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Sexual Precocity in a 16-Month-Old
6 @& r* k2 y7 m% A, R& u* yBoy Induced by Indirect Topical1 {$ o* v1 c2 m2 r. j
Exposure to Testosterone: P+ g! R0 V. V7 M% O" b+ B: Q4 t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* ^$ r8 s/ F8 I0 m$ z$ d
and Kenneth R. Rettig, MD1- H" ~& [3 E& S5 Y8 F& w) y; c
Clinical Pediatrics- D/ U; p9 Q( n* k
Volume 46 Number 6' o9 `) L5 Q: w4 ?- y; k, I+ K: J
July 2007 540-543
* x) b5 C+ I2 b9 t© 2007 Sage Publications
9 l# Q3 g9 i5 ?, ?7 t10.1177/0009922806296651; b' H3 U& t) V; a: n) u
http://clp.sagepub.com
4 K) Q5 R, L$ p% _/ w' }hosted at
3 N1 ^& [$ y6 n! r1 [2 T7 }* w8 }8 nhttp://online.sagepub.com
+ o/ P" }# t% m1 M/ \7 \" }Precocious puberty in boys, central or peripheral,) `+ y4 j9 L& H4 G
is a significant concern for physicians. Central3 f+ C* I7 f/ G: d: F1 J
precocious puberty (CPP), which is mediated
  d* `1 b5 j/ \$ ~" h' Fthrough the hypothalamic pituitary gonadal axis, has
  s- R6 S* w- s% [" Ga higher incidence of organic central nervous system
/ v7 f& G" j2 n' Llesions in boys.1,2 Virilization in boys, as manifested
! s8 k$ v  a& O4 C) Xby enlargement of the penis, development of pubic
' |8 X. y: _4 n+ {6 Rhair, and facial acne without enlargement of testi-
! h% k- ^9 ?- r9 Z0 K( @& M& |cles, suggests peripheral or pseudopuberty.1-3 We
" m! `( P3 Q* |9 ~! t7 kreport a 16-month-old boy who presented with the
- Z) S8 A4 B7 e" }5 c4 Zenlargement of the phallus and pubic hair develop-9 X% d! V( M; t: D
ment without testicular enlargement, which was due8 m% u4 ]+ }; I
to the unintentional exposure to androgen gel used by
( ]( I9 T' j7 F, i" Qthe father. The family initially concealed this infor-3 X. d$ a9 Y: C2 q- d/ J
mation, resulting in an extensive work-up for this
  g- U- y9 L6 }0 k6 Hchild. Given the widespread and easy availability of- `# K5 Q1 _) ?  H& ^
testosterone gel and cream, we believe this is proba-
+ }+ s$ J# @4 g# p3 t- h  S) t: h+ Kbly more common than the rare case report in the
5 O' E/ |4 `% A, l# e$ Iliterature.4; F1 H- p/ e+ w, s( @7 B# Q# Z& g: t
Patient Report
6 c4 r* m3 i6 [" z' @A 16-month-old white child was referred to the2 u8 w4 F3 @4 K( R8 R
endocrine clinic by his pediatrician with the concern; Y* C: x2 B7 I$ w4 W- v
of early sexual development. His mother noticed5 Z# P* [  q" @2 r! c
light colored pubic hair development when he was
$ a9 v, @8 i4 a) g9 ~$ ?From the 1Division of Pediatric Endocrinology, 2University of
! M( _4 v) q4 I0 B$ @South Alabama Medical Center, Mobile, Alabama.
  Y+ i, v2 ]5 ]0 Z. {- G& @3 |Address correspondence to: Samar K. Bhowmick, MD, FACE,
  O+ P  d- A3 E6 |Professor of Pediatrics, University of South Alabama, College of2 S" W% u" W6 c- F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 D9 `' C9 K2 I/ S$ |
e-mail: [email protected].  Y( D) l! v0 Z) X1 S3 x0 a7 }( Z7 w
about 6 to 7 months old, which progressively became' B# K* x; m3 W6 e" e/ r
darker. She was also concerned about the enlarge-
/ q# o+ J( V( a6 Wment of his penis and frequent erections. The child
( I$ h6 m! W, Z% Rwas the product of a full-term normal delivery, with
& X% e5 D, e) r! @% ?a birth weight of 7 lb 14 oz, and birth length of9 Q( J9 Y8 ~4 G* t& w( j" Y
20 inches. He was breast-fed throughout the first year
  J4 f" P, `2 c- u& k- T- Oof life and was still receiving breast milk along with
: Y$ ^/ t6 w8 J3 ~3 Z; Usolid food. He had no hospitalizations or surgery,2 c, h9 {5 k' A7 e" u
and his psychosocial and psychomotor development
1 {7 j: h2 w1 s5 G1 Pwas age appropriate.
+ j% Z3 j9 q3 X  ]+ rThe family history was remarkable for the father,
5 [4 l" g- T% T7 x1 M& Twho was diagnosed with hypothyroidism at age 16,4 N  K1 l) Q1 C4 \" [! j  @
which was treated with thyroxine. The father’s
, N* j: ~* X- a) T0 ?- vheight was 6 feet, and he went through a somewhat/ `% |* ~( G0 H& [  `4 N# m' R
early puberty and had stopped growing by age 14.
0 h. j) A  K3 C( wThe father denied taking any other medication. The  Y% r$ W/ b. X& i
child’s mother was in good health. Her menarche
' l3 X& }: u! Lwas at 11 years of age, and her height was at 5 feet
5 W3 |- y  N2 v5 inches. There was no other family history of pre-
( Q, @. `5 x/ W, r+ u# C* ucocious sexual development in the first-degree rela-2 H  d* t) z/ B6 `
tives. There were no siblings.
6 {- q: L/ O' \$ Y7 [  j2 KPhysical Examination
6 k# d5 F2 U6 X- nThe physical examination revealed a very active,
  Q# o" N, e& Vplayful, and healthy boy. The vital signs documented
# D& G' }7 g8 i+ q2 ma blood pressure of 85/50 mm Hg, his length was3 X; _- e6 T+ l8 X$ J3 w* n1 `9 M
90 cm (>97th percentile), and his weight was 14.4 kg. o- M. b: o. R9 F( n
(also >97th percentile). The observed yearly growth
- K4 \3 N# h* W& ]- M  B4 w) U: \( }velocity was 30 cm (12 inches). The examination of
: r& @5 g  w% }1 n+ Y& q# Hthe neck revealed no thyroid enlargement.
