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Sexual Precocity in a 16-Month-Old
/ |& F- Z  P" g* ^! E! VBoy Induced by Indirect Topical3 ~1 S% C2 D) r: j/ H) ?
Exposure to Testosterone
3 @' I  M( \' H+ g6 ySamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 R& d2 p8 K  {- N. N
and Kenneth R. Rettig, MD1
9 _5 ^% r& Y! u0 Q/ c2 p9 _Clinical Pediatrics
' k, j2 Q& r5 y2 ~  n; V9 r4 nVolume 46 Number 6
1 b9 u0 A( J8 O* O+ GJuly 2007 540-543/ j3 N& f( `: x+ q+ O
© 2007 Sage Publications
! O; E  P3 R- C' X* y& i10.1177/0009922806296651: D0 f9 B& \" ~, J
http://clp.sagepub.com/ g& ~# P& p1 E8 t8 G4 i
hosted at  n' e; U5 ^$ P, L! S# m
http://online.sagepub.com. B7 l# ?! E3 z
Precocious puberty in boys, central or peripheral,  U+ j) A8 A' ~2 x+ @
is a significant concern for physicians. Central' @7 I$ S& k; [5 B0 |7 T. o7 ^
precocious puberty (CPP), which is mediated
& y$ A' q$ _- X' x! K0 a5 fthrough the hypothalamic pituitary gonadal axis, has; d( {1 ]3 A6 V0 U7 h5 T5 k4 s
a higher incidence of organic central nervous system
' i! g3 t% K1 u( H2 g. a( L7 blesions in boys.1,2 Virilization in boys, as manifested
) Y1 q* Y( ^2 _. d4 h# Oby enlargement of the penis, development of pubic2 W0 D, a+ Y5 q: O" r
hair, and facial acne without enlargement of testi-# x! i8 V/ I7 m$ r+ w
cles, suggests peripheral or pseudopuberty.1-3 We
! s) r( i/ E8 c" Sreport a 16-month-old boy who presented with the
/ t, n) G& Y1 Tenlargement of the phallus and pubic hair develop-9 H8 n- Z' K( a) W9 r( d( ?
ment without testicular enlargement, which was due9 @4 o; Q- t1 z8 ]
to the unintentional exposure to androgen gel used by
4 p  v6 }  N; s" I# v* Q  hthe father. The family initially concealed this infor-
2 `1 x6 `( \) o' Zmation, resulting in an extensive work-up for this
; a8 Q( c+ n; g4 X3 b% Jchild. Given the widespread and easy availability of- l, k9 Z' d# u# B' [% {
testosterone gel and cream, we believe this is proba-
' e) E- N/ c0 hbly more common than the rare case report in the- e7 P" d6 h; {5 U0 M
literature.4
9 ~) u' k+ h" nPatient Report2 n$ X+ F- x% q5 z/ o3 B
A 16-month-old white child was referred to the1 y* u( U* l. H
endocrine clinic by his pediatrician with the concern6 |' x, F( g0 Q4 v0 N. h7 X
of early sexual development. His mother noticed5 |1 \' \& I3 O0 G5 i& p
light colored pubic hair development when he was
* a# u1 }! Z3 i+ FFrom the 1Division of Pediatric Endocrinology, 2University of/ V9 L0 i0 x" e7 T( T
South Alabama Medical Center, Mobile, Alabama.$ |. D# W! Q1 ~7 V* M
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 u( j* s3 n5 Q5 V: f
Professor of Pediatrics, University of South Alabama, College of5 |- K$ M6 \" c
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 B& B  u- U: }. h4 P6 \1 fe-mail: [email protected].4 \1 ]) O* K: p# t
about 6 to 7 months old, which progressively became
' w+ R2 O- F& i. @; o1 d) xdarker. She was also concerned about the enlarge-
" l0 r6 ]. J9 B) Lment of his penis and frequent erections. The child
: T7 D( s7 o; Wwas the product of a full-term normal delivery, with
0 B5 A% M7 d, H, ]% ]3 ~- h( B% }a birth weight of 7 lb 14 oz, and birth length of) C/ {! H% i# C# R/ h! o+ _
20 inches. He was breast-fed throughout the first year6 X) I* V9 ^" {; O* H  ?5 M, {
of life and was still receiving breast milk along with0 u" L, x. R: n+ v: y% ?* O
solid food. He had no hospitalizations or surgery,+ X2 ^* {. n5 w; X
and his psychosocial and psychomotor development% v, U9 ^% g( i* t
was age appropriate.! s6 ~8 ~/ M, [4 s
The family history was remarkable for the father,
' i2 E  Q9 Y; [: P/ E1 @who was diagnosed with hypothyroidism at age 16,
4 ^6 j  h3 U0 Twhich was treated with thyroxine. The father’s
2 e  {, z. g; i: D' T% k3 u! y8 eheight was 6 feet, and he went through a somewhat1 _4 \- a: J( m  y9 f
early puberty and had stopped growing by age 14.
* H  U9 y, H+ ?7 AThe father denied taking any other medication. The8 g( o# V( t& l. c2 W
child’s mother was in good health. Her menarche) L9 T2 @; R2 I. Q
was at 11 years of age, and her height was at 5 feet
# y) V+ `% S  v7 w4 `5 inches. There was no other family history of pre-3 k# ]# W0 u$ e# c4 v& F! _
cocious sexual development in the first-degree rela-. ?% w- L; H6 k1 J
tives. There were no siblings.0 I" M& t* E* X
Physical Examination
, T8 l- _$ X8 U; G+ O& }The physical examination revealed a very active,
9 X! |# Z: x* jplayful, and healthy boy. The vital signs documented# i& a% m1 x% _& l/ O- g' h5 z
a blood pressure of 85/50 mm Hg, his length was
! e+ `2 \3 N) q( d: P90 cm (>97th percentile), and his weight was 14.4 kg
' f; _$ P% Y" ]9 D0 g! l(also >97th percentile). The observed yearly growth0 L& l7 j0 |8 L
velocity was 30 cm (12 inches). The examination of
+ v9 t2 O( [/ j0 {( T9 e, Nthe neck revealed no thyroid enlargement.
