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Sexual Precocity in a 16-Month-Old
9 S' L5 u6 E  O7 [* ^Boy Induced by Indirect Topical
* A1 h* ^$ b9 O4 t) q, [" bExposure to Testosterone/ }( c6 \3 O4 [) j( B5 i
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! U, t, M- y+ B# c' B2 Q2 |3 l; eand Kenneth R. Rettig, MD1
' C8 ~/ v' h$ vClinical Pediatrics; C7 O* l6 D3 i
Volume 46 Number 6$ d. T! [: F5 h* H  ^
July 2007 540-5433 ]3 r5 Z! ]2 @
© 2007 Sage Publications
! O$ F' n5 s, S' v5 D# N# [6 m  v+ i10.1177/0009922806296651# Q, y2 X: e" B' U# [
http://clp.sagepub.com
1 s" b/ d1 @; R9 {. R1 thosted at; n  ], p+ R$ O& C5 s5 V# ]% @4 P
http://online.sagepub.com
+ v8 Y" J* k! Q2 k, TPrecocious puberty in boys, central or peripheral,  E( u+ c- P2 [1 |/ M, P! {
is a significant concern for physicians. Central
% ]+ k- E, {4 E1 r8 aprecocious puberty (CPP), which is mediated6 q9 y2 P' {9 K) x( w
through the hypothalamic pituitary gonadal axis, has# K+ p8 a& J4 q8 a+ L
a higher incidence of organic central nervous system& w3 g" T5 g0 A
lesions in boys.1,2 Virilization in boys, as manifested- u; |8 j, W, q( T2 N) F7 h1 b
by enlargement of the penis, development of pubic
! b4 x1 G0 i1 n1 w+ J$ ?( khair, and facial acne without enlargement of testi-$ Q, v$ I% A( }, v
cles, suggests peripheral or pseudopuberty.1-3 We/ H& H% U7 e, B  L! z3 d
report a 16-month-old boy who presented with the
* X5 {, v+ O1 F' q3 D: V, jenlargement of the phallus and pubic hair develop-" T! S* X+ U" G& o7 ~0 O. ]) P
ment without testicular enlargement, which was due" K( g) g9 Y) p* l
to the unintentional exposure to androgen gel used by
6 g7 K/ {7 `( c" N) p+ ]3 Gthe father. The family initially concealed this infor-
  y  n, `( k: h- D6 a6 zmation, resulting in an extensive work-up for this
+ _( O+ m' h, G/ u* X- e( Qchild. Given the widespread and easy availability of& L- c3 B+ J1 P6 I6 y' N7 Q& Z
testosterone gel and cream, we believe this is proba-7 x- w; ~5 A/ H' R" _
bly more common than the rare case report in the
& [% r( L7 ~! O" Hliterature.4
# W9 a) {+ Q' B5 X& ^. D. h1 K8 K) W: mPatient Report
7 h7 Y4 I/ E5 {! y: M: l' i( `A 16-month-old white child was referred to the2 r0 @+ A+ i8 H! y
endocrine clinic by his pediatrician with the concern1 J5 c2 a: W# K6 R( j* I+ ?. H, Y
of early sexual development. His mother noticed
# Z+ D; Q. h6 W$ J! ?# [light colored pubic hair development when he was' x1 r4 V& N: \8 d  g/ r
From the 1Division of Pediatric Endocrinology, 2University of: C( d. k9 P1 r: l" M5 f7 @
South Alabama Medical Center, Mobile, Alabama.8 T( q9 [5 {6 i% R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 c8 a% ]9 ~$ V) p! L! aProfessor of Pediatrics, University of South Alabama, College of* P; O, J) s* E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 L! k3 }0 [, ?( Y
e-mail: [email protected].
( f5 X( Y9 g1 l$ h, j8 wabout 6 to 7 months old, which progressively became
- a3 y% l$ m3 v$ X. K/ {/ [darker. She was also concerned about the enlarge-. t3 h2 u, ^1 z; r9 z
ment of his penis and frequent erections. The child  y" Q8 ?6 j% t2 n& h3 [2 z
was the product of a full-term normal delivery, with
2 s9 B; c+ a9 Y' D) Pa birth weight of 7 lb 14 oz, and birth length of
; n6 b' ]8 _: U: f* C7 X20 inches. He was breast-fed throughout the first year4 q0 Z" z" p+ Y1 y3 N# O' U
of life and was still receiving breast milk along with
& [* r: e; R6 Q+ p7 Y( u2 a' ^( W; Dsolid food. He had no hospitalizations or surgery,! _2 h' w; I. d
and his psychosocial and psychomotor development
; P7 ~) y8 E8 j/ M& E9 D. c. c* b. t3 twas age appropriate.
: P* _7 q6 j2 [: D$ bThe family history was remarkable for the father,7 T5 h! j/ O' Q1 L
who was diagnosed with hypothyroidism at age 16,
+ h8 v* O, F) s3 e; w$ O; |which was treated with thyroxine. The father’s5 k* A2 d2 F; G$ ?; Z1 C: S* V1 v1 y
height was 6 feet, and he went through a somewhat
; O  m6 i$ F$ V' i7 vearly puberty and had stopped growing by age 14." f$ V: _0 `4 G9 ^6 e5 v7 b
The father denied taking any other medication. The; Q6 R- T2 H9 T$ _
child’s mother was in good health. Her menarche& x( {  e- [) J( A& _' B4 U
was at 11 years of age, and her height was at 5 feet
# V, [9 a/ J8 [1 L) F/ |  w! u5 inches. There was no other family history of pre-- ^- |# }+ I+ \6 g# J
cocious sexual development in the first-degree rela-
+ q1 A7 B4 q, @8 s7 S2 x3 o) Itives. There were no siblings.
