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Sexual Precocity in a 16-Month-Old  q7 r" Y3 i7 W! Z& k+ s( @% _
Boy Induced by Indirect Topical& Q5 e- e# S: S: L" j
Exposure to Testosterone1 F) j  ]' f: {
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 `8 s; D; T) vand Kenneth R. Rettig, MD1
4 B5 D0 Q& |- YClinical Pediatrics0 j5 n. v& o, g! t' ~& u8 g
Volume 46 Number 6
+ M2 ]* l% z/ v, @% _; XJuly 2007 540-5437 s6 n( V4 X- Y; z# k; d* @
© 2007 Sage Publications$ |  h; I$ A1 Q5 a% R. r
10.1177/0009922806296651; I6 X4 K: G, ?& j' C
http://clp.sagepub.com
  v, g6 W; D  i) P, C  k3 shosted at! G9 E) H. G, I% ~
http://online.sagepub.com$ w+ A) j! K& Q# R7 B
Precocious puberty in boys, central or peripheral,  `* e1 D- d2 n$ F/ R5 h2 f
is a significant concern for physicians. Central
& u; h! _5 |) `6 a) t7 pprecocious puberty (CPP), which is mediated
' k# x8 ^' W8 X0 V9 S" Z1 Othrough the hypothalamic pituitary gonadal axis, has
# y6 N2 j, F2 a7 x! X9 Y; a: Qa higher incidence of organic central nervous system
0 x" s7 X" n+ P' `( q$ G+ Elesions in boys.1,2 Virilization in boys, as manifested
8 r7 u: C4 N) x: i  Gby enlargement of the penis, development of pubic, K3 q, w+ R. p8 }: t+ o
hair, and facial acne without enlargement of testi-
7 o3 E6 p) Z/ \cles, suggests peripheral or pseudopuberty.1-3 We
2 s/ r, i0 h8 jreport a 16-month-old boy who presented with the7 v- E2 W; h$ r2 _: C9 A4 ^6 Z& J$ `
enlargement of the phallus and pubic hair develop-
2 s! V% [! Y- S6 lment without testicular enlargement, which was due
! }: Z: l5 B/ F8 Y! i7 X4 f' eto the unintentional exposure to androgen gel used by! `- l4 m9 }! ~9 m/ Y5 d
the father. The family initially concealed this infor-2 l. F# R; E. ]3 U! Q/ |! A
mation, resulting in an extensive work-up for this
* C9 @6 F1 C) `' g" m+ ?child. Given the widespread and easy availability of
2 x* ~7 I/ _$ p2 w4 wtestosterone gel and cream, we believe this is proba-4 L; N1 {5 M) Q5 v( H4 Q7 c
bly more common than the rare case report in the, M% i4 c; ?, B; r) v
literature.41 u8 q+ R# I! W/ A2 [
Patient Report
9 b; ?* x% p; J6 OA 16-month-old white child was referred to the
$ F$ {6 V/ t$ [! P  F. wendocrine clinic by his pediatrician with the concern1 P5 V2 k6 \7 C1 L* Z
of early sexual development. His mother noticed8 W+ X1 @; D  o5 N" Y
light colored pubic hair development when he was
( E. |. D/ w9 O+ M* ^From the 1Division of Pediatric Endocrinology, 2University of) E- P2 f# b& o' r. r- R5 T
South Alabama Medical Center, Mobile, Alabama.4 ?+ k6 h, B9 [3 C2 z% J5 Z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 p, z) L, J; S  p; }# {Professor of Pediatrics, University of South Alabama, College of* ^% c1 M3 s8 Q8 P% d, ~3 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 n# \8 N/ V: I0 ee-mail: [email protected].3 N8 J% M# N- }0 p% [  v
about 6 to 7 months old, which progressively became
( \+ D( U* c; e, g0 r8 ?$ bdarker. She was also concerned about the enlarge-
3 V; S0 S$ q) L- O" |" N, Hment of his penis and frequent erections. The child
" l  g7 O. q2 r6 F" t, Vwas the product of a full-term normal delivery, with! F! g# S* r9 K, B' @' }: W  [
a birth weight of 7 lb 14 oz, and birth length of9 M+ Q& n8 u7 x1 b) k
20 inches. He was breast-fed throughout the first year' O$ Y4 P# g" D# Y
of life and was still receiving breast milk along with% d" @- y$ o7 ]1 o3 u
solid food. He had no hospitalizations or surgery,
7 G$ d5 g  c3 O! Z, v: k6 M" ^4 vand his psychosocial and psychomotor development
+ z3 Z8 h) _8 C8 l6 i8 U8 ~0 Xwas age appropriate.
' z  k- _$ e6 Z' z  AThe family history was remarkable for the father,
" C( E4 _* `" ~: M9 rwho was diagnosed with hypothyroidism at age 16,  W1 R4 Y' _% e; ~& f9 k$ ?8 H
which was treated with thyroxine. The father’s5 m2 V# G% a0 Y
height was 6 feet, and he went through a somewhat
/ e' r9 }. i" s+ Zearly puberty and had stopped growing by age 14.; K& h2 e) R% h& a8 p, c
The father denied taking any other medication. The
% S  |+ k6 r& z0 g* Y. r; M# Tchild’s mother was in good health. Her menarche
- Z, p. G; R4 M' {6 Ywas at 11 years of age, and her height was at 5 feet4 q9 I# }$ M8 m9 ^
5 inches. There was no other family history of pre-
! ^) p1 p& D7 x0 ^9 Kcocious sexual development in the first-degree rela-
7 p6 j  s" U. V  A  s7 Ftives. There were no siblings." u3 _6 W' a1 h( R7 E
Physical Examination
8 N6 M: w7 J: o6 W; b$ k1 W' g6 R: \% ^The physical examination revealed a very active,
" L' O: A' ^5 ?; }0 z+ f% N. Fplayful, and healthy boy. The vital signs documented2 l5 C0 }+ r7 B3 z# ^# {
a blood pressure of 85/50 mm Hg, his length was  K% j1 }; e& {- {6 o
90 cm (>97th percentile), and his weight was 14.4 kg' D+ Y; _9 O6 n5 x
(also >97th percentile). The observed yearly growth
+ F  o; G8 }! c0 c! q; a! gvelocity was 30 cm (12 inches). The examination of
4 }* c0 E" N2 E$ g0 ~, pthe neck revealed no thyroid enlargement.
