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Sexual Precocity in a 16-Month-Old" C2 @. {9 P4 M$ t7 B' q
Boy Induced by Indirect Topical
0 L, v* H6 @1 Q8 D( |Exposure to Testosterone
# y$ L$ \  w0 K; v. _, A* `0 MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 U# v/ T3 w. Land Kenneth R. Rettig, MD1# q9 _+ T, T  b/ O) P
Clinical Pediatrics- q5 ^' T! Y* z) V
Volume 46 Number 6+ I7 ]' d; v" V) a. t
July 2007 540-543
4 R5 C3 B* L& ]! a5 p2 s© 2007 Sage Publications( X- G0 z' a- b
10.1177/0009922806296651! U8 n4 s  t4 n+ f/ }% }; [
http://clp.sagepub.com
+ p/ {: f" {% w+ p+ {hosted at
6 v1 h- R; t2 [: dhttp://online.sagepub.com
7 ?, x' I; ?, B8 B& rPrecocious puberty in boys, central or peripheral,4 Z6 }$ T- h, {) q
is a significant concern for physicians. Central+ a8 [; |/ F/ g* B9 G' ~. Z
precocious puberty (CPP), which is mediated6 r2 g- |# Q  X6 a5 B9 J* j0 E
through the hypothalamic pituitary gonadal axis, has
- r  k6 c& S. `' M& C  b+ Z% Ea higher incidence of organic central nervous system
2 G0 x6 L. v# W- p8 _2 N' `. clesions in boys.1,2 Virilization in boys, as manifested7 L# C4 W! Z' _% r' [2 r
by enlargement of the penis, development of pubic
1 E1 P  T4 L6 e9 m' T$ \hair, and facial acne without enlargement of testi-% F. M& ?, F5 L
cles, suggests peripheral or pseudopuberty.1-3 We
- w6 D2 t/ m/ V7 {! j/ O$ mreport a 16-month-old boy who presented with the6 j3 r% e6 Z. r1 t5 f
enlargement of the phallus and pubic hair develop-2 ?6 j% R7 L/ L3 H
ment without testicular enlargement, which was due4 i: ~+ q4 t$ E+ f+ E
to the unintentional exposure to androgen gel used by
) \- \: \9 o* b8 m% Z6 W- v6 gthe father. The family initially concealed this infor-
; v6 L/ V1 R* _0 o) qmation, resulting in an extensive work-up for this
/ f0 e  Y" h1 v8 O2 W( zchild. Given the widespread and easy availability of
# k% ^: _7 @) j6 Z" e  {& y, Jtestosterone gel and cream, we believe this is proba-6 n9 j) K  u$ f/ f' b$ F& {6 \
bly more common than the rare case report in the
' y4 H. G& J4 s( kliterature.48 _* ?1 m) |' H, w; F; y
Patient Report7 I& B6 E3 r$ @/ A
A 16-month-old white child was referred to the% M0 _# `; U$ F
endocrine clinic by his pediatrician with the concern
$ `+ U) n+ K' m* ?% r6 s1 v  cof early sexual development. His mother noticed
0 w6 H1 G: p+ slight colored pubic hair development when he was5 C' ^9 P/ B2 o% W, E+ b( U) @- o2 X
From the 1Division of Pediatric Endocrinology, 2University of2 A& J$ O  @; p2 L
South Alabama Medical Center, Mobile, Alabama.2 i; C" X0 q8 d& |/ k) n
Address correspondence to: Samar K. Bhowmick, MD, FACE,, }! v. |' h7 ?" U
Professor of Pediatrics, University of South Alabama, College of
% c8 v7 u3 `  n9 V8 |* dMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' I& x+ E" t7 \$ F, `
e-mail: [email protected].# V& _% a& V" V
about 6 to 7 months old, which progressively became
/ d4 }3 O" E2 Q3 u- E/ e2 odarker. She was also concerned about the enlarge-6 L2 |* {; ]0 }, `
ment of his penis and frequent erections. The child
, S9 ?7 C. u, G" O, Ewas the product of a full-term normal delivery, with, b$ h& p+ w* D* A: {
a birth weight of 7 lb 14 oz, and birth length of
; g7 b5 w' o( y4 D20 inches. He was breast-fed throughout the first year
, ]: s% s1 P6 fof life and was still receiving breast milk along with+ V$ `! ~* G! r! F" U, `+ W  W1 [
solid food. He had no hospitalizations or surgery,+ }+ v! b. _* H: A
and his psychosocial and psychomotor development
* a- x( T+ I) P8 |) lwas age appropriate.  {6 Q% A9 I! x1 @
The family history was remarkable for the father,
. M4 F% z. P5 Q0 j8 a  a0 _: nwho was diagnosed with hypothyroidism at age 16,
4 d$ v. D2 A/ I8 P8 B. e7 Owhich was treated with thyroxine. The father’s+ m4 u; _" s2 J7 W  u# Z
height was 6 feet, and he went through a somewhat" `3 ~/ d0 N- I
early puberty and had stopped growing by age 14.
' V0 |) `2 v# `+ zThe father denied taking any other medication. The
# g' {$ i( B9 p) K1 u9 wchild’s mother was in good health. Her menarche
) b- b0 t" h0 X& G4 e! [  r1 vwas at 11 years of age, and her height was at 5 feet
% r1 K1 n! Q" b3 H' T/ m5 inches. There was no other family history of pre-
+ i% i- r8 g" Z+ N# j! |$ [cocious sexual development in the first-degree rela-4 w* w2 `6 Y2 v( K9 R* H( o
tives. There were no siblings.# ^) v0 y; G1 ~7 q
Physical Examination' m% G% t0 R' T, z% w
The physical examination revealed a very active,
0 B& _9 S4 b: K* q$ Mplayful, and healthy boy. The vital signs documented' P- m+ [0 E/ F4 B
a blood pressure of 85/50 mm Hg, his length was) O, x7 ?+ ?+ H- K: H! F, I+ a
90 cm (>97th percentile), and his weight was 14.4 kg8 U, C+ n7 ~5 y# {0 t  \
(also >97th percentile). The observed yearly growth) E  [3 h% ?  N. g* m' D( M5 n
velocity was 30 cm (12 inches). The examination of. E* s# g- y0 I' r8 o" ]( R# h
the neck revealed no thyroid enlargement.
