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Sexual Precocity in a 16-Month-Old
) N* @1 a- ]9 o2 nBoy Induced by Indirect Topical
8 u1 b$ j: {7 F7 }! \Exposure to Testosterone2 L9 K& A+ c6 K) Z1 a
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& j( {" b; P# d& ~. Y  [and Kenneth R. Rettig, MD1# u  I- h9 D* Y) B  |
Clinical Pediatrics& T, N/ C% a( ^+ e8 o0 o
Volume 46 Number 6
5 g$ `3 B7 S7 p/ B5 ?% P  P- d& r! @July 2007 540-5438 h+ H; @5 u; E- L) i+ T5 _6 Y! S
© 2007 Sage Publications( _  K7 x1 ]9 k, _3 H2 {( D
10.1177/00099228062966518 |+ K9 f5 S$ p. @1 X. H$ q5 D
http://clp.sagepub.com
, f- l6 K4 u/ w0 N: z$ hhosted at/ i1 x  v' {* O  c: @" L+ c
http://online.sagepub.com
- ?! r! S2 b, W* k, XPrecocious puberty in boys, central or peripheral,
# X4 f; [! j: T6 U& yis a significant concern for physicians. Central
. N/ c( ^) q6 fprecocious puberty (CPP), which is mediated1 k/ y- L5 e2 p' [& S4 `
through the hypothalamic pituitary gonadal axis, has
( k/ u+ t1 s2 p# P4 Ua higher incidence of organic central nervous system
  h1 F4 v& [4 z3 ]5 L& Mlesions in boys.1,2 Virilization in boys, as manifested( z) m- c* l3 O& w) `) e9 a
by enlargement of the penis, development of pubic
1 _! I9 ~: j# W2 K+ H. khair, and facial acne without enlargement of testi-
( @5 N. b- b+ }% U2 V: Q& acles, suggests peripheral or pseudopuberty.1-3 We2 J& P; v; ?+ w2 h* F% G6 l" r
report a 16-month-old boy who presented with the' [4 y* V0 }) |- h8 u5 M1 b
enlargement of the phallus and pubic hair develop-
, i8 l6 A' x- e1 y) Nment without testicular enlargement, which was due
7 _/ ?- F$ `, D) k6 Pto the unintentional exposure to androgen gel used by1 ^3 r' l: y1 L7 ~' g
the father. The family initially concealed this infor-
$ W0 p- h( Y8 smation, resulting in an extensive work-up for this
' P2 F+ k# o7 o0 d) Z6 gchild. Given the widespread and easy availability of
  Z- L. [0 m% p( o& }testosterone gel and cream, we believe this is proba-
3 }' p7 i# `4 W& B: X* Jbly more common than the rare case report in the
: w9 P' E3 ?/ n$ Y, c, R8 [literature.4) C7 [' Z  ]+ H, p" n/ F, m
Patient Report/ U. Z7 R8 d: B  @% u
A 16-month-old white child was referred to the
8 D( j  h: m& y! V9 Nendocrine clinic by his pediatrician with the concern
$ I% O0 k, u! y  ^! C- t1 [( cof early sexual development. His mother noticed
+ d0 s, b: r0 p. w& N' S! S6 p8 v; Rlight colored pubic hair development when he was( I* z! p6 ]# k3 ~
From the 1Division of Pediatric Endocrinology, 2University of
1 G: z5 M) B8 W! Y  N! hSouth Alabama Medical Center, Mobile, Alabama.* C& p; s# y3 {+ {: W8 W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 S  u8 r0 \$ a- s8 T! y( gProfessor of Pediatrics, University of South Alabama, College of
7 @1 V0 m, y; |( ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# B5 Q* m: O! B7 r; g  y( _
e-mail: [email protected].
; R/ G$ T3 O: c4 d3 Y. Vabout 6 to 7 months old, which progressively became
( {* o# \" `8 \darker. She was also concerned about the enlarge-
2 U7 a* [: L7 \" ^* u4 J3 G# T; Nment of his penis and frequent erections. The child
1 |0 ~% H' m3 d' u1 zwas the product of a full-term normal delivery, with
; F: [9 _5 n) ]" x, }8 P9 T! `a birth weight of 7 lb 14 oz, and birth length of
6 J- Z( p+ T7 ~* y20 inches. He was breast-fed throughout the first year
( j' x* n' m8 |  Iof life and was still receiving breast milk along with) L! ^' W! T; X3 ^3 `6 _4 E
solid food. He had no hospitalizations or surgery,
( t# n6 c% h9 a1 K2 U: S6 o8 _and his psychosocial and psychomotor development
% P) L  X2 K0 J6 e8 o3 Lwas age appropriate.6 ]; W$ q  w$ h
The family history was remarkable for the father,7 o6 n* _* v( ?$ f; G- N, R
who was diagnosed with hypothyroidism at age 16,% h8 |! V% g  I4 `2 z* c# I; J
which was treated with thyroxine. The father’s
9 w$ o" A; g( M9 ~" Pheight was 6 feet, and he went through a somewhat7 Y3 k$ c/ C6 [7 p5 o) v1 x8 \/ i' g
early puberty and had stopped growing by age 14." t$ u1 `+ Y+ `2 x$ E# D
The father denied taking any other medication. The
5 [5 E/ Y/ F  J' E% t7 ochild’s mother was in good health. Her menarche
1 j# _) w( ?  hwas at 11 years of age, and her height was at 5 feet
. c) Y+ [) b0 x+ C0 _* H' S6 q. O5 inches. There was no other family history of pre-8 p% E2 O7 {! l0 G4 [
cocious sexual development in the first-degree rela-
# {9 ]" U8 a* |+ htives. There were no siblings.
  j7 G- ~7 p  D1 ]( bPhysical Examination8 Z5 Y% _* l# M- m7 }* ^* l
The physical examination revealed a very active,5 m+ Z( M# f( h. [) s. M) u5 N
playful, and healthy boy. The vital signs documented
/ t% Q& F. S2 v" ~% j; Ua blood pressure of 85/50 mm Hg, his length was$ a8 F  ~" C/ }& ?/ M3 `  o
90 cm (>97th percentile), and his weight was 14.4 kg- s7 b$ }3 m& U# F/ E, d- m" W
(also >97th percentile). The observed yearly growth! E/ c9 {  L# Y) j
velocity was 30 cm (12 inches). The examination of' L& w4 j$ B* w3 ?6 V; [
the neck revealed no thyroid enlargement.
