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Sexual Precocity in a 16-Month-Old
$ {" ^5 f" c& k9 NBoy Induced by Indirect Topical
6 X' J$ u7 e8 N6 g# {& I. LExposure to Testosterone
/ o! x9 ~$ y! I# g0 c9 cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 f; V* c7 r8 Y3 E
and Kenneth R. Rettig, MD18 q& K6 @- R/ x# @3 }3 D2 K
Clinical Pediatrics
8 e0 Y; `% V* Y0 g8 H$ f0 vVolume 46 Number 6
3 S1 v; O! d  }% i6 [July 2007 540-543% i6 K% T! T& g& G6 [( [1 M
© 2007 Sage Publications
3 n6 B- n9 r) O6 j8 Q& p4 m* R10.1177/0009922806296651
! y' O1 ~* j2 \2 L3 ahttp://clp.sagepub.com
0 X9 L5 S9 X) n( ]/ B. Y) x6 Vhosted at& V9 a4 |1 r; a. M5 p5 D
http://online.sagepub.com1 w, Y8 G' ^  L- `& e# o$ k% G
Precocious puberty in boys, central or peripheral," a; W1 @7 w# d1 m; k# {6 _8 I. L, x' V
is a significant concern for physicians. Central$ F* J- U$ p3 w) I# H/ N
precocious puberty (CPP), which is mediated: }, S$ |# c4 e) X# v! {' u: x
through the hypothalamic pituitary gonadal axis, has
2 [  c9 I2 ^$ h, {0 M# @2 t1 ma higher incidence of organic central nervous system3 Y0 C2 ~1 Y- q0 b* o3 O  y
lesions in boys.1,2 Virilization in boys, as manifested
0 h0 C3 b6 U# D; I0 ^  uby enlargement of the penis, development of pubic$ D) I( ?* m0 J! V$ V
hair, and facial acne without enlargement of testi-3 \' [( q( v3 `; D+ e
cles, suggests peripheral or pseudopuberty.1-3 We+ c/ ^) O: _, y3 L
report a 16-month-old boy who presented with the
9 b( q1 A1 Y: qenlargement of the phallus and pubic hair develop-: _5 w. M# H7 @3 s+ M
ment without testicular enlargement, which was due
* I& v7 Y. t" b( m" B& yto the unintentional exposure to androgen gel used by- I) v, K. N8 y; n6 f9 |
the father. The family initially concealed this infor-8 g) k" k% i6 u1 B( l; W- K! E
mation, resulting in an extensive work-up for this/ ^. y: w. t4 V: T4 t
child. Given the widespread and easy availability of+ n8 O* {) q9 G# A
testosterone gel and cream, we believe this is proba-
2 z& e  c; Y* D( R/ K6 e" S# N% Lbly more common than the rare case report in the0 {4 N. a0 ~0 i' s2 x; @
literature.4  L$ q; G0 b) }! u
Patient Report- e+ E& p# G3 y8 g' @/ v
A 16-month-old white child was referred to the
) ]; h" E& E1 u  E- K% T1 Pendocrine clinic by his pediatrician with the concern; e6 R( {$ y+ z! I
of early sexual development. His mother noticed7 W9 ]9 x6 h% O! I9 I  e9 u8 X' i' h
light colored pubic hair development when he was
+ B7 x9 G) G* `3 l+ q' }+ KFrom the 1Division of Pediatric Endocrinology, 2University of
( e1 q5 ^# P7 g+ s' USouth Alabama Medical Center, Mobile, Alabama.# @0 y* u8 i7 {3 O7 D' g
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 h, B6 G# q2 X3 Z% ^' s; jProfessor of Pediatrics, University of South Alabama, College of  L2 H+ X  E4 ]3 y3 s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 T8 R% L. y* F7 R( X$ p1 v3 be-mail: [email protected].
& o9 Q# ]- @. t0 rabout 6 to 7 months old, which progressively became
" ?9 s: Q: z- ~: Q' zdarker. She was also concerned about the enlarge-
3 v# Y* d8 u/ W2 D- c- vment of his penis and frequent erections. The child
( J# I: ?: W) t- t: Rwas the product of a full-term normal delivery, with
6 b) c( p: l! h5 h6 |) j: V  Ja birth weight of 7 lb 14 oz, and birth length of
6 K2 H; L6 v2 y  L  z% _20 inches. He was breast-fed throughout the first year
; G- t+ k1 _# \) M0 Pof life and was still receiving breast milk along with
, p1 p9 k0 j1 Vsolid food. He had no hospitalizations or surgery,
% I" h& K6 l$ n* ?& p8 f7 sand his psychosocial and psychomotor development
' U. t4 d& `7 v; ]was age appropriate.
. J$ ?: C. L, L; W" W+ m4 `The family history was remarkable for the father,
0 X' L- [- L' Y% t# F, ?7 Twho was diagnosed with hypothyroidism at age 16,5 x6 V2 e/ A( i' \1 o8 D1 f
which was treated with thyroxine. The father’s+ m5 \. I9 N' e
height was 6 feet, and he went through a somewhat, j  l1 \" X# U1 b
early puberty and had stopped growing by age 14.$ }5 _. W' E9 M* ^/ D0 t* T
The father denied taking any other medication. The
% \7 N2 q. g7 a& n4 b; ~* Bchild’s mother was in good health. Her menarche
% E4 {1 |# d4 |7 Mwas at 11 years of age, and her height was at 5 feet% r' b+ U, Y- j+ i4 H
5 inches. There was no other family history of pre-$ e% z% f! l) e; k+ `; G
cocious sexual development in the first-degree rela-" O5 X' X9 y( L
tives. There were no siblings.
