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Sexual Precocity in a 16-Month-Old) ]% A$ _+ P7 L7 K
Boy Induced by Indirect Topical
) D7 N! Y1 v" D; t5 e! }2 p* qExposure to Testosterone5 `+ b2 k4 u6 e8 }* A9 B* z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, }6 K0 L5 F5 L% A' u- L5 k
and Kenneth R. Rettig, MD17 R8 P( h/ i7 t! W6 x. f* `
Clinical Pediatrics
" h7 V: k+ `6 j9 V% Y4 {' t% vVolume 46 Number 6
  @: V4 X/ w8 oJuly 2007 540-543
) m& K7 v' ~$ \# Y& r9 Y/ }© 2007 Sage Publications
7 s- g" f& H) s0 x7 K# e+ }10.1177/0009922806296651# f0 P6 O4 t+ y: R- A! O2 b8 w0 g
http://clp.sagepub.com7 c/ Q7 d6 b: y9 {
hosted at
2 f1 d( t8 j! }+ qhttp://online.sagepub.com, F8 L& q; J* u! j: ^% y- M/ K6 |
Precocious puberty in boys, central or peripheral,
9 W- O# h  T6 B2 ]: Dis a significant concern for physicians. Central1 v3 t8 F  F  m8 y% u, l! d2 N1 S3 m
precocious puberty (CPP), which is mediated# b' g: c4 G" E! Y! p5 e
through the hypothalamic pituitary gonadal axis, has; O9 Q1 D( j6 S: G$ K3 ?3 C
a higher incidence of organic central nervous system
# U6 K9 J) P$ J% g) K' }lesions in boys.1,2 Virilization in boys, as manifested' c$ f8 }9 |* C
by enlargement of the penis, development of pubic" O+ l! Y# K7 X. f0 o$ {
hair, and facial acne without enlargement of testi-
& W) r. n' ?3 b) q2 Gcles, suggests peripheral or pseudopuberty.1-3 We
6 B: E& n1 R- G5 h2 U% Treport a 16-month-old boy who presented with the
2 w2 x- l( `8 @4 ienlargement of the phallus and pubic hair develop-. u/ D" S( ]+ p/ S3 O$ P2 s
ment without testicular enlargement, which was due3 ?' _5 K0 w3 N4 i3 o
to the unintentional exposure to androgen gel used by
5 C' n% L- D, c8 R' xthe father. The family initially concealed this infor-3 x- }; Z' W% ?) q, i& l( d9 n
mation, resulting in an extensive work-up for this
$ ]4 u: K  D1 Pchild. Given the widespread and easy availability of
( [8 c1 N, t' l' z! q# l) j+ etestosterone gel and cream, we believe this is proba-
. F  B$ N) s7 T9 u$ Ably more common than the rare case report in the
5 m7 V! U, n, ^: J+ aliterature.4! Z$ d+ @( k- W: h  G! o: T
Patient Report
% ~  J! `$ W4 r3 H8 j/ ^  V$ v" QA 16-month-old white child was referred to the/ Z# r. Z8 \/ J9 h1 n. @! s: X1 y3 J! o
endocrine clinic by his pediatrician with the concern+ z! X" A- v$ _) T
of early sexual development. His mother noticed6 m8 P. Z% o0 G; l3 C2 k
light colored pubic hair development when he was
. `* P1 N6 a5 ]# I& |0 G, a" FFrom the 1Division of Pediatric Endocrinology, 2University of# j) e- J+ v8 p
South Alabama Medical Center, Mobile, Alabama.
- d! a- ^- K( J  [Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 B* p! _4 v- j& `Professor of Pediatrics, University of South Alabama, College of
; B% \* K2 H4 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 b: y7 b# w4 |2 \1 A
e-mail: [email protected].' f1 z: ^# \: O6 ^# p. a
about 6 to 7 months old, which progressively became& ?# p8 c- S8 F3 S& X. u  o
darker. She was also concerned about the enlarge-* Q, H& H6 f( K5 i) h2 g
ment of his penis and frequent erections. The child# l3 B" m: S& B  O  c; r
was the product of a full-term normal delivery, with  Q# ]# \: }. W* N
a birth weight of 7 lb 14 oz, and birth length of" V, y# H6 V( k2 B
20 inches. He was breast-fed throughout the first year' v$ y2 G* t: w
of life and was still receiving breast milk along with
( \8 u1 B  B: {) {! L% J% k3 Hsolid food. He had no hospitalizations or surgery,
% j/ W$ J/ _0 q* B% d  Cand his psychosocial and psychomotor development) v5 a! R: k$ I
was age appropriate.8 f) v! |- d1 D2 [; \- J
The family history was remarkable for the father,
$ d  T) t! |! d, p( g0 D+ ]who was diagnosed with hypothyroidism at age 16,& M( v, a( l$ [
which was treated with thyroxine. The father’s
) A$ j4 j: J4 b' d$ r: Qheight was 6 feet, and he went through a somewhat% X! A7 O: v7 O* a; C& b
early puberty and had stopped growing by age 14.8 a3 J) s! p, P, y. h/ x
The father denied taking any other medication. The0 n- k! ?0 y( C* y
child’s mother was in good health. Her menarche% k) M/ f' F2 L5 m+ O3 ]6 y/ i
was at 11 years of age, and her height was at 5 feet7 m! H9 g0 z5 F8 ^& s' E$ p2 E
5 inches. There was no other family history of pre-
/ L* U  T! M8 J3 ?  l! \# Zcocious sexual development in the first-degree rela-) V- G% M" h$ k' k, u- h
tives. There were no siblings.' F' c' C  {5 C& |2 m' W
Physical Examination7 R1 i2 v. r( v$ @! {  ~
The physical examination revealed a very active,
$ Z: S4 r. z0 Eplayful, and healthy boy. The vital signs documented
# E0 G8 t3 O8 _8 Aa blood pressure of 85/50 mm Hg, his length was
4 ]( J3 H: {% E+ L2 }90 cm (>97th percentile), and his weight was 14.4 kg: @2 g, B* V. J' ~6 G! V- U
(also >97th percentile). The observed yearly growth
$ Y$ A- w! f% b7 j  A) Kvelocity was 30 cm (12 inches). The examination of' e! x: Z% `; w$ X, a
the neck revealed no thyroid enlargement.; z* N/ w& {4 G; k7 \5 g6 f# t$ j% a
The genitourinary examination was remarkable for
$ C+ m6 |7 a2 ]" jenlargement of the penis, with a stretched length of
. ~. Y, L- B5 w0 O0 ?8 cm and a width of 2 cm. The glans penis was very well( P7 G8 I* f4 @
developed. The pubic hair was Tanner II, mostly around
) H, Y- j8 i- P  a% A540
  ]+ l( I, G" x; @2 Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% c/ e% J  f. z: Z' wthe base of the phallus and was dark and curled. The
5 K+ R! H  v  D. b+ [% Wtesticular volume was prepubertal at 2 mL each.
; i/ j' i- k4 Q5 S( MThe skin was moist and smooth and somewhat: e5 }& l* V5 K4 z  `7 k( Z
oily. No axillary hair was noted. There were no6 L5 {2 c) A: T" H9 T4 r
abnormal skin pigmentations or café-au-lait spots.
