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Sexual Precocity in a 16-Month-Old
4 m# m6 H7 g, C& B, `Boy Induced by Indirect Topical' o' U( F$ }) g
Exposure to Testosterone
* W8 C4 @4 H# m7 M, `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# v, G, h) }# C6 H" X7 T$ l# E3 ?) D
and Kenneth R. Rettig, MD1$ v9 M7 x$ ?0 W' g* _; T
Clinical Pediatrics: Y3 N7 ^: F3 j) O2 L- |! J; e; r
Volume 46 Number 6
  K$ r& E0 I( i; t  EJuly 2007 540-543
! z5 u- }2 U6 W8 _, x© 2007 Sage Publications; w: B) V! \$ `: Y' K  ?1 \
10.1177/0009922806296651
0 q$ t& o7 g  w& B. T( z& R/ ~http://clp.sagepub.com8 C4 p3 H0 ~' d6 g) K( Z
hosted at
7 x3 D/ D& }% N, x# c' g+ shttp://online.sagepub.com
1 W3 `. F1 |, C# P4 I) |Precocious puberty in boys, central or peripheral,9 P8 w. s! o4 J1 V' {' k# ~8 ^" h& F
is a significant concern for physicians. Central& V: ^4 [9 k; H. N% G) I; R& J2 m# X
precocious puberty (CPP), which is mediated
! W7 f" W, g0 k7 Sthrough the hypothalamic pituitary gonadal axis, has- A' [- u& i9 o" H5 F% ?; u! c& y
a higher incidence of organic central nervous system
, A6 ^# ]$ B) ]0 k2 S; olesions in boys.1,2 Virilization in boys, as manifested
2 s# J6 u( C( W% m3 v$ m3 Gby enlargement of the penis, development of pubic
) C) q2 `( l4 ~0 uhair, and facial acne without enlargement of testi-
$ ?. D7 t1 d# ]. B; Tcles, suggests peripheral or pseudopuberty.1-3 We8 o0 u4 b+ x: y0 E/ ]+ J
report a 16-month-old boy who presented with the) H  e3 C" ~* p# x6 p2 j' t- b5 l
enlargement of the phallus and pubic hair develop-
2 _% o5 y' n" d0 o. U; W9 [ment without testicular enlargement, which was due
2 n; H; G4 s, \to the unintentional exposure to androgen gel used by
. X$ J4 E% v( f9 Zthe father. The family initially concealed this infor-
2 T! ^' U6 b4 K5 n. E( e" wmation, resulting in an extensive work-up for this
1 |3 n9 U1 m4 K  x! kchild. Given the widespread and easy availability of9 v1 \5 y$ z1 \# a3 [3 j5 D
testosterone gel and cream, we believe this is proba-! Q" }0 ^2 z; Y( x
bly more common than the rare case report in the1 i( L6 u; {% c. N; u, i3 f9 @* s
literature.43 C" q9 n$ t2 Y" w
Patient Report
9 k% {5 ~( D! f6 R# }A 16-month-old white child was referred to the) M+ h- H5 s. w
endocrine clinic by his pediatrician with the concern
' J  f: V# d" Y+ A  `of early sexual development. His mother noticed- A. b6 j4 n* e
light colored pubic hair development when he was. f; u7 l1 M) p0 i8 j# T. n
From the 1Division of Pediatric Endocrinology, 2University of
- H2 R% q4 G: A, g: |South Alabama Medical Center, Mobile, Alabama.. F8 e2 C: K8 Q- w& c1 [8 f
Address correspondence to: Samar K. Bhowmick, MD, FACE,) J* L/ F( c( p
Professor of Pediatrics, University of South Alabama, College of
: t: l9 S. q; a' h2 sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: k& \" o' }6 _' Ee-mail: [email protected]., a5 H4 S2 ?1 Y  q9 m7 `+ }
about 6 to 7 months old, which progressively became9 M8 t$ A" j) I; W+ g1 \
darker. She was also concerned about the enlarge-" y5 d4 X' w) j8 y) X5 t- V
ment of his penis and frequent erections. The child2 K; b  V; m' c1 [, d
was the product of a full-term normal delivery, with5 Y! P& j+ x0 u$ B" I! }% b- s
a birth weight of 7 lb 14 oz, and birth length of
. }, J. K! m, X2 H. f& @3 T/ q4 c20 inches. He was breast-fed throughout the first year
; b3 O& }0 u2 m- uof life and was still receiving breast milk along with
& I: {& Q& z; G. H% Isolid food. He had no hospitalizations or surgery,# O7 M! K* [5 q; e& l" [
and his psychosocial and psychomotor development" @  Q- Q# f7 y' ~
was age appropriate.. }! S4 B& k9 K
The family history was remarkable for the father,
9 p( m& C! t8 x2 D5 lwho was diagnosed with hypothyroidism at age 16,
' L3 G, R7 `1 J2 Fwhich was treated with thyroxine. The father’s, C4 ~$ W) ~! Q( j# M: ]5 d
height was 6 feet, and he went through a somewhat' n$ I/ c- l5 y4 v4 v# S( V) `5 }
early puberty and had stopped growing by age 14.
: T4 d" F) f" e" p; {+ S3 eThe father denied taking any other medication. The9 Y3 ~" i) S( t7 u$ f
child’s mother was in good health. Her menarche; @. `- ^5 u! p8 v( j
was at 11 years of age, and her height was at 5 feet
9 j7 ~1 l+ W* A# z: m$ g5 inches. There was no other family history of pre-
. K4 Z* r; S6 W7 Q" |7 Xcocious sexual development in the first-degree rela-
6 i% V3 p+ e) X& ^$ t' G0 ptives. There were no siblings.( c9 C; c; D" W
Physical Examination0 ]" t3 d! ?' b5 x
The physical examination revealed a very active,9 r* q2 K: [2 [
playful, and healthy boy. The vital signs documented$ O. k% t4 {6 i5 H
a blood pressure of 85/50 mm Hg, his length was
" v- [; R' A, x9 `& A/ ~, o90 cm (>97th percentile), and his weight was 14.4 kg, C% i% p' p- }. q: v- {1 E' @
(also >97th percentile). The observed yearly growth
- f9 E. i& g" [+ N) Hvelocity was 30 cm (12 inches). The examination of; ~- ?$ y( q0 f; `
the neck revealed no thyroid enlargement.
