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Sexual Precocity in a 16-Month-Old# P7 {9 R& ~3 `
Boy Induced by Indirect Topical
! Y, m( i: w& g3 e' pExposure to Testosterone% L  n/ y8 F( S% Q, @. G" b
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 u6 g5 I5 J& O4 I3 `" t8 \and Kenneth R. Rettig, MD1  @& b9 f. S$ k  H' @% ?% ?
Clinical Pediatrics0 I9 Q# \: X* @
Volume 46 Number 6  S. }0 z  P- R/ y) d" A3 M
July 2007 540-5436 z6 ^% m0 E+ u* X; C
© 2007 Sage Publications, u, r5 R, b& c, [. ?* B
10.1177/0009922806296651# o: A6 ?7 k/ M6 X8 F
http://clp.sagepub.com+ \. u+ ]! J  W& @9 N, K+ r
hosted at
4 |# A, y9 f( C) z* Chttp://online.sagepub.com  o+ D" W3 Z( h- n( r- I$ S. e
Precocious puberty in boys, central or peripheral,& w% B: }- n8 x; r; R$ l: y
is a significant concern for physicians. Central
! D2 H( j- v8 Lprecocious puberty (CPP), which is mediated
* Q* u( A7 K8 V, t/ W, ^through the hypothalamic pituitary gonadal axis, has
$ ~% N  e+ M1 S# h( sa higher incidence of organic central nervous system
0 `1 W" ^, h; C5 olesions in boys.1,2 Virilization in boys, as manifested
) r  @: i! F5 Z% \; {. A* p7 Jby enlargement of the penis, development of pubic
) ~6 }! H) Z+ {7 }hair, and facial acne without enlargement of testi-" ]" w3 C, N" S
cles, suggests peripheral or pseudopuberty.1-3 We6 @, \, z4 l6 j4 J3 O
report a 16-month-old boy who presented with the1 s4 w, f$ ]- t& T
enlargement of the phallus and pubic hair develop-
$ ^4 W& O) n3 g+ s% G0 z: I& pment without testicular enlargement, which was due) t' a! M6 D5 \- j# q; Z2 _
to the unintentional exposure to androgen gel used by8 G/ U5 b: ?# i! T0 o* n
the father. The family initially concealed this infor-9 L" F' S; K- f; N, g
mation, resulting in an extensive work-up for this
& ~0 n& b" W4 T6 p6 Z+ l5 R3 wchild. Given the widespread and easy availability of
' u( u2 I/ V; E2 \, C% J5 ]testosterone gel and cream, we believe this is proba-; w+ `# I7 `) P1 {  m2 U6 V+ Z* W
bly more common than the rare case report in the0 v+ Z; f- M  y
literature.4
5 P9 ^9 @* h2 ?' t( v0 [Patient Report/ ~- _$ s$ h, D* w
A 16-month-old white child was referred to the' B$ L% g5 {( O+ {
endocrine clinic by his pediatrician with the concern' t* V5 ^6 s' @5 Z  O- ?
of early sexual development. His mother noticed
8 {; X5 e* m0 j: k; L4 D% qlight colored pubic hair development when he was
3 l- ^0 r1 g, y; u1 LFrom the 1Division of Pediatric Endocrinology, 2University of
! W& A' U) A  j' D2 M, ]& X. }! zSouth Alabama Medical Center, Mobile, Alabama.0 y5 t7 a! _; {5 p4 Q; ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 l" M+ S% {4 U
Professor of Pediatrics, University of South Alabama, College of
( u5 m: _- W: K' l4 x- f0 YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) j% ?- l1 A. m1 r& \+ w
e-mail: [email protected].! ?  J2 [1 u8 j8 P1 I
about 6 to 7 months old, which progressively became
- V# M  e+ A; A" M, z; X2 jdarker. She was also concerned about the enlarge-
- e4 c% {2 D, t5 j* h! Iment of his penis and frequent erections. The child
1 i+ f2 p; N, Q  H0 L# Jwas the product of a full-term normal delivery, with
6 v) w2 O+ i( U) @9 _5 ]' R( E1 w5 Ra birth weight of 7 lb 14 oz, and birth length of
6 H8 _2 [# O, w  z; u. u4 m20 inches. He was breast-fed throughout the first year
* b5 F, L5 R. W$ m$ kof life and was still receiving breast milk along with
2 O. b# p! d" V# Osolid food. He had no hospitalizations or surgery,
- u; v2 \7 ], E4 U) k& kand his psychosocial and psychomotor development
& A# h8 k) y# l9 i, Gwas age appropriate.
  \' |! x# t1 F& YThe family history was remarkable for the father,
! k% U% n- [% v1 Q' s/ c; ~- j& twho was diagnosed with hypothyroidism at age 16,$ Y& I, u  Q7 c, q" [: G
which was treated with thyroxine. The father’s# ], C; b/ |) M; h& D$ t1 d
height was 6 feet, and he went through a somewhat
2 \+ s$ g4 e7 Z/ T" u) Nearly puberty and had stopped growing by age 14.
; f: u$ l8 y) o) `8 PThe father denied taking any other medication. The4 D5 K5 S: g' O" l) z. I7 k: L
child’s mother was in good health. Her menarche
# k/ a; V9 y2 o) H% n: j0 a6 wwas at 11 years of age, and her height was at 5 feet
: j  g" d# H* @- C4 C5 inches. There was no other family history of pre-4 }* C0 N7 u* j) u, o  r
cocious sexual development in the first-degree rela-' {$ i: |4 D$ ~+ i2 b  L- o
tives. There were no siblings.
