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Sexual Precocity in a 16-Month-Old
2 t# T3 Z' w$ S& `( lBoy Induced by Indirect Topical# C$ Y! f* \. f, G6 x; d8 K* T
Exposure to Testosterone
+ X8 x4 J7 }$ [" ^$ g1 ~1 [0 {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 I6 [& r7 ]+ i! i' `: s( _and Kenneth R. Rettig, MD1
/ T4 o; T% x# u4 Z$ F( M) U# }Clinical Pediatrics
3 x( v+ Q/ ~- k% W8 I: S" g* KVolume 46 Number 6! {5 e* g" m9 }& W- I$ N
July 2007 540-543
( {. j0 D6 z; I) K3 J! g9 B$ o% p9 H© 2007 Sage Publications7 g1 K2 g) o1 f) T1 [
10.1177/0009922806296651
9 E7 _: N% a6 @; y; Fhttp://clp.sagepub.com) U5 R5 T$ E4 L& R% K
hosted at9 e2 z. I/ j+ Y
http://online.sagepub.com
& b% z$ C- H, J5 \2 w+ BPrecocious puberty in boys, central or peripheral,; I6 ]% E( v1 e( G
is a significant concern for physicians. Central
6 M% C1 G5 n3 m0 {precocious puberty (CPP), which is mediated
  `* c0 i0 c9 O9 B% I5 mthrough the hypothalamic pituitary gonadal axis, has/ R# [! u1 ~$ n
a higher incidence of organic central nervous system
; B6 v! p- Y: B  Clesions in boys.1,2 Virilization in boys, as manifested
; f$ v; b3 f: ?by enlargement of the penis, development of pubic0 ~" J2 I# J3 Q  G
hair, and facial acne without enlargement of testi-
; ~7 v9 b$ R6 d6 Fcles, suggests peripheral or pseudopuberty.1-3 We/ ~) ]6 I% n( [6 @
report a 16-month-old boy who presented with the: @& h* r8 Q+ W! Q' V( z
enlargement of the phallus and pubic hair develop-0 {5 `9 O& c/ s2 i. _/ ^8 [
ment without testicular enlargement, which was due
6 {7 U' E. g( z5 h. z7 Ito the unintentional exposure to androgen gel used by
+ g: E6 n2 l) N7 pthe father. The family initially concealed this infor-
2 H5 A4 s7 f" M% Emation, resulting in an extensive work-up for this. M! S) G* i0 W: J1 b* Z5 t
child. Given the widespread and easy availability of$ q! @2 o1 |4 e  S: ^; ]
testosterone gel and cream, we believe this is proba-
3 d9 w9 W+ i2 c. g. F, wbly more common than the rare case report in the
3 }- d- b/ r' M* x* f# aliterature.4
. }- h; U5 w% n# wPatient Report
3 X; X% I7 {9 NA 16-month-old white child was referred to the
  Z$ I5 S0 m5 s2 j' D" s2 Bendocrine clinic by his pediatrician with the concern
: S( ]( K6 _+ Hof early sexual development. His mother noticed
* M# ?7 e3 W4 W- t$ R* glight colored pubic hair development when he was
; t' C& T) y4 K$ Y5 E4 mFrom the 1Division of Pediatric Endocrinology, 2University of
8 a, `& F+ `* ^8 N# QSouth Alabama Medical Center, Mobile, Alabama.# P3 ^) W0 `4 f. L# E9 U' i$ o5 B
Address correspondence to: Samar K. Bhowmick, MD, FACE,; i* }5 h9 ]9 ~( m5 h# F! y+ H
Professor of Pediatrics, University of South Alabama, College of8 u5 t  f7 J+ E6 ]
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) d$ a$ ]. v  l- }0 z/ m
e-mail: [email protected].
2 e' j2 K  i% s% V" q3 y* i9 C6 u# Aabout 6 to 7 months old, which progressively became* Z3 N1 m# `& {4 S0 p/ `# I
darker. She was also concerned about the enlarge-( u' J( l6 F! n" v
ment of his penis and frequent erections. The child/ r& e0 a* r: @+ d) n* ^
was the product of a full-term normal delivery, with
* W1 i# |, B& d5 ya birth weight of 7 lb 14 oz, and birth length of
% [& m( M  k9 h; a2 H! m* w  r( X20 inches. He was breast-fed throughout the first year
. }5 G+ \0 A. ]& Eof life and was still receiving breast milk along with$ r7 N# C& z3 @5 K
solid food. He had no hospitalizations or surgery,/ k  r0 O/ w. D
and his psychosocial and psychomotor development/ ~9 \6 E1 M8 `# E! v: w. O
was age appropriate.
; d8 @5 l% x0 RThe family history was remarkable for the father,
2 d' K. F2 [2 E, Z% K/ z7 Y+ h9 N# Ywho was diagnosed with hypothyroidism at age 16,  y  ?# e* X6 M& Y$ Y* {
which was treated with thyroxine. The father’s7 e8 ], z. q- d4 s$ k
height was 6 feet, and he went through a somewhat
) U+ k8 k9 ^  o& O. ]early puberty and had stopped growing by age 14.
/ h, `# u9 {4 i2 ^* DThe father denied taking any other medication. The
* T9 o% v0 r, s0 Bchild’s mother was in good health. Her menarche
9 F+ s$ F" M  e8 C! cwas at 11 years of age, and her height was at 5 feet% J6 T/ i8 o) c& C4 y% A' h  o
5 inches. There was no other family history of pre-
1 m0 |6 q4 K" u$ h8 F- O5 Q+ bcocious sexual development in the first-degree rela-, x  p0 K/ V1 I% g1 ?) t6 u8 ?
tives. There were no siblings.
* H) [) L2 Z% L' P9 I+ KPhysical Examination
' a  B) w& D0 VThe physical examination revealed a very active,$ D/ l; G& z+ k- H
playful, and healthy boy. The vital signs documented
9 f. n4 o& k# \" u* d$ Aa blood pressure of 85/50 mm Hg, his length was  x7 W# k6 z9 G0 ?  i4 q* b
90 cm (>97th percentile), and his weight was 14.4 kg: o" l6 E  j/ |: j* D2 u+ f: }
(also >97th percentile). The observed yearly growth) P3 g7 o& q7 S' T" G1 r" V+ _3 E
velocity was 30 cm (12 inches). The examination of4 U1 g3 d8 x# w
the neck revealed no thyroid enlargement.
