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Sexual Precocity in a 16-Month-Old9 I( Y& c0 J5 [/ Z- d
Boy Induced by Indirect Topical+ [2 x( K5 B7 T( ~) h( T
Exposure to Testosterone, |1 ?9 d5 m' @: L4 H0 I5 ~
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! m3 l, X8 b" S; s' _0 O" o) n/ a* w
and Kenneth R. Rettig, MD1
+ r. U# }: r; V, B2 g2 z  BClinical Pediatrics# k3 U+ f8 n/ ^* I3 |% ~* k
Volume 46 Number 65 @" E% t) h& R* K) P2 r
July 2007 540-543
" Y. K. p8 ?! s# `" j© 2007 Sage Publications/ i7 u/ g4 s, m4 Z/ @' Y
10.1177/00099228062966513 h* a0 u9 T( E% q
http://clp.sagepub.com
$ ]) A; U4 C4 d# l+ y" e/ n  Chosted at
0 D% I! }5 l0 a, ?  D" k/ k% Ohttp://online.sagepub.com
" Q( @) w: q# s9 u) w: h5 GPrecocious puberty in boys, central or peripheral,2 d7 i$ Y: ~0 a- t" m/ A# {8 y
is a significant concern for physicians. Central8 G! t& h+ T8 w" Y: |) w  F
precocious puberty (CPP), which is mediated7 w: _' p' \! o
through the hypothalamic pituitary gonadal axis, has  y2 z2 R1 S' ^5 b+ Q& M5 P! h
a higher incidence of organic central nervous system5 R! |' ]2 _" P% U1 ?
lesions in boys.1,2 Virilization in boys, as manifested* d. N4 K# o) Q+ j- d3 Z; ~
by enlargement of the penis, development of pubic7 A0 z9 e; p! f' Q$ {$ \9 w$ b( Z) v. i
hair, and facial acne without enlargement of testi-* I. J! n: w$ b- b
cles, suggests peripheral or pseudopuberty.1-3 We
/ d/ j, ]: W3 I- I+ y  |report a 16-month-old boy who presented with the1 U2 ]/ m$ l5 A/ \3 ?# _
enlargement of the phallus and pubic hair develop-4 A0 _% S6 G6 |; R+ \& v
ment without testicular enlargement, which was due
( {( q* }; z+ i3 D0 Sto the unintentional exposure to androgen gel used by: @6 O  B6 }: v5 i% W: J8 D% O
the father. The family initially concealed this infor-0 P  C( ~9 G! D5 q" D3 w* y2 a& y8 J
mation, resulting in an extensive work-up for this+ B0 ?7 l8 s3 C' p
child. Given the widespread and easy availability of( s$ [3 f" t' e3 t2 m% K  e  N
testosterone gel and cream, we believe this is proba-2 ]' U/ j4 S# m1 V( l3 ^
bly more common than the rare case report in the
' X+ `7 D: w! H# J, oliterature.4/ E$ Z" \2 n5 g# W9 y, S! g& R
Patient Report4 E- }) m7 ?+ }6 C: y# e( R3 H
A 16-month-old white child was referred to the8 d: B( N" D6 d; S, R( z: L
endocrine clinic by his pediatrician with the concern* C) j5 y; r  e- R
of early sexual development. His mother noticed7 A- R% O) A- d
light colored pubic hair development when he was+ G2 j2 D% b3 i3 v" d
From the 1Division of Pediatric Endocrinology, 2University of4 }* u* P& F  }  [0 A  l+ y0 D
South Alabama Medical Center, Mobile, Alabama.- S* i# U2 ?4 @% b8 c5 G4 J( q- u
Address correspondence to: Samar K. Bhowmick, MD, FACE,- w% c! q6 y  U  u0 p. b  V
Professor of Pediatrics, University of South Alabama, College of) U0 T1 R/ Q: H) F4 @
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# G; K$ Z- B- o) Y8 M& P
e-mail: [email protected].
7 w4 R' A1 F9 P+ w. a! yabout 6 to 7 months old, which progressively became4 D2 _& i' ?3 |6 `# A$ ~2 G
darker. She was also concerned about the enlarge-
) h' M6 n# ?& L& p  z& j$ O# rment of his penis and frequent erections. The child
5 K: s; m: J, W* P3 v2 s, w  n: swas the product of a full-term normal delivery, with: y; y1 E& i% }% }0 S2 o3 V
a birth weight of 7 lb 14 oz, and birth length of
4 n1 l3 q6 m0 U  N: k$ }5 `20 inches. He was breast-fed throughout the first year
) }1 V. ~; M4 @' Bof life and was still receiving breast milk along with
' S& {$ t. Y8 q$ w, b  psolid food. He had no hospitalizations or surgery,
" S3 r* R  P8 b! zand his psychosocial and psychomotor development
$ V2 D2 _0 d0 j* Rwas age appropriate.! ^4 S+ t$ T+ X" r4 w
The family history was remarkable for the father,- C7 S1 w" C$ V4 m
who was diagnosed with hypothyroidism at age 16,
( t2 ~& j6 [# A+ a$ F; `' l5 }# C* U' Cwhich was treated with thyroxine. The father’s
0 j, b. B) R" t  }height was 6 feet, and he went through a somewhat4 ?/ ]% {. T& {
early puberty and had stopped growing by age 14.3 m2 t7 Y, K( M" g' g
The father denied taking any other medication. The
' Y/ h( w- Q6 q1 S+ E. wchild’s mother was in good health. Her menarche# `: x2 P: v! U
was at 11 years of age, and her height was at 5 feet
9 p( ?# e, m3 x$ _) {5 inches. There was no other family history of pre-
7 H7 }8 \' n" }( ^9 B" xcocious sexual development in the first-degree rela-9 [6 Q' Z- D' s. l
tives. There were no siblings.
