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Sexual Precocity in a 16-Month-Old+ T& B0 D5 `6 A# ~
Boy Induced by Indirect Topical  f9 h2 }" E* i1 M7 L* m
Exposure to Testosterone% {+ a7 v# `  X5 ~( O
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 q# a. G; D* `; E( f" b/ xand Kenneth R. Rettig, MD16 @* }7 p! Q" e1 o
Clinical Pediatrics
, I$ X( O; a5 n) Q2 ^Volume 46 Number 6: ?* T6 x  Q+ [* }+ \7 o3 k* \
July 2007 540-543: W, `/ \, r- f3 e. i' C
© 2007 Sage Publications0 M- G7 \6 E4 `' U
10.1177/0009922806296651
! k( [5 N6 t/ i; B; Ihttp://clp.sagepub.com
$ D% w7 ^! c' ?hosted at
* l) l9 X/ j" h- g4 v+ \http://online.sagepub.com( ]' e2 J' }( V5 F( |
Precocious puberty in boys, central or peripheral,& G7 t4 j" w; t
is a significant concern for physicians. Central( ?5 q+ m. b) n  W" {$ l/ K! n* v
precocious puberty (CPP), which is mediated
: B& m* @. E8 h1 e6 T7 g' ]! E' tthrough the hypothalamic pituitary gonadal axis, has
$ E: ?% [' Z! f# G9 N) m, {a higher incidence of organic central nervous system
) _1 f# ?3 ^, y) w7 L/ Jlesions in boys.1,2 Virilization in boys, as manifested* m) Y2 c2 g6 q: @( ^$ I# K
by enlargement of the penis, development of pubic
" R4 ^7 G* ~+ D/ _hair, and facial acne without enlargement of testi-
  e" d* p. a! t6 G. W. bcles, suggests peripheral or pseudopuberty.1-3 We* U$ o# p& j; G7 y1 H
report a 16-month-old boy who presented with the
/ q4 w: V: h5 |0 lenlargement of the phallus and pubic hair develop-% w0 T/ A( b) |6 y
ment without testicular enlargement, which was due
! R  e  }. X; A# `0 pto the unintentional exposure to androgen gel used by1 D/ I- F, u8 x# C  I5 C
the father. The family initially concealed this infor-
& M! L/ S) B4 ?% [! |; n# Mmation, resulting in an extensive work-up for this
% X9 B6 z% b, q1 [2 D1 ^child. Given the widespread and easy availability of
; C) y- n$ I) z! w& [8 [+ Z4 itestosterone gel and cream, we believe this is proba-# Y8 m& ?) u" @1 Y
bly more common than the rare case report in the
2 p7 w/ [! T2 b* ]2 Lliterature.4. `9 s! f5 Y. X% L. n
Patient Report+ j  [2 b& L0 ^- k) J# t/ `! a
A 16-month-old white child was referred to the' J# G: L/ y6 j: ?7 ^! X2 Z
endocrine clinic by his pediatrician with the concern9 J$ T5 n5 b" q
of early sexual development. His mother noticed
; ?% I6 D6 v- m! d  Z! l5 i9 llight colored pubic hair development when he was8 q& P  P% f  |, u9 R( q0 q
From the 1Division of Pediatric Endocrinology, 2University of" z5 i* O! O6 S8 b5 |+ x7 M' g" t3 F
South Alabama Medical Center, Mobile, Alabama.
+ I6 W7 J' p. S/ n' ?Address correspondence to: Samar K. Bhowmick, MD, FACE,
" F; t% k- t: m! y. oProfessor of Pediatrics, University of South Alabama, College of
: o8 I; ]( b: m4 c3 n; i, m, sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
' l7 @0 f8 Y1 H( p4 T; Y- a8 He-mail: [email protected].
" d4 e6 O1 e8 [% @# C- jabout 6 to 7 months old, which progressively became* b; m1 M3 ^1 D
darker. She was also concerned about the enlarge-
2 x' f8 x1 t# M+ y+ A& Vment of his penis and frequent erections. The child
8 P( T. o( |) t( @! ]' J" Z+ Xwas the product of a full-term normal delivery, with' u2 m0 _8 C- I! N6 D7 b4 T
a birth weight of 7 lb 14 oz, and birth length of2 T6 s% G: l/ G
20 inches. He was breast-fed throughout the first year" `7 }4 k" A) W2 d2 G/ d
of life and was still receiving breast milk along with
, M+ {9 ^! c& G- o/ Rsolid food. He had no hospitalizations or surgery,% A! I5 Y" j0 g" [/ ^5 K7 U. [
and his psychosocial and psychomotor development* M( Z! t) b* L$ J6 N
was age appropriate.5 S& b) M/ t9 q) X0 o/ h8 p
The family history was remarkable for the father,
0 w) v7 K* G& K6 \4 M: n) _who was diagnosed with hypothyroidism at age 16,# `( E  Z2 |" V' x4 v/ \
which was treated with thyroxine. The father’s
( _9 B8 u' Q: Xheight was 6 feet, and he went through a somewhat9 X5 Z* Q8 I5 K2 c& l
early puberty and had stopped growing by age 14.( W: x6 H% K* k
The father denied taking any other medication. The
7 X5 }2 u0 g/ b' M8 ~4 S3 jchild’s mother was in good health. Her menarche
" u) _- q  r8 y6 Twas at 11 years of age, and her height was at 5 feet
: K$ M0 P" m* s9 S" O: Q1 }6 h5 inches. There was no other family history of pre-- I8 S* o& A' r  ?4 n( y" v
cocious sexual development in the first-degree rela-  q* T  E5 M) C  g0 X' b) n
tives. There were no siblings.# U6 [2 n( v- p4 {9 w* J6 N
Physical Examination: b) e+ U2 P& w5 w( i
The physical examination revealed a very active,9 ?- X* V" `7 t+ A5 ]* s' X4 J
playful, and healthy boy. The vital signs documented. ]& S9 V: p2 }) |3 Y6 O% V
a blood pressure of 85/50 mm Hg, his length was
" W* r4 \9 ~3 E9 u6 O9 E6 p90 cm (>97th percentile), and his weight was 14.4 kg% m2 R# o; X" A& s: d& q" k) i/ f
(also >97th percentile). The observed yearly growth& X3 R$ z) R6 L4 r5 O7 V
velocity was 30 cm (12 inches). The examination of4 W6 P2 P. F) J/ q% x; A: w7 N; i* Q! _
the neck revealed no thyroid enlargement.
