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Sexual Precocity in a 16-Month-Old( i6 m7 `. H. M1 V' R! n
Boy Induced by Indirect Topical
9 l2 Z2 D' v0 M( ]0 ]0 J  QExposure to Testosterone
9 U$ i9 C4 |, ~7 MSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. U" l$ l& S( g3 G& H; R3 G- _and Kenneth R. Rettig, MD16 A9 X5 K" M8 Z/ \( b% B) m" p. C9 b5 ~3 [
Clinical Pediatrics: I5 ?. J, [' y1 C( J7 c2 t2 G
Volume 46 Number 69 f0 Y; i! j3 e3 L
July 2007 540-543
+ Z/ L  E) Q5 \" T3 n3 E0 C5 ^© 2007 Sage Publications
( j8 _  i! B0 C% \4 n% H  T10.1177/0009922806296651! e3 T, v. e' s; N# }9 s0 K
http://clp.sagepub.com2 |4 J) s* ^7 T
hosted at( ]( {! {) I% i) ]1 X3 A/ A
http://online.sagepub.com2 o& M0 N. N  m4 B
Precocious puberty in boys, central or peripheral,& ]- ^% S6 T' v6 Y6 W
is a significant concern for physicians. Central
* u: P7 T& F5 {5 w8 M: C" kprecocious puberty (CPP), which is mediated
+ l' V0 ]) T, y! W. E2 Fthrough the hypothalamic pituitary gonadal axis, has/ Y, L" Y+ k9 a  O( L; p
a higher incidence of organic central nervous system
0 K; j4 I! M7 d/ rlesions in boys.1,2 Virilization in boys, as manifested1 I8 _) U1 e. |8 c( l1 v
by enlargement of the penis, development of pubic3 w$ w, t  W- z. q' A* D: |: u( L
hair, and facial acne without enlargement of testi-
' l3 L* y1 S: M, V8 ccles, suggests peripheral or pseudopuberty.1-3 We
+ Y7 M1 Y, a. b  Dreport a 16-month-old boy who presented with the
9 n' F% x- a- d" [$ j( b0 b6 `enlargement of the phallus and pubic hair develop-
. X" L, T  h& |, @ment without testicular enlargement, which was due
) B0 ?, [% Z& Fto the unintentional exposure to androgen gel used by3 u" G; \' @8 T  u. s1 E4 \1 x5 G+ A
the father. The family initially concealed this infor-5 p0 f. i7 }4 X% Z& G  S2 y* D
mation, resulting in an extensive work-up for this2 E# I: G( A7 z6 F# W/ L. T/ r' Q& \
child. Given the widespread and easy availability of( N/ [: ]3 I8 r. c4 }& \
testosterone gel and cream, we believe this is proba-
- J) h" X- [1 B* k- Cbly more common than the rare case report in the3 f9 q# \& C* W* X- `6 h
literature.4
4 u" D+ I6 ~% g4 FPatient Report+ y& x5 F( I* z
A 16-month-old white child was referred to the
7 C1 I% b/ |( v3 T8 a$ Wendocrine clinic by his pediatrician with the concern
/ G4 f( ]1 h6 C3 x$ f( b! K6 hof early sexual development. His mother noticed
. V: w7 G8 E' |& wlight colored pubic hair development when he was
% E- y1 u1 y* B% ]# }From the 1Division of Pediatric Endocrinology, 2University of
* s& m2 G4 {6 }* j: z" iSouth Alabama Medical Center, Mobile, Alabama.
1 ]/ H+ q7 ]0 i4 ]3 HAddress correspondence to: Samar K. Bhowmick, MD, FACE,$ f3 G  t" N" v0 V3 k' Q- q" A
Professor of Pediatrics, University of South Alabama, College of
0 i$ t/ u0 D. i1 a4 \$ G" C' jMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 X  d$ Y/ K' @+ Q7 F8 o/ N
e-mail: [email protected].
: `/ B: _) j! F: V) N7 |9 @about 6 to 7 months old, which progressively became
; \/ [' z4 y3 r& e$ s7 j' _darker. She was also concerned about the enlarge-' @( ?1 T" H) ?, u
ment of his penis and frequent erections. The child
: @1 _: L. @- {4 ^2 f! l0 ywas the product of a full-term normal delivery, with
1 ?, j/ s$ j$ Z" {4 O, Wa birth weight of 7 lb 14 oz, and birth length of
/ U5 i7 H( X7 d  k4 W! G20 inches. He was breast-fed throughout the first year
; m) |/ ^2 M# i! I" ^of life and was still receiving breast milk along with
/ e4 B% y$ r! g0 jsolid food. He had no hospitalizations or surgery,* n% W  w' @6 `1 U
and his psychosocial and psychomotor development
4 I# W4 z/ f. x* F* n. `5 S& Nwas age appropriate., n! {" V5 |; s, E
The family history was remarkable for the father,0 g. y5 A% U5 b8 E4 p6 v' X
who was diagnosed with hypothyroidism at age 16,
% Y. c. k2 e9 a3 A  q6 ywhich was treated with thyroxine. The father’s$ l4 u" Z- ^1 k- H" p
height was 6 feet, and he went through a somewhat
: h8 V/ F" ?4 I$ w! zearly puberty and had stopped growing by age 14.+ z/ g1 f# D* y) l) h8 N0 U
The father denied taking any other medication. The& w% t3 B7 V, S3 a( g% j
child’s mother was in good health. Her menarche% U$ U$ t) r* N. U
was at 11 years of age, and her height was at 5 feet
% Q/ w# y5 z/ U3 Q5 inches. There was no other family history of pre-/ ~7 w2 x' V! ^* e
cocious sexual development in the first-degree rela-& a  W* e1 L' `* B
tives. There were no siblings.
- m1 Y5 D2 h5 `" jPhysical Examination1 ?. b* e+ B/ Y
The physical examination revealed a very active," D& T7 d* C: G! r* k
playful, and healthy boy. The vital signs documented% Q2 L3 A( x! a1 [2 q: \
a blood pressure of 85/50 mm Hg, his length was
9 f+ V9 k6 F2 f( ^# F  @90 cm (>97th percentile), and his weight was 14.4 kg
$ C3 ^* J$ D& \% }9 c2 L(also >97th percentile). The observed yearly growth1 Y5 s" o; h0 G
velocity was 30 cm (12 inches). The examination of8 ]2 z7 G1 r6 ?$ g% R4 Z
the neck revealed no thyroid enlargement.