4 X3 H1 D) r. n! u% NPhysical Examination
9 H+ R0 x( ?3 r6 {0 T0 c# sThe physical examination revealed a very active,3 M" p- A, H+ O5 r# E0 N# m8 S( `
playful, and healthy boy. The vital signs documented/ I! f; l' g6 y- u8 C( |: `
a blood pressure of 85/50 mm Hg, his length was1 {7 ^1 E* v  @) B
90 cm (>97th percentile), and his weight was 14.4 kg: ]! K2 Q  y' Q' x+ F9 k2 f
(also >97th percentile). The observed yearly growth
8 m+ q1 B+ n2 h: x+ evelocity was 30 cm (12 inches). The examination of
( B: p( j9 p. f+ m* w# Uthe neck revealed no thyroid enlargement.- }" |  `! e3 f3 j: j
The genitourinary examination was remarkable for
- k. @/ ^! _: h! wenlargement of the penis, with a stretched length of  V8 u  J- P6 S
8 cm and a width of 2 cm. The glans penis was very well( m7 R6 a2 J- o$ j0 n  j* M
developed. The pubic hair was Tanner II, mostly around
4 T- ~7 h3 x6 k5 R540
* i8 p, F9 H6 C: tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 F: ]& a4 f' l4 c% V$ L% U. d, I8 }
the base of the phallus and was dark and curled. The
& K+ m8 ^$ C- Y, ?0 Ltesticular volume was prepubertal at 2 mL each.
+ R  b. V9 ]3 a" aThe skin was moist and smooth and somewhat1 E, R! o& y& A& V# I/ b' V4 L) h
oily. No axillary hair was noted. There were no
7 B$ S6 p- q4 x$ u3 M$ }& ]abnormal skin pigmentations or café-au-lait spots.
( @9 {: [- g7 W  mNeurologic evaluation showed deep tendon reflex 2+( O6 q/ a2 ~  ]' V/ o
bilateral and symmetrical. There was no suggestion; F! d0 I) x6 K& s
of papilledema.0 ?8 Z( [: x/ w; C+ B; t* w
Laboratory Evaluation
# K* P# n  M1 n, H& i5 i% d  ZThe bone age was consistent with 28 months by
# A1 @! Y- K9 Dusing the standard of Greulich and Pyle at a chrono-
  P/ o% Q* c1 @logic age of 16 months (advanced).5 Chromosomal
3 C6 m* I0 \4 Akaryotype was 46XY. The thyroid function test: d3 j9 G1 o; l4 |0 G' Y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 Q! k) l) j& I8 B8 x
lating hormone level was 1.3 µIU/mL (both normal).' ?9 A  K, W1 b) y' \
The concentrations of serum electrolytes, blood
" [+ M9 n6 W6 d6 v' K& surea nitrogen, creatinine, and calcium all were
6 T! \$ U4 z( `. l  c$ W" Fwithin normal range for his age. The concentration
9 R) J# l+ ~6 [) E2 B$ ~of serum 17-hydroxyprogesterone was 16 ng/dL0 ^% V; L3 m$ S% c- v) |
(normal, 3 to 90 ng/dL), androstenedione was 20
+ z; {. I9 ~6 ^' ^0 ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 _' h; e- v  v' J& xterone was 38 ng/dL (normal, 50 to 760 ng/dL),( N; r+ p; ?+ l+ b/ [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; e% H* T, p. K5 l& |" ?) k8 O; L1 ]7 K
49ng/dL), 11-desoxycortisol (specific compound S)3 V9 R! I; m# ?( q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, R$ X! i7 {- [6 Q2 f" D. v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: Y/ [  M1 }4 s$ e  p( |+ B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" o1 O/ C1 q8 H4 [and β-human chorionic gonadotropin was less than
4 p  }7 X( L1 h9 P2 r  s7 y* x5 mIU/mL (normal <5 mIU/mL). Serum follicular5 I# t* k6 L8 r9 {% g
stimulating hormone and leuteinizing hormone
+ B$ a: D7 ^' Z, D& E) wconcentrations were less than 0.05 mIU/mL$ o9 I& ?( ]2 E2 R( ]. y
(prepubertal).
9 e* }% e+ t+ J0 e/ q- RThe parents were notified about the laboratory# t, S  c0 M8 Y$ d; A& ~! v4 |
results and were informed that all of the tests were
$ t. r* ^  E) H9 r2 Wnormal except the testosterone level was high. The4 |1 u1 A! X) g, P: o# C; [# ^4 |
follow-up visit was arranged within a few weeks to
: [+ ^! L" B. i$ ?1 ~obtain testicular and abdominal sonograms; how-7 n1 ?7 H) x# M3 B
ever, the family did not return for 4 months.
+ l1 D$ ]. c. ePhysical examination at this time revealed that the9 c: ^, y/ X9 l8 i; Z
child had grown 2.5 cm in 4 months and had gained3 |3 @6 L- ?0 l  L2 }) q+ ~0 _* U
2 kg of weight. Physical examination remained
( o1 K/ ]: ~* L# T) U& W3 Wunchanged. Surprisingly, the pubic hair almost com-2 g7 G/ p* B0 J6 x- \9 m
pletely disappeared except for a few vellous hairs at
2 N) e3 r  q& y1 G/ A1 athe base of the phallus. Testicular volume was still 2
8 a% k. i  U' j* W; m) e# ZmL, and the size of the penis remained unchanged.
* V& f7 b* A* a0 w  vThe mother also said that the boy was no longer hav-0 N0 j! B+ U  b& v. G; _
ing frequent erections.
! ^/ W8 S* v; h" F0 h  G+ zBoth parents were again questioned about use of0 B0 d% C" z; P& u( j$ A
any ointment/creams that they may have applied to& Y" U0 k4 e+ e3 f
the child’s skin. This time the father admitted the
8 d- N. H9 t3 G: V( ?Topical Testosterone Exposure / Bhowmick et al 541. m( Z& w' d4 K
use of testosterone gel twice daily that he was apply-
4 A+ b* s9 P: ?0 V3 s. h2 x5 g0 g' aing over his own shoulders, chest, and back area for
6 {) Y; w, Q$ v% h) E" Xa year. The father also revealed he was embarrassed& Z  d. n1 D4 h4 p$ w  v0 T
to disclose that he was using a testosterone gel pre-
4 Y  B- r; h% H* O- }* \8 Y/ P- G0 }scribed by his family physician for decreased libido8 P! g9 K2 H4 U
secondary to depression.
1 w: s6 E* V5 z/ g2 J0 j3 DThe child slept in the same bed with parents.
0 a! Z0 h: l( WThe father would hug the baby and hold him on his
4 c9 n. E8 n# M( H2 Z7 z1 R5 Pchest for a considerable period of time, causing sig-
/ @, [0 ?# U+ q0 P  i4 jnificant bare skin contact between baby and father.
