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Sexual Precocity in a 16-Month-Old
1 c& Q; p4 Q. U) j' ZBoy Induced by Indirect Topical5 W$ y  c. [+ @% p
Exposure to Testosterone0 ~2 d7 ]( B, E; w$ W" p
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: H. E& x( R( `3 Y. R% {! O# a' ~
and Kenneth R. Rettig, MD1
5 _0 L0 ?& @* P: ?5 C; G+ z7 ^. aClinical Pediatrics  d9 a7 S% Q. c1 G$ q& }! P$ U
Volume 46 Number 6+ K. c# ?  X$ c6 b9 D  h5 q  t
July 2007 540-543
; U2 }8 W( I& X# c  A  v' D© 2007 Sage Publications& v, N# e6 h5 o- ~8 a) g# e
10.1177/0009922806296651& w- j2 M0 Q% _) @7 F9 w" c
http://clp.sagepub.com
" J) E, M) Z/ o& bhosted at' }, ?% B" l$ E. I
http://online.sagepub.com
9 m' s. W, e4 K& Z, z) C* DPrecocious puberty in boys, central or peripheral,
6 D7 D! \/ b& a( q- N) bis a significant concern for physicians. Central
8 W% ^6 T  U  m  Q5 ?, mprecocious puberty (CPP), which is mediated/ }7 r5 k# P8 }6 r- o
through the hypothalamic pituitary gonadal axis, has
; C5 y9 r' ~) v! A3 wa higher incidence of organic central nervous system
$ ?: L  f3 \4 klesions in boys.1,2 Virilization in boys, as manifested
6 M. ~' H+ J  e1 z3 g2 G: `: pby enlargement of the penis, development of pubic
6 U7 l  f9 k( v, ahair, and facial acne without enlargement of testi-
: A( Q; f, r0 Y; h) F% ~0 _cles, suggests peripheral or pseudopuberty.1-3 We( m0 U; W) w& K* Z$ ]$ d) \2 E! H0 @
report a 16-month-old boy who presented with the% Z# \& h' c- P; w+ F
enlargement of the phallus and pubic hair develop-
# Y. S! q) `0 z7 X! P8 ]+ ?ment without testicular enlargement, which was due9 e3 o7 T4 s  `9 \! B( c: q! q
to the unintentional exposure to androgen gel used by) U3 ^. c0 R7 N' s
the father. The family initially concealed this infor-$ j1 _, U* s/ ^" H
mation, resulting in an extensive work-up for this
+ I* G& D. T5 R. v3 Vchild. Given the widespread and easy availability of3 ?, q! V  h% Z1 v4 D( }/ b
testosterone gel and cream, we believe this is proba-
+ W& i* k4 ~5 K: C5 j8 q( Dbly more common than the rare case report in the' ^/ T* K% C! n, A/ {8 d
literature.4: Z, Z+ ]4 ^& K
Patient Report
6 v' {6 ^3 c- [9 QA 16-month-old white child was referred to the( z+ C/ y' ~( W* F% e
endocrine clinic by his pediatrician with the concern2 p# S4 _1 F1 E0 k; f3 _$ L$ d
of early sexual development. His mother noticed
7 Q$ q- z* q" {light colored pubic hair development when he was
" c( p- @3 W# O3 D: m" e0 wFrom the 1Division of Pediatric Endocrinology, 2University of5 F1 a  }( J2 X* h5 C& ]- E
South Alabama Medical Center, Mobile, Alabama.
) F2 U: m5 ~9 T2 uAddress correspondence to: Samar K. Bhowmick, MD, FACE,, Q3 S/ v( `* x5 o/ _
Professor of Pediatrics, University of South Alabama, College of
" |4 [  o6 \  R9 z- b. JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 g$ o* R2 {, j& k* r6 a5 w% E* {5 ?e-mail: [email protected].
, r% W" I5 u9 A! M" U: X$ Habout 6 to 7 months old, which progressively became( E1 j$ m: G- e! a8 d$ {" ^8 g& Z
darker. She was also concerned about the enlarge-
8 N/ {% O* Y* w, Wment of his penis and frequent erections. The child
2 [$ N' f, p) M$ y1 @+ |was the product of a full-term normal delivery, with
, g4 `( E0 a1 a" Z- m- v8 x* [5 F0 ia birth weight of 7 lb 14 oz, and birth length of9 ]( S) P; Q2 M$ R5 ?0 ~. e5 ~
20 inches. He was breast-fed throughout the first year) N: A, y% Y/ a% Q6 h! e
of life and was still receiving breast milk along with" s" s9 u  `9 d) {
solid food. He had no hospitalizations or surgery,
3 y) ]$ v) m/ O, y1 F5 P9 O7 o. d/ |and his psychosocial and psychomotor development
! R% s8 j0 f- k' ~% Dwas age appropriate.
1 G- o9 z3 Y5 fThe family history was remarkable for the father,
2 I! ^  k8 [- C* r6 Pwho was diagnosed with hypothyroidism at age 16,! ?+ {- m9 T- ]: Z! N- M: R) ~& F
which was treated with thyroxine. The father’s" m2 V, O2 j! ?9 |% ~. u
height was 6 feet, and he went through a somewhat" }3 r' H+ }7 s$ v! e
early puberty and had stopped growing by age 14.' b- M* Z+ i, k) V
The father denied taking any other medication. The3 D( o" g: z# N
child’s mother was in good health. Her menarche' [" V; N& U! o6 _1 Y- \
was at 11 years of age, and her height was at 5 feet; Y9 r) k8 C# [5 L$ t/ M- x
5 inches. There was no other family history of pre-
% v! l, i" f. i2 k7 ecocious sexual development in the first-degree rela-
+ J/ V7 S  X. d7 @tives. There were no siblings.
+ v6 D. `0 X* ~. K8 ~: q0 YPhysical Examination
& O2 ^9 ~6 \  |The physical examination revealed a very active,' c7 n* n  c: U# C/ L- M, I
playful, and healthy boy. The vital signs documented- O3 X  @! b) U! r
a blood pressure of 85/50 mm Hg, his length was6 I% N6 V# {5 M: O" O4 _/ X
90 cm (>97th percentile), and his weight was 14.4 kg# U/ l7 u2 q6 l5 o) L- ^6 z
(also >97th percentile). The observed yearly growth) c7 R" I- i9 l4 c8 z
velocity was 30 cm (12 inches). The examination of4 Y! A& U! c0 e& |/ `" G. v. a, S# E
the neck revealed no thyroid enlargement.
