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Sexual Precocity in a 16-Month-Old8 a: `+ }) U1 D; |0 n; O0 x+ W
Boy Induced by Indirect Topical
( k1 k- q4 U4 t) s0 e2 RExposure to Testosterone+ L! Z4 R9 u) B( D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 {  I5 E$ A6 c9 G4 E; \
and Kenneth R. Rettig, MD12 ~: k- |; _5 H/ _) l
Clinical Pediatrics" g) q* N# k- Q
Volume 46 Number 6% P/ g) |6 E1 M' j) }% Y2 J7 e
July 2007 540-543# f, C0 J0 s$ p7 P" L& F* m. d
© 2007 Sage Publications" w% G5 Z; r  A+ J6 S9 q; E
10.1177/0009922806296651- Q7 j! \) e# M0 L& p
http://clp.sagepub.com3 k1 L6 K- y7 [
hosted at
8 u4 d7 ^* k$ }( j9 z: r, \http://online.sagepub.com
5 E. Z" S) N4 g4 kPrecocious puberty in boys, central or peripheral,# T2 d& S4 X; |
is a significant concern for physicians. Central  _/ J: S' C6 N: B0 a6 n
precocious puberty (CPP), which is mediated( X8 w: H2 w- F: [( @
through the hypothalamic pituitary gonadal axis, has
. {! |! v1 w. ^" x  H' |! V( L0 Aa higher incidence of organic central nervous system7 c0 p* I. b' c6 h7 V8 G
lesions in boys.1,2 Virilization in boys, as manifested- e" _) E5 q  M) ?* H* R) |
by enlargement of the penis, development of pubic7 {/ [* c6 Q5 z* V9 f9 z
hair, and facial acne without enlargement of testi-) E2 N" N: \4 ^! `1 W/ I" G
cles, suggests peripheral or pseudopuberty.1-3 We" p) K2 ?8 g* A8 O' d% L
report a 16-month-old boy who presented with the, B1 e* g5 i7 e: ^
enlargement of the phallus and pubic hair develop-
' g* H+ b4 }; l+ `ment without testicular enlargement, which was due
7 Q( Q! j4 t$ S! [7 V" i1 g; Wto the unintentional exposure to androgen gel used by7 O7 X& q: v2 {
the father. The family initially concealed this infor-
6 d( s3 q% ?7 H0 V; q- p4 G' wmation, resulting in an extensive work-up for this  m: t: H& n0 W9 c: e
child. Given the widespread and easy availability of
8 W+ H! j; m+ N- g7 a+ L7 f  Mtestosterone gel and cream, we believe this is proba-
( S2 J: O+ P5 u& F, dbly more common than the rare case report in the3 i9 B% d7 o. z* I8 ]
literature.49 `. T" ]7 _9 p7 H0 U+ q5 q. \
Patient Report
. j/ E' |6 Y7 `% @. E$ V$ @) TA 16-month-old white child was referred to the
  T6 e: Y" O% f/ }endocrine clinic by his pediatrician with the concern& d( a: n  J" S  }2 H
of early sexual development. His mother noticed; k% g& Z; U; h
light colored pubic hair development when he was
  I. l) L3 y" C8 w$ q- JFrom the 1Division of Pediatric Endocrinology, 2University of9 Z+ i" O- G. A2 d7 d5 N
South Alabama Medical Center, Mobile, Alabama.
