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Sexual Precocity in a 16-Month-Old
  U) A! j; l$ F5 v7 PBoy Induced by Indirect Topical4 ~3 z- }1 S6 D0 Z% B/ {0 w
Exposure to Testosterone0 A$ s* e0 d* s1 P
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 @( A- X) n* S7 g2 X! L; I2 W+ W$ sand Kenneth R. Rettig, MD11 c- F; ]  }$ {5 b
Clinical Pediatrics
/ f( X, `( N0 N) WVolume 46 Number 6% I! E* r' L0 O0 q% \% E) a) m4 T
July 2007 540-543
% c0 B3 p# @0 v. {; Q( u© 2007 Sage Publications- @1 `" M' j( p* y3 \
10.1177/0009922806296651
$ d  X1 H1 G4 D( c; P& c9 Whttp://clp.sagepub.com  y* i& c9 z5 _9 s- C2 J. ^
hosted at
. D7 _  ~; p" ]* j* Q; s! `http://online.sagepub.com- i( P7 K! o  Y- u7 i& [. O
Precocious puberty in boys, central or peripheral,
6 f8 j- T# R3 Eis a significant concern for physicians. Central
( ^" @8 J  W, nprecocious puberty (CPP), which is mediated
( n- L1 g' H# i5 H/ M- R$ ythrough the hypothalamic pituitary gonadal axis, has4 y7 g* _3 K3 E# u
a higher incidence of organic central nervous system
0 u1 c8 `" H% `; Vlesions in boys.1,2 Virilization in boys, as manifested
1 g# r( u- z0 ?* ]1 ~5 Y, bby enlargement of the penis, development of pubic% w$ R: J5 X9 @& g; ?& w6 m. C
hair, and facial acne without enlargement of testi-3 g6 G$ d$ e9 f* b$ }. Z5 ~% F) h
cles, suggests peripheral or pseudopuberty.1-3 We: A- m5 B, z# i' }/ I; M8 h
report a 16-month-old boy who presented with the
3 [- Z) J: I# y+ W6 A7 O! p" g- P+ tenlargement of the phallus and pubic hair develop-+ J& G  T/ \  X' b1 h5 y( o3 w
ment without testicular enlargement, which was due
0 v0 F5 c2 S' K1 \+ qto the unintentional exposure to androgen gel used by
; Y+ B+ p2 ]% s" n( K, F( g. uthe father. The family initially concealed this infor-/ d# ?: {9 ^0 `9 N) I, q
mation, resulting in an extensive work-up for this) c6 \) L, z& g& F' y* U6 q! V# F- r6 K
child. Given the widespread and easy availability of
# I  W* F( G$ E3 R  ]testosterone gel and cream, we believe this is proba-
& }" T6 F' j% f+ [# b( Vbly more common than the rare case report in the' Y7 I( l( l+ g2 a$ V. N& [
literature.4& y1 F7 M; `# h7 w: j' ^* i
Patient Report
3 F9 L3 Z# x  J2 o/ D- ]A 16-month-old white child was referred to the
/ C4 K, o5 y7 S& O* J/ `- Aendocrine clinic by his pediatrician with the concern
- |5 [- V2 d+ Gof early sexual development. His mother noticed
4 x  V: w/ i" l" Y2 g8 Slight colored pubic hair development when he was
2 ^7 S4 k( P3 y  h) f5 m9 d% x0 }From the 1Division of Pediatric Endocrinology, 2University of' g1 S& v9 }8 w- D/ z$ V
South Alabama Medical Center, Mobile, Alabama.0 [3 V2 N$ j9 N
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 ~  C# \( F5 p; y3 {3 O
Professor of Pediatrics, University of South Alabama, College of: V, i$ b5 I7 w% e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: d& m3 o/ `- j9 se-mail: [email protected].
, J' L' c3 K; D& vabout 6 to 7 months old, which progressively became
9 P- L( M- M% `6 e8 K# Idarker. She was also concerned about the enlarge-
. z$ }. s" D: P( Ument of his penis and frequent erections. The child" ~" ?* p: ~( i6 t6 u4 {# L* n
was the product of a full-term normal delivery, with+ i6 k6 t, u' H! R0 h* g
a birth weight of 7 lb 14 oz, and birth length of
3 Y  Y9 U- k  U) }20 inches. He was breast-fed throughout the first year
; P& X6 d: W$ [$ H! w! R% pof life and was still receiving breast milk along with
3 `7 H$ G4 S# v5 ?( jsolid food. He had no hospitalizations or surgery,
- ?% |& g. ^  Q5 h9 Q: M" xand his psychosocial and psychomotor development# [4 Q, L3 v3 v$ |: Z* \9 g
was age appropriate.; s1 o8 S0 w! F
The family history was remarkable for the father,6 c/ h2 |2 D$ u/ F. e& x: P+ A% t
who was diagnosed with hypothyroidism at age 16,0 \* ~3 d0 }4 w3 E! n
which was treated with thyroxine. The father’s* j# y9 ?" U( n( X
height was 6 feet, and he went through a somewhat, l0 ?, X3 R7 ~9 }4 d' l
early puberty and had stopped growing by age 14.
: C& a2 M% h+ RThe father denied taking any other medication. The
6 H* D1 n' D9 tchild’s mother was in good health. Her menarche: |) E$ E* `) F3 D4 L" b/ t
was at 11 years of age, and her height was at 5 feet
# F  q! h9 N  x7 ?  B" b5 inches. There was no other family history of pre-
8 V- k* n, Z$ D1 q# jcocious sexual development in the first-degree rela-$ r9 w1 [% x' ^
tives. There were no siblings.
