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Sexual Precocity in a 16-Month-Old+ s, k0 Z# W4 Y+ S* U7 B, n
Boy Induced by Indirect Topical  k( r5 Y7 \6 i
Exposure to Testosterone
+ V0 N3 T8 t: B& C7 R  DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 R# H  c' l; V( l
and Kenneth R. Rettig, MD1
; _  @9 K: p( d: y/ aClinical Pediatrics
+ ?' m+ R" d& K; WVolume 46 Number 6
+ X+ T1 d. c) C1 z# LJuly 2007 540-543. O' l; o; W2 R
© 2007 Sage Publications
0 h0 G) U+ B$ B5 J+ s# L( i' f- @# S- u3 P10.1177/00099228062966514 j% i, }4 L  ]& B( d
http://clp.sagepub.com2 m5 M  D9 c1 ?$ a
hosted at4 M' c% q( d4 m3 i# m
http://online.sagepub.com. n0 ^- M. L' A" _6 r
Precocious puberty in boys, central or peripheral,# l+ P$ u" E3 j; Z( i
is a significant concern for physicians. Central; K9 X. c# x3 a, q8 x& f9 F4 L
precocious puberty (CPP), which is mediated
. b8 @1 R! U( b# y* h* G' E2 L  ythrough the hypothalamic pituitary gonadal axis, has
2 \9 I' B7 R0 q7 u7 H/ Oa higher incidence of organic central nervous system- y: `5 ~2 c$ B
lesions in boys.1,2 Virilization in boys, as manifested; c4 q: O6 a4 u; N: v+ p8 a
by enlargement of the penis, development of pubic/ V; ?2 I. X; T3 R
hair, and facial acne without enlargement of testi-
  o" v1 q) x* Dcles, suggests peripheral or pseudopuberty.1-3 We
* _) R4 l* N9 R& d5 d# G/ ?. ^# p# greport a 16-month-old boy who presented with the
9 R; x3 R* W( ?& w: I4 henlargement of the phallus and pubic hair develop-
" s* c1 V: w$ z; T! Yment without testicular enlargement, which was due- D7 s* y; _3 c, T* M2 y$ Z
to the unintentional exposure to androgen gel used by
  d. J& o3 ^& d8 O- \* Dthe father. The family initially concealed this infor-
# n; z: `  k7 C! r& k+ m! Hmation, resulting in an extensive work-up for this
6 f$ y# ?# h# k& w$ schild. Given the widespread and easy availability of
- c& X; s. Y7 ~, ?% `testosterone gel and cream, we believe this is proba-
' _3 H9 t" ?! ?4 x$ L/ }6 jbly more common than the rare case report in the
' t, f; k' ~  Qliterature.4
2 @  ~6 `  A9 Z, v) W; e3 u2 h. ~1 u- h" ?Patient Report+ o3 b2 `  K1 W, n$ C, X2 b
A 16-month-old white child was referred to the
8 f$ c1 @3 r5 {2 a1 q% f6 @7 ~1 Eendocrine clinic by his pediatrician with the concern
. {! t' s3 Q* Y4 r9 m2 D1 D3 z7 |of early sexual development. His mother noticed* G. M+ u7 h6 q) G4 ?# j4 e8 i
light colored pubic hair development when he was
# _/ f8 P1 Z. X$ QFrom the 1Division of Pediatric Endocrinology, 2University of
" U$ I/ ]( _. @/ t" L" T! rSouth Alabama Medical Center, Mobile, Alabama.
$ j, Y* j# k( x' E) i( QAddress correspondence to: Samar K. Bhowmick, MD, FACE,; H* Y  a4 b/ [. |( v& @* @7 Q: L' T$ a! r
Professor of Pediatrics, University of South Alabama, College of* o* j% `0 z3 ~) n5 i0 c( x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- q; j$ q/ T9 C+ H1 ze-mail: [email protected].
$ G) K6 L/ a: Fabout 6 to 7 months old, which progressively became
- u! X. [5 w3 ~8 N- w" o: pdarker. She was also concerned about the enlarge-2 n8 I0 y5 o7 F" z5 Y: K. }& u
ment of his penis and frequent erections. The child
% W1 u  R; @; K8 [6 s2 D) zwas the product of a full-term normal delivery, with4 b2 X  S3 P% L5 T' j
a birth weight of 7 lb 14 oz, and birth length of
# `# r0 s& C- t/ L20 inches. He was breast-fed throughout the first year; Z% N% B! Y7 Q/ {) @( P+ u7 b! L7 O
of life and was still receiving breast milk along with
0 H; Q3 \7 x- Z0 Q! n5 z1 D3 O9 @8 [solid food. He had no hospitalizations or surgery,
/ y% ?3 q2 `4 M" u; Y3 ^) Dand his psychosocial and psychomotor development
2 v$ T5 U  o4 j9 z* b# F, a1 S8 gwas age appropriate.
6 G/ Q7 R- P8 u: S7 b7 VThe family history was remarkable for the father,! i# B6 u: s/ p4 ?& U
who was diagnosed with hypothyroidism at age 16,
# J# i. K  d" i2 O  ewhich was treated with thyroxine. The father’s
- L% H. b9 m! `height was 6 feet, and he went through a somewhat% {9 n5 P' F! @8 J9 r1 z4 q0 S
early puberty and had stopped growing by age 14.
7 e* z6 W, q* S1 [The father denied taking any other medication. The
7 Z" u3 b5 C! r2 e9 w0 Achild’s mother was in good health. Her menarche
" }4 ^7 w8 B$ ^) k8 lwas at 11 years of age, and her height was at 5 feet
* C) b& a! C5 a' o7 z" Q& R0 w5 inches. There was no other family history of pre-
8 J& D" p1 g1 ]. U2 bcocious sexual development in the first-degree rela-/ T8 U4 j- ~- E+ ], Y/ u
tives. There were no siblings.* ^9 w  q& @0 s* P6 T
Physical Examination( ^% B( C- X( N+ G
The physical examination revealed a very active,! A0 n4 ^* `, m! I6 x6 `
playful, and healthy boy. The vital signs documented
% Z; X0 U4 v3 b& ga blood pressure of 85/50 mm Hg, his length was5 ^6 G' k* N8 ]- A
90 cm (>97th percentile), and his weight was 14.4 kg/ w$ @8 z! H+ k) \$ ]- ?8 t
(also >97th percentile). The observed yearly growth
. J7 \8 D. Y6 z( g- M3 W& Nvelocity was 30 cm (12 inches). The examination of
. C) T8 M+ H$ r3 \9 Fthe neck revealed no thyroid enlargement.