7 a  ^) o$ R% F2 _The genitourinary examination was remarkable for/ x8 ~% b( C( Y" o
enlargement of the penis, with a stretched length of
, G) U$ V5 ]- H8 M- ^7 e% H8 cm and a width of 2 cm. The glans penis was very well
0 C# z& \# w( M9 `8 K3 Edeveloped. The pubic hair was Tanner II, mostly around
2 z0 V8 h9 B  D- n& ]% }5401 ~. m% z/ A5 t, m9 v( @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 _  M% m* i0 S: f- l
the base of the phallus and was dark and curled. The
# x* p3 X8 M) s! @1 s8 M3 Utesticular volume was prepubertal at 2 mL each.
: ~9 P5 e) q7 f+ f- _The skin was moist and smooth and somewhat
- p& @) m) Z- u6 N( k" x% P) ?oily. No axillary hair was noted. There were no  m$ i( i& W& b# }3 b
abnormal skin pigmentations or café-au-lait spots./ t" ~) Z" v& S* N% X& g
Neurologic evaluation showed deep tendon reflex 2+5 i+ u) ~. g- z5 _/ ?. f# I( C+ B
bilateral and symmetrical. There was no suggestion
% U  m, z9 a2 }/ Q" T7 ?of papilledema.
. U2 O0 Z+ k: \( gLaboratory Evaluation$ I7 q2 g  \& }( M' c
The bone age was consistent with 28 months by" I3 E& \: A: r/ k) L9 q, s
using the standard of Greulich and Pyle at a chrono-
3 H! f" e& [/ Ologic age of 16 months (advanced).5 Chromosomal( d) B# t+ ]3 v6 }: _
karyotype was 46XY. The thyroid function test  N) Z3 }5 d& U3 u2 {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 m+ `" o; F8 h6 l8 b1 plating hormone level was 1.3 µIU/mL (both normal).
% g& W( i0 p/ n1 ~2 OThe concentrations of serum electrolytes, blood
2 E; l. L) @2 Curea nitrogen, creatinine, and calcium all were3 Y- x( p' P1 H
within normal range for his age. The concentration4 D5 [: J/ v* Q6 q
of serum 17-hydroxyprogesterone was 16 ng/dL( Y9 _9 D- x9 m8 g6 E. |% X6 Z
(normal, 3 to 90 ng/dL), androstenedione was 20
: j+ W2 t5 o0 G# S3 }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% U/ g9 c3 o. T2 i) d0 s* J! z( D/ {terone was 38 ng/dL (normal, 50 to 760 ng/dL)," L; s+ C8 Q( a; K' i# x
desoxycorticosterone was 4.3 ng/dL (normal, 7 to5 L! X1 b" n) a- I2 {" |: n( Y1 a! R
49ng/dL), 11-desoxycortisol (specific compound S)/ B, S$ K& j6 n3 m( f7 m
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) N8 c% W5 t! V; |: |tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
  t$ J3 L& D, }9 `4 O) s) O- S6 Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" t: u; G- _& f  @/ Sand β-human chorionic gonadotropin was less than
' y3 M/ _$ }' n6 p9 I: N8 z5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 V" y% s5 @6 }7 Estimulating hormone and leuteinizing hormone) s  f7 d$ @& y/ \" k( H( }- r
concentrations were less than 0.05 mIU/mL
7 C: H  J: e3 t* }6 [* J" e  p4 b) p(prepubertal).
1 S3 Y9 H) x, X5 O+ @$ X- ?The parents were notified about the laboratory
1 G5 p! d. w& C, T3 i3 uresults and were informed that all of the tests were
3 {4 ^, n$ K3 b8 f7 z7 ~' j: snormal except the testosterone level was high. The) J. Q9 x" O! ^# U' T& F# L5 w6 t0 Q
follow-up visit was arranged within a few weeks to0 ?: {( t3 Z. b) x  t- D2 p/ K  n
obtain testicular and abdominal sonograms; how-
% O* F- U+ {" z8 pever, the family did not return for 4 months.
# {& O( B# V: g* s0 Z) @& n; gPhysical examination at this time revealed that the( Y8 a$ Q& w& R* A; ?
child had grown 2.5 cm in 4 months and had gained
. m- }+ j; G' _  C6 w5 q2 kg of weight. Physical examination remained7 f; Y9 I( u) d8 S
unchanged. Surprisingly, the pubic hair almost com-5 S+ u* C' h1 \
pletely disappeared except for a few vellous hairs at
, z3 @  K% j! w8 W9 b& Bthe base of the phallus. Testicular volume was still 2
* c' F! p) p9 n7 R3 C$ MmL, and the size of the penis remained unchanged.
, ]! L7 {9 t" J4 w. z6 q. {The mother also said that the boy was no longer hav-* e$ `8 P7 Z% P; d( z* i
ing frequent erections.: I4 B3 p3 Z7 E& U
Both parents were again questioned about use of
* H! v% c; H. X# j" G  k. c* Vany ointment/creams that they may have applied to
( `0 S; i* L7 o  h8 k+ ]' }. H. R2 d+ Hthe child’s skin. This time the father admitted the/ a5 p' o% d, {: E
Topical Testosterone Exposure / Bhowmick et al 541) _7 r) W$ _. S7 |
use of testosterone gel twice daily that he was apply-
4 E8 \1 y4 Q; g0 ~: @ing over his own shoulders, chest, and back area for# Q. K) _/ }' a2 Z" H5 n
a year. The father also revealed he was embarrassed/ {' }: A1 a6 n* k  ~0 h( a
to disclose that he was using a testosterone gel pre-6 e& ^! A  m" G7 W
scribed by his family physician for decreased libido- }1 N5 w+ P, x3 D6 \2 e6 i
secondary to depression.
8 v% B5 F  g& n6 Q8 v6 `The child slept in the same bed with parents.+ A# K/ \, [# w* A, r
The father would hug the baby and hold him on his
$ c9 I# M! z: n! A/ Qchest for a considerable period of time, causing sig-2 p" @! [0 _5 F. T; t3 M! C
nificant bare skin contact between baby and father.
