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Sexual Precocity in a 16-Month-Old; [7 |- c0 H* |1 |
Boy Induced by Indirect Topical$ G1 D7 B6 @$ s: h' N
Exposure to Testosterone# M- x8 V) \' d( K8 p$ P  s% Y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 B( h4 d) M+ |' `and Kenneth R. Rettig, MD1
/ U8 s, f/ m# i! g) }Clinical Pediatrics9 ~) x, E5 ^+ {- I: Y! \
Volume 46 Number 6
* y8 `! D% f! b- x1 X4 ]9 e* G8 }July 2007 540-543
# ^) a. t' v) J8 w+ s6 Q3 @. c© 2007 Sage Publications
1 v' V* k" e7 u: O: O10.1177/0009922806296651
, z; J* F) e8 R$ J" V2 i' Dhttp://clp.sagepub.com( A0 F$ \* b7 i4 {+ X1 ?* p" ?+ L
hosted at" N( {0 {- h- y1 {
http://online.sagepub.com
1 ^8 n. [/ w- {8 @( A& xPrecocious puberty in boys, central or peripheral,
. f2 I! K' h4 W! J7 l2 w/ Ois a significant concern for physicians. Central
& F* v  _6 D9 w2 y* X7 P6 s, `precocious puberty (CPP), which is mediated/ F/ H+ t; v% s0 w) A' u
through the hypothalamic pituitary gonadal axis, has9 e  \: f) u5 B; Y0 u# x! D
a higher incidence of organic central nervous system
; D0 M' A) Q) o2 z1 S- S7 u% Olesions in boys.1,2 Virilization in boys, as manifested5 O# e6 u% ]6 I
by enlargement of the penis, development of pubic5 c1 k: ~  t2 f& @, ~8 R
hair, and facial acne without enlargement of testi-' J$ @- A9 b( R( X$ M, b
cles, suggests peripheral or pseudopuberty.1-3 We
" x" y5 x: B  u5 K9 l! n. preport a 16-month-old boy who presented with the4 y4 _7 u0 d' l9 p
enlargement of the phallus and pubic hair develop-
, [5 R; n5 W: h* N& _4 }ment without testicular enlargement, which was due1 j3 t9 F/ c* ]5 I& P! c% J" p
to the unintentional exposure to androgen gel used by& Y5 H: V. t$ R/ F, j5 ~1 P
the father. The family initially concealed this infor-
- I( t- _! z: F* @( n$ ]7 ^9 zmation, resulting in an extensive work-up for this( [; e3 N; p& }, l
child. Given the widespread and easy availability of
! M) D) _! Z* C( H7 ]# D7 ytestosterone gel and cream, we believe this is proba-: o8 o3 R5 v! T! h4 D
bly more common than the rare case report in the
  D, q+ V. L0 H+ k# z' K, fliterature.4
7 q2 U3 I" U. `7 T6 X! oPatient Report2 i, o1 x- p' v( R% w/ e
A 16-month-old white child was referred to the
* |$ I7 u+ R- ~' d8 F  dendocrine clinic by his pediatrician with the concern& S3 |$ Q0 A. K/ M
of early sexual development. His mother noticed
6 [3 E0 }3 Y0 E# h. {# {3 k' Vlight colored pubic hair development when he was0 ~9 N# I2 i4 D% W) z/ v. h- S
From the 1Division of Pediatric Endocrinology, 2University of6 l* ?, Z( E5 b" {3 n" [8 t5 n
South Alabama Medical Center, Mobile, Alabama.
! b' C0 `0 m8 K+ F1 I6 c$ c; h0 aAddress correspondence to: Samar K. Bhowmick, MD, FACE,9 K" g/ q5 F8 X7 ?# F
Professor of Pediatrics, University of South Alabama, College of
5 y: R8 }' @# H' s/ aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* I3 }( u4 ^$ ]* C
e-mail: [email protected].
! V- H: B7 e! U% ^0 uabout 6 to 7 months old, which progressively became8 B% P, ~8 s/ e/ C( y6 N* v  E3 B. ?
darker. She was also concerned about the enlarge-3 K3 y, m  u+ O) d. c. z
ment of his penis and frequent erections. The child" c6 y: o* }$ p- {7 K
was the product of a full-term normal delivery, with) y$ y8 {5 ]: G  [* [
a birth weight of 7 lb 14 oz, and birth length of+ K1 Z7 N" h1 U: B8 I
20 inches. He was breast-fed throughout the first year3 H2 p- P0 Q1 ]% j7 x2 a' v; Q
of life and was still receiving breast milk along with, F3 R- B% F, B& |" h' r9 `
solid food. He had no hospitalizations or surgery,2 `( e: ]: }" z6 O3 w5 d
and his psychosocial and psychomotor development0 M, U/ d; }: d( Y
was age appropriate.( ~4 e5 E# S$ o) V8 ?
The family history was remarkable for the father,. D5 a$ F, u/ [& {8 u
who was diagnosed with hypothyroidism at age 16,& M" g+ g  Z% O* i% O; l; ]; X* K
which was treated with thyroxine. The father’s6 c0 j& w0 V# _* a; D3 W, ]
height was 6 feet, and he went through a somewhat$ U* K0 A2 P  n8 q
early puberty and had stopped growing by age 14.$ u/ h- m6 e  O& R5 t& S
The father denied taking any other medication. The" _6 c, ~  o( |# D6 ?: V
child’s mother was in good health. Her menarche. \8 P4 w: ~/ v
was at 11 years of age, and her height was at 5 feet: H/ a5 i, m. u& F* K2 ]
5 inches. There was no other family history of pre-& Y- M% z9 e6 Y* o, f/ w' h
cocious sexual development in the first-degree rela-
% H7 ]) i" t3 L' w$ ?- L7 m  Ftives. There were no siblings.0 F  }  q. ~3 j0 X6 X, v3 j
Physical Examination
0 [# z: b# E1 T# u2 }7 XThe physical examination revealed a very active,! O  y& b: ^" q9 I
playful, and healthy boy. The vital signs documented2 ~3 c' m7 ^, t  f5 v9 {. F
a blood pressure of 85/50 mm Hg, his length was" `' R! g- H9 |- f" z$ m) V% p
90 cm (>97th percentile), and his weight was 14.4 kg
" v( G% \8 t( F0 f# }(also >97th percentile). The observed yearly growth
% l! N( ]6 k: c( z, p* }velocity was 30 cm (12 inches). The examination of
/ u( K- ]- B9 y" o/ |the neck revealed no thyroid enlargement.; L: R8 Z3 G. [+ o' ]
The genitourinary examination was remarkable for
- U. D9 `) x7 T1 V9 Renlargement of the penis, with a stretched length of9 p& W6 j9 A- D" X5 r
8 cm and a width of 2 cm. The glans penis was very well
; D( Q1 @+ o# edeveloped. The pubic hair was Tanner II, mostly around
5 J( @! j2 ]9 Y1 v: ]# ^540
, B& d6 \- i+ y& o) qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 ^% H8 l' L1 l
the base of the phallus and was dark and curled. The
. a2 t( ^. J5 l5 v, u4 y  @- qtesticular volume was prepubertal at 2 mL each.
