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Sexual Precocity in a 16-Month-Old) ^4 n$ }% ^4 ?
Boy Induced by Indirect Topical
2 K: W$ d( a2 E; pExposure to Testosterone
9 M5 U- v+ f9 `  }3 [% s) q7 \Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' [" V- j9 c* l5 eand Kenneth R. Rettig, MD1
9 b/ d# b2 {5 y/ r* p9 F2 RClinical Pediatrics1 S# t2 K9 t' a
Volume 46 Number 6
! B& ]* I1 s) t* i  zJuly 2007 540-543
) V" x! h' N. v( E2 g© 2007 Sage Publications
* s. n( [  N, m10.1177/0009922806296651
" w/ N& X; u! \  M% W4 dhttp://clp.sagepub.com
. i/ ]5 v& L- y3 Y; Ahosted at
+ _6 ]: {& |9 t% x/ D- V3 h0 M& bhttp://online.sagepub.com% Y$ M7 b2 ]' q
Precocious puberty in boys, central or peripheral,, t$ Y% h$ `. l
is a significant concern for physicians. Central
$ V, G: C! L5 o. b8 tprecocious puberty (CPP), which is mediated
# @  c7 \. @" fthrough the hypothalamic pituitary gonadal axis, has0 K5 {( B" c% y9 B. r7 W6 @/ B1 Y
a higher incidence of organic central nervous system
; D! k8 R( e2 {, ylesions in boys.1,2 Virilization in boys, as manifested
4 ]/ U5 A/ ^9 X" Q- @by enlargement of the penis, development of pubic
; ~, l; j" J! \hair, and facial acne without enlargement of testi-
8 n5 g6 R  F# K( Jcles, suggests peripheral or pseudopuberty.1-3 We+ f% N. c" j7 g
report a 16-month-old boy who presented with the
# l( F) Y$ D1 R: f( kenlargement of the phallus and pubic hair develop-! e- H- ^4 X& A- }5 Y
ment without testicular enlargement, which was due
6 z; u3 q1 o9 e. j# pto the unintentional exposure to androgen gel used by
' T! r5 v. @$ x  L, n1 ^7 |the father. The family initially concealed this infor-
* \! |; \; o2 j3 J  q# d$ t& {  cmation, resulting in an extensive work-up for this
; D- u) _7 X# Z5 ~# S1 Z6 `child. Given the widespread and easy availability of" D5 W+ E- _; W
testosterone gel and cream, we believe this is proba-' N8 R% e2 W' \9 s& ]
bly more common than the rare case report in the/ ]# T+ m% b; f' u" n" c
literature.4$ u0 f& Z% P, }1 A; j
Patient Report
* _$ [  N" E0 \% l& zA 16-month-old white child was referred to the% X( V' X1 h/ ]8 Y" s+ ?
endocrine clinic by his pediatrician with the concern
( s2 }) b& h* @' Q; Qof early sexual development. His mother noticed
9 M5 `5 A! j5 w& ~$ z# q! n5 jlight colored pubic hair development when he was
0 ]9 e5 e* A) t0 G6 F* ]$ BFrom the 1Division of Pediatric Endocrinology, 2University of
6 q: j& h% I) ], R# U! m/ A" cSouth Alabama Medical Center, Mobile, Alabama.
# c, O3 D4 l: ]& t1 s6 t0 BAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 |- c* n& r0 B9 I: q
Professor of Pediatrics, University of South Alabama, College of
$ w6 q4 B; i* lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 d/ y! b" P& q3 M% ^( H' q0 {e-mail: [email protected].) Z: t9 T5 r# ?& I/ f! x9 S2 k  }
about 6 to 7 months old, which progressively became* C) R7 b% ?. B* V& i' I+ X
darker. She was also concerned about the enlarge-
" W# b, F6 Y) M& ^6 {: y/ mment of his penis and frequent erections. The child
7 E+ k4 K- q; x5 Twas the product of a full-term normal delivery, with
! l+ P' R& U4 _3 D6 e" Oa birth weight of 7 lb 14 oz, and birth length of8 O* `1 ]) B4 z& a" l
20 inches. He was breast-fed throughout the first year
' j2 [4 ^9 h& [# i3 |1 d' Hof life and was still receiving breast milk along with% k- W* I4 ]; }5 }
solid food. He had no hospitalizations or surgery,
5 G2 v: ^9 S# ~2 a1 Q. fand his psychosocial and psychomotor development( g: F0 M' d9 |; I
was age appropriate.; P. L4 w5 U7 J* S0 d
The family history was remarkable for the father,  C3 ]$ M+ l! r. a& q* \0 K
who was diagnosed with hypothyroidism at age 16,5 t$ p( Z  `3 K8 T- F
which was treated with thyroxine. The father’s6 `0 F! ]- o' A; a% Y( t0 l  P
height was 6 feet, and he went through a somewhat* X3 @$ n$ J! @3 r' F
early puberty and had stopped growing by age 14.& S( G# v7 M. a1 V- B1 b
The father denied taking any other medication. The7 l: H' Y+ N, b* S9 i6 }* {2 }4 C( S
child’s mother was in good health. Her menarche
) \) ?+ F5 }! ^' A& pwas at 11 years of age, and her height was at 5 feet
2 m- _+ k/ f% a5 S! A5 inches. There was no other family history of pre-2 _. o9 c! _- c' I5 ~3 N' e# @: i
cocious sexual development in the first-degree rela-1 E( q5 F, Q; X, c4 L
tives. There were no siblings.
8 u5 c% T  a+ d5 h0 N9 |  e' h: dPhysical Examination
) o) ^( U+ V9 C& E& d2 E7 N! v; kThe physical examination revealed a very active,
' s2 {5 b$ L5 |, V. J6 @* aplayful, and healthy boy. The vital signs documented
& F% r/ }' G& r. p7 x3 L0 d% oa blood pressure of 85/50 mm Hg, his length was( V1 B) J, N9 F4 C' q
90 cm (>97th percentile), and his weight was 14.4 kg
) r: u8 ?" I# U' z(also >97th percentile). The observed yearly growth4 M5 @6 i6 m, c' X
velocity was 30 cm (12 inches). The examination of
% p& P4 {9 D  O, k, V  }the neck revealed no thyroid enlargement.
