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Sexual Precocity in a 16-Month-Old
( `, n) W0 H2 U! W2 X0 L! F- c- RBoy Induced by Indirect Topical5 E+ O& W- b0 G* q: A' M
Exposure to Testosterone) B- c* _$ v2 m# I, p, ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* u; z4 \$ M9 |4 g! c2 `5 `, p
and Kenneth R. Rettig, MD1
( |( X7 ~* ~3 qClinical Pediatrics8 g% @  a% Q5 L9 |6 b
Volume 46 Number 6* x4 E4 O" `, [- H
July 2007 540-543
, X$ l5 f" Y( f: ]/ ^- K$ r© 2007 Sage Publications! F. X! o$ z7 H+ s1 O; P, |4 o
10.1177/0009922806296651
6 l. L9 N6 B6 O' J6 l# yhttp://clp.sagepub.com
; j) a' I8 t) v# t+ @hosted at
- X  ]2 k6 H9 Y  v* c, h) ohttp://online.sagepub.com; q; Z; _4 H% q0 S* _- t! c
Precocious puberty in boys, central or peripheral,) }" x- v  E! S3 S  z
is a significant concern for physicians. Central
8 w2 `2 R5 s2 a- pprecocious puberty (CPP), which is mediated6 Q  B. G; g4 r9 T' ]5 M% H4 A
through the hypothalamic pituitary gonadal axis, has! ]: g& c* E4 D" R
a higher incidence of organic central nervous system
" ]" Q9 M2 H7 ?% p# \. {- Q% g/ E% Tlesions in boys.1,2 Virilization in boys, as manifested2 s" W: s+ b! o
by enlargement of the penis, development of pubic
! ]& P, ?1 h6 c% M5 n- Khair, and facial acne without enlargement of testi-* E3 q- Y4 H- t3 G+ `  ~! ^
cles, suggests peripheral or pseudopuberty.1-3 We
! k& }6 {4 q' e9 t6 W! S5 m( j6 Creport a 16-month-old boy who presented with the
: S& N- \" x. E: q( Wenlargement of the phallus and pubic hair develop-" V7 \  k' y  E( G
ment without testicular enlargement, which was due4 j8 ]  \& P6 A
to the unintentional exposure to androgen gel used by! w+ w) Y7 s" ]& ]
the father. The family initially concealed this infor-. H1 K8 `9 S) b% Y& O$ I- U
mation, resulting in an extensive work-up for this
! K& U: q2 n9 ~child. Given the widespread and easy availability of$ U3 W- X1 u5 T) F
testosterone gel and cream, we believe this is proba-
4 A2 |' z0 ~# B: B! V; g: }bly more common than the rare case report in the
  n* ?3 |: c# d" g. s+ S) b/ ?literature.4/ G  G/ m' y0 s/ K% h3 J( v
Patient Report& n5 I# |" O) J8 Q% B% V2 J: J
A 16-month-old white child was referred to the, U7 j0 G( d/ M% G) [
endocrine clinic by his pediatrician with the concern
: }6 `1 N1 y3 S0 \of early sexual development. His mother noticed3 w, _# f/ |3 {: u, V5 b
light colored pubic hair development when he was6 U5 y1 \, r; n/ w  d' R, z
From the 1Division of Pediatric Endocrinology, 2University of8 C* F) I$ S  n1 {
South Alabama Medical Center, Mobile, Alabama.: x; S( I7 i" U
Address correspondence to: Samar K. Bhowmick, MD, FACE,
% L$ [# F- K$ V* y* @3 a$ B0 p5 I  IProfessor of Pediatrics, University of South Alabama, College of
* f; P4 P8 Q% g% o6 I8 u+ |0 w: g2 BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 C6 G& O0 R. O3 s9 z! qe-mail: [email protected].
( W# ~- F; R! i8 E1 l( N3 gabout 6 to 7 months old, which progressively became2 l4 q* h# A( e- z
darker. She was also concerned about the enlarge-
3 T. o1 z" X: z! L# Sment of his penis and frequent erections. The child- `  d. o) V+ D6 j1 J! Z
was the product of a full-term normal delivery, with) i: j$ H+ M3 N; |" x
a birth weight of 7 lb 14 oz, and birth length of
9 `0 f, x, P0 w- G+ x0 D8 o+ Y20 inches. He was breast-fed throughout the first year
- G+ ?0 \/ E+ e# g) U% ]% Qof life and was still receiving breast milk along with- C$ E/ }3 W2 s- a2 O  {6 U" u
solid food. He had no hospitalizations or surgery,4 w( A. W7 I8 J2 e) L4 \2 ]4 q
and his psychosocial and psychomotor development2 b  \) a; V4 L' V
was age appropriate., ~; m/ z2 N" v& F7 A* {
The family history was remarkable for the father,5 j% W3 @  H# G0 [5 O7 R1 m7 a
who was diagnosed with hypothyroidism at age 16,
6 i2 |) h3 N$ I5 h9 f; R# g& Gwhich was treated with thyroxine. The father’s7 j; v1 P* Z9 }+ Y
height was 6 feet, and he went through a somewhat
) C3 G% |- n+ P* Q& [: X, Wearly puberty and had stopped growing by age 14.
" ^7 Z  o7 Q- B; z4 P! \- |The father denied taking any other medication. The
7 L: |9 L9 n! Gchild’s mother was in good health. Her menarche2 d( w  p) g( L/ H5 e
was at 11 years of age, and her height was at 5 feet
5 W1 K# \7 Y( K% L; e2 Z6 C5 inches. There was no other family history of pre-
8 n/ Z. O  b" U) a1 ~" @cocious sexual development in the first-degree rela-
' X( a, A2 ]# q* X0 [. d* wtives. There were no siblings./ |- @0 a( V4 u1 A* z) Y3 P0 O: W9 S  A
Physical Examination, A7 [: J- Z3 V+ i% c/ v" J! q4 B
The physical examination revealed a very active,
# U# n7 Q$ K2 M+ z/ Eplayful, and healthy boy. The vital signs documented
9 O" S+ S  `+ Ga blood pressure of 85/50 mm Hg, his length was  ~* h+ d/ N" x( k0 z
90 cm (>97th percentile), and his weight was 14.4 kg1 ?& P# R. j1 v0 x: m
(also >97th percentile). The observed yearly growth
6 I6 p7 G$ a! s/ J0 x  g9 bvelocity was 30 cm (12 inches). The examination of
) k6 a7 \, [( [5 w& w1 Ethe neck revealed no thyroid enlargement.
