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Sexual Precocity in a 16-Month-Old
" Z( }. c# _* C; i! kBoy Induced by Indirect Topical
0 O- `7 n, P) C6 zExposure to Testosterone
$ k. N- O8 E  \* G; XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 K  U; m; d8 c5 {2 {$ ]and Kenneth R. Rettig, MD19 N0 x# y/ x: _: R2 N- S7 R5 E8 @
Clinical Pediatrics3 c9 ?  B, b/ w! [) t4 e4 Y
Volume 46 Number 6% a* q( |  _% n2 D6 {. K  J
July 2007 540-543
# d8 x) v" F. j6 f7 p; N© 2007 Sage Publications( a/ @2 d  @& E' I4 `
10.1177/00099228062966519 V% x: s- @) H/ }" {
http://clp.sagepub.com. m- k% Y4 t  Y# W1 Q; j0 A' h& O
hosted at
! }7 r6 O& Z' h6 ahttp://online.sagepub.com
, u0 M( Y4 O1 d5 @+ _+ JPrecocious puberty in boys, central or peripheral,8 v! |; C" E( C$ u$ c
is a significant concern for physicians. Central& R; a2 u3 a+ T6 J) j9 D
precocious puberty (CPP), which is mediated
2 l6 T( A/ h3 r5 Z9 ?through the hypothalamic pituitary gonadal axis, has& f+ w! b  S- `5 P* |  D: t' [9 [
a higher incidence of organic central nervous system) G& y& e& x" H/ q3 g! w" ?
lesions in boys.1,2 Virilization in boys, as manifested
. l+ C3 E  j  ^8 B( ~by enlargement of the penis, development of pubic+ }3 b. }- V% r: J) e
hair, and facial acne without enlargement of testi-* Z' U1 ^. N! ]/ r& Z! `/ y5 h
cles, suggests peripheral or pseudopuberty.1-3 We; G- n/ I  @( p, ?
report a 16-month-old boy who presented with the3 X+ \" i1 R) I: D: ?
enlargement of the phallus and pubic hair develop-% ]0 x+ I' V$ i3 X
ment without testicular enlargement, which was due- `9 R5 P2 C6 y8 z* y$ ]
to the unintentional exposure to androgen gel used by) [/ h% K, I" U6 o9 D
the father. The family initially concealed this infor-
' o* Z9 S( o  h, Q8 kmation, resulting in an extensive work-up for this
  }* o+ g; n/ T1 p6 W9 _; [( zchild. Given the widespread and easy availability of
& z& I; V+ N4 I. ]: |testosterone gel and cream, we believe this is proba-+ d& n: V2 g9 f9 ~6 K  t/ I! h
bly more common than the rare case report in the( C: P, q5 B+ z% |# z
literature.4
3 n' ], d7 Y+ X$ Z% [% t* f' gPatient Report/ W& a' R" \% D, S8 h
A 16-month-old white child was referred to the
5 N& g; D0 Q9 H4 P9 q3 Fendocrine clinic by his pediatrician with the concern
( @! y. \: ?/ l  {' Oof early sexual development. His mother noticed
: Y. z  ~) \0 l& T! Z8 [light colored pubic hair development when he was
! `- F% w* e0 l" Q" e* QFrom the 1Division of Pediatric Endocrinology, 2University of
) {4 B+ _% e: O" {South Alabama Medical Center, Mobile, Alabama.
2 T: N( X! S/ ^- zAddress correspondence to: Samar K. Bhowmick, MD, FACE,4 c. i2 X, G8 t
Professor of Pediatrics, University of South Alabama, College of
1 }1 l' v' Y; r) \+ _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; `0 R0 q) j  s- F5 {% z9 x' re-mail: [email protected].
% E/ }9 D0 ]# ]1 d5 sabout 6 to 7 months old, which progressively became+ [' H2 Z& d  g  a
darker. She was also concerned about the enlarge-! x1 X1 U/ x% P, R- G  S
ment of his penis and frequent erections. The child+ M" S( r* L" I7 s; ?; F/ N& q
was the product of a full-term normal delivery, with) R% [1 X: O$ r/ _! {8 q
a birth weight of 7 lb 14 oz, and birth length of
3 V9 M! F0 \) K20 inches. He was breast-fed throughout the first year
+ L) N: b; F- O4 e/ x+ G- eof life and was still receiving breast milk along with: `0 r+ p7 L: t' q+ V- A
solid food. He had no hospitalizations or surgery,8 {7 k3 l! ?: E: |, ^
and his psychosocial and psychomotor development
$ \5 i$ U3 ]6 H" {$ z5 hwas age appropriate.- ^- g. q# P4 H# y+ H- j  `  [
The family history was remarkable for the father,
. q9 A" }. a* A4 k! U/ m+ ?! F/ W" t6 Lwho was diagnosed with hypothyroidism at age 16,
8 M7 C2 P- N, s3 y) Nwhich was treated with thyroxine. The father’s
% `  l. W4 D. V. B! w% l6 [height was 6 feet, and he went through a somewhat- u6 O! L- ~* `0 U9 ^3 H! u
early puberty and had stopped growing by age 14.1 l+ E/ Q& m5 w! g: ^# D# w. a( m/ c
The father denied taking any other medication. The
6 n6 K* V6 ^! _. `3 C0 bchild’s mother was in good health. Her menarche) g$ P' F0 C2 T/ d- m" F: a, g% s
was at 11 years of age, and her height was at 5 feet% }- _' V9 R3 {5 ?
5 inches. There was no other family history of pre-0 |; a6 `( \( {6 }
cocious sexual development in the first-degree rela-. J0 G% E* X& n) |
tives. There were no siblings.+ y  M9 W. _' v- \& ^
Physical Examination0 L0 }+ v. {1 }0 W8 q8 P" D- p
The physical examination revealed a very active,* k4 D+ e0 ?2 q) }7 u5 A& j
playful, and healthy boy. The vital signs documented
7 \% y7 e6 p$ y6 T2 b% T' n) Xa blood pressure of 85/50 mm Hg, his length was/ D+ K4 d- d$ `
90 cm (>97th percentile), and his weight was 14.4 kg
: n6 q) y1 @: w" A* [; g(also >97th percentile). The observed yearly growth& b' B' e# e7 I8 ~% j: w8 |& E
velocity was 30 cm (12 inches). The examination of
& {8 }$ G) T; S! j/ ?! O+ K% Athe neck revealed no thyroid enlargement.
