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Sexual Precocity in a 16-Month-Old0 U+ b; x) j; m$ a3 D: q
Boy Induced by Indirect Topical
! n' ]/ a& ]; f# R' O. WExposure to Testosterone
- ?1 \  F2 `4 o) LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 \9 S2 Z1 s5 |# C9 p: t& [0 Oand Kenneth R. Rettig, MD1. d8 J% a# h+ D  F- a
Clinical Pediatrics
6 l, Q4 M3 F* q% y0 A3 H, AVolume 46 Number 6
0 L! v0 x, h$ U2 }* L" Z( FJuly 2007 540-543
2 G+ V( |, H& c7 b, u- _" `; q© 2007 Sage Publications
( i0 i9 b2 n3 x2 R10.1177/00099228062966510 H% D( H& B$ W# @0 C. R
http://clp.sagepub.com
2 z. @  T/ G1 {4 ~hosted at
8 K& x; j# q, `! {) M# Yhttp://online.sagepub.com, H5 v4 g- ?- n  {4 L
Precocious puberty in boys, central or peripheral,
& t/ B- C& r) f3 T! |* Cis a significant concern for physicians. Central
8 \. d* {; D* u0 s1 l+ M7 j- |* uprecocious puberty (CPP), which is mediated4 H& I7 }9 [: N( a+ j
through the hypothalamic pituitary gonadal axis, has
: B8 V( w6 Z4 ca higher incidence of organic central nervous system3 v( r' P+ S" J0 z  X' V4 a2 v
lesions in boys.1,2 Virilization in boys, as manifested3 T3 [3 v9 Q8 U# C4 b9 H
by enlargement of the penis, development of pubic
' T# z/ d* Q- p6 E, q# d, _% Qhair, and facial acne without enlargement of testi-
5 Q. D, R" c% W7 Ycles, suggests peripheral or pseudopuberty.1-3 We3 W9 p0 L/ ^* D* {" ]( v
report a 16-month-old boy who presented with the
5 {$ m  ?! z+ B& p* \enlargement of the phallus and pubic hair develop-
$ H" q3 p/ }) E: J/ d+ O: |ment without testicular enlargement, which was due
8 |  C: P% u; G3 Yto the unintentional exposure to androgen gel used by0 c7 J9 n7 h; K. X1 O
the father. The family initially concealed this infor-9 u% M: p7 R( D. n( ~& ]* h
mation, resulting in an extensive work-up for this( `5 l6 c( f. h# e7 |# O
child. Given the widespread and easy availability of+ r! U- F+ y( I+ h$ R
testosterone gel and cream, we believe this is proba-/ c* F; o" o0 G6 d2 D
bly more common than the rare case report in the
& R2 [3 |) j+ b* |# Mliterature.4, D, {& s& p; c0 y  p. ~# l
Patient Report
0 {# F& I0 \0 X1 g8 t% {A 16-month-old white child was referred to the* x8 o/ Q2 K- _* `2 o
endocrine clinic by his pediatrician with the concern
/ ~% C/ I! n& z0 L% Qof early sexual development. His mother noticed
) P% g2 d8 {: M- Xlight colored pubic hair development when he was
: S2 M6 M0 A4 }: |- GFrom the 1Division of Pediatric Endocrinology, 2University of
) b  D3 G9 ~& L) `3 ESouth Alabama Medical Center, Mobile, Alabama./ K3 Z9 u! C! v$ n& V
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 F  G" C/ Z" T) fProfessor of Pediatrics, University of South Alabama, College of$ d- c+ B1 e3 @# y6 p) B7 G0 F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" n& c/ @, n" i8 v, U7 me-mail: [email protected].
: C! S: {3 S8 ~) v5 D: ?% Babout 6 to 7 months old, which progressively became; q- G1 |: W* f- [
darker. She was also concerned about the enlarge-1 H. _. \7 N+ w. M+ w5 `
ment of his penis and frequent erections. The child
; N2 i# }. ~, U6 @+ o; w. Wwas the product of a full-term normal delivery, with- t, r! k3 W* B: S2 y8 H% w
a birth weight of 7 lb 14 oz, and birth length of
5 @5 ]5 B  n6 [+ L, Z4 U20 inches. He was breast-fed throughout the first year( E1 S/ W7 o9 g: T' q% C
of life and was still receiving breast milk along with
2 d% D. S. \( \- Q  x9 G& O% w; Msolid food. He had no hospitalizations or surgery,
- y! \( v4 J( z4 Q% ?0 Uand his psychosocial and psychomotor development
6 m# j7 ~; D! |0 ^& lwas age appropriate.2 x( s* r) K* w
The family history was remarkable for the father,. F  _  ^4 s' }% {0 q5 b: Z
who was diagnosed with hypothyroidism at age 16,
; i8 c& E6 D  C9 Hwhich was treated with thyroxine. The father’s/ p( Y" w- }( L" u8 _
height was 6 feet, and he went through a somewhat9 O( `/ t+ [7 {
early puberty and had stopped growing by age 14.
4 ?/ x6 i1 r# }4 c: u8 bThe father denied taking any other medication. The, @  p; H: S/ M6 A
child’s mother was in good health. Her menarche4 A7 |. \/ J+ G: f6 }7 ?3 f
was at 11 years of age, and her height was at 5 feet
# P2 @/ s6 G0 v- p( t& S( w% ?5 inches. There was no other family history of pre-1 U6 U5 L% r. o1 U
cocious sexual development in the first-degree rela-
0 F* F7 Y8 p9 v/ y% l9 Wtives. There were no siblings.
. v5 G3 g) }5 A# n. f: @9 _Physical Examination
- ~  P) Z9 l  P7 W1 T$ U' ^The physical examination revealed a very active,3 O6 \! C* _4 y* v% f
playful, and healthy boy. The vital signs documented( t, R, e1 l$ A, f
a blood pressure of 85/50 mm Hg, his length was! y0 ]  K! L0 I$ c# F
90 cm (>97th percentile), and his weight was 14.4 kg3 X' {' K7 F/ P0 B2 j) T/ k
(also >97th percentile). The observed yearly growth4 V5 c7 U# P3 z# m/ q8 }
velocity was 30 cm (12 inches). The examination of4 f! p7 {9 ^# e5 r6 \1 |* J
the neck revealed no thyroid enlargement.