& o+ d. Z  S0 |6 z* I3 z; w* zAddress correspondence to: Samar K. Bhowmick, MD, FACE,
- _+ t, Q, @& g( E: m, w7 wProfessor of Pediatrics, University of South Alabama, College of
3 y7 \1 z  T& Q, \  b2 P/ i% nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 i3 P' H. N' s+ c2 V, u. Ge-mail: [email protected].6 t- P: t9 I! X- D. P8 k+ e( @
about 6 to 7 months old, which progressively became
; a: f3 d2 P( m3 rdarker. She was also concerned about the enlarge-
5 D3 @, b5 ]/ Gment of his penis and frequent erections. The child
' [3 N' j& y6 R" S/ jwas the product of a full-term normal delivery, with
1 [3 K9 ~0 v: g  J5 i' s2 Ia birth weight of 7 lb 14 oz, and birth length of
0 x7 \! n6 ~4 u& V9 Z) M' X6 a20 inches. He was breast-fed throughout the first year
5 `1 T! P$ G6 P) i5 {: q0 c; Lof life and was still receiving breast milk along with1 }1 w- b4 L& u( N
solid food. He had no hospitalizations or surgery,: o4 Q  u% L, d- Y, w0 j
and his psychosocial and psychomotor development$ j. `5 E% U: Z0 i/ A6 y
was age appropriate.( G" y' N. ?. F1 }% M, X8 ?7 _
The family history was remarkable for the father,
) r3 W* ^& R- {8 ?  y" jwho was diagnosed with hypothyroidism at age 16,; }: ?: y$ M; {
which was treated with thyroxine. The father’s
' E1 _$ s2 l( C, p, A; @height was 6 feet, and he went through a somewhat
, J! D0 R5 z/ y0 Pearly puberty and had stopped growing by age 14.5 }6 H* r$ j/ P8 z1 [+ V; h. [
The father denied taking any other medication. The8 m# o, Q) H7 d' `) k, J
child’s mother was in good health. Her menarche
2 h* ?* Q& @& a+ nwas at 11 years of age, and her height was at 5 feet) s4 r; m" \6 [. K" n- @' ^; K
5 inches. There was no other family history of pre-& ]& }4 t+ i" I. r6 z
cocious sexual development in the first-degree rela-$ X% E- S9 A% P9 `- g
tives. There were no siblings.3 R# i; N5 v$ ~
Physical Examination
. f% H* n; `% D8 RThe physical examination revealed a very active,7 f2 s4 b6 y0 c, j! B& Z/ s9 Q% i
playful, and healthy boy. The vital signs documented6 y3 Y( B# a. ?, ~& W# _7 J
a blood pressure of 85/50 mm Hg, his length was. Z8 u5 \6 J# {+ |, c3 X
90 cm (>97th percentile), and his weight was 14.4 kg
- p7 s+ `4 k, N7 l  ^7 K(also >97th percentile). The observed yearly growth
) g8 ~6 ]2 h1 h# b9 \# n! R: qvelocity was 30 cm (12 inches). The examination of
; C: F6 G+ Y5 P& tthe neck revealed no thyroid enlargement.
& ?4 {  h) ]( xThe genitourinary examination was remarkable for6 Z1 v; X. f; N9 M5 k! f$ F% d; o
enlargement of the penis, with a stretched length of3 v, P  R) ?3 h: m! t% Z7 b" f
8 cm and a width of 2 cm. The glans penis was very well
9 D( v5 {) z& xdeveloped. The pubic hair was Tanner II, mostly around* k9 ?  I: b1 \( `
540+ E% g+ e( D# p2 @3 V2 C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# e# i; d+ E. n8 k1 K% C$ ~* zthe base of the phallus and was dark and curled. The
! z' u+ u: h. {& i- ?( Ltesticular volume was prepubertal at 2 mL each.
, b0 m8 G7 L2 U$ m  JThe skin was moist and smooth and somewhat7 V. h' i: w/ `( r- o
oily. No axillary hair was noted. There were no8 `3 h6 e. _2 I2 F6 t! M, ?' ~
abnormal skin pigmentations or café-au-lait spots.
+ n# l) {9 o) n( ]9 M( |* CNeurologic evaluation showed deep tendon reflex 2+0 y4 _5 y: q, O( k% X6 ~
bilateral and symmetrical. There was no suggestion
$ W2 Y: E4 o3 k4 F2 y7 bof papilledema.
5 `3 ~4 F+ x1 Y2 l% M+ s/ _Laboratory Evaluation* F) W  j  M. q! @5 j4 f7 H
The bone age was consistent with 28 months by" `6 m9 u: D5 G; f
using the standard of Greulich and Pyle at a chrono-3 a: F  t9 `: h: }
logic age of 16 months (advanced).5 Chromosomal
2 N7 \& J+ x, R/ G& S/ ykaryotype was 46XY. The thyroid function test' R' Y" ?. J, p  x1 u
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ J, ~; I# _& @6 }8 N. c' b
lating hormone level was 1.3 µIU/mL (both normal).5 D- e' b2 u/ ?. ?
