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Sexual Precocity in a 16-Month-Old
9 A+ X* y" ?+ n2 T# EBoy Induced by Indirect Topical2 E7 R) r7 [" `- b( N  G& \/ f1 [' E6 @4 q
Exposure to Testosterone
; L7 A# Y% a0 N) O! r. c' sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 ]& g  X7 A* s, W( x
and Kenneth R. Rettig, MD10 w  s! B& i3 u2 v; E3 |
Clinical Pediatrics
: g9 [) J. u) x  bVolume 46 Number 6: I. U0 N5 O& |4 R" W/ j9 H
July 2007 540-543, f! ~% k* a* T5 G+ y6 S$ w
© 2007 Sage Publications) J: a: t) s. N* ^8 K2 g9 d3 x
10.1177/0009922806296651( d; t( L4 O' I- I* n& x
http://clp.sagepub.com9 s( J' m8 K% `) W- c
hosted at5 Y" P6 c3 z( y$ r- W3 s  X4 |' s
http://online.sagepub.com% l5 H& B, R9 ~- }! |4 ?( K
Precocious puberty in boys, central or peripheral,/ p8 d8 q/ W/ u6 g5 ?
is a significant concern for physicians. Central
1 B4 N0 o/ J4 S9 d+ jprecocious puberty (CPP), which is mediated
" T& j% V6 `4 lthrough the hypothalamic pituitary gonadal axis, has  _3 f! }: {) f& t; \" B
a higher incidence of organic central nervous system
+ R) W9 v' N* ?/ o% xlesions in boys.1,2 Virilization in boys, as manifested
* U4 R) E) z4 Eby enlargement of the penis, development of pubic7 C8 n6 P* R1 m/ ~7 D) u) ?
hair, and facial acne without enlargement of testi-
( h0 V5 y" A; v' v" P+ i! l! Dcles, suggests peripheral or pseudopuberty.1-3 We& y6 _! B# d8 D" R( C1 b4 H  @0 q
report a 16-month-old boy who presented with the- k$ Z. n$ E* H- ?# P
enlargement of the phallus and pubic hair develop-2 E7 F. m) w/ B- l7 R3 d0 t7 P
ment without testicular enlargement, which was due( q( v: V* v9 R7 Y, s
to the unintentional exposure to androgen gel used by. P! o- [+ O5 d0 D* Z
the father. The family initially concealed this infor-
, m( t6 M* x7 ?2 jmation, resulting in an extensive work-up for this. O8 H8 i$ Q: @/ Q6 x" ^2 J
child. Given the widespread and easy availability of8 H* E! z: O, s8 I" U2 I" }
testosterone gel and cream, we believe this is proba-
' H6 b8 @* {# ]% k5 D  H: rbly more common than the rare case report in the
3 g* J, ~- W2 g9 f% p6 V4 Y0 U+ Uliterature.4" ]- X3 A5 e! R: f6 k1 O
Patient Report
1 @* `' ~- s% D, qA 16-month-old white child was referred to the
2 F! q- k+ C3 a. P: fendocrine clinic by his pediatrician with the concern7 A2 Y( K; V- X
of early sexual development. His mother noticed+ t, e" Y: O/ ~
light colored pubic hair development when he was
2 @* J. [6 J9 M6 D% kFrom the 1Division of Pediatric Endocrinology, 2University of* S* H4 L; W* k- ^9 u& {
South Alabama Medical Center, Mobile, Alabama.
+ ^% a/ X) ?* P2 P. [- k) K7 WAddress correspondence to: Samar K. Bhowmick, MD, FACE,0 n# V- e7 S7 g! S7 ^0 A7 y; U+ |$ o
Professor of Pediatrics, University of South Alabama, College of- w! u% I% o6 _$ k. G1 t9 @
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, ~2 e; S, D' @, S
e-mail: [email protected].
( _' \; Y6 Z, P* D9 b% eabout 6 to 7 months old, which progressively became
, e& w" Z9 \1 U" {4 _/ M9 E' `darker. She was also concerned about the enlarge-$ h3 Q+ ~; h2 A! [
ment of his penis and frequent erections. The child
* C" H( B3 Q& j2 a# L5 e$ Cwas the product of a full-term normal delivery, with
; C' I. }1 i4 p/ |+ y" m+ k7 a9 \' ~* ?4 Wa birth weight of 7 lb 14 oz, and birth length of
0 i3 f+ s- M, d0 Y2 ?1 M20 inches. He was breast-fed throughout the first year5 ]3 |/ L$ |, d
of life and was still receiving breast milk along with
& r4 r$ a  s# R) k; w8 l* ssolid food. He had no hospitalizations or surgery,
! Z$ [# ~# z' x" B1 oand his psychosocial and psychomotor development
1 F. \0 j5 X. k) O6 a' Iwas age appropriate.8 i5 `9 [; w: {3 ]; _# I; y
The family history was remarkable for the father,* l- l% `, W9 u4 i( \6 V+ b2 C5 g0 j
who was diagnosed with hypothyroidism at age 16,) J7 _/ ~: y  I+ M/ w7 g
which was treated with thyroxine. The father’s
$ e7 H8 ^( ~& _6 b4 P- F9 i1 oheight was 6 feet, and he went through a somewhat" O: [' M& M3 k3 c& H
early puberty and had stopped growing by age 14.9 b3 m) q* }' {1 U$ K- i
The father denied taking any other medication. The
, J# k  o) G/ v' H  [  E* d: Wchild’s mother was in good health. Her menarche1 a! R& S/ f# H6 E
was at 11 years of age, and her height was at 5 feet
3 F( a, t& l  s3 {2 Q5 inches. There was no other family history of pre-/ F/ m" I5 H4 F$ B5 G. m' l+ _
cocious sexual development in the first-degree rela-
+ ]2 u: J; C. J3 U8 R0 D% M+ }. Stives. There were no siblings.- s" E$ P) z9 j: D
Physical Examination; l6 o8 U- R  ?5 M2 w
The physical examination revealed a very active,
# o# w5 f. z$ r! a/ K% eplayful, and healthy boy. The vital signs documented" K4 u% K2 T: J' u! @2 D: ]. N: c- P
a blood pressure of 85/50 mm Hg, his length was
7 K2 R; @5 [! n' Y( ~% g90 cm (>97th percentile), and his weight was 14.4 kg3 ?. A' b5 @* `9 M3 s
(also >97th percentile). The observed yearly growth: d1 c$ L& f0 o& Q/ d4 k# ]; A' b5 R