( j+ m& E5 M8 V- N! `# k! gThe genitourinary examination was remarkable for
$ n2 z& j0 z# v; Denlargement of the penis, with a stretched length of, S# z/ u% u* X, e$ V1 a
8 cm and a width of 2 cm. The glans penis was very well4 z& l4 d4 Z6 y/ W
developed. The pubic hair was Tanner II, mostly around
2 E" T$ x: d# F" |$ x$ |( E: \540# X4 Q# S" ~) n4 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 S* l  k9 Q# p2 {) O4 L% k) b7 {% m# g
the base of the phallus and was dark and curled. The3 F* e5 F, F" N- ^) f
testicular volume was prepubertal at 2 mL each.
& J2 g! G: [; \, x9 }5 uThe skin was moist and smooth and somewhat
2 `9 F1 d1 O6 Z" ~* e1 {3 s' `oily. No axillary hair was noted. There were no2 O/ a: ~* b/ i: c. W
abnormal skin pigmentations or café-au-lait spots.
3 u* n9 U. X8 S( NNeurologic evaluation showed deep tendon reflex 2+5 u$ _7 T, e, J2 X0 j7 O
bilateral and symmetrical. There was no suggestion
1 B" ]* J; U; {) k' v. Kof papilledema.
! P7 @" Y; g6 j2 n/ I( [Laboratory Evaluation
$ P! v$ Q6 w% S+ S& v4 xThe bone age was consistent with 28 months by
, M* J; I" T0 `+ G, ausing the standard of Greulich and Pyle at a chrono-- ^3 {6 t6 h8 b+ L
logic age of 16 months (advanced).5 Chromosomal+ H- K* g0 l+ |2 @
karyotype was 46XY. The thyroid function test+ m- z& i% c% A8 w7 p' g! g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( g/ i: O( e0 ^lating hormone level was 1.3 µIU/mL (both normal).& r% W; W3 l0 o0 l* ~4 Y3 d6 b
The concentrations of serum electrolytes, blood
' [. f! I+ a" t) uurea nitrogen, creatinine, and calcium all were* e& Y" P* A; L0 n0 d$ t( n
within normal range for his age. The concentration, F+ r4 V+ s6 B; r  e2 j
of serum 17-hydroxyprogesterone was 16 ng/dL
% k" Y: E" Q9 t/ b$ l(normal, 3 to 90 ng/dL), androstenedione was 20
1 h4 S5 U; f& z4 M3 M$ _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: j0 R/ K8 e+ eterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 s3 @! }. g+ h$ ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 A0 l) J: x2 ^; ~: r49ng/dL), 11-desoxycortisol (specific compound S); ^1 }- G) Z6 z* d1 o4 r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 {& B2 U" \& E  l9 @$ l9 j: Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ G3 [- Q1 g% n& g: [testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 F- h/ A1 d) {7 [1 ^2 H
and β-human chorionic gonadotropin was less than
  v# {) i9 {6 Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
) S0 r* m( k5 O+ M* r! Z) b% ]7 j/ @  sstimulating hormone and leuteinizing hormone5 l1 S1 }; p6 p$ L
concentrations were less than 0.05 mIU/mL
5 g& n" n3 \2 P0 r5 F( D1 U- c(prepubertal).
! N$ O+ _. F6 EThe parents were notified about the laboratory! t1 x( R- v' Z7 M, T$ ]+ v
results and were informed that all of the tests were
) ~; w6 }* y0 ?; H2 {4 I" F) }* Hnormal except the testosterone level was high. The
4 D/ ^4 g" P$ k) c; n" `follow-up visit was arranged within a few weeks to
7 x8 Y: E) G+ Q) E$ U8 yobtain testicular and abdominal sonograms; how-
, i/ _; P+ |2 j( }7 f( Z6 @ever, the family did not return for 4 months.
, B( z5 B+ I& k# U7 ~8 q- {Physical examination at this time revealed that the
- Y3 ]  n1 K# |1 ]6 m# f7 Gchild had grown 2.5 cm in 4 months and had gained
5 f7 G/ A. V" r' e( Y% c0 O2 kg of weight. Physical examination remained4 \7 N3 z2 a4 q
unchanged. Surprisingly, the pubic hair almost com-
* K0 h8 A7 n& n6 |pletely disappeared except for a few vellous hairs at
+ T- v4 H( X- A& Lthe base of the phallus. Testicular volume was still 25 ~/ N) [2 {7 M$ B1 i* U$ K$ w5 S
mL, and the size of the penis remained unchanged.
9 B# U1 L2 r9 sThe mother also said that the boy was no longer hav-
( c- O" I. Z4 @; k- w" q! Ving frequent erections.
' G9 \# f, _9 ^4 ]Both parents were again questioned about use of
, y# ?+ c4 l' e; }* [, q3 H) R2 wany ointment/creams that they may have applied to% V+ U/ x* {4 o6 ^# J2 U' d/ p
the child’s skin. This time the father admitted the5 i. s+ `9 N: P+ V' l
Topical Testosterone Exposure / Bhowmick et al 541* K. X4 A8 R* M) O
use of testosterone gel twice daily that he was apply-
; {4 p/ [( k# d" h& A7 {) n3 ring over his own shoulders, chest, and back area for
$ j" `4 a' }# g- N1 [# ]a year. The father also revealed he was embarrassed
7 ?3 b: n& `* i4 Jto disclose that he was using a testosterone gel pre-
6 X5 ]3 K) p7 s( i/ rscribed by his family physician for decreased libido
: L# _6 t6 h1 q; B, [( w* Asecondary to depression.. `1 q6 ]1 Z5 m! x0 K! J) G' ^
The child slept in the same bed with parents.
' F3 ]: z  L+ H8 M0 rThe father would hug the baby and hold him on his
8 w. A" q2 |9 h6 ]chest for a considerable period of time, causing sig-$ j0 O( v) J0 o: ^, a
nificant bare skin contact between baby and father.
