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Sexual Precocity in a 16-Month-Old( A: u+ d& W/ `- }
Boy Induced by Indirect Topical- @5 W1 V4 ]7 J  S1 y
Exposure to Testosterone4 o0 a& R3 i, g7 N6 [
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ M* f+ I* T  T& \/ A9 Y7 E! ~
and Kenneth R. Rettig, MD1
0 A  D( D9 a; v6 E6 sClinical Pediatrics
/ r+ i. H4 u) L5 e1 A# e1 RVolume 46 Number 6
- w/ k9 j( b; U; D$ B8 s8 M4 G$ ^July 2007 540-543$ h  _% i9 g: C3 P
© 2007 Sage Publications- t, l( h" E9 I$ f, i8 j( j
10.1177/0009922806296651, \& e, w- D8 S. v; Y4 y# P& G
http://clp.sagepub.com
) f9 R3 R7 \! o1 d- v/ R. d7 xhosted at0 l) c5 z/ e* M
http://online.sagepub.com
0 D& V- V1 M! `) hPrecocious puberty in boys, central or peripheral,# E: J/ c& W* @# u7 ^+ ]$ S
is a significant concern for physicians. Central
+ U6 u$ ]' n, B0 pprecocious puberty (CPP), which is mediated
' Z6 C. E( p* gthrough the hypothalamic pituitary gonadal axis, has6 m9 G. k0 `/ z0 g
a higher incidence of organic central nervous system
. K2 N3 B" E0 z* `9 {: Ylesions in boys.1,2 Virilization in boys, as manifested
0 H2 C9 P# F) {by enlargement of the penis, development of pubic# }! y- W5 O! g. ?( c! \; u- x
hair, and facial acne without enlargement of testi-
/ I+ c& ~/ v. r3 G" p  X$ vcles, suggests peripheral or pseudopuberty.1-3 We
- S, m: j) h/ y; N$ \5 {/ M& dreport a 16-month-old boy who presented with the: T' Y' m# h! @2 v- R
enlargement of the phallus and pubic hair develop-% S, [1 L4 }# B+ b  P  j
ment without testicular enlargement, which was due, t, s. e$ s1 ?  y' e1 ^4 w
to the unintentional exposure to androgen gel used by  `! u4 V( H- k% @/ m1 ^
the father. The family initially concealed this infor-
  p/ b- t, Q" e8 [3 b& `9 x# P: Q, kmation, resulting in an extensive work-up for this; n5 Y, ?- S3 k2 \: M+ b$ r% L
child. Given the widespread and easy availability of
3 b, u( F  W* ttestosterone gel and cream, we believe this is proba-
1 p" r9 g9 C  g- Ably more common than the rare case report in the' p. P$ d" H: E' N
literature.4
, c& h$ ]4 ]4 g0 qPatient Report
, y+ M9 q4 N8 oA 16-month-old white child was referred to the) N9 t( q! ?- ^  c3 t5 N9 e3 o
endocrine clinic by his pediatrician with the concern$ T" \; g3 C' f; Z9 C
of early sexual development. His mother noticed
$ s4 s/ F) y/ A) M" ]$ p3 j/ glight colored pubic hair development when he was) q5 v" X2 N( |. b
From the 1Division of Pediatric Endocrinology, 2University of
' h( X, F7 J1 r" rSouth Alabama Medical Center, Mobile, Alabama.- W$ I: z2 ]; Z9 H2 I9 H
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 B4 D! _2 b/ ]Professor of Pediatrics, University of South Alabama, College of7 @! X0 w( A, y! f8 ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% L2 @5 t: q5 l/ h+ S2 r: S, W5 E
e-mail: [email protected].( z/ V8 _( |5 k+ |0 {" a
about 6 to 7 months old, which progressively became
, y3 L. U7 \" I6 x0 C9 Qdarker. She was also concerned about the enlarge-
, X* r& ~6 m3 b0 P! Ament of his penis and frequent erections. The child
5 n# |4 V& v' L( F/ V% Hwas the product of a full-term normal delivery, with
6 M6 T% G. i8 d# Ea birth weight of 7 lb 14 oz, and birth length of
! r$ A- k% f, m20 inches. He was breast-fed throughout the first year1 m+ p8 Y, Y/ {, s: e, h
of life and was still receiving breast milk along with. h3 a0 s4 l# j- i( p
solid food. He had no hospitalizations or surgery,9 K* I* q2 h5 o: H* u
and his psychosocial and psychomotor development4 n& P) s" ^* c2 j# q5 g, C- `
was age appropriate.
! z: X" F" @( ?- \% eThe family history was remarkable for the father,- v4 ~5 Y/ S% V2 f
who was diagnosed with hypothyroidism at age 16,
3 T. [5 }6 H$ K: e$ \  O5 U. Pwhich was treated with thyroxine. The father’s: `7 @" y" ?9 @" Y
height was 6 feet, and he went through a somewhat
3 `$ @" @0 m, R( a6 Kearly puberty and had stopped growing by age 14.8 y. g& P9 l& ]% N. M
The father denied taking any other medication. The2 w6 L' k8 ~$ I+ F7 Z7 ]3 Y
child’s mother was in good health. Her menarche% b8 b8 Y5 m8 N: D; _6 Z  `/ O
was at 11 years of age, and her height was at 5 feet9 R" K2 o9 `3 F# F
5 inches. There was no other family history of pre-* t4 ?9 H! @- o/ Q
cocious sexual development in the first-degree rela-
) ~5 [% W3 @1 ~) F) M) U( `/ atives. There were no siblings.5 f" Y( \( v$ F
Physical Examination1 V7 d+ H$ u' M. v3 U0 z% c
The physical examination revealed a very active,3 N$ o$ ?# [% D
playful, and healthy boy. The vital signs documented9 {! B) u  r* m0 a$ M" Z
a blood pressure of 85/50 mm Hg, his length was
) V7 s! `4 L2 X, q! b  O# l90 cm (>97th percentile), and his weight was 14.4 kg
* ~! @6 d) o6 I  K+ ^(also >97th percentile). The observed yearly growth, d, W" k1 T7 p% B/ @3 s
velocity was 30 cm (12 inches). The examination of8 P! u7 @- V9 `3 ?
