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Sexual Precocity in a 16-Month-Old" N& ?" g( Y8 I. U2 _0 T5 ]
Boy Induced by Indirect Topical2 P$ B7 F+ W% B3 K
Exposure to Testosterone1 \7 Q  `' U7 A5 A! j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 r, p+ y+ c' P6 k6 \and Kenneth R. Rettig, MD18 Y$ H+ c7 k. u! Y
Clinical Pediatrics
' U8 {, F8 C9 u  S/ q0 Q3 {Volume 46 Number 65 A5 X! V6 H9 I! b2 I
July 2007 540-543
8 u# m* p* x- e; I0 ]© 2007 Sage Publications0 x0 P7 ]0 G5 H+ Q
10.1177/00099228062966513 r' J( a# o7 y9 Z
http://clp.sagepub.com
7 ~: `+ r& }9 x2 S9 p; _' f& Phosted at
2 ?2 N3 _3 [8 Z  x1 k5 U7 fhttp://online.sagepub.com/ o+ M' h  D8 l
Precocious puberty in boys, central or peripheral,
9 j- A/ [6 U1 B  u% gis a significant concern for physicians. Central
6 S' b$ `/ {. F$ [precocious puberty (CPP), which is mediated
6 e+ c& E3 C3 r: U; h3 x! @through the hypothalamic pituitary gonadal axis, has
8 I  ]" r2 }3 d  @a higher incidence of organic central nervous system
8 z: P! F5 ^7 C( b+ @! U( tlesions in boys.1,2 Virilization in boys, as manifested
& U4 J0 y( \  Y: ]( D) ?by enlargement of the penis, development of pubic4 e+ g- ?# R4 m- j5 K6 M$ S
hair, and facial acne without enlargement of testi-
1 |# N4 |7 B9 {cles, suggests peripheral or pseudopuberty.1-3 We
  j; @! \* S/ b- c3 A6 L! vreport a 16-month-old boy who presented with the* b: [8 x9 |8 P) x* Y* h% `: \0 C
enlargement of the phallus and pubic hair develop-0 L3 Q" A8 `% O8 ?' |( c
ment without testicular enlargement, which was due
- i/ W& w3 a" Y" Tto the unintentional exposure to androgen gel used by
% a  ~9 V+ z! gthe father. The family initially concealed this infor-
( D$ K% I" m# R/ Y) }mation, resulting in an extensive work-up for this1 G) }/ F3 M2 D$ j+ {4 l
child. Given the widespread and easy availability of9 o& B( n1 z. z* y
testosterone gel and cream, we believe this is proba-0 c) o  I% \, B
bly more common than the rare case report in the2 O; |5 i6 v3 c; {  q7 \  G
literature.4
% s. a* c2 S2 U: \  bPatient Report
7 \. Y& w6 w, S5 G1 ?! q; D! d' kA 16-month-old white child was referred to the
4 m6 m' w2 v# z+ U" m0 p( _' uendocrine clinic by his pediatrician with the concern
, N6 F! \& X- P$ Xof early sexual development. His mother noticed
7 u9 z$ Q$ T+ y' Q1 @light colored pubic hair development when he was' L" O$ G9 _8 G, k' [
From the 1Division of Pediatric Endocrinology, 2University of
+ S4 N. x/ M5 h" }- m# ^7 lSouth Alabama Medical Center, Mobile, Alabama.
: @7 L, r5 d$ d8 z+ eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& [4 S/ v* N/ T# u) ZProfessor of Pediatrics, University of South Alabama, College of
4 f( r6 f! e- e$ Y( L! T) a7 ^Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 a/ d0 x5 ?0 H& \: Fe-mail: [email protected].
$ J3 @9 T6 V; M4 M! E6 {about 6 to 7 months old, which progressively became  W& R; z0 `9 T. u1 t5 J- K
darker. She was also concerned about the enlarge-" h( ^2 v+ T+ O  p" Y" v& b7 K' ]
ment of his penis and frequent erections. The child
  c3 a. D* L) W8 v( mwas the product of a full-term normal delivery, with
. ]* b2 w. ]1 R) x/ _8 G2 j7 ta birth weight of 7 lb 14 oz, and birth length of
2 H1 ~, f7 e, V: H$ z3 ]/ I20 inches. He was breast-fed throughout the first year$ H; D8 T" x/ }( w1 p( G
of life and was still receiving breast milk along with
9 D' E5 z. a- K' B8 B2 Q- R& _solid food. He had no hospitalizations or surgery,9 ]4 [( _9 V' @- H9 n1 d* M6 M
and his psychosocial and psychomotor development
1 Q0 J4 ~0 Z2 s( Wwas age appropriate.
4 o. @; \& E# a6 m9 h, V0 ^7 \The family history was remarkable for the father,5 R/ L7 g. B: p; s* }0 D- j" S
who was diagnosed with hypothyroidism at age 16,! Z  t2 S# P0 O6 l4 Q# M9 J) A
which was treated with thyroxine. The father’s7 r  Q; a) x" ^/ g6 |& I4 K
height was 6 feet, and he went through a somewhat
/ e+ Q  e: V. \& Yearly puberty and had stopped growing by age 14.
+ d# n" i. j0 p, pThe father denied taking any other medication. The( B; @0 e8 M) a& Q  H  B  q9 h9 h
child’s mother was in good health. Her menarche
. g( U* U  l% W! A- _  ]0 m' Pwas at 11 years of age, and her height was at 5 feet
1 T' \* g. ~; e5 inches. There was no other family history of pre-' V, g* {9 f( i9 {# x$ L$ N7 W3 E( F
cocious sexual development in the first-degree rela-! B5 t7 U' m. P2 P3 ^
tives. There were no siblings.
4 q: ?4 G# |1 z5 @4 o% P/ sPhysical Examination$ J, v8 E5 `0 c- t* N
The physical examination revealed a very active,
" K4 a" O. `8 y; jplayful, and healthy boy. The vital signs documented  [7 Z+ _: l2 r
a blood pressure of 85/50 mm Hg, his length was
7 [. N0 g# s0 k$ n" E/ @7 D' W90 cm (>97th percentile), and his weight was 14.4 kg) ~6 P1 m& e2 ?6 \% G; R* i( z
(also >97th percentile). The observed yearly growth
3 L4 _4 k2 e1 Q" g& n7 t3 \1 s- b9 zvelocity was 30 cm (12 inches). The examination of4 k7 L% `! R- ~
the neck revealed no thyroid enlargement.
