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Sexual Precocity in a 16-Month-Old
# Z) x1 F# B& s# K% Z4 c7 h- KBoy Induced by Indirect Topical& J8 ~# x# U; Y' ~/ I
Exposure to Testosterone! C" M2 K/ G3 i7 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  [1 X! e. b2 q- o' {* Q1 C
and Kenneth R. Rettig, MD19 V9 |  r$ |1 U" {
Clinical Pediatrics! R6 u+ \/ ?5 K+ ?7 ?
Volume 46 Number 6
; p! e4 a0 Z" P1 o" `July 2007 540-543
& |8 U8 r4 {) Y  f9 i" V© 2007 Sage Publications- t4 W+ L, [0 @  G
10.1177/0009922806296651# {1 X2 ~( }. y5 S
http://clp.sagepub.com8 h' Z" b$ H, q& S* E$ F
hosted at* R6 b- ]1 C$ G4 u
http://online.sagepub.com& Y6 O. T: y& J0 j
Precocious puberty in boys, central or peripheral,
3 A6 \  ]& b+ y: F+ [is a significant concern for physicians. Central
' Q" B* x4 A) Bprecocious puberty (CPP), which is mediated
% I1 V  d/ ~8 S! V5 T+ s# v2 i( A) Uthrough the hypothalamic pituitary gonadal axis, has; |7 d- H/ }' R- g5 w
a higher incidence of organic central nervous system8 n4 K5 G& p" k
lesions in boys.1,2 Virilization in boys, as manifested
( H3 r+ W2 ~+ Hby enlargement of the penis, development of pubic. a& [0 F$ Y3 o5 B% l$ g5 }
hair, and facial acne without enlargement of testi-$ E) D$ v+ V0 x' Y* t1 T4 v5 a
cles, suggests peripheral or pseudopuberty.1-3 We  m; {# `8 h- s+ c
report a 16-month-old boy who presented with the% h& @+ R7 r$ ^4 i6 d6 C4 E, p8 k
enlargement of the phallus and pubic hair develop-- }6 g. ^% n( M  U" C9 V
ment without testicular enlargement, which was due5 o5 d* R5 O# ~$ i, L# `0 Z0 W
to the unintentional exposure to androgen gel used by
! v0 ]) F- |# Z1 v) _& Y9 }) f- othe father. The family initially concealed this infor-& X9 f) U" V2 p
mation, resulting in an extensive work-up for this5 e2 N! u0 F9 t
child. Given the widespread and easy availability of
6 f, x" j$ Q; v' e4 Rtestosterone gel and cream, we believe this is proba-
4 r- {  H, @9 E; A! p8 qbly more common than the rare case report in the: C/ {% h1 F' `, E
literature.4+ p2 s( @9 [. I
Patient Report& O6 m9 s3 ^5 w! F& f$ X4 h4 j" ^
A 16-month-old white child was referred to the
" E/ a8 V- C+ X1 \endocrine clinic by his pediatrician with the concern
6 x/ R0 Y& [9 i0 |" R* r# m9 Mof early sexual development. His mother noticed' m) ~8 E1 T; g
light colored pubic hair development when he was
% o0 o- H+ e3 u: R5 w; S1 z8 FFrom the 1Division of Pediatric Endocrinology, 2University of
0 H* {) r# U2 L  JSouth Alabama Medical Center, Mobile, Alabama.( \: I9 F" |8 f3 r
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ `9 A/ F* C( ]
Professor of Pediatrics, University of South Alabama, College of( v0 u" U: Q" @' f3 }
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: r& M" z( Q8 @+ me-mail: [email protected].
  I/ l4 K# \9 L" f) ^9 u, ^about 6 to 7 months old, which progressively became: A9 _* P1 o" w  d( O" t
darker. She was also concerned about the enlarge-) x# f# Y- x1 P' |4 n% T" u) p
ment of his penis and frequent erections. The child
0 S1 ]8 N$ d8 O& ~  X3 v0 jwas the product of a full-term normal delivery, with
9 F2 i; p' v2 Q0 Ja birth weight of 7 lb 14 oz, and birth length of
6 {3 S/ Q1 x* m. y' v# l8 ?20 inches. He was breast-fed throughout the first year0 h- K+ F* j' F) {. M, ?# x' T
of life and was still receiving breast milk along with8 Z  U( _$ |2 j
solid food. He had no hospitalizations or surgery,# f* A! o# ^3 J# Q- J, |/ C
and his psychosocial and psychomotor development
) k/ H, @( ^, \* m: ~( Mwas age appropriate.
& R5 I9 w! o, I" \' }The family history was remarkable for the father,
& _! j( X* n# @( _4 R" Cwho was diagnosed with hypothyroidism at age 16,( A- j# T' e% u& U5 k: X4 d; w
which was treated with thyroxine. The father’s/ C8 {) l; T4 L( @- j) ~8 p! K
height was 6 feet, and he went through a somewhat
0 d' \) Y* \/ A, jearly puberty and had stopped growing by age 14.
2 M8 ~! P% @' r9 f5 Z4 T4 y9 l% HThe father denied taking any other medication. The
& ]3 J6 ^) Y2 R, dchild’s mother was in good health. Her menarche
' e  ~; s( j9 ?( r- owas at 11 years of age, and her height was at 5 feet
9 \" r/ u7 Y0 k1 }% d* q8 \5 inches. There was no other family history of pre-1 c: O, b8 z4 h3 h) R; H
cocious sexual development in the first-degree rela-7 v7 w3 J' D& {* e  U/ n2 W
tives. There were no siblings.
( R; S$ V! \( U. Z( @- LPhysical Examination$ M4 J5 V: A- T1 G1 C% s: Y
The physical examination revealed a very active,6 l- b) N# C7 ?) w
playful, and healthy boy. The vital signs documented
/ F1 S: Q! {2 X: oa blood pressure of 85/50 mm Hg, his length was2 W, s3 F, C" ]" a5 y) B# ~6 I& Z
90 cm (>97th percentile), and his weight was 14.4 kg, f9 E6 v7 U' U/ v
(also >97th percentile). The observed yearly growth
3 ?1 C3 C, j+ @2 @, E* k  Pvelocity was 30 cm (12 inches). The examination of9 o8 O, D; d. y: h
the neck revealed no thyroid enlargement.