. S% E% Y5 R+ e  j( QThe father also admitted that after the phone call,! X7 B+ f3 e+ z8 s, N  O
when he learned the testosterone level in the baby
: p9 l! Z. V6 D0 f% ewas high, he then read the product information
1 {* m5 Z/ l/ Upacket and concluded that it was most likely the rea-7 {) o) R. i  x4 _7 r/ E
son for the child’s virilization. At that time, they
7 c( K2 E( J& m2 x6 p. O  w$ rdecided to put the baby in a separate bed, and the2 D! {, O6 Q8 A8 A# B7 ]
father was not hugging him with bare skin and had: J# l  a0 i4 u) z( @
been using protective clothing. A repeat testosterone1 M$ R' O1 A1 T$ N; Q6 O9 ^' @
test was ordered, but the family did not go to the" Y1 o0 ~) h! M
laboratory to obtain the test.1 i& U8 ]8 B, A" G* e
Discussion
  \; e7 j$ x4 q! `" IPrecocious puberty in boys is defined as secondary) E1 N, g( f) n( \' C- j1 y
sexual development before 9 years of age.1,4
7 A9 n  T- `% O: c/ a( C$ n7 UPrecocious puberty is termed as central (true) when# ?0 A- J8 x. _* S( M7 L1 E  h5 O
it is caused by the premature activation of hypo-
/ i' K1 G) p8 M+ L9 M3 sthalamic pituitary gonadal axis. CPP is more com-
' B3 p8 s/ B% ]! f. l# s$ zmon in girls than in boys.1,3 Most boys with CPP% y, ~  k, Q" G  p
may have a central nervous system lesion that is6 n" f- c% @# R  u: }
responsible for the early activation of the hypothal-
! K% \! X) |) xamic pituitary gonadal axis.1-3 Thus, greater empha-
# x7 ]4 y& X: j, b, Q& N" F2 Xsis has been given to neuroradiologic imaging in
6 [- b+ X9 |) W9 t6 q9 E: `boys with precocious puberty. In addition to viril-
( g; V/ t9 f9 k4 x7 pization, the clinical hallmark of CPP is the symmet-
( v. G: X: Q) Crical testicular growth secondary to stimulation by
; C( q3 ~7 n0 j# b+ e6 I8 q  {gonadotropins.1,3
* M0 A! I6 X7 ZGonadotropin-independent peripheral preco-% R/ P/ k6 j" E- O: A- B' ]
cious puberty in boys also results from inappropriate- \, A+ L/ U  B5 _8 a+ g
androgenic stimulation from either endogenous or5 L$ g- M. s( i' c5 s; n
exogenous sources, nonpituitary gonadotropin stim-
8 N; q- n9 y! D8 E, d( H9 aulation, and rare activating mutations.3 Virilizing5 q: @& m  ?/ y+ m+ g# N! p4 {6 V$ F
congenital adrenal hyperplasia producing excessive8 a5 ]/ ]2 D9 _/ ]! f' [' O; n
adrenal androgens is a common cause of precocious- p: U) M/ e" `" I( M3 a( I- L
puberty in boys.3,4
7 w1 v) I: ?9 K5 }5 |% \1 z' J0 E% `The most common form of congenital adrenal6 `( s: i' H' n
hyperplasia is the 21-hydroxylase enzyme deficiency.# M' d7 t( v3 J# K/ t
The 11-β hydroxylase deficiency may also result in
8 m- t! F5 J/ Z8 g$ dexcessive adrenal androgen production, and rarely,, n/ r3 m: v; O) ?6 m# a
an adrenal tumor may also cause adrenal androgen: l" z0 \4 V- g7 n
excess.1,3
6 w; q8 H! @. h8 J- A# s, E: }+ Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 u# \6 n# r( @3 C% z4 s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& q8 y( ~6 x3 j+ f
A unique entity of male-limited gonadotropin-
- r: i. i, [4 Jindependent precocious puberty, which is also known! g3 G2 J6 m2 e( r0 S' d; E" d  S' J
as testotoxicosis, may cause precocious puberty at a
( m+ T1 W( f7 F6 Overy young age. The physical findings in these boys3 C+ `* S' t% u% b6 G! C
with this disorder are full pubertal development,
' u7 _9 c* F! g) |; eincluding bilateral testicular growth, similar to boys
8 H# g) L& N8 P* ?6 l4 H4 q4 S2 ?: Cwith CPP. The gonadotropin levels in this disorder
6 z" D- Z) n2 H( U% Nare suppressed to prepubertal levels and do not show" o1 ~* A0 Z' I8 b' z5 S/ [
pubertal response of gonadotropin after gonadotropin-( o; `0 q/ F2 ~4 `8 K  P) W
releasing hormone stimulation. This is a sex-linked; {$ _5 V$ }  S0 q
autosomal dominant disorder that affects only
& s+ s& l# j! H5 g& Z/ Y6 B( V( Umales; therefore, other male members of the family
2 i- n# A$ G, e; f$ z/ `may have similar precocious puberty.36 e. Y4 M* l8 J% I6 y6 [  p: o
In our patient, physical examination was incon-
3 U$ w9 Z% \( E9 Msistent with true precocious puberty since his testi-
2 {* n, S$ b  H; Q% c+ Ycles were prepubertal in size. However, testotoxicosis
- O, y  E1 m: Q6 D. N0 Vwas in the differential diagnosis because his father  ^+ Z# e+ `; ]8 g. g) v
started puberty somewhat early, and occasionally,2 j  D' U8 w; o; Q  v3 d
testicular enlargement is not that evident in the
; X5 O  q" P1 ibeginning of this process.1 In the absence of a neg-
- e8 q3 }, P, W2 native initial history of androgen exposure, our
: T" R. |# H; A: b7 y5 _biggest concern was virilizing adrenal hyperplasia,
' F& e% C9 j. Eeither 21-hydroxylase deficiency or 11-β hydroxylase3 t6 J( N' W" C
deficiency. Those diagnoses were excluded by find-+ A  K5 T8 L. G" h( c
ing the normal level of adrenal steroids.
$ d3 \! p: \4 p' GThe diagnosis of exogenous androgens was strongly  U8 v5 Y6 F3 ^
suspected in a follow-up visit after 4 months because
& {% A! G6 ?' w0 ithe physical examination revealed the complete disap-
' D* q) x1 \; K% L  ~& r* t/ D* U- Dpearance of pubic hair, normal growth velocity, and0 N4 B! u0 }' e8 [* H1 j  S: M" Q& n
decreased erections. The father admitted using a testos-  r  t) d5 X6 Z! l) @4 j( }! a* c) }- z
terone gel, which he concealed at first visit. He was0 L/ O* ?1 f% E. m4 R/ N
using it rather frequently, twice a day. The Physicians’
' F; T5 [; b& g. J, Z$ G" _+ ?Desk Reference, or package insert of this product, gel or9 g( R) Y1 @) M8 g5 b
cream, cautions about dermal testosterone transfer to
: P1 X0 E. ~- n* I, ^' ]unprotected females through direct skin exposure.
