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Sexual Precocity in a 16-Month-Old% T4 q* N" z! `3 Z
Boy Induced by Indirect Topical: ^. }0 v/ [+ A1 t0 f3 S
Exposure to Testosterone4 |/ T* a; N$ I* i0 z  P  a& ~' A, O6 j1 j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. p7 ~% Z/ o! m- ?# B# t/ {and Kenneth R. Rettig, MD1
1 Q5 ?, L7 J3 i/ JClinical Pediatrics
+ j5 y( L$ E2 H5 s9 gVolume 46 Number 6
5 W1 k3 O& t2 E3 M3 k$ OJuly 2007 540-543
" K* _3 V3 J' S8 v6 b) _© 2007 Sage Publications) q5 a( o5 x7 p% _( U  b) j: o! W/ l
10.1177/0009922806296651
4 S. R9 l: y0 n; v( Khttp://clp.sagepub.com
5 H) Y0 W% q6 [; G, Thosted at+ u( I& w# \% ~" w, H2 s0 P. ~
http://online.sagepub.com
. M2 b2 M; W2 ]# IPrecocious puberty in boys, central or peripheral,  ?3 F" C* _6 J" I' a+ b6 Y
is a significant concern for physicians. Central
* A( P2 Z5 t+ B/ b7 iprecocious puberty (CPP), which is mediated( P& Q6 S4 x, w9 g
through the hypothalamic pituitary gonadal axis, has9 P5 ]) S5 X. j! N' h
a higher incidence of organic central nervous system0 D6 X& ~: r; B8 e3 Z
lesions in boys.1,2 Virilization in boys, as manifested
& ]4 ]- S/ w6 I1 N1 |by enlargement of the penis, development of pubic9 c( @) I$ [9 F9 I  v
hair, and facial acne without enlargement of testi-, ]. z  p, V8 g/ x+ Y5 O3 `$ b
cles, suggests peripheral or pseudopuberty.1-3 We/ N5 q. M) G, q& m8 M' W, e/ t
report a 16-month-old boy who presented with the
/ e& w+ I% E7 a) qenlargement of the phallus and pubic hair develop-+ {$ @' I7 y2 t: N/ S
ment without testicular enlargement, which was due
5 |5 S6 {  g. i- {7 T9 mto the unintentional exposure to androgen gel used by0 ]- ~0 R; `2 P! {' S2 b' S) {
the father. The family initially concealed this infor-
, g( ~$ ^1 X* ?2 O  ~# Wmation, resulting in an extensive work-up for this
4 h2 |4 ?8 f# \( E; t/ Mchild. Given the widespread and easy availability of( i4 H6 t: X1 J3 ^" T7 M. Y
testosterone gel and cream, we believe this is proba-: Y; j5 d  x8 \
bly more common than the rare case report in the
# g7 a" |& s/ N1 wliterature.44 J- a5 k  q& `$ A! ^
Patient Report, w' i- I7 \% w/ x9 b6 A, R" K2 V
A 16-month-old white child was referred to the
" N- _" K8 u2 v& r6 `$ S  tendocrine clinic by his pediatrician with the concern& @- N7 s9 f( }: a( h# n
of early sexual development. His mother noticed
" w/ N( W  H: ^light colored pubic hair development when he was
% D. K0 e: E$ GFrom the 1Division of Pediatric Endocrinology, 2University of
. f. `4 q* R+ c+ ?South Alabama Medical Center, Mobile, Alabama.
) D. s3 G- T5 t. ?) N0 ?3 K8 o& ^- bAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' s: q  t7 Z4 WProfessor of Pediatrics, University of South Alabama, College of
+ V! x  U7 w+ d& M1 q! T0 R# ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ Q4 x9 F  W/ N1 X/ A! c( T& B9 |
e-mail: [email protected].
( S, d) t6 S4 gabout 6 to 7 months old, which progressively became9 |9 a5 H: A5 u* ^9 f- Y* l
darker. She was also concerned about the enlarge-
# K( Z; I/ `! }( S  ?5 }ment of his penis and frequent erections. The child
; e( ^: w( Y# g; v: ~* u7 L% a7 Wwas the product of a full-term normal delivery, with! g& G) ?. G! F$ t
a birth weight of 7 lb 14 oz, and birth length of
8 R) d* _5 f+ d8 T; \( ?9 S8 U4 o20 inches. He was breast-fed throughout the first year
6 F" {' k. M' x7 Q  Bof life and was still receiving breast milk along with: L. h# c! I: f9 B6 T* g5 U
solid food. He had no hospitalizations or surgery,5 z0 c8 g. Q# u6 Q* G* f1 Q
and his psychosocial and psychomotor development( C" ^$ \+ V$ V/ L6 I
was age appropriate.
1 r; p) Q3 h- y4 hThe family history was remarkable for the father,2 D1 ?8 P3 b9 x  Z7 D0 M8 k
who was diagnosed with hypothyroidism at age 16,
3 F3 C9 ?& m5 Z. }8 r# wwhich was treated with thyroxine. The father’s
5 ?- }# J0 ~, w% pheight was 6 feet, and he went through a somewhat
- J. G5 Q( x; F7 l% `* P3 ]( dearly puberty and had stopped growing by age 14.2 D+ ~" |! ?  P- f% ?% e; X
The father denied taking any other medication. The% o, V+ F  a$ n: ^, t
child’s mother was in good health. Her menarche
; B6 Y1 y8 [5 [& z; C* twas at 11 years of age, and her height was at 5 feet; |) R5 E4 ~: T1 O% H/ t
5 inches. There was no other family history of pre-
  E3 M- o/ b* u1 S; l- Dcocious sexual development in the first-degree rela-( ^. A) v: k5 X8 L+ v" w) y
tives. There were no siblings.
; D. g; H$ ^9 }7 k( ~" oPhysical Examination
! z5 T) ^" z8 @( Z) R: c6 sThe physical examination revealed a very active,
1 D4 B, c# ]9 Y. N( W! hplayful, and healthy boy. The vital signs documented
7 i$ `- p" v8 l! H* `# x0 s5 ha blood pressure of 85/50 mm Hg, his length was1 \8 c! w) C' Y. F+ ^8 z/ G0 j; Y& c
90 cm (>97th percentile), and his weight was 14.4 kg- b  \7 v. A* J* [
(also >97th percentile). The observed yearly growth
- e) U) f& K4 v2 a% Z, o! i9 _velocity was 30 cm (12 inches). The examination of7 i" P9 X& @4 N1 [* r7 P0 r
the neck revealed no thyroid enlargement.