% m" W: T$ J' G- P: Y0 [The genitourinary examination was remarkable for
3 K) }+ J8 j0 ^/ I5 B: E* \2 henlargement of the penis, with a stretched length of
5 r0 P$ L4 W& r" o; [: J* n. ?8 cm and a width of 2 cm. The glans penis was very well
% K5 ~% U/ {% P+ K1 O8 b7 b- ddeveloped. The pubic hair was Tanner II, mostly around* A7 }+ t  x$ a
540, L: C4 j3 ~; _$ S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 r. u& w0 V, b0 T5 k  _9 W4 T
the base of the phallus and was dark and curled. The3 s" f: j# B4 A) t) l
testicular volume was prepubertal at 2 mL each.2 h. z, j+ E/ G6 Q
The skin was moist and smooth and somewhat
/ _% Q: c+ r2 K9 Z. s4 Yoily. No axillary hair was noted. There were no6 w& L4 N) f% N
abnormal skin pigmentations or café-au-lait spots.
# z+ P2 O) Z; p3 O5 n+ q% mNeurologic evaluation showed deep tendon reflex 2+& j# ]+ j/ n! n! j
bilateral and symmetrical. There was no suggestion
: G+ y: a0 g" {" eof papilledema.
! l; C' @* {* u8 T4 c/ p$ i& VLaboratory Evaluation
9 O5 s, _2 ?5 z" X" ^) aThe bone age was consistent with 28 months by
- S8 r# r7 ]3 d9 k/ ^  tusing the standard of Greulich and Pyle at a chrono-& I" N' T* z$ F: f9 c! _( _
logic age of 16 months (advanced).5 Chromosomal3 t! I) Q5 x' G$ t! f% c
karyotype was 46XY. The thyroid function test2 t& e" _7 Z, a& M+ d5 W9 w. b3 A! @& p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ p/ }- E, `& ?4 w) T- E* W$ U
lating hormone level was 1.3 µIU/mL (both normal).
- k& w/ Z+ B$ g3 k% E  Q% @/ i# IThe concentrations of serum electrolytes, blood
' l' T$ z( E# T* [5 h- murea nitrogen, creatinine, and calcium all were
8 x% h" F/ z- G( z1 z; s( Twithin normal range for his age. The concentration
. c2 Y. S( l! X( a$ C# Vof serum 17-hydroxyprogesterone was 16 ng/dL
4 l' p4 N2 X) p2 ]4 V5 C  V" r(normal, 3 to 90 ng/dL), androstenedione was 20
6 S) L% r) l' K. kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 ?8 d6 w% |' H; z8 N% Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 ?& a. P5 N. t4 ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 {1 n( V6 i9 ]5 I: v: g3 I1 }- g49ng/dL), 11-desoxycortisol (specific compound S)
' J' N6 k* o" ]$ }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- \+ }4 j2 p9 ]/ N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& R1 M: Z9 S6 J  v6 _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; _% p* E, G: s4 U+ ^! F$ U. Eand β-human chorionic gonadotropin was less than) b5 u9 C! ]* y% ?  o2 _
5 mIU/mL (normal <5 mIU/mL). Serum follicular* A& S! m$ g* I0 J* K
stimulating hormone and leuteinizing hormone
, F! D5 b& O6 S( e1 K/ H7 bconcentrations were less than 0.05 mIU/mL
: h; Q2 v- ]7 P(prepubertal).  l2 j5 s: f# j" |" Y
The parents were notified about the laboratory5 Y6 S+ F. D( Z4 H. A3 d- D
results and were informed that all of the tests were% e7 C8 f0 G# A$ M0 @( L% p8 Y
normal except the testosterone level was high. The: f, n- N1 v, a
follow-up visit was arranged within a few weeks to
# U$ Q0 z2 C- v% t: kobtain testicular and abdominal sonograms; how-
! V7 d; W3 B0 N5 r  ~$ K4 i! hever, the family did not return for 4 months.5 u1 K0 E$ c4 q9 L- x! [. N2 K$ @
Physical examination at this time revealed that the
+ M# I/ N$ b& G/ r/ i, rchild had grown 2.5 cm in 4 months and had gained
7 Z" t7 G9 g& T$ i6 w9 P, C6 D  Q( r2 kg of weight. Physical examination remained
' S; W* F7 K4 G' n3 Kunchanged. Surprisingly, the pubic hair almost com-
/ Q! A2 n5 O! O0 M$ E2 V" wpletely disappeared except for a few vellous hairs at# r+ j9 U$ p7 ]. z0 T  ^
the base of the phallus. Testicular volume was still 2
% M' n0 {+ w( Q5 a0 l- |mL, and the size of the penis remained unchanged.
1 D# x) r. W0 @, XThe mother also said that the boy was no longer hav-
" o5 ]8 }* Y3 ^8 E5 X  ~4 sing frequent erections.