velocity was 30 cm (12 inches). The examination of
0 B; ?4 }) ]* c# r% Wthe neck revealed no thyroid enlargement.
. w7 E6 s5 ?9 x. O" _$ _4 {- _The genitourinary examination was remarkable for) G4 V% f  V0 ?$ Y+ x- V0 g/ H. @
enlargement of the penis, with a stretched length of% j8 ~% p* {, v
8 cm and a width of 2 cm. The glans penis was very well4 I6 J' }9 K. i' Z; N; V* w* f
developed. The pubic hair was Tanner II, mostly around& c  c7 ^$ f  |
540
9 N. j) P) J/ H- m7 p! a2 {) kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' M* o6 e8 ^1 m2 `6 \/ x" K  Gthe base of the phallus and was dark and curled. The/ F5 \6 I: S. c  Y) _  |
testicular volume was prepubertal at 2 mL each.8 u/ }$ z  ?8 R5 [" g1 h
The skin was moist and smooth and somewhat2 q# k/ k& ^: o: s0 N+ y& ^# F
oily. No axillary hair was noted. There were no
3 ]+ W" `$ n9 t* e1 T% fabnormal skin pigmentations or café-au-lait spots.
8 U* j  E5 E+ d" Z- r: L" yNeurologic evaluation showed deep tendon reflex 2+
; |( F1 L3 ~" d5 O, ?# h* G  lbilateral and symmetrical. There was no suggestion
! [5 ?% j2 f/ jof papilledema.7 k% w; L8 x" f7 f4 h& ~0 X+ T5 B
Laboratory Evaluation9 l# U0 o$ y! n& h
The bone age was consistent with 28 months by
4 p7 s4 i7 q5 D% ]1 L  |using the standard of Greulich and Pyle at a chrono-4 v* ~# g" ?" h# W9 I/ H9 r6 W
logic age of 16 months (advanced).5 Chromosomal
! Q0 b! _: D+ X. W0 x: r4 `karyotype was 46XY. The thyroid function test
# V3 G- P5 u" W8 r5 _# R, S" nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-$ R6 r7 z: e% Y4 k! N
lating hormone level was 1.3 µIU/mL (both normal).
- b- X) P4 a( XThe concentrations of serum electrolytes, blood
7 Q' G* j: A* B0 d  r; Furea nitrogen, creatinine, and calcium all were
0 Z! _6 [& X/ O4 w2 c! ]9 ewithin normal range for his age. The concentration8 g7 X' S; ]" P3 Z! K
of serum 17-hydroxyprogesterone was 16 ng/dL, j1 J+ O+ y6 N: w
(normal, 3 to 90 ng/dL), androstenedione was 20
) K- N  y3 W6 @7 h2 T% I, Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* r: f& j, J% Zterone was 38 ng/dL (normal, 50 to 760 ng/dL),
% Y6 e# u# S5 |( F! @  [* }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% m/ h3 t' _; m  `; s; i1 W$ S49ng/dL), 11-desoxycortisol (specific compound S)
5 f" ^' K7 N& u, R) Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ u, G$ [6 d- N" q- H- d) l$ A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, M# a( P4 ~# d6 n- M, }testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 K7 J' ~% _* o6 M( k6 n& }
and β-human chorionic gonadotropin was less than5 Q2 I5 b" W; s) k; e2 F
5 mIU/mL (normal <5 mIU/mL). Serum follicular
& j! `$ R3 L) o( u: F6 P; e# ustimulating hormone and leuteinizing hormone# z- P: {5 b1 B# x( E4 V
concentrations were less than 0.05 mIU/mL
" E3 P2 L( d! x: M2 P" v(prepubertal).
: K( p+ U1 J  qThe parents were notified about the laboratory/ V7 r- j- j! i: @4 f
results and were informed that all of the tests were
" k4 A7 R7 _" N3 cnormal except the testosterone level was high. The
. e3 L3 D* }0 p+ y: Z, Nfollow-up visit was arranged within a few weeks to
; S' f4 c, x7 G# q- `3 q: }, hobtain testicular and abdominal sonograms; how-  q/ O- G" l+ S3 {7 V
ever, the family did not return for 4 months.
2 I; l# T3 H6 L8 J  fPhysical examination at this time revealed that the9 Y8 i" q: @0 v$ D
child had grown 2.5 cm in 4 months and had gained
+ D& {7 i. i5 S. `2 kg of weight. Physical examination remained
8 R8 R/ L- x- J5 p' t% bunchanged. Surprisingly, the pubic hair almost com-
# O! A2 t3 U' ]* f2 n8 f9 |pletely disappeared except for a few vellous hairs at& T$ q6 ?5 M$ `* v6 E5 z
the base of the phallus. Testicular volume was still 22 D, n6 z" n) U- @3 f  n% s5 V
mL, and the size of the penis remained unchanged." T' C% V# D9 I
The mother also said that the boy was no longer hav-/ T3 n- G8 u& ]# m4 P
ing frequent erections.% s5 _' g1 T5 B( }" \  q( z
Both parents were again questioned about use of
) m5 U# r: D9 iany ointment/creams that they may have applied to
5 p( r( v' J7 g6 s& c- U7 Zthe child’s skin. This time the father admitted the& d4 J! ?/ Y3 {, e4 b
Topical Testosterone Exposure / Bhowmick et al 541
" L/ z' ?7 ]/ Buse of testosterone gel twice daily that he was apply-; s# r: |( f8 M. a' Z/ X
ing over his own shoulders, chest, and back area for
$ c0 \6 x0 C) c  E- y1 Ra year. The father also revealed he was embarrassed
2 ~$ W3 F2 b9 ^9 O% c2 V3 pto disclose that he was using a testosterone gel pre-) l1 ]: J5 G4 W5 i
scribed by his family physician for decreased libido' p- m- d/ [1 D7 W
secondary to depression.; S' B$ q1 |' Z" M
The child slept in the same bed with parents.
