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Sexual Precocity in a 16-Month-Old
5 t4 I7 R. D% P  L- A, `Boy Induced by Indirect Topical
- `( w! D! z. {Exposure to Testosterone/ z8 ^! Z; I! f' o% _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# s5 E. D) x# ^  |4 j1 _and Kenneth R. Rettig, MD1
( i$ N/ r8 _% x% C/ K2 SClinical Pediatrics- O, ?. U% P4 M0 ^( s3 L! c, \
Volume 46 Number 6: a( o& f$ F7 [4 e" I! q
July 2007 540-543. r2 {" x6 z0 V2 s; ?! ]7 ^
© 2007 Sage Publications* r& ?" W7 o# p- ~
10.1177/0009922806296651
8 M3 V# x5 }+ |6 L5 nhttp://clp.sagepub.com% d$ C7 @' D% C0 m: L0 M
hosted at
( D+ f" \5 [/ J6 C; Yhttp://online.sagepub.com5 b6 X) t3 q3 W' T+ ~, b
Precocious puberty in boys, central or peripheral,
; g9 Q2 ~& p- H* \! d- h1 Dis a significant concern for physicians. Central/ D$ ?" R0 t# h5 F
precocious puberty (CPP), which is mediated
2 E6 l/ O. j* p/ lthrough the hypothalamic pituitary gonadal axis, has
# I3 |! |: T7 Y) G# J, v. Ba higher incidence of organic central nervous system
. q' \5 a- |! }0 u* x* x0 ~- Qlesions in boys.1,2 Virilization in boys, as manifested
+ l; Z2 V9 B. Kby enlargement of the penis, development of pubic# i1 L. L) |# U- z4 g4 ^
hair, and facial acne without enlargement of testi-2 x# j8 K* J( T( q4 K. b5 L: v
cles, suggests peripheral or pseudopuberty.1-3 We* v+ h( i. r( x; _3 o  U7 S
report a 16-month-old boy who presented with the1 o. a5 l- y; n$ v
enlargement of the phallus and pubic hair develop-& V. H% G; g) ?# h% h  f
ment without testicular enlargement, which was due; h( O9 y1 o) s2 Y) q2 \
to the unintentional exposure to androgen gel used by
8 D; [. [9 |* _, v- A3 e" fthe father. The family initially concealed this infor-: }, E9 j$ }5 y
mation, resulting in an extensive work-up for this
; o2 i( l8 W& _/ L$ s* O9 hchild. Given the widespread and easy availability of
9 [7 J' B+ ^! z- }testosterone gel and cream, we believe this is proba-
) I) B, Z0 e! b; u2 Q2 zbly more common than the rare case report in the
5 V* `! V$ g: w! S9 X- nliterature.47 [+ w1 |, p3 S
Patient Report
( k# S2 s: g" j! _0 D9 Y* _# TA 16-month-old white child was referred to the0 Q7 t3 }  k' B+ s0 c
endocrine clinic by his pediatrician with the concern
" y: c5 F+ @& p& j  Z* r  I: Yof early sexual development. His mother noticed+ k# Y- [9 w& A2 Q% u
light colored pubic hair development when he was
! _0 I+ s7 ~- Z% l0 e- A0 ~  N7 rFrom the 1Division of Pediatric Endocrinology, 2University of( V. f  S' H* U( U5 R" m. E
South Alabama Medical Center, Mobile, Alabama.3 [; l/ h' r$ f* i
Address correspondence to: Samar K. Bhowmick, MD, FACE,; a+ G0 @7 T7 o& w# ], a  _) d
Professor of Pediatrics, University of South Alabama, College of% n: z! c2 e6 A- a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ ~6 C2 J' y/ |8 i: Z
e-mail: [email protected].
3 e8 Z3 E2 d% o+ u' q" Cabout 6 to 7 months old, which progressively became
: E+ h) X9 P4 y* s* F2 C* Edarker. She was also concerned about the enlarge-
0 x: d7 ]4 h0 k& R7 f! v/ Hment of his penis and frequent erections. The child
6 L/ T6 d9 g( t. b' {0 ]was the product of a full-term normal delivery, with6 S1 s, G3 X2 T1 {5 f8 ^
a birth weight of 7 lb 14 oz, and birth length of
; _! U3 l8 b& H7 W20 inches. He was breast-fed throughout the first year
! F8 n" {, h( ?  @# Z7 C' J; Qof life and was still receiving breast milk along with/ J+ @; @+ N7 q( |8 z
solid food. He had no hospitalizations or surgery,; _6 M2 a" I7 c# L9 z
and his psychosocial and psychomotor development, r; E, j% W) S1 O
was age appropriate.1 w, v. {# F/ X; L0 H  h8 d" x/ B" I
The family history was remarkable for the father,) k7 N) p( K) ?8 C
who was diagnosed with hypothyroidism at age 16,
5 u6 Q0 I* `9 s% h  s# Rwhich was treated with thyroxine. The father’s% h) U2 _  e. L7 f+ T2 q
height was 6 feet, and he went through a somewhat$ V, K' P5 S: g7 v) Q
early puberty and had stopped growing by age 14.
