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Sexual Precocity in a 16-Month-Old7 k& `1 ^1 {- }5 |* R
Boy Induced by Indirect Topical  \# N' Y% {) R' G% A9 g" y
Exposure to Testosterone
3 `+ W& f! W5 q3 r" QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! H- Y+ j* o, C: F# }
and Kenneth R. Rettig, MD1! h( `2 @) A) q7 f: y
Clinical Pediatrics* n  A# S, Q' i7 b5 x4 i' E% H
Volume 46 Number 6
! O  H# W! [0 a$ D  N6 CJuly 2007 540-5439 \+ Y( |/ V( A6 `- c
© 2007 Sage Publications/ J) T( X8 v8 ]! b
10.1177/0009922806296651& a9 a; Z7 b. J% a7 U. a% V
http://clp.sagepub.com3 Y  X% g& A& f2 A. u. X1 i7 E
hosted at4 K' I, D6 b0 `8 P0 ^
http://online.sagepub.com
! F- [1 p& |$ s) C0 L7 r- kPrecocious puberty in boys, central or peripheral,
# [: B. y: G, j; F6 [/ f' y8 yis a significant concern for physicians. Central
% T3 d7 Q2 |; m( p! H" v- h# qprecocious puberty (CPP), which is mediated
" _; ?) z9 n: bthrough the hypothalamic pituitary gonadal axis, has; \0 Q1 `! K/ n7 V! @9 P, F6 y
a higher incidence of organic central nervous system+ @5 ]0 G( K7 v7 m8 N6 i9 h* r# d
lesions in boys.1,2 Virilization in boys, as manifested
2 W1 G' h) n  L; [by enlargement of the penis, development of pubic3 r& X6 N  _7 Q" j; {! a: y
hair, and facial acne without enlargement of testi-
" F2 |& @$ v" N* N& a  c5 kcles, suggests peripheral or pseudopuberty.1-3 We, ]2 j; a, n/ t) P( H& g
report a 16-month-old boy who presented with the
  F) n; r5 t' _% s" Renlargement of the phallus and pubic hair develop-% r/ @, w% X* B
ment without testicular enlargement, which was due
. F; y& n4 W* [9 z( k% a- Ato the unintentional exposure to androgen gel used by1 c+ X5 q6 j- v8 H/ T1 Y( S
the father. The family initially concealed this infor-0 y( M' C- p( J6 p1 {4 A: k4 @4 @5 J
mation, resulting in an extensive work-up for this; [" x' z- `* ?# U1 ]
child. Given the widespread and easy availability of
* y. j4 @$ K  u( |testosterone gel and cream, we believe this is proba-
  E( ~/ v! V  ebly more common than the rare case report in the5 ^- c/ q0 b% n
literature.4
2 v. Z& j. x4 d# IPatient Report
0 b+ x: e# T; ^) ^* \6 _A 16-month-old white child was referred to the# R- S/ \0 ]4 B- V$ J7 j
endocrine clinic by his pediatrician with the concern
8 b9 k' w* V2 y& g, y1 ?of early sexual development. His mother noticed
3 {& i6 _# C+ x; Plight colored pubic hair development when he was
* z* o) |+ e3 u  n1 e( cFrom the 1Division of Pediatric Endocrinology, 2University of6 r/ F( }0 R) |* G1 s
South Alabama Medical Center, Mobile, Alabama.% [: c, g( m  x4 K" R
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ A& H  h. E4 `! {/ a8 T  W
Professor of Pediatrics, University of South Alabama, College of
4 O' `- n* f& ]7 R/ ]; J( Q5 GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& B) Q! b5 {( {4 Z4 h. ]5 ce-mail: [email protected].
8 q, w, }8 E3 `8 \- Vabout 6 to 7 months old, which progressively became3 b9 G% ?) m/ l, f5 e& }4 ~
darker. She was also concerned about the enlarge-
% j/ K7 y  L% n* ument of his penis and frequent erections. The child, {* z! S' T+ U7 @* a- [  \! u& e! ?
was the product of a full-term normal delivery, with* i. ~' l6 F( p1 [6 q
a birth weight of 7 lb 14 oz, and birth length of
  Y" `6 E: M+ P9 b7 p20 inches. He was breast-fed throughout the first year0 Y7 N# J; N  ^' o0 D* \
of life and was still receiving breast milk along with
: f/ ~9 _- \4 Dsolid food. He had no hospitalizations or surgery,, v3 v9 H7 Q& t% M0 o3 }
and his psychosocial and psychomotor development
; q) W5 B8 r6 j2 B. f9 a2 Bwas age appropriate.
4 T& W& t7 D+ I# ]The family history was remarkable for the father,
, D" V  I  A2 U# q5 O1 gwho was diagnosed with hypothyroidism at age 16,2 D, ?3 w" g) T4 R
which was treated with thyroxine. The father’s8 j* _) }) h3 u1 K8 V
height was 6 feet, and he went through a somewhat0 ^5 Q# {/ L. k5 i
early puberty and had stopped growing by age 14.# ^/ ]# r5 E7 x3 o( A$ t2 Y
The father denied taking any other medication. The
+ L( m) U! j! W8 y# z, z( _! J5 K4 Rchild’s mother was in good health. Her menarche
8 Q# G/ }' A( R" hwas at 11 years of age, and her height was at 5 feet' r. z+ `  f  q. V% }
5 inches. There was no other family history of pre-
' p4 G9 n9 N/ R# Ncocious sexual development in the first-degree rela-
0 p  j$ g7 v6 F8 s% r5 w, a& t1 mtives. There were no siblings.
& X& ^5 `/ I' O, k- aPhysical Examination, R  H* V" i# t' u, ?  k% Q% N
The physical examination revealed a very active,% x  n, b1 |4 _' J
playful, and healthy boy. The vital signs documented5 S9 s. r# m3 i5 k
a blood pressure of 85/50 mm Hg, his length was! c/ ?& N( M+ u) ~2 P
90 cm (>97th percentile), and his weight was 14.4 kg' V! D' t, w! J  W  |! X
(also >97th percentile). The observed yearly growth
7 _- }) A% Y1 K+ Hvelocity was 30 cm (12 inches). The examination of7 ^4 l/ O, ]; {4 |
the neck revealed no thyroid enlargement.
