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Sexual Precocity in a 16-Month-Old
: Y0 b$ J4 T; H( v7 y' vBoy Induced by Indirect Topical, ^1 l, c4 W7 h  D: f
Exposure to Testosterone, R) a% N; ^' y! r" M
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  X* G9 ]5 T. }0 U" Z
and Kenneth R. Rettig, MD1' B! w* B6 n# i* h+ `$ d" @% b
Clinical Pediatrics
- E! t7 G9 w6 b  TVolume 46 Number 6  h6 c6 X  {6 \5 H) C5 _7 p9 _2 r# j
July 2007 540-543
- ]7 C* E1 R( h# i9 w# R" Z7 C" |© 2007 Sage Publications
! h5 w: u. |+ ^9 L% E! F( Q/ i2 b10.1177/00099228062966511 v) e1 k# K: y9 Z
http://clp.sagepub.com3 k  P3 o4 @) @0 r5 g8 w7 L" @3 J
hosted at
0 h. e7 N" L/ G* t# R3 Nhttp://online.sagepub.com
0 X. H9 p  M6 V+ w+ J- t/ t9 cPrecocious puberty in boys, central or peripheral,
. R" z* E6 Q* x. ~6 n% e6 fis a significant concern for physicians. Central; Q; x3 I' [4 O. i7 D
precocious puberty (CPP), which is mediated: S' G. g5 \7 d% v* L0 o) M
through the hypothalamic pituitary gonadal axis, has4 C7 n& \) d$ T$ {# A
a higher incidence of organic central nervous system5 y+ n; k& v5 p( R
lesions in boys.1,2 Virilization in boys, as manifested
+ e  _8 z% c: c+ \% q" Bby enlargement of the penis, development of pubic
" P/ E5 ]  W$ qhair, and facial acne without enlargement of testi-5 P' ~( e0 y% k$ q9 r" ^
cles, suggests peripheral or pseudopuberty.1-3 We9 g: r. ^' _. K  x/ l
report a 16-month-old boy who presented with the
4 p8 {' Q& |% o1 b6 @$ [( d0 h" |4 Xenlargement of the phallus and pubic hair develop-& t- z5 P8 ~: U% C5 e  L9 P1 q8 B
ment without testicular enlargement, which was due' Q% x, }/ S1 A% P+ v, C
to the unintentional exposure to androgen gel used by5 R' G1 {3 G& F, h. M) ]2 p# |$ L
the father. The family initially concealed this infor-) i) [5 `9 v' d7 s3 P9 p2 h
mation, resulting in an extensive work-up for this
7 J- @8 C; @, j, cchild. Given the widespread and easy availability of
% L3 I. q; w9 U' l9 S0 O& C& gtestosterone gel and cream, we believe this is proba-: M4 G& ]* {3 F: F. |2 j
bly more common than the rare case report in the
0 E7 [. E* M) c; k  \* Gliterature.4# k. I, N. p) {0 ?
Patient Report/ m" w) i- J. F7 H0 ]& W: p
A 16-month-old white child was referred to the8 i' }# ?/ u8 b% D5 g6 {3 K
endocrine clinic by his pediatrician with the concern+ e) X3 J* Z) m+ d( A1 \; _
of early sexual development. His mother noticed0 n9 h2 F; i+ L* f
light colored pubic hair development when he was
5 j/ w0 e1 F2 i$ S$ @$ J: _From the 1Division of Pediatric Endocrinology, 2University of
2 {1 f, E& B2 s2 ^) k; GSouth Alabama Medical Center, Mobile, Alabama.
4 }" Z# }! _0 G5 ?5 wAddress correspondence to: Samar K. Bhowmick, MD, FACE,
* j' |; A4 _% w/ |" Y7 N# RProfessor of Pediatrics, University of South Alabama, College of
3 u7 y* l2 N( j) a6 E8 l% t& k6 JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% M- D& \, Y. M6 M0 e) Ce-mail: [email protected].% m1 T* E! A& X
about 6 to 7 months old, which progressively became  U+ B& z; U. v: A4 K  i& `0 z6 a
darker. She was also concerned about the enlarge-
3 P) E+ s$ N1 [7 a- Ament of his penis and frequent erections. The child
, K" J9 g& W/ ~' ?5 jwas the product of a full-term normal delivery, with6 }# P) _, T2 q6 P. G
a birth weight of 7 lb 14 oz, and birth length of
0 A9 {" ~& \5 c, t2 [  }" i20 inches. He was breast-fed throughout the first year3 \1 v0 R  F* i! d. N" R" g0 J
of life and was still receiving breast milk along with+ v2 K4 X- @8 B# D) Z
solid food. He had no hospitalizations or surgery,
2 g$ \: c6 [) d9 Uand his psychosocial and psychomotor development, u1 s. n& X& s, G; ^- f
was age appropriate.- }! J  v: @0 P2 U$ D
The family history was remarkable for the father,
/ I( `, o3 Y2 Z; j7 xwho was diagnosed with hypothyroidism at age 16,
  N/ B8 }, k4 A" @5 R" ywhich was treated with thyroxine. The father’s! r# J9 c5 A( O8 @! c
height was 6 feet, and he went through a somewhat- V$ _& O/ p& Y
early puberty and had stopped growing by age 14.  t7 w9 h0 ?) A1 X
The father denied taking any other medication. The
& P" Y" N% |- Rchild’s mother was in good health. Her menarche
# f1 Q* `8 S. D+ n, Ewas at 11 years of age, and her height was at 5 feet
$ G# q. u5 ^9 y3 T# v2 B, `! c* D5 inches. There was no other family history of pre-
5 F/ K+ h4 r. H4 Acocious sexual development in the first-degree rela-( O4 r3 @3 o2 F1 a
tives. There were no siblings., R; G0 S0 Z0 a5 S' y: T, O
Physical Examination
* M0 h2 ]; r$ m! I3 w7 |1 nThe physical examination revealed a very active,( @2 M/ ~9 x' V! w8 \
playful, and healthy boy. The vital signs documented
( z5 i9 h' S% ra blood pressure of 85/50 mm Hg, his length was5 I2 |. X. X6 E. _; ]. _
90 cm (>97th percentile), and his weight was 14.4 kg
+ S% x! I6 J: U1 ~! i2 E& O(also >97th percentile). The observed yearly growth7 u3 p5 @" L# Q8 U
velocity was 30 cm (12 inches). The examination of* j1 v& I/ u- C* z
the neck revealed no thyroid enlargement.