8 W- Q7 y" Y, lThe genitourinary examination was remarkable for/ S* Y3 |9 S2 \  R( @5 Z2 |) b6 i1 s
enlargement of the penis, with a stretched length of& V# Z; M& _. Y2 T
8 cm and a width of 2 cm. The glans penis was very well
. z5 R+ c# S$ C8 I* T4 q  ?! ]developed. The pubic hair was Tanner II, mostly around
" N4 }' i! W+ ~* ^540
3 K$ l7 |6 Y& {/ `4 f" Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 }. r- ^# ~$ p! w1 K1 Cthe base of the phallus and was dark and curled. The
, |' Y9 Q0 v8 J$ btesticular volume was prepubertal at 2 mL each.. g( C# r- o: M+ @. D% n6 \/ j6 w
The skin was moist and smooth and somewhat0 ?* |3 C5 F: }4 Y" _
oily. No axillary hair was noted. There were no3 y9 |7 m6 f0 Z" V6 d, t( r8 ]) j
abnormal skin pigmentations or café-au-lait spots.
3 n+ ^  N! i/ |5 Y, d$ O* W# u" B% oNeurologic evaluation showed deep tendon reflex 2+
/ w0 `! r8 l3 b2 sbilateral and symmetrical. There was no suggestion
( z5 \8 c# S& S# m) Z  ?1 p1 Xof papilledema.
2 K- b  q6 \9 D& i  [6 v3 TLaboratory Evaluation1 m; K' e# f& X# M6 p6 v# d
The bone age was consistent with 28 months by
3 O  h6 v  @6 Z, Q7 _using the standard of Greulich and Pyle at a chrono-* d( b: Z+ H* T2 H' f7 o
logic age of 16 months (advanced).5 Chromosomal% E7 h0 A2 }+ _& i( j  n" m
karyotype was 46XY. The thyroid function test6 a& j/ h) _& m2 k! H9 @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ x3 O9 f4 U4 d! K; E; M' a
lating hormone level was 1.3 µIU/mL (both normal).) u3 _+ V* ]6 u8 }
The concentrations of serum electrolytes, blood
! g# O1 U5 |& K+ R1 U- S' d$ \' gurea nitrogen, creatinine, and calcium all were
7 h8 n( M$ R" \2 K5 ~6 Awithin normal range for his age. The concentration
0 I6 O& s( y: ~, Oof serum 17-hydroxyprogesterone was 16 ng/dL
- |' e2 Z* i" H. M5 U+ R  z% ^5 J(normal, 3 to 90 ng/dL), androstenedione was 20- f2 c+ e9 J$ m+ J0 ?; m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; ]" @5 ?9 {+ ^5 I- Z( w/ x+ `, Y9 `terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ d% @) `- K% g; y( W* s. ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" n, g8 O' {- s1 b$ a5 F' q49ng/dL), 11-desoxycortisol (specific compound S)& ^; A' [! t6 t8 N. p- M. p" r- ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 @) N8 \5 A+ i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) v/ Y4 S, Q5 u% P( Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),% T9 s4 `. ]6 _
and β-human chorionic gonadotropin was less than$ r2 J" o6 p1 `8 x% Z! C, H' c
5 mIU/mL (normal <5 mIU/mL). Serum follicular. A  u' Q) Q" _* J! c8 F
stimulating hormone and leuteinizing hormone* a: X9 K% X9 e9 P, ?2 A: m/ h
concentrations were less than 0.05 mIU/mL! V6 Q9 |. R: R: H% A
(prepubertal).
' Z9 C( z& U, I; Y* h" rThe parents were notified about the laboratory
, {2 E4 L3 _6 {5 K9 C6 Jresults and were informed that all of the tests were; @6 c- b5 F% ]) ?$ [/ S
normal except the testosterone level was high. The% T+ t; C6 |3 D' n3 v* j
follow-up visit was arranged within a few weeks to3 j) J9 ~6 d& \! F
obtain testicular and abdominal sonograms; how-8 _2 G' d! v7 e- p9 a) T
ever, the family did not return for 4 months.  f3 K. P, e! ?
Physical examination at this time revealed that the
0 x- h4 u$ \6 M1 z; i% l5 G# C1 Nchild had grown 2.5 cm in 4 months and had gained0 q5 u) k0 K- T7 t3 t
2 kg of weight. Physical examination remained* e. _, k: ], U" z
unchanged. Surprisingly, the pubic hair almost com-& u# _$ F7 z6 H; Q$ T! T
pletely disappeared except for a few vellous hairs at
: n3 M, A8 G: |6 Y# q$ x, l* V2 j  H5 [the base of the phallus. Testicular volume was still 2% m2 o( ^( K; W- r
mL, and the size of the penis remained unchanged.
5 Y8 G; p( M0 u" o$ G1 pThe mother also said that the boy was no longer hav-
' }8 `9 o) V4 x) qing frequent erections.+ ^) H- y# c7 z' L* E7 }. P
Both parents were again questioned about use of) B. b, M" @* g' m* K
any ointment/creams that they may have applied to8 u# O% k5 z! A( n
the child’s skin. This time the father admitted the
1 A! _$ V* X4 K# R  TTopical Testosterone Exposure / Bhowmick et al 541
7 `; L: {2 P* v* q5 Y2 a/ x8 Kuse of testosterone gel twice daily that he was apply-- P1 d3 Y* m) Z& `
ing over his own shoulders, chest, and back area for* |/ `  [" J* P& t( a% Y- A5 i
a year. The father also revealed he was embarrassed
( d: e9 f5 |- |; v& y+ Oto disclose that he was using a testosterone gel pre-1 A$ E$ k/ S! i3 \# l
scribed by his family physician for decreased libido2 X: {, ^, s0 n1 S
secondary to depression.0 G& Q7 v; w. _, @; i* G9 E1 n
The child slept in the same bed with parents.
7 j, h2 |4 ~+ v7 CThe father would hug the baby and hold him on his# ]7 C8 M5 a" o) y+ H2 Y" I
chest for a considerable period of time, causing sig-
  y' V, I" A( d! e' C# i! Knificant bare skin contact between baby and father.