; g( g; K( v3 e# `2 x7 m: m; mThe genitourinary examination was remarkable for5 f9 y1 h( e% _
enlargement of the penis, with a stretched length of
- b  Y5 h  ]8 N$ r8 O# S8 cm and a width of 2 cm. The glans penis was very well/ J* X: f0 r8 O; K1 a, q' n2 J8 N
developed. The pubic hair was Tanner II, mostly around
& W' a. i3 m3 s! K3 P540( `1 P, T0 ~  O1 X( l( i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' j! o: {) b9 H7 p7 c! i4 ?the base of the phallus and was dark and curled. The& }$ l, C: L. l1 p* f
testicular volume was prepubertal at 2 mL each.: U5 t5 f! C6 ]& b. s
The skin was moist and smooth and somewhat
; L; n0 k- d/ l. }3 s* X8 b: roily. No axillary hair was noted. There were no
& ^0 R; N8 p" v* ?$ n: v0 }3 K% aabnormal skin pigmentations or café-au-lait spots.' G  O2 l. l4 k: ~6 e9 i2 g
Neurologic evaluation showed deep tendon reflex 2+
& D4 w5 o# w# o2 ubilateral and symmetrical. There was no suggestion, T: I6 Q% W; E" z- ?! c7 n
of papilledema.  y5 E, Q9 Q- h+ R( y% ?& c8 O6 y$ {( E
Laboratory Evaluation# h/ r9 l; C* o0 C
The bone age was consistent with 28 months by
: i. S0 }# n4 H& H' jusing the standard of Greulich and Pyle at a chrono-8 d* W5 d: J% n8 _( Z" v  P
logic age of 16 months (advanced).5 Chromosomal
5 p) j. |9 `8 V* P% ?+ @karyotype was 46XY. The thyroid function test9 Z$ r% _$ f6 J: N& T2 Q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ _- l, b( t% |: t
lating hormone level was 1.3 µIU/mL (both normal).
3 m6 v8 i" \! m2 e4 b* E7 u/ BThe concentrations of serum electrolytes, blood
% z, U4 ?& O( |' m! u# rurea nitrogen, creatinine, and calcium all were! {/ p# g% n6 ]4 ~' w3 B" P
within normal range for his age. The concentration
" t' E9 v' C% g( nof serum 17-hydroxyprogesterone was 16 ng/dL  n6 v( {: q1 n& k
(normal, 3 to 90 ng/dL), androstenedione was 20
: h9 w8 g8 \, y& g3 p6 nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 W' z" t$ m* i' u2 ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ c2 ~& ~7 M/ o' i3 w. A. `( T4 J$ hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
- [1 e; S$ A- H9 \4 R49ng/dL), 11-desoxycortisol (specific compound S)) M7 l" G, N/ L! D4 w3 D4 D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 E3 N( v3 k' t, m1 |tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, ]3 y' A. o" itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),& N' g6 C( i' D& H- E2 S& r* H
and β-human chorionic gonadotropin was less than
4 V. n9 I, d) |' L2 N: T1 U) ]5 mIU/mL (normal <5 mIU/mL). Serum follicular
. q4 l6 S+ W, S; d9 n5 T/ s8 Hstimulating hormone and leuteinizing hormone
# ^0 B. x) u  f- y& q4 s. Nconcentrations were less than 0.05 mIU/mL1 t: m% m3 R/ c# `8 L6 u2 W" A
(prepubertal).1 d% l) N* T$ V- q
The parents were notified about the laboratory/ z  l( W' G" i! t5 K$ _4 S1 P( L
results and were informed that all of the tests were
# m# ^- {# W% ]: k8 U2 E8 i% ]1 Nnormal except the testosterone level was high. The8 t( g# b7 N5 V3 a2 `0 O" e8 W+ F
follow-up visit was arranged within a few weeks to
6 F5 F' O6 m# d( i6 Uobtain testicular and abdominal sonograms; how-1 D, R( l+ \, T! ^% U1 V# E* R
ever, the family did not return for 4 months.
& N( V  [2 a6 k9 P; r! ZPhysical examination at this time revealed that the  p# m( O! o. g3 S! H" r
child had grown 2.5 cm in 4 months and had gained
$ G) T4 v. s. v3 a4 {; P9 k8 I/ O2 r& f2 kg of weight. Physical examination remained
' `, T) {" z5 L1 t/ }unchanged. Surprisingly, the pubic hair almost com-
+ x% s- \* ^3 L8 apletely disappeared except for a few vellous hairs at
* [" y. L4 |1 mthe base of the phallus. Testicular volume was still 2
' v: v2 D, O& y$ Y5 n+ B: T/ pmL, and the size of the penis remained unchanged.
' @* ^0 K* T4 T1 }! l  YThe mother also said that the boy was no longer hav-
2 @- C; ~8 u7 V# P1 F/ ]! ]1 M5 cing frequent erections./ S) I- Z2 t' D8 }
Both parents were again questioned about use of* Q2 g: R$ E% W9 R7 {) U, l% u
any ointment/creams that they may have applied to
/ p! l3 r% T: D. ?* uthe child’s skin. This time the father admitted the" T; c, l/ Q" _4 o7 J) I! n0 {
Topical Testosterone Exposure / Bhowmick et al 541
( S7 p# e; T  ?  v1 w$ O. a5 ^use of testosterone gel twice daily that he was apply-/ c0 M" r/ D% J  U" g, Q9 q
ing over his own shoulders, chest, and back area for# a7 f: ?$ v! f4 s( {& n/ ?
a year. The father also revealed he was embarrassed: s6 \% T/ b/ s5 L
to disclose that he was using a testosterone gel pre-5 s# }0 v3 W8 \" a2 b) [
scribed by his family physician for decreased libido$ y/ p# d7 A3 P) f# B4 T
secondary to depression.
! g& i# b5 [) p. Q+ Z5 _7 `/ LThe child slept in the same bed with parents., j6 }0 f2 g; }1 g
The father would hug the baby and hold him on his
1 C0 K+ N" c( nchest for a considerable period of time, causing sig-
, e! ?) o) d) b( x$ [nificant bare skin contact between baby and father.