- D) B$ \. R  u% FBoth parents were again questioned about use of  y6 |( H( f( u  t0 d& d
any ointment/creams that they may have applied to% I% p+ N$ |2 i% R0 V5 D
the child’s skin. This time the father admitted the2 `  W" V( Y, N$ y9 s% `
Topical Testosterone Exposure / Bhowmick et al 541
$ q% e% B; n, e- uuse of testosterone gel twice daily that he was apply-
2 {9 m4 t. R% J6 Ying over his own shoulders, chest, and back area for
2 n  Q% W( X5 E/ A" Ga year. The father also revealed he was embarrassed
/ V4 w) \- n) M% E( Mto disclose that he was using a testosterone gel pre-. t, w1 \7 Z- {, \2 F2 c! a5 g: U
scribed by his family physician for decreased libido; X( e2 x: W+ k$ _
secondary to depression.! D$ k2 d$ f: u: `
The child slept in the same bed with parents.9 ]5 Y( G# c4 L, a; B
The father would hug the baby and hold him on his
! D9 |) P9 |, }3 C: mchest for a considerable period of time, causing sig-
1 X5 y' m0 }, G4 w6 X. h( nnificant bare skin contact between baby and father.( t! t& s6 \4 T. h; O* H$ s) m
The father also admitted that after the phone call,
, E. `1 U* U7 jwhen he learned the testosterone level in the baby+ X: T" ^5 O  k! I* M
was high, he then read the product information
+ a: I+ e  w) m3 V0 f& Kpacket and concluded that it was most likely the rea-, i" Q6 K% q; l0 `
son for the child’s virilization. At that time, they
4 ]; t$ L/ U: m7 C, t4 ndecided to put the baby in a separate bed, and the. D, |$ H7 I( G
father was not hugging him with bare skin and had
8 f. m' j3 m" \, c( ebeen using protective clothing. A repeat testosterone
. Z8 d7 O/ @% C; Y+ y: \test was ordered, but the family did not go to the) o; k  l/ ?3 d" N  e0 [
laboratory to obtain the test.! ?7 c  b& }; O) `; S- S
Discussion  T0 d; J0 C! i* l5 N! M" r
Precocious puberty in boys is defined as secondary* ]) |1 x2 i" L' u' z" i
sexual development before 9 years of age.1,4
4 w& u7 S" e( ^$ |Precocious puberty is termed as central (true) when. y8 y. s) R, l' r3 W3 Z5 m/ H- P
it is caused by the premature activation of hypo-) n0 u- Y( V# q. T5 b- e
thalamic pituitary gonadal axis. CPP is more com-: y- p6 t3 {3 H6 T3 A0 ~. B
mon in girls than in boys.1,3 Most boys with CPP
2 L! T, M8 b; i) mmay have a central nervous system lesion that is
, y3 Z. j  \: T" n. presponsible for the early activation of the hypothal-3 F8 G( V# [5 r3 \5 w
amic pituitary gonadal axis.1-3 Thus, greater empha-/ g+ A0 y1 B; ]7 Y9 o2 O& ?
sis has been given to neuroradiologic imaging in
! W0 X+ a9 T+ y! u. Mboys with precocious puberty. In addition to viril-# y# Y# H( F$ w7 m
ization, the clinical hallmark of CPP is the symmet-
( R' O5 }& p& v# m3 Yrical testicular growth secondary to stimulation by
/ B7 ]2 m- `0 j) x9 Cgonadotropins.1,3  B( W( N3 n/ y9 l
Gonadotropin-independent peripheral preco-
; E) b) K' L  [! j' g: B8 `2 w1 d- Gcious puberty in boys also results from inappropriate2 V9 G. k8 x# e) X0 ]  q
androgenic stimulation from either endogenous or
4 @- e3 b) x9 |8 ~% f& Dexogenous sources, nonpituitary gonadotropin stim-
! k* f8 @' e* J4 v, eulation, and rare activating mutations.3 Virilizing* p1 R7 `; J1 J" H0 B: ?% W
congenital adrenal hyperplasia producing excessive
$ j  [  P2 s/ s8 P# {' o2 wadrenal androgens is a common cause of precocious6 a4 {3 E2 v( [' o
puberty in boys.3,4
7 i: Y: b, k/ ?( [" [The most common form of congenital adrenal7 e7 {/ y* J/ j( X6 [# m3 r5 |: k
hyperplasia is the 21-hydroxylase enzyme deficiency.
% ]- T4 K4 T/ P. f% M0 W. x8 y) yThe 11-β hydroxylase deficiency may also result in
& L' D2 o6 D5 B/ h0 _3 l" v0 dexcessive adrenal androgen production, and rarely,
& i/ @4 R! u  a7 C1 E0 v/ uan adrenal tumor may also cause adrenal androgen/ M( z: f* M& w9 ]5 Z
excess.1,3; [; M, l$ g5 Y- H+ A* S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; {; f6 ?5 i8 ^4 w. p542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 d- i2 X# T3 i- v4 L3 L# w& `
A unique entity of male-limited gonadotropin-
* A! C0 X- ]6 _4 Q% h9 N. |& W) R1 k- Kindependent precocious puberty, which is also known# f7 Y8 O; u# [& D( M0 \/ K, w- ?
as testotoxicosis, may cause precocious puberty at a
% ^, f( _) V! ?% M* g* w0 {4 Xvery young age. The physical findings in these boys. B4 J  _$ F3 s4 s1 W/ U" i  `" z
with this disorder are full pubertal development,5 e# V, w+ s7 t: i5 p% J' b
including bilateral testicular growth, similar to boys/ O3 R/ G& r6 W9 k( l" C
with CPP. The gonadotropin levels in this disorder. ?( E" B9 A6 o& W* H; a
are suppressed to prepubertal levels and do not show
$ e) ?# I9 m  r& T" V) lpubertal response of gonadotropin after gonadotropin-- J9 |8 M% o, U4 f4 g- b. w1 T5 U6 a* M
releasing hormone stimulation. This is a sex-linked: h3 s7 h0 w0 U* ^+ @& d1 J
autosomal dominant disorder that affects only5 S$ c' P5 G* `/ b
males; therefore, other male members of the family
& n' S4 ~3 J% _* I  t5 nmay have similar precocious puberty.3
9 @$ f5 z1 H5 j& }1 EIn our patient, physical examination was incon-
; o& v" o$ I; P) Usistent with true precocious puberty since his testi-. u+ j0 F& N# m) k! p) p
cles were prepubertal in size. However, testotoxicosis
3 s4 K$ j7 L  a& ywas in the differential diagnosis because his father
8 J+ {. S* {9 {6 a. Y& _started puberty somewhat early, and occasionally,
2 W8 k1 L' M. F3 U1 X# Q5 ^6 ~4 Ftesticular enlargement is not that evident in the
0 e! ^& ^, v6 b" i' A3 dbeginning of this process.1 In the absence of a neg-
) v  S9 C* n! Q# \) p+ ]ative initial history of androgen exposure, our
$ F; `  f* }: p$ Y7 \7 Bbiggest concern was virilizing adrenal hyperplasia,3 I" e% e% I, t# [0 ^& j$ ?
either 21-hydroxylase deficiency or 11-β hydroxylase
, ?1 _" B9 U$ E* H6 @: Fdeficiency. Those diagnoses were excluded by find-
6 c5 [! H' ?& _8 iing the normal level of adrenal steroids.
