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Sexual Precocity in a 16-Month-Old8 h% R( n' U, i1 W$ p0 ^/ u
Boy Induced by Indirect Topical2 H0 I' T1 _! u, l: H9 e1 R
Exposure to Testosterone
3 ~& C( M3 P! @, sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: s1 Z2 H. s# cand Kenneth R. Rettig, MD16 G3 `8 q4 j9 j1 A* f. F
Clinical Pediatrics
% w/ X1 `/ ?7 S. AVolume 46 Number 6
% |  w) `0 Q& G7 Y" `! |5 x# uJuly 2007 540-543. ]" {/ _0 B3 r7 i
© 2007 Sage Publications! B9 Z1 K' F3 ~& \
10.1177/00099228062966515 y% D; v; m' K- \# ^& m$ c" _
http://clp.sagepub.com
+ X( j; J9 m/ U) p( w) }9 w3 q! J# ^  ^8 Nhosted at+ E* L$ p" Z# L5 w% \3 G% X  Z
http://online.sagepub.com
/ H+ D* g# H; T4 u0 PPrecocious puberty in boys, central or peripheral,
& s( w  z1 f2 T* \4 _/ F* _" xis a significant concern for physicians. Central, R" F2 y7 @; O  t9 ?
precocious puberty (CPP), which is mediated$ u: @9 |; }4 j# e3 @) p3 B- F
through the hypothalamic pituitary gonadal axis, has, U! q. a: _+ _
a higher incidence of organic central nervous system
1 t- W' _9 D, _lesions in boys.1,2 Virilization in boys, as manifested
6 p" d0 k4 e  {. c, p. q% ?  [by enlargement of the penis, development of pubic( c, A0 L# [# z
hair, and facial acne without enlargement of testi-# ^8 g: d5 T& N# @" s
cles, suggests peripheral or pseudopuberty.1-3 We
+ K; k/ ]& u+ _$ ~: Sreport a 16-month-old boy who presented with the+ d: W9 @% {6 o) g1 \
enlargement of the phallus and pubic hair develop-
( m5 k1 A) K# oment without testicular enlargement, which was due5 C) q5 Q% \& X
to the unintentional exposure to androgen gel used by/ \2 l5 e! d! F1 i' Z" e6 H
the father. The family initially concealed this infor-' W0 ]' r) H; Y% u6 `$ M" u
mation, resulting in an extensive work-up for this
. b) W5 c& p4 Schild. Given the widespread and easy availability of
8 t- L7 c  z5 L* H* v5 dtestosterone gel and cream, we believe this is proba-
: `7 Z: P, h) L7 p& ~bly more common than the rare case report in the
" k4 v4 X. C$ T6 t. @5 l+ E% e) R: Eliterature.4
$ X% V  @2 w4 \9 O9 KPatient Report
; I6 C% e/ y% V5 E2 s; J4 VA 16-month-old white child was referred to the
3 m) I! ?5 x  Q) d% ]2 Y8 h$ yendocrine clinic by his pediatrician with the concern
5 e: O  P  I+ d+ C1 _5 P  X) C6 Xof early sexual development. His mother noticed1 `8 \0 N* _& w
light colored pubic hair development when he was
' a+ n, G. F: p7 Y/ xFrom the 1Division of Pediatric Endocrinology, 2University of0 _2 o# d9 x( }& L8 p
South Alabama Medical Center, Mobile, Alabama.6 ]2 Y& W- n' Y' V- n2 M% [
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 z2 D3 m' d0 _4 l+ _
Professor of Pediatrics, University of South Alabama, College of
) m& z  l) y" w. @. {6 lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( D. x6 ~/ M5 x* a, X
e-mail: [email protected].
$ ]9 X4 k% @6 Y+ f1 \( V+ I- pabout 6 to 7 months old, which progressively became
  f  ]3 E# L" \' k% Ndarker. She was also concerned about the enlarge-: e7 X2 ^# c6 ]" W, {
ment of his penis and frequent erections. The child
2 J! G/ ^0 c3 o4 g, ]# i/ gwas the product of a full-term normal delivery, with$ K% P1 H3 w: H: f# Z
a birth weight of 7 lb 14 oz, and birth length of8 U' a9 X) L7 S4 Z
20 inches. He was breast-fed throughout the first year
( F: P2 S/ O3 O9 jof life and was still receiving breast milk along with
6 ^7 b# m1 |; m# n4 ]5 y0 _solid food. He had no hospitalizations or surgery,
3 w) M: }! a9 q* h3 g( mand his psychosocial and psychomotor development2 a# r+ T( w* |2 F; v
was age appropriate.
0 m2 n/ G6 o$ q2 TThe family history was remarkable for the father,# U9 Q+ D4 q8 A
who was diagnosed with hypothyroidism at age 16,
3 y3 I0 F2 M1 L1 S9 ~which was treated with thyroxine. The father’s/ a8 a+ r" i) u9 s( p- R; L
height was 6 feet, and he went through a somewhat3 W1 W' K6 T: z2 R. _$ T2 A  s
early puberty and had stopped growing by age 14.
+ _  L% C& ^- VThe father denied taking any other medication. The
) `) g  n, }5 n) A( qchild’s mother was in good health. Her menarche
- r0 O! L& g, W. b2 Lwas at 11 years of age, and her height was at 5 feet
2 |/ Q7 y5 s1 B5 inches. There was no other family history of pre-( R1 V- U6 r; u% ]) {
cocious sexual development in the first-degree rela-' Z0 \* H. [1 N! y( Y2 P7 ^2 c, N
tives. There were no siblings.
$ f. T1 L+ L5 y" J8 n  HPhysical Examination. s) ^8 E, E, A  @! p5 }/ y
The physical examination revealed a very active,, [" Z4 }4 Q* ~! W1 V" V3 t6 Z2 s
playful, and healthy boy. The vital signs documented. d( F( A" w: G" ?' g
a blood pressure of 85/50 mm Hg, his length was
0 I) z6 `3 V0 ]' B& U0 |2 o3 f90 cm (>97th percentile), and his weight was 14.4 kg; n; S, q8 S" Q+ N3 e: y
(also >97th percentile). The observed yearly growth4 q1 [# C3 `" _
velocity was 30 cm (12 inches). The examination of; J7 R# Q* F: D" G5 F+ {) \
the neck revealed no thyroid enlargement.
