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Sexual Precocity in a 16-Month-Old9 _+ k* r" @( ?& ^) t1 |* E1 s
Boy Induced by Indirect Topical
. Y, n* I, {0 w7 wExposure to Testosterone7 H8 `/ g' M! b# {$ R6 ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) Y0 v5 |0 }4 R% ~and Kenneth R. Rettig, MD1
2 e$ p2 e' g9 MClinical Pediatrics% s% K1 e3 E) ~7 P% I
Volume 46 Number 6
" ^  Z! I. `' X( K2 U- xJuly 2007 540-543% R& j4 n4 c0 `, O% _0 D: ?
© 2007 Sage Publications
  G: o2 ]9 T! f5 s- K% j) J/ w10.1177/0009922806296651* E6 [5 n9 p6 [* v8 X4 d5 ~5 l
http://clp.sagepub.com
2 V% r2 ]( X7 w' W6 Bhosted at
; K( X# F  K2 uhttp://online.sagepub.com
: F  [3 s$ t$ M' T! H. g5 D# DPrecocious puberty in boys, central or peripheral,3 R' _1 k2 L" O! {  h
is a significant concern for physicians. Central7 v: d0 H4 v, W' C* }( f2 m0 l
precocious puberty (CPP), which is mediated) a9 [! e8 T4 }, f! ^$ L
through the hypothalamic pituitary gonadal axis, has
2 i9 R1 x# |% z+ @a higher incidence of organic central nervous system
0 p$ I6 ?# s4 y4 k$ C+ Ylesions in boys.1,2 Virilization in boys, as manifested( m7 l4 ^- u8 g  T" G2 I
by enlargement of the penis, development of pubic
: A5 [& f& j3 M/ A( ahair, and facial acne without enlargement of testi-
. V; r+ `6 F) R4 U+ ?4 I3 Zcles, suggests peripheral or pseudopuberty.1-3 We/ i) I0 W; s- F" u8 p
report a 16-month-old boy who presented with the
2 R! ?: f/ F# v% w$ jenlargement of the phallus and pubic hair develop-
, j" r5 K2 B6 S) O" ?8 kment without testicular enlargement, which was due  S8 \% l7 F3 |5 [
to the unintentional exposure to androgen gel used by3 k, x6 V4 \8 E4 r
the father. The family initially concealed this infor-
7 I9 E; M2 o' n8 Emation, resulting in an extensive work-up for this
' z6 T9 N  \0 p( [5 x" `child. Given the widespread and easy availability of) I1 D' \7 \) l3 N: z+ X
testosterone gel and cream, we believe this is proba-
+ z! P8 c2 v# D: Cbly more common than the rare case report in the
+ A3 {, f. D5 e4 f* u5 ~8 Xliterature.44 z/ a% l7 [. m  v1 ^! o' q
Patient Report" Z2 N, W' I) \) N* l* }  \$ F
A 16-month-old white child was referred to the
: `+ L0 {& ?8 L: q$ Fendocrine clinic by his pediatrician with the concern( @+ ]0 v) H: A% `3 l: A
of early sexual development. His mother noticed
" E, @& X  p9 ]- D( K) _light colored pubic hair development when he was. [! M, r3 Z, i' S
From the 1Division of Pediatric Endocrinology, 2University of2 t# ~5 U/ ^0 _. Y4 n
South Alabama Medical Center, Mobile, Alabama.7 z. C; g  r" [( l
Address correspondence to: Samar K. Bhowmick, MD, FACE,- r; J) l& l3 c9 \
Professor of Pediatrics, University of South Alabama, College of
% Q& g! ]$ l' o8 r: {5 \5 hMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# e" Y% R& B" f  \% T
e-mail: [email protected].
( a1 c& R: n8 }4 ?$ D7 eabout 6 to 7 months old, which progressively became
, L+ B+ x. J7 q! W4 udarker. She was also concerned about the enlarge-! `! s! B* H- U, z
ment of his penis and frequent erections. The child
7 v# N( q7 w" V, w1 [1 K# uwas the product of a full-term normal delivery, with
; [1 j. v. E( W+ |1 `' V( o6 qa birth weight of 7 lb 14 oz, and birth length of
) u$ I& A; v8 }. e20 inches. He was breast-fed throughout the first year
. W. z* ]" ]+ x! M/ q% t% Jof life and was still receiving breast milk along with
6 A+ O, A  \& I5 y  s' q, osolid food. He had no hospitalizations or surgery,
$ Y! |' n& t, V( Wand his psychosocial and psychomotor development! h; |7 R$ F: J) p! ?; _3 }
was age appropriate.
4 n/ |! H$ h0 v& }" P  }$ u2 BThe family history was remarkable for the father,/ H- a" }5 n6 |( I% w# C
who was diagnosed with hypothyroidism at age 16,
; c$ M4 j5 m) y, O- B' awhich was treated with thyroxine. The father’s
0 j0 @$ G" z$ _6 {$ ~height was 6 feet, and he went through a somewhat
) M  t5 y7 b. _* P) Iearly puberty and had stopped growing by age 14.& B; E+ A* p; ~% e
The father denied taking any other medication. The
5 \! ]' A# k+ Q; f3 @' gchild’s mother was in good health. Her menarche
) s4 i+ T) E3 I+ X/ U  X$ b8 kwas at 11 years of age, and her height was at 5 feet+ }) q' @+ o$ e) b
5 inches. There was no other family history of pre-
1 b1 N" R0 ]. o: ~% L4 ]+ Scocious sexual development in the first-degree rela-
, j4 }  A( A7 f7 ytives. There were no siblings.
