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Sexual Precocity in a 16-Month-Old
8 e4 i. H+ V3 B( B% h, SBoy Induced by Indirect Topical7 ~' ^0 }4 N3 [1 K" a5 ~
Exposure to Testosterone/ K& p6 `3 D& i+ ~* z% w& ?
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ |% U$ D) a/ d# [
and Kenneth R. Rettig, MD1: W2 j. X" n; }6 i
Clinical Pediatrics
0 q( P0 \5 x0 D$ [Volume 46 Number 6* v1 V: r5 u. ]2 |
July 2007 540-543
) y; u6 a: c+ ~© 2007 Sage Publications
( F! h0 Y8 y* @9 Q10.1177/0009922806296651
. i7 F* i, k2 e# H% Nhttp://clp.sagepub.com
5 b) c6 z+ ]$ z" ^2 K2 e% g2 L4 uhosted at
/ W( z0 L% ^( T: h1 A0 p/ x* uhttp://online.sagepub.com/ _! |+ O/ T( e+ O7 b* v( ^
Precocious puberty in boys, central or peripheral,! r1 q9 m$ d! B- V2 A  `
is a significant concern for physicians. Central6 H* \- B2 E: ^) o! ~
precocious puberty (CPP), which is mediated+ U8 i' K# j) q
through the hypothalamic pituitary gonadal axis, has
, {# a3 u8 o" b- s& F" }, }a higher incidence of organic central nervous system) P' \5 a9 Z3 w$ W/ z6 Y) ^6 ~- K- G( ]
lesions in boys.1,2 Virilization in boys, as manifested
8 p7 F) h' i1 w$ M1 `8 Rby enlargement of the penis, development of pubic( b4 ?+ D  k7 g7 i
hair, and facial acne without enlargement of testi-
% H0 @  q$ L" ~# {2 y2 t( tcles, suggests peripheral or pseudopuberty.1-3 We
2 Y. i; V7 o4 s0 ireport a 16-month-old boy who presented with the
. i. J/ r5 [  O: ^3 m4 G. `0 A, cenlargement of the phallus and pubic hair develop-
, |+ X. s8 `. Oment without testicular enlargement, which was due* @4 R7 A$ o0 Z! m# x  O8 L# t
to the unintentional exposure to androgen gel used by: h% e5 M( O! j6 r& w9 c% Y4 {9 M
the father. The family initially concealed this infor-# P5 Y! |8 `5 W
mation, resulting in an extensive work-up for this
0 a8 H$ h0 c# b9 B7 e2 }) S4 ^child. Given the widespread and easy availability of
  M8 o) h3 ^3 k" R) wtestosterone gel and cream, we believe this is proba-
4 t3 `, `6 L, ?2 o/ gbly more common than the rare case report in the" ]8 p, A2 [5 j9 g5 r- K$ B
literature.4
7 S4 |4 R: p; P2 Z# s8 ?) MPatient Report
4 t: }+ n% d: R+ U, b3 M$ {9 YA 16-month-old white child was referred to the; m: q+ W# J6 T* }
endocrine clinic by his pediatrician with the concern6 ]/ G5 ]+ z% ~. z1 @' ?3 k- {
of early sexual development. His mother noticed
$ Q5 h( ~7 i) k' {3 A5 Qlight colored pubic hair development when he was8 G- `8 Q7 ^$ K6 ~
From the 1Division of Pediatric Endocrinology, 2University of% P; s* M9 r7 v5 i  w" D5 G+ t
South Alabama Medical Center, Mobile, Alabama.6 a2 J8 d: I  W# B& d
Address correspondence to: Samar K. Bhowmick, MD, FACE,+ e7 _1 L# L. F( I& u, J3 P
Professor of Pediatrics, University of South Alabama, College of
9 e% Y8 n1 V+ X: r2 X+ |Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) e7 o9 [$ Y9 W8 k. O( I9 u
e-mail: [email protected].
  `. i1 y% g# {* vabout 6 to 7 months old, which progressively became0 E% \6 j( ^6 ]* o  E9 G) z8 A
darker. She was also concerned about the enlarge-& T( q; M, a. \' o) v" A! h
ment of his penis and frequent erections. The child
7 ~, t. P& `- z$ M2 v9 L1 i/ Xwas the product of a full-term normal delivery, with
' `, A+ m  _1 R2 Da birth weight of 7 lb 14 oz, and birth length of) L9 h5 E7 _; I" g5 `( h
20 inches. He was breast-fed throughout the first year
; j: j! P0 i' ^) \5 ^1 kof life and was still receiving breast milk along with7 h9 M- l' Y! w+ U$ \
solid food. He had no hospitalizations or surgery,& j4 @) q8 {. G' l+ v
and his psychosocial and psychomotor development
# {& }+ O& U( K; s9 awas age appropriate.- C6 F& J# ]# l; E
The family history was remarkable for the father,' B& l6 A$ s5 |
who was diagnosed with hypothyroidism at age 16,
( \5 @  {# f1 D4 ]which was treated with thyroxine. The father’s: t/ M0 k6 h! {7 \" E& K- C0 A
height was 6 feet, and he went through a somewhat, G# ?- F, Y* N5 n# e  J, c
early puberty and had stopped growing by age 14.# m5 r# }( R* E9 P# ^
The father denied taking any other medication. The" h9 ?" V# N$ Z( P0 S
child’s mother was in good health. Her menarche8 `3 f7 Q) V  [# h1 s7 n4 ?2 g
was at 11 years of age, and her height was at 5 feet( ^. {: Y1 @, G3 Q! ^# y& [
5 inches. There was no other family history of pre-
6 ?  _2 v  A- d! p- u* A' Z0 Ucocious sexual development in the first-degree rela-- k4 u# O4 V2 l1 C" o
tives. There were no siblings.
4 ]7 F" q: ^+ Y7 E/ M0 XPhysical Examination- ^+ t" f# g" m8 j
The physical examination revealed a very active,
. v' i/ S4 B3 Y3 lplayful, and healthy boy. The vital signs documented; F3 A  z" P: c1 ]
a blood pressure of 85/50 mm Hg, his length was
7 L, F4 U0 |0 k( C90 cm (>97th percentile), and his weight was 14.4 kg6 x4 {1 a  }3 _% g
(also >97th percentile). The observed yearly growth
2 P- b9 o' q( cvelocity was 30 cm (12 inches). The examination of$ i, U+ D, @3 m: t+ v5 L6 Q8 j* g2 I
the neck revealed no thyroid enlargement.