: _0 t3 T/ j0 h4 O  iNeurologic evaluation showed deep tendon reflex 2+8 x  l- M2 E( ~( V  y4 {* k
bilateral and symmetrical. There was no suggestion; i5 p& I5 l/ X  G5 @( \9 C
of papilledema.# E* O" a4 j$ X& H2 S8 G
Laboratory Evaluation% u1 y$ \0 w( f; [6 U- L( l4 G' x
The bone age was consistent with 28 months by
* c  @0 ]8 d9 Q. _0 `' Rusing the standard of Greulich and Pyle at a chrono-; @& P; U# |5 _  S! [9 V
logic age of 16 months (advanced).5 Chromosomal% H$ U) _. A& x
karyotype was 46XY. The thyroid function test
: y/ |- H3 f( @/ _7 y4 `7 n: Oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" Y; n2 \+ W0 f* _3 `; v
lating hormone level was 1.3 µIU/mL (both normal).0 p! l; h+ j' c/ N$ v
The concentrations of serum electrolytes, blood
. c/ k. X2 T0 S" y, [  Ourea nitrogen, creatinine, and calcium all were
3 w& y$ V# W2 P6 k7 Swithin normal range for his age. The concentration
+ Z0 z' E! L2 Lof serum 17-hydroxyprogesterone was 16 ng/dL
6 i3 ?8 n: m- O6 C' f  j: g(normal, 3 to 90 ng/dL), androstenedione was 20: ^, f; m3 x, a0 e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 c& T7 P5 O& a4 e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),( ^6 z  s9 |6 P: j/ A# G
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( Q( J! d0 B5 \3 }
49ng/dL), 11-desoxycortisol (specific compound S)
9 w- H6 |, ]; E+ ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) N9 s+ `/ N# L' I6 Y# gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; h5 y; K7 k: `* N2 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ {0 {. L# X+ I8 ^8 S
and β-human chorionic gonadotropin was less than" y7 n2 g+ N  Q# U4 t7 ~& }. v9 k" N
5 mIU/mL (normal <5 mIU/mL). Serum follicular# b2 J% L# ]# w" @1 s$ y
stimulating hormone and leuteinizing hormone* k1 B* N! B) x3 p1 u+ p+ }0 p
concentrations were less than 0.05 mIU/mL  t4 |6 }% w1 S9 a$ l8 c4 y- I
(prepubertal)." W# {  v, R% \
The parents were notified about the laboratory, H- l! r+ e9 g
results and were informed that all of the tests were
/ w) S% L/ d: x& Wnormal except the testosterone level was high. The2 M% U+ g: R7 E& [
follow-up visit was arranged within a few weeks to# H# r! l& a- I& U/ z3 h
obtain testicular and abdominal sonograms; how-
  g, }( i' P2 L, t, Sever, the family did not return for 4 months.4 M! n0 V+ @& h0 P/ |8 C
Physical examination at this time revealed that the
" s" M! ~/ Q9 @child had grown 2.5 cm in 4 months and had gained' r* D5 E) W) B2 A
2 kg of weight. Physical examination remained& X2 }* u  G- ~6 {( @9 G1 A1 D
unchanged. Surprisingly, the pubic hair almost com-
$ \/ x. _! Y8 [$ e3 b, Opletely disappeared except for a few vellous hairs at  M* {8 f4 Z. H1 l! n( i+ p
the base of the phallus. Testicular volume was still 2* j- X8 a( @# }6 z- A: E# ?+ g; m
mL, and the size of the penis remained unchanged.
, p0 J, W, `; P! W9 d! CThe mother also said that the boy was no longer hav-
0 Y2 m. N5 I# Xing frequent erections.
/ U3 p1 Y; }6 X9 W2 YBoth parents were again questioned about use of
3 h8 A0 u9 u3 q; [' Z" F8 ?any ointment/creams that they may have applied to6 C. [$ K' a( s0 M
the child’s skin. This time the father admitted the
3 ?! x8 P, B* v$ S7 nTopical Testosterone Exposure / Bhowmick et al 541" w! H: {+ h/ A( ?
use of testosterone gel twice daily that he was apply-
& a: P3 D; V7 I$ M5 N6 Xing over his own shoulders, chest, and back area for9 `8 G1 d  R: d, K% O
a year. The father also revealed he was embarrassed
* b% v! a9 S/ i% Vto disclose that he was using a testosterone gel pre-" O! p, l2 k- F, J
scribed by his family physician for decreased libido- p1 \  T" B) ]* c8 x9 H- ?) E! l, I, U
secondary to depression.