$ A# @  f. S+ K$ I+ UThe genitourinary examination was remarkable for
9 K+ u% l' Y8 Penlargement of the penis, with a stretched length of
6 G) v) t6 ?' n6 n! g; J8 cm and a width of 2 cm. The glans penis was very well) l2 e! l) Q5 P4 a) Q  K1 e
developed. The pubic hair was Tanner II, mostly around) l: T+ f" q$ k+ }3 R2 N! l9 n9 D
540
5 n5 I9 T7 ^5 [  A' ~  uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' m( O1 n# S! k2 ?
the base of the phallus and was dark and curled. The& {: k" u& J7 g0 k- z: e
testicular volume was prepubertal at 2 mL each.$ C' u  @; B/ y, Q$ o
The skin was moist and smooth and somewhat
7 t- C! T+ z& U: j- D4 eoily. No axillary hair was noted. There were no9 H  C7 N) _) X- K, ]+ u6 D
abnormal skin pigmentations or café-au-lait spots.: K$ @0 U5 d7 p$ J$ W- O4 l
Neurologic evaluation showed deep tendon reflex 2+
3 I5 ~: P6 n3 d- \5 y( b3 cbilateral and symmetrical. There was no suggestion
2 w, \/ G- v' O6 X8 N# cof papilledema.( C! P+ r% i; a% k" @2 S7 d* I+ Y5 p
Laboratory Evaluation
! H7 l0 z+ C( W1 ?) C0 v) G7 P( DThe bone age was consistent with 28 months by1 d0 N2 I3 V8 \9 f. C. C9 Z8 v
using the standard of Greulich and Pyle at a chrono-; p0 l/ U  Q7 @& m; Z  [
logic age of 16 months (advanced).5 Chromosomal3 p+ c* V7 M+ T
karyotype was 46XY. The thyroid function test
! C4 S1 z5 @, q. i+ I, U& H$ Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 {& ?3 H( q: T* {3 a$ Mlating hormone level was 1.3 µIU/mL (both normal).
5 Q+ X8 ^! W4 q5 H( S" q0 hThe concentrations of serum electrolytes, blood' Y  O( [* E  i. w/ B. P
urea nitrogen, creatinine, and calcium all were' i, H) Y' X6 p3 i4 A6 ~6 C
within normal range for his age. The concentration
% s; q  o7 i+ `  U- t+ i( |of serum 17-hydroxyprogesterone was 16 ng/dL! D9 `) i4 q' G- @0 L
(normal, 3 to 90 ng/dL), androstenedione was 206 _! E' f! p  k9 R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-  q! b  o. ?" r6 o$ R( a" ]' f/ W. h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 V5 `- R9 }0 H. Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 K: m3 Y: I3 f& a' R* S4 l- ^49ng/dL), 11-desoxycortisol (specific compound S)$ l4 R: V; K# y# D  d. F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% ?# t8 D  p  j2 j' X. a  u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- b& l3 @7 K1 c8 P  itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 X# \1 Z5 O5 M8 F0 }5 y6 Eand β-human chorionic gonadotropin was less than; E9 f2 f) @' o1 ?$ V* h
5 mIU/mL (normal <5 mIU/mL). Serum follicular
! d' i* C1 l- a2 Ystimulating hormone and leuteinizing hormone  v, p! ]: }& K1 E
concentrations were less than 0.05 mIU/mL) O' S* x6 p  s7 Z; B
(prepubertal).
, V' N' M2 e, L0 G& JThe parents were notified about the laboratory
* U$ q2 W! i& R9 E- K( Vresults and were informed that all of the tests were
1 k$ W6 |  }/ q6 Cnormal except the testosterone level was high. The
9 m' C! \5 f8 _: D- c1 r  Rfollow-up visit was arranged within a few weeks to
5 ~* N: k( w7 j9 q. M0 _& B( S. Eobtain testicular and abdominal sonograms; how-
( Z! a- s! a3 g' v+ S' e+ Kever, the family did not return for 4 months.
6 n9 g5 \, U% J) ]) GPhysical examination at this time revealed that the8 z' Q3 m1 X9 n. I0 g
child had grown 2.5 cm in 4 months and had gained; i& B; _1 G" q; S
2 kg of weight. Physical examination remained8 n+ U; k2 {# ^
unchanged. Surprisingly, the pubic hair almost com-3 |) o" l# `* z! `, ~; V% j
pletely disappeared except for a few vellous hairs at
! Y* w% @  j5 z- W, v7 g2 ithe base of the phallus. Testicular volume was still 2
' X; X: s; t$ o' g8 ]0 W8 ZmL, and the size of the penis remained unchanged.9 o; q" _2 k: O; Z; u9 A* ~
The mother also said that the boy was no longer hav-. E7 K3 G; w- p* c( n3 y5 e
ing frequent erections.
& m: ~; q! F+ k$ ?+ T* `! d- LBoth parents were again questioned about use of
* U* `! r, G- C* q) Aany ointment/creams that they may have applied to, K6 m- G/ f! K/ H8 Z
the child’s skin. This time the father admitted the
& s8 D/ R* {. i. R2 ]Topical Testosterone Exposure / Bhowmick et al 541, s; l- |- A  _2 Z
use of testosterone gel twice daily that he was apply-
; G2 E1 d  i$ `/ e& c6 H: L. king over his own shoulders, chest, and back area for& W% a( J3 m$ k9 h4 b1 b8 h
a year. The father also revealed he was embarrassed
  s' N# }. o) n1 @1 v7 q+ Fto disclose that he was using a testosterone gel pre-* Q+ W9 w# z6 C- @! Q( q
scribed by his family physician for decreased libido8 m. l0 \: c3 o1 N3 W9 T
secondary to depression.5 g0 e; {# R+ s1 n6 p$ N% h4 H
The child slept in the same bed with parents.
: q3 R6 l1 \$ N0 x7 AThe father would hug the baby and hold him on his
6 J$ N) g+ l( j1 h8 K! g1 ?chest for a considerable period of time, causing sig-
! U& r' `7 t  |* X( [. mnificant bare skin contact between baby and father.% g9 j4 B, m7 C7 |
The father also admitted that after the phone call,
4 W4 o/ Y" `- }7 B+ u' Gwhen he learned the testosterone level in the baby* J1 ?6 {" j/ w
was high, he then read the product information& s6 q. y3 _- D  [% E* _5 c; h
packet and concluded that it was most likely the rea-, u& j( Q- F! m; S5 f
son for the child’s virilization. At that time, they
0 D3 @3 r  P) h2 n4 Zdecided to put the baby in a separate bed, and the4 t  K3 m7 N$ T; R6 t* B
father was not hugging him with bare skin and had
+ Z% b- M9 V! }" l- Wbeen using protective clothing. A repeat testosterone
% b7 m: ]4 p& Rtest was ordered, but the family did not go to the8 q! s0 ?5 q  o8 v3 t
laboratory to obtain the test.