4 o8 a6 s6 `( ESerum testosterone level was found to be 2 times the
* N# d' T8 a6 l6 f0 pbaseline value in those females who were exposed to
7 l+ L$ H: E; Q0 d8 H. J* oeven 15 minutes of direct skin contact with their male
) }( F; B% J, q) J' ?partners.6 However, when a shirt covered the applica-- C' t+ r* ^& E& O
tion site, this testosterone transfer was prevented.' j; B. W$ v* m  }9 v! G
Our patient’s testosterone level was 60 ng/mL,
8 [8 B+ Z5 z# D( \  y. a1 Lwhich was clearly high. Some studies suggest that
- {/ g- J( R7 l" qdermal conversion of testosterone to dihydrotestos-
6 l7 J1 o5 c+ L; _+ }0 Iterone, which is a more potent metabolite, is more% Y* o& a5 M' x' o+ Q5 s
active in young children exposed to testosterone
4 C1 j# }' l, Bexogenously7; however, we did not measure a dihy-
' b) `, _* k, V$ M6 T5 Y9 v+ mdrotestosterone level in our patient. In addition to1 v- J5 I, Z9 R. M- N/ x
virilization, exposure to exogenous testosterone in, }7 d- @* Y5 z( Q  F0 F4 X* d
children results in an increase in growth velocity and6 j5 \3 s1 u' y- M  d3 M) u
advanced bone age, as seen in our patient.
0 V2 U6 f0 S" B" U5 }! x& p# u! |The long-term effect of androgen exposure during8 J1 d+ `: g: p9 ]
early childhood on pubertal development and final: f  A4 Z& J# R# a# f* H
adult height are not fully known and always remain
& O1 D" s$ ^$ v- v6 ^0 h( oa concern. Children treated with short-term testos-
2 ?1 V( J+ R5 K( Y) d- ?terone injection or topical androgen may exhibit some+ {# t  O( d& K, _  a' T
acceleration of the skeletal maturation; however, after
3 x1 x% u' C$ q9 n# _5 |cessation of treatment, the rate of bone maturation
3 r3 V) l; v8 K0 s% Bdecelerates and gradually returns to normal.8,9
! P, X% g9 m9 X0 S0 R% R, KThere are conflicting reports and controversy
* F' J$ l. b3 ^over the effect of early androgen exposure on adult9 g$ S5 T* z5 j1 L) P
penile length.10,11 Some reports suggest subnormal- ^  K& g- _% i" x/ n$ e& q
adult penile length, apparently because of downreg-3 R9 ^/ ~& S0 c5 w  {5 E
ulation of androgen receptor number.10,12 However," W- @: _$ F6 n
Sutherland et al13 did not find a correlation between% S- R% L& z' P5 A0 B
childhood testosterone exposure and reduced adult. H* [6 v0 f; g9 @  A$ p8 [& b
penile length in clinical studies.$ Q2 C% k! W  J/ Q5 D# h# V; f
Nonetheless, we do not believe our patient is4 x) g  i& h" ]" y0 ]8 A1 h8 _
going to experience any of the untoward effects from
# P! V5 U+ z8 J( }0 M9 utestosterone exposure as mentioned earlier because
+ {! h! s' i  d  L) mthe exposure was not for a prolonged period of time.
: C$ Z+ g  B1 d# Q! i8 T4 ]" nAlthough the bone age was advanced at the time of7 d0 r/ Y1 [# u7 J* u. Y* f
diagnosis, the child had a normal growth velocity at% H2 U: |- G& e" l- V
the follow-up visit. It is hoped that his final adult5 e. l/ H" W1 }& g" i
height will not be affected.1 T' \5 y# F9 y/ v
Although rarely reported, the widespread avail-/ C+ H. L; g- k9 v
ability of androgen products in our society may
1 e4 y! b6 Z4 P$ R/ ^indeed cause more virilization in male or female
8 g. V, D4 e- I' g# Mchildren than one would realize. Exposure to andro-
+ ^6 z" Y. O" P) j, t; J, Xgen products must be considered and specific ques-
. T3 v. A' N6 I" K( dtioning about the use of a testosterone product or6 I' @" I3 M' i2 u% i, x
gel should be asked of the family members during) u8 O. f4 G; E. o5 A
the evaluation of any children who present with vir-% O7 S4 p/ }9 y' _5 a
ilization or peripheral precocious puberty. The diag-
( I# r8 t3 l+ P! t  f& c" c7 Snosis can be established by just a few tests and by5 g8 q- ?- T& o6 s/ k
appropriate history. The inability to obtain such a, m% l! D6 |& v6 x4 X) ^7 U" ~8 U
history, or failure to ask the specific questions, may
9 a! i$ f. n  G6 S9 \8 a# zresult in extensive, unnecessary, and expensive
  I% z! ~/ c7 y* f# a2 M. u/ G7 pinvestigation. The primary care physician should be
  P2 o2 p) M. n( S3 m( ~- Zaware of this fact, because most of these children9 O3 ^% d2 ~0 d- y* f9 G6 w
may initially present in their practice. The Physicians’2 S* ]1 q( h2 U$ L, C
Desk Reference and package insert should also put a; M, r& y9 [5 ?. O
warning about the virilizing effect on a male or
: |& O: E+ a) z$ Ifemale child who might come in contact with some-5 }! S( l5 C& I2 L
one using any of these products.