6 N, s: r  V7 z( J5 ]The father also admitted that after the phone call,/ J8 ~5 p% l5 T9 U4 m' s9 e
when he learned the testosterone level in the baby$ y5 i! n% Z; S) `. B6 A
was high, he then read the product information
5 I. J( W9 }3 a  U& G* b# X+ y3 Cpacket and concluded that it was most likely the rea-7 b& L5 Q6 c( h  f: c% @
son for the child’s virilization. At that time, they
' }" n; z$ J% [' F3 Wdecided to put the baby in a separate bed, and the: f1 h0 ]  p5 Q8 Q' C7 d
father was not hugging him with bare skin and had
1 I5 g3 s, \" t- L  |" f% d9 Obeen using protective clothing. A repeat testosterone) }$ W4 J% }: w& M) N
test was ordered, but the family did not go to the
' ~  J" F7 ?4 jlaboratory to obtain the test.
$ }  n% [/ J% E$ n/ ~Discussion
  N% ~) B. F; C$ M1 YPrecocious puberty in boys is defined as secondary5 K( K+ h  n& \3 v  m+ D9 ~
sexual development before 9 years of age.1,4
; Z/ }3 O: V9 ^3 Y: Y; n2 qPrecocious puberty is termed as central (true) when
' h, r9 Y1 L" Yit is caused by the premature activation of hypo-
' J# g& w" U9 Y, s" c% R2 o8 ]thalamic pituitary gonadal axis. CPP is more com-
$ p) R1 w" Z$ z: u; t/ c" ~) f% rmon in girls than in boys.1,3 Most boys with CPP, p) ~5 N9 o4 H; J3 l% d# |
may have a central nervous system lesion that is
- `1 K4 {) N7 K6 A; {% uresponsible for the early activation of the hypothal-
. ^, `% t- W: a9 Famic pituitary gonadal axis.1-3 Thus, greater empha-* x4 y5 r& h& J: s1 X" y
sis has been given to neuroradiologic imaging in9 f3 G1 @: w/ E2 v
boys with precocious puberty. In addition to viril-
  S# U7 R: B1 N( Q2 ^/ y& aization, the clinical hallmark of CPP is the symmet-
1 p0 |% h- Q7 x: U9 Frical testicular growth secondary to stimulation by
3 n+ t* U% {$ a5 F/ }) K9 ?gonadotropins.1,3
. |. m# R; w3 w: rGonadotropin-independent peripheral preco-
4 {* n, `: j! c5 ~4 ccious puberty in boys also results from inappropriate% Q2 X, v' \3 P- c, M
androgenic stimulation from either endogenous or
2 P) N0 S: a1 ^6 m4 C* X- c! S1 dexogenous sources, nonpituitary gonadotropin stim-
. j! O+ H9 D$ |! ?ulation, and rare activating mutations.3 Virilizing
, B8 N, _  Q3 X3 R, ycongenital adrenal hyperplasia producing excessive
' y; Y, L- w. ?0 Z9 _! p, [adrenal androgens is a common cause of precocious
# O4 v' O3 P1 d$ u3 A# F+ @puberty in boys.3,4
4 O) i$ p2 j3 g- T% S: ^9 L9 ]The most common form of congenital adrenal
8 Q) ~" B7 b& fhyperplasia is the 21-hydroxylase enzyme deficiency.
* F, |6 t  s+ J) HThe 11-β hydroxylase deficiency may also result in
6 L5 m7 x# N: W) @% }excessive adrenal androgen production, and rarely,+ y. B! K: u, i# x
an adrenal tumor may also cause adrenal androgen
& C9 y+ p4 Z6 i3 sexcess.1,3' }) W3 z) q# w" e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& B8 Z1 H8 \5 L
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. z; e+ Z$ g, p$ b8 V; R
A unique entity of male-limited gonadotropin-( C9 ?9 [5 Q. G5 l% O
independent precocious puberty, which is also known8 L! u' v. O8 K9 @  V0 A# c6 r6 h
as testotoxicosis, may cause precocious puberty at a
4 f' v" c* }( ~  u8 Every young age. The physical findings in these boys5 {  X- u" o% s
with this disorder are full pubertal development,, K. o, I: r" `' V5 i9 Y
including bilateral testicular growth, similar to boys
( d7 ~0 J: m3 [- x5 L% ]with CPP. The gonadotropin levels in this disorder
7 R/ n1 N7 n! B0 ]3 Rare suppressed to prepubertal levels and do not show
: c* \8 n2 N% }; _! y$ f0 w2 H( Cpubertal response of gonadotropin after gonadotropin-
+ D* Y2 m4 q; _& Creleasing hormone stimulation. This is a sex-linked
2 T* ]  D6 f3 X0 v4 l* Bautosomal dominant disorder that affects only. E, I1 [. Q! y: T2 C" X
males; therefore, other male members of the family
. S+ ~5 V6 K" \& G- K6 o  nmay have similar precocious puberty.34 @9 _8 p# R0 \' l& M
In our patient, physical examination was incon-( z. ?* P7 g" ~/ {! N$ r
sistent with true precocious puberty since his testi-" q2 m: ?' E1 Z4 a1 Y# ~
cles were prepubertal in size. However, testotoxicosis& i4 g7 G: ~) k9 _2 d6 U4 s! X2 B
was in the differential diagnosis because his father. w0 B. b8 |# V6 V, d7 U
started puberty somewhat early, and occasionally,% i, L1 V6 e- p- d6 Q) A! M! ?