$ W: S! r! Y5 t( ^) e0 xThe skin was moist and smooth and somewhat# z. n2 q) W4 L' s& s+ e
oily. No axillary hair was noted. There were no
/ {7 u2 [& t' C7 P- V7 B& ^& w6 \abnormal skin pigmentations or café-au-lait spots.0 w0 c# }, h# Y6 r- |
Neurologic evaluation showed deep tendon reflex 2+
# z8 G+ s8 T$ i/ G6 ibilateral and symmetrical. There was no suggestion
3 \; J. v/ W  k; z: Dof papilledema.: x) [& D6 w4 `
Laboratory Evaluation
, {5 V) B' c1 z* `+ ?, XThe bone age was consistent with 28 months by
% K6 l( x* o! H; w2 E6 v) @6 Susing the standard of Greulich and Pyle at a chrono-
: i& u% e! W: d9 C, |logic age of 16 months (advanced).5 Chromosomal
* Q6 S. {/ w; G; f$ I% x% z% nkaryotype was 46XY. The thyroid function test$ S" o% v, M6 F7 v5 I# n! k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ x, B7 b0 o" O9 }/ xlating hormone level was 1.3 µIU/mL (both normal).
: i' ]1 V% x- I5 `The concentrations of serum electrolytes, blood' \3 k4 W, V. C1 u
urea nitrogen, creatinine, and calcium all were
& u$ m! i( N2 Y7 h) S" Z4 ~6 H# |/ Fwithin normal range for his age. The concentration! Y( O# @7 h& @  L6 J- T
of serum 17-hydroxyprogesterone was 16 ng/dL
  S; _! T( E' I( a/ a(normal, 3 to 90 ng/dL), androstenedione was 20
1 E' _& S2 j$ y1 F  l( bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- O- j8 f5 T2 C$ p  b% Z7 g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& L0 I& W6 C' z8 g2 ~
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 n# c" f6 Y5 U3 R2 T
49ng/dL), 11-desoxycortisol (specific compound S)
5 M( w( G- @5 B6 g1 ?  iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 w, y9 O3 R( u8 Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; E0 P% l3 U- Q+ e+ v" I# S3 x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# N* A' w( ?+ b" Tand β-human chorionic gonadotropin was less than
. M2 j! W2 S6 b5 q8 o5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 U. x" T% a) m' M+ X% X  m2 `6 kstimulating hormone and leuteinizing hormone! }3 U: y! r8 y4 {8 U# V. w
concentrations were less than 0.05 mIU/mL
, x3 y$ v8 A" z. g: Z  Z(prepubertal).3 r' H9 N8 E+ x* n5 k" L
The parents were notified about the laboratory4 l; G" H0 ]: E; t9 i
results and were informed that all of the tests were* r6 K9 @5 f# A7 n
normal except the testosterone level was high. The4 E8 ?. G" \/ J8 k! L$ B
follow-up visit was arranged within a few weeks to. H. E. o0 M, U0 I" m. T% h! R- |
obtain testicular and abdominal sonograms; how-
- ^. i# y' Q/ b1 d0 w, m: t3 \ever, the family did not return for 4 months.7 W2 s3 M8 H2 Q
Physical examination at this time revealed that the
* v% A+ g4 r: V& G+ M2 B- Ychild had grown 2.5 cm in 4 months and had gained
( m9 x# X2 O4 C7 P6 n) x2 kg of weight. Physical examination remained  k) |. r7 u& ~2 c* X" N
unchanged. Surprisingly, the pubic hair almost com-
$ l. n2 R! l# f7 s% G4 t/ Jpletely disappeared except for a few vellous hairs at/ Y, K  O' B; c# B4 G8 }+ j
the base of the phallus. Testicular volume was still 2- {2 [: T& y2 H
mL, and the size of the penis remained unchanged.; Y3 d4 i2 T7 T# E, c/ J
The mother also said that the boy was no longer hav-& }% p: S: v& E) j
ing frequent erections.9 e  ?6 v+ H1 x2 s# `+ _, h
Both parents were again questioned about use of3 Q# J1 j9 G# P, `+ i
any ointment/creams that they may have applied to. E4 n9 T) t) F- Q& e( z: T/ s7 h
the child’s skin. This time the father admitted the
+ D3 `! Z$ _' gTopical Testosterone Exposure / Bhowmick et al 541
1 T* ^/ a# z5 k% {0 Kuse of testosterone gel twice daily that he was apply-
- L: V, [+ h8 x: Ling over his own shoulders, chest, and back area for
$ M# s4 Z* w, s0 F- ka year. The father also revealed he was embarrassed
& M" Z0 |% U$ n; u" ]1 Y3 }& d' }to disclose that he was using a testosterone gel pre-9 V/ ?2 z, Q$ H& |1 w6 c
scribed by his family physician for decreased libido6 E" n& c! L* y% A2 Z8 K
secondary to depression.
; [7 x2 J+ l  e* }The child slept in the same bed with parents.
- Y4 w! M; d$ @/ t( m! ?' |The father would hug the baby and hold him on his2 U$ }* o% _3 p' A; a
chest for a considerable period of time, causing sig-
" i) o' w; l9 ~nificant bare skin contact between baby and father.