% n! _5 Z! q0 q, X9 pThe genitourinary examination was remarkable for3 V0 |1 _. m) @( L' \: X
enlargement of the penis, with a stretched length of  Q0 U3 F( s0 R' I' e% f
8 cm and a width of 2 cm. The glans penis was very well
5 u; z% s/ R  o6 K/ x1 h5 pdeveloped. The pubic hair was Tanner II, mostly around( `4 K' J# }  D  v8 e3 {# e
5409 N& w" f: `4 E  r) Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ o$ n" L& ~/ u: d0 D! l  Mthe base of the phallus and was dark and curled. The
0 [( T, S9 p; d; m; `* ttesticular volume was prepubertal at 2 mL each.! V" W0 C5 Z# R6 x3 h. {$ ]
The skin was moist and smooth and somewhat! R, i7 w, t* C$ a
oily. No axillary hair was noted. There were no
/ R- }% n% @! \/ Zabnormal skin pigmentations or café-au-lait spots.
8 A* e5 t9 ^  {9 f: ~. ONeurologic evaluation showed deep tendon reflex 2+; h: ~. F" W4 D& w
bilateral and symmetrical. There was no suggestion% O, k' W' K1 l' C* m
of papilledema.
% |3 l6 u- V2 C) eLaboratory Evaluation5 [( Q9 Q; O. m  J4 n, ]* p
The bone age was consistent with 28 months by2 X- F) k, T. C. I
using the standard of Greulich and Pyle at a chrono-1 j& P/ W. d  V' a+ T
logic age of 16 months (advanced).5 Chromosomal
- L% f0 f. j% |  Wkaryotype was 46XY. The thyroid function test
+ S. T% j" a2 y# H# x4 }+ E9 zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  Y% z5 \3 X! w& b0 _lating hormone level was 1.3 µIU/mL (both normal).
1 b' v; E% }+ c4 V1 D* rThe concentrations of serum electrolytes, blood
2 ~' m" S6 W" F9 L2 lurea nitrogen, creatinine, and calcium all were
0 K7 @3 ]2 [/ w$ U) }! Uwithin normal range for his age. The concentration
& W( E! c7 E3 A- fof serum 17-hydroxyprogesterone was 16 ng/dL( h- r, L2 c4 i' ~
(normal, 3 to 90 ng/dL), androstenedione was 20, @- ~1 C, B1 a6 Y% e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ \! P7 k2 k: H+ C" f& Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 d: S( ]6 p0 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to& P( [! U* L* H
49ng/dL), 11-desoxycortisol (specific compound S)" r8 t* Y* E0 C* {. x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' m+ x) l1 N. ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% Z: Y  T: t: q' A6 m& K: ?7 Y+ itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 \0 ^- o3 Y9 i0 {
and β-human chorionic gonadotropin was less than+ i2 h# s2 t2 |" K, [5 y8 |! V# _8 d
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 b1 X2 x+ U8 V3 p+ R, f' A
stimulating hormone and leuteinizing hormone
8 d# d" q0 e0 j+ h9 C$ M$ J9 }5 Kconcentrations were less than 0.05 mIU/mL! c4 b8 o( P! G8 `) M; q
(prepubertal).5 u6 k. l+ m- t* X
The parents were notified about the laboratory( y+ @* h- K' i- [3 C
results and were informed that all of the tests were
! m9 J1 g: x! ^: e- jnormal except the testosterone level was high. The
" M& L. j+ T+ x& _1 T; e+ r( Lfollow-up visit was arranged within a few weeks to  M  F+ a. f7 q3 ]% v9 c) k
obtain testicular and abdominal sonograms; how-" i7 x* ~+ N8 g( Q: W
ever, the family did not return for 4 months.( h; t& B, t+ @: u
Physical examination at this time revealed that the
# B9 v$ X4 O5 i1 {child had grown 2.5 cm in 4 months and had gained' z  q7 C3 a" x8 i: {
2 kg of weight. Physical examination remained
! u: \$ b. s2 W3 E2 s* k: ?* \unchanged. Surprisingly, the pubic hair almost com-
4 o9 v4 C' ?3 ^' Xpletely disappeared except for a few vellous hairs at
# G9 h$ w1 z3 D: U& {+ c0 \the base of the phallus. Testicular volume was still 2
4 M# T$ O9 [9 jmL, and the size of the penis remained unchanged.
1 d- O  W! n0 V% `' IThe mother also said that the boy was no longer hav-
+ F5 v# r  G: ^8 C0 W# @! J* c: ?ing frequent erections.6 H* n; P2 `+ W# w
Both parents were again questioned about use of
" c& c0 }$ z9 |& M4 r! F: ~any ointment/creams that they may have applied to: H# l/ t" {+ n- L9 {' D1 o
the child’s skin. This time the father admitted the; P( i1 z  W( p4 j1 h
Topical Testosterone Exposure / Bhowmick et al 541
6 _) B8 k( G, c6 Nuse of testosterone gel twice daily that he was apply-" H1 ~8 x* C. ]* z3 o, {  b9 P
ing over his own shoulders, chest, and back area for. X: w0 L8 k1 O- z; _
a year. The father also revealed he was embarrassed
. r. x$ t  Z: V+ e0 N  {3 ?( f+ [9 Oto disclose that he was using a testosterone gel pre-6 ?' A, C; _( C) M9 P8 m
scribed by his family physician for decreased libido; @+ e& C: W- Y4 l; y
secondary to depression.# M& W2 O$ u  a
The child slept in the same bed with parents.
