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Sexual Precocity in a 16-Month-Old6 D" T2 G" G, e
Boy Induced by Indirect Topical) J! S  g7 s, q, I# Q% _$ [6 Q
Exposure to Testosterone
6 \2 Z1 N1 O+ U3 m8 fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 _* O# Z/ `4 h4 l7 E
and Kenneth R. Rettig, MD10 _+ l( z( J+ Y0 a
Clinical Pediatrics7 A8 L3 R5 P' h! z
Volume 46 Number 6/ t# L! L1 z3 T* W
July 2007 540-543
' P4 d7 d1 \" l: r) U" B& y# ^© 2007 Sage Publications
$ l2 v% o+ a* h3 F% R10.1177/0009922806296651( Q; A7 C. u! H* J% V
http://clp.sagepub.com
+ V' K3 ?1 _/ f0 }hosted at6 E6 Z3 z. a4 p6 }9 V' U
http://online.sagepub.com
) f$ r9 q  \, N3 H3 Z" L7 y$ ^" {Precocious puberty in boys, central or peripheral,
( V, h0 u8 R( k+ O) z; q* ]is a significant concern for physicians. Central
% _0 W9 _9 A4 `) o, H% a! d/ T4 ^precocious puberty (CPP), which is mediated
" F/ U2 u6 M& e8 ithrough the hypothalamic pituitary gonadal axis, has
/ I5 f% V4 [0 d4 L" M, b% I, {a higher incidence of organic central nervous system
5 U% F5 V, C- h# w! E: ilesions in boys.1,2 Virilization in boys, as manifested5 P. b* P" t* ^0 l% h7 B7 g7 g
by enlargement of the penis, development of pubic
7 ?6 f6 C+ Q# l& `0 r" g' p, \hair, and facial acne without enlargement of testi-
) M% u5 O8 Z1 M" O" Icles, suggests peripheral or pseudopuberty.1-3 We
) `4 i- Z; ?3 n  breport a 16-month-old boy who presented with the- a) f0 k: m/ h- O/ V8 ]) \
enlargement of the phallus and pubic hair develop-0 O; m; ?! c4 {7 F4 A
ment without testicular enlargement, which was due7 q& n0 i7 ?% ]2 Z8 j) y* ?$ W
to the unintentional exposure to androgen gel used by
- c1 i0 W) l4 G. ?7 N3 _6 C. Gthe father. The family initially concealed this infor-
5 o+ n1 y' M8 r, c5 B' smation, resulting in an extensive work-up for this# ~5 ]7 y# j; X- M/ ]0 E
child. Given the widespread and easy availability of
0 N& k9 K0 O7 p& |testosterone gel and cream, we believe this is proba-' ?9 v, n/ Y6 }6 w; V1 E/ a8 t
bly more common than the rare case report in the
& b0 m9 N! z! y4 A" d' d/ c6 uliterature.4
4 G% O9 Q- r$ @Patient Report
5 k3 L# B8 V6 f- JA 16-month-old white child was referred to the
" X! o: G& a, x. ^; R% bendocrine clinic by his pediatrician with the concern
: h( w8 V. e6 O: T# X4 H1 }of early sexual development. His mother noticed
* ]9 V+ n+ j1 e6 z1 r5 s$ X4 B4 Tlight colored pubic hair development when he was
4 C0 W1 z- `. U0 UFrom the 1Division of Pediatric Endocrinology, 2University of$ M. _  y+ y2 E; ~2 c& r6 t
South Alabama Medical Center, Mobile, Alabama.; Q, D9 h. m) E( k  p6 s; j
Address correspondence to: Samar K. Bhowmick, MD, FACE,
3 K' N3 ?* v9 KProfessor of Pediatrics, University of South Alabama, College of& ]+ s; o+ X2 T- J, W* m) @4 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  v6 i. j8 ?% Q! L9 f+ j
e-mail: [email protected].
) p8 E0 L6 }, Q" F6 sabout 6 to 7 months old, which progressively became, c  q% U  K# O" I7 o7 z) m. y
darker. She was also concerned about the enlarge-" a9 y" u0 O+ O: K/ l# z
ment of his penis and frequent erections. The child
7 D: h! m( w4 u" awas the product of a full-term normal delivery, with( C5 h$ s9 U" M& _3 K6 K8 [
a birth weight of 7 lb 14 oz, and birth length of: t  C& g' G; C
20 inches. He was breast-fed throughout the first year' b( v2 u' w5 b6 K+ N
of life and was still receiving breast milk along with
6 U! o. d, m9 b+ _, t0 ?- |solid food. He had no hospitalizations or surgery,
* Z* g& {, ]1 O+ Y# q% Z( |" t3 Mand his psychosocial and psychomotor development
8 @( ^. C- T. ]$ ]6 X. pwas age appropriate.
) a/ j, o" ?4 K8 h1 l6 T1 ?The family history was remarkable for the father,
! R) S# l- C9 d. j: J0 U! x% hwho was diagnosed with hypothyroidism at age 16,
, {5 Q/ o6 C, _7 Gwhich was treated with thyroxine. The father’s
0 W. Q7 }$ @, Gheight was 6 feet, and he went through a somewhat+ x& X* b+ F4 y9 i, h
early puberty and had stopped growing by age 14.5 S7 z* L( A5 `% {* w% |! \/ ^' v
The father denied taking any other medication. The
; u, \3 c1 F& F1 Lchild’s mother was in good health. Her menarche
# t7 S0 S9 V: A3 I: ^# Qwas at 11 years of age, and her height was at 5 feet
& ?! `4 l4 @# X9 S' V5 inches. There was no other family history of pre-( Z7 K! `4 T1 O
cocious sexual development in the first-degree rela-
2 l5 w, c, D$ A( qtives. There were no siblings.6 T6 `( q. P/ m: h1 D! h
Physical Examination8 m/ ~( Y$ p' Z. {5 T, g% ^- l
The physical examination revealed a very active,
9 A+ r: M6 H0 p, Rplayful, and healthy boy. The vital signs documented+ z5 Y: \' n% V& l
a blood pressure of 85/50 mm Hg, his length was( Z& G- [0 i5 y% t, U
90 cm (>97th percentile), and his weight was 14.4 kg) [. i+ [' U8 {$ N" }7 _2 }6 Y
(also >97th percentile). The observed yearly growth
3 B9 M3 `8 F) `& s: I4 x( }( i) hvelocity was 30 cm (12 inches). The examination of3 r# u2 T! _- Y+ ^( ~; b6 V# C  \
the neck revealed no thyroid enlargement.' L2 i- d, j( p4 Z
The genitourinary examination was remarkable for
, X9 g- N" K0 \enlargement of the penis, with a stretched length of
. w& h+ a' Y% [% z7 k8 cm and a width of 2 cm. The glans penis was very well
6 `; G- j. j2 {, A3 kdeveloped. The pubic hair was Tanner II, mostly around
# Y3 S5 U0 ~0 B) L8 W) n5401 `0 p; U8 `$ o2 E' C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" w" W/ i8 r# V' H0 Fthe base of the phallus and was dark and curled. The
( g8 M' H! L( V. H& N+ Q& y: atesticular volume was prepubertal at 2 mL each.4 M! k7 K: Q1 D& W% d9 s
The skin was moist and smooth and somewhat' I5 U# n: O" G+ ]8 z, g$ V
oily. No axillary hair was noted. There were no' _, h. l' B+ W, x, {8 J
abnormal skin pigmentations or café-au-lait spots.