3 ]8 p. M- @5 U; A+ h) F2 ^1 _5 e; |The father also admitted that after the phone call,
3 p- ]3 c/ H. F9 d. c# `9 ?when he learned the testosterone level in the baby% S# P8 ~6 R" P
was high, he then read the product information
0 V/ [% W* l, @8 D- g; d6 f! k( Wpacket and concluded that it was most likely the rea-
. L  r8 k3 f1 h& z( V" Fson for the child’s virilization. At that time, they, I9 h1 h/ |8 g1 c9 k4 o$ h" W
decided to put the baby in a separate bed, and the5 Y! R- v$ L2 H" w
father was not hugging him with bare skin and had
, a  L& i9 M% bbeen using protective clothing. A repeat testosterone+ g8 L. Y8 D# [+ c6 @4 s. ]
test was ordered, but the family did not go to the' {) Z- r; E. E3 T! N) {) _/ L
laboratory to obtain the test.: x9 P4 i* l2 I5 a5 g. t
Discussion  ^  f- V6 u' c- L( z, S7 }
Precocious puberty in boys is defined as secondary
" W$ ]8 X1 G. j4 z4 {3 p) }sexual development before 9 years of age.1,4( A; C5 C1 W5 a0 h" ^3 @4 B
Precocious puberty is termed as central (true) when
2 w' k" F. C" w. l/ @( w; U/ bit is caused by the premature activation of hypo-
2 O+ x; F5 i+ F% Rthalamic pituitary gonadal axis. CPP is more com-
- n" H' Z# ]& l1 t5 J6 Tmon in girls than in boys.1,3 Most boys with CPP1 F/ b" \7 J+ @  P
may have a central nervous system lesion that is# c2 K. V5 G) M9 y, h
responsible for the early activation of the hypothal-
. y/ }9 w! {& j* ~& @& uamic pituitary gonadal axis.1-3 Thus, greater empha-
' g6 i8 v! f5 c3 @  M3 Xsis has been given to neuroradiologic imaging in- g' O% `* K0 a# W4 E1 V8 n0 _
boys with precocious puberty. In addition to viril-
7 j* d) H2 T8 Yization, the clinical hallmark of CPP is the symmet-: n( }. y- h! H. k7 g, o
rical testicular growth secondary to stimulation by1 ^% y$ j8 M# S+ m, ^. I
gonadotropins.1,3! l* L* |1 I; M$ e8 P( K9 x$ B& P1 o% q
Gonadotropin-independent peripheral preco-9 c( }. {( ~% ?' _
cious puberty in boys also results from inappropriate1 G: `/ P+ W' O0 `
androgenic stimulation from either endogenous or
1 T. T' Y8 }6 q4 i- Bexogenous sources, nonpituitary gonadotropin stim-
% P. X8 K# k& x& ^% c9 julation, and rare activating mutations.3 Virilizing- @3 F% \$ ]4 c: j
congenital adrenal hyperplasia producing excessive  l0 F) m& u- O  A4 Q  q) O& \* Q$ z" F
adrenal androgens is a common cause of precocious
% t( E! J4 c: f& Mpuberty in boys.3,4
# o( M* e  j$ l  |, SThe most common form of congenital adrenal
5 T- p2 U9 z3 T; |3 Q9 P3 lhyperplasia is the 21-hydroxylase enzyme deficiency.
. d) ^: b# [1 u. _1 p* OThe 11-β hydroxylase deficiency may also result in! Q/ X" V$ e0 H4 P* u
excessive adrenal androgen production, and rarely,
% V9 S5 F/ y; zan adrenal tumor may also cause adrenal androgen
, e% H, w3 F# ]6 o4 `! mexcess.1,3- {" D' ?* S# ^5 Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. }" _7 L0 |8 V  |- s9 r  Y542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 b6 X. u; t+ J6 W
A unique entity of male-limited gonadotropin-1 _6 D+ J  b, N
independent precocious puberty, which is also known
' }! r6 ]( E5 ?/ C8 das testotoxicosis, may cause precocious puberty at a+ I- H+ v0 \  c: l2 }, P
very young age. The physical findings in these boys$ j  C+ n% n! e0 s
with this disorder are full pubertal development,, Q/ u1 m2 U6 C/ D# s& Y$ g3 J) m
including bilateral testicular growth, similar to boys
8 n# v' r4 Z4 K, hwith CPP. The gonadotropin levels in this disorder: i$ U+ t) E4 u( e+ n6 b+ R
are suppressed to prepubertal levels and do not show- x/ ]3 O; l* E- z$ |7 |
pubertal response of gonadotropin after gonadotropin-- r. r  P6 U5 q6 M
releasing hormone stimulation. This is a sex-linked
! v+ p" ^# t8 |) oautosomal dominant disorder that affects only
- i; @9 l9 m4 j: c0 R' Ymales; therefore, other male members of the family" j1 V2 H# F* p, F+ O, F
may have similar precocious puberty.3
$ |+ T' S! Z; OIn our patient, physical examination was incon-, h+ s9 `/ T: U( s1 v/ c: s6 ?" H" S; W
sistent with true precocious puberty since his testi-- a# @2 [0 J7 W! g6 I% V
cles were prepubertal in size. However, testotoxicosis, l7 y. `6 X6 o* k
was in the differential diagnosis because his father
% O% i+ |$ \8 [: {# A! I! r7 hstarted puberty somewhat early, and occasionally,7 s' {6 k* M  d: H) A" D7 C
testicular enlargement is not that evident in the
& T6 `" [+ n, E# g6 Obeginning of this process.1 In the absence of a neg-
' L. V2 l' e. u5 u: g0 oative initial history of androgen exposure, our
% \- i: N8 f7 H% h0 _6 Wbiggest concern was virilizing adrenal hyperplasia,
) b6 n9 G! S) Seither 21-hydroxylase deficiency or 11-β hydroxylase' n0 j" P9 i0 O" N' N& {; |
deficiency. Those diagnoses were excluded by find-
4 \3 E5 z4 f9 }9 aing the normal level of adrenal steroids.
3 I: W# {) P( S3 ?The diagnosis of exogenous androgens was strongly2 w! S, y3 Z5 n7 y. {. ~: ^; O
suspected in a follow-up visit after 4 months because
2 r6 M$ V- a0 `$ W1 y, D8 e  bthe physical examination revealed the complete disap-. k% D" f! z/ @3 B0 g. g' C7 M- Q
pearance of pubic hair, normal growth velocity, and
: Z4 a# H" d% y% O/ C' idecreased erections. The father admitted using a testos-
7 z5 f6 A- h( j- Oterone gel, which he concealed at first visit. He was
! ?7 I% y( _6 L. Xusing it rather frequently, twice a day. The Physicians’
% _4 |' d1 H4 [% D% qDesk Reference, or package insert of this product, gel or- T6 W5 {/ {5 }3 p7 Y6 h( V2 I
cream, cautions about dermal testosterone transfer to
. y  i5 i, x4 B- ?- ~$ u8 ounprotected females through direct skin exposure.