; w: |" a  P( J) D) [( HThe genitourinary examination was remarkable for
- C6 S- |$ b: b1 i2 j! J. Jenlargement of the penis, with a stretched length of, R5 n! P, c0 n1 y. L
8 cm and a width of 2 cm. The glans penis was very well* [0 r# o* ]( z2 i6 I
developed. The pubic hair was Tanner II, mostly around
. a# j; t; b/ [# v, J5401 W. u  b; K! i6 B& o- b- s1 f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: e# N: D5 \+ T. ~- _: x" l9 R9 j
the base of the phallus and was dark and curled. The
' Y7 Q( c7 g& J  w* `testicular volume was prepubertal at 2 mL each.# p, e, R: ]6 u; R! P8 H4 p7 k) N
The skin was moist and smooth and somewhat0 B7 `' M7 g- t3 j' W3 |# A/ N
oily. No axillary hair was noted. There were no5 D$ m: O7 s7 O3 M+ g7 d0 d
abnormal skin pigmentations or café-au-lait spots.
! v" W1 Q. x. s- C& q& ^Neurologic evaluation showed deep tendon reflex 2+5 ]8 t5 g. \8 ]
bilateral and symmetrical. There was no suggestion% F( ^5 x- A/ N  E1 F. D
of papilledema.- l' j2 t5 b2 B* R3 B; Y
Laboratory Evaluation7 w$ {8 S& s# F( P6 ?" V* a4 M( e& E
The bone age was consistent with 28 months by
" a! D, T0 Z. Z, O/ husing the standard of Greulich and Pyle at a chrono-8 ~: e' E. d. d. J1 U
logic age of 16 months (advanced).5 Chromosomal
' [! w/ p7 G' Y! X% R' @: Skaryotype was 46XY. The thyroid function test6 Y( {" G- w, l) o: q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 t4 z* S. n6 w! f* V5 wlating hormone level was 1.3 µIU/mL (both normal).3 ~* L% X5 [/ v1 l7 x# u+ E6 }
The concentrations of serum electrolytes, blood3 n7 S7 G1 A) I& @( p5 R
urea nitrogen, creatinine, and calcium all were: h1 u: C) [, z% ?
within normal range for his age. The concentration. J  X, L9 n1 o- g' L- Z
of serum 17-hydroxyprogesterone was 16 ng/dL
2 {6 N0 G6 ~  [; S& B; a(normal, 3 to 90 ng/dL), androstenedione was 20
" K5 W3 u2 x' _) z9 d1 Bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; X- D/ p* l3 C: x% uterone was 38 ng/dL (normal, 50 to 760 ng/dL),1 E) L% l& {0 \; |# o4 B! l6 _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 k  Z$ Z8 t  i9 i6 k5 H
49ng/dL), 11-desoxycortisol (specific compound S)
' P" ?5 m) [% {5 l3 _was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 ~5 a1 H# X# v- t* g& J' A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total  k. K& h6 |1 c0 k6 z* r" ^' g2 j6 k5 J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 C; [- O& _( E/ P" P2 fand β-human chorionic gonadotropin was less than+ X. J& l* A5 @0 H: m1 o0 \
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) x) x( f9 P* B7 }stimulating hormone and leuteinizing hormone! S/ o4 a+ Q( f. M3 @
concentrations were less than 0.05 mIU/mL
7 \; s0 B0 p* S5 X& Q- L(prepubertal).( _& W3 [; m/ C2 M+ l
The parents were notified about the laboratory
2 Q9 C; L' o+ c5 [- c# h3 f1 {results and were informed that all of the tests were' F& B1 o: z( M" c. _  P
normal except the testosterone level was high. The5 t0 j! M$ y8 [
follow-up visit was arranged within a few weeks to- [2 L" g' z- Y$ m
obtain testicular and abdominal sonograms; how-
, }1 P. C- Q/ sever, the family did not return for 4 months.
8 i7 r3 B2 b6 o$ P. ?% e) x% `Physical examination at this time revealed that the
6 d9 ]# t% F- Q  E1 achild had grown 2.5 cm in 4 months and had gained
9 k( W3 c/ ?5 G8 t+ z+ Q  B1 m, t2 Q0 B2 kg of weight. Physical examination remained( Q0 n; }2 q) M. [
unchanged. Surprisingly, the pubic hair almost com-1 ~- X' X& O3 B- P! j
pletely disappeared except for a few vellous hairs at
  o% f, q/ P, q: Q1 c$ b* Sthe base of the phallus. Testicular volume was still 29 W& L! A3 G. v* o
mL, and the size of the penis remained unchanged.
, j% R( x  O6 O. k4 W+ VThe mother also said that the boy was no longer hav-/ o" ?8 M/ Y1 U: v
ing frequent erections.
# m# r: N9 P: H& f4 H) [. ?Both parents were again questioned about use of) T+ }( g, Q% b; Y
any ointment/creams that they may have applied to6 b7 H6 Z0 p- K% T  H
the child’s skin. This time the father admitted the# a4 e0 D+ K! r" K4 Z; o1 g
Topical Testosterone Exposure / Bhowmick et al 541
1 M+ X- _4 V9 ^9 m' K7 quse of testosterone gel twice daily that he was apply-
4 `* M8 p$ D( T1 t1 \4 Hing over his own shoulders, chest, and back area for
, I* j' Y; n( Y' @( R2 Y6 ea year. The father also revealed he was embarrassed4 c, @9 A8 G6 V8 D
to disclose that he was using a testosterone gel pre-; z0 `; q# [$ \# i
scribed by his family physician for decreased libido& m8 m, A8 Q3 o* g# j& `* k
secondary to depression.
& K) }7 e7 Q, P0 p* i" }7 sThe child slept in the same bed with parents.' o+ M3 a: w) L& Y
The father would hug the baby and hold him on his
8 t$ u6 A  t! u; H. ]% uchest for a considerable period of time, causing sig-
/ F, K/ j* l! u/ t! a9 hnificant bare skin contact between baby and father.
