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Sexual Precocity in a 16-Month-Old
: e1 A) l2 a1 p# X5 x9 oBoy Induced by Indirect Topical
+ U- z; Q! K. L0 r0 `/ JExposure to Testosterone
' C1 b0 c# O; i/ e( U8 U2 {: B& K) e$ pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 c3 O9 _0 ]3 P$ o; y3 L# P; oand Kenneth R. Rettig, MD1- s2 k% T+ ?1 V0 H
Clinical Pediatrics) A' V  r% B* o' V0 |
Volume 46 Number 6
, U( B. ^. D3 v# y% q! {  \* iJuly 2007 540-543* R4 p, I. }4 L9 K! [1 x! j
© 2007 Sage Publications; P7 x, ]; u! E& k% v3 L
10.1177/00099228062966518 t$ l) ~. A# A
http://clp.sagepub.com: {- c8 P7 q: a* R6 O
hosted at+ x  U/ q6 \" ~( T* V
http://online.sagepub.com! m" t2 I9 Q$ S9 b
Precocious puberty in boys, central or peripheral,
. ^: F. G& |, K. \4 Cis a significant concern for physicians. Central
% i0 ^+ }0 ?% d. j' \precocious puberty (CPP), which is mediated" D. L2 q! N% }8 I$ I
through the hypothalamic pituitary gonadal axis, has6 ~6 P: t3 h- P/ _- z" h( T
a higher incidence of organic central nervous system# f/ e! V0 m' A! p' n: i9 W7 k
lesions in boys.1,2 Virilization in boys, as manifested& S  N* w% O0 F( v5 d' I; t
by enlargement of the penis, development of pubic( Z% [5 X& b" y$ T' x, k1 d- D; f
hair, and facial acne without enlargement of testi-
" ^1 `) ?8 `0 i, x/ x7 N! Ecles, suggests peripheral or pseudopuberty.1-3 We5 T7 @5 F3 @! C: r. S/ W. C; F& P
report a 16-month-old boy who presented with the
1 S3 A2 y0 d9 M& P3 O& lenlargement of the phallus and pubic hair develop-- S; `* K# ~4 Q1 m5 @) M9 O
ment without testicular enlargement, which was due
- }  G( i0 E' _3 ito the unintentional exposure to androgen gel used by8 |; ~6 e& w( [
the father. The family initially concealed this infor-
6 q3 k7 `1 P! u! A5 t- Vmation, resulting in an extensive work-up for this
* h/ ?4 |* C( @# schild. Given the widespread and easy availability of( L# ~) x9 i! Z! }# N; v
testosterone gel and cream, we believe this is proba-8 q) h/ p% l& a+ p' y1 [* }
bly more common than the rare case report in the
. H3 d1 W* C& v6 \: o9 m! R5 Uliterature.43 f7 T3 Y8 O; G& X: E3 `  M: X
Patient Report
4 T- e1 |5 _5 i+ oA 16-month-old white child was referred to the
; ?0 J9 N: B1 O+ dendocrine clinic by his pediatrician with the concern
( n. t4 I0 [( }% \- ]of early sexual development. His mother noticed" h+ P3 G1 ]2 I, o$ y* \1 I
light colored pubic hair development when he was! G4 a4 R6 L$ U) @3 x! `
From the 1Division of Pediatric Endocrinology, 2University of: C( S+ J! D& c1 m9 X
South Alabama Medical Center, Mobile, Alabama.
& G, ^6 a2 m$ [) k* l; oAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 f. y$ e4 h& L' u2 l) |6 Q
Professor of Pediatrics, University of South Alabama, College of
) B$ \& }# p3 e: S8 yMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& M; }3 s! ]: P1 z
e-mail: [email protected].
2 y; z# Y  |. Q4 Babout 6 to 7 months old, which progressively became1 J, U: b$ }$ ^" c( h. m" v
darker. She was also concerned about the enlarge-6 R8 c9 [% S4 s! n
ment of his penis and frequent erections. The child
, I$ {) v: S* f# R# mwas the product of a full-term normal delivery, with/ L, R1 T# {( \& e
a birth weight of 7 lb 14 oz, and birth length of
% ]6 D% [$ _1 [2 u6 R20 inches. He was breast-fed throughout the first year' E$ F# |6 F2 Q  D1 }, R
of life and was still receiving breast milk along with
* [! K! M* _5 i5 K. L0 w% Isolid food. He had no hospitalizations or surgery,
' ~, a/ |5 Y/ z' i  }and his psychosocial and psychomotor development% C/ Y( \/ J% k. m
was age appropriate.
/ P0 Z4 N7 j5 y' U4 @2 I# |: SThe family history was remarkable for the father,
& G2 s) z6 `9 c" l7 Wwho was diagnosed with hypothyroidism at age 16,3 ]: P6 ^; L% L& H" i: m4 D
which was treated with thyroxine. The father’s8 y  Q; [; Z8 ]# W1 E* C
height was 6 feet, and he went through a somewhat
9 `  p* u# ?+ m, u0 d# u+ s. B8 y- fearly puberty and had stopped growing by age 14.
1 _2 k! y8 a! mThe father denied taking any other medication. The( F* `* X( B+ p. M  S  P
child’s mother was in good health. Her menarche- U' T0 w* Y* Q2 p. S% m& P
was at 11 years of age, and her height was at 5 feet; z: ?$ ^. N" [- P  H! p. d
5 inches. There was no other family history of pre-# J$ V4 N" V4 l
cocious sexual development in the first-degree rela-
9 j5 T- n4 M4 C4 K/ ]8 e3 `0 U( S, _tives. There were no siblings.* N9 h# y9 f- K( v% ]
Physical Examination! I6 U5 Z) O0 [* L8 c4 z: h
The physical examination revealed a very active,7 p% i  v- l  O0 k
playful, and healthy boy. The vital signs documented
, @/ t& {5 n( |+ i5 fa blood pressure of 85/50 mm Hg, his length was- }8 }0 J! N: e/ X# O! n1 k( b9 R5 f
90 cm (>97th percentile), and his weight was 14.4 kg
+ ?& b6 x+ c& S(also >97th percentile). The observed yearly growth
% y8 S- F3 s+ {/ D5 n& cvelocity was 30 cm (12 inches). The examination of
6 o. @3 I, B) \4 d7 J5 S* mthe neck revealed no thyroid enlargement.