( r# a/ W6 U: A; Z* u" n" jPhysical Examination- S* b9 W- j, x, W
The physical examination revealed a very active,
1 G7 ~: u" X, g" Vplayful, and healthy boy. The vital signs documented
4 m4 M% G) P  o! H5 z9 {9 Wa blood pressure of 85/50 mm Hg, his length was# B$ N, j9 m: Q* i( i; k
90 cm (>97th percentile), and his weight was 14.4 kg
5 s" G. {( {1 m4 S(also >97th percentile). The observed yearly growth
2 t$ T! k, B1 H! _; W+ v5 f4 P3 A& Svelocity was 30 cm (12 inches). The examination of
% R' ?. Z6 a6 W2 q) ~6 I- [! Othe neck revealed no thyroid enlargement.6 v2 V" r) `* ?. L
The genitourinary examination was remarkable for
+ x; s8 j/ h# i# H4 yenlargement of the penis, with a stretched length of' ?; x3 L6 \- a' ~, Y
8 cm and a width of 2 cm. The glans penis was very well
+ {/ F! z$ X6 [developed. The pubic hair was Tanner II, mostly around
: L- ]: J" }$ s5 `2 J9 @540: Q# B( O/ d* y$ E  E: B1 H  D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  Z$ W; N2 X$ D. U! `* o' f
the base of the phallus and was dark and curled. The4 v0 Z" N3 f4 Z3 ]  d  \  q
testicular volume was prepubertal at 2 mL each.
4 V) o# g+ {, D; W: v' g3 M. J4 EThe skin was moist and smooth and somewhat2 }; X! M, P4 Q
oily. No axillary hair was noted. There were no7 g3 W7 g' U2 n
abnormal skin pigmentations or café-au-lait spots.
- \8 K: }$ W0 H' ZNeurologic evaluation showed deep tendon reflex 2+
0 a6 b+ Q& |# B4 t. Z. H/ Sbilateral and symmetrical. There was no suggestion6 i. o- N  G3 x
of papilledema.
4 _1 R% Z$ U- W( }" I& }, NLaboratory Evaluation
* q0 t2 z8 {7 V7 S( ]/ FThe bone age was consistent with 28 months by& p6 J0 z' {4 Q) ]
using the standard of Greulich and Pyle at a chrono-# O( u) M2 U: U$ m
logic age of 16 months (advanced).5 Chromosomal
% e2 d" f( U' d) A+ h" v7 {karyotype was 46XY. The thyroid function test" ]' F/ I' U: C
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ J' D/ j8 @" s) v6 ~0 V/ I
lating hormone level was 1.3 µIU/mL (both normal).
& l) P% A( K( p, aThe concentrations of serum electrolytes, blood0 n1 {7 L" a6 e( `
urea nitrogen, creatinine, and calcium all were7 T6 u3 P! S) X. C& \. z3 n" I
within normal range for his age. The concentration
& w- J$ P6 ~/ cof serum 17-hydroxyprogesterone was 16 ng/dL/ T# |0 p+ @6 v* S: n9 e
(normal, 3 to 90 ng/dL), androstenedione was 20
& _' ^& S" p4 B4 n+ n1 S! Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 f; v! f( s* \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),- {' _+ X; S0 j- f5 ]0 A4 {
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 g, C) \  g; u0 f7 Q3 H5 p: g49ng/dL), 11-desoxycortisol (specific compound S)* A4 n- `7 g4 q9 z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 t. Y3 P. X  z6 ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ Y; _: V# H' A1 \+ u0 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 V" P* c( i. g4 p% b/ `
and β-human chorionic gonadotropin was less than
; x0 \5 r" t4 A  q1 \5 mIU/mL (normal <5 mIU/mL). Serum follicular
% O8 @0 I  x4 A, k. s6 d0 a8 w0 R4 istimulating hormone and leuteinizing hormone
3 d( e  ?& P2 |& r7 i3 L( Rconcentrations were less than 0.05 mIU/mL
: Y% Y- s. v% B3 X+ z8 @, M7 z' n1 u5 x(prepubertal).
6 ^( {5 k, V* s7 h3 I) o% |7 W# B  eThe parents were notified about the laboratory
  a$ c1 V1 L8 ~6 i1 P% X" }9 uresults and were informed that all of the tests were
& y: x6 u9 U  H, l/ z+ V9 }normal except the testosterone level was high. The2 C' s1 f$ t: r* \6 K4 ?+ b- A
follow-up visit was arranged within a few weeks to/ K7 s  K. D. c' l. Z4 H7 q
obtain testicular and abdominal sonograms; how-0 n; D2 H, d8 t4 i
ever, the family did not return for 4 months.  L6 e9 }. e+ {/ X% l0 u
Physical examination at this time revealed that the
! w% @% x  l  T$ g0 V4 i' \child had grown 2.5 cm in 4 months and had gained
& ?' x) B6 V% N: @7 J/ U2 kg of weight. Physical examination remained% ]. d+ ?$ S9 l- Y: \- o
unchanged. Surprisingly, the pubic hair almost com-
  t0 a+ X$ T; G, b7 }8 i3 \5 npletely disappeared except for a few vellous hairs at
- ]7 F) K1 C  D' N% Rthe base of the phallus. Testicular volume was still 2
9 P) a4 y# \) T+ ]) N" I. BmL, and the size of the penis remained unchanged.. f5 U8 C0 a) e" l* d7 P3 N1 @( \
The mother also said that the boy was no longer hav-
! ?4 ^( W% R3 D% wing frequent erections.' o+ }) [% }  w, _& W- h5 O. H
Both parents were again questioned about use of
$ e* ?0 I4 V, g) A4 M4 }# {any ointment/creams that they may have applied to/ v! a( \& i# S5 f
the child’s skin. This time the father admitted the
5 A# F: }" S5 o7 d) e5 `( ZTopical Testosterone Exposure / Bhowmick et al 541
- q: T% @7 Y6 N& H  c; uuse of testosterone gel twice daily that he was apply-3 D( g" u9 V. `
ing over his own shoulders, chest, and back area for
+ m3 F: a* t5 W4 \2 ea year. The father also revealed he was embarrassed6 ?7 W2 @  ^6 Q4 `  J2 E( J1 N  q& J
to disclose that he was using a testosterone gel pre-
  b5 B& F$ y! L! Fscribed by his family physician for decreased libido
4 M% M1 q6 v3 y8 Nsecondary to depression.7 G$ ^6 n5 P2 c& L9 ~( l; D% m
The child slept in the same bed with parents.5 ?2 R6 f, u. C# _' O3 k
The father would hug the baby and hold him on his3 G2 ?9 W% g5 c7 j% g
chest for a considerable period of time, causing sig-0 P$ }$ [" m: n) a! t
nificant bare skin contact between baby and father.
