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Sexual Precocity in a 16-Month-Old
9 f# D' F% t+ q% U+ G" q  N9 gBoy Induced by Indirect Topical
+ t7 N! x& n% u' sExposure to Testosterone" `$ m" _5 Q2 v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. D; R/ ~& [4 f. E9 E
and Kenneth R. Rettig, MD1& M2 c' M1 I6 C" o% r& e  @0 b/ _
Clinical Pediatrics
# F0 ~- ]' l8 {3 o9 {" v  wVolume 46 Number 6. X9 D/ c( Z5 {
July 2007 540-5432 e! T5 O1 X; o+ a! A
© 2007 Sage Publications
& ?" R: k8 r) d% Z1 K4 y! I10.1177/00099228062966513 r8 @$ b/ `" a- i. }) ^
http://clp.sagepub.com
$ u  m) R4 t! K, Jhosted at: d* f$ K4 i8 G9 A4 ]& K
http://online.sagepub.com) t# Q7 }( t/ k6 `
Precocious puberty in boys, central or peripheral,/ ~: X: s9 d1 W4 }6 g2 ^' e
is a significant concern for physicians. Central8 M& t+ V: K) s) v# q( O- C" o
precocious puberty (CPP), which is mediated9 X1 G: w4 E' l
through the hypothalamic pituitary gonadal axis, has
* U: O! r; ^5 M- H& B+ La higher incidence of organic central nervous system
  L' A- j1 i$ d9 t! Ilesions in boys.1,2 Virilization in boys, as manifested4 ~% j% y3 Z/ L0 K8 U2 z  ~( s. z
by enlargement of the penis, development of pubic7 E, P/ q" F- m9 @
hair, and facial acne without enlargement of testi-
4 I8 T/ v4 L9 Mcles, suggests peripheral or pseudopuberty.1-3 We( a4 Z0 V1 G, V, b4 K0 N
report a 16-month-old boy who presented with the
4 d* q2 j; ?7 n6 u9 @enlargement of the phallus and pubic hair develop-4 u* v/ \$ @# g7 l; y, X  m7 h
ment without testicular enlargement, which was due& I2 U( I: I$ D8 Q7 @7 O. e3 R' }) }
to the unintentional exposure to androgen gel used by
8 h9 \% B2 J) bthe father. The family initially concealed this infor-8 v! }# o8 e: P. D# ]
mation, resulting in an extensive work-up for this
6 ^+ z4 _+ s! m: Uchild. Given the widespread and easy availability of6 @8 h  u2 S" \5 e' f
testosterone gel and cream, we believe this is proba-, @( I0 a" `$ M) J
bly more common than the rare case report in the
  t0 r6 H: D1 X! Dliterature.4
4 B6 ^5 g1 `5 w' PPatient Report( J- \/ o& I# L( v3 g
A 16-month-old white child was referred to the0 c% {$ h0 J  G! V/ U# e) v& H+ Y
endocrine clinic by his pediatrician with the concern* A. P8 g2 n2 O% s
of early sexual development. His mother noticed
# ~, S" b* T5 [3 q7 @9 R5 Flight colored pubic hair development when he was8 Z; I5 U! G7 F7 u) c8 s7 ^: u
From the 1Division of Pediatric Endocrinology, 2University of
! x. ?0 A- }! v/ wSouth Alabama Medical Center, Mobile, Alabama.
5 c+ \, S) A( j( k2 a5 FAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 ?/ r8 Q0 X6 l+ k% I: M
Professor of Pediatrics, University of South Alabama, College of
* H" q  n% y  I) m7 bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, g9 p2 S" M, J1 c  Fe-mail: [email protected].
+ t4 A) @0 e( n5 yabout 6 to 7 months old, which progressively became
  r+ l# U# V$ C8 e7 G0 Vdarker. She was also concerned about the enlarge-
8 j! L( q! {$ k& fment of his penis and frequent erections. The child# Q4 P  u- z& f4 t3 ~/ e
was the product of a full-term normal delivery, with2 l& m( z! H$ _/ t. f: E+ x+ j
a birth weight of 7 lb 14 oz, and birth length of
. M7 m& \# i7 V5 A; B  w& z20 inches. He was breast-fed throughout the first year  A8 t! G& \0 i# p. J1 l; A& ?
of life and was still receiving breast milk along with
+ f  o( C% Y& x7 E2 ~- vsolid food. He had no hospitalizations or surgery,/ X8 \6 q& A1 O! ^/ j3 X3 _" D1 s
and his psychosocial and psychomotor development
- D  L/ P) v, O+ G$ S; `: _. R1 T; @* qwas age appropriate.
0 Y& P! e7 n. o- q1 L9 j# W$ AThe family history was remarkable for the father,
8 H0 ^3 J7 B! S" h7 i4 l& ]who was diagnosed with hypothyroidism at age 16,
/ Y# k5 B6 X3 v  mwhich was treated with thyroxine. The father’s& e% _, I6 L1 U9 K( M+ A
height was 6 feet, and he went through a somewhat) \! L" ]6 l- _, E8 C
early puberty and had stopped growing by age 14.
" Z# [" ^5 N( Q& C+ x! G1 x7 h: BThe father denied taking any other medication. The
$ ~% F+ ~3 G- t! l* c6 y( gchild’s mother was in good health. Her menarche' ]% U: m, _# J- z; L8 r8 V5 T
was at 11 years of age, and her height was at 5 feet2 M5 n0 c. j% \6 T
5 inches. There was no other family history of pre-7 w' w, p7 p8 Z! ^3 G  z% ^- ?
cocious sexual development in the first-degree rela-
3 H% }# Q$ c. J" Y0 i, X5 V# B! ftives. There were no siblings.) e  e% W3 X6 q$ g
Physical Examination
, v$ W- X: m) \) n+ Q/ @The physical examination revealed a very active,
# h# d% w4 ]$ T1 _playful, and healthy boy. The vital signs documented+ r, }: t, E: U; i% [7 C; b
a blood pressure of 85/50 mm Hg, his length was) S8 ]5 D1 c! T3 n. D$ V
90 cm (>97th percentile), and his weight was 14.4 kg! O( s, i. Y- C2 o
(also >97th percentile). The observed yearly growth
; G1 J* n- p; l: b* v  uvelocity was 30 cm (12 inches). The examination of6 ~9 r5 G" y+ T5 U. ]' C
the neck revealed no thyroid enlargement.
