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Sexual Precocity in a 16-Month-Old
0 k( O  _0 o  X0 fBoy Induced by Indirect Topical
0 |0 W3 ~& O' `: p) F# ]Exposure to Testosterone' F% ]8 {& |. r" m' V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 c' e' B9 _) z0 u: Pand Kenneth R. Rettig, MD12 M2 N2 T7 f. L1 m
Clinical Pediatrics
0 [7 Y) c# K$ f) O1 E$ d' aVolume 46 Number 6% s6 I1 t. A& U! j, w" G& {
July 2007 540-5433 c' k" g3 Z; j# \+ g7 ~
© 2007 Sage Publications& c- S" u9 m4 S2 u$ [
10.1177/0009922806296651- \0 ^. R! j9 [% e6 o
http://clp.sagepub.com- T/ _2 g! R) e  ^  P* ~9 C
hosted at' V4 \6 a+ v# q* |7 _, R' F% Q$ J
http://online.sagepub.com
, m& q  `0 |0 @0 M& KPrecocious puberty in boys, central or peripheral,4 R" u5 k% M: i* R( s
is a significant concern for physicians. Central
, D; N0 ]: ]- K7 \6 x- J5 m" F/ Eprecocious puberty (CPP), which is mediated5 Z8 J1 R+ d: M& _0 |( z) l4 y
through the hypothalamic pituitary gonadal axis, has
1 V% {5 [7 L/ Y; Ta higher incidence of organic central nervous system1 |# z0 @3 I: m' U+ P, {4 f
lesions in boys.1,2 Virilization in boys, as manifested
; z$ t7 Q0 i# }by enlargement of the penis, development of pubic
% i, z1 m% W! n# m( H, Shair, and facial acne without enlargement of testi-  d$ m# }, V' e) w
cles, suggests peripheral or pseudopuberty.1-3 We
; @( x, k1 }2 J& F% i/ D, O6 |: breport a 16-month-old boy who presented with the1 l2 f* U3 w; s& W6 A7 {: u
enlargement of the phallus and pubic hair develop-
! ]# Q" T3 }2 e/ Sment without testicular enlargement, which was due  q: [! _! \7 q( f
to the unintentional exposure to androgen gel used by
: h4 z4 l2 Y6 ^& Z5 \! z/ c3 \the father. The family initially concealed this infor-
$ M* V& K0 ]" O+ |+ v5 U/ R% k. W, @mation, resulting in an extensive work-up for this" E$ b3 x2 l+ B% U- H. c* g& R
child. Given the widespread and easy availability of1 |1 t1 @* C8 n
testosterone gel and cream, we believe this is proba-
, s' l3 ?% N8 v1 A$ k% x. Hbly more common than the rare case report in the
) [4 q# l" I6 @! O0 w7 f3 l( cliterature.48 @5 M  t3 e; ~" N' ~0 \& L& i
Patient Report0 W/ @. a3 Y8 V0 z
A 16-month-old white child was referred to the3 D) |' T: B5 v; K0 W
endocrine clinic by his pediatrician with the concern
( P4 x8 I* U# q4 L0 E, Eof early sexual development. His mother noticed
9 _1 B7 Z3 r7 ^; wlight colored pubic hair development when he was- k9 \: D& z: i
From the 1Division of Pediatric Endocrinology, 2University of0 U- L: V3 r1 y4 s; K, p, o
South Alabama Medical Center, Mobile, Alabama.
0 R6 O' p* u6 l- e+ D4 J! KAddress correspondence to: Samar K. Bhowmick, MD, FACE,
% L# v2 H- @+ X+ y( k: z9 nProfessor of Pediatrics, University of South Alabama, College of" H5 ~8 k$ l" y+ G! f& H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ R4 w  _% K; q. Ce-mail: [email protected].  k# p2 u6 Y& N6 w
about 6 to 7 months old, which progressively became
. U' h7 T: R0 j) n( V5 F3 R- Jdarker. She was also concerned about the enlarge-7 n: n  E: T4 r  c' `% z) P
ment of his penis and frequent erections. The child
+ o7 o* E) E+ ]2 }/ jwas the product of a full-term normal delivery, with
# R2 D0 c* O3 {# t2 Ia birth weight of 7 lb 14 oz, and birth length of( \, t: Q- z5 a6 b$ x% B
20 inches. He was breast-fed throughout the first year( I! K5 c, ^! V) h5 a* |$ B
of life and was still receiving breast milk along with! B, G- K3 {% x
solid food. He had no hospitalizations or surgery,
7 T" T6 w+ |5 p: d$ P+ kand his psychosocial and psychomotor development  ^$ ~1 i7 H# S1 {, g) X  Y
was age appropriate.
, n* L5 Y2 w1 Y0 M: dThe family history was remarkable for the father,
- _+ ~5 N. ]. T$ Ewho was diagnosed with hypothyroidism at age 16,
7 J, u! Z! @7 n0 T7 u# H5 `1 Uwhich was treated with thyroxine. The father’s" f5 O$ J8 U8 ], z2 I/ x
height was 6 feet, and he went through a somewhat
: m6 Y) J( m- W( E2 Wearly puberty and had stopped growing by age 14.
/ C0 Y. |4 a3 q: FThe father denied taking any other medication. The1 F/ N0 k4 w. ^
child’s mother was in good health. Her menarche! e- m, U7 c- C# Q
was at 11 years of age, and her height was at 5 feet
5 h7 S4 y: W  ]5 inches. There was no other family history of pre-
" u/ }: R( v! d& j( Xcocious sexual development in the first-degree rela-3 v; l; @: T; T
tives. There were no siblings., ], O: i2 V% F& Z6 F( h
Physical Examination1 p  S0 |7 [# |( u
The physical examination revealed a very active,
3 Y7 v8 Z3 P  R/ }1 _% mplayful, and healthy boy. The vital signs documented( a, U+ O3 o4 `2 k; P6 g
a blood pressure of 85/50 mm Hg, his length was/ j4 d1 x0 Q! v& `
90 cm (>97th percentile), and his weight was 14.4 kg- t! G! [+ V9 T, Q& m5 [/ Z
(also >97th percentile). The observed yearly growth; j: \: _" W* x, ?4 S/ v, e  l
velocity was 30 cm (12 inches). The examination of5 \+ T  t# S7 P/ c; m' Z
the neck revealed no thyroid enlargement.* K8 [1 o4 n2 j( o, n
The genitourinary examination was remarkable for
/ d3 ~3 s- X9 l) g7 @enlargement of the penis, with a stretched length of
+ G3 k& P8 o! J, G: b8 cm and a width of 2 cm. The glans penis was very well
( X6 Q7 a! i7 Y! V6 K% R; xdeveloped. The pubic hair was Tanner II, mostly around
0 R# B+ Q3 m2 M" Q  w540' P+ D8 m( I( ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) E0 R% ]* _: ~8 P% Y9 I+ Pthe base of the phallus and was dark and curled. The7 h0 q& w& m5 r; n
testicular volume was prepubertal at 2 mL each.