- O6 P7 K8 l1 `- @The father also admitted that after the phone call,6 u$ U( q+ ^( r# }
when he learned the testosterone level in the baby8 u' n& O7 a7 \& B" ~$ T) e
was high, he then read the product information
: [8 W% x2 v  h) I6 W" p1 d! lpacket and concluded that it was most likely the rea-
, s" R4 k/ M2 N: a7 t# L% x: Uson for the child’s virilization. At that time, they
+ t6 |$ B* A% N, Y: C( vdecided to put the baby in a separate bed, and the# U/ Y& P6 i1 w! P% ]$ @$ A
father was not hugging him with bare skin and had
0 D/ n9 J* i6 K4 v# g& @0 O: Rbeen using protective clothing. A repeat testosterone
6 R2 S" j* R( z+ l/ Ptest was ordered, but the family did not go to the
/ S  f# V* P: v/ e( h% ^9 Mlaboratory to obtain the test./ i$ ?  A, C/ f' I. @* x
Discussion" t- n+ L7 q% N, ]4 J
Precocious puberty in boys is defined as secondary
1 n8 q* s% W( g9 f9 A5 rsexual development before 9 years of age.1,4! v8 Z/ T9 m8 l4 F8 h- L
Precocious puberty is termed as central (true) when. T8 N4 x2 u6 z  m* h( E
it is caused by the premature activation of hypo-
9 l6 u4 L" ]: O! @thalamic pituitary gonadal axis. CPP is more com-
4 U4 d' b' ~& i0 Xmon in girls than in boys.1,3 Most boys with CPP6 |: K3 P8 V9 b6 N/ ?! M/ g
may have a central nervous system lesion that is
3 E! W4 e- W1 T6 r& Cresponsible for the early activation of the hypothal-
& ]- x6 e) O& K+ z: w! N" lamic pituitary gonadal axis.1-3 Thus, greater empha-9 n- W( g; W) M5 H4 G
sis has been given to neuroradiologic imaging in
+ r0 D1 U; {1 F- _boys with precocious puberty. In addition to viril-
8 h) W( q) X7 K' |ization, the clinical hallmark of CPP is the symmet-
* w8 m3 r8 n) S* G1 qrical testicular growth secondary to stimulation by& R( h4 b1 `6 R# r" k
gonadotropins.1,3, `2 w, m& O6 C& W! j
Gonadotropin-independent peripheral preco-( S. |3 O. ?* F. j, U
cious puberty in boys also results from inappropriate! G* b+ k2 a: \7 Y0 A
androgenic stimulation from either endogenous or  I( V0 Z. B: a. C8 P/ L' y% A# g
exogenous sources, nonpituitary gonadotropin stim-
$ O7 }6 {& [( V7 b/ Q  tulation, and rare activating mutations.3 Virilizing
  m" V1 b1 t( I$ @. e6 mcongenital adrenal hyperplasia producing excessive# t/ z0 L7 @- P9 P; s  U5 e
adrenal androgens is a common cause of precocious- S3 ^) p0 l1 g! {+ Q; U! N- d+ }
puberty in boys.3,4
4 G, i  L9 R$ U& k3 LThe most common form of congenital adrenal
! p  H1 R6 ]* ^hyperplasia is the 21-hydroxylase enzyme deficiency.' U6 _1 e  K: Y
The 11-β hydroxylase deficiency may also result in' P. z+ _8 o; `4 @$ Z
excessive adrenal androgen production, and rarely,  ]2 ^; s: `, ~6 h( p" d
an adrenal tumor may also cause adrenal androgen
1 K$ I! @' L5 n6 B& q$ b5 G2 e4 ]excess.1,3
" a# ^! o- V( f$ c% A% `9 kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* {: |" m8 l! c4 @- e: H& x542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' @1 ~+ R4 o) T; d) TA unique entity of male-limited gonadotropin-
; n4 ?6 K1 l9 B) M* F( d0 H2 F( |6 jindependent precocious puberty, which is also known
: A8 X8 `. `. y' o& v' C2 v! Has testotoxicosis, may cause precocious puberty at a
) `% ]% U* T, ?/ D, |- l( d3 vvery young age. The physical findings in these boys
4 @6 G/ D( c5 @% E0 I: c8 F, c( zwith this disorder are full pubertal development,. P( b. P' _- O! F( u
including bilateral testicular growth, similar to boys4 R% n' u% O9 C" f7 @
with CPP. The gonadotropin levels in this disorder
7 y: I# f" n* A: Qare suppressed to prepubertal levels and do not show
6 u9 r; C5 s# Xpubertal response of gonadotropin after gonadotropin-
0 R( H% r3 x9 [& xreleasing hormone stimulation. This is a sex-linked
) \; x0 _3 R) eautosomal dominant disorder that affects only
. o: d+ d$ F: i, z( F3 a1 F$ Dmales; therefore, other male members of the family
  n7 {7 N5 y* i7 cmay have similar precocious puberty.3( ~4 g  l- |; ?5 `3 i& ]/ e' ?
In our patient, physical examination was incon-
6 h  k; z) T/ G% t/ X" Asistent with true precocious puberty since his testi-
1 F2 Y+ N0 n1 A" T; o' |5 ~cles were prepubertal in size. However, testotoxicosis- g& e( x  W1 G+ z4 C( \  N- ^
was in the differential diagnosis because his father
; p1 ?$ L$ L* v6 q, C' Astarted puberty somewhat early, and occasionally,& M" f/ ?$ N7 m
testicular enlargement is not that evident in the
' X# B4 G8 ^9 E5 B5 B3 ]beginning of this process.1 In the absence of a neg-5 ?, T  c7 d, F4 `% G7 D5 o
ative initial history of androgen exposure, our. P1 Y+ a/ |: m8 P
biggest concern was virilizing adrenal hyperplasia,
# a4 G' g! C8 W3 D1 Heither 21-hydroxylase deficiency or 11-β hydroxylase; K3 f% f9 `3 e5 J
deficiency. Those diagnoses were excluded by find-
, \" X* h' o8 Ring the normal level of adrenal steroids.- e1 Q0 @, x9 o; U5 b
The diagnosis of exogenous androgens was strongly7 C) i! d8 A  }- O4 V: ^
suspected in a follow-up visit after 4 months because0 M; G% u2 P% {; A- X7 d
the physical examination revealed the complete disap-
% q' \* h' r6 F3 e8 mpearance of pubic hair, normal growth velocity, and
0 J$ l9 X1 l: _! M' e( Rdecreased erections. The father admitted using a testos-# i; w9 Y/ R, o1 D; @6 Y( O5 R, ~
terone gel, which he concealed at first visit. He was
0 t. B* D6 b* ^  ?7 m6 [' R9 B  `8 ]using it rather frequently, twice a day. The Physicians’
" ^' }& n( ^9 c  W+ r- hDesk Reference, or package insert of this product, gel or2 ]+ q" y* h! p6 d
cream, cautions about dermal testosterone transfer to$ o0 p, ~2 I( _6 l
unprotected females through direct skin exposure.
