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Sexual Precocity in a 16-Month-Old" y3 D, E( S. s& p* y( T8 @
Boy Induced by Indirect Topical
: ^; P5 }* K3 E7 P! lExposure to Testosterone3 l% ^4 e1 Z  ]4 r
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  ^% @! |+ q7 \. I8 @2 Z
and Kenneth R. Rettig, MD1/ z6 e& \2 \6 U/ }
Clinical Pediatrics$ a8 Y  ?, ~3 |8 q! z$ ?& ]
Volume 46 Number 6; J7 r% f7 v! B1 ~
July 2007 540-543
1 H& q/ d( A2 {8 g6 F© 2007 Sage Publications
: B" J- ~  @& t, t. g% [0 h10.1177/0009922806296651
+ A4 z* R. r8 F+ y3 khttp://clp.sagepub.com4 B, q. \. b" {3 h# |) j- t
hosted at
5 W' I) U  L# x# B; ~' [0 Xhttp://online.sagepub.com
$ N2 W1 ]: J" TPrecocious puberty in boys, central or peripheral,
' i# j; O1 B  g3 x& T% Kis a significant concern for physicians. Central& s+ Z# I  D  I- W8 O
precocious puberty (CPP), which is mediated+ T- x% q- B9 D, N$ e9 d# o- h
through the hypothalamic pituitary gonadal axis, has- Y6 `0 F# ?$ x
a higher incidence of organic central nervous system! d4 p- z! K) ]. H3 Z
lesions in boys.1,2 Virilization in boys, as manifested
1 V; s% Q3 k* [8 F! C" y9 Uby enlargement of the penis, development of pubic7 l9 Y  v$ Y0 }! x* b+ R7 B
hair, and facial acne without enlargement of testi-
, @) @& e, m1 f! K' u' L& ]" I9 Acles, suggests peripheral or pseudopuberty.1-3 We
1 q( b2 ^6 c' d* U, G" w% preport a 16-month-old boy who presented with the
9 q+ b' ?$ v. A( m- V* x8 g  |enlargement of the phallus and pubic hair develop-' D! v" T* T  k! i8 Y2 t$ F
ment without testicular enlargement, which was due3 Q* J* i5 n) N" |  C
to the unintentional exposure to androgen gel used by
2 c# B, ^; u: g* L" Y6 @& fthe father. The family initially concealed this infor-$ E% E' E+ i+ ^
mation, resulting in an extensive work-up for this" t4 Q  J; ]- C. N2 c. s4 _, m
child. Given the widespread and easy availability of
& |% c0 M9 G* e  ~* Qtestosterone gel and cream, we believe this is proba-# D. m$ z/ t4 `9 F% |: Z
bly more common than the rare case report in the
6 \0 ^: m- `, k$ n4 tliterature.4
; T. \6 ?0 `9 ~4 dPatient Report
6 T* o5 Y4 g3 c# B% K' v- pA 16-month-old white child was referred to the
" A9 Q/ B3 ~7 w9 q. ?. g+ dendocrine clinic by his pediatrician with the concern& H& `' _( S- y1 v% {
of early sexual development. His mother noticed* [5 Q( D. V( m. j9 C  z
light colored pubic hair development when he was. A6 Y4 ~, X7 P" V
From the 1Division of Pediatric Endocrinology, 2University of: Z' v# K% _/ V
South Alabama Medical Center, Mobile, Alabama.
. k  a. v) r) r9 R# hAddress correspondence to: Samar K. Bhowmick, MD, FACE,  y7 N! L8 b& {4 g5 f7 C
Professor of Pediatrics, University of South Alabama, College of/ N7 K2 g9 i4 C$ L* z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, d( c7 {5 ?; a$ X2 D  J0 \
e-mail: [email protected].
7 Z7 h2 A0 b% h7 w3 X7 p0 labout 6 to 7 months old, which progressively became0 |' ?$ S; p' a- U/ N" _8 y
darker. She was also concerned about the enlarge-3 ]9 T0 V. A' `# F( U4 n
ment of his penis and frequent erections. The child
2 V  Z) p; s% }% mwas the product of a full-term normal delivery, with
2 I' {+ P3 ^1 Ya birth weight of 7 lb 14 oz, and birth length of5 C4 E& h$ I/ |1 c
20 inches. He was breast-fed throughout the first year2 _/ n7 N" Z2 B( e
of life and was still receiving breast milk along with
5 V, Y7 Y" V% C- R  Psolid food. He had no hospitalizations or surgery,7 t' \0 ~" ]; I% `" S" A  o
and his psychosocial and psychomotor development
; H- Y# a$ ~: {0 }was age appropriate.; ?/ p( F% }3 f  f% E* l
The family history was remarkable for the father,
+ m* G; J# \, {, Bwho was diagnosed with hypothyroidism at age 16,' F1 f9 V5 R( Y; }& O
which was treated with thyroxine. The father’s9 y9 Q: }2 P& I( @9 e) ]) ^; a  f
height was 6 feet, and he went through a somewhat
+ D( l5 Q( C2 k/ k2 m: \early puberty and had stopped growing by age 14.
0 N- J1 E; r" c2 z9 n' e, hThe father denied taking any other medication. The6 g9 T% Y. ^" P. k$ P1 T: L
child’s mother was in good health. Her menarche
3 W$ g) ]$ R5 c# k/ X4 Cwas at 11 years of age, and her height was at 5 feet1 E; w. V& n; F' {( _$ @- _. c
5 inches. There was no other family history of pre-  m: x3 `5 r5 b$ Y0 r
cocious sexual development in the first-degree rela-
; L0 R% ]. l* ktives. There were no siblings.! c7 t: I" o) o3 I( m* r/ w
Physical Examination
3 I( }8 z2 [. b: T8 f" @The physical examination revealed a very active,9 \( D8 E& v' \7 [/ u
playful, and healthy boy. The vital signs documented
2 G& }$ Z2 N0 \% K& ~: Xa blood pressure of 85/50 mm Hg, his length was/ F$ v, W% z2 p1 a$ U" i
90 cm (>97th percentile), and his weight was 14.4 kg+ w& Z$ u' E( `' X
(also >97th percentile). The observed yearly growth
& V% W7 f; x4 n, L. b: @; `. fvelocity was 30 cm (12 inches). The examination of6 F; R6 ~% G7 Q0 F$ s* ~* b1 i+ o
the neck revealed no thyroid enlargement.! l/ l& b( q3 `8 `. Y5 y2 s6 l
The genitourinary examination was remarkable for. F/ K1 J0 d# ~: ?8 Z6 D
enlargement of the penis, with a stretched length of7 b" C, B' T5 m4 t
8 cm and a width of 2 cm. The glans penis was very well
9 d1 q" C+ z2 j* z- rdeveloped. The pubic hair was Tanner II, mostly around: E: B1 ?# P$ i: T" `$ o0 o
5407 b( s  P- f8 Q% Z9 Y5 d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" X" |3 _, L8 x, h+ p8 t
the base of the phallus and was dark and curled. The! W$ l- K6 u' J- j  {
testicular volume was prepubertal at 2 mL each.