4 Y% ^, B- [8 a1 m! \  b1 _9 J5 zThe father would hug the baby and hold him on his
2 p' S2 l' _! B5 ~) a: m3 kchest for a considerable period of time, causing sig-
+ d0 V& ?0 V% {0 Z& onificant bare skin contact between baby and father.: g  z5 Y, R* g& N' ~* N
The father also admitted that after the phone call,
; Q5 v9 n# w* Y+ o+ M# A/ c3 awhen he learned the testosterone level in the baby
0 N- `) \' M9 a1 ^& v: wwas high, he then read the product information  n/ l$ B0 @" c: a; B) r
packet and concluded that it was most likely the rea-
! ~5 x% J. u% E0 V- ~5 d' ~son for the child’s virilization. At that time, they, z% [; u: c  P& ~5 z
decided to put the baby in a separate bed, and the
' }4 U* n  a5 ifather was not hugging him with bare skin and had" ?: ?$ j# k( I- W1 b: n
been using protective clothing. A repeat testosterone  y- R0 }3 ~, }, e/ g7 v
test was ordered, but the family did not go to the2 x+ z+ }" w$ S) k" p
laboratory to obtain the test.0 Y% L" T8 W% J  k3 F
Discussion2 Y2 ]! B$ n7 B; G
Precocious puberty in boys is defined as secondary1 K5 u/ `1 L9 \3 l' c
sexual development before 9 years of age.1,4
1 |4 o' i3 P/ F1 X) FPrecocious puberty is termed as central (true) when$ R/ n1 Q, v) y2 {2 _: A6 R
it is caused by the premature activation of hypo-& R8 B: b' a5 x1 U  m; U* s& ~3 k
thalamic pituitary gonadal axis. CPP is more com-
( u* a0 e# Y6 k% k; q: B$ }mon in girls than in boys.1,3 Most boys with CPP- z/ d/ P* b- e! X7 u
may have a central nervous system lesion that is/ B. R; c9 W/ L! x5 v5 N: F
responsible for the early activation of the hypothal-
) }/ o4 T) [, W7 z# y  K9 vamic pituitary gonadal axis.1-3 Thus, greater empha-
8 R3 x: K0 [; ?+ U% K8 O" dsis has been given to neuroradiologic imaging in- p' @. _: K5 B  {
boys with precocious puberty. In addition to viril-3 j4 k" u! a# R, t
ization, the clinical hallmark of CPP is the symmet-' h! f. Z% M; ]) s$ Q, f  l' g
rical testicular growth secondary to stimulation by
- w7 ^, E" p0 F1 H! h  Wgonadotropins.1,3
, v7 y, [; Y$ v" ?: i; v3 KGonadotropin-independent peripheral preco-
2 [7 T8 }; j: D, z$ Q: S! kcious puberty in boys also results from inappropriate' L/ N3 Z- Q# w: O$ ^
androgenic stimulation from either endogenous or
& @$ L! p4 b7 C! jexogenous sources, nonpituitary gonadotropin stim-
* u9 {+ l3 Y) G- i8 c' Wulation, and rare activating mutations.3 Virilizing5 g1 l/ J7 v. F  |9 L3 a
congenital adrenal hyperplasia producing excessive% N) x) S/ I9 e2 D9 i" U2 Q% ^; h
adrenal androgens is a common cause of precocious$ h3 T$ v: P) \; a8 a8 Z* h
puberty in boys.3,4! L7 B/ X5 K# s, X6 O" p) T+ j
The most common form of congenital adrenal6 M. R! L, ~( \! R! z8 {/ q
hyperplasia is the 21-hydroxylase enzyme deficiency.# t; o$ y( |# w# E- w. u) n
The 11-β hydroxylase deficiency may also result in
5 c+ }, H  X$ v$ L8 @0 qexcessive adrenal androgen production, and rarely,) O- Z2 t9 p# k) ~
an adrenal tumor may also cause adrenal androgen
* o8 O0 ^2 J7 J7 |+ t1 q# Jexcess.1,33 n+ s5 M6 ?2 x+ A- _/ f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- k' m. J$ s4 Y/ A: \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' s7 ]* o' w" e9 d3 r: U! T
A unique entity of male-limited gonadotropin-
) C8 \- `, B1 lindependent precocious puberty, which is also known
) b0 C' m7 @- A2 \3 {as testotoxicosis, may cause precocious puberty at a! A: Q5 o: r) D0 ~( `  z/ g+ H
very young age. The physical findings in these boys
9 E0 B5 i# w4 jwith this disorder are full pubertal development,
% W3 @% s: O* _including bilateral testicular growth, similar to boys% Z6 B4 r9 K+ {, F2 w- M6 o
with CPP. The gonadotropin levels in this disorder, n/ \/ I- h: H4 k- L
are suppressed to prepubertal levels and do not show
+ X  Y5 A+ y( B% _9 D, B. ^pubertal response of gonadotropin after gonadotropin-% O. ^5 R% g0 c( t6 B
releasing hormone stimulation. This is a sex-linked# {( l9 l$ `0 g. E! U5 r# n  z
autosomal dominant disorder that affects only
2 l0 \! {4 m$ e8 `4 V$ R' Hmales; therefore, other male members of the family  u( t. ^0 Z# B9 |  \
may have similar precocious puberty.3
" ^) i4 z+ q$ c: @$ p; X! e- mIn our patient, physical examination was incon-( ]4 \2 s2 A. x4 e+ p( k
sistent with true precocious puberty since his testi-
4 Y: ~) N% ]- {- a$ K( {5 i5 ?2 Icles were prepubertal in size. However, testotoxicosis; p* F* }% l7 ^( {4 O1 M* d
was in the differential diagnosis because his father
* \) o* s3 {$ g( Z  }) Pstarted puberty somewhat early, and occasionally,
: Z+ l0 \4 K- l' u8 |6 |testicular enlargement is not that evident in the1 G# ~' @- N6 N9 K2 K/ Y* Y" P! P
beginning of this process.1 In the absence of a neg-
: y; \' E+ k' m5 n( A4 C1 dative initial history of androgen exposure, our
4 ^7 w! Q# @5 N' }, P# n, Nbiggest concern was virilizing adrenal hyperplasia,. w9 ?/ r) d5 D7 ~8 B
either 21-hydroxylase deficiency or 11-β hydroxylase' Q! |2 y/ O7 Z' H* Q- N5 X7 S; ^
deficiency. Those diagnoses were excluded by find-: L& {6 D3 @  S& w* N, Y+ C$ t
ing the normal level of adrenal steroids.: k! Q/ B8 N% ]7 H5 o
The diagnosis of exogenous androgens was strongly
/ M0 l4 |) z1 h: U3 G3 p( _2 D1 esuspected in a follow-up visit after 4 months because0 m4 N! P$ y8 @  R
the physical examination revealed the complete disap-
: g% N$ U8 E2 E) F7 E; P7 D6 tpearance of pubic hair, normal growth velocity, and
4 ~. R5 M: Y1 l$ j* a; u" i# L7 f1 kdecreased erections. The father admitted using a testos-' ~& {8 [# L/ i( d8 A
terone gel, which he concealed at first visit. He was
9 _# K8 h( I  }8 N. \1 @) Z7 Busing it rather frequently, twice a day. The Physicians’( F3 T+ z7 m% V+ Q: p' H6 R4 e
Desk Reference, or package insert of this product, gel or7 K8 ?3 Q  Y" G1 r3 g5 ?( h: l
cream, cautions about dermal testosterone transfer to- N  @( Z( q; P7 `$ b- k
unprotected females through direct skin exposure.
