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Sexual Precocity in a 16-Month-Old
" ^5 \0 y0 l* z) ]6 SBoy Induced by Indirect Topical
. H* ^1 @2 U# M! xExposure to Testosterone  a. r. K0 A- L; R) v8 u$ @( W9 R" {
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ n- c7 f1 q4 t- A8 C9 q" o
and Kenneth R. Rettig, MD1* g  W2 y! A/ }8 Y+ }; z3 W8 _/ w
Clinical Pediatrics% l) e* f( a7 s$ R
Volume 46 Number 6
6 P6 L' ?6 t1 Z6 T" U% A" VJuly 2007 540-543
: {$ M5 W' [6 _% c% c© 2007 Sage Publications# G# h$ |1 ~: |
10.1177/0009922806296651
( q5 I: _5 w% M) V& [http://clp.sagepub.com: v) `; C" Q: ]& ]
hosted at
- q* Z4 y4 b6 x! B: Lhttp://online.sagepub.com
* ]5 T5 J- x; l6 ]0 G. iPrecocious puberty in boys, central or peripheral,
7 h, e/ \# g0 }6 J, Q/ Ris a significant concern for physicians. Central+ x+ d. Q4 L5 A) g2 p
precocious puberty (CPP), which is mediated
: j$ H4 J. d. f3 n; D- kthrough the hypothalamic pituitary gonadal axis, has
" G1 M( L" Z: O: ga higher incidence of organic central nervous system% t: z& e: Y0 D4 b# r. F1 G1 i
lesions in boys.1,2 Virilization in boys, as manifested- _  f: l  _7 H$ `/ |  O3 z9 p
by enlargement of the penis, development of pubic9 u7 q5 B4 R( n$ f
hair, and facial acne without enlargement of testi-. W" O7 L- R' [  X! v
cles, suggests peripheral or pseudopuberty.1-3 We  n: f5 O8 F# ]/ `- V" W
report a 16-month-old boy who presented with the0 R7 a' H$ Q! F* h: T0 N% ?6 C
enlargement of the phallus and pubic hair develop-
6 E0 `, X$ ?9 |: z5 K5 ]! h1 xment without testicular enlargement, which was due
# c  S: p6 J6 h5 ^- P' Q1 d! p  d3 Hto the unintentional exposure to androgen gel used by
: Z% p/ d6 W/ N1 x! a% g1 kthe father. The family initially concealed this infor-
$ b: O5 r' q2 P: D" W4 @3 Xmation, resulting in an extensive work-up for this
% a7 {7 U( @# R$ r4 Echild. Given the widespread and easy availability of4 a' Y% z1 @; K2 T: q* l
testosterone gel and cream, we believe this is proba-
; I( D  B  I) D: @2 i+ ~% [bly more common than the rare case report in the, Y/ j# ~+ ]( Q5 M
literature.4: o: X( \9 Y; L* p2 D
Patient Report, e, ^% `) z: h) \( p9 S  a
A 16-month-old white child was referred to the
3 m$ m( i7 f! l2 `; V3 Gendocrine clinic by his pediatrician with the concern
7 @9 Q% B- J: h% {9 H% I) Z! U" Kof early sexual development. His mother noticed
7 [$ V" ]7 J/ u/ e4 Nlight colored pubic hair development when he was
. Q, J8 A( K! r+ G( |6 J+ wFrom the 1Division of Pediatric Endocrinology, 2University of
2 E/ t: E4 c& T- ^% s! V1 g& Q/ jSouth Alabama Medical Center, Mobile, Alabama.8 H' E- Y- C! _) L, x2 n: Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 H4 n. ^* k& x  _- ]" y- h
Professor of Pediatrics, University of South Alabama, College of8 D3 C/ g! N$ f% k& f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 Q8 d2 X  d+ Q! J2 w* o$ H" w
e-mail: [email protected].
. r( I2 a( v- yabout 6 to 7 months old, which progressively became
# i- D$ t* s% T" \darker. She was also concerned about the enlarge-
' H: E& \' H* j8 l5 c" Mment of his penis and frequent erections. The child  P9 T% R  T/ C1 }) J7 Z4 r
was the product of a full-term normal delivery, with
% O6 F3 m1 i1 |8 Ra birth weight of 7 lb 14 oz, and birth length of
4 R; A8 ?7 H& w7 ~4 ^  m! k' Y20 inches. He was breast-fed throughout the first year1 ^( C+ |! |2 r, k9 d& r5 u
of life and was still receiving breast milk along with# i1 H) w% z% F* f8 e1 J
solid food. He had no hospitalizations or surgery,3 f% A" `' `" w# o1 w5 G* ?0 F
and his psychosocial and psychomotor development" \! l& p0 i$ `
was age appropriate.
$ a/ ^0 w8 e9 l/ qThe family history was remarkable for the father,
! d- T7 Q) E1 g8 ]( ~: E# uwho was diagnosed with hypothyroidism at age 16,' [$ e8 Y" h  a8 A
which was treated with thyroxine. The father’s. G5 }; \+ c; @% R# ^, Z7 `
height was 6 feet, and he went through a somewhat- U3 U2 A% h4 l6 U+ G2 f
early puberty and had stopped growing by age 14.$ t* z1 Y' t) I' @
The father denied taking any other medication. The
! c$ b6 }' T7 Bchild’s mother was in good health. Her menarche
3 I) E5 B0 k8 D' k, n: hwas at 11 years of age, and her height was at 5 feet# h9 L) o# j2 `
5 inches. There was no other family history of pre-: C8 f. D( q! i/ ^! f4 t  r
cocious sexual development in the first-degree rela-5 _7 b0 u; J. ~) Z: s
tives. There were no siblings.
8 K5 j! \% j( F9 b1 u* c0 D% yPhysical Examination9 q" O1 z3 N9 H0 B6 q
The physical examination revealed a very active,8 {' ?8 \, r8 H8 G' a+ M
playful, and healthy boy. The vital signs documented% [+ D* ~  d* V" g
a blood pressure of 85/50 mm Hg, his length was
0 ?0 y$ }4 U( |& S4 l! `4 \90 cm (>97th percentile), and his weight was 14.4 kg
6 y. L& E, S$ R) e(also >97th percentile). The observed yearly growth  M+ {8 [& Z# C" i
velocity was 30 cm (12 inches). The examination of; j* \% e) J; j+ x) p6 G
the neck revealed no thyroid enlargement.
