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Sexual Precocity in a 16-Month-Old
0 ?- u# ^- p9 [0 hBoy Induced by Indirect Topical
/ X  e" g0 Y+ OExposure to Testosterone3 Q! @  j5 @- v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 y9 Z" `. R; o* u, V
and Kenneth R. Rettig, MD1% Z! S$ w" }. [9 c) I: \
Clinical Pediatrics, b9 {! k1 N7 t% r( r1 a, o6 R
Volume 46 Number 6+ z; \6 ^7 c5 X, h) b8 ^
July 2007 540-543
0 S/ G7 p5 T/ f' }; z' h© 2007 Sage Publications' W! U) A# C5 ^! w: [
10.1177/00099228062966515 q$ _. D3 ~, e" O
http://clp.sagepub.com
8 W6 F) e2 s% k& O' E- S; c6 \. ~. vhosted at
# k: F$ v' k5 ], D  c3 _! _" h+ C+ mhttp://online.sagepub.com& o' ~5 p$ g) ]( W! ^7 B9 o
Precocious puberty in boys, central or peripheral,
* \+ o) h4 j) G0 eis a significant concern for physicians. Central
6 A8 o0 o" N7 Z" B4 e6 C: f) zprecocious puberty (CPP), which is mediated& C* I6 Q; ^. `4 _, U' i! i
through the hypothalamic pituitary gonadal axis, has  G+ E. x& p1 R2 g- \4 r; c
a higher incidence of organic central nervous system$ a! U2 A6 ^( D% {) D
lesions in boys.1,2 Virilization in boys, as manifested: h! ^4 ]8 d  ?5 o) j
by enlargement of the penis, development of pubic
* X5 E/ N9 {4 f. `/ T9 Ghair, and facial acne without enlargement of testi-
3 U; Z! t, t! ^cles, suggests peripheral or pseudopuberty.1-3 We$ X. `, C- ^" X) @
report a 16-month-old boy who presented with the
8 H* z6 \( q+ |+ `enlargement of the phallus and pubic hair develop-* s$ L6 M. O4 N9 k
ment without testicular enlargement, which was due6 o3 y9 e$ }8 d' n# n
to the unintentional exposure to androgen gel used by
3 C& _7 n  x7 w0 p3 O5 N* G& Fthe father. The family initially concealed this infor-4 I* q2 S0 p/ T
mation, resulting in an extensive work-up for this
( w6 x2 S/ u  u7 rchild. Given the widespread and easy availability of
6 M; j$ I7 N  j1 q+ Btestosterone gel and cream, we believe this is proba-0 m$ `8 J# s0 ]" Q# p6 n3 J
bly more common than the rare case report in the2 o! K' d& H6 n, V4 O9 D; k
literature.4
5 c+ N* T2 Y+ d7 }5 U+ Z( [3 PPatient Report
: X, p% j+ @! U0 CA 16-month-old white child was referred to the3 F2 Z. n' j/ q- {
endocrine clinic by his pediatrician with the concern& M# H; @4 i4 [& j! G0 }. @1 k
of early sexual development. His mother noticed
  Y5 U, Z' B: _7 ~+ Glight colored pubic hair development when he was; f" l$ S) I" x9 a3 x- z; L$ j
From the 1Division of Pediatric Endocrinology, 2University of) L6 r: Q! M; g
South Alabama Medical Center, Mobile, Alabama.; V9 f% M' `6 S+ T# x
Address correspondence to: Samar K. Bhowmick, MD, FACE,
3 f% f5 u8 o) d& i0 UProfessor of Pediatrics, University of South Alabama, College of$ ^7 y; d% i! z' @9 {4 G9 U$ [
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( v6 V( z/ O0 ~) q2 {7 He-mail: [email protected].
  C& X  `& b& x& F  r4 l, f  Dabout 6 to 7 months old, which progressively became3 k" {0 \  L+ ?6 v+ \& C
darker. She was also concerned about the enlarge-5 _* R/ b0 ?" {) K5 y, c# g
ment of his penis and frequent erections. The child2 V- h* a1 ~$ p* ]5 ?8 U# N2 W9 j
was the product of a full-term normal delivery, with1 `7 d" u) H+ q8 A4 |0 m8 A; J$ S
a birth weight of 7 lb 14 oz, and birth length of/ K7 }' ?) M& x$ q
20 inches. He was breast-fed throughout the first year8 l& R4 ]7 x) _. k5 D$ G: G
of life and was still receiving breast milk along with1 C9 U! O8 i7 }3 h
solid food. He had no hospitalizations or surgery,. A- O; Y( ]& w" u/ L* U, A
and his psychosocial and psychomotor development
8 j$ K. c: L2 }& T. ?1 Pwas age appropriate.
8 S  ^  ~" A$ Z% h6 \The family history was remarkable for the father,' k6 U* T7 R  H
who was diagnosed with hypothyroidism at age 16,' T( v( B& S5 C; {, X2 B0 [
which was treated with thyroxine. The father’s
& r) i$ b+ n- E9 j. C) k2 \height was 6 feet, and he went through a somewhat
! \2 {: ^0 I0 y4 N5 f1 [early puberty and had stopped growing by age 14.- R% ?% ]' Q; _6 U" x5 v5 s
The father denied taking any other medication. The5 I$ T  Z! Z6 g# Y; k  S
child’s mother was in good health. Her menarche( V. F0 ?$ }9 Y6 n
was at 11 years of age, and her height was at 5 feet6 j6 A+ B: p( q# g: R5 c3 l
5 inches. There was no other family history of pre-
! z2 |$ F% G; Q% a" [cocious sexual development in the first-degree rela-0 u5 M0 [. Q+ d( s' {; J- Q+ p
tives. There were no siblings.1 i+ ?" F0 I8 i  k" I) m! |2 Z+ {; T
Physical Examination7 [  B: Y& m2 k* p1 Z
The physical examination revealed a very active,
# V' e  m- U% z6 Wplayful, and healthy boy. The vital signs documented- N3 M* ^* M* f1 U/ L+ ]- g
a blood pressure of 85/50 mm Hg, his length was* p$ w5 b0 ^9 A9 a
90 cm (>97th percentile), and his weight was 14.4 kg
( ]7 J" x8 n& y' @(also >97th percentile). The observed yearly growth9 Z- o% B5 Z6 b, C) ?9 g0 _$ Q2 W0 Y
velocity was 30 cm (12 inches). The examination of
/ l4 R. z: |# j( q% U1 y' bthe neck revealed no thyroid enlargement.