; H/ \) V( {, V: k1 e8 k/ a1 i" }! kThe genitourinary examination was remarkable for1 J9 s; g# S0 t0 ~% `
enlargement of the penis, with a stretched length of
9 ?! n$ ~3 g/ z( ?8 cm and a width of 2 cm. The glans penis was very well
8 z, g+ A# d/ w3 u. }developed. The pubic hair was Tanner II, mostly around1 E3 m3 n( h' o
540$ D) `. Y( c! k) N5 B0 ?, u& A$ }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 Y* H. z! h! j" |1 D/ w7 M+ `the base of the phallus and was dark and curled. The7 B& h9 r/ i8 u  A6 h+ X% U
testicular volume was prepubertal at 2 mL each.
0 e' b& `! X+ k' ~" RThe skin was moist and smooth and somewhat/ r, S3 b1 Y' U/ b% K
oily. No axillary hair was noted. There were no' f3 d  z, J, d, g8 N, r5 f
abnormal skin pigmentations or café-au-lait spots.
: E" i- z4 w4 @Neurologic evaluation showed deep tendon reflex 2+
! c# j" Y) N" z8 w5 Cbilateral and symmetrical. There was no suggestion
+ U) j( O) |8 V* Y9 {' |# M( ^of papilledema.3 X: B3 e' _# ~0 K
Laboratory Evaluation
1 e" |# F% i; }! B& ~/ b, w1 e. oThe bone age was consistent with 28 months by. g* Y! I' X" K6 w
using the standard of Greulich and Pyle at a chrono-3 @: U6 z  v7 j
logic age of 16 months (advanced).5 Chromosomal. n6 V: Z) s' R: o- S% l$ v
karyotype was 46XY. The thyroid function test; p' ^% O# h3 f( T- a% m( K
showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 k* n* b0 L* D; L1 y; n
lating hormone level was 1.3 µIU/mL (both normal).( m. L/ D% M0 {4 ^) Q- L
The concentrations of serum electrolytes, blood
  ]9 {% J7 @2 O0 t9 Purea nitrogen, creatinine, and calcium all were% z# ?* W) \; R* \& Q1 S9 i# G
within normal range for his age. The concentration. K- I) M% t3 J, y6 U- ]+ P8 O' }+ d
of serum 17-hydroxyprogesterone was 16 ng/dL
2 j2 f6 Z2 k* n" R+ p(normal, 3 to 90 ng/dL), androstenedione was 20! M7 x' q: K! Z- @" S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ I8 x) m, ~  ]# B' @, vterone was 38 ng/dL (normal, 50 to 760 ng/dL)," R  ~5 N" ^( C5 ]  K# c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" ]- z9 R4 w6 U, p( d49ng/dL), 11-desoxycortisol (specific compound S)/ i5 }: F/ S3 g( ^! O2 o$ T( h, ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) \5 A6 _- F( v! W  D0 n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 Z4 E  p1 i$ S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% m+ u& h  h5 \0 z# J. g) j
and β-human chorionic gonadotropin was less than& [$ a4 k9 i. k" D
5 mIU/mL (normal <5 mIU/mL). Serum follicular- s7 y/ `( p# @( Q/ [/ q0 |5 p
stimulating hormone and leuteinizing hormone
/ x, [( D8 }& ^9 O$ x& nconcentrations were less than 0.05 mIU/mL7 v7 U6 w: n- q$ r* O/ D4 A
(prepubertal).3 r' k3 b1 E9 I/ U. x$ Y6 ?4 l6 c
The parents were notified about the laboratory* J$ Z4 E7 D4 y. `: g
results and were informed that all of the tests were4 e) q0 X- O+ u& t2 y
normal except the testosterone level was high. The, F- E; z' x) w
follow-up visit was arranged within a few weeks to
  L: _$ {. w) {  {0 _obtain testicular and abdominal sonograms; how-6 B. H. R" z: y) |& X& }7 `
ever, the family did not return for 4 months.: _) H* g5 V/ i3 j, l" \- Q& c% b
Physical examination at this time revealed that the
# c& I" u' ^' t4 p& `: {child had grown 2.5 cm in 4 months and had gained
4 z' {* ^7 P2 Y5 b8 U/ g# U. k( N2 kg of weight. Physical examination remained9 N# ]8 ]% _  \
unchanged. Surprisingly, the pubic hair almost com-
! t3 a" `: b+ Y0 e* r# ?: o5 R. Upletely disappeared except for a few vellous hairs at
' j- s3 g0 V# h' u0 n8 @  U( T' Xthe base of the phallus. Testicular volume was still 2
* c& U: P$ c3 k- S; bmL, and the size of the penis remained unchanged.& m" t' J7 w7 m- C( \
The mother also said that the boy was no longer hav-1 y$ e; l/ `" V) d6 z+ N& }$ D) P. m
ing frequent erections.
$ r1 o6 I: }! B7 ?7 dBoth parents were again questioned about use of
/ `2 l# ?2 B. V8 X" zany ointment/creams that they may have applied to) }" s9 c  {' T% E
the child’s skin. This time the father admitted the+ t: _+ n5 A8 \) {4 n
Topical Testosterone Exposure / Bhowmick et al 541
6 B$ e3 g- X) g: @use of testosterone gel twice daily that he was apply-8 d$ R; S& Y8 L8 d7 b2 L1 I6 _
ing over his own shoulders, chest, and back area for5 @* p( x' f1 `9 w/ G
a year. The father also revealed he was embarrassed1 [- }% _6 Q9 t/ R8 X
to disclose that he was using a testosterone gel pre-, _& J, M4 |4 F+ y, ~+ \
scribed by his family physician for decreased libido# P3 F& S! A6 V, x) i: w
secondary to depression.8 ], k( J* n8 T1 K' J
The child slept in the same bed with parents.; g0 n8 ~. G2 m$ ^5 {( R' ^7 t1 K
The father would hug the baby and hold him on his
: s( B% H/ E3 x; `3 H( Echest for a considerable period of time, causing sig-  z& c, p# z7 _' V
nificant bare skin contact between baby and father.