The concentrations of serum electrolytes, blood
0 _; f# @- f0 w6 D5 e/ F+ yurea nitrogen, creatinine, and calcium all were
: R1 |# b, T8 A# ^- H. @' uwithin normal range for his age. The concentration
: P) \1 T" C* yof serum 17-hydroxyprogesterone was 16 ng/dL- a' ]! m1 `2 T
(normal, 3 to 90 ng/dL), androstenedione was 20
% d/ A0 y& F" w% L' ^: `' Sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 D& [* P4 b1 \/ C; Z) ~& `7 o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. `, z3 F" p  y1 T: ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 {) O* X7 j% y/ ~& U% j: X3 _) j3 q
49ng/dL), 11-desoxycortisol (specific compound S)
8 i" ~9 i: ]% p% Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! B4 l9 F  b7 ~* d6 i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ k" F$ Z0 Y. N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! Z( ^/ R3 U. _. j; Z% @+ dand β-human chorionic gonadotropin was less than
8 Z0 Q! {7 e5 X4 a- U5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 Y* D3 D. f2 D( y( Ostimulating hormone and leuteinizing hormone; ^, a' c) e7 `& W
concentrations were less than 0.05 mIU/mL
$ v1 {% M% G9 E(prepubertal).; W, {! B# K( o8 I: ]& Q4 U# y
The parents were notified about the laboratory
, j6 h8 ]* G3 j1 V; U4 `) G* cresults and were informed that all of the tests were3 d4 Y, S  D+ F5 y/ b" b: L* m
normal except the testosterone level was high. The, A8 D: N7 ~, f' B% r' E
follow-up visit was arranged within a few weeks to
7 p' o. r0 E0 F. Gobtain testicular and abdominal sonograms; how-
5 q0 S- P) |% D& Pever, the family did not return for 4 months.$ N* s, E  J1 q- Q/ B: ?, g
Physical examination at this time revealed that the% ^, Q6 \& q. Y4 ~
child had grown 2.5 cm in 4 months and had gained/ i4 E% |  p2 A: ~2 D* c
2 kg of weight. Physical examination remained8 H; Y* q' G; R; k4 o* e; z% `
unchanged. Surprisingly, the pubic hair almost com-
: {0 ^/ W0 j* P8 r( \pletely disappeared except for a few vellous hairs at% C0 l8 a4 S  k$ O/ S1 B0 }% G
the base of the phallus. Testicular volume was still 21 p, y# D+ R1 _$ u% \9 q7 |3 l( U
mL, and the size of the penis remained unchanged.
* B, N; z' ]& H' s. }The mother also said that the boy was no longer hav-; x) x3 N  v6 E$ E7 M
ing frequent erections.  a4 O, H+ w1 r6 C/ _' I
Both parents were again questioned about use of
5 z' j- |9 d9 J% D5 M  Sany ointment/creams that they may have applied to
/ ]  E1 U. I! s8 wthe child’s skin. This time the father admitted the
- _! x, c9 n  t/ `9 j: \% yTopical Testosterone Exposure / Bhowmick et al 541
5 I& k) X* {; T& o6 Euse of testosterone gel twice daily that he was apply-( R+ V+ |* k. l0 A" P$ U) Y
ing over his own shoulders, chest, and back area for
8 u) L( X( `8 n, ], Q) ]a year. The father also revealed he was embarrassed& J1 _: Z: I% Q& L- m7 d4 N
to disclose that he was using a testosterone gel pre-+ L$ A! V3 I; @- P
scribed by his family physician for decreased libido& M+ k7 s& G( L& }3 D9 T# J
secondary to depression.+ V# n) }4 K. s( K
The child slept in the same bed with parents.
8 j8 ~9 F, A% f2 _  \' iThe father would hug the baby and hold him on his
; r9 v; ^: n- L" e& W4 H# b* `chest for a considerable period of time, causing sig-' U' [7 ~! \! y$ {8 i3 t; G+ f
nificant bare skin contact between baby and father.