the neck revealed no thyroid enlargement." I: |$ E1 Y4 h
The genitourinary examination was remarkable for9 l. d# V2 e5 y8 F# u
enlargement of the penis, with a stretched length of: N- j$ p) a: a8 t0 g
8 cm and a width of 2 cm. The glans penis was very well0 t) I4 F1 U+ M5 @9 A" w8 Z+ X
developed. The pubic hair was Tanner II, mostly around
6 t# b% S8 z+ n( d/ x! d540
. H" ~, V( {3 X. Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 r0 Z0 l, ]/ K- r# Q  S
the base of the phallus and was dark and curled. The/ j/ u4 X; A' O& B
testicular volume was prepubertal at 2 mL each.9 Y7 j2 W# U, g, L; t$ x3 {
The skin was moist and smooth and somewhat+ f4 P# N( [. \3 j2 [5 ?
oily. No axillary hair was noted. There were no) N7 [- r. P* w# d4 A7 e# O
abnormal skin pigmentations or café-au-lait spots.
' R6 ^2 }3 x8 ]Neurologic evaluation showed deep tendon reflex 2+( I2 N* d( Z( [6 @% s# k: i# ?2 J
bilateral and symmetrical. There was no suggestion% I2 |9 y/ b* k; i9 y( F
of papilledema.& @$ B& u& y; q& ?2 G* `
Laboratory Evaluation" d* W0 R$ r5 V3 _
The bone age was consistent with 28 months by9 G7 ~" y6 v0 Q, f
using the standard of Greulich and Pyle at a chrono-
$ h, n/ p2 p$ o% O0 ~4 d! M- M' [logic age of 16 months (advanced).5 Chromosomal
6 |/ E* _- p5 zkaryotype was 46XY. The thyroid function test+ O+ g: q4 h  h* P. l* }
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. R7 A& J0 i6 Q7 z; a" V8 clating hormone level was 1.3 µIU/mL (both normal)., M- m2 D# W0 g8 T; o0 f
The concentrations of serum electrolytes, blood
3 g: I5 c9 B4 V6 N2 r% q% Z( F1 qurea nitrogen, creatinine, and calcium all were
( ~, U- M; ?" d8 fwithin normal range for his age. The concentration. a0 y' J8 c* t  ^, k% V
of serum 17-hydroxyprogesterone was 16 ng/dL9 k4 y9 G6 L; L0 N7 Q7 J% M
(normal, 3 to 90 ng/dL), androstenedione was 208 w4 p2 `1 d4 O5 r6 P% C3 _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ t. a; }  O* q( J$ }  H; y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: L7 H" a8 l' ]- Q8 ~  ^" W8 L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" b- x, x$ F3 A
49ng/dL), 11-desoxycortisol (specific compound S)
& n" V9 w3 ^& q+ t4 s& r2 c. dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! a5 ^- e5 `: f0 y: b/ rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. e0 q7 Y3 |( D/ c3 v+ vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' |7 ?. }! j- l, n# m# L; @# A
and β-human chorionic gonadotropin was less than
, q% A4 j: z; W; x) p. L) W0 ?" }5 mIU/mL (normal <5 mIU/mL). Serum follicular
& G+ p. p) ^6 v5 M/ h# G4 Astimulating hormone and leuteinizing hormone! I; {$ ^+ o  |! c% f- W
concentrations were less than 0.05 mIU/mL
/ F# y* ?" j+ ?! {3 P5 F& D(prepubertal).5 G. O; o* W1 Y+ k$ F! {
The parents were notified about the laboratory% d% J' A- Q) J5 W  [6 p7 i
results and were informed that all of the tests were
. Z1 c6 d( k2 r  c& E: M3 Enormal except the testosterone level was high. The7 j8 L' `: |! g: t6 Y. G
follow-up visit was arranged within a few weeks to
, `! a, U# {) c: l% Jobtain testicular and abdominal sonograms; how-/ m3 p5 v% ~# R6 W5 ]4 R: J# }2 w
ever, the family did not return for 4 months.
5 w/ _" s& x# c5 V  UPhysical examination at this time revealed that the1 T  V5 o- W2 R3 r6 s$ e5 H1 A
child had grown 2.5 cm in 4 months and had gained* H; U: f6 c6 q0 J
2 kg of weight. Physical examination remained" ^- x2 T& N7 Y+ z( ]! @- K9 m! y& e
unchanged. Surprisingly, the pubic hair almost com-
- ?/ \8 d2 Z* T% l) L5 L6 B9 D/ vpletely disappeared except for a few vellous hairs at
+ |  h2 t4 t! V0 Uthe base of the phallus. Testicular volume was still 2+ Q' ~0 b% W9 O6 S0 J, F. D. v
mL, and the size of the penis remained unchanged.
3 N+ d7 \8 ~) KThe mother also said that the boy was no longer hav-9 G+ }' l& L3 u2 r. H
ing frequent erections.  ~7 g  |' s5 F$ }& _
Both parents were again questioned about use of" i7 ]% i, b7 c, L; X5 p
any ointment/creams that they may have applied to# _6 P5 Y( B" W
the child’s skin. This time the father admitted the) U# h# Q6 S. G4 }" a
Topical Testosterone Exposure / Bhowmick et al 541: n3 P# Q2 W+ ~
use of testosterone gel twice daily that he was apply-$ R0 _! ]' x* s3 v
ing over his own shoulders, chest, and back area for
5 o- w, T. m2 {$ ~3 }$ A: s' _a year. The father also revealed he was embarrassed8 M7 H: F, x& y
to disclose that he was using a testosterone gel pre-
8 D, J. S% D& o( d2 s: Q# k2 Qscribed by his family physician for decreased libido
; ]: K! c2 j6 isecondary to depression.7 }7 F) m+ W( n( D/ Q+ c/ w4 i
The child slept in the same bed with parents.) Q" U$ c" \2 G$ a/ U
The father would hug the baby and hold him on his
! ]! a: L" c8 F0 G7 ^: Gchest for a considerable period of time, causing sig-2 F6 `9 s: D# S  O% n
nificant bare skin contact between baby and father.
