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Sexual Precocity in a 16-Month-Old. y4 O3 U/ D/ g# S. k; z" @8 |
Boy Induced by Indirect Topical: w# `6 @3 x$ _/ z& X
Exposure to Testosterone6 [3 Z- B' O# x. ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ X" y5 ~! X7 Y& cand Kenneth R. Rettig, MD11 m+ Y' i& `  ?0 E/ z  O
Clinical Pediatrics1 y# ?2 i7 s8 I$ j8 q2 Y( S
Volume 46 Number 6$ ~- e2 p2 v9 {8 P6 B8 H. R! t
July 2007 540-543
' O% A% o+ q% ?% D3 P0 g© 2007 Sage Publications
- ~: \: _* v+ t  `2 C8 o2 \+ Y10.1177/0009922806296651
. o$ S3 T/ h) p' G7 Xhttp://clp.sagepub.com
5 S( ?6 l$ n( }7 e" Hhosted at
& B& H  b( K. h: Nhttp://online.sagepub.com
2 T1 [6 H& q1 y1 \" S' y: t* ]3 GPrecocious puberty in boys, central or peripheral,& f6 K0 k* g$ }, e8 t
is a significant concern for physicians. Central
$ O# J9 o0 g1 G+ ?; Nprecocious puberty (CPP), which is mediated
( z, |6 y( b; F4 S6 g; \( Wthrough the hypothalamic pituitary gonadal axis, has+ _7 C9 }( C" k. Z/ v% Z% M/ N. h( ^
a higher incidence of organic central nervous system
: F) P4 S6 [6 q% _1 llesions in boys.1,2 Virilization in boys, as manifested2 \& j7 g+ t( }' G& r, M' W3 F# @
by enlargement of the penis, development of pubic
. k+ f, A% f, y) |& Y/ S# @hair, and facial acne without enlargement of testi-5 C; {7 \; J, f, m8 P: B& p" f& V% Q) f' p
cles, suggests peripheral or pseudopuberty.1-3 We
5 T! ^; t0 n- e4 Qreport a 16-month-old boy who presented with the0 t+ l( ?8 v. Q* q- G0 {! ^+ t
enlargement of the phallus and pubic hair develop-
" P3 F" a9 {* V% ement without testicular enlargement, which was due) {; m5 [+ }* A& J% w# @. ]
to the unintentional exposure to androgen gel used by0 J/ W8 I7 J* A! _5 i# Q8 P& k
the father. The family initially concealed this infor-
+ n3 s8 j  k9 `8 l* w- [mation, resulting in an extensive work-up for this% v8 e% C. ?% L; X  E9 j  G
child. Given the widespread and easy availability of4 V+ Y* [1 T- `2 @- P' ^
testosterone gel and cream, we believe this is proba-- t, Q6 d5 o( s* `/ }
bly more common than the rare case report in the
# M: H0 ]" K- O9 a5 gliterature.4
" q3 j0 \) u7 }0 xPatient Report5 ^  y3 y2 u" m" d
A 16-month-old white child was referred to the
+ A% s" Z( `" K; A3 J! c  sendocrine clinic by his pediatrician with the concern
: h" k2 J" j& T1 R3 E/ Zof early sexual development. His mother noticed1 j& x4 X! B4 K' c7 i% U
light colored pubic hair development when he was9 I2 w# B" x( }, a/ J2 w
From the 1Division of Pediatric Endocrinology, 2University of
# ?  a) v1 Y3 v5 v, KSouth Alabama Medical Center, Mobile, Alabama.8 K! |, H; p" e$ m2 s* w
Address correspondence to: Samar K. Bhowmick, MD, FACE,# \  _/ g; z% T" w
Professor of Pediatrics, University of South Alabama, College of  b1 b3 j7 M! c  Y, V( r( c" h" e3 l0 x+ x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 K0 D' k! C6 y; p
e-mail: [email protected].
/ ?9 ^9 p( r7 v) B2 A0 i2 \about 6 to 7 months old, which progressively became
& L$ j0 w, I: v2 o/ m+ Bdarker. She was also concerned about the enlarge-
! t# H0 Z" S: Y& a9 S; v& }5 O& Yment of his penis and frequent erections. The child' _) ^3 @& T9 ~% L7 I% |3 m
was the product of a full-term normal delivery, with% H% R# S# M9 n1 v5 t. E
a birth weight of 7 lb 14 oz, and birth length of- n, A* A! i2 U
20 inches. He was breast-fed throughout the first year# D/ F. {1 k$ P; d/ w9 z
of life and was still receiving breast milk along with
, C9 q3 o' N1 R9 a) M9 ssolid food. He had no hospitalizations or surgery,- q2 F6 J4 W1 w* [2 z- U9 b3 Q
and his psychosocial and psychomotor development
. o+ Y$ q0 ~: W9 @# o6 l( ^was age appropriate.( I) N2 U3 q' ?
The family history was remarkable for the father,
( n1 }+ u- E1 o  ^& kwho was diagnosed with hypothyroidism at age 16,
5 c  G1 {8 q% o5 h( l% Mwhich was treated with thyroxine. The father’s
# w& C8 P0 S& O; u. sheight was 6 feet, and he went through a somewhat9 B$ R# |: `5 _
early puberty and had stopped growing by age 14.
6 E6 g- g5 d# EThe father denied taking any other medication. The8 x% I7 x* g  @/ L+ }+ p
child’s mother was in good health. Her menarche: v( t1 O3 |1 T% q9 r6 M, ?
was at 11 years of age, and her height was at 5 feet
5 p# N; d! D( U, ]4 k5 inches. There was no other family history of pre-+ p" G- |- m. \" I9 j/ p
cocious sexual development in the first-degree rela-
8 U7 o) ]' b) q! [7 B0 p$ G" p. btives. There were no siblings.0 D+ Q5 W) z- w( ^% P/ g( p6 L
Physical Examination
  a0 b  _) Z9 f# CThe physical examination revealed a very active,
( c* H2 u6 H1 b7 ^6 P/ zplayful, and healthy boy. The vital signs documented
6 R) n! I+ z) \. fa blood pressure of 85/50 mm Hg, his length was
* x* v7 X+ U7 W6 Q: J5 v90 cm (>97th percentile), and his weight was 14.4 kg1 P* }* P8 X4 m* S. L0 }; C
(also >97th percentile). The observed yearly growth
* W7 u* I/ h' p! Q* c# S/ Qvelocity was 30 cm (12 inches). The examination of* }4 x; [' h2 r  r
the neck revealed no thyroid enlargement.9 x8 c# S+ c! ~+ Z- F2 [
The genitourinary examination was remarkable for
0 c" r4 r, [* ?  T/ Z" Yenlargement of the penis, with a stretched length of
" r( y) D/ R  D# N9 b& u8 cm and a width of 2 cm. The glans penis was very well
5 n6 r9 x0 ?( z8 Ideveloped. The pubic hair was Tanner II, mostly around
( J; C: C) B1 K2 K- o+ U- q. r5400 f' O  |% @0 k, G' w' K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 }8 v& G7 o! |0 i+ G& O% n% Dthe base of the phallus and was dark and curled. The
4 v0 ^5 Z/ O2 P" R: ]testicular volume was prepubertal at 2 mL each.