/ g) q, r6 i0 sSerum testosterone level was found to be 2 times the
! c5 z+ \. A( d3 {baseline value in those females who were exposed to
) |& l' n# B. D% f. I. geven 15 minutes of direct skin contact with their male6 [* y; i" A2 U; F2 t  B( ], b! H
partners.6 However, when a shirt covered the applica-
% O) U# {0 F1 z# mtion site, this testosterone transfer was prevented.
$ X8 I# V! u: ~Our patient’s testosterone level was 60 ng/mL,
  ^  ?6 p  J& P- U" Lwhich was clearly high. Some studies suggest that6 [! H# |( u, P, I/ N' M# ~
dermal conversion of testosterone to dihydrotestos-: W6 J/ f; @" A5 T' g4 F3 {- v& u
terone, which is a more potent metabolite, is more$ |' z% X" W( J; ~, y! G8 n
active in young children exposed to testosterone
* n; d! P* s! i, W7 mexogenously7; however, we did not measure a dihy-9 i$ b6 T! i3 N1 Q6 c, V
drotestosterone level in our patient. In addition to
! O0 {8 u8 W. `+ {virilization, exposure to exogenous testosterone in2 a0 `+ ~$ G/ ~8 t  ?
children results in an increase in growth velocity and. o, Y! ~3 A" L$ g
advanced bone age, as seen in our patient., Z0 m  o; j" R. k3 }2 M3 O0 l
The long-term effect of androgen exposure during$ w9 B% |9 Z/ J9 Y+ x% a  g
early childhood on pubertal development and final
' ?% x. X1 Q0 v1 R1 i% wadult height are not fully known and always remain
' Q- Q- b. U  k2 ^2 ra concern. Children treated with short-term testos-
! s, W2 c! F# f- y- xterone injection or topical androgen may exhibit some# ~7 D8 ?, d" V! K7 @: s# m( n
acceleration of the skeletal maturation; however, after  c' `; F/ _# Z3 u. j
cessation of treatment, the rate of bone maturation
% Q, R" Q! m5 _- Fdecelerates and gradually returns to normal.8,99 N3 u, p  k( y0 l6 v
There are conflicting reports and controversy# w" n# U/ C0 e/ H, v7 _2 k
over the effect of early androgen exposure on adult8 i( B3 `; z9 I
penile length.10,11 Some reports suggest subnormal9 m0 K9 X* q3 a8 e
adult penile length, apparently because of downreg-5 N0 A% F# Y! |5 o: }# t/ }
ulation of androgen receptor number.10,12 However,9 q) @) X; i1 U. H: ^1 \7 O) ]
Sutherland et al13 did not find a correlation between
3 Q( A7 q) Y9 {3 f- Jchildhood testosterone exposure and reduced adult2 I! Z7 t1 A+ V( u
penile length in clinical studies.( n/ Q6 u1 B# W4 ]! A% J  z0 X6 S
Nonetheless, we do not believe our patient is
1 I: Y8 `! ~1 e+ k  M. ngoing to experience any of the untoward effects from5 t& a1 W3 W& x" l
testosterone exposure as mentioned earlier because! @' b# e5 K/ @& e
the exposure was not for a prolonged period of time.
/ Z. c- s( N  ~5 s  r9 y1 AAlthough the bone age was advanced at the time of- X  m" D( V# Z# r" ]: h# N9 r* h
diagnosis, the child had a normal growth velocity at  z, o7 Y* a* k5 e. X( F
the follow-up visit. It is hoped that his final adult% p9 `  `/ ^" K; [  A
height will not be affected.
# T, J$ w3 Z& W) ~# v, ~4 nAlthough rarely reported, the widespread avail-
* u/ M: Q2 K" U( T2 i  mability of androgen products in our society may7 K$ P6 p, O. B) y" L4 T- u) k8 u
indeed cause more virilization in male or female; Q$ S, t6 I3 N0 i8 ]
children than one would realize. Exposure to andro-) w5 e( `/ c9 y' [! @: z- a8 ~1 e
gen products must be considered and specific ques-
" q6 Q+ j! T2 itioning about the use of a testosterone product or
% a) X% f% t: C$ G; Qgel should be asked of the family members during
! c1 ^# |( m4 [; _the evaluation of any children who present with vir-
4 G1 R) t- |3 q/ }  W; x2 A8 I' bilization or peripheral precocious puberty. The diag-
7 i  ~# r  J) c) G0 L$ |- r' lnosis can be established by just a few tests and by
4 G, \0 |5 ]6 X2 vappropriate history. The inability to obtain such a- d7 n+ W1 M# @; R/ P4 U  O
history, or failure to ask the specific questions, may
0 x/ h, `; L9 k7 `% Z1 p4 yresult in extensive, unnecessary, and expensive! V" \! a6 U) W8 U. S
investigation. The primary care physician should be. v* g( }, g8 Z$ i( [" t2 D! p! m
aware of this fact, because most of these children6 j. j& ^6 R/ i  `' U5 W, e) g" u
may initially present in their practice. The Physicians’4 g, H; N9 W0 e& }
Desk Reference and package insert should also put a
+ U& s2 Q$ f$ ]4 }) [5 mwarning about the virilizing effect on a male or. H) ~' Z. H4 m* I# x' r0 r- w
female child who might come in contact with some-& a3 L- [" B; e
one using any of these products.
- ^0 ?; k  u, U4 O7 ]References
  y) [3 _( U6 r" T! q4 ?1. Styne DM. The testes: disorder of sexual differentiation
; r: o, a2 O7 @7 \9 e, B7 \6 ]and puberty in the male. In: Sperling MA, ed. Pediatric
+ E3 i+ s2 s! R; P; d2 K6 UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 k* h; h* q; E4 B" ~2002: 565-628.