- B/ f2 O+ }/ IThe genitourinary examination was remarkable for
. m/ p1 q; F! S7 z8 c5 F/ Fenlargement of the penis, with a stretched length of, ]. v6 a8 c0 y- o6 p% X
8 cm and a width of 2 cm. The glans penis was very well8 k! J: b7 b! i7 X
developed. The pubic hair was Tanner II, mostly around
5 @( S, Y4 H4 _9 r3 ?. t5409 y- @7 A8 }5 F/ h* J" X5 K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 I+ \, R+ x- D' N5 j4 ^9 mthe base of the phallus and was dark and curled. The; @: S/ S6 J8 @
testicular volume was prepubertal at 2 mL each.: ~- C/ W! x0 Y# n
The skin was moist and smooth and somewhat6 k0 m" h+ F4 ^9 ^1 l2 l9 r5 y
oily. No axillary hair was noted. There were no
9 L: P/ V. g  m2 [( Mabnormal skin pigmentations or café-au-lait spots.. l' ^! Z1 u% e4 N2 z: Z
Neurologic evaluation showed deep tendon reflex 2+
" X; v; M- V4 l/ hbilateral and symmetrical. There was no suggestion! u6 d) a  @  y. Q% A1 I4 t: u
of papilledema.2 ^* ]( ]* Y: T( A3 x
Laboratory Evaluation
: e+ s& g% z0 ^6 V1 ]The bone age was consistent with 28 months by: Z1 \- O+ ]3 H
using the standard of Greulich and Pyle at a chrono-( `) O1 s5 O) D0 J# P
logic age of 16 months (advanced).5 Chromosomal
. Z$ Q3 w& L& U: ]6 fkaryotype was 46XY. The thyroid function test
5 T* {7 z; g6 R! s8 `1 ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( K% F% M0 l& {lating hormone level was 1.3 µIU/mL (both normal).. v! C2 J5 u. F) ~
The concentrations of serum electrolytes, blood. `% {+ Z0 \* S( L  H6 V
urea nitrogen, creatinine, and calcium all were
8 g) h" i( Y1 q0 v8 r9 Cwithin normal range for his age. The concentration! A+ N2 n9 g  \+ w4 O1 [  T7 E
of serum 17-hydroxyprogesterone was 16 ng/dL% [! |5 k7 B: g$ X) ^7 t8 M, M. b
(normal, 3 to 90 ng/dL), androstenedione was 202 x; c0 Q8 s8 b
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
9 e  S- k8 g5 U0 l( C& Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),  [# A7 I3 T7 e" h6 L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
& `- {% u. a. W( G+ f% Z; u/ j49ng/dL), 11-desoxycortisol (specific compound S)
" j+ o! o$ Y/ _5 w; Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 D3 V* L9 f8 R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 k" C% ~- N4 Z! t5 F/ c
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ c, ^0 N# @1 s, i; L: ^" K0 {
and β-human chorionic gonadotropin was less than
, H& p, F% ^% U: R5 mIU/mL (normal <5 mIU/mL). Serum follicular" C0 R. C; F; J# C
stimulating hormone and leuteinizing hormone
  u! D" y8 l8 x' B4 o! Gconcentrations were less than 0.05 mIU/mL
4 T8 m" a9 ?+ E# M- I$ j' p# a(prepubertal).- i$ E9 W- k& l, g6 G7 f: W
The parents were notified about the laboratory9 O- ]3 y* Z; i8 u0 u
results and were informed that all of the tests were: i% A, S& d4 b2 g2 t: G
normal except the testosterone level was high. The
' c7 H3 q9 ^# k/ m- Dfollow-up visit was arranged within a few weeks to" u! H3 W1 s$ H$ K3 T( W
obtain testicular and abdominal sonograms; how-# L+ j' y+ f, S2 ?  w8 v4 p
ever, the family did not return for 4 months.+ ~3 V* {- M3 M& {0 u0 P
Physical examination at this time revealed that the
9 ]1 a& X: a* H- mchild had grown 2.5 cm in 4 months and had gained
. E) o. l) [7 `* K0 @9 R. s2 kg of weight. Physical examination remained
4 N0 N2 |; }  w6 {0 Tunchanged. Surprisingly, the pubic hair almost com-
  q" m# i3 D5 R6 n1 jpletely disappeared except for a few vellous hairs at
4 N$ U) X( ~5 H  }. _, a5 othe base of the phallus. Testicular volume was still 2& M/ g( S2 @% {
mL, and the size of the penis remained unchanged.
  o" r/ U' B8 M/ c% d' [7 uThe mother also said that the boy was no longer hav-
* \/ X+ K0 Y2 n& |ing frequent erections.
( i, B- V: c/ Z# v4 ?2 {& lBoth parents were again questioned about use of' R* @5 {4 }$ @9 V' o2 i
any ointment/creams that they may have applied to
! l5 R% V# z7 gthe child’s skin. This time the father admitted the* w# h+ f6 [6 O4 z5 e7 N
Topical Testosterone Exposure / Bhowmick et al 541) X. O( A( U0 u
use of testosterone gel twice daily that he was apply-; s4 T( v+ p' R7 ~% a1 t
ing over his own shoulders, chest, and back area for
0 ?& V! H2 M+ e& wa year. The father also revealed he was embarrassed2 P. e( D7 V$ W0 x/ J
to disclose that he was using a testosterone gel pre-& ?7 V0 M$ i- H; `3 G/ |5 w
scribed by his family physician for decreased libido
$ `, P' B0 [) _secondary to depression.
; @: t! u' |; W+ W3 s" r6 l; @2 ^The child slept in the same bed with parents.3 m2 D% Y! z+ z
The father would hug the baby and hold him on his  }8 m0 k! `/ |- t/ {* m6 X/ G
chest for a considerable period of time, causing sig-% }; x  k; G, m& ]* T
nificant bare skin contact between baby and father.
