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Sexual Precocity in a 16-Month-Old
& P+ i# y; q( u# _Boy Induced by Indirect Topical
8 Q6 X) [8 l! e1 ]7 u4 H  B2 B1 lExposure to Testosterone9 I1 Q4 x0 i7 Z' ~
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' ^, b* \# N* t- t9 h- @% ?* Sand Kenneth R. Rettig, MD1
/ s  W! n5 t+ l. r3 s: M5 HClinical Pediatrics- \  l; V- B9 V
Volume 46 Number 69 ~+ @% L! V  X" D! x  d7 g
July 2007 540-543
# [0 P& z; P2 ?9 M! T6 u1 F) t© 2007 Sage Publications: N) B/ J' B' ]9 T, h0 H! C
10.1177/0009922806296651
8 I* S- d) ?# U) \: Dhttp://clp.sagepub.com% N7 C# v1 L2 N7 X( P
hosted at
# O6 T* E/ c: E5 i% Ghttp://online.sagepub.com
- p: q6 A+ n, ?" F/ MPrecocious puberty in boys, central or peripheral,9 x( \& @9 v6 a! h
is a significant concern for physicians. Central% b# ^& y0 f! h9 c! |0 N6 K
precocious puberty (CPP), which is mediated  i: w+ ~5 u- i. Z" A# C
through the hypothalamic pituitary gonadal axis, has
: v. C7 _: I5 W& M, |a higher incidence of organic central nervous system  v# @. m% k# _& m
lesions in boys.1,2 Virilization in boys, as manifested
2 T( S0 ?$ W+ a2 Wby enlargement of the penis, development of pubic4 C- k$ ]! [4 W( k5 I& V
hair, and facial acne without enlargement of testi-# ]5 d1 g1 p+ x3 y: O1 }
cles, suggests peripheral or pseudopuberty.1-3 We
* {* ?8 _* A2 w: Dreport a 16-month-old boy who presented with the
. `( c* X1 b4 q( d% ?enlargement of the phallus and pubic hair develop-
) |: f4 y! z! \) g. p% T7 `ment without testicular enlargement, which was due7 S  g0 k; H& _+ M
to the unintentional exposure to androgen gel used by  m, t" C" u5 r6 P
the father. The family initially concealed this infor-4 O) N- h# m4 E$ U
mation, resulting in an extensive work-up for this
- p  g, C$ s/ O' d/ R% R5 A0 Qchild. Given the widespread and easy availability of- x9 i4 G$ k# R
testosterone gel and cream, we believe this is proba-
: O" b3 }/ U. e# |1 N. obly more common than the rare case report in the
, J% o2 b: E5 m8 h; ?literature.40 ?2 E& Z) _& G$ M! x8 K; m5 Q
Patient Report' g1 K  }3 b  P& d, k, q
A 16-month-old white child was referred to the% Z2 b* f0 g. D1 k! s9 D" _
endocrine clinic by his pediatrician with the concern
( g) x0 ?$ B# E5 u8 i: wof early sexual development. His mother noticed+ V8 {4 R1 k0 G
light colored pubic hair development when he was  k, u# \+ T4 H& o
From the 1Division of Pediatric Endocrinology, 2University of
7 T7 [3 P- E# g9 W+ |/ fSouth Alabama Medical Center, Mobile, Alabama.: v. y# Z% I# P9 [& q' w$ [- D' }& U
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* [' G% Q1 K- k5 |/ WProfessor of Pediatrics, University of South Alabama, College of
% `5 r* d3 v! R& R, ~- ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 v. Z  [0 l% B' W3 |' W' X
e-mail: [email protected].* j5 I. g7 j1 B$ q0 ?
about 6 to 7 months old, which progressively became3 F  l3 z+ |; l6 A
darker. She was also concerned about the enlarge-& z& d, y' v6 z" f3 y+ J
ment of his penis and frequent erections. The child4 C8 @' i* @1 w6 ]. f
was the product of a full-term normal delivery, with! S% |4 e2 i+ A
a birth weight of 7 lb 14 oz, and birth length of
+ J' e  j, }0 k7 B7 ?20 inches. He was breast-fed throughout the first year
- V( |% Y/ [5 d4 k4 |# \! qof life and was still receiving breast milk along with
( I6 J: L) I7 E0 V/ L: c2 ysolid food. He had no hospitalizations or surgery,
4 ]6 m6 G6 q9 f+ I3 r; _! wand his psychosocial and psychomotor development0 B+ m; `1 k- G- x' W
was age appropriate.0 i: H% ]3 |% z; n
The family history was remarkable for the father,
( R* p- _9 `# C8 p/ ]# cwho was diagnosed with hypothyroidism at age 16,
* a2 h1 S* {+ B5 G. w* K6 ?which was treated with thyroxine. The father’s5 B4 e& h: c& G( Q# o
height was 6 feet, and he went through a somewhat" e+ l* F% d' u2 h
early puberty and had stopped growing by age 14.
$ H! ^6 t/ Z% s# ^( k( rThe father denied taking any other medication. The" p" w5 I/ d' o9 n7 T/ f
child’s mother was in good health. Her menarche' t4 ^% k" W1 s4 o+ e0 |
was at 11 years of age, and her height was at 5 feet- d4 v0 p8 \! u& X, @& ~
5 inches. There was no other family history of pre-9 u. D& _8 \1 ]4 }# U
cocious sexual development in the first-degree rela-) U# d( K7 X" L) m* Y: F% Q
tives. There were no siblings./ S: r! y$ ^( R' d
Physical Examination
. ], L2 a# g# N% E; s, X" {The physical examination revealed a very active,8 v! I6 Q/ Q2 Q$ s/ N$ X* r3 Z- @
playful, and healthy boy. The vital signs documented
' j- v2 ~7 t7 W  Ka blood pressure of 85/50 mm Hg, his length was$ X, z- a( u: A2 t& H7 h2 Y8 X
90 cm (>97th percentile), and his weight was 14.4 kg
, p6 X: u7 ]2 G4 b2 P  |(also >97th percentile). The observed yearly growth7 U6 |) G3 P$ ~8 s5 U9 q' ]: l+ q
velocity was 30 cm (12 inches). The examination of5 _0 a( e- e) ?6 p2 @
the neck revealed no thyroid enlargement.. w# @5 c! @$ R/ J! Q8 ?  Y6 C& f
The genitourinary examination was remarkable for3 M! b$ a% T% B
enlargement of the penis, with a stretched length of
' h0 ]! ^  j4 s# c. _9 D8 cm and a width of 2 cm. The glans penis was very well
: z$ d2 Y& z2 c$ @2 E& H2 Fdeveloped. The pubic hair was Tanner II, mostly around
( I6 n& O* ~; E% V$ Q( y540$ x3 Z4 [3 }& u& F8 p# T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 q% U$ i& i7 v# }the base of the phallus and was dark and curled. The+ \, e) E: [8 M  k) \) C* F8 j- N. q
testicular volume was prepubertal at 2 mL each.7 T) j+ h5 t' g  }
The skin was moist and smooth and somewhat
" n$ u! g) O1 i* g3 ioily. No axillary hair was noted. There were no9 s: e6 m" U1 g8 r5 F6 M
abnormal skin pigmentations or café-au-lait spots., |2 D. I+ v$ ^% P: p# P
Neurologic evaluation showed deep tendon reflex 2+
4 v! B, d* {8 {  v6 ibilateral and symmetrical. There was no suggestion
* X; x) A4 _) Bof papilledema.
