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Sexual Precocity in a 16-Month-Old  w- X& n% A$ @2 m7 U7 L
Boy Induced by Indirect Topical5 t; S7 D7 J7 c" p3 a; U" E
Exposure to Testosterone
% ?2 P; g6 J# |' M2 d7 USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 U; P3 R0 ^2 O) O5 b. ]5 X, b
and Kenneth R. Rettig, MD10 U4 J9 B$ P* t) C/ R
Clinical Pediatrics1 X! R$ M, m- y+ j2 D- Z
Volume 46 Number 6
- w  d" z) G: ]% F9 N, BJuly 2007 540-543
' y! z9 s# P. l& Q; k0 R8 S© 2007 Sage Publications# Y" h+ j( h% }+ Y5 H& b: i7 s
10.1177/0009922806296651
0 R8 i& b. [4 x: ~; Ohttp://clp.sagepub.com' s( c. t& @0 P! X  H% o
hosted at
! u' P% T8 A: Xhttp://online.sagepub.com% [( ?( z& }+ p1 v0 g
Precocious puberty in boys, central or peripheral,
% }3 y: z5 i3 z$ K8 }. w: zis a significant concern for physicians. Central* L; Q8 W2 F, }, K. i( N
precocious puberty (CPP), which is mediated
( Z7 Z' N6 y1 w: Q& |/ d4 Kthrough the hypothalamic pituitary gonadal axis, has& l5 @4 C4 ]" K
a higher incidence of organic central nervous system( m7 c; O4 q% N9 Q8 L! z  n% E
lesions in boys.1,2 Virilization in boys, as manifested# D, `3 E4 q5 s0 Z* p# S- z
by enlargement of the penis, development of pubic
& V7 z) S" F% Y- S8 O* M8 khair, and facial acne without enlargement of testi-
  j& Y  _4 L+ ^9 y5 T3 z) Q) Icles, suggests peripheral or pseudopuberty.1-3 We
: @  u: z. `0 h% greport a 16-month-old boy who presented with the2 n9 ~4 y& f4 q- n% w  q/ e0 U
enlargement of the phallus and pubic hair develop-
6 Z' _6 Z, ~8 j' O0 P: f( cment without testicular enlargement, which was due
4 _: y7 o& M3 i. J8 Sto the unintentional exposure to androgen gel used by& ]4 I. b2 z0 O" k
the father. The family initially concealed this infor-+ W3 X$ b0 E; q, y( ^! @
mation, resulting in an extensive work-up for this2 n! b6 G( S" b2 r* k
child. Given the widespread and easy availability of
- Q0 S5 Z) k7 r* k. Ftestosterone gel and cream, we believe this is proba-
$ \3 C$ n( }1 d) t" Q, J# z9 E, qbly more common than the rare case report in the: L3 h. w/ y( u6 y
literature.4; V. x1 [$ u' e/ `
Patient Report
2 h- t" p, o# U; TA 16-month-old white child was referred to the
" ~6 F7 r% {+ |3 S. ]  mendocrine clinic by his pediatrician with the concern1 x. [" n4 X% N2 I% H' P* u
of early sexual development. His mother noticed
' Y9 i8 b# y, o  H  u6 z, Slight colored pubic hair development when he was
5 d& A9 j. C6 `) [From the 1Division of Pediatric Endocrinology, 2University of
; d' ]8 i! |6 O# S4 t! OSouth Alabama Medical Center, Mobile, Alabama.! W0 X+ a" a9 c: l+ u' B- I5 p0 Z3 W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. ^' X2 v0 u; j8 v: R& T0 I) H. TProfessor of Pediatrics, University of South Alabama, College of
/ S1 N% D7 i) {6 y0 {# y# {' nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" Z) O3 T+ f7 W& @) M6 {5 v  O
e-mail: [email protected].
8 s4 k5 e0 a0 \. oabout 6 to 7 months old, which progressively became
" ~2 X+ k7 \9 ~$ `. J2 S4 G7 odarker. She was also concerned about the enlarge-
; _1 b% i& o1 q2 c4 o& rment of his penis and frequent erections. The child  K0 {( R5 @4 m7 T+ O; k
was the product of a full-term normal delivery, with
) c- q1 ?' k5 Z& M8 F( @a birth weight of 7 lb 14 oz, and birth length of$ H9 D" V: v5 F& t% s0 b; Y3 ~( U
20 inches. He was breast-fed throughout the first year4 a0 D- T4 y* z4 t9 e
of life and was still receiving breast milk along with. w) a. ~* a/ r
solid food. He had no hospitalizations or surgery,
( h' N* d) S3 T7 b4 G$ mand his psychosocial and psychomotor development' D7 f; h9 M. W: Y: c+ Q, y
was age appropriate.+ H+ l  f$ Z- |; f/ w7 l
The family history was remarkable for the father,
& j% G2 S0 i  u' g3 k1 S9 cwho was diagnosed with hypothyroidism at age 16,
2 i! v* w( a4 k3 Swhich was treated with thyroxine. The father’s. I4 H$ [: r4 C; ~4 S$ \$ \
height was 6 feet, and he went through a somewhat
7 e: `6 x7 e6 cearly puberty and had stopped growing by age 14.1 @& R  r# ?4 l$ A5 J9 e
The father denied taking any other medication. The
) R  [/ C) S& wchild’s mother was in good health. Her menarche
7 m0 u2 o9 ?! P/ {2 U- F, `was at 11 years of age, and her height was at 5 feet
8 Z2 N! w& K5 U+ J) a) w7 T# E5 inches. There was no other family history of pre-
4 Z' U- Y- Q+ ?4 Kcocious sexual development in the first-degree rela-
2 j3 w. ]% z4 E+ y2 F: P2 P7 dtives. There were no siblings.  B5 d/ l4 C) y1 V) p  ]  p, ]
Physical Examination
7 U' |! K6 ]7 F7 |0 _  C* o9 |/ x" K* OThe physical examination revealed a very active,
6 D/ A4 b, W; I. \5 e* B" n7 D  vplayful, and healthy boy. The vital signs documented' X/ K+ u! N! S8 d6 u- L0 J
a blood pressure of 85/50 mm Hg, his length was) A( U* j) S4 F4 S' g% G5 r
90 cm (>97th percentile), and his weight was 14.4 kg
4 \+ F% T. G7 V" `(also >97th percentile). The observed yearly growth
" p' j2 _% N% h- X8 [3 {/ e: ]# W3 vvelocity was 30 cm (12 inches). The examination of* b0 N5 H! ^# v- ^! y3 e
the neck revealed no thyroid enlargement.