7 I0 {- j8 S4 YPhysical Examination8 g; ]4 T6 X5 A6 M( D! u
The physical examination revealed a very active,& ]5 D$ h! d! T1 a( p
playful, and healthy boy. The vital signs documented2 h3 H' i" }) n4 _7 O
a blood pressure of 85/50 mm Hg, his length was3 A, s- @9 t; u7 @
90 cm (>97th percentile), and his weight was 14.4 kg- H2 m- Q% N# j) W( `1 ?! @5 ~
(also >97th percentile). The observed yearly growth( y  f: b5 n; U& T* m
velocity was 30 cm (12 inches). The examination of: Q' i2 y, @% _1 D- n
the neck revealed no thyroid enlargement.0 v5 R4 q" K; d- n
The genitourinary examination was remarkable for
: R+ V8 N! M4 q5 g+ Lenlargement of the penis, with a stretched length of/ ^, S( D5 F: ]% Q
8 cm and a width of 2 cm. The glans penis was very well
& N9 I% [! n# p+ tdeveloped. The pubic hair was Tanner II, mostly around) \8 B& Y, ]8 q& Q- o- f# y3 i
540
3 p0 Z7 }* q( yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 j4 Z! p! V- P9 u9 ?+ _the base of the phallus and was dark and curled. The. C  C, a$ ?- d( K; t
testicular volume was prepubertal at 2 mL each.  M( z& M' f- s8 k& H, c. @
The skin was moist and smooth and somewhat; }/ J4 y, r# E+ P& p4 D2 Q
oily. No axillary hair was noted. There were no
7 i; a* f4 Z" P+ T& F) Dabnormal skin pigmentations or café-au-lait spots.# Y. s6 x' k( A; h& R9 q
Neurologic evaluation showed deep tendon reflex 2+
9 y9 ?. d8 b9 Ibilateral and symmetrical. There was no suggestion
' h+ B& d* w! s+ F% u$ ^of papilledema.+ R5 \: ?0 K, @2 \+ ?, h
Laboratory Evaluation
& }3 Z$ D( f! t5 S; `, ]The bone age was consistent with 28 months by1 J9 f/ w. c  B& T
using the standard of Greulich and Pyle at a chrono-  p% v& s1 {- M* f( v7 i
logic age of 16 months (advanced).5 Chromosomal
9 a* ~/ a( S" y- W* e$ nkaryotype was 46XY. The thyroid function test
& M. R$ H5 u. g4 A, zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 I( X/ ^) E& }  Alating hormone level was 1.3 µIU/mL (both normal).
! n  v% Z& _! \* h6 fThe concentrations of serum electrolytes, blood2 y* H9 _4 ?) Q, `
urea nitrogen, creatinine, and calcium all were
8 _1 q' L$ f$ S$ a% ]6 Zwithin normal range for his age. The concentration
# ]6 h1 x# \: j# oof serum 17-hydroxyprogesterone was 16 ng/dL
& ?: @) F3 M; m1 T4 w(normal, 3 to 90 ng/dL), androstenedione was 20
( V3 Q" ~5 s6 G( L  Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" J# a0 n, F4 e0 e" d! k% Iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
  o7 p5 k% P7 C* v% F  L2 rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" c: }1 P- s+ f) I. I9 u
49ng/dL), 11-desoxycortisol (specific compound S)
( {4 u/ L( w+ Y1 q; q9 E) }' s( rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( r* s/ e" R& \4 t, g, t6 S, ]
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& X* i! H' J( }( m8 G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 V1 V: `  I( w* {& aand β-human chorionic gonadotropin was less than
  U0 f; @7 v9 K) v5 mIU/mL (normal <5 mIU/mL). Serum follicular% C- V4 n5 s* |, k
stimulating hormone and leuteinizing hormone
% b* ~0 k$ a+ c* dconcentrations were less than 0.05 mIU/mL4 P' }* a$ j. Y8 p* U/ ]
(prepubertal).
% c9 c  w; N7 I& }4 J- X5 k9 gThe parents were notified about the laboratory5 v3 C+ A1 ?; H0 ^! z: _7 q
results and were informed that all of the tests were7 \5 ]$ K# e( W( s
normal except the testosterone level was high. The
+ }0 ?0 t9 Y+ j3 u' d! e2 G' z$ Pfollow-up visit was arranged within a few weeks to1 ~" w- H, ~" `$ z1 ]: Q
obtain testicular and abdominal sonograms; how-
7 R' g; g& e2 R1 h2 f% N( M) lever, the family did not return for 4 months.( J( ~; s; L6 }2 i
Physical examination at this time revealed that the: a, W9 d9 T' s9 X
child had grown 2.5 cm in 4 months and had gained
$ j- w' @2 N& B* W0 n( g. f2 kg of weight. Physical examination remained+ [! W7 A# a2 S+ N" `$ W( {
unchanged. Surprisingly, the pubic hair almost com-
5 s! k9 W$ a& _; g4 A) N* Opletely disappeared except for a few vellous hairs at; }  d( b3 J7 w7 h% a( J8 c
the base of the phallus. Testicular volume was still 2: x( A! b+ J! k% I+ J
mL, and the size of the penis remained unchanged.
8 D: W: w& V* d/ E9 @The mother also said that the boy was no longer hav-
5 y8 P. z; f, n' f; b" Oing frequent erections.3 g4 M' Z8 m# _+ S& r8 v( z& W
Both parents were again questioned about use of  g0 h& `; A5 H" z# s5 |
any ointment/creams that they may have applied to
: s1 c" R! x8 P% W" K/ xthe child’s skin. This time the father admitted the0 A! G7 f) N  d4 p; D
Topical Testosterone Exposure / Bhowmick et al 541
$ _9 t% _2 u7 Z' R0 fuse of testosterone gel twice daily that he was apply-0 b9 l. ^8 J$ \0 w" P! O4 [& y& L; p
ing over his own shoulders, chest, and back area for
2 `! B0 G; ~. u& F* S2 @6 `a year. The father also revealed he was embarrassed; I- O& ]1 |3 P0 ?* g& P1 T7 Q
to disclose that he was using a testosterone gel pre-
  h+ ], d$ t) I+ }# [$ }scribed by his family physician for decreased libido
1 @+ q* k3 H- F) c" Tsecondary to depression.
2 L% I4 ?& o+ Q- i# ~/ JThe child slept in the same bed with parents.
1 M9 I! x" d, B+ t, e) Z5 w4 iThe father would hug the baby and hold him on his! D! O+ s; z1 \
chest for a considerable period of time, causing sig-
% ]3 C  C2 j) d2 c+ U1 |nificant bare skin contact between baby and father.