: f- I2 G9 a  \2 {8 R2 \Laboratory Evaluation- i. `( t+ Z6 J3 n0 X0 N# l- D) D
The bone age was consistent with 28 months by
) D2 r" d2 J* M! Wusing the standard of Greulich and Pyle at a chrono-" ~, H% P1 w! H# T8 W8 E
logic age of 16 months (advanced).5 Chromosomal- A( R% d) }+ o
karyotype was 46XY. The thyroid function test
& q" p$ V9 l& l' bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-8 J+ |/ x6 \0 b7 m4 @  l* I
lating hormone level was 1.3 µIU/mL (both normal).
' h- d4 E5 O- BThe concentrations of serum electrolytes, blood# k7 m2 O$ ]; K7 B- a
urea nitrogen, creatinine, and calcium all were5 q4 r% F6 u5 q( F8 _% v
within normal range for his age. The concentration! A3 v% R4 u2 P/ X
of serum 17-hydroxyprogesterone was 16 ng/dL
! z' Q7 z5 n' F4 \1 d( {$ E4 s(normal, 3 to 90 ng/dL), androstenedione was 206 L2 Z6 _9 \) U( e" e1 ~, |1 q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) H5 i, J* A( l# ~3 X) mterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ ~+ z3 D+ o& K' o8 x* w4 b( v" g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 y: ^8 n) L1 B# i
49ng/dL), 11-desoxycortisol (specific compound S)
$ k& L3 l( [& K& `) ~( Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& l1 t8 V& _% k6 I: S. Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 R) ~( k0 N- r4 W) U& n9 W% [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 ^  V& [" H8 h" J9 W' Q% G, I
and β-human chorionic gonadotropin was less than1 |/ |  k4 }, W% N5 w. N
5 mIU/mL (normal <5 mIU/mL). Serum follicular! d- t% c' O5 W" l& {/ u
stimulating hormone and leuteinizing hormone
" x7 z9 R) k: X! X2 Kconcentrations were less than 0.05 mIU/mL6 q9 [- r! n6 p4 a" I
(prepubertal).* Z0 N$ }0 a- B0 @
The parents were notified about the laboratory3 Q- [2 t9 r! `# U: N$ {# \
results and were informed that all of the tests were  [% A( f8 d. l9 F& K8 ]
normal except the testosterone level was high. The
- r: r1 @! W/ {+ l; i: P- j2 lfollow-up visit was arranged within a few weeks to
: Q+ [/ H, Y. k  ~+ Oobtain testicular and abdominal sonograms; how-
1 F1 s# S8 B) Y5 ]ever, the family did not return for 4 months.+ \$ `# L9 ^$ D& f3 c
Physical examination at this time revealed that the
2 t( c( G5 q4 X8 [child had grown 2.5 cm in 4 months and had gained- t) R5 G/ \6 L; s" Y; b, [
2 kg of weight. Physical examination remained/ A8 w5 ]! }2 u
unchanged. Surprisingly, the pubic hair almost com-7 F/ J. b# e. F) J* }- i9 c) L
pletely disappeared except for a few vellous hairs at
+ t* ~: O) {( H! x5 `% h7 xthe base of the phallus. Testicular volume was still 2
- b8 P5 U1 S# N2 ZmL, and the size of the penis remained unchanged.& k& J9 U+ W  u; D
The mother also said that the boy was no longer hav-
, `# a- T* W" \( J4 `1 `, ling frequent erections.
( U1 D  b, _7 cBoth parents were again questioned about use of2 n/ K& n; U2 m9 F' V
any ointment/creams that they may have applied to
. |9 w4 Q% }% c' Z7 Vthe child’s skin. This time the father admitted the, S% \5 N9 i, Y! F( l; n" s
Topical Testosterone Exposure / Bhowmick et al 541
. S& m# D8 ]& x5 O7 }6 e6 buse of testosterone gel twice daily that he was apply-
2 \; z, F* {8 P# qing over his own shoulders, chest, and back area for. e. p- F: {! g- b( }1 K5 Z* V- s* \
a year. The father also revealed he was embarrassed! }0 E. f) e# J8 z" w. O1 Z
to disclose that he was using a testosterone gel pre-7 `( s- j$ V' ]( p( m
scribed by his family physician for decreased libido- W3 z) m& e3 c. @8 A9 }
secondary to depression.$ `+ V9 |2 r3 o/ D; A8 T
The child slept in the same bed with parents.7 w% l3 z$ \2 Y; ?. Z/ Y4 C: u* y
The father would hug the baby and hold him on his3 C$ F; L. y8 R3 {/ `) d( N
chest for a considerable period of time, causing sig-4 s2 O- ?8 e1 y. F: @
nificant bare skin contact between baby and father.0 g; k2 x) x" k7 Q, B
The father also admitted that after the phone call,
7 e! H7 Z% [  X  V7 B2 B2 t. q: F4 Nwhen he learned the testosterone level in the baby, H. p1 A, l- f, E
was high, he then read the product information" H# S5 X7 P$ S2 k) v8 D
packet and concluded that it was most likely the rea-# G4 n. c6 H8 s/ n! {. L
son for the child’s virilization. At that time, they9 D: m- I  v8 H4 T0 L
decided to put the baby in a separate bed, and the( C1 O  W/ y4 T& b/ G
father was not hugging him with bare skin and had
1 {4 t, c1 k# U5 u9 Tbeen using protective clothing. A repeat testosterone
2 M. ~% C! p8 q& \: ftest was ordered, but the family did not go to the
( {! _1 Y. U! z, H/ x9 O3 o( dlaboratory to obtain the test.