" R8 N4 R9 m! [# @7 K4 \Physical Examination
9 E! d" [. U( P+ |) K+ YThe physical examination revealed a very active,
, Y' I. R5 ]1 s- r4 E% I1 q  gplayful, and healthy boy. The vital signs documented
' j% S& t) L9 f% h, [8 Aa blood pressure of 85/50 mm Hg, his length was+ Z, E: c7 }! \& J: I- O3 X' e/ c
90 cm (>97th percentile), and his weight was 14.4 kg" t. X& S* o/ K+ e- y. k9 ^9 U
(also >97th percentile). The observed yearly growth8 B# L. d# O( s0 m6 T* ~7 ?. W8 Q
velocity was 30 cm (12 inches). The examination of( c! d  S; _! o
the neck revealed no thyroid enlargement./ s# V: q$ I- R0 {
The genitourinary examination was remarkable for
; E7 b% W7 k/ s& O1 r  senlargement of the penis, with a stretched length of$ ^0 i1 U, k, J0 J& k. s
8 cm and a width of 2 cm. The glans penis was very well, Z% a: ~0 m+ K, P- k/ v/ S
developed. The pubic hair was Tanner II, mostly around
2 Q  x6 ^8 z2 f; P2 Z# @5403 F# x/ Q. k/ A: c( j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 |* B9 S2 g( V' Othe base of the phallus and was dark and curled. The
7 u* |  y7 C8 R/ g* i8 ?' `  d1 c) c+ D" Xtesticular volume was prepubertal at 2 mL each.
+ s( a' N) E; KThe skin was moist and smooth and somewhat# \9 y# \- D* @& b+ C- T3 l
oily. No axillary hair was noted. There were no
+ C3 ?& w1 k( T( K. ~0 t! M( ]( Sabnormal skin pigmentations or café-au-lait spots.) d8 }8 W3 r) U1 r
Neurologic evaluation showed deep tendon reflex 2+
# G, n- e% C1 E3 w# o% Bbilateral and symmetrical. There was no suggestion
, }3 R8 y/ _8 D3 r: }of papilledema.
4 ~6 r( o' O- T, y1 N- m4 JLaboratory Evaluation
% ]" }8 C/ ~7 a4 ZThe bone age was consistent with 28 months by
" D  B* Z& V! x; Xusing the standard of Greulich and Pyle at a chrono-
5 V+ X! g, [5 Z' flogic age of 16 months (advanced).5 Chromosomal
* U( f" g7 e- Z7 E, N0 okaryotype was 46XY. The thyroid function test
9 \. j  K7 P1 V6 kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: [3 a: i$ \* k# \8 ^9 Dlating hormone level was 1.3 µIU/mL (both normal).: q+ H* k# J7 @# e  E7 m
The concentrations of serum electrolytes, blood
( b+ Q" U7 ]' V5 c. X. y) ?urea nitrogen, creatinine, and calcium all were/ V& @, R& C. N
within normal range for his age. The concentration% @  n0 h, L( A) a
of serum 17-hydroxyprogesterone was 16 ng/dL
/ @# w8 K- e/ ?% t(normal, 3 to 90 ng/dL), androstenedione was 20
4 Y% A3 ?* m1 T6 A- h6 ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 n4 Z) g0 B4 {+ t$ n1 T3 u8 o7 Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),! ^5 A0 o) s  d2 u" w% i) M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 M, r2 P( r% C5 t" Y7 \9 L49ng/dL), 11-desoxycortisol (specific compound S)& i7 m/ ?( L& h- v, L! R& N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, ?, p* `% v! w1 u( f+ y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' s7 z( J8 d: K5 r' l$ Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 E2 m5 H# k+ Q% U) a) Jand β-human chorionic gonadotropin was less than
( A6 D! l* V. |2 H6 w5 mIU/mL (normal <5 mIU/mL). Serum follicular3 v, \3 H  r+ G9 M' ]/ d
stimulating hormone and leuteinizing hormone% Z  i; P9 S9 T. i
concentrations were less than 0.05 mIU/mL( c9 `7 D8 X8 N4 Z. N9 P) Z
(prepubertal).- a9 v" i, r( v9 T3 |0 `  B
The parents were notified about the laboratory
) `' i5 }+ \, m4 @4 rresults and were informed that all of the tests were$ P) j9 I% t& [4 N
normal except the testosterone level was high. The
; O: H/ Y* B$ J' ]follow-up visit was arranged within a few weeks to
. x4 w) C5 d9 m* [obtain testicular and abdominal sonograms; how-
# ~; [+ s+ u! ?; \* Eever, the family did not return for 4 months.; B: @/ n- a3 {% v; w0 R6 F
Physical examination at this time revealed that the$ Q. D  @4 v- S
child had grown 2.5 cm in 4 months and had gained" x$ }  K5 G0 F, T
2 kg of weight. Physical examination remained
; W2 @: a3 D6 I3 ^- q- T2 y' Cunchanged. Surprisingly, the pubic hair almost com-
: s% }6 }% q7 P, J/ b2 |' qpletely disappeared except for a few vellous hairs at6 U5 S2 r; y: E& k* a; T
the base of the phallus. Testicular volume was still 2
+ m. |; n6 j$ U# JmL, and the size of the penis remained unchanged.7 d% d& B- j9 t; F* ^9 z
The mother also said that the boy was no longer hav-
/ v5 ?; r6 G* M# D" G  v+ ping frequent erections.
. X, `1 {' \2 S: j& ABoth parents were again questioned about use of8 V& P8 p+ I3 z' ^9 l
any ointment/creams that they may have applied to
1 Z/ V/ T" S3 ~* F1 l: \the child’s skin. This time the father admitted the
: S& [3 i# v( E9 z' MTopical Testosterone Exposure / Bhowmick et al 541
% m1 }: s$ Q0 l3 S+ vuse of testosterone gel twice daily that he was apply-( W0 D  W. u4 o" i% m" K$ L
ing over his own shoulders, chest, and back area for
  Q9 I3 {9 Y: e, X6 C# r) Na year. The father also revealed he was embarrassed
* U: X. a! _2 [: m* ?to disclose that he was using a testosterone gel pre-
# h4 t5 H: U3 \scribed by his family physician for decreased libido) e. H$ S- R" x
secondary to depression.- t% V: p/ H6 E) d+ Z
The child slept in the same bed with parents.4 E5 V: ^, N' l# j2 K
The father would hug the baby and hold him on his5 v# n9 f9 ?8 z- i& @/ B
chest for a considerable period of time, causing sig-
9 N, B% R! k2 @4 n" znificant bare skin contact between baby and father.! Q8 |. i% d) N; c8 b
The father also admitted that after the phone call,
' t' j9 o: [0 X5 W$ i' Swhen he learned the testosterone level in the baby( ?9 B9 l: g! F8 w3 l+ }
was high, he then read the product information
" r6 w9 d  H+ m  [6 Z) Bpacket and concluded that it was most likely the rea-
4 U# B0 M5 K( t' ason for the child’s virilization. At that time, they0 ?: N7 s: q; F, o
decided to put the baby in a separate bed, and the1 V' n& u, V4 ?! T0 v7 g) n- A+ ]
father was not hugging him with bare skin and had
; l$ y6 m* {8 f4 o, Gbeen using protective clothing. A repeat testosterone1 h$ f2 N* N0 K3 [' g
test was ordered, but the family did not go to the9 _' Z/ r  m$ a, x% s7 i
laboratory to obtain the test.
