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Sexual Precocity in a 16-Month-Old4 E' c$ ?, Z. a+ m- ^7 r) I! s9 Q
Boy Induced by Indirect Topical
+ o5 g4 V! g, {- K9 SExposure to Testosterone6 R) p2 C9 T4 G6 m/ a
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) V0 p7 A; p: z" |0 x9 P0 @8 Gand Kenneth R. Rettig, MD1' |+ @* ~. b- W& N2 ]& y0 L) w
Clinical Pediatrics3 ]$ r1 ~2 s- j. \
Volume 46 Number 68 X9 o, L( c. l5 T* w9 s- s' i4 g
July 2007 540-5438 K2 U' o& {6 {8 V. L) a7 x! J
© 2007 Sage Publications. D  L6 x9 N* S# n% [7 l  j6 A+ H
10.1177/0009922806296651
$ K0 L( W1 C, y5 w# Thttp://clp.sagepub.com/ }$ X3 V& o- @) \+ W/ i# F$ F9 X& t# ~
hosted at  f' p6 f0 }& q& v% H
http://online.sagepub.com4 ~. H! Z/ z" U% n4 \
Precocious puberty in boys, central or peripheral,, P, U. n/ ^& G# j2 R# U4 @0 P
is a significant concern for physicians. Central
( R" K  u8 e$ q& d+ x, D0 a0 R+ T$ Vprecocious puberty (CPP), which is mediated* d3 x: J5 k0 Y' P0 c4 l& d6 I
through the hypothalamic pituitary gonadal axis, has
& h+ @! v: S+ v: K5 ^a higher incidence of organic central nervous system/ z' [# Y( A/ E1 v! |/ ]
lesions in boys.1,2 Virilization in boys, as manifested
' X4 Q9 A' i# B1 q- |$ n2 k: ?by enlargement of the penis, development of pubic
( S2 L+ m$ c8 p" s5 I! Lhair, and facial acne without enlargement of testi-" x# B: F5 U$ `4 ]
cles, suggests peripheral or pseudopuberty.1-3 We! D2 J% E1 e1 v6 D
report a 16-month-old boy who presented with the
1 m1 t4 H+ Z6 v, Fenlargement of the phallus and pubic hair develop-
$ @; P5 B8 V9 P* h. a2 L9 @6 Pment without testicular enlargement, which was due
/ }+ V( u1 c$ Gto the unintentional exposure to androgen gel used by
( O$ H. m: F* H% c* Dthe father. The family initially concealed this infor-8 e! N4 t& s$ ^9 _
mation, resulting in an extensive work-up for this3 Q/ P8 w- A! U. _' ?
child. Given the widespread and easy availability of1 p8 K. g/ n8 A2 r7 c. \6 |
testosterone gel and cream, we believe this is proba-
7 k/ P# U" L: m6 n: E, _0 ibly more common than the rare case report in the6 @) Y# S; n- o* T1 U+ r
literature.49 Y9 G4 g4 C1 V% Q( S
Patient Report4 K" e7 L+ e. X' P  t. W
A 16-month-old white child was referred to the6 R7 M% S0 i5 l: r- |. T
endocrine clinic by his pediatrician with the concern& A. i9 X5 T9 _$ ?. E0 w
of early sexual development. His mother noticed
7 ~+ A, E; d/ e4 K% l5 Elight colored pubic hair development when he was
) j  ?3 \' _) X$ d2 x. a6 xFrom the 1Division of Pediatric Endocrinology, 2University of7 e9 F" ]0 a! |* [4 \' X
South Alabama Medical Center, Mobile, Alabama.
2 c+ a- J: r  R- C( c' X" ]Address correspondence to: Samar K. Bhowmick, MD, FACE,
. L! l! X$ r$ u# A) g3 _& }+ jProfessor of Pediatrics, University of South Alabama, College of3 \0 @+ j4 ]8 T+ I) {# N7 l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 b' f  h1 c, r: @; S9 K
e-mail: [email protected].
- J0 |9 P& s1 Q) Tabout 6 to 7 months old, which progressively became
8 U6 c' C  r* W! }- ?: q. Adarker. She was also concerned about the enlarge-
- W/ t3 x! F& R$ B5 ^ment of his penis and frequent erections. The child
2 m9 D& L, `) e% Iwas the product of a full-term normal delivery, with7 h0 N4 s2 P9 b% D
a birth weight of 7 lb 14 oz, and birth length of
8 ?! [( v' k8 h" N4 ~( F20 inches. He was breast-fed throughout the first year
2 s: @) K- o! _of life and was still receiving breast milk along with# c# G8 w+ P/ B" x( J$ J
solid food. He had no hospitalizations or surgery,! K( ?9 D3 F! w. N% U& S
and his psychosocial and psychomotor development
- I1 j- D2 p' J3 i2 C1 A$ Hwas age appropriate." Z6 ^4 q- m, l; W# d
The family history was remarkable for the father,0 H$ R& z2 f, s& P2 E  m
who was diagnosed with hypothyroidism at age 16,9 F; D" M* y, l% p
which was treated with thyroxine. The father’s
9 @8 p! `8 W: `height was 6 feet, and he went through a somewhat1 x# o1 u2 ]& @; d, n
early puberty and had stopped growing by age 14.
9 \/ b5 S$ y! |5 B7 O9 t; h6 q0 [The father denied taking any other medication. The
3 O2 A  P8 e; M) U1 P  |& _/ r" `child’s mother was in good health. Her menarche! w0 V% k) B+ x
was at 11 years of age, and her height was at 5 feet: k9 I! o7 E, W" T* y+ K* ]- k
5 inches. There was no other family history of pre-/ }6 Z& `& @. _% Y! Q
cocious sexual development in the first-degree rela-
: F' N! y/ r+ m( o6 E+ J" wtives. There were no siblings.
2 O( r7 W1 \1 c/ o8 l0 k+ }Physical Examination
0 a6 M8 G% k; j7 a4 }, _- B6 KThe physical examination revealed a very active,: z6 u5 D- e0 X0 `8 ~6 n/ ]
playful, and healthy boy. The vital signs documented
0 j; v: L% G) K1 u9 Na blood pressure of 85/50 mm Hg, his length was# a4 S" E& J  z* I9 A8 l1 s' ?
