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Sexual Precocity in a 16-Month-Old
: `" E4 D6 h: v. R/ O6 ]) gBoy Induced by Indirect Topical
1 m# ^% l2 G/ {3 q- O: @6 A# _Exposure to Testosterone/ c" \0 m% A1 j1 a; w, ~2 Q
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! S6 }  \4 s* F' i2 E, `+ U' [and Kenneth R. Rettig, MD1- f, h, B) q5 n4 z8 U; l% k
Clinical Pediatrics3 k1 u5 A3 Y7 q
Volume 46 Number 6
/ G  O8 U" g" E3 a) X$ CJuly 2007 540-543
7 j/ o2 P8 Z8 E& {7 o© 2007 Sage Publications" v' n" u; p0 i  B$ _
10.1177/0009922806296651
5 I) R' w3 i6 ]# N; O: O  v5 E$ }' ihttp://clp.sagepub.com0 a" Q+ q4 K2 F
hosted at2 H4 f: d7 M3 h
http://online.sagepub.com
0 C$ x' [% K% {& t" A( T& k0 oPrecocious puberty in boys, central or peripheral,5 E+ x7 U: K; t1 p8 K
is a significant concern for physicians. Central2 O4 }1 }' ?) G; }! n) o' ^
precocious puberty (CPP), which is mediated
8 }% }9 `9 V  |7 O# \  I3 ithrough the hypothalamic pituitary gonadal axis, has. E1 P! e- l1 O& s+ ?
a higher incidence of organic central nervous system
- Y( l" {0 A3 j0 d# d7 Llesions in boys.1,2 Virilization in boys, as manifested
7 P8 ]5 P/ _4 `8 W; Fby enlargement of the penis, development of pubic0 w) N5 V2 p0 i/ g- G) g4 \
hair, and facial acne without enlargement of testi-) p5 W9 u! m6 R' P
cles, suggests peripheral or pseudopuberty.1-3 We2 m9 ^) n- k8 o+ b. J4 U7 r2 o
report a 16-month-old boy who presented with the( ]$ ], s& g* A1 A
enlargement of the phallus and pubic hair develop-
% B5 m0 f- b* D$ hment without testicular enlargement, which was due
7 A! Z  w; t# N5 X9 o( m. x5 Pto the unintentional exposure to androgen gel used by- F+ l, E6 [. A) K* e
the father. The family initially concealed this infor-/ B0 C. _7 I) A8 {
mation, resulting in an extensive work-up for this
+ S: X# d- A5 g. _% V5 Gchild. Given the widespread and easy availability of
- t" a' B; ~0 ~$ n/ w* K0 wtestosterone gel and cream, we believe this is proba-  u" \, @, Q3 d
bly more common than the rare case report in the
6 x; w9 k- a" P) X" G; c: `literature.4
+ |8 X, k! f: W0 K! W# Z3 i& {2 iPatient Report
+ V5 v' i& z4 T3 {5 b8 ZA 16-month-old white child was referred to the
, F  i# n/ s& q2 Dendocrine clinic by his pediatrician with the concern6 i9 |% I5 s4 v9 `$ v
of early sexual development. His mother noticed3 p/ E; o, W, O+ F* c9 b( L! S
light colored pubic hair development when he was
( r- W! `0 S: ?0 U& kFrom the 1Division of Pediatric Endocrinology, 2University of
( `3 D# L7 r5 G% ]South Alabama Medical Center, Mobile, Alabama.
, ~: P5 M  `" C( eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
2 ~+ g4 C- e% \& m9 sProfessor of Pediatrics, University of South Alabama, College of
! l9 x+ ~1 q+ j# J' CMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 w. P" }2 W) l! Ee-mail: [email protected].# G# T; P) H7 k3 \, s  l+ g
about 6 to 7 months old, which progressively became
; x8 y4 D# ^1 v& ?" Sdarker. She was also concerned about the enlarge-
. a8 l' d$ u/ g/ S& hment of his penis and frequent erections. The child3 m1 u1 Q8 f. Y% ]
was the product of a full-term normal delivery, with$ W: S* D& J$ y8 F( s8 P
a birth weight of 7 lb 14 oz, and birth length of% q: |! O0 `- `& q4 K) O
20 inches. He was breast-fed throughout the first year
8 {# a% l6 L' p" ~/ Mof life and was still receiving breast milk along with
: G* i' k+ M, u* E" |" G+ \9 Tsolid food. He had no hospitalizations or surgery,6 `3 `& B" Z5 v  K) e- E
and his psychosocial and psychomotor development3 k$ Y& W1 z' N1 J3 E4 j
was age appropriate.5 r5 t9 k: ]1 n+ F/ ^0 y1 U
The family history was remarkable for the father,* d: J3 _. a* A/ b
who was diagnosed with hypothyroidism at age 16,
8 d) _  o5 X3 [- [* C! X) ]which was treated with thyroxine. The father’s
! e/ q. r9 a$ B  l3 bheight was 6 feet, and he went through a somewhat+ T1 ^% U$ `8 w) V* v
early puberty and had stopped growing by age 14.
% }4 S7 \0 S1 z0 b2 nThe father denied taking any other medication. The
* v3 [  Z' ~4 @7 S( y( ]# P& Tchild’s mother was in good health. Her menarche  q( S. v2 ~. ]: D
was at 11 years of age, and her height was at 5 feet
4 w0 w; t+ E/ [. H. u5 inches. There was no other family history of pre-
, m, B, W0 J- [5 b" ?/ ococious sexual development in the first-degree rela-
' k1 E! K; W# ~  Itives. There were no siblings.