  P9 _' S6 @9 T( R# y1 UThe father also admitted that after the phone call,- B- z8 O+ {% G  y6 T
when he learned the testosterone level in the baby
# G+ F; z" t  m; w9 J4 kwas high, he then read the product information
- I, t, k& o$ N  O  U7 _) m: fpacket and concluded that it was most likely the rea-
6 r1 H- `+ r% l2 l+ ?son for the child’s virilization. At that time, they
- J' z3 B/ v- \, c2 d) `- |  ]& Edecided to put the baby in a separate bed, and the  u- i, I* {5 G1 @4 x* h- a
father was not hugging him with bare skin and had
% N; g$ A5 m: W. k2 t: D6 y6 _been using protective clothing. A repeat testosterone
+ o+ b9 ~. y1 ]test was ordered, but the family did not go to the
: @' b* z/ s$ Y, m: l% P( |laboratory to obtain the test.; F( T; z, r  k1 j, G& z/ d  F; ]
Discussion
8 n6 D+ N9 i* [( z! LPrecocious puberty in boys is defined as secondary
$ j3 G' x- F( A5 _" l( zsexual development before 9 years of age.1,4  p9 D8 `1 X& Y4 e' Q8 u
Precocious puberty is termed as central (true) when
7 p: ~0 y; f# M$ K$ d; S& D0 U0 Iit is caused by the premature activation of hypo-5 ], |& Q! b4 _
thalamic pituitary gonadal axis. CPP is more com-
1 s) @. c, \/ T, Ymon in girls than in boys.1,3 Most boys with CPP
: |! p( K- n/ M! U! Vmay have a central nervous system lesion that is
$ ^' u) @7 g( U" q/ |4 \4 l. [responsible for the early activation of the hypothal-  k& x: R, v- p* l, Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
; O' L9 m3 ^2 G+ fsis has been given to neuroradiologic imaging in
+ n0 v* y3 f0 \9 Rboys with precocious puberty. In addition to viril-4 I( n0 O# z2 ~4 ~% G
ization, the clinical hallmark of CPP is the symmet-
9 e) x* e! I. f2 c7 i9 ^- Nrical testicular growth secondary to stimulation by
% e6 a2 M# @8 Y7 s$ {( e4 H2 Qgonadotropins.1,39 m( A. S) R  J) }  ]
Gonadotropin-independent peripheral preco-6 F8 Q# t, O/ {" t- l
cious puberty in boys also results from inappropriate+ N. S+ S' W0 S, i
androgenic stimulation from either endogenous or; O7 o& Q2 U5 }0 }. h6 s
exogenous sources, nonpituitary gonadotropin stim-3 e& V1 a3 ^! O% M" s
ulation, and rare activating mutations.3 Virilizing
# }) v* Y7 ]! y9 ~- Wcongenital adrenal hyperplasia producing excessive
! M4 }) B0 z* Yadrenal androgens is a common cause of precocious
1 R1 Z, C9 T% Q* z2 w% Fpuberty in boys.3,4
# V) @: r# l5 n' x1 h/ eThe most common form of congenital adrenal9 a: q7 w* \( h& ?8 H
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ E& N1 |9 D# ?3 Q4 [The 11-β hydroxylase deficiency may also result in! N3 z, c, H" a0 ^, v% \3 i
excessive adrenal androgen production, and rarely,( v  v6 ^; a2 |) r; E8 e) [
an adrenal tumor may also cause adrenal androgen
* h- a1 L  d" ^, Yexcess.1,3
/ C. B. |9 I2 D% Y, {2 j# `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; T, |6 _3 U! H0 q3 b
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& W& i+ H$ P7 k$ O+ bA unique entity of male-limited gonadotropin-
0 i) E! g+ F$ |9 X+ z/ \independent precocious puberty, which is also known- r5 E3 m9 ~* ]
as testotoxicosis, may cause precocious puberty at a
; j2 W% d" j3 y: p1 R% n! Ivery young age. The physical findings in these boys
/ q4 I  z' [& |with this disorder are full pubertal development,
5 n; F1 z: X3 aincluding bilateral testicular growth, similar to boys
1 a4 }1 O, t/ ]6 H3 j& Z/ |$ Bwith CPP. The gonadotropin levels in this disorder6 x* A; P: h$ G8 @5 ^
are suppressed to prepubertal levels and do not show& z: p/ g3 V) x3 f; V! ]' x
pubertal response of gonadotropin after gonadotropin-1 r, c/ u- x& [$ z8 X6 I
releasing hormone stimulation. This is a sex-linked
$ Q# e- o& H. f/ sautosomal dominant disorder that affects only
2 N$ O4 f2 n. `/ r" Xmales; therefore, other male members of the family& e% v$ n9 O/ J; A
may have similar precocious puberty.31 ?; M8 X2 |9 V& h
In our patient, physical examination was incon-9 W! B- U: f4 f. s
sistent with true precocious puberty since his testi-7 g' E; _8 P8 }2 \1 U* J' {! g3 ~6 U
cles were prepubertal in size. However, testotoxicosis! }2 m- G3 n2 ]4 v' D3 o
was in the differential diagnosis because his father3 a5 [! R4 f& `. `+ b) ?
started puberty somewhat early, and occasionally,7 t$ ^) g0 o1 y# G; I
testicular enlargement is not that evident in the3 h9 J/ k* I) j3 T
beginning of this process.1 In the absence of a neg-/ _; U0 h- S/ ?2 ~& g
ative initial history of androgen exposure, our
( I" D) Y6 M. X0 {: Ibiggest concern was virilizing adrenal hyperplasia,0 y' w5 S; b! o6 D5 J2 g  x
either 21-hydroxylase deficiency or 11-β hydroxylase! y8 G. T, Q9 f  c1 t
deficiency. Those diagnoses were excluded by find-
+ d6 I3 x7 G7 v" ?2 Uing the normal level of adrenal steroids.
% s2 A9 t& Y1 I; l/ IThe diagnosis of exogenous androgens was strongly
# d7 T8 i5 }8 `9 W3 S9 L' S# s( dsuspected in a follow-up visit after 4 months because* x: @. q" S7 D+ l0 p4 h
the physical examination revealed the complete disap-
2 }2 l& j( c+ B- c! \pearance of pubic hair, normal growth velocity, and9 H: Y3 L; z6 C7 F6 D% |
decreased erections. The father admitted using a testos-
. F2 [6 e6 A) ^9 S& kterone gel, which he concealed at first visit. He was
* G' g/ \+ }( s: Vusing it rather frequently, twice a day. The Physicians’
# E' H2 J% n$ P" pDesk Reference, or package insert of this product, gel or
0 p/ G" Y+ z  _! e% Lcream, cautions about dermal testosterone transfer to. S: y2 |2 q% J8 ~3 W- A7 S- x
unprotected females through direct skin exposure.
