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Sexual Precocity in a 16-Month-Old
0 j; O4 e' a4 _/ f5 L/ SBoy Induced by Indirect Topical% f7 B% \, l4 j! a* h* X' m
Exposure to Testosterone- o4 ?6 z2 v0 |7 g1 F
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ z9 q4 r, `. j: B9 C
and Kenneth R. Rettig, MD1; t! q- @/ ^% e# \3 Q6 a$ B
Clinical Pediatrics7 \3 [  c. D6 V6 R* P5 k
Volume 46 Number 6
1 I  C+ G  ~+ z3 S  RJuly 2007 540-543
) X* _0 K& R" F/ M© 2007 Sage Publications
8 k' f* j! h' ^, D10.1177/0009922806296651: t; }8 Z. M3 w. r& o0 C" K0 S, r
http://clp.sagepub.com
8 J* B! p" q2 `; y- E' @( lhosted at
0 y3 S5 D: Z3 m' uhttp://online.sagepub.com+ V1 w" ]  B$ E: N3 ^6 @' ?3 V
Precocious puberty in boys, central or peripheral,
# b3 L& F1 A7 g$ O7 Sis a significant concern for physicians. Central
$ E1 y5 w: T: \6 a8 @precocious puberty (CPP), which is mediated
) [& w  U3 [+ \1 c. A9 f/ Wthrough the hypothalamic pituitary gonadal axis, has
6 h, U: H& _& F$ y9 T, ca higher incidence of organic central nervous system+ W. I, l: R1 y6 s
lesions in boys.1,2 Virilization in boys, as manifested# H6 `+ k+ z. x0 J& f6 |' l7 W
by enlargement of the penis, development of pubic9 f7 ^3 ]* O& s: ~
hair, and facial acne without enlargement of testi-
8 F4 e" f7 ^5 Z" a( y, Ocles, suggests peripheral or pseudopuberty.1-3 We
% B( F# p2 @8 g- y; J* O8 f4 m) ^report a 16-month-old boy who presented with the
& A- p8 C4 _4 B; o) i' J& eenlargement of the phallus and pubic hair develop-+ ^7 f' E- f4 _
ment without testicular enlargement, which was due5 w% P, Q$ B" A% z: G( o  \9 b
to the unintentional exposure to androgen gel used by
$ C7 g, `, t0 }/ c: m/ kthe father. The family initially concealed this infor-. I: G: c& a" p  X; N4 T
mation, resulting in an extensive work-up for this1 _3 R1 w9 X' `' y8 i$ N1 {  e
child. Given the widespread and easy availability of$ m" {0 T2 o8 q. o$ m1 b' H+ r
testosterone gel and cream, we believe this is proba-" J/ D9 o  H& `. }1 a$ Q
bly more common than the rare case report in the
9 e8 f/ |5 i# ]; b1 J0 _literature.41 A7 d: S6 C' H: f
Patient Report  N' R3 F, ]" K* `/ m5 O/ H6 j
A 16-month-old white child was referred to the
" g0 T- g4 x& i% H" C, C8 bendocrine clinic by his pediatrician with the concern
$ E! t) M/ X/ W- v+ aof early sexual development. His mother noticed. O6 j4 a0 v8 l& u
light colored pubic hair development when he was
! E5 n7 ^% B' U. h' AFrom the 1Division of Pediatric Endocrinology, 2University of
) h: e' b( r7 a4 C  u/ U& }  BSouth Alabama Medical Center, Mobile, Alabama.
3 `$ C) \7 r7 l, T7 ~( PAddress correspondence to: Samar K. Bhowmick, MD, FACE,
6 E- j, M* h7 Z8 M5 e9 rProfessor of Pediatrics, University of South Alabama, College of
- z5 C+ d- R  O. O1 _9 v+ G  JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; ^8 [' Y' z5 F6 [( Ne-mail: [email protected].
& N8 `' i4 `& v8 s% T( D- N& Cabout 6 to 7 months old, which progressively became- A) b/ U, p! T) L2 O  R
darker. She was also concerned about the enlarge-) @  ?- @$ ]* F9 Y) s
ment of his penis and frequent erections. The child8 u2 {; y" i3 s2 _$ V( ^
was the product of a full-term normal delivery, with' T5 H! Z% F  I; |  l8 `
a birth weight of 7 lb 14 oz, and birth length of0 D9 ^5 E& J6 h9 N3 l4 i9 j& n6 [
20 inches. He was breast-fed throughout the first year& p0 }" b; |. k( x; |3 ^8 j
of life and was still receiving breast milk along with
6 j- \9 V; T4 r. \0 x+ |1 esolid food. He had no hospitalizations or surgery,
/ p) `: Z' w1 F0 Eand his psychosocial and psychomotor development
/ W, d% C5 y, P* D3 ~" ~, K- L* iwas age appropriate.. o7 w& @. w1 Z
The family history was remarkable for the father,4 r8 @% h* f( w/ j- @
who was diagnosed with hypothyroidism at age 16,
7 H  @" L/ |4 ]which was treated with thyroxine. The father’s3 l; @3 d' Z7 }5 z. g7 t
height was 6 feet, and he went through a somewhat4 z  |2 h' s1 F) g
early puberty and had stopped growing by age 14.% b4 G* N* l) p
The father denied taking any other medication. The
$ Z2 W) X2 q7 X/ Uchild’s mother was in good health. Her menarche
9 D5 j/ w0 F) e" Swas at 11 years of age, and her height was at 5 feet
1 O* K8 @4 T5 E; l5 inches. There was no other family history of pre-
1 n* U) E4 v8 w' d2 Bcocious sexual development in the first-degree rela-
* w: q9 F+ V1 D2 E/ X* ^: ~tives. There were no siblings.