. S; t4 R7 Z: [& IThe genitourinary examination was remarkable for; C3 {. Q4 O! a% D1 R/ a! Y/ d
enlargement of the penis, with a stretched length of
) i- K* @* g1 _2 u9 m: i$ w" X8 cm and a width of 2 cm. The glans penis was very well
) c- ^1 M, A: z! `developed. The pubic hair was Tanner II, mostly around0 u; f5 c5 k" F. @9 v
540
0 t) {2 Z  _& V4 W2 |! @0 o9 Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ h6 U; N# v; \( ?. k
the base of the phallus and was dark and curled. The0 C" _+ ]' Q/ O* x! `% e0 n
testicular volume was prepubertal at 2 mL each.
$ M8 i( Q0 h/ v% D( w9 TThe skin was moist and smooth and somewhat6 q2 _) s2 L( s$ e
oily. No axillary hair was noted. There were no& K% Z* ]+ p2 |* \* `  l2 i+ f
abnormal skin pigmentations or café-au-lait spots.9 L2 ~. ~; Q/ ?+ @3 c* a" [
Neurologic evaluation showed deep tendon reflex 2+8 {$ R9 h5 ^4 R. J
bilateral and symmetrical. There was no suggestion
0 A5 |4 W* r/ @2 n5 Fof papilledema.7 Y0 \$ i" E$ x4 i+ z7 w
Laboratory Evaluation, d6 p, u9 T( t2 M; y# C5 ~
The bone age was consistent with 28 months by
, G8 ]' ^' U/ I  musing the standard of Greulich and Pyle at a chrono-* p5 L% |+ i% r) f
logic age of 16 months (advanced).5 Chromosomal
# n/ E# R% Q# t2 N. W9 b1 Dkaryotype was 46XY. The thyroid function test
6 @# R. J$ I) h. yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) E! Z6 S& p8 C8 `
lating hormone level was 1.3 µIU/mL (both normal).* e- b* y1 ]2 I
The concentrations of serum electrolytes, blood5 h3 p) k+ O3 O4 q, W& h4 V2 P, z
urea nitrogen, creatinine, and calcium all were8 S2 Z, B$ ?; N
within normal range for his age. The concentration
0 }( z+ E- ~8 a4 Pof serum 17-hydroxyprogesterone was 16 ng/dL0 Y' o, ?, x$ V7 r' ]2 w1 M
(normal, 3 to 90 ng/dL), androstenedione was 20
6 G2 g  R# s0 L4 Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( c/ z/ \$ g% k6 C3 a# }
terone was 38 ng/dL (normal, 50 to 760 ng/dL),1 p  G) U- ~6 t8 T+ i( G  J
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ P0 X+ e0 [1 B& F( ^+ {( d) ~
49ng/dL), 11-desoxycortisol (specific compound S)
: \& B9 R' l: q6 C9 @" `9 Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ R- N7 L5 Q. U3 c9 b% @5 Ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 z, s8 b# D8 C7 t: ~0 a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 z0 l2 b" P, U' ?' uand β-human chorionic gonadotropin was less than. X* j  d' Q' W9 I6 i! b
5 mIU/mL (normal <5 mIU/mL). Serum follicular5 u7 r$ ~: {, ~2 [, x* j  F
stimulating hormone and leuteinizing hormone" V3 `! r4 g6 s  j: h4 Y" y* L
concentrations were less than 0.05 mIU/mL  V  X3 Q4 q4 j) s" J% @. s
(prepubertal).
9 \) N' E( t' c% E5 {. wThe parents were notified about the laboratory; \# C- e* Q6 c
results and were informed that all of the tests were
0 s0 [- e6 @" U4 C! t; t2 Z, b2 \normal except the testosterone level was high. The8 h6 \5 `) d1 E* ?
follow-up visit was arranged within a few weeks to
9 @* G, }, t. J4 y7 A! U2 Gobtain testicular and abdominal sonograms; how-: {3 @7 j- t3 X' q
ever, the family did not return for 4 months.1 x' t/ t6 C: j1 B' k1 _+ }
Physical examination at this time revealed that the( l5 h5 Y. J. i
child had grown 2.5 cm in 4 months and had gained) U. B& T3 o3 m0 D4 u/ ?
2 kg of weight. Physical examination remained
, r0 C0 x( o- I/ R  d' ?unchanged. Surprisingly, the pubic hair almost com-6 C8 R2 Q% P  I# N& O% o; s
pletely disappeared except for a few vellous hairs at
3 m! a* A/ l) Q5 D' O! i% Nthe base of the phallus. Testicular volume was still 2# q! o0 Q1 ], M. v( |! `5 W# B, w
mL, and the size of the penis remained unchanged.0 M5 T2 b% s2 w. ?) @% m: l
The mother also said that the boy was no longer hav-- x+ j7 @/ L% F5 n2 N
ing frequent erections.8 @& d! n' V0 C. t6 {" j/ j" F) W' w+ `
Both parents were again questioned about use of3 ?7 f) Q2 t/ u/ W( I
any ointment/creams that they may have applied to
) H: N! ?& }# r3 p) w7 ?the child’s skin. This time the father admitted the
0 p  u6 L+ W+ NTopical Testosterone Exposure / Bhowmick et al 541
0 z, p, _8 c- Quse of testosterone gel twice daily that he was apply-: n0 q. Y! y+ Q& ?% P
ing over his own shoulders, chest, and back area for
2 y5 A" ?- t- Y% P: h9 K, `* xa year. The father also revealed he was embarrassed
9 y2 g0 r# s+ ~$ G9 m! ~( jto disclose that he was using a testosterone gel pre-3 U* |& Z2 w1 V) {6 ]
scribed by his family physician for decreased libido
/ n" K/ {1 P* \6 c- K3 M( Esecondary to depression.
' o& j& u$ l2 aThe child slept in the same bed with parents.
- d( @6 f3 K& QThe father would hug the baby and hold him on his$ \& q5 [5 p* w0 O
chest for a considerable period of time, causing sig-$ [! T7 j2 R$ G4 K, z7 d
nificant bare skin contact between baby and father.