2 c: H% m7 C2 eReferences) {4 w) S* c3 R! b, @2 i2 C
1. Styne DM. The testes: disorder of sexual differentiation& ~8 O# C8 m2 o& h+ D3 J
and puberty in the male. In: Sperling MA, ed. Pediatric- {% y, V% P% Y9 i7 Q: |3 m. o% N
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- O8 n/ D% ]6 }
2002: 565-628.  p* C0 k1 l2 C! d0 r
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- C9 C! }/ {5 z: ~9 j7 G
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old" a- T2 a5 x; F: G7 \
Boy Induced by Indirect Topical) G; S6 _+ e0 b8 g$ T' j: x
Exposure to Testosterone
9 c( j3 L0 H4 v( s' X" ySamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- ?9 Q7 v7 ]4 E, q
and Kenneth R. Rettig, MD1
/ B% {; A" T- K% HClinical Pediatrics
1 \4 V* h% z8 N* D( B/ ~8 k0 t; U3 |Volume 46 Number 6
0 m% T; H4 U4 X; ~2 o! {July 2007 540-5433 \/ |% F  S4 ~0 D3 k
© 2007 Sage Publications* @: Y% G+ C" F4 J) {$ v  D
10.1177/0009922806296651/ @. b0 f7 G+ K; q, N
http://clp.sagepub.com
" a9 L  ?5 h+ Ihosted at
/ D/ n3 |0 p3 E: uhttp://online.sagepub.com) v2 n5 b) Q' P9 t3 H5 P! h
Precocious puberty in boys, central or peripheral,; }+ J0 b+ R3 o" Q( {* d/ u
is a significant concern for physicians. Central
4 q# G+ D0 o( ], b! c0 @precocious puberty (CPP), which is mediated
! p2 k, Y) @( s. R2 bthrough the hypothalamic pituitary gonadal axis, has1 Q3 S3 ?1 H0 U3 ]
a higher incidence of organic central nervous system3 }* S: y4 u% v
lesions in boys.1,2 Virilization in boys, as manifested
" N3 m8 ?/ e# h, M8 |by enlargement of the penis, development of pubic
/ y) @" P- a% m  _7 [hair, and facial acne without enlargement of testi-* L) Z9 t  e% [( E
cles, suggests peripheral or pseudopuberty.1-3 We
$ o. [' Y* }3 Z) areport a 16-month-old boy who presented with the
9 P. l- X: M6 R3 J  Benlargement of the phallus and pubic hair develop-
8 Y6 W( F% e; n( v+ }) W9 ]' e7 cment without testicular enlargement, which was due( J, J6 v. H4 E& F$ ~2 B- L1 l
to the unintentional exposure to androgen gel used by
# a! R& L6 E4 b/ j! G, {; Kthe father. The family initially concealed this infor-' e4 e( G1 C2 V/ r* ^* G
mation, resulting in an extensive work-up for this; Q) ^' z+ o# F+ [" X
child. Given the widespread and easy availability of, A% j# X0 F" D4 l0 M% Y. ?
testosterone gel and cream, we believe this is proba-
  Q( O5 w3 {$ M9 ybly more common than the rare case report in the7 F7 [. c, Z2 u  |
literature.4
4 c5 q% a  a: f5 GPatient Report2 O! B) A2 h8 O; u+ q) Z
A 16-month-old white child was referred to the
) U! ]- A* s$ ^7 e$ J& k* n3 Gendocrine clinic by his pediatrician with the concern7 O. W( d5 q6 m# h  a% A
of early sexual development. His mother noticed! ?0 R4 H8 A, F+ U$ C
light colored pubic hair development when he was  }0 G" b5 T  m
From the 1Division of Pediatric Endocrinology, 2University of
$ h/ v- t2 a' G1 W  z8 QSouth Alabama Medical Center, Mobile, Alabama.
: ^" w6 P/ Y" B$ u( G0 MAddress correspondence to: Samar K. Bhowmick, MD, FACE,
2 W  e$ |6 [4 L. d5 JProfessor of Pediatrics, University of South Alabama, College of
8 Z2 R7 g6 ~0 A0 f+ B* ]6 pMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& M) w4 W. y1 Z8 N4 c$ _
e-mail: [email protected].7 j* ^2 R- K2 {, r6 R% |
about 6 to 7 months old, which progressively became
9 l/ H) K8 C) L9 C( {  y4 wdarker. She was also concerned about the enlarge-
! p+ @6 c: O: I1 ~3 \* bment of his penis and frequent erections. The child% `$ k# w! ^- N3 L; z, {
was the product of a full-term normal delivery, with- i5 \1 T7 D6 r; A; k
a birth weight of 7 lb 14 oz, and birth length of/ ^+ G7 A" D6 s% j
20 inches. He was breast-fed throughout the first year
7 K- b: H8 x% }2 ^of life and was still receiving breast milk along with
. ?6 o3 r7 s; d6 P( y- |% fsolid food. He had no hospitalizations or surgery,
* B( k4 J, o9 I1 |and his psychosocial and psychomotor development# [7 w' L) y4 x5 a5 x3 w
was age appropriate.
  H7 A4 `. {  i# j% D2 fThe family history was remarkable for the father,# v  n& d6 i! f. D/ g
who was diagnosed with hypothyroidism at age 16,/ `  d4 h1 l( Z2 T/ M) `
which was treated with thyroxine. The father’s8 F/ G: H( Y% L" Y7 t
height was 6 feet, and he went through a somewhat
. z2 N3 ?9 t  j; P: E/ \$ D( d# qearly puberty and had stopped growing by age 14.5 x7 f+ q2 w0 s( s& U: c; t  R
The father denied taking any other medication. The
. y1 q- s1 x% ^  c# Bchild’s mother was in good health. Her menarche
, H8 y5 I0 c5 T( g- c/ ]3 ewas at 11 years of age, and her height was at 5 feet
9 ]& V& Z! k+ b+ ~5 inches. There was no other family history of pre-* w' I/ J$ d3 l! g% `
cocious sexual development in the first-degree rela-
- e; O$ T6 J  ~( O* Mtives. There were no siblings.% _* z; f3 \2 e3 r; {+ @, `0 F
Physical Examination
: r; [5 R- w( G; ~: Z, MThe physical examination revealed a very active," O* k8 s3 F+ ]9 q1 {" w1 Y1 p
playful, and healthy boy. The vital signs documented1 b, k; v8 P: c
a blood pressure of 85/50 mm Hg, his length was$ K0 h- Z+ R5 ?3 u
90 cm (>97th percentile), and his weight was 14.4 kg3 r8 _0 A1 q6 j( H
(also >97th percentile). The observed yearly growth! z, g  N4 C9 R& {, l! j# t
velocity was 30 cm (12 inches). The examination of: D  H" o5 ?) e9 Z2 j) W& }* q
the neck revealed no thyroid enlargement.