90 cm (>97th percentile), and his weight was 14.4 kg5 {5 Y8 [3 a+ j! o) W+ d0 o
(also >97th percentile). The observed yearly growth
3 U5 U3 k5 c! n/ E- o- e8 l. pvelocity was 30 cm (12 inches). The examination of
6 H( M" n; k4 w5 X- D% `% G2 z, ^the neck revealed no thyroid enlargement.
2 F) b) `  l/ ~9 _: G0 IThe genitourinary examination was remarkable for4 l$ r7 A7 q6 i; i/ }% u( w% u. w
enlargement of the penis, with a stretched length of' O) U0 p% r3 \2 H& P
8 cm and a width of 2 cm. The glans penis was very well
- {9 D7 }5 y  u5 X$ odeveloped. The pubic hair was Tanner II, mostly around
  }0 S' D) a/ }9 I8 _7 Y8 Z540
6 K; O2 E) A2 |: Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) H! f' |& Y5 t( j3 [, c
the base of the phallus and was dark and curled. The
# ~2 x0 c4 g* f/ c5 b$ xtesticular volume was prepubertal at 2 mL each.1 _) }8 e& m' ~8 U0 m5 k
The skin was moist and smooth and somewhat! x/ I. ?/ q) k6 a2 b) ?
oily. No axillary hair was noted. There were no. r: W& ]3 b' p$ B
abnormal skin pigmentations or café-au-lait spots.
* U0 ^# R3 e# Z2 wNeurologic evaluation showed deep tendon reflex 2+
! t8 {2 A  h2 O, d2 Qbilateral and symmetrical. There was no suggestion: g: I+ D/ @- Z
of papilledema.& L, j4 i% Y. D( Z, K$ R
Laboratory Evaluation; `2 I- E. X3 G5 y' ?4 O, x: t
The bone age was consistent with 28 months by
$ T" W3 n' I% I$ t, busing the standard of Greulich and Pyle at a chrono-" i1 T. L, d: Z1 G
logic age of 16 months (advanced).5 Chromosomal
0 l5 @  k# q: Skaryotype was 46XY. The thyroid function test8 @( Y3 Y5 C% C& Y% V. M, I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
! w7 q0 C9 s) \! ?lating hormone level was 1.3 µIU/mL (both normal).; m$ \! g% Q- j/ l7 H0 S
The concentrations of serum electrolytes, blood  {" s  B8 l6 g9 t" S: [7 S. _
urea nitrogen, creatinine, and calcium all were4 ?; K. [1 R( Z8 d) A- _4 v
within normal range for his age. The concentration: W# P# |: }9 ~
of serum 17-hydroxyprogesterone was 16 ng/dL& h; O" O8 r* W) p
(normal, 3 to 90 ng/dL), androstenedione was 20; M! z& X6 _, X. T, \" Y/ T- o2 [
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) [9 F, @& {. |0 xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 N2 u2 R7 L( S% N* Z8 O3 cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to! O0 ^: P# q7 {) X3 V
49ng/dL), 11-desoxycortisol (specific compound S)+ n# U1 {5 P; j- j% t/ V. z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& Z5 u7 w" v# k5 K0 J  Q8 xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# \7 U; G+ j' \  K/ |% \. y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- ^# O( i8 K, l4 ?- Kand β-human chorionic gonadotropin was less than
& a& x4 X% T- U- c5 G/ K5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 `; F. h4 w6 Y/ H8 hstimulating hormone and leuteinizing hormone
1 D' M6 ^% `8 e6 E$ A8 k7 cconcentrations were less than 0.05 mIU/mL5 F& L! m3 f4 w; s' B# S8 d
(prepubertal).
0 i* D% U" s1 iThe parents were notified about the laboratory& L" E- q$ z) o
results and were informed that all of the tests were4 H( r2 C: O! x8 l. A* p
normal except the testosterone level was high. The
8 ?$ R/ ~3 O+ x( `follow-up visit was arranged within a few weeks to, `6 \2 G0 i/ h' S
obtain testicular and abdominal sonograms; how-! k" U; U4 F+ i& z( p
ever, the family did not return for 4 months.% F( ^( v# Y5 N1 z
Physical examination at this time revealed that the
! x0 M( E5 I& g" A' wchild had grown 2.5 cm in 4 months and had gained% n/ A& r2 T- l
2 kg of weight. Physical examination remained
- e* l5 ?% d$ Nunchanged. Surprisingly, the pubic hair almost com-! P1 `; M1 i' v; m) F7 t
pletely disappeared except for a few vellous hairs at& y( N8 y" m' ~: w) p
the base of the phallus. Testicular volume was still 2  ]$ }8 [; b' l( a7 n3 _
mL, and the size of the penis remained unchanged." Y7 \) p8 C) C5 ~. x+ e
The mother also said that the boy was no longer hav-: ?( S" \1 E& H& A+ s4 Y! ]
ing frequent erections.
, b5 {( _! K: n, g8 Q6 {Both parents were again questioned about use of
+ p: z: Z3 Q9 t0 p- m. R* @any ointment/creams that they may have applied to8 o+ }+ o8 Q0 b' B
the child’s skin. This time the father admitted the9 Q) S/ E# y. |/ E1 m5 X" o
Topical Testosterone Exposure / Bhowmick et al 541, R6 Z4 y# }  E) `7 _5 i3 u
use of testosterone gel twice daily that he was apply-
& t7 M; [2 d% r, A1 Ring over his own shoulders, chest, and back area for
/ [4 B4 \$ z5 Ia year. The father also revealed he was embarrassed
; O, A0 \8 V- O0 ato disclose that he was using a testosterone gel pre-
+ F3 s! h2 o! G* Kscribed by his family physician for decreased libido' X  c. _7 U/ Q0 u
secondary to depression.