$ u' Y! }0 [) {The genitourinary examination was remarkable for8 V6 o9 ?8 ^$ H2 I
enlargement of the penis, with a stretched length of7 l' Z9 X- B. L" v, s
8 cm and a width of 2 cm. The glans penis was very well
+ b. }" a2 V/ M) C' r! Edeveloped. The pubic hair was Tanner II, mostly around1 `5 q8 p$ U0 {8 P
540" a9 t( ^& w: c4 r/ D( e  t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 b* H, K) h2 v$ j+ y" Sthe base of the phallus and was dark and curled. The
$ \( V; J, I* Ztesticular volume was prepubertal at 2 mL each.
2 ]& c: v- [" z# n$ d2 z, I" X& qThe skin was moist and smooth and somewhat
) o) E# H* `9 D! b7 @. T3 [* Koily. No axillary hair was noted. There were no
; e. K- m0 u" `3 D% }% labnormal skin pigmentations or café-au-lait spots.+ r+ V, n" ~/ j7 E6 c
Neurologic evaluation showed deep tendon reflex 2+
( U1 f+ E, K: [% H- c; G! {7 _bilateral and symmetrical. There was no suggestion) `) l9 U9 ]! A0 l( X& p2 z8 z
of papilledema.- |( }+ n' y, d
Laboratory Evaluation
) w7 ]( D( F/ B, P, o- wThe bone age was consistent with 28 months by4 A, a2 {& e5 D/ Q3 u% h
using the standard of Greulich and Pyle at a chrono-) u3 r6 U. [* [5 ?' I
logic age of 16 months (advanced).5 Chromosomal# H2 W1 J0 c0 \0 T9 i
karyotype was 46XY. The thyroid function test1 C. @  _- l2 E. U* Y: d0 j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ W2 c  m9 {8 u2 q% V0 s7 o0 a3 D
lating hormone level was 1.3 µIU/mL (both normal).
. O8 t' J7 F9 {& D: @2 [9 kThe concentrations of serum electrolytes, blood
4 Y2 y# Q1 C3 |. F! \7 A* P# ]urea nitrogen, creatinine, and calcium all were
3 J0 K+ U9 N9 L! E1 r( _" P( ^within normal range for his age. The concentration
8 v" O5 j  @8 h/ Z" p. r; wof serum 17-hydroxyprogesterone was 16 ng/dL3 ]" M; b. C4 p1 W$ u% n
(normal, 3 to 90 ng/dL), androstenedione was 201 v+ I( A! J& ~9 S% g
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ o% O- L4 I. Z7 Z' Uterone was 38 ng/dL (normal, 50 to 760 ng/dL),( C* K. G* Q) H$ F0 b. a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; T& I4 I5 N1 _" |7 w9 Y# P7 i
49ng/dL), 11-desoxycortisol (specific compound S)( H  F% [$ |. y8 @1 Y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! R. k, a4 u, n* `9 Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ ?. T0 \; j0 s8 U# ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
. l. X& t+ m7 N$ r  xand β-human chorionic gonadotropin was less than
$ L1 g" P* r9 y% r5 mIU/mL (normal <5 mIU/mL). Serum follicular# G- e5 F" _4 `2 u, [! S: m
stimulating hormone and leuteinizing hormone
# D( u' g: ]( j* g: \* Y3 qconcentrations were less than 0.05 mIU/mL) b+ r  N; a1 j$ N# f
(prepubertal).+ M* e  D, L, K' m4 n" c  R) G
The parents were notified about the laboratory$ A, _5 H9 e# @  Y: t+ ^
results and were informed that all of the tests were
% P5 O. F6 h3 o% Z" k( Snormal except the testosterone level was high. The
$ q: N7 G4 m) Wfollow-up visit was arranged within a few weeks to9 w( w% Q& V5 Y
obtain testicular and abdominal sonograms; how-' `6 |& P1 O; h0 E
ever, the family did not return for 4 months.
# r- Z% x# q2 n9 U$ g% ]3 cPhysical examination at this time revealed that the
+ x7 Q* f! O" s) n# nchild had grown 2.5 cm in 4 months and had gained& X6 c+ B: o4 D) A: D  }$ F) F
2 kg of weight. Physical examination remained+ s6 E4 U4 g# B& [4 K' ^! I
unchanged. Surprisingly, the pubic hair almost com-  \6 W' l5 I- i
pletely disappeared except for a few vellous hairs at
4 X& d% ~9 H5 o' Qthe base of the phallus. Testicular volume was still 2
' ~% j. h$ ^8 V. w' M) ?9 z+ Z4 \+ Y* ImL, and the size of the penis remained unchanged.  f6 P1 N' o8 V4 V  e, [5 N
The mother also said that the boy was no longer hav-
5 [; [: N7 B% f; ring frequent erections.) p7 M. s: w# {; F: [
Both parents were again questioned about use of
& s" v" P9 a' y3 X2 D, M3 u3 k$ ?any ointment/creams that they may have applied to5 ^0 @9 M$ t9 C' `  V7 I
the child’s skin. This time the father admitted the( Z' ]9 J& M+ _, @; [/ N
Topical Testosterone Exposure / Bhowmick et al 5419 e7 i1 |# g: Q  }6 s% @0 u; t, V8 t2 _
use of testosterone gel twice daily that he was apply-
4 x/ }! r; H; ?+ K. x7 I- b9 J! n4 Qing over his own shoulders, chest, and back area for" t4 t$ O5 u$ G& ^4 t7 p
a year. The father also revealed he was embarrassed
- t) o; t. ^) k  bto disclose that he was using a testosterone gel pre-" K1 \% ^- U, h* K3 g# e% O
scribed by his family physician for decreased libido0 N' w. P5 Y1 g8 R, h. r6 L' o
secondary to depression.1 Y  {9 `# d# T$ i  g# p
The child slept in the same bed with parents.0 `# w) a8 N9 i1 x4 X. p5 n' n
The father would hug the baby and hold him on his
9 H' X: S7 n# Schest for a considerable period of time, causing sig-
& ^6 c8 S4 @; U- x3 Unificant bare skin contact between baby and father.