. A/ U% U7 _1 q: C: ~5 [The genitourinary examination was remarkable for
. ?% k( c2 b% M" henlargement of the penis, with a stretched length of
+ P' G+ b- \( [* @+ n$ d) V  d' r8 cm and a width of 2 cm. The glans penis was very well
) p; q4 _; r, zdeveloped. The pubic hair was Tanner II, mostly around. g( F1 Q. }4 v/ t+ u
5408 p8 o/ b% D+ A8 [0 c" H  u: S% X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 r2 d! Y  S, \& m5 Rthe base of the phallus and was dark and curled. The
/ X! f+ S: {/ j0 ttesticular volume was prepubertal at 2 mL each.) C3 e- p( D% s' P) ]
The skin was moist and smooth and somewhat
8 W. H5 d# Q1 j3 ^& a2 O0 \oily. No axillary hair was noted. There were no
8 \+ Q* t9 V/ nabnormal skin pigmentations or café-au-lait spots.- }1 d, B5 q: B8 l5 m
Neurologic evaluation showed deep tendon reflex 2+
% A8 J4 d/ O0 |. ?bilateral and symmetrical. There was no suggestion
! Y4 d3 l5 D; ^+ R) m* q2 aof papilledema.
5 s3 g& M! P6 h3 ]- dLaboratory Evaluation
& e, M/ o1 ^% f! Y  U* t+ X9 UThe bone age was consistent with 28 months by
8 V0 n9 N  M. Z% ~using the standard of Greulich and Pyle at a chrono-1 C0 G, [! n0 y2 |: c
logic age of 16 months (advanced).5 Chromosomal
6 T% r' [- b+ z2 I1 Zkaryotype was 46XY. The thyroid function test5 }1 C/ Y: G- T. _& {' [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 }8 K9 H9 E1 t) i1 q1 f2 k; Z( F' k1 tlating hormone level was 1.3 µIU/mL (both normal).
* d+ ^5 u; _3 G' ~- ^$ p% eThe concentrations of serum electrolytes, blood( l* t. @! `6 e$ g% Y
urea nitrogen, creatinine, and calcium all were  V5 O" T% L/ J6 r
within normal range for his age. The concentration
& T( s, p8 D) E; r  Oof serum 17-hydroxyprogesterone was 16 ng/dL( ^" y' P( Y. [6 t$ A
(normal, 3 to 90 ng/dL), androstenedione was 20' x) t$ J: r3 D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 V1 N2 U; G* g' [
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ n- r& {9 Q( T7 p( {! Q; r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to3 @! y5 d" ]( Z' f
49ng/dL), 11-desoxycortisol (specific compound S)
) w7 G& V2 }# Y  Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ x. o$ J+ d/ [: I% mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 ~) z- m% Q3 X) |$ l% }" t
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& G) f0 I1 ~8 S) l
and β-human chorionic gonadotropin was less than
- U9 q! |1 E' U- J6 |# d, f3 x. r4 f% x5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 B' }8 O+ o; k, z! _stimulating hormone and leuteinizing hormone
, q! A+ \( C6 Q3 S. m7 oconcentrations were less than 0.05 mIU/mL
) @: W+ W% N- J(prepubertal).
/ q4 T8 m! M0 U4 D3 nThe parents were notified about the laboratory+ I1 e; {" v2 c- A, v7 O- U8 o
results and were informed that all of the tests were5 X! r* {0 p9 q" _$ ~) w6 k3 F2 o* w
normal except the testosterone level was high. The7 G' ?- @: \( A2 k: }
follow-up visit was arranged within a few weeks to5 P. m; S9 [: s+ W& a6 f
obtain testicular and abdominal sonograms; how-; [$ F$ t& N" U
ever, the family did not return for 4 months.
( v2 L/ _7 e' L- X  MPhysical examination at this time revealed that the: d  ]. L1 m5 r- x: R2 t. s5 r! `$ ^
child had grown 2.5 cm in 4 months and had gained
' b2 J0 k5 o0 k2 v5 y( b2 kg of weight. Physical examination remained  T' o# ^/ t: y% ~6 P
unchanged. Surprisingly, the pubic hair almost com-2 s2 |/ w) D  l4 e
pletely disappeared except for a few vellous hairs at' |8 m  S  I% z: S+ @: d
the base of the phallus. Testicular volume was still 24 \7 E  S# C0 ~
mL, and the size of the penis remained unchanged.
% V9 F" W% S1 @1 o& PThe mother also said that the boy was no longer hav-
- j/ J: P! d* K+ u* W. v! B' fing frequent erections.
0 a3 J2 A5 I( n1 U; z0 K( dBoth parents were again questioned about use of" q. ~2 G/ C( Y( e' D
any ointment/creams that they may have applied to
. ?1 d$ J: Z0 w4 [7 sthe child’s skin. This time the father admitted the
3 {& S0 G% O9 I! i/ _& _( t: NTopical Testosterone Exposure / Bhowmick et al 5411 w- L  ]9 p# j( v( O% v& W% W
use of testosterone gel twice daily that he was apply-2 I' @3 V! H) q& ?
ing over his own shoulders, chest, and back area for
) j+ W+ I1 L: ~% D: _6 K% Xa year. The father also revealed he was embarrassed
, ^1 A8 g) v: r$ `$ ^to disclose that he was using a testosterone gel pre-
5 g: D, h1 f, r( V& i2 escribed by his family physician for decreased libido. d0 Y1 D+ Y+ w7 K
secondary to depression.
/ O1 S) J/ G- ~. T* K0 @2 M  LThe child slept in the same bed with parents.