1 J. F7 Z" ?0 U& lDiscussion
' s5 s  g. S+ f9 N2 q6 vPrecocious puberty in boys is defined as secondary
0 H* a1 I' l/ Q* `' ^sexual development before 9 years of age.1,44 d' [3 o1 n* R+ b8 S$ i3 t
Precocious puberty is termed as central (true) when7 [) _7 V. N# F9 C) w" J; M# K2 M$ |
it is caused by the premature activation of hypo-: C7 y; e  W* P$ D
thalamic pituitary gonadal axis. CPP is more com-" H: |/ _1 R/ y' x$ i0 x: G$ P
mon in girls than in boys.1,3 Most boys with CPP% v7 y+ w$ b7 s0 J
may have a central nervous system lesion that is
  Q2 l0 ^- t4 Rresponsible for the early activation of the hypothal-( v# `; Q3 W+ T3 h7 ~% k4 d$ h
amic pituitary gonadal axis.1-3 Thus, greater empha-
! P3 W: F% x+ e+ \sis has been given to neuroradiologic imaging in4 I. W. q1 _" b! }+ L
boys with precocious puberty. In addition to viril-! p5 K$ R  v% D$ P8 S: a
ization, the clinical hallmark of CPP is the symmet-
9 q1 T0 j6 d8 `  k" {4 jrical testicular growth secondary to stimulation by
2 H  s' U$ ^" X) egonadotropins.1,3/ ?5 X% Y: X* y7 h
Gonadotropin-independent peripheral preco-
' W% p: x6 r  W2 K: h! _: ^1 k: O4 `cious puberty in boys also results from inappropriate+ B4 ^6 `0 _9 k' f
androgenic stimulation from either endogenous or
* b# U/ s! \: T* A$ s2 Rexogenous sources, nonpituitary gonadotropin stim-' L+ [0 {, p6 q' Z8 u+ Q
ulation, and rare activating mutations.3 Virilizing
) ]& K2 C) d; b4 A1 p( gcongenital adrenal hyperplasia producing excessive( r$ o; R9 Z$ l9 y- q$ W
adrenal androgens is a common cause of precocious
  a2 K2 B0 x1 }) X- S: a( ypuberty in boys.3,4; A: c6 }  e' \3 j% k4 E! _
The most common form of congenital adrenal
( F  j. S) V# y9 P. rhyperplasia is the 21-hydroxylase enzyme deficiency.
4 c8 ]: P2 t; @0 C7 M4 dThe 11-β hydroxylase deficiency may also result in
; _8 h8 [" d" {4 xexcessive adrenal androgen production, and rarely,
8 ^9 t0 b- g' jan adrenal tumor may also cause adrenal androgen
  B* ?$ M  b+ cexcess.1,39 o( n% G* j  @0 D, Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 C; I9 M. y" {! D3 w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- }$ s/ b. w! D) H$ _# X2 ZA unique entity of male-limited gonadotropin-
$ @- x0 C5 f# l# J9 }independent precocious puberty, which is also known1 \/ ^( R5 W/ J7 l' Q: h1 N( @
as testotoxicosis, may cause precocious puberty at a
3 g- M2 m* `/ }  H' s' e2 |very young age. The physical findings in these boys8 I. z0 C$ J  Y1 H# O7 M! @2 V
with this disorder are full pubertal development,
* s" `; t$ M7 x: Y5 ]& d1 I# g, k% cincluding bilateral testicular growth, similar to boys: n8 |$ F# |4 Q2 R# N$ p/ W
with CPP. The gonadotropin levels in this disorder; O8 ?/ g6 ^4 W* l1 ^
are suppressed to prepubertal levels and do not show# m1 n! U( X, p* T. `
pubertal response of gonadotropin after gonadotropin-
6 ?+ v# i4 d* T$ [3 ^! w/ xreleasing hormone stimulation. This is a sex-linked
. I$ R7 ]  |# i9 K! Tautosomal dominant disorder that affects only
- B% I) h1 _% M! G7 A! ]7 q7 fmales; therefore, other male members of the family4 Z: N2 _$ F7 P* M& r& G9 J' D
may have similar precocious puberty.3
7 k$ f4 ~  P4 d1 u! W3 RIn our patient, physical examination was incon-$ g  F( l; p- x% u
sistent with true precocious puberty since his testi-2 W$ ~! X" o: z- O/ e
cles were prepubertal in size. However, testotoxicosis9 S: u6 b+ n  o2 t
was in the differential diagnosis because his father( {; c+ V5 W' {' f
started puberty somewhat early, and occasionally,! u6 R: P5 Q8 L1 U/ d9 k$ f$ Z1 m- W& C
testicular enlargement is not that evident in the
# M9 {  Z+ H9 j3 m9 O" ^& bbeginning of this process.1 In the absence of a neg-
$ i4 V9 y1 y3 o; tative initial history of androgen exposure, our5 g+ g# @2 y+ W. w# X
biggest concern was virilizing adrenal hyperplasia,' o% V6 {, M3 X4 [! a8 u3 N8 E# h0 D
either 21-hydroxylase deficiency or 11-β hydroxylase3 I4 g& {% g# o5 i: p
deficiency. Those diagnoses were excluded by find-
& W2 Y4 L/ ~9 f( Ying the normal level of adrenal steroids.8 g4 @# Y3 v$ [* q) D
The diagnosis of exogenous androgens was strongly3 ~( Z3 V/ e1 Y' e7 C3 V
suspected in a follow-up visit after 4 months because% K! d; L1 m: O! D4 z
the physical examination revealed the complete disap-9 J( V. `- w, J
pearance of pubic hair, normal growth velocity, and
# h3 S4 N. O7 c- Y3 W/ s, [  r" odecreased erections. The father admitted using a testos-
8 p/ y7 v1 f& K+ Nterone gel, which he concealed at first visit. He was* F  n  |8 R# Q! K* ?- f( G5 `
using it rather frequently, twice a day. The Physicians’. c% _+ P0 W) q- E9 c8 D
Desk Reference, or package insert of this product, gel or
% t7 u1 \: \5 c3 L/ dcream, cautions about dermal testosterone transfer to4 F; G1 v" m) @: T4 P5 @5 p
unprotected females through direct skin exposure.% A& C0 d/ ?2 V2 p4 ~! J+ a+ A
Serum testosterone level was found to be 2 times the7 X& H* i, y" ^4 I9 m
baseline value in those females who were exposed to
, }) Z! |% {/ J3 d  z# E3 U9 meven 15 minutes of direct skin contact with their male; q6 V$ h$ Z3 u& E$ n1 \' E+ Q; J) F
partners.6 However, when a shirt covered the applica-& r5 U" n, [9 b& m  a' E* W
tion site, this testosterone transfer was prevented.