/ N+ B, [. Q* @' EThe genitourinary examination was remarkable for
9 g: z1 X- C. b& K, f$ S: benlargement of the penis, with a stretched length of% ]4 v3 Z' ^& ^$ S3 F: S4 [+ l
8 cm and a width of 2 cm. The glans penis was very well
: W, Q) h- g  Z( y" D. |1 ndeveloped. The pubic hair was Tanner II, mostly around4 W" L; Q' J  H) K: _( D
540: @$ c0 ]3 v* ^& V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 K$ G" M, f. i0 d3 R8 Y
the base of the phallus and was dark and curled. The/ {+ O5 }# s* `) S/ K4 Z' e- ]. C$ C
testicular volume was prepubertal at 2 mL each.* G# h" o8 |# v! y+ V
The skin was moist and smooth and somewhat
5 X# O8 B% ^( k! W# d. coily. No axillary hair was noted. There were no
' [' K5 g; ^# B2 Z5 Vabnormal skin pigmentations or café-au-lait spots.
) ?' K' B2 s  G8 \2 O3 A  |7 v( ]Neurologic evaluation showed deep tendon reflex 2+' K' L" {" s8 M! k
bilateral and symmetrical. There was no suggestion# L5 h% K$ v2 O. E. I: Y/ j9 P
of papilledema.3 j1 Z: N1 A9 y+ _$ j. \) E
Laboratory Evaluation3 Z2 o$ S. y7 J% _2 r6 O
The bone age was consistent with 28 months by8 V3 C2 u# {& F4 V% Y
using the standard of Greulich and Pyle at a chrono-
/ m  Q+ \1 y( x4 n+ J: A! h( Tlogic age of 16 months (advanced).5 Chromosomal
6 J9 v5 j1 }2 w3 [% G  W, jkaryotype was 46XY. The thyroid function test
$ ~: c7 j( j# T8 r1 Pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 f( k( I4 F3 ?, L3 Slating hormone level was 1.3 µIU/mL (both normal).  Q0 F/ F  z* f( I
The concentrations of serum electrolytes, blood
2 u% M$ o" t. {, e( F# K. c, Yurea nitrogen, creatinine, and calcium all were
4 m+ u, E0 m) Cwithin normal range for his age. The concentration& {0 ^* i! A0 G. N
of serum 17-hydroxyprogesterone was 16 ng/dL
1 B9 ~% d& i( l* r(normal, 3 to 90 ng/dL), androstenedione was 20
5 C* G/ T; |! O. q" m8 sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 _- m% W5 S% v4 D$ ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) t6 J# X) d5 a' B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ ?6 [# ]% G* y. k2 ^) h9 g; H
49ng/dL), 11-desoxycortisol (specific compound S)
( M) z' q9 N/ gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* H& Q; O6 k1 o$ Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* Y2 k9 A: e6 d1 U, u1 H) e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% V$ l8 u) X$ d: dand β-human chorionic gonadotropin was less than; R9 Q8 l' E: \1 |3 X# W# B; W: B
5 mIU/mL (normal <5 mIU/mL). Serum follicular2 [" J8 P3 U0 O' J7 y
stimulating hormone and leuteinizing hormone
, p2 ~' u: H& j9 X. B5 }+ econcentrations were less than 0.05 mIU/mL. k( V8 X( l' `4 P  _  {
(prepubertal).. I, f) B( h/ p+ e- Z- c
The parents were notified about the laboratory
" ^0 j/ S' V( S0 V& E& U" o2 gresults and were informed that all of the tests were5 x1 \3 f5 C. r- e' X
normal except the testosterone level was high. The' e( u/ G6 ?3 X! h6 }. E) |
follow-up visit was arranged within a few weeks to+ i1 N: E2 G! z- T6 H
obtain testicular and abdominal sonograms; how-$ z3 ]5 q$ D0 w7 f
ever, the family did not return for 4 months.9 b: f# M/ S! D% F$ W) a& s+ l; b2 ]
Physical examination at this time revealed that the
6 j7 _, {& F' y1 \8 p8 _# Jchild had grown 2.5 cm in 4 months and had gained
2 v5 ]0 M) I2 |  f4 D2 kg of weight. Physical examination remained% J' `" P( m0 Y! T+ D6 M$ l
unchanged. Surprisingly, the pubic hair almost com-9 n2 k: v- g; p
pletely disappeared except for a few vellous hairs at) y6 t' B4 P0 b
the base of the phallus. Testicular volume was still 29 o7 t# S9 {0 u2 k
mL, and the size of the penis remained unchanged.
& u, B. d' z) C9 J1 |( @; L" q1 U& `The mother also said that the boy was no longer hav-# c8 U* a9 P2 M
ing frequent erections.
% ^7 f; V" X# M. z2 x' ^7 a& MBoth parents were again questioned about use of
% b2 N$ `5 R: z' lany ointment/creams that they may have applied to/ o9 ^2 Q1 ^0 f9 ?" a
the child’s skin. This time the father admitted the
& @, t5 o1 i4 ?0 y5 Y9 iTopical Testosterone Exposure / Bhowmick et al 541
* S7 V; ^/ j' |% @0 A9 |0 huse of testosterone gel twice daily that he was apply-, I) b9 S7 I9 d% w0 l, t
ing over his own shoulders, chest, and back area for
, I8 Z5 x& |8 _( |- pa year. The father also revealed he was embarrassed5 m9 f! H, w2 @* I
to disclose that he was using a testosterone gel pre-
: C1 K; w: G' }/ R* escribed by his family physician for decreased libido
; n  |! O/ z; v6 ^! R* tsecondary to depression.7 |1 x$ Z0 a( z: u/ B8 T2 d# L
The child slept in the same bed with parents.
