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Sexual Precocity in a 16-Month-Old4 |  v8 n1 a  R
Boy Induced by Indirect Topical
! ?! j* `. p; D0 |- QExposure to Testosterone1 ]: u6 A* m  u# ?4 F8 {
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2+ C3 w2 Y7 m$ @2 p$ ]$ a, D3 ]& R
and Kenneth R. Rettig, MD1) E  ^# _7 K0 b  V' u% c9 l
Clinical Pediatrics
7 U& h  V5 t( Q. P* [/ y, J- ?" TVolume 46 Number 6. O+ }. V7 {% O2 i
July 2007 540-5438 U# O- R) {) x+ z; u) K: s0 y/ S
© 2007 Sage Publications3 t' D- Q: \3 @4 z
10.1177/0009922806296651
/ a: v) E3 z7 C$ Ohttp://clp.sagepub.com- D# a8 ~1 L7 j% f# t, ~* ^$ g. l
hosted at
' b0 [8 ^1 f/ A4 K$ H& y" Xhttp://online.sagepub.com  ]5 r  [- D; c
Precocious puberty in boys, central or peripheral,& m5 @0 ^9 u$ W4 M* `  V& A
is a significant concern for physicians. Central
( |! z3 s( d1 L; l5 i/ Tprecocious puberty (CPP), which is mediated
* q: \+ a% o; L! G3 m9 y) Othrough the hypothalamic pituitary gonadal axis, has
+ }, G, i4 q$ r* A, d: L0 W2 e$ x6 l4 _a higher incidence of organic central nervous system
5 b0 b& I& b; e  g0 ylesions in boys.1,2 Virilization in boys, as manifested. Y  c9 q1 D" s0 m* P$ `
by enlargement of the penis, development of pubic
- {( q# Q8 J; J3 thair, and facial acne without enlargement of testi-
+ U! q% B- E0 C* I' Scles, suggests peripheral or pseudopuberty.1-3 We
% V' G7 @" h4 Jreport a 16-month-old boy who presented with the- ^! L" r6 O5 l/ G# A) @& R
enlargement of the phallus and pubic hair develop-5 z& q# L1 w+ h; N
ment without testicular enlargement, which was due
+ @1 {: U. J3 Z: Wto the unintentional exposure to androgen gel used by5 I/ w( n0 p$ M% y
the father. The family initially concealed this infor-
  j" h& Z4 O9 x; F9 t7 }mation, resulting in an extensive work-up for this
! X; g6 D- Z1 d: q" Echild. Given the widespread and easy availability of' |7 B; o: |' B7 a: _
testosterone gel and cream, we believe this is proba-
* l4 u" B# ?$ R) P4 X5 Nbly more common than the rare case report in the
. e" h6 j2 L1 {% {" P8 H/ [, U/ zliterature.4. d8 E. q+ m" W: _; f7 s
Patient Report$ O* y- {; f) T
A 16-month-old white child was referred to the- O+ u3 z2 p& I( _) _4 H0 w% V
endocrine clinic by his pediatrician with the concern
2 \4 Q8 u" m* Bof early sexual development. His mother noticed
  b; l% I% N" Qlight colored pubic hair development when he was/ u% o2 s5 }5 K/ Z
From the 1Division of Pediatric Endocrinology, 2University of
2 V. h, V) c. NSouth Alabama Medical Center, Mobile, Alabama.  ?1 g" B$ W" y! v7 r, Q9 d
Address correspondence to: Samar K. Bhowmick, MD, FACE,  P6 @( a1 W+ D5 D! @, m5 w: x# j8 n( W
Professor of Pediatrics, University of South Alabama, College of
1 \; u1 T# E$ d) a8 Q: K: G. kMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 J" y: K0 [8 k+ |3 ?1 Ce-mail: [email protected].
' B* j' X$ a5 jabout 6 to 7 months old, which progressively became
, K$ L, j* o: V- Edarker. She was also concerned about the enlarge-
! D. ]: \) A8 @1 p; Tment of his penis and frequent erections. The child' w% N7 t) A0 @8 X3 r! Z% c
was the product of a full-term normal delivery, with! ]6 w; Y8 ?/ P; a* a: ~
a birth weight of 7 lb 14 oz, and birth length of( `; G8 y  V6 d. c/ t5 Z
20 inches. He was breast-fed throughout the first year
; f. ]4 {  D; ?0 m5 L/ K$ fof life and was still receiving breast milk along with
* V9 K" h/ l. z  [+ w) dsolid food. He had no hospitalizations or surgery,
8 E* v/ j6 y( l. eand his psychosocial and psychomotor development
# i' c! v9 B/ S- K, T3 Y/ [was age appropriate.
# d4 K: m- w6 k6 B" `The family history was remarkable for the father,
/ p+ B2 L9 r1 _! Z, j% h$ Twho was diagnosed with hypothyroidism at age 16,' [% B) x* y0 U/ |2 V
which was treated with thyroxine. The father’s1 ]. Z& y$ R1 ^  J9 D+ [
height was 6 feet, and he went through a somewhat
' v4 s: m. e6 u8 W, i& I6 Rearly puberty and had stopped growing by age 14.
& {1 S9 s1 {) V6 D8 G& O4 }The father denied taking any other medication. The
: ]6 H+ B8 b: ^- Lchild’s mother was in good health. Her menarche+ M+ z0 k1 @( l" s
was at 11 years of age, and her height was at 5 feet& t* N& G' S! e1 W1 R" X
5 inches. There was no other family history of pre-# y. {( r1 Y3 \+ _) K0 H' {- J# ^
cocious sexual development in the first-degree rela-
# b" p! e  T/ j0 P$ U! W. ]tives. There were no siblings., T' |4 Z# u, s  J$ s, P
Physical Examination+ o* o! v& x$ P$ ^! p* J4 c
The physical examination revealed a very active,
% i7 [, }- I9 _% @1 y4 iplayful, and healthy boy. The vital signs documented
  i- S! a0 o" e2 E5 s; }a blood pressure of 85/50 mm Hg, his length was
0 }2 g# J) ?+ T6 r; C" c90 cm (>97th percentile), and his weight was 14.4 kg# h! \4 S& ^; O7 [  z- f( j: _) ^
(also >97th percentile). The observed yearly growth
$ I! P$ g8 L" Bvelocity was 30 cm (12 inches). The examination of9 W) U; D% ]( }) m  m3 o6 T3 J$ n
the neck revealed no thyroid enlargement.: [, u; C6 ]* x4 G+ v
The genitourinary examination was remarkable for
, q# M, |- j5 f" O3 S8 \enlargement of the penis, with a stretched length of
0 |1 H& u7 {2 J. @8 cm and a width of 2 cm. The glans penis was very well
  }, r; l" W  D8 M) G% j  V$ xdeveloped. The pubic hair was Tanner II, mostly around; }4 ?8 e" Z9 `: b- G0 \
540: O/ V# G9 \; W* Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 a: h/ @$ _8 S4 M& Jthe base of the phallus and was dark and curled. The
* n1 P3 ?$ E4 ~3 @: C- ]testicular volume was prepubertal at 2 mL each.