& @, B2 l; L' n/ V/ A& NThe genitourinary examination was remarkable for
1 L8 g6 @8 b8 g5 ^8 m0 Renlargement of the penis, with a stretched length of* I0 j( |6 R8 b
8 cm and a width of 2 cm. The glans penis was very well
# u8 P  z5 N, a( e4 p; Udeveloped. The pubic hair was Tanner II, mostly around& N6 T$ X# T/ k* C$ N
540- `  }  y7 C8 N" X' [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* h8 D& t1 G; m& c! ^' @# K6 k- fthe base of the phallus and was dark and curled. The6 p2 j7 A2 a+ X  G1 n- B9 u; g
testicular volume was prepubertal at 2 mL each.
. X/ C8 `6 ?" _2 r6 l8 y! C! VThe skin was moist and smooth and somewhat
$ J, L1 k7 ]6 r/ i+ [; boily. No axillary hair was noted. There were no1 a: i5 _& C# [4 i2 {5 [& k
abnormal skin pigmentations or café-au-lait spots.1 R1 F; d3 R) Z; W
Neurologic evaluation showed deep tendon reflex 2+5 f0 k' Z, I/ x, R* c, Q
bilateral and symmetrical. There was no suggestion
- Z+ U& P. J8 a5 W8 Bof papilledema.
( K/ G! I0 s6 a$ @- DLaboratory Evaluation
; Z. e( E) N& u' k/ h- I% MThe bone age was consistent with 28 months by% ?+ o' @- z2 ^0 P
using the standard of Greulich and Pyle at a chrono-
% I9 a" q- a. h5 G5 f  blogic age of 16 months (advanced).5 Chromosomal
/ c% Y6 j2 |, F  [: _+ y0 Ykaryotype was 46XY. The thyroid function test( g2 n6 f2 c0 e+ _$ ^
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# T9 z# U' {9 u' k/ o$ Dlating hormone level was 1.3 µIU/mL (both normal).
9 l- u5 O" O5 Z3 c% X, |# X2 g5 T; jThe concentrations of serum electrolytes, blood
$ k9 g% r3 e. n/ e$ Y2 s- K( U1 Lurea nitrogen, creatinine, and calcium all were4 \; p: S) h5 e
within normal range for his age. The concentration# _, v" D5 n9 v6 x9 I
of serum 17-hydroxyprogesterone was 16 ng/dL2 x5 a: M1 K/ p0 S1 n
(normal, 3 to 90 ng/dL), androstenedione was 20
2 q# v% G' n' d$ |! q" Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- ^$ M9 @1 t+ ?. fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 T; q. }( M) O8 P) E7 q7 {desoxycorticosterone was 4.3 ng/dL (normal, 7 to# W* A* M# U" q: _5 W( C* H2 E
49ng/dL), 11-desoxycortisol (specific compound S)
4 j2 ]4 W( @+ M# Z5 b8 l  |was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, Q1 M5 W  \! z: P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; ^: b0 M% X2 p" T; }+ o- U+ {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 ~- V; N$ n  u$ ~: G' x) x
and β-human chorionic gonadotropin was less than
: c6 x3 n- F+ V1 M1 D$ g5 mIU/mL (normal <5 mIU/mL). Serum follicular4 e9 ^0 ?& o& ?0 j% U
stimulating hormone and leuteinizing hormone
( p: O5 l7 e: E9 r, |5 y6 {concentrations were less than 0.05 mIU/mL$ Q; P% z: j, \
(prepubertal).
, |0 g1 z6 M5 o# B7 f4 {The parents were notified about the laboratory
7 D9 r  [: Q8 _3 P( Rresults and were informed that all of the tests were; j! X6 _7 l( Q* S! v( H
normal except the testosterone level was high. The, B% q2 G8 Y9 i0 q
follow-up visit was arranged within a few weeks to! F8 m8 ~7 m3 U5 e, }
obtain testicular and abdominal sonograms; how-8 Y& M3 t) p/ r% I8 s+ ]1 W
ever, the family did not return for 4 months.) C5 ~' {4 D7 U  r
Physical examination at this time revealed that the3 q# e/ ]& P8 ?5 `
child had grown 2.5 cm in 4 months and had gained
: }, m+ q' I/ K0 D$ U3 |% r7 H  z2 kg of weight. Physical examination remained
2 g. n5 ]$ s* C7 Y, @# c6 O! j8 ~( [unchanged. Surprisingly, the pubic hair almost com-1 k( R6 G1 A; r3 ^; b1 b
pletely disappeared except for a few vellous hairs at
/ g* L  U8 u% C, ^4 j( H& I, T) jthe base of the phallus. Testicular volume was still 2
6 o+ k% }6 Q" ^. d/ X; b! Z, VmL, and the size of the penis remained unchanged.
! l4 \( [# C- X" m7 C% E/ VThe mother also said that the boy was no longer hav-
  g5 g" g& E" S5 c- [ing frequent erections.. l) N. s* H  V2 _/ r
Both parents were again questioned about use of
8 H0 V1 y; ]6 R$ J4 Dany ointment/creams that they may have applied to$ i9 j; {! I; @& Y3 ]8 B
the child’s skin. This time the father admitted the
" |+ i# V7 _( J$ Q& B, bTopical Testosterone Exposure / Bhowmick et al 541% A2 h, K4 u2 c) r5 |4 z
use of testosterone gel twice daily that he was apply-
" ?& Y: c- c; D$ K$ T/ E  Sing over his own shoulders, chest, and back area for& J1 p$ g0 O  C' W2 I- r( c! U
a year. The father also revealed he was embarrassed! D7 {3 X6 B" o( R
to disclose that he was using a testosterone gel pre-
4 o5 S% |* l+ I; Qscribed by his family physician for decreased libido) s( R0 W$ [& ]3 |& B
secondary to depression.' J5 E% @7 |$ U6 V# E
The child slept in the same bed with parents.9 y8 T2 G3 c5 W& n# Q1 F
The father would hug the baby and hold him on his; H7 _$ W  E( u2 F; a
chest for a considerable period of time, causing sig-
- \3 b% W% Q0 L5 l$ F* P0 [) Lnificant bare skin contact between baby and father.* Y3 O/ a& T0 q
The father also admitted that after the phone call,
! `. z' S  T: K" Awhen he learned the testosterone level in the baby. |+ P7 D6 _, C* Z) Q; a
was high, he then read the product information
  q! p2 T% k. m" V* B, x! @. g6 j- Ppacket and concluded that it was most likely the rea-( Y3 ~. A- J& z  G: Q
son for the child’s virilization. At that time, they
( m2 v+ a9 B% B3 b8 K5 wdecided to put the baby in a separate bed, and the/ T; g; j, I$ G7 `" \: D
father was not hugging him with bare skin and had
0 R# Y  V0 V: H5 X. l7 ?been using protective clothing. A repeat testosterone8 p+ a. F- j3 s. k3 ~% @, W- f8 S
test was ordered, but the family did not go to the& _' _& a9 u; P$ Y
laboratory to obtain the test.