) D. P1 T8 Y- U" t3 QThe genitourinary examination was remarkable for3 T' z# R" G1 H
enlargement of the penis, with a stretched length of0 r) i2 }) s: v
8 cm and a width of 2 cm. The glans penis was very well
; @$ I1 ?( u" g+ g' [developed. The pubic hair was Tanner II, mostly around+ a$ a+ r1 U6 n. q4 T' N$ z
540' c! V2 j1 D9 e. |% u! B0 x7 |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- X# Y" D; v8 S; y( h- C  Ethe base of the phallus and was dark and curled. The
$ |( @/ k. a4 ~8 Z) utesticular volume was prepubertal at 2 mL each./ S" N6 D/ R, I' R
The skin was moist and smooth and somewhat4 E1 f/ i5 I% @: r: V, C( Y
oily. No axillary hair was noted. There were no
) p  a6 ~! a9 W4 o- G+ H' Wabnormal skin pigmentations or café-au-lait spots.
* l- \# [' G! |* A2 d/ x# V- t7 \Neurologic evaluation showed deep tendon reflex 2+/ [( |+ L' K/ u1 l$ a
bilateral and symmetrical. There was no suggestion/ c* V  Y9 Q8 H7 @" z. E6 S) r% d
of papilledema.
4 Y  M2 E$ G: y, Z6 J3 b2 @6 \, ALaboratory Evaluation
- ]+ k0 @# G2 A  bThe bone age was consistent with 28 months by2 H! x: ?1 f6 ^, {) ^6 `* j
using the standard of Greulich and Pyle at a chrono-( V2 R$ \; [2 w! G: H- V
logic age of 16 months (advanced).5 Chromosomal
2 O- ^( ]5 y; b+ K) K  H3 ekaryotype was 46XY. The thyroid function test/ s" m. O: Z* Q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# T# T' C" m7 U# _/ e  flating hormone level was 1.3 µIU/mL (both normal).
* v! p& S+ x* P( qThe concentrations of serum electrolytes, blood
8 {/ ?. F- ^# s" M; F( \urea nitrogen, creatinine, and calcium all were2 q$ w4 ^3 ^4 Y. o; c% b
within normal range for his age. The concentration  ^* O( o/ [) [- Q0 o1 p8 ~9 h; B4 _
of serum 17-hydroxyprogesterone was 16 ng/dL
; Q. |. Y  ~2 f% b/ x" m: E(normal, 3 to 90 ng/dL), androstenedione was 20' t& N+ u( e, G+ _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 D! w3 c7 p# V2 T0 k# Eterone was 38 ng/dL (normal, 50 to 760 ng/dL),
) `2 E, u; w2 Y+ P) Ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 i9 j& X- ?3 s+ {# U8 ~& z
49ng/dL), 11-desoxycortisol (specific compound S)& {! o" j+ H* f0 d8 ^* c! Y' E3 p
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 z. X" f; Z/ ^9 _tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' \  S. |& H# i2 o* j
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ V& M# J7 ?2 I
and β-human chorionic gonadotropin was less than
  z8 J  v* D. w1 Q5 mIU/mL (normal <5 mIU/mL). Serum follicular! K; _' `" M- R+ w& V1 l
stimulating hormone and leuteinizing hormone; H. P; _, {# {4 \
concentrations were less than 0.05 mIU/mL
$ J, |- q! ^1 f" V' q4 g! D4 s8 @(prepubertal).% }; [: V! }  e" N# {
The parents were notified about the laboratory
5 X, i$ H% i* p! p& ^results and were informed that all of the tests were
3 L1 }. D% T1 w/ d  W/ inormal except the testosterone level was high. The
/ _" C/ N9 |2 I, \: s$ wfollow-up visit was arranged within a few weeks to' U' {- O7 |* j7 d+ B' A, w
obtain testicular and abdominal sonograms; how-7 K3 E# A# t. A7 S8 W  i
ever, the family did not return for 4 months.- q4 l) O8 H& v6 j& J# `1 @/ m( H8 F
Physical examination at this time revealed that the
& a- F2 ]$ n0 X  e% Z/ e" Z7 A$ E- Fchild had grown 2.5 cm in 4 months and had gained
3 U3 k( @& A& }; H& y  ~2 kg of weight. Physical examination remained
; R0 y# @8 }; w& K9 dunchanged. Surprisingly, the pubic hair almost com-
& ^6 Q5 {0 o6 J4 J/ ^( |6 Opletely disappeared except for a few vellous hairs at. z- s8 G1 ?- f' g- }0 |
the base of the phallus. Testicular volume was still 2
5 Q1 x2 k6 ~; n! P# Q7 h* K8 VmL, and the size of the penis remained unchanged.5 p6 M6 m# s- T, z
The mother also said that the boy was no longer hav-4 y' k  _' n# `9 `6 ^$ W- w
ing frequent erections.
8 S) a  Q/ @8 \$ E5 L% l7 KBoth parents were again questioned about use of+ s! h" o) E4 H8 f
any ointment/creams that they may have applied to
7 c, d& y. w, Zthe child’s skin. This time the father admitted the
2 S) A+ O+ e& d# n6 @, Q* \1 mTopical Testosterone Exposure / Bhowmick et al 541& J1 R" F! N/ w
use of testosterone gel twice daily that he was apply-
' d& N3 A4 z' b' @7 f' Oing over his own shoulders, chest, and back area for
% J  u, |% Q- @# S! Xa year. The father also revealed he was embarrassed
: k4 O2 \0 G* v4 s5 Hto disclose that he was using a testosterone gel pre-2 G: I* P7 ^8 u7 {0 j* ^3 h" y
scribed by his family physician for decreased libido) }/ F1 E  n" F  E, A
secondary to depression.0 u8 l7 M* u/ [3 ?2 O
The child slept in the same bed with parents., I! [9 D% U4 r. m4 k
The father would hug the baby and hold him on his
& M* T6 A, [2 P' dchest for a considerable period of time, causing sig-
: n' d; A& O7 }. Jnificant bare skin contact between baby and father.