8 Z" s7 m& T, rThe genitourinary examination was remarkable for0 Y) |  X! b7 `, Q, N$ o
enlargement of the penis, with a stretched length of
; Z; j% o& m, j9 i: d5 j, ^8 X* y8 cm and a width of 2 cm. The glans penis was very well
& s$ S5 K: o* k9 r# S* o" R5 mdeveloped. The pubic hair was Tanner II, mostly around" x( C& Q2 }) t4 V* q" |( o% X8 u
540
: j% e2 |% o" N: aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 x; ~! y) l! t1 U7 K, Q+ }+ S
the base of the phallus and was dark and curled. The
  l3 b% F; d$ N  K$ D( Vtesticular volume was prepubertal at 2 mL each.
+ t* Z( m; R5 ~$ ]8 D9 `The skin was moist and smooth and somewhat+ _5 V: E# m- {  u# {2 I6 [
oily. No axillary hair was noted. There were no
- M. a9 r3 r7 p. @* k1 m. Aabnormal skin pigmentations or café-au-lait spots.$ i0 x! S7 a/ O' r# j- i
Neurologic evaluation showed deep tendon reflex 2+3 t, {9 Y8 {* Q
bilateral and symmetrical. There was no suggestion# l9 c$ G3 s% \* g
of papilledema.
) y4 G- B' m$ \Laboratory Evaluation
& D7 k) F: r- J6 |The bone age was consistent with 28 months by; Y2 B1 O0 b3 R2 ~
using the standard of Greulich and Pyle at a chrono-
2 l1 g" T6 f5 x9 D& ?7 Q) \, `( {1 Llogic age of 16 months (advanced).5 Chromosomal* J5 B8 l. _- Q8 ?
karyotype was 46XY. The thyroid function test
+ Y( Z# S$ b% v* Cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" U( U5 O7 L& f6 [
lating hormone level was 1.3 µIU/mL (both normal).: c2 A1 H; K5 u; v7 d
The concentrations of serum electrolytes, blood+ u) ^8 O, ^2 ?* g- [
urea nitrogen, creatinine, and calcium all were
6 S9 r5 C( J5 c+ Mwithin normal range for his age. The concentration) J0 [! k# L. ]* r+ v8 e$ {+ a
of serum 17-hydroxyprogesterone was 16 ng/dL! A. K. V1 X! S
(normal, 3 to 90 ng/dL), androstenedione was 20
$ P2 ^' O5 A5 h* ]) ~: [ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 L5 ?6 E0 I$ X* t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),- e4 l1 c4 _, C( V: [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 X0 u7 {8 I9 `6 `
49ng/dL), 11-desoxycortisol (specific compound S)  ~/ F$ c/ V+ [$ X" ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) M& ^) \8 X1 h5 t5 e7 t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 w% q4 k$ X, p0 s9 \, P
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 o3 p' S4 ^4 O" |( c+ Aand β-human chorionic gonadotropin was less than2 J! t, ]! u* ]: Y* O
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 o- A3 S/ X# @; v6 d; V
stimulating hormone and leuteinizing hormone" z2 U& z( ]& x- j2 `
concentrations were less than 0.05 mIU/mL
+ B: t3 m# i7 e9 `# k8 Z" E6 `7 T- d(prepubertal).0 y7 ]: \. N8 S8 h) Q. B
The parents were notified about the laboratory
& P% D, Y# l; y" W* @results and were informed that all of the tests were3 R4 {! W* d+ |. I, k
normal except the testosterone level was high. The
5 w9 o; d1 s! w0 i8 m7 N* s& g/ L8 Q' `follow-up visit was arranged within a few weeks to0 b; ?+ o, z& e
obtain testicular and abdominal sonograms; how-
. B+ {; Z) u7 B$ P3 b7 V/ d9 eever, the family did not return for 4 months.
+ h, \/ J) l* l: k/ A5 }Physical examination at this time revealed that the- G1 d4 X# B) e8 B& W# c' w
child had grown 2.5 cm in 4 months and had gained2 H+ h- w' c$ }' z! q
2 kg of weight. Physical examination remained
7 l# [/ [( a( c* j  }4 e0 Gunchanged. Surprisingly, the pubic hair almost com-
  F  G' f# F4 wpletely disappeared except for a few vellous hairs at
4 @, u( n# D: B- X' w1 R5 c/ \. A! ithe base of the phallus. Testicular volume was still 2
6 `7 U6 i5 @" X- BmL, and the size of the penis remained unchanged.8 ]5 Q6 _) `. A! @
The mother also said that the boy was no longer hav-/ g! E2 M) ]/ C" R( ~1 D
ing frequent erections.# s) H$ ~& T2 `3 W0 [& [2 g
Both parents were again questioned about use of9 m: o. A8 C2 Q+ N9 i8 U% p8 b
any ointment/creams that they may have applied to
+ c% J* f9 r. q& Uthe child’s skin. This time the father admitted the
) S. g( c: ^2 t- Z1 k. ]2 |4 U* HTopical Testosterone Exposure / Bhowmick et al 5414 j, H" X6 W, M. `/ z+ p
use of testosterone gel twice daily that he was apply-
  J5 B; a1 t4 Z0 D" z2 R# Fing over his own shoulders, chest, and back area for
0 v/ I& y6 D/ S4 C) B, Na year. The father also revealed he was embarrassed
6 A# F8 @; I0 r, @7 tto disclose that he was using a testosterone gel pre-
: @+ P' V$ t. D! Gscribed by his family physician for decreased libido& V( E( u2 c! {
secondary to depression.
: l3 h: a; i& AThe child slept in the same bed with parents.
9 g7 _  m" }/ B7 L6 W3 EThe father would hug the baby and hold him on his
3 e: i* p  g% C7 u4 t4 Jchest for a considerable period of time, causing sig-
! l4 I; z6 j* r5 ]0 ^nificant bare skin contact between baby and father.