* X* `2 |8 T- i, Z' @9 k/ PThe genitourinary examination was remarkable for
* h/ H+ q* h& `& Benlargement of the penis, with a stretched length of
4 |* f+ _9 Z; z  t4 c9 [; ^; G8 cm and a width of 2 cm. The glans penis was very well
* U9 u% H1 r( N3 S, a0 c& tdeveloped. The pubic hair was Tanner II, mostly around
9 B) ~4 L  y6 g( u' H540
! G" ]) w: A% ~9 Z0 R6 p) r* jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 `) t0 S6 h* H# {/ W: M* vthe base of the phallus and was dark and curled. The
2 d: H* D3 R( r0 ktesticular volume was prepubertal at 2 mL each.7 _1 H% T# Z4 \; x% x4 G
The skin was moist and smooth and somewhat* }$ p! z1 d( y2 A; X. D. O" k4 B2 A
oily. No axillary hair was noted. There were no
* }' H7 Q/ P9 p& g) Babnormal skin pigmentations or café-au-lait spots.# P# o+ a2 g4 n6 E* G2 b
Neurologic evaluation showed deep tendon reflex 2+% F) A  s. Y$ e  {& z
bilateral and symmetrical. There was no suggestion
) e1 Q, x8 C. J. Z. v6 oof papilledema.
4 T& l# e3 U( h  m0 m8 A7 d1 hLaboratory Evaluation
" \. G0 k& x$ _% VThe bone age was consistent with 28 months by+ v  T6 j" \; d* q6 O
using the standard of Greulich and Pyle at a chrono-
9 H" v" y' G2 a" G# p; [3 b' {! llogic age of 16 months (advanced).5 Chromosomal
; g6 P1 \" N9 [karyotype was 46XY. The thyroid function test1 w+ T/ ]0 L6 C8 c
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 {5 V3 p5 r( |% s
lating hormone level was 1.3 µIU/mL (both normal).4 ^! W$ e6 r; q
The concentrations of serum electrolytes, blood
4 D7 @3 ^5 a5 x% E0 vurea nitrogen, creatinine, and calcium all were
4 t$ l* k7 z5 Q+ @# \5 e3 lwithin normal range for his age. The concentration
; r" J. o. W. _2 C' Wof serum 17-hydroxyprogesterone was 16 ng/dL
+ J; L$ G' S# {6 X(normal, 3 to 90 ng/dL), androstenedione was 20
; z; S) ^# T8 v6 r+ m( Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ N. L7 a7 B; U" b; p1 sterone was 38 ng/dL (normal, 50 to 760 ng/dL),. _% z9 t6 o! z; J3 x7 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 \+ {  {% x. q: h4 \
49ng/dL), 11-desoxycortisol (specific compound S)+ h% d$ k. S3 _% d7 O: V& K' j
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 Z) n8 _3 m. O
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ a% R6 ]; G& s; e' ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 n/ Q( U+ ?! V8 T  U3 e& ]- x- e! |and β-human chorionic gonadotropin was less than5 G0 Y; _& g$ D, ~& E9 r
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 z+ H/ c4 W& F( i+ n2 J9 c5 i) |stimulating hormone and leuteinizing hormone' y3 g$ \4 A" S' W! D$ _
concentrations were less than 0.05 mIU/mL" ^- v& v. z( r# g4 U3 |
(prepubertal).$ H5 H0 E: N& }# U; \  J9 ~/ i* [
The parents were notified about the laboratory: w4 w# N7 a% Y, ?& A* L
results and were informed that all of the tests were; O! Y2 N# Q8 O: y, w# P) H9 F
normal except the testosterone level was high. The+ j: c# S5 v. k+ y( }% J+ H' T
follow-up visit was arranged within a few weeks to
+ V0 {: n/ p3 u' xobtain testicular and abdominal sonograms; how-+ T& H- b& h7 _) C/ `3 B6 H
ever, the family did not return for 4 months.6 j' Q1 ?9 P, Y- d  ~8 N
Physical examination at this time revealed that the9 C. ~( ?' a5 G4 N
child had grown 2.5 cm in 4 months and had gained
9 N: K, o% r" Z1 G# S- W/ c  @2 kg of weight. Physical examination remained6 B+ b) m# `- O  t, K) J- S* v. s7 Q
unchanged. Surprisingly, the pubic hair almost com-
+ W9 p- |. G. V% W. L0 v0 F  u7 qpletely disappeared except for a few vellous hairs at
" Q9 r. x/ P7 l) v* ?! Vthe base of the phallus. Testicular volume was still 2
+ s! J0 {* U0 E( ?$ emL, and the size of the penis remained unchanged.
9 G) `- Y% L- S2 E7 c- v3 ~The mother also said that the boy was no longer hav-0 }' |9 X7 [" d' E3 n
ing frequent erections.) ^8 O1 f- [4 R6 s
Both parents were again questioned about use of
' Y/ A/ V0 a; {% k5 d3 _0 oany ointment/creams that they may have applied to% j8 R: A% E! Y* c8 N; i* i
the child’s skin. This time the father admitted the2 @$ H6 |' L3 q5 f
Topical Testosterone Exposure / Bhowmick et al 541
0 _6 i" P$ \+ F" b+ i( h4 Y2 N1 Z) ~& }use of testosterone gel twice daily that he was apply-
5 h+ c5 N$ r# K, j6 V4 f+ Fing over his own shoulders, chest, and back area for
1 {, H1 s. ^6 Q, b0 `* ya year. The father also revealed he was embarrassed! @7 j/ A& B" X+ d  Y3 |" k6 ~4 n7 |
to disclose that he was using a testosterone gel pre-
8 B, S8 g; M: a5 b- j6 ]) mscribed by his family physician for decreased libido' ~" M6 L% N0 s/ x% g
secondary to depression.
# x2 a- n- u; ^" C" E* z8 qThe child slept in the same bed with parents.; f( V3 w; a- H" S$ k) X8 s
The father would hug the baby and hold him on his* f" z* e; _% H
chest for a considerable period of time, causing sig-3 X" [0 i1 ^8 x8 N
nificant bare skin contact between baby and father.
