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Sexual Precocity in a 16-Month-Old8 ?- b8 f* r' A
Boy Induced by Indirect Topical
5 z/ }3 ], n5 b. j6 ]Exposure to Testosterone8 r9 w! ]$ x1 G! `/ X" ~
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- P+ ?9 b5 f( `and Kenneth R. Rettig, MD13 z. N: }0 ?$ Z1 d
Clinical Pediatrics: K- K4 s! m- |7 U& Y
Volume 46 Number 6  M' u1 @0 o4 ^& B) M$ j$ }1 \& v
July 2007 540-543
- L( |& L8 g+ l: _+ `© 2007 Sage Publications
8 V" v, Z+ i4 [- e10.1177/0009922806296651
! c9 U" P7 X1 |1 b" ?4 B9 Hhttp://clp.sagepub.com
+ a' r: @5 ?0 L+ u7 Z3 {8 O) r  F' w; nhosted at
9 Z% `) d' U# b) shttp://online.sagepub.com
7 e0 z# J# b4 V- J9 hPrecocious puberty in boys, central or peripheral,8 L$ M& s( n9 h8 _& Q/ W* j
is a significant concern for physicians. Central
1 t* ^# x. {, U1 s* w# K. U. V, xprecocious puberty (CPP), which is mediated- Q. [/ P2 \+ q+ h9 k) M$ {1 y
through the hypothalamic pituitary gonadal axis, has
( S& W- C9 k2 k" J; c3 ba higher incidence of organic central nervous system; w2 v- W  @% x* ~$ G0 |
lesions in boys.1,2 Virilization in boys, as manifested' i! G8 N' a2 R! N& S
by enlargement of the penis, development of pubic& Z9 l5 i* E% {6 ^& J
hair, and facial acne without enlargement of testi-7 Z0 p) k, G# X9 h, u$ p0 E9 f
cles, suggests peripheral or pseudopuberty.1-3 We% d0 h5 [1 Y5 m# O5 m
report a 16-month-old boy who presented with the2 N; S; M. d7 p5 W
enlargement of the phallus and pubic hair develop-
: W8 F1 ~2 A0 O, @4 I0 nment without testicular enlargement, which was due" S* J0 m2 Z/ _0 W( v/ M* G* V
to the unintentional exposure to androgen gel used by
7 R) v) k! V1 D) S. p2 ?the father. The family initially concealed this infor-
+ E; g5 k' D6 P* h0 s. hmation, resulting in an extensive work-up for this2 f9 d/ A& }: ~3 \* B5 L
child. Given the widespread and easy availability of& i, f5 F/ R3 T) b9 _; U
testosterone gel and cream, we believe this is proba-% b( N: |5 Q* ~
bly more common than the rare case report in the
1 ?7 j# ^  o4 ]2 l( rliterature.4  f* R) |  Y8 @6 {% X# _/ `
Patient Report
9 c, R/ ~# {4 b# U5 A) R# `A 16-month-old white child was referred to the6 {* D. h# q, u4 x1 \
endocrine clinic by his pediatrician with the concern
% B: q  I# G; a" j7 g- w; zof early sexual development. His mother noticed
, E7 L  ^0 D4 M/ Rlight colored pubic hair development when he was
& u$ u$ N* a" w& Q' g+ v. vFrom the 1Division of Pediatric Endocrinology, 2University of
3 x3 P4 W3 A* t( XSouth Alabama Medical Center, Mobile, Alabama.4 \4 W( `3 o; h
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 I9 }7 N* x' t* z( P  vProfessor of Pediatrics, University of South Alabama, College of- a# o: C2 [7 g" A+ z) z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 C: k' \$ I  @; n* X+ Q7 Re-mail: [email protected].* }  M4 H/ |% T8 i- v6 [
about 6 to 7 months old, which progressively became! `- J1 J; a5 Y3 b& G4 K1 J
darker. She was also concerned about the enlarge-# y6 ?& N" J  O+ I' a3 _# y2 R& r
ment of his penis and frequent erections. The child
5 I4 G7 i1 [( C$ t; G$ ^& v1 `was the product of a full-term normal delivery, with
: g, r3 R6 {: o5 O: Ka birth weight of 7 lb 14 oz, and birth length of* s% l1 T4 q% H0 o8 s) L) U
20 inches. He was breast-fed throughout the first year" O0 r  U2 i' G9 [/ B" m; `* g
of life and was still receiving breast milk along with
% G8 B. ?3 `. X. @5 {solid food. He had no hospitalizations or surgery,
/ s3 R( m; S, e: }7 Hand his psychosocial and psychomotor development
- a# ~! `' ~" E; h, ?( Ywas age appropriate.
% M, {- M# r# U6 x% w9 OThe family history was remarkable for the father," I* o; z3 n1 ~/ j
who was diagnosed with hypothyroidism at age 16,
: B; L9 i  e, uwhich was treated with thyroxine. The father’s9 N( y3 A/ P0 j, T7 T+ D+ s9 J
height was 6 feet, and he went through a somewhat* o  g6 B# S* c' H
early puberty and had stopped growing by age 14.
- P6 d$ N! L6 @. v$ \* TThe father denied taking any other medication. The; j: v. {! D5 t& E2 g  ^
child’s mother was in good health. Her menarche5 h, N0 T3 A$ J. C* @% k6 ?- S
was at 11 years of age, and her height was at 5 feet
8 M; E8 Y$ {1 N; w9 `0 S9 k" m+ ]9 M5 inches. There was no other family history of pre-
3 V, l$ {# I+ ~& Ccocious sexual development in the first-degree rela-& n; Z" A! K$ t- {9 ~0 l
tives. There were no siblings., [9 p9 ~! K6 E4 j$ Z1 @" t: Q
Physical Examination
8 ^/ u* N. U. H, H6 S- wThe physical examination revealed a very active,& Y9 q4 h+ J/ `" r# w* G
playful, and healthy boy. The vital signs documented& g- p( q7 N8 x: Q
a blood pressure of 85/50 mm Hg, his length was
/ e1 j+ d5 Y1 o$ `& Q9 }$ Y" J90 cm (>97th percentile), and his weight was 14.4 kg6 v& U* u( A4 g7 a
(also >97th percentile). The observed yearly growth) ^% ]- U; M2 g
velocity was 30 cm (12 inches). The examination of( M: c5 `9 P6 B, k! W6 q
the neck revealed no thyroid enlargement.