6 a$ W+ P& ?* ]) ~9 _: TThe father also admitted that after the phone call,
4 M' r( k7 U/ p0 l2 Y+ |when he learned the testosterone level in the baby
  X) V8 f& h* @( i3 qwas high, he then read the product information# |- }) y  S, s3 G' u' T: A
packet and concluded that it was most likely the rea-/ d! T2 H1 v6 _: ?7 |
son for the child’s virilization. At that time, they
& W- ~* n3 @6 c; E' T" `* G7 ddecided to put the baby in a separate bed, and the
6 D/ Y" P/ T6 Vfather was not hugging him with bare skin and had7 O) p; w  Q6 [* v: n! q: T, y
been using protective clothing. A repeat testosterone% R, {3 @  ^5 G
test was ordered, but the family did not go to the. G; d" h9 i% v3 U
laboratory to obtain the test.; a2 S. d& M, Z  R. T) v7 A
Discussion6 L1 Z, z0 d% V, Z! J: |: c
Precocious puberty in boys is defined as secondary
5 M: M8 m! ?+ e) }( Hsexual development before 9 years of age.1,4
5 I5 I3 h/ r2 O- jPrecocious puberty is termed as central (true) when
7 `- ?% e0 U0 u+ m  d, J4 lit is caused by the premature activation of hypo-
" c2 T" |$ L! j. r$ r6 F! ^' d/ rthalamic pituitary gonadal axis. CPP is more com-6 M/ N( ~, h, B9 {$ K2 ~
mon in girls than in boys.1,3 Most boys with CPP
( X6 ^# s$ P) L$ K7 i  O8 q! ^may have a central nervous system lesion that is
* n4 v& H0 l; `/ Yresponsible for the early activation of the hypothal-
$ a* W; w3 u4 ~0 ramic pituitary gonadal axis.1-3 Thus, greater empha-
/ m! v' `) F! K/ u+ ~sis has been given to neuroradiologic imaging in! p0 _8 k+ Z; V  s
boys with precocious puberty. In addition to viril-3 y9 G, V6 j5 ~; ~
ization, the clinical hallmark of CPP is the symmet-7 F, Q1 ^  O- D
rical testicular growth secondary to stimulation by( p/ g' P4 ]; Z, g* Z; O6 f
gonadotropins.1,3) h  n' P" k) Y# a
Gonadotropin-independent peripheral preco-# f+ x! N& \- O& i1 @
cious puberty in boys also results from inappropriate
! u2 E* J: s* \5 z' ?- v+ ^) nandrogenic stimulation from either endogenous or
4 f; l4 D4 ~$ F2 `- texogenous sources, nonpituitary gonadotropin stim-  k) S8 R1 J7 Q5 S; e) p
ulation, and rare activating mutations.3 Virilizing
9 G. J2 B! \- d6 X5 j! T% k$ Y2 ^congenital adrenal hyperplasia producing excessive$ l& N$ N+ w! ~- ~6 k6 o
adrenal androgens is a common cause of precocious
3 N) e  N  r# _! P( Wpuberty in boys.3,41 U5 [2 Z+ W9 y4 \5 e
The most common form of congenital adrenal0 Z; ]  p1 o% J2 P: V- h# K
hyperplasia is the 21-hydroxylase enzyme deficiency.; C  E1 d$ M% z% @' ^. W1 u
The 11-β hydroxylase deficiency may also result in- k5 F8 r+ H5 d1 C& w7 l! Q; d
excessive adrenal androgen production, and rarely,2 p7 W' s% t& u) F; q7 l
an adrenal tumor may also cause adrenal androgen
4 m5 w/ `/ e1 fexcess.1,3
7 b! b( M. n& h- Q$ Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; y+ i8 b  p8 w% z/ t# N3 T
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 u  T' O4 [  F" l) A" e% E! z; X
A unique entity of male-limited gonadotropin-
% |+ t2 S* v1 Q  Cindependent precocious puberty, which is also known
2 L* s6 }8 V0 E2 Yas testotoxicosis, may cause precocious puberty at a
* V9 A! M/ B' C5 d1 I! Bvery young age. The physical findings in these boys
" O7 b. i' k! t9 Fwith this disorder are full pubertal development,
9 s* ^& @" L8 [1 k$ Fincluding bilateral testicular growth, similar to boys% V7 `7 o, l  n/ p7 C
with CPP. The gonadotropin levels in this disorder
% S  O7 b! K7 ]) rare suppressed to prepubertal levels and do not show  _: R, `- n: x4 z! ?
pubertal response of gonadotropin after gonadotropin-8 l" Z2 ~2 p. Q
releasing hormone stimulation. This is a sex-linked
! P8 L' G% H: R* `# h3 w3 d' Pautosomal dominant disorder that affects only8 L3 a' q+ z5 W8 i* e+ f  [0 f7 k
males; therefore, other male members of the family
7 D5 W3 V) a; Z7 ]# |6 r+ b1 _may have similar precocious puberty.38 p) D0 W6 q" a9 t! i9 L) |* x
In our patient, physical examination was incon-, n$ X* p8 `* R7 h
sistent with true precocious puberty since his testi-
3 d/ P* n( a7 }3 O( \2 h. [: A- K: mcles were prepubertal in size. However, testotoxicosis
0 W  S& d+ N% J, s6 k, |9 Dwas in the differential diagnosis because his father' n, r4 g, m4 A6 S$ E3 Y
started puberty somewhat early, and occasionally,
/ j& B- E+ n3 w2 E; l: y( Otesticular enlargement is not that evident in the
9 Q# h) s/ L+ A+ N) |beginning of this process.1 In the absence of a neg-
. F) _: y' O& U: J; U) O5 L9 ?: lative initial history of androgen exposure, our
4 Y4 \& w6 d* \3 t1 ^biggest concern was virilizing adrenal hyperplasia,
, K* S/ w6 a/ jeither 21-hydroxylase deficiency or 11-β hydroxylase
% h4 N' R% \: h8 \' d# g5 _deficiency. Those diagnoses were excluded by find-
! [: i6 B4 r4 ~7 W& L6 [ing the normal level of adrenal steroids.7 f- L9 J) p8 j  g/ K+ m
The diagnosis of exogenous androgens was strongly; `- s. y" h. E/ U* \5 T, z
suspected in a follow-up visit after 4 months because' m# ~1 v8 e1 X9 d2 A
the physical examination revealed the complete disap-+ q+ _' r5 [/ v1 F+ M+ l! H; T
pearance of pubic hair, normal growth velocity, and$ a5 h( j8 u* T0 N6 j
decreased erections. The father admitted using a testos-
) k5 W# }' x- f2 J' Dterone gel, which he concealed at first visit. He was, @; w, S( T/ [3 Y
using it rather frequently, twice a day. The Physicians’
( O6 h% M/ R) ?Desk Reference, or package insert of this product, gel or  Y9 D) a, L! b6 u0 K( K: g0 q
cream, cautions about dermal testosterone transfer to8 P" f0 c; D6 u
unprotected females through direct skin exposure.' b5 v" a' D) o: p
Serum testosterone level was found to be 2 times the
: ~! _5 H9 m" y" ?baseline value in those females who were exposed to9 l/ |% o/ W  g# r# o
even 15 minutes of direct skin contact with their male1 E" X0 i5 g- m4 p7 A  n
partners.6 However, when a shirt covered the applica-
- q/ [6 K" A) {) l8 k2 ?( u4 F+ Etion site, this testosterone transfer was prevented.