$ x4 S5 i4 }& K/ XDiscussion+ D, M3 z2 K- q1 J) ]
Precocious puberty in boys is defined as secondary% d/ N& X& }' M7 q, J
sexual development before 9 years of age.1,4
1 u: A- C; N7 B) ?; J; ?Precocious puberty is termed as central (true) when
6 o0 b# G& H: k; q1 f& J0 b! V2 dit is caused by the premature activation of hypo-. Q% ], b2 C+ k& s$ I- k8 G$ T
thalamic pituitary gonadal axis. CPP is more com-
% N0 ]& J1 t$ H3 p( ~4 Bmon in girls than in boys.1,3 Most boys with CPP+ [8 `7 `" q+ J3 m3 x' Y
may have a central nervous system lesion that is
. {, y6 p  N2 f& Rresponsible for the early activation of the hypothal-8 j( }3 }4 b& H' x4 V
amic pituitary gonadal axis.1-3 Thus, greater empha-7 }4 ?. t& c8 [% Q  ]3 C( y
sis has been given to neuroradiologic imaging in
& A: p) _# ~; E. `' iboys with precocious puberty. In addition to viril-
8 ^" {3 O! D; I) S8 Uization, the clinical hallmark of CPP is the symmet-
8 l& ?9 G$ _! o2 i& V6 n" erical testicular growth secondary to stimulation by
$ _3 s* g, m- X& u% z; I/ {  Wgonadotropins.1,3
7 a3 e$ U0 S% K8 g- l& [6 gGonadotropin-independent peripheral preco-5 E# [/ y; h; \) X% Q1 n# s- f
cious puberty in boys also results from inappropriate' I: ?7 m3 B0 ^' ~& n. y
androgenic stimulation from either endogenous or
/ N6 W5 q3 F6 ^% V, [! ?" Jexogenous sources, nonpituitary gonadotropin stim-
1 E; |& i. k* b7 O% q) culation, and rare activating mutations.3 Virilizing
$ C/ i  j3 @/ T8 vcongenital adrenal hyperplasia producing excessive
9 o8 v0 R# M& e, R% uadrenal androgens is a common cause of precocious* t& M3 @  b  Z. q
puberty in boys.3,4
& L4 N+ y7 ]  U  ^- e# r4 qThe most common form of congenital adrenal! m- N8 Q6 b; n. N, |
hyperplasia is the 21-hydroxylase enzyme deficiency.
! }4 V0 m0 u; P7 V+ ^! b' SThe 11-β hydroxylase deficiency may also result in
* E1 H/ l+ J# J! v. aexcessive adrenal androgen production, and rarely,- q6 b: f* @/ C6 m$ f
an adrenal tumor may also cause adrenal androgen
0 w& H8 |( M+ U% ~3 L0 Oexcess.1,3
& Q; U8 n& \/ A& O  ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  ]9 v4 V- ?( Q2 @2 A* _* t: H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- e8 z) T5 V5 C. P& n) M
A unique entity of male-limited gonadotropin-
  g6 o  t1 G, \' aindependent precocious puberty, which is also known6 e3 l) S1 t: B! {
as testotoxicosis, may cause precocious puberty at a
) N8 Y7 C! z4 _, n- C' _0 J# Fvery young age. The physical findings in these boys
$ O8 o$ Q, Z8 C' B' _- |+ Ywith this disorder are full pubertal development,9 H/ S0 I" X& `- p4 D4 Y' G$ z
including bilateral testicular growth, similar to boys. @# U/ F" E! _5 q3 N
with CPP. The gonadotropin levels in this disorder
9 L0 J$ {( C$ I! C; M& Aare suppressed to prepubertal levels and do not show: R9 F" I, F8 b* m- t( D4 @
pubertal response of gonadotropin after gonadotropin-% w8 u" }! p  o: }9 V* T
releasing hormone stimulation. This is a sex-linked4 w" c  L' K0 F; \6 o
autosomal dominant disorder that affects only
$ Y+ [, e/ d) m4 J1 Q1 T" Y3 a' o( gmales; therefore, other male members of the family9 j  P* B. W8 u$ R3 i6 b
may have similar precocious puberty.30 ^! `% V; m# \' U# k
In our patient, physical examination was incon-
! I6 D1 j# n/ t1 z/ k% W7 i: [8 fsistent with true precocious puberty since his testi-5 T1 ~% P( s1 y# z  B! c5 f
cles were prepubertal in size. However, testotoxicosis
$ n. {+ W/ a+ o) i& jwas in the differential diagnosis because his father
! M3 r/ Z  O9 d; Estarted puberty somewhat early, and occasionally,3 G4 e1 i- u3 k, ^( S' [
testicular enlargement is not that evident in the( o# I3 K. v( p' G$ P9 l7 g' W4 V
beginning of this process.1 In the absence of a neg-
. d  r4 K7 |  h2 yative initial history of androgen exposure, our( h5 ]; k% J) j  a: P
biggest concern was virilizing adrenal hyperplasia,
- n/ C) Y7 |' `/ V# yeither 21-hydroxylase deficiency or 11-β hydroxylase
; m6 N) N4 G3 [: R2 w& A: p/ r$ Ldeficiency. Those diagnoses were excluded by find-6 `3 M; K; z6 l0 |/ T) ]9 j
ing the normal level of adrenal steroids.. x0 ^$ O! A: q6 G2 N4 W& e
The diagnosis of exogenous androgens was strongly% z" @: ]" N& k. v) h% J: z
suspected in a follow-up visit after 4 months because
. @' T/ j. z6 q! t$ ]8 L4 l5 xthe physical examination revealed the complete disap-
8 Q6 w3 V+ `% x) _% T3 Apearance of pubic hair, normal growth velocity, and: |4 z2 ?4 G/ r2 f9 T
decreased erections. The father admitted using a testos-
2 G- Y8 N0 x+ K# c8 I, p6 p8 kterone gel, which he concealed at first visit. He was& {: V. m. P# H4 y7 Q  F: U" O/ v
using it rather frequently, twice a day. The Physicians’
- _. Z  @  d% t/ i7 p; e/ T' F5 ]1 dDesk Reference, or package insert of this product, gel or
# V- N2 ?! z, w) |$ qcream, cautions about dermal testosterone transfer to2 \) x+ a( |  m: a
unprotected females through direct skin exposure.