. D: t. @0 W3 b& h: \6 pThe genitourinary examination was remarkable for- S, k9 z# r6 ~# i
enlargement of the penis, with a stretched length of, m8 Q# w2 l' q( i2 @0 n7 ~
8 cm and a width of 2 cm. The glans penis was very well
! M' r& Z" H4 o0 p  Udeveloped. The pubic hair was Tanner II, mostly around. t' j" ~: |* ^( m) c+ ~
540
0 i  l" s$ [; g7 k4 i$ O  n! Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- w5 @. |- r& l' N
the base of the phallus and was dark and curled. The
; g( q3 Z7 f  `6 d; D! c) etesticular volume was prepubertal at 2 mL each.
* T6 ?9 X. t! }2 g* KThe skin was moist and smooth and somewhat
+ m: F+ z  a, L2 \oily. No axillary hair was noted. There were no& `6 W/ t- e0 o& s
abnormal skin pigmentations or café-au-lait spots.
$ l) c: e" M/ w6 k' |# oNeurologic evaluation showed deep tendon reflex 2+# j1 I* `* X& ~* ~3 _- h
bilateral and symmetrical. There was no suggestion/ N2 v, c: G7 N5 A! h0 K, G
of papilledema.: E  N6 q( b1 ^) x: U
Laboratory Evaluation, S3 k% S5 C8 r; Z3 F
The bone age was consistent with 28 months by
6 F0 D" L: P3 pusing the standard of Greulich and Pyle at a chrono-( P3 J/ v; b9 {& |7 Z
logic age of 16 months (advanced).5 Chromosomal( [+ x/ V; R" K9 }" N9 R
karyotype was 46XY. The thyroid function test& T  T) G* U; K" c. l# F
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
* v! {% }( q$ d" L7 klating hormone level was 1.3 µIU/mL (both normal).7 g) z4 \  H8 k4 Y0 f4 Q+ K
The concentrations of serum electrolytes, blood9 w- h9 J- U2 o1 |# i8 P
urea nitrogen, creatinine, and calcium all were
6 \1 P, F7 \8 q% k+ Nwithin normal range for his age. The concentration5 H) d6 U5 X# O6 c2 w
of serum 17-hydroxyprogesterone was 16 ng/dL' H! X1 x/ H( a7 S0 L" U
(normal, 3 to 90 ng/dL), androstenedione was 20  O( F. L# a! b! i$ ^: w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" A. K8 ^# q) X# J4 f' Hterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 \3 A: k/ V- C) u- K- u) H& T
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& N$ x/ ^9 F0 P/ I3 J+ [: t' C2 S3 y
49ng/dL), 11-desoxycortisol (specific compound S)+ c% E- W* I7 i% f6 w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# m8 H# I$ e. u6 d% g1 r# x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 d/ J+ O& {- G* J+ c+ W+ r  u  ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. n! L9 B5 _. B3 e
and β-human chorionic gonadotropin was less than5 U4 l  _4 ?% q( Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
, C: h* K: e# k9 nstimulating hormone and leuteinizing hormone/ u# g1 f' w( M3 {
concentrations were less than 0.05 mIU/mL4 p+ g6 _  N& b) e
(prepubertal).
/ p. l7 U  k' v8 o$ ?The parents were notified about the laboratory
; j3 N$ G* n$ K; u& H- W: T" ?8 eresults and were informed that all of the tests were
8 K1 [0 {! r  P( j. knormal except the testosterone level was high. The
4 @5 S1 N, N4 w5 c% u/ E4 a1 E5 jfollow-up visit was arranged within a few weeks to+ b) ?% [" ]' o) r" z2 ~
obtain testicular and abdominal sonograms; how-
+ b7 _& e# Q2 A, T9 q; N2 Z  Pever, the family did not return for 4 months., r5 o- D: w7 ~) F( T3 u4 o
Physical examination at this time revealed that the
9 a* x4 A4 F# h' e, ?- zchild had grown 2.5 cm in 4 months and had gained  A& k& o% v" T- N9 g: Z
2 kg of weight. Physical examination remained+ h! r, M# [; s  ~; x- b
unchanged. Surprisingly, the pubic hair almost com-2 G9 q! [' n9 k0 X6 d
pletely disappeared except for a few vellous hairs at
# C( h& m# J6 lthe base of the phallus. Testicular volume was still 2. w  i- F1 i3 x/ D" p/ M: j8 [
mL, and the size of the penis remained unchanged.
8 T8 E! ]% D* I# s5 M; U6 kThe mother also said that the boy was no longer hav-
6 x1 f* `4 r4 x  M" ~$ Qing frequent erections.# _0 G  i& y1 ~" p: h8 x3 w
Both parents were again questioned about use of/ ]( a4 Z- u* Q; V0 a
any ointment/creams that they may have applied to
: H# s& \" E3 ]* e; Sthe child’s skin. This time the father admitted the! X) A* N" l7 \; N( l% I2 c& h+ N" ?
Topical Testosterone Exposure / Bhowmick et al 541
) `+ k! Z2 A5 t/ u, z% Euse of testosterone gel twice daily that he was apply-) h% H; s, z: M$ o/ {* n- R2 G
ing over his own shoulders, chest, and back area for
+ x' H2 R, I$ E) Z+ u0 Ia year. The father also revealed he was embarrassed
5 K. }/ W3 D4 Kto disclose that he was using a testosterone gel pre-+ |& n1 W  p. R0 f3 Z! l! C
scribed by his family physician for decreased libido( t2 {3 n% f/ @. @2 b+ Y
secondary to depression.
/ C4 r2 Y' m' pThe child slept in the same bed with parents.1 H% r& i( e( H- W$ U& ^5 P
The father would hug the baby and hold him on his
/ [* b/ s6 m7 o8 X; zchest for a considerable period of time, causing sig-
! Y6 L2 I7 p! W6 b1 d' tnificant bare skin contact between baby and father./ r$ ]0 B. Z0 B5 S) P
The father also admitted that after the phone call,
/ N  z4 V  k3 w8 Z: _( fwhen he learned the testosterone level in the baby
2 v' f) i! Q0 c" ewas high, he then read the product information! J- K$ ]! q2 N. o
packet and concluded that it was most likely the rea-
% R8 R# `  L% B% Z* ~2 ~, wson for the child’s virilization. At that time, they' C, j, p' E9 o% r
decided to put the baby in a separate bed, and the
. T# n: F7 a" V  u2 }( b. D0 Qfather was not hugging him with bare skin and had5 n7 _7 ?- d2 c: w
been using protective clothing. A repeat testosterone  E4 ^8 O( v5 L6 V+ h
test was ordered, but the family did not go to the
( A2 K! o; u, E8 vlaboratory to obtain the test.
