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Sexual Precocity in a 16-Month-Old
7 ^4 X4 R2 ]+ C. F) LBoy Induced by Indirect Topical
0 G: H& {! G+ qExposure to Testosterone
. w( |! S& r. ]: Z) w  }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* V% A$ P9 h- o! z2 w5 w/ Wand Kenneth R. Rettig, MD1
' y% t6 b( m$ v( y1 Z; ]Clinical Pediatrics1 P( y$ C) H) f- l2 @& Y" W- V
Volume 46 Number 6
# z8 G4 e! `# @, H  ?1 V" G1 q% fJuly 2007 540-543
- f+ O4 V% k' R3 X( T© 2007 Sage Publications) z7 A: ]9 F* p' ?( N* b
10.1177/0009922806296651# U( t7 H7 S4 |- [& q
http://clp.sagepub.com; H2 l* D  p: x0 u! C" ?% N2 ]$ v
hosted at
$ ?' [5 l! Q$ H/ i% Y5 a) @0 Lhttp://online.sagepub.com1 }8 P$ R4 y  C* h
Precocious puberty in boys, central or peripheral,
0 u6 E4 W5 S# M% V: e! d, p+ Gis a significant concern for physicians. Central
& m; J* t( K- ~, ]$ [& N: N" cprecocious puberty (CPP), which is mediated: V/ m" Y* L% @+ ]" Z3 I% s
through the hypothalamic pituitary gonadal axis, has, L( f0 ~/ y4 @' Q5 u$ {
a higher incidence of organic central nervous system; l- K  L) t0 \3 b, {# v9 P
lesions in boys.1,2 Virilization in boys, as manifested# N: ]8 @% V, A8 y* Y% K" O
by enlargement of the penis, development of pubic( Y+ K3 x4 S& e6 z- A
hair, and facial acne without enlargement of testi-
" Q* {, W# F* t. j% _, Hcles, suggests peripheral or pseudopuberty.1-3 We
( O3 Q! A/ W( f0 L) {% O$ Wreport a 16-month-old boy who presented with the
8 d& a, u" `" U0 k' senlargement of the phallus and pubic hair develop-
0 p9 g$ r& _" @: |: {; c& Yment without testicular enlargement, which was due) P/ s0 }6 Q" o* r& E- i4 p
to the unintentional exposure to androgen gel used by
1 f- C6 @# g8 b) x2 C$ J( @: _the father. The family initially concealed this infor-& B+ r8 p5 p4 z6 S4 p
mation, resulting in an extensive work-up for this
; `# ^+ A+ q0 N) F% ?' r, d% F$ Echild. Given the widespread and easy availability of3 r3 @3 E* u9 d$ E; k) J
testosterone gel and cream, we believe this is proba-
# f6 n. X% O3 }* x6 e/ g  s5 gbly more common than the rare case report in the
! p! C9 p4 L) Mliterature.4
. c9 B3 k# q6 ^/ CPatient Report
/ n* E) G8 X; J5 _: QA 16-month-old white child was referred to the
+ ?0 T; [5 l0 Z8 o0 `' Gendocrine clinic by his pediatrician with the concern
) ^1 W& h$ m; d3 f, Jof early sexual development. His mother noticed
9 }6 |+ V9 [3 I: ~5 [+ D' Q$ Qlight colored pubic hair development when he was3 r' c/ N8 w7 {! S
From the 1Division of Pediatric Endocrinology, 2University of
/ z- ?. J8 C' rSouth Alabama Medical Center, Mobile, Alabama.7 T5 n5 M$ w" q3 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' d& ?' d' Y( G( U* y4 BProfessor of Pediatrics, University of South Alabama, College of
# s4 `+ @6 k* z+ ~' _" RMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# D0 r* a9 ]" \e-mail: [email protected].3 O" Y5 u6 J$ |5 x/ e' T
about 6 to 7 months old, which progressively became
+ P0 L4 |: p) y' N8 m, d6 Zdarker. She was also concerned about the enlarge-
6 U$ I6 }, l9 x0 l7 [# jment of his penis and frequent erections. The child( t6 \/ N! }; i# q( ~8 D' v$ u5 k
was the product of a full-term normal delivery, with7 w2 T/ E* R5 B* N4 O- I1 {! R! m" H
a birth weight of 7 lb 14 oz, and birth length of
3 N/ s0 n% |! E0 m& I20 inches. He was breast-fed throughout the first year: }) d2 u6 t; x* U9 I& g2 f
of life and was still receiving breast milk along with
- a* L+ `$ x3 \; v8 L  C7 |8 F3 Rsolid food. He had no hospitalizations or surgery,( b) d& N. m* y: ?0 u
and his psychosocial and psychomotor development% K0 b+ x5 y7 |; D
was age appropriate.