; _, O) A5 X1 H0 ?( xOur patient’s testosterone level was 60 ng/mL,
- J9 r3 [  l% Awhich was clearly high. Some studies suggest that
9 F! x/ N5 a, w. {  [6 Mdermal conversion of testosterone to dihydrotestos-
3 c4 B# a3 `) c! l% o# Nterone, which is a more potent metabolite, is more' A5 F! D3 m- w8 J" o7 t% B. {
active in young children exposed to testosterone
' z+ V+ s5 B0 `4 a) U2 y% Aexogenously7; however, we did not measure a dihy-+ m( i1 N4 c5 J) D2 K% {
drotestosterone level in our patient. In addition to5 l- l+ y; M2 i+ r
virilization, exposure to exogenous testosterone in& d6 R) I( f$ R: g, d# u
children results in an increase in growth velocity and1 `) r4 I8 a1 [2 C3 a+ u+ F7 t+ i# m  ]
advanced bone age, as seen in our patient.
( G" m. H6 ]! m2 n, J( N: I& a" }The long-term effect of androgen exposure during" Z: M* e/ t9 c# U
early childhood on pubertal development and final
3 C! g8 H- C/ B6 Nadult height are not fully known and always remain" M' S6 m. W% J  M* |7 f
a concern. Children treated with short-term testos-+ B- v" J% q8 r$ Q' m
terone injection or topical androgen may exhibit some
! _, h! l* f7 ?. O( ]6 [5 [acceleration of the skeletal maturation; however, after) m2 ^3 ]) V! F* Y! j
cessation of treatment, the rate of bone maturation- y: @5 z8 h& ?  o. O* j
decelerates and gradually returns to normal.8,9/ M' X4 w# B. }# O* D1 I* i
There are conflicting reports and controversy: {. {. C5 U1 Z/ ^9 q' ^8 G0 d
over the effect of early androgen exposure on adult4 z2 d. ^9 b; s8 i2 ?/ X' }
penile length.10,11 Some reports suggest subnormal
: h( i5 M7 i8 e' x  |- ~6 u( d/ R/ Tadult penile length, apparently because of downreg-
+ Y5 u& Q% _4 ^% N6 j" M  iulation of androgen receptor number.10,12 However,
$ k5 S9 S7 Y  C. F5 P4 A6 NSutherland et al13 did not find a correlation between
( b0 ^- k) [. k+ t' l; a& j' j' jchildhood testosterone exposure and reduced adult) Y0 [8 G5 ~/ W4 x' i$ f, ^( `) H
penile length in clinical studies.
% Z# K( A3 F7 U4 Z; w/ Y) A3 PNonetheless, we do not believe our patient is
& O( P. D* \9 O" T, J9 d6 Mgoing to experience any of the untoward effects from
4 N* u: X/ }! X, etestosterone exposure as mentioned earlier because
2 Q  C* g$ ]" ?$ H0 j* i5 [7 t; U2 `the exposure was not for a prolonged period of time.7 g+ O: E1 W8 Q: ~+ M( |
Although the bone age was advanced at the time of
3 x' p; e1 H" @& P( Kdiagnosis, the child had a normal growth velocity at
' H" C8 p: q  W' o4 H& Ithe follow-up visit. It is hoped that his final adult
* d( \& q  E1 R9 r% {height will not be affected.
$ E, V9 t6 j6 X  H- kAlthough rarely reported, the widespread avail-0 e) E6 L7 s" R6 Y; _, B
ability of androgen products in our society may
! h9 h* d6 L4 |' Oindeed cause more virilization in male or female; j" W# [/ C7 i3 V  e3 ~
children than one would realize. Exposure to andro-# H0 N$ H1 e' K
gen products must be considered and specific ques-) L# b; C$ r! g# Y% b
tioning about the use of a testosterone product or
4 b* x5 Y; U* ]* D% f4 g+ `1 Q2 [gel should be asked of the family members during5 g; _+ x* h. _+ B7 e" x0 i
the evaluation of any children who present with vir-7 o4 Q/ e8 f5 q( O& ^- h
ilization or peripheral precocious puberty. The diag-5 l# A* H; V. h+ i* b
nosis can be established by just a few tests and by
& x5 x7 |4 j. r! @2 xappropriate history. The inability to obtain such a4 K( R) S* s& S: N; K: Y  B  F
history, or failure to ask the specific questions, may1 J. \" y, ]& j( q( i% D
result in extensive, unnecessary, and expensive' t- G; v4 Y+ F
investigation. The primary care physician should be
! {* z6 ~% O) n4 gaware of this fact, because most of these children4 a* ]5 C$ ^: f4 @6 n% I5 ^; t) q
may initially present in their practice. The Physicians’) ?% h+ i" f* b) ^
Desk Reference and package insert should also put a6 [; I- y2 |3 J6 c" p4 H  n
warning about the virilizing effect on a male or/ ^, j8 L3 i- M6 J5 g- [
female child who might come in contact with some-& v! n( o6 H7 [7 _
one using any of these products.3 R1 L4 l) x  t5 a0 I% k
References& ^4 ^: V; V' D5 v% s
1. Styne DM. The testes: disorder of sexual differentiation* |1 A) o$ P9 d# ]% m- a% ^/ h6 e
and puberty in the male. In: Sperling MA, ed. Pediatric$ V! c( `+ Y" c0 M( s2 H
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 E7 V* ~$ t; T9 q
2002: 565-628.