1 [+ c# V( s/ j3 {. _3 [The genitourinary examination was remarkable for
1 ~2 F/ R+ j$ B& b4 J' Q5 O5 Benlargement of the penis, with a stretched length of
3 O0 l+ ]" a! W% N  o1 U9 G' q9 Q8 cm and a width of 2 cm. The glans penis was very well
5 V3 F% d. B% z3 G7 W2 [/ I5 ddeveloped. The pubic hair was Tanner II, mostly around& ]7 I1 k2 u9 Y& G2 b3 l. }& l* o
5406 x- t! E  S0 E5 h2 G# d6 Y2 y0 ~8 ]- Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ x; L6 {  v8 W6 K+ o5 h8 Othe base of the phallus and was dark and curled. The& l( R5 w# H0 ^' s, Z6 C
testicular volume was prepubertal at 2 mL each.
6 L1 B; E: |% UThe skin was moist and smooth and somewhat) f/ ^5 H: {3 C8 \0 L
oily. No axillary hair was noted. There were no
0 ~% F+ ?% L8 B3 `' v( l+ babnormal skin pigmentations or café-au-lait spots.
1 O, m  Y8 |' ^9 hNeurologic evaluation showed deep tendon reflex 2+
* S2 U8 {  M* E9 p- ~: u) cbilateral and symmetrical. There was no suggestion
- r! p  B) d  A8 qof papilledema.! b; t( n. k* E2 ~+ A9 V( o  f( F
Laboratory Evaluation
5 G0 W) [% C) m0 cThe bone age was consistent with 28 months by& k5 {4 \: H# `
using the standard of Greulich and Pyle at a chrono-
% S0 u" a- b; i! {( a! Ilogic age of 16 months (advanced).5 Chromosomal5 R; _" c' a: n
karyotype was 46XY. The thyroid function test/ V4 o* O# p: N7 w4 K/ G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 O! j; U; E- c2 F6 }* F; }lating hormone level was 1.3 µIU/mL (both normal).
# ~1 E; U) i" W: L% {0 @The concentrations of serum electrolytes, blood
! C+ R2 P) A8 M, Z' curea nitrogen, creatinine, and calcium all were3 D. ?& w4 T; t( A6 [- }& i
within normal range for his age. The concentration
( I+ H7 A" n. X& R" M4 ?& Uof serum 17-hydroxyprogesterone was 16 ng/dL
: [" p7 {8 H" @" w" K1 F4 V4 j4 T+ C(normal, 3 to 90 ng/dL), androstenedione was 20# w0 b' J* G# Y" j3 \1 X  \" Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& x* y+ v2 D; m' l) m2 E0 L& }! I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ t: m( ?# }. ?0 r; P) vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to9 u8 Z8 x  ~3 X8 y
49ng/dL), 11-desoxycortisol (specific compound S)
$ A7 @8 D, r/ k/ ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 F8 j, {  j/ f; e4 I
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* \' {! |8 m' ^$ l9 e+ R+ _! m, H* Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 \) w3 R; ?! S( H" H2 q+ T
and β-human chorionic gonadotropin was less than
& h( I2 ~/ Y; k. I7 h! Z2 {% o5 mIU/mL (normal <5 mIU/mL). Serum follicular, d$ Z" B5 V) p
stimulating hormone and leuteinizing hormone
0 \. X$ p# ~5 L8 u. I' uconcentrations were less than 0.05 mIU/mL
& e: t! x1 B  \% V; Q2 h(prepubertal).
$ H# u8 A6 B8 r6 x9 w8 D* n; N5 W& @The parents were notified about the laboratory; ?% M' P: M) r6 d1 a- ~, |0 U, |8 K( c
results and were informed that all of the tests were6 V6 I) t* _! V. i
normal except the testosterone level was high. The5 C0 O- x# [4 C
follow-up visit was arranged within a few weeks to7 n2 }& o8 j' ]2 ?% }" V
obtain testicular and abdominal sonograms; how-
6 p1 m  c$ Q8 r& ^! Q7 kever, the family did not return for 4 months.
; K0 r" n1 v$ f+ ^Physical examination at this time revealed that the9 d2 i& H  [% S' R
child had grown 2.5 cm in 4 months and had gained- Z/ e7 i& p. g( c
2 kg of weight. Physical examination remained
# }2 d3 ?5 I2 o' R5 O# Nunchanged. Surprisingly, the pubic hair almost com-) V, E% e" q0 ?+ t2 k) X: K0 m
pletely disappeared except for a few vellous hairs at5 c, Z+ M3 m5 E' N8 [4 g" ?
the base of the phallus. Testicular volume was still 2  S) n! I5 a4 {9 o: u  c. d! l0 p
mL, and the size of the penis remained unchanged.6 P! D% v6 n' `7 _4 `) v; `
The mother also said that the boy was no longer hav-$ R5 ?* ~0 A7 P" [( ^: \+ F* Q
ing frequent erections.8 z8 W: O# |* {3 \
Both parents were again questioned about use of
- j: m: D% T! e: W6 N$ _any ointment/creams that they may have applied to: R, x( N% o2 q8 }
the child’s skin. This time the father admitted the
: W: q' ~, [. }8 k  b. o( HTopical Testosterone Exposure / Bhowmick et al 541
5 v! x1 i) a. n' s" P$ `use of testosterone gel twice daily that he was apply-
0 l+ G- V9 \; Z9 l/ Aing over his own shoulders, chest, and back area for' V7 A5 O$ ~) r+ D- t8 H0 K
a year. The father also revealed he was embarrassed, I& c- q* c- I, ^
to disclose that he was using a testosterone gel pre-
1 S, t& Z9 w4 }3 N# ~4 {: N- q+ {scribed by his family physician for decreased libido
! w( k4 t4 p. O2 g% Fsecondary to depression.