* I7 B5 a$ K5 q7 a- oThe child slept in the same bed with parents.. \& O8 s* `2 ?4 H' i
The father would hug the baby and hold him on his
2 ^: s9 N. C4 r, h+ H& F6 @: ]chest for a considerable period of time, causing sig-; `1 Z8 o% z  Z* \  m
nificant bare skin contact between baby and father.7 o1 P% [# A" |; O
The father also admitted that after the phone call,' P+ s# E) d2 e3 |4 U5 N
when he learned the testosterone level in the baby, y7 i+ n3 ^5 Q( M$ N: G
was high, he then read the product information
) B: S9 u( F4 }packet and concluded that it was most likely the rea-7 f; m* j# r% b' h$ m. q
son for the child’s virilization. At that time, they6 t  B+ G$ B5 b
decided to put the baby in a separate bed, and the
% N) A. `$ R  E0 Y) Nfather was not hugging him with bare skin and had9 D* H* x, q9 h2 u
been using protective clothing. A repeat testosterone
. H. ]' {) o9 h' v0 u9 n4 b0 Etest was ordered, but the family did not go to the9 n5 B$ c, @# s: G$ s2 n4 M
laboratory to obtain the test." E/ W* P7 u3 F
Discussion
4 e) E) J6 g$ F) O! _; \Precocious puberty in boys is defined as secondary/ S* ?9 Y1 h/ T  ~$ ^/ j* d" b
sexual development before 9 years of age.1,43 T9 G. q* }! ]/ o# {
Precocious puberty is termed as central (true) when2 ?* s1 b5 a9 q; ^% w
it is caused by the premature activation of hypo-) t5 U% h( ^% N- |. S9 X8 a
thalamic pituitary gonadal axis. CPP is more com-
! k: U5 Y7 u1 g2 U) l/ ~: Fmon in girls than in boys.1,3 Most boys with CPP9 q+ y4 c5 X2 R9 g9 f9 D0 f
may have a central nervous system lesion that is
& {2 e) M' E. lresponsible for the early activation of the hypothal-) `+ H* ~. Y* Y1 c, L; u( \
amic pituitary gonadal axis.1-3 Thus, greater empha-
# x. e% i- y% s. X5 msis has been given to neuroradiologic imaging in
6 P% |& l* G6 e, a2 H" iboys with precocious puberty. In addition to viril-
1 @  R3 ]. Z! {$ @% e2 pization, the clinical hallmark of CPP is the symmet-
9 _+ x" e3 e% `8 h1 t" m( irical testicular growth secondary to stimulation by7 C3 U) P! p+ ^7 a# ^
gonadotropins.1,3
7 m4 }# A) M; W6 ?* z* t# F# hGonadotropin-independent peripheral preco-
; x; i/ e( P" fcious puberty in boys also results from inappropriate
9 m% W; X9 \7 S$ I& Uandrogenic stimulation from either endogenous or* V: \1 G9 N4 E" t. y
exogenous sources, nonpituitary gonadotropin stim-
! l" [; |& t* y% C4 i" kulation, and rare activating mutations.3 Virilizing
' a! [# H; H. x/ N9 z; D- ^congenital adrenal hyperplasia producing excessive
: C- A  |" j6 U+ [" k; Iadrenal androgens is a common cause of precocious
5 v, L; ?' p! W9 \puberty in boys.3,44 L8 |6 F$ q& D+ M7 r) v) U
The most common form of congenital adrenal
7 V, }9 o7 D$ hhyperplasia is the 21-hydroxylase enzyme deficiency.
$ W7 X8 p* H" _" K& bThe 11-β hydroxylase deficiency may also result in
" Z! r& ~; A* w; H- V# eexcessive adrenal androgen production, and rarely,
# s' a  @* r* x6 `an adrenal tumor may also cause adrenal androgen
3 [4 X- n8 J' e% O$ S3 ^excess.1,3
: E7 K/ p8 ?2 _( S) `- rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) O" r5 s6 `6 T# C1 k( @8 r- i542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! x$ L7 a7 f' k4 ^1 s3 e6 h' e+ tA unique entity of male-limited gonadotropin-1 r( o6 }6 M6 _8 e( c  G* `; Z
independent precocious puberty, which is also known
8 o7 z  ^% B5 X+ v& Z% X6 [- \as testotoxicosis, may cause precocious puberty at a5 Q, c( ]: ]( @( o$ Z& F( k! |! |& j# G
very young age. The physical findings in these boys
& ]; c& s) c: A, \- Iwith this disorder are full pubertal development,) P! L/ h3 X9 Z. h" p0 }; Q4 F
including bilateral testicular growth, similar to boys% q1 F4 a+ A- Q0 A
with CPP. The gonadotropin levels in this disorder
& W1 G2 C0 q9 }are suppressed to prepubertal levels and do not show
) T% |7 _; x2 [/ _# D: Jpubertal response of gonadotropin after gonadotropin-& l4 G) y0 V8 |# l. k
releasing hormone stimulation. This is a sex-linked
3 e2 K9 H8 H1 E7 Oautosomal dominant disorder that affects only. n" Q0 t, S4 q, A
males; therefore, other male members of the family  }8 Q: h( d- P/ C* d5 M4 f: Z3 y
may have similar precocious puberty.3( O% i1 _! Z$ x7 U
In our patient, physical examination was incon-7 l/ |1 ?/ G( @+ E; ]
sistent with true precocious puberty since his testi-! y- N! p) E* `" F, x! f4 \
cles were prepubertal in size. However, testotoxicosis3 e5 q) I! I% m- T
was in the differential diagnosis because his father
$ q2 L9 f) Q. @8 U+ U+ Mstarted puberty somewhat early, and occasionally,
2 c) ~2 I' j5 @1 e9 Rtesticular enlargement is not that evident in the
8 b& I8 H6 o- {8 ]beginning of this process.1 In the absence of a neg-
9 g4 M0 X8 S. T" Z% z8 R4 }ative initial history of androgen exposure, our: A$ l7 q2 E  V' |
biggest concern was virilizing adrenal hyperplasia,. E- R! U* l: B2 Y% w) ~1 a, R
either 21-hydroxylase deficiency or 11-β hydroxylase5 F/ i9 n5 L2 l8 \! G5 O
deficiency. Those diagnoses were excluded by find-# g8 r3 Q( z( J8 T, d2 R; e
ing the normal level of adrenal steroids.' b/ H0 Y+ N# |2 R, j
The diagnosis of exogenous androgens was strongly
( A) U$ m- G6 r# @8 A( V$ I# Ksuspected in a follow-up visit after 4 months because
/ `' I$ h+ w6 ^+ ?7 N) Q1 u( i* ]the physical examination revealed the complete disap-  l6 Z5 {! m8 E
pearance of pubic hair, normal growth velocity, and
; u+ |# t3 J# G1 h3 R4 vdecreased erections. The father admitted using a testos-3 p7 s. C6 h* d% V! l
terone gel, which he concealed at first visit. He was
: `0 H" E" ^7 [0 P% G0 V) Iusing it rather frequently, twice a day. The Physicians’
: o5 \1 [3 n3 H) U8 P1 h0 \Desk Reference, or package insert of this product, gel or
/ n4 A7 f& x, G7 J5 A. [& Scream, cautions about dermal testosterone transfer to
: d$ l& e3 ]8 x5 o/ p6 M% h( ]0 Ounprotected females through direct skin exposure.
