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Sexual Precocity in a 16-Month-Old
; u7 F. G& W* Z! `; z1 mBoy Induced by Indirect Topical% O$ U+ {! ]3 ~. ]. j5 q% u
Exposure to Testosterone+ k) ^6 a7 F% }4 |3 A2 Y- G% s
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 Z2 R* F# y* Y  H% K( N1 \) a: Tand Kenneth R. Rettig, MD1
" X/ X: Q( O" |! N3 \9 ?Clinical Pediatrics/ }8 p% m% m1 l# f3 M
Volume 46 Number 6
& f* v3 B! f, t+ f" @. M4 kJuly 2007 540-543
7 W- G3 [/ w* }' O© 2007 Sage Publications5 [9 q+ H2 `' R5 }
10.1177/0009922806296651/ h( q1 v, j2 T4 [  N1 z
http://clp.sagepub.com
& }' a$ x9 q# D, y& [5 P/ @: `hosted at
  B( h! l+ Q5 ]1 d9 chttp://online.sagepub.com. ~0 Y1 V8 L. L1 M6 w  M8 `2 w
Precocious puberty in boys, central or peripheral,
2 L5 H8 a' b, u- Yis a significant concern for physicians. Central
! f7 ]" q8 ^: O: S- [precocious puberty (CPP), which is mediated
6 |( Q4 W' n6 j  T$ sthrough the hypothalamic pituitary gonadal axis, has
5 w3 ]0 Y+ [9 va higher incidence of organic central nervous system
& c/ D1 [) e2 ^/ D! Q0 f* Ilesions in boys.1,2 Virilization in boys, as manifested
6 v, k$ }$ V: U- bby enlargement of the penis, development of pubic
0 b  q- M) \( w/ Xhair, and facial acne without enlargement of testi-7 f! }. Z' v/ ~% x! U! i' C) M
cles, suggests peripheral or pseudopuberty.1-3 We
* T0 ^+ l2 y/ |4 e* J& \report a 16-month-old boy who presented with the
5 ~5 b* M- f: `' m2 xenlargement of the phallus and pubic hair develop-6 I9 g" ^7 i  m# o9 r
ment without testicular enlargement, which was due- w8 [0 Z5 t4 k' y2 m
to the unintentional exposure to androgen gel used by
4 j% t6 H7 M* P9 Dthe father. The family initially concealed this infor-8 M: J) v; ?! D9 ?/ p
mation, resulting in an extensive work-up for this
& n, O' j$ v0 z! _3 \7 Gchild. Given the widespread and easy availability of
. [8 P# w( a2 _$ |. ktestosterone gel and cream, we believe this is proba-9 n' }! f( T2 w+ q9 U
bly more common than the rare case report in the
  m7 A) k0 L, [' B! a0 {, Aliterature.40 Y. f1 C6 K: K) E) _  b
Patient Report. ?1 Y% U! x# ^
A 16-month-old white child was referred to the
* Z0 F5 q2 m# A# Z" rendocrine clinic by his pediatrician with the concern% k: a" j6 V1 K6 S2 Q% I
of early sexual development. His mother noticed
* N$ j6 ~0 ~6 R0 ]2 rlight colored pubic hair development when he was6 r' ^8 w. N/ e) p% j% a
From the 1Division of Pediatric Endocrinology, 2University of9 c5 v: s6 p7 H% A
South Alabama Medical Center, Mobile, Alabama.
2 b: v) O. G4 h7 UAddress correspondence to: Samar K. Bhowmick, MD, FACE,
# c) L% U/ L  `) `3 tProfessor of Pediatrics, University of South Alabama, College of
* ]$ x6 z$ M4 k# l" FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 [1 P$ p2 j' P6 `4 ?3 {4 z0 _: N
e-mail: [email protected].2 _* n$ N2 Z. ^) I! U" }+ ~: j
about 6 to 7 months old, which progressively became4 _) R: N* \3 Q* _3 ?0 y1 S
darker. She was also concerned about the enlarge-3 ~1 O& X% J+ F- v# M6 n
ment of his penis and frequent erections. The child
: o. ]& j! P5 q/ _: C# m2 Nwas the product of a full-term normal delivery, with8 A3 M! E" D/ v6 R9 C
a birth weight of 7 lb 14 oz, and birth length of
' w5 G/ [  `9 E  \/ b* R5 ]20 inches. He was breast-fed throughout the first year
! X3 Z- W; G! h; I" H1 I) x* cof life and was still receiving breast milk along with6 I$ S8 U( `% W
solid food. He had no hospitalizations or surgery,9 w# d3 t* I, F- a2 F4 J
and his psychosocial and psychomotor development) ^* S9 Z: ^' j- ^% }1 S
was age appropriate.9 B/ I4 [6 b: i" e
The family history was remarkable for the father,) o: ^& m& m7 @$ J% Z
who was diagnosed with hypothyroidism at age 16,# i0 B1 m6 Q  k/ D0 `! G
which was treated with thyroxine. The father’s
: ~$ x- B+ A3 i% n9 F. ]height was 6 feet, and he went through a somewhat1 w3 Z4 i! l" b- G+ A5 h! C' l) o
early puberty and had stopped growing by age 14.
# T* M4 L7 }8 h& W" D5 YThe father denied taking any other medication. The
# K8 ~$ Q% }. schild’s mother was in good health. Her menarche
0 g3 D9 b9 v8 F/ Dwas at 11 years of age, and her height was at 5 feet5 s1 ]) y: @0 |  ?: Z& p7 _
5 inches. There was no other family history of pre-: j# K  U3 j5 O; K9 o! F( J
cocious sexual development in the first-degree rela-
) D$ z( T3 A, q6 Z" j( `( t2 ^# Ktives. There were no siblings.- o: ]. B  U! C& w1 [7 m
Physical Examination
& P8 U6 Z  I4 l6 m; mThe physical examination revealed a very active,
. @6 y$ L2 A) t) c. v- Y) Q* rplayful, and healthy boy. The vital signs documented
. W4 F6 G3 R/ S+ Z" Y: xa blood pressure of 85/50 mm Hg, his length was" ^% q+ @2 o$ t
90 cm (>97th percentile), and his weight was 14.4 kg
3 U! k1 z5 {/ J! W7 `. w* Q(also >97th percentile). The observed yearly growth+ J2 T& k3 m; ^+ L: w5 l
velocity was 30 cm (12 inches). The examination of- n! P9 F! @- p1 `' J+ r
the neck revealed no thyroid enlargement.
