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Sexual Precocity in a 16-Month-Old
( ~! f4 F, _6 f6 ^1 ]Boy Induced by Indirect Topical
* ~( |, {% B  i9 ?& D% ^! vExposure to Testosterone
1 i2 d1 ~3 k# E" K) }2 t# lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ t8 X! t6 `" P5 b/ ~8 {% Xand Kenneth R. Rettig, MD1
* F7 }2 U5 H% M1 FClinical Pediatrics
* n$ ]8 H# r. x! RVolume 46 Number 65 G& Q; d: l0 i" _; m# K/ v
July 2007 540-543- s- }) \& A1 N  N9 x3 J
© 2007 Sage Publications
9 V# u) E# F! `  n- S10.1177/00099228062966513 U* z5 a4 Z* D9 G, ^9 \$ L0 _  ^- y' H5 J
http://clp.sagepub.com
. n' `3 D& q# F5 I% v8 h( V; Q  Xhosted at% ?" r) y/ l+ q9 k, }# O3 x' w  ~
http://online.sagepub.com& _: G! \) I$ R* ]0 V: D
Precocious puberty in boys, central or peripheral,3 T: u3 P7 e2 p* C
is a significant concern for physicians. Central# d" |5 S! J0 q
precocious puberty (CPP), which is mediated
) [) E6 r/ u/ gthrough the hypothalamic pituitary gonadal axis, has8 @+ W1 Q- r. ]9 m
a higher incidence of organic central nervous system
* D/ G% z, z  hlesions in boys.1,2 Virilization in boys, as manifested# i+ m7 h. p% ?& K  J6 K( u
by enlargement of the penis, development of pubic
# @/ A! j( l7 |: E9 Z. Phair, and facial acne without enlargement of testi-
1 |6 ?, D4 y4 X# Z3 t! |cles, suggests peripheral or pseudopuberty.1-3 We
# ^( S. h9 j/ ?, \report a 16-month-old boy who presented with the1 z( b- u+ E7 ?3 |5 K! Z2 v
enlargement of the phallus and pubic hair develop-
" I+ s; g4 G3 a$ Z* Nment without testicular enlargement, which was due
+ ~1 e# x5 r' I- `% Cto the unintentional exposure to androgen gel used by
3 U  C. t2 @" `/ @2 i2 S# d. T9 rthe father. The family initially concealed this infor-
& a( q. j7 k/ L/ ~& cmation, resulting in an extensive work-up for this& b8 ?/ b' b3 R4 s- F: A2 d. [, b% ?4 S
child. Given the widespread and easy availability of' I. d( d* Q9 n* I1 K# B
testosterone gel and cream, we believe this is proba-7 Z% h3 b3 \2 ?4 q
bly more common than the rare case report in the
: {1 F  n. d* j( V+ Jliterature.4
. g" C' j% ~$ V; Z) gPatient Report
. ?2 f! {* }6 a' Z- k/ d5 ?; A  AA 16-month-old white child was referred to the+ m0 Y* }( @8 x2 s
endocrine clinic by his pediatrician with the concern4 L: u# X# d. B9 C
of early sexual development. His mother noticed6 F) M' n, e: h9 U/ r4 Q! c
light colored pubic hair development when he was
! [4 v# c. g) z; t: n$ xFrom the 1Division of Pediatric Endocrinology, 2University of) G6 z/ ?) u! T, Z4 k" d
South Alabama Medical Center, Mobile, Alabama.& ]7 h0 i# w- @. {+ L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. n; I: J3 P, {* Q, RProfessor of Pediatrics, University of South Alabama, College of& ]/ |# I6 t! _7 V& {+ l9 G7 N9 R
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! y9 o; A$ P! s: D1 a) Ie-mail: [email protected].
; j* m% d/ M+ o, Eabout 6 to 7 months old, which progressively became
: i/ B: J) O) v( Udarker. She was also concerned about the enlarge-0 i" i) `8 W6 K8 y3 \
ment of his penis and frequent erections. The child+ [9 m! \& [: M  ?  z7 G: T( k
was the product of a full-term normal delivery, with& g* o; P) p* L" h7 z
a birth weight of 7 lb 14 oz, and birth length of/ X' q6 X: `, y, m/ j
20 inches. He was breast-fed throughout the first year2 F' m" Z1 ^( Z* o# l
of life and was still receiving breast milk along with
; X( m4 _& c; n/ X/ r/ S' h# Vsolid food. He had no hospitalizations or surgery,
, G& q  r, y* x' {and his psychosocial and psychomotor development
. r0 u9 |9 W/ o9 z( G$ ywas age appropriate.
3 i  h' h6 @- w0 n/ ]) }3 ]2 A9 |The family history was remarkable for the father,
! L6 d: m7 @* ]0 V7 L1 K2 ?who was diagnosed with hypothyroidism at age 16,
2 s9 k4 k' N( \* i7 ~- Z, jwhich was treated with thyroxine. The father’s
0 ~$ [2 N- A* X, ?# e, [9 Kheight was 6 feet, and he went through a somewhat) S1 B5 C) }+ J4 h; R" [- k
early puberty and had stopped growing by age 14.# x. Z& m5 I" Z: G
The father denied taking any other medication. The5 m9 l+ s8 |1 o/ r6 w$ O' x1 s
child’s mother was in good health. Her menarche+ e% r' ~% W7 O8 l
was at 11 years of age, and her height was at 5 feet
1 }% s  w0 s: Q6 t) s/ ^5 inches. There was no other family history of pre-" D6 s. }, W4 o% V' `
cocious sexual development in the first-degree rela-6 N. D7 v$ w) a' p9 _
tives. There were no siblings.: r4 y$ D6 e9 J% N. R! _
Physical Examination
9 e7 A' ~$ r6 Y5 wThe physical examination revealed a very active,3 h8 {/ K9 u! ^  t1 \1 Q+ P5 L
playful, and healthy boy. The vital signs documented* F7 ?+ V: S6 [) @
a blood pressure of 85/50 mm Hg, his length was
. J8 o) D" Y7 u& S1 E' g90 cm (>97th percentile), and his weight was 14.4 kg
6 p5 O" j$ s# K) W1 }(also >97th percentile). The observed yearly growth
& `: |0 m( H8 C/ S, vvelocity was 30 cm (12 inches). The examination of
# t4 m3 \0 c4 T! athe neck revealed no thyroid enlargement.; w( `2 ?/ g0 `0 W
The genitourinary examination was remarkable for
5 e4 b) X" a0 M- Tenlargement of the penis, with a stretched length of: Y1 F' b" A) }* U$ A3 E
8 cm and a width of 2 cm. The glans penis was very well8 P9 f: e& Y8 V  G3 f
developed. The pubic hair was Tanner II, mostly around
! Y" c& N  z0 Z  O( d+ V& X540
  O( J- l+ {5 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" G* D0 c' e& v* p9 Pthe base of the phallus and was dark and curled. The