0 ~) B% E6 [1 N* v# cThe child slept in the same bed with parents.. X/ k1 Q; O! u) M0 p
The father would hug the baby and hold him on his
  @: x" F  _9 W- Ychest for a considerable period of time, causing sig-
  E. O" G. w' E  P' g' ?nificant bare skin contact between baby and father./ q0 y8 i9 g8 M  S/ i* p
The father also admitted that after the phone call," o9 N) q5 x  F' |, P; v
when he learned the testosterone level in the baby% Y+ _- s/ l- {0 {+ _
was high, he then read the product information
8 c( N" x! o: `6 Ypacket and concluded that it was most likely the rea-7 X3 @( g8 u5 h' g/ g9 K4 t
son for the child’s virilization. At that time, they9 S. p* G% H; \
decided to put the baby in a separate bed, and the* h( d# ?3 C, q+ j' a( u
father was not hugging him with bare skin and had
' ^8 {- A% W; k9 ibeen using protective clothing. A repeat testosterone
6 a, ^! o2 }% a! y4 Y/ R5 atest was ordered, but the family did not go to the4 K0 Q% M; X1 F8 p, m$ J' Z
laboratory to obtain the test.- \6 V8 P( z: [2 x0 K
Discussion
8 p( H/ x4 d; jPrecocious puberty in boys is defined as secondary
. l( ]; P, {$ l) Bsexual development before 9 years of age.1,4& G4 I0 `& [4 {, C. @2 W9 _7 d
Precocious puberty is termed as central (true) when
- z3 N, Z* X/ d3 b" H5 |7 G) Lit is caused by the premature activation of hypo-+ W% b* L, ~0 d6 A9 b0 }/ O" b
thalamic pituitary gonadal axis. CPP is more com-& @( H8 i$ ]: ?( o' @
mon in girls than in boys.1,3 Most boys with CPP& `( K' l& X. q- X
may have a central nervous system lesion that is' l8 L: t' V, {4 W
responsible for the early activation of the hypothal-
+ e2 W0 W2 @$ }5 [3 l# _amic pituitary gonadal axis.1-3 Thus, greater empha-$ p& g/ i9 ]) f3 t' T
sis has been given to neuroradiologic imaging in
! z1 x9 U" `. y6 s8 @/ c0 cboys with precocious puberty. In addition to viril-2 C1 F' W8 G. u
ization, the clinical hallmark of CPP is the symmet-/ E  j" C4 E8 I
rical testicular growth secondary to stimulation by
/ h" F0 v# m* G/ lgonadotropins.1,3
" P5 n% R8 |6 u2 r: r+ C* gGonadotropin-independent peripheral preco-+ W1 u0 T5 w) R( `. J3 U- u: G
cious puberty in boys also results from inappropriate- _* ]% _3 s) E
androgenic stimulation from either endogenous or
9 Z/ S1 D( Q) F9 |exogenous sources, nonpituitary gonadotropin stim-5 T8 T4 w8 u  q' G4 c- Z
ulation, and rare activating mutations.3 Virilizing+ n8 y4 x* H. T! V* l" A% I
congenital adrenal hyperplasia producing excessive; |  ?9 i( P* l/ n# y) w7 U8 w
adrenal androgens is a common cause of precocious3 P/ o! \8 C' K- C
puberty in boys.3,4
7 @! f9 O8 B; r; t) w5 m8 t: BThe most common form of congenital adrenal
6 d4 ~+ P( I; [1 Thyperplasia is the 21-hydroxylase enzyme deficiency.8 {* D' m- {$ U% y% d! ]
The 11-β hydroxylase deficiency may also result in- h- `4 h( q. h% r
excessive adrenal androgen production, and rarely,
, Y6 ^- K$ F. H" ~0 Nan adrenal tumor may also cause adrenal androgen
. f6 k8 ?9 {( Nexcess.1,3" y! l0 i; y+ b6 o5 W5 `, O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- r% Y9 I6 O) R* U# c2 e: T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# V, r: M" X6 [% U& C8 @6 B
A unique entity of male-limited gonadotropin-; Y& Q& V5 J4 v  g
independent precocious puberty, which is also known6 a4 j( z. y$ q5 n/ \! b
as testotoxicosis, may cause precocious puberty at a
0 f0 ]0 J# H& L* Every young age. The physical findings in these boys5 j* ?; w) k/ O7 u, ^
with this disorder are full pubertal development,* E7 C0 \+ |2 F) K3 @, E8 n1 U2 V
including bilateral testicular growth, similar to boys
( ]$ T. @+ r6 j5 r" x8 Twith CPP. The gonadotropin levels in this disorder) ^7 l9 h2 J7 R, h" c4 m3 O
are suppressed to prepubertal levels and do not show+ `( O: X" s2 o' F7 `  J2 J' R: P$ J
pubertal response of gonadotropin after gonadotropin-, [- b7 X; u! U6 G. l3 Y
releasing hormone stimulation. This is a sex-linked) n0 J  {# ?" l; y+ Y
autosomal dominant disorder that affects only; d) r8 ~. {6 k. _
males; therefore, other male members of the family
9 K$ F: J9 l/ v: H% J. \may have similar precocious puberty.3
& G& F% x2 P& d: [% bIn our patient, physical examination was incon-
+ z% Y0 B% x; B( g' X1 Asistent with true precocious puberty since his testi-- H8 E4 j" Y7 w& `" p
cles were prepubertal in size. However, testotoxicosis- M) c' A( k, r' T0 I& @
was in the differential diagnosis because his father
; s8 ]6 U) z, T0 \' Pstarted puberty somewhat early, and occasionally,
4 y) r% l( M1 |, atesticular enlargement is not that evident in the
8 b, s3 H! X# C9 Nbeginning of this process.1 In the absence of a neg-
8 G% p+ v+ P7 aative initial history of androgen exposure, our4 L. ^2 o4 o* M& G; o
biggest concern was virilizing adrenal hyperplasia,7 H6 U4 P( U  A( f, W
either 21-hydroxylase deficiency or 11-β hydroxylase
' ?! L) y' Y6 W% ydeficiency. Those diagnoses were excluded by find-! \( Y1 c& J6 P3 w' n! p* s4 a
ing the normal level of adrenal steroids.! y1 a" G& o# }" d5 l) G* z
The diagnosis of exogenous androgens was strongly+ \# r+ L; k+ D7 p* Y: F/ H  @
suspected in a follow-up visit after 4 months because5 \/ G0 B! F: H" x+ l
the physical examination revealed the complete disap-* D& c6 {% ^$ A# h8 b% k
pearance of pubic hair, normal growth velocity, and
) F' A* f1 S/ N  z1 B: H- P- \decreased erections. The father admitted using a testos-
* ]9 F* ?8 {* oterone gel, which he concealed at first visit. He was
) s* _1 b; \/ {6 Z! j, Tusing it rather frequently, twice a day. The Physicians’- y* g; v5 A# n% F5 {5 c# m% {
Desk Reference, or package insert of this product, gel or$ X9 B2 r$ J& x3 F( x
cream, cautions about dermal testosterone transfer to
$ x4 o% Q7 k' a3 N- Junprotected females through direct skin exposure.2 L) p: ]! r* @; Q# J! S
Serum testosterone level was found to be 2 times the/ X9 c: [, j# Z9 d" K
baseline value in those females who were exposed to
% t( s' R; m7 F# Y9 Beven 15 minutes of direct skin contact with their male& q4 [+ g: `& R% t7 n9 h
partners.6 However, when a shirt covered the applica-  R0 W- b8 e  a# t9 Z, m
tion site, this testosterone transfer was prevented.