" X7 i8 i( z: }/ W- v" z) t" QThe genitourinary examination was remarkable for3 _4 @- _$ }" H3 @5 Y$ ~0 {: x. T
enlargement of the penis, with a stretched length of
2 F9 D* |, j- j4 ~* c8 cm and a width of 2 cm. The glans penis was very well
3 `9 M2 U$ [3 z$ l" Pdeveloped. The pubic hair was Tanner II, mostly around
' |4 V  k0 P. _8 x5403 t+ i0 j# N7 ]" \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 i2 C6 h  n$ n0 k, I9 V( e% Sthe base of the phallus and was dark and curled. The
0 d# x, J2 z4 Ktesticular volume was prepubertal at 2 mL each.
5 [: z+ f1 P' D9 i( M" CThe skin was moist and smooth and somewhat
( L# r( P4 `" H! U/ X! A0 j( joily. No axillary hair was noted. There were no
" t5 R. Q  d$ d3 p$ c  q( Rabnormal skin pigmentations or café-au-lait spots.! z! Q( E0 _- D' ~, w! [( [
Neurologic evaluation showed deep tendon reflex 2+- Y' ^: r" v( K4 z
bilateral and symmetrical. There was no suggestion8 G- ^% A# z0 @  `2 }' k8 Q" a
of papilledema.
( k; j% I9 p% x" uLaboratory Evaluation. ]& W$ E) L1 R0 Q4 e
The bone age was consistent with 28 months by3 I$ j  o% f; R
using the standard of Greulich and Pyle at a chrono-' N0 @6 R' c" j0 F5 o
logic age of 16 months (advanced).5 Chromosomal
7 G3 o# t7 B; q* [6 W: Akaryotype was 46XY. The thyroid function test% @5 V" {( k& {, j6 h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ d4 a% g8 }8 L( k3 |  Xlating hormone level was 1.3 µIU/mL (both normal).  f6 c9 B# M- \( I
The concentrations of serum electrolytes, blood+ @0 a) H( n- `' A& I) f9 T/ G; z
urea nitrogen, creatinine, and calcium all were/ w: ]. a, |% X0 z. T
within normal range for his age. The concentration" a, }6 b: T( F7 o- @& N4 ~/ o
of serum 17-hydroxyprogesterone was 16 ng/dL
7 t  T+ d$ g* Z% @; B9 t' i: R(normal, 3 to 90 ng/dL), androstenedione was 20' I) {- Y9 m/ K( z9 N. n; r
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 _+ P8 a- h% \% sterone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ C- N0 D/ a8 u) v8 jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  F7 }( E) N+ g8 N4 N' \49ng/dL), 11-desoxycortisol (specific compound S)6 L: h( K( e! s* ^0 L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( K0 V  J4 J# D5 `; u# @' u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ r+ u( C5 M6 V- c; b; X) C8 ?5 D9 n
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; X7 X5 P8 o2 d8 x  z
and β-human chorionic gonadotropin was less than* \6 k! {8 C5 N0 s
5 mIU/mL (normal <5 mIU/mL). Serum follicular0 q0 B- A" _3 ^( P2 Q+ j9 h1 v
stimulating hormone and leuteinizing hormone
$ E4 Y  x% O& \( D" R* Gconcentrations were less than 0.05 mIU/mL
. X* O  S$ h# A9 P& u(prepubertal).
$ j( E1 r* P2 h9 lThe parents were notified about the laboratory
) i1 ?8 [: g2 d8 gresults and were informed that all of the tests were
3 [$ \1 Q' o9 `normal except the testosterone level was high. The
* D) m8 c; i8 m9 cfollow-up visit was arranged within a few weeks to
- F4 [$ N3 e9 K  m3 E0 Jobtain testicular and abdominal sonograms; how-) y( h1 l8 U2 n7 I2 ^; V
ever, the family did not return for 4 months.# w7 W1 ~* q: u; W1 G  T/ M6 |
Physical examination at this time revealed that the
$ d0 f& C9 t4 H- h0 R, Dchild had grown 2.5 cm in 4 months and had gained3 B2 y) t! L: S! L- S6 X
2 kg of weight. Physical examination remained, I  L7 y) b9 n- `. i) p8 T
unchanged. Surprisingly, the pubic hair almost com-( H( x! Y+ f4 N* ]: i7 m$ A
pletely disappeared except for a few vellous hairs at
0 }% y9 F/ M8 X# O+ j! Rthe base of the phallus. Testicular volume was still 2; S0 `+ Y$ S5 U2 s! s1 v" K, v
mL, and the size of the penis remained unchanged.9 e+ a+ H% e( ^5 F  B
The mother also said that the boy was no longer hav-
6 S- O; Z! Z/ J, e6 J+ Q5 A. N& ving frequent erections.* _4 R. {, V5 e1 x* h8 N  a: w
Both parents were again questioned about use of
5 H/ Z3 \# n' g" eany ointment/creams that they may have applied to
9 ~8 S6 X  r2 i, V' |& u; @- j- Z$ zthe child’s skin. This time the father admitted the
& l6 U4 `3 a4 E* y2 nTopical Testosterone Exposure / Bhowmick et al 541
/ \  V4 a% a- }6 e# L" yuse of testosterone gel twice daily that he was apply-( M, ~* M+ A( ]; O: j
ing over his own shoulders, chest, and back area for
& t; e3 X( F0 j; g) T2 [, i5 ka year. The father also revealed he was embarrassed
$ \4 W, W: P2 k4 Cto disclose that he was using a testosterone gel pre-* [4 W# ^: P* P  f- |' j
scribed by his family physician for decreased libido9 ^: V" ^5 C% W7 W7 R! |
secondary to depression.
2 E  F/ t0 b0 ^' }0 K! K; C6 H# {The child slept in the same bed with parents.
+ H! h3 B. D/ T8 {- q/ {The father would hug the baby and hold him on his- L+ \. S; j. ^# o5 t- u$ u
chest for a considerable period of time, causing sig-) k  s7 }5 T! f# _$ z4 A
nificant bare skin contact between baby and father.