& u; F$ ]/ j2 F4 G0 T1 PThe genitourinary examination was remarkable for/ G6 A! i. J0 f6 ]& }
enlargement of the penis, with a stretched length of
) o, `5 B+ r6 `8 cm and a width of 2 cm. The glans penis was very well! j9 a& I& X7 b$ Z. v( J
developed. The pubic hair was Tanner II, mostly around* U7 [: _; v$ [; b- l
540
- O+ j, t% B' X" `8 L8 L7 w3 @0 Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  J3 ~" k5 t7 j" g4 z/ W* Fthe base of the phallus and was dark and curled. The0 S  Q  M7 Q4 B5 m8 u( v0 f, u; d$ N/ p
testicular volume was prepubertal at 2 mL each.6 ~! Z9 O6 V" {$ y2 q3 L2 @
The skin was moist and smooth and somewhat+ Q: J0 a' G9 G: I
oily. No axillary hair was noted. There were no
) H6 Q; z! R* a$ yabnormal skin pigmentations or café-au-lait spots.4 i6 \- ]5 p" ?) Q2 U
Neurologic evaluation showed deep tendon reflex 2+1 J7 t- _2 K2 n* k5 D* I. Z
bilateral and symmetrical. There was no suggestion
. y  M# U4 R7 n. W  r8 gof papilledema.
' L0 Y1 P$ l/ w% M8 c  ILaboratory Evaluation$ {* a* |2 a% O) s  K/ _
The bone age was consistent with 28 months by8 \# ?6 q$ a: }+ }) D4 B  ^! f
using the standard of Greulich and Pyle at a chrono-
" c1 q# x3 D, q7 l. k, n& z7 ~9 `logic age of 16 months (advanced).5 Chromosomal
0 u; a6 F* q1 N  i9 }5 [karyotype was 46XY. The thyroid function test  e/ m; B! S7 X0 x$ r
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# ~6 N2 S4 O4 P8 |& Y0 P
lating hormone level was 1.3 µIU/mL (both normal).
& s7 ~, g  X% ^- T/ Z, a8 k: D* TThe concentrations of serum electrolytes, blood
3 Y9 O! p7 K) y$ E( Xurea nitrogen, creatinine, and calcium all were1 x  i4 Q6 h5 Q% e: r: l% p2 h
within normal range for his age. The concentration
2 e) y; m! s( k5 `! P" g+ y& `of serum 17-hydroxyprogesterone was 16 ng/dL& Y2 \/ q/ N. _# X, p- t- {
(normal, 3 to 90 ng/dL), androstenedione was 20
; k' U$ X* Q5 f# I# i7 B% ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ r$ O& w; o8 b8 L4 ]; O. w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% M6 S8 @' @5 ^' l/ s4 ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 s" p. }2 G# i. i( H
49ng/dL), 11-desoxycortisol (specific compound S)/ H- D) W: ~4 B/ k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 }" r5 f4 y5 [3 ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 E% O: ]& g% Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' C; D6 P/ [0 x' o; a
and β-human chorionic gonadotropin was less than
1 j; R  v5 m6 K  |0 }5 mIU/mL (normal <5 mIU/mL). Serum follicular3 z* I+ `3 G+ x/ S; Y% T
stimulating hormone and leuteinizing hormone  H* _  ]$ C, h8 g. T
concentrations were less than 0.05 mIU/mL
  Z: I6 i5 J& @6 Q% a) ]5 n(prepubertal).' y6 R/ I2 Z% g0 Z; k% r
The parents were notified about the laboratory
& i1 d2 V6 l! P# m# [results and were informed that all of the tests were
; S9 [7 W4 @" x% E% `, rnormal except the testosterone level was high. The
6 i2 N3 _3 V, k* \0 cfollow-up visit was arranged within a few weeks to
$ E$ y5 ?# l6 C, z5 @obtain testicular and abdominal sonograms; how-0 V. V- b/ g3 s: p$ V. r' s4 q
ever, the family did not return for 4 months.
7 v; B$ ?. t  i. UPhysical examination at this time revealed that the
2 U( W' k3 T: f+ achild had grown 2.5 cm in 4 months and had gained9 k9 x) l' \8 f/ E0 g3 b
2 kg of weight. Physical examination remained# r1 a, g8 Q; R( `; Y
unchanged. Surprisingly, the pubic hair almost com-
( U# b" Q$ ]+ apletely disappeared except for a few vellous hairs at) X0 i- T5 M8 B- _' g% M% \( O; y
the base of the phallus. Testicular volume was still 2
; l; x' @7 f/ L3 BmL, and the size of the penis remained unchanged.
6 H% W9 Q. k( |6 z6 SThe mother also said that the boy was no longer hav-
+ ?/ b* n$ {5 s( |ing frequent erections.- D5 @1 C, a2 u" `! [3 |0 D/ x
Both parents were again questioned about use of, S& ~# _* T% {  M/ k  Y! U
any ointment/creams that they may have applied to
* C. d' Z2 Y! ~9 Y0 O& Zthe child’s skin. This time the father admitted the# q1 F4 c7 C1 Q; C0 k* W  I5 l
Topical Testosterone Exposure / Bhowmick et al 541
; P, \1 ]8 e3 L+ F2 D8 @& Vuse of testosterone gel twice daily that he was apply-0 `1 l. v" c3 B4 y4 t
ing over his own shoulders, chest, and back area for
$ I0 O2 X% x' s: pa year. The father also revealed he was embarrassed
0 n/ b% Y6 P' Q# a8 U2 mto disclose that he was using a testosterone gel pre-- x1 s2 J9 B7 Y9 i6 B
scribed by his family physician for decreased libido4 p  k+ L9 b: k4 F
secondary to depression.
; n5 L3 e4 M& D5 p* h1 d% nThe child slept in the same bed with parents.