! t- ~1 r( b3 q$ o6 H. ^! oThe father would hug the baby and hold him on his
8 P# B% |2 _1 e6 O! A: w& L* C% rchest for a considerable period of time, causing sig-
8 T* D- B4 Y7 E) j4 g$ h/ Rnificant bare skin contact between baby and father.
9 h* y$ o9 c5 `) p9 W6 m! S% hThe father also admitted that after the phone call,
# _9 U4 s' t. R+ Dwhen he learned the testosterone level in the baby
' w1 {3 ~+ o. Q; }was high, he then read the product information* N) M3 ~) F0 o
packet and concluded that it was most likely the rea-
+ i! L" u1 G( S/ p" j) vson for the child’s virilization. At that time, they
4 Q4 \4 H2 J+ z, Q) x, Rdecided to put the baby in a separate bed, and the
, j1 ?, E& E% O2 ufather was not hugging him with bare skin and had
- \# r9 ?" n* C6 I+ P: ~2 ~been using protective clothing. A repeat testosterone
6 x: B* X9 m" k: Ttest was ordered, but the family did not go to the6 T0 f. x! ]; m; ~# c
laboratory to obtain the test.
9 C; L: y5 F& a; ^/ V9 g; cDiscussion2 f% q" `: j, o4 A# E
Precocious puberty in boys is defined as secondary0 K6 b+ \& Q3 S- D, L
sexual development before 9 years of age.1,45 H9 z& U# H- o0 i+ o
Precocious puberty is termed as central (true) when* g# _' E' P$ W  ~* x
it is caused by the premature activation of hypo-
: Z4 p7 E" \& o/ Q, f2 Uthalamic pituitary gonadal axis. CPP is more com-
* l* K( ^3 K) E) O- Y( wmon in girls than in boys.1,3 Most boys with CPP) D( ~% N0 m2 Q( \7 F0 A" h
may have a central nervous system lesion that is1 ~$ j" S% J/ s! ?& b
responsible for the early activation of the hypothal-) b" J" M1 z4 B7 J3 i0 y: N5 T
amic pituitary gonadal axis.1-3 Thus, greater empha-4 @7 R; Z: j4 X( z! \& Z: F+ S% x
sis has been given to neuroradiologic imaging in
1 M! f) ?" S+ `boys with precocious puberty. In addition to viril-& \/ ]4 F8 w" |$ O8 d. b- |
ization, the clinical hallmark of CPP is the symmet-  U. d' R# O" y, C7 m0 r
rical testicular growth secondary to stimulation by
. D% l& i% `3 b/ u! t, I8 F  wgonadotropins.1,3% @3 c& Q! Q6 V4 x$ H7 Y5 z. r
Gonadotropin-independent peripheral preco-
; c1 T% I. r4 ~" zcious puberty in boys also results from inappropriate
3 t# y) G3 `: C; h  n: m7 [androgenic stimulation from either endogenous or# e* P$ c& p4 n* U, \2 ~# a
exogenous sources, nonpituitary gonadotropin stim-
3 E1 t* c! `3 w+ `ulation, and rare activating mutations.3 Virilizing
1 j( T! a  ^3 {congenital adrenal hyperplasia producing excessive  D+ d6 S+ ]( G& R0 L/ q7 n* k
adrenal androgens is a common cause of precocious
$ c3 ]4 E7 z8 v# Hpuberty in boys.3,4( b1 j0 P0 j* l& V. _" F
The most common form of congenital adrenal
- w+ ]5 O* Y5 f) K* B, Xhyperplasia is the 21-hydroxylase enzyme deficiency.
6 f5 @. A2 J# r& a7 U9 CThe 11-β hydroxylase deficiency may also result in
" _7 Z- b- R: o' h% R7 Pexcessive adrenal androgen production, and rarely,2 t3 K8 P* b7 W0 i
an adrenal tumor may also cause adrenal androgen, w/ Z- I2 g& v4 z5 ?2 M
excess.1,3
& R9 E' k( {: g: h# G. {. ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, c8 Q& }  {2 v, m: {
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 U7 Y; y0 F+ ^7 {* t0 w6 B
A unique entity of male-limited gonadotropin-
7 v9 E+ l: J8 X5 L2 ~independent precocious puberty, which is also known
4 E% v9 X' h% f) fas testotoxicosis, may cause precocious puberty at a5 @, u& s, c; J! I
very young age. The physical findings in these boys
0 f6 D8 O$ \7 ^+ b( lwith this disorder are full pubertal development,
/ s& d6 c0 D' `  {' B' @2 X8 Dincluding bilateral testicular growth, similar to boys
3 ]8 _5 l8 C* c5 m1 E3 Qwith CPP. The gonadotropin levels in this disorder
7 ^6 L+ f4 ~3 `0 D. Q9 Bare suppressed to prepubertal levels and do not show
, g9 ~- s; M' t: ^+ ?+ opubertal response of gonadotropin after gonadotropin-
# e/ Q% Z0 m' a! N4 }$ `; Wreleasing hormone stimulation. This is a sex-linked# N+ `& o$ \" [$ {, x# q
autosomal dominant disorder that affects only
, C8 F& f5 i, @& s5 o- f8 fmales; therefore, other male members of the family2 [$ g) F7 }- y/ N5 b0 \! ^
may have similar precocious puberty.3
0 v+ t& B! f' r* w$ I6 \In our patient, physical examination was incon-9 {$ O; z; P6 y+ B
sistent with true precocious puberty since his testi-  F- m$ G' O+ m  Z+ Y7 M4 q1 T/ }
cles were prepubertal in size. However, testotoxicosis% t% I6 u8 e# ?" F' o7 c# Y/ K
was in the differential diagnosis because his father
( M2 q/ O3 n: P4 Mstarted puberty somewhat early, and occasionally,6 u5 C& g& J6 p/ r2 v3 U5 H) {# f  x
testicular enlargement is not that evident in the' h, Q1 T4 p6 K$ S
beginning of this process.1 In the absence of a neg-
3 v) r$ n. Z, R; d' Zative initial history of androgen exposure, our4 h+ `8 O- W1 i; v4 N7 d
biggest concern was virilizing adrenal hyperplasia,
4 F" l0 E" Z7 B: Ceither 21-hydroxylase deficiency or 11-β hydroxylase) P' P/ s( @  J
deficiency. Those diagnoses were excluded by find-5 e( @; L  a: ^5 d+ O" k3 T, v# L: P
ing the normal level of adrenal steroids.+ J' \% ]8 I, P. \
The diagnosis of exogenous androgens was strongly- f  ^/ @+ X" I
suspected in a follow-up visit after 4 months because
8 F: J: v8 i! y$ C0 B& J* hthe physical examination revealed the complete disap-
# o  w( l  y5 t) P" _pearance of pubic hair, normal growth velocity, and
) W6 F! C& s( C4 m9 n7 Ndecreased erections. The father admitted using a testos-
. P2 O2 ^' @3 q+ ~! `# k# m5 U! hterone gel, which he concealed at first visit. He was  W% U% ?4 ^9 }/ |
using it rather frequently, twice a day. The Physicians’
9 v5 J/ `3 _3 M; P; ?/ z" QDesk Reference, or package insert of this product, gel or
/ s* s: v' V8 I* [" d. icream, cautions about dermal testosterone transfer to
- D! ?; a) x0 ^% z2 s2 \# munprotected females through direct skin exposure.