+ ^$ M' `9 `5 L$ u' a; L- CThe skin was moist and smooth and somewhat, W! d; R# D9 n+ w4 c
oily. No axillary hair was noted. There were no
$ A: n; |; I. [6 O2 I* H2 Dabnormal skin pigmentations or café-au-lait spots.
- E6 p5 L7 n' F$ m2 vNeurologic evaluation showed deep tendon reflex 2+! Q, y, r' ~5 b2 }% ?' o) m" @
bilateral and symmetrical. There was no suggestion
9 d# V2 E; _6 O8 a7 R, b0 C+ S9 Zof papilledema.4 x7 o# r, r$ V7 c! L
Laboratory Evaluation
( v) k$ d0 I$ `4 s2 e9 ZThe bone age was consistent with 28 months by& z% c% e5 Q& z- s# V! ^7 c
using the standard of Greulich and Pyle at a chrono-
4 H" j. {* ~) R1 Tlogic age of 16 months (advanced).5 Chromosomal; g" ^6 ]- X! o  W
karyotype was 46XY. The thyroid function test
8 H8 _8 I' s4 c4 a/ k' m1 tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
" e1 p8 f9 f0 t/ \6 Z1 D; n' tlating hormone level was 1.3 µIU/mL (both normal).5 D# D5 @4 w+ ~4 K. n1 ^
The concentrations of serum electrolytes, blood
' R, t6 d) \9 ~$ C: z  i$ eurea nitrogen, creatinine, and calcium all were
7 m2 X2 o4 b0 w8 M; i! w+ m" rwithin normal range for his age. The concentration
7 y0 a6 ^, m$ k9 {. e: F6 G8 |of serum 17-hydroxyprogesterone was 16 ng/dL
# Q% {3 n! Q% t0 |; U4 S(normal, 3 to 90 ng/dL), androstenedione was 209 u  E) {% V6 U8 x5 I+ l
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ o* I+ U2 h5 m7 b; @2 F5 rterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 W  b0 v6 ^; B5 P5 M- ?9 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ U3 c0 @" p* q: P( y* ]2 s
49ng/dL), 11-desoxycortisol (specific compound S)6 a2 j- H2 b6 h3 W& q  f5 c
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, k: Y7 g9 J( N. s% H
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ O2 I3 Z  |  V- {* v7 W& a  _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 u$ q4 Z/ S2 h  v, b/ N& a
and β-human chorionic gonadotropin was less than
! o! a* S) d2 H5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 `( @8 y; W8 U9 ^8 H( E1 Xstimulating hormone and leuteinizing hormone9 J" v0 Q% p) ^" ?9 [( S* s
concentrations were less than 0.05 mIU/mL
9 u! p+ u4 U) C/ s" x(prepubertal).
1 s" B. k1 P* F9 a7 \6 Y+ KThe parents were notified about the laboratory
2 I# s3 }1 e: Nresults and were informed that all of the tests were! t& ]. i6 Q! u+ ~% d4 e9 S! N
normal except the testosterone level was high. The& S4 I) p8 n! f- z& t  I
follow-up visit was arranged within a few weeks to
" x0 h# v, c# v( ?2 fobtain testicular and abdominal sonograms; how-- H7 `0 V! u# E- ^% Y1 ^1 W
ever, the family did not return for 4 months.
  V! N0 L6 o) S8 a: T' [* K' j- tPhysical examination at this time revealed that the. x. v5 F$ t# B3 D6 w
child had grown 2.5 cm in 4 months and had gained
( O& |5 T' n2 j- M" z- O' P2 kg of weight. Physical examination remained
2 E  m1 i* Q3 U1 p+ k" e% Q  E( Vunchanged. Surprisingly, the pubic hair almost com-
& H5 ^7 ]0 N5 W% u! ^5 I* K2 vpletely disappeared except for a few vellous hairs at( C* A& n" e" y" J% d# s1 f
the base of the phallus. Testicular volume was still 2
+ M9 Y4 c( e" m& TmL, and the size of the penis remained unchanged.: H4 o' k2 m: G, T. w, _* j
The mother also said that the boy was no longer hav-
$ C* U0 p/ }! d/ L2 Fing frequent erections.
: [( s# P% _: ^6 t+ D' D, l! U. {Both parents were again questioned about use of
) R7 R. T) t: ^3 bany ointment/creams that they may have applied to0 G: s+ B: W1 f  v' k4 ^8 p
the child’s skin. This time the father admitted the9 s+ L- q4 Q) u2 @. ]: n/ ?2 w
Topical Testosterone Exposure / Bhowmick et al 541
+ V( |: a# X$ R8 Huse of testosterone gel twice daily that he was apply-& ~! x8 H# \* E% t1 u, f* B2 D5 w
ing over his own shoulders, chest, and back area for
4 Z; d6 ~1 w$ C) o- @a year. The father also revealed he was embarrassed3 Y+ i. |( I3 F2 K" b$ O: M
to disclose that he was using a testosterone gel pre-
& s% Z9 H9 @# Q* a5 U8 Vscribed by his family physician for decreased libido% D  f# Y0 j* F4 l1 Y8 M, O9 Q
secondary to depression.
2 ^/ X1 H& W5 _% ?4 f$ nThe child slept in the same bed with parents.