' h- g) y7 J! y4 H! |6 CSerum testosterone level was found to be 2 times the( }4 y) V% z( N" c
baseline value in those females who were exposed to. _  v- B9 |8 s8 S$ U
even 15 minutes of direct skin contact with their male
7 u, p8 i: H; F" U8 y- Qpartners.6 However, when a shirt covered the applica-
1 Q( a! u# l! O0 y7 m8 M5 |tion site, this testosterone transfer was prevented., w; k( H. }$ L( Q$ \, j0 R# R: M
Our patient’s testosterone level was 60 ng/mL,# n" E& r' ]+ K" a$ h* `
which was clearly high. Some studies suggest that
4 L8 J5 k( x( M8 d6 O* s4 Ydermal conversion of testosterone to dihydrotestos-; \) L3 r" f6 J' @2 s) B4 a4 c
terone, which is a more potent metabolite, is more; O+ K/ K( ^# w' Y4 F7 s7 S
active in young children exposed to testosterone" h7 r5 [( o! N! C
exogenously7; however, we did not measure a dihy-
( q8 Q( w3 B' h8 N( m) ^drotestosterone level in our patient. In addition to: Y# W: a  _2 A$ S  I1 w
virilization, exposure to exogenous testosterone in3 N$ G6 G4 g! N. a/ ~! y2 J
children results in an increase in growth velocity and
7 M6 ~/ E  x* M+ j; Fadvanced bone age, as seen in our patient.
2 X: _: K9 P4 `The long-term effect of androgen exposure during# B# H6 G( L3 n
early childhood on pubertal development and final+ s+ v& ~8 T4 H$ u! I- X; W% M
adult height are not fully known and always remain7 L3 x( m% _; `" l' H
a concern. Children treated with short-term testos-
# D) c  h) z7 `' T# j) s6 C1 ^terone injection or topical androgen may exhibit some
, C4 ^( H  _. I  Z" u# u' b( F- hacceleration of the skeletal maturation; however, after
1 K6 k' M$ j/ G$ d! m1 Z" bcessation of treatment, the rate of bone maturation9 q0 Y+ H6 Z% s' G
decelerates and gradually returns to normal.8,9
9 l  Y9 f  A( ~2 G8 d6 LThere are conflicting reports and controversy& A8 @3 O- b0 n& u6 n8 j
over the effect of early androgen exposure on adult
6 u* S4 \! i( p/ Apenile length.10,11 Some reports suggest subnormal
; ~3 r+ c2 \% \: p0 W4 oadult penile length, apparently because of downreg-5 M5 W3 w( ?. r( u( U! f
ulation of androgen receptor number.10,12 However,
' l; h3 u9 C. @" ^5 gSutherland et al13 did not find a correlation between' U* ]1 F( H6 ~9 |% T
childhood testosterone exposure and reduced adult
% D* a; K* q& C4 k  z: T; Rpenile length in clinical studies.
- X' N% K- z: S  _Nonetheless, we do not believe our patient is
' \8 a4 c4 Z+ Y# j" v$ D3 ?* fgoing to experience any of the untoward effects from
) D* W& C- C+ q7 r6 V8 Jtestosterone exposure as mentioned earlier because  G* K8 U  a" z7 L' Y; L
the exposure was not for a prolonged period of time.
9 N1 j' Q; D1 |8 h- U, O# CAlthough the bone age was advanced at the time of
1 l2 E8 W* B4 {. \9 k  W0 ?diagnosis, the child had a normal growth velocity at9 R% y( E1 Y( `( R' E9 k$ x7 ?
the follow-up visit. It is hoped that his final adult
1 V) X% A: P1 d& Theight will not be affected.( G4 V3 C! Z3 q4 f2 W' v3 r
Although rarely reported, the widespread avail-
  ?) ^( z1 F( ?  @; hability of androgen products in our society may
* ]3 b6 C& b5 Y& A, R/ v( oindeed cause more virilization in male or female2 }; e9 @" f  [7 i' K* `
children than one would realize. Exposure to andro-
7 G$ ]7 C1 ^8 H1 h/ R; ?9 a( ?gen products must be considered and specific ques-
$ O# T- m% y) e1 H! gtioning about the use of a testosterone product or
) M/ V+ L4 \: O: W: n$ Ngel should be asked of the family members during
) r9 H: r9 o5 u- athe evaluation of any children who present with vir-" a# O2 t3 l9 C  X
ilization or peripheral precocious puberty. The diag-
9 D# Q; V+ S9 ?nosis can be established by just a few tests and by
1 M$ z, V, S* W* }7 S3 O* {! c4 eappropriate history. The inability to obtain such a
# h5 b5 m, T- x1 T& Z+ n. B2 f+ Khistory, or failure to ask the specific questions, may$ t/ \! T- n! ~3 P, E  I
result in extensive, unnecessary, and expensive
3 u) W! g$ u, ~6 F. Winvestigation. The primary care physician should be
! `  y+ `4 O( D  K6 R& raware of this fact, because most of these children
' {" o. b% j* J* Q6 o2 tmay initially present in their practice. The Physicians’
, J- e: j0 b: [/ w* ?& XDesk Reference and package insert should also put a% l7 f- h: W& h
warning about the virilizing effect on a male or
8 n! n2 v7 u# t6 ?5 }female child who might come in contact with some-
9 `0 t/ U8 v. {! Tone using any of these products., T/ c7 h, V" J
References
/ X$ b3 I, t7 w' V  L# p1. Styne DM. The testes: disorder of sexual differentiation
3 N% K1 ^# j) ^and puberty in the male. In: Sperling MA, ed. Pediatric
4 q3 a  M* b: w! qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ N) g' V$ E) N% J
2002: 565-628.
