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Sexual Precocity in a 16-Month-Old# B* n6 q5 E& y( C: U  x8 k
Boy Induced by Indirect Topical
2 P6 c5 c; |3 K3 \. D* e3 {( DExposure to Testosterone$ W8 A( B% c8 B) ^+ [2 \
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 w0 y4 r) h, Q( i
and Kenneth R. Rettig, MD17 w3 z) m$ i. c% k  Q! Q  Y
Clinical Pediatrics0 e- W2 u3 ~: c4 T! z
Volume 46 Number 6
% t/ }$ c4 n9 g* D. zJuly 2007 540-543/ m$ T8 t# t5 d5 M
© 2007 Sage Publications
/ W: l- N" {9 Y2 W/ s4 Y* l10.1177/0009922806296651
. W$ B- t: r; t9 K, v) e: Y5 ]http://clp.sagepub.com
" L2 K- z' d% Q# F2 Ghosted at
' h8 s8 A+ i2 [; E: [$ |6 vhttp://online.sagepub.com
2 h2 r, t& ~! i0 S; S7 |Precocious puberty in boys, central or peripheral,
) I+ r( H  O+ kis a significant concern for physicians. Central5 }6 o* J& U3 D( x  U6 d
precocious puberty (CPP), which is mediated
9 o. Z7 i2 x; G/ v% W$ R7 ~through the hypothalamic pituitary gonadal axis, has* v% S$ p0 P2 J  Q4 o5 S
a higher incidence of organic central nervous system6 i9 H) r1 w8 ~: M
lesions in boys.1,2 Virilization in boys, as manifested
& _1 f' ?6 @1 p, e# e% L$ F' ~by enlargement of the penis, development of pubic) t2 A3 p5 Z5 V5 Y7 w+ u* h; B$ b
hair, and facial acne without enlargement of testi-
) B; Q  m' }5 H& i* k6 g( ~cles, suggests peripheral or pseudopuberty.1-3 We5 e' I% c% H. V; I: ?( o2 G, H
report a 16-month-old boy who presented with the8 ?- p8 H, Y% b% y/ j6 _% X! T
enlargement of the phallus and pubic hair develop-
, q5 v( R- p- R3 d: rment without testicular enlargement, which was due
4 P/ x/ g2 C6 X; Cto the unintentional exposure to androgen gel used by: [9 O! P$ f9 n, b( x
the father. The family initially concealed this infor-
) @8 A. a# ~5 n0 x  }mation, resulting in an extensive work-up for this4 y) t' O: y3 t3 r6 X
child. Given the widespread and easy availability of* \9 M4 F" ]6 @7 H( _
testosterone gel and cream, we believe this is proba-4 q3 l7 Z: y: ^! ?' U% @* h
bly more common than the rare case report in the- x. y- \! O1 f2 y4 }
literature.4
$ Y4 D& I6 l/ e* c5 BPatient Report5 q  Y/ f* l2 Z. @9 X3 j
A 16-month-old white child was referred to the
$ i# V( |  b+ k) _+ _9 qendocrine clinic by his pediatrician with the concern! t8 |8 E% S# q' i
of early sexual development. His mother noticed
" ~# p. G4 U. F: Vlight colored pubic hair development when he was# E8 ^& u  _* ?: \4 [; j
From the 1Division of Pediatric Endocrinology, 2University of
% E6 U, r. L) M: @9 lSouth Alabama Medical Center, Mobile, Alabama.
6 Y. L  Z# D8 @7 n8 ^% b5 H. z% FAddress correspondence to: Samar K. Bhowmick, MD, FACE,) N! |% V$ s$ p. i% a) |
Professor of Pediatrics, University of South Alabama, College of
0 c) k3 s9 C  X+ XMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  A% G4 V$ T" t% ^1 Z; E5 Oe-mail: [email protected].
# |) L, K0 W  K* g5 U' |about 6 to 7 months old, which progressively became
4 V# S4 C: Z7 J% @, Pdarker. She was also concerned about the enlarge-
" N6 q1 V  Y$ s, u- y$ n3 Vment of his penis and frequent erections. The child
! v0 `+ Z5 g: U- r6 z  `* M% X. @was the product of a full-term normal delivery, with; M- r. k) A% q. ?5 }- C7 @
a birth weight of 7 lb 14 oz, and birth length of
( @' }8 [* {) u3 D- X) r+ t20 inches. He was breast-fed throughout the first year
3 Y0 A7 n; l. U" ^, W( Cof life and was still receiving breast milk along with/ \+ r5 b, d" A" w. G
solid food. He had no hospitalizations or surgery,
0 f6 {/ K$ W/ D7 n) vand his psychosocial and psychomotor development/ r0 G$ R* j' m
was age appropriate.
6 p  i  l6 f3 AThe family history was remarkable for the father,
; j3 V1 U* J% e5 s2 g7 bwho was diagnosed with hypothyroidism at age 16,. w* i- G/ v# `& P1 M$ _2 R, g0 \
which was treated with thyroxine. The father’s
2 F- C; G" i' Y% X# ?height was 6 feet, and he went through a somewhat
$ D5 s8 Q! y0 D4 g* pearly puberty and had stopped growing by age 14.
$ {: H4 b+ e# ]5 I/ p3 L- ?The father denied taking any other medication. The6 k; K2 W) w4 O
child’s mother was in good health. Her menarche
" M  g% @- k1 J. S. y9 @8 |$ F# Jwas at 11 years of age, and her height was at 5 feet
+ b, v/ m  ]+ A( W5 inches. There was no other family history of pre-
' R/ W9 `* t4 L# V) T& p) @& |cocious sexual development in the first-degree rela-3 F, e4 H. j+ `# J
tives. There were no siblings., G) P. T# ~9 U+ v$ h: V
Physical Examination
+ Q$ W! z, @. B: G( }* e) UThe physical examination revealed a very active,' B3 ~) |1 V2 L/ K3 _. W; F7 L: q
playful, and healthy boy. The vital signs documented8 X8 t' `; ?$ e% Z  a7 d6 G, k
a blood pressure of 85/50 mm Hg, his length was/ G# O+ F- j# G; Z) m) T+ I7 O
90 cm (>97th percentile), and his weight was 14.4 kg
7 ?+ l0 h3 W# E# j& M(also >97th percentile). The observed yearly growth# \, X$ o0 ~3 }3 }- M5 z* ?$ f
velocity was 30 cm (12 inches). The examination of1 ?- W% u) p/ H% ~5 O: k4 y
the neck revealed no thyroid enlargement.