8 N4 k5 I- h/ E0 ^. UThe father would hug the baby and hold him on his; X" W# S% Y; p  x0 {8 u
chest for a considerable period of time, causing sig-/ u7 D6 O9 ]9 r$ C8 z3 p. F3 K0 G
nificant bare skin contact between baby and father.8 S& S$ a7 r. T% l, F
The father also admitted that after the phone call,
" Y4 E! P- o% k( V" Q: C9 v! gwhen he learned the testosterone level in the baby' l3 U& `, D+ e' J* {
was high, he then read the product information
2 z9 S" e1 r  y& Lpacket and concluded that it was most likely the rea-
6 m5 v0 e: X$ X" M; J  X1 Y8 }' Gson for the child’s virilization. At that time, they
' h1 A2 R5 m4 n& Z. f6 Gdecided to put the baby in a separate bed, and the! l- @' P  o0 v& `/ C; \
father was not hugging him with bare skin and had
- ~. y4 q  ?8 k3 A- qbeen using protective clothing. A repeat testosterone$ Y* j+ V' Q! s9 i8 B& o
test was ordered, but the family did not go to the
1 _8 g9 H- E& f. J0 N. m4 d# z8 Glaboratory to obtain the test.
5 [* M) A5 H9 \$ e3 ^Discussion
$ ^3 h9 M/ v$ a9 |8 zPrecocious puberty in boys is defined as secondary. r, l  s' l* L; L( o+ U1 X- ~
sexual development before 9 years of age.1,4: N& Z/ b  `! ~
Precocious puberty is termed as central (true) when
" z3 a6 h  N3 g. R( Xit is caused by the premature activation of hypo-
5 v5 X! \" t8 p, |! {' _thalamic pituitary gonadal axis. CPP is more com-; @* W3 T/ ?6 K% h
mon in girls than in boys.1,3 Most boys with CPP
5 i- `1 p5 |& n5 U5 Xmay have a central nervous system lesion that is
4 L" o5 X: U* X! Qresponsible for the early activation of the hypothal-
; m9 i* ]+ c" O& Mamic pituitary gonadal axis.1-3 Thus, greater empha-
9 P8 _* M: O  p- usis has been given to neuroradiologic imaging in
* T3 ~4 H' C8 M+ ^. V, ?boys with precocious puberty. In addition to viril-
8 \  j# t1 T  p2 r! Xization, the clinical hallmark of CPP is the symmet-0 P$ v8 T. E& r4 ~- _  W# J+ v
rical testicular growth secondary to stimulation by3 P% m; D8 l. P- _
gonadotropins.1,3
1 C5 ?# x" ?) yGonadotropin-independent peripheral preco-
" y% b, @9 `# K" J  h7 Bcious puberty in boys also results from inappropriate1 H* V' _  ^% P5 {
androgenic stimulation from either endogenous or
+ Z- l; m  f! i, }/ |, t% iexogenous sources, nonpituitary gonadotropin stim-
! F/ r7 a; c; V: }8 ]  Yulation, and rare activating mutations.3 Virilizing0 J% G; P$ n, j4 q; O0 J, @
congenital adrenal hyperplasia producing excessive3 |5 v" T2 ~9 R
adrenal androgens is a common cause of precocious1 h$ |/ G% V, }+ D+ G' O& X
puberty in boys.3,4! }( J" r- O% Q0 v7 ~' j1 K% H
The most common form of congenital adrenal7 i$ J% Q* a( r6 u) a
hyperplasia is the 21-hydroxylase enzyme deficiency.* F0 D" l5 {9 `9 d
The 11-β hydroxylase deficiency may also result in
! y( ~) T& t/ cexcessive adrenal androgen production, and rarely,4 s2 T& x4 l$ b* s2 o. ?- E
an adrenal tumor may also cause adrenal androgen/ |- d8 _  o! `4 p
excess.1,3
+ S$ G1 `2 j/ N4 R1 @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 e+ |% Y3 @& o$ x3 a
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! ]  y! }/ k8 x4 j* I' c
A unique entity of male-limited gonadotropin-' K+ c8 p: X( l2 A' {
independent precocious puberty, which is also known& O( v! r; H5 ~8 h
as testotoxicosis, may cause precocious puberty at a
+ h; I9 A, Y; ivery young age. The physical findings in these boys+ [6 C! C* [% t! T
with this disorder are full pubertal development,1 }4 |  }) ^- X+ r6 v! y* @- @3 W  g" d
including bilateral testicular growth, similar to boys
! y3 T( m6 p5 y" ewith CPP. The gonadotropin levels in this disorder
+ z4 ^: g  V+ O6 v7 _8 ^+ bare suppressed to prepubertal levels and do not show( U/ ^: P  z  @1 X
pubertal response of gonadotropin after gonadotropin-
( l7 Q$ s$ Z5 G/ Ureleasing hormone stimulation. This is a sex-linked
9 V' u1 E6 c) j0 D& a$ tautosomal dominant disorder that affects only8 m* a1 \. g4 @( c) i" \
males; therefore, other male members of the family
8 \8 {- d+ l6 X$ W% ^- jmay have similar precocious puberty.3
) p; p4 V$ g+ L  L. i+ jIn our patient, physical examination was incon-
! j. v  H# o) u  qsistent with true precocious puberty since his testi-$ `6 U. ^7 S% N. h# F& v1 u/ i
cles were prepubertal in size. However, testotoxicosis
* M/ }9 l% j5 [  K' I" U5 {6 jwas in the differential diagnosis because his father
- ?+ D. s  P( u7 v9 Ystarted puberty somewhat early, and occasionally,  w7 ]: [. Z/ W& \- `
testicular enlargement is not that evident in the% W( U' o5 ?" B( l' S% ]