) O# p& q% R, UPhysical Examination# b& m' m8 e2 i0 O0 M' V. N" F. Y
The physical examination revealed a very active,
; b2 Q# i+ o0 ?0 G! p0 N3 @/ G" }playful, and healthy boy. The vital signs documented- n  G4 A. L' F
a blood pressure of 85/50 mm Hg, his length was
0 \- w! {& U5 ~. g# q90 cm (>97th percentile), and his weight was 14.4 kg
% y* Z. z! A% y- Y9 G(also >97th percentile). The observed yearly growth* i" I' M! I2 x+ ?9 e6 w! @
velocity was 30 cm (12 inches). The examination of
6 T/ k4 a2 U) P( Nthe neck revealed no thyroid enlargement.  `" u. ?, @; z# x/ G1 V
The genitourinary examination was remarkable for; T0 L, R; H' d6 n
enlargement of the penis, with a stretched length of
7 }9 L( Q3 o- d: t0 s: D. ]( Q% k8 cm and a width of 2 cm. The glans penis was very well& p/ c+ }% l$ o, d$ M. j* F5 y
developed. The pubic hair was Tanner II, mostly around
- ^. h( l, G0 d+ _, Q540
  f* n% P: j' B  vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( |5 p, l. b% [# Athe base of the phallus and was dark and curled. The1 U( _4 e% N% I( w
testicular volume was prepubertal at 2 mL each.  E, H- H# T! |. J! G$ L, n( ~
The skin was moist and smooth and somewhat
# I( }- K  u. ^. @' voily. No axillary hair was noted. There were no
0 X4 w& E! T* C$ X' a+ {abnormal skin pigmentations or café-au-lait spots.
  `! B& t6 g; O4 f; R/ a( {Neurologic evaluation showed deep tendon reflex 2+
) S7 B! b$ T0 r& C! }bilateral and symmetrical. There was no suggestion- J) ^( t+ [& b. ^/ \8 Z& {" n. ^
of papilledema.
: z- K* G4 j- o. N/ |  N: oLaboratory Evaluation
6 R4 @6 ]. I1 r- t0 C* sThe bone age was consistent with 28 months by
+ n4 X( R) I* g& h( \using the standard of Greulich and Pyle at a chrono-
9 o; Q8 V- S: v& E) llogic age of 16 months (advanced).5 Chromosomal- j5 n0 E7 }' }. f2 `' \$ L
karyotype was 46XY. The thyroid function test
/ I: k, L" x& {* Tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, T0 h- b) Q( W. w
lating hormone level was 1.3 µIU/mL (both normal).& N. ^( E, G& M  c; [9 i
The concentrations of serum electrolytes, blood, ]5 y$ a; c" X$ ~% a+ ^, A7 ?
urea nitrogen, creatinine, and calcium all were. m* U  H) ^  l  E( v2 L
within normal range for his age. The concentration. M$ G! K: ?$ M; R' z
of serum 17-hydroxyprogesterone was 16 ng/dL! J% I( N9 O" y
(normal, 3 to 90 ng/dL), androstenedione was 20
3 [# H7 J3 M$ O9 x, `+ e* Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 M  P2 H* m7 |3 F2 Q% s+ g2 z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 I- ?+ Z" }% F# |# C4 l- ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ _! i+ f/ K7 S& a3 l
49ng/dL), 11-desoxycortisol (specific compound S)
  e; C  \0 y3 X: O9 rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 K8 [; y: F8 K# G+ d; g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: v7 @5 Y9 y& r0 ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- \$ j- M6 `* d5 s+ mand β-human chorionic gonadotropin was less than4 J# I! D6 n$ l  D8 U3 }, I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# g4 @/ z1 y2 z$ H. B- [stimulating hormone and leuteinizing hormone
9 K5 G. p* X3 k+ @; z& {concentrations were less than 0.05 mIU/mL
- `/ W! o" J" P7 m! D- R: H* D7 \(prepubertal).
& I; d3 m% z, D3 `8 J7 d" l+ SThe parents were notified about the laboratory4 M: t/ C" B3 M' P) S! m7 v0 f
results and were informed that all of the tests were
+ x7 `* g% E* j0 pnormal except the testosterone level was high. The
+ Y$ `( ^9 T4 X1 ?$ j$ N' Qfollow-up visit was arranged within a few weeks to4 V, k" j+ z. K7 d, Z( V6 d1 c
obtain testicular and abdominal sonograms; how-
. T2 N( h; V- J8 h: kever, the family did not return for 4 months.+ t: D, O5 i9 i) f# w4 g
Physical examination at this time revealed that the7 J9 r& k; N5 o; a
child had grown 2.5 cm in 4 months and had gained0 R0 K: K2 C3 d  u1 L4 H
2 kg of weight. Physical examination remained7 Y( t0 z4 j( C9 h" S- X
unchanged. Surprisingly, the pubic hair almost com-
; `8 }6 A, A# S( u  G7 P7 Cpletely disappeared except for a few vellous hairs at2 G- W* d7 ]9 W3 q, B2 o' h
the base of the phallus. Testicular volume was still 2% K3 I* v. b$ f& R# \7 x* C
mL, and the size of the penis remained unchanged.8 A0 B5 `  n/ Z) u% K
The mother also said that the boy was no longer hav-4 ~% x0 l( _1 e, R! F: R
ing frequent erections.5 g8 i; J4 p$ M
Both parents were again questioned about use of
8 F! N6 M  Q; x. |any ointment/creams that they may have applied to9 f% L7 o# [# U0 x9 p# |
the child’s skin. This time the father admitted the
3 Q& t3 y6 |" ATopical Testosterone Exposure / Bhowmick et al 541
- G, h- J# @5 J) |+ b" q1 Muse of testosterone gel twice daily that he was apply-* C2 m( e- l' T
ing over his own shoulders, chest, and back area for
# o" B  w- |8 K6 Ma year. The father also revealed he was embarrassed
/ T- ?( J) I5 f. |: Q  H  ]6 Mto disclose that he was using a testosterone gel pre-8 c: l3 p) I" \- D+ v* E
scribed by his family physician for decreased libido
9 l5 }! M7 H6 ^# D/ N. asecondary to depression.
/ F2 }( `  Q0 c5 O1 r+ KThe child slept in the same bed with parents.
$ [7 ?% {' @1 ^  s1 M5 E% s- q" QThe father would hug the baby and hold him on his
: s) v( o; Y( E. S) g1 p  echest for a considerable period of time, causing sig-+ k  l! O( I1 v" c3 Z  d
nificant bare skin contact between baby and father.