, u! r- x$ |" [' G/ @1 B- A1 f3 zSerum testosterone level was found to be 2 times the! r* ?6 H- i) n' ^+ O) j
baseline value in those females who were exposed to6 w5 q. }6 R& a' s8 P* J! W( ?& F% P
even 15 minutes of direct skin contact with their male
$ ]! V3 i/ i# Q2 ppartners.6 However, when a shirt covered the applica-7 p1 j$ R( e! d. m2 n
tion site, this testosterone transfer was prevented.5 M& W" S, P. r: t
Our patient’s testosterone level was 60 ng/mL,7 f1 l6 v: G) K5 T' M& l" @
which was clearly high. Some studies suggest that  [2 M2 g3 F6 ?5 [; q6 d7 \
dermal conversion of testosterone to dihydrotestos-) @* @6 u8 W  J: I! D/ b1 B$ y
terone, which is a more potent metabolite, is more* o" m1 l8 u+ L+ _, A
active in young children exposed to testosterone" R# u& r. ^$ l7 O) C
exogenously7; however, we did not measure a dihy-
7 Q4 W: M, {& t9 e& S; p( @( Tdrotestosterone level in our patient. In addition to. q* [, G" R+ M. s
virilization, exposure to exogenous testosterone in
+ S0 B& s4 s2 W0 f: q. [children results in an increase in growth velocity and
0 k/ m9 i# g/ I" j5 E' Oadvanced bone age, as seen in our patient.& c# K9 m$ Z1 v5 T* @( A
The long-term effect of androgen exposure during
4 c, O0 P& j; c- ]/ a8 V* ]) Iearly childhood on pubertal development and final
# l4 y9 g2 R7 s# Uadult height are not fully known and always remain6 l6 I# Z- y3 U
a concern. Children treated with short-term testos-
$ P4 \( R5 _; G/ b5 Lterone injection or topical androgen may exhibit some' D' X5 ~: A  e7 L9 B$ _. e! u7 @( V
acceleration of the skeletal maturation; however, after
8 l6 @* ]/ u1 p6 m* C! S; o* a% T: pcessation of treatment, the rate of bone maturation
& C& V! m: X4 \7 U0 sdecelerates and gradually returns to normal.8,96 c% V& [! j# G& Z5 x
There are conflicting reports and controversy
+ X8 b( W4 n' k0 v+ oover the effect of early androgen exposure on adult
/ W5 ?0 C; m( L9 a( ~9 \6 B0 c- Rpenile length.10,11 Some reports suggest subnormal
, y$ X3 j5 T! C6 e3 {* nadult penile length, apparently because of downreg-
- @. f9 j) z! aulation of androgen receptor number.10,12 However,* K& C7 s: e$ e* ~  [9 R
Sutherland et al13 did not find a correlation between
  @5 F% l7 C$ o9 |$ M- Achildhood testosterone exposure and reduced adult8 W+ j& |2 o" L$ T" i; Z
penile length in clinical studies., V' n" q: l: [( b
Nonetheless, we do not believe our patient is
5 j; d! u* v+ Fgoing to experience any of the untoward effects from
" \/ P+ ~, q9 ~1 ~0 ]7 ttestosterone exposure as mentioned earlier because7 U2 t7 R7 e  x0 A, d+ }( R
the exposure was not for a prolonged period of time.- E2 ~; R) i/ D+ M9 v
Although the bone age was advanced at the time of5 z- w3 v. p, O, Y
diagnosis, the child had a normal growth velocity at: z  a! [" t2 u" x; w/ i8 @
the follow-up visit. It is hoped that his final adult
9 h$ p) T) M7 F% Uheight will not be affected.
5 }' F, z' V2 _" Q8 u$ Q* D! ~Although rarely reported, the widespread avail-
0 x; k- Z' M, O+ kability of androgen products in our society may- M$ f, M9 H/ m" F/ A3 \
indeed cause more virilization in male or female/ P" S3 p" p, g" x
children than one would realize. Exposure to andro-
/ V! B. l8 @  mgen products must be considered and specific ques-" I. k3 Z  M  c# M1 ^5 _
tioning about the use of a testosterone product or$ r0 C6 P( y* H* n2 v2 l
gel should be asked of the family members during. T, I9 @) s$ q# O
the evaluation of any children who present with vir-
$ v9 z- y& J6 lilization or peripheral precocious puberty. The diag-+ S% g2 a, x) @1 a/ T: D' b8 k' X3 E
nosis can be established by just a few tests and by
+ M  E' v- U4 A) w$ y8 t) vappropriate history. The inability to obtain such a% ?* d. H' ~( ]  M
history, or failure to ask the specific questions, may( ~, b) ^0 l+ c+ g4 j
result in extensive, unnecessary, and expensive& r/ I8 ^8 j  Z7 O) o, T) Y
investigation. The primary care physician should be6 g- e, ^" k& V
aware of this fact, because most of these children, O3 f+ X" k; J
may initially present in their practice. The Physicians’
  P6 v& Q0 l5 O' r' K" V2 zDesk Reference and package insert should also put a5 [6 S4 g5 Q% u4 ?! G3 Y  Y
warning about the virilizing effect on a male or
' l2 r7 J3 v2 v& K- Z0 vfemale child who might come in contact with some-
% W: C9 ?5 c; _- oone using any of these products." ~  u9 g. _) E9 j9 V, n
References
/ ^  F6 j0 @* m1. Styne DM. The testes: disorder of sexual differentiation
- V5 M9 O# L- D4 `3 u- {5 oand puberty in the male. In: Sperling MA, ed. Pediatric
* O6 X# O& `" M6 H3 _. UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ ?9 r6 A) {* X7 x
2002: 565-628.