! o+ D4 E& }: ^; V$ UThe genitourinary examination was remarkable for' _& I. `2 l5 `5 @
enlargement of the penis, with a stretched length of+ w$ u& S  \7 _* y+ E) U8 q9 V. j/ x
8 cm and a width of 2 cm. The glans penis was very well
' G, x7 e' g. w; z% adeveloped. The pubic hair was Tanner II, mostly around
2 @) D7 }0 N4 Y  ]! W2 N( t540: {' T2 K7 ^3 v; Z8 f3 Z' v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! y7 h) X/ ]6 ?" h& \$ A3 a/ Gthe base of the phallus and was dark and curled. The0 o: i2 m7 M! d4 t: R$ P
testicular volume was prepubertal at 2 mL each.
, z6 B4 r" `* H' ~7 GThe skin was moist and smooth and somewhat- L% v" i- r1 a0 N
oily. No axillary hair was noted. There were no. ?  x- f" G5 o4 N
abnormal skin pigmentations or café-au-lait spots.
! {, w  g4 W" t1 WNeurologic evaluation showed deep tendon reflex 2++ |7 f2 ?" T2 }- ^
bilateral and symmetrical. There was no suggestion
/ d4 e  H; u# f7 n7 S( U) }- iof papilledema.
) R$ A7 N% c: W4 R6 v6 ?7 t8 zLaboratory Evaluation
8 e5 v" p! p6 O4 r, p2 OThe bone age was consistent with 28 months by
  H; A1 s1 q1 k4 C9 [* nusing the standard of Greulich and Pyle at a chrono-
- ?$ ~3 V3 p1 `9 B( D6 f# a' s, J1 plogic age of 16 months (advanced).5 Chromosomal: U% }  r; n& w
karyotype was 46XY. The thyroid function test
+ ~! H4 D! j9 a, pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) z1 J6 b0 G* q: K0 R: E) d8 L
lating hormone level was 1.3 µIU/mL (both normal).4 G7 B& c4 t# t% T1 k( x0 {
The concentrations of serum electrolytes, blood) W7 ?* U2 q1 @- V& G$ c
urea nitrogen, creatinine, and calcium all were
; W2 W, N: C9 A, l' b1 s$ Vwithin normal range for his age. The concentration
2 v* b  ^" J6 T; F' V# C% j5 Vof serum 17-hydroxyprogesterone was 16 ng/dL% ~! U9 d) z' B- c2 M! C: ?2 h
(normal, 3 to 90 ng/dL), androstenedione was 20
: l2 y& Y. c3 d+ h; @2 U, bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ @3 h3 d7 c/ j3 yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 S, m" Y% Q4 A% l" d! Idesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 ^/ R2 T; d5 e  e3 L: z
49ng/dL), 11-desoxycortisol (specific compound S)
% b- Y! q0 B# B) E+ f! bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( m% t) `0 F5 }9 H/ u7 A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 i& ^1 ?7 W1 [5 ~- R# U" W% V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* N) H# {8 x' T( N+ ]
and β-human chorionic gonadotropin was less than7 h. c7 e; X* r' p3 h( N# k
5 mIU/mL (normal <5 mIU/mL). Serum follicular# C. Z6 g* {, _% l: a
stimulating hormone and leuteinizing hormone
* s0 `" o0 `1 H+ B+ I4 Rconcentrations were less than 0.05 mIU/mL
% z, ?$ v5 z, g# E(prepubertal).
. O( g* g* U( |* Z3 A! N# EThe parents were notified about the laboratory
% v6 f6 X3 O: Z* K* \results and were informed that all of the tests were
: u2 W3 X( F! z8 R7 _normal except the testosterone level was high. The
" h1 ~+ M/ n# U. b+ dfollow-up visit was arranged within a few weeks to
1 `/ k  n* Y8 W$ I+ [obtain testicular and abdominal sonograms; how-
* {& ?- b# s/ Z/ N3 y% T1 q7 r- Dever, the family did not return for 4 months.
: r1 ~7 e0 X4 v4 L: [Physical examination at this time revealed that the' s! ]( _  j. Y8 ^9 b0 F# \# ~
child had grown 2.5 cm in 4 months and had gained+ d' k4 v3 b+ \( ~0 g5 g2 Q
2 kg of weight. Physical examination remained
% B6 H2 {% u2 Uunchanged. Surprisingly, the pubic hair almost com-
) V9 @( Y9 F# Ypletely disappeared except for a few vellous hairs at% h/ E7 C/ w5 B: o! \
the base of the phallus. Testicular volume was still 28 t) u: f8 G' s) S3 }
mL, and the size of the penis remained unchanged.
; B% p0 E7 }. W% U. n/ ]The mother also said that the boy was no longer hav-& }) o% X2 t9 I# Q) c/ x: i
ing frequent erections.
7 M/ ^) W. B9 j1 }' [; s* jBoth parents were again questioned about use of
+ O  B) z( ]' s4 k! W- yany ointment/creams that they may have applied to
' m5 o6 l  R1 t7 Othe child’s skin. This time the father admitted the$ G# i5 }: l! e  n1 ~
Topical Testosterone Exposure / Bhowmick et al 541$ L$ B4 p2 U) [0 b5 y+ O# B
use of testosterone gel twice daily that he was apply-
: n; d4 K3 ]: c" q0 ping over his own shoulders, chest, and back area for9 M/ p# l# v  x+ }- o% D9 c
a year. The father also revealed he was embarrassed
' ^+ L& h* X% U/ \- g8 n" a) s8 fto disclose that he was using a testosterone gel pre-
& n: q  B9 T) |" k: M: m  z9 Gscribed by his family physician for decreased libido% m+ N  L, e% d1 q! Q# |
secondary to depression.0 X3 h- D* d$ D! z/ r
The child slept in the same bed with parents.