4 ~; a" Z  I& B2 hThe father also admitted that after the phone call,) Z/ b* m0 I) t: y
when he learned the testosterone level in the baby
8 ^, J  I, T7 w/ \; v# A9 Q  i- }was high, he then read the product information
. y3 ~* Z0 ~: F3 e7 L+ Npacket and concluded that it was most likely the rea-
' a  I- r$ B7 }# }) Z% f. M7 Gson for the child’s virilization. At that time, they
1 `" i, w  c9 _, u' mdecided to put the baby in a separate bed, and the
- x! J, r& ~1 @father was not hugging him with bare skin and had
2 M% B; u& S' j0 X8 pbeen using protective clothing. A repeat testosterone
' S) t- S' b) Z% c5 utest was ordered, but the family did not go to the
$ y, Y- x, r5 d7 G3 \( Z0 l" Hlaboratory to obtain the test.
% a1 R. V. J  ^5 }' u6 k2 e/ Q$ g% qDiscussion
) Z" ~  O; Z8 J' U, {Precocious puberty in boys is defined as secondary. v+ C/ s$ f: A, G! q) t
sexual development before 9 years of age.1,4
# z9 }0 n0 Y) k* HPrecocious puberty is termed as central (true) when
7 U% B5 S' g4 ?5 r, ait is caused by the premature activation of hypo-/ d( [: R9 `7 F0 u4 W" Q, h( d
thalamic pituitary gonadal axis. CPP is more com-
8 |( H) p# }' y$ v0 G- w" Y: qmon in girls than in boys.1,3 Most boys with CPP/ C  |4 p9 D- U" N& l8 \
may have a central nervous system lesion that is! |2 |4 ?: ~' b: C8 R" {7 @
responsible for the early activation of the hypothal-
5 Z2 W3 i: X. D. jamic pituitary gonadal axis.1-3 Thus, greater empha-
2 a0 i! i3 Q# J7 v) X* Esis has been given to neuroradiologic imaging in
2 ^: M4 Y: }0 f1 o4 S% F1 Wboys with precocious puberty. In addition to viril-% ]) w% Q/ z5 {. W
ization, the clinical hallmark of CPP is the symmet-
- k3 k6 f: Y% M6 B5 r* Z+ |rical testicular growth secondary to stimulation by0 r* K! t2 r# m
gonadotropins.1,30 W0 e$ a- `! d  D9 A$ N
Gonadotropin-independent peripheral preco-. ~% s, A) A/ e( J* Y! ~
cious puberty in boys also results from inappropriate% B- v0 J7 @6 x8 y9 c! I
androgenic stimulation from either endogenous or
. F, O) j% q: v+ D* v, L! pexogenous sources, nonpituitary gonadotropin stim-
) u$ B, V# G7 _6 W8 j, rulation, and rare activating mutations.3 Virilizing
0 a: S. s  C5 ccongenital adrenal hyperplasia producing excessive
* m% e; z! c; G; H3 Y6 m3 iadrenal androgens is a common cause of precocious, z$ v' C. L1 r/ F, M) b) w. f
puberty in boys.3,4
$ n8 a( u+ w" HThe most common form of congenital adrenal. A$ d9 `' R/ x9 F* S
hyperplasia is the 21-hydroxylase enzyme deficiency.
) h1 c" T( X- c, h  fThe 11-β hydroxylase deficiency may also result in
9 r8 p1 z/ z' p& K3 ~5 fexcessive adrenal androgen production, and rarely,0 \' ?1 U* V- m& d4 J. R& U
an adrenal tumor may also cause adrenal androgen
5 f4 g/ K- z$ A* C- Zexcess.1,3/ x) S0 {4 Q- {; p: e/ N. q$ B4 D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 G( B# a7 u/ J+ W542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 `; z* n$ g$ k! E5 z9 TA unique entity of male-limited gonadotropin-
. F5 V/ q$ ?  `1 ]* H, Oindependent precocious puberty, which is also known
( B! |: F. s$ X9 i( |# H" B; Gas testotoxicosis, may cause precocious puberty at a* n& Z) P& r( l7 [% D
very young age. The physical findings in these boys
5 m) S3 R8 v& M6 V) Pwith this disorder are full pubertal development,& P/ o* p/ Z' K2 [  }
including bilateral testicular growth, similar to boys$ q4 [7 a3 D* P2 u" P! W- `
with CPP. The gonadotropin levels in this disorder& L* W, J3 b' |6 g
are suppressed to prepubertal levels and do not show
0 F4 F% Y7 c  `* L# K- M8 ppubertal response of gonadotropin after gonadotropin-7 \8 E5 U+ Z: g( M0 E' q- R! m3 b
releasing hormone stimulation. This is a sex-linked
) M* f% D) g4 b: w& rautosomal dominant disorder that affects only
; k3 B: I0 ^& ?0 Z; F, j1 y# qmales; therefore, other male members of the family
& Y/ w  [4 \! A% Kmay have similar precocious puberty.3
  a/ g% F* ~. h; I+ ?: \In our patient, physical examination was incon-9 a' W. f5 e' q8 k& j
sistent with true precocious puberty since his testi-; B* P: m) [2 j& I4 R
cles were prepubertal in size. However, testotoxicosis: g- |  A! J' W7 |
was in the differential diagnosis because his father
1 L) s7 `, [: K. o5 ~started puberty somewhat early, and occasionally,
  P' V* H  Q/ }$ X7 ?5 a$ Ftesticular enlargement is not that evident in the
$ z2 n% m" u0 C6 ]# U. X9 q$ ^beginning of this process.1 In the absence of a neg-
5 c7 T9 p5 B. H8 B+ B: Gative initial history of androgen exposure, our
( n$ n8 a3 m: J$ N( ~biggest concern was virilizing adrenal hyperplasia,
% W' I  C" }& W* q8 R, S# s; Yeither 21-hydroxylase deficiency or 11-β hydroxylase/ t2 p/ s! a, L, _
deficiency. Those diagnoses were excluded by find-9 i$ R0 y* c3 J
ing the normal level of adrenal steroids.) q$ |7 u( C5 k
The diagnosis of exogenous androgens was strongly# x+ [$ j( P$ ?! h
suspected in a follow-up visit after 4 months because
" m3 i4 U1 L. o5 {+ ^' `" nthe physical examination revealed the complete disap-* f6 Z: k9 P& x: A- [! H
pearance of pubic hair, normal growth velocity, and; P1 W3 M1 i( A; S7 P7 Z( M
decreased erections. The father admitted using a testos-
; z! {! L4 F* {terone gel, which he concealed at first visit. He was8 C9 y5 y9 z: \/ i, P+ N" K
using it rather frequently, twice a day. The Physicians’
7 l3 H" i. F1 X# _. [) ^) VDesk Reference, or package insert of this product, gel or
1 R4 H1 z6 I9 Q- k2 f) P7 l) Wcream, cautions about dermal testosterone transfer to& K/ }+ z! s6 _9 b  m# v' n
unprotected females through direct skin exposure., Q/ c( L7 n( \$ w" U
Serum testosterone level was found to be 2 times the
! \, h3 C6 b% ^) Qbaseline value in those females who were exposed to
% \7 g" S+ f4 j7 [/ C. heven 15 minutes of direct skin contact with their male
" L' t9 n$ i. [* v, xpartners.6 However, when a shirt covered the applica-
4 \: s4 S! G' I4 \' ktion site, this testosterone transfer was prevented.