9 F& G& o. E, I" _The father also admitted that after the phone call,5 ]1 W7 @2 w! e1 L$ V" r( p
when he learned the testosterone level in the baby
: m9 ~: o; A0 V1 [% owas high, he then read the product information( q  _6 p6 t; p$ K9 G' b
packet and concluded that it was most likely the rea-' J8 j, t2 h3 Z( E3 b- M
son for the child’s virilization. At that time, they: v; y  M9 b. \# A) L
decided to put the baby in a separate bed, and the0 |3 \* l( G1 w: t  b( E
father was not hugging him with bare skin and had
5 d/ r* t" r% R8 F# e( abeen using protective clothing. A repeat testosterone
6 N. s) P# E4 ^9 G4 G/ j% H8 ?test was ordered, but the family did not go to the' J3 X9 ^0 x$ s* s1 X
laboratory to obtain the test.; {1 [7 n& j' `4 z
Discussion
  C" Q! N. k) y& W6 kPrecocious puberty in boys is defined as secondary
! N( ]; I0 f, F6 p3 Z- ]sexual development before 9 years of age.1,4
' j6 g0 K' k5 a+ r. p7 F7 I$ nPrecocious puberty is termed as central (true) when1 Q# ^2 t2 d7 l8 k2 I
it is caused by the premature activation of hypo-$ n* u9 K2 U7 I% u1 U
thalamic pituitary gonadal axis. CPP is more com-+ t% t+ O# h" D. \7 U8 h4 i
mon in girls than in boys.1,3 Most boys with CPP3 o* R  h& p0 x7 {: v% u% F
may have a central nervous system lesion that is! p$ P3 e1 [( [5 \. C9 f8 Y8 t6 U
responsible for the early activation of the hypothal-1 h& ^) q% ?3 c& ?$ c; ^7 s, U  Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 _) t1 k9 V7 b1 ^0 Z, Xsis has been given to neuroradiologic imaging in  P% K$ x1 R" N
boys with precocious puberty. In addition to viril-
5 i7 ~/ M+ Q! `4 A7 Y6 Pization, the clinical hallmark of CPP is the symmet-
2 G/ |8 R% [1 \, }rical testicular growth secondary to stimulation by
- A0 i% m- e* P# L. Z. J/ z7 Ugonadotropins.1,3
4 u# f. ~1 l" \5 YGonadotropin-independent peripheral preco-  z% J# T9 R+ `; x& S/ E3 M' `( R
cious puberty in boys also results from inappropriate% V- N5 D! F& X2 v- P4 k: P' T. G
androgenic stimulation from either endogenous or. J+ _  w* |! h2 Y
exogenous sources, nonpituitary gonadotropin stim-
# x9 ?  Y; k& f: \( ^ulation, and rare activating mutations.3 Virilizing: M& u& ^9 s+ b; |% ?# b
congenital adrenal hyperplasia producing excessive
% N9 E( g" }5 u# w1 I1 l' ]adrenal androgens is a common cause of precocious
) s5 ~, O* n8 R; v: n2 N: j; G% dpuberty in boys.3,4
0 e% b& k& z# t2 t+ n' z- {The most common form of congenital adrenal! l5 m8 O6 [. W9 B# O+ z
hyperplasia is the 21-hydroxylase enzyme deficiency.4 ]0 B! e) T- F# M; l: p$ l
The 11-β hydroxylase deficiency may also result in3 l1 J- I/ S0 J8 N" v* Y
excessive adrenal androgen production, and rarely,1 y" |$ p/ v4 Z' v# z9 Z: @
an adrenal tumor may also cause adrenal androgen# b1 D1 J' q* j6 e0 i: d5 f3 q
excess.1,3
4 y0 X: a/ S( S, x$ ?0 h! Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. e# a4 [' _! X8 ~7 S% U$ @; S+ G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* `6 ?( O; p( O# a0 u
A unique entity of male-limited gonadotropin-
# \0 ]0 q8 B1 C1 E$ Bindependent precocious puberty, which is also known
8 A0 Z3 H( e% ], ~# h# Pas testotoxicosis, may cause precocious puberty at a2 w+ ?- F$ e+ s4 e( I0 s. v
very young age. The physical findings in these boys
% _( R% ?' i4 K# fwith this disorder are full pubertal development,7 b4 q' }0 e3 \/ m
including bilateral testicular growth, similar to boys8 [5 X! F0 M! o/ B# |1 U
with CPP. The gonadotropin levels in this disorder0 |% i1 ^" o5 w  f% k+ {
are suppressed to prepubertal levels and do not show
# @. J/ v2 {  z9 vpubertal response of gonadotropin after gonadotropin-
: w7 H# J' e# _- I$ O3 `$ |. J8 Breleasing hormone stimulation. This is a sex-linked
$ m) `0 {, Z+ ?9 R8 hautosomal dominant disorder that affects only
' j, S0 @; _, K- z' z7 Q2 Tmales; therefore, other male members of the family- B) y8 M9 D1 }  ]0 _
may have similar precocious puberty.36 M, n  n5 T. ?2 d% @* ^8 h
In our patient, physical examination was incon-) ]3 ?1 Y7 V# Y9 R7 h$ s7 u
sistent with true precocious puberty since his testi-! U. z9 P6 p8 x/ \9 n' j8 i
cles were prepubertal in size. However, testotoxicosis3 b+ y$ Q* j& G0 ]/ B
was in the differential diagnosis because his father
6 _- @- z1 V; B$ s1 Ystarted puberty somewhat early, and occasionally,2 p* X8 [  ^( }
testicular enlargement is not that evident in the- z  y" o. F& _3 v2 x
beginning of this process.1 In the absence of a neg-7 Q4 ^9 `: E, j1 y
ative initial history of androgen exposure, our! ~) s6 \4 X/ |" {  h
biggest concern was virilizing adrenal hyperplasia,0 D4 b- u" N8 P/ t
either 21-hydroxylase deficiency or 11-β hydroxylase
. q" ?, F& E1 |% o. \$ u) y( R  pdeficiency. Those diagnoses were excluded by find-
% {' U+ b& @: ~! oing the normal level of adrenal steroids.; ^" W0 I9 S# T0 y
The diagnosis of exogenous androgens was strongly
; A" |: Y. t0 k( p6 ^- vsuspected in a follow-up visit after 4 months because
