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Sexual Precocity in a 16-Month-Old, K* P: j" U8 _4 O# y2 I' z2 e
Boy Induced by Indirect Topical
9 b* q) l$ b& E. SExposure to Testosterone3 }) K# f' s  |2 U8 o0 a+ c% S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 N' b( F+ F/ J  o5 M* h$ r
and Kenneth R. Rettig, MD1
& W) b4 _) D' E) ?! |7 DClinical Pediatrics; o' X+ _1 G4 j# F& D
Volume 46 Number 6+ ]) l; J, J7 E- F& h& T/ H, k1 m
July 2007 540-5438 V# V) b7 O0 ]  [4 C9 }+ A& |
© 2007 Sage Publications5 Q- B/ F! B) M7 R
10.1177/0009922806296651# h) T9 ^1 o# t+ d+ f8 y" X
http://clp.sagepub.com6 }# ?) R! Y4 h, e( T* F* j. s) C( v
hosted at
; o* Z! x* T2 c$ ~& T- ?http://online.sagepub.com) g2 ^* c0 V( ~/ ~' \  @& `8 m
Precocious puberty in boys, central or peripheral,' B3 O6 @5 D. J! [* d' X
is a significant concern for physicians. Central
; V6 c9 g; p4 s$ R1 @% sprecocious puberty (CPP), which is mediated
5 O) L0 Z8 l0 D. S* }9 G0 h9 cthrough the hypothalamic pituitary gonadal axis, has
. w7 ]/ ?: x* aa higher incidence of organic central nervous system1 U* ]6 F5 p7 `( [9 r  W
lesions in boys.1,2 Virilization in boys, as manifested
6 \# J6 `8 l# F5 `by enlargement of the penis, development of pubic: _) E, a; z& i3 X; G' s
hair, and facial acne without enlargement of testi-
8 L2 C# [) @/ \- L0 w3 d% vcles, suggests peripheral or pseudopuberty.1-3 We
; y& R, Y: x9 }  \3 qreport a 16-month-old boy who presented with the
) i- r. T& j. [enlargement of the phallus and pubic hair develop-
9 a% R, H  H. ?. Cment without testicular enlargement, which was due
7 a. Q' v& [+ E' K0 R4 sto the unintentional exposure to androgen gel used by
3 q" t- ?: a  P* D7 m; i+ {  s  o7 Gthe father. The family initially concealed this infor-
9 W. m# b3 `2 `9 F; F7 Fmation, resulting in an extensive work-up for this
3 R6 t+ T) e8 q, X" Pchild. Given the widespread and easy availability of
" x  D* F! A: i: v0 xtestosterone gel and cream, we believe this is proba-
, g0 c: F: L2 \( D& ^$ m0 Rbly more common than the rare case report in the
, ?3 l$ b# G$ iliterature.46 W  |3 P$ }5 j( s9 L/ @9 t  Q$ D
Patient Report3 h, K7 i0 K: l) a: I2 @% u/ {- d
A 16-month-old white child was referred to the
* D  A/ |  L7 Y! w$ `6 Y3 hendocrine clinic by his pediatrician with the concern
3 C, P& w2 @5 m- G2 vof early sexual development. His mother noticed) O7 G& c4 I" k" [9 M
light colored pubic hair development when he was* [! _3 c! f' V' c2 z5 C
From the 1Division of Pediatric Endocrinology, 2University of* `' ^7 s) W# i: c! ]2 Q7 c
South Alabama Medical Center, Mobile, Alabama.
( ~5 x5 S0 o' n! XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 b1 k4 @- _* IProfessor of Pediatrics, University of South Alabama, College of. H" p/ r, N' K3 f5 E5 L) y- N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* d9 T$ x6 B, x' M; u) R
e-mail: [email protected].
  p6 C. p6 X# q: b7 Q3 C) ?* oabout 6 to 7 months old, which progressively became4 }: \1 G# D$ E' e, q
darker. She was also concerned about the enlarge-7 Z. B$ y# L/ D7 s* M+ O
ment of his penis and frequent erections. The child
. ^% ]4 O3 V3 p/ R( f2 Iwas the product of a full-term normal delivery, with
# x" ?) o- n& H2 D  la birth weight of 7 lb 14 oz, and birth length of
2 h/ W6 i1 k% j& h4 \; y20 inches. He was breast-fed throughout the first year+ {# g! H) K, }% e
of life and was still receiving breast milk along with# B- u9 P' b5 F* j5 V
solid food. He had no hospitalizations or surgery,
$ ?2 i, V8 c7 D( t6 Q, A; \) o$ ~and his psychosocial and psychomotor development# A1 [" b% E- P! X+ V
was age appropriate.
1 ], R& z# @9 T3 lThe family history was remarkable for the father,3 s2 L' D* t) v- f- s6 c: v
who was diagnosed with hypothyroidism at age 16,
& }: U! L' q* [3 {) [" v. ^which was treated with thyroxine. The father’s
% s" Z% y. S4 U& ~% ]5 sheight was 6 feet, and he went through a somewhat1 r" G) d9 G. C/ T! I
early puberty and had stopped growing by age 14.* A! V3 R% ~: f. J% v# z
The father denied taking any other medication. The3 ]7 ^, x3 P0 {# n. O
child’s mother was in good health. Her menarche
4 V/ n* x: B+ \/ M0 i. g/ v6 y9 Twas at 11 years of age, and her height was at 5 feet
4 g/ ?) Z4 q; t) [4 x- i$ w$ |5 inches. There was no other family history of pre-
9 D! J9 J! @1 X! w) tcocious sexual development in the first-degree rela-/ g: y& |: t7 q5 [) z$ P
tives. There were no siblings., _& [! f9 q( U5 y8 e- M& F, }/ {
Physical Examination
; ]6 D. o" l  |0 jThe physical examination revealed a very active,
9 ]9 X' T# Y) {! s1 e& Bplayful, and healthy boy. The vital signs documented; @" W9 d0 G- D
a blood pressure of 85/50 mm Hg, his length was
$ k* }  P7 O5 _) v4 v! C90 cm (>97th percentile), and his weight was 14.4 kg0 c& o: [  M9 B& N2 m
(also >97th percentile). The observed yearly growth7 ~% A3 p+ }$ R' u' \  A! U
velocity was 30 cm (12 inches). The examination of! G$ [% w9 A/ [" e$ Q4 _4 W
the neck revealed no thyroid enlargement.' `/ r# k! N* @7 h9 B
The genitourinary examination was remarkable for
: X7 m% H8 I* c' kenlargement of the penis, with a stretched length of7 a5 q% M5 T/ Z$ }+ N; j( v, P: C
8 cm and a width of 2 cm. The glans penis was very well
: c- V9 Q7 U2 `* }& f/ {2 d+ v  ^' pdeveloped. The pubic hair was Tanner II, mostly around
1 |9 w) y5 _% m. M$ o540
8 {. b3 }) u6 E( ~2 @7 {& w6 tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( T) W, ?3 S. O7 e3 E. U/ n& @7 B% Nthe base of the phallus and was dark and curled. The
: B5 x4 Y( S$ l$ Z$ Vtesticular volume was prepubertal at 2 mL each.