2 P) ]5 @5 @) U; Q/ M- rThe father would hug the baby and hold him on his4 V, T; I: A, i. y, J
chest for a considerable period of time, causing sig-
4 H4 e% h7 @& J, f) Qnificant bare skin contact between baby and father.3 L3 U1 K- r  j" ]- o) |6 n+ q( O
The father also admitted that after the phone call,
! @4 M; P8 A3 E! o% zwhen he learned the testosterone level in the baby
5 U6 j; v) S$ |3 f, z$ \1 z; Twas high, he then read the product information
# q# |' K' ^) W# Xpacket and concluded that it was most likely the rea-" y  R' S2 H; F# K2 i  j
son for the child’s virilization. At that time, they
5 N1 q( S) P0 @0 Qdecided to put the baby in a separate bed, and the
, j. J( O2 H& i( K' x* ?father was not hugging him with bare skin and had; Z$ W( `  P4 K0 g( u
been using protective clothing. A repeat testosterone
6 F( H2 x" M1 d& X' a5 `4 [test was ordered, but the family did not go to the
1 z2 A. M/ H& A7 J' ylaboratory to obtain the test.. @' F$ z, p5 S! f
Discussion
, o: G, @. G3 Y" t! e& y8 yPrecocious puberty in boys is defined as secondary9 N( c4 p. O5 j3 l
sexual development before 9 years of age.1,46 W" _; n* g. S4 m- {  x
Precocious puberty is termed as central (true) when
3 y$ a7 v6 z$ Bit is caused by the premature activation of hypo-/ }0 z9 D$ i( G0 [
thalamic pituitary gonadal axis. CPP is more com-( J- ?( r+ r. a4 Z
mon in girls than in boys.1,3 Most boys with CPP. a6 k1 H" @. n9 c6 X0 Z$ n
may have a central nervous system lesion that is2 s* D1 S8 v( v$ T4 H' L
responsible for the early activation of the hypothal-
5 b" f) T6 `, L" e2 qamic pituitary gonadal axis.1-3 Thus, greater empha-
1 T' ^9 d" y) C6 ~* B3 X- zsis has been given to neuroradiologic imaging in
: y5 u+ s8 ~- P8 Vboys with precocious puberty. In addition to viril-0 R( y6 R: |: c! V" B; T; ^
ization, the clinical hallmark of CPP is the symmet-
& B/ D* Z! U1 X: \, [' _( N2 {. zrical testicular growth secondary to stimulation by
  g' }- z% R8 E8 P5 M+ [gonadotropins.1,30 c( ?, w# j' u1 B# j* }
Gonadotropin-independent peripheral preco-
7 V" Q- I* }7 n3 d  [4 a9 ecious puberty in boys also results from inappropriate
* T. u% g5 _9 R% i) P: Mandrogenic stimulation from either endogenous or2 d7 o/ n0 S0 G' J
exogenous sources, nonpituitary gonadotropin stim-
1 u) U9 I" V# F1 N4 E7 W7 G# fulation, and rare activating mutations.3 Virilizing- ]5 s0 b9 [) V" |" p
congenital adrenal hyperplasia producing excessive$ }: T! c7 e0 K$ `' c
adrenal androgens is a common cause of precocious
- _4 V3 z- U; r# Qpuberty in boys.3,46 F8 o$ S- R) j+ I( a$ G
The most common form of congenital adrenal5 ?1 _/ g0 r$ @$ ^) n
hyperplasia is the 21-hydroxylase enzyme deficiency.
4 V  ~/ r* e5 o. B' YThe 11-β hydroxylase deficiency may also result in
+ h  h5 }+ u% J& qexcessive adrenal androgen production, and rarely,9 y, \) _2 b# s9 G
an adrenal tumor may also cause adrenal androgen6 T' w& q3 Z- ?) s8 Z$ a) P* M
excess.1,3
3 I$ A) x% w, t% N* f; Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 x! |3 W( A# t0 e  ^$ w' w542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) g: z3 }* [2 ^3 GA unique entity of male-limited gonadotropin-
3 d2 |! g6 M' U1 tindependent precocious puberty, which is also known, E% T1 z$ w) k( `0 \. I3 `/ g$ ?
as testotoxicosis, may cause precocious puberty at a
  |" R6 {0 Z4 g; _# ?very young age. The physical findings in these boys7 E9 P9 w: P8 S# `& L
with this disorder are full pubertal development,
% ?4 F8 e9 C! N& i9 h) F1 ^including bilateral testicular growth, similar to boys
- C3 O. L! E" S3 e9 S. Qwith CPP. The gonadotropin levels in this disorder5 X; m# M: r% ?- r7 Z+ t* c: @# Q
are suppressed to prepubertal levels and do not show
" f! _/ Q& n0 H( E7 s. ipubertal response of gonadotropin after gonadotropin-" q5 F$ U" T6 A! d1 k7 c
releasing hormone stimulation. This is a sex-linked
' K2 `/ u! T2 t+ e  P) cautosomal dominant disorder that affects only
9 G, M/ Q7 a" X" p- D- b) S( Vmales; therefore, other male members of the family6 \4 K2 K+ z" s' s0 P* w! t8 C( `" c' o
may have similar precocious puberty.3" m4 u- G; o: d7 m
In our patient, physical examination was incon-1 H% F' M! F4 M& D
sistent with true precocious puberty since his testi-' W2 ~. e. O: G9 f( Y. m+ O
cles were prepubertal in size. However, testotoxicosis( L  |2 G5 h5 e' j& L
was in the differential diagnosis because his father% q1 {) o8 D1 P  v4 W
started puberty somewhat early, and occasionally,
7 [7 m! [0 F6 l* \' }testicular enlargement is not that evident in the
! Q: t* A9 U/ S" T+ g' Y0 n. A" W1 Ebeginning of this process.1 In the absence of a neg-
, n: K1 N% a; p  Y$ t1 v/ w5 ]# tative initial history of androgen exposure, our& m" G2 [" z; j1 F' U
biggest concern was virilizing adrenal hyperplasia,% P2 k5 h+ u' i& L0 z" J$ P: Y
either 21-hydroxylase deficiency or 11-β hydroxylase
# f0 l$ A* h+ E% G0 ]3 S* {deficiency. Those diagnoses were excluded by find-
* g- _# L; h/ I0 H! k. king the normal level of adrenal steroids.- m1 e& a* P2 m
The diagnosis of exogenous androgens was strongly
& d$ j3 f% j4 T) o/ R  l+ Lsuspected in a follow-up visit after 4 months because
1 O% A; m" I' _1 wthe physical examination revealed the complete disap-
2 k7 q" i* f/ I1 vpearance of pubic hair, normal growth velocity, and
- d: B' D2 D  E0 i6 H; Ydecreased erections. The father admitted using a testos-
& R4 Y' E% g( x/ bterone gel, which he concealed at first visit. He was  r* s) I, f% ?1 o4 ?9 R- ~! l
using it rather frequently, twice a day. The Physicians’
+ K2 y8 ^# \, a! V: r# jDesk Reference, or package insert of this product, gel or' d% }  v* a  Y4 ?8 j' U  E
cream, cautions about dermal testosterone transfer to+ a/ e% Y( ^( g, W
unprotected females through direct skin exposure.