- }, @) @" m& t% m2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ Z8 l. ]0 k9 E/ m1 x/ M! n2 j3 n6 Cpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) s" g, w8 m( w$ B7 R) _* p
Boy Induced by Indirect Topical
% S8 x0 t* n- I" wExposure to Testosterone  w( b: A* y9 ~& J, c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 C" I: q* ]- m+ iand Kenneth R. Rettig, MD1. A  O$ @/ o: t4 d7 V5 c$ x0 f
Clinical Pediatrics
1 ?+ u! e( r! tVolume 46 Number 6" H. f7 r* ?, Y0 G( Y; Y6 c
July 2007 540-543. _7 D  }! F8 }1 w0 d3 c
© 2007 Sage Publications+ }0 Y0 n- x1 M3 m  g% Z4 X5 D* g
10.1177/0009922806296651
% d$ M1 {8 i1 L5 M3 ?) nhttp://clp.sagepub.com- @4 o* t1 c" i# i
hosted at9 U8 i& N7 a) s1 p  U3 A9 B
http://online.sagepub.com4 O4 ^" _  T4 O
Precocious puberty in boys, central or peripheral,( e, B$ b8 Y7 q* q
is a significant concern for physicians. Central6 m- w; `1 J' |4 P
precocious puberty (CPP), which is mediated
; l# y  ]! C3 s7 l) [# Ythrough the hypothalamic pituitary gonadal axis, has
5 }2 \. x/ @1 p( J+ P9 za higher incidence of organic central nervous system
  r( G1 ?3 A7 _0 C9 e( C" ?lesions in boys.1,2 Virilization in boys, as manifested; M8 m$ B3 }+ i$ D
by enlargement of the penis, development of pubic. A7 d: A7 r: k) k( g6 Q" b
hair, and facial acne without enlargement of testi-
( n$ @( @; v7 j% g4 _. qcles, suggests peripheral or pseudopuberty.1-3 We
) h# `$ L# T: [2 O0 hreport a 16-month-old boy who presented with the
; ~+ n0 m- j; L! P$ i2 fenlargement of the phallus and pubic hair develop-
' q/ U+ j; F, W% D( pment without testicular enlargement, which was due" I8 ^2 F  P; y5 [7 D
to the unintentional exposure to androgen gel used by
/ v, U, Q6 [& g- k6 M+ Z) Sthe father. The family initially concealed this infor-
' i+ E. a4 s- j( cmation, resulting in an extensive work-up for this- ?; A1 X4 _, I( [: w8 T# p8 i
child. Given the widespread and easy availability of  l8 a, J. q8 j
testosterone gel and cream, we believe this is proba-
+ V( g2 Q# d3 {1 y. x  x8 g0 zbly more common than the rare case report in the
3 v% p! U: p3 Q/ g( w* N' [% v# ]literature.4
2 {1 [) t2 O3 _, @" S6 ^5 tPatient Report' f; k) [5 \* z1 M2 Z
A 16-month-old white child was referred to the2 U, S6 O: }5 S1 m. j! U6 Z6 B% Y+ e
endocrine clinic by his pediatrician with the concern% F% X* a/ w0 k3 ^( i6 C
of early sexual development. His mother noticed: D; t) A5 Q' q& b, o
light colored pubic hair development when he was
- h! U+ }0 H+ T4 o% l$ b0 LFrom the 1Division of Pediatric Endocrinology, 2University of$ o4 \; S$ }" I& z
South Alabama Medical Center, Mobile, Alabama.
/ P5 z6 ?+ L; b# kAddress correspondence to: Samar K. Bhowmick, MD, FACE,3 X5 D, r  [2 u  x5 t' E5 [7 R
Professor of Pediatrics, University of South Alabama, College of
3 {- `" l5 b3 ]% O0 CMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 f7 E2 R( j+ v6 K! ?. Z' P
e-mail: [email protected].
* `) ?6 @7 a( eabout 6 to 7 months old, which progressively became
1 v9 a! \$ U* K/ b, B1 ]darker. She was also concerned about the enlarge-
0 V5 ^; O$ Z+ b4 nment of his penis and frequent erections. The child! H" Q! L1 e" Z; m
was the product of a full-term normal delivery, with: w# U( B: `' c! _5 R
a birth weight of 7 lb 14 oz, and birth length of! ~. b4 |  b( x( p3 E* b- I
20 inches. He was breast-fed throughout the first year& G6 C" j3 m: l" i+ N/ F  M
of life and was still receiving breast milk along with
4 i- K+ H1 k( }* {7 _solid food. He had no hospitalizations or surgery,9 c7 q' C+ ?, @4 X3 Q
and his psychosocial and psychomotor development1 i* |' R1 i" T5 I, g$ H
was age appropriate.
. Q6 d* }9 B5 r" ?The family history was remarkable for the father,
2 W9 H9 d% v- {! X4 Fwho was diagnosed with hypothyroidism at age 16,2 p9 Y2 V3 R; f! D
which was treated with thyroxine. The father’s
1 ~  Z1 M  k% l1 eheight was 6 feet, and he went through a somewhat7 s9 K; m/ o# D
early puberty and had stopped growing by age 14.
$ q2 ]) e# v! B3 R5 EThe father denied taking any other medication. The
4 f- q% f5 Q7 ~2 @child’s mother was in good health. Her menarche
( o% F1 D2 V, ]# Q% g/ K. Wwas at 11 years of age, and her height was at 5 feet
  z. C- F' Z% ]+ I  @3 g5 }6 V+ m5 inches. There was no other family history of pre-