/ {- _8 `! b  ]2 JThe genitourinary examination was remarkable for
& |# K1 O8 H4 F, G! @9 {! z- K( s4 o* p. @enlargement of the penis, with a stretched length of
* I$ ^3 l* T5 k* |% m# S' f% r8 d8 cm and a width of 2 cm. The glans penis was very well
7 ?  g+ Q3 v1 r$ `) jdeveloped. The pubic hair was Tanner II, mostly around
7 |% V. r- q7 ~8 G/ T5 n540( t: t/ c& H& L7 z( L0 R: c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; [, |2 S' b3 N$ U
the base of the phallus and was dark and curled. The- @3 B" Y; b0 _" q) M9 e, {
testicular volume was prepubertal at 2 mL each.8 s) h+ ~* ]' |+ c; {
The skin was moist and smooth and somewhat" C9 J+ Q. P' z/ q$ l0 O- ?
oily. No axillary hair was noted. There were no% m; E" g3 x3 V9 V" H
abnormal skin pigmentations or café-au-lait spots.
5 [2 M8 _4 m4 ONeurologic evaluation showed deep tendon reflex 2+
! X8 U) y* J& `1 ibilateral and symmetrical. There was no suggestion; |5 B8 j# t" ?) z. m8 B, V
of papilledema.7 e: M; L  C7 r) f  w1 I8 _
Laboratory Evaluation4 ~  o* m; l. B3 G
The bone age was consistent with 28 months by
  \5 L# K  e' ]. wusing the standard of Greulich and Pyle at a chrono-) j; O2 G3 O$ K: g' b
logic age of 16 months (advanced).5 Chromosomal8 w9 D  P  {( b7 y6 N; q. w
karyotype was 46XY. The thyroid function test
0 r# L3 g6 A3 dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
. e) o! k7 o1 Y0 Xlating hormone level was 1.3 µIU/mL (both normal).2 m0 B3 p4 l$ W% }, A5 @  g+ O
The concentrations of serum electrolytes, blood
$ p! K$ F) W8 f/ @; ]7 I2 Curea nitrogen, creatinine, and calcium all were* @- C5 _( B1 b: u* r/ A% m4 N
within normal range for his age. The concentration
) n9 k; j* ]! i4 Z4 u4 jof serum 17-hydroxyprogesterone was 16 ng/dL
1 O% H& m9 z' P7 ?" q1 n(normal, 3 to 90 ng/dL), androstenedione was 207 K, l0 |/ F) C8 Q3 M% ~8 w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* }8 K. X9 @. \$ k' A; |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! L8 ?6 G0 m/ ~+ H5 s3 F, Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! A5 f' m$ k9 A+ u, @+ x1 {  t2 ~49ng/dL), 11-desoxycortisol (specific compound S)# h6 V2 u0 U$ c0 u1 |* E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: l+ Q* ]# R6 D- v- _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 s  Y, F0 u) x4 Z) G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' f$ }4 L# ]) m9 E! Z( m( Mand β-human chorionic gonadotropin was less than, D8 Q) I$ g; q# s
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 D, l/ F4 u3 Z6 v) P
stimulating hormone and leuteinizing hormone6 A5 B( Z$ A: f% _
concentrations were less than 0.05 mIU/mL8 x' ^/ B1 F% e/ a- C
(prepubertal)./ a& Z; _* s8 W/ \+ M
The parents were notified about the laboratory5 K1 E8 c: F- x6 \# o0 g
results and were informed that all of the tests were' l+ D; r2 L% ?
normal except the testosterone level was high. The
  P# C4 j1 {3 T/ o! ^8 p+ `follow-up visit was arranged within a few weeks to7 F$ \/ F: u& J* k: O7 s
obtain testicular and abdominal sonograms; how-
  ^' _2 k. i  U3 w; Z* S& Pever, the family did not return for 4 months.
! ]* w5 o( c* TPhysical examination at this time revealed that the/ k; {( a' L7 c
child had grown 2.5 cm in 4 months and had gained% x4 r6 s, I, ~5 _4 x- J! |
2 kg of weight. Physical examination remained  I" P3 y& {+ M/ i; y8 ^% e1 M
unchanged. Surprisingly, the pubic hair almost com-
8 f) {9 {3 U/ ^2 upletely disappeared except for a few vellous hairs at
: Z( w3 ~& B; r! l! O3 nthe base of the phallus. Testicular volume was still 2- t8 I( ^/ E) X) c1 |  n; {
mL, and the size of the penis remained unchanged.
. G  {- w; d# U3 B& m, QThe mother also said that the boy was no longer hav-0 J% M% B! }3 s+ H; M" ?, D& |
ing frequent erections.. i* M' E! J8 m  t9 A) e! `& W" z
Both parents were again questioned about use of
' l: k/ K$ ]; Y* T$ N& _any ointment/creams that they may have applied to
/ z0 g2 w( a' pthe child’s skin. This time the father admitted the
& V, P6 H1 d) r! HTopical Testosterone Exposure / Bhowmick et al 541
2 P: G- z+ c  Z; Q' i2 {3 ruse of testosterone gel twice daily that he was apply-
% U8 V) g( l4 G5 T# y& j  t" ding over his own shoulders, chest, and back area for3 N3 X6 r+ L7 }! S. v% l
a year. The father also revealed he was embarrassed
6 u3 J8 A/ q. B4 }) |" ]to disclose that he was using a testosterone gel pre-
0 P! h4 u& Q0 u6 w4 X) y9 bscribed by his family physician for decreased libido
& h# `) D+ A& ~6 y- G$ e6 `secondary to depression.