testicular enlargement is not that evident in the/ n+ M! x% E! d+ B( i
beginning of this process.1 In the absence of a neg-$ O2 f( |6 P. ?8 Q/ l; m( [
ative initial history of androgen exposure, our
+ T" W  x5 |! O0 g" ?# W" {/ tbiggest concern was virilizing adrenal hyperplasia,
4 B' @4 B2 D( n- }) reither 21-hydroxylase deficiency or 11-β hydroxylase
: P& _, @8 H9 m+ P* y3 u9 ~* _! ~! Ydeficiency. Those diagnoses were excluded by find-
7 N, J3 l+ e6 }) v8 H" r: u% p( _- Ling the normal level of adrenal steroids.& E3 E, V, N- K6 D. z
The diagnosis of exogenous androgens was strongly
, G5 S/ P5 C2 q' ?suspected in a follow-up visit after 4 months because
0 T. v. _* \/ r" _  K+ W* [the physical examination revealed the complete disap-8 j9 J1 F9 n, C7 m
pearance of pubic hair, normal growth velocity, and
1 A* W5 S1 ^0 ~3 g5 s  G4 Cdecreased erections. The father admitted using a testos-% ~, w& W% \! r/ r
terone gel, which he concealed at first visit. He was. T4 U( n3 r3 \
using it rather frequently, twice a day. The Physicians’. J: @3 X' P! m( _0 U  h! ^9 j
Desk Reference, or package insert of this product, gel or3 _4 a6 c6 x1 j% F
cream, cautions about dermal testosterone transfer to
4 j: N. R; {5 [2 B7 _8 `8 bunprotected females through direct skin exposure.2 v8 i  g# {# ^
Serum testosterone level was found to be 2 times the% J' \6 s# T8 b
baseline value in those females who were exposed to- A9 W& L3 @2 b
even 15 minutes of direct skin contact with their male7 w1 ^' S; r6 j; |: J7 u9 s
partners.6 However, when a shirt covered the applica-
3 A, w, Q5 v  q: P, |7 ktion site, this testosterone transfer was prevented.
% z2 l4 w" u- P  K$ h0 WOur patient’s testosterone level was 60 ng/mL,
5 V6 Q: r; \, z" v8 c( ?which was clearly high. Some studies suggest that
# ~! W/ J- N5 E1 W# h/ Ndermal conversion of testosterone to dihydrotestos-
& m8 |; U% H/ c2 H5 W7 a3 u5 jterone, which is a more potent metabolite, is more- K: w$ _- Z! ~2 V
active in young children exposed to testosterone
, D. J3 Z# S& p1 \3 |! Cexogenously7; however, we did not measure a dihy-" x6 x1 n7 Q2 l: r! a2 p
drotestosterone level in our patient. In addition to
% Z9 ]; S8 r  q9 j( E1 mvirilization, exposure to exogenous testosterone in  l5 T0 m0 y# Y% s) ]- O
children results in an increase in growth velocity and
% `- Y0 Z* l0 e8 i3 _, n; oadvanced bone age, as seen in our patient.  t' I& m+ {0 j+ ^, O5 a
The long-term effect of androgen exposure during1 I0 M3 z, Q. u5 g( U8 t( d
early childhood on pubertal development and final
! Y6 n+ o/ u6 M6 \adult height are not fully known and always remain
- f# M  }0 w* m7 Q8 q8 B5 Ya concern. Children treated with short-term testos-/ O! o( K% a/ L1 v. l
terone injection or topical androgen may exhibit some
) `" d  J* {# L6 Zacceleration of the skeletal maturation; however, after
9 Q) a! W6 f2 ~! C, b; s2 |. `  D7 Bcessation of treatment, the rate of bone maturation2 X# w1 u4 `5 X, L
decelerates and gradually returns to normal.8,9  u+ y% N- l1 g
There are conflicting reports and controversy% Z) B3 {; P& W( H  b
over the effect of early androgen exposure on adult! ]9 s# j: W$ E8 n% [3 z
penile length.10,11 Some reports suggest subnormal
0 j6 c9 y# E" N3 k- D9 n, M, Xadult penile length, apparently because of downreg-# C  k9 [: z9 U
ulation of androgen receptor number.10,12 However,
7 f0 J' C! F: }( c7 eSutherland et al13 did not find a correlation between, A* y  W) @) a9 Z6 O1 [1 [
childhood testosterone exposure and reduced adult. d$ @% u: v0 k: u+ U# l
penile length in clinical studies.
( V+ h' R* _$ R, fNonetheless, we do not believe our patient is* x. M/ o4 ]3 z1 M& `" `4 x
going to experience any of the untoward effects from* d- [/ v/ _' {+ x4 m5 M
testosterone exposure as mentioned earlier because
* y4 u2 |9 k% X2 ~) S! F- o$ R+ othe exposure was not for a prolonged period of time.& n8 d7 V2 ^; d$ P  I4 t
Although the bone age was advanced at the time of) H) x6 [2 R( d: v& b6 a
diagnosis, the child had a normal growth velocity at
: }, ?% s8 G% Y; Ythe follow-up visit. It is hoped that his final adult2 R$ D; O0 z! @. D6 F
height will not be affected.
) w& W9 i/ U8 y+ TAlthough rarely reported, the widespread avail-
, Z6 r' r0 w2 G) d' Uability of androgen products in our society may
8 R% l& s4 Q( G/ |+ m1 V/ Z! hindeed cause more virilization in male or female$ V7 y: B" E- S. Q9 T2 p1 L; S: W
children than one would realize. Exposure to andro-0 L3 Y. j( Y7 x1 c3 }
gen products must be considered and specific ques-& L% I- X1 S! q
tioning about the use of a testosterone product or
" B, R1 M/ v; m! jgel should be asked of the family members during
9 g: T9 S3 @) H, dthe evaluation of any children who present with vir-
1 l, }2 H% r2 h+ c8 k8 z) Iilization or peripheral precocious puberty. The diag-5 \6 y+ W% M: P0 g" r
nosis can be established by just a few tests and by8 V, R' }0 L0 S
appropriate history. The inability to obtain such a1 a9 P' t+ z7 s
history, or failure to ask the specific questions, may
. N# N- i2 V0 f% L1 {result in extensive, unnecessary, and expensive. w0 `4 \; }3 |1 q5 H2 q8 T
investigation. The primary care physician should be
! X6 k& y' ?* Oaware of this fact, because most of these children  Y0 V6 O" s  |- r# ]
may initially present in their practice. The Physicians’$ t  {7 L8 `9 J& ]+ P+ p
Desk Reference and package insert should also put a
& Q' e% S8 c3 t2 P  ?+ E/ C8 dwarning about the virilizing effect on a male or4 W6 f/ |: ?* v$ @
female child who might come in contact with some-8 @. S* _: P8 }0 A, e
one using any of these products.
) y& X" F' o- B3 Y9 MReferences& {8 s0 y5 e. V3 S* r( W1 b7 S- \  V
1. Styne DM. The testes: disorder of sexual differentiation
, o& w4 z9 s  c: S  a5 D! Eand puberty in the male. In: Sperling MA, ed. Pediatric9 U4 }! k0 m7 v
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 t5 P2 k$ u4 p1 Q
2002: 565-628.