# {6 a1 |. q' \. yThe diagnosis of exogenous androgens was strongly
( @3 ]3 B5 r# Dsuspected in a follow-up visit after 4 months because
0 V$ t6 J7 r! D, R) Y6 S! nthe physical examination revealed the complete disap-' o$ [1 K7 Y; G  A$ ^
pearance of pubic hair, normal growth velocity, and
8 `2 L2 E4 U& m; p9 [) s1 |' p0 kdecreased erections. The father admitted using a testos-: s" y0 L/ @/ j8 u+ D
terone gel, which he concealed at first visit. He was9 E1 t/ m7 }* ~+ d6 H
using it rather frequently, twice a day. The Physicians’
3 K5 `' t, n8 N$ d8 ~Desk Reference, or package insert of this product, gel or
% u2 v0 l+ V7 Ecream, cautions about dermal testosterone transfer to' c) b; ^: k$ u6 j) H
unprotected females through direct skin exposure.
# c3 a  U  @& U5 B! m8 g0 ^6 E" OSerum testosterone level was found to be 2 times the
: c* [' c! |3 B1 d1 G9 Vbaseline value in those females who were exposed to5 a6 V: l: X) d, k
even 15 minutes of direct skin contact with their male
1 R1 r4 S, j2 x) D% c1 Hpartners.6 However, when a shirt covered the applica-% D7 P. Z2 F, Z, _  x  G
tion site, this testosterone transfer was prevented.+ s9 }3 M4 g3 A- e- Z
Our patient’s testosterone level was 60 ng/mL,
2 B" Y/ a5 L8 ^& C/ vwhich was clearly high. Some studies suggest that
% s3 v: W# C7 q+ O6 X! w& R  E8 Idermal conversion of testosterone to dihydrotestos-
& w2 ^9 L3 w' w+ y2 Q3 \4 v" w- uterone, which is a more potent metabolite, is more
$ t  T! A  V* Bactive in young children exposed to testosterone
8 R5 j4 h! S: K' _5 d) K( I% K! Aexogenously7; however, we did not measure a dihy-
- J/ |+ b$ y& V) ndrotestosterone level in our patient. In addition to5 w) R+ W6 P0 c) y; z8 ]0 }
virilization, exposure to exogenous testosterone in
; Q7 b% s4 a( G2 Jchildren results in an increase in growth velocity and" o% ~% t$ `" E
advanced bone age, as seen in our patient.5 G: ~  X$ F) u# p9 v' ]
The long-term effect of androgen exposure during" c% H# M2 X- o3 ^
early childhood on pubertal development and final
5 T8 ]; j' P8 Q! C& Vadult height are not fully known and always remain
  K& j7 C* d4 S/ B: V# f9 T  S, S$ `a concern. Children treated with short-term testos-
( n5 C$ c# P3 C' }" Rterone injection or topical androgen may exhibit some
& ^# E) P. `7 m, u% _: O3 Jacceleration of the skeletal maturation; however, after4 q9 V" J2 S! o4 r8 V5 c& C7 E
cessation of treatment, the rate of bone maturation
9 D8 z+ a9 p& e3 Rdecelerates and gradually returns to normal.8,9
2 d7 R. }7 s) Z% I* T( D9 jThere are conflicting reports and controversy
' q; h. F. ]8 J6 O% Pover the effect of early androgen exposure on adult
, X& N; Z& x4 }0 @penile length.10,11 Some reports suggest subnormal5 ]3 S, P4 Z: w* Q' e! t6 R6 a
adult penile length, apparently because of downreg-
; k" ~& ^& ^  J- S$ u9 Eulation of androgen receptor number.10,12 However,2 Z$ Y' f4 r! h4 W  `: R0 M
Sutherland et al13 did not find a correlation between
( e1 ?# s; Y) jchildhood testosterone exposure and reduced adult$ C0 e- t  X& j) G8 m
penile length in clinical studies.
* g1 J1 s1 Q% l3 n7 O' y9 ~- MNonetheless, we do not believe our patient is0 J7 S; F; i( \1 b
going to experience any of the untoward effects from
0 n$ U* \4 _# a  |% d2 W, [) ~testosterone exposure as mentioned earlier because
  |3 H8 i, S4 M" C1 Bthe exposure was not for a prolonged period of time.- [) k& }4 v6 R4 Z
Although the bone age was advanced at the time of- F7 e3 ~8 X: Y# m- }" j! ~
diagnosis, the child had a normal growth velocity at* o: ~+ E) r6 e! u) ^- O1 B; l
the follow-up visit. It is hoped that his final adult
4 [- z" v# K, P* n: B4 A" q+ [9 b6 Jheight will not be affected.
4 q) f3 e: |! M6 {Although rarely reported, the widespread avail-
) _1 w& [- A/ L7 ~7 Lability of androgen products in our society may
% \( ]0 B( ?: V$ h3 D% Z: Jindeed cause more virilization in male or female
9 s% U7 }+ U% v$ Hchildren than one would realize. Exposure to andro-. V" C( a: X" {+ j/ f, P
gen products must be considered and specific ques-
6 F( z8 z6 a) K6 l4 g8 Dtioning about the use of a testosterone product or
: J. C$ z( T: d6 Q" s& Zgel should be asked of the family members during
4 o/ o( b! F" y* a9 {) L) t7 Fthe evaluation of any children who present with vir-& l% Z. [( w: G
ilization or peripheral precocious puberty. The diag-
1 [9 S( s3 q$ q! S- h4 L- A  xnosis can be established by just a few tests and by, I3 {+ g8 g" a& ~) v
appropriate history. The inability to obtain such a/ B; E! ~' x; X& N/ q: j  y
history, or failure to ask the specific questions, may$ A- e) e* j* y9 S
result in extensive, unnecessary, and expensive
: K6 f( g% t- Z$ q/ Sinvestigation. The primary care physician should be$ W# B+ J. F. K
aware of this fact, because most of these children
+ ]& {8 Q: \$ v$ Y7 a1 Dmay initially present in their practice. The Physicians’