' K4 @" w- `) |1 u+ lThe skin was moist and smooth and somewhat& b( _4 i" K! k0 g
oily. No axillary hair was noted. There were no
" A$ d! z% `' j/ \# pabnormal skin pigmentations or café-au-lait spots.
7 U$ O6 V8 X9 N0 f5 }Neurologic evaluation showed deep tendon reflex 2+
2 Q, @- Z, A* K  Q$ m2 m# a, dbilateral and symmetrical. There was no suggestion8 x  T3 _! Q* W! ?* p: o& w9 c
of papilledema.
6 H1 \9 r0 I! b3 D- i" K) I( g2 b$ oLaboratory Evaluation) h+ c# N; c' \+ A
The bone age was consistent with 28 months by
* \3 a( n# d% {; Eusing the standard of Greulich and Pyle at a chrono-5 b9 X* X( u2 ]: Z& J
logic age of 16 months (advanced).5 Chromosomal
% B5 ?0 \" c! f  H5 ?. vkaryotype was 46XY. The thyroid function test& |8 s8 n+ Y/ z7 \6 F7 Y9 w" H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: j9 [3 |: X" x
lating hormone level was 1.3 µIU/mL (both normal).
8 g+ A$ V) v+ ^6 R' d/ }  A  J5 k3 SThe concentrations of serum electrolytes, blood# y, R4 |) ]* c# x9 L6 T1 c* r
urea nitrogen, creatinine, and calcium all were
9 U, T6 b, M4 m0 Lwithin normal range for his age. The concentration  y  n, O* _3 f* `2 e( e
of serum 17-hydroxyprogesterone was 16 ng/dL  \$ M( v  n2 n- I$ M3 W
(normal, 3 to 90 ng/dL), androstenedione was 20' S7 U3 t# {5 I! z( X! l& H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% c( B0 e" k7 E+ X: a; k
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
  b0 Z) d( q5 m$ f4 ~desoxycorticosterone was 4.3 ng/dL (normal, 7 to. C/ N; B$ q( z' ]. K
49ng/dL), 11-desoxycortisol (specific compound S)* M* L6 G! x( o1 ~6 B/ G
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) {9 z& j" S# S% I# t7 ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 x9 A3 K! v% `4 R" ~- `5 k& E9 R8 ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 i1 g! P3 @! t% ]
and β-human chorionic gonadotropin was less than
, V3 J0 E0 [# v! ~1 t5 mIU/mL (normal <5 mIU/mL). Serum follicular* K! r% ~! h3 a1 p
stimulating hormone and leuteinizing hormone
8 y+ Y# \" `. R3 H8 `concentrations were less than 0.05 mIU/mL
9 R3 d: `8 P/ M# s  F! G7 \(prepubertal).
2 W9 f$ P$ i; D( U/ \- M- C. R, AThe parents were notified about the laboratory
$ O* Q/ N; c( xresults and were informed that all of the tests were
% Z7 @1 a3 Q5 O7 w* T; f8 anormal except the testosterone level was high. The
- _" t+ v# u3 N! X6 sfollow-up visit was arranged within a few weeks to
+ E, h  v  i* a& Kobtain testicular and abdominal sonograms; how-$ O4 }4 f# Z8 y
ever, the family did not return for 4 months.
4 y4 h' y/ H$ u0 fPhysical examination at this time revealed that the9 G5 F" l; G3 I& I- l5 q
child had grown 2.5 cm in 4 months and had gained
7 X* f7 L) _4 X& D& X+ v) }2 kg of weight. Physical examination remained
6 ^) R* r. u' J& V: Zunchanged. Surprisingly, the pubic hair almost com-* Z6 S& Z# R" e2 ?7 H, `; e, Q
pletely disappeared except for a few vellous hairs at# F* i) K, z4 W9 {
the base of the phallus. Testicular volume was still 2* L/ W. U) W/ r' j6 c6 i
mL, and the size of the penis remained unchanged.: {0 h& a( g7 k7 [' i9 m
The mother also said that the boy was no longer hav-( t1 V0 L1 s& X& m: x
ing frequent erections.& q" I/ m9 ?0 g7 U, |( R
Both parents were again questioned about use of
+ m+ U5 U" h* W: A; Yany ointment/creams that they may have applied to
( G! L. A3 P# C" C3 V% S( V, othe child’s skin. This time the father admitted the- J  Y- D+ M/ [2 @% k
Topical Testosterone Exposure / Bhowmick et al 5419 _+ n' Y2 R3 O, |* @  F
use of testosterone gel twice daily that he was apply-9 I. R$ I/ W' A# F% j$ g
ing over his own shoulders, chest, and back area for. A+ ]4 k. w9 B# o' k1 p
a year. The father also revealed he was embarrassed( e7 A- e: |6 F" T4 Z' f( u
to disclose that he was using a testosterone gel pre-! v2 h# _$ G) O8 ~# \+ C
scribed by his family physician for decreased libido# c5 Y1 f+ [: \2 t0 ~' a: E
secondary to depression.! Z" C% V4 J' ~8 J
The child slept in the same bed with parents.: _9 m. T# ]" _* c! K
The father would hug the baby and hold him on his% t5 C0 t1 b/ k, _
chest for a considerable period of time, causing sig-, |/ |( |/ N' ^- [5 X
nificant bare skin contact between baby and father.% f4 Y' E9 J: k6 W9 V2 [1 T
The father also admitted that after the phone call,
6 D% Z6 ?; f  C9 y) Jwhen he learned the testosterone level in the baby
. ]3 n# ^8 K, L% {was high, he then read the product information% }) Q& v9 A% j/ @1 Y
packet and concluded that it was most likely the rea-, m7 o4 N: s6 W; M* L
son for the child’s virilization. At that time, they
; @  g$ k9 k; M/ Idecided to put the baby in a separate bed, and the6 u2 o* a9 {5 y5 a% [9 H, O
father was not hugging him with bare skin and had
! j! {9 b2 d! J  ubeen using protective clothing. A repeat testosterone+ q+ k$ y6 g. `9 c
test was ordered, but the family did not go to the
3 m- }5 I( @4 G' _' F, o7 wlaboratory to obtain the test.
