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Sexual Precocity in a 16-Month-Old
1 ~! S+ D, a6 v% {- Y" v, lBoy Induced by Indirect Topical
* S: G' h+ V8 |* JExposure to Testosterone
) }  {4 v6 ^! j) P( nSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 W3 ^- I2 u9 z0 |3 Qand Kenneth R. Rettig, MD12 T1 L* C- R7 U3 x5 K) M0 o9 B
Clinical Pediatrics- ]/ z8 P' h) a6 d6 p) K1 {/ H/ a
Volume 46 Number 6
& a$ [5 H. `4 t; A# jJuly 2007 540-543( U, S8 m* h, a
© 2007 Sage Publications
& }, f$ R0 g3 B& x( `- b10.1177/0009922806296651, H( T3 Y7 M& O* v( W2 _
http://clp.sagepub.com
; I7 ]4 L* e* Shosted at  T2 h/ y9 q" W1 f0 V/ [& _' i
http://online.sagepub.com
8 V8 j/ E9 O9 oPrecocious puberty in boys, central or peripheral,
; n5 E. ]5 |9 U1 \; d% m2 H+ y" Wis a significant concern for physicians. Central
; C0 S. q$ N2 J, o! wprecocious puberty (CPP), which is mediated$ i; T9 A& J2 s  y& h& ~9 u1 q
through the hypothalamic pituitary gonadal axis, has
4 l+ m. y: e% Aa higher incidence of organic central nervous system
. F5 Z3 m2 ]5 Z, Q% e9 R2 Wlesions in boys.1,2 Virilization in boys, as manifested
) O5 Z4 C8 o- t4 Hby enlargement of the penis, development of pubic# W% K& N  K" N: H
hair, and facial acne without enlargement of testi-
8 a6 @. t/ _. l3 G3 ]9 ^cles, suggests peripheral or pseudopuberty.1-3 We; L) r( K6 u  j+ x
report a 16-month-old boy who presented with the
) C6 G; q8 K( \9 D8 ]9 kenlargement of the phallus and pubic hair develop-; J' i1 P0 D9 j1 U1 U6 d. }
ment without testicular enlargement, which was due4 B4 J3 t" H8 T& z
to the unintentional exposure to androgen gel used by/ ?$ @6 Y' Q8 g* M' x
the father. The family initially concealed this infor-
$ D5 l6 O3 h% W' N$ X6 k- p! q7 dmation, resulting in an extensive work-up for this# D3 p: e5 d: b6 }
child. Given the widespread and easy availability of. q6 \  k) I% {: ]+ J9 V% O
testosterone gel and cream, we believe this is proba-! x$ L# M: A2 t2 O" a% N8 s
bly more common than the rare case report in the; O% Q7 s$ {) Y' m; B6 f, t
literature.4/ @5 h* k+ l1 D8 w
Patient Report  g6 S; j2 t; i& u& G. [
A 16-month-old white child was referred to the
8 Z0 r0 O% b1 ~3 Kendocrine clinic by his pediatrician with the concern
" @6 `! b" A4 uof early sexual development. His mother noticed
4 _; k1 H" |: }0 C  l1 [9 G5 R/ Nlight colored pubic hair development when he was! T. z* i* r! q) K3 E
From the 1Division of Pediatric Endocrinology, 2University of, _1 a7 A) a! E% G& u
South Alabama Medical Center, Mobile, Alabama.
. j1 o) s" ~- x$ P' ^7 q  NAddress correspondence to: Samar K. Bhowmick, MD, FACE,% t# E8 F" S( v3 a- _+ Y
Professor of Pediatrics, University of South Alabama, College of
8 G' J) L: f: L% T+ L: {Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  g# d5 C- a! {8 }, f
e-mail: [email protected].( r; j! u3 @& N
about 6 to 7 months old, which progressively became, O4 f, F* t- W1 o% }
darker. She was also concerned about the enlarge-
4 A1 \) n& r- [! G2 }6 pment of his penis and frequent erections. The child1 J9 b5 V; J* h2 {5 @+ L$ }9 Y
was the product of a full-term normal delivery, with1 I) g! A7 _2 d- G+ j
a birth weight of 7 lb 14 oz, and birth length of
0 V: c$ l  Z7 U" F4 y& W# q20 inches. He was breast-fed throughout the first year1 a" G. E% Y& |; v8 M/ C
of life and was still receiving breast milk along with
& v7 l+ N0 P6 lsolid food. He had no hospitalizations or surgery,# C, s9 f- Z( M8 G7 M: {
and his psychosocial and psychomotor development# g- c* a. f1 l# f$ y- X
was age appropriate.
, G2 y2 h# j; A+ vThe family history was remarkable for the father,) G0 u( L, Z0 ~* b
who was diagnosed with hypothyroidism at age 16,
& i6 O: T! p% i: Z8 _: q0 Vwhich was treated with thyroxine. The father’s
" G" |5 f  L5 f* C/ i& Oheight was 6 feet, and he went through a somewhat8 j3 X( a2 Z0 e' B! ]; v
early puberty and had stopped growing by age 14.7 y) w' N* P" W" s- I' `3 a1 r
The father denied taking any other medication. The& o( D8 v- j- G9 {( s" Y, A
child’s mother was in good health. Her menarche2 k1 ?& M9 l+ d0 L9 R
was at 11 years of age, and her height was at 5 feet) \. j' a# J  l9 u) ]% V
5 inches. There was no other family history of pre-
, h, }2 @, }0 h+ h, Bcocious sexual development in the first-degree rela-
) H1 e4 q& J  L" ^9 L5 i2 ntives. There were no siblings.
% z3 F! Q4 f4 y( h  y$ m6 ?( E3 DPhysical Examination
) m# B+ k2 I" z* B( J& ]* j, fThe physical examination revealed a very active," X+ c% O* ]4 ]) A2 c  X
playful, and healthy boy. The vital signs documented
5 G/ ]# Z* E5 m2 \7 Ma blood pressure of 85/50 mm Hg, his length was3 k, r4 j* M& b# a5 p3 l
90 cm (>97th percentile), and his weight was 14.4 kg
' D- E- G% f+ Y, {' L# A, C; Q8 R(also >97th percentile). The observed yearly growth8 V+ x! f% b2 R
velocity was 30 cm (12 inches). The examination of4 `4 O2 w7 s. ^$ n$ p# {
the neck revealed no thyroid enlargement.
