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Sexual Precocity in a 16-Month-Old6 U- L% q/ E3 H* q2 o1 }# r
Boy Induced by Indirect Topical3 t$ S$ K/ W% Y0 `
Exposure to Testosterone
2 d9 m# S6 f! zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 u2 O% C: q$ ]! jand Kenneth R. Rettig, MD1
) W9 n: |( |" }% a4 t1 vClinical Pediatrics8 Y; u/ L6 _3 P! v# `
Volume 46 Number 6- j( ~* D2 M. d' y+ e: y2 Q5 v
July 2007 540-543) A. i4 h) P2 {
© 2007 Sage Publications1 `! K, b1 o4 I+ a8 x. A
10.1177/0009922806296651
" F9 O1 f# a: @. |, Lhttp://clp.sagepub.com, p& V. Q0 C/ v4 j7 B
hosted at+ K0 I# }- t" }  n5 e
http://online.sagepub.com5 W8 @: m& Y# J5 E, _+ r' I: \
Precocious puberty in boys, central or peripheral,
/ W, k" z7 ~9 v: n- C. X# Xis a significant concern for physicians. Central/ F  v, G* A. p- Y
precocious puberty (CPP), which is mediated
1 @3 O: v8 Y( j1 k3 |through the hypothalamic pituitary gonadal axis, has1 E6 ?4 @+ V- V5 S7 I, A6 }* o
a higher incidence of organic central nervous system; H! x! w) ?% `" v
lesions in boys.1,2 Virilization in boys, as manifested
$ v" ~% h! ]6 bby enlargement of the penis, development of pubic0 k# d- H0 V: s8 R
hair, and facial acne without enlargement of testi-- ?1 d1 Z! D* M4 n
cles, suggests peripheral or pseudopuberty.1-3 We
/ O8 r  K* \) w* `' ?7 a7 Q& ereport a 16-month-old boy who presented with the
6 @0 f. J& f6 V' A8 d: Cenlargement of the phallus and pubic hair develop-
, p0 v& q* L- J# H7 Mment without testicular enlargement, which was due
7 K2 }! H. Z3 W: H6 J2 p( _" u7 m* Xto the unintentional exposure to androgen gel used by6 s0 a, A3 w; U6 b& Y" t. \( W
the father. The family initially concealed this infor-, ]" [+ [- {+ x+ k
mation, resulting in an extensive work-up for this9 i+ E- j2 l' |( n' T1 z
child. Given the widespread and easy availability of
9 A) W/ a0 Y- m' Ttestosterone gel and cream, we believe this is proba-, p. y+ \8 k) i: }7 A- s4 H
bly more common than the rare case report in the
' C  P9 y% a5 B, g" Gliterature.4
. m* B3 p6 A& g' e; YPatient Report
. F+ u: v" b) F7 @- f' @- BA 16-month-old white child was referred to the+ U7 q& I5 n( F/ d( P! Y* D
endocrine clinic by his pediatrician with the concern& M- [; c4 R9 b1 K5 f6 r
of early sexual development. His mother noticed1 |  o' F- k$ p6 g
light colored pubic hair development when he was
/ `6 B0 j- A) E3 e" ]) Z' }From the 1Division of Pediatric Endocrinology, 2University of
$ v- E" D/ z& u' {/ wSouth Alabama Medical Center, Mobile, Alabama.3 J. o! P+ g( E# O1 p* T  o9 U
Address correspondence to: Samar K. Bhowmick, MD, FACE,& p& D* W, [& |7 _1 a. {( L
Professor of Pediatrics, University of South Alabama, College of% q; v  |0 h# @0 r7 n$ G9 b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' w3 }; u. B+ W; |: {+ [e-mail: [email protected].- H' g  Z/ ~4 h1 F+ F
about 6 to 7 months old, which progressively became
" q7 ?, X; r1 w, p7 o/ p" r9 Z7 K, Ddarker. She was also concerned about the enlarge-' G' `& X( G& l! V; W& f0 I6 F
ment of his penis and frequent erections. The child' {9 ?; E6 B" W4 ]1 h: u
was the product of a full-term normal delivery, with3 D. s, a! T# g0 r2 ]2 Y
a birth weight of 7 lb 14 oz, and birth length of
1 j* L2 l* P" j/ e. T" I( N) s) Y% ^20 inches. He was breast-fed throughout the first year# O/ s% k. A4 ~# D5 o, V
of life and was still receiving breast milk along with9 z$ X( g  }: z+ r
solid food. He had no hospitalizations or surgery,% ?+ Z! E* b5 o/ z- _( a& _
and his psychosocial and psychomotor development% P. a) c& K- `/ U: Y4 w% |2 |6 @
was age appropriate.& N( r# M. V% P, {# B
The family history was remarkable for the father,
* {8 Y! C, \& [+ \who was diagnosed with hypothyroidism at age 16,
# o/ v9 V  {; S4 s" twhich was treated with thyroxine. The father’s
3 S  a) ?1 `; g, p' [4 }height was 6 feet, and he went through a somewhat* ?5 b; a2 u+ |8 s* h
early puberty and had stopped growing by age 14.
+ ?2 l$ _2 G$ v# _! z& BThe father denied taking any other medication. The$ V; y) D$ [: W) D1 J; r' I8 L8 D
child’s mother was in good health. Her menarche
. T* e5 P1 J. q  |- Iwas at 11 years of age, and her height was at 5 feet: B- R% Y9 T. K  f% f* v1 @1 s
5 inches. There was no other family history of pre-7 z  @. @; \+ y9 B1 r% S: A# B
cocious sexual development in the first-degree rela-5 l4 x/ f2 t; {( g
tives. There were no siblings.
' n& o2 f2 h, J* o. I8 TPhysical Examination
- l& \& D$ q$ @6 |The physical examination revealed a very active,
- C6 Z% [/ k8 H! P. v3 H& w* nplayful, and healthy boy. The vital signs documented
3 L% E5 U) u& h# V2 u6 S# ya blood pressure of 85/50 mm Hg, his length was
2 n( |/ ]+ z& I& L* z  z) `90 cm (>97th percentile), and his weight was 14.4 kg
3 a" D6 _0 S3 h  }) S# _7 Z: ^(also >97th percentile). The observed yearly growth% G& }$ |5 S/ E' J! W
velocity was 30 cm (12 inches). The examination of. H6 W/ g7 @! ~( V, m
the neck revealed no thyroid enlargement.