( C0 A/ [+ _& sDiscussion. K  ~. ?4 \; y) `
Precocious puberty in boys is defined as secondary9 V$ ?+ F' M) ^6 J1 k  D
sexual development before 9 years of age.1,4
3 {5 D7 ~) w* _9 wPrecocious puberty is termed as central (true) when
, ]% T4 Q$ `! s( w" i/ j7 t8 yit is caused by the premature activation of hypo-/ O3 @1 d  `- |8 P1 i1 U7 y/ |
thalamic pituitary gonadal axis. CPP is more com-
- `% D( j, K/ ]mon in girls than in boys.1,3 Most boys with CPP
1 ]0 C0 o$ B  [. @8 A9 S/ zmay have a central nervous system lesion that is
7 `8 ^9 K- g6 Bresponsible for the early activation of the hypothal-  B1 f8 Q0 N0 M' _9 E9 X, i
amic pituitary gonadal axis.1-3 Thus, greater empha-
4 P: b8 P% q' P( x' U- V4 _sis has been given to neuroradiologic imaging in) p# D, O0 L8 d* `
boys with precocious puberty. In addition to viril-
! ~! B& r3 H5 e3 x9 m. Y3 S# I+ x2 v1 C5 yization, the clinical hallmark of CPP is the symmet-/ l  K" g9 T0 @1 u
rical testicular growth secondary to stimulation by0 I! I4 Z/ ^# W, b
gonadotropins.1,34 x4 m6 t3 ~$ W7 M
Gonadotropin-independent peripheral preco-8 Y, w. j  {7 L! |* I
cious puberty in boys also results from inappropriate, P' a" Y3 Q( d1 V; h+ A& h
androgenic stimulation from either endogenous or
9 _& |$ k, F5 i$ X+ `exogenous sources, nonpituitary gonadotropin stim-0 g7 Q8 p# ]" ~) y7 V" I1 K0 b
ulation, and rare activating mutations.3 Virilizing0 ?2 y% ~: X$ n1 I2 e, j" e
congenital adrenal hyperplasia producing excessive
' u4 ^" Q- c/ r6 O$ Vadrenal androgens is a common cause of precocious
& u. [0 Q' h4 I# q  H6 s5 N1 ppuberty in boys.3,4
  q2 k$ A4 [6 ~% b8 q" PThe most common form of congenital adrenal9 n+ |1 C2 y3 c. ^: q' j
hyperplasia is the 21-hydroxylase enzyme deficiency.
% e, V, [) l% ~The 11-β hydroxylase deficiency may also result in
9 o) |* h$ I. D1 r$ e* \excessive adrenal androgen production, and rarely,0 K1 N' |; ^" ~- Z
an adrenal tumor may also cause adrenal androgen
+ x; L) q* ^$ I! xexcess.1,34 Z8 I* F( a% s9 N/ K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 [7 e! s% j7 H% @% s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ R4 D% ?' c- o9 O7 l: {A unique entity of male-limited gonadotropin-; ^. f5 f, P- _$ S: X1 J
independent precocious puberty, which is also known
7 R" W* K) k, u4 s& ~+ P8 [( Gas testotoxicosis, may cause precocious puberty at a! }2 W& h; K0 d3 @* b
very young age. The physical findings in these boys0 a; w, D% m. Z# A, A
with this disorder are full pubertal development,0 {( T& g) _7 b4 S- ^, A7 R8 P7 J3 D
including bilateral testicular growth, similar to boys
9 ?3 `7 g& r$ r9 }with CPP. The gonadotropin levels in this disorder: S# q, Z8 r- F/ |& e  ?
are suppressed to prepubertal levels and do not show, J. ?+ G6 L& D2 E
pubertal response of gonadotropin after gonadotropin-
6 F4 i1 l2 t5 P5 J! t* qreleasing hormone stimulation. This is a sex-linked* C; q$ O- p( W# [
autosomal dominant disorder that affects only
9 m2 W) M. P# Bmales; therefore, other male members of the family
! P& r1 m" Y' [0 V3 Rmay have similar precocious puberty.3& t- ]8 f  m+ S, I# d  T0 p; X
In our patient, physical examination was incon-4 c  s# i8 |8 m4 J
sistent with true precocious puberty since his testi-
4 a# D9 |# `* q" L4 |" jcles were prepubertal in size. However, testotoxicosis% l. D6 ^+ n( ~! V2 u" b/ \3 y, ~% _
was in the differential diagnosis because his father
8 Y* ?3 W  z2 k$ p' G9 R, s2 Astarted puberty somewhat early, and occasionally,
  m- q4 W; t6 i/ ?; ~' qtesticular enlargement is not that evident in the# U# T2 ~$ j+ ~, J2 A/ |
beginning of this process.1 In the absence of a neg-
- V% s: I3 J6 a; _" ~! X6 dative initial history of androgen exposure, our
" L3 t: J) J- xbiggest concern was virilizing adrenal hyperplasia,
2 m2 \) `; ?* G. neither 21-hydroxylase deficiency or 11-β hydroxylase) ~# O3 g! k- D8 w. W. W" o" W
deficiency. Those diagnoses were excluded by find-
5 y8 z7 G9 m% i( `0 oing the normal level of adrenal steroids.7 ^+ M: n8 Z; _# ?
