! g# h$ _# w
may have a central nervous system lesion that is
6 @" p4 P6 M' \6 {2 e. i* Y8 G# _, G" n$ rresponsible for the early activation of the hypothal-$ w7 a4 ^5 Z+ v# c- m* }1 ^1 ]
amic pituitary gonadal axis.1-3 Thus, greater empha-
4 Y: C7 [$ X( F7 [0 f2 k2 Z+ Usis has been given to neuroradiologic imaging in. m/ i) b5 W# n2 y7 A
boys with precocious puberty. In addition to viril-
4 z- [; p6 K) l% v4 yization, the clinical hallmark of CPP is the symmet-
: F, [- }6 @6 m7 \% Erical testicular growth secondary to stimulation by
5 v1 u1 i  ^# w# b/ i( ]gonadotropins.1,3
  b# L% |& Z  F; `& IGonadotropin-independent peripheral preco-
1 `5 e, ]5 H8 ?) A5 j2 R0 ~5 {cious puberty in boys also results from inappropriate/ G7 a+ q: j+ j# q
androgenic stimulation from either endogenous or3 B: L6 Z5 ]) i
exogenous sources, nonpituitary gonadotropin stim-
) a( ]8 Q6 M. H$ {3 c4 Qulation, and rare activating mutations.3 Virilizing
7 s0 u+ V0 J3 A% F7 o6 gcongenital adrenal hyperplasia producing excessive( J/ o& }4 Z: ?9 e; u
adrenal androgens is a common cause of precocious
: T% F- Z$ U  t2 \1 {) A9 m( Jpuberty in boys.3,4% x( X) Z8 Q) ~* n8 d, c- {
The most common form of congenital adrenal0 T. g' H+ E: W0 c4 m) b4 y
hyperplasia is the 21-hydroxylase enzyme deficiency.
! z9 I% H- l" ?The 11-β hydroxylase deficiency may also result in3 r. J' x" L/ j$ I/ A3 W1 p
excessive adrenal androgen production, and rarely,% @& R: H# f2 l  S% z
an adrenal tumor may also cause adrenal androgen; r( ^# c9 v, @$ _
excess.1,3% I& T' q. k4 \7 M$ y2 Y1 J. S. I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 ]4 g4 @% a# ?, _2 R! T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 t7 C% N6 }0 i" ]A unique entity of male-limited gonadotropin-$ E* I1 @/ j- q7 u0 X- r8 s
independent precocious puberty, which is also known2 N! L$ G% R( R5 d
as testotoxicosis, may cause precocious puberty at a
/ z7 o" M% O1 U! overy young age. The physical findings in these boys6 I' x, ?/ `) T  f2 M) n
with this disorder are full pubertal development,
5 k9 Z! o# M  f% t% x0 a6 \including bilateral testicular growth, similar to boys
: c  I! k+ D% H3 L, L9 s0 zwith CPP. The gonadotropin levels in this disorder& [! a$ x' A% @+ W4 @, g
are suppressed to prepubertal levels and do not show
' Y# U! C6 Z- A5 b& q' [& e1 }pubertal response of gonadotropin after gonadotropin-' X; i9 N/ G: f7 n6 C
releasing hormone stimulation. This is a sex-linked
! }/ c) {; d' hautosomal dominant disorder that affects only) f- R7 C3 W, c: p
males; therefore, other male members of the family3 @4 O& ^3 {- V( z4 B1 y6 m5 M" ]
may have similar precocious puberty.3
  P# `- C) {. f8 W! }9 rIn our patient, physical examination was incon-, W# e8 P  q1 }0 m: Y
sistent with true precocious puberty since his testi-
6 R. X2 H: P! t9 A) E8 Rcles were prepubertal in size. However, testotoxicosis& H+ [" R/ J8 I6 W
was in the differential diagnosis because his father
4 w8 B2 z( Y4 o4 z+ ?# o( `/ gstarted puberty somewhat early, and occasionally,
! c2 k$ v% d2 b7 h8 t) W: jtesticular enlargement is not that evident in the
0 [. W$ c3 q" a# |8 a  E: ?, J. Z9 W& F1 qbeginning of this process.1 In the absence of a neg-
0 z( z% p: b8 s, pative initial history of androgen exposure, our
+ [- B; T" P' h- J9 e3 _biggest concern was virilizing adrenal hyperplasia,
9 y* j$ t, k. W' H7 u2 Peither 21-hydroxylase deficiency or 11-β hydroxylase8 t& F0 v0 E& X0 c
deficiency. Those diagnoses were excluded by find-( G6 H" u$ x. P% E1 u# A1 a
ing the normal level of adrenal steroids.3 A( ?" v% }2 |, ]' p" s
The diagnosis of exogenous androgens was strongly/ h) C: y7 Q( i8 ~! o; S* \/ T  I
suspected in a follow-up visit after 4 months because8 v  z* D$ N; ]$ g: _3 f
the physical examination revealed the complete disap-7 M% K) n  W- c9 i6 ~$ j
pearance of pubic hair, normal growth velocity, and1 O+ A% m- ?$ T
decreased erections. The father admitted using a testos-
" F  B) o. w( O+ Oterone gel, which he concealed at first visit. He was
! l1 a- t" N. ?( O0 a! Gusing it rather frequently, twice a day. The Physicians’
: U1 S# Y! o2 V8 F9 HDesk Reference, or package insert of this product, gel or/ I: o! {4 [$ j' Z/ X9 t
cream, cautions about dermal testosterone transfer to. c: \+ v- c, r1 q: G" P- T
unprotected females through direct skin exposure.