, w( U+ q+ i( [+ @The father denied taking any other medication. The
0 Z6 _: ?3 h  f2 s: A  |8 echild’s mother was in good health. Her menarche
6 H8 u3 ~# u- _& l& O0 I' gwas at 11 years of age, and her height was at 5 feet
8 G$ O3 k/ R" F+ D# u, Y3 ^! T5 inches. There was no other family history of pre-
9 A3 [! \( c& u" z$ O# V$ @cocious sexual development in the first-degree rela-
& N- I" f1 E) s: p% Z; itives. There were no siblings.' Y# h# w$ }4 W" q6 L9 z: G5 f9 ^
Physical Examination
0 P7 V8 A6 M  v, @* K9 ?The physical examination revealed a very active,
( u, @3 l! E. P5 o% _" x% ]% Yplayful, and healthy boy. The vital signs documented
& k1 z, z5 \1 s2 G2 oa blood pressure of 85/50 mm Hg, his length was
( X7 p4 I! P2 U2 Q90 cm (>97th percentile), and his weight was 14.4 kg
7 e! X- G# C# d2 T(also >97th percentile). The observed yearly growth/ T6 Y3 _. |; g, e$ x
velocity was 30 cm (12 inches). The examination of7 Z+ a6 V5 K) F# ]" g; T
the neck revealed no thyroid enlargement.$ Q$ w: ]* }! M. p1 K* t
The genitourinary examination was remarkable for
3 J) r4 I5 h' A  r+ p; d4 \' Kenlargement of the penis, with a stretched length of
6 W; I, E' O4 Q/ v& c8 cm and a width of 2 cm. The glans penis was very well
2 L  K' F$ A9 K: h% I  ~( wdeveloped. The pubic hair was Tanner II, mostly around
' c/ v2 Q) y9 q) a& s5 D6 W# F540
) M* T! c$ q; b: [; r9 g5 p7 h& ~0 nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" o' ]2 Y* L. R! t, ]- s7 x( d/ a. }the base of the phallus and was dark and curled. The
" h9 t2 i0 F$ C* [6 L! Dtesticular volume was prepubertal at 2 mL each.# J3 |; Z7 {3 }
The skin was moist and smooth and somewhat' f1 l1 W- F$ i5 O: Z/ P! t
oily. No axillary hair was noted. There were no$ V; N2 |% w  {, z1 O
abnormal skin pigmentations or café-au-lait spots.$ b2 v0 Y& N6 W1 C- u5 @: g6 M. n
Neurologic evaluation showed deep tendon reflex 2+
" ]& ^& d  ?" B# [. _8 j" N6 ibilateral and symmetrical. There was no suggestion
! w* [8 S: Q) [; d/ Vof papilledema.. A, u) x- D0 R3 o1 k
Laboratory Evaluation
* n5 W' b$ n& d* I7 [  n% H* uThe bone age was consistent with 28 months by
8 y# x# g% ^$ c. I) w2 C3 Jusing the standard of Greulich and Pyle at a chrono-
2 u9 ?# B/ `9 ~. C# P0 wlogic age of 16 months (advanced).5 Chromosomal
6 L# L8 H5 O8 t0 lkaryotype was 46XY. The thyroid function test
" P0 i' O: Q/ ~8 e% l; v0 gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 a5 k# z  v0 Y0 M+ T
lating hormone level was 1.3 µIU/mL (both normal).
4 h; P: r6 F2 o/ g/ a$ pThe concentrations of serum electrolytes, blood
* {8 O: D  j- [. V# furea nitrogen, creatinine, and calcium all were
5 g# v2 S. A% T# {7 mwithin normal range for his age. The concentration
2 P, V: }5 b; ]5 ^; jof serum 17-hydroxyprogesterone was 16 ng/dL
# m  ]( S3 [- @: T: a% @(normal, 3 to 90 ng/dL), androstenedione was 20- d0 z/ U4 R/ T7 C* j1 p  M* r3 T
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 y' X( ^' J" Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),& f* c8 p- N# i( K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to5 t5 c4 N6 c; f
49ng/dL), 11-desoxycortisol (specific compound S)
9 A9 l! }' n* Y6 o9 Twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 P! {, e, o! o1 k- C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! {: [7 B8 h& Z3 j  P  b& g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* n+ ^6 w* ?/ ~  z; Q6 L
and β-human chorionic gonadotropin was less than
7 d- H9 ?+ @. w1 B: G5 mIU/mL (normal <5 mIU/mL). Serum follicular2 l% L: |/ ]) k# {* K: }5 G) o0 |
stimulating hormone and leuteinizing hormone1 n$ I# A& x: R$ N
concentrations were less than 0.05 mIU/mL' u2 A: a- v/ k/ e+ o
(prepubertal).$ u5 _+ k  X- h( ]  t5 t
The parents were notified about the laboratory: g& q! ?: v, ]2 y: u
results and were informed that all of the tests were
( q9 x' N3 H- j& bnormal except the testosterone level was high. The
, H( [. R$ y/ A/ r, l+ ~7 ifollow-up visit was arranged within a few weeks to5 c3 X1 Z* o8 Z$ S7 M
obtain testicular and abdominal sonograms; how-
  L8 ~) V% p2 dever, the family did not return for 4 months.4 M  Z4 ]7 c$ C1 p0 }4 I+ r7 {0 w
Physical examination at this time revealed that the
1 j& i1 E7 U$ ?8 rchild had grown 2.5 cm in 4 months and had gained7 o5 ~/ A( D* |0 ^: k
2 kg of weight. Physical examination remained/ |$ s8 B$ Y6 d3 G: D9 x. D
unchanged. Surprisingly, the pubic hair almost com-
% ^9 t" M' Y* L# h& opletely disappeared except for a few vellous hairs at8 h* F1 G( W7 s, |
the base of the phallus. Testicular volume was still 25 E1 \2 X: n3 ^1 o# Q
mL, and the size of the penis remained unchanged.; Y( o# v' `8 r2 q" V6 u# l2 z% m
The mother also said that the boy was no longer hav-
* l$ K  q* T& x! L' Bing frequent erections.  ^8 q4 u) M. ?' Y' a, Y
Both parents were again questioned about use of1 ?" d! ]- H% I" g+ H& @" J& n* h3 h
any ointment/creams that they may have applied to
9 ?1 F% Y' u1 C  Othe child’s skin. This time the father admitted the
9 [* W7 _) B. m/ Y6 Z& [" C1 ^' c% nTopical Testosterone Exposure / Bhowmick et al 541. h6 G; e6 L3 }+ w  w
use of testosterone gel twice daily that he was apply-
, C: a4 @5 G! {' G8 s4 O8 I; Bing over his own shoulders, chest, and back area for
2 F+ v2 F1 t5 l- B7 R. `a year. The father also revealed he was embarrassed7 B2 z' p( w; W+ [  a
to disclose that he was using a testosterone gel pre-
# f+ v+ n. f( fscribed by his family physician for decreased libido/ e, e% w7 p, m; g+ n% F- w' w# B
secondary to depression.+ h- t$ L- b! O
The child slept in the same bed with parents.