3 z% P, D# v! k9 _; S& wThe genitourinary examination was remarkable for! l: N: O5 [( D! _3 f# k
enlargement of the penis, with a stretched length of
" Q0 x/ f" R* [  I" O8 cm and a width of 2 cm. The glans penis was very well
5 g! p: k, A2 z! [0 Tdeveloped. The pubic hair was Tanner II, mostly around
4 {5 A, H  k, H9 B6 p, g* s540: q) u3 V- a! u* A0 b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- l3 L" |9 A4 a9 U6 G
the base of the phallus and was dark and curled. The
! V( Z1 [0 N5 I" u8 ~- k8 {testicular volume was prepubertal at 2 mL each.7 }4 W+ l! v, c9 ?1 Q* Z$ X* R
The skin was moist and smooth and somewhat* u' Q( }. _/ N* h
oily. No axillary hair was noted. There were no/ q$ {) X/ ?; o3 S6 g* M6 W" B
abnormal skin pigmentations or café-au-lait spots.7 c. S' J, a4 ~, p) w" Z3 m
Neurologic evaluation showed deep tendon reflex 2+
  Q- @- c0 y: V% W9 x0 J7 K5 J; Kbilateral and symmetrical. There was no suggestion# Q8 v" s; `( V% u
of papilledema.
( W$ x7 S6 {* @0 l6 sLaboratory Evaluation" G! ]2 m% R8 L) X
The bone age was consistent with 28 months by3 Q: O' ^; O: g. a
using the standard of Greulich and Pyle at a chrono-0 T) Z8 ^: c5 _: ^
logic age of 16 months (advanced).5 Chromosomal5 K: j% s, `/ l) Q7 \) F1 p
karyotype was 46XY. The thyroid function test
  b2 u5 q; C& nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-; g% i7 r' ]: r- H, j8 Z
lating hormone level was 1.3 µIU/mL (both normal).) D) i$ A- C; q$ Z$ b
The concentrations of serum electrolytes, blood2 s! V0 A/ Q2 E" \7 u
urea nitrogen, creatinine, and calcium all were
. e$ I; \& B" m2 Nwithin normal range for his age. The concentration5 ]1 y2 |5 t. l# G4 B
of serum 17-hydroxyprogesterone was 16 ng/dL
9 i* z8 [* j! {8 x, {4 E, d6 `(normal, 3 to 90 ng/dL), androstenedione was 20
1 F0 P" C! z; Y* |& jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 f% Y8 ~+ _' Y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" U# X$ v, t/ z  Pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to- y7 u) w$ W! P6 O; `! N
49ng/dL), 11-desoxycortisol (specific compound S)
  _  [) x, k2 Y  ?2 E  Q! r/ r, \was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 g0 |: X9 l) h" O7 G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' C1 n  z4 G- ~; y1 z8 i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" p5 @9 a6 X/ K8 C* E4 Pand β-human chorionic gonadotropin was less than
% J! p: q  {3 [; U$ t1 s& q& w2 S5 mIU/mL (normal <5 mIU/mL). Serum follicular
. n! E- Y# E7 }stimulating hormone and leuteinizing hormone/ d: x# |$ ]! G% g/ @8 V' N% ~
concentrations were less than 0.05 mIU/mL2 u/ l1 l7 O% x5 y
(prepubertal).
( \) T5 P) A2 }* _8 h# vThe parents were notified about the laboratory6 ~2 U/ n0 ~' |' e- w! [
results and were informed that all of the tests were9 G/ C: N: s/ y2 d6 t1 k$ K# G
normal except the testosterone level was high. The% A# f# G+ U2 T- p( W0 l( I+ S
follow-up visit was arranged within a few weeks to
' Y) i! {# x3 O( e' jobtain testicular and abdominal sonograms; how-: N8 k7 |' Z0 w/ I, s' k
ever, the family did not return for 4 months., q% y5 a- Y9 L
Physical examination at this time revealed that the: ]% N/ q* W7 n1 J
child had grown 2.5 cm in 4 months and had gained
5 ^% D' V6 ~- G! f2 kg of weight. Physical examination remained# M2 }$ ?# B  K0 l2 S
unchanged. Surprisingly, the pubic hair almost com-! R0 |" |, |/ f! V$ ]
pletely disappeared except for a few vellous hairs at. j9 n0 f" y7 q! t! @$ k
the base of the phallus. Testicular volume was still 26 b/ h& m  {! E7 h6 W
mL, and the size of the penis remained unchanged.9 ~1 F8 k4 I8 B$ a6 q; c
The mother also said that the boy was no longer hav-5 V% p7 Q8 k- t$ l; B
ing frequent erections.* i- @9 e, i" v8 a- ?4 r
Both parents were again questioned about use of
6 J+ C' V, u$ h8 dany ointment/creams that they may have applied to
  v: ~1 v; x6 ]) A6 J8 ^the child’s skin. This time the father admitted the' x1 Y2 S7 b1 R3 I
Topical Testosterone Exposure / Bhowmick et al 541
5 ~: e) p  T' Xuse of testosterone gel twice daily that he was apply-1 @; i% l0 [9 t) |/ G
ing over his own shoulders, chest, and back area for( D9 P4 I/ s: \3 ^
a year. The father also revealed he was embarrassed
: k; {2 p# o2 n4 _  M1 x% ^to disclose that he was using a testosterone gel pre-) ~: @3 n# k8 W- Y& w8 e+ c! _  C
scribed by his family physician for decreased libido
. g4 r; r1 S: hsecondary to depression.
: a1 k0 F) z- n1 d# K! CThe child slept in the same bed with parents.
* g6 c4 G4 t& z2 m3 _1 a: W2 h# aThe father would hug the baby and hold him on his7 Y* ~  |" q1 b
chest for a considerable period of time, causing sig-6 R: f% T" Q% A4 x2 I; x7 f. K
nificant bare skin contact between baby and father.