* I* x& ?4 V1 [+ g7 WThe genitourinary examination was remarkable for
9 l1 Y( A! L2 j: w1 Fenlargement of the penis, with a stretched length of* G0 [+ M5 T4 F3 h
8 cm and a width of 2 cm. The glans penis was very well1 x. v9 e& c3 ?8 H- \% Q3 S
developed. The pubic hair was Tanner II, mostly around
0 x* g. X2 T0 ~- f5 O5406 ]# s3 H8 V0 q) C! B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 |- v; m2 `7 I  Mthe base of the phallus and was dark and curled. The
3 ~& @! E4 Z3 }, W9 U; W. Rtesticular volume was prepubertal at 2 mL each./ _9 {$ n0 A: G: t% g
The skin was moist and smooth and somewhat7 ^/ T  S% ^) ]$ l; j$ J7 n, d
oily. No axillary hair was noted. There were no3 g' U: u- b% d/ v" Y1 q& W7 a+ H
abnormal skin pigmentations or café-au-lait spots." r. g  c  ], Z2 K1 @3 m9 Z0 h% L
Neurologic evaluation showed deep tendon reflex 2+
5 L& |  G/ q/ o- q% L% Dbilateral and symmetrical. There was no suggestion, Z1 d. D: G. u/ C9 X3 w0 g4 ^
of papilledema.% `0 A# W* t% y& k& P
Laboratory Evaluation
- ^; ?- i) k- N$ CThe bone age was consistent with 28 months by* V% R$ |6 @6 e. F
using the standard of Greulich and Pyle at a chrono-
+ I$ m7 d& R3 Y7 e; blogic age of 16 months (advanced).5 Chromosomal
. {3 p2 l. M3 P  {! d% a# p  c* Rkaryotype was 46XY. The thyroid function test
, x: ?, G- k( O3 |1 R" ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 Z/ G. ]  W) A% ^7 l
lating hormone level was 1.3 µIU/mL (both normal).& L7 o: m9 e* P* o* f
The concentrations of serum electrolytes, blood$ |2 @. a% t& f; [/ a3 {
urea nitrogen, creatinine, and calcium all were$ p2 G: h: q& j+ ~0 C
within normal range for his age. The concentration7 E7 Q: P; X* ^/ e/ O1 i* G
of serum 17-hydroxyprogesterone was 16 ng/dL
$ R2 v0 z% ~+ e! [' B, Y(normal, 3 to 90 ng/dL), androstenedione was 20
" z- D: A6 F# m4 |4 h# |% Y0 k7 Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- z- }8 T. Q: H+ T5 ]/ L* k+ l# f# }terone was 38 ng/dL (normal, 50 to 760 ng/dL),: D/ x/ D$ J4 X: Y  i5 n
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( m; s: K( D$ z! ?49ng/dL), 11-desoxycortisol (specific compound S)
7 ]3 L  |' e' v! ?* U& mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" S4 X- f5 P9 Q1 u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total- d# m0 |# X1 G5 v$ {/ H: d
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 Z: x! S! q( B% X% ]$ p5 F
and β-human chorionic gonadotropin was less than
, ^. H" \* A, Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
  q( B' J/ K1 e% h% I2 l9 P2 c, Tstimulating hormone and leuteinizing hormone4 H7 ~$ T+ {' q; K4 R
concentrations were less than 0.05 mIU/mL4 q6 j! U; M# V  C: M5 G& g
(prepubertal).; R! p( d, z  Z; V( O2 E/ Y% k- E' E
The parents were notified about the laboratory: L+ H- M( d- h% K! d7 y
results and were informed that all of the tests were* h, S  d9 g! Y! A% K7 Y
normal except the testosterone level was high. The; r/ v! q# Y) v% T. {- q9 e- y1 o2 I
follow-up visit was arranged within a few weeks to- f2 A6 M/ s6 [4 O' n
obtain testicular and abdominal sonograms; how-; o( c' Z' t8 t2 m
ever, the family did not return for 4 months." |+ Y: }! z5 N; L+ L( ^
Physical examination at this time revealed that the
9 l) ^. P* h& K9 @# d+ Schild had grown 2.5 cm in 4 months and had gained9 `. D' C% |* o! b+ t0 D0 u7 S
2 kg of weight. Physical examination remained; y1 A( i. Y) M1 E' K6 r5 R
unchanged. Surprisingly, the pubic hair almost com-
) Y2 E4 l7 D9 o! g4 jpletely disappeared except for a few vellous hairs at3 b- r2 D& V. a0 {$ h! Q! r: P
the base of the phallus. Testicular volume was still 2
1 y; M) G" V2 s" g2 V1 hmL, and the size of the penis remained unchanged., Q# `& D' _0 d) d7 Z4 \, h0 C: S
The mother also said that the boy was no longer hav-
( `" l. J" i0 G. {3 ~# m5 N( w- u* bing frequent erections.
  }( I7 s5 R' o$ U: B. |1 e' lBoth parents were again questioned about use of3 T! ^# w4 Z/ ]+ X1 ~
any ointment/creams that they may have applied to
& o! z+ t) {" y3 A3 mthe child’s skin. This time the father admitted the( R: @  H( [5 U2 q
Topical Testosterone Exposure / Bhowmick et al 541
( b9 L7 ]" e) O) S' zuse of testosterone gel twice daily that he was apply-
$ A9 i2 \; p0 Y. z& ]( }ing over his own shoulders, chest, and back area for' _. S# f  N( F# z2 p2 \4 M2 l
a year. The father also revealed he was embarrassed9 _, S, q8 g. r4 k# {3 C) e
to disclose that he was using a testosterone gel pre-: l$ _3 N' t9 A
scribed by his family physician for decreased libido' B( A5 D7 m1 Q9 T; A
secondary to depression.% H! V6 _, Z% n2 o$ J9 u
The child slept in the same bed with parents.9 W' a: V0 ?; I7 F; f4 y9 Q- V
The father would hug the baby and hold him on his
9 f, a& X( R4 S/ e  Tchest for a considerable period of time, causing sig-
! k& q2 W" A$ u" Unificant bare skin contact between baby and father.