/ }7 G4 x2 A) ~. i6 d) B  sThe father would hug the baby and hold him on his* z1 w, x# c) }) g) o
chest for a considerable period of time, causing sig-
  z: }# ^9 }6 B: I4 A# t6 hnificant bare skin contact between baby and father.$ i7 d- }8 |8 ^1 V
The father also admitted that after the phone call,: w# E& Q, A- E0 j# m  F
when he learned the testosterone level in the baby
! u4 t1 H* ~) V" Iwas high, he then read the product information, k$ N- G& \9 h( X2 i" @
packet and concluded that it was most likely the rea-# S8 k. {5 M* p; ?4 X; r
son for the child’s virilization. At that time, they
7 l9 D# D4 s, \, y+ hdecided to put the baby in a separate bed, and the
8 o$ f( ^0 _  H- q1 lfather was not hugging him with bare skin and had( I- E0 B( d. m
been using protective clothing. A repeat testosterone
  w( D4 Q% ?# ]  ttest was ordered, but the family did not go to the
2 d4 ~/ j# E& l$ ?5 `' l9 l3 Olaboratory to obtain the test.
1 n! \1 c; P& Z% t+ qDiscussion
2 \0 S. V; o7 m+ k- o$ z4 k5 X, RPrecocious puberty in boys is defined as secondary$ D( I; `. K4 d9 c- K4 v4 l
sexual development before 9 years of age.1,4
. y' F7 B9 O9 ~& P. J, y4 _7 O4 WPrecocious puberty is termed as central (true) when
" J! _% |( ~1 Y3 z3 Vit is caused by the premature activation of hypo-
4 h, S$ E; I% o5 K* ^; [6 `thalamic pituitary gonadal axis. CPP is more com-& u; Q9 i& U# I# {4 c% m* D, Z1 ]
mon in girls than in boys.1,3 Most boys with CPP! i$ @! e& b3 F7 w9 j
may have a central nervous system lesion that is
, b+ {! M' b; Q; \0 bresponsible for the early activation of the hypothal-+ i% r0 F5 C' m9 A. k& O& L
amic pituitary gonadal axis.1-3 Thus, greater empha-
& g# d0 ~6 t* n$ H  P8 `sis has been given to neuroradiologic imaging in. K  W: j5 {2 o+ s2 ~
boys with precocious puberty. In addition to viril-
$ m$ L7 F  H1 t: n& t  L( ]ization, the clinical hallmark of CPP is the symmet-8 K6 c9 U" W$ f% ]3 {! M
rical testicular growth secondary to stimulation by, k: ^- a# q; O; ]. t( h; G
gonadotropins.1,36 o  l, ]; I$ F' r
Gonadotropin-independent peripheral preco-
+ f2 D. K9 H' m7 ?! Q1 T. S! T% v+ Mcious puberty in boys also results from inappropriate
, z/ e8 I  r- N$ O( ^0 Tandrogenic stimulation from either endogenous or9 A6 L3 m9 Y7 v' s1 U! Y: P  ~; H: r
exogenous sources, nonpituitary gonadotropin stim-4 h1 {' x% ^( J9 Q
ulation, and rare activating mutations.3 Virilizing
( P* I9 w5 c3 l: econgenital adrenal hyperplasia producing excessive
# f: m) z. e' ]) Cadrenal androgens is a common cause of precocious  x% q9 X  _( m
puberty in boys.3,4
$ w6 B, l/ [& y) b) vThe most common form of congenital adrenal
! @$ E: R: L9 ~  chyperplasia is the 21-hydroxylase enzyme deficiency.
  G4 r! `; i# O) M1 hThe 11-β hydroxylase deficiency may also result in
7 o; ^7 R" c' \  U, Eexcessive adrenal androgen production, and rarely,
: P& q, P- `- `an adrenal tumor may also cause adrenal androgen& ?7 @6 h# s9 J. c2 e% O7 Y& n5 R
excess.1,3- `! m: f8 S9 X% f3 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) m, P) M9 a8 ]2 Z& M. z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& ]! f. Y3 {  C& l0 J
A unique entity of male-limited gonadotropin-9 f- T. n; S6 s
independent precocious puberty, which is also known8 Q* ^3 {1 ~% ~) j
as testotoxicosis, may cause precocious puberty at a
" T! w: z2 C" l! P0 mvery young age. The physical findings in these boys: ?$ z6 V* ^# S/ r- T, F
with this disorder are full pubertal development,
* _% F0 g: \5 V2 ]3 s1 e: n1 qincluding bilateral testicular growth, similar to boys
5 M( ~) I- p: J* R$ vwith CPP. The gonadotropin levels in this disorder
# l" S/ ^9 {0 i- c- J- L7 Aare suppressed to prepubertal levels and do not show
* C# n( H# d4 G- r$ a0 k6 y+ Apubertal response of gonadotropin after gonadotropin-% I( |0 w- d( e1 n- f8 _1 N6 r: |, O
releasing hormone stimulation. This is a sex-linked
8 h* G- D4 ^3 M/ U% A) Q! ]autosomal dominant disorder that affects only8 F8 y8 P! o- b- y, b6 Z- q% h7 u% k) j
males; therefore, other male members of the family: ?4 H0 ^4 s- K, q+ [& `4 c" @
may have similar precocious puberty.3* Y& e& U* Y0 U8 K
In our patient, physical examination was incon-  D+ B6 _4 k2 L* `+ \
sistent with true precocious puberty since his testi-; Y* {! Z& S" Z4 j5 w$ [
cles were prepubertal in size. However, testotoxicosis
  E, P& T! }& ~7 @* G* L. Xwas in the differential diagnosis because his father
: `2 o2 g6 G! |0 T$ V: [. j) C8 Y# w& _0 qstarted puberty somewhat early, and occasionally,
3 U' v8 q0 B% u+ @3 \7 _testicular enlargement is not that evident in the
( Y8 u- T7 [0 jbeginning of this process.1 In the absence of a neg-' b" a& W3 s+ L8 W( r. ]1 C
ative initial history of androgen exposure, our; {6 J- [  z3 s8 k* R. ~
biggest concern was virilizing adrenal hyperplasia,
; a! c4 L" [# a- p  ^* J% S! feither 21-hydroxylase deficiency or 11-β hydroxylase" G8 d8 q' h4 P5 s* G
deficiency. Those diagnoses were excluded by find-
" S4 r, Z5 o$ P% }ing the normal level of adrenal steroids.
1 n8 S, V9 r- J  h% EThe diagnosis of exogenous androgens was strongly0 f. j) C- k0 ?9 ]& m6 y
suspected in a follow-up visit after 4 months because! J1 O( n  `2 V* G% z: {. a
the physical examination revealed the complete disap-  m/ _0 i! T/ k1 ?
pearance of pubic hair, normal growth velocity, and
3 n; G9 ?1 Z' ]3 s9 a# y* Xdecreased erections. The father admitted using a testos-
( u8 `: \/ }* Wterone gel, which he concealed at first visit. He was
4 e9 ~% N4 V+ i) @9 \2 q5 i9 {using it rather frequently, twice a day. The Physicians’
- I  c" ^# {' s6 q4 q1 [2 l; y; R$ HDesk Reference, or package insert of this product, gel or
2 n. ?2 i# P$ ~( Z' ycream, cautions about dermal testosterone transfer to
' F0 r# C5 N. d4 x4 @+ ounprotected females through direct skin exposure.