5 }1 }6 V9 N/ K5 `; P5 l+ }The father also admitted that after the phone call,3 x6 }8 s; y" d- J' n6 d2 H
when he learned the testosterone level in the baby
8 ^- }1 }" g) w1 @' K2 Zwas high, he then read the product information" q! b7 F% s+ E+ i9 p
packet and concluded that it was most likely the rea-" K! a+ _# Q7 s% l: O
son for the child’s virilization. At that time, they
* F! f' Y! _) d& f% b& [( H) Mdecided to put the baby in a separate bed, and the3 F. t0 J! c& f2 R
father was not hugging him with bare skin and had
5 J; b6 g1 a. v( t) X# y, c3 F: hbeen using protective clothing. A repeat testosterone! ^3 Z2 x7 ^: _% F, d
test was ordered, but the family did not go to the# w8 L- l/ K/ x1 F7 P: v
laboratory to obtain the test.4 P9 ]) b. w, Y8 z4 F8 E
Discussion
- E2 J5 U7 C1 c! VPrecocious puberty in boys is defined as secondary
# y( X2 g6 [# {7 ?2 L' isexual development before 9 years of age.1,4! m% X: |, q. F! }) z
Precocious puberty is termed as central (true) when
# p* G4 }& e, |% G5 Z; P7 L6 F2 Rit is caused by the premature activation of hypo-
) T" r& Y: a3 Xthalamic pituitary gonadal axis. CPP is more com-- a' D' [9 g; p) M/ ]
mon in girls than in boys.1,3 Most boys with CPP+ m/ x* X) b1 z% a4 g# q8 ?
may have a central nervous system lesion that is" r% ]* n# d4 d9 S- v5 I
responsible for the early activation of the hypothal-
( m( X9 I& v# y' J) t/ q: A# pamic pituitary gonadal axis.1-3 Thus, greater empha-+ k4 N  Z' M; Y% A: Y( k! U1 ]
sis has been given to neuroradiologic imaging in4 q" k4 e: k2 M. o) A! x
boys with precocious puberty. In addition to viril-' I. S1 W# l& f0 q9 R- S5 U
ization, the clinical hallmark of CPP is the symmet-
8 D0 O, j% t7 @( }: Orical testicular growth secondary to stimulation by& R! x& J" J, d5 b! E) s+ A
gonadotropins.1,3- I1 X+ u$ j/ j" Y! D- h7 C  z
Gonadotropin-independent peripheral preco-
5 ?$ W1 }( ?+ {1 Rcious puberty in boys also results from inappropriate7 z9 ]7 `$ l' s
androgenic stimulation from either endogenous or6 ^4 ^6 W( n8 O; \! E
exogenous sources, nonpituitary gonadotropin stim-
- f4 }$ ?4 N6 \) Y2 rulation, and rare activating mutations.3 Virilizing
. l' u) O. \1 p) q5 _& A5 tcongenital adrenal hyperplasia producing excessive* q# X2 K6 G) `( z5 c: F' F/ o
adrenal androgens is a common cause of precocious
* i6 w0 {, i% j/ l2 _puberty in boys.3,4* J* W3 ^( u0 r% J
The most common form of congenital adrenal
, o  A( B: R) z  `* r! vhyperplasia is the 21-hydroxylase enzyme deficiency.
6 F9 @9 I6 i3 u6 O5 A2 @The 11-β hydroxylase deficiency may also result in
( t  q; r* {: B' W3 p0 Zexcessive adrenal androgen production, and rarely,; O8 i6 g9 G1 e8 _  G6 Y) Q
an adrenal tumor may also cause adrenal androgen
& Z: @& i$ f% p. ~+ Jexcess.1,3
" I( X% ^" ^, Z: Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* `; f8 {' e! x7 d) ?7 P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ p2 D: [2 v* v: xA unique entity of male-limited gonadotropin-, D, N7 o8 l9 E3 |
independent precocious puberty, which is also known" q7 \6 w* \, e6 ?