& g* k1 O" b9 s$ B; q2 g" e# f3 GDiscussion- |; F: }1 L0 [/ w1 i
Precocious puberty in boys is defined as secondary# _, L  Q0 }/ l+ K+ p2 N
sexual development before 9 years of age.1,4. c8 s3 {- {! T+ I6 V
Precocious puberty is termed as central (true) when
! l" S$ n) n& z* e$ H8 ]it is caused by the premature activation of hypo-# Y8 G, A7 M% d; F0 ~. x" x
thalamic pituitary gonadal axis. CPP is more com-$ T4 \9 ^5 R6 A, e; i: [' }
mon in girls than in boys.1,3 Most boys with CPP
8 J0 B/ r) ^0 n* Tmay have a central nervous system lesion that is
" A' ^7 f9 H5 w5 bresponsible for the early activation of the hypothal-) v6 m0 A. b4 @! j
amic pituitary gonadal axis.1-3 Thus, greater empha-* l4 `; B6 W6 x, C
sis has been given to neuroradiologic imaging in4 h, T& T( z% G7 t. p
boys with precocious puberty. In addition to viril-  X2 A" K6 F& F5 w- L3 o
ization, the clinical hallmark of CPP is the symmet-
8 o& g0 a5 {* a5 _rical testicular growth secondary to stimulation by( I2 O2 e& z0 _; q. W0 @1 ]
gonadotropins.1,3
( T- ~" W! }) y7 L/ }9 k! G# LGonadotropin-independent peripheral preco-5 P  H. ~9 A" O* V
cious puberty in boys also results from inappropriate* @6 P, Q; }7 A; H, T% c# c5 h2 S; @
androgenic stimulation from either endogenous or4 l* @$ E+ G( E* n
exogenous sources, nonpituitary gonadotropin stim-$ z/ t' E0 p3 Z. P0 F7 W% e# r& d/ G
ulation, and rare activating mutations.3 Virilizing& |8 f& j/ ]2 k  c. t
congenital adrenal hyperplasia producing excessive. K7 @3 v( R/ w- K
adrenal androgens is a common cause of precocious+ j; R( M2 f: `
puberty in boys.3,4
( v7 ~8 i; [; FThe most common form of congenital adrenal/ |& X# n) y. C
hyperplasia is the 21-hydroxylase enzyme deficiency.' d( G  F2 G" y( M+ C# D1 F
The 11-β hydroxylase deficiency may also result in4 E  @) Y& `* t1 M7 c7 g( e
excessive adrenal androgen production, and rarely,
# C8 s5 X2 `# G4 K. {5 xan adrenal tumor may also cause adrenal androgen
# X9 t, y, C' Y2 Texcess.1,3% R+ q1 v% Z7 {" p3 D* j) h4 Q. T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) q) U+ H: X; b: E9 ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& m$ m& \( _1 X) ~2 b
A unique entity of male-limited gonadotropin-6 X/ M1 H9 I3 [: d* v2 c& E
independent precocious puberty, which is also known+ L' o2 i1 `! K& B0 M  b
as testotoxicosis, may cause precocious puberty at a2 x# _  q. i( N, W) D( t' H
very young age. The physical findings in these boys: B% g6 A' e- }+ @3 S9 d6 T
with this disorder are full pubertal development,
6 I/ s1 ~& r8 e% b2 B7 x: Vincluding bilateral testicular growth, similar to boys& b5 {" ^# w1 E! q' r  Z
with CPP. The gonadotropin levels in this disorder; S' D' T9 R, y4 i) S+ O, K
are suppressed to prepubertal levels and do not show: L/ q6 r/ T! y* }
pubertal response of gonadotropin after gonadotropin-
  ^1 D! s$ _" sreleasing hormone stimulation. This is a sex-linked
! o: V  ^# O1 d3 F: s) qautosomal dominant disorder that affects only) H+ l/ Q+ X3 ?+ F
males; therefore, other male members of the family
6 F; v6 c1 c; p/ xmay have similar precocious puberty.3
4 S! ~. K  j0 t  D# _; S# G% oIn our patient, physical examination was incon-
9 Q; ^5 a( [$ ^4 v, C; D" Qsistent with true precocious puberty since his testi-
- A, `; e+ a6 ?( \& \cles were prepubertal in size. However, testotoxicosis
1 k/ q8 {0 \& G0 [# D$ L9 Ywas in the differential diagnosis because his father
4 v) w& V1 X: W- }4 l  X4 ~5 t4 ?started puberty somewhat early, and occasionally,1 ]/ F( b8 S& K# ]- h. Q  D
testicular enlargement is not that evident in the
- ]8 C4 T! G4 u6 Wbeginning of this process.1 In the absence of a neg-
. s* z3 X+ R5 sative initial history of androgen exposure, our
& h* v. h+ y+ n6 ?1 _( ebiggest concern was virilizing adrenal hyperplasia,; ?0 @, G2 d6 g2 b. N6 `8 |" F
either 21-hydroxylase deficiency or 11-β hydroxylase
1 `2 k$ p9 B" u, y+ Jdeficiency. Those diagnoses were excluded by find-
' b# L/ e4 c! W! ]7 Ring the normal level of adrenal steroids.0 ?4 m. O; P) A9 n
The diagnosis of exogenous androgens was strongly( G$ W! z0 c- _- t. [& ]% _
suspected in a follow-up visit after 4 months because0 F: l% K' y: R2 G; s7 g: P- S2 I
the physical examination revealed the complete disap-
* m+ J: L6 b, y- B2 Epearance of pubic hair, normal growth velocity, and7 C! M2 `& q# B0 Y% K
decreased erections. The father admitted using a testos-
2 w/ t$ f: Q3 x1 Yterone gel, which he concealed at first visit. He was3 L5 J( u! z: {, E* H' \
using it rather frequently, twice a day. The Physicians’& I& P0 y( H1 F7 q) ?