" E: N. [3 F4 c, cThe child slept in the same bed with parents.' O9 A4 @. i# m
The father would hug the baby and hold him on his( [% X) R( a$ O. k: I- r
chest for a considerable period of time, causing sig-( Z  w/ ^( y- X8 \3 j% }
nificant bare skin contact between baby and father.7 Z" R5 Q) g) ^
The father also admitted that after the phone call,
$ X( v1 d5 w% _3 p  m' F. b, \4 kwhen he learned the testosterone level in the baby
8 @  }% w( R2 I/ s" nwas high, he then read the product information
3 Z, A% \& ~: p" m: a" p+ }  vpacket and concluded that it was most likely the rea-4 Z4 `9 ]5 O, A, Q; y
son for the child’s virilization. At that time, they
% `7 R0 w$ h9 t& L  k0 vdecided to put the baby in a separate bed, and the" `7 k5 b6 m' R+ H6 _: F
father was not hugging him with bare skin and had
1 e  F7 K0 V4 pbeen using protective clothing. A repeat testosterone9 L8 k( D" i1 s% B. g
test was ordered, but the family did not go to the
$ @) x# j$ r* Rlaboratory to obtain the test.8 O5 D5 [0 Q" p7 P
Discussion# V6 C. C2 w/ F) H% e- b( a
Precocious puberty in boys is defined as secondary0 G- ]+ ~/ Y6 K1 C* h# p; i  [1 C
sexual development before 9 years of age.1,4
+ n  z4 f3 ~! i9 L$ qPrecocious puberty is termed as central (true) when
5 T- e  p. j5 k! r2 ]it is caused by the premature activation of hypo-
/ m! i/ C1 h6 P) O# @thalamic pituitary gonadal axis. CPP is more com-
, E" U5 ~: z! W, f- `2 kmon in girls than in boys.1,3 Most boys with CPP+ w2 ^: R: _) j4 w/ y( ]
may have a central nervous system lesion that is* f1 A8 G8 p" h! x+ `) K
responsible for the early activation of the hypothal-
( }, u0 V& |8 J8 j8 Samic pituitary gonadal axis.1-3 Thus, greater empha-% s. L& N0 h! x6 [% ~
sis has been given to neuroradiologic imaging in- ^1 e& ^  _6 i) d
boys with precocious puberty. In addition to viril-
! Q1 ~# m  S# A: H, v0 oization, the clinical hallmark of CPP is the symmet-1 W" s: ?; @9 A3 I+ o
rical testicular growth secondary to stimulation by& _1 L' u- l, l8 O& b$ a
gonadotropins.1,3' G( d+ u5 i' E9 P6 i4 M
Gonadotropin-independent peripheral preco-. W- O: W5 i4 x# k8 a
cious puberty in boys also results from inappropriate* U5 G% @1 @% G6 Z4 u8 X' I$ T8 V
androgenic stimulation from either endogenous or( {: f! l( w" v0 G7 r- W
exogenous sources, nonpituitary gonadotropin stim-, Q) b5 ^& T( Q+ V# b2 P! A
ulation, and rare activating mutations.3 Virilizing
) z+ r) R: p: e2 P( V+ \( ]congenital adrenal hyperplasia producing excessive. U4 j6 h. h6 f# y  l: Z; B$ ?
adrenal androgens is a common cause of precocious
- T0 U2 B3 X. d  }/ N. L) Xpuberty in boys.3,4
! ]. d$ ^3 d* {3 yThe most common form of congenital adrenal
* V# j/ J' x: t6 U0 shyperplasia is the 21-hydroxylase enzyme deficiency.0 Q3 m; R4 r' W' r1 n
The 11-β hydroxylase deficiency may also result in$ {' m# ~8 _3 {- x* }2 \& A
excessive adrenal androgen production, and rarely,
; U' d7 {) g, D( R$ tan adrenal tumor may also cause adrenal androgen3 u5 D- D; h) H. Y
excess.1,3
/ Z( q+ A' ?5 D  s2 m) X  g( ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 _* Q; G$ ~9 V- R  V+ Y$ e542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( Z+ q5 @" f3 ^  [+ ]
A unique entity of male-limited gonadotropin-5 d. x4 n6 q9 O7 m% v
independent precocious puberty, which is also known
1 {5 L$ V* u2 O  L% O5 o7 das testotoxicosis, may cause precocious puberty at a' x( q- q' }0 T8 b; m+ h: b
very young age. The physical findings in these boys6 k7 S6 o" `7 a9 H8 i" w
with this disorder are full pubertal development,/ w: @: C% }, O5 Z9 v2 z
including bilateral testicular growth, similar to boys
4 A9 C- c$ O9 [- u  e) ^5 q; Dwith CPP. The gonadotropin levels in this disorder
2 V8 M8 h3 x7 y; u7 S, \' Q6 Fare suppressed to prepubertal levels and do not show- A  X" w: a  Z) S5 d* S+ j; a! _+ U5 I+ x
pubertal response of gonadotropin after gonadotropin-  x+ _8 O: L* ~, r2 j' u: X
releasing hormone stimulation. This is a sex-linked- A5 P& G% k, s! V
autosomal dominant disorder that affects only; C, \* T, t% a+ g6 t' z
males; therefore, other male members of the family
+ p4 T, r  J! J$ F& Umay have similar precocious puberty.3
- Y1 t; C  Z, K2 jIn our patient, physical examination was incon-6 {, ~! H, T  F' `! G; M
sistent with true precocious puberty since his testi-0 M( O9 C; }. m* a; K
cles were prepubertal in size. However, testotoxicosis* N4 R1 b" I2 E  r1 D3 X# p
was in the differential diagnosis because his father
1 O2 Z$ Q' n, p- _/ Y! Vstarted puberty somewhat early, and occasionally,
" [% q3 O6 q1 Y9 E! A2 G0 A0 Ktesticular enlargement is not that evident in the
6 q7 X8 S# }4 kbeginning of this process.1 In the absence of a neg-4 S$ F, o# S# o
ative initial history of androgen exposure, our
1 B* m1 i: e; @9 @% _. r% K1 a. obiggest concern was virilizing adrenal hyperplasia,: X, f2 a" b$ |( D# P3 L6 R- z
either 21-hydroxylase deficiency or 11-β hydroxylase
# G8 M% B' ]& b/ L1 w6 k- ddeficiency. Those diagnoses were excluded by find-
9 C- p6 M8 j$ ?3 ^# Zing the normal level of adrenal steroids.
% a, O7 n0 E7 ?5 l  wThe diagnosis of exogenous androgens was strongly
2 f4 u1 {# `7 L- ^# D$ z1 N0 a: Rsuspected in a follow-up visit after 4 months because
/ S% J: V& A! b  {the physical examination revealed the complete disap-9 F. K# _. p0 h! L4 X& j
pearance of pubic hair, normal growth velocity, and- i7 ^9 x3 ~8 _
decreased erections. The father admitted using a testos-$ f) @" G/ P: _, [' R) ]3 J
terone gel, which he concealed at first visit. He was
; R9 U5 t, b( U. G# i4 E$ xusing it rather frequently, twice a day. The Physicians’" ^- d" s3 f( p( {6 |
Desk Reference, or package insert of this product, gel or
( b! N( @0 _; Z& I  Q% p) B. ccream, cautions about dermal testosterone transfer to* t3 X. y. X! b0 S2 i7 h/ m5 |
unprotected females through direct skin exposure.