7 [9 X) W3 o6 zThe father also admitted that after the phone call,
9 o3 H! C1 ]- A* s/ p% B8 gwhen he learned the testosterone level in the baby4 n# O) u9 ^) E: _
was high, he then read the product information0 b+ R3 s. {/ p  v# r* S
packet and concluded that it was most likely the rea-
! @- Q- p; ]8 Qson for the child’s virilization. At that time, they
6 h  @# i" s: E. z' Y. Wdecided to put the baby in a separate bed, and the
- v7 h# T  }% u0 |father was not hugging him with bare skin and had
" |" B! e9 b& \6 I; gbeen using protective clothing. A repeat testosterone
5 \3 o( N$ V6 u! P& u5 M; {6 Ptest was ordered, but the family did not go to the% r3 f) m$ O# h( H7 ~
laboratory to obtain the test.$ h; Q1 K0 m9 p3 j$ W8 [
Discussion" `" p0 R% Z* o8 p# S  T
Precocious puberty in boys is defined as secondary
, Z2 [2 ^, i. F; csexual development before 9 years of age.1,4
6 o# M: N6 z5 E6 k* u& q9 M3 mPrecocious puberty is termed as central (true) when3 J# M: O) z/ j5 G
it is caused by the premature activation of hypo-
; i; l% B2 u. K8 O/ f, G8 \thalamic pituitary gonadal axis. CPP is more com-
* h- p" P" T) L( w  F# x  Z; zmon in girls than in boys.1,3 Most boys with CPP9 s0 N  e' O4 G) Z7 j! T2 T" ^
may have a central nervous system lesion that is
9 K+ a. D& S0 \( |: kresponsible for the early activation of the hypothal-
( V" r: j/ L% }; X  C) B! Q1 F6 Namic pituitary gonadal axis.1-3 Thus, greater empha-4 C+ i6 w8 s4 \  P
sis has been given to neuroradiologic imaging in
. H" X* L, H" Q0 @$ v2 y/ J* Rboys with precocious puberty. In addition to viril-4 B# i+ P6 X' q7 b, T# W" U
ization, the clinical hallmark of CPP is the symmet-
. ]4 E# b! X/ I! drical testicular growth secondary to stimulation by' D  c. g6 _% S* W0 F& y
gonadotropins.1,3! P4 W+ B9 \' H! M& n( V! M4 h+ l
Gonadotropin-independent peripheral preco-
$ v& B9 p* ]! R9 e+ x7 C# j9 Wcious puberty in boys also results from inappropriate
* l; {/ Y% ~# }8 Oandrogenic stimulation from either endogenous or
' `- I( e. \, g& b0 `6 e9 Gexogenous sources, nonpituitary gonadotropin stim-
) F5 T* C* e+ D& u& t, {0 b2 Y/ bulation, and rare activating mutations.3 Virilizing
0 Z+ v* H! M6 m2 s$ a! icongenital adrenal hyperplasia producing excessive
( d1 `3 e' Z4 [1 O" G/ I; Zadrenal androgens is a common cause of precocious
. |* C7 f# m# l* @; M! Tpuberty in boys.3,4
$ b1 t. p/ o+ iThe most common form of congenital adrenal
5 c- T; i7 H% x+ }0 f; Vhyperplasia is the 21-hydroxylase enzyme deficiency.6 H. r! a( c  d' k! y. ~
The 11-β hydroxylase deficiency may also result in3 h+ G( ^, v. R& o& X
excessive adrenal androgen production, and rarely,3 a1 B9 ~4 O/ h2 o8 r8 b5 `
an adrenal tumor may also cause adrenal androgen7 X4 y- M- M6 ^# m% K2 K# U
excess.1,3
, o2 C( m; i3 N" E0 Hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 F% M) R$ R# X- v5 z- p1 j
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 O& B5 N, P' @4 {& S4 d# y4 I' ?- b
A unique entity of male-limited gonadotropin-
6 F$ h2 {2 _$ F2 p1 h8 q3 Tindependent precocious puberty, which is also known$ n" Z8 [2 I6 Y! n* g( Y* F1 ~
as testotoxicosis, may cause precocious puberty at a
( k: Q4 P) J; i! ~/ ?3 R! v5 d6 e' Overy young age. The physical findings in these boys
* x) e1 [" b. k' ^9 awith this disorder are full pubertal development,. X1 x: y" M8 U, T' |0 g, J. s  I
including bilateral testicular growth, similar to boys) k3 n; ^: P% i4 b1 L" M
with CPP. The gonadotropin levels in this disorder
  r% {( f6 v$ A1 u9 o, Care suppressed to prepubertal levels and do not show' H/ U5 I+ ?8 ?: @4 H
pubertal response of gonadotropin after gonadotropin-
, L  U+ |) Y) F% r0 D# X7 Creleasing hormone stimulation. This is a sex-linked
6 P  s+ ?$ ]/ h! `8 G8 j  O: ^- zautosomal dominant disorder that affects only( k$ B6 w- P8 `4 l
males; therefore, other male members of the family
; [% ?7 |" Y; y4 s: Xmay have similar precocious puberty.3
! H# ^( \0 K/ \7 G7 BIn our patient, physical examination was incon-0 ~, O" n: c; c) I9 U8 B7 W5 Q
sistent with true precocious puberty since his testi-" ]* b2 ]. T, N5 a' n
cles were prepubertal in size. However, testotoxicosis
" w& S% e2 A1 u% h4 [was in the differential diagnosis because his father3 @! X6 O: a$ G" i: r! [/ S1 H
started puberty somewhat early, and occasionally,% d* @+ a9 u- D' \- Z7 f  R
testicular enlargement is not that evident in the8 h4 P2 l: z/ o2 v7 K! ~1 C- n+ p
beginning of this process.1 In the absence of a neg-3 N5 X$ c: r' m+ W
ative initial history of androgen exposure, our2 r3 p* V% Q/ H0 m+ v
biggest concern was virilizing adrenal hyperplasia,
8 o" ^0 G$ b1 j6 D% {; l$ jeither 21-hydroxylase deficiency or 11-β hydroxylase
4 Y) [6 o7 K6 f* u, J6 wdeficiency. Those diagnoses were excluded by find-# g% J( |2 s3 \
ing the normal level of adrenal steroids.
