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Sexual Precocity in a 16-Month-Old; ]5 x* `; f: w% W9 Q- o
Boy Induced by Indirect Topical
3 |# I- H/ z4 ]# I# D4 l+ ]6 w. FExposure to Testosterone
3 i0 {3 \8 F. X" i$ [' `, MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; }2 q2 O# @5 O, ?; s! v  X
and Kenneth R. Rettig, MD1
1 w* t% A6 I$ P* S/ [7 n1 F" F8 AClinical Pediatrics+ h7 S+ g7 j6 s- U! J
Volume 46 Number 61 C1 ?& e9 i9 f& O6 a3 b
July 2007 540-543' ?8 {3 w- C2 h) \0 H- K8 l2 {
© 2007 Sage Publications
7 G# B# d# y5 Q. y' |" l3 j8 o; l10.1177/0009922806296651
0 b% A0 U, ~% g* a# {! D1 y( Rhttp://clp.sagepub.com0 o( J! t3 R* E+ ]$ k; b
hosted at
% \9 ?' i8 y: _) w4 _* r3 H3 }http://online.sagepub.com! S: k7 i; ]! H; T0 v$ Q0 T
Precocious puberty in boys, central or peripheral,
3 S( D5 E4 G3 z; y+ D6 ?is a significant concern for physicians. Central
) r: Z6 ~( i2 Q& m; {precocious puberty (CPP), which is mediated
5 T$ s- R- |" x+ x2 s. Q9 C" othrough the hypothalamic pituitary gonadal axis, has
' S) K+ d0 D) x* Oa higher incidence of organic central nervous system% c' O( E1 s$ K+ u7 T( v: p
lesions in boys.1,2 Virilization in boys, as manifested
" [- A8 c4 j8 ^7 @' j' Nby enlargement of the penis, development of pubic% x/ G+ I, [4 k5 ~
hair, and facial acne without enlargement of testi-
+ k4 N9 A2 \) m& A7 ^2 u! B8 ?cles, suggests peripheral or pseudopuberty.1-3 We2 Q0 P3 g0 t& L
report a 16-month-old boy who presented with the
0 [4 |; t; J% I' N+ |) s1 aenlargement of the phallus and pubic hair develop-
% K9 Z1 I6 r, G2 }: W: l- Lment without testicular enlargement, which was due0 e1 T* G* B( @; G, \
to the unintentional exposure to androgen gel used by
, Y6 f3 R' p. C! R2 ^4 jthe father. The family initially concealed this infor-& p, M5 B! Z# k8 e; z6 R# U
mation, resulting in an extensive work-up for this
! J3 i) k- L7 N* mchild. Given the widespread and easy availability of& u7 K" H3 Z7 x$ i2 s
testosterone gel and cream, we believe this is proba-' }4 E% i( s' Z# C  f
bly more common than the rare case report in the
8 q+ u; b& M/ I- |% vliterature.4
9 K1 e/ |8 x1 h2 z, T! rPatient Report( U! A/ k9 w; a+ I& _  o
A 16-month-old white child was referred to the$ z1 f, p8 [8 w$ {" X' ^
endocrine clinic by his pediatrician with the concern
! d9 n' h$ C7 X( N1 N+ ~! Iof early sexual development. His mother noticed
9 k7 c" c1 x) X; E+ a1 Xlight colored pubic hair development when he was( I8 Z# K7 W" `2 I
From the 1Division of Pediatric Endocrinology, 2University of+ |6 b$ s5 m4 Q: k7 J8 v0 b
South Alabama Medical Center, Mobile, Alabama./ ^' a4 k/ F- H+ L6 \0 n$ i, g
Address correspondence to: Samar K. Bhowmick, MD, FACE,; v) q( j1 x1 c. {
Professor of Pediatrics, University of South Alabama, College of0 G0 o/ z& D/ T+ c/ Y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! X( M' {' l, R1 i- ?+ @
e-mail: [email protected].: l/ |. U& S/ f& e8 v
about 6 to 7 months old, which progressively became
6 s" s9 F4 u, y' T$ n9 ?darker. She was also concerned about the enlarge-, @, a/ L. s1 S! M4 \  D
ment of his penis and frequent erections. The child" T1 n( A& h# S
was the product of a full-term normal delivery, with
# c# q" |1 b. Ea birth weight of 7 lb 14 oz, and birth length of. ?3 k5 B3 b. }: E' w) u2 p$ f% G
20 inches. He was breast-fed throughout the first year
5 A! E5 N. T0 `3 ]of life and was still receiving breast milk along with# p2 h) n" p: Q, b' @* v# ~
solid food. He had no hospitalizations or surgery,
5 b' v6 y+ ^& H# T+ t+ sand his psychosocial and psychomotor development
8 Y- K! Y/ b# D8 ]3 ^8 y( Z# j0 T' X8 Ywas age appropriate.
4 o! j) r+ g' {; @( `The family history was remarkable for the father,
! p5 f6 j6 ^, u2 {+ Owho was diagnosed with hypothyroidism at age 16,; @3 ~) v  R2 f
which was treated with thyroxine. The father’s/ y8 d3 m% i8 y
height was 6 feet, and he went through a somewhat4 T. N# g2 _& [+ s! X& l9 S+ Y
early puberty and had stopped growing by age 14.
7 C. x* F5 |! |" D8 B: b& T$ VThe father denied taking any other medication. The! k, {7 O" Z/ O2 m4 ?/ t
child’s mother was in good health. Her menarche
; w9 s9 j4 [! b6 n: Qwas at 11 years of age, and her height was at 5 feet& U. ]! e3 Q& O  a$ ]& V: U( `
5 inches. There was no other family history of pre-$ i, f6 C" i( W4 t2 J
cocious sexual development in the first-degree rela-
  T, S; Y9 }4 P$ ftives. There were no siblings.: G" o! U- l: n
Physical Examination
* T4 A! c7 H( }" eThe physical examination revealed a very active,& e" K" o  ?$ {* l4 S! H7 r* ^- X% S
playful, and healthy boy. The vital signs documented
7 N7 p& h4 b/ [* h' d' `- da blood pressure of 85/50 mm Hg, his length was
- m0 a. F+ C% ?+ n! u) X4 e90 cm (>97th percentile), and his weight was 14.4 kg8 A: S  h% z" [" }4 \3 [' W& Z  _
(also >97th percentile). The observed yearly growth% a8 M, l+ `5 S) E
velocity was 30 cm (12 inches). The examination of
$ [( H. ?2 I# [. y( P' E; }; `9 Ethe neck revealed no thyroid enlargement.