7 ?! d, q2 R) F8 \Physical Examination
# X  o9 _& K  MThe physical examination revealed a very active,. Z. p  h" |7 V' g. X
playful, and healthy boy. The vital signs documented
7 {# T' P- H/ s( J  U, ra blood pressure of 85/50 mm Hg, his length was9 l, R- K' _5 p5 X  j
90 cm (>97th percentile), and his weight was 14.4 kg
# M$ P5 l8 u, O(also >97th percentile). The observed yearly growth
1 X+ A7 [$ t' L% q2 O7 k* Yvelocity was 30 cm (12 inches). The examination of3 q9 o% L9 L2 F2 \9 W4 s
the neck revealed no thyroid enlargement.2 C) O: o, @" j2 p2 \2 N2 {$ P
The genitourinary examination was remarkable for+ k5 z7 q9 R) y+ T# Z6 w
enlargement of the penis, with a stretched length of  e7 z- j3 U, B. ^% u" b: f
8 cm and a width of 2 cm. The glans penis was very well) S( l  T) x$ K2 i
developed. The pubic hair was Tanner II, mostly around4 f) |6 L- T( |" q3 B0 L; r
5400 Q5 f1 Y  p8 t/ d& c/ m
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the base of the phallus and was dark and curled. The
/ U, G0 E. H3 }2 wtesticular volume was prepubertal at 2 mL each.4 p' d. ~5 Y6 }7 i+ @' W
The skin was moist and smooth and somewhat/ Q" C% @4 q) ?' s# v
oily. No axillary hair was noted. There were no, ~% K  m. ^: \+ j: Q* _* ~/ m
abnormal skin pigmentations or café-au-lait spots.
8 H' ?4 O. A0 M' d  ^: iNeurologic evaluation showed deep tendon reflex 2+" B8 R5 q$ J5 G9 N7 n
bilateral and symmetrical. There was no suggestion
2 _( p+ M) I  m* [% Zof papilledema.+ w2 h% ]& q# V3 t9 `" ^
Laboratory Evaluation
4 P- E* U1 _" Z( S0 y# V; LThe bone age was consistent with 28 months by! }7 r+ h3 `8 _  y5 s
using the standard of Greulich and Pyle at a chrono-
; _+ _9 x+ k+ \- v* alogic age of 16 months (advanced).5 Chromosomal
% E8 T( J, J, H7 Ckaryotype was 46XY. The thyroid function test
! |. N: O+ f+ [showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 A( E& n3 B: K8 G; m
lating hormone level was 1.3 µIU/mL (both normal).3 M+ |$ S6 H4 k& E3 c- N
The concentrations of serum electrolytes, blood
3 Y/ R) a  k3 i$ O/ j* Aurea nitrogen, creatinine, and calcium all were
! u* X: N* x' _- l* P7 t; A6 f% i) wwithin normal range for his age. The concentration
# Z9 \9 \4 z' h" L$ n% {7 Qof serum 17-hydroxyprogesterone was 16 ng/dL
; Y: E: L, w9 o$ d: n(normal, 3 to 90 ng/dL), androstenedione was 20
! ^( G% {1 t9 B+ ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, T& c  k2 T) i. \terone was 38 ng/dL (normal, 50 to 760 ng/dL),( M3 W2 ~! N4 b% P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 ^, h! E4 }. d$ I% Z8 p; h4 h49ng/dL), 11-desoxycortisol (specific compound S)/ i9 L* n; Z* u# [* @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% s4 W# k% W& G: E$ F% Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 m2 Z# N* {# A, ^0 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 e% j' }9 r: x: U) |  D) h4 A8 |9 I
and β-human chorionic gonadotropin was less than' @& }; P6 l' ]; a' u
5 mIU/mL (normal <5 mIU/mL). Serum follicular- K; {6 U5 u. Q
stimulating hormone and leuteinizing hormone0 g$ T; ~& O) \5 d9 I% L+ x7 m8 a
concentrations were less than 0.05 mIU/mL' c7 ?$ a: V/ ]3 u7 N' y/ X
(prepubertal).7 T/ V4 z% y0 f& F" a- j9 V" z) J
The parents were notified about the laboratory
. U! \2 I8 F: v& gresults and were informed that all of the tests were
- S3 e) Q; B. O$ ?, a' `$ V$ ^normal except the testosterone level was high. The9 n2 `: W8 s( g
follow-up visit was arranged within a few weeks to- X2 t9 m* u0 S+ l* K9 v: W
obtain testicular and abdominal sonograms; how-
, `; D  P) f0 H+ Q$ D6 R' mever, the family did not return for 4 months.
! ]- k0 c7 L. R$ ]Physical examination at this time revealed that the
/ o) U* E/ |9 U. u7 _child had grown 2.5 cm in 4 months and had gained
+ K6 B% X9 |; e# l9 F9 d8 r% Z6 |- ?2 kg of weight. Physical examination remained
$ `( a$ |: D0 T# X/ X6 ?- ?. Tunchanged. Surprisingly, the pubic hair almost com-
' g& }  p$ v% \pletely disappeared except for a few vellous hairs at7 U8 a. k" B" E2 `5 I0 v  G
the base of the phallus. Testicular volume was still 2
1 o% i3 X  C: K5 S+ C# V# A0 `mL, and the size of the penis remained unchanged.
. j5 X( M+ W$ {% n% f$ `+ ?The mother also said that the boy was no longer hav-+ u+ _/ a- L3 x4 k# k0 S
ing frequent erections.: [) z+ B  N6 Y  E( @
Both parents were again questioned about use of; ~" J# a, }. E. }* \8 [
any ointment/creams that they may have applied to0 t9 d. L1 V& K" F, `% x; c, I
the child’s skin. This time the father admitted the
4 k' X4 I1 T+ @3 _. d- b1 nTopical Testosterone Exposure / Bhowmick et al 541
4 M  O- ]" j- ]1 V. Muse of testosterone gel twice daily that he was apply-& e- V$ }" w0 M2 C6 w! q$ k" V6 l3 L
ing over his own shoulders, chest, and back area for* D  g( v; q% U5 C/ i# j1 S2 s
a year. The father also revealed he was embarrassed1 O9 {' G. a) e# Z  f, c
to disclose that he was using a testosterone gel pre-
+ Z1 L, s2 H) T1 w' K. N$ iscribed by his family physician for decreased libido
; ?; w, `" m- M' E# ^' fsecondary to depression.  G; o/ P3 T( A5 r
The child slept in the same bed with parents.
; t3 I5 b; d. m% R. ^The father would hug the baby and hold him on his" U* {+ G; L; ~$ Y& X0 }
chest for a considerable period of time, causing sig-8 I8 w7 {/ K- v3 z3 h
nificant bare skin contact between baby and father.