0 J2 p/ z6 `5 c( W& A; S# ^8 Q$ aSerum testosterone level was found to be 2 times the
4 a* n. j! X5 x% Pbaseline value in those females who were exposed to0 s) l/ Z+ ^2 r' f  b0 f: T
even 15 minutes of direct skin contact with their male% F  Q# w, _! l! B
partners.6 However, when a shirt covered the applica-" d3 L) T3 x+ ?, V
tion site, this testosterone transfer was prevented.& U  N. ]5 d7 s7 Q; |, P; ^" w
Our patient’s testosterone level was 60 ng/mL,
* P5 Y2 i$ N5 o0 |which was clearly high. Some studies suggest that
( Z2 T3 ^9 W7 Vdermal conversion of testosterone to dihydrotestos-
! f- F8 [, p) b3 w4 dterone, which is a more potent metabolite, is more3 ~2 c; Y" A0 _3 }
active in young children exposed to testosterone
9 j5 y- n3 P# I: G2 ^exogenously7; however, we did not measure a dihy-
( h7 I$ b( Y. J& b  `- Cdrotestosterone level in our patient. In addition to( Z6 j& u: K6 l8 w
virilization, exposure to exogenous testosterone in, A2 n  P- ?: y+ Z. L
children results in an increase in growth velocity and
/ ?; P. C! K& P+ |( s0 n5 radvanced bone age, as seen in our patient.* g6 A4 H! {0 F: @7 t2 ?& y
The long-term effect of androgen exposure during
$ m3 T/ @' G) Vearly childhood on pubertal development and final7 [3 Z0 R+ t, i2 r; R- ~; r4 J- N
adult height are not fully known and always remain
$ W. C/ J* @7 I9 e0 ~* t3 ?: fa concern. Children treated with short-term testos-
0 ~, I5 S0 ~6 E! o( ]; G8 Vterone injection or topical androgen may exhibit some+ o7 ~0 z8 d9 Z+ H
acceleration of the skeletal maturation; however, after- |' A0 a: A  n2 l2 a3 E4 q
cessation of treatment, the rate of bone maturation4 I) A& L: v1 g' c' g
decelerates and gradually returns to normal.8,9
$ }7 i, c; k. I1 cThere are conflicting reports and controversy
: i* u% t" E9 l6 Mover the effect of early androgen exposure on adult
$ u3 O6 s5 t8 _4 l0 d' Ipenile length.10,11 Some reports suggest subnormal* E" X1 H/ p5 M- r5 u$ ?! {3 \
adult penile length, apparently because of downreg-
( K/ n. h" x2 K& A0 rulation of androgen receptor number.10,12 However,
/ v% Z* v- T/ t( G( B( FSutherland et al13 did not find a correlation between' U! a$ f8 }" j1 G. ~  b: A6 t+ l
childhood testosterone exposure and reduced adult& E' a# @, {, k  m
penile length in clinical studies.
- }' _- z! Z' \2 d! NNonetheless, we do not believe our patient is
8 I: M3 @; E/ {5 t9 h3 mgoing to experience any of the untoward effects from9 ]" M; S  q7 [) e5 H2 ?" G
testosterone exposure as mentioned earlier because
- O" @3 h" W; Qthe exposure was not for a prolonged period of time.
' r9 M9 T+ O( i" C5 S' EAlthough the bone age was advanced at the time of
% }5 z! r0 K5 d" w) Idiagnosis, the child had a normal growth velocity at
# Y8 c2 Z$ Q/ ?2 }( ]" D0 B, z. Z2 B5 _the follow-up visit. It is hoped that his final adult) p) U( y; K" C( c
height will not be affected.
3 u( j0 A8 k, u- V3 c" _Although rarely reported, the widespread avail-7 v' }: h% o# h$ D* ~
ability of androgen products in our society may% C. C1 m8 j4 V* ?! M" ?, c! U
indeed cause more virilization in male or female
- A4 i1 D- q4 }! ]children than one would realize. Exposure to andro-' t/ c) j2 E% `' r0 B6 n' y) U0 i9 i
gen products must be considered and specific ques-
7 e. W' W5 n2 Otioning about the use of a testosterone product or
4 X" r1 l) S  {. V+ [" _) C; Qgel should be asked of the family members during3 e) V! b$ D) a! A6 i& G4 A9 s  |
the evaluation of any children who present with vir-; ?9 h# a) R$ F
ilization or peripheral precocious puberty. The diag-, [* h1 _# g' [. ^
nosis can be established by just a few tests and by
/ _5 {! x! l! B+ ~# u) n/ ^appropriate history. The inability to obtain such a
% `% l' `# h3 H4 q  [8 Vhistory, or failure to ask the specific questions, may0 y6 ]: }  N; f- y8 }
result in extensive, unnecessary, and expensive) r9 d- X- r1 o5 {2 F2 q
investigation. The primary care physician should be: w4 H' [# g2 h/ g! a1 E' B
aware of this fact, because most of these children: r8 U' A8 ^" A
may initially present in their practice. The Physicians’
1 I+ z1 j: {2 d; lDesk Reference and package insert should also put a
, i- ~! J  T) l7 ]* d3 `( bwarning about the virilizing effect on a male or
. ~5 S  H: D, Q, Z9 v; Ffemale child who might come in contact with some-( q1 q% Y7 h* R7 D- [: k
one using any of these products.5 U$ v9 A  e6 }& ~. D& p
References% H/ T' g1 U- I' T/ Q
1. Styne DM. The testes: disorder of sexual differentiation
6 ^" J" w2 T) Vand puberty in the male. In: Sperling MA, ed. Pediatric& j# f, H( A7 r5 @+ ?& @5 c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* m# Y/ j% v0 }+ s; [% {
2002: 565-628.- {; G6 J% A3 x2 Q5 V# N2 |1 W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 f# Y. {. \  n4 V
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old" k# i; f1 I" I* c
Boy Induced by Indirect Topical7 I5 p* L# `: ~1 c+ ]
Exposure to Testosterone
6 O- D) y6 `3 r. Y% iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# g3 ]  w( F6 s) G: v  Sand Kenneth R. Rettig, MD18 c! g1 ?  R4 W! R( V: z
Clinical Pediatrics
5 u/ `/ P9 x: Q, n+ W1 kVolume 46 Number 62 q: ]2 a5 S: T7 ?