' ]: D2 h  l$ z+ x" q9 ^9 F0 b1 iThe genitourinary examination was remarkable for9 ]' e5 F* m. h& X3 L: C
enlargement of the penis, with a stretched length of- g5 w$ o4 x2 Y: a8 d$ e
8 cm and a width of 2 cm. The glans penis was very well$ Q- |7 x  g# K  ~5 y- G
developed. The pubic hair was Tanner II, mostly around! r, X% x- w/ l2 J
540
, |* l. |5 T7 ^. l+ rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  O* H5 y4 s+ W9 x- c/ A+ T
the base of the phallus and was dark and curled. The
2 D% N0 u9 ?6 S9 U, a0 C1 rtesticular volume was prepubertal at 2 mL each.( |. v* A& V7 a; ~# g
The skin was moist and smooth and somewhat0 W. F, N, f( k" g# P2 N7 A/ v9 z
oily. No axillary hair was noted. There were no
, G9 H  p  _/ _  }, ^' e5 babnormal skin pigmentations or café-au-lait spots.
! S" e. T. a3 U2 DNeurologic evaluation showed deep tendon reflex 2+
* \0 t) I3 k6 W, M9 Z! y- Z6 wbilateral and symmetrical. There was no suggestion
1 [; u: M6 ~# l+ d1 p  Vof papilledema.
5 l6 t/ M2 T: V3 D* vLaboratory Evaluation
4 u9 L( g. C5 u: e/ a+ ^The bone age was consistent with 28 months by2 c5 ]6 O# W2 ^- ~% Z7 u0 `
using the standard of Greulich and Pyle at a chrono-) |! W4 ^# h% }
logic age of 16 months (advanced).5 Chromosomal
) L" y) K; P4 ~karyotype was 46XY. The thyroid function test
' H; `% f  P2 V4 Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 V" w5 w, s3 q4 xlating hormone level was 1.3 µIU/mL (both normal).
8 s, O/ O- M$ m3 P6 a# V, N7 NThe concentrations of serum electrolytes, blood
9 d8 g# Y, c2 g! x- z) M9 |7 \urea nitrogen, creatinine, and calcium all were7 P6 z4 Z1 D$ {5 F
within normal range for his age. The concentration# y/ j6 `8 ]& }4 ^% e/ q
of serum 17-hydroxyprogesterone was 16 ng/dL( w3 m  {& G! Y6 C' c! w$ D
(normal, 3 to 90 ng/dL), androstenedione was 20
% `- }% m# Y2 r& o/ f( B6 ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! @* }: F; O! v7 mterone was 38 ng/dL (normal, 50 to 760 ng/dL),- D" n: ^; b  E* E6 C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! j9 X6 s" g0 _- |2 H  n( k  K49ng/dL), 11-desoxycortisol (specific compound S)0 b* m- f% C- S- |4 [( @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! A: `# O( ]/ A- Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, S5 R8 N* E. Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' [! p# n1 y8 V, Z& v* {7 k
and β-human chorionic gonadotropin was less than" h  _' |! Y7 y
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 O% m6 x8 f3 o$ Y! D$ j. `
stimulating hormone and leuteinizing hormone4 t! F6 t7 E4 y: z0 x9 s, p3 O8 Z' p
concentrations were less than 0.05 mIU/mL( O: J6 X4 ^  M' F* m' }5 g& e
(prepubertal).$ v- n. @- z/ h4 `
The parents were notified about the laboratory
8 B8 k. u: k) C/ ^- V8 C; uresults and were informed that all of the tests were7 F1 e: D( }+ B5 }, t
normal except the testosterone level was high. The3 P& k2 G# O7 t7 B
follow-up visit was arranged within a few weeks to2 b* w1 z# j2 O2 S
obtain testicular and abdominal sonograms; how-
* R) o. b* S; a3 oever, the family did not return for 4 months." J' N4 }3 n. f: B- r  m
Physical examination at this time revealed that the
7 k- I% K: c3 B% s. e; \) S/ Fchild had grown 2.5 cm in 4 months and had gained
6 r$ }0 L+ q) N: F2 kg of weight. Physical examination remained
9 g! e- L2 u6 l" R& y- \2 Q5 gunchanged. Surprisingly, the pubic hair almost com-. ~1 W# o8 v6 J4 @/ c0 n2 h, ?
pletely disappeared except for a few vellous hairs at
& R. X. v' T: othe base of the phallus. Testicular volume was still 2- T/ t) p: [/ k) X2 @+ H
mL, and the size of the penis remained unchanged.4 I& Z3 V9 I5 a; Z* K
The mother also said that the boy was no longer hav-) i* A8 z/ u8 M/ J
ing frequent erections.
. O: v5 U2 L  w8 R' N" l$ a2 `Both parents were again questioned about use of
, C1 d+ p/ w* C1 ~* v4 F% t* Gany ointment/creams that they may have applied to
9 t- n- j- b; t% j- s! d3 }the child’s skin. This time the father admitted the
7 _9 m- a: w; j. VTopical Testosterone Exposure / Bhowmick et al 541
, O) k* s1 n1 y% Buse of testosterone gel twice daily that he was apply-
) F0 w" n7 Z( D/ T2 m, ]ing over his own shoulders, chest, and back area for( v/ U+ m/ n2 J+ Q  P
a year. The father also revealed he was embarrassed
1 A8 X# r7 {- x+ ]2 }to disclose that he was using a testosterone gel pre-( Q# `: L& ~( ~4 {! V0 E7 V
scribed by his family physician for decreased libido
5 Q! E. Y& R6 J* l5 ]: ^secondary to depression.
4 B) q, k5 Q/ P5 JThe child slept in the same bed with parents.# p. b2 @5 f2 C
The father would hug the baby and hold him on his
; A* t( d, h9 p2 K; l5 [8 K; R1 Rchest for a considerable period of time, causing sig-
- x% k  e* P- Z, {" x; Vnificant bare skin contact between baby and father.