. s3 A: L3 h" f% aThe father also admitted that after the phone call,
3 d; q# W+ ?# Q, o  |8 Gwhen he learned the testosterone level in the baby
" D3 [5 V# T& }* Cwas high, he then read the product information
8 S7 T8 T# e3 k. _% Tpacket and concluded that it was most likely the rea-
# a! b& J5 l6 p, N  L) O" bson for the child’s virilization. At that time, they0 |* V2 H: g8 v2 `: c8 J" ^0 F
decided to put the baby in a separate bed, and the
% H# j8 |+ J& }' [& N% efather was not hugging him with bare skin and had0 W# }1 L: q9 V6 |) h- I& Y
been using protective clothing. A repeat testosterone( L9 R! a4 {2 G  }! s
test was ordered, but the family did not go to the
9 `) V1 C; H0 g0 l1 |( @6 @/ }/ Claboratory to obtain the test.
, g# h8 s8 F; J( A/ a2 h2 ^/ sDiscussion
) u  o/ f0 X; UPrecocious puberty in boys is defined as secondary
  |* Z3 O% B6 E1 n, c0 A3 ?sexual development before 9 years of age.1,4
4 ~3 r# q# ^  h( A9 z4 LPrecocious puberty is termed as central (true) when
8 H. f2 P! {8 qit is caused by the premature activation of hypo-: T0 J0 y' Z: [) p+ ~. p' U' n* l
thalamic pituitary gonadal axis. CPP is more com-
. O  S4 R2 U; g5 T( _7 U% _8 cmon in girls than in boys.1,3 Most boys with CPP
+ w1 J& q5 V4 d$ P5 ]8 r! Umay have a central nervous system lesion that is4 E+ u4 U% M& E2 W: k8 p
responsible for the early activation of the hypothal-! R  I- |  n% E, s" ?- @
amic pituitary gonadal axis.1-3 Thus, greater empha-% A1 N7 S( u% |0 t
sis has been given to neuroradiologic imaging in0 X6 H- N, }$ d: b
boys with precocious puberty. In addition to viril-: }& E7 W, w& ]8 t+ M- u+ P
ization, the clinical hallmark of CPP is the symmet-
+ {% ?- a4 c6 {+ x6 erical testicular growth secondary to stimulation by: F. S2 g: T% r4 l6 e9 o' C4 Z
gonadotropins.1,3
( @& H' o; q( ]  ~  N1 w3 @. FGonadotropin-independent peripheral preco-0 k" _& ^1 l6 ^% q! ~
cious puberty in boys also results from inappropriate
3 @$ }6 X  y: @2 B9 p( h& aandrogenic stimulation from either endogenous or; O6 `8 g' l* x( t% s/ f2 E
exogenous sources, nonpituitary gonadotropin stim-
- e# G6 p) j8 f- v7 G  B. L$ julation, and rare activating mutations.3 Virilizing
3 s7 m* o0 C' m9 F+ V3 ]! acongenital adrenal hyperplasia producing excessive) d9 [9 U6 U9 z& L
adrenal androgens is a common cause of precocious
7 {/ D& x3 c6 q0 Apuberty in boys.3,4* Y2 e5 J& P/ j$ Y( h. T1 M
The most common form of congenital adrenal
) j  d) ]8 A" Z& ^) e# Q$ h6 F$ Q; \hyperplasia is the 21-hydroxylase enzyme deficiency.8 ^  m# p1 `" R
The 11-β hydroxylase deficiency may also result in) l; ]1 w) U+ s0 A+ R# S
excessive adrenal androgen production, and rarely,7 h) X; V* O9 Y7 b: v
an adrenal tumor may also cause adrenal androgen$ C) u: l& C4 z! a( g
excess.1,3
& G; Z& G! {& Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 t1 d( D' C8 ~, T8 B6 Y2 M542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 H3 ]" W0 y8 z6 s% m6 o, @; nA unique entity of male-limited gonadotropin-
& e. ?' G3 c( S' Mindependent precocious puberty, which is also known
3 r1 Z8 e5 M6 Y0 j7 x2 A7 {$ \as testotoxicosis, may cause precocious puberty at a
5 A# m8 H* y, v7 G4 Zvery young age. The physical findings in these boys/ N+ u* M6 P5 U4 P! L; [7 C
with this disorder are full pubertal development,& z, R: L; b5 X: |1 g
including bilateral testicular growth, similar to boys& W0 \9 j4 Z! _
with CPP. The gonadotropin levels in this disorder
! g5 X! F- ^: z0 @0 G9 v* Gare suppressed to prepubertal levels and do not show
4 [( S1 s7 E! Cpubertal response of gonadotropin after gonadotropin-5 j: i2 Z- x" s- Y1 A- H
releasing hormone stimulation. This is a sex-linked
- T2 d$ L  t! Vautosomal dominant disorder that affects only
9 v7 q4 Q" m  G8 y: W$ Hmales; therefore, other male members of the family* D" L* K- R) Q
may have similar precocious puberty.3
. D2 g' f6 Y7 T" z( N2 Y6 ZIn our patient, physical examination was incon-) M3 c3 Y6 k  O
sistent with true precocious puberty since his testi-
1 v7 z! i2 X: P( a6 z9 r; Zcles were prepubertal in size. However, testotoxicosis
7 |- b2 E3 s" k; a- Wwas in the differential diagnosis because his father
( Q, i% W! |; r( G% \8 a2 l+ ?started puberty somewhat early, and occasionally,
+ l$ a9 Y5 V4 ^9 O# wtesticular enlargement is not that evident in the
# V3 ?* I+ `1 A9 ^  Z6 b5 Fbeginning of this process.1 In the absence of a neg-, z* C6 w+ q2 n2 D; Q
ative initial history of androgen exposure, our/ t' n8 c8 q! ~/ g) @+ {* O' z
biggest concern was virilizing adrenal hyperplasia,
& k+ T  K; X  R7 _! j" Seither 21-hydroxylase deficiency or 11-β hydroxylase
3 V3 p( i- W6 P: b  D. ^6 e/ J6 ~deficiency. Those diagnoses were excluded by find-
* `# b5 Z" S; l3 b! K0 u: h& ?ing the normal level of adrenal steroids.! p7 y# y! E0 c& m: Z
The diagnosis of exogenous androgens was strongly
% n: a2 x# {& f+ D; b* o. d2 A0 Jsuspected in a follow-up visit after 4 months because
' a7 p6 j* F% w# cthe physical examination revealed the complete disap-; J3 b* G2 X3 H  Z0 b
pearance of pubic hair, normal growth velocity, and9 {: x9 Q) L$ h1 J6 x7 |& {. b
decreased erections. The father admitted using a testos-% _( ?* ~% p) B' K7 O
terone gel, which he concealed at first visit. He was
: O: ^% p( C) lusing it rather frequently, twice a day. The Physicians’% ~( e9 t8 e$ u  r# G5 X, X
Desk Reference, or package insert of this product, gel or
' f1 c$ z, j. dcream, cautions about dermal testosterone transfer to
$ d) M# J( Y% g# `7 ?: n1 R5 d8 @unprotected females through direct skin exposure.