; C! P* ^6 F: V6 CThe father also admitted that after the phone call,
7 A: T1 |* j& Q3 g! R4 H$ _when he learned the testosterone level in the baby
. v4 W/ Y' ^1 l3 s8 t. Xwas high, he then read the product information
& @9 W: m% y! B* Apacket and concluded that it was most likely the rea-) K* r8 D8 U# a1 o! ?, w8 |  x
son for the child’s virilization. At that time, they
1 N$ M9 K, N8 Qdecided to put the baby in a separate bed, and the
3 D0 ^& a2 E$ w3 V8 n5 Zfather was not hugging him with bare skin and had6 n$ A: _- Q/ C6 N
been using protective clothing. A repeat testosterone/ k1 }$ j% l/ R) C: C2 L# V+ u5 k* X5 j
test was ordered, but the family did not go to the( ^/ F3 c& A& C3 f& i9 }, K
laboratory to obtain the test.
7 x# P$ F; D* u% V9 C/ }' _% xDiscussion8 ~' c! |$ u$ W8 |
Precocious puberty in boys is defined as secondary( h) c. D6 ?" o% s, T. ], X
sexual development before 9 years of age.1,49 V2 S# T+ Z+ P8 ^. a
Precocious puberty is termed as central (true) when, a! M& H* L( C1 o8 `: q1 L
it is caused by the premature activation of hypo-$ l0 ^" j* J+ L5 |* }& m
thalamic pituitary gonadal axis. CPP is more com-
/ A, a  I8 b$ x9 d: E0 vmon in girls than in boys.1,3 Most boys with CPP' }0 a2 a5 E2 w" O. S: w6 l0 E
may have a central nervous system lesion that is8 X- V% B. A: t5 F
responsible for the early activation of the hypothal-. y7 t! g; F, D# y$ O; h  g
amic pituitary gonadal axis.1-3 Thus, greater empha-
) p% a4 N7 E% Hsis has been given to neuroradiologic imaging in
6 D/ `# ~0 F# a- j1 c9 O2 y& G( ?2 Fboys with precocious puberty. In addition to viril-
5 s# R4 u( f! y4 x" B8 W* T9 M$ Rization, the clinical hallmark of CPP is the symmet-* @8 [: v* q) k* Y
rical testicular growth secondary to stimulation by! I9 M5 v4 f, b1 L6 i( s+ y
gonadotropins.1,3
7 G9 |! O; ?  T, [* a8 U2 l* uGonadotropin-independent peripheral preco-
( R9 O8 l2 X! Q; |cious puberty in boys also results from inappropriate8 s, y; J! u* P( C! y) A# g
androgenic stimulation from either endogenous or. y4 Y- L7 \2 t8 }
exogenous sources, nonpituitary gonadotropin stim-
+ I0 J- B7 S% `6 p4 c1 uulation, and rare activating mutations.3 Virilizing8 D6 G2 _; M7 n4 L! J. D0 k2 @
congenital adrenal hyperplasia producing excessive
7 O$ T' ?$ [5 q5 R; E9 }/ x( Qadrenal androgens is a common cause of precocious6 j: a2 _1 t" E4 ^
puberty in boys.3,4/ H8 d$ i/ m8 V+ a
The most common form of congenital adrenal
" D3 n6 O5 E. p! L' d# Xhyperplasia is the 21-hydroxylase enzyme deficiency.# |9 q8 u* W6 Q0 E8 M" ^" Q/ m
The 11-β hydroxylase deficiency may also result in
4 l4 J) a& k- J& R: e7 X/ \excessive adrenal androgen production, and rarely," X" N* t8 _5 c6 N/ f
an adrenal tumor may also cause adrenal androgen6 s4 C4 j, ^! |2 O5 n
excess.1,3
- [# G9 E) n" I- K9 Z( Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" x/ N0 }" S/ c# t8 h6 U0 i4 ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 A& o+ z" Z" I& k8 ^A unique entity of male-limited gonadotropin-! ?& W( F6 A; t# r" b
independent precocious puberty, which is also known, d6 B; {4 o; k/ t" r; n
as testotoxicosis, may cause precocious puberty at a
3 G' Q" D% i: R' T3 G$ overy young age. The physical findings in these boys
( b9 f. Q5 {! uwith this disorder are full pubertal development,, \' h0 i6 F& S
including bilateral testicular growth, similar to boys
% V" Y* E2 |& Y4 t1 ~  O1 Xwith CPP. The gonadotropin levels in this disorder- k2 r# ?/ T- O, U( X
are suppressed to prepubertal levels and do not show
7 P5 X1 E; N+ a1 k; Q; Mpubertal response of gonadotropin after gonadotropin-$ f1 E) y2 n8 b9 f/ u7 D
releasing hormone stimulation. This is a sex-linked( }' r1 J0 w8 N- n
autosomal dominant disorder that affects only
( {) Y. S1 b5 W) Cmales; therefore, other male members of the family4 J: K  s5 K0 {  z* ]! A7 l( j. F# y
may have similar precocious puberty.3  F& f: ^4 r: t' I# {: p5 }" h# s
In our patient, physical examination was incon-7 ?  m% {8 h- r/ U. p! n* s
sistent with true precocious puberty since his testi-
' S4 e; p9 a( S  X9 v$ T$ t) Jcles were prepubertal in size. However, testotoxicosis6 r  L# F; [* G8 U
was in the differential diagnosis because his father
4 R1 S. V6 A% {, kstarted puberty somewhat early, and occasionally,
2 H( R& X8 I( B! W/ ytesticular enlargement is not that evident in the
9 z( w. {3 P4 m$ H, e$ Y) Xbeginning of this process.1 In the absence of a neg-
0 s9 S$ C3 w  P8 Uative initial history of androgen exposure, our
% A* c* F7 @. S- S4 @! rbiggest concern was virilizing adrenal hyperplasia,
3 c3 y. {' c6 M! C9 \9 meither 21-hydroxylase deficiency or 11-β hydroxylase
  a( a6 c' Q/ ?! n0 [$ K: }1 xdeficiency. Those diagnoses were excluded by find-
  C5 t# @* [' b  l* H/ ving the normal level of adrenal steroids.
3 P8 ^" i1 Q) m: @3 FThe diagnosis of exogenous androgens was strongly! g5 T2 i8 m+ @. |0 W6 d
suspected in a follow-up visit after 4 months because- d8 l, ]+ s7 Z9 ~, d, s" n
the physical examination revealed the complete disap-8 F, d, H0 K, t4 @0 N
pearance of pubic hair, normal growth velocity, and7 X, e; G+ a7 t! M
decreased erections. The father admitted using a testos-( {8 C6 v# l/ G% M" C- Y
terone gel, which he concealed at first visit. He was5 C/ \: j  Z& k1 `* P" }  N& q6 j
using it rather frequently, twice a day. The Physicians’
* u1 N) P- z' O' C% D  eDesk Reference, or package insert of this product, gel or" Q0 T* i/ r2 F  v* v% m
cream, cautions about dermal testosterone transfer to
4 u! h2 }: r% z/ y( n+ Y. r; h& ?+ cunprotected females through direct skin exposure.