/ Z8 _' Q7 B  iThe genitourinary examination was remarkable for9 A2 h" n" o! ~6 Q/ M0 B
enlargement of the penis, with a stretched length of
5 D& a4 L5 R! Y* n: P8 cm and a width of 2 cm. The glans penis was very well
- x3 D; e( u* p7 [  V2 R; Fdeveloped. The pubic hair was Tanner II, mostly around
% E: {* ^/ \3 E5 v. O" V540% H" c# r* L( \' v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ ]% u$ I* Z% b' |/ d6 i2 Y/ ~
the base of the phallus and was dark and curled. The) s, G' P9 j7 {- G, L) ~; \
testicular volume was prepubertal at 2 mL each.; }* y3 a$ I/ C3 O
The skin was moist and smooth and somewhat( c4 p1 T6 C  s) O. e5 w7 w
oily. No axillary hair was noted. There were no. n5 I. T* H7 D+ [$ U1 I
abnormal skin pigmentations or café-au-lait spots.7 O# p. F/ f, l
Neurologic evaluation showed deep tendon reflex 2+& w! Y9 M# E* z1 n. W/ I4 L
bilateral and symmetrical. There was no suggestion  j/ \; A) D: `$ j0 n& T
of papilledema.2 j4 H% @8 j+ w$ A
Laboratory Evaluation$ C1 }: Y! l  G' U. G
The bone age was consistent with 28 months by+ i* V4 Z& M/ C! U. T1 S
using the standard of Greulich and Pyle at a chrono-
& j. {$ `. J& d: N1 @# J" Dlogic age of 16 months (advanced).5 Chromosomal
4 p' o: t( z8 W" Fkaryotype was 46XY. The thyroid function test
- J; N# Y" o: H$ x: Y6 r  Oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-. n( T' z1 v& s% F/ j3 A3 X3 c
lating hormone level was 1.3 µIU/mL (both normal).* u! J& K4 o# u4 R
The concentrations of serum electrolytes, blood
# J. ~7 Q, P) E: Hurea nitrogen, creatinine, and calcium all were
; ~0 {0 `' R: p$ H6 x$ ?within normal range for his age. The concentration2 n- r; `' U! R/ x
of serum 17-hydroxyprogesterone was 16 ng/dL' m( m+ f9 D9 q, Y2 I' k
(normal, 3 to 90 ng/dL), androstenedione was 20% _- Y3 u  f. a# f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- m  P! o# O% ]% h! `* I; E% ~$ R
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
' m3 Y; V5 N; n1 }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
& P! l5 w5 O* y) @2 s49ng/dL), 11-desoxycortisol (specific compound S)- q5 L9 ]- |5 o' V( ?
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 s* J7 F5 ^+ C3 m8 G$ F% q+ Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total  H( ]5 C( z1 @8 o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) m! Y/ m( _, i. G$ @% I" e+ g$ g0 s
and β-human chorionic gonadotropin was less than: i) B$ P3 k, o: e
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 ^  k3 c0 Z. v% C4 I& g. mstimulating hormone and leuteinizing hormone
# N& e% K7 \4 [- L  {1 Cconcentrations were less than 0.05 mIU/mL; R7 d" \; u  D  A8 J2 B  N2 Y
(prepubertal).5 i; t+ Y+ t4 Q( N/ v+ A
The parents were notified about the laboratory/ d2 }: p; P" ]5 f
results and were informed that all of the tests were
9 B4 h# w( q4 d, w) e; T% f  Q7 K9 ~normal except the testosterone level was high. The1 V0 y8 u: ^& u8 p5 l  R1 x7 M) H- ]
follow-up visit was arranged within a few weeks to
- g% t& M8 Q4 y& x! b; H: |obtain testicular and abdominal sonograms; how-0 {# _5 [' @$ X0 ~, |4 s' f# e
ever, the family did not return for 4 months.: C1 v) d. q0 P3 A8 r; e
Physical examination at this time revealed that the
$ ?* U( N2 N$ I5 hchild had grown 2.5 cm in 4 months and had gained5 L8 \' p! ]7 q8 \4 r
2 kg of weight. Physical examination remained
6 h/ x/ S7 F0 F3 O+ a! Munchanged. Surprisingly, the pubic hair almost com-
& @9 s, B, z5 X+ v% m" r0 Zpletely disappeared except for a few vellous hairs at
* l/ U! j' A7 l. w5 b. A$ r, Xthe base of the phallus. Testicular volume was still 2
4 n: k% N4 v; DmL, and the size of the penis remained unchanged.7 x' j2 ^8 H) x3 P" j
The mother also said that the boy was no longer hav-
" E. a$ _" A' A7 j( s: j' Y  B; hing frequent erections.% e! G* g4 N% S' `. G' _* c# Y" @) d2 [
Both parents were again questioned about use of
5 L) Z( S! {/ D& h" ~( sany ointment/creams that they may have applied to
. b0 U* s! m  X& i" x# r( zthe child’s skin. This time the father admitted the
) v3 Y5 b8 F7 a; K1 VTopical Testosterone Exposure / Bhowmick et al 541
4 R7 l( J" J6 @6 Z! `# q' o* nuse of testosterone gel twice daily that he was apply-
$ i& N# t# k. R) ~' X) {ing over his own shoulders, chest, and back area for
4 C4 B' l, k7 F( [: i; l7 Oa year. The father also revealed he was embarrassed
* b+ S5 x3 ?. g1 E: [4 e$ vto disclose that he was using a testosterone gel pre-
( v7 Y" c( a% b. t" k5 Qscribed by his family physician for decreased libido9 `- `. B, ]( ?
secondary to depression.* _4 `' H! ?" A5 o; k0 o" w
The child slept in the same bed with parents.
; F+ X. c/ [: P) ?The father would hug the baby and hold him on his. Z- U2 c7 C  a( p6 w( t# e! x' u# f
chest for a considerable period of time, causing sig-" J4 o% O2 x* V* v
nificant bare skin contact between baby and father.