4 T: V0 V9 ^  y' Z7 ]Discussion
# q. N# a+ j; ^5 ^1 vPrecocious puberty in boys is defined as secondary" ?: B+ ?0 b1 V' u8 y( u' [
sexual development before 9 years of age.1,4
6 _2 Y3 Y; r" c4 w: Q. m% I& MPrecocious puberty is termed as central (true) when
/ |' b0 V- J( f9 Bit is caused by the premature activation of hypo-9 T1 |) j- }6 r0 I! }; D; ~; @
thalamic pituitary gonadal axis. CPP is more com-3 x* y" _; W. h1 a  Z$ x9 i
mon in girls than in boys.1,3 Most boys with CPP2 a  W! @0 L) X' y% O
may have a central nervous system lesion that is
) V2 p* u8 V2 N2 p) K# Dresponsible for the early activation of the hypothal-
" n* ^# \# @2 {. V( \# ~amic pituitary gonadal axis.1-3 Thus, greater empha-
  R$ k: U. X7 jsis has been given to neuroradiologic imaging in9 q; G$ }- D/ v) M
boys with precocious puberty. In addition to viril-! |$ b# i. B: {3 p9 B, I& x) f7 {
ization, the clinical hallmark of CPP is the symmet-
3 ~' ~) L" Q: J- K5 m% Xrical testicular growth secondary to stimulation by: m: [# I7 K% }: p
gonadotropins.1,3, E  L; C9 _0 a1 `+ a; g: {
Gonadotropin-independent peripheral preco-
+ p& K) x4 D, ^. F+ q! o8 rcious puberty in boys also results from inappropriate6 h$ P# ?1 u9 O; y" f
androgenic stimulation from either endogenous or
; P% E$ Q: w: H" k- C3 u/ @6 E- yexogenous sources, nonpituitary gonadotropin stim-) X) K2 d' y* j6 [
ulation, and rare activating mutations.3 Virilizing5 l4 I3 [" Y6 n1 }/ W8 V
congenital adrenal hyperplasia producing excessive
# P' @, v2 |. o$ I4 [+ \0 Madrenal androgens is a common cause of precocious- O5 I9 W* Y3 L5 |5 [
puberty in boys.3,4. Y, N  B% A6 M
The most common form of congenital adrenal# ^( u; h8 u# v5 u0 b
hyperplasia is the 21-hydroxylase enzyme deficiency.5 y1 |, g4 j# ^! t" E& _( s
The 11-β hydroxylase deficiency may also result in5 j: X2 B: I( a, }/ o  g" D
excessive adrenal androgen production, and rarely,1 x$ f: k8 ^( A8 l* S; V
an adrenal tumor may also cause adrenal androgen0 i" P; ~5 w) U( h3 |
excess.1,3
, k; r6 V* i1 `% \3 b; c9 tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' l# v# z# f* y* R8 o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% F( Q4 @2 c/ E' j4 ^
A unique entity of male-limited gonadotropin-
; O# |& ]: r' X. E% cindependent precocious puberty, which is also known
( z5 \  n, w8 ^7 w; O* x. e1 uas testotoxicosis, may cause precocious puberty at a
3 Q1 l7 |, j% q( ^- Cvery young age. The physical findings in these boys
( H, {2 J& `  ?" C' uwith this disorder are full pubertal development,: B. O8 Y6 @3 b5 R9 S( h
including bilateral testicular growth, similar to boys- \- O2 \! a( o2 |. J" J
with CPP. The gonadotropin levels in this disorder
1 p! d* c9 u. ?1 v2 hare suppressed to prepubertal levels and do not show, V. G- W- [* a5 `3 k. I2 e$ U1 Z4 Y
pubertal response of gonadotropin after gonadotropin-. E( w/ h8 U6 t. v# N
releasing hormone stimulation. This is a sex-linked  h! j% q6 j  K0 J' X; L
autosomal dominant disorder that affects only- S# ^; e$ y, f0 {
males; therefore, other male members of the family
9 L% J5 ?0 ?; @2 i" Q+ \may have similar precocious puberty.37 x) L" n: \- p& H  j
In our patient, physical examination was incon-
/ u* g, G) L5 p. p1 Jsistent with true precocious puberty since his testi-9 D7 z6 b; z( ~' D% g: B
cles were prepubertal in size. However, testotoxicosis; V2 t8 f0 b) }  x' j: d
was in the differential diagnosis because his father
4 }  M" y2 A4 D: {0 xstarted puberty somewhat early, and occasionally,
1 _, v; ^9 s2 x9 M  utesticular enlargement is not that evident in the
! N  V1 J5 Q9 o& s: ?' W4 gbeginning of this process.1 In the absence of a neg-4 l1 l0 H% P- _! ^
ative initial history of androgen exposure, our, p' i( @7 V1 h9 K# e. ~; X8 C1 s
biggest concern was virilizing adrenal hyperplasia,8 s  e  C: C- ]. ^  D) L2 p* P
either 21-hydroxylase deficiency or 11-β hydroxylase  x0 n/ A9 `: O; Z
deficiency. Those diagnoses were excluded by find-, M+ M- Y# b2 G+ C: i1 S3 j$ d
ing the normal level of adrenal steroids.