7 ^1 t) Q, z, ^3 T& e2 Q. ]- s1 XThe family history was remarkable for the father,
* e& R8 ^8 e% S  bwho was diagnosed with hypothyroidism at age 16,# V- c+ f4 [' a3 K" M
which was treated with thyroxine. The father’s- j  R* C$ e" H1 k& Y
height was 6 feet, and he went through a somewhat, l+ h; d* G9 a. |8 i/ F
early puberty and had stopped growing by age 14.9 g8 ~2 K4 ?5 A" A( q: [- A
The father denied taking any other medication. The
( u" f% j+ A9 Lchild’s mother was in good health. Her menarche
+ ^3 q" ]7 ~# U( w" a6 H5 U) twas at 11 years of age, and her height was at 5 feet* T6 K0 Q! a0 T# w! q$ c. k
5 inches. There was no other family history of pre-
2 I9 c7 z/ a: B, e/ w; b! \cocious sexual development in the first-degree rela-
4 e/ y% H+ e0 xtives. There were no siblings.* U% p( V8 y2 F$ Q$ l& s5 D" s2 |
Physical Examination/ J% F( s0 Q1 F( k& U8 }2 v
The physical examination revealed a very active,
  ]; O! f( Z3 N, i+ ^( a, X( xplayful, and healthy boy. The vital signs documented; c5 F* ^" [' t8 r) \
a blood pressure of 85/50 mm Hg, his length was
. P1 ?$ A# e0 V9 _$ `2 ~' Z90 cm (>97th percentile), and his weight was 14.4 kg) c  p3 ]$ c" {2 M0 Q
(also >97th percentile). The observed yearly growth
  V& c1 _# t4 Y8 L, p* Vvelocity was 30 cm (12 inches). The examination of- Q$ F" y" K5 F8 `  R" a8 }
the neck revealed no thyroid enlargement.5 _. _4 E: z$ x
The genitourinary examination was remarkable for1 Z  e8 O+ g6 d; c6 b: g) F2 v$ k7 l
enlargement of the penis, with a stretched length of- |4 [% G) i! U- O7 J
8 cm and a width of 2 cm. The glans penis was very well. y! b: M0 D; W: p+ }6 P' g; @
developed. The pubic hair was Tanner II, mostly around. z  s* D' j9 R* E
540; y+ o% q% b. A5 b: T' W% F$ r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* Q8 ~* l9 L1 c+ ~7 }6 kthe base of the phallus and was dark and curled. The7 q+ L$ u! g8 r. P" G
testicular volume was prepubertal at 2 mL each.; ^$ R% a$ Q/ ~
The skin was moist and smooth and somewhat
# R( Q) [; W6 e( V$ w4 J( i; r9 Y3 W! Poily. No axillary hair was noted. There were no
! }  g7 g: f; p6 ]5 dabnormal skin pigmentations or café-au-lait spots.0 {  _! a2 k9 S& S* d
Neurologic evaluation showed deep tendon reflex 2+
: s0 k. e7 Z; u3 z( L8 ]0 z  qbilateral and symmetrical. There was no suggestion" s+ g; F7 G* j$ i% w2 F5 G9 \
of papilledema.- s5 k; G( p8 N6 L
Laboratory Evaluation
3 k1 M  m  ~! i' o& c' G0 _* o+ w# eThe bone age was consistent with 28 months by* I! A$ o! W" ^# w
using the standard of Greulich and Pyle at a chrono-. k5 T2 K3 M; O+ Z
logic age of 16 months (advanced).5 Chromosomal& h* N4 R2 }; P; C
karyotype was 46XY. The thyroid function test
+ V& O! G+ o- _9 oshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
: _) C  C2 c& o, Ilating hormone level was 1.3 µIU/mL (both normal).
- H  c! F& M' N7 j5 O+ X0 a, r" aThe concentrations of serum electrolytes, blood
5 @% z7 r5 _7 r$ ?. Q# Gurea nitrogen, creatinine, and calcium all were
! [5 d5 S! F% f2 Q" F! l" Xwithin normal range for his age. The concentration- [9 C$ e8 V1 D8 W' C, i% E. S
of serum 17-hydroxyprogesterone was 16 ng/dL
' G( S6 J9 ?0 B8 u$ F: u7 P(normal, 3 to 90 ng/dL), androstenedione was 20
1 h; u3 g9 x8 l4 ^$ f6 |0 E6 ]9 kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- W" J  w; n( L) S' ?3 x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 `& A* K2 N* }) `& M1 a9 `" }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# h- ]6 E5 H: K( Y49ng/dL), 11-desoxycortisol (specific compound S)
, x3 m9 g7 G, [6 Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 ~( c/ @: V6 ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 P" B. P% a4 n: O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 q; k' e2 X. j) ?8 ^and β-human chorionic gonadotropin was less than9 ]; p, f5 \  v4 t1 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
+ o0 \8 q/ `' Q: W8 X3 Dstimulating hormone and leuteinizing hormone
6 U7 o% s% B! S% `concentrations were less than 0.05 mIU/mL
8 `0 e# Y/ D/ z! {# J4 c(prepubertal).2 ^; x' E+ X* o  W* g+ i; C
The parents were notified about the laboratory
* c) ^* v( O- X8 T) C1 t3 }results and were informed that all of the tests were
! T2 H) c4 x& G3 x: ?, snormal except the testosterone level was high. The$ ], D/ @$ F8 K! ~* I
follow-up visit was arranged within a few weeks to0 S, W/ d9 ~) Q: x0 L- F0 Z
obtain testicular and abdominal sonograms; how-4 D. u' F8 F. ~9 b" ?( k# o
ever, the family did not return for 4 months.) y) t7 A" j" t) F7 h# E0 _' J! x$ `: g
Physical examination at this time revealed that the6 N3 K% {$ ~5 b5 M1 N# V
child had grown 2.5 cm in 4 months and had gained0 }$ A5 S" m9 y) y* Z8 k3 s" I& Q
2 kg of weight. Physical examination remained+ p+ {  w& n8 Q0 M; n0 l
unchanged. Surprisingly, the pubic hair almost com-
+ u! `5 C4 Y8 opletely disappeared except for a few vellous hairs at# r( z+ ~: f1 l: p. Q
the base of the phallus. Testicular volume was still 2! |' l6 ~. A" z" ~0 |; V) t
mL, and the size of the penis remained unchanged.$ c! G5 o9 X/ d
The mother also said that the boy was no longer hav-9 _% t2 X  y" L
ing frequent erections.6 b6 D( P! u: X. o9 `% M
Both parents were again questioned about use of
# w! m: F0 {* d( I) Yany ointment/creams that they may have applied to
9 T2 z6 B2 b) r- Z; h6 mthe child’s skin. This time the father admitted the
* \- b1 x1 u, s5 STopical Testosterone Exposure / Bhowmick et al 541
: ^& ?3 ~% ?# s* q3 ruse of testosterone gel twice daily that he was apply-3 A1 O* F, o; x! n9 C# A
ing over his own shoulders, chest, and back area for
' c  v  H/ M  I: \/ ?: aa year. The father also revealed he was embarrassed5 Q( M( y! ?' @8 f+ r: a1 ?& F
to disclose that he was using a testosterone gel pre-1 o* B% s  Y+ Z5 A6 |# w8 [% F/ N
scribed by his family physician for decreased libido
7 C) k  M( ]: {secondary to depression.) W. ?. e  s6 y8 r5 f( h4 Z  V
The child slept in the same bed with parents.; l) I+ W0 j) d# g3 [
The father would hug the baby and hold him on his- s6 C! l( \0 l( Y; Y/ ?$ N- K+ e
chest for a considerable period of time, causing sig-, r/ @' G( H( {% h& L( {# @
nificant bare skin contact between baby and father.