3 _6 _8 d% a3 X8 I, qthe physical examination revealed the complete disap-
7 ]3 D" y1 Y. k$ mpearance of pubic hair, normal growth velocity, and5 d- X7 U9 [5 n; M& Z6 u! ^
decreased erections. The father admitted using a testos-& ~9 J! l& \) P
terone gel, which he concealed at first visit. He was
) q+ S8 _  ]* R, m! qusing it rather frequently, twice a day. The Physicians’
1 C' K1 \# B$ X. o& rDesk Reference, or package insert of this product, gel or/ O  m$ |2 j3 X, O* b& W. z
cream, cautions about dermal testosterone transfer to
: F% {: U8 U& b* H' Y9 Funprotected females through direct skin exposure.( ~4 Y. @& ~& P1 f
Serum testosterone level was found to be 2 times the
2 e" x, S! S- \8 y3 @baseline value in those females who were exposed to  o. O) y, H5 Z+ c7 H8 {
even 15 minutes of direct skin contact with their male
8 n" L# a' O. I  K8 V4 k8 |" O0 _partners.6 However, when a shirt covered the applica-
/ p# X( U' [. Ltion site, this testosterone transfer was prevented.! Q: N7 ~0 r5 Q2 }
Our patient’s testosterone level was 60 ng/mL,
$ F& g; Y5 k% U' Lwhich was clearly high. Some studies suggest that% `0 k' W. Z' H" B& M
dermal conversion of testosterone to dihydrotestos-
, m, d; A' x; ^; @6 Z* Xterone, which is a more potent metabolite, is more
0 {, {9 ^& P6 J4 i2 zactive in young children exposed to testosterone
' ?1 {, r$ t) [! D( K) a$ zexogenously7; however, we did not measure a dihy-" q+ O4 A* w2 E" }! @0 o0 [" z
drotestosterone level in our patient. In addition to
1 |4 B4 D1 X9 n& Rvirilization, exposure to exogenous testosterone in) q1 y: o# z# F  W+ Z1 _
children results in an increase in growth velocity and
$ {7 D' b& \9 `$ Q- qadvanced bone age, as seen in our patient.
' H2 s% |: r" W- LThe long-term effect of androgen exposure during$ V1 p: ^0 S) ^& K
early childhood on pubertal development and final
+ H9 |4 F$ X3 q) uadult height are not fully known and always remain
: z3 t5 g6 l) V1 D: G1 Xa concern. Children treated with short-term testos-/ o; b/ H- \& |
terone injection or topical androgen may exhibit some
4 @: _+ I7 _! ?0 A# Z4 _: macceleration of the skeletal maturation; however, after
; i& x  `* C3 R- r9 |# |cessation of treatment, the rate of bone maturation" V8 d! ?0 Q; _& i7 M
decelerates and gradually returns to normal.8,98 ^/ J8 S* N4 E
There are conflicting reports and controversy
8 X! d4 o/ B  s) b2 Yover the effect of early androgen exposure on adult# A' a6 _  A; O) j
penile length.10,11 Some reports suggest subnormal2 w; I: W) k4 \
adult penile length, apparently because of downreg-
! ]# G( X& |, A3 i' Lulation of androgen receptor number.10,12 However,6 L$ }: a9 A* p& C* `$ ?. Q  h! A
Sutherland et al13 did not find a correlation between/ y' }" }+ X4 p& f7 }# v$ S
childhood testosterone exposure and reduced adult
0 p/ y$ R# j- |7 i; O9 }; |' Ypenile length in clinical studies.
" U$ Z: \0 O# B% Q- RNonetheless, we do not believe our patient is
; I$ y1 M4 ^2 d, Q: f& xgoing to experience any of the untoward effects from
3 N( p2 S  y  }& i* p0 W& ^testosterone exposure as mentioned earlier because
% |/ a/ R7 }% C: {/ gthe exposure was not for a prolonged period of time.
' A! A' n6 b4 Z. sAlthough the bone age was advanced at the time of' s4 l; H5 f7 P& V
diagnosis, the child had a normal growth velocity at
; y; W8 U: h: I7 p% f( [9 hthe follow-up visit. It is hoped that his final adult
( j# D  K7 V/ l" `; ^( P) j0 Theight will not be affected.  O2 P" p% G& G
Although rarely reported, the widespread avail-) P6 {. ]5 z+ W- R9 |% f
ability of androgen products in our society may1 Z6 s/ x7 _3 m& R% l
indeed cause more virilization in male or female
+ D7 b6 k2 q5 Q6 t' E% Ychildren than one would realize. Exposure to andro-* e0 l' |) o* [5 n) B
gen products must be considered and specific ques-
- P  P5 b6 b; l8 j' ^tioning about the use of a testosterone product or( ?& U) x( d* E
gel should be asked of the family members during. Q# O8 E) K. t
the evaluation of any children who present with vir-2 _3 m- D3 D, ]) h3 e) A' y
ilization or peripheral precocious puberty. The diag-
  X+ D% n2 O, c, tnosis can be established by just a few tests and by
4 H+ W3 K6 E9 }4 happropriate history. The inability to obtain such a% l- w' g% m/ |) D5 z% C% n  f
history, or failure to ask the specific questions, may9 ]; m4 x, C" s0 \) o" O5 {
result in extensive, unnecessary, and expensive# a6 _4 N& W3 V$ [
investigation. The primary care physician should be5 |6 x; R* a3 K) m
aware of this fact, because most of these children$ W# R' ?# c7 a1 t
may initially present in their practice. The Physicians’" ~( }" v) ?' G: a
Desk Reference and package insert should also put a" ?+ g% r, {4 Q( K% H
warning about the virilizing effect on a male or
. [7 q1 o0 Y' p, W. B* Ufemale child who might come in contact with some-