& i) [- j( J9 f  p, EThe diagnosis of exogenous androgens was strongly: r! }1 H4 m% N; ]5 [, j% k7 M
suspected in a follow-up visit after 4 months because
5 Y0 |6 c- s$ u# J, }the physical examination revealed the complete disap-; p1 o1 g5 k7 y6 W1 Z( Q: Y
pearance of pubic hair, normal growth velocity, and6 w- b" b3 D, ^" o! l
decreased erections. The father admitted using a testos-
; `. x& m6 }4 e% J/ A& {( v. v$ rterone gel, which he concealed at first visit. He was
) d- X$ V3 N/ z# _. i+ p4 ausing it rather frequently, twice a day. The Physicians’' u, {) s- d8 ]* Y. _
Desk Reference, or package insert of this product, gel or
- H8 {3 s# d' Z: t9 w7 j7 scream, cautions about dermal testosterone transfer to. ?) U8 _/ p1 S
unprotected females through direct skin exposure.
: T+ M; z: C) n) ]; ^  CSerum testosterone level was found to be 2 times the
) e5 ^* G3 G5 G' ]9 \- t* G0 Fbaseline value in those females who were exposed to
9 }$ X* [) L  i0 Beven 15 minutes of direct skin contact with their male2 T7 q% @1 U$ s6 H: `2 V% V
partners.6 However, when a shirt covered the applica-, v: j- T6 d4 z4 h4 l4 `
tion site, this testosterone transfer was prevented.
# f0 D  ~5 y. |2 ]Our patient’s testosterone level was 60 ng/mL,
8 s) n  s2 P7 Ewhich was clearly high. Some studies suggest that
! ?: A9 o: A/ l# ]. vdermal conversion of testosterone to dihydrotestos-
( ]0 l# |7 {1 Fterone, which is a more potent metabolite, is more
% [) y" }9 `9 }- h( |active in young children exposed to testosterone+ z0 B0 Y+ c# Q" w
exogenously7; however, we did not measure a dihy-3 f* ~; ]2 R( n) I) _5 h" v
drotestosterone level in our patient. In addition to
. D  i' l5 C+ b; {, y, s' f4 ?% Rvirilization, exposure to exogenous testosterone in4 |0 A0 E+ m; u1 X
children results in an increase in growth velocity and# M9 R0 `, X' r1 _! s( ^
advanced bone age, as seen in our patient.
: k' r7 ]) R# f7 s) @9 E, MThe long-term effect of androgen exposure during- D; S% d7 a' @) F" O
early childhood on pubertal development and final
% ~0 d* n. \2 U) @. b# yadult height are not fully known and always remain
/ D% ?) X- s2 M6 {a concern. Children treated with short-term testos-
3 c' k; p1 T6 d: lterone injection or topical androgen may exhibit some
4 Q  B. O1 o9 _( l! B! z2 J9 \! xacceleration of the skeletal maturation; however, after# Q. p* ^+ N7 p# f; \7 \+ h* {
cessation of treatment, the rate of bone maturation* y  w. j+ t9 l# n3 _/ y8 R
decelerates and gradually returns to normal.8,9
. y3 X& Q. H$ r/ {+ HThere are conflicting reports and controversy
- j- j* |% M  b- p9 l6 y; Tover the effect of early androgen exposure on adult3 f: w5 K0 T1 E4 v
penile length.10,11 Some reports suggest subnormal$ u+ L2 I& V6 K5 d# S* O7 f) {
adult penile length, apparently because of downreg-
5 O9 P, P, @6 w. Tulation of androgen receptor number.10,12 However," {  E7 ^4 u4 |: c$ z' h
Sutherland et al13 did not find a correlation between, N3 r, `- K' k+ N0 g0 h
childhood testosterone exposure and reduced adult
9 T" j  O  _# N+ N- [1 R0 ?penile length in clinical studies.0 ]" R# i3 Z- ~# T
Nonetheless, we do not believe our patient is
: i5 V; N! z' j: \8 }7 Hgoing to experience any of the untoward effects from% i& Y% |- T# \* H+ B: _) s
testosterone exposure as mentioned earlier because
6 ]* q1 C) }# y+ ethe exposure was not for a prolonged period of time.
" C* T, j6 Z- g5 u1 e# B2 UAlthough the bone age was advanced at the time of
! b2 i2 ~8 l& v4 F, Hdiagnosis, the child had a normal growth velocity at, B8 ]/ P# w2 l  v) K1 v
the follow-up visit. It is hoped that his final adult( n, {: f0 d, {( j
height will not be affected.) {; M$ A/ [, b* u; x( f6 S* d; p9 s
Although rarely reported, the widespread avail-+ A0 ]  ~% X9 W$ E4 D* l1 G
ability of androgen products in our society may
+ n( [, S# _; _2 F2 H) q- Oindeed cause more virilization in male or female! x$ C) ?1 D& `( i; r) v4 D
children than one would realize. Exposure to andro-
8 o# v" ?( _0 H: M) o' X! fgen products must be considered and specific ques-5 w. l9 R' ~6 y% {# j' t5 }
tioning about the use of a testosterone product or
; p& `0 H! T6 g$ `1 |gel should be asked of the family members during
( {) U2 F$ V6 i# Tthe evaluation of any children who present with vir-
& S- G# C+ u- F" [ilization or peripheral precocious puberty. The diag-/ H4 i/ w9 h. z, g
nosis can be established by just a few tests and by
0 `* G1 m% A. nappropriate history. The inability to obtain such a# x8 k7 E  f& x) e
history, or failure to ask the specific questions, may. b- ?1 x5 L; H# h( j1 d+ {9 ]
result in extensive, unnecessary, and expensive+ u* I2 e1 l& L4 L
investigation. The primary care physician should be
  w- R' q; e9 p+ Vaware of this fact, because most of these children
" N3 Y, f, @3 [  F8 ]8 E! Pmay initially present in their practice. The Physicians’
4 b  X/ E' J# e% c5 @$ [7 X# A# cDesk Reference and package insert should also put a5 D6 |  ?; S9 N/ ~
warning about the virilizing effect on a male or  w7 t; x6 T3 Y8 T
female child who might come in contact with some-
$ z1 g/ R/ l& ]7 ^# G- B1 j8 Uone using any of these products.* A8 q* A5 d7 h4 D1 E
References) {& `1 P- ~( z+ \4 ~% g
1. Styne DM. The testes: disorder of sexual differentiation5 u9 y; N$ C6 @  |
and puberty in the male. In: Sperling MA, ed. Pediatric
6 q0 W/ Z2 W5 s0 \, C8 R0 J9 x' uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 g5 o  k, x9 t
2002: 565-628.