0 k% M+ w' D% X) ^. OThe diagnosis of exogenous androgens was strongly
+ S8 z% e. j) d/ h% p# Z8 N/ V: o# h* Asuspected in a follow-up visit after 4 months because
8 @* \2 \7 r% gthe physical examination revealed the complete disap-+ c  r' b' a& ~
pearance of pubic hair, normal growth velocity, and) |; U/ W! ]4 G( E! m5 e) X* O
decreased erections. The father admitted using a testos-
/ K4 I( E8 v& f* w( c4 Cterone gel, which he concealed at first visit. He was
% K4 M# t. c6 [5 S8 h8 ?using it rather frequently, twice a day. The Physicians’& W/ P" f! A% b) q; \7 G
Desk Reference, or package insert of this product, gel or/ K6 e% [/ @/ g5 ?  T6 n' a+ W
cream, cautions about dermal testosterone transfer to
; B, }5 x% w. Z" \- w5 Cunprotected females through direct skin exposure.
4 c% Y2 `: z( SSerum testosterone level was found to be 2 times the9 k; O; V4 [) h+ S' t: g) c' H
baseline value in those females who were exposed to1 H0 m  R  U9 y" H0 U0 q
even 15 minutes of direct skin contact with their male3 k* t$ z- y6 p4 a8 E
partners.6 However, when a shirt covered the applica-
! C3 N4 X' r. t8 l; Y2 dtion site, this testosterone transfer was prevented., v7 U. p$ U" @7 _& r( c
Our patient’s testosterone level was 60 ng/mL,0 r: r' h; X3 v
which was clearly high. Some studies suggest that+ M; ?" x* p1 J6 C! U8 o8 H
dermal conversion of testosterone to dihydrotestos-
% G& k( ^7 z- p" Hterone, which is a more potent metabolite, is more
2 [" g% T3 z5 O1 |& {7 dactive in young children exposed to testosterone
* E: ?8 r) s/ T3 Texogenously7; however, we did not measure a dihy-7 C. p, B4 k" w1 l
drotestosterone level in our patient. In addition to: V. v7 I# G+ B" J4 C4 E
virilization, exposure to exogenous testosterone in8 s& Z7 r' T- E# S$ S* z7 {# }; C
children results in an increase in growth velocity and
+ ]& i" w+ I, c8 S4 S  o. v) Tadvanced bone age, as seen in our patient.
2 X& I. h3 f( Q; g$ j. P3 KThe long-term effect of androgen exposure during
2 F7 e6 o4 w( y2 k: ]early childhood on pubertal development and final+ e: W- m3 Z) T3 b! i$ M4 |5 O
adult height are not fully known and always remain2 e/ f& M$ v1 a$ I' g, U
a concern. Children treated with short-term testos-
9 g+ |4 @9 n1 C) T1 r/ Eterone injection or topical androgen may exhibit some
+ r% S; A+ g8 A- D+ nacceleration of the skeletal maturation; however, after$ H8 u' z/ x5 m- I
cessation of treatment, the rate of bone maturation
6 H  m+ V. |( F2 M* D2 ldecelerates and gradually returns to normal.8,91 {- U5 s' Y; R0 Y5 t) w& z
There are conflicting reports and controversy
7 ]" ?+ a8 G: F- |* eover the effect of early androgen exposure on adult
/ [* s) _- U8 R- H/ l6 p- ?1 y0 V: zpenile length.10,11 Some reports suggest subnormal, }7 Y( c# o" G+ o% C5 ?
adult penile length, apparently because of downreg-1 N: T4 h+ J9 O
ulation of androgen receptor number.10,12 However,
' I( [9 R8 G1 \0 O+ k. E' C& zSutherland et al13 did not find a correlation between
  V3 ~9 ^' x- \8 U: [% c3 |6 |childhood testosterone exposure and reduced adult
4 u! O! k2 S& q8 {; w/ Y8 f/ e, E5 G# ~penile length in clinical studies.& c; B; ^% m4 g3 y  h! h1 x" c$ a
Nonetheless, we do not believe our patient is
/ W: Y1 X( J4 w7 `8 T) Mgoing to experience any of the untoward effects from
% s, [' H5 g/ K- y. C* ^8 ltestosterone exposure as mentioned earlier because
& X% R' }5 E/ ^( r$ b# v; A% b/ t5 w" fthe exposure was not for a prolonged period of time.
; a* E; f5 L# d& t4 RAlthough the bone age was advanced at the time of, Y" a( P! L( a6 B5 S. h
diagnosis, the child had a normal growth velocity at
8 Z+ f# O" U9 {- athe follow-up visit. It is hoped that his final adult7 u; C) u: k9 R* d7 R5 y; M% ]
height will not be affected.' l0 z7 j2 i* H* |  S
Although rarely reported, the widespread avail-$ g0 z5 r1 M+ J8 [: Z. g
ability of androgen products in our society may
/ ^6 x0 b' M  A3 n6 w( ^2 B; a& U- Cindeed cause more virilization in male or female
) e% O, R  M4 `3 Z1 a; q$ c3 ~children than one would realize. Exposure to andro-
9 A! T" h1 p5 h6 W- \+ C# bgen products must be considered and specific ques-7 }# W2 L* v3 M, s- T. i
tioning about the use of a testosterone product or' g' V+ z: r6 {2 Y# g
gel should be asked of the family members during
0 y9 @* h! R) `. A* q1 ]" y. Vthe evaluation of any children who present with vir-
; U( B$ V' I; G6 {0 c& C& a  N( iilization or peripheral precocious puberty. The diag-8 X) s' l, ]) B# C' b$ x8 e9 S. O
nosis can be established by just a few tests and by
0 ^1 |" d1 L; t3 K" {: c* H) Yappropriate history. The inability to obtain such a
$ N( ?/ i( E) F! |+ |history, or failure to ask the specific questions, may
9 M  c4 k6 @, c/ k8 fresult in extensive, unnecessary, and expensive/ t. I6 J7 f0 c, O
investigation. The primary care physician should be2 D7 G$ O/ o* ~7 s* ^
aware of this fact, because most of these children
* K: B7 Y& Z/ R- u9 C1 g0 _0 ]& ~& Ymay initially present in their practice. The Physicians’1 r; D! g" o+ ?" Q$ t
Desk Reference and package insert should also put a
1 I( ]' d2 p; z# S( G5 y5 G# Awarning about the virilizing effect on a male or
* N' O: P! i+ |: j9 Xfemale child who might come in contact with some-  m8 {2 q% \( P- B
one using any of these products., t, V& x! p$ o2 j7 ]7 B) ?' O
References