9 O$ L6 n5 k  n2 N& |, b( wThe genitourinary examination was remarkable for- A, z" p8 t) Y
enlargement of the penis, with a stretched length of
% H7 Z* n% {! }2 q! J8 cm and a width of 2 cm. The glans penis was very well3 L% ]1 P$ z# r9 W  T
developed. The pubic hair was Tanner II, mostly around
" I1 Q4 {6 K2 q, G# l0 j540: O: P4 A! C5 x& Z4 J2 j6 Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 s1 O# y2 P0 H' N% V8 e0 ~the base of the phallus and was dark and curled. The
+ b. W) i9 l1 L& \# c4 \testicular volume was prepubertal at 2 mL each.
# I6 s8 S( R% ?( QThe skin was moist and smooth and somewhat
; U' v3 C  P" m3 @, C# b! ~oily. No axillary hair was noted. There were no
/ u3 L$ E$ T3 A) T# S+ Cabnormal skin pigmentations or café-au-lait spots.
; t: J6 E8 l0 k& r2 c: W5 ^3 RNeurologic evaluation showed deep tendon reflex 2+
. n7 ?! O7 v% c. F2 {  b$ Wbilateral and symmetrical. There was no suggestion
9 p4 K5 v4 c  Yof papilledema.0 r( U# V5 A% y/ a
Laboratory Evaluation3 S" K! Q! C2 Q# m1 n( n  P
The bone age was consistent with 28 months by3 g) J) e5 k# M; A
using the standard of Greulich and Pyle at a chrono-
( }8 ]. }+ I4 E' P/ J3 Elogic age of 16 months (advanced).5 Chromosomal
2 ^6 A7 a9 v# akaryotype was 46XY. The thyroid function test: i  b7 q+ K& @+ Y: H- X
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) F4 E/ k" m* d3 j0 e% p9 Olating hormone level was 1.3 µIU/mL (both normal).
( g% M' X; o7 f. i  p0 A9 VThe concentrations of serum electrolytes, blood
2 X' i1 i3 v6 p5 Durea nitrogen, creatinine, and calcium all were$ C9 p3 x6 m9 i! d8 v9 W, K
within normal range for his age. The concentration) T% F- F" D  }
of serum 17-hydroxyprogesterone was 16 ng/dL
0 N' P# i  e  C! I! L(normal, 3 to 90 ng/dL), androstenedione was 20
$ E9 h  W* s$ F6 R/ f. o$ D6 q& Kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# @; [9 p4 N  y: D( vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 T5 S$ o5 W$ w& n* e  s& |. O2 ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) V9 x1 h( K5 D# y0 r$ H3 o49ng/dL), 11-desoxycortisol (specific compound S)5 @9 X6 t6 j# e
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 ^3 n3 s' R4 m9 J& r+ r3 p& N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 o' h7 c/ U2 }testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; i  i, P! B% P( dand β-human chorionic gonadotropin was less than
2 O- c, x; g( I7 p5 |( j5 mIU/mL (normal <5 mIU/mL). Serum follicular
* e* w$ m, i3 d8 X  I) y/ cstimulating hormone and leuteinizing hormone% \2 \; v, k" t7 }. f6 w* v; P
concentrations were less than 0.05 mIU/mL$ I- N0 I5 R) V0 a5 [7 c
(prepubertal).
, r3 Q2 i2 `6 B5 }. t6 iThe parents were notified about the laboratory# K1 i+ }9 F( w5 r5 `/ B
results and were informed that all of the tests were
' m9 T0 S* ?4 ~1 W2 xnormal except the testosterone level was high. The
$ W* ?9 S+ h) V" Ufollow-up visit was arranged within a few weeks to
% t0 w, z. Q- W- f1 X2 W* Vobtain testicular and abdominal sonograms; how-
$ e# u. Z$ V1 B/ C4 ]ever, the family did not return for 4 months.
/ x, J8 _4 _& s9 [# TPhysical examination at this time revealed that the& w, {) i4 e/ N+ m" q
child had grown 2.5 cm in 4 months and had gained
5 O+ f% ]1 A/ z5 u* r/ {2 kg of weight. Physical examination remained
3 v/ _7 V6 ~8 }unchanged. Surprisingly, the pubic hair almost com-% w. @3 u: Q1 j" e7 _+ [
pletely disappeared except for a few vellous hairs at8 A6 |0 V0 p' G' u7 ~8 U6 W6 p
the base of the phallus. Testicular volume was still 2
9 x2 k- T! j5 {8 G* r$ Z. I* EmL, and the size of the penis remained unchanged.6 u* t/ e/ i+ d' j& @& j8 }1 W
The mother also said that the boy was no longer hav-
% }3 s. C/ G$ E: |# Z9 U. aing frequent erections.
& p- r  O  X  X9 w8 E5 _9 ]4 jBoth parents were again questioned about use of
3 j0 [$ z: u) x6 v" G9 w. R! aany ointment/creams that they may have applied to
; J1 Y! D6 e" hthe child’s skin. This time the father admitted the
' ]- J$ j. `. L* a4 c# }Topical Testosterone Exposure / Bhowmick et al 541  O/ O$ m% @! S+ y3 O; E
use of testosterone gel twice daily that he was apply-" Z2 U3 ^' c/ w% m' e
ing over his own shoulders, chest, and back area for! e* B6 o- W+ e% D" N  O
a year. The father also revealed he was embarrassed
4 _1 K0 S5 ^5 r* Q3 jto disclose that he was using a testosterone gel pre-8 a% O5 W- N  b! d# h! y# R- ^9 l
scribed by his family physician for decreased libido
' L+ V$ y0 ~# E) g7 W3 Lsecondary to depression.) F8 E; E1 M* @5 N6 h
The child slept in the same bed with parents.