4 }; L1 l0 ?. y. f: p  sone using any of these products., u! Z8 ]4 Q! c$ u5 r2 Z
References
: V0 H( W) N# J2 Y/ B" \; f0 K1. Styne DM. The testes: disorder of sexual differentiation4 \  E0 k. [3 F
and puberty in the male. In: Sperling MA, ed. Pediatric
1 F# w! X: L* v0 G! E3 M1 oEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 A5 B7 E  O' P/ g( {1 W2002: 565-628.3 {# G/ r6 F  l) k6 ~$ ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& R) N$ V0 {3 F
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* A! F. t1 E$ X- W- D: v. v
Boy Induced by Indirect Topical
. S, Q8 N( W* `8 R; OExposure to Testosterone4 j1 |. C3 q& a" b7 t& e" T& `
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 f, {; a8 E7 Gand Kenneth R. Rettig, MD18 [% w4 D( h% Z4 k
Clinical Pediatrics
: B- L% Y$ g: K! o$ F% e/ r9 Z: a, wVolume 46 Number 6- ^3 P, e& k' z8 `9 G' |0 p/ j
July 2007 540-543: H/ J. e8 p' @
© 2007 Sage Publications$ P8 e+ ~- R1 j$ d3 E! ~2 _
10.1177/0009922806296651
( l1 B: P# B+ q9 p5 A* lhttp://clp.sagepub.com1 ?$ k" }" M4 n  M+ ^
hosted at6 _  M6 A0 I0 U6 F+ Q/ ^2 c
http://online.sagepub.com$ R6 w) r% g. @
Precocious puberty in boys, central or peripheral,
( b. \* X; h$ v  @* t7 Kis a significant concern for physicians. Central
$ b% s& F' l# s# oprecocious puberty (CPP), which is mediated* [& `2 `" T1 B1 o/ I/ y
through the hypothalamic pituitary gonadal axis, has7 U# G/ |) d) a
a higher incidence of organic central nervous system
% s( I8 B9 a; V+ {4 {: ~2 olesions in boys.1,2 Virilization in boys, as manifested
+ J( Z- @  F* `' V$ S0 G7 Pby enlargement of the penis, development of pubic
2 I/ [: a' E# o/ u5 h! b; Dhair, and facial acne without enlargement of testi-2 a0 g9 p9 P0 f, H2 {( A) j
cles, suggests peripheral or pseudopuberty.1-3 We6 X/ j6 M& @/ U: K6 C  u3 A" G
report a 16-month-old boy who presented with the3 n" @6 D6 s/ T  d
enlargement of the phallus and pubic hair develop-
. b$ W9 z2 q9 ?8 W' ], Wment without testicular enlargement, which was due) p# o; V- d4 Z4 {) L
to the unintentional exposure to androgen gel used by
, F1 J2 M2 |, a  r+ w# W& S( Jthe father. The family initially concealed this infor-( q# G5 }2 w$ o' ]9 F
mation, resulting in an extensive work-up for this9 Y+ P& k3 i) [" ~
child. Given the widespread and easy availability of
1 x1 Z# A. T7 g2 s" s5 _7 r! ?  ztestosterone gel and cream, we believe this is proba-
( n! P# o* y2 @# mbly more common than the rare case report in the* r" I  Q" q+ I! g% D, N
literature.4' E! Z' v6 L0 C0 H
Patient Report
2 r. F3 \% c+ u/ [0 CA 16-month-old white child was referred to the
( T# n8 ]  f% }1 J  N- v8 \endocrine clinic by his pediatrician with the concern
2 l3 f. `6 o+ d9 A# ?2 W; T- Z8 U5 Zof early sexual development. His mother noticed
( ]  H' w; D6 p# Z, Xlight colored pubic hair development when he was- M. Y/ f4 J' E/ w
From the 1Division of Pediatric Endocrinology, 2University of) F8 X# Z3 L& t. T
South Alabama Medical Center, Mobile, Alabama.
4 c- p- X! ]) j! V. Y# L+ j4 UAddress correspondence to: Samar K. Bhowmick, MD, FACE,) q; s! v+ f: y: {! {
Professor of Pediatrics, University of South Alabama, College of
3 w8 E, ~: |5 f) c& ]0 N3 _& gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 E8 R7 A2 Q. s2 q* X$ |1 C' {e-mail: [email protected].
6 U" L: \# b8 S- vabout 6 to 7 months old, which progressively became
) l  h+ w8 q  p# i1 A# Jdarker. She was also concerned about the enlarge-
% q7 O; ^+ Y- |( y' ~ment of his penis and frequent erections. The child
. }' S0 s$ F6 m2 Z8 O+ Ywas the product of a full-term normal delivery, with6 W8 N' b( \* h7 ~, @" J
a birth weight of 7 lb 14 oz, and birth length of
0 v" I0 C6 U0 X6 w9 A20 inches. He was breast-fed throughout the first year
! D. D; Y& j3 U8 b) Bof life and was still receiving breast milk along with) U( m* Y8 z& o
solid food. He had no hospitalizations or surgery,
3 }, u2 U0 N3 S, C3 I0 I8 iand his psychosocial and psychomotor development
/ W+ N- [9 [( ?" Iwas age appropriate.
2 i/ e  N; Q( O  IThe family history was remarkable for the father,
) D. i0 A! \* Rwho was diagnosed with hypothyroidism at age 16,! {6 Y5 \) I1 L* L0 g
which was treated with thyroxine. The father’s3 T' ]" z" x- P  m6 b! Z. K7 b( P( E
height was 6 feet, and he went through a somewhat6 F7 K% j" b9 j9 n' E
early puberty and had stopped growing by age 14.
$ J; C/ l6 b: JThe father denied taking any other medication. The
# e" I- U( J4 X. y* v- }child’s mother was in good health. Her menarche+ s/ U1 H/ X6 M2 T
was at 11 years of age, and her height was at 5 feet: C  B8 ~0 n  f0 u: t3 e5 Y
5 inches. There was no other family history of pre-
4 S! }3 Z: j9 e- Z  W+ icocious sexual development in the first-degree rela-
. @; m4 m+ U7 L! L2 H' E  y6 s# |; O7 ntives. There were no siblings.% I+ p5 a* I) d! E: O: m
Physical Examination
* b/ e8 c% n( H$ MThe physical examination revealed a very active,/ F9 o; T0 G' r8 ?