0 Y$ a' ]$ r# @The father also admitted that after the phone call,
& i  @$ e! K& \$ G- Owhen he learned the testosterone level in the baby
- }. {0 U& `8 Q8 d* O, o9 F. Nwas high, he then read the product information4 H( Z* T$ w& m0 z4 G& `4 }; ]7 c
packet and concluded that it was most likely the rea-
4 S% [8 X9 b- b. k" Gson for the child’s virilization. At that time, they
1 z, g( U6 f6 a/ O( B9 W6 z  Ndecided to put the baby in a separate bed, and the
5 S" V+ ^& o' i( I; L2 S8 A& }father was not hugging him with bare skin and had
( V1 z! R  n- l4 M( z! N. {been using protective clothing. A repeat testosterone! }4 ~& q" y) K% o% e7 }
test was ordered, but the family did not go to the4 c/ P; ]7 Y* W2 k1 ~: k) @
laboratory to obtain the test.) l3 E4 D6 X1 b8 ?& j. l
Discussion
$ t) I7 O9 G& c+ D  u1 l) y, PPrecocious puberty in boys is defined as secondary9 c8 S3 f1 O& u( k* |" m) |+ X6 T% f
sexual development before 9 years of age.1,4. Z8 z" [6 q/ l! P$ z' ~
Precocious puberty is termed as central (true) when
9 k$ d" f/ I+ P7 Fit is caused by the premature activation of hypo-
6 p, X7 g9 l" U7 a& x: t. hthalamic pituitary gonadal axis. CPP is more com-7 [: K4 T! I0 D' y6 h' J9 Y7 p
mon in girls than in boys.1,3 Most boys with CPP& z$ O( Y: \3 h$ t
may have a central nervous system lesion that is
. p- p8 ^% ^& ?  n! y* A+ _* h4 Dresponsible for the early activation of the hypothal-& p; m# \. I+ X( S& D9 z6 P
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 |- p8 B# {8 a4 Dsis has been given to neuroradiologic imaging in/ l- S) \. K. ~5 h8 Z. a* F
boys with precocious puberty. In addition to viril-: z) y  r, x! c5 K2 t
ization, the clinical hallmark of CPP is the symmet-
# _% e- v9 e5 R" _rical testicular growth secondary to stimulation by
" F# O2 r' w: e% q- Jgonadotropins.1,37 W4 K1 ~* g7 A
Gonadotropin-independent peripheral preco-
9 y7 }9 |" g  X& m* K- fcious puberty in boys also results from inappropriate
6 }: F9 X, O; a7 z8 Candrogenic stimulation from either endogenous or+ {" Z# p3 o+ s+ t! a7 C- ?
exogenous sources, nonpituitary gonadotropin stim-
, F' m7 {& J; T& ?& o& |. bulation, and rare activating mutations.3 Virilizing
; v) Q9 H( V) Q) |7 Y9 ~- \2 x+ D0 ucongenital adrenal hyperplasia producing excessive$ s8 s$ j$ x/ w0 I: H
adrenal androgens is a common cause of precocious
- u0 }6 T$ P# g4 hpuberty in boys.3,4; v( x( i! \0 N( x
The most common form of congenital adrenal
* i0 f$ s; X- ohyperplasia is the 21-hydroxylase enzyme deficiency.
, E' p9 I+ Q. s: f# AThe 11-β hydroxylase deficiency may also result in
- J6 ?& R8 l3 o9 ?. z+ O  Aexcessive adrenal androgen production, and rarely,1 ], Y$ ]# R9 B# v
an adrenal tumor may also cause adrenal androgen4 h9 ^* Y* E$ i. O
excess.1,30 x3 D: X. O5 }4 k, `7 d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ ?3 g8 w% K2 g& x4 Q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" Y7 f: P: k4 j) t/ {; [; nA unique entity of male-limited gonadotropin-
7 |+ e( Z+ Y. w, N: J, @8 ?independent precocious puberty, which is also known
% s7 ^+ B, ^1 A! yas testotoxicosis, may cause precocious puberty at a) [3 g" Y/ U9 _% R
very young age. The physical findings in these boys
+ L( o3 u1 A! {! twith this disorder are full pubertal development,1 Y0 A+ V, ?8 P  o4 k8 j
including bilateral testicular growth, similar to boys$ P6 w& g2 I' L1 u( d4 x1 n. w, a  g
with CPP. The gonadotropin levels in this disorder
( u2 ~& Y! d. _$ K9 s# Qare suppressed to prepubertal levels and do not show
. r7 a! I# C( spubertal response of gonadotropin after gonadotropin-  t; w9 k* x3 V; ?* M) k
releasing hormone stimulation. This is a sex-linked
% H# J3 @- @5 k( Rautosomal dominant disorder that affects only/ F; o8 t% C0 H: B( S" G
males; therefore, other male members of the family! u, @9 R. j* T5 q* I( Q
may have similar precocious puberty.32 @* f0 I' O. n8 X* C- r) z& z& J
In our patient, physical examination was incon-# w. i6 a1 g  [  v
sistent with true precocious puberty since his testi-( V$ T$ O; J% ~, M
cles were prepubertal in size. However, testotoxicosis
. K1 K1 Q: q: I% G3 awas in the differential diagnosis because his father
9 L3 ~/ M- U( o% c5 T# W/ E: _started puberty somewhat early, and occasionally,! ?) {6 O1 k8 O4 s0 [  \
testicular enlargement is not that evident in the
5 \, x5 L2 p6 [  P  ~* p5 kbeginning of this process.1 In the absence of a neg-
* d- D* F% y, kative initial history of androgen exposure, our
; j: n  ?# L5 l0 Y; Abiggest concern was virilizing adrenal hyperplasia,5 V1 Z$ D, k- v5 J: G3 W( C, B! p- V2 H
either 21-hydroxylase deficiency or 11-β hydroxylase. d4 d( Z0 f, W8 T# m3 o3 _( {
deficiency. Those diagnoses were excluded by find-
* Q5 X8 c2 v5 F4 L" g8 `3 ^$ Y/ King the normal level of adrenal steroids.