  `7 q: ^! d1 r% W8 g6 i+ rThe father would hug the baby and hold him on his
9 @; N; G- h5 f9 O0 ]chest for a considerable period of time, causing sig-
) o" G- k. @1 V* @; P4 W% x) fnificant bare skin contact between baby and father.4 c! U6 O2 I4 n" F
The father also admitted that after the phone call,4 B5 {7 o" Q4 S# ~$ m
when he learned the testosterone level in the baby1 \0 u5 t4 X- Q! t" Q' B% A. L0 }
was high, he then read the product information
& p0 @  S5 B" K8 ^' r1 bpacket and concluded that it was most likely the rea-1 [4 W3 x1 ?8 |9 ~/ Y# r
son for the child’s virilization. At that time, they
) l4 w0 T) w- _" ^/ fdecided to put the baby in a separate bed, and the
+ q% L6 V0 O+ Y# bfather was not hugging him with bare skin and had
& i% a) b3 @+ bbeen using protective clothing. A repeat testosterone
( V) C% C8 K2 e7 f9 L0 d! h" x6 Y& L' dtest was ordered, but the family did not go to the
  G# T0 x' r3 s8 i. p& xlaboratory to obtain the test.! F; Z5 T1 v& J- n( C9 w6 f
Discussion! q0 P: F1 u8 G" i
Precocious puberty in boys is defined as secondary$ b9 ]  Q) d3 o! j% c: s# L% p9 v7 q
sexual development before 9 years of age.1,4
% r9 s) H: u  |5 xPrecocious puberty is termed as central (true) when
$ G" g( c9 o: e0 E  |7 y" Wit is caused by the premature activation of hypo-
7 ^& d2 M3 P# T/ G5 Z' x- a) I8 Dthalamic pituitary gonadal axis. CPP is more com-
; t5 b9 s0 `  f* e- `' h+ v* Fmon in girls than in boys.1,3 Most boys with CPP
1 p% y: S8 a5 ^; u! b$ P/ P0 o( Ymay have a central nervous system lesion that is
; L0 U& R( `" Xresponsible for the early activation of the hypothal-
7 `9 k3 ~( [+ \( i( g( }amic pituitary gonadal axis.1-3 Thus, greater empha-7 T; Y8 i+ O/ [: R. P/ p+ v" l
sis has been given to neuroradiologic imaging in* i1 M8 Y& `# I, Q  \1 A% @, Y
boys with precocious puberty. In addition to viril-
# Y' x' }& u- d) P( }) s% Kization, the clinical hallmark of CPP is the symmet-
  Y- y* ^* ^1 \" Drical testicular growth secondary to stimulation by
: L/ w' m, Y, ^4 \8 P% T- ~1 c, rgonadotropins.1,3
2 b8 z# f+ w7 Z) b8 d& ?9 L# TGonadotropin-independent peripheral preco-
9 T, p4 ^( x3 o2 L. j' @/ Kcious puberty in boys also results from inappropriate+ Z6 W- ]+ ]( R/ F& M- e3 Z% Q
androgenic stimulation from either endogenous or2 s" d5 _- D1 ~7 j
exogenous sources, nonpituitary gonadotropin stim-
4 C+ u. d8 E: |( \; nulation, and rare activating mutations.3 Virilizing- v3 L% R4 _, v" r- m9 l! V3 @
congenital adrenal hyperplasia producing excessive# U' r" f$ C9 t
adrenal androgens is a common cause of precocious
; C2 C$ G* Q' S# {0 D- X: u, Spuberty in boys.3,4
% m0 x2 i8 B2 S4 BThe most common form of congenital adrenal" j- P' \) v! J3 [0 v% x( D9 P
hyperplasia is the 21-hydroxylase enzyme deficiency.$ q0 O" K8 S! k. W1 ]- E( b) e$ B
The 11-β hydroxylase deficiency may also result in
  {; ]6 E, ]1 a/ T9 ]$ `/ A* Vexcessive adrenal androgen production, and rarely,
1 M! a7 [5 ~' Tan adrenal tumor may also cause adrenal androgen6 m& M5 w: o9 D  |8 R% f
excess.1,3$ f9 A0 ]( ]4 g( {: c& _9 i% N
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 a% T" M5 e4 w3 N2 ]% F" y4 K542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 i6 N/ j; c1 E$ }
A unique entity of male-limited gonadotropin-
) J2 h2 G- H( h* m3 Cindependent precocious puberty, which is also known, c2 x: k9 c) [: F$ _: @
as testotoxicosis, may cause precocious puberty at a
* T  w" }9 K/ K6 K! i. o& Ivery young age. The physical findings in these boys5 a3 ?; C7 @/ K6 c! M! M
with this disorder are full pubertal development,+ d1 p; `7 z& u5 _' H) W( `
including bilateral testicular growth, similar to boys
/ U: ]( E" M3 e& e" ywith CPP. The gonadotropin levels in this disorder
8 N9 o( {8 s; S( g! [, I/ y7 Nare suppressed to prepubertal levels and do not show
3 I/ }, s4 g5 b. q& `) Wpubertal response of gonadotropin after gonadotropin-4 Q* k- q6 A( x$ |% ], V5 M  v% b) R
releasing hormone stimulation. This is a sex-linked' G( Z3 v0 {% [/ _
autosomal dominant disorder that affects only" D, J8 B1 W  B6 F
males; therefore, other male members of the family
0 h6 |6 ^+ ]& qmay have similar precocious puberty.3
2 {4 Z% m& t$ L" R+ uIn our patient, physical examination was incon-2 Y. j; S) M' z3 i! h2 @
sistent with true precocious puberty since his testi-1 J0 @6 z5 h7 {' w5 t
cles were prepubertal in size. However, testotoxicosis
: ?7 I0 r3 T# I: lwas in the differential diagnosis because his father
+ f8 a# z9 ^+ ]2 i" f% `8 t, kstarted puberty somewhat early, and occasionally,5 c2 `6 s' g: f$ S  O
testicular enlargement is not that evident in the- A0 w& G7 z; E) }+ ^: y) t" h4 v
beginning of this process.1 In the absence of a neg-
. v8 D$ {' U4 z! w- ^8 ^: bative initial history of androgen exposure, our
- T7 R% j9 b% N. ~biggest concern was virilizing adrenal hyperplasia,: [( p: s2 {+ Y. V4 J
either 21-hydroxylase deficiency or 11-β hydroxylase
% C' a" i2 {/ Y# Tdeficiency. Those diagnoses were excluded by find-1 t6 x. E5 {8 W! Q( m) w
ing the normal level of adrenal steroids.