; F/ `' R9 R; G' ~! X. _, RThe father also admitted that after the phone call,
+ K" _8 @8 E4 q# Jwhen he learned the testosterone level in the baby
6 `# t6 Z+ k2 iwas high, he then read the product information5 c' ^, [2 n5 x, k) J  ~- k) B
packet and concluded that it was most likely the rea-
) d# D' Q3 r! C) M/ ], bson for the child’s virilization. At that time, they. v3 u( q' |3 P5 |* s
decided to put the baby in a separate bed, and the8 }0 K9 p# \- S0 Y
father was not hugging him with bare skin and had
4 Y) }. q2 Q$ d* a6 rbeen using protective clothing. A repeat testosterone- l# v( C& W4 _. j
test was ordered, but the family did not go to the
) s$ D7 y6 o# A' E( ^laboratory to obtain the test.  l8 R- Z$ ]& |, {
Discussion
" t3 H/ f1 Q3 z! N* R9 h4 c( @Precocious puberty in boys is defined as secondary; Z  L2 T/ l5 Y- e  X+ F3 s: h3 m. O
sexual development before 9 years of age.1,4  v$ `& }3 l/ i) m# A
Precocious puberty is termed as central (true) when
, d: i5 [  s4 @) e/ W* Mit is caused by the premature activation of hypo-
3 A% y2 u& C# x8 \thalamic pituitary gonadal axis. CPP is more com-+ B0 \( r/ K  N4 B: E9 z& _
mon in girls than in boys.1,3 Most boys with CPP9 W0 x$ e* o( [3 K0 U
may have a central nervous system lesion that is! v" t0 ~# A1 {0 ]- y: M
responsible for the early activation of the hypothal-' B% G- d, ^% f
amic pituitary gonadal axis.1-3 Thus, greater empha-0 @9 d% b" t2 [( p
sis has been given to neuroradiologic imaging in' k& F& q+ ]. V) u' T) `
boys with precocious puberty. In addition to viril-$ A' \$ S$ Q" e" g) s! |; O4 u
ization, the clinical hallmark of CPP is the symmet-
9 i  x1 O/ R, `& [9 l4 Mrical testicular growth secondary to stimulation by8 f7 ^% ^4 j. d
gonadotropins.1,3
5 {# @  a3 @& F, a7 @' f" T( SGonadotropin-independent peripheral preco-% i; k7 N% U+ R' _( W
cious puberty in boys also results from inappropriate
+ `1 }: M9 ^0 jandrogenic stimulation from either endogenous or
4 J1 e5 T) {/ ^* n3 ~' ~exogenous sources, nonpituitary gonadotropin stim-; y. S2 a( w% G; x
ulation, and rare activating mutations.3 Virilizing
( ?* ]5 p# @, f* F: Gcongenital adrenal hyperplasia producing excessive
; |  P: T3 w7 L3 J* Iadrenal androgens is a common cause of precocious% ?  i% U8 H8 X: y( n& P6 P: f. _: `
puberty in boys.3,4
1 R( z& k7 h4 O( O: ]The most common form of congenital adrenal% U% s3 D$ w9 N. X; [' u; }3 v0 v+ H6 u
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 ^5 w# L, D! d& `" E- O1 J1 O" z- ^The 11-β hydroxylase deficiency may also result in' D  K& I" k) ^+ N: x7 y
excessive adrenal androgen production, and rarely,% }/ t2 m1 L% Q& Q# V
an adrenal tumor may also cause adrenal androgen3 G3 s- H/ ~' W  i" x5 o$ X
excess.1,3
' h6 Q$ g$ X+ Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 {+ c! D+ S4 X% A0 v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 V  m3 }/ D9 e7 X: uA unique entity of male-limited gonadotropin-9 v* Z6 C! y4 {! l0 b
independent precocious puberty, which is also known
0 b( A0 s% d; {) r# M8 M* t8 s( f' Aas testotoxicosis, may cause precocious puberty at a
1 p7 M1 y, x% h9 Jvery young age. The physical findings in these boys# d* m) k. Z1 |& p2 o' V# B
with this disorder are full pubertal development,3 W+ t# ~+ r' g- E% P8 c( U- N
including bilateral testicular growth, similar to boys* H' O6 d7 q; N) ~# `
with CPP. The gonadotropin levels in this disorder
9 }" H! X1 }  `are suppressed to prepubertal levels and do not show
4 \) u0 o/ [: E, u8 [pubertal response of gonadotropin after gonadotropin-; N( ]0 [$ a: d7 L/ I4 c
releasing hormone stimulation. This is a sex-linked
. e# c* r. R' P7 e% Y. Jautosomal dominant disorder that affects only" |- W$ Y; C3 A0 t6 d% t
males; therefore, other male members of the family% |1 p  Y. i1 i2 a; X
may have similar precocious puberty.37 [" C3 N) v2 o& X) ?
In our patient, physical examination was incon-# J4 u1 B: @3 ]' R' ~
sistent with true precocious puberty since his testi-
- R; O: E" j( q, l% C2 I+ V2 Gcles were prepubertal in size. However, testotoxicosis  Y5 t3 k8 Z8 W- `. G( u
was in the differential diagnosis because his father! |; T$ Q& J. K  @. M$ {
started puberty somewhat early, and occasionally,
( @& ~) B( l% R+ i" mtesticular enlargement is not that evident in the
, L) }7 C4 |. b/ h' D2 `- z0 jbeginning of this process.1 In the absence of a neg-
: v) P4 h8 a. D# ^* ~( m0 j, \ative initial history of androgen exposure, our
% O/ t1 k- I2 S2 @" v- ~( Q( w/ ^biggest concern was virilizing adrenal hyperplasia,5 v% @& w6 u) Y) n* e3 k
either 21-hydroxylase deficiency or 11-β hydroxylase+ p- W  w) F3 h$ Y3 @4 z) R2 ]
deficiency. Those diagnoses were excluded by find-
' U+ Q. e9 ]" q; a9 p. qing the normal level of adrenal steroids.