4 ^% H2 R) I- y* R5 G- o( c, ?Our patient’s testosterone level was 60 ng/mL,7 z+ E5 G3 Z9 D, p" G, t7 w
which was clearly high. Some studies suggest that( l  M0 H$ o4 \5 r; }
dermal conversion of testosterone to dihydrotestos-4 E8 G7 P" c" C/ J8 D
terone, which is a more potent metabolite, is more
# e7 r; W# l: |9 i1 Q  bactive in young children exposed to testosterone
9 n7 ^3 M7 G9 S6 Z: H# J: \6 W8 C" pexogenously7; however, we did not measure a dihy-
! V7 W$ X7 D. `7 \5 ]5 G" r% D/ |drotestosterone level in our patient. In addition to2 D) _$ Y* V  w. P' {% G2 A
virilization, exposure to exogenous testosterone in( ]. X/ R3 H9 ^8 F/ i
children results in an increase in growth velocity and1 [3 r5 P. Q) C
advanced bone age, as seen in our patient.
! r: O4 \' W8 ^) U. @3 _+ NThe long-term effect of androgen exposure during
6 D# I& h" }  \$ Z8 gearly childhood on pubertal development and final7 `9 X& D; y$ G
adult height are not fully known and always remain2 F# [  _9 `) x, l( T, T6 K, D
a concern. Children treated with short-term testos-! X- q  z$ `0 F# h9 [' s6 V3 Q
terone injection or topical androgen may exhibit some
5 [+ d$ S+ t* z% h: Uacceleration of the skeletal maturation; however, after/ n1 |; l7 Y7 v" a$ o$ a) g& N
cessation of treatment, the rate of bone maturation( \3 @" [) D! }) u4 Q5 Y; v6 F
decelerates and gradually returns to normal.8,92 L  ^. N# c4 ]3 o/ F8 P" q
There are conflicting reports and controversy
! H' T# s7 g5 Xover the effect of early androgen exposure on adult! [3 ?7 B+ p$ j( ]$ c) F
penile length.10,11 Some reports suggest subnormal9 v$ e7 N5 y. x2 S
adult penile length, apparently because of downreg-
; t/ M5 S9 C; Z, s- _ulation of androgen receptor number.10,12 However,
$ M9 _. Y% T. W( P9 }7 }. L; xSutherland et al13 did not find a correlation between
8 a- U, E# M9 S8 x1 Q" w$ G; V$ Kchildhood testosterone exposure and reduced adult. U; B' g( `1 }' U7 U3 y3 A- T
penile length in clinical studies.
3 `8 K. H+ R* @0 E( I7 ANonetheless, we do not believe our patient is
1 O7 T' W! z1 Cgoing to experience any of the untoward effects from
2 ^+ B" Z4 F, T, f, O, j. U+ Utestosterone exposure as mentioned earlier because! P* \) j) l0 ?" g
the exposure was not for a prolonged period of time.7 o( K# l- i/ p5 S
Although the bone age was advanced at the time of, x4 e# Q( M- A4 r, n* Z+ k1 g+ i
diagnosis, the child had a normal growth velocity at
6 i$ ~# [  |& g( Cthe follow-up visit. It is hoped that his final adult4 B% O* o  s) a$ t
height will not be affected.
4 `; O) N" M" X8 _6 r9 BAlthough rarely reported, the widespread avail-
8 V. W/ y0 x, b1 vability of androgen products in our society may5 g9 U; d4 b# G7 m2 g7 |5 z
indeed cause more virilization in male or female
; J$ D; J/ @$ v9 t$ i- r+ u+ U: Achildren than one would realize. Exposure to andro-
- t' Y8 ]- a0 w$ e' O7 j/ ~7 bgen products must be considered and specific ques-
+ D1 v2 r" Z4 G7 q! R& btioning about the use of a testosterone product or# x/ @$ [& B$ i$ ~7 t4 N
gel should be asked of the family members during
/ p+ v. Y7 }* b$ Q5 }the evaluation of any children who present with vir-6 t; A$ q7 i# g. g2 E3 x8 f
ilization or peripheral precocious puberty. The diag-  ]. {/ l' I  T9 a* C' T4 y7 h3 S
nosis can be established by just a few tests and by" z" u9 M$ B( v# c% V" K2 a# ]
appropriate history. The inability to obtain such a9 r7 `- v, m7 f+ N7 @* ~
history, or failure to ask the specific questions, may
$ P0 Q, u$ u; D9 oresult in extensive, unnecessary, and expensive* h1 t% S& @  T) V
investigation. The primary care physician should be5 w7 ?: x. i5 k" A+ m7 q
aware of this fact, because most of these children2 w: B) ]: M+ A. ]
may initially present in their practice. The Physicians’
6 x( e1 f$ V$ p; xDesk Reference and package insert should also put a
% W2 U  n$ F% W" ewarning about the virilizing effect on a male or
) v4 Y0 A/ u( z" X# Cfemale child who might come in contact with some-
  L! t& i- |. s+ _: o9 ]+ |/ None using any of these products.  x4 v8 K3 l% F. M8 u8 }% d
References
) Z! z. ?3 a0 K" ^( D1 L2 [" b; v1. Styne DM. The testes: disorder of sexual differentiation' S; L. ~9 W! B7 |" D  I
and puberty in the male. In: Sperling MA, ed. Pediatric5 Q9 P0 ^. E5 v/ L
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 G$ _3 }2 J6 N+ j0 H+ c# I
2002: 565-628.& W& X* N& l; _, x$ N  }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 G5 P& D% \  `. Lpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ \- E; I8 K6 `& ?: V& n, eBoy Induced by Indirect Topical4 Q: X2 r, }1 k4 b2 S4 I
Exposure to Testosterone