0 r+ R- I* ~1 J/ ], _/ h/ mSerum testosterone level was found to be 2 times the
% V! T; U3 N3 L- ]: ?baseline value in those females who were exposed to+ V( v$ p8 q: X( b  p1 b4 {3 {+ A: g/ ~
even 15 minutes of direct skin contact with their male! L  h& o- W: X# B* e* p0 q
partners.6 However, when a shirt covered the applica-
  {$ `' _1 D* m+ ~* ition site, this testosterone transfer was prevented.9 q* e" |% x" |# G) w
Our patient’s testosterone level was 60 ng/mL,
; i; u5 v$ k2 @+ e8 Ywhich was clearly high. Some studies suggest that4 b- Y" _. \- F" ^7 z6 r: o$ V
dermal conversion of testosterone to dihydrotestos-; m; [: t: H# U9 A8 ]: X8 J# R
terone, which is a more potent metabolite, is more
1 O/ ]. t/ G5 a2 j7 k: H; Sactive in young children exposed to testosterone  M4 E0 J# d1 {. |
exogenously7; however, we did not measure a dihy-
" e: ?1 ?: t  r* o4 Zdrotestosterone level in our patient. In addition to2 u7 k* G, D4 f. H( _: P
virilization, exposure to exogenous testosterone in
/ |. Z" s5 y9 r1 F; Y5 _9 achildren results in an increase in growth velocity and& {% f4 O9 N) V0 Q# i
advanced bone age, as seen in our patient.9 ~0 r6 L2 N  N8 T8 O9 Y1 X
The long-term effect of androgen exposure during4 B: r. E0 u- F# J
early childhood on pubertal development and final
* T5 x& T* f( A! N6 L: |adult height are not fully known and always remain, p- F( o4 a$ r, r3 h( j& I
a concern. Children treated with short-term testos-
% _% {; q( G# h4 a+ Tterone injection or topical androgen may exhibit some
$ Z% l' Y; F" hacceleration of the skeletal maturation; however, after( A" ]/ ?) e" m* f2 j/ H  o
cessation of treatment, the rate of bone maturation. E0 X( i9 ?' M# x: v% U
decelerates and gradually returns to normal.8,9; C  K. a5 V0 ?* V% [) b
There are conflicting reports and controversy. \- q2 `( G3 m. W
over the effect of early androgen exposure on adult
5 H2 n/ x2 f) N' @9 @; o+ C, Upenile length.10,11 Some reports suggest subnormal
0 A7 w/ E; n7 M) c& h! c* Gadult penile length, apparently because of downreg-
( }6 F1 v  S- j0 N4 m2 ^" xulation of androgen receptor number.10,12 However,& w" N5 v0 @5 N1 b% `% u, \
Sutherland et al13 did not find a correlation between
0 n$ h) N0 l4 d# Dchildhood testosterone exposure and reduced adult
3 f4 x  |4 Q1 B+ Qpenile length in clinical studies.: K2 A$ o) J, p6 `+ [6 @
Nonetheless, we do not believe our patient is
8 y( k) h4 x8 @going to experience any of the untoward effects from
( ?% ?) Q, Q* D; R0 J3 J& n5 {0 ztestosterone exposure as mentioned earlier because
& k6 t$ S3 {, U; O1 y1 K: Sthe exposure was not for a prolonged period of time.1 ^. b2 a# y! H& y. t7 [
Although the bone age was advanced at the time of
2 v9 t6 Q" j- Rdiagnosis, the child had a normal growth velocity at
3 R- E4 X' u# ythe follow-up visit. It is hoped that his final adult# o" Q+ r: f9 \& U5 v
height will not be affected.  s4 j! |: O* s* \& j1 W: \$ ^- S
Although rarely reported, the widespread avail-& S. g$ }. k7 Q3 S
ability of androgen products in our society may) a% l  S, i0 c9 \7 d
indeed cause more virilization in male or female8 O. [" }6 r! A" ]" |
children than one would realize. Exposure to andro-
0 S) y: |: n" Y; r$ Y* t! `' Cgen products must be considered and specific ques-- }3 R  A. R1 I" d( C
tioning about the use of a testosterone product or
9 p: [" S& A3 R3 Q+ vgel should be asked of the family members during
; Z8 c+ G* v4 r5 V4 H4 L- v+ d$ vthe evaluation of any children who present with vir-: F0 r# V% ?6 U) m- O
ilization or peripheral precocious puberty. The diag-
. y" d9 ?7 g# h* S$ h6 Gnosis can be established by just a few tests and by
/ y0 l/ _% @/ b+ U/ `appropriate history. The inability to obtain such a) R! v" |2 S7 l; b" _* W' _
history, or failure to ask the specific questions, may
) G. I" J* o, W1 x$ j4 Bresult in extensive, unnecessary, and expensive# V7 }4 `* |* h/ C" c
investigation. The primary care physician should be
4 \: z  _( d, D8 U5 C" ~$ X: ]! h( m  ]aware of this fact, because most of these children6 ~9 l* I# S9 U7 ~' t$ |
may initially present in their practice. The Physicians’
/ w4 w/ x) _0 ]# W1 _1 ADesk Reference and package insert should also put a
% l0 V- s; N8 T! f& o/ qwarning about the virilizing effect on a male or# y( z$ n7 q+ j- G' g0 }2 v
female child who might come in contact with some-
) y7 s( k3 F; r. Y3 i) \2 q# Rone using any of these products.3 G7 i- n- O& o1 C1 t4 f8 P' o
References
& t1 B$ Q# R8 v1. Styne DM. The testes: disorder of sexual differentiation2 ~* Q1 X+ g2 ~; B
and puberty in the male. In: Sperling MA, ed. Pediatric9 \2 |: o2 `; y3 F, _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; |* ^2 d+ f" h8 K# x
2002: 565-628." C% Y& H- k, e% W. B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 T" ]! d% o7 i, y3 u
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 c; a$ N# A' j5 X
Boy Induced by Indirect Topical' S% V& I; B5 X. k1 y
Exposure to Testosterone
; X( {( D: x: t& u+ \3 z3 X2 ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- U& T! Y3 q; o- s% P2 O
and Kenneth R. Rettig, MD1( V# ~. }8 T  U  c
Clinical Pediatrics