; }0 P0 Y. T$ n9 \' UThe child slept in the same bed with parents.; p6 \  u! Z, |1 C; m+ i+ w. w# x' A
The father would hug the baby and hold him on his' |6 O" c: X' C- c8 {7 w' p7 d% C
chest for a considerable period of time, causing sig-: a1 O  s2 q* |  i/ @( r: A6 K9 B
nificant bare skin contact between baby and father.* A% L/ T1 k! z) ~: R/ _
The father also admitted that after the phone call,5 D1 |6 ?" L) g  g: T8 }6 x5 r
when he learned the testosterone level in the baby) K7 Q2 n% s& u+ e* p# w3 {
was high, he then read the product information
. |/ t7 l3 {" F' ?# a( [packet and concluded that it was most likely the rea-
+ |& F7 b1 _6 S2 x7 i6 H2 Pson for the child’s virilization. At that time, they* s4 ^+ y' |( I% N
decided to put the baby in a separate bed, and the. T2 O1 y, J3 B) A
father was not hugging him with bare skin and had6 o4 U2 x! R0 x" H
been using protective clothing. A repeat testosterone
7 L/ X; j" y$ F& vtest was ordered, but the family did not go to the
- ]+ T& u; _2 h; \0 Vlaboratory to obtain the test.5 U, h) L& Y- H9 t; i8 Q3 U
Discussion
6 F9 g. d* F: z4 k0 uPrecocious puberty in boys is defined as secondary6 L# U5 ^9 L" V) b* v% {
sexual development before 9 years of age.1,4
% U6 K' \, J  s5 n. @/ V3 k, SPrecocious puberty is termed as central (true) when
" F8 u! X* l3 S2 J0 G# ^it is caused by the premature activation of hypo-7 D5 f1 d, J9 v' u
thalamic pituitary gonadal axis. CPP is more com-
; D# Y3 S8 _( _; I" A4 s$ |* gmon in girls than in boys.1,3 Most boys with CPP
! U( r: w. Z; \0 U3 J" Umay have a central nervous system lesion that is  i1 J( d' `5 |  p" o3 l
responsible for the early activation of the hypothal-- r' p+ q3 N- y2 X: }3 O; B
amic pituitary gonadal axis.1-3 Thus, greater empha-
  r- w7 J) u0 z7 psis has been given to neuroradiologic imaging in
$ N- @# i$ Z0 _6 J+ V% e. ^boys with precocious puberty. In addition to viril-/ V8 I/ W8 M5 H9 n2 d) A
ization, the clinical hallmark of CPP is the symmet-
, a3 o: a2 j& x+ e6 urical testicular growth secondary to stimulation by
9 v* d2 |9 @, ^+ Ugonadotropins.1,33 r0 S" {5 [& p# O0 s
Gonadotropin-independent peripheral preco-
: R& r6 A0 s! t( {7 q5 d9 ucious puberty in boys also results from inappropriate
6 f4 p2 H5 }; K1 }5 T" _5 _androgenic stimulation from either endogenous or
1 L" o% }/ m( bexogenous sources, nonpituitary gonadotropin stim-
5 u. M) Z- o. k' P/ mulation, and rare activating mutations.3 Virilizing) B9 F# [5 Z  r- o8 H2 N# j
congenital adrenal hyperplasia producing excessive
- J7 X+ x4 u4 Padrenal androgens is a common cause of precocious
8 [) v( J) A, L* R; k) r2 ]puberty in boys.3,48 d- N9 X! A9 B  M7 e
The most common form of congenital adrenal% r' d- G; y0 I& H* m
hyperplasia is the 21-hydroxylase enzyme deficiency.
" J* T+ f# H% mThe 11-β hydroxylase deficiency may also result in
2 l; ^) C8 u. e8 |excessive adrenal androgen production, and rarely,# k" {- x# q- X6 W( M
an adrenal tumor may also cause adrenal androgen
4 r; T' t3 {+ }( _3 t7 R; Sexcess.1,3
* e0 _  {6 Y; w2 Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. v3 [/ e9 z7 v) ~) {" o* [% a4 l542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: F# t1 n4 w! D5 n+ Y0 i. W% _A unique entity of male-limited gonadotropin-
- X* j) {+ B. M' C5 b: V' Lindependent precocious puberty, which is also known
; m/ ?# E# E2 C: Y5 Sas testotoxicosis, may cause precocious puberty at a2 A) m. Z( T' D9 r$ B; U
very young age. The physical findings in these boys! p: a3 S7 d! _. b" {2 r% I3 h
with this disorder are full pubertal development,
* `( z: B: u. Dincluding bilateral testicular growth, similar to boys7 X5 ~6 S: l: Q3 x+ x
with CPP. The gonadotropin levels in this disorder
7 W6 R" n6 Z: @9 G, N" B3 Vare suppressed to prepubertal levels and do not show
9 n' L) j' I: apubertal response of gonadotropin after gonadotropin-* y3 S/ o2 u  ?, s7 T
releasing hormone stimulation. This is a sex-linked
7 z( u2 G& v) B" Fautosomal dominant disorder that affects only
' I* x% ~2 T6 [$ ?+ ^males; therefore, other male members of the family' D6 g# M% @/ r( N  `
may have similar precocious puberty.3
$ |3 o+ N! e) O" H6 UIn our patient, physical examination was incon-
8 U4 {  K4 l6 _8 {& P1 a0 \$ jsistent with true precocious puberty since his testi-
  W0 x+ J, `- S. I+ v9 ycles were prepubertal in size. However, testotoxicosis; J: \6 {% @: I: ]* X$ ]; Y3 K! u" M
was in the differential diagnosis because his father
# e" ?$ S+ Q+ U7 c+ X3 Y! ystarted puberty somewhat early, and occasionally,9 o8 E0 }0 x, u' t- l9 y) A
testicular enlargement is not that evident in the5 A8 ]4 w# J$ M3 F4 @
beginning of this process.1 In the absence of a neg-' U8 f+ x& H5 N# w
ative initial history of androgen exposure, our
: O$ f( m4 A/ u# N  C, T6 @biggest concern was virilizing adrenal hyperplasia,
  ]0 V. ^4 @( Q, E1 Leither 21-hydroxylase deficiency or 11-β hydroxylase
& w+ c  r! P6 G1 W# C! Z% B: ^deficiency. Those diagnoses were excluded by find-* B& [" |$ q8 U7 d' S) H. J$ r
ing the normal level of adrenal steroids.
: L6 X9 `1 y# e2 MThe diagnosis of exogenous androgens was strongly
- S4 z- ?% u' n! m& Q5 _( d) Ssuspected in a follow-up visit after 4 months because# `% y5 ~& W$ ]$ a$ Z, |& a/ R
the physical examination revealed the complete disap-
' v' V- S$ N" |, g& p" y$ opearance of pubic hair, normal growth velocity, and
9 m4 }9 F5 w; U' @! [2 Vdecreased erections. The father admitted using a testos-
# S& K, e" A6 t4 E- `! s$ a: e  ^) uterone gel, which he concealed at first visit. He was
, \) u$ y$ ]* p7 Lusing it rather frequently, twice a day. The Physicians’! s' ]0 v7 v& l$ `, J8 Q( O9 o
Desk Reference, or package insert of this product, gel or" R9 @" B+ Y' _% n5 Z
cream, cautions about dermal testosterone transfer to2 `: v9 x+ N& `# ~
unprotected females through direct skin exposure.