- E( i/ V, I) O" ^3 A" J  o$ YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. G1 L( T$ R- t  U; Q7 f) T+ eand Kenneth R. Rettig, MD1& h  X. ]& G6 r: }8 S: y: f3 ]$ I" n
Clinical Pediatrics* _" u9 X" [' @7 k; x4 m4 Q
Volume 46 Number 6
0 Y2 G. v/ V& h  E" R  s% xJuly 2007 540-543/ `( Y) p5 Z) l
© 2007 Sage Publications
0 Q, Q+ G" L) b0 J- p& g4 M10.1177/0009922806296651
. T( k, q* Q1 h- H1 l7 M5 ]2 c4 R( Ahttp://clp.sagepub.com
* W% ^7 @, D9 R( k' o/ L  [hosted at" C0 y. a, C9 e) _  h6 ]2 ^; x" a
http://online.sagepub.com+ g$ y' W2 N' W0 j, ]) [7 x
Precocious puberty in boys, central or peripheral,9 {) U3 N& Q" |: a
is a significant concern for physicians. Central
/ @' q! S. R6 H, @( Q/ pprecocious puberty (CPP), which is mediated
. t$ r+ B+ f) G7 N2 F" C. Ithrough the hypothalamic pituitary gonadal axis, has
5 T8 w  d$ r& q+ d/ Ba higher incidence of organic central nervous system
7 A! x: @; _* o$ i$ v$ \lesions in boys.1,2 Virilization in boys, as manifested
3 |  C+ K- U( |2 X0 K# \* Jby enlargement of the penis, development of pubic9 H1 v$ m  }, n* o$ L, `& p
hair, and facial acne without enlargement of testi-" d& M4 J# R* Q  L& u! _0 p
cles, suggests peripheral or pseudopuberty.1-3 We) I1 k! ^& b. p2 s: [2 |) m
report a 16-month-old boy who presented with the
- q$ d! A. R+ Z  wenlargement of the phallus and pubic hair develop-
7 F* j6 l# Q! a  Cment without testicular enlargement, which was due
6 A) w0 c& C0 |2 j) O! R! T, \, W( bto the unintentional exposure to androgen gel used by0 G; Q1 S5 x! b& s2 l
the father. The family initially concealed this infor-- l/ o4 u5 S7 R- z# B6 `& }
mation, resulting in an extensive work-up for this* B1 c+ c* A" Q1 H  v, W
child. Given the widespread and easy availability of8 M# S# C3 Y1 K' k6 J' ~( D+ g
testosterone gel and cream, we believe this is proba-
& H8 K. s: ^* b) C- {bly more common than the rare case report in the
9 R- B% k6 ]* ^literature.4, l  {, v  x+ |3 k
Patient Report
% J* v: L0 T) C! U4 rA 16-month-old white child was referred to the2 ]& {; K& d+ d( G1 x
endocrine clinic by his pediatrician with the concern6 R2 {9 f* V* f6 J6 p  B! v' A
of early sexual development. His mother noticed+ Z0 Q2 H( `$ @  ]+ S; ^
light colored pubic hair development when he was! x# V2 H; S4 O* d& `
From the 1Division of Pediatric Endocrinology, 2University of
3 d0 S7 {9 j' h4 C' Z/ ]: g1 XSouth Alabama Medical Center, Mobile, Alabama.
# g5 O0 F9 F1 n+ ~: eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 Q3 f/ u& m" A% F% Q+ p- U" ?Professor of Pediatrics, University of South Alabama, College of* N4 L* X7 f( d' x+ U* D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 W/ F1 O1 m# h" C+ }* V3 g' j: l
e-mail: [email protected].
/ q& X* E9 U7 {$ R( Pabout 6 to 7 months old, which progressively became
! S  Y) a/ c! jdarker. She was also concerned about the enlarge-
: l; m( R; s$ xment of his penis and frequent erections. The child9 v' I# c. I- A4 \
was the product of a full-term normal delivery, with! Q2 s0 p5 E, I  y7 B0 e. X
a birth weight of 7 lb 14 oz, and birth length of
/ N3 P* U6 E$ A* q+ O; R20 inches. He was breast-fed throughout the first year
( ?/ X' @4 a+ lof life and was still receiving breast milk along with9 Q4 ]; |! H/ k; |* I$ n
solid food. He had no hospitalizations or surgery,
( B( [% g! B" k( pand his psychosocial and psychomotor development
" u# x! d! E3 D/ p% @" @was age appropriate.0 v& T) {  W0 ~" \: z+ h  a+ ^! m
The family history was remarkable for the father,
! R! u2 r6 z+ g5 ywho was diagnosed with hypothyroidism at age 16,, i/ V& b4 P5 T2 C' D5 e/ A
which was treated with thyroxine. The father’s$ F+ j5 c# D* \8 p
height was 6 feet, and he went through a somewhat
6 o" C4 r. q  U5 E4 jearly puberty and had stopped growing by age 14.
0 J% }2 r/ B8 FThe father denied taking any other medication. The
7 J- d& `8 I1 B9 @child’s mother was in good health. Her menarche
! _4 O* P7 ^( D( U% k; Z& p7 x0 Y1 ~was at 11 years of age, and her height was at 5 feet
! e+ c: e5 O' P% q" r5 inches. There was no other family history of pre-; L  S% u& Q3 |* H
cocious sexual development in the first-degree rela-( y9 K$ A  Z7 ^
tives. There were no siblings.7 A- A9 v* \. J9 t
Physical Examination
* \9 \/ }) s' i, Z9 e. o3 ]The physical examination revealed a very active,$ L6 d' a6 ?: b
playful, and healthy boy. The vital signs documented
' F" v% T* n% Ja blood pressure of 85/50 mm Hg, his length was
9 U2 r/ A9 x) z, J) u90 cm (>97th percentile), and his weight was 14.4 kg4 T' h8 g2 M+ w
(also >97th percentile). The observed yearly growth% l( u, }. S* `7 L* x' k1 X
velocity was 30 cm (12 inches). The examination of. g- @! `) W6 q+ m$ ?- |
the neck revealed no thyroid enlargement.$ f% L( w" S9 b$ P. h( _( ?