% L7 s: [% k+ U  I- T7 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 N8 \! j9 p+ `3 o9 c: _3 J( N
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old% z  `9 @& o* q3 v) x) A9 k6 C
Boy Induced by Indirect Topical
. i: l% s5 G4 U& J% V- [Exposure to Testosterone
4 @0 x0 z! e* o: u6 ?Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ S) q' `$ h2 |  x, {% H8 e
and Kenneth R. Rettig, MD1# ~* w3 n% _. b; {0 c: U
Clinical Pediatrics
) x9 {- A3 i( H& QVolume 46 Number 6
5 P( Y$ H- [( K" q, q" YJuly 2007 540-543
( |; I8 Y9 U6 C+ L) e; l0 T© 2007 Sage Publications
8 C8 k2 G% r6 w  G9 S2 x10.1177/0009922806296651
7 ^$ K: E- h+ B4 {, Yhttp://clp.sagepub.com
3 B$ l. }8 q2 G3 o- }hosted at
. c" W2 @+ Y) O+ W: N- zhttp://online.sagepub.com
% a" ^+ K% w( N. t( A" ^Precocious puberty in boys, central or peripheral,
7 `* {  x- S4 [& Gis a significant concern for physicians. Central
" l1 Q/ L/ ^. s% S- ?, Zprecocious puberty (CPP), which is mediated
' A9 h; m" j% U4 l$ R3 V* T+ u, q# Q9 Fthrough the hypothalamic pituitary gonadal axis, has
( L/ [; y# k0 ^( va higher incidence of organic central nervous system
: C1 q5 O! k! w; |- Llesions in boys.1,2 Virilization in boys, as manifested
3 F$ ~4 c2 k! c: L( W8 Xby enlargement of the penis, development of pubic
$ V! U0 `) Y5 R) a0 Dhair, and facial acne without enlargement of testi-9 j# \3 W5 A* ?# _9 V6 S
cles, suggests peripheral or pseudopuberty.1-3 We
. z5 K7 P3 ?  N- y! areport a 16-month-old boy who presented with the
" Z/ a( }' M  N3 A' z  z$ ~, V% Renlargement of the phallus and pubic hair develop-- P2 a+ o" c/ a) G2 l
ment without testicular enlargement, which was due
3 W6 F4 |6 o8 p! A- Ito the unintentional exposure to androgen gel used by
( q; f5 I: Q5 F% |the father. The family initially concealed this infor-
7 X1 X# L( m8 y  Wmation, resulting in an extensive work-up for this" [6 f+ B1 F0 q- z! A5 y2 A# \5 I
child. Given the widespread and easy availability of: Q) i$ M+ ?5 R  j5 a
testosterone gel and cream, we believe this is proba-
7 i9 h0 h/ x+ N1 b1 R# nbly more common than the rare case report in the3 K% y  t: ^1 R* Y8 e1 D
literature.4
$ \  N1 f8 q  V# X! j' \Patient Report" b  G* P, Z. m2 T, Q7 ?/ D8 v
A 16-month-old white child was referred to the# e. _2 E8 X" r: T4 R( g
endocrine clinic by his pediatrician with the concern0 B7 O' u. p  i
of early sexual development. His mother noticed
9 H$ _- P* R9 o$ klight colored pubic hair development when he was
6 s3 B+ `9 I& D0 E' g, NFrom the 1Division of Pediatric Endocrinology, 2University of; \- x, g. d: i) z
South Alabama Medical Center, Mobile, Alabama.
& z' p+ g( u5 I2 U! e+ j  _Address correspondence to: Samar K. Bhowmick, MD, FACE,% r3 M6 W+ G& X& m) _
Professor of Pediatrics, University of South Alabama, College of" K0 d0 B; X( `, _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! F/ I4 F  C6 w3 ~) S$ _9 he-mail: [email protected].
6 B! c; W' v+ u; J+ T* |* ]8 N! N8 _about 6 to 7 months old, which progressively became( E1 K. `8 b3 }$ x& k
darker. She was also concerned about the enlarge-
! x( z' w" I3 Zment of his penis and frequent erections. The child0 |) c- l( z  M1 |! M; _  j2 g
was the product of a full-term normal delivery, with
+ q8 R- d! t2 L* ja birth weight of 7 lb 14 oz, and birth length of/ T( f& r* u- {9 A2 _4 {* q/ y0 i
20 inches. He was breast-fed throughout the first year
  y4 a8 E" [4 R, v: k& D) {! ?% Wof life and was still receiving breast milk along with
; [9 Y# i6 W2 e* T! wsolid food. He had no hospitalizations or surgery,. a5 r# r( N) }+ D
and his psychosocial and psychomotor development7 }& V, P! m3 \% m! ^; F4 w
was age appropriate.
' o8 ~* V. i: fThe family history was remarkable for the father,8 l" t; P& j# Y) b* e3 H7 U, n
who was diagnosed with hypothyroidism at age 16,
4 e! T1 q/ u( j% g- B# Y) Gwhich was treated with thyroxine. The father’s
) ?+ L4 g! o/ ]1 i% H4 D# cheight was 6 feet, and he went through a somewhat
- J+ L: B& V9 P1 a6 bearly puberty and had stopped growing by age 14.
1 b0 F0 K9 \6 b# eThe father denied taking any other medication. The
4 `. H8 [9 s; \. ^: P4 s; q) Cchild’s mother was in good health. Her menarche0 Q6 d. ^0 G* g! |( W! E0 {
was at 11 years of age, and her height was at 5 feet9 {$ C" K2 r1 C+ I
5 inches. There was no other family history of pre-
* }3 V- f+ t1 \% Y( o! t( e9 dcocious sexual development in the first-degree rela-0 R2 t# f$ }* j" f
tives. There were no siblings.
; S$ ~5 P/ h1 C' z4 v. Y) T8 t* S$ YPhysical Examination) b; O8 H* x+ F5 l6 l3 l
The physical examination revealed a very active,8 S2 q! a* Z6 t7 t# a
playful, and healthy boy. The vital signs documented
: ^2 l( T" N, {2 S( h+ _3 Ca blood pressure of 85/50 mm Hg, his length was
  T7 [2 G4 _7 `/ n! k1 i/ S+ l# f% u90 cm (>97th percentile), and his weight was 14.4 kg
( n0 P; N" E* S  E) L+ N0 Q(also >97th percentile). The observed yearly growth3 L  \$ [; Y3 }2 `% _
velocity was 30 cm (12 inches). The examination of# p, F: ~# }# o! S+ O' ?! h, v& s* a
the neck revealed no thyroid enlargement.