- \3 t3 a8 j8 }3 v3 nSerum testosterone level was found to be 2 times the9 D+ @. f& H2 Y+ ]" E0 M) [
baseline value in those females who were exposed to
* L$ B6 h- O1 H# G# geven 15 minutes of direct skin contact with their male
& e" |# w; g7 H, A  y' Epartners.6 However, when a shirt covered the applica-4 Z1 S2 D' B1 ?6 n, Z( T; l" b
tion site, this testosterone transfer was prevented.* H2 P4 a  W8 D# \1 N) x% D
Our patient’s testosterone level was 60 ng/mL,
! c$ P+ ]+ z. K% u6 w% W- Iwhich was clearly high. Some studies suggest that
, b; e: Z0 u7 b! z1 kdermal conversion of testosterone to dihydrotestos-  w+ l4 r* w) Z. ?
terone, which is a more potent metabolite, is more+ g2 w' F" G$ p7 F' o3 w
active in young children exposed to testosterone6 c4 C! a% [# D4 b3 d) U  ?* [
exogenously7; however, we did not measure a dihy-) q. E* b/ K9 G4 U
drotestosterone level in our patient. In addition to, d+ ]4 Y# q; {0 ~% U
virilization, exposure to exogenous testosterone in: q' F+ v4 G5 x' d4 ]7 D/ `1 B: r
children results in an increase in growth velocity and
* Q& ^" Z. A& [  gadvanced bone age, as seen in our patient.
4 U1 d0 ?& k; S# S0 x" o" dThe long-term effect of androgen exposure during2 b7 L1 B7 D  I
early childhood on pubertal development and final
1 i  r  x! V6 J$ C+ q6 K1 zadult height are not fully known and always remain, b3 z/ d/ D: }% n& {. o( l! |& x
a concern. Children treated with short-term testos-
1 l9 ]1 k  k# |0 ~& z# Pterone injection or topical androgen may exhibit some
( ]- }1 `; V0 B- sacceleration of the skeletal maturation; however, after
! e2 |6 R4 }- O& gcessation of treatment, the rate of bone maturation- w$ T6 W$ Y/ r# h% S
decelerates and gradually returns to normal.8,9
- O+ x5 _2 |+ ?% F; Y" gThere are conflicting reports and controversy
! M) i9 {! D1 B% ^8 Mover the effect of early androgen exposure on adult- I, g5 b& Z9 u
penile length.10,11 Some reports suggest subnormal9 v5 [- k' |7 l8 H8 P# ?4 t
adult penile length, apparently because of downreg-
5 d. E$ @1 F, @! }+ m% gulation of androgen receptor number.10,12 However,% |$ \" D9 i3 }$ @, c
Sutherland et al13 did not find a correlation between
2 }" {( o6 S  rchildhood testosterone exposure and reduced adult" N  ^5 N+ b7 \% j
penile length in clinical studies.! j" D2 Z# ~; H- T1 M4 d
Nonetheless, we do not believe our patient is& W/ i  B0 R" [6 t3 D' \: W6 D0 B
going to experience any of the untoward effects from) k+ W. _- p! s& R9 L) n3 E0 `/ i
testosterone exposure as mentioned earlier because6 ~, {8 L+ p5 c: v: g
the exposure was not for a prolonged period of time.2 ]2 Z/ r% s& p3 `) d0 X& A
Although the bone age was advanced at the time of
: r( h: p0 P5 G; I% {diagnosis, the child had a normal growth velocity at# _6 ~* D5 f4 {( E- Q4 L3 Y# U) l
the follow-up visit. It is hoped that his final adult
" C  r' T( w: B( Y* ~4 Aheight will not be affected.
4 c, h% W. E2 J  M  X# xAlthough rarely reported, the widespread avail-
* h8 _  B1 l* ?+ E3 Dability of androgen products in our society may! M# l' t1 B4 n$ E- Z* y/ j3 S
indeed cause more virilization in male or female
7 U$ H& a6 c# I. G( [7 f, t5 Vchildren than one would realize. Exposure to andro-
% }' ?! [: F. W9 p2 s- P+ Lgen products must be considered and specific ques-( l3 K6 a0 o: X- F( `; o+ o
tioning about the use of a testosterone product or2 g* Q2 }7 O. L+ U; n/ \
gel should be asked of the family members during
7 {; c3 s2 b% `7 M/ k9 m3 mthe evaluation of any children who present with vir-
' C2 @/ g: Q- g5 |# I% \: Vilization or peripheral precocious puberty. The diag-
. C+ s2 [. P- ]nosis can be established by just a few tests and by; S+ V7 R8 s6 T. _5 W/ L% J
appropriate history. The inability to obtain such a( B2 Y' Z, t4 {* Z! y0 Q" u
history, or failure to ask the specific questions, may5 D5 o8 e/ A( C. U3 i7 z
result in extensive, unnecessary, and expensive
6 G8 s/ _: [. T, \% G0 K" einvestigation. The primary care physician should be4 y# W: k, F& Z1 i7 E
aware of this fact, because most of these children( Z: m8 b2 j5 `) V3 B( H( e8 @7 |. y
may initially present in their practice. The Physicians’
6 X7 M! R8 S6 C" F4 |3 B& w* n" RDesk Reference and package insert should also put a; C& o1 _, E8 ?7 |* K
warning about the virilizing effect on a male or
8 K( ?6 J4 m0 |: @, C0 P( @female child who might come in contact with some-
. ~8 S, w5 S- N1 `, ?6 vone using any of these products.
% q8 P6 n$ o% _; Q. X1 ^+ \References) f0 R/ v- i  }; v
1. Styne DM. The testes: disorder of sexual differentiation
% W! b% R0 `! b7 j) m( eand puberty in the male. In: Sperling MA, ed. Pediatric! \( h4 @8 H9 i# N3 V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. R# T9 @! @- I9 K( J- L$ k2 x
2002: 565-628.