- U, O( j8 n# `# M  d, B" N) qThe skin was moist and smooth and somewhat) d; Z* |- d9 Y
oily. No axillary hair was noted. There were no
0 J$ k0 \) K: w5 cabnormal skin pigmentations or café-au-lait spots.
9 x. p% E( C( y7 l# g8 XNeurologic evaluation showed deep tendon reflex 2+
: @9 C- |5 R+ ?0 [  d- h) fbilateral and symmetrical. There was no suggestion
( h8 u/ O0 ~7 t1 h4 j! B8 Eof papilledema.
1 l) |/ C' W. w- aLaboratory Evaluation
! z, F2 x( Z2 J- U1 mThe bone age was consistent with 28 months by2 q' x$ e" f; n6 b/ S; A' O! l
using the standard of Greulich and Pyle at a chrono-* T& ^+ r8 u: x% i/ b( c  {
logic age of 16 months (advanced).5 Chromosomal. ^# ^$ s& z4 b7 V
karyotype was 46XY. The thyroid function test
" {5 C0 S6 ?. e9 gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 M: `- n8 \) C% olating hormone level was 1.3 µIU/mL (both normal).
; P4 q. _( A) F$ q$ _6 LThe concentrations of serum electrolytes, blood
2 Y8 w6 |+ s9 }' w$ |3 rurea nitrogen, creatinine, and calcium all were
; z1 J5 _, u  s, T. dwithin normal range for his age. The concentration: A4 C/ Y4 `& ]2 f# y* J+ B, o
of serum 17-hydroxyprogesterone was 16 ng/dL
) N1 c$ |- d' `(normal, 3 to 90 ng/dL), androstenedione was 20
+ Z$ H% y; m, ~, d' ~" B! T7 s+ nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& m$ ^+ w# k4 D, Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 k" G$ E: ~# U2 e/ kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 ]' f) E0 @% |% B6 [. O3 h4 n2 W) q+ C49ng/dL), 11-desoxycortisol (specific compound S)8 s0 _" C1 J: E' ?! N; I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 p8 u1 O( g6 P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; c9 F. Z0 I3 N" G- M7 [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," m4 Q6 J9 n2 V# D  ~4 N
and β-human chorionic gonadotropin was less than
5 C% S4 J; i1 H% l$ i. ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 _3 A. R& T3 p' o0 Xstimulating hormone and leuteinizing hormone6 R( O$ z& F7 ~2 t
concentrations were less than 0.05 mIU/mL
& r1 X$ i  c3 g8 g2 O(prepubertal).9 t9 l9 o! T% ~. e0 x
The parents were notified about the laboratory5 e' U, q# ~+ g: `
results and were informed that all of the tests were
2 U9 L9 _. L; pnormal except the testosterone level was high. The
! E* H+ g/ |& Tfollow-up visit was arranged within a few weeks to$ p+ r# U. g8 V* O
obtain testicular and abdominal sonograms; how-1 `5 _4 s% E' C2 ]( R8 y" b4 ]5 N
ever, the family did not return for 4 months.
1 p6 O7 P( x+ k) lPhysical examination at this time revealed that the
3 N5 B4 O$ h/ k0 H; achild had grown 2.5 cm in 4 months and had gained
+ c5 F8 J; F8 r6 k* y2 kg of weight. Physical examination remained" K, O/ `" L7 }
unchanged. Surprisingly, the pubic hair almost com-7 }2 u/ H0 ^) E
pletely disappeared except for a few vellous hairs at2 s: i$ S4 z5 _8 ^. I# h2 R7 A
the base of the phallus. Testicular volume was still 2. X7 v! ^% ], G# v7 Q! i. {) L
mL, and the size of the penis remained unchanged.3 Q3 ^5 }* a) Q0 Z
The mother also said that the boy was no longer hav-
' w" y  k' ~8 Oing frequent erections.7 ^; f! Y5 k# {- D# @$ \" A' F
Both parents were again questioned about use of
4 d3 o( w4 |( i* g2 e3 iany ointment/creams that they may have applied to! E4 C# W! _- @+ J+ E4 m
the child’s skin. This time the father admitted the& t" o  F1 f$ x4 H' V: Q" F8 B
Topical Testosterone Exposure / Bhowmick et al 541/ T+ g) ?5 {# {2 X
use of testosterone gel twice daily that he was apply-
& a, y& E, U0 B8 k+ J* U/ H# Ding over his own shoulders, chest, and back area for
- n& M7 U. _" g2 C7 ~a year. The father also revealed he was embarrassed- U+ t3 X- [4 w) R* T9 n/ F
to disclose that he was using a testosterone gel pre-
$ t7 o+ ?0 M, i7 V% i+ t7 Z. F' S3 u0 Oscribed by his family physician for decreased libido
5 t  m4 @: ]$ f) u3 I% {6 xsecondary to depression.
. o0 _- W2 `$ }# TThe child slept in the same bed with parents.
3 x& _( c8 [7 c' h# e/ c( ?The father would hug the baby and hold him on his5 E' D2 N; Y! e
chest for a considerable period of time, causing sig-
5 b, P3 q0 g4 t# q, V% Hnificant bare skin contact between baby and father.
