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Sexual Precocity in a 16-Month-Old
& d# [2 A$ u1 @8 g; \Boy Induced by Indirect Topical. Y& O. \* h4 s( a1 e% }% L
Exposure to Testosterone4 ~7 C( N, [6 ?( e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 k0 ^0 Q6 r) \( m
and Kenneth R. Rettig, MD1
7 P4 P# N" M* z# O; }5 gClinical Pediatrics
$ J0 b5 w. L6 z( m3 [4 X# ?9 ?Volume 46 Number 6- Y0 S& M  d4 q. R+ s% Y5 j
July 2007 540-543; U. c: {5 _. K& i* {9 K& G2 j' w
© 2007 Sage Publications# V! T# v+ w. `: p  Q
10.1177/0009922806296651/ W" z3 T$ M' X$ ?) O. L
http://clp.sagepub.com
- d* k- I& X8 U3 Phosted at
( r3 n" H6 a" X9 d# R3 O/ thttp://online.sagepub.com, w6 Y9 I" F+ E0 O5 ^& o$ }2 a
Precocious puberty in boys, central or peripheral,
5 m5 @! v1 s5 g8 F0 |% [2 }, Pis a significant concern for physicians. Central7 B2 \2 `8 t6 h" \: |, l/ w$ `
precocious puberty (CPP), which is mediated0 i& e. F& E, r( r/ u
through the hypothalamic pituitary gonadal axis, has" z5 X' K  a& I3 p1 e
a higher incidence of organic central nervous system2 u* A2 j  R- b; w
lesions in boys.1,2 Virilization in boys, as manifested- b$ ]  K/ T4 y
by enlargement of the penis, development of pubic
; `, y  R- X" J5 F4 L; G3 Khair, and facial acne without enlargement of testi-+ M0 Q$ c, z( M9 c$ m- t
cles, suggests peripheral or pseudopuberty.1-3 We
3 [5 E/ W" e) {1 c. C% Lreport a 16-month-old boy who presented with the
' C# ^8 ~: a7 v. {/ Z- senlargement of the phallus and pubic hair develop-1 S0 E; o) r) N; u0 m3 N/ E
ment without testicular enlargement, which was due
! g' b% |5 L' v3 lto the unintentional exposure to androgen gel used by
! H# X! @/ k# _- ?! \/ c8 Y! [the father. The family initially concealed this infor-
6 t: p2 `4 O% o& }+ U9 N7 bmation, resulting in an extensive work-up for this
. ^: E% _5 n/ y) `% Ochild. Given the widespread and easy availability of
) G8 n, a: b) Q' D6 Z5 ^* U$ ytestosterone gel and cream, we believe this is proba-/ _6 }2 y9 f$ `+ Y; s6 i# h
bly more common than the rare case report in the( c' T0 l7 j7 H& z* n7 X
literature.4/ C2 A# ~( C$ p. }8 S$ D" g
Patient Report- {& ^" k4 D8 i/ M. d6 `3 f
A 16-month-old white child was referred to the
0 p6 Y/ J: I* _9 X+ hendocrine clinic by his pediatrician with the concern
9 G( M/ A. u, f: S; T: D; Uof early sexual development. His mother noticed
! H8 e6 R( Q$ o: Llight colored pubic hair development when he was
2 }' A$ R- c3 f$ g* ZFrom the 1Division of Pediatric Endocrinology, 2University of
: ~: V" M. J: t! `* MSouth Alabama Medical Center, Mobile, Alabama.' v$ z. `- z0 p
Address correspondence to: Samar K. Bhowmick, MD, FACE,% U$ W& ~- o1 ?* N
Professor of Pediatrics, University of South Alabama, College of' H9 A% m, c8 E9 V5 b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% f% T4 s6 [+ a7 J* _# t7 a
e-mail: [email protected].
, |3 A, L- ^1 ^/ S( r) v, Y# gabout 6 to 7 months old, which progressively became
; |2 U, z2 c1 o, @) n! @darker. She was also concerned about the enlarge-
; T8 S$ ?3 b. K+ ^0 P6 |ment of his penis and frequent erections. The child
) f/ S" `" Y  h2 K- I2 f( u  gwas the product of a full-term normal delivery, with2 Q9 `& V: X6 H9 F# f0 P1 E; T
a birth weight of 7 lb 14 oz, and birth length of
2 |; F7 m: P1 f# ?, }; {20 inches. He was breast-fed throughout the first year  d/ r! W" z& N7 z( \3 S
of life and was still receiving breast milk along with
0 [3 B) ?8 c! B$ Hsolid food. He had no hospitalizations or surgery,
  {7 K4 C# n5 {+ xand his psychosocial and psychomotor development7 x6 a6 n! m) T5 l; a/ Y
was age appropriate.
" d) H) r# }+ ZThe family history was remarkable for the father,
: a" R2 p8 R. B1 v8 d. z5 C8 `9 B+ _who was diagnosed with hypothyroidism at age 16,
6 J  ?+ U9 B* _3 a# {which was treated with thyroxine. The father’s
  r8 s6 n& f) V! o& G7 Kheight was 6 feet, and he went through a somewhat) X2 i7 q6 p3 q
early puberty and had stopped growing by age 14.: @5 [3 L! l/ I' C/ n! I/ Q
The father denied taking any other medication. The( F4 L9 v( [; A& a
child’s mother was in good health. Her menarche' v0 D5 p0 Q2 M
was at 11 years of age, and her height was at 5 feet# ]0 J$ X. f  i( X; @0 \
5 inches. There was no other family history of pre-0 M9 N; P5 x5 m4 v& x0 m9 J  P/ n
cocious sexual development in the first-degree rela-
6 ]0 V& N8 A1 H6 p, d5 l+ ~tives. There were no siblings.
9 Q8 d* v- Q  ]# m, i- @' {" GPhysical Examination
" n( ]9 b. {; yThe physical examination revealed a very active,; C( y4 X  K9 L' P/ M& f
playful, and healthy boy. The vital signs documented5 {) h5 l& M6 e! d9 q  E( k4 ~
a blood pressure of 85/50 mm Hg, his length was
1 d4 [- t5 F# D$ o$ l2 E# ]7 B: [; B  ?90 cm (>97th percentile), and his weight was 14.4 kg
+ u7 Z. v4 W8 \( K, e% H(also >97th percentile). The observed yearly growth
+ D- [% o0 r6 y/ L  L' F3 Xvelocity was 30 cm (12 inches). The examination of5 Z# f! N+ G) l/ Y4 J/ m5 Y- f& K
the neck revealed no thyroid enlargement.