July 2007 540-543& f! S! p+ g" }- b: }
© 2007 Sage Publications
& B+ p$ r8 e+ V1 f8 V& q7 j0 I10.1177/0009922806296651' D/ ~# f( b+ ^0 \0 @
http://clp.sagepub.com( A& N5 U# g% U
hosted at7 v" F, S: V1 J( P; J
http://online.sagepub.com
1 D# ~. u! k0 Q, E: sPrecocious puberty in boys, central or peripheral,9 S2 {  F6 e! M- g7 f! u
is a significant concern for physicians. Central  [# X# g  i0 K: N: c8 ~: v1 A/ k
precocious puberty (CPP), which is mediated& W( G" X4 Y3 C9 G; k% N5 V
through the hypothalamic pituitary gonadal axis, has
& T9 ^( t+ q4 G" v2 za higher incidence of organic central nervous system
! ?1 b! b2 o* b8 f# Dlesions in boys.1,2 Virilization in boys, as manifested
# R: q+ J$ O( T& K# p5 Gby enlargement of the penis, development of pubic+ a5 x' H' j3 x$ N0 [% U
hair, and facial acne without enlargement of testi-
* z( q5 r9 N, @" l1 ?cles, suggests peripheral or pseudopuberty.1-3 We
) j% s7 [( p' L- sreport a 16-month-old boy who presented with the' K. ~. r8 a( W5 O, H2 h$ ?
enlargement of the phallus and pubic hair develop-1 G! b* b8 v8 ~$ G0 A
ment without testicular enlargement, which was due  R7 C6 R7 B9 H2 ^) c
to the unintentional exposure to androgen gel used by
- z5 _( J  A4 z. y) o) Pthe father. The family initially concealed this infor-+ u5 P7 S5 i- U2 ?2 S  Z
mation, resulting in an extensive work-up for this% F. u8 @/ K7 E) C  Z! L' o0 b
child. Given the widespread and easy availability of
3 K7 `+ \( l) S8 z. b+ etestosterone gel and cream, we believe this is proba-
6 J# u$ n" {5 I7 X! ebly more common than the rare case report in the* U: q; ]6 ?, r7 i
literature.4
3 x/ a# c; s/ S* @Patient Report* t7 r# T9 f3 M; A/ ~* r% e% q
A 16-month-old white child was referred to the
' Y2 K- m2 D8 X7 W/ E$ s) N1 Hendocrine clinic by his pediatrician with the concern
* S  `" h4 B! e- l7 [: f; r3 [7 Gof early sexual development. His mother noticed
, k0 S% G0 H) J* l" }* elight colored pubic hair development when he was. b; V* q* [) I' G# k; ~1 ?
From the 1Division of Pediatric Endocrinology, 2University of
/ r  P3 |7 H3 M  S3 KSouth Alabama Medical Center, Mobile, Alabama.: r. z! [% E  f1 O
Address correspondence to: Samar K. Bhowmick, MD, FACE,# H- Z" X; b- {' W2 r
Professor of Pediatrics, University of South Alabama, College of, f# O! W6 j8 k6 A
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; D8 ^, J: p: i* v8 R
e-mail: [email protected].
+ C$ K! ?5 C- j8 R9 s+ ~' Dabout 6 to 7 months old, which progressively became- K$ ~) \: C' ^, w
darker. She was also concerned about the enlarge-
4 g1 M; L# o3 [" M' d& xment of his penis and frequent erections. The child
- o. a$ H' n/ X8 H- xwas the product of a full-term normal delivery, with9 K' A' G' B) W7 n. e
a birth weight of 7 lb 14 oz, and birth length of9 k& z/ Q5 Q6 J
20 inches. He was breast-fed throughout the first year
7 [/ T$ S1 o$ D: C/ }: D+ bof life and was still receiving breast milk along with" \1 t& r1 [4 t% J3 @; a3 c6 D
solid food. He had no hospitalizations or surgery,9 N1 `; T$ N) Z" C( c
and his psychosocial and psychomotor development
8 J2 n& W" d# w* F" k) jwas age appropriate., D4 a5 |3 J# I1 i( O
The family history was remarkable for the father," ~/ {2 k+ |5 a. `7 s5 u
who was diagnosed with hypothyroidism at age 16,  W9 F4 W2 W' P) R( r) _2 Z! g9 G
which was treated with thyroxine. The father’s
4 S$ \- M: Z( o4 l/ bheight was 6 feet, and he went through a somewhat( W+ b8 a# Z/ e, j" d% k. T- i
early puberty and had stopped growing by age 14., w  g% e2 w' D6 G) W8 ^
The father denied taking any other medication. The
5 p/ H, m" c9 Q+ S9 \1 {child’s mother was in good health. Her menarche
8 m9 b0 y/ T  a* e: ]9 m! t$ j- }was at 11 years of age, and her height was at 5 feet
7 J& b1 {1 f9 ?8 [5 inches. There was no other family history of pre-6 A- l; \. d# |' _( \
cocious sexual development in the first-degree rela-9 K2 p* U2 x( P* o: R+ L
tives. There were no siblings.  M6 J: ^- x* k+ V0 h
Physical Examination5 Q0 ~0 y) [+ P3 L
The physical examination revealed a very active,- A; a8 N- c* z3 w7 c- Q
playful, and healthy boy. The vital signs documented( t8 l& l: j# S6 ]8 M3 f
a blood pressure of 85/50 mm Hg, his length was: L9 y" ~+ X3 g
90 cm (>97th percentile), and his weight was 14.4 kg3 Q: R" B5 W$ f2 p( [' y
(also >97th percentile). The observed yearly growth8 i2 ~6 I# o$ j: Z
velocity was 30 cm (12 inches). The examination of0 G1 S; t# a5 @% A  h
the neck revealed no thyroid enlargement.