. w& T3 n+ ?4 H* N  b6 C& JThe genitourinary examination was remarkable for+ ^- H8 I$ `/ x' Q
enlargement of the penis, with a stretched length of( h# v( M% I) o% Z
8 cm and a width of 2 cm. The glans penis was very well& q: J4 x+ Z( O! V4 K! V$ h
developed. The pubic hair was Tanner II, mostly around
  @+ b* y. M2 R  S: n/ i540+ B( m$ {( l# k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" x7 Z8 L- `3 \0 V
the base of the phallus and was dark and curled. The
* c0 p& ]$ L( E+ |testicular volume was prepubertal at 2 mL each.# d4 o1 A7 g& X4 e" o/ b
The skin was moist and smooth and somewhat- y% O# e& N. m5 D- G- j
oily. No axillary hair was noted. There were no
7 j0 N5 ?2 o" x5 N# Q* r! [abnormal skin pigmentations or café-au-lait spots.0 t( c0 r! \+ G3 Q8 h8 k! x
Neurologic evaluation showed deep tendon reflex 2+. {* o0 ?) p+ R9 p: c+ l, L
bilateral and symmetrical. There was no suggestion
: C' n. M6 t- \- K3 Fof papilledema.3 k7 n8 a6 z& G  x& Q: w' n
Laboratory Evaluation
. P2 v2 |5 b7 v- U/ U; OThe bone age was consistent with 28 months by9 B! w) ]8 O1 J8 V5 E
using the standard of Greulich and Pyle at a chrono-1 v6 u: Z# q- _3 K: Q
logic age of 16 months (advanced).5 Chromosomal
+ j3 J/ r) Q& S7 B* h. i9 s) wkaryotype was 46XY. The thyroid function test+ U+ U, B# Y& a8 V* @0 n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 I( O6 M. n. H1 P/ hlating hormone level was 1.3 µIU/mL (both normal).2 L" F5 c# w6 M$ _6 I1 \
The concentrations of serum electrolytes, blood/ E' w1 O$ b, L5 h' l* N3 D: l
urea nitrogen, creatinine, and calcium all were
( P$ r2 o& _2 |: {within normal range for his age. The concentration
' l; b! `( G& E9 F7 k$ Z0 iof serum 17-hydroxyprogesterone was 16 ng/dL* |; k& V2 d# G$ l# h9 \" x; x
(normal, 3 to 90 ng/dL), androstenedione was 20- e8 n; ]0 n8 V' U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: _( v4 ~" c# b: g9 I: o4 w2 Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( M7 y& q1 Z; P4 Y+ y! q1 kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ C5 B0 K2 @7 L9 V- l# P8 S49ng/dL), 11-desoxycortisol (specific compound S): z6 h" k5 T# C! h. D/ \8 P
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( \( a% S" V' [& z4 `% @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ L3 ]1 u. ]& c2 q+ {1 ?testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" R# H6 b# B/ |8 u+ h: d: @and β-human chorionic gonadotropin was less than
3 V0 U5 m7 Z! L6 t* V5 mIU/mL (normal <5 mIU/mL). Serum follicular! V- z5 ~( N9 N% x" r
stimulating hormone and leuteinizing hormone
( f6 ^& p( u2 @6 Tconcentrations were less than 0.05 mIU/mL) J+ D$ c1 R. \8 O- l
(prepubertal).
6 F+ r; S  w: Y6 qThe parents were notified about the laboratory
, S; Z6 r, s3 kresults and were informed that all of the tests were
* z' N, R8 y; |1 Mnormal except the testosterone level was high. The
' V3 o& Y! s- C: p9 Y% ~$ qfollow-up visit was arranged within a few weeks to1 o8 K( ]1 F" {+ `! q
obtain testicular and abdominal sonograms; how-. B, W) b, L  C4 s) i
ever, the family did not return for 4 months.
! `3 t- p8 F- A' n" E- dPhysical examination at this time revealed that the
# [# V: D( D6 @; y( Zchild had grown 2.5 cm in 4 months and had gained
, A& r& I. I6 ]" h0 c* `2 kg of weight. Physical examination remained$ H) v  h& J- h
unchanged. Surprisingly, the pubic hair almost com-3 C, a" l& u2 Z7 r' \' \, _4 V
pletely disappeared except for a few vellous hairs at
. V$ Q! F  q4 T) b: F5 uthe base of the phallus. Testicular volume was still 2
2 _. _( r. x; g4 `) MmL, and the size of the penis remained unchanged.
2 {9 B9 _9 B( L1 Y! NThe mother also said that the boy was no longer hav-# U/ `: G' ^5 s0 T& x
ing frequent erections.4 _1 [# s' C8 O+ H0 M
Both parents were again questioned about use of
+ d* H2 f0 _. V9 Dany ointment/creams that they may have applied to0 ^& Y+ j5 g: m4 i0 U
the child’s skin. This time the father admitted the& B5 w! v; e) @+ j
Topical Testosterone Exposure / Bhowmick et al 541
, x& p; S  }$ H/ f; muse of testosterone gel twice daily that he was apply-
" ?: F  z' O$ Ving over his own shoulders, chest, and back area for
# D3 `1 k" U' o5 F+ Q" la year. The father also revealed he was embarrassed
0 a8 f. ]( B, d0 }8 n5 Z* S" zto disclose that he was using a testosterone gel pre-2 b8 x8 h; L  e( C9 u
scribed by his family physician for decreased libido6 p* D. I. u' _7 [# {' w  F" X
secondary to depression.0 l' t1 Y$ {) v* n: W5 {: ~
The child slept in the same bed with parents.
+ w) p8 W; Q$ Z1 ]$ t# r, |The father would hug the baby and hold him on his
( U, K; s$ o0 c& l$ _/ ^) _chest for a considerable period of time, causing sig-
: g; V0 ~# s) H! C" Cnificant bare skin contact between baby and father.