% G0 k, w. u+ Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. ?# Z& S  v5 T0 |% Z. B5 W
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old$ s8 D* n8 w3 c( V: o/ e
Boy Induced by Indirect Topical6 \, y/ d8 L9 ?1 W; [* D
Exposure to Testosterone
% J6 P9 j( ?% j+ O7 rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! Z7 i# z' b; J% v3 J) w( n% Land Kenneth R. Rettig, MD1
: ?+ `& [) W$ m; z! C' B( HClinical Pediatrics. l: F1 i" x- S" k  w# T- m# m" j. k
Volume 46 Number 62 y, U+ V* m- _! k  }# z5 d4 H
July 2007 540-543
& z8 y/ r1 z, C. f( x© 2007 Sage Publications
" N' ~, W/ Z4 G) h% ?10.1177/0009922806296651
' S% n8 N$ b& C2 g: h+ W9 L8 v5 ]http://clp.sagepub.com0 k' M2 ]) W# J3 n( w( W7 ?* c+ n( I
hosted at/ H9 K/ G; o8 P8 j0 c! K
http://online.sagepub.com' A/ E' [" a% [
Precocious puberty in boys, central or peripheral,
3 ]3 j$ c0 T4 D8 zis a significant concern for physicians. Central/ _4 A. V% O, I* l
precocious puberty (CPP), which is mediated6 h1 U2 `! d+ y' |
through the hypothalamic pituitary gonadal axis, has
# ~5 r& J( }2 ]& \+ Za higher incidence of organic central nervous system
: w. Q0 O% s- K* m( ilesions in boys.1,2 Virilization in boys, as manifested
9 [$ a4 x6 u3 Y3 K% ]2 fby enlargement of the penis, development of pubic2 }* h! y6 }  y7 v+ R* j  C# u+ d
hair, and facial acne without enlargement of testi-2 t" Z4 ^) z+ c
cles, suggests peripheral or pseudopuberty.1-3 We
& k6 v9 M4 H2 V9 |. _) e) F: m( [7 Mreport a 16-month-old boy who presented with the
; F9 `! y1 X) h* |& oenlargement of the phallus and pubic hair develop-7 D/ W, C3 w! l9 _1 j1 t
ment without testicular enlargement, which was due
% u; j. w9 y% S6 S) wto the unintentional exposure to androgen gel used by
6 ]2 B4 q  M" ?the father. The family initially concealed this infor-  y5 P! a& I, q# _6 m8 d
mation, resulting in an extensive work-up for this
" ?# ]1 G# y1 t% @! h) }& S+ V) [child. Given the widespread and easy availability of. o" z2 a9 o% {: Y
testosterone gel and cream, we believe this is proba-
0 p1 i4 _5 P. _/ I% w+ Z* Bbly more common than the rare case report in the# ~$ g1 [; Y! B3 o% g9 H9 N
literature.4% r6 r& E: E2 w
Patient Report
% ^, Q+ [4 e; b2 D7 |0 kA 16-month-old white child was referred to the
0 S5 L4 }, B$ Wendocrine clinic by his pediatrician with the concern! U6 x0 T+ h" U$ Q$ ]; T8 h
of early sexual development. His mother noticed  n9 T6 j# ~3 x* A
light colored pubic hair development when he was
( A+ ^2 K1 F  @* S; v, yFrom the 1Division of Pediatric Endocrinology, 2University of
( q6 V1 h) B- D4 O1 eSouth Alabama Medical Center, Mobile, Alabama.8 v+ G8 R  _/ z6 \( X, j; V
Address correspondence to: Samar K. Bhowmick, MD, FACE,! G" x2 r. x; c5 X- L
Professor of Pediatrics, University of South Alabama, College of+ q: q/ q! Z0 t% {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 O, d% x" {% `" t
e-mail: [email protected]., r# k# \4 ~, V, L4 w$ g8 {6 j# c
about 6 to 7 months old, which progressively became- D2 R  N8 L9 y' l2 F' E1 k/ ]
darker. She was also concerned about the enlarge-
, x8 t; F8 ~+ U9 Q; Ement of his penis and frequent erections. The child
& |% `( i0 j1 ~was the product of a full-term normal delivery, with
' @7 C% k4 I6 ?$ F" o; Y# r6 Va birth weight of 7 lb 14 oz, and birth length of
) p2 ^2 j, O4 I; X! N* W9 r2 w8 H20 inches. He was breast-fed throughout the first year
( N7 F* E) V$ Y8 L# Hof life and was still receiving breast milk along with
" n  x) ~# g5 X, u. p/ Z1 B. X2 h+ lsolid food. He had no hospitalizations or surgery,+ P% t% d  @" ?! \+ A$ ~
and his psychosocial and psychomotor development; c: `7 \+ Q8 F/ h& z& H2 g) Z
was age appropriate., e; d" T3 j5 u; z% T
The family history was remarkable for the father,
/ M4 d( ]1 y# v, ?5 b& [& Qwho was diagnosed with hypothyroidism at age 16,
) |" N: C+ d+ Hwhich was treated with thyroxine. The father’s
! h; E' p, H) l6 w, Cheight was 6 feet, and he went through a somewhat* ]% G' r/ S( q% ]' Z, s3 A
early puberty and had stopped growing by age 14.* K% r+ a0 g+ e' U" f- Z% |
The father denied taking any other medication. The  O. y0 s* x+ e
child’s mother was in good health. Her menarche; Y" l$ D; f* [
was at 11 years of age, and her height was at 5 feet, k0 @" E* G# d
5 inches. There was no other family history of pre-
' I1 Z! c- E. lcocious sexual development in the first-degree rela-
" u+ U$ ^$ x! L) ^tives. There were no siblings.. D) T  u  R' w2 I" G5 y$ h
Physical Examination
) ]( \3 P! }* a5 {7 U; ~  UThe physical examination revealed a very active,5 J# o( d6 f7 l7 j
playful, and healthy boy. The vital signs documented) ]7 {/ d# N& C. f2 H# P
a blood pressure of 85/50 mm Hg, his length was
0 f4 k: w' L, k8 S" m) K' f3 f90 cm (>97th percentile), and his weight was 14.4 kg% {5 M! D+ F/ W9 x& E+ [% D+ Q6 x
(also >97th percentile). The observed yearly growth* Q4 X: Y+ e7 @! ?
velocity was 30 cm (12 inches). The examination of
) A4 }/ J: E5 F$ qthe neck revealed no thyroid enlargement.) h  [3 v8 `* {* i: n
The genitourinary examination was remarkable for2 C: q* a1 x, }# E; @( G# l9 a9 ^
enlargement of the penis, with a stretched length of
/ s+ A& N8 S0 \" h* {! F2 }+ M8 cm and a width of 2 cm. The glans penis was very well
: i6 R4 q! k! [6 V8 q* hdeveloped. The pubic hair was Tanner II, mostly around
  J( ?* u' ^- {6 Z* M) N540
( p, I; j5 Y. r9 n: H7 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' a- ?5 x. x' d' T7 m- Q; T/ v) {
the base of the phallus and was dark and curled. The/ \+ |, g7 k  Z2 v) Z4 L# T6 o
testicular volume was prepubertal at 2 mL each.