' k2 k4 X% D2 o' l6 }& _; bThe genitourinary examination was remarkable for
2 u! L; T4 ^0 N$ f* lenlargement of the penis, with a stretched length of
" K/ }0 K" G4 ]9 D  r. F  X( Y8 cm and a width of 2 cm. The glans penis was very well+ L0 W+ S6 ?; m
developed. The pubic hair was Tanner II, mostly around
3 K: [9 h( G, K7 S& j540
/ J" F/ U% q( j4 D6 q6 m" yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 {! A6 Q) h4 o8 E6 n( L2 Ithe base of the phallus and was dark and curled. The
+ N! U& k- d6 o$ C9 J# Itesticular volume was prepubertal at 2 mL each.
! Q# {3 C! ]( B! }  {  {4 ZThe skin was moist and smooth and somewhat
( F) L( \" ?9 T7 poily. No axillary hair was noted. There were no' }4 W3 c$ `5 o2 y8 L
abnormal skin pigmentations or café-au-lait spots.4 |1 a" C: s  M, ?
Neurologic evaluation showed deep tendon reflex 2+
  ^6 d" v# S7 M( }# Xbilateral and symmetrical. There was no suggestion
- @( m& q& l- Y  r. Gof papilledema.) M1 \9 S: r8 @- y3 ?2 D& K
Laboratory Evaluation
% p; j& b+ l0 ?* sThe bone age was consistent with 28 months by
1 A# p2 R0 A$ O7 eusing the standard of Greulich and Pyle at a chrono-
4 D2 D2 [) N1 n) g; Elogic age of 16 months (advanced).5 Chromosomal& i% b/ ^$ u% L! y0 ^
karyotype was 46XY. The thyroid function test
- `! v9 [  U. u/ F8 P+ R' X& o. ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 s$ s. T0 A# U) v0 Q
lating hormone level was 1.3 µIU/mL (both normal)." n; Z1 w2 d! w2 {4 }
The concentrations of serum electrolytes, blood
$ ^" L/ `  ?1 C7 e* Kurea nitrogen, creatinine, and calcium all were2 d9 v6 W$ E* ?" }3 e/ I( t# _
within normal range for his age. The concentration! I  o8 O, {" t& J7 l+ n
of serum 17-hydroxyprogesterone was 16 ng/dL
0 E8 |2 E: q+ l* ^( c, Q& G(normal, 3 to 90 ng/dL), androstenedione was 20# i  r  r7 x6 s) H% v5 n. h8 k) Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ Y$ d/ ^8 G) T$ O
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# r: \( q; [# U/ T% f3 A) ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 w) p$ _  \9 n2 H. F- t( l49ng/dL), 11-desoxycortisol (specific compound S)8 l2 X# {* ]/ S# p
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) W) b! ~  D% @+ l# d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 n' |0 ?" K' R5 Q6 k: o7 ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 ]* k' ?) e# f9 v5 H! U
and β-human chorionic gonadotropin was less than  e5 k3 j6 E$ s  {; t0 `  `
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 a* ]6 _1 W% W, L6 E3 |; ?2 e* q
stimulating hormone and leuteinizing hormone9 }- x2 I3 F9 X& }' Z
concentrations were less than 0.05 mIU/mL
( z: `7 N0 b$ S0 {4 V(prepubertal).5 j) o1 b" \; A5 ~; u& z1 p' y
The parents were notified about the laboratory: ]" p" c1 C, F' a+ v3 B& a' g
results and were informed that all of the tests were
9 h$ [9 k- p+ B9 y2 Pnormal except the testosterone level was high. The
' f/ i! H/ `. _; |) |8 }follow-up visit was arranged within a few weeks to9 u  ?% T, p. z5 a+ P# c% A; s
obtain testicular and abdominal sonograms; how-% p0 t; y. N% S& L. x
ever, the family did not return for 4 months.
( F/ X4 r  }  m3 `( FPhysical examination at this time revealed that the% S5 W* ]2 z) ]! {2 w. U
child had grown 2.5 cm in 4 months and had gained3 ^) ?3 \! F& c& s5 R# \% G
2 kg of weight. Physical examination remained/ ^- `9 W8 _, o9 K
unchanged. Surprisingly, the pubic hair almost com-
, R1 j$ Q- t. Y/ Z, [* bpletely disappeared except for a few vellous hairs at2 m) U8 c  b$ i; t* U8 D# f6 e' k
the base of the phallus. Testicular volume was still 2. v1 S% d% z0 a. D1 T2 R
mL, and the size of the penis remained unchanged.! o, ~5 e6 y* |/ r" I4 @7 o
The mother also said that the boy was no longer hav-
; ]- q0 v) _, s) _$ z3 Hing frequent erections.
  {; H/ T" j' JBoth parents were again questioned about use of
$ ?; J  X( l2 f7 [! Q8 Z! |any ointment/creams that they may have applied to
) C$ D5 |$ Q6 T" V  pthe child’s skin. This time the father admitted the1 q) }# K6 E) T5 g  L- U9 n6 S- h! ?4 q
Topical Testosterone Exposure / Bhowmick et al 541' B: y- L3 L$ ?7 m$ |% ]
use of testosterone gel twice daily that he was apply-- f" ?* D) r0 [; c( l! A% N- ]3 Q
ing over his own shoulders, chest, and back area for1 z& S: U2 X* `3 ]4 s6 i* L$ I& ~
a year. The father also revealed he was embarrassed! a- d5 J& T1 H( @( R) q- Q1 c
to disclose that he was using a testosterone gel pre-
# o! \' {6 ~# ?9 zscribed by his family physician for decreased libido
& p8 y: a- j- D7 R2 d, W$ ~secondary to depression.
+ B! y/ G% h: \7 B; sThe child slept in the same bed with parents.$ {: I5 U4 K' [( ~9 o
The father would hug the baby and hold him on his  m, T/ g* ?& ~; Y
chest for a considerable period of time, causing sig-3 i/ C/ w. ^$ _& W9 N
nificant bare skin contact between baby and father.