2 `7 z; i0 {. ?  q( eThe father also admitted that after the phone call,
  O+ M7 r* Z9 P& e0 Awhen he learned the testosterone level in the baby2 P( y' ]: [1 @! [3 u, d  G, w# Q
was high, he then read the product information7 E- ?# |9 M4 c( d, y" k
packet and concluded that it was most likely the rea-! O8 X7 z' M. l- W( Z! K& P
son for the child’s virilization. At that time, they
' k6 b" I0 h/ g* l0 ?decided to put the baby in a separate bed, and the  G- ~, J2 X0 f, j
father was not hugging him with bare skin and had) a1 y1 x. s- E3 D% ]5 r. y
been using protective clothing. A repeat testosterone! A; i; Q  Z  u1 ^/ B2 g5 r3 s
test was ordered, but the family did not go to the: z0 f% i7 T5 U9 i2 U
laboratory to obtain the test.5 _/ d; t4 `* h; F$ ]
Discussion
, ^  k5 Z0 H  `# _$ h/ mPrecocious puberty in boys is defined as secondary
, x) D' y& p2 z. V3 Dsexual development before 9 years of age.1,4
& y& ?4 ?, F5 K% A6 iPrecocious puberty is termed as central (true) when
3 B4 y& [) i  o* M% Nit is caused by the premature activation of hypo-
3 l$ N6 N6 S  e5 J# gthalamic pituitary gonadal axis. CPP is more com-
! y+ j& F1 n$ Z/ e! |( Wmon in girls than in boys.1,3 Most boys with CPP
; y6 f$ g0 C4 v( H% N8 Imay have a central nervous system lesion that is- X4 k4 B' G( o! _! e" L4 O4 i
responsible for the early activation of the hypothal-" ^- C( q. w3 h! r9 q: g$ f
amic pituitary gonadal axis.1-3 Thus, greater empha-
* S; H& A: H1 ]" msis has been given to neuroradiologic imaging in
5 ~* Y$ k6 F8 b; G+ iboys with precocious puberty. In addition to viril-
- k' @' g% S' |( z2 H" Oization, the clinical hallmark of CPP is the symmet-  [. q" o5 q& P/ V
rical testicular growth secondary to stimulation by
- u- B( r# ?0 L6 tgonadotropins.1,3
2 k# E0 {& A) x" {Gonadotropin-independent peripheral preco-
2 C: n2 X' M0 pcious puberty in boys also results from inappropriate$ e  L# }' d8 E3 k
androgenic stimulation from either endogenous or
4 a& l# e+ A* Q* H8 Jexogenous sources, nonpituitary gonadotropin stim-
) Y# R/ F0 U3 B: x: ?! X9 ~/ julation, and rare activating mutations.3 Virilizing
$ i- h% |4 l. X  v. u0 T, Vcongenital adrenal hyperplasia producing excessive% j8 ~9 j2 y# l* I9 `& A/ A! y' f9 U
adrenal androgens is a common cause of precocious
4 @+ E/ H4 A: K8 k$ zpuberty in boys.3,4: o5 U7 D, U5 E' j' I& I1 Y! y
The most common form of congenital adrenal
# u- i9 Z9 s; b; @5 \' J2 @hyperplasia is the 21-hydroxylase enzyme deficiency./ U# {. k& x- I3 l
The 11-β hydroxylase deficiency may also result in
2 m7 |* B5 w* `4 _- K* Lexcessive adrenal androgen production, and rarely," _2 `$ s3 _) M- Y' v1 G
an adrenal tumor may also cause adrenal androgen
: U' V  `7 K0 B9 F: |" pexcess.1,3
. ?1 P: g0 {( _& k( i# mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& L# [5 R1 Z; Y8 O6 G542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& K, M7 D" c' k$ Z+ J8 N/ t' \
A unique entity of male-limited gonadotropin-; [: Y% }1 b+ ?4 [
independent precocious puberty, which is also known0 b4 j  G2 Z4 M( B; ]. t
as testotoxicosis, may cause precocious puberty at a! o% G% [! v' H4 M! @* C2 f
very young age. The physical findings in these boys
# J) `9 s3 I6 @! R" o2 qwith this disorder are full pubertal development,
+ K/ `: j+ Q5 u9 X$ u5 L. wincluding bilateral testicular growth, similar to boys+ i2 }8 n+ ^6 g2 U. o! y, a. b' l
with CPP. The gonadotropin levels in this disorder# P$ r! j/ |( B2 q! K0 o
are suppressed to prepubertal levels and do not show
! Q7 }! O$ h2 q% S1 ]% lpubertal response of gonadotropin after gonadotropin-
6 m4 {. b- S2 I# O) treleasing hormone stimulation. This is a sex-linked
: h6 t: O$ _- c; J+ Xautosomal dominant disorder that affects only4 W$ e/ C. i* m9 R2 A* [" E) b
males; therefore, other male members of the family! N) w, }* r1 K1 ~& m. y# V% b
may have similar precocious puberty.3- ~1 O. d$ n+ z9 k+ s0 e
In our patient, physical examination was incon-2 q3 R2 G& y7 d
sistent with true precocious puberty since his testi-, `3 M: p% z. H8 g8 E' k
cles were prepubertal in size. However, testotoxicosis7 y9 D9 a: s/ d7 e' F: a7 C* O
was in the differential diagnosis because his father
" U' S2 ?2 M; q2 xstarted puberty somewhat early, and occasionally,! \. m5 D$ i1 }
testicular enlargement is not that evident in the+ U& E( k- I9 V
beginning of this process.1 In the absence of a neg-# R4 w% k0 A" F9 M8 P! R/ D* B
ative initial history of androgen exposure, our* i2 H6 r! ?4 ?, v6 b
biggest concern was virilizing adrenal hyperplasia,
( ~9 \" q1 S& Q" f- g3 teither 21-hydroxylase deficiency or 11-β hydroxylase
5 _/ G. B* D0 adeficiency. Those diagnoses were excluded by find-6 g* u& s# b- R4 N
ing the normal level of adrenal steroids.  i; d9 Z1 m2 x0 y2 E0 V7 w- Q
The diagnosis of exogenous androgens was strongly# u$ m% w% j, E2 H$ {
suspected in a follow-up visit after 4 months because0 c  L. O5 L; R0 {% l, e
the physical examination revealed the complete disap-# s7 k) }7 N! i8 l4 U' k
pearance of pubic hair, normal growth velocity, and1 d% J( B% x7 \% k
decreased erections. The father admitted using a testos-
9 t+ D& }7 b' O$ c9 I& C( U( mterone gel, which he concealed at first visit. He was) b) z: f1 ~5 o: X8 F( z& t* `
using it rather frequently, twice a day. The Physicians’8 d3 j: v( O; c/ l1 u
Desk Reference, or package insert of this product, gel or
+ W# M& i# N; X/ ~3 w1 Ecream, cautions about dermal testosterone transfer to" G/ o7 m- f% q$ ?
