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Sexual Precocity in a 16-Month-Old
  _+ C5 k5 m8 jBoy Induced by Indirect Topical  [$ U. V2 O+ h) M  `4 I" o& ~
Exposure to Testosterone: ~  Q6 f& N7 x. G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! I; H1 l7 h8 v
and Kenneth R. Rettig, MD1
. H/ c  ]; |, a( n# S, v6 `- K" c+ AClinical Pediatrics& R3 L. J- e( Z. q1 U/ W1 d/ S2 ]* \
Volume 46 Number 6
. ^; V5 N5 Y, R" y! V& B: |" LJuly 2007 540-543+ R! u# X9 k2 k% n" g: c  m2 w: d, O
© 2007 Sage Publications- O$ v9 \6 h! V4 _/ d& z
10.1177/0009922806296651" w3 v" i6 E; `8 D# M
http://clp.sagepub.com
* i. [6 k9 @( Z  F, d/ Uhosted at3 s1 b  k) s2 G3 K
http://online.sagepub.com" G6 O* T. G# n: b! E9 U( n
Precocious puberty in boys, central or peripheral,7 r9 w0 ]6 P6 D! E! x! u
is a significant concern for physicians. Central
1 Q+ L: r( F0 mprecocious puberty (CPP), which is mediated: n1 u7 }7 N* \0 T
through the hypothalamic pituitary gonadal axis, has# i/ `9 c2 O. b# U: u
a higher incidence of organic central nervous system& G* @  F- i; ?
lesions in boys.1,2 Virilization in boys, as manifested' c- W" Y) y2 I3 t# m: h# z: H
by enlargement of the penis, development of pubic) @% C9 ]; [' r! z8 t  z% ]
hair, and facial acne without enlargement of testi-6 b9 E) [4 X/ {1 F& H& c' K
cles, suggests peripheral or pseudopuberty.1-3 We
; I0 Q, Y6 G' G. zreport a 16-month-old boy who presented with the
" o' F$ m% T3 b4 P" X7 }enlargement of the phallus and pubic hair develop-
2 u; ~! x: p, n- E: Y  ~ment without testicular enlargement, which was due0 a  D6 @2 w6 k8 q% H
to the unintentional exposure to androgen gel used by
1 S9 Z" J2 I/ n, \the father. The family initially concealed this infor-
; u0 c$ F! L/ O9 \* n6 ]6 |+ Smation, resulting in an extensive work-up for this
4 C$ Q1 d# S' X& Dchild. Given the widespread and easy availability of" m+ M+ ]8 ?! t$ `* C: u' a8 u
testosterone gel and cream, we believe this is proba-1 t7 |# r& w/ W8 _5 d+ [* G
bly more common than the rare case report in the
; F7 b$ s- k- K  pliterature.4# U: |" [# N- n( d' I* O9 W
Patient Report
" [6 e- {$ N7 I0 SA 16-month-old white child was referred to the
6 J2 p- [4 d& r7 J) U' Nendocrine clinic by his pediatrician with the concern
/ D2 L8 C# }. \+ w! B6 Gof early sexual development. His mother noticed- S9 A9 K6 U1 I/ f
light colored pubic hair development when he was9 }! }! N: ^$ z* U  h3 @' p
From the 1Division of Pediatric Endocrinology, 2University of  B5 f, W, C# C0 b; e) O
South Alabama Medical Center, Mobile, Alabama.
& P( a9 s) i" @4 k: @* z* eAddress correspondence to: Samar K. Bhowmick, MD, FACE,4 O/ P, t. j. @8 [, b- r
Professor of Pediatrics, University of South Alabama, College of% Z( {6 |. o3 d  m
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 C% B( J* |, K
e-mail: [email protected].
# d/ Q( o4 o0 A: R1 Habout 6 to 7 months old, which progressively became
( ~; {' X- w2 ?9 u. sdarker. She was also concerned about the enlarge-
0 ?/ V+ i# z& S% ~# o" y/ hment of his penis and frequent erections. The child
' R3 j2 n3 X# `  q: twas the product of a full-term normal delivery, with" p+ T4 ?/ a3 h4 c; G
a birth weight of 7 lb 14 oz, and birth length of
" m  K: X! ?, h! q4 N9 h1 _20 inches. He was breast-fed throughout the first year
% e" Z, N$ I0 j0 Oof life and was still receiving breast milk along with! r& _1 X, Q0 F8 h* r7 K+ P7 {# F
solid food. He had no hospitalizations or surgery,
4 W$ q' d1 b5 S/ Wand his psychosocial and psychomotor development
6 z$ `6 ^4 q6 X4 J, S+ U) \was age appropriate.; X, D/ j* V6 j- n! M$ ^( e
The family history was remarkable for the father,9 x+ e8 O4 y# f+ {+ A% ^0 A) j( ]
who was diagnosed with hypothyroidism at age 16,
0 L/ L5 P- r* p" f  J% \8 jwhich was treated with thyroxine. The father’s2 g' g) o  d, e* e: l
height was 6 feet, and he went through a somewhat0 m0 ^' y9 `! ]( T1 A0 c1 W
early puberty and had stopped growing by age 14.
6 }2 T  j- r- L  KThe father denied taking any other medication. The$ p7 l) D# j: s3 ~& Z
child’s mother was in good health. Her menarche& X* I( f& _: l) x
was at 11 years of age, and her height was at 5 feet$ Q# {  K9 G2 M, `% s6 a
5 inches. There was no other family history of pre-6 x  C% U. ~0 v% ]' o; Y% m% i
cocious sexual development in the first-degree rela-' w2 L3 n0 i. m6 o% }
tives. There were no siblings.