- ]/ ^1 v0 z) J" Q/ j) mOur patient’s testosterone level was 60 ng/mL,
, `% T7 m! B; H9 }which was clearly high. Some studies suggest that2 s& S. z2 E; w! ]
dermal conversion of testosterone to dihydrotestos-
* Y# I" R- x1 `9 Yterone, which is a more potent metabolite, is more
+ v! j7 H. G1 [active in young children exposed to testosterone$ f! m! |5 R. z& ^# L: L
exogenously7; however, we did not measure a dihy-& t8 G# ~1 F5 X9 C$ L& m$ @$ E2 P
drotestosterone level in our patient. In addition to8 p% X) E, K; ]
virilization, exposure to exogenous testosterone in, g# N" k8 _  A/ x* ^# Z5 ?7 D
children results in an increase in growth velocity and' }0 b; d/ ?) a- k. S% H. A: Z
advanced bone age, as seen in our patient.
+ f: N4 G1 j0 s  Z5 j; H  eThe long-term effect of androgen exposure during
6 _) F7 d, b5 B2 t( `5 T- H# p; P, Vearly childhood on pubertal development and final! i4 u/ Z3 t# c6 R2 p% Q
adult height are not fully known and always remain
$ N4 t5 w0 K& `: s( H0 c( e* B9 }a concern. Children treated with short-term testos-+ L! ^) E) R! Q! I' m& H
terone injection or topical androgen may exhibit some
0 w" k& t1 w' |acceleration of the skeletal maturation; however, after
2 w/ p) g' i8 q$ f1 O7 B& z$ Z# _cessation of treatment, the rate of bone maturation
" e6 e3 o/ o3 I+ v, jdecelerates and gradually returns to normal.8,9
: o# {: j3 d/ t( C/ {" }2 ^There are conflicting reports and controversy" X( p: y8 ^* h4 c* F7 |
over the effect of early androgen exposure on adult) c7 }1 o& K5 P( ]
penile length.10,11 Some reports suggest subnormal9 z9 n  W$ L- t! l
adult penile length, apparently because of downreg-: V# _. S* g; W+ r& x
ulation of androgen receptor number.10,12 However,
& K/ t) U$ w: u% t1 XSutherland et al13 did not find a correlation between2 r  O. a; b3 z$ [
childhood testosterone exposure and reduced adult- t5 b4 W" l$ t$ f2 x3 G
penile length in clinical studies.# x* Q" ]2 ?) y) }6 Y( p
Nonetheless, we do not believe our patient is  K8 }( n+ d. d% Y$ A  |
going to experience any of the untoward effects from4 I" l7 x4 M1 n% C! Y+ }' L* z3 t
testosterone exposure as mentioned earlier because8 ^; ~. k6 z9 K+ s4 ^% @/ @2 r: o
the exposure was not for a prolonged period of time.. Y& p/ W5 h% ]! `. l0 T
Although the bone age was advanced at the time of
: l/ c3 D2 |7 t! Udiagnosis, the child had a normal growth velocity at/ x  E, W) S0 f6 @6 V( f5 F
the follow-up visit. It is hoped that his final adult) `; p- F+ z$ O
height will not be affected.
* C! c  Z2 S2 G2 z$ n! T5 k  fAlthough rarely reported, the widespread avail-6 _( k$ g1 O# ?7 U
ability of androgen products in our society may
, Z0 u; l+ A- }, k$ dindeed cause more virilization in male or female  e; p) c% ^7 `9 k* ]5 w
children than one would realize. Exposure to andro-
1 K$ Z; ^5 D1 W1 |gen products must be considered and specific ques-8 Y( Q1 G7 e( x' J5 i& A; Y
tioning about the use of a testosterone product or* h2 T" a4 I% T4 u3 g+ h
gel should be asked of the family members during! U% U5 V$ f2 r9 [
the evaluation of any children who present with vir-( s. E3 m; r% X8 L. s1 f, h2 A
ilization or peripheral precocious puberty. The diag-
& E5 R9 H: S' Y7 x& m! H2 D( l2 U) ~nosis can be established by just a few tests and by, k- s/ k' `$ o) Z' }" }* ]1 ]5 g
appropriate history. The inability to obtain such a9 \, L1 `% v7 w1 _+ r
history, or failure to ask the specific questions, may' \0 B6 k( ]7 n( _7 z' x( J
result in extensive, unnecessary, and expensive) N* m! B6 N/ i; b
investigation. The primary care physician should be  m. Z8 t& d; @: }2 R3 e3 g5 f
aware of this fact, because most of these children
8 ]$ S5 H$ k6 A/ f; G7 Qmay initially present in their practice. The Physicians’- D" G% J: A$ t* A
Desk Reference and package insert should also put a9 x8 z+ `' W1 z+ T. r: n
warning about the virilizing effect on a male or& l/ w, A$ ?2 t0 f; T
female child who might come in contact with some-
* h3 y7 ?- W( D8 p0 J, y( h8 n% Xone using any of these products.0 c! p* I% X6 E: V0 b5 O
References
" v: \/ B1 q- S. U: R7 _1. Styne DM. The testes: disorder of sexual differentiation0 |) {4 S2 `! i, O, j7 r% N" ^
and puberty in the male. In: Sperling MA, ed. Pediatric
0 t3 M: W' ?, B! S, q6 aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: u1 ?) N) H9 q4 H2002: 565-628.