Desk Reference, or package insert of this product, gel or
; \, a6 C* o& s+ ]1 [% j0 acream, cautions about dermal testosterone transfer to* c. J6 X8 @' I, p$ }
unprotected females through direct skin exposure.. U9 |1 C  O' V+ z  E/ @
Serum testosterone level was found to be 2 times the6 w. s( z. P# _& ^4 q3 k
baseline value in those females who were exposed to
8 a$ b+ W& g5 p' T: l" beven 15 minutes of direct skin contact with their male1 Q& i+ d3 @6 O, T8 |$ `, }8 B
partners.6 However, when a shirt covered the applica-
' y' Q2 j' `6 i: C' Xtion site, this testosterone transfer was prevented.: Y6 L! g8 m% e& i
Our patient’s testosterone level was 60 ng/mL,
; k2 y5 P; p1 Q% X7 @* Z& \6 P! rwhich was clearly high. Some studies suggest that
& M8 A( T2 g- v9 c9 Cdermal conversion of testosterone to dihydrotestos-0 d$ z( ]  I2 {. s
terone, which is a more potent metabolite, is more
  T! b' s6 j; ~/ _4 F$ j* cactive in young children exposed to testosterone
; V- P7 j0 ?- M( Kexogenously7; however, we did not measure a dihy-( V# _6 Z! V' {4 `6 z. E
drotestosterone level in our patient. In addition to
9 F3 W3 h7 p0 |. U2 Nvirilization, exposure to exogenous testosterone in0 g* V# x0 ]1 r& Y: @
children results in an increase in growth velocity and
6 @* |8 }" n- z  V0 uadvanced bone age, as seen in our patient.. n  r- a2 ^- u/ L. y0 K, J3 y
The long-term effect of androgen exposure during
% v4 o+ Y  e2 L$ o8 m8 Hearly childhood on pubertal development and final
) P/ m, u1 \& b4 Vadult height are not fully known and always remain( X) B: j# w$ o0 u* h
a concern. Children treated with short-term testos-& r  Z6 A% |7 {5 f" B
terone injection or topical androgen may exhibit some
' _  o, \6 e; {9 ~acceleration of the skeletal maturation; however, after
: k5 e5 T! X& l. qcessation of treatment, the rate of bone maturation
2 t$ N) o3 D9 E! {  P/ q- qdecelerates and gradually returns to normal.8,9
' B! e. u) y: i  fThere are conflicting reports and controversy: y7 o0 g4 a1 n5 r3 H) c
over the effect of early androgen exposure on adult
+ m6 C+ d  g' E) \& t; Y, Gpenile length.10,11 Some reports suggest subnormal, `' }; X9 y  ]
adult penile length, apparently because of downreg-) i3 T; Q# }" m  q* }3 \/ A
ulation of androgen receptor number.10,12 However,
7 V( ^! F2 N+ W* {/ hSutherland et al13 did not find a correlation between
: Y  l+ m  ~. g1 {; W2 E2 [/ S: S2 u2 Mchildhood testosterone exposure and reduced adult
4 d# z# J, x: xpenile length in clinical studies.
; Y6 X0 X5 Z4 A  [+ m5 ENonetheless, we do not believe our patient is9 l$ W9 J6 c; D' G1 Y4 F9 T0 E5 Z
going to experience any of the untoward effects from3 @) I; R1 Q6 c  \- ?( Y# r6 V
testosterone exposure as mentioned earlier because/ G1 q" V! p% u1 \3 N9 N  C
the exposure was not for a prolonged period of time.
' `. h9 k& Q& qAlthough the bone age was advanced at the time of9 L5 g! e2 U$ k
diagnosis, the child had a normal growth velocity at
- X8 d2 q2 Q  w' ythe follow-up visit. It is hoped that his final adult7 b9 \0 y" v/ }  ~# Y  S/ q7 u
height will not be affected.% H, |. o" A6 a  I9 }
Although rarely reported, the widespread avail-2 t6 `' U+ b/ A0 q" i8 {: O
ability of androgen products in our society may# u- A, y! X8 _- V& ^+ o
indeed cause more virilization in male or female
8 c. v/ G, ]( ]5 Vchildren than one would realize. Exposure to andro-. W7 [6 S+ p: R9 I. S) ]+ r1 g: Q0 r6 Y
gen products must be considered and specific ques-! v3 G# k9 J, q  b
tioning about the use of a testosterone product or
3 {$ ^. E7 @$ c  Kgel should be asked of the family members during9 \7 W& I* D7 E2 Z0 j; a
the evaluation of any children who present with vir-  i# G! A8 S, K* @9 k- T
ilization or peripheral precocious puberty. The diag-. k0 m7 L2 h! s) }( w
nosis can be established by just a few tests and by4 P" m2 ~% g' K* V6 M& @" w
appropriate history. The inability to obtain such a& x0 J0 p3 @' t/ D, [. E% ]% i/ V1 u
history, or failure to ask the specific questions, may
+ P$ A( Y9 ~7 X- Yresult in extensive, unnecessary, and expensive, n- t1 g- @3 L4 R0 _4 g, G
investigation. The primary care physician should be
$ X2 R4 h$ Z1 T& I& |) taware of this fact, because most of these children
3 z# B; }  T- J% l: y" omay initially present in their practice. The Physicians’
  |. I. y0 R8 [8 s- wDesk Reference and package insert should also put a8 F3 o& _  W2 {% M, J0 I
warning about the virilizing effect on a male or
& r/ n& O) F& U* v3 E# e( Afemale child who might come in contact with some-
3 k# S8 {4 a) N1 k( @1 v3 m5 |one using any of these products.
+ [+ k. X) C8 y- b& c9 G0 F# NReferences$ D! f, F5 R- H3 q8 L
1. Styne DM. The testes: disorder of sexual differentiation; ?  C& H* [" o+ n: f/ L; B9 y
and puberty in the male. In: Sperling MA, ed. Pediatric8 u% O/ h2 J* m' t; n" P9 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; v+ d; j% e; C& @2002: 565-628.