  ?6 ~6 M! E, XThe genitourinary examination was remarkable for- Z' G5 P+ K; b
enlargement of the penis, with a stretched length of
/ `) V- l. q) U# q: t: G: M/ `8 cm and a width of 2 cm. The glans penis was very well
1 `; k. y/ N* S/ d; c  y; ^+ edeveloped. The pubic hair was Tanner II, mostly around: B" l. O0 ?1 u7 ^8 Y
540( X5 k; i, ?3 {6 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% L) T4 O# C1 V3 U1 z" Othe base of the phallus and was dark and curled. The0 }, ]+ w; `9 [5 b/ P2 U
testicular volume was prepubertal at 2 mL each.( R' |% A# @7 }: S" E& G2 j  J
The skin was moist and smooth and somewhat' P) D: c1 L) _% x: x2 K6 F
oily. No axillary hair was noted. There were no- u0 j, S- D1 p& _; P
abnormal skin pigmentations or café-au-lait spots.* v+ J( p2 }) u* X7 g9 _, q, p2 N- }
Neurologic evaluation showed deep tendon reflex 2+
" v+ _  I6 y  o3 c. p8 Mbilateral and symmetrical. There was no suggestion
/ N+ p' g6 w# Dof papilledema.+ ?8 Q5 y% }0 l* D2 o9 b6 R
Laboratory Evaluation
( A4 j% H, _" ]- U- C: ~The bone age was consistent with 28 months by
5 _) W) Z6 [- h) a* C7 L& ?4 @using the standard of Greulich and Pyle at a chrono-, K) A4 Z* j" L( M# z- T8 S; |
logic age of 16 months (advanced).5 Chromosomal3 Z: w* L4 l1 @1 e
karyotype was 46XY. The thyroid function test
- W. z$ k4 H* Z; N2 w. gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
# ]& b* Z' q4 ~: B$ ?8 Nlating hormone level was 1.3 µIU/mL (both normal).2 T- K" X' a' t: Q9 O: g) n9 b9 |
The concentrations of serum electrolytes, blood8 J. g' n  y; F' T! ~
urea nitrogen, creatinine, and calcium all were: c+ C' K0 {' z' j' b+ f
within normal range for his age. The concentration2 x$ `( r( R0 m6 t7 W$ o
of serum 17-hydroxyprogesterone was 16 ng/dL3 G5 r( j! J! g
(normal, 3 to 90 ng/dL), androstenedione was 20
! l- O, D" w/ ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ i1 A% p0 n, W8 b* @; L7 Z0 Pterone was 38 ng/dL (normal, 50 to 760 ng/dL),& L7 T; q( @2 \0 Y9 A! R  r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 Z$ I1 y3 g- R( o, z3 W
49ng/dL), 11-desoxycortisol (specific compound S)
8 C7 y  M+ b8 v. E9 j9 h6 D3 D! rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  s1 ?& y& }5 e- w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* l& }) R6 d* r* j$ ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: \8 f( G9 K# h1 |, Hand β-human chorionic gonadotropin was less than, [' F3 u+ d7 f+ @7 j: z
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 z" K$ i' ~1 m
stimulating hormone and leuteinizing hormone
9 E6 Q2 G4 ]2 qconcentrations were less than 0.05 mIU/mL
" c. I* ]2 L5 H* P7 x% T(prepubertal).
# K4 L9 j4 {$ I8 x$ J/ IThe parents were notified about the laboratory
2 n4 d# z, k+ Z7 tresults and were informed that all of the tests were
( @, [# u) I( z9 ^5 F$ Inormal except the testosterone level was high. The6 W/ m  U+ t( |* O
follow-up visit was arranged within a few weeks to9 V# H7 b" Y0 i& D5 _  H  y
obtain testicular and abdominal sonograms; how-
  ?/ F" C$ n  T6 E0 Z* i3 B  aever, the family did not return for 4 months.
% _( Z4 a- U% Q, W  \* i( w) |8 UPhysical examination at this time revealed that the# D5 Y6 a1 R3 K5 E) L7 K+ A' s
child had grown 2.5 cm in 4 months and had gained
9 X% j2 K$ n3 h& Y6 i+ `2 kg of weight. Physical examination remained% _; A  Y% U- [# {( A  o
unchanged. Surprisingly, the pubic hair almost com-
& W* D; ^; u  d6 s5 Opletely disappeared except for a few vellous hairs at
* K0 ^! Q4 p8 v6 b  K  E0 Hthe base of the phallus. Testicular volume was still 2
9 F9 t2 a$ |" q/ }  Y# ^mL, and the size of the penis remained unchanged.
! Y8 X* ?  b! o; y, ]- FThe mother also said that the boy was no longer hav-4 P8 f8 O4 C6 Z$ K+ ~
ing frequent erections.( F8 }9 F/ t# w; u3 i
Both parents were again questioned about use of6 \# c: m  o" k' T$ s: O* S
any ointment/creams that they may have applied to
0 p1 h' ^  H  F" s0 H% E, |the child’s skin. This time the father admitted the5 G+ b4 D6 n5 k6 ?