4 B& Q4 P3 w  P" l1 @2 W  `The father also admitted that after the phone call,
% ]7 I6 f# M8 S# f' swhen he learned the testosterone level in the baby
7 B0 t5 C# b: G6 H+ J  U- {was high, he then read the product information( m2 ?/ }# R, |
packet and concluded that it was most likely the rea-
% u/ t) j/ U6 I: O: Lson for the child’s virilization. At that time, they
3 Y- h. g* `' |! |% odecided to put the baby in a separate bed, and the5 `) B( O9 P" H# }6 d6 H
father was not hugging him with bare skin and had
3 Q1 a' Y9 b+ x! A* rbeen using protective clothing. A repeat testosterone
& `( x* a% `4 s8 f. dtest was ordered, but the family did not go to the
* W" ]  B- Y) F* J, elaboratory to obtain the test.
- S, z/ y% c- r, VDiscussion. Y9 o5 W8 T4 g+ g% H( Y+ Q
Precocious puberty in boys is defined as secondary
" v. w/ C/ m9 q. N: R3 Wsexual development before 9 years of age.1,4! P& d! ^) b. k3 x1 Y
Precocious puberty is termed as central (true) when( J2 [& p& {1 I  c( A1 w# B2 S
it is caused by the premature activation of hypo-
" U7 p+ y1 m+ m3 i9 \, I0 H4 c: Lthalamic pituitary gonadal axis. CPP is more com-
/ v( Y7 }6 V. h: K& @mon in girls than in boys.1,3 Most boys with CPP
* ^" Q7 E! t! l  Pmay have a central nervous system lesion that is6 Z7 l  m$ N. W. Y3 `8 s
responsible for the early activation of the hypothal-
" x" U. E3 `) Z8 h7 D8 v9 P' U. Xamic pituitary gonadal axis.1-3 Thus, greater empha-) `8 R& N/ o% \. E& V0 Q" A1 m/ s% @- @& }, d
sis has been given to neuroradiologic imaging in
* ~+ J# L# Y/ g) R8 X1 t1 n- ^boys with precocious puberty. In addition to viril-
8 `" l  V  N9 ?( V7 P$ O% V, kization, the clinical hallmark of CPP is the symmet-& q* g1 i0 R8 C
rical testicular growth secondary to stimulation by" z6 J8 P# Q, [+ J2 V! O1 \- S. p' `
gonadotropins.1,3- J9 _- n" j0 |- {2 ?9 `/ `; J, }7 m
Gonadotropin-independent peripheral preco-$ N) S* P- x' L8 [( P1 h
cious puberty in boys also results from inappropriate; g+ \6 O/ G( m$ `
androgenic stimulation from either endogenous or
; `/ Z/ w3 Q- e& r$ \" Lexogenous sources, nonpituitary gonadotropin stim-
. t# ]; R1 p, k: }6 mulation, and rare activating mutations.3 Virilizing
7 Q3 u, r7 g( B4 Ucongenital adrenal hyperplasia producing excessive
) @" V- Y* N" C* \) H; i/ Kadrenal androgens is a common cause of precocious1 u* K1 v5 o  v$ t
puberty in boys.3,4- A; i- {+ e1 E+ Q- ]- |+ v
The most common form of congenital adrenal
+ F# z/ m0 z  N5 ~hyperplasia is the 21-hydroxylase enzyme deficiency.
. m, j/ ~6 d& {0 U3 Y1 \) pThe 11-β hydroxylase deficiency may also result in+ E. v7 w/ _$ m* @5 ?
excessive adrenal androgen production, and rarely,+ z/ D6 r, J. E3 X
an adrenal tumor may also cause adrenal androgen7 h: s# n% ?  F& J$ G+ g
excess.1,3
, A" t. S- F' `  X) Q; _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" D: @* K/ {& u9 E542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 a  i. o$ Q4 E! R6 l2 ^A unique entity of male-limited gonadotropin-. M% N! a1 ~( K1 a5 n! n/ j
independent precocious puberty, which is also known
, T0 @2 f) s& Z) m& fas testotoxicosis, may cause precocious puberty at a9 m: n2 ^5 ]( M# m3 ?
very young age. The physical findings in these boys$ f; M6 ^7 N- X3 f$ U2 [6 R2 E+ o
with this disorder are full pubertal development,9 c7 E1 y' K$ s" b* g4 q
including bilateral testicular growth, similar to boys
2 e) e( t/ g, q+ p8 ywith CPP. The gonadotropin levels in this disorder* f% ?" ], p$ I! ^
are suppressed to prepubertal levels and do not show
- L+ Q' t, q/ Q3 _3 S# V! {& Upubertal response of gonadotropin after gonadotropin-
' K' o* D% |6 L( areleasing hormone stimulation. This is a sex-linked" \3 W9 W2 ~: \0 X2 |
autosomal dominant disorder that affects only4 G6 X3 `0 B, p  R! y
males; therefore, other male members of the family& S3 _1 |# C0 Z( ?/ Q) Y
may have similar precocious puberty.3' ?: p: Z  S7 @8 t
In our patient, physical examination was incon-
1 y/ d/ b0 S" {& lsistent with true precocious puberty since his testi-  D5 ?# J& {6 x7 j0 _: n
cles were prepubertal in size. However, testotoxicosis( @+ f& I9 q- P6 }; m
was in the differential diagnosis because his father5 a+ y; {* k+ G
started puberty somewhat early, and occasionally,
  [- s  Y" f! @* ~testicular enlargement is not that evident in the* l  {1 m' I( ?  g  Q1 N, M
beginning of this process.1 In the absence of a neg-
0 s1 c2 a  X2 r$ sative initial history of androgen exposure, our
9 j$ [; l+ i0 T$ |, Xbiggest concern was virilizing adrenal hyperplasia,
0 |7 h' h" M% j- ?) `  k" u6 g0 L  f8 _either 21-hydroxylase deficiency or 11-β hydroxylase
/ O3 q7 n4 y9 {, x0 Fdeficiency. Those diagnoses were excluded by find-
/ G8 F) D1 x: Q7 Q8 C9 D8 Eing the normal level of adrenal steroids.& N2 N3 A% V. l. F+ s2 V
The diagnosis of exogenous androgens was strongly4 H) G( S1 V/ M8 Y
suspected in a follow-up visit after 4 months because# @+ w0 ]) o/ L; h
the physical examination revealed the complete disap-
/ Z* e: r4 S6 g$ B  Epearance of pubic hair, normal growth velocity, and6 x% V/ S9 y$ \, U
decreased erections. The father admitted using a testos-
3 }: k, V& A/ y& Z$ Dterone gel, which he concealed at first visit. He was$ e+ I4 X" V. l
using it rather frequently, twice a day. The Physicians’0 `! b0 Q1 A2 @9 O+ o( G6 h' M% W0 p
Desk Reference, or package insert of this product, gel or* x5 A# ^7 k% h, E) Z) h( H
cream, cautions about dermal testosterone transfer to* G8 j, ]3 X/ f( B
unprotected females through direct skin exposure.