- m; v. a1 J6 v4 |& |- N" t6 T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" ^, E' I9 e( _6 z: L' I8 M
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old- `. T* w' N* o. V8 u/ ]
Boy Induced by Indirect Topical
1 y0 o' j# n( o4 v' HExposure to Testosterone
/ o2 [; b6 x4 @4 |% r. k2 [* fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 b. r, {1 t* v
and Kenneth R. Rettig, MD1
3 X/ b* D3 P3 W! `  lClinical Pediatrics$ i1 z% f  }. w( K# g
Volume 46 Number 6
( u; E; m4 U9 t7 n6 D( ~" bJuly 2007 540-543
8 e% E1 s, l" w3 w5 c" j9 V4 ~- N© 2007 Sage Publications
  S; g/ O1 U( X+ @10.1177/00099228062966519 i( ~6 _/ U# r2 e7 H. y
http://clp.sagepub.com
/ E# u# m5 U- H  V9 k6 I7 `hosted at
$ `7 r8 P# Q! G6 \7 Ohttp://online.sagepub.com
( \2 @4 [" B/ n! K, }- F4 N; uPrecocious puberty in boys, central or peripheral,
( p5 o* Q' a. ^is a significant concern for physicians. Central9 C9 w: F/ }1 u% [9 V
precocious puberty (CPP), which is mediated
6 a2 e; L" j0 \' N- dthrough the hypothalamic pituitary gonadal axis, has4 ?" d3 c2 ?. Z
a higher incidence of organic central nervous system
9 K. A5 _! _& s% ?$ a$ H' P6 Xlesions in boys.1,2 Virilization in boys, as manifested
* o9 n0 d3 w* @( U6 b4 z# J+ @by enlargement of the penis, development of pubic
& i( ?/ G( s& y+ n2 F6 uhair, and facial acne without enlargement of testi-4 U5 L/ I4 k: [/ T, I' j1 X' o
cles, suggests peripheral or pseudopuberty.1-3 We
8 ]& p5 b4 A1 R0 c2 s# C1 I/ ?1 Oreport a 16-month-old boy who presented with the
0 D3 |! }3 H( p7 Yenlargement of the phallus and pubic hair develop-
, ]/ k; _& J( ^3 h- {ment without testicular enlargement, which was due9 m3 g" d! r8 G8 H8 E
to the unintentional exposure to androgen gel used by
' A0 E! ]: O7 m& W' g9 cthe father. The family initially concealed this infor-7 b( S, {4 s0 s( ]
mation, resulting in an extensive work-up for this
$ w% _8 X2 M1 tchild. Given the widespread and easy availability of, w! F1 f$ o+ T1 C3 c
testosterone gel and cream, we believe this is proba-) c" j0 V7 \- F4 y: B/ S/ G
bly more common than the rare case report in the  |- e: t, U4 P! ~4 f3 S
literature.4
' d6 F& J. Y, E+ F4 h: SPatient Report0 Q  N% U4 J6 V' t# t
A 16-month-old white child was referred to the
5 {2 [9 w. Y! V5 Rendocrine clinic by his pediatrician with the concern- _* ?* I5 ~9 A2 K6 S! X1 i" O* H8 A
of early sexual development. His mother noticed
2 n: m0 w) z" D! v9 h$ j: f7 a) m3 wlight colored pubic hair development when he was
, [8 d# F% H6 ~3 Y- BFrom the 1Division of Pediatric Endocrinology, 2University of6 r' x; J, a  [9 K4 {5 }
South Alabama Medical Center, Mobile, Alabama.
8 d1 Z/ f5 s2 a3 n* |Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 t& f8 F6 o& ^* EProfessor of Pediatrics, University of South Alabama, College of- p4 u+ ]. c6 |3 A0 s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ Q% d4 P, i; s) c  Z9 T
e-mail: [email protected].9 v. {  P) U! T6 J* B* G! H& _" g
about 6 to 7 months old, which progressively became
2 n  v, n3 R5 E+ T$ vdarker. She was also concerned about the enlarge-
, [. f* ^4 E+ H$ ~5 I$ x1 {- w( Zment of his penis and frequent erections. The child- s3 b! h8 y2 X  v! v% H% F$ V. |
was the product of a full-term normal delivery, with
( A, E0 Y( ]4 N/ b0 ]7 xa birth weight of 7 lb 14 oz, and birth length of
( h9 g2 P9 }, Z% k6 q3 G20 inches. He was breast-fed throughout the first year
8 v# I& i& c& j4 I" s- p7 wof life and was still receiving breast milk along with( d2 q. {* W4 f
solid food. He had no hospitalizations or surgery,+ Y# P, Z- G& h6 U
and his psychosocial and psychomotor development! }0 k  V6 l8 ]) C  f
was age appropriate.) N" w0 I6 m7 z2 o5 V- C, g- _
The family history was remarkable for the father,6 F2 ~" V5 l; U; q$ F7 ~% i/ f
who was diagnosed with hypothyroidism at age 16,% W5 I" E* _' t% B6 T
which was treated with thyroxine. The father’s  C, A4 y9 `4 n" c' A2 b4 Z, n: B' F
height was 6 feet, and he went through a somewhat
, Y1 u9 x5 H  P3 l& b6 M% fearly puberty and had stopped growing by age 14.
) \# h, D- D, z1 sThe father denied taking any other medication. The9 b5 E; F  b; n# Z/ {/ X; X
child’s mother was in good health. Her menarche
2 \2 Y* {+ m  H6 L$ Owas at 11 years of age, and her height was at 5 feet
  n3 k; u/ a5 K- Y' G+ H: L, {* P4 y5 l5 inches. There was no other family history of pre-
# j/ w/ d! v) \  D" V! N0 l* Fcocious sexual development in the first-degree rela-, J+ j# R) E" P" l2 U) |2 X' [+ j
tives. There were no siblings.
( L. S2 y3 l; ZPhysical Examination
' |$ c" b! q% v5 q7 W1 k4 yThe physical examination revealed a very active,% f3 V) G/ F- }" K
playful, and healthy boy. The vital signs documented! W, ^& z" q/ l* g
a blood pressure of 85/50 mm Hg, his length was. H% A: J2 K' T8 g7 x# P
90 cm (>97th percentile), and his weight was 14.4 kg
% w( q. O3 O8 x. L$ \; |4 F( k(also >97th percentile). The observed yearly growth, I# L/ r7 c- i8 S
velocity was 30 cm (12 inches). The examination of6 q  @. X& v! e
the neck revealed no thyroid enlargement.