( C, d5 i# d) f/ |( u9 E7 uThe skin was moist and smooth and somewhat, c& U- g1 A! v' U& w7 [
oily. No axillary hair was noted. There were no
, S6 P; r, Y# j* q# gabnormal skin pigmentations or café-au-lait spots.
+ l% C0 J8 W2 ~( E# ^6 m8 ]Neurologic evaluation showed deep tendon reflex 2++ k6 j; h, ~# O6 T% X$ f# l
bilateral and symmetrical. There was no suggestion2 H9 L) v  f7 ~" p
of papilledema.
! T9 P6 ]+ P" iLaboratory Evaluation3 @. ]0 B6 P$ D( x; J7 k( _9 x2 i
The bone age was consistent with 28 months by) w& ~5 g+ B2 ^) |# h/ J& C
using the standard of Greulich and Pyle at a chrono-
$ ?% o( Y+ X' k) x5 {$ klogic age of 16 months (advanced).5 Chromosomal" l3 R6 h( k6 w8 H- K  B! m; B
karyotype was 46XY. The thyroid function test
8 v8 v! c- ~3 I1 q3 h4 C! Lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) ]1 a0 U, M2 ~7 }& b' s/ Z' H
lating hormone level was 1.3 µIU/mL (both normal).
* A6 u8 ~2 x# W; VThe concentrations of serum electrolytes, blood
4 V) ~  o! V% H, y3 B. R3 Wurea nitrogen, creatinine, and calcium all were
. ?' r0 _% H1 Q( ^within normal range for his age. The concentration* W& q) z: m/ E8 L1 L
of serum 17-hydroxyprogesterone was 16 ng/dL+ _6 w/ X9 E, E/ w7 K
(normal, 3 to 90 ng/dL), androstenedione was 20
% I# B8 ?: u% R9 ]+ x; Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 B2 @8 h* ^6 w* iterone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 N- V. F; l: H9 b, T2 V. \, Xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to, ]  r" O; R* O+ a4 j
49ng/dL), 11-desoxycortisol (specific compound S)& x) e6 M6 B8 }; G7 c6 J
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" s+ N5 ?$ U! ?. G# J" p! B
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 k" m, _8 K, w3 u9 x2 q, o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 h2 T- e# y7 V; J) G
and β-human chorionic gonadotropin was less than
) r5 n) B" \5 [  X. g5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ Q, O, K1 X. T8 p6 [stimulating hormone and leuteinizing hormone  ?) a% B( B4 a7 v4 {# F
concentrations were less than 0.05 mIU/mL
$ Q4 A" d; X% @# W3 |+ R* c8 Q(prepubertal).( o) j; G6 `. d6 w& t8 X; f: w* }
The parents were notified about the laboratory
7 u% F  {  U/ R3 B% gresults and were informed that all of the tests were
% b) A0 j3 Q8 R' Tnormal except the testosterone level was high. The
( C/ L7 a; @* mfollow-up visit was arranged within a few weeks to& |0 Y& x6 J- \# \+ O/ Q
obtain testicular and abdominal sonograms; how-
0 c* K! I* |& X5 o* n( s9 _* i' jever, the family did not return for 4 months.4 R0 p1 v9 r& Z9 H) j1 X" Q
Physical examination at this time revealed that the& d  I3 [% ?$ N/ k9 p
child had grown 2.5 cm in 4 months and had gained/ O4 o- J8 d( K, [; F2 f
2 kg of weight. Physical examination remained# M, M2 H8 ]& b. v: G/ O" T% t
unchanged. Surprisingly, the pubic hair almost com-
2 h& M5 {0 \" v# Z' T- p  d1 t% qpletely disappeared except for a few vellous hairs at
, k$ |* g7 a, othe base of the phallus. Testicular volume was still 2
9 @7 f2 {! v1 g4 m, KmL, and the size of the penis remained unchanged.3 ?" O- `6 H) G' B( {) c
The mother also said that the boy was no longer hav-) M: }2 X7 v4 z9 E) g
ing frequent erections.
) q0 ]! C& [5 Q9 J9 FBoth parents were again questioned about use of! w! n3 n- _- |9 V! R4 _4 p; t7 H* d
any ointment/creams that they may have applied to
, k' j! J, C0 g" I7 hthe child’s skin. This time the father admitted the: Y" ^6 k) x' M0 V4 o# S* K
Topical Testosterone Exposure / Bhowmick et al 5412 K, T6 `( ?, G- [9 K
use of testosterone gel twice daily that he was apply-
. {! S, t( K. U2 M% Xing over his own shoulders, chest, and back area for7 H4 w& }' p6 ^7 q. i
a year. The father also revealed he was embarrassed
" I4 K! n; `7 @4 W9 p+ {) Fto disclose that he was using a testosterone gel pre-
7 L3 }8 }+ ^, r6 H2 m8 S: Wscribed by his family physician for decreased libido
) m$ [% S8 T! ]0 ]9 Z: B" w, r& Csecondary to depression.
+ W* ?- R) D$ J% |0 v. ^$ mThe child slept in the same bed with parents.