! D' i1 B# b: Y3 RThe father also admitted that after the phone call,# @: J, L( s- A. Z
when he learned the testosterone level in the baby# Z) n% s6 `1 ?
was high, he then read the product information8 ?: A7 S) O! o6 w3 p8 b
packet and concluded that it was most likely the rea-
# Q/ D$ |' G" n5 [! I" F4 cson for the child’s virilization. At that time, they
3 V4 X9 {# }; b  R$ \4 c: _5 Jdecided to put the baby in a separate bed, and the8 y8 `0 y" o' S; E! ^) ]
father was not hugging him with bare skin and had' N6 b& q1 X* v& s, _
been using protective clothing. A repeat testosterone
% ~8 U0 J' C- n1 {% Dtest was ordered, but the family did not go to the
9 z$ c4 g. i) P1 g% k1 q; ilaboratory to obtain the test.5 z) S% r1 c% q/ i
Discussion$ J, R3 O- o9 N" E5 M9 c  t& W/ u
Precocious puberty in boys is defined as secondary
  F% s# q/ v2 x, @) D. C4 vsexual development before 9 years of age.1,4+ y5 i% i% X! E5 ~% Y
Precocious puberty is termed as central (true) when
2 a) ^; F  p9 cit is caused by the premature activation of hypo-( x; S9 k* `& {9 l6 {
thalamic pituitary gonadal axis. CPP is more com-6 e$ K* B" B: n& n7 L3 V1 j4 ^
mon in girls than in boys.1,3 Most boys with CPP
# t: }0 N8 }9 O# A" D3 v' imay have a central nervous system lesion that is
) I) \7 I/ n4 k9 e% @0 Eresponsible for the early activation of the hypothal-
" e- }  J" f- W  E" kamic pituitary gonadal axis.1-3 Thus, greater empha-
7 b% g( \/ f' T. I, h& u, gsis has been given to neuroradiologic imaging in) Z7 Q# p7 j: r8 L6 Q+ l
boys with precocious puberty. In addition to viril-: z3 e8 U7 o2 X( g% V& z) p$ t7 g, s
ization, the clinical hallmark of CPP is the symmet-* i* y6 n! r$ }- I& s4 b
rical testicular growth secondary to stimulation by; I( F2 q7 L6 B8 Z
gonadotropins.1,3# B; C2 J4 r! c, D, ^! H* R1 W
Gonadotropin-independent peripheral preco-
5 x9 H4 p% \- n( V; m) ]* |cious puberty in boys also results from inappropriate$ g! g( v: T! U( v
androgenic stimulation from either endogenous or1 k4 V9 ]$ k& V5 ^4 q  V8 l# r/ c
exogenous sources, nonpituitary gonadotropin stim-
; [4 H2 n2 d# z6 p) xulation, and rare activating mutations.3 Virilizing. {& Z  ?# t* A% r0 G3 h. v) ?
congenital adrenal hyperplasia producing excessive
1 E* |: W. S8 |2 F8 |adrenal androgens is a common cause of precocious
- A9 h, d/ x  r" f6 w+ ]  U: xpuberty in boys.3,47 V  g4 N* E+ J$ \
The most common form of congenital adrenal
9 N: S( I$ M$ Q8 E+ e; w) ~5 jhyperplasia is the 21-hydroxylase enzyme deficiency.  k5 A* A2 @! \1 x7 Q7 k; `5 I
The 11-β hydroxylase deficiency may also result in& H+ c5 t# {: x2 y
excessive adrenal androgen production, and rarely,7 r/ l. c$ R% A$ t  w) s- X
an adrenal tumor may also cause adrenal androgen  ^6 E( l+ V4 y$ E7 J
excess.1,3- t+ \3 @7 N) I' p7 d; }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 I7 K  K: O' I  E5 l6 V( I) D  X% J7 M542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& A  q1 L) {" n$ ~! U, {A unique entity of male-limited gonadotropin-3 E( ?+ [* K. N: C: Y; i6 ], G! o
independent precocious puberty, which is also known
" M5 A! g! g& j7 h9 oas testotoxicosis, may cause precocious puberty at a
) ]$ G5 z+ J9 R6 {, h7 Tvery young age. The physical findings in these boys
+ A0 t( ^' |3 H/ f) M  Ewith this disorder are full pubertal development,
" L4 H5 N. G* W% [; e6 b: K8 Fincluding bilateral testicular growth, similar to boys
! C1 u1 b  j! Q6 gwith CPP. The gonadotropin levels in this disorder
5 S: h2 Z2 X# r8 Y) c) F/ C4 Uare suppressed to prepubertal levels and do not show0 h4 u3 y) O$ c/ d+ r! G
pubertal response of gonadotropin after gonadotropin-2 e  r% d' M3 G) H
releasing hormone stimulation. This is a sex-linked6 M6 M3 A! z7 c3 p, Z
autosomal dominant disorder that affects only
3 ?. o# P& @; v" n3 U( c. l' ]males; therefore, other male members of the family
6 U/ X5 j- F; V% I- e) }" Xmay have similar precocious puberty.3* S  O4 g3 `" h: L6 ]8 w9 h
In our patient, physical examination was incon-
) s; a$ j3 C. m5 i# p+ N8 _sistent with true precocious puberty since his testi-
, N8 v, i9 \; n$ Q/ g+ H) _cles were prepubertal in size. However, testotoxicosis# o5 S+ m* D& G& K( v/ {5 w( r) T
was in the differential diagnosis because his father2 u* w  X9 v- \/ S
started puberty somewhat early, and occasionally,3 i3 H- w; `' W1 O2 k+ f; U. s
testicular enlargement is not that evident in the
  k3 d" `% O" k4 s0 d5 O6 @beginning of this process.1 In the absence of a neg-
4 ]5 j& H4 `& [6 r( v: r, uative initial history of androgen exposure, our: v  Q  Q7 A  t: R" _
biggest concern was virilizing adrenal hyperplasia,8 g/ D8 q1 h% M! o9 ?
either 21-hydroxylase deficiency or 11-β hydroxylase5 s  o# y+ |( N' v0 T
deficiency. Those diagnoses were excluded by find-
" P% v: H% c* `ing the normal level of adrenal steroids.
