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Sexual Precocity in a 16-Month-Old
+ H, J+ j/ f) K1 Q9 h% gBoy Induced by Indirect Topical' z' E% R' ^3 v! w' S) P- U
Exposure to Testosterone/ i! O7 o  X4 N( S5 |' `3 k
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* g, t9 {. y5 g! t( j  fand Kenneth R. Rettig, MD1
; b8 @0 M3 K/ y! y4 y5 h. @/ h4 e( IClinical Pediatrics8 @( O) L2 V' E$ r8 R+ h% D. x
Volume 46 Number 69 ~9 F6 U5 F! i3 C
July 2007 540-5434 ~+ }) b+ K' `' O) e+ y5 G2 |
© 2007 Sage Publications- a5 I6 o$ U8 f. }+ B2 a
10.1177/00099228062966516 w, p: L$ R  {" [& k. v5 `8 }
http://clp.sagepub.com7 }' o- Q" k$ M$ r, A7 s7 H! O
hosted at
6 J$ R* x1 q' u7 J/ Khttp://online.sagepub.com1 T" D9 c* ~  v: s7 O+ K
Precocious puberty in boys, central or peripheral,. u$ a3 `' U6 P  T- g" Q
is a significant concern for physicians. Central
; J4 K! E/ R3 `& h' h0 N4 D  Mprecocious puberty (CPP), which is mediated1 r0 Z( F3 n) P3 d1 H" H( |" r- [; E
through the hypothalamic pituitary gonadal axis, has* \: C" `+ O1 e4 x3 I% W
a higher incidence of organic central nervous system% n4 G$ t7 h  [5 i2 `/ C" S
lesions in boys.1,2 Virilization in boys, as manifested
- Y4 @, o8 ]% ^) @2 j' U. W- q4 }by enlargement of the penis, development of pubic* j# X7 l( p4 d7 ~" Q/ M
hair, and facial acne without enlargement of testi-' W- N& a* G# e
cles, suggests peripheral or pseudopuberty.1-3 We
3 U1 Q3 L/ l  h6 d8 Vreport a 16-month-old boy who presented with the: x7 x5 J/ B& c7 z% G
enlargement of the phallus and pubic hair develop-# |3 D1 \$ J$ C" ^! q
ment without testicular enlargement, which was due
- q6 K2 v/ \6 C5 tto the unintentional exposure to androgen gel used by
! r5 A% w$ o; Tthe father. The family initially concealed this infor-3 r1 Z% x9 m  @8 O* u: Y9 t3 w$ R
mation, resulting in an extensive work-up for this4 E) A/ t/ w, S
child. Given the widespread and easy availability of
. x: a( ^* t2 f, M% W  Qtestosterone gel and cream, we believe this is proba-5 x$ A- b2 S; n; W4 M% s. r
bly more common than the rare case report in the7 i; O; q0 d& t1 f
literature.4
* ~0 F- {5 E  S) V: A$ R. ]. W+ X* |Patient Report7 S: a) K' C9 U, ^
A 16-month-old white child was referred to the
- f3 j) d1 [7 N, E4 kendocrine clinic by his pediatrician with the concern
# f4 l8 |8 a: V) w  ?) e. jof early sexual development. His mother noticed& W% o, S' z) u
light colored pubic hair development when he was( S! J/ d0 |+ l
From the 1Division of Pediatric Endocrinology, 2University of5 t$ g$ U$ X+ h9 X. \, S( `6 ~9 z6 }$ N
South Alabama Medical Center, Mobile, Alabama.6 l: O: o/ X  k# n/ X
Address correspondence to: Samar K. Bhowmick, MD, FACE,. G* s/ r3 d! a, Y: p: k+ @
Professor of Pediatrics, University of South Alabama, College of, A  B) N0 K) z% U7 j! \
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% y( l0 h0 C/ h7 ~+ Je-mail: [email protected].. l; }2 g6 J" T: Q/ t
about 6 to 7 months old, which progressively became
% @; x4 S( f  M' k  B! q8 _darker. She was also concerned about the enlarge-3 E: p$ O- v/ e0 C' Z$ g
ment of his penis and frequent erections. The child
6 s, f& Q# z1 G3 {was the product of a full-term normal delivery, with2 L) f0 c$ ]1 ^# p& B
a birth weight of 7 lb 14 oz, and birth length of
. V9 i4 g6 o. H0 h' w. ]20 inches. He was breast-fed throughout the first year
+ g' z) p$ l$ \5 {/ B9 ~' vof life and was still receiving breast milk along with: l) ~/ |9 [7 ~! q7 p3 b- Z& o
solid food. He had no hospitalizations or surgery,. L/ t( @% V1 r' `7 ~/ e1 a
and his psychosocial and psychomotor development
# x. t5 V# G, Wwas age appropriate.
9 A, e+ T5 {9 B. `! fThe family history was remarkable for the father,
% V, L" e$ r- T  h! ?who was diagnosed with hypothyroidism at age 16,$ c: c2 P% u9 E, Q9 T. M
which was treated with thyroxine. The father’s
: A0 G" t; C9 p& ]* s! t3 |1 theight was 6 feet, and he went through a somewhat8 K! n! G5 a1 x
early puberty and had stopped growing by age 14.  B6 ~, h4 s; u& a4 I
The father denied taking any other medication. The8 x; P: l5 I  P& j
child’s mother was in good health. Her menarche; i' q1 E" @- B* Z0 P
was at 11 years of age, and her height was at 5 feet2 e" \% X, |! \6 E$ z( B' d# v* a
5 inches. There was no other family history of pre-% b6 n- G* _, V) g8 S- q
cocious sexual development in the first-degree rela-
6 |/ z( ?' f* f7 ?! w. M, Y5 Wtives. There were no siblings.  X0 V: ?8 H) w# k: g6 O
Physical Examination
. K; J, X% G7 q: ?: a1 q7 M" u  x6 CThe physical examination revealed a very active,
% l8 C4 p1 r+ m& P* w% D5 Hplayful, and healthy boy. The vital signs documented
% v7 a9 T6 r0 o5 J) Ra blood pressure of 85/50 mm Hg, his length was
9 \. p" I: Q1 R( ^9 O' @* |% G90 cm (>97th percentile), and his weight was 14.4 kg
) w' p5 Q- [. K& _+ Y7 L# {( f(also >97th percentile). The observed yearly growth
5 p# ~: J+ }, l6 \9 v, e( m" Evelocity was 30 cm (12 inches). The examination of
; n- i1 U  `! q# T0 qthe neck revealed no thyroid enlargement." Z( o+ g& ?/ ^1 m/ Z
The genitourinary examination was remarkable for
/ b- V- \* l( o$ Lenlargement of the penis, with a stretched length of6 ]5 y. g' v9 S1 x7 X" @
8 cm and a width of 2 cm. The glans penis was very well
: Z6 z8 r9 [. {' T9 q- ~developed. The pubic hair was Tanner II, mostly around
9 W5 F1 g# ~- H" i+ l; h540. K8 G  D6 Z9 W' m+ O& O; m8 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ `* }* K& T. B1 ?+ B. \the base of the phallus and was dark and curled. The