* I5 |7 E7 @* @( j- f9 E2 hOur patient’s testosterone level was 60 ng/mL,' g% ?* T$ J- t: q8 h! s
which was clearly high. Some studies suggest that
; z. y0 I/ I5 _4 @3 }' \9 Ldermal conversion of testosterone to dihydrotestos-
; Y+ o5 x6 I/ z/ xterone, which is a more potent metabolite, is more
' b9 c( e/ Q- ^$ E3 @active in young children exposed to testosterone+ V; e# A& j3 I6 J4 a; X  ^
exogenously7; however, we did not measure a dihy-; d) t3 y7 I7 _# ]
drotestosterone level in our patient. In addition to. O6 g8 J/ ^0 g! c$ v7 A
virilization, exposure to exogenous testosterone in" R8 g- F  R, S: A& k3 K
children results in an increase in growth velocity and
6 u. _: N( b. i' b+ V8 Nadvanced bone age, as seen in our patient.
, o  ~' ?- u. O5 ZThe long-term effect of androgen exposure during
: X+ ~: a3 E$ p& [& S7 ^; Gearly childhood on pubertal development and final
# N2 t- O7 d- E- O* f: ^adult height are not fully known and always remain3 ~+ i* w' l5 ]0 E
a concern. Children treated with short-term testos-+ P7 n  Y! g& }) c
terone injection or topical androgen may exhibit some, W& k% K, K* N" Z
acceleration of the skeletal maturation; however, after; L: X; B0 q: Y2 P& y5 t; s! T
cessation of treatment, the rate of bone maturation
0 c" g' h8 q* m' gdecelerates and gradually returns to normal.8,9* G6 B5 `- k8 b4 ~! l' G
There are conflicting reports and controversy4 ~; k. ~8 `" }* r0 @4 f$ T
over the effect of early androgen exposure on adult
4 G: i' h; I- L' Y9 m( Ipenile length.10,11 Some reports suggest subnormal
! H8 z$ C2 ~. E# i( b/ {  k1 O& L8 y# Yadult penile length, apparently because of downreg-
- `8 T1 G( R5 D! J. Eulation of androgen receptor number.10,12 However,0 C# a7 d: a; O7 \
Sutherland et al13 did not find a correlation between
8 d3 S$ T. U$ M0 Ochildhood testosterone exposure and reduced adult6 B0 ]$ [' Z7 {2 |& A
penile length in clinical studies.
$ T* p- e+ H' i( A' \, s! nNonetheless, we do not believe our patient is
9 ]3 B+ v; D5 I: tgoing to experience any of the untoward effects from; J$ r% c/ k" p) R7 S" F  G) s
testosterone exposure as mentioned earlier because
( c+ K0 v# n$ I5 gthe exposure was not for a prolonged period of time.$ _- S. H4 N; m) k
Although the bone age was advanced at the time of" |$ [! z; l* N4 r
diagnosis, the child had a normal growth velocity at( V/ i1 U. ~" d2 `6 Q
the follow-up visit. It is hoped that his final adult& N' T0 h6 v0 u
height will not be affected.
. }) @7 h4 v7 R% r1 T  ~Although rarely reported, the widespread avail-5 p1 B" Q% [  i# c
ability of androgen products in our society may* m  B* n7 [3 `/ }0 ]/ B& D
indeed cause more virilization in male or female2 N; d3 `1 Y+ T& }9 G1 o
children than one would realize. Exposure to andro-8 y" B3 x! Z' ~$ l- a4 D
gen products must be considered and specific ques-4 F3 g: H! D$ i- s1 ?! K1 W! g" d
tioning about the use of a testosterone product or, k; e- m+ s& \. f1 }7 \
gel should be asked of the family members during" d8 O! X# P- Y; G
the evaluation of any children who present with vir-  k* C+ `# z* P; s7 _/ `
ilization or peripheral precocious puberty. The diag-
3 v7 v  [. P' b$ b+ V( ~& K& Tnosis can be established by just a few tests and by/ S9 Q. h6 i3 z" t1 w3 J2 r
appropriate history. The inability to obtain such a; O/ n4 c1 a8 ]! p
history, or failure to ask the specific questions, may( T9 V6 x& B2 A+ a
result in extensive, unnecessary, and expensive) E& `4 J. R5 o8 H/ d5 o& Q
investigation. The primary care physician should be: ~+ R+ O& w$ L9 v: g
aware of this fact, because most of these children
. m) c" C$ Y' y4 A' P' h# Omay initially present in their practice. The Physicians’2 X/ z7 l5 |5 p. o; b) t
Desk Reference and package insert should also put a9 H6 p: p5 }9 ?  _5 V& H. z
warning about the virilizing effect on a male or
& e2 c0 n* m) ~# {/ x% J1 X1 c* Xfemale child who might come in contact with some-
. u6 {  k) v- g2 \one using any of these products.