2 V& M! e, x. Q& @" t8 }testicular volume was prepubertal at 2 mL each.5 V/ v8 B9 i4 ]4 T0 D
The skin was moist and smooth and somewhat$ o! k  p! P' r2 y9 _
oily. No axillary hair was noted. There were no0 A1 m, p/ A" {4 F" P; x0 Q
abnormal skin pigmentations or café-au-lait spots.0 K  S2 x1 o4 x! ^* ^! a3 g
Neurologic evaluation showed deep tendon reflex 2+) ^4 s$ a! c9 u& o
bilateral and symmetrical. There was no suggestion
# G& I1 L+ W. g4 `% {+ Yof papilledema.
" D6 ~( [* ^! s% o4 g6 ?- b% d7 rLaboratory Evaluation8 J5 N0 O# K& Y, `
The bone age was consistent with 28 months by4 e* d8 m0 W/ y% A( L8 u) r) a$ B
using the standard of Greulich and Pyle at a chrono-) d7 Z4 N/ Z6 E% D
logic age of 16 months (advanced).5 Chromosomal
8 {' p# M# N- b1 {karyotype was 46XY. The thyroid function test1 t6 E- ^0 L& w0 e5 M& e
showed a free T4 of 1.69 ng/dL, and thyroid stimu-  W5 I& y8 t' z7 E3 a* J% u# n" I$ P
lating hormone level was 1.3 µIU/mL (both normal).
# o" c$ w: _, gThe concentrations of serum electrolytes, blood
# W) L3 \0 v4 N7 Gurea nitrogen, creatinine, and calcium all were5 g4 B# `. @8 q2 G
within normal range for his age. The concentration
, U: ]7 u3 t0 h8 V0 @) T! Y$ o; ~of serum 17-hydroxyprogesterone was 16 ng/dL
& f- A+ v4 U# _* k! h4 [% W1 ]) z(normal, 3 to 90 ng/dL), androstenedione was 20& r5 d1 h% {0 `5 i
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 J4 f4 p9 ]# V0 d% U; r* m
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% E3 j$ N" b, ]; X+ b1 B9 Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ y# E. t, v; L& q49ng/dL), 11-desoxycortisol (specific compound S)
) S( ]/ |5 Y+ Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  f+ }; h- v2 t, a/ w  u1 L
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: }7 C$ F1 D9 b- n7 j$ d& R% k# ^testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& b$ d3 M  V7 ]& X* c0 band β-human chorionic gonadotropin was less than- v( \" c& Q, N, |
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 s' E) `; m5 c& p9 k
stimulating hormone and leuteinizing hormone+ |9 o9 l8 C, W# o- B9 {, d
concentrations were less than 0.05 mIU/mL; `) H/ {' D) w' X# @+ j5 T
(prepubertal)./ o  Y. v% V6 |3 S
The parents were notified about the laboratory
2 a7 L! g6 i: M7 h) Kresults and were informed that all of the tests were; J( F$ N2 c2 L1 g
normal except the testosterone level was high. The
6 d3 u: ]( {6 [  q! Ofollow-up visit was arranged within a few weeks to" G) e+ ]1 t3 G
obtain testicular and abdominal sonograms; how-. y( j& t( t* G0 g& @2 j6 k
ever, the family did not return for 4 months.. ]+ x" A$ O5 ^4 N, p; {8 G
Physical examination at this time revealed that the' w4 q0 K/ `6 `1 ~5 k) M0 e" B
child had grown 2.5 cm in 4 months and had gained
2 V% I% N, A) y! M7 g% Z2 kg of weight. Physical examination remained
4 [6 ~1 v8 x" Ounchanged. Surprisingly, the pubic hair almost com-( B4 |" a( n! `3 p5 b3 _
pletely disappeared except for a few vellous hairs at
3 f, O+ n. ~  N1 L# e  ^the base of the phallus. Testicular volume was still 2& G+ k( S/ D2 Q4 p( R
mL, and the size of the penis remained unchanged.
& D( G# s3 e% a* c/ RThe mother also said that the boy was no longer hav-# f. A$ ]# D3 b+ K9 E! ]6 X. y
ing frequent erections.- ^: k7 a* n( h  P$ Y) T& h
Both parents were again questioned about use of
0 V6 ]1 R: w/ e5 ^any ointment/creams that they may have applied to
9 x6 U6 X9 q0 E' kthe child’s skin. This time the father admitted the. J. r/ c$ V, f5 _6 t
Topical Testosterone Exposure / Bhowmick et al 5415 n$ L# o4 g% ?6 P
use of testosterone gel twice daily that he was apply-
* @) x) \1 t! x- o3 ~! }1 X, ding over his own shoulders, chest, and back area for
3 X! T4 j5 P  C7 f" J9 ?9 A$ _# _a year. The father also revealed he was embarrassed& ?5 }4 j- c  |& B- N, h$ ^
to disclose that he was using a testosterone gel pre-9 r! q8 u, {; R) S& a
scribed by his family physician for decreased libido0 S* G) V! W# `" V% g3 l- W
secondary to depression.5 d* Y8 t5 {: T4 ^( E
The child slept in the same bed with parents.
, G2 @0 [) N+ o0 t4 bThe father would hug the baby and hold him on his# g5 i  J8 ^# X% h/ C  E, n* l
chest for a considerable period of time, causing sig-) @9 x* o, R* C$ K
nificant bare skin contact between baby and father.