0 W/ q2 I- ~- A4 n& ~1 ZSerum testosterone level was found to be 2 times the
4 _% g( `- @, t$ j! Fbaseline value in those females who were exposed to; E0 h% o1 z5 w: {7 k) n# j8 u
even 15 minutes of direct skin contact with their male
6 m1 D: Y6 I( g1 ypartners.6 However, when a shirt covered the applica-
8 J0 \2 I% K3 r; Ztion site, this testosterone transfer was prevented.$ K4 E! d8 j/ m/ c4 F2 c* y
Our patient’s testosterone level was 60 ng/mL,  g; q0 F; t9 c; [/ a: r: V
which was clearly high. Some studies suggest that( R; h, G/ F6 D6 ?# J9 a3 B, Z8 R
dermal conversion of testosterone to dihydrotestos-
7 `; i% g) ~2 y: @8 Zterone, which is a more potent metabolite, is more
, {0 s) b) I* l" n) z$ Sactive in young children exposed to testosterone
' q  B7 d* i  aexogenously7; however, we did not measure a dihy-2 f- V" E. m8 `* }; T" N3 M
drotestosterone level in our patient. In addition to
0 e' @" F4 `3 h! K  Xvirilization, exposure to exogenous testosterone in
3 Z' s& t4 K! g( _- T0 v+ Mchildren results in an increase in growth velocity and. }2 {% w! B8 H" a4 ~) V% F
advanced bone age, as seen in our patient.
( a/ C4 I3 t- J4 Y6 \5 YThe long-term effect of androgen exposure during
9 Y: r5 ]  A" ^( L3 H, Xearly childhood on pubertal development and final
1 `$ K: L; P; u2 |0 }adult height are not fully known and always remain% C, G2 q1 {/ u+ z
a concern. Children treated with short-term testos-8 ~9 }9 w/ o9 Y2 B7 S6 _) X$ G
terone injection or topical androgen may exhibit some' H6 G7 V, Z( V
acceleration of the skeletal maturation; however, after
/ c2 l7 K5 |* ?& A5 f6 n) Rcessation of treatment, the rate of bone maturation
9 o1 D6 r/ E! @$ x( O; Tdecelerates and gradually returns to normal.8,9
5 [* @7 a- r# e6 h4 p6 L; T" P" |There are conflicting reports and controversy
; d* p  W1 B* n+ E+ s' Uover the effect of early androgen exposure on adult: s; Q, Y, D& O$ G: @5 Y
penile length.10,11 Some reports suggest subnormal
3 |' Q& X" M' x4 n! [9 d, ~! ?. z2 _; vadult penile length, apparently because of downreg-
/ b7 I; s2 [7 k8 G! L2 aulation of androgen receptor number.10,12 However,
. I- O# s" J% \; {' W% E+ T* {Sutherland et al13 did not find a correlation between& e, j. R! n  E8 Y# b* C( [
childhood testosterone exposure and reduced adult7 N3 G4 k9 l/ Z/ I6 |- N: w
penile length in clinical studies.. M) M3 j$ N! d. X3 m
Nonetheless, we do not believe our patient is7 h# s+ g8 J0 g1 R) Y& I, H+ T# p
going to experience any of the untoward effects from
6 K# C$ E' U3 dtestosterone exposure as mentioned earlier because) V5 @/ i" }8 m7 _7 g, U7 P
the exposure was not for a prolonged period of time.9 S' Q/ {; K1 s# c8 {2 @7 q
Although the bone age was advanced at the time of
2 F6 Q- f4 Z8 V( i: h* }diagnosis, the child had a normal growth velocity at; @% z# l8 `; @) u  C
the follow-up visit. It is hoped that his final adult
2 c4 M( T) e; B9 `" O) N2 Dheight will not be affected.$ O9 v, y! |' M6 r
Although rarely reported, the widespread avail-' |) e: j/ k0 [! V
ability of androgen products in our society may5 \1 A* P* G6 J& f  V
indeed cause more virilization in male or female
) X4 \  k) _  |( s. Vchildren than one would realize. Exposure to andro-# W1 F1 U4 U6 Y$ M# S& z- m
gen products must be considered and specific ques-& X9 M- ~8 _8 R* O
tioning about the use of a testosterone product or& K4 ]  S* U! Y2 ~% c  e
gel should be asked of the family members during
5 Y9 ?6 `3 J: \the evaluation of any children who present with vir-8 l8 y+ Y% b! ~. m) G0 p! Z
ilization or peripheral precocious puberty. The diag-$ C$ I: f6 J' u; ]8 Y+ r0 e
nosis can be established by just a few tests and by, ]  w) o; P! o  T/ W7 T
appropriate history. The inability to obtain such a
  M4 Z. ]% J$ Z. @' l2 _history, or failure to ask the specific questions, may
* i) \% n$ l7 v+ M; v4 A2 aresult in extensive, unnecessary, and expensive; ^! [! a# Z; ]( _* I' N8 P
investigation. The primary care physician should be
+ {( w5 v6 y  D! z! l# }$ M0 xaware of this fact, because most of these children
& e2 Q0 N/ Z) O1 ~may initially present in their practice. The Physicians’
; L  s0 T; n$ z3 b/ \/ h( F' i6 NDesk Reference and package insert should also put a
4 B  e! \/ @# N- ?( `6 Twarning about the virilizing effect on a male or
+ K1 P) ]3 v6 Z7 jfemale child who might come in contact with some-' P6 m& A: U0 d" r( `
one using any of these products.
/ _5 L. `- J9 N$ i- l; kReferences$ h5 N' C  H7 g! k: [" c& c* y
1. Styne DM. The testes: disorder of sexual differentiation
, r. W9 r# I/ v: K. m6 R/ Wand puberty in the male. In: Sperling MA, ed. Pediatric2 w. _) \0 Y; e! Q+ z- z' U# ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 \* I, R; ~" H5 u$ ^9 q0 [2002: 565-628.