% K6 A; L2 i8 D& {The father would hug the baby and hold him on his  P* h9 s9 w* X' A9 W
chest for a considerable period of time, causing sig-
0 O* @8 v/ |0 J0 Unificant bare skin contact between baby and father.' D) A" c1 K* l  O# b4 x
The father also admitted that after the phone call,
7 C7 i) s: J( |- e+ r, N( A6 Jwhen he learned the testosterone level in the baby
* k; |! p6 s6 c3 f/ ]' Z# v3 ~6 ?8 Swas high, he then read the product information
! y: x4 f0 g4 H+ `6 r8 V! |0 i& ppacket and concluded that it was most likely the rea-
1 v" o8 Z9 H3 w- }* Zson for the child’s virilization. At that time, they
/ I# l! w9 E/ H5 f, \5 t8 fdecided to put the baby in a separate bed, and the0 v( o5 f; _& i& h$ _; J4 u
father was not hugging him with bare skin and had& \2 r4 |% N) A0 g1 X2 p/ a( O
been using protective clothing. A repeat testosterone1 q  d/ U* s9 [* k) L
test was ordered, but the family did not go to the
/ N# M* g+ d0 ^6 F4 Flaboratory to obtain the test." Y! e8 p% [4 ]9 a2 C3 ?
Discussion' J$ n0 y3 \" {3 [+ \. _. A
Precocious puberty in boys is defined as secondary0 v3 U! ]0 F8 y/ ~: _* |
sexual development before 9 years of age.1,4
, ^- j; Q/ h3 a  bPrecocious puberty is termed as central (true) when
& @' ]$ f5 ~. ^# ait is caused by the premature activation of hypo-
6 N. I, _, I, @. P4 s4 a" g1 j- n0 Rthalamic pituitary gonadal axis. CPP is more com-5 H6 U1 S4 \1 m' m1 N
mon in girls than in boys.1,3 Most boys with CPP
' Y. [9 `" y4 }5 }! Pmay have a central nervous system lesion that is
+ s. k" H( I+ Z* G  L7 w& qresponsible for the early activation of the hypothal-
1 a% H4 Z# ~, t( ~amic pituitary gonadal axis.1-3 Thus, greater empha-' `5 W$ U+ ]) u# X0 @: c' p% I
sis has been given to neuroradiologic imaging in
1 ]& T9 V3 d( P8 g- z+ n% hboys with precocious puberty. In addition to viril-9 Z& O" ~% m6 i
ization, the clinical hallmark of CPP is the symmet-
, {+ B! ?2 H7 E9 o. B5 Vrical testicular growth secondary to stimulation by
0 U% B9 W! l: I0 b* q5 agonadotropins.1,3
; d- {' X6 v1 r# Z6 H, g+ zGonadotropin-independent peripheral preco-
+ j/ g* _3 P0 Z7 O1 Q. @cious puberty in boys also results from inappropriate2 q7 x: \8 t2 |# H. o
androgenic stimulation from either endogenous or
4 j6 }# f5 s* o7 k6 uexogenous sources, nonpituitary gonadotropin stim-
) u6 L: d0 P+ [; Wulation, and rare activating mutations.3 Virilizing: ]8 M+ m6 Y6 x9 f3 w. W
congenital adrenal hyperplasia producing excessive& t6 ~! M) {$ M0 I
adrenal androgens is a common cause of precocious1 U/ ?9 F$ U4 w- A
puberty in boys.3,4
2 L% y, M% N) S2 C: gThe most common form of congenital adrenal
1 J  y6 L* Q4 X3 T* D5 i$ Thyperplasia is the 21-hydroxylase enzyme deficiency.: e5 z; X3 G: h
The 11-β hydroxylase deficiency may also result in
$ I/ y! m9 q; T. p# Pexcessive adrenal androgen production, and rarely,9 p  t' o' J0 S. y6 V* M
an adrenal tumor may also cause adrenal androgen, H! F2 p2 F& I$ B
excess.1,3
& z0 k4 v+ m, N4 ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; [* c5 Y, C7 w5 s* C7 K542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 B8 N" @" C# O$ M0 V) O8 K
A unique entity of male-limited gonadotropin-" c+ _+ O7 S  U5 K3 h* K& @
independent precocious puberty, which is also known' u0 u8 ^2 S, }& t
as testotoxicosis, may cause precocious puberty at a/ Y3 p7 T5 o% ~2 D% |
very young age. The physical findings in these boys
; r; A+ _" B7 q* mwith this disorder are full pubertal development,
6 h, [. m# k' `+ p4 H4 Sincluding bilateral testicular growth, similar to boys" v+ q5 ]! ]2 V. v5 j) C" G
with CPP. The gonadotropin levels in this disorder
* {' d* E( ?, [! u: I1 Nare suppressed to prepubertal levels and do not show3 m7 C( m# k) L: l
pubertal response of gonadotropin after gonadotropin-: B0 [4 c1 l9 p9 f' ^4 T5 D$ t
releasing hormone stimulation. This is a sex-linked. B2 |/ ]1 T# y9 N9 \2 ~
autosomal dominant disorder that affects only
$ g, u' A! H5 N$ ?8 X) k9 Umales; therefore, other male members of the family$ E7 L4 K4 E& z
may have similar precocious puberty.32 r" D3 ]$ G+ ]% o
In our patient, physical examination was incon-1 h1 Q$ m; x1 u$ A$ r+ L
sistent with true precocious puberty since his testi-  H' J3 r$ T# y
cles were prepubertal in size. However, testotoxicosis9 P4 ^2 P6 H3 ?$ n" p
was in the differential diagnosis because his father5 [9 ]5 x3 H. `; s2 S; Z  S
started puberty somewhat early, and occasionally,' I. d* t1 Y9 D7 z4 J" _
testicular enlargement is not that evident in the
) z# x8 s" p5 H. vbeginning of this process.1 In the absence of a neg-
, t5 i/ B+ u! r0 v1 Z2 dative initial history of androgen exposure, our
. |3 y1 {) m( B& U, {; D2 c8 abiggest concern was virilizing adrenal hyperplasia,
  `+ {) W; a5 {1 w1 _8 Feither 21-hydroxylase deficiency or 11-β hydroxylase
5 w4 C; n7 b6 f* Pdeficiency. Those diagnoses were excluded by find-
) o- u& y3 c. n6 C% W" n' }) Fing the normal level of adrenal steroids.: f! r$ W* }0 G' z# K4 C* d" _1 W% {
The diagnosis of exogenous androgens was strongly7 y5 L& [3 D; ]9 l
suspected in a follow-up visit after 4 months because( F0 m' i9 o- L. V( _8 E7 Q+ G
the physical examination revealed the complete disap-) W& O7 Y" k. T# w. _) x' ?
pearance of pubic hair, normal growth velocity, and& _/ f0 `' Z3 x0 E. r
decreased erections. The father admitted using a testos-4 P, O+ R" |9 D2 O: H* C7 E( r
terone gel, which he concealed at first visit. He was# H+ ]- f9 Q3 O9 v; f% B' x
using it rather frequently, twice a day. The Physicians’/ g- D# S" @, U, `1 r* h) P
Desk Reference, or package insert of this product, gel or
  e8 j( N4 }' c3 H! }cream, cautions about dermal testosterone transfer to. J3 p/ x6 O9 n% a$ `7 i
unprotected females through direct skin exposure.