The diagnosis of exogenous androgens was strongly
& R' ?* m" L2 F) Ysuspected in a follow-up visit after 4 months because
3 ]) Q2 u6 ~0 r" F# ]  q, Xthe physical examination revealed the complete disap-8 {( k- S( A4 C3 g9 w
pearance of pubic hair, normal growth velocity, and& a, u2 E, k6 n' E
decreased erections. The father admitted using a testos-+ F' z0 d. b2 P/ N
terone gel, which he concealed at first visit. He was
5 x" t7 a8 t& C- h% \( X% [using it rather frequently, twice a day. The Physicians’2 q  [- G/ J; C9 I: ?5 v. X; C8 l
Desk Reference, or package insert of this product, gel or- \0 g8 b0 S. g  M8 z
cream, cautions about dermal testosterone transfer to
, S- @. Q* N) l: Lunprotected females through direct skin exposure.
9 \  O8 r/ S# \1 S& L3 T  L6 _Serum testosterone level was found to be 2 times the' j4 ?( [& T  j2 U) J
baseline value in those females who were exposed to
  ]- O: q7 E% U, e# Deven 15 minutes of direct skin contact with their male9 X& X; s5 Z: h( g2 \
partners.6 However, when a shirt covered the applica-" u- a; ^7 V/ E3 y6 }& \
tion site, this testosterone transfer was prevented.: |( \: U. \- `" l4 e" W
Our patient’s testosterone level was 60 ng/mL,
5 a6 F5 D) B6 K# D2 L6 U% Rwhich was clearly high. Some studies suggest that
* X& S1 L7 `: z; w0 V  M7 odermal conversion of testosterone to dihydrotestos-" k$ W3 Z* G3 Y' d4 j* D
terone, which is a more potent metabolite, is more$ D5 [. l$ `6 s# v
active in young children exposed to testosterone" ?. ?0 X7 h5 d; b
exogenously7; however, we did not measure a dihy-" N! @0 |9 @! h' w
drotestosterone level in our patient. In addition to
- _  [% t, c. d: C$ c1 vvirilization, exposure to exogenous testosterone in: x9 p2 {5 j1 h9 v: \8 U! X/ h/ g
children results in an increase in growth velocity and
& z+ m! d9 v( B5 X  E3 @advanced bone age, as seen in our patient.8 _" N1 q$ D5 B$ o) |! o& |' m
The long-term effect of androgen exposure during& v' Y1 A5 l( m; x4 A7 j% k8 F0 a
early childhood on pubertal development and final( j/ J/ s" G9 V1 f$ D4 G
adult height are not fully known and always remain
( _- X! p/ A: B1 fa concern. Children treated with short-term testos-4 t/ s* z0 P5 q0 A( _" c
terone injection or topical androgen may exhibit some
  E$ c% J6 Q9 v* Tacceleration of the skeletal maturation; however, after/ U9 q0 I% L% J: u9 R# P) o
cessation of treatment, the rate of bone maturation7 k3 \; M! @  [, x0 L
decelerates and gradually returns to normal.8,95 V- y) S- i4 ~7 T; I8 q* N
There are conflicting reports and controversy0 j9 f0 M$ v0 O4 C
over the effect of early androgen exposure on adult* |" r8 O: E0 e
penile length.10,11 Some reports suggest subnormal
8 t. X' M- w4 S, N0 H' M" x  z2 dadult penile length, apparently because of downreg-
" t9 L& x( b  n, r; X7 `ulation of androgen receptor number.10,12 However,* h5 U4 X( L' G3 x0 e( s7 X' p. ~
Sutherland et al13 did not find a correlation between
9 W8 @" @2 z, K( i, Z6 ]childhood testosterone exposure and reduced adult* s5 p+ {# K" X: \& }! y& F
penile length in clinical studies.
0 E+ B4 N$ s+ l, t1 k4 A5 Y" cNonetheless, we do not believe our patient is
2 ~: d9 ?6 Z- Y" h; f1 s' T! ^9 dgoing to experience any of the untoward effects from
. T' b0 U5 Y" A8 }/ M5 E# Z$ ?testosterone exposure as mentioned earlier because+ ], ]. f1 F2 ]7 ^
the exposure was not for a prolonged period of time.4 R/ O; h$ F; u2 @+ V' o, @
Although the bone age was advanced at the time of
' s( G, v; p5 ?7 s$ P& e- K$ j+ `diagnosis, the child had a normal growth velocity at
* J2 B5 V$ f+ Y6 R( wthe follow-up visit. It is hoped that his final adult; U4 Q8 x1 b) F- n- w* Y! v
height will not be affected.1 u% y4 U3 R7 Y/ z
Although rarely reported, the widespread avail-' {+ d* U* L! z' m3 ~! l/ {, n
ability of androgen products in our society may' F/ B+ ]9 W- g9 a1 e0 Z8 \: F  H
indeed cause more virilization in male or female1 |- i1 l5 r5 o8 ?/ e/ v
children than one would realize. Exposure to andro-
! i* o$ Q3 r4 v* Ngen products must be considered and specific ques-3 A+ P5 b; P$ G# d
tioning about the use of a testosterone product or
+ A4 C' G9 [" U7 d+ m, p1 Hgel should be asked of the family members during* ^- W9 i. p+ g% c  d2 G7 ^1 I
the evaluation of any children who present with vir-) [5 m6 a( x( t: Q
ilization or peripheral precocious puberty. The diag-
6 ]% _+ i! h4 inosis can be established by just a few tests and by
1 t, M. H: Y- n( Happropriate history. The inability to obtain such a
- m1 Z' R5 U, r: i8 i. Mhistory, or failure to ask the specific questions, may
- `7 d7 K- Q+ V  b  s( Qresult in extensive, unnecessary, and expensive
7 B4 s3 a7 ~$ a9 _# t; t! p' Einvestigation. The primary care physician should be: o$ U3 u( {- d3 f9 D! N2 Q
aware of this fact, because most of these children
2 ~! w3 _9 s1 L3 Q3 Umay initially present in their practice. The Physicians’' J* _# g3 Z1 ^* ^
Desk Reference and package insert should also put a
  z! b- V) [0 l6 Hwarning about the virilizing effect on a male or
! D2 v) c% e- V" A- r- Cfemale child who might come in contact with some-9 v9 Z) h9 s7 P) g+ f0 w: j6 H
one using any of these products.9 Y+ }4 l$ l7 X+ L+ s
References1 l0 q) @, H7 W- H$ ~4 ^
1. Styne DM. The testes: disorder of sexual differentiation
5 b6 i3 S/ _( kand puberty in the male. In: Sperling MA, ed. Pediatric
& n7 s  R# c) sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 c$ J1 u9 {) E2002: 565-628.1 Q# q  Y4 H* v& ?. O0 M6 f4 U
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 s8 f$ o9 l- U+ w. n8 mpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old( t- V; X7 P8 o