7 q: d8 e: q6 p# u7 z/ qThe father also admitted that after the phone call,
7 }3 p/ _# e' z( Zwhen he learned the testosterone level in the baby  e2 S9 h$ ]. b" d
was high, he then read the product information6 k3 J4 o# K, S' @! j
packet and concluded that it was most likely the rea-
) L' u# d0 h+ fson for the child’s virilization. At that time, they
/ P' T1 |5 a  s% rdecided to put the baby in a separate bed, and the0 L5 @4 S2 V# D$ }% Z2 D
father was not hugging him with bare skin and had! M+ U, m6 h2 Z* L: R
been using protective clothing. A repeat testosterone
$ |# t  s3 Y  ?" E' U8 s  c$ Z4 Gtest was ordered, but the family did not go to the1 ?  m5 A7 @, r5 K; ^8 {
laboratory to obtain the test.
3 X; M6 i5 b9 Q+ aDiscussion' p& N0 H) Q2 K, c
Precocious puberty in boys is defined as secondary
+ G% a, }# o! _" @" j) msexual development before 9 years of age.1,40 t6 |# O  I" F1 W( J* Y) L2 _9 z
Precocious puberty is termed as central (true) when$ ^1 i" H- [2 \1 k- y
it is caused by the premature activation of hypo-
1 |& T6 h4 B3 z4 b. |; {thalamic pituitary gonadal axis. CPP is more com-( p- w" `5 D6 `0 ~* f& I& R5 P
mon in girls than in boys.1,3 Most boys with CPP5 h6 }& w1 m0 Z# ~3 {
may have a central nervous system lesion that is
( `1 X. v9 x. r9 t) {responsible for the early activation of the hypothal-; \6 `0 |' M; c  U4 j
amic pituitary gonadal axis.1-3 Thus, greater empha-( g4 Y# Y( T9 E: V
sis has been given to neuroradiologic imaging in
! L# O. }1 q3 C, J3 w+ [boys with precocious puberty. In addition to viril-/ o0 n7 w4 r3 \. c6 l# y
ization, the clinical hallmark of CPP is the symmet-0 V" e# b2 S2 w+ Z0 z
rical testicular growth secondary to stimulation by; W+ f, R' Q/ [0 S  |! h+ b
gonadotropins.1,33 m6 |9 v+ D# V* a5 o8 T
Gonadotropin-independent peripheral preco-9 V+ ?$ `& v& A' F+ F6 q
cious puberty in boys also results from inappropriate
: ]4 `& z+ Q/ J! J7 I8 T$ }+ ^androgenic stimulation from either endogenous or" _6 V# z) R# \& t- Q/ [/ X- r. V
exogenous sources, nonpituitary gonadotropin stim-
6 ~. E6 G7 R0 j/ y6 l$ ]# Culation, and rare activating mutations.3 Virilizing/ {7 `5 y! q) i; Y
congenital adrenal hyperplasia producing excessive* b' k6 v" f1 b* R6 E8 i1 C
adrenal androgens is a common cause of precocious+ j+ v7 O5 H; ]4 q6 j% k
puberty in boys.3,4& J( M4 Y9 b9 S% |: i
The most common form of congenital adrenal+ |- ]0 n8 R0 x/ O4 K% p' Y1 k8 e
hyperplasia is the 21-hydroxylase enzyme deficiency.
: [  @4 H. v: [1 _1 _* @0 SThe 11-β hydroxylase deficiency may also result in
' ~& |, Y  H" D$ H+ qexcessive adrenal androgen production, and rarely,
/ X/ _4 O5 I' X* u. c, {3 \an adrenal tumor may also cause adrenal androgen, |/ K5 \: N% B4 U! M
excess.1,3' k6 s6 \9 n  Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  |- v5 g8 f3 t5 l. b1 f+ z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. [. b3 s& H# \8 [/ M2 N! V* ^
A unique entity of male-limited gonadotropin-
7 n3 y# {+ M* _- `: @independent precocious puberty, which is also known% z. x4 W* F1 Q+ q
as testotoxicosis, may cause precocious puberty at a
5 w. X3 c% }6 f# fvery young age. The physical findings in these boys
, p, \$ j7 k$ M4 G4 X1 N" Xwith this disorder are full pubertal development,9 |; F8 {0 I" R. y
including bilateral testicular growth, similar to boys) [! _/ f1 j" |. ~# y- w; s* w/ d
with CPP. The gonadotropin levels in this disorder6 n: W) j! A  z
are suppressed to prepubertal levels and do not show
, q- W( D& d- q' M) q5 A& w/ r+ npubertal response of gonadotropin after gonadotropin-3 r! m+ D6 E, v4 E- |
releasing hormone stimulation. This is a sex-linked
" h- W# z- G9 c7 v9 Hautosomal dominant disorder that affects only
+ G" g5 j4 m3 q/ i: p& Ymales; therefore, other male members of the family& @8 r$ V$ c5 [7 V- T" B& m. L
may have similar precocious puberty.3
6 R  A2 [1 a: e' |: ^2 |- ~& jIn our patient, physical examination was incon-  `) K+ C$ h: F8 a. m
sistent with true precocious puberty since his testi-
1 f* `2 k8 f* {5 }! v# Xcles were prepubertal in size. However, testotoxicosis" V* R6 S) j) E  U( y1 [
was in the differential diagnosis because his father. b: A: _+ x8 d! y
started puberty somewhat early, and occasionally,
' z6 f2 k  y1 o1 Ytesticular enlargement is not that evident in the1 N9 y" T0 P# l" N; j
beginning of this process.1 In the absence of a neg-! t& M  T' L9 l5 Z5 `8 t; [, ~
ative initial history of androgen exposure, our3 d5 w8 A: D: Q5 F/ j, T. ^* K
biggest concern was virilizing adrenal hyperplasia,+ u/ K( f: u' R# i) q6 @
either 21-hydroxylase deficiency or 11-β hydroxylase0 i7 ?' c/ t$ ]/ O4 c
deficiency. Those diagnoses were excluded by find-# e  m8 h' [$ u7 ^
ing the normal level of adrenal steroids.
) y+ J$ @8 ^# aThe diagnosis of exogenous androgens was strongly
% C% ?0 X# v2 n/ c. N( Lsuspected in a follow-up visit after 4 months because
( E7 X5 T/ f7 o+ G5 H0 Fthe physical examination revealed the complete disap-
8 ?: D: h: u4 W# b4 a' Rpearance of pubic hair, normal growth velocity, and  c3 a  [* Q" Q% G/ G2 ?7 w' _
decreased erections. The father admitted using a testos-
. U$ ~0 ^( w2 Z6 b7 ]terone gel, which he concealed at first visit. He was& P  w& T) G% ~' h8 Y5 {
using it rather frequently, twice a day. The Physicians’6 x! N( `" {7 l
Desk Reference, or package insert of this product, gel or
3 U( P* J3 h* n+ S" H( a: j9 h& kcream, cautions about dermal testosterone transfer to
$ m! n4 J! E) {* y% eunprotected females through direct skin exposure.