" @4 I/ u7 _( T" I  c7 a: |9 cThe father also admitted that after the phone call,/ |3 r% v* q. C& w8 b. A
when he learned the testosterone level in the baby
2 c9 D" V' f+ R* ]was high, he then read the product information3 ?1 ]1 Z& Z& t- g: ~1 P: q
packet and concluded that it was most likely the rea-- B) }, l0 g% t! a
son for the child’s virilization. At that time, they5 F* g' O) W" r
decided to put the baby in a separate bed, and the/ _9 C/ ^) T" }, i: v8 f2 B
father was not hugging him with bare skin and had% Y; l$ G! [; M; }+ a* ]2 g
been using protective clothing. A repeat testosterone
/ d) Z" m$ L  X- R; {test was ordered, but the family did not go to the
0 O( q8 }7 B8 D+ ], P7 Blaboratory to obtain the test.
' K3 }  ]: f: I8 wDiscussion
4 ?+ i- b; o& @: k, s1 n( CPrecocious puberty in boys is defined as secondary
7 B9 {4 B2 `, r" x( ssexual development before 9 years of age.1,4) R% K  g9 d) Q. R* w. ^
Precocious puberty is termed as central (true) when
9 B/ L: d' x, u2 `it is caused by the premature activation of hypo-
( n9 H8 s) z3 I8 n' c8 uthalamic pituitary gonadal axis. CPP is more com-; `8 _* t  J, l5 `
mon in girls than in boys.1,3 Most boys with CPP# p8 P! |& S7 N; U
may have a central nervous system lesion that is
1 o& }, b0 u& E2 o( n: d! O5 B% B& \responsible for the early activation of the hypothal-( l: j  T/ j4 |. i+ t
amic pituitary gonadal axis.1-3 Thus, greater empha-
# N! e9 H; f; L3 b. N/ ysis has been given to neuroradiologic imaging in
0 O  u* _5 B) ~. sboys with precocious puberty. In addition to viril-
/ e$ m: d1 {6 y2 P$ e$ Y, g  K4 Uization, the clinical hallmark of CPP is the symmet-
; A: Q( |0 V6 r7 D3 F2 e2 q  Crical testicular growth secondary to stimulation by  i4 E& T, o, _( C+ Q% O8 N  a
gonadotropins.1,3
# z+ S; w! x" ?/ c7 Y# [Gonadotropin-independent peripheral preco-+ w  g( _# A( t; t6 S( e
cious puberty in boys also results from inappropriate( K4 N  M$ D6 Y" e
androgenic stimulation from either endogenous or' @4 Z) ]5 W/ k; y, J4 K, k/ m
exogenous sources, nonpituitary gonadotropin stim-: r! y1 Q8 i( p; @- W. |; l
ulation, and rare activating mutations.3 Virilizing  A' |) S3 F  a3 ^$ Z# C: O; B# l
congenital adrenal hyperplasia producing excessive
; g( t/ ]1 e1 N: h" Y+ i) T- v, oadrenal androgens is a common cause of precocious
& r7 L, M: |; n& g- \puberty in boys.3,4# k# Z/ M6 P) \
The most common form of congenital adrenal
& l) u( G7 l3 }0 M6 Thyperplasia is the 21-hydroxylase enzyme deficiency.
) @% M' A# Q9 V  ~) D+ a3 KThe 11-β hydroxylase deficiency may also result in; w$ \& N0 m- x7 Y# g
excessive adrenal androgen production, and rarely,
! i- x3 f& p/ _/ G) t1 `- e+ han adrenal tumor may also cause adrenal androgen' v- D+ V8 h, R( k- g$ o
excess.1,3) g5 u9 {. N. Y3 y( {; X: w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ s5 Y3 l2 [# P( Z; x9 _
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 R! J6 B* @( K2 Z$ I
A unique entity of male-limited gonadotropin-
/ o+ N1 n0 k1 Q0 N$ b. n# {6 lindependent precocious puberty, which is also known
: }6 F* x' N/ H7 k+ `as testotoxicosis, may cause precocious puberty at a
3 ?. @: |4 T! a+ {4 Q6 c! y! ^very young age. The physical findings in these boys
3 G, z+ i+ }( Q" g/ a& iwith this disorder are full pubertal development,
! W6 ?! C* X) _+ J9 {including bilateral testicular growth, similar to boys
4 R, G  s" {1 N, ^with CPP. The gonadotropin levels in this disorder
% z0 W+ X6 b) V" X* ?& n  C$ Nare suppressed to prepubertal levels and do not show( z7 P  M7 J4 A6 C# ~
pubertal response of gonadotropin after gonadotropin-- f) q4 W- l2 ?0 B; ~6 D
releasing hormone stimulation. This is a sex-linked2 }: I% V2 u: ?0 i& y. R2 e
autosomal dominant disorder that affects only* S2 ?+ ?( `" s+ l$ p; O
males; therefore, other male members of the family
9 w4 k; h. M0 e2 wmay have similar precocious puberty.3
+ p  t2 U8 W  e3 }In our patient, physical examination was incon-: Z) Y# i; R% r5 `$ X
sistent with true precocious puberty since his testi-: v. C3 Q* j  K+ G
cles were prepubertal in size. However, testotoxicosis' ~( e1 K) E& @' Q
was in the differential diagnosis because his father+ o) w1 b( j/ X, _2 `8 j
started puberty somewhat early, and occasionally,
! f0 e2 N# D" S7 Gtesticular enlargement is not that evident in the: ^3 m; Y. ^  C, `$ E8 v
beginning of this process.1 In the absence of a neg-. N" `8 E' u* ]8 [* X+ N
ative initial history of androgen exposure, our
  n6 s  d$ i0 t% ~0 hbiggest concern was virilizing adrenal hyperplasia,# {# L' J4 Y- R# A
either 21-hydroxylase deficiency or 11-β hydroxylase
- J! q, L. J* S1 x# @/ J$ xdeficiency. Those diagnoses were excluded by find-/ _/ d$ @) O9 X9 a  U
ing the normal level of adrenal steroids.