7 p& E( a/ V2 X( m: TThe father also admitted that after the phone call,' R' W4 c" b8 H% O
when he learned the testosterone level in the baby# d& }2 [7 U% `4 j7 N
was high, he then read the product information
6 A. B* @# t, N1 v; z2 @9 a1 Upacket and concluded that it was most likely the rea-
( S& n& \1 Y. v& u5 {, hson for the child’s virilization. At that time, they
: s% F' }3 ^. Q6 m8 Idecided to put the baby in a separate bed, and the8 @: d5 d+ e" U6 ]/ T
father was not hugging him with bare skin and had
% C# b2 H6 `3 p4 T5 fbeen using protective clothing. A repeat testosterone( ]6 {3 ]# H  c0 X$ N" o6 y
test was ordered, but the family did not go to the8 c9 H$ ]4 d3 r0 s, k
laboratory to obtain the test.
' T4 z. }* H2 g: E5 ADiscussion
; E( S" J3 Z8 q8 D9 n* bPrecocious puberty in boys is defined as secondary) q* }6 V6 n+ k1 e( M
sexual development before 9 years of age.1,4
2 K# T  q+ @: z+ a' tPrecocious puberty is termed as central (true) when
* p; |! F7 s" f4 V% Uit is caused by the premature activation of hypo-  ]3 o2 `3 h. k7 ]! V
thalamic pituitary gonadal axis. CPP is more com-# E; I$ E4 X9 V% ~! T$ i4 `
mon in girls than in boys.1,3 Most boys with CPP/ X  K6 \3 m. I; w  m1 ~0 n
may have a central nervous system lesion that is
) S2 d7 u# g5 G% u, jresponsible for the early activation of the hypothal-
2 p1 @% g2 x9 ?" ?+ J( Mamic pituitary gonadal axis.1-3 Thus, greater empha-' D/ v# ]/ D! }  I; ^  Q
sis has been given to neuroradiologic imaging in" D* E& |. M2 ], ^( ~4 \
boys with precocious puberty. In addition to viril-
8 W  ^, `( j1 ~& c* gization, the clinical hallmark of CPP is the symmet-
: S' @/ Y+ O( r9 w* \rical testicular growth secondary to stimulation by
6 p' V3 K3 l% `gonadotropins.1,3
/ ?' B9 H9 @  q% a5 m5 }! VGonadotropin-independent peripheral preco-* k2 {8 J$ _5 ~# ?
cious puberty in boys also results from inappropriate5 Q  x3 o/ i' M( R* c) n
androgenic stimulation from either endogenous or3 Z; k- e5 _. l8 ]* h- X7 j
exogenous sources, nonpituitary gonadotropin stim-
8 [1 ]1 C( t8 a$ vulation, and rare activating mutations.3 Virilizing3 ^4 b$ i& G  s) G6 G
congenital adrenal hyperplasia producing excessive& L8 y3 m3 h% S6 N1 q1 t
adrenal androgens is a common cause of precocious
  V* |! l; a3 qpuberty in boys.3,48 B% G4 u1 T$ `  r+ w9 ^6 B* X
The most common form of congenital adrenal
- i2 k/ ?1 f5 l/ Ehyperplasia is the 21-hydroxylase enzyme deficiency.- J8 o. S9 F; j7 F/ e( H1 _9 i
The 11-β hydroxylase deficiency may also result in
3 M4 s0 w4 B: @+ [excessive adrenal androgen production, and rarely,: g1 T0 H* d$ D8 C" U4 L% `
an adrenal tumor may also cause adrenal androgen
: z0 q4 V* Y, n4 e1 M: |! \excess.1,3
5 z' ^4 p, E, `! cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  @5 u) ?7 f. r. l
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, G: p! y: l6 u9 W7 `* s
A unique entity of male-limited gonadotropin-' V' r0 Q  d4 M# ]' M- C3 ]2 J) @
independent precocious puberty, which is also known
/ p* w7 H$ l5 a7 j/ d0 o; m- tas testotoxicosis, may cause precocious puberty at a: A; z% \3 }5 g- D2 u" d6 i5 C
very young age. The physical findings in these boys
- }) t6 G# s4 c6 V, N* E, Awith this disorder are full pubertal development,
6 j: t) @5 [' V" P4 Y* fincluding bilateral testicular growth, similar to boys
! O/ V/ G2 `2 `with CPP. The gonadotropin levels in this disorder3 E1 F3 a" W# r3 O
are suppressed to prepubertal levels and do not show5 l: Q2 Y+ Y0 z: u9 s7 O' J- P
pubertal response of gonadotropin after gonadotropin-
+ W% R! h3 Y) a1 P2 Yreleasing hormone stimulation. This is a sex-linked* o, S* J; {( r% ]9 a# Q
autosomal dominant disorder that affects only& ?0 }5 M# h9 n% z$ U; A5 b7 i
males; therefore, other male members of the family
, ~4 Z7 w# B8 u) i+ M4 y# t( P5 G( q+ h/ gmay have similar precocious puberty.35 [% [* N, e# P, V% t9 t9 i) y; R$ e
In our patient, physical examination was incon-
& p" J0 b7 |3 W6 c, ]sistent with true precocious puberty since his testi-  g; d( M# i$ W
cles were prepubertal in size. However, testotoxicosis9 ?* A: i% u6 E5 u  x8 W3 U3 ~
was in the differential diagnosis because his father1 E6 ~% i  S2 @4 j4 L" g5 {
started puberty somewhat early, and occasionally,
: r% [, t# i& z; @+ c) x- ttesticular enlargement is not that evident in the3 z0 \  Z  d0 i  v0 Y
beginning of this process.1 In the absence of a neg-
4 }7 Z- ^' X. Hative initial history of androgen exposure, our: m: x$ U5 M9 l
biggest concern was virilizing adrenal hyperplasia,
* f0 Z6 y0 Z& P* C% W# }* Seither 21-hydroxylase deficiency or 11-β hydroxylase  O( R2 S( b. g
deficiency. Those diagnoses were excluded by find-
# ]; h/ `! h) ]8 ^( b$ ling the normal level of adrenal steroids.0 S; M+ \5 Q& D
The diagnosis of exogenous androgens was strongly) ~& N+ {1 D: \( }( p* B9 _
suspected in a follow-up visit after 4 months because
1 f' T1 i8 w0 \' Fthe physical examination revealed the complete disap-
7 I* t; r' E4 Q9 ^pearance of pubic hair, normal growth velocity, and2 m0 K  v; R5 D. o
decreased erections. The father admitted using a testos-