3 D& j+ I; F2 W/ o2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 I% z8 J% }6 T9 [) n5 E9 m
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
* V0 G+ G5 i3 W- VBoy Induced by Indirect Topical
! x- @& u- C9 DExposure to Testosterone' c. I. w3 [, x9 |7 u( t/ Y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 D  p2 u! f" `; d# a& W( J2 A+ X
and Kenneth R. Rettig, MD1' `6 |  f, }) m# x" B( U' v
Clinical Pediatrics  w" e8 I! ~0 f4 I0 g2 B! X/ q
Volume 46 Number 60 @# |7 @  E% ]$ N
July 2007 540-543
% i8 v& G! r# N© 2007 Sage Publications) O2 E4 R, c. `4 }2 b2 {3 H( |5 w
10.1177/0009922806296651
) A; M8 W4 q' V, W( H7 C! bhttp://clp.sagepub.com4 [: X  `. i# U" W* O
hosted at7 V& {2 p; B) D6 n$ t+ T
http://online.sagepub.com  S; v+ X. M4 r8 Z$ w
Precocious puberty in boys, central or peripheral,2 Z. f( P7 Q) Y. `* U
is a significant concern for physicians. Central; M4 }" }  f. |5 Z
precocious puberty (CPP), which is mediated7 }: k5 k3 f5 d8 C' N
through the hypothalamic pituitary gonadal axis, has
( i! ]. m1 [# d2 da higher incidence of organic central nervous system% ?& q5 G3 ~( }& L* y. L) |- @' H
lesions in boys.1,2 Virilization in boys, as manifested
: C3 j' ?, u: g; S1 Y/ cby enlargement of the penis, development of pubic
8 L/ z  ^  H4 Q/ Nhair, and facial acne without enlargement of testi-
- f; W8 ^" g/ d& p, t# Xcles, suggests peripheral or pseudopuberty.1-3 We# h  E% K& J: I# u7 Y  m5 @
report a 16-month-old boy who presented with the% w' c1 J  T* z. U  B; p" e
enlargement of the phallus and pubic hair develop-. h3 Y- y& T2 A8 G
ment without testicular enlargement, which was due
( F# g5 ]& e6 I! G+ e1 e0 p. Gto the unintentional exposure to androgen gel used by/ d$ t; L4 `+ m  K) z9 w4 v
the father. The family initially concealed this infor-
' ~3 m. X2 U  x5 k6 @$ I  F0 Zmation, resulting in an extensive work-up for this
0 D6 O+ {* R* g6 V( C- n" f3 q) |" pchild. Given the widespread and easy availability of
0 k* t3 P4 c+ l0 m7 z' X& a4 I! X2 Ttestosterone gel and cream, we believe this is proba-
. \! l" I; z7 ~+ J/ ibly more common than the rare case report in the% h4 q$ q8 u, ?2 T1 @, q
literature.4
$ I( ^: n0 E$ V, b. xPatient Report* D! [2 B. d' @3 x
A 16-month-old white child was referred to the
+ r# C) R# G" k% \! p3 Pendocrine clinic by his pediatrician with the concern& L- E4 J% i3 S* g2 D5 a
of early sexual development. His mother noticed% C) S  J+ i' P$ C1 q) K- j
light colored pubic hair development when he was
, E8 J- G- Q3 S9 g( R4 I. nFrom the 1Division of Pediatric Endocrinology, 2University of8 ~( i# T" a$ F# F
South Alabama Medical Center, Mobile, Alabama.
8 E5 S8 l( o4 y( nAddress correspondence to: Samar K. Bhowmick, MD, FACE,' c! s& I* z: l+ c: h& B
Professor of Pediatrics, University of South Alabama, College of% X( A; Y2 x, b! l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 w% x. S7 N' `9 \" e. {8 ~5 ie-mail: [email protected].  u" A% W3 ]; M( S! a1 h+ y
about 6 to 7 months old, which progressively became  ~6 j( K( q  I  P6 ]# d' n
darker. She was also concerned about the enlarge-
- S* R& T9 q( {1 ^8 oment of his penis and frequent erections. The child
! l9 P; v  m* J% qwas the product of a full-term normal delivery, with" R7 V. w  p& n/ R  c
a birth weight of 7 lb 14 oz, and birth length of- y7 o: `5 H7 ~# t5 {# l% h" p
20 inches. He was breast-fed throughout the first year
3 x0 m8 ^6 x* m. A/ H/ L$ hof life and was still receiving breast milk along with
  B" a' }$ n0 r: N# @8 `0 hsolid food. He had no hospitalizations or surgery,
* J. q3 G! P, j2 w: Vand his psychosocial and psychomotor development4 q/ X: a( r8 F7 }# E
was age appropriate.
$ o! j6 e# Z& ^; M5 r, [4 j' XThe family history was remarkable for the father,
; g+ l4 f) _+ o9 pwho was diagnosed with hypothyroidism at age 16,
- q1 q* S+ W5 Y8 |( _; Owhich was treated with thyroxine. The father’s
7 {  V7 p8 m9 m% \4 r+ i. cheight was 6 feet, and he went through a somewhat
0 _: V4 t0 f0 r. V; Nearly puberty and had stopped growing by age 14.* G7 P$ Y7 B/ C* V
The father denied taking any other medication. The
* o: x% B/ }: M) J8 s0 Rchild’s mother was in good health. Her menarche
' F+ E/ J* a, z* ^% Lwas at 11 years of age, and her height was at 5 feet
8 Y! |: X7 j% m$ W7 g, k5 inches. There was no other family history of pre-
3 L  p: _& Y& Pcocious sexual development in the first-degree rela-
1 y: K, h6 L  a$ J+ {tives. There were no siblings." ]; A4 j' t6 }- Y* g+ y2 t6 q
Physical Examination
/ V, f# |! z9 u+ UThe physical examination revealed a very active,
  \' D' v5 z  S4 e3 S( N7 Q" A% uplayful, and healthy boy. The vital signs documented; a0 i( q  Z+ f$ u$ ~! d
a blood pressure of 85/50 mm Hg, his length was
* d; t( s" {# p7 d1 \6 w90 cm (>97th percentile), and his weight was 14.4 kg8 v: Q" m5 q5 G6 z" x) `; B
(also >97th percentile). The observed yearly growth
1 `; b2 J* ^/ j/ f5 `6 X7 tvelocity was 30 cm (12 inches). The examination of
3 n0 M2 ~( T; p8 R& h7 Kthe neck revealed no thyroid enlargement.