8 A7 m0 V2 q3 R  EReferences0 V% Q9 ~' Z- O* a- m
1. Styne DM. The testes: disorder of sexual differentiation
( D9 [9 z7 P6 ^$ O( }and puberty in the male. In: Sperling MA, ed. Pediatric
# J2 `3 a! g8 l2 ZEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; b1 j3 q; C, \& L! X3 N' G2002: 565-628.+ v7 j0 E% ]/ Y- {$ s4 o
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" ]1 F$ @$ M8 `$ n. I5 _" G
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ i7 T& n" H3 V$ o7 f# T/ u! W3 vBoy Induced by Indirect Topical
6 g5 m5 i- t; K# ZExposure to Testosterone
! M, `: g/ N9 G' i2 Y& b- q+ YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* x8 z: b4 J0 u, k" @/ land Kenneth R. Rettig, MD16 W( {1 [- U# o1 ^! T
Clinical Pediatrics
! s( X/ q6 x  pVolume 46 Number 6
2 H6 g. ?( \! E7 F: n! |July 2007 540-543
; k2 y  j4 J4 i& e# s© 2007 Sage Publications
5 J  U/ a! \* X7 _$ V10.1177/0009922806296651
3 O# b. O. s. F2 Q' lhttp://clp.sagepub.com
/ B; ~1 a$ T# T6 U/ O! L2 v5 yhosted at
7 z. I' D3 N: }, b5 n$ b5 M' Shttp://online.sagepub.com
. A  A2 e/ d1 N# wPrecocious puberty in boys, central or peripheral,7 p/ w, N- g8 W' q( d
is a significant concern for physicians. Central1 E) @0 E1 [) q
precocious puberty (CPP), which is mediated
. A! @: m$ ]1 rthrough the hypothalamic pituitary gonadal axis, has
8 w3 B* v( x; q/ o. f6 G2 U# ?a higher incidence of organic central nervous system: u, O- T2 C: s& ]$ r: M
lesions in boys.1,2 Virilization in boys, as manifested
# f: s- T! ]2 V9 F+ ~by enlargement of the penis, development of pubic# X( N( O, E- P8 x
hair, and facial acne without enlargement of testi-: N0 R8 h$ K, R" a4 I
cles, suggests peripheral or pseudopuberty.1-3 We7 y! i& R8 a4 M' k
report a 16-month-old boy who presented with the
! d1 `( b+ n( M& `. B# senlargement of the phallus and pubic hair develop-
9 ~: B- s. n; ^ment without testicular enlargement, which was due
1 L( y0 ]' r) {- }9 H8 Kto the unintentional exposure to androgen gel used by
3 s2 H4 ?. k4 \( x. I7 P  ], Kthe father. The family initially concealed this infor-( I( j# ]. w4 Y. C( Q( p
mation, resulting in an extensive work-up for this
$ [, x- B- ~9 X8 M/ V% kchild. Given the widespread and easy availability of
; r* h9 I4 i5 q, ~- _4 Wtestosterone gel and cream, we believe this is proba-% ~4 a, L/ X" j2 u
bly more common than the rare case report in the6 w$ H7 J" C2 s- g/ ~, B) G  V8 R
literature.47 Y) t2 s7 f0 I  _; V8 ]# g
Patient Report8 e7 ]0 n' I7 G
A 16-month-old white child was referred to the
. L( N# d- A0 w, hendocrine clinic by his pediatrician with the concern
3 u8 R6 M" R0 @$ Z0 {of early sexual development. His mother noticed% m0 D8 X  M6 x
light colored pubic hair development when he was
0 c- N* o3 k0 x$ c: f1 s6 X" sFrom the 1Division of Pediatric Endocrinology, 2University of4 G" ?( }" s7 |- ~3 a: A; R% q
South Alabama Medical Center, Mobile, Alabama.
- p9 @8 Y% U0 rAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 M) I/ h- G( G1 d0 ]4 ]3 P8 OProfessor of Pediatrics, University of South Alabama, College of4 _( G1 K8 J' u# U# k# n* u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 ]2 {2 L  I8 c  Fe-mail: [email protected].( {9 z  N) x/ @, C* U+ w
about 6 to 7 months old, which progressively became
2 {: M9 H: U- W4 edarker. She was also concerned about the enlarge-1 x% ]# W5 \. {; f: A- N; b
ment of his penis and frequent erections. The child
9 z% O  X% `0 J5 d6 bwas the product of a full-term normal delivery, with
9 I9 D% {& F; Ya birth weight of 7 lb 14 oz, and birth length of, [: _2 A. _( H1 R# T, u4 A
20 inches. He was breast-fed throughout the first year: Y: P2 ^/ M) u9 V, i
of life and was still receiving breast milk along with7 U4 L- o7 Q# T' {5 o7 c
solid food. He had no hospitalizations or surgery,
! R: t# s( F8 S. Gand his psychosocial and psychomotor development
2 d3 Q& j0 O2 {8 m) I9 F# twas age appropriate.
7 n, B& Y! }, b7 H; @The family history was remarkable for the father,
& [8 Z: l5 v0 k& u8 rwho was diagnosed with hypothyroidism at age 16,
3 c1 k4 ^: r0 ^4 x  iwhich was treated with thyroxine. The father’s& V& f  Q: n$ [
height was 6 feet, and he went through a somewhat
- t0 }+ P( t- c1 _% [- r# eearly puberty and had stopped growing by age 14.
1 R( M- i9 W$ R2 yThe father denied taking any other medication. The
+ f: ]: W# F: z# L: ?child’s mother was in good health. Her menarche3 D7 U3 {2 ?. V
was at 11 years of age, and her height was at 5 feet
, N1 ?& }4 o& S+ k/ ]/ O, k5 inches. There was no other family history of pre-
( R/ d6 P) W$ {/ k# m( L. _. Wcocious sexual development in the first-degree rela-
# {+ Q7 Y! i, C( k5 m/ Ktives. There were no siblings.6 p/ E: h! l* H& P' }0 @0 s8 J
Physical Examination! P# @0 Y5 Q! d9 K
The physical examination revealed a very active,
' M1 k( M3 {% x- `playful, and healthy boy. The vital signs documented1 N+ z+ l% }) Q# C7 @# V
a blood pressure of 85/50 mm Hg, his length was
! A9 r6 T' m) a- L/ w90 cm (>97th percentile), and his weight was 14.4 kg; J/ `! v9 F  M/ w# O! |, x: q) y
(also >97th percentile). The observed yearly growth
! @0 z: ~0 o7 ~" `  {  uvelocity was 30 cm (12 inches). The examination of6 O5 Z- U& l8 W4 ~& C  B
the neck revealed no thyroid enlargement.