- T+ j" }3 ]# l& T0 N: f& |' hThe diagnosis of exogenous androgens was strongly
- C: F0 q1 G! Q0 X, d4 gsuspected in a follow-up visit after 4 months because4 `) O/ R  a$ J
the physical examination revealed the complete disap-8 g1 C/ ~, y! w! ^+ Q9 r
pearance of pubic hair, normal growth velocity, and" A/ }# H  J& f& M& Y6 \& \
decreased erections. The father admitted using a testos-
/ g& w! J: U0 e/ b) @; ?; Lterone gel, which he concealed at first visit. He was# |' k- `) q+ q& |
using it rather frequently, twice a day. The Physicians’
# p: v0 E( [$ ^6 X* [, Z8 j* g5 pDesk Reference, or package insert of this product, gel or
! S/ ]1 Y4 l8 d* p+ xcream, cautions about dermal testosterone transfer to8 Z) a: v; y1 G* Q$ C) S% C# W
unprotected females through direct skin exposure.
) B# {8 ^. g) `! p9 Q8 Y/ v% ~1 R: C6 o+ OSerum testosterone level was found to be 2 times the
0 B5 G6 j) Y9 t# r7 ?baseline value in those females who were exposed to) w4 a4 e8 N  _0 `5 h5 w
even 15 minutes of direct skin contact with their male
$ }. d( p. N2 K: p1 e8 j+ ipartners.6 However, when a shirt covered the applica-
# a" c$ E2 ^0 ation site, this testosterone transfer was prevented.% ?4 Y: z( w2 ?6 ?; n
Our patient’s testosterone level was 60 ng/mL,
. ~$ B3 m9 V/ S0 ]2 G& pwhich was clearly high. Some studies suggest that
! _) q9 S2 E# ^$ zdermal conversion of testosterone to dihydrotestos-
. t. P3 r0 @6 m! x! {terone, which is a more potent metabolite, is more4 a8 f+ v$ `; h$ V$ S2 C, w1 G
active in young children exposed to testosterone- o' E9 K: n' S! t$ \( d: \1 |/ V
exogenously7; however, we did not measure a dihy-, c' M0 k  p% K" |+ e' A! r: D; l
drotestosterone level in our patient. In addition to1 X. u$ M. h% b; X& j
virilization, exposure to exogenous testosterone in4 {, b( [/ x' k' C
children results in an increase in growth velocity and
* j/ `. I5 S$ g* S! ~advanced bone age, as seen in our patient.% U% P7 e0 W# Y
The long-term effect of androgen exposure during# f  S! O' v7 Q, t
early childhood on pubertal development and final
) j4 }% p4 V  X* j/ o4 Cadult height are not fully known and always remain  x: y; A. @& G" R, s+ g3 V2 I9 v
a concern. Children treated with short-term testos-
& u* @* B) Q, u' P. Uterone injection or topical androgen may exhibit some
7 J2 D) z$ l1 F3 `2 yacceleration of the skeletal maturation; however, after
4 e- U4 w3 Q& \0 A5 d1 |5 zcessation of treatment, the rate of bone maturation
6 c* P& F6 [: X( V2 Jdecelerates and gradually returns to normal.8,9
* {  F" w6 f" V. G5 M$ @There are conflicting reports and controversy' X) X) @. z1 G5 D
over the effect of early androgen exposure on adult: s2 w2 c0 P( K  k2 r% r, B) i$ K
penile length.10,11 Some reports suggest subnormal0 b9 Y1 w: j! T$ [
adult penile length, apparently because of downreg-0 y" C% N! l0 u, p
ulation of androgen receptor number.10,12 However,
& u3 z6 i0 V  G; MSutherland et al13 did not find a correlation between
8 a( E* |# y. l% v2 w# mchildhood testosterone exposure and reduced adult7 G& f- o9 c/ h/ s; s5 ~
penile length in clinical studies.7 Q$ x  ?6 U9 g5 D) O  I" Y
Nonetheless, we do not believe our patient is0 g: z8 n, [$ P( ]
going to experience any of the untoward effects from7 \. D9 K3 X9 C3 M+ B8 H. A
testosterone exposure as mentioned earlier because$ j2 O& L  ?# m
the exposure was not for a prolonged period of time.% B1 V0 n5 l; }  Y$ V+ M1 K
Although the bone age was advanced at the time of
9 e9 F/ x) @0 U3 Idiagnosis, the child had a normal growth velocity at
* A8 y* T3 n4 K1 \/ kthe follow-up visit. It is hoped that his final adult
1 `+ t* C3 H1 hheight will not be affected.7 L- _; n3 c: j& F0 c3 K; L
Although rarely reported, the widespread avail-+ I/ S1 m1 E6 h* O6 z, [! s
ability of androgen products in our society may
. Y$ {3 M* R3 ]( N8 W( z% Sindeed cause more virilization in male or female
; k. Y4 m: o' [3 ^% nchildren than one would realize. Exposure to andro-1 |3 U# I0 b) q* d
gen products must be considered and specific ques-+ h! Q5 g: R) X* F9 H7 C3 c
tioning about the use of a testosterone product or# l9 d' Y, ~! B& c7 ^0 U
gel should be asked of the family members during/ ?, e, ^8 N, I9 a4 a4 F
the evaluation of any children who present with vir-0 Z3 o/ R* \) ]7 t
ilization or peripheral precocious puberty. The diag-
2 \4 V* Y" k$ u9 B  U! gnosis can be established by just a few tests and by) b+ a' i# e+ L
appropriate history. The inability to obtain such a3 o# m$ D9 |* N& O1 |
history, or failure to ask the specific questions, may
" b. R0 ]+ K9 L% Yresult in extensive, unnecessary, and expensive
$ F$ ~2 {% j$ Rinvestigation. The primary care physician should be# x5 z' h5 o3 m, b6 T' |
aware of this fact, because most of these children9 k) R0 _5 J- k
may initially present in their practice. The Physicians’- R! u' d7 k0 |2 I  t3 u8 H
Desk Reference and package insert should also put a
$ P1 P$ R: X# n9 [9 Q: G' Z2 ?! [warning about the virilizing effect on a male or
; i9 z2 R* v" H' afemale child who might come in contact with some-7 C7 k4 a5 g4 D: X! u# t; \- C
one using any of these products./ r5 {# l% Y- s6 w
References
( }6 G5 d, @  d, b1. Styne DM. The testes: disorder of sexual differentiation; D5 _" d! U" e9 v6 Y1 X- q, l