- ?% }4 W4 v7 D' x6 D( {The skin was moist and smooth and somewhat
2 K8 Y. c8 @! G* J  g! soily. No axillary hair was noted. There were no: Y. o3 D. w% N3 e2 x! e
abnormal skin pigmentations or café-au-lait spots.% H) x7 ^& @5 Y; i8 [4 \
Neurologic evaluation showed deep tendon reflex 2+
9 ~" g& w6 ]* v. Wbilateral and symmetrical. There was no suggestion
$ z6 i7 \( @. t# Y; {+ uof papilledema." A; |3 a# h, x2 i& E: r2 x( G
Laboratory Evaluation: g" n4 `! d8 R5 |% z" k! \- C
The bone age was consistent with 28 months by2 w! C' j$ P# g( U' R( z& B
using the standard of Greulich and Pyle at a chrono-
  i8 n: w/ R' a3 x1 Flogic age of 16 months (advanced).5 Chromosomal
  @& \5 M( R; m5 l  A- M! ~karyotype was 46XY. The thyroid function test
" e, X9 [; x4 X% ~8 a* L+ _showed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 c+ @7 c4 G$ N. e# q8 B4 tlating hormone level was 1.3 µIU/mL (both normal).
+ t% E5 ]* Z* C! I/ EThe concentrations of serum electrolytes, blood
7 i6 p4 \) s  J8 `: C: Turea nitrogen, creatinine, and calcium all were4 @) s8 `4 ]8 W2 E+ n* ~+ ~2 f* |; ]
within normal range for his age. The concentration
1 w9 r$ |2 p) ?4 X7 @' ?$ @2 Zof serum 17-hydroxyprogesterone was 16 ng/dL
8 a, n- y+ J" N8 ^+ h(normal, 3 to 90 ng/dL), androstenedione was 202 S% f+ r# Y5 T# c: L6 c5 N
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- b6 m( i2 ^/ [! Mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; f" {5 q; W+ P! ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 O6 s, S% C; x! b( M/ x49ng/dL), 11-desoxycortisol (specific compound S)* c$ b2 k7 n! \9 [3 n) ~! n
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 I1 i1 f2 Z, ]/ S4 x$ I0 r- p1 mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. R1 z; _, e0 Z8 r/ o+ d* a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ F. t4 P) j- D- o+ d5 p% T- R
and β-human chorionic gonadotropin was less than
3 T6 W! F) q! Z# u5 mIU/mL (normal <5 mIU/mL). Serum follicular; I! O) R3 Z( ?. @
stimulating hormone and leuteinizing hormone
4 X1 l( S% L/ b; P( e# W2 xconcentrations were less than 0.05 mIU/mL4 h/ N6 H) U7 T/ X# J
(prepubertal).
4 G4 u2 C3 D6 ?" C6 N7 P! `: y0 ?- ]The parents were notified about the laboratory
( G5 }) [; o* ]  X, s0 S$ z  K4 Jresults and were informed that all of the tests were
! }4 d7 d3 v! Y7 Snormal except the testosterone level was high. The
( g) l+ r% e2 H8 \, Lfollow-up visit was arranged within a few weeks to, ?- Z9 B. k, f' {( e& w) X3 h
obtain testicular and abdominal sonograms; how-! T" }5 i: c* v7 h! }
ever, the family did not return for 4 months.
" G, S! g! y; O( `4 ]Physical examination at this time revealed that the
5 N( O( B3 E1 ?: Y. ~child had grown 2.5 cm in 4 months and had gained. f& s/ S1 d2 n; @* ?* ]' B6 L, Q# H4 h
2 kg of weight. Physical examination remained4 [9 {0 _  y0 a
unchanged. Surprisingly, the pubic hair almost com-
% L1 K" H8 U; _+ ]7 w2 p2 Ppletely disappeared except for a few vellous hairs at
% l  h4 o1 o# j; e/ w( e$ I8 l# sthe base of the phallus. Testicular volume was still 2
1 n! T6 a3 O, w/ A. ?3 j- w6 hmL, and the size of the penis remained unchanged.
3 a4 X8 k$ Z4 m  l" ~( }- DThe mother also said that the boy was no longer hav-/ y4 @+ i' S% G- O3 D# k6 H
ing frequent erections.& t! O5 Z7 R2 o( w  D' ?
Both parents were again questioned about use of
* A) p! ^) |6 H) T3 j- }3 jany ointment/creams that they may have applied to. b- t3 Q( U0 j* y1 A8 M
the child’s skin. This time the father admitted the0 o( a4 p  r5 Y5 i5 j
Topical Testosterone Exposure / Bhowmick et al 541$ x0 s% v. l* `+ `+ ]7 }/ q, A
use of testosterone gel twice daily that he was apply-
# M0 ~2 o) P! U  P( n0 J7 R0 wing over his own shoulders, chest, and back area for
. \) h( D' k* ?9 O7 }+ G+ Sa year. The father also revealed he was embarrassed
* y" h( G2 b& X* L/ b/ J  Oto disclose that he was using a testosterone gel pre-; T) ^3 t$ x! }) \) t8 M1 h7 w4 E4 V! |
scribed by his family physician for decreased libido. l2 |6 ^8 }( k( i( T
secondary to depression.