! @" y- ^& |8 y% q9 \The genitourinary examination was remarkable for
' |+ p5 A0 m' `enlargement of the penis, with a stretched length of# k2 m& n, m9 ]' L) E5 U! g
8 cm and a width of 2 cm. The glans penis was very well5 a% v' v7 y2 T, \0 P5 z
developed. The pubic hair was Tanner II, mostly around4 r- ?1 D1 c" O2 N1 v
540$ t' P; ~# u" u# [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, Z& x: Z- p* Ythe base of the phallus and was dark and curled. The; V, P4 e# s4 R. D3 \
testicular volume was prepubertal at 2 mL each.
. ?) d' G- M4 [& [* G4 |* xThe skin was moist and smooth and somewhat
' m4 m1 u% A# p0 @$ noily. No axillary hair was noted. There were no
1 O8 R" ^5 k3 O  ^2 T9 Tabnormal skin pigmentations or café-au-lait spots.3 z* h! t. I7 C- x- P  |3 ?* G2 f
Neurologic evaluation showed deep tendon reflex 2+4 o$ }. S9 ]( ]9 c& q4 C+ z# J2 u
bilateral and symmetrical. There was no suggestion% A% G0 ]3 ~# O9 C" i( `
of papilledema.
/ A! X: M7 x. v/ n* P( x1 sLaboratory Evaluation
1 W% i# C8 y/ f7 oThe bone age was consistent with 28 months by
9 R9 h! M( P. X# [/ nusing the standard of Greulich and Pyle at a chrono-
  o% X- D" g" r2 Blogic age of 16 months (advanced).5 Chromosomal+ ^% ~/ Z8 b* Z6 H8 G3 n7 }
karyotype was 46XY. The thyroid function test- z: D/ ~6 _: X6 Z, E, U
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, n6 ~& F4 h, X, R- Q9 h/ {6 A6 g
lating hormone level was 1.3 µIU/mL (both normal).3 u5 N5 y% E) }5 y1 X0 t8 z$ B
The concentrations of serum electrolytes, blood
  O( I4 ~) C, Kurea nitrogen, creatinine, and calcium all were, U1 b& S) B% n: _0 e0 A/ |
within normal range for his age. The concentration
( q# E( k1 T6 S! G7 B% H- }3 |$ a$ Iof serum 17-hydroxyprogesterone was 16 ng/dL* G& L* F" C0 C7 l$ b" o) ^
(normal, 3 to 90 ng/dL), androstenedione was 20
- ], G# s9 X) ?- Q# Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ N: G& t3 a; c9 U/ o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 }5 @, @) i. C) p8 o! r& K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 o* j  q- `* s+ V' N; ]
49ng/dL), 11-desoxycortisol (specific compound S)/ O4 J8 y1 _3 }  Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- ]9 ^/ W, r9 [6 R( a" J) |; s$ E- J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* S9 L5 x! c% D  l& D
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- s! N/ d- l5 V+ ^9 hand β-human chorionic gonadotropin was less than6 x: N/ S$ [# B) b8 R6 l
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 L4 v  d5 }7 P) z* V/ {& xstimulating hormone and leuteinizing hormone
$ t) r$ C9 R; M) ]. Q: oconcentrations were less than 0.05 mIU/mL/ n) f1 ~" ^1 q" |1 k( O% `" C
(prepubertal).
2 f5 c: E( ~# \$ GThe parents were notified about the laboratory
/ H% V* H7 V$ l8 Bresults and were informed that all of the tests were
1 ~  P" ^- P$ D- Unormal except the testosterone level was high. The
9 j) D, q' N* P. U- [! Qfollow-up visit was arranged within a few weeks to
: d! Y# G+ u) w$ Z: Q; Fobtain testicular and abdominal sonograms; how-
- N  _+ {% o$ never, the family did not return for 4 months.
3 w9 A# A' x4 {% x% X1 HPhysical examination at this time revealed that the
: [- F3 Y6 M6 @* y% Zchild had grown 2.5 cm in 4 months and had gained
' M9 A' k" O1 z1 ?6 X& y2 kg of weight. Physical examination remained
& \5 e" x6 a) `3 A$ c  ?( A! kunchanged. Surprisingly, the pubic hair almost com-+ v  S0 @2 @- \+ K" c2 r
pletely disappeared except for a few vellous hairs at, T' j- |" E0 R7 m  R$ W
the base of the phallus. Testicular volume was still 2
9 c  h( k. f4 |' c9 @mL, and the size of the penis remained unchanged.
- \# R* M$ K- ~) T5 _9 |8 dThe mother also said that the boy was no longer hav-6 e9 B3 e% \- O! u( L4 p9 `
ing frequent erections.
& k; ?) k# i- @# r% ~Both parents were again questioned about use of/ K: u1 n6 V: C" P) y1 q) V
any ointment/creams that they may have applied to
: |+ `" ~9 @2 e" ~; t0 lthe child’s skin. This time the father admitted the
% l9 A& [  N  ~; a' s+ ~6 [Topical Testosterone Exposure / Bhowmick et al 541
6 W( G4 P# U6 Euse of testosterone gel twice daily that he was apply-
7 [; N0 ]  z% n  T- Cing over his own shoulders, chest, and back area for
/ K# i! G1 k3 y) J2 s& |1 ca year. The father also revealed he was embarrassed4 h& V! K4 v) Y
to disclose that he was using a testosterone gel pre-
2 Y% O4 I/ y- lscribed by his family physician for decreased libido3 a2 u& [. ?, w
secondary to depression.& r, ^$ c4 y( z/ ~
The child slept in the same bed with parents.
