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Sexual Precocity in a 16-Month-Old
+ s- n. K; s9 @. F2 r2 nBoy Induced by Indirect Topical
4 L+ e+ V  N( F& @% rExposure to Testosterone0 o# M) R2 g8 H! Y, d( d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 D- w9 `3 |3 r' G% _5 zand Kenneth R. Rettig, MD1. I5 I0 w( j* a$ r& n( |
Clinical Pediatrics
' T; I: S* f. v" V! P$ o  JVolume 46 Number 62 C# P/ O3 L, c! v9 ]* l6 S
July 2007 540-5439 X" e( o% `0 ~. f
© 2007 Sage Publications! x- F5 w$ i' I
10.1177/0009922806296651# p& G9 }4 z5 v1 X5 T4 b
http://clp.sagepub.com
, k2 d; L% k) ~9 E" bhosted at1 ]5 I% P' \5 |- M8 z; G+ \
http://online.sagepub.com
! h, \( K8 g. V# u8 F/ n0 vPrecocious puberty in boys, central or peripheral,4 V* R+ k# F/ E! w5 U0 v: r
is a significant concern for physicians. Central
' h4 r' G) K, G& ~precocious puberty (CPP), which is mediated& ^% f! C, I& ~, [$ ^! q
through the hypothalamic pituitary gonadal axis, has+ Y, M$ k9 E* s! o7 O  _1 C$ _
a higher incidence of organic central nervous system! J! R6 o9 J5 V1 \/ e
lesions in boys.1,2 Virilization in boys, as manifested1 d: [) ?( Q& g* y2 D: Q% P
by enlargement of the penis, development of pubic
6 c6 P* c; s% vhair, and facial acne without enlargement of testi-
7 |" K& N; x' i, L7 b2 tcles, suggests peripheral or pseudopuberty.1-3 We
; ]" @9 _# Q' X1 X  ^, o) mreport a 16-month-old boy who presented with the9 T1 ^- n0 B/ ~! Z
enlargement of the phallus and pubic hair develop-5 R" `5 P# P; _; q% d
ment without testicular enlargement, which was due
% p  d- ]! Q* f8 @! T& i* tto the unintentional exposure to androgen gel used by
; ~1 I/ I. m9 [  Ythe father. The family initially concealed this infor-
6 J! S! i( o& Q/ `9 f" Bmation, resulting in an extensive work-up for this8 I! V, u' Y' V- q
child. Given the widespread and easy availability of4 c! e: J5 |: B# \! v4 U
testosterone gel and cream, we believe this is proba-1 o+ _% ], b9 @' Z% `) O/ L6 `
bly more common than the rare case report in the
) C( [, Q4 K: O) u4 g0 X* [literature.4- |0 O; O7 Y% V( ^
Patient Report! x  }( ?9 I4 O+ P3 C; T
A 16-month-old white child was referred to the  E* J. |; A$ M! H# L: t+ a
endocrine clinic by his pediatrician with the concern9 l# N- N& T9 Q! a% i
of early sexual development. His mother noticed
+ Z( B, ?7 u: K8 [7 m2 Klight colored pubic hair development when he was
, ^: d4 L+ c/ X3 m! nFrom the 1Division of Pediatric Endocrinology, 2University of
* \7 u0 P1 y# ^3 k/ I& c$ p4 D( sSouth Alabama Medical Center, Mobile, Alabama.
  M- y/ Z, i; mAddress correspondence to: Samar K. Bhowmick, MD, FACE,. r% i2 \+ [) I6 [  ?
Professor of Pediatrics, University of South Alabama, College of3 H9 x' G! y* k5 \, f4 t7 |% ~
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 T) i. d( Z6 Z/ b) W- f* T
e-mail: [email protected].* K: {! k/ Z7 b
about 6 to 7 months old, which progressively became
1 \4 C; Q  T% jdarker. She was also concerned about the enlarge-8 F! s) ?) w8 x$ O  Y7 A, l# ]) n# j
ment of his penis and frequent erections. The child) l0 L3 b# q2 r' k: f0 M' h. W, i! w
was the product of a full-term normal delivery, with, \% G% O* x5 w8 y( q" H: P. O
a birth weight of 7 lb 14 oz, and birth length of
9 ?* Y1 F. b0 a. `0 c. q& D20 inches. He was breast-fed throughout the first year
) d* |+ C* T- C/ v3 U( iof life and was still receiving breast milk along with0 x' h  X3 j1 k
solid food. He had no hospitalizations or surgery,
3 W7 A/ j9 i* X0 N4 }6 Y& S% Zand his psychosocial and psychomotor development
. c$ E9 n4 R  X/ D8 C7 b, r4 ]7 zwas age appropriate.. W5 p; a* W. f% U6 G
The family history was remarkable for the father,
, u, n4 E; N$ Mwho was diagnosed with hypothyroidism at age 16,
0 t6 m8 K( `4 n, Owhich was treated with thyroxine. The father’s
/ G) p6 b% K/ ?height was 6 feet, and he went through a somewhat
' N' H2 Q+ r* a; C! gearly puberty and had stopped growing by age 14.
- X" L3 S! O  l+ rThe father denied taking any other medication. The
6 ]2 b" s# ^) t+ T& ichild’s mother was in good health. Her menarche0 }7 O0 p0 X/ B, r4 J# j- @% i  ^; Y
was at 11 years of age, and her height was at 5 feet3 B) _1 p; u6 P7 |3 x4 x2 R
5 inches. There was no other family history of pre-
+ I5 W, |& C/ p7 w! ]: @9 }& wcocious sexual development in the first-degree rela-2 [% M! Y7 n" h4 ?: ~0 b3 k
tives. There were no siblings.
7 H6 N" Q/ W1 |5 N2 \  ]Physical Examination
- v) g4 ~4 K- V, D/ m( \The physical examination revealed a very active,
% H7 w2 E$ `7 ?4 Aplayful, and healthy boy. The vital signs documented
" d' x# r: A: ja blood pressure of 85/50 mm Hg, his length was  k. N& B0 Y. c" z0 U$ ~8 F
90 cm (>97th percentile), and his weight was 14.4 kg# S' R" C0 v6 C6 J  l4 u
(also >97th percentile). The observed yearly growth
- W! [, u! t6 W2 @0 _, Y0 ~velocity was 30 cm (12 inches). The examination of
9 z+ d) R5 C  J& n6 q/ h1 t( h, p5 Vthe neck revealed no thyroid enlargement.