beginning of this process.1 In the absence of a neg-
. N( |% {# W: v7 Eative initial history of androgen exposure, our
* M( T6 q" ~( F  v' X# Tbiggest concern was virilizing adrenal hyperplasia,
% F, V2 p/ Y: T2 o7 ~. h9 Ueither 21-hydroxylase deficiency or 11-β hydroxylase
9 P# V. O! u+ p) {/ Ydeficiency. Those diagnoses were excluded by find-
9 N/ b, e2 |: F1 S3 i- w$ R& ging the normal level of adrenal steroids.
5 R3 y" g( t/ g  `5 _The diagnosis of exogenous androgens was strongly$ o/ u! q5 T" m( w$ }1 |7 E8 p
suspected in a follow-up visit after 4 months because; J' z* }% T9 l$ b
the physical examination revealed the complete disap-1 T, K6 h) F  |9 `5 v
pearance of pubic hair, normal growth velocity, and" T' I$ q7 ?7 F$ S$ u( T
decreased erections. The father admitted using a testos-+ a0 h# [- r) W  J
terone gel, which he concealed at first visit. He was
0 ^, |- E$ e; X: c. j) Ousing it rather frequently, twice a day. The Physicians’
2 A/ \! u" I" n! {* P+ XDesk Reference, or package insert of this product, gel or" l" P% S1 C9 Q, B* @# O: H0 \+ B
cream, cautions about dermal testosterone transfer to
: S$ q, h' u( uunprotected females through direct skin exposure.- T; S8 P) n+ g5 ~, T2 d- S
Serum testosterone level was found to be 2 times the. P2 v$ D8 o- n$ E
baseline value in those females who were exposed to& ^% V! C1 n* |* O$ b% R
even 15 minutes of direct skin contact with their male
3 `3 g4 ]2 ]9 D5 k, h' x3 N& epartners.6 However, when a shirt covered the applica-
! j- l/ E; O1 Z& b. [tion site, this testosterone transfer was prevented.6 s. Z* F+ V' k$ f: ]- `3 B
Our patient’s testosterone level was 60 ng/mL,$ f! i2 B- c  w9 P0 A
which was clearly high. Some studies suggest that( A; ?8 v" v" r% n8 ^8 P0 F) x9 S
dermal conversion of testosterone to dihydrotestos-% r1 I, D' h+ n) W; ^
terone, which is a more potent metabolite, is more0 K0 i. Q% B( l9 b! @* T
active in young children exposed to testosterone
0 _4 w1 `  P6 aexogenously7; however, we did not measure a dihy-' w$ z- W* U9 ~3 b0 X0 o
drotestosterone level in our patient. In addition to  V. m! J$ r; [3 P& T
virilization, exposure to exogenous testosterone in: _5 ]  n) F( u; w2 w5 A/ r
children results in an increase in growth velocity and% P, ~. \* i; R' ~
advanced bone age, as seen in our patient./ T2 H5 a) `' A7 {
The long-term effect of androgen exposure during
. ]% P7 |  K) @* eearly childhood on pubertal development and final5 W; d8 W" c. }- ]4 z  X/ Z1 `
adult height are not fully known and always remain
) B! C0 P% z, }/ }a concern. Children treated with short-term testos-
0 R) Q" h  ]! Y2 Q( z8 Z- m6 r* [terone injection or topical androgen may exhibit some
1 r, @) F* c" T, n4 N$ kacceleration of the skeletal maturation; however, after
/ y0 f  Y$ l, @6 @1 I" C8 zcessation of treatment, the rate of bone maturation
: a" t) _% Y  s$ S  @" zdecelerates and gradually returns to normal.8,9
" K2 M% {; s: J- W; tThere are conflicting reports and controversy
7 D1 p" _9 l5 O# ]over the effect of early androgen exposure on adult
  L# Q/ i" p- T$ j- upenile length.10,11 Some reports suggest subnormal3 F" c- w- [8 w: H# q
adult penile length, apparently because of downreg-# V* ^- S0 e8 G9 }
ulation of androgen receptor number.10,12 However,
9 I4 G1 Z: L+ G/ S( ZSutherland et al13 did not find a correlation between" F- u2 L+ j: Q' o( s, Z
childhood testosterone exposure and reduced adult
- f! x- r; d8 V% R* a8 X2 tpenile length in clinical studies.
6 S( M! Z/ r6 B$ I" P8 ONonetheless, we do not believe our patient is
/ O# E7 k1 M' ~' t3 f+ r. {$ ]7 S' H% tgoing to experience any of the untoward effects from) B' V6 u" _9 r: i
testosterone exposure as mentioned earlier because3 h7 y+ Y6 E- r/ j/ T
the exposure was not for a prolonged period of time.5 G8 t' `4 Z$ |% P
Although the bone age was advanced at the time of- g3 ]4 g) ~2 K# E* z) k
diagnosis, the child had a normal growth velocity at
- p3 u% X* M. T' c2 v& N! uthe follow-up visit. It is hoped that his final adult
- ]0 j. ]* u/ Q0 @. ]" jheight will not be affected.5 Q" o6 h2 k" c0 m
Although rarely reported, the widespread avail-2 k. Y; J: E; N7 u* Y
ability of androgen products in our society may
3 ^- E4 c; o6 ]8 O7 `" ^% G' nindeed cause more virilization in male or female
. L( G7 V: ^7 fchildren than one would realize. Exposure to andro-
$ b8 a1 K4 U/ a: [/ Xgen products must be considered and specific ques-
- Q1 j  R! [, g) a4 ~tioning about the use of a testosterone product or
. ^% D0 u2 d: Ugel should be asked of the family members during
' _0 o$ o1 }1 w  ^$ Kthe evaluation of any children who present with vir-  p2 B4 E3 Y* F  j0 u" N
ilization or peripheral precocious puberty. The diag-' @. I! g( V* ?6 h8 I
nosis can be established by just a few tests and by
* ]& C6 O4 @& A  Y. r1 M- fappropriate history. The inability to obtain such a
0 U( P4 n6 g6 v" e! U2 L8 ]) Ohistory, or failure to ask the specific questions, may
% W7 a) `  s* n% i( I/ m5 Bresult in extensive, unnecessary, and expensive3 {6 x- @, o& @
investigation. The primary care physician should be
1 ~, Q+ D$ Z7 A- f: h# F; W' vaware of this fact, because most of these children
! B& r9 X) S5 T. _1 C1 P$ K1 nmay initially present in their practice. The Physicians’
  L2 S) {& V1 |6 NDesk Reference and package insert should also put a
: Z$ Z% R* F; i, xwarning about the virilizing effect on a male or! @  V) \1 f( i0 @) |' }+ q" i