3 {% j, A9 _" A0 S8 [% ]) F; n/ ]% FThe child slept in the same bed with parents.) g3 n* J1 a9 C% ]
The father would hug the baby and hold him on his5 l8 N( X1 s7 R& R
chest for a considerable period of time, causing sig-) e  q3 L" z  |' c/ z8 _
nificant bare skin contact between baby and father.  E, c! q  J$ _  p
The father also admitted that after the phone call,, Q$ L8 j% ?1 g! O3 j
when he learned the testosterone level in the baby
9 [! E# \- N) |was high, he then read the product information
' W3 l# V3 X* X4 l* g' Dpacket and concluded that it was most likely the rea-4 Y( I7 q2 g% F3 V# L: h
son for the child’s virilization. At that time, they1 z: H, H% c3 l5 H9 @+ y
decided to put the baby in a separate bed, and the
2 p  g7 B1 X, Z# m9 N( Ffather was not hugging him with bare skin and had
- _9 f; \. T! ~) x; ]7 ^$ tbeen using protective clothing. A repeat testosterone' W0 ?3 j# u9 J) u+ m# _
test was ordered, but the family did not go to the6 E& V5 y! s/ Y7 H
laboratory to obtain the test.
0 ]/ r9 [1 F3 T; _6 L* ~4 KDiscussion
0 c" @, m+ L" C% t3 X4 p+ l6 BPrecocious puberty in boys is defined as secondary6 N8 Q( u- p3 w( b
sexual development before 9 years of age.1,47 ?+ _/ ~: a7 x& h2 Y9 f  P
Precocious puberty is termed as central (true) when
* U# \' _, f/ N( X( G- s+ sit is caused by the premature activation of hypo-; {( c* u& ~7 X" x
thalamic pituitary gonadal axis. CPP is more com-
! @, \7 L3 y4 t+ S" |8 xmon in girls than in boys.1,3 Most boys with CPP
* w# r! R3 r! _0 P; y- C+ A& bmay have a central nervous system lesion that is
1 |8 O1 \, F4 ~responsible for the early activation of the hypothal-2 d' \' b" k+ H
amic pituitary gonadal axis.1-3 Thus, greater empha-2 B, t% p, e6 H% ^5 T
sis has been given to neuroradiologic imaging in
1 m/ s- x' D' m' E! q. ~$ p- qboys with precocious puberty. In addition to viril-3 T$ q7 N0 O2 ]& C2 ]
ization, the clinical hallmark of CPP is the symmet-
7 }. w% G  I) O, [+ Crical testicular growth secondary to stimulation by
; F' g* G4 F! Ngonadotropins.1,3
- O* o7 U+ a" X4 \Gonadotropin-independent peripheral preco-% d7 n! `4 m( v1 @% g
cious puberty in boys also results from inappropriate
  e! p. ~5 {  ~androgenic stimulation from either endogenous or
$ @6 U6 w2 ^, T9 J4 u; z, [exogenous sources, nonpituitary gonadotropin stim-
3 T( G* B6 k/ ~ulation, and rare activating mutations.3 Virilizing
/ g5 b7 }+ h' P1 v3 L' f5 pcongenital adrenal hyperplasia producing excessive- x0 ^0 {! H2 m$ `+ \  B
adrenal androgens is a common cause of precocious0 e+ p, d7 ^3 J$ ]) |
puberty in boys.3,4
4 R# D8 b, K. z4 nThe most common form of congenital adrenal" ]0 M: k: r/ t) Q+ S1 S' x
hyperplasia is the 21-hydroxylase enzyme deficiency.7 A) [9 s$ U- S- v% c
The 11-β hydroxylase deficiency may also result in# [; Q1 P* U# g4 a9 t" ~- t0 d& Y
excessive adrenal androgen production, and rarely,7 d6 T6 D) O3 q6 \% K
an adrenal tumor may also cause adrenal androgen
! |  Y- ]8 o$ Q+ _excess.1,3! ^" ]& Q! g6 O6 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 ?# @6 [4 J  D( c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: t: M4 A3 R; e6 a1 u1 t% @0 ~A unique entity of male-limited gonadotropin-) G0 @6 k; A2 V* \9 X- P. x
independent precocious puberty, which is also known
3 d, k# t$ G4 l5 B, qas testotoxicosis, may cause precocious puberty at a4 P! e% B% o! Y. g& Q
very young age. The physical findings in these boys
6 n, y, M, U- O3 C  S  H& `6 mwith this disorder are full pubertal development,9 \5 J! E8 {, @6 x7 t# P# K
including bilateral testicular growth, similar to boys
8 O, P* |& ^2 _$ X( q% V" e8 V% hwith CPP. The gonadotropin levels in this disorder
7 x8 E/ n; b- _, l' n: d' }are suppressed to prepubertal levels and do not show* S' i9 b" `& \2 L7 p  V1 e
pubertal response of gonadotropin after gonadotropin-
' B* Q, Q  E0 ^" \9 w6 lreleasing hormone stimulation. This is a sex-linked0 |" x, Q7 B8 h% U) u9 v7 S9 n
autosomal dominant disorder that affects only
8 {& \' T, j$ w, W+ G9 \6 Cmales; therefore, other male members of the family
8 z$ g: h8 p# D( Y7 Y6 Bmay have similar precocious puberty.3
$ d% e$ X$ n, J% V' W$ [In our patient, physical examination was incon-
/ T- p5 E9 U$ F+ y) @sistent with true precocious puberty since his testi-9 d. n6 X: t' Z2 R, D6 A
cles were prepubertal in size. However, testotoxicosis: l, Z- q- M8 y/ O  |, Y
was in the differential diagnosis because his father8 ^6 Q3 G" X' ], \0 x/ D
started puberty somewhat early, and occasionally,: n$ ^* S0 _) L$ l. F2 ^+ K7 s. W
testicular enlargement is not that evident in the8 {. `5 M3 k: b9 c" j+ F# X
beginning of this process.1 In the absence of a neg-5 h% S& j) G$ u- C5 W# Z- O0 b$ E
ative initial history of androgen exposure, our
* s  I7 h) n% @; `; O+ y# \biggest concern was virilizing adrenal hyperplasia,
! V% n" o4 k' B5 Y3 V: Z/ ~! |" oeither 21-hydroxylase deficiency or 11-β hydroxylase, R5 J/ L5 h# X' `7 l6 j7 p: j
deficiency. Those diagnoses were excluded by find-: e5 S- B. _, V7 l4 h- \
ing the normal level of adrenal steroids.