8 {" ?' Q- R1 x- E1 r7 [The skin was moist and smooth and somewhat4 M- Y$ K* |" T2 N
oily. No axillary hair was noted. There were no. @' c$ X2 H( f
abnormal skin pigmentations or café-au-lait spots.9 Z+ @9 p, u6 L9 @! z- N% Q
Neurologic evaluation showed deep tendon reflex 2+6 r' h- t8 \4 \  ]( v
bilateral and symmetrical. There was no suggestion; Z$ h( ?, K8 n4 y! I- V7 G) `
of papilledema.
" e- d5 }5 b  a: QLaboratory Evaluation2 K/ D9 h5 x, ?+ C/ G
The bone age was consistent with 28 months by& z" g+ m4 W4 Z1 l
using the standard of Greulich and Pyle at a chrono-, G: W/ s- c" i4 z5 Q0 _* k3 \+ ^! _
logic age of 16 months (advanced).5 Chromosomal0 \1 m9 R5 I' ?# ~
karyotype was 46XY. The thyroid function test6 n8 }  }2 }, u/ f7 e. E, M( R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 D( u! C, }: H# m$ C+ dlating hormone level was 1.3 µIU/mL (both normal).3 j5 s7 _) n# k  }3 ^
The concentrations of serum electrolytes, blood4 M5 A2 J( B( i
urea nitrogen, creatinine, and calcium all were9 i7 y) D3 ^6 D3 _$ o" h5 P' C9 E
within normal range for his age. The concentration
% M- m( t1 t* {' O; yof serum 17-hydroxyprogesterone was 16 ng/dL9 g% V4 z  T$ @* I* v$ J# \/ M# h
(normal, 3 to 90 ng/dL), androstenedione was 20
+ ~" n5 K5 o) L+ ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( D7 G' {! |' R  I! ]terone was 38 ng/dL (normal, 50 to 760 ng/dL),4 `5 F. R' t; S  d0 W" t9 \
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# r/ N$ k/ t7 E49ng/dL), 11-desoxycortisol (specific compound S)5 x- [* M# h2 ^' A
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  y4 Q9 d$ g- r9 Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( d/ J1 J; w5 K7 I$ gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 w7 P$ e) D& u$ X6 i) z1 G
and β-human chorionic gonadotropin was less than
4 d7 w4 D% x1 Z. G/ L, O6 M5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 S7 \9 Y/ C" hstimulating hormone and leuteinizing hormone
* Z3 ?" u" U' c) ^9 Y" Nconcentrations were less than 0.05 mIU/mL
+ f6 @, U- E5 X6 F3 D(prepubertal).
# M9 M- m' m8 u4 T: y* |5 CThe parents were notified about the laboratory$ r1 T+ p( ], [- L6 _+ b% v) C% V% h
results and were informed that all of the tests were
! I/ l0 |' [: Fnormal except the testosterone level was high. The+ ^7 @, H3 b( D3 `) |6 s0 W
follow-up visit was arranged within a few weeks to
/ _9 y6 n- p& L, H. Bobtain testicular and abdominal sonograms; how-  G1 _  J9 d( ]; i- y/ j9 V! N5 O
ever, the family did not return for 4 months." d) L. {5 Z& B
Physical examination at this time revealed that the. O: {, U. R$ t: J; _. ^: Y" c9 {' a
child had grown 2.5 cm in 4 months and had gained
8 F+ z$ o! y5 C, c: W3 A2 m% Y2 kg of weight. Physical examination remained  L0 V/ v3 b+ W. b3 T
unchanged. Surprisingly, the pubic hair almost com-
' ?3 d  l; H2 N  |1 a% w6 Hpletely disappeared except for a few vellous hairs at2 H& _& ]" L" y
the base of the phallus. Testicular volume was still 2* x9 Q* \: c0 `, v
mL, and the size of the penis remained unchanged." ?7 y: |8 f' ~3 u% j0 Z0 K
The mother also said that the boy was no longer hav-
; {: ?* r. k" K1 ^9 u$ uing frequent erections.8 F. d8 f% K) ~# A5 F
Both parents were again questioned about use of# G( j- ]" F( T! v( l
any ointment/creams that they may have applied to' ~# x& r$ A. K  y: C9 m
the child’s skin. This time the father admitted the' ]* a0 c( }9 ~1 I0 w$ N
Topical Testosterone Exposure / Bhowmick et al 541
! _8 g$ c- J9 k( l4 Nuse of testosterone gel twice daily that he was apply-
4 B' e3 v+ r/ I4 r5 r) {  ving over his own shoulders, chest, and back area for
! ]$ H$ D& g3 [2 ua year. The father also revealed he was embarrassed
/ b$ M! z4 _1 N8 j2 v5 ?  Wto disclose that he was using a testosterone gel pre-; `1 k/ ]; T; G( o  T2 f. B
scribed by his family physician for decreased libido1 n/ \+ [' b, {! W, {; E. @" O
secondary to depression.