% l% ^1 S3 c+ I" p2 Q( T+ M% ZThe father also admitted that after the phone call,
* D# P9 w* r, ?8 F+ Xwhen he learned the testosterone level in the baby8 J  R" ]4 U  P5 N2 T/ R
was high, he then read the product information* Z. a2 ^6 N5 ^6 b$ N2 G
packet and concluded that it was most likely the rea-+ L+ a- g- L+ Y5 q$ t( @
son for the child’s virilization. At that time, they& v* g) h4 k6 k, m3 ~! I& y, ^
decided to put the baby in a separate bed, and the. C( |7 ~- f5 S7 g! C
father was not hugging him with bare skin and had
) o; }! _3 n0 ^+ A% v6 z: hbeen using protective clothing. A repeat testosterone
' c; U) U. C% W. wtest was ordered, but the family did not go to the
0 `3 t* M4 P: mlaboratory to obtain the test.
4 D) E2 ^9 ~: }% c! R, |Discussion
( M# g& A! c8 K, u+ O+ D" [4 b' y7 u6 nPrecocious puberty in boys is defined as secondary5 n7 I* A+ s3 Q/ g; K% N
sexual development before 9 years of age.1,4& T" N- H  c2 x7 a9 X+ F: s- ?
Precocious puberty is termed as central (true) when, ^$ f4 ~3 O2 X# K! t
it is caused by the premature activation of hypo-( [6 J0 v( O5 q, r2 Y/ Q
thalamic pituitary gonadal axis. CPP is more com-0 J0 z3 L$ n# t( Q/ ?* t8 U- g
mon in girls than in boys.1,3 Most boys with CPP: H$ T9 w+ ]. T' o
may have a central nervous system lesion that is
3 B! w4 ?9 F$ \$ h1 Iresponsible for the early activation of the hypothal-) s4 g3 Y$ P" j& c9 z! P
amic pituitary gonadal axis.1-3 Thus, greater empha-3 t2 u* w& J7 n; r: T1 h
sis has been given to neuroradiologic imaging in
. G) K0 j6 i2 s5 Mboys with precocious puberty. In addition to viril-
1 x9 s7 E" E3 sization, the clinical hallmark of CPP is the symmet-
: \; N- A+ P( k, nrical testicular growth secondary to stimulation by& m% y1 j- z( g3 `& ?( r
gonadotropins.1,3, n0 A+ o/ z' I1 U+ R
Gonadotropin-independent peripheral preco-
& P% d( {+ x% l; Fcious puberty in boys also results from inappropriate* w# S; j# @* l4 |
androgenic stimulation from either endogenous or4 u9 e, p% B& E) H- r
exogenous sources, nonpituitary gonadotropin stim-
* ?! \4 B1 M5 C, i: z9 wulation, and rare activating mutations.3 Virilizing6 J. z5 q* w7 R+ o0 ]) I
congenital adrenal hyperplasia producing excessive% j0 q. u3 I4 _
adrenal androgens is a common cause of precocious
( E& ~& g" s1 C1 Dpuberty in boys.3,4
# g' ]. B7 X( x1 }+ R. \3 QThe most common form of congenital adrenal8 S% I/ x. H3 B% p7 b0 _9 \
hyperplasia is the 21-hydroxylase enzyme deficiency.7 [# }  Y' T2 Z" ]- |& S' @
The 11-β hydroxylase deficiency may also result in8 m6 a# j: Z  x8 {
excessive adrenal androgen production, and rarely,1 y* ?$ O1 [5 W( v# s7 L
an adrenal tumor may also cause adrenal androgen" t+ L# i% `5 _4 _
excess.1,3
- a0 D- E. [0 O' Q) h  a/ K% N" \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# N7 h. ?; Y( p1 ?4 n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ f; }+ z( X6 N5 J3 [6 `
A unique entity of male-limited gonadotropin-# L* l  h7 D* R( ?8 ^
independent precocious puberty, which is also known
6 j/ z& M0 Q2 M7 y) d0 b! Das testotoxicosis, may cause precocious puberty at a
+ S6 o* S. H' G" q6 svery young age. The physical findings in these boys
3 y5 L3 Q5 p/ p: Rwith this disorder are full pubertal development,) C' P% s& C' V, }1 e' |4 o
including bilateral testicular growth, similar to boys
6 k5 \* ?& D( j! S- [with CPP. The gonadotropin levels in this disorder$ j( b, h  U* e5 w
are suppressed to prepubertal levels and do not show1 _- ^. F5 I7 Z8 k
pubertal response of gonadotropin after gonadotropin-
! y) ~( J, U6 N$ w* G% M' |releasing hormone stimulation. This is a sex-linked
- C8 a2 _# r* `/ Hautosomal dominant disorder that affects only
+ X5 p+ Q+ a. U1 \7 Z# B" Wmales; therefore, other male members of the family
- q8 B7 e5 d$ l& S* Gmay have similar precocious puberty.30 d. o# [( h% d; @; {% Z6 p; }
In our patient, physical examination was incon-
. r; j! f1 [2 Fsistent with true precocious puberty since his testi-
1 p0 _6 M4 _) bcles were prepubertal in size. However, testotoxicosis
3 y" |. S. g5 O# M" |" ?% n8 Ywas in the differential diagnosis because his father
( F5 O+ u5 r  ~5 Pstarted puberty somewhat early, and occasionally,
( r- Y+ a7 j! W) xtesticular enlargement is not that evident in the8 z2 \& C$ }' Y% {$ m
beginning of this process.1 In the absence of a neg-
7 |3 M$ s& `1 bative initial history of androgen exposure, our
$ ?4 J3 p1 o7 c8 m7 [8 rbiggest concern was virilizing adrenal hyperplasia,- Y) H* \3 s1 n! b$ R6 q, O
either 21-hydroxylase deficiency or 11-β hydroxylase. t$ B, ~1 a6 `! D
deficiency. Those diagnoses were excluded by find-
0 _; O3 v1 H9 [) [7 }ing the normal level of adrenal steroids.