0 N# u% e( d5 f7 u! n$ kcocious sexual development in the first-degree rela-
# f; W; ?( k' d1 \% |; x5 _/ B3 \tives. There were no siblings.
( t0 v% C) c& a) P3 T6 \2 ?Physical Examination
  i! T# x2 q7 A5 OThe physical examination revealed a very active,
6 @: m- m7 C4 Y' k! Uplayful, and healthy boy. The vital signs documented
( i2 M) G* ?) P4 Z5 P( Ha blood pressure of 85/50 mm Hg, his length was
$ |8 _3 O  @" n' U90 cm (>97th percentile), and his weight was 14.4 kg6 B3 E! b. p6 M
(also >97th percentile). The observed yearly growth0 j) Y" a, z" @4 s+ p
velocity was 30 cm (12 inches). The examination of5 @+ Y$ a- B4 F* ]( L" h* |
the neck revealed no thyroid enlargement." ?9 H& l+ r- [6 j
The genitourinary examination was remarkable for3 c3 z/ u; n, r  s# ~
enlargement of the penis, with a stretched length of
2 z! \& H$ Q2 N7 u$ ?8 cm and a width of 2 cm. The glans penis was very well
  A# C( S" J& z  Y7 I7 Rdeveloped. The pubic hair was Tanner II, mostly around8 B$ u$ D4 _  l, Y
540; s9 @: Q9 p0 b5 Q3 _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 p' k: `1 O4 T' O, Sthe base of the phallus and was dark and curled. The
+ @. s# Z9 J. n! f: Q4 v: xtesticular volume was prepubertal at 2 mL each.5 k, j( x5 I7 Z: [* P
The skin was moist and smooth and somewhat6 D  e/ L/ B) ~( A* C" Q
oily. No axillary hair was noted. There were no( ]6 B! o3 Q5 q' k4 b
abnormal skin pigmentations or café-au-lait spots., V, W) f# D# |5 E# ]+ B
Neurologic evaluation showed deep tendon reflex 2+
* [- C9 E! R. u! |4 `bilateral and symmetrical. There was no suggestion
3 x1 o( ~5 d: p6 @5 V( Kof papilledema.
. d8 X$ }! M' A7 [* VLaboratory Evaluation1 F1 [6 U+ a$ b# n. N1 f
The bone age was consistent with 28 months by
- q, J3 z% ~+ x) |using the standard of Greulich and Pyle at a chrono-
6 k8 i& t' b# s" ^logic age of 16 months (advanced).5 Chromosomal
- n6 v+ M" D5 z3 {- Okaryotype was 46XY. The thyroid function test- r. m2 s4 R. ]5 W4 @; p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# {2 }$ |  w4 v/ R+ ulating hormone level was 1.3 µIU/mL (both normal).; L4 ^( W. C4 k5 A) J
The concentrations of serum electrolytes, blood3 D( J- A- ^* J6 a
urea nitrogen, creatinine, and calcium all were, F9 W4 s- S' A: ~
within normal range for his age. The concentration
6 o; K6 ~6 S' [+ Mof serum 17-hydroxyprogesterone was 16 ng/dL& w% f4 ~  k& z
(normal, 3 to 90 ng/dL), androstenedione was 20* ~2 t6 X* P4 A4 |
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 k- W. A& j# Q. ~5 ]- w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),' C! F) Z1 x/ |4 e, L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* t7 R- u: D2 \/ K
49ng/dL), 11-desoxycortisol (specific compound S)  v5 H4 ^" R, j! K/ c
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- R, B5 c' K9 A( O1 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; g! j3 `8 }+ Y) q3 [0 A% \4 v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),, ~( W' \8 H- \4 D) Q) {" k* n
and β-human chorionic gonadotropin was less than9 c, [6 x% b& Q+ O" V0 n
5 mIU/mL (normal <5 mIU/mL). Serum follicular% q/ X9 r$ w0 y% z  J0 j
stimulating hormone and leuteinizing hormone3 B" D5 b. ^9 a  W
concentrations were less than 0.05 mIU/mL
4 R% ~0 b, Q2 a; P(prepubertal).# z+ y; n, A% p, Q& l6 f8 t  |
The parents were notified about the laboratory$ V0 z$ C5 r  |0 ~7 D0 t
results and were informed that all of the tests were1 ^7 @; \3 @( e) R, x. z
normal except the testosterone level was high. The
  N" c9 h& w2 o3 l  d+ T4 _# Ufollow-up visit was arranged within a few weeks to8 c- R% R8 m1 C2 ]5 F5 D
obtain testicular and abdominal sonograms; how-7 ~# ?# S( w$ i
ever, the family did not return for 4 months.
2 O. ]. i6 _; N) i: |Physical examination at this time revealed that the4 a( Z; T# O( x. f' w$ Y  S
child had grown 2.5 cm in 4 months and had gained. c! N; K7 a7 Q0 P" v
2 kg of weight. Physical examination remained0 l4 d( z4 {" W( f4 O
unchanged. Surprisingly, the pubic hair almost com-( w3 x0 q1 `$ C
pletely disappeared except for a few vellous hairs at
: Z( F: Y" N3 X# ythe base of the phallus. Testicular volume was still 2+ w( D8 G: f8 g
mL, and the size of the penis remained unchanged.; J( s  e+ Z$ D1 @
The mother also said that the boy was no longer hav-
" x% `) J& H8 k1 A" g! n$ `9 g" Jing frequent erections.
8 k( B- e4 r# {0 Z- ~0 EBoth parents were again questioned about use of
  I3 a+ p, c: `9 V- T7 Dany ointment/creams that they may have applied to
8 e" |; B" n$ Vthe child’s skin. This time the father admitted the5 d+ e3 Z4 V) F
Topical Testosterone Exposure / Bhowmick et al 541$ `0 _. K2 O8 K/ ~% v
use of testosterone gel twice daily that he was apply-' G6 E( ~1 Z  x+ [* [/ a; P
ing over his own shoulders, chest, and back area for
1 D- ~  ?+ D, V! U! K- S7 Q! N: |( Ca year. The father also revealed he was embarrassed5 O2 d! N) C4 ]8 Y7 `1 M( @2 l$ G
to disclose that he was using a testosterone gel pre-. ]6 |3 \9 v5 V. \
scribed by his family physician for decreased libido( O6 a  j* R- X0 _
secondary to depression.
9 @% W# @* K3 r* Y* V7 T) V% ZThe child slept in the same bed with parents.. k( P0 F* G% q9 l8 j
The father would hug the baby and hold him on his. @+ ?6 n1 V: _" V
chest for a considerable period of time, causing sig-4 ]9 M" l  T, q2 d* j; Z# g% V  `
nificant bare skin contact between baby and father.: K2 r" W( q( K8 r/ l% P" h( x8 n
The father also admitted that after the phone call,
$ P  Z4 c5 W0 ]; M0 ~% Zwhen he learned the testosterone level in the baby
" R1 m' a, Z+ l  M% Nwas high, he then read the product information
/ _: Y' s* ^& g- s1 Zpacket and concluded that it was most likely the rea-: f/ b1 u: L% r0 {
son for the child’s virilization. At that time, they# H. e& ~4 X+ j6 _* D
decided to put the baby in a separate bed, and the
' X6 l$ o  X. Cfather was not hugging him with bare skin and had- i) Y0 l0 J/ w' s; o
been using protective clothing. A repeat testosterone
0 Q" ^% ]! G  |+ q' T8 [test was ordered, but the family did not go to the
0 q3 r( I; A% C4 s4 Y! n  k- jlaboratory to obtain the test.