% }  R# F4 t9 N7 g! T3 cSerum testosterone level was found to be 2 times the1 Z6 m& G5 |2 I6 |2 m
baseline value in those females who were exposed to+ S8 L4 g5 N' m* b5 }
even 15 minutes of direct skin contact with their male# }& f' w2 k- s' ]6 s
partners.6 However, when a shirt covered the applica-, K6 v8 A& ?. v$ P. R8 H7 r
tion site, this testosterone transfer was prevented.$ J1 f6 V& _( h. {  {, B
Our patient’s testosterone level was 60 ng/mL,  q4 m( s" y7 P$ h3 J* K
which was clearly high. Some studies suggest that0 K5 S: t6 ~7 w+ m& D5 s2 ~' n' P
dermal conversion of testosterone to dihydrotestos-& T% U+ t9 o( X$ \, y4 Q
terone, which is a more potent metabolite, is more
. C9 H$ O. v" ?; ~, Y: K4 B' y1 tactive in young children exposed to testosterone; K  V3 ~- G1 J9 g
exogenously7; however, we did not measure a dihy-( ^2 W8 ]" |' z! e& D
drotestosterone level in our patient. In addition to
* C+ ]2 r' v6 J% L8 }( r  M# S$ y! Avirilization, exposure to exogenous testosterone in) I% q3 O: B  D" z
children results in an increase in growth velocity and3 D! x  {! v5 v* V& f* l
advanced bone age, as seen in our patient." X2 v( M) ^4 T0 {+ S3 n& A) z# N
The long-term effect of androgen exposure during
% [0 D2 P) ?! q/ M; W5 Z0 Zearly childhood on pubertal development and final
/ e, a7 y4 U# s" H* }+ h1 Radult height are not fully known and always remain
, a0 m& s8 ?  B. @# n1 Ca concern. Children treated with short-term testos-
0 T* n* Q" r4 m$ r* C4 iterone injection or topical androgen may exhibit some
7 V8 z4 x  G$ ]acceleration of the skeletal maturation; however, after
& [% g! F- D; D) L6 n' f: Acessation of treatment, the rate of bone maturation
1 ^! y% W/ B1 qdecelerates and gradually returns to normal.8,9
4 h# S( d' _9 \: KThere are conflicting reports and controversy% ]$ K2 D1 Q" l2 W
over the effect of early androgen exposure on adult$ T. i" d' \2 Z- s( |
penile length.10,11 Some reports suggest subnormal- I7 t) H) H! O/ @! \4 C9 I5 N( K
adult penile length, apparently because of downreg-% h' o" D: N. S) R* a6 A; C9 C6 a
ulation of androgen receptor number.10,12 However,
1 E, R3 R6 z5 d0 @& g4 aSutherland et al13 did not find a correlation between! N6 l" F1 h, a' L
childhood testosterone exposure and reduced adult
" {4 `6 ^: Y9 M& w% ]penile length in clinical studies.- D) C+ E, K9 V; S4 Q& ^" s4 a
Nonetheless, we do not believe our patient is
$ Q3 n; q. G  t: g% bgoing to experience any of the untoward effects from$ P7 T& j7 q1 e  u# \
testosterone exposure as mentioned earlier because: u1 u$ W& I$ R
the exposure was not for a prolonged period of time.# R. z! g  M8 f' g* l3 L2 h4 k$ {
Although the bone age was advanced at the time of
& D- z8 O4 ~0 w) e: m, Adiagnosis, the child had a normal growth velocity at$ `3 j8 ^9 M8 q5 v
the follow-up visit. It is hoped that his final adult
+ J6 q$ E+ o3 f. Oheight will not be affected./ x3 L2 O  v% A- [2 o
Although rarely reported, the widespread avail-
2 @; J/ O. @* Dability of androgen products in our society may7 O" Q) X; z" |9 G* J
indeed cause more virilization in male or female# E: t' [, ^! d/ b
children than one would realize. Exposure to andro-, G, G. v* [6 ]* n9 B6 P( w
gen products must be considered and specific ques-
* R4 d" S" L" x  _5 c7 z4 Vtioning about the use of a testosterone product or& a8 g/ e* t& c$ `( h
gel should be asked of the family members during, N: i* S% M' f7 H( X
the evaluation of any children who present with vir-- `9 Q  Z. `- Z9 l+ T7 f: }
ilization or peripheral precocious puberty. The diag-
- X, S; v" i$ y. q# tnosis can be established by just a few tests and by
$ K% }5 M1 @! }! H/ Oappropriate history. The inability to obtain such a
2 c" X( j( ]/ `6 Q* f5 n. d- Shistory, or failure to ask the specific questions, may
, Q; `- g% J: Fresult in extensive, unnecessary, and expensive
9 [! I% p0 L7 M. tinvestigation. The primary care physician should be
7 d7 e; \1 S5 I& Q- [# x1 K) faware of this fact, because most of these children$ i' \* h: t) h8 ]8 F
may initially present in their practice. The Physicians’
9 P% U; p# |$ x5 D9 sDesk Reference and package insert should also put a
* @& N8 x' ~' r8 c7 xwarning about the virilizing effect on a male or
+ u5 i8 v% j' ]female child who might come in contact with some-
) }8 }% o+ e7 V+ l2 O- Vone using any of these products.4 X+ \9 P8 U& i2 ~+ w) ^/ i4 D
References+ e& Y, X5 D: a* O+ X+ m
1. Styne DM. The testes: disorder of sexual differentiation
9 p2 W$ ~. D4 ~! a% C: h, K5 o+ Uand puberty in the male. In: Sperling MA, ed. Pediatric' o9 x; W; n  Y- y: Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ V& e* E6 {5 p5 R. y- V/ V% A2002: 565-628.) O2 X0 Z/ U7 j& u" f# Z% R- M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 S2 j& G" j% @9 ?  f3 O3 W  Qpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