Boy Induced by Indirect Topical0 q% ~* D/ v+ V4 S$ Z: `
Exposure to Testosterone
% F* y( v- X: P" rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 v( f6 p8 y' Y5 c8 k# ]and Kenneth R. Rettig, MD17 n/ c* e8 m5 K. ^$ U" T
Clinical Pediatrics9 e0 S5 C" q0 ?% d. t6 z
Volume 46 Number 6
8 U  B% ~$ r. v) T, }July 2007 540-5437 {+ N$ o. p3 L- N
© 2007 Sage Publications  x1 x5 ~/ V% J
10.1177/0009922806296651
% V. J) Y* ], w' x) ~http://clp.sagepub.com
8 u' p- ]- P( xhosted at5 a# B) v- R' u$ l6 g1 [1 I
http://online.sagepub.com1 O5 }/ `( @" a& A* u/ h' `
Precocious puberty in boys, central or peripheral,% H0 r$ d2 Y# _& L3 E' e" @. m2 e
is a significant concern for physicians. Central* ^1 h6 W9 L# T$ e
precocious puberty (CPP), which is mediated
4 A2 k# V6 S" k/ S( l. ythrough the hypothalamic pituitary gonadal axis, has
+ G  n' H- ?! I* @" ^a higher incidence of organic central nervous system- u+ r8 T9 e( d8 m6 i5 x% E
lesions in boys.1,2 Virilization in boys, as manifested
6 M9 U; I. s- N! @6 r7 Kby enlargement of the penis, development of pubic8 V: Q4 ]# N5 K& H3 _
hair, and facial acne without enlargement of testi-: r; e( _' L7 r$ K% G& L  o
cles, suggests peripheral or pseudopuberty.1-3 We1 R1 r% F; w" T  Y8 Q5 Z7 u
report a 16-month-old boy who presented with the
$ |! i! k; @; I+ T9 g9 menlargement of the phallus and pubic hair develop-) ~1 R- m- V" m5 E& I6 B/ u( ^
ment without testicular enlargement, which was due
6 R' a/ e& J8 q7 X0 ?& ?- y- N# Sto the unintentional exposure to androgen gel used by+ x( N1 \4 T% {6 m9 P/ V- k; y
the father. The family initially concealed this infor-
0 y$ L- G! [" P- f2 Y; g/ y& gmation, resulting in an extensive work-up for this9 d7 X$ B0 ]( P6 c
child. Given the widespread and easy availability of
# l9 U# m2 g0 @/ ?7 @- P; d" O! C, n8 ztestosterone gel and cream, we believe this is proba-+ V! Z1 l+ I% x0 e
bly more common than the rare case report in the, T1 z8 j0 O! t( |2 d
literature.4: k2 b2 [( p6 M9 m% Y# X
Patient Report7 Q$ @4 M" E% k  U+ C' ?' y$ R' _
A 16-month-old white child was referred to the
4 \8 h* v- |6 O  o/ z" T! P! lendocrine clinic by his pediatrician with the concern+ \  ~, V- V# I' t
of early sexual development. His mother noticed
- ]: ?" x' a1 C. D2 ?- [" G- rlight colored pubic hair development when he was2 q+ r* k3 z. H5 j! \
From the 1Division of Pediatric Endocrinology, 2University of7 |0 Y# a  V# ~2 ^' f8 z- M
South Alabama Medical Center, Mobile, Alabama.5 A1 t4 ]& Z$ P
Address correspondence to: Samar K. Bhowmick, MD, FACE,+ {3 x, a' v7 |, j# \0 ^
Professor of Pediatrics, University of South Alabama, College of
# m* i1 m, @/ E" k( u: ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 a! ?% A3 R) f9 K
e-mail: [email protected].
% t6 u( Q1 i, Jabout 6 to 7 months old, which progressively became! I1 U2 A, K" u7 x
darker. She was also concerned about the enlarge-, T: |/ b8 t! }6 g6 n8 b2 Z- U
ment of his penis and frequent erections. The child$ m  P" ]; ^8 S$ C
was the product of a full-term normal delivery, with
  u" n) w3 d6 V6 o6 ~; x9 Y; ca birth weight of 7 lb 14 oz, and birth length of
. r1 @  g! Y  }  i6 v; _20 inches. He was breast-fed throughout the first year+ b; L+ r1 r+ a5 V  V
of life and was still receiving breast milk along with
6 l- s$ b9 \+ \# h+ f1 qsolid food. He had no hospitalizations or surgery,9 r9 T) W7 ^) n: q6 X& A
and his psychosocial and psychomotor development
+ L4 i' r/ [$ ?4 _& S" ~was age appropriate.  `5 l. T) B+ v8 w' V
The family history was remarkable for the father,' C  [7 ^/ h. T6 Q, Q
who was diagnosed with hypothyroidism at age 16,3 |# N1 N* p2 }4 h
which was treated with thyroxine. The father’s% e2 h" K2 C$ X3 e# f* G# F
height was 6 feet, and he went through a somewhat2 M% G! D& o+ x5 a
early puberty and had stopped growing by age 14.) t4 l. G/ E1 ]
The father denied taking any other medication. The
. S3 M2 \; r5 mchild’s mother was in good health. Her menarche7 w. L5 O# n1 \; E$ _
was at 11 years of age, and her height was at 5 feet% R. ?" D; R" M( \4 m$ E8 _
5 inches. There was no other family history of pre-" n6 s9 a. l7 ?1 D
cocious sexual development in the first-degree rela-
4 ]1 [. f( i! m9 Ztives. There were no siblings.& K, D$ i5 t* B$ j* Y0 q4 n5 l
Physical Examination
; J$ P3 N8 `& u0 AThe physical examination revealed a very active,' I1 F  V4 H( P% j
playful, and healthy boy. The vital signs documented" k# {4 x9 b/ {" x
a blood pressure of 85/50 mm Hg, his length was6 N1 w+ \* v2 B7 T
90 cm (>97th percentile), and his weight was 14.4 kg+ B* b$ D1 H) ^' ]+ |
(also >97th percentile). The observed yearly growth2 \9 Q$ {$ j+ J& s
velocity was 30 cm (12 inches). The examination of: ?/ q- s: P! o
the neck revealed no thyroid enlargement.1 ^6 T5 a% d1 z# x
The genitourinary examination was remarkable for! K- w2 C- d8 ^* o
enlargement of the penis, with a stretched length of  J* A) O: A9 `' {  g
8 cm and a width of 2 cm. The glans penis was very well( A; ~2 ^: [) S5 f! q9 i. f
developed. The pubic hair was Tanner II, mostly around9 r) u5 b. d4 s
540
5 ^' m0 {. Z2 B( K8 eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 M- ]+ Q/ M, L$ _& E7 l3 h3 ythe base of the phallus and was dark and curled. The4 A8 A* y1 C( _, }
testicular volume was prepubertal at 2 mL each.- _! t  _" e$ Z0 ?9 B( J! l) y& D: E
The skin was moist and smooth and somewhat
7 {( |, x* M' eoily. No axillary hair was noted. There were no
$ F0 v, o0 p+ _9 h5 ^  Vabnormal skin pigmentations or café-au-lait spots.