% L2 p" y. ?$ c% q* LThe father also admitted that after the phone call,
. J3 P% l0 z1 q( F+ y* q1 J8 C- Swhen he learned the testosterone level in the baby. M$ B/ o. L/ y# K5 n4 D! c
was high, he then read the product information
& B# g% h) d5 c% h4 ?& N( kpacket and concluded that it was most likely the rea-
6 A$ e* x) B, _son for the child’s virilization. At that time, they
0 J9 j: V$ w) ?0 Ydecided to put the baby in a separate bed, and the5 F' R/ z4 V1 {* e7 B
father was not hugging him with bare skin and had2 v0 b2 {3 J- b9 f( Q1 c, j
been using protective clothing. A repeat testosterone
( r; z; v% h, l  p/ p% m  m0 htest was ordered, but the family did not go to the2 K! W& J  O7 K8 l
laboratory to obtain the test.
! F0 I4 U8 m* e6 G1 @Discussion1 j& g$ @- `+ K' X$ Q  b
Precocious puberty in boys is defined as secondary  R: q, O- l6 f
sexual development before 9 years of age.1,4
! p+ f" J; t: z5 `' V- zPrecocious puberty is termed as central (true) when; {  I8 J, V9 `8 `/ a; v9 ]
it is caused by the premature activation of hypo-
$ C( [* o! w/ D7 mthalamic pituitary gonadal axis. CPP is more com-
, a- @+ R# p  `9 wmon in girls than in boys.1,3 Most boys with CPP
- E+ o% L7 [& W, u- Qmay have a central nervous system lesion that is  e) D# d0 b3 [# E3 _- }' t4 N
responsible for the early activation of the hypothal-- }! E& M2 L) R" i% l' ~
amic pituitary gonadal axis.1-3 Thus, greater empha-
( {$ _  O' Q& N7 r7 Psis has been given to neuroradiologic imaging in, {! C  P( Q8 c" m$ g7 z- F/ R
boys with precocious puberty. In addition to viril-) M7 H1 ^3 }1 W: P/ R+ f+ v: t0 }
ization, the clinical hallmark of CPP is the symmet-
/ _+ @& Q7 |+ d6 R# x+ s+ nrical testicular growth secondary to stimulation by
( f" w! C. L' e' ^gonadotropins.1,3
: b5 J$ s# v) E! c+ SGonadotropin-independent peripheral preco-# y+ k/ a. d+ k6 U" q/ m  v
cious puberty in boys also results from inappropriate, [" s* k; d, x) @# l, P. S2 [
androgenic stimulation from either endogenous or
) W9 }" N) E" ^7 Uexogenous sources, nonpituitary gonadotropin stim-
/ S3 K, i3 G9 n6 f- j0 M% S7 oulation, and rare activating mutations.3 Virilizing
4 R! b6 o' u- d% \congenital adrenal hyperplasia producing excessive
" h2 Q( e3 y- L) Vadrenal androgens is a common cause of precocious
7 ]) `: y8 V5 P& mpuberty in boys.3,4
2 n5 B, p, }) z; J; P/ }The most common form of congenital adrenal# I6 L' I6 K) T& t
hyperplasia is the 21-hydroxylase enzyme deficiency.+ E4 \1 [  T6 P  w9 F* [, Q# K7 i
The 11-β hydroxylase deficiency may also result in
; I/ @9 m0 ^9 |# T) iexcessive adrenal androgen production, and rarely,6 X* T9 K, I- R, T+ _2 |2 a# ?$ l& D
an adrenal tumor may also cause adrenal androgen
) ]9 t. N4 g" m. K" R" E1 Qexcess.1,3
; \! p7 u8 I( R' n0 b% ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ^2 Q0 e6 a) N7 N! k+ a6 C% Z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( A: K. R% C9 H  Z, u; ]
A unique entity of male-limited gonadotropin-
1 ^$ @$ B* j" N% r/ }independent precocious puberty, which is also known
/ v# T. L5 ^3 w( y1 U% ~% _1 Nas testotoxicosis, may cause precocious puberty at a, L, D$ J9 J. g! W# L( E8 e
very young age. The physical findings in these boys4 E( t: {( n8 M/ u( }2 Y7 b
with this disorder are full pubertal development,6 R  T) w% q/ a; k
including bilateral testicular growth, similar to boys  @# I/ c0 w; Q" X
with CPP. The gonadotropin levels in this disorder
4 l. L$ }3 O1 `' N! E- Nare suppressed to prepubertal levels and do not show
% f4 s7 ^; x; qpubertal response of gonadotropin after gonadotropin-
' }# M& V& O9 H+ [2 ^; W+ nreleasing hormone stimulation. This is a sex-linked' j2 Y, v, D5 h9 P4 _6 ?& v! ]
autosomal dominant disorder that affects only
2 q7 W9 f5 D# d" R" n: gmales; therefore, other male members of the family
/ B0 t* g6 k3 {3 G7 a" N% jmay have similar precocious puberty.3* U3 u/ Q5 a; p" g+ o
In our patient, physical examination was incon-7 q6 N1 A/ P  B3 F( f
sistent with true precocious puberty since his testi-
4 ~: j: \3 B3 `; l8 \5 Bcles were prepubertal in size. However, testotoxicosis) `2 I* A- `" `6 p) A6 j$ S
was in the differential diagnosis because his father
. }1 U. N  J- j/ t/ C! _* O/ vstarted puberty somewhat early, and occasionally,' }' U9 }5 C9 ]- c6 y" J, b
testicular enlargement is not that evident in the; s7 a) O2 D% p( S) x0 i
beginning of this process.1 In the absence of a neg-
- I0 x: M# ]  d% B+ \$ {$ h9 y+ w) K  H* Zative initial history of androgen exposure, our
. l/ i+ O$ B; ]biggest concern was virilizing adrenal hyperplasia,
5 ?4 C4 X+ i, W  P( Eeither 21-hydroxylase deficiency or 11-β hydroxylase4 R4 ^* h6 m0 Q* @3 Q1 Q- Q+ L+ Y
deficiency. Those diagnoses were excluded by find-
6 J. w4 W" i8 \+ }+ t4 h( q7 B" ting the normal level of adrenal steroids.  y6 e: K1 a* w0 z
The diagnosis of exogenous androgens was strongly
% a1 p/ L6 X, E; O6 }; t$ wsuspected in a follow-up visit after 4 months because
/ m7 W8 u  z/ B7 i% mthe physical examination revealed the complete disap-4 q; C7 i  C, R0 n3 k% f
pearance of pubic hair, normal growth velocity, and- b0 ^4 s( V7 t8 B/ X, p: {  ^1 Y
decreased erections. The father admitted using a testos-
; H% Q; ~; {" ~& Dterone gel, which he concealed at first visit. He was
5 w1 r; M) w6 p% Uusing it rather frequently, twice a day. The Physicians’5 p0 p1 S9 X" ?1 o& v$ A
Desk Reference, or package insert of this product, gel or
. z8 S4 _2 S% u2 }4 g3 bcream, cautions about dermal testosterone transfer to$ S: |. z1 U! U+ w% t
unprotected females through direct skin exposure./ t+ \5 ]3 R% r$ c
Serum testosterone level was found to be 2 times the5 p( b; B3 B$ K- \" ^" B- Y1 v/ O