$ o2 b4 v# z. J; m+ pThe diagnosis of exogenous androgens was strongly
. v- ?% @  }9 N  K' Z4 Csuspected in a follow-up visit after 4 months because
, o. B  S' K: o) A( I/ Mthe physical examination revealed the complete disap-
4 i: ]9 K6 F0 T6 x4 D" B$ B" hpearance of pubic hair, normal growth velocity, and+ e) X# j( S( @" M- d
decreased erections. The father admitted using a testos-' Q9 ?$ T1 K; a. A! \5 p
terone gel, which he concealed at first visit. He was
9 b+ v7 D7 q+ h/ A9 D$ Xusing it rather frequently, twice a day. The Physicians’1 n9 V9 r7 F( B' h4 f
Desk Reference, or package insert of this product, gel or
0 i: ?6 ?3 m( }% I; r+ _cream, cautions about dermal testosterone transfer to
* d, I2 f+ [& [( q: H% L: Cunprotected females through direct skin exposure.! Q( C8 D& v( q' ]: O
Serum testosterone level was found to be 2 times the
6 p6 r. B& a7 r  K/ R8 ~9 R2 {baseline value in those females who were exposed to
; Z! ]2 S0 f1 E% v6 a: ~0 A7 d, Neven 15 minutes of direct skin contact with their male8 r) K% T( E, w5 G* z6 k
partners.6 However, when a shirt covered the applica-
/ S4 j1 g+ ?: q5 \: N4 ction site, this testosterone transfer was prevented.
3 _4 h2 t! h% M; ~, a5 YOur patient’s testosterone level was 60 ng/mL,
/ a* H# v+ P0 @! Dwhich was clearly high. Some studies suggest that
- Q$ C2 Q' h+ Y: F8 Cdermal conversion of testosterone to dihydrotestos-
+ f  x! E/ P; Sterone, which is a more potent metabolite, is more. f7 u$ Z9 ^. }0 V+ P$ H8 B5 _
active in young children exposed to testosterone: H( ^' |0 t" w" M! l
exogenously7; however, we did not measure a dihy-) |# i. q$ z7 ?* m
drotestosterone level in our patient. In addition to
- V) _1 b5 T" E7 d1 m/ ^% c. svirilization, exposure to exogenous testosterone in
6 `* P0 d0 H5 i8 Ychildren results in an increase in growth velocity and
2 L2 L3 Z4 {" {, radvanced bone age, as seen in our patient.' f* D# x% ?& {) r. o9 X
The long-term effect of androgen exposure during
6 h6 [' |% ^) y; Y8 o/ Hearly childhood on pubertal development and final5 l3 p' C* ?! G& Y
adult height are not fully known and always remain9 o5 n6 i# Y% |* I; E; T* O
a concern. Children treated with short-term testos-/ D! D9 t! y( @3 t  j
terone injection or topical androgen may exhibit some$ b* e/ @. v: \0 I
acceleration of the skeletal maturation; however, after
% v  E0 K6 s9 r+ j- I" `; d# Ncessation of treatment, the rate of bone maturation
3 Z/ e; S- c* ~3 Idecelerates and gradually returns to normal.8,9! y6 f. W/ v: f) E
There are conflicting reports and controversy
# Y& [! O. i8 U5 `  @over the effect of early androgen exposure on adult
4 R8 u9 G( _; x8 M4 cpenile length.10,11 Some reports suggest subnormal* s# l3 X1 W5 Q0 s5 B& w5 N- X
adult penile length, apparently because of downreg-6 t+ T* b) _9 x8 j- f8 t9 F9 T
ulation of androgen receptor number.10,12 However,. G- Z! }8 ]2 y( x
Sutherland et al13 did not find a correlation between- G4 e: F, D/ L& h
childhood testosterone exposure and reduced adult
% T; O# ^: l9 I! y* k; E9 Jpenile length in clinical studies.+ T5 G, k& X1 ^6 N2 v; i
Nonetheless, we do not believe our patient is/ g! N4 A4 d/ J  b5 a. ]& p
going to experience any of the untoward effects from
& A8 L: C- X3 R# N% mtestosterone exposure as mentioned earlier because, z0 m% ~9 E# _" v$ |* s1 o
the exposure was not for a prolonged period of time." y6 D* I. s, |; X/ u6 P
Although the bone age was advanced at the time of2 \2 i: O# b1 C/ h. B  H' U
diagnosis, the child had a normal growth velocity at2 x" Y0 R* w- I% D
the follow-up visit. It is hoped that his final adult) }8 U  r6 P7 J; j7 q9 |; Y
height will not be affected.! C% `3 o# b6 B5 h$ n6 T4 M+ T
Although rarely reported, the widespread avail-% P4 Q, @/ K& H& l% ^; {% k# [
ability of androgen products in our society may( A1 ?$ \4 u( D
indeed cause more virilization in male or female
4 I1 X2 u8 }/ Tchildren than one would realize. Exposure to andro-' W6 P) D# N0 X3 V' P3 t* d
gen products must be considered and specific ques-8 I5 w5 r* s7 }, h4 j
tioning about the use of a testosterone product or  D5 w- `; a  _
gel should be asked of the family members during
7 Y) P3 L1 ]) K) J( dthe evaluation of any children who present with vir-
# S6 g* P* ]# iilization or peripheral precocious puberty. The diag-
6 m9 i1 P: [( s! }nosis can be established by just a few tests and by' z+ K1 s; Z* @7 ]6 G- M/ D( \" Q7 z
appropriate history. The inability to obtain such a4 s8 b0 ^8 R: P6 I# I* g
history, or failure to ask the specific questions, may. |4 C9 L& x( K$ z) D7 z
result in extensive, unnecessary, and expensive
. k; B9 W! j5 x4 L9 Qinvestigation. The primary care physician should be
3 @  O; @) B+ k9 C0 Qaware of this fact, because most of these children
% ~' P% t+ W) ?may initially present in their practice. The Physicians’
% X) K# y8 R! U; n8 IDesk Reference and package insert should also put a
, D# S6 h7 h# _( d8 j9 Q, jwarning about the virilizing effect on a male or
1 A' E6 d5 P( ^% ?7 Efemale child who might come in contact with some-
, D$ W6 e7 P/ ?" \one using any of these products.