- c, |( a+ Z5 x+ r1 p$ o% h* KThe father also admitted that after the phone call,
3 G* l7 W; y7 Ywhen he learned the testosterone level in the baby3 ?8 H0 }! N" V- \3 e
was high, he then read the product information4 T. X6 W& c+ a$ a" _6 U
packet and concluded that it was most likely the rea-' W+ ^1 }) ^0 u/ p* [% K6 c
son for the child’s virilization. At that time, they4 [1 N5 ~. f  R: Z* y( C
decided to put the baby in a separate bed, and the5 `- W& k( K& H: n
father was not hugging him with bare skin and had# A! |- S# f$ s, A7 M# T
been using protective clothing. A repeat testosterone, l, }1 v) t) |8 A
test was ordered, but the family did not go to the0 ?2 C$ R" l. E0 [
laboratory to obtain the test.8 P9 w1 B/ w5 l# y6 y
Discussion' Z" e9 V; @2 Y( m( k
Precocious puberty in boys is defined as secondary
* A! H/ A4 _# Q* R' Esexual development before 9 years of age.1,4; g, |1 @9 c5 T- _; l" e& I
Precocious puberty is termed as central (true) when" H- N7 f3 k# y8 j  c. f
it is caused by the premature activation of hypo-' {5 s9 [5 _  g8 A# {
thalamic pituitary gonadal axis. CPP is more com-& w. `: i- n3 u. Y5 ?+ x3 n. C; h
mon in girls than in boys.1,3 Most boys with CPP; j. c0 \6 K. a( H
may have a central nervous system lesion that is. c- N9 J0 ^2 W9 O: P8 U& Y
responsible for the early activation of the hypothal-. F( b5 U1 i9 J
amic pituitary gonadal axis.1-3 Thus, greater empha-
0 f( }: z1 _- ~" c$ _0 }sis has been given to neuroradiologic imaging in
. Q! ]6 I) N2 A1 a$ S# @2 P: z; [& cboys with precocious puberty. In addition to viril-9 Q1 _5 Z6 D- B# k: W3 n1 O5 L
ization, the clinical hallmark of CPP is the symmet-' ?8 F% J$ {( ]8 q! N- c0 Z
rical testicular growth secondary to stimulation by& M* p  a, B* `4 W7 y# x* n
gonadotropins.1,3
! z+ J! o" n. [, O+ C" }Gonadotropin-independent peripheral preco-, l6 h1 u2 ^: P* g* S
cious puberty in boys also results from inappropriate8 }8 D- q9 Q3 m! E" g7 O
androgenic stimulation from either endogenous or
) E9 A) u6 i- U; f. Oexogenous sources, nonpituitary gonadotropin stim-" `, k" [4 q8 {3 L* Z1 e1 E
ulation, and rare activating mutations.3 Virilizing2 B6 H3 a& v2 a. Y- e% Z" S9 y: V" h
congenital adrenal hyperplasia producing excessive! Q1 R* c' }6 T
adrenal androgens is a common cause of precocious
! t! }$ r' D1 S+ d( J0 xpuberty in boys.3,44 u8 M. y9 ^2 a0 z$ i" d
The most common form of congenital adrenal4 v8 f3 i- x1 D0 d3 |
hyperplasia is the 21-hydroxylase enzyme deficiency.
; B, A& p! J+ g# V8 b, d9 {The 11-β hydroxylase deficiency may also result in
" K9 e. j, y4 j& l5 _/ Aexcessive adrenal androgen production, and rarely,$ n, n9 p- U; Z0 Z
an adrenal tumor may also cause adrenal androgen
" J6 c" i$ E1 c% l$ [+ Z; M8 O8 Eexcess.1,3
9 `4 Z8 s3 F9 M  Z4 q' ^, Z% {7 Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  e& @, q3 `! s+ ?. V! T2 w4 K+ ]$ P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% y9 w& `4 M& Q6 A4 y: jA unique entity of male-limited gonadotropin-
- m* h  E- Z0 h* ?% xindependent precocious puberty, which is also known1 M, n" }4 t' t$ P
as testotoxicosis, may cause precocious puberty at a
" v$ [3 q* q" Dvery young age. The physical findings in these boys
; S% {/ [! d" d# V7 F* T% q. `% twith this disorder are full pubertal development,) W& o1 M$ s. J: `" v
including bilateral testicular growth, similar to boys
+ T/ q/ |# i) Pwith CPP. The gonadotropin levels in this disorder2 M- P: D. [1 T1 x7 {
are suppressed to prepubertal levels and do not show
+ B, L: v1 N) z, Ppubertal response of gonadotropin after gonadotropin-5 X1 ~* d! s. l1 B, p% m* u
releasing hormone stimulation. This is a sex-linked) s1 p8 `1 n9 r$ l
autosomal dominant disorder that affects only* b9 S! @' {* R8 x+ c4 b- T4 X
males; therefore, other male members of the family
) B4 |7 k+ `" a' N2 I% P/ g6 Pmay have similar precocious puberty.3+ B8 c; b2 Z8 K/ W
In our patient, physical examination was incon-1 b  O: t' ?+ y9 Q. W) K
sistent with true precocious puberty since his testi-
- t- D8 L7 e. M5 wcles were prepubertal in size. However, testotoxicosis
. L5 ]. i2 P# [was in the differential diagnosis because his father! Y; B2 G# r/ _, L
started puberty somewhat early, and occasionally,2 @3 T! d$ b- M/ J: l* A8 P* x
testicular enlargement is not that evident in the# m6 l3 [$ G8 b- P/ f/ y2 A% G  q
beginning of this process.1 In the absence of a neg-
6 m8 m5 ^% f: `/ t) sative initial history of androgen exposure, our
  s8 W$ w8 Q: Y$ M' ebiggest concern was virilizing adrenal hyperplasia,
7 z; x" `) G1 l; i) J+ ?5 |: qeither 21-hydroxylase deficiency or 11-β hydroxylase
! w9 C, {: I9 E& q1 ndeficiency. Those diagnoses were excluded by find-% c6 |+ z) B7 S- v: K. ^
ing the normal level of adrenal steroids.7 Y- T0 G: V+ N& A7 M9 f! c, t* i  w
The diagnosis of exogenous androgens was strongly0 k3 Y6 [+ s! @9 u! o2 ~
suspected in a follow-up visit after 4 months because/ i: Q. w- \- _$ |7 H
the physical examination revealed the complete disap-
: z6 F6 A4 z8 f. R' Gpearance of pubic hair, normal growth velocity, and* E$ e. }5 a" b: }
decreased erections. The father admitted using a testos-
$ A- s) E0 P( I9 |8 j1 Rterone gel, which he concealed at first visit. He was
4 t  D" m" Z8 V" ~using it rather frequently, twice a day. The Physicians’  g1 a7 Y) J/ E# D3 g
Desk Reference, or package insert of this product, gel or
: D" e5 ~( G- U! M" h8 A- }cream, cautions about dermal testosterone transfer to
, A* [# G) D: l2 Wunprotected females through direct skin exposure.