: U$ R+ }8 F) U( i* _# ]# HThe father also admitted that after the phone call,' c9 m4 l+ t" N
when he learned the testosterone level in the baby
2 `# y5 q: L; ?6 W5 e" [was high, he then read the product information5 ~* F5 {2 u) m4 ]
packet and concluded that it was most likely the rea-
; u! f9 w. ^  t4 k$ }% l, `, ?' Json for the child’s virilization. At that time, they
" W. }; ~7 ]! q/ fdecided to put the baby in a separate bed, and the
$ j) Y6 C+ T) t/ O1 X6 j) mfather was not hugging him with bare skin and had" B4 {! ?$ e; R. Y5 g/ c
been using protective clothing. A repeat testosterone
! k% H6 {% f: b5 Jtest was ordered, but the family did not go to the
& `- U7 e  S+ O+ O* Mlaboratory to obtain the test.$ u7 p) G. O- y2 B# o' {
Discussion; n/ P* }1 @: {8 ^$ E- S9 [" `
Precocious puberty in boys is defined as secondary
& q) _% D9 r6 h- ^6 x- Zsexual development before 9 years of age.1,4
' W+ R3 V- r+ y1 UPrecocious puberty is termed as central (true) when
+ o; u' e. w! k' Qit is caused by the premature activation of hypo-: {& J, s+ r% {* Q# P, W$ |  J4 f" d
thalamic pituitary gonadal axis. CPP is more com-
" Z$ z# g. Z0 Z% E) H! q' i' Wmon in girls than in boys.1,3 Most boys with CPP" Z: ?/ |' ]/ F/ R2 z& s
may have a central nervous system lesion that is
$ w+ o0 _4 f% l) t7 {4 ]3 G1 U/ I8 ]responsible for the early activation of the hypothal-
! G- O$ a- c& d2 }8 h% A, c" namic pituitary gonadal axis.1-3 Thus, greater empha-8 D7 T( W9 w4 }0 {# y9 m. T
sis has been given to neuroradiologic imaging in
# q7 o0 o2 V3 M8 `boys with precocious puberty. In addition to viril-
( K  i6 Q9 f5 }ization, the clinical hallmark of CPP is the symmet-
- c# D) n  ~, [7 D9 b% Mrical testicular growth secondary to stimulation by- a; \/ A! j% i3 y% L2 L1 }
gonadotropins.1,3
$ v2 X/ O8 L: j5 j) G) mGonadotropin-independent peripheral preco-: @  S3 u" T; r5 G
cious puberty in boys also results from inappropriate5 T. L3 ]" Y5 {& n  u6 o# O5 ]/ l
androgenic stimulation from either endogenous or: j# L, I& C' s: a1 ?
exogenous sources, nonpituitary gonadotropin stim-
$ @; o7 Q. f- n! i/ Hulation, and rare activating mutations.3 Virilizing
. `# n  n: `$ s8 G: D! `congenital adrenal hyperplasia producing excessive
" R: F$ s0 l9 \adrenal androgens is a common cause of precocious
' B* v3 P: N0 F- Zpuberty in boys.3,40 |% Y  W5 \, ]7 N- Y' j
The most common form of congenital adrenal5 q! s) h% b" q1 f& D
hyperplasia is the 21-hydroxylase enzyme deficiency.+ B; i$ H% ?8 y0 a- d9 D; ~; a3 w
The 11-β hydroxylase deficiency may also result in
# j. P# t( x1 c1 m. `excessive adrenal androgen production, and rarely,
' V+ z+ ~8 X4 Han adrenal tumor may also cause adrenal androgen. A: Y8 Z* t! J- N3 A. v7 d
excess.1,31 L1 Z0 e- t: e* }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  S5 [% L  Y* S1 C4 }542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ P% K$ D3 r9 w& \- @7 g
A unique entity of male-limited gonadotropin-. _6 R- u$ c% J8 q
independent precocious puberty, which is also known# Y; C* i, [0 T  h8 ]) B- Q3 F. N7 G
as testotoxicosis, may cause precocious puberty at a
( f- S% f3 r, S1 }. Wvery young age. The physical findings in these boys
% k  `+ Z& C: |6 t) Twith this disorder are full pubertal development,
5 @- j; f& v9 p0 G$ Pincluding bilateral testicular growth, similar to boys" c, m& ?+ k; N8 x
with CPP. The gonadotropin levels in this disorder
$ t: r3 ~( k% Vare suppressed to prepubertal levels and do not show5 k3 T7 ~- {0 n2 C* I9 L& L: o
pubertal response of gonadotropin after gonadotropin-
& p* {% a7 ~# G# |" [# `, T9 Nreleasing hormone stimulation. This is a sex-linked* z; I- Z& E1 d( c2 H
autosomal dominant disorder that affects only
" \9 T6 V8 y+ i9 n( {" k, fmales; therefore, other male members of the family
3 b' D) F- x/ ]# K6 O. O1 O* f8 \% imay have similar precocious puberty.3
+ u4 d9 Z/ Y. v% i. C- vIn our patient, physical examination was incon-
" l5 S7 l4 ?* A# F7 Q3 Esistent with true precocious puberty since his testi-
) A  ^/ j( I- v6 K" w6 o" @: Dcles were prepubertal in size. However, testotoxicosis
$ {  Y/ z- i, h) [was in the differential diagnosis because his father
$ _; h) h) b4 s( Zstarted puberty somewhat early, and occasionally,( w9 l( J% T" [
testicular enlargement is not that evident in the/ y6 v) L* M3 o% `1 _+ w) t3 [( X
beginning of this process.1 In the absence of a neg-
- \( r6 T  i1 K" ?' E$ }- Jative initial history of androgen exposure, our
) [+ P" ?# n  v  Rbiggest concern was virilizing adrenal hyperplasia,
" g& k6 {+ h4 [either 21-hydroxylase deficiency or 11-β hydroxylase
( _' S8 q, s( j8 c/ O- M# Kdeficiency. Those diagnoses were excluded by find-8 m' R* S, {! _7 n4 J
ing the normal level of adrenal steroids.