4 C" G9 v0 s) X  xPhysical Examination
- ~' J; b9 U- f# J* b# w; L( eThe physical examination revealed a very active,
% w- S6 H( H+ s8 h2 k- xplayful, and healthy boy. The vital signs documented3 H% W& G2 P# M" h
a blood pressure of 85/50 mm Hg, his length was
5 x5 R; L: ?0 B2 M: P1 A& b- |! |90 cm (>97th percentile), and his weight was 14.4 kg
9 t7 B4 n$ ]; h9 S(also >97th percentile). The observed yearly growth
1 R+ W+ w4 |8 g) Mvelocity was 30 cm (12 inches). The examination of6 Z0 E! X' t$ t" Q) c+ l4 [
the neck revealed no thyroid enlargement.; D- z) o* T2 _. Q4 s
The genitourinary examination was remarkable for/ F" ?& f4 B' F5 F
enlargement of the penis, with a stretched length of" v% F9 Z. S" X: D" D- D
8 cm and a width of 2 cm. The glans penis was very well
6 u0 {9 e2 d8 z% a& mdeveloped. The pubic hair was Tanner II, mostly around% F1 V! E  p* _, W" f( p3 t
540
: m' X$ ?* G2 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 D/ G4 [  Y& J1 y" m3 B! Rthe base of the phallus and was dark and curled. The0 p8 S7 Q3 I' I. Z' D
testicular volume was prepubertal at 2 mL each.+ s3 R9 w# z, ~% t
The skin was moist and smooth and somewhat/ a6 ?. P) R: {% M; U+ \( a4 y
oily. No axillary hair was noted. There were no
& V% d, T) W" D- O$ habnormal skin pigmentations or café-au-lait spots.
' g0 k* k% ?4 @9 c0 iNeurologic evaluation showed deep tendon reflex 2+% [% Y1 q0 u! {+ y2 {$ J
bilateral and symmetrical. There was no suggestion, Z0 i5 p( l4 t
of papilledema.
. z4 A9 x* I: F/ z# H5 Q6 yLaboratory Evaluation0 S6 l2 T6 E* Y: q" h+ c9 n$ h
The bone age was consistent with 28 months by
, c6 F2 i- E6 {8 {# Musing the standard of Greulich and Pyle at a chrono-9 W) D1 @7 W, Q5 ~7 d& \
logic age of 16 months (advanced).5 Chromosomal
. O- K4 L* _3 M, z  n  [karyotype was 46XY. The thyroid function test
) p6 `3 U' N5 vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: |: I$ `: D( b/ I  S2 [
lating hormone level was 1.3 µIU/mL (both normal).
  P- E6 U- ]# K8 U$ A, g; {3 [' nThe concentrations of serum electrolytes, blood
) _0 c. u# T. f5 P; Z3 j" Murea nitrogen, creatinine, and calcium all were
6 J" Z$ i& @0 f2 p# ~2 gwithin normal range for his age. The concentration
0 I. j! e% G  Q% Gof serum 17-hydroxyprogesterone was 16 ng/dL
1 r9 d% q& s1 T. k7 W" R& a% @! r(normal, 3 to 90 ng/dL), androstenedione was 20
" n/ j" t4 ?( ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ U6 e: Y" S$ `# s2 v" P3 U8 Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
- a4 c$ f  t2 |& x' J# y  w  C' Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to' u% S) q, T! A* V1 p" o
49ng/dL), 11-desoxycortisol (specific compound S)3 H$ p: F$ G$ i, I( k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- C6 Z- o/ P; u; \- E/ e" Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 v2 n0 ?3 f* J& Y+ r+ z* w) m" ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 a0 h+ C( o9 Z* d
and β-human chorionic gonadotropin was less than* \* F  A9 u+ K
5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 G3 {' B( z3 V3 M# W6 |stimulating hormone and leuteinizing hormone
9 s4 \, x/ P, H% b% o" Mconcentrations were less than 0.05 mIU/mL* z" [! T( v% x: y+ j" F% X
(prepubertal).8 n5 r0 l# M7 G& U5 h: Y
The parents were notified about the laboratory
- V  E* `5 ~  [* n7 i8 `+ presults and were informed that all of the tests were! E1 Y% _& N+ B3 f1 [9 A& B
normal except the testosterone level was high. The
, x) _: w$ E" `1 Gfollow-up visit was arranged within a few weeks to" a* P% g' V# q6 }
obtain testicular and abdominal sonograms; how-
$ y2 t9 j4 G+ D  Z( B0 }6 v& L; |. `ever, the family did not return for 4 months.
) B- \0 n" g3 Y/ S, c9 i3 w& EPhysical examination at this time revealed that the
; ?, ~0 E% Q0 ]) ^5 gchild had grown 2.5 cm in 4 months and had gained
2 o! K4 u0 G5 b* ~8 z& V# N7 O) E2 kg of weight. Physical examination remained% q+ S# A* _$ g$ l  X% Z; D
unchanged. Surprisingly, the pubic hair almost com-
: K) z: s  c* I0 O8 m8 v; l9 Upletely disappeared except for a few vellous hairs at
' U* l+ |% ]% l+ _the base of the phallus. Testicular volume was still 2# G6 P' q1 Y' m# y6 z, G
mL, and the size of the penis remained unchanged.