- h2 M6 L8 Y4 \The diagnosis of exogenous androgens was strongly
" A4 T3 G( Y0 R% r! w9 F1 ~9 f& Z. U7 gsuspected in a follow-up visit after 4 months because6 C4 K( Z: L6 t* w3 C) V
the physical examination revealed the complete disap-
. \5 T  ]( N3 ]4 o9 ]pearance of pubic hair, normal growth velocity, and
4 b) }, a( k2 K& C, Mdecreased erections. The father admitted using a testos-
  \& A3 H, L1 M) k4 Y- p0 yterone gel, which he concealed at first visit. He was5 J! v" g# l0 U4 |8 z$ r' q
using it rather frequently, twice a day. The Physicians’8 _$ y$ T" Q- N8 I
Desk Reference, or package insert of this product, gel or, _' `# S% {  i1 a
cream, cautions about dermal testosterone transfer to: w6 J. m) l) v: X& ^5 Z! r
unprotected females through direct skin exposure.
) l' N+ f9 `% uSerum testosterone level was found to be 2 times the
& k: C, v7 n3 D' d) Bbaseline value in those females who were exposed to& z) B: {9 E' @+ w# P! \
even 15 minutes of direct skin contact with their male
+ f( u) A- x& f3 Ppartners.6 However, when a shirt covered the applica-- d2 E* X, l: f" B9 ]
tion site, this testosterone transfer was prevented.
4 _$ G' \% x0 [5 JOur patient’s testosterone level was 60 ng/mL,3 @$ W- e$ @8 }" l7 c* u- ~
which was clearly high. Some studies suggest that, J) z- l1 I4 f% p
dermal conversion of testosterone to dihydrotestos-
$ }6 G9 c' C8 t8 W9 j) q9 oterone, which is a more potent metabolite, is more3 y5 q3 q4 `' F1 p0 I: z" Q
active in young children exposed to testosterone
! g; a% V  i" f* [7 [5 Z2 Cexogenously7; however, we did not measure a dihy-
) y# o8 H7 u4 U$ ldrotestosterone level in our patient. In addition to
' H' T  ~4 A% z/ u( ivirilization, exposure to exogenous testosterone in/ R8 v$ z! b. g2 x. ?
children results in an increase in growth velocity and' G  D' ]9 c% B' l2 p" O. n
advanced bone age, as seen in our patient.- L; t- ?8 s* \* W# y$ b
The long-term effect of androgen exposure during
8 u8 c3 O; C5 l* F( _  W$ a$ u  bearly childhood on pubertal development and final  }" N  T8 O- v' O% H
adult height are not fully known and always remain2 m$ e/ ~" R" Y
a concern. Children treated with short-term testos-* w+ [/ \. u/ {, K/ s  D) T0 |1 _1 V
terone injection or topical androgen may exhibit some" }; P5 B# E; ^$ J
acceleration of the skeletal maturation; however, after# ~3 z+ s3 `. c, H4 w1 P$ O
cessation of treatment, the rate of bone maturation: P" g1 x: A# Y. d/ N
decelerates and gradually returns to normal.8,91 g+ w0 a' x8 A9 Y* ^
There are conflicting reports and controversy$ ]: L4 [2 ?: {2 F% s' ]# B, S
over the effect of early androgen exposure on adult
8 |4 Y4 H2 w: h+ X& _' d, Npenile length.10,11 Some reports suggest subnormal5 c! C4 p* w$ k# R
adult penile length, apparently because of downreg-
/ Y& l: t8 ^9 H' {ulation of androgen receptor number.10,12 However,& H- K% A* d, _) S4 \
Sutherland et al13 did not find a correlation between
* V" p' l0 V, ^2 m, Fchildhood testosterone exposure and reduced adult
0 y6 O% v+ a7 Y; N1 apenile length in clinical studies.3 V2 Y, m2 u, |! Q4 K6 `
Nonetheless, we do not believe our patient is1 G' Q. x% g( B, Q1 X
going to experience any of the untoward effects from, Y; M0 ?: I, y" G
testosterone exposure as mentioned earlier because0 J4 n1 N1 S; z) n* e; y5 j
the exposure was not for a prolonged period of time.# @+ p) U! P, ~9 ?2 f, a% Z
Although the bone age was advanced at the time of' Q: b1 Q/ P! S) @3 Z- }7 L
diagnosis, the child had a normal growth velocity at8 e* y& `4 l/ w; a
the follow-up visit. It is hoped that his final adult  t; ]" e1 n. K5 I2 o. [$ g8 w! @
height will not be affected.6 }/ y' K/ H  D5 E7 _0 v1 [" w
Although rarely reported, the widespread avail-/ x0 k/ e, G" A& {
ability of androgen products in our society may
, y4 r: u. m4 c& J: c; Yindeed cause more virilization in male or female
. O$ n2 a5 _8 {) G2 Pchildren than one would realize. Exposure to andro-
. J% r( ?, i+ H6 E) ggen products must be considered and specific ques-1 M" O) U! U1 @4 N; \
tioning about the use of a testosterone product or
# p$ M/ @6 v# x  pgel should be asked of the family members during
7 `% h. q5 `6 nthe evaluation of any children who present with vir-' ?1 s" y' P. C2 I$ _1 k; v& S5 G
ilization or peripheral precocious puberty. The diag-
2 l' g6 i3 R$ w6 onosis can be established by just a few tests and by! l$ c# h+ [, D$ x- Q: S+ Z
appropriate history. The inability to obtain such a/ V7 Z' O  o5 t8 a$ M: K; s4 _
history, or failure to ask the specific questions, may
- E5 F$ g! V% H. O3 K) vresult in extensive, unnecessary, and expensive
6 d/ J- g$ q6 \1 L! Sinvestigation. The primary care physician should be0 _# P$ a7 t" }3 r
aware of this fact, because most of these children
) {. F* f$ z: w7 ]7 N4 @: amay initially present in their practice. The Physicians’
, |: X) a1 r" s0 KDesk Reference and package insert should also put a1 b/ G8 V/ n% u( [! |. _
warning about the virilizing effect on a male or
2 Y# F5 ^+ _' e; ?  |% V; y0 zfemale child who might come in contact with some-, C3 K; e7 q# y7 u* c) s
one using any of these products.
8 {- `" v0 F8 c; x0 @6 |References* ?7 M0 L: m; t
1. Styne DM. The testes: disorder of sexual differentiation" K7 k) R( }/ s
and puberty in the male. In: Sperling MA, ed. Pediatric
8 h  N6 W( y9 [( Y. h: y! xEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. U5 P" W7 K" s2002: 565-628.