( Z! G" e" p, uDiscussion7 M/ v# t* Z( {$ v  J- r
Precocious puberty in boys is defined as secondary& P7 D& v/ j& h& a. P; Y/ Z
sexual development before 9 years of age.1,4
% T$ B! I6 q- S8 o' [6 R8 ]5 y! |Precocious puberty is termed as central (true) when
4 x+ @; A7 F5 u' T: g0 J9 k/ M7 `it is caused by the premature activation of hypo-7 ~4 ~/ k8 C7 x
thalamic pituitary gonadal axis. CPP is more com-0 r; B& I5 y5 {6 k% o7 d
mon in girls than in boys.1,3 Most boys with CPP
0 d) r& I0 i8 o: |7 U$ [  Zmay have a central nervous system lesion that is
2 l% L* t8 h& y" o5 Xresponsible for the early activation of the hypothal-# ?) F+ [7 E+ m/ I
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ |5 j- b& o4 u( C7 ]4 wsis has been given to neuroradiologic imaging in$ r) v- A3 l; s% y' c2 P% a
boys with precocious puberty. In addition to viril-
  N: N7 h  G% H2 }ization, the clinical hallmark of CPP is the symmet-( e9 R; _3 Z2 ^/ u" s$ ?/ s
rical testicular growth secondary to stimulation by
* f+ X: l' D- H% e: I! t2 A  ?( ^gonadotropins.1,3
) r7 g. q6 e0 l( f7 F1 pGonadotropin-independent peripheral preco-
. M% f; Y7 {# v- M2 u4 [% f  r+ [cious puberty in boys also results from inappropriate: i) \1 H) P4 c6 B2 U
androgenic stimulation from either endogenous or: G( O1 f5 E9 c7 E6 m9 Y/ \/ I  o
exogenous sources, nonpituitary gonadotropin stim-3 t# }' s& n; w; e1 Z; K- P" x! o6 V
ulation, and rare activating mutations.3 Virilizing
4 R7 Z9 Q/ T; D" v7 y- t- qcongenital adrenal hyperplasia producing excessive
) o: }: p0 C' K+ w9 o( hadrenal androgens is a common cause of precocious8 Z6 q5 r+ P& t. W8 B* V
puberty in boys.3,4
$ B* Z1 t0 U% P% ?8 ^; ]/ d" s$ B) fThe most common form of congenital adrenal1 O; J% M5 Y7 _7 g% [
hyperplasia is the 21-hydroxylase enzyme deficiency.
" \# V4 L+ @& c& L# iThe 11-β hydroxylase deficiency may also result in
2 |) Z7 S* n- ]: ~; q9 Texcessive adrenal androgen production, and rarely,
* U% b1 e$ O9 G' a. Aan adrenal tumor may also cause adrenal androgen
6 o, c+ g2 Z9 \excess.1,3
0 Q9 v$ p$ x  ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 H; `1 }- x0 ^6 P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: c' G7 C9 u5 T& ]A unique entity of male-limited gonadotropin-
3 @6 J# Z0 v/ ]: H, ^: Vindependent precocious puberty, which is also known
( t1 p% x/ {2 G9 Las testotoxicosis, may cause precocious puberty at a
0 z: R) u/ J5 h: O) Uvery young age. The physical findings in these boys
, U; g# }  W, o( }: H- d  Iwith this disorder are full pubertal development,
+ v9 m$ h* y: U9 v7 _including bilateral testicular growth, similar to boys8 l6 p* \5 L9 `* c; D# E0 D  Q' r7 ]
with CPP. The gonadotropin levels in this disorder
$ A( v3 \6 Q; k. ~* Pare suppressed to prepubertal levels and do not show) p. o  K+ H+ {; d
pubertal response of gonadotropin after gonadotropin-
* W0 D$ I, X* H; v) A3 Nreleasing hormone stimulation. This is a sex-linked1 |* ?2 G6 a% O8 a: A
autosomal dominant disorder that affects only0 @) d6 k  w3 x  `( F. `
males; therefore, other male members of the family8 u% d; L. v9 y' h
may have similar precocious puberty.3
. C* f' G3 E/ W+ T3 w7 `In our patient, physical examination was incon-" {: K7 v7 R3 S# a) [
sistent with true precocious puberty since his testi-& N5 _% s* ?; K! t2 S
cles were prepubertal in size. However, testotoxicosis
3 P$ K  V9 C0 J; @. t' S+ E( B0 gwas in the differential diagnosis because his father, R  ?2 _' _* y) S- {. O
started puberty somewhat early, and occasionally,
9 H0 \( m1 `# ?5 s  xtesticular enlargement is not that evident in the- `1 x: d: w+ m# N6 x* f0 V3 M
beginning of this process.1 In the absence of a neg-- A! y8 Y  e4 O! s- s3 F3 e( j5 Q
ative initial history of androgen exposure, our
6 ^. i8 Q2 g1 y$ K: ebiggest concern was virilizing adrenal hyperplasia,
" b( m% f6 y" ^7 S- t" Ieither 21-hydroxylase deficiency or 11-β hydroxylase
) J1 y7 `6 Y) `' tdeficiency. Those diagnoses were excluded by find-
; @: Q# I$ V- i( m3 g  d5 [9 R/ C  zing the normal level of adrenal steroids.8 q4 d8 U& \! R
The diagnosis of exogenous androgens was strongly9 I! U4 [( M1 C, ?- a! r  S9 V
suspected in a follow-up visit after 4 months because
( W0 I4 e" H) q6 Y+ n( L$ |the physical examination revealed the complete disap-2 t3 j9 D* K+ q! F
pearance of pubic hair, normal growth velocity, and
8 g# k( P" E# l5 A' B1 tdecreased erections. The father admitted using a testos-" o" c; w2 y4 }4 l
terone gel, which he concealed at first visit. He was! z% @0 s/ ~0 ?% O5 T
using it rather frequently, twice a day. The Physicians’$ d) X* K/ I) O- P8 }
Desk Reference, or package insert of this product, gel or- r* @: n3 N2 ?! S
cream, cautions about dermal testosterone transfer to
; G6 J# r3 n& Cunprotected females through direct skin exposure.! K3 N" ?+ @4 v/ w( ^, ~
Serum testosterone level was found to be 2 times the, ?" ?. |! N0 K% a& \
baseline value in those females who were exposed to* c; u5 y& \1 y" i$ L
even 15 minutes of direct skin contact with their male
' P% c& h" v1 J# t7 P5 Dpartners.6 However, when a shirt covered the applica-6 t8 G7 J1 [' B8 b
tion site, this testosterone transfer was prevented.