/ `2 f3 n7 l$ e" G0 F$ V  ~2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 a. W1 u# y3 m# Rpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" l4 E3 F* s2 w" O; E4 b: _Boy Induced by Indirect Topical2 x& f: v5 a- p3 ?3 Z
Exposure to Testosterone
: Z, s- i, n5 W+ E; S5 pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: h+ W, O" P' ~  d& R+ \and Kenneth R. Rettig, MD1% s6 w& V; t, x" X  D  [5 q
Clinical Pediatrics
& n& N* R# \8 z' b2 G2 ^Volume 46 Number 6; V; X+ v1 S) @0 H' H3 g
July 2007 540-5434 z( ^4 \3 m: {. V0 }, n3 o
© 2007 Sage Publications" K$ Z0 A/ B/ ]. B+ t0 _2 t/ F/ Q% @2 @
10.1177/00099228062966513 ~& @& K* o+ e# f* x
http://clp.sagepub.com5 Y+ N& X+ d. e8 g: j4 [
hosted at
5 q2 }) i- C' g# C. s, P+ ohttp://online.sagepub.com& x$ J, P" M9 G7 V  I
Precocious puberty in boys, central or peripheral,& H/ |( r3 a1 n$ G
is a significant concern for physicians. Central( H" M9 ~: b1 f5 ^2 p4 `
precocious puberty (CPP), which is mediated# K5 ?7 [  k- P- w' E
through the hypothalamic pituitary gonadal axis, has
! {, {& t8 X9 T! [2 v+ Ra higher incidence of organic central nervous system9 z2 C- Q2 A$ x& N" d0 q2 q
lesions in boys.1,2 Virilization in boys, as manifested' d( A& K! [* i9 V, A
by enlargement of the penis, development of pubic5 f/ R/ a; E* ~! q/ S# p3 u) E5 F, G  J
hair, and facial acne without enlargement of testi-% d* U4 g/ }% t4 \! f! ^4 I2 O
cles, suggests peripheral or pseudopuberty.1-3 We
/ j# N# X' B) Mreport a 16-month-old boy who presented with the3 j  I0 g0 b# c% d/ B
enlargement of the phallus and pubic hair develop-. k5 y0 p; M  `5 W1 L
ment without testicular enlargement, which was due, [/ H4 e) z7 A  C% _& Z$ m
to the unintentional exposure to androgen gel used by- P: c( g  \4 T( M6 ^) Z0 {
the father. The family initially concealed this infor-
9 ]! ?/ q' X6 U$ d$ r. Pmation, resulting in an extensive work-up for this! d  `; b& v% q8 h, h
child. Given the widespread and easy availability of
0 y8 C) e5 u. w2 l; ~2 |testosterone gel and cream, we believe this is proba-
; B8 {+ w" k1 l2 c; v& dbly more common than the rare case report in the' {; w$ [* E. O3 n- q& u4 S; o
literature.4
8 R" K5 v8 k$ iPatient Report% f  ^' @8 o: B+ y' Y/ o4 U+ d
A 16-month-old white child was referred to the% h7 e0 ^- I: c" E
endocrine clinic by his pediatrician with the concern
9 [# W! u# Y. j3 _of early sexual development. His mother noticed) t0 l: G, O1 g1 a5 M/ b
light colored pubic hair development when he was9 T0 g8 P' O, N( W* r" \, Z
From the 1Division of Pediatric Endocrinology, 2University of- g- c+ r! {& A; ~0 N0 Q+ l
South Alabama Medical Center, Mobile, Alabama.
1 P% G# G2 m0 F6 HAddress correspondence to: Samar K. Bhowmick, MD, FACE,
* R" v. g, A; }. e# k* }% U" JProfessor of Pediatrics, University of South Alabama, College of/ e8 Y+ i8 |0 \- b; u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- d) S  M1 K6 Xe-mail: [email protected].2 d/ [% a* `6 l+ K5 }% K
about 6 to 7 months old, which progressively became
) ]. M  U+ u3 Hdarker. She was also concerned about the enlarge-! K' i0 t" a0 g' K
ment of his penis and frequent erections. The child+ d- \' O$ i& W9 P3 b  e, C
was the product of a full-term normal delivery, with! L6 e. _8 x" z( @! J; u8 M# n0 E, q
a birth weight of 7 lb 14 oz, and birth length of
$ J1 v% |( j: \0 w+ [20 inches. He was breast-fed throughout the first year0 M! Y- _9 m$ ~
of life and was still receiving breast milk along with
4 s; r) }  ^1 Ksolid food. He had no hospitalizations or surgery,2 ^, ~, y  c8 Y+ r5 i' l
and his psychosocial and psychomotor development
0 u3 J8 U; G* V9 f* G* R+ ?5 bwas age appropriate.6 |% K* h3 ~) A4 T% R3 a( b
The family history was remarkable for the father,
+ F& R7 b: b5 ^% s% ?1 k* N. Awho was diagnosed with hypothyroidism at age 16,, }( f9 ?1 Q& [+ Y% D+ p( }
which was treated with thyroxine. The father’s
5 `2 ~/ j, r+ R- R+ ?- p0 Hheight was 6 feet, and he went through a somewhat* W3 b0 p( H7 x. @- g
early puberty and had stopped growing by age 14.. B& R3 e! l: a; y4 A
The father denied taking any other medication. The
3 ?* k4 M8 `5 ~" H( Mchild’s mother was in good health. Her menarche1 j# p: x; _- r, m
was at 11 years of age, and her height was at 5 feet
, _$ R/ e) M# r5 s8 p0 L8 o5 E2 L5 inches. There was no other family history of pre-1 h* N, D- d, n# T% N& }& M
cocious sexual development in the first-degree rela-. P% O+ Y6 t/ l
tives. There were no siblings.4 W" U. S/ f5 G
Physical Examination  j4 i( N9 ~8 C% k5 P, o( c3 _. I
The physical examination revealed a very active,
, M) P( Y9 i; `, I; u) yplayful, and healthy boy. The vital signs documented3 `2 q  e/ ^, Z4 v! ?
a blood pressure of 85/50 mm Hg, his length was# {$ \: W0 C4 H
90 cm (>97th percentile), and his weight was 14.4 kg( c- `+ y. Y# c1 E8 j  ?$ x
(also >97th percentile). The observed yearly growth: L! G- g: \+ o# k: }  ?
velocity was 30 cm (12 inches). The examination of
% B3 i7 G. r1 {4 ^0 mthe neck revealed no thyroid enlargement.