( w: N4 }$ z) r2 [) U* J. Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; X; m* R& T( v$ N0 z; }+ kpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
4 X: K2 i! W/ Z6 x% j* cBoy Induced by Indirect Topical
1 i5 d# ^5 J5 ]* ]7 }1 S2 AExposure to Testosterone
- ~3 e1 R* v" O5 _3 _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ Z% K; h+ Q3 rand Kenneth R. Rettig, MD1
2 \; P; v/ x0 {. v7 HClinical Pediatrics
4 e5 P+ \  {: |4 ^& f6 p* YVolume 46 Number 6& @# k9 ?% @* g; Z8 z
July 2007 540-5434 v0 K; [8 p1 f" B$ o- @
© 2007 Sage Publications, B& P! x' B0 T; z8 p# H
10.1177/0009922806296651
8 i& x! @' T' Fhttp://clp.sagepub.com
) l5 [! r0 y% t$ j+ E2 U5 W9 @7 `hosted at* K. y+ \, q+ Q
http://online.sagepub.com: ~) O# _0 c& g" V% V
Precocious puberty in boys, central or peripheral,- v. t3 z3 {5 }# e& a. Y4 }
is a significant concern for physicians. Central
5 u0 f- d' A1 ~" m1 [2 I0 W+ v4 H# qprecocious puberty (CPP), which is mediated
2 r  l2 I) _9 Cthrough the hypothalamic pituitary gonadal axis, has
) _! `! @, I( |* ~6 Sa higher incidence of organic central nervous system
' ~! N1 _, K+ W, D$ tlesions in boys.1,2 Virilization in boys, as manifested
. ]) y& \0 P3 _- a/ uby enlargement of the penis, development of pubic  S- {0 J4 v  {* [- b# L# J
hair, and facial acne without enlargement of testi-/ K& ^: f8 U7 R3 J
cles, suggests peripheral or pseudopuberty.1-3 We
3 C$ ^) M: i( U" X* P; B  G; {0 X# freport a 16-month-old boy who presented with the1 {& ]7 C; w' P, b' w: v% z8 v3 o+ n9 A
enlargement of the phallus and pubic hair develop-' H0 [; F* ~  M1 [
ment without testicular enlargement, which was due$ e( p* o! b. P3 X
to the unintentional exposure to androgen gel used by4 O: A3 ?& v2 \8 R6 y( a
the father. The family initially concealed this infor-
" j8 _6 r* R$ n$ g+ Rmation, resulting in an extensive work-up for this! J. J' m3 A1 C9 N
child. Given the widespread and easy availability of
! Z! t) h9 U1 {7 _0 `' Htestosterone gel and cream, we believe this is proba-! A* f+ d# ]3 j# @/ P  c
bly more common than the rare case report in the
; D+ z' y8 s3 m( C: oliterature.4
4 n; E  Z/ B$ o& N' K( yPatient Report
* d/ e( H2 k2 ^0 W0 ^A 16-month-old white child was referred to the
3 H" k9 B0 O; B1 l* g- i5 Tendocrine clinic by his pediatrician with the concern( l- [8 a  X( \! L- q
of early sexual development. His mother noticed/ J4 A0 l; _% k2 ?0 E
light colored pubic hair development when he was
6 G$ ]7 ^, H8 vFrom the 1Division of Pediatric Endocrinology, 2University of
. V7 O' j# k4 kSouth Alabama Medical Center, Mobile, Alabama.' P3 r( l: ]5 k8 v6 ]/ v7 ^# Z) R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, U8 d/ q8 U, t) `Professor of Pediatrics, University of South Alabama, College of2 A1 R1 g) B+ \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ T2 ?& H7 f$ z
e-mail: [email protected].
+ L" p) r& f2 L% Q/ @) ]about 6 to 7 months old, which progressively became! i( b  A" y( t4 K- i) N
darker. She was also concerned about the enlarge-" [  u' V  a4 P* x7 l
ment of his penis and frequent erections. The child
7 X* F! s+ |8 D' B& f$ Xwas the product of a full-term normal delivery, with
( k$ ^. i6 X+ P. w& Ua birth weight of 7 lb 14 oz, and birth length of! L* ~! [5 z9 H. [; A# D. A  n
20 inches. He was breast-fed throughout the first year
3 x+ i# x- Z$ z2 b4 Y1 d! wof life and was still receiving breast milk along with# i2 P) [  d+ K( }( r" `) P+ [
solid food. He had no hospitalizations or surgery,
5 J6 G# s5 r3 q! X. s7 Wand his psychosocial and psychomotor development8 Y6 r. V( N* s2 f8 e
was age appropriate.- y2 j! {" L% ]5 o/ c
The family history was remarkable for the father,8 s9 I0 d  M; Y6 P
who was diagnosed with hypothyroidism at age 16,
1 T: f4 d5 D+ r4 Q) gwhich was treated with thyroxine. The father’s5 Z9 I; B7 t9 F) Y0 E9 N* R
height was 6 feet, and he went through a somewhat* @6 k6 P% u3 d) f7 j* U6 _5 F/ h4 c
early puberty and had stopped growing by age 14.$ r2 w8 m9 s& r
The father denied taking any other medication. The
* K; |5 |( S6 B& K5 c1 `child’s mother was in good health. Her menarche; B0 B3 x; u( x$ y, \
was at 11 years of age, and her height was at 5 feet
9 L4 e" F; p( E9 i5 inches. There was no other family history of pre-
" I" W! R* A) x: Jcocious sexual development in the first-degree rela-- q$ F; L, m) c& ?0 l3 I; G
tives. There were no siblings.. G* t) h! u7 p( S
Physical Examination; \* S6 g3 q" `
The physical examination revealed a very active,# G5 |! k1 U+ x& F7 f
playful, and healthy boy. The vital signs documented
& ^- q& [! U: ua blood pressure of 85/50 mm Hg, his length was! H4 p! d. z. x0 P
90 cm (>97th percentile), and his weight was 14.4 kg
3 b  V- B4 g6 j4 R# Z(also >97th percentile). The observed yearly growth0 h$ E) @& G6 u6 i' n
velocity was 30 cm (12 inches). The examination of
: U5 U2 ?4 C" Y* lthe neck revealed no thyroid enlargement.