8 g4 S3 n+ z9 J' xSerum testosterone level was found to be 2 times the* R5 b6 l& g" q- n
baseline value in those females who were exposed to
' J( O# T) X2 E4 S3 J; D4 o- g( feven 15 minutes of direct skin contact with their male4 e1 O% ^( L/ \4 n3 K
partners.6 However, when a shirt covered the applica-
5 r  P( e' s# ~5 f+ F1 Wtion site, this testosterone transfer was prevented.
9 H, P  i9 @: r6 w; oOur patient’s testosterone level was 60 ng/mL,. U, Y$ \' @& H; B/ u3 ]" B* c% L
which was clearly high. Some studies suggest that; l9 z4 M: O4 E6 L
dermal conversion of testosterone to dihydrotestos-# }; ~7 L' }/ q/ `$ g2 X0 ?
terone, which is a more potent metabolite, is more
+ r% x  r! q0 j0 H2 ?active in young children exposed to testosterone
" }5 n  L# r9 V5 [; A0 Vexogenously7; however, we did not measure a dihy-8 P+ P& M1 H. q( x2 F& R' I2 W  m
drotestosterone level in our patient. In addition to2 d$ `& S1 Q$ N% p
virilization, exposure to exogenous testosterone in
6 S4 u! a/ W; ]# Wchildren results in an increase in growth velocity and
8 e$ c" r: e7 g$ A: x0 Iadvanced bone age, as seen in our patient.9 H  ?, v$ J; D1 h# N7 R# C
The long-term effect of androgen exposure during/ D" s* \7 ~2 d" Z: J5 A
early childhood on pubertal development and final8 H- |) Y, A" ?: B8 d2 M
adult height are not fully known and always remain, C/ R- a9 o. R4 @. A$ P
a concern. Children treated with short-term testos-
1 Y' g& F7 ~$ C8 B4 v8 q9 P. o# bterone injection or topical androgen may exhibit some  M9 c2 [+ S/ ^8 q& W1 b
acceleration of the skeletal maturation; however, after
; o# u  d' {- q5 l. C  v' Kcessation of treatment, the rate of bone maturation
6 c+ o6 M0 I" O; O4 Jdecelerates and gradually returns to normal.8,9  w2 i. [$ L% x$ ]+ q7 ~$ m3 ?
There are conflicting reports and controversy
4 r! f3 p5 l  p8 v/ Yover the effect of early androgen exposure on adult5 U1 U( m# i3 j, n) A5 o, Y( v
penile length.10,11 Some reports suggest subnormal& I' z  W- }' W0 Q1 l6 Y
adult penile length, apparently because of downreg-
* t; x' i9 Z# n: D# `ulation of androgen receptor number.10,12 However,# W* j: v* H" z8 t# K  y
Sutherland et al13 did not find a correlation between, }+ s( k! y3 p) b8 V3 _
childhood testosterone exposure and reduced adult
2 L2 ?) `3 t2 z% ^/ Jpenile length in clinical studies.
3 j8 p' g4 i! z7 c# zNonetheless, we do not believe our patient is
$ q, f% M7 h! o5 bgoing to experience any of the untoward effects from  Q, v, V. D5 x. ^. w" F0 y
testosterone exposure as mentioned earlier because! a, k- }" E# S
the exposure was not for a prolonged period of time.! R5 h4 [. y' B1 N8 ^- W/ M& O
Although the bone age was advanced at the time of
# o2 ]  y' j" ], u* pdiagnosis, the child had a normal growth velocity at
8 u8 `! `+ O: N0 a) kthe follow-up visit. It is hoped that his final adult+ c5 F. g. c% x: x
height will not be affected.
% |! Q+ K) z* h$ K9 aAlthough rarely reported, the widespread avail-
; A$ W9 o. p9 j& {. \, fability of androgen products in our society may4 G% Y- a! B4 {5 U0 l
indeed cause more virilization in male or female+ o; g4 r. ~/ v% _9 I
children than one would realize. Exposure to andro-2 ?% N$ M" Z! b" i# M& {
gen products must be considered and specific ques-
0 M' t$ Y' L  E7 \+ R8 Q* p5 e- Z0 stioning about the use of a testosterone product or' o7 R7 S, f8 t4 U6 V% j
gel should be asked of the family members during
& d7 y( E! H% `" X& [7 W5 G* Zthe evaluation of any children who present with vir-
& v" s9 t- H2 Y% `% ]* Y8 F% lilization or peripheral precocious puberty. The diag-  D( m$ h: r0 R* c8 ~+ _' e
nosis can be established by just a few tests and by
& J  }, ]4 m9 u* c6 [( Uappropriate history. The inability to obtain such a& G8 B- M0 {/ M. I! g
history, or failure to ask the specific questions, may
! x1 Z, y4 h! kresult in extensive, unnecessary, and expensive
# v$ H$ V5 y5 ^/ `( p! \investigation. The primary care physician should be6 o! S. S$ _" k
aware of this fact, because most of these children
7 ]6 m( i& ~0 k6 Q* K. G! m" Lmay initially present in their practice. The Physicians’
( ~' A) O: c+ \' G- m" x  eDesk Reference and package insert should also put a
; K- S; J9 c7 \2 _! Awarning about the virilizing effect on a male or
& I9 T. p) c0 [" k  Rfemale child who might come in contact with some-8 k- D* P$ p9 f4 l: e. \) l, W! i
one using any of these products.$ C6 c+ K$ I0 y' N! C4 @
References
  r8 f! P- E4 w3 j3 u: b1. Styne DM. The testes: disorder of sexual differentiation2 ?( N* d6 L, @9 G
and puberty in the male. In: Sperling MA, ed. Pediatric
( t8 J3 c* L& d3 r2 L& \8 aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ U) X5 L" Y4 P, ?- \2002: 565-628.; r) }( O7 \5 g, l- n) \$ q; s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! W8 v" D2 ]0 ]8 k5 v
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