* U7 `' B# U$ r$ G" Z  I, x' J" BThe father would hug the baby and hold him on his
+ ~4 E; }' J- f1 A0 |" p* I2 U$ ?chest for a considerable period of time, causing sig-' {$ x& W. k  u9 b& `/ I
nificant bare skin contact between baby and father.% q, S6 J1 B$ m1 X, P& R
The father also admitted that after the phone call,
! T/ Z0 x' c6 B, Pwhen he learned the testosterone level in the baby
4 Y" Q: r- M  b4 a1 ]. J0 {2 Rwas high, he then read the product information9 J9 G" h, P; T$ z4 u3 W9 R
packet and concluded that it was most likely the rea-: P  c3 O( s% H' D7 f" j) }( R
son for the child’s virilization. At that time, they
) K. C) K) e4 h# y; y. n% vdecided to put the baby in a separate bed, and the) j- O2 ]2 A9 }5 h1 S4 I/ B4 @, q; L
father was not hugging him with bare skin and had
2 Y: x2 D  g& ?6 |! lbeen using protective clothing. A repeat testosterone
! k# t! u/ ~, ntest was ordered, but the family did not go to the
9 }9 W9 R" T, u4 B% j! S8 Rlaboratory to obtain the test.
! B& ~$ [1 {% ]& A% x: [Discussion
' M* g: ]5 w7 n$ h4 JPrecocious puberty in boys is defined as secondary7 D$ s& t4 X( n2 F* t/ i' b
sexual development before 9 years of age.1,4
1 [8 p( ]+ u6 p  \* PPrecocious puberty is termed as central (true) when2 ]8 z$ t7 b! b
it is caused by the premature activation of hypo-
! I5 \; X& \. ^- l8 X7 l1 d( athalamic pituitary gonadal axis. CPP is more com-
6 v, u" X* E- k1 Amon in girls than in boys.1,3 Most boys with CPP
) m6 o+ L  m3 h6 A8 D9 Nmay have a central nervous system lesion that is
! s, a3 f+ d  {responsible for the early activation of the hypothal-
8 v* g9 F7 W" A5 N! m5 v+ Famic pituitary gonadal axis.1-3 Thus, greater empha-2 b; x" A4 d6 S8 ?$ G% v
sis has been given to neuroradiologic imaging in+ b0 u# t$ l0 g' Q9 M
boys with precocious puberty. In addition to viril-
' F& G9 `8 C- N, A  l1 x4 Tization, the clinical hallmark of CPP is the symmet-
/ i# e/ E. G4 V( \. ?rical testicular growth secondary to stimulation by; ~) v" q. J0 G2 x: o6 P$ F) Q
gonadotropins.1,33 J6 y9 o# I. l& I: L
Gonadotropin-independent peripheral preco-. N0 C) D# V7 }6 C$ ^. L9 g8 I2 h
cious puberty in boys also results from inappropriate; Y! ~6 S$ k: y" N
androgenic stimulation from either endogenous or
+ D  L1 N& t1 e8 ?4 Uexogenous sources, nonpituitary gonadotropin stim-
# H0 f; M3 p  i) z% z- e$ Bulation, and rare activating mutations.3 Virilizing# w/ O0 z5 a4 ]# t
congenital adrenal hyperplasia producing excessive
9 r3 ^  R8 R6 ]( ]$ @' wadrenal androgens is a common cause of precocious$ L/ z6 j7 n( o* \. W
puberty in boys.3,4
) T# t/ F' `4 s$ d) \6 n/ v$ n3 eThe most common form of congenital adrenal
8 b, ^8 M2 H: O7 @hyperplasia is the 21-hydroxylase enzyme deficiency.
$ o" e5 m$ Q* b! DThe 11-β hydroxylase deficiency may also result in
- a9 S& ?8 f2 {+ zexcessive adrenal androgen production, and rarely,! C  D; G) \. }2 S
an adrenal tumor may also cause adrenal androgen$ T2 L% x) `  _- w, ~
excess.1,3
0 u; h& o% w* N* uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: U* z0 J6 A  C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 ^- [# y+ {1 f6 X% GA unique entity of male-limited gonadotropin-
5 Y6 r' t% B3 y6 M' C  W& `independent precocious puberty, which is also known8 }2 _- t" D. X$ j4 t0 h! r7 o
as testotoxicosis, may cause precocious puberty at a
5 y- u( h0 G# I( dvery young age. The physical findings in these boys# {2 Q4 |6 l7 W! M' i. q
with this disorder are full pubertal development,4 N8 N, [; n7 u- b
including bilateral testicular growth, similar to boys0 b4 D) r; d0 ?! C4 q. b
with CPP. The gonadotropin levels in this disorder. O" a% z' N; C" ]6 O: v
are suppressed to prepubertal levels and do not show
1 H5 @; Y& W* c  q4 Lpubertal response of gonadotropin after gonadotropin-0 b$ N+ c4 w9 ~& X) I& f
releasing hormone stimulation. This is a sex-linked+ D8 [2 D* v5 P9 D9 p! T
autosomal dominant disorder that affects only
( R" _- `* V; C  J& y1 o3 Y2 `  wmales; therefore, other male members of the family  N# R) E) `9 o+ g+ J4 s0 I9 {
may have similar precocious puberty.3
3 h" M- ]+ a/ s$ b+ C1 {: I! x1 gIn our patient, physical examination was incon-
/ |9 Q7 q: b1 vsistent with true precocious puberty since his testi-
5 _' f; o, z) p5 U8 W" U: R6 acles were prepubertal in size. However, testotoxicosis
) ]! u7 Y# r1 k9 u  U3 jwas in the differential diagnosis because his father6 k/ J& s0 [& P0 i( r5 d9 B  }
started puberty somewhat early, and occasionally,
# E8 U7 M0 v! g- i2 ]testicular enlargement is not that evident in the
6 Y- s- g; J, N& e% {2 a. j( sbeginning of this process.1 In the absence of a neg-6 Z) z. M' z% M
ative initial history of androgen exposure, our
  e% W  m+ _: R" g6 ^" Ebiggest concern was virilizing adrenal hyperplasia,
3 {( ?* O  ~$ g: beither 21-hydroxylase deficiency or 11-β hydroxylase4 F& ?# ~, L4 t  w7 [
deficiency. Those diagnoses were excluded by find-
: ?' ^. _  h# A7 ~! Ping the normal level of adrenal steroids.) d7 A; ^5 `' }7 {" R$ N
The diagnosis of exogenous androgens was strongly  U. ^- N2 f0 b1 q
suspected in a follow-up visit after 4 months because6 m1 ], k( ^; A; A8 a
the physical examination revealed the complete disap-
