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Sexual Precocity in a 16-Month-Old) y, {% Z& Y* r2 t4 _
Boy Induced by Indirect Topical
7 y. o: C$ u, h8 A9 zExposure to Testosterone" P) Z6 ^7 l  B" p
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ M# }: U: |  x6 X1 M; z  t* y/ Dand Kenneth R. Rettig, MD1
; {' A; _( G9 j0 g2 dClinical Pediatrics
/ Z- g' T& z  u3 jVolume 46 Number 6; M* L( l4 h! g" f8 T/ ^8 o
July 2007 540-5431 y9 u# c3 n; E1 l
© 2007 Sage Publications
, G2 P  l' u3 Z0 R. S: f3 c9 _10.1177/0009922806296651
  n- U/ H* X' Khttp://clp.sagepub.com
! C; g, M' t# ?) ^- C7 J7 r$ e. ?# g: Bhosted at0 ~* R2 Z' ~: E6 E5 b7 z; j5 {7 {
http://online.sagepub.com
1 r; a9 B7 d8 P; uPrecocious puberty in boys, central or peripheral,
! ^$ f: M' _* f* H6 Y" L# ais a significant concern for physicians. Central
! W; \, [& Z8 \/ T0 K: }2 m* {precocious puberty (CPP), which is mediated
% O8 E- e% E+ tthrough the hypothalamic pituitary gonadal axis, has1 _1 u$ g& W4 O$ G' J
a higher incidence of organic central nervous system
! I# ?" T$ E. [2 @. dlesions in boys.1,2 Virilization in boys, as manifested# U5 k/ g) c, n" i
by enlargement of the penis, development of pubic7 T& j3 a4 |- y( l
hair, and facial acne without enlargement of testi-0 G- h8 p. u: I" k
cles, suggests peripheral or pseudopuberty.1-3 We
" Y. _2 a+ N( Kreport a 16-month-old boy who presented with the! _0 i8 q( {" [
enlargement of the phallus and pubic hair develop-
( U: F  k( K1 e0 C$ D- V5 ]ment without testicular enlargement, which was due* c6 C6 C; l# R* d9 E6 q- N9 K' `
to the unintentional exposure to androgen gel used by
; h, `* n( L" |/ i3 Gthe father. The family initially concealed this infor-
! v. S. `6 f- Z" \$ emation, resulting in an extensive work-up for this4 L! \9 z* Z: {# J8 H
child. Given the widespread and easy availability of: p6 v& [8 ~9 e& j" w7 m0 m3 n
testosterone gel and cream, we believe this is proba-4 E( r7 w  ?0 @, Y, j3 g. Z! H( J
bly more common than the rare case report in the# Z2 Z) o/ B! b' s  [/ w, `
literature.4
; T: l  Y, [8 |# S1 K. x8 M" [4 }Patient Report, |& e2 Y8 j. C) X& W
A 16-month-old white child was referred to the
0 W% c$ y  ]9 S) @' p3 E: ]endocrine clinic by his pediatrician with the concern( v* x, M" ?4 V1 i) Y
of early sexual development. His mother noticed  c1 d6 \" v3 k8 l* Z0 }
light colored pubic hair development when he was
% x! m9 M3 a) o+ E* Z. TFrom the 1Division of Pediatric Endocrinology, 2University of2 Y- }7 P% U( L" Y
South Alabama Medical Center, Mobile, Alabama.
* W  L! B! R1 }  d0 A, {Address correspondence to: Samar K. Bhowmick, MD, FACE,( X' k6 E- b! X3 H! k4 U( u, V
Professor of Pediatrics, University of South Alabama, College of
: j" }5 H$ E+ g+ ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ C+ P& v/ M7 k& q$ u1 i/ z
e-mail: [email protected].
! M, M4 n% }/ e7 wabout 6 to 7 months old, which progressively became2 p8 ?$ L+ r# g5 q6 g
darker. She was also concerned about the enlarge-
% Y1 Q' o8 a) r! L+ t+ z$ nment of his penis and frequent erections. The child
$ P  ^, {: r) b1 {, g6 @& F- owas the product of a full-term normal delivery, with
2 M* N9 M2 \- E, @' V  Z! v& K! g' T* ta birth weight of 7 lb 14 oz, and birth length of) \+ I7 @% Y# }/ A0 Q4 ]2 \
20 inches. He was breast-fed throughout the first year
0 U9 o2 X3 G) [8 k' nof life and was still receiving breast milk along with' O& J& f6 `/ X
solid food. He had no hospitalizations or surgery,
/ ~3 Y! K& C5 Q* land his psychosocial and psychomotor development6 h$ D: l3 b" E9 ?1 J
was age appropriate.
2 S! @8 p& ^+ Y( LThe family history was remarkable for the father,9 s$ W  ~0 E& M4 Q( M% W! d
who was diagnosed with hypothyroidism at age 16,5 D# G) K' Z) F2 i1 s. `
which was treated with thyroxine. The father’s% y) L2 ^; [. @2 }2 a2 r4 w! A
height was 6 feet, and he went through a somewhat
/ e- b, {* G  B; bearly puberty and had stopped growing by age 14.
! J+ n/ D& X2 @1 }The father denied taking any other medication. The$ R8 u1 ?: h* M; p5 U
child’s mother was in good health. Her menarche
6 b' a6 H" V: \was at 11 years of age, and her height was at 5 feet, W1 K9 [3 W/ u( ^8 `( O
5 inches. There was no other family history of pre-
" L$ ]9 u: `+ L$ V& Mcocious sexual development in the first-degree rela-  ]; V5 |* F( q4 j  f
tives. There were no siblings.
1 d, d! |5 ?! a5 VPhysical Examination
7 Q! W+ J& A. o2 wThe physical examination revealed a very active," a, v2 |$ Z! C  J5 q* P* V
playful, and healthy boy. The vital signs documented& O: l; S# Y( J' K3 ]
a blood pressure of 85/50 mm Hg, his length was, L: A' i% B7 o
90 cm (>97th percentile), and his weight was 14.4 kg# y- a6 W$ y" P2 w3 h: z, m
(also >97th percentile). The observed yearly growth
0 m/ E- c" k: Y& C) V3 N: ]( ]: Ovelocity was 30 cm (12 inches). The examination of
; x& D& C, }( zthe neck revealed no thyroid enlargement." S7 o8 C: t1 v* }; f9 |
The genitourinary examination was remarkable for
, P) z" Q- j5 [enlargement of the penis, with a stretched length of" d7 D3 w: L# i, u) L
8 cm and a width of 2 cm. The glans penis was very well
! S# _/ J2 }: a3 f% Y" \" udeveloped. The pubic hair was Tanner II, mostly around* _/ N# c, B$ ?' w
540
' O+ J" g; h% ~/ g2 g% Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 p: z/ |" f* q4 [; L  b! I1 O& Dthe base of the phallus and was dark and curled. The; r/ f) o3 j- K8 [/ m2 h7 P
testicular volume was prepubertal at 2 mL each.