0 }& O* Z7 n, }6 g8 ~" {The father also admitted that after the phone call,
5 R9 m9 F& Z+ }# `: t" Fwhen he learned the testosterone level in the baby
# u& m9 u& ~7 zwas high, he then read the product information
3 k5 z' ^6 T8 G0 T0 npacket and concluded that it was most likely the rea-
, ~$ y9 J+ a" N& m) H& Cson for the child’s virilization. At that time, they2 g; x! j: _5 D; e0 E4 V6 t1 W
decided to put the baby in a separate bed, and the' K, x5 w# ]6 h( f  k( h6 P
father was not hugging him with bare skin and had
- X7 k( n1 z% V  B" |been using protective clothing. A repeat testosterone
& v6 ]0 c$ h' D& w# M4 m6 H1 a9 ^. a% Otest was ordered, but the family did not go to the/ T0 ?8 O# c, W
laboratory to obtain the test.
8 e& u8 A: N* D& \3 d& z3 ]Discussion" M  \$ g: t8 i5 O- C  u9 B8 n
Precocious puberty in boys is defined as secondary( @+ D/ z  o) j5 l
sexual development before 9 years of age.1,47 e8 T# m# [- W& o% Q# T4 B
Precocious puberty is termed as central (true) when! [& _; U2 O2 a! z9 _+ L; Q& g# M
it is caused by the premature activation of hypo-
9 D: G5 l9 J) s' D8 Uthalamic pituitary gonadal axis. CPP is more com-
$ Q. C+ p3 `& t8 Pmon in girls than in boys.1,3 Most boys with CPP8 d* V6 G$ j4 K- I3 }
may have a central nervous system lesion that is
$ p. o1 S  a) q$ ~1 y; }( h; lresponsible for the early activation of the hypothal-
8 Q: Z- L2 c; X+ Q. O! Zamic pituitary gonadal axis.1-3 Thus, greater empha-2 H* |/ i$ E8 e% \
sis has been given to neuroradiologic imaging in
$ t9 A6 a7 g7 b7 @$ sboys with precocious puberty. In addition to viril-
1 Q+ m% F7 T  p: r1 aization, the clinical hallmark of CPP is the symmet-
+ \: U: S. U3 irical testicular growth secondary to stimulation by3 G( [2 L& F6 G9 o- W% T. T' `0 J
gonadotropins.1,3- n2 a; ^6 p7 f- D: D* D0 ?) H
Gonadotropin-independent peripheral preco-
7 H/ O; c, z( I3 Pcious puberty in boys also results from inappropriate% V7 \: \, g! _8 Y
androgenic stimulation from either endogenous or$ z3 Z1 l! _# l9 _
exogenous sources, nonpituitary gonadotropin stim-& d$ Z1 q! F2 A# C
ulation, and rare activating mutations.3 Virilizing$ N0 I6 `* J4 z! U% P$ _% }6 \
congenital adrenal hyperplasia producing excessive
  E" [6 P+ y! q6 Dadrenal androgens is a common cause of precocious
2 G$ x/ m& R' Y; \# p; M; f' Spuberty in boys.3,46 J/ _1 ^8 A4 S; X5 S
The most common form of congenital adrenal
1 `7 `6 t5 R9 _( ?hyperplasia is the 21-hydroxylase enzyme deficiency.- X2 k' P" Q% S, Q' E1 ^# A
The 11-β hydroxylase deficiency may also result in
% p, A4 K$ q- L9 Z, q4 b/ Oexcessive adrenal androgen production, and rarely," Z# g1 Z9 }" p8 o! X, c
an adrenal tumor may also cause adrenal androgen
7 S/ o$ X: k5 x: Y+ t2 s9 `" p$ ]9 mexcess.1,3
% m$ ]. S/ A: c5 m7 B2 }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ @9 H  g- U# k: i% N- @
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 R- ]- K. B: V/ t/ vA unique entity of male-limited gonadotropin-
1 P8 A7 U! F5 m% Z" O  uindependent precocious puberty, which is also known, L+ U  L2 r0 c; H6 h6 ~
as testotoxicosis, may cause precocious puberty at a
+ i) L6 p, {' g/ Kvery young age. The physical findings in these boys# j1 Z6 v8 K* U" i+ E$ o) [$ @
with this disorder are full pubertal development,
3 R  e. _* d0 R0 ~) ]including bilateral testicular growth, similar to boys
3 T! }5 A: g) E7 ?with CPP. The gonadotropin levels in this disorder0 i! p/ q+ L& L/ p6 @
are suppressed to prepubertal levels and do not show& w. U$ J7 G$ ?' B! s8 g, Q  Q
pubertal response of gonadotropin after gonadotropin-
8 L* T* f& b9 v* Creleasing hormone stimulation. This is a sex-linked
% p% |5 y- j8 r' O; j" kautosomal dominant disorder that affects only" G) ]6 p5 E6 {/ h) r+ G: A+ d
males; therefore, other male members of the family" @" b. r0 Q5 ]$ ^- P6 c# w
may have similar precocious puberty.33 C1 R4 |, g5 ?7 g! n- Y
In our patient, physical examination was incon-8 t* \# h1 N5 n3 f2 n, c# e
sistent with true precocious puberty since his testi-
9 x* K6 \9 k9 u6 vcles were prepubertal in size. However, testotoxicosis
8 o2 J3 i, l1 v5 {6 V5 Uwas in the differential diagnosis because his father; Q6 h; A& h( \" e
started puberty somewhat early, and occasionally,7 N  v" `1 v% W
testicular enlargement is not that evident in the- K5 c) ~) X; b# a( e6 V
beginning of this process.1 In the absence of a neg-
' L$ ?( F' ?: s3 H; x. oative initial history of androgen exposure, our% `: {; x9 n1 T
biggest concern was virilizing adrenal hyperplasia,( f$ ]$ i3 S% n/ p' c. k' ^( g
either 21-hydroxylase deficiency or 11-β hydroxylase+ q: M+ d8 n1 u: d
deficiency. Those diagnoses were excluded by find-; [2 F0 V" c. b4 n( f) i
ing the normal level of adrenal steroids.