: H- Z' U- O# B* S7 |3 D+ \( T2 q3 m" NSerum testosterone level was found to be 2 times the& C& |: O  Z" Z
baseline value in those females who were exposed to
4 G0 N+ p6 E8 t3 \, |even 15 minutes of direct skin contact with their male6 ~& k3 c9 u1 p9 Q6 }0 o, q1 W
partners.6 However, when a shirt covered the applica-
; i/ W6 F! V' E* a7 }tion site, this testosterone transfer was prevented.
. z0 _: b7 O- i. YOur patient’s testosterone level was 60 ng/mL,6 F* U( C  i# X6 \' N) ]
which was clearly high. Some studies suggest that+ {: x0 A2 b! u' I. ~
dermal conversion of testosterone to dihydrotestos-
- N, j6 m7 t& aterone, which is a more potent metabolite, is more& I6 R% c1 a% j' f
active in young children exposed to testosterone. o  U; }1 {" t* Q4 e9 x
exogenously7; however, we did not measure a dihy-5 F2 n# X7 n% j/ c
drotestosterone level in our patient. In addition to
- v% b2 p- Z5 l8 L7 v. Jvirilization, exposure to exogenous testosterone in
& A; ]% L& Y4 h, m7 s! R! i% J) y0 _children results in an increase in growth velocity and
6 O; i0 k8 S# ]advanced bone age, as seen in our patient.  D/ A5 H$ a! y4 W2 E5 B' w
The long-term effect of androgen exposure during
* O3 Y9 V7 w7 eearly childhood on pubertal development and final
, W7 t5 X. D: |9 l9 \" f2 `2 radult height are not fully known and always remain
- W6 h. B* s# v# o, ia concern. Children treated with short-term testos-
$ {. [7 U% g8 d( `% q* v4 W& Sterone injection or topical androgen may exhibit some
+ c4 _. S7 u% ^/ X1 N9 f" q# c4 qacceleration of the skeletal maturation; however, after) S1 a4 x6 y& m" u0 \5 r5 _
cessation of treatment, the rate of bone maturation( Q3 C' N  A' k1 x1 e
decelerates and gradually returns to normal.8,9' P5 y! C2 |" F
There are conflicting reports and controversy2 z/ b2 y, N/ \
over the effect of early androgen exposure on adult1 Z! [% X* p5 G* Y2 |. D
penile length.10,11 Some reports suggest subnormal
) R' T. L2 t7 i9 T* B& g, ^adult penile length, apparently because of downreg-1 Z- l% O  i% v  h0 P0 U/ G9 l
ulation of androgen receptor number.10,12 However,2 ~* x- K" u$ z/ w; i. R0 `
Sutherland et al13 did not find a correlation between
( d/ k( h: \  O! ~2 @: J  ichildhood testosterone exposure and reduced adult* d  h& ?0 L/ }, [/ r- z7 d& l
penile length in clinical studies.
" v, P4 V7 A) U2 g: TNonetheless, we do not believe our patient is
2 K+ Q; x/ c- }) Vgoing to experience any of the untoward effects from& ^5 k* c, M( @  u$ b
testosterone exposure as mentioned earlier because
2 m( u, ~# n, d9 Fthe exposure was not for a prolonged period of time.6 e3 a3 \. _& q
Although the bone age was advanced at the time of8 }4 w! h  I* A" f" B
diagnosis, the child had a normal growth velocity at. h6 x( t6 A0 r
the follow-up visit. It is hoped that his final adult
" S/ I: U) a  o  Y$ |+ S/ @1 Nheight will not be affected.8 }2 ]; b" }! \
Although rarely reported, the widespread avail-- O; V# X6 ~0 e( a" i' b" R+ p" i
ability of androgen products in our society may
) P) c- T* _3 B  Tindeed cause more virilization in male or female
- K. u( W' T; O0 w" X: X' w$ tchildren than one would realize. Exposure to andro-
$ o% P3 a" J+ r( P9 Jgen products must be considered and specific ques-
% i: S& L# c2 W9 g' O  i# ptioning about the use of a testosterone product or
% |, |6 i9 W( E& Ngel should be asked of the family members during% j; x. H4 R/ k. ~; f
the evaluation of any children who present with vir-8 @6 X7 W4 e( b$ I
ilization or peripheral precocious puberty. The diag-2 M" k+ ]8 C" ^" u# `& @# Y
nosis can be established by just a few tests and by) p8 _! K- h8 }' J! m6 a# y7 C# ]
appropriate history. The inability to obtain such a
3 x+ v, o& f2 T: k3 h; Thistory, or failure to ask the specific questions, may
2 R* W5 m4 X+ I* dresult in extensive, unnecessary, and expensive6 w7 ^: f1 P2 c6 s$ d. H
investigation. The primary care physician should be9 l& W/ {5 \0 q  d
aware of this fact, because most of these children
; C2 q: B0 d: f( Z. m# f  [may initially present in their practice. The Physicians’
4 O+ q: g% m2 [' V. E' rDesk Reference and package insert should also put a
/ |/ l# h- u; F# ]1 t& _warning about the virilizing effect on a male or6 S' ~" V: \3 [% t. g! x
female child who might come in contact with some-( @7 g) I* d% ~) D$ U3 k, {2 o
one using any of these products.
& x/ @2 [/ ~9 X( w# @8 J/ ?# P8 XReferences" u: {- {. C# h: S* C4 ~* K
1. Styne DM. The testes: disorder of sexual differentiation
' W) b9 n# Y, b5 f  nand puberty in the male. In: Sperling MA, ed. Pediatric/ c/ G( Y' T' q0 u. {9 O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ l, v% M2 c& E% q3 r
2002: 565-628.