& P  a$ I: {+ L( ?* V7 f- R7 r" SSerum testosterone level was found to be 2 times the
& F! Z$ a4 u, e; b/ i1 O/ h6 Tbaseline value in those females who were exposed to9 I5 d, {, B" ^! L, B7 |
even 15 minutes of direct skin contact with their male
' r5 a$ C" r! ^1 ~$ c3 o) n$ j+ g3 Vpartners.6 However, when a shirt covered the applica-1 `( P* N" h# `1 B4 t& r
tion site, this testosterone transfer was prevented.
2 I6 r" u% y1 e! d9 }8 N9 qOur patient’s testosterone level was 60 ng/mL,& v5 D* l+ ~& q; P
which was clearly high. Some studies suggest that
& M. z4 `! l) y; c' T2 |dermal conversion of testosterone to dihydrotestos-" N3 b7 L7 d; K5 o) F7 T2 `0 c8 t
terone, which is a more potent metabolite, is more, W# E7 U3 d" S7 A1 L: [
active in young children exposed to testosterone: s" t7 h( [7 I) s; x
exogenously7; however, we did not measure a dihy-" z! R9 R, @+ t% c- ^7 T
drotestosterone level in our patient. In addition to" ~, O7 v& v8 i8 h0 D3 }+ ^
virilization, exposure to exogenous testosterone in* C) Z# r" k+ e; ^* J, P
children results in an increase in growth velocity and
- T( }! Y4 Z3 B9 B6 [& Fadvanced bone age, as seen in our patient.
5 n% g9 p4 d4 {The long-term effect of androgen exposure during
) P, W+ y  h- r7 x' I" Hearly childhood on pubertal development and final
/ J' o0 [# b( gadult height are not fully known and always remain
3 \3 c& e  i- r* s3 e3 d0 Ja concern. Children treated with short-term testos-$ P2 h4 a- \% ], N
terone injection or topical androgen may exhibit some
7 }1 S, w0 u! N. t6 T" o+ sacceleration of the skeletal maturation; however, after
+ ?% @% V5 k* Wcessation of treatment, the rate of bone maturation  X, U! J0 u* P
decelerates and gradually returns to normal.8,9
( U8 ]3 s. x$ h6 wThere are conflicting reports and controversy, A4 X; V6 x) H% }- h2 _. |
over the effect of early androgen exposure on adult
7 H* M9 L2 y4 x2 mpenile length.10,11 Some reports suggest subnormal
% `/ u' w4 s" j; j+ badult penile length, apparently because of downreg-0 U! m- g9 o  D8 g  {
ulation of androgen receptor number.10,12 However,
4 v& m  R  Z' {5 S- N5 u6 M* K; f! vSutherland et al13 did not find a correlation between2 L7 O/ N3 }" T4 T1 G& v% C
childhood testosterone exposure and reduced adult3 \! v( l8 z, c2 ?0 @4 c
penile length in clinical studies.
0 I; S6 [! ^* Z; M3 t3 Z/ e* bNonetheless, we do not believe our patient is
, ?7 t; |9 C, V& m* xgoing to experience any of the untoward effects from
* k4 ~! N4 f. I6 ?testosterone exposure as mentioned earlier because
. ^8 r6 N! U; w( T0 F  Sthe exposure was not for a prolonged period of time.
- L! q4 J8 w3 l! r2 H6 ]1 x2 v6 z$ L! TAlthough the bone age was advanced at the time of
2 r; t3 K) {# Gdiagnosis, the child had a normal growth velocity at
1 o; I2 v( T5 V$ p3 nthe follow-up visit. It is hoped that his final adult
: _5 U8 [2 s) p% c6 sheight will not be affected.
2 E0 H4 c, I4 I3 ]Although rarely reported, the widespread avail-
4 s& x8 y) q$ @' V' lability of androgen products in our society may4 ~" `4 H" y% `0 e1 [
indeed cause more virilization in male or female
/ u4 J3 K4 U5 tchildren than one would realize. Exposure to andro-8 `& ?4 H' R. x  z- I8 b3 G
gen products must be considered and specific ques-+ _6 T+ z3 D; s! Z# c3 s) q
tioning about the use of a testosterone product or
* u+ [* L4 L. E2 B6 x7 o! O4 x+ Mgel should be asked of the family members during; s5 l( A$ s6 f
the evaluation of any children who present with vir-# Q1 S  m% m/ f2 V0 P' t
ilization or peripheral precocious puberty. The diag-
. y: A: f5 j( I/ A: anosis can be established by just a few tests and by
- @( e4 k/ D8 qappropriate history. The inability to obtain such a) _3 [5 |# u3 Q1 {+ P
history, or failure to ask the specific questions, may* j2 E2 d- Y1 F5 r# e3 E
result in extensive, unnecessary, and expensive
( G. X( d8 [" g3 ?6 ?; l# hinvestigation. The primary care physician should be
! g$ |  z' L4 v. H- waware of this fact, because most of these children
0 I$ g" J2 `7 V6 Umay initially present in their practice. The Physicians’) _! q' R' }/ ?$ b4 ?
Desk Reference and package insert should also put a
: ], `- l( c; S$ E/ G2 }$ Gwarning about the virilizing effect on a male or5 |, `+ s$ d, U; _' j% l
female child who might come in contact with some-9 e) v/ {8 S) S- S  e
one using any of these products.
# W' V% [& c* ~: L4 P5 F3 G; gReferences6 X9 |# q$ X2 {  c0 [, y1 L
1. Styne DM. The testes: disorder of sexual differentiation
8 T: y- C1 s* R- ]0 K( cand puberty in the male. In: Sperling MA, ed. Pediatric7 S3 {7 X" e# p/ z) x9 y$ u
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 j  u/ o/ ~+ L$ j2002: 565-628.