3 U3 R9 b2 _1 j7 k2 `. R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- N  x4 b- b: I) d& Z" p
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ A# i" m0 y* ]# @. pBoy Induced by Indirect Topical
, n' w) l/ Z3 x: g, _Exposure to Testosterone
7 d- t$ s7 s; ^; Q$ O8 E$ YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 [+ R! J: p% z5 j- Z
and Kenneth R. Rettig, MD1
& x% T1 D  x4 G, n9 oClinical Pediatrics
. s+ S8 w0 n! W5 L4 J8 RVolume 46 Number 6
: Z1 |5 @% @" x# F1 g4 H* vJuly 2007 540-543) O! h# p1 a' s0 o" Q
© 2007 Sage Publications* j& W* K* I" R3 Y) i8 m" {
10.1177/0009922806296651
. n% V* ~" |: P" ^http://clp.sagepub.com
! F* K- N$ |) K3 W; Mhosted at, x% E" r+ f6 j% O+ K
http://online.sagepub.com7 |! ~5 G9 t! F. ]* V1 k
Precocious puberty in boys, central or peripheral,
3 H; i8 Y$ q8 ~" Q7 q* {7 s  ?4 Sis a significant concern for physicians. Central
( l  R! R( s4 C0 l) N3 t( i  Rprecocious puberty (CPP), which is mediated
! \( X* P6 H" w0 @  @9 Z/ V& tthrough the hypothalamic pituitary gonadal axis, has+ e0 B; b% e1 u8 P
a higher incidence of organic central nervous system6 h' c7 m8 ]0 b4 P
lesions in boys.1,2 Virilization in boys, as manifested
4 h+ v; _$ U2 Cby enlargement of the penis, development of pubic: u2 y/ _( K9 u5 m4 n
hair, and facial acne without enlargement of testi-
5 k/ [. C7 O2 L# r# j! z4 |cles, suggests peripheral or pseudopuberty.1-3 We
1 A8 W7 ~. J! o* }' J1 e# p# J' dreport a 16-month-old boy who presented with the- O0 G- G3 f* j
enlargement of the phallus and pubic hair develop-8 g1 y5 ~9 i0 P' E2 b# O1 o
ment without testicular enlargement, which was due
. u: i+ |- z" q0 ?- Ato the unintentional exposure to androgen gel used by
' h  A- E+ n: h# g; v% j5 H! pthe father. The family initially concealed this infor-
- w" w# B! {& T- X# Y4 ~% \mation, resulting in an extensive work-up for this
: k! K$ @1 Y2 S) o4 Y+ ^child. Given the widespread and easy availability of
% X$ r- n9 W: H4 B& G, stestosterone gel and cream, we believe this is proba-
3 K5 Z5 P1 D* Q8 k. v, Q9 S+ E# hbly more common than the rare case report in the5 w1 {) [* @+ x3 G. H
literature.4! i! a$ E: l9 O: P& P
Patient Report
" u" W6 R* A4 d/ X' O8 d0 |, ]- a) m( tA 16-month-old white child was referred to the  Y- A& B% V. W8 K" \
endocrine clinic by his pediatrician with the concern7 S) A( G* ~5 e7 |: o
of early sexual development. His mother noticed  y: D: Y! V0 `" ?' ~
light colored pubic hair development when he was
1 M, P: u( L  m& J( FFrom the 1Division of Pediatric Endocrinology, 2University of
0 O1 I: p: f* u1 A* W8 zSouth Alabama Medical Center, Mobile, Alabama.
; ]7 r0 Z, R5 ?- |Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 Q& N& i6 {, N7 b7 [Professor of Pediatrics, University of South Alabama, College of4 X* L$ c" {3 g( C6 U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% j1 p+ ?: Q( O9 n' Y( G' w
e-mail: [email protected].
% `+ O* x$ o$ V/ F7 F1 E* Kabout 6 to 7 months old, which progressively became
. p7 n8 Q. Q1 S3 k1 J6 j5 Jdarker. She was also concerned about the enlarge-' h3 u- n9 \: D; g
ment of his penis and frequent erections. The child
6 n8 R. Y. w; q1 f& gwas the product of a full-term normal delivery, with. w' s, F- k; l* i2 @& a
a birth weight of 7 lb 14 oz, and birth length of
$ y8 x6 Q+ T( o0 \7 o6 ~20 inches. He was breast-fed throughout the first year
; x1 Q6 q$ Q% f' Jof life and was still receiving breast milk along with
+ v1 l! \, R: Y9 msolid food. He had no hospitalizations or surgery,5 I% L, T! @( t
and his psychosocial and psychomotor development
. W0 x; [& V$ S/ L) Q( f/ }7 Uwas age appropriate.2 D7 {7 I+ F+ u7 I( i
The family history was remarkable for the father,# p$ B/ K6 z, B6 G
who was diagnosed with hypothyroidism at age 16,$ N$ o  T" {2 b; h
which was treated with thyroxine. The father’s: O  F# N5 A' F& {9 b
height was 6 feet, and he went through a somewhat& E* j! B; J3 [# Y
early puberty and had stopped growing by age 14.' R/ K8 `% G7 B' @2 }
The father denied taking any other medication. The9 p4 u# D  k, q4 b. w7 P/ N$ l
child’s mother was in good health. Her menarche0 Z: K0 H! o/ f5 k& ?, I
was at 11 years of age, and her height was at 5 feet
. x7 X$ b/ W* D; ?5 inches. There was no other family history of pre-* D! t/ C7 L5 s
cocious sexual development in the first-degree rela-& p" y" n8 _$ r* X& u
tives. There were no siblings.+ Q$ S# q+ ]4 L- Q: Z& n1 t
Physical Examination
  E( d+ l4 k& ~' \The physical examination revealed a very active,
' P; N- d7 s  c4 ~" Aplayful, and healthy boy. The vital signs documented
2 e2 ]5 `7 f: l! I! r" r3 ]7 E0 ta blood pressure of 85/50 mm Hg, his length was& g# N$ |- p4 D7 L
90 cm (>97th percentile), and his weight was 14.4 kg
$ W3 I* D0 D* R8 K7 g0 R7 ?(also >97th percentile). The observed yearly growth
$ `* `* a3 {$ {/ O6 y3 vvelocity was 30 cm (12 inches). The examination of
+ Y, a/ A3 ]5 N, ^. I' |9 X4 Fthe neck revealed no thyroid enlargement.) j6 l% {! I8 p3 l: u1 |5 F; C4 E
The genitourinary examination was remarkable for6 z' x  b) s# d  w
enlargement of the penis, with a stretched length of5 d+ y, Y, |: ]; o. x6 y
8 cm and a width of 2 cm. The glans penis was very well
7 h5 M7 z% e! P  m8 |developed. The pubic hair was Tanner II, mostly around
* U& ~, y; a' y540
# F2 Y" t: y4 h: U$ Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ K4 i0 f! p; z2 X' z4 Dthe base of the phallus and was dark and curled. The- o% `& m( u1 l
testicular volume was prepubertal at 2 mL each.