) G# M& C) B* xThe father would hug the baby and hold him on his
  J  M+ B3 M# l$ i7 |' ychest for a considerable period of time, causing sig-1 ^, Q5 N; B8 c* ]; j: U
nificant bare skin contact between baby and father.5 H4 P& |/ l' p; m
The father also admitted that after the phone call,% o) _3 v7 B4 m$ I  o
when he learned the testosterone level in the baby! M" N2 s+ L7 K+ P# Y
was high, he then read the product information
; _) F; d' {. x: ]7 G4 r) Gpacket and concluded that it was most likely the rea-
, n" f1 x% ^& p8 e% n3 Uson for the child’s virilization. At that time, they# w/ e' E+ q9 V- U# R& n
decided to put the baby in a separate bed, and the
7 _- M% f  v" O9 S) A/ }father was not hugging him with bare skin and had
; t2 z) R/ ^& ], kbeen using protective clothing. A repeat testosterone0 a5 j' R/ @* D  a2 j
test was ordered, but the family did not go to the% o! Y* }5 O* h/ s% l7 z
laboratory to obtain the test.
# C' C! h. l* X( `Discussion! E' [7 H6 ~. t
Precocious puberty in boys is defined as secondary
4 D/ z( M+ d6 t2 Q; ssexual development before 9 years of age.1,4' R7 M+ t/ E( B/ S, P
Precocious puberty is termed as central (true) when6 o2 s9 H; k- ]
it is caused by the premature activation of hypo-
1 i3 a" Z$ i. P2 P0 bthalamic pituitary gonadal axis. CPP is more com-4 G& A3 v  t' S. W6 M6 Z' V8 I
mon in girls than in boys.1,3 Most boys with CPP
# I) i: f& M3 [# v" _; Gmay have a central nervous system lesion that is5 P% d# |  j3 `; q8 _9 ~4 R
responsible for the early activation of the hypothal-
$ V& z" O$ W1 O$ D0 \amic pituitary gonadal axis.1-3 Thus, greater empha-1 `5 X- I! G* z. p) y0 E
sis has been given to neuroradiologic imaging in
3 M! j& y6 C" gboys with precocious puberty. In addition to viril-. `* v" F/ z9 p8 l
ization, the clinical hallmark of CPP is the symmet-. j/ m" \6 g/ w- t; g# W1 N
rical testicular growth secondary to stimulation by
2 t! `; L. j4 D9 Q& {& _, G* Pgonadotropins.1,3/ x' M' d; I6 m3 |$ @1 M
Gonadotropin-independent peripheral preco-$ x- _% y; Y/ M4 f' p2 j$ t
cious puberty in boys also results from inappropriate) k4 H; S, s. W- G& t$ j- T( J$ q2 h
androgenic stimulation from either endogenous or
- f- Y# ^1 H) ?( }  E: Y( @exogenous sources, nonpituitary gonadotropin stim-! {% k( e9 R- C+ s. a+ ^. U
ulation, and rare activating mutations.3 Virilizing
4 i. ^' [! X4 l/ C! Y: ]congenital adrenal hyperplasia producing excessive* B. {  @- @8 v5 X/ f
adrenal androgens is a common cause of precocious
$ w2 k+ }8 S; d& rpuberty in boys.3,4
/ w) H0 M5 P5 |' t# j6 e$ m+ vThe most common form of congenital adrenal
0 N$ W* A! U) G* O* y( ehyperplasia is the 21-hydroxylase enzyme deficiency.  c0 M6 s; H1 X4 B3 j4 t9 F
The 11-β hydroxylase deficiency may also result in
6 e  J/ Y! H( _6 Y7 |excessive adrenal androgen production, and rarely,
4 l+ m' W2 S) D* a$ z. pan adrenal tumor may also cause adrenal androgen
/ {/ o9 g- M% P# E: A( L9 H" r7 |excess.1,3
$ ?' J: R" p8 u! B; ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 m# Q2 o; T. {: y! j, }+ U! C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( V% m- I  f; U/ t
A unique entity of male-limited gonadotropin-
3 e( I( F, t1 R9 b* C5 Tindependent precocious puberty, which is also known
# c7 @2 Z' R4 Pas testotoxicosis, may cause precocious puberty at a1 ]0 j; f/ b2 t9 ]4 H% P8 ]
very young age. The physical findings in these boys
/ S" S, I9 W  ]with this disorder are full pubertal development,
7 {/ W1 p5 a  R/ m' A/ uincluding bilateral testicular growth, similar to boys
  O2 ~& ^9 G( K; o* Hwith CPP. The gonadotropin levels in this disorder7 M6 B: R) `% p9 A9 O2 X* n
are suppressed to prepubertal levels and do not show7 l) {- m0 w0 b# {1 T
pubertal response of gonadotropin after gonadotropin-7 A+ }& K0 ^7 _. _$ b) y1 f5 T9 R
releasing hormone stimulation. This is a sex-linked- y# f4 a0 `0 \4 J1 ]% _3 G! ~* U4 q
autosomal dominant disorder that affects only) k. w% [& Y! l: e0 T
males; therefore, other male members of the family
  _$ z1 F3 k3 _0 Y) {1 zmay have similar precocious puberty.3
) r% u2 T) e9 N# _; {In our patient, physical examination was incon-
: J9 \9 N/ ?/ y4 N+ j3 hsistent with true precocious puberty since his testi-
$ \. j. n3 }1 m: E8 K1 X( f1 M0 a) ncles were prepubertal in size. However, testotoxicosis
" R2 x8 V: t* j6 j' P% hwas in the differential diagnosis because his father
2 {" w+ E' F: `; Q4 K, |: e) E* dstarted puberty somewhat early, and occasionally,
; ^, t# Z2 R! e( ntesticular enlargement is not that evident in the1 c0 p- B* O: d5 F8 Q
beginning of this process.1 In the absence of a neg-/ E, J/ x; C9 q( K( ~: {
ative initial history of androgen exposure, our; i6 n  v; ^" d! R0 @
biggest concern was virilizing adrenal hyperplasia,
% h, s) k. W0 j, ~either 21-hydroxylase deficiency or 11-β hydroxylase
# N7 r7 @. u: V" c9 Pdeficiency. Those diagnoses were excluded by find-+ b2 ^6 L$ y0 V* H4 r/ W  y+ Y6 E
ing the normal level of adrenal steroids.+ }. @! ~$ S8 Z& i0 D
The diagnosis of exogenous androgens was strongly
# ?, ?2 h! ?$ v9 x9 I* u9 r8 g+ ksuspected in a follow-up visit after 4 months because
8 q5 e, ]: J0 y# V$ Ithe physical examination revealed the complete disap-
. e! T8 n0 u" s6 G# Spearance of pubic hair, normal growth velocity, and
# T7 Q& _" x! Q4 F' u7 I, ldecreased erections. The father admitted using a testos-/ C* R# ?6 t3 q1 e3 S
terone gel, which he concealed at first visit. He was
' O  h: ]- T9 P* s. S# \using it rather frequently, twice a day. The Physicians’
7 s! F' e% x$ ]/ J7 xDesk Reference, or package insert of this product, gel or
/ s: N+ B( @9 R; ccream, cautions about dermal testosterone transfer to
$ B3 P% S1 i8 x3 |: ]9 Bunprotected females through direct skin exposure.. A1 ?7 ^2 i* l, ~) {
Serum testosterone level was found to be 2 times the8 r( \) h. M% a0 l! h
baseline value in those females who were exposed to
$ o) s' C( w; \' Xeven 15 minutes of direct skin contact with their male
2 B0 e4 C' H5 E# |! spartners.6 However, when a shirt covered the applica-
6 f+ ~3 u$ D) z5 htion site, this testosterone transfer was prevented.