1 t8 w6 Q+ k- H  X2 u8 X. wpearance of pubic hair, normal growth velocity, and1 M- b4 w. t9 h/ [
decreased erections. The father admitted using a testos-2 B8 i1 ~' P. K" ~9 F* j4 H
terone gel, which he concealed at first visit. He was, @' O7 C8 O9 a9 r' j8 _7 G1 ~
using it rather frequently, twice a day. The Physicians’
. h9 L( M0 ^. y. I0 ?9 [Desk Reference, or package insert of this product, gel or
; z2 h5 T/ b4 g; R+ x' hcream, cautions about dermal testosterone transfer to
+ E! Y! S2 {- o1 i; b0 qunprotected females through direct skin exposure.$ k  G  K( h* e' _0 M
Serum testosterone level was found to be 2 times the
- ~4 H* u1 I) A& S. e" [baseline value in those females who were exposed to
% v3 \5 L! n  heven 15 minutes of direct skin contact with their male! V2 H& y; g5 O4 L/ ]7 M- z4 Q9 G
partners.6 However, when a shirt covered the applica-
1 h/ s# F$ p# ?2 n7 q! rtion site, this testosterone transfer was prevented." s9 H! ~" G5 n/ f% @6 H# r# S
Our patient’s testosterone level was 60 ng/mL,
  S, s$ o6 c/ vwhich was clearly high. Some studies suggest that8 t$ F  @8 D# f* ]3 {( q
dermal conversion of testosterone to dihydrotestos-
: i4 b2 g, k+ k' U: v+ W4 s0 Qterone, which is a more potent metabolite, is more
! e  X0 _, p5 r$ [# t$ m5 B/ Hactive in young children exposed to testosterone
, v+ C2 D  c& Y+ y# @exogenously7; however, we did not measure a dihy-$ g' \0 F! q3 P- O5 M
drotestosterone level in our patient. In addition to2 H5 z+ e6 ?& k: J/ S" F6 a9 ^% Y* T2 e
virilization, exposure to exogenous testosterone in# D* w! `- ?, n6 U3 r% Q$ W
children results in an increase in growth velocity and
: G; Q# _2 |4 `3 Q0 y$ E3 Tadvanced bone age, as seen in our patient.
7 x! C; n  e; ?! z  m, v# M, dThe long-term effect of androgen exposure during/ h1 _% j) M/ s  m1 T
early childhood on pubertal development and final9 A6 N, q, ?0 W
adult height are not fully known and always remain
4 X1 z. Q6 J3 |5 V: X6 pa concern. Children treated with short-term testos-
( B. t* L: O2 l$ `terone injection or topical androgen may exhibit some  Z" D- q: {8 }- }
acceleration of the skeletal maturation; however, after% S% U* Z3 r! Q8 n
cessation of treatment, the rate of bone maturation2 f$ j% X6 m* S4 X  k
decelerates and gradually returns to normal.8,9  z) T/ K, w! G' @7 r3 G6 z4 ]6 u
There are conflicting reports and controversy. B4 Y& v6 g% s8 d! M0 E" v
over the effect of early androgen exposure on adult
* O/ w1 L4 G5 m2 _2 T  L  x) U7 lpenile length.10,11 Some reports suggest subnormal8 d/ B' W6 w8 B, `. O* T
adult penile length, apparently because of downreg-* A6 b0 N. d4 m* ^5 |  Z
ulation of androgen receptor number.10,12 However,. B$ d* I- n/ _( R+ v- g
Sutherland et al13 did not find a correlation between" m" L3 _9 H% N' X& A) I. i
childhood testosterone exposure and reduced adult, p+ v$ |6 C( o$ f5 U+ K
penile length in clinical studies.
3 p1 i% X* R* ]& @4 ~5 A' Z  bNonetheless, we do not believe our patient is
8 N. I! ?% T+ y* K# v! y) wgoing to experience any of the untoward effects from2 a. G: H) r9 A0 ]
testosterone exposure as mentioned earlier because
( Q& m2 Q8 s: n! |7 Ethe exposure was not for a prolonged period of time.; Q' E2 c- s8 o+ {
Although the bone age was advanced at the time of
3 M, H* ^. n) u0 Jdiagnosis, the child had a normal growth velocity at
  ]  i0 O3 n% ?0 E% Z2 J/ Ethe follow-up visit. It is hoped that his final adult
3 f/ s+ {4 c3 Cheight will not be affected.4 i9 G2 P3 a! H6 ?9 _& E6 u
Although rarely reported, the widespread avail-
9 U  \/ Q% _; I& p  Nability of androgen products in our society may! ~9 x2 p4 t1 w, n8 \
indeed cause more virilization in male or female
9 O! ~' Q+ x. l+ e6 K2 ichildren than one would realize. Exposure to andro-
8 k, g7 f# Z8 i  }: `gen products must be considered and specific ques-
: u2 F1 C2 z/ y8 Otioning about the use of a testosterone product or
3 ~; p, p. I/ p5 lgel should be asked of the family members during
4 ~/ r' A+ H  _% }the evaluation of any children who present with vir-
( M% l5 o' G' i) f* ~& w1 j5 u/ Nilization or peripheral precocious puberty. The diag-( B" O& u& ^" ]. S
nosis can be established by just a few tests and by9 F8 t( t& w% A: ^
appropriate history. The inability to obtain such a
0 F; {! i+ {" M4 K' @history, or failure to ask the specific questions, may2 G/ Y& m  q' d1 a8 a9 ?$ S
result in extensive, unnecessary, and expensive% `' o- u$ y. K' {2 Z$ s
investigation. The primary care physician should be
2 e+ i1 d0 B( x6 P' ^& Q1 baware of this fact, because most of these children
* r% c6 r6 V9 m( ~may initially present in their practice. The Physicians’
, x" H' |, X) C2 \( y( VDesk Reference and package insert should also put a& G" |3 C- U/ ^& y! }% x
warning about the virilizing effect on a male or
2 P' [9 Q6 k$ v1 ]7 sfemale child who might come in contact with some-9 o8 Y; z1 \1 P; S+ r
one using any of these products.
2 i+ m1 \3 X7 s2 f2 MReferences. }  F' l, \! b0 h
1. Styne DM. The testes: disorder of sexual differentiation. M1 m8 Q$ C% j
and puberty in the male. In: Sperling MA, ed. Pediatric' ]6 C: m, M4 S" K3 K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# E8 T) ]3 M- `6 \, H" u
2002: 565-628.