7 W& E5 [9 ~2 v5 D$ Z% y' g. IThe father also admitted that after the phone call,) l' H5 e! x- {7 D! q2 d
when he learned the testosterone level in the baby) ^- i' v* i# g7 k8 i1 g& v
was high, he then read the product information
& S6 u, q4 e% e4 j$ S, ]( I6 dpacket and concluded that it was most likely the rea-
# }8 T, o1 L; i( `  m% qson for the child’s virilization. At that time, they1 W0 Z$ c. ?0 N% C: e
decided to put the baby in a separate bed, and the# D( G  e# Q# u
father was not hugging him with bare skin and had
! G2 P8 J! S7 u& ^( v" z' u" abeen using protective clothing. A repeat testosterone
+ r* a& D' T$ B$ \( |2 rtest was ordered, but the family did not go to the3 q$ K6 _2 j2 {3 R
laboratory to obtain the test." O5 B! `( I: R+ ]: m0 t5 P- ?. `5 N
Discussion# e) j6 K3 v, V% S, ?6 f3 `
Precocious puberty in boys is defined as secondary
& S8 A$ ^) _) ]  j2 d2 Ksexual development before 9 years of age.1,45 q& }/ ?- n9 B% ^" ?) a7 V4 h
Precocious puberty is termed as central (true) when
7 a& K/ ^* v- }+ I9 J# x  U& jit is caused by the premature activation of hypo-. [2 t0 H0 I* V7 f: \
thalamic pituitary gonadal axis. CPP is more com-+ m3 p+ H) t  M1 {* a
mon in girls than in boys.1,3 Most boys with CPP/ ~9 [, I! Q7 G. t
may have a central nervous system lesion that is4 c# K% K) v& Y# f' V' \& d! C
responsible for the early activation of the hypothal-! x. j6 f3 X$ @8 N0 h/ Y( B( l" T0 y( v
amic pituitary gonadal axis.1-3 Thus, greater empha-5 [) v4 C& r' A- \: L0 G
sis has been given to neuroradiologic imaging in( A% n7 }% n6 a3 C- Z  y
boys with precocious puberty. In addition to viril-
" I" l9 r! b7 mization, the clinical hallmark of CPP is the symmet-
& c, Y: T% W, r3 F4 n" t/ C( h+ {rical testicular growth secondary to stimulation by
/ i* b- Q9 x4 Pgonadotropins.1,3
) H! N4 }4 T* `2 k, ~Gonadotropin-independent peripheral preco-
! K2 l- N! F; M- [2 A* xcious puberty in boys also results from inappropriate1 b9 E/ C% R. b% s5 g
androgenic stimulation from either endogenous or3 E; k6 E' B* P) W3 D, T! a/ |
exogenous sources, nonpituitary gonadotropin stim-5 c) j5 d/ z" Y! ~+ B
ulation, and rare activating mutations.3 Virilizing3 b* e, \; Q7 ]
congenital adrenal hyperplasia producing excessive& a2 S' j& U) A! X  W% c4 k
adrenal androgens is a common cause of precocious5 ]3 X9 {7 u7 d0 Q+ p" Y
puberty in boys.3,4( @( ?. W6 ]' j( _+ k9 ?$ n0 S! x+ u; H4 e
The most common form of congenital adrenal
% Y5 C% y3 {( g+ _5 Shyperplasia is the 21-hydroxylase enzyme deficiency.
' v2 w5 W: b3 f9 D8 T9 [$ ?2 QThe 11-β hydroxylase deficiency may also result in
& P2 h) ^$ s0 g; I9 g5 O) Xexcessive adrenal androgen production, and rarely,
- y4 \! `' U0 T: Yan adrenal tumor may also cause adrenal androgen
. E1 U* f6 Q8 E2 p7 bexcess.1,3+ B/ v& b; h  B7 w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 l+ z! Q1 `* o% ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 F$ z$ ?% y/ y7 P$ d$ P' X% M# q0 l
A unique entity of male-limited gonadotropin-
0 z# W1 d2 J, e" k0 jindependent precocious puberty, which is also known
( }$ k1 J' i* u  Z' Das testotoxicosis, may cause precocious puberty at a
9 ^' P) V* K& C2 R0 U  zvery young age. The physical findings in these boys( d! _% m) I1 o
with this disorder are full pubertal development,
3 M* g2 G$ i% z& N% ~( c9 v; gincluding bilateral testicular growth, similar to boys* b+ ^+ j/ Z/ g8 Y" _. p
with CPP. The gonadotropin levels in this disorder
+ L; P: s& F5 G5 D' `are suppressed to prepubertal levels and do not show
) g/ @. ?" o7 d8 tpubertal response of gonadotropin after gonadotropin-
" b8 |7 e8 C5 Y. dreleasing hormone stimulation. This is a sex-linked3 }; D! y4 Y2 C* G, G# m* y/ L/ M
autosomal dominant disorder that affects only
, O9 T  q8 z9 f- Lmales; therefore, other male members of the family0 ?' B) C% r0 f" x+ Y, A  J
may have similar precocious puberty.3
) i3 l. D) j  HIn our patient, physical examination was incon-& ~& q+ b$ Z5 z# `" `* m" q
sistent with true precocious puberty since his testi-
9 M) K2 ^' c5 S  m4 F8 A0 [9 ecles were prepubertal in size. However, testotoxicosis
  a# I+ J4 ?0 }0 b# ^was in the differential diagnosis because his father* T! {( C/ A( ^  C% N$ F0 I) @
started puberty somewhat early, and occasionally,, j  L* f9 o8 d" g5 s# x5 C
testicular enlargement is not that evident in the. E% X+ [) Q4 W. j5 S6 C
beginning of this process.1 In the absence of a neg-: q# g2 a' g% A/ w
ative initial history of androgen exposure, our; R& Y& t. V( k6 t
biggest concern was virilizing adrenal hyperplasia,& M( r, x  q( q4 `+ E0 b- i$ J
either 21-hydroxylase deficiency or 11-β hydroxylase
& f0 }1 T0 T: l; |6 K) Edeficiency. Those diagnoses were excluded by find-
- u# i0 [' F# f+ [9 R! [' sing the normal level of adrenal steroids.! [9 X/ r2 W9 v8 g9 V# d* _- m
The diagnosis of exogenous androgens was strongly