5 ^: M, g, D- O2 K; y$ ^The genitourinary examination was remarkable for+ H) h4 K" h) P7 Z
enlargement of the penis, with a stretched length of8 ?3 ]9 r7 f( A( o: J+ {$ i
8 cm and a width of 2 cm. The glans penis was very well% @5 h: {. I8 ^2 K8 q# {9 t7 ?
developed. The pubic hair was Tanner II, mostly around
4 ~! ?! m' s4 i# C' Y& N& ^) Y0 A% O! w5405 |2 O+ M& I' f4 X& A6 w' B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% d+ ]: ?7 X1 w* }8 g5 h
the base of the phallus and was dark and curled. The
: u& b# E$ Y) w9 Q* K$ ]8 ~( ?testicular volume was prepubertal at 2 mL each.
# m$ n$ v* {5 A* IThe skin was moist and smooth and somewhat3 ~. |$ t. B& e; C
oily. No axillary hair was noted. There were no( Y/ V+ Q: p3 d& t# s, X
abnormal skin pigmentations or café-au-lait spots.
4 s0 N* |8 I$ k9 r3 m. |; VNeurologic evaluation showed deep tendon reflex 2+
, S: R) P  _2 M3 r6 o- p# |0 d* Obilateral and symmetrical. There was no suggestion8 y& |! \& U: e4 v* Y, H$ F) \+ O
of papilledema.
- k( S" n2 T; F8 r5 R4 @/ |Laboratory Evaluation( ]0 P# w- t9 A
The bone age was consistent with 28 months by
; J" N7 J  y& C0 Pusing the standard of Greulich and Pyle at a chrono-
/ u' s; r# E% Q! Blogic age of 16 months (advanced).5 Chromosomal
6 T1 i$ G$ T9 B+ O( \2 r" j$ pkaryotype was 46XY. The thyroid function test- w! e  k; Y* |7 P1 S( L; m
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 T: U+ G2 q: s+ _
lating hormone level was 1.3 µIU/mL (both normal).2 T5 I- v1 D/ Y
The concentrations of serum electrolytes, blood
. c3 w4 G1 J9 |. a# O7 e# l" Uurea nitrogen, creatinine, and calcium all were
$ Y! h8 |) l0 C! R7 z5 _within normal range for his age. The concentration
% W1 x" Y* m8 V/ Z+ tof serum 17-hydroxyprogesterone was 16 ng/dL
" Z$ a( S2 o1 ]2 x  L2 n(normal, 3 to 90 ng/dL), androstenedione was 20( _. V# G4 O) e' S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: E% r0 l+ x1 u- i, zterone was 38 ng/dL (normal, 50 to 760 ng/dL),
) F1 o+ u& S; @% j; ^  T7 W6 s% z0 o1 C. udesoxycorticosterone was 4.3 ng/dL (normal, 7 to/ O# _2 X9 i0 ?+ X0 M$ w
49ng/dL), 11-desoxycortisol (specific compound S)( n4 [" |0 M  T* c3 {
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 N* S, }& Y3 {  b" M& Dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 D" Y% h1 _* q5 R
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! J# ^: J; X: z' S" B- g2 s) w/ W, H
and β-human chorionic gonadotropin was less than
4 _. i" f. b$ J# Y! W5 mIU/mL (normal <5 mIU/mL). Serum follicular$ N0 Q, |3 w, k1 f0 [1 q% Z# b
stimulating hormone and leuteinizing hormone* y) ^! z3 }) R$ C9 i
concentrations were less than 0.05 mIU/mL
% @6 w/ d6 u9 z3 v(prepubertal).) X& t) M, A/ H2 S- B; O0 z
The parents were notified about the laboratory
! K5 ?. [! Z9 Aresults and were informed that all of the tests were
% j7 X7 s2 b/ G4 G+ n0 Mnormal except the testosterone level was high. The/ l( P5 z' A! U" |
follow-up visit was arranged within a few weeks to8 p$ b+ F. |* v! t, e2 \
obtain testicular and abdominal sonograms; how-$ @7 I' z; i. v' \' `4 y
ever, the family did not return for 4 months.- m- {, S& q) `0 D, \8 u7 l, O- b) h
Physical examination at this time revealed that the8 b( T# u+ y3 h* t9 I1 x: l
child had grown 2.5 cm in 4 months and had gained1 S. Z8 S4 J/ F* h$ q  q
2 kg of weight. Physical examination remained
# x3 T. p- Q, o# funchanged. Surprisingly, the pubic hair almost com-$ H' U. {0 m" t6 w
pletely disappeared except for a few vellous hairs at  w6 S) l3 Z0 W! r# w
the base of the phallus. Testicular volume was still 2
6 H/ ?& A7 _: J* W+ c+ EmL, and the size of the penis remained unchanged.% g# O8 L* P6 L# O
The mother also said that the boy was no longer hav-) w% K$ `0 I  O
ing frequent erections.
* Y9 i0 w0 n8 s/ u' j- D: _Both parents were again questioned about use of
2 X/ h6 s* i( ~# n' s5 ?: Pany ointment/creams that they may have applied to, d# i5 j2 i1 n5 V$ `* S9 ^
the child’s skin. This time the father admitted the' B: K0 F- v  ^- H6 p
Topical Testosterone Exposure / Bhowmick et al 541
' @. }; Q4 G3 a# s$ buse of testosterone gel twice daily that he was apply-4 C( T6 ?) l: [6 r2 x+ x, b. @
ing over his own shoulders, chest, and back area for$ ^7 u  e; t" c3 Z
a year. The father also revealed he was embarrassed+ }' S; m7 ]$ K( X3 M5 I
to disclose that he was using a testosterone gel pre-: B. s7 V( e7 L4 U: U3 p& O
scribed by his family physician for decreased libido
8 ~; }$ I! z; _/ h! K* Msecondary to depression.
