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Sexual Precocity in a 16-Month-Old
$ l6 c, `  ~% Q/ eBoy Induced by Indirect Topical
9 Y1 j+ R) w/ [Exposure to Testosterone3 |" N: g6 ?9 v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# n, n& B* W  a0 u2 i
and Kenneth R. Rettig, MD11 k" {: s7 S! q/ h  D" g2 [1 M6 i
Clinical Pediatrics8 L, C3 n" [* `" |% M7 K( P
Volume 46 Number 6
2 E, p9 s; f& e" s, J9 WJuly 2007 540-543
1 N+ y1 [* k- ^4 b# k5 ?© 2007 Sage Publications. U- Q! ~) F$ K
10.1177/0009922806296651
6 m4 ?" _, m+ X( ^, A3 q! nhttp://clp.sagepub.com3 c" o, b/ m/ j* I) ?3 _; F) Q  ^
hosted at
: W: O4 J6 k+ v: \( fhttp://online.sagepub.com
5 i  z& G5 s8 a/ NPrecocious puberty in boys, central or peripheral,
6 u5 n3 s" i. ]1 k# A7 S/ Fis a significant concern for physicians. Central; z) z. c( k* l7 M4 a3 a
precocious puberty (CPP), which is mediated6 @$ w: c! i* ?6 j! C
through the hypothalamic pituitary gonadal axis, has
% g: d: \7 k* U& B6 a1 r* b3 xa higher incidence of organic central nervous system3 N8 Z" H' `2 F+ _4 A
lesions in boys.1,2 Virilization in boys, as manifested8 C3 |( q# \* \3 y1 r
by enlargement of the penis, development of pubic
1 C% V  i! `* z( L6 i2 ohair, and facial acne without enlargement of testi-
4 c4 k% ~" J! y2 Acles, suggests peripheral or pseudopuberty.1-3 We
+ p! e) O8 M$ Vreport a 16-month-old boy who presented with the
: J9 H3 h' `8 K& I3 U6 Tenlargement of the phallus and pubic hair develop-
  Y$ {+ b# O$ y; x' ]ment without testicular enlargement, which was due
/ G8 M+ q4 K3 a& o( s% [to the unintentional exposure to androgen gel used by; g+ I  C. V' c8 N$ A" Y
the father. The family initially concealed this infor-- }3 y) z- G: w8 O4 y5 g2 v
mation, resulting in an extensive work-up for this7 b% |- G+ Q0 R. \* _5 `
child. Given the widespread and easy availability of
: U9 g8 ]/ n4 |" xtestosterone gel and cream, we believe this is proba-1 ~; N# F% K+ @7 i- }8 j! V
bly more common than the rare case report in the
: ~9 |$ w( j  i) n  jliterature.4, ], _$ U: R) I$ k1 f
Patient Report# J% ~7 `' x/ s- H; G
A 16-month-old white child was referred to the
% e, o# D0 `) _; Mendocrine clinic by his pediatrician with the concern
  e% ~  B, d! T' s( E& K' [$ Sof early sexual development. His mother noticed8 k0 ]6 m; D, e5 h8 O9 V% Y) d
light colored pubic hair development when he was( A. O/ ~) d( S0 W, t
From the 1Division of Pediatric Endocrinology, 2University of
+ u& ]0 r1 N; N, ]4 U2 m1 F8 ^5 r( MSouth Alabama Medical Center, Mobile, Alabama.
* q" P! }  k( ]Address correspondence to: Samar K. Bhowmick, MD, FACE,* o5 g7 F- R5 g8 x" m1 c' Z
Professor of Pediatrics, University of South Alabama, College of
" u' G6 V* F6 tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 O! \0 A' V- j* F4 J0 ^$ r: r
e-mail: [email protected].
) [' r9 A- `3 w/ w5 Iabout 6 to 7 months old, which progressively became2 c. Y. B5 p1 U! f- d
darker. She was also concerned about the enlarge-3 b" X% w* x/ g7 Y2 N
ment of his penis and frequent erections. The child! F3 n1 H0 q: K8 ~
was the product of a full-term normal delivery, with
& t# T. P5 ?1 Y" e! t  M% O8 Za birth weight of 7 lb 14 oz, and birth length of: }4 o- e+ x1 m% P. e
20 inches. He was breast-fed throughout the first year5 |) g1 a: s& w# c& [  x9 a3 K$ k, j/ R
of life and was still receiving breast milk along with
/ w& f- \4 O; `3 H* t# f" tsolid food. He had no hospitalizations or surgery,; O% u: W$ x# {0 y3 k9 ]
and his psychosocial and psychomotor development: \6 e# j" s* T7 L! G
was age appropriate.* |6 z1 T$ q. D
The family history was remarkable for the father,1 m. I& I5 O3 V/ X8 v- d2 ^+ Z& c
who was diagnosed with hypothyroidism at age 16,; q" ~0 r8 a: H" Z1 Y
which was treated with thyroxine. The father’s
# {$ G: a" |' X& i2 zheight was 6 feet, and he went through a somewhat7 }4 H( t7 V9 [" q& i3 U1 F
early puberty and had stopped growing by age 14.. s7 W6 _+ q) V) z' x" ~& A* f) P7 H
The father denied taking any other medication. The
4 F3 K2 Z6 d) f# n/ W0 p/ i" j1 F0 zchild’s mother was in good health. Her menarche
1 ?5 U) i& D* W- g" Dwas at 11 years of age, and her height was at 5 feet
5 N0 u4 v" d/ N& l. }7 @: P* t: r5 inches. There was no other family history of pre-; [0 R8 g* I" l: E1 F4 Z) E/ t
cocious sexual development in the first-degree rela-
0 Y3 \8 ]; I5 F0 a1 M  D5 [/ ^& \tives. There were no siblings.
6 b  j/ {  Z  W+ ^# ~; u( RPhysical Examination3 O9 V' \# V* I9 F
The physical examination revealed a very active,8 Q! i) B3 Q# h; y
playful, and healthy boy. The vital signs documented+ Y0 D" e. s8 V* v& A4 Z6 m
a blood pressure of 85/50 mm Hg, his length was1 l$ u3 d9 ?4 S
90 cm (>97th percentile), and his weight was 14.4 kg
) S2 K: h* X' v6 F, g) @: t/ G' `(also >97th percentile). The observed yearly growth
8 H8 L; n0 N/ l/ k3 _0 \velocity was 30 cm (12 inches). The examination of
2 C& |. L# X1 |& h& ithe neck revealed no thyroid enlargement.8 u/ g% \+ \& N( \& s
The genitourinary examination was remarkable for
. ~) P2 S8 r8 uenlargement of the penis, with a stretched length of( N9 B) N- B, y! a
8 cm and a width of 2 cm. The glans penis was very well
( z  r- G! \5 I* ^) i% T! Ddeveloped. The pubic hair was Tanner II, mostly around
6 n7 j: A/ {( J/ A/ q1 g- E7 ]3 z540
( b7 f6 `' v$ {, Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! L' i" w1 g2 }the base of the phallus and was dark and curled. The) r, f# q6 I! F! B' b: a  O. C+ ?