" U& m( I4 Q! M$ n" W) ?' Z/ C; _7 RNeurologic evaluation showed deep tendon reflex 2+; ?; v/ @3 J9 N' c& Q! @
bilateral and symmetrical. There was no suggestion
# v% \( e, ~. m5 B. y5 Jof papilledema.
. o. U4 J- x' ?; A% l. PLaboratory Evaluation
" }: U9 H* f1 vThe bone age was consistent with 28 months by/ c# U7 W& d& f7 ~
using the standard of Greulich and Pyle at a chrono-
$ p! c' M& x# g. u6 Z$ {logic age of 16 months (advanced).5 Chromosomal
& @  t# Y4 z' Kkaryotype was 46XY. The thyroid function test6 J$ s2 l" P  K
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: Z& B2 \/ x; D7 s  z4 x( Q7 {+ Olating hormone level was 1.3 µIU/mL (both normal).
8 q3 T9 w2 `6 I2 b7 [( HThe concentrations of serum electrolytes, blood
4 E# C4 _7 M# w5 Q$ b0 surea nitrogen, creatinine, and calcium all were! O# S2 R  A5 d- M% N" s2 x/ Q9 W
within normal range for his age. The concentration
( q6 s. R1 p* N" Q0 a) M! zof serum 17-hydroxyprogesterone was 16 ng/dL
1 P6 h! |3 I& B  Q% H(normal, 3 to 90 ng/dL), androstenedione was 20- ~9 I, R& \" m" _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 R- b" d! a$ \$ x! \4 f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 ?# w" x: q$ }4 Rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( k; G% w, Z) s. [49ng/dL), 11-desoxycortisol (specific compound S)
* A0 ~* g9 _8 Z  e$ u+ mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 b& c$ t. }" l$ c6 {
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# j5 c* i- `; R: l9 p- G) P9 gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 d  q% y8 n) P# [6 {0 ]% H
and β-human chorionic gonadotropin was less than: b! i9 V- V8 S  _
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 ?/ V+ b0 M: q3 \" Q6 T
stimulating hormone and leuteinizing hormone
# v9 B; O; x+ l: p3 m& }concentrations were less than 0.05 mIU/mL
" D9 c, K. N- a/ x/ g(prepubertal).3 c( @9 O$ ^/ S" v  ^
The parents were notified about the laboratory2 }% p: C" I8 g; g% O5 G/ \
results and were informed that all of the tests were
. a) G$ V% h9 ^/ Hnormal except the testosterone level was high. The
' B. p' n' A4 ^4 e5 g! C6 z, E# ~; _0 kfollow-up visit was arranged within a few weeks to
# g! G+ K1 p$ U; a# V4 robtain testicular and abdominal sonograms; how-
- C5 W9 l+ o: K; C; J5 h9 H0 d1 hever, the family did not return for 4 months.& h2 I( D+ V! k* e6 V6 Q; W
Physical examination at this time revealed that the
3 X; A, E/ f! f% }* hchild had grown 2.5 cm in 4 months and had gained' T$ ~0 _- M% L2 Q. z/ j6 Q3 R
2 kg of weight. Physical examination remained
2 l9 n! z( o: e. v1 P: Y! k; E" P4 _4 Tunchanged. Surprisingly, the pubic hair almost com-
1 T: I; |# ?  j$ h) a. U$ hpletely disappeared except for a few vellous hairs at  l: r3 l+ {% `
the base of the phallus. Testicular volume was still 23 q  u! ~  }4 R0 D" E. M1 ?
mL, and the size of the penis remained unchanged.. ?( O  T# K$ n5 G% k$ v
The mother also said that the boy was no longer hav-
) i# H8 o( l; k  Z$ e3 Q6 Z$ n' Iing frequent erections.: @! d2 U' E# R, M7 j
Both parents were again questioned about use of
& P1 F0 {. [4 ]' b9 [any ointment/creams that they may have applied to0 u1 P9 G! `/ j: P# G
the child’s skin. This time the father admitted the
% B! P; D9 g0 \3 {4 ETopical Testosterone Exposure / Bhowmick et al 541
$ m* @$ g: R/ f% n7 Zuse of testosterone gel twice daily that he was apply-
$ [" K0 j  M2 {) Uing over his own shoulders, chest, and back area for3 i7 B8 y8 A( W; Z
a year. The father also revealed he was embarrassed0 a  ^% g. G# D+ b2 ^: ?
to disclose that he was using a testosterone gel pre-
( ?: K. F/ {/ E# B( L9 G, T8 J0 G1 Cscribed by his family physician for decreased libido7 p& c% P+ P+ y; v
secondary to depression.