. G* @* I/ ]6 \" g) tPhysical Examination0 h2 }2 m2 Q/ z! G; U
The physical examination revealed a very active,
1 P5 u9 f9 c' q" I2 C' e! Cplayful, and healthy boy. The vital signs documented. D7 S) Z* @) Y$ [. ?
a blood pressure of 85/50 mm Hg, his length was
- I$ F4 {* Z+ E0 e: Y2 o: s+ P90 cm (>97th percentile), and his weight was 14.4 kg
+ b! E* I2 U. y) i* Y(also >97th percentile). The observed yearly growth
+ G7 G& \4 L. B0 y3 p2 w8 y: {velocity was 30 cm (12 inches). The examination of
0 W3 G5 j. c/ N) q1 j) B/ z; m! mthe neck revealed no thyroid enlargement.; U& Z1 T) z% u; Z
The genitourinary examination was remarkable for
- w9 o" z: M. l9 r) Z/ yenlargement of the penis, with a stretched length of
; s6 ?5 A9 r( j" @8 cm and a width of 2 cm. The glans penis was very well
5 S8 [! t# C5 r0 ldeveloped. The pubic hair was Tanner II, mostly around8 |& v; M* K0 M/ K2 x1 n* A, Q3 C: Z2 D
540$ p" D  a8 K. J- ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! T1 ~; n, |6 ]/ n" jthe base of the phallus and was dark and curled. The" e9 Q) z" j) ?: t' M# Z7 U+ c0 G
testicular volume was prepubertal at 2 mL each.
/ L4 {+ z, h' FThe skin was moist and smooth and somewhat
  n  D0 O4 t$ l9 u- V8 J* Y4 koily. No axillary hair was noted. There were no
' U: `6 V  N- M/ s! |$ Eabnormal skin pigmentations or café-au-lait spots.) G& ^! b9 O* E, ?
Neurologic evaluation showed deep tendon reflex 2+
) @% s& V4 H* S) Fbilateral and symmetrical. There was no suggestion  g, Q1 Q* C5 W
of papilledema.
8 v6 Y& V8 V& S5 Z# `% oLaboratory Evaluation$ J, S. q- C/ N6 T
The bone age was consistent with 28 months by+ o7 m$ }6 {; R+ v) A" Q5 D
using the standard of Greulich and Pyle at a chrono-& l3 o8 ^) t5 g; t( w
logic age of 16 months (advanced).5 Chromosomal
+ U5 _( x3 J7 g  B9 ~# g$ P' T+ G; ]karyotype was 46XY. The thyroid function test' o5 Z* e! k* l3 H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, `: g, y/ I6 E; B- o% r
lating hormone level was 1.3 µIU/mL (both normal).
7 n2 B: t% g9 k. B# EThe concentrations of serum electrolytes, blood
5 Y) i3 ^7 O& w3 m0 c2 m0 t( x! Eurea nitrogen, creatinine, and calcium all were' p* w8 u* R" D  x7 V: {  q
within normal range for his age. The concentration" S1 m) r9 T) p& V2 k
of serum 17-hydroxyprogesterone was 16 ng/dL& C# g- _% i& u$ [+ A
(normal, 3 to 90 ng/dL), androstenedione was 20
7 t" B$ ?8 K) Y2 ]* s. E1 g' mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# }6 O. M% S2 w3 x3 |; Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),; |6 ]7 A. d, r, v9 c% N; {$ s
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% E+ H& R6 j- ?5 K. c. _49ng/dL), 11-desoxycortisol (specific compound S)
1 f1 m( N3 v5 ^+ N: rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( f! U. X  w  L& b' c* Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% @8 K$ h$ m* x8 H
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) b, A% h7 x5 U$ Tand β-human chorionic gonadotropin was less than
% r) M$ i2 e# T! G9 C, G+ U9 m5 mIU/mL (normal <5 mIU/mL). Serum follicular7 Q) c0 e3 `$ B$ |! s
stimulating hormone and leuteinizing hormone6 N, a$ C4 M' h/ ~
concentrations were less than 0.05 mIU/mL/ p& a6 F1 v+ Z: J- T( R
(prepubertal).! p( V8 `- t6 w
The parents were notified about the laboratory4 y8 e% i% R$ T0 \' P
results and were informed that all of the tests were" z6 {9 L3 q6 L/ V
normal except the testosterone level was high. The
5 N, G, |- x# U4 l& {follow-up visit was arranged within a few weeks to
+ W7 w$ D% G' _4 S' w2 Hobtain testicular and abdominal sonograms; how-
& a) i- L; e# C2 a1 G, K. Uever, the family did not return for 4 months.3 \0 Z+ ^. p+ F- E; e6 w! m& o8 ~( q7 l
Physical examination at this time revealed that the
  i: [1 q: `* Ochild had grown 2.5 cm in 4 months and had gained
& s; Y+ R2 r( R' Y8 r5 f9 O2 kg of weight. Physical examination remained
  p" c* I7 S$ K/ V" l1 eunchanged. Surprisingly, the pubic hair almost com-
) Y& _8 I; p# m% n0 Epletely disappeared except for a few vellous hairs at4 G- D3 v, `2 S! S% l) h
the base of the phallus. Testicular volume was still 25 p! I6 N' N( \( S  _0 ^* u
mL, and the size of the penis remained unchanged.
2 n+ G/ [8 E' y/ w; {! lThe mother also said that the boy was no longer hav-: H4 Y7 Q5 l4 C2 x+ ]% H0 P
ing frequent erections.
, B! Z: W" z9 g2 h1 {4 D. }Both parents were again questioned about use of
* u8 P' {( t: M/ s/ Bany ointment/creams that they may have applied to
( ~  S8 ^4 W( `2 I, Hthe child’s skin. This time the father admitted the
' Q7 j2 I  Y* K' W. gTopical Testosterone Exposure / Bhowmick et al 541
& j6 ]' k# F: y/ Tuse of testosterone gel twice daily that he was apply-
' F) M' W6 q( n; Eing over his own shoulders, chest, and back area for8 D3 U& l9 }- C3 {2 a6 K
a year. The father also revealed he was embarrassed9 u0 n. k) B# i" I8 w
to disclose that he was using a testosterone gel pre-- v2 E3 K7 `9 y  T. m- x% C7 _! R
scribed by his family physician for decreased libido
0 |, P6 O/ C* ]+ Q+ psecondary to depression.
3 G/ h. h: k2 @- N8 GThe child slept in the same bed with parents.# ?  g4 w. p8 x& B( N$ A  a
The father would hug the baby and hold him on his- Q# ~+ b" a3 i: i) ~0 p
chest for a considerable period of time, causing sig-
; L7 x2 X  l5 N" {9 pnificant bare skin contact between baby and father.