7 G! t0 ?# q( ]) u& r6 h0 Ftesticular volume was prepubertal at 2 mL each.
$ @5 D0 M$ I" {9 cThe skin was moist and smooth and somewhat
1 l) t) L  x& G& xoily. No axillary hair was noted. There were no) j: b( V3 v" i6 [8 b* `( b
abnormal skin pigmentations or café-au-lait spots.
( m  |5 Y& x/ A" XNeurologic evaluation showed deep tendon reflex 2+( v- k7 L- j9 `' G7 Z7 X& A
bilateral and symmetrical. There was no suggestion9 _, a8 W# O% Q
of papilledema.& _  U1 G) M& ?8 F
Laboratory Evaluation
  `+ m8 k3 g2 h0 F7 B$ |! sThe bone age was consistent with 28 months by( k6 E3 K2 P7 z
using the standard of Greulich and Pyle at a chrono-3 z" r: Y, C8 d; G) I4 q7 |6 ~
logic age of 16 months (advanced).5 Chromosomal& A# O$ g9 L* a
karyotype was 46XY. The thyroid function test- v% N8 Q7 H2 j. j+ g, u. B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. k& G2 Y/ K: k
lating hormone level was 1.3 µIU/mL (both normal).) }9 [3 q* l/ I1 h
The concentrations of serum electrolytes, blood, F- I4 f" L  H+ g/ G7 K
urea nitrogen, creatinine, and calcium all were  j( z* {8 q9 l
within normal range for his age. The concentration2 n; A. M& u  Z, U* W. r
of serum 17-hydroxyprogesterone was 16 ng/dL
) a0 C2 r' d2 M(normal, 3 to 90 ng/dL), androstenedione was 207 H( }1 k- c6 V  m2 J7 c6 V4 c
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ H7 t) \" y. u1 T$ x) H7 a# _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 s" c/ O( o8 {6 N2 y& I6 `/ X+ Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to$ W) m, T: H" m8 Z
49ng/dL), 11-desoxycortisol (specific compound S)& [  l1 E: z0 e
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 A2 g. v; X" q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) ?6 r- [, W/ S. r- z  u! z! j8 [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
: {% L' M& [1 _/ Q9 Mand β-human chorionic gonadotropin was less than. B' R& {0 P- m5 X) C
5 mIU/mL (normal <5 mIU/mL). Serum follicular& \; @' c! [4 ]& I) V
stimulating hormone and leuteinizing hormone
7 y! C- H  j; o' s7 ^, Cconcentrations were less than 0.05 mIU/mL
" H( k9 W3 V  F, w' v" q9 z0 U(prepubertal).
5 L4 \% W2 ]  T6 {) R: |5 uThe parents were notified about the laboratory
- z- _' u2 H+ o/ vresults and were informed that all of the tests were
  }9 f7 W% X+ p, L7 Qnormal except the testosterone level was high. The/ ?0 C& C2 L* H( J: e+ r
follow-up visit was arranged within a few weeks to& m& o5 ?2 |) n
obtain testicular and abdominal sonograms; how-
4 G( w% X! m# Jever, the family did not return for 4 months.
+ w: `9 n" m" X; x' ^) J5 xPhysical examination at this time revealed that the
7 G. {' J# H, x  s4 g6 t! Gchild had grown 2.5 cm in 4 months and had gained
. R( m! r1 T" e* M+ L7 B2 kg of weight. Physical examination remained* b4 f% V  @/ m5 G- ?% ^# S) E
unchanged. Surprisingly, the pubic hair almost com-3 T7 x* X6 ?" s* {9 v. b
pletely disappeared except for a few vellous hairs at' ~5 @$ D! f; n, ^
the base of the phallus. Testicular volume was still 2
, p. v; F6 m* T" U' ImL, and the size of the penis remained unchanged.. {; }8 g6 r# F1 a4 j$ b5 J5 H. u
The mother also said that the boy was no longer hav-
3 ]/ [+ E" F- w/ c! E7 S9 Z- ?) ging frequent erections.! H3 y+ `" _: x% ~% w+ @& d& d
Both parents were again questioned about use of
: d' [4 u( d" ]/ m8 ?any ointment/creams that they may have applied to% J# B# W# |4 }- J, l
the child’s skin. This time the father admitted the# c, \/ @+ B! e; E
Topical Testosterone Exposure / Bhowmick et al 541
6 u+ a9 B3 [- Luse of testosterone gel twice daily that he was apply-
% h; w- Z3 x: q  Aing over his own shoulders, chest, and back area for6 G7 G' C3 |6 e9 L- Q
a year. The father also revealed he was embarrassed' P, n' ^1 a. ^( }
to disclose that he was using a testosterone gel pre-( w8 f% a# O; `: X' T
scribed by his family physician for decreased libido
2 |) g% U  m/ e& \4 l+ N+ jsecondary to depression.
4 E/ H* T" P- c5 B; |. I! H/ uThe child slept in the same bed with parents.$ `7 n% g5 H! J4 ~  j1 V
The father would hug the baby and hold him on his$ Q' x9 A4 d$ _# W- B4 f' F
chest for a considerable period of time, causing sig-" K. F; i; W0 {; t  A6 `
nificant bare skin contact between baby and father.