* r" p) ^' c) d6 h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 o. [2 R3 S( z# Q8 m' v
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" h$ t# {- E6 T- F( d" `Boy Induced by Indirect Topical
4 J3 e4 p0 x8 E2 b- {8 Y7 ?2 x8 n( UExposure to Testosterone
7 j* a3 V- s8 ^0 a" T' _5 e# BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ n* F- G& H7 \" F7 N: \0 }and Kenneth R. Rettig, MD1" X  L: ^, j& T4 o' d
Clinical Pediatrics
: \4 k1 R  b1 W# P/ T+ i, A0 xVolume 46 Number 6
5 _; r( h( N) V, J  \; p8 C4 kJuly 2007 540-543
; n3 w  `* ]. `+ g© 2007 Sage Publications, O0 [1 T; B2 C, y1 {
10.1177/0009922806296651! q5 [8 J! r. Z0 x3 w: n4 \8 Y, ~
http://clp.sagepub.com0 m, e( G' e7 x0 N0 `( w
hosted at5 q( C! O/ O) B$ ]
http://online.sagepub.com8 f4 y/ r9 k, ?9 h+ L5 w/ Z
Precocious puberty in boys, central or peripheral,
9 M6 _9 Z+ K$ ~' Lis a significant concern for physicians. Central  y% n7 K) P( E$ Q& ?' s
precocious puberty (CPP), which is mediated# r  A$ H! M. y# @& P& _* D
through the hypothalamic pituitary gonadal axis, has
. f2 i; B! l: t- t% qa higher incidence of organic central nervous system
1 q" `) G- q4 J0 n" ]( \lesions in boys.1,2 Virilization in boys, as manifested+ M) M$ r$ s9 n3 Q8 I! \
by enlargement of the penis, development of pubic
- A$ v) H3 k9 u7 o; z$ [, mhair, and facial acne without enlargement of testi-5 e4 I. t. ]3 H! O$ V
cles, suggests peripheral or pseudopuberty.1-3 We1 j5 f& R7 o, {& _
report a 16-month-old boy who presented with the
2 O) v3 v/ `. }% C1 d/ renlargement of the phallus and pubic hair develop-+ t+ M  h/ w( c
ment without testicular enlargement, which was due. R$ d* r" q4 d
to the unintentional exposure to androgen gel used by
* f2 A4 f4 Y% k* ]5 T7 ]the father. The family initially concealed this infor-
$ {  C$ B4 J% g; _* L6 I9 ~6 Bmation, resulting in an extensive work-up for this) q( i! _7 b% o+ Z3 A/ H' U2 Q5 o
child. Given the widespread and easy availability of
4 O& E, m4 l4 h3 R4 b/ a3 U# rtestosterone gel and cream, we believe this is proba-
1 U8 t* A! |0 A4 N5 V4 X" Hbly more common than the rare case report in the
5 Y6 ]9 j# L3 |% ~4 Cliterature.4) K  G8 ]$ Y8 U/ w- |; w2 [' I
Patient Report& X9 {; O& O& V: L9 g  T
A 16-month-old white child was referred to the
8 |# K. _6 d$ `* L  Iendocrine clinic by his pediatrician with the concern
4 l7 N9 }: n8 \8 n8 P3 i4 x' rof early sexual development. His mother noticed: X& F$ S5 w- u
light colored pubic hair development when he was
7 j! i6 c/ `: wFrom the 1Division of Pediatric Endocrinology, 2University of. E* _! O* L9 u1 |3 s
South Alabama Medical Center, Mobile, Alabama.( u/ B2 ]. P' q- d9 u7 T) R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 q! O3 f) R) R/ q- d% F' U' QProfessor of Pediatrics, University of South Alabama, College of
# I' `+ y3 [1 ~/ \8 h8 u! OMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ a$ w. H" g: Oe-mail: [email protected]., T5 Z: k% _. H0 y+ ?0 T6 A3 a
about 6 to 7 months old, which progressively became
- k) r: R2 G' ydarker. She was also concerned about the enlarge-/ J+ m; V; X/ m( g
ment of his penis and frequent erections. The child
; l, X6 H( c6 W: F( b6 Ewas the product of a full-term normal delivery, with' J( l7 e) P# N3 [5 u! ~0 W
a birth weight of 7 lb 14 oz, and birth length of
+ l, y$ b5 V0 _( f) K2 u20 inches. He was breast-fed throughout the first year9 \, B/ ^2 j7 k2 s( [
of life and was still receiving breast milk along with' i" b+ O3 n0 _& m$ S
solid food. He had no hospitalizations or surgery,9 U9 F$ w" m+ \5 i2 d
and his psychosocial and psychomotor development
! s& Z( M. s0 {. w& Kwas age appropriate.. f' h; p3 S5 y6 Z2 Q4 K6 b
The family history was remarkable for the father,
- F! H% H6 a- h* [# pwho was diagnosed with hypothyroidism at age 16,' D2 P" s: v  q) |$ |( ~
which was treated with thyroxine. The father’s  n; y+ F. _0 v8 U) j' g
height was 6 feet, and he went through a somewhat8 ]/ h* G( P2 A) h5 h0 L
early puberty and had stopped growing by age 14.) A8 M6 l  j) ~5 p8 n; ?5 \0 R: x
The father denied taking any other medication. The3 ^) r# p( F# L; l, M
child’s mother was in good health. Her menarche
2 u" Q/ x+ t$ t; @) awas at 11 years of age, and her height was at 5 feet
; F( y( Y- J, J/ W5 inches. There was no other family history of pre-2 H4 s- O5 F1 q3 G
cocious sexual development in the first-degree rela-5 i$ O0 v( K6 o2 C7 c& H+ U" I  d3 p8 @
tives. There were no siblings.& x/ W/ Z/ Z3 _, v: u: W* l
Physical Examination
8 g0 s2 l6 d) ?2 nThe physical examination revealed a very active,2 q/ O. a" d1 j- s& G
playful, and healthy boy. The vital signs documented$ y* _- e' p$ W% D. f
a blood pressure of 85/50 mm Hg, his length was
0 i+ \, u& P2 {% h& J90 cm (>97th percentile), and his weight was 14.4 kg
  `8 Z( ]; K5 T; E2 X(also >97th percentile). The observed yearly growth
$ j0 R! `  I8 z7 lvelocity was 30 cm (12 inches). The examination of
4 x* J' w7 S) X- A( A6 Xthe neck revealed no thyroid enlargement.