( T' @; y6 H/ \2 A1 PThe diagnosis of exogenous androgens was strongly2 ^" G0 d) [8 f1 z6 {3 p
suspected in a follow-up visit after 4 months because( x$ I; h% I3 s) E9 j8 s" a
the physical examination revealed the complete disap-
4 \6 G7 N# p! X* M6 S; qpearance of pubic hair, normal growth velocity, and
. D* ]6 m( |/ k' q9 [2 p7 @decreased erections. The father admitted using a testos-
9 c6 g0 {# k) u- Wterone gel, which he concealed at first visit. He was. j9 e; f; d- E8 Y  K
using it rather frequently, twice a day. The Physicians’" ~7 p" Q  F+ ~2 G$ g  T# @9 {
Desk Reference, or package insert of this product, gel or9 f4 h* ?' P. Z2 P
cream, cautions about dermal testosterone transfer to8 q4 ~5 @; P6 y
unprotected females through direct skin exposure.1 E) s8 e: \2 @# s1 m, K  I4 H
Serum testosterone level was found to be 2 times the& V. ^& k$ ^; S9 C# c
baseline value in those females who were exposed to( U3 T; D0 T. Y5 x! Y
even 15 minutes of direct skin contact with their male
7 y0 C+ _# ]3 L: E4 g, a0 |partners.6 However, when a shirt covered the applica-
# s' _; K- T% _( J( }& B9 P0 Ation site, this testosterone transfer was prevented.
) n# W. v5 G6 k7 J6 }9 xOur patient’s testosterone level was 60 ng/mL,6 K5 w; ?- A/ y" a
which was clearly high. Some studies suggest that! t3 B6 e; i  D1 z8 j6 `
dermal conversion of testosterone to dihydrotestos-
0 }' G+ _% N! kterone, which is a more potent metabolite, is more8 |. z& b. ?) N2 ^8 m
active in young children exposed to testosterone
2 @9 g8 m/ q! K& H( cexogenously7; however, we did not measure a dihy-
2 h" S0 N4 E) Z$ O: D" i* Hdrotestosterone level in our patient. In addition to  q& _2 z- a# h- R+ I4 M  [
virilization, exposure to exogenous testosterone in5 j4 V7 J9 f5 X# n* t# M# t
children results in an increase in growth velocity and4 k9 ^7 g$ V/ z" c. A* V1 U% y
advanced bone age, as seen in our patient.( S3 A# c) L) F& \/ m5 H# b6 C1 G
The long-term effect of androgen exposure during# T0 {0 H7 y8 F$ l- m- N) t
early childhood on pubertal development and final
& x& V, x& v( {+ Badult height are not fully known and always remain1 T/ A# ]0 M9 c. P( l+ f# T" J5 e
a concern. Children treated with short-term testos-( N* M8 \+ g  K& V% N% m
terone injection or topical androgen may exhibit some
) r4 G* j: M4 ^4 R7 r1 [3 jacceleration of the skeletal maturation; however, after% R& v/ z/ L4 |) A, x# t
cessation of treatment, the rate of bone maturation
* ]  |/ G! \* _decelerates and gradually returns to normal.8,9/ m7 b1 K; o/ s0 f
There are conflicting reports and controversy
! R  M" N; G2 Q0 U  R( Dover the effect of early androgen exposure on adult( ^" f  c  v; k) N8 _  w' A' _2 G: K
penile length.10,11 Some reports suggest subnormal
0 P5 W' u6 F! qadult penile length, apparently because of downreg-) R# V1 f, q* G) i6 G
ulation of androgen receptor number.10,12 However,
$ o1 ?* f! G8 i2 R6 m, zSutherland et al13 did not find a correlation between1 a0 a+ t* q9 Q7 h% H
childhood testosterone exposure and reduced adult
8 K0 V& t7 r6 b9 f3 g; |6 G" K- tpenile length in clinical studies.
: E5 q# V$ Y5 Y0 ]' P1 v; dNonetheless, we do not believe our patient is; a0 n" k  ]3 @
going to experience any of the untoward effects from
0 w: X$ {. G, Utestosterone exposure as mentioned earlier because
; J, n6 c9 P: L! }the exposure was not for a prolonged period of time.
+ X' |2 z% d) P/ _Although the bone age was advanced at the time of9 @* }0 j7 B  ~. l* u* T
diagnosis, the child had a normal growth velocity at
! A% y: i- q% ^the follow-up visit. It is hoped that his final adult
* y. p6 d7 e& w2 z& zheight will not be affected.
+ g5 n" ^+ ~# L$ @+ PAlthough rarely reported, the widespread avail-0 B- w, S3 [7 v: B
ability of androgen products in our society may. {9 t/ R. c" i; L0 B# s
indeed cause more virilization in male or female
  `, u  U' }% echildren than one would realize. Exposure to andro-
: n, _1 u. T, ?9 n, v) \# |- ]gen products must be considered and specific ques-
9 F# f, d# ]% f& f$ Qtioning about the use of a testosterone product or- ^+ a7 I% x4 F( N
gel should be asked of the family members during6 B' a! W9 s% j- D" F9 `
the evaluation of any children who present with vir-
7 I# ~$ u: r$ C8 b" L1 }. Iilization or peripheral precocious puberty. The diag-: t; I% [3 P) o& @) k: G9 B8 O
nosis can be established by just a few tests and by9 i9 @" C; s# g" p7 K5 N/ F- Y
appropriate history. The inability to obtain such a6 x$ F! ?- G) \# j7 S
history, or failure to ask the specific questions, may
: ^- I/ i  y# j3 Presult in extensive, unnecessary, and expensive
2 c  |1 \- N7 Q' G( r& ^investigation. The primary care physician should be1 _% Y1 {4 T# H) Q" g' Y. F
aware of this fact, because most of these children
  J: J+ \0 r3 {9 g3 N4 Dmay initially present in their practice. The Physicians’
: @9 }% D; J: [6 C% @Desk Reference and package insert should also put a  y& U: U* A- c+ d- t' {9 f
warning about the virilizing effect on a male or
8 O+ p4 o, E. H! W* @& n" [, cfemale child who might come in contact with some-
$ d& u+ Z2 x- ^( D- Z5 wone using any of these products.
/ ^( ^8 R( Q, i' v5 I, F9 v! sReferences
! q) M# g# J- a* P1 a+ |1. Styne DM. The testes: disorder of sexual differentiation% N5 {, ~; T) \% ~9 G% f
and puberty in the male. In: Sperling MA, ed. Pediatric2 {7 T7 k4 Y" Y% _, u; w/ p! U5 l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ q( F7 k! E' P
2002: 565-628.