$ `: E: h+ e% Y% t3 X, NThe father also admitted that after the phone call,
# g3 L2 ~8 z" o( {3 e9 @* F" x5 Y) Bwhen he learned the testosterone level in the baby
' a" k" z* P* r( f: S3 q. Vwas high, he then read the product information4 |6 e% P: R. v, [* a
packet and concluded that it was most likely the rea-
$ x% t( u" F8 f" J' W  hson for the child’s virilization. At that time, they: {5 A" B: b4 l7 Q% ^% H+ {+ ^; t
decided to put the baby in a separate bed, and the% B5 V" y2 Q7 Q" p
father was not hugging him with bare skin and had- x5 h$ O% O7 ?$ K/ M- G
been using protective clothing. A repeat testosterone4 H% }- E1 I' v% ~2 i
test was ordered, but the family did not go to the
5 O2 ?, E7 J. W& U3 C- @  T; Flaboratory to obtain the test.8 P. Q  o+ S3 J5 t) [: s- M3 e
Discussion
; r. X0 G: f( D) lPrecocious puberty in boys is defined as secondary* t5 h$ M- _. W- c9 s$ `
sexual development before 9 years of age.1,4
! J% o$ z+ ^7 j6 V: CPrecocious puberty is termed as central (true) when7 I7 w+ K/ B$ e
it is caused by the premature activation of hypo-
% f. c4 F/ E+ c5 [% \, zthalamic pituitary gonadal axis. CPP is more com-
( y- P$ U) h& r# ^$ `" p9 X, smon in girls than in boys.1,3 Most boys with CPP
) M5 J& s' c6 L# N1 u2 T/ hmay have a central nervous system lesion that is
  X5 S# r6 J6 ^9 ?responsible for the early activation of the hypothal-
; k- J- }$ V( y; ramic pituitary gonadal axis.1-3 Thus, greater empha-& J9 Q/ Y$ {: I+ D; d) e4 Q4 p2 g
sis has been given to neuroradiologic imaging in  _$ M' R8 G* p5 i2 {. u
boys with precocious puberty. In addition to viril-) k3 R0 B. k$ N4 @) Y6 }" W
ization, the clinical hallmark of CPP is the symmet-* S, t6 E7 m2 {7 d
rical testicular growth secondary to stimulation by& o2 @; S) a/ ]* y
gonadotropins.1,3
) P" F9 A# C2 `" `8 y4 H/ ]+ `Gonadotropin-independent peripheral preco-
8 \5 d8 j" f5 L4 Xcious puberty in boys also results from inappropriate
% G# @2 ^- J. d9 I# }/ K$ o( B7 Uandrogenic stimulation from either endogenous or3 w9 q1 |5 C- j6 Y) {
exogenous sources, nonpituitary gonadotropin stim-/ P4 @7 N1 z/ J9 L& A4 q  t) Q
ulation, and rare activating mutations.3 Virilizing
6 U0 e/ |5 u. _( mcongenital adrenal hyperplasia producing excessive4 }( s0 Z$ R* l+ l3 E0 j$ f
adrenal androgens is a common cause of precocious: q6 C& b- Q3 `! Q# T% O
puberty in boys.3,49 c& Y7 d. p& K0 v/ d: F
The most common form of congenital adrenal
0 r! E! j% F( ?- R+ X3 r" q8 Jhyperplasia is the 21-hydroxylase enzyme deficiency.3 h7 W+ }! g& F* D3 G6 n
The 11-β hydroxylase deficiency may also result in
$ W* k8 I' d0 }- Q3 R. Z7 rexcessive adrenal androgen production, and rarely,
2 T# W5 w0 ~+ C4 pan adrenal tumor may also cause adrenal androgen
3 L* h  ], I# bexcess.1,3
! w% S! H' B7 V- I6 l& }0 Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 ?( }) e% o% x, c+ i542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: i9 n; f- a5 e2 B. G; W6 T* _: LA unique entity of male-limited gonadotropin-
. [1 M' I2 z$ h$ Vindependent precocious puberty, which is also known( F. t; y; H5 r! S
as testotoxicosis, may cause precocious puberty at a
6 |- H1 t- x4 X9 S. Xvery young age. The physical findings in these boys' \) ~: S% v" ]+ [' \% n
with this disorder are full pubertal development,' u" ]( q# G# @# J
including bilateral testicular growth, similar to boys
( @2 W/ f, J0 f1 C. w5 D- Vwith CPP. The gonadotropin levels in this disorder- V5 W. @% C; T: K) J8 m) l+ ?
are suppressed to prepubertal levels and do not show/ N8 z* V  W3 y$ V4 p7 ]
pubertal response of gonadotropin after gonadotropin-
, W2 Q8 u4 r' q0 W% C$ Hreleasing hormone stimulation. This is a sex-linked, z  z8 H, W5 y4 N. s; }0 T
autosomal dominant disorder that affects only
  f3 f: b4 Z- {9 tmales; therefore, other male members of the family8 x# s% n" J' `6 [# G/ @
may have similar precocious puberty.3- s' u. y) O$ p6 B: ^3 `
In our patient, physical examination was incon-6 Y2 U4 c( R2 L+ B$ [' F
sistent with true precocious puberty since his testi-
2 E6 j( I( a& V' l9 u4 k% H$ J$ ^cles were prepubertal in size. However, testotoxicosis: g& X5 T" f) l1 o
was in the differential diagnosis because his father: W! S0 `& I! u7 ?( P  X! E# }
started puberty somewhat early, and occasionally,( F9 o. R* o/ @8 _
testicular enlargement is not that evident in the1 u& ^5 z$ r% E, A, w
beginning of this process.1 In the absence of a neg-7 {2 D1 j+ S- X& Q) [8 {+ e" [- g
ative initial history of androgen exposure, our
& w- k, e( z: v- k8 u9 Ybiggest concern was virilizing adrenal hyperplasia,
1 A3 l. J  N' e5 U( y6 C* \either 21-hydroxylase deficiency or 11-β hydroxylase
+ a1 l7 @" i# {" mdeficiency. Those diagnoses were excluded by find-/ `7 j  A9 F8 g( S( @8 \# p9 C
ing the normal level of adrenal steroids.
2 F% s% W9 i8 U3 q4 A5 W  h2 sThe diagnosis of exogenous androgens was strongly
, n$ H: S6 \5 [* [suspected in a follow-up visit after 4 months because- `4 U* A; o, U3 J; ?
the physical examination revealed the complete disap-4 b# I/ N7 F$ y& V+ a& y  ]9 q
pearance of pubic hair, normal growth velocity, and
2 q' n( @% Q2 h3 y6 H7 Ldecreased erections. The father admitted using a testos-
3 h4 C" ^! v* o# r  vterone gel, which he concealed at first visit. He was2 d8 V: B+ o% g! w% r& [' F/ V4 ?
using it rather frequently, twice a day. The Physicians’$ N, M8 S9 Z0 s! W7 l
Desk Reference, or package insert of this product, gel or
9 `- d+ [1 Q# jcream, cautions about dermal testosterone transfer to
$ t7 G+ Z- k8 F. y; funprotected females through direct skin exposure.