% {$ e' O7 _9 z8 A% ~4 uThe diagnosis of exogenous androgens was strongly
- O, d0 @5 E, y5 q* Lsuspected in a follow-up visit after 4 months because
% B' D6 j0 T$ R# H' sthe physical examination revealed the complete disap-
7 ?7 n  {& z2 R: h4 K$ fpearance of pubic hair, normal growth velocity, and9 E# `7 Z8 B9 t2 r- y
decreased erections. The father admitted using a testos-; f( S5 B  e" Z. z
terone gel, which he concealed at first visit. He was
# ]  ?$ l0 Y; s' W# }' jusing it rather frequently, twice a day. The Physicians’
: f- Q/ o4 H6 N" {2 {Desk Reference, or package insert of this product, gel or5 V# M9 B4 u( e
cream, cautions about dermal testosterone transfer to- {9 b3 @7 |3 r% C
unprotected females through direct skin exposure.
! O$ m2 ?; |4 P9 M6 x3 j5 a, CSerum testosterone level was found to be 2 times the+ U: N2 f4 G% s$ k; ]' [+ Q# x/ w& Z
baseline value in those females who were exposed to, H7 k! S7 i7 u8 x
even 15 minutes of direct skin contact with their male
7 }7 a) {$ K: b, r6 vpartners.6 However, when a shirt covered the applica-
+ f* c7 ?4 M1 y  f9 ?! D5 Ztion site, this testosterone transfer was prevented.
  @: E. ]) T  C3 uOur patient’s testosterone level was 60 ng/mL,: H3 R  t: V* k  P
which was clearly high. Some studies suggest that7 M. W! [4 {7 G/ |
dermal conversion of testosterone to dihydrotestos-  Y) i8 O8 I, d% R/ u/ G. h( U
terone, which is a more potent metabolite, is more  J- M) u. W/ Q2 B1 S7 R
active in young children exposed to testosterone
1 v+ r2 K; G- w, S" ]7 ~  g+ rexogenously7; however, we did not measure a dihy-' |8 ], B/ o6 b/ k
drotestosterone level in our patient. In addition to4 d: V  Y; q. D- B! B2 [3 W/ _( \; p
virilization, exposure to exogenous testosterone in
7 E6 j( e. l2 {* D3 d7 vchildren results in an increase in growth velocity and
# a. k+ ?0 k+ ?- ladvanced bone age, as seen in our patient.
/ m$ ~" Z, P" j  s/ _The long-term effect of androgen exposure during
: }2 i$ {7 O7 ]' u8 h7 |/ A! yearly childhood on pubertal development and final
) v) `& i+ y$ Q7 I! ^" ^; yadult height are not fully known and always remain# V  _7 a* r& X6 Q% q+ M
a concern. Children treated with short-term testos-0 c, O/ \& J! b, @
terone injection or topical androgen may exhibit some
' e4 j9 C* e' l2 x% Y. f7 Cacceleration of the skeletal maturation; however, after
8 y% b# L$ J' u8 F" F3 x- d. ~cessation of treatment, the rate of bone maturation# v7 |) v7 A" y' g6 `
decelerates and gradually returns to normal.8,9
4 G2 ]0 `. ]! I0 ~$ B6 I) fThere are conflicting reports and controversy
# _+ N% S! D7 f  }  x7 Nover the effect of early androgen exposure on adult+ a' a1 v; i+ f! b# a
penile length.10,11 Some reports suggest subnormal
/ D, }! D! _/ O$ zadult penile length, apparently because of downreg-
4 D: Y9 p- V3 G% P# }ulation of androgen receptor number.10,12 However,
4 |) A/ \  h& x7 lSutherland et al13 did not find a correlation between
; h7 A$ U  ^9 i6 t: n6 zchildhood testosterone exposure and reduced adult
9 U' u: n) [' [5 C8 v. Apenile length in clinical studies.( _( A. V4 }9 \  s* o
Nonetheless, we do not believe our patient is1 Q1 \' d% h- P* I9 \* {5 ^, r" l
going to experience any of the untoward effects from
  e! |4 e1 U7 Dtestosterone exposure as mentioned earlier because
  u$ m5 a& }7 I4 lthe exposure was not for a prolonged period of time.5 `" ]- r" M% ?5 m
Although the bone age was advanced at the time of
1 d+ \  r5 ]# Q" C+ Q9 xdiagnosis, the child had a normal growth velocity at
- o% l7 O- J  Dthe follow-up visit. It is hoped that his final adult% D7 Y1 U$ W& `
height will not be affected.7 S1 S& x% N8 A* d/ N1 d
Although rarely reported, the widespread avail-) }! s+ D* i  L8 x/ F0 |# x, H
ability of androgen products in our society may
! y4 K( M: i5 R  c2 w$ T' cindeed cause more virilization in male or female
- I6 v4 t4 K+ M9 [& Bchildren than one would realize. Exposure to andro-
" D2 V8 B! z* `: Z7 A& T; Ngen products must be considered and specific ques-
) k/ i6 s. I* m) W+ P! G2 Etioning about the use of a testosterone product or
% D& g& E) v5 y; R# \- C; E8 i* rgel should be asked of the family members during, v7 S0 _6 t7 Q, i
the evaluation of any children who present with vir-
* z4 w! d% E& \. e$ s7 @# Y( Xilization or peripheral precocious puberty. The diag-
0 \" t( b, b3 t) ]" F  p( c' Knosis can be established by just a few tests and by
# L3 l9 r& h( W8 f* }5 Sappropriate history. The inability to obtain such a
# `# u3 T8 x2 T, R% f. T6 o* ~' r# ehistory, or failure to ask the specific questions, may
: ?. L+ x. `& t( f5 V* ?( Mresult in extensive, unnecessary, and expensive
* N+ ]& I+ @; `$ O! w! E& u/ yinvestigation. The primary care physician should be5 C% A# n, Q( A3 l  u, ~1 W
aware of this fact, because most of these children. Q) h# ^/ E7 V
may initially present in their practice. The Physicians’; L1 G4 {# p4 U+ v  k: B3 C% B
Desk Reference and package insert should also put a
4 I8 N  g3 k3 F7 \( M1 u/ y4 p  Ywarning about the virilizing effect on a male or
/ ~( U% a5 j  h" H4 J# I' ffemale child who might come in contact with some-. S; j; d% ~+ x. }/ Y
one using any of these products.  v: F7 C# \) ]) [' A. W
References
6 m) W; h% k) {4 Y+ l1. Styne DM. The testes: disorder of sexual differentiation" I2 q# ?( ]  l" ~* v+ _
and puberty in the male. In: Sperling MA, ed. Pediatric1 b- u; |! K1 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 o0 `- Y+ I4 D1 k+ M5 _* M% u
2002: 565-628.