1 o  x' C" ?# {The diagnosis of exogenous androgens was strongly- d' C2 \. t% R# y
suspected in a follow-up visit after 4 months because0 j3 }7 _4 @! B6 k: ^% W7 u
the physical examination revealed the complete disap-$ M/ C+ w! [5 J% R8 z$ u
pearance of pubic hair, normal growth velocity, and0 A! x- d6 P& m& w$ S0 U! C
decreased erections. The father admitted using a testos-6 S* Q- ^' }4 @
terone gel, which he concealed at first visit. He was
5 K$ V% |/ L( {8 Vusing it rather frequently, twice a day. The Physicians’
: S. x0 z  v5 G" q+ DDesk Reference, or package insert of this product, gel or
# x7 w& K! X9 }8 U! d/ ccream, cautions about dermal testosterone transfer to
" B1 C: J/ j& u) V! J# Yunprotected females through direct skin exposure.
/ D$ [; X4 R" `6 F* U" ASerum testosterone level was found to be 2 times the8 z6 s, A& N, P! j
baseline value in those females who were exposed to1 d' T& C2 b6 ^) I- N0 {  l; ^* Q
even 15 minutes of direct skin contact with their male
. G8 b. `/ i$ \8 D. C; zpartners.6 However, when a shirt covered the applica-" s3 Z1 T$ L- x7 P6 W, Q
tion site, this testosterone transfer was prevented.+ ?. R- x  U7 P) W
Our patient’s testosterone level was 60 ng/mL,
0 H9 \) u, t2 U: t  Gwhich was clearly high. Some studies suggest that
; J1 p' I9 W9 {& l7 Edermal conversion of testosterone to dihydrotestos-
* g9 p9 r/ l  y3 b8 bterone, which is a more potent metabolite, is more' h1 U& p* D" T5 x
active in young children exposed to testosterone
" [% ]' t9 |% v  N; cexogenously7; however, we did not measure a dihy-
5 w: x, G5 @2 bdrotestosterone level in our patient. In addition to
1 b! b5 I: r7 [virilization, exposure to exogenous testosterone in- I) {1 o" w1 Z0 _: z6 Q: g/ `3 W
children results in an increase in growth velocity and
: l& r) X% i+ l7 @0 V3 radvanced bone age, as seen in our patient.
" O' X$ w" _! D1 }6 i0 {The long-term effect of androgen exposure during" s4 j4 p- @; {0 N' t/ d
early childhood on pubertal development and final
, U3 o" ?* y4 F% `1 fadult height are not fully known and always remain& p4 a- F2 a( d. O8 e/ [% g
a concern. Children treated with short-term testos-
, s( `% {' m2 e) c; r4 W3 aterone injection or topical androgen may exhibit some  K: E  M; ?2 W/ O5 x8 O: i# g
acceleration of the skeletal maturation; however, after
* t$ J# S1 Z% E- h& ^; S' tcessation of treatment, the rate of bone maturation+ W& u6 y) M$ {( ^. f. U# f
decelerates and gradually returns to normal.8,9  k% p% _" f+ X4 h& [
There are conflicting reports and controversy6 @, C, V4 ~* n2 V2 x. k+ z
over the effect of early androgen exposure on adult
- L0 c6 D" k6 k' g: \8 H3 rpenile length.10,11 Some reports suggest subnormal: }' F  I% Y4 b
adult penile length, apparently because of downreg-$ G" {2 d6 `& r
ulation of androgen receptor number.10,12 However,
  E, B& i, ^5 c9 ?Sutherland et al13 did not find a correlation between8 z% I+ a2 N8 o2 o, o
childhood testosterone exposure and reduced adult9 N) b1 O) s. X2 p" E* a: W
penile length in clinical studies./ U! _& B" h1 B3 K) B/ d4 [
Nonetheless, we do not believe our patient is. N% N  l0 I1 H- T5 W
going to experience any of the untoward effects from% v2 f8 F1 Q; h  u4 u7 @8 Z9 @
testosterone exposure as mentioned earlier because
$ p! N. ~/ t8 T# Nthe exposure was not for a prolonged period of time.
3 E) v9 K4 c0 V% G! j0 Q: SAlthough the bone age was advanced at the time of" q" q+ [5 `" d% D7 Q4 G8 w
diagnosis, the child had a normal growth velocity at/ ^2 v) t, {3 s) q
the follow-up visit. It is hoped that his final adult, {6 V% X( J  w5 [! m
height will not be affected.
- E( K  |' A/ X4 W7 O. u3 SAlthough rarely reported, the widespread avail-
6 H+ {/ u0 }  p, ^ability of androgen products in our society may, e" T% B1 z& a+ L# p9 `& I7 z
indeed cause more virilization in male or female
; i5 o- {. D4 v' Ochildren than one would realize. Exposure to andro-$ T/ J( {( f! T& W
gen products must be considered and specific ques-
1 a! j$ r7 J* P( ?; ~. X& stioning about the use of a testosterone product or
8 ^% Y& k% U2 f- M. B, }. A% Xgel should be asked of the family members during7 D6 O+ O7 L) ?. M' p- ?
the evaluation of any children who present with vir-
' L( A3 X/ U$ E$ silization or peripheral precocious puberty. The diag-
* ~6 y4 F& D# G% vnosis can be established by just a few tests and by
, R/ |8 K! p2 c# ^appropriate history. The inability to obtain such a
* U7 e% D2 [0 {8 U: g8 B, d; ehistory, or failure to ask the specific questions, may  f! S/ S- x. X3 l& [" v' b
result in extensive, unnecessary, and expensive
; U2 |9 H# V: Y6 _6 @/ Hinvestigation. The primary care physician should be9 n0 I! M+ M7 |3 K8 \* a
aware of this fact, because most of these children% L+ n3 h! S* E) Z$ i
may initially present in their practice. The Physicians’
* a/ y$ r* M9 ~! m; S; RDesk Reference and package insert should also put a
* ]  v, N1 F9 @1 B# ^- _' [1 ^( hwarning about the virilizing effect on a male or. f5 l; f0 l: ^5 ]; o
female child who might come in contact with some-
# n; x2 ~( O* ?- @one using any of these products.: m0 g3 j" j8 L0 z) C0 r; P( q
References
" a1 t9 `% n* q1. Styne DM. The testes: disorder of sexual differentiation# X+ B4 H7 h# V0 `" s$ z' x+ p6 \