3 Q% L* z8 d9 B' W9 [suspected in a follow-up visit after 4 months because
8 g6 S9 L, U* x; R8 v. tthe physical examination revealed the complete disap-
/ J( f4 E( o% J- Y& a7 n8 Q& Epearance of pubic hair, normal growth velocity, and
) Z' [% h& _, j2 f/ m; V. U" adecreased erections. The father admitted using a testos-
% x0 ?  S- x$ u0 Z- C/ V; gterone gel, which he concealed at first visit. He was
0 Q* r' m! t1 _4 Y; ^2 Iusing it rather frequently, twice a day. The Physicians’4 R7 N4 a3 P- F% Y
Desk Reference, or package insert of this product, gel or0 d% l4 i5 S3 p: \" w; a- ^4 A$ _4 K
cream, cautions about dermal testosterone transfer to1 E% F' ~8 e/ S2 q5 F
unprotected females through direct skin exposure.( y: E4 a- F5 U' {6 u+ e$ F1 P
Serum testosterone level was found to be 2 times the
. }! F  p* d2 hbaseline value in those females who were exposed to5 q$ z& A0 r4 Y& W1 N* W: m, s
even 15 minutes of direct skin contact with their male! G. ^5 R- D7 l9 E$ Y- W
partners.6 However, when a shirt covered the applica-
8 i4 ]- V6 Z1 h# E: w# otion site, this testosterone transfer was prevented.+ h. _( E, U: v! H
Our patient’s testosterone level was 60 ng/mL,% n* b, I6 Z3 P  }# Y6 t- ]3 a  K
which was clearly high. Some studies suggest that
$ W2 F' x  i3 }( }9 J* x9 ]' Odermal conversion of testosterone to dihydrotestos-) t9 ], e* f1 D* J
terone, which is a more potent metabolite, is more9 {6 P* \: \$ J8 f; y0 N
active in young children exposed to testosterone
: P8 O! n  ]4 z: B3 y6 Eexogenously7; however, we did not measure a dihy-
( g$ ]% X- D: ]" M9 |drotestosterone level in our patient. In addition to
! N- |6 X: x* Avirilization, exposure to exogenous testosterone in, h9 x# W9 M0 H9 N4 Y
children results in an increase in growth velocity and
% H, t% W( N! ^  E2 I: madvanced bone age, as seen in our patient.5 G6 v4 Y: |& [! v8 A- R
The long-term effect of androgen exposure during0 x9 {3 S2 t6 ^0 s1 s: _  }( k7 z
early childhood on pubertal development and final
; _/ E, I, t' }  e% d9 o) Z# aadult height are not fully known and always remain
& W: A; Q/ L. t# ka concern. Children treated with short-term testos-: i: b1 C$ u5 T( b
terone injection or topical androgen may exhibit some
- d+ K4 ?# x# z+ U) q6 Y1 i& F$ ?2 E* uacceleration of the skeletal maturation; however, after: G: z' M; S$ a" O
cessation of treatment, the rate of bone maturation; W" G: Q7 v1 M' c7 C/ r3 q' \7 \
decelerates and gradually returns to normal.8,9
  s% n3 ?+ a; d- c/ f8 d* k( l% YThere are conflicting reports and controversy; m9 @" m5 i1 U; ~- z, O
over the effect of early androgen exposure on adult0 S4 j# z1 q+ b& o
penile length.10,11 Some reports suggest subnormal; f9 X' C$ c7 ]. r
adult penile length, apparently because of downreg-' o3 A" f7 t. \9 j1 V1 d, N. ^
ulation of androgen receptor number.10,12 However,8 u  o, V# n2 @. K& z/ G! D( T
Sutherland et al13 did not find a correlation between% ~" O; u8 t# G( ^8 P% g
childhood testosterone exposure and reduced adult3 ^. ]; i7 e1 ^. I. \. y: A
penile length in clinical studies.( U2 ?1 N6 i) V8 y* |
Nonetheless, we do not believe our patient is  |3 w. J7 I% d
going to experience any of the untoward effects from
- e; j& b/ y$ n& r. o5 K$ l  `testosterone exposure as mentioned earlier because8 C0 p9 Y* e, z: ]& ]* @3 |
the exposure was not for a prolonged period of time.
: n/ f. d3 T% FAlthough the bone age was advanced at the time of+ i3 b9 _1 N' S1 T
diagnosis, the child had a normal growth velocity at
6 u* o$ C  x6 H8 |9 Cthe follow-up visit. It is hoped that his final adult2 O6 P5 ?3 i! m) s1 q- r3 G
height will not be affected.
" n' \, G) ?& i$ J# J/ aAlthough rarely reported, the widespread avail-9 U; [: a$ k  U; |+ r" d7 E( I
ability of androgen products in our society may6 E' ]3 C- ^- U% {+ P/ r1 o
indeed cause more virilization in male or female0 G& L8 D( |' f$ t
children than one would realize. Exposure to andro-
. W! t7 R# ~5 A2 }$ C" X. x/ v7 g3 ~gen products must be considered and specific ques-% e4 @0 U  r4 R4 Q) B' a, O
tioning about the use of a testosterone product or
7 ]8 m5 X; d: Jgel should be asked of the family members during
6 s. J. a! g3 @the evaluation of any children who present with vir-
& N3 a& H6 j, `% Z2 wilization or peripheral precocious puberty. The diag-$ E5 z. U( J2 u9 n) h9 ]
nosis can be established by just a few tests and by+ m; l6 @, W) }$ l
appropriate history. The inability to obtain such a
8 ^! i( e1 p' _8 \5 h9 `% nhistory, or failure to ask the specific questions, may
! f5 b" m: j* A& R! l: C. eresult in extensive, unnecessary, and expensive, p. f. P" P# K+ @8 M6 @; V
investigation. The primary care physician should be1 x0 ]7 y6 D! \
aware of this fact, because most of these children
3 s8 a; _1 z- }may initially present in their practice. The Physicians’6 S; z5 E1 U* n+ W. V& i, }5 Q
Desk Reference and package insert should also put a