) a/ r: b$ o, P. `" A  R% J# mThe father also admitted that after the phone call,8 ^& A# B! ^" ^- J' J& }1 x% ]
when he learned the testosterone level in the baby
5 H( y5 {/ U( P, L# Iwas high, he then read the product information
4 W: d4 z( ]9 upacket and concluded that it was most likely the rea-
9 |% p3 ~) {2 v* Vson for the child’s virilization. At that time, they
* u* V9 e( I3 j8 V8 ^4 Ndecided to put the baby in a separate bed, and the' Z: y! l/ O+ r1 j+ D
father was not hugging him with bare skin and had
9 Q, H; w" Q( h& j( t8 Ubeen using protective clothing. A repeat testosterone
' c: O8 k& X& E6 ytest was ordered, but the family did not go to the8 }9 I5 ^5 N# W8 J
laboratory to obtain the test.+ Z' j& e& g0 z4 d( s  h7 T
Discussion8 i0 B% ~; u( Q3 X
Precocious puberty in boys is defined as secondary
2 Z3 j  I" Q- k" I9 Gsexual development before 9 years of age.1,48 ?0 i2 M. V& R2 f8 ^8 K- d0 x5 U* \$ V
Precocious puberty is termed as central (true) when% k5 A9 Y* O/ `8 N
it is caused by the premature activation of hypo-
- R0 Z( r- n! X/ e% Othalamic pituitary gonadal axis. CPP is more com-
9 ~, r+ ^1 x8 ]mon in girls than in boys.1,3 Most boys with CPP% C7 Z0 \8 ]9 A  V- Z  R
may have a central nervous system lesion that is
! a( B6 Q+ |+ a1 r4 W& Dresponsible for the early activation of the hypothal-! v) u' h1 w0 k; \. `& H; b
amic pituitary gonadal axis.1-3 Thus, greater empha-5 L3 r/ m, b# k5 M- ]5 `1 D5 p
sis has been given to neuroradiologic imaging in, ~( V+ _- \( u7 w6 G8 ?! g+ ^; ?
boys with precocious puberty. In addition to viril-0 y6 R) I) \% f8 S+ O
ization, the clinical hallmark of CPP is the symmet-3 H5 V9 G' h+ x( X7 i+ }
rical testicular growth secondary to stimulation by
- X" {. M! a9 w; P3 O4 J# x! kgonadotropins.1,3: U1 B$ [% n% l7 b% l  C
Gonadotropin-independent peripheral preco-) X  ?5 F4 ]; k. Z% t9 ^
cious puberty in boys also results from inappropriate
7 D- Y+ ]5 N! O3 \androgenic stimulation from either endogenous or+ Y- `& @2 k% b$ i( @/ l; d
exogenous sources, nonpituitary gonadotropin stim-
2 _" x- R/ O7 t3 Julation, and rare activating mutations.3 Virilizing
. g* j+ D! ?5 E0 r3 ]/ wcongenital adrenal hyperplasia producing excessive8 N: _. `6 `! o4 j
adrenal androgens is a common cause of precocious
6 L4 b3 i; E! r9 E1 [2 |8 Z+ M9 {puberty in boys.3,47 c+ i6 J( }& @
The most common form of congenital adrenal0 q9 V3 K. u) c! w0 E/ E2 x
hyperplasia is the 21-hydroxylase enzyme deficiency.( r9 Z/ k" o0 ~4 j5 |2 ~1 ?
The 11-β hydroxylase deficiency may also result in
' Q0 b5 u* [6 E% \1 B6 iexcessive adrenal androgen production, and rarely,
; m; Y% z. O/ H& h8 y' Oan adrenal tumor may also cause adrenal androgen
6 p% z4 g. z# _6 `! `( Nexcess.1,3- l; I5 u7 A8 L: D. o$ @1 ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: d: e+ n& t0 A' w/ @. W6 P/ ~4 C
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ j) v/ a* D  y
A unique entity of male-limited gonadotropin-, n# Y3 E9 q: a! K- o) b+ {( Y" G
independent precocious puberty, which is also known7 f  ]; y6 l8 v
as testotoxicosis, may cause precocious puberty at a
- M" k( g& ], @. ~3 Kvery young age. The physical findings in these boys; F8 }1 L/ {& B1 l" a* G  |% T
with this disorder are full pubertal development,& m- a3 B) |. i7 Y& }$ K
including bilateral testicular growth, similar to boys% f! Y( a8 X. ?2 p2 F  I! h: N
with CPP. The gonadotropin levels in this disorder1 G: E3 F' Z7 l' M
are suppressed to prepubertal levels and do not show: o1 p! n$ y6 `: L0 C' D
pubertal response of gonadotropin after gonadotropin-5 G' [5 C8 ]1 `# h2 }# |/ s
releasing hormone stimulation. This is a sex-linked$ T# g* N; k) _
autosomal dominant disorder that affects only
$ v6 y9 |. y. y# K- imales; therefore, other male members of the family
* p8 r$ g% _. m2 S6 t$ Q5 Xmay have similar precocious puberty.3
- M: ?) o" L3 b: s" zIn our patient, physical examination was incon-) f; R# S( k3 P' U8 ]2 C  u+ |
sistent with true precocious puberty since his testi-+ p3 G5 b  c" e! `/ y0 ~
cles were prepubertal in size. However, testotoxicosis
  q- ]6 p3 b) Z2 {; ]4 U: nwas in the differential diagnosis because his father
+ @, C+ D( M& n# b, l5 `4 Lstarted puberty somewhat early, and occasionally,8 m& K5 t) Y, a/ |; a
testicular enlargement is not that evident in the$ h/ \8 [+ p# v
beginning of this process.1 In the absence of a neg-
% R$ x) A' c" gative initial history of androgen exposure, our2 ?7 V; |) H& f0 ~/ B  |
biggest concern was virilizing adrenal hyperplasia,/ z% d9 e5 A8 q# M' L
either 21-hydroxylase deficiency or 11-β hydroxylase7 a# Y/ w1 C$ g- c
deficiency. Those diagnoses were excluded by find-
& C; Y% a) u& Ting the normal level of adrenal steroids.) p+ r$ o, c7 E
The diagnosis of exogenous androgens was strongly
2 T) ~( W3 c' M4 |suspected in a follow-up visit after 4 months because- @, o; Q/ U/ g/ V' m) M$ G, n
the physical examination revealed the complete disap-! g; f0 s# \$ `& D' c
pearance of pubic hair, normal growth velocity, and