0 w0 g+ W5 l( N- x& {Serum testosterone level was found to be 2 times the
  p3 O* f; ^6 m7 I# E! lbaseline value in those females who were exposed to
+ w; P* E. h& o# ~7 deven 15 minutes of direct skin contact with their male
' K  E8 r- W' Q, R+ e! B) epartners.6 However, when a shirt covered the applica-  k; }$ W  ^# q* u9 z
tion site, this testosterone transfer was prevented.* j4 I9 Z1 o2 l: i
Our patient’s testosterone level was 60 ng/mL,6 q4 w$ H8 R' Q( v" k( [9 _
which was clearly high. Some studies suggest that
! F' o5 i4 n5 a1 cdermal conversion of testosterone to dihydrotestos-) S; z- _0 [9 I2 e5 o/ P# b4 w
terone, which is a more potent metabolite, is more. i/ t, M. {  R
active in young children exposed to testosterone
' F& A: ~# `; A6 Uexogenously7; however, we did not measure a dihy-
' d: [. D' y3 K5 Ldrotestosterone level in our patient. In addition to. @% l  }/ k: M* ?- b# G
virilization, exposure to exogenous testosterone in  ^' ~, q# i& z3 O" ^, y( f4 j
children results in an increase in growth velocity and
( K- ^  R/ g5 |+ J+ W2 wadvanced bone age, as seen in our patient.
/ E) _5 F& W- B9 }, ?The long-term effect of androgen exposure during
  u7 ]" c3 i) s( a  Jearly childhood on pubertal development and final0 Z+ }' R# z" o4 g& @
adult height are not fully known and always remain
4 W' w  [% }2 ia concern. Children treated with short-term testos-
' Q; f; ?  P* ~2 n* {& x  Pterone injection or topical androgen may exhibit some
0 `' |0 f' T6 E+ iacceleration of the skeletal maturation; however, after1 V/ C9 N7 b/ ]: w
cessation of treatment, the rate of bone maturation
4 S) o* K( F/ x1 q( ydecelerates and gradually returns to normal.8,9
9 v6 ]( N) }0 c3 \9 u6 d9 VThere are conflicting reports and controversy
/ }7 \! s1 |; K7 Z3 eover the effect of early androgen exposure on adult0 m" |; e: J: Z0 b" q  F
penile length.10,11 Some reports suggest subnormal  }8 F+ _9 d& \( I. k6 ~" }
adult penile length, apparently because of downreg-
5 M: q& ^, [! ]ulation of androgen receptor number.10,12 However,# j% B1 R! a: V! w& K
Sutherland et al13 did not find a correlation between4 U2 c. I" [, m. z7 @4 l/ D. ]& Z  X
childhood testosterone exposure and reduced adult/ f4 ?2 u0 J3 `, E
penile length in clinical studies.8 }/ M  Y+ O& b& A2 i3 w
Nonetheless, we do not believe our patient is: P7 s. u8 c( V* T1 L, u4 a- k- [
going to experience any of the untoward effects from
) y* |" @  K0 n& ptestosterone exposure as mentioned earlier because
- V. ]2 o: U: Tthe exposure was not for a prolonged period of time.7 `! z* ]4 ]# p' O8 b
Although the bone age was advanced at the time of. m% J9 G, O3 U7 e7 a3 U
diagnosis, the child had a normal growth velocity at3 @" x) T$ a; i6 K
the follow-up visit. It is hoped that his final adult2 ?0 h+ l- |' D3 m- D; V. _, ^# O
height will not be affected.
6 \4 c, H4 V( d" sAlthough rarely reported, the widespread avail-
3 K  M# w2 V. j- Y6 P# i) ~ability of androgen products in our society may
+ h1 x0 `( g8 r5 E+ I- Z6 Zindeed cause more virilization in male or female
+ Z7 i4 x: Z1 G" r* j6 F3 R* p) J  tchildren than one would realize. Exposure to andro-
$ S# h7 E9 y) K8 `' L* kgen products must be considered and specific ques-
( L4 L' t8 t4 O; [: b4 \5 ztioning about the use of a testosterone product or
  |4 a/ j" ^- g' r- `2 m2 cgel should be asked of the family members during
( R4 o& Y8 ?  h7 ?% [the evaluation of any children who present with vir-% |# k! {2 D/ ?: m( j
ilization or peripheral precocious puberty. The diag-
  S& \0 h, i& U' Z+ inosis can be established by just a few tests and by/ y2 y9 `5 r! w
appropriate history. The inability to obtain such a& u7 S& Y; b% ]/ @' S
history, or failure to ask the specific questions, may
( N0 E0 x' _( O. l; V  Q) ~0 }result in extensive, unnecessary, and expensive- B  g8 D+ j! T9 L- n4 x
investigation. The primary care physician should be2 t6 C  e2 T- }, |4 F
aware of this fact, because most of these children
% b8 `! F  ~8 [' {, x. h. a+ Zmay initially present in their practice. The Physicians’  X1 y) x( F* J$ }
Desk Reference and package insert should also put a2 X9 b3 ^3 `; Y* H; ?0 o
warning about the virilizing effect on a male or
7 X" I+ y5 I9 A( T4 P* Ofemale child who might come in contact with some-
1 m1 Y+ A% B1 O# V% `one using any of these products.