; ^2 g  r! |9 a6 uDiscussion: b% v6 [3 _3 y% N
Precocious puberty in boys is defined as secondary2 q0 |6 m$ T. W7 q+ \( i
sexual development before 9 years of age.1,4
' z5 p; D$ R( B$ n# iPrecocious puberty is termed as central (true) when% l  c0 P4 {: b: o
it is caused by the premature activation of hypo-, \& l9 ^0 l5 e! K# F) x) p
thalamic pituitary gonadal axis. CPP is more com-
6 ^: D9 t) {, C! I, c+ bmon in girls than in boys.1,3 Most boys with CPP# [) u: B' M& y6 R
may have a central nervous system lesion that is0 s, x: w  t0 s- D
responsible for the early activation of the hypothal-
% x7 A; a) c* x. Famic pituitary gonadal axis.1-3 Thus, greater empha-
6 t- x- S0 Q; W, J0 [sis has been given to neuroradiologic imaging in
( g% C& R' Y; I# o* w1 k! P: ~boys with precocious puberty. In addition to viril-
, z3 g! V5 G4 k( v. g# Z; jization, the clinical hallmark of CPP is the symmet-# s* [, A' i" p, l; ?- h! R% b
rical testicular growth secondary to stimulation by$ {" |# V! f1 @+ m. n, L  D
gonadotropins.1,3; X) @2 {/ s$ n# r+ |
Gonadotropin-independent peripheral preco-  I7 |% r1 _% G+ r$ [  X& x
cious puberty in boys also results from inappropriate
! p+ N& A5 m- {androgenic stimulation from either endogenous or2 }, t1 c$ E0 Z% u4 o$ ~- t* W
exogenous sources, nonpituitary gonadotropin stim-
! m1 j, \  d0 J+ z) Lulation, and rare activating mutations.3 Virilizing; X  o( U. `2 c8 Q' ]) S
congenital adrenal hyperplasia producing excessive
: y& H. Z% k2 q# Y! s+ z) ^adrenal androgens is a common cause of precocious
, A8 d; G) e* f& b- Vpuberty in boys.3,4
4 v$ A  B8 p/ m0 e# cThe most common form of congenital adrenal
) P3 x2 I! u+ nhyperplasia is the 21-hydroxylase enzyme deficiency.
# Z  r- ?) \# z, p# |The 11-β hydroxylase deficiency may also result in
' [( U% z6 H. @$ B2 Dexcessive adrenal androgen production, and rarely,
0 n4 b+ v  G3 |0 Z4 w* F1 Qan adrenal tumor may also cause adrenal androgen- R* k- S5 B. g, D* w4 [
excess.1,3
7 P& C5 z9 }3 R1 W& Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  g. P3 x+ M* ~4 T% G9 R' ~
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ d; Y0 _1 C4 O& u2 L
A unique entity of male-limited gonadotropin-
0 G" B) I" G$ ~! r  V, xindependent precocious puberty, which is also known
; w0 m) _. J/ T6 n1 B; E' C- Vas testotoxicosis, may cause precocious puberty at a
1 |! D7 I' s6 y, Dvery young age. The physical findings in these boys
$ Q. H7 l) e# X$ A; pwith this disorder are full pubertal development,, j$ O; b. `' X- R. }5 ^8 K* R% P
including bilateral testicular growth, similar to boys2 ^! ~0 \+ m( Q7 v$ y
with CPP. The gonadotropin levels in this disorder
8 a2 A# T7 f' q' Oare suppressed to prepubertal levels and do not show  E; h4 y; r9 n/ b
pubertal response of gonadotropin after gonadotropin-5 Z: ^7 t* |  ]3 f
releasing hormone stimulation. This is a sex-linked2 y3 t; `0 H- ?4 t
autosomal dominant disorder that affects only
/ M4 o" P5 j0 J1 D; y% Q4 Nmales; therefore, other male members of the family
& q1 k) \) G' W% }# Amay have similar precocious puberty.35 e5 _$ D- U7 u3 B" j
In our patient, physical examination was incon-
- E# Q7 \2 L6 B/ I# F: lsistent with true precocious puberty since his testi-! _# \( q1 ?6 k- _; {
cles were prepubertal in size. However, testotoxicosis
8 U& n- X  }7 B' u' J8 Ywas in the differential diagnosis because his father
/ F4 H* V5 V- J) r: L+ rstarted puberty somewhat early, and occasionally,8 {4 z! P4 u- I, l
testicular enlargement is not that evident in the
$ {/ C5 @/ X9 t5 L& Z; B4 U' m5 mbeginning of this process.1 In the absence of a neg-
+ R1 \. `3 \' t% ^( {ative initial history of androgen exposure, our* C$ S+ S' u5 u2 h8 r5 p* s& K/ {
biggest concern was virilizing adrenal hyperplasia,
! ^, Z( @5 |! C' seither 21-hydroxylase deficiency or 11-β hydroxylase  O* O8 _( Q4 `" w
deficiency. Those diagnoses were excluded by find-
2 u; ~0 y0 O- ]' v5 E: Jing the normal level of adrenal steroids.