- n$ K" W# w& r0 K# y/ b( nSerum testosterone level was found to be 2 times the* H# b4 k* l  t2 ?6 b  p5 T. d
baseline value in those females who were exposed to+ k0 I& `% a5 z0 H  ?" i' M
even 15 minutes of direct skin contact with their male1 t9 m7 A5 `6 n5 U# Z* G4 w
partners.6 However, when a shirt covered the applica-7 w* j% `1 ]( P) l4 }
tion site, this testosterone transfer was prevented.' T4 C& O; T, ?2 {/ A* x
Our patient’s testosterone level was 60 ng/mL,7 y$ V$ G/ R' |) Y' @6 X; }0 z$ Z
which was clearly high. Some studies suggest that* l+ Y5 d1 P; m- b- U* m1 N7 f
dermal conversion of testosterone to dihydrotestos-  P5 b$ h/ F$ s0 S( n& |8 {
terone, which is a more potent metabolite, is more
+ a5 Y, z6 l1 t: x" a: u. v/ aactive in young children exposed to testosterone
% }% L; f1 P" d( `exogenously7; however, we did not measure a dihy-- R9 i# I+ `; j
drotestosterone level in our patient. In addition to
- ?: `9 Q0 M8 S- Y8 w# V- Vvirilization, exposure to exogenous testosterone in) l3 ]! I" Q3 M
children results in an increase in growth velocity and# N9 t( G$ i+ p2 E! ~2 y
advanced bone age, as seen in our patient.7 k) O* @! |. _: q0 v. M8 `
The long-term effect of androgen exposure during
! j4 v1 p6 v$ N' K- Bearly childhood on pubertal development and final
! T. c& x5 W' q3 _& x5 vadult height are not fully known and always remain& J9 L& M1 {! e6 w9 p7 @$ B, U
a concern. Children treated with short-term testos-
% d. h$ n% Z5 t1 M, vterone injection or topical androgen may exhibit some
" m: s- \) j/ l) k- M$ C# [4 gacceleration of the skeletal maturation; however, after" v9 X  x0 `9 f
cessation of treatment, the rate of bone maturation# D  z. v# D* X2 |, A! K
decelerates and gradually returns to normal.8,9! z0 P' w' d2 f: g% P) m5 Q% H
There are conflicting reports and controversy
) Z. t. S" e7 O& I" \5 fover the effect of early androgen exposure on adult
' _, U# a( x' I8 Rpenile length.10,11 Some reports suggest subnormal3 i/ m1 f4 X  i+ u( n1 p, P
adult penile length, apparently because of downreg-1 R$ p8 f5 S( w, y9 t
ulation of androgen receptor number.10,12 However,
, [# J$ I+ }5 Y; b& o( x: j& P; {Sutherland et al13 did not find a correlation between
9 B0 K2 f3 ]* D& Kchildhood testosterone exposure and reduced adult, p7 ]8 l8 c9 D4 a
penile length in clinical studies.  t! V6 t& s3 T/ X5 L+ x' E3 N
Nonetheless, we do not believe our patient is5 j9 C4 X. x% r: K0 E. H; f
going to experience any of the untoward effects from# |+ X3 V1 n( @& ]1 l
testosterone exposure as mentioned earlier because
* D7 ]! i+ |2 ~* f: C) }4 F2 |& ethe exposure was not for a prolonged period of time.. A9 A+ B# B: ^+ A; w! W- z" n
Although the bone age was advanced at the time of# l0 _' A* E& O6 p; A/ e# J
diagnosis, the child had a normal growth velocity at- X3 [5 v% y+ h# q" `
the follow-up visit. It is hoped that his final adult
; \, J- D1 U8 X; |9 [height will not be affected.