/ M& q. J8 z  ~! v  eThe genitourinary examination was remarkable for0 Q' @1 C8 I7 l3 l7 O5 F9 B5 q
enlargement of the penis, with a stretched length of/ j0 w" h% g% c% B: _$ F- \
8 cm and a width of 2 cm. The glans penis was very well7 M, |2 X" Q3 L
developed. The pubic hair was Tanner II, mostly around
. F, q  ^( W: C6 U! I! W) ^8 c5409 _! c4 K0 _3 @# S5 d5 @- X8 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: Z! W# j6 c  h9 t3 |0 d/ D) a0 xthe base of the phallus and was dark and curled. The* j2 @  n/ v4 [- u$ _5 {" U
testicular volume was prepubertal at 2 mL each.
! e0 W! H0 X0 \9 R) h1 vThe skin was moist and smooth and somewhat
6 o/ A+ V. |. A! X$ Poily. No axillary hair was noted. There were no
% E" X/ ^3 J1 x  ]7 V! [9 zabnormal skin pigmentations or café-au-lait spots.
- e& W! A4 v7 e* v- xNeurologic evaluation showed deep tendon reflex 2+
- }6 h  b* `: b! Hbilateral and symmetrical. There was no suggestion
$ {8 S& u( E1 i& I: tof papilledema.
& ?! x  |) z* b3 _5 F" O$ XLaboratory Evaluation
- i- T5 t6 a* n' W+ K1 y' }- r- fThe bone age was consistent with 28 months by2 D+ [; A/ O, B
using the standard of Greulich and Pyle at a chrono-' p) _% e( t  r0 V4 g
logic age of 16 months (advanced).5 Chromosomal
; u4 |0 s" [1 Q$ u6 R6 Skaryotype was 46XY. The thyroid function test. ?; i# J$ C; U5 G' B, i/ C
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 E& f) L/ [. _9 Z2 ]* }0 W
lating hormone level was 1.3 µIU/mL (both normal).
2 |+ t4 v" s$ [* i" \' YThe concentrations of serum electrolytes, blood
* @$ _; o' Y! ^4 Purea nitrogen, creatinine, and calcium all were  u, s9 H1 q  u; L
within normal range for his age. The concentration1 X& n( n1 b' n
of serum 17-hydroxyprogesterone was 16 ng/dL
/ C" n' K. j6 b; @( |+ M! Q(normal, 3 to 90 ng/dL), androstenedione was 20
# s$ M0 ~. p3 W8 r. |2 }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ J9 Z( q6 u( S  E2 k$ c4 k# [
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ U6 z5 I- |7 r- x  i" f; Ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to/ w2 }/ _$ N% ?
49ng/dL), 11-desoxycortisol (specific compound S)+ V: a# C2 J+ P" b7 M/ e5 N( \
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 t4 }, ^5 s# f* \0 p
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 G; _2 l. @# j# a; M& F; [3 S0 N3 ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 x4 U9 x2 N) u& i% E2 p1 eand β-human chorionic gonadotropin was less than
& m/ I0 L5 n. R5 mIU/mL (normal <5 mIU/mL). Serum follicular5 |+ g! ~: p2 H9 T5 f
stimulating hormone and leuteinizing hormone& t3 X3 ~, M7 A  \
concentrations were less than 0.05 mIU/mL
( R  ^2 s* B* O(prepubertal).
( Z7 i6 g- D, ~  l, ?The parents were notified about the laboratory
# \8 R; L7 A8 f, L9 xresults and were informed that all of the tests were
8 X* W' T- w" F7 Pnormal except the testosterone level was high. The5 O* h- P/ P. {  T9 I
follow-up visit was arranged within a few weeks to
8 r  q6 s' g. l! ?6 z) w; o& tobtain testicular and abdominal sonograms; how-& M3 \# N& p1 M0 l) l
ever, the family did not return for 4 months.0 @) F# u% ]- @& y$ v' U+ V, x
Physical examination at this time revealed that the
+ f5 Q: t; s7 }# achild had grown 2.5 cm in 4 months and had gained
0 I$ l; J: Y* V( D* A6 |: A- u) x2 kg of weight. Physical examination remained3 i* X: {! t% c& ^: k
unchanged. Surprisingly, the pubic hair almost com-
6 @4 a% b! [- F! Zpletely disappeared except for a few vellous hairs at
/ l0 y  K& T1 W* ethe base of the phallus. Testicular volume was still 2
% c0 k' I+ ?; ImL, and the size of the penis remained unchanged.
* M# K, f! @! |, z/ v& U* h2 RThe mother also said that the boy was no longer hav-4 V9 M; q) V9 T' b7 |
ing frequent erections.
; c; D6 b  r/ D0 y& H2 k( ZBoth parents were again questioned about use of$ V0 O9 k+ ]4 ^5 p! H
any ointment/creams that they may have applied to/ F; V! [6 L' n. ^' P
the child’s skin. This time the father admitted the. v9 e1 G/ S- n% b
Topical Testosterone Exposure / Bhowmick et al 541
! }7 M  P/ P9 d. R: K2 J3 Ruse of testosterone gel twice daily that he was apply-
" r! B3 F' q6 @8 H! king over his own shoulders, chest, and back area for
2 ?$ P- m, ^3 o2 va year. The father also revealed he was embarrassed6 U5 M- g* I) ~
to disclose that he was using a testosterone gel pre-# @$ x4 |5 c& N# u% K
scribed by his family physician for decreased libido
" w9 t5 p7 |3 b2 q: h4 k2 c9 _secondary to depression.' _% k: D8 a1 ]: o0 R, q
The child slept in the same bed with parents.6 b/ ]0 l) ^6 l# k. @8 b
The father would hug the baby and hold him on his
. m3 Q  o, T) kchest for a considerable period of time, causing sig-6 C7 U6 ^8 i( f5 U( A0 I
nificant bare skin contact between baby and father.% T3 j9 J+ C+ Q
The father also admitted that after the phone call,
  R1 X2 C$ j4 ^4 m( Pwhen he learned the testosterone level in the baby
3 e6 G/ o/ A# k; Y# O7 Nwas high, he then read the product information) Q! V; t* m$ }% s( Q3 w* S; J, N, K
packet and concluded that it was most likely the rea-
% b, B* l! X  v$ h% W9 qson for the child’s virilization. At that time, they+ h* Z& D; P6 A, U! @- l8 Z
decided to put the baby in a separate bed, and the) T4 j. g! G8 R( j- ~* n
father was not hugging him with bare skin and had
7 g; \! l4 \1 ~$ ^! u4 @been using protective clothing. A repeat testosterone. j3 R( \' n* x9 N
test was ordered, but the family did not go to the' R2 R5 B2 ~( k3 s4 Z. W% B5 y+ l
laboratory to obtain the test.