2 H. ?/ A' J9 \) w+ K8 VSerum testosterone level was found to be 2 times the# a$ ~: w' K3 Z; l+ _" y
baseline value in those females who were exposed to
& T( r3 s' v( X* k! m6 |even 15 minutes of direct skin contact with their male
% X$ O  h. b. O' A& e$ Fpartners.6 However, when a shirt covered the applica-4 o! n& l4 r7 ?# h! ^/ B( |
tion site, this testosterone transfer was prevented.
' N7 p- w1 X/ P) Q( COur patient’s testosterone level was 60 ng/mL,  e  d3 L- v7 P2 N
which was clearly high. Some studies suggest that
0 F6 T4 [; ~4 V8 `# W& m7 Edermal conversion of testosterone to dihydrotestos-
9 v; v6 ?+ h. _, O3 yterone, which is a more potent metabolite, is more2 t; K4 v% S4 X7 U( x- X
active in young children exposed to testosterone
, T2 K+ ^4 n1 a' I3 Z0 w1 hexogenously7; however, we did not measure a dihy-, S# V' [3 u: h" o
drotestosterone level in our patient. In addition to2 E8 a& x$ c3 `5 x- g* A
virilization, exposure to exogenous testosterone in
3 R+ f& Z0 j% ?1 A$ {5 c* lchildren results in an increase in growth velocity and
# M/ z7 U$ ^, n. L0 ^, Eadvanced bone age, as seen in our patient.  ^( Y5 E" X. A, H* ]8 x7 t% T9 u" `
The long-term effect of androgen exposure during. @6 f3 R+ q! V! j4 [2 ^. W- @: N7 ?
early childhood on pubertal development and final' _2 n1 A4 E% f$ X; j! O; z8 J
adult height are not fully known and always remain
6 ], p' p/ M0 ~# c0 h. q# ga concern. Children treated with short-term testos-9 N$ S: y2 i( {: A' ^- N3 k6 f" v
terone injection or topical androgen may exhibit some
" s( O1 j2 r( g# e; q# {2 W6 m7 @9 Yacceleration of the skeletal maturation; however, after+ T4 k! r& P# i( u5 i
cessation of treatment, the rate of bone maturation
: W2 |( ~; K' b) ]5 `3 |decelerates and gradually returns to normal.8,9
: [: U3 ~2 F+ t8 `9 u, v) v0 WThere are conflicting reports and controversy
* Y- E5 p* V3 N$ Pover the effect of early androgen exposure on adult5 j+ r& N2 P% m, e
penile length.10,11 Some reports suggest subnormal
$ W" b+ g& k' S& t+ x* w. O! jadult penile length, apparently because of downreg-, v7 p6 O3 X6 d4 z" m3 H
ulation of androgen receptor number.10,12 However,/ n( E: g- O. D% m
Sutherland et al13 did not find a correlation between
/ o3 W2 y5 n: C2 e1 M9 \childhood testosterone exposure and reduced adult$ U. V7 O% h: t
penile length in clinical studies.
, s( ]; B5 `9 }1 SNonetheless, we do not believe our patient is
9 F$ k. n4 o: o* h; t! vgoing to experience any of the untoward effects from
; L0 w( s2 n* @testosterone exposure as mentioned earlier because  R% A9 F2 K7 [+ X, s2 h
the exposure was not for a prolonged period of time.$ V! G# x- b, K$ n+ }
Although the bone age was advanced at the time of
1 b* N; q- I# ?$ Qdiagnosis, the child had a normal growth velocity at
8 X3 v3 T, {2 ~/ h8 hthe follow-up visit. It is hoped that his final adult, q! _) D' l! t1 n2 ?: n% ~
height will not be affected.  `( y% L5 v8 |0 c: z
Although rarely reported, the widespread avail-! `6 X3 L" y" W
ability of androgen products in our society may" j* S$ i3 f/ O9 b- ^  b) X
indeed cause more virilization in male or female
+ g  p" n8 ^- x' V9 h/ {2 y# Kchildren than one would realize. Exposure to andro-
& H# y7 h8 I* k6 {# fgen products must be considered and specific ques-7 ~) F" {' u8 z. b
tioning about the use of a testosterone product or
9 o2 z9 M* ^$ o6 X- t; @gel should be asked of the family members during
9 u# |! x2 z1 h: ^0 ithe evaluation of any children who present with vir-6 O0 [  U' |9 y) m: O
ilization or peripheral precocious puberty. The diag-
6 Q7 j, d6 ?; h, r1 Cnosis can be established by just a few tests and by
/ }2 [" Y6 N6 Aappropriate history. The inability to obtain such a
  t! {" T5 K$ ~# mhistory, or failure to ask the specific questions, may4 n+ u4 |: z$ g  F4 L
result in extensive, unnecessary, and expensive
0 \' Y( V: z% K" dinvestigation. The primary care physician should be6 q8 A( e4 I; `( p( @! @
aware of this fact, because most of these children
) R4 _& p$ S$ T* X$ Amay initially present in their practice. The Physicians’
& M* [* q$ A# F. BDesk Reference and package insert should also put a
) V* i4 m5 L, @. u" p; ]& Z7 b# \warning about the virilizing effect on a male or$ S8 p1 U0 C' B  e
female child who might come in contact with some-$ P* N" w; x0 _
one using any of these products.
. {% q$ N. F+ F* J$ q1 s. IReferences1 s1 B" m9 z! z% a5 r& G9 B
1. Styne DM. The testes: disorder of sexual differentiation0 Q- A; ]( v. }, f" X
and puberty in the male. In: Sperling MA, ed. Pediatric
: |* k. |  [* u$ F, G( W% g% XEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! w7 b% n4 C2 n) e3 T2002: 565-628.