Topical Testosterone Exposure / Bhowmick et al 541
! v& o, `/ {/ ^, C/ Iuse of testosterone gel twice daily that he was apply-
+ f0 S# p! v, U9 z/ [ing over his own shoulders, chest, and back area for- l( F- _. q' C) |  T0 B7 `
a year. The father also revealed he was embarrassed
9 N4 ]/ f! A. E- m$ R5 U$ L9 Yto disclose that he was using a testosterone gel pre-! O5 _5 k" w, ]" s" K
scribed by his family physician for decreased libido
$ g+ y( ~) w" M1 L- i8 Ysecondary to depression.2 O8 S+ Z  G0 ]5 w7 N
The child slept in the same bed with parents.& j- J6 z/ s$ B- v
The father would hug the baby and hold him on his
2 ~+ C; F6 a, H3 y' z/ T, achest for a considerable period of time, causing sig-  X  @* P* D4 i8 T
nificant bare skin contact between baby and father.9 n/ X. m* [* P2 e6 B1 m  E" E
The father also admitted that after the phone call,
( d) r0 p3 n2 O( \" u1 _" owhen he learned the testosterone level in the baby
; b  i9 j6 V" kwas high, he then read the product information; e5 Y8 `% ]8 }( P
packet and concluded that it was most likely the rea-
2 P- h1 H. P5 J! Y9 h* A. @8 Gson for the child’s virilization. At that time, they
+ ~& F: a; z+ K% h* mdecided to put the baby in a separate bed, and the- y8 B& B8 s# D  X" I& S
father was not hugging him with bare skin and had0 ]. k9 R3 Y( j1 R
been using protective clothing. A repeat testosterone
" f5 l' i1 M3 b+ a) \* rtest was ordered, but the family did not go to the, s6 j: r$ Q+ I) q
laboratory to obtain the test.2 D: @4 `! S" Z, T/ p  J
Discussion
2 |2 M7 Z: ^- n; ?, |1 f: u7 JPrecocious puberty in boys is defined as secondary
; c; w5 ~7 x1 N4 U8 i' g/ a1 jsexual development before 9 years of age.1,4
" A; ]- l) i! |. X! ?6 }5 I5 z/ WPrecocious puberty is termed as central (true) when
9 i5 h6 ~8 a2 x9 a" g$ d4 F# Oit is caused by the premature activation of hypo-' M4 @4 q8 j0 g* F- [5 H
thalamic pituitary gonadal axis. CPP is more com-1 U& s3 p& Z0 Z
mon in girls than in boys.1,3 Most boys with CPP
" k1 h- m7 c  Q; Wmay have a central nervous system lesion that is0 D( x  r' h: w9 G
responsible for the early activation of the hypothal-
6 N4 g3 W1 k, t; m  _: Lamic pituitary gonadal axis.1-3 Thus, greater empha-3 e1 g, `% l% E5 ~1 S& G* \# W5 ^
sis has been given to neuroradiologic imaging in
  ^3 D4 l% I, O. C1 T& F2 rboys with precocious puberty. In addition to viril-: M1 [, b' z# D1 T/ F
ization, the clinical hallmark of CPP is the symmet-% D% A+ K: k7 U" ~# v
rical testicular growth secondary to stimulation by* Y% i9 B& P5 {( i" G9 |9 Q
gonadotropins.1,34 c1 ~# @& n3 o$ _" @
Gonadotropin-independent peripheral preco-
+ P9 b8 u! ~) O6 d1 ^% ccious puberty in boys also results from inappropriate
3 g6 _* i- ~# w5 Z+ O7 `4 T- Wandrogenic stimulation from either endogenous or
2 Y2 r0 Z7 d( e- Y5 _exogenous sources, nonpituitary gonadotropin stim-7 [* T) {- H0 |  y8 o
ulation, and rare activating mutations.3 Virilizing
" j4 L. A4 U9 D. @- T3 C  C! Qcongenital adrenal hyperplasia producing excessive
, b6 h; _7 w0 p9 \9 w0 @adrenal androgens is a common cause of precocious' ?" {$ O/ ^4 Q* l" O9 p
puberty in boys.3,4
' K$ B4 V4 V! E$ T, XThe most common form of congenital adrenal) y  U9 o  ~3 ?7 M4 s7 ?
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 I' ~( b. @% S4 n$ O3 B+ jThe 11-β hydroxylase deficiency may also result in: O1 y% w% }5 Y+ v, Y
excessive adrenal androgen production, and rarely,
0 Q% L1 W1 M$ Z$ G5 Ban adrenal tumor may also cause adrenal androgen# `# m' s( r' ?; n
excess.1,3
! T% e" k! m, kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 \2 y' X0 d6 L, M4 h8 S. ?+ O542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- V+ F/ O, P5 |# Q9 D+ E
A unique entity of male-limited gonadotropin-
6 N% E6 h/ s2 uindependent precocious puberty, which is also known" C: G# s5 V) k5 j' m2 n
as testotoxicosis, may cause precocious puberty at a6 k( H- {  X: v% C
very young age. The physical findings in these boys: q& m  x$ \2 l- z
with this disorder are full pubertal development,
/ y5 M8 t( a3 l2 i- }7 f+ Hincluding bilateral testicular growth, similar to boys) i, w% ~! O7 i. y, `
with CPP. The gonadotropin levels in this disorder
8 j8 H+ x! `  r! v0 Qare suppressed to prepubertal levels and do not show# n1 v* D9 k3 `% e
pubertal response of gonadotropin after gonadotropin-
- ]: J, @# r5 ]  n4 Greleasing hormone stimulation. This is a sex-linked6 i3 q8 H% i+ l3 Y# h1 Z, q
autosomal dominant disorder that affects only
0 L' b; \) T4 b' t4 E7 Rmales; therefore, other male members of the family- y4 |* ]. c. S0 R( m  p* P# q
may have similar precocious puberty.3; P5 U3 u( c$ X$ S* I6 X: d( r
In our patient, physical examination was incon-
5 }7 v7 `" C0 esistent with true precocious puberty since his testi-2 V  W) k, Z4 m: h
cles were prepubertal in size. However, testotoxicosis; V0 e' D: r9 G8 f) ^
was in the differential diagnosis because his father: j/ \/ X3 Z, d' Q2 L* Q2 _
started puberty somewhat early, and occasionally,
" Z1 h" c; Z6 p6 etesticular enlargement is not that evident in the
3 S4 r2 \7 X4 R/ V: \7 Pbeginning of this process.1 In the absence of a neg-
6 ^& H0 N% b7 b7 q" sative initial history of androgen exposure, our
5 W$ G" ^3 e' a8 ], Q0 Zbiggest concern was virilizing adrenal hyperplasia,
. \+ G; b6 z5 n  ^& deither 21-hydroxylase deficiency or 11-β hydroxylase
% c- V$ J8 {3 h+ D8 @deficiency. Those diagnoses were excluded by find-
+ j8 \# K0 e/ e. w$ T9 e. cing the normal level of adrenal steroids.