& g8 ]5 l% R, w& ^The father would hug the baby and hold him on his2 i7 A. |; V) d& a2 j1 P) [3 G' I1 s
chest for a considerable period of time, causing sig-2 C4 R5 e& T3 h% |' \
nificant bare skin contact between baby and father.( G$ @4 j; o4 W! b
The father also admitted that after the phone call,3 [& e3 i8 C' |! {; B* z1 i
when he learned the testosterone level in the baby
* g- Q7 e9 d: L! h- ewas high, he then read the product information
1 [* U* J8 U# B7 @packet and concluded that it was most likely the rea-5 C, o4 g/ \$ P1 q6 b/ b
son for the child’s virilization. At that time, they( v" {, T6 S5 Q' }8 j
decided to put the baby in a separate bed, and the
/ }$ I; ]. t! |5 g: E4 l* [, Gfather was not hugging him with bare skin and had& o4 n# B7 ~% p$ F' }0 G1 ?3 r
been using protective clothing. A repeat testosterone* u1 p, H$ ~' ?8 J& o9 R7 {
test was ordered, but the family did not go to the
5 U7 R: o' K. v9 I! @- }  Klaboratory to obtain the test.+ w3 W: Y2 ?) g1 p' N
Discussion
4 S" R" ]; O$ R) V1 e5 bPrecocious puberty in boys is defined as secondary
6 L0 Q  [+ ^0 E8 }$ t. o1 Isexual development before 9 years of age.1,4
: E2 X+ }! s% ]! H5 JPrecocious puberty is termed as central (true) when* |2 q: D' k# z2 |
it is caused by the premature activation of hypo-
# U( O( b4 G1 Z6 k* F, P) ]thalamic pituitary gonadal axis. CPP is more com-( `! F. m1 h1 @3 z
mon in girls than in boys.1,3 Most boys with CPP
& @+ g" T: G# R' Y3 ^may have a central nervous system lesion that is
- u/ u1 v* D' Yresponsible for the early activation of the hypothal-2 l: a3 ~. Q7 X* L! l5 ^) n6 E* A
amic pituitary gonadal axis.1-3 Thus, greater empha-" h% c- N1 S3 f4 h
sis has been given to neuroradiologic imaging in
# }8 o! O7 [8 U+ |; E; Bboys with precocious puberty. In addition to viril-9 B8 t$ ?$ Q# S( _! H2 Q. F
ization, the clinical hallmark of CPP is the symmet-0 e5 i0 R3 Z9 ?5 f6 |
rical testicular growth secondary to stimulation by: I- G2 _# H6 X4 [, f# O
gonadotropins.1,3
; y. \3 |/ D# n" V3 V$ y+ v: wGonadotropin-independent peripheral preco-
* y) N' I* G0 G. K9 c8 Y: J6 f8 r+ Ycious puberty in boys also results from inappropriate
1 a* c; [* U+ E# }% h6 {androgenic stimulation from either endogenous or4 ^6 Z! [0 ~5 r
exogenous sources, nonpituitary gonadotropin stim-
& D/ r" ?; [) vulation, and rare activating mutations.3 Virilizing3 [  N$ w8 F- e
congenital adrenal hyperplasia producing excessive
5 T  p9 g. R  t# n8 l  _adrenal androgens is a common cause of precocious! P, n( j' r+ h: o8 ]) Q+ e1 E
puberty in boys.3,4. j0 p, N* O7 H& l
The most common form of congenital adrenal
$ r3 u) l; e- m' T" lhyperplasia is the 21-hydroxylase enzyme deficiency.$ Y( `0 H$ b1 Y( I$ s9 V+ J" z: l
The 11-β hydroxylase deficiency may also result in6 ~) X5 b( L2 }+ [
excessive adrenal androgen production, and rarely,9 o, V/ I: x/ h0 L
an adrenal tumor may also cause adrenal androgen
! H( p9 P3 U9 `) aexcess.1,3  c4 P( |- ?& N; U. C, \7 q  C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 \8 _6 |: p0 Q& v  }! ]542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 @5 }# k/ a' n3 F, c, R) m
A unique entity of male-limited gonadotropin-
, n& t8 w, H$ J9 m7 mindependent precocious puberty, which is also known' H5 f6 H) x! m" j- z$ [7 ^
as testotoxicosis, may cause precocious puberty at a
3 ^. P- R. C' m- L, f; |very young age. The physical findings in these boys
+ V* _: A3 d7 D6 z1 V- `5 Mwith this disorder are full pubertal development,
6 i# A* W; O, Eincluding bilateral testicular growth, similar to boys
$ o' O; O0 y1 s* Jwith CPP. The gonadotropin levels in this disorder0 j, q1 Q$ D. X
are suppressed to prepubertal levels and do not show7 h8 \6 D& m2 Z
pubertal response of gonadotropin after gonadotropin-$ W3 F& z& P5 h  D' X% a4 v' P
releasing hormone stimulation. This is a sex-linked
% P0 k! @3 Q: Bautosomal dominant disorder that affects only
/ e7 C' p: u9 C; Imales; therefore, other male members of the family
7 g2 Y1 Y, P# Y1 Z4 d1 d2 ^& A+ Gmay have similar precocious puberty.3
  {1 F9 v6 O+ ]$ ~  qIn our patient, physical examination was incon-
, t0 x& e+ r2 W5 |3 @9 y4 Fsistent with true precocious puberty since his testi-0 C; C' k- g, F- b9 [
cles were prepubertal in size. However, testotoxicosis
9 W5 U! J6 v) M: k6 Qwas in the differential diagnosis because his father
1 ?! l) k* g" r* L* j) j2 I; s9 Ystarted puberty somewhat early, and occasionally,' v! t, o9 L- g
testicular enlargement is not that evident in the
0 J2 f9 x& l3 n2 k  Y( D7 Kbeginning of this process.1 In the absence of a neg-
" h! I% r1 z! s# u+ I. R* ^4 Qative initial history of androgen exposure, our
/ C( o+ r1 N6 E8 {! z* q4 ~) x8 |, e& {biggest concern was virilizing adrenal hyperplasia,9 M) ?; o* @! u
either 21-hydroxylase deficiency or 11-β hydroxylase
% K) l3 K! [+ V% u& {) r+ [deficiency. Those diagnoses were excluded by find-
4 A+ I2 K) Y5 ~2 E" K+ Ning the normal level of adrenal steroids.
) X) L0 V+ G4 T5 A- L* fThe diagnosis of exogenous androgens was strongly
, }3 E) j% B8 l+ A0 ~# a8 i+ `suspected in a follow-up visit after 4 months because
$ H" Q: C+ L6 k/ Bthe physical examination revealed the complete disap-8 B% [8 O/ m' Q
pearance of pubic hair, normal growth velocity, and
, Q  R8 d' z+ {/ X6 o( S" y9 [& Cdecreased erections. The father admitted using a testos-
& q& ]& E& Z5 hterone gel, which he concealed at first visit. He was  H" G4 B. M2 @0 A4 ^9 z& X$ I
using it rather frequently, twice a day. The Physicians’( }+ o  o' W+ }1 g" t8 {% E) j
Desk Reference, or package insert of this product, gel or5 N5 ?; W+ O8 Y% r& O: r
cream, cautions about dermal testosterone transfer to
. f% a' H' V. M) i3 Z" b, S: punprotected females through direct skin exposure.