+ q1 t0 K: F0 H4 Q( X# a0 F) h. A" N$ Q4 NThe child slept in the same bed with parents.2 Z9 j" J+ L: C
The father would hug the baby and hold him on his
% h* T- g, q7 Y' }+ ochest for a considerable period of time, causing sig-
! v3 z2 z  i: qnificant bare skin contact between baby and father.. e3 f1 L. y8 N4 P" |8 h
The father also admitted that after the phone call,0 c' l* y7 y+ i2 f  S9 b$ f8 e
when he learned the testosterone level in the baby
! ^& y' X* y# R0 Rwas high, he then read the product information
/ n' S& b" ^: Z$ J& fpacket and concluded that it was most likely the rea-3 o9 f' V0 G) G% ]. C. L- Y
son for the child’s virilization. At that time, they
% d8 N. l7 k; H& Mdecided to put the baby in a separate bed, and the2 N( P' U( @& Q5 ]
father was not hugging him with bare skin and had
  B5 E1 q7 o$ `" e5 V0 @7 Fbeen using protective clothing. A repeat testosterone+ s  N+ B: d+ j0 ?: }, C9 p5 ?$ B
test was ordered, but the family did not go to the
2 r. q! C$ K" p  elaboratory to obtain the test.
; n, Z4 \# b5 p6 mDiscussion: v- M8 R+ _3 Q/ j- I
Precocious puberty in boys is defined as secondary
+ q; Z" \% y. K- N) gsexual development before 9 years of age.1,49 G. ?5 R' b6 U+ p; ^  |9 [- ^
Precocious puberty is termed as central (true) when  J/ H6 j( S  n9 E6 R
it is caused by the premature activation of hypo-1 j3 E/ v/ z7 k& |
thalamic pituitary gonadal axis. CPP is more com-
7 ]2 J+ x  R6 Z& Q8 ymon in girls than in boys.1,3 Most boys with CPP
, b0 v" |. u; }) S, o7 Q- Hmay have a central nervous system lesion that is
4 M; I& L! {/ H1 \responsible for the early activation of the hypothal-
4 g/ t0 ?+ O$ y, g! k4 O  \amic pituitary gonadal axis.1-3 Thus, greater empha-
( b" k# |$ _" y0 I1 x1 C3 gsis has been given to neuroradiologic imaging in
% U/ ~% R& |; F" C0 V! a2 D8 Nboys with precocious puberty. In addition to viril-% H& l6 v9 e! d, c) O3 o
ization, the clinical hallmark of CPP is the symmet-# X; c6 }3 v" g0 \* q7 _0 S
rical testicular growth secondary to stimulation by
; c6 y/ K+ \" D* ^& Rgonadotropins.1,3" C  A& p. o5 F4 ]; ^% i. O
Gonadotropin-independent peripheral preco-
  J, W% s* y; L  Dcious puberty in boys also results from inappropriate
0 D% A: d6 v: I+ U% ?androgenic stimulation from either endogenous or3 C  r! ^. W& Q# {9 S
exogenous sources, nonpituitary gonadotropin stim-
6 E- E* Q- w9 J; e4 n% gulation, and rare activating mutations.3 Virilizing
' ^8 |% W* t5 F" I- _) fcongenital adrenal hyperplasia producing excessive
* N1 n$ W0 }! z' ]" V) _adrenal androgens is a common cause of precocious
0 {, n# Z% O$ D0 \puberty in boys.3,4
# ]8 J' M% S* q: e  E* c( C9 NThe most common form of congenital adrenal
0 S8 u* V; s1 f; `hyperplasia is the 21-hydroxylase enzyme deficiency.
/ m3 t" b4 g/ TThe 11-β hydroxylase deficiency may also result in* c1 S* R; Q+ i" [
excessive adrenal androgen production, and rarely,
2 B8 j- `1 k) ~+ Z  x- n- S' b  dan adrenal tumor may also cause adrenal androgen) I+ P* h; I; I, ?: o  g4 K# m6 Z
excess.1,3( F4 H+ i+ w+ i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- e. u: H2 p+ l3 y, N$ p; _& w# {( C
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' k# L: n- r" Z; B8 V% xA unique entity of male-limited gonadotropin-
* O  |, r7 R! T  U7 Rindependent precocious puberty, which is also known3 n3 t1 |/ O0 ?9 K
as testotoxicosis, may cause precocious puberty at a
8 E) B) X" C5 f" p1 ~2 jvery young age. The physical findings in these boys! D% H9 i8 w* q7 P8 s
with this disorder are full pubertal development,0 r; W% C9 z7 f& k7 D- Y) r% W
including bilateral testicular growth, similar to boys5 T" m% J- X' E
with CPP. The gonadotropin levels in this disorder
$ Z- [& u% _9 Q  X% s0 y$ fare suppressed to prepubertal levels and do not show
' O% f  P# _- xpubertal response of gonadotropin after gonadotropin-
7 w: z! F, B/ G1 G6 a2 B/ d& O! z1 jreleasing hormone stimulation. This is a sex-linked& C. ^: K2 O! E  F
autosomal dominant disorder that affects only3 }# @2 `$ T/ L9 z+ k
males; therefore, other male members of the family
* A" ]# }1 h4 s/ U& c& |- d2 n# Ymay have similar precocious puberty.3
6 E+ G' s$ R( A; ^( ]In our patient, physical examination was incon-5 r9 i1 A0 F. a2 ?$ Y
sistent with true precocious puberty since his testi-+ o, z- \! l+ Y+ L$ ?8 f2 M
cles were prepubertal in size. However, testotoxicosis' o" l9 V* E! z$ @
was in the differential diagnosis because his father1 q% Y1 i6 {7 t" L; `
started puberty somewhat early, and occasionally,
$ i& v. T" _7 C8 @# gtesticular enlargement is not that evident in the
( o5 M2 u: f) a) J0 v3 S& j% jbeginning of this process.1 In the absence of a neg-
! Z% ~# Z0 g. x3 K- ~ative initial history of androgen exposure, our
& S; _" I5 O# E& j% ]3 s! ?biggest concern was virilizing adrenal hyperplasia,! a0 i7 I: S  Z- g; D9 f% x
either 21-hydroxylase deficiency or 11-β hydroxylase( n4 c6 x$ m0 B$ Z" M/ P5 v
deficiency. Those diagnoses were excluded by find-: s  p5 Q% ^9 P2 y
ing the normal level of adrenal steroids.