playful, and healthy boy. The vital signs documented
# h5 d* F& K5 s2 q& a# A6 }: a) l& na blood pressure of 85/50 mm Hg, his length was
) x: Z2 K  m' ~; J8 ], g$ s0 [90 cm (>97th percentile), and his weight was 14.4 kg
! J, D  K& P8 k( R/ v(also >97th percentile). The observed yearly growth$ Y2 F, o2 W' F/ _
velocity was 30 cm (12 inches). The examination of! O$ V! P- _( W$ t/ O' a9 q
the neck revealed no thyroid enlargement.2 _7 H9 o. d+ t" J% I
The genitourinary examination was remarkable for1 X' U+ ]5 _- S. N% [+ y& N' Z5 _
enlargement of the penis, with a stretched length of
( P# \* u# L* j/ u. a2 A8 cm and a width of 2 cm. The glans penis was very well& l( Z) g( R* |% }) s. T7 g' v
developed. The pubic hair was Tanner II, mostly around
; `5 v* W; s/ u1 ]5404 t' u* o8 h4 l+ j9 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 z* l+ r" k, V" {the base of the phallus and was dark and curled. The3 ?6 k5 n$ p) M  W9 H) j
testicular volume was prepubertal at 2 mL each.+ \" \( j7 b) ^
The skin was moist and smooth and somewhat
3 V' K" t& _, W- J! ^oily. No axillary hair was noted. There were no2 S4 {9 M+ [) D9 z, v" ^
abnormal skin pigmentations or café-au-lait spots.
# d% D) T0 u; V# i% Z& SNeurologic evaluation showed deep tendon reflex 2+9 t# z  w! g1 y: f# R3 ]6 F0 @$ s
bilateral and symmetrical. There was no suggestion& S8 C" |; y" S
of papilledema.
' P" j2 F+ u; y& ~* L( `  ^6 o, |5 t: zLaboratory Evaluation
1 m1 G0 I+ Y; vThe bone age was consistent with 28 months by! q: R, Q# ^2 r/ ]6 e. W' [
using the standard of Greulich and Pyle at a chrono-
' _6 W2 q0 I6 _1 s3 i% ~1 {3 nlogic age of 16 months (advanced).5 Chromosomal
2 p1 h: j! _- T- Q1 k$ o# w/ C: Lkaryotype was 46XY. The thyroid function test5 z1 \6 k! s, j' |7 }+ D8 `
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 @( ^/ L9 r( h2 d! ]lating hormone level was 1.3 µIU/mL (both normal).* V' k% n& Q, f# x0 @/ B* ~
The concentrations of serum electrolytes, blood: }5 M$ T" J4 e' B2 p, f4 I
urea nitrogen, creatinine, and calcium all were" }. Y  S0 T' c# d
within normal range for his age. The concentration
0 c5 D0 e+ d  pof serum 17-hydroxyprogesterone was 16 ng/dL$ K3 w* f& I8 i4 U
(normal, 3 to 90 ng/dL), androstenedione was 20: {: h$ I9 r' y- B5 e, Y$ Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 _9 \' g* l0 Y$ |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 A6 E5 v& i- l8 u2 ?! O' Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to: V8 d8 ]& @- |2 Y2 b/ r
49ng/dL), 11-desoxycortisol (specific compound S)/ |0 h/ `+ U: x+ w7 B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- V9 N1 [5 c5 Q; x9 ^7 q% }' r" Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; f2 {5 F7 d- [* O3 `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, A- ^' n* Q3 W. L4 I0 T# [
and β-human chorionic gonadotropin was less than
! s3 l1 o; M7 s2 u; z$ T( j  V8 Z5 mIU/mL (normal <5 mIU/mL). Serum follicular" H$ Z  u' X% q+ G8 K
stimulating hormone and leuteinizing hormone
; Q. \  [. A9 U8 f# tconcentrations were less than 0.05 mIU/mL1 G# K+ y* u' N
(prepubertal).
& z" A2 O7 R2 F1 M2 tThe parents were notified about the laboratory: v! I# }8 n# |" U* O
results and were informed that all of the tests were; V5 j6 v; g/ q$ g7 z* N: f! z
normal except the testosterone level was high. The  I, d* w, ?; L0 J) D. e& {
follow-up visit was arranged within a few weeks to+ m/ n& u/ ]0 |7 y& m
obtain testicular and abdominal sonograms; how-7 y0 h- l. Z+ [' I
ever, the family did not return for 4 months.4 E8 p: j3 n  a3 x8 n- |( c
Physical examination at this time revealed that the* G2 W% P/ V$ }" k
child had grown 2.5 cm in 4 months and had gained
  x' U" U" y! p6 o2 kg of weight. Physical examination remained5 |7 B0 U, ?0 [
unchanged. Surprisingly, the pubic hair almost com-
! G0 c6 I% |! n1 z0 s* k& C2 ypletely disappeared except for a few vellous hairs at4 a0 T! y. Y1 Z
the base of the phallus. Testicular volume was still 2
4 ]+ g! T, P8 y1 A  u' umL, and the size of the penis remained unchanged.
. u9 N3 _; M1 aThe mother also said that the boy was no longer hav-
+ T2 V( V& F+ j! O* a) i2 Cing frequent erections.
2 M$ ~& `) K8 G  m; N: K9 n1 i  ZBoth parents were again questioned about use of, Q& h7 W/ k. E
any ointment/creams that they may have applied to# z. a! F- f: \$ I
the child’s skin. This time the father admitted the
, B$ ]* U* a- m7 OTopical Testosterone Exposure / Bhowmick et al 541! |3 ]4 w. {1 b% }  G( ?
use of testosterone gel twice daily that he was apply-
5 m9 @7 E( v2 d7 _( `, F& ^ing over his own shoulders, chest, and back area for/ Q) X  V+ K5 G3 i" A) s  R
a year. The father also revealed he was embarrassed" T: J- X! h4 j  z
to disclose that he was using a testosterone gel pre-* h2 {$ S! V# ~0 i: H  j1 Q- |. h
scribed by his family physician for decreased libido
9 ^6 I5 d* O$ X" ?% bsecondary to depression.8 }4 y8 @0 W0 {4 U3 `
The child slept in the same bed with parents.; l( y4 {4 c7 S( H: e
The father would hug the baby and hold him on his; M2 Y  o2 u8 Y4 t& V6 _& j4 X
chest for a considerable period of time, causing sig-
0 T/ J: U+ i9 D3 y9 U  p; r0 g1 Snificant bare skin contact between baby and father.
2 E: B8 i6 ~9 S" K" uThe father also admitted that after the phone call,
) `" P% ~9 `% m' F1 A0 t, gwhen he learned the testosterone level in the baby7 ]; y( z' ~6 d: J* ~+ \
was high, he then read the product information
" |/ i) g: R' R& K7 n! m+ [packet and concluded that it was most likely the rea-7 j' x2 @& s% `
son for the child’s virilization. At that time, they1 e# g; r+ \7 V) p$ `$ i5 u( x
decided to put the baby in a separate bed, and the
1 ~4 A% r4 w5 Z! ~& Q4 rfather was not hugging him with bare skin and had
) K1 E$ q) |6 Jbeen using protective clothing. A repeat testosterone
& I" _( J( a$ mtest was ordered, but the family did not go to the
! a& \  R# [4 _& w) r5 qlaboratory to obtain the test.