4 v+ s& e; F( G8 ^5 AThe diagnosis of exogenous androgens was strongly( `6 j5 r8 z$ {2 p5 ]3 G6 P1 c7 d& J
suspected in a follow-up visit after 4 months because! ?, b8 l% G* z  A  ^  W. \% Y, i. a
the physical examination revealed the complete disap-
* W! s# p( c1 Cpearance of pubic hair, normal growth velocity, and+ F# a! x1 P& j$ c; l0 Z% w
decreased erections. The father admitted using a testos-* N7 j2 \6 o! R) A5 d' s9 H
terone gel, which he concealed at first visit. He was
/ O- T4 |6 }( _: `- G/ s: Tusing it rather frequently, twice a day. The Physicians’
2 |0 v7 O: N4 c  K% _8 LDesk Reference, or package insert of this product, gel or2 c8 b$ Q2 `$ `% y7 X& h
cream, cautions about dermal testosterone transfer to
  _5 U  _& x. Bunprotected females through direct skin exposure.
/ T2 z7 r. l- L* `Serum testosterone level was found to be 2 times the* H" b; K0 a. k0 H$ y* i0 G6 R
baseline value in those females who were exposed to
+ Q# A* G+ F- ^even 15 minutes of direct skin contact with their male2 ^+ _5 }' y1 a( J$ j2 @2 q+ Z( H
partners.6 However, when a shirt covered the applica-6 J6 u! x0 P$ ~
tion site, this testosterone transfer was prevented.
: P5 W8 u5 ~7 P" NOur patient’s testosterone level was 60 ng/mL,0 R6 M0 o, J6 Q* Q: v7 A0 A; o
which was clearly high. Some studies suggest that
& I) U2 e, L$ K& o! wdermal conversion of testosterone to dihydrotestos-
, y: `" w, r7 C  qterone, which is a more potent metabolite, is more
! y! }* B8 h/ B' H5 ~- ?2 Wactive in young children exposed to testosterone
2 [4 S: }6 L! l! w8 [exogenously7; however, we did not measure a dihy-' d( b0 E) Z0 Z
drotestosterone level in our patient. In addition to
* R5 ~( i; b, G4 z5 ?4 w) @9 H  Nvirilization, exposure to exogenous testosterone in& T( z0 d+ g8 E' ]/ @* w) R
children results in an increase in growth velocity and4 {7 y6 H$ |4 p  R. P) b9 b
advanced bone age, as seen in our patient.( v, W$ ]" ], N
The long-term effect of androgen exposure during' T: X# t8 m  q5 w
early childhood on pubertal development and final
% m8 b) u( h$ _+ z+ g. W% Vadult height are not fully known and always remain' k% ]* m; u3 g/ A  @% c
a concern. Children treated with short-term testos-
+ \% V6 ~( p+ L/ }terone injection or topical androgen may exhibit some
4 \4 y% ^  ?! T4 S- C( i- D6 `acceleration of the skeletal maturation; however, after
; d% q; l1 T, R6 H4 hcessation of treatment, the rate of bone maturation
) |+ o  E+ i0 {/ y6 U" }decelerates and gradually returns to normal.8,9* k4 x$ ^. h5 C6 F! N. v
There are conflicting reports and controversy: w- m! n& y# O# D
over the effect of early androgen exposure on adult* Q1 R5 W3 U7 B, k
penile length.10,11 Some reports suggest subnormal
% m3 Y6 q' M: ]! Y9 }, ^" j+ Iadult penile length, apparently because of downreg-; ~% O# F2 f9 R
ulation of androgen receptor number.10,12 However,& a9 b7 h, k6 Y( v
Sutherland et al13 did not find a correlation between
. t: ~  `3 c( U9 T7 J: Z& Uchildhood testosterone exposure and reduced adult
& w3 C  u4 Q! f5 C, @$ Kpenile length in clinical studies.
$ S% M, k4 a* P" C( S# |# X! zNonetheless, we do not believe our patient is
- u* ^, N/ f/ L; v1 u7 ~, b  {going to experience any of the untoward effects from& J  E- o* S( {- n6 ~
testosterone exposure as mentioned earlier because% ^% Y' ?: R2 [* G- H; l# h+ H0 r. k
the exposure was not for a prolonged period of time.
" d5 k- T7 J( U) ~Although the bone age was advanced at the time of/ j1 ?0 [6 T' ]+ y8 j
diagnosis, the child had a normal growth velocity at/ M; S! o( w' x7 F5 T7 H* P1 _
the follow-up visit. It is hoped that his final adult5 M: }8 k' e) O2 ^) `0 I
height will not be affected.