- @( u# D) b& F, T7 ]# |6 a2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 v; l, W$ l  d  Wpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
4 I) P! F0 \6 |Boy Induced by Indirect Topical  ~9 j" P7 X* O+ _- l7 V: U; u
Exposure to Testosterone
8 Y, {2 k4 w; _$ g# L4 {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% l" y# p- P0 a& ^: f! V$ O) G: Y/ rand Kenneth R. Rettig, MD1
3 i6 V. C+ L* d% Z% I0 _. _& F3 k  ?) _3 [- sClinical Pediatrics7 }2 P6 E+ j1 V! i9 ~+ \) ?. x' i
Volume 46 Number 6" F# k' }3 Q; I3 U5 f8 }, F) d8 a+ s0 s
July 2007 540-543: y' I" C* W( P9 v
© 2007 Sage Publications" X  Y" c- l5 d7 U: y
10.1177/0009922806296651- W( t5 x" |+ _1 u' C  N# i  }& n. Q
http://clp.sagepub.com* d; _' A8 V) t: p5 C6 h* {( A9 a
hosted at. S2 k& y8 m. Z
http://online.sagepub.com
9 v- C2 w. u* l- C6 {- uPrecocious puberty in boys, central or peripheral,5 y4 q# H* x$ J! f
is a significant concern for physicians. Central& _& F6 ]+ R* g1 K+ ?& U5 X
precocious puberty (CPP), which is mediated
( A( y' E4 U5 I4 U4 ^( cthrough the hypothalamic pituitary gonadal axis, has5 R' R% b* s6 p! a) _% ?, s0 Z
a higher incidence of organic central nervous system8 ~: w' M7 K" u9 }9 J3 a' D
lesions in boys.1,2 Virilization in boys, as manifested- j& ^! I4 e* y$ j* e
by enlargement of the penis, development of pubic
) Z. a" o) ?: f' C7 ^3 x; f& Xhair, and facial acne without enlargement of testi-
" j( z0 {( H+ g$ t; |6 }cles, suggests peripheral or pseudopuberty.1-3 We
  I# _+ J# {0 t9 d3 Breport a 16-month-old boy who presented with the
, w# M. `1 M$ Y+ Tenlargement of the phallus and pubic hair develop-
3 W7 M5 P* c, ]* M0 Q3 n; ument without testicular enlargement, which was due! w% ^' x! x2 J" i7 y
to the unintentional exposure to androgen gel used by! Q' @! [8 @8 j: B
the father. The family initially concealed this infor-
: U1 {( l% v4 y% {mation, resulting in an extensive work-up for this& e, g& B; G$ c: {) R
child. Given the widespread and easy availability of
& p6 X+ C+ m/ n% W2 Z; htestosterone gel and cream, we believe this is proba-
, i) ~& B" t, R- `& q  sbly more common than the rare case report in the
! ~7 R7 ]: e/ Zliterature.4) c2 }" ]" R5 V! p' G
Patient Report
/ f" |" o8 R6 e5 A6 }) sA 16-month-old white child was referred to the( i+ F" k% W. |9 [6 `2 e
endocrine clinic by his pediatrician with the concern" D0 K: ^3 ^: A5 S8 n' t
of early sexual development. His mother noticed
' y' u! s1 t% `* w3 k& l" Olight colored pubic hair development when he was
: x9 R9 O+ X) Q) w9 U3 FFrom the 1Division of Pediatric Endocrinology, 2University of+ @0 ]' w) _% Y
South Alabama Medical Center, Mobile, Alabama.
! T; D7 [5 p& v" M4 D( q# w, A+ ~Address correspondence to: Samar K. Bhowmick, MD, FACE,+ @0 i% g! A$ |
Professor of Pediatrics, University of South Alabama, College of" A4 M9 \5 ]* d9 u0 c8 b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# y) ?! W% ]; x8 N' we-mail: [email protected].( y) l' |4 N; p& G
about 6 to 7 months old, which progressively became
' H) X! ~) o) f: ^0 fdarker. She was also concerned about the enlarge-1 q) z9 M. A4 Y, _7 d+ Z
ment of his penis and frequent erections. The child
7 i* j5 ~3 }5 D- F; h! O# Cwas the product of a full-term normal delivery, with
8 |( r5 T: |  _: Sa birth weight of 7 lb 14 oz, and birth length of1 I- I9 R. U; V" G
20 inches. He was breast-fed throughout the first year6 X$ E1 r& C* p- H) K5 d- _
of life and was still receiving breast milk along with
9 z( y& U8 h; z* D% @solid food. He had no hospitalizations or surgery,
( _/ D0 x1 \' R: H. Qand his psychosocial and psychomotor development
: T+ P& B( N: X# Z3 L" W2 p0 }was age appropriate.  X  H% Z* R2 {7 y3 X  T
The family history was remarkable for the father,
4 P' q4 ^  k( nwho was diagnosed with hypothyroidism at age 16,
/ }! i( G- T0 r# j' lwhich was treated with thyroxine. The father’s
$ ~  c9 @" Q# |- Z; i6 Pheight was 6 feet, and he went through a somewhat
# p$ E; Q5 N9 Uearly puberty and had stopped growing by age 14.4 T  G- h* q# a1 ]" \  u% I" e
The father denied taking any other medication. The
. n- F: ^7 C* h, Dchild’s mother was in good health. Her menarche) l% a4 `# Z3 }/ h" R
was at 11 years of age, and her height was at 5 feet
4 j3 u+ @  n5 o2 D( C# s5 inches. There was no other family history of pre-# y* T% i. [2 q( H5 H5 u1 F! y
cocious sexual development in the first-degree rela-8 d; S: k2 X+ N; p
tives. There were no siblings.! w3 W3 V! K: k7 [- A
Physical Examination6 D, {- A( ^' J* P
The physical examination revealed a very active,( q* b8 J6 X6 f4 W
playful, and healthy boy. The vital signs documented
$ y; d- L6 J- {/ Aa blood pressure of 85/50 mm Hg, his length was
  F- s  u) q& N0 t+ T" c0 Y1 h90 cm (>97th percentile), and his weight was 14.4 kg
/ F, \4 K6 F, z(also >97th percentile). The observed yearly growth
% r! N: n* e4 {. kvelocity was 30 cm (12 inches). The examination of( K* f' U2 H( _- r4 Q3 J' v6 x# H7 }
the neck revealed no thyroid enlargement.