$ ^) x  m, `* `( Q; K, `* P- ySerum testosterone level was found to be 2 times the, s& E8 B/ Q2 o# X
baseline value in those females who were exposed to
6 a. S' r9 q, P  ?, k# X, |even 15 minutes of direct skin contact with their male4 ^6 C: @6 M% N8 |* y
partners.6 However, when a shirt covered the applica-6 i9 n" u! n- k5 n6 }+ `9 f
tion site, this testosterone transfer was prevented.* L! o+ e7 C: ^2 h; o7 X
Our patient’s testosterone level was 60 ng/mL,9 M8 E$ y. r- `& ~2 q
which was clearly high. Some studies suggest that2 \* M1 R1 n# g9 B& r
dermal conversion of testosterone to dihydrotestos-
$ s1 K2 K  ~3 q7 k9 L' h- oterone, which is a more potent metabolite, is more( @* c  Z$ t# X  [9 D0 I
active in young children exposed to testosterone! ]( I3 r- j1 W$ u: o
exogenously7; however, we did not measure a dihy-3 Y+ H& `  B. u3 j
drotestosterone level in our patient. In addition to0 N( J+ z, T# J
virilization, exposure to exogenous testosterone in0 d7 D& \! G: _- t/ Y1 m
children results in an increase in growth velocity and3 k2 ^) X( G0 r! s0 a+ P
advanced bone age, as seen in our patient./ h. ]( ]5 B, q- G
The long-term effect of androgen exposure during; j# \# x+ o( o3 `% W/ L
early childhood on pubertal development and final4 z/ X. F5 w9 `- `5 G
adult height are not fully known and always remain' i* C, U6 ^* ^
a concern. Children treated with short-term testos-3 o; x: `: g4 q' B: h
terone injection or topical androgen may exhibit some
* @$ v- Z8 J# j2 g( h* z4 L& }acceleration of the skeletal maturation; however, after- k. m7 o! r# ~- ~. H
cessation of treatment, the rate of bone maturation3 f' I! b/ Z) X8 ]! L5 {& U
decelerates and gradually returns to normal.8,9
2 M1 f: j1 a3 E$ k/ {7 `! jThere are conflicting reports and controversy5 S; H! T: z- q: \* e6 b
over the effect of early androgen exposure on adult
. M# C2 T) {8 ]0 kpenile length.10,11 Some reports suggest subnormal$ T7 v. c. K0 H6 {4 }- L  v
adult penile length, apparently because of downreg-5 K% J9 o, e1 V. O3 E: E* J3 W/ x, H# f
ulation of androgen receptor number.10,12 However,: w9 l) X; \$ L1 {4 G& p+ g' |
Sutherland et al13 did not find a correlation between; P1 E& l/ F0 I. O: I
childhood testosterone exposure and reduced adult
7 z( W4 ^, U' j5 h5 mpenile length in clinical studies.
" w6 H. c/ K- i7 B4 V; j! D* GNonetheless, we do not believe our patient is
- _3 x: w3 y: Vgoing to experience any of the untoward effects from5 m  q- q8 q+ P8 F0 o, @  ?
testosterone exposure as mentioned earlier because. l9 }9 l( E+ Z7 Z3 I
the exposure was not for a prolonged period of time.$ O4 Q2 p( R' ^* K; F
Although the bone age was advanced at the time of
) m  ?$ _7 q- O, U6 Fdiagnosis, the child had a normal growth velocity at
: T( q* F% K7 t1 {* L5 {# I; t& C& nthe follow-up visit. It is hoped that his final adult
0 B% H* U9 ~8 G: H3 ]6 Fheight will not be affected.# @) A" ]# U7 W6 q/ |& U& Y' A
Although rarely reported, the widespread avail-
" b2 b3 W: s4 q) f, A$ J3 lability of androgen products in our society may3 M4 x5 O  s- Q4 ?% r' |8 }
indeed cause more virilization in male or female$ ^7 i4 \# K5 B& A) o. R8 j- @
children than one would realize. Exposure to andro-; U$ h' t! J& A, c( q5 Z$ l. s- K
gen products must be considered and specific ques-; B+ o) `" }, R( h* U% y
tioning about the use of a testosterone product or
$ `2 N! M, I1 a, {2 S. J9 F3 dgel should be asked of the family members during
3 R+ |) H: {# q- u7 i2 @; h/ Wthe evaluation of any children who present with vir-
2 Q3 N+ G+ O9 o! ^* ]$ }ilization or peripheral precocious puberty. The diag-' S& G# Z" f- f* h( z8 A* s/ V) |2 u
nosis can be established by just a few tests and by0 l8 X. G& y! f, _( o
appropriate history. The inability to obtain such a
5 {8 K  R5 c: k2 g+ Y$ \" dhistory, or failure to ask the specific questions, may
% Z9 I# ~7 d0 g0 M9 W. hresult in extensive, unnecessary, and expensive  ]. v( J# b, A, d6 Y2 F
investigation. The primary care physician should be3 K( Y- _" ?# F+ ?- G- I% a( E
aware of this fact, because most of these children! p2 C1 p, c4 S, K- M6 Q$ ^
may initially present in their practice. The Physicians’1 p9 O( d/ }, I) T$ i. _
Desk Reference and package insert should also put a: O) R; P' B4 Y5 F
warning about the virilizing effect on a male or& O+ t3 w8 P& q3 K
female child who might come in contact with some-8 j2 W2 e/ ^( U# R4 D7 |) R
one using any of these products.
& `! I# k$ [: W/ V8 f; A! {References
9 Y0 }' D3 d+ {3 D: c/ ^7 c! D' o' R1. Styne DM. The testes: disorder of sexual differentiation9 @# H3 V6 n; x: }  V
and puberty in the male. In: Sperling MA, ed. Pediatric
) @: j1 }8 f' L9 S4 uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 T" x  v6 H4 ~2002: 565-628.