/ {1 B% \6 Q2 z0 NSerum testosterone level was found to be 2 times the
; `5 q; `. ~% W. A8 P5 b' D6 {  Pbaseline value in those females who were exposed to1 p( P* n; X% E, q1 w2 d1 b; b
even 15 minutes of direct skin contact with their male1 t, V  W8 _0 e6 {" ~
partners.6 However, when a shirt covered the applica-5 ], ~3 ^% V( Z
tion site, this testosterone transfer was prevented., x/ {- J: c9 r6 O3 W
Our patient’s testosterone level was 60 ng/mL,
! d% e: @( J  w8 lwhich was clearly high. Some studies suggest that% f. x- c2 C& _- P/ M
dermal conversion of testosterone to dihydrotestos-
3 u7 L* e; d' v/ H' c% }0 i; s' [terone, which is a more potent metabolite, is more
4 L* q* H% E' ~2 [active in young children exposed to testosterone, y. P% E( P5 }  |) o7 [
exogenously7; however, we did not measure a dihy-) N/ \4 ?. b) t5 u9 f
drotestosterone level in our patient. In addition to  f2 H, J3 B7 D; q  a3 R
virilization, exposure to exogenous testosterone in
$ D5 _! J' ?8 A8 Hchildren results in an increase in growth velocity and
+ O4 T0 F& D6 K4 X* J8 c& z1 ^$ iadvanced bone age, as seen in our patient.1 d) U  H! s, D
The long-term effect of androgen exposure during& G" a+ i9 i1 f& R! N
early childhood on pubertal development and final
. w9 ~" y5 f$ t- Padult height are not fully known and always remain
* T6 _7 H+ z5 X+ f$ o0 o8 C1 ka concern. Children treated with short-term testos-: u: m/ C7 f) ]. w
terone injection or topical androgen may exhibit some
& g4 ~+ t8 [( |, g$ [7 bacceleration of the skeletal maturation; however, after
* Z9 {( l  G  L  _7 u# P+ E) hcessation of treatment, the rate of bone maturation
) [0 J* D: z. k6 Y6 Z& q$ m" Udecelerates and gradually returns to normal.8,9. m6 g& W2 w9 c! ?5 M3 t
There are conflicting reports and controversy, q1 J  V7 |( i/ J' h
over the effect of early androgen exposure on adult* |, u" H4 L' k% d
penile length.10,11 Some reports suggest subnormal
5 ~. w. k: a) n  N& Fadult penile length, apparently because of downreg-
% j3 O" ~& Q$ `6 `4 X  a5 Q( c3 ~ulation of androgen receptor number.10,12 However,
# c( a0 Y% t3 i! m# K9 xSutherland et al13 did not find a correlation between* ~* s- x+ w8 u* p. i: Y" w
childhood testosterone exposure and reduced adult$ M5 s6 z; k, X9 `
penile length in clinical studies.
. Q6 P: m' d! D0 L6 r& ?Nonetheless, we do not believe our patient is
; x1 |9 e8 M* n3 C: `going to experience any of the untoward effects from9 E3 |8 @% ]( O5 D, V/ c3 ]1 ?
testosterone exposure as mentioned earlier because% |% {* i. {8 W: ?
the exposure was not for a prolonged period of time.: Z4 Y; F3 ?' T- g7 n6 W% _
Although the bone age was advanced at the time of9 R3 ]- d( q/ R& ^5 O& u" c
diagnosis, the child had a normal growth velocity at
" q' T5 L% ]' u3 `the follow-up visit. It is hoped that his final adult
7 D5 ]3 Y9 y! I  J! hheight will not be affected.
1 I8 j6 G; }0 b1 u( xAlthough rarely reported, the widespread avail-
& z3 e2 S7 T; B# Kability of androgen products in our society may. \  R1 M9 e: w$ q3 [* j0 O
indeed cause more virilization in male or female
1 Y8 i" [+ z/ echildren than one would realize. Exposure to andro-0 l0 `3 A( e5 y0 |8 \/ i. d# W
gen products must be considered and specific ques-
) H% R  }" \# O8 S9 \1 G' h. [$ mtioning about the use of a testosterone product or
2 Y2 D' W: B+ r( R+ cgel should be asked of the family members during4 f4 R3 T' J; f% A
the evaluation of any children who present with vir-; \# Q3 n- V0 |2 ~9 w
ilization or peripheral precocious puberty. The diag-1 b' u5 R$ O$ D4 C5 i' m
nosis can be established by just a few tests and by
/ f( L8 k- m. F( ^appropriate history. The inability to obtain such a
: K" O# r- ~2 qhistory, or failure to ask the specific questions, may
0 A  D2 n. M3 N. k6 hresult in extensive, unnecessary, and expensive
( |$ N; V4 t# i  v) a7 @; _* `* Jinvestigation. The primary care physician should be( G# y9 K/ S, ~4 w1 n, d% ]- q
aware of this fact, because most of these children
$ w0 x$ n+ y! z  \4 ]may initially present in their practice. The Physicians’
9 c) i4 E; I& j" v, A; N& x8 EDesk Reference and package insert should also put a
6 f9 k, F% t! F- G. Lwarning about the virilizing effect on a male or
  o+ }: c; h# K  L# {female child who might come in contact with some-! r, z. Z. A  B: ^% K; q+ k
one using any of these products.