& w6 H/ s# }+ h+ [0 O7 s5 ?The genitourinary examination was remarkable for8 X4 a+ ]1 y, M5 ]9 O0 |
enlargement of the penis, with a stretched length of  ?3 a8 U/ K( D9 w7 Y
8 cm and a width of 2 cm. The glans penis was very well9 A7 j; F/ [; L  w5 s
developed. The pubic hair was Tanner II, mostly around2 u4 m& G. k$ Y6 c
5408 A- w# b0 D* p# [4 B3 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 V3 R) o' m6 r3 s8 q( T* othe base of the phallus and was dark and curled. The5 y, s. ~8 O8 Y. F
testicular volume was prepubertal at 2 mL each.9 J* r2 s8 k; H! ]6 S
The skin was moist and smooth and somewhat
" g2 p  o% h; u- d3 @( j0 F9 O" voily. No axillary hair was noted. There were no/ C* u4 {9 z7 n! Q, o' A  ^( }6 b( P; B
abnormal skin pigmentations or café-au-lait spots.! `3 ?9 e6 G# X' _5 q
Neurologic evaluation showed deep tendon reflex 2+5 X( L% H: t6 e
bilateral and symmetrical. There was no suggestion- ~* w' a) F. k; ~" F" A
of papilledema.
. V2 {- ?% D3 e" s* VLaboratory Evaluation
0 k6 e6 x. W  ]) Y( Y7 t0 a& @$ L  x; WThe bone age was consistent with 28 months by. z( q/ j. d! l! C" A
using the standard of Greulich and Pyle at a chrono-( i# N5 a. A% [6 v7 a9 g
logic age of 16 months (advanced).5 Chromosomal# o$ F8 N2 p( q
karyotype was 46XY. The thyroid function test  T/ \  v4 r  H3 V# p' e/ N
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  U8 D( c9 P! `' W9 Q, D2 G+ d) i" P  Alating hormone level was 1.3 µIU/mL (both normal).8 t9 v% ^6 ^# x
The concentrations of serum electrolytes, blood
* v. I; Y& k/ s5 M$ ]urea nitrogen, creatinine, and calcium all were9 ?- V0 z! }) b- _3 }7 s
within normal range for his age. The concentration
0 O% @) N( m" _; ^of serum 17-hydroxyprogesterone was 16 ng/dL
$ D$ h! s( N% D! H6 c8 k- R2 {(normal, 3 to 90 ng/dL), androstenedione was 20: f6 q1 V( p3 Y. ]- s
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: H, k/ T8 l0 T. w1 n  x4 r- t! Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; _5 R! F7 b& w" B: C  _5 v1 ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! U" g+ A6 a1 j  N3 m49ng/dL), 11-desoxycortisol (specific compound S)
( E1 P: u! T, n* u* H, Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( y# A  W2 _9 \) g, }( ?tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' n! S1 P. e5 N- s  C9 u& `
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),( j) ^: y) T) C, _* e' Z
and β-human chorionic gonadotropin was less than# H" D- }( Q- E% @2 g% \7 C6 n: Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 ^% ?( D$ r" a5 Zstimulating hormone and leuteinizing hormone/ m- W8 N2 c; o
concentrations were less than 0.05 mIU/mL
; P5 T9 M# p& H0 [7 x  n9 y  r(prepubertal).
# d- Y4 D3 B2 v6 UThe parents were notified about the laboratory3 L0 K5 L, E# |1 v
results and were informed that all of the tests were4 H# Y- C1 {3 B' ^
normal except the testosterone level was high. The
' V4 J1 l; g; @6 M9 f' sfollow-up visit was arranged within a few weeks to/ i1 K+ ^: r2 @5 V8 V; ~9 p
obtain testicular and abdominal sonograms; how-
" L. n  g% Z% {$ F! Oever, the family did not return for 4 months.
8 l+ l8 t  T5 j; s3 APhysical examination at this time revealed that the
( E( t" e1 U7 Cchild had grown 2.5 cm in 4 months and had gained2 a9 X0 I; g' f9 _
2 kg of weight. Physical examination remained4 O3 u$ K9 j, {7 N
unchanged. Surprisingly, the pubic hair almost com-. I% j* C: R1 ^$ C
pletely disappeared except for a few vellous hairs at
# u( _+ }4 O6 ]% b( L  P; Zthe base of the phallus. Testicular volume was still 2
8 ^2 |1 }: |! x. t# v4 M. mmL, and the size of the penis remained unchanged.3 A" V* U. N$ @$ j: j* @% P0 }8 M
The mother also said that the boy was no longer hav-  N0 L) X- c" {) i
ing frequent erections.' H1 l, V9 f" f8 Y0 V
Both parents were again questioned about use of8 R) X% a2 c5 Y. q
any ointment/creams that they may have applied to
) p, {5 N4 ?6 ^6 v- Y2 Vthe child’s skin. This time the father admitted the
$ K& e; u5 M2 z* v) ]3 STopical Testosterone Exposure / Bhowmick et al 541
& c, @, f. B: ~$ H  z  ]use of testosterone gel twice daily that he was apply-
7 k" G" ^7 r* @8 V* ^ing over his own shoulders, chest, and back area for
/ Q$ D& l1 ~' c8 f/ x. ~a year. The father also revealed he was embarrassed
; \2 [  ~3 G9 Q$ w9 I0 b* ~( J# ^% hto disclose that he was using a testosterone gel pre-0 r5 @5 O6 ~$ I; G5 \3 s
scribed by his family physician for decreased libido& b# w, q. n4 M0 }# G0 S- U
secondary to depression.. q7 O1 [9 `! g' ?. N
The child slept in the same bed with parents.
3 i( i8 t7 |" n7 {- o- rThe father would hug the baby and hold him on his
1 E* S$ K% U) ?# w, l1 T$ L* Lchest for a considerable period of time, causing sig-
" w! T, g; m# l* ]nificant bare skin contact between baby and father.. B( w% U5 w* B5 u+ ]( t9 C
The father also admitted that after the phone call,) t, R! B8 W+ i1 ^  v) J0 U/ ]
when he learned the testosterone level in the baby
3 n+ F/ C' p9 j4 Swas high, he then read the product information
( y4 ~- c; E" Zpacket and concluded that it was most likely the rea-
2 x, ~! G5 r. \. vson for the child’s virilization. At that time, they- {1 P% t" S. w3 P, G" j
decided to put the baby in a separate bed, and the
6 v% A- i$ L( ^: {father was not hugging him with bare skin and had+ H0 C* V+ H% G+ B, j& c
been using protective clothing. A repeat testosterone
' o5 E, W; h; Z; b' d- [9 dtest was ordered, but the family did not go to the5 k" h$ j  k  d5 m4 j/ k' j! `
laboratory to obtain the test.