4 p2 j! A. j& A( W7 EDiscussion0 n/ A3 `/ C9 E
Precocious puberty in boys is defined as secondary: ?) v6 x5 p6 B! b( `2 `
sexual development before 9 years of age.1,4
0 V! z, D# b/ p( @. \Precocious puberty is termed as central (true) when
- c0 x* d. ]; |; }) E: Hit is caused by the premature activation of hypo-# C" ~0 v) L! g" i
thalamic pituitary gonadal axis. CPP is more com-( |. G- |/ O! y
mon in girls than in boys.1,3 Most boys with CPP
. V5 @4 i/ k7 I. @' amay have a central nervous system lesion that is
& `, y' `7 ^% presponsible for the early activation of the hypothal-
* ^, F, c3 h. {8 |5 Famic pituitary gonadal axis.1-3 Thus, greater empha-$ l2 P: N' Y/ e; @" N& m0 N
sis has been given to neuroradiologic imaging in
) _, A( r* ]- C& pboys with precocious puberty. In addition to viril-. o7 B' J+ q; M' _+ s$ c1 `
ization, the clinical hallmark of CPP is the symmet-1 Y/ I  W" q% w) y1 y; u
rical testicular growth secondary to stimulation by# _" C2 w. _5 H6 b  c1 o+ E. x& ^/ g
gonadotropins.1,30 o5 H. p5 o& V; s9 H( o
Gonadotropin-independent peripheral preco-
6 I+ S0 Z8 W8 z2 K6 y$ s! K! mcious puberty in boys also results from inappropriate! D# D# Y: w; G; s- x1 P
androgenic stimulation from either endogenous or
' [; b0 g4 {: A2 j3 c3 _5 Y3 Pexogenous sources, nonpituitary gonadotropin stim-
" E* T5 K- l' ~& m9 Lulation, and rare activating mutations.3 Virilizing; R- t( R  c$ n, D3 V0 g
congenital adrenal hyperplasia producing excessive! t. K7 E1 M& Q- V9 C
adrenal androgens is a common cause of precocious
  \$ ~" g; N3 M9 |) a$ M- U4 Vpuberty in boys.3,4
; G+ @% C( i8 LThe most common form of congenital adrenal
: F8 b. K0 ^' F1 k  zhyperplasia is the 21-hydroxylase enzyme deficiency.) }1 D" ~2 u: P# [
The 11-β hydroxylase deficiency may also result in. C: b% M" z4 V: R
excessive adrenal androgen production, and rarely,
5 b1 O& h; p! k! @+ Wan adrenal tumor may also cause adrenal androgen
# \7 Q3 J5 z6 R/ p% j% a$ _excess.1,3' d5 a) s" L0 a! |$ U5 i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ x( A6 L# f" l1 ~9 d! e4 J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: `7 z: i! j1 L* g
A unique entity of male-limited gonadotropin-8 S$ y" N# i, W" W4 K+ B  {! s
independent precocious puberty, which is also known
" I3 E% ]* [2 N. T$ Zas testotoxicosis, may cause precocious puberty at a
6 W3 g5 a8 E1 R3 Ivery young age. The physical findings in these boys
2 O2 W7 k. T" D/ wwith this disorder are full pubertal development,, o; w: Z1 m8 _! s; O# k2 X
including bilateral testicular growth, similar to boys  A  Q; b$ u- S1 v( B
with CPP. The gonadotropin levels in this disorder
  x9 n6 T' f& I' R; M  s7 [are suppressed to prepubertal levels and do not show
' d6 l- u" {  d6 m( p6 h. T8 npubertal response of gonadotropin after gonadotropin-
- ~% W2 V9 v0 F% q: b/ breleasing hormone stimulation. This is a sex-linked
) ]0 {* |! l, o4 Oautosomal dominant disorder that affects only
' d1 J+ g# W% w4 M, i$ Vmales; therefore, other male members of the family3 [1 j- t8 ^# |
may have similar precocious puberty.3
: X2 y* i0 q4 C1 f* T" z4 b3 X8 IIn our patient, physical examination was incon-/ {- ]7 {: C- h  L3 a! n! y6 X
sistent with true precocious puberty since his testi-; O+ {  z) P/ X; z+ f! S% `
cles were prepubertal in size. However, testotoxicosis+ i0 G& S# Q2 i) v5 D' ?