: Q- A$ s6 T  c$ G- ]Physical Examination
$ l1 e7 _$ m$ C. SThe physical examination revealed a very active,0 l$ t% i' E! t. K3 _
playful, and healthy boy. The vital signs documented
9 R$ @: o( y$ ?/ w. J2 |% Fa blood pressure of 85/50 mm Hg, his length was+ X# E8 C' ~& q- ]" Y8 Y
90 cm (>97th percentile), and his weight was 14.4 kg0 F5 h' n& h9 Q* G6 R/ K9 u
(also >97th percentile). The observed yearly growth
6 D! a: W9 b0 F7 Yvelocity was 30 cm (12 inches). The examination of
8 D5 p9 P9 H7 I, v- m6 q2 m% }the neck revealed no thyroid enlargement.- h8 _8 Y0 h, R: I( n5 i
The genitourinary examination was remarkable for
1 k( r) x: s1 |4 tenlargement of the penis, with a stretched length of/ w9 L, R6 Q1 u
8 cm and a width of 2 cm. The glans penis was very well' T5 [& r$ E. ?2 g, C8 E
developed. The pubic hair was Tanner II, mostly around0 u- x, W7 ?3 ^
540/ L" T; @% e5 V; L9 m+ p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- N3 V+ F+ h- r1 j1 o4 E' w
the base of the phallus and was dark and curled. The* S: ^- |' @# \1 k8 w
testicular volume was prepubertal at 2 mL each.9 V0 v( Q; u% g7 u6 I
The skin was moist and smooth and somewhat
# u& P6 s  t2 Y& ?oily. No axillary hair was noted. There were no; L! H  X+ q5 @5 Y( I
abnormal skin pigmentations or café-au-lait spots.5 K+ {$ d# L' F+ U4 h& p" y, ]! }
Neurologic evaluation showed deep tendon reflex 2+& z& I7 t+ B1 c
bilateral and symmetrical. There was no suggestion* v/ h' w/ r+ ?/ E  n$ H
of papilledema.9 b! p1 @# F, D8 y
Laboratory Evaluation. O! Y# {: D) r
The bone age was consistent with 28 months by
) S  t0 f5 x/ P2 Y* wusing the standard of Greulich and Pyle at a chrono-- `) h& }- N/ u+ G" C2 t4 _. ?
logic age of 16 months (advanced).5 Chromosomal
, @2 n! |& s. E0 g$ u' ?7 O% D% n+ e0 _karyotype was 46XY. The thyroid function test
' F) \: W& ]+ e. g% C: L4 p" C$ p3 Ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 A' \& g9 [+ h
lating hormone level was 1.3 µIU/mL (both normal).$ S# D  B- b( b% i  H# U+ t0 j, r
The concentrations of serum electrolytes, blood- V; m+ @: l3 \0 S" I& i0 n: F/ g5 M
urea nitrogen, creatinine, and calcium all were+ m( q; M5 v; r( C+ G
within normal range for his age. The concentration
) g5 x/ {* h2 ^' K: Dof serum 17-hydroxyprogesterone was 16 ng/dL& |+ N3 p' h9 I2 c8 D# g+ q
(normal, 3 to 90 ng/dL), androstenedione was 209 U6 M, G2 d  v8 T+ g2 Y) @
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 P5 x+ M* q: ]" A; Y' X3 nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
# H3 C, \2 Q; I( Z/ v/ l9 D5 Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to/ T0 e! ~5 N( ?2 N! p9 s
49ng/dL), 11-desoxycortisol (specific compound S)  w6 k0 p* Q% X+ f  _$ v  M
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 {2 r# O  ~8 {% F6 W" ltisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  i* t, v! t& K- E, I# r4 y$ Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) j- }3 f( H" zand β-human chorionic gonadotropin was less than
$ z  M* _' Z* f$ O9 o$ H8 B( q. }5 mIU/mL (normal <5 mIU/mL). Serum follicular
, O% _; `0 ~6 @- \+ b  Gstimulating hormone and leuteinizing hormone: o) }, j0 `( O9 u
concentrations were less than 0.05 mIU/mL
2 _* L! O4 K% q. f* I  K; Q& F(prepubertal).
2 P5 I+ B3 F8 n7 l# y* F- CThe parents were notified about the laboratory' F! S3 c* \0 K- ]& P# }$ {# M8 h
results and were informed that all of the tests were
7 m5 G( I+ |( lnormal except the testosterone level was high. The; N' v0 X# K* C2 y$ K
follow-up visit was arranged within a few weeks to: A- A2 ?$ z6 O5 C4 F& Q
obtain testicular and abdominal sonograms; how-, Z1 P% C6 m2 t+ c
ever, the family did not return for 4 months.4 C' X+ j7 Z: m' M
Physical examination at this time revealed that the
8 N* G6 ^+ r1 V: S: n$ dchild had grown 2.5 cm in 4 months and had gained' f1 T- P) e1 t# Z6 L" q
2 kg of weight. Physical examination remained. Q' f) u$ k' C1 F
unchanged. Surprisingly, the pubic hair almost com-
+ F- u9 E# m/ o9 t% D/ Upletely disappeared except for a few vellous hairs at  N) P5 o6 S1 G0 Y
the base of the phallus. Testicular volume was still 2/ ]9 f$ ^# i$ [3 U8 N! g/ x- e
mL, and the size of the penis remained unchanged.8 m& |# x- s! w$ f0 n, H6 ^( X5 D
The mother also said that the boy was no longer hav-
: F7 p$ P$ h, L1 q4 u4 Ving frequent erections.
: a% r9 f8 f3 t* H! d% h2 {Both parents were again questioned about use of
) M8 g8 J0 i1 t" E& H- B- _+ ~any ointment/creams that they may have applied to0 q# N4 G- K8 a# Q+ O
the child’s skin. This time the father admitted the
2 d0 }* L: c0 {, V: e3 l: XTopical Testosterone Exposure / Bhowmick et al 541
+ |, f/ n) V% k( b: f( B1 {use of testosterone gel twice daily that he was apply-
% W0 K( G% X7 S- f) Ding over his own shoulders, chest, and back area for: H! p; ^! i& M- t) W4 Z9 \
a year. The father also revealed he was embarrassed5 C% Y. S0 k' f  \
to disclose that he was using a testosterone gel pre-
9 m0 K) r' |+ P/ ?+ B/ P# jscribed by his family physician for decreased libido
* o& }( N' G0 o5 [secondary to depression.: }( D( _. P. H: z% E; x
The child slept in the same bed with parents.
8 I6 b$ |/ s$ ]( LThe father would hug the baby and hold him on his4 |$ d7 F9 f0 P( O
chest for a considerable period of time, causing sig-: F( w7 s/ y8 f4 d3 s
nificant bare skin contact between baby and father.