& c9 {, F  j& l: B& d+ SThe genitourinary examination was remarkable for; X1 ~! ?3 g# V& D( c% D% U) ~: a2 i
enlargement of the penis, with a stretched length of( @& H% @% B! t* s0 E
8 cm and a width of 2 cm. The glans penis was very well- b* n8 |# r" e: [4 |
developed. The pubic hair was Tanner II, mostly around" C4 g: j- F  E
540
' r8 Z( |( w: e) j0 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" Y$ S4 t2 v, k! L/ f
the base of the phallus and was dark and curled. The
2 v9 C9 t2 s/ n5 U. j0 Etesticular volume was prepubertal at 2 mL each.
) c; p: w( L4 _1 ?" y* FThe skin was moist and smooth and somewhat
* z/ K7 ~) V6 P& Q1 ]3 toily. No axillary hair was noted. There were no
0 M, N/ l  B, gabnormal skin pigmentations or café-au-lait spots.# `  Q- T2 c2 _. k
Neurologic evaluation showed deep tendon reflex 2+
3 }+ B. J+ \- V8 L- \bilateral and symmetrical. There was no suggestion2 e+ z$ T) [; H) B0 x* H' V
of papilledema.# ^$ K- l5 E' p# N" d( `
Laboratory Evaluation
6 e7 y/ Q" X( m4 DThe bone age was consistent with 28 months by; g. X$ U* y2 C
using the standard of Greulich and Pyle at a chrono-
) K/ h+ v; g4 C8 U) ]' z0 ilogic age of 16 months (advanced).5 Chromosomal) U& l6 G$ [5 c7 @3 s8 _
karyotype was 46XY. The thyroid function test
; Z6 y: l/ D* P( f# ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ x  D9 g) @" z- [. V- h
lating hormone level was 1.3 µIU/mL (both normal).
7 ]- M/ V8 M: i7 f8 T+ vThe concentrations of serum electrolytes, blood" V# g6 B0 s3 P9 ^0 |2 o
urea nitrogen, creatinine, and calcium all were  L; P* p' I! E( p7 f
within normal range for his age. The concentration
' [; ], f( q9 c! Z' v# Z+ bof serum 17-hydroxyprogesterone was 16 ng/dL
' N0 @# _# ]1 P: T9 i(normal, 3 to 90 ng/dL), androstenedione was 205 j. S) d* w7 e% U* c5 c
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 [# i1 |8 Y7 H# O# h9 W1 J% O
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; g# f5 B7 p/ [" y6 k5 M+ e5 S
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, N6 w( Q; f6 }  W7 D/ N+ {$ x; U' B
49ng/dL), 11-desoxycortisol (specific compound S)
" l" w6 V: Q/ E0 I/ o: o# q0 l' k  g/ I; Mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ A, t. q2 `" Y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) R% g8 i' \! C, M" Q& w# i' V' xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& |: ^% F, {4 t  u- n7 z4 W
and β-human chorionic gonadotropin was less than
6 y2 t9 q( T1 X1 l- T5 mIU/mL (normal <5 mIU/mL). Serum follicular
% g5 h9 h0 t5 T2 y% q, [stimulating hormone and leuteinizing hormone! T1 _/ ]  p/ h/ p  N+ U4 x/ Y$ X
concentrations were less than 0.05 mIU/mL
; |/ L, b1 `' K: W" d$ u(prepubertal).) y$ R9 ]; G4 x5 Y
The parents were notified about the laboratory1 a6 n; V0 Q& N
results and were informed that all of the tests were1 z  S! ?5 d9 y$ N7 ]) V6 A' P+ d7 |
normal except the testosterone level was high. The
5 |9 Z% U$ q0 |/ E# x& xfollow-up visit was arranged within a few weeks to# b$ N5 h/ q2 T; U0 l0 S3 b! |
obtain testicular and abdominal sonograms; how-8 ~$ o: ]$ c0 ~* V, X
ever, the family did not return for 4 months.
# z" e# A0 p$ r+ D9 NPhysical examination at this time revealed that the
* Q/ s9 [: d. I, e2 I  Nchild had grown 2.5 cm in 4 months and had gained7 s5 @" I6 C" H; T/ B
2 kg of weight. Physical examination remained
) A# k5 |5 N( y7 K1 {unchanged. Surprisingly, the pubic hair almost com-3 q" u: h8 u1 Q$ p# y
pletely disappeared except for a few vellous hairs at" m- M: F! e' g9 K3 Y$ j
the base of the phallus. Testicular volume was still 27 @& G5 s" [! v+ \( j
mL, and the size of the penis remained unchanged.; A9 q/ H' x# n# S
The mother also said that the boy was no longer hav-
3 p  F  o2 n* y) F* M5 [ing frequent erections." l' i! s- X+ f( A0 U1 r# N& a
Both parents were again questioned about use of
5 [# h8 F3 y7 E3 Eany ointment/creams that they may have applied to# x% t& X3 R; `
the child’s skin. This time the father admitted the$ w! d4 }; K. m$ y2 K4 d: f0 J# L
Topical Testosterone Exposure / Bhowmick et al 541
: y: x, ?2 p1 m! q) S8 y  F* Nuse of testosterone gel twice daily that he was apply-
$ ^4 B( V- S6 h2 ting over his own shoulders, chest, and back area for( K2 [+ O# Z) }9 z3 h6 _5 q
a year. The father also revealed he was embarrassed( @  N0 C% f3 Z3 m% K
to disclose that he was using a testosterone gel pre-
5 S% j  o& D( E& fscribed by his family physician for decreased libido& P- ?# c8 V( d  k5 [: O; j
secondary to depression.) C/ J$ f$ D7 t- l. V  L2 q
The child slept in the same bed with parents.$ g& T" |0 X3 b
The father would hug the baby and hold him on his
1 Y3 q7 f1 S; ?$ dchest for a considerable period of time, causing sig-  M# F5 l8 v3 C+ n