* v$ [0 C1 L' O9 N6 JThe diagnosis of exogenous androgens was strongly* l0 K7 X. z* K9 C- U1 F
suspected in a follow-up visit after 4 months because! J# o+ D. @7 y
the physical examination revealed the complete disap-. n# g% ~& g7 K, q# ]; {
pearance of pubic hair, normal growth velocity, and
, A3 Q4 X9 k! B; [1 v: Hdecreased erections. The father admitted using a testos-* j3 T2 f% G* t6 J! {; E
terone gel, which he concealed at first visit. He was) s6 r  }- R% B4 S6 |
using it rather frequently, twice a day. The Physicians’' |' t/ I5 q7 f; a( l. U' C" O
Desk Reference, or package insert of this product, gel or
2 I; Y1 [. F8 U' Z8 _+ ^- ~cream, cautions about dermal testosterone transfer to) W0 F0 L; t. R2 w  k3 z) c- h: X
unprotected females through direct skin exposure.% D& c. J9 _7 n4 s9 C; H% A
Serum testosterone level was found to be 2 times the6 x2 l% E& y7 G* i
baseline value in those females who were exposed to
* A: G5 e, ^& q) w5 Ceven 15 minutes of direct skin contact with their male7 }, [0 t7 X6 S9 I4 n. U
partners.6 However, when a shirt covered the applica-, r6 V; x( G# i9 R1 P% t7 V
tion site, this testosterone transfer was prevented.$ X" b' y6 y7 H3 Y* _
Our patient’s testosterone level was 60 ng/mL,4 f: D/ K: d/ S
which was clearly high. Some studies suggest that( ^3 `4 d1 J7 Q  a7 V
dermal conversion of testosterone to dihydrotestos-
" ?2 B! B" R3 ^7 s: Aterone, which is a more potent metabolite, is more
' @1 ~5 W6 k( V* @active in young children exposed to testosterone
  Z3 o: \9 b6 o: N$ Z9 Nexogenously7; however, we did not measure a dihy-9 E, q1 ]9 Y; l+ `; u7 _
drotestosterone level in our patient. In addition to
1 f& I, x, i! s/ f: N8 qvirilization, exposure to exogenous testosterone in! k/ w6 y4 f- H1 Y6 w& @+ J
children results in an increase in growth velocity and, d! X  {( K/ l
advanced bone age, as seen in our patient.
* |; Y0 Y) D- b2 N; ?- t+ u+ @- c6 m: c% jThe long-term effect of androgen exposure during
, ?8 \8 z7 c# z4 q5 vearly childhood on pubertal development and final
! v" S+ o  R( c. b$ m3 f8 qadult height are not fully known and always remain
, M9 U/ O9 r, R" Oa concern. Children treated with short-term testos-0 m) w8 i: u8 P$ ~+ @% f4 d' n
terone injection or topical androgen may exhibit some
3 |% [" N$ M4 M7 Tacceleration of the skeletal maturation; however, after" ~  ?5 H4 t" @7 S
cessation of treatment, the rate of bone maturation; Y6 P; y2 I* p: y
decelerates and gradually returns to normal.8,9
  D& C  [8 U$ L/ x, W. VThere are conflicting reports and controversy
* y, f4 y' ?7 Q& [4 T' P5 T+ }over the effect of early androgen exposure on adult
4 \: V5 q$ N$ apenile length.10,11 Some reports suggest subnormal( L' n' C7 l3 o- c
adult penile length, apparently because of downreg-
6 X: P" [  O' b7 L: dulation of androgen receptor number.10,12 However,8 N& i) C- W; v" F
Sutherland et al13 did not find a correlation between
) k% m5 W7 s$ n+ O6 i* N" rchildhood testosterone exposure and reduced adult
2 [$ f1 a8 F1 L1 B) t  Ipenile length in clinical studies.
3 Z- c1 X9 c& W: {. i# dNonetheless, we do not believe our patient is
( X% C+ [7 O. u; q4 r9 t, m0 `. Ngoing to experience any of the untoward effects from
( G- |/ j) Z; a" A  Y# Y$ @6 N. g0 Dtestosterone exposure as mentioned earlier because6 {) k7 I4 X1 E. Z6 h
the exposure was not for a prolonged period of time.% U5 a1 @9 x! p- {/ O: n
Although the bone age was advanced at the time of2 g( L  E, g# y
diagnosis, the child had a normal growth velocity at
/ }# O- H& O0 I$ F* U8 Gthe follow-up visit. It is hoped that his final adult
; v( j( J6 C( P, e1 F4 B- Rheight will not be affected.5 Y, W1 H4 S8 S8 |& n5 N+ `9 H
Although rarely reported, the widespread avail-! S  _8 U. h3 S2 y8 ]* d9 B% w
ability of androgen products in our society may# N' M) Y* ]2 }2 \% I4 S/ V& q
indeed cause more virilization in male or female
% D2 {- y& {* y' ^children than one would realize. Exposure to andro-
* z8 D' O8 X8 ^gen products must be considered and specific ques-
7 J6 Z! v( P/ T  |' ytioning about the use of a testosterone product or
; O$ I0 E" }  F% g) |& Egel should be asked of the family members during( }5 ^% d4 R7 Q' C0 H
the evaluation of any children who present with vir-
: I+ L$ l9 c7 g6 Silization or peripheral precocious puberty. The diag-
7 q, O* l0 y; w! f3 ]( h2 @6 u& x) jnosis can be established by just a few tests and by
) i: V; }5 Z9 {& L% |* Xappropriate history. The inability to obtain such a. z8 u9 |% V# j3 u
history, or failure to ask the specific questions, may
5 D/ ~* D$ L- @" l" I' Lresult in extensive, unnecessary, and expensive
9 D" @& y& ]( Ainvestigation. The primary care physician should be
5 L3 a! |* |: k8 J: o& aaware of this fact, because most of these children2 ~# [" f9 v4 v3 b- L. k& \
may initially present in their practice. The Physicians’3 L, C! y5 }( B
Desk Reference and package insert should also put a& t; t, o# T% c! \5 ]  O; e, Q2 w. k( l
warning about the virilizing effect on a male or
, t# X$ x/ B/ a3 k3 ?" d$ Mfemale child who might come in contact with some-
$ A  B7 X/ J7 Gone using any of these products.: [2 ~4 V8 ~1 k: b+ F! Q$ Q6 k
References, w" |3 P: D, R2 ?0 f
1. Styne DM. The testes: disorder of sexual differentiation
$ s' ~4 N, q# R( t& l* T6 uand puberty in the male. In: Sperling MA, ed. Pediatric
6 c/ C+ I  ]7 o! AEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 J' ]) c- u; ^+ {2002: 565-628." p1 k2 S5 A9 ~0 z- g3 y. W3 z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& v, D7 V( p4 O9 l1 }" Lpuberty 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
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
/ q$ I8 M0 B2 N0 ~7 }9 |7 r& 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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