female child who might come in contact with some-2 [* k5 x9 }! O$ T  H, s/ A7 @1 H: a
one using any of these products.7 J4 z2 Y+ s: P% ]
References/ k& Y" @0 z1 m! F) u
1. Styne DM. The testes: disorder of sexual differentiation& H" {* e3 ]' n1 V
and puberty in the male. In: Sperling MA, ed. Pediatric
" ?) ~4 L: H0 `( j, o) A; ]; P1 y) sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 p6 n! z- W# D. s& L* ~; ^( W8 w2002: 565-628.* i$ A: G' k1 Y( Z! K7 }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" S) T" G' f0 m$ _. ~, u+ z
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
, o7 W$ d) C2 N( S, D/ b7 ]Boy Induced by Indirect Topical
$ @, C* Z: Y  B! @, _7 e) `Exposure to Testosterone5 r' X+ r4 f) A1 q/ g
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' Y6 p5 y! C; ~+ q3 x- _) m2 |and Kenneth R. Rettig, MD1
* Q4 K$ x/ Z% M: T) }" JClinical Pediatrics$ g- B: g& c' z+ S* {' d) h
Volume 46 Number 6  |& _9 R6 e, w  |/ T" W8 N
July 2007 540-543
' _; P* g. Q/ D© 2007 Sage Publications
% H( _$ j5 K. v10.1177/0009922806296651
) y* U+ H$ H8 M8 s& z5 u$ ehttp://clp.sagepub.com
# Z7 n! I! H! N8 ?. O3 ~hosted at
7 h5 \* P9 U2 C. |5 W8 F% Nhttp://online.sagepub.com
1 ~8 j, I, q9 y% o4 p. U1 }Precocious puberty in boys, central or peripheral,8 K) I' N3 i5 {9 {/ t
is a significant concern for physicians. Central
! |  m6 O3 B! s3 Uprecocious puberty (CPP), which is mediated
: G9 t$ i- G+ p# u- T0 uthrough the hypothalamic pituitary gonadal axis, has
- Z5 y6 B+ L7 n9 c& F! t2 _7 ~3 x0 K' Da higher incidence of organic central nervous system1 i9 c( S; u: x2 H
lesions in boys.1,2 Virilization in boys, as manifested9 _5 n# u3 u0 G. _6 l
by enlargement of the penis, development of pubic
7 L  Z5 o  ?$ ~8 Y; N% H% ?; @- [hair, and facial acne without enlargement of testi-
1 B& ^& v; C+ n- {8 V+ ~. rcles, suggests peripheral or pseudopuberty.1-3 We! ~. O) z$ q/ j' H/ w
report a 16-month-old boy who presented with the
! |* t8 P$ ]) s, ]+ ~6 i6 u0 Oenlargement of the phallus and pubic hair develop-
8 R. C$ X% f6 y2 E  tment without testicular enlargement, which was due' ]" y; [* a; s
to the unintentional exposure to androgen gel used by4 ^& \" G" z' D( V
the father. The family initially concealed this infor-
0 d. s- U* x( U. ], @5 f5 Y8 Nmation, resulting in an extensive work-up for this
' g; I0 c: X, e; ichild. Given the widespread and easy availability of
' z! z  l( w! O2 I7 itestosterone gel and cream, we believe this is proba-
& w! c( g; s& n4 w- r7 zbly more common than the rare case report in the
: q" G& @% G4 y$ v5 Bliterature.4
" D. B$ K0 {9 [# G" e, f& \Patient Report
: W7 P; M7 B) q2 f7 pA 16-month-old white child was referred to the
+ t* e5 [# q. }endocrine clinic by his pediatrician with the concern' g  ~, {2 _0 c4 J% b0 e, C0 A0 W( \
of early sexual development. His mother noticed
; {, D( j8 S5 j/ P3 Z# |light colored pubic hair development when he was" \8 f; n) V+ e
From the 1Division of Pediatric Endocrinology, 2University of1 ]$ S7 F  O/ x
South Alabama Medical Center, Mobile, Alabama.) e" L1 v- {' q" m
Address correspondence to: Samar K. Bhowmick, MD, FACE,
: G* Z- H5 A5 \Professor of Pediatrics, University of South Alabama, College of% d. @) R1 U# G& e  N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 Y# Q9 ^) f9 V9 L8 Oe-mail: [email protected].
  [6 p: j1 u; w  wabout 6 to 7 months old, which progressively became5 T- y. Y% ^7 |9 L
darker. She was also concerned about the enlarge-
6 x. R' D- @1 N$ j6 ?) I* W: W7 y5 kment of his penis and frequent erections. The child
6 N8 G$ i- @# {5 X6 ?. \( t3 Xwas the product of a full-term normal delivery, with) T: s$ Q, V$ w
a birth weight of 7 lb 14 oz, and birth length of
5 V- M* i, W/ I20 inches. He was breast-fed throughout the first year9 \- J2 A' r# g7 a6 L
of life and was still receiving breast milk along with+ r% L3 B9 B% ^& r- ]! j& \- c8 f2 j9 `
solid food. He had no hospitalizations or surgery,2 W2 B( S0 @' B3 d$ z
and his psychosocial and psychomotor development
, D  J; _8 J; J  Owas age appropriate.
& C( B1 A1 M* MThe family history was remarkable for the father,0 z, n1 g3 \8 v
who was diagnosed with hypothyroidism at age 16,# y6 E" F% `& ]+ _3 F
which was treated with thyroxine. The father’s
' T0 J" S% n8 z5 iheight was 6 feet, and he went through a somewhat2 l& D6 w$ a. f7 {( ]* T3 h5 L
early puberty and had stopped growing by age 14.
$ d0 R: j# D! d3 V! J& i( y) BThe father denied taking any other medication. The
( ~) M( n& b4 ochild’s mother was in good health. Her menarche
# |2 |  @6 l8 E: \" |was at 11 years of age, and her height was at 5 feet3 S* l8 L4 [: J  q, c; t" v1 ^
5 inches. There was no other family history of pre-) p% }8 M/ w' ]+ [' ]
cocious sexual development in the first-degree rela-* p% ~% T, a/ M; A$ I
tives. There were no siblings.
( O' s" ~' S/ X2 q( D; ^, qPhysical Examination8 C' Q8 P9 U9 K$ A
The physical examination revealed a very active,
% f) A3 n1 G! q: Lplayful, and healthy boy. The vital signs documented
+ \0 z( I, y- I0 ba blood pressure of 85/50 mm Hg, his length was
) N0 v. W9 H" B$ }% }90 cm (>97th percentile), and his weight was 14.4 kg. E; }$ I% k8 I; y
(also >97th percentile). The observed yearly growth4 R' n, z5 r/ y0 ]
velocity was 30 cm (12 inches). The examination of
9 e. [  I3 l9 b( @6 ~! ?the neck revealed no thyroid enlargement.