) A* b* f* @% LThe genitourinary examination was remarkable for
' y$ g' a# O+ f4 y* Genlargement of the penis, with a stretched length of/ w8 I4 V3 ~. W9 i5 N
8 cm and a width of 2 cm. The glans penis was very well
$ H, Q% Y8 i9 o6 Ldeveloped. The pubic hair was Tanner II, mostly around2 r: I1 ~9 I( Q5 x6 y; I$ C" C
540
5 B0 ~" L) f& @+ h. C; g  a8 T0 l: rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 m& Y, h8 I/ a% l  w5 `5 s5 w
the base of the phallus and was dark and curled. The4 h! S& R! a& z" _3 q
testicular volume was prepubertal at 2 mL each.* x) w1 l9 n% w% @
The skin was moist and smooth and somewhat
) O9 D7 U! D; L  y  \1 hoily. No axillary hair was noted. There were no0 G) k7 L& H/ [' a" t, h
abnormal skin pigmentations or café-au-lait spots.
0 d, M: t0 G: [' y8 ZNeurologic evaluation showed deep tendon reflex 2+# y: ^( H3 w' d: d0 m. _0 m
bilateral and symmetrical. There was no suggestion2 M( j& ]" |' z% c$ O: S
of papilledema.
+ ]1 [# k; S5 n" D1 [2 m0 rLaboratory Evaluation: S9 `8 J3 W/ W7 f9 ^$ f
The bone age was consistent with 28 months by! U- N$ B, |7 [& t7 V9 H, _: L
using the standard of Greulich and Pyle at a chrono-
2 u! Q; {% m: o9 A% _: wlogic age of 16 months (advanced).5 Chromosomal
5 X2 {* R+ f6 gkaryotype was 46XY. The thyroid function test' h7 P* ~7 O8 L7 o; s* v( g. b9 o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" ?  B! c: l" g5 P1 A
lating hormone level was 1.3 µIU/mL (both normal).
+ w: e/ ^- b% IThe concentrations of serum electrolytes, blood  n* S- n* {7 g
urea nitrogen, creatinine, and calcium all were. V" A! ^0 \/ v
within normal range for his age. The concentration
% F# ]0 u# ], u% ^3 h* }, Bof serum 17-hydroxyprogesterone was 16 ng/dL: z# W- L# u5 }% S! T' s
(normal, 3 to 90 ng/dL), androstenedione was 20
) b% T3 o, i5 Vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; y* X9 Y5 S+ q5 y+ w& u
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& J2 X* D; u! H7 ~- f+ Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! i$ b3 S$ [7 M( P, F0 B49ng/dL), 11-desoxycortisol (specific compound S); V' |  F+ P9 k% E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: b8 {- g$ b: V. {: o1 P+ [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- R5 f! A! u4 y) i; q4 D( i) Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 g/ e" m8 I1 F6 hand β-human chorionic gonadotropin was less than
6 C5 {5 t$ l4 V, }5 mIU/mL (normal <5 mIU/mL). Serum follicular3 \! M; B; E- }: F' i" Y
stimulating hormone and leuteinizing hormone
7 J0 S  S( T1 z6 D( tconcentrations were less than 0.05 mIU/mL8 z" ~1 r' B$ _
(prepubertal).
& w/ J. W8 _2 ~8 s2 w5 F. ~The parents were notified about the laboratory+ k8 X0 C1 g% [; d9 a; T. s
results and were informed that all of the tests were. ?2 Q- p5 N3 [, W8 l6 |9 _
normal except the testosterone level was high. The
' U- }: f/ I; g; j" r8 T0 Lfollow-up visit was arranged within a few weeks to
: w/ D) t: B/ `. z% `) Nobtain testicular and abdominal sonograms; how-
) J  _8 M2 ?( T. q5 hever, the family did not return for 4 months.
) Y8 g3 Q% C- Y9 T8 r3 y) d# hPhysical examination at this time revealed that the0 ?2 B/ O, j! L$ @% Z0 Y+ @$ R& v
child had grown 2.5 cm in 4 months and had gained
  W2 z) \  N6 J- D: G1 m2 kg of weight. Physical examination remained; A7 Q. d: u" `7 R, k) q6 a
unchanged. Surprisingly, the pubic hair almost com-; U; Y/ }/ B. v. p4 C' c- o
pletely disappeared except for a few vellous hairs at
/ {* J7 V2 k* j# h9 E; rthe base of the phallus. Testicular volume was still 2
0 ~9 a9 W* v6 FmL, and the size of the penis remained unchanged.
- w$ J- x$ D$ N) x6 K) VThe mother also said that the boy was no longer hav-
! [5 u2 v$ J7 [# I9 p7 H7 K3 Jing frequent erections.% {+ b: v3 ]; p0 ~* x
Both parents were again questioned about use of
& P, p! ]' k1 l0 I; f% many ointment/creams that they may have applied to
; f  O# g7 q% E) C& Cthe child’s skin. This time the father admitted the2 a8 j) N0 t, U  Y+ a* r6 ^$ W2 n
Topical Testosterone Exposure / Bhowmick et al 5412 u0 }/ ^* ?! C& ?1 y
use of testosterone gel twice daily that he was apply-
( @+ t% h' E* f( U/ Ming over his own shoulders, chest, and back area for4 G: d. h2 B6 e# J2 W0 C& n' c
a year. The father also revealed he was embarrassed/ Y1 K1 i: X4 R7 m$ ]4 P
to disclose that he was using a testosterone gel pre-
( J* M9 q0 t1 _* g% d+ G' x3 E: h' cscribed by his family physician for decreased libido& G! T# P- p% U/ p* l# t
secondary to depression.) e2 X% l5 Q' w) f2 O% g
The child slept in the same bed with parents.3 H5 G6 Q2 m$ U/ P* g8 N2 j
The father would hug the baby and hold him on his
' \( [3 {$ Y* n% ?8 D6 o, _4 Y0 Ochest for a considerable period of time, causing sig-