5 A% Z$ E' s% x, F) B- L# mSerum testosterone level was found to be 2 times the
0 ?8 Q1 b# g0 i+ b! \! [* t8 Mbaseline value in those females who were exposed to* X: @* M3 L- b" x: U& S% e
even 15 minutes of direct skin contact with their male
2 A2 j" E4 H7 n" ^' O/ wpartners.6 However, when a shirt covered the applica-
0 u5 M! K+ Z, ~+ M3 U" Q8 ^tion site, this testosterone transfer was prevented.0 r$ M# C8 l/ g. I) f
Our patient’s testosterone level was 60 ng/mL,. y# ^$ d2 z  K# l8 m. r9 L
which was clearly high. Some studies suggest that" y" o5 o! f% c. `4 i4 A( [1 G
dermal conversion of testosterone to dihydrotestos-9 a2 z0 G; e. y5 }! }9 J, `2 }
terone, which is a more potent metabolite, is more& E& Y) L) T+ I. }9 ^$ E
active in young children exposed to testosterone: F0 F% F4 l+ w& A' a1 ^$ @
exogenously7; however, we did not measure a dihy-
# s/ y% u# l$ r# Y/ E4 k! L1 \drotestosterone level in our patient. In addition to
: j) @. ?' c- `% u1 `( ivirilization, exposure to exogenous testosterone in7 i- R% a+ f8 ?, g$ Q. A  q
children results in an increase in growth velocity and5 d" z! L; W" N3 |6 z9 N
advanced bone age, as seen in our patient.6 D$ |* N8 J# o8 F+ s; D9 l
The long-term effect of androgen exposure during' ]  Z2 |7 r! K9 _
early childhood on pubertal development and final1 v$ G$ s* D2 H9 e8 ^) H; r
adult height are not fully known and always remain+ j) Z3 s- e& M8 s7 X
a concern. Children treated with short-term testos-
, N) {% D& n4 d7 p' o* a% ?1 nterone injection or topical androgen may exhibit some
9 x3 S0 j* ~3 b0 v9 i) x9 `5 K2 ?2 |4 lacceleration of the skeletal maturation; however, after
$ N6 p) X; D4 t+ A$ \cessation of treatment, the rate of bone maturation
( G* p! t, ?1 E0 @' Adecelerates and gradually returns to normal.8,9
! i, g9 `' I9 T' Z& i& Z1 yThere are conflicting reports and controversy( b: H) f: |4 j1 I' i
over the effect of early androgen exposure on adult) c7 \0 V1 C9 T1 \9 S
penile length.10,11 Some reports suggest subnormal9 S# v% i+ ]7 q/ y- P  F
adult penile length, apparently because of downreg-) R5 `" y7 E6 @' v. T7 c% Z
ulation of androgen receptor number.10,12 However,
0 h) r  @* I0 [% h  q+ R: y. R% RSutherland et al13 did not find a correlation between$ K, h4 w  K6 A6 e4 _4 Z
childhood testosterone exposure and reduced adult
6 K% k' }/ A% O4 m: h5 cpenile length in clinical studies.* U$ d, W" C3 F2 r" a3 J9 `
Nonetheless, we do not believe our patient is! W# u4 t0 p2 {: h  A* s
going to experience any of the untoward effects from; f* X4 H* H3 l2 R' K3 V
testosterone exposure as mentioned earlier because8 q+ B1 c& r$ F1 V6 }4 D" S
the exposure was not for a prolonged period of time.
3 j. [& T! {3 j; q' M: LAlthough the bone age was advanced at the time of+ }4 y8 i- ?) J8 o
diagnosis, the child had a normal growth velocity at
' m+ G# n, c" o5 Lthe follow-up visit. It is hoped that his final adult& [+ N7 O& f7 f6 ~5 A
height will not be affected.1 K; i- U8 z  w
Although rarely reported, the widespread avail-; ^  b# Q3 Q" u6 L5 R) F3 b
ability of androgen products in our society may5 b8 }' |" J2 s& n
indeed cause more virilization in male or female) ~* h6 G/ B  P- d& I& ^/ o
children than one would realize. Exposure to andro-+ r" W0 L, v8 ]% \- L
gen products must be considered and specific ques-
/ q# @( i' t7 x& v2 O. O& otioning about the use of a testosterone product or6 {, H6 ~. D  _) v' P* @
gel should be asked of the family members during- j. n! y5 Z4 m$ p+ |6 _
the evaluation of any children who present with vir-
" d' |+ w9 L) Iilization or peripheral precocious puberty. The diag-# `  i! u: n8 U2 c
nosis can be established by just a few tests and by4 d0 D* ~/ _: ~
appropriate history. The inability to obtain such a
1 Y: L" i" b1 t$ g* G% uhistory, or failure to ask the specific questions, may
6 g. U+ x. h8 G3 I  d6 k% b! fresult in extensive, unnecessary, and expensive
) M3 |9 R" ~2 }8 y# \% ninvestigation. The primary care physician should be
; l3 A& j9 o1 s; g0 L8 `aware of this fact, because most of these children. r0 A5 g6 B6 Q
may initially present in their practice. The Physicians’
1 z1 g" f7 A' w7 B% A3 w6 [Desk Reference and package insert should also put a
2 g2 ?2 k( ]) Y; r5 s1 [1 }warning about the virilizing effect on a male or
2 n) p0 o" j( S) Dfemale child who might come in contact with some-
2 n% @* {2 \* v( |one using any of these products.6 N7 ]7 k9 q# U; f0 g* m; T
References/ D: J) r4 L% C: O
1. Styne DM. The testes: disorder of sexual differentiation
$ m4 A* [# ]. g, L8 Y) _and puberty in the male. In: Sperling MA, ed. Pediatric
* j' m. I5 x9 s7 D& |2 g& i! ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- q  s4 K( D4 X  I: _2002: 565-628.