7 V  X6 [1 L" y5 n# tThe diagnosis of exogenous androgens was strongly: K& @) ]  E2 n8 A9 F
suspected in a follow-up visit after 4 months because
. H8 V" ?/ X. E9 d* Hthe physical examination revealed the complete disap-
4 s8 f$ M, K* h9 ]9 E- P, Rpearance of pubic hair, normal growth velocity, and  ^+ g( A0 F" A# f; C8 L- M
decreased erections. The father admitted using a testos-
0 s3 ]  j; h) R/ Z  lterone gel, which he concealed at first visit. He was; c& C& `! L/ ]7 T( ^2 Z- c
using it rather frequently, twice a day. The Physicians’& r+ ]9 e7 Y6 j1 h5 S- K
Desk Reference, or package insert of this product, gel or, C* f0 G/ y. i+ U) u
cream, cautions about dermal testosterone transfer to2 P' Z; D6 D. J0 r
unprotected females through direct skin exposure.7 X( l5 x0 ]6 T* o" [# k, d! A
Serum testosterone level was found to be 2 times the
" u5 {7 L% F( cbaseline value in those females who were exposed to
8 ~' k& k0 G2 l' x/ leven 15 minutes of direct skin contact with their male
" m" d% k/ S. I! ~8 ]partners.6 However, when a shirt covered the applica-
& P' z$ v2 M7 q* Vtion site, this testosterone transfer was prevented.
  C, k$ O8 A5 D; m$ Z4 z: OOur patient’s testosterone level was 60 ng/mL,
1 M2 y, P3 `) R7 d+ {9 X% Owhich was clearly high. Some studies suggest that
  l" t  m* _3 p& @4 {dermal conversion of testosterone to dihydrotestos-
2 a) w( b* r9 G' I9 Y: E, @terone, which is a more potent metabolite, is more
/ P( N  ^* ~2 `+ T4 mactive in young children exposed to testosterone: w; y5 t- v5 X/ a% ?
exogenously7; however, we did not measure a dihy-9 ], J2 I/ i! F3 N; c
drotestosterone level in our patient. In addition to
! v4 u; ]7 e$ I. jvirilization, exposure to exogenous testosterone in
3 n5 |) p: l  n% {children results in an increase in growth velocity and0 Y8 Z+ x0 x! @- Y$ _# i( s/ G
advanced bone age, as seen in our patient.
, C+ D0 k8 F! ~" n- s- l1 g/ N4 A" RThe long-term effect of androgen exposure during
7 G9 N0 g1 ?3 ~* H( `1 |9 x) Searly childhood on pubertal development and final' v6 F1 T' o8 Y9 n( u0 ?
adult height are not fully known and always remain
1 i* i5 {6 W3 |7 N$ y/ Z8 r4 K0 ya concern. Children treated with short-term testos-
) ?1 r9 v$ a8 z. qterone injection or topical androgen may exhibit some
8 L$ m% o: F  Iacceleration of the skeletal maturation; however, after
+ ]; C, u! `" I% R! ucessation of treatment, the rate of bone maturation. N* H* C0 J( e3 H/ L& B- X# I" b
decelerates and gradually returns to normal.8,9) @6 e) I5 K1 |3 D# }( p
There are conflicting reports and controversy) T# D% `) l* B+ y4 ~5 S
over the effect of early androgen exposure on adult
5 `( R9 k1 G' u2 u) P$ Ipenile length.10,11 Some reports suggest subnormal
  s; [: r9 L+ l  N1 A* Iadult penile length, apparently because of downreg-8 K* t/ W" j: @! B5 r/ }
ulation of androgen receptor number.10,12 However,
" @2 |' c) `1 J3 r6 c0 \Sutherland et al13 did not find a correlation between6 j" P4 c  q9 n
childhood testosterone exposure and reduced adult( M$ x+ K, t) C' M* R  `
penile length in clinical studies.% i' n+ {8 Y, _$ M; C  N" I
Nonetheless, we do not believe our patient is/ E8 v# R/ g: S: a
going to experience any of the untoward effects from* r; w5 R$ @& {) L7 e2 H. `; c
testosterone exposure as mentioned earlier because5 b; E2 d: N% g) c. v8 C
the exposure was not for a prolonged period of time.' q9 i( I% i* ~3 W
Although the bone age was advanced at the time of7 R6 q! Q0 x" D, L' k% }
diagnosis, the child had a normal growth velocity at8 p9 E& @& g7 @& S% j- ~+ `$ Q
the follow-up visit. It is hoped that his final adult! |9 L  B8 A. l+ I, k; a
height will not be affected.
, M8 i, |5 e' m3 |% z4 f# }Although rarely reported, the widespread avail-
# k# l: o; \% Z% {/ pability of androgen products in our society may# t# Z, c: I4 i* o
indeed cause more virilization in male or female
9 y5 ]. p! S$ P: k0 Cchildren than one would realize. Exposure to andro-
0 K' @& B% g3 ~1 B7 Bgen products must be considered and specific ques-
/ [* c$ ]2 ?, D3 `  N( L8 T+ ttioning about the use of a testosterone product or
9 K7 p& N. _. N5 E* P5 ugel should be asked of the family members during# J. k! }& `4 m' F% }; g5 _
the evaluation of any children who present with vir-$ y+ N$ f1 j+ L0 x& `  @) V& d
ilization or peripheral precocious puberty. The diag-2 J4 j& u% `7 R) f& M# o/ I
nosis can be established by just a few tests and by
0 `* A! Z: a; i$ }+ _: Pappropriate history. The inability to obtain such a0 C) _( G) z% f& B1 e
history, or failure to ask the specific questions, may
, S# l6 q: }% kresult in extensive, unnecessary, and expensive
' {, a  f% [4 `) g4 L" b9 pinvestigation. The primary care physician should be
  `: i+ O) G5 Z1 o5 J2 H  W9 \aware of this fact, because most of these children  Q4 s6 N) x$ S, D0 z$ u* d! p
may initially present in their practice. The Physicians’
8 c7 J: e7 W' h8 \Desk Reference and package insert should also put a
" H# A: H% D$ L: K' Q8 `4 K. W' iwarning about the virilizing effect on a male or$ j$ |5 H+ Z: v3 _