7 q5 e! e: @& `' @9 RAlthough rarely reported, the widespread avail-- Y6 g1 J/ |5 F% h( u
ability of androgen products in our society may& B4 p5 H6 _/ D0 E: }
indeed cause more virilization in male or female
- q, A( D$ t8 Q4 L( K# @% achildren than one would realize. Exposure to andro-. p% f: ]4 ?+ j' N1 c7 i
gen products must be considered and specific ques-8 M" K* J7 O8 ?7 y. Z# W" ?$ l; A
tioning about the use of a testosterone product or# A  L+ X( D9 x( ^+ O
gel should be asked of the family members during4 F! S/ y, I( D; R! [2 s- D
the evaluation of any children who present with vir-: l: v- u5 m' S! \4 R4 B+ s: t9 f
ilization or peripheral precocious puberty. The diag-
" c6 y# v, {1 e; C7 \nosis can be established by just a few tests and by
  w: R4 O; F* `5 `appropriate history. The inability to obtain such a; L' C9 m/ `4 ?& w$ Y
history, or failure to ask the specific questions, may% Q% P0 P( \6 _& A
result in extensive, unnecessary, and expensive
3 ~; W# U$ p* v) B: sinvestigation. The primary care physician should be
2 j0 w* F) t$ m( N$ u6 oaware of this fact, because most of these children
9 p' s. B4 }) _$ }) U% ymay initially present in their practice. The Physicians’
% v0 A3 }0 V# |% Z0 C+ FDesk Reference and package insert should also put a6 Y1 O& G8 z* E& ^* a
warning about the virilizing effect on a male or
7 n6 E; A" I# D; sfemale child who might come in contact with some-
" C; Y8 K5 O# qone using any of these products., \* U" _+ e' M3 i+ E% _
References. H& f9 r# w: v4 r3 c, [* ]
1. Styne DM. The testes: disorder of sexual differentiation
7 K3 K& U) E$ a- ^; _and puberty in the male. In: Sperling MA, ed. Pediatric# P* O8 h& [; @( q% I1 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& Q2 ~; ?6 D, }% u( P" b
2002: 565-628.( ?$ y" T6 E7 ]# F  C- a* F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 S% I( ]7 i7 S8 u  o: f
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 @" g+ @8 B5 j( E" B2 X- {
Boy Induced by Indirect Topical
" S! q- R  P) g- ~" i5 ~+ A( l5 ?$ pExposure to Testosterone
3 o% k8 z8 a: [) F$ E; m6 LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ f; {6 |9 @5 k2 hand Kenneth R. Rettig, MD1
; b% k5 }* e; dClinical Pediatrics5 `+ y+ A- C+ J2 Q) t2 b4 E
Volume 46 Number 6& C0 Z( F2 U5 N3 ^
July 2007 540-5435 G$ y" p1 r7 D4 ~/ k% P
© 2007 Sage Publications! s1 u+ ]7 |  c2 [4 Y; B5 P( Q
10.1177/0009922806296651
6 Z  c4 p9 r+ b) a: ]+ I; t; C! ehttp://clp.sagepub.com
/ S* @9 \# K3 U3 z* f" s* n- Rhosted at
: V* ], W8 P7 d% t- X+ V3 q; W! ehttp://online.sagepub.com- i' A# h  }0 F/ b# c# d
Precocious puberty in boys, central or peripheral,
5 w7 O7 U( w7 ?5 r0 n0 tis a significant concern for physicians. Central+ g+ U# |: e3 {% o9 _
precocious puberty (CPP), which is mediated
9 x3 |2 @- c* \; @+ T/ c# i% Sthrough the hypothalamic pituitary gonadal axis, has4 n$ ^) Q2 u+ q8 j. a  }. f; X# k
a higher incidence of organic central nervous system3 }# H1 e" j+ o( A3 m
lesions in boys.1,2 Virilization in boys, as manifested" y9 O& D* c, y! n' a1 w
by enlargement of the penis, development of pubic
5 B6 {' i4 Y1 g/ \4 N; ]9 h/ y+ Nhair, and facial acne without enlargement of testi-
' u! ~- F; i" V5 P/ b. D; Xcles, suggests peripheral or pseudopuberty.1-3 We
/ p! K8 }# L- I8 `  _: Qreport a 16-month-old boy who presented with the
! s$ w8 h" M8 {8 ?& @3 [enlargement of the phallus and pubic hair develop-" e" t0 ~/ v. C8 i, ?+ U, p
ment without testicular enlargement, which was due3 D% E8 ~2 D3 Y
to the unintentional exposure to androgen gel used by
& _: B. p. I; A: bthe father. The family initially concealed this infor-
' c7 ^& S1 Z( `mation, resulting in an extensive work-up for this8 y! q8 N2 Y$ h4 ?( u. X
child. Given the widespread and easy availability of
1 @2 I) @3 y9 c" W  F! Qtestosterone gel and cream, we believe this is proba-- u! ^+ h& T! G3 A* B- M/ g7 c
bly more common than the rare case report in the4 R5 w2 P3 r! V$ ?. M
literature.4. x. F4 i$ _: I
Patient Report
. d# N" _* v) }A 16-month-old white child was referred to the
* [; r& l0 l  X+ E; Z: p$ yendocrine clinic by his pediatrician with the concern
  E6 J) \. b' e- a+ ^of early sexual development. His mother noticed6 s/ S1 u) w5 E4 H
light colored pubic hair development when he was
, f2 R: K0 s" t% ?4 [From the 1Division of Pediatric Endocrinology, 2University of
9 @' d- `- {! P; N, u/ xSouth Alabama Medical Center, Mobile, Alabama.; e+ [0 w# \7 y+ W* V. A
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 i6 c8 h/ Q; c) Z+ k* T9 I. rProfessor of Pediatrics, University of South Alabama, College of
3 {# J& Z: y& B! x: Y$ xMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, \* O) e2 h2 y% ^4 R* v
e-mail: [email protected].  @* E4 `" T& l
about 6 to 7 months old, which progressively became: ?$ e1 w; ^& f
darker. She was also concerned about the enlarge-8 C+ Z8 V; _3 d# L) q  r
ment of his penis and frequent erections. The child+ r- @4 `- n1 e2 O( K2 j
was the product of a full-term normal delivery, with! B6 N2 T$ k+ D1 {
a birth weight of 7 lb 14 oz, and birth length of
! A! ^# H* W- z! p* _20 inches. He was breast-fed throughout the first year! H, ~# K: n5 _
of life and was still receiving breast milk along with. Q2 n4 n3 n2 o9 ^
solid food. He had no hospitalizations or surgery,) e! H8 p7 a$ Q1 L8 j
and his psychosocial and psychomotor development
/ u- I9 h/ p& q8 l' c* ^4 lwas age appropriate.
/ e5 d, f/ v: t9 M( s0 X- yThe family history was remarkable for the father,
  l; X! D% B0 [  |- }- y: Hwho was diagnosed with hypothyroidism at age 16,
1 @. e: O2 k8 X# u( pwhich was treated with thyroxine. The father’s5 e4 K8 o2 o5 M' m# G
height was 6 feet, and he went through a somewhat7 G) A, Z$ @5 v9 D: ]9 o. f7 t
early puberty and had stopped growing by age 14.$ v( l1 s7 S- W* E$ l8 S
The father denied taking any other medication. The% a: f: P$ u6 v( I- H
child’s mother was in good health. Her menarche
: T. I' o* A" N3 D* o: Twas at 11 years of age, and her height was at 5 feet" o6 n# W" L* b, [% B) x
5 inches. There was no other family history of pre-* i1 z0 @4 Y1 G# G3 Z, ^
cocious sexual development in the first-degree rela-! s& ^2 p5 h2 Y% W% G9 e$ _
tives. There were no siblings.