# p6 H7 E' R' Y0 z5 M' ^1. Styne DM. The testes: disorder of sexual differentiation6 `4 J. o' g4 ^
and puberty in the male. In: Sperling MA, ed. Pediatric
* Q$ o3 S. T* O) t6 L, i3 {Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
* a2 V; ~, d: @' q$ ]2002: 565-628.! J4 ~3 z; O/ T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ U! |9 I0 h$ l( U5 Zpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
: X) ]# l4 g8 @Boy Induced by Indirect Topical( `/ V" K( g. O, v% K' K$ S; ^
Exposure to Testosterone
2 z& H9 }. g  O% E1 X2 \& \Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( @/ W( w  a7 l3 e4 `$ c( M' ]- jand Kenneth R. Rettig, MD1, W0 h$ m! t$ q& e/ z0 w' s$ t& J
Clinical Pediatrics- U# q3 K2 E: L) i0 W- a
Volume 46 Number 6! V) v# k. ^( J( \+ Z9 K
July 2007 540-543* j& A7 c  }% X1 R9 G2 r5 V$ l3 {
© 2007 Sage Publications7 W, x% l1 \7 U3 d' h+ l
10.1177/0009922806296651" h( Z( X! g( v! t$ f% m
http://clp.sagepub.com
- ?0 O$ L. ]% ]2 S# dhosted at
% l6 Q0 b8 u2 p. n8 x- G' n* Fhttp://online.sagepub.com
$ M; k1 |4 j4 h6 C) zPrecocious puberty in boys, central or peripheral,* D0 v% i7 g  x; X
is a significant concern for physicians. Central$ P' n6 Y  D4 Y( v
precocious puberty (CPP), which is mediated9 h" r% \/ F9 _: [! T
through the hypothalamic pituitary gonadal axis, has
/ E5 g( I+ H! K1 C3 w, `a higher incidence of organic central nervous system! e+ z: @# E( b( a6 w
lesions in boys.1,2 Virilization in boys, as manifested- `; e3 [' Y3 j4 B
by enlargement of the penis, development of pubic0 E$ w; H0 t' C4 U5 E4 ~8 O* F( y
hair, and facial acne without enlargement of testi-
# m1 h9 l; b+ n' z. o' u- ~cles, suggests peripheral or pseudopuberty.1-3 We
: ^6 r5 j' p9 H7 A& }. areport a 16-month-old boy who presented with the
# ?: u! V1 ~( n* a4 n- k1 Kenlargement of the phallus and pubic hair develop-0 d  S* l' V0 J9 _( {( ]
ment without testicular enlargement, which was due
8 ]: [5 Z& N) jto the unintentional exposure to androgen gel used by
; R+ U0 X/ F0 d, h7 zthe father. The family initially concealed this infor-
( {' G: Y- l9 l3 F" q& ?; _" Ymation, resulting in an extensive work-up for this- D) a/ @3 ]; F* h" X( P
child. Given the widespread and easy availability of
& S0 f1 E. u/ E2 t0 V! F: }, btestosterone gel and cream, we believe this is proba-
% E8 p+ L; _6 t5 |2 Vbly more common than the rare case report in the$ T! G, ~# T  i
literature.41 V) n% f; m7 k
Patient Report
3 u& \( w5 Q9 Z5 n# _% ZA 16-month-old white child was referred to the  f1 _8 S: q6 S5 m! }# g2 s
endocrine clinic by his pediatrician with the concern4 a" w0 Q0 h% _! p0 d1 P
of early sexual development. His mother noticed- F6 p9 ~- z) H* P$ Y/ K8 O
light colored pubic hair development when he was2 g' H; h$ Z- [+ m  t/ ^0 J! s
From the 1Division of Pediatric Endocrinology, 2University of
3 i7 Y" U3 ~% s# c( D1 ?/ mSouth Alabama Medical Center, Mobile, Alabama.
# }5 C* T' _4 ~! b/ OAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ U/ D6 a8 Y4 J% V. VProfessor of Pediatrics, University of South Alabama, College of
# @, M9 |, m7 Y8 S# HMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  `8 D5 o1 T5 [/ G$ {/ z6 ?( y) }
e-mail: [email protected].& A8 U$ \( A( `
about 6 to 7 months old, which progressively became0 \$ j. d4 [6 {1 [. A) ~3 O
darker. She was also concerned about the enlarge-
0 K  k' B! ^3 \% W8 f5 }2 _ment of his penis and frequent erections. The child
) B3 J8 n7 c% V5 ?7 Lwas the product of a full-term normal delivery, with
  K1 s  a+ j' M) j. h1 X8 s3 Ka birth weight of 7 lb 14 oz, and birth length of6 h. V. m# l) f7 L
20 inches. He was breast-fed throughout the first year
9 h. U4 m  @/ F9 H& ^+ Oof life and was still receiving breast milk along with0 Y- X" Y2 V2 v6 t; P
solid food. He had no hospitalizations or surgery,
- j+ ^3 s" E: Y7 C2 O1 m0 I  Mand his psychosocial and psychomotor development
7 f0 u; W# ~9 _9 J  m. gwas age appropriate.. c" ^* Y- K0 n" F: S( Y
The family history was remarkable for the father,7 E, ~0 m0 s! s0 D+ E# f* K
who was diagnosed with hypothyroidism at age 16,& Y) x6 G  }" {, B8 ?/ G5 Y
which was treated with thyroxine. The father’s
& _/ l$ [& P  S; Uheight was 6 feet, and he went through a somewhat/ E8 s5 H. W: O! u6 k
early puberty and had stopped growing by age 14.
8 B% y  P2 g! M& X; k$ s6 ]4 {% lThe father denied taking any other medication. The
! ?% s( Z7 t2 [, j2 xchild’s mother was in good health. Her menarche
9 B5 ]: J# N9 R) A$ C# }4 d8 A4 Ywas at 11 years of age, and her height was at 5 feet; T5 i, u! ?4 I- y- ~% n! `. \/ [
5 inches. There was no other family history of pre-
8 X  A7 d+ J7 s3 X1 x! a- {, Dcocious sexual development in the first-degree rela-
2 N2 a6 B& a* M9 t/ ]+ G$ ?tives. There were no siblings.
  O: k& t' y8 NPhysical Examination
5 J9 T5 n1 u# OThe physical examination revealed a very active,0 r( I% p" ^% h1 A3 `5 e+ w
playful, and healthy boy. The vital signs documented
3 T4 S$ z" d* k, d0 D6 ha blood pressure of 85/50 mm Hg, his length was
' I/ m1 E# B6 \7 q: k# i* w90 cm (>97th percentile), and his weight was 14.4 kg
1 ]( W; ~: {' `(also >97th percentile). The observed yearly growth# `0 L! i6 |9 Q: `' H
velocity was 30 cm (12 inches). The examination of8 f) Y) L6 A! E2 C; m
the neck revealed no thyroid enlargement.