2 U, `9 u' \6 R! R5 h3 b2 D; R. c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! ^( k( {7 j9 c; ^, k+ V. B8 f
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) i1 b0 G. e3 W3 x- E
Boy Induced by Indirect Topical- N/ j4 w% p3 z$ T; J0 _7 t
Exposure to Testosterone0 y7 K/ m& e$ P6 M  W+ d# x3 ?3 R
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" n3 O& N- M0 j) ]
and Kenneth R. Rettig, MD1. ]: I' E9 y7 \& X. D' b( N' m% e
Clinical Pediatrics8 X; I. a0 y/ [# e: f7 A- `* T
Volume 46 Number 6# T. @" ^$ C1 j# M$ L
July 2007 540-543& L, {( v1 V8 T, F' \5 s3 l
© 2007 Sage Publications5 W$ ?* v8 H7 I& m# l' `
10.1177/0009922806296651
4 M1 D6 y$ ]  p0 D0 ohttp://clp.sagepub.com; U+ T) F' A: w; G/ V
hosted at! a1 W  s, t( v' c! }, D/ {
http://online.sagepub.com) |. U4 [; e; v" C
Precocious puberty in boys, central or peripheral,
( H1 @- [% o# p* E5 b/ lis a significant concern for physicians. Central5 J8 `3 U2 h9 G5 X; m/ ?
precocious puberty (CPP), which is mediated
3 Z+ g! `$ L- _+ A: i6 n  E7 Rthrough the hypothalamic pituitary gonadal axis, has1 g0 B) j1 D2 h3 Z
a higher incidence of organic central nervous system
- i. u/ }, b2 Z1 A: S& `8 L3 clesions in boys.1,2 Virilization in boys, as manifested
5 h1 W" ^& d( g. Yby enlargement of the penis, development of pubic' F+ `  X1 y2 B
hair, and facial acne without enlargement of testi-1 E* v2 i& h+ f2 E
cles, suggests peripheral or pseudopuberty.1-3 We
$ ?5 i- u) ]7 ?9 D9 }7 K' Kreport a 16-month-old boy who presented with the
  T3 M2 r( Y/ q2 c8 M& `' J, _enlargement of the phallus and pubic hair develop-+ U, J4 E  O! z9 @
ment without testicular enlargement, which was due
" d( Z# d# N0 b0 ?6 `8 Mto the unintentional exposure to androgen gel used by- K! o) E  |! ^6 R( c
the father. The family initially concealed this infor-- ]4 P. r( Q% E) }) K4 N1 o
mation, resulting in an extensive work-up for this
& `9 h1 D# F" }8 F3 N8 C- n) B* [child. Given the widespread and easy availability of
( b4 _' i& i! b0 d- stestosterone gel and cream, we believe this is proba-, V9 x" X; k# {) k9 Z# I
bly more common than the rare case report in the% k- J2 c- [8 [9 S
literature.40 @2 R/ a  g% W: M+ {# v
Patient Report9 ]  j8 r2 E+ E; L# N$ |
A 16-month-old white child was referred to the
! s; N9 y$ X6 `7 ]+ \endocrine clinic by his pediatrician with the concern
% ]8 k' w( V" b2 v6 i1 Dof early sexual development. His mother noticed/ k! [- l, i7 g- M! c
light colored pubic hair development when he was
0 E! @8 p+ }3 iFrom the 1Division of Pediatric Endocrinology, 2University of
* c. @1 a/ B- F5 `( @" fSouth Alabama Medical Center, Mobile, Alabama.7 ^3 V8 l3 ]) J/ S% \
Address correspondence to: Samar K. Bhowmick, MD, FACE,# \) R( \* x- T6 K$ W
Professor of Pediatrics, University of South Alabama, College of
) b( m  `* u) b( ]! ?4 z  lMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 u' b' V& K8 x2 T4 S1 Je-mail: [email protected].  c# @$ Z8 w9 }+ R
about 6 to 7 months old, which progressively became' v, C/ d/ d/ z+ y* i  ?5 S
darker. She was also concerned about the enlarge-. [6 F4 @, D- y( N# z6 X
ment of his penis and frequent erections. The child
& j* n; \- l4 d8 |* f$ ?2 _was the product of a full-term normal delivery, with& N/ K" f, o6 e) Y: t& A! h
a birth weight of 7 lb 14 oz, and birth length of
8 [; u! w  M9 e: }20 inches. He was breast-fed throughout the first year6 _4 E2 z0 @2 h( m! z- L5 n
of life and was still receiving breast milk along with
+ U* w" L% y) @2 msolid food. He had no hospitalizations or surgery,
0 o4 A4 w& B) I6 {; @and his psychosocial and psychomotor development
) }" `& t9 i$ t- N7 D( \was age appropriate.: L- T" C# f7 _" d$ ~
The family history was remarkable for the father,' W+ L+ a6 W0 E
who was diagnosed with hypothyroidism at age 16,
; r' k1 v- C9 K% Hwhich was treated with thyroxine. The father’s
1 V( Y* A! t/ v3 B# U7 zheight was 6 feet, and he went through a somewhat
& \1 w1 K. W" J8 G( Learly puberty and had stopped growing by age 14.
# |( ]8 K5 C0 `" CThe father denied taking any other medication. The, ^  n. l7 T' N* F' W- d
child’s mother was in good health. Her menarche, y  N9 ]$ ~8 }( K( c
was at 11 years of age, and her height was at 5 feet
( O' F0 F- ^6 V! ^5 _5 inches. There was no other family history of pre-
% m2 L8 y+ ^- Q3 L8 W3 P1 L: w; C4 \cocious sexual development in the first-degree rela-, I. G: s  B/ j9 f% ~$ q/ \" k7 p
tives. There were no siblings.: l) K8 N( C3 e! S! w; e2 `
Physical Examination
* T8 n% Q, d0 I% u$ U! ZThe physical examination revealed a very active,
$ ?# P$ ^9 q, i5 ~# e; D1 oplayful, and healthy boy. The vital signs documented6 n) `/ ?7 T9 E& r8 `2 j  x! K
a blood pressure of 85/50 mm Hg, his length was
, F0 T; P% T9 l) i90 cm (>97th percentile), and his weight was 14.4 kg8 B. @+ [$ \6 O2 w
(also >97th percentile). The observed yearly growth4 P; [& ]/ Q4 m, a4 z
velocity was 30 cm (12 inches). The examination of
' }( p2 r) l" g7 w" qthe neck revealed no thyroid enlargement.. I$ O' f$ y3 R" C
The genitourinary examination was remarkable for' U  o3 g8 U3 h1 V9 ~7 |4 e
enlargement of the penis, with a stretched length of
, t$ ]5 h& z( F. p7 R1 Y- w8 cm and a width of 2 cm. The glans penis was very well* ~( d' {) B0 m5 D! n. Q
developed. The pubic hair was Tanner II, mostly around
6 u$ R* J) g! Q+ g6 P/ V540
6 c" _& j6 q- k4 n# ]' U+ J/ tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! `$ U$ V, i5 I$ ]" }" V( W  w) c8 Hthe base of the phallus and was dark and curled. The
  m# Z" N" a6 y- `' b3 }testicular volume was prepubertal at 2 mL each.9 A0 B0 Z2 U% ~. \( v
The skin was moist and smooth and somewhat
% j/ C+ }) r) S7 y4 w& _  Doily. No axillary hair was noted. There were no" `4 J2 @+ B7 n: ?  f2 [5 w' v
abnormal skin pigmentations or café-au-lait spots.