6 E6 u# X) ~0 N4 AOur patient’s testosterone level was 60 ng/mL,/ p/ R* N2 j# U  K+ m4 V/ i) m# f
which was clearly high. Some studies suggest that
9 I2 n  R4 w7 l1 b9 d. s4 }# V$ i0 Zdermal conversion of testosterone to dihydrotestos-* L' e( t1 r! E
terone, which is a more potent metabolite, is more
+ B" X- w. W% m4 Tactive in young children exposed to testosterone, Q. L0 k2 j6 F, I" w$ i
exogenously7; however, we did not measure a dihy-
6 |. b- P7 [: M; Cdrotestosterone level in our patient. In addition to
5 s* ]6 j6 u* F# Qvirilization, exposure to exogenous testosterone in% [5 a/ `, x+ X
children results in an increase in growth velocity and$ h7 I% P& D5 G" |  h
advanced bone age, as seen in our patient.
, p# R2 a: R: U* K1 GThe long-term effect of androgen exposure during8 T7 a, k1 d) W- U# Z  z, Q
early childhood on pubertal development and final
% f  N' x* g, X5 hadult height are not fully known and always remain
0 z5 `* u7 s7 i' Z+ Ya concern. Children treated with short-term testos-8 |- E" C8 k. B6 L' W8 ?/ C6 s% k" W% n
terone injection or topical androgen may exhibit some1 |5 x6 F7 l* y+ D8 @, q% b7 R3 Z
acceleration of the skeletal maturation; however, after
  A% f0 e3 A: o9 f! M+ I/ U! ^cessation of treatment, the rate of bone maturation, D5 x' W* `" t' O: Y
decelerates and gradually returns to normal.8,91 C1 F- d5 b7 J" C
There are conflicting reports and controversy' C+ S6 @  ?! C* {( \6 @
over the effect of early androgen exposure on adult
/ W7 B/ k/ W. n" A) Kpenile length.10,11 Some reports suggest subnormal/ c* J+ E8 D7 w
adult penile length, apparently because of downreg-
/ p! R$ C3 ]; F1 eulation of androgen receptor number.10,12 However,& L) e+ r" V( c
Sutherland et al13 did not find a correlation between! `3 o2 N) U( T+ k7 ?& @2 P& v
childhood testosterone exposure and reduced adult0 f9 A( C& I1 Z2 g! N
penile length in clinical studies.
9 c" h( z& }% M' L/ R6 `9 Y2 V# qNonetheless, we do not believe our patient is
. g$ n8 ^. o3 ~7 N8 S0 S1 H0 k: vgoing to experience any of the untoward effects from
3 U' B, `. l9 o) a* M/ qtestosterone exposure as mentioned earlier because' n2 r- d0 S, f) D0 f
the exposure was not for a prolonged period of time." ~3 @% k  u: d; u" t
Although the bone age was advanced at the time of0 [0 ]3 v$ S; w# [' A# Z! ]
diagnosis, the child had a normal growth velocity at) C' ]. @9 Y2 U. i7 ~0 {3 o
the follow-up visit. It is hoped that his final adult1 n8 h" N3 I* P- E9 @2 j' m
height will not be affected., l" ^; f. {8 f
Although rarely reported, the widespread avail-
; w: \  Z+ a: M3 z- ^1 K  [ability of androgen products in our society may
! ?+ |8 }7 @, N: a# d9 @! Findeed cause more virilization in male or female) q$ M  F- |9 H+ X) R
children than one would realize. Exposure to andro-/ [) A# b# h/ `6 q% i/ L. q. n. G
gen products must be considered and specific ques-
6 Z2 ^" S5 J0 y9 G: Itioning about the use of a testosterone product or% N6 G4 L) I: F: D# c
gel should be asked of the family members during
5 @5 N5 M: E! J9 Qthe evaluation of any children who present with vir-
, q/ R" S) k# J! I8 ?ilization or peripheral precocious puberty. The diag-
% a  g8 F. _2 E, _0 P1 }# K- Hnosis can be established by just a few tests and by" p* X$ f1 N; O* z4 t
appropriate history. The inability to obtain such a
; m1 K/ V4 p$ q+ S4 K( M9 rhistory, or failure to ask the specific questions, may
" Y1 f  Z  }! F4 s5 k+ P# Tresult in extensive, unnecessary, and expensive
& C# J5 t  \. E' m, T) A  S! Zinvestigation. The primary care physician should be
( x# S. U2 D5 ~, U- T: e, zaware of this fact, because most of these children
3 M7 t+ K( r: y& vmay initially present in their practice. The Physicians’4 N1 D2 D/ `) P3 I
Desk Reference and package insert should also put a6 W$ K0 f! j' J* q& k; k
warning about the virilizing effect on a male or
/ P! Y7 d+ R! A# Ffemale child who might come in contact with some-2 Q/ a* K7 O6 Y; e
one using any of these products.% c% i( n, B0 g1 Q
References
# P% I6 y7 T8 e3 L5 |) D, f1. Styne DM. The testes: disorder of sexual differentiation& D7 B% d& C- R8 ^* c
and puberty in the male. In: Sperling MA, ed. Pediatric& b0 v4 s  i) R) A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: ?6 F; B; ~& S
2002: 565-628.