; E8 z+ E: I( T- ]1 l* vDesk Reference and package insert should also put a
6 v" q0 r- t# R* r7 b4 }% nwarning about the virilizing effect on a male or6 o# J$ Q% T% n
female child who might come in contact with some-' M2 V8 v# T# F/ D. [
one using any of these products." y( y- v2 t8 X+ j  }6 a) x
References8 P/ K( o" W* Q
1. Styne DM. The testes: disorder of sexual differentiation# `0 L! i7 z' e& |1 \. ~
and puberty in the male. In: Sperling MA, ed. Pediatric
/ w- R2 m8 U6 b( `Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- {  h% y' g8 e0 z- T% L5 M% @
2002: 565-628.7 E2 Q# ~  A$ p  ?- ^, R% X* @& s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 Z" R' ]7 o& h+ l
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* A7 t; _! ~8 [. v5 E( L7 V# b
Boy Induced by Indirect Topical
! z$ D" X) l8 {4 A' b1 tExposure to Testosterone
9 A; _1 D7 R! n8 ^Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: ?8 S, J2 i' L
and Kenneth R. Rettig, MD1
3 S: U0 I5 Y  _Clinical Pediatrics3 c; K, }. E& _, z  P1 {8 C3 P
Volume 46 Number 6
/ V+ `1 ?7 U$ d$ qJuly 2007 540-5432 e6 B4 E2 y9 V7 [
© 2007 Sage Publications+ _; f$ x- R: {+ X+ \/ i8 o
10.1177/0009922806296651
* L9 t) M: b9 E: b' Ihttp://clp.sagepub.com
7 H0 n+ J8 w0 khosted at7 D: I  L: ^6 v# M
http://online.sagepub.com9 t6 H" [$ ~% z% J6 F) K; {
Precocious puberty in boys, central or peripheral,
9 W, Y' d8 J# p& xis a significant concern for physicians. Central& n, W7 T3 `& `, p; [7 @  i$ l. }
precocious puberty (CPP), which is mediated
& \' M8 s2 c4 D, T4 K& Athrough the hypothalamic pituitary gonadal axis, has, q/ `1 e- e. d# ]7 }
a higher incidence of organic central nervous system% F; o) j6 v/ h4 r2 \* V
lesions in boys.1,2 Virilization in boys, as manifested
  f+ y) ~0 q  c, L! Dby enlargement of the penis, development of pubic
) r! H) b# o; _3 G2 i  W0 [hair, and facial acne without enlargement of testi-- S( P: L; e9 s6 x/ o
cles, suggests peripheral or pseudopuberty.1-3 We. q1 d1 Q1 z7 D+ b2 s1 h, o: y
report a 16-month-old boy who presented with the6 H. D0 {4 f  r; n
enlargement of the phallus and pubic hair develop-
: o* w+ s9 C! O# Q) @9 Cment without testicular enlargement, which was due
% u3 [* W3 t! W% Y$ w0 e, x) ?to the unintentional exposure to androgen gel used by
' J" X  w9 d# {; k8 rthe father. The family initially concealed this infor-
; U0 s3 v# b) I- n/ ?mation, resulting in an extensive work-up for this
4 @% \2 X! U/ D- g0 j4 d$ _7 _7 Nchild. Given the widespread and easy availability of1 n: i% G/ Q: }+ R8 }2 g, ~
testosterone gel and cream, we believe this is proba-% h. u0 e6 g0 m$ S
bly more common than the rare case report in the
, ~, I" j3 G% l* Z- }literature.4
/ d: k& P1 x2 \6 uPatient Report0 p) ^9 e* _* [' w
A 16-month-old white child was referred to the
3 c* m5 F8 X- P2 ?2 O+ pendocrine clinic by his pediatrician with the concern( v' C! A+ i" M" o3 b3 G( Y8 l6 g' J
of early sexual development. His mother noticed
- {- c* }. ]; k; flight colored pubic hair development when he was+ V4 s! i  n$ [1 n) F
From the 1Division of Pediatric Endocrinology, 2University of5 q# }- N6 m5 `/ s; x
South Alabama Medical Center, Mobile, Alabama.
) f8 O+ j: I  N& s% s& O& V* y. SAddress correspondence to: Samar K. Bhowmick, MD, FACE,. z2 h, P9 r/ y3 [$ W5 y0 s) A
Professor of Pediatrics, University of South Alabama, College of6 m  k+ G1 Q; V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 I& q2 P" f* A" o' {! w: Y3 De-mail: [email protected].! X$ N# v+ I2 b9 F6 G% p
about 6 to 7 months old, which progressively became' `$ |( @6 o- d  g! Y
darker. She was also concerned about the enlarge-7 [7 q. c. x4 _0 S" n1 D1 i
ment of his penis and frequent erections. The child
/ n9 @0 e/ M& r) W6 V/ A/ a: Mwas the product of a full-term normal delivery, with. q) \4 `7 Z* Z  N1 S
a birth weight of 7 lb 14 oz, and birth length of% y4 T% k2 I* t- }& s" \) C8 O
20 inches. He was breast-fed throughout the first year
) {- K* B. {9 D0 eof life and was still receiving breast milk along with5 p" N0 \* H" T: n: {3 i3 T  Q! f
solid food. He had no hospitalizations or surgery,2 `3 q) `- n; B* A# p7 q7 s
and his psychosocial and psychomotor development
1 F1 r5 O* f( D" |: swas age appropriate.
$ \& V( I% _  i5 v0 q" ]- x* PThe family history was remarkable for the father,) c. |0 p8 @% W4 }
who was diagnosed with hypothyroidism at age 16,& p' _: _) ~5 `% w) J
which was treated with thyroxine. The father’s0 }% X3 j+ K; N! x- x7 A4 M) ^
height was 6 feet, and he went through a somewhat$ X+ h7 v# B% y  q
early puberty and had stopped growing by age 14.9 m: ?! @" ^9 R
The father denied taking any other medication. The
' d+ ~) x: `, B* h3 W# D) Lchild’s mother was in good health. Her menarche- o: ?( E' A: ~, q/ @
was at 11 years of age, and her height was at 5 feet
) B% o: C9 H7 x: Q3 k4 \0 p4 U5 inches. There was no other family history of pre-8 f( d0 {6 X4 `9 l" k