  w6 _" t; O7 t  z% c. vterone gel, which he concealed at first visit. He was8 T; q# A- m* i$ p8 \: V
using it rather frequently, twice a day. The Physicians’
6 ^" C5 O9 Y: @& @Desk Reference, or package insert of this product, gel or
9 ]4 V4 }; D/ I+ x/ B  I9 Q$ \cream, cautions about dermal testosterone transfer to
# k( ~* A( |# k  ?& V' Vunprotected females through direct skin exposure.! s2 H* m3 I' r4 i! L, Y4 Y6 t
Serum testosterone level was found to be 2 times the
- X, v" ]8 o+ ?. m0 abaseline value in those females who were exposed to
0 V* S' h/ n/ g2 F7 Eeven 15 minutes of direct skin contact with their male
. M( @& _6 ]8 ]$ n6 [3 kpartners.6 However, when a shirt covered the applica-% L3 t+ \6 e! H3 e* E
tion site, this testosterone transfer was prevented.7 c' X* h! c  }$ S
Our patient’s testosterone level was 60 ng/mL,
- W0 ~* n) V' E. c7 ~- ~8 u( w9 ~. lwhich was clearly high. Some studies suggest that7 t7 \, Y" O$ S  ]& }3 l
dermal conversion of testosterone to dihydrotestos-
3 y* Z, ~; E  L4 Bterone, which is a more potent metabolite, is more
9 L! n- C9 H. S; ^/ Sactive in young children exposed to testosterone
8 d- H1 ]/ I& E- T3 Oexogenously7; however, we did not measure a dihy-1 d1 ]7 W: l6 Y; T; H
drotestosterone level in our patient. In addition to
' |5 M# Q& k0 A; `$ Jvirilization, exposure to exogenous testosterone in7 @& Z) E# O' o- R3 y6 i
children results in an increase in growth velocity and0 ?' m: F) X5 L; _4 |" B2 N
advanced bone age, as seen in our patient.- [! \3 {; S9 D3 A' S( T
The long-term effect of androgen exposure during
! s* b2 A( {: T$ }early childhood on pubertal development and final' G, w% I2 o" l" Y1 P3 W# j1 Q& N
adult height are not fully known and always remain) ]1 X! F( A* W  p; h! _, K
a concern. Children treated with short-term testos-
0 i9 }" H( V" ~- k* d% Y* Lterone injection or topical androgen may exhibit some
  b4 T2 I# G. i& B& L5 K5 P9 v' Q* _acceleration of the skeletal maturation; however, after
: H/ L* g! b1 Jcessation of treatment, the rate of bone maturation
6 U$ d! k2 y/ Sdecelerates and gradually returns to normal.8,9% w% {0 T- M' e" z
There are conflicting reports and controversy  H* n0 B0 @: }
over the effect of early androgen exposure on adult% y3 g! ]6 A- L# A' V2 |
penile length.10,11 Some reports suggest subnormal0 {7 ^7 c* K2 }  J
adult penile length, apparently because of downreg-
' L9 j+ h9 P8 j, a- j, rulation of androgen receptor number.10,12 However,- x4 s- a: N5 ~2 {8 b+ i
Sutherland et al13 did not find a correlation between% z- C, _( @3 W1 f
childhood testosterone exposure and reduced adult
1 O3 {) O% c) hpenile length in clinical studies.
! o3 E4 a1 @0 e' P: G& ?0 \Nonetheless, we do not believe our patient is9 a; B; h. E1 ^4 q3 L2 Y
going to experience any of the untoward effects from
( a" H0 p% P6 l0 h" ~% Y; b- U' F, gtestosterone exposure as mentioned earlier because
" h& M7 K" Q) E) C' z' I; G# A/ `the exposure was not for a prolonged period of time.
* ?0 w2 d2 t7 W& d: M& q5 v) {Although the bone age was advanced at the time of
1 T0 ?9 ^. q: |1 fdiagnosis, the child had a normal growth velocity at6 m. \5 u; u, e& w/ Z* W
the follow-up visit. It is hoped that his final adult2 d! _- z' D% ]; Y" E
height will not be affected.0 z8 f3 U- V. A! `( j$ {
Although rarely reported, the widespread avail-1 P9 g4 d& K; p  T$ r
ability of androgen products in our society may; q4 d' @  z2 S1 R6 k
indeed cause more virilization in male or female4 H5 T) B5 r4 w1 d- m
children than one would realize. Exposure to andro-
1 z9 z8 ]  ^7 O$ wgen products must be considered and specific ques-
& E% q7 Y* F' N- \tioning about the use of a testosterone product or$ S5 m, b( N2 U) `) u7 D: {
gel should be asked of the family members during3 \  @' C. q" U% O, M# j% P! C
the evaluation of any children who present with vir-. T4 Q( n, m0 Q& O# a8 a1 {# m
ilization or peripheral precocious puberty. The diag-
  a8 g0 Y7 u& Vnosis can be established by just a few tests and by
2 M6 p0 m' a6 Xappropriate history. The inability to obtain such a* N; i. |. ]* M6 s9 j
history, or failure to ask the specific questions, may
. i2 Q% U. C  F( ?3 rresult in extensive, unnecessary, and expensive: |0 b5 I2 }: J$ s$ O, g7 s
investigation. The primary care physician should be. `. H! N0 e7 X' C( X4 v. X
aware of this fact, because most of these children
1 z; k) o( h* Q, A! t) Pmay initially present in their practice. The Physicians’
+ J/ ^6 N8 r9 N+ B- y4 _5 J' tDesk Reference and package insert should also put a
/ h! f% P, @. _- m$ J3 Ywarning about the virilizing effect on a male or
; i4 a4 p- m( t. n2 R( pfemale child who might come in contact with some-: i# ~; l( ]) o5 o: ^
one using any of these products.
7 J' b4 @. c& F8 }& WReferences
! q( ?, W2 n/ s9 j3 F1. Styne DM. The testes: disorder of sexual differentiation
3 B7 x. g6 b) I: g# t  J( ?and puberty in the male. In: Sperling MA, ed. Pediatric$ Z" G6 H( @3 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) g# G" p- b9 {9 N, v2002: 565-628.