3 N  t- W6 u: P1 b1 [3 f$ Y& z  a% hwarning about the virilizing effect on a male or' \8 g7 `9 D' B7 Q: r
female child who might come in contact with some-9 S% u  R7 Z. b1 R; H0 Q
one using any of these products.% y& x. H3 I$ M
References) F9 Z* U. l! k, f
1. Styne DM. The testes: disorder of sexual differentiation1 W6 w  e( ^7 s( K$ q& O, p8 S7 s
and puberty in the male. In: Sperling MA, ed. Pediatric
% j. ~7 ?6 L! j5 z! [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 o3 t* H1 c/ N# o8 ]+ U$ h+ k  R2002: 565-628.% L0 `0 }3 w2 d% D$ J* B! K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% d- |" i1 G$ c
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old0 t. d8 z/ }& s  z" }
Boy Induced by Indirect Topical
$ s1 r2 D+ G+ R7 h0 BExposure to Testosterone
4 z% ~. D% U& m) \" b2 I! N1 G0 @  vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  d+ W4 X, ]- h6 u5 J4 h
and Kenneth R. Rettig, MD1
9 |+ E8 `8 j. f, XClinical Pediatrics* O$ p, B& m+ F% E* J. q0 v5 o) [& t
Volume 46 Number 6( i  |4 P' [  m( S9 Q. ?9 o. o
July 2007 540-543
1 w" K3 ~+ w2 f& `© 2007 Sage Publications- y) T  M9 y' I/ z( \, b3 L4 C( M
10.1177/0009922806296651/ A6 j5 b9 o4 y, B
http://clp.sagepub.com$ u/ H+ L- ~% u* [
hosted at
) F5 M  y& h2 z# q5 c! P( ahttp://online.sagepub.com3 g( ]5 Q+ S7 U" ]) t3 ^5 U
Precocious puberty in boys, central or peripheral,9 Y0 D8 d, Q, L5 e9 @5 C
is a significant concern for physicians. Central
. x2 l6 {- t: B; L5 w: o" vprecocious puberty (CPP), which is mediated
( H/ X3 h: {6 s5 K: T( u$ ?through the hypothalamic pituitary gonadal axis, has
# G. \" S/ [; }$ w  r4 |' P" ~a higher incidence of organic central nervous system
' K9 U# H) t3 x9 ]lesions in boys.1,2 Virilization in boys, as manifested% m( Q) O) V, W' j" U
by enlargement of the penis, development of pubic
5 k1 e0 j7 ~: Y; Thair, and facial acne without enlargement of testi-
& |5 \+ ?4 I$ L- q. xcles, suggests peripheral or pseudopuberty.1-3 We8 Q: e2 F4 l' s3 J
report a 16-month-old boy who presented with the! T# m2 H* X4 J7 s8 T% M
enlargement of the phallus and pubic hair develop-
" `% B- L. }# S' l: hment without testicular enlargement, which was due: e* ~% B' Q4 k' C" R9 n
to the unintentional exposure to androgen gel used by
: }; T& X. h( k3 s2 y8 |* ]; wthe father. The family initially concealed this infor-3 a: Y- y5 ?% U4 Q) c1 i3 i
mation, resulting in an extensive work-up for this7 A' n9 R: x8 F
child. Given the widespread and easy availability of9 _* @$ t% c9 K4 [, ?
testosterone gel and cream, we believe this is proba-
. C: i. C- ]; @" D3 i% g+ Ably more common than the rare case report in the! K7 ^1 s  S, ~2 Y: i; v
literature.48 R/ G! ^7 U: w9 X$ _
Patient Report+ L- K$ l0 x/ I% `' n. ^% i
A 16-month-old white child was referred to the8 c4 s. D: k7 f" d
endocrine clinic by his pediatrician with the concern
. T+ |8 }6 r8 ^+ q$ b. [. Uof early sexual development. His mother noticed
! @8 d( ~' z( Tlight colored pubic hair development when he was3 R' u/ p. @$ o
From the 1Division of Pediatric Endocrinology, 2University of
! T+ J3 i) ?1 i# }South Alabama Medical Center, Mobile, Alabama.
: e: _$ t! G( T6 Z0 Y8 cAddress correspondence to: Samar K. Bhowmick, MD, FACE,! Q' g" S0 ]6 d3 V% n, E8 b
Professor of Pediatrics, University of South Alabama, College of& s- w  m$ @3 g4 z1 s9 T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 j) S! [7 B" _6 U/ j0 {
e-mail: [email protected].# Z; i9 w+ G2 c7 @- L
about 6 to 7 months old, which progressively became
: v1 U& z  ?8 r$ `: W" pdarker. She was also concerned about the enlarge-) r) y7 |: m" l  G. I; b
ment of his penis and frequent erections. The child
- \: v: b! d, [" Twas the product of a full-term normal delivery, with6 Y0 I2 n7 z$ r; @, h( ^' e# d! L9 P
a birth weight of 7 lb 14 oz, and birth length of
6 @6 J% }# p3 q; g20 inches. He was breast-fed throughout the first year
8 E: p2 k8 s) _: ~' T; y6 c; Wof life and was still receiving breast milk along with& W' s/ c4 S8 o2 R2 T
solid food. He had no hospitalizations or surgery,; Q+ F- r" h7 E
and his psychosocial and psychomotor development/ j4 X' F2 c0 q! r6 R6 D; g
was age appropriate.1 |; q! v' }% X$ J1 U, u
The family history was remarkable for the father,
4 F3 |" \/ P  |9 cwho was diagnosed with hypothyroidism at age 16,
2 K% h3 D1 k' Fwhich was treated with thyroxine. The father’s
! `* t8 _1 `, {  X0 zheight was 6 feet, and he went through a somewhat: \0 x3 d- {& H) w
early puberty and had stopped growing by age 14.
% N' h' f2 h1 l, P  O6 G  AThe father denied taking any other medication. The: ]( |( V2 l- V' }- x  n9 w
child’s mother was in good health. Her menarche8 b) j* I' X( d/ N
was at 11 years of age, and her height was at 5 feet, ?( S2 m* }8 g
5 inches. There was no other family history of pre-' {: r% \4 ^/ v/ [$ t# b# U
cocious sexual development in the first-degree rela-3 C; b$ H  w6 h! C" G
tives. There were no siblings.