5 N; P: U/ o: n8 C# mPhysical Examination
  S( Z( ~3 F! U) |% l# e0 J! SThe physical examination revealed a very active,% }% G( q" i* E+ S. R1 m+ N
playful, and healthy boy. The vital signs documented
" `; [4 _# M- o; Z; s+ U0 B2 Sa blood pressure of 85/50 mm Hg, his length was
7 h, q( s/ t1 |5 }9 Y4 A90 cm (>97th percentile), and his weight was 14.4 kg
% D9 S0 A, ?; |! e. Z# d(also >97th percentile). The observed yearly growth
0 |: w: Q% y7 u% {' _velocity was 30 cm (12 inches). The examination of5 n* g! w  B; s# P
the neck revealed no thyroid enlargement.5 w9 z  |* |1 l( }; z
The genitourinary examination was remarkable for; y; i7 [+ }, r
enlargement of the penis, with a stretched length of  _+ u' `1 A+ G2 G; \
8 cm and a width of 2 cm. The glans penis was very well, h- e. e& M$ E/ o) o+ t1 |3 m
developed. The pubic hair was Tanner II, mostly around
3 Z7 g1 a% e+ `0 |540) c! P6 i0 z" d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% m" I9 X/ K, c5 C
the base of the phallus and was dark and curled. The
# C* \) _# z& ?! s$ a5 _8 a  ktesticular volume was prepubertal at 2 mL each.
, W. p/ y# C+ J8 J7 bThe skin was moist and smooth and somewhat
# X) N6 E1 i4 e& P% R* ^# a7 ooily. No axillary hair was noted. There were no
' D( n% c, _, e5 ?( ~" Pabnormal skin pigmentations or café-au-lait spots.. S1 e+ H  @' \6 O0 Z7 Z) W) x
Neurologic evaluation showed deep tendon reflex 2+
9 g9 G6 L4 p6 L7 M) Hbilateral and symmetrical. There was no suggestion
: @$ N8 s) `7 Z% ^. ?) }of papilledema.% i# p7 @1 I' K0 x2 k& i
Laboratory Evaluation
1 f$ A' d7 Q7 a* G' L1 s& j! \- a, V9 iThe bone age was consistent with 28 months by3 B7 `8 t6 h8 C2 i
using the standard of Greulich and Pyle at a chrono-
  ?7 L* f1 ?; I8 Wlogic age of 16 months (advanced).5 Chromosomal5 T& ^4 C! Y  d1 ?; E
karyotype was 46XY. The thyroid function test
) J$ N2 M  ]& m- D5 Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-6 N5 u6 x6 s; ^* T3 c
lating hormone level was 1.3 µIU/mL (both normal).- g3 p3 o- n3 X/ c& b' C
The concentrations of serum electrolytes, blood
: j8 M$ ]4 x" E) _3 L8 h8 x% burea nitrogen, creatinine, and calcium all were1 f2 d+ C( Q$ e6 m
within normal range for his age. The concentration
* G. I' c& D: |of serum 17-hydroxyprogesterone was 16 ng/dL
; c/ I+ c, \! z4 L(normal, 3 to 90 ng/dL), androstenedione was 20
; C. v5 U( d, {3 ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: t7 ^* M+ Z+ O: n" H+ C0 _terone was 38 ng/dL (normal, 50 to 760 ng/dL),* T9 m; D; m4 C' F8 `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 k4 Q7 \6 S' a( d/ q3 G* [
49ng/dL), 11-desoxycortisol (specific compound S)
& J/ f' \& d" p- L2 @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 Y2 n4 ?4 ~8 ?( ~% _7 K% jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& @; `' k/ l1 w9 U: ^testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 @7 u6 h$ `  b1 r, |0 fand β-human chorionic gonadotropin was less than6 {1 e$ c; ?' I7 {
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 Q8 \9 \9 y4 m% V% }% istimulating hormone and leuteinizing hormone9 _4 r. x7 s9 r
concentrations were less than 0.05 mIU/mL
( H4 w/ w) J, E" n- l6 p(prepubertal).
! Q+ h0 ?7 q( f6 U: k# YThe parents were notified about the laboratory* p/ [6 |& U% J% |- e7 Z7 Y
results and were informed that all of the tests were/ G9 L3 Z4 L2 ]
normal except the testosterone level was high. The/ I9 p& p# N* d1 \. o
follow-up visit was arranged within a few weeks to
) g/ K( y- j# aobtain testicular and abdominal sonograms; how-
' R# b1 T( a( @  @ever, the family did not return for 4 months.3 V" H2 o! v* m8 r9 N/ d5 a0 u" e
Physical examination at this time revealed that the/ o: f1 L' m# W/ I3 i8 d9 U  w
child had grown 2.5 cm in 4 months and had gained) A& Z. z$ |% A3 R. d, ^$ T. z* G; ]
2 kg of weight. Physical examination remained! b! R" P1 d) v6 H  t
unchanged. Surprisingly, the pubic hair almost com-
% C$ T# j# v$ S" r; epletely disappeared except for a few vellous hairs at; m7 A2 D2 `  H( Z3 u9 H7 P$ E
the base of the phallus. Testicular volume was still 2
4 X9 j/ k5 T1 c: D/ W2 O  a1 ?mL, and the size of the penis remained unchanged.
' j9 s& v+ X8 s5 C- b4 fThe mother also said that the boy was no longer hav-' @  S6 ]. E" B$ _4 S2 H9 j: Q
ing frequent erections.$ d5 q$ Y9 H# u
Both parents were again questioned about use of+ f; m+ c+ D% v  e/ d" B
any ointment/creams that they may have applied to( x, S$ r/ U$ ~. q+ T
the child’s skin. This time the father admitted the
* I* e3 y  A' Y5 u" d" pTopical Testosterone Exposure / Bhowmick et al 541! L3 e3 w# L" j
use of testosterone gel twice daily that he was apply-+ n1 Q9 u1 p+ }* a* O% N, w0 Q/ l4 u
ing over his own shoulders, chest, and back area for& h7 q: @3 ~, p4 ^6 W8 j% i
a year. The father also revealed he was embarrassed
3 f9 R+ q( k; n4 ^* T+ K" `to disclose that he was using a testosterone gel pre-
) V4 U5 I- D( |# j& R  ~scribed by his family physician for decreased libido
" \' l* p. i9 R2 a& C$ c+ z3 G5 hsecondary to depression.- h8 J/ W2 l7 M3 i4 ]  I
The child slept in the same bed with parents.
2 n5 V" e4 ]9 b5 A& V+ F: cThe father would hug the baby and hold him on his( T! x  `! W3 o
chest for a considerable period of time, causing sig-
/ e# Q/ C2 q8 W7 fnificant bare skin contact between baby and father.