7 @$ R1 @3 J; q" a4 VThe father also admitted that after the phone call,. Z: n. n6 U' c/ p& y- \" c" O6 \  |& N
when he learned the testosterone level in the baby
3 h; `4 z$ o- x6 W4 p5 G  h6 U+ nwas high, he then read the product information0 }# U3 t( G8 ?& _# ?+ j
packet and concluded that it was most likely the rea-* d/ |% @8 n8 E/ `. N% s
son for the child’s virilization. At that time, they
' @6 F: j5 E, wdecided to put the baby in a separate bed, and the! J% p4 d/ ]5 e% r2 F3 J
father was not hugging him with bare skin and had, }0 ]" w  Z" |( J6 O! X
been using protective clothing. A repeat testosterone
' B$ J' j, z6 ?4 J/ R* @: Rtest was ordered, but the family did not go to the) i5 q7 d5 h% Z8 l( K2 k
laboratory to obtain the test.
+ [) d& l  D7 ]* ~7 Z% bDiscussion
- |4 a# l: v4 ~- A  c0 h+ F; P! xPrecocious puberty in boys is defined as secondary
& o) k. K* h& R3 Vsexual development before 9 years of age.1,4" ?0 B9 `; w( `0 p' E
Precocious puberty is termed as central (true) when
" T1 J/ b* ]  ?% ~" Kit is caused by the premature activation of hypo-
; R6 X2 {; ~2 d) V3 Athalamic pituitary gonadal axis. CPP is more com-5 e9 b/ K9 o. Q. C# ]+ b- B
mon in girls than in boys.1,3 Most boys with CPP. J8 T& {# U, H& ~2 Z+ G1 f
may have a central nervous system lesion that is
/ \/ l0 H* b" Y8 qresponsible for the early activation of the hypothal-
. b! h/ `# c6 C" t0 R  C1 i4 j; pamic pituitary gonadal axis.1-3 Thus, greater empha-
1 F# L- X# r* q; M3 m6 v3 `sis has been given to neuroradiologic imaging in
5 c' |" d% m8 x; R1 T. C1 Lboys with precocious puberty. In addition to viril-
5 h4 f) b/ h0 m! h* X  W3 Cization, the clinical hallmark of CPP is the symmet-
( X6 F. A( l4 Y& jrical testicular growth secondary to stimulation by
: X( M4 `' G( sgonadotropins.1,3  W, B" W. A1 c
Gonadotropin-independent peripheral preco-+ p: p0 ^, [; Z6 J7 z
cious puberty in boys also results from inappropriate. W6 K; N; v% B+ s+ Y
androgenic stimulation from either endogenous or# A. f, \6 w) k  y- [
exogenous sources, nonpituitary gonadotropin stim-
" [& h" F) W9 ^5 Lulation, and rare activating mutations.3 Virilizing
! ~# p+ [' M$ M: D. T: F* Xcongenital adrenal hyperplasia producing excessive
8 |, N1 ?$ q" nadrenal androgens is a common cause of precocious
0 M" n' V2 e' w9 Q, Spuberty in boys.3,4: C& U( T6 X- c7 m$ F7 P
The most common form of congenital adrenal
) H  s5 N4 {! w$ G5 lhyperplasia is the 21-hydroxylase enzyme deficiency.
' D: j4 E1 @0 z% k: Z) y  m+ Y+ ]/ |& B3 ]The 11-β hydroxylase deficiency may also result in
9 }" y$ F* c5 |1 {* s9 Fexcessive adrenal androgen production, and rarely,/ f. R  \  a  D1 K8 u, t$ B$ C, T
an adrenal tumor may also cause adrenal androgen
: s( K, _1 `5 q' ^, f6 @: L; Vexcess.1,31 y3 v3 ~+ n' H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# a# q- T7 m/ W2 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 _6 L9 w1 Z) J
A unique entity of male-limited gonadotropin-* n$ ^3 p( V$ [6 [7 q! ^
independent precocious puberty, which is also known
! ?' j  e  c/ I' d6 Pas testotoxicosis, may cause precocious puberty at a8 A; L' K7 s1 b
very young age. The physical findings in these boys
6 _- g& J& O% c2 c' a* |9 r* q% _6 Cwith this disorder are full pubertal development,
+ c8 A2 P9 a. h0 h: e7 P) Zincluding bilateral testicular growth, similar to boys  y& `$ m7 c0 S. Q" Q+ W; ~
with CPP. The gonadotropin levels in this disorder+ N! ^- g% U0 M: B) a
are suppressed to prepubertal levels and do not show
+ D+ b1 L8 J7 `$ K( s, T0 ?pubertal response of gonadotropin after gonadotropin-
4 r* f+ m) e  Z- c3 K9 oreleasing hormone stimulation. This is a sex-linked  D& b, _* h5 U1 q" e% F' C
autosomal dominant disorder that affects only. t! f; c* F$ o
males; therefore, other male members of the family
  S7 [% S3 Y; o% O2 T* h2 ]may have similar precocious puberty.3, M5 {) K, c: K2 u7 L
In our patient, physical examination was incon-8 B6 \" V6 b; y' K# |8 w
sistent with true precocious puberty since his testi-; T, A  n% f* d* Y9 F# [8 s' C
cles were prepubertal in size. However, testotoxicosis; w4 T0 D- O9 |3 i3 P
was in the differential diagnosis because his father
0 q* E4 y. P6 S6 R. o- j7 Gstarted puberty somewhat early, and occasionally,) m! X, k# U. w$ N4 _
testicular enlargement is not that evident in the
0 L: D3 g) i6 g1 D+ P  ebeginning of this process.1 In the absence of a neg-' A1 u, ?4 _% k
ative initial history of androgen exposure, our
4 N  M  c7 Q1 kbiggest concern was virilizing adrenal hyperplasia,
1 @2 Z2 P3 [' g# Ceither 21-hydroxylase deficiency or 11-β hydroxylase
, o- e7 T( m& r3 {5 cdeficiency. Those diagnoses were excluded by find-
1 B% h7 T; V, n: [& p- ting the normal level of adrenal steroids.
" E. ^+ W/ o4 J: ^6 r5 K5 r& oThe diagnosis of exogenous androgens was strongly
& {+ J3 v1 ^- ]suspected in a follow-up visit after 4 months because" a4 v! h/ j: b: j) c& O
the physical examination revealed the complete disap-
# t5 i, l2 b, F' D; a+ Ppearance of pubic hair, normal growth velocity, and
8 e( d; g; K: D( Y9 udecreased erections. The father admitted using a testos-7 W3 [  {# I- E. j! O% u/ g
terone gel, which he concealed at first visit. He was- Z6 @& w- w/ B! x7 [- l& j& y
using it rather frequently, twice a day. The Physicians’
8 q+ z  x! k! vDesk Reference, or package insert of this product, gel or
1 _( d" J! h# ]' d0 a& Tcream, cautions about dermal testosterone transfer to, x3 J* P* j; j% O9 x
unprotected females through direct skin exposure.