4 j6 l- Q2 s- C0 \, q4 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" e+ u0 P  B0 v3 M  x  h
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
: b0 a5 d, ?% ]9 PBoy Induced by Indirect Topical! ~3 G/ p2 B3 Z: q; ~! X% c  W
Exposure to Testosterone
, W# N) @0 @" _, N) D9 GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 _4 W2 e& W, J* a1 w/ C9 ?
and Kenneth R. Rettig, MD14 F. l" `4 `$ s  j) b; H4 ]
Clinical Pediatrics& J2 U7 ]  |$ A7 \
Volume 46 Number 6
9 s: N( \# c; vJuly 2007 540-543
# |. M/ u3 O+ m© 2007 Sage Publications2 d% J1 e7 d2 s3 ]  I# i! w
10.1177/0009922806296651& B: Q: V: F2 ?7 V' o
http://clp.sagepub.com
+ g$ f9 m3 ]6 W0 M( f5 T: X! D3 {hosted at
) |5 n$ }+ t3 Qhttp://online.sagepub.com
* Q2 D4 w- A' yPrecocious puberty in boys, central or peripheral,, I. J+ z7 S' \# |) n3 F4 J! a
is a significant concern for physicians. Central$ C# B" g8 O" O- I8 Q
precocious puberty (CPP), which is mediated  j4 m/ i- n" E7 Z, y% m
through the hypothalamic pituitary gonadal axis, has3 d$ R& w  b, v3 n4 f
a higher incidence of organic central nervous system
  y, c- b) L/ l1 vlesions in boys.1,2 Virilization in boys, as manifested
+ {$ U7 P( K" @6 vby enlargement of the penis, development of pubic
3 T/ v) k) L( u) Z4 \7 v2 m/ U0 I0 Yhair, and facial acne without enlargement of testi-% F- B( b3 B+ A3 t
cles, suggests peripheral or pseudopuberty.1-3 We# Y- ]1 \( W- F# G; P7 e
report a 16-month-old boy who presented with the
' A) c) Z9 Q+ E  L" _' ?0 U. henlargement of the phallus and pubic hair develop-6 g2 x* I0 s" M+ x3 t( U
ment without testicular enlargement, which was due( K4 T' i0 V4 m6 [! {3 d+ O
to the unintentional exposure to androgen gel used by
5 G! [$ c- F# K8 r7 tthe father. The family initially concealed this infor-
7 d# {7 g4 N3 c4 m8 ^4 C  Qmation, resulting in an extensive work-up for this* b& [5 A4 f3 |$ N" U: p+ k
child. Given the widespread and easy availability of
! p9 z! a3 `5 {4 G2 [testosterone gel and cream, we believe this is proba-
0 |* j: n4 p0 Y1 A5 ebly more common than the rare case report in the
  t4 I4 s4 l: _  w- q' Qliterature.4
* h; c4 d4 q$ |# `! p2 g2 QPatient Report
8 g" X/ d& r; o: RA 16-month-old white child was referred to the
. [5 I  Z9 q, a$ R/ F% \" n# cendocrine clinic by his pediatrician with the concern
% N: Z  [1 |* _1 Rof early sexual development. His mother noticed7 {9 l9 X% @7 |- ?
light colored pubic hair development when he was
# p, S3 _- x/ I! m) T! oFrom the 1Division of Pediatric Endocrinology, 2University of
4 z6 K! l% V9 j" L& }" u6 ]South Alabama Medical Center, Mobile, Alabama.: H: C* a  @1 s, z* \9 L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 |* [8 e% F5 j. e& yProfessor of Pediatrics, University of South Alabama, College of
: F/ Y9 T8 l" S1 |; mMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- Y; a! ~+ L+ ee-mail: [email protected].) a; T; K% d' M
about 6 to 7 months old, which progressively became0 }3 y! |, v+ R' q7 R5 O( y
darker. She was also concerned about the enlarge-
! _3 S  m" P- H5 L( I, X# V% R. sment of his penis and frequent erections. The child, ]' `0 u7 f$ l7 H, P9 @7 E
was the product of a full-term normal delivery, with
' j2 ~$ q) ]9 t, e  g: Ia birth weight of 7 lb 14 oz, and birth length of4 G+ R' _; Z5 p8 j$ [1 z0 }
20 inches. He was breast-fed throughout the first year
. A6 c  N  A) g6 S- y& _of life and was still receiving breast milk along with
1 p3 J0 x6 _' `+ Y, \* \0 Ysolid food. He had no hospitalizations or surgery,& p" @/ v7 m' V
and his psychosocial and psychomotor development
+ L- E; H9 }8 C, Q0 K5 E0 dwas age appropriate.
7 N( a0 X) V- c+ i# `6 |# VThe family history was remarkable for the father,
1 v' J6 v' p0 ]7 rwho was diagnosed with hypothyroidism at age 16,
/ r! i+ ~" x* \1 q1 l- c1 |: mwhich was treated with thyroxine. The father’s- j5 F2 L4 S0 o  Y4 W6 e* H
height was 6 feet, and he went through a somewhat
" E3 w) A: p, {9 bearly puberty and had stopped growing by age 14.2 d) `/ M( V3 q8 E. S1 U
The father denied taking any other medication. The
; p! @; X, c" @4 s: `child’s mother was in good health. Her menarche" t/ H5 e" K) x3 P! b; k3 }
was at 11 years of age, and her height was at 5 feet6 |3 ]6 M( i8 z+ K( O& r
5 inches. There was no other family history of pre-; ~- v0 b6 |3 x9 a" Y+ ]9 p7 k
cocious sexual development in the first-degree rela-1 n1 C* k& Q( W2 P$ Z" D$ D2 `; J; A0 ]
tives. There were no siblings.