% N. |3 `6 a6 Z- B* R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 S. g4 D2 Q. W' C% ^puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
) ~, |! s4 `8 {" N) aBoy Induced by Indirect Topical; `5 U. a' [  v. E
Exposure to Testosterone& i4 g3 c6 r& |$ \* u) T! }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; a2 c7 }4 w6 O
and Kenneth R. Rettig, MD1
: j. g8 Y6 D% X- }3 S8 U3 T( y- ~Clinical Pediatrics2 ]) }0 c+ q+ o' }- C3 K; l
Volume 46 Number 6+ V8 |) H( }+ v+ e) z
July 2007 540-543
- r$ p* B8 l& r) y  }# j© 2007 Sage Publications
6 Q- s7 Z! B" E$ r8 l' @1 C10.1177/0009922806296651
' w# u4 C  d! R' _% P7 {* bhttp://clp.sagepub.com  P! p+ b3 H4 L) B1 Q- f
hosted at
% W& s  c& h+ B9 Z% }http://online.sagepub.com* T6 B# X  n5 }. t3 V. _+ D" S. K8 y
Precocious puberty in boys, central or peripheral,
0 S! @- T% J. v+ his a significant concern for physicians. Central
/ [5 M8 e9 V7 y2 p4 w( ^' nprecocious puberty (CPP), which is mediated
- B. U; R6 ~  ~7 jthrough the hypothalamic pituitary gonadal axis, has. A! |( G- E8 D( m/ {
a higher incidence of organic central nervous system
' W1 d) H' n+ [* \! S# O; Dlesions in boys.1,2 Virilization in boys, as manifested, S& m! T) y; l: z2 V6 A. S
by enlargement of the penis, development of pubic
1 ~1 A5 y4 \& o9 Chair, and facial acne without enlargement of testi-
* {- f3 `/ {2 Gcles, suggests peripheral or pseudopuberty.1-3 We& I* p$ b; F- S# P5 S$ J
report a 16-month-old boy who presented with the$ D( D+ T. I; A
enlargement of the phallus and pubic hair develop-
9 e" M  w0 W& L$ g1 _( B; s( oment without testicular enlargement, which was due3 y5 W7 B! s3 O0 J
to the unintentional exposure to androgen gel used by
0 S+ ~9 A7 v4 i& i* z( y% K, dthe father. The family initially concealed this infor-
% J  Z* L# @% R) h* kmation, resulting in an extensive work-up for this. H3 `  w0 s! ^
child. Given the widespread and easy availability of  K+ T: g' T6 c% a" i
testosterone gel and cream, we believe this is proba-( r: e. Z/ o. W
bly more common than the rare case report in the, {3 x: @2 ^: _( S
literature.4
$ S  m# i1 k3 o# FPatient Report1 V  x2 b0 |" w) b2 E/ m* \
A 16-month-old white child was referred to the
- Z& @: Q& S: H3 dendocrine clinic by his pediatrician with the concern" G( D( [# X5 K4 U
of early sexual development. His mother noticed
$ ^6 S: W& V! U% i2 E/ O: I1 ]light colored pubic hair development when he was! f8 ]. g9 o8 E
From the 1Division of Pediatric Endocrinology, 2University of9 E. g4 m* y8 m/ H
South Alabama Medical Center, Mobile, Alabama." {) |7 P* b  _! w" s8 q( E4 _& X! C
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; o* M% {5 n2 I8 l) {Professor of Pediatrics, University of South Alabama, College of9 T' M% x, f5 s, k  w
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 r9 ?  r6 N9 ?- t3 g4 d; f9 n. Fe-mail: [email protected].
% M. g9 p6 g0 d6 O1 }about 6 to 7 months old, which progressively became  n1 P3 ?' @4 h" j- G
darker. She was also concerned about the enlarge-( y# r4 K$ r7 C: I
ment of his penis and frequent erections. The child
+ a( M! K- ?  {8 b) Jwas the product of a full-term normal delivery, with- C& K: u5 U% W+ O4 j5 u! k# u6 V+ B4 s
a birth weight of 7 lb 14 oz, and birth length of
( Q2 h4 p7 W( c" y6 o- f20 inches. He was breast-fed throughout the first year! ]6 ?% [& X2 J3 X# h+ P  {; k
of life and was still receiving breast milk along with4 |; U' T* ~9 R: c- Z
solid food. He had no hospitalizations or surgery,# D  n* e3 l. C; N9 [8 f4 S
and his psychosocial and psychomotor development/ l0 z! R) q' {6 h4 e
was age appropriate.
  S( G# a! q" e- pThe family history was remarkable for the father,$ Q) M* p$ y) h1 p+ s( h
who was diagnosed with hypothyroidism at age 16,; |# X/ N4 q; B+ b' {
which was treated with thyroxine. The father’s
) k# Z% J# I) g$ bheight was 6 feet, and he went through a somewhat' \- ^) s/ o9 n6 y7 f
early puberty and had stopped growing by age 14.
& _! v% ?! d/ R: kThe father denied taking any other medication. The( U* t3 n+ n& g9 H8 P! Y3 x
child’s mother was in good health. Her menarche
! }( |5 d' ^: U# S! ?) Twas at 11 years of age, and her height was at 5 feet5 G5 M: Z2 s+ X  g) Z, f3 U
5 inches. There was no other family history of pre-
. p2 o/ H3 `; v1 X  n7 Y" lcocious sexual development in the first-degree rela-) P: ?5 ^: [7 M  C7 M" A8 @2 F8 P
tives. There were no siblings.. U. r) k& o+ `( |* m
Physical Examination
0 B  w! A' ~! |, AThe physical examination revealed a very active,/ T7 D% m( s9 k+ ^9 O3 T
playful, and healthy boy. The vital signs documented* I( H! k/ u( i; l. a& q* I% y
a blood pressure of 85/50 mm Hg, his length was6 c4 z# v/ \# J& t' [+ O
90 cm (>97th percentile), and his weight was 14.4 kg
( W* U* l2 Y! Z  B. d(also >97th percentile). The observed yearly growth
4 F' ~+ m  ?% Nvelocity was 30 cm (12 inches). The examination of
! D" ^0 b. U' Q- hthe neck revealed no thyroid enlargement.