" i8 @% S, H+ Z6 LThe father would hug the baby and hold him on his1 ^/ T/ \% {! w5 v
chest for a considerable period of time, causing sig-  h7 s3 h4 k3 b" p% B
nificant bare skin contact between baby and father., N) M2 }2 A8 a3 s; X; N- f( r8 ]6 l' r( [# ^
The father also admitted that after the phone call,
1 l8 W! ~8 q  }* u1 ?0 j2 G# cwhen he learned the testosterone level in the baby9 m# g5 b8 x' C
was high, he then read the product information
* s9 F- C6 |. I! N# p$ Tpacket and concluded that it was most likely the rea-3 Y9 t8 ?% @3 z4 L% R& }7 J
son for the child’s virilization. At that time, they
, }! E, y7 y1 V; O* Tdecided to put the baby in a separate bed, and the
" k* m: ]1 ?' E5 l( F2 R# D& G- f+ Bfather was not hugging him with bare skin and had
% t/ @. O+ i- K1 u2 hbeen using protective clothing. A repeat testosterone
$ Y) I4 H$ v$ a8 V1 xtest was ordered, but the family did not go to the7 Y; a/ G6 I2 c% P$ S4 l
laboratory to obtain the test.
, H9 o  s5 i: s' z6 eDiscussion) r3 W* `. o+ u* F, \
Precocious puberty in boys is defined as secondary8 @( O# U9 ]& u
sexual development before 9 years of age.1,4
$ x8 R% ]  k+ ]0 J' M) a8 @6 {8 f4 }Precocious puberty is termed as central (true) when
1 r/ \) X( {( \& f/ V+ H8 Vit is caused by the premature activation of hypo-( E- s6 M9 |3 w/ o
thalamic pituitary gonadal axis. CPP is more com-
6 h* @+ j' u+ j5 N; X% ymon in girls than in boys.1,3 Most boys with CPP
6 J2 L. W) E: @8 Xmay have a central nervous system lesion that is
1 t' V! \% S+ r3 x! E7 Lresponsible for the early activation of the hypothal-2 P8 M# R" D  N' @) b
amic pituitary gonadal axis.1-3 Thus, greater empha-9 ^% m+ y7 |' [; B
sis has been given to neuroradiologic imaging in& G2 X$ J7 Q" u
boys with precocious puberty. In addition to viril-5 `- k$ x: X; k5 L
ization, the clinical hallmark of CPP is the symmet-) t# r6 V1 O  d: U
rical testicular growth secondary to stimulation by
9 }  }+ p* F" cgonadotropins.1,39 C5 D2 g( d1 R
Gonadotropin-independent peripheral preco-
$ m; J6 D9 `$ Z' S% X8 \- y" C( Lcious puberty in boys also results from inappropriate
  O, J. ?+ }/ w8 ^# u2 S  Randrogenic stimulation from either endogenous or
& B0 n5 n* t# W/ v2 u, q1 N0 K2 oexogenous sources, nonpituitary gonadotropin stim-
1 v1 p$ W4 A, \! m5 l6 hulation, and rare activating mutations.3 Virilizing& K3 T; l8 [7 A6 N8 b
congenital adrenal hyperplasia producing excessive
$ Z& B( ]6 Q) D' ^7 Z1 Kadrenal androgens is a common cause of precocious
+ M5 E. T( H" G. k1 V2 Q! c; _: c6 }puberty in boys.3,4
# }) h4 D* M7 G+ D0 O( m3 OThe most common form of congenital adrenal
" e: x' v) |% M2 @1 Zhyperplasia is the 21-hydroxylase enzyme deficiency.. K, P9 w3 s$ u) `9 m
The 11-β hydroxylase deficiency may also result in" N" [  Z0 l1 H3 S, m
excessive adrenal androgen production, and rarely,! p$ u! r) n1 I6 C6 `3 a3 z
an adrenal tumor may also cause adrenal androgen
# t/ P5 ~- O  wexcess.1,3
/ o+ l1 q2 K1 Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* i  U; q+ y( D. ^3 a+ s' D542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; m/ T. C& T! o; K2 pA unique entity of male-limited gonadotropin-! K4 |) |. z$ i
independent precocious puberty, which is also known; K. m! C7 A# k  j4 n/ w, S" D
as testotoxicosis, may cause precocious puberty at a
4 v' j5 J# V! `$ q% w5 Qvery young age. The physical findings in these boys
% `- i5 h* x- {8 C" K: ^: Z* }3 iwith this disorder are full pubertal development,9 R% L- D. \& k& ]9 p7 k/ n9 o
including bilateral testicular growth, similar to boys
/ |8 l1 l8 j( U5 i5 \( f; Z) n* `) Qwith CPP. The gonadotropin levels in this disorder
. x: }) y% ?( A) P; A8 h- Yare suppressed to prepubertal levels and do not show& E* G, V8 W. t+ }
pubertal response of gonadotropin after gonadotropin-
) `& `7 {2 ^( f! T1 R8 }" }releasing hormone stimulation. This is a sex-linked
, w2 N$ ]/ ~% Xautosomal dominant disorder that affects only
" |8 t/ {& v; L  U2 Gmales; therefore, other male members of the family
) I4 t1 q  L$ v! o9 D6 fmay have similar precocious puberty.3
# n" h1 ~7 t5 R* AIn our patient, physical examination was incon-
3 ]4 {! C0 }3 A" q8 a+ osistent with true precocious puberty since his testi-
# k3 i, T/ j  G. X' T0 ^- Z+ c& gcles were prepubertal in size. However, testotoxicosis; e; v- R  V6 F( S# I4 ~, J
was in the differential diagnosis because his father" N! K& m# C0 G& ~
started puberty somewhat early, and occasionally,; [9 z, C/ G, S, O6 i( ~; X$ i
testicular enlargement is not that evident in the
' G. ~9 K  @( k, ~9 s3 i6 Q; vbeginning of this process.1 In the absence of a neg-! g# U+ ~! K: d6 ~; G0 {
ative initial history of androgen exposure, our2 G# G/ \$ [" u+ Z# o. v. L; L
biggest concern was virilizing adrenal hyperplasia,$ n  n( _; O# H4 ~  Q0 T* h
either 21-hydroxylase deficiency or 11-β hydroxylase. S" M# _/ G3 ~. Z6 c& s: y8 E( I
deficiency. Those diagnoses were excluded by find-
7 _0 ?$ c+ `% D* n! eing the normal level of adrenal steroids.