; F1 ?" T9 p: l, }$ V8 IThe father also admitted that after the phone call,
3 ?; _. p3 z2 X0 Y* nwhen he learned the testosterone level in the baby8 j3 B- q" f0 L
was high, he then read the product information$ m1 K; r7 {4 p* ~
packet and concluded that it was most likely the rea-$ m- Y* i5 _. m3 f. c/ _/ v- O
son for the child’s virilization. At that time, they
' _: t8 c) R" e1 Y. ?7 W* ^+ K6 |decided to put the baby in a separate bed, and the5 x, B' p1 b2 J) G3 e; ^" l
father was not hugging him with bare skin and had& C6 Y2 A  J; s1 `. I- o2 z
been using protective clothing. A repeat testosterone
5 B5 A- Y/ H) X2 ctest was ordered, but the family did not go to the- j4 d& l# F/ _( e" M9 [- P: n
laboratory to obtain the test./ z% G3 n) w5 a% k( A  @
Discussion5 W* d4 l" T- g! O, l
Precocious puberty in boys is defined as secondary
" i8 L- ]. D/ k$ w2 r2 m& zsexual development before 9 years of age.1,45 Q- o* `0 W9 h; W/ \
Precocious puberty is termed as central (true) when
, N1 H4 Q+ x5 I. Y) \, @it is caused by the premature activation of hypo-: t4 L+ W4 O+ G5 B0 F: G8 }7 \0 i) ?
thalamic pituitary gonadal axis. CPP is more com-
: j1 H) e9 j' l* ymon in girls than in boys.1,3 Most boys with CPP
" i5 n, A- K, }- Cmay have a central nervous system lesion that is
# R+ [/ \# Z4 M+ jresponsible for the early activation of the hypothal-
- t. i* o# X2 d5 W( xamic pituitary gonadal axis.1-3 Thus, greater empha-
" y- L* Q, T" d2 Tsis has been given to neuroradiologic imaging in
6 f7 r& {& p3 i4 C7 u7 m+ B" Jboys with precocious puberty. In addition to viril-' F; ?* m: N8 M# k1 L
ization, the clinical hallmark of CPP is the symmet-5 y* r5 s9 @2 w; C: N  Y' l2 Q1 r
rical testicular growth secondary to stimulation by
4 V* w) U4 Z2 a9 Xgonadotropins.1,3
& L6 `, F1 {) x! Z! E  @& y6 ~! BGonadotropin-independent peripheral preco-" [: p* I; D# Y5 S- _( A
cious puberty in boys also results from inappropriate2 p2 w+ u2 Q- X0 m
androgenic stimulation from either endogenous or8 @/ O& ^7 |$ r  V! U" @; Z
exogenous sources, nonpituitary gonadotropin stim-7 j  y6 \/ `$ c$ U/ S) _
ulation, and rare activating mutations.3 Virilizing
, o/ _0 k9 u; Qcongenital adrenal hyperplasia producing excessive
/ N4 I  k/ h- [( e, Tadrenal androgens is a common cause of precocious, q* [  j, [  }" ?4 T1 p6 z
puberty in boys.3,4' S8 @! f3 ?7 _% {
The most common form of congenital adrenal
- T8 h) C5 n# h  D9 W& u* {hyperplasia is the 21-hydroxylase enzyme deficiency.
" T1 C, E: c; v! R/ F) zThe 11-β hydroxylase deficiency may also result in
  L5 _  C2 G5 p$ w! J. b5 o$ h0 C/ K: \" Yexcessive adrenal androgen production, and rarely,# u5 T7 d" S: k  s
an adrenal tumor may also cause adrenal androgen
' l2 P/ r: D- D# R  v9 Y1 m$ w& Jexcess.1,3
8 E, U" u/ K8 E; v- ?% G% eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ p- |/ V$ B. D542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" `( y2 N0 c% `+ S6 T4 E8 DA unique entity of male-limited gonadotropin-2 z  \9 Y0 u% m- M
independent precocious puberty, which is also known
$ K6 ^& L& N$ t9 t! q. e/ V' @8 [as testotoxicosis, may cause precocious puberty at a( n* K  h+ G; e- p' I
very young age. The physical findings in these boys
% @$ k' a+ n3 Zwith this disorder are full pubertal development,
; G- ]- F# g  |including bilateral testicular growth, similar to boys
+ Q1 M/ l2 Z* d5 D3 f$ o$ ^with CPP. The gonadotropin levels in this disorder
: {  P5 b, a9 ^) G3 Oare suppressed to prepubertal levels and do not show3 ^: o/ v/ \& q3 L& O. F# T) Y
pubertal response of gonadotropin after gonadotropin-
, p/ a, G6 H" f2 ^releasing hormone stimulation. This is a sex-linked
7 ~9 f* o- F) I: e; o+ b. fautosomal dominant disorder that affects only
+ B( m$ F4 M! }2 E# u. Bmales; therefore, other male members of the family% I; j- A4 _( J" U/ v8 w5 t
may have similar precocious puberty.3
" k; ~4 y4 M) B: ?! E1 {) B9 XIn our patient, physical examination was incon-$ f. c1 t1 ]0 A4 J* H2 n9 J
sistent with true precocious puberty since his testi-8 t5 b9 w  W2 n' m% G  O
cles were prepubertal in size. However, testotoxicosis
" D; @; _7 v! dwas in the differential diagnosis because his father1 ^: }8 V% Y, k
started puberty somewhat early, and occasionally,6 w2 E& l; H9 h9 Q* W5 a
testicular enlargement is not that evident in the
; [- w; q* a5 }beginning of this process.1 In the absence of a neg-- N( K" f! c, _& {
ative initial history of androgen exposure, our
4 |1 g* Y7 [9 T; a4 h1 Xbiggest concern was virilizing adrenal hyperplasia,5 Y2 e  m) x# U
either 21-hydroxylase deficiency or 11-β hydroxylase
/ X( B1 Q1 m$ d6 @0 P3 `2 hdeficiency. Those diagnoses were excluded by find-$ @# L; c; T  a7 g$ n
ing the normal level of adrenal steroids.! j2 p  X8 Z# H4 q. o; R
The diagnosis of exogenous androgens was strongly) I6 c4 Z' {7 i; p$ q0 W
suspected in a follow-up visit after 4 months because
  S1 H3 J" E5 d# h4 cthe physical examination revealed the complete disap-3 y& p4 I6 k4 S8 D$ _# K; N
pearance of pubic hair, normal growth velocity, and
# l1 ?+ `2 Z7 X3 k) jdecreased erections. The father admitted using a testos-
7 N" q2 \# ^0 q, f( ~terone gel, which he concealed at first visit. He was
; [/ ^. ]/ j! D. d4 w, f+ {0 `using it rather frequently, twice a day. The Physicians’
  O9 R; {5 g6 t4 {5 |Desk Reference, or package insert of this product, gel or+ e! X% i' d* Y' W
cream, cautions about dermal testosterone transfer to# p0 h1 L" c6 D5 B7 K8 J% `$ o9 z
unprotected females through direct skin exposure.2 L$ Z) ]6 V. P" o# u0 t
Serum testosterone level was found to be 2 times the
% F+ L& X' L+ p5 D% N6 pbaseline value in those females who were exposed to/ w  S+ s/ |) R/ e0 y+ F. c
even 15 minutes of direct skin contact with their male+ w" c" `& J6 q, l1 ], q
partners.6 However, when a shirt covered the applica-
  n) ?; D% H, R; Ytion site, this testosterone transfer was prevented.