cocious sexual development in the first-degree rela-
4 J, }7 N1 D% [; ?- l5 Y) r$ ~tives. There were no siblings.
6 _. k1 ?! ~% c$ c0 b' dPhysical Examination
% }7 C  x5 W) `5 W/ eThe physical examination revealed a very active,; e" |+ x' k' d3 D9 ?4 Q" R
playful, and healthy boy. The vital signs documented& L/ x1 [8 z& ?9 G
a blood pressure of 85/50 mm Hg, his length was$ W( x. Q  C0 x
90 cm (>97th percentile), and his weight was 14.4 kg
. z$ i* v" V6 u+ c(also >97th percentile). The observed yearly growth
, |8 Y! k- K# Dvelocity was 30 cm (12 inches). The examination of6 Y' z  Z0 H  d7 o7 t
the neck revealed no thyroid enlargement.1 v6 _% m4 m9 ]2 C+ ?  s& y
The genitourinary examination was remarkable for
% v! c$ t( n  h1 K. u1 Oenlargement of the penis, with a stretched length of9 q4 S/ y- Y  q9 x/ l: j5 E! g
8 cm and a width of 2 cm. The glans penis was very well' v" f: X4 Z3 Z
developed. The pubic hair was Tanner II, mostly around
. i8 e* g5 V4 r2 U' J2 j540
' V  w3 Q$ k9 h# {7 u, V# L4 Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 v4 i. H5 x$ n- l7 E
the base of the phallus and was dark and curled. The/ C8 y) `. H! a! A7 l( {8 a" _
testicular volume was prepubertal at 2 mL each.6 `  S5 S: ~0 Y& n, _/ I
The skin was moist and smooth and somewhat
/ S6 c+ X6 ]. Ooily. No axillary hair was noted. There were no
' z9 [3 B9 o0 h0 q& }5 uabnormal skin pigmentations or café-au-lait spots.
5 k1 ]+ K% b. @: E/ C; P1 t+ i# vNeurologic evaluation showed deep tendon reflex 2+
  v; A7 T) h2 N: h0 j: h% xbilateral and symmetrical. There was no suggestion
$ Z$ F  c! e! |6 l* V! V8 {of papilledema.) t0 b1 W& j- k5 X: L- U$ r2 c+ K
Laboratory Evaluation
& R, O6 i. z  t8 c$ XThe bone age was consistent with 28 months by
# r# O# S1 ~: wusing the standard of Greulich and Pyle at a chrono-4 I- D0 D& m& n- c
logic age of 16 months (advanced).5 Chromosomal1 M* S/ p, u' J  \6 ?. z0 M
karyotype was 46XY. The thyroid function test
* `0 y0 X  \5 N4 Q- @& Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  M$ B0 n7 J/ T0 I% a! H( v* {lating hormone level was 1.3 µIU/mL (both normal).7 ^5 I6 L7 d$ Z/ t
The concentrations of serum electrolytes, blood
+ y; f( O5 ]8 P$ E  B& @) Kurea nitrogen, creatinine, and calcium all were
0 Y7 i2 O6 R& m+ Owithin normal range for his age. The concentration) o, S  ~, O  v
of serum 17-hydroxyprogesterone was 16 ng/dL
7 \* n; G; P' `+ l# s1 u8 |6 s(normal, 3 to 90 ng/dL), androstenedione was 20
" X5 M# k7 Q% l, m2 Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 r! Q: U. a8 k5 w/ h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ c2 G! O- d0 T& G' K' N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 R% D8 E, |9 Y* n2 u7 w3 I8 U
49ng/dL), 11-desoxycortisol (specific compound S): I' R0 |( x9 X# ~  H& b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) y5 s& X  ]* o, V$ B$ z: Btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# Z6 n& f9 ]$ v: y# N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 y- X: Z7 O5 \3 L
and β-human chorionic gonadotropin was less than
! z; q% P* q8 C  K5 mIU/mL (normal <5 mIU/mL). Serum follicular
4 o. V2 E& b# c! U0 {stimulating hormone and leuteinizing hormone3 |& i, _: S1 V0 {( ^; h6 \& o. d
concentrations were less than 0.05 mIU/mL
8 @* i" C, q2 V% j. P(prepubertal).
( [" X. ]& ]4 S5 lThe parents were notified about the laboratory8 T: ~. r( l6 N/ D3 Z3 A. B8 z
results and were informed that all of the tests were" j; d4 y2 A! P+ p
normal except the testosterone level was high. The" a* A- I) H2 }1 D5 w/ h
follow-up visit was arranged within a few weeks to
& _- g1 I/ w! l/ X. ?2 }obtain testicular and abdominal sonograms; how-
3 g: \3 [' y0 R0 t" }3 A" Jever, the family did not return for 4 months.0 [6 b: f* E6 F
Physical examination at this time revealed that the3 f) I6 z: U5 ?- F9 y) J3 P
child had grown 2.5 cm in 4 months and had gained
8 D- O2 e, i; |5 M2 kg of weight. Physical examination remained! i. _2 a7 g$ O, m* t
unchanged. Surprisingly, the pubic hair almost com-3 k  o: w1 k, ?& g
pletely disappeared except for a few vellous hairs at
# x+ y2 k1 _2 }( q6 `; ^9 Z/ r; hthe base of the phallus. Testicular volume was still 20 ~& S+ A3 a  @5 b7 w
mL, and the size of the penis remained unchanged.
; Y* m& q4 L) F. N0 V, yThe mother also said that the boy was no longer hav-
9 ^. i, U' [8 ]  sing frequent erections.3 ^8 J% c4 A8 h4 A* m5 h
Both parents were again questioned about use of
& ~4 E) U, B5 p8 \any ointment/creams that they may have applied to7 B7 L" ?6 V* C6 U. p
the child’s skin. This time the father admitted the( D, D: U+ u1 a0 a& T) P
Topical Testosterone Exposure / Bhowmick et al 541
7 ~' Q# N4 O7 u- x, Luse of testosterone gel twice daily that he was apply-. u' x9 Y2 ~' L, K  |" O
ing over his own shoulders, chest, and back area for, ~$ z1 N( Q+ ^8 v
a year. The father also revealed he was embarrassed
9 H. ?: w; a! |6 `* b( }& }to disclose that he was using a testosterone gel pre-
/ W" |9 L9 {, G9 X# uscribed by his family physician for decreased libido
; F& t; I# M8 F; Jsecondary to depression.
- m9 U( F* Y2 Q4 I; ^  x2 vThe child slept in the same bed with parents.