. ?- s; l& V; E1 D' H! qThe skin was moist and smooth and somewhat
6 }6 R& l9 R( q; Joily. No axillary hair was noted. There were no% I/ Q- I5 @9 K
abnormal skin pigmentations or café-au-lait spots.0 g; ]$ b; `& d2 c" D& U
Neurologic evaluation showed deep tendon reflex 2+
8 m; i' A4 i' |  P) K' [bilateral and symmetrical. There was no suggestion
1 K  _+ \9 J/ p( @' mof papilledema.% c# \9 X) |1 C8 K* C
Laboratory Evaluation
1 O+ J. ?8 H, K" a& d9 wThe bone age was consistent with 28 months by9 |5 g% i. D/ u. ^+ u2 t
using the standard of Greulich and Pyle at a chrono-
( ^" S. a0 o3 X6 T0 e9 n2 `logic age of 16 months (advanced).5 Chromosomal% u3 x2 ^- T- G5 k
karyotype was 46XY. The thyroid function test. Y4 n8 k: s# H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" N! c( g1 B+ S# {% v6 o( f4 m
lating hormone level was 1.3 µIU/mL (both normal).1 P% c- o0 j  L$ {- i3 z
The concentrations of serum electrolytes, blood6 ]3 N# P: l/ K" O# F5 B9 s# b
urea nitrogen, creatinine, and calcium all were2 G& E1 l& h, c9 J- q
within normal range for his age. The concentration6 |& E, g5 [5 r9 L
of serum 17-hydroxyprogesterone was 16 ng/dL" Q# R7 ~( w  U7 c2 g* p* ?6 b
(normal, 3 to 90 ng/dL), androstenedione was 20
1 [: e( u* Z5 `2 ]  P" [2 g9 Z- N7 ~: cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; O$ N' Y# S+ ]4 a4 z4 {8 t  X6 k( S
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* A' J1 s+ T4 y8 O' z: z0 x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 ?& z* h& g5 f6 N# x* m7 T49ng/dL), 11-desoxycortisol (specific compound S)  M# L$ X. h% ^" t! [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; k" f+ l5 S% \; m% h7 i. D3 J% `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! |+ q/ s' m4 a8 _; R+ k2 x6 a" N8 [testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, |, R" N6 J8 r5 e' L
and β-human chorionic gonadotropin was less than/ j& v/ D  s; Z( l' Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* a$ p  p+ Q+ [stimulating hormone and leuteinizing hormone
" \4 F# _" o* ~8 I5 X3 e0 oconcentrations were less than 0.05 mIU/mL: q* I2 n( p1 x, z% T  M. R1 Z* m1 H* t
(prepubertal).1 Z( A2 Z1 ]# V. z3 X3 c
The parents were notified about the laboratory6 l! k* W+ x3 H9 U& d
results and were informed that all of the tests were, s: C/ H5 D1 `; ~0 I
normal except the testosterone level was high. The. C$ U' K# J+ z4 k
follow-up visit was arranged within a few weeks to+ i  ^* U( M7 P5 h6 M8 u* l; Z
obtain testicular and abdominal sonograms; how-
9 {7 I7 b3 _0 ]! `( H4 j" rever, the family did not return for 4 months.
" k4 D+ j% W) H8 y0 g6 NPhysical examination at this time revealed that the
( O. o' B" j+ Y4 F- f. e) X& O/ gchild had grown 2.5 cm in 4 months and had gained
! T- A) R4 {' W& c2 kg of weight. Physical examination remained
% }! n5 R' K# H/ h( \( f2 W( iunchanged. Surprisingly, the pubic hair almost com-
5 J0 {. G* T7 C! Q- l6 vpletely disappeared except for a few vellous hairs at
& C, m$ r, w* m' C* Q4 F" Z" lthe base of the phallus. Testicular volume was still 2
* r! W& h5 E6 @9 {  Z5 O$ SmL, and the size of the penis remained unchanged.
1 S+ ^& o. U# m: B5 qThe mother also said that the boy was no longer hav-. T3 @" i  t5 z- f2 U
ing frequent erections.
9 O7 {& V8 c/ f1 gBoth parents were again questioned about use of1 D6 y& v% ^: z% f- q0 [2 L  W
any ointment/creams that they may have applied to  `5 F' A" {4 E
the child’s skin. This time the father admitted the
# B% d7 ~+ D8 F1 t. R# _Topical Testosterone Exposure / Bhowmick et al 541
0 T: y( b; I" |! x* Y. b3 a: [1 ~, zuse of testosterone gel twice daily that he was apply-8 ]) E; M) ^7 K# D: k6 d
ing over his own shoulders, chest, and back area for
4 Q  H' Y" f4 n7 P' `. xa year. The father also revealed he was embarrassed& `* ?$ i2 ~3 F# b' \  Z
to disclose that he was using a testosterone gel pre-
6 K8 n; R6 z6 q( v/ Z/ u' h4 Fscribed by his family physician for decreased libido9 X# Y- x7 @2 D- t8 Z+ \7 W
secondary to depression.4 ]5 T) Q- K! i
The child slept in the same bed with parents.
' t2 t% z/ z1 R7 TThe father would hug the baby and hold him on his# I+ q$ m3 l% z4 F
chest for a considerable period of time, causing sig-
! y, A3 f' Q- v' s5 Nnificant bare skin contact between baby and father.