The genitourinary examination was remarkable for* w* Q! l: t% e: Y- ]  L
enlargement of the penis, with a stretched length of( m4 R* G3 D+ H" R; @
8 cm and a width of 2 cm. The glans penis was very well! h# X7 Q: C9 ~7 o8 s' \
developed. The pubic hair was Tanner II, mostly around/ W$ j3 f/ m4 `7 g; }% b
540
( ]* o$ H! Z0 q( m4 Z. A" L+ Z7 kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% `& ]* r+ v9 W/ u
the base of the phallus and was dark and curled. The
& _( d6 _: ^2 Z4 s: Etesticular volume was prepubertal at 2 mL each.
8 v8 f' k4 h! {9 s- F3 IThe skin was moist and smooth and somewhat
9 R5 h) K6 D5 O" Y9 Woily. No axillary hair was noted. There were no
9 ?. y/ Q& h! Gabnormal skin pigmentations or café-au-lait spots.
" I. K$ p# C" P$ I& W. _0 V) bNeurologic evaluation showed deep tendon reflex 2+
9 r% a' S  w3 xbilateral and symmetrical. There was no suggestion7 Y( _. d& w. n5 Y6 }
of papilledema.
$ ]0 i0 P4 m% x, L/ ?Laboratory Evaluation
4 P1 B8 p4 R% z9 x$ i; {( MThe bone age was consistent with 28 months by
' ~0 W$ r1 Y+ Ousing the standard of Greulich and Pyle at a chrono-
+ }; _: B. r' Dlogic age of 16 months (advanced).5 Chromosomal; m1 \: e3 ]3 C8 p
karyotype was 46XY. The thyroid function test
- s6 s" p) h% ?* Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
% q; r' H4 Q) l) ~, ~5 H$ ylating hormone level was 1.3 µIU/mL (both normal).
2 u# Y6 x6 C1 ?; A  J1 g" OThe concentrations of serum electrolytes, blood+ `( T$ L! b/ `* o5 R' C2 S* }" f, p5 l
urea nitrogen, creatinine, and calcium all were
" G& L3 A: Z( i2 w3 zwithin normal range for his age. The concentration
) s/ R0 q4 A! |. H) \of serum 17-hydroxyprogesterone was 16 ng/dL
* ]% \2 L1 t$ T2 W(normal, 3 to 90 ng/dL), androstenedione was 20; V. Z4 N* T; A
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 c7 a# e; {# @terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ c- D+ {( S3 y' u: U+ z
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
, _2 @3 f( N2 g" t, y2 o7 B49ng/dL), 11-desoxycortisol (specific compound S)' _  `4 f' O: F/ t- x4 X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( X, s& F, l- r1 v2 `9 V* F- [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' m" H2 M; x/ A" U
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 W- q" @+ z: {$ n9 ?0 Gand β-human chorionic gonadotropin was less than
, ~. z6 U- t. F6 R  A5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 b6 H1 F% Y* H. Pstimulating hormone and leuteinizing hormone
- p0 G" d/ c# u5 T1 `2 p5 K4 Zconcentrations were less than 0.05 mIU/mL
- f) ?5 n8 m0 k/ m5 s4 X(prepubertal).4 `, A2 I5 \* {; s' D! L% ]: s
The parents were notified about the laboratory" ^) J. U3 Y" B5 K4 c& Q
results and were informed that all of the tests were8 }" ^) z' _6 f* p& R8 d  G
normal except the testosterone level was high. The
) n$ Q: k; J0 ?3 C* l) h$ ^( Jfollow-up visit was arranged within a few weeks to" V+ \9 [. w/ _0 I
obtain testicular and abdominal sonograms; how-
2 q1 W4 s0 u& B' H, W8 q( O( `6 m1 vever, the family did not return for 4 months.
4 q" I1 \4 d, q; L4 z! VPhysical examination at this time revealed that the
* G9 k) ~$ Z8 Z) t" S( l, F+ Lchild had grown 2.5 cm in 4 months and had gained
5 N3 W/ D5 ~, w1 |. I9 q2 kg of weight. Physical examination remained
& }8 n3 m: u$ ]0 c1 ounchanged. Surprisingly, the pubic hair almost com-  I9 a* N4 {  X
pletely disappeared except for a few vellous hairs at
& E7 h* C) t. u* V! m+ rthe base of the phallus. Testicular volume was still 2" M  T; I, b2 D% C1 k  Q
mL, and the size of the penis remained unchanged.
; B3 J# y: `' \4 }The mother also said that the boy was no longer hav-
$ p% G) ~$ t9 d, w( j+ Wing frequent erections.( z8 a' M/ i  q+ c; t
Both parents were again questioned about use of- O' v8 T% C& R8 {( `' S: N
any ointment/creams that they may have applied to
1 c; r" a5 ]! m$ D9 i" ~0 \  Rthe child’s skin. This time the father admitted the0 U* M9 G) V  ^+ H8 o
Topical Testosterone Exposure / Bhowmick et al 541
7 O( a. x7 t- vuse of testosterone gel twice daily that he was apply-
) r4 t& V; s9 b; f8 ming over his own shoulders, chest, and back area for" W, G0 ]1 [1 Q8 e) r
a year. The father also revealed he was embarrassed
) {: c- v7 Y" U9 t$ @to disclose that he was using a testosterone gel pre-
% ^# b8 o& M9 h' P# n( ascribed by his family physician for decreased libido
, Y2 i: _* w4 Z# ^" vsecondary to depression.+ Q8 n% v5 ^, Y
The child slept in the same bed with parents.
7 ~' e9 F+ @2 b" dThe father would hug the baby and hold him on his. O: r$ @$ f1 R' {/ A* H# T
chest for a considerable period of time, causing sig-. b7 b* c( X7 H% r% Q! ^% \
nificant bare skin contact between baby and father., y: U; i9 m8 y2 L6 C! h7 P
The father also admitted that after the phone call,
- k+ c8 H8 Z. S$ a* s. H0 j( {6 jwhen he learned the testosterone level in the baby
) V" E: T$ A: }3 F5 w% e3 Fwas high, he then read the product information
7 `( |9 J/ ?& Ppacket and concluded that it was most likely the rea-# y8 A4 w- S/ Z6 i7 v
son for the child’s virilization. At that time, they
& J1 _; d6 `- F) x1 `- [3 @decided to put the baby in a separate bed, and the
( i2 T( p! ?! O* _2 d, H" Nfather was not hugging him with bare skin and had
  f  \! p) e' r4 b" R7 b) T9 c' ?been using protective clothing. A repeat testosterone
. ^/ _2 `: {0 \, k6 }: g3 F+ v. otest was ordered, but the family did not go to the& n/ ^* }: F8 J0 U, U" S
laboratory to obtain the test.