0 o4 A4 f8 p: w. {( y! l# O6 ]3 OThe genitourinary examination was remarkable for' V7 W) v2 \1 ^' h/ S" o- E" `
enlargement of the penis, with a stretched length of8 q9 c0 T. _2 v5 u# N9 J
8 cm and a width of 2 cm. The glans penis was very well
" {& s5 j$ y6 g( }' \! ~developed. The pubic hair was Tanner II, mostly around
6 r  `6 V) K4 R" v1 L& f( _0 ~540
4 }3 W$ w7 U3 lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 B. j) z5 M, l7 Z; r$ w3 X5 Sthe base of the phallus and was dark and curled. The
0 m7 y& x7 g$ o; xtesticular volume was prepubertal at 2 mL each.
# q- r+ A+ @- z' Z1 K6 }% oThe skin was moist and smooth and somewhat/ o5 E' p: K9 o3 H1 ]/ t
oily. No axillary hair was noted. There were no0 t5 ]! y, H8 z2 Q1 k
abnormal skin pigmentations or café-au-lait spots.
9 h/ h2 R, w4 R* u  h6 |Neurologic evaluation showed deep tendon reflex 2+
& Q# ?( E  @! H3 I; R- Abilateral and symmetrical. There was no suggestion9 H. S( r' h6 N' ^; z8 j6 e
of papilledema.
: n+ {; s0 O) {: h, W" r7 iLaboratory Evaluation
7 \( W2 s- c" k$ a( r9 U* A5 aThe bone age was consistent with 28 months by+ ?  ?7 ^- q* E  a* D
using the standard of Greulich and Pyle at a chrono-
9 `; N) N# n; P5 ?# n0 glogic age of 16 months (advanced).5 Chromosomal
$ u# V$ X& L, Ekaryotype was 46XY. The thyroid function test; I4 x0 t3 s+ b$ l! D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( a3 O& g3 B$ \, `  m3 w2 p
lating hormone level was 1.3 µIU/mL (both normal).
' h* j' f4 B/ i- M) R( t5 ~The concentrations of serum electrolytes, blood& x: ?0 U9 d) E7 F
urea nitrogen, creatinine, and calcium all were; ~( D. p  @1 y( w7 A+ r) h
within normal range for his age. The concentration' e, `; w- A! B
of serum 17-hydroxyprogesterone was 16 ng/dL1 n8 [% g) G2 M6 V$ b/ P; \+ O
(normal, 3 to 90 ng/dL), androstenedione was 20
1 i) s2 j% x& {( S. S8 H6 mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
1 P" r, h% p1 q$ hterone was 38 ng/dL (normal, 50 to 760 ng/dL),# p7 I1 c6 o- r: ~5 z2 n+ W! }7 j
desoxycorticosterone was 4.3 ng/dL (normal, 7 to& ^) L1 P8 t. L6 z5 y; Q
49ng/dL), 11-desoxycortisol (specific compound S)
5 d1 H- N; u: K, rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 Q+ ^; M6 u) ^  X
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total  i# M: @9 G/ {6 D6 U  a
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& W9 y6 |5 G$ v9 l- N% N3 Wand β-human chorionic gonadotropin was less than
6 S5 u$ z) _6 {2 p5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 F5 O! h7 `& k" ~1 P1 Mstimulating hormone and leuteinizing hormone/ V4 g2 g. m. P5 [3 d
concentrations were less than 0.05 mIU/mL9 r6 `5 ~$ x  M) ]$ O
(prepubertal).% n, e0 L  s$ @: {
The parents were notified about the laboratory
0 r0 l) m# s" n9 U% B4 F' qresults and were informed that all of the tests were5 ?% J& R- W+ C
normal except the testosterone level was high. The8 O) \! h, e; t# y
follow-up visit was arranged within a few weeks to
3 `$ ^* w. @0 s. sobtain testicular and abdominal sonograms; how-8 ]' \& T( ?/ s
ever, the family did not return for 4 months.1 p2 [( C* B3 F$ z, }" Q
Physical examination at this time revealed that the
4 ]  f  F+ |0 o4 X# ?child had grown 2.5 cm in 4 months and had gained
# A+ K7 |; h1 G3 E2 kg of weight. Physical examination remained
$ h% l, N, c4 c8 x3 l6 hunchanged. Surprisingly, the pubic hair almost com-/ e4 C" y5 G" k3 \+ h/ ^
pletely disappeared except for a few vellous hairs at
/ z4 v' {# e* N$ N1 ^the base of the phallus. Testicular volume was still 2
2 `6 j1 |9 F# v  kmL, and the size of the penis remained unchanged.
8 ~+ P- }5 D# X3 x" \The mother also said that the boy was no longer hav-
: h" e- e% |" R* V" ]/ jing frequent erections.) i; n, @) ^/ U6 [; A- k4 n
Both parents were again questioned about use of, z- X6 J8 r. P% A! k
any ointment/creams that they may have applied to
. j2 v" E9 @) d( |  B7 [* r2 j8 N; qthe child’s skin. This time the father admitted the7 s' A9 c! E( D/ e
Topical Testosterone Exposure / Bhowmick et al 541
1 d8 R5 N) y5 {% d- Y* buse of testosterone gel twice daily that he was apply-
3 P# a5 P, R4 V4 F, B. ~& A# E* uing over his own shoulders, chest, and back area for8 \7 @% S4 N/ t" L* X8 {/ J" y4 Z0 M
a year. The father also revealed he was embarrassed
! t- u2 n* F# s8 [. j. V$ x. f) Wto disclose that he was using a testosterone gel pre-$ ^. L" D' P+ B- t6 `. Z# R5 C
scribed by his family physician for decreased libido7 X; g1 o8 H1 ]6 u
secondary to depression.
: H% y- a! i9 _5 h; n4 ]The child slept in the same bed with parents.