, Z; |( X; q+ w& ?' Y: E' wBoy Induced by Indirect Topical+ m+ h6 j/ u. q+ y8 ^
Exposure to Testosterone
6 t  G0 a  v' u" _! X6 RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ ]* m( r6 x3 S1 sand Kenneth R. Rettig, MD1. G# ~) q+ k9 j4 f+ E. c! e% W
Clinical Pediatrics
0 d& f; h1 J! S% G' c& o0 s" uVolume 46 Number 6# s, m7 P4 Z0 ]
July 2007 540-543
# B4 m" S0 A3 M, B" ?9 V" Z7 x© 2007 Sage Publications3 \4 W: o. \1 k( h
10.1177/0009922806296651
# `0 b5 U/ |8 y7 R! thttp://clp.sagepub.com7 e- l9 v5 V5 b3 \3 K1 i& j
hosted at
* `' e/ h: v4 y" Whttp://online.sagepub.com# h! d6 `# I  n3 D9 h
Precocious puberty in boys, central or peripheral,4 p8 x& g' _7 F0 z- q3 B% w5 @# X% w
is a significant concern for physicians. Central
( Q/ M$ s6 F2 D: _) a# `# Wprecocious puberty (CPP), which is mediated
6 r9 E3 l0 ~' A& I1 Z# n4 Kthrough the hypothalamic pituitary gonadal axis, has% V' L+ @* G7 F/ _3 n; V1 t1 I4 b
a higher incidence of organic central nervous system
6 @5 d/ _% Q2 S/ A( |, Blesions in boys.1,2 Virilization in boys, as manifested& Y# Z- x0 ]4 n- {1 j! e
by enlargement of the penis, development of pubic
8 c- H: n2 ]6 T$ j( _2 fhair, and facial acne without enlargement of testi-
: k0 E/ d" B6 }& p$ @# \( f1 Gcles, suggests peripheral or pseudopuberty.1-3 We4 F: ]4 J2 j* m
report a 16-month-old boy who presented with the
, |* K. r; f) |8 T6 Nenlargement of the phallus and pubic hair develop-$ ]6 V2 x' L' ~& _' p
ment without testicular enlargement, which was due
' b0 c9 s. r0 e, Uto the unintentional exposure to androgen gel used by
8 F3 y- A: f; U* F) u7 Vthe father. The family initially concealed this infor-
' @/ b# W2 e6 \4 k5 y1 omation, resulting in an extensive work-up for this
4 i4 m. z9 w' _4 Echild. Given the widespread and easy availability of
4 d5 {: K/ G+ Ftestosterone gel and cream, we believe this is proba-; `/ d- W; c' S- p9 L: M: u
bly more common than the rare case report in the
  @& @" n) I3 m( rliterature.4& T1 |& {' C9 y9 d
Patient Report
$ q  P2 \- r  c( l/ L% B9 U7 oA 16-month-old white child was referred to the! }" M. I2 t8 D  A' x2 K# ]
endocrine clinic by his pediatrician with the concern$ v1 |. i. f+ ]
of early sexual development. His mother noticed1 W1 L4 V/ K: W2 A9 O* |7 B2 u6 I0 E
light colored pubic hair development when he was
* s5 ~: j* @4 m) j' q& Z/ D  R1 TFrom the 1Division of Pediatric Endocrinology, 2University of
' j$ x9 H3 Q. U' _* w4 U2 D% W8 O, ASouth Alabama Medical Center, Mobile, Alabama.+ ]; l. ]# Z. W6 E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
" q& M  ]* S! H# i9 H3 [Professor of Pediatrics, University of South Alabama, College of$ @& t! J2 H& _. V: a6 `% M: ~) D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. E- G" N* @' [( @4 A+ w1 ~e-mail: [email protected].7 o: J- x% E8 Y: o9 b5 A  E/ g
about 6 to 7 months old, which progressively became
( d- d7 X5 a% z5 U4 Hdarker. She was also concerned about the enlarge-
- O! ^2 O! w) Sment of his penis and frequent erections. The child( Q2 R2 C! s0 M5 a
was the product of a full-term normal delivery, with& Y$ P; [1 M# R% x7 k4 d4 Z5 e  M
a birth weight of 7 lb 14 oz, and birth length of
8 ^, ?5 o3 A- n+ ]20 inches. He was breast-fed throughout the first year
4 b9 ~8 x6 [7 |* O9 |of life and was still receiving breast milk along with
. s+ |- j% a8 E' j7 V0 usolid food. He had no hospitalizations or surgery,/ L# Q- q% {8 i9 P+ `3 N, D
and his psychosocial and psychomotor development
1 T: {; C6 @. X: kwas age appropriate.! H' |4 T+ w/ a; T; l$ G; V
The family history was remarkable for the father,* F$ ~8 A# Y1 u7 U2 W  `; X; o
who was diagnosed with hypothyroidism at age 16,$ \& E2 n7 S' y
which was treated with thyroxine. The father’s7 X9 o3 W: q* s5 E0 `" E" ^2 R
height was 6 feet, and he went through a somewhat0 g& r  N* v! Q4 r; c2 G
early puberty and had stopped growing by age 14.' f' u' F) X' _$ B0 W4 n
The father denied taking any other medication. The
& `( p7 V1 \2 D# n6 K  `/ u& T# g' Ochild’s mother was in good health. Her menarche
" f6 \1 ~9 P! d  Z6 ^" d$ Nwas at 11 years of age, and her height was at 5 feet; h9 E1 |: `1 C4 }/ o3 C
5 inches. There was no other family history of pre-
- {; V. X0 a5 l9 }; J9 ?6 ]% y, ]: acocious sexual development in the first-degree rela-& T4 |! E1 N% V* o# h/ L* \, A
tives. There were no siblings.* H# b: j6 Q  ~- C0 p& A
Physical Examination
: E$ ?# G) w- y, P6 c/ M6 o+ uThe physical examination revealed a very active,5 p6 h4 t, c2 C: r+ _2 i2 C- \
playful, and healthy boy. The vital signs documented
! p# U  M- S8 I% ?$ oa blood pressure of 85/50 mm Hg, his length was% j$ ^& p( y$ \% k7 Y
90 cm (>97th percentile), and his weight was 14.4 kg( N, x& c7 R8 r! @3 u% |9 x9 R' V
(also >97th percentile). The observed yearly growth' U$ ]' A/ m% H! I
velocity was 30 cm (12 inches). The examination of9 B* }  o4 Q2 a6 a6 T5 X
the neck revealed no thyroid enlargement.