! B- `+ x1 F, h( h! h  I- yThe mother also said that the boy was no longer hav-
5 g3 C  q$ G, E1 }4 W  o/ Xing frequent erections.% o* K9 a0 J' G
Both parents were again questioned about use of3 U' K" O! _- s" e  Q- ^
any ointment/creams that they may have applied to+ T& B# `: A- F8 V
the child’s skin. This time the father admitted the7 n+ `4 t1 Z& v5 b0 n
Topical Testosterone Exposure / Bhowmick et al 5411 ^3 K& v  r2 I  _' |/ Z  i
use of testosterone gel twice daily that he was apply-$ O0 Y: g& o( h
ing over his own shoulders, chest, and back area for
3 M7 U2 c: _$ z( Qa year. The father also revealed he was embarrassed& w" A( }: F( }: _
to disclose that he was using a testosterone gel pre-
4 ~! \% G# r, Z# Uscribed by his family physician for decreased libido
1 S3 k% m: D. g; o( qsecondary to depression." z6 J/ Y% g# U8 I
The child slept in the same bed with parents.* F4 X1 a, s8 T6 K# [4 K: a! o
The father would hug the baby and hold him on his5 n; l4 i0 `5 f; f
chest for a considerable period of time, causing sig-
5 E& Z$ J7 T) pnificant bare skin contact between baby and father.% K1 ?! q; L, i4 S; _) g, r
The father also admitted that after the phone call,
- U+ m5 @1 v; p; N6 w% Kwhen he learned the testosterone level in the baby
) G# @" ^2 h/ ywas high, he then read the product information
+ r; k& y3 k( B1 opacket and concluded that it was most likely the rea-
( U4 s2 B6 e6 [- S# v+ w9 F. |son for the child’s virilization. At that time, they
! B0 y1 O7 F8 i/ ^decided to put the baby in a separate bed, and the! C4 Z' U/ E, r9 ]: {
father was not hugging him with bare skin and had
* M- c0 ?. I) ubeen using protective clothing. A repeat testosterone: B, Y" M6 L# L+ A" d. Q6 T8 D0 @
test was ordered, but the family did not go to the
7 G- }2 C2 A. s8 Q9 K" ylaboratory to obtain the test.6 P: B! C" ^  p6 _
Discussion  }; U+ x4 Z; c
Precocious puberty in boys is defined as secondary$ q* c$ @8 u7 U
sexual development before 9 years of age.1,4* T, |5 A3 @# q% C; O
Precocious puberty is termed as central (true) when" M; [+ ^- {" D/ n* W
it is caused by the premature activation of hypo-
' O; w1 L  H/ S! x3 e9 D& j/ [thalamic pituitary gonadal axis. CPP is more com-
; `# r9 f7 K- Z, s2 c, P% G+ u4 o$ Emon in girls than in boys.1,3 Most boys with CPP% }1 E" P" k3 }
may have a central nervous system lesion that is4 t$ z9 i% N* i. y# _* o" O1 H  u
responsible for the early activation of the hypothal-7 V" Y4 h- q$ C5 {; L
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 l  l. r, \, T( w9 a- Asis has been given to neuroradiologic imaging in
1 u+ R: r. Q1 k# k+ }, s9 X7 ]boys with precocious puberty. In addition to viril-
, u/ x: Q7 M' w7 @5 @ization, the clinical hallmark of CPP is the symmet-; ^! k# F, m% [
rical testicular growth secondary to stimulation by
; p8 [8 s4 z2 ?" B' j$ b0 X. Cgonadotropins.1,3; g* Q: Y) d9 P$ L" k2 b7 Y
Gonadotropin-independent peripheral preco-
+ Q/ I. Y3 _" o2 L% d0 C; V; vcious puberty in boys also results from inappropriate2 l; M+ P5 g" k3 p) p( _5 W
androgenic stimulation from either endogenous or
$ t$ p1 E; K& H  [5 e1 J1 |exogenous sources, nonpituitary gonadotropin stim-- c9 f2 Y; w, L  n) F: i8 T8 M1 S/ A& U
ulation, and rare activating mutations.3 Virilizing
! ^/ M+ h1 ^" E# s" m. A0 F# I2 Bcongenital adrenal hyperplasia producing excessive* [2 J) }( W! h* ~
adrenal androgens is a common cause of precocious' N' D; G1 _; T6 f( M
puberty in boys.3,4+ C5 U. [1 f2 f) O' P3 d) _. F
The most common form of congenital adrenal4 n8 T2 L7 E4 v: Q, ?- m. Z
hyperplasia is the 21-hydroxylase enzyme deficiency.: F5 H  V$ E( S: c/ T& i
The 11-β hydroxylase deficiency may also result in
5 G1 \2 U, O# Q9 j) m4 c2 dexcessive adrenal androgen production, and rarely,
- h# E& ]3 u/ ~! d# ]an adrenal tumor may also cause adrenal androgen
5 l0 ^' ]8 D9 l8 X- ^excess.1,3& z: P0 r+ c+ J$ c, G* u# A0 W- g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 B) @+ v. K2 e; j5 `! Q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 Z, p' r3 z% hA unique entity of male-limited gonadotropin-
0 F( _2 ?6 ~4 p6 tindependent precocious puberty, which is also known0 T. R% \; d: d/ a- ]
as testotoxicosis, may cause precocious puberty at a3 Y; ~" Y" z; K  ^: @
very young age. The physical findings in these boys
4 ^. E  t, \) a: v( B1 I+ F) wwith this disorder are full pubertal development,& B6 S0 k6 B& b: O" s0 ^
including bilateral testicular growth, similar to boys
/ Y$ U2 m5 Z- t  _6 Bwith CPP. The gonadotropin levels in this disorder! L) q; T  b' c
are suppressed to prepubertal levels and do not show
1 X3 ]) \) ]# S$ O- f, P% lpubertal response of gonadotropin after gonadotropin-
) @3 Q) d) A' s# o+ l: k" areleasing hormone stimulation. This is a sex-linked
& k9 b% F; o3 K3 y+ E- Qautosomal dominant disorder that affects only" r: _9 n% @8 N
males; therefore, other male members of the family
3 |9 K& l- ^% }+ O6 K2 f  emay have similar precocious puberty.32 R$ v5 r: `5 D3 x% |! j
In our patient, physical examination was incon-
! B1 a7 W2 d% X" x; [sistent with true precocious puberty since his testi-
0 ^- Z* }3 Z% c- `7 s, Vcles were prepubertal in size. However, testotoxicosis' `; {7 T$ S1 F
was in the differential diagnosis because his father
8 S( o5 r  ^. `) y+ estarted puberty somewhat early, and occasionally,4 w5 l2 T* n% [: X
testicular enlargement is not that evident in the
; @9 Y- i; Q8 e" G) |beginning of this process.1 In the absence of a neg-
$ S4 T3 _+ p4 N3 n, V: o, zative initial history of androgen exposure, our5 K- V% _% `2 `7 J8 B
biggest concern was virilizing adrenal hyperplasia,
0 L+ w% c2 P! Y$ Q" Yeither 21-hydroxylase deficiency or 11-β hydroxylase
! u: C3 x) a  t, \9 [2 j& Hdeficiency. Those diagnoses were excluded by find-- G5 f' w4 x' u  R4 R' ?
ing the normal level of adrenal steroids.