nificant bare skin contact between baby and father.: a( O+ Z0 h, Z, ]1 y. a+ \: z
The father also admitted that after the phone call,
; W7 k9 n8 Y, {- t) L7 Twhen he learned the testosterone level in the baby
( A* g. V1 l" [$ \; ~9 ?0 |was high, he then read the product information; T; X4 k# n! B6 l- l
packet and concluded that it was most likely the rea-0 c' M) }' O, u! V' y1 q; k
son for the child’s virilization. At that time, they
" v5 q# v, i% b) z4 t! `5 Rdecided to put the baby in a separate bed, and the
/ Q+ U" a# h, q+ efather was not hugging him with bare skin and had2 P9 [! K" W6 T! V: @
been using protective clothing. A repeat testosterone$ Y( U8 \3 }5 \! ^) U8 ~
test was ordered, but the family did not go to the
7 w  A* L& G. ?, @laboratory to obtain the test.; j6 u5 ~7 r5 i/ j/ r
Discussion/ v$ g0 p; m% ]& a8 I9 K) R
Precocious puberty in boys is defined as secondary+ @. l# W  A3 a
sexual development before 9 years of age.1,4/ }. V! Y" A6 s1 W8 T0 ]6 a2 a
Precocious puberty is termed as central (true) when9 m2 i7 a& W' u( o, T9 ~
it is caused by the premature activation of hypo-
) y7 u5 o( [0 i0 M* Y. U  Pthalamic pituitary gonadal axis. CPP is more com-0 D- B1 Q5 G) z% p2 ?  \' K
mon in girls than in boys.1,3 Most boys with CPP: @% d+ ]! J1 c2 {
may have a central nervous system lesion that is
: x8 ]8 G. y8 G, L5 K( P4 C/ D( }responsible for the early activation of the hypothal-
* s2 @' U$ b* A) Famic pituitary gonadal axis.1-3 Thus, greater empha-
3 l2 M2 ]( D1 Z$ D/ j! Ssis has been given to neuroradiologic imaging in
" V6 P$ y5 a7 |6 S( v5 Iboys with precocious puberty. In addition to viril-) h- m+ z2 n, f/ X# V
ization, the clinical hallmark of CPP is the symmet-% ^. A7 _7 H0 ~
rical testicular growth secondary to stimulation by
( y. T( c" z# y6 I$ s# J/ P$ z5 Xgonadotropins.1,3
- R) `7 ?  k3 _5 oGonadotropin-independent peripheral preco-' B9 t/ u0 y/ x# j: T
cious puberty in boys also results from inappropriate
+ [1 K& f8 X3 G+ A, @androgenic stimulation from either endogenous or
7 |8 O2 x+ _6 e. Jexogenous sources, nonpituitary gonadotropin stim-
% _' P3 F2 v! F& Y# @5 Gulation, and rare activating mutations.3 Virilizing+ Q' u5 X- _$ ^8 q  L" P* n
congenital adrenal hyperplasia producing excessive+ i3 {; Y; b. J8 l$ S# P
adrenal androgens is a common cause of precocious
6 ^2 J( a  a, l$ v6 p; Qpuberty in boys.3,4
. Y3 S8 T% P5 `5 p" oThe most common form of congenital adrenal
! J/ h5 A5 q2 }- E7 Y' Zhyperplasia is the 21-hydroxylase enzyme deficiency.+ L6 E2 K. J- S) s( I8 r0 K
The 11-β hydroxylase deficiency may also result in. j2 P* S$ _# h6 F: ]" D3 p% s
excessive adrenal androgen production, and rarely,0 i: z* }7 @/ W+ G1 v
an adrenal tumor may also cause adrenal androgen
' k0 ?" B$ q1 x. C3 V2 y) iexcess.1,38 P5 A2 S) O+ u& S2 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 I& ^2 x7 @; K. j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% R. t/ A! u1 |% ]+ k
A unique entity of male-limited gonadotropin-4 I2 N& L" q+ i  x  w
independent precocious puberty, which is also known
: A) h# C- b/ R+ Q2 yas testotoxicosis, may cause precocious puberty at a
' b# y/ }( N2 Xvery young age. The physical findings in these boys
8 L. M& B0 Y: D, [& c' Q" G, V$ cwith this disorder are full pubertal development,
7 k/ y9 n8 f0 z3 l- n4 Nincluding bilateral testicular growth, similar to boys' x% X4 j; A6 E- Y" }5 w- W
with CPP. The gonadotropin levels in this disorder
0 {# w% ]) w$ C3 Q. G% aare suppressed to prepubertal levels and do not show
* g0 q3 @& V% M% Z8 o, o9 V% Dpubertal response of gonadotropin after gonadotropin-
- l" {5 l' I9 g6 v( C. k8 ^releasing hormone stimulation. This is a sex-linked+ g) V. O6 h" S4 D
autosomal dominant disorder that affects only
8 L+ B, u3 g7 F8 y) q/ y) Dmales; therefore, other male members of the family
2 r! U0 E3 o  K1 n7 F4 M3 c  Rmay have similar precocious puberty.3
$ @2 f- G- J1 z$ I& z- yIn our patient, physical examination was incon-: U" g& c* o" A  K4 j8 N
sistent with true precocious puberty since his testi-( t2 ~( |  ^: ^3 |$ t& ~1 b. S
cles were prepubertal in size. However, testotoxicosis" \4 U& j" x* p$ t( j
was in the differential diagnosis because his father
: {/ Y4 m  Q. c4 X" M; nstarted puberty somewhat early, and occasionally,8 U: r- Q3 R) F
testicular enlargement is not that evident in the
) ~. l  a5 R. Bbeginning of this process.1 In the absence of a neg-0 y2 i8 G8 O# D
ative initial history of androgen exposure, our
4 e* I: U2 M' j0 f0 _4 p" rbiggest concern was virilizing adrenal hyperplasia,
3 i, m/ H. ~3 T: t' seither 21-hydroxylase deficiency or 11-β hydroxylase
& c& q- X( d7 W& ^deficiency. Those diagnoses were excluded by find-7 o+ a/ \' {0 W9 b; O& y* v' x
ing the normal level of adrenal steroids.