1 y5 @) o+ V  f' C# }3 w; K8 [The diagnosis of exogenous androgens was strongly5 }: m  E7 x: W
suspected in a follow-up visit after 4 months because5 [: P+ a2 k' Q; O
the physical examination revealed the complete disap-
  ~9 J" l8 D- e. v% M0 [% apearance of pubic hair, normal growth velocity, and% t, K& ]8 T/ f" c7 C6 j
decreased erections. The father admitted using a testos-
8 d3 e9 d4 a4 Z+ Q/ m! w# dterone gel, which he concealed at first visit. He was
# U- ^0 `/ y4 ^( q0 z* {0 ausing it rather frequently, twice a day. The Physicians’
0 r& l! @+ T/ y; }Desk Reference, or package insert of this product, gel or
6 W! \! I( U" `: A, A7 J5 O- ~- fcream, cautions about dermal testosterone transfer to
* t  N  j. |/ Y1 j( Punprotected females through direct skin exposure.- j6 N# y: z: [
Serum testosterone level was found to be 2 times the
: U5 e& Q; x! q# g% ?! i# g' }5 jbaseline value in those females who were exposed to/ T# x$ L* G3 i9 t7 S6 }
even 15 minutes of direct skin contact with their male+ I" I/ Y5 }% h8 J: d; n
partners.6 However, when a shirt covered the applica-
% N8 b/ l9 S; ~. P1 u/ wtion site, this testosterone transfer was prevented.
' Y% H- f: R& j( cOur patient’s testosterone level was 60 ng/mL,- A* u' T* X1 f; Z
which was clearly high. Some studies suggest that
6 X9 l8 l; D) X( k0 _dermal conversion of testosterone to dihydrotestos-1 O" \0 Z/ p  I/ n/ l, e: u
terone, which is a more potent metabolite, is more" R. J4 {9 y# F8 [2 @: U1 z
active in young children exposed to testosterone: f$ X* c# V2 G1 o4 J# B
exogenously7; however, we did not measure a dihy-+ ^1 n6 v: n5 [$ Y% K
drotestosterone level in our patient. In addition to
/ ]4 m- r  G+ A3 H+ ?4 K! nvirilization, exposure to exogenous testosterone in
/ y3 J3 t9 @2 u/ [children results in an increase in growth velocity and
# X! q; R& Y- x4 r, y' c2 T  kadvanced bone age, as seen in our patient.5 J  F* v$ S9 x' q: E9 Z
The long-term effect of androgen exposure during8 c5 a( n7 O  f  b5 o) J& B
early childhood on pubertal development and final/ T% g9 U0 l5 G0 F3 O# q
adult height are not fully known and always remain5 r9 V" z, m0 h* a9 _
a concern. Children treated with short-term testos-
3 h6 i" H+ z+ T- e$ Y; `terone injection or topical androgen may exhibit some
9 [* d  z6 K' D  Z  G- v! zacceleration of the skeletal maturation; however, after' r5 Y- A9 q) d
cessation of treatment, the rate of bone maturation
" l: P/ ^: k- w: W! E" r/ Mdecelerates and gradually returns to normal.8,9! o' f3 P$ n) f. Z- C
There are conflicting reports and controversy6 {+ a/ J8 ~- @9 |1 l+ W; a
over the effect of early androgen exposure on adult
3 \- i* ]$ w" \" t, z2 s- }* k& Ipenile length.10,11 Some reports suggest subnormal
6 z1 k" i; D- q# wadult penile length, apparently because of downreg-
3 o, G& R$ Z( n' G( W, j+ mulation of androgen receptor number.10,12 However,+ {6 x* Z1 ]9 ~6 @, E
Sutherland et al13 did not find a correlation between
. m, J, F/ U' D& r* c6 [$ Echildhood testosterone exposure and reduced adult, C# p$ D& l& {5 r# r+ k4 |+ O
penile length in clinical studies.2 h. `# ?% E) b
Nonetheless, we do not believe our patient is
* ]0 y- R% u. N) Lgoing to experience any of the untoward effects from; ~: @) a5 `0 Z9 N$ W
testosterone exposure as mentioned earlier because: T+ y  b+ P& C0 ]1 ~. R4 S6 m! Z
the exposure was not for a prolonged period of time.- U! _. J2 _) {
Although the bone age was advanced at the time of' ^- l8 ^0 U; a$ P' {) S2 |5 U
diagnosis, the child had a normal growth velocity at
: z3 R5 I5 ]/ c* p9 Qthe follow-up visit. It is hoped that his final adult
* [1 C  {5 Q2 i/ B( Pheight will not be affected.! Q- r" T, [- }- a. d7 ^* C* {
Although rarely reported, the widespread avail-3 i7 ^. R- ^) y$ h
ability of androgen products in our society may, L& w" V) f! ~, J$ S
indeed cause more virilization in male or female) v. D/ y. O9 t- w- ]1 @
children than one would realize. Exposure to andro-
. U$ G' G" x; ]0 N8 Y! T( ugen products must be considered and specific ques-
0 u. y/ x  @5 y& G: [3 k) [  A0 Utioning about the use of a testosterone product or
$ U0 n6 }9 G( y) V( o4 Y* ugel should be asked of the family members during7 r/ U- l$ K4 }
the evaluation of any children who present with vir-
( J' t2 H$ T0 A, vilization or peripheral precocious puberty. The diag-% F! B! R: V. @- d, @
nosis can be established by just a few tests and by
' N, `" W- r1 Z% oappropriate history. The inability to obtain such a
8 J4 s4 N7 v! f; V8 z( chistory, or failure to ask the specific questions, may
- a- k0 y) S4 o3 u3 o9 Yresult in extensive, unnecessary, and expensive5 J; c! b6 q6 _; c- [* H. B
investigation. The primary care physician should be& P; Y: v/ l3 S6 b  z- t& N+ J
aware of this fact, because most of these children6 m, {( |1 D. g+ _% ~" `  B
may initially present in their practice. The Physicians’% r& P% P! a0 [2 C4 K" d7 T0 w2 J
Desk Reference and package insert should also put a
6 l0 D2 y# E$ T$ Rwarning about the virilizing effect on a male or) H1 L3 x  F+ p" t; \' R" }
female child who might come in contact with some-* }) D' @- s7 y  q- x9 G1 V
one using any of these products.3 S! r% e, Z6 `5 ^6 M4 p
References
8 E3 c3 T- q: J6 v7 E1. Styne DM. The testes: disorder of sexual differentiation3 L+ U4 X/ |$ i' R7 C
and puberty in the male. In: Sperling MA, ed. Pediatric) E( q9 j3 N0 ~0 V8 V) e* U
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% C8 d  W, e  v$ k& Z5 C/ f2002: 565-628.