1 n$ u* N3 F- X6 V  tThe child slept in the same bed with parents.) {, k' O2 k9 v0 z" }- j
The father would hug the baby and hold him on his
; U- [/ a) M/ u6 Ychest for a considerable period of time, causing sig-) @8 z( ?$ M. D4 O9 [9 F) M
nificant bare skin contact between baby and father.4 W2 |4 P  m1 ^' ]  ^- Y4 ^2 r
The father also admitted that after the phone call,1 @# V4 }) Y% {: I% ^/ x! w
when he learned the testosterone level in the baby
4 E- G$ W$ ^9 \7 X& q* j: |was high, he then read the product information, F. e) f8 {. V
packet and concluded that it was most likely the rea-2 v" V' }4 W5 u0 L7 u, H
son for the child’s virilization. At that time, they
. V8 [+ c% G; Q0 K/ G( q$ C# Sdecided to put the baby in a separate bed, and the0 j, P6 g) p& Y
father was not hugging him with bare skin and had
  M# q  J) m4 [been using protective clothing. A repeat testosterone
4 O( _& w. w8 e7 P) u1 p/ w& a' Stest was ordered, but the family did not go to the% _+ T4 e: F. I+ L. k. `! k
laboratory to obtain the test.
, d3 m! \& ^# c0 x5 s3 p- FDiscussion# p$ a/ v; \) m, n4 M
Precocious puberty in boys is defined as secondary6 C1 J+ j1 [, V
sexual development before 9 years of age.1,4
3 C4 R0 f) @" X4 `0 |" Y' _Precocious puberty is termed as central (true) when* x, c" X: C/ V0 g) f
it is caused by the premature activation of hypo-
8 y8 d/ i3 B3 Lthalamic pituitary gonadal axis. CPP is more com-! D: v* i; A$ F$ J: ~+ g
mon in girls than in boys.1,3 Most boys with CPP. F* q3 z% `3 ~2 }1 M
may have a central nervous system lesion that is9 X) _2 C' v* R2 g; o
responsible for the early activation of the hypothal-+ v: [6 `3 f5 Y$ k) U
amic pituitary gonadal axis.1-3 Thus, greater empha-( l5 \- S0 z# @8 L# h% {& b: v, }; u
sis has been given to neuroradiologic imaging in
0 d& r. t6 H& gboys with precocious puberty. In addition to viril-
4 O# k4 x3 v* j* j* a& i4 l) r* xization, the clinical hallmark of CPP is the symmet-- F: P, G1 A( ?
rical testicular growth secondary to stimulation by4 s' J' d2 c4 O/ k
gonadotropins.1,3
3 {& p4 X6 F9 D1 k3 j7 FGonadotropin-independent peripheral preco-0 A5 ]) q7 ~: v5 _1 u
cious puberty in boys also results from inappropriate$ g* u! I1 s  Z
androgenic stimulation from either endogenous or8 W. K* g; v. l- f9 B2 Y& W. A
exogenous sources, nonpituitary gonadotropin stim-
% Z6 J. S% X" ~  Hulation, and rare activating mutations.3 Virilizing
# b* V& J6 N  `* T; ^congenital adrenal hyperplasia producing excessive
4 o0 T' V4 f; p- R: ^$ tadrenal androgens is a common cause of precocious. X# w- ]8 y: \
puberty in boys.3,49 L( _# Z/ [4 X- H8 C6 h% T9 K9 X
The most common form of congenital adrenal
, z' i# t7 {, Q0 A; L* Vhyperplasia is the 21-hydroxylase enzyme deficiency.: C3 l" K/ r7 M; q3 C8 s
The 11-β hydroxylase deficiency may also result in
& Q$ n3 T2 N$ @& B# \. B  ^3 dexcessive adrenal androgen production, and rarely,
1 ]- |5 f9 `& d3 [& m2 R) Ian adrenal tumor may also cause adrenal androgen
! z: d. t8 c2 Q5 U+ ^$ }excess.1,3# m# u8 V0 k. I( ]$ Q1 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# J& l, b' M" Y. x. }542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) \- K2 O! T% j* e
A unique entity of male-limited gonadotropin-
! @9 o  t5 _$ R9 Pindependent precocious puberty, which is also known7 c4 j. ?6 I( p# O2 B
as testotoxicosis, may cause precocious puberty at a" M8 p3 }, P# U6 @0 G8 P7 u) v- G
very young age. The physical findings in these boys; c# k4 x+ l- a9 V
with this disorder are full pubertal development,$ k5 H1 D' q- E' T, Y
including bilateral testicular growth, similar to boys
! P7 R4 [* Q+ e9 i% qwith CPP. The gonadotropin levels in this disorder: l+ [  v) B, |. _, o
are suppressed to prepubertal levels and do not show$ N: V/ U: b# V
pubertal response of gonadotropin after gonadotropin-
0 U. \* e1 ^) j. s: e9 ]9 l+ v+ Areleasing hormone stimulation. This is a sex-linked
3 b1 w. C) Y6 Q) _autosomal dominant disorder that affects only
' |! G" J/ C, s' V+ g3 m. i3 K* Nmales; therefore, other male members of the family- V, ]: z4 a0 t7 ~# L0 D
may have similar precocious puberty.3
& d, j8 Z0 }6 G& P4 S3 \In our patient, physical examination was incon-# I  C+ z0 j: P6 x0 X' Q# |
sistent with true precocious puberty since his testi-" O6 }6 a6 f6 ?4 q2 {0 i
cles were prepubertal in size. However, testotoxicosis
# d3 s% g. N! T- b  _8 _5 xwas in the differential diagnosis because his father  V5 M/ Y% Z+ p
started puberty somewhat early, and occasionally,
# J! v# `& c1 Z, o9 P; |- |8 Ltesticular enlargement is not that evident in the  q/ Q2 h7 B) J
beginning of this process.1 In the absence of a neg-1 w: @/ C9 @8 {0 R2 {3 j' }
ative initial history of androgen exposure, our% O- s) |4 ~$ a+ }
biggest concern was virilizing adrenal hyperplasia,- ]* m1 E# Q, W! }. G, j" Y% i* Q$ I# \7 [
either 21-hydroxylase deficiency or 11-β hydroxylase
% Z5 [  F6 [3 d5 a! Kdeficiency. Those diagnoses were excluded by find-
- g' ]5 c2 K7 ]( E* d5 z/ @4 _ing the normal level of adrenal steroids.
% {0 m: R- z( j1 J" ]( E" x9 CThe diagnosis of exogenous androgens was strongly$ a9 ?2 f  K+ r1 u) Z2 y& o
suspected in a follow-up visit after 4 months because
1 u1 s- _' d* tthe physical examination revealed the complete disap-* R/ L$ \- q9 x: X5 ~
pearance of pubic hair, normal growth velocity, and
: @9 X! F) O# }- |& `& Q" Qdecreased erections. The father admitted using a testos-& P4 d: j: h4 Q1 ^1 y
terone gel, which he concealed at first visit. He was
6 ]2 c: j% @0 s4 c" iusing it rather frequently, twice a day. The Physicians’
  x* H" Q' o: j. K) KDesk Reference, or package insert of this product, gel or
. _; e3 j' Z& S$ C% N) o2 Hcream, cautions about dermal testosterone transfer to% B5 c! i% \1 x7 E% r
unprotected females through direct skin exposure.