; c. r$ m% w. M5 u/ j/ U+ ?+ bDiscussion$ F+ \. }1 A' U2 G6 V3 T. U7 x
Precocious puberty in boys is defined as secondary
: I; t$ M$ i0 J' `+ gsexual development before 9 years of age.1,4
. B) b' h; a1 g5 NPrecocious puberty is termed as central (true) when7 w% T0 b+ \9 p8 U- ?! P9 H% m& x
it is caused by the premature activation of hypo-
: i% y7 d4 w6 O  uthalamic pituitary gonadal axis. CPP is more com-- x, k( }! q& r% a& M' k
mon in girls than in boys.1,3 Most boys with CPP
8 N' N% a4 g1 Smay have a central nervous system lesion that is( N8 W( j% I( a1 f7 i$ J
responsible for the early activation of the hypothal-
' M  l. M- F5 t( uamic pituitary gonadal axis.1-3 Thus, greater empha-
, V  @0 p3 \' x1 T* y+ c3 lsis has been given to neuroradiologic imaging in1 }$ w% K6 Y1 ^& j1 s/ }( P
boys with precocious puberty. In addition to viril-
8 y' E; v; g7 p4 X8 U; C9 aization, the clinical hallmark of CPP is the symmet-' e: a) o2 j. ^
rical testicular growth secondary to stimulation by( w+ h& T  r3 o8 A" B% x# S
gonadotropins.1,3
! Q# E4 _& m; a' l+ {& KGonadotropin-independent peripheral preco-- s: x6 F0 j4 Y9 V
cious puberty in boys also results from inappropriate
$ N" {6 D- x7 B* y7 R1 n! r% `androgenic stimulation from either endogenous or
: d1 T8 h- F* c* X: m! p- `exogenous sources, nonpituitary gonadotropin stim-; `- c5 H  }# x6 I# n+ W- R1 @  q
ulation, and rare activating mutations.3 Virilizing
% E; A2 x0 W* |7 Ncongenital adrenal hyperplasia producing excessive
( t5 _8 u/ p0 z/ Z" Wadrenal androgens is a common cause of precocious* l3 `8 n0 h3 x! F( J9 h5 @) v
puberty in boys.3,4  N" \! i6 Q' ]* U# w& q
The most common form of congenital adrenal3 D) m# `3 u: s3 \
hyperplasia is the 21-hydroxylase enzyme deficiency.0 z+ I& m  E5 k
The 11-β hydroxylase deficiency may also result in
# B0 s  B3 M+ Z( k! Fexcessive adrenal androgen production, and rarely,
$ L- L4 R. @9 [) ]an adrenal tumor may also cause adrenal androgen) t/ \1 [) ?8 B. M
excess.1,38 t" H4 F6 {' Q/ m# t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( n: L& [. n# c+ n4 r, H
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ ^& ^/ t* I: \8 `+ z) W4 wA unique entity of male-limited gonadotropin-
& ^, x/ A( P1 [7 ^; S; Q. t$ @, hindependent precocious puberty, which is also known1 d6 ^/ x4 d  r' z$ A
as testotoxicosis, may cause precocious puberty at a3 P' t. @+ D$ |! j8 T) i
very young age. The physical findings in these boys: J/ I9 b3 _* n5 u8 V7 N- w
with this disorder are full pubertal development," K6 r5 X: Q. Y6 A! l  H. e
including bilateral testicular growth, similar to boys
0 A5 C6 D6 l+ @* j; R4 I; [2 g9 ?with CPP. The gonadotropin levels in this disorder
0 o  O% |) e' F4 V- O2 g9 ]are suppressed to prepubertal levels and do not show- @# o, s/ w; F8 u# t( s0 a3 a
pubertal response of gonadotropin after gonadotropin-$ M7 G! X6 _0 @# K  A% Z/ X
releasing hormone stimulation. This is a sex-linked
& a, i1 a* f) c4 sautosomal dominant disorder that affects only) |: K/ {: A9 z4 X/ D
males; therefore, other male members of the family& [- B% W) d6 H, N8 u8 B
may have similar precocious puberty.3
9 V7 b6 U6 {* X* ]! T$ R$ XIn our patient, physical examination was incon-
2 g4 t7 a$ u. Z9 Osistent with true precocious puberty since his testi-
; i( B" c" ^: [: Q  Jcles were prepubertal in size. However, testotoxicosis% D* u5 A+ C$ j
was in the differential diagnosis because his father' h* @5 ]5 h. x; M" Y; ~- T3 y, u9 r# S
started puberty somewhat early, and occasionally,
" y* R- I3 @) `testicular enlargement is not that evident in the( p; K# p& v8 \2 N/ \
beginning of this process.1 In the absence of a neg-
2 t* t# x( N6 P( m1 X: Yative initial history of androgen exposure, our' D9 I  V1 L- H; F3 `4 v9 ~3 ~
biggest concern was virilizing adrenal hyperplasia,
) t8 v7 m( x. p# n9 Q$ b; J2 Yeither 21-hydroxylase deficiency or 11-β hydroxylase- O- O; w* m# E; ]; [& O& a% `5 K
deficiency. Those diagnoses were excluded by find-
( ~6 V; p( g8 ?& t# M# ?ing the normal level of adrenal steroids.; d; v. A, i4 p  d+ Z% o9 z+ f9 H
The diagnosis of exogenous androgens was strongly
$ D! p; [+ n4 Z4 Y: A6 qsuspected in a follow-up visit after 4 months because& Y9 _8 c3 w. N3 U6 e
the physical examination revealed the complete disap-
( e8 T. g; r5 J7 M# q: Npearance of pubic hair, normal growth velocity, and! H0 {2 f5 n/ U6 s6 K
decreased erections. The father admitted using a testos-7 U: D$ ^' S; e# C# b% g! l1 o1 ]/ J
terone gel, which he concealed at first visit. He was
3 ^; ^& [" f6 ^% |" ]using it rather frequently, twice a day. The Physicians’
4 s  L* l3 ^# m; V. a  EDesk Reference, or package insert of this product, gel or
9 K3 L$ U: h4 j& A% e( i1 ^cream, cautions about dermal testosterone transfer to
3 d/ O( |& R9 h  Y8 J" bunprotected females through direct skin exposure.) S! ^1 A1 y' O& e. M
Serum testosterone level was found to be 2 times the
0 H  G. p! h' t2 l0 cbaseline value in those females who were exposed to5 d# L8 A5 T' h0 B
even 15 minutes of direct skin contact with their male
& ~  X' u; V% u0 `partners.6 However, when a shirt covered the applica-6 j+ S, w+ W) j3 `# q( L# a
tion site, this testosterone transfer was prevented.