" u/ V  e, U, F+ Z( NOur patient’s testosterone level was 60 ng/mL,
; A- n) ]. J  g) b- c: mwhich was clearly high. Some studies suggest that
5 K( E7 I6 b6 Q; }+ U& A  o- Edermal conversion of testosterone to dihydrotestos-  I% ~) R0 p5 H8 B
terone, which is a more potent metabolite, is more1 c8 {6 e" B( m8 O. B7 u
active in young children exposed to testosterone! ], Z4 F7 D5 A$ a3 k  M
exogenously7; however, we did not measure a dihy-
$ n' w* f% q0 C( Ndrotestosterone level in our patient. In addition to1 z- J. q6 h$ [( c7 ]
virilization, exposure to exogenous testosterone in
. Q5 f# e/ g3 ^( C; @% A  F2 ]children results in an increase in growth velocity and" x1 u2 {& n2 W1 Z  l' A9 t2 T
advanced bone age, as seen in our patient.
0 a' e, Y/ E$ sThe long-term effect of androgen exposure during6 \' Z& _  D3 B3 I/ J' z
early childhood on pubertal development and final+ p+ n7 L) ~3 z& F( N( Z1 t( n2 b
adult height are not fully known and always remain
" p, V& ~$ r* \' Y$ Ka concern. Children treated with short-term testos-
- `* d" M2 N2 K3 {9 h. R+ b4 D3 \- Y) Fterone injection or topical androgen may exhibit some! `7 i& c  C, p% a
acceleration of the skeletal maturation; however, after2 q+ i4 m5 _( U$ r
cessation of treatment, the rate of bone maturation
: f' d, [7 T6 Ndecelerates and gradually returns to normal.8,91 t+ G3 B/ }2 z0 e! i1 }9 R1 ^: L
There are conflicting reports and controversy
, N6 p# t6 K6 [+ d7 Fover the effect of early androgen exposure on adult
! |( r2 A3 g' h' P4 [& openile length.10,11 Some reports suggest subnormal
- ~5 b' X2 ]! W0 N% k# k8 uadult penile length, apparently because of downreg-  P+ ~+ G4 B9 Q( J( b4 l8 K  O, @
ulation of androgen receptor number.10,12 However,* Z- J4 F# r7 ?, j$ C* z9 w
Sutherland et al13 did not find a correlation between; p3 @4 x' P5 V" s) a6 p
childhood testosterone exposure and reduced adult
; n0 j0 Z& @6 N  l; M: Ipenile length in clinical studies.! j  K3 E5 K# W9 t- K
Nonetheless, we do not believe our patient is6 e8 z% y1 D% W8 k2 `' ]
going to experience any of the untoward effects from: }' s% d7 ?/ D3 }
testosterone exposure as mentioned earlier because! d3 u7 l( l* Z: k! \6 `
the exposure was not for a prolonged period of time.
( U  c) c: \1 ~+ w, lAlthough the bone age was advanced at the time of
) [5 d, N1 g& ydiagnosis, the child had a normal growth velocity at
- Z$ g" Z; |/ D  h; C( A3 d7 ]6 Xthe follow-up visit. It is hoped that his final adult
* v$ C+ f: L( z, Yheight will not be affected." D$ e4 s! D! n7 e3 r. W$ G
Although rarely reported, the widespread avail-& E' B( ]; z' @8 z3 l
ability of androgen products in our society may
5 C  a+ o% b. Findeed cause more virilization in male or female
: D0 l  b8 J1 Uchildren than one would realize. Exposure to andro-
* T1 z+ ?; ?. C1 a3 P' Bgen products must be considered and specific ques-4 q# e& e  S* A$ N7 G( q
tioning about the use of a testosterone product or
% c' Y6 M) [: ]gel should be asked of the family members during- x- [2 |& J7 J1 n8 Q1 O2 X% }
the evaluation of any children who present with vir-) D( X( z  u+ v1 Y' z8 x( q& D3 b& _
ilization or peripheral precocious puberty. The diag-4 @& _; h, K: ~. {) t/ {
nosis can be established by just a few tests and by
8 T& |0 x, r1 p; |6 d. ^. ]  yappropriate history. The inability to obtain such a- j" U' W; u" c( O% x- b+ v2 B9 \) f
history, or failure to ask the specific questions, may4 e. O& l  Q6 `" |
result in extensive, unnecessary, and expensive
+ r# v  S& t8 r; H% t) I6 W- xinvestigation. The primary care physician should be
  ^, X! {+ D& _( G) v; s2 [9 daware of this fact, because most of these children1 F) F# |2 d3 r4 N9 r* ]9 x: |5 X/ S
may initially present in their practice. The Physicians’
  I& f( Y* U* j, r# C* z5 b  xDesk Reference and package insert should also put a
/ H7 u; \  j9 B/ u2 g  Gwarning about the virilizing effect on a male or" w. u/ o. Z$ h
female child who might come in contact with some-
- N% ]3 \- U+ A5 c1 Pone using any of these products.1 |3 R# ?+ J' B: u' _: [/ V, I$ l
References
0 \; \% z  @  ]4 m. X* U) Z! e9 S9 H1. Styne DM. The testes: disorder of sexual differentiation
' `/ q- W1 I% I/ R1 ]8 L5 hand puberty in the male. In: Sperling MA, ed. Pediatric
* P- a$ G4 q1 qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 B) d5 p5 e" K5 w. m% C6 n9 m3 c$ x: B
2002: 565-628.