2 K3 r) ?$ `" U9 c. iThe genitourinary examination was remarkable for5 q; w7 M6 X# a8 Z: O( c7 e
enlargement of the penis, with a stretched length of
# ^1 b9 Y5 t7 ?5 t8 cm and a width of 2 cm. The glans penis was very well
5 o( x# m/ u! e8 }# }+ kdeveloped. The pubic hair was Tanner II, mostly around
( s4 K; m, F, i3 w9 W, s% A5404 w5 O; Y- ?, j: K1 y- K" [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ Z1 v, i/ `; W2 k8 _. t- @the base of the phallus and was dark and curled. The& r) e9 c- g: c" M% Q" J8 v
testicular volume was prepubertal at 2 mL each.5 g3 f( c4 J: d3 n8 M& @
The skin was moist and smooth and somewhat$ J+ y% O& a- p# S# i* M
oily. No axillary hair was noted. There were no
& e: S/ {" j  C8 I9 iabnormal skin pigmentations or café-au-lait spots.9 z/ C" z; z0 N" R$ e
Neurologic evaluation showed deep tendon reflex 2+7 C/ d. q* m$ V8 x4 |$ c, P' X
bilateral and symmetrical. There was no suggestion' z* \" A3 v& q  S' B. [; y: T
of papilledema.) e' J1 L; \$ x8 A8 a
Laboratory Evaluation
1 q8 c8 r( U' M* N3 ^The bone age was consistent with 28 months by2 }2 F4 K5 S+ u0 ~' ~2 p
using the standard of Greulich and Pyle at a chrono-3 g5 q$ p8 o  C0 |) z4 F6 Z9 l
logic age of 16 months (advanced).5 Chromosomal  D/ e+ i4 Q7 ~# [. H
karyotype was 46XY. The thyroid function test% o+ y$ i7 K1 x( g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 k* N$ K# e3 r7 p3 R9 {' i
lating hormone level was 1.3 µIU/mL (both normal).
( R! ~4 G( ]% J* |# i0 T- H9 sThe concentrations of serum electrolytes, blood9 m5 r- p# k8 d0 Z, c
urea nitrogen, creatinine, and calcium all were) g4 {) k1 W; c7 H
within normal range for his age. The concentration
( s3 G6 A. m% [2 g8 {of serum 17-hydroxyprogesterone was 16 ng/dL
9 Z& e0 _( T4 T0 C& L! T(normal, 3 to 90 ng/dL), androstenedione was 20
* J  t% v& R; n2 @6 Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( ?' E1 i& N6 l, A- a
terone was 38 ng/dL (normal, 50 to 760 ng/dL),% o! r3 p  @  t6 D6 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ R# R; V' @9 g4 c/ u2 D49ng/dL), 11-desoxycortisol (specific compound S)
/ u) x# K- M  j, m, j# B; vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: W" Z, V! ?% K2 S; l' W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ k! ~- x" b( atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 }1 W! m  I* l/ S( b! a+ |
and β-human chorionic gonadotropin was less than
  N3 O1 q/ j$ d4 s7 _6 d5 mIU/mL (normal <5 mIU/mL). Serum follicular/ Y6 d6 x0 a: G- x: _6 c5 G4 N  ^
stimulating hormone and leuteinizing hormone: o$ n0 f3 P9 Y. ~5 O9 x
concentrations were less than 0.05 mIU/mL
; D7 Z" c9 m, Y5 w( C- F  f2 l' z8 D(prepubertal).
, B6 {1 c* b$ d; g; V$ yThe parents were notified about the laboratory
5 V& y- l  S! v0 a$ iresults and were informed that all of the tests were
5 \( s* K3 z' I& Z1 Inormal except the testosterone level was high. The
0 W" T! G+ N8 t" u1 ]" Z$ {follow-up visit was arranged within a few weeks to+ V: L$ n2 g, O* m# K! Z1 X- ]
obtain testicular and abdominal sonograms; how-
* }- N. r4 B( Q3 V% R+ D: Q1 ^) aever, the family did not return for 4 months.+ r. M/ i. N& l: V9 a! f0 x, q. F
Physical examination at this time revealed that the( ?  b( v8 P- O9 J; f0 S  F
child had grown 2.5 cm in 4 months and had gained2 J, G, y. y8 r$ [1 o
2 kg of weight. Physical examination remained
) q/ W# @6 }1 }/ C% F7 C# N6 ounchanged. Surprisingly, the pubic hair almost com-7 t6 c; e7 _3 \& a  P
pletely disappeared except for a few vellous hairs at
& ^. r1 I! A8 K" E& {  j; Bthe base of the phallus. Testicular volume was still 2
/ n) e, g& i7 i# G; n- B2 imL, and the size of the penis remained unchanged.$ W' R) r6 ?( c* `  A' [, M
The mother also said that the boy was no longer hav-
; M% C! H; ?* p0 W0 o; l- N& f/ zing frequent erections.
8 x" U  g2 H/ T" S/ i3 z  s' k% YBoth parents were again questioned about use of) E- e- R1 ]3 y0 X1 _' ~8 h0 i
any ointment/creams that they may have applied to6 o4 j7 ^+ W% \' e1 Q7 w" ?
the child’s skin. This time the father admitted the
, \  p& R7 h; P& NTopical Testosterone Exposure / Bhowmick et al 541$ r. S2 q. s: n) Z! A  D' P2 n) n
use of testosterone gel twice daily that he was apply-
4 w0 D! [& E  S- Ming over his own shoulders, chest, and back area for# ^# L" U) h$ Z5 @4 u/ m* D, C
a year. The father also revealed he was embarrassed
3 h" e3 c/ P  oto disclose that he was using a testosterone gel pre-8 i3 {) V& G0 E: u
scribed by his family physician for decreased libido- d! V- `8 O/ B" z/ H$ }3 C" l# E
secondary to depression.
# b' J* x0 ^9 ?1 GThe child slept in the same bed with parents.
- }8 w3 G; k8 u  W* M4 r3 [; o' qThe father would hug the baby and hold him on his
& N0 O! Z3 b3 fchest for a considerable period of time, causing sig-
8 L/ [" J5 b2 k5 G% e9 e9 Fnificant bare skin contact between baby and father.
* X. M! z. J( U; a3 z6 L! f- ~The father also admitted that after the phone call,( m* O- R9 U" |& ^
when he learned the testosterone level in the baby" o: U5 [/ k/ U+ ^- x6 T7 ]6 x
was high, he then read the product information4 W9 ]/ Y$ O. l; R3 z
packet and concluded that it was most likely the rea-3 @; h1 x9 y: O6 t7 O& }) Q
son for the child’s virilization. At that time, they
) {. V' o+ _  J9 {decided to put the baby in a separate bed, and the
  ~- i  W: K7 R: Q, J" C0 [& {father was not hugging him with bare skin and had
7 S- ?% ]& S- I+ }8 Wbeen using protective clothing. A repeat testosterone
& E8 x# f- n$ p0 Vtest was ordered, but the family did not go to the; p4 q% [  x" O8 a8 u- z
laboratory to obtain the test.