1 W: o+ M, u4 }) P5 PThe diagnosis of exogenous androgens was strongly
+ ~1 t6 \. }) Ksuspected in a follow-up visit after 4 months because& P& @; R1 {: S5 K6 V0 @
the physical examination revealed the complete disap-- }) c7 q8 |0 H2 D' P8 W
pearance of pubic hair, normal growth velocity, and
1 o9 Z+ |  b, F$ S6 v% C& {decreased erections. The father admitted using a testos-
) _6 b! D9 k0 q7 j6 ^1 T& Xterone gel, which he concealed at first visit. He was
6 e; z9 F2 \2 n' C+ F* Ausing it rather frequently, twice a day. The Physicians’
2 Y  Q# E3 _  j7 C" z  {. ODesk Reference, or package insert of this product, gel or
1 Q# f5 L/ R% L4 G- k; i1 g( P4 ncream, cautions about dermal testosterone transfer to: V" ^( c4 {5 j+ F* F
unprotected females through direct skin exposure.
' W0 s) U2 t4 `3 p6 [+ VSerum testosterone level was found to be 2 times the
3 x- ]8 x* c8 X/ lbaseline value in those females who were exposed to
: G2 I. `7 p0 ?6 [even 15 minutes of direct skin contact with their male
6 n3 ?6 P6 W! a) m2 X, Q8 J2 Bpartners.6 However, when a shirt covered the applica-
5 u6 `" a2 z  K" v7 a( ftion site, this testosterone transfer was prevented./ n- H+ ?% M( h
Our patient’s testosterone level was 60 ng/mL,
6 `7 c' A. `. u' i* lwhich was clearly high. Some studies suggest that
) z- p' e9 S- H- i9 r" I4 X3 gdermal conversion of testosterone to dihydrotestos-! S. t- h; I9 q7 N
terone, which is a more potent metabolite, is more5 |" D6 Z( m, g6 \# t; _
active in young children exposed to testosterone$ v: r6 c! T% j7 M$ \, a
exogenously7; however, we did not measure a dihy-
1 d# F( i0 Z. r( d1 O1 V$ F# }drotestosterone level in our patient. In addition to
" h- q2 D# [4 t0 k7 i4 l; X! `. [virilization, exposure to exogenous testosterone in+ ^: x8 r7 u* S" u; r& A
children results in an increase in growth velocity and* W) g7 {  l( F8 }& @. _
advanced bone age, as seen in our patient.8 P9 o; F  E) J- d
The long-term effect of androgen exposure during0 C% d* v. Q1 D7 S
early childhood on pubertal development and final
7 S6 b0 s% b$ q* O; Padult height are not fully known and always remain
- G1 M+ W, v% J" _+ x: qa concern. Children treated with short-term testos-
3 f* u) K0 E  O. m# ~. Fterone injection or topical androgen may exhibit some
8 n& u% t9 T) r5 U) M/ ]acceleration of the skeletal maturation; however, after1 F% n1 @( L0 l! A3 u
cessation of treatment, the rate of bone maturation
2 ^/ P& }0 N, cdecelerates and gradually returns to normal.8,9
, V' n) ?+ C4 G" e+ EThere are conflicting reports and controversy
0 z+ O3 o" Q. J/ U7 t$ I+ Y1 K* ~over the effect of early androgen exposure on adult/ C. d2 s, s0 t0 {" H# ]  s3 q
penile length.10,11 Some reports suggest subnormal
$ x- P3 Y) [, c3 m3 l2 f+ z7 P+ Kadult penile length, apparently because of downreg-/ H4 r# e& _' S7 s5 Z6 [9 r! ]
ulation of androgen receptor number.10,12 However,9 v7 p: N# O+ J+ c6 N+ x
Sutherland et al13 did not find a correlation between
$ a! L& ^" g! h# ]" [childhood testosterone exposure and reduced adult! [7 D4 Q+ U" t: l
penile length in clinical studies.% b9 J! H* [( R2 L" L
Nonetheless, we do not believe our patient is2 `7 v6 X! a! |) A0 l, y
going to experience any of the untoward effects from
2 C! v, v0 l2 W' }testosterone exposure as mentioned earlier because' G; C, E9 d0 L3 n5 L1 n+ y
the exposure was not for a prolonged period of time.
! [: g/ y" m, a; tAlthough the bone age was advanced at the time of# @' @- \5 z& F( e* `# ?% D
diagnosis, the child had a normal growth velocity at
5 X* q$ `) F) j7 m! k" tthe follow-up visit. It is hoped that his final adult
5 U) J! _7 Z7 `4 o# ]' lheight will not be affected.- o1 ^+ P6 ^* j* X2 z; b9 t
Although rarely reported, the widespread avail-  }+ ?" B( ?2 Z& j- g2 L9 c
ability of androgen products in our society may
4 v! z! F7 `% A! Y; Tindeed cause more virilization in male or female! e5 p" m+ V9 G  t: D; T. u
children than one would realize. Exposure to andro-
* e7 t; n7 o$ v: L! T5 J5 L8 U1 Pgen products must be considered and specific ques-/ q' V& P. `# V/ A8 Q! J! t- a
tioning about the use of a testosterone product or. s' P$ w1 K: J  ~3 `
gel should be asked of the family members during
3 D; }- v8 U9 s7 O/ b( e# Sthe evaluation of any children who present with vir-
1 q6 y9 O$ z; Q2 ^5 Bilization or peripheral precocious puberty. The diag-
* q, N; v$ ^8 j, ?- lnosis can be established by just a few tests and by) \( K' B% Y: K) M+ d5 t; h
appropriate history. The inability to obtain such a6 I# A/ e+ P: B0 L% T5 g3 J; @
history, or failure to ask the specific questions, may
+ @8 B. V; ^! R4 wresult in extensive, unnecessary, and expensive
! O' ?, _( W# ]: P5 @( d/ o' Yinvestigation. The primary care physician should be
* t/ I  ~' @6 ?6 R2 Eaware of this fact, because most of these children
" |% v; w* \/ r3 l' V" h8 l* ?9 vmay initially present in their practice. The Physicians’
  f+ L5 z& _0 C1 J( ?2 o; hDesk Reference and package insert should also put a
& B* a2 x% F8 I( w4 Vwarning about the virilizing effect on a male or3 J1 z$ R8 w8 @* r/ U) J, e
female child who might come in contact with some-% y$ x# w' q+ T! _2 X
one using any of these products.
5 n9 P; s, ^& O9 bReferences
) H/ E+ H- o3 q' t2 ^1. Styne DM. The testes: disorder of sexual differentiation* l; l# w" F( m4 o" r7 u
and puberty in the male. In: Sperling MA, ed. Pediatric" }  I2 X9 g: R) D% O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ v0 K6 \; w% Q& p
2002: 565-628.