as testotoxicosis, may cause precocious puberty at a( C/ ^" n* o, }: E
very young age. The physical findings in these boys  X& [3 ~/ }+ n, T* l
with this disorder are full pubertal development,
  ]  l3 X; u( D: C, bincluding bilateral testicular growth, similar to boys
# n4 g% p% D$ t: T% F( H! bwith CPP. The gonadotropin levels in this disorder
+ y8 x! Q, T* a' w% care suppressed to prepubertal levels and do not show, `9 [% R) S3 k8 X2 O
pubertal response of gonadotropin after gonadotropin-4 _9 V* l$ a" v7 X5 n( W
releasing hormone stimulation. This is a sex-linked" F+ q" X0 g5 r4 x7 ]- T
autosomal dominant disorder that affects only5 N' g0 G  q; K( r  X. C3 x
males; therefore, other male members of the family$ b- A3 k& O5 u
may have similar precocious puberty.35 \+ J# ]0 b1 `0 H6 ^% ~6 }; Y
In our patient, physical examination was incon-; h) g' I% e% J8 ^! g
sistent with true precocious puberty since his testi-. ]9 I1 s7 \7 B5 @
cles were prepubertal in size. However, testotoxicosis
; b$ L. G2 V3 C0 A7 L: E3 Qwas in the differential diagnosis because his father
6 g7 g2 D! B/ t' I5 e6 Vstarted puberty somewhat early, and occasionally,( Z9 {/ K- |7 f% i0 F. E8 [: K
testicular enlargement is not that evident in the+ u- N1 I% A" G: I3 [$ p
beginning of this process.1 In the absence of a neg-+ J/ x+ f, [" p( z8 l- C5 n
ative initial history of androgen exposure, our0 Q( d; [* o8 Z6 V: S0 |% Z  V" v: l
biggest concern was virilizing adrenal hyperplasia,1 O0 }! M) d8 M3 N( z, }
either 21-hydroxylase deficiency or 11-β hydroxylase  o" Q( Z  O: L) f  x4 ~# L8 R
deficiency. Those diagnoses were excluded by find-2 C1 B- w+ _: N  F6 p3 o
ing the normal level of adrenal steroids.8 m6 z( i. e: X' T: G/ y: G
The diagnosis of exogenous androgens was strongly% i2 ~9 S& k5 r/ z) u8 b& o2 N
suspected in a follow-up visit after 4 months because; [1 a8 V5 S& H/ X% x, O$ R/ R1 [
the physical examination revealed the complete disap-, D2 A+ Y8 [% B: a4 y+ S
pearance of pubic hair, normal growth velocity, and
# U* n7 S( t2 f7 C5 q7 J, Edecreased erections. The father admitted using a testos-3 v8 F2 I8 x% W; ?3 M. f$ |& o
terone gel, which he concealed at first visit. He was
/ t4 j# p8 C, L  f; Y% Nusing it rather frequently, twice a day. The Physicians’
1 z& C' |3 H; ]6 ]! `3 c, X; x8 t. t1 NDesk Reference, or package insert of this product, gel or% M/ {* a; f0 \
cream, cautions about dermal testosterone transfer to' h5 A; X4 i6 q4 z% M
unprotected females through direct skin exposure.
6 ^0 }6 N' a( k' C. X1 w3 rSerum testosterone level was found to be 2 times the
5 ]7 f2 O0 a' m. S/ F' Qbaseline value in those females who were exposed to8 b  Q: r1 H7 V- J( o
even 15 minutes of direct skin contact with their male
4 a. u4 W; ^: \; J) G5 fpartners.6 However, when a shirt covered the applica-: ^3 l* R7 u2 }0 H- B' j* x
tion site, this testosterone transfer was prevented., n3 e& M0 V: k9 R
Our patient’s testosterone level was 60 ng/mL,
  G5 K8 x- @: n8 awhich was clearly high. Some studies suggest that  m" W! [5 W) P0 c) j9 K
dermal conversion of testosterone to dihydrotestos-
5 T5 p2 W( s: \& Fterone, which is a more potent metabolite, is more% J. w+ ~+ R  i/ H. Z( V  f
active in young children exposed to testosterone: C7 `  }$ A. a, V5 K
exogenously7; however, we did not measure a dihy-
( w/ v( l" h/ {; ?: ~drotestosterone level in our patient. In addition to
" \8 D, s' a" m' A: B  t# Jvirilization, exposure to exogenous testosterone in7 \, @4 s* F2 J9 Q
children results in an increase in growth velocity and
. U  K' R1 N9 ~, [! e- y  ?3 E& ^advanced bone age, as seen in our patient.