6 J' ~9 z+ E5 h0 t; wThe father also admitted that after the phone call,9 _6 i: G+ T+ O8 [6 Q
when he learned the testosterone level in the baby" N7 R7 L; B6 w- h( I
was high, he then read the product information
# o8 I4 E* ^/ S! ]packet and concluded that it was most likely the rea-3 D% w5 Q+ P8 V4 \( l
son for the child’s virilization. At that time, they2 @( _1 p0 l% I) |6 ?
decided to put the baby in a separate bed, and the+ v4 x) Z  V" ?
father was not hugging him with bare skin and had/ N  s6 I; v0 x
been using protective clothing. A repeat testosterone( K0 U% E7 O) U
test was ordered, but the family did not go to the+ L5 l- x* J( r) E8 c
laboratory to obtain the test.
) z) k' B. S$ {& c& G# |Discussion% p9 @* r# L2 M! P
Precocious puberty in boys is defined as secondary
* x6 @! j4 C5 o% c% B2 bsexual development before 9 years of age.1,4
9 G9 U8 m2 \) e2 x7 `Precocious puberty is termed as central (true) when" u# P* P, d, A6 Z/ j: e' Z
it is caused by the premature activation of hypo-; W4 e& p: Y- t# x$ Y6 \
thalamic pituitary gonadal axis. CPP is more com-' q7 k7 N. `0 O* G$ E$ O+ B
mon in girls than in boys.1,3 Most boys with CPP
3 V9 r) \2 }, h3 N; v6 Fmay have a central nervous system lesion that is5 J7 ?9 z4 i9 n: V/ f
responsible for the early activation of the hypothal-* V/ e1 k/ D7 h+ p
amic pituitary gonadal axis.1-3 Thus, greater empha-' D0 Y# a+ a  W- U7 q, P" k
sis has been given to neuroradiologic imaging in
$ A& n% e+ I% O8 p% c4 m' ?' R1 qboys with precocious puberty. In addition to viril-  ^2 w6 H7 d7 `- u) [  p
ization, the clinical hallmark of CPP is the symmet-  o* q. f( E" j  X3 c  @
rical testicular growth secondary to stimulation by1 W# }3 h9 }0 N
gonadotropins.1,31 i; z$ R' E; F6 z5 V
Gonadotropin-independent peripheral preco-
- O; `. K* Q2 M! ]: f6 X; `+ t! qcious puberty in boys also results from inappropriate5 e3 t$ a! ~+ o! v5 W
androgenic stimulation from either endogenous or
+ L0 b4 X; ~% d  I6 @. Y4 Wexogenous sources, nonpituitary gonadotropin stim-$ u" \" @2 r. u2 f
ulation, and rare activating mutations.3 Virilizing# w" ~0 T) Z5 D8 E6 Q" T
congenital adrenal hyperplasia producing excessive9 d& e. b6 a+ l6 ]7 s4 L% I1 G
adrenal androgens is a common cause of precocious# }+ a; q7 R0 |+ z8 y. ^2 D6 r) `
puberty in boys.3,4
% e" z% }- |, r# HThe most common form of congenital adrenal
* E$ e6 o# \% _# r: b# Fhyperplasia is the 21-hydroxylase enzyme deficiency.3 g3 O. G0 j0 O' z) |
The 11-β hydroxylase deficiency may also result in$ J- v6 I# U2 C3 [. v6 ~4 f/ H
excessive adrenal androgen production, and rarely,& Y+ V, u: e7 T, @% l
an adrenal tumor may also cause adrenal androgen4 a; F* |. d# f0 W+ \7 s
excess.1,3
3 T( i1 X1 N; E+ D! }& j/ ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) b9 D/ `: `4 M; ~5 d0 z3 a' u, R542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; e. h/ E( i2 ~A unique entity of male-limited gonadotropin-: [# r" y3 v# e" n0 o
independent precocious puberty, which is also known
( I6 k% i" U# q; }as testotoxicosis, may cause precocious puberty at a6 g; k; M/ }, ^( F0 [# {& @/ u* N
very young age. The physical findings in these boys
" y$ e$ M$ w  L; {( H5 dwith this disorder are full pubertal development,! D5 L) X! ?1 v# q! @$ u& V
including bilateral testicular growth, similar to boys& @: A- y# |( G1 {2 {
with CPP. The gonadotropin levels in this disorder: T4 f6 I, l% i. k0 m
are suppressed to prepubertal levels and do not show9 C# T0 }8 S% g( M( b# I, P
pubertal response of gonadotropin after gonadotropin-# N6 d( U% V! Q5 x1 v0 x
releasing hormone stimulation. This is a sex-linked
5 s$ l7 }, S# h3 I" nautosomal dominant disorder that affects only1 Y$ D6 L( m/ v
males; therefore, other male members of the family
; _7 u: _4 s- V9 ]may have similar precocious puberty.30 O& o1 J8 F; |: J! y
In our patient, physical examination was incon-' C5 S5 t; B1 i: K) m
sistent with true precocious puberty since his testi-* x+ \9 D1 r8 R1 u: j
cles were prepubertal in size. However, testotoxicosis& E1 z7 ]/ E& k9 ?' R2 S! \
was in the differential diagnosis because his father
2 }2 |; U" G1 v& f4 j' Kstarted puberty somewhat early, and occasionally,: i2 q0 N  {( I
testicular enlargement is not that evident in the
- k" C4 j; ]2 K; A  bbeginning of this process.1 In the absence of a neg-8 W) v4 w5 b! A- V: t3 k
ative initial history of androgen exposure, our
8 C- C7 H6 r) S2 n& p2 t9 ?. zbiggest concern was virilizing adrenal hyperplasia,
9 H' y& c# \# T1 j! Y: Z1 `either 21-hydroxylase deficiency or 11-β hydroxylase
+ Q' y# k( w& @* `7 L6 a3 ideficiency. Those diagnoses were excluded by find-$ G2 L1 D- n  I& x: t; T
ing the normal level of adrenal steroids.$ @; L* u4 g4 _, G) Z+ @/ D# Z
The diagnosis of exogenous androgens was strongly7 v* y4 _- x! S( J4 x. ^1 e
suspected in a follow-up visit after 4 months because" I/ @1 ^3 i; k
the physical examination revealed the complete disap-
" F6 n0 R7 f+ v  l( ?pearance of pubic hair, normal growth velocity, and, C: [; p/ ^4 @6 t5 R5 r
decreased erections. The father admitted using a testos-
: s7 k2 u2 e' B& S, X' Nterone gel, which he concealed at first visit. He was: g0 ^  p! S# u3 y1 J8 t* {: V
using it rather frequently, twice a day. The Physicians’
" t( Y3 I; j' W, S6 ?Desk Reference, or package insert of this product, gel or( X; d, }# C0 z
cream, cautions about dermal testosterone transfer to
. H7 Q  D* w* }9 V2 J" {) Bunprotected females through direct skin exposure.