8 D3 O1 r5 }7 z5 T% c1 GThe father would hug the baby and hold him on his
9 i. G, @) J/ Kchest for a considerable period of time, causing sig-1 p! X3 S0 j1 K6 W" w1 _+ |" d0 u
nificant bare skin contact between baby and father.3 l  |% _2 |$ T1 A6 a' a( |, R
The father also admitted that after the phone call,- d9 w5 i5 D. G/ o1 T
when he learned the testosterone level in the baby) {' o, s% a$ A3 @4 R2 j: ^
was high, he then read the product information
2 n2 M2 r+ c- G$ q& _packet and concluded that it was most likely the rea-' \( |7 [  P, c$ s. `9 [
son for the child’s virilization. At that time, they' f+ _2 V) x+ l3 o( b. H( O
decided to put the baby in a separate bed, and the
% ]$ K& S8 Y3 E. Y. q. [8 ?6 Z1 Qfather was not hugging him with bare skin and had
  }. K8 b; F2 T% ^6 O: a1 E- tbeen using protective clothing. A repeat testosterone" W8 w1 X. D( n$ l; k* [( L
test was ordered, but the family did not go to the, p% v! _  l6 j- j8 ]/ p
laboratory to obtain the test.8 |# ]( I6 F! O% Y0 B
Discussion
. i! c5 c% J# q: V$ c- DPrecocious puberty in boys is defined as secondary9 C) O' E, N2 f7 [# v
sexual development before 9 years of age.1,4% \( x7 v& P( O8 r5 P# L
Precocious puberty is termed as central (true) when
0 O: i4 L, z3 T- I4 Cit is caused by the premature activation of hypo-
% ^- _+ D6 L( W5 z) w3 X* Zthalamic pituitary gonadal axis. CPP is more com-/ z3 Z" q- Z  ?9 y, [9 z
mon in girls than in boys.1,3 Most boys with CPP& d) e: E/ [" z
may have a central nervous system lesion that is
& S, G, u# h* ~responsible for the early activation of the hypothal-
% `$ L8 l8 ^; d+ u* C3 Z* F) Mamic pituitary gonadal axis.1-3 Thus, greater empha-
" m0 t0 ?" s; f4 O9 o: q( psis has been given to neuroradiologic imaging in$ t2 C8 x, E( ^2 y* W" s# O. A% x* Y
boys with precocious puberty. In addition to viril-) D1 P: I. @8 E6 f; R- f
ization, the clinical hallmark of CPP is the symmet-
( m6 d/ [3 i8 F6 s* vrical testicular growth secondary to stimulation by
7 }1 h' _* S, N/ @gonadotropins.1,3
) A/ ~, W( U, ]$ R. e; j! GGonadotropin-independent peripheral preco-$ F: ?$ |8 O& V+ x8 @. Q
cious puberty in boys also results from inappropriate
" P& `; G& j. Tandrogenic stimulation from either endogenous or
4 {/ s2 n. B4 L4 C$ Qexogenous sources, nonpituitary gonadotropin stim-& [: w  C3 k" D; w
ulation, and rare activating mutations.3 Virilizing
% f" o+ M7 F5 ]) H5 o/ Lcongenital adrenal hyperplasia producing excessive! O$ {4 J' }" ~9 h4 U
adrenal androgens is a common cause of precocious
4 S) ?) R9 x- ]/ ^) dpuberty in boys.3,4
1 u% w; ]8 D: s. l. e% |The most common form of congenital adrenal3 n: D' w! j+ N. `5 y
hyperplasia is the 21-hydroxylase enzyme deficiency.
% e1 B; R) r* F, U3 S6 f7 r: VThe 11-β hydroxylase deficiency may also result in
' m6 N& h  u2 @4 w5 R$ nexcessive adrenal androgen production, and rarely,' ?/ e4 B- y3 i
an adrenal tumor may also cause adrenal androgen
4 O+ s( \- S* c$ j, q. f3 Z7 I$ v% y" |excess.1,3
; h+ ?# _- Z# J/ kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: Q$ L/ I# @+ }5 H" b6 z# S
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 E2 u! O' k0 o' H; L% n  F* J, VA unique entity of male-limited gonadotropin-, \! ^" d6 _  T: U* k2 R
independent precocious puberty, which is also known) N% k2 {( G* i
as testotoxicosis, may cause precocious puberty at a
: i8 d$ L. R2 T# I: W! B# y: Uvery young age. The physical findings in these boys
! l; P, ^) A* y- v* x! ^with this disorder are full pubertal development,; d" B5 L0 @% {- I& ~3 o
including bilateral testicular growth, similar to boys
/ u. u1 p% e; T2 cwith CPP. The gonadotropin levels in this disorder
0 ~8 k& z; ]$ u( c  rare suppressed to prepubertal levels and do not show% y2 V. n. k# T' S9 \
pubertal response of gonadotropin after gonadotropin-$ I' b: C& T4 \: j( K* d* M8 y
releasing hormone stimulation. This is a sex-linked6 _' }3 K- O* v  L
autosomal dominant disorder that affects only2 r, v, n" A1 X! }. K$ M
males; therefore, other male members of the family
( Y& w+ J9 f5 G, i( i5 Z/ S3 rmay have similar precocious puberty.36 H  k0 O* B7 z$ u$ \
In our patient, physical examination was incon-0 r% n3 j5 Y+ @9 T( N5 s( x7 G
sistent with true precocious puberty since his testi-
' t: W  ]6 w) g/ K# a# }" d6 V, acles were prepubertal in size. However, testotoxicosis
6 I' z% q0 B/ h& Y5 A: Dwas in the differential diagnosis because his father
. y* `3 Z- U& F0 \. q* j2 estarted puberty somewhat early, and occasionally,0 w6 ?1 E$ E. C2 L2 z
testicular enlargement is not that evident in the% B" j" I" |0 ~: r
beginning of this process.1 In the absence of a neg-
. b$ z& \  L% m& Aative initial history of androgen exposure, our+ i; [6 |- S# u  |$ c% R
biggest concern was virilizing adrenal hyperplasia,
- k# Y* j. R& ]8 w: I  Z5 veither 21-hydroxylase deficiency or 11-β hydroxylase
( _* Z1 o% {" R: A6 }) xdeficiency. Those diagnoses were excluded by find-
) W" E8 F- E7 e+ y. j3 D1 [6 ping the normal level of adrenal steroids.# F( b5 o' o7 v, u4 y
The diagnosis of exogenous androgens was strongly& V! @( }+ N- O
suspected in a follow-up visit after 4 months because
8 W# Q3 r5 A7 G& e) c( ?2 }% N2 Cthe physical examination revealed the complete disap-; M" _: i$ X1 Z$ x; i/ ?
pearance of pubic hair, normal growth velocity, and. m) [2 p" z0 B
decreased erections. The father admitted using a testos-: x6 Z" i: D8 s/ L5 e2 J
terone gel, which he concealed at first visit. He was6 K& d- B  C  d5 S
using it rather frequently, twice a day. The Physicians’
4 \8 k, C7 m9 ^Desk Reference, or package insert of this product, gel or
, }, u1 [. G; W" }% Z$ Dcream, cautions about dermal testosterone transfer to7 F# I5 h- X+ R1 Z7 y; y
unprotected females through direct skin exposure.