and puberty in the male. In: Sperling MA, ed. Pediatric
: e9 l) Y! Y* a2 Y1 r8 B0 d6 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 I4 T4 J3 f9 B7 ?: C# r2002: 565-628.- \& j  C. g* D; V
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 V, p- ^7 v/ F
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
8 y6 o$ `* f, M! {' N9 uBoy Induced by Indirect Topical  V* C; x4 C- Q: I3 y/ q2 r3 q
Exposure to Testosterone6 W& d! r3 ]9 q* f) {1 L0 s$ i
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ o5 S+ ^" {$ I  S2 n; w; b) H
and Kenneth R. Rettig, MD1
3 ?  ~. ?5 l" Y- T; HClinical Pediatrics; U' F% W" u% m  C: c
Volume 46 Number 6
2 J: V, r# Y2 o% F0 K! ^July 2007 540-543' H# @8 ?1 G+ [! H! Y' {& T/ A
© 2007 Sage Publications' e8 S# Z6 x0 `: j5 F" U+ J  e
10.1177/0009922806296651
$ G+ F" T! R' O5 Ohttp://clp.sagepub.com5 T* S& ^( A; ^6 m9 X6 M
hosted at
, E/ q9 S5 E; i; Vhttp://online.sagepub.com
0 x- J) j# ?  [* h& yPrecocious puberty in boys, central or peripheral,
9 ]& E0 I+ ?% \/ v, w! Zis a significant concern for physicians. Central
% n6 R8 v8 j  ~# p3 Qprecocious puberty (CPP), which is mediated! a- ~; D: n5 D* O5 t( k
through the hypothalamic pituitary gonadal axis, has
  R" _& Z; L  U) n7 s0 {" Za higher incidence of organic central nervous system
1 y6 s7 d6 }* e) r- H5 klesions in boys.1,2 Virilization in boys, as manifested
: U6 f- l% F8 ~+ s$ yby enlargement of the penis, development of pubic" A1 b. F9 q8 h4 i
hair, and facial acne without enlargement of testi-
+ X0 _0 i7 P( Z9 ycles, suggests peripheral or pseudopuberty.1-3 We
* }% D4 a+ z2 m/ `& ~% treport a 16-month-old boy who presented with the, t5 w! N$ Y" B* e% N8 N
enlargement of the phallus and pubic hair develop-
0 b+ c9 m* Z. E: t: H6 Qment without testicular enlargement, which was due
. N6 [- D: ^8 I% u' s$ o" I8 |to the unintentional exposure to androgen gel used by% D1 u$ ]' v3 w+ a2 x4 B
the father. The family initially concealed this infor-
% M1 {  G2 v1 b# l  emation, resulting in an extensive work-up for this
. v9 T* c0 \" y1 }: p/ f' Dchild. Given the widespread and easy availability of
7 _* N  ~* T  j/ b1 f! J2 q" z  Ttestosterone gel and cream, we believe this is proba-; W, ?; M  s9 b$ B# X- e  I8 m
bly more common than the rare case report in the
. L) R2 G/ g3 C* Y+ lliterature.4
% q$ ~% P" a' c# [9 W/ \0 GPatient Report# a: m# l4 ^  T7 q( w" E/ J; k
A 16-month-old white child was referred to the; u, }' J& v! L, o' K. d% Z
endocrine clinic by his pediatrician with the concern
$ `& S% C# P8 O0 b# pof early sexual development. His mother noticed
) w2 Z# l; m7 i* z6 h$ Jlight colored pubic hair development when he was3 u6 M. m4 {, w; u' t
From the 1Division of Pediatric Endocrinology, 2University of1 V+ S  E, s) }- C4 s% {% u
South Alabama Medical Center, Mobile, Alabama.
) J* P$ J) Y, N" K1 `% ]Address correspondence to: Samar K. Bhowmick, MD, FACE,7 Q  C. L/ H/ M  `! U* K2 `
Professor of Pediatrics, University of South Alabama, College of
4 C# c- s& n* Q# }2 aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" ]# M( n+ z" ~  d' \% k; X- P  M- Ve-mail: [email protected].  j7 S; L( @4 o) S3 d. W
about 6 to 7 months old, which progressively became; B. Z5 K5 K' Q4 @% g7 P# n
darker. She was also concerned about the enlarge-# A* s* S! @- w& H
ment of his penis and frequent erections. The child
# \3 \' w) e8 n- ?# s2 @  N4 s: Nwas the product of a full-term normal delivery, with; w" z0 {" Y7 a' P
a birth weight of 7 lb 14 oz, and birth length of
6 k1 E" A: `4 ?" a7 U$ I20 inches. He was breast-fed throughout the first year, r$ P7 J4 p/ K' O! d
of life and was still receiving breast milk along with
5 I+ Q6 J6 O, ]3 w" psolid food. He had no hospitalizations or surgery,
( Q9 ~! u$ `  V6 t- A: r! Tand his psychosocial and psychomotor development
! \8 T- H* [* }was age appropriate.1 O" C/ \% }" j2 Z
The family history was remarkable for the father,& O2 Y- g! W! z+ K; P1 V
who was diagnosed with hypothyroidism at age 16,
# q: T! h8 p! @which was treated with thyroxine. The father’s
# _2 ~; K8 a& p  \; Eheight was 6 feet, and he went through a somewhat
9 B' c+ B' ^  G& A# s* `% [early puberty and had stopped growing by age 14.
  A* v% ~7 _# lThe father denied taking any other medication. The
& Q# X. Z% W. L3 r- ~9 Mchild’s mother was in good health. Her menarche% D, m& P- j) C7 }  G( s5 O
was at 11 years of age, and her height was at 5 feet, _5 o7 G; r) h8 ]+ P; B
5 inches. There was no other family history of pre-* n) C4 U: n7 _' u. s, Z, k  {
cocious sexual development in the first-degree rela-
8 I: I% w1 e' N/ J0 A: dtives. There were no siblings.: _- E$ a. e) k% B  s4 w
Physical Examination' G3 k7 ?2 ?, w% ]3 J
The physical examination revealed a very active,
( f' P0 k0 J. u/ W4 Gplayful, and healthy boy. The vital signs documented# f- O) u- z2 Y8 w/ k
a blood pressure of 85/50 mm Hg, his length was/ b  {" j0 X1 m& L) j* {7 B
90 cm (>97th percentile), and his weight was 14.4 kg
  T% |; g# b8 ^7 X(also >97th percentile). The observed yearly growth9 A3 k5 ^. e$ W0 Y' z: a$ l
velocity was 30 cm (12 inches). The examination of
  m8 |4 A5 ~4 y* qthe neck revealed no thyroid enlargement.$ u7 f' a  h4 y% {$ Q& ?