. ~7 y3 |; J  p6 b0 _The diagnosis of exogenous androgens was strongly+ A' Q/ u% E, V' A' \
suspected in a follow-up visit after 4 months because% s# W4 V6 |/ Q% a" y' ?
the physical examination revealed the complete disap-# G& P" W$ ?8 f; j' L& C
pearance of pubic hair, normal growth velocity, and
0 @+ {4 G7 G# {1 c8 [+ l( ddecreased erections. The father admitted using a testos-: p, H. U$ u9 _5 }2 j6 X/ @1 \
terone gel, which he concealed at first visit. He was
: Q% [) K- [: A1 d4 r9 Ausing it rather frequently, twice a day. The Physicians’
/ e5 n- m: B* \6 [# VDesk Reference, or package insert of this product, gel or
5 Z: ~- p$ `: M2 A% b  l# scream, cautions about dermal testosterone transfer to
: z$ a! O, @, Iunprotected females through direct skin exposure.  F% c" D. k& b8 D
Serum testosterone level was found to be 2 times the3 n' ]% f0 @- f/ [1 I3 W. L0 ~9 J
baseline value in those females who were exposed to8 v$ g3 Y/ j* x6 n' [; K
even 15 minutes of direct skin contact with their male
2 t1 ^9 ~! r) B5 R  Q2 epartners.6 However, when a shirt covered the applica-
' s, l6 x7 U( \/ Ftion site, this testosterone transfer was prevented.( Y. V+ U' ^8 X
Our patient’s testosterone level was 60 ng/mL,
) {6 ^4 r+ Z7 rwhich was clearly high. Some studies suggest that8 X% I8 X" l  Q, N; b2 d
dermal conversion of testosterone to dihydrotestos-
7 G- X! w/ g% p4 g3 Mterone, which is a more potent metabolite, is more
2 d( r* g, b9 s- lactive in young children exposed to testosterone
' U, N6 D5 f" ~5 u, fexogenously7; however, we did not measure a dihy-, q# J& Q" x  |- @9 r' g/ j
drotestosterone level in our patient. In addition to
0 \6 T; F1 Y' V6 f3 `virilization, exposure to exogenous testosterone in5 T/ R7 Z# B8 }+ r
children results in an increase in growth velocity and
/ W, H3 v3 G' H) \! O8 vadvanced bone age, as seen in our patient.
3 R2 u3 F5 f+ r' y- p/ J$ qThe long-term effect of androgen exposure during: P# ?& E/ t* |2 a2 [" _2 h5 U
early childhood on pubertal development and final4 \2 v/ g5 e$ o; N' \; l
adult height are not fully known and always remain
7 W, M/ N( L  v. Y; d; A1 f- la concern. Children treated with short-term testos-
2 X+ J( k3 p, W/ l  Q8 B1 nterone injection or topical androgen may exhibit some
1 ^* t# g# C; q; ~8 Y% Bacceleration of the skeletal maturation; however, after0 s; b0 m: b% {8 W
cessation of treatment, the rate of bone maturation
2 R. d+ R# x( Z# E  Y+ i. idecelerates and gradually returns to normal.8,95 m; @' X7 D9 h( p" n/ i' F0 U* o
There are conflicting reports and controversy6 X, Y% B, q5 n4 x# M: U  ~
over the effect of early androgen exposure on adult
+ c) ~9 {7 H8 M; Ypenile length.10,11 Some reports suggest subnormal
3 i; s. h) Z0 ^6 l0 Tadult penile length, apparently because of downreg-8 C2 p# D) v1 ]' x: O
ulation of androgen receptor number.10,12 However,/ d+ r* [0 R! Q" o" S7 Z
Sutherland et al13 did not find a correlation between4 S) }  _& e5 z, E  ^
childhood testosterone exposure and reduced adult
( e( Z) k( M) [/ S% h, x! L# s2 Openile length in clinical studies.
6 h2 F, {# X, ?4 m$ [1 u9 X& VNonetheless, we do not believe our patient is
/ M' j7 C/ N5 r9 \/ m6 F# Tgoing to experience any of the untoward effects from
3 p* r* I. T! u1 ktestosterone exposure as mentioned earlier because
7 O- d: w  V% h* P$ Z; w8 fthe exposure was not for a prolonged period of time.2 k" X/ Z% _  c% W8 T+ P
Although the bone age was advanced at the time of
; \% X% v. K) \+ ldiagnosis, the child had a normal growth velocity at
3 {+ I: f! C7 Z4 f* @the follow-up visit. It is hoped that his final adult
3 i, o. o& T. r; fheight will not be affected.- W3 t2 k4 z1 w0 Q' j
Although rarely reported, the widespread avail-/ F* z  Z# p+ v1 j
ability of androgen products in our society may
  ]6 V  p9 W1 t( Hindeed cause more virilization in male or female
+ a% f. y6 _# ]& O# Jchildren than one would realize. Exposure to andro-- |" U# U  I& D9 k
gen products must be considered and specific ques-
3 K6 R8 Y; O: L, H- T( c: C" ptioning about the use of a testosterone product or
! L" I+ F, `5 B7 a# B5 |gel should be asked of the family members during
9 ^( h3 L  _: f0 |7 R! Uthe evaluation of any children who present with vir-, F# H! p; t% d
ilization or peripheral precocious puberty. The diag-$ D% l% y+ L: t  t
nosis can be established by just a few tests and by2 l9 k% q; L7 Z/ {: e( l
appropriate history. The inability to obtain such a
6 P1 r4 h2 u# {" m. K2 Z9 T, Khistory, or failure to ask the specific questions, may5 D1 Q! ~, D: ]; B4 N/ M
result in extensive, unnecessary, and expensive
2 d: w) j- @2 T  F( {: _' e  Xinvestigation. The primary care physician should be
+ h( i* `+ d* i$ Oaware of this fact, because most of these children4 [2 a. H* t& W4 y% ?! t
may initially present in their practice. The Physicians’7 q$ M. u& A& Z8 `8 G# ]* a9 F
Desk Reference and package insert should also put a7 v) h" y7 @; X- G) W% Y
warning about the virilizing effect on a male or
* K3 [# T7 V/ r9 P7 z  F9 o% efemale child who might come in contact with some-
6 a; i9 H, c7 z" {; oone using any of these products.* g" p& `9 d0 r/ I6 r
References
2 i+ m, y- V/ G  m1 G0 s1. Styne DM. The testes: disorder of sexual differentiation% W) `/ ]) V& L! [
and puberty in the male. In: Sperling MA, ed. Pediatric4 C. @3 @, z) y# m8 i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( ?4 Y# }% D( c  O8 Q( |2002: 565-628.