0 V, Y; h  @$ B3 ?2 D0 dThe father also admitted that after the phone call,# ?$ i0 k! g6 L' p: _
when he learned the testosterone level in the baby
' H/ G- B. i2 e, Xwas high, he then read the product information
& V2 g/ h6 v* _+ D7 i1 T) ~packet and concluded that it was most likely the rea-5 v6 K6 t3 L3 w( A9 N2 I& c/ @
son for the child’s virilization. At that time, they
! K. N2 k: ^% ~- Y, xdecided to put the baby in a separate bed, and the$ K3 w# \8 U0 h" \% Y6 Z
father was not hugging him with bare skin and had  W& t& a) R- d2 D/ n! X+ B
been using protective clothing. A repeat testosterone7 H" q7 k& `; j3 x# j
test was ordered, but the family did not go to the
0 t4 q. ]3 x) x6 c* e, z: D: flaboratory to obtain the test.
6 _+ [9 v; z  c1 W' ^5 DDiscussion
6 k1 c# Z" @: j6 ]! w: QPrecocious puberty in boys is defined as secondary
( b6 Y2 D. g, @. g# s" vsexual development before 9 years of age.1,4- t# X- U2 X, v! X+ `3 g3 U
Precocious puberty is termed as central (true) when
+ P) l8 k. U; P+ h4 M  i" nit is caused by the premature activation of hypo-( b' T9 W& \8 [( J* J
thalamic pituitary gonadal axis. CPP is more com-. P, W0 l5 N) K9 G. C
mon in girls than in boys.1,3 Most boys with CPP* j) Q! B% ^( j2 V
may have a central nervous system lesion that is
  c/ i! n. L* n9 hresponsible for the early activation of the hypothal-
' ?# v2 R6 Y" R, ~+ }$ uamic pituitary gonadal axis.1-3 Thus, greater empha-
0 H, N/ u' d* f4 ^sis has been given to neuroradiologic imaging in8 V; ?5 [* _3 C
boys with precocious puberty. In addition to viril-: X( C0 a' S; |- G& e- [  e: @
ization, the clinical hallmark of CPP is the symmet-
. k3 u1 A7 ?8 b( z+ prical testicular growth secondary to stimulation by  l& q& N3 L$ z3 a# O2 |% ^
gonadotropins.1,3$ c$ s$ }) }- ~8 Y1 b& `* S
Gonadotropin-independent peripheral preco-0 K$ R4 `& v6 c9 F5 `
cious puberty in boys also results from inappropriate* e# L4 o, h0 ~* I( D, c
androgenic stimulation from either endogenous or8 W, j. ^! m9 V# Q
exogenous sources, nonpituitary gonadotropin stim-
8 o0 o( y! o$ |  }; o( Xulation, and rare activating mutations.3 Virilizing/ q7 J, T: r* W# F8 w& O7 Q
congenital adrenal hyperplasia producing excessive/ r* q8 O" P+ O/ j' R
adrenal androgens is a common cause of precocious( }0 B% i  W% y- x/ h
puberty in boys.3,4* x2 u9 {% H& O' t
The most common form of congenital adrenal: Y; U* V* {  [4 X) z$ q
hyperplasia is the 21-hydroxylase enzyme deficiency.
* z) d& O* \+ F* x! P/ nThe 11-β hydroxylase deficiency may also result in
& T+ e- m$ a7 o: jexcessive adrenal androgen production, and rarely,# l+ s6 k& I: D. J
an adrenal tumor may also cause adrenal androgen
% k0 R, b8 ~& P6 ~/ Zexcess.1,3# Z: K; V* A! w; T5 t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ ~7 z! b, h2 f5 q6 F% F+ z" w542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 a2 h; ?- e/ GA unique entity of male-limited gonadotropin-
8 B, c4 [$ G6 i: {$ V2 |+ G1 Oindependent precocious puberty, which is also known
5 r. q4 G% ^" ^& @' X9 ras testotoxicosis, may cause precocious puberty at a
' E; x, q6 T2 b. t& N. D6 Svery young age. The physical findings in these boys
5 R, K9 A% F: c0 Q$ Gwith this disorder are full pubertal development,
0 X1 v4 J. O' i% ^+ V5 qincluding bilateral testicular growth, similar to boys
0 @- ?) Q7 K/ Nwith CPP. The gonadotropin levels in this disorder) B% [) l5 {4 j  u3 S* e- x
are suppressed to prepubertal levels and do not show
/ ^5 L. L1 o! z  {9 v0 y( {; }pubertal response of gonadotropin after gonadotropin-! g% f6 d6 n, n- v& V, e
releasing hormone stimulation. This is a sex-linked
7 t, a9 R# I) V6 S+ _8 }autosomal dominant disorder that affects only# H# d) w4 t2 D% H5 A
males; therefore, other male members of the family
3 E. L7 l$ I  x9 w5 }may have similar precocious puberty.3
; \! r: b; X% QIn our patient, physical examination was incon-
, K5 j* S; ^1 k+ Asistent with true precocious puberty since his testi-+ q( }3 `5 N2 I7 M
cles were prepubertal in size. However, testotoxicosis) Z3 b" _( j, k0 p- G6 N
was in the differential diagnosis because his father: ], X0 i& _: {7 @4 l
started puberty somewhat early, and occasionally,
$ ~5 |* f8 s' b. h0 O3 X9 jtesticular enlargement is not that evident in the# G# ^' c7 l# v" f
beginning of this process.1 In the absence of a neg-
, @) G! Y* b; V2 x, M! ^, W' Tative initial history of androgen exposure, our; u6 _* i" T4 y& Y/ o. ]$ y2 s
biggest concern was virilizing adrenal hyperplasia,2 v# y. U" V  I4 c! ^* `2 @
either 21-hydroxylase deficiency or 11-β hydroxylase
8 K' q# o4 J; qdeficiency. Those diagnoses were excluded by find-
: w! N( i/ k& {1 ging the normal level of adrenal steroids.8 P! W' `- k4 R
The diagnosis of exogenous androgens was strongly
# w' D. t& i% T$ Gsuspected in a follow-up visit after 4 months because
, ~! R) O  u+ N* V) Q( _the physical examination revealed the complete disap-! t! ^. m* ?' B) R8 l
pearance of pubic hair, normal growth velocity, and
/ M5 l5 p2 j" ^* A' l3 N7 W* c+ Sdecreased erections. The father admitted using a testos-! x6 ^! F7 b& j' ^8 x3 U- n2 Y: H