# {4 t; x; M3 H7 U3 ^9 xSerum testosterone level was found to be 2 times the
- a3 b* m8 w) W; ]8 \" q; ^) c: U% Hbaseline value in those females who were exposed to# I! I5 |4 E; U
even 15 minutes of direct skin contact with their male
$ K9 ?; _# i9 A. C, a/ Hpartners.6 However, when a shirt covered the applica-
! O* J9 d7 l! Q% M' Ation site, this testosterone transfer was prevented.
; R; d: }" I( y3 H9 e2 i& OOur patient’s testosterone level was 60 ng/mL,
  o, @% W2 G1 C2 f5 h; t- }which was clearly high. Some studies suggest that
6 u6 u: o# B! ^( c3 ^# \9 Vdermal conversion of testosterone to dihydrotestos-
7 U; c5 y! f" o6 h1 J) Dterone, which is a more potent metabolite, is more4 P& V# n+ U: k3 O, @  P
active in young children exposed to testosterone6 L( }$ L# b) Z( ]* x
exogenously7; however, we did not measure a dihy-
: |; v& H$ R3 sdrotestosterone level in our patient. In addition to
4 \$ ~( }. Z' n& A) Cvirilization, exposure to exogenous testosterone in8 `: C+ w7 y6 [' r; N6 w4 [5 G
children results in an increase in growth velocity and; _0 P* C0 N# V& R: z$ D9 U) N+ Z
advanced bone age, as seen in our patient.
6 I( u, U5 Y: _2 R1 M7 N& wThe long-term effect of androgen exposure during
, v, R! [: v) o0 r/ q% I  [early childhood on pubertal development and final" H2 k# r$ w9 ?* y
adult height are not fully known and always remain' J& e9 I7 N) P
a concern. Children treated with short-term testos-
% I8 w) l. ~  }terone injection or topical androgen may exhibit some
7 t, P+ W; Q2 N* oacceleration of the skeletal maturation; however, after
0 ^7 [' A( y" n5 d# ]4 n+ Vcessation of treatment, the rate of bone maturation! R0 `- U4 `2 r4 J4 A! i
decelerates and gradually returns to normal.8,96 L' j! J2 Y* t
There are conflicting reports and controversy3 J# M9 J1 b5 d& I$ R
over the effect of early androgen exposure on adult! h2 Z' ~8 G% ^  ~1 S% M: h( S
penile length.10,11 Some reports suggest subnormal$ K* e; r) o2 D) D' W
adult penile length, apparently because of downreg-
" ~* ]* K0 ?1 b# {ulation of androgen receptor number.10,12 However,
: U  ]/ I( b+ t. rSutherland et al13 did not find a correlation between9 V3 {$ m# ~) |4 B" ~# a+ c, r
childhood testosterone exposure and reduced adult7 ]# _1 _* I4 v) w( X# \& P
penile length in clinical studies.
9 a* k6 O! @6 ?5 kNonetheless, we do not believe our patient is! Y0 _; Y3 |/ f8 C
going to experience any of the untoward effects from
: Q' i  s! a6 L* f: p% ftestosterone exposure as mentioned earlier because3 |0 C4 J% H6 i3 [; R# U
the exposure was not for a prolonged period of time.9 z# u& F/ U7 [, Q4 X: {' n
Although the bone age was advanced at the time of
) Y3 e2 {) w- \) @: e% Udiagnosis, the child had a normal growth velocity at
* B7 h* S! Q2 K, Bthe follow-up visit. It is hoped that his final adult
8 {, x3 d! Q7 x* B) @. m6 Uheight will not be affected.; x% {' v  b) F9 _' K
Although rarely reported, the widespread avail-
8 j; e" N$ K' O$ N/ B" Aability of androgen products in our society may
# G4 ~; ?% q2 i  O# @, g, f* jindeed cause more virilization in male or female! L! H5 J# _$ \! D; |4 ]0 h& c
children than one would realize. Exposure to andro-
8 l; S( b+ v! v4 p- ]4 q  jgen products must be considered and specific ques-; Z3 S# @; _6 {2 x
tioning about the use of a testosterone product or+ ?* i7 A( v" l
gel should be asked of the family members during( F; [% c; i+ _3 `& \: t8 f7 n
the evaluation of any children who present with vir-
% a1 n. P% Y" ?  i  i2 V( A4 [8 kilization or peripheral precocious puberty. The diag-
" d, N/ X- h/ H6 W1 }" snosis can be established by just a few tests and by
+ }* J, b. R8 J7 t" k  `appropriate history. The inability to obtain such a9 w  J2 D1 R# u1 G
history, or failure to ask the specific questions, may
, J2 S+ \" }9 l: ]  ^result in extensive, unnecessary, and expensive
7 A0 B1 |: _3 ]- tinvestigation. The primary care physician should be
# {3 z  Y# y+ b. k) Yaware of this fact, because most of these children) e+ P6 W3 W8 o* ~$ r5 Z; [
may initially present in their practice. The Physicians’
0 q7 Z( a( b/ gDesk Reference and package insert should also put a
; ?. c; s0 S- Kwarning about the virilizing effect on a male or
7 F1 |/ h$ ], Y4 _' lfemale child who might come in contact with some-
8 ^' V- ]; f0 b  }% gone using any of these products.2 {& L0 X" Y2 `+ m9 s* D- _, |; V
References
) j0 j, V3 D, L. F4 o5 l1. Styne DM. The testes: disorder of sexual differentiation
( g* x/ V) J' a4 Eand puberty in the male. In: Sperling MA, ed. Pediatric6 C# V2 a' G& y8 U8 ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 o8 ?3 {( R; P/ v
2002: 565-628.4 M+ _+ l$ k. H
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ j: J& A' P# K. m3 T0 H9 ^puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
0 L, q* P* w! Y" s  lBoy Induced by Indirect Topical' V' s) ?2 G$ c& |1 E# Z
Exposure to Testosterone
  c( _  E9 m# Q+ `6 X: I5 `: hSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, P  o6 Z7 l# W7 K
and Kenneth R. Rettig, MD1
9 Q& I+ @, K9 A1 cClinical Pediatrics
% s" B% |  b; w6 ]. VVolume 46 Number 6: }( A0 u) A- q: G# m  m