3 f6 W) c3 \- n' `* C+ n) `The father also admitted that after the phone call,6 J( A% T. v. \+ O! s* n
when he learned the testosterone level in the baby. c  H) m( l/ C0 p
was high, he then read the product information' L, d8 }5 |0 A, |
packet and concluded that it was most likely the rea-5 O0 q4 J6 ?* @; v0 N& ]2 |# g) M$ s. |0 M
son for the child’s virilization. At that time, they
* w7 w" r, P, _+ O& _4 h) r( G' Adecided to put the baby in a separate bed, and the0 z! {1 X8 h6 U$ y7 O- N# S
father was not hugging him with bare skin and had
" ?; e' l/ V8 N6 V9 Gbeen using protective clothing. A repeat testosterone
( C% S7 R" W5 ftest was ordered, but the family did not go to the9 t& A  o! s) p  p. l; L, D
laboratory to obtain the test.7 R. b5 G% l: {. t  k
Discussion9 H  b( I# n& f2 C/ [# l3 |
Precocious puberty in boys is defined as secondary# j! {3 ~3 ^0 l3 @3 |" g
sexual development before 9 years of age.1,4
( D  \: `0 J; l: W9 KPrecocious puberty is termed as central (true) when
! F# S8 k1 X/ _4 ~) f) Y: Q( Nit is caused by the premature activation of hypo-" [# J3 G) y. B; R5 M, B1 f1 [, j
thalamic pituitary gonadal axis. CPP is more com-; ]. M5 T* [; O
mon in girls than in boys.1,3 Most boys with CPP6 U6 f3 H( p# S9 t
may have a central nervous system lesion that is
8 G3 Z* s! F' z1 {' B$ Aresponsible for the early activation of the hypothal-5 V7 w, H/ T  s+ _2 L6 |
amic pituitary gonadal axis.1-3 Thus, greater empha-5 T6 q" u5 J1 ^- g2 h1 Z7 @6 |
sis has been given to neuroradiologic imaging in2 b( c% F4 ^  ?$ X" V: T
boys with precocious puberty. In addition to viril-$ y+ |+ V& y- H5 O& E8 D
ization, the clinical hallmark of CPP is the symmet-
% r7 S! v1 N" r, ]rical testicular growth secondary to stimulation by
0 k0 C1 _- ]1 h( e. \gonadotropins.1,3
. m2 }( K( J8 x, yGonadotropin-independent peripheral preco-
+ g. X. O) s4 v* u& wcious puberty in boys also results from inappropriate7 }! A" E7 S& h7 a% t$ O6 ]& I2 V
androgenic stimulation from either endogenous or
# n1 e" u% H" P2 Dexogenous sources, nonpituitary gonadotropin stim-
, a# n+ U1 U3 Z1 [4 t: yulation, and rare activating mutations.3 Virilizing
! f5 u7 P  L- z! Acongenital adrenal hyperplasia producing excessive
' R0 [" @* Y7 a$ C) u$ U5 M6 @adrenal androgens is a common cause of precocious2 d6 v: B' z; {. c
puberty in boys.3,4; q' @, ?7 g3 M
The most common form of congenital adrenal3 Y; G9 S9 |* U' B4 q! D3 U, p
hyperplasia is the 21-hydroxylase enzyme deficiency.0 [( f# a  E* V
The 11-β hydroxylase deficiency may also result in
8 A" S4 s, M( r) x, Gexcessive adrenal androgen production, and rarely,
' ^0 D% _  ~$ P3 N4 }) man adrenal tumor may also cause adrenal androgen: p& O  G9 \6 i  b
excess.1,34 [( R8 k: r7 m- t/ C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- N' l/ }$ V+ T2 h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% s+ }7 g6 |3 u0 L( i: U8 S  J# wA unique entity of male-limited gonadotropin-
# t9 V( ^' ]; V7 [( {independent precocious puberty, which is also known$ t" g( L; ?1 C% M4 U$ u+ _/ r
as testotoxicosis, may cause precocious puberty at a$ Q; Q$ m) p6 `2 P/ s7 V! j
very young age. The physical findings in these boys5 d2 J: V' _0 ?! v$ o2 K8 V1 E6 Y
with this disorder are full pubertal development,
9 P* |. k; U1 |% {/ \- r3 T- cincluding bilateral testicular growth, similar to boys
4 g/ c( C; d) G) u1 s4 n" xwith CPP. The gonadotropin levels in this disorder
9 ~$ U; W7 @, G! P0 Oare suppressed to prepubertal levels and do not show2 W3 o2 ~. h! B2 j! c
pubertal response of gonadotropin after gonadotropin-
( ~) R9 c8 A5 Q4 x4 @* Jreleasing hormone stimulation. This is a sex-linked
, b8 R# k6 w; D$ {autosomal dominant disorder that affects only2 Z8 B( m& ~, F' h% `
males; therefore, other male members of the family# v9 ]8 e0 e: a
may have similar precocious puberty.3# r0 p0 \2 l1 j' V  n. e
In our patient, physical examination was incon-
  E5 d3 j+ C( c& Z- [sistent with true precocious puberty since his testi-9 h& ?; t: V. X( t% S& a
cles were prepubertal in size. However, testotoxicosis
6 B8 B1 ^0 h  u, x1 N# w& W& o& zwas in the differential diagnosis because his father. \) [7 |3 z7 s& h# C! S2 T$ ~
started puberty somewhat early, and occasionally,. h8 p9 G+ U; g6 T
testicular enlargement is not that evident in the" l& ~1 x* A, O/ e- `- R9 h
beginning of this process.1 In the absence of a neg-
3 H& O2 E! w, T# o/ kative initial history of androgen exposure, our
* h6 T+ V6 |1 F% K, obiggest concern was virilizing adrenal hyperplasia,
: p( c5 k1 i/ ^8 T/ S' B, r! Ueither 21-hydroxylase deficiency or 11-β hydroxylase' `( n0 W# @6 w7 I
deficiency. Those diagnoses were excluded by find-7 e" o6 d% W& V# ]. r
ing the normal level of adrenal steroids.
  ~2 B. }3 o7 A$ _, }: `The diagnosis of exogenous androgens was strongly
6 P; G$ V; d' l. W, i6 F: tsuspected in a follow-up visit after 4 months because0 y; N2 ~4 J* ]0 [( E- q6 e7 Z
the physical examination revealed the complete disap-0 R" D- J1 a0 w. ?
pearance of pubic hair, normal growth velocity, and* a, r& w1 D4 D7 ~1 P' @6 J, N
decreased erections. The father admitted using a testos-
: k( S7 B1 i; L4 yterone gel, which he concealed at first visit. He was% Y6 t1 ]: F0 |
using it rather frequently, twice a day. The Physicians’6 |, q" L2 E2 {
Desk Reference, or package insert of this product, gel or
* X5 X# i) n1 _2 L* c5 \cream, cautions about dermal testosterone transfer to0 W: }+ V: T1 W( K! b
unprotected females through direct skin exposure.