and puberty in the male. In: Sperling MA, ed. Pediatric
6 U- n) N- l$ @3 A( x6 KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 K9 C9 k- f4 q. Z7 Q) V2002: 565-628.
; @1 e" _8 `9 t' G7 |' g) @# j# {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, [* V& z% J2 V; a, h& npuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old' x) N# h* Z0 `6 b& N8 I; g) o. R
Boy Induced by Indirect Topical
, b# C' l' D" @5 ^* K1 S* \Exposure to Testosterone- r7 j. ?5 y: \2 A& }, }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% ]* H: y) [0 f5 i$ }  fand Kenneth R. Rettig, MD13 y5 c5 h) U/ E/ j4 m% C1 ~. q
Clinical Pediatrics
+ w7 M3 s5 ^, Q! s5 \  a0 GVolume 46 Number 6' Y* j6 L' h4 q( Z) k# f
July 2007 540-543
! f+ ~6 P, M8 t$ ?& `3 {© 2007 Sage Publications
4 ^8 O7 w4 V5 O. w10.1177/0009922806296651
' P" T2 N$ w- M$ M# J- Uhttp://clp.sagepub.com0 u$ Y! \, A* o. n% e2 ?- E. O
hosted at; W. `- O/ e0 S: W% w
http://online.sagepub.com. l3 l1 X$ E4 L9 f! W2 a4 C
Precocious puberty in boys, central or peripheral,6 B  I# x+ D* l
is a significant concern for physicians. Central0 i" ?9 q8 k. h- F0 h3 d
precocious puberty (CPP), which is mediated" V; ?8 O/ ], z; Q( }. b/ G( X
through the hypothalamic pituitary gonadal axis, has
$ i8 R; j4 t2 T& Va higher incidence of organic central nervous system9 O+ I$ j8 B1 d& V! `1 z; m
lesions in boys.1,2 Virilization in boys, as manifested
  s6 O7 ~; w' P7 X1 H- }by enlargement of the penis, development of pubic
. h: ~" V! e, M3 ehair, and facial acne without enlargement of testi-8 n% j6 m; g4 p* R' m3 `+ E, N3 c
cles, suggests peripheral or pseudopuberty.1-3 We$ y, t; {2 L* x6 V* d
report a 16-month-old boy who presented with the
! w' X4 L: ?5 }3 m: N# {% Renlargement of the phallus and pubic hair develop-4 Y4 H: W8 a. [1 W" t
ment without testicular enlargement, which was due; W4 i9 q* _/ e& i8 U
to the unintentional exposure to androgen gel used by" l6 q% J% p2 W
the father. The family initially concealed this infor-
& m' u8 s1 g8 `6 @mation, resulting in an extensive work-up for this
) g) |, i% }* e/ t+ W) p) schild. Given the widespread and easy availability of3 k2 m; z$ t! u+ Y
testosterone gel and cream, we believe this is proba-
1 T: z; H. p/ L+ Lbly more common than the rare case report in the
. A6 E1 f* V5 vliterature.4
1 `- H' }, A5 P6 l& Q0 J, PPatient Report
- l) X# Z  [& s" U7 e0 ~! XA 16-month-old white child was referred to the
' i1 ?. ?2 x* b5 N1 U' x, _) sendocrine clinic by his pediatrician with the concern) F# |. d8 o' f/ C$ t1 [
of early sexual development. His mother noticed
) i, M- x8 M) A2 wlight colored pubic hair development when he was
3 h# v% L8 O% U2 E" UFrom the 1Division of Pediatric Endocrinology, 2University of& p9 f; y0 i6 {5 ]
South Alabama Medical Center, Mobile, Alabama.8 K# O& h, L$ \, i
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# ]. c7 B: B+ X1 B( _  u# wProfessor of Pediatrics, University of South Alabama, College of
3 ~# F* i! h9 b# [$ ?" ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ u6 W" o* a  j& |% Xe-mail: [email protected].4 n0 m3 R( Q- d- n" {# F1 f
about 6 to 7 months old, which progressively became
  D) y$ D  u( b$ M4 U/ edarker. She was also concerned about the enlarge-$ j6 g+ }; h0 r7 _
ment of his penis and frequent erections. The child- o3 e$ b" h  F& f$ H9 x6 [4 p
was the product of a full-term normal delivery, with
, A. q0 ]: ^: c  da birth weight of 7 lb 14 oz, and birth length of- G# \; C, p; a
20 inches. He was breast-fed throughout the first year. b7 K/ H# N, X6 y
of life and was still receiving breast milk along with
( V+ i- P# p6 i3 K7 Qsolid food. He had no hospitalizations or surgery,4 O/ b$ \% Q' B) U3 V7 d/ D5 T+ i
and his psychosocial and psychomotor development
" o; |7 t% A. l0 _was age appropriate.1 S$ G& x  \, F1 R
The family history was remarkable for the father,
$ j) f- r$ o! d" b/ nwho was diagnosed with hypothyroidism at age 16,
" @" z& o' y3 W- G# C3 l- bwhich was treated with thyroxine. The father’s* C; C& p. c# y; e9 Y
height was 6 feet, and he went through a somewhat+ ~$ ?. A' A+ P8 r; ]
early puberty and had stopped growing by age 14.
2 [! E: O+ E6 L- ], CThe father denied taking any other medication. The
5 L+ G" _7 I% O# T+ N2 w7 bchild’s mother was in good health. Her menarche# c- f$ j/ w9 P& y# T$ U
was at 11 years of age, and her height was at 5 feet6 s; ?0 J1 W: L  H1 u9 A2 S0 P
5 inches. There was no other family history of pre-" n$ u8 C- W/ C5 \5 a9 T8 k. e& n
cocious sexual development in the first-degree rela-
. g4 E+ D9 H  t# O$ Ltives. There were no siblings.. [: @4 N2 n0 ?$ }. G- G
Physical Examination5 a( p  d5 F$ z' {1 A+ k; B
The physical examination revealed a very active,+ v4 ?8 [8 n1 |' h6 P
playful, and healthy boy. The vital signs documented
- j2 y$ C; Q! K5 o+ k( ^1 c1 I& f( @a blood pressure of 85/50 mm Hg, his length was
, D. \( H0 C/ Z! u' A6 [90 cm (>97th percentile), and his weight was 14.4 kg6 k  Z3 o5 r4 W# g8 w( }( L4 s
(also >97th percentile). The observed yearly growth
- j. {% Z' \) y' S# x/ j1 [velocity was 30 cm (12 inches). The examination of- I8 D6 v6 v+ J+ t* B) y% i
the neck revealed no thyroid enlargement.6 Q/ e) k$ U5 b0 Z3 E4 g
The genitourinary examination was remarkable for  I1 D7 u, _7 G- d6 E1 O% Z
enlargement of the penis, with a stretched length of
# t( @  }4 U( z) r( T8 cm and a width of 2 cm. The glans penis was very well2 E1 U1 k/ B7 ~  l9 B- B! p  f
developed. The pubic hair was Tanner II, mostly around
4 s7 J! Q" S, ~540/ N8 t' a7 K8 @& i, c* W8 j" B6 k
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the base of the phallus and was dark and curled. The+ e* D' U6 }9 P3 i, O
testicular volume was prepubertal at 2 mL each.; a# o* h+ S$ u# v/ S; L9 J/ d( w
The skin was moist and smooth and somewhat
( I0 E7 m' b% y/ E* Eoily. No axillary hair was noted. There were no+ q* @8 F/ u: T+ S6 e0 D8 n
abnormal skin pigmentations or café-au-lait spots.