& S7 Q+ Q- I4 b) x: L0 jThe genitourinary examination was remarkable for
' t  @$ f+ N: I/ Genlargement of the penis, with a stretched length of
( a! Z  v4 h, u) u. @8 cm and a width of 2 cm. The glans penis was very well0 \  H( w* T+ i! Z+ A
developed. The pubic hair was Tanner II, mostly around
! h/ \- |6 E8 J. j540
3 x. i& Z1 h6 S, i7 C0 sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ `6 X8 N: L& r6 B. m
the base of the phallus and was dark and curled. The
+ W2 o3 t% i4 g  n- K8 _testicular volume was prepubertal at 2 mL each.8 T) H# x9 o) e* b
The skin was moist and smooth and somewhat6 x9 b* `+ i% J* J
oily. No axillary hair was noted. There were no) e* v6 w, S9 ^
abnormal skin pigmentations or café-au-lait spots.
0 h- P1 z. ]2 Q+ [4 lNeurologic evaluation showed deep tendon reflex 2+  _2 P3 l  S3 I
bilateral and symmetrical. There was no suggestion, ]" d3 j+ l% t/ E( z7 U6 H$ d
of papilledema.6 @0 J6 e2 Z2 T! {0 Q6 S6 u  ?
Laboratory Evaluation. v4 u' b/ W  \' E
The bone age was consistent with 28 months by2 h7 i' x' N  G  K
using the standard of Greulich and Pyle at a chrono-+ w' l! z' E/ T
logic age of 16 months (advanced).5 Chromosomal+ y  g9 B/ k% A4 P+ @$ q" @7 T! k: l
karyotype was 46XY. The thyroid function test) `* `) k' K; r$ s
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: @' O$ Y- X$ b2 E
lating hormone level was 1.3 µIU/mL (both normal).
/ }5 }- j9 T6 T! ^) s) RThe concentrations of serum electrolytes, blood' X+ F5 F9 c$ M
urea nitrogen, creatinine, and calcium all were8 h4 M2 ~- S$ n. O* N
within normal range for his age. The concentration! N# E0 U* \1 x; y* x6 _
of serum 17-hydroxyprogesterone was 16 ng/dL: G& o2 _- R8 p8 L/ F* `
(normal, 3 to 90 ng/dL), androstenedione was 20# X3 t' H. R3 j( V5 q: |0 B
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 l2 \. d* D( _2 c; Hterone was 38 ng/dL (normal, 50 to 760 ng/dL),' A# S6 a( n# y  P' t
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 K# M) @5 R' D( {
49ng/dL), 11-desoxycortisol (specific compound S)3 K$ T; [. Q7 J+ B$ ?3 l' k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ d! {. e; g9 I9 a$ |% \5 xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 t' O; j4 ~7 V5 {2 x  Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# x. q1 H. h% J# t; B  N. U! uand β-human chorionic gonadotropin was less than
. j! g, J  ~5 |5 mIU/mL (normal <5 mIU/mL). Serum follicular
% I: p) O5 r" q8 fstimulating hormone and leuteinizing hormone8 U/ U$ ~# e* l. j+ U
concentrations were less than 0.05 mIU/mL9 d# e2 P( ?4 s8 [4 H# l, ]/ c
(prepubertal).$ A( u! X0 S* B. p8 O# K# ?. H: ?+ k
The parents were notified about the laboratory( p+ K" o+ ]. j/ h6 @- l
results and were informed that all of the tests were8 Q. b# S) S  a, j. K! ^
normal except the testosterone level was high. The! i- |1 \1 B$ @
follow-up visit was arranged within a few weeks to
$ @9 Y; f2 ], k4 A9 q6 N1 c! Y$ ^obtain testicular and abdominal sonograms; how-: S; I$ }- X  U* N. _4 s
ever, the family did not return for 4 months.! E3 Y" j1 Q& b0 P# n
Physical examination at this time revealed that the
  y- T0 Q+ _# E( d3 Y9 v2 u) bchild had grown 2.5 cm in 4 months and had gained" X8 |9 `/ ?0 u; z2 Y1 S0 x# k+ ]1 s
2 kg of weight. Physical examination remained
1 a: K! }& T4 X' V7 _unchanged. Surprisingly, the pubic hair almost com-
, K" z' S% L# l1 U* m" _pletely disappeared except for a few vellous hairs at" ]3 {% \# {0 x6 r3 \) s# \2 N0 m
the base of the phallus. Testicular volume was still 2  T, Q, [, q) O- M
mL, and the size of the penis remained unchanged.
. ~1 Y) V: b+ m: eThe mother also said that the boy was no longer hav-
2 T/ Y' `! }5 x* q6 x( S: N* `( Ding frequent erections.+ u, ]( d9 e0 t! ]
Both parents were again questioned about use of$ R' T  k8 c& z8 B
any ointment/creams that they may have applied to* k# b' c* W! {% ?& w
the child’s skin. This time the father admitted the0 C5 s: g1 \) D8 @+ ]
Topical Testosterone Exposure / Bhowmick et al 541& v: _6 i. d* Y: G* F1 `; V
use of testosterone gel twice daily that he was apply-4 s6 [  d  D. M! a: Y. f
ing over his own shoulders, chest, and back area for
- T' W1 _1 |( ~+ ca year. The father also revealed he was embarrassed
( Q5 q4 {0 ^; d- }to disclose that he was using a testosterone gel pre-
4 k5 O( V( C. o" I' i; L0 Hscribed by his family physician for decreased libido; M" v# q: M7 O8 f  b. A7 S
secondary to depression.
& X; k  F& L/ k( N  eThe child slept in the same bed with parents.) z' n$ }' M5 u8 N2 W
The father would hug the baby and hold him on his* Y) i. ?4 w) Q/ J6 U" O5 K- q1 \  o! a- |
chest for a considerable period of time, causing sig-( S( ]/ S5 }7 I: {+ ^( j8 s
nificant bare skin contact between baby and father.