4 k, ]1 P5 j- [+ j9 |, @1 k3 BReferences
' |1 V5 E2 a% w) m8 |# A1. Styne DM. The testes: disorder of sexual differentiation, |3 G& }, G+ s! z) z
and puberty in the male. In: Sperling MA, ed. Pediatric
" m! G6 U4 `. U: V' z8 l1 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ e/ e( u: _' E. R
2002: 565-628.7 q2 y) L4 s' _& q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" m" l' E- w6 M, N0 L& Zpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
) c' W' P% n  X6 h/ S) YBoy Induced by Indirect Topical
' I& X, n4 o' e/ j3 p5 Z$ uExposure to Testosterone5 `0 l+ Z) i! N( N: X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' x1 p8 }! n9 O: ?& S0 xand Kenneth R. Rettig, MD14 F3 P: k# W. Z  S* L) z* r; `
Clinical Pediatrics, m# J( k  u, W+ w9 n% N
Volume 46 Number 6; }2 E1 q$ @' H$ _8 u" H* M, U$ W
July 2007 540-543+ v8 H7 A! w, o& x/ O6 A
© 2007 Sage Publications
/ p5 Z# b- F/ q/ A0 q10.1177/0009922806296651) i- Z6 t4 c# F, w/ X& z2 h
http://clp.sagepub.com
4 _3 i  ?. ?" Y9 xhosted at
$ k: ~- n8 O  Ihttp://online.sagepub.com
2 W6 H8 K0 v) w# {; U: k0 nPrecocious puberty in boys, central or peripheral,
( w  D8 D4 G# [# O2 ois a significant concern for physicians. Central& I* S3 C1 R0 L6 Q2 F+ c
precocious puberty (CPP), which is mediated$ p4 d) \! O1 R. O
through the hypothalamic pituitary gonadal axis, has# W$ J! P. i3 S" |( Y% O
a higher incidence of organic central nervous system: t0 U- s* d( K# j7 N
lesions in boys.1,2 Virilization in boys, as manifested4 V" `) j3 Y- A- p, K5 I' m
by enlargement of the penis, development of pubic
7 `, [8 i. M0 p$ ghair, and facial acne without enlargement of testi-7 `' a# M, Z4 p) k, c& ?1 e1 n
cles, suggests peripheral or pseudopuberty.1-3 We- @* }& o% j7 {& q5 j7 x( J/ L
report a 16-month-old boy who presented with the9 }+ k! i8 B5 o: O! i
enlargement of the phallus and pubic hair develop-
& r0 I% O! A8 `' ?5 L2 ]ment without testicular enlargement, which was due* P4 q0 ~. w; n5 y) G) T7 X
to the unintentional exposure to androgen gel used by3 S, e$ O! J4 e: Q9 \; U+ M8 h
the father. The family initially concealed this infor-
: }- |4 Q! M7 E8 \7 r! F) L. nmation, resulting in an extensive work-up for this
6 a8 R& U- W- T5 k% mchild. Given the widespread and easy availability of6 C& X- y& E4 _* M: c! O
testosterone gel and cream, we believe this is proba-
2 C3 D1 k; P0 ably more common than the rare case report in the
& Y: j: i/ u7 }/ x( N+ s0 O" H* Cliterature.4
: y; l# }$ M  J; X( [Patient Report+ W7 t, Z& P3 q2 N5 b$ X6 @
A 16-month-old white child was referred to the: H/ A5 I1 Y$ O3 Z: }% T
endocrine clinic by his pediatrician with the concern6 i3 `: M8 ^' f0 S
of early sexual development. His mother noticed
" x/ [3 ~6 Z% q( Blight colored pubic hair development when he was: U2 V" s1 _2 s9 ~
From the 1Division of Pediatric Endocrinology, 2University of" \- Q# G# o! P8 w* ]+ g" @1 h& [
South Alabama Medical Center, Mobile, Alabama.6 D4 W0 c7 h& h6 T
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 @* u  r; F. z. c  F7 G6 }
Professor of Pediatrics, University of South Alabama, College of1 J6 r2 L/ ]1 [+ w" _8 ?( M
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  P. L. c  m' X. O5 re-mail: [email protected].( r! W' R2 z; m/ \! A
about 6 to 7 months old, which progressively became& D9 O6 y- S0 W0 Z$ E3 m
darker. She was also concerned about the enlarge-) G" k7 v6 j, ?( m  S6 B. ^' Y* Y8 ~
ment of his penis and frequent erections. The child% K& |8 L: @' U& g
was the product of a full-term normal delivery, with
  F$ ^$ @% F8 s- z: Za birth weight of 7 lb 14 oz, and birth length of' @* x$ i$ G7 o$ d1 l
20 inches. He was breast-fed throughout the first year
8 w2 R; G+ B: B3 T. y" `of life and was still receiving breast milk along with
' }  a. |/ ?0 s4 \solid food. He had no hospitalizations or surgery,+ t5 o) x/ C; A6 y# c& z
and his psychosocial and psychomotor development" N7 k1 j5 g. R. N* x: H
was age appropriate.% n* s( ?( v6 d5 A; p
The family history was remarkable for the father,
/ I7 T% K% h4 `0 L" Iwho was diagnosed with hypothyroidism at age 16,
( ?9 w( r' H# t" D; Y6 N- Rwhich was treated with thyroxine. The father’s+ _+ D' G$ r9 [1 L7 {