July 2007 540-543: d6 L% a4 J* D8 c7 L
© 2007 Sage Publications
" O+ {' n: h; {& H10.1177/00099228062966512 d1 D3 [- d, V4 a' e
http://clp.sagepub.com
# y) E) |3 G0 |0 |8 o5 Mhosted at% N5 W9 G8 D8 F& B" Q$ d
http://online.sagepub.com
7 D9 A' r0 D" bPrecocious puberty in boys, central or peripheral,( ^, i9 y% P" r$ P, T1 @
is a significant concern for physicians. Central' e& x; J8 F! m! i7 v3 E
precocious puberty (CPP), which is mediated
* D: c( s( p- s5 d3 x+ Gthrough the hypothalamic pituitary gonadal axis, has0 |2 H! k/ b# v  s! }
a higher incidence of organic central nervous system
/ p( d1 L8 M$ [. b% i. zlesions in boys.1,2 Virilization in boys, as manifested
+ C7 [% N  q/ N, H# p1 o% N: j/ q- yby enlargement of the penis, development of pubic
0 k$ V" M' \+ i8 nhair, and facial acne without enlargement of testi-
  `5 l1 `' r& ^cles, suggests peripheral or pseudopuberty.1-3 We3 w5 x' w! P: I  W, t9 o+ C: W/ P
report a 16-month-old boy who presented with the
* n  T3 b* j# `7 }3 U# B' fenlargement of the phallus and pubic hair develop-
; Z4 n5 c' A$ G, U+ Yment without testicular enlargement, which was due9 U  {5 _) b8 ~
to the unintentional exposure to androgen gel used by
( p, H1 A/ [9 J5 E% U9 T- b6 H0 n6 pthe father. The family initially concealed this infor-
# {7 w4 H7 n( w+ s& ], Xmation, resulting in an extensive work-up for this
: D1 g' H& x" s. E) Cchild. Given the widespread and easy availability of+ c4 }) d' G2 l4 i% e. D  F
testosterone gel and cream, we believe this is proba-
3 u/ a5 j6 ?. tbly more common than the rare case report in the
1 c2 X( n' i& Mliterature.4
* ?, F9 Z. U1 N/ tPatient Report6 h9 L9 X' P0 f  n4 E
A 16-month-old white child was referred to the
( a0 k. h/ c% }* F$ D0 n" w5 rendocrine clinic by his pediatrician with the concern
( H2 d# a) q0 _/ Pof early sexual development. His mother noticed
+ d6 P. |3 m9 D# M8 W2 h, W1 Nlight colored pubic hair development when he was
: C( t0 p; n) ]6 k* |From the 1Division of Pediatric Endocrinology, 2University of! z, s& [% Z7 D* A, p
South Alabama Medical Center, Mobile, Alabama.. _- ?5 A1 `! C5 P6 u8 T( P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ E- _% K' a4 u# @3 ?8 s/ I3 u/ MProfessor of Pediatrics, University of South Alabama, College of
$ |" t) C4 s7 o. U/ f% [Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ y7 u, r/ j- a4 @- de-mail: [email protected].
% w6 G. V8 x0 _. W7 a' Mabout 6 to 7 months old, which progressively became
% x$ Q# Q: U/ S) h* g( M  |darker. She was also concerned about the enlarge-
" C" D! V9 s) G& L3 e+ Y( x$ nment of his penis and frequent erections. The child3 S: \7 R5 o( G
was the product of a full-term normal delivery, with
' F. c! j" a) S: e- q: ea birth weight of 7 lb 14 oz, and birth length of# N" I. Y/ F; X1 n! y: x4 ^% @
20 inches. He was breast-fed throughout the first year3 M; c5 s5 u- B$ N1 h! s+ z) q2 S
of life and was still receiving breast milk along with+ c6 Q, B0 s$ @! j: J' ]
solid food. He had no hospitalizations or surgery,
3 B! ?5 h% x7 [! d: mand his psychosocial and psychomotor development
# P, `) V. f7 R, @3 Qwas age appropriate.2 Q& y9 }+ s% e  m" _& x  F
The family history was remarkable for the father,
% Y: M0 u3 L& x7 zwho was diagnosed with hypothyroidism at age 16,& R8 V1 u# {3 F' a4 ]; R/ g; F
which was treated with thyroxine. The father’s
) G. g! V: O. Q0 ^  }  lheight was 6 feet, and he went through a somewhat
" e' B, l$ u9 _early puberty and had stopped growing by age 14.
  I0 U6 C8 z/ Y- n, ]- {, S. }The father denied taking any other medication. The
% o- _5 ?, U$ b" i1 Q% V% Fchild’s mother was in good health. Her menarche' z7 d' S# f1 F4 J
was at 11 years of age, and her height was at 5 feet( x- Y& A  A9 r
5 inches. There was no other family history of pre-3 R6 ^6 ?8 }) g! }; |
cocious sexual development in the first-degree rela-+ y* m0 {. N& K2 i* f1 f2 V" m
tives. There were no siblings.. k! Z* n/ @( t) g
Physical Examination
- V% o7 ]8 y. d# d+ y0 K  f) x- rThe physical examination revealed a very active,
9 U& H7 e# k, O0 }4 }: X% oplayful, and healthy boy. The vital signs documented
- l) E6 v' g' z4 K& ^a blood pressure of 85/50 mm Hg, his length was! j: c/ @& s# X: h0 j4 {8 ]+ Q
90 cm (>97th percentile), and his weight was 14.4 kg
" E" t1 O: K9 g$ |& ~9 _& S(also >97th percentile). The observed yearly growth  Y' F  H( @  Y) `6 Q/ {9 e
velocity was 30 cm (12 inches). The examination of
3 B& W6 v! e5 ]6 r* g1 Q7 c. P0 Qthe neck revealed no thyroid enlargement.( N! [( i1 e* }
The genitourinary examination was remarkable for1 \# y/ H- k6 q6 G$ o% S  e
enlargement of the penis, with a stretched length of
- j5 v4 K7 j( B( @! R5 T8 cm and a width of 2 cm. The glans penis was very well
  X* D' g3 _3 \  b( Pdeveloped. The pubic hair was Tanner II, mostly around
% ^& S9 r1 s0 M- B7 Z8 w7 o540, V* f% _+ S* o+ Y( ~. w9 B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! ]" I  x  v- z9 x) R, u! Pthe base of the phallus and was dark and curled. The) p2 L! Q# x) V" H) b
testicular volume was prepubertal at 2 mL each.