$ h# y  U6 M7 YThe skin was moist and smooth and somewhat, A0 {6 H; @; q" X; f) r, a
oily. No axillary hair was noted. There were no& z) {; L$ g+ o7 D
abnormal skin pigmentations or café-au-lait spots.! I# i- R5 u* \1 J/ M
Neurologic evaluation showed deep tendon reflex 2+
# q& _: m( I. {* ]) t+ Dbilateral and symmetrical. There was no suggestion
2 M# ^3 P3 Y( t9 E1 _of papilledema.# U+ S7 c: |- K# ?$ d
Laboratory Evaluation# ]! `- ~+ D& s+ [
The bone age was consistent with 28 months by( q3 \: X$ L' L3 S5 U1 G
using the standard of Greulich and Pyle at a chrono-' D+ h+ F; P/ T, c
logic age of 16 months (advanced).5 Chromosomal
0 g; ?" ^2 g, J7 N: l  Q5 tkaryotype was 46XY. The thyroid function test
4 e5 b+ Z  g' Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 t. B9 `# B0 U/ Plating hormone level was 1.3 µIU/mL (both normal).
7 V& R0 `+ {. h) zThe concentrations of serum electrolytes, blood' a$ P- q) {& r& v8 B2 A
urea nitrogen, creatinine, and calcium all were  _" u+ W  M. f6 x5 [: M: N) q3 |- l5 ~
within normal range for his age. The concentration
/ C* T2 _" N) X, hof serum 17-hydroxyprogesterone was 16 ng/dL
( [! g* z0 _, s0 Z(normal, 3 to 90 ng/dL), androstenedione was 20
% T* d% r% j- a: ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( ]7 P& ?" x- U) s4 ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 m( c7 X! X1 E4 U8 ^4 H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) o5 }+ W) x% D' E6 V. I/ I49ng/dL), 11-desoxycortisol (specific compound S)) y8 s* `0 A. m' r# K/ P! ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 T( Q) c* y7 b$ \6 }2 R% s$ [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 ~6 f  o8 h9 Z+ B4 N" N8 dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: n* ?, J4 c0 I% ^7 land β-human chorionic gonadotropin was less than
0 F) g0 u$ C! m' m7 H5 mIU/mL (normal <5 mIU/mL). Serum follicular
) D  B; D  V; }0 Bstimulating hormone and leuteinizing hormone) U; `- N4 Y2 M$ b
concentrations were less than 0.05 mIU/mL
% w" ?, k+ H2 Z' O; ~9 @; s(prepubertal).
9 q7 k. q/ F9 C' `; RThe parents were notified about the laboratory
% l1 @$ j5 [4 L: Hresults and were informed that all of the tests were2 ^3 ?/ t- F5 e. |2 F+ J# w% i
normal except the testosterone level was high. The
; K8 ~  a6 y4 _1 y( M- ~2 a6 n) yfollow-up visit was arranged within a few weeks to; w$ u$ L( y* B# Q
obtain testicular and abdominal sonograms; how-
( y  A# Y( z% yever, the family did not return for 4 months.
$ L4 r! r& x- c1 z9 hPhysical examination at this time revealed that the8 b1 f, f. r7 a
child had grown 2.5 cm in 4 months and had gained, `: \( M, T8 ~. Y1 d: [( l3 G
2 kg of weight. Physical examination remained
0 b3 c, i( Q$ ]  ?. q& eunchanged. Surprisingly, the pubic hair almost com-
$ m. Q  ]) Q$ d% H! p/ ypletely disappeared except for a few vellous hairs at5 w  B: [- P6 O: n( T
the base of the phallus. Testicular volume was still 25 i8 C' X3 ~3 u* r8 r
mL, and the size of the penis remained unchanged.
" M4 H0 G+ L* }The mother also said that the boy was no longer hav-
9 n2 I, g0 M. u0 C: ?4 h9 ring frequent erections.
/ _; V' N. L& ]/ ?+ O# F" MBoth parents were again questioned about use of1 [3 |% C( `& }; n
any ointment/creams that they may have applied to2 x1 z( D3 c- q$ X! n  G
the child’s skin. This time the father admitted the3 K3 I! M* ?5 Q1 @4 s1 J: m9 u" ^  }
Topical Testosterone Exposure / Bhowmick et al 541' ~0 I* _8 D# R% m1 t3 y
use of testosterone gel twice daily that he was apply-" v' D' T4 n! Q% }; V, t' \$ \# N3 m
ing over his own shoulders, chest, and back area for# L4 ~  ~9 Z$ k$ C: M% ]6 Y* }# y
a year. The father also revealed he was embarrassed8 K; c: `' p8 [- H# i: C5 ^6 A
to disclose that he was using a testosterone gel pre-: S( y% M; }# B. ?
scribed by his family physician for decreased libido
0 r1 p3 D  Q! H2 A7 ^secondary to depression.
/ B! _9 d9 e$ `2 M$ FThe child slept in the same bed with parents.
* B7 i% `+ q$ {/ K( ~7 @5 Y$ VThe father would hug the baby and hold him on his0 M9 N. ?$ k  d3 v
chest for a considerable period of time, causing sig-
; H- s% F; p6 i% w8 \nificant bare skin contact between baby and father.% F2 h# j8 F9 W# `7 ^
The father also admitted that after the phone call,
( e2 }7 o$ z2 c+ t8 u* Fwhen he learned the testosterone level in the baby; k1 `, Y( A3 E, B8 C
was high, he then read the product information
/ j, |" k/ j7 F8 Y1 p: b6 b: vpacket and concluded that it was most likely the rea-" Z0 D4 ~' n; O8 R
son for the child’s virilization. At that time, they
) @: y) w6 {3 h) F' H( Ddecided to put the baby in a separate bed, and the
: z" c! K$ b5 q& f  @8 j  tfather was not hugging him with bare skin and had
5 e: N! L! y  r3 B( t- ~5 ~been using protective clothing. A repeat testosterone, e/ T, W  |* ^/ d& G% r8 q
test was ordered, but the family did not go to the
% _, \3 ?$ d7 L- ^5 q  D' {laboratory to obtain the test.