0 l" c8 z8 ]6 v2 pDiscussion) u2 D3 J% e' w# G" i
Precocious puberty in boys is defined as secondary
' ~/ e* ?$ Y4 V! I2 U. |sexual development before 9 years of age.1,4
, N: @0 U/ x/ B' V, g9 |4 ]( [  ZPrecocious puberty is termed as central (true) when4 P# a& z# ^, O' [* ^* g* |: k
it is caused by the premature activation of hypo-: t+ Q) o4 I1 A6 T
thalamic pituitary gonadal axis. CPP is more com-! f6 z2 @. a$ A1 g! z) X
mon in girls than in boys.1,3 Most boys with CPP+ [0 C# \% ]- U! J
may have a central nervous system lesion that is
9 \1 B; p+ s" _5 K. \$ Zresponsible for the early activation of the hypothal-! A& f4 `# q, D$ Y0 H; \) T' _
amic pituitary gonadal axis.1-3 Thus, greater empha-
5 P4 g( h3 ?/ l/ jsis has been given to neuroradiologic imaging in
( ]/ l6 c* e+ W# @( v& t/ f* y! J" iboys with precocious puberty. In addition to viril-1 Z: P$ g( u! G5 i
ization, the clinical hallmark of CPP is the symmet-
% `# _# A) M: s5 Erical testicular growth secondary to stimulation by. k. }: U' K4 i8 e$ P0 j/ |
gonadotropins.1,3
6 x; ]- ?- e% T, A+ GGonadotropin-independent peripheral preco-+ C  u7 H3 _9 r
cious puberty in boys also results from inappropriate. z( j$ H# N7 g$ B8 u4 a
androgenic stimulation from either endogenous or
/ @1 S4 E+ e" E5 S0 T2 r5 l! sexogenous sources, nonpituitary gonadotropin stim-. @2 k8 A& u) W3 D- ?$ q0 l
ulation, and rare activating mutations.3 Virilizing
/ _) S' i, z/ z; g  x, U* Qcongenital adrenal hyperplasia producing excessive
' s# ^5 l0 J% I3 r/ R& X6 `- w: C6 h& ladrenal androgens is a common cause of precocious
9 O3 B* u  ?/ Y9 B/ y2 t  {puberty in boys.3,4' N0 b8 [6 S, w% u! l8 p$ Q
The most common form of congenital adrenal
' `* K# _7 q" e  y. h! {hyperplasia is the 21-hydroxylase enzyme deficiency.. U! u2 _# H' _4 S8 t# S
The 11-β hydroxylase deficiency may also result in
0 {4 S, y3 c  V6 V* ~* O2 rexcessive adrenal androgen production, and rarely,: [2 g: J+ `$ X* s
an adrenal tumor may also cause adrenal androgen! z/ ]  a+ H1 P
excess.1,3
* T, \( O- z- ^- f( pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& k. i. {8 `7 ^9 g9 o) T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; j2 O. H2 v1 e" F% c* D6 c# \3 cA unique entity of male-limited gonadotropin-
" d1 M2 s0 N7 n0 i1 a+ p; Nindependent precocious puberty, which is also known6 X! k7 _2 d: ~- A7 c
as testotoxicosis, may cause precocious puberty at a1 j6 }3 ]) Y' {- T  E
very young age. The physical findings in these boys. w0 H: r; u* B" y  a4 L7 l
with this disorder are full pubertal development,1 z: P* T9 U8 H% t5 n
including bilateral testicular growth, similar to boys! z# v; R3 r$ e; z- k
with CPP. The gonadotropin levels in this disorder* t2 N0 t9 e$ V
are suppressed to prepubertal levels and do not show
" H2 l% H( O' o- I( a' z% Ppubertal response of gonadotropin after gonadotropin-
6 x6 d  A0 o7 {6 e+ M5 w  l  e, u! J  dreleasing hormone stimulation. This is a sex-linked
5 v! a5 K' [3 `0 k6 L4 _autosomal dominant disorder that affects only
, ~* a* p9 f$ S$ C! v  d$ wmales; therefore, other male members of the family
- G& f1 i. O" |may have similar precocious puberty.3# I! V' m$ e" R( D5 }# Y/ t$ X2 ]
In our patient, physical examination was incon-8 j+ R! h2 j8 e* D) o: W
sistent with true precocious puberty since his testi-
3 I. p  K% \; o4 U8 m& Ecles were prepubertal in size. However, testotoxicosis
' F6 r6 a, k6 swas in the differential diagnosis because his father2 e$ t0 w+ ]+ i' i- b
started puberty somewhat early, and occasionally,- y( f: a$ {2 @, O
testicular enlargement is not that evident in the' s% f: b, I5 _, m" v/ s
beginning of this process.1 In the absence of a neg-  ?! h+ L3 z, X3 x- k5 K1 E6 c7 e
ative initial history of androgen exposure, our" N0 ^0 v# h$ ~$ @. |" A& Z- Y
biggest concern was virilizing adrenal hyperplasia,# r% v( l* ]+ \7 @; u" U4 c
either 21-hydroxylase deficiency or 11-β hydroxylase
! }7 P. ?, I; Ndeficiency. Those diagnoses were excluded by find-
, k' j$ j  S# V8 k5 g5 e0 e  ring the normal level of adrenal steroids.0 `- O% x: `/ s, U$ E' s9 X* q
The diagnosis of exogenous androgens was strongly7 P- R, q# z( u( C" N. O7 t2 {
suspected in a follow-up visit after 4 months because
5 C# R. o/ f  Ithe physical examination revealed the complete disap-1 ]! m2 W# c8 @; P* X
pearance of pubic hair, normal growth velocity, and
/ B1 |, p- T2 J/ G8 G; {decreased erections. The father admitted using a testos-( w* e/ C8 s2 p. Z! O9 L
terone gel, which he concealed at first visit. He was
+ _8 x3 z/ N# Jusing it rather frequently, twice a day. The Physicians’
+ \3 ~' O5 |8 e/ V0 ZDesk Reference, or package insert of this product, gel or
/ c3 a( W. s; p8 m; k1 H' W: i# hcream, cautions about dermal testosterone transfer to
* f2 D& X; o5 K1 ~9 }; @unprotected females through direct skin exposure.& h- |4 M0 n/ I. A" m2 D, I
Serum testosterone level was found to be 2 times the
& c$ q" ?& Q$ ^. e5 k; a, y+ }baseline value in those females who were exposed to# @; k! f8 U' M* e2 I
even 15 minutes of direct skin contact with their male
: G; h9 @3 o- g! K+ ?- M3 k/ ]. qpartners.6 However, when a shirt covered the applica-) M( A8 E/ n1 `. }( i7 x
tion site, this testosterone transfer was prevented.0 P2 h' N) j9 w! ~7 o5 M! ~1 c0 M  F
Our patient’s testosterone level was 60 ng/mL,
1 |; m( T3 s& |. wwhich was clearly high. Some studies suggest that8 Z, D8 [- `  B( a  K
dermal conversion of testosterone to dihydrotestos-
1 Q2 i# [+ a2 N; F% nterone, which is a more potent metabolite, is more
1 ^" P8 p3 d/ X+ iactive in young children exposed to testosterone$ u4 q# j. a8 L. s
exogenously7; however, we did not measure a dihy-
0 N+ ^0 l0 y5 p6 P2 m/ Y2 G4 {drotestosterone level in our patient. In addition to/ t: E4 J, k% E
virilization, exposure to exogenous testosterone in+ X% r, d4 F4 W  X8 ^* A
children results in an increase in growth velocity and
  G& H5 _: r5 F& tadvanced bone age, as seen in our patient.