; Y; C. j9 B& K" T2 K; m/ A4 G  lSerum testosterone level was found to be 2 times the/ n( c# M$ h, F8 Z% E9 S! P1 d. z
baseline value in those females who were exposed to
) g! N, o/ F3 U2 a% U  Feven 15 minutes of direct skin contact with their male& F+ _$ P$ B, l4 m7 R  p
partners.6 However, when a shirt covered the applica-5 \0 O0 R: |4 |( R0 e! ]
tion site, this testosterone transfer was prevented.' D+ l+ |# R+ g: F4 q* D
Our patient’s testosterone level was 60 ng/mL,
" o9 @' L- l6 T/ w9 h# Rwhich was clearly high. Some studies suggest that* `  a; ~( \- n* [& \. w
dermal conversion of testosterone to dihydrotestos-5 V0 h) u; z- Y& E0 D# Q
terone, which is a more potent metabolite, is more
0 w" p2 q( b! p' o% ~- gactive in young children exposed to testosterone
' l- w& t& _1 K0 X2 B" G9 nexogenously7; however, we did not measure a dihy-, s) J# }. I* B7 `& F- f
drotestosterone level in our patient. In addition to
$ ^* p& V; _% A- l9 P; ivirilization, exposure to exogenous testosterone in6 O: @" q3 M5 m& Y  m6 X
children results in an increase in growth velocity and
+ h' e  T4 J# Y! y+ sadvanced bone age, as seen in our patient.! N& I8 B9 |, R, _, V
The long-term effect of androgen exposure during7 q5 \+ t" K4 X1 H9 s
early childhood on pubertal development and final
" r8 Y+ U* N3 C/ j1 k7 w) Q7 Zadult height are not fully known and always remain6 @& y6 f5 t+ U' D. J1 S* z3 q
a concern. Children treated with short-term testos-- N+ ]. t8 l, b9 ]
terone injection or topical androgen may exhibit some
7 b$ S3 n  g( D6 [! ?acceleration of the skeletal maturation; however, after
2 t( r8 }) G$ e5 N& Icessation of treatment, the rate of bone maturation
9 L; u4 }+ Y: ]1 U! hdecelerates and gradually returns to normal.8,9
" T  o3 s* i: x# o7 _0 hThere are conflicting reports and controversy* j/ b( T1 O4 w
over the effect of early androgen exposure on adult! w; [2 m& ^2 W# w3 h+ ^" f
penile length.10,11 Some reports suggest subnormal
8 u3 H, L( B1 a1 Radult penile length, apparently because of downreg-
' i/ k. X- ^3 X" f" qulation of androgen receptor number.10,12 However,
2 {2 G$ ~( {' A7 K! A7 Y7 \: DSutherland et al13 did not find a correlation between, L  ~1 ^5 y, B5 o3 D1 `
childhood testosterone exposure and reduced adult
$ _- b# |7 j2 v) Hpenile length in clinical studies.0 L% N- f) g( R8 f: o
Nonetheless, we do not believe our patient is( A0 _& j! E$ W/ o6 [2 J' g. O
going to experience any of the untoward effects from
  w3 }9 L0 M! C3 p; e2 ^7 itestosterone exposure as mentioned earlier because+ @2 Y4 }7 {  n
the exposure was not for a prolonged period of time.$ ?5 w4 j( I% q7 e4 K7 l
Although the bone age was advanced at the time of. o/ y* R  f8 {1 o& B, N
diagnosis, the child had a normal growth velocity at9 e, Z: s9 B1 u) C
the follow-up visit. It is hoped that his final adult" i( P; [5 E9 ]1 h
height will not be affected.4 m8 w4 F1 ~; Q' n
Although rarely reported, the widespread avail-$ v$ g6 V3 y0 D: d6 q
ability of androgen products in our society may
( I' e% j$ O/ G9 O7 _5 _indeed cause more virilization in male or female
* S1 Y! l/ k9 N$ O, z* @% O& Z( kchildren than one would realize. Exposure to andro-/ v2 v% j5 \7 P* f6 o1 |
gen products must be considered and specific ques-
7 O" j& z. }! m% Xtioning about the use of a testosterone product or
  U% F) s, Q3 S1 I- Rgel should be asked of the family members during0 z' W( n: g# E8 U: n+ x
the evaluation of any children who present with vir-5 n1 A3 H* J- L% q: X% P4 l
ilization or peripheral precocious puberty. The diag-
& Z' ~# H6 L" r- J! _, F5 v" l- Pnosis can be established by just a few tests and by
; A/ b6 a) f! w/ T5 G; ?/ A" u. pappropriate history. The inability to obtain such a1 t1 g7 j& [8 U, y, T. V* h
history, or failure to ask the specific questions, may- O% y( d% \8 l$ s  C
result in extensive, unnecessary, and expensive
/ S2 g/ G2 v2 s# e9 pinvestigation. The primary care physician should be6 r6 ]  A' l8 R0 _7 B
aware of this fact, because most of these children: k$ f% `' V7 K# ~
may initially present in their practice. The Physicians’! b% o7 r( X* }: k( {# k% m* V
Desk Reference and package insert should also put a0 q* H6 j( Z0 ^/ K: A0 \8 M, o/ E
warning about the virilizing effect on a male or1 {$ Z0 k1 T$ k1 l. y% K2 Y
female child who might come in contact with some-
6 S2 }/ v# M% ~" z; [- z: D: ]one using any of these products.
- K+ F9 _1 q# K/ P, Z+ S; p& \) VReferences) Y3 u2 E" [* N$ j+ V
1. Styne DM. The testes: disorder of sexual differentiation  a. q2 ^7 O6 B: O. `0 ?
and puberty in the male. In: Sperling MA, ed. Pediatric( p$ r% u/ l( d  ^5 M- T2 x
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' }* x/ k2 M9 O/ X( m) _2002: 565-628.