' x8 T1 [% D) v& J( H4 YAlthough rarely reported, the widespread avail-
0 D0 y  T3 x2 k3 Y+ zability of androgen products in our society may0 l$ y+ j; [9 C0 }$ E- ]
indeed cause more virilization in male or female5 ^# u% Q9 e7 G8 S! c  C4 X
children than one would realize. Exposure to andro-
; m0 m6 \2 F: {3 v8 hgen products must be considered and specific ques-
- _& x* Q# e6 A' Z$ h* ?+ z7 Gtioning about the use of a testosterone product or' s; B( j3 R, T6 J) ?
gel should be asked of the family members during: l# f" v# j/ e$ g6 r7 e9 g" J/ K
the evaluation of any children who present with vir-
6 w, F% ]* F9 M* Z. cilization or peripheral precocious puberty. The diag-
% E& h$ i& L1 j/ Anosis can be established by just a few tests and by, W8 x0 n/ H* u" J! ?
appropriate history. The inability to obtain such a1 ]( g" x  b% ]
history, or failure to ask the specific questions, may
0 v. {. c( K# ?! K( Z6 }' oresult in extensive, unnecessary, and expensive
, W) d( e$ E" E' xinvestigation. The primary care physician should be& u/ Y( C" A, ?9 F, W
aware of this fact, because most of these children' O: f, ]: y5 B
may initially present in their practice. The Physicians’- o: j3 f/ l, L! K3 h2 V: w
Desk Reference and package insert should also put a2 O  u; _+ n/ ?8 o) D& a4 E5 B
warning about the virilizing effect on a male or
6 m7 X" n: M5 D' l1 K" e) Lfemale child who might come in contact with some-- ~- _( I( Q4 w) B7 T" J/ W
one using any of these products.
4 R0 a5 E0 W8 Z8 N8 H( P4 {0 j  tReferences( {- _+ O  X( W  b/ u6 _
1. Styne DM. The testes: disorder of sexual differentiation
6 L' p$ [2 E/ @2 L1 z, Pand puberty in the male. In: Sperling MA, ed. Pediatric9 @- {1 G, L/ m) x  P
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 a3 j. W8 y8 K) U' m2002: 565-628.
, L1 _" ^4 R0 o5 b/ R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 n* a9 X, t. fpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
5 q# `. v3 ?) W2 k/ l% _$ CBoy Induced by Indirect Topical
# G$ f5 o# w2 ~. v4 W3 Q6 EExposure to Testosterone
. ~! w: `( Z- n+ ZSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 M+ l+ G6 h# |. D
and Kenneth R. Rettig, MD14 h: n, x" }0 B. s/ a
Clinical Pediatrics
, E, Z( z+ z( W" [- W1 ?Volume 46 Number 66 f3 ?6 C* I9 a1 H
July 2007 540-5431 j$ S6 y  Z/ t8 ?
© 2007 Sage Publications
0 x0 g$ b( s3 q, S/ K10.1177/0009922806296651
" x4 O5 Y( @+ x$ Q! Dhttp://clp.sagepub.com2 j- m+ @3 T- h2 k; _
hosted at7 I2 [% @% N& e# V+ A
http://online.sagepub.com
7 G, u$ O5 k2 j' `( B( h+ qPrecocious puberty in boys, central or peripheral,( B' w8 T4 U8 }
is a significant concern for physicians. Central
% U3 x0 A8 q' ^2 zprecocious puberty (CPP), which is mediated& S5 s$ Y! L4 @: c! i' j
through the hypothalamic pituitary gonadal axis, has# t6 u& g# J# ]: y+ A. K
a higher incidence of organic central nervous system
6 N8 ~9 I6 t, ?" N, S% d  ]lesions in boys.1,2 Virilization in boys, as manifested' w4 a+ |/ V8 v% R7 d, y& V
by enlargement of the penis, development of pubic2 a$ a* m5 _, u
hair, and facial acne without enlargement of testi-
, D, V6 @$ R, fcles, suggests peripheral or pseudopuberty.1-3 We2 g+ F4 x0 B& `9 ?9 m7 n
report a 16-month-old boy who presented with the- H2 A. L" j! ]% ?