9 Z4 p' R/ l: L' H% c* R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- Z1 F/ t/ r/ d# g2 p9 Z4 p6 ?
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old! M6 c# u3 d6 H  N0 r$ E
Boy Induced by Indirect Topical8 k1 T: n5 y  l; p' l6 ?0 @  f
Exposure to Testosterone
4 ^+ V: R- B, f! j# @8 {2 oSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" v3 D7 f4 S# m7 @$ s& x
and Kenneth R. Rettig, MD1, H' F4 V5 a4 a6 U. R
Clinical Pediatrics$ P+ N! s! B: ]$ R% e( J6 A
Volume 46 Number 6( l% B  O- `. V# q8 f7 U
July 2007 540-543
% y5 i8 a, ?  ]2 l4 ~© 2007 Sage Publications( @5 ^& P: W/ ~# U! V/ Z9 H
10.1177/0009922806296651
4 [8 f, Y# n  H$ G# U, X3 S* |1 bhttp://clp.sagepub.com: E0 m) I& v1 A) x; ^$ e
hosted at# J: @  L( K3 O4 L) w2 F! ]4 m" w
http://online.sagepub.com
/ T3 @3 S- \9 \Precocious puberty in boys, central or peripheral,
9 y! D) I! _& s; f" G1 m# Dis a significant concern for physicians. Central0 [; \% U" W  x1 F7 G9 C. [9 t+ x
precocious puberty (CPP), which is mediated3 M* U* u( X; ~# z# I. o" h- W- }
through the hypothalamic pituitary gonadal axis, has/ N4 j4 e, B- a6 f) ]$ Y
a higher incidence of organic central nervous system
- ^; o- P# {# i5 h/ jlesions in boys.1,2 Virilization in boys, as manifested: e& H. w4 ?: I2 ~7 q4 @5 K
by enlargement of the penis, development of pubic2 ~, X5 D" ^8 v
hair, and facial acne without enlargement of testi-  X7 j" k# P4 m3 k! @
cles, suggests peripheral or pseudopuberty.1-3 We9 {6 g  H( n2 h! S5 c# ?
report a 16-month-old boy who presented with the' f% Q& |) s: K. |, H! S, S& \
enlargement of the phallus and pubic hair develop-+ m" \+ K' m6 P
ment without testicular enlargement, which was due
0 t, @8 V  y( A5 p& j2 p# Tto the unintentional exposure to androgen gel used by
( _, h( x4 x9 M: }" ^; {# S! H- P8 nthe father. The family initially concealed this infor-
2 F# s7 e$ [$ y+ r6 e6 amation, resulting in an extensive work-up for this; f: j" J: ^( g
child. Given the widespread and easy availability of( f$ I+ i1 u" M4 Q5 ?
testosterone gel and cream, we believe this is proba-8 e$ m1 T9 B* Z
bly more common than the rare case report in the
$ \: @- R2 V7 uliterature.43 J: m+ U5 D6 [
Patient Report
6 ]: z2 w0 J0 f$ m5 `+ CA 16-month-old white child was referred to the
1 Q" ]' T8 z- x, P8 X$ H  pendocrine clinic by his pediatrician with the concern: j3 }. d; n: u* u
of early sexual development. His mother noticed
2 q* o" i7 b2 ?6 a1 X+ Tlight colored pubic hair development when he was
. Q' a" W; W6 Z: a# \From the 1Division of Pediatric Endocrinology, 2University of; `! c- ?% P" _; s' Z8 w, V
South Alabama Medical Center, Mobile, Alabama.
! [3 S0 i/ h9 [; f& n' ~' q4 FAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' x  {- l# H1 ~, H7 y" `$ mProfessor of Pediatrics, University of South Alabama, College of8 K/ D2 l* w: p& S8 m0 k2 I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ ~- e1 w# Q7 F/ w4 A# Fe-mail: [email protected].
7 G0 ^8 k. ?3 |! M/ O$ cabout 6 to 7 months old, which progressively became
: Y% E9 Y4 w9 z2 |  l, w& o, M; S2 }darker. She was also concerned about the enlarge-
& w- s4 M% t8 j$ X1 [; a7 P! n- _3 ?! M$ _ment of his penis and frequent erections. The child
: W& p! r' u6 `$ j: n9 Swas the product of a full-term normal delivery, with
' V$ L6 k# ?) N& g4 s5 E( C5 K3 [3 Ea birth weight of 7 lb 14 oz, and birth length of1 [$ ]4 P) t/ F* ^
20 inches. He was breast-fed throughout the first year6 w3 M0 F$ [2 b  W/ \) {, y" b
of life and was still receiving breast milk along with/ U* ^  i6 y% b$ T4 `4 `6 v
solid food. He had no hospitalizations or surgery,0 P. I. G6 t6 i3 Z
and his psychosocial and psychomotor development) T( x" w4 t, |9 y5 e* @# v
was age appropriate.$ q: ?7 s! G/ |9 b
The family history was remarkable for the father,
( O1 G& D; S3 r/ gwho was diagnosed with hypothyroidism at age 16,
$ k+ x* w. o$ J$ nwhich was treated with thyroxine. The father’s
( j& A7 Y4 Y/ J0 j0 Y- u3 w0 S$ I7 J; Lheight was 6 feet, and he went through a somewhat: b# V/ J% k2 a' H6 G9 s# @
early puberty and had stopped growing by age 14.
' D! c3 `2 w2 b3 D9 UThe father denied taking any other medication. The
$ ]$ c' |/ E/ d1 J) uchild’s mother was in good health. Her menarche
2 @& R' ^  x: ]3 W8 p3 cwas at 11 years of age, and her height was at 5 feet
7 F- _( f" m$ b/ }5 inches. There was no other family history of pre-
' i5 o9 m: B$ w2 |cocious sexual development in the first-degree rela-
  A+ h3 r' u1 Utives. There were no siblings.5 F& t) Y" p& ?0 V8 }6 G6 m
Physical Examination+ e4 L9 E( ]& I0 y4 V* K7 ^
The physical examination revealed a very active,3 m: h3 s% g$ {) W- _' X
playful, and healthy boy. The vital signs documented* k  `3 `3 U* T  j" P, d
a blood pressure of 85/50 mm Hg, his length was. w6 t0 r8 k1 ^8 w( x
90 cm (>97th percentile), and his weight was 14.4 kg
0 P& Z2 @# i9 s: C, m(also >97th percentile). The observed yearly growth
# Z' }, e# f  o- mvelocity was 30 cm (12 inches). The examination of7 O# @$ G- ~# W. t( V! _
the neck revealed no thyroid enlargement.