. y0 T8 m% `- NPhysical Examination$ z9 z+ W9 w0 H
The physical examination revealed a very active,
" L! V6 Y2 b& yplayful, and healthy boy. The vital signs documented) Y; Z/ z2 N4 y  v
a blood pressure of 85/50 mm Hg, his length was
4 N* i, f( C2 u5 R, @90 cm (>97th percentile), and his weight was 14.4 kg
+ ~# J7 r/ j" f3 [: C, T8 m(also >97th percentile). The observed yearly growth
  _: N9 u8 m: s! I8 p8 ?. lvelocity was 30 cm (12 inches). The examination of
3 O5 k3 f) e7 `' e0 Ithe neck revealed no thyroid enlargement.
) ?+ `: s& j) g6 kThe genitourinary examination was remarkable for
0 I3 j, J1 H5 i# T, Ienlargement of the penis, with a stretched length of
# s& c: x9 k% A" c3 ~4 u0 K8 cm and a width of 2 cm. The glans penis was very well
" {  ^. u' `5 ?) p# z& O2 ydeveloped. The pubic hair was Tanner II, mostly around
' y( F7 g' M# z540
" \3 @0 \' q4 g1 a& u# yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# b" L5 p# T& ^0 q3 u8 ]the base of the phallus and was dark and curled. The
' s; e9 T% d! s2 k" E! }* \2 Rtesticular volume was prepubertal at 2 mL each.$ r! H+ C/ M! p: p/ a7 b) i2 `
The skin was moist and smooth and somewhat
8 P' ^$ k+ Y8 i/ w# m& toily. No axillary hair was noted. There were no
* D5 d* s1 u5 n# H  Wabnormal skin pigmentations or café-au-lait spots.
+ w) I! m8 L: I6 YNeurologic evaluation showed deep tendon reflex 2+5 \* d! w% X; N3 ^3 s
bilateral and symmetrical. There was no suggestion
* D- i6 b9 \! E* z  aof papilledema.
* f5 [0 h# }- U* p/ z4 A8 @Laboratory Evaluation
, a# {% A/ s8 b& LThe bone age was consistent with 28 months by
% }( t2 E$ l0 o2 fusing the standard of Greulich and Pyle at a chrono-
; l! Y7 s' C; t! v4 Blogic age of 16 months (advanced).5 Chromosomal5 a* s# n& t% n. H" L3 p1 f
karyotype was 46XY. The thyroid function test* ]% X3 I& W  U1 G; {: o* D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ f# o5 N: i4 n1 n8 ]lating hormone level was 1.3 µIU/mL (both normal).2 J4 ~% O' m5 p5 s
The concentrations of serum electrolytes, blood. e9 c  l# l* ?' h+ H
urea nitrogen, creatinine, and calcium all were
3 |( w7 n- j1 h/ L1 ^within normal range for his age. The concentration* u% v) s! i# M, V6 z
of serum 17-hydroxyprogesterone was 16 ng/dL7 T( t6 y5 t6 |# N# u
(normal, 3 to 90 ng/dL), androstenedione was 203 [, ~: ?% x* D1 H7 e$ C6 J1 [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* C* f3 ?/ v& t1 o7 I9 m' Vterone was 38 ng/dL (normal, 50 to 760 ng/dL)," B2 u" S4 P3 y$ }& y* ?$ n- }( z0 C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" n- Y. y/ \7 s' f: A' S, Q2 J
49ng/dL), 11-desoxycortisol (specific compound S)' f6 W8 J1 P, M2 L* A5 w7 O3 f
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ ?- t# T3 g9 o# Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ f) @( X9 K/ Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),  a1 l+ I9 L+ q& b- b
and β-human chorionic gonadotropin was less than5 o! e2 P( C7 ]  t9 Y! B
5 mIU/mL (normal <5 mIU/mL). Serum follicular  i6 U0 F) V4 k0 C3 ]
stimulating hormone and leuteinizing hormone! e3 f2 h+ P' n# z5 g0 W  z
concentrations were less than 0.05 mIU/mL
% Y' r: H) o# Z(prepubertal).
& U1 X: W8 m0 F' e: L/ O  ^& tThe parents were notified about the laboratory" Q, Z# o2 @0 }
results and were informed that all of the tests were- _" N8 ?2 {+ m: Q
normal except the testosterone level was high. The
! W6 i, P2 k$ B! @! xfollow-up visit was arranged within a few weeks to
& ?8 B  H  q# C/ e' f0 G& Pobtain testicular and abdominal sonograms; how-
: e# B6 `/ u( xever, the family did not return for 4 months.0 \/ H3 V* e2 N& X
Physical examination at this time revealed that the' @3 L1 `: e# U9 e; }& G1 L
child had grown 2.5 cm in 4 months and had gained% h! t- Q7 t' |4 ~* |5 a. ]
2 kg of weight. Physical examination remained5 t9 W3 g, R. R2 @& d
unchanged. Surprisingly, the pubic hair almost com-
8 t$ e  c& {3 C% D. n4 ^pletely disappeared except for a few vellous hairs at
" e' ~( K+ a6 w" cthe base of the phallus. Testicular volume was still 2
! T% ?1 l) Q( C9 `mL, and the size of the penis remained unchanged.
( U: _2 g: N! V5 VThe mother also said that the boy was no longer hav-
( }9 ?) y7 e, f- F# \6 Hing frequent erections.3 ?( D, Z* k/ p3 Z+ }( B
Both parents were again questioned about use of
' i1 m1 E1 l5 D: X) A- Pany ointment/creams that they may have applied to: ^: F$ e$ J9 I2 ]  X: @0 a
the child’s skin. This time the father admitted the
2 P0 P6 d' d) B1 y2 s+ B7 lTopical Testosterone Exposure / Bhowmick et al 541+ [, D( P7 \* L9 v* i% c" v3 q
use of testosterone gel twice daily that he was apply-; ?' {5 o! D1 j5 U- X6 }  j
ing over his own shoulders, chest, and back area for* U# w4 K: R1 H0 F$ [  m  c/ |
a year. The father also revealed he was embarrassed
; Q- q' y  s# g3 C& xto disclose that he was using a testosterone gel pre-
5 u! ^; v3 t2 r: N5 u' g( m2 wscribed by his family physician for decreased libido
  H& E# [% |. }; csecondary to depression.
$ Z* y5 S, v& B. L# h) qThe child slept in the same bed with parents.# `( W( ~6 |5 f. \# L
The father would hug the baby and hold him on his% q" o$ W8 {4 p+ P4 b; W6 g9 p
chest for a considerable period of time, causing sig-
+ @1 }. [. K% R3 q. ]" P. n/ nnificant bare skin contact between baby and father.