9 k5 x% ]# T' v& r( i5 f+ d( B$ zOur patient’s testosterone level was 60 ng/mL,
' k* c, B: r' S$ c# ?which was clearly high. Some studies suggest that. x; c% Y# d. L2 V' V
dermal conversion of testosterone to dihydrotestos-2 E6 }9 u( F- y$ f# T( f7 b% s0 f8 D
terone, which is a more potent metabolite, is more
' B$ E  R9 |9 o' \active in young children exposed to testosterone
4 g+ z8 a. i+ ^" ]# D7 b5 y$ Q4 sexogenously7; however, we did not measure a dihy-9 m; B% z- [: d, n- u
drotestosterone level in our patient. In addition to
' e$ x! U$ u# \, |5 [- Rvirilization, exposure to exogenous testosterone in" \" `9 {9 g: l2 q$ }5 D6 c8 A
children results in an increase in growth velocity and4 q% ^. _2 U( ^
advanced bone age, as seen in our patient.
2 ?+ p8 A6 n1 Q' ]6 yThe long-term effect of androgen exposure during
' l  u7 X0 J6 k! ~; ?5 pearly childhood on pubertal development and final
- ?8 w  J. h0 _: J- P  t$ Padult height are not fully known and always remain7 I: I3 V) S/ q4 W1 a3 P6 E" E7 U7 S
a concern. Children treated with short-term testos-$ o. B( @/ ?/ y) L6 q- P6 r3 z
terone injection or topical androgen may exhibit some( _4 f2 ?% H0 G) c5 i8 u, n- U
acceleration of the skeletal maturation; however, after
2 N$ {* D9 _: {. tcessation of treatment, the rate of bone maturation
- M2 ~4 o9 P* o# A1 i% Tdecelerates and gradually returns to normal.8,9
1 P  \7 H( w* F7 @$ R9 l3 \- E/ dThere are conflicting reports and controversy- R) E% T* H4 n7 x$ E
over the effect of early androgen exposure on adult
: g( D' o9 [5 v0 F% hpenile length.10,11 Some reports suggest subnormal
+ e! n! C0 q* n6 }  l' Cadult penile length, apparently because of downreg-
: V/ W$ @. E# iulation of androgen receptor number.10,12 However,* O+ i$ w% O; ^
Sutherland et al13 did not find a correlation between( H8 \8 s5 x: a
childhood testosterone exposure and reduced adult
* J. M5 V, i) h4 s4 G9 p) t# gpenile length in clinical studies.5 L' E& W% R4 @* W' Y
Nonetheless, we do not believe our patient is2 ]6 D4 s7 K$ E) @8 s' `
going to experience any of the untoward effects from
4 I) n+ A3 q  d  h/ t. atestosterone exposure as mentioned earlier because" K- v7 e/ g& o8 P
the exposure was not for a prolonged period of time.
( L& R4 g" A7 v2 VAlthough the bone age was advanced at the time of2 e# q3 G3 b8 ?5 N8 Y, U
diagnosis, the child had a normal growth velocity at5 a. A7 A  \0 b! K7 y+ |/ K
the follow-up visit. It is hoped that his final adult5 h6 U& l# n1 `4 E5 d! B( o
height will not be affected.
, t9 d* Z2 g# T+ Y% S1 bAlthough rarely reported, the widespread avail-& c2 F5 ~0 k& \# W' X+ d- |% k
ability of androgen products in our society may9 I: n/ v# c* \3 @1 B6 `- ?" v
indeed cause more virilization in male or female9 C" c: E& M% n# M" s
children than one would realize. Exposure to andro-
, ?- ^; I& g9 ^. d$ A' x' cgen products must be considered and specific ques-
% R& _/ `/ A8 h( ntioning about the use of a testosterone product or
1 Z/ l/ U' m, igel should be asked of the family members during( x) B# d8 _! G6 N
the evaluation of any children who present with vir-+ D7 W/ F; Y3 F& y8 @* k4 q
ilization or peripheral precocious puberty. The diag-* S- S4 k0 [% n' S
nosis can be established by just a few tests and by7 e* @" i" c9 C
appropriate history. The inability to obtain such a4 J4 S6 e4 J! x; r) t6 l. t
history, or failure to ask the specific questions, may- u: E/ g6 D% t0 x6 Q
result in extensive, unnecessary, and expensive
' F/ s- ]1 A  |5 y6 d9 Minvestigation. The primary care physician should be
- `( P. f3 R; z% `* l5 u% K8 t  Taware of this fact, because most of these children7 t# H. c/ q. F( I) @4 N
may initially present in their practice. The Physicians’9 {4 ^$ Y2 h! ]0 k+ a) `! s: Y
Desk Reference and package insert should also put a
2 e; O7 D2 D. ~' z3 s; Ywarning about the virilizing effect on a male or6 f5 T5 q9 ?& z1 y6 Y1 |
female child who might come in contact with some-
/ n6 O0 K9 I) C) C0 x1 F9 fone using any of these products.
* j9 \2 \4 A# r1 H8 r, wReferences
* C6 c# ?6 H% M* \2 m  W1. Styne DM. The testes: disorder of sexual differentiation- F- `, ]1 x( q
and puberty in the male. In: Sperling MA, ed. Pediatric
. W$ e5 |5 X; t" m/ C( [+ L: }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 ^. R) v& O* ?) K2002: 565-628.