, ^1 _1 _0 W4 u7 p/ s" LThe diagnosis of exogenous androgens was strongly
  P- F. B' i. msuspected in a follow-up visit after 4 months because
* l) X6 L, n- G2 Zthe physical examination revealed the complete disap-/ v( M7 `: m4 w  l; D
pearance of pubic hair, normal growth velocity, and
8 {9 E! `: J* t  w% Z. b7 mdecreased erections. The father admitted using a testos-/ n5 z# G! D7 z- i; Y) R, }
terone gel, which he concealed at first visit. He was' P- z5 Y- v$ @6 ~8 V
using it rather frequently, twice a day. The Physicians’5 }4 e- O; h7 n0 n3 \
Desk Reference, or package insert of this product, gel or
' r, g0 B, h2 E+ R, W9 |- Scream, cautions about dermal testosterone transfer to
# B) P8 X- a! Dunprotected females through direct skin exposure.
4 w3 }9 d8 @. M. d2 _6 xSerum testosterone level was found to be 2 times the
) L3 y: N' ]1 nbaseline value in those females who were exposed to# g2 W3 o8 v6 T0 Y+ }
even 15 minutes of direct skin contact with their male7 w- P9 y7 U, b# `0 B- r
partners.6 However, when a shirt covered the applica-
! _0 ?; O) b8 K* Y% g: qtion site, this testosterone transfer was prevented.9 A+ C- B: O6 @7 M8 `; d% m
Our patient’s testosterone level was 60 ng/mL,
' f, U; G! t3 }- _2 T8 I& B' _which was clearly high. Some studies suggest that
& E) G- A1 H% I/ s& r+ u( H3 @9 ?dermal conversion of testosterone to dihydrotestos-
! [9 F/ l+ E2 G7 kterone, which is a more potent metabolite, is more8 Y( \- F% Z! |$ g6 p6 r: ^
active in young children exposed to testosterone5 ?2 V% K8 i# S, T
exogenously7; however, we did not measure a dihy-- [3 n2 L/ M8 Y1 d: E7 Q8 M
drotestosterone level in our patient. In addition to
, f6 M8 d! K+ w# t8 ~virilization, exposure to exogenous testosterone in1 h" y: Z$ P" J  H
children results in an increase in growth velocity and. W( c. w6 G5 Y* j
advanced bone age, as seen in our patient.
- [3 c* y5 I! Y+ R5 KThe long-term effect of androgen exposure during
8 ]5 q' ~: b( z2 g3 V, ?% n' Tearly childhood on pubertal development and final
& U$ R* L6 B& o* m. u" _2 |adult height are not fully known and always remain
; y, v8 v, v: t2 T" Ia concern. Children treated with short-term testos-
& x4 t* p7 o; aterone injection or topical androgen may exhibit some
4 @1 W! l4 ~9 {4 `$ c0 Z$ Yacceleration of the skeletal maturation; however, after
: B5 k6 _# n  L$ Ecessation of treatment, the rate of bone maturation6 \1 @+ b5 m. G7 E7 I
decelerates and gradually returns to normal.8,9+ \  ~7 ~' j$ T: f
There are conflicting reports and controversy
" ]4 j/ \4 Q6 I/ I0 Z7 i7 Oover the effect of early androgen exposure on adult
9 }) y3 V1 B9 O3 L3 ]% o% dpenile length.10,11 Some reports suggest subnormal; O- q' n6 O6 w2 ?7 a/ W
adult penile length, apparently because of downreg-0 v; F. b; R$ I; W
ulation of androgen receptor number.10,12 However,  v% s+ K3 j* |
Sutherland et al13 did not find a correlation between
0 n6 w) V/ ~* k' X" nchildhood testosterone exposure and reduced adult
. b3 ]* f, Q$ x8 K, N; jpenile length in clinical studies.
4 u) b9 o3 d* C" ]2 X: [Nonetheless, we do not believe our patient is
; m( N: Y5 u" l! p$ Ogoing to experience any of the untoward effects from/ L4 @6 c0 N) j9 Y! C* S
testosterone exposure as mentioned earlier because# e# x% O5 @# `& s
the exposure was not for a prolonged period of time.5 a6 c8 g, z4 g5 N' v# L3 e
Although the bone age was advanced at the time of
8 g+ p2 z/ q( C: l& R4 m! xdiagnosis, the child had a normal growth velocity at
& H( X# Z! E7 C( G* Dthe follow-up visit. It is hoped that his final adult+ l  J( l( J3 c- e! b
height will not be affected.) r+ y  _( v8 b8 a
Although rarely reported, the widespread avail-0 l1 @8 W. r3 c" I$ s
ability of androgen products in our society may
0 A) E9 K- v$ f' C& Y/ [2 J0 Yindeed cause more virilization in male or female+ B& W! B, z5 d/ d) M- k! o% P" `
children than one would realize. Exposure to andro-
% _4 ]1 p  I  Rgen products must be considered and specific ques-
( l' g3 R0 l& l; ktioning about the use of a testosterone product or0 h6 F, F# D( |7 j: a4 \0 r/ `' a
gel should be asked of the family members during
6 u0 n) Q- J5 i# x5 B1 P1 t% rthe evaluation of any children who present with vir-  ?, D  ^$ w) B7 c2 ?) N
ilization or peripheral precocious puberty. The diag-
) J, S# p% A/ S4 [! _- _" w1 ^. ]! Ynosis can be established by just a few tests and by! N+ z* s) e! a0 U" Q3 y
appropriate history. The inability to obtain such a
: q& h; p6 `" E! h9 m! phistory, or failure to ask the specific questions, may9 `+ L, ^2 J& ^
result in extensive, unnecessary, and expensive
& t7 Y. K( I2 sinvestigation. The primary care physician should be
. x" \& f2 c: Y# x/ ^5 b$ }3 b  Oaware of this fact, because most of these children  D& N- g" `- T
may initially present in their practice. The Physicians’( ]9 E' R/ B% D) F; ^! q$ ?# L
Desk Reference and package insert should also put a
, l, |3 p% {) r( e; ~2 zwarning about the virilizing effect on a male or/ l7 Q7 c# A9 w3 ?
female child who might come in contact with some-/ W8 \8 L0 x7 \9 \, r
one using any of these products.
. v, \+ e, _/ x" m1 ]) rReferences1 M: x5 D, u- Y2 n( M
1. Styne DM. The testes: disorder of sexual differentiation
; a6 O6 {5 \7 u/ ~* }6 Band puberty in the male. In: Sperling MA, ed. Pediatric
8 z" G4 v' @6 ?* x/ [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 ?3 t$ M) ?- Y1 k2002: 565-628.