3 @' E0 m9 X2 c- ]# ZThe father would hug the baby and hold him on his
0 L' t* V6 @+ O! |chest for a considerable period of time, causing sig-  B) N. u# B4 y1 ~& W6 }5 m" j
nificant bare skin contact between baby and father.7 W+ [* X& i) A( D6 R% _% ]# c7 f: {0 \
The father also admitted that after the phone call,
& b# F6 E" o# r! N! {8 [8 mwhen he learned the testosterone level in the baby
# i! z0 V5 M6 a: x6 T9 M8 Iwas high, he then read the product information& x% y; Q7 V' i0 G; m$ ^: a& I
packet and concluded that it was most likely the rea-
# |: I) t, V2 D# t7 m" Gson for the child’s virilization. At that time, they4 B6 k. w4 L/ h3 Q
decided to put the baby in a separate bed, and the
( f) c, i" y) \3 hfather was not hugging him with bare skin and had
, @; F; r; V3 I+ F; d4 \been using protective clothing. A repeat testosterone5 M  F8 `/ E3 U( A
test was ordered, but the family did not go to the( ^8 N& ]- z2 |5 \* D. }0 U
laboratory to obtain the test.
% l2 f6 F9 b6 b% sDiscussion0 |6 v. ~: U8 `7 I3 k. r; t9 _
Precocious puberty in boys is defined as secondary
+ W  q5 g# f1 i- E# _# {" F' b& wsexual development before 9 years of age.1,4* q: `. o5 p. W
Precocious puberty is termed as central (true) when
3 y; k9 F8 F1 x7 f8 pit is caused by the premature activation of hypo-
5 I9 ~( t' [' A) a$ nthalamic pituitary gonadal axis. CPP is more com-) y  X* j/ X# Y7 e! v# M  K" P) l
mon in girls than in boys.1,3 Most boys with CPP
9 }2 W" F- y) N3 Jmay have a central nervous system lesion that is8 E9 M' o: N. i9 w/ w
responsible for the early activation of the hypothal-
( P0 D3 J' i$ [0 J' Pamic pituitary gonadal axis.1-3 Thus, greater empha-
+ ~* i3 l+ L9 N0 r! j) x( G7 ssis has been given to neuroradiologic imaging in3 w, [0 B0 B! L5 `5 E
boys with precocious puberty. In addition to viril-4 ^  f$ ~( k6 B2 X( F% W' i
ization, the clinical hallmark of CPP is the symmet-
% M( }5 P+ z  O$ r) }: h/ orical testicular growth secondary to stimulation by( U) j6 p- x/ T% J' m( T
gonadotropins.1,3
, I) B6 m( w: s1 ~- {Gonadotropin-independent peripheral preco-
* q0 r. R' K  L( \; I6 y, Kcious puberty in boys also results from inappropriate* g% t$ n- W3 b) ?' @
androgenic stimulation from either endogenous or
$ Z7 f- K# n: F1 D) kexogenous sources, nonpituitary gonadotropin stim-/ ^. n: ^: M% M# }1 f" ^& \8 L
ulation, and rare activating mutations.3 Virilizing. W& \! ]) I: M8 G2 z6 M+ P
congenital adrenal hyperplasia producing excessive
. R7 J2 q) j& z  B! q) L. kadrenal androgens is a common cause of precocious. r+ A+ x( B2 E' R. w. `0 s% J
puberty in boys.3,4' `8 W8 {7 B; H2 U$ A: v7 |
The most common form of congenital adrenal
; W9 l# k$ R( K( S! d; Nhyperplasia is the 21-hydroxylase enzyme deficiency.8 a0 f% ]( w! ~* S$ _
The 11-β hydroxylase deficiency may also result in
  C4 Q$ A& Z1 O3 m2 d7 b# cexcessive adrenal androgen production, and rarely,  ], g& F( Z0 v$ g4 A
an adrenal tumor may also cause adrenal androgen
+ w5 A: d+ W) J1 cexcess.1,36 j. l7 g" m0 z$ w* \4 r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  O0 B% `4 ?) u3 D4 y" q2 W- o542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 h: t$ P: Y! W
A unique entity of male-limited gonadotropin-
( M4 W& Z+ a: o7 `; J, ]: lindependent precocious puberty, which is also known, I4 c3 m' |/ F* r& n; V
as testotoxicosis, may cause precocious puberty at a
% E( e; ]! r. l+ `) @very young age. The physical findings in these boys
6 ?: C0 k2 a1 f. Dwith this disorder are full pubertal development,% ^6 A0 w6 F/ _! l' S# p+ v
including bilateral testicular growth, similar to boys
$ ~9 Y; I" D( Pwith CPP. The gonadotropin levels in this disorder
, }" n6 o5 b/ Q2 E# H1 P: x& Z: w( Lare suppressed to prepubertal levels and do not show
% ~& }& r! [  Z6 dpubertal response of gonadotropin after gonadotropin-# t4 d' \3 X, G3 P
releasing hormone stimulation. This is a sex-linked
" K9 K/ `/ A6 S) u$ F" wautosomal dominant disorder that affects only+ }. i+ F$ t) M  p' _  F$ a
males; therefore, other male members of the family
' P7 U0 Z' E% k* f* _) P) amay have similar precocious puberty.3$ x& ]2 v, Z( v
In our patient, physical examination was incon-
/ d8 B& @5 S- p4 e' M7 G' {sistent with true precocious puberty since his testi-
  r& }5 {4 T, R# h2 o6 U. k3 x% D, fcles were prepubertal in size. However, testotoxicosis2 J6 b  h% O' Z/ L! L8 _* A6 k6 e2 A
was in the differential diagnosis because his father
% q9 n8 x, {- ~4 e- jstarted puberty somewhat early, and occasionally,  V5 g3 ^3 r2 q3 O5 }5 q& U+ y. _
testicular enlargement is not that evident in the$ u/ G) Y/ G. Y, r
beginning of this process.1 In the absence of a neg-
2 z* U  E) i- {5 @$ G8 sative initial history of androgen exposure, our! s8 _; n, P. D6 ~6 o
biggest concern was virilizing adrenal hyperplasia,- X& g4 ^' @9 ~( |
either 21-hydroxylase deficiency or 11-β hydroxylase; j& S$ v+ V( U$ e
deficiency. Those diagnoses were excluded by find-
  z. l; k9 ]( _) H4 o, `/ V# a# \ing the normal level of adrenal steroids., S, V9 }" _% g- A5 @2 K  D$ m1 @
The diagnosis of exogenous androgens was strongly
, I1 e5 I. y0 V& x8 G' Xsuspected in a follow-up visit after 4 months because; A5 O( B/ t0 I' i; Q$ l0 A. }
the physical examination revealed the complete disap-
) w; n" n: m" @+ m" spearance of pubic hair, normal growth velocity, and2 ^+ Z7 }% r" k  Y
decreased erections. The father admitted using a testos-6 @9 N5 Y! M0 T0 E6 q
terone gel, which he concealed at first visit. He was% n% ^, n2 ?( G( W
using it rather frequently, twice a day. The Physicians’
5 X) c7 }- R% x3 x& PDesk Reference, or package insert of this product, gel or  O6 G9 k9 R( i8 f. p
cream, cautions about dermal testosterone transfer to8 z; Y" }( A) {9 \& x! Q
unprotected females through direct skin exposure.