; Q$ E: b5 n7 Z) }Discussion
. A+ _0 x- e( L2 [Precocious puberty in boys is defined as secondary" }! S6 {! \- ^5 I$ a
sexual development before 9 years of age.1,4
2 P4 R( N7 o! h( P& t- h& nPrecocious puberty is termed as central (true) when
. P3 J) p! ^+ W1 |7 @7 Lit is caused by the premature activation of hypo-
$ r$ \2 Z" p7 X# Fthalamic pituitary gonadal axis. CPP is more com-6 ?) s) r' w$ r. o' P) L1 c/ s
mon in girls than in boys.1,3 Most boys with CPP
  A- m2 g3 x/ Z3 x* r, `may have a central nervous system lesion that is$ B/ {$ a) W9 C  ~- L0 \2 ?3 l4 ~
responsible for the early activation of the hypothal-
$ i; X$ w2 x; M) Vamic pituitary gonadal axis.1-3 Thus, greater empha-/ Y$ K7 F% O* o+ z  ~* ?
sis has been given to neuroradiologic imaging in  [8 X. s0 r9 {" o0 \! v
boys with precocious puberty. In addition to viril-) o% ^, I. d' ]! i- s
ization, the clinical hallmark of CPP is the symmet-
1 d* k/ T. k" ?$ A( U4 arical testicular growth secondary to stimulation by% W$ w1 Q' C9 g& q' [
gonadotropins.1,3
! E) ^0 C9 g. o) r( c/ dGonadotropin-independent peripheral preco-
1 u1 C) E* q% q7 j  ]8 Q3 L3 Vcious puberty in boys also results from inappropriate
8 }3 S+ j# }0 E( r+ T1 aandrogenic stimulation from either endogenous or; v$ K$ M1 A( C5 x7 K* F
exogenous sources, nonpituitary gonadotropin stim-1 }+ d6 _5 c( D9 }9 h9 M8 X
ulation, and rare activating mutations.3 Virilizing' E" G1 O) A7 M/ E( S) j
congenital adrenal hyperplasia producing excessive% N+ m. w! ]( v' X4 s3 W
adrenal androgens is a common cause of precocious5 J5 g' l9 n! E2 I9 L/ H
puberty in boys.3,4
( ^! p$ i+ a7 `. I1 Z( z/ J& sThe most common form of congenital adrenal
4 b# D! o5 V' }7 mhyperplasia is the 21-hydroxylase enzyme deficiency.: {0 [  l/ G) k
The 11-β hydroxylase deficiency may also result in
7 u' P- u3 ]' u1 c+ T8 mexcessive adrenal androgen production, and rarely,$ X4 [9 C" ]5 t+ k) h4 E9 q- c8 d
an adrenal tumor may also cause adrenal androgen3 c0 F+ u" o' M* a) h
excess.1,3& `' j$ }! k* p  H* z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  l, c3 q: E9 D% Q3 J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! v' x1 J+ A+ k3 s9 Q& v6 T
A unique entity of male-limited gonadotropin-( D7 b# H5 _. v1 ?7 ^0 U0 |% a" O
independent precocious puberty, which is also known% Z0 B9 h2 D4 }: ~3 m1 _
as testotoxicosis, may cause precocious puberty at a2 a  _, S# |8 E2 D
very young age. The physical findings in these boys
: D, F, M( [9 ~$ s. i. _% I1 iwith this disorder are full pubertal development,
) v4 r4 S% z+ A: J& qincluding bilateral testicular growth, similar to boys
  w2 P6 r) i4 t" N3 Ywith CPP. The gonadotropin levels in this disorder
. X& N  t4 c# p: w) ~are suppressed to prepubertal levels and do not show5 T  K) F% E1 L1 ]) i
pubertal response of gonadotropin after gonadotropin-
% W- g  C0 \! w/ ?1 ]; u: yreleasing hormone stimulation. This is a sex-linked$ a! c8 q3 b$ h% a9 @
autosomal dominant disorder that affects only
2 N3 ~' z; t. W' @3 Nmales; therefore, other male members of the family5 Q  \" E$ Z2 G0 G( f2 D9 L
may have similar precocious puberty.3
! ?3 \0 j# Z7 v2 ^% OIn our patient, physical examination was incon-
% |0 L2 |$ ?. d; }! _' {; Bsistent with true precocious puberty since his testi-# s2 x; w8 _% _: j) L
cles were prepubertal in size. However, testotoxicosis
6 F( d% X) M6 n+ V: Gwas in the differential diagnosis because his father) q7 ^$ K, u8 F5 a+ n
started puberty somewhat early, and occasionally,
  R( p9 z0 I2 n  w# ]! Xtesticular enlargement is not that evident in the  R" @0 S. v2 f2 b6 o! d, Y
beginning of this process.1 In the absence of a neg-5 t& v! N5 p8 x& m/ Q  ^6 L+ R
ative initial history of androgen exposure, our' d! x9 m. [' r! U, U+ s: q
biggest concern was virilizing adrenal hyperplasia,# ~0 m! @1 J0 R* I! C! l2 h  f
either 21-hydroxylase deficiency or 11-β hydroxylase0 d$ V3 _, p  Q) f6 z
deficiency. Those diagnoses were excluded by find-
+ |$ c. L6 x; k" `: S7 y+ }# oing the normal level of adrenal steroids.* S! [& R/ N7 C0 E8 m1 V
The diagnosis of exogenous androgens was strongly
8 |) Z* p/ n3 |4 B) S3 asuspected in a follow-up visit after 4 months because
6 z7 q1 A  D$ E6 i2 Q# bthe physical examination revealed the complete disap-
0 {7 U  _* j4 Lpearance of pubic hair, normal growth velocity, and
, U& s& L, B: X, L) |* {7 Ddecreased erections. The father admitted using a testos-
3 `5 P: `( R( j7 s- sterone gel, which he concealed at first visit. He was9 `3 o2 f7 Q% B- E* u$ T
using it rather frequently, twice a day. The Physicians’
3 k# ~. m. F% U' a. P' kDesk Reference, or package insert of this product, gel or# S  o3 N( \$ k3 `
cream, cautions about dermal testosterone transfer to0 g4 |/ X* U+ E+ V. C: _8 V9 g& d
unprotected females through direct skin exposure.$ n6 i. B8 b5 F8 I6 P
Serum testosterone level was found to be 2 times the
9 {8 n# N' N/ }. c: q) Vbaseline value in those females who were exposed to5 p9 [( z, p4 a0 l4 s
even 15 minutes of direct skin contact with their male
' g  o0 m$ O- ~) e2 Y+ opartners.6 However, when a shirt covered the applica-, E3 B0 |- V, b3 C' w4 s
tion site, this testosterone transfer was prevented.