& w% }* }; I5 o, v% d) ?5 [+ n: n! d0 TThe child slept in the same bed with parents.: Y; k5 e# J" k1 g' J; T4 l
The father would hug the baby and hold him on his
6 n2 ~" p; X( x- T5 z: a$ ^+ Jchest for a considerable period of time, causing sig-! P# ]7 {& W! v* u5 c- e. |
nificant bare skin contact between baby and father.: Y: n5 E+ i7 ~- b) [: a6 J8 S
The father also admitted that after the phone call,
* P6 E3 d( g* y  V4 M( b- W, Twhen he learned the testosterone level in the baby7 ?) E0 b7 J2 V/ k& z. C# X
was high, he then read the product information/ @- v" F. p7 B! F
packet and concluded that it was most likely the rea-
# D  Y: @' O/ @0 G2 c: ^/ ?son for the child’s virilization. At that time, they+ @6 {& q2 h0 w' ^8 F& l/ ^+ q
decided to put the baby in a separate bed, and the
0 u4 o+ G2 j) ]6 }9 l; _2 n8 vfather was not hugging him with bare skin and had* {* k0 r" V7 R
been using protective clothing. A repeat testosterone: @6 g. O8 o2 r& O6 R8 n2 S7 P! V
test was ordered, but the family did not go to the
# ], H. [4 E# l6 H$ F- Vlaboratory to obtain the test.
1 l# \% R' R) c/ G& j. f  ~Discussion
7 `" ^. y/ T$ OPrecocious puberty in boys is defined as secondary! M, i6 U9 N+ k- r
sexual development before 9 years of age.1,4
: ?5 p# Q1 [- [* y* P2 E7 tPrecocious puberty is termed as central (true) when
+ Y) p- ^+ ?# _6 c& Y! hit is caused by the premature activation of hypo-* Z& N3 Q+ s6 }% S6 n) @$ n9 e1 p- p
thalamic pituitary gonadal axis. CPP is more com-
# E$ c# h. P9 pmon in girls than in boys.1,3 Most boys with CPP
- k, g2 {5 H/ B. Zmay have a central nervous system lesion that is; {8 y( F7 p, O( `9 {# E2 X
responsible for the early activation of the hypothal-0 E5 j. R3 A) w# b; ?
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ n" ]: C5 |: i2 J7 `- Jsis has been given to neuroradiologic imaging in! \9 G" {. P+ A" u$ U4 O+ Q6 d
boys with precocious puberty. In addition to viril-9 U( N5 G+ W, e  V$ G
ization, the clinical hallmark of CPP is the symmet-
6 J0 M. E& P# frical testicular growth secondary to stimulation by; m1 g8 H( U7 j8 L% ?* r& V
gonadotropins.1,3) \9 w8 u% e. [- ^
Gonadotropin-independent peripheral preco-( `% l; j+ @& x; ~6 R2 [
cious puberty in boys also results from inappropriate
+ X' }- F6 X, \" L" m0 ^androgenic stimulation from either endogenous or
( q: e) M; A0 s4 mexogenous sources, nonpituitary gonadotropin stim-
* O5 R* M+ c- v+ U0 t& Z3 Hulation, and rare activating mutations.3 Virilizing
6 k( h3 I2 S6 Ycongenital adrenal hyperplasia producing excessive
3 _% B- e) N& Yadrenal androgens is a common cause of precocious
$ @* J# h: l8 F( s4 ppuberty in boys.3,48 K% X9 c) B2 p$ C& J
The most common form of congenital adrenal- ~( |, t" X5 O9 l% F  e) S' D4 g
hyperplasia is the 21-hydroxylase enzyme deficiency.$ H1 z, J( d; T8 R! M( w
The 11-β hydroxylase deficiency may also result in* P1 X, M$ X. W1 {
excessive adrenal androgen production, and rarely,: g5 Y3 z, R, N! v$ ]
an adrenal tumor may also cause adrenal androgen
2 J4 ?3 T5 x( G7 h4 ]' q' l$ i5 t  ]! ^excess.1,3: k4 q" a/ D& C+ P5 W" C8 i) }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' {: T* H% z& |  j: ]5 B% N542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& u" c6 f- a. o3 r4 W- V& O# p
A unique entity of male-limited gonadotropin-' }& R6 t# E7 r. p# x& p
independent precocious puberty, which is also known. f6 h% c( g1 E( j( U5 G
as testotoxicosis, may cause precocious puberty at a$ ^' }( ^# l3 i
very young age. The physical findings in these boys
% Z2 Y2 u- s; ]8 t9 P* Ywith this disorder are full pubertal development,
$ E8 @! [( y% d; k/ I3 bincluding bilateral testicular growth, similar to boys
  \* H+ e. }7 J: `with CPP. The gonadotropin levels in this disorder
0 L$ {* t& E0 x3 x3 ^are suppressed to prepubertal levels and do not show
2 C" X7 J: g+ I$ i7 t; {pubertal response of gonadotropin after gonadotropin-
3 g  I  p7 Q3 B) A# Mreleasing hormone stimulation. This is a sex-linked
, Z7 ^( w+ s2 e0 r" C9 Iautosomal dominant disorder that affects only
7 `" s, n, K. a/ f4 ^! Wmales; therefore, other male members of the family+ b- V: x# U5 G0 g& f) }
may have similar precocious puberty.3" g$ j' L, d  U5 b( Y
In our patient, physical examination was incon-
1 R( s. {' T- b' o8 L  p: X! hsistent with true precocious puberty since his testi-
, K) L$ A# O$ Z& C" Acles were prepubertal in size. However, testotoxicosis
2 a( I- Q- C! `( rwas in the differential diagnosis because his father& t' e+ r* \' d, S: F
started puberty somewhat early, and occasionally,
) Q& j+ t# z% [- c9 Q6 Vtesticular enlargement is not that evident in the0 C  A# }0 I) ]/ l, X
beginning of this process.1 In the absence of a neg-
( k3 H$ m7 k/ }ative initial history of androgen exposure, our( b; \) U, ~2 H
biggest concern was virilizing adrenal hyperplasia,/ L5 R# E* e9 l. t. a
either 21-hydroxylase deficiency or 11-β hydroxylase
5 U+ S) z7 [; i9 H' x' b+ ?7 ]) Odeficiency. Those diagnoses were excluded by find-/ D+ y. F: A! V+ S7 @, ]
ing the normal level of adrenal steroids.- p( @8 `2 R1 N* S: b% b; {! q
The diagnosis of exogenous androgens was strongly
- V6 m6 z+ U- q# \suspected in a follow-up visit after 4 months because
/ k6 m4 T' n/ v2 R% k# Uthe physical examination revealed the complete disap-1 ^* C; \; r/ q/ ~" f4 ?
pearance of pubic hair, normal growth velocity, and
$ D8 L& e7 a% W: M; Edecreased erections. The father admitted using a testos-, ]7 c. D$ }4 J; n
terone gel, which he concealed at first visit. He was
* q$ \* x3 [: g$ B& ]using it rather frequently, twice a day. The Physicians’
* I; S6 a/ }) L, y  a1 L; `0 uDesk Reference, or package insert of this product, gel or
. N. S4 H1 I0 l5 w9 z7 ccream, cautions about dermal testosterone transfer to2 U. i1 l/ ?/ f8 V
unprotected females through direct skin exposure.