4 g% D7 r2 ^. o- z9 Q4 @The diagnosis of exogenous androgens was strongly
% \2 J8 P- ^; _) o- B7 Bsuspected in a follow-up visit after 4 months because
/ y. f2 J7 g- l& b( H4 G7 k) E$ K4 dthe physical examination revealed the complete disap-
  \; Y9 u# U$ H8 }7 v6 e2 f: Bpearance of pubic hair, normal growth velocity, and8 q/ g" S+ G; h1 v1 C; o
decreased erections. The father admitted using a testos-0 z/ y+ w  Q0 B$ H0 p# ?
terone gel, which he concealed at first visit. He was
( S, g& B/ X# k+ Nusing it rather frequently, twice a day. The Physicians’
  \$ C8 @0 r; Y  kDesk Reference, or package insert of this product, gel or
4 {9 s7 A! h0 \3 U* O+ X3 Xcream, cautions about dermal testosterone transfer to
, e3 z7 A) C' n2 Z8 W# Ounprotected females through direct skin exposure.
1 V& u( _6 R$ ]7 E- S, }% u5 ^2 ?Serum testosterone level was found to be 2 times the0 m0 a4 |: }- v7 Q  ^
baseline value in those females who were exposed to# Z- h  l% b$ d8 c9 X: y
even 15 minutes of direct skin contact with their male
, w3 L3 t1 {9 h( l' u$ `" v7 Npartners.6 However, when a shirt covered the applica-: k+ n+ y. C, q+ Y
tion site, this testosterone transfer was prevented.3 e: O/ ], g9 p9 O8 _$ V- e/ w
Our patient’s testosterone level was 60 ng/mL,# K* N0 h3 E9 \+ C
which was clearly high. Some studies suggest that
* {4 o7 b6 Q6 T5 p! ldermal conversion of testosterone to dihydrotestos-. T3 f$ s# Q. Z* U6 T; {3 T/ S
terone, which is a more potent metabolite, is more0 N( h6 e* ~5 l
active in young children exposed to testosterone) o5 U& L- x, G9 C/ |% y
exogenously7; however, we did not measure a dihy-
2 g2 d) H6 a+ p( [drotestosterone level in our patient. In addition to
; U4 {# e9 }# y2 Uvirilization, exposure to exogenous testosterone in
/ D5 I. A0 h. D5 G6 X0 qchildren results in an increase in growth velocity and" L- s; c! X2 T. z! ]" W
advanced bone age, as seen in our patient.
5 j1 |2 s9 T; ]6 {4 p7 GThe long-term effect of androgen exposure during
2 o: F5 G: T$ U# i9 Tearly childhood on pubertal development and final
" s. Q7 g" j" w0 ]& Tadult height are not fully known and always remain2 K  S0 I9 x6 c5 G" Z$ d: Q+ ~
a concern. Children treated with short-term testos-' G& I5 u  l! M
terone injection or topical androgen may exhibit some
( Z- \7 L$ ]" o- @8 F  L2 Lacceleration of the skeletal maturation; however, after" E1 Y$ I8 r5 ?3 Y9 N: ^
cessation of treatment, the rate of bone maturation
! i2 w6 C- M, A8 d8 ]- U: r5 Odecelerates and gradually returns to normal.8,9
( s3 p& q( K8 EThere are conflicting reports and controversy
/ P  }2 Z  Z' C8 Q/ E* G  z7 T* g2 rover the effect of early androgen exposure on adult: h" T6 O% J' a) W6 g$ b
penile length.10,11 Some reports suggest subnormal  }6 a9 T/ Z( s, e3 h% d/ t
adult penile length, apparently because of downreg-
* f& l* m3 _: X4 ~, e' zulation of androgen receptor number.10,12 However,+ S# S" z0 O% r+ W" h
Sutherland et al13 did not find a correlation between  {5 r" W/ y: D0 e
childhood testosterone exposure and reduced adult
! j# Y! E3 G- Q8 bpenile length in clinical studies.
! t2 }  X+ c5 y: ?+ W# uNonetheless, we do not believe our patient is% o" ^% W+ D$ W& S+ A$ Z+ d
going to experience any of the untoward effects from
1 P- b) p$ I+ q7 @9 h6 W5 y  dtestosterone exposure as mentioned earlier because' R2 d. P7 ~, A
the exposure was not for a prolonged period of time.
0 w6 G% P; d, FAlthough the bone age was advanced at the time of
6 x% s( M- E. v$ y" p  p) Sdiagnosis, the child had a normal growth velocity at0 C& H- `& p1 m" L4 C0 o8 r
the follow-up visit. It is hoped that his final adult
. `7 X8 @# ^' z' a* Q3 h3 iheight will not be affected.
) @& C% z8 O% K, BAlthough rarely reported, the widespread avail-
2 X1 z( z8 }% [* m+ `4 o/ g, @# m7 X* Cability of androgen products in our society may
6 V, c; Z+ t3 H8 e5 X* R; qindeed cause more virilization in male or female3 v0 L. d; l/ e# i- i
children than one would realize. Exposure to andro-# C$ Y5 ~( w& c  m, Q
gen products must be considered and specific ques-, z( A- ^% M5 M' ?& j
tioning about the use of a testosterone product or
  v5 A( y1 M6 Y1 kgel should be asked of the family members during
" l$ h/ a3 C6 Bthe evaluation of any children who present with vir-3 b4 u+ S9 M& ]
ilization or peripheral precocious puberty. The diag-
* X' P) P5 v- y; u# l1 X8 r4 s" Qnosis can be established by just a few tests and by" N3 m: X2 J5 C
appropriate history. The inability to obtain such a  F- ~. t) z7 h- X
history, or failure to ask the specific questions, may0 _: l# Q: Q; l9 v) a% n3 P
result in extensive, unnecessary, and expensive' a# G6 i% N7 f: \* E3 |
investigation. The primary care physician should be
5 j% [/ ]) V: C  z8 m; D0 [6 Aaware of this fact, because most of these children& M, _. l; p9 }. @: i7 |
may initially present in their practice. The Physicians’
2 c& C* X. T$ x3 ^4 ?8 f2 ?1 LDesk Reference and package insert should also put a
1 q; ?1 t# o! [- pwarning about the virilizing effect on a male or
& C' S- G7 l% d! Q5 Rfemale child who might come in contact with some-3 x4 e: @$ }8 n) g
one using any of these products.
- x+ o! n# N. y8 J+ GReferences" L; d- W; r2 [3 r5 C+ A
1. Styne DM. The testes: disorder of sexual differentiation& k* E( v6 E% ^5 d. X9 p7 O: y& l
and puberty in the male. In: Sperling MA, ed. Pediatric
$ t  Z/ j- ?. p8 A+ A5 z* SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ b# O/ {3 g% e+ }1 o- ~/ P$ h
2002: 565-628.