unprotected females through direct skin exposure.+ b% ?1 R3 T1 V( ^5 @
Serum testosterone level was found to be 2 times the2 Q7 X/ z; B/ C" N  B& o: ]
baseline value in those females who were exposed to
- s5 q+ a  N8 w2 b( S6 X+ Seven 15 minutes of direct skin contact with their male( a; j6 t3 |; n: G) N
partners.6 However, when a shirt covered the applica-9 V/ k  D& P6 l3 g* o8 u
tion site, this testosterone transfer was prevented.+ M1 ~( C/ e& K6 z( o! z# t
Our patient’s testosterone level was 60 ng/mL,4 W, b) q: T/ l5 P
which was clearly high. Some studies suggest that( X9 Y- i* @$ ]( q. N
dermal conversion of testosterone to dihydrotestos-7 f3 l! `! ^) b
terone, which is a more potent metabolite, is more' Y, j- m3 w/ H- R
active in young children exposed to testosterone) p8 E$ ~7 |3 U# [
exogenously7; however, we did not measure a dihy-
# Z+ I0 p; o3 ?/ R4 G3 m  Mdrotestosterone level in our patient. In addition to* c5 L) _$ |* J" [* i
virilization, exposure to exogenous testosterone in
0 I8 N/ |( G" D* y, f, p' Echildren results in an increase in growth velocity and
" L+ {/ X& q4 C% Tadvanced bone age, as seen in our patient.
! ?# u, U1 s( D  XThe long-term effect of androgen exposure during
, v. P0 W- L% [1 _# eearly childhood on pubertal development and final) z0 K& a, _$ o2 |9 y$ \7 {
adult height are not fully known and always remain6 l- p8 W, [+ p5 ~4 G
a concern. Children treated with short-term testos-
$ i& @* S1 j+ x3 B2 Eterone injection or topical androgen may exhibit some) U# k' O8 k: d7 j, b: A6 k
acceleration of the skeletal maturation; however, after
/ U: m! W5 a* N% F* Ccessation of treatment, the rate of bone maturation
1 s2 v2 ~9 o, r5 K# Udecelerates and gradually returns to normal.8,9
1 \0 ?# E) P5 ]7 H1 O1 Z) T' ?/ p4 NThere are conflicting reports and controversy
; U" R3 M0 Y4 o4 A, D9 c5 \over the effect of early androgen exposure on adult
/ N3 K; Y  M0 C; R" i# ypenile length.10,11 Some reports suggest subnormal
5 H5 w, p& v# s) Cadult penile length, apparently because of downreg-
1 q% J1 H; a( F8 I( qulation of androgen receptor number.10,12 However,) \% x% F3 Y5 V& d2 `/ J
Sutherland et al13 did not find a correlation between2 V/ d- Q' O# b5 C" d
childhood testosterone exposure and reduced adult) Z2 i3 {8 M* P! [: U' `) x& F
penile length in clinical studies.1 n, m7 h7 ~2 E' r$ s
Nonetheless, we do not believe our patient is
# u: Y* ?( D* L1 ?9 Lgoing to experience any of the untoward effects from8 w' h+ C  O4 v' S8 O/ f+ e( h  q$ O
testosterone exposure as mentioned earlier because( A/ Y. r+ ^3 X- s$ Z5 h
the exposure was not for a prolonged period of time.2 S" q& r0 P# k+ \7 J/ p
Although the bone age was advanced at the time of
; l# J" x. p  b( Z! s8 N8 ldiagnosis, the child had a normal growth velocity at
( |* E9 \/ C+ i. ^* Gthe follow-up visit. It is hoped that his final adult: z1 S: A* X6 ]3 f# ]1 Y  Z8 g& Q
height will not be affected.4 Q3 H' h0 }; e
Although rarely reported, the widespread avail-* S6 g- K1 O1 B7 S
ability of androgen products in our society may
# b6 v3 \. L: [8 q, dindeed cause more virilization in male or female
# z2 b- L) z: g) e1 tchildren than one would realize. Exposure to andro-
6 N9 y$ f3 O% q; ]/ egen products must be considered and specific ques-
/ F! U* i( i; M0 t+ I* gtioning about the use of a testosterone product or
  @% x& `) }8 l8 Vgel should be asked of the family members during
! s  [( p5 p+ v+ l% G& \% D: w. }the evaluation of any children who present with vir-
  O, c+ |$ O/ C5 ?' _+ |ilization or peripheral precocious puberty. The diag-
4 n0 S* D9 F; \( \* `nosis can be established by just a few tests and by
# }! u/ C( z3 w) v. rappropriate history. The inability to obtain such a
" C4 @! c2 P1 i3 |( \0 Q4 P( fhistory, or failure to ask the specific questions, may9 d8 k! w$ e/ a" i/ F
result in extensive, unnecessary, and expensive6 q7 o& R* g$ J7 j& I9 E
investigation. The primary care physician should be6 M3 N5 C7 f3 L4 |9 D
aware of this fact, because most of these children1 P, Y) Y7 ?1 `' _+ x
may initially present in their practice. The Physicians’
- ^9 }0 O  |! w' B8 UDesk Reference and package insert should also put a+ Z& ?8 P3 h8 L# y  J7 j! T; @
warning about the virilizing effect on a male or7 K5 L- A( O7 a% R4 Q1 m) a* B
female child who might come in contact with some-
% @* ^/ e$ O' Done using any of these products.8 u: s2 j" o0 [: h; d/ |* M7 @9 T
References
* g& l6 C8 P; P4 E' l1 `1. Styne DM. The testes: disorder of sexual differentiation
8 I7 V3 o" h: e, P) y5 a3 h' A4 vand puberty in the male. In: Sperling MA, ed. Pediatric0 k8 {& g/ u8 e: t+ l8 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; g' Q4 }" B: U
2002: 565-628.