enlargement of the phallus and pubic hair develop-$ t. ?  G& Y0 Y
ment without testicular enlargement, which was due  z9 h' W) P  o# n$ ^# v! f: r
to the unintentional exposure to androgen gel used by
, Z1 M. @" q- ?# ?the father. The family initially concealed this infor-# ]  f+ I3 Q$ r8 I9 W* _
mation, resulting in an extensive work-up for this
* {) M+ L  i+ mchild. Given the widespread and easy availability of
! z- P6 A3 b+ T) l& F  I7 Utestosterone gel and cream, we believe this is proba-( u$ L6 g9 C  D- ?5 P! |8 Y! k1 C
bly more common than the rare case report in the
6 w, W# ~, e) \8 y% h/ Bliterature.4" Z5 A- _' f% g8 \/ ~2 v
Patient Report
' K% c7 C6 E) U& m" j( VA 16-month-old white child was referred to the
0 H1 n. u- I" S4 @6 Kendocrine clinic by his pediatrician with the concern  q* |1 Q8 @: _  [0 l! z* a% k
of early sexual development. His mother noticed
: S) C, W) ~! o% nlight colored pubic hair development when he was) @5 d* S) Q) h
From the 1Division of Pediatric Endocrinology, 2University of6 J, R. k2 I, o8 a+ e2 G
South Alabama Medical Center, Mobile, Alabama.' ~9 ]+ M, j% C
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 d& S; q. G2 a$ b) z5 \" rProfessor of Pediatrics, University of South Alabama, College of) Z* c0 u8 d7 C+ P, R4 i
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% e' C( I# W) D7 n! }8 k
e-mail: [email protected].
: L  I& V8 ^$ k8 C# D9 Nabout 6 to 7 months old, which progressively became0 N5 R% F6 p/ [# }" h
darker. She was also concerned about the enlarge-" a$ z8 {$ a$ `. ~
ment of his penis and frequent erections. The child# B8 V, o- j* v7 D! }& D' e
was the product of a full-term normal delivery, with" v( ^2 R. H$ D+ M  K  \$ L) Z
a birth weight of 7 lb 14 oz, and birth length of! s0 _0 h1 W/ o7 o2 k) [4 e3 W
20 inches. He was breast-fed throughout the first year
, R& ^6 R, O( Q$ |" m& S  y* X5 C! S4 gof life and was still receiving breast milk along with
" S! b- u7 d7 w. o) ]( D0 b9 x+ Bsolid food. He had no hospitalizations or surgery,1 l+ \- a9 F9 ~9 s' B3 }( H
and his psychosocial and psychomotor development9 A6 X0 m6 d8 o' N& C3 U3 r9 {1 P
was age appropriate.
8 K9 E, x9 {: W& ^2 kThe family history was remarkable for the father,
+ P) @0 P7 }8 E- U, D; Y- `who was diagnosed with hypothyroidism at age 16,6 e, C  i0 |' v( n
which was treated with thyroxine. The father’s4 a6 p9 F) m" i
height was 6 feet, and he went through a somewhat
" N- w: T2 F3 O6 ?; _early puberty and had stopped growing by age 14.3 ]7 ?, p7 e/ \! j( g) g
The father denied taking any other medication. The* L0 T9 F' u) n8 V! O) `
child’s mother was in good health. Her menarche
1 \: b; s8 k1 twas at 11 years of age, and her height was at 5 feet
# F3 D  B5 s! c# j, ?/ z3 Q5 inches. There was no other family history of pre-) f6 {2 N+ ]1 y/ U3 \" @- S3 j2 U
cocious sexual development in the first-degree rela-$ a; a8 f* T' e$ b0 q
tives. There were no siblings.
6 c0 G1 D- x9 k% `Physical Examination
& l6 B3 N# |* M" M( M* E  pThe physical examination revealed a very active,
$ E$ k) p2 T3 n' C- O/ K, Gplayful, and healthy boy. The vital signs documented' X0 F& @, k  K2 d$ @: x
a blood pressure of 85/50 mm Hg, his length was  L# [) r  U7 l
90 cm (>97th percentile), and his weight was 14.4 kg
6 z  V: G+ n8 A( y. o; `4 J( H(also >97th percentile). The observed yearly growth7 _( |7 v* b5 {! G
velocity was 30 cm (12 inches). The examination of
. {- T; Q( D7 h" F) G# L4 |3 h- U6 Xthe neck revealed no thyroid enlargement.' a7 z4 y: T% B5 B& I
The genitourinary examination was remarkable for3 c% S& \! ^7 k' }% f
enlargement of the penis, with a stretched length of
( N+ u' {! b1 }' S+ F( p; ~8 cm and a width of 2 cm. The glans penis was very well
9 U8 H1 v& a! l- ~) r) X$ O* g6 c& J9 xdeveloped. The pubic hair was Tanner II, mostly around0 |# [0 f, X( t; x. \( I# B. o
540- u9 a$ x* J7 s) b4 S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 l+ a' q9 z5 U- r8 ]the base of the phallus and was dark and curled. The8 x1 ^/ A  I: ?
testicular volume was prepubertal at 2 mL each.