( G1 r/ C; v5 E2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 r$ q. ]* u( ?! V6 j
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
& _7 B: w5 M* L2 g: c# E1 o/ }Boy Induced by Indirect Topical3 o) F1 ]. B: r
Exposure to Testosterone3 z& U" `3 p! n, q4 K) r
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" a0 g, O+ ^& h6 V6 n( s  B
and Kenneth R. Rettig, MD1& x0 s/ q) s  a) Z+ C9 V8 a+ s
Clinical Pediatrics8 b! \  Q& n# g' A! A) x/ Y. ~, H0 |
Volume 46 Number 6
' ]: C7 B: {1 f4 H2 s; H7 U2 VJuly 2007 540-543
5 K9 U" N" w3 r5 T© 2007 Sage Publications7 w" C" o# ?' v3 L9 w: G, q
10.1177/0009922806296651# k* e0 N2 p# ]7 r
http://clp.sagepub.com) x! m; c; e/ r* x" E( ^
hosted at$ V5 z& B( i4 f) m. t
http://online.sagepub.com
; j4 V- e, c; r' ?0 F: RPrecocious puberty in boys, central or peripheral," @; J# Y/ P8 g: P( I; x
is a significant concern for physicians. Central$ t4 k/ X3 r* v
precocious puberty (CPP), which is mediated+ p3 m$ z5 m. X9 f* `8 `* f
through the hypothalamic pituitary gonadal axis, has) w  Y! ]+ K/ A+ V% v
a higher incidence of organic central nervous system
7 ?* O  ~: o2 [4 U7 flesions in boys.1,2 Virilization in boys, as manifested
  T& f' X' t/ c! o2 Lby enlargement of the penis, development of pubic
+ L8 {, C. |4 `$ g% \: \( V# ]5 D6 ihair, and facial acne without enlargement of testi-
+ |" v6 |3 }( N) M5 Rcles, suggests peripheral or pseudopuberty.1-3 We
0 H/ k2 b2 {3 Y. ~3 c/ _report a 16-month-old boy who presented with the( C6 A  ~6 `3 D1 w* @
enlargement of the phallus and pubic hair develop-! T& _6 `$ D  G% P5 J$ Y$ R
ment without testicular enlargement, which was due
; c+ d% a8 F3 I5 v' {' |7 Ito the unintentional exposure to androgen gel used by/ s( R, Z' V5 V& \+ T8 ?3 P
the father. The family initially concealed this infor-
6 `% `. F, G+ \5 G) P! m+ Y6 a+ ~mation, resulting in an extensive work-up for this
6 O* \& ~% G" |* `) Ychild. Given the widespread and easy availability of) T6 n) ^7 J+ e4 g0 i/ }8 O
testosterone gel and cream, we believe this is proba-% Y3 k! q' Y: M# T" _
bly more common than the rare case report in the
2 L% i# [" ]1 J1 k8 s, |( q* rliterature.4
3 e8 y$ C9 I5 KPatient Report% P: j9 F1 ?" D7 s- [7 r4 s
A 16-month-old white child was referred to the
. m2 ], h% I4 R9 uendocrine clinic by his pediatrician with the concern
3 j' W7 G$ A/ ^' ?. eof early sexual development. His mother noticed
: O, ]9 k* Q* b* `+ Q' |light colored pubic hair development when he was
3 R1 A% `) U- A- ?From the 1Division of Pediatric Endocrinology, 2University of
! C! C# B1 g: j$ uSouth Alabama Medical Center, Mobile, Alabama.: t0 r. D1 Z) g7 n5 J  f, a
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 D5 R7 a4 J7 C' m( `6 `Professor of Pediatrics, University of South Alabama, College of& n) k6 ?, F4 ~2 b$ B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ I) f) [% X+ R6 F& l
e-mail: [email protected].8 x& a5 `# ]; B: c$ r) g
about 6 to 7 months old, which progressively became9 t& w$ z0 V3 c) B
darker. She was also concerned about the enlarge-: g4 Q% O% W+ t# \; w0 w0 S
ment of his penis and frequent erections. The child
' f1 j' e2 V# \8 ?, t" |was the product of a full-term normal delivery, with- p% X* X3 x, ~% `! F
a birth weight of 7 lb 14 oz, and birth length of2 L8 o$ S4 t; Y: n
20 inches. He was breast-fed throughout the first year8 B7 g( F* g7 c( L( E5 e
of life and was still receiving breast milk along with
( f) |9 G/ G! s. p; V8 Fsolid food. He had no hospitalizations or surgery,
/ @: V9 u6 S3 q, band his psychosocial and psychomotor development/ L' J3 C. ^* H. V0 d8 t- E
was age appropriate." V7 d) z% q' N7 X: V) n
The family history was remarkable for the father,0 v% D+ ^( w& ~
who was diagnosed with hypothyroidism at age 16,
" F( @- ~; J" r0 k1 ywhich was treated with thyroxine. The father’s
) N3 L: P  f5 V& R6 u, ~height was 6 feet, and he went through a somewhat5 a5 R& J) a. t9 D) T
early puberty and had stopped growing by age 14.
+ V$ F/ k/ i& t- e6 O% rThe father denied taking any other medication. The
* ?0 A* g% f  I" {! y8 Echild’s mother was in good health. Her menarche
$ H! }$ G" W$ ~7 b/ Xwas at 11 years of age, and her height was at 5 feet
( r) \1 E* d! I' ?6 }7 [/ c: X5 inches. There was no other family history of pre-
. r7 I6 a2 n/ }, wcocious sexual development in the first-degree rela-
4 \/ h0 T( J8 Q) Y1 J0 g  itives. There were no siblings.
* @" v/ H# F8 E( y. ^4 f$ A* MPhysical Examination
+ ?' |- L+ D0 C. {The physical examination revealed a very active,
1 c5 L  P0 z* \! t7 T) kplayful, and healthy boy. The vital signs documented7 q, b5 b3 M8 P4 T2 ~
a blood pressure of 85/50 mm Hg, his length was: m4 ?' G0 ?4 c3 c5 B) l
90 cm (>97th percentile), and his weight was 14.4 kg7 O. A" \  e6 L! H9 ?
(also >97th percentile). The observed yearly growth  k% q7 T9 H0 |4 A+ h2 H& u- n4 h
velocity was 30 cm (12 inches). The examination of
& H5 K1 Z1 r) ^/ Tthe neck revealed no thyroid enlargement.