5 E; h) G2 W3 g* `Serum testosterone level was found to be 2 times the
' `9 s# V" m9 X4 Q) a3 Jbaseline value in those females who were exposed to
0 O; s9 ^8 a4 d" G$ X+ geven 15 minutes of direct skin contact with their male
# z7 a: l6 M' k! ?partners.6 However, when a shirt covered the applica-
. K( F3 d2 G; j7 i! ~tion site, this testosterone transfer was prevented.; {2 H  M9 `: o, v6 Z* A1 y
Our patient’s testosterone level was 60 ng/mL,
0 u' N) u# M7 w9 x+ ^which was clearly high. Some studies suggest that
& V* o! C& d7 L* w* [" h, @dermal conversion of testosterone to dihydrotestos-
/ J! O' Y) D7 J, i. }terone, which is a more potent metabolite, is more
% y0 H; ?& ?/ }/ U1 ~  _( |active in young children exposed to testosterone+ {; n* x9 |0 q0 [; q; e2 b) v
exogenously7; however, we did not measure a dihy-* |) ~, s: W& w  i
drotestosterone level in our patient. In addition to; z: }5 ~: Q( Q% N
virilization, exposure to exogenous testosterone in
( m+ Z* h0 S) I( v( [children results in an increase in growth velocity and
7 S! m8 R! c9 ^3 l0 i( m8 k2 }1 yadvanced bone age, as seen in our patient.) K6 X# J6 H4 x: g8 D
The long-term effect of androgen exposure during9 _0 _9 S  D2 B, H: X
early childhood on pubertal development and final% j$ L: t; n$ M; t% n
adult height are not fully known and always remain
" i, g1 z$ B' R: \a concern. Children treated with short-term testos-
' I( [" \( y7 O0 \$ `9 Fterone injection or topical androgen may exhibit some
0 P/ f% o3 C. b# w% y* a5 D  Iacceleration of the skeletal maturation; however, after
; |. x8 @# C! V6 w2 w' ]cessation of treatment, the rate of bone maturation+ ?: K0 p5 k5 U/ R/ W
decelerates and gradually returns to normal.8,9* g1 z3 Y5 t! l7 [
There are conflicting reports and controversy
0 V4 G; @- I0 z) `over the effect of early androgen exposure on adult6 w$ V/ G: s4 _) f
penile length.10,11 Some reports suggest subnormal7 k3 x+ n' O, F
adult penile length, apparently because of downreg-
* P8 q. S" s  P% U& K5 O2 Yulation of androgen receptor number.10,12 However,
, t7 D8 E5 _9 d9 s* |5 ASutherland et al13 did not find a correlation between
5 _" ?' F! y2 Xchildhood testosterone exposure and reduced adult$ T  x2 I0 z- E$ J
penile length in clinical studies.0 ]  X$ h( M2 k6 ^' v
Nonetheless, we do not believe our patient is
: F0 x) H3 |- v5 c+ i9 O/ H! N6 pgoing to experience any of the untoward effects from. a/ J7 w* B' s$ G) Q3 l
testosterone exposure as mentioned earlier because
# L) F* ~0 g5 [0 y7 ]/ n+ wthe exposure was not for a prolonged period of time.( R9 b/ N& w4 n! P8 o# L5 R
Although the bone age was advanced at the time of7 p/ U8 ^* Y* Z5 _( k
diagnosis, the child had a normal growth velocity at
' h$ F0 m6 e. e& Tthe follow-up visit. It is hoped that his final adult
, U- I* b2 _0 C% M' j3 y% [- Hheight will not be affected.4 I2 w7 A# I! f2 V
Although rarely reported, the widespread avail-
7 g  w1 W$ C& [ability of androgen products in our society may3 S$ U3 i- ]8 e7 c% I5 E$ v
indeed cause more virilization in male or female
' H4 R2 O- I8 U( ]' Dchildren than one would realize. Exposure to andro-
" U+ ]/ f4 x% H' ]7 V; dgen products must be considered and specific ques-
/ R/ e- G# {, t/ g5 |! U2 _tioning about the use of a testosterone product or
/ n7 \1 E* k  y9 d1 Tgel should be asked of the family members during7 a# Y. q" Q. v6 ]% D$ ]
the evaluation of any children who present with vir-
- Q* I. N6 a6 @9 {( L8 kilization or peripheral precocious puberty. The diag-
8 G5 Q. a) L- e+ H4 S& ?nosis can be established by just a few tests and by
8 N, B* x0 E1 e5 }5 i  A  n0 Fappropriate history. The inability to obtain such a
8 _5 Y7 W& I: L& s2 i$ bhistory, or failure to ask the specific questions, may
  P2 b% A' B! F5 |' h. Sresult in extensive, unnecessary, and expensive8 m: B8 s+ b1 I# U! k+ S& ], Y
investigation. The primary care physician should be
1 q$ v. r9 |3 Caware of this fact, because most of these children, c2 K  P# f# `* f: ]8 C4 E
may initially present in their practice. The Physicians’
! k6 k( O3 R7 PDesk Reference and package insert should also put a0 p! ?" X% |, I  x- G4 A2 u! h! D
warning about the virilizing effect on a male or. @; j8 x4 j4 M6 z' Q' ^) E- Y
female child who might come in contact with some-
2 P% M: I4 d, S# V) t9 x' V, Yone using any of these products.
; \# f2 w6 ^6 [% W; BReferences! N% c+ u* R7 ~/ |* {3 N2 A
1. Styne DM. The testes: disorder of sexual differentiation7 N' l8 Q, t- T5 R
and puberty in the male. In: Sperling MA, ed. Pediatric) A7 n* l/ I) G. ?) z( `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ Q4 d$ I; ?5 r6 L7 I6 j5 l5 m2002: 565-628.