; g8 k; P% R1 WThe genitourinary examination was remarkable for
" S' ^* a, c9 W  }# Jenlargement of the penis, with a stretched length of
7 }0 s; K+ E/ g/ _8 cm and a width of 2 cm. The glans penis was very well
, p$ X+ |& o4 _& [: d( a; Zdeveloped. The pubic hair was Tanner II, mostly around; l, x7 S1 z/ C  k# n; T1 A
540& Z8 U8 i0 R7 _& H9 I, C
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$ }, x" |4 Q+ U+ Q) \* h6 @the base of the phallus and was dark and curled. The
: O2 L& h2 j' p. l+ htesticular volume was prepubertal at 2 mL each.
+ c9 Y; O. \' r% P: ^- pThe skin was moist and smooth and somewhat
& |& u% m% V5 d& Boily. No axillary hair was noted. There were no
& m# E3 k8 G4 B* a, Zabnormal skin pigmentations or café-au-lait spots.( v- N  M" n, R  X  ^: v1 P
Neurologic evaluation showed deep tendon reflex 2+, m# V1 `# Z# U0 b2 T  K. w3 U+ L
bilateral and symmetrical. There was no suggestion1 ?: B0 Z: z2 I
of papilledema.% N- F1 O6 z- m, m5 N3 X
Laboratory Evaluation
& j2 I, E$ O/ D: y; LThe bone age was consistent with 28 months by+ M$ L: h) J+ Q
using the standard of Greulich and Pyle at a chrono-
, W/ U+ U( h# \. clogic age of 16 months (advanced).5 Chromosomal
, U! X# x2 D9 R2 Vkaryotype was 46XY. The thyroid function test/ ^% K: @. C# E- Y! f/ p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# U* I* ~, B: O4 W7 G
lating hormone level was 1.3 µIU/mL (both normal)., ?) a5 N2 K+ T
The concentrations of serum electrolytes, blood$ D. f; @5 g5 I! O
urea nitrogen, creatinine, and calcium all were/ }0 |3 t. f- `- A2 a
within normal range for his age. The concentration: X6 l0 q; K+ G* F5 y& B) M
of serum 17-hydroxyprogesterone was 16 ng/dL
6 l# h+ T3 x# g( `4 X% ]0 |/ _(normal, 3 to 90 ng/dL), androstenedione was 20
, [1 `  s+ R6 Q8 mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  R  [( q8 w! {0 N" I( Y9 p- |6 {terone was 38 ng/dL (normal, 50 to 760 ng/dL),% i5 x$ u, V8 C' H' N6 c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to  P0 V' i$ M8 u% B, C
49ng/dL), 11-desoxycortisol (specific compound S)
( X- T8 F$ X! V5 @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 a1 q, c' k) R/ h0 x! ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! s  T. F, M7 b5 i& q6 T
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# Z& j9 l% b: ^9 J% Jand β-human chorionic gonadotropin was less than
. R9 \, H1 E& K1 B5 mIU/mL (normal <5 mIU/mL). Serum follicular3 f5 m7 t2 \. E3 p* O
stimulating hormone and leuteinizing hormone
. f% J2 h6 c+ _' Z$ U% Lconcentrations were less than 0.05 mIU/mL2 T/ ?7 f0 v) E6 F: w; \0 O! N
(prepubertal).* g  t2 T& f; Y: H
The parents were notified about the laboratory" l7 A% v0 D& g8 q
results and were informed that all of the tests were- n" ?+ G* o! \
normal except the testosterone level was high. The
: ]" ]7 ]! `; J) C0 w* V5 w) Zfollow-up visit was arranged within a few weeks to
' K/ w2 K1 b; q/ \' p3 Robtain testicular and abdominal sonograms; how-4 j" `5 R# J" e8 e( G
ever, the family did not return for 4 months./ N7 _6 ~. s( [* a) ?
Physical examination at this time revealed that the* h7 x7 [, I! Y4 D# A
child had grown 2.5 cm in 4 months and had gained: E, s5 P9 }9 O$ h& z& i
2 kg of weight. Physical examination remained
5 C, Y; W" Y. B8 q2 b8 G! @6 \unchanged. Surprisingly, the pubic hair almost com-6 B  d1 v3 ^/ w0 t
pletely disappeared except for a few vellous hairs at
, t  V/ o; D' ]$ z" Zthe base of the phallus. Testicular volume was still 23 I/ a$ C" n/ {+ D& S/ E2 O
mL, and the size of the penis remained unchanged.1 U3 _( m% B. ^, z
The mother also said that the boy was no longer hav-5 n  @  B* e$ D2 b" Z. r2 _/ n& w
ing frequent erections.