4 E  v: p' ?" {! q( v: ~2 Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 h0 G) C) b% c4 B- d( H5 ~puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
  w. n" T  [! B1 ?Boy Induced by Indirect Topical
  i& @) y2 E5 b: F2 yExposure to Testosterone5 O- D/ o1 j7 Z, W* K0 g7 L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, ]6 t! {/ ~6 ~. E* Q, f  P) T/ {% _3 B
and Kenneth R. Rettig, MD1
$ b( Z8 m; ^- Y0 |* n+ KClinical Pediatrics
+ a9 a  q6 D2 |4 P: JVolume 46 Number 6
8 y+ t* P  }: `% RJuly 2007 540-5439 W( Q2 H% m' z" K
© 2007 Sage Publications# A7 f! w9 g* W6 v! {5 B3 k
10.1177/0009922806296651
/ l7 f' R) A, hhttp://clp.sagepub.com
, f0 s% d3 Z4 [" j2 ~6 L) K' |hosted at
* W8 e" a9 u* y' w# b: l( q" K1 zhttp://online.sagepub.com
1 r7 s0 e7 I( ]. L/ m& yPrecocious puberty in boys, central or peripheral,/ q( i7 A; s! l3 k; n
is a significant concern for physicians. Central( ^7 b" X( l1 M) Q5 `1 H7 [2 U+ N
precocious puberty (CPP), which is mediated
0 v' t# l% h$ z& @; w7 o% ethrough the hypothalamic pituitary gonadal axis, has
; {9 s# x+ W2 m. f3 l( e" X# |; H, ]9 Pa higher incidence of organic central nervous system$ j$ A+ I( J0 X# q; K1 I4 {
lesions in boys.1,2 Virilization in boys, as manifested' c$ U* t( [4 m2 E; g
by enlargement of the penis, development of pubic
: f) b! \" W7 ~- a# i4 G, uhair, and facial acne without enlargement of testi-; E& {% V& h" D% {7 a0 i' |: a' r
cles, suggests peripheral or pseudopuberty.1-3 We
4 r/ O9 R2 q) T" a: |. [# `report a 16-month-old boy who presented with the
9 n7 i2 U4 z! X  g5 l( N. Zenlargement of the phallus and pubic hair develop-5 w" Y7 x5 J6 ^2 [
ment without testicular enlargement, which was due! F% F( W; N; l) f7 D
to the unintentional exposure to androgen gel used by3 H% E! W$ i8 I* U  J
the father. The family initially concealed this infor-# r! y/ l9 `) ^- x9 r. B
mation, resulting in an extensive work-up for this
0 J' [/ B, W$ n2 j0 k. }1 O# Wchild. Given the widespread and easy availability of
9 s, \! J+ J+ I# F1 n) [, ktestosterone gel and cream, we believe this is proba-; w- V* e& z  c; B# h8 U% U
bly more common than the rare case report in the
, r9 {7 u- y- D0 j; Wliterature.4
+ N3 W1 Z7 M/ B! ~0 f. ZPatient Report' d. s6 m. P$ L5 [) j$ ^" T/ F
A 16-month-old white child was referred to the0 o  U. C: \9 k$ M* g
endocrine clinic by his pediatrician with the concern9 c% q. G5 J" C/ M; A
of early sexual development. His mother noticed" f4 ~( q7 X# G6 Y' h
light colored pubic hair development when he was; C! e) ~9 g/ Z) ?2 d) s# e
From the 1Division of Pediatric Endocrinology, 2University of7 }7 u+ m7 S- K
South Alabama Medical Center, Mobile, Alabama.
# l2 W6 m2 d1 ]9 \" S* n% zAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 h8 w9 g$ u- j
Professor of Pediatrics, University of South Alabama, College of" S1 R1 f( z. F! W& W* W( b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- l, N1 }7 Q; q) ?( pe-mail: [email protected].) M2 e) e1 F2 y9 R$ U* S
about 6 to 7 months old, which progressively became
9 W) `, n( l! \9 v4 ~( ~' Udarker. She was also concerned about the enlarge-) K: R3 f$ V  H8 s
ment of his penis and frequent erections. The child
+ e- \# G6 U" R. H4 C. ^was the product of a full-term normal delivery, with
- |6 @9 x3 B- A2 i2 _a birth weight of 7 lb 14 oz, and birth length of* ]# x% ?* X% [' s! \2 {
20 inches. He was breast-fed throughout the first year6 N+ [% h% t+ ]6 x$ q9 m
of life and was still receiving breast milk along with
! G, ?: b" U. G6 e. p' |$ Isolid food. He had no hospitalizations or surgery,7 J( O' [4 W  t6 Z7 M9 Y0 _
and his psychosocial and psychomotor development9 s& g+ S( X0 K# d2 P
was age appropriate.
  J: j$ W" U- X, m; T5 O# m5 n* GThe family history was remarkable for the father,
/ ~5 w  ~) O  X( X* q* @% Ewho was diagnosed with hypothyroidism at age 16,
2 v$ {) I# S* j. ]) Owhich was treated with thyroxine. The father’s% O% y9 N& b. Y+ R! T4 y
height was 6 feet, and he went through a somewhat- B6 f; ~% y/ B% H
early puberty and had stopped growing by age 14.% E9 d4 d) ?" Y$ {
The father denied taking any other medication. The1 [3 m( ~9 d, y$ P
child’s mother was in good health. Her menarche
4 S+ C1 W/ [: y  o/ _was at 11 years of age, and her height was at 5 feet
; F: K1 k7 N' k5 inches. There was no other family history of pre-: R2 N  f! `/ {3 m6 s9 Z/ i# V
cocious sexual development in the first-degree rela-
! P7 X: h6 c$ D# u" A! d8 P5 S/ htives. There were no siblings.4 R  _* ~) c, ^+ ^
Physical Examination2 t* F  M- v% w3 `0 j
The physical examination revealed a very active,
% u$ D1 G, d( f+ x& l& {playful, and healthy boy. The vital signs documented
. U0 E1 A  K' g* i' ^- Za blood pressure of 85/50 mm Hg, his length was0 X1 [9 Z2 Z6 x8 H
90 cm (>97th percentile), and his weight was 14.4 kg
+ n# G* s* T% w(also >97th percentile). The observed yearly growth- D9 E+ n. ]1 P' y# O
velocity was 30 cm (12 inches). The examination of
/ W) ]& z& o8 bthe neck revealed no thyroid enlargement.