3 t' D, o6 F& K" J3 u) k# cVolume 46 Number 6
" I, x/ w. @/ A/ UJuly 2007 540-543
' |6 w( F( M- g© 2007 Sage Publications
* |% q+ p! f5 H10.1177/00099228062966515 Q/ u5 b1 c( u* B6 `
http://clp.sagepub.com
+ u9 U+ S# t" X) I3 }0 Vhosted at4 z% h0 A) ~% N
http://online.sagepub.com
; Z$ w0 _8 X# b$ o8 S3 r0 sPrecocious puberty in boys, central or peripheral,
8 f( f: Y$ `1 ~" ~is a significant concern for physicians. Central. D- [+ |. O4 n5 S3 Y+ U
precocious puberty (CPP), which is mediated
/ g" ~: k, y5 O9 g, m7 Pthrough the hypothalamic pituitary gonadal axis, has
8 x7 T# d' U0 h9 V% A* ^2 ?5 Z0 Wa higher incidence of organic central nervous system" J8 m) m- Y2 a7 s8 P* @
lesions in boys.1,2 Virilization in boys, as manifested# w2 p$ s! w& K' M* c
by enlargement of the penis, development of pubic
: Q  Y9 M5 h4 Shair, and facial acne without enlargement of testi-) c, k' ]9 P4 t+ K7 q
cles, suggests peripheral or pseudopuberty.1-3 We2 Q' K7 `0 f  v3 d! P
report a 16-month-old boy who presented with the
  y7 W$ {3 ~+ N% k3 i0 R; Qenlargement of the phallus and pubic hair develop-7 U- Q6 O  D  `' y4 }
ment without testicular enlargement, which was due
6 b% v/ I* f0 H) W. qto the unintentional exposure to androgen gel used by# Q9 M# g3 U4 ^" b# h% b
the father. The family initially concealed this infor-, Q' v, |. ^0 T$ R, M7 k
mation, resulting in an extensive work-up for this
& c( G( u) s6 T" r7 ]! }9 s, jchild. Given the widespread and easy availability of
' p" _7 N8 O5 `  h, vtestosterone gel and cream, we believe this is proba-
- K1 o# V" P8 Qbly more common than the rare case report in the
( h+ L" B. l( J" S  z/ ?' f* w! _literature.4, {% g1 j& v6 e
Patient Report9 _+ V( C5 H) G. M( d# s9 S
A 16-month-old white child was referred to the
: j5 }  k- {# Y1 k6 b$ uendocrine clinic by his pediatrician with the concern2 k; e! \8 F2 n/ `3 K: s7 Z
of early sexual development. His mother noticed. r( H+ t8 u/ a: T4 i
light colored pubic hair development when he was
/ f* n* F! ]' f) ~  @From the 1Division of Pediatric Endocrinology, 2University of" n- q/ {( K2 a
South Alabama Medical Center, Mobile, Alabama.
0 r9 U+ r* J/ O) Q* N; k& jAddress correspondence to: Samar K. Bhowmick, MD, FACE,$ o, U$ h" y* t2 E
Professor of Pediatrics, University of South Alabama, College of6 T8 T  S0 B- H& M" Z8 I- U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) L' r, `% l$ R8 C. ^$ t* a
e-mail: [email protected].1 U" q- i$ V! q7 ^% U7 v
about 6 to 7 months old, which progressively became
' Y. {6 ^, n; ]8 xdarker. She was also concerned about the enlarge-
6 E9 P  N+ T$ W, k+ m) P7 u+ Wment of his penis and frequent erections. The child6 w1 O) _+ w2 C3 i
was the product of a full-term normal delivery, with
$ o, p" y1 F2 x8 r9 c. na birth weight of 7 lb 14 oz, and birth length of+ `( `7 Z9 {; \4 n* z. Y
20 inches. He was breast-fed throughout the first year
. [6 d" {. U; }* L6 Mof life and was still receiving breast milk along with
# T# A0 M2 t# m0 Z8 Z; E6 bsolid food. He had no hospitalizations or surgery,& a- e4 a( J5 U9 R! D0 d
and his psychosocial and psychomotor development
/ q4 |1 g& B+ }1 a% y: C* E& ^/ awas age appropriate.8 K1 c9 y1 U" o; s6 Q* e/ N0 K
The family history was remarkable for the father,, s% {# j. h% J
who was diagnosed with hypothyroidism at age 16,5 x# d8 S4 b0 k0 N% Q- Q( Y, ^7 J
which was treated with thyroxine. The father’s
3 v# g% m" H) Q) j  i6 v! Y4 [( S, }height was 6 feet, and he went through a somewhat# `8 d+ w) w0 U+ S& l: e' y! ?
early puberty and had stopped growing by age 14.' t% H! h4 R# R: e* t5 Q
The father denied taking any other medication. The
! u# |% ~" F. Pchild’s mother was in good health. Her menarche6 Z  ~6 Z: E; l: c% r; F( z
was at 11 years of age, and her height was at 5 feet
. h" y9 u5 H+ {, \0 a* l! q8 a5 inches. There was no other family history of pre-2 \: |9 u& B! k8 G, F
cocious sexual development in the first-degree rela-3 C4 f7 Y' X2 B% J" H8 m! v
tives. There were no siblings.
" H4 G/ d" T8 c" f! S9 Z( b- O" _Physical Examination- y, C' K: ~: G9 U# [6 v" I! U
The physical examination revealed a very active,
* i8 T; R3 F' jplayful, and healthy boy. The vital signs documented, B% I( o6 S/ D- b2 ~
a blood pressure of 85/50 mm Hg, his length was
4 S. T, I9 S1 _1 `90 cm (>97th percentile), and his weight was 14.4 kg5 w- t$ F4 d! G: h# E# Q9 m3 r
(also >97th percentile). The observed yearly growth
2 C' Z3 z. h+ D% ^1 uvelocity was 30 cm (12 inches). The examination of" t( L2 A8 I5 g" i% E
the neck revealed no thyroid enlargement.2 m7 D& t' l  Y4 t; F
The genitourinary examination was remarkable for' }3 n$ x. O$ y6 Y3 g: ^! R" L
enlargement of the penis, with a stretched length of) f# e+ {' c6 Y
8 cm and a width of 2 cm. The glans penis was very well- F  o! {8 i( P  n. [+ t2 o
developed. The pubic hair was Tanner II, mostly around1 y7 C* K2 m9 f3 E- d
5409 Z8 g/ C1 V& ]9 q4 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( S! k" P8 l& z. ^8 l3 I
the base of the phallus and was dark and curled. The3 G# y! p( J4 m* |+ K6 s4 N0 l
testicular volume was prepubertal at 2 mL each.