- u3 y/ G' X% N, g8 A1 R' k, C- H3 f8 |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* X; G* k, s, T  f$ @& y" _
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old' H, u; L7 l. M# c( `5 Z! O
Boy Induced by Indirect Topical- w: T+ X6 b% D7 Y. p
Exposure to Testosterone& a8 ^: ]/ I9 ?. G9 G  f/ w6 d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( L+ I& Z' j. S2 I$ q
and Kenneth R. Rettig, MD14 D- f; g3 d: D( G- Y
Clinical Pediatrics( ~6 r& x# b' r0 ]: x
Volume 46 Number 6
1 X. m6 ]. H' O- {July 2007 540-543
# Q7 ~  _$ v' x; M4 k" J8 x© 2007 Sage Publications
! m6 [2 h% k. @; U# A10.1177/0009922806296651
9 ^) i9 A  j( shttp://clp.sagepub.com
7 b" H% d9 R- N7 E/ s& W. {8 p% O: i2 X; Whosted at! T7 N. X8 q" t$ f% R
http://online.sagepub.com
$ T) S7 R3 t% X' h; B- J' @3 j1 WPrecocious puberty in boys, central or peripheral,# m1 X, q8 \1 D' K' Y$ Y
is a significant concern for physicians. Central
3 L& G  d4 @5 E# E3 Tprecocious puberty (CPP), which is mediated5 o. r" [5 n- F" ?, N( K7 ]
through the hypothalamic pituitary gonadal axis, has
" Q5 |; k, V0 y, f; v! r- @a higher incidence of organic central nervous system* g8 b, M) d- J" H! J$ v$ B
lesions in boys.1,2 Virilization in boys, as manifested
9 T7 k1 v/ J  O; D5 n5 k' {by enlargement of the penis, development of pubic( j; F  K0 y! _" O) h4 j! j# ^
hair, and facial acne without enlargement of testi-% ~( ?2 }2 r1 @. Y
cles, suggests peripheral or pseudopuberty.1-3 We% d5 k7 P1 s& S7 q* B' N; a
report a 16-month-old boy who presented with the
8 G! v; S% u( G/ qenlargement of the phallus and pubic hair develop-6 e& G( n: y& Q
ment without testicular enlargement, which was due
9 a. u$ g$ k4 ?: T* B  E4 Wto the unintentional exposure to androgen gel used by" Y7 n9 G9 C: D! Y( n# @
the father. The family initially concealed this infor-
/ M$ |8 t' U/ s' X& [mation, resulting in an extensive work-up for this
4 X4 m( {1 O; M) |/ Dchild. Given the widespread and easy availability of% @( `2 O& q7 a
testosterone gel and cream, we believe this is proba-
5 G2 T: ]5 a$ e" M7 i- Hbly more common than the rare case report in the
8 v4 h3 F4 Q# K% u* n4 Bliterature.4
4 L' I( ^, y) yPatient Report# B' v7 t! p5 J1 z4 i* l
A 16-month-old white child was referred to the
! o7 |2 M, N5 [& L) ]/ Q3 l$ ~) Aendocrine clinic by his pediatrician with the concern
) l' ]( @; ]) B0 Z1 jof early sexual development. His mother noticed( Z0 y9 k% R( O
light colored pubic hair development when he was+ n+ I: ~6 ~1 e5 u( j/ I, P/ X
From the 1Division of Pediatric Endocrinology, 2University of/ E+ b% r9 k  {7 ?
South Alabama Medical Center, Mobile, Alabama.
3 j" K, v( X+ G2 M$ rAddress correspondence to: Samar K. Bhowmick, MD, FACE,: X3 u$ S! c- A2 Z
Professor of Pediatrics, University of South Alabama, College of
" B0 L& C1 o# V" YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; Q8 G7 i" K, ]+ a2 l6 we-mail: [email protected].
( u7 v" F' r3 Kabout 6 to 7 months old, which progressively became( Y) b. f- E8 U  I7 ], n
darker. She was also concerned about the enlarge-
' l, H5 w( r" i) Ument of his penis and frequent erections. The child
! T) m0 F! o' b2 Ywas the product of a full-term normal delivery, with
1 Z7 c; D4 K4 x1 J* h/ ca birth weight of 7 lb 14 oz, and birth length of6 @% B* X( X5 m+ F1 q2 K
20 inches. He was breast-fed throughout the first year
4 O8 ]' B/ ?8 z  P$ Eof life and was still receiving breast milk along with
/ C! U. o, l! T! p5 {. j* }$ H( Ksolid food. He had no hospitalizations or surgery,
: s$ E: i: u9 zand his psychosocial and psychomotor development
$ U1 h( o8 M! Z0 p/ a2 [was age appropriate./ o% A9 ?* I" r! t. `
The family history was remarkable for the father,
0 f" K' t( B; Vwho was diagnosed with hypothyroidism at age 16,3 Q: S: v( [$ {$ S7 G3 M/ c
which was treated with thyroxine. The father’s: @0 s  G, {4 t6 i" }( U
height was 6 feet, and he went through a somewhat& g$ U4 B# r- Y1 N
early puberty and had stopped growing by age 14.9 t7 _# q/ i5 L7 n) m& H
The father denied taking any other medication. The
# d, a6 r% S+ i' d3 k, W! ]child’s mother was in good health. Her menarche1 V+ e4 a$ c* r: E
was at 11 years of age, and her height was at 5 feet7 J. [; U/ i9 f& O6 `/ i# K' b
5 inches. There was no other family history of pre-
4 W/ P- `) m5 G# m  v3 ncocious sexual development in the first-degree rela-
+ {! ^6 H6 m* Z$ ~1 F  }9 Otives. There were no siblings.
# j; b' `$ H% @7 ~0 `( o3 |Physical Examination
3 Y+ i) {7 W* M% P- F. cThe physical examination revealed a very active,
7 ]3 H$ D& s8 Hplayful, and healthy boy. The vital signs documented
  ~' s! N( H+ X" y: U6 Da blood pressure of 85/50 mm Hg, his length was" H8 W# k  h# z3 Z) j
90 cm (>97th percentile), and his weight was 14.4 kg
- v  K9 M* B- x7 g$ n0 i+ }(also >97th percentile). The observed yearly growth
+ F8 L7 K* |2 }' m$ @) z* cvelocity was 30 cm (12 inches). The examination of0 r+ g  n3 T& }# C$ B/ L7 X
the neck revealed no thyroid enlargement.