5 ]* c* e2 |  V6 ]$ \9 t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! a7 B0 r# `6 Q7 spuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
& P2 ]9 ?& Q/ Z: e. oBoy Induced by Indirect Topical
5 R. p4 T/ ^5 w. q  `* t% qExposure to Testosterone
+ n/ P! c  r3 o$ \, g) B; JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 X. }7 b% [3 G7 l+ Zand Kenneth R. Rettig, MD1
1 ?$ u7 B! h& U# C  _& g  w0 ]* oClinical Pediatrics: E- u4 R9 J7 q3 j, W7 n  n
Volume 46 Number 6
, s# F; S5 _( W& N* x6 F4 ZJuly 2007 540-543
% O( a* N3 |: h* W# ?4 w- a  L© 2007 Sage Publications! |0 `  V# O) K! ~# h# u0 Y
10.1177/0009922806296651+ U  ?  ~4 ^0 w/ ]; O, {
http://clp.sagepub.com& @4 X8 R6 O5 f) L
hosted at' W$ `7 Z# f: q. W* C
http://online.sagepub.com+ H* z/ Y: L2 b. I3 c
Precocious puberty in boys, central or peripheral,/ L8 F' p9 {3 t" D: O0 Z3 C
is a significant concern for physicians. Central
% h) D# m+ w+ q4 q0 {7 j% xprecocious puberty (CPP), which is mediated
2 C8 J9 M) }! ^0 F: ~. n$ h& ]6 ?through the hypothalamic pituitary gonadal axis, has7 ?" b5 h. E& M* J8 ^
a higher incidence of organic central nervous system4 T; s+ t1 B7 q0 z
lesions in boys.1,2 Virilization in boys, as manifested
' s& H3 C: D. H  nby enlargement of the penis, development of pubic
! i, a. |3 z8 Jhair, and facial acne without enlargement of testi-
( g$ g' f! ]% J7 G8 N( Hcles, suggests peripheral or pseudopuberty.1-3 We1 k" S2 B( ^+ [& a! N
report a 16-month-old boy who presented with the
& C6 I# d) N, g, c, A0 R, R6 Oenlargement of the phallus and pubic hair develop-4 D. K$ Q$ ~/ n- R/ a
ment without testicular enlargement, which was due
2 d. e: S& P' C+ h$ O5 fto the unintentional exposure to androgen gel used by
. A. l' h* C- {0 k4 V. [5 ]the father. The family initially concealed this infor-! t* I6 i/ k/ {7 K& Y
mation, resulting in an extensive work-up for this( K' [. C/ A0 ^$ q4 S; s
child. Given the widespread and easy availability of
' n. H* J# _; _testosterone gel and cream, we believe this is proba-3 [+ H, S1 ]# Q, B4 O6 K, _
bly more common than the rare case report in the
# Z6 {! y" C' }4 w8 \literature.4' w9 W0 ^( Z7 m/ t0 d9 A
Patient Report
5 w+ x5 `# ]3 J' E5 u  @1 D2 `A 16-month-old white child was referred to the) P3 V3 U: F' j# U( ]0 \" `, y. A
endocrine clinic by his pediatrician with the concern# @7 D% G4 L( o/ {* ]+ P) O
of early sexual development. His mother noticed2 A2 o- c9 q6 n5 k  s2 V" \4 T# C3 [
light colored pubic hair development when he was. _0 w# ^) F4 J1 x6 F" ~1 w* L
From the 1Division of Pediatric Endocrinology, 2University of
, I% d8 Y; Y8 vSouth Alabama Medical Center, Mobile, Alabama.; X* b  A+ \$ J
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; V9 X8 S3 g! @8 ]  H* EProfessor of Pediatrics, University of South Alabama, College of* r2 O' p0 x3 ]& [; R. V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  |! T- b, d' f8 W& c* fe-mail: [email protected].
7 l7 r* \* N8 E( m) S; @' Iabout 6 to 7 months old, which progressively became
9 A- A- t  n$ H% `# u1 H- Xdarker. She was also concerned about the enlarge-
( \1 l: L2 O. Yment of his penis and frequent erections. The child
- L9 J8 `9 e7 }8 }! }- Gwas the product of a full-term normal delivery, with
/ b' K& n7 d5 X- {) La birth weight of 7 lb 14 oz, and birth length of, U* t$ ^$ c  M/ ]
20 inches. He was breast-fed throughout the first year2 `: p) c& Y  }; @4 J
of life and was still receiving breast milk along with; {4 E7 i/ H2 i/ F& @+ W" I, h
solid food. He had no hospitalizations or surgery,# z. v/ O9 V  n0 v8 P+ k
and his psychosocial and psychomotor development
, W7 Y2 D7 k- ^2 wwas age appropriate.3 A- o1 T. D( x# i: u; [
The family history was remarkable for the father,4 W8 C5 W. }- c# u, l
who was diagnosed with hypothyroidism at age 16,& I; _( E2 G2 I5 y6 ~' B
which was treated with thyroxine. The father’s
6 M! b8 G1 \0 I# Cheight was 6 feet, and he went through a somewhat5 ?8 e6 h. b0 q
early puberty and had stopped growing by age 14.5 ^/ v6 ?2 X* D7 P+ K
The father denied taking any other medication. The1 G0 N1 Y! k" P1 J: U
child’s mother was in good health. Her menarche6 l0 v+ _% r9 ^8 R/ @
was at 11 years of age, and her height was at 5 feet
3 c1 x6 j3 t, L4 U: I  G5 inches. There was no other family history of pre-
9 S  z9 N: Z, o8 d% ccocious sexual development in the first-degree rela-9 J& S2 R- w* e+ I
tives. There were no siblings.
+ m! W9 N( n' C" T; e. Y7 gPhysical Examination, e8 B# A/ O5 c) h+ o. B, b9 d
The physical examination revealed a very active,9 u5 Z3 F6 @* m- q8 y" E- g+ C
playful, and healthy boy. The vital signs documented
' F7 d) o0 Q/ @: [a blood pressure of 85/50 mm Hg, his length was( f9 H( _2 s, x0 [% L
90 cm (>97th percentile), and his weight was 14.4 kg
0 n" H; `: Q/ y* D. a# W% {% e% E7 P# q(also >97th percentile). The observed yearly growth( |/ F. y* B0 |5 m/ q* W
velocity was 30 cm (12 inches). The examination of; D6 T' }9 t8 Z# i
the neck revealed no thyroid enlargement.