" A% s/ J# n5 e* D. O+ z8 z4 _5 SSerum testosterone level was found to be 2 times the
. b- W& ]9 }, R" Zbaseline value in those females who were exposed to9 ^5 B( S1 }% ]8 \+ X
even 15 minutes of direct skin contact with their male
+ r8 ?$ U# \0 u6 fpartners.6 However, when a shirt covered the applica-
' G; m$ S' v, Ption site, this testosterone transfer was prevented.
$ `9 U! ~: l: R4 i( V5 qOur patient’s testosterone level was 60 ng/mL,
' E& b: d# B; L0 P; d& xwhich was clearly high. Some studies suggest that  K4 R/ i8 U0 E9 ?, e
dermal conversion of testosterone to dihydrotestos-5 B; k* x! m  z, w: F+ _
terone, which is a more potent metabolite, is more: v; d  i1 H% ?# g: G; E
active in young children exposed to testosterone; y: L: T% V+ l5 i3 E$ m9 R
exogenously7; however, we did not measure a dihy-
9 `3 ~- C8 x7 bdrotestosterone level in our patient. In addition to
, z7 ]" Q1 M6 r, dvirilization, exposure to exogenous testosterone in# E! p8 e8 X$ R, y
children results in an increase in growth velocity and
2 R7 V* N) ~" R0 g! d# z5 c6 }9 W2 sadvanced bone age, as seen in our patient.
% Q) e: ]: n5 Y5 F5 X8 k6 L- PThe long-term effect of androgen exposure during, K. H. O5 C( J: V( o/ {) ^9 l
early childhood on pubertal development and final. R) T! L' b3 s
adult height are not fully known and always remain& L4 K2 q+ p8 [$ f/ A
a concern. Children treated with short-term testos-
6 M/ v& e& r, f  k5 \* }5 N0 h/ Iterone injection or topical androgen may exhibit some
6 ?- A, \6 G' J0 Gacceleration of the skeletal maturation; however, after1 d, ~1 |  _1 @. W
cessation of treatment, the rate of bone maturation" a' R5 Z7 w( N% C- n( x  Y
decelerates and gradually returns to normal.8,9
4 f* G( Q# ]" U( p0 v7 M* DThere are conflicting reports and controversy
" l( H& k6 v6 n/ s. `0 c+ Vover the effect of early androgen exposure on adult
* p6 |' m! s( q0 ypenile length.10,11 Some reports suggest subnormal. B2 V) T8 U8 N
adult penile length, apparently because of downreg-9 i* p, B: U. ~' H0 f
ulation of androgen receptor number.10,12 However,: ?; q% Y- k! @) f! a; Z
Sutherland et al13 did not find a correlation between/ V8 G2 x: |% `& Q" O" A( w: M
childhood testosterone exposure and reduced adult* D3 x. u  B$ i" O
penile length in clinical studies.  ]( o# r5 Y) N( I) U6 r. f& ?9 z
Nonetheless, we do not believe our patient is
& t1 `" Q3 O& @* b) ?1 z  sgoing to experience any of the untoward effects from
" Y  u# a! y; n; p5 e" ^testosterone exposure as mentioned earlier because
/ \: u  w( R: r1 B+ b+ athe exposure was not for a prolonged period of time.
3 ?% i1 R0 I. t& M. v- F; ^% q. P5 G9 jAlthough the bone age was advanced at the time of( a2 s  f# c' S* Y
diagnosis, the child had a normal growth velocity at
6 N( g8 [4 U* e% T1 P6 lthe follow-up visit. It is hoped that his final adult
3 I9 B$ E: ?9 o6 m" w# N# m" B  W, A" rheight will not be affected.) p1 v9 e0 W4 E& Q* o7 w
Although rarely reported, the widespread avail-
7 L) u, A4 e: f2 m( O, A8 l1 [ability of androgen products in our society may
* A& D- P" _8 h1 N1 Cindeed cause more virilization in male or female% e% O/ j7 i/ J% u, c6 V' x+ N
children than one would realize. Exposure to andro-
& b8 }# y5 J+ l7 ?gen products must be considered and specific ques-: ]3 H. k+ C( |% R( ^
tioning about the use of a testosterone product or' ]) q, W  q0 F+ F/ v
gel should be asked of the family members during
. A* c6 S9 P4 G9 y3 A2 u+ Uthe evaluation of any children who present with vir-
* f, j. v4 o; Q- g; o$ Kilization or peripheral precocious puberty. The diag-5 @  J7 E. _0 W. ]1 k
nosis can be established by just a few tests and by  _% h! ~5 b6 p- e
appropriate history. The inability to obtain such a
- Q' h- ^8 r) u+ Y. whistory, or failure to ask the specific questions, may
9 C' s; Z2 O" [/ p& B) Wresult in extensive, unnecessary, and expensive
( J$ _  g4 |' J; k5 g. {investigation. The primary care physician should be! M6 h9 H- s3 G5 i$ B0 I
aware of this fact, because most of these children
0 M+ M0 r+ A2 Zmay initially present in their practice. The Physicians’
5 G0 M, V4 g1 X- z% o0 |Desk Reference and package insert should also put a2 s; A* @5 H( i1 M
warning about the virilizing effect on a male or& K# ^. T( g- r) h1 A4 L8 S; m/ p; C
female child who might come in contact with some-
8 g! Y* ~0 L* O$ G- k* \one using any of these products.! G6 \1 i! \/ Q  \
References
8 |' f/ V' c: \5 [8 u1. Styne DM. The testes: disorder of sexual differentiation
: ?, T9 U, e* o/ c3 k! n5 Jand puberty in the male. In: Sperling MA, ed. Pediatric
) r4 P' k; m( v! G" z. kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" K1 {$ V( p  s: l2 [  J# M2002: 565-628.3 Y3 z/ {3 W- s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) q; m/ l, Z. Z
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 k8 K9 x# K4 E0 l; f6 _
Boy Induced by Indirect Topical) Y- O' d" L9 _7 i, m
Exposure to Testosterone
% {2 T+ d3 ^9 {6 Q- zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  Z! R: _- [/ s& `# u8 Wand Kenneth R. Rettig, MD11 S  E. I% _) U0 ]: _/ P1 I
Clinical Pediatrics
: X, [5 |* }) Z9 m+ E/ b. }Volume 46 Number 68 X: T  m2 w4 c+ V: y) B$ L