: y4 f" ]8 u" g' z7 ~2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ T( k" S8 }6 G: Kpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old" l+ g( ~! v0 Q+ X7 \9 x! H
Boy Induced by Indirect Topical4 {" Q" S6 B2 I8 Q: W' p1 O! h
Exposure to Testosterone  r1 `) H7 m% d) X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 I) x( v  q% ?' Y1 Oand Kenneth R. Rettig, MD19 `* }; c  C. s& r
Clinical Pediatrics
5 ?: R. r/ r6 VVolume 46 Number 62 B, d1 ^3 o  u& ^
July 2007 540-543' }" f8 i0 M  K7 ]9 ~# ]9 f: \
© 2007 Sage Publications' A' C. h, b8 j* ^
10.1177/0009922806296651$ g, G; [' C3 }/ J$ ]# L
http://clp.sagepub.com" o: Y( \0 y0 M, @+ }
hosted at2 F# |( `% L' E6 i: R( Y1 u3 x
http://online.sagepub.com
) T1 b0 ^5 Y/ t2 KPrecocious puberty in boys, central or peripheral,2 T8 V9 K1 D7 x
is a significant concern for physicians. Central2 }# n4 @+ I4 m: r4 ]: G# }8 [: Q! Y
precocious puberty (CPP), which is mediated* s6 _4 o+ k* m% |. m- _% G6 C4 {
through the hypothalamic pituitary gonadal axis, has+ m' S2 c  l) d8 j
a higher incidence of organic central nervous system) B- G) B  A1 B% N
lesions in boys.1,2 Virilization in boys, as manifested0 j5 }) |9 {8 Y) E4 d9 N3 q
by enlargement of the penis, development of pubic
) @" I% c+ G/ b) t; s6 `hair, and facial acne without enlargement of testi-( Y$ k# A/ c/ H8 @& i6 R' u' `1 `
cles, suggests peripheral or pseudopuberty.1-3 We
5 |, B5 O! ~* G5 I$ J2 ]% lreport a 16-month-old boy who presented with the
, v* R1 r" v/ ^6 U+ Z0 menlargement of the phallus and pubic hair develop-
5 m$ a) E! k4 X4 H* p0 nment without testicular enlargement, which was due2 g, k8 t: q1 ^5 p
to the unintentional exposure to androgen gel used by" z& Y$ k1 E1 X# c, n
the father. The family initially concealed this infor-
0 \: v* k+ C$ J3 cmation, resulting in an extensive work-up for this* `9 ]7 l7 [* E, ]- H3 Y3 n  Y+ W
child. Given the widespread and easy availability of0 B' b3 A$ a9 @" X* M( A  C8 n& x
testosterone gel and cream, we believe this is proba-
' r* b0 O8 B% L4 q/ Kbly more common than the rare case report in the
- q) u, @. v- w. ?3 e0 mliterature.4
4 m; h5 x$ m% u2 k7 D+ W+ r( J$ ?0 OPatient Report, c. z) W- h5 F" |* S2 g
A 16-month-old white child was referred to the" W2 Q  N# S# f. p( ^9 k- m
endocrine clinic by his pediatrician with the concern
0 b% ~# `( a0 J; S/ u7 yof early sexual development. His mother noticed
% D% Q+ `6 f) S9 c" Glight colored pubic hair development when he was1 S7 R9 Y- m2 t3 w
From the 1Division of Pediatric Endocrinology, 2University of
6 y' d* E: P9 V6 M3 i) _0 jSouth Alabama Medical Center, Mobile, Alabama.) p4 {- I; r. }& C( q3 `  o! N7 L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
3 h' v- Z* K& O" I! CProfessor of Pediatrics, University of South Alabama, College of
7 F" `0 A5 x% G: ~9 ~6 w# [Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ ^! i3 j5 v9 k% |6 t3 ]5 Y
e-mail: [email protected].
9 i  e2 ^! t' r( n) m3 iabout 6 to 7 months old, which progressively became
0 P. M7 i7 J2 k8 S: Q0 W: {darker. She was also concerned about the enlarge-
* m" q! g9 X  Rment of his penis and frequent erections. The child: a, s+ g6 g& D1 M5 U* P
was the product of a full-term normal delivery, with
, L, A/ U5 a5 z  Na birth weight of 7 lb 14 oz, and birth length of; V# ^7 x* P5 N/ O
20 inches. He was breast-fed throughout the first year
- |+ O7 S* p- j. |4 ]! L: K$ B3 Eof life and was still receiving breast milk along with8 e  G& o/ |; p" t2 @' Z
solid food. He had no hospitalizations or surgery,& u5 ?" @' g( f% s' K" f4 e
and his psychosocial and psychomotor development  H# k# I4 z2 ]4 r
was age appropriate.
. R% W! B$ j* I" v  ~5 @$ AThe family history was remarkable for the father,4 f+ H0 M* {3 @: f
who was diagnosed with hypothyroidism at age 16,7 _3 n! g" ?1 ?9 y) @* F
which was treated with thyroxine. The father’s
8 p, Q/ X' `7 Sheight was 6 feet, and he went through a somewhat7 W! e. [  P! o) o7 h
early puberty and had stopped growing by age 14.
/ p9 ^# {! x2 OThe father denied taking any other medication. The4 o8 Y! O0 t( U% l; O6 D
child’s mother was in good health. Her menarche) V- `' o7 ^+ q3 O, `
was at 11 years of age, and her height was at 5 feet: u) y1 d$ }0 D7 \& y3 Z
5 inches. There was no other family history of pre-0 F  b+ _1 N; q- s0 ?6 G
cocious sexual development in the first-degree rela-0 F5 ?- P$ @  o% I" ?
tives. There were no siblings.+ f, R. k* ?4 P1 t4 ^- \
Physical Examination4 |3 ~' S9 L  K/ |3 ?( m
The physical examination revealed a very active,
4 r7 g/ ~4 r0 ^  oplayful, and healthy boy. The vital signs documented$ n- Y+ C2 G# g( |( p/ E& j
a blood pressure of 85/50 mm Hg, his length was/ g6 F' T6 ~0 w+ x6 K
90 cm (>97th percentile), and his weight was 14.4 kg
. T% q  F: A, i(also >97th percentile). The observed yearly growth0 Y) c& L5 F( d. D- L) M/ g* F
velocity was 30 cm (12 inches). The examination of
7 _+ O  z- B, N; Tthe neck revealed no thyroid enlargement.