/ S; o9 {& y# n/ Y! iNeurologic evaluation showed deep tendon reflex 2+
& e2 Q" x5 r: v4 i+ \+ f! tbilateral and symmetrical. There was no suggestion
* N9 O  K9 t( g: L7 n2 m: Vof papilledema.
8 ^- V* g0 L% N9 r6 Z) A( Z- B! _Laboratory Evaluation" ^4 r* t2 S* a: h1 b4 Q
The bone age was consistent with 28 months by1 q0 Q( O2 m7 Q6 Y
using the standard of Greulich and Pyle at a chrono-0 G* S8 k- e" P( y0 c0 z- x  ?
logic age of 16 months (advanced).5 Chromosomal5 R! V( n) K" j7 H" W
karyotype was 46XY. The thyroid function test
, C; }+ }  m  [, t% Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: p4 Q0 G3 p$ a4 j- Elating hormone level was 1.3 µIU/mL (both normal).7 q5 g* v2 }$ Q& c3 K
The concentrations of serum electrolytes, blood) [$ Y4 A$ s0 ^2 d  [8 d2 u
urea nitrogen, creatinine, and calcium all were
+ {) ]9 A! b7 H) C0 K3 Twithin normal range for his age. The concentration
/ ?8 j3 `/ j4 D5 `7 s, [, w: ]of serum 17-hydroxyprogesterone was 16 ng/dL; ?- ^& b1 i* {: u+ T' D
(normal, 3 to 90 ng/dL), androstenedione was 20
$ E. P2 ]7 d' h# t6 G) Sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, T* E2 H) A+ H" D# S3 }terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 B  A. p3 y, J* M1 L- G! ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) y; t7 S5 Z: ?; a% y4 N; T49ng/dL), 11-desoxycortisol (specific compound S)
& D& U3 F: ?# N6 Fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% C: D' ]. s& d$ |8 K) htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 F6 V. @! l# t: Y( \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 c, o# z# E; q9 v$ A/ c: D2 Q
and β-human chorionic gonadotropin was less than) e! _9 E" Z( b* ?+ N" b
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( y' N% _$ P, j$ j" Z( s8 t+ |stimulating hormone and leuteinizing hormone3 T  ]/ T$ S/ m" [; }9 D  k( o: `
concentrations were less than 0.05 mIU/mL, C9 P. P2 B  P4 \1 p% V9 K
(prepubertal).
/ O9 z  j* L. Q; g3 \The parents were notified about the laboratory* Q# A$ ~. `" @* a/ |  n
results and were informed that all of the tests were
6 d' U% @- `* ~! {7 I4 ]normal except the testosterone level was high. The
2 D7 p. C# P) }  i; lfollow-up visit was arranged within a few weeks to  p5 x. X8 e* V+ _) c; O, s
obtain testicular and abdominal sonograms; how-
( q1 q7 I& l# f3 L! sever, the family did not return for 4 months.  A& J0 p) V. y# l0 L; T- h
Physical examination at this time revealed that the
  A( T5 j8 c  t& g+ f: }% \, schild had grown 2.5 cm in 4 months and had gained
, a. c; K9 l& `; G6 N7 R; U2 kg of weight. Physical examination remained
0 s0 b1 G  Q7 U: g  R4 p3 v$ U: [unchanged. Surprisingly, the pubic hair almost com-6 e" c8 \; M/ L1 g( x1 e
pletely disappeared except for a few vellous hairs at
$ o2 S* A4 F  ~% d2 ]0 W& Gthe base of the phallus. Testicular volume was still 2
! u* S; p! g# _8 ~mL, and the size of the penis remained unchanged.
# j* x, n$ P0 a+ \! d4 h7 OThe mother also said that the boy was no longer hav-, _2 w5 h6 p  Q
ing frequent erections.
5 z  |- W$ ~1 M2 _* K' s* n* T8 GBoth parents were again questioned about use of
9 m, \$ ]4 |4 j9 H* N& Hany ointment/creams that they may have applied to
$ M; Y) n6 x6 ~, Q- f4 z2 Zthe child’s skin. This time the father admitted the) ]4 p$ a6 E! K- D( `- C
Topical Testosterone Exposure / Bhowmick et al 541
$ l  ]/ @3 z. t. ^) ~2 K- x# huse of testosterone gel twice daily that he was apply-6 n! f# _; f+ H  y& [; g) P
ing over his own shoulders, chest, and back area for
$ m; b$ i( `" ]a year. The father also revealed he was embarrassed
3 G8 Z+ L4 [1 U% }' B  Zto disclose that he was using a testosterone gel pre-6 l3 S" o; }% V* Z$ z# x
scribed by his family physician for decreased libido) h/ J$ U) [- h0 Q: p
secondary to depression.
# M. Z7 {) J9 @7 f1 aThe child slept in the same bed with parents.3 K6 Q  S9 \" |
The father would hug the baby and hold him on his
  [0 |: @1 |. h6 K  Y! L" |' nchest for a considerable period of time, causing sig-
( K, e% w* u0 ?: Lnificant bare skin contact between baby and father.