8 m3 b2 N* ^, o3 B5 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& Z  I6 b: E% R+ k* j  O7 h- a7 @
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
8 g3 o% e9 q; }) v0 jBoy Induced by Indirect Topical  k5 ~% E# n; [: }+ x6 s
Exposure to Testosterone
4 r- h4 C2 \7 b( R  O% USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 K% `7 y0 ]" ?3 X: W7 K
and Kenneth R. Rettig, MD1
! G5 o$ X1 T# |1 X5 e( w! z4 FClinical Pediatrics# o  s4 \  p! |7 x( s# L
Volume 46 Number 6
9 _! s* W5 T( x% M& B' dJuly 2007 540-543/ u* {& n+ Y3 A
© 2007 Sage Publications, ]7 u. _6 \  s
10.1177/0009922806296651
- d+ Z8 ^4 @8 Thttp://clp.sagepub.com
# P. Y* h" f1 D2 phosted at+ N2 ^; J, l! B1 Y: P6 z
http://online.sagepub.com
5 y* x- K3 N1 |' K1 O+ HPrecocious puberty in boys, central or peripheral,
# z' _- H: O& lis a significant concern for physicians. Central' ~9 D/ s3 y# ^" a' n& b/ N1 I) H
precocious puberty (CPP), which is mediated- v, H3 `; _+ {, ?, H' N
through the hypothalamic pituitary gonadal axis, has/ h1 \9 b% I! X
a higher incidence of organic central nervous system# K% n- R" q1 e2 x$ n* D2 Z8 n
lesions in boys.1,2 Virilization in boys, as manifested
) J% J% u! K5 jby enlargement of the penis, development of pubic; Y" {( c- [" n) B( ?0 Z
hair, and facial acne without enlargement of testi-
. I- w3 z# ~  p1 w3 U6 n- [cles, suggests peripheral or pseudopuberty.1-3 We
6 I* i( v9 `6 m- W  ureport a 16-month-old boy who presented with the" r1 y  k" s7 i# C
enlargement of the phallus and pubic hair develop-0 s/ e' D' v5 ?% {3 [0 q* \
ment without testicular enlargement, which was due
1 }- F. q+ ^* M" O! x* hto the unintentional exposure to androgen gel used by, c" ~. P8 E: c
the father. The family initially concealed this infor-
4 i5 w  O0 e9 a% k/ u4 K0 Xmation, resulting in an extensive work-up for this
8 _$ O, Q0 h8 d: q' Fchild. Given the widespread and easy availability of
6 W2 G& F- ~2 \testosterone gel and cream, we believe this is proba-3 z+ w& ^* T+ ^3 s" s" A" U4 i
bly more common than the rare case report in the
: B6 V& ~/ T! J! t/ {. n' h# l8 r+ fliterature.46 c  I2 V2 g! d: m8 G( u, q
Patient Report: r8 N: W  ?  e  y
A 16-month-old white child was referred to the
; l% h0 N0 N5 K8 u6 r- Cendocrine clinic by his pediatrician with the concern
, T$ e+ }* i1 r, B) Jof early sexual development. His mother noticed
. g6 T1 r9 Q: O' rlight colored pubic hair development when he was
1 h& }( V9 X" T9 a+ mFrom the 1Division of Pediatric Endocrinology, 2University of$ T6 C; b1 P/ u- n
South Alabama Medical Center, Mobile, Alabama.  n; ~, r+ {- H" ]
Address correspondence to: Samar K. Bhowmick, MD, FACE,
  E0 m  k+ B1 ~* s4 qProfessor of Pediatrics, University of South Alabama, College of$ r" p( y. {" ?* O7 O5 L8 j! c; I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" h& Q: h- T( ]  ~% Le-mail: [email protected].
! w2 s* s" |: v! Tabout 6 to 7 months old, which progressively became9 Q6 F. r- ?6 R& H) G# w' ?
darker. She was also concerned about the enlarge-$ s9 f; q# R9 |" z
ment of his penis and frequent erections. The child' w0 j! ~8 X" h; `
was the product of a full-term normal delivery, with
9 u: x: F0 w5 }* ^) Ma birth weight of 7 lb 14 oz, and birth length of
& r4 r' V: v2 m1 B20 inches. He was breast-fed throughout the first year  w1 ^! \2 o* G3 T. S
of life and was still receiving breast milk along with
1 l. E' F8 j5 r" Q& Psolid food. He had no hospitalizations or surgery,
) Q; p4 o; m6 X8 Yand his psychosocial and psychomotor development
; p- ^3 U: J+ I, X0 E" G: Pwas age appropriate.9 ~1 D4 }7 `+ i  n" L. L6 q$ I
The family history was remarkable for the father,
5 j) y6 u( E# H1 G  v+ Swho was diagnosed with hypothyroidism at age 16,5 c6 c$ r4 G3 d  n1 ~
which was treated with thyroxine. The father’s6 m; o$ r) K3 \* U
height was 6 feet, and he went through a somewhat9 J, c; |) G# n0 r* q- O
early puberty and had stopped growing by age 14.# [+ Q& R% `7 i! k  g5 o, |7 N
The father denied taking any other medication. The
/ N/ ]3 p; ]: z4 d* fchild’s mother was in good health. Her menarche
' A! H. c4 x6 t+ _2 Fwas at 11 years of age, and her height was at 5 feet/ u; S" X* e6 j* @  `
5 inches. There was no other family history of pre-
/ ]! m5 a% n" h( }9 q/ hcocious sexual development in the first-degree rela-
) [# s! e+ H8 t& I: S: _# stives. There were no siblings.5 _3 d, O6 d) m4 n6 I) _4 u
Physical Examination' d( b: v+ X6 S# e+ s
The physical examination revealed a very active,
8 R, }4 t% B# p; f' j0 d' \playful, and healthy boy. The vital signs documented
# }/ h5 v# ~- p. ja blood pressure of 85/50 mm Hg, his length was
6 D4 A: X8 ~- v8 q: p/ D# S90 cm (>97th percentile), and his weight was 14.4 kg. O4 N# [: O% ~
(also >97th percentile). The observed yearly growth
9 H" S/ m  a; m; Kvelocity was 30 cm (12 inches). The examination of. U9 w" s& k% p
the neck revealed no thyroid enlargement.