: D# _- X/ i) OThe father also admitted that after the phone call,
- T' K( }/ Y/ l  t( E5 d/ Xwhen he learned the testosterone level in the baby; W# _/ ?" o& \# m6 M5 H0 B' r
was high, he then read the product information: G9 o/ C' \' \5 y. Y9 ~
packet and concluded that it was most likely the rea-
/ X: l( B# D) ~8 `2 H% z. Dson for the child’s virilization. At that time, they+ Y* l* Q5 w: k6 B' p
decided to put the baby in a separate bed, and the
  I( g; X2 I: s+ a  Z0 |- m6 K( x4 Ifather was not hugging him with bare skin and had
- U5 H/ C" }2 b; obeen using protective clothing. A repeat testosterone/ s! N7 F8 I" C3 u  f9 q9 n4 F
test was ordered, but the family did not go to the) m- r; v, f2 ?; c
laboratory to obtain the test.
+ ?5 M, x7 Z1 w8 e$ kDiscussion$ S& K- `7 e; K. f; [3 \3 B# X; V
Precocious puberty in boys is defined as secondary
  Z6 ?% \1 ]+ o* f, F; }sexual development before 9 years of age.1,4
) @+ S2 t: L% x& A  z# ?' lPrecocious puberty is termed as central (true) when$ ~3 b% f( f0 a6 @4 p# Z
it is caused by the premature activation of hypo-
$ Q  n2 W5 \- athalamic pituitary gonadal axis. CPP is more com-
: @" i% X, `& Jmon in girls than in boys.1,3 Most boys with CPP
9 Q, m( O- h' D" ~) b+ cmay have a central nervous system lesion that is
: i( R9 a1 S" {; iresponsible for the early activation of the hypothal-: u) `' b# Z* z
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 {% `6 k  Y! p( q$ Xsis has been given to neuroradiologic imaging in
- V# P9 R- r/ x- q% m. E* Q$ Fboys with precocious puberty. In addition to viril-
/ r) S+ D+ Y/ }* t3 H7 ]1 p) kization, the clinical hallmark of CPP is the symmet-9 t" N1 t" e, M
rical testicular growth secondary to stimulation by
/ s/ d! z% ^8 T4 [7 T! L% F$ {gonadotropins.1,3
/ U2 l5 }1 L7 ?' z  M/ ZGonadotropin-independent peripheral preco-0 D# r$ F  X3 M% H. L. g# N
cious puberty in boys also results from inappropriate9 D9 ^5 ~( h. [* P. ]" I
androgenic stimulation from either endogenous or5 E" \# O- {. r  r
exogenous sources, nonpituitary gonadotropin stim-
6 d% J8 b. D/ I2 l* p, r% Rulation, and rare activating mutations.3 Virilizing8 z. J4 d. R3 K% j5 C7 }6 |5 y7 ?: J" \
congenital adrenal hyperplasia producing excessive& d+ v' ^2 X7 E  @; P& P
adrenal androgens is a common cause of precocious
) R8 n- q. g3 _7 ppuberty in boys.3,4
+ z& S! u, e) r8 m: E7 M- HThe most common form of congenital adrenal
0 C  \- @/ s# m3 D5 ~3 p- nhyperplasia is the 21-hydroxylase enzyme deficiency.+ |, z! T& V, P+ J3 ?
The 11-β hydroxylase deficiency may also result in
6 j0 e; x, d5 J# }" [8 r4 K( P  w1 X4 `excessive adrenal androgen production, and rarely,; t7 E0 O0 l3 t
an adrenal tumor may also cause adrenal androgen
; |: @, T$ n2 Eexcess.1,3& J  c6 n3 e. A+ {8 Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! u+ R0 V' T  H2 v6 |5 a+ `
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ K4 _0 n) }! i7 c- d
A unique entity of male-limited gonadotropin-$ v0 C) B' T6 i8 x1 ?% f7 b, Z
independent precocious puberty, which is also known
( `+ \0 Z' E) {+ @  r& F; Sas testotoxicosis, may cause precocious puberty at a
9 k9 X' m" b, H( C  S6 Y1 Uvery young age. The physical findings in these boys- ?3 p$ Q. V! I5 a" m0 G% g
with this disorder are full pubertal development,4 \) e7 s- Y% s0 [; ?: V/ Q- W
including bilateral testicular growth, similar to boys. ~' i5 @. k! W: ?% G7 E7 K  n  X/ K
with CPP. The gonadotropin levels in this disorder- o9 }: e+ @( l9 Q
are suppressed to prepubertal levels and do not show
( S7 i* E$ Q& O! N: rpubertal response of gonadotropin after gonadotropin-
' f2 Y: ?4 Z3 ^1 C% _releasing hormone stimulation. This is a sex-linked) \# `4 J8 n& n) M- C. L3 j
autosomal dominant disorder that affects only
, w* w- Z, A# `  u8 Dmales; therefore, other male members of the family
+ n% |" y. Y. p8 {) {' v$ I9 }1 I  wmay have similar precocious puberty.3
9 D( K5 `+ C( Q- c5 VIn our patient, physical examination was incon-
& D8 v& u0 b% z2 ^sistent with true precocious puberty since his testi-& D2 r9 j& K# u, W
cles were prepubertal in size. However, testotoxicosis
! K& d4 j9 B: \2 l* Hwas in the differential diagnosis because his father8 s+ m$ E, O! ?
started puberty somewhat early, and occasionally,) M! Y: C4 j  c8 y% S8 i1 G9 n- P
testicular enlargement is not that evident in the
3 K7 l" L  g& j$ R& {beginning of this process.1 In the absence of a neg-3 T$ [! a. e" F* C( ^; T; k7 o9 i5 w
ative initial history of androgen exposure, our4 G' E  V4 V! Y/ f
biggest concern was virilizing adrenal hyperplasia,
: C+ n: n" n! L; b. ?* ~  ceither 21-hydroxylase deficiency or 11-β hydroxylase
* c& V% `7 F' Y, d* R  adeficiency. Those diagnoses were excluded by find-8 `4 ?! @# p! ^& C0 |
ing the normal level of adrenal steroids.8 y; y2 p' X6 X& P% {
The diagnosis of exogenous androgens was strongly
8 w; U& ?1 q) g4 N) }3 s( ]5 gsuspected in a follow-up visit after 4 months because
5 c; n8 Y7 s7 D) q7 Uthe physical examination revealed the complete disap-
: ?# H  |  Y2 w# L4 d& Xpearance of pubic hair, normal growth velocity, and$ B/ p! b" P+ h7 j! D  P
decreased erections. The father admitted using a testos-
* H* r& w2 z+ A: xterone gel, which he concealed at first visit. He was
8 M/ H5 s- P8 X1 G& R  Dusing it rather frequently, twice a day. The Physicians’
  {. s" O) ]9 N! w1 BDesk Reference, or package insert of this product, gel or
$ E2 d$ a1 r) {* fcream, cautions about dermal testosterone transfer to
, [& n& R( t* h" i  y$ Z  Xunprotected females through direct skin exposure.8 D' O9 s& d: b5 k
Serum testosterone level was found to be 2 times the
$ {5 Q  G1 E; Zbaseline value in those females who were exposed to
/ P9 v& f4 K4 z$ L6 teven 15 minutes of direct skin contact with their male
& c2 X2 a; ~9 O5 L& Vpartners.6 However, when a shirt covered the applica-
' w5 P9 @$ Q8 I7 D8 c8 _6 Ttion site, this testosterone transfer was prevented.