, m' E' f* M. H- Q% J* `The genitourinary examination was remarkable for
) \, l* j7 W- D% j* y: d' oenlargement of the penis, with a stretched length of
* X6 {8 O, C  z& o& U/ a8 cm and a width of 2 cm. The glans penis was very well
4 B' Y1 `$ m6 ^& ]- ~. F  wdeveloped. The pubic hair was Tanner II, mostly around$ V, D" U7 N/ I6 m, T& B
540
% p5 E5 [$ H- B8 t+ C7 ?$ `$ p- Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# G! O$ j' Z6 s$ z$ Q9 E; T
the base of the phallus and was dark and curled. The' |2 h4 u7 g2 |
testicular volume was prepubertal at 2 mL each.
# W+ Q4 E. d3 C" x9 t: `7 iThe skin was moist and smooth and somewhat
- i& _& t$ t1 t: \oily. No axillary hair was noted. There were no
/ \! K  [. q) J) {# g0 i# U* @* Eabnormal skin pigmentations or café-au-lait spots.1 l$ h2 B6 ~1 X, L+ [
Neurologic evaluation showed deep tendon reflex 2+7 Y% {2 f& ^# A
bilateral and symmetrical. There was no suggestion' w$ y# w$ M$ C, X9 l
of papilledema.
. G! g! W5 |7 i( x" GLaboratory Evaluation
. X6 }  ]7 x$ S; f8 u* Y* v2 z' Z5 TThe bone age was consistent with 28 months by
1 d2 Y* O) e' O( O; Yusing the standard of Greulich and Pyle at a chrono-
; }2 S* Y" j) \logic age of 16 months (advanced).5 Chromosomal
8 V! s% x  b" V$ ?5 ]; o. Wkaryotype was 46XY. The thyroid function test
0 v  s7 r% x3 ?: Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, B$ s8 y$ b, c$ I5 d& r  V- m# f/ f
lating hormone level was 1.3 µIU/mL (both normal).# ]3 D' x/ H9 B, b7 a
The concentrations of serum electrolytes, blood
4 [8 a. [  e1 _( Burea nitrogen, creatinine, and calcium all were
) o8 t' v* _& ^! vwithin normal range for his age. The concentration
. y- Y' V9 r7 d6 H& B2 F" y1 _! eof serum 17-hydroxyprogesterone was 16 ng/dL
7 d& o% r/ k9 p- {% g  O( ?/ i(normal, 3 to 90 ng/dL), androstenedione was 20
- P. B4 s3 W1 xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 W- s) m1 c. ]. _- O7 C
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& v; g  m- E( r8 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 k; N0 l4 I7 _, b
49ng/dL), 11-desoxycortisol (specific compound S)  }% r3 n2 V! {5 a+ |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ t6 K& y1 b: `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ I$ g* g. }0 r6 ^/ Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),% w( V2 e+ w) P: X3 a$ Z$ J2 p9 v2 C
and β-human chorionic gonadotropin was less than( b/ I. U, h/ w3 o% n% c/ {! P9 L$ g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ v% ^! E# o% e" Astimulating hormone and leuteinizing hormone$ [, K8 R* g8 b; B7 G% u
concentrations were less than 0.05 mIU/mL
  l; d6 G2 D0 G# h/ F(prepubertal).: K! o: c, A  d6 Y
The parents were notified about the laboratory
4 ?/ ~* T. z& gresults and were informed that all of the tests were* L; q2 D2 s) W* U1 A
normal except the testosterone level was high. The* L1 h- q( T3 q( E% e
follow-up visit was arranged within a few weeks to3 Y. c8 g' c/ J6 Q: o, M% c+ A
obtain testicular and abdominal sonograms; how-8 d( y% B& i7 ^5 t2 U9 w8 ^+ T* I
ever, the family did not return for 4 months.; {+ ]/ N' Q  O( s# w
Physical examination at this time revealed that the. m! _+ C* `. n' q2 M$ i4 a( F1 i
child had grown 2.5 cm in 4 months and had gained5 X7 d% G+ W9 C5 @' n' d7 V* A5 T
2 kg of weight. Physical examination remained
) E% g2 D( u6 S) }5 ]8 ?0 y8 Ounchanged. Surprisingly, the pubic hair almost com-
/ l' `" X+ l5 n* ], Z2 {  ^pletely disappeared except for a few vellous hairs at3 v% c7 i) ^+ O7 S7 q- M9 u
the base of the phallus. Testicular volume was still 2
) t4 ]4 l) X" [" U" K7 u- e* _mL, and the size of the penis remained unchanged.' B4 h9 l8 Y+ j: @
The mother also said that the boy was no longer hav-
; T  h1 I5 X* P: b& Y' D! m. W& @ing frequent erections.8 [6 r4 b: S% s- c, S  `* J" x" m2 {7 F
Both parents were again questioned about use of
! C3 j; p5 e- q+ g6 k, p% s$ Sany ointment/creams that they may have applied to, {0 C1 B$ k6 B" K% {+ p# I0 e% [
the child’s skin. This time the father admitted the
, ~, d% T5 D5 P- c. W7 D- pTopical Testosterone Exposure / Bhowmick et al 541# J, C% k& ~7 r, o! p7 v$ o
use of testosterone gel twice daily that he was apply-
# H1 V+ x" v# |$ }& Iing over his own shoulders, chest, and back area for
1 |4 @% U& Q0 T7 Wa year. The father also revealed he was embarrassed5 H. V. P8 N1 s1 z3 e6 ^3 v! Z
to disclose that he was using a testosterone gel pre-
1 v* G+ W3 k; b. Bscribed by his family physician for decreased libido- X7 ~+ s8 t: p6 g7 S
secondary to depression.
! U+ x& u& g! L: @9 X0 P/ q$ bThe child slept in the same bed with parents.$ M' ~; k1 e7 Y0 {2 [- q
The father would hug the baby and hold him on his
$ q& b9 W. U  r; I1 H; ichest for a considerable period of time, causing sig-1 K7 d1 |" s2 n( [; W9 F9 K8 t; Y0 Z
nificant bare skin contact between baby and father.