The genitourinary examination was remarkable for* I$ T: q+ k( ~6 @
enlargement of the penis, with a stretched length of
# t, i. e7 P$ u( o8 cm and a width of 2 cm. The glans penis was very well2 c! t$ M% O' I- ~& r
developed. The pubic hair was Tanner II, mostly around# Q8 B# Y! U# B7 D2 T! j) Y9 b* U9 H
540
8 i6 F! y* J3 z! q- e* ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, G$ D9 U6 b. ?6 M$ `
the base of the phallus and was dark and curled. The
5 D3 j1 x- y6 L; p6 Itesticular volume was prepubertal at 2 mL each.9 s8 v2 _% M. k6 i. ^% S% @$ ?; Q
The skin was moist and smooth and somewhat
3 ^% ~- h8 `0 ?- noily. No axillary hair was noted. There were no
! }0 {2 V+ V/ [0 H8 D1 f: Mabnormal skin pigmentations or café-au-lait spots.: f0 r$ I% _0 e1 R5 P
Neurologic evaluation showed deep tendon reflex 2+' g5 n$ K" R2 F0 w- `
bilateral and symmetrical. There was no suggestion8 p* L! ]; ~( D( v$ O2 S0 d
of papilledema.
$ _' ^( N$ w- b) b6 r8 k/ A9 TLaboratory Evaluation+ @0 z7 L- y8 O+ L' A& ^( h
The bone age was consistent with 28 months by
6 b- G$ B  \* m& W' Lusing the standard of Greulich and Pyle at a chrono-
) w% e1 Z1 {/ c  f4 A( t/ llogic age of 16 months (advanced).5 Chromosomal* X7 ^5 M  \4 {  g, V# c
karyotype was 46XY. The thyroid function test
, h8 |5 H1 c6 `showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 L. a( p" Y0 T* \
lating hormone level was 1.3 µIU/mL (both normal).& h8 S# J& @4 }0 w* K
The concentrations of serum electrolytes, blood8 f( z9 X( F$ n
urea nitrogen, creatinine, and calcium all were8 o: n8 Z6 W3 I/ ?
within normal range for his age. The concentration% v. _- x% v4 i2 T$ l1 O; t: r
of serum 17-hydroxyprogesterone was 16 ng/dL, k2 x  z: ~$ ]" s8 y
(normal, 3 to 90 ng/dL), androstenedione was 20* c( W# Z  y: ]( u3 T! H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ D; J5 g- q8 l7 T' [. Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& z/ C0 |, \: xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 \* Z/ C6 i1 X+ ^8 d# e49ng/dL), 11-desoxycortisol (specific compound S). R4 F; r; A0 b7 G" @" t* L) q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. u0 Z; f) b+ c2 K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( N5 q* s( [, L4 Y, P! E2 ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; _/ S2 |& ]1 b& O
and β-human chorionic gonadotropin was less than' n0 V: h6 U5 p( S& ?6 u! B1 ^% U; h
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 K2 _& p4 @$ ^% U! F' U& X
stimulating hormone and leuteinizing hormone. d( C/ U! n6 Z4 ]
concentrations were less than 0.05 mIU/mL0 ?% D4 c3 l* O; u9 B
(prepubertal).% s8 G& W$ g7 v4 i/ n7 q0 P- H
The parents were notified about the laboratory
& W$ O5 z% ?5 ^' H7 m7 Aresults and were informed that all of the tests were
8 e9 }$ b. Y. G: M: \6 vnormal except the testosterone level was high. The
+ J+ \" I3 u4 }" s9 I$ ?: ]7 Jfollow-up visit was arranged within a few weeks to
- Y3 j2 r$ o/ a% I2 bobtain testicular and abdominal sonograms; how-/ b: k0 x6 \0 r! K( ~9 R
ever, the family did not return for 4 months.
  ?: m$ r. t5 k, V4 N" @  @Physical examination at this time revealed that the1 i) F$ R% |- |: w  z( Y
child had grown 2.5 cm in 4 months and had gained6 e9 y+ W% h$ ]
2 kg of weight. Physical examination remained1 o2 K0 f5 m# u$ A: \1 u8 ^
unchanged. Surprisingly, the pubic hair almost com-
  m) v8 J3 p+ Q8 B8 z; [  Dpletely disappeared except for a few vellous hairs at
- Q7 o6 G+ E- {$ Q+ u7 l6 cthe base of the phallus. Testicular volume was still 21 i6 C/ r5 h) a5 k$ @
mL, and the size of the penis remained unchanged.
- C0 K6 L: ^! A. S( r( JThe mother also said that the boy was no longer hav-0 _0 ]! F6 a, i6 W" M% [7 K7 n
ing frequent erections.2 ^) P5 Z3 p% f+ c8 m
Both parents were again questioned about use of
, t; ~; x3 y+ Cany ointment/creams that they may have applied to
; {; ?/ b" W2 I9 L1 p0 M% lthe child’s skin. This time the father admitted the
6 q6 d: K) [2 h1 {Topical Testosterone Exposure / Bhowmick et al 5415 c) t) E, o0 H! s2 |5 V
use of testosterone gel twice daily that he was apply-
+ k( D1 e& H- P+ L3 ning over his own shoulders, chest, and back area for
0 ]! x, d6 N( F  o) b: J$ Ca year. The father also revealed he was embarrassed
+ f$ T* R0 y" C+ n/ Lto disclose that he was using a testosterone gel pre-
( G" N5 e* K% e( P. p7 F& ?/ |scribed by his family physician for decreased libido
& W8 i  l4 S: G, n2 Y5 F6 y  D2 }secondary to depression.# I' r' i4 S) F) {
The child slept in the same bed with parents.; c: b: B  U0 B/ k' Y
The father would hug the baby and hold him on his7 @& ^0 N) g' m$ w' d( w0 i
chest for a considerable period of time, causing sig-- Q5 N, c, V: |% p8 _
nificant bare skin contact between baby and father., R9 c& g$ h6 ^  R: e) M# n; E
The father also admitted that after the phone call,
2 I9 K3 ^( w2 ]# V! Swhen he learned the testosterone level in the baby9 n, Z5 p1 B1 y" ?/ K- ?6 E2 C
was high, he then read the product information- F7 j$ h$ b& ~/ H# d, `0 j
packet and concluded that it was most likely the rea-
9 T* x2 f" L  [' w" Yson for the child’s virilization. At that time, they
0 q: c) d$ p, \: u/ Idecided to put the baby in a separate bed, and the; s( x7 w$ \  S- P# k) j$ t! B  c
father was not hugging him with bare skin and had
* m3 ?8 e1 w# c0 S7 mbeen using protective clothing. A repeat testosterone! }  l5 z+ H, a; n2 Z
test was ordered, but the family did not go to the) W# m, A' q: w
laboratory to obtain the test.