( _& m& X$ j- N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 {8 W2 u, j$ m4 j- g% S
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old0 w* N" F' ~. o2 v2 e1 P9 ]
Boy Induced by Indirect Topical
8 C- B4 E3 [9 XExposure to Testosterone: W4 X* J* ?8 n& y0 B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ i/ K7 L, f/ ?0 i2 }and Kenneth R. Rettig, MD10 Q" }7 M- }1 q  R) I& A
Clinical Pediatrics
' N: q5 T% a+ b3 v" @Volume 46 Number 6' I+ B1 g1 J8 h# J
July 2007 540-543
* F- p! O9 r" i( ~© 2007 Sage Publications
/ T5 V( ^- s  I% n" o10.1177/0009922806296651
/ p/ u3 d; D2 n2 j6 |http://clp.sagepub.com  Q; a, V. h6 Z
hosted at* k& R/ ^/ k9 U0 y/ l# Y
http://online.sagepub.com0 a, l/ [2 P6 _! E8 N# s
Precocious puberty in boys, central or peripheral,. Y; S8 f: f3 s$ p' ~: l
is a significant concern for physicians. Central( q+ `& m8 Z- z
precocious puberty (CPP), which is mediated
8 m; e, |: n0 n: B* z. Tthrough the hypothalamic pituitary gonadal axis, has) r2 G5 G" L9 D( o
a higher incidence of organic central nervous system& [# p. t. e" E( s: j
lesions in boys.1,2 Virilization in boys, as manifested6 v: D3 G- L+ |% p
by enlargement of the penis, development of pubic+ F( V$ V" U/ I+ o# X7 E# l
hair, and facial acne without enlargement of testi-
4 x4 Y9 t$ Q. K; _" Vcles, suggests peripheral or pseudopuberty.1-3 We) }0 @- E+ d% p- M6 X
report a 16-month-old boy who presented with the
) U, T% [9 T) ^) z. u& i/ |" T  |5 q/ E% penlargement of the phallus and pubic hair develop-
7 U( W: r  u9 Y( o9 _! J) dment without testicular enlargement, which was due( F! {  `( V7 y1 A8 O' i& h' U
to the unintentional exposure to androgen gel used by1 C* @# E0 l2 d
the father. The family initially concealed this infor-
% R5 Z( v$ `. t& a$ H1 Gmation, resulting in an extensive work-up for this
+ p# e3 p! M0 q5 uchild. Given the widespread and easy availability of: t' K! B& B- I. {) g
testosterone gel and cream, we believe this is proba-7 {3 K6 K* B9 {/ G- c% M* t9 V# O2 N
bly more common than the rare case report in the' d2 y& t: v8 X% n) m8 [+ u3 |
literature.4
2 ~9 L; _6 U/ y3 VPatient Report
3 C/ g: Z0 [" L4 e9 D4 XA 16-month-old white child was referred to the! W3 z5 h! E" w+ h/ x! P
endocrine clinic by his pediatrician with the concern; a- {/ q8 r) l* u  `( A7 c
of early sexual development. His mother noticed' E& J! V3 h: v: P4 E
light colored pubic hair development when he was
% u. u1 W5 v, V0 T! q$ C( j) SFrom the 1Division of Pediatric Endocrinology, 2University of
9 H) D; K$ F8 T5 |* sSouth Alabama Medical Center, Mobile, Alabama.0 V3 P% d- o9 m1 u7 W3 [4 \9 r6 I
Address correspondence to: Samar K. Bhowmick, MD, FACE,: J+ u4 Q/ D' @$ T
Professor of Pediatrics, University of South Alabama, College of
1 n; y6 \$ ]/ [Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, s# T* M1 b3 D* v6 N: V
e-mail: [email protected].
0 ^( P; @8 W5 a" p& [5 t/ @about 6 to 7 months old, which progressively became
7 j3 E- R4 s* i* Tdarker. She was also concerned about the enlarge-5 _: L2 v# p4 B* d! H2 S8 D( M3 X* c' Y
ment of his penis and frequent erections. The child/ ]6 }4 |4 a) l0 S
was the product of a full-term normal delivery, with4 ~7 H1 ^, D. L$ Z2 ^
a birth weight of 7 lb 14 oz, and birth length of
3 O% v0 d8 N6 L6 N2 d( f7 \% X20 inches. He was breast-fed throughout the first year6 N, D8 |1 z4 G+ N% r2 a! m$ ]
of life and was still receiving breast milk along with
: l' U% b* r8 ^solid food. He had no hospitalizations or surgery,$ Z! L- X4 P) M3 b: v
and his psychosocial and psychomotor development
6 s- \# d0 r. x; C3 X: c/ R* y/ [- jwas age appropriate.
& P9 ]1 b4 s/ @- T% b' dThe family history was remarkable for the father,
) H( a3 E: X+ K6 I0 i0 s9 I" Zwho was diagnosed with hypothyroidism at age 16,* @: k( ]( R. G4 ^; I
which was treated with thyroxine. The father’s
9 K& G. ^1 a% s1 x. rheight was 6 feet, and he went through a somewhat
2 p& V% K) `0 E1 bearly puberty and had stopped growing by age 14.
. J" O4 m, z6 C- I  L' {2 q/ FThe father denied taking any other medication. The
* r7 N- u$ c- b$ h. zchild’s mother was in good health. Her menarche
: w' G5 F! \3 L: J: @was at 11 years of age, and her height was at 5 feet
7 V5 F! ]; T0 {# C$ J5 inches. There was no other family history of pre-, B: \* z7 ~+ L# q# E. v, n7 ?
cocious sexual development in the first-degree rela-* b3 Z+ u+ T) r) d, j, v4 U! b
tives. There were no siblings.
  v2 [3 @- K" g0 qPhysical Examination" ]* ?5 }$ B$ g  ]! `
The physical examination revealed a very active,% x) q0 V* W& Y# `! v4 B+ d8 W/ z
playful, and healthy boy. The vital signs documented% R7 Y& C/ o  a' Q1 ]4 i4 l: A
a blood pressure of 85/50 mm Hg, his length was
! d+ t0 B1 E- E: i) S$ W$ @90 cm (>97th percentile), and his weight was 14.4 kg
# J7 |% A3 r& i(also >97th percentile). The observed yearly growth
# \2 Z' S' {9 ~& b9 H$ ?$ ivelocity was 30 cm (12 inches). The examination of
6 R7 j" o$ Q/ gthe neck revealed no thyroid enlargement.
* E% e& F% ^+ r6 J. W% O7 QThe genitourinary examination was remarkable for& `1 \/ x8 _+ ?) d3 ?
enlargement of the penis, with a stretched length of
. M4 @6 N: X9 I+ r$ ~& d8 cm and a width of 2 cm. The glans penis was very well
5 X( @* t% R$ o# _developed. The pubic hair was Tanner II, mostly around* X' b8 f7 [1 b% J) y
540% `: s! Q; p  n* E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 u1 a  {; T8 {: e* e. k5 H
the base of the phallus and was dark and curled. The
% M5 c6 q, |: O& D. @testicular volume was prepubertal at 2 mL each.