. l$ v  {% c. m- |1 |decreased erections. The father admitted using a testos-
/ ~# S+ N2 e( L3 F# f9 G  b5 }terone gel, which he concealed at first visit. He was6 d* X1 T  \  I7 Z1 m" X: Z, W
using it rather frequently, twice a day. The Physicians’
1 o% ~/ l: s, _4 M% P" Z- @Desk Reference, or package insert of this product, gel or2 g" \- ~% V) l% P+ l/ C, U2 G
cream, cautions about dermal testosterone transfer to2 t9 U! O  `0 y& t( \; \4 C+ x
unprotected females through direct skin exposure.2 r  X0 f4 q2 J# v7 D
Serum testosterone level was found to be 2 times the) _  d2 n8 R6 ^% E0 {7 G
baseline value in those females who were exposed to
$ V, b; f, F0 ]even 15 minutes of direct skin contact with their male2 S; p& c4 V7 b- k2 k
partners.6 However, when a shirt covered the applica-# \6 }5 m+ a$ g' T  \
tion site, this testosterone transfer was prevented.9 m, g- `$ j$ X4 F; x  P8 A2 L
Our patient’s testosterone level was 60 ng/mL,/ t+ a! D5 `) k  A) k4 \! A
which was clearly high. Some studies suggest that
% h" s1 [0 v% V1 S& h3 ddermal conversion of testosterone to dihydrotestos-2 g; X9 ~( @1 I# d7 H
terone, which is a more potent metabolite, is more  c7 P4 y( v$ [, O9 p: _; k1 f' X' w
active in young children exposed to testosterone: U( X  x8 y5 F9 Z
exogenously7; however, we did not measure a dihy-0 K  R% v9 G9 M8 f1 `
drotestosterone level in our patient. In addition to1 X) D* E: _# y. l, N2 T
virilization, exposure to exogenous testosterone in* `% X0 b( N/ X4 d( {! B
children results in an increase in growth velocity and
, R# N; \. m5 q0 p; F2 qadvanced bone age, as seen in our patient.$ y- h/ h+ l6 T( t
The long-term effect of androgen exposure during, \9 y+ M- i' N9 d0 w
early childhood on pubertal development and final$ H& _4 @: x8 n
adult height are not fully known and always remain
5 o. D! J9 M/ y1 H0 Fa concern. Children treated with short-term testos-3 m0 O, w6 t$ P3 |2 l9 k
terone injection or topical androgen may exhibit some
% r& O! C# @) p; ]2 r. _0 }acceleration of the skeletal maturation; however, after
' V1 d& C6 `- ~% Qcessation of treatment, the rate of bone maturation
3 F) t: L4 Z6 h. [decelerates and gradually returns to normal.8,94 G% `- A: @( J" L9 W  b
There are conflicting reports and controversy& B9 Y. a# k2 B9 |: z+ h
over the effect of early androgen exposure on adult
) O7 i. E2 e& N/ Cpenile length.10,11 Some reports suggest subnormal
! _3 w1 q! E! L4 a# O4 S( nadult penile length, apparently because of downreg-4 [5 s+ S0 r  ~6 A0 L
ulation of androgen receptor number.10,12 However,% g( ~8 [+ q7 U! c
Sutherland et al13 did not find a correlation between: b0 }. b. n2 m! `& Q
childhood testosterone exposure and reduced adult
" T' f9 J3 I0 R- Bpenile length in clinical studies.
" ]  U2 g4 L( CNonetheless, we do not believe our patient is
/ G& M- z# e/ w4 z( K: N6 ggoing to experience any of the untoward effects from6 C) h# l  `0 S' P7 p; y: O1 }
testosterone exposure as mentioned earlier because
$ x" s4 C/ ?. v3 v) ?the exposure was not for a prolonged period of time.- U$ D# ~: n1 l& z
Although the bone age was advanced at the time of) h1 P& f: M8 ?8 g  Q% {5 l2 Z
diagnosis, the child had a normal growth velocity at) c" @8 ]: Q, g0 C  [
the follow-up visit. It is hoped that his final adult+ n- {$ x) B% e( f* h
height will not be affected.% Q2 G2 L+ E) }# W( G
Although rarely reported, the widespread avail-
* u  G' a% W# k- k3 t& ^ability of androgen products in our society may5 s& M1 f( c& h; g& Y$ Y
indeed cause more virilization in male or female) `0 D: _4 d6 i: u: r+ H; [7 F% {  r
children than one would realize. Exposure to andro-
, p' b1 T! c' w5 M# ~gen products must be considered and specific ques-) E  U: P  c% s" S( O3 w( ^2 w
tioning about the use of a testosterone product or
. v0 \+ a. Y! `' i7 bgel should be asked of the family members during' l- D8 v. r/ d$ x# o4 {* j
the evaluation of any children who present with vir-0 @0 X5 }$ Z+ Q. b' l1 x
ilization or peripheral precocious puberty. The diag-3 R- e% d2 i4 t
nosis can be established by just a few tests and by
/ {* {( M5 D/ }3 K: Xappropriate history. The inability to obtain such a" U8 z4 k2 x' m; W7 U3 l+ }
history, or failure to ask the specific questions, may1 l: Q0 s3 k+ Z3 F
result in extensive, unnecessary, and expensive
7 O8 \' z' P* \$ g/ Winvestigation. The primary care physician should be
* F$ G' y! O: z: uaware of this fact, because most of these children; ^, }9 T8 D* z
may initially present in their practice. The Physicians’% g: `1 _9 v  [9 U/ g, h
Desk Reference and package insert should also put a" Y9 o( O4 M& C; }3 R
warning about the virilizing effect on a male or
7 B' A3 j/ t, F( rfemale child who might come in contact with some-4 N/ \4 b) c5 q" ]
one using any of these products.
! |" o1 u( `( m5 {4 P/ R) PReferences9 Z/ O* [5 m; u( V3 ^
1. Styne DM. The testes: disorder of sexual differentiation# d& {4 \7 b' b
and puberty in the male. In: Sperling MA, ed. Pediatric) v/ m3 g6 {1 T$ `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ |, n7 e0 J/ N
2002: 565-628.