1 T& L% ?$ p* ?! L: o9 M: w1 FReferences
& ~" c( j0 B& M5 R% y7 y9 V1. Styne DM. The testes: disorder of sexual differentiation
  ^$ G+ n; N7 ]and puberty in the male. In: Sperling MA, ed. Pediatric. f( r! C4 ~( a! z& Z& J7 K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. u! Z/ s% P- y7 l, K' G2002: 565-628.2 Z6 r, d) Y. A7 j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 A7 G* T- G* n+ m! W' @
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' y7 F7 p4 A* P9 D1 P: i: SBoy Induced by Indirect Topical
' |8 g1 e) P' s6 Q! ~Exposure to Testosterone* M; ~# u2 `& q8 K: H# x+ b8 T: [7 _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 T8 }) X1 H0 R0 [" Yand Kenneth R. Rettig, MD1
  W. @: S" ?( V4 EClinical Pediatrics
/ F9 R4 q* p1 Q8 LVolume 46 Number 6
5 G" ^1 t1 v* h$ @July 2007 540-543* B1 X% m) O: {
© 2007 Sage Publications# Z. U# L& o. r% W) A
10.1177/0009922806296651
* R# \) W# E1 L; d7 p) D; S- k  U* q5 l% [http://clp.sagepub.com  B0 I5 c! O0 u* t0 _
hosted at, E- j, V7 s4 Y$ ~
http://online.sagepub.com
+ H4 d3 n9 N# b+ \8 h% l" \2 K2 RPrecocious puberty in boys, central or peripheral,7 Q/ S! Y4 y6 O' Y- }5 e
is a significant concern for physicians. Central
9 c' G* C2 ^" U$ d6 u( K! uprecocious puberty (CPP), which is mediated  c0 _; \  ?0 R5 p4 ]
through the hypothalamic pituitary gonadal axis, has+ e8 S! _4 T6 K  ?) A' N9 [
a higher incidence of organic central nervous system9 Z  z1 {3 s$ ^) U4 y8 G
lesions in boys.1,2 Virilization in boys, as manifested% H4 X, C% o3 a  g/ {
by enlargement of the penis, development of pubic' [+ X, r6 H* e( d8 R5 u
hair, and facial acne without enlargement of testi-" ^8 q$ q* q* I% J# @* g; }
cles, suggests peripheral or pseudopuberty.1-3 We5 l/ x/ {( B- l0 |9 R
report a 16-month-old boy who presented with the' ~8 k6 n: s0 W, V1 m- O
enlargement of the phallus and pubic hair develop-
% s, ^* P! d5 Qment without testicular enlargement, which was due
1 T6 o, L) D6 J) C. X3 P( Eto the unintentional exposure to androgen gel used by
3 r! l: p% F7 L: Gthe father. The family initially concealed this infor-2 m5 l6 y# B4 k
mation, resulting in an extensive work-up for this
: c* z) ^2 R1 e4 b: _7 S7 ~) Ychild. Given the widespread and easy availability of
$ }, P( ?4 r' B# f+ Z" ^testosterone gel and cream, we believe this is proba-
3 P8 k* @7 E% lbly more common than the rare case report in the' y7 E' ?7 h7 D+ o& u# s
literature.4/ v9 B& f$ N; E) ]+ J4 [. U( j+ ]* B
Patient Report
' [3 f6 g7 l$ Z% W9 B" D, NA 16-month-old white child was referred to the
  M& S+ ?" m# Y! D' k) n# X' Pendocrine clinic by his pediatrician with the concern& h! d. |6 l; h* D1 r
of early sexual development. His mother noticed" S& h& l6 Z' K' F& \9 Y5 m: O& G( K
light colored pubic hair development when he was2 E# G* Y0 C; S' A2 D, i: `) k
From the 1Division of Pediatric Endocrinology, 2University of
+ A: ~4 \0 d6 q, GSouth Alabama Medical Center, Mobile, Alabama.+ `) n2 `$ Q' l, ?! v! b
Address correspondence to: Samar K. Bhowmick, MD, FACE,( h. H. {( P0 K" C2 L! {
Professor of Pediatrics, University of South Alabama, College of7 M8 e' ?& e' B3 ^, h8 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 T, Q9 i3 P* A9 o' _* [
e-mail: [email protected].
1 p* I7 N' q1 R6 b3 q+ Babout 6 to 7 months old, which progressively became
. e% e' f" E5 {) v* S' Z" hdarker. She was also concerned about the enlarge-
$ e& `& q% T; l, C/ ^ment of his penis and frequent erections. The child# l; l" y+ [  b8 O
was the product of a full-term normal delivery, with* K* U' U. |% \$ G- a/ a
a birth weight of 7 lb 14 oz, and birth length of0 D5 J5 n9 q) \1 S
20 inches. He was breast-fed throughout the first year! A5 T0 Z# }5 G. _/ M0 V  o( X
of life and was still receiving breast milk along with
% v2 ?6 a2 r  @& rsolid food. He had no hospitalizations or surgery,# ]& i$ ]) M7 _
and his psychosocial and psychomotor development& i" k# k; C  V: o
was age appropriate.! B2 o  f4 T  p& k
The family history was remarkable for the father,  {5 V" U0 l* ~* s; Q# h
who was diagnosed with hypothyroidism at age 16,7 _5 l, I3 _7 v
which was treated with thyroxine. The father’s9 s* A3 n3 |4 I- W1 [9 }
height was 6 feet, and he went through a somewhat# B* ]( `# x! b. R3 w
early puberty and had stopped growing by age 14.* [8 h2 Z) p+ N: ^+ `; L
The father denied taking any other medication. The
- E- b+ S: J( |) n) ychild’s mother was in good health. Her menarche
3 u* y; z) K7 P. Mwas at 11 years of age, and her height was at 5 feet- \! ^& p8 d& }% G2 b" w
5 inches. There was no other family history of pre-
. X9 l' D- |3 m1 r8 U0 W( |/ }, H+ zcocious sexual development in the first-degree rela-, ^9 ^6 j$ R5 K2 N* W
tives. There were no siblings.+ q0 C  |' l1 j; i
Physical Examination1 T# s9 f* D6 V0 h0 G; W; W
The physical examination revealed a very active,5 W  ~, f# O% [' Q! W; n4 e
playful, and healthy boy. The vital signs documented
% F, H+ Y1 z( r; I2 ga blood pressure of 85/50 mm Hg, his length was
7 h) t4 y2 J: A0 }6 M7 Z0 z90 cm (>97th percentile), and his weight was 14.4 kg  F+ g) s% G6 n1 H) H
(also >97th percentile). The observed yearly growth
5 R3 C1 H* T- j& S$ ^1 K4 fvelocity was 30 cm (12 inches). The examination of/ Z7 O2 ^  \* Z- k; x% q" q
the neck revealed no thyroid enlargement.