+ U) I3 i7 u6 J' \: Y/ L2 l4 P4 @The genitourinary examination was remarkable for
) ~$ i3 N& k4 K# A9 ?# aenlargement of the penis, with a stretched length of
7 L# P9 S6 O9 @8 cm and a width of 2 cm. The glans penis was very well
; I$ w$ j7 Z# O9 K3 c/ [2 {developed. The pubic hair was Tanner II, mostly around$ O2 l0 Q3 c) ]* Y
5404 O, g: B/ V, K/ u1 V2 V+ h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. [6 s* f' b0 K, I" G
the base of the phallus and was dark and curled. The$ B2 B; M: c. @- C4 v
testicular volume was prepubertal at 2 mL each.
5 }( g  d. r* rThe skin was moist and smooth and somewhat( a$ p8 ]5 B/ x2 `7 n8 r$ U
oily. No axillary hair was noted. There were no
+ z) s/ F) }# vabnormal skin pigmentations or café-au-lait spots.3 D( t, Y/ ?: i' Q+ B) [
Neurologic evaluation showed deep tendon reflex 2+
8 v, C4 m+ }# m# o4 n8 B/ c: G( o0 Gbilateral and symmetrical. There was no suggestion
! j5 E2 _8 V3 ]- p* Vof papilledema.# ^5 _8 m$ X7 S4 f. t+ l. t
Laboratory Evaluation
. o' y5 B% g; \9 Y. c3 ?. x8 M6 @The bone age was consistent with 28 months by9 Z: v$ ~. E% Z* L0 h# O) G
using the standard of Greulich and Pyle at a chrono-8 ?- M3 u" G! M/ r4 ?
logic age of 16 months (advanced).5 Chromosomal
: [+ N1 {  S) g  |- O) Xkaryotype was 46XY. The thyroid function test. D/ g/ p/ z& n" z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ \  V/ V5 P! R- ]' k& G1 k
lating hormone level was 1.3 µIU/mL (both normal).5 U# U3 X- R; s5 ^0 E' x9 Z% [% u
The concentrations of serum electrolytes, blood
( i6 F4 |# }- T) @* D9 lurea nitrogen, creatinine, and calcium all were
* K9 H6 E6 D5 H, h  N5 Fwithin normal range for his age. The concentration. z  j2 |* X+ ]& t
of serum 17-hydroxyprogesterone was 16 ng/dL
; _/ [/ d% f, s2 d- x# \, j(normal, 3 to 90 ng/dL), androstenedione was 20
. h1 Q; _; w/ W) a( G, Gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& [9 Z; d/ \$ h6 b/ J: Zterone was 38 ng/dL (normal, 50 to 760 ng/dL),
) P  \5 G5 j- _( wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to# n7 R2 {: }  v$ O
49ng/dL), 11-desoxycortisol (specific compound S)
. E: R9 i' ~7 z( w1 i# n  pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ @5 X* W( a* Z0 U4 h; K. E) Q5 T0 ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 G1 j6 c- T& I! j3 G) S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 b) G5 l2 ]) _1 ^3 X# J% \) x) Fand β-human chorionic gonadotropin was less than8 @# V  A# {8 h# P5 O
5 mIU/mL (normal <5 mIU/mL). Serum follicular
, H' j9 U8 [9 s; y; Q2 ^: kstimulating hormone and leuteinizing hormone4 B# C$ J3 z8 N* a
concentrations were less than 0.05 mIU/mL8 o3 O1 I- p5 c. V. w% g) q
(prepubertal).
1 e1 P8 l9 ]5 b$ g9 Y8 C6 rThe parents were notified about the laboratory  Q' p* b/ p8 S/ e1 u
results and were informed that all of the tests were
* E; V$ g3 F5 J6 B) Qnormal except the testosterone level was high. The9 P- `' d8 c! r
follow-up visit was arranged within a few weeks to
" l4 T2 U" y. ~) Z8 lobtain testicular and abdominal sonograms; how-
6 o: N# f1 [  ?3 S* Zever, the family did not return for 4 months.+ ~5 p3 |4 g. ~+ F
Physical examination at this time revealed that the; O. X+ U5 N7 @. U' R" ]
child had grown 2.5 cm in 4 months and had gained
+ n! T8 G9 ^& V: u2 f2 kg of weight. Physical examination remained
/ |! j5 `9 R0 @unchanged. Surprisingly, the pubic hair almost com-7 A4 z  s! m9 j. H2 [" C: I  Z
pletely disappeared except for a few vellous hairs at
6 i7 {6 a* {& u9 z6 P! athe base of the phallus. Testicular volume was still 2) N7 N& D/ D6 w& H& R# v3 l
mL, and the size of the penis remained unchanged.) N* ?) k( b" W% A
The mother also said that the boy was no longer hav-
9 L3 a0 k1 U  X8 R& k  w8 Xing frequent erections.
3 J" a8 k$ `/ i% T" }  x  WBoth parents were again questioned about use of
! T/ Y8 w. e0 g6 a: ^3 N( N; many ointment/creams that they may have applied to1 [* M/ |. R( _7 ]( S
the child’s skin. This time the father admitted the
* L4 s9 `$ w  M+ V, |" H/ g4 rTopical Testosterone Exposure / Bhowmick et al 541
* z) q+ K: c1 j+ N9 h: w- wuse of testosterone gel twice daily that he was apply-
9 T# ~" k% [& W5 \ing over his own shoulders, chest, and back area for" M& Z# t( ]2 y8 x6 i! }9 o
a year. The father also revealed he was embarrassed  K) w$ D7 ~5 h* y
to disclose that he was using a testosterone gel pre-
! F- U# Y& K% D2 xscribed by his family physician for decreased libido3 b# i0 w- R! h- ?
secondary to depression.