6 T4 p# D6 U8 J, K5 Q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% J6 ?5 Q4 W& x, l# I. J7 ppuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
2 ?6 D$ F/ M7 ?. v% f6 QBoy Induced by Indirect Topical
( m' d$ T# H2 \" [) \  E2 v1 x1 |Exposure to Testosterone& t4 Z/ _# `8 k! n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ t, F5 V( F& T4 \  M
and Kenneth R. Rettig, MD1* S5 a; ?+ B4 ~4 y% R
Clinical Pediatrics$ t# y0 Q, p) N6 N6 s
Volume 46 Number 6
& @3 p2 o" o* ]6 mJuly 2007 540-543
5 [, M" s7 |. b: p. R# s2 n© 2007 Sage Publications
: T6 X- `; b8 _/ O; a- Z# C10.1177/0009922806296651+ g- `9 k" Y- J' s. P
http://clp.sagepub.com9 X! q$ [  y: O
hosted at( J, w2 T$ F5 k% }: g0 B
http://online.sagepub.com- R6 R! a3 Q, ~2 W7 n" R7 ~( t: b
Precocious puberty in boys, central or peripheral,
) O; g3 ?( J2 A' L# wis a significant concern for physicians. Central) R0 e" R! q6 N8 y
precocious puberty (CPP), which is mediated
6 [6 n2 ]$ z1 ~3 _6 n, uthrough the hypothalamic pituitary gonadal axis, has
. v3 j% R7 K: b5 A7 [% B7 Ka higher incidence of organic central nervous system7 T( F( b) C! o" j8 v1 h
lesions in boys.1,2 Virilization in boys, as manifested
& l( w7 W2 R" A$ W) N( p7 b% wby enlargement of the penis, development of pubic
+ P$ s( E5 s& r4 D- E, {# U% Uhair, and facial acne without enlargement of testi-2 A% }7 u" R8 a& m& A% `
cles, suggests peripheral or pseudopuberty.1-3 We
9 d' o  N9 N( preport a 16-month-old boy who presented with the, p' d. r: n4 n, i5 ~
enlargement of the phallus and pubic hair develop-
3 m* Z8 M# u# {# `ment without testicular enlargement, which was due
& G  X9 D& K/ D1 N8 Ato the unintentional exposure to androgen gel used by9 E  ^' {$ k. ^2 F3 h8 W
the father. The family initially concealed this infor-( l# r0 ^7 s. l4 i% Y: M, l* L
mation, resulting in an extensive work-up for this
+ n- S0 R; H; _& Y& Ichild. Given the widespread and easy availability of
: g  l+ k5 s0 _& X: f# ?7 y( x1 ptestosterone gel and cream, we believe this is proba-
0 Y9 d6 G, Z+ _; O, Obly more common than the rare case report in the. f; y, c( @' Z/ g" G7 C  F% B
literature.4
( c+ W0 C2 u2 aPatient Report
( {3 @6 R/ p$ @& X# QA 16-month-old white child was referred to the2 B, J9 ?, S$ ~0 G/ `% z3 H
endocrine clinic by his pediatrician with the concern
. F- s: L9 g7 \8 L" z7 Nof early sexual development. His mother noticed
& c& M- k' W2 l& m( v/ C, M9 x5 t* ^  Rlight colored pubic hair development when he was* i5 ?8 ?# Q: \' f/ }2 c
From the 1Division of Pediatric Endocrinology, 2University of; u9 O2 i. w* v; T0 s
South Alabama Medical Center, Mobile, Alabama., M$ |* }; J3 [2 ?( W3 q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, h8 p- m6 w4 s' D/ b7 |# X8 RProfessor of Pediatrics, University of South Alabama, College of
! H' p7 s: X7 v' Z- w1 xMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) B0 ~, j6 p' Me-mail: [email protected].
/ X0 n  Q) u* _5 [+ z1 ]about 6 to 7 months old, which progressively became9 o. a. i6 i  X) q+ Z
darker. She was also concerned about the enlarge-% W4 b& H) p* K, C
ment of his penis and frequent erections. The child1 |6 `7 s& X- Q# H5 j
was the product of a full-term normal delivery, with
" A5 ~5 P7 r* F- T/ H# V, ta birth weight of 7 lb 14 oz, and birth length of
  m+ |* b- C( t1 B9 Y4 X20 inches. He was breast-fed throughout the first year4 E- G* x4 p# H# T4 F" x! y
of life and was still receiving breast milk along with
2 Y& I7 b2 X9 k: s0 q2 V, Zsolid food. He had no hospitalizations or surgery,
' h. b/ p  S! U& W# ^and his psychosocial and psychomotor development
+ }6 y7 M$ U4 S) Q1 ^8 Gwas age appropriate.
% @3 n/ A3 W* s5 J3 WThe family history was remarkable for the father,3 w. [2 ~0 \+ m: {, Z
who was diagnosed with hypothyroidism at age 16,% Z- Z  U5 l/ ]0 ~
which was treated with thyroxine. The father’s
. b7 u5 c0 ?" ^" z3 \* u' |( Gheight was 6 feet, and he went through a somewhat
  |* a: Z- M1 |, W5 _) `6 e; Zearly puberty and had stopped growing by age 14.
2 u  H" M# I  G2 z3 ?- N" e3 HThe father denied taking any other medication. The9 \* d9 t+ l% x- E
child’s mother was in good health. Her menarche
* A- ~7 G: I" d6 Hwas at 11 years of age, and her height was at 5 feet
: ~- p) t4 w$ b+ `- Y: Z- c5 inches. There was no other family history of pre-
3 @# a% H. |  O6 e( S! e/ C$ l+ B& ncocious sexual development in the first-degree rela-0 x4 N' A; g* [* E1 ?4 i+ S
tives. There were no siblings.) ~  S/ l5 z4 x; o2 b" E
Physical Examination4 s5 k) ]: O; D. h9 U' ?2 I' D
The physical examination revealed a very active,7 s* I: E" U9 q& U/ t" J6 ]
playful, and healthy boy. The vital signs documented
# `! j4 X; p, ta blood pressure of 85/50 mm Hg, his length was; R! X% k/ u) }; O
90 cm (>97th percentile), and his weight was 14.4 kg
6 O( p) Z2 H+ \, @0 k* n, `/ ?1 ](also >97th percentile). The observed yearly growth
/ J  B9 f* t. }9 d0 j0 [4 pvelocity was 30 cm (12 inches). The examination of  q% w! i5 N& C) }1 w
the neck revealed no thyroid enlargement.1 r% E- m/ U/ q, W3 x: ?7 X
The genitourinary examination was remarkable for
+ v6 {! o9 i4 q- ?. z. C, }+ kenlargement of the penis, with a stretched length of# O0 f- G7 }8 T6 y$ T# V' }( q
8 cm and a width of 2 cm. The glans penis was very well0 t' }6 ~- Y# r2 e+ A- l: q4 T) o
developed. The pubic hair was Tanner II, mostly around2 e8 e1 u8 Z9 S; ]3 ?