7 ~, t" `$ r/ k4 \1 p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; q1 @, E9 a& E' r1 f8 G* C
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old# i, J! g% u& v; N* {+ j+ y
Boy Induced by Indirect Topical1 f" h" p# o/ i
Exposure to Testosterone
+ w( A2 C9 o& ^5 sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 E' ^) a3 ]0 ]6 ?% qand Kenneth R. Rettig, MD16 ]( l7 Y9 E, a  i  p+ P
Clinical Pediatrics
- ?9 j& G: |. cVolume 46 Number 6; K$ k& \' Z0 e4 F; K& n( v( V
July 2007 540-543
) P8 X. H8 _2 i6 ^' t3 y- C2 N" h© 2007 Sage Publications- g/ x4 p; |7 h0 J4 s$ ]7 p- A) P
10.1177/0009922806296651
6 R6 `5 y, m5 Q  K2 Nhttp://clp.sagepub.com
" T0 J% K7 E0 ?5 O  _  U  `hosted at4 g5 m6 r0 _7 o% }1 i' b
http://online.sagepub.com2 _/ u+ z# K2 y! |! v$ |
Precocious puberty in boys, central or peripheral,/ K8 v6 z4 H1 ?9 H! `
is a significant concern for physicians. Central8 W5 }9 b) W5 X, M. G) p5 r
precocious puberty (CPP), which is mediated1 c/ f6 l, \' b- p  Z6 ^" H2 F
through the hypothalamic pituitary gonadal axis, has" p, N$ m& @& @; m8 E* H& r- A" w
a higher incidence of organic central nervous system7 ~! s: @+ S6 u* S4 o
lesions in boys.1,2 Virilization in boys, as manifested* T5 g& Y( T9 Y3 P. a1 H8 a. d3 O6 t
by enlargement of the penis, development of pubic4 i& H/ h6 D5 x9 j' W
hair, and facial acne without enlargement of testi-
% |. q2 k  S9 k4 I/ b" Wcles, suggests peripheral or pseudopuberty.1-3 We
0 O7 U) Q- S2 B; M9 d  f; zreport a 16-month-old boy who presented with the- j; f+ D  h: R& L0 |
enlargement of the phallus and pubic hair develop-
/ }* M& Q, @6 g. N2 z( s4 Pment without testicular enlargement, which was due9 Z  F. A5 g5 g' m! I# E5 K, h
to the unintentional exposure to androgen gel used by
- H0 b9 ]( v# N& |  bthe father. The family initially concealed this infor-
0 P$ A# I# L3 k( T$ m) L" }mation, resulting in an extensive work-up for this: M5 n5 P+ n; v
child. Given the widespread and easy availability of8 N5 ?5 @3 `9 l: c
testosterone gel and cream, we believe this is proba-" q9 t. n2 `/ f/ t
bly more common than the rare case report in the2 n) s! @% K( l
literature.4
4 i  s$ F: B2 K& YPatient Report
0 f5 ~& Q( G) M3 h. PA 16-month-old white child was referred to the
' F; q- N1 w. \6 H. ]6 i, Vendocrine clinic by his pediatrician with the concern
  ?0 B4 j; V# Q/ n# t7 ~! ?3 s: uof early sexual development. His mother noticed0 D6 ?0 g" h) Q. F* B6 j
light colored pubic hair development when he was4 m5 c6 [2 M0 Q( d# r; q
From the 1Division of Pediatric Endocrinology, 2University of
( p! I1 h7 }! p: FSouth Alabama Medical Center, Mobile, Alabama.
# d) P* i6 p, `  a* l6 Y2 ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ n( z, Q! [/ |) E) D3 f
Professor of Pediatrics, University of South Alabama, College of6 h) L" K6 Y1 l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* O& ~' i, n" ]% G3 Ke-mail: [email protected].6 W' M! p7 _8 i! S
about 6 to 7 months old, which progressively became
4 y+ @8 F5 E/ Udarker. She was also concerned about the enlarge-
* L" u: m. H( ~2 D9 }! Cment of his penis and frequent erections. The child8 o# ]. X0 C2 K0 H  z9 s, r* g) `
was the product of a full-term normal delivery, with
4 |. Q# Z% J* D' U6 ~: ]( E  La birth weight of 7 lb 14 oz, and birth length of
7 I2 d: o, f: y) U% B0 o8 V20 inches. He was breast-fed throughout the first year
' r9 }. B! ?# {) F2 v* e8 |) N( dof life and was still receiving breast milk along with
; h' ?% E* m( Q8 x  Y9 ^9 Xsolid food. He had no hospitalizations or surgery,# X4 a8 u/ M8 z+ X2 k  c
and his psychosocial and psychomotor development; n# a/ d) T, G
was age appropriate.
0 W+ T# s1 B5 p, VThe family history was remarkable for the father,
- R- k# }) m' J2 N5 [1 ~3 Twho was diagnosed with hypothyroidism at age 16,& J" O+ f0 |" F
which was treated with thyroxine. The father’s  X( ]9 P% s! j$ I' g3 Z2 X1 G5 A
height was 6 feet, and he went through a somewhat3 M; q# `" ^' E) F- V
early puberty and had stopped growing by age 14.
5 I) C3 r& _) IThe father denied taking any other medication. The% ^2 ^  L9 ]) b2 }
child’s mother was in good health. Her menarche$ V" H1 z. E; h5 b- q
was at 11 years of age, and her height was at 5 feet5 i; ^; w% X& W) `
5 inches. There was no other family history of pre-. \+ h" p3 i) c) v+ A
cocious sexual development in the first-degree rela-
1 N9 R7 e; ?& [2 Rtives. There were no siblings.
0 r7 ~) d/ A0 A& \' DPhysical Examination. F: H' X; W+ q5 Y
The physical examination revealed a very active,. }9 r0 m, F0 X9 A5 t7 F
playful, and healthy boy. The vital signs documented
/ P+ O. u. p5 N$ G  s. ia blood pressure of 85/50 mm Hg, his length was
3 h3 l. x( @. L/ F$ x; }  C1 C1 d) b90 cm (>97th percentile), and his weight was 14.4 kg
3 a+ u- I0 |( [: a; |2 ?- c, t* t(also >97th percentile). The observed yearly growth
* v+ x# S9 m9 evelocity was 30 cm (12 inches). The examination of& B% ~4 `' X+ u" X+ B( M$ v
the neck revealed no thyroid enlargement.( G) w8 ]  k" D4 u. H; y
The genitourinary examination was remarkable for- y7 f# G9 q& ~* g) P, S" \
enlargement of the penis, with a stretched length of
" [& S# g+ `4 N5 I; y' e. {5 s8 cm and a width of 2 cm. The glans penis was very well# f3 y& x/ y4 K
developed. The pubic hair was Tanner II, mostly around7 X7 r4 v" |( ?