! w% d' j) n( nThe father also admitted that after the phone call,
  b- I; c# U+ U4 K, M% \when he learned the testosterone level in the baby. a* r7 L0 R7 k2 |
was high, he then read the product information
7 M" p  h+ S, M( E. tpacket and concluded that it was most likely the rea-
$ {6 v3 Z* s! ison for the child’s virilization. At that time, they  k, ^6 k# z+ L2 [7 L
decided to put the baby in a separate bed, and the  P4 @2 D+ m& W7 M
father was not hugging him with bare skin and had
& G* o7 o5 s" v1 O, z" rbeen using protective clothing. A repeat testosterone
* \$ `6 w6 y- w) P/ @test was ordered, but the family did not go to the% {1 X; T7 {4 d* d; r( z6 L
laboratory to obtain the test.
# ?; D- a2 @: C) j6 {+ a9 r; BDiscussion
% R: k6 A6 b9 C$ {+ P0 q% tPrecocious puberty in boys is defined as secondary
6 r9 ?6 @: b1 F' h9 ^sexual development before 9 years of age.1,4
6 n7 m! T1 p) ?( z- G+ ^Precocious puberty is termed as central (true) when5 ^4 i# b+ v  D6 a
it is caused by the premature activation of hypo-- K1 [% R, x0 T# X3 f6 a
thalamic pituitary gonadal axis. CPP is more com-
7 w3 |# L% w: Lmon in girls than in boys.1,3 Most boys with CPP
- k& p! W' g+ H! t0 {( cmay have a central nervous system lesion that is  e5 q* c- l% J; F0 o1 l6 [; ]
responsible for the early activation of the hypothal-+ e" K! H1 H3 j7 p: B
amic pituitary gonadal axis.1-3 Thus, greater empha-8 l3 w0 s: j- {; q2 P: O
sis has been given to neuroradiologic imaging in) K# I$ }  I4 M
boys with precocious puberty. In addition to viril-5 D1 R# r# K& c: U6 W+ e5 u% \
ization, the clinical hallmark of CPP is the symmet-1 H* J# M4 C3 u: t* K
rical testicular growth secondary to stimulation by
$ u( W: V' B3 S  K; qgonadotropins.1,3
- o; R, W  Z9 t" ~# a7 JGonadotropin-independent peripheral preco-
* R+ A, W4 `, {cious puberty in boys also results from inappropriate
# Q) {2 t# d* M: w) [androgenic stimulation from either endogenous or
- A4 _2 V: g, q+ `  N1 B, K3 s6 a- lexogenous sources, nonpituitary gonadotropin stim-
: y$ j. o8 v% y/ |3 E2 eulation, and rare activating mutations.3 Virilizing
3 t' ]& }6 w8 r  acongenital adrenal hyperplasia producing excessive4 G6 f% v1 b; f( w2 y; p+ t) y
adrenal androgens is a common cause of precocious
. V0 d: \' h, `2 j+ B; ?puberty in boys.3,45 D5 z5 R# X8 o) T: e
The most common form of congenital adrenal
: c" |8 H9 P  K- Y  Xhyperplasia is the 21-hydroxylase enzyme deficiency.
& l- U6 r- `! u2 W- `5 M; O6 L2 CThe 11-β hydroxylase deficiency may also result in$ m8 s% u% T. T4 ^) e9 [
excessive adrenal androgen production, and rarely,+ N/ c: [: C& n8 p5 X4 j
an adrenal tumor may also cause adrenal androgen3 |' r4 z) V# k1 @. f  u
excess.1,3
  Q  }3 l2 x( r2 P! T' J6 v) p7 l4 s: yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 w' Z1 |6 ^9 x- [! A4 A/ V
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 p- g  p0 j+ S! x2 y- cA unique entity of male-limited gonadotropin-
: _5 W* I1 r6 g& W+ |0 Qindependent precocious puberty, which is also known
& m' v, y! o) T8 d( zas testotoxicosis, may cause precocious puberty at a
+ N; C- Y& `1 S7 z. Avery young age. The physical findings in these boys2 k7 r# G: q; E! p1 J7 I" X6 ?
with this disorder are full pubertal development,: r. z! a- {4 T' h% l4 X+ g
including bilateral testicular growth, similar to boys
) b) s1 V+ w9 j/ {7 g9 Uwith CPP. The gonadotropin levels in this disorder
) H9 I+ E& r6 Z, H' W$ A; g6 Kare suppressed to prepubertal levels and do not show+ `, U7 S7 w/ s- |2 C' u( X
pubertal response of gonadotropin after gonadotropin-
. w3 w5 U( @. C2 N% \% sreleasing hormone stimulation. This is a sex-linked
7 J) s) o/ f) \) }' Q/ t. ]1 H. G# `autosomal dominant disorder that affects only
! f! M* g' B& u0 Q9 i4 E' K' _males; therefore, other male members of the family
/ u2 V7 d9 M  O  fmay have similar precocious puberty.3- e: n# O4 o% W  S5 ]4 ]
In our patient, physical examination was incon-. v5 d3 r0 P0 B  [' \
sistent with true precocious puberty since his testi-  p8 t- [# x0 t8 S) g% B. _
cles were prepubertal in size. However, testotoxicosis
1 a- ~' E& l3 t; m) l4 Zwas in the differential diagnosis because his father! w; C: z( r  j; k% H* i4 p
started puberty somewhat early, and occasionally,
6 m. @5 S# a- y" Q( x& q/ R) Otesticular enlargement is not that evident in the% u" Q6 }+ e. X* g8 J9 C& i+ P6 G
beginning of this process.1 In the absence of a neg-& A* {0 n5 B$ G. {7 T( w, W9 o1 `
ative initial history of androgen exposure, our
7 \& {: p3 f1 k% kbiggest concern was virilizing adrenal hyperplasia,5 \% d' ?* X- ]