- R4 S* m' h# B3 |; R5 NSerum testosterone level was found to be 2 times the! G; X% o1 b$ {' z1 r$ d; a
baseline value in those females who were exposed to
( ~, H3 Q9 B  c" Seven 15 minutes of direct skin contact with their male
5 }* y: w# ]' {6 _1 D3 w1 ^partners.6 However, when a shirt covered the applica-- u2 k  [2 ~7 ]7 {2 K
tion site, this testosterone transfer was prevented./ L& r  A# A3 p9 D- s( H
Our patient’s testosterone level was 60 ng/mL," V  A+ n8 z; E( q  C, p3 d5 X
which was clearly high. Some studies suggest that
1 j+ w2 E; h' M" N& z* g  C5 Cdermal conversion of testosterone to dihydrotestos-
6 x' M9 h1 n3 J' Wterone, which is a more potent metabolite, is more3 Z% U, d- G: w$ X
active in young children exposed to testosterone
) D6 f3 l  X0 j3 R2 v& pexogenously7; however, we did not measure a dihy-
$ d: ~' E! a( _2 X- N. d& bdrotestosterone level in our patient. In addition to9 E: L4 P9 B; S( I4 T
virilization, exposure to exogenous testosterone in6 q5 x4 I$ @* z  P; Q2 J6 Z$ }7 \
children results in an increase in growth velocity and3 |4 a9 j+ C+ M5 o' f4 L, V& |+ f
advanced bone age, as seen in our patient.0 e0 ^! Z& r7 g. Q  O; ^
The long-term effect of androgen exposure during
* f( i* a) d+ m6 @3 X. _( M9 R; S- ?early childhood on pubertal development and final
# p) }" K$ {1 n# N) h  }$ zadult height are not fully known and always remain
  |: }$ X8 B9 b! K2 ia concern. Children treated with short-term testos-9 q5 p3 \. N3 x% G: W
terone injection or topical androgen may exhibit some
: m9 c( N0 x5 ^1 b: xacceleration of the skeletal maturation; however, after6 q5 u( L, g4 \( K# e
cessation of treatment, the rate of bone maturation; ]# h2 C1 b( T7 ^
decelerates and gradually returns to normal.8,9
9 v1 j; `! \# o3 `) B- ]+ OThere are conflicting reports and controversy' E1 v: r# d  s; \7 p
over the effect of early androgen exposure on adult
+ H* D* S+ _4 q( D$ u" ^+ y, t; mpenile length.10,11 Some reports suggest subnormal5 g# Z6 q% W! {; u9 U0 m
adult penile length, apparently because of downreg-
2 z1 T9 ^3 M3 s# D% E& u3 m; Sulation of androgen receptor number.10,12 However,4 b+ W9 p4 y1 x4 f- x$ j
Sutherland et al13 did not find a correlation between* T' Z0 L. ]/ L" P9 d# M* c; p  B7 N
childhood testosterone exposure and reduced adult
+ B4 S! P, l0 Y: [; |7 ipenile length in clinical studies.
. P; Z. _! g: n+ _Nonetheless, we do not believe our patient is
5 D8 C9 s, x; F2 b$ ~going to experience any of the untoward effects from
# l9 B' }9 `9 P7 {" M8 btestosterone exposure as mentioned earlier because
, i: R6 V7 h5 J) A  v9 t5 R6 Tthe exposure was not for a prolonged period of time.7 N& a3 W* o7 x1 ~* N8 ?
Although the bone age was advanced at the time of( V/ i9 v/ u8 }: n# v
diagnosis, the child had a normal growth velocity at- ?  h2 j# c* b+ t( \
the follow-up visit. It is hoped that his final adult
% `2 u# r/ P4 z% m' |, @! uheight will not be affected.
7 [% ]! e( e5 d2 sAlthough rarely reported, the widespread avail-
9 ^' U# k0 C7 |# eability of androgen products in our society may+ {2 F, t$ w$ y( a2 t1 c1 y
indeed cause more virilization in male or female. w$ N$ D: M# J
children than one would realize. Exposure to andro-
4 o+ W6 U; ^5 ?' J0 @! h! @3 Kgen products must be considered and specific ques-
3 r3 _6 p7 R% n; z+ V6 E3 xtioning about the use of a testosterone product or
$ k* J+ W2 n1 m) g6 Wgel should be asked of the family members during  F- g  R, E* w$ J6 z
the evaluation of any children who present with vir-% ]$ c  s; z5 L
ilization or peripheral precocious puberty. The diag-/ ]4 x5 z" m# Y
nosis can be established by just a few tests and by
6 p( m0 y' @% }$ f0 }1 ^3 Sappropriate history. The inability to obtain such a- d( g. s; l) i& E. ^, p
history, or failure to ask the specific questions, may
5 i% V- q" T8 hresult in extensive, unnecessary, and expensive
9 x$ I  J4 j0 J. r; Vinvestigation. The primary care physician should be+ w0 f, X( P+ t: U
aware of this fact, because most of these children
% `' R: T/ ^- I: B/ i/ X  ^0 Qmay initially present in their practice. The Physicians’* M. j5 o; x& }% H7 S3 R- s3 R
Desk Reference and package insert should also put a* Z1 a4 x2 q# Y& D
warning about the virilizing effect on a male or7 ?/ H+ }* y! J: [- n
female child who might come in contact with some-4 y. v7 q- f9 g0 d* F
one using any of these products./ C' X, i9 ^0 ]. P
References
& P" [. Q' x: s: Z) l' U% Y  W1. Styne DM. The testes: disorder of sexual differentiation
; D! ?' g9 s  L& r) Z) E7 h) {and puberty in the male. In: Sperling MA, ed. Pediatric
% n( \- h5 c% s1 w* R' q( WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  z: ]: _5 x- U; S9 g- d2002: 565-628.) e7 }. O- L3 ^; c% Y9 m- |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 m9 a# {5 B* Y
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
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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
4 V$ v1 e. ]9 b5 u) G- ~
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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