2 C: s2 S4 n4 ~7 Y) ]7 qBoy Induced by Indirect Topical
) v3 [. h) ]1 a- f  O7 F2 d, pExposure to Testosterone; U4 [3 s+ I3 C: i
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  p- H& g/ o  w  _) Pand Kenneth R. Rettig, MD1* Q) V9 i0 j) S7 U8 m# r
Clinical Pediatrics
. ]2 G, X$ D% |Volume 46 Number 6+ s3 }3 l$ ]& E
July 2007 540-543
. o! _% y+ H9 }! O9 |© 2007 Sage Publications) y5 o" `  T; ~- H3 V
10.1177/0009922806296651
' g) d, p$ [7 R) _' ~# lhttp://clp.sagepub.com
5 p! P5 i4 N$ M/ @: shosted at
" j' T( G9 A# u% O: E3 ehttp://online.sagepub.com
! |: i4 x' i8 rPrecocious puberty in boys, central or peripheral,& ]! E; Z. I$ f3 P$ p+ w1 m
is a significant concern for physicians. Central
# @" y) |1 _' ~" l& Dprecocious puberty (CPP), which is mediated
* Y5 S% I  j+ q( e7 Mthrough the hypothalamic pituitary gonadal axis, has
$ A: j; {0 y( }0 r- d9 Y$ v; [a higher incidence of organic central nervous system6 {  \+ K* t' ]- I* v
lesions in boys.1,2 Virilization in boys, as manifested
) o. Y7 |: S9 s% }" W. s' d4 Lby enlargement of the penis, development of pubic
) Q/ _9 W0 i$ ^( G1 U' c* Bhair, and facial acne without enlargement of testi-/ _; W. P+ |; A' f& m, J/ c0 R
cles, suggests peripheral or pseudopuberty.1-3 We# p9 d5 b$ K7 Q/ ?! c/ d/ u' X
report a 16-month-old boy who presented with the
- v; S; v0 ~5 c6 d( m/ Kenlargement of the phallus and pubic hair develop-+ d& G' |- g6 i% {$ w
ment without testicular enlargement, which was due
4 z9 f+ w  Z$ ]+ k. G" c' tto the unintentional exposure to androgen gel used by+ D% f  ^3 J% q" K  `" r/ T
the father. The family initially concealed this infor-
; O; L& V, j; J% }3 i; F" U/ w4 fmation, resulting in an extensive work-up for this) N, o; v# Z$ Y/ ^; y9 K0 M
child. Given the widespread and easy availability of
9 g  O* U( e! a% Ctestosterone gel and cream, we believe this is proba-
( X& K/ {2 W' V* G9 ?# D. Mbly more common than the rare case report in the
8 R, G7 b7 o; B: J+ wliterature.4( _3 j9 G9 P1 k- O3 _
Patient Report" S- D1 t" }0 Z2 v' l& Q
A 16-month-old white child was referred to the! i1 ^# ~: [/ y6 }
endocrine clinic by his pediatrician with the concern
, Y/ U1 A3 U$ d. P$ kof early sexual development. His mother noticed
4 J) y9 p1 u$ R4 Vlight colored pubic hair development when he was
! I! \+ r5 a8 A( _. a+ S3 A; H- n. ZFrom the 1Division of Pediatric Endocrinology, 2University of1 T# [  g2 G; J) w
South Alabama Medical Center, Mobile, Alabama.
1 h1 r% N$ n3 HAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' ^+ {+ G$ @. x& {Professor of Pediatrics, University of South Alabama, College of. r- p8 K; e& a' H' M
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. ~5 ]1 Z3 }. R$ c( W4 `* Ye-mail: [email protected].( [4 q+ J( G0 R+ p4 d# k- s
about 6 to 7 months old, which progressively became( z! H/ n! m) [& |& V
darker. She was also concerned about the enlarge-7 s& x* _7 j9 u0 @6 F! {
ment of his penis and frequent erections. The child& N) d- b3 U% s7 k- l
was the product of a full-term normal delivery, with
. q0 }; a! v+ E* x7 Ua birth weight of 7 lb 14 oz, and birth length of
, u* s4 M6 S6 O8 z3 T! m20 inches. He was breast-fed throughout the first year
! p- ^) X5 B9 }! x6 @) }of life and was still receiving breast milk along with
. N0 u8 j; t- }5 K7 e" Ksolid food. He had no hospitalizations or surgery,
" J3 D( ?' ]$ A6 d3 a7 G  t& n6 q" \and his psychosocial and psychomotor development. q  I9 ~& O' ^; |' U) H3 e0 ]
was age appropriate.
7 Q1 ]/ F4 g, h& D+ WThe family history was remarkable for the father,
% f" c' x; w' |' ]& M) e5 j, O: _who was diagnosed with hypothyroidism at age 16,
3 Z8 ~3 [1 b) h) t( ywhich was treated with thyroxine. The father’s# W6 {7 j& b, b+ }
height was 6 feet, and he went through a somewhat  e& v+ g& S& ]
early puberty and had stopped growing by age 14.
. g# P8 n* y! d2 {( Z% wThe father denied taking any other medication. The/ G" e, G. J4 }) D% W8 [* V
child’s mother was in good health. Her menarche
: b- b: b" \& ~5 Z$ Z1 Hwas at 11 years of age, and her height was at 5 feet- N$ Y. b: c2 J4 U0 U8 [0 q# T
5 inches. There was no other family history of pre-
6 w# p5 {, P/ C0 L! M' f% S& ~cocious sexual development in the first-degree rela-$ I1 [$ P& H) a! d5 B
tives. There were no siblings.
9 O4 l5 `7 I# B- V) W/ L7 G  OPhysical Examination# y5 Y6 q, g+ ]
The physical examination revealed a very active,
4 Z- r, j8 ^& a4 r4 t/ Pplayful, and healthy boy. The vital signs documented
, C4 u# P9 q) ]+ E# n+ V% xa blood pressure of 85/50 mm Hg, his length was
2 V4 ?5 J' ~* t) y) O' o; d' ~! i7 x90 cm (>97th percentile), and his weight was 14.4 kg- R. e0 X1 `2 I) ?0 t. e* Y1 L. V
(also >97th percentile). The observed yearly growth
  E' i( z; E+ pvelocity was 30 cm (12 inches). The examination of
; |/ f* }5 @! _the neck revealed no thyroid enlargement.