( h% r& j2 Q& @, N2 F. EOur patient’s testosterone level was 60 ng/mL,, E7 ?: \8 e/ U. p4 R# m
which was clearly high. Some studies suggest that
, N3 a# c- w5 ~+ j2 Cdermal conversion of testosterone to dihydrotestos-8 H7 U. E' r$ e- o1 K+ J2 D8 ^- t
terone, which is a more potent metabolite, is more4 `' S9 h* v* _  C: m8 b" @. z
active in young children exposed to testosterone1 e" q& \+ G, f6 p. Y
exogenously7; however, we did not measure a dihy-
$ }4 @" J/ J3 V. a/ E! o5 f, zdrotestosterone level in our patient. In addition to/ I+ i: {8 \# s( U0 o! [$ c% L. }
virilization, exposure to exogenous testosterone in5 {# ?$ ~1 o( T) x& [: \; a9 L( ~2 H
children results in an increase in growth velocity and6 H% F( G# @0 l" D8 s; s: F
advanced bone age, as seen in our patient./ b4 q/ r( J' H3 c8 r: t
The long-term effect of androgen exposure during
+ N7 l: O! K* P  Oearly childhood on pubertal development and final
1 v1 D1 K9 ]4 Q4 g9 k0 y* B% T& {adult height are not fully known and always remain3 _; I* p% D5 d% h1 M
a concern. Children treated with short-term testos-
$ R" h5 t! \) E/ \. ?9 G1 uterone injection or topical androgen may exhibit some$ |1 q6 J- t" I& d' B
acceleration of the skeletal maturation; however, after* G, X# _6 C* S0 s5 ?- ^' \! ?' N
cessation of treatment, the rate of bone maturation
6 [: y& h8 G9 C+ B4 b2 `) i# h* v: Idecelerates and gradually returns to normal.8,9: ]8 s3 \! y  c
There are conflicting reports and controversy
9 l4 b; ^8 B6 p+ [$ T# {" Yover the effect of early androgen exposure on adult
. J! t; }% w$ r5 S2 @2 d  cpenile length.10,11 Some reports suggest subnormal
- o1 ~7 B6 a* v" Wadult penile length, apparently because of downreg-
" K& ~4 _! c1 g, G. ^- n% p( }9 s3 Lulation of androgen receptor number.10,12 However,, k6 `9 k; s& {3 U
Sutherland et al13 did not find a correlation between. v& `7 a! H  {" b$ n6 K
childhood testosterone exposure and reduced adult- o, E# J' z7 q  z% J  y
penile length in clinical studies./ a7 r& i7 i0 T$ v
Nonetheless, we do not believe our patient is
4 D. O! D- z  F4 f# ?+ [0 v2 jgoing to experience any of the untoward effects from
+ |2 X9 j: Y) H- l, Qtestosterone exposure as mentioned earlier because$ i1 g$ M! x9 \" q; W
the exposure was not for a prolonged period of time.& {/ j$ H' h+ I1 v# C; n2 |
Although the bone age was advanced at the time of  \: O6 W- B  C* d+ X7 d2 M
diagnosis, the child had a normal growth velocity at
# ]: \+ ?, N6 L7 L. P9 T2 j. a5 Bthe follow-up visit. It is hoped that his final adult
! o7 t7 n; [, i3 kheight will not be affected.$ q- R3 \3 T$ U3 z6 Q! E6 K- a/ @
Although rarely reported, the widespread avail-
( J6 u, W$ ]+ T1 [  q# H" ]! vability of androgen products in our society may
- a0 u* X2 Q2 \3 w& j+ P$ m5 Jindeed cause more virilization in male or female% y9 Q- k1 R5 D' \  F6 G
children than one would realize. Exposure to andro-
8 W- l/ a* J" N7 Q8 H& G* }gen products must be considered and specific ques-8 q" z# O6 j4 o" R; T! ~2 F
tioning about the use of a testosterone product or
$ _6 q+ v9 w* I+ Ygel should be asked of the family members during
# V$ m( [% I" A6 a. u% Z7 athe evaluation of any children who present with vir-: O! S6 f1 p& s4 s1 K' r
ilization or peripheral precocious puberty. The diag-$ h% q2 `  t# I& S5 D  o7 {
nosis can be established by just a few tests and by# r. H5 Q& F2 a" g' o2 q' R# D
appropriate history. The inability to obtain such a0 Z- T8 [# J4 ~/ _2 N
history, or failure to ask the specific questions, may6 X2 w, j. {8 r8 ~7 G% u4 V8 e
result in extensive, unnecessary, and expensive
) ^, N; K% f7 C2 minvestigation. The primary care physician should be8 ^0 l. P9 l& r* q6 P  P
aware of this fact, because most of these children
  a0 H4 |0 E9 N" S& _. V2 qmay initially present in their practice. The Physicians’; R& L1 ~& X: l5 h  n" s3 L/ w
Desk Reference and package insert should also put a+ L7 x& |2 h8 c, C; K4 q1 _
warning about the virilizing effect on a male or' {7 e( K, H* O5 E
female child who might come in contact with some-
+ u' W6 B" B/ h$ {, Pone using any of these products.! f. A( O% d% P0 s+ }5 m
References
  X+ P5 h+ y, ~4 D+ c$ B1. Styne DM. The testes: disorder of sexual differentiation
$ \" U. _9 Z, qand puberty in the male. In: Sperling MA, ed. Pediatric
. m9 ^" k+ V# b$ [+ v: u( qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 l7 w; G  Z" P4 C3 h$ Q, Y' }
2002: 565-628.
1 }+ T% `6 U9 Q$ e0 Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" m$ n; u' k* D/ b" r  ipuberty 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

8 d6 z7 [2 Q5 F; D1 X) `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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