3 q: e& b  s+ N; A5 eThe genitourinary examination was remarkable for2 t& Z! p  ]# E
enlargement of the penis, with a stretched length of( X3 x1 G2 ~3 h5 n9 K
8 cm and a width of 2 cm. The glans penis was very well: F1 m/ Q/ X. L8 V3 \
developed. The pubic hair was Tanner II, mostly around: j* V& o0 {. n. j! q
540
  V1 n; t! Z  \% Z& s/ M! u- j- ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 M9 N5 Y3 {# v& L2 Ythe base of the phallus and was dark and curled. The
% I0 F( Y) \( _testicular volume was prepubertal at 2 mL each.; B0 G" y* p# a. g
The skin was moist and smooth and somewhat# J+ y$ ?& F+ U: f% N& `( X) h9 [
oily. No axillary hair was noted. There were no
9 J. v! c, o# @abnormal skin pigmentations or café-au-lait spots.
" e7 {& [. j9 x* rNeurologic evaluation showed deep tendon reflex 2+
/ p+ q6 l, W; a  S4 \& ybilateral and symmetrical. There was no suggestion0 C" @! L. y0 C
of papilledema.
/ R/ n. S8 w' ^! }$ B1 JLaboratory Evaluation, ]! q- P: o- c" I% {/ m/ g5 i
The bone age was consistent with 28 months by
: f) C4 ]- k- n/ `" V% ]using the standard of Greulich and Pyle at a chrono-
$ u' x/ e( p' C" t9 |7 x; ?logic age of 16 months (advanced).5 Chromosomal$ w+ Y0 V7 ]4 V+ k& F% \$ z
karyotype was 46XY. The thyroid function test4 _( a' Z0 `5 D' R" R7 Y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 Z. ?' _# Z4 c
lating hormone level was 1.3 µIU/mL (both normal).8 x6 K. k( p2 ]/ Q/ C
The concentrations of serum electrolytes, blood
. c( }- [: l! t& x1 c2 @urea nitrogen, creatinine, and calcium all were6 ^- T2 _* `. n0 i5 Q- U) y) J: u
within normal range for his age. The concentration
6 o7 _) A: }9 i0 rof serum 17-hydroxyprogesterone was 16 ng/dL
! }0 h: ~/ \1 B& y$ M9 s1 w(normal, 3 to 90 ng/dL), androstenedione was 20
" L+ i/ J; @8 M: v# B2 Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 n! L1 |4 J, g, \3 Q, T! D6 Tterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! c6 h* M! o) s# m, B* ^8 p6 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to! n& E1 M# f+ `4 d; j* o
49ng/dL), 11-desoxycortisol (specific compound S)3 }  k+ K# Q, `" q7 }# t& @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# X. P% Y8 y% V/ _; q5 B+ ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* {0 U) R! b0 r! I/ H( P6 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' D* s+ }! d* `and β-human chorionic gonadotropin was less than
5 h" Z2 N9 k% {5 G6 V* [" P5 mIU/mL (normal <5 mIU/mL). Serum follicular
% @0 H: g! j" ~: U- Tstimulating hormone and leuteinizing hormone
2 r# N" I7 |9 ~6 b: Y8 |6 `concentrations were less than 0.05 mIU/mL
# q/ m9 N/ [' i(prepubertal).
/ C) o' }" A8 O: m! r6 g: @" OThe parents were notified about the laboratory$ q7 t% v3 ~$ O: }
results and were informed that all of the tests were
1 F) P+ k' d7 l: j! ~normal except the testosterone level was high. The9 g7 N! M$ ], W" T1 {2 P+ P1 Y4 Y
follow-up visit was arranged within a few weeks to% l3 V! k- Y0 ]. O5 D9 H( L
obtain testicular and abdominal sonograms; how-( y& N% }0 Q  O) L+ Y; y+ e5 R
ever, the family did not return for 4 months.
; `" c0 k3 \0 o# f+ B! C- cPhysical examination at this time revealed that the0 N' _; X5 q# u* t6 O
child had grown 2.5 cm in 4 months and had gained
8 g4 M. F. j% W2 kg of weight. Physical examination remained
) J$ a3 p9 Z, d' c' munchanged. Surprisingly, the pubic hair almost com-
3 F5 e% h3 ?2 n0 f: Ipletely disappeared except for a few vellous hairs at9 D" b7 g2 x4 |0 S9 n" _
the base of the phallus. Testicular volume was still 2
( S  v; i' @& Y- I+ gmL, and the size of the penis remained unchanged.! q7 j) b+ }. X! h/ X9 E
The mother also said that the boy was no longer hav-1 _. x& J  m/ D0 R+ O9 \5 z
ing frequent erections.9 F7 R0 j$ {* P
Both parents were again questioned about use of: I  l' T  W! N
any ointment/creams that they may have applied to
2 ~* ^$ f* T( l4 c( ithe child’s skin. This time the father admitted the6 ^" G0 d% e, L; v1 S3 C: N
Topical Testosterone Exposure / Bhowmick et al 541
% G& ^, w" E4 g; Euse of testosterone gel twice daily that he was apply-3 P7 q# e4 |4 ?
ing over his own shoulders, chest, and back area for/ c. q, k- i0 L& ?
a year. The father also revealed he was embarrassed( F- a0 j1 G: T# S( g' v0 s
to disclose that he was using a testosterone gel pre-% S6 u, E, h8 {( \( |
scribed by his family physician for decreased libido
1 O  t$ ~( \: C5 F, `: gsecondary to depression.- ]4 n. x: E& c+ y2 I" W
The child slept in the same bed with parents.