$ ?5 M7 ]. X; y9 K" x9 w# DThe genitourinary examination was remarkable for/ p3 c" e: e- K$ J, R( H" a5 [
enlargement of the penis, with a stretched length of
5 f7 {2 m$ K+ {5 m* b: H8 cm and a width of 2 cm. The glans penis was very well
3 N8 b( w% y8 X7 J; J9 ?: Ideveloped. The pubic hair was Tanner II, mostly around' O: T' x4 D! ~. y4 ^+ ]3 v+ K2 N
540( i) }  Y0 l: `" s2 x8 F* X8 f! |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 Q9 O' Z( }- f. x) j
the base of the phallus and was dark and curled. The
: A8 \2 J8 w5 A6 Xtesticular volume was prepubertal at 2 mL each.- c- O8 q3 T- H. m' M- X8 _: {1 O
The skin was moist and smooth and somewhat
. F3 Q& ]' O7 Boily. No axillary hair was noted. There were no9 W4 P6 N2 G1 P0 f* ^5 a/ O6 u
abnormal skin pigmentations or café-au-lait spots.
0 r3 h; [( k% H) P' qNeurologic evaluation showed deep tendon reflex 2+
" o" d) c1 P( I9 f6 u$ Obilateral and symmetrical. There was no suggestion
& V. {9 T8 C! |+ C& lof papilledema., u' v0 Y' F- K8 b$ E
Laboratory Evaluation! L- C  I. X* c  w% B
The bone age was consistent with 28 months by2 h! \: w/ F3 H7 j1 ^
using the standard of Greulich and Pyle at a chrono-
! `% S- ]4 R2 X% a4 l8 f) z" @logic age of 16 months (advanced).5 Chromosomal0 n+ {1 \1 q: J- ~; l2 X
karyotype was 46XY. The thyroid function test# N+ o- F$ J, u2 S; j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. }$ k) o% ~% I: w- W
lating hormone level was 1.3 µIU/mL (both normal).
$ `' a" D: H8 ]4 U4 [0 [9 MThe concentrations of serum electrolytes, blood' {! ~1 u7 b) e
urea nitrogen, creatinine, and calcium all were7 ?- Y  f7 }  V9 l
within normal range for his age. The concentration
8 d+ H8 P! H4 v3 P( eof serum 17-hydroxyprogesterone was 16 ng/dL
3 h! e' @1 }2 v! v! N(normal, 3 to 90 ng/dL), androstenedione was 20
. i3 l6 W. [8 u$ I% Qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- |+ K1 L1 l  J! y# E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; N3 `! D# s3 j1 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
  S1 S& s! K! I9 k7 R- _$ N49ng/dL), 11-desoxycortisol (specific compound S)7 g# O  D3 \5 [; j; @) N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, P: }, [: b, f) ]
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: w6 v- c3 {- T3 O% K' M! Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 T. i' R( O# O" B% a
and β-human chorionic gonadotropin was less than4 n( H" n" p: J! q7 D' j% x
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# E% E6 S4 f3 S; b6 `) Nstimulating hormone and leuteinizing hormone; _3 C1 v  v( H0 |, q1 w
concentrations were less than 0.05 mIU/mL
- n' g0 ^# }0 E8 S5 x(prepubertal).
9 {# A( x# A& w; q% L' g) `. yThe parents were notified about the laboratory
& O/ O4 H! T, j  uresults and were informed that all of the tests were
; e8 L7 f) q6 Z2 Y' K7 d6 m9 e8 rnormal except the testosterone level was high. The
8 Q1 Z. H$ w9 G7 M7 ^follow-up visit was arranged within a few weeks to
3 L9 B/ E: K" n/ {- b, fobtain testicular and abdominal sonograms; how-" M2 g) o5 I; W
ever, the family did not return for 4 months.
9 X4 e/ }9 K7 o* \) jPhysical examination at this time revealed that the
- W8 A/ j3 c  _child had grown 2.5 cm in 4 months and had gained: B3 O, Q$ U9 X
2 kg of weight. Physical examination remained
/ g( C  v% M4 Y( F1 G# |4 junchanged. Surprisingly, the pubic hair almost com-
! Q+ L4 d- b% N& M' Bpletely disappeared except for a few vellous hairs at
6 F# Y' V+ H9 z2 Ithe base of the phallus. Testicular volume was still 29 r# `3 `) P, y8 x3 L
mL, and the size of the penis remained unchanged.5 G# t  u5 @# d9 t: C( `
The mother also said that the boy was no longer hav-
4 n4 |6 Q1 v( k% k" }4 Aing frequent erections.8 j- u- T; E+ X" [& z7 V
Both parents were again questioned about use of
( Z- H* @! m; d# P' Z" c9 ?! uany ointment/creams that they may have applied to
( c$ N" z' q% q- Uthe child’s skin. This time the father admitted the
0 ^' N$ b  L/ mTopical Testosterone Exposure / Bhowmick et al 541
  i4 T; X% G4 Q. s8 D- d) c) M7 \use of testosterone gel twice daily that he was apply-
3 P9 J5 s4 O& l' Q6 G5 d8 `ing over his own shoulders, chest, and back area for# I/ y( h" E2 T" u( f; Z7 f  B6 }
a year. The father also revealed he was embarrassed' k+ f6 P, k/ N$ }7 [
to disclose that he was using a testosterone gel pre-5 |% h  M# c; p  c8 r$ K
scribed by his family physician for decreased libido
! J+ r$ H$ m! \secondary to depression.  t% _" Z3 x" }
The child slept in the same bed with parents./ n: l5 {, n5 `: u
The father would hug the baby and hold him on his8 I$ w7 a- I, D, C
chest for a considerable period of time, causing sig-# z  ^, `  W, C3 N6 Y3 H7 R" J( c
nificant bare skin contact between baby and father.