- ]1 o$ z/ u# f0 S3 _, d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 ]8 e6 t1 V# `' A- ~puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" S$ q; h  c+ u+ Z+ r. QBoy Induced by Indirect Topical0 Q8 b( s5 @/ p5 Y, q+ b% n
Exposure to Testosterone
2 u! J; M, v% u8 k! sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; G' y2 }! ^+ A/ T& wand Kenneth R. Rettig, MD1+ X; y9 a; C4 H9 @
Clinical Pediatrics0 X$ x' }( S% x7 ~+ @8 e& S) O
Volume 46 Number 6* M( k- F/ A9 N0 y7 M6 Q  C$ X
July 2007 540-543- {; x$ @6 [* E9 g: \4 U/ q% o* m% k
© 2007 Sage Publications1 w4 n8 v% q6 e2 X. C0 I
10.1177/0009922806296651
  |/ ]' _3 l. @- z1 z7 ]http://clp.sagepub.com3 e* F$ ], e( E  g
hosted at/ `. b( \+ X# p) j
http://online.sagepub.com( V5 L6 n" v; H& u9 C, J- x
Precocious puberty in boys, central or peripheral,6 F$ B9 U4 a$ @; Z
is a significant concern for physicians. Central
: J/ ?4 j: d/ qprecocious puberty (CPP), which is mediated
  i( t6 ?8 B. A/ m$ C* wthrough the hypothalamic pituitary gonadal axis, has
+ a  X; z% W; x  ]* ha higher incidence of organic central nervous system
" a' C: r4 d0 Z  j' x  ^lesions in boys.1,2 Virilization in boys, as manifested% `# u3 U' P, c9 F: r' _
by enlargement of the penis, development of pubic
3 w% c* Z7 g$ L" w4 o0 z, a2 Ohair, and facial acne without enlargement of testi-
) G! k1 o( I/ ]5 ocles, suggests peripheral or pseudopuberty.1-3 We
% M+ L6 W% q; u, P  Q5 @report a 16-month-old boy who presented with the
/ v. y) r; b( {! n; zenlargement of the phallus and pubic hair develop-
. V2 b5 m) {! {% q3 Z5 xment without testicular enlargement, which was due8 {6 X/ i3 a; W
to the unintentional exposure to androgen gel used by) z1 i0 t) W9 Y1 Y
the father. The family initially concealed this infor-
1 u9 W- n! O* x. m  Smation, resulting in an extensive work-up for this. a, Z; H% s- o& f
child. Given the widespread and easy availability of
) O0 W6 ~4 r0 W* d  f1 Dtestosterone gel and cream, we believe this is proba-1 ~/ k; h4 Q% H; ]# M
bly more common than the rare case report in the/ t3 u9 K2 J' `
literature.42 ^: f/ y; X0 F* b
Patient Report2 M3 w, k8 ]' y( P. `
A 16-month-old white child was referred to the: F2 ^4 V& `  [7 u: X$ l; R5 O2 g
endocrine clinic by his pediatrician with the concern$ T8 G8 E, w4 K3 _9 J
of early sexual development. His mother noticed
/ B8 @6 x4 S* }' Olight colored pubic hair development when he was  Q2 V3 g4 U7 |4 A+ O
From the 1Division of Pediatric Endocrinology, 2University of
: P8 O, x( f* V" W1 G* d7 HSouth Alabama Medical Center, Mobile, Alabama.
4 z( }0 t" {, n" ?' V" DAddress correspondence to: Samar K. Bhowmick, MD, FACE,: U7 O1 d7 A7 x
Professor of Pediatrics, University of South Alabama, College of
; h  }; ]5 @: T% P9 U3 K# P% zMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& x* ]  K) S5 c& ^4 H" Te-mail: [email protected].
, \$ j$ p3 w4 a& ~about 6 to 7 months old, which progressively became2 C4 }6 `8 V9 @$ m7 N: e- q* ^2 |3 n" i
darker. She was also concerned about the enlarge-
6 [3 ]0 l5 g6 e1 q( I& g6 Gment of his penis and frequent erections. The child- }$ o8 b, k& U: a* _
was the product of a full-term normal delivery, with
. q5 ^5 k5 f" `a birth weight of 7 lb 14 oz, and birth length of
$ q( t2 W  n. v: a6 c20 inches. He was breast-fed throughout the first year/ K9 w2 ~/ }7 q
of life and was still receiving breast milk along with
( ?# q; u* C2 i4 k( A& l) B3 nsolid food. He had no hospitalizations or surgery," B0 F' T: s) G( i+ {1 g
and his psychosocial and psychomotor development' b; S/ w2 I+ T7 m3 b
was age appropriate.; Y' P0 M& c0 H- i' Q
The family history was remarkable for the father,
# u9 G- Q! L6 [/ xwho was diagnosed with hypothyroidism at age 16,. a5 `% m( I( O, U! o
which was treated with thyroxine. The father’s" I6 G  k& G# M; X* h
height was 6 feet, and he went through a somewhat
6 ^$ p$ g3 \' l, \early puberty and had stopped growing by age 14.  B  v+ H/ |6 U, N6 J9 b- L
The father denied taking any other medication. The+ S* k4 U1 t) @, q5 [
child’s mother was in good health. Her menarche
% j: h6 j( u% v+ Nwas at 11 years of age, and her height was at 5 feet
, m, k, _0 g6 {- d$ E4 w) S5 inches. There was no other family history of pre-, o8 n/ J+ u6 F' I
cocious sexual development in the first-degree rela-9 K3 j+ m/ p$ W
tives. There were no siblings.1 @$ X6 V1 `/ M, |
Physical Examination! p) H0 b2 `! S( a
The physical examination revealed a very active,
* O9 r# x# w5 x4 \7 a$ vplayful, and healthy boy. The vital signs documented$ K/ [3 f- p+ c3 Z/ ?! c2 v# a
a blood pressure of 85/50 mm Hg, his length was; I2 E0 J, N# j1 n) P
90 cm (>97th percentile), and his weight was 14.4 kg
3 n/ v: H1 [# m7 J, |/ O(also >97th percentile). The observed yearly growth
: p! R' A: F, dvelocity was 30 cm (12 inches). The examination of( [0 l1 b6 G  i$ w& g  F
the neck revealed no thyroid enlargement.