" u( I" B) n4 S9 q, DThe father would hug the baby and hold him on his( _4 P$ k% d# z
chest for a considerable period of time, causing sig-
% O, ?5 h. |* p0 t8 g2 Qnificant bare skin contact between baby and father.1 Q% w- T% J* w# `% K
The father also admitted that after the phone call,
  x. n0 G$ m) Y/ P& {/ A1 Fwhen he learned the testosterone level in the baby
& o5 }9 h) d. h3 q2 L- Owas high, he then read the product information( H3 j4 o( w- z7 X. W( ^' ?: C& t* W
packet and concluded that it was most likely the rea-6 h$ s  ~) N/ w8 b0 O9 y1 z/ n
son for the child’s virilization. At that time, they$ s' y) {4 ?4 S5 M1 K
decided to put the baby in a separate bed, and the
: t1 K9 e3 U9 Vfather was not hugging him with bare skin and had. p- W" w$ J: m5 n) V9 Y: [
been using protective clothing. A repeat testosterone, T! `  U6 M7 f$ Y4 h) W
test was ordered, but the family did not go to the, B% y. E3 l8 E: H% L/ o+ K  {+ Q% a
laboratory to obtain the test.4 p- `1 K# C8 L- B9 L
Discussion
0 ^$ j2 Y; X; A) j# tPrecocious puberty in boys is defined as secondary
0 C4 B& m6 P9 N8 S4 j* usexual development before 9 years of age.1,4
: N  _6 u/ s: s: A4 uPrecocious puberty is termed as central (true) when, S# |5 o3 B8 w. l2 i1 y0 P# s
it is caused by the premature activation of hypo-
+ U. y$ m1 ^5 `! ]# a& dthalamic pituitary gonadal axis. CPP is more com-* z. j; w7 E% D& l% ?
mon in girls than in boys.1,3 Most boys with CPP4 S9 Z1 p$ c7 C" X$ N/ E0 B. ~
may have a central nervous system lesion that is
7 m0 z7 o/ P, U# T8 @7 C2 I8 Dresponsible for the early activation of the hypothal-% U( Y2 x2 t0 v9 `; x
amic pituitary gonadal axis.1-3 Thus, greater empha-
* z/ P2 Y. m; f3 F( tsis has been given to neuroradiologic imaging in. B' Z4 W+ b6 S9 S
boys with precocious puberty. In addition to viril-, _( ^  m  }( [6 r& E) }
ization, the clinical hallmark of CPP is the symmet-6 `0 H8 \" @% @6 S6 }" d, v1 I
rical testicular growth secondary to stimulation by8 Q( V8 D: J: y) Z3 n1 b3 b
gonadotropins.1,3
5 ~2 H6 ]/ z7 j, _Gonadotropin-independent peripheral preco-% ~( }* Y/ b8 c/ ?$ k5 Q5 R
cious puberty in boys also results from inappropriate" [3 g% w* d0 C
androgenic stimulation from either endogenous or
% k% E& u6 R" j/ ~8 J- ~$ eexogenous sources, nonpituitary gonadotropin stim-
6 Z" m# ^( b! r) y$ i# uulation, and rare activating mutations.3 Virilizing& }: P$ W0 R4 j: l  r! c
congenital adrenal hyperplasia producing excessive' l- R% J  A, j1 |3 r2 r4 c# l+ z  E
adrenal androgens is a common cause of precocious6 Q9 r, F' x; |, X
puberty in boys.3,4) E1 Y' N7 d- z+ ]. x; Y
The most common form of congenital adrenal) r( N5 q: B" u7 S5 S! F
hyperplasia is the 21-hydroxylase enzyme deficiency.
; f  r* j- I, jThe 11-β hydroxylase deficiency may also result in
9 h0 i  u; |# y  l- R& Z8 lexcessive adrenal androgen production, and rarely,# C8 \1 R* c3 |
an adrenal tumor may also cause adrenal androgen
' [" \( K9 v4 M3 M* i. D) Nexcess.1,3
% C1 W& Y; f% I$ [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 ]$ c4 o/ O9 V* \( g  m8 Z0 f542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ d9 Z9 m. H; I/ ~+ J; s
A unique entity of male-limited gonadotropin-
  E* n8 ^9 k. @( q' C9 Nindependent precocious puberty, which is also known
( {2 O! ^, P9 F: B9 h, K3 k- eas testotoxicosis, may cause precocious puberty at a1 m$ @' r. B+ p1 Z4 _: b
very young age. The physical findings in these boys
. Y- ^! ^, X( hwith this disorder are full pubertal development,
; g# n5 s" Y$ qincluding bilateral testicular growth, similar to boys5 ^; [. V& a: B1 K0 a2 U
with CPP. The gonadotropin levels in this disorder8 s# B; `+ D/ ]1 L* M5 n: {
are suppressed to prepubertal levels and do not show( Y/ f. E7 i1 U$ M" X7 D1 r
pubertal response of gonadotropin after gonadotropin-- C6 v* e2 [1 k3 J
releasing hormone stimulation. This is a sex-linked
0 f' h8 q) m' Xautosomal dominant disorder that affects only, {3 c7 _( }+ j. Q
males; therefore, other male members of the family0 l/ c; n* a6 {/ O
may have similar precocious puberty.3
, P7 S+ q: V8 K- }( \5 N8 eIn our patient, physical examination was incon-
+ c' [5 ?" T. B/ u4 Tsistent with true precocious puberty since his testi-
1 }' @( R8 h, z! V3 @cles were prepubertal in size. However, testotoxicosis
" U3 g' y' Q: Z) J- y! J1 ?was in the differential diagnosis because his father
3 F, ]+ [6 S$ ~; R2 U3 rstarted puberty somewhat early, and occasionally,) c( e! u3 D; b8 T
testicular enlargement is not that evident in the+ r( H5 S  Z* f- \
beginning of this process.1 In the absence of a neg-1 J, m! [/ i% O: f6 }3 i5 d
ative initial history of androgen exposure, our$ `1 m6 e1 |' a
biggest concern was virilizing adrenal hyperplasia,1 @) U) H# I$ P! e( t* L  ^2 P
either 21-hydroxylase deficiency or 11-β hydroxylase6 L- r8 ~+ f$ }
deficiency. Those diagnoses were excluded by find-
1 [( i0 `' \. C6 `0 {9 ying the normal level of adrenal steroids.4 f/ v. j+ P8 [" K
The diagnosis of exogenous androgens was strongly
9 W' D/ ~( V- y# |! ?; Vsuspected in a follow-up visit after 4 months because! E0 e2 h/ g2 x, T' a+ K
the physical examination revealed the complete disap-
2 n4 j, q; R4 ]2 Lpearance of pubic hair, normal growth velocity, and
1 S( N# `4 d% J) g- }* T) p% Wdecreased erections. The father admitted using a testos-; E$ o. N$ z" _1 l5 q
terone gel, which he concealed at first visit. He was+ a) Y6 Q$ O. C7 Q  [+ ?" C
using it rather frequently, twice a day. The Physicians’: o! M. ?. x7 X5 a
Desk Reference, or package insert of this product, gel or
# z9 h9 e# Z; e# Y3 K) z2 Bcream, cautions about dermal testosterone transfer to' Q+ F) E! v6 g- u/ t- g  M( |
unprotected females through direct skin exposure.. l9 E8 Q, U, V5 r. F! F
Serum testosterone level was found to be 2 times the
7 V# W% K; N9 {/ m0 abaseline value in those females who were exposed to6 [6 A1 r4 d8 B1 _3 B$ X
even 15 minutes of direct skin contact with their male
; k$ {6 P+ x0 m1 h4 Upartners.6 However, when a shirt covered the applica-5 r& F7 _) g, Z' f5 Y  Z$ b$ h: w+ F8 S
tion site, this testosterone transfer was prevented.