5400 z) ?3 W* H5 f& c
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the base of the phallus and was dark and curled. The. N0 z* G( ]5 v% ^
testicular volume was prepubertal at 2 mL each., T, X; a/ _( S0 e9 z5 G* `+ r% p
The skin was moist and smooth and somewhat5 n3 }/ q3 o2 ]  N( ~4 a8 [1 m
oily. No axillary hair was noted. There were no
# m$ Q% L# h4 Iabnormal skin pigmentations or café-au-lait spots.
8 B6 G+ {' V% Y+ I1 e2 f2 bNeurologic evaluation showed deep tendon reflex 2+
+ u$ n3 f2 U6 x; L; K7 bbilateral and symmetrical. There was no suggestion9 u4 @% B* [, V) t( A
of papilledema.
7 Z' S: n( C! z( c, FLaboratory Evaluation: q5 b" a) I4 V. {
The bone age was consistent with 28 months by! h5 ^5 y  |! I0 h
using the standard of Greulich and Pyle at a chrono-7 j8 b! t8 e- ?; r* w4 [
logic age of 16 months (advanced).5 Chromosomal
+ O% V: J0 ]( `" j3 ]. _karyotype was 46XY. The thyroid function test5 T2 u% |  S! n& q1 E  W* T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-* ]& V6 a- N/ I5 m# q3 W) `9 O& k' R
lating hormone level was 1.3 µIU/mL (both normal).
* P" H  m- j2 U. u' ^+ MThe concentrations of serum electrolytes, blood
; u1 ^4 C9 Z  ]urea nitrogen, creatinine, and calcium all were/ e' K6 U4 F4 e& E7 B# I0 b  @5 ~
within normal range for his age. The concentration! K3 }4 ?+ \% H
of serum 17-hydroxyprogesterone was 16 ng/dL
% K, L' g' f, x" g6 k8 l$ |0 O/ I& m% W1 ^(normal, 3 to 90 ng/dL), androstenedione was 20
" v7 _2 `& o+ C5 A% k! vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 ?8 e6 \0 M3 k, _" m6 K) s
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& Y# I5 K* N5 I- \( H0 z+ N& b( Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 _  Z0 ?$ T; C* H. n$ t) X49ng/dL), 11-desoxycortisol (specific compound S)8 l4 T6 p$ b7 T4 @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: |0 K# Y9 J7 B/ ~. E( }+ L2 A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 o+ l- Q8 O# T) b- f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; p. G1 l& c; n# p& Z3 {and β-human chorionic gonadotropin was less than
- K  Q, l$ {" U' [0 x0 e$ w5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ v! U' U( e$ G; bstimulating hormone and leuteinizing hormone
, C. p( m; V$ [concentrations were less than 0.05 mIU/mL. h0 B) F% r* S2 j. [
(prepubertal).5 y4 ]+ s+ N* T2 ]- E# ]* }- A* _
The parents were notified about the laboratory
/ i- D7 Z0 `. u, w" R  U) eresults and were informed that all of the tests were
5 H) F' i8 E2 dnormal except the testosterone level was high. The* Y+ J; v2 w$ f( S6 I) I& V% a
follow-up visit was arranged within a few weeks to6 j' c& C% y; X. F& L7 G
obtain testicular and abdominal sonograms; how-9 w) s6 Z1 {8 |* r
ever, the family did not return for 4 months.
( X' }! N  r' S, N# x% f, GPhysical examination at this time revealed that the3 p  z2 S" R" ~* {  v
child had grown 2.5 cm in 4 months and had gained- ]% n0 h& t. K# o
2 kg of weight. Physical examination remained( O' Q* E. g! B! z& t
unchanged. Surprisingly, the pubic hair almost com-8 W# w1 y! n8 h* B
pletely disappeared except for a few vellous hairs at
; w" o' t+ R. \+ X6 X( ]3 [! N- Z, othe base of the phallus. Testicular volume was still 2
" H1 c4 F' Q  FmL, and the size of the penis remained unchanged.
# J4 v1 S$ F- d  \The mother also said that the boy was no longer hav-
% r- T% B  ~8 r, L6 E1 S6 ]ing frequent erections.
4 v5 L4 T/ Q( n! c; oBoth parents were again questioned about use of
# T. I( N6 r! V' z2 n8 tany ointment/creams that they may have applied to
4 G% N  u) q) `# Hthe child’s skin. This time the father admitted the( k0 k. P2 g: ?, G; ~4 A1 H3 Y# @( V
Topical Testosterone Exposure / Bhowmick et al 541' p) i. q7 O; ~* z- J( j! D! ?0 Z4 M
use of testosterone gel twice daily that he was apply-
( l3 [3 z0 d' @; Iing over his own shoulders, chest, and back area for
2 M* P8 y/ K3 x7 @a year. The father also revealed he was embarrassed
* f+ L, n" o: K( C1 n3 Mto disclose that he was using a testosterone gel pre-
& d5 t6 S! N1 Dscribed by his family physician for decreased libido
) G" f# X# H1 Asecondary to depression.7 u9 z# `8 P/ Z- g2 ?* j9 F' ?