9 r* j, e/ [5 mThe genitourinary examination was remarkable for
9 n5 W, X7 s# N* Eenlargement of the penis, with a stretched length of
2 t6 d, r  a6 j. o( U: R8 cm and a width of 2 cm. The glans penis was very well
8 d! L4 j7 y1 ?# s5 n6 L6 f3 j/ a& `* `0 rdeveloped. The pubic hair was Tanner II, mostly around
, d( O0 ]* D) L) p2 @2 Q  \540$ s% L* R4 e' l4 t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 t: T" w+ R0 A# t
the base of the phallus and was dark and curled. The# M$ k  K# H3 t( N
testicular volume was prepubertal at 2 mL each.
9 Y9 _+ Y1 C3 u8 ?9 @The skin was moist and smooth and somewhat
% O& O1 A3 U, q1 q! s: O; ^oily. No axillary hair was noted. There were no
3 V! u" s6 s4 J0 G! aabnormal skin pigmentations or café-au-lait spots.
7 E* i  Z  v! H! }+ ZNeurologic evaluation showed deep tendon reflex 2+6 q7 d& v; F1 W: ]7 l
bilateral and symmetrical. There was no suggestion6 i% Q, _/ v* V! t
of papilledema." |- }8 `4 Q+ S4 ~
Laboratory Evaluation! I% v# z6 r; C. g$ M% s
The bone age was consistent with 28 months by
  u6 h) b; z9 ~: `' i1 Zusing the standard of Greulich and Pyle at a chrono-5 p2 u2 M3 U/ N- V- U$ t  K
logic age of 16 months (advanced).5 Chromosomal5 J3 n4 y  |2 X7 A) X$ `$ ~6 }
karyotype was 46XY. The thyroid function test) R9 _0 x3 i( K: {% N' _: v
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; n  b- j1 \5 d" Y- A7 |% s, `
lating hormone level was 1.3 µIU/mL (both normal).
& ~' w/ ?% P. b7 G! wThe concentrations of serum electrolytes, blood
! U  g( a" l+ M9 Qurea nitrogen, creatinine, and calcium all were3 X$ J* z' i! F* x6 Y. R% s
within normal range for his age. The concentration1 h  e7 }7 R% n- y+ ?, V. U; T& T  y
of serum 17-hydroxyprogesterone was 16 ng/dL% x- H2 ^) \9 {: `" {2 w: W
(normal, 3 to 90 ng/dL), androstenedione was 20* \1 [/ D: U( O% Y4 w" G2 |
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- z3 J( i1 L4 g: B0 I& V1 gterone was 38 ng/dL (normal, 50 to 760 ng/dL),
" k) }4 {& k+ q3 `desoxycorticosterone was 4.3 ng/dL (normal, 7 to7 p% k# t+ Z3 w0 O2 n2 I
49ng/dL), 11-desoxycortisol (specific compound S)
) n, s" s- I, i4 x+ M3 T2 g- _was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& o( H$ n) g, }/ vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( A+ |$ W" G) r# w" q* ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& P( D: K8 ^1 \4 vand β-human chorionic gonadotropin was less than
! u- |& I  v2 g9 @0 ~- Z5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 ^6 v- t6 E3 \, @$ K$ wstimulating hormone and leuteinizing hormone% R' f& L' _, e# }! V$ I
concentrations were less than 0.05 mIU/mL  L( V* j, s1 t5 T9 }
(prepubertal).8 H5 m5 x1 G# v. `0 }, n
The parents were notified about the laboratory
% ^. s) {. t& q. n- B3 [/ Hresults and were informed that all of the tests were
2 X- u* `8 [& e1 c" X7 _normal except the testosterone level was high. The7 S2 X8 K5 k8 q2 U
follow-up visit was arranged within a few weeks to% @% H6 w1 }: j! V, g. z' c: s1 ?1 @
obtain testicular and abdominal sonograms; how-- b* g/ G, z! t7 E9 X6 o( ~
ever, the family did not return for 4 months.
# R: `4 M$ q- E$ `0 j" w  V2 _Physical examination at this time revealed that the
' k2 y8 [. n0 N2 M" [/ |! ^) lchild had grown 2.5 cm in 4 months and had gained& _" m# r) d( I' L! C& K
2 kg of weight. Physical examination remained# e, W, d8 Q# P8 a4 p, Y9 u) K$ B
unchanged. Surprisingly, the pubic hair almost com-
( `/ R9 M( ^/ U1 _* n, f& Q: wpletely disappeared except for a few vellous hairs at
1 [' _4 o$ x" Q! u" o1 U1 xthe base of the phallus. Testicular volume was still 2
( @, y! N- y( X4 m' I0 d& fmL, and the size of the penis remained unchanged.
/ {* b( k- v  rThe mother also said that the boy was no longer hav-
8 q, Q. Z, ^9 I. P4 t+ Fing frequent erections.4 G/ w6 I+ K0 ?" C
Both parents were again questioned about use of* B0 Z7 j3 ~8 T; ^
any ointment/creams that they may have applied to
1 ]) |- c9 L. v6 mthe child’s skin. This time the father admitted the5 d: ]/ Q$ Q2 D4 ]) C) V- a
Topical Testosterone Exposure / Bhowmick et al 541% f% g+ n5 C5 E
use of testosterone gel twice daily that he was apply-$ d. ^" M7 j, i6 o& O. n
ing over his own shoulders, chest, and back area for/ Y/ J( a3 I7 V# @) }
a year. The father also revealed he was embarrassed
0 _# B$ @! n7 f6 pto disclose that he was using a testosterone gel pre-
4 V2 g5 V& u) L# C  ?8 x( hscribed by his family physician for decreased libido
, R$ D" c6 C! t2 A& n% ~secondary to depression.
! m* A+ S6 b: T0 K$ LThe child slept in the same bed with parents.! Q9 P& b# S* c0 k, x2 v
The father would hug the baby and hold him on his1 _( d/ M$ u; v% z! }# D4 Q/ C
chest for a considerable period of time, causing sig-/ H. w1 W( j' k- E7 i/ x9 O
nificant bare skin contact between baby and father.