% s1 v6 n: n, ]The skin was moist and smooth and somewhat
+ a, C4 C7 o5 f7 V3 `oily. No axillary hair was noted. There were no
# J! W& D! v7 j0 N* i# {8 Gabnormal skin pigmentations or café-au-lait spots.4 i& w2 X5 d$ s& S0 t
Neurologic evaluation showed deep tendon reflex 2+
4 x7 v: P3 C" ~0 S, k; i. h: ybilateral and symmetrical. There was no suggestion
* S* H* n' i( B; C# H4 [) |of papilledema.8 e/ ^7 Z" B- \( S" p/ e" N% U
Laboratory Evaluation( L0 J$ C4 \& z. B. |
The bone age was consistent with 28 months by
* c4 P2 Q# X  d3 Kusing the standard of Greulich and Pyle at a chrono-
! Y( v0 l) Z: K5 |logic age of 16 months (advanced).5 Chromosomal- b% f5 G' K* ^+ H7 H
karyotype was 46XY. The thyroid function test
- Z+ y9 A0 g% U0 {: g! b+ tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
- Z* F; u7 U7 M! c4 ~5 A* dlating hormone level was 1.3 µIU/mL (both normal).
7 a- i- p; {9 aThe concentrations of serum electrolytes, blood
7 A9 B2 \, e2 _, l9 q; b. @* O0 Wurea nitrogen, creatinine, and calcium all were
' t8 ?" K% C/ a# V( Z3 ^3 bwithin normal range for his age. The concentration! `  G* v. K# a" p% _
of serum 17-hydroxyprogesterone was 16 ng/dL
. \8 h' h' o4 A(normal, 3 to 90 ng/dL), androstenedione was 20
# F  O4 C; b( p. i4 b7 ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; J) @5 J6 u3 k8 y. D- A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ ^% r$ f- \- Q: u, k6 z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: [8 O4 }8 x4 v) O49ng/dL), 11-desoxycortisol (specific compound S)
6 u% n6 |2 _, N0 h% zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. p/ p% T) T8 N1 i# utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 w& W# g3 ?# j: |) T% Y; {& ?2 {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 Z* k' D( w. r- S6 f$ F+ Q
and β-human chorionic gonadotropin was less than
2 V4 R" j5 g% ?) O5 mIU/mL (normal <5 mIU/mL). Serum follicular
( c4 I- i% R/ m+ k1 h- F# Sstimulating hormone and leuteinizing hormone0 m+ |* a$ U) k# q2 z
concentrations were less than 0.05 mIU/mL  x0 _" [( }2 v( Q: ^+ {
(prepubertal).: r6 B: V9 B( c1 _( |
The parents were notified about the laboratory
+ L+ ^# y7 U, M: u) j* Eresults and were informed that all of the tests were
0 P5 ?8 A7 @+ Nnormal except the testosterone level was high. The9 f1 u3 G3 ]% G6 x
follow-up visit was arranged within a few weeks to
  b8 b- {" t: [0 a# ?/ k8 ]9 Zobtain testicular and abdominal sonograms; how-  u  o4 D% Q+ M4 d; z0 V% Z
ever, the family did not return for 4 months.( d* \) M2 A. ~4 [
Physical examination at this time revealed that the! @8 ^2 e+ E; M2 W9 z" o  p
child had grown 2.5 cm in 4 months and had gained
" f. R) A& ^! h4 ~7 ~2 kg of weight. Physical examination remained
8 V  a1 M" K5 F; j0 w, R% munchanged. Surprisingly, the pubic hair almost com-
. ^2 Z& E2 Q; k7 b5 M/ T! s& rpletely disappeared except for a few vellous hairs at/ b2 v& \3 B* y2 Q0 U& \1 L
the base of the phallus. Testicular volume was still 2; Q1 P: i0 N/ _# ^/ c) |4 _, f
mL, and the size of the penis remained unchanged.* K" X7 S: h2 E- r1 p% v
The mother also said that the boy was no longer hav-
0 P- d; c4 U5 D+ {. sing frequent erections.) ]. N& Q$ l. J  k' `( }
Both parents were again questioned about use of$ T" r# z( `7 r4 U5 ~! i8 [: `
any ointment/creams that they may have applied to
& m/ V7 r% w' `# ^0 R& p3 j' tthe child’s skin. This time the father admitted the
2 H/ t3 I5 v5 n3 S6 ]) {8 aTopical Testosterone Exposure / Bhowmick et al 5411 U8 M7 E5 j, s' l4 a
use of testosterone gel twice daily that he was apply-# n, N% w5 b; R8 t
ing over his own shoulders, chest, and back area for  r2 W/ x* [' Y) @9 t9 S+ F
a year. The father also revealed he was embarrassed/ ^. J% B4 X6 Z5 }0 _% D+ E; ~5 R5 X
to disclose that he was using a testosterone gel pre-" U! I; x( t+ C" l) }
scribed by his family physician for decreased libido& k' \+ {& H8 [7 m- a, o
secondary to depression.