* Z" S( h( A6 v/ }# ZThe skin was moist and smooth and somewhat
7 O1 t+ C2 M1 ^' qoily. No axillary hair was noted. There were no
  N  f" r6 U& f3 @  h: V, m! Z% }abnormal skin pigmentations or café-au-lait spots.
: o1 J: j) I$ v" O4 ZNeurologic evaluation showed deep tendon reflex 2+1 g( |. u; c4 q& q
bilateral and symmetrical. There was no suggestion
" {/ M/ U2 P5 x- M) Fof papilledema.( H$ T' L/ Y5 s8 [/ ~5 {8 l& X! U
Laboratory Evaluation& ^/ ]+ ]6 ]7 e8 V7 o3 O6 ^; J
The bone age was consistent with 28 months by
' t. f% O/ o% o3 b; B0 x/ `using the standard of Greulich and Pyle at a chrono-6 \2 U' S3 P6 p: P) J( t2 }
logic age of 16 months (advanced).5 Chromosomal! e, K# P2 w3 [, \# `( L
karyotype was 46XY. The thyroid function test
* m. V# G+ Y9 p6 e, hshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) f0 z' I" M1 R* J) ^% v" x' Z
lating hormone level was 1.3 µIU/mL (both normal).! Z9 p/ O. \+ V3 k- @6 G- h" {
The concentrations of serum electrolytes, blood
3 k) u1 F! T! g5 v/ xurea nitrogen, creatinine, and calcium all were' `, M7 U0 I! x$ [  X5 T3 j, l* S
within normal range for his age. The concentration, J3 m8 h, W$ z3 p; O0 S
of serum 17-hydroxyprogesterone was 16 ng/dL9 z  D; N+ ~/ |+ k3 x% u; Q) X, E
(normal, 3 to 90 ng/dL), androstenedione was 20& Z) V; I% ]( U; Y# j0 x# y& g
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ r1 z, V7 J2 _( U
terone was 38 ng/dL (normal, 50 to 760 ng/dL),( ~; Y% k& h8 b. u
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% V+ ~: Z2 z) I' b! e49ng/dL), 11-desoxycortisol (specific compound S)
) O# h0 W" \3 C0 ^* W0 I# {! Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 J, d4 T4 f3 C8 t$ E8 j' U: ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: I0 j$ _3 N$ ]; ]1 ]5 ?. ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),! W$ y9 V8 X5 z( K
and β-human chorionic gonadotropin was less than
3 V( s3 `! O+ t( d$ J6 [! Q5 mIU/mL (normal <5 mIU/mL). Serum follicular9 Q( n+ L/ l3 Y7 {: ^# K& p  N: V
stimulating hormone and leuteinizing hormone" k+ W7 t* x2 r" |4 p
concentrations were less than 0.05 mIU/mL
! U- X6 J9 D, Q. ]- T(prepubertal).
* l* [& I3 ?3 _4 v4 }- ]: KThe parents were notified about the laboratory
" u8 ]) l) G, r; c4 ^) s6 Kresults and were informed that all of the tests were' {" M# a6 A5 O' K( m9 ]
normal except the testosterone level was high. The, x+ `* q; L4 P4 [1 d+ m6 W3 {
follow-up visit was arranged within a few weeks to5 y3 y/ ]0 r: {, E
obtain testicular and abdominal sonograms; how-9 K9 G$ a( L0 ~5 W% u; a
ever, the family did not return for 4 months.9 e/ N% {; M. b
Physical examination at this time revealed that the: c5 a1 Y" A) {6 V: U) ?2 Y
child had grown 2.5 cm in 4 months and had gained
5 Z0 z7 ]- m4 i. \! {2 kg of weight. Physical examination remained
! L$ o7 g2 {2 n- }' y5 V3 j5 F* munchanged. Surprisingly, the pubic hair almost com-( j" g" v0 V/ e
pletely disappeared except for a few vellous hairs at
' R8 W# J; X4 q1 [the base of the phallus. Testicular volume was still 27 B- x. R2 J( A
mL, and the size of the penis remained unchanged.2 ?# i; l! o+ A3 Z0 f. w7 B9 e
The mother also said that the boy was no longer hav-
* U+ G$ D2 f6 eing frequent erections.0 D& m" {# P+ _& ?& c, M1 _
Both parents were again questioned about use of+ k) Y) ^( r) n$ s% d' H' i. N/ J
any ointment/creams that they may have applied to8 J  E. M$ b3 N: ]
the child’s skin. This time the father admitted the9 U7 v6 b% D8 I$ f" ^
Topical Testosterone Exposure / Bhowmick et al 541
8 Z1 v% T' l! ?use of testosterone gel twice daily that he was apply-9 y5 v2 W. R' F8 u/ `3 z
ing over his own shoulders, chest, and back area for
: {( e8 q  X/ I  K' r5 }) \a year. The father also revealed he was embarrassed% j" D( ?) x1 i8 k, z0 N
to disclose that he was using a testosterone gel pre-1 t% E4 u' d# z9 l
scribed by his family physician for decreased libido* E$ {& D) `$ \+ _
secondary to depression.
- B2 {& r& n# f$ A4 x1 mThe child slept in the same bed with parents.
* N+ E+ t, k  H' T# P' P4 A1 OThe father would hug the baby and hold him on his8 u2 B+ l4 T  U
chest for a considerable period of time, causing sig-8 v% @- {1 w1 w, o. E
nificant bare skin contact between baby and father.