; L1 a) f% s' v* l1 O) F/ iThe diagnosis of exogenous androgens was strongly
! `, R5 Y: G6 g- i) o; c& u8 Vsuspected in a follow-up visit after 4 months because
- F; K4 X8 s( H/ P' X& @the physical examination revealed the complete disap-$ d3 p9 e3 Q: c, R# @
pearance of pubic hair, normal growth velocity, and
8 W; l! \9 q6 m2 Y& I- K. Rdecreased erections. The father admitted using a testos-. L% J& _5 p3 y* P0 q8 g$ A
terone gel, which he concealed at first visit. He was
* r2 @) A& O$ q) f  M& P9 ~using it rather frequently, twice a day. The Physicians’
' W( ^; b2 [( U7 U, }2 Q6 A7 fDesk Reference, or package insert of this product, gel or
" w) k$ ~  J' v* Z+ O& F9 L( F+ s: `cream, cautions about dermal testosterone transfer to
& A& [" D7 g" j( Kunprotected females through direct skin exposure.  F/ z9 Q4 Y0 Z& h1 |
Serum testosterone level was found to be 2 times the4 C3 `! W- x2 u6 V2 `
baseline value in those females who were exposed to8 p6 H6 \& Z4 J0 s: q. e
even 15 minutes of direct skin contact with their male3 Q: w$ w5 a+ \2 J+ {2 @
partners.6 However, when a shirt covered the applica-9 @5 v# v- M! }' H$ n  k) p1 e! c
tion site, this testosterone transfer was prevented.% S8 Y7 N& K0 M
Our patient’s testosterone level was 60 ng/mL,: E+ X  b- f0 T5 U
which was clearly high. Some studies suggest that
! G( M5 ^$ N4 p$ o3 _) y' wdermal conversion of testosterone to dihydrotestos-9 ~" K7 ^, X, o& G  Q% P
terone, which is a more potent metabolite, is more
, j0 |% U4 N9 I; ?6 o* Q8 c$ ~7 \active in young children exposed to testosterone0 c, S$ k  n1 U. {0 O4 K$ g
exogenously7; however, we did not measure a dihy-% o  R$ h: ]2 T; ]. w6 V( J
drotestosterone level in our patient. In addition to7 k" i' _7 d% D  Y
virilization, exposure to exogenous testosterone in
+ b& j/ M8 \+ a  i( q3 `( E0 \children results in an increase in growth velocity and9 o9 o$ C  u) T/ A( t
advanced bone age, as seen in our patient.
+ @$ G' Y1 v' \" I% L% WThe long-term effect of androgen exposure during
# W  L. R  T. e3 j$ s- }early childhood on pubertal development and final3 h) ?) W9 {3 B; k6 K# @; D
adult height are not fully known and always remain
- q  S. t2 Z1 L) ^) j) }( S; Ha concern. Children treated with short-term testos-
% K9 D* l/ B) F$ b4 s8 D4 k# y6 sterone injection or topical androgen may exhibit some
! g# y' M7 H( @, M& I2 d5 |acceleration of the skeletal maturation; however, after. k3 Y& b$ @' k, o( D
cessation of treatment, the rate of bone maturation8 g9 l1 |) p# j2 |4 I
decelerates and gradually returns to normal.8,9, B! `( Z# F1 U6 Z
There are conflicting reports and controversy
8 ?% f4 F2 {% W' O) n- w2 y3 ]over the effect of early androgen exposure on adult
* u/ A, `7 s( b8 L  kpenile length.10,11 Some reports suggest subnormal, i* p, Z6 O3 P( {
adult penile length, apparently because of downreg-
# j; D2 x9 u. n* I* M0 ~) wulation of androgen receptor number.10,12 However,
6 L0 k( u. [* w5 I( D8 ~0 hSutherland et al13 did not find a correlation between
. l7 n7 y" M$ V* Q  M& gchildhood testosterone exposure and reduced adult0 X: a7 M3 L9 J: B* e8 \1 `  u. d
penile length in clinical studies.# F0 m/ P! X/ {$ i
Nonetheless, we do not believe our patient is9 a7 \* b. q, }' K; |. k! p
going to experience any of the untoward effects from
: V9 H; p( g( X. e) B4 gtestosterone exposure as mentioned earlier because# N$ ?0 |- q/ Y) X
the exposure was not for a prolonged period of time.( k; @) ?% ~! H2 a1 r4 f
Although the bone age was advanced at the time of9 u8 [. p4 A$ }2 I6 f( q& u
diagnosis, the child had a normal growth velocity at
( z! n- [+ U4 vthe follow-up visit. It is hoped that his final adult
  S: a; I- G5 F: @5 z: Cheight will not be affected.
. ~8 ~- H" ]5 T7 xAlthough rarely reported, the widespread avail-
9 N8 S* }, [$ ~6 C4 t. g  b9 Uability of androgen products in our society may1 r% p% c. U5 h3 Z+ H6 k
indeed cause more virilization in male or female
! c3 d$ ?1 Q2 Z, E( Q) l* U9 {0 gchildren than one would realize. Exposure to andro-
) O" _, z  X( ]1 {6 Z) _# y3 M; vgen products must be considered and specific ques-
4 _9 N7 j5 I9 T, {8 ztioning about the use of a testosterone product or
! z$ Z' h: n4 K' G- L' igel should be asked of the family members during
6 G* R% A& A) o: p# Q/ ~the evaluation of any children who present with vir-3 E- R- U* P) Y  Y
ilization or peripheral precocious puberty. The diag-
4 W: X; G$ S: R1 A% I# V* O+ mnosis can be established by just a few tests and by
6 q$ X1 @- L" _- n; mappropriate history. The inability to obtain such a% l/ N1 q2 B# S- K# M/ r/ _
history, or failure to ask the specific questions, may
! g3 ]! `, C' t0 G/ o# \# Cresult in extensive, unnecessary, and expensive/ h+ H% L0 z! w
investigation. The primary care physician should be
' L: `9 B  \- L/ @aware of this fact, because most of these children' b! n9 t$ o( E9 Q1 O
may initially present in their practice. The Physicians’
* K7 T# T# Y- O' v! V5 LDesk Reference and package insert should also put a
0 C7 u2 i) O! u, ?! N, `7 w( r% Awarning about the virilizing effect on a male or1 F8 R6 c& k& g) W8 N3 H' @
female child who might come in contact with some-
& F" b3 I2 z+ i! {6 Done using any of these products.
5 L; Z, {5 X5 d$ r* @# uReferences! x  Y5 }5 }6 _
1. Styne DM. The testes: disorder of sexual differentiation
6 B9 p- w+ _& p, Kand puberty in the male. In: Sperling MA, ed. Pediatric
) p3 ~& x5 s2 F* c2 c; C/ XEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) l( c+ K; n2 R
2002: 565-628.
4 ]0 R. Z5 D- X$ Y, h8 ~% l2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. K7 v7 z: m( ?; b+ s- K
puberty in children with tumours of the suprasellar pineal
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發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!

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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点

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發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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4个什么样的?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

2 ^( W/ Z8 Z( B* C6 U& H! A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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