# r% o2 A! z7 D. ^. ~' p) @/ I- XThe long-term effect of androgen exposure during' n: ^# l& b0 T+ W  H9 {0 q
early childhood on pubertal development and final
& V. H% K, I8 D+ w% badult height are not fully known and always remain  S6 F, T" O- J5 I: L2 }
a concern. Children treated with short-term testos-& z7 A8 X5 c% t" e+ K* Z; L
terone injection or topical androgen may exhibit some# i# N* U  N/ Y' R9 g8 Y
acceleration of the skeletal maturation; however, after
+ H; `+ U. u8 l0 O: H; u  scessation of treatment, the rate of bone maturation4 `9 \& L9 Y8 T7 B! g2 d
decelerates and gradually returns to normal.8,93 ^7 q) H6 g$ B1 }
There are conflicting reports and controversy
5 \: w4 Z! e4 G% |. ~3 T7 |- p; w- _over the effect of early androgen exposure on adult) ^5 v" g9 y( [
penile length.10,11 Some reports suggest subnormal
. G% r, `! ^+ G4 E& w# Vadult penile length, apparently because of downreg-
! E0 ?$ e7 }1 R) x# Z, Dulation of androgen receptor number.10,12 However,
% ?( q) G% F" P7 Y' @" \Sutherland et al13 did not find a correlation between: M: ]4 Q6 e$ c" |
childhood testosterone exposure and reduced adult2 a- A$ w. S& J; m; Q& p
penile length in clinical studies.0 |' Q+ e9 |; C
Nonetheless, we do not believe our patient is) R5 s2 _* I- y$ K. G, v
going to experience any of the untoward effects from
) c- `+ Y) H, @; O6 Ctestosterone exposure as mentioned earlier because$ n* \9 s) J1 \8 f
the exposure was not for a prolonged period of time.
; C: P$ v) \$ S8 t7 I- ~! @Although the bone age was advanced at the time of) v" a$ n6 f6 E3 Z
diagnosis, the child had a normal growth velocity at  J9 [4 \! z' h3 h5 _
the follow-up visit. It is hoped that his final adult
5 J) U+ ~( y: cheight will not be affected.. H1 h' U% M+ ?9 |9 }, U+ ]& x
Although rarely reported, the widespread avail-; x, ~0 H9 E7 ^/ F* U
ability of androgen products in our society may
0 A  @+ O. g1 Q8 hindeed cause more virilization in male or female
* y- q! o/ p1 x3 bchildren than one would realize. Exposure to andro-
0 W* v- B  S7 M3 T0 o8 N) Ngen products must be considered and specific ques-
5 }9 ~, _) T/ ~( ptioning about the use of a testosterone product or
9 a& b6 E/ u7 ^7 n2 A& L# `gel should be asked of the family members during, R' z7 n- `6 t2 ^$ o
the evaluation of any children who present with vir-2 U) w/ r. F' U3 a
ilization or peripheral precocious puberty. The diag-+ G/ e/ y- h1 n! ^( ^' E0 Y3 q
nosis can be established by just a few tests and by0 P, L4 H8 g! ^% ^/ ]" q) K
appropriate history. The inability to obtain such a
- X3 f  Q' p. x) A9 Bhistory, or failure to ask the specific questions, may, M0 ?. v$ U: X2 h0 ]7 b
result in extensive, unnecessary, and expensive
% m/ Q+ S1 [7 \$ R: r3 Hinvestigation. The primary care physician should be
/ O. }* p) ]  ~; y2 i% |2 C( Iaware of this fact, because most of these children9 x9 C* O7 F5 G+ \) Z0 O/ H
may initially present in their practice. The Physicians’  B4 D4 K8 G3 p+ m' N# \
Desk Reference and package insert should also put a
; E' B  ]; D4 o1 m' o! A! w: L& g; o6 Awarning about the virilizing effect on a male or- O. l; h- u0 D# {
female child who might come in contact with some-/ K! [1 W0 K' ~* S6 Z
one using any of these products.