" f' j- v8 Z0 q0 ^The genitourinary examination was remarkable for& N2 d! |2 q- Z  e
enlargement of the penis, with a stretched length of" F0 P+ \; x0 N# \8 n
8 cm and a width of 2 cm. The glans penis was very well
6 k+ c0 B& I: U$ g: Adeveloped. The pubic hair was Tanner II, mostly around
7 ]$ C; \; q! Q: |  n4 e540/ ]% f5 ?: Q, Y  Q- i% j  B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  |8 h: Q3 r9 `7 F3 a3 f/ C
the base of the phallus and was dark and curled. The
( z* x/ F2 f  y, xtesticular volume was prepubertal at 2 mL each.
8 |, X/ V6 N! i* X! Z* j* rThe skin was moist and smooth and somewhat' q0 q. ~. S+ Q+ m
oily. No axillary hair was noted. There were no7 U; x# w: g) U# g- R% e
abnormal skin pigmentations or café-au-lait spots.
+ z2 `; D. \/ g9 P; Z, E. t/ J3 ~4 sNeurologic evaluation showed deep tendon reflex 2+6 x8 P( M, w) e
bilateral and symmetrical. There was no suggestion
3 d, Q5 M. j& fof papilledema.6 b& F; |. m* l
Laboratory Evaluation
2 B  h0 `$ D. \The bone age was consistent with 28 months by
9 n, h2 M0 \& `  o" Lusing the standard of Greulich and Pyle at a chrono-
- R2 Y  k9 U3 j+ f5 g* hlogic age of 16 months (advanced).5 Chromosomal9 g( W# W+ ]: V% W: D8 }* A
karyotype was 46XY. The thyroid function test
# j7 D' k1 `- ?/ J* ~showed a free T4 of 1.69 ng/dL, and thyroid stimu-* d8 B$ k4 B8 g9 G/ X
lating hormone level was 1.3 µIU/mL (both normal).
; w" t( n; o2 Y7 a+ e+ EThe concentrations of serum electrolytes, blood
  Q2 a4 B- ~7 S% T; }urea nitrogen, creatinine, and calcium all were
8 b$ ]" z- X  U% p% B6 Z; g$ cwithin normal range for his age. The concentration
# [- S( ^- j4 o: A" Lof serum 17-hydroxyprogesterone was 16 ng/dL) V# Y  y/ l5 {% [* y
(normal, 3 to 90 ng/dL), androstenedione was 20
: d6 t1 f9 l: H) Y8 Q! kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 L- V' B/ \( q+ gterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, X2 B0 m. ~" Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to* U0 b& w* Q' S2 f' a  J! X
49ng/dL), 11-desoxycortisol (specific compound S)
. V  P' [# t. x- q: s' \5 N9 Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 {8 }1 U9 e& htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 O$ [' i" f. @  k" P  S$ N! Y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 b0 ]2 k% a% P: ~' X8 Tand β-human chorionic gonadotropin was less than
6 z: q9 U: Y& v6 Z/ t7 ]5 mIU/mL (normal <5 mIU/mL). Serum follicular
( H0 T0 Z* Q% E+ \# v5 ^/ |stimulating hormone and leuteinizing hormone
' K; d) @, W* a6 Uconcentrations were less than 0.05 mIU/mL; I! B4 C& {5 H: b. y9 c, B
(prepubertal).& M. [& J' y& C
The parents were notified about the laboratory
: ?+ f% i1 y, ?results and were informed that all of the tests were! ?) \6 g' J2 ~0 }) i. ^6 [
normal except the testosterone level was high. The( W3 q4 M, P& e; H: d: `# N& o$ n# `
follow-up visit was arranged within a few weeks to
% _" y" e& B5 @) \+ Fobtain testicular and abdominal sonograms; how-! K( e; w' z* X2 v0 i+ W) _/ G
ever, the family did not return for 4 months.8 f& X: S" r8 }$ ?
Physical examination at this time revealed that the% l0 x- n/ j, p2 R+ t& B: H
child had grown 2.5 cm in 4 months and had gained
5 ]; H* o: X# Q' M5 g2 kg of weight. Physical examination remained% o% P- x" B# b
unchanged. Surprisingly, the pubic hair almost com-
% J7 X* w$ m( A" F4 m. R+ qpletely disappeared except for a few vellous hairs at! T2 h$ P& w2 q; n
the base of the phallus. Testicular volume was still 2+ \- K/ [; e- u
mL, and the size of the penis remained unchanged.2 c3 @- n; e" _
The mother also said that the boy was no longer hav-1 m: Z& @3 G. {1 |/ y  g  o" U7 e4 E+ J+ \
ing frequent erections.
: G% M! u, h/ Z& fBoth parents were again questioned about use of
; ], p! a% f8 F& I$ f$ J" v9 j3 k0 Zany ointment/creams that they may have applied to, M* P  K; F' t$ x7 \1 X
the child’s skin. This time the father admitted the
: |3 p+ j( |: o  L# e4 g) M  XTopical Testosterone Exposure / Bhowmick et al 541! V1 u9 ?2 C9 ]
use of testosterone gel twice daily that he was apply-
( r1 D3 F, _, t6 K6 Hing over his own shoulders, chest, and back area for. `- S: @. B$ ^5 G# V3 w1 n
a year. The father also revealed he was embarrassed5 o, x7 \& a, k. [& s3 Y) X
to disclose that he was using a testosterone gel pre-
- J0 x. H% ~. }" hscribed by his family physician for decreased libido  O9 ^1 T! p, M
secondary to depression.' f6 ]0 z& r4 H
The child slept in the same bed with parents.
( o' K$ o6 b) D* r' \The father would hug the baby and hold him on his
+ e; x3 o$ W' ~2 X. ~chest for a considerable period of time, causing sig-& p7 R/ [* a; W
nificant bare skin contact between baby and father.
. Q4 w- S$ _# A6 L; [The father also admitted that after the phone call,# m0 |9 E/ [) F" l3 r( E5 r
when he learned the testosterone level in the baby% s  W8 V( i; o# Q4 l2 q  l
was high, he then read the product information
" B1 z2 G2 j+ J! h9 u# c) e; Zpacket and concluded that it was most likely the rea-, q/ _3 d0 V3 x/ G$ q
son for the child’s virilization. At that time, they8 X) x" u. i; L7 ]% E3 z5 d8 [8 ~
decided to put the baby in a separate bed, and the; Y' _- P' g$ F( g( m8 i
father was not hugging him with bare skin and had
9 p/ Z, F6 [6 u* Zbeen using protective clothing. A repeat testosterone
+ @$ O: ]9 I+ z5 h( k( dtest was ordered, but the family did not go to the
/ \0 r) }; o! b% v" @( V8 Tlaboratory to obtain the test.