! Q' a, W% E% }% R0 ~Discussion
! i2 Z- H& z0 {% }1 Y" T: V; EPrecocious puberty in boys is defined as secondary+ i3 e" D8 Z8 E
sexual development before 9 years of age.1,45 w/ U; Y2 g( a# r
Precocious puberty is termed as central (true) when
9 j( _" U3 p+ r1 r! Dit is caused by the premature activation of hypo-7 j1 U- n5 I, a: K8 E, l/ l# F
thalamic pituitary gonadal axis. CPP is more com-
" ^6 ?/ ~5 i% W/ u8 f1 \mon in girls than in boys.1,3 Most boys with CPP
, C9 K; k5 D7 {: G" O  F5 e3 Dmay have a central nervous system lesion that is  u5 W; V7 o$ x5 P' b- `/ R
responsible for the early activation of the hypothal-
9 z& y5 {  u# K* s9 Mamic pituitary gonadal axis.1-3 Thus, greater empha-/ m+ J  \' m/ ~+ ]" q
sis has been given to neuroradiologic imaging in
1 k$ |; Z1 ^$ P. x2 H/ Pboys with precocious puberty. In addition to viril-
) _3 \* z* n/ b" ~" `ization, the clinical hallmark of CPP is the symmet-
6 ?8 p7 E: O/ |9 R4 s" w9 jrical testicular growth secondary to stimulation by+ Y, h: `/ i; X- s
gonadotropins.1,36 `" m5 F3 A% U  R0 C# a  P
Gonadotropin-independent peripheral preco-% [" d5 X- K7 g5 O! q. ~) b
cious puberty in boys also results from inappropriate
" t7 L9 O: {" ]7 ]# Qandrogenic stimulation from either endogenous or) V+ Z' e" _0 d7 ]( V3 P5 m
exogenous sources, nonpituitary gonadotropin stim-, T. D( u: d+ ]2 c( {+ H7 {
ulation, and rare activating mutations.3 Virilizing
& z3 w0 R3 `7 mcongenital adrenal hyperplasia producing excessive
! ^0 Y/ }$ }$ o' f. }5 Oadrenal androgens is a common cause of precocious6 x( P/ W  e$ K2 _7 ]% n# G
puberty in boys.3,4+ L; k, m. p+ `% h8 g5 T
The most common form of congenital adrenal, n9 J4 B9 t9 U* `* r: s$ i
hyperplasia is the 21-hydroxylase enzyme deficiency.0 B% ^! ?. b& q# H4 @& e* B
The 11-β hydroxylase deficiency may also result in
9 l5 @( L9 b1 @! z& Dexcessive adrenal androgen production, and rarely,
) I/ v9 T0 K: Y5 M2 \! ?* i' J3 U- _+ ban adrenal tumor may also cause adrenal androgen
) m, v: J7 C5 }# }# s. Mexcess.1,3* X2 J, a5 y) a6 H0 k9 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, M! t" Z. Q- A  S  K' s& z2 h542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! d* t- l1 {1 U% FA unique entity of male-limited gonadotropin-
2 K7 |" @5 Y$ a1 r# tindependent precocious puberty, which is also known7 b+ N; Z) a/ q  e
as testotoxicosis, may cause precocious puberty at a9 X3 A* P' D, m& P8 Q
very young age. The physical findings in these boys
9 [8 x! @/ K: B! ?, fwith this disorder are full pubertal development,
. B3 P: H2 p9 Bincluding bilateral testicular growth, similar to boys( }" |4 D3 Y1 J6 J3 x9 K
with CPP. The gonadotropin levels in this disorder' d; s2 R2 @1 Z! D
are suppressed to prepubertal levels and do not show
2 ~5 w* K/ ]! O' k: s4 L! `pubertal response of gonadotropin after gonadotropin-
4 e7 ^" r+ A1 d+ oreleasing hormone stimulation. This is a sex-linked1 v% Y# s$ a' {, B9 l' U
autosomal dominant disorder that affects only3 S) ?7 i1 C$ p: h6 Q3 ~
males; therefore, other male members of the family
; J7 r0 Y7 N* x5 T4 Dmay have similar precocious puberty.3
6 H" h: W# C. z( e" O) |: QIn our patient, physical examination was incon-
8 P  o% F, k& g, M: e/ K" H  wsistent with true precocious puberty since his testi-# Q, u/ s1 e5 s/ S" r$ s
cles were prepubertal in size. However, testotoxicosis
/ I  P* e( U8 J3 _" D# d" w& M9 Q# qwas in the differential diagnosis because his father" @( F/ v# f9 L: d9 b5 [7 ?0 i- J! w
started puberty somewhat early, and occasionally,2 D$ p8 k" d) S4 p9 i! q
testicular enlargement is not that evident in the
8 P- F/ B5 \0 z! }( `+ E$ c1 D5 A6 Ibeginning of this process.1 In the absence of a neg-( k- Q1 Y# I* U" ~% A& e
ative initial history of androgen exposure, our7 l4 `: `; ^6 g1 h
biggest concern was virilizing adrenal hyperplasia,
- M8 ^, o4 i$ d4 aeither 21-hydroxylase deficiency or 11-β hydroxylase
* c/ k  R2 `+ E7 Q+ M% k# Q" I1 R. a* U/ \deficiency. Those diagnoses were excluded by find-
! B$ k( x+ R1 q% h; X8 Aing the normal level of adrenal steroids.9 O1 F9 a# r$ y8 X9 X
The diagnosis of exogenous androgens was strongly
$ C% S% o3 c+ Ususpected in a follow-up visit after 4 months because' M0 m$ a6 ^4 w0 g8 F$ O
the physical examination revealed the complete disap-
( ^: a) H" C: V: g; Dpearance of pubic hair, normal growth velocity, and
6 ?- l1 @# y7 J1 ~& t( E; X1 }decreased erections. The father admitted using a testos-# F+ x% z2 X. a
terone gel, which he concealed at first visit. He was
9 G3 ^2 q) r5 b4 P& y; E+ Pusing it rather frequently, twice a day. The Physicians’3 C8 H  C' p/ i, g' K
Desk Reference, or package insert of this product, gel or
6 a* ?# g, a) h% s  C; ^cream, cautions about dermal testosterone transfer to6 z4 K  {- w2 t8 f" x' `! J
unprotected females through direct skin exposure.