' }% f# m+ t( s$ s9 Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) i/ _3 T: F0 N3 J1 k5 w) c
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 V& i1 a3 B' E. [4 X
Boy Induced by Indirect Topical  \7 R/ B. `" P  u5 S; M3 e4 `1 i
Exposure to Testosterone
7 ~, A- u( u8 V7 H) h/ {) PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ P# q3 W. }1 r- r0 k$ jand Kenneth R. Rettig, MD1" G# P, M! g! `1 M/ s9 l
Clinical Pediatrics
8 C: G4 M% V; P% Q) |/ LVolume 46 Number 67 x/ H2 c% M, N0 i6 ]* c
July 2007 540-543( f! Y5 z0 g" }3 \
© 2007 Sage Publications2 i1 o& m0 @0 p. k1 p0 r# W
10.1177/0009922806296651# \( w4 _7 \# d9 u+ P/ y" k+ K
http://clp.sagepub.com
- u8 N0 t5 A7 B# {hosted at
5 h9 @7 \; A& ihttp://online.sagepub.com
! M- Z" I8 b8 WPrecocious puberty in boys, central or peripheral,% J  ]9 i( c. V
is a significant concern for physicians. Central
( M+ c! x/ @9 k! x( Oprecocious puberty (CPP), which is mediated
3 @% f* Q6 x  B! q6 N- W# xthrough the hypothalamic pituitary gonadal axis, has
6 r' D& n$ ^( I; {a higher incidence of organic central nervous system- N4 D) ~7 @0 K. x$ F7 x1 A
lesions in boys.1,2 Virilization in boys, as manifested# J! V$ N: F+ R! h: a. P4 P
by enlargement of the penis, development of pubic
4 N2 Y' m( ~) k, _3 Z/ I- \& ^$ @hair, and facial acne without enlargement of testi-
! w$ |. |1 X) g' @, ]- ^" Wcles, suggests peripheral or pseudopuberty.1-3 We  H; E8 t6 W# X- M
report a 16-month-old boy who presented with the" I4 ]9 o; w: C
enlargement of the phallus and pubic hair develop-7 f3 M0 \2 z6 D$ Y. M2 X( G0 c$ W
ment without testicular enlargement, which was due
/ x4 r3 P0 X7 d# p2 Pto the unintentional exposure to androgen gel used by
+ F/ D/ a  k8 A/ F1 \' [3 @5 J5 Sthe father. The family initially concealed this infor-
, P: S$ z. A1 Pmation, resulting in an extensive work-up for this  A" ?. e: |$ ]0 g5 b  E% b! f1 m
child. Given the widespread and easy availability of
$ }9 W- ~) l& e/ ktestosterone gel and cream, we believe this is proba-, C' i) T: z( B1 Y/ ]  m
bly more common than the rare case report in the! N+ r7 W; o* b0 `: x
literature.4! H) |0 o2 j4 g
Patient Report7 [% Y% S# c: X( `& M+ C
A 16-month-old white child was referred to the
$ B+ m- Q9 e- Y: W) [3 ^endocrine clinic by his pediatrician with the concern; {. _5 O2 T1 `7 h% y
of early sexual development. His mother noticed
& j7 J2 g7 _( u, v+ T0 @7 _) rlight colored pubic hair development when he was
" c8 Z" f, C' L* _. IFrom the 1Division of Pediatric Endocrinology, 2University of& W; R% s$ }2 S- {# h' N
South Alabama Medical Center, Mobile, Alabama.
4 E+ \9 v4 }9 B: t7 X; L9 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 }# E7 B% [+ H/ I' q* d# [# dProfessor of Pediatrics, University of South Alabama, College of
6 L" l. o+ t( ]+ LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 K! m. ]1 W7 w5 W4 ]
e-mail: [email protected].. t$ q% t- i: z1 n; W8 L2 o' _/ K
about 6 to 7 months old, which progressively became) ]  c: G  X6 P
darker. She was also concerned about the enlarge-
. H3 j5 L. K7 Z. Tment of his penis and frequent erections. The child" ^* p* l+ x# \8 l4 d1 m
was the product of a full-term normal delivery, with
4 a4 J6 G) y: R, na birth weight of 7 lb 14 oz, and birth length of
( V1 q! H* [; S7 {" A! n1 e( B, p; ^20 inches. He was breast-fed throughout the first year
) k$ U! d) l, Q; qof life and was still receiving breast milk along with1 I7 F" B6 c' V  o1 N2 P- v, j
solid food. He had no hospitalizations or surgery,; |  e1 E, F2 h* p7 B4 _6 f" Y
and his psychosocial and psychomotor development
- ?" m5 J2 a3 j. G* E- b' mwas age appropriate., H0 k6 Q% K+ U3 {* ?7 m7 ?- `
The family history was remarkable for the father,+ H& u: Q# D( ^" b/ L
who was diagnosed with hypothyroidism at age 16,
4 a" u  i- T! ]0 m( Iwhich was treated with thyroxine. The father’s
+ v3 U$ \4 J& }height was 6 feet, and he went through a somewhat
* B  _$ a* c1 Q" t9 Yearly puberty and had stopped growing by age 14.
1 [7 m( s* K6 E8 F& N( `, SThe father denied taking any other medication. The
2 G% |. I5 B( P7 ~( H" E  q, \child’s mother was in good health. Her menarche+ p; ^" h0 d8 R1 }$ E  e
was at 11 years of age, and her height was at 5 feet9 v6 j. {( H; z/ P8 t9 S$ E7 k
5 inches. There was no other family history of pre-
! R2 e0 m( l0 {, hcocious sexual development in the first-degree rela-
, C. t, n. k" |* _: \* Ctives. There were no siblings.
0 E' G1 N2 v4 h; w. yPhysical Examination8 F1 e, }) n& L( ]  W
The physical examination revealed a very active,
( v7 m% o2 K+ B3 P0 \# G6 P- F% xplayful, and healthy boy. The vital signs documented" u  h' Z! D. j% e. X) E/ L
a blood pressure of 85/50 mm Hg, his length was% }. @  s3 D7 b6 k& A6 U0 W
90 cm (>97th percentile), and his weight was 14.4 kg! u! U# Q; M' ]% `
(also >97th percentile). The observed yearly growth
, n6 X0 Z+ I5 gvelocity was 30 cm (12 inches). The examination of' Q# ^0 f6 i7 S) e
the neck revealed no thyroid enlargement.
  d) a" {: g) \' O1 y. S! k4 eThe genitourinary examination was remarkable for
/ p1 r+ Y) u' l" M# V# denlargement of the penis, with a stretched length of0 S$ ~# e: g" w+ H
8 cm and a width of 2 cm. The glans penis was very well
& T4 e! u3 k' C! L% }; hdeveloped. The pubic hair was Tanner II, mostly around
3 n& D; G; x' Z7 ?. X540/ O" \; w9 v5 @% p7 j7 e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; X5 N3 |/ \, F1 h. Tthe base of the phallus and was dark and curled. The, s: J2 c5 e! q" ?( R% l# _
testicular volume was prepubertal at 2 mL each.