testicular volume was prepubertal at 2 mL each.; v4 p0 d' l& O/ {2 s
The skin was moist and smooth and somewhat! _3 Q+ K0 H7 f; |9 U/ x8 e# R
oily. No axillary hair was noted. There were no
5 ?2 I% _3 c; u7 S9 [" N3 yabnormal skin pigmentations or café-au-lait spots.- y  ?% V" @# \1 J2 c
Neurologic evaluation showed deep tendon reflex 2+
" {6 e; y7 t- g$ [# U2 Jbilateral and symmetrical. There was no suggestion
+ x6 Q- h" R- k. n4 t3 X5 ^of papilledema.
9 ?$ P; e; O9 k" vLaboratory Evaluation8 Q, ^, Y" p- Y3 V# m! y
The bone age was consistent with 28 months by
! W; z% G. V0 D4 V" busing the standard of Greulich and Pyle at a chrono-
/ m( x) B, K9 @" s# ]logic age of 16 months (advanced).5 Chromosomal  j) E! T/ S, d- R$ {
karyotype was 46XY. The thyroid function test' e4 p, a; c- q; U2 t! c/ A+ b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-* D; b& A; Q) y; ?5 C
lating hormone level was 1.3 µIU/mL (both normal).0 ?+ `+ D/ U! F/ `  t
The concentrations of serum electrolytes, blood6 g! d# }! }$ R5 N
urea nitrogen, creatinine, and calcium all were' `% O6 [. c4 d% t. R
within normal range for his age. The concentration  [% ?2 R" `2 v! P
of serum 17-hydroxyprogesterone was 16 ng/dL
4 X( Y% I& s8 K2 |6 }% V(normal, 3 to 90 ng/dL), androstenedione was 20
+ b/ \' W# j: h2 ]3 _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 O) g2 b' e$ ?# V! _4 E& h$ [terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 Z3 [* j0 U; `$ ?- T3 }5 h. \
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ o3 c9 B  Y% c6 {, f* l7 y49ng/dL), 11-desoxycortisol (specific compound S)/ o/ M- ]4 z; [" D, Z" m# q* Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 {$ F! R3 d- }7 T: T6 D& Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, `- r* I+ t  D5 J+ Dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 }6 Y0 J/ y. |and β-human chorionic gonadotropin was less than
& i3 Q2 E% P' T5 mIU/mL (normal <5 mIU/mL). Serum follicular( ?* [6 D2 M8 Z8 E: L
stimulating hormone and leuteinizing hormone
7 x+ ?5 E6 @# ^' Q+ kconcentrations were less than 0.05 mIU/mL
3 z& }& Z/ J& h6 N  ^! ^9 N3 D% {(prepubertal).
; R+ q8 ~: Z. s7 r& [8 hThe parents were notified about the laboratory. P5 q# Q9 M8 n' c- l* d3 O" M
results and were informed that all of the tests were$ A! ^4 D! f! p/ g) A6 @
normal except the testosterone level was high. The1 A0 s: g; A( q8 R. a; }
follow-up visit was arranged within a few weeks to
& \5 I0 d- j. o5 _7 z4 @: F2 W5 W7 R; Eobtain testicular and abdominal sonograms; how-4 e" ]5 s/ q$ S
ever, the family did not return for 4 months.2 w' X" ?  D, O: J4 a& Z' N
Physical examination at this time revealed that the
, \: D9 M: i8 I6 r  ?! H# Fchild had grown 2.5 cm in 4 months and had gained
) G% W6 n" }1 C) t) z2 kg of weight. Physical examination remained
, b! q3 B4 q  R$ p/ W6 F! nunchanged. Surprisingly, the pubic hair almost com-
6 U) Q& V1 P' cpletely disappeared except for a few vellous hairs at
% J4 ?/ a+ q2 P0 {( O( wthe base of the phallus. Testicular volume was still 28 ^$ w# B+ {" i
mL, and the size of the penis remained unchanged.6 p1 ?$ }1 L2 K* [& f. `0 `
The mother also said that the boy was no longer hav-' o! p( x' `; n3 [) m
ing frequent erections.
" `. Z. m/ M  r* ^( ]Both parents were again questioned about use of
3 e+ Q# d- F9 f. Uany ointment/creams that they may have applied to+ R, O2 \3 Y7 _
the child’s skin. This time the father admitted the$ O" T# l. H- Q) s9 R$ U
Topical Testosterone Exposure / Bhowmick et al 541" W+ Z  f5 d; v, O
use of testosterone gel twice daily that he was apply-
; e/ d- \; i( h8 Aing over his own shoulders, chest, and back area for
  v- h8 R! D8 n" Aa year. The father also revealed he was embarrassed
+ s; ^- N$ K0 i& X: t9 Eto disclose that he was using a testosterone gel pre-/ w: G0 @4 z+ ~! k0 g; Z
scribed by his family physician for decreased libido. t% M- D* t# {4 z
secondary to depression.
. u5 T/ S6 U/ q* ]3 M- M1 x. B* \The child slept in the same bed with parents.
6 ~6 P# a: l1 N: J! @1 d$ ZThe father would hug the baby and hold him on his+ X. D1 i, ]& e4 N; d
chest for a considerable period of time, causing sig-
; Z! ]8 g' ]! d# ]: cnificant bare skin contact between baby and father.