  {/ s4 N% Q, [& h5 z6 wThe child slept in the same bed with parents.
; v1 U, J0 \% B6 ?, E. F$ QThe father would hug the baby and hold him on his. a' ~2 f( Q) ?9 A) L
chest for a considerable period of time, causing sig-
- z; u- u. P8 }5 w  Xnificant bare skin contact between baby and father.0 u. ^7 q; g4 |4 ^5 @2 S: Q
The father also admitted that after the phone call,
6 @* N5 O7 k; `% H( xwhen he learned the testosterone level in the baby. f. `* G3 i$ i7 t- A5 |8 v' I
was high, he then read the product information
, V0 F4 x: L9 Z& a9 e$ |packet and concluded that it was most likely the rea-
# B# ]) Q/ u- R3 Q% dson for the child’s virilization. At that time, they
8 U% @9 M# Q5 K) n* h" ndecided to put the baby in a separate bed, and the
. Z0 n3 q5 P0 [. I2 wfather was not hugging him with bare skin and had
+ x4 J2 ?3 y/ n+ ^' R$ ]  s0 {been using protective clothing. A repeat testosterone
% G4 n/ G/ `; |- stest was ordered, but the family did not go to the
2 x2 @$ N/ ^$ N* b$ ]; Glaboratory to obtain the test.
6 p5 l0 |4 {% n# L8 f( z% gDiscussion  B+ @# @0 O6 F. b8 n+ ~. X/ Z
Precocious puberty in boys is defined as secondary5 K4 V7 A7 `# ~
sexual development before 9 years of age.1,43 H5 B/ U% f; N3 R
Precocious puberty is termed as central (true) when+ {9 _0 `3 r; X) j9 Y, A* q1 [" X  U
it is caused by the premature activation of hypo-
& @7 e6 u' F+ @6 ?- @( othalamic pituitary gonadal axis. CPP is more com-# `" u7 C; {: b# X! z+ e9 @. H
mon in girls than in boys.1,3 Most boys with CPP9 l8 C! _7 O- Q  f& ~7 d' p' u
may have a central nervous system lesion that is
+ \; @; [3 l" Cresponsible for the early activation of the hypothal-
; ]$ I; E' n( l% Q0 ]amic pituitary gonadal axis.1-3 Thus, greater empha-; ^* F! \; B* T" ^7 V# `
sis has been given to neuroradiologic imaging in' R0 B3 K' T2 ?0 r; ]2 y* n
boys with precocious puberty. In addition to viril-" O6 |7 M: f" E4 [, r* t3 J! ~: R
ization, the clinical hallmark of CPP is the symmet-" W/ E# W+ G5 [5 |+ A
rical testicular growth secondary to stimulation by# G* \* x( k; {
gonadotropins.1,39 Y3 @* j) G0 z6 m, t: E6 ?" c3 s9 h
Gonadotropin-independent peripheral preco-: A5 w2 K2 Q4 e6 {7 }
cious puberty in boys also results from inappropriate
# Z4 J! _3 I' Vandrogenic stimulation from either endogenous or. s$ x5 h% j4 r
exogenous sources, nonpituitary gonadotropin stim-
# d8 `! q% ]0 s; Wulation, and rare activating mutations.3 Virilizing5 D; a# z2 q' r$ d* g2 y6 k
congenital adrenal hyperplasia producing excessive
" u5 G7 K/ Y8 H7 c) Yadrenal androgens is a common cause of precocious- t7 i  \/ {1 X- O6 g: v" W
puberty in boys.3,45 A! H5 S# K2 r( h) X
The most common form of congenital adrenal
0 a5 n7 |6 V' {( m  M; Rhyperplasia is the 21-hydroxylase enzyme deficiency.0 n) s! G2 ]$ V% \
The 11-β hydroxylase deficiency may also result in
) w! S! ]- y1 A* _excessive adrenal androgen production, and rarely,* x3 [8 h" l' Z& l" N