6 L8 p5 I3 E+ F" d1 o: uThe skin was moist and smooth and somewhat: B$ q" e3 k0 k1 e" w; [
oily. No axillary hair was noted. There were no
- _7 D6 j' Z% O' y) B" b* T/ e4 K1 Rabnormal skin pigmentations or café-au-lait spots.
2 S4 m( ~: w8 z  F5 BNeurologic evaluation showed deep tendon reflex 2+9 h( T9 N, @& m8 A7 x  w* n
bilateral and symmetrical. There was no suggestion2 x* D$ ^  T4 Y5 h* H- t- s! u
of papilledema.# x4 u* W! ?( A) z/ ?/ F9 a* _
Laboratory Evaluation& L) C8 V1 s4 D' M
The bone age was consistent with 28 months by
; U3 y# f! ^7 Cusing the standard of Greulich and Pyle at a chrono-
% x: e+ w. a( elogic age of 16 months (advanced).5 Chromosomal
9 d* P/ m  B# w2 T- Kkaryotype was 46XY. The thyroid function test' c" o4 _; n# p6 E, O
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( L9 [, A6 l+ @" N/ elating hormone level was 1.3 µIU/mL (both normal).0 p# X& s/ J6 k% h  O8 |7 @
The concentrations of serum electrolytes, blood% q' A( |6 w, m/ y- G( w, X6 f, w" K
urea nitrogen, creatinine, and calcium all were) u2 t" `  d; o: Z6 u& Q
within normal range for his age. The concentration
& @( Q1 q' X! y6 y5 yof serum 17-hydroxyprogesterone was 16 ng/dL3 M# W3 L) ]9 l( E6 i
(normal, 3 to 90 ng/dL), androstenedione was 20
3 z: r9 x( e; Tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 a5 y4 U- T9 J' P( u& v! u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ Q+ g: ~2 v8 r% B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 Q# [  q" g9 ~/ z( \3 a8 i49ng/dL), 11-desoxycortisol (specific compound S)
0 o2 Q& w3 {1 Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ ?. E0 t% U9 c6 qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, f. a* ^$ \! z) q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* l& Z+ Z: O2 H2 B! v" |' \, Eand β-human chorionic gonadotropin was less than
6 l5 B. T/ S6 e8 P5 mIU/mL (normal <5 mIU/mL). Serum follicular
) I% U' P' ~- z9 k- G4 Zstimulating hormone and leuteinizing hormone
8 ~1 I2 W' N2 R: E. {, Qconcentrations were less than 0.05 mIU/mL% B9 V8 L9 [% i
(prepubertal).
' B- O1 ?$ M* n! FThe parents were notified about the laboratory9 x) K* g+ D1 z. e( ^
results and were informed that all of the tests were" w% B! R! ~4 g* e
normal except the testosterone level was high. The
7 Z# r4 E( {7 S* V9 W4 ~follow-up visit was arranged within a few weeks to
2 N1 g; X2 u" F! ?, z$ aobtain testicular and abdominal sonograms; how-7 w% ?5 B7 V7 w3 i; b$ }& B0 e( Z! M
ever, the family did not return for 4 months.
7 t- T# B9 k7 W7 r9 S6 X& aPhysical examination at this time revealed that the
: ?8 Q* `) v$ C/ Vchild had grown 2.5 cm in 4 months and had gained& _3 v/ R- T- }' I: \, `: E' ]
2 kg of weight. Physical examination remained7 `- a9 u3 Q3 d6 B9 @
unchanged. Surprisingly, the pubic hair almost com-; s* {2 S! \0 [# f6 f! _2 G
pletely disappeared except for a few vellous hairs at
* c7 x" D& T: m# q7 A& x2 |/ wthe base of the phallus. Testicular volume was still 2
; z7 B/ [, U7 b2 UmL, and the size of the penis remained unchanged.
6 M" V" j7 ]3 R& E/ ~2 H6 oThe mother also said that the boy was no longer hav-
4 K# S' x! j5 C6 u1 L3 \9 I7 L) \4 o( Uing frequent erections.4 \: @+ x8 D  N) `) K) v8 l7 B
Both parents were again questioned about use of6 B4 @8 X& w2 n6 R; J6 H% H" e
any ointment/creams that they may have applied to
4 E8 B4 x7 ^! \- q, m& Cthe child’s skin. This time the father admitted the# c! b! Q/ W0 R* ]% v% R9 U7 x2 N
Topical Testosterone Exposure / Bhowmick et al 541
! A/ @7 G/ g* F" K% [2 ?$ luse of testosterone gel twice daily that he was apply-% h7 |5 ~: N% v. X* @5 a
ing over his own shoulders, chest, and back area for
: Y6 d- x3 ^" [8 Z1 qa year. The father also revealed he was embarrassed
! {8 ~6 @; F- Y* \to disclose that he was using a testosterone gel pre-  ^1 ?. Y# ~# `, M$ v
scribed by his family physician for decreased libido+ X" ]0 _" Z9 k8 o) ~
secondary to depression.
6 L7 j( h( v' \! b" }1 i- {; YThe child slept in the same bed with parents.% [2 a! w: D, a" b  D2 h
The father would hug the baby and hold him on his
' o( S& y: M$ G/ E: `chest for a considerable period of time, causing sig-
7 h9 ~& ^: I: r9 O1 xnificant bare skin contact between baby and father.