: h0 M9 c3 \; L% W3 o' n# {/ R" _The child slept in the same bed with parents.* f/ q' e) _2 y* J4 q0 p
The father would hug the baby and hold him on his# q( m5 l& t+ A8 p
chest for a considerable period of time, causing sig-: k3 E3 l+ h/ K" M" [6 o
nificant bare skin contact between baby and father.  S5 v: Q) _$ Z  o% ^' Q- Z, P
The father also admitted that after the phone call,* Q/ v$ n# O3 m8 r6 c
when he learned the testosterone level in the baby+ P. }8 f# ^. k1 V' Y2 T6 w
was high, he then read the product information- u7 G( z5 Z- ]0 H) m6 ^1 z
packet and concluded that it was most likely the rea-* h3 A9 G: r' m. m; G
son for the child’s virilization. At that time, they% f, K9 Z6 [: b) Q, c, u
decided to put the baby in a separate bed, and the
1 G$ N" E# w* Z& ^father was not hugging him with bare skin and had
8 N# x3 j# e  j$ H0 obeen using protective clothing. A repeat testosterone0 d% w) f# s1 Z: e' J+ G9 @
test was ordered, but the family did not go to the
* e' }: L7 B+ _+ K9 C3 a6 \$ Ilaboratory to obtain the test.2 Y" G2 r" A1 X1 `, J
Discussion
( W# c  Z: t  {5 ?! n: V  IPrecocious puberty in boys is defined as secondary
- f1 o$ c: A# X$ h" _/ G8 usexual development before 9 years of age.1,4
6 e4 T" x$ o! Z0 S: qPrecocious puberty is termed as central (true) when
2 X6 y" o( t% d1 V. [/ ]: r, I4 \it is caused by the premature activation of hypo-
. C1 _4 h! w3 L9 p1 A' h: ithalamic pituitary gonadal axis. CPP is more com-
' J! T3 B$ f9 l( u6 D, E5 \mon in girls than in boys.1,3 Most boys with CPP' Q" m+ Y$ H* S' Z  A' e
may have a central nervous system lesion that is
& H3 P9 \  k$ q1 C% u! [responsible for the early activation of the hypothal-
' E) x  k. m5 L1 E' c9 Eamic pituitary gonadal axis.1-3 Thus, greater empha-
0 o' I( b7 V3 ^( i. Asis has been given to neuroradiologic imaging in9 `8 G' Q) r& h7 R
boys with precocious puberty. In addition to viril-
4 h4 S  A  n5 r: {9 [! nization, the clinical hallmark of CPP is the symmet-8 b" b6 h+ t5 o' ]
rical testicular growth secondary to stimulation by
" t! F) S0 A5 i1 e" F+ l! {gonadotropins.1,3& i/ m& _' M; _1 m* ^
Gonadotropin-independent peripheral preco-
* {8 E5 c) v7 g' X, O' Mcious puberty in boys also results from inappropriate; f/ M3 ?! Q' i# o$ \7 r5 A6 x
androgenic stimulation from either endogenous or% f' K# c, c) z5 b3 y) _& |
exogenous sources, nonpituitary gonadotropin stim-
6 E# H1 P: h# |2 [ulation, and rare activating mutations.3 Virilizing5 H, w0 z( I4 x! e% ^
congenital adrenal hyperplasia producing excessive
5 C8 R/ X- ?4 L3 T! G2 V* Fadrenal androgens is a common cause of precocious
/ z2 Z$ a1 Q4 w- [puberty in boys.3,45 v+ c6 q0 D( B$ P, Z
The most common form of congenital adrenal
3 s* g6 p, h- z. R4 Z- Y# X6 @hyperplasia is the 21-hydroxylase enzyme deficiency.
! r& x& Q) \3 k1 L4 `The 11-β hydroxylase deficiency may also result in+ n2 o" D. @' K# \& `( V" Y6 E
excessive adrenal androgen production, and rarely,: w8 }+ A' a; Z* v# K
an adrenal tumor may also cause adrenal androgen
- K; W" r. N4 |" F: H5 V+ _excess.1,3
- \4 D  m& [; o0 ^- i* N8 E) I3 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ f  I5 M1 B7 k- {4 X. l542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 j% ^# ?/ w3 M5 sA unique entity of male-limited gonadotropin-9 H; [& y$ V: s, g' o* |
independent precocious puberty, which is also known
) X" g  M! ]4 ras testotoxicosis, may cause precocious puberty at a6 {, w$ c4 S/ c5 R
very young age. The physical findings in these boys; g0 Q( A4 J1 i( R( I9 K
with this disorder are full pubertal development,
  x7 w# t0 [7 Y+ t+ y& Y" Kincluding bilateral testicular growth, similar to boys+ m% |+ q9 ]3 I8 n9 p' k
with CPP. The gonadotropin levels in this disorder
  V8 \* J8 u# H1 J8 vare suppressed to prepubertal levels and do not show/ q* g# C% m/ w- c
pubertal response of gonadotropin after gonadotropin-
. t9 H8 m. j% d; s- ~5 \5 creleasing hormone stimulation. This is a sex-linked
: F% I- W6 v& }0 b  v& pautosomal dominant disorder that affects only
- g% s5 z# a  I4 r( V# {males; therefore, other male members of the family; z' ^5 ]" y" n' Y' i6 T  F) c
may have similar precocious puberty.39 F" @7 \# I6 }1 k
In our patient, physical examination was incon-
6 h5 [, A9 ?0 K: [sistent with true precocious puberty since his testi-
4 w+ ?/ a$ K/ _. e' U" rcles were prepubertal in size. However, testotoxicosis- W/ J$ F- s! u: m- s7 S; U
was in the differential diagnosis because his father
" Q6 Y4 G6 R) l* L: U: ], wstarted puberty somewhat early, and occasionally,1 {" V3 J" @3 E& ], t
testicular enlargement is not that evident in the% t) Q9 ^6 }# U3 {2 p
beginning of this process.1 In the absence of a neg-
% [7 r6 _6 F2 w1 u& }; Eative initial history of androgen exposure, our$ I" k% A$ K4 }+ m8 [1 R0 I, S
biggest concern was virilizing adrenal hyperplasia,
8 R# [$ s2 U- f0 s8 {- f2 Ieither 21-hydroxylase deficiency or 11-β hydroxylase
' _( L% X2 Q2 S! ^, Z% Udeficiency. Those diagnoses were excluded by find-5 E1 c5 R- u  @4 h, @6 ?0 {( S( ]
ing the normal level of adrenal steroids.  k, Z3 D, z5 `6 z6 A2 f9 T* n
The diagnosis of exogenous androgens was strongly  L# W1 `* i/ k- @
suspected in a follow-up visit after 4 months because
/ j( G, d9 x+ Ythe physical examination revealed the complete disap-9 b. z$ v3 d* n% @) c0 ~
pearance of pubic hair, normal growth velocity, and8 a/ }: L- E% k' T" @
decreased erections. The father admitted using a testos-6 b- y/ e. j, j1 R
terone gel, which he concealed at first visit. He was, b, y9 g/ X$ @( e" a
using it rather frequently, twice a day. The Physicians’1 G% f( E% y5 h1 K
Desk Reference, or package insert of this product, gel or4 ^2 F2 s, F! G+ [3 N
cream, cautions about dermal testosterone transfer to6 I' d- F" ?2 H0 w: n# S
unprotected females through direct skin exposure." M1 z) A* P$ ^3 n, F$ G7 w
Serum testosterone level was found to be 2 times the6 z9 H, [  ^6 V+ b
baseline value in those females who were exposed to
5 _2 o) u3 T! p. Z) q: L9 jeven 15 minutes of direct skin contact with their male
: X2 T1 D. Z2 Q/ t, K9 Rpartners.6 However, when a shirt covered the applica-* a1 p* P/ \0 g
tion site, this testosterone transfer was prevented.  g9 O% d+ M& P3 Z
Our patient’s testosterone level was 60 ng/mL,
* F, X4 u1 V2 P: J( ~which was clearly high. Some studies suggest that0 l4 g4 W) J/ _9 \3 @
dermal conversion of testosterone to dihydrotestos-
6 F$ ]: a: C7 qterone, which is a more potent metabolite, is more+ J! E# |+ F0 ]9 c
active in young children exposed to testosterone
4 b) u# I3 f4 c* \2 K/ Y' yexogenously7; however, we did not measure a dihy-
4 ]- U0 D/ A. W% a3 _3 sdrotestosterone level in our patient. In addition to, @& b! A* `# T+ `
virilization, exposure to exogenous testosterone in# g6 a/ ]6 L2 H5 o9 Y! f
children results in an increase in growth velocity and8 K& W' V' f8 \, H  k0 z
advanced bone age, as seen in our patient.