( `: }4 |; Q; o2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  v2 ]7 L/ V! u# Upuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old; Q8 E% y( J% @0 Z) t+ p
Boy Induced by Indirect Topical
4 M( r( D6 r9 X' N+ KExposure to Testosterone9 C- h7 E% }, ]3 U' }! Y" X; U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! i# i. i" k5 Tand Kenneth R. Rettig, MD1  ~0 F) m' P4 @7 N! @$ V# r/ a
Clinical Pediatrics2 ~( M- q+ {( T* ?3 M
Volume 46 Number 68 ?: Y7 a6 d# n: L" `6 R! s
July 2007 540-543
2 i+ l6 l& l7 t# J+ _  O" e# T© 2007 Sage Publications, H' ]! G; b9 x5 e# E' d: d
10.1177/00099228062966514 N% |1 u4 X& c% [
http://clp.sagepub.com
8 p1 ~/ C- W7 k9 p3 W) l3 K6 Zhosted at
- r# a( }: J- c$ ~http://online.sagepub.com& U  H5 y& O. g1 i7 F' m( x) X
Precocious puberty in boys, central or peripheral,  P: Z( ^3 A, C, q, m
is a significant concern for physicians. Central
& l3 X9 S$ @4 ?6 z% F; p7 vprecocious puberty (CPP), which is mediated
& U8 |* }! z7 y. m" \3 Y% r7 Ethrough the hypothalamic pituitary gonadal axis, has
, i' F9 Y& B9 p( F, S  ?a higher incidence of organic central nervous system
- i) L" Y& o" o  k. `- F, z0 nlesions in boys.1,2 Virilization in boys, as manifested
: Y( i4 B3 B* ]. e5 Nby enlargement of the penis, development of pubic
5 p# R7 N9 b( yhair, and facial acne without enlargement of testi-
' E0 O1 `8 J8 T7 V. |0 kcles, suggests peripheral or pseudopuberty.1-3 We
+ A- h* c- T+ x4 c+ Zreport a 16-month-old boy who presented with the
+ w" X  S* l0 J1 l# henlargement of the phallus and pubic hair develop-
0 ~$ m/ G$ r  dment without testicular enlargement, which was due
8 M0 ]( @# ]+ n- j* oto the unintentional exposure to androgen gel used by
! J7 \( c8 q# k' R$ b# c. nthe father. The family initially concealed this infor-7 ^7 ~) g4 b5 w
mation, resulting in an extensive work-up for this# O) r! w! Q9 @* Q. k- `. G2 }  a  o
child. Given the widespread and easy availability of
' _& C' r4 l' {testosterone gel and cream, we believe this is proba-
2 _4 @5 D9 v7 E/ D- l" l& y% Bbly more common than the rare case report in the
( H/ t0 Z, p7 g4 L& J" |5 ?literature.4% w7 |8 [0 b: B' R
Patient Report
, H3 v/ E  M4 Z& R6 dA 16-month-old white child was referred to the! _' X& _) ]; [
endocrine clinic by his pediatrician with the concern7 J7 ~  L8 j0 i/ [
of early sexual development. His mother noticed
  Z, t2 Y: O  T% F: {' Tlight colored pubic hair development when he was- S( U' Z2 g# @
From the 1Division of Pediatric Endocrinology, 2University of
( p- q0 ^$ J& b9 kSouth Alabama Medical Center, Mobile, Alabama.$ S" U0 M3 j0 ^$ t$ r6 v
Address correspondence to: Samar K. Bhowmick, MD, FACE,) }0 h& y& t- ^5 z
Professor of Pediatrics, University of South Alabama, College of% h5 f7 `0 q+ H. {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! Z5 F8 n; C! w% J. Be-mail: [email protected]., Y7 t& t" ?* u9 f% {
about 6 to 7 months old, which progressively became) i. H+ T# N; b, c
darker. She was also concerned about the enlarge-
9 p" L2 ~- t# \( v9 Q: x! b* Dment of his penis and frequent erections. The child  ?. J. A9 [0 `/ H+ L2 [/ K* l
was the product of a full-term normal delivery, with
. d# x* p5 |- K* }% A1 L" [a birth weight of 7 lb 14 oz, and birth length of
+ M& ]3 Z1 b, l' Y1 K( D7 P20 inches. He was breast-fed throughout the first year1 q, P' I% M- V! ^) S1 E" d
of life and was still receiving breast milk along with. h! j" l& h/ P" f; M
solid food. He had no hospitalizations or surgery,
' m! K0 L8 o7 s1 @- S. K( aand his psychosocial and psychomotor development# a/ O' o9 J) ?
was age appropriate.) C3 m# o6 h6 P! g0 F
The family history was remarkable for the father,
# y+ G$ R4 J9 z/ mwho was diagnosed with hypothyroidism at age 16,
7 A' B! G9 o$ ~9 Nwhich was treated with thyroxine. The father’s
7 [, Y% X" b/ ~0 a* A" ^height was 6 feet, and he went through a somewhat3 O7 E. M6 b' E+ R
early puberty and had stopped growing by age 14.; T9 T, r$ j' e  A+ E0 g( n  `
The father denied taking any other medication. The4 ?, {. I4 `; u# x* K  D
child’s mother was in good health. Her menarche
% h0 s' @/ S9 L/ j' Y; H7 r& qwas at 11 years of age, and her height was at 5 feet- o1 X; t' P. E3 a/ ]- `) G; V
5 inches. There was no other family history of pre-
8 `. R4 i% H: x2 mcocious sexual development in the first-degree rela-
8 n5 B( Q' Y, ^& k( M* b1 V0 _tives. There were no siblings.. L/ O9 a! e) b" k# S
Physical Examination
( x/ q. u5 |4 N+ BThe physical examination revealed a very active,# P( d; |) K+ B- p. Y+ S8 x
playful, and healthy boy. The vital signs documented
- h7 ~% s3 J; X& ?& ea blood pressure of 85/50 mm Hg, his length was
: w1 J' X0 h4 B; x90 cm (>97th percentile), and his weight was 14.4 kg8 @* c2 B4 U6 v/ A8 @) B
(also >97th percentile). The observed yearly growth
6 f  a8 H! }" x7 i# svelocity was 30 cm (12 inches). The examination of3 s7 t/ v' R  q' |! H
the neck revealed no thyroid enlargement.