' F2 O# V# @2 ^, t  R- n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# T6 Y' ?3 x7 j2 M& l7 Cpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 e. K- B6 E' YBoy Induced by Indirect Topical. k& n/ C4 }/ Y% f. R3 E8 ^
Exposure to Testosterone2 P" [4 S" x$ R2 X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 D. }/ G" w# m) J' J0 K- a' G5 B
and Kenneth R. Rettig, MD1
& p8 d5 Y3 u& f$ e3 yClinical Pediatrics
+ L0 _4 N3 t) K2 V' KVolume 46 Number 6
3 l6 C7 X: r5 pJuly 2007 540-543
7 q$ T4 W! b3 O; {" H' p  Q© 2007 Sage Publications
/ [3 s5 z' p5 a8 f* j10.1177/0009922806296651
' `9 a) o: i1 T4 Jhttp://clp.sagepub.com6 F1 e) k- ]- \8 o/ d
hosted at
/ D  K3 m1 E4 L- o# ihttp://online.sagepub.com
1 D1 P3 }: M2 L* A7 GPrecocious puberty in boys, central or peripheral,
* p+ V% U. c* u6 N3 X2 Lis a significant concern for physicians. Central
- u' h( X7 N1 ?. B1 c3 oprecocious puberty (CPP), which is mediated* h* h! @. n7 z2 w
through the hypothalamic pituitary gonadal axis, has  }* b0 l# D- ?0 F6 z* I1 a5 _
a higher incidence of organic central nervous system$ h  r/ d, e* B( _$ Y% y0 Q, U6 N# }
lesions in boys.1,2 Virilization in boys, as manifested3 z+ z7 N: R; S+ ~  _
by enlargement of the penis, development of pubic
  S! b1 _9 B% [; a  ihair, and facial acne without enlargement of testi-3 o8 J& f1 T9 X! W6 D+ ~) E4 b
cles, suggests peripheral or pseudopuberty.1-3 We! h2 z! I0 e9 s1 c& E' H
report a 16-month-old boy who presented with the) E# H- ]0 K1 v8 w" d, C: m
enlargement of the phallus and pubic hair develop-( ?- P* k4 ~/ M" A- j0 q
ment without testicular enlargement, which was due
) d; @8 l8 N2 D# N* {4 R7 sto the unintentional exposure to androgen gel used by. u0 H6 Q' j+ F+ [; c: g' R* m5 e
the father. The family initially concealed this infor-9 P! _; R7 \  {! ~7 T: Q$ ~( r% G
mation, resulting in an extensive work-up for this
4 {7 ^7 {$ ~7 l! e( ], p% t( f- Rchild. Given the widespread and easy availability of
) x' k3 E$ @7 u8 ltestosterone gel and cream, we believe this is proba-
, j& t- E$ @) x; kbly more common than the rare case report in the
+ m; u" m* c' i3 j3 Qliterature.4
3 T: W* y0 g$ v9 X- gPatient Report
5 d5 ?3 t2 q3 W7 {A 16-month-old white child was referred to the
9 P& z7 W$ M" D* z% Lendocrine clinic by his pediatrician with the concern
" O4 |8 @% Q8 p- v& M" f6 Y6 sof early sexual development. His mother noticed
7 _5 G: i6 X6 x/ H% ?light colored pubic hair development when he was
5 B$ p, n' C* e/ EFrom the 1Division of Pediatric Endocrinology, 2University of) ~9 P. B2 j3 B, M' n$ g' y8 O  z
South Alabama Medical Center, Mobile, Alabama." k, d7 n- W/ ?; f
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 Y* ]4 E& Y  P3 i9 q1 H: J6 m* ?3 b
Professor of Pediatrics, University of South Alabama, College of
7 `' O  C" I! H# H, P9 QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 s# p. d) p4 K( Q
e-mail: [email protected].4 X3 k; W& D9 s7 h5 K. H
about 6 to 7 months old, which progressively became& s: @* J8 [" X; x0 K. a; I3 X
darker. She was also concerned about the enlarge-( v( C* O+ _2 D) r
ment of his penis and frequent erections. The child
, ?$ N& h9 `7 Uwas the product of a full-term normal delivery, with2 ~: r! r7 J5 G8 ?  l. s! r/ A& Z
a birth weight of 7 lb 14 oz, and birth length of6 C# f1 f7 `. Q% E- q5 I4 v+ C
20 inches. He was breast-fed throughout the first year
! E6 s2 Z9 v, c9 p/ i3 U! fof life and was still receiving breast milk along with* D9 ^' d$ z+ R( c+ i% v6 k1 g
solid food. He had no hospitalizations or surgery,- u$ c/ N9 Z" W" ~7 j
and his psychosocial and psychomotor development
2 X" S+ r0 [8 D& b7 o: mwas age appropriate.- b1 x' D. O) K8 N/ g! U! U8 N
The family history was remarkable for the father,( U  e; H2 e' U: N( f3 S
who was diagnosed with hypothyroidism at age 16,
/ j; z9 j, d" C# t$ |# |which was treated with thyroxine. The father’s
: Z# p' J. w6 S3 B" t3 cheight was 6 feet, and he went through a somewhat
% B) \. p( S2 J9 M+ u( E* v. iearly puberty and had stopped growing by age 14.5 d: X2 Z3 R8 R! }3 N# ?* ]/ z0 r
The father denied taking any other medication. The  u2 o+ M% g  F& F; t9 @: C9 A/ N. U" y
child’s mother was in good health. Her menarche. C; s( F/ X% B
was at 11 years of age, and her height was at 5 feet  o4 i' T$ F& V- Q
5 inches. There was no other family history of pre-- ]' M6 @7 m  X) Y8 G
cocious sexual development in the first-degree rela-
4 N. E% _& r% k$ h  S8 Y0 t+ ^: d, Ftives. There were no siblings.
- k) o; H! L  z) fPhysical Examination# V5 h- P1 p" C* }
The physical examination revealed a very active,3 O9 G( V7 _+ f1 D: }
playful, and healthy boy. The vital signs documented
; b  O* G! F$ ~4 z2 La blood pressure of 85/50 mm Hg, his length was$ q. _+ x. n. U8 E/ p# V
90 cm (>97th percentile), and his weight was 14.4 kg1 J/ S+ w/ g; w
(also >97th percentile). The observed yearly growth
4 s6 ~6 G& h' I/ D( C. X# Ovelocity was 30 cm (12 inches). The examination of: t  e; w# {8 |3 R
the neck revealed no thyroid enlargement.7 e  u$ g( |6 q& ~- ~
The genitourinary examination was remarkable for
/ b% v4 r# `  M6 }5 K9 K/ d7 wenlargement of the penis, with a stretched length of3 b) G2 c3 }" c* q0 O) |& Q
8 cm and a width of 2 cm. The glans penis was very well
3 q4 f/ w+ ^! b% B* Hdeveloped. The pubic hair was Tanner II, mostly around
( k3 W% |7 t6 Z# n% \1 \! k" `540
! P7 t  W9 F, l1 R4 }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, d! s4 E( N/ m4 P$ X0 E# ?