! x$ c8 H# Q. V& n3 f4 y& ~: xNeurologic evaluation showed deep tendon reflex 2+
$ w% q1 F% l0 P/ T; c3 k( _! ebilateral and symmetrical. There was no suggestion
9 N; Q, h: E8 Xof papilledema.& p- a: V! u$ N/ Y% Q
Laboratory Evaluation
4 C& ?8 c  l  b2 I& l& HThe bone age was consistent with 28 months by8 G# O1 k' Z& [7 M5 m( i
using the standard of Greulich and Pyle at a chrono-. c' D% V/ y0 S) l5 P
logic age of 16 months (advanced).5 Chromosomal
. s9 \( |: S' }/ p2 D" b' b' Kkaryotype was 46XY. The thyroid function test
+ l0 J( d3 Z, v% }showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. ?) E& q/ E. p% I! N0 Olating hormone level was 1.3 µIU/mL (both normal).
1 j0 E2 k; Y7 Q: @& c  v3 VThe concentrations of serum electrolytes, blood& p- y- @" z$ f7 F& _9 A& J
urea nitrogen, creatinine, and calcium all were
1 Z1 e: G( e0 E0 S$ |9 ?( p8 ^, Owithin normal range for his age. The concentration6 z1 y9 L1 O0 e) H: W
of serum 17-hydroxyprogesterone was 16 ng/dL
- c% G: |+ D0 C$ w- c(normal, 3 to 90 ng/dL), androstenedione was 20
  W6 ]5 v' c, ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. y+ C  r) q( m" P4 S3 T- {/ }terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 k* e; C# L/ l- Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 y' j, g& l' R6 s
49ng/dL), 11-desoxycortisol (specific compound S). L+ e+ \5 X' ^4 C
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( z% j. Q3 m; G) p0 R' C4 W: z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& B2 o( x$ m! [% I$ W& W6 Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 i) d- k# X: c; \' l8 v/ @
and β-human chorionic gonadotropin was less than
# T9 t+ y5 S9 O" O9 v4 x: v+ X2 r. M5 mIU/mL (normal <5 mIU/mL). Serum follicular
: x) n( O5 a- g% Y& N2 b* l/ u( M0 \stimulating hormone and leuteinizing hormone
8 N+ S, U. @$ o* Uconcentrations were less than 0.05 mIU/mL/ Z2 e$ Q; l4 U# l
(prepubertal).  }6 \! `) Y, }+ c2 }) T
The parents were notified about the laboratory
, i' a% p; y6 F. }results and were informed that all of the tests were
* t; p1 g  }( t; `8 hnormal except the testosterone level was high. The
7 y2 e( Z- Q& |; nfollow-up visit was arranged within a few weeks to
* N) w# X' H/ r* y. q6 x$ fobtain testicular and abdominal sonograms; how-
) i1 t: ?8 v3 a" y8 e( wever, the family did not return for 4 months.
/ @7 j) d* r! LPhysical examination at this time revealed that the
# d9 }; R7 Y& @child had grown 2.5 cm in 4 months and had gained, G* `' @8 x# i
2 kg of weight. Physical examination remained' |# p" t4 a, y
unchanged. Surprisingly, the pubic hair almost com-! |* |1 [' |7 Q" M
pletely disappeared except for a few vellous hairs at
6 {" q$ i/ Z' A# S' `. n. uthe base of the phallus. Testicular volume was still 2
1 R9 g2 C8 M0 `& C& [. `* OmL, and the size of the penis remained unchanged.
, x  `4 O& T8 L& Q+ {The mother also said that the boy was no longer hav-
  C, X; F' a+ B3 C; i2 p6 k0 D1 R8 _ing frequent erections.3 i3 C1 U/ Y9 [- T- q5 @/ [1 c
Both parents were again questioned about use of
: ]7 {  }5 }$ A4 @any ointment/creams that they may have applied to+ u6 y; G0 X0 ?( b% x& e# Y, ?
the child’s skin. This time the father admitted the0 M6 k* |+ ~/ K$ j. G8 J
Topical Testosterone Exposure / Bhowmick et al 541
4 p: t, ~1 V5 }# P9 ^& j, W6 Puse of testosterone gel twice daily that he was apply-
# V% w- W6 ~, W  e. q5 i1 ^8 \4 N. Aing over his own shoulders, chest, and back area for; e7 {' |/ m  g9 M+ a  Q9 n
a year. The father also revealed he was embarrassed
+ i/ T0 c. o0 M  p) Dto disclose that he was using a testosterone gel pre-
# ^6 l( X5 E; i9 s  P2 escribed by his family physician for decreased libido0 F) E# b* \6 Z: e8 r
secondary to depression.( r3 S7 {) V$ B; c! }
The child slept in the same bed with parents.9 @6 l% ?; Q* M1 _$ B; [7 [
The father would hug the baby and hold him on his
( {5 m( Y5 l% _% lchest for a considerable period of time, causing sig-/ K/ \- ]- ~! }
nificant bare skin contact between baby and father.