1 h% R) W& F. i7 Q1 iThe father also admitted that after the phone call,
6 I; q& u. x  vwhen he learned the testosterone level in the baby
( ^% l  @, d. d2 E* qwas high, he then read the product information, J. h; [4 {  Y5 E4 p3 z
packet and concluded that it was most likely the rea-
: T- X' b/ w: d5 z* U' q- M) u* @# Uson for the child’s virilization. At that time, they
& `: w1 C3 y+ T6 B0 F2 E$ sdecided to put the baby in a separate bed, and the/ w2 s8 c9 ]/ b. C) E& a
father was not hugging him with bare skin and had
' p% B. `0 Q( C0 L. k1 ^2 L4 ~been using protective clothing. A repeat testosterone" {+ p3 K/ }7 }3 d# k- t1 y
test was ordered, but the family did not go to the/ A* T+ o- b* A
laboratory to obtain the test.
$ P# Z- @) M3 uDiscussion
1 D# ]/ b! X! m$ O, mPrecocious puberty in boys is defined as secondary; x  Q! W7 o* N# Q
sexual development before 9 years of age.1,4( d' w3 ]2 W3 r* W; Z
Precocious puberty is termed as central (true) when8 L& A! C5 }7 C9 L8 T. V
it is caused by the premature activation of hypo-% L$ j. x, b1 |; k6 d7 E2 O: e5 Y
thalamic pituitary gonadal axis. CPP is more com-
9 @* S+ Q. \, vmon in girls than in boys.1,3 Most boys with CPP
3 [0 ?' y; w- ~5 ^1 Z6 p4 tmay have a central nervous system lesion that is
+ |; Y0 l7 l% N2 Aresponsible for the early activation of the hypothal-. s  |# Z5 D9 S& _5 r+ \; w
amic pituitary gonadal axis.1-3 Thus, greater empha-* F. P# E* W1 J' p
sis has been given to neuroradiologic imaging in, V$ i, z3 @% J. M
boys with precocious puberty. In addition to viril-/ k5 V- @, U. j
ization, the clinical hallmark of CPP is the symmet-
4 M- h. |, }! s5 \/ Qrical testicular growth secondary to stimulation by
8 M% l+ E4 s8 A7 _gonadotropins.1,3
# I- h; W9 p0 b# kGonadotropin-independent peripheral preco-
( f9 a* r) x0 x5 bcious puberty in boys also results from inappropriate
8 ], h/ g- ~1 @2 h6 {. A, Randrogenic stimulation from either endogenous or8 q: p: Y* U1 i* f* q  V2 ~& f* r
exogenous sources, nonpituitary gonadotropin stim-
7 n! m+ [9 w8 A' ~6 L3 h: ]% julation, and rare activating mutations.3 Virilizing3 m. a* _/ n9 J9 i( L* O
congenital adrenal hyperplasia producing excessive
' F  Y1 n; Y) b' U, Tadrenal androgens is a common cause of precocious
/ g* j  ]: X5 _puberty in boys.3,4
1 p3 C( B7 k- U5 @The most common form of congenital adrenal
6 T4 n" l! B4 G& @% N/ V) p6 Zhyperplasia is the 21-hydroxylase enzyme deficiency.
( I7 Q$ p6 L* C5 y; J+ HThe 11-β hydroxylase deficiency may also result in1 C% T$ e7 `) s1 i2 M. K: s& g  [
excessive adrenal androgen production, and rarely," |! B6 D- Y! o, N% c: L
an adrenal tumor may also cause adrenal androgen% W- Z8 x# M- ]  W; m! s+ k
excess.1,3
" g$ H1 K0 L0 qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( }+ M( G1 ?, O+ x7 H# U5 g542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* d& ]5 S% k% T9 ^8 L0 x0 o
A unique entity of male-limited gonadotropin-
0 D0 ?( G1 ]: p1 d- |$ ]independent precocious puberty, which is also known3 m* ?' ^; X9 z) v+ A6 o% q
as testotoxicosis, may cause precocious puberty at a, R8 `* b) C& b$ G
very young age. The physical findings in these boys5 N+ F2 N' j# O/ [; N5 U* _0 ~! i
with this disorder are full pubertal development,' Z( f4 t, D: f' {* A
including bilateral testicular growth, similar to boys: S7 \: w4 L: D. k
with CPP. The gonadotropin levels in this disorder
! a+ f$ m+ S& J* Y8 U: O1 P5 Nare suppressed to prepubertal levels and do not show
* {5 E0 P8 j7 tpubertal response of gonadotropin after gonadotropin-5 f4 P  [2 R7 W  u' [8 M2 I! s
releasing hormone stimulation. This is a sex-linked2 q+ P, T, v% B+ o) h9 K( J
autosomal dominant disorder that affects only
3 P! N  u0 x( u1 hmales; therefore, other male members of the family) Q; h$ `8 x4 v' E
may have similar precocious puberty.3% `2 S/ [9 q  ?, M/ H. N6 l
In our patient, physical examination was incon-
: J' R0 H+ L, x& K( P6 V8 d& D0 Esistent with true precocious puberty since his testi-  G. P0 ?! e( I* m7 n% v
cles were prepubertal in size. However, testotoxicosis
+ ~/ N' c2 @  v' cwas in the differential diagnosis because his father
, \2 ^6 e4 u2 ^6 h/ O! @started puberty somewhat early, and occasionally,/ c, f2 B. I- ^- A( G$ @
testicular enlargement is not that evident in the
2 J3 T  O& z9 K9 u( @2 q7 {3 N/ Xbeginning of this process.1 In the absence of a neg-
, t) q  W1 }8 n/ b$ Jative initial history of androgen exposure, our7 l0 F, l  @* I1 e* w2 V
biggest concern was virilizing adrenal hyperplasia,
1 B6 N( l* I, Xeither 21-hydroxylase deficiency or 11-β hydroxylase
' V5 B2 q9 ^" Pdeficiency. Those diagnoses were excluded by find-# b( W8 J. d: U! ~" F, w
ing the normal level of adrenal steroids.( ]. P# I( v7 t8 w; N) x' O
The diagnosis of exogenous androgens was strongly3 g! D+ Q  b' X5 B
suspected in a follow-up visit after 4 months because
7 W; `# a8 [4 |4 R$ @the physical examination revealed the complete disap-
  {$ [6 g/ f1 h# ]7 {+ }4 Q3 ~pearance of pubic hair, normal growth velocity, and+ K( O2 k/ k5 }# }8 }9 b/ m9 h  w
decreased erections. The father admitted using a testos-
7 e% r. l: w2 I: Q  |% z" I' Qterone gel, which he concealed at first visit. He was
& g! o8 T, ~0 g6 tusing it rather frequently, twice a day. The Physicians’
: V5 Z# e0 e9 V5 {8 wDesk Reference, or package insert of this product, gel or
+ f# e1 K- E7 v6 B' C9 U. U) [' [cream, cautions about dermal testosterone transfer to. a$ Z0 E! U) Q
unprotected females through direct skin exposure.