9 l$ B! ?) n3 A' Z; M# f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 \& |6 }; u5 F$ f& o. t2 S
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
7 y1 C( b$ V1 \- y% p7 aBoy Induced by Indirect Topical
( K0 q) h( x% XExposure to Testosterone+ Q2 l" ?; J0 u! n) P
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 a. C# |6 x* }; z
and Kenneth R. Rettig, MD1
4 i1 k0 ^  G) k6 T( l( R2 C2 t0 hClinical Pediatrics7 p/ D+ q7 F2 {
Volume 46 Number 6
7 \# w5 B# `% N# ]& r8 x! p* C) F& jJuly 2007 540-5439 g* n) I/ R2 l: D" d/ a; ^
© 2007 Sage Publications6 p& A/ {) e8 W9 C, A
10.1177/0009922806296651
0 c7 k7 z7 \$ w) ~6 bhttp://clp.sagepub.com4 }/ `  F( I- R
hosted at
& Y4 Q+ q6 k* [  bhttp://online.sagepub.com9 c3 ~! X. U2 k% a6 c/ H0 S! r% K
Precocious puberty in boys, central or peripheral,
- C& _% n& y2 |3 _0 g- E+ his a significant concern for physicians. Central
& w/ ^4 `8 A5 Z: _4 m2 m) gprecocious puberty (CPP), which is mediated5 K5 h% a" {$ `+ z8 O- h- B; u4 ]
through the hypothalamic pituitary gonadal axis, has8 e) k# E( c# W! S0 r. k
a higher incidence of organic central nervous system
5 j5 P0 k( a; A0 Y; |lesions in boys.1,2 Virilization in boys, as manifested
3 A- J* L: M5 L3 S4 Pby enlargement of the penis, development of pubic
; G% A9 v8 N2 F0 Shair, and facial acne without enlargement of testi-
2 [/ N% G) ?" x' ecles, suggests peripheral or pseudopuberty.1-3 We- h4 @' ~! ^! C
report a 16-month-old boy who presented with the
4 \) u/ ?7 [( eenlargement of the phallus and pubic hair develop-* x1 ^/ v% h$ w& I4 m( Z+ L) {7 d
ment without testicular enlargement, which was due
' Z, G' P; {% u3 D, Cto the unintentional exposure to androgen gel used by
) o& j# G/ r" J2 p9 X3 [the father. The family initially concealed this infor-* w, n% L# W( e; u  L. _
mation, resulting in an extensive work-up for this3 _" l- g/ |+ b9 K/ F5 U
child. Given the widespread and easy availability of7 `! _+ C$ i3 M0 D1 P5 I5 z; B
testosterone gel and cream, we believe this is proba-3 ~4 F2 S! F) A# F
bly more common than the rare case report in the
, z8 |( a( J% h% aliterature.4
* |$ K! U9 L/ wPatient Report
: l0 M/ c3 Z2 GA 16-month-old white child was referred to the
5 T; ?0 r6 S: `" F  u' Uendocrine clinic by his pediatrician with the concern7 J4 G1 w$ t; Y6 z- {1 Q' |. x* B
of early sexual development. His mother noticed
% G- n4 @" o" c: G/ v/ ulight colored pubic hair development when he was% `; z  X5 n' I8 d& r
From the 1Division of Pediatric Endocrinology, 2University of# `/ R- S) j; V! b
South Alabama Medical Center, Mobile, Alabama.7 B0 F' H! o+ G. P. j2 D
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 y/ i5 e( n# o% W  ~1 D" ?. YProfessor of Pediatrics, University of South Alabama, College of
* M! z5 z) O! C/ D# j: r, AMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 ]% j, ?9 Q/ Z
e-mail: [email protected].
$ O; v1 i4 b) _, E; xabout 6 to 7 months old, which progressively became
/ J/ ~, U1 x2 D- ^) zdarker. She was also concerned about the enlarge-
+ ?7 F$ [: D& C. Qment of his penis and frequent erections. The child: X  Q+ u* p5 M8 }' D8 o
was the product of a full-term normal delivery, with
8 _* K9 `, y* m$ P) W0 ja birth weight of 7 lb 14 oz, and birth length of% F% K2 ~/ I: n8 z- P! m% S
20 inches. He was breast-fed throughout the first year  ~9 m8 Z* U0 E  u. U7 h' O
of life and was still receiving breast milk along with
3 }; {( [% H: G# w/ }0 ~solid food. He had no hospitalizations or surgery,
+ @1 X3 S% v5 ]" Rand his psychosocial and psychomotor development& q! x5 J) C4 ^2 P
was age appropriate.
5 w  t- I( i$ h8 h* g/ X, s$ BThe family history was remarkable for the father,
* M) j  i" ~# s9 Y4 j$ Zwho was diagnosed with hypothyroidism at age 16,
, M% @+ b" s0 n5 V, Iwhich was treated with thyroxine. The father’s
( D1 |2 D+ O# c/ V' Kheight was 6 feet, and he went through a somewhat) {, y9 h+ j! r/ N" j/ a$ F
early puberty and had stopped growing by age 14.8 I3 R$ p  N, }' y) F  F6 z( O7 g
The father denied taking any other medication. The' K' S5 C* I) X5 J- z4 e7 B: y0 M
child’s mother was in good health. Her menarche7 S. q" j  @+ `5 Z
was at 11 years of age, and her height was at 5 feet
1 V" E/ l! G0 R) M! y  `% E5 inches. There was no other family history of pre-
9 F6 r3 y9 G* t" rcocious sexual development in the first-degree rela-6 E5 Z0 Q) X4 y/ S; q
tives. There were no siblings.
! o  B2 }0 U0 M4 [. W. ]) d$ w" }Physical Examination9 l* a8 F( k6 g4 @: l8 B
The physical examination revealed a very active,; `. O' ]. p( M' C5 h
playful, and healthy boy. The vital signs documented! \6 K) g! J) I3 O8 j4 a5 o0 o4 T# X
a blood pressure of 85/50 mm Hg, his length was) `( V, p& K% l- X' l7 A% ?% {
90 cm (>97th percentile), and his weight was 14.4 kg7 r0 a- N+ ?" N  y& v7 d) S
(also >97th percentile). The observed yearly growth
; m, `% E4 U: w  f. Z5 gvelocity was 30 cm (12 inches). The examination of
- V1 \' X$ s: b9 O  O9 b7 xthe neck revealed no thyroid enlargement.