9 }$ x& V1 `6 u. R) P2 e5 h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 @4 I5 ]9 Z; [1 Y4 w  @puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 q0 V5 P3 V: _& e8 H' U
Boy Induced by Indirect Topical* Y7 H# h0 n4 u) q3 {  o( R( i8 J
Exposure to Testosterone3 q. q  Q) @, t3 I9 \+ B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 E8 b6 T( j0 h5 R% y7 B* S
and Kenneth R. Rettig, MD18 ]# G1 e, \( i
Clinical Pediatrics
  d) t6 c4 @4 @6 L, o6 KVolume 46 Number 6
5 ?) M7 P% L5 O6 E) _July 2007 540-5434 _) b" r0 m, x  {) b! E3 K
© 2007 Sage Publications$ l* m; }1 i& g. ~( Q% T
10.1177/00099228062966510 m9 K4 G  J+ z8 c' o! V% {3 M
http://clp.sagepub.com
! K6 F+ a( T- D, ohosted at" g6 E, H1 Q$ T: l' I2 @
http://online.sagepub.com
9 I- Q3 j' R# b. T0 q% x( yPrecocious puberty in boys, central or peripheral,
: T" u% g1 `3 _, L* yis a significant concern for physicians. Central
: c# k, E# W9 o, G5 Dprecocious puberty (CPP), which is mediated* x6 V0 F& W' m' X: _
through the hypothalamic pituitary gonadal axis, has
; ?8 V0 @9 b2 |$ ^7 pa higher incidence of organic central nervous system, f) X" B- B5 b1 B  Z9 p6 F
lesions in boys.1,2 Virilization in boys, as manifested
8 A* H$ Q. l" v4 xby enlargement of the penis, development of pubic
/ R8 l5 T5 ?# h4 z6 o# Qhair, and facial acne without enlargement of testi-
: y% ?$ v6 i4 v- [: X% tcles, suggests peripheral or pseudopuberty.1-3 We
$ U, Y$ ~9 g+ ^report a 16-month-old boy who presented with the
/ W* J9 n7 c4 Z+ C. lenlargement of the phallus and pubic hair develop-( `6 M' n! u3 z3 B# R/ z, t- e+ v* A
ment without testicular enlargement, which was due, O7 u9 M7 f- F  B+ Z+ C
to the unintentional exposure to androgen gel used by' ?1 M8 J- M) K
the father. The family initially concealed this infor-
* b5 G0 m, {" ?' u; [9 \. nmation, resulting in an extensive work-up for this0 t( A$ w$ u- Y3 O  M/ [1 R
child. Given the widespread and easy availability of
) e! m' k* R$ @, [" p6 ^  ktestosterone gel and cream, we believe this is proba-9 e% a* u* v% @5 C1 a# j7 O
bly more common than the rare case report in the" N; c# }2 N  m4 r+ `8 D
literature.4, x$ J7 k: N2 o2 c) n
Patient Report
( {1 e& c& `  b; H) C" d4 r' DA 16-month-old white child was referred to the9 w# @: @( E% e) U" ]
endocrine clinic by his pediatrician with the concern7 q  w: Z1 j! F; e3 C
of early sexual development. His mother noticed
+ T$ l8 h+ D1 T/ z  U  ^light colored pubic hair development when he was
  A2 Z: e/ `0 n& r6 H, rFrom the 1Division of Pediatric Endocrinology, 2University of
- O( u- A. s2 X2 JSouth Alabama Medical Center, Mobile, Alabama.# i" @- k" A4 U
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ P1 H( t9 G* vProfessor of Pediatrics, University of South Alabama, College of5 g' [; W; A1 G% r7 ^6 \5 D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 t9 T0 N# t$ M
e-mail: [email protected].
5 @0 y* V9 v9 }about 6 to 7 months old, which progressively became/ P' \: W' x5 f7 R
darker. She was also concerned about the enlarge-  A" [/ T5 C8 e5 |) B
ment of his penis and frequent erections. The child& t9 o. Y& O% r
was the product of a full-term normal delivery, with* W1 q, \2 v- [8 N5 L
a birth weight of 7 lb 14 oz, and birth length of6 [4 e0 |: o& B0 d5 f. i0 p: D6 j; T
20 inches. He was breast-fed throughout the first year. S! i8 c, r( K4 S* y( `* b5 {
of life and was still receiving breast milk along with3 \# C& J. W/ \) \
solid food. He had no hospitalizations or surgery,
5 p# }; z+ s0 Eand his psychosocial and psychomotor development
! q# U# a3 Q9 y5 y" x& twas age appropriate.* w( L/ Y* e- U  }4 \* q+ p3 S
The family history was remarkable for the father,! V- }; k8 r5 {! T# y8 o
who was diagnosed with hypothyroidism at age 16,
! _2 t1 s. l( J: J2 {3 g8 ywhich was treated with thyroxine. The father’s5 R1 j) P5 s# G; ~3 j" S7 p
height was 6 feet, and he went through a somewhat
# y. p1 P6 u# G* kearly puberty and had stopped growing by age 14.( O- e5 E# v( ~/ c+ g
The father denied taking any other medication. The
0 A  y, t  y9 _+ j# ^. ^5 b: n9 Lchild’s mother was in good health. Her menarche
2 W7 T5 x7 H) Iwas at 11 years of age, and her height was at 5 feet
$ y+ B) a$ b* L" V. u/ C% [5 inches. There was no other family history of pre-6 a7 Z" c0 }; B- x
cocious sexual development in the first-degree rela-9 Z" W+ n7 s% _7 t$ t2 J
tives. There were no siblings.