$ o! G1 H( W8 j- l# d% b% tThe genitourinary examination was remarkable for, t" i* D! a! a. B" V: e
enlargement of the penis, with a stretched length of" `/ J% z8 h5 P2 V
8 cm and a width of 2 cm. The glans penis was very well' k$ ]" o4 }9 r. b
developed. The pubic hair was Tanner II, mostly around: Q+ o6 M3 G0 H0 y" V
540/ d; b* P7 S$ ?, T) |3 d! e* g# Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( j( I7 c8 }' r& Zthe base of the phallus and was dark and curled. The
. {1 U2 F* J: V: Dtesticular volume was prepubertal at 2 mL each.- G5 J5 I/ ~+ Q
The skin was moist and smooth and somewhat' [! D/ [; t( e7 T8 `
oily. No axillary hair was noted. There were no
* F( k( @4 W5 [2 C7 \5 habnormal skin pigmentations or café-au-lait spots.
8 ^: d3 k& `# U" O7 fNeurologic evaluation showed deep tendon reflex 2+
% Z  m+ u5 {+ Pbilateral and symmetrical. There was no suggestion9 ^# n) i4 P6 l+ n. P4 y) E. [$ d
of papilledema.3 b' D% _) l/ _
Laboratory Evaluation
/ V, {3 c6 u/ kThe bone age was consistent with 28 months by0 H, p0 ^( r. ?7 m8 |0 `1 ]- V
using the standard of Greulich and Pyle at a chrono-/ i+ R6 ]' |) k( }0 T* L
logic age of 16 months (advanced).5 Chromosomal
& L2 p) {+ C/ Q3 U! o/ @+ Hkaryotype was 46XY. The thyroid function test9 u' P! H, s, T+ t+ @# j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  J- |6 X  D; ?9 V# v) |lating hormone level was 1.3 µIU/mL (both normal).
9 ^3 i3 ~0 ^/ R$ A' \The concentrations of serum electrolytes, blood- Z2 X( h8 \/ P" Q4 O/ ]! V6 }
urea nitrogen, creatinine, and calcium all were# x2 ^% t" ~2 p2 q$ q
within normal range for his age. The concentration
6 b' v2 e3 \6 h+ v" G& d, k1 Sof serum 17-hydroxyprogesterone was 16 ng/dL
% D8 B1 O+ f" a- I  F& w+ s- @(normal, 3 to 90 ng/dL), androstenedione was 20
( l  h7 u9 K/ F8 T+ i4 A% Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ B6 ^* k; [  e$ F! C% Z5 L3 F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 i& {6 x! H8 V( r) d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 `8 Z" I8 U1 I* s& P9 W# {; P49ng/dL), 11-desoxycortisol (specific compound S)
9 [* m/ d3 j" ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. p, x7 e8 Y1 I# `; B) R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ F7 Z. u5 v- B9 a. b' i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% l& b- T2 j( h. `7 B3 q$ Gand β-human chorionic gonadotropin was less than
4 a) \( s! B# B5 mIU/mL (normal <5 mIU/mL). Serum follicular4 @% H8 s7 I, d; W) b' Q5 {
stimulating hormone and leuteinizing hormone0 j: W# }! J/ P. A# c  `! m# u
concentrations were less than 0.05 mIU/mL; [5 O" F: X5 _
(prepubertal).
6 M9 t# V# }4 c6 I' R1 RThe parents were notified about the laboratory- g9 N6 a( K) E* Z' }9 s
results and were informed that all of the tests were
  K) W- i; ^8 q" [% d9 P. W$ ?; T; qnormal except the testosterone level was high. The
! H1 j, l* f4 Q' ofollow-up visit was arranged within a few weeks to
& H! Z8 k7 O$ L; g- Qobtain testicular and abdominal sonograms; how-4 y, A# D0 k7 u& M* _( Z' O. m. x
ever, the family did not return for 4 months.
$ C  t5 t: I2 p: k5 SPhysical examination at this time revealed that the
; z: K. \7 z- y9 x. Kchild had grown 2.5 cm in 4 months and had gained
. n+ d2 r+ x' W0 f; p9 M2 kg of weight. Physical examination remained
) C% r( X5 J( C3 N6 B7 _unchanged. Surprisingly, the pubic hair almost com-) u" d% i' a* \! Q, d2 H* W. S
pletely disappeared except for a few vellous hairs at
" a) c& I: p5 X# f1 `; Othe base of the phallus. Testicular volume was still 2# J- \5 `( F* d/ q
mL, and the size of the penis remained unchanged.- I) Z, Q; h" G* P5 l
The mother also said that the boy was no longer hav-7 x& k- G% ]! p' c8 _
ing frequent erections.
0 W6 S- g% F) `+ g1 V- r; ?  \Both parents were again questioned about use of
0 K6 K! b$ O' G# L" \# t$ Z) l1 }any ointment/creams that they may have applied to; O2 @* r) h8 F9 J: G( Y) B
the child’s skin. This time the father admitted the
  R" Z; K1 C& [8 b7 [+ {Topical Testosterone Exposure / Bhowmick et al 541) c5 N% \, i# @  C" [% o0 U
use of testosterone gel twice daily that he was apply-1 B# e; Q% t9 U7 o% b( V) W# u2 i
ing over his own shoulders, chest, and back area for4 f2 N; @/ s# v* d. L8 p8 v
a year. The father also revealed he was embarrassed7 P" U! O: I/ r8 N$ T
to disclose that he was using a testosterone gel pre-3 M5 A- n% T; q0 _1 f( Q: ~3 f
scribed by his family physician for decreased libido& G1 N" j# N3 k! v2 I% u+ U
secondary to depression.
/ S- r) A4 d; g. [) q5 s  CThe child slept in the same bed with parents.% r  s$ L, L2 i0 o' j) [! _
The father would hug the baby and hold him on his% C) R  l$ C2 H+ j1 x
chest for a considerable period of time, causing sig-' }, J" N0 j$ H  k' S7 ?5 w
nificant bare skin contact between baby and father.* W) O+ \+ ^, \& [- [
The father also admitted that after the phone call,
4 g* u6 w  ?, p1 R- _1 zwhen he learned the testosterone level in the baby+ F3 e- _  H7 y- H  Q9 j0 }
was high, he then read the product information
6 k! W9 z, l, o7 X5 Z% f1 opacket and concluded that it was most likely the rea-+ L/ r. ]( k: t; J! n6 L
son for the child’s virilization. At that time, they
' W2 M5 C7 W  Mdecided to put the baby in a separate bed, and the2 j: J2 \5 f* ?
father was not hugging him with bare skin and had' Y2 T' I- q1 @( B6 P, F
been using protective clothing. A repeat testosterone" b* L$ N: x+ k# K& b5 c- R1 |
test was ordered, but the family did not go to the% T8 f, x7 Y6 x
laboratory to obtain the test.