terone gel, which he concealed at first visit. He was( O: S: i9 @3 ]' R) v" k
using it rather frequently, twice a day. The Physicians’
8 V3 O# G* A, G1 S" iDesk Reference, or package insert of this product, gel or* l* J7 I  a. G8 T
cream, cautions about dermal testosterone transfer to1 d  S3 {, ~: j
unprotected females through direct skin exposure.8 X9 {; E) e  U
Serum testosterone level was found to be 2 times the* u$ K8 C9 q. u
baseline value in those females who were exposed to; b. Z0 ]* P' K! P0 m7 @8 U
even 15 minutes of direct skin contact with their male$ o: M' x) Y- c  l+ ]
partners.6 However, when a shirt covered the applica-
# w9 e. L# t+ Q. btion site, this testosterone transfer was prevented.! F7 z; i* }  A% P0 i% @
Our patient’s testosterone level was 60 ng/mL,
9 ?$ b% J5 [  C3 ?* H! V2 awhich was clearly high. Some studies suggest that
0 X- `6 o- l1 C- a5 Mdermal conversion of testosterone to dihydrotestos-
/ V6 a/ q. z0 u4 z# B8 Oterone, which is a more potent metabolite, is more
9 i# d; e& r6 p% x# i1 ?active in young children exposed to testosterone
! r% m) Q0 w* o' J4 ], V0 |exogenously7; however, we did not measure a dihy-; O7 E9 e3 z4 x5 ?6 u$ t. v4 v
drotestosterone level in our patient. In addition to
% Y8 S, e/ x/ s8 a. [& U% C. @0 Fvirilization, exposure to exogenous testosterone in9 ^% K( ]+ @8 D) D7 f. u* J; @- x
children results in an increase in growth velocity and
( Q! J7 B! s; E4 T' D1 ladvanced bone age, as seen in our patient.. O- c9 t2 n4 x8 ~# O; q3 `! H
The long-term effect of androgen exposure during
* G0 ^' P$ ?% k- T, v4 X+ Bearly childhood on pubertal development and final
+ O% E6 L9 Q$ m/ }7 _9 Oadult height are not fully known and always remain
; j9 k" p: ?2 da concern. Children treated with short-term testos-
: z; f6 X9 G$ y1 d$ M9 _. Qterone injection or topical androgen may exhibit some6 o, b! g9 b& R. w
acceleration of the skeletal maturation; however, after( I8 U3 u( K' P3 c& t" t
cessation of treatment, the rate of bone maturation  v7 V& ~/ a+ f% d, q. }
decelerates and gradually returns to normal.8,9
8 |! F2 b1 [5 |) i9 ]( x" m4 a* pThere are conflicting reports and controversy
3 K+ e" P, m1 t  j, O, K; }1 D$ mover the effect of early androgen exposure on adult
' R9 ^" A8 m1 e! Q& tpenile length.10,11 Some reports suggest subnormal/ K  _+ t+ f) ^' t& I
adult penile length, apparently because of downreg-1 \2 j# `' }5 S- G! j, h2 c6 r$ h
ulation of androgen receptor number.10,12 However," L& `; h/ g9 h0 K: }
Sutherland et al13 did not find a correlation between- U7 v8 Q# W# |, i1 h' ~& m$ O
childhood testosterone exposure and reduced adult, Z# q9 f8 S7 F
penile length in clinical studies.
) o( X! n/ I: R0 ONonetheless, we do not believe our patient is3 Q& r( ~$ {/ ]+ n* y" z
going to experience any of the untoward effects from2 I- T3 R, y: z, L
testosterone exposure as mentioned earlier because
7 e" w) C+ t% @$ C3 a9 vthe exposure was not for a prolonged period of time.! S# D% \' h5 {2 K2 X
Although the bone age was advanced at the time of
# v" a/ w$ q7 @" Gdiagnosis, the child had a normal growth velocity at- ?! \0 C* z/ U8 T9 j9 ~
the follow-up visit. It is hoped that his final adult
% p9 E. _( _: N& N# @7 Wheight will not be affected.
  j7 n6 t$ @  @. o. hAlthough rarely reported, the widespread avail-* y% W) }& V& U4 ]
ability of androgen products in our society may
$ O1 e& L& `7 k: b" Y3 x, e# \indeed cause more virilization in male or female; }- v" y. X* q
children than one would realize. Exposure to andro-
# h/ f6 v" m5 z% E. y7 {+ o3 Sgen products must be considered and specific ques-
% \+ ?+ i; E1 q& j' \tioning about the use of a testosterone product or1 P; m& q- Z! e8 |; |
gel should be asked of the family members during$ L0 \: D/ q1 H: ]  o4 g7 E
the evaluation of any children who present with vir-
5 }* i* c; K6 A6 L* O4 v, p7 lilization or peripheral precocious puberty. The diag-3 _7 ~  `% U. k
nosis can be established by just a few tests and by
: J, s( `% |3 `" b6 iappropriate history. The inability to obtain such a1 w9 _! b( o$ O% i
history, or failure to ask the specific questions, may6 \7 R/ |; B3 J, J; L' H5 \
result in extensive, unnecessary, and expensive
- ^  z6 ~$ o4 K- ginvestigation. The primary care physician should be
+ K. M+ i8 ]0 S) e8 Haware of this fact, because most of these children) a' g8 {9 Z- T# D
may initially present in their practice. The Physicians’
5 T# F5 f' y- n) ~. PDesk Reference and package insert should also put a5 U7 |9 v% X1 j( N9 t" x
warning about the virilizing effect on a male or$ q0 C, W0 Q! h
female child who might come in contact with some-
" O+ h- L7 l, i" E4 B1 y( Zone using any of these products.% ?5 V, C) H' a6 [* A
References2 Z3 ^3 ~/ d/ `- n# N
1. Styne DM. The testes: disorder of sexual differentiation
* W( M9 l$ l( x$ V7 K5 Xand puberty in the male. In: Sperling MA, ed. Pediatric