" w+ y; V9 h2 z) K6 @; V0 qThe father also admitted that after the phone call,. D. A9 E6 \3 s! ~- }1 k9 i
when he learned the testosterone level in the baby& B9 i. ?' S4 o6 a
was high, he then read the product information3 Y9 u8 ?. v5 B% @% A
packet and concluded that it was most likely the rea-! v' N& ?- W3 E
son for the child’s virilization. At that time, they5 a5 Q( u  E6 V' I1 g
decided to put the baby in a separate bed, and the0 X# L' n9 d, {) D3 m
father was not hugging him with bare skin and had! c. E, I2 ]. X7 ^9 O6 u
been using protective clothing. A repeat testosterone
! ?9 _" `5 L+ h7 j% Ktest was ordered, but the family did not go to the
- h+ c; R3 _) J0 D+ l5 hlaboratory to obtain the test.
7 k& I! E6 ]" EDiscussion( |7 M3 D* ?) {; w8 i5 q
Precocious puberty in boys is defined as secondary4 F2 F- {0 O" ?: A$ q( I
sexual development before 9 years of age.1,4
/ N( q* h2 l) J5 c5 mPrecocious puberty is termed as central (true) when" u+ G- ~) O" ?
it is caused by the premature activation of hypo-
7 D8 T9 s  @  ]* e. z6 J0 Othalamic pituitary gonadal axis. CPP is more com-0 e) n: ?# {3 x9 J/ {
mon in girls than in boys.1,3 Most boys with CPP( G! \3 F0 Q1 s' Q" Q# d, j
may have a central nervous system lesion that is3 ~3 a. I: y3 T" l: E9 D2 @
responsible for the early activation of the hypothal-
0 D  F5 p# Y% e) I- camic pituitary gonadal axis.1-3 Thus, greater empha-
2 c! n. A6 D! U0 J  ^$ Nsis has been given to neuroradiologic imaging in: q/ j% @5 d! |0 \; O
boys with precocious puberty. In addition to viril-
7 X9 z: P0 Y% k* @' F5 c, }ization, the clinical hallmark of CPP is the symmet-  V4 i2 e! G% G) t
rical testicular growth secondary to stimulation by
) k& d! I' v5 Q7 }9 D, z$ Jgonadotropins.1,3
3 E( X, U  C  _/ uGonadotropin-independent peripheral preco-
/ p% I1 E: w$ ?* S5 H/ c4 F' |8 ]cious puberty in boys also results from inappropriate
& K) O: p2 Y- t) c4 d* I! C. tandrogenic stimulation from either endogenous or$ W- Z+ D+ R' M( [$ E
exogenous sources, nonpituitary gonadotropin stim-
% q( g* H1 S3 N# D' eulation, and rare activating mutations.3 Virilizing" R8 S2 I- L" ~5 y4 P1 T
congenital adrenal hyperplasia producing excessive
1 K% g& y, V% A* L. P) z7 R3 q  yadrenal androgens is a common cause of precocious
& z3 `  `& B6 F( ?) upuberty in boys.3,4: y. C9 M- f2 L1 {3 i
The most common form of congenital adrenal9 n& c  q; ~+ j) G& ~# D
hyperplasia is the 21-hydroxylase enzyme deficiency., U8 ]. @- X$ I  ^
The 11-β hydroxylase deficiency may also result in
8 ]  Y( W& e+ w+ m) @/ Texcessive adrenal androgen production, and rarely,- n* I$ f/ @: R
an adrenal tumor may also cause adrenal androgen
5 e6 a* D" N; d' _excess.1,3
0 z; l% h( Y3 xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" d: `6 e* W5 }& _* c
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" g6 S+ i6 p/ |3 r# L6 `6 ^8 T: ?A unique entity of male-limited gonadotropin-
+ s; U" Z9 o+ G0 f9 o9 xindependent precocious puberty, which is also known! T; x( c0 ~5 @5 R* J2 p
as testotoxicosis, may cause precocious puberty at a, Y8 f# k2 ]7 W" }: L. M
very young age. The physical findings in these boys
/ _5 i( Q) @. |0 M: Dwith this disorder are full pubertal development,
3 D/ U7 F, \, W0 h, Rincluding bilateral testicular growth, similar to boys  @; ?, d* d9 B4 F2 ?, W; d& F
with CPP. The gonadotropin levels in this disorder5 c# q- t5 w  |( ?& V( T# z& J
are suppressed to prepubertal levels and do not show  S0 \8 r1 u. D/ E
pubertal response of gonadotropin after gonadotropin-
8 U" B3 N& E4 |' ^/ J% W7 b! nreleasing hormone stimulation. This is a sex-linked
( s. F4 z1 i' P3 s+ ]autosomal dominant disorder that affects only3 \9 x& @: U" t+ v/ N6 T
males; therefore, other male members of the family/ E  R. c7 v: ^1 \
may have similar precocious puberty.3
  W4 Z1 ^! Y$ t! `5 e( tIn our patient, physical examination was incon-. v, k2 u8 O9 G  [0 h
sistent with true precocious puberty since his testi-: A1 L. z/ d0 L- s/ S3 n
cles were prepubertal in size. However, testotoxicosis
* c6 t1 P; f2 N) C0 @) m) C4 Ewas in the differential diagnosis because his father2 _, B) y$ M! m, C7 @
started puberty somewhat early, and occasionally,
( J$ x* @" |# t8 xtesticular enlargement is not that evident in the
* O' [9 P" ^$ f4 B5 lbeginning of this process.1 In the absence of a neg-  ~/ l6 `1 O: J5 t7 U+ U* O
ative initial history of androgen exposure, our; m$ V- {0 b( `6 z# [
biggest concern was virilizing adrenal hyperplasia,: v! N! p2 u  H! f
either 21-hydroxylase deficiency or 11-β hydroxylase
* @1 s0 o: s+ s" j% l6 S2 \deficiency. Those diagnoses were excluded by find-) V- G2 L: x  a# ~/ }. ]- Q
ing the normal level of adrenal steroids.7 _' \! q" Y) F4 ^4 D8 r, t
The diagnosis of exogenous androgens was strongly, k' w% M. `4 \/ n3 Q! e
suspected in a follow-up visit after 4 months because) P3 A* M! d  B. ^& R0 R: g
the physical examination revealed the complete disap-
( [7 H4 l1 t' B+ b; Epearance of pubic hair, normal growth velocity, and+ g4 e8 H; _9 ]& j5 N) b
decreased erections. The father admitted using a testos-0 A( u9 d) p4 ~
terone gel, which he concealed at first visit. He was% v3 g1 S( T( ~/ K
using it rather frequently, twice a day. The Physicians’
& o5 p: }$ r, e$ q" m& Y( T9 cDesk Reference, or package insert of this product, gel or/ ?: `/ `+ j* e4 w" \9 B