+ e; P" q. w) Z: B" v8 RThe genitourinary examination was remarkable for1 H* a. @4 R8 H  f: S2 q0 ]
enlargement of the penis, with a stretched length of7 A# c# z4 Y- G2 R
8 cm and a width of 2 cm. The glans penis was very well
. H7 u8 @/ ~* ~developed. The pubic hair was Tanner II, mostly around3 Z9 c( U8 i2 l* J1 ^
5409 {3 M- U9 S: \* P) K8 w& b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# J, K$ ]" W* ~8 Fthe base of the phallus and was dark and curled. The
6 O3 J* z% k* E- a5 Z9 t# B  Etesticular volume was prepubertal at 2 mL each.
) d0 F3 R- w5 B+ AThe skin was moist and smooth and somewhat
2 n  o; d0 ^% g+ S7 O7 Xoily. No axillary hair was noted. There were no# T5 `! b' H! C
abnormal skin pigmentations or café-au-lait spots.
7 E% L7 g6 W9 \4 E- A- B- F2 X7 VNeurologic evaluation showed deep tendon reflex 2+2 J: S: _% z  l0 I( e# _0 c6 e0 S
bilateral and symmetrical. There was no suggestion
* {& I% c1 Z- ?8 R6 ^3 h7 c! q& k' O$ Vof papilledema.% I9 @; Z% z! v0 a; B- X1 C3 [9 u
Laboratory Evaluation; [7 j$ R# [9 S6 M! j
The bone age was consistent with 28 months by
* I" {5 c7 _0 ?/ w) c# }using the standard of Greulich and Pyle at a chrono-
6 q& Y( J0 E0 w  }/ G( Q, X( r7 `logic age of 16 months (advanced).5 Chromosomal
  s3 W2 K! N  J$ m2 U( o) ikaryotype was 46XY. The thyroid function test7 z* l, l; f+ K* D& U0 F$ L& F3 z1 `: [  D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ D0 r4 C- Z4 R2 f1 R
lating hormone level was 1.3 µIU/mL (both normal).1 W+ g/ E* |0 T3 M( T! `1 T
The concentrations of serum electrolytes, blood
; b1 Z# W0 [3 D3 P  Q5 S: A6 H' murea nitrogen, creatinine, and calcium all were
! s* b2 w, ~, V7 ^, U- M$ owithin normal range for his age. The concentration7 M4 K1 ~: D& ^7 n- t! A
of serum 17-hydroxyprogesterone was 16 ng/dL
/ }; l& u( ^% |$ c" F/ W(normal, 3 to 90 ng/dL), androstenedione was 20# H9 F- u% F7 x# U. t- v/ x$ x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- K1 H; E1 ?2 D4 Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! M6 d+ J& N, S: M, adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( z( V8 Q$ E6 l% q4 p8 f49ng/dL), 11-desoxycortisol (specific compound S)
& S# p" e: j' X2 B" t* k0 j  q4 vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. D( F2 t1 F  S( v9 @) y0 ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( Z* y% c# C! g2 I* ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! i/ f  I/ U1 p/ Sand β-human chorionic gonadotropin was less than
% `  d! A. ?8 ~$ i. W: h5 mIU/mL (normal <5 mIU/mL). Serum follicular+ U* f+ l( H, [* l+ a) o
stimulating hormone and leuteinizing hormone( I$ y7 j: f* e6 N) Z% O& I
concentrations were less than 0.05 mIU/mL2 {) ]6 d2 S  C) |* E' |3 L5 E
(prepubertal).
9 H+ i9 |7 W3 s: `& uThe parents were notified about the laboratory
0 N( ~) D- o, q+ p, h( k2 bresults and were informed that all of the tests were
! U3 Z, F  X! b4 P' g% anormal except the testosterone level was high. The
) b; W3 m, a$ z# v8 ~follow-up visit was arranged within a few weeks to
, O) R3 h# `3 Y- W0 ?obtain testicular and abdominal sonograms; how-
  Z* N  _3 F/ H+ e$ aever, the family did not return for 4 months.
6 Q1 k1 N  u8 O9 o  gPhysical examination at this time revealed that the* @( k! t; }4 H# m9 ^7 ^) o
child had grown 2.5 cm in 4 months and had gained
4 j' _# h- U5 R* D9 D4 X2 kg of weight. Physical examination remained6 F$ H3 z6 k  j2 O) S% T1 p
unchanged. Surprisingly, the pubic hair almost com-: u+ I5 f* ~! {+ _
pletely disappeared except for a few vellous hairs at
% w# V: V9 A" Jthe base of the phallus. Testicular volume was still 26 P- \5 `) w+ a, t0 n. b- I
mL, and the size of the penis remained unchanged.
/ o* ]5 c, I# n& n4 mThe mother also said that the boy was no longer hav-
  p% U3 |! |# k7 b7 ving frequent erections.
0 }* b( G9 d0 W, d6 U4 z0 M4 Z# ], RBoth parents were again questioned about use of" o, z3 g2 Y8 l$ i7 t
any ointment/creams that they may have applied to% z" b4 n1 x- D
the child’s skin. This time the father admitted the7 x$ k& w" F* g- ?6 C$ b9 d( T
Topical Testosterone Exposure / Bhowmick et al 541
$ ?$ e0 A# _) F3 S$ a" O4 d, }use of testosterone gel twice daily that he was apply-! y  L. V( M# _3 O' T! I  f$ [
ing over his own shoulders, chest, and back area for
4 E; d4 F) d, ?7 `0 `1 @a year. The father also revealed he was embarrassed) J0 l# a4 X* N+ J* ?
to disclose that he was using a testosterone gel pre-
9 t$ g3 |' _( O" G% yscribed by his family physician for decreased libido2 S% `0 c6 t) R/ p/ D" @* }
secondary to depression.
3 |8 m' ~4 |0 j3 ^0 c* u3 g+ uThe child slept in the same bed with parents.
5 g5 Z: F0 i  Z9 \8 \- I0 vThe father would hug the baby and hold him on his/ R! s/ ~4 [# i6 n' \& V; Q, h
chest for a considerable period of time, causing sig-
. \* ]: X$ q0 W7 G# ^# @nificant bare skin contact between baby and father.