2 q% @& N9 v0 [3 y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: r8 z/ v2 A" e9 r6 o4 |) Ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old5 u% P( n/ T: U. W! \( O' M1 A9 d7 L
Boy Induced by Indirect Topical
! c5 ^4 v, d( T6 d4 KExposure to Testosterone% e0 s9 u, x/ L6 \5 D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& l: v6 u/ i5 z$ s9 D( Q: wand Kenneth R. Rettig, MD1- E. P- \+ ]% t1 S' ?/ i
Clinical Pediatrics
. f' ~+ R; M' ^) r! HVolume 46 Number 6
7 y# I5 M% |: z" B- ZJuly 2007 540-543
& I4 P% k3 ^; _4 b$ T. Y8 `2 e7 y© 2007 Sage Publications6 S0 S# ~# f. h2 ?. i+ y3 v1 k3 W
10.1177/0009922806296651
6 S  P, u# ~% b- Ihttp://clp.sagepub.com
( T. R9 Q2 f1 A/ m, Chosted at# k2 F  y: P) E/ e& T' k. T. z
http://online.sagepub.com
/ c  U# @* E8 e$ xPrecocious puberty in boys, central or peripheral,
, \# A2 v/ J) Lis a significant concern for physicians. Central
$ @! C- _/ w: c: ^9 d) E4 G+ Jprecocious puberty (CPP), which is mediated& j% E( ^/ ~# }4 p9 O6 G, E9 q
through the hypothalamic pituitary gonadal axis, has8 _. `" S6 @9 K
a higher incidence of organic central nervous system
" z. }8 b# I2 ?6 O" jlesions in boys.1,2 Virilization in boys, as manifested
. E5 R' Y2 k  O; k4 h  Gby enlargement of the penis, development of pubic
, k; l3 }7 l8 ~hair, and facial acne without enlargement of testi-4 ?1 b) K& q4 N, d
cles, suggests peripheral or pseudopuberty.1-3 We* f4 M8 P- _( ]1 f
report a 16-month-old boy who presented with the
% B- ^4 Q6 P+ O4 `enlargement of the phallus and pubic hair develop-
" o, a, d7 w2 |! X7 q0 e& l3 }ment without testicular enlargement, which was due( k' S9 U, y2 Z+ ]& d
to the unintentional exposure to androgen gel used by" z9 ]' P- `: f+ L) x: D% R. L" s9 [
the father. The family initially concealed this infor-; z$ [9 E& Y3 F* T6 d& k' m. [! e
mation, resulting in an extensive work-up for this
$ ]. Q7 m9 ]* r/ q7 ]child. Given the widespread and easy availability of9 v2 `( Z* K# u
testosterone gel and cream, we believe this is proba-
) n. W$ r' W; K; l- r. ^# pbly more common than the rare case report in the
  y8 L, b/ m% a2 l7 W- L3 L% `3 u% Qliterature.4
: ~. T) ?( X3 L3 O- nPatient Report7 p1 L( g, I9 E0 U6 M% u+ Y
A 16-month-old white child was referred to the# g% G' `: L  ^7 R3 M0 z+ F
endocrine clinic by his pediatrician with the concern- y, m0 a2 D% N
of early sexual development. His mother noticed
9 K0 S7 H( k" O4 Ylight colored pubic hair development when he was
. V; F& x; e, T7 a% n, XFrom the 1Division of Pediatric Endocrinology, 2University of/ Z' w, e$ T- w" k
South Alabama Medical Center, Mobile, Alabama.
% D+ Q/ L% }2 ]; ~Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 m: ?7 V1 _$ X! @Professor of Pediatrics, University of South Alabama, College of# M$ r+ f* b4 Y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& G. l6 l; K% Q
e-mail: [email protected].
) ^3 I' g+ `. G/ r, uabout 6 to 7 months old, which progressively became, ]; W0 M/ m) ?  I0 }+ G2 a; X
darker. She was also concerned about the enlarge-
  }  ]8 E1 f& ~+ @0 cment of his penis and frequent erections. The child
9 N) v$ z4 B# v3 L3 Qwas the product of a full-term normal delivery, with: @# `1 D; j: |1 V
a birth weight of 7 lb 14 oz, and birth length of
) ~+ \" z( Z' b20 inches. He was breast-fed throughout the first year
6 ?( P0 @7 k1 s- ?of life and was still receiving breast milk along with
5 Q  j, h# J, V5 m  S: Bsolid food. He had no hospitalizations or surgery,0 L1 S4 g! b6 i* P$ l
and his psychosocial and psychomotor development
+ P8 ?: Y4 ]0 e2 L' _: S) Xwas age appropriate.
3 j1 h; E* ~; u% y. l2 ^The family history was remarkable for the father,
- z  h; K0 B- y5 I- E; I! x4 pwho was diagnosed with hypothyroidism at age 16,
% k1 y+ M' F/ a9 t; V: ewhich was treated with thyroxine. The father’s
1 [. C; a% O6 g& h5 uheight was 6 feet, and he went through a somewhat
+ U  B' l2 }8 {& M: I9 ]7 vearly puberty and had stopped growing by age 14.
5 p! z( h2 E3 {( z2 e7 gThe father denied taking any other medication. The- r+ B9 x4 W9 ]% J# ]! C5 m
child’s mother was in good health. Her menarche' ^" [, b7 V! v
was at 11 years of age, and her height was at 5 feet
9 T5 H  z( z# k. a  V5 inches. There was no other family history of pre-
2 d5 X+ V) j6 Y# D$ b. P& w8 ycocious sexual development in the first-degree rela-$ D: C' o+ `3 X, \: u
tives. There were no siblings.