- P! J1 A/ w6 kThe father also admitted that after the phone call,6 S$ A4 L/ B- Y, B
when he learned the testosterone level in the baby  M+ z% ~) ~) c5 g$ b! t# M
was high, he then read the product information" b5 b$ T9 S9 Z$ [" u
packet and concluded that it was most likely the rea-' v2 C" g; P5 B% e3 G1 Z
son for the child’s virilization. At that time, they4 J6 B" B; D4 G$ k  e9 M! F
decided to put the baby in a separate bed, and the+ l8 Y% S% g7 [1 K' S- a% `& f
father was not hugging him with bare skin and had9 z0 ~1 v( j/ b4 _1 S2 N
been using protective clothing. A repeat testosterone/ O6 f# g" L2 i; _
test was ordered, but the family did not go to the
- [+ N1 ~9 E! v' ]laboratory to obtain the test.
) _  ^7 q# t& I9 ~6 ?- C& {Discussion/ s( J# `8 b8 h2 ^1 D+ f6 ?0 j# W; l& l
Precocious puberty in boys is defined as secondary' Z5 m: j4 L6 S* N1 t
sexual development before 9 years of age.1,4
' `* Q+ i$ ?6 R* y; sPrecocious puberty is termed as central (true) when3 H) g9 p3 y+ a6 O( X
it is caused by the premature activation of hypo-
" x3 e, U  K- y$ W/ D9 F) h+ Uthalamic pituitary gonadal axis. CPP is more com-
* ]9 ~0 @; B9 z% U- E. G3 k+ Imon in girls than in boys.1,3 Most boys with CPP9 S! D. E# X; X' D/ R, U
may have a central nervous system lesion that is
% U7 `7 V" D, Kresponsible for the early activation of the hypothal-9 m; @% J  @$ S* v
amic pituitary gonadal axis.1-3 Thus, greater empha-& I5 E& N" `  b
sis has been given to neuroradiologic imaging in
5 O4 q( e7 t2 X* t  R+ N5 Cboys with precocious puberty. In addition to viril-0 P" K0 V- b" d3 a
ization, the clinical hallmark of CPP is the symmet-
2 C; i) N" M# S1 drical testicular growth secondary to stimulation by) ~( r$ u- K8 b. L
gonadotropins.1,3' {5 o# k& t4 Y
Gonadotropin-independent peripheral preco-( Z, |, b" _0 ~6 f, ~" m& A
cious puberty in boys also results from inappropriate$ E7 V+ R' X3 ~3 b
androgenic stimulation from either endogenous or
- p8 B3 K- o$ C. S7 S# dexogenous sources, nonpituitary gonadotropin stim-
% D& N6 Z" ~) {' hulation, and rare activating mutations.3 Virilizing
0 u3 \  |5 }$ A. A' H" u5 V8 _congenital adrenal hyperplasia producing excessive; Y1 f8 T2 p. G
adrenal androgens is a common cause of precocious' S3 S2 _/ ]7 _+ }5 h9 K! I! r
puberty in boys.3,4
3 E6 V; J- @9 X+ U7 V, \, dThe most common form of congenital adrenal' R1 t; K8 [* J1 p8 N, D0 d
hyperplasia is the 21-hydroxylase enzyme deficiency.6 k* e& v4 ~5 O. C$ {/ I+ o
The 11-β hydroxylase deficiency may also result in
/ q- s2 M2 N9 V8 R- l; p* F6 L3 Cexcessive adrenal androgen production, and rarely,3 l) L$ u2 ^- e3 Z, y; q) y6 F+ f- G
an adrenal tumor may also cause adrenal androgen* f9 W4 v- O) H: m6 e2 ^  D
excess.1,3) b4 Y* @! E7 t/ w. o
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542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, ~8 O2 Q* q2 t1 @# L& f
A unique entity of male-limited gonadotropin-
! s( h- O/ p$ Lindependent precocious puberty, which is also known
  z: j/ N7 _6 O- _. V1 m9 g" E! n/ Eas testotoxicosis, may cause precocious puberty at a! ^3 v: @4 h0 m9 F% |  V* N
very young age. The physical findings in these boys
; w/ T$ D" R, v$ B5 d3 ~; P/ @with this disorder are full pubertal development,
+ \8 ]6 R/ m& a# j: M- fincluding bilateral testicular growth, similar to boys' |4 R* S* J2 c! Y1 b- L/ V
with CPP. The gonadotropin levels in this disorder
# D3 v. z5 }5 o( Sare suppressed to prepubertal levels and do not show- T2 L% C/ X7 l8 }4 Y
pubertal response of gonadotropin after gonadotropin-
- z9 m9 O& R/ \9 H$ Vreleasing hormone stimulation. This is a sex-linked4 }4 F3 ^3 |) v
autosomal dominant disorder that affects only* g* T. `1 A6 o6 b: f
males; therefore, other male members of the family% U, s. Q$ {/ r% @6 A, I
may have similar precocious puberty.36 X2 D# P2 z6 Y/ W3 ?" A& y. @9 S
In our patient, physical examination was incon-' G( Z- y1 d+ @% C! c! t# K! {
sistent with true precocious puberty since his testi-
4 ^" Y- ~  W5 M+ j9 N, F; ]; ecles were prepubertal in size. However, testotoxicosis
0 v3 p" d' p( v+ v! _& {' nwas in the differential diagnosis because his father
- N, Y1 R' O4 ~' d9 hstarted puberty somewhat early, and occasionally,
2 q% n  x$ H: e, Itesticular enlargement is not that evident in the
/ D. N* `4 T- C6 W7 F+ T6 i  pbeginning of this process.1 In the absence of a neg-
/ H! q# i4 a- e! I7 H( k8 z* Gative initial history of androgen exposure, our" [8 `' d5 s3 a" k* _
biggest concern was virilizing adrenal hyperplasia,/ Z5 y& T1 L' G& B
either 21-hydroxylase deficiency or 11-β hydroxylase0 C: t- Q+ P2 i4 ~4 H
deficiency. Those diagnoses were excluded by find-& Y0 c1 |/ t; D. O- r9 H8 Z
ing the normal level of adrenal steroids." {) A6 }- \0 q/ o1 J" L6 V3 g2 ~/ S
The diagnosis of exogenous androgens was strongly
9 D, i- B* ^3 I: q5 i5 asuspected in a follow-up visit after 4 months because
) t* O: y1 i7 b; Jthe physical examination revealed the complete disap-
3 }$ a. b9 J* Epearance of pubic hair, normal growth velocity, and
1 ?1 }3 Q+ k7 m( D1 adecreased erections. The father admitted using a testos-
# o7 T+ \4 l; q# x6 iterone gel, which he concealed at first visit. He was
6 }, d/ i% Q4 O, Gusing it rather frequently, twice a day. The Physicians’8 s# r4 V0 }% q* H% }7 h# G! M% Q
Desk Reference, or package insert of this product, gel or- K; q" r5 f. b% t- Q/ J" _6 n
cream, cautions about dermal testosterone transfer to0 G! h7 x( e, R9 G, u  t( A
unprotected females through direct skin exposure.