9 V9 x) _' d4 l) _0 q/ \, r5 {0 CThe father also admitted that after the phone call,) [4 Q9 s; z; |: G
when he learned the testosterone level in the baby
& U+ b, B- U- Y' h) Pwas high, he then read the product information2 S- I  i6 h: H  i, l5 `
packet and concluded that it was most likely the rea-
/ E' K# O9 k/ D( K8 Z$ Ison for the child’s virilization. At that time, they
, C5 k8 n  _, H' ]' {decided to put the baby in a separate bed, and the
8 d5 `7 k. t/ @& g0 ~2 Sfather was not hugging him with bare skin and had
( @  p$ O: F" E/ S: ebeen using protective clothing. A repeat testosterone
+ y3 i. }6 Z% ^8 O8 utest was ordered, but the family did not go to the
+ \' m4 K8 ^$ |, `/ l$ K  Rlaboratory to obtain the test.
1 r$ W$ Q' }) [1 Z6 j1 z9 F8 DDiscussion
0 v3 n4 a7 ]' sPrecocious puberty in boys is defined as secondary
/ W- N0 l" F1 ^sexual development before 9 years of age.1,44 b; M: K3 b5 D  C2 s* c* p- {1 m
Precocious puberty is termed as central (true) when7 ?$ X' y7 C8 [7 m; \$ g4 m' j1 r
it is caused by the premature activation of hypo-' e+ k$ o3 y* X& h& N( V
thalamic pituitary gonadal axis. CPP is more com-0 j7 R% v* g! B# Z; T; v; j
mon in girls than in boys.1,3 Most boys with CPP
6 N. U7 l5 Z# ^9 rmay have a central nervous system lesion that is0 B# s1 U+ x! q3 M- [; O
responsible for the early activation of the hypothal-
/ s* H0 Z5 a6 d/ Gamic pituitary gonadal axis.1-3 Thus, greater empha-
* {; I# m3 J" J; @+ P$ csis has been given to neuroradiologic imaging in
, I3 s- o( y" h( E" A; Zboys with precocious puberty. In addition to viril-& B* Y1 Y/ P. F
ization, the clinical hallmark of CPP is the symmet-
1 O; W8 @7 V  [" Arical testicular growth secondary to stimulation by; X) k( E, M! q7 ?; g1 i) \7 u
gonadotropins.1,3
# P' a' P  `. A5 z4 |, E9 G/ j) WGonadotropin-independent peripheral preco-
2 Y+ U8 a5 q/ M1 X6 qcious puberty in boys also results from inappropriate
/ ?( |( S3 \! C' a5 ]4 ~; Sandrogenic stimulation from either endogenous or
' `, q. J" f; ^' j' C! ^exogenous sources, nonpituitary gonadotropin stim-
; k" X; |3 D6 I' s/ w- Sulation, and rare activating mutations.3 Virilizing
+ l; n$ d% B7 ~, `+ acongenital adrenal hyperplasia producing excessive, C$ M8 g/ J% V7 R8 h
adrenal androgens is a common cause of precocious
7 X* q; R8 m& Apuberty in boys.3,43 J& o# x. i9 k3 G5 `. \) x& [
The most common form of congenital adrenal. u- c4 d, B. c+ F* P9 K7 A9 q
hyperplasia is the 21-hydroxylase enzyme deficiency.
; b& b: @: n9 FThe 11-β hydroxylase deficiency may also result in! d4 I; p; m, g  d- _8 F7 B! S
excessive adrenal androgen production, and rarely,3 Z. a) h  c* k( o
an adrenal tumor may also cause adrenal androgen
% W3 T; h/ J3 V( }excess.1,3" w+ u# H. ]1 }2 p* |6 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' |2 }5 F5 n+ z5 I
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. i5 h% N+ w/ w* G8 G9 vA unique entity of male-limited gonadotropin-% ?' z( }/ F# E1 Q- P; c' ]3 P1 T
independent precocious puberty, which is also known% Y, f$ G9 v/ y1 Q
as testotoxicosis, may cause precocious puberty at a
* a( W/ e& ?0 C$ Vvery young age. The physical findings in these boys
- X- C; A, e% d* i0 w  }0 }$ dwith this disorder are full pubertal development,
5 m6 b+ Y$ z% z$ G7 E. E( e: K% Bincluding bilateral testicular growth, similar to boys+ P7 L3 K9 k6 ?* y
with CPP. The gonadotropin levels in this disorder
( R; L! P  D: w! u3 k! f& Qare suppressed to prepubertal levels and do not show( N! O# `  A* o
pubertal response of gonadotropin after gonadotropin-
; v' y- K: V. s  [+ breleasing hormone stimulation. This is a sex-linked2 T! y3 B) O* m' }1 R! Y; c
autosomal dominant disorder that affects only
  [, ]. f. L3 w5 [5 Fmales; therefore, other male members of the family
6 W5 E( ]  ^! h3 {1 q0 A5 Fmay have similar precocious puberty.3. G1 R1 \8 z; a9 K1 v0 i4 n9 `; h
In our patient, physical examination was incon-; Q$ `8 o- t$ q  J4 c
sistent with true precocious puberty since his testi-
( P' c: v! e, v% l% p/ r# Ocles were prepubertal in size. However, testotoxicosis3 X( h/ F4 L: j
was in the differential diagnosis because his father# ~; R2 l1 k3 m$ p! e& k6 @
started puberty somewhat early, and occasionally,
" L& l$ }9 K2 ]# f( etesticular enlargement is not that evident in the
8 R/ s- ]' {. abeginning of this process.1 In the absence of a neg-
! W. B5 G6 C8 _1 H$ L9 k3 @9 Qative initial history of androgen exposure, our
2 {* r; J% h# y* t  `: ^! J7 v- Abiggest concern was virilizing adrenal hyperplasia,/ O2 o; B0 k, W1 ?3 M
either 21-hydroxylase deficiency or 11-β hydroxylase) I" {. C. S, Z' Z4 q4 i" Q
deficiency. Those diagnoses were excluded by find-8 V  l) o" E, }4 c5 v
ing the normal level of adrenal steroids.$ ~3 ^3 u  P& b7 f
The diagnosis of exogenous androgens was strongly
5 a* }# V  q: Tsuspected in a follow-up visit after 4 months because; w9 ~; i0 e1 w# R% t+ p6 {2 @
the physical examination revealed the complete disap-
- ]! w; ~2 e- w9 D4 j9 _pearance of pubic hair, normal growth velocity, and& I) Y  y5 j6 o8 c1 h  N7 e# z8 e
decreased erections. The father admitted using a testos-9 J0 N) X6 l# ?3 W) @0 X2 p7 T
terone gel, which he concealed at first visit. He was
/ l% S. [& b0 J. Uusing it rather frequently, twice a day. The Physicians’0 [9 E3 H. c+ w/ r
Desk Reference, or package insert of this product, gel or& Y5 A5 l( b2 r$ s. b* N
cream, cautions about dermal testosterone transfer to
; k3 L4 p- L2 d% bunprotected females through direct skin exposure.