  M2 I$ E' [$ Y, D$ l$ r) U0 g* YDiscussion( ?5 b0 O6 l3 e' V3 W
Precocious puberty in boys is defined as secondary
! M9 |5 g2 \9 C( g% E# asexual development before 9 years of age.1,4
! w3 A+ m% c" z, BPrecocious puberty is termed as central (true) when
  k4 b4 Z/ g) y8 @. K& u: S' I+ N, Vit is caused by the premature activation of hypo-
. f9 P4 X9 q/ D5 U! P. P4 ]$ W( Vthalamic pituitary gonadal axis. CPP is more com-
- V, n+ o  c" D+ W/ p; r! gmon in girls than in boys.1,3 Most boys with CPP  t: q  L/ X7 ]
may have a central nervous system lesion that is: L1 H* N- A- a: `* r, s
responsible for the early activation of the hypothal-
. `4 f2 [6 ~4 ?- c( r* m) F1 Damic pituitary gonadal axis.1-3 Thus, greater empha-0 z* T* [+ x  d6 U
sis has been given to neuroradiologic imaging in
! e& B% {2 c+ i3 Q; _" V4 w2 n$ zboys with precocious puberty. In addition to viril-
2 ~8 I. x8 K$ {/ W* T6 {+ \2 ?/ cization, the clinical hallmark of CPP is the symmet-" {( N0 I7 s0 {8 B! L, ~/ ^. F
rical testicular growth secondary to stimulation by
# T3 p$ S# n' C/ m! |' j* \gonadotropins.1,3
+ c- v- d6 Q' w' r3 B. s7 }4 N* pGonadotropin-independent peripheral preco-
: i# F; b: W" G6 o  z: a2 m) Ycious puberty in boys also results from inappropriate
8 g5 }2 B  T+ j+ i: Vandrogenic stimulation from either endogenous or! k$ R' M+ Y8 D( ], I
exogenous sources, nonpituitary gonadotropin stim-
; ^7 p" @$ Z7 X5 K# ^" j; j9 nulation, and rare activating mutations.3 Virilizing5 u! p* d7 g2 v: z+ z
congenital adrenal hyperplasia producing excessive
3 ]9 J+ c% L0 z4 \9 [# N2 ?adrenal androgens is a common cause of precocious
$ e& P! x- D3 f# B, {puberty in boys.3,4
3 a, ^0 R/ J$ d& s; o  k( v: pThe most common form of congenital adrenal, T  Q3 ~1 j# b* L. E
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 K; f$ l1 E6 vThe 11-β hydroxylase deficiency may also result in" v1 `+ t+ {  }2 S6 w: X
excessive adrenal androgen production, and rarely,- l  z8 v4 j, v5 v1 j- {
an adrenal tumor may also cause adrenal androgen
7 O; [/ O9 c! y" |" ^, ]. ^0 p" Aexcess.1,3
. x& L7 I3 ~- d# V7 Y  ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% t0 X/ M, d# z/ u( I8 O
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 Z9 U8 L" R) a# D% y% M, K- H; w7 q
A unique entity of male-limited gonadotropin-
0 X4 P; r- F. Y; Zindependent precocious puberty, which is also known9 z7 b2 S* z: Z
as testotoxicosis, may cause precocious puberty at a
. s0 _" G( f5 K5 ?' ivery young age. The physical findings in these boys1 Q+ U0 f9 I6 g* H: X4 s& N
with this disorder are full pubertal development," a0 O& C6 z. Z+ y  u: ^  ^
including bilateral testicular growth, similar to boys4 i/ g  V& P% f, d" K2 J/ t
with CPP. The gonadotropin levels in this disorder
3 v. f5 K& d' ^5 Jare suppressed to prepubertal levels and do not show6 T: V1 }( X- v4 A# y* f
pubertal response of gonadotropin after gonadotropin-
$ A* a, a, X, X2 F; ereleasing hormone stimulation. This is a sex-linked: i; a% n! _1 {3 z9 L& p
autosomal dominant disorder that affects only
* e/ O& O( ~4 |9 i* T+ r5 Rmales; therefore, other male members of the family8 _) \0 d; K+ G6 J2 Q
may have similar precocious puberty.3) G& v1 m( o! ^, O/ ]6 \) g4 o
In our patient, physical examination was incon-
- v; @4 G: s3 tsistent with true precocious puberty since his testi-
6 {5 t* D2 g8 @% l5 bcles were prepubertal in size. However, testotoxicosis
, m8 q2 D; D8 c! c4 @! u* @/ Rwas in the differential diagnosis because his father
4 ~4 \7 E/ k0 L8 B% Rstarted puberty somewhat early, and occasionally,& [6 ^- m) G, C
testicular enlargement is not that evident in the; e) ]8 `1 H( _4 N; [
beginning of this process.1 In the absence of a neg-
9 R% o  A$ Z0 \) q" ?ative initial history of androgen exposure, our
6 C" @1 @( `' R  rbiggest concern was virilizing adrenal hyperplasia,
  [- p3 N( n; Z% P1 r8 @- neither 21-hydroxylase deficiency or 11-β hydroxylase! r& D' P, ?* w" H/ e6 t
deficiency. Those diagnoses were excluded by find-
! u. Y+ ?# y) @! Q8 t: Fing the normal level of adrenal steroids.
" c' u$ f6 L. y% Z0 g' H- cThe diagnosis of exogenous androgens was strongly1 j" M6 \- U! G& l
suspected in a follow-up visit after 4 months because
) L! ~. O* D* J+ l: |! Uthe physical examination revealed the complete disap-3 |, x' H' z+ @1 X+ G
pearance of pubic hair, normal growth velocity, and9 F8 c" S) K2 T5 ?% n6 \
decreased erections. The father admitted using a testos-
6 U# ?4 [0 J9 ^' F1 ~8 ?terone gel, which he concealed at first visit. He was
4 \- c! U, H4 d0 Lusing it rather frequently, twice a day. The Physicians’0 o" P" M4 i( N9 ]% M0 ~: q
Desk Reference, or package insert of this product, gel or
5 W9 I# _" T; n3 }1 O1 ?cream, cautions about dermal testosterone transfer to& ~2 x9 N( \0 H2 ~1 b9 N: {
unprotected females through direct skin exposure.