July 2007 540-5439 J  s- j6 r$ X8 k( X
© 2007 Sage Publications$ y, ?8 u4 L9 a0 z2 M/ f0 u, o
10.1177/0009922806296651: d) K1 Y9 o; p1 {2 [! p# ^- M
http://clp.sagepub.com
  G& ?- A9 a# H* O! P, _: P3 o; thosted at/ e) q+ _7 S8 d6 p
http://online.sagepub.com1 ]1 n" ~( t8 z2 ~; d
Precocious puberty in boys, central or peripheral,! r% R: a" @. e/ b& m
is a significant concern for physicians. Central
, I- r6 r# P1 {3 P2 J' _9 d5 q) Uprecocious puberty (CPP), which is mediated1 ]/ f3 \# X  A! `' d# a- C, n# H
through the hypothalamic pituitary gonadal axis, has
: p8 ~; _8 ]- k4 q/ \a higher incidence of organic central nervous system& I) h' i% s$ u% ?# l
lesions in boys.1,2 Virilization in boys, as manifested
( D  N2 [  r& Y6 Uby enlargement of the penis, development of pubic1 p! D+ I: s& u+ j, ^- y  X/ S
hair, and facial acne without enlargement of testi-
/ m. F0 I8 a/ X7 R# x2 P7 B" T' n/ D  bcles, suggests peripheral or pseudopuberty.1-3 We  W$ D: n) u/ h5 ~
report a 16-month-old boy who presented with the) |) b) B5 J( f2 V3 R1 P8 d# ~1 k- E
enlargement of the phallus and pubic hair develop-  `1 p/ H. y/ u  \$ i
ment without testicular enlargement, which was due" V1 Y% P7 @1 |1 H: J! Z% x: ~: v
to the unintentional exposure to androgen gel used by
$ M: y6 s6 D6 X- @1 Zthe father. The family initially concealed this infor-
( a. i2 u, |" I  z" dmation, resulting in an extensive work-up for this
/ a' w; J" J- wchild. Given the widespread and easy availability of2 P4 K, y  ^8 f2 f0 o  c0 |+ E
testosterone gel and cream, we believe this is proba-$ r0 i7 J' y* H  H) @
bly more common than the rare case report in the
. F# Z6 A7 \) m% E0 iliterature.4
$ A! ~* V* T# N- r7 ~; l- G% f9 APatient Report( A4 M% [% U7 [* ?
A 16-month-old white child was referred to the) ^- }1 t5 N. P6 C4 ^8 ^! `
endocrine clinic by his pediatrician with the concern
% ^3 G8 y9 m* X3 D0 W/ qof early sexual development. His mother noticed
' ~2 p7 ?: W' V* ulight colored pubic hair development when he was* F0 H" D" P8 k/ ~$ A3 T
From the 1Division of Pediatric Endocrinology, 2University of
" h) d1 G8 x1 J' p* w; v# gSouth Alabama Medical Center, Mobile, Alabama.5 T% b6 \7 {6 d7 l2 v
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ v" d3 A. |3 O; C' G# u, i
Professor of Pediatrics, University of South Alabama, College of
3 v) m$ B% e. n8 C& J& |+ g; W2 iMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 Q' U6 Z" z% T) E* E) N2 i$ xe-mail: [email protected].0 B; u& k4 D) I5 l; R9 ~
about 6 to 7 months old, which progressively became
$ l. x+ H3 ]8 Udarker. She was also concerned about the enlarge-' H( L; |+ ?2 o' f9 f' d* x
ment of his penis and frequent erections. The child! k$ T& k/ s( y2 `) z
was the product of a full-term normal delivery, with. d) }$ ]* t5 |2 [" V% d, T) e
a birth weight of 7 lb 14 oz, and birth length of9 n* i" C( O1 r) |  ]0 E+ s" i, {
20 inches. He was breast-fed throughout the first year$ [+ u  X0 ^! o' r
of life and was still receiving breast milk along with6 n/ o7 \0 t% G8 U* K
solid food. He had no hospitalizations or surgery,9 b% {7 L; q  Q) B: ?5 `
and his psychosocial and psychomotor development4 k" }8 N! w% i% z* U
was age appropriate.! S: T% M& R4 R$ x7 {. e/ S
The family history was remarkable for the father,7 T, S& M; A) U; u, a: t
who was diagnosed with hypothyroidism at age 16,
4 V$ P$ h% X+ N9 A9 }& ]which was treated with thyroxine. The father’s0 H& f+ I7 v, Q( U
height was 6 feet, and he went through a somewhat
* \, x7 G2 z: L7 uearly puberty and had stopped growing by age 14.9 I# c& ?% R) w! d  u
The father denied taking any other medication. The
( _! u. K: J4 y  W, Q( {7 Achild’s mother was in good health. Her menarche: }  m/ `  o/ u! D1 r# @
was at 11 years of age, and her height was at 5 feet5 z0 A* t5 X9 W. H  [- O2 N
5 inches. There was no other family history of pre-
0 Y5 {3 }6 e* [8 i/ S& B3 d4 Bcocious sexual development in the first-degree rela-
6 N% j1 u: o2 y6 s5 A( }3 Itives. There were no siblings.. R1 W! q3 ^& T2 a
Physical Examination7 J! D5 E/ }. X4 z2 r
The physical examination revealed a very active,6 J; ^+ z) b" K) C, C( @
playful, and healthy boy. The vital signs documented
/ L% |0 D9 f2 o/ R# ?a blood pressure of 85/50 mm Hg, his length was5 m& r8 B# N8 @# Y" Y) m
90 cm (>97th percentile), and his weight was 14.4 kg# v) A, r, e; B, n7 E- P0 ?. V) Y
(also >97th percentile). The observed yearly growth0 I$ U& _7 K" k, ^7 Z3 t2 i0 A% T+ o
velocity was 30 cm (12 inches). The examination of
" {0 K$ b) u2 lthe neck revealed no thyroid enlargement.# A# d/ o3 H$ }
The genitourinary examination was remarkable for
/ r8 J, A1 Z4 V' N4 nenlargement of the penis, with a stretched length of5 N  @1 ?. P( Z! P9 N
8 cm and a width of 2 cm. The glans penis was very well, n: A1 P3 ^- F4 a
developed. The pubic hair was Tanner II, mostly around
; I" k  P: Z4 `0 _3 ~540
' ]' r; [0 T6 f0 q8 z) I) \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 T6 L9 u7 Z9 ?" h4 Gthe base of the phallus and was dark and curled. The0 b2 X' V# z, ~' ^1 r
testicular volume was prepubertal at 2 mL each.