The child slept in the same bed with parents.4 r* U! B! _5 g0 @3 R" n
The father would hug the baby and hold him on his, G% r. ?8 [# D
chest for a considerable period of time, causing sig-+ t0 a8 C6 }9 c! W& _) p
nificant bare skin contact between baby and father.3 F# S5 S$ Q. _* B
The father also admitted that after the phone call,
) Q& @' k- I: s) C) B7 m$ ^% W/ ]when he learned the testosterone level in the baby) K1 ^1 l4 \& K5 R
was high, he then read the product information1 B' e, C$ V9 h4 v& J+ e
packet and concluded that it was most likely the rea-1 L( T: q+ I7 l( h" T
son for the child’s virilization. At that time, they- z: B, d" _" q3 m3 ~% h, q6 O% D; S) h
decided to put the baby in a separate bed, and the* F* h7 ^: ?5 p: p- ~
father was not hugging him with bare skin and had! M" X8 H* I  c- f
been using protective clothing. A repeat testosterone
& w# |9 y6 [' q# c' [5 R+ mtest was ordered, but the family did not go to the& w- G- Q, p4 h
laboratory to obtain the test.: F" X6 N  K5 L  D7 p
Discussion
/ l1 I/ W) \/ A( |( G! s1 \5 mPrecocious puberty in boys is defined as secondary2 c3 c9 h+ Z, f0 x: a
sexual development before 9 years of age.1,4  T1 @  q* d* @) J
Precocious puberty is termed as central (true) when! M/ @5 ]# m! l& E. Z
it is caused by the premature activation of hypo-
/ _0 p) X) _; u+ x' v3 g8 gthalamic pituitary gonadal axis. CPP is more com-
% F' O! H/ q5 ?6 P; y6 vmon in girls than in boys.1,3 Most boys with CPP
& p' \% C) i0 x; E& lmay have a central nervous system lesion that is: u! q& Q1 ^4 d  B
responsible for the early activation of the hypothal-
$ p1 _3 ~" ?! x. \/ y8 b4 _7 o9 p$ Ramic pituitary gonadal axis.1-3 Thus, greater empha-
. n6 L8 G. ?, f. jsis has been given to neuroradiologic imaging in  }0 ^$ s7 _  M3 j1 o# L# D# \
boys with precocious puberty. In addition to viril-
$ G+ L1 p3 _4 xization, the clinical hallmark of CPP is the symmet-
3 f$ v( ?# B+ r3 Hrical testicular growth secondary to stimulation by
+ p5 B- ~/ f; d! P, w3 Xgonadotropins.1,3" ], z7 d3 }* U1 I; a) k) F
Gonadotropin-independent peripheral preco-6 c; P5 L- o" ~1 v
cious puberty in boys also results from inappropriate
' k2 L( t) @6 z: n6 F" Bandrogenic stimulation from either endogenous or
! a5 F8 Z# h+ Y6 i0 Nexogenous sources, nonpituitary gonadotropin stim-
0 W  u- \! o  |  [ulation, and rare activating mutations.3 Virilizing/ ]/ i2 J8 B, c) F% B1 `1 U' d9 J
congenital adrenal hyperplasia producing excessive
. Q) c6 p! F! u) Y+ u) ?adrenal androgens is a common cause of precocious5 H, f7 I: ]8 S8 {. L
puberty in boys.3,4* H! k% t' d5 H4 q# {
The most common form of congenital adrenal7 S# @$ e9 P9 B2 O( F5 @& j& W  O# I
hyperplasia is the 21-hydroxylase enzyme deficiency.
% p* H0 X1 d4 H+ z! h$ B; a/ TThe 11-β hydroxylase deficiency may also result in6 x( ^' S& j% [+ E2 Z8 H
excessive adrenal androgen production, and rarely,
% ?$ b: {0 c5 F8 C* D+ _an adrenal tumor may also cause adrenal androgen0 R4 }) m$ ?% u! Z- l
excess.1,32 @( y! n  J1 x4 b2 z, V$ E
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542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! J% E0 P. M& q4 P7 }# E
A unique entity of male-limited gonadotropin-
! K" A2 |) F- e/ C8 G7 C* uindependent precocious puberty, which is also known' S) q" d: M% O8 v, I" p, `
as testotoxicosis, may cause precocious puberty at a
. y8 V7 O4 R! x9 g1 B) t% Overy young age. The physical findings in these boys" v# x5 D& o1 _% m) |! d
with this disorder are full pubertal development,1 V) t. R' s) G# p' T$ A
including bilateral testicular growth, similar to boys
7 u$ G) k# z& b  k( u) K3 twith CPP. The gonadotropin levels in this disorder
; w0 T3 [7 {( @5 ^3 h6 @9 jare suppressed to prepubertal levels and do not show, H+ ?, V' ]& Z) C" C
pubertal response of gonadotropin after gonadotropin-& Q& ]9 ]# A5 v) f: T1 c% f+ u7 H4 I
releasing hormone stimulation. This is a sex-linked
& v, y4 T7 T% p( aautosomal dominant disorder that affects only) I( b- @3 X: P- N$ w7 E
males; therefore, other male members of the family
: W" F& q! P6 g- p! ]) Fmay have similar precocious puberty.3& j1 X3 B& L9 X- C
In our patient, physical examination was incon-4 x! T: p( |$ ^9 q+ Y2 ]" v
sistent with true precocious puberty since his testi-0 v; k, w" o$ N; q( `& V- X4 a' h
cles were prepubertal in size. However, testotoxicosis
4 F6 [5 k1 k3 J" |was in the differential diagnosis because his father3 u- a* o/ k# R+ o+ ~  Z
started puberty somewhat early, and occasionally,
7 [( p3 z+ e& L( k' P# \testicular enlargement is not that evident in the' ]2 L6 {; r( t" [6 D, p% Q) Z9 {
beginning of this process.1 In the absence of a neg-
0 O/ f4 W' q) t- Q  S$ T8 {ative initial history of androgen exposure, our+ p; z# R3 I! c' o$ S) Z3 ~2 u$ O
biggest concern was virilizing adrenal hyperplasia,
* K: _/ m/ v( ~either 21-hydroxylase deficiency or 11-β hydroxylase
2 H2 [6 _" T5 V: }deficiency. Those diagnoses were excluded by find-0 M, Q' w2 c! b
ing the normal level of adrenal steroids.2 G7 h  e+ y0 R1 ?' D
The diagnosis of exogenous androgens was strongly
/ p4 {+ s0 O: O) `9 b6 \3 N, vsuspected in a follow-up visit after 4 months because! Q5 E6 |3 l/ q) _# F* ]; ^  o
the physical examination revealed the complete disap-& O, X# o4 B# M" Y/ g
pearance of pubic hair, normal growth velocity, and
/ J: {% C& K! I: f% P" mdecreased erections. The father admitted using a testos-
6 q" ]( A  S0 @2 v$ z' uterone gel, which he concealed at first visit. He was! J* W7 g0 L, K6 b
using it rather frequently, twice a day. The Physicians’
& @0 K) B9 c5 P: w% s# ~# xDesk Reference, or package insert of this product, gel or: I8 v( U( m8 q3 \* r& ?7 d! V; _9 [; o
cream, cautions about dermal testosterone transfer to
, p; D0 I( x. M* `+ c+ x; sunprotected females through direct skin exposure.