' v, ^( L/ k3 x* P7 Q! ZSerum testosterone level was found to be 2 times the6 K+ n' E- Q3 i! ?( E. u
baseline value in those females who were exposed to
3 O% m- g: r' p5 G! `even 15 minutes of direct skin contact with their male0 \) {3 B9 A* t1 q4 s. T
partners.6 However, when a shirt covered the applica-
! z& a1 {4 o2 Gtion site, this testosterone transfer was prevented.
9 X5 S% @7 w! I8 v$ |+ J9 i& JOur patient’s testosterone level was 60 ng/mL,
# U1 _: q5 _9 Cwhich was clearly high. Some studies suggest that3 T9 R* u2 ~0 W% Q; ^
dermal conversion of testosterone to dihydrotestos-
, F+ s8 @. `2 e* R' x0 Rterone, which is a more potent metabolite, is more0 B4 l2 w$ |3 j* y2 F! n
active in young children exposed to testosterone
7 D9 S5 z5 t2 \$ D% Cexogenously7; however, we did not measure a dihy-
0 m" H3 U" A$ n" L5 u4 N' _$ Z( }drotestosterone level in our patient. In addition to/ D# a4 h% N9 w) a$ R/ @: v# g( x
virilization, exposure to exogenous testosterone in9 v% B) Q2 Y2 T
children results in an increase in growth velocity and0 N2 o3 R9 G  w' k7 s/ f
advanced bone age, as seen in our patient.
4 F9 O8 y) o! Z; r# [The long-term effect of androgen exposure during
+ @* u+ m) J2 [# B% searly childhood on pubertal development and final" d% w4 `0 v  i7 ?- K" j
adult height are not fully known and always remain
) L# n9 T$ D1 W8 |! w3 ua concern. Children treated with short-term testos-# G) A2 Q$ V  H6 L+ v# a
terone injection or topical androgen may exhibit some" e; O+ v% G! i2 R- s, E
acceleration of the skeletal maturation; however, after
4 p+ x3 X" `1 O* H% Dcessation of treatment, the rate of bone maturation
& v# h# b% u6 C. ?( Rdecelerates and gradually returns to normal.8,9
' o- |" D- a) S; qThere are conflicting reports and controversy& f. ?  u8 U" h" I* j" S) v
over the effect of early androgen exposure on adult
& d8 j' M. ^4 Ypenile length.10,11 Some reports suggest subnormal
9 ?9 z+ P4 N' w) ?2 o5 Uadult penile length, apparently because of downreg-
3 J% D6 ?# V# x" fulation of androgen receptor number.10,12 However,' f) ?- E0 I" ^2 R$ L& M" x. d1 ^
Sutherland et al13 did not find a correlation between% q& p) V/ ]! E
childhood testosterone exposure and reduced adult
1 T0 `, z8 ~4 Mpenile length in clinical studies.8 r5 a& V. c8 F2 [& |7 P
Nonetheless, we do not believe our patient is
8 r1 x/ g( E* H  W' p/ pgoing to experience any of the untoward effects from5 n& T. D7 ^) Y
testosterone exposure as mentioned earlier because1 f; ?6 t0 T. B) _5 d! F0 r) o
the exposure was not for a prolonged period of time.' m! e* G! J) q
Although the bone age was advanced at the time of  \1 K8 \2 |1 s9 S
diagnosis, the child had a normal growth velocity at
6 F7 I( a% C' r) F' Bthe follow-up visit. It is hoped that his final adult7 s, g, B2 |3 y; c& X2 Y3 ]
height will not be affected.
3 _2 F3 _5 X8 F* m  p- ]5 X1 GAlthough rarely reported, the widespread avail-
* f' x& \7 G! ~  Z  @ability of androgen products in our society may9 E4 U4 {) Q% O/ |) Z) k, F
indeed cause more virilization in male or female
" m2 O0 q! Y' y$ }' l- g: Pchildren than one would realize. Exposure to andro-- D. X2 r. c( ~5 `
gen products must be considered and specific ques-
$ q5 N0 D9 \/ }+ _# wtioning about the use of a testosterone product or
1 V0 [8 z% X* \! l9 ?gel should be asked of the family members during
- X) [2 l# i& h: i9 e; ?3 v" O% lthe evaluation of any children who present with vir-% a: h& U) N7 v, J
ilization or peripheral precocious puberty. The diag-, m. y8 J& O$ m( y# D
nosis can be established by just a few tests and by% N7 F3 F7 p) A5 \3 G+ h. k  d0 Z4 j  c
appropriate history. The inability to obtain such a3 V* k1 F- d" _! ]0 h$ F$ g- T
history, or failure to ask the specific questions, may* T$ O8 W+ h6 Z( u4 L
result in extensive, unnecessary, and expensive# F) }7 d* u% L
investigation. The primary care physician should be
6 c% V: W8 `" c7 K+ z/ w8 F) Eaware of this fact, because most of these children% M1 B! |# j- I: ~3 J' q
may initially present in their practice. The Physicians’2 M" q) b: L0 y, f4 d, b
Desk Reference and package insert should also put a9 k1 T' v8 i. l0 d
warning about the virilizing effect on a male or- b3 K8 u: v4 b
female child who might come in contact with some-
8 p) w6 a3 U% ~7 Q% lone using any of these products.' a9 G  p3 R+ \* t2 \% E- F
References
8 V/ R/ Y. e, g9 `1. Styne DM. The testes: disorder of sexual differentiation% r& K. v" f/ _% R/ @9 u
and puberty in the male. In: Sperling MA, ed. Pediatric8 O+ E9 c# S- G# A/ U2 R
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 W9 H% c: A0 s8 ]+ v3 f2002: 565-628.
0 N, v  N- J8 j$ V) N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' J: S' o( P. i  a- {1 R' k. @
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
/ E" k% R- C! J! }% |) i
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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