! Z. T$ s* G' u5 k4 e" oSerum testosterone level was found to be 2 times the& U* y. [" U1 ?; @
baseline value in those females who were exposed to. x4 }2 F/ s) A. k! N' [! E
even 15 minutes of direct skin contact with their male* w- i6 ^* u  W$ D' {& P
partners.6 However, when a shirt covered the applica-
! O9 [$ m8 P( I' ?4 i4 t9 m# Ttion site, this testosterone transfer was prevented.
3 V, f' v5 @3 A9 K6 ]Our patient’s testosterone level was 60 ng/mL,( A. S8 U2 m0 R- A/ m
which was clearly high. Some studies suggest that: v- \3 X* C9 P2 y: f0 K% @
dermal conversion of testosterone to dihydrotestos-1 D. c' r7 A9 u  U8 v
terone, which is a more potent metabolite, is more
6 j& T0 y- q# ?' \" o5 d1 qactive in young children exposed to testosterone
" L, N* H  U( F- G" ~, R3 C% yexogenously7; however, we did not measure a dihy-1 \7 ]( r- R1 b8 p$ n
drotestosterone level in our patient. In addition to  F$ |  o! e; }5 q( v
virilization, exposure to exogenous testosterone in
$ I2 K( z" U+ Z1 j; N4 `6 G6 R6 mchildren results in an increase in growth velocity and2 [# K# ]. q$ j$ Q, Y2 V2 ^0 B0 C
advanced bone age, as seen in our patient.$ u4 N0 Z" Y5 g) k* E4 t
The long-term effect of androgen exposure during( X5 W: s! a4 p4 m( R# E
early childhood on pubertal development and final
9 H$ q8 t2 ]% y' N+ W; b; G9 d  O; \adult height are not fully known and always remain8 ?! ^7 T; \4 ]0 `( b2 m. k' b
a concern. Children treated with short-term testos-
; g- M4 y8 f- d$ X- {+ }terone injection or topical androgen may exhibit some
2 z" A( U. X* S5 z: tacceleration of the skeletal maturation; however, after
. t7 X* U8 B1 ]- X2 d2 F: Ycessation of treatment, the rate of bone maturation
1 k# X& w. Z* q9 Udecelerates and gradually returns to normal.8,9
% s- B1 c0 O- v3 MThere are conflicting reports and controversy0 y% E7 b4 q4 P" Q. e$ |5 t$ l
over the effect of early androgen exposure on adult' Z0 Z* e* O6 X' @& `
penile length.10,11 Some reports suggest subnormal
  x$ t" M9 G% W7 G1 m0 Zadult penile length, apparently because of downreg-
- _+ v- X: D. H; z$ Fulation of androgen receptor number.10,12 However,
- @+ B9 D9 i) d6 LSutherland et al13 did not find a correlation between5 j( X6 m0 d  t6 \  ^$ }/ f
childhood testosterone exposure and reduced adult3 g4 T/ K1 r5 r0 z8 d
penile length in clinical studies.
5 m# i; w5 G8 P' JNonetheless, we do not believe our patient is& H" y, a) b7 O* N1 E
going to experience any of the untoward effects from
, s; [2 e1 m2 F# qtestosterone exposure as mentioned earlier because0 V6 x% R0 M% \
the exposure was not for a prolonged period of time.
% W1 b( m1 M* o9 ]8 _. r1 ]2 GAlthough the bone age was advanced at the time of! B" b. _% g7 |5 ]6 w, l
diagnosis, the child had a normal growth velocity at8 K& ~% s1 |* a! h2 q/ [+ O
the follow-up visit. It is hoped that his final adult5 t" v! [9 O8 m# }4 @# g( {) g2 {
height will not be affected.
9 y8 J$ J4 Y4 H' A( BAlthough rarely reported, the widespread avail-
' S9 Z5 c8 `7 @  iability of androgen products in our society may
7 C$ q/ t8 ?% L# B) D% t/ }8 A  findeed cause more virilization in male or female! w1 x1 ~2 F! r9 `2 O0 C4 f, ~
children than one would realize. Exposure to andro-
3 Q6 U1 E# c! a! e) |; d; n/ Hgen products must be considered and specific ques-6 T4 W# _2 ?- R( N6 ?" c% k
tioning about the use of a testosterone product or
8 t  v4 ]; [0 e/ v) }gel should be asked of the family members during" R( t0 d* a- g! @) _* p0 i6 q" ^
the evaluation of any children who present with vir-- ?0 G2 v/ N* |# p) P4 V1 }
ilization or peripheral precocious puberty. The diag-; n; d; R. R* ]) ~1 G
nosis can be established by just a few tests and by
) k! a& ~8 u" Qappropriate history. The inability to obtain such a
  [/ S/ x9 q6 m% O# }history, or failure to ask the specific questions, may9 J7 N- H6 T2 Q3 L/ \* Y/ \8 l+ `$ n6 K
result in extensive, unnecessary, and expensive- O0 P2 A2 _, X! F
investigation. The primary care physician should be2 v2 Z, d+ |3 Q0 |: ~: A
aware of this fact, because most of these children" q% V6 K( z+ V7 f
may initially present in their practice. The Physicians’
/ g6 t# G# V" n) ?4 v6 ^Desk Reference and package insert should also put a% Q. _6 O8 A4 b! b+ Z7 f: t0 v7 `
warning about the virilizing effect on a male or
& V. F) |0 O' u7 R; i2 E  ofemale child who might come in contact with some-
; x+ ^* m; Y7 U$ L8 a8 J. c" p% H5 none using any of these products.7 R2 \1 o! W  ]' V6 f1 ?" O
References
0 v" O( ^% C, ^2 H9 B1. Styne DM. The testes: disorder of sexual differentiation
2 s8 G! ^0 f) y; \0 g6 Rand puberty in the male. In: Sperling MA, ed. Pediatric  L! m& h3 m% E( q$ h* j9 B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! n4 [" q! a3 c; X; {! S4 @
2002: 565-628.: Y7 n+ ?; S4 x, U8 e4 \
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. v0 q1 W7 V" B  K) s) A' |