0 Z8 S8 m- O1 s' wThe father also admitted that after the phone call,
0 |" w8 C, a9 z3 V* m3 Lwhen he learned the testosterone level in the baby
7 L! k; L1 x& b# o. I1 awas high, he then read the product information1 a- V; n8 q" m
packet and concluded that it was most likely the rea-; o" b2 x2 y6 s: i, y8 t  }
son for the child’s virilization. At that time, they
* r3 h+ v# v; x! z. s2 ^- _+ i' a. tdecided to put the baby in a separate bed, and the
/ L, m% P2 Y& M, u- z& m% I5 Xfather was not hugging him with bare skin and had
2 S+ j" k) t; ]6 y  E6 o# s  Obeen using protective clothing. A repeat testosterone4 i4 i0 W# m% _4 q. Q& r
test was ordered, but the family did not go to the" O) }1 |5 i3 |) I  t
laboratory to obtain the test.
# t. J0 ?3 R8 c) T9 MDiscussion
) \* L4 _' Q7 t3 t& h. T6 CPrecocious puberty in boys is defined as secondary
5 t7 O  q: D  D: F6 }sexual development before 9 years of age.1,4
. }, a( b, ^$ ~; P/ JPrecocious puberty is termed as central (true) when! L5 k; C, H& y3 D
it is caused by the premature activation of hypo-) X6 V; f4 ~9 f8 `5 }  H+ v
thalamic pituitary gonadal axis. CPP is more com-
- j! ^, C3 ~! ~4 ~, Mmon in girls than in boys.1,3 Most boys with CPP
5 \4 K6 R; s* ^4 fmay have a central nervous system lesion that is
4 h+ p3 h) l; Gresponsible for the early activation of the hypothal-/ |4 D' Y( u# @; t
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 R9 f7 `. @" r' N8 n) [' qsis has been given to neuroradiologic imaging in" ~$ y* w; M0 n) o+ e
boys with precocious puberty. In addition to viril-
  o3 M7 Y5 H% |# E  u1 Aization, the clinical hallmark of CPP is the symmet-
+ y0 f3 q& o; R! s& i/ a& c- Srical testicular growth secondary to stimulation by
4 f1 ]9 F  J7 bgonadotropins.1,3! }  w6 u. _* b. x" D
Gonadotropin-independent peripheral preco-$ V0 W: z4 e1 Z9 z3 F" Y
cious puberty in boys also results from inappropriate
5 A1 o# T$ R/ F* N0 R7 [# zandrogenic stimulation from either endogenous or( R# ?( I) s8 h
exogenous sources, nonpituitary gonadotropin stim-
5 f4 [. P3 ]8 Culation, and rare activating mutations.3 Virilizing; w  O/ Q7 r  r# e8 k
congenital adrenal hyperplasia producing excessive
6 I2 Y) }, k/ I& d/ oadrenal androgens is a common cause of precocious
9 @0 b. ~2 ^# wpuberty in boys.3,4
0 N- U9 K& }0 x2 X. `+ eThe most common form of congenital adrenal: {' l5 w1 }- X! b0 X) A4 f
hyperplasia is the 21-hydroxylase enzyme deficiency.: k6 E' I1 b! C7 S7 @/ |
The 11-β hydroxylase deficiency may also result in
+ Z2 r* E/ t. B2 ^5 B/ e( mexcessive adrenal androgen production, and rarely,/ o# P: @* m! e
an adrenal tumor may also cause adrenal androgen% m: _- p; @5 Z
excess.1,3- e- L( q+ ?" H$ J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 b0 t5 D/ `. R; x! i9 H$ x542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ ?% `! }  W& Z7 H
A unique entity of male-limited gonadotropin-: N* y* ~3 l) `' v2 n  b
independent precocious puberty, which is also known6 ~+ O9 o$ Y! i* y
as testotoxicosis, may cause precocious puberty at a
1 s! Q$ K5 d. {( a$ l* ~; Pvery young age. The physical findings in these boys
, x8 c) c. K- F0 Hwith this disorder are full pubertal development,
1 m( U' A5 z6 k+ }" Zincluding bilateral testicular growth, similar to boys
) C! M9 a% R% c3 B% U! R- i$ Pwith CPP. The gonadotropin levels in this disorder2 G8 W* n9 R+ X- M
are suppressed to prepubertal levels and do not show
% C6 @* z- A: O3 X6 F- zpubertal response of gonadotropin after gonadotropin-
. j1 b* `" j) S2 w8 ^/ Q! C& qreleasing hormone stimulation. This is a sex-linked
* q& d; T, y' I0 m3 o- m) U9 tautosomal dominant disorder that affects only7 j& }* r* S3 e/ `- [. F3 D
males; therefore, other male members of the family5 J- T( f$ U" |' U% {/ v6 o* _# J
may have similar precocious puberty.3
% t( \- N3 b( J3 E6 f5 X: YIn our patient, physical examination was incon-
6 O' O! ]( ^, s3 @, zsistent with true precocious puberty since his testi-
  Y) k8 N5 x- z# Ucles were prepubertal in size. However, testotoxicosis/ S& L/ H4 |/ c4 j8 s& w* W+ Z
was in the differential diagnosis because his father# n/ H# F- L& h4 n+ T) O
started puberty somewhat early, and occasionally,% k( l2 S7 c( ~: e
testicular enlargement is not that evident in the+ O8 d3 v/ ]- \; q( T* D
beginning of this process.1 In the absence of a neg-* S! _4 l4 C; Y1 t5 ?/ Y
ative initial history of androgen exposure, our* k3 J8 {8 |. o
biggest concern was virilizing adrenal hyperplasia,
, d* F- m5 F2 U0 s7 I$ |either 21-hydroxylase deficiency or 11-β hydroxylase
5 _  y( @1 X+ C8 J9 z6 F' Udeficiency. Those diagnoses were excluded by find-$ Y/ x& C4 u$ }
ing the normal level of adrenal steroids.  F3 Y# P8 c+ z+ e7 `+ @; }
The diagnosis of exogenous androgens was strongly1 w6 }! _( W6 N
suspected in a follow-up visit after 4 months because
% f" H- u' r2 v( P6 E- ?the physical examination revealed the complete disap-
) d! [( H, v  I" B) o+ jpearance of pubic hair, normal growth velocity, and
- w" Z' K8 F% ]0 B/ P# N1 x! [) jdecreased erections. The father admitted using a testos-
% w  r1 S' l# W) W1 \% oterone gel, which he concealed at first visit. He was4 t4 \. o; O( V
using it rather frequently, twice a day. The Physicians’