) m! `8 T! e# R( S* ?/ G& X) M* CSerum testosterone level was found to be 2 times the5 v  K' l* v  B
baseline value in those females who were exposed to
% D) j8 R$ U* I- u1 s* yeven 15 minutes of direct skin contact with their male! t. t$ h! v5 G  \, h9 A! D' v
partners.6 However, when a shirt covered the applica-
: k2 Z* R/ r: T5 C# d2 Qtion site, this testosterone transfer was prevented.
" ?& X, \8 U' N- uOur patient’s testosterone level was 60 ng/mL,
6 U1 g, ]) |+ G( T3 wwhich was clearly high. Some studies suggest that9 m# s3 a. _9 O
dermal conversion of testosterone to dihydrotestos-
. D" t8 F3 s# }terone, which is a more potent metabolite, is more$ y2 d  \: @. s7 O* t5 S8 J
active in young children exposed to testosterone4 H# O% E4 \0 I" n3 v! N) {/ P
exogenously7; however, we did not measure a dihy-
' A4 H4 F0 h9 Z2 V- A' W3 Zdrotestosterone level in our patient. In addition to
3 o( q  X2 \3 ~& |virilization, exposure to exogenous testosterone in# y; E! t, b" L5 Q
children results in an increase in growth velocity and  j! z* q- t" s; l
advanced bone age, as seen in our patient.
- K" e  P* D3 yThe long-term effect of androgen exposure during
; M3 t1 A2 H  n* r1 @- m* ^- Z6 {5 Zearly childhood on pubertal development and final
. p/ y  S; @# S# h" r  Jadult height are not fully known and always remain  K, L- v: |5 v- N3 i# M
a concern. Children treated with short-term testos-
  L4 Y: E5 R2 T6 }terone injection or topical androgen may exhibit some
! ~& O$ {; E* f5 Y" _: }" nacceleration of the skeletal maturation; however, after2 W! r# P, S3 y
cessation of treatment, the rate of bone maturation
% A: i3 R- D) S; z% kdecelerates and gradually returns to normal.8,9! y0 B$ {, D$ h$ [# n2 }4 W
There are conflicting reports and controversy6 B; B% h1 E; R, P( e  C; e% Q
over the effect of early androgen exposure on adult! t8 j$ ?4 r2 x
penile length.10,11 Some reports suggest subnormal
3 I' X  K+ }, G- K4 @+ @adult penile length, apparently because of downreg-
: }) F4 y, I4 |# Q7 l3 `ulation of androgen receptor number.10,12 However,9 C- V7 Y1 k# O" T, i; P, }
Sutherland et al13 did not find a correlation between
! U( u9 @4 ~/ u8 R! K1 Ochildhood testosterone exposure and reduced adult
: d2 d# ^3 F) f. K4 F7 Epenile length in clinical studies.
+ e3 h. Y$ |* U4 q5 \- ]- PNonetheless, we do not believe our patient is
  H3 O/ I" l* m8 D! @2 \: n) {' Y- G7 ^going to experience any of the untoward effects from1 a% e; j  m- c( C8 c. H- Z/ F) \0 ?
testosterone exposure as mentioned earlier because
# L# v7 H* _; v# ~+ U) Wthe exposure was not for a prolonged period of time.
; l$ S+ |  ?2 j0 g( ^9 QAlthough the bone age was advanced at the time of
" y4 A% J) |3 \, udiagnosis, the child had a normal growth velocity at& T* h6 c- E) |  w/ H: R' ^4 o
the follow-up visit. It is hoped that his final adult
1 _  E: a% I: H, Fheight will not be affected.
" B& a( I% [0 i3 H# A7 FAlthough rarely reported, the widespread avail-
( G' }& b1 e. T  Nability of androgen products in our society may
8 m8 U# b9 u( B6 Q( V7 q+ n5 U5 ~indeed cause more virilization in male or female3 G' J2 V% v+ E
children than one would realize. Exposure to andro-
6 N( t$ x5 ?1 R. V  igen products must be considered and specific ques-
, Z. e' q1 K$ y! W8 vtioning about the use of a testosterone product or7 M9 `& `$ b' e+ E
gel should be asked of the family members during$ ?( ?7 T  w* \! Q9 |, c
the evaluation of any children who present with vir-
( z: p1 Y. N9 W5 _( ~6 |3 ?; Ailization or peripheral precocious puberty. The diag-# {3 m" P7 f( r) e) D
nosis can be established by just a few tests and by
( Z3 w  m, ^, H% r: Iappropriate history. The inability to obtain such a/ G9 A5 u7 ~2 g4 g: i; d* t
history, or failure to ask the specific questions, may
$ k* G. t( K2 |- G4 Iresult in extensive, unnecessary, and expensive
% V. y6 k4 B! Z2 f5 M0 Tinvestigation. The primary care physician should be  G4 i4 r# y1 b# e$ C& y8 W
aware of this fact, because most of these children3 j* g$ d7 ?- y/ w
may initially present in their practice. The Physicians’
. w+ F( B: l( cDesk Reference and package insert should also put a5 F9 A' Y0 U3 m2 g% q2 _0 V2 L
warning about the virilizing effect on a male or2 k7 G' z4 t. d
female child who might come in contact with some-
% ^) U- F+ @  T1 [& i8 Mone using any of these products.
3 W6 a2 ?# y! pReferences5 ]# ^5 V" D' {) {* m+ v4 Y0 j' r
1. Styne DM. The testes: disorder of sexual differentiation
' V5 r0 r7 y' F' dand puberty in the male. In: Sperling MA, ed. Pediatric2 o$ [& [: a" Z% U& s8 `, k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- \. ~4 Y8 d4 G' G7 a, M* {. u1 r# K2002: 565-628.
& Z0 s( u' T  G, [/ X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& E; M  D- }7 B6 Epuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
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
; O; W5 e- ?, i$ j2 T
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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