2 A, ]4 a3 l6 e5 ?References
. L3 v3 T5 {9 `3 U: G) W7 \3 Y1. Styne DM. The testes: disorder of sexual differentiation& a/ W! e% K: y- e) d: `$ p9 Z
and puberty in the male. In: Sperling MA, ed. Pediatric
) G4 \: q* b1 YEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 m2 P/ [7 U* M7 \2002: 565-628.  b' U, f9 i+ V! p  D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& O1 |* O2 T+ f/ h9 N2 a
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ |8 q' |) w+ o; }; G. u" N3 vBoy Induced by Indirect Topical/ h- ~. a2 D& w' ?  B) h/ n% n
Exposure to Testosterone
% t  Z* c' N8 {! l2 [! tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. g  s$ p7 o9 k( [2 t
and Kenneth R. Rettig, MD1
% e8 e& q3 a- h* d: f4 |5 sClinical Pediatrics
+ b" w  p8 @# Q  AVolume 46 Number 6
# O- u- i. ~' o3 YJuly 2007 540-543
' u% M6 h, H  ~- [* z( V* r# C© 2007 Sage Publications  \/ H# U# U4 A4 l" B& o* o$ K
10.1177/0009922806296651
- T* A7 \5 E6 Q4 L' thttp://clp.sagepub.com" J( t* y; `  X5 L
hosted at# R2 F, u3 e7 Y9 K( W
http://online.sagepub.com
6 ~/ O$ L8 d) h) o) PPrecocious puberty in boys, central or peripheral,! `' ]6 B% C& [6 L1 t
is a significant concern for physicians. Central5 ?8 z  E/ A% y; J
precocious puberty (CPP), which is mediated
# W/ C2 C" Y% O2 Wthrough the hypothalamic pituitary gonadal axis, has
2 b2 i7 Y, D* Q! P9 ~a higher incidence of organic central nervous system2 V0 d# c( Z  n# o) A+ w. p: j, v
lesions in boys.1,2 Virilization in boys, as manifested5 U% k& R; y, j# [% G( K) H
by enlargement of the penis, development of pubic
. D2 C3 V4 h! Whair, and facial acne without enlargement of testi-
3 t# a: A( W, K% }cles, suggests peripheral or pseudopuberty.1-3 We7 T) ]) n) r. H; h! K
report a 16-month-old boy who presented with the, t2 z+ l  y1 |! p0 \: j* `
enlargement of the phallus and pubic hair develop-  L; _& L. @; M
ment without testicular enlargement, which was due+ R- A5 {5 z* d, R
to the unintentional exposure to androgen gel used by
/ N6 Q$ U' y" y+ Y6 g9 I4 zthe father. The family initially concealed this infor-2 W# [6 V8 ~/ [* g0 f- Q$ z- z# H' M/ T
mation, resulting in an extensive work-up for this" P6 Z! l/ N$ o: s& v
child. Given the widespread and easy availability of9 P' u  Q* O, s7 ]) |3 b6 p; w
testosterone gel and cream, we believe this is proba-6 _& a  g8 f! K2 E# [9 g
bly more common than the rare case report in the  H7 a2 _3 e1 I* H4 d
literature.4% l9 U1 t$ W; x; r: E( P
Patient Report0 l* C; D9 G1 s3 _0 L3 C# y
A 16-month-old white child was referred to the; \' f$ ]$ W# D; Q" Q$ T* @7 q
endocrine clinic by his pediatrician with the concern! ~( V# J, t% M, l
of early sexual development. His mother noticed( O7 M* m) @; }* ?
light colored pubic hair development when he was  d# Q9 E5 z! }+ I9 b6 X
From the 1Division of Pediatric Endocrinology, 2University of8 B1 m% W: k  r! s9 l4 r  s2 {
South Alabama Medical Center, Mobile, Alabama.