+ U, `2 l0 p: B. @  `. F& q6 l2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 T5 L8 g8 E. e5 ?puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' K8 G  Y8 k  B6 ~Boy Induced by Indirect Topical
- \5 b, e: B8 T: M! sExposure to Testosterone; _+ a9 C+ f1 u
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" S. ?' H2 o  @% k! l: r3 Iand Kenneth R. Rettig, MD1' G) F. J1 E; W) \: ]
Clinical Pediatrics
. I. w; M2 i9 n# DVolume 46 Number 67 M* H1 F# a8 C& |' O
July 2007 540-543; o( S# o$ z9 v0 {' Y' t1 q7 q/ T: p7 \
© 2007 Sage Publications" i1 v8 O0 ^/ f5 X6 d
10.1177/0009922806296651
( i, i  M! {6 G7 Z5 `; N( f3 bhttp://clp.sagepub.com
, o" z( V8 H7 W* `/ ahosted at9 c% g, J* }: D6 A, j0 G
http://online.sagepub.com2 L* A( I, n5 s4 O' Q5 n4 T
Precocious puberty in boys, central or peripheral,
" ~- N. H( ?/ ~is a significant concern for physicians. Central
2 W& _+ Q; J% j. P8 y, ^precocious puberty (CPP), which is mediated
* ^  x: j3 l: Q& `# {through the hypothalamic pituitary gonadal axis, has, b4 S4 C0 L3 o, {+ G8 n
a higher incidence of organic central nervous system( s6 E8 a* x  s% y/ c
lesions in boys.1,2 Virilization in boys, as manifested
! A) J  K3 c: Oby enlargement of the penis, development of pubic
9 d2 P1 W) `: Q4 r1 [" chair, and facial acne without enlargement of testi-
3 w: k0 v, B& y+ F& H& ~; S2 Jcles, suggests peripheral or pseudopuberty.1-3 We8 X' z4 ]1 i# L9 M$ G& ]
report a 16-month-old boy who presented with the
  X) r( d$ j/ G' r) }2 |enlargement of the phallus and pubic hair develop-
2 T% p# ~7 E0 v6 C( l0 Tment without testicular enlargement, which was due" y9 V% w1 o# \
to the unintentional exposure to androgen gel used by& R3 R/ K6 a$ ^1 E( Y* u6 P
the father. The family initially concealed this infor-
7 a8 U) l0 G0 a' ?5 X& N) wmation, resulting in an extensive work-up for this
1 o- E: }7 k; ?& G3 z. s4 rchild. Given the widespread and easy availability of( F. y- \4 J1 R; P5 H# J
testosterone gel and cream, we believe this is proba-
$ L9 C/ Z* }0 y1 u5 x) {. Wbly more common than the rare case report in the$ V, H: y7 L; ]$ k) Z6 i6 s# M
literature.43 v6 a5 i# A- |/ D4 g' \
Patient Report7 ~* F' r* [' u
A 16-month-old white child was referred to the
4 [6 \1 A  ]( n0 p  eendocrine clinic by his pediatrician with the concern. ?9 [# ]4 i3 U" Q. k1 u
of early sexual development. His mother noticed
5 s' w2 t# z% W" Y$ H, f5 a+ c# x+ Rlight colored pubic hair development when he was
& B* c) m3 Y) x9 s4 A, ]% w* TFrom the 1Division of Pediatric Endocrinology, 2University of6 A+ p" i% r( O; l: M7 y
South Alabama Medical Center, Mobile, Alabama., Z( j7 s+ _9 O, d3 _
Address correspondence to: Samar K. Bhowmick, MD, FACE,# n3 O( l. ?& u; V# G* T- L
Professor of Pediatrics, University of South Alabama, College of
0 H$ K" L% H% K) fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 R3 q' D  r8 \* Z7 W9 R
e-mail: [email protected].1 p+ ?" P) e0 W
about 6 to 7 months old, which progressively became7 B# J. z" ^0 t3 q8 s
darker. She was also concerned about the enlarge-! Y# |1 i8 w$ C7 E3 S
ment of his penis and frequent erections. The child, e+ @3 E/ I# @: d9 i4 |2 L# q
was the product of a full-term normal delivery, with
$ W- x/ r0 K/ H8 Ma birth weight of 7 lb 14 oz, and birth length of
8 u- V2 }9 L* k: v/ i20 inches. He was breast-fed throughout the first year! I5 W6 Y& I8 r% h) \3 o4 ^
of life and was still receiving breast milk along with" {2 S; t$ d+ ]
solid food. He had no hospitalizations or surgery,
0 G: b9 e+ h3 ]$ sand his psychosocial and psychomotor development0 l+ |2 n1 Z" r* O9 [, W& ^- g
was age appropriate.6 ~$ ?' q* z4 }5 u2 z9 Y+ `: L
The family history was remarkable for the father,
7 X# C; z$ G: h0 j) p! G" l% c7 \who was diagnosed with hypothyroidism at age 16,
6 w, I* N, @1 p# @; Z5 h( Lwhich was treated with thyroxine. The father’s8 ]1 m$ p% v1 x4 j2 l* x) D6 A, B3 ^
height was 6 feet, and he went through a somewhat2 o4 Y+ z9 c& _, m, e$ ~
early puberty and had stopped growing by age 14.( H7 n8 s4 t7 [3 |( y
The father denied taking any other medication. The: s9 N2 R; i4 c8 m$ e! I
child’s mother was in good health. Her menarche
  @' I+ ?9 [0 Dwas at 11 years of age, and her height was at 5 feet6 T% z( Q% C$ u6 @* K
5 inches. There was no other family history of pre-
1 L% z/ T# @  z8 `, d5 f3 Ecocious sexual development in the first-degree rela-( s( R+ P: ^' p
tives. There were no siblings.! [  B0 Z6 a+ m# B. u5 |
Physical Examination6 E6 i' `3 f8 S; L: l& ~* `6 w
The physical examination revealed a very active,: v9 ^% d2 P$ d( t" i
playful, and healthy boy. The vital signs documented8 f+ c* L  M3 D* H* t: K
a blood pressure of 85/50 mm Hg, his length was) S4 c1 R% \5 q0 M6 u- @' q: a4 R
90 cm (>97th percentile), and his weight was 14.4 kg
, x1 v! }' K: G9 W(also >97th percentile). The observed yearly growth
) K- N2 K! F' c' Ivelocity was 30 cm (12 inches). The examination of$ n% d! g/ d' `% ]: q
the neck revealed no thyroid enlargement.