either 21-hydroxylase deficiency or 11-β hydroxylase
! P( @0 {- f1 ], tdeficiency. Those diagnoses were excluded by find-
5 E7 u9 r# t6 _ing the normal level of adrenal steroids.
" j4 S1 t1 k) M; N+ zThe diagnosis of exogenous androgens was strongly
) u3 \6 s2 u' e3 _& Xsuspected in a follow-up visit after 4 months because
; Z, g2 Z; u5 ^) m/ tthe physical examination revealed the complete disap-; F  w* I. v& q
pearance of pubic hair, normal growth velocity, and
! {3 H' J- Z: y; C$ hdecreased erections. The father admitted using a testos-
0 e; t2 d! p- l) o' w' l/ dterone gel, which he concealed at first visit. He was5 I! F# [& L: n+ F5 z4 R
using it rather frequently, twice a day. The Physicians’: C+ n2 t7 l3 k' J$ Z4 `
Desk Reference, or package insert of this product, gel or; P" M# u$ E. Y. [
cream, cautions about dermal testosterone transfer to% F' c/ r2 w# J7 V
unprotected females through direct skin exposure.2 @) Q* j& E. Z9 R6 \' c) @! r
Serum testosterone level was found to be 2 times the2 F; @( c" |- d7 L0 Q* {& l
baseline value in those females who were exposed to" ?: c  Q  u" x3 O
even 15 minutes of direct skin contact with their male* q6 ?5 ~/ r3 P8 f( J
partners.6 However, when a shirt covered the applica-
3 ~* E3 O1 Y  g: i6 ltion site, this testosterone transfer was prevented.
) @6 h4 I# y) M( a; H" TOur patient’s testosterone level was 60 ng/mL,( |) F9 ]! A6 f$ H4 E/ s' C
which was clearly high. Some studies suggest that2 l5 n4 Z7 F$ n9 V4 @- V2 X% H. _
dermal conversion of testosterone to dihydrotestos-
: w/ z/ E5 F3 i! j( @9 gterone, which is a more potent metabolite, is more
9 X4 }* u) h( [0 ?; vactive in young children exposed to testosterone
4 T& J5 I6 ?  s, Gexogenously7; however, we did not measure a dihy-1 F# F4 [# T& \0 z/ u) o3 i
drotestosterone level in our patient. In addition to" ?9 ^& V- Y+ g/ j9 v
virilization, exposure to exogenous testosterone in
4 X( ?. N0 ~6 f8 w, P0 fchildren results in an increase in growth velocity and
" u" x/ H# M  b- I5 ~, M) J8 I* L- madvanced bone age, as seen in our patient.# e: [8 R) D1 N0 C7 R
The long-term effect of androgen exposure during) p. r4 R5 G' e$ }) m8 I5 ]0 e
early childhood on pubertal development and final
+ u, J# M/ f, z- p9 P1 ]( {' nadult height are not fully known and always remain
4 B  x7 T8 z; F, T; V" j4 na concern. Children treated with short-term testos-3 s7 t$ u1 d: V3 i
terone injection or topical androgen may exhibit some, P, D* B8 Y5 P$ c
acceleration of the skeletal maturation; however, after
7 v5 K& X% m' ocessation of treatment, the rate of bone maturation
% k, E6 G0 x; n* A9 J- F7 R6 @decelerates and gradually returns to normal.8,95 V6 ~6 {8 k- h
There are conflicting reports and controversy1 z( N" g4 n' |; m5 ^1 i2 N" H
over the effect of early androgen exposure on adult* A# c! @7 T5 B1 ~" c8 g" i: m2 N
penile length.10,11 Some reports suggest subnormal
. A2 t/ D  I: H0 B$ z$ f5 ]adult penile length, apparently because of downreg-
- i0 G2 @9 [+ M4 Kulation of androgen receptor number.10,12 However,
; V1 C% y% O; ^7 A: b" SSutherland et al13 did not find a correlation between
. K* ?7 b+ r3 @2 A0 O9 echildhood testosterone exposure and reduced adult
5 F- k  o2 f* m6 d5 W5 Kpenile length in clinical studies.+ B( ?' j" V* ?6 }( X
Nonetheless, we do not believe our patient is) m- M& h# p& j
going to experience any of the untoward effects from8 j, r7 A1 ?- w" k/ P5 M' o
testosterone exposure as mentioned earlier because
/ l) G* n: ]0 d; Ithe exposure was not for a prolonged period of time.3 |* Q' T% U/ I9 j; S4 y1 ?
Although the bone age was advanced at the time of* n5 R# c* L! A: Q
diagnosis, the child had a normal growth velocity at* q5 A# O4 O5 c* ^# q
the follow-up visit. It is hoped that his final adult
& n$ |$ G7 u, y$ cheight will not be affected.! I* W7 T) L, ^( [6 G
Although rarely reported, the widespread avail-/ g# f' u. B# J) q% o
ability of androgen products in our society may
* w* `( I2 z& j2 A/ dindeed cause more virilization in male or female/ [! D. U' R/ a+ [
children than one would realize. Exposure to andro-+ J$ R: j) V8 T3 B& I
gen products must be considered and specific ques-
8 g% @; k6 h# C6 ktioning about the use of a testosterone product or
9 M) f' j0 y/ i: p% \. Lgel should be asked of the family members during
" I1 W# L  C& xthe evaluation of any children who present with vir-. U& i% X( \5 i8 A
ilization or peripheral precocious puberty. The diag-3 v" Y3 J0 n& |
nosis can be established by just a few tests and by
, z. P$ f) [2 D( o4 d& lappropriate history. The inability to obtain such a
% w0 U2 a6 l  K1 Z" W9 W, ]history, or failure to ask the specific questions, may
* Z% w- ^5 W. J0 z* Q% g" ]result in extensive, unnecessary, and expensive
! r$ X5 T* M) L& M/ Linvestigation. The primary care physician should be: t& A- J" f+ b
aware of this fact, because most of these children
% b6 {( t5 `$ d4 `: G0 S. `may initially present in their practice. The Physicians’
9 P$ S) M  _% g! y/ r5 d+ b7 iDesk Reference and package insert should also put a- Y. K( L. A% P8 g
warning about the virilizing effect on a male or; P1 [# S: i/ ?! b, ?, E2 a9 b
female child who might come in contact with some-
7 x7 R( n7 U8 J& kone using any of these products.
( R: \+ S( s: d/ dReferences
+ C$ G6 N& d; K0 P1. Styne DM. The testes: disorder of sexual differentiation
4 |6 k9 I" \0 S6 s  H; K- ]and puberty in the male. In: Sperling MA, ed. Pediatric# f) j. ?2 {. d( {2 s0 y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ h: Y1 W& P1 D+ A* }
2002: 565-628.
" U- q2 r1 N$ \& j1 w; x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 k+ S8 Y* G4 _+ Bpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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

0 p% y7 O7 H3 b, C% I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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