& W0 M/ `/ Q. N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& C$ R3 ~7 r1 L- [% y/ f
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 B; U* O* ?# n4 I1 k0 G) W. g
Boy Induced by Indirect Topical" x9 ^2 Z& [. R% l( v, j3 s, K
Exposure to Testosterone7 s  M* e- m  g8 a
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. J+ ^6 D# C  @% u% m
and Kenneth R. Rettig, MD1% O, {8 M0 ?; W4 J/ V
Clinical Pediatrics
( i6 [( f  B9 t( |7 UVolume 46 Number 6
' V+ t; {0 B. Z  d4 _7 ~9 L' \5 |July 2007 540-5433 [3 [0 Z& U5 o- b9 U
© 2007 Sage Publications
" `$ |) Z; L7 P0 E10.1177/0009922806296651
- }+ k7 w% |8 D2 }* E+ p$ \http://clp.sagepub.com1 @! f! a$ N8 _" |, r0 W
hosted at
  `; ?2 S8 n; S2 n, c: Shttp://online.sagepub.com5 v8 u0 j- j. }3 T3 j* J% p
Precocious puberty in boys, central or peripheral,8 p. K+ x; {9 H) o
is a significant concern for physicians. Central
- _9 x, z8 B+ W8 hprecocious puberty (CPP), which is mediated
" G( t8 }" l0 w- P* n0 q& ]8 h  Hthrough the hypothalamic pituitary gonadal axis, has
6 ~( M. }# I1 }* I# y' }a higher incidence of organic central nervous system
/ Y; u: L# B/ Z! ?* y% Mlesions in boys.1,2 Virilization in boys, as manifested/ q/ o4 ]! Q& h: p& Q) Q
by enlargement of the penis, development of pubic
! |  `8 c+ Z; w8 j3 Hhair, and facial acne without enlargement of testi-
* @5 i9 B/ c+ y' N& S; ycles, suggests peripheral or pseudopuberty.1-3 We. m$ j, {% K: X5 D$ ^
report a 16-month-old boy who presented with the
4 l8 Q% c/ c# d# n* M, y3 H8 A7 `enlargement of the phallus and pubic hair develop-! }3 r" {/ D  _5 W+ y9 Z$ Q3 w9 K
ment without testicular enlargement, which was due! M% Z* [3 _8 y6 e- k" \
to the unintentional exposure to androgen gel used by! P* z7 j# ?! Y% j& s, T9 Y* ?1 b
the father. The family initially concealed this infor-: i# [+ V9 F$ I* p
mation, resulting in an extensive work-up for this, p/ o6 }& A& w. f
child. Given the widespread and easy availability of
) g* V: N( b% x. E1 _# x% Ctestosterone gel and cream, we believe this is proba-
3 [: G  I+ p. f( |bly more common than the rare case report in the+ J, ~+ n$ A" d: _( w- f& e
literature.4
. J& f) Q% f) k3 ]- X7 b4 GPatient Report- k+ H: ~0 B. v5 ?
A 16-month-old white child was referred to the, ^, E4 J' M; I( l# F; V; D
endocrine clinic by his pediatrician with the concern
- r* [) _+ V9 V. L- U4 C. wof early sexual development. His mother noticed0 m: F* y2 A* c& D
light colored pubic hair development when he was6 r- D' M4 T8 ~3 T2 ~+ w3 |
From the 1Division of Pediatric Endocrinology, 2University of
* K( {: a" U4 F0 JSouth Alabama Medical Center, Mobile, Alabama.7 d3 o* Y) w* V$ D% S. T  u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ h6 D- D2 |2 N+ S# W5 X9 yProfessor of Pediatrics, University of South Alabama, College of
7 u+ b- f7 m  h4 C) u- D$ {1 oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- y" n; F) ?9 g+ F3 U& Me-mail: [email protected].
1 s% x* Y; n6 L1 a: l2 n7 C! z* `5 uabout 6 to 7 months old, which progressively became
& d2 ~7 B8 `& Y4 o% A' ~9 l9 jdarker. She was also concerned about the enlarge-
3 Q7 z! A  Q# T% [9 S2 k: ?+ Y" hment of his penis and frequent erections. The child8 D* a, G% E  v& @3 M9 Y; @
was the product of a full-term normal delivery, with
% w$ V6 u) G- y( {5 n, la birth weight of 7 lb 14 oz, and birth length of
6 ?# y- [% Y$ a) z- I: X20 inches. He was breast-fed throughout the first year
/ [# A' ]. i5 ^: r: [2 J; J* {5 Pof life and was still receiving breast milk along with
: a8 s' s) @1 Esolid food. He had no hospitalizations or surgery,3 L: k* t  D. O3 O+ k
and his psychosocial and psychomotor development
8 Z$ h. z) v3 T0 j  y, w5 O, L# ]! cwas age appropriate.# |6 Y! Y, {) n
The family history was remarkable for the father,, j: X8 B+ |! ~
who was diagnosed with hypothyroidism at age 16,
, S! W) R. @, |8 Kwhich was treated with thyroxine. The father’s* m% [4 F* B# \- i7 x3 B, G
height was 6 feet, and he went through a somewhat; }0 B" b! X9 E: i: R. _0 h
early puberty and had stopped growing by age 14.
+ \" o, g+ ^7 u! C1 u5 i5 I) nThe father denied taking any other medication. The8 x$ ]1 u5 z- k/ o9 {9 n# f
child’s mother was in good health. Her menarche
% }3 q2 s, R3 J- l" f# V2 L' E& pwas at 11 years of age, and her height was at 5 feet3 a3 u/ r1 r% L3 m1 L1 k. o
5 inches. There was no other family history of pre-
! k" j0 j! D  ^9 `+ ccocious sexual development in the first-degree rela-
5 t, L2 b; l2 o6 x: H9 X  |/ W4 n1 P1 Ltives. There were no siblings.. T, G/ f, d0 J; V  \
Physical Examination' @! h) J+ v! K( A- ?3 W. m* ~
The physical examination revealed a very active,
( W0 `, Z( i$ u3 ~2 Q# |/ iplayful, and healthy boy. The vital signs documented
: @, d  i8 d8 M; ha blood pressure of 85/50 mm Hg, his length was  i, z2 D! w7 J* U0 Z6 ^3 E% d( U
90 cm (>97th percentile), and his weight was 14.4 kg% M# F. M# J* M- ~  ^8 z8 {
(also >97th percentile). The observed yearly growth
$ L6 H' E5 r' M; @: b, i; ~+ Ovelocity was 30 cm (12 inches). The examination of
9 e$ D1 ^" e( k& S3 R0 Wthe neck revealed no thyroid enlargement.