female child who might come in contact with some-
6 K% `; `/ c9 `* V8 _one using any of these products.& I& W7 D% [7 g% M6 u$ ?
References
9 l" s3 ^/ \- i% m& d) t: H! ~1. Styne DM. The testes: disorder of sexual differentiation- n: a& W# ?7 V5 @/ s
and puberty in the male. In: Sperling MA, ed. Pediatric* h( E7 L$ \. [. e
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; {" C1 U+ ?) h, E2 I- ^
2002: 565-628.7 A* d. T; J4 `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ S& V7 c; j3 o/ u* h7 t( o
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old. ]6 l6 T( E) r# }# R* P  g3 J
Boy Induced by Indirect Topical. k% l( l; X: {; G
Exposure to Testosterone
- o9 \. J$ ~) d+ v) D- VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. G: }6 Z. S) i
and Kenneth R. Rettig, MD1! |+ p; e* B) @- A; O: A* m8 t8 m
Clinical Pediatrics
, l1 F( H* X% q8 w3 v7 C6 cVolume 46 Number 6, S. t6 v7 }; {1 A
July 2007 540-543
, {# i/ n5 ]+ a© 2007 Sage Publications
( x, V) W: N% ]  \3 i10.1177/0009922806296651
+ o) Y4 C6 i1 V' i( _7 hhttp://clp.sagepub.com- `! m; ~; u0 a& n$ {
hosted at
- O6 s+ E% E( b; @# m2 s2 Uhttp://online.sagepub.com  Q, z  e2 s/ {9 m8 G- L
Precocious puberty in boys, central or peripheral,
1 u4 }1 }4 \& X$ H+ w9 {' f1 ?  Iis a significant concern for physicians. Central
5 a) ]/ g5 l9 |8 X0 eprecocious puberty (CPP), which is mediated
2 w) v* d: q$ z. X1 |through the hypothalamic pituitary gonadal axis, has, Z2 ^1 m7 q! C3 y3 U0 ?
a higher incidence of organic central nervous system2 `- S. n' s7 J/ y: d4 @' Y
lesions in boys.1,2 Virilization in boys, as manifested
" ]8 {; P& P/ e  e7 l0 ^by enlargement of the penis, development of pubic
. S% v5 g1 K) C: @0 P$ E9 ohair, and facial acne without enlargement of testi-1 F3 ~! @( R  P( ]6 \# R7 }2 F
cles, suggests peripheral or pseudopuberty.1-3 We1 N# c  o: P- R  O$ R0 y* u, ~
report a 16-month-old boy who presented with the
: ^% `2 ~( W/ Wenlargement of the phallus and pubic hair develop-) ]# H2 ~  q* W! B, j
ment without testicular enlargement, which was due
& z. M/ a: s" q: j7 Rto the unintentional exposure to androgen gel used by* ~2 ?: J" W5 G" ^, S5 x0 i
the father. The family initially concealed this infor-
# s! k2 h9 Q8 U! _* k: ]( pmation, resulting in an extensive work-up for this
5 a; K; Y" l" H4 u) C% @child. Given the widespread and easy availability of3 g. N4 g# {* _4 h
testosterone gel and cream, we believe this is proba-7 N& h7 a# _* A4 Q5 W$ f" d" u
bly more common than the rare case report in the
9 j/ ]3 X$ @+ w( J. y2 {1 _literature.40 o* N: L5 {+ M0 I0 n
Patient Report
/ ?& I8 y/ V% Y; [% ?A 16-month-old white child was referred to the
. C" |; G* S1 G7 [$ Oendocrine clinic by his pediatrician with the concern
3 f7 j6 K& Y  Z+ y; o( pof early sexual development. His mother noticed! _) h3 N- J$ C9 v# o# Q
light colored pubic hair development when he was2 O$ l& W' f8 p! O- E* l: v6 _
From the 1Division of Pediatric Endocrinology, 2University of) R% Z1 O' M5 Z$ |# N' }
South Alabama Medical Center, Mobile, Alabama.) Q) q# U: c6 ?; r  _. m5 |0 M
Address correspondence to: Samar K. Bhowmick, MD, FACE,- H7 T4 s- X! S2 {0 T+ B2 M
Professor of Pediatrics, University of South Alabama, College of
+ D: y: c; C# h8 fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 M- R' I  C) I! s2 b3 ~3 De-mail: [email protected].
7 n3 C7 n& O$ @% |about 6 to 7 months old, which progressively became/ A; u$ b* G8 a* n# T, I- C
darker. She was also concerned about the enlarge-
; t8 N7 D" b$ L9 v  `6 H  I) gment of his penis and frequent erections. The child
- ^+ c4 N" S6 p, u* awas the product of a full-term normal delivery, with2 t! v2 O# m) K& [  i% `
a birth weight of 7 lb 14 oz, and birth length of
# Z5 ]5 p! A" q" J/ P20 inches. He was breast-fed throughout the first year5 n6 W5 G: O3 c6 Y2 t# ]1 n
of life and was still receiving breast milk along with5 n/ k  R4 ^; N# _/ y7 o1 q+ d
solid food. He had no hospitalizations or surgery,
) a! o, _  F# H6 }' ^and his psychosocial and psychomotor development0 x5 m$ X  V, Y; e4 J0 x4 b
was age appropriate.4 o5 p! |+ a" a6 f: ~. U* q, \) E. u
The family history was remarkable for the father,
: o7 b) q- |" I6 h" `who was diagnosed with hypothyroidism at age 16,2 `, h% ~! G4 W, o% r. j
which was treated with thyroxine. The father’s
9 z2 p3 ~1 Y2 y. iheight was 6 feet, and he went through a somewhat/ t. U) N( W8 {, Z7 g
early puberty and had stopped growing by age 14.* \) e( |$ _$ M! ~
The father denied taking any other medication. The
, `  e8 o5 F! B& nchild’s mother was in good health. Her menarche
9 z  R0 v. D2 ewas at 11 years of age, and her height was at 5 feet; ^( K. O2 Z' M' [2 r
5 inches. There was no other family history of pre-- J7 i/ D! O, V$ v
cocious sexual development in the first-degree rela-! t8 G& \0 v1 ?* Z4 \8 A
tives. There were no siblings.