5 ~% G$ G' |% [* o; ZThe genitourinary examination was remarkable for
9 d0 u- d& z) z/ n% Q( Genlargement of the penis, with a stretched length of* R6 k: @' H+ M
8 cm and a width of 2 cm. The glans penis was very well# P& s. F& x% d
developed. The pubic hair was Tanner II, mostly around' l8 n! e' P4 G) G% v" z9 |
540
& o$ x; {# w! H: x- z- fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# }3 v  ^6 D, Z: [, ~
the base of the phallus and was dark and curled. The8 ^/ E& g1 q* F  j7 ~
testicular volume was prepubertal at 2 mL each.* f% f7 |8 r+ k% \5 \  ~! ?
The skin was moist and smooth and somewhat
. Q/ y# |5 }0 B1 w" M  P0 foily. No axillary hair was noted. There were no
( Q8 f5 u( ~2 z0 tabnormal skin pigmentations or café-au-lait spots.0 V7 o1 x8 S8 {$ @6 @
Neurologic evaluation showed deep tendon reflex 2+
7 O! P; W) A. _% M( Jbilateral and symmetrical. There was no suggestion5 |; W7 v' Z, X( m1 l
of papilledema.
. b3 y* E6 H+ m0 B3 ^( ?7 lLaboratory Evaluation
2 N% P$ G) s3 D4 M' Z- H5 D- r1 zThe bone age was consistent with 28 months by: i6 N1 q9 Y) v* h  d
using the standard of Greulich and Pyle at a chrono-
$ T6 J1 c2 D+ K* ?, f# i+ \logic age of 16 months (advanced).5 Chromosomal
* l' B3 [" R+ a0 ukaryotype was 46XY. The thyroid function test1 f7 V5 d7 b. L: w
showed a free T4 of 1.69 ng/dL, and thyroid stimu-) t" \; p# T6 \4 O- ~6 h
lating hormone level was 1.3 µIU/mL (both normal).
% v! f1 U  Z! {. L" }5 q$ aThe concentrations of serum electrolytes, blood
3 Z; j0 l) i. E- x- r" `urea nitrogen, creatinine, and calcium all were
# m/ X6 k! w' P% [8 r4 i: Dwithin normal range for his age. The concentration& k( c$ N* Y* W  D9 k2 s* g
of serum 17-hydroxyprogesterone was 16 ng/dL" m; b$ Q. M  l* |! i" A# ^+ W
(normal, 3 to 90 ng/dL), androstenedione was 20
1 J5 O4 N8 h- R' P' A  Q0 A3 [ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- {7 q1 r. B# _, X+ ]( [terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ z5 e- _9 F" `# `0 k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; M9 e3 Q2 Q8 M5 x* t/ W9 G3 m
49ng/dL), 11-desoxycortisol (specific compound S)3 a& }0 m0 ?: K8 i6 j
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 J9 a; y& |9 D; H: Z$ _tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, }! J! Y9 O  e$ h5 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: b. D; a, X, u% y% z; cand β-human chorionic gonadotropin was less than
" k. _+ o3 O6 F5 mIU/mL (normal <5 mIU/mL). Serum follicular. G! y! E( M, l4 o
stimulating hormone and leuteinizing hormone+ M. M+ s, w' z" Y) l4 ]
concentrations were less than 0.05 mIU/mL2 l# R! Q1 E/ O
(prepubertal).
/ G& d5 A# j4 i7 T5 D) N: ]2 ?* ]The parents were notified about the laboratory
9 `4 o; i5 [/ B5 e0 S" `results and were informed that all of the tests were
% M, q: u6 o) N3 T1 ~normal except the testosterone level was high. The. ]6 T. N, }. A5 I/ I
follow-up visit was arranged within a few weeks to
% S2 L  @5 W8 t1 mobtain testicular and abdominal sonograms; how-
7 h- r# W, I9 F; d5 u. fever, the family did not return for 4 months.
9 L. z) \/ A% t) c* nPhysical examination at this time revealed that the  f0 w( ?2 M4 e; D  M1 I# g
child had grown 2.5 cm in 4 months and had gained
  v/ |9 t% ]$ q" _8 o8 S2 kg of weight. Physical examination remained
% [& y) Z' C9 T  i( aunchanged. Surprisingly, the pubic hair almost com-
# l/ e5 d' w  B# \. }pletely disappeared except for a few vellous hairs at
5 }$ t  W7 j5 k  h8 F2 Hthe base of the phallus. Testicular volume was still 29 ~3 c/ F6 M0 F1 |! v
mL, and the size of the penis remained unchanged.) J9 v! w2 H! W3 j( n
The mother also said that the boy was no longer hav-
! w8 [  I6 e- h( ^ing frequent erections.
! C7 \( t( P3 d: ~& M" _2 N) dBoth parents were again questioned about use of- h2 r$ l% E  ?2 [/ O4 r
any ointment/creams that they may have applied to
5 U( Y& h6 B& {& Q2 o' w9 i4 w, T  d8 Wthe child’s skin. This time the father admitted the
, y1 g2 {( k& i0 h- gTopical Testosterone Exposure / Bhowmick et al 5412 p( q& ]6 x8 I9 _
use of testosterone gel twice daily that he was apply-
  h+ L4 ^, T# d$ i6 V/ ding over his own shoulders, chest, and back area for) n& f# h% s- G" M- g
a year. The father also revealed he was embarrassed
6 ~6 L1 g0 d% r( N- _5 qto disclose that he was using a testosterone gel pre-2 {4 B$ ^" s% i1 b7 B. a
scribed by his family physician for decreased libido: g, b$ s& J9 {& E3 C' Q) L4 c
secondary to depression.' C* `8 w# x3 K* x& V* a% H
The child slept in the same bed with parents.
7 T  O) n; M; O1 @" {: VThe father would hug the baby and hold him on his! h, S# b/ w; C% T1 o' i6 ]$ q5 X$ r
chest for a considerable period of time, causing sig-  `! }7 r$ h8 T2 k1 [- h
nificant bare skin contact between baby and father.