the base of the phallus and was dark and curled. The1 u' {; P' m0 z$ N3 Z
testicular volume was prepubertal at 2 mL each.. H, ?: G" a) e" r  `
The skin was moist and smooth and somewhat% Y/ l7 l; [0 x, L1 P7 v$ |
oily. No axillary hair was noted. There were no) L" F( w, K& C/ `. i3 K. a1 h
abnormal skin pigmentations or café-au-lait spots.- U8 }) G1 Y5 M" D% Z3 ]6 S
Neurologic evaluation showed deep tendon reflex 2+
5 a- e, r% g* a7 n/ \, j9 y5 Kbilateral and symmetrical. There was no suggestion2 z  K* t6 [  P. l
of papilledema.
% q5 L$ z2 Y( w. y1 x- j# y9 uLaboratory Evaluation# ]  D! l8 q. d: {& o
The bone age was consistent with 28 months by
! ]( O/ F/ G3 I" [# W; z: \  C0 jusing the standard of Greulich and Pyle at a chrono-9 n: t# y, c& O) W) R
logic age of 16 months (advanced).5 Chromosomal
, C6 _5 Q1 O4 O* g8 o: t1 gkaryotype was 46XY. The thyroid function test+ x! {" N7 D6 }5 }, U, ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 `* \( c$ f$ s* X% ^8 ?5 }- z
lating hormone level was 1.3 µIU/mL (both normal).; I# I$ w  {! ?- Y+ B
The concentrations of serum electrolytes, blood9 v/ d& D% K8 g. ^! v  y
urea nitrogen, creatinine, and calcium all were
" U3 [- v: ~7 Y* V  Xwithin normal range for his age. The concentration9 g; x( i+ [: f2 R$ w5 s, [
of serum 17-hydroxyprogesterone was 16 ng/dL
! ]; K! a+ ]- E7 w' m(normal, 3 to 90 ng/dL), androstenedione was 20" u- {" v+ x- A8 U1 b
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
9 ]- ?7 t6 T/ G1 Y( s2 Aterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 `( i: V/ h  Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 i- l# T' ~) A, k4 R49ng/dL), 11-desoxycortisol (specific compound S). k! @6 h4 r9 l' H& Y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 s3 P- T& z  Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 T, r, d" V9 G5 C; A
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ o( ?" H4 X! `
and β-human chorionic gonadotropin was less than
/ P2 Z$ X& d5 m5 a" Z1 o/ f# ^0 ^" `5 mIU/mL (normal <5 mIU/mL). Serum follicular) @; H9 @2 }# M" f( n- q! Q5 i
stimulating hormone and leuteinizing hormone* h* j/ ?1 a+ u+ T' U% Z/ h8 C
concentrations were less than 0.05 mIU/mL
0 r& l( o. C( g! B2 @- r(prepubertal).# V, L; @. E- c6 B  `
The parents were notified about the laboratory
. K) R6 S( J, e8 presults and were informed that all of the tests were) d& V) e; k- Z0 G8 \2 N8 t% i
normal except the testosterone level was high. The
9 ?3 o2 \& ?) U/ Tfollow-up visit was arranged within a few weeks to
4 G: d7 z& b8 k' jobtain testicular and abdominal sonograms; how-
0 A( c( z0 s+ j+ t& Tever, the family did not return for 4 months.
- E/ V- `6 E4 t1 {1 SPhysical examination at this time revealed that the
' v+ u2 ^  j0 y# i# Cchild had grown 2.5 cm in 4 months and had gained0 g( u) H1 V4 A4 O* Q
2 kg of weight. Physical examination remained  S  A8 |5 S: o
unchanged. Surprisingly, the pubic hair almost com-0 L, ~8 [: p. F1 F4 C2 |
pletely disappeared except for a few vellous hairs at' J2 e6 P2 D6 }
the base of the phallus. Testicular volume was still 2' J- U' U& i3 E5 V, N' g
mL, and the size of the penis remained unchanged.7 u  b5 O8 n. o" n) l
The mother also said that the boy was no longer hav-1 [6 P% X! u4 ]* O" ~& M  h4 m# L
ing frequent erections.9 |" X0 I- D% ~" _; m6 D' ~$ o' g
Both parents were again questioned about use of- }1 `4 ^( A, `" N7 R$ Y/ W
any ointment/creams that they may have applied to- J1 @- o+ @( o2 B4 L7 T
the child’s skin. This time the father admitted the; B9 W, p, g# W! \9 ^& h
Topical Testosterone Exposure / Bhowmick et al 541
( ~/ z9 Q6 F1 ^/ c4 w( z  g8 {use of testosterone gel twice daily that he was apply-( W! A2 m, H/ y
ing over his own shoulders, chest, and back area for
, S2 i' R3 C/ B4 _4 x3 Ua year. The father also revealed he was embarrassed& ?, H; v! D9 n0 \& U
to disclose that he was using a testosterone gel pre-8 [7 `5 V% L; b! }! M# f
scribed by his family physician for decreased libido
7 E$ _6 h+ d! Wsecondary to depression.. o; U" z! M- F; B
The child slept in the same bed with parents.
& X( [/ X  j7 lThe father would hug the baby and hold him on his2 ?) q5 }7 Y* L$ o4 F% w
chest for a considerable period of time, causing sig-
: z7 y" k  a) Q; q4 S  X7 T' dnificant bare skin contact between baby and father.