9 [5 L0 K, J9 L1 L5 GReferences
4 F# M5 Q' k& ^. I: O1. Styne DM. The testes: disorder of sexual differentiation
- v8 t# i. V. A9 {2 m. Uand puberty in the male. In: Sperling MA, ed. Pediatric- D: ~8 S: R6 P) O! e2 r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 T8 e+ K4 X! V3 ~2002: 565-628.% H( n" O9 k- g+ u# W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. Y* ^' a3 x' ]  M' r8 r8 X9 V
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) e5 H" N* K- q. R) N6 g
Boy Induced by Indirect Topical% D: V5 g: @/ k+ \
Exposure to Testosterone
9 O/ S1 I' Q7 v" ]; P$ W2 tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- f, B1 u  m9 i6 r
and Kenneth R. Rettig, MD1
% [6 d: Z' a4 d& R1 pClinical Pediatrics
# b2 r) V1 @* Y. U. M* ^% O* KVolume 46 Number 6, z& H9 O- e4 @3 O# y
July 2007 540-5432 B0 ^6 B2 y/ d0 S5 \& [
© 2007 Sage Publications
* H! s7 m% m/ |8 b. P2 _7 B10.1177/0009922806296651
1 ]. ^: J! _  U; ?2 E5 }http://clp.sagepub.com
+ V# `! v/ Q2 t. [hosted at
& [$ N5 D% b2 ]6 |$ d  T' Uhttp://online.sagepub.com# u1 x6 y: R- S* I8 R+ j1 C* U
Precocious puberty in boys, central or peripheral,
$ o6 v. \; u9 L& Q  Qis a significant concern for physicians. Central  E) F  |4 S5 ?" D% ?' f: f2 D
precocious puberty (CPP), which is mediated+ [( X: ^) t- b9 r$ G% \! n0 r
through the hypothalamic pituitary gonadal axis, has
! {8 B5 ?; f0 ?- o, w1 h2 Ra higher incidence of organic central nervous system6 S% W9 K' Y. B2 R4 v
lesions in boys.1,2 Virilization in boys, as manifested, u& O  ^  Z* K: ^; g. d  E4 q
by enlargement of the penis, development of pubic( |2 |! V2 a' @
hair, and facial acne without enlargement of testi-
) }. ]/ r- ]2 e4 Dcles, suggests peripheral or pseudopuberty.1-3 We
6 M0 N0 _2 [/ k* V& y1 b; kreport a 16-month-old boy who presented with the
$ [+ s+ e1 M- n! _0 wenlargement of the phallus and pubic hair develop-0 r6 u, a7 Y7 D2 U
ment without testicular enlargement, which was due
( O( E# N4 u7 Z6 ato the unintentional exposure to androgen gel used by5 l# i( k6 T4 e0 v* v1 X3 M
the father. The family initially concealed this infor-
, X: d/ e- K; K, v, V* emation, resulting in an extensive work-up for this; e1 E5 P( W1 @# |
child. Given the widespread and easy availability of
; Y! R/ H1 E3 O; J, rtestosterone gel and cream, we believe this is proba-  L1 X% u& ]* h+ k- {
bly more common than the rare case report in the4 d3 u) F( b+ ]: \& }' w  M- l& Q+ F7 T
literature.4
, r9 S5 s: B$ H# ^' t8 VPatient Report
1 s/ o% A7 @1 I% u& h! lA 16-month-old white child was referred to the5 \3 d& }+ h3 [; {5 k
endocrine clinic by his pediatrician with the concern- b) U9 U5 R8 {0 l; m/ L
of early sexual development. His mother noticed" b4 V! H0 k, A' S4 |5 P- g
light colored pubic hair development when he was
& H2 H  u8 z% qFrom the 1Division of Pediatric Endocrinology, 2University of3 q/ W7 _$ B4 e' i( D8 A/ W
South Alabama Medical Center, Mobile, Alabama.
' n9 j4 ]- ]: A/ {: M7 {4 eAddress correspondence to: Samar K. Bhowmick, MD, FACE,
0 X4 Q) Z+ V0 z- m( FProfessor of Pediatrics, University of South Alabama, College of6 f9 a, O0 x. Y  a+ D7 f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# B% ]; c; h/ R7 d
e-mail: [email protected].
1 k1 u4 _8 Q6 e& u' ?about 6 to 7 months old, which progressively became
1 m' G1 P, {# {8 h9 ], Kdarker. She was also concerned about the enlarge-
& x) s" X! N" ?% m4 L7 Dment of his penis and frequent erections. The child( p$ G7 F, |+ @  ~- G" I  E5 h+ L
was the product of a full-term normal delivery, with
3 V1 \% G/ Q. a# t; wa birth weight of 7 lb 14 oz, and birth length of
% ~  y/ y6 j* `/ ?9 f20 inches. He was breast-fed throughout the first year1 n& \7 \/ I) ~, A2 q) N+ w
of life and was still receiving breast milk along with- I) o0 h' E' R- [
solid food. He had no hospitalizations or surgery,
! C  x0 z% w: U3 X! \8 B/ {8 dand his psychosocial and psychomotor development) B( I, q; F8 I) k: P$ h) y! X6 D
was age appropriate.1 \% R, u1 @3 j0 W! b
The family history was remarkable for the father,
, _; d  x9 V7 s3 Hwho was diagnosed with hypothyroidism at age 16,
$ Q! x! x0 t. t4 k2 N$ Uwhich was treated with thyroxine. The father’s
. X$ q9 Z( l2 {height was 6 feet, and he went through a somewhat* u5 o. `1 u. e; ~0 q) ^
early puberty and had stopped growing by age 14.
8 u  {+ ~" F7 U  n0 `The father denied taking any other medication. The
0 r# P  c" g5 f0 jchild’s mother was in good health. Her menarche. M% Y, V4 |' \8 z6 D& k
was at 11 years of age, and her height was at 5 feet; b' B( p, W  y
5 inches. There was no other family history of pre-
$ q8 N$ Z4 u& B3 b% g1 F, g. Q1 f- dcocious sexual development in the first-degree rela-
" X3 A+ l, x( D4 \+ Ytives. There were no siblings.
. Q+ j2 w( w; V* ^* wPhysical Examination
2 {$ C" [. E4 C, B8 @The physical examination revealed a very active,
# a# O$ I- u% c5 F6 V. Rplayful, and healthy boy. The vital signs documented2 X& n5 F3 p, P0 t8 O. N
a blood pressure of 85/50 mm Hg, his length was9 P% A3 E" W) T2 |/ @, x: s
90 cm (>97th percentile), and his weight was 14.4 kg" S+ t" y' H/ a, N4 Q
(also >97th percentile). The observed yearly growth
+ L: O+ w+ E! h# O4 r7 o* r7 f$ J* j/ {velocity was 30 cm (12 inches). The examination of& C4 F7 G/ P8 O( _; p
the neck revealed no thyroid enlargement.1 E* H" ^  z1 X* a
The genitourinary examination was remarkable for# L& C* }1 G2 |) [( x# R8 }9 q" q5 F; q
enlargement of the penis, with a stretched length of
. _" w: t( A, M/ D6 ~0 c8 cm and a width of 2 cm. The glans penis was very well7 x9 [5 J6 `" G7 J9 ~: P7 x
developed. The pubic hair was Tanner II, mostly around
% \3 J' ~: _# V540) U6 N+ ~8 m& n, O- f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ `1 l- J& f5 Z. T5 p; e6 N' j
the base of the phallus and was dark and curled. The8 @0 c2 I) {4 d$ F  {3 ?
testicular volume was prepubertal at 2 mL each.& T6 X- `2 J. i- B+ H
The skin was moist and smooth and somewhat
: J3 \/ @, {! Z* yoily. No axillary hair was noted. There were no
- Y/ y; y9 F+ x6 |, e% |; mabnormal skin pigmentations or café-au-lait spots.