1 h1 L) E+ \5 V! X. ^( wOur patient’s testosterone level was 60 ng/mL,
  j. g) f0 m/ @3 ~3 J( i- F. lwhich was clearly high. Some studies suggest that
. S9 X5 G) w5 Z/ ^0 o; zdermal conversion of testosterone to dihydrotestos-
+ F. F% Y% e1 J, B& Lterone, which is a more potent metabolite, is more: h/ M' T. m7 D! L
active in young children exposed to testosterone! y7 m9 K; b1 [
exogenously7; however, we did not measure a dihy-
* y& I# V2 E8 s. V7 j+ ~1 [drotestosterone level in our patient. In addition to
) }$ }4 S; k) e# b* Xvirilization, exposure to exogenous testosterone in" B+ r$ O- N$ x9 P
children results in an increase in growth velocity and7 D5 c" ?0 X( m$ W* A  B
advanced bone age, as seen in our patient.8 V- @" \! s8 w7 a: d
The long-term effect of androgen exposure during
+ p, x, m: S" N3 E5 u9 _: T; P5 rearly childhood on pubertal development and final# a# F0 d$ d: h% n
adult height are not fully known and always remain
1 W* C  V, M, I7 d& a& ta concern. Children treated with short-term testos-- r' h6 X  v& B; t* h" k
terone injection or topical androgen may exhibit some' U1 O, _/ |4 M- q* K( }6 t
acceleration of the skeletal maturation; however, after
' H6 N# q; S9 g4 n3 |6 Z8 Xcessation of treatment, the rate of bone maturation  k: Z% I; D) l) X3 B: t6 d
decelerates and gradually returns to normal.8,9
; k) v. C9 O9 r( E7 x: B4 j# H4 ~There are conflicting reports and controversy0 a, L; |+ y; O6 O: z+ h5 P
over the effect of early androgen exposure on adult
5 j, s4 P5 \% t4 ~& P' E0 Ipenile length.10,11 Some reports suggest subnormal; ]6 Q1 o) w9 }2 o' Q' O6 z+ Q
adult penile length, apparently because of downreg-
: w; T8 u( d( o* x' P, Mulation of androgen receptor number.10,12 However,) r! X# W6 t* L8 b# r* L& A& E
Sutherland et al13 did not find a correlation between( W- G  `; D5 t2 H7 U, O
childhood testosterone exposure and reduced adult$ D3 L2 w2 Q% a! W6 G1 K) ^, A
penile length in clinical studies.
0 d5 M( U* D2 A! L% }- k  _Nonetheless, we do not believe our patient is
4 S% a* I* g' s3 O+ x1 Bgoing to experience any of the untoward effects from* Q- c$ l6 z' c; p$ Z' n
testosterone exposure as mentioned earlier because8 k7 t  Y( z" Z1 ?* c5 p
the exposure was not for a prolonged period of time.* F) [& d2 b) Y- D% k
Although the bone age was advanced at the time of
1 N' Y/ ~' w# d. A4 h1 ^diagnosis, the child had a normal growth velocity at; N8 k# }" E3 J. ~; {
the follow-up visit. It is hoped that his final adult
- U/ a! `- E, s! p3 Qheight will not be affected.
1 f4 [9 U% R  oAlthough rarely reported, the widespread avail-
: u* |+ M, [, K' G/ A2 ~ability of androgen products in our society may) k- {0 L* w: @  `
indeed cause more virilization in male or female
/ ~& C; A. \" n& R5 G6 C$ A9 G; v4 cchildren than one would realize. Exposure to andro-0 Z+ N8 M- {7 ^* x) ^; Q
gen products must be considered and specific ques-
/ j& W, o1 H- b0 f; Xtioning about the use of a testosterone product or
; f( a( j1 b5 o! J$ K* Egel should be asked of the family members during+ O, C, O1 w- B0 {) m
the evaluation of any children who present with vir-% y8 r7 R$ E, X* N/ k5 c$ @; G$ N
ilization or peripheral precocious puberty. The diag-
" u7 k1 B9 m" j8 r, }nosis can be established by just a few tests and by! f2 e8 S/ m, N/ ?6 x
appropriate history. The inability to obtain such a% B- x+ C$ P; y
history, or failure to ask the specific questions, may" J! N4 T; K0 _- H2 ?* P1 a& R+ z
result in extensive, unnecessary, and expensive7 F# p( d3 y7 I+ e* x2 Y
investigation. The primary care physician should be2 p9 A. y2 y) b5 Z- ^
aware of this fact, because most of these children
8 H; t5 a; Q0 D& p( Vmay initially present in their practice. The Physicians’7 Y' x" M! C- \1 y& c4 v
Desk Reference and package insert should also put a
' ?! I% I, y1 Swarning about the virilizing effect on a male or! `6 i# V1 `$ C, M; v- M3 @
female child who might come in contact with some-
$ c. @8 J$ _! |1 O" r) I8 eone using any of these products.
3 D" z4 _# o; j5 d6 _References
, e/ X/ b5 z- J/ B' C: d: C1. Styne DM. The testes: disorder of sexual differentiation4 S7 }& S- A7 z) H: z7 q
and puberty in the male. In: Sperling MA, ed. Pediatric
/ x1 x( I  E3 }$ x! G! H+ gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  G) z3 c/ d5 X0 R( A$ ~
2002: 565-628.