height was 6 feet, and he went through a somewhat
9 E, G; k' H7 w4 _* Oearly puberty and had stopped growing by age 14.
* k' R# i! m9 gThe father denied taking any other medication. The
# D) ?/ [; m0 h, ^$ fchild’s mother was in good health. Her menarche; \! w3 N$ Q5 c0 w( `; D( O
was at 11 years of age, and her height was at 5 feet( @( D3 O6 I1 Y; z; j9 o- M
5 inches. There was no other family history of pre-
6 H! c- X: [  h- p, A2 ?8 r' V" |cocious sexual development in the first-degree rela-
* L4 s! |, D* Ctives. There were no siblings.. T5 m2 B' R; |( E
Physical Examination
6 n& X1 b+ G+ }" P, b: |# oThe physical examination revealed a very active,
0 L( E  i+ g* [/ B; qplayful, and healthy boy. The vital signs documented
7 }3 f6 n9 V& \1 q! k7 Ca blood pressure of 85/50 mm Hg, his length was
2 _! o% R1 G# ^! w5 [90 cm (>97th percentile), and his weight was 14.4 kg, ]" l9 a5 ]1 a, X( S- T  k: M$ k
(also >97th percentile). The observed yearly growth6 m" Y/ _  F, F% ]/ b
velocity was 30 cm (12 inches). The examination of* ]" H0 c: ~; p3 B: T* f+ V
the neck revealed no thyroid enlargement.3 E% U; ~1 c, Q) f  A+ x% Z
The genitourinary examination was remarkable for
) g% [% Z/ w$ N" ?0 U( Z! Senlargement of the penis, with a stretched length of4 |# o: ~; d+ Z
8 cm and a width of 2 cm. The glans penis was very well6 B+ _7 h5 b1 t0 a' a
developed. The pubic hair was Tanner II, mostly around8 p: L8 c) y# m: @& X, O- m# Z
540
$ Y; K1 }) Z; i: U. aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 l* b, a! c8 E8 J4 B' Qthe base of the phallus and was dark and curled. The" e' H1 d* t3 T( l1 z) w, q1 L0 m
testicular volume was prepubertal at 2 mL each.9 n$ k  _9 g+ m3 @
The skin was moist and smooth and somewhat, z6 d8 c6 e9 T  B) }& m' m
oily. No axillary hair was noted. There were no6 Q* [# a. C- T
abnormal skin pigmentations or café-au-lait spots., Z) W, e" }1 Y" c1 ]/ P; G7 S
Neurologic evaluation showed deep tendon reflex 2+* O) B7 G/ q' i! {
bilateral and symmetrical. There was no suggestion) p5 e2 Q5 \& p
of papilledema.& u  V6 j4 c% ]" m7 m
Laboratory Evaluation
0 M% Y" d& f" D  r% W. iThe bone age was consistent with 28 months by
# X- k9 I0 x8 C, q6 W2 susing the standard of Greulich and Pyle at a chrono-
* E* j, Q  b; N6 t  Zlogic age of 16 months (advanced).5 Chromosomal
7 [" Q7 ^' ^% c; C! E7 T2 Tkaryotype was 46XY. The thyroid function test2 c8 U0 A: f4 h. s% K( D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" X$ v7 `) o  u2 M0 u/ _. V$ R
lating hormone level was 1.3 µIU/mL (both normal).
$ n9 K0 @# K% a0 W1 ]The concentrations of serum electrolytes, blood9 }$ \+ C8 t* t; o* ], }
urea nitrogen, creatinine, and calcium all were0 j/ H& R7 X: Z! ]. Q- C
within normal range for his age. The concentration
: K4 v. z2 R; |! Mof serum 17-hydroxyprogesterone was 16 ng/dL3 f" A/ w7 M  B* b  c( ~% _, U! W$ Z$ J
(normal, 3 to 90 ng/dL), androstenedione was 20  }" |. [0 ^, w8 u
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- s7 q* \5 m) a7 ~7 Rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 D: k5 a: v, U! C0 m& W4 @9 @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; v( e3 d, [5 O: s' y$ U# p49ng/dL), 11-desoxycortisol (specific compound S)
1 u3 {9 ?9 q3 e0 T) @( p0 Ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' `: L, O/ S+ K7 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# A+ [+ f# w  Y: otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 p/ r  e' f  e* |, U2 \- E+ A4 R
and β-human chorionic gonadotropin was less than4 T+ }; ~: ^1 U; w0 X; `
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; v6 \4 Y2 W+ O3 Qstimulating hormone and leuteinizing hormone
' g! j. X% i9 D" {concentrations were less than 0.05 mIU/mL+ g+ W* o. e& Y8 N
(prepubertal).
7 w- h1 r; {8 i3 e+ ~# N' K# H/ h5 ?The parents were notified about the laboratory3 `0 d9 }9 k4 N" n% {6 u- n& I
results and were informed that all of the tests were
* ?- I. F7 x0 {8 m, Fnormal except the testosterone level was high. The0 ]# ^4 o( l6 ^7 `
follow-up visit was arranged within a few weeks to: b! J5 K, C3 R& Q) f* A8 T5 u
obtain testicular and abdominal sonograms; how-
" n% ]  v8 I0 C' r( m9 C3 Tever, the family did not return for 4 months.' e2 ]( Z" R1 w, u8 W( q
Physical examination at this time revealed that the0 x0 s& k5 {2 {: J  r
child had grown 2.5 cm in 4 months and had gained5 `+ I; z# @$ s9 i5 Z7 t. B
2 kg of weight. Physical examination remained/ M$ G; |- ?& h: R
unchanged. Surprisingly, the pubic hair almost com-0 Q) h; m" ?1 g
pletely disappeared except for a few vellous hairs at; S! [" O* E8 _( K$ b. m
the base of the phallus. Testicular volume was still 2
$ y0 p2 @) Y6 }: p* tmL, and the size of the penis remained unchanged." O6 V0 W' A0 s+ _1 F$ K1 g3 t7 J2 }
The mother also said that the boy was no longer hav-
: {1 h6 B) v5 H( H% f7 \ing frequent erections.9 ~* ^" [/ t5 K0 P
Both parents were again questioned about use of4 f$ z% {2 C, ?! U1 i
any ointment/creams that they may have applied to# M0 a( i2 f* S) c
the child’s skin. This time the father admitted the
6 L& {3 l+ z: t6 s" n" e* G. ]Topical Testosterone Exposure / Bhowmick et al 541  ^% x7 O6 [( E
use of testosterone gel twice daily that he was apply-
& `3 U1 I; Z- Z0 S. P/ ]ing over his own shoulders, chest, and back area for
6 l0 D/ J/ [# r6 l4 }# w0 xa year. The father also revealed he was embarrassed  k; I* t  F# q  A' Z" e
to disclose that he was using a testosterone gel pre-
: D5 i; U: s: |$ nscribed by his family physician for decreased libido9 j8 j* w8 J, p* |$ |, U
secondary to depression.
. K$ j5 E& `# r7 QThe child slept in the same bed with parents.
% t' b6 i( x" d/ v- eThe father would hug the baby and hold him on his. I3 `4 Y4 Z5 A3 G
chest for a considerable period of time, causing sig-' Q1 K! M" x* N0 M
nificant bare skin contact between baby and father./ @& u/ D4 P6 y' Y: M/ H' r
The father also admitted that after the phone call,* S/ O' s7 S# g) ?8 t
when he learned the testosterone level in the baby5 W! Q% W- v6 T# K
was high, he then read the product information8 \" n7 ^$ S4 `3 O* R% J
packet and concluded that it was most likely the rea-+ N, m2 E. \' ~4 g: g/ y- V9 G
son for the child’s virilization. At that time, they
/ A9 _8 {8 R5 ?decided to put the baby in a separate bed, and the
( y' q. q2 d2 A5 o% o7 `father was not hugging him with bare skin and had# g* E- |- M3 Z( u5 i
been using protective clothing. A repeat testosterone& }# j& G" P7 I
test was ordered, but the family did not go to the/ m4 c* I  j. A
laboratory to obtain the test.