% A( j* f4 T: a( _The genitourinary examination was remarkable for. X# t" z1 K: R* S( E
enlargement of the penis, with a stretched length of
0 t8 F) p2 L/ b; e0 S  X8 cm and a width of 2 cm. The glans penis was very well4 U8 _- z$ ?8 T! e1 w1 U4 {' s
developed. The pubic hair was Tanner II, mostly around/ @. ~/ Z* a$ |7 H: u9 U
540
. |& y6 b8 g: m; x  Q# Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 E- O7 E" p+ }( Cthe base of the phallus and was dark and curled. The
& c4 G6 `- Q% C1 J8 E2 Z  T" dtesticular volume was prepubertal at 2 mL each.
* R' u  l- O# F1 XThe skin was moist and smooth and somewhat' f# |, v* `  j( v
oily. No axillary hair was noted. There were no: S0 g( X- G2 N0 j/ l0 }
abnormal skin pigmentations or café-au-lait spots.9 g! {6 T, v4 C' X* U8 ]# I
Neurologic evaluation showed deep tendon reflex 2+7 W: C. g* Z/ o' Z8 x
bilateral and symmetrical. There was no suggestion/ R2 ^6 ?: f; ~9 Y6 d! e
of papilledema.
0 S6 r. n$ f; Z1 _Laboratory Evaluation3 s' J0 Q/ _; `! }+ e: e9 y
The bone age was consistent with 28 months by
3 w+ [4 `  c/ x- S; Musing the standard of Greulich and Pyle at a chrono-
3 i8 f. K9 ~) f+ _logic age of 16 months (advanced).5 Chromosomal- C2 p+ i9 o  K) \
karyotype was 46XY. The thyroid function test# F+ K5 M# f! C4 D7 e; t
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: Z' c% w: f- ?0 U* i. t
lating hormone level was 1.3 µIU/mL (both normal).( s; d$ v8 M, W0 |
The concentrations of serum electrolytes, blood
0 P% y+ H; u, @) _: W8 P* n- Lurea nitrogen, creatinine, and calcium all were' [( F1 E) ~& i. E1 m  ^: d4 l
within normal range for his age. The concentration
5 l  \; o- Y' s0 b6 ~" Oof serum 17-hydroxyprogesterone was 16 ng/dL
( ]! }6 p" i9 [+ j(normal, 3 to 90 ng/dL), androstenedione was 20
5 D) s6 {0 N- o3 d6 B' @! L8 Vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 G* I5 ~8 v; K8 K% g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, e2 v% |, f7 J* R& r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. B# n  ^7 D  h# X* ~% h: g49ng/dL), 11-desoxycortisol (specific compound S)
/ H' x4 m( i9 v9 O. c- vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& o- Q4 d) Z; G* p, O
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) o( Z* k( r8 [* N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: p* N, g# H8 @; j8 ?5 Oand β-human chorionic gonadotropin was less than
/ O& O. |. n1 n0 J6 X' p4 q5 mIU/mL (normal <5 mIU/mL). Serum follicular# }% a9 v  p% x4 A4 x7 ]
stimulating hormone and leuteinizing hormone! X3 g( Q3 X, L% P
concentrations were less than 0.05 mIU/mL
8 }, G3 @! S3 ^3 Z2 K9 K8 y(prepubertal).
5 u' H- r$ i- s! H5 \. L8 }9 ~  CThe parents were notified about the laboratory
4 T% _; |# E" {9 A. yresults and were informed that all of the tests were
6 h' D" G3 D: N9 }3 L6 `normal except the testosterone level was high. The
- e' l3 K. h% j# ^/ \follow-up visit was arranged within a few weeks to1 g4 \$ y- f$ p& J5 @
obtain testicular and abdominal sonograms; how-' q+ x1 q; E! \2 Q. z4 r
ever, the family did not return for 4 months., [0 ~' L3 o! u( X
Physical examination at this time revealed that the
. D; O& f) [' K: g9 h8 t% k: ^child had grown 2.5 cm in 4 months and had gained
! P. y4 P, o9 a2 kg of weight. Physical examination remained
( ]: D1 x0 r& _) U: P/ ounchanged. Surprisingly, the pubic hair almost com-
  t: m, Y* \7 a9 S( u0 x; ^% Ypletely disappeared except for a few vellous hairs at* u9 |3 W& w1 J3 Y
the base of the phallus. Testicular volume was still 2
: F" n' S& y9 G, ymL, and the size of the penis remained unchanged.
# a* Z. K( ?3 bThe mother also said that the boy was no longer hav-
) [3 `# ?' a4 ving frequent erections.
; {; W/ e4 H% w+ JBoth parents were again questioned about use of; ~) ^2 G5 c5 X& @
any ointment/creams that they may have applied to
9 y" P: h1 @8 Q# {the child’s skin. This time the father admitted the
! P8 ^6 Q4 H: ^' J% hTopical Testosterone Exposure / Bhowmick et al 541
2 `8 s8 X$ w9 C& Y% tuse of testosterone gel twice daily that he was apply-! ]( Y- `- t; f# F% `1 ?1 V
ing over his own shoulders, chest, and back area for
# g" b) `5 |: z1 i9 R3 Xa year. The father also revealed he was embarrassed0 Z. F- ?/ u5 b) b. C6 k$ f
to disclose that he was using a testosterone gel pre-
9 e, X: W( R' Q) A, Hscribed by his family physician for decreased libido1 d: Q: K# b' I0 y9 y! ^. w, P2 I
secondary to depression.2 N. [: K8 ~. B, b8 P; f9 l
The child slept in the same bed with parents.
  i7 U2 E/ s% |, YThe father would hug the baby and hold him on his) A  g* x! \5 j: x
chest for a considerable period of time, causing sig-
! o2 r3 X6 t. A! z6 ?3 ?nificant bare skin contact between baby and father.