# z( {$ X' o, p8 U/ gSerum testosterone level was found to be 2 times the
1 _4 N6 Y! S2 c; a' qbaseline value in those females who were exposed to
' l6 z. ]' n; J' n4 W* O( Peven 15 minutes of direct skin contact with their male
; q, ^$ s5 O+ m- J! i5 Epartners.6 However, when a shirt covered the applica-5 X" |9 Q$ E* O" j' P6 I
tion site, this testosterone transfer was prevented." s( `% L. F; d6 `6 A
Our patient’s testosterone level was 60 ng/mL,
" g* p0 F2 P) h" q! V, K4 nwhich was clearly high. Some studies suggest that6 c/ U$ d4 y  o
dermal conversion of testosterone to dihydrotestos-" f' X1 O) E- V+ s# t) Q
terone, which is a more potent metabolite, is more! r9 d2 F' B: ]( `
active in young children exposed to testosterone
$ h4 `& }; T7 T+ sexogenously7; however, we did not measure a dihy-4 b) k  F( Q( q# p2 G% }
drotestosterone level in our patient. In addition to9 f$ O6 l( E6 _% n6 l, a
virilization, exposure to exogenous testosterone in
' ^4 l/ B8 G- y8 O# M; |children results in an increase in growth velocity and
& i# x1 t9 X$ Hadvanced bone age, as seen in our patient., ?. N2 b# h( |! b  H) i
The long-term effect of androgen exposure during( X, {  |* r/ Y$ l- s* p
early childhood on pubertal development and final
/ e/ j8 V3 {* b) S9 Oadult height are not fully known and always remain
# u! Z2 i  N; ta concern. Children treated with short-term testos-
- x, O  z/ r8 J$ p( E9 Cterone injection or topical androgen may exhibit some  r) \/ [) p+ {- O1 t! e) F; r
acceleration of the skeletal maturation; however, after
( C# E" t9 T/ \$ d/ e- Pcessation of treatment, the rate of bone maturation: x  C- E) Y2 `+ N; D
decelerates and gradually returns to normal.8,97 C$ c& i% g, l4 D2 V- g
There are conflicting reports and controversy
  w' R$ i* t/ vover the effect of early androgen exposure on adult
2 U8 D% F- i5 k! Dpenile length.10,11 Some reports suggest subnormal
- `! I: ]6 h9 E" Y5 u5 A1 zadult penile length, apparently because of downreg-
( L  n) l. o3 A4 S. A! [' Y9 U3 ~ulation of androgen receptor number.10,12 However,* g5 x% W: Q4 M- L( d( ]+ `5 t" C
Sutherland et al13 did not find a correlation between$ [( R- S0 V1 o8 R) Y
childhood testosterone exposure and reduced adult
$ _% M& u8 q2 n: \$ R* D7 Xpenile length in clinical studies.: p% V5 A9 S1 h8 U/ G4 E6 z
Nonetheless, we do not believe our patient is3 D6 o% n) C/ ]% Z& Q8 a9 t! x9 G
going to experience any of the untoward effects from
( m8 s' Y  m; S+ ^$ c8 htestosterone exposure as mentioned earlier because* _9 g- u5 k) J
the exposure was not for a prolonged period of time.
2 ]0 Q4 @/ S) [Although the bone age was advanced at the time of
- w) s2 \; l1 Pdiagnosis, the child had a normal growth velocity at
, D& g4 k( P( }2 ithe follow-up visit. It is hoped that his final adult" S/ @6 b  G" Z' r6 l
height will not be affected.
1 m. S  P  ?. _% U" F  r0 ]% \Although rarely reported, the widespread avail-4 i! }& h) a3 x2 `* S( ~
ability of androgen products in our society may0 d7 C: v1 ]7 s2 `
indeed cause more virilization in male or female
: g% M/ y( D  l# a0 G  R, }children than one would realize. Exposure to andro-
! w. P% Y2 h' d- U9 O% F4 Igen products must be considered and specific ques-2 _+ U4 a( A0 a" j
tioning about the use of a testosterone product or! _% A" W$ b. F$ c- Y1 A
gel should be asked of the family members during- u- _: {! j+ ?2 \- t& @
the evaluation of any children who present with vir-" G; b3 y7 v+ b3 I9 i9 J- d
ilization or peripheral precocious puberty. The diag-0 j5 I$ O, K# J/ K: H
nosis can be established by just a few tests and by
2 E- Z2 v) G3 X2 G3 H" Z  Eappropriate history. The inability to obtain such a& I$ J0 G$ n7 z9 E: Z
history, or failure to ask the specific questions, may
) r4 S' V0 i- v# Dresult in extensive, unnecessary, and expensive0 _6 v) ?9 p  q3 C, h+ J2 n) o
investigation. The primary care physician should be5 A2 a! N9 R- F7 X- i
aware of this fact, because most of these children
  ^* x+ c+ Y, F7 omay initially present in their practice. The Physicians’
4 R+ L1 Z; I  e: R) iDesk Reference and package insert should also put a% @, k( m- A3 k& @/ |4 `
warning about the virilizing effect on a male or
4 p0 Y5 N' O. [: b; _- E( b( K1 i: Yfemale child who might come in contact with some-" |7 F0 a9 c+ q5 i5 `' d! h9 O
one using any of these products.1 k/ Q% B& q& n$ Y% d
References+ ^3 g$ K" Y( e9 n4 L
1. Styne DM. The testes: disorder of sexual differentiation
1 m- l. O2 h* j4 j* `2 v! R" `and puberty in the male. In: Sperling MA, ed. Pediatric
- w3 R  s' X" B* gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! ^& Y) }, A* g) c, R& f6 s; [) Y
2002: 565-628." I, L; B" \7 `- t
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: D+ W+ _1 P; ]: B1 z6 `
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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 f, `; I9 L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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