. r, U6 t, v3 \' `* F2 HThe genitourinary examination was remarkable for
9 b% F; s5 ^; M: `- oenlargement of the penis, with a stretched length of
# C, t0 {) M9 j2 ]3 y! i8 cm and a width of 2 cm. The glans penis was very well( L# l' g6 V) I4 J
developed. The pubic hair was Tanner II, mostly around/ `: n2 \: z# K
540
- y3 e. Z8 k. \9 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! y$ N* b: s/ x& n  |/ Sthe base of the phallus and was dark and curled. The
! {$ l/ D1 {0 Q! \testicular volume was prepubertal at 2 mL each.
# l$ P; \4 L* E, T% D- _: dThe skin was moist and smooth and somewhat
8 h$ P" ?& s' F% S) F( xoily. No axillary hair was noted. There were no' i* {/ G4 @# Q: ]! I2 n# Q
abnormal skin pigmentations or café-au-lait spots.# @  Z- ]) G& u4 G! n; F' b
Neurologic evaluation showed deep tendon reflex 2+
6 J! T+ o0 ^7 h) Abilateral and symmetrical. There was no suggestion4 H4 n9 N6 B* S4 [3 `
of papilledema.
8 j$ n9 f- j7 u8 s) k+ LLaboratory Evaluation+ Z2 T. }3 S2 o/ a4 u0 q' }7 h
The bone age was consistent with 28 months by' u3 n2 L6 W. X* l% h, A& [
using the standard of Greulich and Pyle at a chrono-3 L* b, g, m+ `: K, v
logic age of 16 months (advanced).5 Chromosomal( m' @! @' B% k. M
karyotype was 46XY. The thyroid function test, s/ T- n- N7 Q# J' W% W
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ r1 Z: t* @3 p: blating hormone level was 1.3 µIU/mL (both normal).
3 C/ Q9 w6 J" V. |. ?The concentrations of serum electrolytes, blood/ t+ g: r" ?$ m3 S
urea nitrogen, creatinine, and calcium all were
5 F" ]( ~- g3 O, a; vwithin normal range for his age. The concentration. v& _0 Q- G, d1 j+ e
of serum 17-hydroxyprogesterone was 16 ng/dL
0 p, t# b1 E* U! O7 f: t(normal, 3 to 90 ng/dL), androstenedione was 20
4 y$ p0 @  U& V/ Z' y/ Q4 T3 Cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* [: g: j) I; {1 b4 zterone was 38 ng/dL (normal, 50 to 760 ng/dL),' T3 y, Q. M$ Q' z: v7 }6 D
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ e- g" F% d5 v. M49ng/dL), 11-desoxycortisol (specific compound S); d, u1 v8 e; i. F, _8 t9 t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( ~' E, z( V. {tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  }2 J; X  U$ W! ?( x, V' }testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 X% R5 s, ^- j" l- i2 V  {) D! b
and β-human chorionic gonadotropin was less than" F. }2 K6 H8 R+ u- g' Q" ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 z; W; G0 o' L1 C' p
stimulating hormone and leuteinizing hormone
, ?+ M" V; _3 v( O' e( Tconcentrations were less than 0.05 mIU/mL
0 M2 Q9 s1 g5 S' U(prepubertal).
; j7 w7 G" |. b) QThe parents were notified about the laboratory
4 R( I1 k6 ~. u+ Z3 d- x1 i) tresults and were informed that all of the tests were% R" Z& G% o. Z
normal except the testosterone level was high. The: x) F! \; g9 n1 O# h8 l
follow-up visit was arranged within a few weeks to# K! [- e' _# _. K) f0 Y6 f$ m$ e
obtain testicular and abdominal sonograms; how-7 U( V- d8 T) @" j/ M% R
ever, the family did not return for 4 months.) E* ~/ O. t1 y. W1 ~
Physical examination at this time revealed that the
% w" {- c7 k1 M/ }1 u" h. Hchild had grown 2.5 cm in 4 months and had gained
! F$ G% o: e8 p  t( L# B5 x" J2 kg of weight. Physical examination remained
% X4 f( L9 j9 x( Munchanged. Surprisingly, the pubic hair almost com-) h: z7 p) _4 `
pletely disappeared except for a few vellous hairs at8 J$ [! Z) ^  Q. D
the base of the phallus. Testicular volume was still 2% K: i/ B$ U5 i3 ~" S2 j. u
mL, and the size of the penis remained unchanged.- g; v  ?0 q, M) }
The mother also said that the boy was no longer hav-
8 V. B' d: T/ [3 ?, Wing frequent erections.
# U) s( D$ g" ^" v0 E$ QBoth parents were again questioned about use of1 P) m, x8 ]4 Z8 t/ p. b
any ointment/creams that they may have applied to
5 i! Y: @$ q/ s; q4 [. _3 i1 Ethe child’s skin. This time the father admitted the
! C$ Q6 f, [: O2 ~Topical Testosterone Exposure / Bhowmick et al 541+ w0 H0 |+ l2 H
use of testosterone gel twice daily that he was apply-2 F) }# z5 [7 K4 B. h, y, G1 ?# {
ing over his own shoulders, chest, and back area for9 h( D0 Z! P7 G( d+ n) f/ i
a year. The father also revealed he was embarrassed! c2 z2 n6 z$ i/ s
to disclose that he was using a testosterone gel pre-1 \2 j5 Q; o, k# M
scribed by his family physician for decreased libido
3 @9 Y$ X* m, Y6 c6 b9 gsecondary to depression.
! z, [- `+ K% N" a& P4 @The child slept in the same bed with parents.
6 l* J0 _$ V+ x  l9 d: ^The father would hug the baby and hold him on his# X3 K% k# |+ q# I3 `* L$ [1 o
chest for a considerable period of time, causing sig-
$ d& p; a. I, c+ Knificant bare skin contact between baby and father.