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
* L# d, z2 s! Z. IBoy Induced by Indirect Topical& N" N: }% o& _7 U: q. \. J
Exposure to Testosterone: p! ], G# d! U0 G, F
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 n- }, G$ _) U8 Eand Kenneth R. Rettig, MD1
/ j0 c2 V8 `, F9 @5 A5 N1 \0 hClinical Pediatrics
9 {2 `0 }. R( a/ l  I8 E- r! l" PVolume 46 Number 65 g! [9 _% E; F. ?( }% J- S; w9 s
July 2007 540-543' u) L2 L) z$ f( m2 y
© 2007 Sage Publications
% x6 G) a2 D) j  Z* s10.1177/0009922806296651
4 P& X0 H  e' @0 ]8 l/ j# whttp://clp.sagepub.com/ V) {' Q: G- w+ {5 ?) F- G
hosted at# c: {5 O$ Q! z1 @- C
http://online.sagepub.com
! Y3 Y0 K! C4 X. |7 j1 Z3 HPrecocious puberty in boys, central or peripheral,
% q7 ^# @& y, |0 lis a significant concern for physicians. Central
9 ]% o% V; s" b7 Iprecocious puberty (CPP), which is mediated3 }0 U8 H2 E0 j; p1 T
through the hypothalamic pituitary gonadal axis, has
0 }# ^2 q/ l! U* u& f. |1 R2 Y4 V/ Va higher incidence of organic central nervous system
0 R4 z. A9 ]( t9 d* ]lesions in boys.1,2 Virilization in boys, as manifested
. ~1 C( p* X: W" x" o" rby enlargement of the penis, development of pubic
( h; B! Y2 N# K, j5 Whair, and facial acne without enlargement of testi-
1 Z* E9 p, \7 S, D4 e% ycles, suggests peripheral or pseudopuberty.1-3 We3 B% a% O7 _, }  x# O: C
report a 16-month-old boy who presented with the
) r9 r5 w3 T8 r$ Y* Genlargement of the phallus and pubic hair develop-
1 }( D. Q( ~* Q( ^8 Fment without testicular enlargement, which was due- }- m$ h9 e6 B4 \# [/ d
to the unintentional exposure to androgen gel used by
+ ?# D- h. P3 r2 s/ \* Hthe father. The family initially concealed this infor-! u5 _. T; n* \8 {9 s
mation, resulting in an extensive work-up for this' B! A6 _* Q1 z5 K; k0 m- E; j
child. Given the widespread and easy availability of8 O: `/ Y  b6 O- a- `0 e7 ]
testosterone gel and cream, we believe this is proba-
: B# N; ?0 D* X. Y1 I* h$ Ybly more common than the rare case report in the. C  n% y5 x) L3 d/ X
literature.4( I5 \. z, k; l8 m, u+ d
Patient Report
: W: X8 N8 e5 u8 U' pA 16-month-old white child was referred to the
+ a' m) m$ z8 ^0 n6 B4 `  `& B' Bendocrine clinic by his pediatrician with the concern
1 b. P/ ^* u1 }of early sexual development. His mother noticed" n! H8 h2 n( _( _# e2 R1 u* b2 Z
light colored pubic hair development when he was
3 K& Z5 u. C% J1 zFrom the 1Division of Pediatric Endocrinology, 2University of
% }+ h5 H" ?: V; [, @: ASouth Alabama Medical Center, Mobile, Alabama.
1 O: K8 Q& D! K+ ]- s- }1 eAddress correspondence to: Samar K. Bhowmick, MD, FACE,: x3 _4 o1 y0 f2 m% f" J
Professor of Pediatrics, University of South Alabama, College of- ~& z' G8 G" [
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- C8 f+ [9 S8 Y: Q5 R) p( p
e-mail: [email protected].3 [; E# P& ~. ?0 u9 L
about 6 to 7 months old, which progressively became6 }' N' x# Q" v* n
darker. She was also concerned about the enlarge-% g4 S' ?! C4 q' R
ment of his penis and frequent erections. The child
: W8 P9 M" X% e7 ]& wwas the product of a full-term normal delivery, with
8 A& `/ m! @* P# H& [3 V3 N8 k; w0 ba birth weight of 7 lb 14 oz, and birth length of
1 [) `- d+ `/ T. d. x+ _- c4 x4 \20 inches. He was breast-fed throughout the first year
: w5 l7 a# K+ o/ N: x6 \1 d! r' Bof life and was still receiving breast milk along with& F. y2 I) B+ o  H3 y
solid food. He had no hospitalizations or surgery,7 H4 @8 u* I' Y4 @% R" R" a/ ?
and his psychosocial and psychomotor development7 p; c: G8 y: i3 [$ y" K9 @
was age appropriate.2 M+ E) y. W- r# k+ W
The family history was remarkable for the father,
8 n# f7 P& t( d3 @0 q  zwho was diagnosed with hypothyroidism at age 16,2 _" q$ w/ m5 ?& G) A5 l1 o
which was treated with thyroxine. The father’s
/ e5 ~% O  ?, z3 _7 Oheight was 6 feet, and he went through a somewhat
2 L  C) N2 U  b1 {+ l" t( F1 Bearly puberty and had stopped growing by age 14.8 R5 t3 B! G  N& [
The father denied taking any other medication. The
$ O% H# }8 V" C4 ~1 s& }child’s mother was in good health. Her menarche' I: _9 }+ e$ \5 S% X7 N2 k) @
was at 11 years of age, and her height was at 5 feet% ^8 N, H4 m  {1 |
5 inches. There was no other family history of pre-
1 O; f. Q$ Z/ V, H; q: ncocious sexual development in the first-degree rela-( Q  y! P2 ]' e# u
tives. There were no siblings.
) {* w3 Y, D8 c1 zPhysical Examination
& G8 z/ e% E( W5 F2 VThe physical examination revealed a very active,5 ^0 V7 @! g$ e5 }/ L( ?
playful, and healthy boy. The vital signs documented8 s: {8 s& B: s- e
a blood pressure of 85/50 mm Hg, his length was
0 T8 J/ V5 z* e90 cm (>97th percentile), and his weight was 14.4 kg
: Z7 S" c) w% E, G4 D(also >97th percentile). The observed yearly growth' ?+ M$ p6 I  x6 u5 A
velocity was 30 cm (12 inches). The examination of& m& p; ?# d: R7 X
the neck revealed no thyroid enlargement.