( ]/ X! O9 I: n: \. g6 H3 M" ^The father also admitted that after the phone call," O( W. `) U& u1 I8 G6 i  m
when he learned the testosterone level in the baby. K4 S( ~' e6 o; Q" y1 W
was high, he then read the product information
4 g6 X. A5 W$ Z* A& z4 \3 G5 |packet and concluded that it was most likely the rea-& ^+ M9 k/ L) X6 G! @
son for the child’s virilization. At that time, they; _, _* Z2 K0 `# D. [6 N9 n2 D6 E
decided to put the baby in a separate bed, and the
1 K9 }/ M  S7 }( [father was not hugging him with bare skin and had9 l+ w/ z' m3 b* ]1 ]  k( x
been using protective clothing. A repeat testosterone! ?/ x& q2 o' G+ v/ C% J' `
test was ordered, but the family did not go to the
" l! p( D: C9 g9 d/ u/ P& t8 w6 Xlaboratory to obtain the test.
2 M" N6 ~4 m8 ~4 L' T1 Q1 o2 Q0 KDiscussion
- P) W: l4 k6 Q" c! a: ^Precocious puberty in boys is defined as secondary( `' U4 K+ W2 n/ X: D) G% d+ C  h
sexual development before 9 years of age.1,4
4 o& E/ V- U+ E- q3 g- x, f. V1 ^0 U; qPrecocious puberty is termed as central (true) when' v* y! k' m# o# ^# u
it is caused by the premature activation of hypo-2 _9 l# c- Q0 ?2 B% H/ _/ v; H
thalamic pituitary gonadal axis. CPP is more com-6 n3 r" ~6 @* a8 i
mon in girls than in boys.1,3 Most boys with CPP0 j! D$ K# V- S1 V- @: h
may have a central nervous system lesion that is1 {7 Q4 F0 a" j
responsible for the early activation of the hypothal-, U3 ?* h. w6 F* ~$ O
amic pituitary gonadal axis.1-3 Thus, greater empha-
# V% F! k% k1 R% U6 P1 V' m% Ysis has been given to neuroradiologic imaging in! B9 ?2 M$ I6 M# U
boys with precocious puberty. In addition to viril-3 j2 Q2 `$ T7 ]1 s; M; s. B3 {% T* L
ization, the clinical hallmark of CPP is the symmet-
! d5 K- P; D2 V5 U. h4 p, rrical testicular growth secondary to stimulation by9 R3 ?8 w! T! C/ j5 q
gonadotropins.1,3
: Z1 K- J1 k1 p6 g% UGonadotropin-independent peripheral preco-
! {$ B, d+ |8 p5 j6 Ecious puberty in boys also results from inappropriate' b' q# A! y) x2 H$ j
androgenic stimulation from either endogenous or) R0 y$ w' N# J- J
exogenous sources, nonpituitary gonadotropin stim-
- C  @; R& R3 y% z6 \3 Kulation, and rare activating mutations.3 Virilizing
7 w3 E7 S  B/ ?% _# Fcongenital adrenal hyperplasia producing excessive
0 r: H, Y8 o+ K4 ^3 Y8 }adrenal androgens is a common cause of precocious3 O% p9 ]: @3 z2 g
puberty in boys.3,4
7 o; ?- V* ~8 TThe most common form of congenital adrenal
7 q! v7 ]. A7 |1 i  ~3 ?9 nhyperplasia is the 21-hydroxylase enzyme deficiency.5 h) n2 y8 z4 Z9 [# K* b5 r
The 11-β hydroxylase deficiency may also result in! ~5 Z* A" I" Q: G& b3 P! ]/ A
excessive adrenal androgen production, and rarely,' X. Z, v) }4 H6 b) t! c
an adrenal tumor may also cause adrenal androgen5 y! a/ w. q" l8 I
excess.1,3) K6 k9 W; l2 e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& `: J! _; I0 n  U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; T  x5 v4 o1 L* ?; e, wA unique entity of male-limited gonadotropin-
* u2 I; O" a  \8 |8 windependent precocious puberty, which is also known
0 X: O" S; b7 k0 uas testotoxicosis, may cause precocious puberty at a, I. N+ b' n9 u( g
very young age. The physical findings in these boys
- \" j6 }+ f, \' T9 m  O! |  _with this disorder are full pubertal development,! f7 R  F" a0 T& ^  w# g3 X# p( m
including bilateral testicular growth, similar to boys
: p. l8 ]- K+ d3 q( Vwith CPP. The gonadotropin levels in this disorder  E$ a! p; n$ g& F$ g. s
are suppressed to prepubertal levels and do not show# `. e7 H' z1 P* R
pubertal response of gonadotropin after gonadotropin-8 C- ^$ @5 T/ q8 b! T* }7 {/ b  b
releasing hormone stimulation. This is a sex-linked: P* }% M7 h; j( m1 J* p9 N
autosomal dominant disorder that affects only! r9 b- T# Q; e' R( E
males; therefore, other male members of the family' T; a$ L2 [  f0 z
may have similar precocious puberty.3- _. l0 X  P! w
In our patient, physical examination was incon-
( R' |- W: z6 ~' m$ psistent with true precocious puberty since his testi-
6 h6 K! t* n/ \: m# i4 p+ z/ Bcles were prepubertal in size. However, testotoxicosis" b5 H  l+ U# t" p
was in the differential diagnosis because his father
9 O' p8 N; n; l$ Kstarted puberty somewhat early, and occasionally,
- G+ l$ K7 c, P+ ttesticular enlargement is not that evident in the
3 q6 Y5 z' y' N) N( _% K: `beginning of this process.1 In the absence of a neg-
7 U$ x' w8 q7 i, o. i4 vative initial history of androgen exposure, our1 V3 a7 Z" @/ R/ ]! c. w0 j1 K
biggest concern was virilizing adrenal hyperplasia,
; O+ C3 d- K0 F9 m' eeither 21-hydroxylase deficiency or 11-β hydroxylase
$ G; B) P3 X; N. ?& J. Fdeficiency. Those diagnoses were excluded by find-
5 S% h+ g% s! E3 hing the normal level of adrenal steroids.( @0 |5 k: Q2 m, T
The diagnosis of exogenous androgens was strongly
  i% X; W) N' z3 u& ysuspected in a follow-up visit after 4 months because* K. k& ^* ]  s& E6 K- v7 T" V3 L) |9 n
the physical examination revealed the complete disap-
6 ^+ [3 E" C* |6 _" E: p7 jpearance of pubic hair, normal growth velocity, and
$ |) s- _/ R9 G9 N7 Sdecreased erections. The father admitted using a testos-
' g4 j/ T! F6 m5 F, \terone gel, which he concealed at first visit. He was
! B  U2 j) x4 j4 v9 H0 b. Iusing it rather frequently, twice a day. The Physicians’- M% Q3 u" K- q
Desk Reference, or package insert of this product, gel or; Y; Z& y6 r7 N' b# S7 H- w+ j
cream, cautions about dermal testosterone transfer to
8 Q% g" _) p7 Aunprotected females through direct skin exposure.
$ x6 v7 R4 q  S. {. ISerum testosterone level was found to be 2 times the
4 o1 K% Z) q7 b, W$ V3 a; E- X( tbaseline value in those females who were exposed to% [' ~. W) `, ]0 n7 R6 K: l
even 15 minutes of direct skin contact with their male8 m6 y6 w) j$ {0 F% V
partners.6 However, when a shirt covered the applica-
- p4 N6 t6 n; A$ z' }tion site, this testosterone transfer was prevented.