4 M) @+ H5 X6 p$ i1 v2 w! Y& anificant bare skin contact between baby and father.
- ~7 y$ S3 D$ j% v5 WThe father also admitted that after the phone call,4 {4 [4 }4 T7 @; ?" U* D# ]* i) T1 O
when he learned the testosterone level in the baby
1 l/ w0 {$ }. c0 l3 F1 ~  {5 ]9 Rwas high, he then read the product information- Z1 D& f( A1 ]7 V) z( e7 `
packet and concluded that it was most likely the rea-
! O$ E. v3 l6 v1 _! S' [son for the child’s virilization. At that time, they
3 X; u7 U; Y7 A' M; \decided to put the baby in a separate bed, and the
# A% v3 K- L" A+ v  ffather was not hugging him with bare skin and had9 _# U5 G( e5 m
been using protective clothing. A repeat testosterone# R8 I3 o$ `! z$ r- N2 x/ |1 ^
test was ordered, but the family did not go to the
% l: S2 N$ W$ R! e$ Olaboratory to obtain the test.5 r& G" Q& X  j# L, e; H+ w  s
Discussion1 m% [' i8 g( W5 u% w% w
Precocious puberty in boys is defined as secondary# j, ~9 T0 u6 |8 @8 u# @4 U
sexual development before 9 years of age.1,40 i1 Y8 e+ q0 u# f. A
Precocious puberty is termed as central (true) when  b1 t- C: r) o
it is caused by the premature activation of hypo-
* \! L2 @0 |* M# ^9 Y; qthalamic pituitary gonadal axis. CPP is more com-2 n6 K7 ?2 m3 [+ k9 D
mon in girls than in boys.1,3 Most boys with CPP
% ]) H8 t. @5 Q9 z: C# d( \. y* Wmay have a central nervous system lesion that is; z  B) M% F# Z5 K
responsible for the early activation of the hypothal-
3 Z2 Z0 M, [$ y' C+ m& C% H' oamic pituitary gonadal axis.1-3 Thus, greater empha-
7 y5 s6 z5 X+ g9 Usis has been given to neuroradiologic imaging in
& f" ?$ R. h/ D7 d+ jboys with precocious puberty. In addition to viril-
. {( U0 i& d( @& v/ yization, the clinical hallmark of CPP is the symmet-. o8 S2 |, X# A& P+ h; g0 N
rical testicular growth secondary to stimulation by
7 r$ W# W3 G# t: E7 G( i$ ~( vgonadotropins.1,3
8 u$ F8 p' V, VGonadotropin-independent peripheral preco-8 }  ]( {2 j. G9 C. I2 a' p
cious puberty in boys also results from inappropriate/ I) Q! U* m7 |$ Q
androgenic stimulation from either endogenous or
, V9 E7 D# `) u. b% i+ |) Oexogenous sources, nonpituitary gonadotropin stim-9 f9 r. T; ?: W; R# J" }
ulation, and rare activating mutations.3 Virilizing
# n4 `/ f- a# U4 x! f* x5 F5 `) \congenital adrenal hyperplasia producing excessive
, f! t+ R. C+ m- _( q9 u. c4 [* Uadrenal androgens is a common cause of precocious
: z; @: N- s( v: cpuberty in boys.3,4
7 v5 D1 h2 U. u* M/ \! Z/ @& RThe most common form of congenital adrenal
, X+ }# h( f, o/ }/ ~4 y5 Fhyperplasia is the 21-hydroxylase enzyme deficiency." o& r  T; u. |, J0 H
The 11-β hydroxylase deficiency may also result in+ l3 _% j" E+ \0 i3 ]# q$ P) x6 z
excessive adrenal androgen production, and rarely,' x' E! o+ C+ y/ W
an adrenal tumor may also cause adrenal androgen* _4 D3 q( ~0 h& _- q# d
excess.1,3
2 ^4 U# \( m( j) {; L" nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! T% u1 |* L. [0 Z% [. b( V
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. X. S" o  f  p; v2 u* Y
A unique entity of male-limited gonadotropin-7 ~" ?2 n9 r: t/ s# g
independent precocious puberty, which is also known
8 r" h. n  A/ \' _. uas testotoxicosis, may cause precocious puberty at a  g7 ~, g( B0 i: D" c8 q. V7 j
very young age. The physical findings in these boys
4 b) I4 j) O6 f& t" ^with this disorder are full pubertal development,
, t# E' Q3 w2 q; p2 v; Gincluding bilateral testicular growth, similar to boys
$ p2 T; f/ R3 Pwith CPP. The gonadotropin levels in this disorder6 d/ l* Z* F$ C; Z& O1 @& R
are suppressed to prepubertal levels and do not show; j$ w6 ~3 l7 j; S
pubertal response of gonadotropin after gonadotropin-
0 ]) t, @" ~6 d& e; {releasing hormone stimulation. This is a sex-linked; N$ }2 {8 a5 b7 U
autosomal dominant disorder that affects only5 ~5 C( ~+ \1 W6 u# l
males; therefore, other male members of the family
& W/ L# a% K. I8 mmay have similar precocious puberty.37 b' H5 x( v/ y3 F5 t
In our patient, physical examination was incon-
  R4 f9 Z, [/ H; g4 A: v5 q) Ksistent with true precocious puberty since his testi-
, |* m2 E9 E% Y4 b& ?1 x; {cles were prepubertal in size. However, testotoxicosis! b. a' \3 O6 @0 R0 q
was in the differential diagnosis because his father
4 T, F& I1 A% _6 W, ustarted puberty somewhat early, and occasionally,
% ~* X9 @% e% m: A1 Ltesticular enlargement is not that evident in the
5 p0 p7 S* K1 A: b5 q4 \0 ?( W& X$ Lbeginning of this process.1 In the absence of a neg-9 A# {" o) X4 `$ A; x: l! P& L
ative initial history of androgen exposure, our
/ |/ {/ M# `; Gbiggest concern was virilizing adrenal hyperplasia,( X9 x* S, }; s6 I, L
either 21-hydroxylase deficiency or 11-β hydroxylase5 ~* U5 H' T8 a% t" z: W8 M( Z
deficiency. Those diagnoses were excluded by find-
$ w/ ~. S9 o% ning the normal level of adrenal steroids.' W8 I/ i# t) B  v/ P, O4 i
The diagnosis of exogenous androgens was strongly) f7 o* H& A1 I3 y! [- J7 I/ h$ ^5 Q
suspected in a follow-up visit after 4 months because' L; C9 D7 x8 R' [8 `6 M1 b( I+ A
the physical examination revealed the complete disap-, I) y. h/ \" T
pearance of pubic hair, normal growth velocity, and7 K9 e! b0 ~" E# N
decreased erections. The father admitted using a testos-
" E* D6 M4 Y4 R0 j$ i. Yterone gel, which he concealed at first visit. He was
4 R+ g4 D9 U* Zusing it rather frequently, twice a day. The Physicians’  R0 [* v8 }& s! A8 k
Desk Reference, or package insert of this product, gel or! k9 Q! X+ [/ s* Y7 [, N
cream, cautions about dermal testosterone transfer to
2 X; v$ n3 Z& G, f  G  I9 q; V6 Tunprotected females through direct skin exposure., u; v3 h, p- T7 a& k
Serum testosterone level was found to be 2 times the& u! ~1 Z# V" T
baseline value in those females who were exposed to3 |' W8 R& H. q. o9 u' c5 v
even 15 minutes of direct skin contact with their male
! O( @- L! C6 g! C8 k2 ipartners.6 However, when a shirt covered the applica-* a9 G) G& Y9 i. e
tion site, this testosterone transfer was prevented.