baseline value in those females who were exposed to6 m7 Z; A* G9 \1 o; h
even 15 minutes of direct skin contact with their male
+ K5 h( U) k, w2 R# p9 lpartners.6 However, when a shirt covered the applica-
# m1 Y: j) g& X& w" I7 T8 J% `& mtion site, this testosterone transfer was prevented.
4 @; E9 Q! n  s3 Q; LOur patient’s testosterone level was 60 ng/mL,
* g/ e$ X- B( L5 rwhich was clearly high. Some studies suggest that$ q$ H$ O# R, F5 n/ n2 A
dermal conversion of testosterone to dihydrotestos-" p( p. h7 ~* z' G7 W* W1 x
terone, which is a more potent metabolite, is more# B) T1 }5 i% j2 A
active in young children exposed to testosterone* o" d4 p0 H# R" F- b' _2 U
exogenously7; however, we did not measure a dihy-$ M: b) J8 F8 _6 G
drotestosterone level in our patient. In addition to9 q6 |9 q  w7 m& W* e$ `- `
virilization, exposure to exogenous testosterone in
) H; [% d9 `, H2 W$ Nchildren results in an increase in growth velocity and$ P5 t7 S4 Q4 z2 g
advanced bone age, as seen in our patient.4 e, L% w' ?4 a4 ^5 E4 u
The long-term effect of androgen exposure during
. C) T/ Q8 `4 x+ ~: I' f8 ^* ^8 [early childhood on pubertal development and final9 @5 t  m, T$ |7 v5 M
adult height are not fully known and always remain  P) q5 w% O& e' N! I
a concern. Children treated with short-term testos-
* i9 c! s( J, N+ Q% _2 mterone injection or topical androgen may exhibit some, r2 \& b5 b4 B- V0 m
acceleration of the skeletal maturation; however, after
5 q, Z- `2 N- e2 [cessation of treatment, the rate of bone maturation
. n' }2 W: h9 h: y8 P5 P3 {decelerates and gradually returns to normal.8,9
2 N& h$ k- f  s$ O' e; L2 g- f( TThere are conflicting reports and controversy5 C" n  ]* f% I: @  V% T. w
over the effect of early androgen exposure on adult( R4 R2 b9 o$ k/ E3 z# f
penile length.10,11 Some reports suggest subnormal
0 g+ d8 }; ^2 ^6 R: a8 W. Hadult penile length, apparently because of downreg-
0 W9 `9 B7 r. u5 M' O% G+ Kulation of androgen receptor number.10,12 However,2 d7 m& k3 c5 o1 X  [
Sutherland et al13 did not find a correlation between
, b3 S( D4 s* M) |8 q' Q# Dchildhood testosterone exposure and reduced adult1 z7 N4 h; F6 g4 z2 k4 K
penile length in clinical studies.
( o3 c; h* v, J% bNonetheless, we do not believe our patient is  ^6 A. k0 e4 a( W) U" k' d
going to experience any of the untoward effects from8 T( R$ o9 ~4 Y" |# }
testosterone exposure as mentioned earlier because
5 a. K; }4 n( C8 Z; t/ @the exposure was not for a prolonged period of time.
. Q3 a9 T9 `4 FAlthough the bone age was advanced at the time of! l0 E* j! k; {9 b# D9 ?
diagnosis, the child had a normal growth velocity at! V6 K& U& L* A7 L2 j' B( Y
the follow-up visit. It is hoped that his final adult( \, U$ r8 J  X& {; ~9 [1 F
height will not be affected.
' W) F/ W: U: q" Z+ |4 L2 bAlthough rarely reported, the widespread avail-
9 E7 J* A/ I" Q2 k, ?ability of androgen products in our society may
' C5 [# i& }3 h) n( Q. t8 b3 Gindeed cause more virilization in male or female. |1 k. L3 t/ s9 Y& T- Q1 O
children than one would realize. Exposure to andro-
/ n7 o! T% I' M3 {# t, ~1 Ngen products must be considered and specific ques-
& j4 w& W1 `5 B0 ytioning about the use of a testosterone product or1 S( V0 ^7 X! ]9 x
gel should be asked of the family members during+ i' y' o- F6 i; a# d1 i, ?; F0 f& f
the evaluation of any children who present with vir-
$ ~5 x1 S' O: E3 P+ Nilization or peripheral precocious puberty. The diag-
& K% O9 n1 k" znosis can be established by just a few tests and by: X) N, j2 @% f0 f( Y4 K  v+ H* ]
appropriate history. The inability to obtain such a2 y, i4 W1 \% {+ o/ J: X
history, or failure to ask the specific questions, may
4 p/ B6 ]& H; {2 C% N: W! Y4 }result in extensive, unnecessary, and expensive  `7 [# e  M# m6 R
investigation. The primary care physician should be2 S% r7 F9 g- l7 ?" w: D9 A# e; T
aware of this fact, because most of these children% c' N, a& x9 v% M3 l# C
may initially present in their practice. The Physicians’/ v+ F# `" i4 G6 G
Desk Reference and package insert should also put a
; c" j1 W, D8 u) q, |% Q( Z3 s3 X% swarning about the virilizing effect on a male or
! p/ P  T" U$ C6 j. I6 `$ j' P* Sfemale child who might come in contact with some-9 t8 F2 w% m2 {- k  e" Z9 O
one using any of these products.
& N4 ?& S% \) `( U( n- D- aReferences8 `- Y: C# g8 [  k. B# I+ @' ^7 r
1. Styne DM. The testes: disorder of sexual differentiation
# ]: ^! F3 z' F% v0 land puberty in the male. In: Sperling MA, ed. Pediatric
8 Z# B2 }9 S: n% a1 H( ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 D/ H5 Y5 D' C# [
2002: 565-628.