2 C3 A3 _2 O" ?Neurologic evaluation showed deep tendon reflex 2+' B5 s/ f# _6 v" K- a
bilateral and symmetrical. There was no suggestion
: Q" r& p- o* w( C* q2 `, }* e' Nof papilledema.1 Z9 K) G7 v* R2 K, O
Laboratory Evaluation
, k) x( N  P+ L) o# RThe bone age was consistent with 28 months by' \2 G+ u' y, m* T5 Y1 j% V
using the standard of Greulich and Pyle at a chrono-
4 s4 W) b" m. c! e! Flogic age of 16 months (advanced).5 Chromosomal+ e8 r7 {2 g  F( K
karyotype was 46XY. The thyroid function test
2 I, J1 j: ~% g# k7 Kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! X3 ?6 a2 P% |% R2 \6 p* Qlating hormone level was 1.3 µIU/mL (both normal).
3 \: _5 l9 p3 t/ CThe concentrations of serum electrolytes, blood
0 ]* `0 w7 q* w$ d5 jurea nitrogen, creatinine, and calcium all were
! ]; A6 l# |$ G- i3 |within normal range for his age. The concentration9 `1 N( j: \" O# ~4 T0 p: I; x) K! s
of serum 17-hydroxyprogesterone was 16 ng/dL
. e& T" |9 F' e(normal, 3 to 90 ng/dL), androstenedione was 20( i- l- U& X: e" X- R2 W; j+ i$ g) B
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: }; |. Q  O) r! V& A4 D! h7 r
terone was 38 ng/dL (normal, 50 to 760 ng/dL),% r/ i2 i' w# Y& E0 B7 {9 j
desoxycorticosterone was 4.3 ng/dL (normal, 7 to3 q$ g7 U# |0 K5 t* {, Q) d- k7 d+ A
49ng/dL), 11-desoxycortisol (specific compound S)
( d6 N0 g; |# @4 n5 g- G+ Fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& Z; y0 s+ r4 T( w7 A' M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total  e& Z7 `# J1 k6 G$ d9 ~' }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 Y; K2 s, t4 d7 n0 g0 ~
and β-human chorionic gonadotropin was less than3 }/ p! A$ d, ^( l# V4 ?2 k1 Y
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 Q% t& n+ T* P. S$ x7 B
stimulating hormone and leuteinizing hormone
! L0 _* S* I  Kconcentrations were less than 0.05 mIU/mL3 N+ X* f, _6 X
(prepubertal).
/ }' c( u" }; [) lThe parents were notified about the laboratory
- H- j; ?  {9 N3 [results and were informed that all of the tests were+ F, B/ Q. `$ r$ k  ], a4 G0 Y
normal except the testosterone level was high. The
, [* }  _. q6 j2 _follow-up visit was arranged within a few weeks to
  b/ [# G% k$ v  s( |, \2 Iobtain testicular and abdominal sonograms; how-6 n8 i+ k$ c, {8 _
ever, the family did not return for 4 months.
! t" G6 K0 z; n9 c  ~8 L3 ^+ s* ZPhysical examination at this time revealed that the$ S4 S& n$ d9 @+ @1 c, z7 Y
child had grown 2.5 cm in 4 months and had gained& M6 j/ X  L- L/ f3 E2 o) l
2 kg of weight. Physical examination remained1 `$ }' i9 y- T
unchanged. Surprisingly, the pubic hair almost com-
% x0 d* w' y% C6 e6 z5 O7 wpletely disappeared except for a few vellous hairs at
- D. \# B. ]% i6 Hthe base of the phallus. Testicular volume was still 2% y$ y3 @* B- h# Q
mL, and the size of the penis remained unchanged.* r# _, K% [+ O# c/ }
The mother also said that the boy was no longer hav-. u! Z2 ~# r  W/ X# r& ~, Z
ing frequent erections.! N8 g' B2 G/ p5 h4 H9 B; {
Both parents were again questioned about use of  V5 S$ L) M4 r! z
any ointment/creams that they may have applied to
1 u* ^, Y* B. o& \5 _the child’s skin. This time the father admitted the% `$ Y( {- h1 H; B  o1 ^
Topical Testosterone Exposure / Bhowmick et al 541
  Q" o) p% O+ |' wuse of testosterone gel twice daily that he was apply-+ t+ E- d) _( j, v* g
ing over his own shoulders, chest, and back area for
8 K' C: ~9 m9 Ia year. The father also revealed he was embarrassed; ?' [+ P2 e3 S4 G
to disclose that he was using a testosterone gel pre-* }7 @8 f; }  Y& A9 `6 s
scribed by his family physician for decreased libido- n7 i8 A+ ?; w& g7 Q4 @) a3 G
secondary to depression.
( Q, S9 ~- }& I9 C/ ?, h' |7 W; g9 OThe child slept in the same bed with parents./ l$ ]: [/ p# m7 S5 q' n) U
The father would hug the baby and hold him on his" w% o/ R6 R: k9 G1 `) F0 E9 z
chest for a considerable period of time, causing sig-+ t' F* A4 E5 g# s% K) ^1 Z# O
nificant bare skin contact between baby and father.
) T: {: @% a$ f& r/ aThe father also admitted that after the phone call,
8 U% q3 i( M* p3 zwhen he learned the testosterone level in the baby
, [' S- `8 F6 U9 q4 @1 Xwas high, he then read the product information
5 x1 O# s" k* @packet and concluded that it was most likely the rea-4 h, k1 z5 X/ M$ q# j( Z% @
son for the child’s virilization. At that time, they# ~: Q/ K- N7 A$ r8 o& {
decided to put the baby in a separate bed, and the
$ w3 }8 N9 P* p2 L' }+ u7 I) Y- `father was not hugging him with bare skin and had/ w+ T: d7 S( V; e+ ^" M% Y. u
been using protective clothing. A repeat testosterone; X+ j0 j( a* s$ ?' E* j" {
test was ordered, but the family did not go to the
+ W. H/ p* |, y) Z" O6 }laboratory to obtain the test.