540
, s: r* i" ]! z1 _at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& ^  k" K# J2 i
the base of the phallus and was dark and curled. The% R& R+ n& a  @& J. X& L4 F
testicular volume was prepubertal at 2 mL each.
/ C1 `) H( o. @, H) qThe skin was moist and smooth and somewhat
: w4 d. A! G! `7 B7 ^oily. No axillary hair was noted. There were no/ I* D( W9 X) W2 u
abnormal skin pigmentations or café-au-lait spots.
7 ^' N. ~  w) J: u1 O; eNeurologic evaluation showed deep tendon reflex 2+9 h% ]- ~. K: u  A& ]
bilateral and symmetrical. There was no suggestion+ J2 C. _# Q2 |
of papilledema.6 P) |) M( f5 W% c% |
Laboratory Evaluation5 \7 B: e9 o, m% D+ e) h
The bone age was consistent with 28 months by) k* s; V$ l  e
using the standard of Greulich and Pyle at a chrono-- l; ]; r5 n! i& C1 I1 L3 }
logic age of 16 months (advanced).5 Chromosomal
# j; z1 a9 C3 l7 P  ?7 [# L: i. lkaryotype was 46XY. The thyroid function test7 [! a+ L2 K2 T& L; N1 Q8 F; H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, u/ U" A2 h' w1 Klating hormone level was 1.3 µIU/mL (both normal).7 `8 e' R! z! n9 ^# u
The concentrations of serum electrolytes, blood
% a4 T3 e1 o3 Q# G- kurea nitrogen, creatinine, and calcium all were
& u% m! p0 m' J3 @7 m6 cwithin normal range for his age. The concentration
, w9 _# o0 H) c" Bof serum 17-hydroxyprogesterone was 16 ng/dL+ c0 ~8 }5 l# S+ i2 P0 T* Z4 c
(normal, 3 to 90 ng/dL), androstenedione was 20
4 H3 b5 k. ^* Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: }, @. O! t; e2 B+ T' f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 W! {. R9 V1 N& o1 ^4 |' Jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to7 X4 ~! @) {8 K1 W$ N
49ng/dL), 11-desoxycortisol (specific compound S)
7 g0 p' W: J. J4 {* y7 ~. k) Fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( i8 p5 X# y8 ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# X: b* W9 k) g3 t$ M! }testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 }  ?% F* m* b3 y3 yand β-human chorionic gonadotropin was less than
/ O% Z- z& m: f; P! Y, t/ y5 mIU/mL (normal <5 mIU/mL). Serum follicular* ~& }: D2 z! O( p! j
stimulating hormone and leuteinizing hormone
$ _. e  \) h" Y) ?2 f$ ~concentrations were less than 0.05 mIU/mL% n8 T4 Q2 w3 M0 S- a: u6 @% z
(prepubertal)./ u' F. g+ s9 S- E
The parents were notified about the laboratory
2 |  n1 J; {3 W0 n; Nresults and were informed that all of the tests were
& J9 p( }1 \6 j2 Unormal except the testosterone level was high. The; T/ E6 z% d0 s/ S6 P; u
follow-up visit was arranged within a few weeks to
+ ^8 f+ e8 H( @# l3 r) Y2 Q! lobtain testicular and abdominal sonograms; how-
& d4 A, I2 C) w$ F" |# Pever, the family did not return for 4 months." J3 A! V! L+ V* w" D- H0 a
Physical examination at this time revealed that the
, N6 ]6 V+ X; T% }7 A9 t" @4 ^# schild had grown 2.5 cm in 4 months and had gained
1 r1 y3 ?7 h8 y2 E) t) K2 kg of weight. Physical examination remained
, a3 b' E/ k9 h' W& Uunchanged. Surprisingly, the pubic hair almost com-
) B( f1 m  d' dpletely disappeared except for a few vellous hairs at) }5 p0 |6 N1 u* c
the base of the phallus. Testicular volume was still 2
. b5 Q2 h+ O7 P/ r& S9 LmL, and the size of the penis remained unchanged.  o% A" u& G( y7 A
The mother also said that the boy was no longer hav-9 e* R. u( s0 ]8 R, s( D; r- W6 E& i, e
ing frequent erections.* n/ m7 O4 I5 Q" P+ D1 }! l, o
Both parents were again questioned about use of$ D( @# C7 R  g+ D0 J0 d' L
any ointment/creams that they may have applied to
) V6 H. J3 N5 p- V$ F& f4 X' g# rthe child’s skin. This time the father admitted the0 q: H5 Z6 k6 v* f0 \
Topical Testosterone Exposure / Bhowmick et al 541
5 i% r% d1 T/ `- b$ l! F, tuse of testosterone gel twice daily that he was apply-
# A# K9 @9 W. S+ ~9 q8 ?7 b/ ?ing over his own shoulders, chest, and back area for, p: e. c7 {" [" h! Z
a year. The father also revealed he was embarrassed  h4 a- R2 K5 ?, ^
to disclose that he was using a testosterone gel pre-4 E2 u1 e9 m; L+ W
scribed by his family physician for decreased libido
9 x9 \) v% U/ z2 u. csecondary to depression.( w# O$ C) `8 V% V3 |; E8 Z
The child slept in the same bed with parents.+ b# T% c0 @* p% G9 a& a/ @
The father would hug the baby and hold him on his
, k% ^! O$ a- |& x! }chest for a considerable period of time, causing sig-
' L& N! h+ O0 y+ V: \  Qnificant bare skin contact between baby and father.( V2 [* \7 Q  _- W$ Z7 {
The father also admitted that after the phone call,9 t) w' Z3 R, r, z0 V- v
when he learned the testosterone level in the baby. i* s4 S# I# _3 Y) a' H8 K. V! U