& t- Q$ ?$ A3 s$ U* R2 WThe skin was moist and smooth and somewhat8 p0 ~. ?& |& D5 a. }8 i% W4 _0 m
oily. No axillary hair was noted. There were no
$ D3 _, P$ A! ^/ Iabnormal skin pigmentations or café-au-lait spots.: f. d  B6 t4 x( J) K4 f$ e
Neurologic evaluation showed deep tendon reflex 2+0 u$ R' Y/ L6 w% j4 i9 d
bilateral and symmetrical. There was no suggestion
( q1 B3 q: k' i. L  ^of papilledema.
  \) |* ?: ~( i- d* m: H( J. x" wLaboratory Evaluation
. Z* o/ J+ b7 y$ d) N* ~! n/ rThe bone age was consistent with 28 months by
' o1 j* k( t: f; G5 R  kusing the standard of Greulich and Pyle at a chrono-" V, N6 E) y( A- D: Z
logic age of 16 months (advanced).5 Chromosomal& Y: ~0 A# X1 ]0 E0 f5 H
karyotype was 46XY. The thyroid function test/ B4 T1 D& l3 f2 }0 _0 x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) T3 d! B  U  {4 K5 h) olating hormone level was 1.3 µIU/mL (both normal).
2 }# j! Q" c( N; ?! P- y8 |5 FThe concentrations of serum electrolytes, blood2 [, L6 E6 r5 S* w) N( f4 P
urea nitrogen, creatinine, and calcium all were
$ Z* d; `- p0 e4 N" M+ V7 m; C/ cwithin normal range for his age. The concentration' w! F1 O" [, h. T
of serum 17-hydroxyprogesterone was 16 ng/dL
' f5 \( K/ |& p(normal, 3 to 90 ng/dL), androstenedione was 20
- h0 O7 c. r! g7 A8 Y: Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  O" J3 b1 t* z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ n0 O6 ]# L, e& R# r  Z4 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. n1 y5 K+ {- @2 `1 ]; H
49ng/dL), 11-desoxycortisol (specific compound S)5 C- O: o/ p5 m9 l  J; m7 I! u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% O% }4 {5 X4 Z3 o7 n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- G$ y+ g0 v8 J8 a9 htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! b* d& C" _# [3 u7 y" wand β-human chorionic gonadotropin was less than
8 p. M2 X1 a( F; D6 n5 F# x- A5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 f+ t. O6 y: R, b1 wstimulating hormone and leuteinizing hormone
% D& B3 R$ {: T, dconcentrations were less than 0.05 mIU/mL9 E! S! N# j1 D* E4 z
(prepubertal).9 _0 a0 Q( y4 k  k# d% `
The parents were notified about the laboratory! s; [! B  A5 B: C5 ]
results and were informed that all of the tests were! d2 F& g# i$ T' k, e( T
normal except the testosterone level was high. The( l: `; k0 p( h
follow-up visit was arranged within a few weeks to
0 H9 z& q. M+ U( Kobtain testicular and abdominal sonograms; how-9 e9 H. o7 f4 q
ever, the family did not return for 4 months.
+ \5 V& Y7 A/ {% T5 B) f' n; m% J9 JPhysical examination at this time revealed that the
+ H6 H3 Q2 l6 x  q* a: mchild had grown 2.5 cm in 4 months and had gained
& r1 Q& {1 @0 P1 j; `% `: e2 kg of weight. Physical examination remained, a- i4 n! V% V- F
unchanged. Surprisingly, the pubic hair almost com-- B4 p! E( ?, K7 O% a# {
pletely disappeared except for a few vellous hairs at" H: [" r2 G5 N( W
the base of the phallus. Testicular volume was still 24 @' K; n! C3 y8 f$ x. M
mL, and the size of the penis remained unchanged.+ x2 V, n4 \& S: Y7 Q/ Z
The mother also said that the boy was no longer hav-
# N% R% L" m  l- e3 j  R: `ing frequent erections./ v' a8 a! P9 Q$ m! g" Z
Both parents were again questioned about use of
1 ]2 E  \4 G; r. y1 z% Bany ointment/creams that they may have applied to. [2 P  ^4 j+ g
the child’s skin. This time the father admitted the2 l4 G4 S- t. ~: o# [% @% p
Topical Testosterone Exposure / Bhowmick et al 541) U, j. d/ B1 M" r0 X" ?
use of testosterone gel twice daily that he was apply-& Y/ X+ M" F4 r1 h4 A
ing over his own shoulders, chest, and back area for
4 y( I; L: H# j9 N, ?8 _a year. The father also revealed he was embarrassed# O5 `. f  v1 i$ C6 l
to disclose that he was using a testosterone gel pre-
5 y) c4 O' g/ u$ r6 lscribed by his family physician for decreased libido! ]5 O& h5 I. v" ~  i# t0 G
secondary to depression.
. f# C5 w, E: L7 d4 I5 w0 F0 L) dThe child slept in the same bed with parents.9 o  t! y, Q  B4 W$ `
The father would hug the baby and hold him on his
, v/ T2 ?9 u- z1 D) f& Vchest for a considerable period of time, causing sig-3 f* F6 o% K( E, y! q( K
nificant bare skin contact between baby and father.