+ f' T8 K) [4 R3 i1 {: `Discussion
+ Y. c8 C) u, O. V8 UPrecocious puberty in boys is defined as secondary- |7 r! _4 s" @( C
sexual development before 9 years of age.1,4
; A* P! {# n0 @- lPrecocious puberty is termed as central (true) when4 Z" c9 ?# F- R& I+ J
it is caused by the premature activation of hypo-
7 ^0 p( p0 l% s" y; H  Ithalamic pituitary gonadal axis. CPP is more com-& W- y0 A* z. r
mon in girls than in boys.1,3 Most boys with CPP. w: g, e/ s  i. h* C' e
may have a central nervous system lesion that is
9 M( X* n' G4 E% qresponsible for the early activation of the hypothal-, W0 Z7 Y5 N1 d' v- g
amic pituitary gonadal axis.1-3 Thus, greater empha-
' i5 H* {: y6 F  u* m* ?# gsis has been given to neuroradiologic imaging in
+ A+ A# F/ |" I8 G  B/ P) f4 I$ N% Mboys with precocious puberty. In addition to viril-  v  F4 J% A' ^" j4 m* W2 n) ^8 C
ization, the clinical hallmark of CPP is the symmet-
- V& `( x  ?- m# g, ]1 [' Krical testicular growth secondary to stimulation by/ |8 M* i- N; r/ Y. h
gonadotropins.1,3: H* R: b& ]0 H: X  E
Gonadotropin-independent peripheral preco-! y2 ?" r$ S( F
cious puberty in boys also results from inappropriate; }# \8 w4 D: X& P
androgenic stimulation from either endogenous or' p6 c: T" }* g+ o# m  ]7 n0 f
exogenous sources, nonpituitary gonadotropin stim-6 c  i) J# y3 N. ^- P
ulation, and rare activating mutations.3 Virilizing( ?& v- `& S* q, ~# q4 R
congenital adrenal hyperplasia producing excessive
. R! o) {5 U% madrenal androgens is a common cause of precocious
  Z9 s7 s0 I$ Ipuberty in boys.3,4
9 S! j3 [' O2 x, a/ b5 u% LThe most common form of congenital adrenal& @$ a" @8 p4 h' L  B0 X$ q' M+ v( f
hyperplasia is the 21-hydroxylase enzyme deficiency.; U. j; F: B2 w/ E/ j
The 11-β hydroxylase deficiency may also result in
! S0 V9 t1 n  R9 }: [8 l( Z; u+ Fexcessive adrenal androgen production, and rarely,
, y! i: C! w$ y) }an adrenal tumor may also cause adrenal androgen* v0 w' z- B1 g
excess.1,3( n# a3 S1 [, U' w# ]( j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, T0 T" L" \! r. `9 @542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* b: G# ^! K& u; R% N, ~" dA unique entity of male-limited gonadotropin-6 s6 t$ G  m. p+ f, h
independent precocious puberty, which is also known+ @$ Z% ~8 R; p  y
as testotoxicosis, may cause precocious puberty at a
& p2 P: D- I" G6 v7 N6 gvery young age. The physical findings in these boys% X4 E4 T' Y. ^0 E8 {" x/ f3 }1 d( b
with this disorder are full pubertal development,; Z' C1 M" W8 j) ]# |$ [3 a6 L3 J
including bilateral testicular growth, similar to boys
5 N/ \9 ]7 V. r# `& x" L3 p8 Rwith CPP. The gonadotropin levels in this disorder, P* J$ t- Q) R$ q
are suppressed to prepubertal levels and do not show6 f0 _4 u) ^9 c; g) V( b* E( G$ {
pubertal response of gonadotropin after gonadotropin-
5 g5 N, {3 _# Q# g, b2 ireleasing hormone stimulation. This is a sex-linked
. U1 m5 J/ f, _+ J' L& C4 ]* t* k+ \8 Wautosomal dominant disorder that affects only
9 `& F3 n, g" r" c! x& R$ omales; therefore, other male members of the family
* {( l" ?, y5 w% }% ?4 S. Omay have similar precocious puberty.3, }, }3 D& z8 ^/ @
In our patient, physical examination was incon-
2 {: a. T- `  w8 E3 c! ^+ P) A4 vsistent with true precocious puberty since his testi-1 }) F  r3 p# M: ]- O1 j# n1 A3 B
cles were prepubertal in size. However, testotoxicosis
$ k* R6 B4 b; D$ @8 V& Y, r- B5 Fwas in the differential diagnosis because his father' Y+ `% v* M0 }' a
started puberty somewhat early, and occasionally,
0 W/ y6 w$ l. U& gtesticular enlargement is not that evident in the
# b+ ~, H) n/ |beginning of this process.1 In the absence of a neg-( ]0 t- B( w2 C/ _
ative initial history of androgen exposure, our1 C! l* c/ C" n5 }/ `% p' Y2 G
biggest concern was virilizing adrenal hyperplasia,
; M6 F5 s! w5 q% c2 \either 21-hydroxylase deficiency or 11-β hydroxylase8 }, h! v4 \/ `6 ~0 g9 L
deficiency. Those diagnoses were excluded by find-
- l  C4 I, _) P% r. ying the normal level of adrenal steroids.