8 z- c$ Z) x* A( K9 ]+ A2 UThe father also admitted that after the phone call,4 N( |% m! F% p; p( g
when he learned the testosterone level in the baby
% X$ ]4 E; I3 E7 P, k$ Lwas high, he then read the product information* m$ |1 f; Y/ t
packet and concluded that it was most likely the rea-( ]5 w! ^9 h  e, F  P
son for the child’s virilization. At that time, they
7 b7 i1 Q, X1 ~& J/ Odecided to put the baby in a separate bed, and the
5 s& b0 y* Y! a8 L# c1 tfather was not hugging him with bare skin and had% B' e0 F8 k0 R5 z( ~7 \' b
been using protective clothing. A repeat testosterone
6 v, j% [" ]4 f% P; {9 k7 ^: Ttest was ordered, but the family did not go to the
6 c' o. q- \- r9 e! V2 Q+ E+ h$ k( E" Xlaboratory to obtain the test.' ]6 d+ F9 \3 `6 c- Z( T9 D9 T
Discussion2 K/ b7 k  L9 J( ?
Precocious puberty in boys is defined as secondary
3 G. p( a- r9 H% ]sexual development before 9 years of age.1,41 f& |! P& S; ~
Precocious puberty is termed as central (true) when
, L4 L! V/ F% i5 @$ [" a" `; Q- vit is caused by the premature activation of hypo-' J. X7 E& S: \0 c# U% g
thalamic pituitary gonadal axis. CPP is more com-3 R; H7 E& T; `* N4 F
mon in girls than in boys.1,3 Most boys with CPP
; [/ f" ]3 @; f: `may have a central nervous system lesion that is
6 V8 N: y0 ^" f, m0 O: s3 E( V" aresponsible for the early activation of the hypothal-7 P* s/ z- @0 `
amic pituitary gonadal axis.1-3 Thus, greater empha-4 s: `: y! r% S% W
sis has been given to neuroradiologic imaging in
# _8 m9 [( |( Gboys with precocious puberty. In addition to viril-3 v) `5 e1 O' e
ization, the clinical hallmark of CPP is the symmet-
: \+ U& [- m: p) q( hrical testicular growth secondary to stimulation by: K, F) w* r: H3 w% p
gonadotropins.1,3& _3 a; a- b0 c7 N6 m1 B
Gonadotropin-independent peripheral preco-
$ ]9 g! n! c; I4 }/ i( l7 hcious puberty in boys also results from inappropriate( q% L8 w; k* R2 L) E- Q
androgenic stimulation from either endogenous or
* b. L0 O0 D& O  i# K. |5 Texogenous sources, nonpituitary gonadotropin stim-
0 ]* G# s' Z5 G5 I3 c. Bulation, and rare activating mutations.3 Virilizing+ Z8 C  z7 r# `1 b' s$ F
congenital adrenal hyperplasia producing excessive
: ~1 P  t0 l# m: e8 _5 ]adrenal androgens is a common cause of precocious
: H) d  X5 m$ W) r3 ppuberty in boys.3,4. ^- n! F- P! [; h
The most common form of congenital adrenal
3 C  c: _) q6 ~hyperplasia is the 21-hydroxylase enzyme deficiency.
" n2 `& v" e- @2 _( s" ^. SThe 11-β hydroxylase deficiency may also result in$ F. k2 n. y0 k0 b, Y2 j# o
excessive adrenal androgen production, and rarely,
: F- y/ N/ z( {1 D3 a% @9 o& Man adrenal tumor may also cause adrenal androgen
; a8 \; B* r" pexcess.1,31 C  q1 ]1 z7 y# ?! O) U  V) y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) s( E: W' _  T8 |- \6 [, Q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 b. S8 Z4 k9 f' OA unique entity of male-limited gonadotropin-
) Q% i0 f2 |, k+ U3 Findependent precocious puberty, which is also known3 Y' A8 e0 i- W6 A2 g. j
as testotoxicosis, may cause precocious puberty at a) B/ s' K# K9 u6 F- l
very young age. The physical findings in these boys! u# B' ?* I- i) f
with this disorder are full pubertal development,7 G. U0 c0 V; r
including bilateral testicular growth, similar to boys
1 c6 b& u* p3 b, H& J3 ~% q0 uwith CPP. The gonadotropin levels in this disorder/ S9 E3 z$ e  j! i8 {7 f5 M. z
are suppressed to prepubertal levels and do not show
, Z, r# s( {) `! dpubertal response of gonadotropin after gonadotropin-
7 f; i& x+ ?1 n. O3 Treleasing hormone stimulation. This is a sex-linked" N  p; I) S8 o4 |- N" f
autosomal dominant disorder that affects only4 o/ h/ b8 L. @: y9 p; c6 M
males; therefore, other male members of the family2 N9 G% |2 o! {/ M; Y% [
may have similar precocious puberty.3
0 K% U) w7 D6 g) zIn our patient, physical examination was incon-
6 E  l9 H) V/ E; M; Nsistent with true precocious puberty since his testi-# E8 i% `" A6 g/ F8 @
cles were prepubertal in size. However, testotoxicosis/ D1 J9 b6 X& M2 y* |$ b! |7 k; ~
was in the differential diagnosis because his father% d6 t: N2 Q4 b2 a
started puberty somewhat early, and occasionally,
2 l) C6 B2 V8 {) l" ^: Ptesticular enlargement is not that evident in the
% k- Z$ G0 O' a- j4 sbeginning of this process.1 In the absence of a neg-0 W# d4 u; R9 r) r
ative initial history of androgen exposure, our2 S$ I+ ~2 K" \: S" _; ^  R
biggest concern was virilizing adrenal hyperplasia,
) O* g5 P/ B5 P  K" Reither 21-hydroxylase deficiency or 11-β hydroxylase3 b1 x# r9 s! I8 b0 p
deficiency. Those diagnoses were excluded by find-" O* y4 Z+ i/ w/ i/ |
ing the normal level of adrenal steroids.7 B" U1 t# C+ P0 B' j
The diagnosis of exogenous androgens was strongly/ N4 @4 G3 r/ {' Y* V
suspected in a follow-up visit after 4 months because
  @6 ?6 E& T0 `2 u! R9 [9 W" h8 Tthe physical examination revealed the complete disap-
; O2 U6 K# ^% O% e' W& _pearance of pubic hair, normal growth velocity, and6 ^& M) W4 d+ N) Z8 c$ Y+ o
decreased erections. The father admitted using a testos-2 ]2 E7 h$ n4 E3 M; E
terone gel, which he concealed at first visit. He was
! L  I: `. s4 }8 B. Qusing it rather frequently, twice a day. The Physicians’% M, ?3 I7 z- u( \/ |, y
Desk Reference, or package insert of this product, gel or5 [  T, X% K9 Z( ^
cream, cautions about dermal testosterone transfer to8 x% a0 w1 Z8 D$ F  a) T
unprotected females through direct skin exposure.