/ [9 M0 o7 S+ H8 J: P, L4 L$ `, bThe father also admitted that after the phone call,
2 o2 W3 m8 C9 g' P- @when he learned the testosterone level in the baby% V( C- c( ~$ |0 J
was high, he then read the product information
3 z; ?2 D6 Y6 G2 j+ v  Z9 [# Rpacket and concluded that it was most likely the rea-
& }8 s1 `: D0 [9 U/ Uson for the child’s virilization. At that time, they
$ ?' T; H# K6 J: g6 j) f8 B% F4 [decided to put the baby in a separate bed, and the* D6 z1 R) O* D( d" t* A- u) z1 b
father was not hugging him with bare skin and had
: w' k' Z" G: W0 a  gbeen using protective clothing. A repeat testosterone
* W4 |) _2 Q! I' a" m4 v5 rtest was ordered, but the family did not go to the
: p( A) X5 a5 Q! S7 olaboratory to obtain the test.3 i+ f" W" C8 F9 E- b  i; [% O
Discussion
% @* L; e( C0 N# F8 S- \Precocious puberty in boys is defined as secondary
$ M  |+ W0 O4 |4 t  [& y, S0 {sexual development before 9 years of age.1,4  V6 z1 j5 c( d
Precocious puberty is termed as central (true) when: `8 }; {; p0 q' S8 j8 B
it is caused by the premature activation of hypo-3 q/ P: S; w& s' m) J5 E
thalamic pituitary gonadal axis. CPP is more com-# X. ~) f( i" `* R- G
mon in girls than in boys.1,3 Most boys with CPP3 D9 b8 o  X' M2 s
may have a central nervous system lesion that is
2 I6 {  N# j( b6 t  Tresponsible for the early activation of the hypothal-( i/ `; T  d& L- R
amic pituitary gonadal axis.1-3 Thus, greater empha-
  T, S# e% z1 N+ j8 E* _( csis has been given to neuroradiologic imaging in
3 M6 L9 @+ {0 N4 \7 mboys with precocious puberty. In addition to viril-
, b6 }/ `: J5 j/ p4 Mization, the clinical hallmark of CPP is the symmet-5 G2 b9 m/ T1 r& N/ I) n; {$ v
rical testicular growth secondary to stimulation by
9 i, f0 B; `: l6 `gonadotropins.1,3
2 M* I/ f( ^, a2 N) ~7 `Gonadotropin-independent peripheral preco-7 a+ ~# `% A; W- l9 n
cious puberty in boys also results from inappropriate" G# `+ F2 Q  t- N8 _2 y) J/ n
androgenic stimulation from either endogenous or" o/ F( k, K; b. {4 m
exogenous sources, nonpituitary gonadotropin stim-: `+ a; \2 O& G; ]# Y5 M* B& Z
ulation, and rare activating mutations.3 Virilizing
5 m+ I7 ]( Q0 Z( I# {4 m! ncongenital adrenal hyperplasia producing excessive  A7 `4 R& @' S
adrenal androgens is a common cause of precocious
' k, j4 P+ C" d2 A# ~6 f- R  Ipuberty in boys.3,4
1 Q/ I* X, Y! @6 a+ D. gThe most common form of congenital adrenal
1 m) h% e5 D/ L& v- k( t$ _: {hyperplasia is the 21-hydroxylase enzyme deficiency.4 I" E5 J3 C) `. f/ d8 b# S
The 11-β hydroxylase deficiency may also result in0 L: M/ ^0 _. M( d# O
excessive adrenal androgen production, and rarely,
- j2 R) v% M! j6 v% R5 zan adrenal tumor may also cause adrenal androgen+ _+ x) C5 ?. h: H6 E, C
excess.1,3
& O% U. |: a! g+ t0 W+ `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 i( r/ v6 {! G; x* _' ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 l1 l& D% F) @' r. IA unique entity of male-limited gonadotropin-8 Z& K1 @; ]2 h* J) x' X; L
independent precocious puberty, which is also known: F( ?% g2 [5 s; w' `
as testotoxicosis, may cause precocious puberty at a% y( r4 u2 L) P) q
very young age. The physical findings in these boys  r. E( ~9 Y' `" W/ N: z* P
with this disorder are full pubertal development,
1 z, U/ ?* J6 ~including bilateral testicular growth, similar to boys
( d- E; h9 {* {with CPP. The gonadotropin levels in this disorder
9 h! u5 a8 L/ ~8 M8 Lare suppressed to prepubertal levels and do not show  v7 ~* A) Y3 v$ z/ A
pubertal response of gonadotropin after gonadotropin-
5 B4 T" l" a; l" Y; Y# W7 @) dreleasing hormone stimulation. This is a sex-linked  p, T6 u4 O' [! X' X+ ~' f
autosomal dominant disorder that affects only
' [7 X( r! k% _" xmales; therefore, other male members of the family
  N- {3 G% q; U: H. wmay have similar precocious puberty.3. _* F* H# e- O- f. ^, y9 C/ l
In our patient, physical examination was incon-
( ]0 U$ ?+ s) X% O2 K0 Z$ h7 x  asistent with true precocious puberty since his testi-
; Z- @5 e; O+ K' a$ D) fcles were prepubertal in size. However, testotoxicosis
4 E4 a3 v8 c! H5 `5 Jwas in the differential diagnosis because his father
. r) l7 A( l# v. X" ~started puberty somewhat early, and occasionally,5 G3 ?2 J$ H! L% D
testicular enlargement is not that evident in the
* c' \2 U  H8 i7 y8 H8 ~# Tbeginning of this process.1 In the absence of a neg-& R; z( z8 g+ a# S" t2 u8 g, w
ative initial history of androgen exposure, our
- z! ?3 B: d6 B: z4 G; ibiggest concern was virilizing adrenal hyperplasia,6 Q9 ~& \& b" _/ m: f+ s9 Y  ?
either 21-hydroxylase deficiency or 11-β hydroxylase
$ T" A/ G/ h/ T/ kdeficiency. Those diagnoses were excluded by find-
" o$ n+ u( |6 m( Wing the normal level of adrenal steroids.' W8 I" o  O/ M$ l2 O) d% w& Y4 x
The diagnosis of exogenous androgens was strongly
: k1 H6 j( g5 ]( rsuspected in a follow-up visit after 4 months because- w. t8 D( G5 k: e2 H
the physical examination revealed the complete disap-/ m: E: w: P. d, ~' k6 I
pearance of pubic hair, normal growth velocity, and
  q: N/ ]+ A& e0 H$ k* Mdecreased erections. The father admitted using a testos-2 A# g# f$ S: o1 F' g  _% u1 Z
terone gel, which he concealed at first visit. He was
) k2 r) r9 t0 R, H: Vusing it rather frequently, twice a day. The Physicians’) ^+ N& s8 `: z) C( L
Desk Reference, or package insert of this product, gel or& t$ q6 u  X& M0 Q" m2 ?7 [
cream, cautions about dermal testosterone transfer to
3 ~- _3 o% J) v# c0 S% R& ~unprotected females through direct skin exposure.