2 {$ |# [" V* Q0 J1 uThe father also admitted that after the phone call,4 \& ?3 _1 h" D6 V% s
when he learned the testosterone level in the baby
* e$ J' ~% Q6 o, Qwas high, he then read the product information% x6 w1 c/ F5 ~  a. a
packet and concluded that it was most likely the rea-
8 p; I6 L" o* o$ Kson for the child’s virilization. At that time, they
! [/ k, X* Y2 b# l9 Y1 J1 x; udecided to put the baby in a separate bed, and the2 d. r6 N4 p$ f( c
father was not hugging him with bare skin and had
9 N% R) @9 e: d: D# Ubeen using protective clothing. A repeat testosterone& y. R! B2 P8 X
test was ordered, but the family did not go to the
8 W7 }( R! a- @laboratory to obtain the test.& b6 R7 v# p3 R" @6 [3 D- ^8 J
Discussion
" [& j7 C6 T$ u8 a% @& c; \$ gPrecocious puberty in boys is defined as secondary
5 M& N3 I  n$ t# q, o% m0 esexual development before 9 years of age.1,4
, S- `9 w$ g  T( [2 j1 x0 c, aPrecocious puberty is termed as central (true) when
' g& F3 V5 y: |6 B4 a. \4 p6 G  dit is caused by the premature activation of hypo-' ]! R. ^2 O% g$ u4 d2 t5 D% T/ U
thalamic pituitary gonadal axis. CPP is more com-
7 x% u  Y) i3 ~" l; `mon in girls than in boys.1,3 Most boys with CPP( [% y/ D/ A/ _' F$ B6 F2 i
may have a central nervous system lesion that is
* J" T) u1 b2 J2 Eresponsible for the early activation of the hypothal-( P3 R; [, [7 T, `/ l: s6 X
amic pituitary gonadal axis.1-3 Thus, greater empha-, r  z* K5 B5 Z0 v6 Q0 L" V  \- u
sis has been given to neuroradiologic imaging in" F  r& c: m( L( `* Q% m* ^
boys with precocious puberty. In addition to viril-9 \; x: m  k6 M9 A4 k
ization, the clinical hallmark of CPP is the symmet-
. T, v- ^- i: S9 orical testicular growth secondary to stimulation by
. k5 X. K1 L3 |, B5 Egonadotropins.1,3* x+ o' o& {# h  r. F* @
Gonadotropin-independent peripheral preco-% I' L8 f. s4 w9 x* P! W( f. n
cious puberty in boys also results from inappropriate# \8 L& ^1 _% I9 E
androgenic stimulation from either endogenous or! s* B4 u! x5 x. T1 B2 f/ G+ |& }
exogenous sources, nonpituitary gonadotropin stim-
; i* T. K/ s5 T/ @$ u+ Julation, and rare activating mutations.3 Virilizing6 Z5 i% i( [  d& P- H1 L
congenital adrenal hyperplasia producing excessive
7 n4 Q# v4 S: U$ a* Cadrenal androgens is a common cause of precocious2 _. a; q. b1 O" @+ W
puberty in boys.3,49 ]$ O3 Y2 e0 J3 @5 a  U
The most common form of congenital adrenal
7 z7 N( |) P8 c) I7 M, Uhyperplasia is the 21-hydroxylase enzyme deficiency.
7 }! q. [  k3 ~6 fThe 11-β hydroxylase deficiency may also result in
/ m0 _4 Y$ {) X- M  l" e; Kexcessive adrenal androgen production, and rarely,9 c- s0 k7 l. K& E
an adrenal tumor may also cause adrenal androgen
, D$ @" j$ m. w; kexcess.1,36 v& E) c6 o5 o6 C' _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 g/ y0 ?: I- I3 E+ E# T! n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 K2 C- ^: C" ~: j* h  R" }A unique entity of male-limited gonadotropin-
  E/ @' V( J+ q3 H6 Y( @) `independent precocious puberty, which is also known9 G% N4 v. Z6 `$ h0 A3 x: R% B
as testotoxicosis, may cause precocious puberty at a
' ]: o6 b5 U' k: {very young age. The physical findings in these boys- @. m) X' m+ Y- J% @. l3 S5 k
with this disorder are full pubertal development,. m2 U' v) U# J  X; p# u
including bilateral testicular growth, similar to boys' b5 x0 g7 ~4 l$ W8 C1 x
with CPP. The gonadotropin levels in this disorder
# z# I/ B6 V/ P; m( G, Fare suppressed to prepubertal levels and do not show4 x1 d$ r, ~  A
pubertal response of gonadotropin after gonadotropin-
: i3 `) k" F9 wreleasing hormone stimulation. This is a sex-linked
6 `0 K+ t8 P$ u$ m$ w  n  Lautosomal dominant disorder that affects only
! b7 _$ U# t8 \7 r# J! V8 V7 [9 nmales; therefore, other male members of the family
. p% v+ z. K8 e+ M: _8 ~9 D; }% r1 fmay have similar precocious puberty.3+ g! V! M/ D& }& z# W
In our patient, physical examination was incon-) C# t) ?  W  k* y% E7 q
sistent with true precocious puberty since his testi-
2 D  w+ A; [6 V& D+ ycles were prepubertal in size. However, testotoxicosis
- O$ O5 g/ N' J0 V' M- U1 awas in the differential diagnosis because his father  |  m2 Q9 o5 y9 X
started puberty somewhat early, and occasionally,/ k; a& w; x/ a; G
testicular enlargement is not that evident in the1 V( E) V" t7 f% t3 |5 b7 ]6 R; v
beginning of this process.1 In the absence of a neg-
3 o: z3 [& v5 c# Lative initial history of androgen exposure, our" S2 j2 ^+ t- l, q$ a; b( V
biggest concern was virilizing adrenal hyperplasia,
1 z' ]" b" V' A: t9 e& m, Ieither 21-hydroxylase deficiency or 11-β hydroxylase  g4 V9 _- l9 g* S3 }' W- Q! m. P
deficiency. Those diagnoses were excluded by find-$ M( ^3 ~7 `( ?
ing the normal level of adrenal steroids.