) M3 @" p0 s. p% [5 wNeurologic evaluation showed deep tendon reflex 2+
. D& p6 [& J# P; D4 E, F& I1 Kbilateral and symmetrical. There was no suggestion
/ }# ^. H8 v( g$ P; c; m$ S1 |of papilledema.
- b; u: a( K5 S2 p) jLaboratory Evaluation
5 V% e! q2 g: wThe bone age was consistent with 28 months by
" {. I5 N4 Q! \; |- M( Pusing the standard of Greulich and Pyle at a chrono-% x5 V% r4 H& D) D2 ]
logic age of 16 months (advanced).5 Chromosomal
- m: J$ V: h# A. ^( hkaryotype was 46XY. The thyroid function test
6 z7 H3 X& b( R7 zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-8 w; a' S' `+ {6 R
lating hormone level was 1.3 µIU/mL (both normal).9 _& E2 r- c  X3 B6 M- g, P$ C& o- x
The concentrations of serum electrolytes, blood! t# j1 |1 h4 h- ], G
urea nitrogen, creatinine, and calcium all were
1 p$ z0 v6 s6 J# z0 x& [within normal range for his age. The concentration
9 q- W+ T2 n3 @0 I! k# U# Tof serum 17-hydroxyprogesterone was 16 ng/dL: a5 n, D4 a. L1 N
(normal, 3 to 90 ng/dL), androstenedione was 20
7 a& q7 T5 n. ?( cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( V; ~) t; l4 `: c& F2 P/ o* hterone was 38 ng/dL (normal, 50 to 760 ng/dL),: C" \; @  p7 I8 T0 T" }, q. w. ~$ P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
, v% u: K* c( I) q9 r49ng/dL), 11-desoxycortisol (specific compound S)
8 V" Z- R8 [# jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) q  N& P+ o8 Z- f  Q5 Vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! K% A' ]3 s# N' D$ ^; c, Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),: y2 X2 j6 V& r/ m4 N, s. J
and β-human chorionic gonadotropin was less than" Q9 c. b2 c: }) G2 Y" k6 }/ W# \6 W9 Y
5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 D) M8 v3 ]* V! d6 q) x2 U/ [: xstimulating hormone and leuteinizing hormone3 m5 h. h( f2 Y
concentrations were less than 0.05 mIU/mL
; e5 ~1 h) ?' E1 [' p$ [(prepubertal).
5 p4 s# o3 C2 S; `5 XThe parents were notified about the laboratory
9 [, \" `; Q+ u. e, h( l, }results and were informed that all of the tests were, \" b8 ~0 b$ ]8 _; K" o
normal except the testosterone level was high. The
/ ~; w: z& e8 ]6 p* ?- R; ~follow-up visit was arranged within a few weeks to. I/ l; W+ D( t+ g
obtain testicular and abdominal sonograms; how-
9 [* X# F2 z7 W1 Hever, the family did not return for 4 months.3 F& F7 w+ a% M  O5 k  e
Physical examination at this time revealed that the
) T* R1 b4 Q8 n; ]& J( t1 nchild had grown 2.5 cm in 4 months and had gained5 a3 f& e4 O, I' p5 n' x. O5 C4 ]) G
2 kg of weight. Physical examination remained: I$ A2 e; A) q0 b$ u9 _
unchanged. Surprisingly, the pubic hair almost com-
+ G. \7 w2 ?" z3 `0 Apletely disappeared except for a few vellous hairs at
/ |5 T1 e  K8 b1 C; a  w, Lthe base of the phallus. Testicular volume was still 2) D5 e4 l- l: |- [: C
mL, and the size of the penis remained unchanged.
# j9 O, B4 O* w# OThe mother also said that the boy was no longer hav-$ K& g" J, U( |! C: ]
ing frequent erections.; t  I# Z2 Z% |0 t: b2 H
Both parents were again questioned about use of
7 j3 V' |6 ?2 }& [' aany ointment/creams that they may have applied to' j8 `1 c# [% A' H
the child’s skin. This time the father admitted the
" g0 N: B1 b. `- L- bTopical Testosterone Exposure / Bhowmick et al 5410 _  V& k' W% a/ A
use of testosterone gel twice daily that he was apply-- `3 d2 X, d( N% V0 W
ing over his own shoulders, chest, and back area for) c. O6 _7 J* }2 m( `' h% i: g' a# g
a year. The father also revealed he was embarrassed$ g1 |9 B: R8 b; X" u$ o, e3 @0 a! E5 h
to disclose that he was using a testosterone gel pre-
) S0 k% t& Z9 z# f# zscribed by his family physician for decreased libido& a- Y2 ~: c& l4 ], _' v1 ?5 i. p
secondary to depression.
" P8 [) T) |2 B- KThe child slept in the same bed with parents.