/ f" J8 M6 _/ C& E) FThe genitourinary examination was remarkable for% {( ]+ k* M$ o' O  k* d
enlargement of the penis, with a stretched length of2 U+ X* V- F7 Y* G6 O, Q% r7 C
8 cm and a width of 2 cm. The glans penis was very well" D8 G9 d6 n7 R- _; b0 ~9 G* S
developed. The pubic hair was Tanner II, mostly around
: o* O/ d. p, f, A( r540
  m0 c" F) O+ E$ g+ a. Z6 Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( N3 O2 i9 Q4 o& ]  n- S9 |7 Lthe base of the phallus and was dark and curled. The
% v& H0 e8 G, }2 Y; a* h6 Ptesticular volume was prepubertal at 2 mL each.
, A- `1 ?9 C% w) I# w# |1 ]The skin was moist and smooth and somewhat
  V  b0 m1 P8 h% moily. No axillary hair was noted. There were no
/ x" A6 I4 r- ]. c- k& Iabnormal skin pigmentations or café-au-lait spots.4 ?% q& \" D) F2 S" C* g
Neurologic evaluation showed deep tendon reflex 2+
, G& S% v5 a1 P0 A( i: l: l+ I- B0 }bilateral and symmetrical. There was no suggestion2 l# n1 X; j+ k* d% {& d% ~6 y
of papilledema.$ p7 j9 l- E3 m% c! A* S% Y
Laboratory Evaluation
# G$ a9 t# ^) X4 B# q) bThe bone age was consistent with 28 months by' b1 ^/ b# Z2 w5 `9 w8 a) L
using the standard of Greulich and Pyle at a chrono-
$ \- p9 b" n, J$ llogic age of 16 months (advanced).5 Chromosomal" U! v/ }+ U$ Q1 ]
karyotype was 46XY. The thyroid function test
" c: s) W+ a4 j5 cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 Y: o# c) L' K& j- R9 Z0 B
lating hormone level was 1.3 µIU/mL (both normal).
4 p( N5 ~8 i$ L2 g# {1 |The concentrations of serum electrolytes, blood
2 l1 s/ s. |6 F+ b8 N, S# Q$ [  rurea nitrogen, creatinine, and calcium all were9 W) m! V. C4 f/ Y. Q9 \+ I
within normal range for his age. The concentration3 w5 y+ Q$ I/ X# D! l9 A: `
of serum 17-hydroxyprogesterone was 16 ng/dL
0 K- G7 Q) a* B(normal, 3 to 90 ng/dL), androstenedione was 207 v" E0 p( W. ~! e1 F0 ~
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% Z, X6 h! F3 B, S- c/ sterone was 38 ng/dL (normal, 50 to 760 ng/dL),
. ?5 z3 _: m7 F7 u. j% {6 hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to7 r1 `0 r) C' d2 Y$ q5 F% K3 u
49ng/dL), 11-desoxycortisol (specific compound S)
4 r* h* K$ o* C* _) y# ~: u9 l6 Q: Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ p! P6 W7 A; W2 k  v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ u8 I8 R  t  {, d; g! y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; ~+ |5 s9 H+ p+ xand β-human chorionic gonadotropin was less than
0 v7 @/ X' Y' x$ j& H1 o& q5 mIU/mL (normal <5 mIU/mL). Serum follicular5 G5 R4 Q. M6 Z/ h
stimulating hormone and leuteinizing hormone" c/ U. S6 f& d6 l; g
concentrations were less than 0.05 mIU/mL
% n. M3 Y7 h! D4 o& G(prepubertal).
6 K7 H. h; s4 L5 w6 D9 v; I: ]2 LThe parents were notified about the laboratory
  _# B* A- \* c7 G7 Sresults and were informed that all of the tests were9 {9 T. r  i: D3 n" r
normal except the testosterone level was high. The6 I2 @0 |7 _7 F. w0 t. o" S
follow-up visit was arranged within a few weeks to
$ U. s  a  Z1 Q5 A1 mobtain testicular and abdominal sonograms; how-
% D" K5 Q% m; S1 e8 jever, the family did not return for 4 months.# l: [# Y% ^6 F6 v; D
Physical examination at this time revealed that the
2 q" C5 C% P+ k# r2 a% nchild had grown 2.5 cm in 4 months and had gained
, a" C* P1 [5 ~1 v% I4 J) Y; b2 kg of weight. Physical examination remained
  P0 f, W# J) W7 R# d/ ~unchanged. Surprisingly, the pubic hair almost com-8 u' v0 i6 G4 A( f' d) [1 j
pletely disappeared except for a few vellous hairs at
  z6 f' a0 O. J' P1 q2 Tthe base of the phallus. Testicular volume was still 21 V, i8 w8 u( i) `
mL, and the size of the penis remained unchanged.2 z# ?9 D9 e* a: p/ i5 P
The mother also said that the boy was no longer hav-' |0 I1 V3 h- K' b) ?7 B4 s8 z
ing frequent erections.
6 F2 h7 J! x) _$ f  c' nBoth parents were again questioned about use of8 V, Q% H* G" }% P) W
any ointment/creams that they may have applied to1 u5 e5 {: s. E
the child’s skin. This time the father admitted the0 o( P; G4 p  ~& p
Topical Testosterone Exposure / Bhowmick et al 541; P6 e5 U; [6 G+ T& L% b
use of testosterone gel twice daily that he was apply-3 K0 M8 m( D9 P( o: N
ing over his own shoulders, chest, and back area for: q1 ?! o$ ~! c1 e/ \
a year. The father also revealed he was embarrassed
5 J6 U8 k9 i5 I* M: Nto disclose that he was using a testosterone gel pre-
* s" `0 }, t+ q3 }scribed by his family physician for decreased libido
, c2 B8 |9 ~) [4 x: @& usecondary to depression.
' T6 I" N' A/ F# gThe child slept in the same bed with parents.