; m, y1 m7 H4 x1 tThe genitourinary examination was remarkable for; V. @  Q2 D! Y# i2 `- n* t
enlargement of the penis, with a stretched length of; `( K3 ?& r& g; R" A" x
8 cm and a width of 2 cm. The glans penis was very well0 B, V4 |! d6 \6 {
developed. The pubic hair was Tanner II, mostly around1 ^$ R; G3 r1 V# C
540! @) }: {* Q! ]6 r' Q. k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. b6 z( j# F; [4 B3 O6 `& @the base of the phallus and was dark and curled. The
; C# G9 i/ \" V) j0 a2 gtesticular volume was prepubertal at 2 mL each.; a; |3 ^$ O& f8 \% Y  F
The skin was moist and smooth and somewhat1 a& d* ]) W6 P' U" |( h# }& L
oily. No axillary hair was noted. There were no) p* _9 ~3 T' k
abnormal skin pigmentations or café-au-lait spots.( }8 F/ p, z. J/ l2 g6 E
Neurologic evaluation showed deep tendon reflex 2+
; p# T; C; {  N0 I# f  @, bbilateral and symmetrical. There was no suggestion
5 |, s5 s- c+ Aof papilledema.
0 ?/ @7 S, Y/ Y3 F. ZLaboratory Evaluation0 p2 q: v$ k1 `; }" B
The bone age was consistent with 28 months by) ^; Y9 R( u9 n6 `9 ~. u: A
using the standard of Greulich and Pyle at a chrono-( `3 G  v& x' \) p5 \
logic age of 16 months (advanced).5 Chromosomal
* {( J: X3 b$ X7 `- ^% ckaryotype was 46XY. The thyroid function test
$ @( o# x9 M9 sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 k5 \1 E3 ^, I- `9 |lating hormone level was 1.3 µIU/mL (both normal).6 V+ `) r: v2 t2 C, n) S, A
The concentrations of serum electrolytes, blood
. a) a. Y. n4 d) ^! E6 ^urea nitrogen, creatinine, and calcium all were
$ x2 M8 M% ]0 {  E; S) Twithin normal range for his age. The concentration( c7 A# K0 ]" s$ t4 S' v% x
of serum 17-hydroxyprogesterone was 16 ng/dL
3 }- T( P4 ~1 k( Z7 L& E7 f(normal, 3 to 90 ng/dL), androstenedione was 20
8 |, k/ t4 N8 Vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% P" l7 Z2 I* D5 b* F  d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 Y* v- B3 l+ j
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 {# p& N  w5 p4 o0 @49ng/dL), 11-desoxycortisol (specific compound S)
" }% i  N7 n  S- T/ s) x3 ?* z: o6 @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! q" Z6 u: S" g( ]" _tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( z. a" {! D) e1 |5 _' |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! d9 I* c' b4 S7 H. h! o
and β-human chorionic gonadotropin was less than
1 n) W$ L4 G' e1 i" K, W0 w% ~5 mIU/mL (normal <5 mIU/mL). Serum follicular
* V4 B: J/ c' w: {stimulating hormone and leuteinizing hormone/ |, C, o1 W1 p: ^% i5 K
concentrations were less than 0.05 mIU/mL
6 s+ f: N0 L- o/ {7 ?(prepubertal).
5 x0 {" [2 ~8 O  L; ]' e. |# K1 JThe parents were notified about the laboratory4 u! p& P% P( T8 {+ b
results and were informed that all of the tests were2 Z" ~0 G5 w# G# D* r
normal except the testosterone level was high. The, i9 a( C+ x& I! _/ O% G4 t; ~9 W
follow-up visit was arranged within a few weeks to
. X. m% w, ]( qobtain testicular and abdominal sonograms; how-
$ e3 L' w# G3 @ever, the family did not return for 4 months.
! |" X* j" r$ T: K, VPhysical examination at this time revealed that the
8 H7 ^4 S6 ]* P3 D: {+ [# kchild had grown 2.5 cm in 4 months and had gained! E1 _" Z: s: p) [! F
2 kg of weight. Physical examination remained7 V  b. M% }" q- X$ u
unchanged. Surprisingly, the pubic hair almost com-) N' z% z* B( y& S: N
pletely disappeared except for a few vellous hairs at  K( q6 x% h& @8 T; x: O, u
the base of the phallus. Testicular volume was still 2! o& c" }6 D8 E
mL, and the size of the penis remained unchanged.
4 w& z( w+ R/ b- M# ~# c/ tThe mother also said that the boy was no longer hav-  q& N& m' |* R8 n+ z: j
ing frequent erections.
$ D) v7 ~  r7 g  ^+ g1 LBoth parents were again questioned about use of
, k4 M9 e8 w' q+ i& y7 H/ kany ointment/creams that they may have applied to6 [# V% E7 c: K2 F2 S) o
the child’s skin. This time the father admitted the
4 `/ e( o( E# L( XTopical Testosterone Exposure / Bhowmick et al 541
* R; B2 G& P+ c. Ouse of testosterone gel twice daily that he was apply-
/ V. n, O% q3 ?7 \1 Ging over his own shoulders, chest, and back area for
. {2 b9 g' U1 U0 T) M8 j6 P) O, }( Ma year. The father also revealed he was embarrassed
% x; _' ?  N! r8 ]2 s/ Tto disclose that he was using a testosterone gel pre-1 N, f, X! S# R8 j0 W
scribed by his family physician for decreased libido
" Y7 s& a2 z, Asecondary to depression.
' P" w" a9 T3 ?5 N/ cThe child slept in the same bed with parents.
! @+ A! F* N7 f7 i" CThe father would hug the baby and hold him on his
, B- d' L3 Q" i! y5 M) C# wchest for a considerable period of time, causing sig-
1 }% }0 ~! X. V5 F) P" J! `nificant bare skin contact between baby and father.+ v- K; `2 a- l. H
The father also admitted that after the phone call,# z! n* ?- D4 T# q" x4 U0 h. |
when he learned the testosterone level in the baby
3 B; G7 M' I. Vwas high, he then read the product information
) q  C3 \% f$ t( O8 ppacket and concluded that it was most likely the rea-
9 ], e6 `- B9 fson for the child’s virilization. At that time, they
7 U* V5 r! t: o2 `4 H& \decided to put the baby in a separate bed, and the" Z, B9 V% \! N
father was not hugging him with bare skin and had
2 u2 D+ I; m) \been using protective clothing. A repeat testosterone! A0 l5 f0 s& P7 X$ K$ w
test was ordered, but the family did not go to the7 r% ]8 C+ Q  T1 a& X9 o% w2 k
laboratory to obtain the test.