: P' r) y7 J4 y3 R! qThe genitourinary examination was remarkable for: e% I: a+ |5 {, ~$ w
enlargement of the penis, with a stretched length of; |: W4 A+ `2 T7 y; G( [# E& y
8 cm and a width of 2 cm. The glans penis was very well6 a# a1 b* C' t; I) s- L# a
developed. The pubic hair was Tanner II, mostly around
# S! M6 c1 c! O4 Y/ L5408 p6 O- l( l$ ?& B3 Q: z9 K! ?" y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 ]# O" {1 f. K# t
the base of the phallus and was dark and curled. The
' u0 {- D: _% I" j; E# ]/ jtesticular volume was prepubertal at 2 mL each.' y6 L# c3 D: M! |+ ^) i
The skin was moist and smooth and somewhat
; p2 o6 t6 }7 koily. No axillary hair was noted. There were no
6 Z' l- ^" S/ [# ]) Habnormal skin pigmentations or café-au-lait spots." Y+ @9 T9 C' _" K; W
Neurologic evaluation showed deep tendon reflex 2+
) t* F6 i% R+ m7 o, abilateral and symmetrical. There was no suggestion& J3 V& g' y8 t
of papilledema., H3 N  H; t7 m* N3 f
Laboratory Evaluation( u& j5 o- d# `1 U0 Z. o# q! G
The bone age was consistent with 28 months by5 p  n+ R9 g  |, |: H0 i( ?  Z
using the standard of Greulich and Pyle at a chrono-% d0 T8 n) O1 L. }3 D: m
logic age of 16 months (advanced).5 Chromosomal
3 T+ I0 V/ w, g1 Q5 k' }0 kkaryotype was 46XY. The thyroid function test) N3 t) ]0 X/ t/ W6 E$ G8 @! I) G! M5 N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' K! F3 y; p1 M5 x6 ^
lating hormone level was 1.3 µIU/mL (both normal).8 c8 H# W" J& I; n
The concentrations of serum electrolytes, blood
: Q5 [  i) j" {) }! P! @' turea nitrogen, creatinine, and calcium all were
9 e; a7 ^7 ]: W& A8 V2 A) I$ ^+ g4 ^( Gwithin normal range for his age. The concentration
3 Q# j! D0 ~% ^# s$ K# Y4 g- Aof serum 17-hydroxyprogesterone was 16 ng/dL
5 N% g: Z- S, l: [& g6 b$ S) Y( R(normal, 3 to 90 ng/dL), androstenedione was 20
; T  `! u& L- u% k% j- rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ x( u. \8 R0 S8 `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ ?  C) B$ A+ P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 S9 c0 W/ c6 x/ U49ng/dL), 11-desoxycortisol (specific compound S)
& h. J$ ]% T" N$ F9 Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 R* w* q* x6 \- s3 J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  c$ |' H: {3 O8 l% S% H+ {' F; Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, b7 C1 j  @# S2 s! S  |% iand β-human chorionic gonadotropin was less than; s" N$ c8 S. m  N' j! u- ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 L# g3 x3 \6 [/ T+ v) _  C3 a% Astimulating hormone and leuteinizing hormone
$ H. v! r2 R% \  |' j$ uconcentrations were less than 0.05 mIU/mL; C7 Y! R) K+ D+ L* v' \0 u3 M, U0 @* P! G
(prepubertal)., R6 Q8 R' L6 O' r
The parents were notified about the laboratory
3 i5 @4 g0 K0 Jresults and were informed that all of the tests were
. U# B* ~3 Y/ c; d# Wnormal except the testosterone level was high. The
! }& H! |5 P% K- W6 Lfollow-up visit was arranged within a few weeks to0 G, T+ O9 z8 `* M0 n. o, t
obtain testicular and abdominal sonograms; how-2 C2 M% f2 H5 d* |
ever, the family did not return for 4 months.
8 t; Q1 R) `8 E2 s  CPhysical examination at this time revealed that the
  Z) h/ K: v2 n1 [. Ochild had grown 2.5 cm in 4 months and had gained" _) o1 b  w. \) h
2 kg of weight. Physical examination remained
3 F5 |3 H. J( E. c3 R2 Q0 j7 dunchanged. Surprisingly, the pubic hair almost com-
' _& }, R1 T. D- Q" Y8 @pletely disappeared except for a few vellous hairs at
; b! R. X9 t* ]; R  q7 P& pthe base of the phallus. Testicular volume was still 2; q0 X( w6 w5 W/ L
mL, and the size of the penis remained unchanged.
/ g4 _# j5 q: p2 {The mother also said that the boy was no longer hav-$ g+ _1 H* L$ R& Z) b
ing frequent erections.& _# J8 H" q- M! A
Both parents were again questioned about use of
# c" T2 u( A7 e% X5 p+ [any ointment/creams that they may have applied to
/ f/ V1 r1 V3 mthe child’s skin. This time the father admitted the3 K- u5 K- K2 {  ~% v$ k: m
Topical Testosterone Exposure / Bhowmick et al 541
% S& ~  R6 h1 z' o2 ?$ ^use of testosterone gel twice daily that he was apply-
+ y0 U, m1 z1 S2 \# J7 d. D' D# \ing over his own shoulders, chest, and back area for
4 X+ x) R% J5 `3 \% W0 p% ua year. The father also revealed he was embarrassed
$ [. r) e( Q$ e+ q9 x/ m2 y5 Nto disclose that he was using a testosterone gel pre-; `% b- E# B& Q$ k
scribed by his family physician for decreased libido/ \& Q3 L. C, J: C
secondary to depression.% {8 b0 b. r& J0 R! {
The child slept in the same bed with parents.- k7 |) z& c1 N
The father would hug the baby and hold him on his
; C+ ^1 e8 j% B3 t' Lchest for a considerable period of time, causing sig-
( b3 p' o0 J# ]1 j( |  tnificant bare skin contact between baby and father.9 q# N/ R( _. ~, A% z  O
The father also admitted that after the phone call,: t6 m& o& M# r! @
when he learned the testosterone level in the baby
9 g5 w3 }" P; ]7 Y8 awas high, he then read the product information. A8 P/ Y& }/ ?( _
packet and concluded that it was most likely the rea-4 a& a# f& U3 S
son for the child’s virilization. At that time, they, x# m% i( i( _- {; }. O- c
decided to put the baby in a separate bed, and the& D/ d" C) v) p% P
father was not hugging him with bare skin and had
/ ?6 v# }+ o, ybeen using protective clothing. A repeat testosterone
/ b% b0 j# O2 d) X/ C& Utest was ordered, but the family did not go to the
$ T. ^, t: _( plaboratory to obtain the test.