' @9 {* J7 d! L& ]0 D8 N% N8 A1 |9 xSerum testosterone level was found to be 2 times the
* {% M: o7 X& }4 y& o7 |# v; a- Xbaseline value in those females who were exposed to' P4 ~- `3 t  J4 a5 X1 Y% _& G' e9 a
even 15 minutes of direct skin contact with their male
5 f0 }+ A' _! J3 v9 fpartners.6 However, when a shirt covered the applica-( a) o5 e5 A6 X, z# o- R; W4 Y
tion site, this testosterone transfer was prevented.1 a5 h( |- S) M, @( {, y
Our patient’s testosterone level was 60 ng/mL,
- e! Y3 R  o; d9 s# q5 q* Q& Kwhich was clearly high. Some studies suggest that5 j/ g# l" v/ _# n6 R
dermal conversion of testosterone to dihydrotestos-
7 Y  R, H; v) a( @: [; G$ s' w6 pterone, which is a more potent metabolite, is more! K/ l7 J( v; A0 K  D
active in young children exposed to testosterone
! C$ T% E: B# T& Vexogenously7; however, we did not measure a dihy-) j9 k7 p- B- N; A3 p3 s: X
drotestosterone level in our patient. In addition to
- H5 k: z0 T! |/ e, X3 {. X4 q! Wvirilization, exposure to exogenous testosterone in
2 c; G! X% Z7 z: i. G* @, ?" jchildren results in an increase in growth velocity and3 b- G  Q+ {3 b$ @# V
advanced bone age, as seen in our patient.9 a2 X6 g4 h( m9 D
The long-term effect of androgen exposure during9 R& h9 {; O" Z. e
early childhood on pubertal development and final; E; Y3 c# o' U, D6 h! b
adult height are not fully known and always remain
9 w0 f% X% }. \+ Qa concern. Children treated with short-term testos-6 S5 U' r' g5 v, g6 F3 V* j
terone injection or topical androgen may exhibit some1 \+ m1 X& k- n- F- l
acceleration of the skeletal maturation; however, after
) I9 I9 j' Z2 m" `6 ]7 `( {cessation of treatment, the rate of bone maturation# R0 f6 G- I5 A& Z% m
decelerates and gradually returns to normal.8,9: _( @5 X0 v! h
There are conflicting reports and controversy! F; G1 l( ?  R% s: k/ U
over the effect of early androgen exposure on adult
- e  `- W0 A. z- z$ L# [: cpenile length.10,11 Some reports suggest subnormal
" M; H$ ?' K5 g  }adult penile length, apparently because of downreg-) d& d; X' S: s! u* l' `& N
ulation of androgen receptor number.10,12 However,+ O, M+ O- q8 s
Sutherland et al13 did not find a correlation between8 W, _! Y, h& G3 Y, c5 f
childhood testosterone exposure and reduced adult( w% ?% _; P# y# u6 H0 J2 i
penile length in clinical studies.  {, M$ ?3 G* K0 U$ z. m6 v& d- H
Nonetheless, we do not believe our patient is+ Y* J: S( K8 b0 G9 {7 B$ W
going to experience any of the untoward effects from# x3 K" d" ~' q0 |7 w
testosterone exposure as mentioned earlier because' J. D5 b# a- v
the exposure was not for a prolonged period of time.1 @! {; {) v" l* Z
Although the bone age was advanced at the time of% k. q+ S. Q/ d' b9 [
diagnosis, the child had a normal growth velocity at
6 D4 S* y( m! _5 gthe follow-up visit. It is hoped that his final adult  {5 u1 {* B2 V) j( i4 ^# h
height will not be affected.
3 |4 _$ r1 j) K+ D0 h1 z; z! d* tAlthough rarely reported, the widespread avail-
2 a; S1 l+ h3 Oability of androgen products in our society may/ g$ G' B8 u& {( _6 N& s: w
indeed cause more virilization in male or female
; P# u$ x8 T0 R9 U8 A% wchildren than one would realize. Exposure to andro-6 n8 l3 ]1 c8 D3 e' n9 I# O! M
gen products must be considered and specific ques-
6 S" f) m4 H  R$ [; Z7 ^tioning about the use of a testosterone product or
" D$ T+ A5 W: M( f' @1 _gel should be asked of the family members during
+ z5 i) @2 d+ xthe evaluation of any children who present with vir-: B  y, H+ K8 E+ N8 a! k7 ^4 Q& Y+ Z0 p
ilization or peripheral precocious puberty. The diag-8 ]3 U9 g2 C. V$ n2 F
nosis can be established by just a few tests and by
& }4 t, Y  Z& j, oappropriate history. The inability to obtain such a/ _* w1 u0 i& _
history, or failure to ask the specific questions, may
# S. a3 t4 C& Zresult in extensive, unnecessary, and expensive7 ~7 [& C' ]5 f2 Y4 G
investigation. The primary care physician should be$ E7 ^! }7 w$ y: ]6 ~
aware of this fact, because most of these children: b2 Z# f6 l4 V- A
may initially present in their practice. The Physicians’
! H7 m& T% r; d! h- S: w3 DDesk Reference and package insert should also put a" t$ S- h8 \4 ]- V- _+ {6 H
warning about the virilizing effect on a male or& P4 W  Y* p  t# x- {& i+ H6 d0 U