an adrenal tumor may also cause adrenal androgen
& i) n! Y5 ~6 {: w4 o1 {0 Wexcess.1,3
: T9 t# p5 ~* z7 Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% P+ O1 |+ B' p1 r6 W6 B% z* G
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 A- x' j8 K9 t$ _& J) k4 `, U
A unique entity of male-limited gonadotropin-
% I4 H; D1 Q' ?9 Y* hindependent precocious puberty, which is also known0 P  \+ @9 ?: n5 }
as testotoxicosis, may cause precocious puberty at a
5 O, _( N$ d. h1 Hvery young age. The physical findings in these boys
3 H& K4 b) X5 z7 M, s" ~. i. Fwith this disorder are full pubertal development,1 f) F! d+ M9 p; P( i) m" k( w
including bilateral testicular growth, similar to boys
' @- c- x: U# ?, }5 ~+ f) Awith CPP. The gonadotropin levels in this disorder  e* V( z9 A1 B( j
are suppressed to prepubertal levels and do not show- P& T) B5 c' e; w5 P; b) i
pubertal response of gonadotropin after gonadotropin-$ z. c, n8 h7 Z! ^7 {
releasing hormone stimulation. This is a sex-linked) K! L! \# n' P. ?/ L4 B0 k
autosomal dominant disorder that affects only
  }4 q. k; e* _males; therefore, other male members of the family
0 V$ `: c, X4 v1 omay have similar precocious puberty.3
+ z2 z" V  S: vIn our patient, physical examination was incon-
9 A$ A$ f5 V' z9 T3 d+ o8 fsistent with true precocious puberty since his testi-5 g. F4 |; j7 p( a* i
cles were prepubertal in size. However, testotoxicosis; `8 i) p0 A$ A; S; j5 o. q% H( f
was in the differential diagnosis because his father
& a/ w1 W& h% C9 l' |+ t) Pstarted puberty somewhat early, and occasionally,
. [# {& Y: z$ p( j4 f. s1 G( v- dtesticular enlargement is not that evident in the
! B) ~9 g2 R( z5 ^, x* F' j' ^8 }1 k5 H0 _beginning of this process.1 In the absence of a neg-8 W" u. Y; r7 s! l' c
ative initial history of androgen exposure, our# t. ~) I* M4 w0 T  m) V% t5 _
biggest concern was virilizing adrenal hyperplasia,
  q% A8 o6 [' R( p9 j% Ieither 21-hydroxylase deficiency or 11-β hydroxylase
' T* c: @' M9 B6 q) t" [deficiency. Those diagnoses were excluded by find-* [; p9 S6 ]/ e' W
ing the normal level of adrenal steroids.7 p8 b2 Q0 Y  X9 u6 M5 c+ h; D
The diagnosis of exogenous androgens was strongly7 K* O  i* @; x  e1 p) i
suspected in a follow-up visit after 4 months because- T% K  A# n0 [3 o/ b
the physical examination revealed the complete disap-2 |* h' v2 t! }
pearance of pubic hair, normal growth velocity, and
# ?5 B3 M% R8 ?6 I- Q6 gdecreased erections. The father admitted using a testos-
; B) t# i) m4 l# fterone gel, which he concealed at first visit. He was2 ?- ?! B. m8 @7 ?) l$ [7 n
using it rather frequently, twice a day. The Physicians’
  q+ D  o! P( E$ kDesk Reference, or package insert of this product, gel or9 |: g: w& \" I! j/ G
cream, cautions about dermal testosterone transfer to
: {2 ]- }9 l$ S9 s) Ounprotected females through direct skin exposure.