9 x6 G! [% @, e* YSerum testosterone level was found to be 2 times the2 {! ^5 y  f  }# K2 O/ N4 W6 a' G
baseline value in those females who were exposed to- }. v5 k* z8 W, U% y
even 15 minutes of direct skin contact with their male
' W; r1 j3 y6 u  f6 p8 K: Lpartners.6 However, when a shirt covered the applica-
; E0 {/ ~- X+ p* {4 C5 ltion site, this testosterone transfer was prevented.& a1 e& f6 c6 m2 l) y
Our patient’s testosterone level was 60 ng/mL,
" l" g+ Y4 Y4 }2 i$ h' Ewhich was clearly high. Some studies suggest that
4 G4 d, b( [" `0 o2 d- c: n$ sdermal conversion of testosterone to dihydrotestos-" g# W  U, ]" N5 X
terone, which is a more potent metabolite, is more
5 A& z- j. L3 u$ cactive in young children exposed to testosterone
1 ^2 r# [2 Z( V* X- y1 oexogenously7; however, we did not measure a dihy-
8 S3 C& T3 R' kdrotestosterone level in our patient. In addition to7 x1 ^5 E& }& o8 y  B  X) c4 u# w$ M
virilization, exposure to exogenous testosterone in. }7 {. Y* e8 G. c+ @
children results in an increase in growth velocity and& q" x$ ?8 t0 G6 _6 L) L$ j8 y6 y
advanced bone age, as seen in our patient.
& P8 Y( s4 A* a0 TThe long-term effect of androgen exposure during/ D* P2 t, ?$ @! I$ v
early childhood on pubertal development and final
5 K# D4 f2 g. W3 m7 s& ?- nadult height are not fully known and always remain
: K! R) D$ s" \; `8 I2 O' D2 ?% Z6 Ia concern. Children treated with short-term testos-( Q" G1 p7 a1 a- e  `- o7 r7 o
terone injection or topical androgen may exhibit some
8 n/ X( A/ i4 i8 @  e0 X; }acceleration of the skeletal maturation; however, after
' L3 y. z* w' A4 f+ z# |+ n1 Y$ Acessation of treatment, the rate of bone maturation
- i3 h! {; q( W3 v) J$ M; U5 Ydecelerates and gradually returns to normal.8,9
1 g) c6 b* t4 w+ N. |There are conflicting reports and controversy
& }$ [1 U4 e3 u; Nover the effect of early androgen exposure on adult3 ?! L1 X6 n) Z: n4 Y' ^3 p0 o
penile length.10,11 Some reports suggest subnormal
/ d! a+ L, Y% W8 f' j1 |, L; k: madult penile length, apparently because of downreg-% }) q1 \) ^; g* i
ulation of androgen receptor number.10,12 However,& P- M% u1 |' F" _. g( d
Sutherland et al13 did not find a correlation between
4 M9 E" S3 D7 U& J0 E* u+ Mchildhood testosterone exposure and reduced adult
9 Y4 G5 o) d, }3 Q- P1 }penile length in clinical studies.
/ G' n% z, J* jNonetheless, we do not believe our patient is
1 M3 o( B7 w: z4 Jgoing to experience any of the untoward effects from& B8 _$ M: Z3 R% s
testosterone exposure as mentioned earlier because  v& k- @6 N* m2 @  D
the exposure was not for a prolonged period of time.* V/ a( h. D8 t6 G- x% J+ \
Although the bone age was advanced at the time of
! A  ]& P. b6 y" y/ ediagnosis, the child had a normal growth velocity at7 _* W1 ?# z/ w' S2 S+ _' {% a9 z6 C
the follow-up visit. It is hoped that his final adult3 z7 \; P9 K, I+ m, Z. d
height will not be affected.' v$ I+ v% J, I5 i+ l6 `
Although rarely reported, the widespread avail-
7 n/ B' F6 ~* m; |ability of androgen products in our society may
% W# t- v" o' D& O% U5 [6 Lindeed cause more virilization in male or female1 K/ Z) v! [8 n0 B. v: @3 l- f
children than one would realize. Exposure to andro-. J8 I/ }0 Q. O. |* W# @& Q7 F
gen products must be considered and specific ques-) C5 c* e2 x, s& E; C0 {% u: d* e8 E
tioning about the use of a testosterone product or- }3 I6 W  ?3 L8 T6 i# P
gel should be asked of the family members during2 ?# N5 k0 s' Z, O; Z: I. }
the evaluation of any children who present with vir-
' Y- e$ \9 J$ z/ [5 G8 Jilization or peripheral precocious puberty. The diag-$ U) \2 {5 z! H) S8 |+ P
nosis can be established by just a few tests and by3 f5 c* ~4 ~. [
appropriate history. The inability to obtain such a
0 V2 R, j, |! {. b7 a5 N! Dhistory, or failure to ask the specific questions, may
' u' E/ T2 B3 p% }result in extensive, unnecessary, and expensive
  r+ D1 d$ C3 V- J$ E/ L* qinvestigation. The primary care physician should be
9 C' |; d: X1 `$ t8 I  F6 Aaware of this fact, because most of these children
9 i! g9 S$ |! s5 ~4 T2 |' N; |may initially present in their practice. The Physicians’3 G' x* T' {5 B$ t' ?( g4 i
Desk Reference and package insert should also put a3 k# @4 d! F& w0 S" H
warning about the virilizing effect on a male or' ^2 |& x( C. a7 S, d1 g% o3 c$ ]
female child who might come in contact with some-% X1 |" [) z2 K* W5 z# Z, g8 }
one using any of these products.; x9 d* \  [( Q1 _+ S$ v9 w
References
/ k) W- M0 l3 E8 q3 M% U% c1. Styne DM. The testes: disorder of sexual differentiation
, a$ }4 _7 G% T2 N' ^4 hand puberty in the male. In: Sperling MA, ed. Pediatric% C3 Y2 d1 ]1 u: d. h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& u) k3 L  F1 K3 ^( I- m+ Z
2002: 565-628., C+ g4 f- p4 @" j; o) I
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 ?" ~& t' v  s" o' Q
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

8 Y. p2 p+ [5 V' |. j3 H- \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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