2 B8 O( ?0 u) [The father also admitted that after the phone call,
; h9 K/ L& D# M- r$ `when he learned the testosterone level in the baby
( a- U5 P) x* T+ j' Twas high, he then read the product information$ K9 ~5 u9 X: M' i. J0 ?/ v1 O$ x
packet and concluded that it was most likely the rea-, m6 n. X. ?9 Y: w! @% P7 N
son for the child’s virilization. At that time, they
1 w+ u! w5 c" n6 m  G7 Y) ?& h: kdecided to put the baby in a separate bed, and the. S+ d1 s1 [% H6 x, i, `( j
father was not hugging him with bare skin and had
2 ^; `$ s$ a+ E# y0 W) d3 A4 C( O8 Sbeen using protective clothing. A repeat testosterone" D3 X% E* C# _  {
test was ordered, but the family did not go to the
0 ~7 J- U# l) z9 T' L5 x; glaboratory to obtain the test.) I  V  j( U6 ?. y: r$ _
Discussion
0 [1 G$ I# c. h& CPrecocious puberty in boys is defined as secondary
, z! [! @, R5 a; b, F) j% a3 X4 W" vsexual development before 9 years of age.1,4( B( x% c2 c' \# x
Precocious puberty is termed as central (true) when) l3 `4 \! H6 K+ f" X  T
it is caused by the premature activation of hypo-
9 a  Z: E1 a: g! @+ U/ ]: sthalamic pituitary gonadal axis. CPP is more com-
/ Y7 r: a3 C) a2 Z: k: {# Amon in girls than in boys.1,3 Most boys with CPP
* t& C  Q! v+ Y, ymay have a central nervous system lesion that is
- n8 P8 v: T) x5 f% f% a& Vresponsible for the early activation of the hypothal-
& Y: F9 P0 h% N: qamic pituitary gonadal axis.1-3 Thus, greater empha-
& c3 p% \- X) `  c( vsis has been given to neuroradiologic imaging in
' P  s# |$ \* b+ o6 j/ ~boys with precocious puberty. In addition to viril-& x7 n2 P# d0 B
ization, the clinical hallmark of CPP is the symmet-3 |) b  X0 `+ d4 Z. d$ ~3 u
rical testicular growth secondary to stimulation by& A5 {4 |" e: a" P
gonadotropins.1,31 _) P- |# U$ N. o, i
Gonadotropin-independent peripheral preco-# B, y! q8 F) Z" N
cious puberty in boys also results from inappropriate, B! ^9 d! E0 S. ?
androgenic stimulation from either endogenous or1 ]. H; ~8 r5 F! w
exogenous sources, nonpituitary gonadotropin stim-
8 b4 w* [3 @8 W& g1 |. _7 u. |! zulation, and rare activating mutations.3 Virilizing4 ?. l' W; l; j2 y
congenital adrenal hyperplasia producing excessive
8 u6 H* |1 f4 c  q. M& Oadrenal androgens is a common cause of precocious
$ C+ S# P; u3 P/ Qpuberty in boys.3,47 l; F- y$ i5 m- K3 K( ?& C
The most common form of congenital adrenal2 D; O" ?3 a8 }6 a$ u: {
hyperplasia is the 21-hydroxylase enzyme deficiency.$ x& s. @: v* K1 H
The 11-β hydroxylase deficiency may also result in
: G8 j4 Z$ c" L) C& m1 U: l$ Lexcessive adrenal androgen production, and rarely,
4 u  [" V; Q/ H  O6 H3 b0 Uan adrenal tumor may also cause adrenal androgen1 R  c$ q: d$ ~+ k: l6 B
excess.1,3
5 `, U8 ^9 y4 ~6 w4 g6 K3 Z1 ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% D* J1 V9 {) @' F/ d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. s% ?. o5 w% G' {. O  R7 [
A unique entity of male-limited gonadotropin-
7 s+ \9 @; f! j) mindependent precocious puberty, which is also known, a4 K+ l2 \+ B, Q
as testotoxicosis, may cause precocious puberty at a
, u: @8 \5 B/ i3 Xvery young age. The physical findings in these boys
9 ?# n, p+ j$ b5 d; gwith this disorder are full pubertal development,
. y7 a6 T9 e4 f4 u$ k$ q# Zincluding bilateral testicular growth, similar to boys+ Y; x& A1 }3 V0 Y3 ]2 R* }
with CPP. The gonadotropin levels in this disorder. j" `2 }$ |7 [2 j
are suppressed to prepubertal levels and do not show& [( r6 K8 x; r: J) W9 H! q0 ]- Z$ N7 z
pubertal response of gonadotropin after gonadotropin-
1 @) K/ H+ r/ N' n& J7 M1 Rreleasing hormone stimulation. This is a sex-linked
9 w. u' K, j1 Y4 n/ [autosomal dominant disorder that affects only
. S: T! `+ D- [1 P/ E, a5 Fmales; therefore, other male members of the family' s! L9 K- m5 U  u$ j: N  l8 X3 h. |
may have similar precocious puberty.3* m1 f+ S0 d7 h) G0 s3 M
In our patient, physical examination was incon-
; p) A/ \1 j9 R/ R  L0 a8 h" {sistent with true precocious puberty since his testi-  d5 ^$ b. w; F' A. k$ ]
cles were prepubertal in size. However, testotoxicosis- t8 o, e8 k& Y2 w
was in the differential diagnosis because his father
* Q/ q$ Z, w' Y. _. Qstarted puberty somewhat early, and occasionally,& v7 Z$ G. i9 M/ [+ f- A' B* S
testicular enlargement is not that evident in the
( g/ u  Z0 t( \# I  Rbeginning of this process.1 In the absence of a neg-
* @4 {. u& ~; y! e) c& \ative initial history of androgen exposure, our
5 S) b. t0 @5 Y$ obiggest concern was virilizing adrenal hyperplasia,
& I2 s) f8 P- `6 Q  S+ qeither 21-hydroxylase deficiency or 11-β hydroxylase. _" Y3 N# Q$ v; t2 s
deficiency. Those diagnoses were excluded by find-7 C* N# I! M8 Q  G' L% R% q6 T. O0 _
ing the normal level of adrenal steroids.3 t4 f8 \" T' y+ J7 F' @/ u; \6 g
The diagnosis of exogenous androgens was strongly
) o4 t0 Q' J2 R8 \0 ?% |% R- ^suspected in a follow-up visit after 4 months because4 z3 A7 ]* ^; {5 Y' X8 H; X4 g- U$ g: \
the physical examination revealed the complete disap-4 r" _" W7 C; Y* N9 u- ~
pearance of pubic hair, normal growth velocity, and
0 r( c/ _+ j& Y1 Mdecreased erections. The father admitted using a testos-4 J* h0 ]7 ~, L
terone gel, which he concealed at first visit. He was
3 P- D3 V% V; n6 U% g1 ~0 z" xusing it rather frequently, twice a day. The Physicians’& R# |7 |& S" D6 Z
Desk Reference, or package insert of this product, gel or( G0 p$ ?5 z  H: {9 z7 q
cream, cautions about dermal testosterone transfer to+ A* ]+ q( N8 L- f* {  s4 _- v
unprotected females through direct skin exposure.