( l3 U3 u/ @1 a. g) J! Y# {8 T( EPhysical Examination
; \% d3 Z* _3 A8 W% [The physical examination revealed a very active," j, k' I5 q- K+ u: d
playful, and healthy boy. The vital signs documented! S0 {( ^7 E0 ~/ K! M: E8 l6 \
a blood pressure of 85/50 mm Hg, his length was, X4 c1 C# h5 W9 Z0 P8 S
90 cm (>97th percentile), and his weight was 14.4 kg+ D' N, o6 q5 I$ o
(also >97th percentile). The observed yearly growth  r6 T9 b$ \/ o/ z% t3 ~2 {  _
velocity was 30 cm (12 inches). The examination of$ q/ ]& _' N! k2 g8 {" D9 N
the neck revealed no thyroid enlargement.7 t: o! F6 U" X% j: u$ e
The genitourinary examination was remarkable for
. C. x. v- ?+ G* n; ^9 xenlargement of the penis, with a stretched length of$ t8 `2 l1 j& o- S
8 cm and a width of 2 cm. The glans penis was very well
3 y' \# K, p3 h- z, \, Wdeveloped. The pubic hair was Tanner II, mostly around1 M% i2 x/ N( x$ P6 D# P4 i
540# R; D! |  X7 Q  S/ E" l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' I- e: O5 u. y9 S& ^% p
the base of the phallus and was dark and curled. The( \  h8 q; N$ d
testicular volume was prepubertal at 2 mL each.* A$ d8 p0 a/ [# s" Z
The skin was moist and smooth and somewhat9 U# D0 B2 I5 W& }4 h# C6 m2 }7 ]
oily. No axillary hair was noted. There were no
; |* D( O( d! X2 a) s+ gabnormal skin pigmentations or café-au-lait spots.- B8 a8 P" q$ h# q7 y( k" N5 a& ^
Neurologic evaluation showed deep tendon reflex 2+( ^5 j: ~+ ?9 b6 ~) a- c! H) R
bilateral and symmetrical. There was no suggestion  E0 N+ f! Q) A8 E; b! D
of papilledema.9 C8 j. \" h$ U9 f# Q& F
Laboratory Evaluation
; O& W( H4 x# [8 D' ~The bone age was consistent with 28 months by
! j5 t7 d! z" O" c5 Yusing the standard of Greulich and Pyle at a chrono-
4 k# z8 O  A/ ^+ z" Vlogic age of 16 months (advanced).5 Chromosomal: D; ?  P/ |. \% B0 w
karyotype was 46XY. The thyroid function test! f- g* I7 F% H6 u  R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 c, {, q/ D3 H5 {0 {+ ^
lating hormone level was 1.3 µIU/mL (both normal).
% r6 w" G# I- r  P7 I; SThe concentrations of serum electrolytes, blood. z( X; b" b5 |+ k' R8 v
urea nitrogen, creatinine, and calcium all were# U  G& L( n4 ]" ]( x
within normal range for his age. The concentration
% p! `) u" A. J$ c# `7 Q0 Tof serum 17-hydroxyprogesterone was 16 ng/dL
( B$ V7 E$ d5 b7 J. C0 g(normal, 3 to 90 ng/dL), androstenedione was 207 C: A/ W& X* N9 c0 V
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% A: H% w5 I3 C% O* J/ J9 K5 _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. M4 }$ W- w5 `9 n6 D. i6 H  Kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
; x. h4 h/ \% ]/ E# L49ng/dL), 11-desoxycortisol (specific compound S)
- I0 G2 J5 Z. e' b: gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ R7 r7 C# U7 o+ s' a6 q! h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 L8 Y, U; N6 k* h5 V- b' t+ [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# d7 [1 B5 d. b+ A  ~+ g% _- fand β-human chorionic gonadotropin was less than- y& M" J+ O1 j* H% }+ B
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" i8 {/ N; \; _" ]+ sstimulating hormone and leuteinizing hormone/ V3 E+ F& a  f2 Q$ ]: |& y( B' E
concentrations were less than 0.05 mIU/mL" o6 \* r1 }& p" S
(prepubertal).
) }& F6 p) U1 T8 a3 pThe parents were notified about the laboratory2 W) d4 J7 p% F2 b- ]( h
results and were informed that all of the tests were* o. t9 A' ]/ I! b
normal except the testosterone level was high. The
" D! D' Y6 o# N% P4 `1 gfollow-up visit was arranged within a few weeks to- z# u. ?7 N; Y' R& E
obtain testicular and abdominal sonograms; how-$ M; c: ~( f/ x2 b& ^4 R" I: z/ {
ever, the family did not return for 4 months.& g: q6 e5 _2 B, d# P' C# e0 V
Physical examination at this time revealed that the+ Q- `; c- v2 R  O. O& Q
child had grown 2.5 cm in 4 months and had gained& x' ~* L2 Q: k1 V7 o/ l
2 kg of weight. Physical examination remained
2 ?/ N3 z$ K5 l* [unchanged. Surprisingly, the pubic hair almost com-
6 I$ C8 T5 h5 cpletely disappeared except for a few vellous hairs at5 ?7 l7 x0 R% X" D. ~9 i3 a5 Z$ v
the base of the phallus. Testicular volume was still 21 Z0 }! `: E, L4 R* N- J! Y
mL, and the size of the penis remained unchanged." l  e) g  I4 ], |
The mother also said that the boy was no longer hav-- p) [  ]% {% V+ P2 \" N* Z
ing frequent erections.
7 f1 b, E; m- F) o) g9 W. |& zBoth parents were again questioned about use of3 X4 _( X; Z1 D3 @; X* [
any ointment/creams that they may have applied to" g' z- c0 `6 [/ }' x* K. d
the child’s skin. This time the father admitted the
, M5 X: M- f0 n; iTopical Testosterone Exposure / Bhowmick et al 541
8 M7 Z/ H3 N8 J! w" ]3 ~use of testosterone gel twice daily that he was apply-! @  l. |; a# M) K  }8 z' B
ing over his own shoulders, chest, and back area for
3 _! A. U! r2 O4 N0 |a year. The father also revealed he was embarrassed# n- b$ p2 \  i3 q6 k; W' |7 U
to disclose that he was using a testosterone gel pre-2 u& K  M* P: g* Z% y9 j) \+ A
scribed by his family physician for decreased libido
  e, H3 X' f' hsecondary to depression.# Q. t2 {1 d$ x1 Z
The child slept in the same bed with parents.