4 i; b: X; e/ \& sThe genitourinary examination was remarkable for
2 Z. [) m3 K$ r( Y! ~+ tenlargement of the penis, with a stretched length of
$ H& ^' Y7 e& t9 M8 |, D8 cm and a width of 2 cm. The glans penis was very well
4 h6 h0 g9 r& [2 n" V) |6 P; U) _+ ldeveloped. The pubic hair was Tanner II, mostly around
7 ^) J4 |) T( q9 D6 F- O2 \. b0 A540
, ?3 s+ y0 u5 O" u5 h8 x" [  q2 pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" ?' a$ n  X4 ^# T9 e, q
the base of the phallus and was dark and curled. The& `: c7 z4 A+ d
testicular volume was prepubertal at 2 mL each.5 C" w7 N& u( g  L9 |0 i
The skin was moist and smooth and somewhat: H# A" X! O/ S, M# ?
oily. No axillary hair was noted. There were no" d4 m) D7 Y7 b. f  _3 t. T( T
abnormal skin pigmentations or café-au-lait spots.9 z, l9 c. D/ U/ t( S3 @
Neurologic evaluation showed deep tendon reflex 2+9 r0 n% L6 T7 S- F
bilateral and symmetrical. There was no suggestion; i5 B9 x$ j" H; _4 Z4 W
of papilledema.! f* }) U, U0 |. m1 o. ^& Q6 ]
Laboratory Evaluation$ J2 x5 m2 f% \! C3 J
The bone age was consistent with 28 months by# _( w" P3 ~% E6 C' q: D9 g1 a
using the standard of Greulich and Pyle at a chrono-3 n; K3 F# l: Z
logic age of 16 months (advanced).5 Chromosomal
. X% f' G3 o3 Y% i% r0 ekaryotype was 46XY. The thyroid function test4 p1 O4 |' F" I4 G! H  {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 a4 q& |4 `, {3 m8 ]3 [lating hormone level was 1.3 µIU/mL (both normal).! {' X5 n3 `" i
The concentrations of serum electrolytes, blood
7 M0 }9 O! ]$ M% l- durea nitrogen, creatinine, and calcium all were
' M5 V- Y4 k9 Q% w" z9 Fwithin normal range for his age. The concentration
% O: @. W2 y0 G" x+ y- g# d4 N7 ?of serum 17-hydroxyprogesterone was 16 ng/dL. C8 V& K/ X( o4 L
(normal, 3 to 90 ng/dL), androstenedione was 20; J# K# C* R$ G. x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 I( G5 r7 \1 F2 B4 T# c) vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
# m4 s2 H* _0 A- E' e& jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
% V  y0 R! ]1 i* r' ]- G7 {49ng/dL), 11-desoxycortisol (specific compound S)( R4 R# l. c& _# M. e8 C6 t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 Z; ]5 Z2 v& N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# i0 z: H3 ?4 htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ l  w! g: w3 ?1 Y4 h  Eand β-human chorionic gonadotropin was less than
* g. o3 ~% R* \: _/ k5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 A  b0 x. N1 K8 v& B6 n( n+ Gstimulating hormone and leuteinizing hormone1 H- L! W8 I* X* f
concentrations were less than 0.05 mIU/mL$ j6 [- N  X1 C5 n0 }" P
(prepubertal).
( N: W+ W/ E' b- D3 N2 PThe parents were notified about the laboratory
$ X$ F  M5 d# X9 ]# p# \6 d/ yresults and were informed that all of the tests were
. D1 \/ `; @. M; j( H, Fnormal except the testosterone level was high. The2 [# ]. R  @: [0 Z5 P; m
follow-up visit was arranged within a few weeks to
7 a# ?/ [* B& A. M' i, Pobtain testicular and abdominal sonograms; how-
2 x! ^) Q' ^6 n5 Kever, the family did not return for 4 months.
. f. ^1 g* e3 [# ]Physical examination at this time revealed that the
4 ]! O* i" r4 q4 j) Qchild had grown 2.5 cm in 4 months and had gained
* l0 ~; I. ~1 j2 kg of weight. Physical examination remained/ L2 }% m+ Z% W  _
unchanged. Surprisingly, the pubic hair almost com-" e: k) S( }" C/ H$ t9 A
pletely disappeared except for a few vellous hairs at
0 ]+ {/ e5 h# g! y. Vthe base of the phallus. Testicular volume was still 22 r7 ?9 s4 r" d. M
mL, and the size of the penis remained unchanged.5 P6 Y+ ^0 R' f
The mother also said that the boy was no longer hav-7 a' m# ^  Q7 Z* C
ing frequent erections.
$ a0 `( D  l5 S& {* iBoth parents were again questioned about use of8 }  T) G" U* ?! o1 F5 K
any ointment/creams that they may have applied to
" P/ o. d: L! E7 b* H& b/ Athe child’s skin. This time the father admitted the
) y# d, A& W5 [& [Topical Testosterone Exposure / Bhowmick et al 541
; m% l; }- L! q& h6 \3 ^/ `3 tuse of testosterone gel twice daily that he was apply-! N  U/ q' S% P6 E. ~
ing over his own shoulders, chest, and back area for
% l: [  q& k& m" ia year. The father also revealed he was embarrassed
5 v* `6 G5 P* I1 vto disclose that he was using a testosterone gel pre-
. t/ k- ]' d$ tscribed by his family physician for decreased libido
2 m6 ]. h8 ~/ @/ Esecondary to depression.
  V0 q9 l: H' g$ v0 tThe child slept in the same bed with parents.
6 |! L3 N8 |3 q1 a$ s2 FThe father would hug the baby and hold him on his
0 a, p7 \! G8 _/ vchest for a considerable period of time, causing sig-
8 |: g/ N8 {" p' W0 mnificant bare skin contact between baby and father.
5 |/ E5 @' V/ s" y' W6 HThe father also admitted that after the phone call,$ j4 x0 X( Q1 M% s( s: m
when he learned the testosterone level in the baby! \) ?" X9 p* h2 i
was high, he then read the product information9 {) Y" x8 W* A0 d  c
packet and concluded that it was most likely the rea-
: a3 Z6 P9 n1 sson for the child’s virilization. At that time, they0 N0 _- H6 X+ X# _
decided to put the baby in a separate bed, and the
+ g4 v: o) N  v& `5 ~* `father was not hugging him with bare skin and had0 d5 l" N, }9 i; Q
been using protective clothing. A repeat testosterone1 G/ O# r; N2 e; y! K8 w
test was ordered, but the family did not go to the* |0 p1 ?0 J) \; s: V3 T
laboratory to obtain the test.