" d# ]% @& S5 YThe genitourinary examination was remarkable for
' T, j; U; n! B7 B! x+ Jenlargement of the penis, with a stretched length of, F4 H5 o' o% Q* b( k# B, q
8 cm and a width of 2 cm. The glans penis was very well' G5 d8 f3 ^. D' D  @) U, H
developed. The pubic hair was Tanner II, mostly around
! o8 y) N% z3 J# \3 Z# @540; N6 c3 ~+ l) ^% S
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* \6 ?  C, T# m' I  c6 H) \
the base of the phallus and was dark and curled. The
0 U1 I4 v! w" w' j3 R+ {testicular volume was prepubertal at 2 mL each.
2 `# ^( V4 F# k% `5 QThe skin was moist and smooth and somewhat
% O5 b) G, ]$ Joily. No axillary hair was noted. There were no
4 a3 Y7 t. w8 k% [6 F+ i, `4 @abnormal skin pigmentations or café-au-lait spots.
" |( Z3 _1 E- u( D7 L6 J6 KNeurologic evaluation showed deep tendon reflex 2+
4 `" T! {* m7 F: pbilateral and symmetrical. There was no suggestion
. a: S/ `0 U1 w' c8 n( x( C$ Tof papilledema.; l8 _* h; V) \  g: U# c
Laboratory Evaluation
0 s9 N- e! h. E( N  G2 D6 YThe bone age was consistent with 28 months by
9 y% |8 Y4 P0 g3 {using the standard of Greulich and Pyle at a chrono-
2 K( Y" Q+ Q6 }; h. ]. m. Llogic age of 16 months (advanced).5 Chromosomal( Z: W' [% r. w  k' G" f
karyotype was 46XY. The thyroid function test
8 O' a# Q: S; o- h4 ?showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% ~6 |% ]/ v' w" _lating hormone level was 1.3 µIU/mL (both normal).7 R% C/ }" b/ H+ X9 I
The concentrations of serum electrolytes, blood
& u& C& O, W1 ^( v, I4 F1 Jurea nitrogen, creatinine, and calcium all were
. @7 \7 @/ }7 V, Y* T" mwithin normal range for his age. The concentration- y" F* s- U/ U4 I, ]) [
of serum 17-hydroxyprogesterone was 16 ng/dL; U6 E# e# d8 L! I: H2 f/ L5 o
(normal, 3 to 90 ng/dL), androstenedione was 20$ {/ k! b' a7 f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 q2 |1 m" R. K+ A& C9 F* a; [4 Q/ U
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( K& [0 z& k* `8 K: t: y; U( {desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 @# @' g; I2 i9 e( o0 s: r* }
49ng/dL), 11-desoxycortisol (specific compound S)
1 L' r: K. m6 q) {; Fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& `9 I/ U( G/ V$ f$ [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 w8 X4 O4 `* r, s& K1 Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 a  G7 F1 J9 O" Pand β-human chorionic gonadotropin was less than
- X' f3 C+ t3 J& u' K5 mIU/mL (normal <5 mIU/mL). Serum follicular3 j+ |% ?& |  ^* [' d) v
stimulating hormone and leuteinizing hormone7 @! M$ Z' q+ B$ W1 Q& Y* t% ^3 b
concentrations were less than 0.05 mIU/mL7 E! o3 {' Z3 R7 ^% H5 y, v
(prepubertal).
: K; |& F8 d3 HThe parents were notified about the laboratory
+ ^+ L: g( K4 c0 \results and were informed that all of the tests were$ x4 N" s# I0 W/ G; O4 ?& @7 e  X
normal except the testosterone level was high. The
+ L  \* B7 C. H4 W8 @$ y8 Z. ^follow-up visit was arranged within a few weeks to
: ]6 s' p+ l% Pobtain testicular and abdominal sonograms; how-+ W" n9 h7 C- K+ z6 _- o
ever, the family did not return for 4 months.- s  }9 w0 [' E( N- L5 q3 C
Physical examination at this time revealed that the
  g& d1 ^7 A! ochild had grown 2.5 cm in 4 months and had gained& A- ^) r2 `4 z" g2 u7 A! w
2 kg of weight. Physical examination remained5 _$ ~- V/ W3 X4 \( w3 v
unchanged. Surprisingly, the pubic hair almost com-
8 G) y# y* H9 p6 c( A) v" G" r+ ipletely disappeared except for a few vellous hairs at9 o9 [: j# q4 J
the base of the phallus. Testicular volume was still 2
- p& i5 J- h2 o  [1 Z6 k; c  DmL, and the size of the penis remained unchanged.3 Q$ f: H- P' f% z
The mother also said that the boy was no longer hav-! h# |, |; U$ y% Y4 q! k
ing frequent erections.
$ ~5 ~1 S! A9 |! m5 z) @Both parents were again questioned about use of2 m. p& y1 `4 s# L0 E
any ointment/creams that they may have applied to5 {  F8 H4 q# [1 i; x
the child’s skin. This time the father admitted the
8 P. e6 Z  F" m' tTopical Testosterone Exposure / Bhowmick et al 541
/ l  ~9 `4 K: n0 ~use of testosterone gel twice daily that he was apply-" Z5 H3 r; T# \: W, ~& n' o# O# n
ing over his own shoulders, chest, and back area for
+ S4 z- B0 I* ?4 r# u) @a year. The father also revealed he was embarrassed
1 A2 \5 v! E3 c# X6 C- N# Z; ^0 s! wto disclose that he was using a testosterone gel pre-
! X0 R4 b6 G5 m. G+ \scribed by his family physician for decreased libido' t+ d. R, q) C2 d6 D
secondary to depression.! g% n) h) l9 O' e: Q
The child slept in the same bed with parents.3 L  G: Q$ x! e( e8 e
The father would hug the baby and hold him on his
, q, \9 x' h* V$ Vchest for a considerable period of time, causing sig-
5 K/ K- J* F+ \# Z+ S8 ~! k9 vnificant bare skin contact between baby and father.2 N6 J/ P. {5 z$ C) V5 k
The father also admitted that after the phone call,2 P" e/ @  l% u3 o
when he learned the testosterone level in the baby  J, y  w" m! C1 u" l1 q
was high, he then read the product information6 _: T" N! s& c7 L4 R1 E
packet and concluded that it was most likely the rea-* ~# y. h" B( O$ C3 R$ F
son for the child’s virilization. At that time, they% m9 _9 @/ @$ J# y6 W
decided to put the baby in a separate bed, and the" G: i+ W' b. ~* w3 G
father was not hugging him with bare skin and had9 l) x, `% {2 v; s" b$ g8 w
been using protective clothing. A repeat testosterone
+ [% ~& ?9 a6 v2 Y7 ltest was ordered, but the family did not go to the+ r  G9 C5 r8 n, H! T  I/ x
laboratory to obtain the test.