$ I; W9 f9 W! K9 n; y" [# q; \The father also admitted that after the phone call,
, w/ F9 H; w' ^3 y# qwhen he learned the testosterone level in the baby
( [6 H; l6 t( W! M) ~+ _) j7 I# D9 fwas high, he then read the product information! H% Q; D5 f2 l0 S
packet and concluded that it was most likely the rea-
7 T3 g1 u# m+ |' }. Bson for the child’s virilization. At that time, they) }5 N1 b/ Q! K  z1 ~  e6 s
decided to put the baby in a separate bed, and the# ~6 @1 f3 H# y' j& C3 I
father was not hugging him with bare skin and had
9 F2 r) \1 }- s/ Hbeen using protective clothing. A repeat testosterone
9 N( Q; M, i" C9 l: Ytest was ordered, but the family did not go to the* g& Z$ e5 e; H- @6 @3 U: X
laboratory to obtain the test.( q' I. [6 ?3 ~- N
Discussion
7 j) ~( |5 t/ u% f% Y2 SPrecocious puberty in boys is defined as secondary
6 {/ i# S$ Z( ?. y& p9 vsexual development before 9 years of age.1,41 k3 W  z( f6 s6 f- m! g8 z
Precocious puberty is termed as central (true) when
+ x7 l  d# T  I( {' Nit is caused by the premature activation of hypo-' k# T' x. V0 G6 B* K' b% \
thalamic pituitary gonadal axis. CPP is more com-
$ ~$ `, ~+ B* Y) ~0 u& ymon in girls than in boys.1,3 Most boys with CPP1 }/ g) |  \  U+ P. A/ d$ F: [
may have a central nervous system lesion that is5 {' W. i7 Q2 k
responsible for the early activation of the hypothal-
; |& t: Q+ s' U! C, @# z- Iamic pituitary gonadal axis.1-3 Thus, greater empha-/ `& }* p/ j6 q- V& K% y$ U
sis has been given to neuroradiologic imaging in
* y1 d' J+ C! I- v0 O) Tboys with precocious puberty. In addition to viril-# D6 C( s- m- ~: W; x8 R2 A- G
ization, the clinical hallmark of CPP is the symmet-' \, A" f4 j! [( e% [  [
rical testicular growth secondary to stimulation by6 l4 w, e0 U( u: H( Z
gonadotropins.1,3
' n3 V$ V) l' f) L1 h% NGonadotropin-independent peripheral preco-4 J6 `( B, [, r
cious puberty in boys also results from inappropriate9 I- u; W. X0 C9 X6 A
androgenic stimulation from either endogenous or
8 p. h" v& x9 w! O1 sexogenous sources, nonpituitary gonadotropin stim-
, q6 ?6 N% \3 I# \5 |9 Y6 m+ vulation, and rare activating mutations.3 Virilizing
$ X  ]& Z8 L- U; t. ^2 scongenital adrenal hyperplasia producing excessive
% {/ r6 ~1 ^) I9 _adrenal androgens is a common cause of precocious+ x3 q/ n8 ~( s5 e" [0 ~# @
puberty in boys.3,4
' n" t6 [  L$ c: T1 |" m, ?The most common form of congenital adrenal
; y6 z( \% E% s- w" A* G0 l# b2 w, zhyperplasia is the 21-hydroxylase enzyme deficiency.
6 _+ w9 c" n* fThe 11-β hydroxylase deficiency may also result in
2 H, F2 d/ b) yexcessive adrenal androgen production, and rarely,
! ?6 \& s' L& a* ~an adrenal tumor may also cause adrenal androgen2 Z) A% Q9 X" {) Z. [/ |7 J: h
excess.1,33 r# E$ v/ I% S; V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, x# Z, G" T5 _5 E) B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* C* G0 f# J1 B4 W
A unique entity of male-limited gonadotropin-
, o7 [( l5 E0 f# ]3 h* E6 q4 rindependent precocious puberty, which is also known$ A5 a) ~# l* Q6 Q  C
as testotoxicosis, may cause precocious puberty at a
% n* g9 o; V% ]( R1 U+ V. ^very young age. The physical findings in these boys
. y7 ~, m! V' a/ Qwith this disorder are full pubertal development,
, G1 d0 P' N. q0 y% R# m6 N  Dincluding bilateral testicular growth, similar to boys# y; X- y4 i0 a- d+ c) P* O
with CPP. The gonadotropin levels in this disorder6 K9 R; q2 Q, X
are suppressed to prepubertal levels and do not show
1 E# m' n0 h! vpubertal response of gonadotropin after gonadotropin-( C! ^' ~! `* M+ ]" w% s1 J3 i
releasing hormone stimulation. This is a sex-linked
$ R# p3 o9 r" x: Zautosomal dominant disorder that affects only
( U1 L& k2 v( d5 z; Amales; therefore, other male members of the family
: _5 Z0 n" O6 Z4 O, smay have similar precocious puberty.3
; o& Y/ @0 E1 J6 zIn our patient, physical examination was incon-
" g) }9 I6 i0 N. [; a6 t$ ?' L' W; isistent with true precocious puberty since his testi-" a1 C& w6 o* @' N5 q/ e& g% w
cles were prepubertal in size. However, testotoxicosis
# G! [) |4 L7 H8 A$ F% O- o& y3 Cwas in the differential diagnosis because his father4 i2 q, e0 w' A; E2 M* F$ V" a
started puberty somewhat early, and occasionally,: I2 f* o5 M2 q+ c
testicular enlargement is not that evident in the. r% W. G/ x, M; M
beginning of this process.1 In the absence of a neg-
7 d% ]  M2 c& ?9 O& ?5 B/ ]# ?' m5 @ative initial history of androgen exposure, our( Q0 h9 S5 b/ _
biggest concern was virilizing adrenal hyperplasia,* R' s; x- M4 R+ w- V1 O
either 21-hydroxylase deficiency or 11-β hydroxylase
+ q. M# S. V* s5 H2 N( e' S! ndeficiency. Those diagnoses were excluded by find-, }' ]) t# l" ]& c$ W
ing the normal level of adrenal steroids.+ f) q9 n+ _. F6 F1 i& f3 z& L* I+ p
The diagnosis of exogenous androgens was strongly0 l% c  [) G6 I% N2 i& ^/ @
suspected in a follow-up visit after 4 months because# W/ B, k1 z3 T" a
the physical examination revealed the complete disap-5 A  }* B* a. l  _2 I, ~8 A
pearance of pubic hair, normal growth velocity, and
2 Z+ w5 O9 ~% a4 F1 T& idecreased erections. The father admitted using a testos-
/ f" F# j1 u6 D( S7 S. H, }terone gel, which he concealed at first visit. He was$ ^* @& ]* z* u5 q# D. }. z6 h
using it rather frequently, twice a day. The Physicians’