6 v2 I1 x2 ^2 Z" J0 UThe skin was moist and smooth and somewhat6 x+ f3 |& q7 A7 l1 p
oily. No axillary hair was noted. There were no
2 [, R. X1 i% v4 i+ t$ T4 _abnormal skin pigmentations or café-au-lait spots.- f3 p! D& i6 _6 e
Neurologic evaluation showed deep tendon reflex 2+, b  C- K' f+ E+ t" h
bilateral and symmetrical. There was no suggestion9 v2 Y- _0 `  b* R0 ~
of papilledema.
5 T6 ?8 H' I! ^; k" F1 D' ZLaboratory Evaluation
. F& J  S) Z+ K* GThe bone age was consistent with 28 months by, ^# C- j0 S  f7 G
using the standard of Greulich and Pyle at a chrono-6 Q! g' w+ q) o' A
logic age of 16 months (advanced).5 Chromosomal7 ~7 j0 p6 {7 E) T0 R
karyotype was 46XY. The thyroid function test$ ~2 E/ Z: Y* Z( a+ h2 J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 J. q* D9 N8 F, ~" o
lating hormone level was 1.3 µIU/mL (both normal).) [/ ?; j- k. p  d$ S, z- D
The concentrations of serum electrolytes, blood" m% R" R- o$ H: Q' ~" c" t& E
urea nitrogen, creatinine, and calcium all were) `+ x) C3 |* ~3 X* o, ^5 X
within normal range for his age. The concentration9 O/ T. h- u; J  F* |+ t" {3 V& z
of serum 17-hydroxyprogesterone was 16 ng/dL" {1 L$ P# Z& |1 s' L# o5 V
(normal, 3 to 90 ng/dL), androstenedione was 20
% H, ?8 a+ ]* X  f. Qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* x7 a% s7 `, kterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 Z# F  G* @2 s" Q8 y! Q0 O
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. D8 o: Q! L- g! Q4 z49ng/dL), 11-desoxycortisol (specific compound S)0 r% F, ^$ t' W: E+ x9 ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; m' w! z0 L, T0 Q8 z9 X* a! p# T! m2 {
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. I" Y6 R; O8 J1 E1 U2 n$ k- [testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" X& ~) c9 h; s% pand β-human chorionic gonadotropin was less than
4 I: _. o' L! _" B5 mIU/mL (normal <5 mIU/mL). Serum follicular( ?% y& m6 A/ h( b5 f
stimulating hormone and leuteinizing hormone
8 }! i; K6 V; k( ?" r& Z0 pconcentrations were less than 0.05 mIU/mL
( I/ J2 \( I  i) n! B(prepubertal).8 b5 \3 n( U- Y8 g; x6 S4 w
The parents were notified about the laboratory2 S, ~+ Z( j: d: r6 u0 Q
results and were informed that all of the tests were. `4 D3 Y/ j, j$ [/ F* {
normal except the testosterone level was high. The
- G2 _% W4 v, ^' Efollow-up visit was arranged within a few weeks to: O& D/ n- J8 \, Q; f# Z0 N
obtain testicular and abdominal sonograms; how-4 N9 g4 {& G% l  u
ever, the family did not return for 4 months.; y( {, Z# {- V# i  Y2 d
Physical examination at this time revealed that the
  ~3 w$ r% y* {( E  ]$ jchild had grown 2.5 cm in 4 months and had gained
- a( u$ G2 Q" I; M2 kg of weight. Physical examination remained
. N6 M( D* m8 r  M9 h; Yunchanged. Surprisingly, the pubic hair almost com-. ^& s1 q- r9 T6 s0 x) `7 I
pletely disappeared except for a few vellous hairs at
9 E& V. h  w3 ethe base of the phallus. Testicular volume was still 29 M, _' O1 l# j% u8 `: v- S
mL, and the size of the penis remained unchanged.6 R7 Z( }8 Y- H; {. [" Y5 _
The mother also said that the boy was no longer hav-/ O; `) j5 Y4 {8 @8 N
ing frequent erections.
2 V  v7 N8 F' w+ oBoth parents were again questioned about use of3 s- t+ e0 _1 t  H/ @8 b( i
any ointment/creams that they may have applied to
6 `" m4 w  I) L0 T. Rthe child’s skin. This time the father admitted the
/ E' J9 z0 v2 A) nTopical Testosterone Exposure / Bhowmick et al 541$ o: @5 V) m7 P+ @% M% y5 Z
use of testosterone gel twice daily that he was apply-
1 J% a5 j$ f# B" |- {/ Xing over his own shoulders, chest, and back area for% H0 c* U6 K. \) ?3 h& H
a year. The father also revealed he was embarrassed( B- m3 n4 ~% |
to disclose that he was using a testosterone gel pre-, ^* ^; _8 @# q4 e- V5 r3 L
scribed by his family physician for decreased libido6 E$ a+ @! L3 X
secondary to depression.- s1 E" q1 w/ L) x- g
The child slept in the same bed with parents.
1 z) I8 {- O' @2 _The father would hug the baby and hold him on his, v- m5 x( _0 w
chest for a considerable period of time, causing sig-) r3 C, t" q" y' T1 a: }4 A% j+ V3 I
nificant bare skin contact between baby and father.7 t9 v- Q1 [- H' T" Y. t- T
The father also admitted that after the phone call,
! z, v1 l9 j% ^5 c; Gwhen he learned the testosterone level in the baby
. c% v0 K0 g8 b& s( u2 L- s6 y5 Fwas high, he then read the product information( F+ ~. P, P0 D( E6 z3 S4 L" X
packet and concluded that it was most likely the rea-( U2 G8 b" J# F
son for the child’s virilization. At that time, they' V2 N  b& K! T( h" i
decided to put the baby in a separate bed, and the. ~" {$ N! E8 D/ B* ^: g
father was not hugging him with bare skin and had, E  i; \+ u7 a2 G
been using protective clothing. A repeat testosterone
" j- \3 L% p" m- O  O3 Utest was ordered, but the family did not go to the7 u9 s, o- @* U: ^+ v
laboratory to obtain the test.