$ }/ \' O' P& Y. i0 rDiscussion
0 y% r, ?( J' c3 gPrecocious puberty in boys is defined as secondary
; i  t, b* A' o* \( p" O' g' M+ k& lsexual development before 9 years of age.1,4
9 A* O$ H* y. x& kPrecocious puberty is termed as central (true) when
$ p' f5 E, l9 k+ I& j3 z% cit is caused by the premature activation of hypo-: M% F: J# s1 A0 Q! n9 Q2 ?) f  A3 I
thalamic pituitary gonadal axis. CPP is more com-/ N% c3 B, }& P; \
mon in girls than in boys.1,3 Most boys with CPP1 b: n4 W/ a0 J8 N
may have a central nervous system lesion that is
* p8 U' k3 G2 X: Oresponsible for the early activation of the hypothal-5 r0 l/ n3 o2 t! |( k. {8 ]
amic pituitary gonadal axis.1-3 Thus, greater empha-
" b9 I% |: c$ P4 L; h  W9 E  Msis has been given to neuroradiologic imaging in
" H  @4 `/ T6 pboys with precocious puberty. In addition to viril-) |7 C! ^7 K6 W- p" ?* F# u# o
ization, the clinical hallmark of CPP is the symmet-) u/ c4 |3 L" E8 a. R# x
rical testicular growth secondary to stimulation by! d& f. n, J7 m0 i- B$ x
gonadotropins.1,3
! Y. _& b" K7 {& X1 U4 |Gonadotropin-independent peripheral preco-
+ g+ P# q" W3 qcious puberty in boys also results from inappropriate
" O4 n$ A8 g7 f, \/ F7 w& {% candrogenic stimulation from either endogenous or5 J2 q1 M. c# }8 s( \
exogenous sources, nonpituitary gonadotropin stim-
8 V* L5 ]- n: S: u/ V& k8 D5 bulation, and rare activating mutations.3 Virilizing
- F) f: B; {( U4 \2 g5 d: Jcongenital adrenal hyperplasia producing excessive( f% x$ T9 f; g$ Y  I: F. G& m
adrenal androgens is a common cause of precocious, z- f! [7 P! g
puberty in boys.3,47 p0 Z; D2 `2 X
The most common form of congenital adrenal( o$ w0 t, ^8 E# w
hyperplasia is the 21-hydroxylase enzyme deficiency.
* T5 H. ]5 k/ m- b+ V0 X9 A3 TThe 11-β hydroxylase deficiency may also result in) `5 M+ d* v% M: t/ |/ ]: T
excessive adrenal androgen production, and rarely,  s. Z" p& U5 ~. M# @3 N
an adrenal tumor may also cause adrenal androgen7 w5 y. e. T1 {4 V1 D4 m. {- L
excess.1,31 v: F  `* a9 V7 s3 Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 \  X3 S" ?& e7 Q: X# |542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 O" r. E5 X- o7 y
A unique entity of male-limited gonadotropin-
4 H1 d: u% P( E! |independent precocious puberty, which is also known
  i* E$ p2 Q1 F$ j  \/ D7 ras testotoxicosis, may cause precocious puberty at a- y" H1 x% O; L0 _# C
very young age. The physical findings in these boys) |3 Z4 K+ F* r
with this disorder are full pubertal development,
- T, s0 R+ D2 n9 E' Pincluding bilateral testicular growth, similar to boys/ o% c6 W  |7 j' T5 o; }* C" o0 s
with CPP. The gonadotropin levels in this disorder
( `+ q' `! e( q, S% E' `! {are suppressed to prepubertal levels and do not show
3 S+ t- P0 u3 Tpubertal response of gonadotropin after gonadotropin-  Z6 }. U3 }2 P
releasing hormone stimulation. This is a sex-linked
7 ^! Q4 {9 x& q& G1 r6 {: yautosomal dominant disorder that affects only
9 }# ~2 W3 F, S7 N: t, Hmales; therefore, other male members of the family
0 B6 Y; m8 M% S  j# X# bmay have similar precocious puberty.3* Q; O3 P! ~. a2 Y. M
In our patient, physical examination was incon-
0 p5 T' V: p( e7 {( l7 ]; Asistent with true precocious puberty since his testi-! j8 S' a. [# j" J
cles were prepubertal in size. However, testotoxicosis
9 l- G9 j+ i5 s+ e$ v6 Wwas in the differential diagnosis because his father
: k4 {. K- P3 Q6 |7 rstarted puberty somewhat early, and occasionally,: H- ~- \$ |& g  k4 {% D
testicular enlargement is not that evident in the
( a7 e- C* I' sbeginning of this process.1 In the absence of a neg-0 }2 R* G( @; n0 b9 g
ative initial history of androgen exposure, our
0 t1 ]1 s' Z/ A9 O) p7 Ibiggest concern was virilizing adrenal hyperplasia,
* R/ f, n$ W3 s4 ^either 21-hydroxylase deficiency or 11-β hydroxylase+ @% Q0 m( X- r$ t4 ?; r
deficiency. Those diagnoses were excluded by find-5 _2 B8 J- H  H$ w7 p2 z
ing the normal level of adrenal steroids.
# Z4 v) s) Z) u, uThe diagnosis of exogenous androgens was strongly
/ e4 ]" l* Z5 Xsuspected in a follow-up visit after 4 months because
4 ~4 R/ Q; q+ ^4 A( @" b3 \- \the physical examination revealed the complete disap-7 e, s/ o- D1 x) m0 Q* u& s
pearance of pubic hair, normal growth velocity, and3 h* w- h8 C' w- B7 ~
decreased erections. The father admitted using a testos-0 p/ x. |% {# K
terone gel, which he concealed at first visit. He was
6 a+ h( V6 i6 k/ B+ ausing it rather frequently, twice a day. The Physicians’, f# s& l- [) ]- g
Desk Reference, or package insert of this product, gel or0 |1 _4 a! M% b2 Z
cream, cautions about dermal testosterone transfer to7 l* s6 {- j1 e/ L# F
unprotected females through direct skin exposure.