# J' l) F7 s  ^6 X2 SPhysical Examination
4 O8 A' W7 O) t4 P* DThe physical examination revealed a very active,7 A% q3 Q3 y! W$ w" s  Q7 t( j
playful, and healthy boy. The vital signs documented, I0 u* O. r, S6 k0 s9 [7 S
a blood pressure of 85/50 mm Hg, his length was( O3 F- j; Z( b! T/ ~! P
90 cm (>97th percentile), and his weight was 14.4 kg( p1 Z2 u8 q( J+ v, L
(also >97th percentile). The observed yearly growth. `/ ^$ O" b4 J$ B0 l
velocity was 30 cm (12 inches). The examination of- Y! B$ s  Z4 {( e( r) Q
the neck revealed no thyroid enlargement.! n7 W1 ?' s8 A; n
The genitourinary examination was remarkable for! W) U& Q! O( o$ S6 m  @' T5 W. Q- x
enlargement of the penis, with a stretched length of" V/ `6 a" R8 D' d
8 cm and a width of 2 cm. The glans penis was very well
: j4 D" |5 U* M; l5 q% Mdeveloped. The pubic hair was Tanner II, mostly around8 o+ ~3 g# O) F5 l$ @
540
8 m' k6 M# V$ J, F% y" zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ ]5 t. Q+ ]5 w' Z! qthe base of the phallus and was dark and curled. The
7 F$ A" i% E+ }' v, U4 Ztesticular volume was prepubertal at 2 mL each.
9 O, l/ u( Z, R8 z. y6 z# ?" gThe skin was moist and smooth and somewhat
% n' H2 ~5 T, n' noily. No axillary hair was noted. There were no) f1 d- \0 f+ `
abnormal skin pigmentations or café-au-lait spots.
* u+ @$ n. r6 N' o! k# ~6 Y; nNeurologic evaluation showed deep tendon reflex 2+
& n1 k$ R+ z& `; u& E+ j" s" fbilateral and symmetrical. There was no suggestion
! D) R/ a+ x3 _+ O9 N- y/ rof papilledema./ W! q6 s" O# D
Laboratory Evaluation
* `8 |7 f( {3 E( e2 y" f. |; M! nThe bone age was consistent with 28 months by; J+ r+ H3 C! `0 k$ ?
using the standard of Greulich and Pyle at a chrono-1 [( e; w- N. D1 g. b4 m
logic age of 16 months (advanced).5 Chromosomal
  X- {9 t2 S3 i6 @: T4 lkaryotype was 46XY. The thyroid function test
& ?$ C8 s+ N( oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 s/ c. _4 X' Elating hormone level was 1.3 µIU/mL (both normal).
0 K! ~9 L+ x/ l0 O8 h4 C( e& J! }  Z4 RThe concentrations of serum electrolytes, blood
5 [3 W- p' W3 ]; i! [urea nitrogen, creatinine, and calcium all were+ v: u. [0 |; p$ n/ \/ l
within normal range for his age. The concentration
1 S- o# Z6 T' Bof serum 17-hydroxyprogesterone was 16 ng/dL
6 x4 ~# t( L' p8 {3 I3 u(normal, 3 to 90 ng/dL), androstenedione was 20
+ z6 E9 H+ d9 y  j: j4 Nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; }* N) |& t& p6 N% Z3 ]" c- C0 d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( z' l  N+ N- G6 a/ Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to, {* T0 Q9 @' m' s' D
49ng/dL), 11-desoxycortisol (specific compound S)
$ D  b0 E- M% c, ]0 X& A6 @, lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# `7 b. v% O; _  V5 C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ N/ t$ V) C% d) ^5 N3 @9 E! Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* y" \/ A9 X3 N+ @' p* D
and β-human chorionic gonadotropin was less than
! j, u. P' Z' M/ W0 s& Z1 h5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 R0 m. v5 ~% P8 ystimulating hormone and leuteinizing hormone: {3 O' r. R% \3 K3 Q7 C
concentrations were less than 0.05 mIU/mL% v/ M5 w- d9 m8 v( \
(prepubertal).( G& P( f" v( ?" U1 _
The parents were notified about the laboratory! B4 o  S' q2 w. z$ b  d+ e% X8 c
results and were informed that all of the tests were. n* B8 u  Y. S) ]. w! I
normal except the testosterone level was high. The1 p( ]# Z6 x) G- ^% h$ x6 X5 J
follow-up visit was arranged within a few weeks to
" {: ~9 V2 B. d6 K+ Z. I* M, Aobtain testicular and abdominal sonograms; how-
! Z+ e3 W7 J; R/ P8 n7 t% wever, the family did not return for 4 months.
/ `3 A1 @( Y# o" H" k9 v( A6 `" I2 fPhysical examination at this time revealed that the
+ ]0 V+ m1 ?7 r; ?) Q$ g  t3 uchild had grown 2.5 cm in 4 months and had gained9 S( i7 d4 K3 B7 ~: z6 m
2 kg of weight. Physical examination remained
: E; R7 g, q( y0 x* Iunchanged. Surprisingly, the pubic hair almost com-
3 A# t- K5 a9 e/ a, ]; h2 R- Xpletely disappeared except for a few vellous hairs at8 D9 N! c" p7 p) i6 Q8 l7 t
the base of the phallus. Testicular volume was still 2
7 I: A& p: Z$ `/ GmL, and the size of the penis remained unchanged.( _2 r5 W; m6 z' Z2 K* e$ B* S
The mother also said that the boy was no longer hav-
$ Y& Z# n/ r( d8 ding frequent erections.
8 K5 m& h; Q% w9 N2 [" LBoth parents were again questioned about use of0 q/ {) E( \* R4 A! x! _; R) A
any ointment/creams that they may have applied to( j' J% T5 {) V/ m; ~) s) d7 y$ f2 H$ h
the child’s skin. This time the father admitted the
8 }" n( P" }; |; L) l, W( rTopical Testosterone Exposure / Bhowmick et al 5419 L. Z/ C$ K1 A# I1 _
use of testosterone gel twice daily that he was apply-0 l% f$ l# x2 t
ing over his own shoulders, chest, and back area for
7 A5 Y) t. T* D& `' h; u; O- m0 g+ B5 da year. The father also revealed he was embarrassed0 k& A0 H8 T0 K- p4 x5 v
to disclose that he was using a testosterone gel pre-. w$ `: m  |( r) g
scribed by his family physician for decreased libido& @5 g; G2 }. w  b' F
secondary to depression.- d" f6 v1 F5 h% D6 F. q
The child slept in the same bed with parents.' [0 `6 x( V2 u
The father would hug the baby and hold him on his
( D5 |' _5 c  w, U+ a" pchest for a considerable period of time, causing sig-
* W- D2 o" p8 H2 e( ~- Inificant bare skin contact between baby and father.1 t( e5 _( S/ l' k  @
The father also admitted that after the phone call,) u3 h$ `$ ^9 K" w
when he learned the testosterone level in the baby3 J9 w( w8 n; q; w0 Z: F. H7 n$ p% v
was high, he then read the product information
5 c* }4 }" V5 d( Opacket and concluded that it was most likely the rea-
+ {  T6 P: N( M. sson for the child’s virilization. At that time, they! q* ]& N+ m2 \, ~2 D) E; S
decided to put the baby in a separate bed, and the
% Q: Q+ v. p/ ?: Pfather was not hugging him with bare skin and had
/ l+ ~0 Q$ w- h( ]been using protective clothing. A repeat testosterone. q" j, f" z+ `, t
test was ordered, but the family did not go to the! s$ W  W9 v; ]
laboratory to obtain the test.