2 f# }, x; L( h/ w7 JOur patient’s testosterone level was 60 ng/mL,
% h, e) t" B/ q  s0 Kwhich was clearly high. Some studies suggest that
6 j, C" z) ^7 I: Z" X( I  odermal conversion of testosterone to dihydrotestos-
; M  @" i: v4 o7 r/ K; Xterone, which is a more potent metabolite, is more
; O. P; S/ `, a4 V* K* E+ wactive in young children exposed to testosterone' q) ~; N* p' l6 L/ b9 a0 }1 J( @
exogenously7; however, we did not measure a dihy-* w* v7 A) J0 l
drotestosterone level in our patient. In addition to( I6 \, R9 m% l- [
virilization, exposure to exogenous testosterone in
. m+ j, {9 t: o2 e, Qchildren results in an increase in growth velocity and, o7 V0 K: y- V$ U& q+ u. Q& s
advanced bone age, as seen in our patient.# I8 m$ ]6 _! u; h8 p! z* F
The long-term effect of androgen exposure during4 o; H, w6 c) y
early childhood on pubertal development and final6 J2 G+ @" \9 T1 E1 b
adult height are not fully known and always remain( T1 v3 J3 y7 ^  n
a concern. Children treated with short-term testos-& {+ N* U! q4 M7 u& ^. D
terone injection or topical androgen may exhibit some
: I+ [, |/ b1 H& Sacceleration of the skeletal maturation; however, after4 F3 j$ H* T* X' e# n/ D
cessation of treatment, the rate of bone maturation: D% @0 n9 z5 b2 ?& F
decelerates and gradually returns to normal.8,9
4 w! z4 d: _) v7 W, QThere are conflicting reports and controversy9 r1 n  w2 l* @" w. p
over the effect of early androgen exposure on adult8 W; R& x5 H. L9 U- }* \1 P
penile length.10,11 Some reports suggest subnormal7 [# |1 C9 [# A& H% V
adult penile length, apparently because of downreg-% r, t; n. j/ g" P, T1 {7 o
ulation of androgen receptor number.10,12 However,% x& g( \4 c! ~9 D+ l3 i6 G$ ^
Sutherland et al13 did not find a correlation between' M9 e+ v! ]: H# P& \
childhood testosterone exposure and reduced adult+ T, `  h$ u/ ~+ |/ l2 Z, n, K1 X
penile length in clinical studies.' T. @1 b. r, @3 F8 a* p8 U' Y3 P5 k
Nonetheless, we do not believe our patient is& L/ K# Q! _" N4 }+ j6 R5 U: o8 a
going to experience any of the untoward effects from% x" |& `* y1 G- o0 W! M" ]
testosterone exposure as mentioned earlier because+ A$ a: v* r* Z, I+ f- m
the exposure was not for a prolonged period of time.  I$ u; u! H' ^8 E5 v$ o- d
Although the bone age was advanced at the time of
7 r- Q# F4 K/ H+ L, {diagnosis, the child had a normal growth velocity at
! }& e# H2 Q/ ithe follow-up visit. It is hoped that his final adult
2 \6 P7 ]: u' x  L' K* Rheight will not be affected.
. C+ ~2 P; y" B1 e! d) ^3 _' |' tAlthough rarely reported, the widespread avail-& c8 h/ D) z4 e1 Q
ability of androgen products in our society may" Q: u) @, K* }1 W! N. r7 i' j. t
indeed cause more virilization in male or female
6 E( n1 G( `  h; ~children than one would realize. Exposure to andro-
- D% |& ]! m, M; @, ]4 l+ Zgen products must be considered and specific ques-$ r6 F0 _, F1 d4 s
tioning about the use of a testosterone product or4 O% Z7 b8 [$ @5 V9 M/ W2 U8 m, z
gel should be asked of the family members during0 K" `/ @! n( a  U, V
the evaluation of any children who present with vir-
- j  K- W/ t4 i; U5 L" M9 ]ilization or peripheral precocious puberty. The diag-( x! e6 f9 V( I& p
nosis can be established by just a few tests and by. }$ c- b. J3 v- a  I" V( D
appropriate history. The inability to obtain such a
/ _/ Y; U+ G/ D+ _1 \/ L* V& vhistory, or failure to ask the specific questions, may" R. {0 k! ]0 \# U) V/ S. Y* p
result in extensive, unnecessary, and expensive
3 h/ I9 u. Z' ]- I7 s. k: ainvestigation. The primary care physician should be
5 A+ E0 l) R; Haware of this fact, because most of these children/ }# ~8 q' E. n4 S) P: ~
may initially present in their practice. The Physicians’
/ Q8 N+ \+ z! j: h; @% _) jDesk Reference and package insert should also put a
* d) Y) J8 J0 a! s/ l3 V7 Jwarning about the virilizing effect on a male or
- U( z7 N6 o0 J6 b  A+ Vfemale child who might come in contact with some-
+ M  R& n6 I. O) }# G$ O7 B5 Wone using any of these products./ K. ~2 j3 `3 \! g" L
References% S7 R% X3 S8 h# ~) p( T
1. Styne DM. The testes: disorder of sexual differentiation
: Z2 Q  I/ ^1 V2 }) ^0 F* x% Tand puberty in the male. In: Sperling MA, ed. Pediatric9 p5 D8 x0 P0 C
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  S& p! n9 \# x" @( d
2002: 565-628.2 Z6 o# p! Y$ Q. T7 A, |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' e9 D$ x0 o8 m' a( M! J# \+ {2 fpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old# c4 L/ @* q& j; q# u6 n
Boy Induced by Indirect Topical: |: Y  r# G# a' ^! g+ s
Exposure to Testosterone
! A+ w- g/ Z! @$ s, _. q7 t' U) v8 gSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# f7 Y' I. Y5 j2 q+ M1 E