# F) `: c6 O$ ~) ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% k( ~7 `6 e. r
2002: 565-628.3 q' _9 |$ z; _  Q2 j- s+ _! |* k8 C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- J: Y6 D# [8 G
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ P( v' ^3 n3 M% T2 G4 BBoy Induced by Indirect Topical
  ?) B6 |' p8 v) R( ?4 r' E+ |Exposure to Testosterone
2 r9 f+ V# Q, P/ \( U7 o! c. LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 G8 g6 w2 P3 e, n2 f6 M. nand Kenneth R. Rettig, MD1
$ p) A/ D) {. s- EClinical Pediatrics
! C, |3 D. T3 `; m( {- F: rVolume 46 Number 6
- [2 n$ n/ y0 E) G' v. m/ m# ?July 2007 540-543
/ b- @: i! S& s3 K4 Y© 2007 Sage Publications; a) z* y/ N9 r! S$ y4 T  B2 z/ y2 w
10.1177/0009922806296651
. H( g; l6 U/ F' Z, I; ]http://clp.sagepub.com$ D% T& c2 g; ]# }0 E
hosted at
1 u7 }  F; Y; _/ s  Z3 Y- e  Zhttp://online.sagepub.com
7 c8 O0 E& b- L% h$ @Precocious puberty in boys, central or peripheral,
0 I, G8 m6 X! Gis a significant concern for physicians. Central0 \: h" a1 {- |1 b& n6 l6 A8 S; s
precocious puberty (CPP), which is mediated
+ ?: a6 c9 _: o0 N) V+ mthrough the hypothalamic pituitary gonadal axis, has* n! h1 |1 g" ?2 |, G
a higher incidence of organic central nervous system
5 D+ _9 B4 C7 V+ \% ^lesions in boys.1,2 Virilization in boys, as manifested+ n, g4 N1 Y0 O, T( K$ ^# V
by enlargement of the penis, development of pubic
( {# ^0 v3 b% J2 i5 Thair, and facial acne without enlargement of testi-4 x( E1 ]$ c; S  l7 b2 z; V
cles, suggests peripheral or pseudopuberty.1-3 We" b0 }" O  ?( f# C7 {$ I
report a 16-month-old boy who presented with the) F" j8 o! }, l$ T$ `! O* t+ u4 R
enlargement of the phallus and pubic hair develop-
; j7 G" r- v7 mment without testicular enlargement, which was due
, v$ L* P, h: \, F7 r8 ato the unintentional exposure to androgen gel used by
0 x: r1 I: [5 G- }( v3 H; C  Uthe father. The family initially concealed this infor-
2 J3 V. h5 Z" fmation, resulting in an extensive work-up for this
" \' O0 A; b+ Q; ^child. Given the widespread and easy availability of
) B" f3 o( w" [3 W) t' G; Xtestosterone gel and cream, we believe this is proba-
9 k0 O9 `! s0 v0 }# u' m- n2 }3 Zbly more common than the rare case report in the  ^6 f4 p$ V) t) Y
literature.4& i" ~" f$ g8 l7 U2 `# \
Patient Report5 L3 x# Q' a" r; g5 V
A 16-month-old white child was referred to the7 M$ s* B" O! i
endocrine clinic by his pediatrician with the concern2 B4 G7 e' a& Q5 K( F
of early sexual development. His mother noticed/ U* L3 R  Y5 }) _9 x
light colored pubic hair development when he was+ V" H: [6 g; B( G' e
From the 1Division of Pediatric Endocrinology, 2University of
" K) ]( J1 e) q* l% ISouth Alabama Medical Center, Mobile, Alabama.
' e' m. K! b6 j3 W  j* a/ q( W& Z3 cAddress correspondence to: Samar K. Bhowmick, MD, FACE,0 a$ S5 S6 |2 k& P+ z& k
Professor of Pediatrics, University of South Alabama, College of. y$ D0 h; _' A- d; n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- l' Y& B& t! T7 K6 b4 be-mail: [email protected].
. `6 \2 S3 ^) R, e4 @* L6 Z  i; Labout 6 to 7 months old, which progressively became# Q6 r/ `% T8 f& v
darker. She was also concerned about the enlarge-
9 [/ [: Y/ w$ L: |1 l( g" Hment of his penis and frequent erections. The child
# I$ V. X' g9 ?9 n! }. s! [$ ]) Owas the product of a full-term normal delivery, with* w. J0 M; y: t6 x  ]1 S1 }6 [3 B
a birth weight of 7 lb 14 oz, and birth length of# N$ W: G, `5 Z7 T
20 inches. He was breast-fed throughout the first year% ~  H! i& O0 {3 q$ @' ^
of life and was still receiving breast milk along with
/ b" |, \+ Q( o8 e0 l3 Vsolid food. He had no hospitalizations or surgery,
# P. E. J% {- S$ yand his psychosocial and psychomotor development
8 J5 K8 S$ a- d4 A) ~8 J& H) }was age appropriate.
3 k5 c5 u" i( X# bThe family history was remarkable for the father,
2 M2 h3 n+ s9 @$ R7 P+ bwho was diagnosed with hypothyroidism at age 16,
, n- b7 q5 Y; Z) Q3 h$ [4 j4 owhich was treated with thyroxine. The father’s
. K- z" O9 l' z9 M! |- Lheight was 6 feet, and he went through a somewhat. N0 w4 }% l/ p! Y* ?) W: j8 J" U$ G
early puberty and had stopped growing by age 14.: N; I- w/ D1 n2 y! _
The father denied taking any other medication. The
* V8 k$ Y$ u9 F" O9 y) o, Mchild’s mother was in good health. Her menarche
0 |) q$ O  B% l3 ywas at 11 years of age, and her height was at 5 feet3 b. m; f9 y: `. r. f  C7 Y
5 inches. There was no other family history of pre-1 G. |3 ^; u4 N7 a  W$ b$ o2 l4 m) e
cocious sexual development in the first-degree rela-9 F9 N5 y$ x+ O, E
tives. There were no siblings.4 }5 S( r! N* v( \8 I2 ~
Physical Examination
: g% h6 _. d- C0 T* GThe physical examination revealed a very active,0 a+ j1 T& x7 C+ ?2 J
playful, and healthy boy. The vital signs documented
) l( e8 S1 P- _& F' ]4 x% Oa blood pressure of 85/50 mm Hg, his length was
0 g7 z% g: w$ a9 S0 Z90 cm (>97th percentile), and his weight was 14.4 kg
9 t' G* M, A9 F8 N(also >97th percentile). The observed yearly growth/ m) m0 @0 O% e0 d! t
velocity was 30 cm (12 inches). The examination of4 q, d+ k% m! p1 s
the neck revealed no thyroid enlargement.