; Q: z; R3 {  s, W; i" |, FThe father also admitted that after the phone call,
0 n  b$ @" i- N( k& l' M+ X* n' awhen he learned the testosterone level in the baby
5 p' u/ ^: B5 U5 gwas high, he then read the product information
6 [4 C0 r1 V+ B. F% }packet and concluded that it was most likely the rea-
6 X& {: ^5 G3 f; E$ `son for the child’s virilization. At that time, they' G3 C9 g8 C: F$ ^, \
decided to put the baby in a separate bed, and the
9 _: D" n9 s  L* X1 u, f. F) ^4 s% kfather was not hugging him with bare skin and had
( {) k* H6 y  ^6 ~0 ybeen using protective clothing. A repeat testosterone% V# s  n+ N  e9 }7 N8 I! u
test was ordered, but the family did not go to the; I+ N* I5 \2 X* Q
laboratory to obtain the test.
- O3 Y4 X/ {! D0 U1 C& @% x0 I/ G2 pDiscussion" B0 q, I) E/ A+ z1 Q- w, _- @
Precocious puberty in boys is defined as secondary4 m, ^) p$ D7 Q% D5 Q
sexual development before 9 years of age.1,40 b6 Y# L* s4 h) k7 D
Precocious puberty is termed as central (true) when
. j. E% u4 L1 x, P! L' _" Git is caused by the premature activation of hypo-; Q; \4 I& v+ r( l; r
thalamic pituitary gonadal axis. CPP is more com-4 r, H! K6 _; ?# L& }
mon in girls than in boys.1,3 Most boys with CPP4 D  p* l; y# G: A' s
may have a central nervous system lesion that is
3 Y7 E: B( k  c+ f  H, M) }responsible for the early activation of the hypothal-7 @9 a' W: ^3 p6 O
amic pituitary gonadal axis.1-3 Thus, greater empha-  V3 S& k4 v) t$ a5 U' ^- n: `3 ^
sis has been given to neuroradiologic imaging in
+ x5 Q0 q" B) p! R, Sboys with precocious puberty. In addition to viril-
  V, d" p5 q: \0 yization, the clinical hallmark of CPP is the symmet-
1 M+ b3 i5 z/ p# M; o; A+ erical testicular growth secondary to stimulation by) ~! u; S4 [3 |+ l2 F
gonadotropins.1,37 ^# e; M5 D# ]. R4 N
Gonadotropin-independent peripheral preco-% ]. [" S# A8 O; l0 f
cious puberty in boys also results from inappropriate
2 X- u3 ~, Y1 tandrogenic stimulation from either endogenous or
/ p8 t; X) ~' b4 O- R* m8 X2 ?* Uexogenous sources, nonpituitary gonadotropin stim-; W. \9 ^1 ^+ T2 d/ W
ulation, and rare activating mutations.3 Virilizing. J3 o- I. r$ z) z& T, o) V
congenital adrenal hyperplasia producing excessive
0 p) i9 t& k6 dadrenal androgens is a common cause of precocious% `8 X' P( M. a) F, ^5 C8 \
puberty in boys.3,4
+ T7 T* i- J& A; J6 \, N2 q6 \0 ^The most common form of congenital adrenal; }9 x( ]- q' Q' g! k
hyperplasia is the 21-hydroxylase enzyme deficiency.' A5 l  ~  h! D; o8 T
The 11-β hydroxylase deficiency may also result in$ k% O. z) Q% s+ {/ [$ ~) U& Q  P
excessive adrenal androgen production, and rarely,
, ]# i( N; Q' G, _an adrenal tumor may also cause adrenal androgen
" e1 m( ]( o+ _. u1 Y5 l. hexcess.1,3
) A$ P1 _% D6 T) W+ eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# C) `* n, i5 _' M$ H5 P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# h* L! W) m# O
A unique entity of male-limited gonadotropin-7 K6 c, @  a' D3 i" q3 L
independent precocious puberty, which is also known
3 }9 K7 s) k1 _0 |8 O6 Ras testotoxicosis, may cause precocious puberty at a
/ l2 i/ I8 |1 [9 W, nvery young age. The physical findings in these boys
# O; a4 @, H$ Z  s8 o% X" H2 kwith this disorder are full pubertal development,/ C% w  K1 V7 f' x& \* [0 T7 g
including bilateral testicular growth, similar to boys# R  e( G% g4 T" }3 s: `, M
with CPP. The gonadotropin levels in this disorder
4 b/ w- i0 v& r1 I+ c- O, c3 l# e" uare suppressed to prepubertal levels and do not show4 i0 w, \2 Y& I
pubertal response of gonadotropin after gonadotropin-) W" K$ t: @$ O- F% ]1 R
releasing hormone stimulation. This is a sex-linked9 T, M. A$ Z6 ~0 L5 l
autosomal dominant disorder that affects only
1 d% L6 ?( p) `( l0 {5 Mmales; therefore, other male members of the family$ T$ [# E( x" f( m6 i
may have similar precocious puberty.3
  a- _9 R- B! vIn our patient, physical examination was incon-' q. _5 y5 v2 L5 ?$ u  a
sistent with true precocious puberty since his testi-: M, U: A4 g2 L( ^3 B: O
cles were prepubertal in size. However, testotoxicosis
+ ^, j. h1 N* A* L# e- F( rwas in the differential diagnosis because his father! T  l* ^! w; ~. A, }  O
started puberty somewhat early, and occasionally,  t5 `9 O7 t& t. ^) s$ _
testicular enlargement is not that evident in the
* Z* s$ ]) D. t6 F5 {% x  @& H$ Rbeginning of this process.1 In the absence of a neg-/ r2 F  l  ?  c1 E( p5 U
ative initial history of androgen exposure, our
: c4 u5 t) O, j; R# ubiggest concern was virilizing adrenal hyperplasia,
& Z6 V3 K3 f% N' d3 z) u, [* |either 21-hydroxylase deficiency or 11-β hydroxylase( a; ?1 I: C; ~, C9 d9 f
deficiency. Those diagnoses were excluded by find-
, O6 j3 B# \5 S2 J; Jing the normal level of adrenal steroids.
$ p8 A( \* k) _% BThe diagnosis of exogenous androgens was strongly
- ]9 X, I/ e  R! U6 Vsuspected in a follow-up visit after 4 months because
  n3 h, j8 }. Y0 L$ d5 a5 D6 q' othe physical examination revealed the complete disap-# ]1 B2 N8 m# o" d( i. Q
pearance of pubic hair, normal growth velocity, and5 G/ t' Y& a2 p7 u9 L1 O3 D$ E; Q
decreased erections. The father admitted using a testos-& H  N! |- I3 J( y$ T4 A6 h
terone gel, which he concealed at first visit. He was
5 j3 [- N, a* B. eusing it rather frequently, twice a day. The Physicians’5 Y+ R! U- H( e& [3 ?, e
Desk Reference, or package insert of this product, gel or
" H, Z, p9 |* r, P# f( V* Fcream, cautions about dermal testosterone transfer to
4 k4 X" T' U' l$ uunprotected females through direct skin exposure.