/ M1 [, r7 P. D1 x5 s; sSerum testosterone level was found to be 2 times the
, M# |, o& Q0 s: @0 s! J8 B" S4 Zbaseline value in those females who were exposed to
9 ^* O* k4 C, B8 Leven 15 minutes of direct skin contact with their male/ V0 P* b0 U: A* x  c& @3 s
partners.6 However, when a shirt covered the applica-
* @8 V$ L- c+ h, e1 c9 J& ^tion site, this testosterone transfer was prevented.2 }5 G8 U* m! w& c  P/ T) h( l
Our patient’s testosterone level was 60 ng/mL,
) c( H& t/ ^1 h. o! Rwhich was clearly high. Some studies suggest that
  M" m" N9 ^4 A% t  Tdermal conversion of testosterone to dihydrotestos-: J' |, G  S, ~5 e* L  c
terone, which is a more potent metabolite, is more
6 f# X9 N) ]. G, E$ Iactive in young children exposed to testosterone0 m3 v3 `; L0 ?8 g2 |! T
exogenously7; however, we did not measure a dihy-: k4 S& g; m2 g& `2 K' O; L9 Z2 d' l
drotestosterone level in our patient. In addition to7 d* i$ T  v9 l  N& j8 b
virilization, exposure to exogenous testosterone in! m$ t: B* S' l4 m% P+ y
children results in an increase in growth velocity and
1 ?# q4 f# e* H! o- r4 F4 Fadvanced bone age, as seen in our patient.
# |8 k8 q7 n; |) z" y: i- AThe long-term effect of androgen exposure during% c3 n3 m; ], N2 t" T3 ]! b9 J) ^' ~
early childhood on pubertal development and final' n; Q! J5 Z0 s. ]9 d
adult height are not fully known and always remain' {5 M# Y" N! m, X, \) |3 R
a concern. Children treated with short-term testos-
% ~; m$ |9 R' y2 H5 F$ k5 Eterone injection or topical androgen may exhibit some. j" g8 A& y. k& H' [
acceleration of the skeletal maturation; however, after9 L7 i) q6 U  Q0 i
cessation of treatment, the rate of bone maturation- m6 T1 D, f! h3 D  T
decelerates and gradually returns to normal.8,9
& s: q4 O  ]: z& R9 T0 MThere are conflicting reports and controversy
  E$ ~# y) h9 e, r9 e, u. ]over the effect of early androgen exposure on adult& d( I+ S& z9 o& q
penile length.10,11 Some reports suggest subnormal+ I& ]: ?, A& I" e" k
adult penile length, apparently because of downreg-& g( T8 q5 `9 }" T4 D  ^& G
ulation of androgen receptor number.10,12 However,
+ E( r# J# {* P7 q  m8 aSutherland et al13 did not find a correlation between" ?' j* T8 J3 }. J. \6 l
childhood testosterone exposure and reduced adult) P6 L/ `+ w, L& P! Y* o) C8 @
penile length in clinical studies.8 p& H& {4 }% z( N( e( v2 E
Nonetheless, we do not believe our patient is3 y  G) G0 |. X& _2 d/ P$ e3 ]
going to experience any of the untoward effects from
5 @3 B4 ]5 h5 S! X- ctestosterone exposure as mentioned earlier because
1 z8 q& t6 V" J/ Mthe exposure was not for a prolonged period of time.3 E) t% L% {5 _" X; m
Although the bone age was advanced at the time of/ \- h% _; J9 a% K" Y" l
diagnosis, the child had a normal growth velocity at
6 H: Y3 m( x% h) R: ]& E0 Fthe follow-up visit. It is hoped that his final adult
+ @% n0 B5 S( G( J  {height will not be affected.
  t& c4 k3 q9 aAlthough rarely reported, the widespread avail-! u" E# `' r! W3 R: j; \2 E
ability of androgen products in our society may
  D; o& ]" ~! kindeed cause more virilization in male or female* S- J+ n# k9 y! t
children than one would realize. Exposure to andro-4 N2 ?" b" a% \/ ]
gen products must be considered and specific ques-# y. I2 n) G9 t) W6 q. j- \2 A
tioning about the use of a testosterone product or& \5 C: q5 K1 J. K  P8 f
gel should be asked of the family members during  g% @$ A% X) c5 J6 u1 w: }
the evaluation of any children who present with vir-0 f% P6 y0 T. k/ b& t. @
ilization or peripheral precocious puberty. The diag-4 }# I- d9 r: {
nosis can be established by just a few tests and by
$ A  N( H( D2 _7 jappropriate history. The inability to obtain such a( d* C9 Z6 S( r  \( Z" s
history, or failure to ask the specific questions, may# c) }) M* f4 `5 M( u2 b$ }: d* N2 |
result in extensive, unnecessary, and expensive
( ?( J% a' d7 einvestigation. The primary care physician should be2 M8 p' L6 @: w* P3 J7 l0 L
aware of this fact, because most of these children
  x8 h! Q# r  }$ ^/ Hmay initially present in their practice. The Physicians’
- ]2 r& [6 `( G9 I" V" qDesk Reference and package insert should also put a
5 s) y) D2 V" F4 A4 P$ X* nwarning about the virilizing effect on a male or# d( `) B2 j8 b. C+ j- t7 a
female child who might come in contact with some-
  l  V0 M8 I3 _* B! G; l' D8 e2 `  Aone using any of these products.$ e$ ^: ]8 M/ n  R
References
  t+ D* y6 |% ?- w1. Styne DM. The testes: disorder of sexual differentiation5 t/ G" S  h! d& X, e
and puberty in the male. In: Sperling MA, ed. Pediatric
9 J7 }$ E$ X& H9 T& hEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 J! K3 u" D$ j4 r0 y! @2002: 565-628.7 t- @8 M, F" b* J! p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ q0 c" l/ f% {6 ^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

$ X" z' i6 r8 y" Y" S; q) R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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