% Z! E/ v/ T; j0 z0 T  z9 YDesk Reference, or package insert of this product, gel or
" C- ~8 R! n  Ecream, cautions about dermal testosterone transfer to7 V. R5 q! P6 ]; T7 J" I
unprotected females through direct skin exposure.8 E! T' a5 A5 P( |/ F
Serum testosterone level was found to be 2 times the, D2 Y6 v+ c, N6 c1 x: x
baseline value in those females who were exposed to$ q8 E! F# t) P# N* A
even 15 minutes of direct skin contact with their male. A  w, F# {/ B; T8 {
partners.6 However, when a shirt covered the applica-' u' S5 D# \+ w. h  h) C  \
tion site, this testosterone transfer was prevented.. f" N, J+ H* K; d. \
Our patient’s testosterone level was 60 ng/mL,
6 l4 N. U& ~# e7 U5 [$ B8 H6 u7 lwhich was clearly high. Some studies suggest that( ^: \: e$ U6 M$ I% Z' m9 R
dermal conversion of testosterone to dihydrotestos-" F5 H2 v! ]: z7 u4 E. i
terone, which is a more potent metabolite, is more2 v. O) v0 S! G4 e2 K9 s, B
active in young children exposed to testosterone
4 ^* Z, W  O7 T! I$ Lexogenously7; however, we did not measure a dihy-7 F! r  G" ^) E8 u; T* W
drotestosterone level in our patient. In addition to) Y3 Y- J7 J& b7 t8 H$ l
virilization, exposure to exogenous testosterone in
7 X0 l4 z3 V8 Xchildren results in an increase in growth velocity and
7 u6 N- _$ O; s) t: _& }* Uadvanced bone age, as seen in our patient.+ B* q6 q" y  V5 G/ r' ?3 G- l, g9 p
The long-term effect of androgen exposure during
6 n  B, X  p% [3 c5 E7 kearly childhood on pubertal development and final: H; R4 u$ B6 d
adult height are not fully known and always remain5 j- b$ w0 F% [. I9 d9 B9 k
a concern. Children treated with short-term testos-( r/ k, Z+ {5 n- r8 H# g) `
terone injection or topical androgen may exhibit some6 j" M) d5 u1 T( Z, U: b4 b& j
acceleration of the skeletal maturation; however, after
/ n' U; a! [( _! a0 V, |: h8 u' Pcessation of treatment, the rate of bone maturation2 ]( J8 V# t2 {2 O: w& U# w
decelerates and gradually returns to normal.8,9
# e8 @0 ?7 O3 ~* MThere are conflicting reports and controversy6 ?  c6 g( Z' H; K6 D; e6 m. ?) \" M
over the effect of early androgen exposure on adult4 k, ^% l, m$ N# a
penile length.10,11 Some reports suggest subnormal' W, j' |" s- a4 ~/ Y/ `
adult penile length, apparently because of downreg-- `7 F7 |8 O% H) I: i: C% m+ \( v& V
ulation of androgen receptor number.10,12 However,
7 e; n6 z: z2 Y/ s/ ?9 YSutherland et al13 did not find a correlation between
& y( v" T) s5 S' n& e( b/ \childhood testosterone exposure and reduced adult% |/ {% U( z1 N
penile length in clinical studies.1 L. }1 I1 U  _
Nonetheless, we do not believe our patient is+ F' k5 y+ D9 k3 |% r9 f$ z
going to experience any of the untoward effects from6 x: M: M9 O+ W1 w  z3 `
testosterone exposure as mentioned earlier because
8 s% {$ h" ]3 e+ B1 p1 Rthe exposure was not for a prolonged period of time.
! k( Y  E# p) i; x: AAlthough the bone age was advanced at the time of
+ g! c5 F% z5 E- fdiagnosis, the child had a normal growth velocity at' B. Q" b  A5 C9 T" Q
the follow-up visit. It is hoped that his final adult1 e* f* I) B5 C! J* N
height will not be affected.7 N5 \) E9 G. ~6 h1 e
Although rarely reported, the widespread avail-" F; I' J/ ?7 ]& N5 L  y+ Z4 q5 K
ability of androgen products in our society may  r; }5 e+ x5 R4 Q2 U& _) M2 m
indeed cause more virilization in male or female2 B2 C  c1 q4 O# _5 t
children than one would realize. Exposure to andro-
( y3 A+ p2 U$ Z$ @0 X7 vgen products must be considered and specific ques-2 A4 G$ D1 }. a) I5 U! I
tioning about the use of a testosterone product or
1 K' y$ i6 V5 m+ Mgel should be asked of the family members during2 }& E# M1 ]" s/ H/ }0 d* J
the evaluation of any children who present with vir-
& j# E4 d% \, ^4 ~ilization or peripheral precocious puberty. The diag-- }* u1 L; _' [3 `7 ?8 H) A2 t
nosis can be established by just a few tests and by
+ l& p3 F0 D0 r. Y+ L) M$ M$ Kappropriate history. The inability to obtain such a
, W# B" a) C7 }5 {history, or failure to ask the specific questions, may
7 }0 @  Z4 a( W) ^# Gresult in extensive, unnecessary, and expensive
) ?, j# s6 J% @- i3 f( ninvestigation. The primary care physician should be7 @+ p1 Y4 W+ r3 c
aware of this fact, because most of these children2 ^6 W, {. {5 u2 {' y
may initially present in their practice. The Physicians’" E+ a. u1 h2 k8 M
Desk Reference and package insert should also put a; z' v$ u( T4 [
warning about the virilizing effect on a male or. O3 w0 v" P$ J
female child who might come in contact with some-+ v. |- `* b# x
one using any of these products.
' y: E! u: Y* x; B/ xReferences
& T2 a/ F5 R/ }$ a1. Styne DM. The testes: disorder of sexual differentiation
/ K- d9 I- _+ H1 h5 F0 Land puberty in the male. In: Sperling MA, ed. Pediatric
" k, ~' c# a9 V/ \/ R9 U1 r9 e6 DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% I' e/ L8 B! _5 X0 k$ S3 ]8 F
2002: 565-628.
) S3 x9 S1 k3 M! H$ e2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' ?5 ~! Y5 D; A" c6 M8 ~
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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
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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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