7 i, ~! _( ]4 c( i' _* bThe father would hug the baby and hold him on his; p! V! a* C' p0 a
chest for a considerable period of time, causing sig-
* o) \+ f0 Z1 q: I+ |0 o9 i7 x  Nnificant bare skin contact between baby and father.) P, D* c- [! q/ X! x1 s* B3 H
The father also admitted that after the phone call,
( B$ Y5 q2 W4 V7 c: d  U" S1 a- ?when he learned the testosterone level in the baby5 W. O; v9 ]) Q" N& }; h, A& _6 j
was high, he then read the product information4 D3 ^) M5 W( V, Y7 ?
packet and concluded that it was most likely the rea-. o/ Y$ `" e  a& m6 w
son for the child’s virilization. At that time, they
3 P- [* x0 {; o. Pdecided to put the baby in a separate bed, and the
' a5 `- O) w7 efather was not hugging him with bare skin and had
8 a" s' f9 S3 v$ S& h! K. \) ?been using protective clothing. A repeat testosterone* {; x0 G/ |0 X# ?& S" n) G1 [/ a
test was ordered, but the family did not go to the
# ^# ?0 r- I5 Q" g7 Ilaboratory to obtain the test.
. @7 q* z) a3 g3 C$ {6 oDiscussion
% H/ n" {, `; R3 z. gPrecocious puberty in boys is defined as secondary
0 A$ c, t' ?! [8 ~# H1 zsexual development before 9 years of age.1,4
) Y2 ]  q( t7 d+ ^" jPrecocious puberty is termed as central (true) when2 i3 f4 _* m* I3 r5 a
it is caused by the premature activation of hypo-- G( [1 d3 q+ B- y# n8 m
thalamic pituitary gonadal axis. CPP is more com-$ `, [* d' ~6 F5 ?
mon in girls than in boys.1,3 Most boys with CPP/ B  b( `# @: p% P% r
may have a central nervous system lesion that is6 T* w4 v3 z. l+ t/ s( c) s3 ?3 o* _
responsible for the early activation of the hypothal-
) S+ z/ o" B# G+ R; M- Wamic pituitary gonadal axis.1-3 Thus, greater empha-
" {& L: k# X; Ssis has been given to neuroradiologic imaging in
& f6 F$ k2 B# `. kboys with precocious puberty. In addition to viril-
* m3 Z/ u$ N! |$ ]! Jization, the clinical hallmark of CPP is the symmet-
3 t, n8 Z. c% G. X: J" ?: brical testicular growth secondary to stimulation by
+ J4 y( Q. `9 Z( x, ugonadotropins.1,36 j1 t+ [1 o  f$ z  s+ D
Gonadotropin-independent peripheral preco-
$ C; w) T+ y( ^) h' Fcious puberty in boys also results from inappropriate
  F4 F3 ^5 I: K* X# A( W+ Uandrogenic stimulation from either endogenous or1 ?* @1 n, k: S7 b6 ]8 ~
exogenous sources, nonpituitary gonadotropin stim-0 m1 q" N+ e; U  v. I4 p
ulation, and rare activating mutations.3 Virilizing
: L1 O- \2 V: m4 xcongenital adrenal hyperplasia producing excessive5 N& }8 q) z# L' L1 Y; h
adrenal androgens is a common cause of precocious
- a4 {4 x% \% |: {! K' Xpuberty in boys.3,4" q) J3 S. H2 L  s  D4 o, m/ M/ U2 L! S
The most common form of congenital adrenal
; u, H+ F6 y1 @- Y$ jhyperplasia is the 21-hydroxylase enzyme deficiency.
( e: O5 j0 @" \# X. _The 11-β hydroxylase deficiency may also result in
. W' d1 G( J8 j8 Z) ?. rexcessive adrenal androgen production, and rarely,
. y5 J8 ]) t' ian adrenal tumor may also cause adrenal androgen* q# t9 `) O$ R' q- b. t
excess.1,3
" Z; l" Q+ Y: n4 B/ W% z2 p- V7 Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. P0 D5 @5 k3 f6 P  `542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ I% l; {) X3 b5 m7 R& ^
A unique entity of male-limited gonadotropin-  q% G# c$ W$ K7 a$ v  }* l- ]% j
independent precocious puberty, which is also known; p9 |' ?1 z  v( F( n1 Q3 P8 ?& c
as testotoxicosis, may cause precocious puberty at a
, h6 O8 F) O0 P0 b! @4 svery young age. The physical findings in these boys
  b' n  Y3 Z1 Y, d0 Fwith this disorder are full pubertal development,
+ m/ e% m0 `7 u8 @+ Yincluding bilateral testicular growth, similar to boys
' ?7 R" T$ C9 W+ {3 Mwith CPP. The gonadotropin levels in this disorder
$ M' G( Q$ m$ |  Z' a( Iare suppressed to prepubertal levels and do not show
1 B  z2 |+ N+ i0 W9 J( E: qpubertal response of gonadotropin after gonadotropin-
0 Z+ ?" L3 J4 R( I# Breleasing hormone stimulation. This is a sex-linked
  _! f# @* D3 [9 E: dautosomal dominant disorder that affects only
  `: p" I8 l  Z( K. g! U' {$ f) {$ Y/ ?males; therefore, other male members of the family
$ T# q* \" F( ~! d7 Q( x; j! R7 Jmay have similar precocious puberty.3
3 A2 H* Y5 t! J" LIn our patient, physical examination was incon-
* {( c* I" X" Jsistent with true precocious puberty since his testi-
7 B  L4 H* N: V' Y  i6 wcles were prepubertal in size. However, testotoxicosis7 E0 h* P- ?8 U- s1 ?
was in the differential diagnosis because his father
! G& q  E/ u; G& Estarted puberty somewhat early, and occasionally,. m1 T: r" m9 B; T2 D
testicular enlargement is not that evident in the' o* j) Y- r, p
beginning of this process.1 In the absence of a neg-
# f1 `' E# K; N( iative initial history of androgen exposure, our
' @" t1 ]4 o/ l% j9 bbiggest concern was virilizing adrenal hyperplasia,/ z& t6 |2 |! x+ K4 s! F
either 21-hydroxylase deficiency or 11-β hydroxylase, u9 O& E6 d+ c: X7 L
deficiency. Those diagnoses were excluded by find-* P* y' x' P' W
ing the normal level of adrenal steroids.- R" D- w3 `! u, p% _+ i' y
The diagnosis of exogenous androgens was strongly* ]7 `3 i) I$ o  S; p+ Q
suspected in a follow-up visit after 4 months because' W* |" |: _, q( A# F- k
the physical examination revealed the complete disap-
8 m6 x1 _+ ~) {4 Z0 ]4 kpearance of pubic hair, normal growth velocity, and7 {& ]: |" d/ s/ {" K% I6 w
decreased erections. The father admitted using a testos-
: [* g8 j+ c) k/ I  l8 Uterone gel, which he concealed at first visit. He was/ ?! `6 ]2 t( p
using it rather frequently, twice a day. The Physicians’1 u# r: I1 q) \2 W; ]! Z( J
Desk Reference, or package insert of this product, gel or% p; t, d3 n' T& a& h# ^' G" I; z4 Q
cream, cautions about dermal testosterone transfer to. o( d. P: l  U3 ?; u
unprotected females through direct skin exposure.