- K+ P$ {* b& P5 K% iBoth parents were again questioned about use of( u/ m% j- b: J/ s. h" [
any ointment/creams that they may have applied to
. t; ]  q9 O# s$ o) Dthe child’s skin. This time the father admitted the2 b3 y( I2 w" n- s, \( X0 ?4 f" X- ~
Topical Testosterone Exposure / Bhowmick et al 541
  i' y* a$ m" g  w& m+ Puse of testosterone gel twice daily that he was apply-
) `7 t+ J2 R$ G: z# f0 N( cing over his own shoulders, chest, and back area for, Y+ M: i, Y9 {* E5 w8 L
a year. The father also revealed he was embarrassed7 w9 @$ s+ Y4 V5 c
to disclose that he was using a testosterone gel pre-& o' f1 }- S: k0 i4 u2 z2 i4 f
scribed by his family physician for decreased libido3 s- L( r' D# X: ^) O& C
secondary to depression.. p0 T% T- F0 H" o
The child slept in the same bed with parents./ p0 T* P9 L" h) o! k. \
The father would hug the baby and hold him on his
( B4 K; {; p1 U5 x4 \chest for a considerable period of time, causing sig-
% C3 T+ L# `. ~. `nificant bare skin contact between baby and father.  U0 w8 c$ o$ E+ h6 ^" e
The father also admitted that after the phone call,& V: S* t0 R- R5 s% u0 \3 \
when he learned the testosterone level in the baby
  x! C- q6 ^) A9 u5 @0 f9 hwas high, he then read the product information) [  s2 Z5 ^7 U) g$ q3 M
packet and concluded that it was most likely the rea-
  W. I  G$ Z0 X+ B4 Q" N1 W+ y, oson for the child’s virilization. At that time, they
% p  e/ k/ Q. Udecided to put the baby in a separate bed, and the
+ x2 W, W- B! t$ @father was not hugging him with bare skin and had
4 h  j% m* E2 z. k% a4 tbeen using protective clothing. A repeat testosterone
5 Z& i1 v9 [  Q/ N; w' mtest was ordered, but the family did not go to the" M* ]3 d) o, }3 u$ k3 r
laboratory to obtain the test.8 j7 _! h/ f- v1 z5 N
Discussion1 s& x( `: F, e7 c+ L% e
Precocious puberty in boys is defined as secondary
1 G8 j5 w6 m( Z6 r9 C. \sexual development before 9 years of age.1,4; C. g' o! D  \" r, n
Precocious puberty is termed as central (true) when9 J) j8 t4 m! e
it is caused by the premature activation of hypo-+ ^0 Q2 G! C0 A0 V/ z+ @/ p
thalamic pituitary gonadal axis. CPP is more com-
: a& h: ^0 S* x  ]+ S0 Q& O* [mon in girls than in boys.1,3 Most boys with CPP+ P; t; _9 ?* V9 V& w5 C
may have a central nervous system lesion that is
7 P6 {0 w9 s- A4 p# tresponsible for the early activation of the hypothal-
* F  |/ W' k9 ]# ]+ k7 Vamic pituitary gonadal axis.1-3 Thus, greater empha-
+ W% `0 q( y9 Fsis has been given to neuroradiologic imaging in
1 B5 Y% m7 K3 T- n# vboys with precocious puberty. In addition to viril-
& @9 A2 K6 U+ @, ~4 N1 R* ~, i% Yization, the clinical hallmark of CPP is the symmet-
- i) D3 {8 P1 n! _( i) Drical testicular growth secondary to stimulation by$ G4 T' ?) }, m2 k6 `
gonadotropins.1,3, Y6 X9 K7 V( \
Gonadotropin-independent peripheral preco-
. Q6 s8 Z6 b9 b/ x" S; m( [cious puberty in boys also results from inappropriate
% a" ^# R4 K6 t) c5 H/ _. x' g/ Zandrogenic stimulation from either endogenous or2 a  M( S" s) B: }& D9 v
exogenous sources, nonpituitary gonadotropin stim-
; O; l, |. N9 Q) X6 s0 Vulation, and rare activating mutations.3 Virilizing( M- Q7 b! {2 G! ?0 |
congenital adrenal hyperplasia producing excessive
- A& I$ `) [; gadrenal androgens is a common cause of precocious
+ M2 F0 y" d, W) b7 v- Rpuberty in boys.3,4
$ N5 j9 Y+ j8 x! \6 x3 o2 y/ tThe most common form of congenital adrenal% v' `( g* w9 T4 k' c6 U/ [
hyperplasia is the 21-hydroxylase enzyme deficiency./ A% k8 n5 K& T6 O( k$ \
The 11-β hydroxylase deficiency may also result in/ x$ F3 M6 q6 ?. `
excessive adrenal androgen production, and rarely,1 ~0 Q  ~) N  D, }8 d# |
an adrenal tumor may also cause adrenal androgen  R1 o) q6 M4 j" p$ Q( i# X
excess.1,3' h0 ^9 f2 a8 C: @8 n7 t, E  s
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" N: E+ @7 Q9 P4 W: D3 p: W/ m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ R% e& b; ?) {' s. H
A unique entity of male-limited gonadotropin-
! y& j: S2 l* Y" T- F5 }& ?# Bindependent precocious puberty, which is also known& Z( W/ T7 I$ ~; X: c3 O8 e6 ^
as testotoxicosis, may cause precocious puberty at a
5 e1 Y4 M5 \3 b' j' b7 Z6 {very young age. The physical findings in these boys2 r3 `! z8 }* W7 _
with this disorder are full pubertal development,: Z7 J1 E, S+ v& I/ a0 P
including bilateral testicular growth, similar to boys
8 K& q" v1 _: s6 T( p; s. dwith CPP. The gonadotropin levels in this disorder) b* H' U8 Y3 S# V8 |/ y
are suppressed to prepubertal levels and do not show
$ Q7 [# k" `: f. C$ K& w; l% }pubertal response of gonadotropin after gonadotropin-
4 X5 p, B2 H2 U& ereleasing hormone stimulation. This is a sex-linked) m/ V6 K! }. p: i" Q6 A
autosomal dominant disorder that affects only
1 H% d# f$ @7 [2 Gmales; therefore, other male members of the family) i' V: M; R7 x- [4 f- e
may have similar precocious puberty.33 p) x( F* U* w* r9 L! w0 _( n
In our patient, physical examination was incon-
1 n8 z* X4 }' f4 Ssistent with true precocious puberty since his testi-0 S& S: B0 I- R! c  u! @, y
cles were prepubertal in size. However, testotoxicosis
/ N) E; E! B1 v2 {8 Iwas in the differential diagnosis because his father$ T8 o5 E. W- ?0 X( m, q
started puberty somewhat early, and occasionally,
  e" |1 k8 h; E* b- D6 `% Z, Htesticular enlargement is not that evident in the
! u2 r. R7 ]. \( `# j5 W. u, x" _beginning of this process.1 In the absence of a neg-
4 v# ?7 {6 Y6 M! rative initial history of androgen exposure, our, Y( C0 D2 ~  |- U6 x+ o
biggest concern was virilizing adrenal hyperplasia,7 h6 }( b9 _% ~- u
either 21-hydroxylase deficiency or 11-β hydroxylase
/ ]8 U  ?# Y% t" B; tdeficiency. Those diagnoses were excluded by find-
. v+ J4 w2 ~' Z7 k' v" Oing the normal level of adrenal steroids.
) {- s9 d, I- V5 R: N1 iThe diagnosis of exogenous androgens was strongly0 w! B" u- ]# }( G! `, e
suspected in a follow-up visit after 4 months because4 L; a) T. s1 u0 a+ M
the physical examination revealed the complete disap-8 |$ x8 e3 [: w' @0 C
pearance of pubic hair, normal growth velocity, and) S. r/ A6 e  ?) A6 n6 f; O# N
decreased erections. The father admitted using a testos-6 G7 x. |+ R; z0 q
terone gel, which he concealed at first visit. He was  Y; k6 p1 k! d* V9 p! s! G
using it rather frequently, twice a day. The Physicians’4 G- o  D# F# f5 q
Desk Reference, or package insert of this product, gel or
% j' `9 W/ ]8 {- U: z' l1 {6 [cream, cautions about dermal testosterone transfer to* E4 K# A# u& \
unprotected females through direct skin exposure.