0 b: Z; `) b4 ~4 k8 JPhysical Examination+ S$ @. ]1 F$ ~! }7 m2 W4 ]2 Z
The physical examination revealed a very active,  I# ]) C% {: H, S+ q
playful, and healthy boy. The vital signs documented
6 X% I2 G' L+ W( ]  T9 w0 Ga blood pressure of 85/50 mm Hg, his length was
& F0 T/ U: I2 E/ B7 X& f9 Y3 t90 cm (>97th percentile), and his weight was 14.4 kg
& H/ H$ P3 u* `$ C  V(also >97th percentile). The observed yearly growth
6 D3 Q' W0 f( ?; s1 bvelocity was 30 cm (12 inches). The examination of
1 V2 z1 D$ M; Ythe neck revealed no thyroid enlargement.6 z1 f+ C9 F, d; W- W5 W8 v
The genitourinary examination was remarkable for
* A3 x7 o. f7 z) x( s& z0 wenlargement of the penis, with a stretched length of* ?% p  ?" p; _. j$ Q
8 cm and a width of 2 cm. The glans penis was very well
7 N0 f( R. O" J9 e! hdeveloped. The pubic hair was Tanner II, mostly around: x3 s; h: w1 B7 P1 u( P
540
6 C% u  B2 w8 \7 J  E7 P1 n& _' cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! g4 i" y+ x/ t6 rthe base of the phallus and was dark and curled. The
0 c- R! P& Z, z" \7 V& N8 htesticular volume was prepubertal at 2 mL each.
5 P. r  h$ B9 j9 L# S# FThe skin was moist and smooth and somewhat
& j" }! H4 _& k* s. {( d# Woily. No axillary hair was noted. There were no
* R# N; Z* x( D# x" Vabnormal skin pigmentations or café-au-lait spots.7 \& A' ?' [9 [) _
Neurologic evaluation showed deep tendon reflex 2+
: j# u  L' }; W. ?9 I  u9 s; nbilateral and symmetrical. There was no suggestion
& u% K; f4 K9 V! V1 Tof papilledema.
3 E8 t9 [) ^" l- _- g/ {1 vLaboratory Evaluation
. S  [) y) S! D# r; w# xThe bone age was consistent with 28 months by
3 l( g( g1 ]5 ~3 |1 {1 B3 husing the standard of Greulich and Pyle at a chrono-( _  l' v7 Q# t* ^; _4 [# s
logic age of 16 months (advanced).5 Chromosomal
0 L  B2 x  H5 T3 zkaryotype was 46XY. The thyroid function test
6 R% j& G) M' j  cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- k0 X+ `, h1 _# N* |
lating hormone level was 1.3 µIU/mL (both normal).
6 \- w+ Z$ u7 X, l% v' sThe concentrations of serum electrolytes, blood, |* G' c, }) J! Y& b; }3 z
urea nitrogen, creatinine, and calcium all were
6 B+ Y" }; O# U& pwithin normal range for his age. The concentration1 O3 z6 `/ q8 _& {# B6 i6 x
of serum 17-hydroxyprogesterone was 16 ng/dL
: r6 g1 f- T5 e6 A(normal, 3 to 90 ng/dL), androstenedione was 20
# g: y! Q' J  png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 i! Z' H# k" A2 |terone was 38 ng/dL (normal, 50 to 760 ng/dL),
) K: H7 O* R8 j! |7 c. fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  W7 N( h8 x5 T& {6 q& \49ng/dL), 11-desoxycortisol (specific compound S)
& P% ]: Q' R# L9 T: awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 h7 t* x3 ~5 F8 p- [, m0 k# X7 ^tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: H& {; I% @7 P- Y. U2 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 i# N- Z8 y/ Iand β-human chorionic gonadotropin was less than
$ F  l' c0 l  V! p8 z5 mIU/mL (normal <5 mIU/mL). Serum follicular! z4 t2 Z" X0 Y+ M& e1 l2 F# z% T/ H
stimulating hormone and leuteinizing hormone
" q: i* j  A* K2 [' l- qconcentrations were less than 0.05 mIU/mL
% t6 T7 e0 P# d6 `(prepubertal).6 u" g: |  U# t% z% L7 E
The parents were notified about the laboratory6 j9 k, Q2 ^9 k: G/ p
results and were informed that all of the tests were
) J/ ?$ F* \! {normal except the testosterone level was high. The/ A2 t- _, p! {+ v" P9 X; J6 s
follow-up visit was arranged within a few weeks to. Y9 T* B3 d- l+ d2 k1 m; R5 Y
obtain testicular and abdominal sonograms; how-
) g; R. K+ L! ]6 W) O+ Aever, the family did not return for 4 months.
' H- P  o: a# [3 P( h6 v$ V$ VPhysical examination at this time revealed that the9 a/ `& r( z5 h3 q4 Y/ Z7 r/ A7 o
child had grown 2.5 cm in 4 months and had gained  l: v' y2 {2 N/ _4 q& `! A" p
2 kg of weight. Physical examination remained
) r4 m; h5 T- X/ s: cunchanged. Surprisingly, the pubic hair almost com-
  N$ }1 s, d5 k* U2 a, z* opletely disappeared except for a few vellous hairs at
# d, K( O0 g2 T7 ]0 f, g% Tthe base of the phallus. Testicular volume was still 2
" g# R2 Z4 f  K4 R9 \8 b# m- ^mL, and the size of the penis remained unchanged.
/ e- t, Y0 I" L. q9 I: CThe mother also said that the boy was no longer hav-; r! k- r" j4 N% \
ing frequent erections.0 K7 c9 E4 ]* p: k: ~; m, r
Both parents were again questioned about use of
1 G7 ~0 a8 ~! S- O# E+ U4 Oany ointment/creams that they may have applied to
: Y  W$ h2 T" v% W. L! V: Ithe child’s skin. This time the father admitted the
9 f9 P% t8 M2 p% [/ n: I* k# D: w# rTopical Testosterone Exposure / Bhowmick et al 541. X) d8 l7 \9 h) G0 f
use of testosterone gel twice daily that he was apply-% Y/ h- Z2 \$ e% P
ing over his own shoulders, chest, and back area for" h+ Q. m2 X* l# e
a year. The father also revealed he was embarrassed
- X5 X. y$ ?! w; Y- \to disclose that he was using a testosterone gel pre-
: E0 b6 k6 D; ?4 [5 ?0 Gscribed by his family physician for decreased libido
4 ]% z+ z& z& c0 Wsecondary to depression.
; w% j8 d3 I. w; ^4 o7 cThe child slept in the same bed with parents.' o6 }$ F! \" R! ~  p7 D
The father would hug the baby and hold him on his
& W# q8 X) K  m( z1 s7 {+ o7 Ichest for a considerable period of time, causing sig-4 A: \/ f0 J4 Q3 `- P9 \
nificant bare skin contact between baby and father.