( F# i; _' h2 @2 b0 T; yThe skin was moist and smooth and somewhat
& c: j' c$ U( R; a: Poily. No axillary hair was noted. There were no$ A: g; v* Q3 r; {
abnormal skin pigmentations or café-au-lait spots.1 u. o( C/ M/ {
Neurologic evaluation showed deep tendon reflex 2+
9 f) M2 f+ f* E. Zbilateral and symmetrical. There was no suggestion
# E2 l' `2 q- sof papilledema.6 u$ b( W+ L+ B0 W! ^
Laboratory Evaluation
9 p; h9 s' A" A! q1 R' L' H; O1 A, SThe bone age was consistent with 28 months by
5 I5 w5 Y& t- n* m4 M! `using the standard of Greulich and Pyle at a chrono-# j) U6 k  S; s& N
logic age of 16 months (advanced).5 Chromosomal
( |* Q( A5 a" C, fkaryotype was 46XY. The thyroid function test
7 b0 ?8 z1 x1 f9 \6 Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 [( D' E6 z" b- [. P3 Elating hormone level was 1.3 µIU/mL (both normal).# v7 x8 b4 {: g  A  V8 K- S5 K* H+ Q
The concentrations of serum electrolytes, blood
. ?/ ~) j2 v3 g- c& F# a  Wurea nitrogen, creatinine, and calcium all were$ N2 P" G# U9 w( p1 R5 @
within normal range for his age. The concentration; Z2 g% F/ W" T; Y: y9 n: m- k
of serum 17-hydroxyprogesterone was 16 ng/dL
* d- N; T0 P  p  v# P(normal, 3 to 90 ng/dL), androstenedione was 20: `) |4 J) |, d! M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& H/ p5 N4 n" y. V# L6 a& Sterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 C# A% ?3 F$ L: b+ F' ]& P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 o! I. q$ v; E  B
49ng/dL), 11-desoxycortisol (specific compound S)
- W9 T+ G2 [& ?& ]3 o' D5 ^+ Nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! o( H5 l& G8 k0 Z8 [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 l) ]  b" B7 J9 xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  ?% t+ ~! Z0 c( `and β-human chorionic gonadotropin was less than
$ B" k# _: c4 O. j' H' y5 mIU/mL (normal <5 mIU/mL). Serum follicular
" g$ d+ q" \; z; p9 sstimulating hormone and leuteinizing hormone8 s& L5 [" n' X( ?, m+ |1 c
concentrations were less than 0.05 mIU/mL+ q2 u/ L: }% Z
(prepubertal).
2 W- u/ e6 [' ^( x4 J4 ~+ R* Q2 pThe parents were notified about the laboratory
" D9 H( D; |' G+ nresults and were informed that all of the tests were
; O0 E" ]. a" z* y8 j) L" cnormal except the testosterone level was high. The
# F' B3 C+ |0 r- m5 E+ |4 B5 x% Hfollow-up visit was arranged within a few weeks to- ^. l- N9 e) P' w; H
obtain testicular and abdominal sonograms; how-4 m+ |6 ~" z4 u0 @' h
ever, the family did not return for 4 months.
$ t3 l+ Z  A8 |' A+ }# w5 ^) uPhysical examination at this time revealed that the+ @" q5 V0 |: z' ^$ G
child had grown 2.5 cm in 4 months and had gained
6 m1 _- b& `0 C% r- x. P+ ?2 kg of weight. Physical examination remained& G! w4 m4 M7 G, i
unchanged. Surprisingly, the pubic hair almost com-
, c0 N- O8 h0 ~) O& O4 L* \pletely disappeared except for a few vellous hairs at
/ A. E& m8 x  o4 ?1 Q, Dthe base of the phallus. Testicular volume was still 2' Q3 H( ?& ^  _/ m% }3 c
mL, and the size of the penis remained unchanged.' D2 E. J4 H. F" G, U8 a
The mother also said that the boy was no longer hav-
; N6 D6 @2 G0 [4 m2 Ling frequent erections.
3 `; g/ _' T# z* ]Both parents were again questioned about use of
& ?+ V* B  Q* Gany ointment/creams that they may have applied to
/ y5 J$ t4 q/ F4 _, y; Dthe child’s skin. This time the father admitted the
* N5 D, M, g) V1 r5 c( C  e1 FTopical Testosterone Exposure / Bhowmick et al 541
7 i& U  E) J2 t1 z5 ~4 F5 wuse of testosterone gel twice daily that he was apply-
# e- N0 Q4 W- E3 i+ K2 @0 ~ing over his own shoulders, chest, and back area for. Q6 I5 [# g, x0 G9 E7 ]
a year. The father also revealed he was embarrassed
  d3 E  y0 F, r) Ito disclose that he was using a testosterone gel pre-! ?5 D2 F5 }1 s: p+ c; K, L9 C+ q
scribed by his family physician for decreased libido
7 O: }4 N1 O# I9 F% dsecondary to depression.6 d7 c$ d- C3 j/ j6 G. C' F6 V" o& i6 B
The child slept in the same bed with parents.+ V/ |5 {7 C* U* @
The father would hug the baby and hold him on his* ~6 A. T% _# [' o3 L! G4 W
chest for a considerable period of time, causing sig-
& J* g& \/ j# ^! Z1 W: {+ h* Tnificant bare skin contact between baby and father.: Z7 o( q) O  P  N$ d3 f
The father also admitted that after the phone call," M5 f2 Q9 p' ]' K) f, p
when he learned the testosterone level in the baby; H7 J: \, _5 r
was high, he then read the product information+ M& X9 a- u4 {3 O( H# \! H
packet and concluded that it was most likely the rea-, ?5 I/ M4 @9 u. ^+ T4 q
son for the child’s virilization. At that time, they
1 w& l  J6 s# {% ~decided to put the baby in a separate bed, and the
" N6 q2 s3 U  e7 X0 j; Wfather was not hugging him with bare skin and had
% l& z  J, y5 s1 Zbeen using protective clothing. A repeat testosterone
7 I5 j8 n4 ]- z& R! Z% Mtest was ordered, but the family did not go to the* {0 _* ~' b2 R  I
laboratory to obtain the test.