; h) E, i# Y, fDiscussion
: `: ~& x# @& ^0 z7 O0 EPrecocious puberty in boys is defined as secondary
$ Y% ~$ |# H9 msexual development before 9 years of age.1,4  d  @  K5 S. W# T3 k6 X1 h  u! K- F
Precocious puberty is termed as central (true) when
8 Z2 A: N1 E' x. Vit is caused by the premature activation of hypo-- L  O' o7 d; B, g4 a
thalamic pituitary gonadal axis. CPP is more com-
, {; q% I7 ?; Y5 y: z; |8 p& ^mon in girls than in boys.1,3 Most boys with CPP5 B% n, @: Z: k  D  ^0 g* c! S( P/ ?
may have a central nervous system lesion that is( v' L) [, A6 w" J* `
responsible for the early activation of the hypothal-' i% I) X8 I, ~4 K
amic pituitary gonadal axis.1-3 Thus, greater empha-
' ~( s# n" K2 i9 Nsis has been given to neuroradiologic imaging in
9 G7 b+ c) X: X) E2 @9 V+ }0 \2 }boys with precocious puberty. In addition to viril-1 L4 I6 Z7 b) ?# \5 F: l0 w( i
ization, the clinical hallmark of CPP is the symmet-5 \) e" [* w$ Z' A, G' G5 x  W" G; ]
rical testicular growth secondary to stimulation by$ r9 C% ]7 a$ A( {; d
gonadotropins.1,3& M3 ^) W! M; e7 ]* \! ]
Gonadotropin-independent peripheral preco-
) e% q9 [6 n' z; O2 j* b1 ocious puberty in boys also results from inappropriate
- Z3 O3 W1 z6 J* Z3 P, candrogenic stimulation from either endogenous or
9 f  a# {' @$ Z& pexogenous sources, nonpituitary gonadotropin stim-6 P1 |0 x+ T& F' r, `9 V' T
ulation, and rare activating mutations.3 Virilizing
- {! i( [5 F3 j& J8 t( ccongenital adrenal hyperplasia producing excessive
1 ]" t) t6 P- ~! Xadrenal androgens is a common cause of precocious" S) }7 Q1 G, L7 P9 u
puberty in boys.3,4
: [, a1 x( E5 C# d0 G/ v2 TThe most common form of congenital adrenal
9 g# p; b. p+ v$ ]; ~hyperplasia is the 21-hydroxylase enzyme deficiency.
' k- d+ e8 n$ G% |The 11-β hydroxylase deficiency may also result in( g2 A% x! h; G* ^
excessive adrenal androgen production, and rarely,& o6 Q- l8 k+ t* K. ~, x' I
an adrenal tumor may also cause adrenal androgen) U. n' n( |/ R4 v' Y7 k5 `0 g% {
excess.1,3+ F8 `. N2 Q1 _2 i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: c* D, g8 S7 N; a
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ X* T5 A' m4 A, G& g* ^* e. z# e' a
A unique entity of male-limited gonadotropin-: Z  {% S3 I' z! `# c$ r
independent precocious puberty, which is also known
* v+ R" R- s5 J- Z7 {/ M" Zas testotoxicosis, may cause precocious puberty at a- x4 G& x. @# n
very young age. The physical findings in these boys; |, h# R. b$ v" ~& e  u
with this disorder are full pubertal development,: C7 D% P1 v  o7 C; i
including bilateral testicular growth, similar to boys
1 a9 ]  t; T! j* p$ Z6 Q) vwith CPP. The gonadotropin levels in this disorder/ U6 U2 @# ]9 Z7 h9 H: E
are suppressed to prepubertal levels and do not show
6 X4 N' J( c+ b5 r0 T$ Cpubertal response of gonadotropin after gonadotropin-: f) @& J7 e8 H5 [9 l4 m
releasing hormone stimulation. This is a sex-linked
, q( H. G2 Z3 S- j" fautosomal dominant disorder that affects only
$ j% F2 [9 ?( D# T) Tmales; therefore, other male members of the family
% I( D( {( n" i* i4 jmay have similar precocious puberty.3$ X- v2 i0 _2 P; Y; h1 h
In our patient, physical examination was incon-, Z1 J; d* r- b2 J) b* H
sistent with true precocious puberty since his testi-
6 r! ?9 v: F7 |0 G+ [9 ycles were prepubertal in size. However, testotoxicosis# D% u. G0 H7 r
was in the differential diagnosis because his father4 ^# E0 y  r6 _3 E
started puberty somewhat early, and occasionally,
1 k$ d5 `; k+ ^( B+ N- n' M: f* I8 Wtesticular enlargement is not that evident in the$ t  D6 |; u! d# F% l' E
beginning of this process.1 In the absence of a neg-
# m+ f' C. e0 J; Eative initial history of androgen exposure, our8 P; A! g7 v& V3 H4 \% u7 e
biggest concern was virilizing adrenal hyperplasia,
$ B5 X) y2 N, b9 j% k; p+ O$ Neither 21-hydroxylase deficiency or 11-β hydroxylase! {0 ]8 y" L5 x# ?! V$ b
deficiency. Those diagnoses were excluded by find-
. f. ]3 t+ q8 q8 }8 uing the normal level of adrenal steroids." U7 z2 N! @% q  M4 S
The diagnosis of exogenous androgens was strongly7 i% o; b" Y$ [
suspected in a follow-up visit after 4 months because
, y$ Z" ]: P8 Zthe physical examination revealed the complete disap-+ f* ~1 v% u. ^' U+ A) u5 j6 A5 }
pearance of pubic hair, normal growth velocity, and
% p; ?) ^0 U; \# sdecreased erections. The father admitted using a testos-5 G* p9 E  A& \7 B- B8 n' B/ K4 Q/ v
terone gel, which he concealed at first visit. He was
$ U# Q1 K6 \- M3 @, yusing it rather frequently, twice a day. The Physicians’
# T2 o/ Q+ w6 j3 M7 n/ mDesk Reference, or package insert of this product, gel or
% |/ z8 X+ U- }& _8 vcream, cautions about dermal testosterone transfer to. ^2 d: O9 Z* O! b) `9 T
unprotected females through direct skin exposure.