7 ]( y! ~& w0 ]5 @2 E1 N) cThe father would hug the baby and hold him on his
1 H& j) p+ S, ochest for a considerable period of time, causing sig-
( D" z0 @! A& a1 |2 a1 Y: h8 v+ |& P5 Vnificant bare skin contact between baby and father.( P( J  L+ }, m% N- g; x5 L
The father also admitted that after the phone call,+ G/ e3 p) E6 c4 ^9 c/ g# _% ~5 H
when he learned the testosterone level in the baby
' K9 t6 b+ k$ D8 rwas high, he then read the product information
% R' z# x" _( \( V  _4 n! Apacket and concluded that it was most likely the rea-. H" p  k/ R5 @3 b8 C: N$ M2 k
son for the child’s virilization. At that time, they
0 A; E7 U7 E& }decided to put the baby in a separate bed, and the6 v8 V, s& _% ~9 @+ y
father was not hugging him with bare skin and had* @, V- n( r8 ^% f% O7 W4 @
been using protective clothing. A repeat testosterone* Z  n/ f! Q0 R5 g; l2 `; B! O+ s
test was ordered, but the family did not go to the
! p: d" B! U5 Elaboratory to obtain the test.# P/ w5 e0 f5 L) [0 i
Discussion3 H$ c% Z$ h3 R# A7 I
Precocious puberty in boys is defined as secondary
* M( ?3 J, c4 x1 _; Zsexual development before 9 years of age.1,4
  N) o; X. D5 x) @+ c, [Precocious puberty is termed as central (true) when
* q1 ]+ W. t' F4 }it is caused by the premature activation of hypo-
. I7 G; \. V6 @6 zthalamic pituitary gonadal axis. CPP is more com-
( P3 l1 s1 o2 ^3 G8 ?; p/ omon in girls than in boys.1,3 Most boys with CPP! g; w" N! F- z, |) f( F
may have a central nervous system lesion that is
2 g: Y- r* `7 ^3 o* m+ U2 oresponsible for the early activation of the hypothal-
1 n/ G3 C+ F3 L3 s/ q4 bamic pituitary gonadal axis.1-3 Thus, greater empha-
% e/ d. ]# P/ t- h6 N0 _7 ?sis has been given to neuroradiologic imaging in
4 u/ v! f8 B. Jboys with precocious puberty. In addition to viril-
) w; q6 n3 c: e( Xization, the clinical hallmark of CPP is the symmet-
& }# \5 Z1 o% P0 e4 D% Q- r, Vrical testicular growth secondary to stimulation by
' L9 X1 v# @- P3 Zgonadotropins.1,32 G2 l6 \: E$ B: O2 D$ S+ D
Gonadotropin-independent peripheral preco-
- q7 g; x1 a" m) q0 H2 p7 J: e. h( Mcious puberty in boys also results from inappropriate
0 j) g& Y; X, b3 M' `& @androgenic stimulation from either endogenous or
; F3 p# o+ i5 q' j; W  D" Cexogenous sources, nonpituitary gonadotropin stim-
& J- r, S4 w- A) @8 h; @9 A1 [7 Y& Mulation, and rare activating mutations.3 Virilizing
, c; {* {$ X; n- p7 U1 k& pcongenital adrenal hyperplasia producing excessive
% i. b8 @' ?/ l; r! i  {adrenal androgens is a common cause of precocious( u% ?; ?: L# t, m& g/ j: P5 e
puberty in boys.3,4/ ~# y" c# u" o8 b9 F+ O$ ?/ g7 a
The most common form of congenital adrenal0 f+ y* H7 V( u; B: Z
hyperplasia is the 21-hydroxylase enzyme deficiency.0 N% P+ ]8 P2 C! _- O/ q! `3 `
The 11-β hydroxylase deficiency may also result in
3 k3 q/ y# K( F# |2 Dexcessive adrenal androgen production, and rarely,
/ a" [( ^1 F1 w& K) }" y5 lan adrenal tumor may also cause adrenal androgen
+ F8 U/ e$ ]! |6 s0 e. U, ~excess.1,3
/ W# C5 V3 e5 [3 y; W6 Q$ @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% f$ W  B; |7 o5 E5 u542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. k9 V, E( n. b! c8 L9 ]6 }A unique entity of male-limited gonadotropin-: l% `9 [7 E5 [, e  I6 o6 T
independent precocious puberty, which is also known
8 V* n9 w# i7 X7 r6 B% M" y* Yas testotoxicosis, may cause precocious puberty at a* \" A, F* A# C& Z8 {
very young age. The physical findings in these boys
2 X, x6 }& g$ Z9 U# ]with this disorder are full pubertal development,
7 o, V  ^5 s& y6 x  X9 |including bilateral testicular growth, similar to boys
5 t& E- L7 S2 i1 ^* Bwith CPP. The gonadotropin levels in this disorder  d: Q2 x9 [! E6 X
are suppressed to prepubertal levels and do not show
, T$ P8 y  V5 y% `2 dpubertal response of gonadotropin after gonadotropin-
& ]7 g# b# _( Areleasing hormone stimulation. This is a sex-linked
' l* h. `+ u  {# t1 I5 w; sautosomal dominant disorder that affects only
5 h' f2 ~. d3 {& r. R: y6 omales; therefore, other male members of the family
- ?& V+ S- i  W7 t* H1 R6 b# H! Lmay have similar precocious puberty.35 w# b" B( R: o! u
In our patient, physical examination was incon-6 I5 F' W( {8 D# Q/ e6 D
sistent with true precocious puberty since his testi-
, c; @  A. L: u( U& a' B# V/ s# @- xcles were prepubertal in size. However, testotoxicosis
% D5 N8 o: [6 |) v) H/ b7 p  cwas in the differential diagnosis because his father
$ }! Q1 F5 p/ T0 s8 P! S% Pstarted puberty somewhat early, and occasionally,
6 |7 Z- P/ {5 Z$ I: d0 _testicular enlargement is not that evident in the
; ~0 M# O! C- A  q0 v$ nbeginning of this process.1 In the absence of a neg-
$ C# b, [6 N8 L% l3 @9 Hative initial history of androgen exposure, our
: F, c0 `' ?% P! obiggest concern was virilizing adrenal hyperplasia,
! i6 Z+ ~: t7 \either 21-hydroxylase deficiency or 11-β hydroxylase  C+ T4 m9 k  {, j/ i4 @1 \/ Q1 h  j
deficiency. Those diagnoses were excluded by find-; Y! r. G8 A* O7 w8 V& c
ing the normal level of adrenal steroids.
) Q$ R) o; U. G- m( w) ^, }The diagnosis of exogenous androgens was strongly
9 a: e- }8 s: g; x( xsuspected in a follow-up visit after 4 months because
( J1 P5 c( q; N8 I1 nthe physical examination revealed the complete disap-6 c; |  |& e7 q+ K6 z+ b
pearance of pubic hair, normal growth velocity, and, u  [9 Y7 U6 [! Y8 a, ]
decreased erections. The father admitted using a testos-
! i6 c  I5 k" ^% h% ]0 m7 [terone gel, which he concealed at first visit. He was$ }: Q$ E" u2 j/ `( A" }
using it rather frequently, twice a day. The Physicians’
% i% |$ v# e( NDesk Reference, or package insert of this product, gel or* l/ o7 @5 Q& H$ F
cream, cautions about dermal testosterone transfer to
/ [4 `& Z$ R2 R3 ?& o+ O: @0 ~; b2 D' iunprotected females through direct skin exposure.