and Kenneth R. Rettig, MD1. f5 ^6 w, S9 b/ b' l) W* m
Clinical Pediatrics; d( |' W9 S4 {) x" X
Volume 46 Number 6
1 H: u1 p3 k( _July 2007 540-543" e* G' w" _1 ~
© 2007 Sage Publications+ I" v# o8 X: W/ g/ o! l) Z
10.1177/00099228062966518 A# d, e& Q. c3 N* O7 H+ a+ E
http://clp.sagepub.com1 o1 K3 s" Z. k
hosted at* |( }& C+ Q6 d; t! G. B
http://online.sagepub.com' B4 F) v# z) z" T0 i# A
Precocious puberty in boys, central or peripheral,
* ^' o) m+ v2 k% tis a significant concern for physicians. Central
+ ]+ k+ T. c/ ]) s0 o) Y$ Kprecocious puberty (CPP), which is mediated2 h% `+ K# i# B6 W$ I5 m( p3 I
through the hypothalamic pituitary gonadal axis, has, Y. s+ B4 j2 F$ |) h9 j
a higher incidence of organic central nervous system
1 S3 Z2 `' K2 e6 E# |1 a5 Llesions in boys.1,2 Virilization in boys, as manifested& J/ |+ h3 \) a. s! T' O% q
by enlargement of the penis, development of pubic
6 J- T* Z! F: |$ w, |' V2 T* I( Uhair, and facial acne without enlargement of testi-
* {, B2 x+ H5 j2 h7 s/ M3 ]cles, suggests peripheral or pseudopuberty.1-3 We
" y4 E& f2 d' _) ]  [report a 16-month-old boy who presented with the, M! i4 [0 f3 v, v
enlargement of the phallus and pubic hair develop-
% X* S$ o' n' Ement without testicular enlargement, which was due
$ S$ _& h/ L0 r% `to the unintentional exposure to androgen gel used by3 Z; G7 S; \6 y. E
the father. The family initially concealed this infor-% c6 G; F1 {, o2 ?4 ^% G0 J& [" T
mation, resulting in an extensive work-up for this, Y6 x% b: T1 K) s' U% W* b
child. Given the widespread and easy availability of
& _# P7 ~/ I6 S: ctestosterone gel and cream, we believe this is proba-% U( i/ u; D) @9 ~% q
bly more common than the rare case report in the2 f. T4 p( B5 E& q: `6 c5 I0 M$ I
literature.4* |( @7 M4 {; B: E( J- M- T  q
Patient Report
& C6 Y/ K; r& U5 C  d+ ~A 16-month-old white child was referred to the
$ P+ R3 u4 @) O) E  A2 ^/ vendocrine clinic by his pediatrician with the concern
( T! E% x# T  n. p( [* dof early sexual development. His mother noticed
2 g5 d) s) e7 \3 j8 glight colored pubic hair development when he was
' W7 {- h. d( HFrom the 1Division of Pediatric Endocrinology, 2University of
$ G# f9 G' Y1 A9 @7 [% ]5 TSouth Alabama Medical Center, Mobile, Alabama." N% h# _8 f( g, R$ Y6 ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- h6 b0 T' c: Z7 U# }Professor of Pediatrics, University of South Alabama, College of
- [+ L( ]! {, _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 G9 A' A  ?& z: l/ ]$ i1 a3 Oe-mail: [email protected].1 _+ _: |. ~" R
about 6 to 7 months old, which progressively became
! a, y7 s: s0 m( K' E; cdarker. She was also concerned about the enlarge-
; K7 f% ~9 U. Q$ Q+ a! }ment of his penis and frequent erections. The child
: w8 t/ s$ _& n# Y  Mwas the product of a full-term normal delivery, with. B" Z! B& d0 @& Q  Q
a birth weight of 7 lb 14 oz, and birth length of: @3 m6 q/ z/ w5 j! z
20 inches. He was breast-fed throughout the first year
6 r% I- [6 h3 E. s! t* L3 J4 Hof life and was still receiving breast milk along with
; L" r' e$ q$ M% Asolid food. He had no hospitalizations or surgery,! W8 J2 _2 e' R$ _( ]$ N* i; H
and his psychosocial and psychomotor development
' R; ~( o/ [3 X$ P8 k+ x) kwas age appropriate.; D( Y2 H8 `+ `  {' `2 `
The family history was remarkable for the father,
  I( {4 V% P. @. H# swho was diagnosed with hypothyroidism at age 16,0 Y& z% u2 W0 l. M" Y
which was treated with thyroxine. The father’s
5 C, X2 Z1 r; Y9 [. lheight was 6 feet, and he went through a somewhat
$ y2 R/ r( g# G% E1 ?early puberty and had stopped growing by age 14.% `; E4 U  _; y# c5 x" w( \7 \
The father denied taking any other medication. The; p4 t) Z8 e% r. \
child’s mother was in good health. Her menarche2 v" D1 O4 H1 i% Y% |& @' J
was at 11 years of age, and her height was at 5 feet, g3 B9 v0 W7 V
5 inches. There was no other family history of pre-$ B) Y" {: ]; ~! R2 E
cocious sexual development in the first-degree rela-% Y6 U& o% H! Y# r% ?# q
tives. There were no siblings.9 Z& R# V9 I% A& ?" _/ s# @* E/ d6 [9 E
Physical Examination
; \- j) ~% r# G9 KThe physical examination revealed a very active,4 y- k+ s, k: u; ^" Y: E' B
playful, and healthy boy. The vital signs documented( {- L. q; W9 Y7 z% w- d$ x7 T
a blood pressure of 85/50 mm Hg, his length was
1 g3 E# e0 H5 z9 U( z90 cm (>97th percentile), and his weight was 14.4 kg( e& u- t* R% }3 K" c8 `: H( s
(also >97th percentile). The observed yearly growth
$ l- F( T9 ~/ X3 ~' fvelocity was 30 cm (12 inches). The examination of
! U8 z$ ?, Q' O' Rthe neck revealed no thyroid enlargement.5 T, D+ ?* T: s. n$ f$ ?