. d: w5 ?+ h9 _1 V! lThe genitourinary examination was remarkable for
" b/ q1 d# h8 e1 X" Qenlargement of the penis, with a stretched length of1 f7 T4 B7 A& [* f( @( R# }5 _! @
8 cm and a width of 2 cm. The glans penis was very well" G$ Q1 R0 U; |$ O
developed. The pubic hair was Tanner II, mostly around3 R6 A; [* ~- c; x# Z- a  u
540: R9 S+ W6 c( q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; U2 g( J( b+ [/ I* j* t- d
the base of the phallus and was dark and curled. The
' q  l& L6 G" {testicular volume was prepubertal at 2 mL each.% C* u: {7 a: [5 @! K3 V  M! t3 {
The skin was moist and smooth and somewhat; ]  i( J8 S+ z
oily. No axillary hair was noted. There were no
& ~* t% V/ @" I) i7 [2 K7 ^abnormal skin pigmentations or café-au-lait spots.
( X4 C. ^1 L+ r5 }: K, w3 RNeurologic evaluation showed deep tendon reflex 2+
, J# G+ c5 i5 X  Abilateral and symmetrical. There was no suggestion
) A2 p# ^& |0 U! Hof papilledema.% v' {3 F" B. j3 K( ]3 W2 _6 P
Laboratory Evaluation, X, V6 l- K4 i0 e' a6 j: \
The bone age was consistent with 28 months by
2 O3 k1 ?, `$ \& e6 T5 ousing the standard of Greulich and Pyle at a chrono-
  J- z0 \- M* Flogic age of 16 months (advanced).5 Chromosomal
# F" ~* S. B& G1 [1 a9 O3 s2 ~karyotype was 46XY. The thyroid function test
3 i; _# o  Y; q3 [showed a free T4 of 1.69 ng/dL, and thyroid stimu-( p1 r( T# U) B8 l$ @
lating hormone level was 1.3 µIU/mL (both normal).
% U0 p# _/ T3 X9 f7 ]# a6 dThe concentrations of serum electrolytes, blood( P$ z7 W' _5 z0 h
urea nitrogen, creatinine, and calcium all were
+ N5 X: }' J0 B% W' a8 b( T* ewithin normal range for his age. The concentration
! ^) }% X! u: B1 \of serum 17-hydroxyprogesterone was 16 ng/dL
% R6 ~4 e# m- ?- t; |(normal, 3 to 90 ng/dL), androstenedione was 207 K7 U- O1 c: u6 m) z2 t! x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! `' y; O9 P1 Y$ J. j3 Wterone was 38 ng/dL (normal, 50 to 760 ng/dL),- j/ t  x% K; ]6 I# K8 \# D, b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: m5 M# K6 e! o# q! l49ng/dL), 11-desoxycortisol (specific compound S)
6 I& o6 @- W' o- y7 Z8 gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: b& d- K2 Y: i! G+ R, H  t2 P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% c) b% x$ c/ o! itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 Q! }! O/ K1 N6 T3 i1 land β-human chorionic gonadotropin was less than
6 a0 z5 j* K- }: C7 b5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 ~, e: n" O# ystimulating hormone and leuteinizing hormone7 I; Z8 ]4 w2 h9 l& a3 w
concentrations were less than 0.05 mIU/mL
& d, |7 o. p! h/ U& A: k) Z(prepubertal).
* U7 ]6 m( n9 h! eThe parents were notified about the laboratory
, {5 ^# r% F) Fresults and were informed that all of the tests were, i6 |* z# }8 U2 `3 t
normal except the testosterone level was high. The! g* ~5 W/ h+ ?2 @
follow-up visit was arranged within a few weeks to
  m% y3 f5 a8 I1 i, o- U6 O) V/ Uobtain testicular and abdominal sonograms; how-
3 |; Z) n$ O* \5 Oever, the family did not return for 4 months.8 j# @6 o5 R, Q- X# G" m* s/ t
Physical examination at this time revealed that the
' Q" O/ x5 k0 ?: c1 dchild had grown 2.5 cm in 4 months and had gained  H/ H: a; ]9 U) y7 g. M
2 kg of weight. Physical examination remained4 k/ u& Y0 P( M  U% ?3 ^
unchanged. Surprisingly, the pubic hair almost com-: [: e' G( a! q8 X- K( f) c' Y
pletely disappeared except for a few vellous hairs at9 ~! D0 F3 j- f) S4 Z
the base of the phallus. Testicular volume was still 22 _+ r4 J8 `1 ^9 n6 U0 U) S" c
mL, and the size of the penis remained unchanged.
( h  n! J$ c" d( n5 U& K  U/ \The mother also said that the boy was no longer hav-
! O3 M% Q8 A- Xing frequent erections.) l# T& K% Z0 W
Both parents were again questioned about use of
' w1 D9 x( P, m$ X4 I) }any ointment/creams that they may have applied to
6 `' ?+ }- q% m3 Y( V" a/ [the child’s skin. This time the father admitted the: E, G% g" G2 A
Topical Testosterone Exposure / Bhowmick et al 541
  ?' O7 Z0 `0 C: x  p" Xuse of testosterone gel twice daily that he was apply-% Q6 W: m- m5 ^8 U1 ?4 E3 X- p4 q
ing over his own shoulders, chest, and back area for# M6 f) k, C' M% c+ D% T
a year. The father also revealed he was embarrassed
0 g% x4 w" W  q5 h; V7 Rto disclose that he was using a testosterone gel pre-
4 R2 k, H7 J1 s3 Yscribed by his family physician for decreased libido* _! r* Y% N! }7 d! Y
secondary to depression.
( C, l4 @* N- u% y( W3 }The child slept in the same bed with parents.1 H. \- l$ Z& A
The father would hug the baby and hold him on his
* R8 l* o2 G2 F2 G+ j% n+ cchest for a considerable period of time, causing sig-
9 y. M  Q7 }( V' F3 ~1 d( vnificant bare skin contact between baby and father.
# M" A7 G- v: a5 O" ?/ OThe father also admitted that after the phone call,0 t5 a3 P" \2 e1 }6 ^: n4 y1 I% b
when he learned the testosterone level in the baby# @4 a# B1 {* A* o
was high, he then read the product information9 t3 h; J$ l7 u  Z5 Y5 [- q: F
packet and concluded that it was most likely the rea-
: ~# f0 i1 O1 O! @" \/ @son for the child’s virilization. At that time, they6 }) S$ p& j- i6 n: I" d/ ]
decided to put the baby in a separate bed, and the6 W8 J( G( M. G. C% H/ D/ Q4 [5 W* b
father was not hugging him with bare skin and had
9 O$ n7 l8 y5 z% ]been using protective clothing. A repeat testosterone' g- c8 M) e% s1 m: k
test was ordered, but the family did not go to the
" k9 o$ \% x# t) m; N5 ulaboratory to obtain the test.