$ c6 Y7 S: F0 c' _8 sThe father also admitted that after the phone call,
" ~' Y: @! `0 e- U- pwhen he learned the testosterone level in the baby; Y" u: l. E; R! }
was high, he then read the product information* i/ B3 M1 ~" O8 q; @, h3 L
packet and concluded that it was most likely the rea-- G- e2 G" p2 m4 h) Y& Y8 n; C- W
son for the child’s virilization. At that time, they# Y% H+ I) j# v9 |
decided to put the baby in a separate bed, and the6 {% }' W" p  \, z6 A' d
father was not hugging him with bare skin and had
- I1 [+ W; u+ L; ebeen using protective clothing. A repeat testosterone
& Y+ W1 R  C4 i3 \* Q4 ktest was ordered, but the family did not go to the
% @. z2 _- B# l, {' xlaboratory to obtain the test.& ^  W. H& }% l, c% z
Discussion
; Y; b1 s( l" f5 @) E$ C; O) m4 u7 aPrecocious puberty in boys is defined as secondary% @9 m2 D( i" ^# [5 {7 v) f. A$ L
sexual development before 9 years of age.1,4% C# r! K& f+ k4 C! V( f
Precocious puberty is termed as central (true) when
3 Z% C2 v3 b" Z7 `/ iit is caused by the premature activation of hypo-
7 x8 K: F3 x/ kthalamic pituitary gonadal axis. CPP is more com-
" O1 t- V1 l% Omon in girls than in boys.1,3 Most boys with CPP+ H4 E! {6 R( I/ }6 n+ {5 D1 U2 E
may have a central nervous system lesion that is
. ~2 j6 M/ r- ~$ Rresponsible for the early activation of the hypothal-
) [' V6 U% D3 {7 r9 E2 M0 damic pituitary gonadal axis.1-3 Thus, greater empha-% t7 b3 O$ ~5 P; W
sis has been given to neuroradiologic imaging in6 G& A- O5 P: b( k& S# q7 z$ I6 o
boys with precocious puberty. In addition to viril-
% j5 U' V# c. D2 Tization, the clinical hallmark of CPP is the symmet-. {5 o; M5 x1 |
rical testicular growth secondary to stimulation by
( v+ m  \) C9 ?  rgonadotropins.1,30 p, `2 V% g. F6 a) n& o
Gonadotropin-independent peripheral preco-* T, i) n: ?2 S
cious puberty in boys also results from inappropriate
  ]5 P' e3 \" i; M: _androgenic stimulation from either endogenous or
9 s& @$ h. E4 t- v2 [. p. F3 t1 N6 pexogenous sources, nonpituitary gonadotropin stim-
* Y, P, z8 m: |ulation, and rare activating mutations.3 Virilizing: {: f0 }; r, I  B! V) }
congenital adrenal hyperplasia producing excessive, q4 e  v+ ^% n8 s
adrenal androgens is a common cause of precocious; _, I9 T7 q5 L6 g6 q  A( y
puberty in boys.3,4
+ Z/ ~5 K3 M; S8 MThe most common form of congenital adrenal
" Y! R# q( F7 O, m# [- Q) Lhyperplasia is the 21-hydroxylase enzyme deficiency.
2 w' [, O, k' h$ }/ f  A7 v0 p! ?The 11-β hydroxylase deficiency may also result in
) k2 U9 j  k9 v' Iexcessive adrenal androgen production, and rarely,$ X& K# `' F( j  p8 W* {3 t5 ~
an adrenal tumor may also cause adrenal androgen9 C. A1 z$ [  o/ U3 L
excess.1,3" L. u* |; Q5 i' [( K5 l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, `7 U8 B* V; F2 N: X* `0 V1 n3 q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) f  _# H$ l$ d% x% i6 e/ U
A unique entity of male-limited gonadotropin-8 F" y1 Z$ `# K& S
independent precocious puberty, which is also known# a3 Y0 t! E. i$ S  ]
as testotoxicosis, may cause precocious puberty at a' B0 i6 v5 P5 h% g  M+ O# a, D
very young age. The physical findings in these boys1 l6 w8 |7 m  R  t) r6 s
with this disorder are full pubertal development,
9 p/ s5 i7 K2 P- `5 s) O# A5 Lincluding bilateral testicular growth, similar to boys
. v; a7 l$ i; U2 h' e3 e% xwith CPP. The gonadotropin levels in this disorder
& o; e" D0 x3 d1 I( F8 O5 iare suppressed to prepubertal levels and do not show) i7 r/ v& }8 T7 k$ l: n/ u: P9 o  U
pubertal response of gonadotropin after gonadotropin-" J! }0 l' O: E5 `1 f
releasing hormone stimulation. This is a sex-linked1 g- z, j8 Z, u. u" y% |
autosomal dominant disorder that affects only
  T  U8 c% Y- F- a. g- R3 c& ~males; therefore, other male members of the family
$ F' a# y3 y# W$ _% ~& Lmay have similar precocious puberty.3
8 K, [: S  M  \8 `+ ?+ yIn our patient, physical examination was incon-
' c' y6 m3 `9 k) J/ x+ t+ _sistent with true precocious puberty since his testi-
! p/ p2 R3 \# e/ C; j2 Kcles were prepubertal in size. However, testotoxicosis
8 f5 b. H6 t' W/ Awas in the differential diagnosis because his father; o  ]+ ]  E; E% Z' ]
started puberty somewhat early, and occasionally,1 p* F7 R7 Y& d: j; ^
testicular enlargement is not that evident in the
3 n. X/ u1 ~; q# ?" j' Wbeginning of this process.1 In the absence of a neg-
& i" k5 ?. J2 S( P: }* @. `! l6 Yative initial history of androgen exposure, our
0 ^) B* o4 ^5 Vbiggest concern was virilizing adrenal hyperplasia,' i) O5 I& t" Y$ o1 H! e
either 21-hydroxylase deficiency or 11-β hydroxylase: ?; C& s9 [, p4 O& Z4 b' ^2 X: s
deficiency. Those diagnoses were excluded by find-
$ K: `  V- p* N8 p5 u& king the normal level of adrenal steroids.