# @# P: x$ C. N1 ~& X  MThe genitourinary examination was remarkable for' [" B2 l* d# d  g8 C* L) Q& v0 e
enlargement of the penis, with a stretched length of
7 d" p+ @1 N  a; y  _! C8 cm and a width of 2 cm. The glans penis was very well, |) |8 m- v/ w  d% T
developed. The pubic hair was Tanner II, mostly around
3 W$ U4 Z% R9 B2 T540
) c4 X' F9 B  \0 Q3 Q- r2 t5 Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 t* ?4 ]& ~( ?/ p9 n
the base of the phallus and was dark and curled. The$ P8 B1 K. _" ?( G
testicular volume was prepubertal at 2 mL each.! {3 Z9 d. v" `1 n& v# K
The skin was moist and smooth and somewhat
3 U! W/ \) W, B1 voily. No axillary hair was noted. There were no/ J' z( W1 v! k& J- |) L7 z# \6 N
abnormal skin pigmentations or café-au-lait spots.
; P/ F' T* X  e+ u) S; k* BNeurologic evaluation showed deep tendon reflex 2+/ p# w3 K7 \. n  ~( m2 A& ?$ l
bilateral and symmetrical. There was no suggestion7 _$ r  R( S2 y; M! g! O: ^
of papilledema.
0 q' R2 _- _# _. i7 ULaboratory Evaluation" U" u. \  z$ s9 k1 u2 B. o6 l$ {
The bone age was consistent with 28 months by* X+ v4 t4 H- r4 X
using the standard of Greulich and Pyle at a chrono-
- T6 p: `+ O8 nlogic age of 16 months (advanced).5 Chromosomal5 I+ W8 ]+ v# u5 c- G$ a. k
karyotype was 46XY. The thyroid function test7 k# }* a4 M8 `0 P
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 _/ D% B* {% i+ a' _lating hormone level was 1.3 µIU/mL (both normal).& c1 R/ E7 j7 X* ]
The concentrations of serum electrolytes, blood( q3 o( z2 M# m; d" x
urea nitrogen, creatinine, and calcium all were- F0 H6 m. p, C+ U
within normal range for his age. The concentration. l( P# y* Y& n$ \, K5 T! t! |" R
of serum 17-hydroxyprogesterone was 16 ng/dL
+ P" R% M2 d' h; r$ ^/ o; }(normal, 3 to 90 ng/dL), androstenedione was 20
; T% r( X9 m+ \: Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-! b* G% l' t' P3 D4 U" {5 I! ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 [+ ~! x0 F; e$ C/ s1 {! _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* i& ^+ W0 ?5 _6 S, d
49ng/dL), 11-desoxycortisol (specific compound S)
: ?2 {; ?3 o0 C: Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 K3 y5 q: m& ^  X9 l- s
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 ^% b5 ~/ L) O7 K! y* q) w6 r
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* W' ~7 y$ |2 M+ m" r. L
and β-human chorionic gonadotropin was less than
. I/ p# [9 |7 V9 b5 I5 mIU/mL (normal <5 mIU/mL). Serum follicular
( T3 c; L# n; Y7 Zstimulating hormone and leuteinizing hormone5 N2 k, `/ M2 |. {
concentrations were less than 0.05 mIU/mL
/ m$ I1 s, `0 x9 O(prepubertal).
2 g" y6 t. G/ `The parents were notified about the laboratory8 H; s4 V' K* w, t& w
results and were informed that all of the tests were( G! ~7 Y7 l  y1 D. q
normal except the testosterone level was high. The
* t) N5 c% w, `: ?2 o5 jfollow-up visit was arranged within a few weeks to* C( `4 O) x) w% k
obtain testicular and abdominal sonograms; how-2 \6 ?: r: q5 w% T) I, x6 T
ever, the family did not return for 4 months.0 |- B: V1 J( D2 M! H% |* J
Physical examination at this time revealed that the
& t$ x) C, I7 Lchild had grown 2.5 cm in 4 months and had gained
3 U! v. G* @# [5 c2 kg of weight. Physical examination remained/ a" t) w. l+ u% V3 \# ?
unchanged. Surprisingly, the pubic hair almost com-
# z. j5 c/ I5 F$ V4 Opletely disappeared except for a few vellous hairs at0 |9 h2 A$ W0 P7 s
the base of the phallus. Testicular volume was still 2# ?% C/ T1 {. U) v3 j
mL, and the size of the penis remained unchanged.
1 O  h' K: f" r( `; ^6 F& O# zThe mother also said that the boy was no longer hav-. a, ^$ o8 L! g, d& n
ing frequent erections.
4 j7 S4 V3 ~3 f" c* rBoth parents were again questioned about use of  ~9 e$ u. e3 c7 R/ \1 j  z+ t8 u
any ointment/creams that they may have applied to
. @! f: d; S0 C7 Z! S' `1 Pthe child’s skin. This time the father admitted the
5 z: @" A/ ^" ETopical Testosterone Exposure / Bhowmick et al 5413 r% z3 }8 E; F
use of testosterone gel twice daily that he was apply-
, j2 n! X/ V# L- Ping over his own shoulders, chest, and back area for2 H" o: W, l9 g9 F7 [' q  @
a year. The father also revealed he was embarrassed
, i! W$ `* S0 c" D+ I) c, x& Dto disclose that he was using a testosterone gel pre-
6 r+ F/ S5 |* F0 r  ascribed by his family physician for decreased libido
! q2 [3 N' g# U* o6 g4 B  F7 `! Ssecondary to depression.
- h% o7 x1 s) n# q5 A  [/ ?The child slept in the same bed with parents.5 s0 e: }& B0 i2 r; J
The father would hug the baby and hold him on his
6 h$ `$ U- J; H% U+ S8 {/ vchest for a considerable period of time, causing sig-
/ x  _: f& f8 e4 Hnificant bare skin contact between baby and father./ `2 @$ G5 K+ F: p
The father also admitted that after the phone call,
' G# k0 L9 f5 k6 G* ]when he learned the testosterone level in the baby/ ~. Z( F' a8 ^) q. `
was high, he then read the product information! l6 v. G$ m0 e1 m9 @; I! l
packet and concluded that it was most likely the rea-
# H$ b" F8 w' Z( b) N7 n, tson for the child’s virilization. At that time, they: g2 c6 F, B% ]* X
decided to put the baby in a separate bed, and the  K1 P7 e+ M+ _1 i! E; G/ ]
father was not hugging him with bare skin and had
0 U) h. i2 S! T1 b" I' ibeen using protective clothing. A repeat testosterone
4 u6 k$ w& _0 v, \: m/ |test was ordered, but the family did not go to the
9 u6 w6 ]! _$ O- A9 K) }laboratory to obtain the test.