3 ^( Q# ~2 S/ [8 ~) B, wThe genitourinary examination was remarkable for7 e3 m/ S5 U9 k2 Y; [$ A  P  R: F
enlargement of the penis, with a stretched length of9 q: \# Z) v, T$ [( L  N
8 cm and a width of 2 cm. The glans penis was very well! U( O7 H" i0 N7 b6 K5 e
developed. The pubic hair was Tanner II, mostly around! U. k5 [+ t" q  C% O3 M
540
6 ?, z5 r, a. ]  n/ kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 M8 X/ A0 n- d; l0 W1 S! Wthe base of the phallus and was dark and curled. The
% g1 v% n" S/ O2 @testicular volume was prepubertal at 2 mL each.8 u' f) T6 ~$ D% A! W9 H: }* Z
The skin was moist and smooth and somewhat
% x4 Y  i: v* g* ], C; s; x# Eoily. No axillary hair was noted. There were no
' s1 l3 Q& B$ mabnormal skin pigmentations or café-au-lait spots.
. M8 o) k/ l) z' ^3 Z- gNeurologic evaluation showed deep tendon reflex 2+
9 ?0 @9 g9 C7 ~' t9 {: bbilateral and symmetrical. There was no suggestion
- ]/ V" X7 B$ v+ \5 Wof papilledema.
3 L% R9 q; ]% ]0 P5 O' oLaboratory Evaluation4 t0 l6 K* @, t& r! X) r
The bone age was consistent with 28 months by' C! O: s7 m( F  O
using the standard of Greulich and Pyle at a chrono-
1 y8 v' i: O1 I" {9 n3 Ilogic age of 16 months (advanced).5 Chromosomal+ \5 n0 Z, u$ d5 S
karyotype was 46XY. The thyroid function test7 Y2 K$ g. V! y4 u8 G4 Q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 N1 b5 o/ ?! \
lating hormone level was 1.3 µIU/mL (both normal).6 x. M# ^+ e. G5 C
The concentrations of serum electrolytes, blood1 k5 o7 u$ }9 q- l/ o% \3 f
urea nitrogen, creatinine, and calcium all were) Y" h9 r) @0 y; Z& L' @
within normal range for his age. The concentration
( }( h, l2 l- x8 f5 H4 gof serum 17-hydroxyprogesterone was 16 ng/dL
5 g6 ^$ u' H) C5 L, G$ \. {(normal, 3 to 90 ng/dL), androstenedione was 20: L3 E9 W; S. ]  o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* U% G' |6 V4 |4 |terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" H# S. E$ D4 c/ r) r4 @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- ], w& o/ z0 o  {! O% R49ng/dL), 11-desoxycortisol (specific compound S)
1 X3 \; R# x$ t3 Y8 vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& R' N, ~, e( R1 Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ S$ j4 ~; \6 s( Z, c" Itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* E& _; H+ \! {& ^& W2 D/ wand β-human chorionic gonadotropin was less than: x; j& p5 |1 P  j
5 mIU/mL (normal <5 mIU/mL). Serum follicular
: f/ K, u/ U, W0 @' @3 |  @( Qstimulating hormone and leuteinizing hormone
* M7 \7 h; G$ S. g4 w& o. B$ R' V  iconcentrations were less than 0.05 mIU/mL
2 n9 _* y; `4 N(prepubertal).
4 B7 H+ z* w9 E4 qThe parents were notified about the laboratory
; h6 v6 m: u1 G) R- {9 nresults and were informed that all of the tests were! H/ j5 g0 ^( c: Q6 |$ u6 N3 v6 {
normal except the testosterone level was high. The
' N/ p" \; m6 Y4 Sfollow-up visit was arranged within a few weeks to
$ G  S2 x1 J% P$ oobtain testicular and abdominal sonograms; how-* d; Z9 m8 p) Z4 A9 t5 Q: U
ever, the family did not return for 4 months.
: w0 \! Y' ^9 h7 I* \- B% t- wPhysical examination at this time revealed that the
+ q; j/ W6 N; Zchild had grown 2.5 cm in 4 months and had gained: z5 n+ D4 o4 K
2 kg of weight. Physical examination remained4 c. j3 a6 A' M& @
unchanged. Surprisingly, the pubic hair almost com-; K5 R  [; O* x  Y  B: r8 J+ r
pletely disappeared except for a few vellous hairs at
: r  C6 v+ W: Uthe base of the phallus. Testicular volume was still 2- E# N; U9 ^, l  d* p
mL, and the size of the penis remained unchanged.5 C3 q8 a1 w6 h4 o. M6 f( J
The mother also said that the boy was no longer hav-2 `& J) ?9 s' k9 m7 Q
ing frequent erections.
* r1 j4 o; d' b/ D+ aBoth parents were again questioned about use of4 r% E2 E. Y+ B6 R
any ointment/creams that they may have applied to
) C% W, {" \' _9 M3 T& `  Z7 g- ]the child’s skin. This time the father admitted the
+ [" D3 ~9 v: R) J: u7 |Topical Testosterone Exposure / Bhowmick et al 541) g' D' c" V& s- C( y& }
use of testosterone gel twice daily that he was apply-
. a+ `1 [# i$ V) ping over his own shoulders, chest, and back area for
5 ~8 |! C4 ^+ I! fa year. The father also revealed he was embarrassed
: k% C1 r& _, |* P  ito disclose that he was using a testosterone gel pre-2 B- @/ c. t  r9 d  y4 R4 f
scribed by his family physician for decreased libido2 S8 x2 {3 }& a* ^0 A# o. \7 T
secondary to depression.  A7 S' Z+ X% r* U8 m) M) e
The child slept in the same bed with parents.+ P: F# W, u) n% F* R: _0 S; I. r
The father would hug the baby and hold him on his
: m; s4 a+ ?+ o' wchest for a considerable period of time, causing sig-
1 U' l# @( E* P6 u" e* ~nificant bare skin contact between baby and father.
7 X! ?4 _8 o3 h* l. \; uThe father also admitted that after the phone call,$ {* i  i$ v% K9 c' i9 T
when he learned the testosterone level in the baby
& U0 X) |! H# X, t/ lwas high, he then read the product information' j0 G% t+ `8 @& ]+ r4 i
packet and concluded that it was most likely the rea-# X; k! E1 L! p! u) M  n
son for the child’s virilization. At that time, they0 e. [9 g; x- j
decided to put the baby in a separate bed, and the/ b$ D6 s9 A% h4 Y  R" i  b
father was not hugging him with bare skin and had) u0 n/ w/ j, O7 y
been using protective clothing. A repeat testosterone7 A2 T+ v% ]6 G0 b9 a4 f% }
test was ordered, but the family did not go to the  L1 Y" I9 z5 g3 B3 D6 g
laboratory to obtain the test.