3 Q, `  y+ N5 v, C' J2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. Q7 k6 J. w' @' }+ k8 m0 |  Q
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) A! h; m+ C' u) y& y1 [
Boy Induced by Indirect Topical: L! T0 Z. v0 j& h! m0 P- J* d) @
Exposure to Testosterone
8 j' F5 R, p. o( X% S- f. NSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& F2 i+ E) u8 X. o- Mand Kenneth R. Rettig, MD1
' l; z% d. n+ }( k: I% W1 ^Clinical Pediatrics
& G1 @' T$ x) S/ U8 @Volume 46 Number 6
" J# @$ c1 A( K+ QJuly 2007 540-543/ P8 a2 Q; V/ u5 @3 w5 g
© 2007 Sage Publications
, F- M" y+ U! A2 Z* o( v2 ^! M10.1177/0009922806296651% J; ~8 @! R. ^, o7 d8 P
http://clp.sagepub.com; ?3 y$ V" G/ x) ?
hosted at
+ q% Q8 q9 D; z" v" {% ?) Phttp://online.sagepub.com* m7 t- t- u* C, q
Precocious puberty in boys, central or peripheral,
3 K/ F8 _. B) A2 g9 ?' vis a significant concern for physicians. Central+ C' {" f1 L$ k$ v
precocious puberty (CPP), which is mediated1 V( I' u: ~# F! v1 m! y
through the hypothalamic pituitary gonadal axis, has
' x. Y) j' f$ g0 Q9 ]a higher incidence of organic central nervous system
, m7 [' Y1 c* @% mlesions in boys.1,2 Virilization in boys, as manifested
, H9 b" N# N% u1 ]( m8 Y: sby enlargement of the penis, development of pubic6 ~: b0 Y+ S7 s7 Z
hair, and facial acne without enlargement of testi-
: ?3 U" R: N& i# f4 k0 `. Kcles, suggests peripheral or pseudopuberty.1-3 We
5 r" V$ a7 C4 `% t: z6 D5 R" r* treport a 16-month-old boy who presented with the% }: P  r8 N/ Q& q
enlargement of the phallus and pubic hair develop-
- Y) H! L9 r" a3 u( Iment without testicular enlargement, which was due
* c- G$ G8 S( V# Xto the unintentional exposure to androgen gel used by5 n3 L: @& {! G
the father. The family initially concealed this infor-7 f+ L- q& n: e$ p& x
mation, resulting in an extensive work-up for this
1 T1 R: [5 U; Q) m/ _* wchild. Given the widespread and easy availability of
8 I% ?) g. Q1 y3 z/ l$ _testosterone gel and cream, we believe this is proba-
9 R% m2 I& d$ Q. W1 ^, W) obly more common than the rare case report in the& |0 w2 C, N8 t* l5 ~" S
literature.4
/ `* o5 {( B) m$ J; w0 kPatient Report
& ], M) Y" z' e" ?( |, H& nA 16-month-old white child was referred to the+ k8 ~. H  K+ \& p0 s
endocrine clinic by his pediatrician with the concern9 V7 X2 t8 H5 g. o
of early sexual development. His mother noticed
& }! C, ^" V6 F' jlight colored pubic hair development when he was
4 v6 O2 {  H& A( jFrom the 1Division of Pediatric Endocrinology, 2University of- j! S$ I# B4 E- j# M
South Alabama Medical Center, Mobile, Alabama.+ @- u  w1 d7 E( A
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ c% o: Y$ b. M5 \+ D: {% uProfessor of Pediatrics, University of South Alabama, College of! @2 S% E+ ~0 f0 a* x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: w4 H( j5 O$ X1 h  w8 }$ N" g
e-mail: [email protected].3 L2 ~+ `0 f1 C  _& ^, E
about 6 to 7 months old, which progressively became
. u+ |7 E8 v0 w4 ?3 Tdarker. She was also concerned about the enlarge-
9 d& d: x  F1 C* p4 ement of his penis and frequent erections. The child, p% o; n) o( ~  I6 R6 y+ v: R/ m
was the product of a full-term normal delivery, with; j% m0 f+ ^/ O" p5 o* F
a birth weight of 7 lb 14 oz, and birth length of
; h# A, N6 b3 X2 T20 inches. He was breast-fed throughout the first year2 f% F' H' R7 [% k6 o4 z- z
of life and was still receiving breast milk along with4 x  S! N# H  N0 {# w
solid food. He had no hospitalizations or surgery," ]4 F; m+ a. v& _8 D# i6 U
and his psychosocial and psychomotor development
6 R# n' E( ?3 @* t% R3 Zwas age appropriate." G! ?% k  M% K4 l
The family history was remarkable for the father,
! K0 r1 d& [% d5 y  i, Bwho was diagnosed with hypothyroidism at age 16,. m: P, B: l5 m
which was treated with thyroxine. The father’s
6 s+ G% h- n( z3 Y5 o' cheight was 6 feet, and he went through a somewhat
9 S* S/ {! [/ H2 searly puberty and had stopped growing by age 14.
. M) c; H  z3 `' _' f6 Q9 RThe father denied taking any other medication. The
0 G9 h0 u9 e0 R9 q, r2 X, ~child’s mother was in good health. Her menarche
! h/ p- @# j  e+ C( w3 x& awas at 11 years of age, and her height was at 5 feet
+ ]& Q7 ^, [+ O5 inches. There was no other family history of pre-
" o4 Y2 G1 \! L: rcocious sexual development in the first-degree rela-
( Q- Y3 X5 Q  T7 u, Htives. There were no siblings.