* [' f# i/ |# ^% [( N& G% _Discussion7 ]9 Y4 F, Y9 p/ ^4 }1 t! D" A0 k; c$ D
Precocious puberty in boys is defined as secondary0 f. n8 G! @# X6 W3 B* n( o
sexual development before 9 years of age.1,4
! P: V* u" B  O  SPrecocious puberty is termed as central (true) when
( B% H. p, n+ T6 cit is caused by the premature activation of hypo-
. z9 C3 D2 U. Kthalamic pituitary gonadal axis. CPP is more com-; [7 _. C( ~* P4 M* y
mon in girls than in boys.1,3 Most boys with CPP
, ]) }4 }5 R( k2 i" F/ t0 F: Emay have a central nervous system lesion that is
' ]' D: X% w% c& z' n9 Xresponsible for the early activation of the hypothal-
9 z' w, o( Q+ g, l4 r0 zamic pituitary gonadal axis.1-3 Thus, greater empha-
0 t6 `* Q: j; t/ l& Q+ u$ Ssis has been given to neuroradiologic imaging in: k5 N1 v4 h- D+ y6 O
boys with precocious puberty. In addition to viril-" g5 Q$ [# F5 P& h! p. E
ization, the clinical hallmark of CPP is the symmet-
9 A5 X# V) V. M% k2 ?/ A* k% b% ?+ ~rical testicular growth secondary to stimulation by# U, z1 m4 _4 i$ H& \
gonadotropins.1,3) _6 N2 `  a. Q/ o1 `
Gonadotropin-independent peripheral preco-& [# {& ~3 T2 Z1 b, p& Q& P
cious puberty in boys also results from inappropriate( |+ l' K! ?7 q* H
androgenic stimulation from either endogenous or* `* i4 u5 a3 ^/ m9 t8 t
exogenous sources, nonpituitary gonadotropin stim-
! u# B! I$ G8 tulation, and rare activating mutations.3 Virilizing! s7 w/ ]' \- y: b: P
congenital adrenal hyperplasia producing excessive
% G7 e* [+ {. T$ }; q0 |2 y: Sadrenal androgens is a common cause of precocious
3 v, N4 x! K% G8 e* e6 X' ^puberty in boys.3,44 b5 Z0 W+ K3 l+ h9 L
The most common form of congenital adrenal6 G8 M9 e3 }  \
hyperplasia is the 21-hydroxylase enzyme deficiency.; @  f( E& {+ z& G: ?7 e
The 11-β hydroxylase deficiency may also result in
! {+ ^( ^5 n# Z6 n( U4 Uexcessive adrenal androgen production, and rarely,
+ f9 n2 f, N9 Gan adrenal tumor may also cause adrenal androgen: b" g# c6 ^, t  B# R: R
excess.1,3! n, n6 u: W4 p( M$ B! M' X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. _' P4 Y$ f* y) z! X) F
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: k5 @% T3 y$ e9 u- I" nA unique entity of male-limited gonadotropin-
. |8 L; m& y4 p2 Q0 |0 p# z: Mindependent precocious puberty, which is also known
/ d# `6 ~3 @6 a8 p: [as testotoxicosis, may cause precocious puberty at a) Y' D6 w  O& v- B2 y8 w& Z5 s
very young age. The physical findings in these boys( b$ W* H- D1 p0 q4 R
with this disorder are full pubertal development,, T" o; p$ b7 l  N
including bilateral testicular growth, similar to boys1 B4 G% {5 |' \& a7 o7 `; A; D
with CPP. The gonadotropin levels in this disorder
% ]: U# ]" G6 M+ S( r4 P5 I2 [% `are suppressed to prepubertal levels and do not show
4 k. P* P. G5 s2 jpubertal response of gonadotropin after gonadotropin-1 v/ i! \" K& ?% D
releasing hormone stimulation. This is a sex-linked' p" f3 Y7 @6 K" q, y/ i: H
autosomal dominant disorder that affects only
8 ?+ Y2 k2 S. umales; therefore, other male members of the family/ }2 l, C3 c6 [4 `: }1 M
may have similar precocious puberty.3
: \  `3 P* R$ L, \; ?+ o7 nIn our patient, physical examination was incon-
" C+ _" l2 S" ^3 Y, jsistent with true precocious puberty since his testi-" H" J* N; p% j( P
cles were prepubertal in size. However, testotoxicosis
7 v% q7 h, k; L$ {  B, iwas in the differential diagnosis because his father# C; U  O# m. U5 T- i/ {  {
started puberty somewhat early, and occasionally,9 W+ Q7 l4 G6 X- s( s& k- g3 U
testicular enlargement is not that evident in the
% R+ c) `  W" Y' _/ Q- dbeginning of this process.1 In the absence of a neg-
+ N. D; I5 m( \, \# S# V+ xative initial history of androgen exposure, our
& d. v; c8 s: @. g- R' D  ?1 bbiggest concern was virilizing adrenal hyperplasia,! S& I+ x; ]  o9 F( l
either 21-hydroxylase deficiency or 11-β hydroxylase0 f/ A& s5 j; g- M2 H- B; @& z( w9 B