" V' m8 W& Y- x4 `9 dDiscussion; q( x# D& A: \- Q0 U
Precocious puberty in boys is defined as secondary6 k. g6 x3 A' C, J" H
sexual development before 9 years of age.1,4
  ?( o1 [8 X( v8 gPrecocious puberty is termed as central (true) when/ T" v3 a% j9 L$ u$ M; [
it is caused by the premature activation of hypo-* `- S; \' C  B) Z2 h
thalamic pituitary gonadal axis. CPP is more com-
, x, {  N( J6 u& j  ]mon in girls than in boys.1,3 Most boys with CPP
* i5 e: C  n3 o4 Z* r' rmay have a central nervous system lesion that is
2 V5 i# L. e, {1 K8 F( [" s$ _* \6 |5 Hresponsible for the early activation of the hypothal-3 O, H8 P) ?, N: E/ O1 L& C
amic pituitary gonadal axis.1-3 Thus, greater empha-: L5 R, M" @: o* u. @- s" c8 p2 C
sis has been given to neuroradiologic imaging in7 P! Z) [$ ^- `( `
boys with precocious puberty. In addition to viril-
; \  `8 z/ n) H) x7 l2 |ization, the clinical hallmark of CPP is the symmet-) c/ p- y6 X9 H
rical testicular growth secondary to stimulation by3 ?1 p; \8 g2 W
gonadotropins.1,3
2 ^5 }% v7 u5 l. @Gonadotropin-independent peripheral preco-3 X+ T6 w0 X" t* _5 k  t$ J9 F
cious puberty in boys also results from inappropriate8 P" J) p3 O- q3 p2 d
androgenic stimulation from either endogenous or7 n7 d; E6 W' ?5 O9 H
exogenous sources, nonpituitary gonadotropin stim-
5 @* K, K, n# X7 R5 O! o! ~ulation, and rare activating mutations.3 Virilizing
9 O- A# L; k- R3 l3 \congenital adrenal hyperplasia producing excessive
+ q4 L9 @3 {4 {+ M. t7 O+ m+ Jadrenal androgens is a common cause of precocious
; d. T  F: q6 x+ hpuberty in boys.3,4
/ g& {) K4 j/ Q5 |+ mThe most common form of congenital adrenal
! g4 d2 ]; t# Thyperplasia is the 21-hydroxylase enzyme deficiency.
/ p, r  ^, y+ a5 y& AThe 11-β hydroxylase deficiency may also result in8 y$ ?, c, b* O4 w: O+ l9 K
excessive adrenal androgen production, and rarely,2 U3 D& S3 j& O
an adrenal tumor may also cause adrenal androgen" K: i& q" U9 R
excess.1,3
1 a3 X' D( m$ I7 \2 W& f5 B7 d  kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 C  U, s! m' n2 d1 i' I3 f9 ~542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 h8 x7 E) H  y9 f4 v
A unique entity of male-limited gonadotropin-/ O. d( e# T) x& S
independent precocious puberty, which is also known3 H$ V8 a9 D; Q; t, s* X
as testotoxicosis, may cause precocious puberty at a
0 u0 T/ ~3 ?6 V/ d* ?very young age. The physical findings in these boys
" x' l9 r' @. `' M1 w. F3 p) G1 Mwith this disorder are full pubertal development,7 b* \; T/ z6 b& p
including bilateral testicular growth, similar to boys
8 n- O2 d+ n* x; a. n. w$ bwith CPP. The gonadotropin levels in this disorder! x/ X0 t5 I; ]+ R. F3 s
are suppressed to prepubertal levels and do not show
% I3 h  ]* K! a. n3 Z* gpubertal response of gonadotropin after gonadotropin-
3 p* c5 O3 x! a! S! A6 w) O  s) W. c8 kreleasing hormone stimulation. This is a sex-linked8 n% |( W% @: k8 E% h
autosomal dominant disorder that affects only
( b5 a- ?; z; X6 @# j7 `6 Qmales; therefore, other male members of the family
1 T1 h4 Y' ~: c6 ?7 pmay have similar precocious puberty.3
- B* W5 a% a& ~, AIn our patient, physical examination was incon-
- |8 m- o3 O9 A. Y" n- Dsistent with true precocious puberty since his testi-
& @! J$ B$ ^# i9 Ccles were prepubertal in size. However, testotoxicosis9 Q( ?  C# n) o1 N# M7 l9 ]$ [
was in the differential diagnosis because his father  b+ m8 |- @8 _: P8 L
started puberty somewhat early, and occasionally,6 w, M+ s. M3 w1 f+ L% i- x
testicular enlargement is not that evident in the
: n* o! a3 M- n: X. b% _. kbeginning of this process.1 In the absence of a neg-
& I8 f2 `0 X! a* t  u+ Y9 _ative initial history of androgen exposure, our; }+ F% k5 ~" Q5 M$ x/ C
biggest concern was virilizing adrenal hyperplasia,
' G# z0 x+ K! K: e8 xeither 21-hydroxylase deficiency or 11-β hydroxylase& d" _. w& J3 j, |
deficiency. Those diagnoses were excluded by find-6 J  z" g  J0 ^; `# m4 s+ d
ing the normal level of adrenal steroids.
% d: G2 f! W* \& h# IThe diagnosis of exogenous androgens was strongly1 s0 h5 v" Z1 L. a& B( L, s4 m* C
suspected in a follow-up visit after 4 months because- t4 s3 E7 y: @6 T/ H4 G* Q" q
the physical examination revealed the complete disap-+ a# V0 o( f1 X
pearance of pubic hair, normal growth velocity, and* _4 M7 Y+ G7 _0 Z2 }
decreased erections. The father admitted using a testos-
# d% L  T% h' V3 m) R9 r2 ?1 Kterone gel, which he concealed at first visit. He was
* V( }% B0 Z7 p" k8 \using it rather frequently, twice a day. The Physicians’* ?: m6 }5 m5 J$ z0 e7 I. t
Desk Reference, or package insert of this product, gel or
9 l+ s* t5 b4 a! Y$ gcream, cautions about dermal testosterone transfer to$ s' X8 W7 h3 r7 e2 l$ _
unprotected females through direct skin exposure.