* e8 R6 K8 t  ]( D: O6 d# KSerum testosterone level was found to be 2 times the- N1 e7 |9 V6 [; P0 u
baseline value in those females who were exposed to
" K  t( H/ F4 N9 veven 15 minutes of direct skin contact with their male2 @0 d4 ]) {# C9 X- O
partners.6 However, when a shirt covered the applica-
2 G: U7 r7 g* ?, ^$ \. \tion site, this testosterone transfer was prevented.9 d& n. P% B- b5 R" u" ^
Our patient’s testosterone level was 60 ng/mL,
5 O5 G7 N. _& X, _+ j/ pwhich was clearly high. Some studies suggest that! |$ f2 ^% @- \! s
dermal conversion of testosterone to dihydrotestos-& D1 v( t' A: U. _) b% s
terone, which is a more potent metabolite, is more
  S8 `; z# U. @: a) Z/ Eactive in young children exposed to testosterone1 S1 {+ P5 u5 Z# t
exogenously7; however, we did not measure a dihy-
% Y7 [7 _$ c' t! ]) [drotestosterone level in our patient. In addition to
- u; Y: k$ |9 Z* svirilization, exposure to exogenous testosterone in' x; z. G2 C  Z1 _
children results in an increase in growth velocity and( {+ ~; v6 Q; I! j( d  N0 T
advanced bone age, as seen in our patient.
/ q" P! N2 x2 a$ f" S4 t. VThe long-term effect of androgen exposure during
( y% P  \8 Z: z' I, E+ \7 j0 jearly childhood on pubertal development and final
0 q$ d; i3 O9 O0 nadult height are not fully known and always remain2 W: n. w) N8 h! w. G! }
a concern. Children treated with short-term testos-
# h1 ?4 G+ F" Bterone injection or topical androgen may exhibit some9 J: e% I/ z) l+ |3 a
acceleration of the skeletal maturation; however, after& y+ z" O. o: T: V5 ]  W6 u
cessation of treatment, the rate of bone maturation; }/ A: F( }* L  z& w: C1 c5 e1 `
decelerates and gradually returns to normal.8,9
1 B8 I7 E/ z2 Z6 c  nThere are conflicting reports and controversy
$ Q3 o% B5 W' _! S  M& L/ T. J4 Cover the effect of early androgen exposure on adult: Q* d# j7 z4 f; S
penile length.10,11 Some reports suggest subnormal' ?4 G3 @) }8 ?1 q  O
adult penile length, apparently because of downreg-6 m8 {$ A( G9 h: z
ulation of androgen receptor number.10,12 However,
) Q! E% @) r9 MSutherland et al13 did not find a correlation between
, D4 N* ~0 N9 [' O+ Y2 y- l+ b: t! L& Pchildhood testosterone exposure and reduced adult, i7 f5 t" \$ X+ B, Z! D5 l( G
penile length in clinical studies.
9 P" z5 j( k5 `2 l1 qNonetheless, we do not believe our patient is
  o! ~2 `0 h5 V5 M9 [going to experience any of the untoward effects from
0 C1 j) c4 h5 Y7 R% `" Ctestosterone exposure as mentioned earlier because! ]- _/ W7 j0 ^& A/ I3 R6 x
the exposure was not for a prolonged period of time.2 c  c4 {. T; f, S8 b
Although the bone age was advanced at the time of
+ S# f% d5 x* a( G; ]6 b' Sdiagnosis, the child had a normal growth velocity at
3 Y- m3 c6 L# t2 K3 {7 \! |the follow-up visit. It is hoped that his final adult
) ?. i5 M" ^& e6 h0 Mheight will not be affected.3 M7 f4 _" j# y- n
Although rarely reported, the widespread avail-
5 Z8 c5 s1 ^1 b' I7 T* @* o$ Kability of androgen products in our society may
  L/ s$ C3 R% f+ E' q; Cindeed cause more virilization in male or female
8 q  A' |8 [4 Z3 i+ hchildren than one would realize. Exposure to andro-
: V) {( J! I, `' ]4 w( O6 u" Fgen products must be considered and specific ques-
% j- ]. n5 x% stioning about the use of a testosterone product or8 ]! a* E# x- V+ S! Y* R
gel should be asked of the family members during2 o, i& ?& s) {& k2 X
the evaluation of any children who present with vir-4 ^5 u: E' L0 Q* T( k
ilization or peripheral precocious puberty. The diag-
+ M9 r  z: e3 E  V, ~1 r6 dnosis can be established by just a few tests and by
7 p7 ?" t7 a9 x! U: vappropriate history. The inability to obtain such a% U4 u0 j2 S( `, d8 Q7 J
history, or failure to ask the specific questions, may
2 e  M& i5 l: B0 l1 ~8 N' `result in extensive, unnecessary, and expensive* @, [( Z5 u; C
investigation. The primary care physician should be! ?& M( n" @& _) s
aware of this fact, because most of these children% x4 C% p, v; q8 U6 V- X( j' y2 t; L
may initially present in their practice. The Physicians’: A! F8 F7 f/ C/ t5 R: s
Desk Reference and package insert should also put a
8 I% y% X7 A1 Q: S1 \warning about the virilizing effect on a male or
  m' Q; X; Y7 g- u: z- efemale child who might come in contact with some-; L% \( v' ~6 w+ C* u# P& a
one using any of these products.: Z# W, o+ A( G4 ?
References. y* ~! z; Z9 `1 l0 u
1. Styne DM. The testes: disorder of sexual differentiation
. F) {, U  N  i2 \3 Wand puberty in the male. In: Sperling MA, ed. Pediatric9 ^" f( K! L2 _: n+ r4 [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" _. i  {6 {0 m- g+ `; I% ]
2002: 565-628.7 o5 g/ P- g" ?6 T8 \# L) o' y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( I6 l. E( s) h, O" k' Jpuberty 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
! j. P' e! s- J! r$ C
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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