deficiency. Those diagnoses were excluded by find-
6 A; A& Z* v( ~( `ing the normal level of adrenal steroids.
  f- t" D- K0 }+ a* A" ]- hThe diagnosis of exogenous androgens was strongly
6 X  |- z6 O8 O" U( }suspected in a follow-up visit after 4 months because
* S$ I& o5 N- M  Uthe physical examination revealed the complete disap-
( X! Z) y4 J  o* d+ kpearance of pubic hair, normal growth velocity, and; y0 k6 ^6 `: ^" _8 E
decreased erections. The father admitted using a testos-
/ U# W. w7 q8 X6 l; Q, ]. b+ J9 Nterone gel, which he concealed at first visit. He was" G4 H! G$ c+ P7 x& L; J
using it rather frequently, twice a day. The Physicians’
4 B3 ~( J- }3 u2 J$ D; H. ^Desk Reference, or package insert of this product, gel or( @3 s; K* \. O9 E. z
cream, cautions about dermal testosterone transfer to3 D% _  ~5 f2 O5 |
unprotected females through direct skin exposure.& A9 p3 d! U# |* U  [4 I
Serum testosterone level was found to be 2 times the
: O/ \; J/ M+ E; J1 U6 Pbaseline value in those females who were exposed to  R0 W- J& z- [: W$ `& x& \" D- V/ a1 f
even 15 minutes of direct skin contact with their male9 L4 O1 @8 a; x
partners.6 However, when a shirt covered the applica-
' s9 |+ z2 R, R0 p. y. mtion site, this testosterone transfer was prevented.* u; g1 E* |2 r& J  j2 @( A) u# K0 j
Our patient’s testosterone level was 60 ng/mL,# j5 N' J3 U! B/ i: g! ~0 l
which was clearly high. Some studies suggest that* K9 `0 q& f9 I) S
dermal conversion of testosterone to dihydrotestos-7 v: ]& A# W( }: q' Y* m
terone, which is a more potent metabolite, is more' C& ^4 D9 s; p( l. A3 R
active in young children exposed to testosterone
. W, m- N$ ]: [" n  N, N8 O  L) eexogenously7; however, we did not measure a dihy-/ ~! l* N( v) m; i; N" c
drotestosterone level in our patient. In addition to
, a7 |) [* |# K3 D, o- M% `8 Rvirilization, exposure to exogenous testosterone in9 z# r3 ^8 M' y& m9 o+ K
children results in an increase in growth velocity and
4 O: S4 ^( h. O# g) a3 P8 ]3 vadvanced bone age, as seen in our patient., z) f  q) S& \6 g# V7 j
The long-term effect of androgen exposure during
) m/ |' G1 D+ l' Uearly childhood on pubertal development and final+ o* L* `% P# E( N3 M
adult height are not fully known and always remain
& b, J$ C5 j2 g' j& j/ c8 ca concern. Children treated with short-term testos-! G& Q+ i" _" [3 K7 {9 I% E0 z+ O
terone injection or topical androgen may exhibit some
; A  K+ Y8 e) k  |9 uacceleration of the skeletal maturation; however, after2 {8 y8 Q) H0 }3 n
cessation of treatment, the rate of bone maturation6 i- L, r/ \1 g
decelerates and gradually returns to normal.8,9
& ?* p' ^: n* I7 F+ oThere are conflicting reports and controversy! P, S$ ^/ d9 H/ f' E2 J
over the effect of early androgen exposure on adult
' ~) y! }( ^# j" E5 V& ~penile length.10,11 Some reports suggest subnormal
, c, H4 L3 B: U) b7 D6 Q9 f) }" \9 Padult penile length, apparently because of downreg-
" a' E7 Y. O5 f# L3 [ulation of androgen receptor number.10,12 However,
$ H( [* V( a; p2 [6 @) m& `Sutherland et al13 did not find a correlation between
) K$ k9 |3 A: E# G1 W) O$ E; Achildhood testosterone exposure and reduced adult) U) c" p5 d) Q8 x% W% c, V4 E3 ~
penile length in clinical studies." h" G& _0 v/ ?
Nonetheless, we do not believe our patient is
( `; W: d/ w0 f5 c. F) ggoing to experience any of the untoward effects from
1 e# b( J0 ~4 S9 V: V9 P* r+ R$ P- Otestosterone exposure as mentioned earlier because8 L+ H% S1 o, ?  e
the exposure was not for a prolonged period of time.
9 j. K3 q: Q/ P- P5 l5 {1 n  wAlthough the bone age was advanced at the time of
8 @2 S) ^- L& f  S6 D! Adiagnosis, the child had a normal growth velocity at
: R4 A( V( d4 `: Uthe follow-up visit. It is hoped that his final adult" b- F; C. {- @9 r* h) K
height will not be affected.
3 J. F$ D4 L1 Y# r& QAlthough rarely reported, the widespread avail-5 Q5 {& l/ F& v8 i# x6 g
ability of androgen products in our society may
$ Y6 _/ G# w* \& }' gindeed cause more virilization in male or female1 p# W9 Y+ a; K2 R
children than one would realize. Exposure to andro-) F6 B" M+ J$ g  g/ k: h9 K7 d# O
gen products must be considered and specific ques-" }& y7 i& Q: J3 U  d$ B  m( e+ k1 s
tioning about the use of a testosterone product or' B0 ?# ~) n  L+ s+ Z% z: W4 h  B3 B( @
gel should be asked of the family members during
  {2 T" u& y# J, Ithe evaluation of any children who present with vir-
* T5 I- H; H4 G2 l; g  |! Xilization or peripheral precocious puberty. The diag-5 p% D6 ?3 P; A! X' Y! Y
nosis can be established by just a few tests and by$ |  [! \3 I6 F- g0 m/ K. P+ |
appropriate history. The inability to obtain such a
+ q2 f& _$ S8 m  p. T+ E, phistory, or failure to ask the specific questions, may
( e+ y4 B3 j7 L  K" j# Iresult in extensive, unnecessary, and expensive/ T* d4 q& ?1 ^/ M
investigation. The primary care physician should be
  G# e$ m# ?# W& [aware of this fact, because most of these children- Y$ E2 \4 S  D- A; Z: _
may initially present in their practice. The Physicians’% v! c8 K; C5 J- y
Desk Reference and package insert should also put a! c  ]7 s" @& i0 t
warning about the virilizing effect on a male or6 ^9 G' K) t5 i1 q/ F
female child who might come in contact with some-
) Z# S* ^; S; J; Q# n; Qone using any of these products.$ Q. q* @& O# `) [) s1 v
References  F, t: s  G! J& d+ ?" k; W
1. Styne DM. The testes: disorder of sexual differentiation/ z* j; |- [$ ]% q9 R6 J
and puberty in the male. In: Sperling MA, ed. Pediatric
8 B$ P/ v2 ?* u- kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 h) N5 h9 x5 K2 q2 Q* R
2002: 565-628.9 N5 y, j# w! f7 f3 [2 r
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 E  N0 \9 l& s2 Ppuberty 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- Y% n+ L
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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