" F+ t5 {% Q, fDiscussion
' v0 g' ?' _( O! h4 u! GPrecocious puberty in boys is defined as secondary
3 H& s% D/ I( Z8 r1 A9 Lsexual development before 9 years of age.1,4
4 F% s* \+ g' G4 Y3 DPrecocious puberty is termed as central (true) when, |, h7 N" B4 u' T0 u
it is caused by the premature activation of hypo-" G/ b2 G5 d" D
thalamic pituitary gonadal axis. CPP is more com-
8 Q" C. p, `! @7 y, l6 Amon in girls than in boys.1,3 Most boys with CPP
8 O3 D# Y- }; j7 u* R% i$ \may have a central nervous system lesion that is
2 f5 g- f. N  _7 lresponsible for the early activation of the hypothal-
7 ]* T$ O: |. f  camic pituitary gonadal axis.1-3 Thus, greater empha-! \% Y" F; Y6 d( M8 e* G! s
sis has been given to neuroradiologic imaging in1 P' G4 j( ]2 [. B0 c  Y
boys with precocious puberty. In addition to viril-
8 a; l  y* j! G8 r; }5 @. j& E$ Fization, the clinical hallmark of CPP is the symmet-4 Y! x3 f, q7 M* c6 c& U& P1 J2 ]
rical testicular growth secondary to stimulation by
" `; o1 V5 J1 Q3 w0 s1 A) bgonadotropins.1,3
' l5 h6 |: u$ w0 D, y& sGonadotropin-independent peripheral preco-
! }& K" Y+ ^# g. l( X: R3 Y% P' s( Mcious puberty in boys also results from inappropriate
, V& }- ^0 E0 M% X  ?/ Fandrogenic stimulation from either endogenous or) @) e9 K/ u% W( ~8 u* n
exogenous sources, nonpituitary gonadotropin stim-& R7 u' t* D" Z; ^4 O6 e4 l
ulation, and rare activating mutations.3 Virilizing+ K0 h' N! \) X1 i! q; g) Q
congenital adrenal hyperplasia producing excessive7 O) r- x" J4 @7 k5 Z
adrenal androgens is a common cause of precocious
3 {7 T7 H$ o% |1 Wpuberty in boys.3,4/ S' D) \$ R' ]. |
The most common form of congenital adrenal
: q% g8 F( ~$ }' Hhyperplasia is the 21-hydroxylase enzyme deficiency.
0 H5 H% C$ h0 m0 r& A4 \The 11-β hydroxylase deficiency may also result in
- ]- K  _, R# p- ?* N5 g( Yexcessive adrenal androgen production, and rarely,+ I8 P4 K3 A; ~
an adrenal tumor may also cause adrenal androgen  s- c- T$ @% ~  Z
excess.1,3% T- U& `& l7 m4 [& c" y3 K( c5 H1 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 |3 G3 Q9 A& v1 w: R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 w5 ~1 v2 s* p: o# H, I! ~A unique entity of male-limited gonadotropin-4 ?% P: k9 U0 |! @' p! R" Y
independent precocious puberty, which is also known" s6 u) g+ W) i# ?+ ?' S0 N) G
as testotoxicosis, may cause precocious puberty at a
; t+ @, V0 o# Z# P0 _  w; Nvery young age. The physical findings in these boys
& E; M1 A) ]9 [& W- _with this disorder are full pubertal development,
) @$ Z* c( x- f7 e! f1 Yincluding bilateral testicular growth, similar to boys8 B3 a7 T8 s$ X# g4 H4 R0 d
with CPP. The gonadotropin levels in this disorder% B& S( d( C: |0 P  O9 ^3 P
are suppressed to prepubertal levels and do not show
  F2 X8 u1 ?( C4 A" Q! xpubertal response of gonadotropin after gonadotropin-* I: S$ Z. J& [- |0 W
releasing hormone stimulation. This is a sex-linked
. V1 S1 J& K2 J' N# J1 V' U- J/ N6 Vautosomal dominant disorder that affects only
% B! M  G0 o+ R! p+ Xmales; therefore, other male members of the family
7 p" Y  B# A" J* E& i: w$ j0 ?/ rmay have similar precocious puberty.3
5 Z$ n" U6 u8 r1 w2 A* L  Z: R% bIn our patient, physical examination was incon-, f9 o+ X+ k6 w) G. a5 h! i- b
sistent with true precocious puberty since his testi-
3 X$ t0 e$ R! u2 T5 ^+ k3 t. j) Xcles were prepubertal in size. However, testotoxicosis
4 i9 i$ U: @2 m" P' S, W& I) kwas in the differential diagnosis because his father
$ N( I3 G; W( X/ v$ pstarted puberty somewhat early, and occasionally,
6 `( U% f' o7 f- o3 W- J& s( Ytesticular enlargement is not that evident in the" a1 W2 P% e2 L" I0 z; A
beginning of this process.1 In the absence of a neg-
* X; u. I2 I( k6 l. b4 g# Vative initial history of androgen exposure, our" t$ B& f* X" L5 b! u2 [& I7 R
biggest concern was virilizing adrenal hyperplasia,' A! w2 |0 |% C+ ?* l! x
either 21-hydroxylase deficiency or 11-β hydroxylase
& |" [7 w& P7 udeficiency. Those diagnoses were excluded by find-) }) u% @. ^  d4 W4 h( K+ U6 C
ing the normal level of adrenal steroids.
* u7 j, f+ E. ^. L/ ]The diagnosis of exogenous androgens was strongly
1 z' x# p! D2 |- bsuspected in a follow-up visit after 4 months because
  c1 U  G' U; M- a8 ythe physical examination revealed the complete disap-
7 F& z/ d8 S4 O, M; s6 tpearance of pubic hair, normal growth velocity, and& j2 u4 l& ?/ W" @
decreased erections. The father admitted using a testos-
2 g5 N  Y  n9 B0 Kterone gel, which he concealed at first visit. He was
' c, l9 E' f) |using it rather frequently, twice a day. The Physicians’8 V+ L+ D/ U" M) v! S" n9 o, R& y; r
Desk Reference, or package insert of this product, gel or' ~2 r; e$ ~' A
cream, cautions about dermal testosterone transfer to
+ H9 z( I- ]* ?unprotected females through direct skin exposure.