8 C) J' Z9 U  f) hThe long-term effect of androgen exposure during" b2 N8 }0 i6 E& [* r/ T
early childhood on pubertal development and final; ^7 I9 j7 ^; w0 P( Q" T5 {) y' C
adult height are not fully known and always remain$ X3 |/ f8 g0 }/ Q% p4 N9 }
a concern. Children treated with short-term testos-$ F, S) y, X4 c# R8 r5 X
terone injection or topical androgen may exhibit some: a# C2 Z" h9 u/ U
acceleration of the skeletal maturation; however, after
+ z. H6 p/ `- V% S: M  Xcessation of treatment, the rate of bone maturation' c. v8 j- T- g" @' K
decelerates and gradually returns to normal.8,9/ X- ^$ b, T% Z8 \' i' L
There are conflicting reports and controversy
/ ]! P: B) z1 N  y+ C2 @+ D: G* gover the effect of early androgen exposure on adult' m+ o, N/ v% c7 ^( ?" q
penile length.10,11 Some reports suggest subnormal6 ^/ {( e! h6 T
adult penile length, apparently because of downreg-
6 R* t8 i4 n/ W" Z& }' nulation of androgen receptor number.10,12 However,
9 |  F; i1 A% P( U+ `Sutherland et al13 did not find a correlation between
" x+ z' x: a) g8 C0 c/ `, k' _childhood testosterone exposure and reduced adult
; d0 J" }6 W6 |$ w* B. b" k5 zpenile length in clinical studies.1 I  `/ z4 o( U, m# s1 h" d" B$ M/ a
Nonetheless, we do not believe our patient is% Z( e& F) S* ^
going to experience any of the untoward effects from; P, G' e8 M* X3 {
testosterone exposure as mentioned earlier because
/ g' d7 G7 D$ P1 ^1 D: Gthe exposure was not for a prolonged period of time.3 a9 F9 F  }0 P( Q9 ]3 V
Although the bone age was advanced at the time of
  R& ~% {' b" [$ ~diagnosis, the child had a normal growth velocity at
% e$ Z; \, d, y% g5 Othe follow-up visit. It is hoped that his final adult
7 B- ~3 i: t7 m) X6 Pheight will not be affected.' I, }, [7 N6 `, B" h$ ^* x5 C# i
Although rarely reported, the widespread avail-0 i9 x- s/ k% o1 G, D  o# b
ability of androgen products in our society may
- ^4 H6 r: J- i' \3 l( d# Uindeed cause more virilization in male or female4 B* T3 n7 ]; u5 o/ v
children than one would realize. Exposure to andro-; ^- h7 O: K4 k5 s$ n, A
gen products must be considered and specific ques-
! F- T9 _. ^% L3 {% y% t$ z% f$ Jtioning about the use of a testosterone product or+ s- R/ D# r& C' Y
gel should be asked of the family members during
  I/ d" ]  S' s) athe evaluation of any children who present with vir-
& ~/ G  I3 I( C! h- k* Filization or peripheral precocious puberty. The diag-
; J1 q5 l, ?1 x0 ?( [6 z* }nosis can be established by just a few tests and by+ O* h- l) u2 S  L
appropriate history. The inability to obtain such a7 V/ v$ e3 Q- B3 S5 M; P! X
history, or failure to ask the specific questions, may
2 R5 N0 k3 e8 c, hresult in extensive, unnecessary, and expensive* o/ _" V' R7 P- A4 @( Y% F8 X! U% U6 A
investigation. The primary care physician should be
: P, S7 W; |% K1 ]1 ^aware of this fact, because most of these children4 M, E3 U" U$ g( O, V0 K7 Q$ F3 J% {# h
may initially present in their practice. The Physicians’6 P0 K1 O( ^9 I: x; \
Desk Reference and package insert should also put a
+ s1 i% {6 X# r! O2 k7 Pwarning about the virilizing effect on a male or4 @. e- _. s, D, W
female child who might come in contact with some-5 n8 C4 q1 l6 h# ?% z( R
one using any of these products.2 b" w8 f0 ?6 {- D. y  Y
References
2 z: {& r! M$ u! q1. Styne DM. The testes: disorder of sexual differentiation4 [+ B% g7 Q7 o2 X
and puberty in the male. In: Sperling MA, ed. Pediatric3 @0 Z! V  N$ |3 @! N2 [7 i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 I  k" i. e* W6 e
2002: 565-628.0 T. |; ~- C+ a/ i" t1 p) X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 H% z; ^  }2 ]$ ?4 I
puberty 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
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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
; s) I  O6 q8 T9 x& o
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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