The genitourinary examination was remarkable for, k$ |3 w3 F( ^2 Q2 z
enlargement of the penis, with a stretched length of
$ l' T# w0 U  X) V8 cm and a width of 2 cm. The glans penis was very well: u) x2 a7 Z7 R
developed. The pubic hair was Tanner II, mostly around# z! r0 [2 m8 G
540& C3 V9 }# M! p8 H9 H4 ^! `& b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* h! E, T5 o% O; f6 y* s; e( }
the base of the phallus and was dark and curled. The0 a& e; Q7 V  x# n' ?! z8 ^! c# a! z
testicular volume was prepubertal at 2 mL each.
1 l/ p; `, N. N% R6 T7 |The skin was moist and smooth and somewhat" K. k+ E) c' n
oily. No axillary hair was noted. There were no
# C  W$ w7 s9 _abnormal skin pigmentations or café-au-lait spots.6 G6 o& g5 V3 q
Neurologic evaluation showed deep tendon reflex 2+
+ X2 I; c2 f+ l* S% kbilateral and symmetrical. There was no suggestion
& P& B5 `! }$ a% o8 J/ hof papilledema.
: r, V% ^3 H6 f( U- V4 o) ~Laboratory Evaluation$ _' S, @1 W0 ?& i( F' e8 K
The bone age was consistent with 28 months by. m5 c. V3 i, N. n  e
using the standard of Greulich and Pyle at a chrono-
1 \9 J5 y* S1 g* S: vlogic age of 16 months (advanced).5 Chromosomal7 ]# }% Y) r! u0 d0 Y$ @
karyotype was 46XY. The thyroid function test
0 k: |' N7 U# ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  Y8 f& I5 \5 M& B3 J! ylating hormone level was 1.3 µIU/mL (both normal).
& B3 x9 ]5 c' w% j5 l, \The concentrations of serum electrolytes, blood
$ q4 d$ U% f% ^$ N4 hurea nitrogen, creatinine, and calcium all were
/ ^" J* X6 C6 m. v9 fwithin normal range for his age. The concentration$ D( R# S7 y3 H7 L+ s" o7 D
of serum 17-hydroxyprogesterone was 16 ng/dL2 h* i$ h6 }6 C) e' H# P, O8 t
(normal, 3 to 90 ng/dL), androstenedione was 20  _* \8 K& G! p: P# ]1 O% }
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  z" g- n: X& l# k" d- Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 C% X8 B7 W' z8 j, P% |: C8 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 \- l! U! R6 j. e. @
49ng/dL), 11-desoxycortisol (specific compound S)- x4 d2 V; B* A7 {3 C- i* a
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) F! A; S% N- b* P) m
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 {  b6 t* x/ J. v+ y9 ^; C, {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# s' y; j  L  K$ s; d7 B6 _; [% ?
and β-human chorionic gonadotropin was less than$ v/ D2 E& W7 z1 b6 i: {$ H. h6 F* v
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  m0 B) x& O% w% r' Lstimulating hormone and leuteinizing hormone
9 ^" s* j$ `: U, \4 W# Hconcentrations were less than 0.05 mIU/mL+ a$ `" N1 Z9 C
(prepubertal).1 n% s7 T2 {) {) h
The parents were notified about the laboratory
' K: G0 J) ]; Xresults and were informed that all of the tests were9 X( r' e: V3 J5 W+ L
normal except the testosterone level was high. The
+ ?/ I- H$ {, h' \  _6 Y1 G2 cfollow-up visit was arranged within a few weeks to
* J+ R7 f/ n4 j+ s8 m- Oobtain testicular and abdominal sonograms; how-
+ v. @$ ?3 X9 M8 O$ y# K* lever, the family did not return for 4 months.
' e- o- p- O7 b6 {- G3 rPhysical examination at this time revealed that the  q+ ^- S: u' }
child had grown 2.5 cm in 4 months and had gained
+ b+ Z7 h, N" ?$ ~5 l' f& ^7 j2 kg of weight. Physical examination remained: ^) z' d2 x5 w/ L0 U; ~! b
unchanged. Surprisingly, the pubic hair almost com-
8 ?2 S# k. T3 g. q2 ^" zpletely disappeared except for a few vellous hairs at
+ O* A1 V' y) z$ I+ G: r# L! Zthe base of the phallus. Testicular volume was still 27 c4 y3 a' K) Q5 x
mL, and the size of the penis remained unchanged.
# W$ w8 s. S& m* j# aThe mother also said that the boy was no longer hav-
3 d! |6 Y1 \2 C% hing frequent erections.2 Y+ A2 `( x0 C3 m  f
Both parents were again questioned about use of
5 p( G$ y2 {3 K0 M4 P" Y+ eany ointment/creams that they may have applied to9 g0 I# h) Z' A, [6 E
the child’s skin. This time the father admitted the- n9 u# f0 a% L9 O& q* G) L. T
Topical Testosterone Exposure / Bhowmick et al 5412 z6 C7 L5 l4 Q* i5 T
use of testosterone gel twice daily that he was apply-
8 r3 a- d- Q# X% a5 P/ `; Aing over his own shoulders, chest, and back area for5 t8 H: w; u* Y0 {" x1 L, K& t
a year. The father also revealed he was embarrassed! X4 b6 T7 t+ E- p, Z
to disclose that he was using a testosterone gel pre-
# ^3 b5 V# x! z" N# ^scribed by his family physician for decreased libido$ j4 U: ?- O9 p# o4 y  c. j5 R1 T0 }
secondary to depression.. t& m' M% Z* e
The child slept in the same bed with parents.  R5 |8 u6 w" i1 D" N7 t
The father would hug the baby and hold him on his; ~5 p7 P/ a+ t# b( g
chest for a considerable period of time, causing sig-2 W# ^1 A  C* O- e6 f6 Y
nificant bare skin contact between baby and father.