) N2 n) K' e6 E7 J' nDesk Reference, or package insert of this product, gel or
4 i; f2 p& ?% x/ a8 h" S! wcream, cautions about dermal testosterone transfer to% a/ c) Y# b" C! k6 {$ z
unprotected females through direct skin exposure.7 T5 s  s/ P4 U
Serum testosterone level was found to be 2 times the  t. Y* a. q% n. B- @
baseline value in those females who were exposed to; s- U5 j; P1 Q; D: `
even 15 minutes of direct skin contact with their male8 d) m( \. i7 W6 n' ^7 G, ~
partners.6 However, when a shirt covered the applica-
: a! l9 w* A* ^7 s8 D, ^+ Mtion site, this testosterone transfer was prevented.3 p- t9 {0 y9 H0 X2 l* w5 ]# `/ Q2 \
Our patient’s testosterone level was 60 ng/mL,
  t7 ^" W$ }8 L6 y' Hwhich was clearly high. Some studies suggest that4 N- t6 O- G; h$ }: G; m
dermal conversion of testosterone to dihydrotestos-: S: |9 c  \& S7 t/ U7 v
terone, which is a more potent metabolite, is more0 u; c; K9 O( F8 i
active in young children exposed to testosterone/ \8 q: B& V! q  _
exogenously7; however, we did not measure a dihy-
8 X% o: E. W: G6 `, e) [9 sdrotestosterone level in our patient. In addition to; O/ |+ x$ [" V6 E5 p
virilization, exposure to exogenous testosterone in  `9 p/ r0 ~% c0 r0 y% T  Z
children results in an increase in growth velocity and# `4 h0 j9 k; X+ H$ L
advanced bone age, as seen in our patient.! C' l5 L  p& }! {
The long-term effect of androgen exposure during
* |0 x  q) s( I4 h9 Z! m% a$ zearly childhood on pubertal development and final9 f3 Z. b' ?' A( p7 [1 l  S) X, Z
adult height are not fully known and always remain
5 p, @$ O4 }! o7 A$ ]$ A* W& Ka concern. Children treated with short-term testos-
; `' F  G4 c6 h) j  T3 B2 e+ E! `terone injection or topical androgen may exhibit some
- G" _: e6 _- H7 \4 g. G6 Aacceleration of the skeletal maturation; however, after
, t* [3 @6 z' i& T( d; Bcessation of treatment, the rate of bone maturation
: q9 b& |, ]) o4 w8 Ddecelerates and gradually returns to normal.8,9! U/ j8 g/ [0 i) c
There are conflicting reports and controversy/ q  x( V  \2 Y# e
over the effect of early androgen exposure on adult
5 V0 ]  G2 v# ^penile length.10,11 Some reports suggest subnormal
5 E9 }# y, W& e1 v5 @" Xadult penile length, apparently because of downreg-
" q3 m. y5 o7 a" ]8 C( Y! _; @ulation of androgen receptor number.10,12 However,! \9 i7 E" z$ }$ Y) s
Sutherland et al13 did not find a correlation between! U8 _, U# \6 Z+ R8 ~8 G, B
childhood testosterone exposure and reduced adult; y* a9 @4 `5 G1 j) Q) A, Z
penile length in clinical studies.- }/ o) ]& r8 \0 |, O6 x
Nonetheless, we do not believe our patient is
+ I3 G' h. @1 a6 s& L0 c0 {going to experience any of the untoward effects from% ]- Z# C* _; }3 h3 F2 H7 I+ s
testosterone exposure as mentioned earlier because4 J$ x, c% x7 R; s
the exposure was not for a prolonged period of time." t+ t' l$ _3 G* A
Although the bone age was advanced at the time of9 G- F# }; V5 J% u
diagnosis, the child had a normal growth velocity at" ?# u( _  [: n0 v
the follow-up visit. It is hoped that his final adult( Q3 A: ~' c- y; P4 S
height will not be affected.
" e# t; B, o6 D; _5 O( n( EAlthough rarely reported, the widespread avail-
) I. `# A! T  `( x0 @, h9 m. G! ^ability of androgen products in our society may; R) n% x( N# X9 a1 e
indeed cause more virilization in male or female  `' U3 E8 P/ O% W9 d& ~8 b+ c! [
children than one would realize. Exposure to andro-
/ ]% w% ^: l, X& o) Ogen products must be considered and specific ques-. w9 \$ K  G# q( ~) b7 W
tioning about the use of a testosterone product or
8 K1 X8 M( F, |' O. zgel should be asked of the family members during' B* p7 j# Q, K
the evaluation of any children who present with vir-" n) w8 ]& r  W) d5 S9 }" W
ilization or peripheral precocious puberty. The diag-
+ W* P! f! j) q; k$ e3 J3 Fnosis can be established by just a few tests and by& o( `, s' i: m* `
appropriate history. The inability to obtain such a1 J5 `2 D7 n) X
history, or failure to ask the specific questions, may
! u' O8 `! H9 h  N! r8 |0 Tresult in extensive, unnecessary, and expensive7 f2 J# A# c) u! g( q% R# n# j
investigation. The primary care physician should be
- k$ J4 @" \  X, vaware of this fact, because most of these children
% H: I2 \; l/ f' C2 j0 ^5 kmay initially present in their practice. The Physicians’  u5 E8 a* b0 f3 ^1 s9 M
Desk Reference and package insert should also put a$ Q" o" U& K$ C7 I3 _" Y- e9 h
warning about the virilizing effect on a male or
* u! O1 H0 N- W. d# }female child who might come in contact with some-
1 {. P. G0 i0 f; A6 gone using any of these products.& S, m- s8 U$ Z" G; f) o/ @
References
: z" Y1 R2 M* L) n9 |3 C0 i1. Styne DM. The testes: disorder of sexual differentiation
4 |& M* O8 z0 G6 ~  t/ Q+ m- [0 s" p, |and puberty in the male. In: Sperling MA, ed. Pediatric
- c: F, V" [% L9 D& A$ HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
  I( C5 f  G- B: R/ O" Q2002: 565-628.3 u; `% d& O/ j5 q) W, H6 n
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 `0 h# w, U! v: n0 N  Ipuberty 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
, H2 i9 z' r: t" C
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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