8 D; M, p' l! iPhysical Examination
# V' Z* M/ S$ s1 m! ~& C( NThe physical examination revealed a very active,8 p% O; Z' k! z+ i
playful, and healthy boy. The vital signs documented+ r4 U4 H: y0 t" `6 \
a blood pressure of 85/50 mm Hg, his length was
$ R& v/ x9 _0 m- f, v; Z* ]8 V90 cm (>97th percentile), and his weight was 14.4 kg+ N' b3 |/ H- J# n/ m9 _5 l8 M, @2 j
(also >97th percentile). The observed yearly growth( V3 k5 \% u9 P$ S9 z( [8 O+ X
velocity was 30 cm (12 inches). The examination of
/ [) n. G, d9 hthe neck revealed no thyroid enlargement., ^0 A# |# A) g, b3 ]
The genitourinary examination was remarkable for
; [( u/ ^+ W; O  R. @enlargement of the penis, with a stretched length of" b1 o1 E; l' R: [9 r6 P8 k
8 cm and a width of 2 cm. The glans penis was very well
' l: V) N1 N, ^9 n* {developed. The pubic hair was Tanner II, mostly around
" Y2 M/ `$ r0 R4 r( T540
' O9 u  J/ f& m7 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 \* a# h! i6 H* k
the base of the phallus and was dark and curled. The
3 @) n9 q1 e1 J& i- Stesticular volume was prepubertal at 2 mL each.
/ u; w' Q5 B( {* d  ^The skin was moist and smooth and somewhat7 R. a8 H1 h4 }2 q  |
oily. No axillary hair was noted. There were no
* P+ a$ M6 d# Y4 M" ~8 habnormal skin pigmentations or café-au-lait spots.
. e1 ?6 x% n$ A, FNeurologic evaluation showed deep tendon reflex 2+& x+ x+ z6 s) N2 [7 v% Y- ~
bilateral and symmetrical. There was no suggestion3 V! w6 \* N) e6 d$ l
of papilledema.) v7 n. c( @! F$ I9 H' o; j! k
Laboratory Evaluation
- U% ]/ N" _  J+ n, }' DThe bone age was consistent with 28 months by
9 u$ b/ P8 F$ i$ g6 _using the standard of Greulich and Pyle at a chrono-, D) r/ D8 b6 _2 `4 F
logic age of 16 months (advanced).5 Chromosomal
0 g2 l5 W9 g7 k% Q# F, r2 vkaryotype was 46XY. The thyroid function test
3 h6 M8 R1 d0 r" F# Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% N  Y4 @; `1 F* M3 P4 F
lating hormone level was 1.3 µIU/mL (both normal).5 z1 [) i' Z6 a# i
The concentrations of serum electrolytes, blood1 c* |, X. m; z3 o
urea nitrogen, creatinine, and calcium all were
9 i7 `  p$ r7 p. `; o' @within normal range for his age. The concentration
4 N7 [" |. b4 q4 F. @of serum 17-hydroxyprogesterone was 16 ng/dL
& [, E$ ?) |7 ~(normal, 3 to 90 ng/dL), androstenedione was 20% _' U* [) l; }5 ^5 o7 k0 {. R7 G6 L( \
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 |- a' ]& Y* ^4 Z; w: B: fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 `5 W* z+ D  ~" \+ B% M; ?2 t; Wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 v5 Q. c, o& T5 N( H) `9 ?49ng/dL), 11-desoxycortisol (specific compound S)
: ~7 t+ X. F  F5 B% M/ R$ hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- W+ g+ C9 G6 s. {* Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  T4 Y% @1 h3 q& X5 z0 dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),) V# Q; ~4 \; }0 C
and β-human chorionic gonadotropin was less than
& M+ V" [) ^' a/ c! f5 mIU/mL (normal <5 mIU/mL). Serum follicular7 x' y2 F. F1 v, G
stimulating hormone and leuteinizing hormone
  t3 L2 F- }+ j* {% Hconcentrations were less than 0.05 mIU/mL
0 s3 E! F) l% m, n7 g+ P(prepubertal).
. Q- {$ N6 s/ k# F! tThe parents were notified about the laboratory
. a# n8 {! {: ?8 Y( Rresults and were informed that all of the tests were: ]- s# c  r* k$ H+ i" R
normal except the testosterone level was high. The
. ~; K0 X4 @8 K' s2 L& T$ c: ffollow-up visit was arranged within a few weeks to
. }- ]/ b$ U% [" V7 [obtain testicular and abdominal sonograms; how-! U& i8 E6 n4 Q  Z0 D: i' U
ever, the family did not return for 4 months.
6 Z" H6 O8 \! MPhysical examination at this time revealed that the
  |0 F7 f, X6 \1 mchild had grown 2.5 cm in 4 months and had gained) ]/ `% h8 u+ K* E. P
2 kg of weight. Physical examination remained& m; {; K8 \% v& l2 G
unchanged. Surprisingly, the pubic hair almost com-9 X; X. s2 C* Z2 F6 I
pletely disappeared except for a few vellous hairs at, Y& {( l. E5 p% \
the base of the phallus. Testicular volume was still 2
0 v1 d* x. Z& B; m; }9 g; {8 RmL, and the size of the penis remained unchanged.+ I# S! G2 @' n* B
The mother also said that the boy was no longer hav-
1 h! a+ e  }7 p  o' \ing frequent erections.% Y3 ~' ?- `1 h
Both parents were again questioned about use of
8 d0 C; @( y5 Q6 ~, V7 P8 Pany ointment/creams that they may have applied to
! L: z8 b7 Z/ N8 b/ Q0 Jthe child’s skin. This time the father admitted the. J5 I  i6 O, X! |% U: I, H  f
Topical Testosterone Exposure / Bhowmick et al 541
* C( U. J# q8 q- kuse of testosterone gel twice daily that he was apply-
# E6 G" O0 U2 ]  Ving over his own shoulders, chest, and back area for
1 u1 e) z* L1 m$ Y7 S/ |- ?# U/ ~a year. The father also revealed he was embarrassed
7 R0 n& C* n; C. g) d; u" J0 F3 L1 Dto disclose that he was using a testosterone gel pre-+ A% U# \- q; ?4 W
scribed by his family physician for decreased libido
0 M* m* ?9 y; R) X8 \secondary to depression.1 Y1 X+ A0 o  ~' V' l
The child slept in the same bed with parents.