7 H7 M4 F. p8 x; G' O9 n. E# E$ OPhysical Examination% d: c! d$ R1 ~1 H! A2 b
The physical examination revealed a very active,$ C% Z0 ]5 S- I. ~! ]0 c
playful, and healthy boy. The vital signs documented! n) z: P1 ]. [  |
a blood pressure of 85/50 mm Hg, his length was& d5 h3 ?# z  w2 Z9 B
90 cm (>97th percentile), and his weight was 14.4 kg
2 X% H; x" k- L% X* j% G# [(also >97th percentile). The observed yearly growth
  C+ w$ |, n! Vvelocity was 30 cm (12 inches). The examination of
0 [8 r, S* t# `the neck revealed no thyroid enlargement.+ `6 ]! [, c( m: E! K
The genitourinary examination was remarkable for
- D) O5 @& Z0 f; l9 Uenlargement of the penis, with a stretched length of( r0 E/ F" o* _" }" e8 w* O3 q
8 cm and a width of 2 cm. The glans penis was very well
$ t6 C! {" T# |  _5 ldeveloped. The pubic hair was Tanner II, mostly around2 Y8 V7 y1 Y' s* X0 a, R
5407 w& _3 K# E2 ]9 m6 D4 m  }, `& F( {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% c( \7 }, q" |. a& c% X* @; x7 {
the base of the phallus and was dark and curled. The
8 P0 I: C  i0 Vtesticular volume was prepubertal at 2 mL each.
  ^' z; m9 D9 N9 SThe skin was moist and smooth and somewhat
+ g5 B9 E. X0 s# X2 Roily. No axillary hair was noted. There were no. C) y5 e8 f5 ]: A* E, l0 K
abnormal skin pigmentations or café-au-lait spots.
* P6 B/ f5 [5 w5 L- q& eNeurologic evaluation showed deep tendon reflex 2+9 p! e) z+ G# j
bilateral and symmetrical. There was no suggestion! y1 P6 z. c3 U; x4 f  }! S6 Z7 m
of papilledema.
( M! A" W- W) pLaboratory Evaluation
4 K8 }+ T0 _0 d) X" YThe bone age was consistent with 28 months by
. [; M8 u8 V+ _$ T& u  d, C# H. Susing the standard of Greulich and Pyle at a chrono-; ^2 X2 V4 W2 g5 p- A. m
logic age of 16 months (advanced).5 Chromosomal( d0 Z1 I: _& l4 T, @/ D
karyotype was 46XY. The thyroid function test$ ]1 ]1 h/ O% D/ b  M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, u1 Z0 H  O4 C# S( Ilating hormone level was 1.3 µIU/mL (both normal).) ?; h- I1 g4 c; i6 v8 U& |
The concentrations of serum electrolytes, blood  h. U- [& b- h8 E; w. m0 P
urea nitrogen, creatinine, and calcium all were
! m9 d0 R8 ^- F  a* [! ~2 t; Twithin normal range for his age. The concentration9 l! t' l) W4 ?# n; o  P9 w% H# D
of serum 17-hydroxyprogesterone was 16 ng/dL0 L$ ?5 ?* G3 |) w
(normal, 3 to 90 ng/dL), androstenedione was 20
  O7 j: H% y( `! u2 Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 ^! O5 F* Y- q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 C5 l. ]9 |1 i5 E4 mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to# s/ y0 x8 C) ~% m5 J5 t
49ng/dL), 11-desoxycortisol (specific compound S)
) a4 w" z! w3 X6 h+ w& {6 jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: f0 F4 y' a% R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# {& a2 s  s9 B: d5 C2 Z1 ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! V$ p. ?% K1 [& q; p; J6 Q8 _and β-human chorionic gonadotropin was less than
( a. T* A2 j9 b* [5 mIU/mL (normal <5 mIU/mL). Serum follicular
" n( ~. B) W5 O3 ustimulating hormone and leuteinizing hormone
1 G- B4 {$ F% V; yconcentrations were less than 0.05 mIU/mL" X" w# r! l0 \
(prepubertal).
4 s- m, X2 M' I3 L+ x- C3 wThe parents were notified about the laboratory9 m3 v  h. R5 l- K7 C  C5 F0 |
results and were informed that all of the tests were$ w" ]. A/ X& X$ u
normal except the testosterone level was high. The
6 x% |) }1 ?% a- Q# K2 y$ kfollow-up visit was arranged within a few weeks to$ R4 }& K3 x: |8 c
obtain testicular and abdominal sonograms; how-5 b1 B+ W7 C0 ]& i
ever, the family did not return for 4 months.
1 q* m. ?4 z6 Y- i  SPhysical examination at this time revealed that the# Y1 }' `$ \. ~( N. x+ I# B
child had grown 2.5 cm in 4 months and had gained
! P. h+ L$ n$ e0 ]3 h6 h" Z2 kg of weight. Physical examination remained/ R8 E. L( Z$ A* e! S5 y' w9 A
unchanged. Surprisingly, the pubic hair almost com-
4 Q1 C5 B% S8 q6 Q0 p4 \pletely disappeared except for a few vellous hairs at3 [$ U7 u+ K/ {5 P. p/ [
the base of the phallus. Testicular volume was still 2
  S! B2 V, C2 N4 B: hmL, and the size of the penis remained unchanged.
8 a. P- H2 _! V& D; D" _The mother also said that the boy was no longer hav-8 r6 f5 n! {& j& b
ing frequent erections.6 K* J* F! K' @) Q) F# W
Both parents were again questioned about use of
) v, Z  s0 i  y7 P* N! Eany ointment/creams that they may have applied to
! s: i1 m8 M, b8 C/ Lthe child’s skin. This time the father admitted the' Y4 I; V) N2 w6 m! n, `
Topical Testosterone Exposure / Bhowmick et al 541
( n* V7 u5 }3 P2 Nuse of testosterone gel twice daily that he was apply-2 o, s' y8 U; ^0 _- P" O
ing over his own shoulders, chest, and back area for
, H/ ?" f& M0 R7 c$ Ga year. The father also revealed he was embarrassed
9 m- y0 E5 K/ D% A& D2 [* Z/ Z( kto disclose that he was using a testosterone gel pre-
1 K& `5 t4 u4 Kscribed by his family physician for decreased libido4 [4 y- S/ W( |
secondary to depression.
' c2 ~' V- |; g3 l3 f. dThe child slept in the same bed with parents.
4 u* n! v3 V9 zThe father would hug the baby and hold him on his5 M- C9 c  U; C3 B+ o% v' E
chest for a considerable period of time, causing sig-  Q/ j: q4 w( P4 c
nificant bare skin contact between baby and father.4 E. i* k( U8 P$ s) a) U) w% Y
The father also admitted that after the phone call,6 Z4 j$ I8 i; J" T3 q9 e$ q
when he learned the testosterone level in the baby
5 K2 r/ Q% o) t* H( }was high, he then read the product information
3 t; |4 m' }# n5 Wpacket and concluded that it was most likely the rea-  E( t( y; u: g+ }0 S) I9 J+ {
son for the child’s virilization. At that time, they
3 t2 x" L2 Q, `5 H; L3 D6 Ddecided to put the baby in a separate bed, and the
8 P, E. B8 o6 p4 ~father was not hugging him with bare skin and had
- T8 v; A; [0 vbeen using protective clothing. A repeat testosterone
6 Q4 p3 B3 `% m/ P9 i, o; ]  b6 @test was ordered, but the family did not go to the
' v3 l& t. r4 Y. Q6 tlaboratory to obtain the test.