2 u' E" J8 v+ PSerum testosterone level was found to be 2 times the
9 J$ ?) F" |! ]+ |2 j( m4 y; X5 ^/ xbaseline value in those females who were exposed to; w- T8 Z1 r5 n, a
even 15 minutes of direct skin contact with their male" }: M' m: |! Q" X4 h1 H
partners.6 However, when a shirt covered the applica-
6 l. S5 P3 ^4 {/ P6 Otion site, this testosterone transfer was prevented.8 B2 d0 g7 j' h1 S0 _
Our patient’s testosterone level was 60 ng/mL,' o5 ~* B0 ^; J, R/ Y# ]( a- [
which was clearly high. Some studies suggest that/ o1 x, D: n! K8 s. b
dermal conversion of testosterone to dihydrotestos-" G$ J$ Q) X. i& a7 T% Q
terone, which is a more potent metabolite, is more( ~6 L, c9 {. o$ U! f, i
active in young children exposed to testosterone
9 R8 H% K* h1 N) Gexogenously7; however, we did not measure a dihy-: z8 d4 W) D, E2 e! C  m5 e
drotestosterone level in our patient. In addition to
9 k1 d! c& i8 c! I+ ]virilization, exposure to exogenous testosterone in
  r5 a* z/ X1 m! s/ H4 x% ^. Echildren results in an increase in growth velocity and8 |4 C& ^- I4 h4 Q
advanced bone age, as seen in our patient.
$ I# P  ]" d5 L! X3 `( E3 }The long-term effect of androgen exposure during
4 L, X" d, Q8 q9 A4 searly childhood on pubertal development and final( N/ A) K3 c! o8 e
adult height are not fully known and always remain5 s1 h  B% a% H; @9 M
a concern. Children treated with short-term testos-) b) [" D3 u: f, [( Y
terone injection or topical androgen may exhibit some2 v/ _) n4 m4 s
acceleration of the skeletal maturation; however, after2 e5 ]; Z) T" n. j! G+ ?; R/ W
cessation of treatment, the rate of bone maturation$ e: k! T7 E" |  T3 m4 |
decelerates and gradually returns to normal.8,9% q) s  g1 L  a# ]( P6 `! K
There are conflicting reports and controversy$ c; A8 d5 t. J+ @- [' w: y
over the effect of early androgen exposure on adult* Z; `/ i$ E: B" R) Y- f
penile length.10,11 Some reports suggest subnormal$ d# a8 @* D8 @
adult penile length, apparently because of downreg-
/ A1 _3 t& N1 Tulation of androgen receptor number.10,12 However,( m: E! g4 J, X) F0 c& y% p
Sutherland et al13 did not find a correlation between9 B0 F4 `7 h. c1 l+ E& r3 b
childhood testosterone exposure and reduced adult& s2 Q& }" f. B( r
penile length in clinical studies.4 c) L  x/ T8 W& N
Nonetheless, we do not believe our patient is
" W0 `8 d) I" {/ F4 C* Pgoing to experience any of the untoward effects from( u1 r( N. l2 I. S
testosterone exposure as mentioned earlier because0 X, P0 }5 l+ I# u0 j: Z
the exposure was not for a prolonged period of time.
2 Q! L& N% N+ d2 l9 \Although the bone age was advanced at the time of0 I! a0 |! H) n+ Y
diagnosis, the child had a normal growth velocity at
/ W" ]' t; j2 _: Z. u7 F; c. Y9 F+ sthe follow-up visit. It is hoped that his final adult7 f: w, L3 ]$ g$ o4 A
height will not be affected.
/ h) {7 r8 ]' A5 GAlthough rarely reported, the widespread avail-2 S. {& n' W; y9 E2 g. A/ s
ability of androgen products in our society may: B% [4 u2 }* {- [
indeed cause more virilization in male or female7 m7 a- P6 b- I# c
children than one would realize. Exposure to andro-
0 c  W; Z# c5 y; }3 k/ o3 Ygen products must be considered and specific ques-
6 A6 N; @8 f$ s" ytioning about the use of a testosterone product or
; P: S! y- m" M2 a- x2 F- T1 M) Tgel should be asked of the family members during! l1 a( S% F  a/ `5 z$ c% \; i
the evaluation of any children who present with vir-. ^4 i% c4 |  j! }
ilization or peripheral precocious puberty. The diag-& P# L4 C, J: `  e$ _7 Y3 u
nosis can be established by just a few tests and by
# t0 c- t; [* u2 c6 ~( E2 gappropriate history. The inability to obtain such a7 e0 D, E- ]; E6 v+ ~
history, or failure to ask the specific questions, may
& R6 r3 Y  M8 t0 _; Oresult in extensive, unnecessary, and expensive
9 B. B, `0 c. M) c' g# L5 W4 |investigation. The primary care physician should be& v7 m! C# U2 j1 s/ ]/ N) m2 b
aware of this fact, because most of these children, {8 M3 ?. n$ p, L6 y! F/ y
may initially present in their practice. The Physicians’- Y7 ^( o5 b/ I5 f# p' K9 K
Desk Reference and package insert should also put a' }$ h! m( x! K# Z
warning about the virilizing effect on a male or
% p& c& g4 M6 E" W' C0 d2 Ofemale child who might come in contact with some-
+ T, c) L* ]) D! x# {4 t, f1 d$ A' eone using any of these products.; B: i% ]: Y) B( V4 e
References
2 m( u, c* k4 s) M2 }1. Styne DM. The testes: disorder of sexual differentiation+ k2 J( w0 `9 A8 n/ Q
and puberty in the male. In: Sperling MA, ed. Pediatric
+ p2 H" L  N* T5 B/ j: CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% t- g; S% |1 Z3 ]; s3 ~
2002: 565-628.7 U- N. d9 h" h; m4 m! {# g- Y% R8 m3 ^" F+ y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 d* w4 {4 i8 K# ^* X4 |3 T8 B