2 ^# x& d% t( N1 ?) T; e! aThe genitourinary examination was remarkable for
& }$ H8 F& V$ z6 \% ^- `2 Aenlargement of the penis, with a stretched length of: O, \0 w# W2 B4 t
8 cm and a width of 2 cm. The glans penis was very well
/ B& V( |8 _. L# p/ Ndeveloped. The pubic hair was Tanner II, mostly around0 I: {; m$ t4 K; o' H0 e
540
( ^$ Z0 u- a8 t# Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# J; q& ]" o* Vthe base of the phallus and was dark and curled. The" j% a6 Q+ t' M5 z/ i
testicular volume was prepubertal at 2 mL each.
. x+ h4 }. g& m: T" r6 t/ x* {The skin was moist and smooth and somewhat; K9 o- d) }$ E1 [5 p$ X+ m0 T
oily. No axillary hair was noted. There were no
3 J; W/ P  I. G6 r6 mabnormal skin pigmentations or café-au-lait spots.7 @% d# l9 o' S' b4 h
Neurologic evaluation showed deep tendon reflex 2+: \; w# Q% y7 {9 j( _4 J5 N
bilateral and symmetrical. There was no suggestion
2 V) ^& ?, \( ]of papilledema.
* G$ g. T  @5 P# ^3 x; wLaboratory Evaluation
7 _# J0 A) N& R2 J. o- j" ], }# OThe bone age was consistent with 28 months by; o8 m3 q0 W/ Y
using the standard of Greulich and Pyle at a chrono-6 @! F+ @) C% R$ z- f
logic age of 16 months (advanced).5 Chromosomal0 @. f) {" {4 w; P8 Q
karyotype was 46XY. The thyroid function test( B- @3 @- b8 n9 L) X. e* n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" R: e/ t8 M: Y7 v8 R7 g4 elating hormone level was 1.3 µIU/mL (both normal).
, c# P/ o- U& v/ ~% Y) m# f5 ?; `The concentrations of serum electrolytes, blood
$ @/ a/ k4 F; M6 ?8 b) X4 ], I: |urea nitrogen, creatinine, and calcium all were- }, C, X  `/ n% ^) H. [# I
within normal range for his age. The concentration
9 r9 E( m+ r8 _1 f" K) rof serum 17-hydroxyprogesterone was 16 ng/dL! X: [6 L( C5 ]: Y; y: H; s' g/ W
(normal, 3 to 90 ng/dL), androstenedione was 20- h2 j. z$ `) W, k
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# ]7 z) k9 t" x, ^/ T8 A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
  l1 y4 f2 Q, S8 J- A# j( ]1 wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
* ~1 g% u6 f2 }2 Y7 H5 P: x2 O49ng/dL), 11-desoxycortisol (specific compound S). t( n6 Z* g3 }! a8 U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% M3 M5 x9 g/ b& F( Vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# k7 L/ k+ h9 R( @5 M0 Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),) w5 f. j- ]/ |! z* w. Q6 Q' H; ~& \8 @
and β-human chorionic gonadotropin was less than
7 Z3 r7 G( |3 a; s8 b1 \4 G5 mIU/mL (normal <5 mIU/mL). Serum follicular
; s: C8 m7 W& E4 u/ e2 nstimulating hormone and leuteinizing hormone% D+ r' g* T0 e7 `0 ]4 x
concentrations were less than 0.05 mIU/mL
3 G8 }8 K: d2 i0 [' y" J& b2 @(prepubertal).
( Q+ o( X2 X0 H. A. m2 ZThe parents were notified about the laboratory
. P: D0 D% d( Q9 s& `4 vresults and were informed that all of the tests were
) H7 v1 z9 l& m2 M& Anormal except the testosterone level was high. The
) a8 M7 `2 z7 a6 ^& q$ }7 H: Xfollow-up visit was arranged within a few weeks to" O" s7 D9 q7 \8 K8 O0 B
obtain testicular and abdominal sonograms; how-: x9 g- S) U+ }" e
ever, the family did not return for 4 months.
- d6 g2 s$ R0 W5 aPhysical examination at this time revealed that the/ F! s6 m7 [8 k3 u
child had grown 2.5 cm in 4 months and had gained
! `/ T2 U  G2 N1 x- c6 Z( K3 Q2 kg of weight. Physical examination remained
' d+ o' S* z5 P5 yunchanged. Surprisingly, the pubic hair almost com-
( l; d' S, B; L# F4 ?7 Ypletely disappeared except for a few vellous hairs at
2 Y4 \7 b/ h6 N3 Wthe base of the phallus. Testicular volume was still 2
& F0 |4 Q! l# y; f  |mL, and the size of the penis remained unchanged.
! W2 P$ [5 ]4 g' qThe mother also said that the boy was no longer hav-
& n+ f* a: d; B4 G  X5 Ring frequent erections.
8 G* T+ i7 X0 i( s# E( e- Q0 N, jBoth parents were again questioned about use of
' f) L( t: G, q% {, p# `' G' ?any ointment/creams that they may have applied to
! j7 i* }0 _: J+ othe child’s skin. This time the father admitted the
, S1 }# A  c/ O: z5 H6 v5 DTopical Testosterone Exposure / Bhowmick et al 541# t8 Y5 a% P% \0 c# x; H4 E
use of testosterone gel twice daily that he was apply-
, E( q* z, T* ^5 f5 ring over his own shoulders, chest, and back area for5 X% t% w; J( R6 K, y
a year. The father also revealed he was embarrassed
' \8 w9 q/ s  |9 c# Z7 hto disclose that he was using a testosterone gel pre-3 K" z2 v8 C2 w' r0 M# K) `
scribed by his family physician for decreased libido1 \; `  v5 {0 o
secondary to depression./ P3 c$ v4 ]8 u1 r2 V, d
The child slept in the same bed with parents.) @. Y) P8 \$ W5 ]% ?