cream, cautions about dermal testosterone transfer to
# D- u+ }  r1 k4 _3 s# a7 T8 m6 \8 Zunprotected females through direct skin exposure.
9 _( w+ ]$ [! d2 a7 W: pSerum testosterone level was found to be 2 times the! |- ~  J; T; @, D# w* x! J: ~
baseline value in those females who were exposed to1 s1 W7 }  @8 H1 D* J# m  m  P- t
even 15 minutes of direct skin contact with their male
5 f& a8 m% A' y% Xpartners.6 However, when a shirt covered the applica-5 ?% _3 w. e: ?
tion site, this testosterone transfer was prevented.) Y5 m3 K( `3 W
Our patient’s testosterone level was 60 ng/mL,
# Q, G# n! g: U2 p; J& `6 \which was clearly high. Some studies suggest that
6 t0 O% k% B  P& i2 l/ hdermal conversion of testosterone to dihydrotestos-6 p3 v( ~% _( s  T
terone, which is a more potent metabolite, is more5 j8 {# X! \. o4 B  ^
active in young children exposed to testosterone
5 _- M+ p0 S" M/ Q" }0 T2 ?exogenously7; however, we did not measure a dihy-
/ I+ S# L9 F: q- g2 zdrotestosterone level in our patient. In addition to/ D( Q1 a' \  {6 U2 j
virilization, exposure to exogenous testosterone in" I1 n, S6 G1 B, P/ @
children results in an increase in growth velocity and7 e( ]4 s+ Z' j2 z! _
advanced bone age, as seen in our patient.( o. E* l3 F- x3 W( N9 ~/ L
The long-term effect of androgen exposure during
7 q* K! `6 w; j3 f; O6 oearly childhood on pubertal development and final
+ U+ U, o) e( G9 F! \adult height are not fully known and always remain  v) M6 X' D$ S" l8 W; h
a concern. Children treated with short-term testos-
. U8 T3 S* K1 _" ?8 uterone injection or topical androgen may exhibit some
% q: a& `1 I& Y9 D  G' O$ kacceleration of the skeletal maturation; however, after
2 n, c+ z* `* ycessation of treatment, the rate of bone maturation( X& w1 s; D: ^0 b
decelerates and gradually returns to normal.8,90 X, X* |# Q, q3 g, y% H( {( Z
There are conflicting reports and controversy
$ z% L  j4 V* K+ V  t! z* P$ Zover the effect of early androgen exposure on adult1 N2 [! v$ G$ b  t$ x1 J( G: q6 r
penile length.10,11 Some reports suggest subnormal* `: O3 m0 y  K& C9 w
adult penile length, apparently because of downreg-) Z7 R4 M/ ~! u
ulation of androgen receptor number.10,12 However,& f' \! x3 A8 O; C
Sutherland et al13 did not find a correlation between
- K" g. f; g" b8 Y2 u5 i1 \childhood testosterone exposure and reduced adult" g  J3 P! |2 U4 L3 i3 c' ?
penile length in clinical studies.
# c0 p' W8 \1 t% r' X+ ENonetheless, we do not believe our patient is" I# D$ s2 C3 [. ^
going to experience any of the untoward effects from
6 i9 ^! p) Q6 z8 |  qtestosterone exposure as mentioned earlier because4 c/ w/ I( _9 U5 l
the exposure was not for a prolonged period of time.! Y/ r  j; A& |( U
Although the bone age was advanced at the time of
/ C% r+ m( g! A. z, m/ i9 Vdiagnosis, the child had a normal growth velocity at) B. U2 M3 }/ X3 b
the follow-up visit. It is hoped that his final adult
' q* k% h1 q- w, \' S, M* @height will not be affected.7 p1 E# b: ]* X2 _& I
Although rarely reported, the widespread avail-! g6 @" y- X( M" b7 G
ability of androgen products in our society may6 B% N3 a9 V) e; p) o& @
indeed cause more virilization in male or female- ?. Z/ e, c# a7 x! V+ ~; b" \
children than one would realize. Exposure to andro-. q  p( w" A: p! y% R
gen products must be considered and specific ques-
0 {. o: ]5 c  p' Htioning about the use of a testosterone product or
' X8 n4 z0 K; U/ m/ Bgel should be asked of the family members during( H3 u* G( @! K5 }2 W2 ?
the evaluation of any children who present with vir-
3 G+ r* O; K2 C: g8 g- t/ Tilization or peripheral precocious puberty. The diag-
' m+ R7 [, N8 E( [" y* onosis can be established by just a few tests and by$ u1 ], `' v3 X/ H' u; _
appropriate history. The inability to obtain such a
" o! ^( b: r; Nhistory, or failure to ask the specific questions, may; a9 @3 d) v% L' }8 Z/ ]
result in extensive, unnecessary, and expensive; y6 @% \, H+ X9 R- P
investigation. The primary care physician should be
# h8 O+ o; W5 @  saware of this fact, because most of these children
# C; h, ?1 P6 hmay initially present in their practice. The Physicians’
! @% l& _& p- J4 ?8 C. R- sDesk Reference and package insert should also put a
' I3 i! i/ K# F: G2 z% kwarning about the virilizing effect on a male or. i. R4 x) c; J; g
female child who might come in contact with some-- f* o4 G* x  b4 W2 o; R1 g
one using any of these products.- I1 J0 m) c: @2 U5 x% B
References4 B2 m" v; `; C  o
1. Styne DM. The testes: disorder of sexual differentiation. z; L( A1 q& }
and puberty in the male. In: Sperling MA, ed. Pediatric# |: Y7 E1 H  a5 I
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 Q+ R1 l9 c5 y9 z
2002: 565-628.8 N( k8 B. T5 E3 w* N( S% A4 p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ t) q1 k* B; Q  y  ?4 Q* }puberty in children with tumours of the suprasellar pineal
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加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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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

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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層
0 x1 }3 U4 }9 o
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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