8 p" o1 `$ b) {3 w' N, YDiscussion
  M0 N1 B1 ]1 F! z) L+ ]) ~Precocious puberty in boys is defined as secondary# A  g1 a  l' o/ P9 J; t. |- C
sexual development before 9 years of age.1,4% t( s5 _: R3 e0 H6 v
Precocious puberty is termed as central (true) when/ f, z% d3 v- m6 w2 \
it is caused by the premature activation of hypo-
, s2 Q/ N5 X- x6 ^) vthalamic pituitary gonadal axis. CPP is more com-
2 G  l, s" r& U9 S  Jmon in girls than in boys.1,3 Most boys with CPP1 J# i6 l  T6 w& F5 [1 d3 u& Z" K
may have a central nervous system lesion that is: f/ |6 w+ i* g5 F, ]& i
responsible for the early activation of the hypothal-
, w+ A* a6 f7 I: A! }: mamic pituitary gonadal axis.1-3 Thus, greater empha-. ?* N$ J1 l$ D# M8 g& c6 C  `& Z' Z5 o
sis has been given to neuroradiologic imaging in/ p. N5 o/ w) a+ ~! R, N8 D9 J* a
boys with precocious puberty. In addition to viril-
1 `2 L) q" C* W8 S( V4 Y1 Tization, the clinical hallmark of CPP is the symmet-
3 K5 W$ C; V  R8 Mrical testicular growth secondary to stimulation by
' [& M1 Y5 G+ h2 Egonadotropins.1,3) v, V; n5 i2 M2 ^
Gonadotropin-independent peripheral preco-
, Y- S( `" ~" Ucious puberty in boys also results from inappropriate
. ~% s+ R4 p: p/ b( F( a& {; @' a7 Handrogenic stimulation from either endogenous or
0 z: O! s2 _! A. C1 I8 \- r7 sexogenous sources, nonpituitary gonadotropin stim-* ^# X  H2 m& z7 l# T# w7 W! n
ulation, and rare activating mutations.3 Virilizing" y( Q( Y+ G+ R& l) H% Y: N/ }
congenital adrenal hyperplasia producing excessive- w) p" F  m: @1 z5 C" I) n
adrenal androgens is a common cause of precocious
' L- y+ A& X  ~. ~# h" j9 npuberty in boys.3,45 P) O3 R4 E! Q. W9 m9 a4 Z
The most common form of congenital adrenal
4 n- X# e! `6 ^+ `hyperplasia is the 21-hydroxylase enzyme deficiency.  J) e0 j$ T/ u* r/ ?0 s. A1 u
The 11-β hydroxylase deficiency may also result in. b1 |  `2 b- e& i. |0 [8 x% F
excessive adrenal androgen production, and rarely,
2 {8 c$ s! p0 l( lan adrenal tumor may also cause adrenal androgen! Y! l7 k1 |8 {8 Z. C( S' b
excess.1,3
& K7 b1 N6 B! o3 m; aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* c/ d2 H* e% _0 T3 x% B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: @/ Y1 q/ `& sA unique entity of male-limited gonadotropin-
( G0 _5 M4 H) i# D' ^, y4 d* ?independent precocious puberty, which is also known
  R. R8 y! ~" S' D2 O) Fas testotoxicosis, may cause precocious puberty at a
! e3 g' e2 {0 n( K- dvery young age. The physical findings in these boys
: q! N: t+ @8 I2 l1 r1 V" vwith this disorder are full pubertal development,# k, F8 G( J* H$ G
including bilateral testicular growth, similar to boys
% J2 _8 o6 N! m  p# K$ n. |4 o( swith CPP. The gonadotropin levels in this disorder
- ~7 ?; C3 j& y+ ?6 n" w6 Ware suppressed to prepubertal levels and do not show! c' M9 |/ ]9 w/ [
pubertal response of gonadotropin after gonadotropin-5 k" W/ \" `& Y9 P' |( A* y, W
releasing hormone stimulation. This is a sex-linked1 D3 ?% e- z& k% V- y9 f  T4 ?