3 T4 w5 M9 k0 j' W( j) D* b6 }Our patient’s testosterone level was 60 ng/mL,
1 v6 S. t/ t, V0 e4 Z- \( ~% b' ewhich was clearly high. Some studies suggest that
3 ]! o* u! O! I" C/ Ydermal conversion of testosterone to dihydrotestos-
1 B" T- [* |4 y) Hterone, which is a more potent metabolite, is more
) K: X6 }  W8 }active in young children exposed to testosterone' T/ ]/ s9 p, k2 M; _+ o& l
exogenously7; however, we did not measure a dihy-! |& ]/ D- V/ d4 s$ t2 P
drotestosterone level in our patient. In addition to
6 v  f+ w8 q5 M- M4 `virilization, exposure to exogenous testosterone in
# w) F* o5 J# Y! p7 W. z! dchildren results in an increase in growth velocity and
( K8 s0 e# C! L" ^6 ?) Yadvanced bone age, as seen in our patient.
+ S# s* h, Q( _3 H* ~; ?% y' aThe long-term effect of androgen exposure during* Y- K. W- R3 M0 d$ f/ y& D! S
early childhood on pubertal development and final: e/ u: v5 P& A) z6 D5 N0 i
adult height are not fully known and always remain
* r; e$ v9 D. y8 Z: Y7 R# P' v4 O& _a concern. Children treated with short-term testos-
! z% E9 `% w. T! Kterone injection or topical androgen may exhibit some5 o- ~# S: n- \1 V
acceleration of the skeletal maturation; however, after
2 T8 g) U5 Z" kcessation of treatment, the rate of bone maturation' C  ^# y8 D; z: u. i  P% z
decelerates and gradually returns to normal.8,9
4 F) h9 W& V7 u( XThere are conflicting reports and controversy- m5 W6 _2 Y( U) k
over the effect of early androgen exposure on adult
  U6 ?1 B8 H8 L6 I+ {1 mpenile length.10,11 Some reports suggest subnormal- f" D8 \; H9 M5 F( J
adult penile length, apparently because of downreg-. Q2 [/ V3 M# I8 E" x
ulation of androgen receptor number.10,12 However,
) p/ u+ ~3 D! X# `Sutherland et al13 did not find a correlation between, p* X% B5 [: H
childhood testosterone exposure and reduced adult
( W$ y7 l9 D/ A1 G% Q/ Ypenile length in clinical studies.
5 Q& B0 H( I" V3 M! I8 l- GNonetheless, we do not believe our patient is/ @. D+ w" i$ @) {* d
going to experience any of the untoward effects from  z4 W9 c0 |$ @3 ~4 }
testosterone exposure as mentioned earlier because! N+ F( L3 u6 P0 B/ o( J
the exposure was not for a prolonged period of time." _/ M* b' R+ i" d
Although the bone age was advanced at the time of
3 H. G' q% y3 s0 e) e' J1 Zdiagnosis, the child had a normal growth velocity at! I8 W" L1 i+ O& W- C+ b. s1 ~; {# U
the follow-up visit. It is hoped that his final adult% i3 C8 @6 Y4 r2 v
height will not be affected.
1 S7 M5 U$ B" S6 t0 G/ B. pAlthough rarely reported, the widespread avail-
/ d6 K- |6 R$ Uability of androgen products in our society may
, c7 O1 E: j5 M$ X- _indeed cause more virilization in male or female
0 E! K7 U! c, G+ X7 _children than one would realize. Exposure to andro-
3 w# s$ Y2 L2 Z* @% agen products must be considered and specific ques-
3 n+ w' }8 \8 F" Q6 ptioning about the use of a testosterone product or
1 V- y2 g  m" h9 y1 M  Wgel should be asked of the family members during
6 `; v& g- i& \7 Xthe evaluation of any children who present with vir-) {  x  m+ h5 z7 }# G
ilization or peripheral precocious puberty. The diag-1 Y, s, x/ A. G, e& c+ m3 u
nosis can be established by just a few tests and by
+ }0 C( N* k0 X' s+ m! d5 j( d1 pappropriate history. The inability to obtain such a
/ F0 b+ J5 k5 X' P4 B* Khistory, or failure to ask the specific questions, may
& r/ \- ]- i" x' I$ g% R% kresult in extensive, unnecessary, and expensive- L8 m" ^) S! J2 C0 s3 X; Z* n
investigation. The primary care physician should be
6 a2 ?' g( j7 Naware of this fact, because most of these children
& X3 f3 d' ]- X  C- M9 x& {may initially present in their practice. The Physicians’
+ n& u) ^: ]: X- u6 ]: SDesk Reference and package insert should also put a
7 h4 C3 [' s/ N: V; _warning about the virilizing effect on a male or( ?, W5 L* o4 [! L; d, K
female child who might come in contact with some-  d4 H% Q% |" y; B  @
one using any of these products.
* u2 Q. \5 D( O9 X" {* SReferences
& T1 E, [% \" j2 j1. Styne DM. The testes: disorder of sexual differentiation$ c5 C) x" Y3 g2 i; y. S1 E) P! Z  h% ~
and puberty in the male. In: Sperling MA, ed. Pediatric
9 l4 j# C) Y/ I/ pEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 x7 a# x# J" E
2002: 565-628.
' Y4 b0 V! x+ p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' W- F2 O& b5 E& \: N" fpuberty in children with tumours of the suprasellar pineal
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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
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
. A, e) {: `" U+ \+ N
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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