+ H. x$ X+ ]9 L' J+ m" }Discussion
# u* _0 e( M. `+ a6 q- sPrecocious puberty in boys is defined as secondary
6 ?, N0 I1 z7 G- P# Csexual development before 9 years of age.1,4/ k( q9 _, ~9 H# P% Z1 u
Precocious puberty is termed as central (true) when0 @4 w) ?6 M& Y5 n( b1 L
it is caused by the premature activation of hypo-/ L8 R/ I2 y% S" _
thalamic pituitary gonadal axis. CPP is more com-- z# ]. ~0 x) S5 x
mon in girls than in boys.1,3 Most boys with CPP, N5 y+ O$ t. V2 L7 p" S& k' j
may have a central nervous system lesion that is
- x$ S$ `3 z% h" l( R: o- n, kresponsible for the early activation of the hypothal-- f6 v$ N( m  P1 Y: i; {
amic pituitary gonadal axis.1-3 Thus, greater empha-
* Z7 m0 ?' [2 D% W/ Tsis has been given to neuroradiologic imaging in
& c% \' ]% e8 b5 J( T& w5 Iboys with precocious puberty. In addition to viril-
# Z" h: ^. f  R" R1 [+ e3 qization, the clinical hallmark of CPP is the symmet-1 W8 v( r+ n) j3 d2 K  r7 f+ m
rical testicular growth secondary to stimulation by5 F$ A. O. R! B. C
gonadotropins.1,31 e+ }; U% B) j- V/ P) ~
Gonadotropin-independent peripheral preco-
8 D8 x$ V* q  o! Y8 ]7 q3 Mcious puberty in boys also results from inappropriate- k( a) ~( H9 @  V" l9 ~
androgenic stimulation from either endogenous or
& r& k  p9 M6 f3 r! a5 A! jexogenous sources, nonpituitary gonadotropin stim-
! z8 R7 r: m$ S1 y" b' \ulation, and rare activating mutations.3 Virilizing4 l8 T: ]9 j0 o" B4 U
congenital adrenal hyperplasia producing excessive
/ O* I5 C" N5 r3 h3 a( {adrenal androgens is a common cause of precocious/ ~4 [, I; _' @2 d
puberty in boys.3,4' H$ q' Z0 P6 I
The most common form of congenital adrenal0 X6 @& V$ }6 i* e4 ]
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 d- L4 D8 e1 D$ g7 p3 N+ ]The 11-β hydroxylase deficiency may also result in
$ n+ W9 b  S6 C9 s( F) wexcessive adrenal androgen production, and rarely,
; k7 x0 t, f2 W+ Q3 Han adrenal tumor may also cause adrenal androgen* l# g: c, g& D; k  ]: }
excess.1,3! ~0 p9 d3 O- ]; P  U9 d* s: m& N) B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" v& E* b- Z6 C& G7 V' X
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ `& v7 N( Z* R' x, nA unique entity of male-limited gonadotropin-
$ d2 a" \6 l9 P4 Y: L1 _' a$ t3 {% |independent precocious puberty, which is also known7 C+ I* a, _- _) A, z" l
as testotoxicosis, may cause precocious puberty at a9 M* Q/ F# ~+ g. v: B+ l, Q
very young age. The physical findings in these boys
3 @+ q4 z( i( Bwith this disorder are full pubertal development," B, l0 w$ f4 p; j, W4 |- S( j
including bilateral testicular growth, similar to boys
) u- E9 s) E1 Q4 Mwith CPP. The gonadotropin levels in this disorder
% y  c# _: a2 u4 Q( N7 Sare suppressed to prepubertal levels and do not show% ~3 ]2 g& _' |0 g7 O6 F
pubertal response of gonadotropin after gonadotropin-
+ \2 r& G' U. K) B5 h: preleasing hormone stimulation. This is a sex-linked
  s' m% E7 f& c  dautosomal dominant disorder that affects only! h) ^( A4 k' b4 s2 y
males; therefore, other male members of the family3 [2 i# {0 j2 g; x7 C: D
may have similar precocious puberty.3! ?0 x2 {+ ?  }# `# s, Z
In our patient, physical examination was incon-
" @0 _# F; Z- }5 b0 s- H* bsistent with true precocious puberty since his testi-0 L+ v" e5 f  z& s! S& P
cles were prepubertal in size. However, testotoxicosis
* n- B0 s# H4 N# s3 ?was in the differential diagnosis because his father  c/ I. A* d- [1 A! M/ |, W8 Z
started puberty somewhat early, and occasionally,7 ]/ p: H7 p' v& l% H. Y
testicular enlargement is not that evident in the
& `  P, x) B' f. S( }% q& Rbeginning of this process.1 In the absence of a neg-
3 g$ Y( _/ g4 Hative initial history of androgen exposure, our
" m3 ]  l5 m  L4 {( m+ Sbiggest concern was virilizing adrenal hyperplasia,/ X% s& R+ l" q, l% |' |. a) V
either 21-hydroxylase deficiency or 11-β hydroxylase8 p  `. S3 e  l
deficiency. Those diagnoses were excluded by find-! q, V- w5 I3 H  F- W; R+ \
ing the normal level of adrenal steroids.( K  ?$ w, L9 Z, H7 P. q
The diagnosis of exogenous androgens was strongly
# L) H: ^6 T' {+ dsuspected in a follow-up visit after 4 months because
! N( z( S7 r9 L5 F4 z5 ~# rthe physical examination revealed the complete disap-
% a' T3 h' q' qpearance of pubic hair, normal growth velocity, and
. v; y5 t5 Z- j* Jdecreased erections. The father admitted using a testos-
0 I# n! m6 S& ^( G' u4 U1 \1 Z  ~terone gel, which he concealed at first visit. He was
7 D# B" y$ m6 B9 Z3 }$ Gusing it rather frequently, twice a day. The Physicians’  U9 m0 U# ~# W6 _# L
Desk Reference, or package insert of this product, gel or5 o: y8 }5 v  z0 a$ F
cream, cautions about dermal testosterone transfer to
0 r/ Z3 u* v, _& gunprotected females through direct skin exposure.& L% S  T; e! P: p5 w8 e8 J
Serum testosterone level was found to be 2 times the
0 U1 @8 Y' k* c2 {, s# e6 m; U8 J: Vbaseline value in those females who were exposed to: K! a; W8 [9 R' _
even 15 minutes of direct skin contact with their male. n' w# t3 M! K5 x* X
partners.6 However, when a shirt covered the applica-  g( t: ]; m: M, X% y- S- e* G
tion site, this testosterone transfer was prevented.