  @( D3 ?& g( q8 OThe father also admitted that after the phone call,
8 s5 S6 [0 }; u- M" Jwhen he learned the testosterone level in the baby
  D% R) r4 {: v8 Swas high, he then read the product information
' b3 v2 X, [; n' Q) |packet and concluded that it was most likely the rea-
) u& t2 j. S0 fson for the child’s virilization. At that time, they4 ^4 P. w/ N! j  j+ ~) I
decided to put the baby in a separate bed, and the+ y+ L+ h/ o8 i9 V
father was not hugging him with bare skin and had5 I, \+ \2 D: ?9 s4 ?
been using protective clothing. A repeat testosterone
8 `* [6 M- c8 \test was ordered, but the family did not go to the% k  X2 {8 F, w% B
laboratory to obtain the test.: |' Y, _" r5 e$ V1 X/ I" z; v
Discussion. E7 b& u' M1 L: p
Precocious puberty in boys is defined as secondary, l; M6 f6 m) Z4 X/ |; M
sexual development before 9 years of age.1,4
$ a) l: M, z9 W7 u! a% f8 W3 tPrecocious puberty is termed as central (true) when: B# b# s1 m7 c: a
it is caused by the premature activation of hypo-  l7 q3 C4 S1 d# _6 [4 e3 s" V" B
thalamic pituitary gonadal axis. CPP is more com-! _6 D" Y& u1 }
mon in girls than in boys.1,3 Most boys with CPP% H7 t! a% N$ }& F% l
may have a central nervous system lesion that is/ m1 }* D8 G3 }+ B2 c* m8 P" ?
responsible for the early activation of the hypothal-
7 r: q$ n" A! oamic pituitary gonadal axis.1-3 Thus, greater empha-; ~  ?# {! }& ]9 Z
sis has been given to neuroradiologic imaging in, j. P% d& [7 ?8 ?. c6 e$ o
boys with precocious puberty. In addition to viril-% x7 H: y2 \6 l! N8 B/ a+ p
ization, the clinical hallmark of CPP is the symmet-4 X. }* f9 T3 t! Z
rical testicular growth secondary to stimulation by. `  m$ H9 x' z/ B. ^  n
gonadotropins.1,3
* m0 o  d0 J7 [! aGonadotropin-independent peripheral preco-
5 `2 K2 A5 b; Y4 o0 R; S7 [% A" qcious puberty in boys also results from inappropriate$ t- c2 F1 L  j4 H( r+ l
androgenic stimulation from either endogenous or2 a6 u0 ^8 x& n
exogenous sources, nonpituitary gonadotropin stim-
3 H* A  {1 L. W/ wulation, and rare activating mutations.3 Virilizing
: K7 s" n6 v- D1 N1 Zcongenital adrenal hyperplasia producing excessive
' A: N  i& F$ G' ?2 ~- r6 @3 I$ eadrenal androgens is a common cause of precocious
# b) F* R  q4 z% U, l5 `puberty in boys.3,43 G# a  r" O: x
The most common form of congenital adrenal$ E" p' |2 K/ P8 y0 o# b( P3 J3 P' m
hyperplasia is the 21-hydroxylase enzyme deficiency.% Q2 k) G5 T& _4 p& j
The 11-β hydroxylase deficiency may also result in$ A1 Q2 T+ o( v. i  n
excessive adrenal androgen production, and rarely,
- ?, M- b# V0 b6 A5 G; ?an adrenal tumor may also cause adrenal androgen
1 B5 F) o9 r  n+ d+ Z4 v  b3 t, ^excess.1,33 u. j3 j: {( s* \4 q* q: o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 p+ p8 h4 N1 \- K, [542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 ]5 l/ u* j( }, v+ T3 b/ ?- h
A unique entity of male-limited gonadotropin-
# l- w  R5 K8 M( l- r" Dindependent precocious puberty, which is also known- @) V/ ^* i  _0 Y. \; S5 _, ^; J
as testotoxicosis, may cause precocious puberty at a
/ @; O2 {4 y+ z4 V. H' avery young age. The physical findings in these boys
5 g3 z) I/ m' z# o* v9 xwith this disorder are full pubertal development,9 e0 {$ P; E. _# X. I- S
including bilateral testicular growth, similar to boys4 q. u% g. r/ A
with CPP. The gonadotropin levels in this disorder1 M3 o. h# g9 z  t, J. b
are suppressed to prepubertal levels and do not show
- C2 h: x- v, x& u7 P5 i( X: Rpubertal response of gonadotropin after gonadotropin-
/ p/ ^2 k1 {, C+ oreleasing hormone stimulation. This is a sex-linked
+ k) [8 P7 g+ G* oautosomal dominant disorder that affects only8 h1 T, \9 ~) o
males; therefore, other male members of the family
3 @3 S9 I7 Y1 F9 O/ umay have similar precocious puberty.3* ?' L( p# b% q5 c+ B
In our patient, physical examination was incon-, a$ a. w6 b. k, p+ ?