; t' s3 p  B, v# [% B3 c3 U; ]The father also admitted that after the phone call,7 i2 z/ Y* U2 h
when he learned the testosterone level in the baby
" B1 ^7 [( Z2 B$ ^# I4 Owas high, he then read the product information
9 s5 e) F% A: Fpacket and concluded that it was most likely the rea-0 h6 `+ I" P0 X4 ]9 a& q
son for the child’s virilization. At that time, they6 |$ K9 b: G9 F; g- c  G4 O
decided to put the baby in a separate bed, and the- ]: P* X. d' D! {- B: c& T
father was not hugging him with bare skin and had
- m+ ~9 ~& r- C; _/ _) b5 zbeen using protective clothing. A repeat testosterone
0 P4 F3 a' Y, G- T* M1 m( i" {test was ordered, but the family did not go to the" R' L9 |9 F1 F1 J
laboratory to obtain the test.( e$ s: e% {! L5 f
Discussion9 p3 ]" ~$ `9 c# |9 l
Precocious puberty in boys is defined as secondary
* v$ z: o6 V2 fsexual development before 9 years of age.1,4
" U3 I; d1 M, @) Q3 D" d* K: l/ V6 tPrecocious puberty is termed as central (true) when
  _7 b: e) L, _2 Z2 }it is caused by the premature activation of hypo-8 Z5 _/ c* V0 b+ Q
thalamic pituitary gonadal axis. CPP is more com-
* m$ f2 Y! {; t8 }+ ~4 M  Mmon in girls than in boys.1,3 Most boys with CPP
8 b5 T, Y1 C5 C" n: Bmay have a central nervous system lesion that is8 A" ]+ y9 s  \  \1 R% o1 @
responsible for the early activation of the hypothal-
7 b' F) \0 ?; M6 Jamic pituitary gonadal axis.1-3 Thus, greater empha-
# Y, Z& v6 Q6 L0 rsis has been given to neuroradiologic imaging in
+ ^7 O# w4 A; N- @3 u+ M* v2 rboys with precocious puberty. In addition to viril-
2 |, g7 `. ^. K- s8 O# ^5 nization, the clinical hallmark of CPP is the symmet-. u  N! f5 X5 b+ H+ R$ h2 K
rical testicular growth secondary to stimulation by
& I; ?! b# ]  H/ n$ E( Ogonadotropins.1,3
) z- l5 Y5 Z) D  k. s% r0 Q4 M8 AGonadotropin-independent peripheral preco-' t6 Y& {* r" o% ~% Y
cious puberty in boys also results from inappropriate
+ q" X; l& L" r/ Gandrogenic stimulation from either endogenous or" r8 l1 D. Y" S. G) E$ b# k
exogenous sources, nonpituitary gonadotropin stim-
7 T+ n1 I: a" D5 m8 [ulation, and rare activating mutations.3 Virilizing
6 ?% n$ M  X3 {5 ~congenital adrenal hyperplasia producing excessive
# l4 x4 j! t: o0 l% L: padrenal androgens is a common cause of precocious' m  d: ?3 ^! e
puberty in boys.3,4) r) r$ b# B1 @) v% {
The most common form of congenital adrenal% ~+ G( q3 `; ?% G, i
hyperplasia is the 21-hydroxylase enzyme deficiency." y0 j: |) E8 R5 b$ d' J  @' a* S
The 11-β hydroxylase deficiency may also result in! C' m  w7 Q% Q1 p* L
excessive adrenal androgen production, and rarely,
- ]: Q3 f+ Q( P6 Kan adrenal tumor may also cause adrenal androgen
' x. ?3 p3 S- S2 }' k: J! nexcess.1,3" a" o4 P, ~, d7 `' h# v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: C, J7 w* }- B5 `3 E% [542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. S3 Z, v4 ?0 ~3 e4 zA unique entity of male-limited gonadotropin-8 _& w; N8 p# o! K/ |$ H: a! |0 D
independent precocious puberty, which is also known1 D: {, F, A, O. |
as testotoxicosis, may cause precocious puberty at a; U* P+ A: ^/ y/ j$ ?3 |
very young age. The physical findings in these boys. U/ \5 M( J1 U- Q) l
with this disorder are full pubertal development,
% t7 H4 Q6 q( h* ~' eincluding bilateral testicular growth, similar to boys& C# c3 T" j/ C$ Z) f4 n
with CPP. The gonadotropin levels in this disorder8 g1 ^- b" |# H3 S" i5 ~
are suppressed to prepubertal levels and do not show
$ T. |8 {. ^6 q1 ]: npubertal response of gonadotropin after gonadotropin-
: X; z! O  b7 ~6 H0 Preleasing hormone stimulation. This is a sex-linked
: M5 v3 u) j1 M5 \# n3 C3 mautosomal dominant disorder that affects only* ]9 |8 b& A4 l- P% e8 c1 X. ^
males; therefore, other male members of the family4 _3 j! w; X) e. P: c5 K5 ?# x
may have similar precocious puberty.3! V+ ]+ G) S" J  M/ M, o( B; q
In our patient, physical examination was incon-
% l5 k9 x8 `( ^sistent with true precocious puberty since his testi-
  h' J# s3 _( S  qcles were prepubertal in size. However, testotoxicosis8 m5 t5 K% |% G1 `
was in the differential diagnosis because his father. u2 b9 U3 h4 I5 R
started puberty somewhat early, and occasionally,) G; `+ r* M/ {6 K& P
testicular enlargement is not that evident in the5 Q* q& Y9 g* S& W
beginning of this process.1 In the absence of a neg-% m6 a1 e  H' u- g( d3 a
ative initial history of androgen exposure, our- P9 y1 A2 A8 [# C* o
biggest concern was virilizing adrenal hyperplasia,# B2 O( E. S- I2 Y3 o) g. c
either 21-hydroxylase deficiency or 11-β hydroxylase
' j7 ?; J7 Q- \: V4 I' G" x8 G& P8 i! Ddeficiency. Those diagnoses were excluded by find-( E) L3 F' O) f5 Y4 h4 _# N" J
ing the normal level of adrenal steroids.
% R/ y6 z# V  j7 q1 Y9 \  dThe diagnosis of exogenous androgens was strongly
1 K$ R; M- N- p9 Rsuspected in a follow-up visit after 4 months because* c$ `8 j" U/ _7 T. @' ]. l' i
the physical examination revealed the complete disap-
# e; t/ r3 N" @" @# m# {pearance of pubic hair, normal growth velocity, and
! P6 `5 P( o! V, J- d9 Z% I2 ndecreased erections. The father admitted using a testos-2 Y4 q( W7 S( I+ O, {
terone gel, which he concealed at first visit. He was! l. M' J; M8 n9 O0 z$ N% o
using it rather frequently, twice a day. The Physicians’8 u- Q7 E4 R: ^, O, |
Desk Reference, or package insert of this product, gel or- I, n" i6 Z8 b1 H8 B/ t
cream, cautions about dermal testosterone transfer to
; J" o. |6 P( _unprotected females through direct skin exposure.+ G7 L+ j+ _2 O0 B8 F6 l+ ?