6 U7 x1 V0 o7 _7 }) B# g) {, \- aDiscussion/ m. u& T0 g& G1 T" p$ R9 h( u& O7 y
Precocious puberty in boys is defined as secondary
0 q, S- Y( d, j1 k+ Z2 fsexual development before 9 years of age.1,4
& ^# L- r# W# {) y( \# P" `' ?3 R0 pPrecocious puberty is termed as central (true) when
* x4 b7 a, I) E& Git is caused by the premature activation of hypo-! W1 K7 L9 F. j
thalamic pituitary gonadal axis. CPP is more com-5 w  u$ R0 t& X+ q: ]
mon in girls than in boys.1,3 Most boys with CPP
3 y; r5 m7 c# g+ zmay have a central nervous system lesion that is8 u4 Y1 {( k. z& F
responsible for the early activation of the hypothal-! |9 J. x9 o4 u( J% n) e6 Z
amic pituitary gonadal axis.1-3 Thus, greater empha-" ?0 l" s4 z2 ~/ }: A, u/ \
sis has been given to neuroradiologic imaging in
* Q1 ^9 E7 W) q& j" N9 Cboys with precocious puberty. In addition to viril-
% a5 w" T! r8 j4 P* sization, the clinical hallmark of CPP is the symmet-
7 Z  J' u7 s- ?- C; Brical testicular growth secondary to stimulation by/ C- L3 k9 W7 z6 J4 S
gonadotropins.1,3- y+ }0 [/ O" e& j
Gonadotropin-independent peripheral preco-
8 t7 j3 g5 y. S( Gcious puberty in boys also results from inappropriate+ a7 ^7 i* E/ k( s# @5 y6 q9 o
androgenic stimulation from either endogenous or8 x( Z5 k2 z* [' ~0 w; u
exogenous sources, nonpituitary gonadotropin stim-
0 {4 K, O/ M6 v- A0 W4 `ulation, and rare activating mutations.3 Virilizing( X+ i; v- }' Z  x6 y5 |2 N; I6 W
congenital adrenal hyperplasia producing excessive- Z* j9 e& X1 h% e' z& p% l+ c
adrenal androgens is a common cause of precocious* p; u) V# h: k; e! s0 X  q
puberty in boys.3,4
7 A! n/ Z' D+ M4 j/ k* t$ [The most common form of congenital adrenal
+ V0 U2 K: T( x+ P/ \! B4 Z7 Xhyperplasia is the 21-hydroxylase enzyme deficiency.
; E7 J+ V9 b* U. {1 n4 |: k. M# YThe 11-β hydroxylase deficiency may also result in
. X. `5 j( a3 f) iexcessive adrenal androgen production, and rarely,2 Q- W& W' d% t3 R
an adrenal tumor may also cause adrenal androgen7 M& E+ W6 G( l5 D
excess.1,34 T- f; U) @& K+ N5 c$ x% _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; J: T( x% c& _3 x0 g0 y: b
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 H) J" G. `! Y) e7 G
A unique entity of male-limited gonadotropin-# S/ r# ?1 a2 }  b" _; O# _
independent precocious puberty, which is also known3 g: ?/ f1 }. x, k
as testotoxicosis, may cause precocious puberty at a
7 `4 s5 P4 @( I9 o3 O, gvery young age. The physical findings in these boys$ T1 d* A0 G; m7 f
with this disorder are full pubertal development,: e8 `; V2 n: {) K1 d
including bilateral testicular growth, similar to boys
# C0 V% }4 R; [: w& ^4 z7 c/ W8 D1 ]with CPP. The gonadotropin levels in this disorder
" c0 N8 D8 h0 }! R# nare suppressed to prepubertal levels and do not show7 u6 i3 M7 Z( ~8 C
pubertal response of gonadotropin after gonadotropin-  m% \! t; z' w- |3 O3 R+ ]
releasing hormone stimulation. This is a sex-linked
8 C7 W- }7 |7 M, i. }autosomal dominant disorder that affects only/ b! A8 r! }% c; T- X
males; therefore, other male members of the family
! G; H) r. l, P- R8 Y- mmay have similar precocious puberty.31 S7 ~6 [8 U" S' U; {$ G& c
In our patient, physical examination was incon-
6 b3 ?( e8 C) Q" hsistent with true precocious puberty since his testi-
/ P  F4 e3 I1 \1 w6 M# K. j  g$ @cles were prepubertal in size. However, testotoxicosis
' Z8 T. t$ ?. Swas in the differential diagnosis because his father( b) P; x% P# F% d, t2 x
started puberty somewhat early, and occasionally,
/ N8 \/ m; y4 Etesticular enlargement is not that evident in the6 o- v% n5 ^4 b+ t' z- T
beginning of this process.1 In the absence of a neg-. E7 f. `; Y$ F( A# M
ative initial history of androgen exposure, our8 e$ M- O2 I9 ?  e; S3 C; e
biggest concern was virilizing adrenal hyperplasia,( d1 B$ K& Q  q6 o; \; e
either 21-hydroxylase deficiency or 11-β hydroxylase. J2 e  ^" r; P' A- Z$ |
deficiency. Those diagnoses were excluded by find-% c$ O0 `  {( X+ @5 ~
ing the normal level of adrenal steroids.  @/ D; x9 f! J
The diagnosis of exogenous androgens was strongly
- b! y* G3 M; ~+ R% B8 ssuspected in a follow-up visit after 4 months because
. X( Z7 M) T4 gthe physical examination revealed the complete disap-
, S0 J/ P9 H* J* h! W+ @pearance of pubic hair, normal growth velocity, and- Y3 |1 g2 y8 Y0 \- I1 `
decreased erections. The father admitted using a testos-! X; s! J* m* c" D4 a
terone gel, which he concealed at first visit. He was
4 m1 h" U$ D; e- B, u& q3 zusing it rather frequently, twice a day. The Physicians’
* }: [! v* a8 U0 N% ~% VDesk Reference, or package insert of this product, gel or
: W5 e& q' d6 x7 G1 M0 bcream, cautions about dermal testosterone transfer to
! c9 H; g' L- b% c: O" junprotected females through direct skin exposure.8 Z+ K% w: z! F
Serum testosterone level was found to be 2 times the; ~4 J' d7 J4 L1 ]! A0 b6 L1 t$ f
baseline value in those females who were exposed to
$ M$ `; U! F2 veven 15 minutes of direct skin contact with their male2 C. U; C" M& h2 X1 Q# S, O# [
partners.6 However, when a shirt covered the applica-
- Q. [9 C4 v! [' h4 qtion site, this testosterone transfer was prevented.