6 i+ N6 Z, E; S0 TSerum testosterone level was found to be 2 times the
0 N3 ^2 s2 S" ]+ x: `, {baseline value in those females who were exposed to
5 c& n% K, G- y; `  geven 15 minutes of direct skin contact with their male
+ w2 f# h6 r" ]  T5 b% Fpartners.6 However, when a shirt covered the applica-: y- u# C  x4 |
tion site, this testosterone transfer was prevented.
7 }5 t' }0 o( J5 {  V9 m$ L2 w  E* WOur patient’s testosterone level was 60 ng/mL,
- {( w; S4 x' D* x$ A' _9 [which was clearly high. Some studies suggest that0 J/ A2 q$ a" C1 d1 j
dermal conversion of testosterone to dihydrotestos-* P' x3 D0 h$ p4 m
terone, which is a more potent metabolite, is more
% b, \4 N+ z3 hactive in young children exposed to testosterone/ X; t6 t! h* @3 I! Y' f- K
exogenously7; however, we did not measure a dihy-
( j  A( k/ |' _- U. o% Mdrotestosterone level in our patient. In addition to6 ^) d, ^4 R6 d: R  I: j
virilization, exposure to exogenous testosterone in" {0 k: q4 N( _; L9 P
children results in an increase in growth velocity and& O, C8 W# ]' R1 j9 W# f, v
advanced bone age, as seen in our patient.
  H% Y7 [5 R2 a# ]The long-term effect of androgen exposure during
4 J0 g; d! ?2 V# o4 _& Uearly childhood on pubertal development and final, D7 Z1 t& l% }' t, Y8 ~
adult height are not fully known and always remain$ \+ R; t! h, Y+ }( Y2 W
a concern. Children treated with short-term testos-
' a; W6 _3 |2 ?4 P6 H+ G: R- g, F5 m1 {terone injection or topical androgen may exhibit some8 o# o0 w% I% R0 `
acceleration of the skeletal maturation; however, after
- w3 l+ j4 Z& K- n* o3 Ycessation of treatment, the rate of bone maturation8 J" [( `! Q2 ?  C7 c
decelerates and gradually returns to normal.8,9) F0 n8 g& [6 M6 _8 {" Z( {4 i
There are conflicting reports and controversy+ w% h* h2 g& Y' I. C: L
over the effect of early androgen exposure on adult+ z2 j$ E+ M" K8 {( C
penile length.10,11 Some reports suggest subnormal- e, B. F* l; N9 v) s
adult penile length, apparently because of downreg-
; @7 {# _  ?+ q6 [% g9 b) |4 U' A; aulation of androgen receptor number.10,12 However,% L/ g3 T: S+ T% V' t0 G, s
Sutherland et al13 did not find a correlation between
  x6 g+ [( K6 wchildhood testosterone exposure and reduced adult+ l4 L2 k$ l$ K' i* W
penile length in clinical studies." X9 b" d( b0 F7 Z5 Z
Nonetheless, we do not believe our patient is
0 f% [2 \9 Y/ ~+ x: e. z% g7 bgoing to experience any of the untoward effects from
  _& m5 P: E8 v5 q5 D4 B0 ]: |% jtestosterone exposure as mentioned earlier because
' \) Y; Z4 q6 H$ ]3 Vthe exposure was not for a prolonged period of time.
+ s5 Z- @9 |8 h3 oAlthough the bone age was advanced at the time of
0 t" h5 G: L6 L3 [diagnosis, the child had a normal growth velocity at( c8 M% E0 `2 u' Q" ]3 b
the follow-up visit. It is hoped that his final adult
3 T' P2 |; [! hheight will not be affected.9 T4 V/ |3 g% D% j
Although rarely reported, the widespread avail-( n) F# `: [  `5 R: p7 L' M9 A
ability of androgen products in our society may- g* U4 c, [& h4 u; s( {7 t
indeed cause more virilization in male or female
6 Z9 a, ^/ B: M2 _* F: Lchildren than one would realize. Exposure to andro-
' {) N6 j' H$ T+ H2 \- Z$ w; Kgen products must be considered and specific ques-
5 ?1 Q" \- ?+ q' v' Ptioning about the use of a testosterone product or
; q3 ?- y$ |/ e5 xgel should be asked of the family members during6 e! O, [5 D; X9 }
the evaluation of any children who present with vir-
/ l: m# ]& n6 h5 U: u/ milization or peripheral precocious puberty. The diag-
) D: h# k) `) Onosis can be established by just a few tests and by
: W7 n% H) [4 G9 V$ I; K1 ]appropriate history. The inability to obtain such a
" P( c5 Q+ {, }! l- E. `history, or failure to ask the specific questions, may0 k+ S$ T, h/ N$ W  U& T
result in extensive, unnecessary, and expensive
. v" `% e1 [  l! j( cinvestigation. The primary care physician should be
" C7 o% ]( j8 ]2 ]9 Paware of this fact, because most of these children( Y2 y& o! U( ?9 d! s9 \5 e, p
may initially present in their practice. The Physicians’  }$ {2 ]2 |6 J- H+ k% x, s
Desk Reference and package insert should also put a" K, p& `2 w# W: f. F
warning about the virilizing effect on a male or: ~0 f* m. R  h2 G9 d9 e9 B
female child who might come in contact with some-/ s9 o/ j/ ~9 t6 _% }- Y
one using any of these products.
# B* Q, ?+ Z; S. i+ N5 j0 U: b, wReferences
6 I- T& X9 d' L. H) G4 t1. Styne DM. The testes: disorder of sexual differentiation
) h8 l: X3 X) w& y+ Jand puberty in the male. In: Sperling MA, ed. Pediatric$ T" c* n2 y' O. [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! k' p' ~. z4 ~# \& X% U
2002: 565-628." e( G' P9 Y' u' d% c$ d: l. W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" e( r) w! K6 d1 O0 [puberty 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!
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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
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4个什么样的?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層
2 e) ^4 l2 O8 m4 C% a1 b
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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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