0 M6 a& P1 m. t" w4 T6 a5 o5 ^The diagnosis of exogenous androgens was strongly
3 [. f# n; k! _. C4 Qsuspected in a follow-up visit after 4 months because
+ ?. K$ f7 ~$ [- g/ k; x' lthe physical examination revealed the complete disap-
; G4 T' M0 F  V0 |$ h8 ~! Hpearance of pubic hair, normal growth velocity, and
& \/ E- `/ }/ L! T. }. B1 j- sdecreased erections. The father admitted using a testos-% ]. B# m! e1 n3 D$ c# @. l
terone gel, which he concealed at first visit. He was5 X9 U+ ^& o& m# _& s4 a2 w
using it rather frequently, twice a day. The Physicians’
: D+ \6 E. R8 {3 Q( FDesk Reference, or package insert of this product, gel or& U1 q( x, }9 Z5 n7 X" w4 K9 P
cream, cautions about dermal testosterone transfer to
- M% a% g& ^1 {: H) `7 b+ \" Ounprotected females through direct skin exposure.# y  t, j& f7 L" E# P
Serum testosterone level was found to be 2 times the
+ T' x' b9 n. h. _4 S) Gbaseline value in those females who were exposed to/ M) Y2 D  Z& u" @' r9 v
even 15 minutes of direct skin contact with their male
6 L, m9 X8 ^) r5 Upartners.6 However, when a shirt covered the applica-
5 m8 `7 G) d% F! C5 }tion site, this testosterone transfer was prevented.
7 h4 H6 b6 z! v& u5 qOur patient’s testosterone level was 60 ng/mL,, }- ~0 V- P8 d5 q) ]
which was clearly high. Some studies suggest that! g2 \" B# p7 j, D  f8 s. k
dermal conversion of testosterone to dihydrotestos-  e: e) ?+ z, z
terone, which is a more potent metabolite, is more
$ J$ B: G5 Q+ zactive in young children exposed to testosterone; P: W  L# H1 D! V5 c' l+ W
exogenously7; however, we did not measure a dihy-
9 G) i. A  x+ Q2 F( Idrotestosterone level in our patient. In addition to
- |  z( m- a3 avirilization, exposure to exogenous testosterone in( T1 k6 b+ ?" z% p
children results in an increase in growth velocity and
# M4 f; x  Y: C0 @6 y9 F$ R2 |advanced bone age, as seen in our patient.. x" T7 L; J. b; {  o" @1 H, f
The long-term effect of androgen exposure during; a( A. |6 V# q4 H
early childhood on pubertal development and final* g* i" M  O! E9 w2 ]
adult height are not fully known and always remain
2 c  c7 f3 G- E3 Q( Xa concern. Children treated with short-term testos-
: A2 u$ m0 }6 o7 e5 mterone injection or topical androgen may exhibit some6 Q1 z) T. H( a( j6 o; z
acceleration of the skeletal maturation; however, after
' X. u3 x9 C7 F+ Kcessation of treatment, the rate of bone maturation
6 U/ d* w3 d/ Y% b& N( _1 Zdecelerates and gradually returns to normal.8,9
* g8 h; u1 h$ F/ t  G7 i3 _There are conflicting reports and controversy
, e5 Q6 U* o! h; yover the effect of early androgen exposure on adult+ G! U, Y+ H; n$ c7 v
penile length.10,11 Some reports suggest subnormal, t& ?& p  Q2 |1 s- K7 O. f) b
adult penile length, apparently because of downreg-& m5 T; ~- P6 s+ B
ulation of androgen receptor number.10,12 However,5 f% k+ H7 r* M
Sutherland et al13 did not find a correlation between
$ q) X) J/ h+ F1 a! Zchildhood testosterone exposure and reduced adult# g9 M* r4 T* `" n4 Q: ~
penile length in clinical studies.
' K" I3 `) U; s) w  f/ @. ?/ {" RNonetheless, we do not believe our patient is
& ?9 i1 @. l1 j1 p1 `% Sgoing to experience any of the untoward effects from9 ^) ?9 [7 P  e5 o/ ]
testosterone exposure as mentioned earlier because
* E7 W; E, h+ A2 ]the exposure was not for a prolonged period of time.
" @" o1 q2 v# S' yAlthough the bone age was advanced at the time of. E& g2 V3 W# v( X1 C- z* u& s
diagnosis, the child had a normal growth velocity at
# u$ ?  W, X0 T' z& a; `the follow-up visit. It is hoped that his final adult" w6 ?" [, V  ~: d6 n
height will not be affected.
9 D+ T6 V- m. N8 q: q9 j  }/ dAlthough rarely reported, the widespread avail-! Y9 E8 x' u% v$ _+ j6 S. e) U, ?
ability of androgen products in our society may4 R7 d: t" j8 `9 v4 b$ X# |* ^
indeed cause more virilization in male or female
2 I: t% Q  K' w# lchildren than one would realize. Exposure to andro-  k. ~1 m+ @9 e/ O6 h; s5 Q
gen products must be considered and specific ques-1 f4 N; @; \( u$ n% U8 w
tioning about the use of a testosterone product or2 F0 Z* m/ ?$ j4 K, F
gel should be asked of the family members during8 {5 ]) ~1 s7 `& g% X: W, R
the evaluation of any children who present with vir-. [  w. E: x' j
ilization or peripheral precocious puberty. The diag-
9 M# d+ c4 I  s( B8 S1 M% I+ lnosis can be established by just a few tests and by
9 F9 A+ F! W5 f& M5 w: Oappropriate history. The inability to obtain such a5 U. u6 Q$ l7 h; D" g/ d
history, or failure to ask the specific questions, may  ^, S# Y3 `( h8 o! A, I
result in extensive, unnecessary, and expensive' P8 |2 ]% _' U5 K9 R* G3 g
investigation. The primary care physician should be. y7 y# S3 X% Z+ ?% `6 J
aware of this fact, because most of these children
3 i" f; u5 N( |2 S1 k% s. m$ `may initially present in their practice. The Physicians’
3 O8 j0 U% L6 n/ BDesk Reference and package insert should also put a
- |' Y8 q6 R7 T0 p3 e' ^warning about the virilizing effect on a male or$ m2 ?3 O2 q" F$ Y2 d. l  Y
female child who might come in contact with some-
  o/ n! ^% ^6 K% }one using any of these products.
% A0 Q9 i( a( `& N% C. q3 B9 M/ TReferences% B) p; f0 O# S
1. Styne DM. The testes: disorder of sexual differentiation
+ p: m* m. R# S" W1 V. iand puberty in the male. In: Sperling MA, ed. Pediatric
  c! R6 \3 g' c1 n  r9 Y3 `. dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" I% y( O: |* v$ E
2002: 565-628.
6 h6 {* i& i; f3 u% U4 c( w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 R1 S# ~" u" a$ ]( a# N7 m( [6 tpuberty 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

/ j4 V6 {; T  }8 b3 |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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