& c4 H7 r$ N# ?5 _' l2 S. zSerum testosterone level was found to be 2 times the
, Q* F! O  z# l9 ~0 f; `baseline value in those females who were exposed to' Y8 N  y# w1 Y7 F, Z7 H
even 15 minutes of direct skin contact with their male, E6 b6 d' {/ {
partners.6 However, when a shirt covered the applica-
! S" B) q7 j- I& M+ [: g3 s( ztion site, this testosterone transfer was prevented." R8 c# u  f) V4 m
Our patient’s testosterone level was 60 ng/mL,
9 r. h' b: p' ]/ Swhich was clearly high. Some studies suggest that# G0 W/ K+ Z3 T! m( b6 S8 d
dermal conversion of testosterone to dihydrotestos-- v3 p& R* t" O* ~% F$ c! ]
terone, which is a more potent metabolite, is more: v5 J/ K0 ?- J5 c- i+ O
active in young children exposed to testosterone3 b' j0 b3 w) g3 x+ l# v! ]
exogenously7; however, we did not measure a dihy-2 S6 L, g7 {- Z) B1 W. X1 I
drotestosterone level in our patient. In addition to
. ]$ b9 M0 C6 g% v5 a7 l. @/ J# Uvirilization, exposure to exogenous testosterone in
9 ^9 O7 u# U0 ?" T1 @6 Rchildren results in an increase in growth velocity and  z2 k; F6 ^0 N; v" N
advanced bone age, as seen in our patient.
+ ~0 `0 |9 B# Q1 ~1 O& BThe long-term effect of androgen exposure during" W5 ~% g0 J' F( p. ?6 O7 d
early childhood on pubertal development and final, `! R' _) ?1 {1 {- `3 C
adult height are not fully known and always remain  Q# L7 x5 \: L, R. f
a concern. Children treated with short-term testos-
) K8 X9 v; W8 ]: Lterone injection or topical androgen may exhibit some- [5 [1 R6 _# G' s$ s
acceleration of the skeletal maturation; however, after
) L) ?' W, ~, R) y) e' kcessation of treatment, the rate of bone maturation
; L7 L. ~6 h% d$ o( c8 ]) }decelerates and gradually returns to normal.8,9
& m; V, `  a' A$ QThere are conflicting reports and controversy& ~* A6 Q! t( n0 z
over the effect of early androgen exposure on adult, w2 I# A! k! U5 f
penile length.10,11 Some reports suggest subnormal5 E% e; J6 j' o! p7 l
adult penile length, apparently because of downreg-
% E2 o- X9 ^, D9 Uulation of androgen receptor number.10,12 However,
/ c6 d1 f* V9 N' `4 FSutherland et al13 did not find a correlation between
& b6 j& @- ?2 T# r, t5 b" E$ O% Uchildhood testosterone exposure and reduced adult7 i1 d3 V; i7 M+ ]
penile length in clinical studies.( B7 ?! d! W: W$ ~; L5 C& o8 ^
Nonetheless, we do not believe our patient is
0 Q. ^0 \6 B# v: Xgoing to experience any of the untoward effects from/ H) ~- j+ L3 k* x" a
testosterone exposure as mentioned earlier because" Q2 X" z! [" A% L& t
the exposure was not for a prolonged period of time.0 @$ {2 F0 w4 |4 t; \7 B
Although the bone age was advanced at the time of. U" h; J5 ~4 K+ t* ^8 _
diagnosis, the child had a normal growth velocity at* s2 A6 K" i6 c8 Q: o8 B9 X; {/ ~: h4 [
the follow-up visit. It is hoped that his final adult
, l5 w% D$ K9 rheight will not be affected.9 O- Q) O5 [% D* i% p  z2 i
Although rarely reported, the widespread avail-! A2 b$ ]3 `3 X0 z/ Y+ \  i- m
ability of androgen products in our society may' ?: ?7 L: p. L/ ]" |+ Y/ N, E
indeed cause more virilization in male or female
6 x' o1 V' v% P! s% R9 i% L% W# Nchildren than one would realize. Exposure to andro-
3 ?( P6 ^) C6 D& N1 {8 p" x! [gen products must be considered and specific ques-2 Z; Z- i# l; R- y, G; ?; A
tioning about the use of a testosterone product or8 p) H6 m7 f/ W* A
gel should be asked of the family members during
$ [! y  T5 P9 L$ m3 M2 Zthe evaluation of any children who present with vir-
# e: a) ~4 h$ a6 Z3 Hilization or peripheral precocious puberty. The diag-
# j; x* U  t- q- x0 l9 Dnosis can be established by just a few tests and by0 J& c  `$ `, m$ |3 m$ M
appropriate history. The inability to obtain such a! _" c3 L! R5 D2 m; }
history, or failure to ask the specific questions, may
) H  N% g, q1 d8 k5 _& k- b3 }3 tresult in extensive, unnecessary, and expensive
5 E" [* O0 |* L0 w9 `investigation. The primary care physician should be
" a6 {8 Z' d! Y+ F" F5 Taware of this fact, because most of these children4 f9 x+ J# A6 M& O( A
may initially present in their practice. The Physicians’
; q# M) c1 ], f: r+ T; xDesk Reference and package insert should also put a
' q' z0 F# E* _- z- o) i# Kwarning about the virilizing effect on a male or
$ D6 s. ?0 S$ T; Hfemale child who might come in contact with some-2 r1 A' V- J- ~+ A/ n2 ^% O
one using any of these products.* a3 K+ l" T4 S1 m
References
# I. M7 H, I/ w) u1. Styne DM. The testes: disorder of sexual differentiation
, p6 B" I# G7 k, B- s5 s' o; V) ^and puberty in the male. In: Sperling MA, ed. Pediatric
: P0 m9 B" h- x' n( |! _, Z7 Q' qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 I8 h# Y" {& A; N, \4 C4 y
2002: 565-628.
# T1 Z5 `  Y2 g% V; r" L# u/ u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 `9 X. M  d8 Y" y
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
$ S+ A+ {& h% w7 q3 D) i5 ~1 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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