' ]( o0 q4 a) ~4 VSerum testosterone level was found to be 2 times the
. V$ l' o$ a% w) I2 Z6 R9 ybaseline value in those females who were exposed to2 r" H/ ?. v! V8 a8 G# b/ S
even 15 minutes of direct skin contact with their male, i/ k: u; K0 n1 R# ~/ M/ O
partners.6 However, when a shirt covered the applica-  v1 `; o9 i. A1 B8 m
tion site, this testosterone transfer was prevented.
3 I3 n7 {6 l  E- r# ?Our patient’s testosterone level was 60 ng/mL,
. b* W% ?$ B9 q) K) r' ]which was clearly high. Some studies suggest that) ~3 J* v" ?+ s
dermal conversion of testosterone to dihydrotestos-
( i* A  Y' f1 Y, pterone, which is a more potent metabolite, is more5 l1 R7 M8 Z. }( O6 I
active in young children exposed to testosterone2 a/ u  _, d" u! j
exogenously7; however, we did not measure a dihy-( K" @& ^7 F3 `! r. j
drotestosterone level in our patient. In addition to5 }* b8 X0 F6 w: j4 i& T1 C" ^
virilization, exposure to exogenous testosterone in
$ {* K+ U* @4 xchildren results in an increase in growth velocity and3 w7 Y! ^% z: J% N9 r1 I
advanced bone age, as seen in our patient.  @2 U# e! v0 X
The long-term effect of androgen exposure during" q9 c% i; x$ \' o9 K0 a
early childhood on pubertal development and final
: y  W, v, N& b, {* w% _: Zadult height are not fully known and always remain
" R' V$ Y+ j, A5 Va concern. Children treated with short-term testos-
, s' F/ k0 E2 Bterone injection or topical androgen may exhibit some' V; V0 c( ?8 q5 k- A  M. Q5 m
acceleration of the skeletal maturation; however, after2 _' ~/ x5 B, ?' ]7 Q
cessation of treatment, the rate of bone maturation
: n8 f7 i( d7 ^, Q( qdecelerates and gradually returns to normal.8,9
; p( J- @: ]; U& p2 FThere are conflicting reports and controversy8 c; r! u1 \: O* ~6 \' u- d
over the effect of early androgen exposure on adult0 y( Z/ M& ?/ J8 ?6 `# o3 W
penile length.10,11 Some reports suggest subnormal4 q7 M7 l& T7 j) v0 s2 _
adult penile length, apparently because of downreg-5 v- L" O1 J1 g6 ~& _/ f" q$ Y$ w
ulation of androgen receptor number.10,12 However,
7 U7 i# K$ }& T! C' xSutherland et al13 did not find a correlation between
/ K  G$ [3 p7 U- d# U+ }' m; v8 S6 m9 achildhood testosterone exposure and reduced adult
2 A5 T' Z( ~/ j( Xpenile length in clinical studies.* w, h& D2 p: y+ Q( \( j
Nonetheless, we do not believe our patient is
: _* k+ O! @- y; K$ Y# q5 u9 W$ Rgoing to experience any of the untoward effects from
, B; N! }& x' ]; F1 Etestosterone exposure as mentioned earlier because
) h" x* [$ v2 \the exposure was not for a prolonged period of time.
( o( V# W) n1 p4 y$ e8 {Although the bone age was advanced at the time of
; o6 x$ |+ n1 ]/ ]4 K( Ydiagnosis, the child had a normal growth velocity at0 k! Y& y: S3 K2 G
the follow-up visit. It is hoped that his final adult
6 ?; a5 Z; T- }# R8 @1 A+ V# Bheight will not be affected.3 Z4 l0 F/ n, A
Although rarely reported, the widespread avail-
3 U! g8 H/ U7 W& Z6 Dability of androgen products in our society may  y( m) n2 Z7 G2 R
indeed cause more virilization in male or female8 K/ w* g: v; r, o
children than one would realize. Exposure to andro-" R! I& E/ R: d' y9 l; j; {! Z
gen products must be considered and specific ques-& v0 ~% K; H% B, z
tioning about the use of a testosterone product or
9 M) h& @+ L- p) Ggel should be asked of the family members during0 a6 s$ \& e/ e- o/ d* \/ a2 j/ V: C+ b
the evaluation of any children who present with vir-+ N& d  I2 R% z; I
ilization or peripheral precocious puberty. The diag-
( s# x/ c4 M  Bnosis can be established by just a few tests and by
7 k8 U; h' F  v6 B2 ~0 i+ K* Jappropriate history. The inability to obtain such a
8 f7 Z' V: I  g- J5 S8 u3 Mhistory, or failure to ask the specific questions, may
7 J! a3 a" L( y' G0 Iresult in extensive, unnecessary, and expensive6 @' `8 E# z) r4 R
investigation. The primary care physician should be
7 r4 _$ M* Q$ K. i# R8 r4 daware of this fact, because most of these children
* n" F8 M3 c1 T' c( {0 D0 s8 Xmay initially present in their practice. The Physicians’, G7 e9 e- O2 x$ u6 _+ J1 q
Desk Reference and package insert should also put a
: q2 P$ s2 ^, V7 vwarning about the virilizing effect on a male or# d& o5 ]+ M$ p
female child who might come in contact with some-
, |. T4 t3 b. g/ q* _8 Done using any of these products.  [7 v# r6 V& M) ]
References# A$ P' `6 ?! a$ W5 ]- X7 m$ ~) I
1. Styne DM. The testes: disorder of sexual differentiation" [7 C/ U5 r; j, ~8 {5 W1 R9 m
and puberty in the male. In: Sperling MA, ed. Pediatric* ]) m$ [1 ]9 M# O" n; k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  p" R" [5 W" b  P% D4 s2002: 565-628.
/ Q9 @: e7 E% c! P+ M& z8 _9 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  W/ I% y; v/ v0 C( Zpuberty 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

' `: {2 h* h- n$ s1 w3 i5 s" l; @, R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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