5 O6 m( i8 [. S  r" Z' c2 QSerum testosterone level was found to be 2 times the; M+ y" ^5 I5 H$ D. X, V
baseline value in those females who were exposed to
* @/ ]# C8 U/ T2 ~3 Q8 U" O# _- Aeven 15 minutes of direct skin contact with their male
3 p8 F3 c- p& R5 o. w: G: e% O. upartners.6 However, when a shirt covered the applica-2 Z7 ]: x, s& o$ X9 o
tion site, this testosterone transfer was prevented.4 _4 e4 b3 R( q$ `, {
Our patient’s testosterone level was 60 ng/mL,
( i( `" s, W& a' G! Z, a& y6 g4 ^which was clearly high. Some studies suggest that* A( A; w! E# }3 c. H7 [0 l/ y
dermal conversion of testosterone to dihydrotestos-0 B" a9 v/ u/ B4 Z, q; [- S
terone, which is a more potent metabolite, is more
: f( ~6 F0 H4 ^- n' ]active in young children exposed to testosterone
+ F2 t7 ]5 E  l. a0 u3 mexogenously7; however, we did not measure a dihy-4 ^+ j+ x% s4 V' ]" N
drotestosterone level in our patient. In addition to! ]. [6 L4 K/ n: A+ m
virilization, exposure to exogenous testosterone in& o/ W4 y* c7 C  o' q( O" [
children results in an increase in growth velocity and6 ~1 g, n' u/ C9 m3 {
advanced bone age, as seen in our patient.
8 Q, v' g1 G; J. f  G4 VThe long-term effect of androgen exposure during) ^& i6 F9 }* T% }* X8 j4 D
early childhood on pubertal development and final
. u- ?# p* x% e) W& y6 y- ^adult height are not fully known and always remain
" G4 A. H( j/ V& I! ba concern. Children treated with short-term testos-
2 T) c: S- W  \$ y* kterone injection or topical androgen may exhibit some6 Y) X1 E: ^! n
acceleration of the skeletal maturation; however, after" @* L4 C6 E# W" d  d" o- |- v
cessation of treatment, the rate of bone maturation
( j/ t6 w) U# ~! F% l9 r: a2 [decelerates and gradually returns to normal.8,99 E  F- k* m6 b% {# ~
There are conflicting reports and controversy
8 \  g+ D$ i; M% I. s, e6 vover the effect of early androgen exposure on adult
' q- p: I) D# O9 }' Y$ ~penile length.10,11 Some reports suggest subnormal
  B- [: b4 f; ~( s0 ], X" m! Z8 gadult penile length, apparently because of downreg-0 L7 K/ \  x( v5 }  e8 s( V
ulation of androgen receptor number.10,12 However,
/ @! R, _  d( X* ^6 U2 xSutherland et al13 did not find a correlation between
4 W* \9 a8 ^8 ~5 n# ^childhood testosterone exposure and reduced adult
4 }3 n' ~% G  e9 ^. r  }7 bpenile length in clinical studies.
2 }/ o* W6 \/ R  ^Nonetheless, we do not believe our patient is6 i# u$ m+ i, ?. T: ?
going to experience any of the untoward effects from
4 o" x7 F8 x9 Y( `- L* [testosterone exposure as mentioned earlier because/ l& }+ I' _; b$ N5 c* {
the exposure was not for a prolonged period of time.2 b& E* e' p1 R% o; W
Although the bone age was advanced at the time of5 n" }2 ]' M; M
diagnosis, the child had a normal growth velocity at
. `: V* X) {+ Q: o3 Vthe follow-up visit. It is hoped that his final adult4 g4 E& l- c$ ^  a2 z) [
height will not be affected.6 n8 {: b8 L% c/ p6 t/ J- Y& u
Although rarely reported, the widespread avail-2 G9 {* E8 y6 f2 F, P; i; v
ability of androgen products in our society may# I9 \! n1 v" V# Q; k, p: I
indeed cause more virilization in male or female
9 P: v" I( M4 ^! J* _+ W" Achildren than one would realize. Exposure to andro-
$ k6 ?8 y. D! m" @( u2 G$ |! rgen products must be considered and specific ques-
' v# \' z. k7 u; y6 k6 p0 itioning about the use of a testosterone product or
+ o! j$ n1 I) K/ c! g. Qgel should be asked of the family members during
& J+ n/ R+ {2 s1 }9 mthe evaluation of any children who present with vir-
. F$ J& v4 f6 p7 k9 p7 Wilization or peripheral precocious puberty. The diag-+ [# n/ l0 F1 S9 u, w1 G/ f+ |% w
nosis can be established by just a few tests and by3 J0 p6 p- F5 {  Y+ e7 [
appropriate history. The inability to obtain such a
" \+ |# n  K6 ehistory, or failure to ask the specific questions, may4 E" ~0 p/ {7 D! u* A! m$ n
result in extensive, unnecessary, and expensive! e; m3 Y2 k" v  ], _& j* }
investigation. The primary care physician should be2 G& l/ m  I3 n2 x: o
aware of this fact, because most of these children
) J4 A& n% e- N8 Y& Y2 Pmay initially present in their practice. The Physicians’) g$ D$ t5 T! Y9 I
Desk Reference and package insert should also put a9 t  \" {' A' {3 T  X; [# |1 H
warning about the virilizing effect on a male or
4 |, ~6 X7 F9 Y) ^! Kfemale child who might come in contact with some-5 L  z+ p; X9 z/ O
one using any of these products.7 n( _- x5 k  x( C7 U% O
References
" f& l+ w, S. m' R6 H& w1. Styne DM. The testes: disorder of sexual differentiation
$ C" T. ?/ F0 }7 }2 gand puberty in the male. In: Sperling MA, ed. Pediatric
1 B1 j9 P# V% ~9 j# hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- p4 e: M/ }1 A( p$ ?5 G2002: 565-628." [; L! w/ n$ v; p3 G. q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 @$ W$ \' j3 j4 c
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 v% T8 C4 [. n% Z8 ]# Y9 h