3 i6 R: s# B9 c5 U5 @. [8 P/ NDiscussion
& t. T5 Y1 Y( n9 APrecocious puberty in boys is defined as secondary
% Q0 T8 _# K* C; Usexual development before 9 years of age.1,4+ {. d' v! U5 [7 Q2 B" g
Precocious puberty is termed as central (true) when
& j, J; q) h5 ]  `- `. y1 Rit is caused by the premature activation of hypo-' [+ J% n: S* o% T7 D. Q
thalamic pituitary gonadal axis. CPP is more com-' S5 A8 X" Y/ R( C9 `
mon in girls than in boys.1,3 Most boys with CPP
1 t( u. P7 x2 ?9 o  P% R& ^may have a central nervous system lesion that is2 j; k) b/ V- L" a
responsible for the early activation of the hypothal-+ p! H$ k% {* I  }7 u
amic pituitary gonadal axis.1-3 Thus, greater empha-
( e5 p& z# K% [sis has been given to neuroradiologic imaging in
4 M4 T8 L4 K2 V7 s$ cboys with precocious puberty. In addition to viril-
, ^! Z0 Y, [/ v& K" uization, the clinical hallmark of CPP is the symmet-
  H, R3 |; z3 t% Crical testicular growth secondary to stimulation by
4 r! ?3 X+ }# ^0 Qgonadotropins.1,3
* }5 Q8 t$ y4 X% w1 u7 rGonadotropin-independent peripheral preco-
5 t+ k) ^. |; ?cious puberty in boys also results from inappropriate
/ P. c  J; i/ c" `6 sandrogenic stimulation from either endogenous or. c/ J5 A- o8 t5 v5 X2 n
exogenous sources, nonpituitary gonadotropin stim-; y4 U8 Q# k' G+ \7 S5 A
ulation, and rare activating mutations.3 Virilizing0 i0 b1 k6 V, w- o2 ^
congenital adrenal hyperplasia producing excessive
1 O$ D6 Y- E1 M6 O5 {adrenal androgens is a common cause of precocious
5 K- U+ s0 k" ?2 vpuberty in boys.3,4
& {. y$ r4 S% o) x3 A: BThe most common form of congenital adrenal
& c" p: r) P" W7 P% f5 @* ^hyperplasia is the 21-hydroxylase enzyme deficiency.
/ s- \: F: Q. G; @/ R5 zThe 11-β hydroxylase deficiency may also result in- `2 O+ B! }& Q0 \! r7 b3 ]' X
excessive adrenal androgen production, and rarely,$ q2 v) j  A; c% X( H9 F
an adrenal tumor may also cause adrenal androgen0 B: C* D) W+ x
excess.1,31 c( Z$ I/ a  a) q3 K. r2 U2 I, n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 m1 B: T8 ^0 X8 U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ P6 Y% n: b: n+ uA unique entity of male-limited gonadotropin-
0 e4 {4 C5 P7 yindependent precocious puberty, which is also known5 F& B" w; b" j5 T
as testotoxicosis, may cause precocious puberty at a
$ M$ D0 V: S" ~: Cvery young age. The physical findings in these boys
3 H3 p4 M, N) V$ owith this disorder are full pubertal development,% j2 ^6 Q* r+ }+ e; U$ l
including bilateral testicular growth, similar to boys
7 ]' o( R9 m$ W$ h2 |with CPP. The gonadotropin levels in this disorder
0 b, s+ J" I' b% ]: t% H- a: |are suppressed to prepubertal levels and do not show
& C% S% d) Y6 n; opubertal response of gonadotropin after gonadotropin-
; L: g$ V# ?/ K3 Mreleasing hormone stimulation. This is a sex-linked
5 ^/ z7 t0 M$ |( c+ Lautosomal dominant disorder that affects only1 b, v9 V" Q4 T4 h9 B4 U
males; therefore, other male members of the family
1 h- c$ X5 @" g  vmay have similar precocious puberty.36 w7 |  N- i- c' E& p* h6 n
In our patient, physical examination was incon-% E& I% K& _. f) F( a" T; J0 h
sistent with true precocious puberty since his testi-
% r9 ?0 J! D4 M% J; i( t$ Jcles were prepubertal in size. However, testotoxicosis; Y: u. ~: A; ~  G: l
was in the differential diagnosis because his father& O3 o* v' h% s3 U# l3 h* C8 S
started puberty somewhat early, and occasionally,& G( G1 C5 N6 z( \) P' X% u" F5 Q
testicular enlargement is not that evident in the
% R& P& d4 l/ g; P* l2 vbeginning of this process.1 In the absence of a neg-
6 P9 ?$ Y/ M2 H) W# w, T; N7 l9 ^ative initial history of androgen exposure, our
2 T$ T. c5 q2 U% r9 u0 Obiggest concern was virilizing adrenal hyperplasia,
' F0 f" ^6 b! q2 e5 r9 Ieither 21-hydroxylase deficiency or 11-β hydroxylase
. `* N$ V# R# C, ^9 a/ I) U: U# ldeficiency. Those diagnoses were excluded by find-
! Q* w+ b' R9 W; Qing the normal level of adrenal steroids.4 N0 x0 c+ }7 x: L8 k4 x* c
The diagnosis of exogenous androgens was strongly/ _0 R, r9 [9 f: W
suspected in a follow-up visit after 4 months because! o% k; Y8 M- l: J% ~
the physical examination revealed the complete disap-
+ y( x' c' g" |1 G$ \pearance of pubic hair, normal growth velocity, and
1 Q9 U8 R9 {1 ~9 X: sdecreased erections. The father admitted using a testos-5 ~- e. G, x: F8 J: n+ p
terone gel, which he concealed at first visit. He was! G/ z( B- K5 q
using it rather frequently, twice a day. The Physicians’
, x" w' W, C* n" {/ D2 [3 ~# CDesk Reference, or package insert of this product, gel or7 P* A# s; v+ J/ B5 S/ Z
cream, cautions about dermal testosterone transfer to3 J( y( J1 {5 G, \- z0 H: K7 `
unprotected females through direct skin exposure.