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old; f5 P! w& c; k) k
Boy Induced by Indirect Topical. o, C* Y% F$ |& f
Exposure to Testosterone' U7 v& e; C( o8 K! Y! R, B7 o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( i' a# q$ [$ W$ r' Uand Kenneth R. Rettig, MD1
! W; m5 r! a  m& m" t' L# QClinical Pediatrics
8 x7 |" ]) p) L3 Y; g6 x+ |" L* |Volume 46 Number 63 ~9 s0 M  C4 h3 [  [5 n
July 2007 540-543! {! b, P9 K/ ?/ g
© 2007 Sage Publications
9 |, s  S, d2 z10.1177/0009922806296651: Y, i7 Y9 O% p! d
http://clp.sagepub.com" Z1 a4 l* y/ ?9 v6 I
hosted at6 Q9 o' h9 U8 f8 r. X
http://online.sagepub.com
! c3 b1 L# f$ P; {9 q8 `Precocious puberty in boys, central or peripheral,
2 _/ v7 o9 o* D! w% G8 e" Ais a significant concern for physicians. Central3 t% ~% Z" Z2 t+ c4 D
precocious puberty (CPP), which is mediated
+ D3 V7 F. t8 M& C# X" X* u4 ]through the hypothalamic pituitary gonadal axis, has# ~0 I9 X% d$ s, S/ N7 ]4 ^+ I  s! v
a higher incidence of organic central nervous system
% p& @; |3 `" w$ X. Y: glesions in boys.1,2 Virilization in boys, as manifested  w; c9 H  C' f1 ]# v  y$ ]
by enlargement of the penis, development of pubic" w& t' G. w& w) ]( n: c5 |
hair, and facial acne without enlargement of testi-# ~3 Z( v* q9 c% W+ }/ x
cles, suggests peripheral or pseudopuberty.1-3 We4 \% g8 ?/ ~7 a9 m
report a 16-month-old boy who presented with the
7 p0 C% t7 A- {8 h" Jenlargement of the phallus and pubic hair develop-# S1 A& s% R/ e2 Z$ N- j! B
ment without testicular enlargement, which was due) n! J2 Z4 J% u
to the unintentional exposure to androgen gel used by9 i# d' u- `5 d4 w6 r9 N
the father. The family initially concealed this infor-) K4 |1 i; v3 s- q  S
mation, resulting in an extensive work-up for this  A7 y3 P. V6 Q2 v3 e, A$ H
child. Given the widespread and easy availability of/ K3 _' O9 z- y, _* U( b1 e
testosterone gel and cream, we believe this is proba-) x; V' Z: H$ N
bly more common than the rare case report in the
3 b% _3 M' _7 p5 o8 |literature.4: u# m- |. K7 @8 Y, m1 b% A
Patient Report% v  T0 T" M! E' z% w" K( \
A 16-month-old white child was referred to the
4 f4 s7 c( c; W  jendocrine clinic by his pediatrician with the concern9 }, j. c$ M3 i4 l! q/ q
of early sexual development. His mother noticed
! D" n& ~! [1 K! E/ X$ elight colored pubic hair development when he was
* T2 d. k/ x; e; qFrom the 1Division of Pediatric Endocrinology, 2University of+ |0 o8 |& _" e! C; Q( O
South Alabama Medical Center, Mobile, Alabama.2 d  g. H$ A+ D7 D
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 H* V0 g4 v% VProfessor of Pediatrics, University of South Alabama, College of
+ V+ g" d; r/ h4 f/ ^Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; H' y( O2 Y( v# Y/ ve-mail: [email protected].
5 \+ g; I2 {% {* fabout 6 to 7 months old, which progressively became
3 n* `9 r# j5 z5 H5 M' udarker. She was also concerned about the enlarge-
. y# h% A, z# B4 A1 P' g5 Y& Ament of his penis and frequent erections. The child
7 `( a9 U2 r9 |/ t3 K. G9 B2 r% Rwas the product of a full-term normal delivery, with
* ^0 [5 z  U* a# X$ sa birth weight of 7 lb 14 oz, and birth length of
* d. \) }- m; R& B20 inches. He was breast-fed throughout the first year
0 u4 \/ j" h4 ~* k* wof life and was still receiving breast milk along with  Q& h4 R1 z8 h4 n* i' w# b7 ^
solid food. He had no hospitalizations or surgery,
6 [6 U4 K0 B# i9 @5 I  L  h5 cand his psychosocial and psychomotor development; u* \) G" K7 Z
was age appropriate.
+ w" Y$ P6 S% _2 y0 R2 z- v9 R* JThe family history was remarkable for the father,, l9 n3 {0 r  K& s5 L* J% I6 l
who was diagnosed with hypothyroidism at age 16,, ~. ]4 w2 p4 \' i- r. p7 ?1 j4 R
which was treated with thyroxine. The father’s9 g8 y1 F% P' _( j( _
height was 6 feet, and he went through a somewhat
/ A( |: x: x6 Searly puberty and had stopped growing by age 14.. l5 y. f* u2 @: \
The father denied taking any other medication. The5 w6 O# U8 D2 p$ z' h" [5 W
child’s mother was in good health. Her menarche0 ?$ k& f6 M9 r
was at 11 years of age, and her height was at 5 feet
/ |: O4 `8 Q( @9 C' X  f5 inches. There was no other family history of pre-
2 V  i/ {3 i7 t2 S; \cocious sexual development in the first-degree rela-
: R8 j9 j. m, |- B% Ftives. There were no siblings.
# }/ W% P, V5 m0 c( k( z- w) K1 ePhysical Examination
, o- [! g! H. r) N% ?+ I( X7 N; p* WThe physical examination revealed a very active,
0 o5 t' a4 C9 t/ Tplayful, and healthy boy. The vital signs documented
9 H) g8 ?2 o4 G2 Pa blood pressure of 85/50 mm Hg, his length was
/ V$ Y# Z; E, C! R% ~- ?90 cm (>97th percentile), and his weight was 14.4 kg$ W  D4 q0 E2 o# N! A
(also >97th percentile). The observed yearly growth' b) r: E3 c0 Z' s  n3 `# `! f, o
velocity was 30 cm (12 inches). The examination of
5 y- d( ]& v- Uthe neck revealed no thyroid enlargement.