5 p1 W; W* U8 W5 D2 wSerum testosterone level was found to be 2 times the& k) j: l, ^5 `: S) A
baseline value in those females who were exposed to
8 j0 K3 f, i) Y$ [" A- geven 15 minutes of direct skin contact with their male8 L& ]5 q3 _6 C
partners.6 However, when a shirt covered the applica-! D2 P7 X1 g" M  l
tion site, this testosterone transfer was prevented.
4 D! y/ t, c- o% v) e0 xOur patient’s testosterone level was 60 ng/mL,
: |1 w' {- E) g" T% X. dwhich was clearly high. Some studies suggest that/ _5 b3 F" j; t/ j7 s7 \
dermal conversion of testosterone to dihydrotestos-# {8 t5 C/ n/ K4 e/ I. T
terone, which is a more potent metabolite, is more
8 _- A; f5 i6 U0 [2 Oactive in young children exposed to testosterone* K" P: K( `+ o& E) D
exogenously7; however, we did not measure a dihy-
0 A8 @8 ?+ }+ I- a% Fdrotestosterone level in our patient. In addition to0 G& m" v/ t' J9 I
virilization, exposure to exogenous testosterone in
( F; ~$ @7 H" Wchildren results in an increase in growth velocity and
/ i2 {& A: x# A1 y4 Aadvanced bone age, as seen in our patient.
2 d# @: |0 e- P) ~) v4 D% P2 @The long-term effect of androgen exposure during
8 A) ]+ V& f4 ?* A) A) k: \early childhood on pubertal development and final5 A' o* [! k) |9 z/ \" }5 J
adult height are not fully known and always remain
% P( ^1 L) c" \4 H8 W) `3 ~a concern. Children treated with short-term testos-! O: W' r; G$ r# U
terone injection or topical androgen may exhibit some
9 i' V8 h% I# p) ]2 V& ?8 V$ }acceleration of the skeletal maturation; however, after& Y* @+ V1 G3 b
cessation of treatment, the rate of bone maturation- N0 h, b! G1 r% h( z+ d( ]5 g/ y
decelerates and gradually returns to normal.8,9
. H& r: W) W" v: D2 n, RThere are conflicting reports and controversy4 p3 K0 v2 G: N  G
over the effect of early androgen exposure on adult
6 J4 Q- Z! Y: S8 B2 z: O% Y$ @5 i' ipenile length.10,11 Some reports suggest subnormal( u% H4 S) W. d* [" X( P% D0 r
adult penile length, apparently because of downreg-
" Y% |. u! m3 \  ]7 Yulation of androgen receptor number.10,12 However,* e& Z1 _2 R. l+ j/ f, q
Sutherland et al13 did not find a correlation between5 F' r: @3 }# ?7 T/ P% G
childhood testosterone exposure and reduced adult
2 C5 {% c# z0 W+ R5 Ypenile length in clinical studies.
( _2 h; u0 t& o4 x* bNonetheless, we do not believe our patient is
5 g" n6 s3 U% |- a/ ^going to experience any of the untoward effects from
) q/ }1 Q+ F- L! {testosterone exposure as mentioned earlier because
, S1 u$ P! a1 {! P. sthe exposure was not for a prolonged period of time.3 `/ ?' W7 |8 Q* d, Y, s! f2 C
Although the bone age was advanced at the time of
* e7 B; S. Q( gdiagnosis, the child had a normal growth velocity at
7 O' k# |% S6 j1 O: ^8 \& i- qthe follow-up visit. It is hoped that his final adult1 c( o9 K+ _( P7 w1 B' f* T
height will not be affected.
" p& a( c5 ~& N9 RAlthough rarely reported, the widespread avail-
- U$ b9 B8 G7 g" Q  T0 ^* }ability of androgen products in our society may
6 m. z& x2 N8 Z8 _indeed cause more virilization in male or female2 Y* t4 L3 i( c8 m5 i
children than one would realize. Exposure to andro-
+ I: a, t$ q% Z4 o: |5 L5 ggen products must be considered and specific ques-7 O+ v( F+ `; Q7 n( m; [: [
tioning about the use of a testosterone product or
, c* Q9 }; ?, D% d; e3 Bgel should be asked of the family members during
" P+ s0 m" f2 ~& v2 b6 _the evaluation of any children who present with vir-7 E* F! m+ u# t8 m$ k) ^
ilization or peripheral precocious puberty. The diag-' |. G; M6 Z0 N- p: w7 L; K
nosis can be established by just a few tests and by
! I: U/ A) h0 D7 p4 qappropriate history. The inability to obtain such a
' U, B) `2 u- j9 A7 Bhistory, or failure to ask the specific questions, may
1 o/ q0 Y$ O1 |. Eresult in extensive, unnecessary, and expensive
7 O3 r" a6 k6 o' g. ]3 @( g& Finvestigation. The primary care physician should be0 t9 f4 y5 X* `1 R% Y5 I" u
aware of this fact, because most of these children
% d( z, z3 c, \9 K( wmay initially present in their practice. The Physicians’
. W+ J+ G$ K; e8 ADesk Reference and package insert should also put a1 U& [8 a6 k: |
warning about the virilizing effect on a male or0 o+ q6 B+ p: o" h1 V
female child who might come in contact with some-
# T$ s7 M. r3 J2 N/ V" Q# j2 Mone using any of these products.% w! O& s# n5 ^( v- x& A
References0 R. t2 ]$ C5 m# B# }
1. Styne DM. The testes: disorder of sexual differentiation
' z" f. \" D8 Y2 n' C4 Z) A' Kand puberty in the male. In: Sperling MA, ed. Pediatric
- L. ~; {* k% Y  n8 @0 s; S! IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, l, ^$ l: f' F/ g- ]$ k9 C% `
2002: 565-628.
; j2 b5 [. `9 d! Y8 X5 ^, @$ V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( S- y" d4 R) v& e! M6 q" spuberty in children with tumours of the suprasellar pineal
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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
2 s$ o, F, [- |
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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