- c7 r5 Y, W* H. JThe father would hug the baby and hold him on his
1 b* y. }0 S) W5 Uchest for a considerable period of time, causing sig-  l7 _+ @# ~1 w4 \3 U
nificant bare skin contact between baby and father.& i& t6 i+ s9 i# J# V' M6 G3 @1 H
The father also admitted that after the phone call,, l: a* o' D7 u! N  ?( E
when he learned the testosterone level in the baby
* d. i# y' r9 v  Cwas high, he then read the product information1 V! ?/ ?8 J7 k1 u( j
packet and concluded that it was most likely the rea-
" o. W3 @% r( H2 C0 p+ eson for the child’s virilization. At that time, they3 {: H2 ~3 Z0 A$ w  r' S
decided to put the baby in a separate bed, and the" `  z2 x" c  i1 s& D
father was not hugging him with bare skin and had! m2 x: `$ U9 \
been using protective clothing. A repeat testosterone) e8 y, l  y& ]* D1 {: @
test was ordered, but the family did not go to the0 W, g, g3 i9 k' x$ t/ |& x
laboratory to obtain the test.2 }0 S$ F! @; u  Q. T! y. o; Y
Discussion+ j) w! d, D' N
Precocious puberty in boys is defined as secondary
" G8 R- a$ i) I; J& ^7 E% csexual development before 9 years of age.1,4. Y& s/ e8 w8 p' w) ^& _
Precocious puberty is termed as central (true) when
$ ]4 a: `6 `# o  ?1 o5 O* p- lit is caused by the premature activation of hypo-1 ?! e! B$ {/ X# t
thalamic pituitary gonadal axis. CPP is more com-
/ m% H' }% j0 A, \7 T! b. J' r* tmon in girls than in boys.1,3 Most boys with CPP- p  J' l' A3 V3 u2 w$ P
may have a central nervous system lesion that is" ?- t( o% W: H
responsible for the early activation of the hypothal-3 b$ |& y2 u0 A, g) z
amic pituitary gonadal axis.1-3 Thus, greater empha-
% q. O" O. k0 ^sis has been given to neuroradiologic imaging in, E, h) {7 e" h+ [) p0 Y
boys with precocious puberty. In addition to viril-
( p4 c4 {3 S! k0 |# sization, the clinical hallmark of CPP is the symmet-  R5 B) K2 N4 _* [7 A5 V
rical testicular growth secondary to stimulation by
$ J: A- y; S0 f2 D% i% Y% o- I  Ngonadotropins.1,3; Y+ C# u% }2 w, F1 {
Gonadotropin-independent peripheral preco-
& U5 P, t! O( s& `cious puberty in boys also results from inappropriate
* Z5 k; B4 k5 _6 X5 dandrogenic stimulation from either endogenous or8 \7 P" I% S1 a: m
exogenous sources, nonpituitary gonadotropin stim-  p, y# `9 ?  s% L% l- Y7 T! x" \
ulation, and rare activating mutations.3 Virilizing2 B5 a2 M3 G4 u9 ^
congenital adrenal hyperplasia producing excessive5 ]  `  w! ?. D% Y  R
adrenal androgens is a common cause of precocious( t1 q- S" ]2 m. Y% ]! y
puberty in boys.3,4
# y4 f9 n3 C  Y* S# \The most common form of congenital adrenal4 T  c0 l4 P. o# `0 J4 u
hyperplasia is the 21-hydroxylase enzyme deficiency.2 W. I' [. x1 |8 H, i+ M; [
The 11-β hydroxylase deficiency may also result in
. t5 \. w6 B; R% D% g% F: ]( C/ Cexcessive adrenal androgen production, and rarely,! O. g) r7 ?) ]: I- f/ C
an adrenal tumor may also cause adrenal androgen  }& h% D, W* x' Z6 }
excess.1,3* ]9 S# A* u  k" p) Z6 N6 R& [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 U: B7 A( w9 n  h8 K542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 g' W. ?4 J$ M% ]5 X6 d4 j& |# c9 ^! r
A unique entity of male-limited gonadotropin-1 }. V" e4 A( _. R
independent precocious puberty, which is also known
9 t8 M0 u  k. |5 N- Sas testotoxicosis, may cause precocious puberty at a
/ [  t: r: ~% v/ s/ A: L- Fvery young age. The physical findings in these boys
" c& Q, W# k+ a6 n3 @8 ?with this disorder are full pubertal development,% V8 O5 l. ^; V, C+ K
including bilateral testicular growth, similar to boys
# b4 ~) p8 E$ Q% J( Kwith CPP. The gonadotropin levels in this disorder
, m% A+ L, M" g% S) Xare suppressed to prepubertal levels and do not show( u' L( P: _- l. a  F: d# g+ O
pubertal response of gonadotropin after gonadotropin-1 y) b7 t9 Q" y! D! c
releasing hormone stimulation. This is a sex-linked2 R8 A7 C* c" e2 n  s
autosomal dominant disorder that affects only
. J# [; G( z7 ymales; therefore, other male members of the family3 G+ z$ m; y9 y4 o. R% Y
may have similar precocious puberty.3
7 s0 |. J0 [9 @$ H* L% h4 jIn our patient, physical examination was incon-$ Z1 E' P, m  B0 S! N
sistent with true precocious puberty since his testi-/ J2 ]/ h: C3 c0 b* \/ F  k0 [
cles were prepubertal in size. However, testotoxicosis, Y" A7 c3 A( X& n, j' H! z
was in the differential diagnosis because his father# F% p' [( w* H8 f. M$ E3 U& a
started puberty somewhat early, and occasionally,+ G# I; x8 C/ C$ Y5 b6 T
testicular enlargement is not that evident in the& w: q: g/ k" H2 y5 M/ b  ^
beginning of this process.1 In the absence of a neg-
. s) y* r- |: Y  I5 U5 A9 I7 qative initial history of androgen exposure, our0 R5 M- n* l% u. @/ X* f  j' U
biggest concern was virilizing adrenal hyperplasia,, `4 {, b  g8 f" K* d
either 21-hydroxylase deficiency or 11-β hydroxylase
! @  `- ^6 w* P1 cdeficiency. Those diagnoses were excluded by find-9 G2 p2 C+ |3 M4 \
ing the normal level of adrenal steroids.5 V$ n! L" a: j4 G( F
The diagnosis of exogenous androgens was strongly5 E* G8 G& g  R5 D1 b: P% V
suspected in a follow-up visit after 4 months because/ R) k% F. D& a" W' g3 f" t
the physical examination revealed the complete disap-- @, |# N* v) o
pearance of pubic hair, normal growth velocity, and
" w# v4 S5 c" T- W9 w. D5 E, Tdecreased erections. The father admitted using a testos-
$ W& c2 x7 p! U9 |$ t9 S' Uterone gel, which he concealed at first visit. He was4 E% e& X; e4 }6 l! Y
using it rather frequently, twice a day. The Physicians’0 u, d" b" n) Z2 T' }0 X: P
Desk Reference, or package insert of this product, gel or/ ?" ]3 s7 A- I  T/ h+ p( E+ G$ g
cream, cautions about dermal testosterone transfer to
( R' E5 Y; R7 U8 e* o! S8 Cunprotected females through direct skin exposure.