) W9 p  {" O( L2 c6 P- q+ b0 ]Discussion, Y" E6 o2 p: k+ p
Precocious puberty in boys is defined as secondary
8 e$ B  ?) |! Q  e0 l% X  W1 zsexual development before 9 years of age.1,4
; \6 J, v$ A" i& ^Precocious puberty is termed as central (true) when
6 O) G3 Z7 m: @& E" bit is caused by the premature activation of hypo-
. n: k9 R8 a" J" v  m. i. l* Gthalamic pituitary gonadal axis. CPP is more com-- s* L% w* F4 ^( B8 y
mon in girls than in boys.1,3 Most boys with CPP
; r; E" E- J0 B1 d( \( w! Qmay have a central nervous system lesion that is
0 A9 i8 Q6 n! o1 U5 @responsible for the early activation of the hypothal-% b- I& @5 g' o) T/ l7 h
amic pituitary gonadal axis.1-3 Thus, greater empha-# `( |6 l9 t+ K8 G
sis has been given to neuroradiologic imaging in
, s# e9 c& d9 j  ]1 c* v. ^0 {0 Zboys with precocious puberty. In addition to viril-6 [: r7 I2 G+ `2 I6 q( q- o8 y$ o
ization, the clinical hallmark of CPP is the symmet-1 z5 Z2 Y6 R8 q+ w5 e4 x
rical testicular growth secondary to stimulation by
  I5 ~5 W5 g" Q9 D3 o2 c4 L/ d5 Qgonadotropins.1,3; F) Y, J4 h5 _  ~. b6 S; e
Gonadotropin-independent peripheral preco-) S" \! c  x2 s. v" J& q
cious puberty in boys also results from inappropriate
8 N- B, b" J  ]  A/ j3 ~androgenic stimulation from either endogenous or
, j, ^( `% X6 B6 y5 Nexogenous sources, nonpituitary gonadotropin stim-
$ D/ o1 r* V$ E) i( ?: |ulation, and rare activating mutations.3 Virilizing
4 A" g# ^& W$ ~+ Gcongenital adrenal hyperplasia producing excessive* L7 ?2 f* E4 l- f0 T
adrenal androgens is a common cause of precocious
8 M5 o2 p( M* S5 Zpuberty in boys.3,4
( |% Y% b; X# F* u1 e# }8 f9 E+ YThe most common form of congenital adrenal
; J3 V* H1 Y, G3 L9 C6 U( shyperplasia is the 21-hydroxylase enzyme deficiency.
& E6 v( h) N+ h9 l9 ]: b& LThe 11-β hydroxylase deficiency may also result in
& j- I, x+ B8 k5 Y+ W* `# Lexcessive adrenal androgen production, and rarely,7 [$ j$ x5 W% i, E6 K
an adrenal tumor may also cause adrenal androgen
* |2 g. S! f2 Eexcess.1,37 D7 D% X8 F/ z& z$ {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, Z2 B0 E/ d# n, B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 i9 F7 a) q1 v7 Q) \, G  V* AA unique entity of male-limited gonadotropin-* n% S  N# r0 f1 E/ J
independent precocious puberty, which is also known
6 L1 z3 o4 ]& _. F) I5 u7 Vas testotoxicosis, may cause precocious puberty at a
  T" |$ }* O% Bvery young age. The physical findings in these boys; ]/ z; B/ L( \  ~9 \) L$ }
with this disorder are full pubertal development,
  z* V4 e: X1 N, k! f6 W( V7 rincluding bilateral testicular growth, similar to boys2 B9 x  R8 }! m% n* r. ?+ s
with CPP. The gonadotropin levels in this disorder3 z) y: I! f: S8 [: f* o- k1 k
are suppressed to prepubertal levels and do not show
4 _( x4 S- Z* T# A7 [- H" ypubertal response of gonadotropin after gonadotropin-. `. n% O. I' ]. P5 L. b' h: C& A6 v
releasing hormone stimulation. This is a sex-linked
# _% l$ h9 [7 a, E# Sautosomal dominant disorder that affects only' ~( U7 U; O4 \# i* y( a
males; therefore, other male members of the family
% i7 P" J! Y, {- Bmay have similar precocious puberty.3
% z: W3 c! n9 d5 f6 CIn our patient, physical examination was incon-" j) F  n9 I' h, F5 b
sistent with true precocious puberty since his testi-
% b0 m. a3 r( {* G% b/ icles were prepubertal in size. However, testotoxicosis
" t, b" }) N# g/ A) Wwas in the differential diagnosis because his father
/ ~9 E- I2 m& G' y0 Bstarted puberty somewhat early, and occasionally,0 k. k4 {' j$ M% f, S3 d
testicular enlargement is not that evident in the
/ h: [; D2 w) bbeginning of this process.1 In the absence of a neg-4 N0 I1 D2 T- q% }0 s' y
ative initial history of androgen exposure, our: y4 c9 C" J1 d2 m# n
biggest concern was virilizing adrenal hyperplasia,8 ]" K4 A( c. t6 Q
either 21-hydroxylase deficiency or 11-β hydroxylase
3 ?* M$ Q+ e0 mdeficiency. Those diagnoses were excluded by find-
; l) G9 n: W2 I2 }* J0 I! R; Ming the normal level of adrenal steroids.