8 _) i- o0 Q# f" k8 jThe genitourinary examination was remarkable for3 x% [. w! Q* b' Y
enlargement of the penis, with a stretched length of
- b$ o* W$ X* `4 a/ j8 cm and a width of 2 cm. The glans penis was very well- V6 @1 z+ I% o  W6 D. G$ e
developed. The pubic hair was Tanner II, mostly around# P- B4 y9 ]" B0 s8 y) u
540* V# _$ Z5 J7 G0 J8 ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 }1 s4 {7 M& J5 j
the base of the phallus and was dark and curled. The
; T# X1 t$ C& N8 S/ z/ @testicular volume was prepubertal at 2 mL each.% f# e9 ^- B2 w4 C. q" g
The skin was moist and smooth and somewhat: J) L' s* I6 R6 G; H; w  ^( C6 f
oily. No axillary hair was noted. There were no! b6 Z# {* o- m0 Y+ v# M& W3 q
abnormal skin pigmentations or café-au-lait spots.3 U' ^4 j7 Q, H6 ~. O
Neurologic evaluation showed deep tendon reflex 2+- `+ G6 q, E9 }+ R1 y# r8 s# {
bilateral and symmetrical. There was no suggestion" E6 e* r8 a! J
of papilledema.
. f. j& a, A  sLaboratory Evaluation
9 f  ]0 ^" v; iThe bone age was consistent with 28 months by
1 l4 Y, N; U2 Q. [7 h% susing the standard of Greulich and Pyle at a chrono-
% D' b  M/ O3 |4 L( l2 Ulogic age of 16 months (advanced).5 Chromosomal7 g: T8 i3 P5 q
karyotype was 46XY. The thyroid function test* A: J  \3 ]+ q# Z1 S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ C  B% S2 _) I0 ?* W( n
lating hormone level was 1.3 µIU/mL (both normal).
7 F1 u2 `2 }, e; Y+ ~3 V; `" yThe concentrations of serum electrolytes, blood
( e4 c" g- F( H0 k# o/ H! {9 Nurea nitrogen, creatinine, and calcium all were
* _4 u7 F8 j9 |) d2 @( p; _within normal range for his age. The concentration
+ n1 ]5 S+ }/ F. Y3 t2 c- p( \of serum 17-hydroxyprogesterone was 16 ng/dL
  x* ~3 H, t  K: u3 ]% }% u(normal, 3 to 90 ng/dL), androstenedione was 209 \6 Q  C- b$ E5 S1 {1 T3 B2 l
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# ^' t% \% e0 P% C0 D! R2 _% kterone was 38 ng/dL (normal, 50 to 760 ng/dL),( d7 s2 n/ X+ O+ A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' z" \$ ^( ]3 ]5 J% E' N49ng/dL), 11-desoxycortisol (specific compound S)
' M# U8 ^6 H* P4 {/ A2 M7 G( _was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 F! X0 p% [! M. W8 s4 w9 A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 e) k2 ?6 P$ a, ~# D/ B/ O; e+ P, B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 n; `3 K: c/ D" D$ p0 C" Kand β-human chorionic gonadotropin was less than
* \3 C1 d! X4 o/ r0 N6 O5 mIU/mL (normal <5 mIU/mL). Serum follicular) D/ p/ Y  B% ?* H! g8 p2 G1 A
stimulating hormone and leuteinizing hormone7 R" m2 n8 T/ K- S( U. W) Q$ P) j
concentrations were less than 0.05 mIU/mL& x6 E9 C  g% t1 r+ T
(prepubertal).
  J$ x( {. _2 B$ b" F9 l+ gThe parents were notified about the laboratory
" F1 Q7 F0 ]% m# ?results and were informed that all of the tests were
4 `( |# e* t3 F6 gnormal except the testosterone level was high. The# L" B5 Z) m9 X3 \9 P- f' P
follow-up visit was arranged within a few weeks to
% k5 ^$ }: n! p+ f" B4 M$ [obtain testicular and abdominal sonograms; how-
6 d% O7 R' U8 J- D' Yever, the family did not return for 4 months.
' V/ n0 i4 m8 v: M( o2 q* @Physical examination at this time revealed that the
5 E" x! u0 c; t7 y0 I4 Schild had grown 2.5 cm in 4 months and had gained
, [7 D, M1 e8 P& O0 X" F2 kg of weight. Physical examination remained$ F, h0 V2 d( a3 O$ c
unchanged. Surprisingly, the pubic hair almost com-
- r4 z4 _5 h* b/ A( j# i) M3 m7 Jpletely disappeared except for a few vellous hairs at
$ a* w+ f. Z  ~0 J9 s; n2 [the base of the phallus. Testicular volume was still 2
, b  K/ W6 R& p0 emL, and the size of the penis remained unchanged.1 D- t5 `- G. S
The mother also said that the boy was no longer hav-+ A8 H3 C) e" @  n* b
ing frequent erections.! ?+ B7 P' T( y2 b6 A! g
Both parents were again questioned about use of; U% H$ Q  m/ b
any ointment/creams that they may have applied to# y5 B; W. Y* f+ U7 P5 Q
the child’s skin. This time the father admitted the/ R( f. `. ]9 H% d1 K3 ~) Z( A
Topical Testosterone Exposure / Bhowmick et al 5416 c/ X) F) N1 j" e# V. s
use of testosterone gel twice daily that he was apply-, L( C4 E% m5 i- \# X# ^9 A1 u
ing over his own shoulders, chest, and back area for
# i4 O# e* i- a6 r* ]a year. The father also revealed he was embarrassed
3 V: |6 F" e  {" \2 S# ~to disclose that he was using a testosterone gel pre-2 z4 W6 P, K, l6 c2 Y4 g. j
scribed by his family physician for decreased libido9 j2 o+ J+ Q. x" I) o
secondary to depression.