( C* N% |5 G. s: ~7 }. M0 x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious  |' R" y4 W3 E3 Q$ m& Z
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
% S1 p& \  \6 {. x  d6 xBoy Induced by Indirect Topical, l! L! C1 |# G3 @) o6 C3 b  K
Exposure to Testosterone' X6 `! b1 U, v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 P; }( I- g: m" e0 }# ?
and Kenneth R. Rettig, MD1  B* k/ L) E/ I6 ^; C7 f
Clinical Pediatrics4 l  Q3 c% {( ~7 O2 r
Volume 46 Number 6
4 s9 }% l; J4 a6 {1 M* }July 2007 540-543" `5 V+ ]& e9 v! t
© 2007 Sage Publications+ d/ f( d! m$ z  ]0 Z
10.1177/0009922806296651- ~; L: B- i! k. t
http://clp.sagepub.com' c- ]$ L: @$ i4 W9 h
hosted at) T9 J3 W! T7 _- v. z
http://online.sagepub.com8 H+ Q' l% e. q
Precocious puberty in boys, central or peripheral,
# z6 ^+ C* e1 |is a significant concern for physicians. Central8 h) Z3 m. E" q- Y
precocious puberty (CPP), which is mediated8 W) a) t# u& ?/ E/ \
through the hypothalamic pituitary gonadal axis, has) H0 [6 G9 {1 Z$ k/ |
a higher incidence of organic central nervous system
# Q! k* X0 G8 ^; @. l* blesions in boys.1,2 Virilization in boys, as manifested
( V1 @2 E0 M5 Dby enlargement of the penis, development of pubic
/ [5 U# T) Y( E. vhair, and facial acne without enlargement of testi-
, h( A" L) r" V$ W& J" Q  rcles, suggests peripheral or pseudopuberty.1-3 We
1 l- d6 g: ?( Z$ T" a( `! k& a3 Dreport a 16-month-old boy who presented with the7 x! c; k  E. A
enlargement of the phallus and pubic hair develop-: r+ E. }# G& }1 C% ?
ment without testicular enlargement, which was due: W) T. c/ p7 Z
to the unintentional exposure to androgen gel used by' `) d( P" n3 |0 Z1 L6 [
the father. The family initially concealed this infor-
( o& `8 Y% b8 ]5 k5 F5 Vmation, resulting in an extensive work-up for this
' q5 W7 h* I4 K3 o- r  ychild. Given the widespread and easy availability of
9 ]2 b1 T1 ]8 Jtestosterone gel and cream, we believe this is proba-
+ Y; `) A. o" F' h; mbly more common than the rare case report in the
6 h/ b" c2 s6 L) Rliterature.4/ w: I0 x! a5 X7 J! P
Patient Report7 F  [# m6 J% Q( `# @5 {3 h/ ~/ N
A 16-month-old white child was referred to the7 o3 K0 f& K8 ~6 ~  {! B
endocrine clinic by his pediatrician with the concern
0 }! O6 w; P, u2 a4 }of early sexual development. His mother noticed1 \* w6 N; S# [7 [0 R! T+ r# p' _
light colored pubic hair development when he was7 V" z/ h' w" t2 s! w
From the 1Division of Pediatric Endocrinology, 2University of
  [/ D/ ^0 C" p# \+ ~( {South Alabama Medical Center, Mobile, Alabama.$ F4 H9 w* k( B+ \
Address correspondence to: Samar K. Bhowmick, MD, FACE,! G  r( p4 x3 m  k" G1 t
Professor of Pediatrics, University of South Alabama, College of
9 J; n/ F5 X' `+ F( yMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ ]- F4 W% g" ?; D  t5 }5 le-mail: [email protected].
- D3 N) L/ d5 Babout 6 to 7 months old, which progressively became# f) I! S  {( o& y- l3 H& D4 x
darker. She was also concerned about the enlarge-- e5 P: w: |1 W* Y6 l; @
ment of his penis and frequent erections. The child! M/ J: j8 H  E  M
was the product of a full-term normal delivery, with) k" C6 u  N6 e+ o6 v! H: G2 J
a birth weight of 7 lb 14 oz, and birth length of
* J" d4 J4 \! C20 inches. He was breast-fed throughout the first year
+ m) z( ]' h, S  y, N' Mof life and was still receiving breast milk along with
) }5 ^1 J9 [0 U5 n  i$ {solid food. He had no hospitalizations or surgery,
7 N; C  v, u% T6 Nand his psychosocial and psychomotor development: D. q5 O, S, E" h) X+ H
was age appropriate.8 `" ^( t4 F' |8 g2 N; j+ K4 {
The family history was remarkable for the father,
$ P& T0 a+ B' Q2 a$ p0 t# Swho was diagnosed with hypothyroidism at age 16," z1 @3 }+ a/ m  B! q
which was treated with thyroxine. The father’s( g0 J' j, r* d  |/ ]2 T
height was 6 feet, and he went through a somewhat
4 d; ^: v+ V% m4 oearly puberty and had stopped growing by age 14.$ O5 s" }3 L; o% y7 ^; y# p
The father denied taking any other medication. The
; A; Z; a4 ~1 z8 R, l) q# Q; Zchild’s mother was in good health. Her menarche/ }+ e/ C) G) u% U" R( a
was at 11 years of age, and her height was at 5 feet
! }8 e8 }6 b" d3 C' h# `! W! R" E. u2 U5 inches. There was no other family history of pre-* a0 L! A, g; w4 [& v0 P5 P) Q
cocious sexual development in the first-degree rela-
% S3 l" v5 b# r/ i: r4 ^& s  [! Ytives. There were no siblings.+ L1 t# O. C( R$ k* e
Physical Examination. `' y7 P& \# u; B6 F: U
The physical examination revealed a very active,
; F- m% Y* W+ e" K- Zplayful, and healthy boy. The vital signs documented
' z; T( R/ e3 f0 ~a blood pressure of 85/50 mm Hg, his length was/ y( t* W* s! ]9 F) Q
90 cm (>97th percentile), and his weight was 14.4 kg6 k' x: }+ t/ x/ Q) a
(also >97th percentile). The observed yearly growth
9 Q. y5 [7 L. G! x6 L' v* E7 u) bvelocity was 30 cm (12 inches). The examination of
. P% _$ {$ i  x6 f4 Pthe neck revealed no thyroid enlargement.; C- k; D/ m$ g3 m" Z' B  q
The genitourinary examination was remarkable for2 v8 c8 [% \, X! j! ^( ~' v
enlargement of the penis, with a stretched length of$ }2 j4 r7 O1 u/ w# F
8 cm and a width of 2 cm. The glans penis was very well
/ S+ t& {5 w, d5 }8 _5 E* odeveloped. The pubic hair was Tanner II, mostly around
2 b  E: ]# Y, z2 B. Z' U540
. d9 k6 j5 p" X/ `( W2 {; Z) ]) bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 L( G" ?" ^; e( G$ dthe base of the phallus and was dark and curled. The
, J* A3 f* ~6 ^6 ktesticular volume was prepubertal at 2 mL each.' @- T( ~' R( ?* ]* d. x; `+ ]
The skin was moist and smooth and somewhat5 A8 l  |# V4 H9 D3 E
oily. No axillary hair was noted. There were no
) W+ P/ j8 W8 r: k" C) uabnormal skin pigmentations or café-au-lait spots.