/ y% @) Y% D. M; n: S% _& R8 [Discussion% Y8 A! T- r: I
Precocious puberty in boys is defined as secondary
9 }& y. s0 ]: r" I5 jsexual development before 9 years of age.1,4% H5 y  t; K; b; s' }
Precocious puberty is termed as central (true) when% U# |0 B" T, S+ t& t( e+ y6 a
it is caused by the premature activation of hypo-' ]/ [4 B. c9 U
thalamic pituitary gonadal axis. CPP is more com-
& s% O$ B3 m0 ]9 Vmon in girls than in boys.1,3 Most boys with CPP4 o/ t) t% J2 ^; m! [% V
may have a central nervous system lesion that is$ b1 o! b% ?& j2 S, @7 Z
responsible for the early activation of the hypothal-
5 B2 d: z' B# A' i3 Tamic pituitary gonadal axis.1-3 Thus, greater empha-8 _+ [+ F" C, I) h5 g
sis has been given to neuroradiologic imaging in/ i7 q- R4 r8 Z8 A* L2 H! M% \! s
boys with precocious puberty. In addition to viril-: d8 p- R, P0 G, _' {. G( {
ization, the clinical hallmark of CPP is the symmet-
8 ~, q3 j+ V3 Nrical testicular growth secondary to stimulation by
: P$ z2 F7 w4 e  c9 j+ o5 Wgonadotropins.1,3
4 [& g3 `7 ^- o% \2 L: E2 q6 jGonadotropin-independent peripheral preco-
+ T# O1 h, P+ I. L$ \' [- Lcious puberty in boys also results from inappropriate
$ y+ z$ E; t1 l9 ~; Dandrogenic stimulation from either endogenous or# n, R# U" \3 ]6 \% G7 b' x& T
exogenous sources, nonpituitary gonadotropin stim-
; u# {( F- P  T8 g" gulation, and rare activating mutations.3 Virilizing$ T9 ~, p& {  d  d: \' T5 ?" l6 L
congenital adrenal hyperplasia producing excessive) R( E5 \- C( a: t' N8 Q4 s
adrenal androgens is a common cause of precocious
6 t1 _. ?* f' upuberty in boys.3,4
; G  Z: {+ ~& D6 T0 \The most common form of congenital adrenal7 d7 b0 Z: L. Q9 T9 R4 d/ c
hyperplasia is the 21-hydroxylase enzyme deficiency.; z# B/ F, s! @# s* M
The 11-β hydroxylase deficiency may also result in8 I2 P/ J0 k" a2 {
excessive adrenal androgen production, and rarely,
0 X' o* U) b: k4 J! b5 Ran adrenal tumor may also cause adrenal androgen: j2 y4 X% e9 D9 V, i+ `! ]
excess.1,3+ w# T( [( d# @8 t4 T1 O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. W6 l* d+ @% B542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, ?  l& D1 W/ _/ P4 K: l% T8 vA unique entity of male-limited gonadotropin-1 C0 b! J7 P: F7 s& X' j
independent precocious puberty, which is also known
; G% o! c# l" F4 |: e7 _3 X) ^; ias testotoxicosis, may cause precocious puberty at a
* {# I6 F$ _: r3 P5 D% L- s6 t/ kvery young age. The physical findings in these boys% Z  e9 I0 H, P; i8 Q/ ?* ~
with this disorder are full pubertal development,' Z, m) H+ W& ?7 V* Q
including bilateral testicular growth, similar to boys
: i. D' f  }& fwith CPP. The gonadotropin levels in this disorder* V2 W* y5 {' p
are suppressed to prepubertal levels and do not show8 I0 ?6 C& e$ a5 L. n% x1 g8 x
pubertal response of gonadotropin after gonadotropin-! v. o# |  v+ _: M2 c4 W
releasing hormone stimulation. This is a sex-linked
. S$ Z2 k# w( J( I9 I' hautosomal dominant disorder that affects only
/ X1 Z; ?8 V8 x* W7 Y, H7 n2 Xmales; therefore, other male members of the family3 A9 I, l# Y5 p
may have similar precocious puberty.3
" m; `+ M9 j( S" I. O3 c, o. bIn our patient, physical examination was incon-; \, U- k3 N+ q+ Z- J& r
sistent with true precocious puberty since his testi-" F: n) q. F% P/ O
cles were prepubertal in size. However, testotoxicosis
  E" _& j/ Q( Z$ I, b* R5 J- rwas in the differential diagnosis because his father. u3 V7 d  V$ [+ V
started puberty somewhat early, and occasionally,) Y& Z1 S6 T5 g+ H3 Q
testicular enlargement is not that evident in the3 e0 y1 [$ A1 w* Q
beginning of this process.1 In the absence of a neg-1 V0 p& {" R4 a$ u& p8 ?
ative initial history of androgen exposure, our
* O5 l% v! a# n5 rbiggest concern was virilizing adrenal hyperplasia,) S  y7 [, _/ D
either 21-hydroxylase deficiency or 11-β hydroxylase' E) @  a, o2 {) ?2 J. ?; E  z
deficiency. Those diagnoses were excluded by find-
" A: s7 A2 E. Fing the normal level of adrenal steroids.! J  M" }/ e. h/ B# @
The diagnosis of exogenous androgens was strongly8 C* E' }& _5 }; V2 I" Z3 `! j8 s5 ?* \
suspected in a follow-up visit after 4 months because2 [) [4 S0 m& k$ U, v
the physical examination revealed the complete disap-' y5 K  t$ B- t4 |% g
pearance of pubic hair, normal growth velocity, and
; {, S7 ~* f! Zdecreased erections. The father admitted using a testos-7 m% K% |5 D3 f' r2 Q% b! l
terone gel, which he concealed at first visit. He was
" V! v* z" p* Ousing it rather frequently, twice a day. The Physicians’
0 R& Y0 {  \) J7 S3 h$ t; |Desk Reference, or package insert of this product, gel or
: y% X  l+ Z- m+ ?; `cream, cautions about dermal testosterone transfer to; _- j7 ]$ T  T* M1 C# P# H& x
unprotected females through direct skin exposure.& f9 Y% y0 `! Z# Q9 R, Q  p+ |
Serum testosterone level was found to be 2 times the, p9 J4 u$ B. V8 M
baseline value in those females who were exposed to
4 X8 k! H! b9 peven 15 minutes of direct skin contact with their male
; p' b7 V* b% E+ y5 Wpartners.6 However, when a shirt covered the applica-0 T* T% n# E9 l5 P& s5 U
tion site, this testosterone transfer was prevented.