+ T8 P$ O2 H, GThe father would hug the baby and hold him on his
& |* w0 y5 L* K- h0 r8 lchest for a considerable period of time, causing sig-
" G4 S( b- J& J. b3 mnificant bare skin contact between baby and father.6 K, s7 `0 G6 g; n& \1 H1 G
The father also admitted that after the phone call,: I9 _4 }* l9 J4 |& M
when he learned the testosterone level in the baby% \5 l2 Y6 d! w' j# S
was high, he then read the product information
* D$ r, e" j. N& {8 d( \% upacket and concluded that it was most likely the rea-
0 I- V% R* _0 w9 ?' G7 F7 ason for the child’s virilization. At that time, they
7 K" a8 Y* H2 Mdecided to put the baby in a separate bed, and the/ P7 [/ ]; {8 B: w9 H$ f
father was not hugging him with bare skin and had! C% n& q% {9 |/ \
been using protective clothing. A repeat testosterone* x" }- P  [% O+ [* E
test was ordered, but the family did not go to the- O/ ]1 C% _8 o
laboratory to obtain the test.$ y( F2 Z* j+ A
Discussion2 P4 f3 {2 M* y/ A" z8 I( y
Precocious puberty in boys is defined as secondary
" a+ d; a& l% D$ u% isexual development before 9 years of age.1,42 _: g9 Q% i. {1 o0 k
Precocious puberty is termed as central (true) when
: z6 |: }- ^2 G  q; q" t0 z5 ?it is caused by the premature activation of hypo-. H7 ?5 e# _: B+ d6 F& v
thalamic pituitary gonadal axis. CPP is more com-% j" ~. j  K0 O+ s7 J# j
mon in girls than in boys.1,3 Most boys with CPP8 L1 Q$ h- \/ C; R% Y2 ~
may have a central nervous system lesion that is
) B7 ^. j# H( C$ L& [6 Iresponsible for the early activation of the hypothal-) l2 h- q- `6 w" M/ v1 x
amic pituitary gonadal axis.1-3 Thus, greater empha-
* T  G! u- P6 p3 z; psis has been given to neuroradiologic imaging in
8 ?+ G: a. E. O, nboys with precocious puberty. In addition to viril-; T& d( c' ]- q9 Y. |7 u6 i  h% x
ization, the clinical hallmark of CPP is the symmet-
* n$ E& s8 J0 e& Frical testicular growth secondary to stimulation by' y6 d9 ^8 G: f! l3 O+ T
gonadotropins.1,3
  A- u9 b& f" A' x6 V0 ^! FGonadotropin-independent peripheral preco-- }, u2 V7 A3 E/ m" M. i: g
cious puberty in boys also results from inappropriate& B$ f% X, }, L0 ~
androgenic stimulation from either endogenous or- P. p5 d- k7 F- s  h7 Q4 n
exogenous sources, nonpituitary gonadotropin stim-8 {0 X$ a* o3 B& D8 O
ulation, and rare activating mutations.3 Virilizing( ?4 {% w+ ~% w* R  c6 X
congenital adrenal hyperplasia producing excessive
/ R( t- X# T( t" \adrenal androgens is a common cause of precocious& ]: H; Q, M( ?& T! Q/ ^4 I( C
puberty in boys.3,4
1 D/ O# e0 y0 z+ n- sThe most common form of congenital adrenal) ^# v3 s& X6 E1 Q. q% `
hyperplasia is the 21-hydroxylase enzyme deficiency.
* D0 W4 y0 r% Y4 iThe 11-β hydroxylase deficiency may also result in
: D- P! c/ A0 a$ W( texcessive adrenal androgen production, and rarely,
2 \9 ^2 a, c( S8 z6 ?an adrenal tumor may also cause adrenal androgen; B- F" }2 w7 m) S' v* I- Z
excess.1,3
$ L6 T) R% ]6 ^# fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  |! A" M, M3 j) ]/ Y: [
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( W4 |3 U  q0 F# u) `. SA unique entity of male-limited gonadotropin-
6 q3 N3 u2 c  L& t/ V1 Bindependent precocious puberty, which is also known
5 y6 N. I! t( Eas testotoxicosis, may cause precocious puberty at a
( S! T7 D1 z( r# f& P$ `very young age. The physical findings in these boys$ \1 D6 W% Q0 X4 |- ^9 n2 [$ d
with this disorder are full pubertal development,
: [2 |4 @/ o; D3 Z3 l- [including bilateral testicular growth, similar to boys
' J' E0 m" m6 u$ `( J8 Y! _/ ywith CPP. The gonadotropin levels in this disorder
+ [+ U* V3 _8 L1 ?% ^are suppressed to prepubertal levels and do not show
& p$ l) s$ G3 upubertal response of gonadotropin after gonadotropin-
2 X4 E" T& y8 H( ]6 F# Rreleasing hormone stimulation. This is a sex-linked) L$ L( t# d5 i8 r
autosomal dominant disorder that affects only1 V$ k  _: t. w  c( P' X
males; therefore, other male members of the family
/ ]8 T9 Y' m/ F5 o0 @  o& h# ymay have similar precocious puberty.3# j) C3 M+ u0 n1 n6 C( ~
In our patient, physical examination was incon-! R$ t3 x; H# G8 @% M
sistent with true precocious puberty since his testi-
) z+ ^+ \+ O& [cles were prepubertal in size. However, testotoxicosis
# d: H8 ?- B$ ~3 f) S" H8 ^was in the differential diagnosis because his father
* [6 b% L6 x+ v* {started puberty somewhat early, and occasionally,; D  O, f! f' b7 |: ~
testicular enlargement is not that evident in the
% y# e0 z: R+ r9 Y% U+ A3 |+ \beginning of this process.1 In the absence of a neg-. z4 @) ]  @4 Q- y' ~
ative initial history of androgen exposure, our
9 @( p4 t, p: P" Qbiggest concern was virilizing adrenal hyperplasia,& A& `8 `1 x; j( q# k. E
either 21-hydroxylase deficiency or 11-β hydroxylase
5 T8 u: c! }& }; Q* q# v1 Y7 xdeficiency. Those diagnoses were excluded by find-
0 b9 `* V8 ^8 |- cing the normal level of adrenal steroids.