9 s+ S# h, N: b/ wThe father also admitted that after the phone call,
$ ~, V* T3 I3 H) P  V6 v* xwhen he learned the testosterone level in the baby
5 O2 ~3 `9 I( |& B0 I6 V  l) |was high, he then read the product information8 V, I4 }, M# S; Q
packet and concluded that it was most likely the rea-& s7 \% t( n) V- p* ~( x6 ~9 ~; w
son for the child’s virilization. At that time, they. c  C/ O2 X$ q: n2 b% y
decided to put the baby in a separate bed, and the2 Y. k- y& r% ?7 X6 r
father was not hugging him with bare skin and had5 k: _( S1 h0 K8 @! N
been using protective clothing. A repeat testosterone
! e4 {/ z/ K9 K% v2 o& Q2 xtest was ordered, but the family did not go to the
, S2 U  u- `! {2 {" I( [laboratory to obtain the test.1 R, \8 \3 i$ E' k
Discussion
! E: W$ G( N: w; JPrecocious puberty in boys is defined as secondary
9 Q( Q* |( m" D$ msexual development before 9 years of age.1,42 D! k- R% O) F; ^, _4 L
Precocious puberty is termed as central (true) when
6 c  u: l8 n1 w1 L# mit is caused by the premature activation of hypo-, N& h3 [+ y$ l$ h
thalamic pituitary gonadal axis. CPP is more com-' }/ f! \+ O+ d# Z( i- E$ [6 O
mon in girls than in boys.1,3 Most boys with CPP
+ M& m6 |" U# d, D, ~; q" j, a( r5 vmay have a central nervous system lesion that is
/ }' s/ L* i: A3 c; Y: D4 kresponsible for the early activation of the hypothal-; K- _' z! w) _" [: r
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 D+ \# g: \  s  K! ?sis has been given to neuroradiologic imaging in
, ?- a) e5 ^+ ]5 R. vboys with precocious puberty. In addition to viril-0 \8 o1 M* s8 M0 y( ~- s# ~2 U
ization, the clinical hallmark of CPP is the symmet-
# ^' S: w: P! U/ Zrical testicular growth secondary to stimulation by& g9 i7 Z' O" u7 L
gonadotropins.1,3
6 _& |" F1 G2 b! k( v0 J( I" YGonadotropin-independent peripheral preco-- [9 e+ U4 {) p$ e2 q
cious puberty in boys also results from inappropriate
( d& @9 f: p7 @androgenic stimulation from either endogenous or
! I: Q( h* ~8 h2 zexogenous sources, nonpituitary gonadotropin stim-9 o# v4 p. ^1 ]0 r3 Z# x! V) Z8 x
ulation, and rare activating mutations.3 Virilizing2 r* |- x# I! ?9 w* m- A9 Q% L
congenital adrenal hyperplasia producing excessive, y% W$ g: s  K# d; d, B
adrenal androgens is a common cause of precocious
- c/ B0 G4 o' R7 D# ~' {& |3 g1 g* Bpuberty in boys.3,4
( G+ Z- F7 C7 G- f8 ]. L# _: B7 VThe most common form of congenital adrenal, V$ b8 C/ H3 ]- a0 K7 |$ ~  ^; W
hyperplasia is the 21-hydroxylase enzyme deficiency.* X: w0 f! W' ~* N& l6 g
The 11-β hydroxylase deficiency may also result in/ i% a$ \0 M/ }. e: E
excessive adrenal androgen production, and rarely,3 J5 B2 z2 ^! g4 W3 N! n, f* R
an adrenal tumor may also cause adrenal androgen
' W5 x( k- d: g! c& pexcess.1,37 \4 D; |7 @2 @4 B; U9 O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, T( p* T9 Q" S* }( i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ P; I% ~- m6 M$ \A unique entity of male-limited gonadotropin-
9 F7 O" `4 X" Q5 c+ J9 i% {independent precocious puberty, which is also known
& c7 }* Y" u+ `6 I6 a5 ]as testotoxicosis, may cause precocious puberty at a9 U. A2 K, g+ w/ d( w( H* Y
very young age. The physical findings in these boys
) l) q+ {! ~' L" i1 K6 U+ gwith this disorder are full pubertal development,$ B. U$ T: l* ^
including bilateral testicular growth, similar to boys3 J% V4 i! @( Q5 A' O* E
with CPP. The gonadotropin levels in this disorder' c; M' B' P3 r% b) O9 U
are suppressed to prepubertal levels and do not show: Y8 q* I' W2 e' h; a/ Z1 C
pubertal response of gonadotropin after gonadotropin-5 ^! [" b- V! y9 `
releasing hormone stimulation. This is a sex-linked
) w; j' }/ ~/ Lautosomal dominant disorder that affects only3 F; Y, ?8 q) [& B# b3 o7 H2 L% x
males; therefore, other male members of the family
  ~7 l, I! M: u  \" _% X1 v: cmay have similar precocious puberty.3: Z, u! P1 I6 [# c
In our patient, physical examination was incon-7 A4 I. _( T/ F( x8 A
sistent with true precocious puberty since his testi-
* I1 I& J; X8 y) Dcles were prepubertal in size. However, testotoxicosis1 g5 `7 P2 |+ H$ I
was in the differential diagnosis because his father+ p3 T: a/ c# H9 N
started puberty somewhat early, and occasionally,
2 @5 \$ V% A2 E* Stesticular enlargement is not that evident in the
- q3 t" T( }1 `/ n! xbeginning of this process.1 In the absence of a neg-# O# K  c8 p0 h( c1 z2 i- |8 y
ative initial history of androgen exposure, our) h' b$ D9 C& ~8 Y4 P
biggest concern was virilizing adrenal hyperplasia,- Z" w; |$ J3 |4 U% n4 f* m
either 21-hydroxylase deficiency or 11-β hydroxylase- p' O* q# _& A2 a8 Z2 Q" O7 p2 m
deficiency. Those diagnoses were excluded by find-
. k" ?, q+ R% F5 [7 ring the normal level of adrenal steroids.% F3 o; f3 D7 V4 M$ E! S/ w" D6 q
The diagnosis of exogenous androgens was strongly& a4 c+ H& N8 V9 x# w* h/ w
suspected in a follow-up visit after 4 months because
) n9 P& o4 r3 R. G2 D4 i8 o. ^7 k1 Wthe physical examination revealed the complete disap-
$ |* F( d9 [$ {/ a; Npearance of pubic hair, normal growth velocity, and" f! K  N% h4 I; u% `  @5 O
decreased erections. The father admitted using a testos-
" a1 w6 _5 V  n: w' r- nterone gel, which he concealed at first visit. He was% z; R1 S0 B/ e+ h
using it rather frequently, twice a day. The Physicians’  e$ x0 P+ I7 B
Desk Reference, or package insert of this product, gel or
: D" L1 N0 f$ ~0 v3 x, b: Fcream, cautions about dermal testosterone transfer to# V# \; d( N( n  n6 O
unprotected females through direct skin exposure.) i1 n1 F* T" h4 Z2 m" M
Serum testosterone level was found to be 2 times the
9 d% g, x, H  lbaseline value in those females who were exposed to
6 K" t6 Z/ o* E) S9 Xeven 15 minutes of direct skin contact with their male
  ]- v4 o0 B0 e, b4 Epartners.6 However, when a shirt covered the applica-
. `* \, g9 X# L7 [0 ytion site, this testosterone transfer was prevented.& b( G6 B+ d  Y7 t6 m. _# J1 |1 I
Our patient’s testosterone level was 60 ng/mL,8 R( z* Q! K5 L$ t& `% _
which was clearly high. Some studies suggest that8 {. `# J8 ^# v
dermal conversion of testosterone to dihydrotestos-
9 Q9 L0 j! a; l2 |4 tterone, which is a more potent metabolite, is more
9 j- B8 L2 n4 y# L" g% `active in young children exposed to testosterone: ?" p5 y. X7 c; h3 o% J/ k
exogenously7; however, we did not measure a dihy-' z7 w! V2 z: @, @1 C
drotestosterone level in our patient. In addition to) M/ D; M) H9 r9 J
virilization, exposure to exogenous testosterone in7 N# j0 |4 m2 T" v/ f' g; H. M) m% O
children results in an increase in growth velocity and8 D# o1 C% X2 \8 m/ C. _
advanced bone age, as seen in our patient.