* {7 w' P) p2 Q" G) kThe father also admitted that after the phone call,
! G1 y4 y2 R5 z0 ^+ R7 W7 ?when he learned the testosterone level in the baby
4 }. ]! c$ f5 W1 r' n( z8 m  uwas high, he then read the product information
( ^9 H# C& _% O5 ?1 s4 F5 y7 Q. r: Opacket and concluded that it was most likely the rea-/ s  Y/ h$ c3 `4 ?2 i2 S* Z2 \
son for the child’s virilization. At that time, they" ]' q5 j# `; ^6 t/ t7 U  J
decided to put the baby in a separate bed, and the& [5 p: S+ `! G$ c: y1 b
father was not hugging him with bare skin and had* d1 f' T: d( P- v- _
been using protective clothing. A repeat testosterone) j1 U8 I6 V8 T6 o: b. c7 \
test was ordered, but the family did not go to the
: L8 E7 W8 D* t( x( _  l/ n) f# jlaboratory to obtain the test.
6 B! V' q# f  T4 Z& C+ r7 x6 ~/ H& nDiscussion
% J& N" y9 R! J! YPrecocious puberty in boys is defined as secondary
+ A4 B5 i8 E% G- F, Tsexual development before 9 years of age.1,49 @% {6 S. l  m' w' r
Precocious puberty is termed as central (true) when! s1 C& Q% Y; L- d
it is caused by the premature activation of hypo-3 Y# t: X( D! |. W& y% b
thalamic pituitary gonadal axis. CPP is more com-
5 ~1 d& [; n9 S4 X8 X, B8 tmon in girls than in boys.1,3 Most boys with CPP
' P) |: ~( q2 n% vmay have a central nervous system lesion that is  d) ]& B1 ^/ H+ E6 v3 l
responsible for the early activation of the hypothal-9 W! U+ ~' B$ D  L$ u1 P+ l# `5 N. [0 S
amic pituitary gonadal axis.1-3 Thus, greater empha-
. r  ^" O4 ~0 `7 Psis has been given to neuroradiologic imaging in
' F4 r  E( w5 {. H$ }boys with precocious puberty. In addition to viril-2 @$ e- Z: B& U9 m0 y; V3 \
ization, the clinical hallmark of CPP is the symmet-
9 ]* [& B5 M) crical testicular growth secondary to stimulation by
  S7 K1 f3 I* |7 V5 @1 Ngonadotropins.1,30 j7 _- z/ r0 e8 Q) n
Gonadotropin-independent peripheral preco-" W: {( L. B7 P! [! f" a6 V
cious puberty in boys also results from inappropriate
7 v& c6 d0 c; p0 H) Bandrogenic stimulation from either endogenous or
6 [, w4 j4 b2 @, o- [/ Jexogenous sources, nonpituitary gonadotropin stim-
5 O+ V1 ^# r# P8 s1 u; f  ^ulation, and rare activating mutations.3 Virilizing
* j$ [! K1 Z0 R9 P# q- S7 M0 x1 Ncongenital adrenal hyperplasia producing excessive
! n& h+ w. {$ ^# W* p8 Fadrenal androgens is a common cause of precocious7 C- @% A) s2 o8 K0 J% B3 _3 h. ]( j9 v
puberty in boys.3,4& P. J! G5 W9 B8 a; o, ?% T3 r3 |
The most common form of congenital adrenal( _; S9 M5 _  p  p+ G7 P4 Y& J* k2 X
hyperplasia is the 21-hydroxylase enzyme deficiency./ T) Q% |8 l1 n: h  H5 W0 D
The 11-β hydroxylase deficiency may also result in
  Y# v0 d: V/ B( F8 L+ rexcessive adrenal androgen production, and rarely,0 b; _# c1 [3 h! @2 i6 y
an adrenal tumor may also cause adrenal androgen
: y& A4 S) j: I4 Mexcess.1,3! `9 |* i! {  k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" y- U, y" v+ @- z) p/ E. H  J
542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 i4 h6 V8 m6 q6 ]: t
A unique entity of male-limited gonadotropin-
3 P: x, s8 d. ]7 z$ |+ o# Lindependent precocious puberty, which is also known
9 `0 v- O9 o2 x3 {* ]as testotoxicosis, may cause precocious puberty at a
. d9 v" N2 `; z. t" L$ avery young age. The physical findings in these boys
& \& v. j1 Z( jwith this disorder are full pubertal development,
- h/ g/ W+ B$ X8 k; ~5 Eincluding bilateral testicular growth, similar to boys
* `4 i. A% S3 s& p: J) ]) Xwith CPP. The gonadotropin levels in this disorder* t! i  i2 t- s4 E
are suppressed to prepubertal levels and do not show  Y! q4 d" I' y, ^3 N/ {
pubertal response of gonadotropin after gonadotropin-
+ j5 j- W2 \2 _releasing hormone stimulation. This is a sex-linked
4 S2 y6 `( R: vautosomal dominant disorder that affects only( r" R+ j4 j* d' G7 C9 Y' V
males; therefore, other male members of the family* @2 R* o, M' M& Y
may have similar precocious puberty.3& s- T  |$ |) p- t7 Y5 g
In our patient, physical examination was incon-
& j$ w5 @; f& L  M: P( g3 Esistent with true precocious puberty since his testi-* p5 j: I: D4 `
cles were prepubertal in size. However, testotoxicosis
0 F0 ]. W# h" N2 wwas in the differential diagnosis because his father) u6 G2 X0 W9 u8 n+ }5 L: y0 W
started puberty somewhat early, and occasionally,
' n7 a! g. T2 |) P8 ?; stesticular enlargement is not that evident in the5 U" j! D6 Q. W* v8 X
beginning of this process.1 In the absence of a neg-( a: ?: n3 p9 @. o# k
ative initial history of androgen exposure, our
, w! ^( A0 x1 i. A' Ybiggest concern was virilizing adrenal hyperplasia,
4 v( L  }$ W" i( {4 \2 beither 21-hydroxylase deficiency or 11-β hydroxylase2 K" O6 @) Z) t+ N, Y9 Y. a% J
deficiency. Those diagnoses were excluded by find-) o3 S& @# E! L. c, Q; v# K
ing the normal level of adrenal steroids.+ N+ d& e8 D9 J0 j5 `5 W  ?