was high, he then read the product information* A/ q6 Z2 |3 G; G! y/ l* }2 _
packet and concluded that it was most likely the rea-5 A" Y$ V2 {; {0 c8 c4 J
son for the child’s virilization. At that time, they
/ v) G9 ]% d% C1 r& w/ \decided to put the baby in a separate bed, and the
) K4 ~7 s3 F& xfather was not hugging him with bare skin and had
- ?# g2 S! S8 Dbeen using protective clothing. A repeat testosterone
& X8 _  P* Q. |! M6 Rtest was ordered, but the family did not go to the' C% i1 Z- J) D; f& a4 p
laboratory to obtain the test.5 h# D+ L( O  f( e" L0 A1 `
Discussion0 ?* }0 h1 R# U5 B
Precocious puberty in boys is defined as secondary
  s8 H0 g2 L0 W6 |9 e& Dsexual development before 9 years of age.1,41 Y1 c2 F5 z3 P3 }3 Z" E/ S! M
Precocious puberty is termed as central (true) when
) Z' }2 E8 C" T) d# wit is caused by the premature activation of hypo-
7 h; D! Q9 B3 Q( {3 `1 Xthalamic pituitary gonadal axis. CPP is more com-# a8 ^$ I8 a, h* u2 G
mon in girls than in boys.1,3 Most boys with CPP
) R: m/ q& d8 p5 P6 `, A( q3 _: _may have a central nervous system lesion that is
( }$ C- n# T9 F" n. M4 E4 Z/ @" t2 M7 ]responsible for the early activation of the hypothal-
' d8 d- i& o# {4 Q- ~  {* s1 u0 }, tamic pituitary gonadal axis.1-3 Thus, greater empha-/ l; n. `! }  X, c9 [6 V! c. D
sis has been given to neuroradiologic imaging in
9 {7 [9 c4 u. v7 k" U: vboys with precocious puberty. In addition to viril-+ c' G; J, e& G! k; H3 V9 E
ization, the clinical hallmark of CPP is the symmet-
. k, b8 p; Y- ~) \7 Lrical testicular growth secondary to stimulation by+ ?$ R1 C6 Y8 r0 z( {3 Q2 A
gonadotropins.1,34 q3 j' Y- G: T! l, a0 b$ l0 {
Gonadotropin-independent peripheral preco-# q) I! d& ?( f  l* ^
cious puberty in boys also results from inappropriate  E" h) M3 F+ P0 h" B# q" _
androgenic stimulation from either endogenous or4 [# h: r% {7 e9 L. [7 f2 R# A- e3 z
exogenous sources, nonpituitary gonadotropin stim-
+ x! }& ?8 z1 w: E- Y4 a* xulation, and rare activating mutations.3 Virilizing! Y; f9 W3 l/ S  L
congenital adrenal hyperplasia producing excessive/ }2 S7 l+ v9 y$ T
adrenal androgens is a common cause of precocious/ J. S8 E# W2 v5 E0 a
puberty in boys.3,48 ~& u) X% M% c+ @
The most common form of congenital adrenal
' n- B1 Q8 {9 n: u" Fhyperplasia is the 21-hydroxylase enzyme deficiency.. _- J" ~) }6 M8 i& X$ }6 R! i+ y
The 11-β hydroxylase deficiency may also result in
; }% w: R. f9 e+ i4 _9 c7 {3 Q4 b* cexcessive adrenal androgen production, and rarely,0 Z+ c; A1 t, o: }( C. ^% e
an adrenal tumor may also cause adrenal androgen) k, C* @8 s/ ~$ X7 J( i7 E
excess.1,3$ w- K$ x2 a/ J3 L- v( Q' I$ x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 ]+ R& u4 i+ Z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& A# `8 [( v6 O
A unique entity of male-limited gonadotropin-/ P6 A' {) b4 }5 O9 X) D3 [: k& a  b
independent precocious puberty, which is also known; T+ M. B, o4 [/ _% z9 R6 d
as testotoxicosis, may cause precocious puberty at a: A. ~2 v7 R/ c+ w5 `  Z
very young age. The physical findings in these boys7 ~+ I; t5 m. e8 ^* V1 r
with this disorder are full pubertal development,6 K, n1 y! P6 |
including bilateral testicular growth, similar to boys
# V' t- O( m8 ^: f1 lwith CPP. The gonadotropin levels in this disorder- C% y3 _. P% `9 h  ^( `
are suppressed to prepubertal levels and do not show5 q! j+ w+ g, g: @6 l! T
pubertal response of gonadotropin after gonadotropin-
4 k7 J& N1 X7 g" O, [releasing hormone stimulation. This is a sex-linked
, U' o' g9 h8 W1 T/ m( dautosomal dominant disorder that affects only* g* S6 x, n# ~
males; therefore, other male members of the family
1 T  \. ?/ M* G# H' S+ r' Mmay have similar precocious puberty.3( E% s4 u4 ?' G9 x/ {) m5 m
In our patient, physical examination was incon-  v+ o$ y8 ^: y7 k4 I
sistent with true precocious puberty since his testi-
' F8 W9 t4 j, Y. q. Jcles were prepubertal in size. However, testotoxicosis: Q- Z% Z7 ]: f* e7 B( o$ n4 j
was in the differential diagnosis because his father
$ }$ b2 F6 I5 m5 dstarted puberty somewhat early, and occasionally,
8 b! N+ R' A/ \  g  \6 Gtesticular enlargement is not that evident in the1 }0 z7 z6 P' H+ q4 ~
beginning of this process.1 In the absence of a neg-  \! Y) h: i) a3 H, \, A' o
ative initial history of androgen exposure, our
5 [0 h( J+ Z% w% [/ t& Ybiggest concern was virilizing adrenal hyperplasia,
- i% G& O; [% t+ n, L! Z6 keither 21-hydroxylase deficiency or 11-β hydroxylase! u  }# h3 ^2 m& u6 A
deficiency. Those diagnoses were excluded by find-) Z" T2 c$ u! H% h" u+ D
ing the normal level of adrenal steroids.