6 `% P  f8 L% ?0 Z" ~' b  b# mThe genitourinary examination was remarkable for
- f1 I3 J0 z  B$ L! U5 B' o% D/ ~* Lenlargement of the penis, with a stretched length of3 G$ i% z% [2 u
8 cm and a width of 2 cm. The glans penis was very well7 E$ q8 e( _3 m" k: t+ N
developed. The pubic hair was Tanner II, mostly around
. ^% ?" s1 j1 A# {, N540) ]1 R. o  ?+ N* `$ u! ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ W. w/ r" q# G0 i3 ~; Wthe base of the phallus and was dark and curled. The
7 x) `3 P2 D9 l! `( `  Atesticular volume was prepubertal at 2 mL each.
3 s3 g4 h, |7 }/ _$ y& N3 }The skin was moist and smooth and somewhat
% B+ i9 i$ B4 a9 K3 }3 j6 Soily. No axillary hair was noted. There were no! L: ~; V  j/ T$ F2 R. e
abnormal skin pigmentations or café-au-lait spots.
( h( ]1 |9 }  f0 t& |7 RNeurologic evaluation showed deep tendon reflex 2+
. ?$ @; e. i/ v; P3 ?6 Tbilateral and symmetrical. There was no suggestion6 D& _+ k" @: N/ c$ `
of papilledema.& n6 I  D) u7 W% ?
Laboratory Evaluation* J6 X  o% G5 f
The bone age was consistent with 28 months by% _( ?8 K% Y. G- s2 \" V
using the standard of Greulich and Pyle at a chrono-. V- V. Y( |  {$ K! q8 K' S
logic age of 16 months (advanced).5 Chromosomal$ |* D* J. f; \+ N, r+ h5 k( S
karyotype was 46XY. The thyroid function test
( L3 U8 o7 u( ?3 S$ u0 `$ [4 @showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ n! M3 \; l- p+ t) ]) ]  K) ~. e, ?1 s7 ulating hormone level was 1.3 µIU/mL (both normal).
% A  L0 p: x" n) @8 f* Q4 [: yThe concentrations of serum electrolytes, blood6 i! H9 F1 s# o3 i0 ?' N! A9 Q
urea nitrogen, creatinine, and calcium all were! g# Q( q5 U& e. A" u
within normal range for his age. The concentration
2 M. n& N* i6 j& D, f1 jof serum 17-hydroxyprogesterone was 16 ng/dL8 C0 [0 }6 ?8 x3 M0 }
(normal, 3 to 90 ng/dL), androstenedione was 20- e4 n( N$ W" y+ H; R1 i/ P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 o7 H% |" u1 v; P. S& \; Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),) m( K! {* x# g  f+ E* w* |6 x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 e' O" K5 K# x3 \  y49ng/dL), 11-desoxycortisol (specific compound S)# R0 _& c* P6 {; A+ l, B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 T; `( d/ m3 `, b. \1 Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) U, s/ @6 T9 {  {9 ]  b2 ~; etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 J6 p' m/ c+ Z
and β-human chorionic gonadotropin was less than: f# c3 ]% o/ s+ J
5 mIU/mL (normal <5 mIU/mL). Serum follicular
& F# x& t* O+ f" c$ L8 B' Nstimulating hormone and leuteinizing hormone
  E: N( P! q  e; Wconcentrations were less than 0.05 mIU/mL. |( z: R% ?9 r9 Y9 F5 N6 x
(prepubertal).
. h/ J3 U4 Z% O  ^# G0 b' O0 ZThe parents were notified about the laboratory
: P4 h; k1 ?- z3 j. Hresults and were informed that all of the tests were
  ^7 b2 \6 u- x5 J7 \% c! ?; anormal except the testosterone level was high. The
- Q8 o* y6 ~% M) u- W: B! `follow-up visit was arranged within a few weeks to
% j( {. {! K+ o% r/ B8 A3 iobtain testicular and abdominal sonograms; how-: Q8 c' j) p  a0 R5 P2 i9 m6 l1 K
ever, the family did not return for 4 months.
& s3 |/ m, h; h' u" H+ xPhysical examination at this time revealed that the1 J, h7 }6 V# _% Y! A
child had grown 2.5 cm in 4 months and had gained$ f. j  ^  B- c% {' d" x
2 kg of weight. Physical examination remained6 A. m/ G, B2 V1 I" w( q
unchanged. Surprisingly, the pubic hair almost com-
) g0 Y- F: l7 c9 S9 h+ Z. X, Ypletely disappeared except for a few vellous hairs at* ?% V$ j% f$ {: `( A6 p/ w4 X; _
the base of the phallus. Testicular volume was still 2+ p1 E$ }, M5 M# E$ M, O% |0 n8 Q
mL, and the size of the penis remained unchanged.
6 N$ i% {+ A7 v6 ]; x3 r& zThe mother also said that the boy was no longer hav-9 m. `" Z8 W' W
ing frequent erections.
6 o9 R- j6 K! Y4 p% L( Z4 F8 C) O  I; aBoth parents were again questioned about use of
! ~( @3 d/ a1 M; j- n; gany ointment/creams that they may have applied to/ R# @2 A" o' V: K6 u% g* [
the child’s skin. This time the father admitted the
3 f. }# |" m) u0 ]; ATopical Testosterone Exposure / Bhowmick et al 541
" J% k3 A9 b7 U1 R* j* zuse of testosterone gel twice daily that he was apply-
5 Q6 b6 b4 W3 _5 r+ Q, Z& Ding over his own shoulders, chest, and back area for
- c6 X, P5 H# la year. The father also revealed he was embarrassed
+ A- C0 t* E/ {# o) ~4 a- D, i$ X: P" {to disclose that he was using a testosterone gel pre-
4 R/ s& y, d" o; e7 ^0 Iscribed by his family physician for decreased libido
% Z9 l, g+ z! U+ L$ c7 tsecondary to depression.