+ M8 ~, x$ n9 hThe genitourinary examination was remarkable for
/ u' P( k1 I  m% v9 R0 @" G6 senlargement of the penis, with a stretched length of' `9 |2 D/ p) ^$ r& ]
8 cm and a width of 2 cm. The glans penis was very well
1 Y9 R  j* a+ k1 a; ^) H0 ~2 B0 S! ^developed. The pubic hair was Tanner II, mostly around
9 d5 b3 s6 S! W540
6 u3 \% E) p+ A& t5 uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- Y- U$ b  S; m7 d1 A
the base of the phallus and was dark and curled. The
8 ^' E# V3 Z# L$ P' j( A6 vtesticular volume was prepubertal at 2 mL each.$ W' |9 i7 z1 ?# W
The skin was moist and smooth and somewhat+ x, w; G. B6 f$ X5 C5 ?" C
oily. No axillary hair was noted. There were no* }$ i/ W6 n* x, _
abnormal skin pigmentations or café-au-lait spots.
. o, o1 ^7 k# ]9 \$ C% v0 KNeurologic evaluation showed deep tendon reflex 2+
1 m' u/ C  i4 F2 F; g: h. h5 J! jbilateral and symmetrical. There was no suggestion
6 B" C+ b/ j: m; \9 {3 |! e# wof papilledema.7 `; F& m4 r7 Y4 m" J
Laboratory Evaluation
; D! Q9 i5 ~0 s3 r. y/ Q5 fThe bone age was consistent with 28 months by
4 N( b2 S4 C& T2 Husing the standard of Greulich and Pyle at a chrono-" U# i; j: j0 [0 Y
logic age of 16 months (advanced).5 Chromosomal
. w! B) V7 ~# v6 M( u  `1 Rkaryotype was 46XY. The thyroid function test
$ h: }1 C- W: ?* \showed a free T4 of 1.69 ng/dL, and thyroid stimu-- D; P, O2 |* Y% _; u# M& U
lating hormone level was 1.3 µIU/mL (both normal).
8 }' B4 q% A8 p9 {$ [The concentrations of serum electrolytes, blood; m/ c& Q) D$ @/ V4 i2 ~5 V) y6 Y
urea nitrogen, creatinine, and calcium all were
8 _5 r5 Q' p2 S; ^# d# Gwithin normal range for his age. The concentration* @/ }+ T# N' \. }' Z
of serum 17-hydroxyprogesterone was 16 ng/dL
3 i" |3 r: k8 o(normal, 3 to 90 ng/dL), androstenedione was 200 R- x" ?$ U5 h5 V# F$ s* q( D' n
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* C5 X2 D4 d! a! m9 z8 {% b) vterone was 38 ng/dL (normal, 50 to 760 ng/dL),' x$ N& C, U% B2 ^& V! x" Y1 ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 O% S/ k7 k0 Z* k0 n49ng/dL), 11-desoxycortisol (specific compound S)3 e/ w2 }/ [0 Q: C  c& T6 L: L) L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ w+ L, N5 k  M3 a) E/ btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 D+ s! P& j. H  ?( S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 j6 M; Q# b, W- L4 S4 ]- p
and β-human chorionic gonadotropin was less than+ |7 O1 N4 W3 n( A2 s
5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 y$ B. m1 i; k& h" U) j8 Kstimulating hormone and leuteinizing hormone7 P  v) z$ h; o5 ^  x$ h$ X6 H) t
concentrations were less than 0.05 mIU/mL
# b# g: v8 A' I(prepubertal)., [+ V( w% R% n- {# q6 h- o% {
The parents were notified about the laboratory
9 M6 Q* `8 N5 X8 g4 a( I3 Presults and were informed that all of the tests were
7 l! ?% V; |0 w7 A- p% j- s3 [& e: Pnormal except the testosterone level was high. The" E3 `4 G( f1 @1 l0 i9 O
follow-up visit was arranged within a few weeks to
/ ~0 f  e! T1 J' xobtain testicular and abdominal sonograms; how-
" m( B  N; z0 _% w1 ^0 \ever, the family did not return for 4 months.0 l% `: ]  g' k2 H5 c" h( E
Physical examination at this time revealed that the
' x) J5 k% g- e" Echild had grown 2.5 cm in 4 months and had gained
) v& G) a. T# `" F) Z7 h" r# K7 a2 kg of weight. Physical examination remained7 ~4 a7 O( E- A
unchanged. Surprisingly, the pubic hair almost com-
4 @8 R) _5 U" T5 A4 P4 _% q9 dpletely disappeared except for a few vellous hairs at6 ]# o6 T) t  V" x
the base of the phallus. Testicular volume was still 21 W7 N+ K; J9 t. p4 t3 ]: c, l, ^' e
mL, and the size of the penis remained unchanged.
; _$ d$ P' ~. L% d* P) mThe mother also said that the boy was no longer hav-
7 e% ^/ V+ `# L6 d) t% \ing frequent erections.
& d6 s; V0 v, m: \" mBoth parents were again questioned about use of# @; ]3 ^$ x& R: x$ a% \! s
any ointment/creams that they may have applied to
$ y% D9 j' s7 Q( G3 Ethe child’s skin. This time the father admitted the' _+ W) N; \: k% a
Topical Testosterone Exposure / Bhowmick et al 541
3 @/ s% Y4 i+ U6 Xuse of testosterone gel twice daily that he was apply-% O# |& T$ b4 s" q$ t- N% S
ing over his own shoulders, chest, and back area for6 Q+ \. h3 T; J& e# y
a year. The father also revealed he was embarrassed% L0 S1 D, [6 @# \' @
to disclose that he was using a testosterone gel pre-
0 ?2 p  \  p$ d: e: z. \scribed by his family physician for decreased libido
: k- T7 I0 }, |# m/ u: Fsecondary to depression.
* U: o; z  j( d% ?The child slept in the same bed with parents., K, @" W# H2 j% Y6 m+ l, m  O
The father would hug the baby and hold him on his
8 x! o% W- X, X; K& Fchest for a considerable period of time, causing sig-
  ^# G$ i. N/ C8 Inificant bare skin contact between baby and father.