) d! A* l5 P# F  H3 a: |Serum testosterone level was found to be 2 times the
4 }7 P. F5 |3 r1 T9 W# A& W/ J) _; ebaseline value in those females who were exposed to$ E% d4 X+ D9 U; c+ E
even 15 minutes of direct skin contact with their male( x9 w; G4 {$ Q0 n+ e4 Q. s; b/ f
partners.6 However, when a shirt covered the applica-1 N( `! T( K% G$ h' |' y  [- ~
tion site, this testosterone transfer was prevented.- P+ Q& C3 X/ a  B2 z
Our patient’s testosterone level was 60 ng/mL,: ]7 Y3 X$ U+ G6 [
which was clearly high. Some studies suggest that
" m. k/ z. T/ U+ n( idermal conversion of testosterone to dihydrotestos-* H! E3 N/ z9 J- B
terone, which is a more potent metabolite, is more* E7 @* ~4 q) y) l( o2 X1 n  }
active in young children exposed to testosterone- w( A7 a- R3 a) ]( P0 c9 L% m
exogenously7; however, we did not measure a dihy-
) o# R6 P( U) O/ e! ~1 F6 ]  r3 o! G6 Ldrotestosterone level in our patient. In addition to' A1 _2 G; f" C+ x& Q' H
virilization, exposure to exogenous testosterone in
* Z: y6 D9 M' K' ]" Q2 Zchildren results in an increase in growth velocity and
0 R  s8 C5 J8 tadvanced bone age, as seen in our patient.
3 o5 i% j8 G3 G6 {7 V# ~9 ZThe long-term effect of androgen exposure during! U# |: Q, O6 v- k5 q7 M- w
early childhood on pubertal development and final1 _+ C' T) t7 [, K% m
adult height are not fully known and always remain$ n9 Z4 v, A9 Q( N9 {/ R# l
a concern. Children treated with short-term testos-
* U8 D& ~3 d/ Z: c5 M  Sterone injection or topical androgen may exhibit some
; U' W" A" W, J1 Y0 wacceleration of the skeletal maturation; however, after8 d7 e5 x: o3 g1 Y2 A* Z
cessation of treatment, the rate of bone maturation) w& `6 v3 V- v( o7 B4 Z
decelerates and gradually returns to normal.8,9& a( s+ {, Z4 l7 N, ^
There are conflicting reports and controversy# I, ]4 O" x4 K
over the effect of early androgen exposure on adult) M% y0 a. k" k1 q
penile length.10,11 Some reports suggest subnormal  W. O: D- ?7 p, S' f; T
adult penile length, apparently because of downreg-& S- A5 J& M3 k; C+ a& l- L3 N
ulation of androgen receptor number.10,12 However,9 Y# D: ?2 r! I& H5 s% [+ F* B
Sutherland et al13 did not find a correlation between- Y, l8 D* z5 K
childhood testosterone exposure and reduced adult* V  n2 H. \; G( T
penile length in clinical studies.- t* y$ \9 T3 K4 |% O$ a3 T
Nonetheless, we do not believe our patient is/ c$ i; e/ W' h6 V4 V: C. @
going to experience any of the untoward effects from, w+ O3 Z) r) T0 [
testosterone exposure as mentioned earlier because! D& Y4 {8 t4 s7 o! `  m
the exposure was not for a prolonged period of time.
9 m) H5 t# Y  \: n4 B4 ^" m# O% TAlthough the bone age was advanced at the time of2 E8 \( X! }" u' j
diagnosis, the child had a normal growth velocity at
0 E/ h6 C7 G/ R8 [6 Dthe follow-up visit. It is hoped that his final adult6 X9 O' m4 ?+ u/ w. {
height will not be affected.2 ]" m' y! w1 c* g% Y5 Y
Although rarely reported, the widespread avail-5 c1 l; G: g. M
ability of androgen products in our society may
  b! B6 p8 x; f# bindeed cause more virilization in male or female
% q/ U+ O+ u  X( c. h" achildren than one would realize. Exposure to andro-" q; a) X. A7 ~4 Q1 u
gen products must be considered and specific ques-' Z8 J0 {$ ]2 r, u+ |; u
tioning about the use of a testosterone product or
/ s) q, ~6 Y) cgel should be asked of the family members during
) g( r- @2 C- u. k. n2 n7 Hthe evaluation of any children who present with vir-
- b0 D6 C; z& z3 silization or peripheral precocious puberty. The diag-- s% y# U8 x- }
nosis can be established by just a few tests and by. t( N( F6 Z6 ^9 u* G
appropriate history. The inability to obtain such a" L7 _* \7 C, v% u" _5 u( x- x
history, or failure to ask the specific questions, may2 R1 r/ J8 C. K
result in extensive, unnecessary, and expensive: O  C3 u( a& y# s6 M
investigation. The primary care physician should be9 u% f% y" T6 q
aware of this fact, because most of these children9 q/ r5 Q6 f$ j3 Q1 c) `
may initially present in their practice. The Physicians’0 J2 |4 d2 w8 ~, h# }+ r
Desk Reference and package insert should also put a# K  j" B% y$ e9 q; d
warning about the virilizing effect on a male or8 }1 Z: w& }! T5 a
female child who might come in contact with some-
' C! X( g4 {& rone using any of these products.
9 a7 O/ O) _  BReferences
0 A1 r* b- ^3 l; d; |* s/ O1. Styne DM. The testes: disorder of sexual differentiation
5 `; H) H2 }  @: L7 ]& C% [0 Kand puberty in the male. In: Sperling MA, ed. Pediatric3 f) u2 g" B; Z7 ~) g" Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 J% j: ]0 p. m0 i2002: 565-628.
  ?* @+ g- s4 }# m+ I* N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ m* t9 u: e& y% Z0 _1 epuberty 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
- P7 i5 I# g9 U1 ^3 B; ], c1 [
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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