" _$ i! [+ l5 X5 s" e1 l  J6 e$ ^Our patient’s testosterone level was 60 ng/mL,2 G+ r  E8 f1 _) j9 E6 P: _. u
which was clearly high. Some studies suggest that( C5 E. Z- J# {& i6 h
dermal conversion of testosterone to dihydrotestos-4 Z( @- ~6 v9 R5 r
terone, which is a more potent metabolite, is more6 Q4 ?0 E3 K# I9 `2 ^
active in young children exposed to testosterone. B! I0 ]% d! c0 K% @# i; S
exogenously7; however, we did not measure a dihy-5 V" X( c& B7 `( d
drotestosterone level in our patient. In addition to
8 S- b+ y; C- uvirilization, exposure to exogenous testosterone in' f* @1 K7 e0 n" e4 J2 K& P: y
children results in an increase in growth velocity and
7 w" Q4 o8 @" D' v" j& l, gadvanced bone age, as seen in our patient." Y( H* s& E: G+ j0 _
The long-term effect of androgen exposure during
6 v! c4 u2 F: b* l9 t! hearly childhood on pubertal development and final
# D4 @/ U2 _0 H8 [& U  D! @adult height are not fully known and always remain
& l3 ]) v4 O' A8 p5 _5 y6 ma concern. Children treated with short-term testos-9 S1 x7 Q+ h1 U  x* B' R
terone injection or topical androgen may exhibit some
$ x( s( A+ c3 N# d, t. K0 Cacceleration of the skeletal maturation; however, after; P& R3 i: f( ~, ?" A6 I
cessation of treatment, the rate of bone maturation) F$ o0 S8 O4 e' R  t' p& z
decelerates and gradually returns to normal.8,90 ]+ Y& ?0 Q3 D" p7 M7 ]7 I
There are conflicting reports and controversy
) ~% Z- t& u8 w8 N$ wover the effect of early androgen exposure on adult1 C7 d+ f- v" C' D% b7 u& K
penile length.10,11 Some reports suggest subnormal; B8 w/ x& z6 F: B( K' s* J
adult penile length, apparently because of downreg-
* A/ i4 Z/ k; x/ `0 P7 w4 J  nulation of androgen receptor number.10,12 However,' J1 R5 Q  O' i5 G$ J6 b
Sutherland et al13 did not find a correlation between  X  K8 r, U2 Y: f' w! C
childhood testosterone exposure and reduced adult
/ B' L6 E* l$ f, R" {) Ypenile length in clinical studies.! U* K, t5 O2 e, c1 Q( ^* C1 G
Nonetheless, we do not believe our patient is1 A) D0 j; `0 N# t4 Z: [' F
going to experience any of the untoward effects from" ^8 L7 k, p" q4 a/ K
testosterone exposure as mentioned earlier because
2 w& {& \, J% i! c! Vthe exposure was not for a prolonged period of time.% b0 g0 l. j8 |- ~
Although the bone age was advanced at the time of3 r6 u* S3 i9 K% V$ G+ w
diagnosis, the child had a normal growth velocity at
6 |/ q+ c. ^: Q4 o, H7 Athe follow-up visit. It is hoped that his final adult
- z; O0 K- p2 A( U' @+ zheight will not be affected.
' p* u* o" A: [; N/ a6 [' fAlthough rarely reported, the widespread avail-0 F& O4 n$ |9 K
ability of androgen products in our society may
: ~) Y/ j9 D5 T; F$ k4 ^indeed cause more virilization in male or female
: k+ t8 l- ]( P/ q# B" [children than one would realize. Exposure to andro-+ b9 n/ Q% o) R5 g, J
gen products must be considered and specific ques-9 u$ n4 y3 s0 ?( v4 Z( B
tioning about the use of a testosterone product or0 o8 `" q% R& _5 @( N
gel should be asked of the family members during
% c7 ^  w# C$ g9 Vthe evaluation of any children who present with vir-. M1 q6 r, ?7 w% |9 E
ilization or peripheral precocious puberty. The diag-7 k- ?7 `! G7 u1 V6 j+ q( }# H
nosis can be established by just a few tests and by
9 X$ i/ m+ D7 aappropriate history. The inability to obtain such a: H. y: L( |; V
history, or failure to ask the specific questions, may3 O4 B- V! o5 e' v0 `* X; V5 z" d
result in extensive, unnecessary, and expensive
7 g' s  O, l, U& ~+ ~! T" Qinvestigation. The primary care physician should be- M8 [( j& A  F! h
aware of this fact, because most of these children! D- R) a8 I0 y9 F  K
may initially present in their practice. The Physicians’
* g2 a& r9 u7 D0 s" M' UDesk Reference and package insert should also put a* Z0 `9 G( V" l: D) U- H1 q% \
warning about the virilizing effect on a male or
+ I- r. h4 t- `+ B0 Xfemale child who might come in contact with some-
" u& v* C7 t. Y/ Oone using any of these products.
% V# u7 [2 p4 {3 PReferences
" n' ^. A; {, X/ @9 [( c* i/ a4 x8 [1. Styne DM. The testes: disorder of sexual differentiation
! a! D2 C  J: t) N" j% Gand puberty in the male. In: Sperling MA, ed. Pediatric
3 H5 m. A$ j# {Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; g; l: j  ?0 o: I, O. e+ z
2002: 565-628.
5 I7 m" l. r6 O& A3 E2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, D; U& x; \5 U+ G% q$ j: [8 D- B. Jpuberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
9 {: z& p/ y' o! s1 b
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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