) T2 N: L4 A- {* O: wThe child slept in the same bed with parents.* \) X) K5 k- |4 K6 N8 X
The father would hug the baby and hold him on his/ B* @/ z4 l7 |4 X* n6 I, q
chest for a considerable period of time, causing sig-
4 R' o/ Y+ o1 Snificant bare skin contact between baby and father.* ~: l7 J/ ^5 C3 U+ X1 V$ d
The father also admitted that after the phone call,- ?/ s* I$ x8 U& `8 R( Q5 y
when he learned the testosterone level in the baby; |. u4 B; T9 k/ F, Q4 [
was high, he then read the product information7 O# J; m, @+ ~+ O# O, A9 H
packet and concluded that it was most likely the rea-
9 h- j6 y  }  N& Vson for the child’s virilization. At that time, they
: P! ]. ?& r  `2 x- D: D" p; Hdecided to put the baby in a separate bed, and the  [% x( e8 m# F1 @; H
father was not hugging him with bare skin and had) o2 `/ h% g9 {' @- ?$ E
been using protective clothing. A repeat testosterone+ G" p7 L$ A. L
test was ordered, but the family did not go to the" t! K9 p% C/ F' @( N) b1 r: X3 t
laboratory to obtain the test.. c% J" g  E8 S9 S1 F
Discussion
) J& s* g" e$ ^, FPrecocious puberty in boys is defined as secondary* D! o, M) O) G1 _0 t1 r) r$ t
sexual development before 9 years of age.1,41 ]7 ~* r5 |6 Q0 `  b; i3 S
Precocious puberty is termed as central (true) when
# i& u; I# U& u& N& s+ Hit is caused by the premature activation of hypo-
: j/ L  F" H! s7 Y. \thalamic pituitary gonadal axis. CPP is more com-
! x1 h) S; J; f6 m2 Smon in girls than in boys.1,3 Most boys with CPP
8 b7 T. |7 T7 J* m0 W7 bmay have a central nervous system lesion that is& E/ @* q6 S0 H4 v) s: j6 A
responsible for the early activation of the hypothal-8 `# U/ R" u: M% `, A, H: a, V
amic pituitary gonadal axis.1-3 Thus, greater empha-
. O6 X2 N( d/ K: Hsis has been given to neuroradiologic imaging in
% ^& `$ ]# ]$ t) ]boys with precocious puberty. In addition to viril-6 d. a% l! M7 |# W- m
ization, the clinical hallmark of CPP is the symmet-: e$ g5 {, v7 X  U
rical testicular growth secondary to stimulation by
7 `  {" J. ]/ {3 Cgonadotropins.1,3
9 G% Q. h. \7 m) Z4 s1 I. vGonadotropin-independent peripheral preco-/ p  C. G2 z; @" b- N; c
cious puberty in boys also results from inappropriate5 c* N' Y0 y! G# |9 W  x
androgenic stimulation from either endogenous or
7 n9 I) c6 }$ t6 \- V7 iexogenous sources, nonpituitary gonadotropin stim-
2 f6 a' U& R! E2 L2 Z+ H+ _ulation, and rare activating mutations.3 Virilizing6 ^% t, k  z3 X& _  b, U, }
congenital adrenal hyperplasia producing excessive
; B3 ?. I& K2 ]  P3 N& `adrenal androgens is a common cause of precocious
5 H/ q" h0 S0 P. Ppuberty in boys.3,45 D9 v# c8 S2 P6 S* f8 F
The most common form of congenital adrenal
4 z3 g* e6 W8 E' r& b7 Thyperplasia is the 21-hydroxylase enzyme deficiency.
) P- m8 I1 d9 ~' N# AThe 11-β hydroxylase deficiency may also result in7 H- z' `7 A" c; W
excessive adrenal androgen production, and rarely,
) b+ s# e. f( [9 \an adrenal tumor may also cause adrenal androgen
0 i+ K5 _1 X& k2 l+ a% _, Sexcess.1,3% o8 _8 l# L5 T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 x- l; ~$ l) K9 U+ b; J) E
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& u; O4 H2 R: P% g
A unique entity of male-limited gonadotropin-& I! \4 i( S6 a2 g# {
independent precocious puberty, which is also known0 w2 T! _& r  y; G
as testotoxicosis, may cause precocious puberty at a
$ O; [" G4 c6 P: O) Every young age. The physical findings in these boys
/ }+ s# @; h( \) t) X/ j7 r- `; bwith this disorder are full pubertal development,
. M/ k9 X4 T+ o  ~6 A7 T. K2 kincluding bilateral testicular growth, similar to boys
: S6 c+ @6 ], f, E8 C  m$ swith CPP. The gonadotropin levels in this disorder6 ~7 u: Y7 @3 q/ o
are suppressed to prepubertal levels and do not show3 ]& r. J/ R9 f- n. v  B: ?' k7 k
pubertal response of gonadotropin after gonadotropin-
2 m: X3 `, K! n5 ^' Yreleasing hormone stimulation. This is a sex-linked9 j7 M+ t  L6 ?% \' y/ R9 V7 p
autosomal dominant disorder that affects only
2 z, \6 }7 T0 M- Z9 Wmales; therefore, other male members of the family
2 g" h# z7 u7 p- A) J. B6 ^8 V, ]may have similar precocious puberty.3* d1 _- Q+ I$ p# \/ W
In our patient, physical examination was incon-7 Q' R% `/ q# e! @; W
sistent with true precocious puberty since his testi-
- o3 N) E3 M5 `0 n8 Icles were prepubertal in size. However, testotoxicosis
/ [8 D: t, m5 Lwas in the differential diagnosis because his father
4 D8 Q5 [2 N4 O8 X1 p# W& Hstarted puberty somewhat early, and occasionally,
# t% g7 ^' u- Atesticular enlargement is not that evident in the
& C3 K# F, m) p9 u- g, e8 }beginning of this process.1 In the absence of a neg-
/ O: _# ~3 \% s. Native initial history of androgen exposure, our9 J" `; E6 a! K7 P9 Y. W' `4 i6 |
biggest concern was virilizing adrenal hyperplasia,
( ]8 N6 V/ O( S# yeither 21-hydroxylase deficiency or 11-β hydroxylase6 C* Z- @  x" U4 f3 F/ v8 D
deficiency. Those diagnoses were excluded by find-
- {; K5 Z6 a/ g) L4 Fing the normal level of adrenal steroids.  I3 p; V* q5 P- g6 ]. w5 f' w
The diagnosis of exogenous androgens was strongly
6 _6 N2 O0 l" u- q% ^- zsuspected in a follow-up visit after 4 months because
3 ~( P$ N+ B5 ]% ~  hthe physical examination revealed the complete disap-# S6 n7 N3 N$ P9 J* W& ^
pearance of pubic hair, normal growth velocity, and( u- T1 I. Y& V2 R& A3 v5 N
decreased erections. The father admitted using a testos-
4 B8 A9 V" R" [4 u% S2 e' eterone gel, which he concealed at first visit. He was3 d) a# u/ r# p5 Q
using it rather frequently, twice a day. The Physicians’
' N2 s* y7 P$ a. h7 Z. KDesk Reference, or package insert of this product, gel or6 t1 H) y/ N+ k9 A1 X' W3 [
cream, cautions about dermal testosterone transfer to
. e$ R+ O8 E. K) y  d' Runprotected females through direct skin exposure.