% b) o6 J5 f: M4 R! o" m/ r5 @The long-term effect of androgen exposure during
0 z) t/ {/ P2 F& u, pearly childhood on pubertal development and final
4 ?- l& K! I, O; s# C& Radult height are not fully known and always remain
' Y5 g! {, z3 [& j$ X: t# M8 R9 ba concern. Children treated with short-term testos-
. {8 D* Z7 ^( wterone injection or topical androgen may exhibit some
) F" ~) `* |( J( A3 tacceleration of the skeletal maturation; however, after
& R, ~2 `6 h8 ?# ucessation of treatment, the rate of bone maturation
: A# J  x" w/ L9 ?% V  x$ adecelerates and gradually returns to normal.8,9: @" W0 h, _- X3 B( t
There are conflicting reports and controversy' N" L6 \  P/ p8 _8 x. {0 q2 n
over the effect of early androgen exposure on adult
+ O) x  l5 x& d: F# A* W/ Y0 cpenile length.10,11 Some reports suggest subnormal
9 e+ |* H* X, ~! r. G1 c! D( Wadult penile length, apparently because of downreg-( U! s4 |3 q& l& O3 e
ulation of androgen receptor number.10,12 However,% |8 O7 I, d6 |2 \# W- J# C3 W) A
Sutherland et al13 did not find a correlation between
. L2 Q- j6 ?. H+ P! _* ^childhood testosterone exposure and reduced adult
# |" M$ M4 \/ V8 B( Z# ~6 tpenile length in clinical studies.
5 m$ Y; N0 ?% ?! W1 VNonetheless, we do not believe our patient is
4 R; f3 V# |* }# S, j' x7 V7 ~& `going to experience any of the untoward effects from( U5 z. Q+ F$ b' [# j
testosterone exposure as mentioned earlier because5 h8 K/ F' u" t
the exposure was not for a prolonged period of time.
3 F& Y5 M( A* w5 n+ Z( W  ~Although the bone age was advanced at the time of5 D( }# A3 ~8 _( x" e2 F: ~7 C
diagnosis, the child had a normal growth velocity at
: j# C! F8 H+ U, A% Xthe follow-up visit. It is hoped that his final adult
& C; ~4 e5 |0 _9 A2 xheight will not be affected.) e9 ^" h0 ^+ p3 j  W( `; {
Although rarely reported, the widespread avail-# E. X9 l7 J& ]4 c
ability of androgen products in our society may5 m1 o$ D! E* H0 G3 E7 N
indeed cause more virilization in male or female
3 @4 e" ^, \% h% [children than one would realize. Exposure to andro-9 q/ h6 _5 J4 b0 l
gen products must be considered and specific ques-
3 _: x/ n! A7 ytioning about the use of a testosterone product or; Q5 J7 {4 L& n2 x  q
gel should be asked of the family members during
, f- |* C9 w4 E  ?+ Tthe evaluation of any children who present with vir-1 V, k6 E6 @. S; d4 L
ilization or peripheral precocious puberty. The diag-4 X; ~& P0 g( t' L
nosis can be established by just a few tests and by
' L/ i9 k0 R6 M3 R9 ^appropriate history. The inability to obtain such a6 |4 b2 D2 k1 }& `' e
history, or failure to ask the specific questions, may
+ |7 i1 z$ T! N4 M" r3 ?. ^1 gresult in extensive, unnecessary, and expensive. T. t5 K$ j. w* D  S2 c
investigation. The primary care physician should be
, k7 V% s, P4 X0 ^8 m) S: E# j4 taware of this fact, because most of these children
! y5 K' y, S. j; `may initially present in their practice. The Physicians’1 @0 ?( r- o2 w1 w. c+ U9 b
Desk Reference and package insert should also put a" o1 J0 }: U' P6 @/ }6 `
warning about the virilizing effect on a male or2 n2 f" E) K- }
female child who might come in contact with some-1 `$ V6 M' g7 G# y, @
one using any of these products.% f3 a# R9 I: n! y# i
References, U3 C) _* F, b+ v
1. Styne DM. The testes: disorder of sexual differentiation
# w3 E) V% b9 Dand puberty in the male. In: Sperling MA, ed. Pediatric
0 I2 B6 J/ h5 K3 R* f  Z/ I0 Z& EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' K+ b! [, @" L
2002: 565-628.
. |6 b, n& f2 S1 f# _; e2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 T; ?4 v% s) W* F9 q; n! {+ Rpuberty in children with tumours of the suprasellar pineal
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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!

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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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
累計簽到:11 天
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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

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發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
累計簽到:3 天
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發表於 2025-1-19 02:41:05 | 顯示全部樓層
+ h: s8 ^' C3 W3 J# `% o% v
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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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