) v- u: v' k4 m* t1 `Neurologic evaluation showed deep tendon reflex 2+% @) p# i, \5 r* ]% t
bilateral and symmetrical. There was no suggestion: k3 _2 V4 p- `" R
of papilledema.; s& c9 T# W. b! [- F1 P
Laboratory Evaluation1 p. i& m4 e9 V& H+ X, G. B7 \$ e& w
The bone age was consistent with 28 months by. h/ c7 y* J  ~" f: u
using the standard of Greulich and Pyle at a chrono-
3 R0 R9 H) N( J+ B2 K' f, V- T: xlogic age of 16 months (advanced).5 Chromosomal
( s, b5 D; u  m7 ckaryotype was 46XY. The thyroid function test
" ?1 j( t. j: Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-* @# R5 D) z  W6 f  U
lating hormone level was 1.3 µIU/mL (both normal).& |! e) }. D( q+ X/ [
The concentrations of serum electrolytes, blood/ x/ c* x6 B, ~
urea nitrogen, creatinine, and calcium all were
* K2 U/ M1 C. rwithin normal range for his age. The concentration# f  M" ^  ]6 |1 z# c) j) d9 J
of serum 17-hydroxyprogesterone was 16 ng/dL
$ ]' K  U9 Q7 c: _(normal, 3 to 90 ng/dL), androstenedione was 20
7 Q& J# A# w4 N" J: @9 ]7 Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, m5 A* i0 f( g+ A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" {  `# C4 S& r$ J1 I' hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 e; C6 P+ w* U# ]% w8 M3 L' I  X49ng/dL), 11-desoxycortisol (specific compound S)' C7 r( @% h% G7 Q) W  [2 u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 b4 R6 M8 U- O: l3 I& p6 Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. i( s" S; I6 \; C, Q* g3 g, l, y0 _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& d# E) j" {; ]6 T! ]9 Y' wand β-human chorionic gonadotropin was less than9 e+ J2 L) n+ a' ^  O& J7 k' J
5 mIU/mL (normal <5 mIU/mL). Serum follicular; N( m' u( f/ B' @: D2 A
stimulating hormone and leuteinizing hormone
9 \4 ]$ E. }3 }; x* u8 }concentrations were less than 0.05 mIU/mL  K7 s2 ?$ r4 I  Z  |
(prepubertal).
/ A0 R% r7 {7 n  E, qThe parents were notified about the laboratory' H" }, ?) D. b6 T4 Z
results and were informed that all of the tests were7 N) r* r$ g3 f, |
normal except the testosterone level was high. The0 |8 N& i8 r! K
follow-up visit was arranged within a few weeks to
: G7 n! G; k2 lobtain testicular and abdominal sonograms; how-
2 g. }/ o# _4 d# eever, the family did not return for 4 months.. h8 u' i) ]5 q4 t+ T% Y9 g
Physical examination at this time revealed that the9 R) J' ?8 I2 {5 `; Z$ \
child had grown 2.5 cm in 4 months and had gained5 b5 a( w: u9 Q" {# k$ p- G% ]( {
2 kg of weight. Physical examination remained- }, A7 _) j* n) ^5 |, A
unchanged. Surprisingly, the pubic hair almost com-! \4 P8 y' p; Q3 L
pletely disappeared except for a few vellous hairs at6 G9 F; n7 k! K$ Y* G
the base of the phallus. Testicular volume was still 2' o/ J! |$ d4 v
mL, and the size of the penis remained unchanged.: V3 k! A( r( r6 G7 a  |  ]( R6 b
The mother also said that the boy was no longer hav-
4 F$ H! g- L4 n( s7 b9 n% sing frequent erections.+ ~$ X6 l& z/ ]/ {& s
Both parents were again questioned about use of
5 h  N! a' V4 R: tany ointment/creams that they may have applied to
) m2 Z7 F; }& x' W% f: O3 @5 [# O& {the child’s skin. This time the father admitted the, o+ B1 @5 I9 o& k$ Q4 R* O' \# _8 e$ o
Topical Testosterone Exposure / Bhowmick et al 541
. J* C6 E1 ~; _8 K: Fuse of testosterone gel twice daily that he was apply-
! U6 U$ f+ E- w0 S( Oing over his own shoulders, chest, and back area for
: y6 `0 M5 y9 Q9 a- j+ Fa year. The father also revealed he was embarrassed
4 m2 ^7 A2 F: R: n# K& |4 \* j6 Wto disclose that he was using a testosterone gel pre-
0 z7 Q% W' Q% ]scribed by his family physician for decreased libido5 Y( p1 T9 v% ]
secondary to depression.
; }; y0 t1 [3 ~' M( K8 [The child slept in the same bed with parents.
' h% H$ ?' V& _5 n# z2 [: }The father would hug the baby and hold him on his
3 _5 N# R; T" l! n7 l4 zchest for a considerable period of time, causing sig-
! Y% J$ K" w9 V! v/ W+ ~: d2 @nificant bare skin contact between baby and father.