female child who might come in contact with some-
- D2 f' ~% H9 m: v% none using any of these products." j0 n* F7 W9 T5 z
References& m1 k; \) P2 p5 B. b) i# x
1. Styne DM. The testes: disorder of sexual differentiation
6 G$ u, ~+ }$ N$ F  aand puberty in the male. In: Sperling MA, ed. Pediatric
1 H3 ?: c) e! [/ b5 REndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 M0 l6 n2 W" X5 n. L3 {2002: 565-628.
- M  z4 D7 X* _) b& U/ ~4 B2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# D3 o) {* C1 C6 l4 kpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old% I- B# c( O( z2 n. I6 y$ O
Boy Induced by Indirect Topical0 O. @% ^8 p3 D1 Y& V) }$ a5 `
Exposure to Testosterone7 G* a( ]9 `/ S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 ~( t% V7 i: W" ~* u% a0 Y8 G
and Kenneth R. Rettig, MD1( Q8 @! Y5 |. L! F7 ~6 G
Clinical Pediatrics5 `6 l/ }) k, }8 |
Volume 46 Number 6
5 P, n+ T4 H& Q+ GJuly 2007 540-543
0 c) n/ k1 G( T9 u& I5 d- j© 2007 Sage Publications
4 S/ M6 W" ?( o  {) j10.1177/0009922806296651' p6 @* F' ^% I# ^% S4 e1 U
http://clp.sagepub.com
6 \$ S& C& y9 G) k/ x- D) Ohosted at
! r6 c8 d5 ~  D) L( j& a: ]http://online.sagepub.com
% K* \0 p7 `/ H- T* bPrecocious puberty in boys, central or peripheral,1 {& T1 a0 f' k
is a significant concern for physicians. Central
, S0 Z+ _& Y* ], J" _- C3 Jprecocious puberty (CPP), which is mediated8 _4 y) s8 M3 G( U3 K& Q) E
through the hypothalamic pituitary gonadal axis, has
2 X3 `/ y5 c4 D0 `# R( Ra higher incidence of organic central nervous system
7 [8 ?5 g8 X  u3 _& o' r- U# Y3 xlesions in boys.1,2 Virilization in boys, as manifested  e, w2 _: H) G$ Q( V' W
by enlargement of the penis, development of pubic# M( q0 `1 j! s5 A+ e( }9 j) B, l. w
hair, and facial acne without enlargement of testi-
( G5 P& H# G1 S. v; f2 Kcles, suggests peripheral or pseudopuberty.1-3 We
8 }4 ~1 i/ w; Wreport a 16-month-old boy who presented with the( P6 I+ v8 `& ]5 F2 Z7 J0 N* A
enlargement of the phallus and pubic hair develop-
( X, a% G/ L% M  u$ vment without testicular enlargement, which was due
. V1 W; v- G$ A2 C) j' j# E. Qto the unintentional exposure to androgen gel used by
8 P5 }; y2 @) L( P* B# Cthe father. The family initially concealed this infor-% @: K. b8 K! Q$ Q& z' r- `
mation, resulting in an extensive work-up for this6 _6 V4 S' O- |) L
child. Given the widespread and easy availability of
" `) I3 e+ p  u& w, ]/ dtestosterone gel and cream, we believe this is proba-
; ^; C9 E  e7 u' @( Fbly more common than the rare case report in the* R2 m  _3 `  H$ R. L
literature.40 M9 F8 D& ?0 x7 a! {
Patient Report5 U8 W  Q$ ?3 n" J1 m
A 16-month-old white child was referred to the
4 }+ B; I: ~& i( n  Fendocrine clinic by his pediatrician with the concern+ o) M# G1 g6 H# w) ~" a  ~$ d9 w( P
of early sexual development. His mother noticed  r- m4 A& k$ L$ K* A# Y3 B
light colored pubic hair development when he was% I) M9 _0 \* C0 K2 Y( I
From the 1Division of Pediatric Endocrinology, 2University of
" u2 c% Q4 S, j; |/ SSouth Alabama Medical Center, Mobile, Alabama.
# h& x6 D. M# g" U) {% ]Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 i. g& l/ L; m8 }" B/ iProfessor of Pediatrics, University of South Alabama, College of
. V3 b% s5 T( K; G/ gMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- s! Y+ e+ F& q7 r6 O6 V4 K
e-mail: [email protected].
# x4 k, ^$ [- C% Oabout 6 to 7 months old, which progressively became! t; Q6 H" ]. a# Q3 H' o
darker. She was also concerned about the enlarge-
1 ?1 G/ E, z' E% p6 r1 L+ T: Dment of his penis and frequent erections. The child
: s; }5 t, Q- `was the product of a full-term normal delivery, with) D; |" ~# Z9 A; S6 E
a birth weight of 7 lb 14 oz, and birth length of
' c3 p3 W3 {; e# K$ |: u1 s20 inches. He was breast-fed throughout the first year
3 ]; T- ~- Y7 h% ^of life and was still receiving breast milk along with# q8 C9 f" c6 P. ?# z
solid food. He had no hospitalizations or surgery,, D9 m, ]- a( ~0 e- ~, n
and his psychosocial and psychomotor development$ K& {3 }2 m1 i' ~/ R' }
was age appropriate.3 V! {  b! ]$ U' I! @
The family history was remarkable for the father,/ t# B* S, E- B' m8 q  n8 m
who was diagnosed with hypothyroidism at age 16,# g4 ~8 A) r, g0 r
which was treated with thyroxine. The father’s
) t9 j1 M4 I2 rheight was 6 feet, and he went through a somewhat
0 w& N4 O  m: N0 @" P$ bearly puberty and had stopped growing by age 14.
5 i5 ]1 P% W3 Q2 zThe father denied taking any other medication. The
/ _  n9 H( r' t0 x9 D6 tchild’s mother was in good health. Her menarche
. u( `  G. J7 A& T- dwas at 11 years of age, and her height was at 5 feet$ n$ w6 ~8 k# Q1 r
5 inches. There was no other family history of pre-) Q+ M4 O2 t" d/ O
cocious sexual development in the first-degree rela-) `! y$ G# t/ l/ r( f) {
tives. There were no siblings.