' [, D2 R' Y0 s- K( P  _Serum testosterone level was found to be 2 times the5 P- ]& [: [% c0 S! _4 R% V- `
baseline value in those females who were exposed to* o$ v- |& X* d' A' |0 `4 d% o# s
even 15 minutes of direct skin contact with their male2 E! M0 v* F' k3 `# M, ]4 c5 X
partners.6 However, when a shirt covered the applica-( }3 e" T  D7 e( |
tion site, this testosterone transfer was prevented.
5 ?0 h" d  I# z$ B+ K# a7 ~/ H1 BOur patient’s testosterone level was 60 ng/mL,  q; ^. Q& e' i& L2 R
which was clearly high. Some studies suggest that+ @: a! J3 u  c+ ]' J, ^
dermal conversion of testosterone to dihydrotestos-
' T- s% i$ Y. A* Nterone, which is a more potent metabolite, is more
, ^5 l1 ]1 |/ _2 F% ~5 R# N" Qactive in young children exposed to testosterone+ i5 W  t9 L" M2 F% f! f, E3 A
exogenously7; however, we did not measure a dihy-% j+ F  a5 s3 g; Z5 L1 \7 a
drotestosterone level in our patient. In addition to7 \3 P7 M2 B7 d
virilization, exposure to exogenous testosterone in4 D+ v0 q. b4 v% A3 ?& Z8 h# z
children results in an increase in growth velocity and+ [0 a/ E, [9 o, o* v: R! D
advanced bone age, as seen in our patient.
/ [7 N+ A7 {* u2 k0 O# P! KThe long-term effect of androgen exposure during6 n: {" r0 M8 D' k+ J
early childhood on pubertal development and final& L# u0 V( S$ v$ M- H( X
adult height are not fully known and always remain5 f' V9 D& ]& t! ~7 v6 T4 F4 q
a concern. Children treated with short-term testos-
6 `& m2 h' u0 |3 e- R- }4 j( m% G! E; Oterone injection or topical androgen may exhibit some
% m+ m( `- H' o9 T+ P. Aacceleration of the skeletal maturation; however, after
" y4 w" f3 e1 l! Xcessation of treatment, the rate of bone maturation
5 q/ l5 i$ {; C% x% ]$ E3 J) \decelerates and gradually returns to normal.8,9
3 ?7 @7 c. C6 R! [4 J$ z- Q3 X2 i4 NThere are conflicting reports and controversy2 R4 m: I5 G0 n: F. T- e
over the effect of early androgen exposure on adult
' D* G# m2 A: I% m/ ppenile length.10,11 Some reports suggest subnormal
. x2 D! e2 M2 E) n2 n! E# K3 H$ ?adult penile length, apparently because of downreg-
; b$ `: G2 S7 m& o% ]ulation of androgen receptor number.10,12 However,
- p' r( |; h1 N; g3 I2 k/ ESutherland et al13 did not find a correlation between
6 A5 h/ h4 m3 a7 N: k8 |# Lchildhood testosterone exposure and reduced adult
) Z) g/ g: q3 @penile length in clinical studies.
" k8 J( y$ X2 j. R0 o7 UNonetheless, we do not believe our patient is
( t9 Y, U3 V3 x% A3 E+ K. xgoing to experience any of the untoward effects from
% M8 q/ r6 u4 ftestosterone exposure as mentioned earlier because7 R1 v8 f. }# y- O
the exposure was not for a prolonged period of time.4 H; K: H) t7 j# \# k8 A
Although the bone age was advanced at the time of( Y! ^( b. L0 W( ^+ a6 S
diagnosis, the child had a normal growth velocity at2 ?3 h' l2 m% o1 P9 ?/ m' T; B' l2 S
the follow-up visit. It is hoped that his final adult0 V/ }6 v5 V* f) A- @% \
height will not be affected.
+ K& _& q  e2 V+ s3 cAlthough rarely reported, the widespread avail-/ O: z- m% U, [8 @( f
ability of androgen products in our society may; |, O. i' ]4 w- I+ T9 ^0 v1 |( u
indeed cause more virilization in male or female
# `2 @; o6 Y3 C8 ^- l- ochildren than one would realize. Exposure to andro-0 J- C/ x9 N* P& Z
gen products must be considered and specific ques-
9 D$ X$ X& C7 {% R( o) `1 ~tioning about the use of a testosterone product or
' ^  x" B; W' N" h: Ggel should be asked of the family members during. o6 |( S7 ?8 b* u- @$ T
the evaluation of any children who present with vir-( `' N' f" W: c
ilization or peripheral precocious puberty. The diag-
; r3 J; I! a2 }# X& O' _; ?nosis can be established by just a few tests and by0 _5 n( k  W. C4 L
appropriate history. The inability to obtain such a
5 `' ~8 g' B1 B8 Z- ^4 Nhistory, or failure to ask the specific questions, may8 K. `" Q* b4 m" R& l$ a0 a9 S
result in extensive, unnecessary, and expensive
! Q% e8 Y* P- g% J* s. e  y* hinvestigation. The primary care physician should be% n) p6 u) h7 `
aware of this fact, because most of these children
+ O3 M2 h) w" ?+ m0 Rmay initially present in their practice. The Physicians’! |  z, b) V9 s0 |/ Z
Desk Reference and package insert should also put a  U9 H+ a% S4 E
warning about the virilizing effect on a male or% P4 _/ W# p1 r& J! F+ e4 V  j
female child who might come in contact with some-
0 O7 h$ ]! g0 P& L8 Z* ~$ J+ qone using any of these products.+ {' S* j4 g$ U
References
  e4 p* Q6 k- k5 Q1. Styne DM. The testes: disorder of sexual differentiation
- S# c, i- B3 M- dand puberty in the male. In: Sperling MA, ed. Pediatric/ ~# |  W1 e( Z1 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) e4 y4 T% j6 N4 q2002: 565-628.
4 Y: J, V: A$ Q& D2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& @6 f2 h' N) Q+ c/ g8 I) R
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
( A9 [7 @3 \! L% I5 h+ K
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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