, C$ n& X% x# \0 N+ o$ nSerum testosterone level was found to be 2 times the
( [5 G$ Y& J  u; I8 M3 k7 y' z2 Abaseline value in those females who were exposed to, ?% }6 o7 L1 w9 [5 q: o
even 15 minutes of direct skin contact with their male
2 `3 S9 |& }( I9 w) @' Tpartners.6 However, when a shirt covered the applica-# }  \6 E  d7 z: `9 b
tion site, this testosterone transfer was prevented.
$ u* X# Y; e* t0 g! _* ZOur patient’s testosterone level was 60 ng/mL,
  s4 Z- r1 c. X3 o/ kwhich was clearly high. Some studies suggest that7 r, W6 X9 Q" f2 J& e; a. F5 n
dermal conversion of testosterone to dihydrotestos-
$ G- f/ j9 a2 ^# w' Kterone, which is a more potent metabolite, is more
+ U: J) A7 ]! u: Tactive in young children exposed to testosterone' s  K$ z( R/ y. m' M
exogenously7; however, we did not measure a dihy-
. Q3 b' ?, w) {/ m4 Mdrotestosterone level in our patient. In addition to
; g- D# [: \5 n. s7 Q/ r6 bvirilization, exposure to exogenous testosterone in
2 @- l) B6 o" D, c6 ^5 _, Cchildren results in an increase in growth velocity and
  S: X8 }, N0 f( [* W" hadvanced bone age, as seen in our patient.  b, b' C3 d& ]5 z% L
The long-term effect of androgen exposure during" s, t8 u$ n9 @4 y5 q9 C- t
early childhood on pubertal development and final% G; G3 i8 p+ V+ ]4 s
adult height are not fully known and always remain
' ]8 c: z/ d: R  Ja concern. Children treated with short-term testos-9 X) m) q, z5 ~5 |
terone injection or topical androgen may exhibit some4 t' G. E7 o" Q$ u
acceleration of the skeletal maturation; however, after# j% i* ]+ Z/ M4 q) R% w6 m
cessation of treatment, the rate of bone maturation2 K% w- @+ m# g9 e- f& g
decelerates and gradually returns to normal.8,9" o! w' r( q8 G6 x% h
There are conflicting reports and controversy
$ X: A- H1 b% p9 {/ k, F  Hover the effect of early androgen exposure on adult
8 X# V% F% o8 t4 P) }penile length.10,11 Some reports suggest subnormal
" _" l  e) _8 x; x' {- X, uadult penile length, apparently because of downreg-; \5 B( w! J( O# V% |
ulation of androgen receptor number.10,12 However,# m! `  {" i( U8 p# E
Sutherland et al13 did not find a correlation between
5 q: z% Q+ k8 E$ u( Q6 G, v- y; Q2 m5 Rchildhood testosterone exposure and reduced adult
  g. L% R0 z6 Q2 c& |  x( R7 C; `% j% Dpenile length in clinical studies.
; `/ p/ U# {) u. l; I0 x- T9 t' W+ UNonetheless, we do not believe our patient is  a0 X: f9 l% V
going to experience any of the untoward effects from+ n; T* r  o9 w# B- P
testosterone exposure as mentioned earlier because/ F9 B3 V8 L, e8 {  `2 \9 x
the exposure was not for a prolonged period of time.8 C# L2 M1 g& H. k+ g, N
Although the bone age was advanced at the time of
# T  H7 [5 V9 z9 u% c4 p0 G% bdiagnosis, the child had a normal growth velocity at3 y0 z1 T( J) d8 }2 H5 Z
the follow-up visit. It is hoped that his final adult
4 H% S8 Z5 V& Q& Hheight will not be affected.9 e& u: O  q5 l5 b/ c
Although rarely reported, the widespread avail-4 t. N2 y; T) }, z8 n
ability of androgen products in our society may: \! L+ P" _0 @4 p* c
indeed cause more virilization in male or female
. [* l& X+ R6 c) i7 Y: _- r8 T( uchildren than one would realize. Exposure to andro-2 w# z+ G) r. z; a( Y8 J* w
gen products must be considered and specific ques-
( ^. e( ^# I, T/ wtioning about the use of a testosterone product or
1 t0 M4 Z- s" s* rgel should be asked of the family members during! \" [' X! [$ o
the evaluation of any children who present with vir-( }- g. N) a, C, N; w" `) H; k
ilization or peripheral precocious puberty. The diag-, f. U9 C& h/ c! c
nosis can be established by just a few tests and by  x4 H/ \' P2 P0 g  o( `
appropriate history. The inability to obtain such a
6 n5 e! p* X+ vhistory, or failure to ask the specific questions, may
/ [( A4 S% X9 V+ C+ Dresult in extensive, unnecessary, and expensive
8 K7 q$ W* u+ A2 Ginvestigation. The primary care physician should be. D, e  a) Q! u( t( Q
aware of this fact, because most of these children" b4 W' z% p' f7 r
may initially present in their practice. The Physicians’
; S% _# m, n: a3 Y; M& b9 eDesk Reference and package insert should also put a9 z3 ]/ P. Y& Z* q2 D
warning about the virilizing effect on a male or
9 k8 ?! }3 F2 H0 X/ p$ R8 Kfemale child who might come in contact with some-
8 a% ^- Q) J3 h8 Lone using any of these products.
* F7 `! d" T0 X# v$ G* ?8 WReferences" h. |! t" A6 X) O# W$ s
1. Styne DM. The testes: disorder of sexual differentiation
- D, ~+ N2 w. G' qand puberty in the male. In: Sperling MA, ed. Pediatric' M  ]& e! {" ?) b
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 h: a  T2 N  {1 c. _2002: 565-628.
% T2 b( v. ?7 A' i. X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 ^' O& ?+ k. {0 T6 v1 T& Jpuberty in children with tumours of the suprasellar pineal
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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!

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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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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

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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

& y! ~5 m7 n: i2 t. F) k9 Z精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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