sistent with true precocious puberty since his testi-
% I, ]3 k5 m: a5 F4 H( qcles were prepubertal in size. However, testotoxicosis7 x' P. C* \& G, u4 G% v2 c6 Q: n3 V, J
was in the differential diagnosis because his father, ~& y- B) `5 R; d4 D) S! P6 W4 r
started puberty somewhat early, and occasionally,* [6 t2 c$ x7 g7 w: h! M6 Z
testicular enlargement is not that evident in the
% z0 E& |" M) M8 R: H+ W5 Kbeginning of this process.1 In the absence of a neg-
. \& ^5 f6 M5 Q$ f4 T; H4 lative initial history of androgen exposure, our
: s# d, z$ G8 c4 }* g$ l* Kbiggest concern was virilizing adrenal hyperplasia,
( ?+ f4 W" f% k9 V2 o0 jeither 21-hydroxylase deficiency or 11-β hydroxylase
% Z' o( s8 M0 f! pdeficiency. Those diagnoses were excluded by find-
2 E  R3 C1 j! P- ving the normal level of adrenal steroids.5 k) E# H. i3 }% G, H) G3 `
The diagnosis of exogenous androgens was strongly6 N6 h! A" \; I* z
suspected in a follow-up visit after 4 months because- o6 v+ S5 ]! P3 j2 b
the physical examination revealed the complete disap-
" w' `, S9 A8 e- }! x. x0 Dpearance of pubic hair, normal growth velocity, and
; r! z) _( z# K1 Rdecreased erections. The father admitted using a testos-
& {+ k2 Z3 M& I: ^terone gel, which he concealed at first visit. He was1 z% e2 @* J) I2 ^' x9 ]
using it rather frequently, twice a day. The Physicians’& v- z$ v7 @4 I( l# Y# b: K
Desk Reference, or package insert of this product, gel or& I, M% y1 y5 F! L: @
cream, cautions about dermal testosterone transfer to
+ h+ D4 ]$ H: ^% \- Vunprotected females through direct skin exposure.8 L' o& J; m- n( r' }# z  b: A, o
Serum testosterone level was found to be 2 times the
6 U+ }( o# j/ R# ]1 l9 r- kbaseline value in those females who were exposed to! M( ~" ?, I) [$ y! R+ F
even 15 minutes of direct skin contact with their male! i0 }8 p: ^  ?% S2 [3 S- R
partners.6 However, when a shirt covered the applica-
% j% o/ N9 |$ Z0 S( etion site, this testosterone transfer was prevented.: b6 [3 Y2 O: Q3 }* J
Our patient’s testosterone level was 60 ng/mL,) s1 G7 m' p5 _: K9 n4 R+ d1 U+ L
which was clearly high. Some studies suggest that
3 [* ^" w7 u5 y5 m0 g/ Gdermal conversion of testosterone to dihydrotestos-
8 [, W# ~/ A0 s2 \5 l  v; e: i: yterone, which is a more potent metabolite, is more
- d- Q) l' ^6 x$ ^' f2 B8 c! u8 pactive in young children exposed to testosterone
7 ^+ x* d- Y; g; C, d3 texogenously7; however, we did not measure a dihy-! k: v  A6 o9 c! O. w
drotestosterone level in our patient. In addition to
% O7 I* i4 c" a( |virilization, exposure to exogenous testosterone in8 f1 |: v0 N( R) z1 ^5 k
children results in an increase in growth velocity and' j) H: ?* u* b. J8 y$ V5 i
advanced bone age, as seen in our patient." h3 L4 {# D5 {5 ]. z3 d
The long-term effect of androgen exposure during! D  E/ T. e: l; V  E
early childhood on pubertal development and final
5 _. f6 V' `2 d7 F6 madult height are not fully known and always remain1 w( M3 [3 C6 y- {7 Z4 c# b
a concern. Children treated with short-term testos-6 [' C  p$ m; \% N# T
terone injection or topical androgen may exhibit some" _4 i$ X# b7 e9 h+ {4 U
acceleration of the skeletal maturation; however, after
& q& m8 h0 |+ W5 ]cessation of treatment, the rate of bone maturation' x( _( j" u2 ~, C8 U
decelerates and gradually returns to normal.8,9" a$ N# v  b7 B9 p$ {/ x2 f! A- e( i
There are conflicting reports and controversy
/ n6 D0 M9 F& c3 W3 n( [& R. ]over the effect of early androgen exposure on adult
* y' N" U* t- s% Y8 openile length.10,11 Some reports suggest subnormal
! ~9 M5 [; d; H2 l; t. aadult penile length, apparently because of downreg-9 v# a# H" G6 m( _0 p
ulation of androgen receptor number.10,12 However,
( j  R/ C$ b  {' B# a* W: xSutherland et al13 did not find a correlation between
4 s) p7 W2 x. v" J- M; ~childhood testosterone exposure and reduced adult
9 |. A: A0 ]7 k4 ]& j5 Kpenile length in clinical studies.6 D" g9 ?5 w4 i- ]
Nonetheless, we do not believe our patient is5 T0 @: s) b- T0 {$ ^! l, T
going to experience any of the untoward effects from& ?2 p4 k# w7 z* d) p* M. E. Y. \7 D
testosterone exposure as mentioned earlier because
! ^# }) t& X5 x, ?2 Hthe exposure was not for a prolonged period of time.. W0 l9 T+ G: x+ ^6 \# b  o# u
Although the bone age was advanced at the time of# |7 e; \$ }! D: E* z9 F1 q% O2 x
diagnosis, the child had a normal growth velocity at) I! ^# U, r9 g6 g5 L. ]3 S- E
the follow-up visit. It is hoped that his final adult  H2 a) {5 s+ A! [
height will not be affected.
+ [, s. m0 ^  ]4 |& ~2 ?Although rarely reported, the widespread avail-
  p, _6 {- F2 w% h* S$ Eability of androgen products in our society may
: v- F9 \& J7 s4 ~2 C  Yindeed cause more virilization in male or female
4 J& V$ W$ G9 N) w6 Bchildren than one would realize. Exposure to andro-$ `) i- X4 B, C$ s$ u6 B
gen products must be considered and specific ques-
2 r2 C& q) K8 O; }+ Q" }tioning about the use of a testosterone product or2 ^# k# F  T) D$ O- P2 i8 v; \
gel should be asked of the family members during. v3 n8 m1 S# I
the evaluation of any children who present with vir-
$ t' J% K& z) ^0 l; Xilization or peripheral precocious puberty. The diag-( P+ M. w) O0 Q  @" U
nosis can be established by just a few tests and by7 p. `# e) v& w. T
appropriate history. The inability to obtain such a
; G# h! t+ @# x+ R  ]  ?! v' ehistory, or failure to ask the specific questions, may
& u, C& T8 ^9 c3 x7 i& h- _0 t: M( cresult in extensive, unnecessary, and expensive
/ |+ j  A  ?- Q) E3 R% H5 r! Winvestigation. The primary care physician should be
# `1 ~1 ^$ J; B( W: G! q. s3 D7 saware of this fact, because most of these children6 c  c: T; U; }: A0 _. U+ c
may initially present in their practice. The Physicians’
5 V9 ]  `( [6 W/ @* SDesk Reference and package insert should also put a
: r/ h1 f+ S0 ?1 l' L$ u2 I5 W5 cwarning about the virilizing effect on a male or
/ N* O3 l8 f2 ]6 W$ h6 r! xfemale child who might come in contact with some-
9 o/ y4 j8 j6 @8 N; h9 {one using any of these products.
8 r* C8 A, ?  f% T" l+ VReferences' A0 Z5 N# R, Y4 [8 y
1. Styne DM. The testes: disorder of sexual differentiation  }9 J! b) ~; k/ o- y& O
and puberty in the male. In: Sperling MA, ed. Pediatric
' Z! [5 x: f8 x2 \% g# BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 G2 b6 M, b0 q) @' A* C
2002: 565-628.5 ~/ ?$ ?" s& V3 O* C
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" ]2 d6 N! e& Z* g2 ypuberty 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

" _- A6 c8 [1 `. F) p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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