8 L5 ^+ i1 W4 QSerum testosterone level was found to be 2 times the) {; I/ z5 c# C, m; y
baseline value in those females who were exposed to
3 c) @( u/ }2 E+ ~even 15 minutes of direct skin contact with their male
1 P" W3 [+ H* E5 Dpartners.6 However, when a shirt covered the applica-* s+ a% U$ o$ F
tion site, this testosterone transfer was prevented.* k9 j7 L& K) I5 s
Our patient’s testosterone level was 60 ng/mL,' L8 n; c  g/ @5 c
which was clearly high. Some studies suggest that( P$ U+ r( w9 ^2 h7 `$ y" t# S  o
dermal conversion of testosterone to dihydrotestos-
8 ~2 X+ ?. V% f+ H5 a7 g. _terone, which is a more potent metabolite, is more+ i. E3 `  f6 t
active in young children exposed to testosterone9 w. F9 I( V; a3 C2 r% |1 x
exogenously7; however, we did not measure a dihy-
$ `# [' n  F& r; Z4 Z$ mdrotestosterone level in our patient. In addition to
; N$ B% F1 i8 d6 D, x! V& fvirilization, exposure to exogenous testosterone in
, e/ I( P  T: k% H3 A! t! ichildren results in an increase in growth velocity and
8 P7 G; s! L" k  Padvanced bone age, as seen in our patient.; I# l6 U$ a# |5 j( |# [. h
The long-term effect of androgen exposure during0 ^3 y5 x6 s8 z2 H
early childhood on pubertal development and final3 R' C% D$ K0 _6 m& U# b
adult height are not fully known and always remain
( ^% C3 d$ K4 S( Qa concern. Children treated with short-term testos-
  `9 I! e$ a, ], F, Uterone injection or topical androgen may exhibit some4 H+ ~" Y5 b( n* f
acceleration of the skeletal maturation; however, after
3 t! w: H6 A) q$ |cessation of treatment, the rate of bone maturation; O4 ~' R+ b1 e5 B: b& f/ P# Q) F
decelerates and gradually returns to normal.8,91 D. _5 E3 i8 M) X9 G2 Y
There are conflicting reports and controversy3 X/ @8 Z" c7 \7 i3 U4 t
over the effect of early androgen exposure on adult
# V( C5 w* F5 x; [4 n8 ?penile length.10,11 Some reports suggest subnormal
: T) P) t0 b0 r0 Dadult penile length, apparently because of downreg-
( M* B- `0 G7 i* Q3 X. I5 lulation of androgen receptor number.10,12 However,7 A1 s: E2 \; L, F3 G( I
Sutherland et al13 did not find a correlation between
# D# t9 J( }/ h' Nchildhood testosterone exposure and reduced adult
& h5 c) [/ Y3 ?# K3 L  U' }penile length in clinical studies.3 e: ?! C1 l$ m8 E
Nonetheless, we do not believe our patient is7 }; B4 Z( B+ O. q. }# ], u
going to experience any of the untoward effects from
0 `$ i. s4 h) c% i2 q3 vtestosterone exposure as mentioned earlier because
4 s1 y8 G* v; [the exposure was not for a prolonged period of time.1 K2 V1 r& s2 w2 `
Although the bone age was advanced at the time of
6 o' r7 ]5 i4 Q7 |  r/ jdiagnosis, the child had a normal growth velocity at. u& x/ ~3 E3 T: S* |
the follow-up visit. It is hoped that his final adult, ~$ ~+ y# {5 e! ?" @
height will not be affected.% G9 c* a* ]$ W% B
Although rarely reported, the widespread avail-
0 y6 e- @: i# U7 h8 eability of androgen products in our society may
  {# [% Z) F2 [$ k: q* `7 c: v" b0 Zindeed cause more virilization in male or female
. d& b, M) b! ?$ ~& F% vchildren than one would realize. Exposure to andro-
, d/ U7 `3 M1 e6 s, o; t2 {0 y2 Wgen products must be considered and specific ques-( S. |! Q9 M% W; q/ e* N' N& Y
tioning about the use of a testosterone product or
7 x8 P- s6 X' D! g7 h2 V  w: [% _4 Ygel should be asked of the family members during; [8 T# V# I; k2 `/ |
the evaluation of any children who present with vir-
, R1 [  K# }' [ilization or peripheral precocious puberty. The diag-
& @. g9 K& U- Fnosis can be established by just a few tests and by
* w8 l1 [! e, J3 ~. H4 }. g" mappropriate history. The inability to obtain such a
- W1 Z! l% E- f3 R3 Mhistory, or failure to ask the specific questions, may. H3 @# H3 Y( p
result in extensive, unnecessary, and expensive1 ?3 _7 ?5 W6 L4 i7 J
investigation. The primary care physician should be8 V0 ]' O0 E' N) v. r
aware of this fact, because most of these children
, r  |0 W# ~1 U- f( Z8 ~may initially present in their practice. The Physicians’/ W8 n" a7 k1 S5 w' ~$ B. q4 [
Desk Reference and package insert should also put a
: v5 T) p: {5 o2 Qwarning about the virilizing effect on a male or
7 M- a6 d6 f( g. b( n6 |5 r6 bfemale child who might come in contact with some-# s- M( Q/ k8 c
one using any of these products.4 W  \; P3 R* I, r3 Q
References
# o4 i' v" E; Z  i9 J* G+ q1. Styne DM. The testes: disorder of sexual differentiation
# l! Q' }0 V% S5 R9 I) land puberty in the male. In: Sperling MA, ed. Pediatric
, W# K7 P+ l+ L4 Z. V! zEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 b4 R+ N3 o) H
2002: 565-628.) F: s. N7 U/ ~/ ~. T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' N$ K2 [* V5 M. r, Y. T% Y. k- Wpuberty 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

* l% t1 V# O. d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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