was in the differential diagnosis because his father
. x7 ?0 a1 v3 g9 Cstarted puberty somewhat early, and occasionally,
' y4 r) @; _9 V# w) Atesticular enlargement is not that evident in the; J, S5 S0 Q  J8 |  K* R" P
beginning of this process.1 In the absence of a neg-8 X4 e9 F0 e1 n, n, p
ative initial history of androgen exposure, our
8 m, B) {& h8 e2 z1 A; L) w# Rbiggest concern was virilizing adrenal hyperplasia,& Y, _6 W" Y! d6 n$ B
either 21-hydroxylase deficiency or 11-β hydroxylase
: |. O2 ]1 `* X% [deficiency. Those diagnoses were excluded by find-. F* c$ s+ \. h2 Z4 D' Q
ing the normal level of adrenal steroids./ B& ~0 G: n: C! d
The diagnosis of exogenous androgens was strongly
( R3 ?' w+ L- e* _1 }) hsuspected in a follow-up visit after 4 months because4 J: t1 ^' X4 V- ]$ t
the physical examination revealed the complete disap-7 f6 q  a$ w/ W4 N7 y
pearance of pubic hair, normal growth velocity, and6 Q2 ^4 v' T/ k2 B; N% r! g5 Q
decreased erections. The father admitted using a testos-  {! E, d' P- D4 Z
terone gel, which he concealed at first visit. He was
) v% \" V! \- x& T* S  N; Vusing it rather frequently, twice a day. The Physicians’
! o& m0 e2 v: r0 D1 l. j2 t0 zDesk Reference, or package insert of this product, gel or
. k$ z. j% Z; u" ]cream, cautions about dermal testosterone transfer to; B- {2 y/ T+ d2 r# n; J
unprotected females through direct skin exposure.  e! |: Z* [8 I- `# D6 x
Serum testosterone level was found to be 2 times the
* D- F( b: I9 f, K  J& A) Obaseline value in those females who were exposed to
0 L' n* g" @# {5 }) xeven 15 minutes of direct skin contact with their male* R  Z% D" d! H; A+ R: p
partners.6 However, when a shirt covered the applica-
, M3 u) S- l9 H$ ytion site, this testosterone transfer was prevented.8 D1 _  W' J8 E3 b5 u
Our patient’s testosterone level was 60 ng/mL,- T* P, b+ i! X& s0 a; ^. k
which was clearly high. Some studies suggest that- b6 g7 E: U& {0 m% D$ W
dermal conversion of testosterone to dihydrotestos-
" G& c  g4 a6 K" }terone, which is a more potent metabolite, is more
9 F$ N0 }- v/ h. lactive in young children exposed to testosterone
) L8 _. O* Y  n+ F+ K: rexogenously7; however, we did not measure a dihy-
6 y- O: k" m0 h+ xdrotestosterone level in our patient. In addition to1 B& H& W& p. p9 Q. }$ Q
virilization, exposure to exogenous testosterone in1 z2 M! C3 m! q/ v, T" M5 B
children results in an increase in growth velocity and1 `  N5 y% `8 \( K& w- W0 q
advanced bone age, as seen in our patient.
2 h# J/ A3 D$ [& ~7 {+ k# m' }The long-term effect of androgen exposure during
; N2 ~9 i3 Y2 Learly childhood on pubertal development and final
) h; ~5 V" O3 e$ H" y# c" |5 h3 [adult height are not fully known and always remain% f+ o1 X0 X. J1 s) @
a concern. Children treated with short-term testos-
  Y1 D1 M" S0 q. t; `& j/ rterone injection or topical androgen may exhibit some
' _- K& N! S9 q$ _. Q2 l9 `/ macceleration of the skeletal maturation; however, after
0 A6 x3 O7 ~$ N: c7 Y) Acessation of treatment, the rate of bone maturation
. |2 ?, N  ~' o$ g* Y8 [4 ~decelerates and gradually returns to normal.8,9
' G5 M( B7 p# u/ B! e( n0 j+ G$ J6 zThere are conflicting reports and controversy
4 O- S/ U8 e1 j, T+ A& ?1 }; aover the effect of early androgen exposure on adult
1 [; p3 e' e, Fpenile length.10,11 Some reports suggest subnormal
7 D  \% K8 z* U4 m. Yadult penile length, apparently because of downreg-
/ g7 _8 q, q5 U# kulation of androgen receptor number.10,12 However,
! [; b1 l; @7 m. KSutherland et al13 did not find a correlation between
- s% y% H' w3 I' d! H. Z$ bchildhood testosterone exposure and reduced adult+ f% W8 z8 i+ V
penile length in clinical studies." n0 b3 [) h& S3 u
Nonetheless, we do not believe our patient is8 q: a3 U; N* U( v! ~6 F% t, F4 ]
going to experience any of the untoward effects from. I8 r3 h0 H$ ^6 z* @+ U4 k- F
testosterone exposure as mentioned earlier because$ m! j! l9 v0 r/ h. T  O  x' b
the exposure was not for a prolonged period of time., d- N- Z! P" Q2 G4 K- I7 |# D
Although the bone age was advanced at the time of
* a  ^  h0 V, t5 pdiagnosis, the child had a normal growth velocity at; m+ `/ _9 W/ v# V! a3 O3 J6 t
the follow-up visit. It is hoped that his final adult! S" D3 m9 D& I+ x/ h( c
height will not be affected.
3 D! @# T" b; [' rAlthough rarely reported, the widespread avail-
) U% c& i3 k/ D4 dability of androgen products in our society may2 I! C' b4 H4 E+ e7 |  E7 Z
indeed cause more virilization in male or female6 S' h8 k+ a; s
children than one would realize. Exposure to andro-7 n9 U" C/ I) h$ J/ w
gen products must be considered and specific ques-
7 K' b/ O9 K9 {3 c) F6 ationing about the use of a testosterone product or0 T9 j- h: M( R' y0 F) X& r
gel should be asked of the family members during% Y/ b# ?3 P3 b& V; h, i. l$ a( A
the evaluation of any children who present with vir-
% N% M& y  _2 w2 vilization or peripheral precocious puberty. The diag-9 n9 @  v, Q. b/ M7 d4 @
nosis can be established by just a few tests and by
# t' ~" N1 q" n" Z$ g3 _appropriate history. The inability to obtain such a3 d7 r* v; q3 a, Z% H' [5 J$ i- T4 \* w
history, or failure to ask the specific questions, may4 ?  |  ^) p* C( i
result in extensive, unnecessary, and expensive; a7 T. _, W% Q7 H
investigation. The primary care physician should be) U4 {/ U0 k2 l3 [0 y% E
aware of this fact, because most of these children+ f$ ~7 M6 c1 R) X
may initially present in their practice. The Physicians’
8 N, T$ \+ p7 U9 C9 j+ g5 H. a; U2 rDesk Reference and package insert should also put a. t- c& t9 ?, d
warning about the virilizing effect on a male or
" U8 x& J  u4 I( m2 F/ X: Ffemale child who might come in contact with some-
3 d: v: o# a6 Q; N" Vone using any of these products.
$ ^$ ?: U( E1 y! Y; yReferences
9 P' u3 a! g$ \0 h1. Styne DM. The testes: disorder of sexual differentiation) v4 S) e9 W/ [% Q1 l7 r
and puberty in the male. In: Sperling MA, ed. Pediatric
4 I1 N! a, f) m7 @Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  n! D* z2 g+ K! K2002: 565-628.
4 n6 l" {$ W1 t, u2 D) S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( |* X- W9 m) c! V
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層
; W2 g1 D  l% s% B' Y9 p! y2 p2 ~) F: ?4 m
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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