" }' p/ t- d. ]2 ?/ u6 M( kThe diagnosis of exogenous androgens was strongly
9 d, n2 o% \5 \suspected in a follow-up visit after 4 months because
5 c( |, S* ~( zthe physical examination revealed the complete disap-
. _1 |4 p3 g5 O9 s( G4 {1 z6 G  t- m% jpearance of pubic hair, normal growth velocity, and- Q8 s+ }, c0 w* Z! [, `! N( V1 B
decreased erections. The father admitted using a testos-% d0 ~* t' O8 L) V- A% \0 W
terone gel, which he concealed at first visit. He was
  ~! @7 }8 o5 T# J, B! _1 Tusing it rather frequently, twice a day. The Physicians’
  e0 Q8 w6 q; d( e, x* UDesk Reference, or package insert of this product, gel or, ~" H6 ?, a1 A( f; m
cream, cautions about dermal testosterone transfer to+ y# W! i6 j) B: l" T! L
unprotected females through direct skin exposure./ G& _, x4 h% \& p  r
Serum testosterone level was found to be 2 times the
: B$ s; B' b! z7 B- h/ z3 C: zbaseline value in those females who were exposed to6 V$ V8 y) b# ?$ B# O* B
even 15 minutes of direct skin contact with their male5 {% y) v7 W$ ~) y& P
partners.6 However, when a shirt covered the applica-
5 e0 ?. n  j! Mtion site, this testosterone transfer was prevented.
7 t8 O& O& _8 Z& D: T$ Z/ k* {" OOur patient’s testosterone level was 60 ng/mL,8 f5 z% W' g' F# s
which was clearly high. Some studies suggest that
- C0 @0 O' y" `7 {* o9 Cdermal conversion of testosterone to dihydrotestos-2 R- v5 K7 ?- D; q2 n# K4 \
terone, which is a more potent metabolite, is more. f& H. _8 r( Z
active in young children exposed to testosterone/ G  R+ H# _+ i3 ?/ f9 f
exogenously7; however, we did not measure a dihy-1 P5 E7 d0 Z+ |! f* l8 i8 e2 R
drotestosterone level in our patient. In addition to& H, ]6 C$ v. c, g
virilization, exposure to exogenous testosterone in# d+ c: a9 ]1 Q! q" }1 d
children results in an increase in growth velocity and0 R% Q3 O4 Z  k: d1 A
advanced bone age, as seen in our patient.4 G2 p6 f6 L: V2 i5 Z: ]" h. E
The long-term effect of androgen exposure during
% @* W' b4 D. k0 nearly childhood on pubertal development and final$ m2 o7 [6 k3 I' U6 [% s4 H: a# a& m$ E
adult height are not fully known and always remain2 W  a( B4 a, y3 |
a concern. Children treated with short-term testos-
0 l9 v  E- L3 ?( r$ i5 @3 F8 V3 p6 Qterone injection or topical androgen may exhibit some
. C, L, k% @" b6 ]& H& K: dacceleration of the skeletal maturation; however, after+ a" y2 z% \! O
cessation of treatment, the rate of bone maturation
- ]6 K2 e$ X( ^& G+ y1 vdecelerates and gradually returns to normal.8,9
6 L; \6 N7 n6 G$ c4 iThere are conflicting reports and controversy
$ P* t0 ?3 d7 [% u- n$ }3 Gover the effect of early androgen exposure on adult9 H3 h6 h6 p! |5 w- f
penile length.10,11 Some reports suggest subnormal
8 T! R8 J6 |: E( V4 W/ Yadult penile length, apparently because of downreg-  [3 Y. o/ k7 i. e
ulation of androgen receptor number.10,12 However,1 K9 U! Y. l1 S8 G
Sutherland et al13 did not find a correlation between$ I8 X6 S% w3 s$ `8 G
childhood testosterone exposure and reduced adult8 j' l" ^% `1 O
penile length in clinical studies.1 c2 b9 H. }* X# Z' W# u: a2 ^0 N
Nonetheless, we do not believe our patient is
' |# W9 ^6 d9 h9 R0 Lgoing to experience any of the untoward effects from0 k, t2 H# \  M
testosterone exposure as mentioned earlier because/ H0 Y9 x. z; n9 r; k1 }
the exposure was not for a prolonged period of time.
+ w' `: t4 d- n: }Although the bone age was advanced at the time of. |# `' L+ K5 i+ p/ P5 I) D
diagnosis, the child had a normal growth velocity at: ^$ w! I9 t) N  E# O+ w: Y
the follow-up visit. It is hoped that his final adult' l( f, v/ c$ G- h1 V
height will not be affected.
: p& ?: J+ \+ g+ O( Z- i" wAlthough rarely reported, the widespread avail-
8 Q9 g2 Y0 u& a. f2 |4 X" d0 bability of androgen products in our society may$ w1 g9 ?- T4 a, I% u) d) v
indeed cause more virilization in male or female& M8 Y; F; H/ Z/ Q: g2 @& n' C0 Q* j7 X
children than one would realize. Exposure to andro-0 k2 ]4 _$ X. i3 U% S
gen products must be considered and specific ques-
# k/ _% A; ~6 F6 ~tioning about the use of a testosterone product or
0 `$ w9 c) }: z; Bgel should be asked of the family members during
. w: Z2 H/ Q* r( {' I& Lthe evaluation of any children who present with vir-
: ~% T* w& H3 C$ ~. I  {8 lilization or peripheral precocious puberty. The diag-* Z$ {( w3 Q, ?& z- ~5 K  t% r
nosis can be established by just a few tests and by
; }7 j+ a; K, wappropriate history. The inability to obtain such a
, P1 B& D$ Z- E3 H' Z  Shistory, or failure to ask the specific questions, may
# e  a. b2 }2 d4 ~8 I# ?0 V! Yresult in extensive, unnecessary, and expensive
/ K& J/ X2 g9 |7 b9 [" l! ^9 minvestigation. The primary care physician should be4 \2 N8 z$ r- D5 l6 d2 E) x
aware of this fact, because most of these children# W& o+ J& L7 F% ^" J, w( w4 W( ]
may initially present in their practice. The Physicians’
- e. d6 k1 |; ^2 c% R1 ]& lDesk Reference and package insert should also put a9 `  u1 E6 W" T9 p
warning about the virilizing effect on a male or8 @6 ^, j  K$ {% \
female child who might come in contact with some-1 f- f2 F5 f0 ?9 {% l
one using any of these products.' k5 ~) y. n0 p5 [0 j) W$ a6 N
References
7 @- F1 _$ H; A9 c8 ?4 k9 _7 ]1. Styne DM. The testes: disorder of sexual differentiation
8 e- E5 L/ l, w) X* v8 ^2 qand puberty in the male. In: Sperling MA, ed. Pediatric& v4 q! y3 S# [4 ^5 Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! D2 B0 X7 F  b" l
2002: 565-628.9 Q+ l+ Z# R* E0 o
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) y$ o0 R6 |# M/ n/ _& W. h1 rpuberty 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
; S$ M/ u/ p' U6 }) z
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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