+ Y) @- M. ?9 Q, t0 fThe diagnosis of exogenous androgens was strongly
5 ]: L* v) w; G/ }: J  d( C6 ksuspected in a follow-up visit after 4 months because
+ o" L6 e2 A6 b# d9 C- z- ?the physical examination revealed the complete disap-
4 f# s+ @/ L7 Z! I% q* N+ J4 F- e9 Jpearance of pubic hair, normal growth velocity, and; E4 k, X# t! y5 l5 x/ s- o! W  I
decreased erections. The father admitted using a testos-
( c' l" x. `! ~4 mterone gel, which he concealed at first visit. He was5 U4 X1 ~4 G9 v$ C& J: C
using it rather frequently, twice a day. The Physicians’$ i+ }& ]' g2 z, D( Y% V: G
Desk Reference, or package insert of this product, gel or, w1 k" m$ x6 g+ Z* N; ~- H4 E
cream, cautions about dermal testosterone transfer to
  @* s; N7 ~6 @: N5 ]" hunprotected females through direct skin exposure.7 ^& W- I! p$ Q0 v2 Z" j
Serum testosterone level was found to be 2 times the+ }8 c# q6 O5 E7 N1 l
baseline value in those females who were exposed to! d3 _: h2 i# s& H" a& E
even 15 minutes of direct skin contact with their male
% x* Q' v# V( k1 E1 h; Xpartners.6 However, when a shirt covered the applica-
6 j) b2 ^% Y& }/ n# B  b7 @  ition site, this testosterone transfer was prevented.
- L4 S' [  p- Z# NOur patient’s testosterone level was 60 ng/mL,4 a$ o" Q0 a  j. F7 f3 y, h' N1 t
which was clearly high. Some studies suggest that  h! u2 s  p$ }0 H% W- w
dermal conversion of testosterone to dihydrotestos-" ?: V: X1 i' L$ Y, O$ _' X) v' S7 \
terone, which is a more potent metabolite, is more
; m$ b1 O) r/ p$ r0 factive in young children exposed to testosterone+ c+ D1 H! E! j
exogenously7; however, we did not measure a dihy-
! Z0 m# a3 Y7 }5 B0 I) rdrotestosterone level in our patient. In addition to
; {4 n2 H; p: ]7 A& l6 U/ cvirilization, exposure to exogenous testosterone in
2 n5 u! L' K( Z7 `: R' Y) ^children results in an increase in growth velocity and
( q& b; J. F/ ]" ]advanced bone age, as seen in our patient.* P2 n( q2 X2 t4 K: G7 X
The long-term effect of androgen exposure during1 X8 ^+ R! E" Z! ~# F
early childhood on pubertal development and final: w, W' k5 H  L
adult height are not fully known and always remain# X2 t3 s' w$ C0 T2 R: s
a concern. Children treated with short-term testos-, m. D0 ?8 E$ ~0 Q6 B2 J
terone injection or topical androgen may exhibit some0 w+ o0 \5 f: c# J9 v8 b% `' X
acceleration of the skeletal maturation; however, after
" c" k- s9 d5 t; E  ~cessation of treatment, the rate of bone maturation
3 `1 }; V7 ^& J- q6 @0 D% y2 edecelerates and gradually returns to normal.8,9' Y/ T, N& f: I
There are conflicting reports and controversy% `$ j/ C2 l3 W6 f" n: p1 W6 q
over the effect of early androgen exposure on adult8 t, r+ }, q, V7 G1 j+ m
penile length.10,11 Some reports suggest subnormal
* P( p( W! ]4 p" Q5 Oadult penile length, apparently because of downreg-
& M5 r5 u8 O/ @4 b7 Mulation of androgen receptor number.10,12 However,
+ H# j6 k/ O, v7 oSutherland et al13 did not find a correlation between  E; a" Q5 _+ E7 D
childhood testosterone exposure and reduced adult- X* q, ?& y& r
penile length in clinical studies.7 [6 _8 p, c6 X5 o2 ~
Nonetheless, we do not believe our patient is
  J3 \- q" g& ^4 q( Vgoing to experience any of the untoward effects from
& y+ W7 f- ~, ^, ~6 C( Wtestosterone exposure as mentioned earlier because7 |) Y$ F( g& Y9 L
the exposure was not for a prolonged period of time.
) e$ a9 o, h& K- }Although the bone age was advanced at the time of# p( ~' {2 i1 p, x
diagnosis, the child had a normal growth velocity at2 a2 I$ D$ q- O/ J2 Q" @
the follow-up visit. It is hoped that his final adult
" O3 ~2 S$ h3 E# |' l9 r- z% Hheight will not be affected.3 M5 @- @  o2 _& f
Although rarely reported, the widespread avail-% D- x1 I" Y; \
ability of androgen products in our society may" L5 P* H$ q4 A0 e: n7 I# P- m. h. F
indeed cause more virilization in male or female+ ~0 T# i2 \; }' r" J
children than one would realize. Exposure to andro-0 Y& S9 o6 {' m& a( c8 m- q) U; ^
gen products must be considered and specific ques-
0 F) h, t8 s3 Y+ a0 e5 n. i0 wtioning about the use of a testosterone product or, ]8 z- @" M4 z7 M- {# C( @
gel should be asked of the family members during
, `' Y5 K& t4 hthe evaluation of any children who present with vir-
, P: |+ D) e! Y! Q0 ailization or peripheral precocious puberty. The diag-
8 U4 j( B% @% e. I7 W6 E" w9 g+ Qnosis can be established by just a few tests and by
  x( y+ f; m2 X* C; mappropriate history. The inability to obtain such a4 ?+ F: l- N! h+ y& r  e) A$ ]' G
history, or failure to ask the specific questions, may
8 g  ?9 C, B0 n6 ]result in extensive, unnecessary, and expensive
: o4 H1 r# y% V. t  L! N- Pinvestigation. The primary care physician should be
/ m0 c& j/ G1 caware of this fact, because most of these children
6 J& L8 Z) A7 k) ^0 T9 r) Lmay initially present in their practice. The Physicians’
& Z5 `3 I+ o. l. ~, CDesk Reference and package insert should also put a5 l+ i4 P1 m- Z. W5 |
warning about the virilizing effect on a male or9 F% _* W- C! Z4 f. u
female child who might come in contact with some-
+ C; t8 F+ Z; ]: u$ tone using any of these products.3 E3 L* c! ~+ U  h4 C) K
References
( [+ e' F: W2 _& L; `% ^) n3 r6 i" [1. Styne DM. The testes: disorder of sexual differentiation
+ ?: o& b- l# A3 band puberty in the male. In: Sperling MA, ed. Pediatric9 l" b. w2 v3 c, [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. \$ F7 t. o# B+ t% ?
2002: 565-628.4 h4 k, b3 e4 T  q- Z( U- j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 [* X9 Y2 m5 d# zpuberty in children with tumours of the suprasellar pineal
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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

1 K. O; h, V" b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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