9 y$ g9 @2 C9 N- W6 p- V* T$ P; i7 jDiscussion
8 ]8 C/ i5 S8 I# J$ D4 w/ jPrecocious puberty in boys is defined as secondary
) o9 I* C' R% V7 Fsexual development before 9 years of age.1,4/ C! }8 z. i0 r) n9 |; y0 {" k
Precocious puberty is termed as central (true) when
  d" @3 M; W$ V$ R" B9 |it is caused by the premature activation of hypo-2 T7 o0 @2 j9 V6 f" `
thalamic pituitary gonadal axis. CPP is more com-
. @9 k+ e; \. h/ k$ |mon in girls than in boys.1,3 Most boys with CPP
7 `3 J5 ^' z# ~. Mmay have a central nervous system lesion that is
  G! ^4 k7 W3 E) b6 B/ }7 Hresponsible for the early activation of the hypothal-4 ]% |7 Z* o& W+ c. E: L$ n2 J
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 z8 l/ Z1 n7 C: M8 {; gsis has been given to neuroradiologic imaging in
, b( S0 d& @3 v2 l8 S# M: W3 w6 Yboys with precocious puberty. In addition to viril-
3 w& a  Y0 d% t" bization, the clinical hallmark of CPP is the symmet-' ]8 a) J, U, Y, k- w! K
rical testicular growth secondary to stimulation by" x# x( y9 V" F; z' A; `
gonadotropins.1,3
9 Y/ q8 c7 R7 X, L7 W! DGonadotropin-independent peripheral preco-
: @4 T2 L) w$ B$ s" Q" kcious puberty in boys also results from inappropriate
& L: @- g6 \# D0 Z) J2 Nandrogenic stimulation from either endogenous or% n8 Y- o4 H$ y5 y; c
exogenous sources, nonpituitary gonadotropin stim-
9 S; `& m8 |( Oulation, and rare activating mutations.3 Virilizing
0 \5 U5 Z4 T2 i" V- U, wcongenital adrenal hyperplasia producing excessive7 h- A# S* a& A# @. x
adrenal androgens is a common cause of precocious
2 h& n! u3 ~( F# p3 ]& n/ Vpuberty in boys.3,4; H8 ~/ s/ f8 U6 g0 C- S3 A0 V
The most common form of congenital adrenal
4 O- N3 j& e( ^% C' chyperplasia is the 21-hydroxylase enzyme deficiency.
. O1 v! e, Q; X1 L3 M4 qThe 11-β hydroxylase deficiency may also result in
7 I1 _  F  J1 E) y- e% H4 g/ l. Wexcessive adrenal androgen production, and rarely,
4 T& D: K7 [% R. n) gan adrenal tumor may also cause adrenal androgen4 l7 y7 X( d0 T0 _4 z1 c  m, W
excess.1,3
  R2 E0 m; }5 w& T- vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, c9 J0 m3 Z+ g; _' T. D4 l) l. [542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" g& N+ c, a7 n. P' \A unique entity of male-limited gonadotropin-* f% p% i3 k8 l. G1 G1 W2 q
independent precocious puberty, which is also known6 ?" h) H& p# ~+ X/ _
as testotoxicosis, may cause precocious puberty at a1 l7 E/ x% ]  Z6 c& K; }
very young age. The physical findings in these boys8 N4 |: A" t0 s3 Z7 M& N8 Y6 k- E
with this disorder are full pubertal development,
4 N: d$ n& d$ g! xincluding bilateral testicular growth, similar to boys4 }7 V6 G$ h+ ]' u$ o* A
with CPP. The gonadotropin levels in this disorder
5 t8 a. u' }. P% t, c5 Iare suppressed to prepubertal levels and do not show
# ?# m7 A9 N& A7 }; j# w0 |8 vpubertal response of gonadotropin after gonadotropin-
( {. h2 n, \1 `6 Z8 a  Breleasing hormone stimulation. This is a sex-linked
7 w6 ]( ?4 e+ P0 ^autosomal dominant disorder that affects only
+ u5 R! O7 j- ?: }) Zmales; therefore, other male members of the family
, `# u( c2 K! }1 t+ u0 W, ymay have similar precocious puberty.3
& }" P$ Y/ g# y( G! N& [8 _In our patient, physical examination was incon-
" D' `, m3 V" Z1 Dsistent with true precocious puberty since his testi-7 g- T3 Q/ }* [6 n5 Q; r7 {' ?: Z. D
cles were prepubertal in size. However, testotoxicosis
5 Y6 Z/ h& D' ^% @* P3 J( I  m9 lwas in the differential diagnosis because his father: h* P# q: l) \7 A/ T+ G
started puberty somewhat early, and occasionally,; e: u5 p3 ^! G" A: L
testicular enlargement is not that evident in the, \+ y7 e+ m0 t" p: H. B. |
beginning of this process.1 In the absence of a neg-
1 m: ^% ?& J9 B1 D) v% `9 mative initial history of androgen exposure, our* X* B9 e" U! \$ m; R( A" H
biggest concern was virilizing adrenal hyperplasia,
5 t, w% i# u: |1 K0 e; C$ beither 21-hydroxylase deficiency or 11-β hydroxylase
2 f( d" z  x& f* Ndeficiency. Those diagnoses were excluded by find-: q- `" s2 E! U1 V% c1 d1 ~+ W
ing the normal level of adrenal steroids.1 d8 m" Q3 r0 m, z: }: Q0 k
The diagnosis of exogenous androgens was strongly
/ Q; w' V; W5 ^$ ?; E% G7 [0 o7 rsuspected in a follow-up visit after 4 months because
) ~" G5 F! f" L" Hthe physical examination revealed the complete disap-
& i4 d6 r+ w4 Y& w4 z+ f( Q% ~pearance of pubic hair, normal growth velocity, and) q3 ^6 ?8 @  X8 O% e
decreased erections. The father admitted using a testos-- x3 {9 @/ h* f2 s. Y
terone gel, which he concealed at first visit. He was; y6 a4 G" V8 B" b
using it rather frequently, twice a day. The Physicians’) f1 j8 h& w. @. J! W3 u0 a; a
Desk Reference, or package insert of this product, gel or/ |/ T( }1 _4 ^5 ^" ?
cream, cautions about dermal testosterone transfer to
4 ]3 J1 A% H1 j- vunprotected females through direct skin exposure.4 K( m4 G* t0 }5 z! ]8 a
Serum testosterone level was found to be 2 times the" m* Z' h9 u) J3 e/ d3 R* k
baseline value in those females who were exposed to" T$ Z% ^3 D0 T
even 15 minutes of direct skin contact with their male
+ ~( |, u% ?6 W  D9 Tpartners.6 However, when a shirt covered the applica-
$ B2 {; l7 ~# K6 ?3 s% Mtion site, this testosterone transfer was prevented.