  M8 [& W1 B/ ?1 V8 P" f. PSerum testosterone level was found to be 2 times the  q9 \4 h( u; P3 u6 @
baseline value in those females who were exposed to/ H9 S1 U/ z$ \$ K& d* t4 t& d
even 15 minutes of direct skin contact with their male. [4 j( g; B" z# e& O9 m' [6 K
partners.6 However, when a shirt covered the applica-
" n( M0 {7 E& V  V; A( ?! ^tion site, this testosterone transfer was prevented.
2 W' V( P; Q. N/ }9 AOur patient’s testosterone level was 60 ng/mL,) `4 M$ `5 P+ I; e* T! B- s
which was clearly high. Some studies suggest that
3 d! t5 k6 W# ^; n5 Ndermal conversion of testosterone to dihydrotestos-
( B0 J2 s1 B- Aterone, which is a more potent metabolite, is more$ A  a6 X0 w( b! D9 o
active in young children exposed to testosterone
8 ]0 w$ f4 q4 @/ \: O! W5 m9 [exogenously7; however, we did not measure a dihy-
8 c/ s8 h2 P/ ]" O& Z$ Zdrotestosterone level in our patient. In addition to
( G9 G! t' \/ o$ S* Z% ]+ }virilization, exposure to exogenous testosterone in' o  Q6 D) k3 m/ ]* t
children results in an increase in growth velocity and- a. w; n3 B  {
advanced bone age, as seen in our patient." O0 ?" I) M% J9 L+ ~, V
The long-term effect of androgen exposure during
4 R& X. L+ c  _7 b6 F9 Oearly childhood on pubertal development and final
3 ^2 Z; V. l! S( dadult height are not fully known and always remain
4 W) u. I0 g: Q5 U* o; oa concern. Children treated with short-term testos-
. s" `- b, v3 d. nterone injection or topical androgen may exhibit some
# |2 V; j7 ]( [  R: k3 k6 Uacceleration of the skeletal maturation; however, after! H7 K& f9 T! J0 W' h' I4 {
cessation of treatment, the rate of bone maturation
9 ]& X9 L2 r/ H2 {decelerates and gradually returns to normal.8,9
- I$ V$ s; A/ G9 t! ]% z% vThere are conflicting reports and controversy
6 M0 r7 \6 C; n; N0 i& ~. \over the effect of early androgen exposure on adult
) h8 m& D  G/ m; ?0 l1 Lpenile length.10,11 Some reports suggest subnormal! R' N- g& i; r8 S$ \5 J9 W$ B
adult penile length, apparently because of downreg-
2 m  _. u! r5 O! F% A& Y$ Gulation of androgen receptor number.10,12 However,+ V1 C7 G, w- c. Y: p. ^
Sutherland et al13 did not find a correlation between
. X# M9 X, d1 N6 o7 Ochildhood testosterone exposure and reduced adult
8 T: n3 N  o6 X$ Xpenile length in clinical studies.
" a" A4 q% p9 _, MNonetheless, we do not believe our patient is
# }! j: E! \% B  j8 x) Jgoing to experience any of the untoward effects from1 c) ~$ E2 e  T: \+ b2 y2 x) f5 E$ l) d
testosterone exposure as mentioned earlier because
+ \2 p! W! u# Q9 `% v) R0 p& E! Uthe exposure was not for a prolonged period of time.* T8 w5 L% t* @/ h1 P( u
Although the bone age was advanced at the time of
6 A0 B2 o7 j) b2 Vdiagnosis, the child had a normal growth velocity at
7 b2 ?! @. ]0 W0 T( U7 {the follow-up visit. It is hoped that his final adult" z. q; \6 n5 ?( x) X# E5 ]8 A
height will not be affected.
! h. a3 S2 z) n( }% OAlthough rarely reported, the widespread avail-
8 A1 n& x( A" U. y+ h2 }ability of androgen products in our society may! R4 R6 q! k' ?# J% Z9 R
indeed cause more virilization in male or female+ G; n, `  f1 W5 c' B5 p1 h1 T
children than one would realize. Exposure to andro-
4 V, a1 `. q% ]2 Y; g% @! Ggen products must be considered and specific ques-
% K3 h0 [) H. Utioning about the use of a testosterone product or3 t* D2 @! H$ z( O0 K2 I
gel should be asked of the family members during
$ A# r, D. o4 l0 [! H5 P, i* }& xthe evaluation of any children who present with vir-+ U/ z8 F9 `$ k) J. g& S% F/ i6 o, d
ilization or peripheral precocious puberty. The diag-1 Z8 n* |% D3 C0 n
nosis can be established by just a few tests and by6 {/ `/ i) e' p2 h# x: W
appropriate history. The inability to obtain such a
3 L- z; ~1 {8 `/ R* Yhistory, or failure to ask the specific questions, may
5 ^9 E$ {! b1 I; presult in extensive, unnecessary, and expensive
. w1 O5 x2 q0 f7 ]8 ^investigation. The primary care physician should be1 D+ n9 U" I: {0 ?
aware of this fact, because most of these children
+ M' h/ T" X. ~( Bmay initially present in their practice. The Physicians’- S2 ~/ j" r0 ?8 r
Desk Reference and package insert should also put a1 A$ V7 w$ u$ g. n6 x1 Y0 r$ b' @% p
warning about the virilizing effect on a male or; s1 _: `/ y# ]" O3 c2 G
female child who might come in contact with some-  N  ?' }$ g- k8 l* O
one using any of these products.& E  k0 {3 j8 M9 }
References5 f) e3 a7 W6 n" v- ]; N2 |- o3 C
1. Styne DM. The testes: disorder of sexual differentiation
2 c7 z+ q  o  b. `0 ?and puberty in the male. In: Sperling MA, ed. Pediatric
3 {9 @1 {& t4 D3 x7 E* tEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( z6 \* m- k3 p4 ^
2002: 565-628.
& q5 o7 f) c2 ?2 W: ]2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( l1 \2 Y' R6 R, h7 c) P+ \
puberty 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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
6 k5 g$ z  G) f
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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