6 K# h2 P0 p6 S- U: EThe diagnosis of exogenous androgens was strongly
0 d& s3 h; h( N$ C* Ssuspected in a follow-up visit after 4 months because  s8 B- N: \8 [; b% B/ g
the physical examination revealed the complete disap-
' I) b4 C/ g. a7 Q; |* u* e0 Ipearance of pubic hair, normal growth velocity, and
  {8 w7 I( `$ U8 H- m1 S+ [* wdecreased erections. The father admitted using a testos-
1 b2 r' S1 D5 Yterone gel, which he concealed at first visit. He was
% w  N4 Q4 a: A  L' o9 `using it rather frequently, twice a day. The Physicians’
) @  S+ X0 k/ Z- n# i6 L- `Desk Reference, or package insert of this product, gel or- N/ ?* A# r) {2 a+ M1 }  S
cream, cautions about dermal testosterone transfer to
4 n1 }8 ~- x2 Q& v4 S& D7 iunprotected females through direct skin exposure.4 p2 X. i, N$ v% W
Serum testosterone level was found to be 2 times the
7 ~: y  p  I9 D- ]3 ?) ]3 }; kbaseline value in those females who were exposed to7 c  b8 l2 B: L/ [' N, X
even 15 minutes of direct skin contact with their male4 X8 ~7 h* b% f; X* P  \
partners.6 However, when a shirt covered the applica-) r) b2 _5 s  d$ c" X
tion site, this testosterone transfer was prevented.
' T. e. H! B9 R( n- E8 AOur patient’s testosterone level was 60 ng/mL,+ ~2 f0 L& o" J: X) {5 b
which was clearly high. Some studies suggest that# p, t' z9 o" w3 B# a% S
dermal conversion of testosterone to dihydrotestos-4 v' l* e3 H  i' s$ X9 F
terone, which is a more potent metabolite, is more7 j' H7 W1 e3 t* W9 Y! h. o( t( \
active in young children exposed to testosterone1 r. G1 a" n8 c
exogenously7; however, we did not measure a dihy-
8 w6 K6 W: o- q2 \drotestosterone level in our patient. In addition to1 L5 [) p2 b, [9 ]
virilization, exposure to exogenous testosterone in
! {% M4 D; N9 _; L) v! b9 Dchildren results in an increase in growth velocity and
+ A" _5 a( o+ w! f. C& |; M' A9 L6 n% padvanced bone age, as seen in our patient.
5 O+ i& Z  H- \/ Z7 P. q% \" VThe long-term effect of androgen exposure during$ a  `4 W4 e, P4 A) U
early childhood on pubertal development and final
1 E/ w, M7 ]' J. b( cadult height are not fully known and always remain1 J5 o8 \- [# @4 @. p
a concern. Children treated with short-term testos-
% a! b* g4 V- i/ X5 {terone injection or topical androgen may exhibit some6 A3 `& v: N6 d  m+ c
acceleration of the skeletal maturation; however, after
9 m- m, M; N5 i0 f  Hcessation of treatment, the rate of bone maturation2 l- p8 X, `6 b$ A6 [
decelerates and gradually returns to normal.8,98 f4 z8 G- s6 g  q$ T" E1 U8 p% R
There are conflicting reports and controversy% m$ m  R( r9 F! a5 S/ w
over the effect of early androgen exposure on adult
" [+ ^6 ]$ s0 kpenile length.10,11 Some reports suggest subnormal1 a. S' _' {/ t) w% Y/ H' Q7 k
adult penile length, apparently because of downreg-
) G7 D  O4 {# Bulation of androgen receptor number.10,12 However,  K1 t8 e5 _( u* c. g9 c7 f
Sutherland et al13 did not find a correlation between
: {  {; Z1 _6 Rchildhood testosterone exposure and reduced adult$ ~3 G! ~% j$ J3 t& k0 q/ s4 H7 G5 ~; |0 l
penile length in clinical studies.( n, K2 J- R! Z' r
Nonetheless, we do not believe our patient is: G  s' ~4 c6 C% a0 O
going to experience any of the untoward effects from
9 Y' E* v; c5 ]) }  |( xtestosterone exposure as mentioned earlier because, q6 T2 L) |- e5 H
the exposure was not for a prolonged period of time.6 s3 a0 b7 K/ U' u$ j
Although the bone age was advanced at the time of
  z2 P3 a- d( q. c+ Zdiagnosis, the child had a normal growth velocity at
) U  W3 P/ W# X( f6 b0 qthe follow-up visit. It is hoped that his final adult* X3 ~% }4 ~$ \2 s
height will not be affected.
2 F0 b/ Y2 [- ?' w* SAlthough rarely reported, the widespread avail-4 h' n; M+ n, y; g4 s9 e
ability of androgen products in our society may
; q, E+ K9 w! S" A& i  ]2 N" Qindeed cause more virilization in male or female
% C0 r7 H' b8 X& [1 i& Pchildren than one would realize. Exposure to andro-
# z( f9 f# T5 ?% Dgen products must be considered and specific ques-
6 T7 y7 c; ~! t% B4 P" W, Ttioning about the use of a testosterone product or0 G% W9 ~7 ?5 Q9 W4 b* T
gel should be asked of the family members during! d' d9 T! @* \
the evaluation of any children who present with vir-
0 k1 I! x& o) |; Hilization or peripheral precocious puberty. The diag-
" U& z7 ]1 L- M) C5 c: ^nosis can be established by just a few tests and by& M) r6 n  Q: n$ \
appropriate history. The inability to obtain such a0 _4 o( `, g8 w$ a6 [7 q
history, or failure to ask the specific questions, may
8 ^) h* K; B8 Q' L4 @' n5 W$ M5 l7 rresult in extensive, unnecessary, and expensive( X4 ?1 ~8 f' S+ d
investigation. The primary care physician should be/ b; k) |% F, O) T+ `4 R
aware of this fact, because most of these children- ~7 h: b- k2 A( o+ e% H
may initially present in their practice. The Physicians’% ]' Z! t4 S: g! k1 c
Desk Reference and package insert should also put a
4 \6 y) a. e5 C- w6 R# Q: dwarning about the virilizing effect on a male or
8 w1 x7 }) M  e; Vfemale child who might come in contact with some-
1 ^( s; p2 L2 F0 T0 `one using any of these products.- i! s2 s8 `* T% j- x: g9 o
References( l) F) \) y/ v' A
1. Styne DM. The testes: disorder of sexual differentiation' Q! t  ^: s7 x  b+ R2 _
and puberty in the male. In: Sperling MA, ed. Pediatric
- r7 d, {% e. p( PEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) k( d0 r! }" C6 h2002: 565-628.
; z1 r( J+ U9 Y; U$ ^5 G7 P& V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 B' t& r7 \4 @: X  I8 l* ^
puberty in children with tumours of the suprasellar pineal
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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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
  V& B; y$ h  X% ^; i$ e
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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