% Q" R0 c# }8 l8 COur patient’s testosterone level was 60 ng/mL,6 j) b. _2 s0 D2 }
which was clearly high. Some studies suggest that
! B' e2 ^* G  M8 Ndermal conversion of testosterone to dihydrotestos-" @& @/ o$ i* ?3 @" ^
terone, which is a more potent metabolite, is more
+ @: S/ g6 ~8 ]6 xactive in young children exposed to testosterone: n' Z  x1 r  }! {' w; `: |8 q4 g
exogenously7; however, we did not measure a dihy-, a/ w" z0 `( g) q" E
drotestosterone level in our patient. In addition to- h2 z  \+ o. o4 a( F8 S" @3 M
virilization, exposure to exogenous testosterone in
& B! b( j5 x9 {5 U' I8 Fchildren results in an increase in growth velocity and8 ~3 l4 b+ x) s% w7 u% l
advanced bone age, as seen in our patient.5 C3 W# b$ t3 w+ j, z7 Q
The long-term effect of androgen exposure during4 @3 P- ~3 V) h* ?
early childhood on pubertal development and final' o# j, Z/ A6 o8 k
adult height are not fully known and always remain
5 F' o* Y- {" b& f# Da concern. Children treated with short-term testos-! c$ \8 v; N' K$ I) f
terone injection or topical androgen may exhibit some6 w9 Q0 F8 J5 w: W2 x
acceleration of the skeletal maturation; however, after
: F. |+ \' q. ?# s) S3 R4 X  Ecessation of treatment, the rate of bone maturation) g0 g1 z; `4 F( L$ R2 D3 D
decelerates and gradually returns to normal.8,9" p4 H) v" K2 Y6 r% H$ x
There are conflicting reports and controversy* F8 {4 D) a, M1 }" }; M
over the effect of early androgen exposure on adult* L( J' H5 a! ~- e  U) w7 y
penile length.10,11 Some reports suggest subnormal, ?. l+ @0 ^& ]  |' V: @
adult penile length, apparently because of downreg-  O( u4 y6 R, F; {- t8 H. o( x% @
ulation of androgen receptor number.10,12 However,2 r5 ^3 |5 j; k6 O
Sutherland et al13 did not find a correlation between
6 ]) a2 p1 U5 @! ^6 c& hchildhood testosterone exposure and reduced adult  E5 |0 @+ k" J3 B& V0 p8 E
penile length in clinical studies.
9 D3 Z: b$ \; TNonetheless, we do not believe our patient is" |* m4 c" p' D# f; M& N1 m* L1 j
going to experience any of the untoward effects from% v* a) I# g2 L  J$ v/ q. ]
testosterone exposure as mentioned earlier because
* |4 U$ ~+ H+ {4 ^the exposure was not for a prolonged period of time.
" I* U; H4 Y3 Q+ `6 LAlthough the bone age was advanced at the time of4 V( ~8 k. W* P
diagnosis, the child had a normal growth velocity at( d3 E" t+ E! V4 c$ h  c/ s3 C4 o
the follow-up visit. It is hoped that his final adult7 d3 e# w4 G% o7 W$ h  d( W
height will not be affected.9 w* w6 w$ Q7 A
Although rarely reported, the widespread avail-
6 ~/ p" i2 k+ T' Z- N4 mability of androgen products in our society may
% U0 \1 V. L) {2 ~indeed cause more virilization in male or female
# \. U3 i# B3 r% ~2 xchildren than one would realize. Exposure to andro-
2 T& i6 H8 N( S# a5 p* Z) F8 ?  wgen products must be considered and specific ques-
4 x, J! ?7 p6 Z: A; i8 utioning about the use of a testosterone product or4 P  R' {) A. Q1 c$ P
gel should be asked of the family members during3 w$ p/ b) B6 p  h
the evaluation of any children who present with vir-
- ~; r8 P0 ?; ^5 D/ M0 b5 W8 milization or peripheral precocious puberty. The diag-
4 ^' r6 J% B7 s* M  x' gnosis can be established by just a few tests and by
, W/ x: i" M7 I* R7 {appropriate history. The inability to obtain such a! B! F# v+ S2 r3 g# n" J. c
history, or failure to ask the specific questions, may
8 g  [# ^; e  h: hresult in extensive, unnecessary, and expensive/ I) |; V1 g* z. q
investigation. The primary care physician should be
$ ^9 I# r8 l  P+ aaware of this fact, because most of these children/ R* _$ T- Y9 f  l9 f7 Y- s3 \1 s
may initially present in their practice. The Physicians’& O" ?) S, y: {) w# Y& M" q
Desk Reference and package insert should also put a
( @1 ~4 h* f& v+ N* k& K, d: rwarning about the virilizing effect on a male or! M3 A4 r8 `2 N, n8 p$ V/ @% s. V+ x
female child who might come in contact with some-
9 _4 s' C- g4 jone using any of these products.
) m' Q1 v' M0 h/ B$ |9 l0 E7 QReferences
# U6 [- ^0 c. q8 A9 q; o1. Styne DM. The testes: disorder of sexual differentiation
% N+ ^3 ^6 B) ]6 Mand puberty in the male. In: Sperling MA, ed. Pediatric/ ?  i, S4 |+ J+ x7 y, D
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- ?( v) |% w5 Q3 p3 `1 W
2002: 565-628.
4 ~2 Q( V3 V7 t' e2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 P* z7 U: O9 \
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
- N6 W. ~# k3 T6 k/ X7 [
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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