* }  Q0 Q/ W2 YOur patient’s testosterone level was 60 ng/mL,& _" P$ y9 ?% ^2 y
which was clearly high. Some studies suggest that
) m! ?0 ^; t" [4 l; U4 G8 hdermal conversion of testosterone to dihydrotestos-) B3 r+ `1 W6 g; J
terone, which is a more potent metabolite, is more- I3 }9 F" S& _/ j+ r( q
active in young children exposed to testosterone: w9 B2 j1 j7 I* K$ S) n& s
exogenously7; however, we did not measure a dihy-$ m8 U$ u2 D7 n2 T; B; i
drotestosterone level in our patient. In addition to" l5 {# H4 w! u8 O- O
virilization, exposure to exogenous testosterone in/ t) M: C, O: g& i) C
children results in an increase in growth velocity and! \9 W# D* `0 X9 `2 G
advanced bone age, as seen in our patient.
# k! {5 ~) \) H* A  U/ nThe long-term effect of androgen exposure during) |1 _* K2 ]6 l5 O* R  g4 T; A( ^
early childhood on pubertal development and final
( \9 P2 |( E6 E) vadult height are not fully known and always remain
5 @) u, l$ I, j5 D0 |8 H# W4 Wa concern. Children treated with short-term testos-  k5 c0 w# b# o2 R6 q+ i
terone injection or topical androgen may exhibit some
) R, `* l  T% a& Macceleration of the skeletal maturation; however, after
0 i$ ~# u* r$ _3 p0 p  X7 Tcessation of treatment, the rate of bone maturation
+ k( D. `" ^* Z- I  [# X7 v+ J. rdecelerates and gradually returns to normal.8,93 ]' H+ i+ ^7 E' D: M, C
There are conflicting reports and controversy+ c. ]- o* d3 H) m
over the effect of early androgen exposure on adult% b+ L2 t' ^% x# ~: f5 \1 `0 d
penile length.10,11 Some reports suggest subnormal& i9 q+ |6 q1 z( q8 e2 q; f, J
adult penile length, apparently because of downreg-
  c$ y! o) A# i0 b  b% x. f: Gulation of androgen receptor number.10,12 However,
% l7 @1 C6 r, k. q/ QSutherland et al13 did not find a correlation between
* G' q' z/ x* d& k6 j' hchildhood testosterone exposure and reduced adult
& S/ W* S) a/ S$ p/ ~6 A; Z7 Fpenile length in clinical studies.
% u& M2 q" J: ~2 b. ?Nonetheless, we do not believe our patient is( e6 S9 S! F/ @6 l  M
going to experience any of the untoward effects from
- f, Y4 f5 D, @testosterone exposure as mentioned earlier because
( x4 c* s8 g" u' ~6 Y. O% Othe exposure was not for a prolonged period of time." h* v7 ]" @# N- y$ v# P+ H
Although the bone age was advanced at the time of1 T: X# E3 r& E2 ~( W$ ^9 q
diagnosis, the child had a normal growth velocity at& _, M  O- r3 K% N7 A5 {
the follow-up visit. It is hoped that his final adult
* v" G0 y- t) y' k1 pheight will not be affected.2 E5 v6 J6 U8 i- a0 _
Although rarely reported, the widespread avail-! j4 l1 A7 @7 B
ability of androgen products in our society may: ?' W) t7 G# R; h4 L
indeed cause more virilization in male or female3 u  v8 _. P: g3 X8 a& ]! K
children than one would realize. Exposure to andro-$ @) t' M* T) o
gen products must be considered and specific ques-8 w6 h' K) J% X( c4 E5 P& s# m, R! D
tioning about the use of a testosterone product or* F: r: Y2 @% ^% v8 G. {1 l8 v
gel should be asked of the family members during! h' Q! U" j! F1 X
the evaluation of any children who present with vir-
1 }4 u- v  A: X) l* G( w& u3 \' F2 y* Jilization or peripheral precocious puberty. The diag-
$ I9 c( p* G. c! L+ jnosis can be established by just a few tests and by/ O3 n! e# r9 O$ d3 h% N. q  I8 f, @
appropriate history. The inability to obtain such a% T" V5 M6 `; ]7 [% _* J6 C' k. I
history, or failure to ask the specific questions, may8 g2 F4 C0 K7 V! W* j: H/ R+ F( h
result in extensive, unnecessary, and expensive
$ ]  }1 C& f- Dinvestigation. The primary care physician should be, A2 a( y. f' {) S# _
aware of this fact, because most of these children4 k2 ]# i5 ]5 v6 o+ b
may initially present in their practice. The Physicians’: j. D( {8 a4 ~9 w5 j9 Z
Desk Reference and package insert should also put a
* i# Z3 E( Z  }warning about the virilizing effect on a male or
3 G; Y5 T3 l& M! p5 A0 G* W9 wfemale child who might come in contact with some-
& Z; E; D, ?$ f+ b+ done using any of these products.
# b9 V+ W* n, V+ tReferences; L# F1 \% f0 _9 E3 j
1. Styne DM. The testes: disorder of sexual differentiation
- D6 _2 N5 U  O  uand puberty in the male. In: Sperling MA, ed. Pediatric
& A0 u! B% d& v/ bEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% k5 \0 H' @" w: ~9 [2002: 565-628.% e8 K2 H4 ]$ M6 i; m& G) Z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ {$ k8 |. r! x1 j) [8 S' Fpuberty in children with tumours of the suprasellar pineal
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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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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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