3 e# x0 O. v; u3 N6 T0 cThe father also admitted that after the phone call,
# t: G( ~/ T0 I! U; ^* Xwhen he learned the testosterone level in the baby0 N" ~  L6 ~2 u; ^% E! m3 x
was high, he then read the product information
" F2 a. R" q$ Z* Rpacket and concluded that it was most likely the rea-- w# a, t- Y5 I/ e+ R
son for the child’s virilization. At that time, they
2 G7 M4 k+ T: cdecided to put the baby in a separate bed, and the% W1 Z# R0 ~) [1 A: e
father was not hugging him with bare skin and had7 A8 ~4 x  ^* Q( @: }3 e  V
been using protective clothing. A repeat testosterone
3 E2 j2 Y3 D" m+ n" v1 |1 Dtest was ordered, but the family did not go to the
# r! V1 W0 q; B3 U( Llaboratory to obtain the test.
2 w) A3 x$ \7 T1 E1 Y7 ?0 IDiscussion7 {* `0 I6 I- X# P( I0 J2 c
Precocious puberty in boys is defined as secondary
' I; o5 A- O$ |7 K: ssexual development before 9 years of age.1,4
# I. I! x. k+ _/ Q7 v: M- _- HPrecocious puberty is termed as central (true) when
3 H0 ?6 b4 |  f% lit is caused by the premature activation of hypo-
) T% M: @, Z+ F9 gthalamic pituitary gonadal axis. CPP is more com-0 A" q: |& v) Z- P
mon in girls than in boys.1,3 Most boys with CPP
' ^5 H5 C9 ?7 ^! G3 p/ w& nmay have a central nervous system lesion that is
# G3 c1 h7 y/ A' Rresponsible for the early activation of the hypothal-$ H! w. H; U" s' ^4 o+ s
amic pituitary gonadal axis.1-3 Thus, greater empha-
# m. K( E+ F' F! r; z6 tsis has been given to neuroradiologic imaging in
. i; L- \$ `2 U  _9 N; C2 @boys with precocious puberty. In addition to viril-
( X0 ^( B- M7 C( Rization, the clinical hallmark of CPP is the symmet-- j& b# X* z# H9 t: C
rical testicular growth secondary to stimulation by
+ s. U3 w1 `6 ggonadotropins.1,31 z2 h# j8 F; ]! {  k% |
Gonadotropin-independent peripheral preco-
* i7 I* V$ N( ^8 g8 @5 Dcious puberty in boys also results from inappropriate
2 w; t4 l$ f' j* landrogenic stimulation from either endogenous or6 B( O+ s8 ?8 I, V1 Q# a! i1 K$ B
exogenous sources, nonpituitary gonadotropin stim-
( x  E5 j' t0 E, b- Fulation, and rare activating mutations.3 Virilizing3 G( _! A! |1 z7 w: `, m
congenital adrenal hyperplasia producing excessive: v+ R8 r; U& x0 ^4 F
adrenal androgens is a common cause of precocious* p! ]. a) i" x+ R
puberty in boys.3,4) @1 {8 g* p9 }7 s) S/ o9 Y; ]8 H
The most common form of congenital adrenal
# _( z$ ~9 m" r9 Jhyperplasia is the 21-hydroxylase enzyme deficiency.
* {- E7 A' J+ j  u9 }5 z$ xThe 11-β hydroxylase deficiency may also result in
* r! ~$ J; _& O3 L1 q, W( wexcessive adrenal androgen production, and rarely,$ s/ Y1 S6 v5 {$ I
an adrenal tumor may also cause adrenal androgen6 J& e& X3 u2 n+ h( S: O
excess.1,3
6 {& \- M7 p# T  {8 A4 f. H& Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# N! S$ p8 h. v% p. ]' l; [7 i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* {$ m* c' {! x6 KA unique entity of male-limited gonadotropin-
2 c! S' v; m& Y  w" B6 Mindependent precocious puberty, which is also known
! X3 k6 e% Z- o, [4 X7 a0 t9 ias testotoxicosis, may cause precocious puberty at a$ o) i7 p* |4 R# q3 V' \  Z. }
very young age. The physical findings in these boys
+ q- F& b) \0 u2 G# @& K. swith this disorder are full pubertal development,/ N* B) a# E- n) g
including bilateral testicular growth, similar to boys$ v; N8 q' l1 c$ j5 f
with CPP. The gonadotropin levels in this disorder
3 ^* n6 Y4 b" ]% e  D  Yare suppressed to prepubertal levels and do not show
7 Y: `- ^6 M1 d' R" b3 ^pubertal response of gonadotropin after gonadotropin-6 _. T) t# o$ Y7 X
releasing hormone stimulation. This is a sex-linked0 U3 h% U( u) R
autosomal dominant disorder that affects only7 e" Q0 g  |8 X, ^# L7 v/ k
males; therefore, other male members of the family: ?9 {6 }1 h; ~$ k
may have similar precocious puberty.3
1 Q$ j4 F" o" q8 hIn our patient, physical examination was incon-" y" M& D( V$ x3 y
sistent with true precocious puberty since his testi-- g" T8 V# H; `( X, V8 h
cles were prepubertal in size. However, testotoxicosis+ ~1 j. r8 }6 [  Y4 b, o
was in the differential diagnosis because his father
% w/ }& C, k7 P+ v5 Q: kstarted puberty somewhat early, and occasionally,
! x5 M: _$ V" [! p: ?; htesticular enlargement is not that evident in the9 _0 o5 S) l  O' v
beginning of this process.1 In the absence of a neg-
) m: C* Y: q  s: @, @( t" Vative initial history of androgen exposure, our
8 R! G5 `& C6 w; E% X# @biggest concern was virilizing adrenal hyperplasia,3 [, P: b. j% ?! o. N5 d- s2 `
either 21-hydroxylase deficiency or 11-β hydroxylase8 w; o8 R0 R. C( n
deficiency. Those diagnoses were excluded by find-
" o+ b2 u8 H  I2 Q! L/ uing the normal level of adrenal steroids.+ d: D. L3 d' G0 X6 J, W
The diagnosis of exogenous androgens was strongly; r! f' L  T6 M
suspected in a follow-up visit after 4 months because
9 l, I$ ], F/ p' z5 Vthe physical examination revealed the complete disap-5 `1 K/ [, z7 D% z) T7 l
pearance of pubic hair, normal growth velocity, and) J' L+ b8 B, ~& h! N- ?$ `7 t
decreased erections. The father admitted using a testos-. d( ^  r8 }4 Q$ O7 q0 {0 g+ U. w3 D
terone gel, which he concealed at first visit. He was
6 c% m* S# t; v' z2 B  r+ pusing it rather frequently, twice a day. The Physicians’
7 |" r& u0 A- z, [( RDesk Reference, or package insert of this product, gel or
/ X% U! K" b9 x. f  z7 Lcream, cautions about dermal testosterone transfer to! N4 Y) `" K2 y! e4 o( N
unprotected females through direct skin exposure.