The father would hug the baby and hold him on his! y1 V' b+ l+ K2 z/ m; G
chest for a considerable period of time, causing sig-
2 Q% H8 ~! S* \7 _nificant bare skin contact between baby and father.
9 G7 M9 m; `. p. \The father also admitted that after the phone call,6 Z0 r' Q! h6 n8 h
when he learned the testosterone level in the baby& `1 d, P+ I: d
was high, he then read the product information- A2 H( t6 [3 Y8 Y4 x6 e0 l$ @; t% ]
packet and concluded that it was most likely the rea-" r( n9 t* x5 k3 \( w2 U
son for the child’s virilization. At that time, they0 X9 z2 l7 z) c' m# y7 ^' a/ a
decided to put the baby in a separate bed, and the
6 n5 ^: t9 K: q7 z% e- p6 M( }father was not hugging him with bare skin and had5 W8 v" u3 |- D5 e$ F/ O
been using protective clothing. A repeat testosterone
0 m& f+ I) A( }. L& E1 |/ {' Vtest was ordered, but the family did not go to the0 _7 `, B3 `; g: g% Q" o$ x. x+ C9 z
laboratory to obtain the test." x& H+ }' k9 M, t" p8 m
Discussion" \  J( Y: ~% @8 U( _
Precocious puberty in boys is defined as secondary7 N; H% o1 j0 f: j9 [' n% Q0 {' O
sexual development before 9 years of age.1,4
: N3 N  I3 N- R2 E+ aPrecocious puberty is termed as central (true) when
5 I! I9 x' R0 a2 [8 ^: v5 c3 iit is caused by the premature activation of hypo-
$ a8 X3 l& H  F8 J& @thalamic pituitary gonadal axis. CPP is more com-/ e1 [3 ?1 r$ ?1 `+ s' z6 x) O) R
mon in girls than in boys.1,3 Most boys with CPP
" [8 N0 a# q! ^8 r2 imay have a central nervous system lesion that is
+ H2 l+ v+ y8 Q6 v' I  v; vresponsible for the early activation of the hypothal-
: c; B2 N* s; Kamic pituitary gonadal axis.1-3 Thus, greater empha-4 n; @8 O& o0 p8 {0 h
sis has been given to neuroradiologic imaging in
/ y; [. e2 C& Tboys with precocious puberty. In addition to viril-
+ O- x" Q6 `- V# q( ?) }) w# S; eization, the clinical hallmark of CPP is the symmet-1 `1 h* X" V$ B/ T, U1 I
rical testicular growth secondary to stimulation by- g0 z$ O; h- H+ N$ W, k  z
gonadotropins.1,34 U5 x! @3 E" _  Z( P* i" g3 P
Gonadotropin-independent peripheral preco-
  a" ^2 j1 U. ~, g/ y8 b  Acious puberty in boys also results from inappropriate: ~$ _3 [0 B. ]- ?, F- f( C
androgenic stimulation from either endogenous or
: [, K* ~' X6 H0 f" F% gexogenous sources, nonpituitary gonadotropin stim-
. _) `8 X0 p2 C0 Q/ aulation, and rare activating mutations.3 Virilizing
& y5 N+ R$ y3 ^6 A: O7 h) xcongenital adrenal hyperplasia producing excessive- V3 r, Z- M' e% @+ \  N
adrenal androgens is a common cause of precocious
% _# J; ~' n9 z- wpuberty in boys.3,46 B0 F! U- J# F/ ~  c7 S9 M8 b
The most common form of congenital adrenal7 ?# |" F2 {' O$ [1 }$ b
hyperplasia is the 21-hydroxylase enzyme deficiency.6 F3 {+ U+ P1 U$ A& H) p9 ^/ x1 A8 \. e
The 11-β hydroxylase deficiency may also result in
% C2 I- Q0 _3 D+ J9 Gexcessive adrenal androgen production, and rarely,4 g2 }+ c+ l  @
an adrenal tumor may also cause adrenal androgen
( Y6 |6 \( O* ]9 z4 Vexcess.1,37 R9 b6 A+ J' `: w3 e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' O+ C) G8 P1 t5 n  [) V% _4 m
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 n# k! A) i' V: L7 p2 ^
A unique entity of male-limited gonadotropin-
: r- ~) g5 U& C9 \+ c' qindependent precocious puberty, which is also known
  n7 M, [! u$ l  \: E( x% N) L. _as testotoxicosis, may cause precocious puberty at a% J8 X# m' l, ^
very young age. The physical findings in these boys9 L7 f7 b7 p: s) l, G
with this disorder are full pubertal development,2 n/ C: p. Z5 R) b
including bilateral testicular growth, similar to boys/ X% l# ^5 e( q: M1 s
with CPP. The gonadotropin levels in this disorder" z6 D. \5 w7 e7 l
are suppressed to prepubertal levels and do not show1 u. l. O) c3 d, k+ i3 l# |7 s3 {7 G
pubertal response of gonadotropin after gonadotropin-  K5 B5 l; u' I4 M0 ^7 b! `3 U; T
releasing hormone stimulation. This is a sex-linked
: x5 y( g6 [, Bautosomal dominant disorder that affects only" o4 W9 U0 }$ _% f8 O! }
males; therefore, other male members of the family
$ @: S% J: n& W4 v7 x; X8 h+ gmay have similar precocious puberty.3
. \$ m& V* g) ~3 h9 DIn our patient, physical examination was incon-' Z6 P, p5 r0 }+ q# c, s2 @
sistent with true precocious puberty since his testi-& H: m2 j3 b0 [* q# r  O
cles were prepubertal in size. However, testotoxicosis
) i! {9 K2 v4 O& F3 N( N$ Z7 b4 awas in the differential diagnosis because his father4 q" @4 ?0 Z1 e/ w) H. ]+ g
started puberty somewhat early, and occasionally,
7 a* Q2 e1 K$ Y* \" Jtesticular enlargement is not that evident in the# |  i, V7 s/ \% g& A
beginning of this process.1 In the absence of a neg-
+ G$ U1 g7 t) L7 l, y- G5 Q  Cative initial history of androgen exposure, our
+ m, |5 g  L9 |' ]$ k2 nbiggest concern was virilizing adrenal hyperplasia,+ [/ k$ G* s. n
either 21-hydroxylase deficiency or 11-β hydroxylase4 [! Z+ ^7 |5 [$ w
deficiency. Those diagnoses were excluded by find-" J$ q2 t7 O( H/ f/ o- E* k$ ^
ing the normal level of adrenal steroids.+ [: l. v: i( k3 m
The diagnosis of exogenous androgens was strongly; k7 @# ~% d# i) b) v
suspected in a follow-up visit after 4 months because
' H3 H  W' f' Fthe physical examination revealed the complete disap-
8 G# ~8 O) f# s: Rpearance of pubic hair, normal growth velocity, and1 s" a0 ?" Z, z' k$ X. H
decreased erections. The father admitted using a testos-: ^& R3 @& Y' n! ]
terone gel, which he concealed at first visit. He was
, |4 k7 p" H- n& a. H+ ?using it rather frequently, twice a day. The Physicians’) W8 e. l# I8 s+ K# @1 R
Desk Reference, or package insert of this product, gel or
5 R4 [% f6 V/ N  ~+ V2 D# Rcream, cautions about dermal testosterone transfer to
1 ]6 J, Y8 s8 Bunprotected females through direct skin exposure.