* D; ^: R6 y" _0 ZPhysical Examination, N. ?9 \4 l% a* [
The physical examination revealed a very active,
3 A5 u. G4 Q- Aplayful, and healthy boy. The vital signs documented. s) Z! [; Y  f8 c# r% S* D
a blood pressure of 85/50 mm Hg, his length was
( \% {1 u0 Z5 ^0 G90 cm (>97th percentile), and his weight was 14.4 kg
/ N  y7 j! H+ X1 y4 O(also >97th percentile). The observed yearly growth) I& @. u! f) R% N# k+ O1 V
velocity was 30 cm (12 inches). The examination of
# o* B) O/ O, Cthe neck revealed no thyroid enlargement.4 ^( u. ^' F9 D' T
The genitourinary examination was remarkable for% V4 `0 H/ E$ w% J
enlargement of the penis, with a stretched length of
: Y/ n/ W( z1 [8 cm and a width of 2 cm. The glans penis was very well
4 j( _6 R* L5 ~7 _8 i( cdeveloped. The pubic hair was Tanner II, mostly around
# x. T/ X3 w8 h540
& @* |, Q8 l1 Q% x. G( K. cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- t* _+ z" i# e2 u) _2 O; gthe base of the phallus and was dark and curled. The
% }3 b6 L& \/ a3 S) J. g3 utesticular volume was prepubertal at 2 mL each.  f! t! N8 z# [0 f
The skin was moist and smooth and somewhat
6 T% _% H# w; }3 L" G* \' \  {oily. No axillary hair was noted. There were no
7 ?: ]6 P2 u2 v/ Q# Jabnormal skin pigmentations or café-au-lait spots.5 t" x. \; U- r- s# ~# h2 D
Neurologic evaluation showed deep tendon reflex 2+  c0 P0 _' G. A5 |; |
bilateral and symmetrical. There was no suggestion
- g. P- I+ P1 k3 C9 b- ?7 I* bof papilledema., s3 M2 Q# R+ }
Laboratory Evaluation0 _) [& W( m% S: n) X
The bone age was consistent with 28 months by
& e' Q2 }. g0 N9 r5 n6 H! Q8 q( E7 Kusing the standard of Greulich and Pyle at a chrono-( F; L# A6 ~6 U2 y
logic age of 16 months (advanced).5 Chromosomal) X2 E. }) k. L+ n' d
karyotype was 46XY. The thyroid function test& w" o6 w+ Y' }7 x3 }
showed a free T4 of 1.69 ng/dL, and thyroid stimu-  y6 w% A' |+ Z3 g# M2 `
lating hormone level was 1.3 µIU/mL (both normal).4 G) \3 A' i  G+ z. L4 m9 k( w
The concentrations of serum electrolytes, blood
4 r$ r' d, Y" _urea nitrogen, creatinine, and calcium all were$ J& d0 R+ z! b; j( p2 s
within normal range for his age. The concentration4 m9 z* K$ y' Y1 r7 S) h  M
of serum 17-hydroxyprogesterone was 16 ng/dL
3 B0 f% N9 W  ]8 I0 ~' H(normal, 3 to 90 ng/dL), androstenedione was 202 S0 m: z4 W! ^  x: t& h
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 o: [# q8 p' M- r9 i, `. X
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 Y6 z. ~4 h! X& pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to/ J$ x: l& J( o- s; A6 m
49ng/dL), 11-desoxycortisol (specific compound S)4 k- h, F- R4 z8 }, {
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, H4 C! ?) D$ Ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 C) o* O! G7 O8 T
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 y2 i0 E# P3 l7 g! B* K0 Z
and β-human chorionic gonadotropin was less than# X7 s4 _8 W* z6 s3 d& n4 w4 k/ b
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 D4 p# x. {6 M0 o1 d7 Estimulating hormone and leuteinizing hormone+ L4 `9 @% N1 F% O. p+ j% f: M
concentrations were less than 0.05 mIU/mL; I% E% D3 c. P0 C
(prepubertal).5 `; U' c* V- G9 c# v1 Q, S
The parents were notified about the laboratory6 t$ a0 c- K! f4 P
results and were informed that all of the tests were+ O5 \( D) I4 o' Y/ F2 J
normal except the testosterone level was high. The
! \" T& J: ]& Dfollow-up visit was arranged within a few weeks to
. L  e$ i1 J- |8 V( j3 Y- f4 ~obtain testicular and abdominal sonograms; how-
, q- o  {1 w/ s5 N4 gever, the family did not return for 4 months.5 ~+ H  Z" Y) ^9 m
Physical examination at this time revealed that the' V7 t: I) z/ ]4 e% s. y
child had grown 2.5 cm in 4 months and had gained
3 n! l: z) J" H2 kg of weight. Physical examination remained
: f& T4 N0 l+ s- o) w2 p3 Iunchanged. Surprisingly, the pubic hair almost com-+ o, ?. y1 N( B$ C/ O
pletely disappeared except for a few vellous hairs at% {) k1 H- d1 y& a! n
the base of the phallus. Testicular volume was still 2
! b& }! Y* c3 y: Z9 S+ D, _mL, and the size of the penis remained unchanged.( B1 e4 c5 o: V$ R/ h
The mother also said that the boy was no longer hav-/ Y- v/ H( v- ~( K5 o4 |
ing frequent erections.
3 l. S# g+ @0 q" `- xBoth parents were again questioned about use of0 K- |9 m1 R$ m  m
any ointment/creams that they may have applied to
# ]8 t- _& g/ {the child’s skin. This time the father admitted the
# J2 a1 h; Z1 g& y' CTopical Testosterone Exposure / Bhowmick et al 541# ]- r8 T9 D' f( X( ?% g
use of testosterone gel twice daily that he was apply-3 D6 N2 i( m: ^8 i/ s
ing over his own shoulders, chest, and back area for
8 ]; c) W: @# s% s' R" Na year. The father also revealed he was embarrassed
( l3 |0 c8 ^' _+ U/ e# X4 ?to disclose that he was using a testosterone gel pre-, \) \9 E- Z: C* D  U1 u1 i
scribed by his family physician for decreased libido; y! T$ [8 E( ^3 c& t
secondary to depression.
; N4 F8 [- c+ dThe child slept in the same bed with parents.% ~3 R, f% j9 X9 L. [9 m: B
The father would hug the baby and hold him on his; W- b/ S' `) H; \* w
chest for a considerable period of time, causing sig-% l" o. G: l# E( E; i0 {  n
nificant bare skin contact between baby and father.