" o' w2 T* Y  a+ Y; kOur patient’s testosterone level was 60 ng/mL,+ P8 y8 P9 y+ B! G# P
which was clearly high. Some studies suggest that9 W9 }7 c( _1 J9 l" Q- S
dermal conversion of testosterone to dihydrotestos-
' a$ o. G/ l6 N+ A- A) Kterone, which is a more potent metabolite, is more1 H/ i, c) u: R) u& Q6 c
active in young children exposed to testosterone/ B! k% b8 g9 _( G
exogenously7; however, we did not measure a dihy-- F% h" o* m: {' V6 L/ Y7 C% Y
drotestosterone level in our patient. In addition to2 s6 C: M3 g: r$ {) C" c
virilization, exposure to exogenous testosterone in
2 T5 V# v1 g' |" Achildren results in an increase in growth velocity and
; m! p5 t+ [+ d, a% `' [( badvanced bone age, as seen in our patient.8 g. Y2 t5 F! R8 U6 d
The long-term effect of androgen exposure during
2 }% u; ]% W+ ^' Q. y1 Z% P2 o* v% x) Wearly childhood on pubertal development and final* t% `0 @( ^9 J  ?# M: ~8 f
adult height are not fully known and always remain# G: P$ {8 j1 P" T2 x, _
a concern. Children treated with short-term testos-
1 }' d/ @* W* Z" t9 N' ?terone injection or topical androgen may exhibit some3 H! H1 u& Z! s; j9 e
acceleration of the skeletal maturation; however, after5 }- d9 P* P( k+ l1 c% x) ^5 z
cessation of treatment, the rate of bone maturation+ y8 j* |8 Q5 f/ H9 J8 V7 |9 L
decelerates and gradually returns to normal.8,9" y+ U# E9 C- t- p( Q
There are conflicting reports and controversy) |* m' f, l7 `. ^) c3 ]+ K
over the effect of early androgen exposure on adult6 g2 }) E# ?3 M/ _
penile length.10,11 Some reports suggest subnormal
7 G1 G$ h% e# M# J( `adult penile length, apparently because of downreg-
" i3 R4 o9 {. \  v. n% gulation of androgen receptor number.10,12 However,% h: e; d% `$ v) E5 i/ R
Sutherland et al13 did not find a correlation between
5 ~' N6 U6 B3 k& ^0 Hchildhood testosterone exposure and reduced adult
7 x6 l4 H. e8 Y3 o/ P. ?: W+ l8 Rpenile length in clinical studies.
9 U! {! [1 U) a8 V$ a, dNonetheless, we do not believe our patient is
8 v& v5 g5 q) f# v7 k9 u; fgoing to experience any of the untoward effects from$ J, ?$ _8 M/ V, p! q
testosterone exposure as mentioned earlier because
8 f' K  ~6 D, ^. Pthe exposure was not for a prolonged period of time.4 M% B" a( o! |5 w7 K) V% |
Although the bone age was advanced at the time of
& r8 c) B& W7 ?9 q4 Y: |diagnosis, the child had a normal growth velocity at
! \! G% G) s( ^# B" L; Athe follow-up visit. It is hoped that his final adult
7 |* x9 I: s7 @& s) Y$ k- c! nheight will not be affected.
9 z, f' S! q" l/ I1 e0 xAlthough rarely reported, the widespread avail-/ q6 ?6 c* y  P* M( w
ability of androgen products in our society may- |. J) F* s9 c4 C& W0 c9 ?
indeed cause more virilization in male or female/ t- O7 z! q! Q. _* B
children than one would realize. Exposure to andro-
0 t" b3 o0 v% B4 B* Q% \gen products must be considered and specific ques-
# ^  T' L  g# ntioning about the use of a testosterone product or
7 W0 L2 C( D/ u' E2 _gel should be asked of the family members during2 L) c+ c1 c' `9 j2 m2 Z; M: v
the evaluation of any children who present with vir-% o9 _+ R: c# v: H
ilization or peripheral precocious puberty. The diag-
8 y  o( @3 _; \2 E/ c5 `nosis can be established by just a few tests and by  g( g6 n/ c- G' P9 f1 R
appropriate history. The inability to obtain such a
7 B! u: Z( e  P2 Xhistory, or failure to ask the specific questions, may/ q5 m, j3 S9 q$ G: J3 \$ z) W8 B
result in extensive, unnecessary, and expensive
# e5 c5 N5 e0 Z! Iinvestigation. The primary care physician should be9 ?8 N; L# k+ s- }. M5 R/ a3 t) ~
aware of this fact, because most of these children
3 q: k- w2 F( S# T  @, B* y7 zmay initially present in their practice. The Physicians’
( [( h0 R" o. I. K) B0 N- ADesk Reference and package insert should also put a
8 _6 i4 ]) i+ L( P% s( y2 j% Mwarning about the virilizing effect on a male or
9 d( b4 u+ [& H5 o) rfemale child who might come in contact with some-
; V/ m  |' }* i% o( i, b% yone using any of these products.# B  M1 O& R+ k  C9 F
References# a! v; a  a: O& D; `- }
1. Styne DM. The testes: disorder of sexual differentiation$ G5 f& Y% ?* V9 s" R- E. `
and puberty in the male. In: Sperling MA, ed. Pediatric
7 k7 z0 U: I, m/ k( P. ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' b  \: v& |, N2 `2002: 565-628.
# {- b/ j  @& w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 h; t# K& y2 \
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
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?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

% h$ s( Q! x5 n* O- z1 d8 I2 W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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