# ]; L" K8 K: o+ w! VThe child slept in the same bed with parents.
- e9 N" Y7 u7 o% G: F- PThe father would hug the baby and hold him on his
  T, S9 H# X# P$ ^. z) j: Zchest for a considerable period of time, causing sig-
9 P( ~! ?1 A2 H) p1 S# @nificant bare skin contact between baby and father.
% n  M7 f5 @3 Y' M! }( y4 TThe father also admitted that after the phone call,
0 K* y: W: ~6 z. t/ n5 o# a1 ~# ywhen he learned the testosterone level in the baby9 ?( C& s8 K' l  Y1 k
was high, he then read the product information0 U2 c9 g( F' N9 n4 e- O  b1 w% S
packet and concluded that it was most likely the rea-: O9 T* w# Z. L
son for the child’s virilization. At that time, they
, S% A. J( \( z: ^: c% v9 qdecided to put the baby in a separate bed, and the4 t0 g. }  Y0 [
father was not hugging him with bare skin and had
; {* a. G* ^1 l; B- `) ybeen using protective clothing. A repeat testosterone$ G! F1 C  q+ N/ V
test was ordered, but the family did not go to the6 ~- U6 w  y0 z9 {/ T% Z- U6 v  U+ I
laboratory to obtain the test.
7 d* k9 P0 v, Q! _Discussion; ^, O: g: s4 G$ A
Precocious puberty in boys is defined as secondary
  n" ^) J. a2 H, A6 f5 Q  a1 Isexual development before 9 years of age.1,4
" x" T+ u- n; l. |Precocious puberty is termed as central (true) when, Q  e/ c# _* |0 T
it is caused by the premature activation of hypo-
1 c6 C2 b& A. Q( k4 ?thalamic pituitary gonadal axis. CPP is more com-
7 Z1 H7 h  _7 R1 q+ D! q) `mon in girls than in boys.1,3 Most boys with CPP% W' U# M6 e9 H: u" i
may have a central nervous system lesion that is' A  [4 i6 A, o9 u. T  ~0 m7 }+ L
responsible for the early activation of the hypothal-
7 p  r2 d1 E& f5 |- s5 samic pituitary gonadal axis.1-3 Thus, greater empha-' w; R1 Z3 |/ @7 B. s! s, o6 g
sis has been given to neuroradiologic imaging in
, [* v* L2 T+ W* h2 M& B7 M8 Aboys with precocious puberty. In addition to viril-) F: x! S+ B# L; N+ J
ization, the clinical hallmark of CPP is the symmet-% R8 x3 q, U6 z* Q
rical testicular growth secondary to stimulation by
6 Z' ~, [; W8 J6 f& N1 rgonadotropins.1,3: V2 Q: n( O  X6 R
Gonadotropin-independent peripheral preco-6 B: @9 \) H! m% K+ z, `$ m% R4 |
cious puberty in boys also results from inappropriate
  q$ c' ~/ Z& l$ [& I8 r& `androgenic stimulation from either endogenous or
( G, I1 f8 ]# i' |) mexogenous sources, nonpituitary gonadotropin stim-9 l4 d  }! H+ x/ L) U  X5 G
ulation, and rare activating mutations.3 Virilizing3 S- e/ D; i" n  o" V4 S: P5 t
congenital adrenal hyperplasia producing excessive: V8 J) I9 o6 ~! ^4 a$ p
adrenal androgens is a common cause of precocious7 D. W' ]4 W: I2 y/ G( K
puberty in boys.3,4
+ U- j- q7 d' `5 Z1 PThe most common form of congenital adrenal
6 r$ y! k% o, R. z: Yhyperplasia is the 21-hydroxylase enzyme deficiency.+ `* b9 g5 |  F0 J+ o+ [2 ]
The 11-β hydroxylase deficiency may also result in6 E$ L9 h7 d- x+ ^
excessive adrenal androgen production, and rarely,
! T7 S. D) Q& San adrenal tumor may also cause adrenal androgen% n- V- B$ l) Z6 m# q9 o) g
excess.1,3
* I4 _; Z6 r+ x( E0 v% E* lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- c# t* H) m2 _4 O/ O8 q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( _6 @* B& m2 b8 N
A unique entity of male-limited gonadotropin-7 \4 C! E% \9 _& e; o
independent precocious puberty, which is also known8 f7 P- W0 }2 s6 T, @+ r. t
as testotoxicosis, may cause precocious puberty at a+ j. F3 s2 r# k$ _9 A9 J" m0 k
very young age. The physical findings in these boys9 S1 c+ }6 n6 {4 \7 ^
with this disorder are full pubertal development,( _: s  i6 y/ m: }- b
including bilateral testicular growth, similar to boys! m0 v) L+ t, G7 S
with CPP. The gonadotropin levels in this disorder
9 [+ w* l" Z6 u3 B/ |8 t1 ~% q# Lare suppressed to prepubertal levels and do not show
5 m! B2 z) m: b. dpubertal response of gonadotropin after gonadotropin-, k' j7 R; S# w/ K1 f  d
releasing hormone stimulation. This is a sex-linked+ Y) r+ E5 n* d) N: R6 r
autosomal dominant disorder that affects only) N9 i0 S- F  U
males; therefore, other male members of the family6 m% P8 s, r! q8 U/ q0 O2 [# d
may have similar precocious puberty.3& ^0 v# T( ^/ u
In our patient, physical examination was incon-( Z; n. }- T  t6 w: a; L  W0 O
sistent with true precocious puberty since his testi-
, ~: d& z3 X9 V. Y8 hcles were prepubertal in size. However, testotoxicosis2 r1 V- T1 @( B# {' a1 o
was in the differential diagnosis because his father9 I3 Z: |  a, o; y- O( d
started puberty somewhat early, and occasionally,0 t- S/ k% ], `$ ]6 t4 I% M
testicular enlargement is not that evident in the! n, I' l2 i* x+ O
beginning of this process.1 In the absence of a neg-
* X4 s& O( R: W" Q! Qative initial history of androgen exposure, our4 T: @: n- p+ m
biggest concern was virilizing adrenal hyperplasia,
5 H: ~1 M6 S! E+ peither 21-hydroxylase deficiency or 11-β hydroxylase
% g& E: a( N9 q5 L" ~+ G) z+ _deficiency. Those diagnoses were excluded by find-+ C0 N9 i+ h: v1 K" V* J3 r; d/ R/ F
ing the normal level of adrenal steroids.1 w( `9 Z  S' ]" k* Z, [5 X
The diagnosis of exogenous androgens was strongly
! @1 G! x, k4 U1 Esuspected in a follow-up visit after 4 months because4 i" O+ T/ z  f3 h$ \
the physical examination revealed the complete disap-0 y) D; x! g  B6 F2 x' H5 Q1 }( N
pearance of pubic hair, normal growth velocity, and
: Y8 f8 O" t( S9 Kdecreased erections. The father admitted using a testos-: d% I' Z! N- B4 p/ ?7 ?, F! p4 w
terone gel, which he concealed at first visit. He was. I: q; h8 o. R7 R/ |, d3 S  J
using it rather frequently, twice a day. The Physicians’
) u7 X* D* f5 b3 lDesk Reference, or package insert of this product, gel or* X- R" d" b( F8 M( `+ M' Q+ Y* _
cream, cautions about dermal testosterone transfer to0 C8 i, l9 Y* }# {! G9 {
unprotected females through direct skin exposure.- Z" O' W1 }) \3 o2 b
Serum testosterone level was found to be 2 times the( c" m; i2 S: S1 O
baseline value in those females who were exposed to
$ Q1 }/ |  v- c% e9 S# ~even 15 minutes of direct skin contact with their male3 S( S; n% g0 K# j2 ?$ _& D- ?' E
partners.6 However, when a shirt covered the applica-# h. W# X7 P$ ~5 k2 L
tion site, this testosterone transfer was prevented.% l# N. U9 [0 W$ o' N1 [# A  x, V5 B  F
Our patient’s testosterone level was 60 ng/mL,4 J% i: V: i8 \
which was clearly high. Some studies suggest that
% g. E, j. \; ^; k$ edermal conversion of testosterone to dihydrotestos-. C6 H8 j0 U7 o0 ^% `- X" D# t
terone, which is a more potent metabolite, is more
0 k' ^6 _. U& U+ bactive in young children exposed to testosterone4 p- R- P) }; i' I* C* u; Z2 ^- E/ Y