, ^9 Z7 p( y) b5 Z7 \The father also admitted that after the phone call,% B$ d% y6 i+ B4 l
when he learned the testosterone level in the baby
/ y/ q  B% w1 m% f+ d5 _was high, he then read the product information- p* j5 c, `4 J# p( Z% u
packet and concluded that it was most likely the rea-+ ~/ S0 K3 H& V
son for the child’s virilization. At that time, they
1 [9 K7 ^9 M" z2 G# Adecided to put the baby in a separate bed, and the% d5 a3 k: `7 I6 m2 f- H/ ]
father was not hugging him with bare skin and had9 F* z: s6 p1 O, J( c$ }2 D3 q! g
been using protective clothing. A repeat testosterone/ j( D, e9 p% b, Q6 i* i' _1 N) K/ H
test was ordered, but the family did not go to the5 K; V! A5 w% {" I
laboratory to obtain the test.
7 }9 R' u' l+ {. E5 ?- VDiscussion
# ?* T1 u, h4 C2 O" d, N5 O: PPrecocious puberty in boys is defined as secondary
  d! M+ f4 I6 {9 Z6 q# i! Esexual development before 9 years of age.1,4" {& q& k! V* d0 J7 D4 N: ^1 u
Precocious puberty is termed as central (true) when/ G+ y7 j$ [+ u1 L8 A% e
it is caused by the premature activation of hypo-
  T3 v, F* O8 ]thalamic pituitary gonadal axis. CPP is more com-
. O' t! G# V, N, x8 r9 f7 Vmon in girls than in boys.1,3 Most boys with CPP$ g: r$ ?$ C9 }( e: q
may have a central nervous system lesion that is  z* U0 u; f4 ?8 r8 J$ v" @
responsible for the early activation of the hypothal-
( m4 ~- P6 A) I2 vamic pituitary gonadal axis.1-3 Thus, greater empha-
' u2 A7 }- g9 F# e( f4 V! @sis has been given to neuroradiologic imaging in
2 j$ n6 @) Q) j) }8 {* W) xboys with precocious puberty. In addition to viril-
3 j, z3 @2 `: s9 [: Bization, the clinical hallmark of CPP is the symmet-$ K: |  |' D# J" P- L
rical testicular growth secondary to stimulation by
4 F* ?  y7 ^' w5 H8 e/ Qgonadotropins.1,3
6 \( J% k$ t$ A! vGonadotropin-independent peripheral preco-
4 o) O% D/ ~3 J+ ccious puberty in boys also results from inappropriate2 b! _! N2 i- P
androgenic stimulation from either endogenous or
" K* g2 c; x9 lexogenous sources, nonpituitary gonadotropin stim-( v$ F3 `  O* M" O7 F* |3 O4 W
ulation, and rare activating mutations.3 Virilizing# i3 r+ ?; Q, m. p2 {4 U# [' ]' `
congenital adrenal hyperplasia producing excessive
" H) E$ z+ T% Z; g& qadrenal androgens is a common cause of precocious6 [. `: A. S4 h! O
puberty in boys.3,44 p4 C' `. v) u: V
The most common form of congenital adrenal
- C( ?3 l! N0 e/ `/ Lhyperplasia is the 21-hydroxylase enzyme deficiency.
( h. {& X$ O% z  s1 K% X: eThe 11-β hydroxylase deficiency may also result in3 [$ T  w2 M4 d
excessive adrenal androgen production, and rarely,7 i5 x0 N5 C  u9 f$ Q. n
an adrenal tumor may also cause adrenal androgen- I8 B: R6 {1 u9 Y- G
excess.1,3+ ]4 k7 p, N. i. K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, l! a, U. w* z( d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- ]; @' I6 b" L! J
A unique entity of male-limited gonadotropin-1 b% t6 i) e+ ?5 _* O
independent precocious puberty, which is also known
' E- v8 y: U! \  V- H: i7 l/ Sas testotoxicosis, may cause precocious puberty at a
- l1 b& v6 b8 q- V) F. a5 g$ Rvery young age. The physical findings in these boys
( f+ X1 v8 U9 |/ V" w5 o! j+ pwith this disorder are full pubertal development,
" Z# V+ _) @' b4 x0 S5 C. q# k4 qincluding bilateral testicular growth, similar to boys3 m& `; B) G5 W+ V% ^' I  D1 ^1 `# y
with CPP. The gonadotropin levels in this disorder
+ S+ I9 T( C. \, ~3 T: Ware suppressed to prepubertal levels and do not show' i- n6 M+ O) U. `
pubertal response of gonadotropin after gonadotropin-
" x2 d# N: r$ G5 K8 Rreleasing hormone stimulation. This is a sex-linked
1 u& j- l$ j/ H4 Q9 ~autosomal dominant disorder that affects only. O! W1 H. q% H5 f9 c, A1 j
males; therefore, other male members of the family2 k7 L, E' x) j/ x
may have similar precocious puberty.3( q% A# ~6 W7 X1 _- g; S) R* Y! `1 r% d
In our patient, physical examination was incon-
" r2 C2 t. m5 n4 F" }sistent with true precocious puberty since his testi-
: x, O3 g) Q* \7 t: n7 B: t& g" ucles were prepubertal in size. However, testotoxicosis
/ q0 S3 j" |5 s# F! gwas in the differential diagnosis because his father0 l' e9 R8 p+ S
started puberty somewhat early, and occasionally,0 y6 W+ f: V* N! o* J
testicular enlargement is not that evident in the2 Y9 `$ h4 h- ^
beginning of this process.1 In the absence of a neg-
! ~- ^  w! \1 H8 f6 {ative initial history of androgen exposure, our
9 s$ Z, k% S$ V0 h5 }biggest concern was virilizing adrenal hyperplasia,
5 v5 w5 }0 n+ h0 e1 Zeither 21-hydroxylase deficiency or 11-β hydroxylase; J1 x! w$ z  p
deficiency. Those diagnoses were excluded by find-
( z) u' t( z2 A" @ing the normal level of adrenal steroids.