* m3 q) ^( ^( J" fThe genitourinary examination was remarkable for
  u4 Y# V; T/ E, Menlargement of the penis, with a stretched length of
  D3 P8 \8 X, b1 w& W  I6 i8 cm and a width of 2 cm. The glans penis was very well2 P0 A( ^# G; u
developed. The pubic hair was Tanner II, mostly around
$ u9 p) J8 z" o540- x6 m. l! x/ }- ]/ d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. W' x9 r6 d6 g# ithe base of the phallus and was dark and curled. The0 K# c' n* t4 k0 c' u8 A
testicular volume was prepubertal at 2 mL each.
$ ~1 e! F5 m& f" tThe skin was moist and smooth and somewhat+ v$ u: e! G# M( f6 L, z
oily. No axillary hair was noted. There were no
: E7 T5 G' f8 u; M: Babnormal skin pigmentations or café-au-lait spots.2 `' D1 Y/ F' D& m+ o0 K- O6 Y, p1 z
Neurologic evaluation showed deep tendon reflex 2+
$ X  [: `3 M8 H0 X1 R3 qbilateral and symmetrical. There was no suggestion
6 i, W: U3 _$ o; cof papilledema.
, P6 Z+ K3 a8 k0 n" H2 F- z% X7 yLaboratory Evaluation
9 q+ M, d# b# v" [/ {% h& a  vThe bone age was consistent with 28 months by
2 _: P; x9 ~. U: B% Vusing the standard of Greulich and Pyle at a chrono-5 ]( _! C  @) B2 z5 P
logic age of 16 months (advanced).5 Chromosomal
9 Z, `' ^# ~* skaryotype was 46XY. The thyroid function test. \9 i* E7 k! Q( \/ B; H% A' {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  M! }4 Q4 R# E+ l* Z1 mlating hormone level was 1.3 µIU/mL (both normal).
2 ^& [& K/ a+ t5 O3 `The concentrations of serum electrolytes, blood5 g" x; Y0 G- g# t% T
urea nitrogen, creatinine, and calcium all were+ P  `+ s" ~6 h4 Z
within normal range for his age. The concentration
$ v5 [$ r, [3 j) T+ Y  w- i- rof serum 17-hydroxyprogesterone was 16 ng/dL+ e: M7 k7 {- E
(normal, 3 to 90 ng/dL), androstenedione was 20
. I4 F" `9 H6 M8 Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 B9 ?# ^4 m, q2 }# T* ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," ]& M; M7 c# d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: E( a  {' L0 Z% Z
49ng/dL), 11-desoxycortisol (specific compound S)
/ r  J6 y) W0 I! ^was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* B: U1 _( m0 j9 T# a  Z$ {% ~8 W( o: S
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' `- t1 H. X% v! D
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& J6 {- N9 ~/ jand β-human chorionic gonadotropin was less than
5 ]/ {0 Q5 B( y7 m# G3 f5 mIU/mL (normal <5 mIU/mL). Serum follicular. w( f, q  d3 o; [9 ~  M
stimulating hormone and leuteinizing hormone0 n! a  b2 j+ h+ A. {
concentrations were less than 0.05 mIU/mL
) i9 j2 u! R) u(prepubertal).
! j+ A4 j$ m7 ]; OThe parents were notified about the laboratory) N7 G$ \! t3 a& W% d
results and were informed that all of the tests were5 Z' ^2 z- R( a/ h
normal except the testosterone level was high. The, Y! d( H" `( y. s) t4 z
follow-up visit was arranged within a few weeks to5 R1 L: s/ }. O, z
obtain testicular and abdominal sonograms; how-2 T( d5 |7 k( L# V
ever, the family did not return for 4 months.
* S# r4 v# l( i1 \Physical examination at this time revealed that the$ L$ f, g: E# z+ f' u
child had grown 2.5 cm in 4 months and had gained
; V/ o8 x5 a  O2 kg of weight. Physical examination remained
3 I( [$ K# N# o% z9 z1 |unchanged. Surprisingly, the pubic hair almost com-3 X. f  O# e) L$ D- ~: _9 i
pletely disappeared except for a few vellous hairs at3 e  Q' k' a! P- @. h
the base of the phallus. Testicular volume was still 2
& L$ [- m6 H7 @" r7 k5 }) X( NmL, and the size of the penis remained unchanged., L  x% z( s4 ~2 d1 O
The mother also said that the boy was no longer hav-* |8 y7 g/ {+ n* W
ing frequent erections.
, i4 V0 m! X3 H- W% v+ A: _9 ^# TBoth parents were again questioned about use of
) |* `& d7 G' W3 W* uany ointment/creams that they may have applied to
7 M3 m, h9 k, ~  }# {! a6 Rthe child’s skin. This time the father admitted the
0 |" {* Q. H7 C$ y% f6 tTopical Testosterone Exposure / Bhowmick et al 541" P  h. d9 X+ ]* `" i9 P
use of testosterone gel twice daily that he was apply-2 c  @! w% Q3 k; \
ing over his own shoulders, chest, and back area for& m( E) q' u* I2 O( R" j
a year. The father also revealed he was embarrassed
1 G0 r1 a% u" }to disclose that he was using a testosterone gel pre-
9 W" i; d# O* Q! u& Pscribed by his family physician for decreased libido8 `# P; l8 Z3 r( P* h
secondary to depression.( h+ d' r6 s1 x+ [5 }' W
The child slept in the same bed with parents.
- Q# D5 K# W; @. t2 Y! p7 eThe father would hug the baby and hold him on his
  v* u1 ]6 F. pchest for a considerable period of time, causing sig-
& Z; c( l" D2 r0 r' Tnificant bare skin contact between baby and father.
' r7 R5 r( R0 A! \4 iThe father also admitted that after the phone call,
# s1 u+ O3 `! [1 X# [! @4 Pwhen he learned the testosterone level in the baby9 m, x7 F; ^( D/ W: ?% `1 c; X& i
was high, he then read the product information
1 {* r& c, s0 y) f% ^7 ^packet and concluded that it was most likely the rea-
* J/ V! `* S$ D' u/ ison for the child’s virilization. At that time, they8 X, Y6 ]+ d) U- C
decided to put the baby in a separate bed, and the
& k: q# ^& L8 i! g% d. W% `: x; ?father was not hugging him with bare skin and had
+ g& c7 o& m* G- q- L$ P; zbeen using protective clothing. A repeat testosterone
+ Z; c4 ^" v& T* w3 A: a" x. Rtest was ordered, but the family did not go to the& N7 g/ m0 B: g
laboratory to obtain the test.