exogenously7; however, we did not measure a dihy-' w2 q$ ~+ G  ^
drotestosterone level in our patient. In addition to, i' }/ I) r3 u  w' K' E  @
virilization, exposure to exogenous testosterone in# j" h; u8 \3 F$ h
children results in an increase in growth velocity and
3 C; `, e8 Q1 @advanced bone age, as seen in our patient.
9 g% x2 |" o1 wThe long-term effect of androgen exposure during9 W2 n+ T! L4 w# b* ]! x' w
early childhood on pubertal development and final
# A0 j' @4 _0 s1 {7 c' y, w% Sadult height are not fully known and always remain
1 U! O; }6 \0 [9 A2 b/ t( Ca concern. Children treated with short-term testos-) g* H0 ]1 w% e, C+ y, L2 B
terone injection or topical androgen may exhibit some
) l2 }1 [8 g- X) P1 E& F; {acceleration of the skeletal maturation; however, after
6 c8 \0 _& u" d! _, [cessation of treatment, the rate of bone maturation* w- u1 l' i% R
decelerates and gradually returns to normal.8,9; ?4 F& {$ s" O( ~3 j8 T0 |
There are conflicting reports and controversy0 O% J; k- ]# W
over the effect of early androgen exposure on adult
1 r* J% P$ U. Q8 r* Xpenile length.10,11 Some reports suggest subnormal+ y3 ^3 [- \! \6 O0 B! t' o
adult penile length, apparently because of downreg-+ L  v+ L( h0 w' D7 T
ulation of androgen receptor number.10,12 However,& Y$ ^; k+ q1 m2 l# v( p1 B! h
Sutherland et al13 did not find a correlation between
- k- W! Q" d# cchildhood testosterone exposure and reduced adult, @8 i% u, h6 o$ r
penile length in clinical studies.( x! L+ u5 y3 ~0 _
Nonetheless, we do not believe our patient is" k- K6 C8 |9 t
going to experience any of the untoward effects from
+ k( l- x  A+ |4 X2 T) \* Q* Itestosterone exposure as mentioned earlier because( }7 N; R! N- K
the exposure was not for a prolonged period of time.2 ?6 r/ p/ g3 i# K( x8 B  D
Although the bone age was advanced at the time of
; |: F9 ]6 v, q5 Cdiagnosis, the child had a normal growth velocity at. s* i$ h5 W! _: b- ^/ X
the follow-up visit. It is hoped that his final adult$ b! I2 B* b! B* _, r& b5 z2 N
height will not be affected.7 Y9 M7 v+ v4 N. ]- K8 D) l
Although rarely reported, the widespread avail-
4 f4 P7 d) k1 b: s# f  t/ u: Sability of androgen products in our society may
8 X, p( v6 c! ^/ b/ o% ]indeed cause more virilization in male or female2 @+ w" z2 r4 `6 r4 i7 k
children than one would realize. Exposure to andro-
0 X5 H1 }' {/ o* H# cgen products must be considered and specific ques-) G4 i( A8 J8 H4 \$ z8 @
tioning about the use of a testosterone product or  G+ O3 Z' Y+ a; P/ y
gel should be asked of the family members during
8 h* ^, `4 h0 l, |: dthe evaluation of any children who present with vir-* b# v' @$ e" V+ F3 z7 k- E4 l1 U
ilization or peripheral precocious puberty. The diag-
: `* w7 U/ _6 w0 A8 w) {. y8 k8 Knosis can be established by just a few tests and by6 U  m4 |. H# C: B9 B7 q
appropriate history. The inability to obtain such a
- s% A  D4 g$ ohistory, or failure to ask the specific questions, may) w, P! G$ b+ b2 Z8 Q/ D! v7 c
result in extensive, unnecessary, and expensive' N; _4 f0 m5 O; F# L% }9 S+ p9 X2 \
investigation. The primary care physician should be
3 W4 K7 ~1 ]5 w* c" X  @/ S7 @aware of this fact, because most of these children
& w/ O, o  ~8 @# x* L5 Dmay initially present in their practice. The Physicians’
% q1 Q. g6 l: Y8 e* l' BDesk Reference and package insert should also put a" |+ q; l: V0 A, a  }) h) _
warning about the virilizing effect on a male or" q5 F3 v( C, x6 b$ }8 R
female child who might come in contact with some-1 ?- E( U! \- q' w. O  C& S
one using any of these products.
) g$ ?( m: Q% l8 G3 RReferences; A: E4 \- c# N
1. Styne DM. The testes: disorder of sexual differentiation
5 q0 H9 u) A) x" E( ?( A. land puberty in the male. In: Sperling MA, ed. Pediatric
( |$ B! [- X" T. D3 C' K& iEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 {8 ~9 j! m$ I0 N6 B2002: 565-628.
! |  D9 S3 y4 i0 b; o2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: ]+ D8 `; j# O" ~0 Hpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
% s5 a9 q0 g/ V6 c
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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