+ B1 }' b8 K, b9 X8 nThe diagnosis of exogenous androgens was strongly
7 V$ \0 A6 ^- |+ Isuspected in a follow-up visit after 4 months because
" V! E) j2 [5 G* [" V- E+ T' wthe physical examination revealed the complete disap-
# C4 y9 B- D: ^* b, Fpearance of pubic hair, normal growth velocity, and
5 B% ?8 K7 J" o& Q; [decreased erections. The father admitted using a testos-, f( U9 q2 J  t- @
terone gel, which he concealed at first visit. He was
0 I$ e  ~& n( z; S2 ^; ]+ Wusing it rather frequently, twice a day. The Physicians’4 e+ H* R/ R0 e, n( C1 H  c
Desk Reference, or package insert of this product, gel or
5 j: S' g& I2 C' f2 L: Y1 p  Xcream, cautions about dermal testosterone transfer to
6 k- {  P1 I7 G6 A7 f! ^  Nunprotected females through direct skin exposure.3 ]2 b3 R0 W& Y0 I: \+ W
Serum testosterone level was found to be 2 times the
) r% b' {( L0 @  ^baseline value in those females who were exposed to
! ~2 m! L  x9 A1 x0 reven 15 minutes of direct skin contact with their male
, ]. [3 ^; {% Z/ b3 y4 G' ^: Q& spartners.6 However, when a shirt covered the applica-1 R/ d. `1 G6 |6 @+ M2 ~7 I8 l
tion site, this testosterone transfer was prevented.
6 z& m  M' t' n: W# b3 `% YOur patient’s testosterone level was 60 ng/mL,! |9 K  `. v. Q( ^! S
which was clearly high. Some studies suggest that
* F, f6 T: B1 G7 d% L4 mdermal conversion of testosterone to dihydrotestos-. M7 J* J/ ^, V" l/ K6 z6 E, p
terone, which is a more potent metabolite, is more
2 N# }! L' F8 s: Vactive in young children exposed to testosterone5 u) h$ f, t5 i' E0 P
exogenously7; however, we did not measure a dihy-
3 k1 Z- @1 Q( F& Rdrotestosterone level in our patient. In addition to4 A+ H0 \  j% A7 @$ y: S9 k
virilization, exposure to exogenous testosterone in/ ^3 o( o" y0 o; M
children results in an increase in growth velocity and
# l, [" p2 N4 M. w+ Dadvanced bone age, as seen in our patient.& D& ^% b- q" N
The long-term effect of androgen exposure during
* J/ T, ?( F2 _. x2 ]$ xearly childhood on pubertal development and final* P( T- o, P) `: D# R
adult height are not fully known and always remain
5 e3 K* o$ b, Ua concern. Children treated with short-term testos-  d: v& @4 Y- e" A
terone injection or topical androgen may exhibit some2 p# o6 {( C6 o/ V' u
acceleration of the skeletal maturation; however, after3 X' y' `/ s$ M
cessation of treatment, the rate of bone maturation
3 |4 l) Z3 z) \1 T$ p) ^% Z+ F; {decelerates and gradually returns to normal.8,9
9 |3 y1 `8 w7 r& \' o% @3 [% TThere are conflicting reports and controversy, ?" e) P) c7 E  J4 }( Y8 _
over the effect of early androgen exposure on adult2 S& r  z% F- U
penile length.10,11 Some reports suggest subnormal2 [6 ?0 ^  d; S% q
adult penile length, apparently because of downreg-
2 U* k' G! s& o) O5 y8 x, Kulation of androgen receptor number.10,12 However,! q7 D0 ~+ U, [
Sutherland et al13 did not find a correlation between' g+ L/ g; f/ f+ d
childhood testosterone exposure and reduced adult6 o% a. H4 t: n
penile length in clinical studies.+ @- A. }6 H" ~6 d( Q) X* T
Nonetheless, we do not believe our patient is- F% P3 i2 m8 I) `( z
going to experience any of the untoward effects from/ h& f! Z8 z' l8 \
testosterone exposure as mentioned earlier because
& q7 b6 {3 ]+ o2 Bthe exposure was not for a prolonged period of time.
( T) I1 t* i; D* O' y. \0 ^Although the bone age was advanced at the time of6 S1 d# s- z( s- s3 ~  x0 d. v8 `8 `
diagnosis, the child had a normal growth velocity at
) k' r  w! z5 q) G, p8 @# athe follow-up visit. It is hoped that his final adult- ^$ T  R- v; P. H0 b
height will not be affected.& e5 v: C  p7 R5 A. g9 a
Although rarely reported, the widespread avail-! z, Z+ N% e; x
ability of androgen products in our society may
, |/ z# o) `! Zindeed cause more virilization in male or female  B) K2 {3 D* D: A; j
children than one would realize. Exposure to andro-
: K' ]& R1 ~* ~1 x6 N& a! ]) |8 kgen products must be considered and specific ques-8 r4 b0 c- h+ l; U$ W6 V; D5 l9 s
tioning about the use of a testosterone product or
: h- u; B, X8 Rgel should be asked of the family members during
" a/ G6 `2 j% j: @& t$ U5 lthe evaluation of any children who present with vir-1 N$ U" [" N  Y0 D$ l
ilization or peripheral precocious puberty. The diag-
. @5 w$ C% e1 `) Wnosis can be established by just a few tests and by" b& P2 x+ t* z0 _, {! D7 M
appropriate history. The inability to obtain such a
# t5 O. g% b* z( j" Y* n6 Ihistory, or failure to ask the specific questions, may
+ e; w; F9 F! x, Fresult in extensive, unnecessary, and expensive
- u$ q) @; N: m# _, Qinvestigation. The primary care physician should be( n1 k5 o% h- u9 D0 x! _+ Y: o
aware of this fact, because most of these children7 @+ O1 p9 z8 J
may initially present in their practice. The Physicians’
' e6 y. P9 D2 v2 x$ q! N- m9 ~* KDesk Reference and package insert should also put a
5 p% t9 e. `; n' Q1 `! E0 t8 [warning about the virilizing effect on a male or1 A+ P( O8 e7 m: r
female child who might come in contact with some-
" S6 ?/ d+ b. j% Yone using any of these products.
0 r) y/ r. _* R/ I5 mReferences
+ H' P* Z# C, L% I$ z' k1. Styne DM. The testes: disorder of sexual differentiation
, I* I3 R2 m" n: Jand puberty in the male. In: Sperling MA, ed. Pediatric
- J. \, Y  s9 b. U3 c' A- F, ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. i4 Q; H3 ~( }' b: w2 z' U9 k2002: 565-628.
, F$ f% t2 H* n4 h5 t0 H# y5 {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' c8 N% {0 n$ npuberty 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
( O; _. E7 |  Y3 Z$ e, r7 r( X
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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