8 o0 e5 C/ h6 ?- b/ MSerum testosterone level was found to be 2 times the
' W! R7 A8 m2 _baseline value in those females who were exposed to8 S, S1 j3 {+ ~& j7 T; R. O
even 15 minutes of direct skin contact with their male
6 I" ]3 d, r, h. ?partners.6 However, when a shirt covered the applica-
5 H4 u( U& J" _- Wtion site, this testosterone transfer was prevented.1 V/ |( }% b7 t$ w1 }$ ]# q% b7 a
Our patient’s testosterone level was 60 ng/mL,
! }0 b7 B6 B/ ?7 [which was clearly high. Some studies suggest that1 A( @. U9 i( @; x7 b6 ~
dermal conversion of testosterone to dihydrotestos-
9 F" k& D6 F( J/ N+ |4 `+ }terone, which is a more potent metabolite, is more
; ^5 ]0 z# E8 I; e; u& d% xactive in young children exposed to testosterone! @7 P* Q  Y# E8 x/ w
exogenously7; however, we did not measure a dihy-! `" N! @9 u6 i7 H6 Y) l% e
drotestosterone level in our patient. In addition to
* y# S8 T1 [3 I9 x* Mvirilization, exposure to exogenous testosterone in) t$ i  s* v: [2 v
children results in an increase in growth velocity and
# P' v: E( e% j- }advanced bone age, as seen in our patient.
0 i- o+ H3 Q; l8 X7 IThe long-term effect of androgen exposure during
  X& ?6 N' d, E  kearly childhood on pubertal development and final
/ U" Y( }6 q. y! }' fadult height are not fully known and always remain
$ \7 k& z: C0 H; Y+ \( }a concern. Children treated with short-term testos-
5 q( x6 V; m" |5 d$ K! _# hterone injection or topical androgen may exhibit some/ b) \1 Z  U5 z- M
acceleration of the skeletal maturation; however, after
0 z6 U9 Q6 k# z& E1 L& }. pcessation of treatment, the rate of bone maturation
, ~# Y3 h7 r" ]/ |) |5 @decelerates and gradually returns to normal.8,9/ L- C3 d; s" K6 w
There are conflicting reports and controversy
% K: e/ O" N2 Gover the effect of early androgen exposure on adult
; J# W4 u4 F/ g5 F: C; ~% n3 bpenile length.10,11 Some reports suggest subnormal
; G2 p7 L8 y5 @6 ^% f9 ]" `adult penile length, apparently because of downreg-7 y) I/ n! w8 A, e" K
ulation of androgen receptor number.10,12 However,' X2 X, x( |7 H7 Y7 e: |
Sutherland et al13 did not find a correlation between' b9 [$ K  X8 p/ ?
childhood testosterone exposure and reduced adult
1 j: \, P1 I. S5 |3 `( tpenile length in clinical studies.! d1 C$ d" c5 B2 X1 ^, P# y" o5 Y
Nonetheless, we do not believe our patient is# |/ m' G" i. g- X
going to experience any of the untoward effects from
: N1 ^9 z/ ]3 }+ e, f7 qtestosterone exposure as mentioned earlier because
* V3 }' G6 r7 O6 Uthe exposure was not for a prolonged period of time.
( ^( B1 k+ A# X5 Q. VAlthough the bone age was advanced at the time of
5 s4 d- X. q' xdiagnosis, the child had a normal growth velocity at
1 `3 Z, d, Z( dthe follow-up visit. It is hoped that his final adult
2 ]) f( o) w: j' gheight will not be affected.7 F0 D/ a8 R3 V( ~8 Q; t
Although rarely reported, the widespread avail-
+ r7 B9 p% G8 ]7 k" b. q/ Kability of androgen products in our society may
5 Y# o7 ]$ t( b6 _  Y& s% H3 v+ Rindeed cause more virilization in male or female
8 L% ?+ `& U1 d: t- W  g; Mchildren than one would realize. Exposure to andro-
' ^* p' A% R) @' [# \1 _# @gen products must be considered and specific ques-
9 P; R& M9 q. \5 X: }0 L* W5 g. @tioning about the use of a testosterone product or7 e% Y* B3 H7 y& Y4 y) w
gel should be asked of the family members during
" x# }& {: g9 x( M; d4 y+ [6 f' {! Jthe evaluation of any children who present with vir-
" Q  i1 m$ r/ I7 j3 X) C: Cilization or peripheral precocious puberty. The diag-! r/ M/ I% [) ^) i: B
nosis can be established by just a few tests and by; F- J7 Y# }0 V/ c* B6 F8 R( u/ B/ _3 w
appropriate history. The inability to obtain such a
1 j; m/ }' i6 o7 q: ?. S( rhistory, or failure to ask the specific questions, may# v. k+ {1 U5 i# \) h. A# t; |
result in extensive, unnecessary, and expensive7 t0 o7 p/ n, r" a# y: a
investigation. The primary care physician should be  f  l7 i. Q* S! O5 j5 m
aware of this fact, because most of these children
) P8 W; h' L8 ~# |may initially present in their practice. The Physicians’
2 V4 y  ~! j* r0 YDesk Reference and package insert should also put a0 s+ {* j* B' s
warning about the virilizing effect on a male or0 ]7 M, w$ o+ ]; j: c$ [% u
female child who might come in contact with some-: `' `9 b% H+ X, n/ N- g
one using any of these products." a# j7 D* c$ M7 n$ s
References) s" R! v' I6 _
1. Styne DM. The testes: disorder of sexual differentiation; a& }( o% z. N6 c4 d7 I
and puberty in the male. In: Sperling MA, ed. Pediatric: U% L; M6 K  o$ T, V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# d6 J1 Z$ z1 H6 @: j) D2002: 565-628.
1 B1 ^4 u# E  D5 ^3 F+ p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 L4 G: ]9 b( y* p- \( apuberty 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

  V3 ?. n8 j+ L, F& R( E1 u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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