/ I" ]9 ?% w3 @0 Z; ]/ P) TDiscussion; g, Z! l( S! o6 f
Precocious puberty in boys is defined as secondary9 Y3 D& r  \' ^" A4 M
sexual development before 9 years of age.1,4: j$ [7 j' g# a' m5 j
Precocious puberty is termed as central (true) when
" \1 w$ ]7 e- u$ R2 q3 }it is caused by the premature activation of hypo-
( O% f, }7 Z6 {" K5 ithalamic pituitary gonadal axis. CPP is more com-
' [- ?& M# M6 y! U5 zmon in girls than in boys.1,3 Most boys with CPP8 V" Y/ A  [; O/ H& b
may have a central nervous system lesion that is/ t9 g6 T8 D* A0 _9 |$ A
responsible for the early activation of the hypothal-  Z) g& x$ d1 T
amic pituitary gonadal axis.1-3 Thus, greater empha-7 G! U: u- d  p1 N  ]
sis has been given to neuroradiologic imaging in
" |' g; D4 B# s2 v; a2 xboys with precocious puberty. In addition to viril-
5 s# @( i/ u) ]- D+ [ization, the clinical hallmark of CPP is the symmet-
& _/ n+ ]& G4 Krical testicular growth secondary to stimulation by0 K9 [3 X8 U, u3 @
gonadotropins.1,3
; D" W" W0 t2 A* ]9 z- iGonadotropin-independent peripheral preco-1 ^7 ^! ~. V: c% ^8 H& U
cious puberty in boys also results from inappropriate" m, n7 h  M# D! N3 f3 z% b3 D
androgenic stimulation from either endogenous or7 ^! ^+ N+ _5 [1 R5 `
exogenous sources, nonpituitary gonadotropin stim-/ m( C; {& G' L! A4 w& j
ulation, and rare activating mutations.3 Virilizing0 e# d. r  N+ n" H( d/ T, t3 h- A
congenital adrenal hyperplasia producing excessive
) U- X- ~" O) {adrenal androgens is a common cause of precocious
1 {' V0 p- f) b: s- ]3 kpuberty in boys.3,4
- |- E0 ?! Y4 L  x" e( JThe most common form of congenital adrenal
' F* o  p. U3 R; O  h7 j0 Shyperplasia is the 21-hydroxylase enzyme deficiency." T2 ]* }9 p9 r' U' Y, g, U2 B
The 11-β hydroxylase deficiency may also result in! w. ]: v2 c5 `/ g  C3 m& N  }
excessive adrenal androgen production, and rarely,
3 t" p% I3 H6 wan adrenal tumor may also cause adrenal androgen3 Q& `+ }& P7 |4 K7 j6 D
excess.1,34 ~* M% Y  k8 c' ?2 h+ x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 v+ y- ]% e( R+ Y7 \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; L8 q, P  N- i( R% m4 D, l: C
A unique entity of male-limited gonadotropin-
: v  Y4 }1 [' S7 ]0 G" O" O9 O* D4 Kindependent precocious puberty, which is also known
" t/ R; Q2 t" Pas testotoxicosis, may cause precocious puberty at a0 _. w7 Y  r. p
very young age. The physical findings in these boys
7 @5 l$ x4 m) d4 b. D. Dwith this disorder are full pubertal development,
5 v" d$ p4 O& F( Y3 D2 k; a) A  Wincluding bilateral testicular growth, similar to boys
9 k. z/ U0 T  W2 K- g5 ]  Fwith CPP. The gonadotropin levels in this disorder7 J% b# H; Z8 M
are suppressed to prepubertal levels and do not show1 j9 t% r) J6 k, M2 G
pubertal response of gonadotropin after gonadotropin-5 K* u5 Z6 x1 f* ]- ~8 a
releasing hormone stimulation. This is a sex-linked
4 e9 D5 A% ?0 c& e" @autosomal dominant disorder that affects only4 e: \9 M* G- N* V2 |) p
males; therefore, other male members of the family- j6 x6 @1 M+ G! h$ @
may have similar precocious puberty.3
  H; y. L+ o7 M$ @0 S4 rIn our patient, physical examination was incon-
7 n( H  Z/ O+ \7 F4 Q, Msistent with true precocious puberty since his testi-/ T* y+ k8 v) ?, x& p
cles were prepubertal in size. However, testotoxicosis
. Q0 F7 Y& o% v& a& h, kwas in the differential diagnosis because his father
/ f; }$ J6 ]1 K" e. T) Astarted puberty somewhat early, and occasionally,% @4 K5 f  y: P) B9 [; d
testicular enlargement is not that evident in the0 Y, o1 F$ s" z: n* a
beginning of this process.1 In the absence of a neg-
' O2 R3 v# J2 W! d1 j: t! t( \& dative initial history of androgen exposure, our1 ~1 F. t. R0 b) E1 Z
biggest concern was virilizing adrenal hyperplasia,
( m& d! a" }" R; e9 a: k+ U) e- ^1 X: Neither 21-hydroxylase deficiency or 11-β hydroxylase9 x& e3 i, ~" t5 r
deficiency. Those diagnoses were excluded by find-  j1 j/ A; O9 e' U  b& I) p- p2 @
ing the normal level of adrenal steroids./ Q2 Y  N+ ~* z
The diagnosis of exogenous androgens was strongly
# }6 j8 V: |$ \! W7 |suspected in a follow-up visit after 4 months because0 V0 f9 t  s( A6 m$ x7 I- A* }
the physical examination revealed the complete disap-
% s% B# T* c4 O0 Zpearance of pubic hair, normal growth velocity, and
3 Q1 W, S0 S) v* W1 Sdecreased erections. The father admitted using a testos-
+ T! G! n$ }7 S7 H4 t2 b6 d9 C# _% xterone gel, which he concealed at first visit. He was% y1 i$ {& e- n1 ?2 o
using it rather frequently, twice a day. The Physicians’
  q" B" a" ]& g) JDesk Reference, or package insert of this product, gel or
7 r* b/ ?$ l$ J* l/ E* acream, cautions about dermal testosterone transfer to
0 B* Z3 S  Q5 \! @6 h" k- Y% xunprotected females through direct skin exposure.( A3 `  x) r  A+ Y& r/ B4 ]' k
Serum testosterone level was found to be 2 times the5 C$ L9 N. a: {4 C( N
baseline value in those females who were exposed to$ f( F' ^* u( `; I
even 15 minutes of direct skin contact with their male6 O% O0 {" D9 r! \
partners.6 However, when a shirt covered the applica-' T7 o' }- L7 `/ C5 M
tion site, this testosterone transfer was prevented., B2 o: Z: C; `" u: r# M; c8 n* x3 n
Our patient’s testosterone level was 60 ng/mL,
7 X  t- a- c' s" N# e6 m& g3 ]which was clearly high. Some studies suggest that
2 u3 p% `, g) ~2 ]9 Tdermal conversion of testosterone to dihydrotestos-
+ f2 |5 Y. J3 I$ xterone, which is a more potent metabolite, is more/ K5 d) {3 U& b7 R
active in young children exposed to testosterone
' n$ j8 E' c* E5 Wexogenously7; however, we did not measure a dihy-. `  q; P: L  s* L$ a+ l