- Y$ ^* l5 E; ?# UThe father also admitted that after the phone call,' `8 x9 \8 K/ p& y. @1 |
when he learned the testosterone level in the baby
" J2 ?' H7 K8 t6 k4 o: nwas high, he then read the product information
6 i3 W3 x( V& X+ hpacket and concluded that it was most likely the rea-
6 j; E2 j% e) U* p8 @# Tson for the child’s virilization. At that time, they
0 ]$ \7 Y2 A( U9 I, }6 h6 l; ?% Hdecided to put the baby in a separate bed, and the
' N5 M; T4 A: v- jfather was not hugging him with bare skin and had
7 R: Z+ R; N0 J; Mbeen using protective clothing. A repeat testosterone: s- i5 M8 ^8 {! b6 p& H2 d
test was ordered, but the family did not go to the$ n& A) w6 G$ V3 V# X. P
laboratory to obtain the test.8 _, L4 e8 B3 z* v/ t4 c3 X- j
Discussion
# R: C: P# E3 D6 aPrecocious puberty in boys is defined as secondary5 j& C1 P) H( s* @* @
sexual development before 9 years of age.1,41 o& s/ U3 o# R- B
Precocious puberty is termed as central (true) when
; I. A& _- |' F9 bit is caused by the premature activation of hypo-
. h) A! w4 Z# }( R* Uthalamic pituitary gonadal axis. CPP is more com-
) N9 v- |7 s) h8 l* u9 qmon in girls than in boys.1,3 Most boys with CPP1 ?7 L( d3 z/ q
may have a central nervous system lesion that is2 H, \1 Y( b% @# w5 }! n' y
responsible for the early activation of the hypothal-
* d2 @3 |  V4 h/ g0 Y0 c: zamic pituitary gonadal axis.1-3 Thus, greater empha-
# `2 I5 j* w1 Q8 Fsis has been given to neuroradiologic imaging in
) X+ Q* e2 n* ^# {6 sboys with precocious puberty. In addition to viril-5 K* B# k  i+ W# ?6 ~
ization, the clinical hallmark of CPP is the symmet-5 ^9 x. c9 c' I9 T) A5 @
rical testicular growth secondary to stimulation by
. l# w4 K6 @1 P! E, D) fgonadotropins.1,3
2 x% n, h3 s) _. X6 ]/ p5 SGonadotropin-independent peripheral preco-4 }/ X/ D! ?. ?# ^6 @- o" e' l
cious puberty in boys also results from inappropriate
& x: B. \5 `7 f: ]& Jandrogenic stimulation from either endogenous or. Y9 Z; D4 r( _
exogenous sources, nonpituitary gonadotropin stim-6 E" Y- k: `- |4 V* p0 N; }, ]/ Q
ulation, and rare activating mutations.3 Virilizing5 I' U. O# I9 V) O" R$ E& s
congenital adrenal hyperplasia producing excessive
: o1 ^9 V/ m( p) _) h1 @8 Z. ?adrenal androgens is a common cause of precocious- m9 C5 z! d6 S
puberty in boys.3,4" m9 w) o8 x3 B( y: k5 K# R: i5 _
The most common form of congenital adrenal
# n' i. u- R  P- ?) ^* Zhyperplasia is the 21-hydroxylase enzyme deficiency.3 z2 s, R8 O) x, `* O3 e  ~, Y8 O- ]' B" f
The 11-β hydroxylase deficiency may also result in( J; n3 z: x6 j, U% J, r: B( c; @0 I; }8 ?
excessive adrenal androgen production, and rarely,
& ^; P! |7 b# C+ z4 Xan adrenal tumor may also cause adrenal androgen
* r3 `5 X) ^& J0 ?! zexcess.1,3# G" q+ t- h; l9 z8 S2 @+ U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% ^5 I# Q  }0 ]! z9 x542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 S! v2 A( N- N3 {* C0 VA unique entity of male-limited gonadotropin-
& h  Q8 j; M/ r0 f( s& M. \# {independent precocious puberty, which is also known
6 l) _4 y$ u! I  O4 n% h  Xas testotoxicosis, may cause precocious puberty at a
" M1 P, n6 o0 v: B, i2 X; cvery young age. The physical findings in these boys
& F! a! x0 f; G. ~with this disorder are full pubertal development,
( x9 f, m! ]4 O. Z/ e' F0 cincluding bilateral testicular growth, similar to boys! q4 }% L/ N, b5 ?& N
with CPP. The gonadotropin levels in this disorder! a# Y/ i% d  _0 t9 p
are suppressed to prepubertal levels and do not show" Q' m3 W. t  F( E
pubertal response of gonadotropin after gonadotropin-2 D+ A9 i3 ]; Z6 ?
releasing hormone stimulation. This is a sex-linked9 E' W6 i0 m* m9 @4 V
autosomal dominant disorder that affects only
" u! e8 A7 `* r# Cmales; therefore, other male members of the family
2 l' C0 l  z9 Q1 Y% Q2 |, dmay have similar precocious puberty.3
/ G# U% R9 a) e& P9 j/ [! }In our patient, physical examination was incon-
3 Z! W$ `: _4 C  qsistent with true precocious puberty since his testi-
) _& p2 `" b- s' m; m7 {8 H  Vcles were prepubertal in size. However, testotoxicosis
; F1 Z* S7 P& k: b/ K4 u; Gwas in the differential diagnosis because his father* G0 ]% g0 d. Q1 P7 r2 O9 u
started puberty somewhat early, and occasionally,
7 f8 Z- S5 P/ |testicular enlargement is not that evident in the  ~0 [6 d5 h  Y4 _# `9 o8 u+ J% I# l
beginning of this process.1 In the absence of a neg-
3 x. K; e+ R$ o/ Z" ]ative initial history of androgen exposure, our; e, B; R" Q* q* m4 ?
biggest concern was virilizing adrenal hyperplasia," f9 \' @0 i1 i% ?4 E* q$ D: W1 Y
either 21-hydroxylase deficiency or 11-β hydroxylase
9 |$ `+ ^1 K4 M; [deficiency. Those diagnoses were excluded by find-
) Q" S3 A) O, a* W' w- xing the normal level of adrenal steroids.