1 V  X  i% ~+ c0 Y. Q1 LDiscussion1 s! T/ t0 b0 E9 m0 a: f
Precocious puberty in boys is defined as secondary
3 B9 I7 H% P! G7 ~, ^* T8 K: esexual development before 9 years of age.1,4
( J, {, G% @. W! p2 [8 X; b" tPrecocious puberty is termed as central (true) when
+ x- b- h' A0 v6 w" Y- t# z) J) y# pit is caused by the premature activation of hypo-
! s% c, k6 B9 j# J9 |, Othalamic pituitary gonadal axis. CPP is more com-+ Y. d) ^! g7 n
mon in girls than in boys.1,3 Most boys with CPP
2 p6 Z) P1 O7 R! B6 l$ G( o2 Lmay have a central nervous system lesion that is4 f- i/ v! c8 l$ \/ n
responsible for the early activation of the hypothal-
0 b' b3 h0 ~$ u% oamic pituitary gonadal axis.1-3 Thus, greater empha-
* I+ E- f5 S: C% o7 Rsis has been given to neuroradiologic imaging in
* w6 s) E( y8 w# }; h1 g' rboys with precocious puberty. In addition to viril-
3 v7 m" z& [1 l1 J4 Vization, the clinical hallmark of CPP is the symmet-! w9 Q% B* I& i7 i
rical testicular growth secondary to stimulation by; l$ o: t; f* k6 W3 u
gonadotropins.1,3. v& @( ^4 k+ i4 k5 Q
Gonadotropin-independent peripheral preco-7 U4 u$ t4 M$ k, [1 S
cious puberty in boys also results from inappropriate
. Y3 P" T% k; z$ Randrogenic stimulation from either endogenous or' ^; n2 H3 K" s( {* g0 }) |$ e
exogenous sources, nonpituitary gonadotropin stim-+ }& e( T7 Y4 y5 ~+ f/ `
ulation, and rare activating mutations.3 Virilizing
) `2 e2 c9 i0 ^( Icongenital adrenal hyperplasia producing excessive8 L7 a& {- Y& e
adrenal androgens is a common cause of precocious
) I  b) Q3 B& m; Ppuberty in boys.3,4  C6 Q: V5 v- d$ N: b/ ~
The most common form of congenital adrenal
+ V; c* [  v# qhyperplasia is the 21-hydroxylase enzyme deficiency.4 e$ y- A4 y! L3 u
The 11-β hydroxylase deficiency may also result in) U" l  g9 q; s) t; ?8 O. U
excessive adrenal androgen production, and rarely,
! \7 A+ x$ G: p  x' j, d8 {an adrenal tumor may also cause adrenal androgen7 }% f9 \* `2 ]/ W- D
excess.1,3
  T/ B/ M, T. ^& N& s* Z& [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* Y9 |2 S1 h6 h9 [) @
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 C+ M  v' W& ?
A unique entity of male-limited gonadotropin-
( t0 U( A8 }- L  q4 `' t3 |2 xindependent precocious puberty, which is also known$ p8 G4 B* e. y5 z
as testotoxicosis, may cause precocious puberty at a
* d2 O' @3 y. rvery young age. The physical findings in these boys
( v% E- L" }) K2 ^: R% awith this disorder are full pubertal development,3 r6 S! |4 r* @$ G
including bilateral testicular growth, similar to boys
1 s) M+ @$ F4 _0 Dwith CPP. The gonadotropin levels in this disorder
  x4 ]/ ~, q7 V( M; ]& gare suppressed to prepubertal levels and do not show
8 f4 U& G: [7 H3 @) p# \pubertal response of gonadotropin after gonadotropin-
/ n4 k8 P' m6 y$ Creleasing hormone stimulation. This is a sex-linked" k& X! V# o$ I6 W
autosomal dominant disorder that affects only
/ F9 @3 v. T2 D  S* L, U  @' I: Umales; therefore, other male members of the family
; L% }% Y8 _6 [may have similar precocious puberty.3
5 H2 r% l; x9 K/ `8 c& ]6 e& }0 kIn our patient, physical examination was incon-" V% I; b+ f3 m! O  }4 B
sistent with true precocious puberty since his testi-
: T$ S/ Y4 g+ W  H$ n# {* kcles were prepubertal in size. However, testotoxicosis
' `+ j0 j" b. V( A- iwas in the differential diagnosis because his father
: i; [$ B% k8 n* o& gstarted puberty somewhat early, and occasionally,
" F) A- C3 F0 ^0 o9 Z5 c2 R1 ptesticular enlargement is not that evident in the
  l4 n2 ]; q/ m% B$ V: abeginning of this process.1 In the absence of a neg-0 J1 R" g& z8 G. N! X) N, G
ative initial history of androgen exposure, our7 j$ |5 b! S4 ]: ?% n( u
biggest concern was virilizing adrenal hyperplasia,
5 H- }( F8 B) Peither 21-hydroxylase deficiency or 11-β hydroxylase
  P9 ?: s. Z* e% P3 |deficiency. Those diagnoses were excluded by find-
3 K- m' ^" }2 r& j' O0 r) ^ing the normal level of adrenal steroids.8 t% ]- f) T$ _0 j1 }' S1 t/ ^
The diagnosis of exogenous androgens was strongly
# Y7 P  ~* j; ?0 h) t1 Q: @% [, Rsuspected in a follow-up visit after 4 months because
2 s! ]- i' T, H7 G3 H7 T- S/ pthe physical examination revealed the complete disap-% k8 z) R: E1 [+ }6 I! u2 k, W
pearance of pubic hair, normal growth velocity, and
, z& Y( ^1 g: p7 p( Xdecreased erections. The father admitted using a testos-; |. s2 _3 J4 \- Y* N! w
terone gel, which he concealed at first visit. He was% ]; L6 c- h9 ]+ @0 q+ q
using it rather frequently, twice a day. The Physicians’
  m5 G2 i0 Y) u- fDesk Reference, or package insert of this product, gel or: @. B, p$ m- p9 P8 b  y+ G
cream, cautions about dermal testosterone transfer to; ^7 u5 A5 n! o7 ~
unprotected females through direct skin exposure.