2 R) E5 {9 s" h% KThe long-term effect of androgen exposure during
( n1 y" d  b- r* s/ E6 o, kearly childhood on pubertal development and final
8 S- q2 [2 @. qadult height are not fully known and always remain6 v' S( D2 F+ g0 T3 E. R
a concern. Children treated with short-term testos-- r& b+ v+ [: G+ ?2 Y( v6 Z& s8 [
terone injection or topical androgen may exhibit some& E( r) ^1 Z9 {( T
acceleration of the skeletal maturation; however, after
: \7 _7 K$ E/ t+ ycessation of treatment, the rate of bone maturation
( M% ^: U$ f, y; y1 adecelerates and gradually returns to normal.8,9% Q  w2 k" t9 a$ A  j, W8 R9 m  J- Q
There are conflicting reports and controversy
, ?# M: G, N/ z9 j* F! P! O: Zover the effect of early androgen exposure on adult
" c* T7 _) Z3 e, f, K; Rpenile length.10,11 Some reports suggest subnormal
" o2 H# [7 x% D/ Radult penile length, apparently because of downreg-! n/ N) B4 R* q$ ^) I
ulation of androgen receptor number.10,12 However,6 D- ^, \" `0 r' L
Sutherland et al13 did not find a correlation between! {) `! `. i$ k9 z5 Y( }# }8 a" A
childhood testosterone exposure and reduced adult) P1 V! [5 [) Z
penile length in clinical studies.3 p9 j1 a: E: S; a
Nonetheless, we do not believe our patient is/ y. ]: M5 @0 j+ \* K% W
going to experience any of the untoward effects from/ ]/ k1 g' f* a8 T1 D# p. {3 K5 D
testosterone exposure as mentioned earlier because
( }# Z  A" i4 M3 Ethe exposure was not for a prolonged period of time.+ m1 u, P4 h$ U6 ]& e
Although the bone age was advanced at the time of9 J* j* x$ ~6 S! g) H
diagnosis, the child had a normal growth velocity at
2 N* _! h- b# \9 t7 m7 Sthe follow-up visit. It is hoped that his final adult
/ }) m1 X3 s( R. Aheight will not be affected.
. H6 Y! g; g) `! }  h1 w4 UAlthough rarely reported, the widespread avail-3 A/ s* D8 R' z+ w
ability of androgen products in our society may
6 _2 n# G4 y% r. _# q4 ?7 Windeed cause more virilization in male or female
. f1 U/ H2 }2 i0 pchildren than one would realize. Exposure to andro-. L  [, V& X& J+ a- a% }
gen products must be considered and specific ques-: O  U3 v5 x/ O3 j$ y4 ^
tioning about the use of a testosterone product or0 u; G9 u- ~6 b3 N! O# v. x. M
gel should be asked of the family members during
$ D3 @+ U3 N9 k2 _/ \) Z& m/ Gthe evaluation of any children who present with vir-( \* _9 D" T/ [* V# e2 ~7 W) c
ilization or peripheral precocious puberty. The diag-$ ?, @6 `1 v" h0 d7 ~( p0 X7 s
nosis can be established by just a few tests and by/ ~' E7 i, Z8 m* c* C" J. T4 }7 q
appropriate history. The inability to obtain such a9 `1 u1 z% R- ?/ W" M9 \* N0 f% p
history, or failure to ask the specific questions, may
% E8 {# S, x& N5 @/ C- ]: Yresult in extensive, unnecessary, and expensive$ n: c, |* u* T8 A4 C3 d9 W' u7 ?
investigation. The primary care physician should be8 ?8 A1 P/ s+ N' K' E
aware of this fact, because most of these children
# S+ M. _0 T2 y2 d+ {; ]may initially present in their practice. The Physicians’
/ O$ Q+ P  \- {6 V- Q$ }6 \& T3 a" ADesk Reference and package insert should also put a
( g. v6 R2 O, y2 T+ c& Vwarning about the virilizing effect on a male or
  j7 u+ a6 }0 Z1 i( A; m' T' Ofemale child who might come in contact with some-* H5 ?8 y, e% f% e
one using any of these products.
3 m* c2 C4 M5 R; n! bReferences
' I7 v7 b7 j  k: U1. Styne DM. The testes: disorder of sexual differentiation# Q, z& g) o- F4 a; J* ~
and puberty in the male. In: Sperling MA, ed. Pediatric. R! W, C* v6 ]- n- M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 |0 \, u  j/ `$ p2 b; T2002: 565-628., P: s3 ?' o" U" J- ?6 F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 f! u& n( C7 j' V+ Cpuberty 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
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

5 B% B. }; M/ e7 w. Z* m! B1 N2 k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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