Boy Induced by Indirect Topical) m  E$ k9 M' C
Exposure to Testosterone; _* V% K3 n4 |0 H# D6 q; f& h: g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 Z5 j4 K/ ~' c1 J' t! L
and Kenneth R. Rettig, MD1; P$ V( v; _$ x* m/ N1 K) `
Clinical Pediatrics
0 L& t" o; i# G2 |% x! m9 OVolume 46 Number 6
" `% T6 U5 b+ Z% j/ `July 2007 540-543. u( R3 y3 g- N# b! }6 y
© 2007 Sage Publications
' r! w# R4 f3 ~( `2 y1 i10.1177/0009922806296651$ j0 b; U1 b5 e. h
http://clp.sagepub.com$ E# N" N; N8 L  I  D' q& m3 h
hosted at
, L1 v  m& j  d: ?6 |http://online.sagepub.com
/ t# l7 [( C( p$ B4 S# p% yPrecocious puberty in boys, central or peripheral,- d/ e: I( U1 J
is a significant concern for physicians. Central( n7 M: q$ Q, w2 x1 C, p
precocious puberty (CPP), which is mediated8 D( e1 y1 d& r1 M
through the hypothalamic pituitary gonadal axis, has
" a5 w' R" e3 c. V& ]a higher incidence of organic central nervous system: i. t4 K: S! m$ |
lesions in boys.1,2 Virilization in boys, as manifested$ Z7 [( k8 w7 a$ Q
by enlargement of the penis, development of pubic
* m+ k# I4 @6 r- i0 t$ {hair, and facial acne without enlargement of testi-, P7 M# {" F: a# `: i! \6 Q1 T" D& }) x
cles, suggests peripheral or pseudopuberty.1-3 We+ c& B6 r0 K4 B5 h4 {
report a 16-month-old boy who presented with the3 z1 T# P2 _1 T0 F' m! c
enlargement of the phallus and pubic hair develop-
# a7 X7 R; D/ b2 x5 V7 |ment without testicular enlargement, which was due
  W3 S, m# n; U' K' c& tto the unintentional exposure to androgen gel used by2 k+ _6 I- o0 s. k
the father. The family initially concealed this infor-
( B/ `  T9 w& }- \* q4 X3 Tmation, resulting in an extensive work-up for this
/ P( ?! W: k5 X" s  r$ X+ {, b/ Pchild. Given the widespread and easy availability of
% {6 X+ K" p/ E7 q- W0 J& c1 k6 Qtestosterone gel and cream, we believe this is proba-
/ M% C) K. s- ~* y6 B7 Zbly more common than the rare case report in the
7 d4 F" u. J8 }; y: Sliterature.4
# D* O- F+ w! c& i) IPatient Report
; u) P# d' K2 D) X; gA 16-month-old white child was referred to the
7 T& a+ \/ ?' v: K. T6 Jendocrine clinic by his pediatrician with the concern/ G$ U8 S4 Y# l2 O8 r0 H3 o- {; w
of early sexual development. His mother noticed
8 z9 |6 B; D. \2 s5 w  \light colored pubic hair development when he was) Q$ h0 G$ S" q( M+ A+ H
From the 1Division of Pediatric Endocrinology, 2University of
) K: Y+ Y' J: NSouth Alabama Medical Center, Mobile, Alabama.+ {8 @5 S1 M3 u* r% q/ b
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" }; h" k3 _6 z2 h4 NProfessor of Pediatrics, University of South Alabama, College of: n: Q( @* `2 T. n: L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' k& u) P' w. i+ a: e, p& k. o; [7 l
e-mail: [email protected].
4 G: _. @- o8 B. p5 @! gabout 6 to 7 months old, which progressively became4 G, S* j2 P3 L: b; p% S4 ?! k
darker. She was also concerned about the enlarge-
5 Y; D0 R; {1 v& [  ~ment of his penis and frequent erections. The child
6 [3 U! I" c3 G6 X% p- p0 a( Bwas the product of a full-term normal delivery, with5 I/ D8 G3 `" G) e7 v+ @7 _2 k) s& a
a birth weight of 7 lb 14 oz, and birth length of6 d3 y2 @2 I! \& Z
20 inches. He was breast-fed throughout the first year1 I& I! I. ~& C. J2 D5 N
of life and was still receiving breast milk along with
, ?  _7 b8 |6 A6 X& K$ ksolid food. He had no hospitalizations or surgery,! B" M1 k+ [# x! d
and his psychosocial and psychomotor development1 S# d, j8 @) I+ n& v& O7 c4 ?
was age appropriate./ H% N' z7 y' e$ l* V
The family history was remarkable for the father,
5 D* @5 r# K8 \7 u: Iwho was diagnosed with hypothyroidism at age 16,
* y& I- x# C3 N3 T2 {which was treated with thyroxine. The father’s9 w, F# G5 j( _! E' L! i
height was 6 feet, and he went through a somewhat
1 Y3 j2 b- T0 D* G$ L/ K( l# eearly puberty and had stopped growing by age 14.. T0 V. p1 f1 m# l+ |5 H% A4 e
The father denied taking any other medication. The
% A! z" b7 |5 `  schild’s mother was in good health. Her menarche- p; A% v/ M) t8 P# F  a
was at 11 years of age, and her height was at 5 feet* X4 Y: ~. ?( m+ m, ]7 o
5 inches. There was no other family history of pre-
$ e0 Y! L) G! T+ [5 pcocious sexual development in the first-degree rela-# z* b6 R: ^9 g4 c. J2 K* H
tives. There were no siblings.2 B' S' I; x" p8 `: g2 S; {1 \
Physical Examination
" k- f8 ~4 N- i9 S3 R- OThe physical examination revealed a very active,' a: v( g$ a8 b3 P2 _/ `# o6 h& c/ x0 k
playful, and healthy boy. The vital signs documented
( T, A3 w, \" z) ja blood pressure of 85/50 mm Hg, his length was
5 D) k7 A% Q2 o# |# c90 cm (>97th percentile), and his weight was 14.4 kg0 g9 h: ^1 G5 s2 L! u5 q
(also >97th percentile). The observed yearly growth* M% L/ f  H7 F4 Z+ A' _7 ]
velocity was 30 cm (12 inches). The examination of
; N. L' J% D4 k, W( M: sthe neck revealed no thyroid enlargement.