: p0 q* F, s: N* P; a/ [9 }. e& f: iSerum testosterone level was found to be 2 times the
3 T6 n4 F) R' _0 |baseline value in those females who were exposed to
, k, w4 [/ K  K0 ceven 15 minutes of direct skin contact with their male
/ Z$ E9 _  E1 i/ r$ ppartners.6 However, when a shirt covered the applica-
& s: B4 X! n. `. P. gtion site, this testosterone transfer was prevented.5 v8 g3 o% v: d3 }' _1 D3 m
Our patient’s testosterone level was 60 ng/mL,: o8 {2 A4 l8 _% {9 y) a" S
which was clearly high. Some studies suggest that
0 U6 r; E( ]) y) M6 T4 ]dermal conversion of testosterone to dihydrotestos-7 S' h/ p. r& u3 L/ Z( D9 x
terone, which is a more potent metabolite, is more7 W9 M( s9 F' m( f
active in young children exposed to testosterone% M; |# G5 ?5 G; @
exogenously7; however, we did not measure a dihy-; |; i: B% _. e
drotestosterone level in our patient. In addition to3 s& X! v% R& s6 q
virilization, exposure to exogenous testosterone in3 G+ ^1 Y; W$ r& n) `  b
children results in an increase in growth velocity and
3 S' w0 X4 z+ D$ J$ _advanced bone age, as seen in our patient.
( ?* p9 j: c2 |8 TThe long-term effect of androgen exposure during* }5 q; b# j9 s7 d5 A- `. j  z6 a
early childhood on pubertal development and final1 K; ~# k1 R, s
adult height are not fully known and always remain
8 S4 ^8 D0 f4 }! b% x" @* {a concern. Children treated with short-term testos-0 s/ W% E; s( ~. l4 E2 j! c) I- U6 f
terone injection or topical androgen may exhibit some
+ |, F, U0 |: u1 o. M6 bacceleration of the skeletal maturation; however, after- }: P6 J# v8 s/ |) k; D
cessation of treatment, the rate of bone maturation
! X# Y( c& C& H9 tdecelerates and gradually returns to normal.8,9
, R* P$ ?! q0 {9 A5 ~2 iThere are conflicting reports and controversy
: g' X  Y% }3 C- Q, \' vover the effect of early androgen exposure on adult8 W9 k( S1 a7 u& |# }1 l
penile length.10,11 Some reports suggest subnormal
) b- W0 [" S6 Z$ Wadult penile length, apparently because of downreg-7 ^! h: Q: I; {* U$ e. r% ^
ulation of androgen receptor number.10,12 However,
& m9 }' r5 ], F+ }0 W+ s4 k0 PSutherland et al13 did not find a correlation between
! H6 P' r* a- ^, J+ R! ]- q4 d8 Zchildhood testosterone exposure and reduced adult1 ^5 k% A* Y: z: s( ]3 P) D
penile length in clinical studies.2 O$ w% J( a  B  A1 f$ m" q
Nonetheless, we do not believe our patient is
4 b, M# Q3 }6 w( |* Ogoing to experience any of the untoward effects from
1 R6 u* T1 E. Y, d% k* I  Utestosterone exposure as mentioned earlier because! X$ |. M1 [1 m- _; {  z
the exposure was not for a prolonged period of time.
; I6 }) c; j1 x, g3 xAlthough the bone age was advanced at the time of" F( a" ^" r, k  I" }( i8 \
diagnosis, the child had a normal growth velocity at
! E- P' \/ J/ V/ c% rthe follow-up visit. It is hoped that his final adult  G" q3 M% [3 }, k' q1 n* F2 \3 q
height will not be affected.% `# w6 @+ S6 c
Although rarely reported, the widespread avail-
9 X" a& A3 L! {) uability of androgen products in our society may# |2 n! h' e9 V& u  G* o/ e8 q
indeed cause more virilization in male or female) h0 \- T2 {: w9 s
children than one would realize. Exposure to andro-8 }3 E* ?! n) K' g, b4 c
gen products must be considered and specific ques-  u$ F9 Y  ?5 D8 q; h5 W
tioning about the use of a testosterone product or1 e1 p$ X0 M; ^- l3 N: k1 Y
gel should be asked of the family members during
/ ^1 d* V) L- k( S0 |6 \* u% Vthe evaluation of any children who present with vir-
' a  q! i4 g: ?% pilization or peripheral precocious puberty. The diag-4 E3 i9 \7 A  @- f) Y
nosis can be established by just a few tests and by
/ ^9 O/ @3 Z1 t4 vappropriate history. The inability to obtain such a/ N* a& v  S& _$ S
history, or failure to ask the specific questions, may
0 d' J1 r6 @0 g6 sresult in extensive, unnecessary, and expensive
* T5 m' w. c- s. tinvestigation. The primary care physician should be4 _, `: E% Y& \  D, L0 y: K
aware of this fact, because most of these children* g, j! A& a+ g  I, v  E- s. Z
may initially present in their practice. The Physicians’
0 V5 g) ]% o2 d7 B  IDesk Reference and package insert should also put a* ]4 N0 y3 R2 b
warning about the virilizing effect on a male or7 s# ]" S; R  L& B; k( R
female child who might come in contact with some-$ o, F* s6 c! R, B
one using any of these products.
/ ~* e$ A* A7 p1 gReferences3 N0 d4 \$ a+ a5 D% G4 j' ^
1. Styne DM. The testes: disorder of sexual differentiation
, _/ j$ I7 I  Y* w0 land puberty in the male. In: Sperling MA, ed. Pediatric& e! _" r6 L2 Q: {$ ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- C/ q! i" L* ^. I2002: 565-628.
7 H+ Y/ n/ D3 `) Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 T  ^: X( v2 [0 j0 K( k8 b
puberty in children with tumours of the suprasellar pineal
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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
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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
) d( g5 k) V) S5 w' u. e8 [
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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