) V% w0 u7 U) G! |6 W: t* I8 L8 l$ @Discussion
( N, {0 ]. x) e! c$ Z! D7 }Precocious puberty in boys is defined as secondary- E0 o0 h% X% j; e+ T
sexual development before 9 years of age.1,4
/ j/ Q8 z) D' k+ I7 p9 v) q5 wPrecocious puberty is termed as central (true) when( h# U* C) J, G0 K" p
it is caused by the premature activation of hypo-
( f+ L* c' [  t5 q4 S* wthalamic pituitary gonadal axis. CPP is more com-4 k1 p3 }+ C. |- `& T! h7 o
mon in girls than in boys.1,3 Most boys with CPP) y- T, W/ m5 z0 q' [0 [$ F9 R5 w
may have a central nervous system lesion that is4 A- _8 E9 l( i- D1 T
responsible for the early activation of the hypothal-
, [  \' \' E# ]8 f( Z* R# a1 ]; Uamic pituitary gonadal axis.1-3 Thus, greater empha-3 p2 ]2 A! [6 }
sis has been given to neuroradiologic imaging in
1 U, @$ |  f4 y# cboys with precocious puberty. In addition to viril-( P* f* }( f' D' I' r& w. D# f1 u
ization, the clinical hallmark of CPP is the symmet-+ M, k) R' |1 k* E7 q. f
rical testicular growth secondary to stimulation by8 H$ R% F' D) _6 P' G5 l6 ^/ f
gonadotropins.1,33 ^3 N: T# ]* P/ q" F
Gonadotropin-independent peripheral preco-; H) j6 e3 g) |
cious puberty in boys also results from inappropriate" _, ]2 a' o" W) {5 k1 B: X+ ^+ z: C, q
androgenic stimulation from either endogenous or
3 B/ A8 L% v3 a7 J8 M3 ?exogenous sources, nonpituitary gonadotropin stim-9 ]  d' u6 N  g; i; ]0 C/ x+ |
ulation, and rare activating mutations.3 Virilizing
1 n# m% g" j$ [! U, q  P2 n) F4 Fcongenital adrenal hyperplasia producing excessive
! u1 B3 v8 h% t: R6 x( O- N- Oadrenal androgens is a common cause of precocious
. @' N, }# E2 D) c- z7 E; p& b% A7 vpuberty in boys.3,4% }1 v: _* {0 f7 w. c- V
The most common form of congenital adrenal
3 y: U# m- F: c4 mhyperplasia is the 21-hydroxylase enzyme deficiency.
' T$ f+ F3 l7 X! [: Q* f3 pThe 11-β hydroxylase deficiency may also result in
6 h; V* n  D9 c0 Y; i+ k$ t5 j5 d; Uexcessive adrenal androgen production, and rarely,
. [* {+ q" E* {3 A5 Gan adrenal tumor may also cause adrenal androgen
8 u* L# r; h& U! }excess.1,3
- N# v# ], R) g; e, V  G4 Q3 \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 h8 T5 J- W& t& X; }542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" t) k4 W+ T, m: I5 t* fA unique entity of male-limited gonadotropin-. l& m; n7 Q/ y# V8 D3 l
independent precocious puberty, which is also known
* K6 ~8 b! {+ b1 Las testotoxicosis, may cause precocious puberty at a, p0 h% e& X7 w3 u. P& `" w- N
very young age. The physical findings in these boys$ K5 I/ t5 S+ J! K' t% B7 i0 F
with this disorder are full pubertal development,) _' Y/ g5 ~) o/ X% h1 a4 m
including bilateral testicular growth, similar to boys, G- O4 v: U/ o7 j0 N! M
with CPP. The gonadotropin levels in this disorder2 t' B8 \( N  z4 H# V' L. V
are suppressed to prepubertal levels and do not show5 B1 b0 W( K3 E) s% S
pubertal response of gonadotropin after gonadotropin-
$ K% F4 E# e6 [/ V* P0 ?releasing hormone stimulation. This is a sex-linked
) v% C' L3 S: \2 I" U, Mautosomal dominant disorder that affects only7 }) c( D* r! k6 |3 E
males; therefore, other male members of the family* \( E0 {3 ]4 ]5 z  O# e' C+ V' C/ K; N2 ~2 Z
may have similar precocious puberty.3
! a4 S" V* g" V: g2 Z1 {In our patient, physical examination was incon-
1 N' W# V& g9 ?6 w( Dsistent with true precocious puberty since his testi-3 ^4 ~2 N. I7 o
cles were prepubertal in size. However, testotoxicosis
1 u( H* J$ F! H; P3 Pwas in the differential diagnosis because his father
1 c* S" S7 ?: \1 w; c6 g' [started puberty somewhat early, and occasionally,  t& _0 j, S8 m9 R6 E! K" N' L* R& h
testicular enlargement is not that evident in the
6 Z1 r+ A! v" z# H. F5 ^  }beginning of this process.1 In the absence of a neg-" s: @' X5 N7 I: |$ t6 _
ative initial history of androgen exposure, our
) D/ \1 w& f+ @1 gbiggest concern was virilizing adrenal hyperplasia,  L8 f/ j/ f4 U' d4 {3 I
either 21-hydroxylase deficiency or 11-β hydroxylase
2 ^! f" ~  k0 w; a4 u9 c8 Mdeficiency. Those diagnoses were excluded by find-8 T4 @( ~0 N6 A
ing the normal level of adrenal steroids.