6 z: i) r7 p8 j% D9 i: h3 H/ z7 {The genitourinary examination was remarkable for7 u4 J% n$ {' F4 ]2 L$ e
enlargement of the penis, with a stretched length of
6 h$ x' ^+ b& e0 @/ z8 cm and a width of 2 cm. The glans penis was very well6 @! {% P) X# ?4 V+ V9 o6 C# L4 k* y
developed. The pubic hair was Tanner II, mostly around5 e1 v4 n1 ^3 x8 Y$ n
540
* L' P: [4 B, m1 O) i: i9 b% p$ Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; c# U/ b& n0 T+ N7 m$ _the base of the phallus and was dark and curled. The
  Z$ c$ N6 o3 y/ w3 ntesticular volume was prepubertal at 2 mL each." z7 M5 w) {9 t7 b9 |
The skin was moist and smooth and somewhat
8 _# b& N# y* s$ Moily. No axillary hair was noted. There were no. [4 C% x6 Q$ e' v# h# N1 P6 P6 i, `
abnormal skin pigmentations or café-au-lait spots.
  i4 O0 t. \! {- G9 ^6 i* kNeurologic evaluation showed deep tendon reflex 2+
% K/ W. Z; z7 q, K1 D3 G- \bilateral and symmetrical. There was no suggestion' Z. F4 @1 [- f" |9 `
of papilledema.2 e& w' \% c5 t; S) k& p0 s
Laboratory Evaluation
- L7 Q8 _; y% O8 h0 z' O) yThe bone age was consistent with 28 months by5 t; e. s% g! H1 _; s6 L, `
using the standard of Greulich and Pyle at a chrono-
5 I6 C3 O9 M" b" V4 l8 Flogic age of 16 months (advanced).5 Chromosomal4 T, f- ]8 p* J. e
karyotype was 46XY. The thyroid function test
. x! }: L& M# V3 E3 S3 Rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 N8 y* H5 L: C* Jlating hormone level was 1.3 µIU/mL (both normal).  w& r* a! _% w3 X9 f; _2 Y% h$ H
The concentrations of serum electrolytes, blood8 i# Q& B! i  i# a. A: K
urea nitrogen, creatinine, and calcium all were
  U; _/ T3 L; c7 d, |& Awithin normal range for his age. The concentration
( ~+ q# t, R' [; u& t. m9 Fof serum 17-hydroxyprogesterone was 16 ng/dL
. p# _1 |1 @* c(normal, 3 to 90 ng/dL), androstenedione was 20
; S; E% W( ?% ]. ~  p- r$ xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 H  f! c! _0 p. e, W. e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 H/ W  Y- U/ m5 E/ I6 A2 o( C( G( }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- _" J; I: o8 u% n49ng/dL), 11-desoxycortisol (specific compound S), O! j6 Q' ]2 ?
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' K7 B7 @+ C" D# _6 M6 xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 {! z; @; S2 C0 j  e3 a; B1 {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 X/ w. W  z/ ?7 {4 Y1 B
and β-human chorionic gonadotropin was less than" D( w* ]% d$ ^6 H" p2 c7 W
5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 d, _8 ?; O0 }8 @6 h$ vstimulating hormone and leuteinizing hormone6 t: q% x, [, K* ~
concentrations were less than 0.05 mIU/mL
5 N$ S4 m# B$ U3 _(prepubertal).
2 T0 n  \1 c- S  ~" JThe parents were notified about the laboratory
2 L/ r; z# T& n; V- ]. fresults and were informed that all of the tests were" Y8 ?$ Y/ p# Y# Q  [* \- Q  ~) r
normal except the testosterone level was high. The3 g% I5 @; `2 Y' X
follow-up visit was arranged within a few weeks to1 B' L) k0 o8 e6 |
obtain testicular and abdominal sonograms; how-
" f, O6 h: I9 w4 U. D# s0 D* vever, the family did not return for 4 months.
9 T  \" O' p' I0 uPhysical examination at this time revealed that the- n# [1 g0 A3 `' C
child had grown 2.5 cm in 4 months and had gained- B! o7 P, e& t8 b3 X
2 kg of weight. Physical examination remained
. o8 Q1 d3 b  H  B6 l2 Funchanged. Surprisingly, the pubic hair almost com-  D( g4 H3 x" D( z# K' `
pletely disappeared except for a few vellous hairs at
( l7 l- v% ?# W+ Y; g6 n  pthe base of the phallus. Testicular volume was still 2
* `( n2 M) p5 X- b3 [) D' A+ c4 g( V3 s2 |mL, and the size of the penis remained unchanged.: B6 f$ ]; C6 t
The mother also said that the boy was no longer hav-6 @, L" w1 M2 |
ing frequent erections.
7 q( i5 m. ~. c% |Both parents were again questioned about use of; l4 `( E) o) q: }1 D
any ointment/creams that they may have applied to5 l5 {& |8 d& _8 J
the child’s skin. This time the father admitted the3 `2 O- T* h# G% X
Topical Testosterone Exposure / Bhowmick et al 541
3 c  V4 l9 c" uuse of testosterone gel twice daily that he was apply-. s4 f4 L& N7 L! K" Z+ c% A
ing over his own shoulders, chest, and back area for5 o# D. N6 W& U
a year. The father also revealed he was embarrassed" o) B4 I5 U' i( N* v0 v. ]* [+ t! X# T
to disclose that he was using a testosterone gel pre-
- k; P3 H  u7 t+ E. Fscribed by his family physician for decreased libido
' N6 J0 ?- A* s2 Osecondary to depression.
# ?$ b$ d1 Y. W3 dThe child slept in the same bed with parents.
" P9 Z9 c1 l5 K& S8 m$ X/ k' [% LThe father would hug the baby and hold him on his
7 o1 a2 R- K+ ]) q0 C; ?4 Vchest for a considerable period of time, causing sig-
7 V) N  ~* x0 G, M8 cnificant bare skin contact between baby and father.* p  P) m# r7 g" r2 l
The father also admitted that after the phone call,1 b) @8 C7 u7 I) {2 W9 q' g
when he learned the testosterone level in the baby% q$ K0 q! F# z1 D
was high, he then read the product information
6 {1 I4 X4 C9 N- _0 n& hpacket and concluded that it was most likely the rea-
! _% B5 U3 ~$ j. X% oson for the child’s virilization. At that time, they2 v/ B" a0 n1 m
decided to put the baby in a separate bed, and the
$ f2 ]' c+ V( k8 T  w' N- Pfather was not hugging him with bare skin and had) V( `) u9 R4 o
been using protective clothing. A repeat testosterone
; k: o& ^& P! J1 ~4 ytest was ordered, but the family did not go to the
. G  v/ |' t  w5 K: ?; w/ D8 L% jlaboratory to obtain the test.