7 f6 |  N5 R' w% b) }2 `( vThe diagnosis of exogenous androgens was strongly
/ l7 m6 W* e2 T- f& X* P, r0 Hsuspected in a follow-up visit after 4 months because
" c: Y/ W4 T: t$ t- Hthe physical examination revealed the complete disap-' p( H8 `( P6 `2 k
pearance of pubic hair, normal growth velocity, and0 Y+ r4 i2 m- I/ q& b! v$ _0 ?5 K
decreased erections. The father admitted using a testos-) z# B( a  v1 ~/ N- f
terone gel, which he concealed at first visit. He was6 _! r8 W0 ^2 d5 F6 c7 }0 H# Q* x
using it rather frequently, twice a day. The Physicians’( Y0 Z5 F2 a0 f/ h
Desk Reference, or package insert of this product, gel or
, ]* Z, }2 y4 Mcream, cautions about dermal testosterone transfer to
, ~6 T" t/ b8 e# U! R6 Hunprotected females through direct skin exposure.& a/ v  `$ Z- }$ V, S5 M
Serum testosterone level was found to be 2 times the
# p% R5 u, ?8 c1 xbaseline value in those females who were exposed to
5 [9 F* p# ^# m# Xeven 15 minutes of direct skin contact with their male
; t' R" U5 N: g$ m7 b5 b. Dpartners.6 However, when a shirt covered the applica-9 J& u8 {+ _1 r3 z
tion site, this testosterone transfer was prevented.) F% H+ H4 H( K. |4 a
Our patient’s testosterone level was 60 ng/mL,
# X* c# @% T# L. Hwhich was clearly high. Some studies suggest that
# O- c7 e: ?3 V  h. f  r+ s& \dermal conversion of testosterone to dihydrotestos-9 j2 {! B6 A3 t/ R
terone, which is a more potent metabolite, is more% \& V& \* f" q1 V7 A
active in young children exposed to testosterone! r3 [9 K8 }! n! m" q7 U, x
exogenously7; however, we did not measure a dihy-
2 n# ~8 [/ A$ `/ ^drotestosterone level in our patient. In addition to
  B9 M* e" m  b" B' w  Jvirilization, exposure to exogenous testosterone in
9 _; U/ W" }% W! ?children results in an increase in growth velocity and9 j1 i8 F" ~; P; a
advanced bone age, as seen in our patient.
: f+ ~" X8 D" b: {# _The long-term effect of androgen exposure during
: U5 `7 A1 e7 M, q. P, G. Hearly childhood on pubertal development and final' q9 j, F. o% W
adult height are not fully known and always remain0 Z( Z7 ^6 N/ q5 N9 l1 l- X# @
a concern. Children treated with short-term testos-9 j% N( t8 a% u+ L8 i  ^( j
terone injection or topical androgen may exhibit some! ]- \: ]& t; e7 X( [  `
acceleration of the skeletal maturation; however, after
7 e. H* w1 k% C1 T+ tcessation of treatment, the rate of bone maturation1 r; H) |& D9 I. J
decelerates and gradually returns to normal.8,9
& c' ^5 ?* e. n6 K- Y% _+ D' QThere are conflicting reports and controversy
/ z, C8 d! ^) @: Y; Qover the effect of early androgen exposure on adult
4 f1 ]. V% A- b! Vpenile length.10,11 Some reports suggest subnormal( q) g1 L2 D* n, |
adult penile length, apparently because of downreg-
# n$ E9 K/ a* |) f% K% z: Z7 }% eulation of androgen receptor number.10,12 However,9 j$ ?7 A4 i  W3 e/ j4 P
Sutherland et al13 did not find a correlation between
( `) z: ~# t( D3 t' `childhood testosterone exposure and reduced adult
; |2 y- |! X" y4 @0 ?/ fpenile length in clinical studies.
6 B, d& ]1 H' R3 ?% G3 hNonetheless, we do not believe our patient is
# Q+ I% D1 b5 P0 {$ Z4 bgoing to experience any of the untoward effects from/ p& x! _  ^3 ?
testosterone exposure as mentioned earlier because
# Y& x  Z' X9 u- Jthe exposure was not for a prolonged period of time.1 I$ w9 ~9 z4 ]8 G/ l7 ]! h
Although the bone age was advanced at the time of
0 i% H, w7 G% ^/ Ydiagnosis, the child had a normal growth velocity at
, ?5 O3 B& {, {9 @5 C* `; xthe follow-up visit. It is hoped that his final adult
) G5 O( w2 l: ?) `3 Xheight will not be affected.
( r6 |; I  V9 l( C( ^# x) B2 g5 @- rAlthough rarely reported, the widespread avail-: R( L8 }, x- k5 y, N
ability of androgen products in our society may2 _2 Q1 O( d' _& Y$ h
indeed cause more virilization in male or female
) K& D, l( e' t5 Z- q: Wchildren than one would realize. Exposure to andro-
' W+ W3 J7 X. F5 N/ |! egen products must be considered and specific ques-
- U" d& `) G2 U2 rtioning about the use of a testosterone product or
$ r; w  W( @2 K9 P* ]gel should be asked of the family members during
& F3 u1 A( d0 W0 h' r4 }. f3 |6 Sthe evaluation of any children who present with vir-
+ g# L! A- H0 [# a" `ilization or peripheral precocious puberty. The diag-4 _3 T; Q1 h$ D' U! l% W
nosis can be established by just a few tests and by3 g3 Z' o4 S" Z7 O3 u; F
appropriate history. The inability to obtain such a4 M: S5 ?: h$ w3 R& K. V- q" X
history, or failure to ask the specific questions, may
6 q) @. V0 q2 b# ^! U* W0 ?result in extensive, unnecessary, and expensive) ~% f1 ?/ N. y4 t$ C* p
investigation. The primary care physician should be3 N. M1 B* ?: d2 I  h' C
aware of this fact, because most of these children3 l# G8 V" i! z1 k
may initially present in their practice. The Physicians’; y& R0 }. A1 X2 f
Desk Reference and package insert should also put a
; E6 l# a& [$ K9 ~2 Owarning about the virilizing effect on a male or
9 f. S" X+ h+ ^: \/ u/ Vfemale child who might come in contact with some-
. G; A7 q8 `$ O$ \7 yone using any of these products.) R0 {4 a% y2 \0 J
References" X/ D  }8 g2 S
1. Styne DM. The testes: disorder of sexual differentiation/ ^3 u) }- A9 j9 K
and puberty in the male. In: Sperling MA, ed. Pediatric
/ t( U% L6 y% ~% u+ _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  F( [2 n7 m; V  W; G
2002: 565-628.' q# X8 I" O* e* P8 R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 v$ M+ ?3 s$ A; z  C
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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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

* a! h+ R0 ^  W! U; [8 a- z' A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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