3 a) p) q  @; Z. |+ b6 Z# P' _/ RThe diagnosis of exogenous androgens was strongly
6 p7 w5 H2 r8 _' hsuspected in a follow-up visit after 4 months because
1 v; l- B) w) o) k4 j9 p0 N' w/ Tthe physical examination revealed the complete disap-$ ~: N( v: y1 R, }5 o
pearance of pubic hair, normal growth velocity, and) z0 Y1 c7 R" F% f$ U  s
decreased erections. The father admitted using a testos-8 n) W. x6 G2 `
terone gel, which he concealed at first visit. He was
3 D1 j5 @2 B& c( T' n( j8 Eusing it rather frequently, twice a day. The Physicians’
% {3 B/ {$ b; I/ ~Desk Reference, or package insert of this product, gel or  s% e% n% B: p5 c% H' u+ G
cream, cautions about dermal testosterone transfer to
' i7 F& D% s" L8 L6 Lunprotected females through direct skin exposure.; S' H- k/ L0 G
Serum testosterone level was found to be 2 times the7 z7 G; s3 Q+ h( {' u8 s& X- j2 C
baseline value in those females who were exposed to
6 |. u2 |: q* i' X3 M9 i, e. _even 15 minutes of direct skin contact with their male
3 E# S, w+ T9 t- Z% jpartners.6 However, when a shirt covered the applica-
) e4 m' k1 k( g& q. Ytion site, this testosterone transfer was prevented.
* H! P: V/ \6 |7 g# aOur patient’s testosterone level was 60 ng/mL,
9 B& ?& c/ S  Z9 l- x( g' c( `* O- A; Bwhich was clearly high. Some studies suggest that
0 J6 p) d* Z+ h# t1 jdermal conversion of testosterone to dihydrotestos-
& N, D, ]3 N; e/ s. R9 R2 Hterone, which is a more potent metabolite, is more+ y; g$ t0 l: I+ H
active in young children exposed to testosterone
3 w* j  V  N+ C$ O) `* oexogenously7; however, we did not measure a dihy-5 D+ Y' F4 |& G
drotestosterone level in our patient. In addition to
3 Y1 @- e+ e, S3 @1 G: evirilization, exposure to exogenous testosterone in
, O0 F. ]3 |( M3 ~4 U6 P2 |children results in an increase in growth velocity and
) D" r$ D. a7 K! A* Zadvanced bone age, as seen in our patient.- e4 Q0 d4 F5 m: _/ K% {
The long-term effect of androgen exposure during# |# x2 _. O6 H" b  w1 h
early childhood on pubertal development and final% U/ d: _  i, ~4 T2 P
adult height are not fully known and always remain0 d* Y' G2 Z8 q4 g
a concern. Children treated with short-term testos-
: q1 u" G! P  f# m0 K) S) x- W0 M) ~1 ^: Mterone injection or topical androgen may exhibit some
$ z/ J# n3 m$ H  e; B; Kacceleration of the skeletal maturation; however, after7 |# [- x' U; T3 t/ q. l0 I; T% F7 ^
cessation of treatment, the rate of bone maturation
5 o/ D) q2 c+ p- t- L3 M. ?  T1 {, Idecelerates and gradually returns to normal.8,9" b& T( M4 ^9 Y3 a' f/ B
There are conflicting reports and controversy* q1 K/ H, M7 t$ O
over the effect of early androgen exposure on adult9 ~3 Z. W; R& R1 T- b" L3 h
penile length.10,11 Some reports suggest subnormal( X& Z) _" Q; W. i4 t; B
adult penile length, apparently because of downreg-6 t, j! [5 ~6 y. o# U
ulation of androgen receptor number.10,12 However," O# s5 M3 |5 m  J" V
Sutherland et al13 did not find a correlation between  O+ \/ e3 T$ z
childhood testosterone exposure and reduced adult
# M9 s! J/ T( C4 _/ Vpenile length in clinical studies.
" x; E% P1 f2 F8 M( @+ Z. j3 hNonetheless, we do not believe our patient is1 l' P' ~  o0 g
going to experience any of the untoward effects from
/ q( p( u, ?+ D9 v; M; Z1 y9 Ttestosterone exposure as mentioned earlier because) K' C% j' N' {1 p
the exposure was not for a prolonged period of time./ _: W) c$ r% ?% d/ v
Although the bone age was advanced at the time of3 q$ f0 _( C* F& `1 g
diagnosis, the child had a normal growth velocity at+ ?9 N7 p, q! C2 M1 k; S
the follow-up visit. It is hoped that his final adult
/ c- |) E. ~$ G  ~! ]height will not be affected.8 Z5 y6 `; O8 w8 S, E3 C
Although rarely reported, the widespread avail-0 [, L; u/ I5 w& W. |7 H
ability of androgen products in our society may. l  |  B/ J) L: B4 s
indeed cause more virilization in male or female, j7 z8 ]" V/ B7 e+ o; l4 g9 D
children than one would realize. Exposure to andro-
& H  x8 L2 c) ugen products must be considered and specific ques-/ _# w- |& r7 |3 S8 Y
tioning about the use of a testosterone product or
( \) j) s3 \: n4 T! bgel should be asked of the family members during
+ P5 {2 |/ m3 |  T2 R" xthe evaluation of any children who present with vir-
1 x- t; R3 a" ^$ tilization or peripheral precocious puberty. The diag-
5 [; O+ K& b& ~$ G* x4 `) lnosis can be established by just a few tests and by/ i, J# R* l6 N- f1 z6 p; r2 q
appropriate history. The inability to obtain such a" o0 a( n2 Q& k. P6 d; F' Z. U
history, or failure to ask the specific questions, may% J1 u8 s6 C9 U' C! q+ N* C2 D) ^
result in extensive, unnecessary, and expensive% [5 R( H( e) s
investigation. The primary care physician should be4 \# I5 s+ W+ F3 ~0 w; |
aware of this fact, because most of these children: P! c9 W" D& S6 l: g9 d: M) d
may initially present in their practice. The Physicians’( z1 L$ j, M. F% ?5 q$ ^9 K  [
Desk Reference and package insert should also put a9 _) X0 Q7 n! c/ ]: A
warning about the virilizing effect on a male or2 E/ ]* w- t2 [7 r$ j
female child who might come in contact with some-
1 }' @) g8 B- H9 Aone using any of these products.
" m* H0 o9 X$ D0 j' GReferences# [' [1 A7 ^. U( X
1. Styne DM. The testes: disorder of sexual differentiation
9 @$ }5 w  B8 k# \7 v7 I* oand puberty in the male. In: Sperling MA, ed. Pediatric. w" H" E8 o1 o+ ?  ~& Y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 _3 u0 Q/ H, A1 [) \# L* y. {2002: 565-628.$ Z& M( e& ~) b5 {: w
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( L' u* h) B2 N, Y1 lpuberty 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
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

7 D9 x. ?' U; J8 p( @. z/ ?& P- g. C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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