! D' `* I( f' |5 q  w, _# TOur patient’s testosterone level was 60 ng/mL,
" q% J! ]/ f& B4 v# H: y8 X  d/ Twhich was clearly high. Some studies suggest that- a+ o0 p# F9 x0 T
dermal conversion of testosterone to dihydrotestos-4 C0 f7 v, Q2 P) e2 w- L8 q
terone, which is a more potent metabolite, is more+ y) a  D' ~# o, M& e" m% X0 S
active in young children exposed to testosterone
' ^3 m) d+ u2 S' J! ^exogenously7; however, we did not measure a dihy-
" r  q$ D/ p" ]" Adrotestosterone level in our patient. In addition to, C& c: Y& u# w0 f1 G+ Z
virilization, exposure to exogenous testosterone in. J( _9 d2 \# a
children results in an increase in growth velocity and# }# T2 q$ H/ s9 L: ]( P3 t7 G
advanced bone age, as seen in our patient.
+ c4 G% x; O; {1 g1 x% qThe long-term effect of androgen exposure during
$ e' q# M3 G  o9 m1 g9 \# `; I4 O% Hearly childhood on pubertal development and final
& R! }5 O  A& ~; O9 Wadult height are not fully known and always remain2 B* N& l" v, `3 z3 c' O+ b
a concern. Children treated with short-term testos-
0 O; w3 e9 V( v& c" Y7 b, aterone injection or topical androgen may exhibit some! Z# h  ~8 q0 k$ g
acceleration of the skeletal maturation; however, after/ d  V$ w- I5 P1 a: R
cessation of treatment, the rate of bone maturation
$ r# g9 s, n1 r3 adecelerates and gradually returns to normal.8,9  c7 U& o- d0 i
There are conflicting reports and controversy9 l3 n$ k& r* p
over the effect of early androgen exposure on adult
" v9 `% k$ M* ?3 L) `penile length.10,11 Some reports suggest subnormal
" f. ~7 ]6 r% Nadult penile length, apparently because of downreg-4 }+ F3 l& A* J+ K3 A* x! ?2 w+ g
ulation of androgen receptor number.10,12 However,4 @) d& X+ M% e
Sutherland et al13 did not find a correlation between) O, V* U& a% S1 r2 u6 ^
childhood testosterone exposure and reduced adult
: b! p( _4 B  f) H: jpenile length in clinical studies.0 w) Y- _; w! ~2 n4 c0 _: j: X
Nonetheless, we do not believe our patient is0 q7 b  L5 `! I, M, Z2 Y
going to experience any of the untoward effects from
, a! `' ^; I4 h$ S" I. |9 jtestosterone exposure as mentioned earlier because: N  M5 N6 p6 ~/ S6 o! o" A
the exposure was not for a prolonged period of time.
9 L/ j) }! [7 Z% S7 uAlthough the bone age was advanced at the time of
0 Y( Q: S8 A6 r, C* c7 h. W) Bdiagnosis, the child had a normal growth velocity at
+ }) @0 t/ I* B# u* u* ethe follow-up visit. It is hoped that his final adult
  F7 Y3 @5 }- X  i9 j; M8 S2 Jheight will not be affected.
3 Z4 [# l5 i3 ^Although rarely reported, the widespread avail-
6 L) _/ P( K' M5 X6 A+ Jability of androgen products in our society may' b5 u( w3 s& P9 N
indeed cause more virilization in male or female/ B7 _9 i+ q4 N( O0 _; k
children than one would realize. Exposure to andro-
2 |% D0 ]% J! P$ igen products must be considered and specific ques-
9 n" N3 j# m& s3 }$ ]0 ^; b5 g6 E/ ~# Xtioning about the use of a testosterone product or
8 D. H4 T" N7 b+ ?2 n3 t3 ]+ E5 ~gel should be asked of the family members during
  p3 O6 W" s  F8 }- ]' Zthe evaluation of any children who present with vir-
/ I5 q! w7 n( N8 y/ Lilization or peripheral precocious puberty. The diag-
) p" R$ [/ U$ Nnosis can be established by just a few tests and by5 c! A4 f$ h+ i
appropriate history. The inability to obtain such a
6 l1 |2 \' X, p: shistory, or failure to ask the specific questions, may9 F  S& g5 @- a9 u6 X
result in extensive, unnecessary, and expensive
# n6 z( h& b5 P6 W: N4 s& cinvestigation. The primary care physician should be& V/ T* @  L( H- f
aware of this fact, because most of these children; o# s* C% ~' J. M$ W$ n2 \# }
may initially present in their practice. The Physicians’. j) w7 j2 c9 W0 K9 W
Desk Reference and package insert should also put a
9 F7 j0 ]/ q% S# O1 {5 _warning about the virilizing effect on a male or
- L- z2 J5 [, Q1 M* |female child who might come in contact with some-
$ w0 S0 c4 j9 g; _( {& K# none using any of these products.: L6 k+ j- n+ ]9 t0 _
References
( G& `+ ~" E) Q4 R& i( m! \, ~2 R1. Styne DM. The testes: disorder of sexual differentiation
* I, @: [9 x% ~, X( d0 z: oand puberty in the male. In: Sperling MA, ed. Pediatric
4 ]5 o1 Y2 Z$ m+ s. P& C  L5 Y4 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! u9 H6 e! A2 p3 ?# A0 p1 G2002: 565-628.
5 k/ Q% q; n& E8 S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; |0 g% }4 F* wpuberty in children with tumours of the suprasellar pineal
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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
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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

" M! j% k" o  M. l, z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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