/ V9 Y2 F) {0 K2 j* T! ~6 }/ s( B( U/ ?Discussion
& }% J5 U2 D/ z# ~! }$ ~% r$ bPrecocious puberty in boys is defined as secondary5 O: F1 ]# Q  X8 k6 d  b+ U
sexual development before 9 years of age.1,4" R1 K" x/ z/ q; n( D3 Q8 q
Precocious puberty is termed as central (true) when
7 k: f- S* L, @8 r% U& ?& a/ t0 iit is caused by the premature activation of hypo-
3 A* G( b: u2 M( pthalamic pituitary gonadal axis. CPP is more com-6 T; @$ ?; Z5 @2 z2 b& m3 l/ F# q
mon in girls than in boys.1,3 Most boys with CPP$ W: ]2 }; A# r; ^  h7 v
may have a central nervous system lesion that is, k4 b0 T* l* Y: k5 B
responsible for the early activation of the hypothal-! [: A3 _) y% {% B. v
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 c( r+ q6 O5 u! `' E" Z; b' d4 Asis has been given to neuroradiologic imaging in% ^! m. Y, I/ T6 \/ w
boys with precocious puberty. In addition to viril-* f5 i3 Q+ X( ~9 Q: r! F' @% y
ization, the clinical hallmark of CPP is the symmet-, p! ^, u+ t2 z
rical testicular growth secondary to stimulation by
7 z7 |  N6 x  C8 Igonadotropins.1,3, p6 K# g4 d3 N3 n6 a
Gonadotropin-independent peripheral preco-
5 \1 x1 o: Y. k" q# Ycious puberty in boys also results from inappropriate' ], q6 y! r0 P* }" c6 D. S, Z1 Y/ ?
androgenic stimulation from either endogenous or; p/ T; O, @" j! c% A
exogenous sources, nonpituitary gonadotropin stim-
/ Z) C5 A& l. Q" y, i3 o' Rulation, and rare activating mutations.3 Virilizing5 ^8 }; r9 M2 p( m/ `
congenital adrenal hyperplasia producing excessive
! i  C1 M; S! z9 Wadrenal androgens is a common cause of precocious8 C& C* j, Q& U% C& `
puberty in boys.3,4
. ]5 Y* f. F. uThe most common form of congenital adrenal2 @6 K  J8 |, }3 V8 L7 N' f
hyperplasia is the 21-hydroxylase enzyme deficiency.
# {' w& i. b2 b0 C% CThe 11-β hydroxylase deficiency may also result in
# N& M* X3 \( D6 ?excessive adrenal androgen production, and rarely,
5 x+ j3 s5 K& L4 C! Gan adrenal tumor may also cause adrenal androgen  N3 l- W% q- U+ L9 C+ e# O& v7 V; [
excess.1,3
' ~5 H( N" g& Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 `: ^4 z. Y. l: ~; k9 E7 P- Z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* e8 H! D# [/ b4 S- AA unique entity of male-limited gonadotropin-+ G* [4 g( N3 K9 H* c; e
independent precocious puberty, which is also known
9 X% n$ S/ J  u+ C: f- m* mas testotoxicosis, may cause precocious puberty at a
7 r# y/ B, p) i5 ~+ ]( m% u5 Xvery young age. The physical findings in these boys% d" P+ u1 e9 ]1 P
with this disorder are full pubertal development,
# V) S8 v" w$ R: M# X& gincluding bilateral testicular growth, similar to boys, \" ?0 K$ S: H8 F- v
with CPP. The gonadotropin levels in this disorder
! \# Z. Z/ N# z$ h$ w0 J0 Tare suppressed to prepubertal levels and do not show
4 A# `% l3 k$ [, I; L2 Cpubertal response of gonadotropin after gonadotropin-
# g' C  _& x& }) u4 Sreleasing hormone stimulation. This is a sex-linked1 `, I' `6 F( I# ?. f
autosomal dominant disorder that affects only
; @) b+ L9 g) {" Z4 n7 \( ?males; therefore, other male members of the family" Z- B. P% C: t! S6 H& A8 W
may have similar precocious puberty.3
9 S5 m( ~; h1 [/ `  EIn our patient, physical examination was incon-
- a' h# X+ j3 e0 Zsistent with true precocious puberty since his testi-& s  Q0 U9 R& p, S  g4 b1 Q" `
cles were prepubertal in size. However, testotoxicosis' u8 F; y! E; ^1 K" m
was in the differential diagnosis because his father9 X2 h( k9 g3 `) P0 |
started puberty somewhat early, and occasionally,  l5 ~6 @9 l7 p0 r, K
testicular enlargement is not that evident in the9 T5 K4 q" W; k4 P/ F7 @
beginning of this process.1 In the absence of a neg-, w; Z0 S  D; |- f6 W4 f) }2 I( _  ?( f
ative initial history of androgen exposure, our
5 n8 f6 j: N5 {' [6 D8 kbiggest concern was virilizing adrenal hyperplasia,
% P5 O8 f1 E" geither 21-hydroxylase deficiency or 11-β hydroxylase
) G6 X3 c6 A9 u9 D' q  mdeficiency. Those diagnoses were excluded by find-8 n" U1 I! r9 Y! N" F; ^
ing the normal level of adrenal steroids.