autosomal dominant disorder that affects only
& L/ Y: |/ ~# M( L" `males; therefore, other male members of the family, a( L# W9 ?0 M! G; f
may have similar precocious puberty.3' j5 O( E6 b1 |* a4 c% {, X% v
In our patient, physical examination was incon-3 j, t. Q' E# u+ I+ o
sistent with true precocious puberty since his testi-5 h6 b. u+ W: G
cles were prepubertal in size. However, testotoxicosis
5 H' T- P8 R! A, H% l' w# a( r" Iwas in the differential diagnosis because his father
0 P9 Q& Y( i& U2 t3 astarted puberty somewhat early, and occasionally,% |3 e0 x9 D' x
testicular enlargement is not that evident in the. T4 ?; q) N5 ]
beginning of this process.1 In the absence of a neg-
/ \3 K  z4 w$ Rative initial history of androgen exposure, our
/ |- e. ]& f6 ybiggest concern was virilizing adrenal hyperplasia,4 V* C9 V+ g  N0 f  }
either 21-hydroxylase deficiency or 11-β hydroxylase) x7 B0 _9 {# I5 @% |- Q7 S8 v( R
deficiency. Those diagnoses were excluded by find-
- I' X- }' d8 O1 q& a' l8 H8 king the normal level of adrenal steroids.6 K4 J, ]6 @0 ^+ I+ o; [
The diagnosis of exogenous androgens was strongly
! W, p$ {, `- y0 x7 asuspected in a follow-up visit after 4 months because
( w) v# t8 Q4 N" U" S* R5 Q3 K/ [the physical examination revealed the complete disap-
+ q" h" X! s/ O- ]( j5 o* N% ipearance of pubic hair, normal growth velocity, and
3 I) g' S( e2 Adecreased erections. The father admitted using a testos-
6 a1 |/ I/ M+ Sterone gel, which he concealed at first visit. He was
; i4 @2 k; ]  @* y5 o" D. t6 Yusing it rather frequently, twice a day. The Physicians’
4 d  u: w/ N% B8 y" Y) ?" ~Desk Reference, or package insert of this product, gel or
8 a" g, d' y4 t: K1 |7 bcream, cautions about dermal testosterone transfer to$ g; |) d; \+ B/ b' W
unprotected females through direct skin exposure.' H2 w3 N& v8 {8 y9 d9 h0 h/ l
Serum testosterone level was found to be 2 times the
8 G0 A0 E  ~( Z* R- U) q9 c6 ~- ~baseline value in those females who were exposed to
& u  Y2 K  C. \+ D' ^+ f3 H" weven 15 minutes of direct skin contact with their male* \2 T2 s! U4 P' O2 S
partners.6 However, when a shirt covered the applica-
# [  X3 g/ _) l! P$ U1 M+ _2 P! ction site, this testosterone transfer was prevented.0 ]9 \  |" J6 h& g' j- Q5 c
Our patient’s testosterone level was 60 ng/mL,
% T0 s9 W; \( W$ U( ewhich was clearly high. Some studies suggest that
$ W% B; J( K2 V9 Ydermal conversion of testosterone to dihydrotestos-- n1 o) p: F0 X4 A* _% S3 |
terone, which is a more potent metabolite, is more1 s* j$ `/ D" P! D
active in young children exposed to testosterone( \: d1 c: y. S& S! W
exogenously7; however, we did not measure a dihy-3 T% \' ~5 T' a
drotestosterone level in our patient. In addition to
6 v* E$ f5 X& e& Y5 s# V. evirilization, exposure to exogenous testosterone in2 J) e+ m' A- m
children results in an increase in growth velocity and
9 v# X( R2 ^; u3 r! Xadvanced bone age, as seen in our patient.7 B: j/ P% v, o' O) ?8 ]9 _
The long-term effect of androgen exposure during
% `* R  E. Z' L" zearly childhood on pubertal development and final/ {& X6 x  [0 ]
adult height are not fully known and always remain
0 g8 M/ q$ F6 ?9 L+ w& v1 ua concern. Children treated with short-term testos-! ~: t  {3 ?3 U& f
terone injection or topical androgen may exhibit some
- Y5 p. w6 ^( [& a+ _! Vacceleration of the skeletal maturation; however, after
( w; ]# c1 B  s" Vcessation of treatment, the rate of bone maturation' z5 K; w/ `# ?; Z+ U- E: R
decelerates and gradually returns to normal.8,9# N9 u* X) Z- f
There are conflicting reports and controversy
! Q3 y$ o# [9 g: l6 Uover the effect of early androgen exposure on adult
8 N, u) J* h) i8 e6 j) ?1 ipenile length.10,11 Some reports suggest subnormal
! s7 ~* @7 d0 d1 z% a- `; e% @adult penile length, apparently because of downreg-) k4 Y1 @( L* U$ b* f$ C
ulation of androgen receptor number.10,12 However,
7 i- ?, j# x! ISutherland et al13 did not find a correlation between
- N) f) \% z, ]9 fchildhood testosterone exposure and reduced adult1 `; J4 t% }3 u0 }* b7 E$ x
penile length in clinical studies.
' [. W$ O& l  k4 D+ fNonetheless, we do not believe our patient is
: y' R; H# c3 u4 I5 H( B5 ^going to experience any of the untoward effects from
4 e+ {3 R& d' ^! D" ^, ftestosterone exposure as mentioned earlier because
( [) s; T: r! R; {) Dthe exposure was not for a prolonged period of time.) t0 m7 Y7 g1 P, r) X: q
Although the bone age was advanced at the time of9 j5 O% }0 Z: {6 Y
diagnosis, the child had a normal growth velocity at
) c# m" T$ U" m" `5 v8 Wthe follow-up visit. It is hoped that his final adult
/ f; S; J6 w0 R3 J1 \$ E0 pheight will not be affected.
# w1 s/ R1 J. O' a  {6 MAlthough rarely reported, the widespread avail-
% R9 x' a$ D) B$ L/ |ability of androgen products in our society may+ D4 G! N, H; M  f% K- j+ j
indeed cause more virilization in male or female
: ^- K4 a. S' m$ r* f& Q/ e1 N5 Achildren than one would realize. Exposure to andro-
* I) v3 s% s  R' n# g" Lgen products must be considered and specific ques-
1 k6 G$ P( t2 E/ W, x9 Ftioning about the use of a testosterone product or
& ?2 ?( H3 C% z" ^) g8 ~. h0 L* B. igel should be asked of the family members during
, P+ U0 _2 \! o( i- g1 ^" Lthe evaluation of any children who present with vir-
0 l7 Q! t* O8 E/ i% ^3 u  Jilization or peripheral precocious puberty. The diag-
, {! U- [8 Z$ g3 f" i( Bnosis can be established by just a few tests and by) k2 U" e) q. R
appropriate history. The inability to obtain such a
1 _/ a+ A) L" Ehistory, or failure to ask the specific questions, may
6 x8 S/ e; V6 p3 z' oresult in extensive, unnecessary, and expensive
( O" c5 v' l/ v& _: pinvestigation. The primary care physician should be9 y  ]$ M& u- E* M$ L
aware of this fact, because most of these children
, P+ ]* M- r* ?+ Z% q1 n3 xmay initially present in their practice. The Physicians’
: B2 ?8 _+ E, H( ?. A; ~0 x& RDesk Reference and package insert should also put a% B8 ~. h3 M% E& t$ E) h
warning about the virilizing effect on a male or( u# r1 v* \' E, p" d8 N
female child who might come in contact with some-
; f- l% m# Y9 f4 zone using any of these products.$ g  e/ _0 p% b9 Q
References9 h4 m! S, C" t4 p
1. Styne DM. The testes: disorder of sexual differentiation6 v  k( T$ ~) r  h
and puberty in the male. In: Sperling MA, ed. Pediatric1 z( z( Q/ Z4 o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 V7 n4 I: \) g, f& p. J. K2002: 565-628.
! `, Y6 l$ a, B. B. c* \2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: D9 M  h0 k0 p
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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!
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

- |* `: o3 b  x" ]( F! I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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