% ?- ^) g+ |/ \0 b2 ~; tSerum testosterone level was found to be 2 times the
, x/ W  d/ v% o7 }9 \baseline value in those females who were exposed to3 H: J1 j& A/ b- L; v
even 15 minutes of direct skin contact with their male7 ~- b# e* m0 p1 h, w# t
partners.6 However, when a shirt covered the applica-. m0 r2 \4 N  Y0 z2 g2 ?
tion site, this testosterone transfer was prevented.& j. `7 J* m+ ]+ S
Our patient’s testosterone level was 60 ng/mL,
: P9 g, \: g' t& E) t/ X% dwhich was clearly high. Some studies suggest that
* A$ `3 u3 R1 t, ~" Xdermal conversion of testosterone to dihydrotestos-! S) X2 ], m" [1 j" Z0 D
terone, which is a more potent metabolite, is more
5 ^0 H9 h1 [: H9 U7 W5 C  F4 d. Aactive in young children exposed to testosterone
  P/ I- U% v0 Q. i1 Y) h6 `3 rexogenously7; however, we did not measure a dihy-6 |: z' x& m' u) j
drotestosterone level in our patient. In addition to. K7 M2 e. J" T  J
virilization, exposure to exogenous testosterone in
. t5 ?" ~' \% U. S  J* vchildren results in an increase in growth velocity and
# T- n% h* F4 Q* Badvanced bone age, as seen in our patient.
& s* L8 h4 [3 d2 FThe long-term effect of androgen exposure during; ^3 l% \5 W' o1 F7 K, s
early childhood on pubertal development and final
0 {: W# p. F) l. a7 ?' madult height are not fully known and always remain
( o6 Z+ C" g4 h& J$ Fa concern. Children treated with short-term testos-/ |% v( I9 O: E: Y: V
terone injection or topical androgen may exhibit some2 p: v1 z$ x7 N7 t* h$ G
acceleration of the skeletal maturation; however, after) b; v% }, V* ?  I2 Z0 t8 I7 q6 {
cessation of treatment, the rate of bone maturation$ d+ G# S" J/ a9 n; _
decelerates and gradually returns to normal.8,9: L" S' i$ i+ ?4 T4 M8 y
There are conflicting reports and controversy. f# {# o1 k3 n8 G7 A5 D
over the effect of early androgen exposure on adult
5 n" J$ r0 A; I5 S4 Q# F6 r' G. \penile length.10,11 Some reports suggest subnormal
; R. y. o# x6 n: f$ Badult penile length, apparently because of downreg-
& u$ M+ a8 d0 u, B5 L: u" f& aulation of androgen receptor number.10,12 However,- C( G9 E$ e5 ^% a/ v" X* ?  p
Sutherland et al13 did not find a correlation between$ s7 s0 Z" T. J% d4 d
childhood testosterone exposure and reduced adult' p4 r5 o4 e/ |  E
penile length in clinical studies.  r1 _  F/ V2 p' {. U3 `
Nonetheless, we do not believe our patient is+ C- x5 K, m: x6 g# R
going to experience any of the untoward effects from, V) S; H# G% d
testosterone exposure as mentioned earlier because# `  O7 h6 a  k# c/ K8 m( Y
the exposure was not for a prolonged period of time.8 G; a+ W' G$ a0 {' Z0 e8 W
Although the bone age was advanced at the time of$ D7 z, ?: g( W+ I3 b2 q7 g
diagnosis, the child had a normal growth velocity at
; ^% x3 v* H! [5 _+ k/ c- Ethe follow-up visit. It is hoped that his final adult
2 i7 M1 @1 C( W  Iheight will not be affected.. g5 E# F. E* T) v3 G5 |/ t% ~: P
Although rarely reported, the widespread avail-4 k1 }! l8 F( |% H
ability of androgen products in our society may. @& b3 @: C4 g9 x9 w
indeed cause more virilization in male or female, P; X8 {/ p6 ~# I3 I
children than one would realize. Exposure to andro-$ v  @8 o7 t- h5 v! F
gen products must be considered and specific ques-
" j( G( D* b/ t2 Mtioning about the use of a testosterone product or% R+ c" g4 @& s4 Q' T+ T& y
gel should be asked of the family members during: @: l# \9 n* F" X- L+ h" ?# z
the evaluation of any children who present with vir-2 Z! i& L3 {9 M
ilization or peripheral precocious puberty. The diag-# U1 Z" u& k0 i+ {! r- m9 ?
nosis can be established by just a few tests and by1 O; P* D1 u1 d6 v3 I6 o  H( Y
appropriate history. The inability to obtain such a6 m; @% J9 D% R" m/ V# \0 c( t
history, or failure to ask the specific questions, may8 ]7 w' d. K+ c$ T* S4 V2 M7 A
result in extensive, unnecessary, and expensive
" H+ E2 r  H  c/ l5 w) binvestigation. The primary care physician should be/ N% f/ X- X' ]1 ?- Y
aware of this fact, because most of these children
' L, x; K2 t& f( ymay initially present in their practice. The Physicians’
& R7 w6 A9 [4 V; y) RDesk Reference and package insert should also put a
3 Y% y6 Z' }0 u/ q% Iwarning about the virilizing effect on a male or8 H' X- \; U" g* L4 o
female child who might come in contact with some-
- w! b& A8 w% ]1 N% c$ pone using any of these products.2 }  T, j# |+ k' u
References
1 b& h3 R5 \8 u# K/ r1. Styne DM. The testes: disorder of sexual differentiation
- ~6 ?' s1 a: Sand puberty in the male. In: Sperling MA, ed. Pediatric
2 W, r" t* [' {% C/ ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# k  U/ s) \# p: F$ B4 l0 S6 y, [# }2002: 565-628., H# ~8 ~. ~$ o' w% H7 B6 ^4 x
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" D( x: l, p: E6 n1 X4 rpuberty 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
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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
3 W1 c) v) a0 G$ 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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