The diagnosis of exogenous androgens was strongly
* T& Z- P6 g5 z- {% |) Rsuspected in a follow-up visit after 4 months because
  R6 \3 e; V2 \8 h& Cthe physical examination revealed the complete disap-
0 C; R5 ]) x. \" c6 Y; Apearance of pubic hair, normal growth velocity, and
5 Q* V; K" a) b- edecreased erections. The father admitted using a testos-! l: }( ^; e  u) e# ]1 k. W
terone gel, which he concealed at first visit. He was
5 n, K& D& Y/ y( b  U# J- l7 x/ u- yusing it rather frequently, twice a day. The Physicians’9 ~9 S/ m+ G/ b% b6 Y2 {
Desk Reference, or package insert of this product, gel or
) `" l+ M" [  m2 D; x% Y! Rcream, cautions about dermal testosterone transfer to
8 B7 W2 P/ ~6 j% R# P4 b$ q( _2 Bunprotected females through direct skin exposure.
1 z" T! \9 [- c0 vSerum testosterone level was found to be 2 times the+ h. P2 g+ ~7 C! J- w5 r' T
baseline value in those females who were exposed to
0 T; a" H+ g" G2 ?even 15 minutes of direct skin contact with their male4 R6 X3 ~! ~" y2 T) V! }3 g
partners.6 However, when a shirt covered the applica-: D# o/ }5 y: W# E. f
tion site, this testosterone transfer was prevented.
/ Z6 e! A+ d4 u7 P& c& R+ xOur patient’s testosterone level was 60 ng/mL,
& Q% d) Y% d7 u0 e2 A7 ^: {which was clearly high. Some studies suggest that
& j5 d9 U9 J0 [/ @7 `dermal conversion of testosterone to dihydrotestos-
' p0 E0 p; ^: V+ i5 Vterone, which is a more potent metabolite, is more
5 ^) R1 j) v9 I9 e" ^* ~active in young children exposed to testosterone% s6 s0 u: n/ P& w, t! Q! `: V
exogenously7; however, we did not measure a dihy-
+ \1 ]+ w4 y6 _, v9 p/ w9 F' Ldrotestosterone level in our patient. In addition to
6 a* |5 n; M& J) ^# J) Tvirilization, exposure to exogenous testosterone in3 D+ C' k/ T2 r: l* ]$ s! b  l
children results in an increase in growth velocity and
& K0 X0 u( O% [advanced bone age, as seen in our patient.
9 _3 F; S8 }4 xThe long-term effect of androgen exposure during
3 E2 r6 O9 L" ]/ Searly childhood on pubertal development and final, |2 b4 D9 G. [  m! z* n
adult height are not fully known and always remain
0 `9 k& y8 b' Q9 u- J5 n' sa concern. Children treated with short-term testos-
; y0 l0 t6 b1 f2 |5 I" iterone injection or topical androgen may exhibit some
, f+ v8 r7 I% m% r. J* E+ }acceleration of the skeletal maturation; however, after
: n. D- J' b! x, w- Pcessation of treatment, the rate of bone maturation
, _& b+ e- W2 p( A7 Q- m: zdecelerates and gradually returns to normal.8,98 v; [, p5 O+ t& H4 n4 J
There are conflicting reports and controversy
  g% ]* M5 p0 o' k+ }over the effect of early androgen exposure on adult
& L" T) Z: g5 w' g' L* O3 j) mpenile length.10,11 Some reports suggest subnormal
& v8 ?$ r$ t, i2 C* s" Ladult penile length, apparently because of downreg-
9 \; J( ?/ c) }# d4 {9 tulation of androgen receptor number.10,12 However,
7 N7 }& f2 Q5 f& RSutherland et al13 did not find a correlation between. f) Z# a: }5 X  E# t8 Q8 u* A
childhood testosterone exposure and reduced adult
1 m% s) w0 h/ X: ~  w0 \penile length in clinical studies.
% Y5 B% ?2 p4 r# ZNonetheless, we do not believe our patient is
% p: k/ e5 d$ f  ygoing to experience any of the untoward effects from
+ ?+ R( w: K1 n: U8 Htestosterone exposure as mentioned earlier because' \0 l2 c8 p- _' d6 o
the exposure was not for a prolonged period of time.
7 S8 J& @5 m" b' M* T# u5 KAlthough the bone age was advanced at the time of; w2 x  `$ t  T/ }& X
diagnosis, the child had a normal growth velocity at, G' [: ~# j7 n) Y+ P' w
the follow-up visit. It is hoped that his final adult- l7 l. b2 R$ m* H8 y) A
height will not be affected.8 N  F, \6 Y0 G9 `8 l6 R5 m
Although rarely reported, the widespread avail-' H( y) J$ S, e
ability of androgen products in our society may
% u* F. M! {/ J" h0 uindeed cause more virilization in male or female# @* V5 B* L# l9 z; u6 s
children than one would realize. Exposure to andro-
' P# A: ]8 i  Dgen products must be considered and specific ques-
' g& h  U* P% V5 n' o% jtioning about the use of a testosterone product or
* o) C7 _# a5 D' Y% W+ ?6 w6 v7 ^* Tgel should be asked of the family members during( q2 [, ?. p7 y4 e( T  W
the evaluation of any children who present with vir-* V, R& \& P  S# T; D
ilization or peripheral precocious puberty. The diag-
- d, t& B  n" L; I9 inosis can be established by just a few tests and by7 A/ t& I( K( \: ^9 d
appropriate history. The inability to obtain such a
2 d5 u- |, v* o+ e$ d: Hhistory, or failure to ask the specific questions, may: e% b# D! o" x
result in extensive, unnecessary, and expensive
$ y8 Q8 `1 e" H. [% b3 ^  j% V9 Vinvestigation. The primary care physician should be
4 v/ n8 }. T, Daware of this fact, because most of these children6 E  ~' _, z7 N
may initially present in their practice. The Physicians’
* v- ]; K: u& dDesk Reference and package insert should also put a
5 J. R" R% a# B7 K4 Mwarning about the virilizing effect on a male or5 f- O5 R' z& B4 f
female child who might come in contact with some-; L8 q5 r0 A) ?. ]: \; u% v
one using any of these products.! T' T8 i% R7 q  x8 V. w5 \
References$ n; Q" n0 S, T. E" N5 @. c
1. Styne DM. The testes: disorder of sexual differentiation
; j2 v; T% W: U* ^- Iand puberty in the male. In: Sperling MA, ed. Pediatric6 M2 ]" z; `+ f& k5 {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 U& _' W) m5 X4 }/ O2 E2002: 565-628.
! d' K2 b& u2 `& q0 j2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 M/ u7 f7 H* g+ d8 `
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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

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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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