drotestosterone level in our patient. In addition to
' M, r5 T  s  u' s* n1 O# ovirilization, exposure to exogenous testosterone in
! Y) h% C, k9 e5 I2 e* }children results in an increase in growth velocity and
0 J, G& J4 E1 G; Xadvanced bone age, as seen in our patient.
, C8 X* h- [0 v' S* y7 X" CThe long-term effect of androgen exposure during, C/ ?  H# L" |$ v: j
early childhood on pubertal development and final4 c' E" k% E2 Y9 `' k
adult height are not fully known and always remain3 X- e' i2 e4 O. y
a concern. Children treated with short-term testos-) [0 t5 |1 F: E6 ~. N
terone injection or topical androgen may exhibit some
- d" `, M. P# l* }# |5 Kacceleration of the skeletal maturation; however, after6 j: M5 R5 ]' J5 J$ P1 T3 h: S7 i
cessation of treatment, the rate of bone maturation
, K! v5 |7 D( q! m. n" [decelerates and gradually returns to normal.8,9
, i( Q* s7 ]! `; u$ v& qThere are conflicting reports and controversy5 N& O5 d/ n3 L. f  b9 K+ ?$ G
over the effect of early androgen exposure on adult
- ~/ Q1 w% Z8 xpenile length.10,11 Some reports suggest subnormal/ t: o, l, w) C/ r
adult penile length, apparently because of downreg-  s, ^# f) X3 X! S* P& L
ulation of androgen receptor number.10,12 However,, Q$ X" r0 U* [: m
Sutherland et al13 did not find a correlation between
8 [2 o: l" D8 Y9 s) ~1 ^childhood testosterone exposure and reduced adult9 H+ K& i, F: l( |
penile length in clinical studies.
: x: R. Q- q, D) SNonetheless, we do not believe our patient is# {3 {  D/ z1 D; ^. q
going to experience any of the untoward effects from
; S) `5 u0 J9 c- a' ttestosterone exposure as mentioned earlier because9 R: l8 I% K9 O7 ?/ a! f0 t
the exposure was not for a prolonged period of time.* e; Y% |! p% b: c$ C% c
Although the bone age was advanced at the time of: b' c  }0 i4 t6 ]5 O
diagnosis, the child had a normal growth velocity at
6 `* }: o) j. p9 U: _# ethe follow-up visit. It is hoped that his final adult* k+ F. B1 T/ ]2 M' ?
height will not be affected.
$ Z$ E- B* }# V$ E2 VAlthough rarely reported, the widespread avail-
1 {( ~- f$ D8 {! E+ fability of androgen products in our society may
% W: v, a/ g* T' n( b1 E2 `, N; Vindeed cause more virilization in male or female9 ]/ H: |+ p2 A3 g, M
children than one would realize. Exposure to andro-, t6 `/ I  P# }" ?8 D
gen products must be considered and specific ques-
! j  o+ N" W7 t8 g, d! b) Ptioning about the use of a testosterone product or
  N- j, m, x) ^4 X9 j8 V! a& T; dgel should be asked of the family members during
1 n: M/ `% f4 H8 d& ]5 K, Dthe evaluation of any children who present with vir-  M9 C% ~( r  ^/ q
ilization or peripheral precocious puberty. The diag-
" z( |/ @, o9 x, a( a& t. snosis can be established by just a few tests and by
' E0 D' N1 }& ^. Eappropriate history. The inability to obtain such a
$ q/ S3 E4 W( Uhistory, or failure to ask the specific questions, may6 k3 S$ V# F1 J% f: Z0 P- h3 m
result in extensive, unnecessary, and expensive
+ u% H( k6 u2 y" ^investigation. The primary care physician should be
' |% `- o; L+ z2 Saware of this fact, because most of these children
4 W6 n- f1 R  Y5 w# ?# C+ rmay initially present in their practice. The Physicians’9 k* ]2 Z4 R" U
Desk Reference and package insert should also put a
2 L! g& x3 h% P( Zwarning about the virilizing effect on a male or0 V  a3 [9 n- k
female child who might come in contact with some-+ a! {8 X! T# \" D4 V# @4 i
one using any of these products.1 `( u5 t  z  J8 r1 M$ A
References: g. ~3 h- y5 e/ C" ~1 f- i7 {
1. Styne DM. The testes: disorder of sexual differentiation* t* U; ]: P  v
and puberty in the male. In: Sperling MA, ed. Pediatric
7 k5 ~& s8 A; H. I- L* ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 c/ {1 `: x  D/ Q- R2 T2002: 565-628.. ]( j, d  Z/ Y* y' ]! \# x1 \8 D; {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. P; v5 W% i( V6 D$ S" Qpuberty 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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
2 {( s, j" a" _. u, L1 o$ @5 Q: q
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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