. N3 z& ]2 Q: m6 E# O& e& E" uSerum testosterone level was found to be 2 times the" q  d5 R; ^! U) }
baseline value in those females who were exposed to9 ~8 ?! `& u3 s& @" b
even 15 minutes of direct skin contact with their male! Y) Y& q* y7 X. B3 _4 p
partners.6 However, when a shirt covered the applica-
4 E8 `& t6 U- v% [3 \: s! stion site, this testosterone transfer was prevented.
5 R" t  i# i+ P: X- pOur patient’s testosterone level was 60 ng/mL,! g7 a8 |2 Y$ ^9 n
which was clearly high. Some studies suggest that
- f& L* c# J" G  i( y# fdermal conversion of testosterone to dihydrotestos-
* v+ C% q( p0 U0 D0 @+ [terone, which is a more potent metabolite, is more
2 C0 I2 `7 `1 ?1 Y: z7 Aactive in young children exposed to testosterone
% x4 z0 v6 D1 H" kexogenously7; however, we did not measure a dihy-
. s& U$ B6 w; ]. q8 }; ^drotestosterone level in our patient. In addition to  _- {9 c% n3 A4 h  m  [# K
virilization, exposure to exogenous testosterone in
, R% r- G" O1 y9 ]children results in an increase in growth velocity and
: A  w% s  M. Q( r0 E1 _2 @advanced bone age, as seen in our patient.; S! I$ J. _6 A, v! c, X
The long-term effect of androgen exposure during7 S8 x' f! L# X" w4 `' \# ]; i+ f# F8 i
early childhood on pubertal development and final$ ?$ b9 Z* C0 L" l
adult height are not fully known and always remain
$ [# A9 D* k8 ~1 ba concern. Children treated with short-term testos-; k0 {$ g' L$ q' K+ B3 C* Y
terone injection or topical androgen may exhibit some2 F5 H) ]! P+ p+ K: |" N
acceleration of the skeletal maturation; however, after6 [( W% f0 O  v' l- w
cessation of treatment, the rate of bone maturation
; a: g8 g6 X; v/ Kdecelerates and gradually returns to normal.8,9& U# J, z7 _' O& P
There are conflicting reports and controversy1 ?0 d. h3 o* J# E9 W+ y3 u6 W
over the effect of early androgen exposure on adult
2 u( k9 l/ {0 V) D6 K& h' Tpenile length.10,11 Some reports suggest subnormal& i  A% G& d# C3 P
adult penile length, apparently because of downreg-# l! v; @* n. y! }8 P& N" N
ulation of androgen receptor number.10,12 However,7 B# y4 N* q& w; O- L+ y; p
Sutherland et al13 did not find a correlation between
' @2 U* x0 C- q7 T8 n% B0 N5 N( Lchildhood testosterone exposure and reduced adult' J$ p; q; o& f# F  x
penile length in clinical studies.
, S8 O5 `5 ~, T" K9 E2 ENonetheless, we do not believe our patient is
' q7 i, U( t% O3 a" Z9 ?1 `going to experience any of the untoward effects from
" n. v" {/ S" v8 D6 M- qtestosterone exposure as mentioned earlier because
$ x& a8 F$ _# Z3 }" qthe exposure was not for a prolonged period of time.4 s! f! B9 x6 H% z
Although the bone age was advanced at the time of  ~0 L$ H" X. I& F, l7 b1 X' U
diagnosis, the child had a normal growth velocity at7 m! C# F5 K; V+ E, t- L( {" x9 b% |
the follow-up visit. It is hoped that his final adult1 \4 p1 j& w. v& J$ ~
height will not be affected.2 @- ?$ f2 n1 Q9 j: Z1 t7 B2 A
Although rarely reported, the widespread avail-( t. u: b1 `% L7 c
ability of androgen products in our society may! Q* U$ Y6 U; f6 A: g
indeed cause more virilization in male or female; o- G1 _  {, i4 h, O
children than one would realize. Exposure to andro-' I2 s3 ^* P  e% ]7 R' i
gen products must be considered and specific ques-
6 e5 s. L  y3 A2 {1 o8 Ktioning about the use of a testosterone product or
7 @3 ~7 M8 j: G) m# A7 egel should be asked of the family members during
: [) O6 m8 u% F6 A+ u8 Lthe evaluation of any children who present with vir-3 [4 p  H% Q: [  u1 l' P* [/ b
ilization or peripheral precocious puberty. The diag-( x8 ]. s. s+ j6 B
nosis can be established by just a few tests and by! |1 |$ X2 b# @1 [+ X
appropriate history. The inability to obtain such a8 y2 X0 O$ f( N
history, or failure to ask the specific questions, may- ~# K$ K2 a( n8 \1 s3 G/ G' K
result in extensive, unnecessary, and expensive
* p% S1 }, @/ Z! m7 zinvestigation. The primary care physician should be( X  R% l3 H7 Z2 }
aware of this fact, because most of these children5 k$ m" z- y' J
may initially present in their practice. The Physicians’
* X) }% n- |; B# jDesk Reference and package insert should also put a3 d9 S* ?: U& e/ l2 U1 y! _
warning about the virilizing effect on a male or( Q9 D6 l, X- i) l0 F7 [
female child who might come in contact with some-/ ~2 Z& c( N# n4 v6 S+ B/ {
one using any of these products., b0 w! p9 O, P, ^. [
References
% b8 \5 [) Y0 g) G1 ]1. Styne DM. The testes: disorder of sexual differentiation* N2 g, p; y0 A! u+ F5 d5 J1 K, O
and puberty in the male. In: Sperling MA, ed. Pediatric
5 a/ ~! a8 C8 q( w0 T+ g" S5 NEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* h# V6 E. s+ }& d) B0 s( j
2002: 565-628.
$ @& I/ F: `; O0 p: ]! L$ R- \& V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 A, F# D8 Z/ ~/ z" i% A) S
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

2 |0 X6 c- L  P" t+ J. `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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