, R  J2 K$ h4 E" e' LThe father also admitted that after the phone call,1 V( [5 H& G- l1 O0 ?$ q  R
when he learned the testosterone level in the baby
0 J0 P% a: j( }: hwas high, he then read the product information3 ~& c7 d8 |# i, u
packet and concluded that it was most likely the rea-
! u: w) O, D6 |( Xson for the child’s virilization. At that time, they4 q$ H3 @; S" @* C
decided to put the baby in a separate bed, and the  w+ S9 l7 y* E4 [: C
father was not hugging him with bare skin and had& H$ k% x6 O7 y5 d6 |" j2 x
been using protective clothing. A repeat testosterone: s5 J  k& ~  j  s/ ~9 G0 E
test was ordered, but the family did not go to the
" N, Z! L$ r7 M, h- E( N1 ulaboratory to obtain the test.0 `5 C0 w# }6 u; ^* }& H
Discussion7 d1 J4 o" Z) S$ T) v
Precocious puberty in boys is defined as secondary  K0 _: j: V( W4 |& i
sexual development before 9 years of age.1,4' H2 Y4 i1 Z! F: R6 }% e0 @
Precocious puberty is termed as central (true) when' \+ H7 Y# D/ y- R
it is caused by the premature activation of hypo-
8 `' r  A0 f, [, U' u  Xthalamic pituitary gonadal axis. CPP is more com-
& `7 P2 V' A, p$ omon in girls than in boys.1,3 Most boys with CPP
' C" \0 {0 a/ e( B, Umay have a central nervous system lesion that is5 ^$ F' {( U8 x0 K' M$ B  z; h
responsible for the early activation of the hypothal-
. T. F. F3 C1 Iamic pituitary gonadal axis.1-3 Thus, greater empha-
. o/ H  H2 d% v* _3 ]1 csis has been given to neuroradiologic imaging in
8 ~* P: Q+ v2 g: ]4 ?) kboys with precocious puberty. In addition to viril-
' |* v* N7 K5 y" V! U. G3 l( qization, the clinical hallmark of CPP is the symmet-
/ u& w: J( i; I0 n. N* mrical testicular growth secondary to stimulation by
: \, K$ r" }0 h, p3 y  }gonadotropins.1,3. k# j& W3 e) R9 s9 E* I, D9 p
Gonadotropin-independent peripheral preco-
1 `* F( o$ W% X5 O6 ]/ qcious puberty in boys also results from inappropriate
% T4 n& g3 U/ s) t/ tandrogenic stimulation from either endogenous or: T" I- q0 \1 i1 e
exogenous sources, nonpituitary gonadotropin stim-
- U5 q0 H  _1 `2 O0 W: zulation, and rare activating mutations.3 Virilizing, Y9 Z' m" p" N+ m* {
congenital adrenal hyperplasia producing excessive
' r0 K4 u4 A* R4 a. n  badrenal androgens is a common cause of precocious
" u! a6 H) L1 D  G: Jpuberty in boys.3,4
7 Z. l3 I; G0 c6 h% JThe most common form of congenital adrenal$ j- x1 ^/ g/ f0 z& e$ v
hyperplasia is the 21-hydroxylase enzyme deficiency.2 c  ^" L0 M& b& t" L) s
The 11-β hydroxylase deficiency may also result in
% F$ Z& p5 m* z. iexcessive adrenal androgen production, and rarely,
, c5 k/ ~" v9 S* Q6 [an adrenal tumor may also cause adrenal androgen
* n2 M* i* I- Dexcess.1,3, R7 h# l/ g2 a2 {7 u( g- E- M2 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 f; _# S! u4 f5 Y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( ^' a. P; b' N* KA unique entity of male-limited gonadotropin-
9 q" t' U( b) v% {$ u* w- f# Eindependent precocious puberty, which is also known* _, q- L, a% S' U4 o
as testotoxicosis, may cause precocious puberty at a+ \, b* P; I, u- |! M1 Z3 D* N
very young age. The physical findings in these boys
( ?+ O8 o+ ]! |7 o( j: k' n4 Mwith this disorder are full pubertal development,0 E: g$ K' {6 u% ]  g7 A
including bilateral testicular growth, similar to boys8 {6 B; Q- {1 m) L
with CPP. The gonadotropin levels in this disorder
' a# D. {/ }! Qare suppressed to prepubertal levels and do not show
2 k9 |0 o- ]7 Y+ ]6 U  M% L4 Ppubertal response of gonadotropin after gonadotropin-
: a4 l4 }; U" n0 y6 }. L$ z4 f) Treleasing hormone stimulation. This is a sex-linked
$ O9 i4 i1 |% R6 I( X2 |6 `autosomal dominant disorder that affects only6 W: y2 G; ?$ X
males; therefore, other male members of the family
2 Z* }  Y  h; V3 ymay have similar precocious puberty.3! D7 V6 X  y1 R: [/ `/ a
In our patient, physical examination was incon-9 n3 v% H' U1 j8 O
sistent with true precocious puberty since his testi-
& e) Z/ n# g3 n$ x$ i" I% F$ xcles were prepubertal in size. However, testotoxicosis2 p% W( N. n4 |$ o3 w7 \$ i
was in the differential diagnosis because his father
' o2 ]5 c3 k* Wstarted puberty somewhat early, and occasionally,9 Q" x: I; I$ f3 ], a! r8 f; C6 S
testicular enlargement is not that evident in the( F, R2 ~% d$ Q$ f
beginning of this process.1 In the absence of a neg-8 G8 n. O/ k9 s+ Y5 P0 S6 E
ative initial history of androgen exposure, our- B& C5 k6 F  Z4 B6 Q- v) Y- a
biggest concern was virilizing adrenal hyperplasia,
/ N/ v4 |( r3 C/ |8 D6 Leither 21-hydroxylase deficiency or 11-β hydroxylase9 @, T) n9 H& e% A' @  z# u
deficiency. Those diagnoses were excluded by find-
5 _  o  c) _( X1 {. ?* }ing the normal level of adrenal steroids.8 i  e2 C" W6 k- `9 X
The diagnosis of exogenous androgens was strongly( G" J( w/ E. k+ r. s9 {
suspected in a follow-up visit after 4 months because* N7 e2 V( Z) b$ [  i0 Q
the physical examination revealed the complete disap-
! T# M$ Q% L( F' S4 Qpearance of pubic hair, normal growth velocity, and) B( l$ m# s3 B5 b- X0 @7 W
decreased erections. The father admitted using a testos-
3 y; E, T; N: u) T% Rterone gel, which he concealed at first visit. He was6 C5 O5 J! a) Z! K
using it rather frequently, twice a day. The Physicians’( v: [+ q5 l- K! _' r, b
Desk Reference, or package insert of this product, gel or) e. u' G# x" F. D5 a6 O
cream, cautions about dermal testosterone transfer to
; t( ]7 h: E4 `! F4 M% {: \4 h9 z6 bunprotected females through direct skin exposure.