. b2 o! O+ ~5 }Our patient’s testosterone level was 60 ng/mL,: q2 Z) M$ Z& R4 k! w/ Q2 x* d
which was clearly high. Some studies suggest that. @7 C0 \) b6 E7 \  p: n- Q2 @& s; m
dermal conversion of testosterone to dihydrotestos-2 K: }5 ~. d( i: `% B- f
terone, which is a more potent metabolite, is more/ z7 A6 Z1 f4 R# h& p
active in young children exposed to testosterone4 Q0 W, N0 x% G; H, R7 ^
exogenously7; however, we did not measure a dihy-
! b4 E" s2 _4 b' Cdrotestosterone level in our patient. In addition to
3 Q# n4 I- ?& k* @- u8 m( ^9 O6 Avirilization, exposure to exogenous testosterone in
! ]" u7 |7 t5 m+ s: d9 l3 u$ R: @children results in an increase in growth velocity and' c, W9 z9 M* ^6 M6 s4 K
advanced bone age, as seen in our patient.
4 k9 n! \. ~: A# \The long-term effect of androgen exposure during9 M! [% ]4 L6 D, v% i% C& R: ^
early childhood on pubertal development and final! i, {' V( ~. u
adult height are not fully known and always remain
& e3 o5 h. i1 ]  W) `a concern. Children treated with short-term testos-4 z, t8 S* r5 m& U/ ?
terone injection or topical androgen may exhibit some
! u  I! v) F/ [% E' {* Cacceleration of the skeletal maturation; however, after
: X. N& h1 @8 x1 P. xcessation of treatment, the rate of bone maturation
# W' K9 A( u) \% R, s, Rdecelerates and gradually returns to normal.8,9
7 @1 c1 j9 ?/ F9 S" GThere are conflicting reports and controversy
' s' L# [: T$ c; G4 ~0 Uover the effect of early androgen exposure on adult
) W. w+ r( a- L( gpenile length.10,11 Some reports suggest subnormal+ D; B; U" h% h0 I8 ~- N1 x3 e
adult penile length, apparently because of downreg-. G: @: L. x9 [4 C
ulation of androgen receptor number.10,12 However,
) e! I2 X# o. }! }/ k/ w+ H# }Sutherland et al13 did not find a correlation between
, a& A2 `/ {" a, kchildhood testosterone exposure and reduced adult
! [1 ]1 J& x  y/ `+ rpenile length in clinical studies.' b! F& H; p0 d1 X8 y7 W5 I
Nonetheless, we do not believe our patient is% x8 O9 V. X4 r/ [
going to experience any of the untoward effects from; ~( k$ ^* w( p8 x( m: q
testosterone exposure as mentioned earlier because$ A4 N) U: U/ Y1 F* u" j1 a# K
the exposure was not for a prolonged period of time.
# K$ ^. n* R/ U- q' U. kAlthough the bone age was advanced at the time of+ M2 t1 B1 H; Z# Y$ S
diagnosis, the child had a normal growth velocity at3 N$ f+ `0 a2 x) `) b) b0 p
the follow-up visit. It is hoped that his final adult! {% s5 Q- I9 ^* u# l% N
height will not be affected.9 {2 [& `6 v, u- |( n8 ^7 D; \7 j
Although rarely reported, the widespread avail-" ?- ~: m) t& A4 M  ?9 m) [' f
ability of androgen products in our society may/ V  Z( P0 m$ n0 R, h  ~3 j
indeed cause more virilization in male or female$ X: U+ N, V7 ^3 K! U1 C- I6 r' ?$ h: P
children than one would realize. Exposure to andro-
6 z; ~9 c0 z7 c8 V- ngen products must be considered and specific ques-
- Z/ i+ n/ ^- a% w0 y! ztioning about the use of a testosterone product or( O  a( l! d9 ~3 z; A; _5 d
gel should be asked of the family members during
& |1 j+ Q  e9 X( e# s) {7 V5 B$ `the evaluation of any children who present with vir-. X3 i0 ^  {7 V8 q- Z2 p) E/ e
ilization or peripheral precocious puberty. The diag-: _( A. t8 s1 f3 ^( Q8 i
nosis can be established by just a few tests and by0 }4 u. ~/ E+ Q% O8 P- u4 r
appropriate history. The inability to obtain such a6 u0 {8 q, A3 X9 b0 M( n
history, or failure to ask the specific questions, may
2 V- L- A8 u8 y: B, |) X1 _4 presult in extensive, unnecessary, and expensive  H6 Q; R( y2 F4 i( v0 F
investigation. The primary care physician should be
9 I1 \; U- `3 `, w. maware of this fact, because most of these children) R" _) [* Z: q0 W2 M9 G
may initially present in their practice. The Physicians’
; S2 j3 N' i6 I8 m( v* F0 [! R5 LDesk Reference and package insert should also put a
) U/ u: _$ P- i: F. b6 z7 [warning about the virilizing effect on a male or0 ^/ u# E# m8 \- `- @7 o
female child who might come in contact with some-
+ W9 B0 O" L# C7 mone using any of these products.
' i$ E- E% ?- TReferences
3 f" k! ^3 }8 W' r; ^! J1. Styne DM. The testes: disorder of sexual differentiation; d6 U: P; A+ ~
and puberty in the male. In: Sperling MA, ed. Pediatric
- a3 |* @- ~* pEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( J0 G; {. q# n# z
2002: 565-628.# c  C6 l+ N4 ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 J  d! u& p- G* P  P/ ipuberty in children with tumours of the suprasellar pineal
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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

6 I  I, `- g$ c6 K# N% d0 K, i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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