+ r& d9 D: F2 N" ~& o  ?Serum testosterone level was found to be 2 times the
; E1 v+ f6 Q$ y$ d# i- y# |* Gbaseline value in those females who were exposed to
( _2 i; ~. R! g& a) [& W' Geven 15 minutes of direct skin contact with their male
+ Q! o0 M! C( w- O9 \partners.6 However, when a shirt covered the applica-3 x$ T  D) y& l: W/ L$ r# I) }
tion site, this testosterone transfer was prevented.9 t$ v' n' }* `1 l% }& p
Our patient’s testosterone level was 60 ng/mL,1 M$ Z( X1 m5 M% y5 `1 E
which was clearly high. Some studies suggest that
" @4 M6 }9 ?6 a% e, Rdermal conversion of testosterone to dihydrotestos-7 s  n1 g7 {, X/ j* Y0 d- K
terone, which is a more potent metabolite, is more
* @0 @' F  g0 dactive in young children exposed to testosterone
2 p: n! h# Z) D2 @, R9 `# texogenously7; however, we did not measure a dihy-
: Z. \; `2 N3 x. C# c9 J# \drotestosterone level in our patient. In addition to5 c& O0 A' T) J7 e( x+ ]
virilization, exposure to exogenous testosterone in
2 k! V: H7 C* k3 dchildren results in an increase in growth velocity and# W, ?" Q  S. y! W# n2 N- I. o9 X
advanced bone age, as seen in our patient.
& {' n( Z1 x3 W) c/ ~5 `The long-term effect of androgen exposure during
9 R. \) @3 n+ N/ p6 x2 m! fearly childhood on pubertal development and final
# D, K+ k+ c" Madult height are not fully known and always remain
( t+ H8 x. ^  @a concern. Children treated with short-term testos-
0 Q, z' ]: i# B/ [9 t- Qterone injection or topical androgen may exhibit some  p7 l; O* n/ g
acceleration of the skeletal maturation; however, after
3 u4 j+ F1 j* J; W9 j/ i; E7 Ycessation of treatment, the rate of bone maturation
2 P) D( D1 _7 ~) `; ?7 ?' L/ mdecelerates and gradually returns to normal.8,93 j6 a0 k: s; K2 ?" u
There are conflicting reports and controversy
: j" x. y: ~% i' j% H. w7 [over the effect of early androgen exposure on adult
$ h- m+ N% T0 ]/ apenile length.10,11 Some reports suggest subnormal+ V+ ?$ l2 _5 }: E- M1 a* \9 E
adult penile length, apparently because of downreg-
: Y" ]5 h- U* \- p5 e0 @ulation of androgen receptor number.10,12 However,
% g, |3 a2 M4 M( ?6 iSutherland et al13 did not find a correlation between
! P' C& V" ?! ?: t- U, ]childhood testosterone exposure and reduced adult$ x1 \# Y3 ^9 c4 M
penile length in clinical studies.
% R( @+ z2 I1 S; W, D" ~Nonetheless, we do not believe our patient is* w4 `1 ]1 C6 m; L: t& J6 ^' G
going to experience any of the untoward effects from
$ h# u2 \! J4 Y0 z  M: Ftestosterone exposure as mentioned earlier because6 M1 x. c* K4 ]8 S- d3 y8 V
the exposure was not for a prolonged period of time.
; u) @- b/ ~1 F. i) P6 BAlthough the bone age was advanced at the time of
% l3 R- R, t& u" L2 {diagnosis, the child had a normal growth velocity at+ C4 E  ^+ q: x
the follow-up visit. It is hoped that his final adult, N: U' X+ I# C
height will not be affected.
* e, z" S' T* _4 v) V1 r9 hAlthough rarely reported, the widespread avail-
- E) ^+ T; N0 K: n% X: W) jability of androgen products in our society may) X; A" A! |/ X6 H! L
indeed cause more virilization in male or female* o+ l# q& h* {+ y1 ~
children than one would realize. Exposure to andro-# Y" _6 ^+ N, o! N
gen products must be considered and specific ques-8 k; w1 i7 f/ j1 n' Y% u
tioning about the use of a testosterone product or
' X+ `# f3 {) k; l. k" y1 Hgel should be asked of the family members during
$ k2 F6 w# Z4 S  A7 ^. [8 A' E  W5 Gthe evaluation of any children who present with vir-. J4 |- q3 J- G. u; m
ilization or peripheral precocious puberty. The diag-5 {  w/ Q) M; J) n' ~
nosis can be established by just a few tests and by
1 O0 d. f4 O7 Q7 X' ]2 s% G/ W8 xappropriate history. The inability to obtain such a
: {9 g0 n! o- W- Y6 Chistory, or failure to ask the specific questions, may0 c; w( k3 [2 v' o; U
result in extensive, unnecessary, and expensive
* v) ^$ s1 R/ N1 q! h+ P. v% iinvestigation. The primary care physician should be7 s) v9 A/ j% t5 o0 k
aware of this fact, because most of these children
" a) `  r- `& W0 K% umay initially present in their practice. The Physicians’  H0 k7 I4 R/ Z7 g9 `
Desk Reference and package insert should also put a; z( B9 V& o) Q* [
warning about the virilizing effect on a male or
, V2 X& X. J, {( I$ \$ K% a4 Ofemale child who might come in contact with some-; {1 T, @2 b: o" L9 c
one using any of these products.; T" c6 ?* b/ _! U: x8 e
References
" _4 ]) x2 R  [& h3 x1. Styne DM. The testes: disorder of sexual differentiation
8 T9 J+ `+ M" aand puberty in the male. In: Sperling MA, ed. Pediatric
8 w$ {' w; s1 T7 B" C, r' oEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' m+ X! @& `3 c7 V  D; J1 F, E0 L
2002: 565-628.$ u( }8 X8 F: ^1 Q! Q2 p! k+ B" q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 g* T- J" ^. p+ a, I. F% v4 Z( M8 apuberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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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
: e0 ?  Q+ X" F1 p/ g, J6 }$ j
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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