! R1 ]0 z! [. qSerum testosterone level was found to be 2 times the
# {: v( s  x8 vbaseline value in those females who were exposed to
7 F0 Y, r! u% ~even 15 minutes of direct skin contact with their male
  v8 ?% g  m# e- |9 C: Ppartners.6 However, when a shirt covered the applica-  q1 I3 O) y3 e, A# }" p) M+ c; s
tion site, this testosterone transfer was prevented.; g$ O! k" W# I& Q1 o2 S
Our patient’s testosterone level was 60 ng/mL,
  E, E3 d* [7 i/ \) K$ qwhich was clearly high. Some studies suggest that! d, o) v& p  l% v5 [
dermal conversion of testosterone to dihydrotestos-: j# l" K. X7 Y$ K
terone, which is a more potent metabolite, is more. b8 G' W. N2 n/ l3 \
active in young children exposed to testosterone
4 L0 a3 a* T- H, {, E* \7 Jexogenously7; however, we did not measure a dihy-$ J7 \" N, {: F( X" Z8 g
drotestosterone level in our patient. In addition to
& c) N0 j+ {; j7 o2 Bvirilization, exposure to exogenous testosterone in
; Z+ r# ?% K2 l- x  R$ Hchildren results in an increase in growth velocity and
9 C- `6 I, y* @4 V; l/ I5 u" Uadvanced bone age, as seen in our patient.2 [; A' z; S2 C: a  y1 H
The long-term effect of androgen exposure during
; d) s& \$ Z" I: }! ]  H8 wearly childhood on pubertal development and final
2 m7 h2 `0 R& ~9 J+ m0 [adult height are not fully known and always remain
; z& W+ ]) Z0 o5 e' \a concern. Children treated with short-term testos-* Q0 K& X* M3 J8 g
terone injection or topical androgen may exhibit some
/ y0 `; z7 I* W- R7 Pacceleration of the skeletal maturation; however, after0 }& K  U3 W$ \' S
cessation of treatment, the rate of bone maturation
0 s# W2 ~# {( m% Udecelerates and gradually returns to normal.8,9
2 ?7 u$ @1 {: mThere are conflicting reports and controversy
; A$ N7 V- X) ?, h1 l& T' xover the effect of early androgen exposure on adult6 y' N2 Y) L5 N0 Y. f
penile length.10,11 Some reports suggest subnormal- l! {& k2 H2 \. j
adult penile length, apparently because of downreg-
. L) a1 t' Q- q2 a: Nulation of androgen receptor number.10,12 However,/ `# F, Z- n0 i, S
Sutherland et al13 did not find a correlation between
; @4 a# a7 Z- M6 Jchildhood testosterone exposure and reduced adult
& S9 }) t, ]% vpenile length in clinical studies.. @. u- A1 y- o0 ?$ O
Nonetheless, we do not believe our patient is, ]  b1 \# p8 J) F6 c# W8 y
going to experience any of the untoward effects from6 Q% B2 S6 h+ @% q: _6 m% N
testosterone exposure as mentioned earlier because
5 c0 ^- u/ h0 A: x8 I+ k$ W3 jthe exposure was not for a prolonged period of time.$ H% }: d5 N2 j2 F. ?3 h- Q
Although the bone age was advanced at the time of3 q+ {$ X6 s: h$ |
diagnosis, the child had a normal growth velocity at6 h/ i/ Q) ^) I, a3 K- H" v2 a
the follow-up visit. It is hoped that his final adult. W- B# n/ J  r  g# h0 t% H
height will not be affected.* V5 j8 H  [7 y: k
Although rarely reported, the widespread avail-
  ~* e  }) ]( S# E) ]% z% h. e7 Nability of androgen products in our society may7 a. m6 _' `3 }% d( L2 m
indeed cause more virilization in male or female
, f) ?# H% d, b' @. M) uchildren than one would realize. Exposure to andro-. N5 ^, x2 G. e4 r) |+ J9 z
gen products must be considered and specific ques-  [8 u/ f! i. j+ ]
tioning about the use of a testosterone product or
% O8 v, @: K+ Hgel should be asked of the family members during/ Y/ n. T- ~9 Y# S! J- C9 x
the evaluation of any children who present with vir-
9 J* M/ p5 ]; m0 Qilization or peripheral precocious puberty. The diag-
# c: j& v, H5 L/ p$ {nosis can be established by just a few tests and by
* }/ \  M4 Y* O% iappropriate history. The inability to obtain such a
7 w7 y. ?2 F* y" Fhistory, or failure to ask the specific questions, may7 z$ f5 |0 t6 U+ C- E
result in extensive, unnecessary, and expensive
3 P9 W7 Q3 |  O, I# Hinvestigation. The primary care physician should be) K" K1 a9 E4 P
aware of this fact, because most of these children
" L% k* r8 W# m5 amay initially present in their practice. The Physicians’
- f& Z0 r# G: P* }3 V1 l1 \$ X/ c4 r5 ZDesk Reference and package insert should also put a
! L9 ]; [, R4 p! w: L" x3 swarning about the virilizing effect on a male or/ N0 L7 I! r8 Q9 `7 `( H
female child who might come in contact with some-/ h& S/ X1 T. `1 F7 r) S
one using any of these products.; _3 P+ i7 `5 X- J
References, @4 K3 U) r# H: {) w
1. Styne DM. The testes: disorder of sexual differentiation
$ e1 S  A! i* e6 S) {4 d- oand puberty in the male. In: Sperling MA, ed. Pediatric0 X% n  e. X/ {. V9 A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 f+ \: z3 A6 K; ]3 M, J6 G; z
2002: 565-628.2 q* s! t  U1 [- y# i% p) Q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' h* u7 T# m5 N: j
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

; n  O4 R! A6 D* \4 {1 W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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