3 Q4 a3 K' {9 N4 g/ R. d- r. \$ z4 A. oThe diagnosis of exogenous androgens was strongly
/ W; g2 {$ z  Nsuspected in a follow-up visit after 4 months because. M( Y  `) r! j" X6 L
the physical examination revealed the complete disap-
3 F- ~& ?. C' ^2 @: I" B2 K4 P( lpearance of pubic hair, normal growth velocity, and, ~9 R/ s& ~; m$ M4 }
decreased erections. The father admitted using a testos-
; P* N' @+ v+ [; {( B* {; B8 q) yterone gel, which he concealed at first visit. He was: f4 a3 K! J, [1 f; z7 d
using it rather frequently, twice a day. The Physicians’% _" Z6 [( d2 z; I# a* s+ ^% U
Desk Reference, or package insert of this product, gel or
/ Z% M" }; s% [) L4 S: Ocream, cautions about dermal testosterone transfer to
1 u. K4 p9 K5 u* h) t) eunprotected females through direct skin exposure.
* f5 J0 E" R& J1 `4 ~( y' hSerum testosterone level was found to be 2 times the
1 ^& ~% K" R$ u  g' M& F- s9 J2 Mbaseline value in those females who were exposed to+ r7 T" O) g! d3 {: @
even 15 minutes of direct skin contact with their male/ l$ B9 f7 F1 b, J  C
partners.6 However, when a shirt covered the applica-+ X. X* `2 Q, p( _1 @6 B: I
tion site, this testosterone transfer was prevented.
' z; Y7 \; f* U/ F9 hOur patient’s testosterone level was 60 ng/mL,
% i0 k5 ^# s2 j6 M  Awhich was clearly high. Some studies suggest that" E# c% J5 c$ X/ G( D" u
dermal conversion of testosterone to dihydrotestos-
8 U9 k# w( m2 I$ w3 jterone, which is a more potent metabolite, is more
) w9 T. z. y6 }& ~  factive in young children exposed to testosterone
6 q+ X3 M9 M8 c& k% S' qexogenously7; however, we did not measure a dihy-5 m/ i5 H; p0 S9 M$ u
drotestosterone level in our patient. In addition to- a% O; V' `1 W
virilization, exposure to exogenous testosterone in; c" B9 r+ I- o6 x- V
children results in an increase in growth velocity and
. v) o: J% Z  }) q& }advanced bone age, as seen in our patient.
, J8 S! i6 r4 K. B6 E) oThe long-term effect of androgen exposure during
  b; K9 B) I4 V% w) Z5 V* Dearly childhood on pubertal development and final
* W+ h( M: p; j/ u" w5 oadult height are not fully known and always remain
' ~, r: e$ O4 I! F+ k1 ~: W( L5 Sa concern. Children treated with short-term testos-
! l# n/ \2 F& s6 yterone injection or topical androgen may exhibit some3 p9 o  L7 {$ Z6 w* k
acceleration of the skeletal maturation; however, after- l) u' f  R" R4 j1 i" V$ `
cessation of treatment, the rate of bone maturation
* G+ L" o) v! O: i, y9 Xdecelerates and gradually returns to normal.8,9
% e3 g3 |) Y9 ~8 h! _" |There are conflicting reports and controversy
- x* [. `# s, O+ Z; |over the effect of early androgen exposure on adult6 {4 r+ n% J9 i7 I) Y
penile length.10,11 Some reports suggest subnormal
' ]7 y7 Z! i1 i1 R4 d5 Q- wadult penile length, apparently because of downreg-9 h0 K6 B& m. E: J1 t% X" B
ulation of androgen receptor number.10,12 However,
. a: L: u3 H5 Z8 v8 wSutherland et al13 did not find a correlation between
: ?4 ]0 U0 j) n: E, r5 y, z9 J! ~6 `childhood testosterone exposure and reduced adult2 M! M: p) n" O$ V8 n
penile length in clinical studies.& o0 t+ M+ F4 _5 m1 k
Nonetheless, we do not believe our patient is) ?: T6 B# T3 p$ [
going to experience any of the untoward effects from# q( b! y: ]- b9 r9 T3 R
testosterone exposure as mentioned earlier because
/ H) q  ^1 P' j( _5 z. _the exposure was not for a prolonged period of time.
- E  d. j, p5 k# ?% B( u1 FAlthough the bone age was advanced at the time of
! H# F& y6 m0 b% a7 K/ Adiagnosis, the child had a normal growth velocity at
# t9 J8 x' U& U, g5 d) x5 X) ?5 m/ hthe follow-up visit. It is hoped that his final adult
3 _+ P% ~( {' A" M- W$ `height will not be affected.
7 l; F- I. F  Z( S9 [/ `Although rarely reported, the widespread avail-1 W( c, c3 F8 D
ability of androgen products in our society may
( |" z4 p0 E. J. y* K5 {0 u; lindeed cause more virilization in male or female
3 \1 O, ~9 `" g' I; Qchildren than one would realize. Exposure to andro-" d4 o; d/ H& U8 l
gen products must be considered and specific ques-* i* S9 M9 a0 F$ m
tioning about the use of a testosterone product or
2 K3 x- t" S$ W' `3 Q8 Sgel should be asked of the family members during
1 N. \! I) D2 Cthe evaluation of any children who present with vir-
3 k: X0 X5 N/ D$ k) |ilization or peripheral precocious puberty. The diag-
1 Y" @4 @" A# o, @9 |nosis can be established by just a few tests and by0 i5 o. n9 |' ?7 _' x+ i" A
appropriate history. The inability to obtain such a
& S: c' D  _$ V' Qhistory, or failure to ask the specific questions, may
2 T( v, |6 q3 [- U  E( [( x; r. ^result in extensive, unnecessary, and expensive
, H" i% Q3 g& ~8 W; x* O8 g! ]6 G: n) Vinvestigation. The primary care physician should be
4 i% j% N2 `/ @# @aware of this fact, because most of these children7 z0 _) s& c: C
may initially present in their practice. The Physicians’
% A. o: w8 D9 Q8 BDesk Reference and package insert should also put a
# `% S. c3 t( H+ }) Gwarning about the virilizing effect on a male or
; v) b$ A% n' @2 T! L& [female child who might come in contact with some-
1 ?* r0 G9 `" Rone using any of these products.
7 z# l, U5 ?. e) C. F: H& o* SReferences* R* E0 N* t  P' P( V
1. Styne DM. The testes: disorder of sexual differentiation  D  G( A$ ^, r
and puberty in the male. In: Sperling MA, ed. Pediatric
( x* _1 s! X. S2 X0 lEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 M3 t0 H' }( A  E8 U2002: 565-628.. S0 s* `8 b' Y; ?
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 k! W' o5 R. A; z2 v6 @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

5 V1 V3 K2 [+ W4 D9 A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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