9 H1 l( p: i' T3 o2 jSerum testosterone level was found to be 2 times the! Q, ~% g8 g( T* c- ~8 Y
baseline value in those females who were exposed to3 x1 T$ w" a1 u- S0 m
even 15 minutes of direct skin contact with their male
% F. m- w8 ?+ R& `' g+ z( hpartners.6 However, when a shirt covered the applica-
4 S5 T; H" t! N, A$ J( ]tion site, this testosterone transfer was prevented.& \3 `& q* ]/ J6 l5 l2 k: d! C7 W
Our patient’s testosterone level was 60 ng/mL,
" n: n0 l* S5 m( mwhich was clearly high. Some studies suggest that0 |2 w4 L5 A! x# U
dermal conversion of testosterone to dihydrotestos-
- o# t) i5 d# l6 `! t2 Uterone, which is a more potent metabolite, is more3 I" M2 j& ?* W  x0 l2 n
active in young children exposed to testosterone8 V' J* h1 c+ Y
exogenously7; however, we did not measure a dihy-- X: x! n- [; a' E  D
drotestosterone level in our patient. In addition to
- Y" D2 R0 r4 J2 }virilization, exposure to exogenous testosterone in
# u6 u/ @# m6 ~2 g$ Xchildren results in an increase in growth velocity and$ T7 s$ C1 E" |9 `; b  o% Y
advanced bone age, as seen in our patient.
% v* K' a! I6 u3 c# d& B4 t) mThe long-term effect of androgen exposure during
- i& p+ {5 Q3 w: x8 ?" B% M0 uearly childhood on pubertal development and final$ M; {0 q1 j) s9 C+ O4 d2 e% A
adult height are not fully known and always remain( m! A, z8 [% X9 V) o
a concern. Children treated with short-term testos-
0 m3 Z6 |: q& C0 Lterone injection or topical androgen may exhibit some% b6 ]9 \$ {' ^/ Y4 Z7 c$ `2 g
acceleration of the skeletal maturation; however, after
; F6 o4 W' e! T& Kcessation of treatment, the rate of bone maturation
( q' A5 M. U/ G! o( [0 e) @( qdecelerates and gradually returns to normal.8,9: w( J! @- A' l+ W6 A: [) i5 l% t! M& `
There are conflicting reports and controversy
" W) E# d9 J7 z. w; `over the effect of early androgen exposure on adult* G8 E* c4 E1 ^7 {
penile length.10,11 Some reports suggest subnormal8 O% T) k: |- j7 C* V
adult penile length, apparently because of downreg-
" U: C- [  g2 K! v* ~) _0 Bulation of androgen receptor number.10,12 However,
) y0 T3 V0 s, X. G- q# u4 u0 vSutherland et al13 did not find a correlation between
5 l: Z8 O- {9 [/ }% e% `3 Nchildhood testosterone exposure and reduced adult7 g+ l$ }) B+ H4 v: J
penile length in clinical studies.' V- ]3 |+ h3 W) Z: e
Nonetheless, we do not believe our patient is
6 q, w8 k. N1 J9 E6 A: Ygoing to experience any of the untoward effects from
7 l" v7 w9 b# J; Stestosterone exposure as mentioned earlier because! x& g8 S7 c" U$ B4 t2 I0 _
the exposure was not for a prolonged period of time., M# ]$ G1 _' _2 y/ H
Although the bone age was advanced at the time of
$ A5 r  a, F: x3 q& Adiagnosis, the child had a normal growth velocity at
  b5 I/ S1 q% k3 f# h* T' sthe follow-up visit. It is hoped that his final adult
7 i. j8 P0 R5 {& V' rheight will not be affected.
, x  H8 Z8 ~; r: z1 K+ f: iAlthough rarely reported, the widespread avail-
7 ?' Z6 k# k; i5 d- S; g6 V/ Z' Uability of androgen products in our society may
5 d5 J; \( |: z( L) Y! y7 u6 mindeed cause more virilization in male or female
' ]4 N; Z: m: ~' f) B) echildren than one would realize. Exposure to andro-
( f, B( X$ `9 ?* Q: ogen products must be considered and specific ques-
* d+ f) X1 L" R% t% Qtioning about the use of a testosterone product or
) O$ E! \6 ^: xgel should be asked of the family members during( t$ _; c/ r+ q" p0 {/ a1 v8 O
the evaluation of any children who present with vir-+ M( X0 k2 r  _  n0 A
ilization or peripheral precocious puberty. The diag-8 |+ y0 P' n9 P0 J
nosis can be established by just a few tests and by: ?5 A% F4 e6 G
appropriate history. The inability to obtain such a
0 X- J3 m$ J- p# X, z) f3 X( O1 Phistory, or failure to ask the specific questions, may
. g! ^6 C9 W0 ~( ~% bresult in extensive, unnecessary, and expensive
% Y4 q. U) d$ |4 ]investigation. The primary care physician should be
( c; M4 y: y3 }  `aware of this fact, because most of these children* o4 K* R! [& `1 l: G
may initially present in their practice. The Physicians’
6 |4 Z9 F) \7 c% PDesk Reference and package insert should also put a# Q1 C% W/ Z1 ~' ]' I# A/ W
warning about the virilizing effect on a male or! q, E2 F! o8 y4 K
female child who might come in contact with some-+ q" o! m* O4 _9 G; B- k$ M7 D; S
one using any of these products.5 J% X9 r+ g7 b# z
References
. @! p4 ~5 r+ ]5 ?6 C! Z# ]$ y/ \1. Styne DM. The testes: disorder of sexual differentiation
8 f  H" M6 i  T; I( iand puberty in the male. In: Sperling MA, ed. Pediatric
/ c4 _2 f4 c) N& Y1 gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 V. d6 V- ?' G* N# W0 N7 s2002: 565-628.. g' l, C) B& s/ c: K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, _4 B* J) W' f# Y/ q
puberty 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

7 B/ E" U6 F! Y  ^5 F7 G- ?' Z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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