8 ?$ _# T" [, D2 @/ p. rDiscussion. |' x+ J# k4 A  }  L9 Q3 }# F
Precocious puberty in boys is defined as secondary( L0 O. B: p, f# z3 W
sexual development before 9 years of age.1,49 M4 e, [0 K; E! G2 O" k4 X: I' ~
Precocious puberty is termed as central (true) when
+ n- e! v7 D) x, o, ^3 ^. wit is caused by the premature activation of hypo-
6 P2 g, a: `: B) T/ @thalamic pituitary gonadal axis. CPP is more com-( W, |2 S# V) |* u
mon in girls than in boys.1,3 Most boys with CPP5 S* Y9 b+ R* ]; G
may have a central nervous system lesion that is
, D% r& J" r+ a0 y* X9 l, Tresponsible for the early activation of the hypothal-
; W0 ^# V1 u& U9 S+ J" M  `0 iamic pituitary gonadal axis.1-3 Thus, greater empha-8 ?: n: d- K% J
sis has been given to neuroradiologic imaging in2 {( z  t  h6 z% S8 F
boys with precocious puberty. In addition to viril-3 b: Q4 p* H# P2 T0 [9 b/ f( g7 D' ^
ization, the clinical hallmark of CPP is the symmet-
# f) g4 g" X6 [. Y5 I, ?' nrical testicular growth secondary to stimulation by
, h; m9 u" p% C5 ~8 o5 u. n+ Wgonadotropins.1,3( `& B% ]8 [$ @( \! Q* D) O9 r
Gonadotropin-independent peripheral preco-
# c! Z7 B& C( Tcious puberty in boys also results from inappropriate
: i1 }4 E  n8 E9 \androgenic stimulation from either endogenous or& J. i$ T! s$ e
exogenous sources, nonpituitary gonadotropin stim-- ~+ }& i3 x. t3 u: B- C
ulation, and rare activating mutations.3 Virilizing1 @8 D/ ~3 _' ^2 Q. {6 q1 C0 T
congenital adrenal hyperplasia producing excessive
1 \/ _5 r# D+ \3 \adrenal androgens is a common cause of precocious7 l$ Z" G# J% \3 `
puberty in boys.3,4; D) v3 j" [; g5 S8 V$ F5 e& ?9 B
The most common form of congenital adrenal: c& G5 i3 q+ D) S9 g* y6 l
hyperplasia is the 21-hydroxylase enzyme deficiency.
. L9 y' o3 O7 v- R% l+ cThe 11-β hydroxylase deficiency may also result in7 L: c5 @  y6 _% t' Q$ f3 i' Y
excessive adrenal androgen production, and rarely,
2 |( h8 @+ ?. {% |an adrenal tumor may also cause adrenal androgen
0 h  }# ?9 m6 e9 |excess.1,3
# s1 C) B, M8 ~8 _# z7 e7 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 O4 d' g  b- [8 B6 D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* o6 Z7 J: j7 N9 ?  H$ g
A unique entity of male-limited gonadotropin-6 y1 f- c: C9 g4 G% g
independent precocious puberty, which is also known& d- R/ d2 I! W7 [, s! Z6 v
as testotoxicosis, may cause precocious puberty at a
+ d! w: F+ Z! i( |very young age. The physical findings in these boys
9 D9 Q" _$ X6 R; B3 `( zwith this disorder are full pubertal development,
8 F% t# V0 o! l- [8 P9 `" tincluding bilateral testicular growth, similar to boys4 t% [. V) E/ K3 [5 z: d
with CPP. The gonadotropin levels in this disorder7 P" J* \8 Y' w; f- v
are suppressed to prepubertal levels and do not show: w3 b( n7 m9 M/ u& ~
pubertal response of gonadotropin after gonadotropin-
, f9 p2 \5 i0 g1 S+ j/ ureleasing hormone stimulation. This is a sex-linked9 w: U3 h* @# G3 x' [& t
autosomal dominant disorder that affects only' A2 n, j  s" I, F' q& b
males; therefore, other male members of the family
. m; \* B4 m4 P* `" [may have similar precocious puberty.3
  g! H- T# ^7 `# l& o+ e' b! b" OIn our patient, physical examination was incon-- k+ y& H6 `, J/ R* C1 A  \
sistent with true precocious puberty since his testi-
( U, b6 Z( Q  [3 W. w. Q; dcles were prepubertal in size. However, testotoxicosis  P" `. z7 q8 ^3 t+ Q0 \1 _
was in the differential diagnosis because his father
/ G. r: R0 _+ L6 \' `: k3 Mstarted puberty somewhat early, and occasionally,
( N  q( ]  A- S" Y' `) d$ w8 Ttesticular enlargement is not that evident in the
+ ~' \5 s$ _+ F$ ?) h& [3 qbeginning of this process.1 In the absence of a neg-
9 e; q+ g( \1 f3 c1 Aative initial history of androgen exposure, our' D$ |$ e& C' Z$ s. }2 k: t7 P
biggest concern was virilizing adrenal hyperplasia,
. T" f3 x) }) V5 U* Q1 q) ?4 ^. R4 ueither 21-hydroxylase deficiency or 11-β hydroxylase
# }+ q" r6 o$ j$ sdeficiency. Those diagnoses were excluded by find-
, `/ X, ^7 j) aing the normal level of adrenal steroids.