3 I- q  ?& P3 y' c) ]$ W# ]9 WSerum testosterone level was found to be 2 times the) s( g: ]& B0 Q# M+ w9 D1 g
baseline value in those females who were exposed to
2 z* D- r0 \) Neven 15 minutes of direct skin contact with their male6 C" j/ R: E2 L! X
partners.6 However, when a shirt covered the applica-# H7 Q* x8 X2 a3 {2 b0 o
tion site, this testosterone transfer was prevented.
4 o* _* J$ t5 `4 c$ C4 H4 }Our patient’s testosterone level was 60 ng/mL,
, O  A" l$ m/ }' O5 C' F6 {: v+ ^6 swhich was clearly high. Some studies suggest that
6 l. Z: A3 p- t. Y' k) xdermal conversion of testosterone to dihydrotestos-
/ G5 w1 J' w  z( Kterone, which is a more potent metabolite, is more
, {' P5 }! C1 P7 K. }+ g- Yactive in young children exposed to testosterone9 d3 r2 m) v  ~; J6 _
exogenously7; however, we did not measure a dihy-
/ C' H9 E; [8 X& s5 ?8 X) Q; C' vdrotestosterone level in our patient. In addition to) H8 a. l; ?1 A- F
virilization, exposure to exogenous testosterone in/ }! i6 t: q- J3 `: C  w
children results in an increase in growth velocity and
6 u# E  X: M/ F; J! `advanced bone age, as seen in our patient.$ O: j; K3 a, d" U. h3 ~
The long-term effect of androgen exposure during# P* V5 i% t, D- H& i
early childhood on pubertal development and final
+ I' S8 K0 @" q5 w  r) ]$ w& nadult height are not fully known and always remain: q& f* k% Z8 D$ d7 {7 s" k4 N
a concern. Children treated with short-term testos-. R. Q  |: [& E+ O8 i5 @$ o
terone injection or topical androgen may exhibit some
2 c- P, R9 \' b9 V0 sacceleration of the skeletal maturation; however, after8 P! x* m$ j4 G. c
cessation of treatment, the rate of bone maturation5 a* W% ?8 k# f$ n- S6 v
decelerates and gradually returns to normal.8,9# Q/ n; p) I( Y
There are conflicting reports and controversy
0 e6 R# ]* Y9 N1 y$ q% iover the effect of early androgen exposure on adult
0 j" |: }) |* P* @penile length.10,11 Some reports suggest subnormal* E; z6 B5 k2 B/ p) t# J
adult penile length, apparently because of downreg-
+ c& ^8 O8 T2 D! p  B: `  mulation of androgen receptor number.10,12 However,' u/ N" d0 X4 v& {) a7 X% _
Sutherland et al13 did not find a correlation between; H- z/ ~. |6 b) W, M3 G# C
childhood testosterone exposure and reduced adult, s" U$ P; }6 _8 v
penile length in clinical studies.+ E) m7 O( u6 a7 b
Nonetheless, we do not believe our patient is+ g9 q) L; k8 Z+ G
going to experience any of the untoward effects from' X7 P: o5 Y# U5 v+ w% A. i
testosterone exposure as mentioned earlier because6 t' R: x$ R4 W3 i) F4 f5 x
the exposure was not for a prolonged period of time.
5 M4 l6 S* ^# m5 i+ UAlthough the bone age was advanced at the time of
& o4 b$ C/ B0 X) S2 Hdiagnosis, the child had a normal growth velocity at( d; c# n$ S' \0 V/ Y1 i: @2 q
the follow-up visit. It is hoped that his final adult
- R5 n4 g' C5 L4 n# u/ J6 s5 Jheight will not be affected.7 S- b$ f% x( H6 p( n4 _' v0 H' |- }
Although rarely reported, the widespread avail-1 I. S8 K5 U6 l+ q  M
ability of androgen products in our society may1 l1 b. s7 {6 k9 t' q# ?
indeed cause more virilization in male or female
1 D4 o! D% k) E) T: {children than one would realize. Exposure to andro-
* A  h" r: R8 C9 ogen products must be considered and specific ques-
, |8 S) M- g2 z7 }# W$ x) [tioning about the use of a testosterone product or
& R0 p8 \/ ]% M: |gel should be asked of the family members during
# B3 Y( E% v. _1 Vthe evaluation of any children who present with vir-5 }7 x# u1 H! q: n
ilization or peripheral precocious puberty. The diag-
5 K* s) h( N' nnosis can be established by just a few tests and by' D! {5 C; O* M
appropriate history. The inability to obtain such a
* ~# X4 q8 [7 w6 S4 S5 Thistory, or failure to ask the specific questions, may
' g% d4 U# C  C7 V8 rresult in extensive, unnecessary, and expensive
( F* H4 r. ^* O2 R/ V! z0 j  ?investigation. The primary care physician should be
0 Q$ x7 ^- p  faware of this fact, because most of these children
2 {% h! m# c: q9 rmay initially present in their practice. The Physicians’6 {. z0 m+ v. v- W5 U6 X
Desk Reference and package insert should also put a
3 _3 X/ o8 `! V% O% S8 Cwarning about the virilizing effect on a male or) E) S/ l: T  r' C3 x5 \
female child who might come in contact with some-) ~+ |8 k- I% C
one using any of these products.
7 i8 }( i5 G" W! `( T' K1 j0 IReferences
$ g; d; {; e+ p4 L1. Styne DM. The testes: disorder of sexual differentiation
+ x' m9 t" L; g; d  ?. s2 oand puberty in the male. In: Sperling MA, ed. Pediatric% A- P3 N9 A' O3 [8 d8 M+ l- v
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 O; T0 z) Q8 l) k- O3 P0 x2002: 565-628.7 m7 l( a! J0 o* r
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 z6 v  B( j) t; M
puberty 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
/ `0 A# T( b  \
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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