Serum testosterone level was found to be 2 times the
9 ]  ?5 I' u' x% j2 ^0 ~baseline value in those females who were exposed to
" z9 L6 T* o8 Y6 x1 Ueven 15 minutes of direct skin contact with their male
; L: ]# m! b; F9 e# C5 T* C: Upartners.6 However, when a shirt covered the applica-
: s8 G7 D( E  D3 ption site, this testosterone transfer was prevented.- R9 B2 O' h  k" o6 e
Our patient’s testosterone level was 60 ng/mL,/ \% S& e/ h6 |9 R' t- @
which was clearly high. Some studies suggest that; X1 |  i8 @  M( F. V( d$ W
dermal conversion of testosterone to dihydrotestos-! w# t0 r" k, Q5 c/ ]; ~( I
terone, which is a more potent metabolite, is more) A2 _" g+ ~3 D. l4 ]
active in young children exposed to testosterone" O  J% j+ s( Q. j8 Z9 Z9 J& M
exogenously7; however, we did not measure a dihy-
( j9 W+ k" A) ]1 Y2 z; H: G/ Ydrotestosterone level in our patient. In addition to
5 H6 x0 a1 n9 h8 s' J7 Evirilization, exposure to exogenous testosterone in
& v& O4 c6 G  _& ?2 Z  M9 O9 Z& Zchildren results in an increase in growth velocity and
. q& P, \) d/ D7 E5 U: m/ p% Hadvanced bone age, as seen in our patient.
* ^* g2 e. T- B! M8 `2 `The long-term effect of androgen exposure during  j$ a0 p) |# }' i; ]; D3 r
early childhood on pubertal development and final& Q; e  d/ z3 k- q3 _+ g9 z  H
adult height are not fully known and always remain8 j, c- i) E+ e6 O+ g# }, \' X; O0 e
a concern. Children treated with short-term testos-9 G# J" N0 b* w: S7 }
terone injection or topical androgen may exhibit some
% @4 ?" r5 F1 h4 Facceleration of the skeletal maturation; however, after
  F  g7 }' M( v2 r! E* X4 dcessation of treatment, the rate of bone maturation4 Y' L; G5 M- o9 }! c# A# R
decelerates and gradually returns to normal.8,9
5 Z7 |6 B  k& g; ZThere are conflicting reports and controversy
# r8 M: g; C- M2 N9 Iover the effect of early androgen exposure on adult) u3 O9 M+ Z$ g: q" o3 ^" ^
penile length.10,11 Some reports suggest subnormal* U. S% }: M+ `2 Y+ r
adult penile length, apparently because of downreg-
( t+ {; B0 u6 S/ D8 s, G6 Tulation of androgen receptor number.10,12 However,& M* C; G8 b0 w. _
Sutherland et al13 did not find a correlation between% O! x% W4 C9 o5 h: q
childhood testosterone exposure and reduced adult7 {& k) m0 h2 ~/ B
penile length in clinical studies.
0 p' Y# m' A. U# j+ P1 W- PNonetheless, we do not believe our patient is. A- F9 ]7 H; K( x( q
going to experience any of the untoward effects from
! b. g( r' Y  Z2 e  N7 b1 utestosterone exposure as mentioned earlier because
2 G) c9 ?+ r4 Tthe exposure was not for a prolonged period of time.& v& P) ^! }7 Y0 r5 D; e# R/ x
Although the bone age was advanced at the time of! [1 J% X4 V3 b: a! Y2 ]
diagnosis, the child had a normal growth velocity at
# J( I+ h2 u- o$ ]3 F2 |) `+ lthe follow-up visit. It is hoped that his final adult4 v' H1 T! Q- }( R
height will not be affected.; X# p5 [7 q! E% |# ^( ^6 z2 X
Although rarely reported, the widespread avail-6 n' `1 _" g2 o5 j* q6 h  e5 x: \  P
ability of androgen products in our society may" T" u( J7 o( Y" D6 X
indeed cause more virilization in male or female
0 w) C5 u! H1 v9 `5 jchildren than one would realize. Exposure to andro-
- r. N8 \) ]# v4 Wgen products must be considered and specific ques-
4 \2 M8 b. ]( W, otioning about the use of a testosterone product or
3 y" m+ D; U6 j: V8 g& I* `3 E$ cgel should be asked of the family members during
. x! r5 _5 W* I& D7 M: _% O. Q4 Athe evaluation of any children who present with vir-
6 q" y4 ]# P6 D- Kilization or peripheral precocious puberty. The diag-& s: E6 i- t5 g- _' o
nosis can be established by just a few tests and by4 l" e1 _0 X% n
appropriate history. The inability to obtain such a" G3 w5 O1 ~3 r9 s) e' a" P
history, or failure to ask the specific questions, may
% J( G1 S) x7 A8 Wresult in extensive, unnecessary, and expensive
, P# K1 }& l$ m& I) Ainvestigation. The primary care physician should be! m$ y. A8 [: t
aware of this fact, because most of these children
" v1 G) M# {3 C  ]may initially present in their practice. The Physicians’" `9 r1 e$ I% |5 \" m* K1 [9 _
Desk Reference and package insert should also put a
! h" B8 Q! l- m9 y( |warning about the virilizing effect on a male or
. q- c4 P+ [# v) G" pfemale child who might come in contact with some-0 R. G' i  P. n# K
one using any of these products.
& G0 x6 N  B7 f/ yReferences
7 }3 k! T* D  C  X/ G% l1. Styne DM. The testes: disorder of sexual differentiation0 }0 T- @5 e2 q3 P
and puberty in the male. In: Sperling MA, ed. Pediatric
1 r. \0 y" r1 g0 {+ D- _" s# y5 T0 kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. c4 Q+ [  i1 D% u* S6 U( r8 Y
2002: 565-628.0 A9 {7 M* J. Q- |& l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ q: Y8 R" y; A( m- G7 \: r% Opuberty 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

5 L+ s: H5 z' E5 o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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