' w, R# {0 u6 @1 p5 SThe diagnosis of exogenous androgens was strongly
8 f7 G* j5 n) L3 D  Wsuspected in a follow-up visit after 4 months because
. F6 d. _% x1 R- R0 c. b7 A! Ethe physical examination revealed the complete disap-8 o- o6 y" c3 s$ w2 p9 c
pearance of pubic hair, normal growth velocity, and( e- {) p$ s7 P1 h# ^  m
decreased erections. The father admitted using a testos-
# M0 Z" d$ g. |! b! A. f4 \3 yterone gel, which he concealed at first visit. He was
% s3 U* f+ ]2 |( Y5 x" F' ]using it rather frequently, twice a day. The Physicians’
- @+ Q9 `5 i& `Desk Reference, or package insert of this product, gel or, G: E& l3 u3 _/ I  _
cream, cautions about dermal testosterone transfer to! [6 M0 _0 I) c! S, z
unprotected females through direct skin exposure.& H1 t5 a, y; ~: X: X0 @
Serum testosterone level was found to be 2 times the  f# c7 {8 l% j' |8 x
baseline value in those females who were exposed to" }" {+ o+ c% E+ q  N" R3 J- E2 @
even 15 minutes of direct skin contact with their male
: p) @+ L* j; f' y/ E) l/ M- Y/ cpartners.6 However, when a shirt covered the applica-7 D& z- e2 e% Z
tion site, this testosterone transfer was prevented.
" p/ o' I8 Y2 m! X# cOur patient’s testosterone level was 60 ng/mL,
2 m( `. F+ [- E6 Q5 Y& l  Nwhich was clearly high. Some studies suggest that
0 S% b, r0 A4 @: }dermal conversion of testosterone to dihydrotestos-
9 m( R3 [9 f. u5 Lterone, which is a more potent metabolite, is more
9 x& b% s- t/ e; wactive in young children exposed to testosterone0 @6 c0 i0 s4 ~) U+ c
exogenously7; however, we did not measure a dihy-: [- |7 C. r5 x8 k9 _
drotestosterone level in our patient. In addition to
: L+ c+ v2 `- I# Uvirilization, exposure to exogenous testosterone in6 d9 O7 D9 z0 t$ m
children results in an increase in growth velocity and
* Y% P, Q0 [9 e( Xadvanced bone age, as seen in our patient.9 P7 t) c4 D6 G; ?/ R2 R- |
The long-term effect of androgen exposure during( n" N: i2 O+ ?. _, r! ~/ [9 p
early childhood on pubertal development and final0 c, k; O8 Q  [7 i! L1 G. F6 J1 z
adult height are not fully known and always remain
% G3 q* L9 G9 U% p, R/ E1 aa concern. Children treated with short-term testos-
7 w& n3 N  z* S& x. aterone injection or topical androgen may exhibit some9 U+ e* x4 _4 z- [3 g
acceleration of the skeletal maturation; however, after
4 l  a0 Q, Q: A- _* E; s0 bcessation of treatment, the rate of bone maturation. D) F% D0 ?6 ^+ [0 W! b  j
decelerates and gradually returns to normal.8,9
0 V7 ]2 U1 i3 |: Y- u' JThere are conflicting reports and controversy5 K6 o* @8 P; q" J- l9 G
over the effect of early androgen exposure on adult
/ N( x1 X9 M$ V) h# G6 ]' h% openile length.10,11 Some reports suggest subnormal/ x: W/ D) i. g# H% N! I/ b
adult penile length, apparently because of downreg-6 N" w1 ~" x. s& G7 O6 m* l
ulation of androgen receptor number.10,12 However,
  B5 \  A4 \- M% c3 A$ m9 G( DSutherland et al13 did not find a correlation between
8 P) l. u& g7 f3 q! k/ r& wchildhood testosterone exposure and reduced adult. J5 y8 C4 P9 d7 g2 s' d4 l
penile length in clinical studies.5 {6 N9 v) Y7 I: A
Nonetheless, we do not believe our patient is( d- g7 m5 O, ?9 k' d
going to experience any of the untoward effects from
2 J5 K0 k, F2 r6 X9 [/ ?testosterone exposure as mentioned earlier because
) D/ b: r' t( f. M7 j2 a) c1 Sthe exposure was not for a prolonged period of time.
& G2 ]9 F9 O2 x% \8 ^2 JAlthough the bone age was advanced at the time of+ M9 Y2 [+ _; O0 `7 M0 D
diagnosis, the child had a normal growth velocity at0 g/ x$ A0 v8 N# t$ `8 r1 F
the follow-up visit. It is hoped that his final adult
+ a# l5 g( F5 P1 S0 Theight will not be affected.
) ]$ J  t$ c6 _9 Y+ n" a! ^Although rarely reported, the widespread avail-
" d+ |+ C, X/ E0 F1 Yability of androgen products in our society may* {' m. k7 J& G
indeed cause more virilization in male or female
( a4 A9 M9 [! f0 O9 ?children than one would realize. Exposure to andro-6 p9 v  n) B3 d' s
gen products must be considered and specific ques-4 k6 Y1 R/ q2 {! O
tioning about the use of a testosterone product or7 D* j6 C2 ~; J; t5 i9 H- {
gel should be asked of the family members during
3 M2 Z& v$ U2 `6 s8 W; qthe evaluation of any children who present with vir-6 K( A# V# }3 l
ilization or peripheral precocious puberty. The diag-' G$ B; y2 o: e- _
nosis can be established by just a few tests and by
4 v" O2 u; R( X* Aappropriate history. The inability to obtain such a
5 Z0 x6 P; u: w* \; F, ?history, or failure to ask the specific questions, may
. j: U# k* I! o( i2 fresult in extensive, unnecessary, and expensive
: b6 t2 @1 r& N% ginvestigation. The primary care physician should be
3 F( P+ d2 \9 e) vaware of this fact, because most of these children
8 `& e% ^- o! D- p; n6 ~. Gmay initially present in their practice. The Physicians’8 \  `: `* T3 o' n) k. l2 t" ]+ z
Desk Reference and package insert should also put a
% Y, c" Q) _4 Z! @2 e; Q* c0 Ewarning about the virilizing effect on a male or  L- z1 t' U( k7 L
female child who might come in contact with some-8 v1 V6 ~. F2 ^, `4 r
one using any of these products.
5 j, N: v  T: @7 e7 CReferences
0 M5 k* t: j6 M5 x$ x1. Styne DM. The testes: disorder of sexual differentiation5 S6 V3 s6 t  e6 x9 q
and puberty in the male. In: Sperling MA, ed. Pediatric0 {! S5 o1 X: N# l9 D! D6 j, ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 Q- I' j7 _- G7 o4 y+ n2002: 565-628.  s- R) k* {1 ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" p7 A7 O/ A/ o: R( U) A0 Apuberty 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

0 W! ~9 m6 z" P: A4 N/ u8 M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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