) O1 b- I3 C: uSerum testosterone level was found to be 2 times the
( z: K0 }6 p' c8 ^; ebaseline value in those females who were exposed to
5 }; r' Y" z% ?2 B4 eeven 15 minutes of direct skin contact with their male9 P9 c% x; ?/ H  e* t* w- W# b
partners.6 However, when a shirt covered the applica-  g' M& Z2 d) M5 X: R
tion site, this testosterone transfer was prevented.
2 {* j& g3 j& B5 Q8 ~$ aOur patient’s testosterone level was 60 ng/mL," z, l  x% l: G
which was clearly high. Some studies suggest that
# }+ W8 e& [: j6 udermal conversion of testosterone to dihydrotestos-
' d7 b- f$ I5 p" f+ ^+ G  k/ }/ Pterone, which is a more potent metabolite, is more- _+ T6 J1 e9 E9 M
active in young children exposed to testosterone3 ~/ `4 ?: s6 \1 @, G
exogenously7; however, we did not measure a dihy-1 ]0 s+ |* R4 s- a* C; }, y  ?
drotestosterone level in our patient. In addition to
! G& E! |, d: Y) M6 L) uvirilization, exposure to exogenous testosterone in: u5 \; g$ o5 Q0 M5 V: z
children results in an increase in growth velocity and
& S  b3 S  h) S& g7 dadvanced bone age, as seen in our patient.
! N3 D. r8 h9 Q2 j' z7 x. \The long-term effect of androgen exposure during
) R7 F. {9 [/ h& g3 x3 D$ Aearly childhood on pubertal development and final
. O9 ^+ G8 E. g: dadult height are not fully known and always remain
8 T$ d1 K  j3 G6 L2 Na concern. Children treated with short-term testos-7 O6 b; W) P. h
terone injection or topical androgen may exhibit some
# x7 F3 Q3 ~8 t6 b) Y) E' J" z) Xacceleration of the skeletal maturation; however, after2 e; u4 z8 a7 Y0 ~9 d- m5 B& [
cessation of treatment, the rate of bone maturation7 g: T" r, b! D
decelerates and gradually returns to normal.8,9. O, l1 B$ c: N* J
There are conflicting reports and controversy9 Z5 c& D4 k1 p% o: v! Z; y7 B0 n
over the effect of early androgen exposure on adult/ v) s( }5 V, J0 \2 G* X2 D
penile length.10,11 Some reports suggest subnormal
$ U$ D4 L+ c8 b" g9 h) Gadult penile length, apparently because of downreg-
: ^0 t% ?# f7 Z1 U( t. m! Kulation of androgen receptor number.10,12 However,
& X& V/ V' O; {7 ?Sutherland et al13 did not find a correlation between' O1 I5 b0 [: B$ k. a9 `
childhood testosterone exposure and reduced adult4 h& ], z" z% n& c1 B- H, j
penile length in clinical studies.2 W2 O! B+ b9 H+ r0 \
Nonetheless, we do not believe our patient is
. m3 t+ U6 o! ]* ]2 N- Q) wgoing to experience any of the untoward effects from
" e1 B- i  j, |& p! m" B* @! x9 Xtestosterone exposure as mentioned earlier because+ P% k! x' r" U) W7 R2 j
the exposure was not for a prolonged period of time.+ g. V8 P3 s9 T! `3 V( U
Although the bone age was advanced at the time of7 \. |1 Z& F) B" b
diagnosis, the child had a normal growth velocity at) |: L/ N/ O6 ^& z
the follow-up visit. It is hoped that his final adult
* }+ L- t0 \9 Y9 `8 r# c# g  |* Zheight will not be affected.) q% s+ T% ~# c7 M1 k) k
Although rarely reported, the widespread avail-
& n  H0 [' h( @! kability of androgen products in our society may
) R( V# _0 J0 x3 \indeed cause more virilization in male or female: W9 ?- K; M3 F) N
children than one would realize. Exposure to andro-# L7 U9 k; I1 l2 |  q3 r# s8 e2 j
gen products must be considered and specific ques-: |( Z0 Y- `2 g+ g
tioning about the use of a testosterone product or
7 Y. n4 H, v$ ?7 u8 x8 Pgel should be asked of the family members during: W2 C" ~; v: R1 ^7 Q, G; B
the evaluation of any children who present with vir-6 a) I7 b; r  G* F( V7 L! H
ilization or peripheral precocious puberty. The diag-
1 e5 h7 ~6 _7 unosis can be established by just a few tests and by0 Z! j1 J( I! h  h. f" g
appropriate history. The inability to obtain such a
" g/ a$ z1 f/ q/ n( C' U7 `  f- ~4 uhistory, or failure to ask the specific questions, may
4 h+ J( p; P; z# t; h& Cresult in extensive, unnecessary, and expensive9 F( |" d3 p  p$ t
investigation. The primary care physician should be
& Q2 E# c( G5 j. n+ J! P' z7 Baware of this fact, because most of these children) E% g  _0 z8 @8 I
may initially present in their practice. The Physicians’
9 j2 |8 g: ?- h7 s8 Z. T% j% I/ _3 wDesk Reference and package insert should also put a
* n* `& @0 C. Pwarning about the virilizing effect on a male or
/ q: ]6 h  F& s6 \. G: r1 ~/ ifemale child who might come in contact with some-
2 N' W! D* Y/ R' F  G% [one using any of these products.
7 E$ I- h/ s" S( d; K1 cReferences9 R% ?6 s% S( ~4 n5 V2 i$ l9 J" h
1. Styne DM. The testes: disorder of sexual differentiation
: z9 f* q9 l+ h. _and puberty in the male. In: Sperling MA, ed. Pediatric. m: N. |) s% [( o: f
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
, S& g' O8 c/ u$ |- o+ ]8 y2002: 565-628.3 M) ^) O3 Z2 Y+ X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 Q( t$ o( {; g$ [8 O$ n/ \% b- a
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
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
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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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