: ^( R( }* s- q5 j9 sThe diagnosis of exogenous androgens was strongly# g* D0 ^# k# \+ [* @7 `
suspected in a follow-up visit after 4 months because
/ K& A8 }0 `" f: Z" uthe physical examination revealed the complete disap-+ i) A) z* P5 ]3 }4 m3 f7 F
pearance of pubic hair, normal growth velocity, and/ Z( N1 ]$ m5 ?1 r4 [
decreased erections. The father admitted using a testos-
* }( A  y: {* O8 {terone gel, which he concealed at first visit. He was9 j' m, @8 a! w5 _
using it rather frequently, twice a day. The Physicians’  E& e) j6 ]9 c2 m0 ?4 C5 }* F6 J
Desk Reference, or package insert of this product, gel or
! }2 ~. G: ]2 q7 S- \) L; W0 kcream, cautions about dermal testosterone transfer to
" \: k5 s, q% d3 ]6 n: bunprotected females through direct skin exposure.. W; B9 q+ L4 p
Serum testosterone level was found to be 2 times the
. R4 }. r0 Q8 e& w; w) @baseline value in those females who were exposed to
! F; `# S0 a+ r( w( M! |even 15 minutes of direct skin contact with their male
8 e( D# E9 h' m* _; gpartners.6 However, when a shirt covered the applica-
! H) Q. R5 ]. x; v5 B& T2 \% _tion site, this testosterone transfer was prevented.5 v; }  o1 [8 K4 f% r, V
Our patient’s testosterone level was 60 ng/mL,
  O2 S9 m, O3 }$ w& V0 E8 ]which was clearly high. Some studies suggest that
! Q" ^( j: h  Y7 n9 w  [/ q7 Hdermal conversion of testosterone to dihydrotestos-' F2 ~9 k% x1 ^
terone, which is a more potent metabolite, is more/ b! r& Z; q8 Y! M+ I
active in young children exposed to testosterone
1 j8 y$ n- J( O- T$ C# gexogenously7; however, we did not measure a dihy-
3 S/ A" j3 P6 y' Gdrotestosterone level in our patient. In addition to( C" R& C( a- `4 H  ?
virilization, exposure to exogenous testosterone in
0 e6 k- g9 z5 ^2 z1 g/ |children results in an increase in growth velocity and
9 |' x  b# J' }# h4 Gadvanced bone age, as seen in our patient.  i+ I- Q$ A- e- [/ |
The long-term effect of androgen exposure during
- l' D0 X) C' Pearly childhood on pubertal development and final
3 p2 Q5 K- G: A5 a/ H( kadult height are not fully known and always remain
1 D- I; E+ ]: V9 Wa concern. Children treated with short-term testos-: s' {1 \8 A$ C8 v  w# Q. K7 o
terone injection or topical androgen may exhibit some
- Y; p, X+ i" O) ^" Sacceleration of the skeletal maturation; however, after: J3 u/ ^" L  e8 N9 |; k$ r' S2 g' b: _
cessation of treatment, the rate of bone maturation0 d( F+ k3 `: z  m6 {
decelerates and gradually returns to normal.8,9
2 H; u* ?% {$ M* g! qThere are conflicting reports and controversy
- c$ _# j5 B, dover the effect of early androgen exposure on adult# [# {7 B  W# |
penile length.10,11 Some reports suggest subnormal
9 v* H% L: r8 Y9 Aadult penile length, apparently because of downreg-
0 e( N: j& u6 u" Sulation of androgen receptor number.10,12 However,! |: p% H% u. p
Sutherland et al13 did not find a correlation between
! y, e% r& P8 ichildhood testosterone exposure and reduced adult; x$ f3 \$ z) O( h- T+ \1 e
penile length in clinical studies.
* H  H7 ?3 b5 c* X  JNonetheless, we do not believe our patient is# Q4 D, Q0 I2 E; e+ l
going to experience any of the untoward effects from7 Y# t, y5 [' A& ~8 }/ W
testosterone exposure as mentioned earlier because3 m1 }# E1 B$ K& [: x
the exposure was not for a prolonged period of time.
8 ?) G6 w: |! ?/ F3 S6 Y* W7 JAlthough the bone age was advanced at the time of1 q& Y/ d. l5 z) c/ x0 U' d( d
diagnosis, the child had a normal growth velocity at
0 |+ r8 e4 ~3 ?& a6 c7 |the follow-up visit. It is hoped that his final adult
7 F7 G9 X8 M7 T/ a6 I% _height will not be affected." P9 V; H9 h1 N8 `5 k! t* S
Although rarely reported, the widespread avail-
- w2 K* y$ N* |: `: V) o& nability of androgen products in our society may1 q( M' w1 I, w- q' y/ i
indeed cause more virilization in male or female0 L  u  k; ^2 d( @( f% u
children than one would realize. Exposure to andro-
; ]. U, |' V! y. y1 kgen products must be considered and specific ques-5 k( ^) F3 V2 n$ r. s
tioning about the use of a testosterone product or# C- r1 \8 N1 L/ O
gel should be asked of the family members during) d* a: B  b/ L* f/ z5 S
the evaluation of any children who present with vir-7 o5 w/ O* A9 F- R
ilization or peripheral precocious puberty. The diag-+ {# j0 M. c+ M% Q( P5 [' ?9 o
nosis can be established by just a few tests and by! K2 w4 x2 b) r
appropriate history. The inability to obtain such a
( y2 g  m' e9 G+ j( ]! [3 j: Chistory, or failure to ask the specific questions, may
3 C+ Z. D# i8 h1 Presult in extensive, unnecessary, and expensive
% G/ t+ u) z8 ~investigation. The primary care physician should be
1 Y( ]& i5 Y( v; M! I  D) |aware of this fact, because most of these children4 _$ J% i4 g# I1 f$ I. _7 H
may initially present in their practice. The Physicians’
$ s( |6 {: i7 SDesk Reference and package insert should also put a
+ P+ @0 @1 L7 {1 R- ?; l" }8 kwarning about the virilizing effect on a male or( T' v. b8 v& N, t9 {
female child who might come in contact with some-
1 v3 M9 S; i6 I3 a# yone using any of these products.2 t, Y7 X2 z4 X0 D2 {* f
References
) N: N1 d) ?, \+ q! d3 `6 s1. Styne DM. The testes: disorder of sexual differentiation
8 ^9 C1 x! r0 p* Q9 g/ m+ K; `6 h4 xand puberty in the male. In: Sperling MA, ed. Pediatric' a1 ]- k2 J  [; d3 m# G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; s& z4 b: O! a5 l, s2002: 565-628.
) O- |  {+ `. H1 \& q& Z  d" b, P2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" C: u, I1 @; v1 |! x$ Ypuberty in children with tumours of the suprasellar pineal
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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
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

9 S9 f2 U* g( s2 I, w' Q0 [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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