" D: A. S; E/ |3 X+ S1 f% Q* K; [The diagnosis of exogenous androgens was strongly, E' w7 P0 n: F5 \
suspected in a follow-up visit after 4 months because
% y$ h- g9 S8 H; a9 Zthe physical examination revealed the complete disap-5 e6 E. X5 E9 V+ l. n" a
pearance of pubic hair, normal growth velocity, and
  j6 Y' Z: a8 V7 cdecreased erections. The father admitted using a testos-
" x5 d+ f, b6 y# y' Fterone gel, which he concealed at first visit. He was" ~; B; v6 B* S) u& Z1 u
using it rather frequently, twice a day. The Physicians’
& T8 u( _" D% |3 UDesk Reference, or package insert of this product, gel or8 d, W8 w9 }4 w( y8 \+ p# j% R# ~/ v
cream, cautions about dermal testosterone transfer to1 n2 k5 a) U0 A  l  G
unprotected females through direct skin exposure." F3 g2 `( z5 Z( ^, {/ ~! c7 t
Serum testosterone level was found to be 2 times the' R& f5 G" \' @, y8 j, M
baseline value in those females who were exposed to" D8 \9 B+ t' d- {
even 15 minutes of direct skin contact with their male0 b0 ]' H. p0 W6 E1 C2 }0 V. d* E
partners.6 However, when a shirt covered the applica-) \+ m: }. _; \1 ?& D: }, J* M2 [6 T
tion site, this testosterone transfer was prevented.
2 ]( `- P9 |5 i  X+ h6 Y: n; ~Our patient’s testosterone level was 60 ng/mL,
7 Y) X$ V% p9 E2 F' n+ J3 lwhich was clearly high. Some studies suggest that
9 C/ I8 k1 Y0 X+ f" R6 ydermal conversion of testosterone to dihydrotestos-
" C1 ?% \$ ~, H% p( Eterone, which is a more potent metabolite, is more
* U+ ]9 L2 v2 U- Gactive in young children exposed to testosterone
9 ^# |4 g3 I5 a7 u% C  h7 e; l! y% Qexogenously7; however, we did not measure a dihy-
9 s' v! |* k8 A/ Z( l8 U7 m% Ldrotestosterone level in our patient. In addition to  b3 X! r5 i3 ]/ ?, e( l- u3 f
virilization, exposure to exogenous testosterone in
4 N& t" V9 P. S/ B) }' [children results in an increase in growth velocity and, n4 X8 q" p$ a% `2 i
advanced bone age, as seen in our patient.
& d, N. _  z: e+ yThe long-term effect of androgen exposure during
9 Y0 N- ^+ |" x8 R7 zearly childhood on pubertal development and final
( }1 \0 j0 T: A" y+ cadult height are not fully known and always remain
6 g0 s% l1 C$ s$ Wa concern. Children treated with short-term testos-
8 E9 @" d3 K4 E6 tterone injection or topical androgen may exhibit some
' Q" C4 h4 J, ~$ z: [acceleration of the skeletal maturation; however, after' ?* m) _0 T% T0 @
cessation of treatment, the rate of bone maturation
+ ~7 D0 R" a) X9 S1 ^. b3 a3 Pdecelerates and gradually returns to normal.8,9% ^) @- M) U" V: `; x
There are conflicting reports and controversy
- b: ], H- Z9 [1 x% b7 Hover the effect of early androgen exposure on adult7 _+ J" S+ \4 |3 d) P
penile length.10,11 Some reports suggest subnormal0 }; x; {% p$ @7 F) H
adult penile length, apparently because of downreg-1 C* S6 f# s' E- b$ N8 Z# H9 C
ulation of androgen receptor number.10,12 However,$ t3 t5 @: T7 }( G) m
Sutherland et al13 did not find a correlation between
0 B. a' P* U9 echildhood testosterone exposure and reduced adult. [; S# `  f* u; T2 e2 F, ~
penile length in clinical studies.
' Z2 w) c) ^2 m" `Nonetheless, we do not believe our patient is7 \9 S2 v. f3 n9 N+ X- G/ P
going to experience any of the untoward effects from8 B# k% c% C: A
testosterone exposure as mentioned earlier because
. W8 b% x! ~, O- W5 pthe exposure was not for a prolonged period of time.
! ~# N, U! a0 G7 OAlthough the bone age was advanced at the time of
3 {( `) @1 I+ |diagnosis, the child had a normal growth velocity at9 ]# X( K1 K! S6 b6 P
the follow-up visit. It is hoped that his final adult$ R- [% T& M$ `4 S/ I4 }; a
height will not be affected.( g% e1 U; C0 {* `7 a. v0 Y
Although rarely reported, the widespread avail-$ v& M* x& t; K+ w% ^" I
ability of androgen products in our society may' A' E! p2 l9 k: c; E
indeed cause more virilization in male or female: G* X3 r+ ]6 K% s9 L2 m
children than one would realize. Exposure to andro-
$ U7 H3 {3 g+ J$ D5 m, O. tgen products must be considered and specific ques-- ^' t1 }0 e% A! `. l
tioning about the use of a testosterone product or
3 [% ]( W! G0 e4 G: _gel should be asked of the family members during
7 w  r0 c; U' k9 g5 T  H3 Sthe evaluation of any children who present with vir-
9 O2 A0 y- ~2 ^) e5 j" f) ]ilization or peripheral precocious puberty. The diag-1 S* C5 V. f( k. `% u1 N
nosis can be established by just a few tests and by( X6 q& s, H: p% r7 C7 Q1 W
appropriate history. The inability to obtain such a
/ D& Y! }1 y% n0 u/ W$ k' N/ Shistory, or failure to ask the specific questions, may$ p! U6 K- x% o
result in extensive, unnecessary, and expensive
2 _) K6 E& w7 ]/ l  Y7 D5 ]investigation. The primary care physician should be
8 t5 r( ~9 F% b$ }aware of this fact, because most of these children/ i  R+ B5 S5 K
may initially present in their practice. The Physicians’
9 U3 f/ w- E4 yDesk Reference and package insert should also put a0 N% K6 N5 D8 `* F7 M: Y2 K  v
warning about the virilizing effect on a male or
8 m6 c; `$ F( [" Q0 l8 a. Efemale child who might come in contact with some-% e4 S/ G( i! }3 O
one using any of these products.
" p3 s$ d' x1 m3 J0 PReferences
. ^/ P: F! k) P1 e& C, h0 S% i1. Styne DM. The testes: disorder of sexual differentiation4 m7 C9 @) f& G7 P9 I
and puberty in the male. In: Sperling MA, ed. Pediatric
' S: v# W, K" `; d' V$ eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: I1 s  I4 V! Z, t: _
2002: 565-628.
8 V4 g6 W& Y# ^: ?7 V- y1 M6 y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' X1 `+ X4 i: p/ e) H' B8 F& 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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
- S0 `" r5 {5 t+ Z$ j
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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