# F; }1 c& p2 v  ~. Q3 U" w' TSerum testosterone level was found to be 2 times the
8 C0 O: x1 N" ~* n7 ]baseline value in those females who were exposed to
+ e( r4 c8 p; Neven 15 minutes of direct skin contact with their male
6 Z6 Q  G' s% Y( J! r) B% b2 D0 opartners.6 However, when a shirt covered the applica-
9 P+ a9 d. ^+ |! |8 {  Mtion site, this testosterone transfer was prevented.' L+ T. K8 ], P; w; @! _+ _
Our patient’s testosterone level was 60 ng/mL,6 }5 m; i. |0 k( l* u: l9 ]2 Z2 l
which was clearly high. Some studies suggest that
0 \4 e# J! @+ z& I- G, Hdermal conversion of testosterone to dihydrotestos-( ?- M4 V3 V) U# E8 H; z0 U' v. ^7 z
terone, which is a more potent metabolite, is more, A' h5 x: d5 f$ Q' f: w4 [4 m0 [  b& g
active in young children exposed to testosterone- U- E) J& j; c. ]9 i% ?
exogenously7; however, we did not measure a dihy-! ?( ?  l3 I" [4 W; {& w( C
drotestosterone level in our patient. In addition to& R2 i) T( P* Q& w4 ]* C( w
virilization, exposure to exogenous testosterone in9 E6 t8 f3 n7 H/ z2 S6 E. N
children results in an increase in growth velocity and& K+ ?- W- o0 S2 j4 {7 L$ g  i
advanced bone age, as seen in our patient.
) H! U1 R, Q* {* z1 d6 _The long-term effect of androgen exposure during' y5 E# k4 [& `# c
early childhood on pubertal development and final
0 l4 S3 P, l# ?( j* d. [' n& Radult height are not fully known and always remain
4 x1 E, i0 n* B, X' e/ u1 ?' v8 ya concern. Children treated with short-term testos-% F: r: `* j2 W' \  u' Y5 w
terone injection or topical androgen may exhibit some- t8 ?# i5 O$ j' M2 i) z' X5 k4 k% b
acceleration of the skeletal maturation; however, after
( A# |7 R; X9 u6 R! C! H6 ^$ Scessation of treatment, the rate of bone maturation
3 c7 W  W$ B& O9 ?3 `decelerates and gradually returns to normal.8,90 n- a/ ], i# Q5 e' M
There are conflicting reports and controversy, c" |8 P* J: \  u
over the effect of early androgen exposure on adult- _5 ?" z" _# |- g, R
penile length.10,11 Some reports suggest subnormal
- U, U) I& k, l+ B+ o$ `adult penile length, apparently because of downreg-# s" Y- _4 ~4 `# G4 s0 S
ulation of androgen receptor number.10,12 However,
0 e0 S8 r% ]* n: k% o) r9 y% ^Sutherland et al13 did not find a correlation between
% n7 @: ?% L% [childhood testosterone exposure and reduced adult* `' a+ _) o3 W5 H
penile length in clinical studies.
4 c# V2 M# f7 h9 P5 k+ Z! f1 ?Nonetheless, we do not believe our patient is
+ K/ q* j& @3 e6 ^going to experience any of the untoward effects from) w6 w% Z2 m1 C' }
testosterone exposure as mentioned earlier because
' O! ^% v+ ?1 |1 ~4 ?the exposure was not for a prolonged period of time.
% v& W2 H$ d/ K( M* JAlthough the bone age was advanced at the time of- }- Z" {# q2 I' ?
diagnosis, the child had a normal growth velocity at) C* ~+ U4 r8 U# }9 F  W) K" G
the follow-up visit. It is hoped that his final adult. ~/ n$ |4 H( q! D6 _% i
height will not be affected.
' |9 w# c# L- t/ [  j8 |Although rarely reported, the widespread avail-
/ P6 t9 M+ a/ V: z1 |3 Zability of androgen products in our society may" A8 [; m1 }% A0 [8 J4 Y
indeed cause more virilization in male or female0 P( B) o  I7 h7 d, b( t( O
children than one would realize. Exposure to andro-& j2 Z7 C" ?1 b1 K6 n2 F
gen products must be considered and specific ques-
# S0 g6 d+ ?1 ~! Ltioning about the use of a testosterone product or
1 O* H( T2 Z7 fgel should be asked of the family members during
2 M. v1 _; Q! F4 ^4 l2 B4 Tthe evaluation of any children who present with vir-9 k0 @4 Q1 C: P0 F7 R$ ~$ C
ilization or peripheral precocious puberty. The diag-; X0 b  p4 {: G1 |
nosis can be established by just a few tests and by- A0 V8 T3 r+ {: e$ w; s
appropriate history. The inability to obtain such a
$ `& ^2 K- }2 e$ @history, or failure to ask the specific questions, may% W* j3 w1 P9 v. t1 E/ j/ p
result in extensive, unnecessary, and expensive
% W2 s8 f3 A, Q: b; o8 Minvestigation. The primary care physician should be
/ E  X6 k0 O4 @aware of this fact, because most of these children
% b$ j- x- R8 F1 p' b: cmay initially present in their practice. The Physicians’+ ]4 M, U* M# E3 A& X+ B# G2 v
Desk Reference and package insert should also put a1 F+ x1 ?8 f6 J4 z2 U+ U0 e' t4 H2 ~
warning about the virilizing effect on a male or/ F  u8 F# N0 P& ?- `0 O, f! _
female child who might come in contact with some-1 v" V/ K3 b3 m( j7 S$ p  Q1 ^# _- j# z
one using any of these products.
- q: {' j4 Q6 C# W9 g1 F, RReferences
2 \9 ], q; d8 w( Z$ U: Z% Q1. Styne DM. The testes: disorder of sexual differentiation. N, k# F$ d% P2 l0 u' a$ L
and puberty in the male. In: Sperling MA, ed. Pediatric
& v9 c, S' r$ B/ wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" M+ O0 i" T9 M+ V  l: H2 `6 j2002: 565-628.! `: A5 C) q5 W/ j$ d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 s3 x0 F( {2 g! c; V3 b) k6 E8 A
puberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
. W) V* s3 M- I: v: {* i  E
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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