7 @; c* }$ y! {8 Q& \( x  I- cSerum testosterone level was found to be 2 times the
  O. b. Q: D7 t5 r3 Z# g7 gbaseline value in those females who were exposed to) |4 p' O$ y: C( V) `" o" m
even 15 minutes of direct skin contact with their male
. i# U! \8 y2 H; K5 Npartners.6 However, when a shirt covered the applica-$ v( l3 _$ c8 K% V7 n! i1 i( r6 W8 E
tion site, this testosterone transfer was prevented.' I! F3 y! ]. G
Our patient’s testosterone level was 60 ng/mL,
6 x, i3 s9 K6 w: ^% jwhich was clearly high. Some studies suggest that
! ]7 X7 _, @" b% T) c! Kdermal conversion of testosterone to dihydrotestos-7 ]+ u$ I1 j6 ]9 v  C; b6 p
terone, which is a more potent metabolite, is more
! Z7 _! O! n; |: Q& i( k7 T- G% b: Z$ y$ yactive in young children exposed to testosterone/ i  S: P' S. M# P7 y& ^6 q& S9 m  Q
exogenously7; however, we did not measure a dihy-
0 n" z7 h1 X* L1 P1 z. Zdrotestosterone level in our patient. In addition to
  R# ^$ v4 D% f/ a* V9 b3 T& f- Dvirilization, exposure to exogenous testosterone in4 h$ |+ n1 c; |, Q5 @0 B
children results in an increase in growth velocity and% m8 c6 j8 Y* p  m) G9 u" X3 w
advanced bone age, as seen in our patient.  K2 [5 ]3 a" c& b8 [
The long-term effect of androgen exposure during1 i* D7 n3 t5 G7 [& J
early childhood on pubertal development and final
, D/ [( \8 O8 N5 Z( g# r( padult height are not fully known and always remain
* _# U3 u5 n. X: Y* }. r( Ua concern. Children treated with short-term testos-% Y: Y' @( P. f! c0 u4 A
terone injection or topical androgen may exhibit some
4 `* e& r; I0 x" r( vacceleration of the skeletal maturation; however, after
( r$ y  U' d7 [( F' Gcessation of treatment, the rate of bone maturation" b( b2 g4 t* v! I+ [: m! p  R0 W
decelerates and gradually returns to normal.8,9
6 e% b; \  |8 s# J- Y  dThere are conflicting reports and controversy; O( D5 j  F, Z* T
over the effect of early androgen exposure on adult! t9 v* [  t6 s. ]* ]/ j
penile length.10,11 Some reports suggest subnormal4 `9 k/ S8 _; B; D5 i- [9 s
adult penile length, apparently because of downreg-
5 Y8 z$ K6 r, ^3 ~+ Uulation of androgen receptor number.10,12 However,
& r. E% H5 ]6 `Sutherland et al13 did not find a correlation between
6 H* E$ L6 U1 i* P, E( Ochildhood testosterone exposure and reduced adult( w, O! Q, V  Q8 t$ T8 h" w
penile length in clinical studies.
, x! U# y/ Q$ ]* dNonetheless, we do not believe our patient is5 W8 `0 I5 k5 j6 V$ b1 |( f
going to experience any of the untoward effects from# {  Y. u# \/ X  o0 x/ l# y: }' A
testosterone exposure as mentioned earlier because
, |( ?  Z/ T2 R$ \the exposure was not for a prolonged period of time.
) R0 |# P3 m9 q' b/ V( oAlthough the bone age was advanced at the time of
( i% r8 J  O& adiagnosis, the child had a normal growth velocity at
7 w' j/ Z6 j' @' ?% R% t8 _& xthe follow-up visit. It is hoped that his final adult3 B: P6 H, ?0 J  a8 I1 z
height will not be affected.1 J' a$ M0 y* W% C/ S, ~6 C3 x
Although rarely reported, the widespread avail-
. [; W& D7 t1 j5 W& X( o" }5 wability of androgen products in our society may* y. o& v/ V( M1 {. M  m4 R* P4 Z
indeed cause more virilization in male or female
; f3 D, d. {/ x, [3 c+ z4 `+ Bchildren than one would realize. Exposure to andro-
) b3 {% p$ m# n( g/ ?gen products must be considered and specific ques-
4 L; Q; L+ {+ r6 q8 z3 Ptioning about the use of a testosterone product or; l/ ~. R9 s: M3 Y
gel should be asked of the family members during
6 |, b! g/ y2 P4 B/ m  T# v% D: athe evaluation of any children who present with vir-
7 ~" G' Q0 A1 ]* e- S# O- |& m. Wilization or peripheral precocious puberty. The diag-
' t+ I8 v- A* m: K2 Tnosis can be established by just a few tests and by" w' D2 @$ Z0 ]5 X2 y+ a
appropriate history. The inability to obtain such a4 ]4 p. w2 r5 s% s6 X7 ]9 }
history, or failure to ask the specific questions, may
. S# @/ |, W5 w$ f% z( Q- r/ \result in extensive, unnecessary, and expensive
9 O# I/ O8 H! e7 Q% kinvestigation. The primary care physician should be
" x, ^" k* |& u7 F5 \# Uaware of this fact, because most of these children$ p6 z" l9 O. n8 t% L$ O% I
may initially present in their practice. The Physicians’- k* Y/ E- g( w$ v' q; B' E- y
Desk Reference and package insert should also put a
* m$ B. n* q. q3 ]warning about the virilizing effect on a male or1 W0 U$ x' S+ Y5 a$ E- u6 J8 o
female child who might come in contact with some-2 H4 P# V/ q- F7 G5 f/ V
one using any of these products.
$ ?: M) ~- l+ _  qReferences
# ^: I! P0 q! L" f( K1. Styne DM. The testes: disorder of sexual differentiation: w- b2 W- s* s1 l
and puberty in the male. In: Sperling MA, ed. Pediatric6 `1 E) j. E7 N' V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& t1 h5 N2 w! T; J& Z- H2002: 565-628." o" c2 L" I7 d9 g3 p- ]! _9 T5 D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 H3 J/ g8 `+ |" xpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
0 K7 ^! R2 _, y3 P5 ?
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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