% b( p  d+ m8 I& wAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 F2 f/ w$ t6 v: T/ j  r
Professor of Pediatrics, University of South Alabama, College of
& f& a+ |1 l5 k0 q4 r1 D4 YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 V1 r. d! B, Y, r# l; de-mail: [email protected].
6 ~8 k* {. Y2 G, Yabout 6 to 7 months old, which progressively became
7 N; o$ J$ U3 M: \+ G* Mdarker. She was also concerned about the enlarge-0 _6 g  g) w$ J7 c# G9 F
ment of his penis and frequent erections. The child6 C* j, g5 ^3 ]3 k
was the product of a full-term normal delivery, with
* Q: t& R% f  u: ?/ u0 o8 k$ Ja birth weight of 7 lb 14 oz, and birth length of+ b/ g( |# k7 V) O4 Z
20 inches. He was breast-fed throughout the first year
: `. T! A6 x5 X0 wof life and was still receiving breast milk along with
' t4 i  h0 L0 [5 _1 a  Vsolid food. He had no hospitalizations or surgery,& ]$ M. p4 Q! O
and his psychosocial and psychomotor development
* A& V" w" r( F* Y* Ewas age appropriate.
/ u( F& Z; R7 ~+ K2 _1 e9 l! AThe family history was remarkable for the father,
6 }" Z5 w( ~* J; ?8 \) Bwho was diagnosed with hypothyroidism at age 16,$ _7 S: g; ^0 k: Q1 v
which was treated with thyroxine. The father’s/ B5 A+ {/ Q3 }* w& A+ L0 u
height was 6 feet, and he went through a somewhat  G$ D- p+ O9 a! U4 m
early puberty and had stopped growing by age 14.
& k/ b) z2 }: Y7 h9 uThe father denied taking any other medication. The" h) |5 O* ]( _- @. E" _! F+ w* }" [
child’s mother was in good health. Her menarche
& t1 |$ c  ]* Y* A- m4 [' Z# H2 h# Owas at 11 years of age, and her height was at 5 feet
; y) h6 \1 E( k6 }5 inches. There was no other family history of pre-
( R0 i* r, r- P: c1 Kcocious sexual development in the first-degree rela-
7 z7 T/ t5 |# K( N& h0 |+ M) l: ~tives. There were no siblings.  V& E8 j4 N! w2 v  h$ j
Physical Examination
. {, `& j: _! Z4 YThe physical examination revealed a very active,+ Z* `, y. ^8 y
playful, and healthy boy. The vital signs documented1 D: @/ I( o/ B- o( ]6 I4 G
a blood pressure of 85/50 mm Hg, his length was, I' ^/ j2 C6 v+ {3 }6 L
90 cm (>97th percentile), and his weight was 14.4 kg, F% n; ]/ v2 h+ e
(also >97th percentile). The observed yearly growth
! f6 R8 F' ]9 M- ?7 V! ?velocity was 30 cm (12 inches). The examination of# G& L0 B# H+ Q# i/ b3 U8 Y. F$ O
the neck revealed no thyroid enlargement.+ J- ~7 C2 [( b
The genitourinary examination was remarkable for
" \" H' b5 y  y% b) G% Kenlargement of the penis, with a stretched length of
; x4 ?  N) Y8 U9 D" n, v: {8 cm and a width of 2 cm. The glans penis was very well  c. `" W* r9 c  Z; C6 o! l+ d. ]7 R
developed. The pubic hair was Tanner II, mostly around
, A! x, o! {2 B6 V& ?# s: ]5403 e# |% F+ y6 J# B$ i1 _$ m: D; S+ }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" d- Q: D) Z0 W) J% ]4 p1 kthe base of the phallus and was dark and curled. The3 w0 k. c& [. ?5 f8 P) E: [
testicular volume was prepubertal at 2 mL each.$ ?6 F  ]7 B+ T3 I4 S7 s
The skin was moist and smooth and somewhat
% V! h4 z9 L7 u3 m* K' {8 doily. No axillary hair was noted. There were no- d1 d& @; @9 G" P4 {
abnormal skin pigmentations or café-au-lait spots.
/ s4 V$ b% o, \7 V+ M8 J9 NNeurologic evaluation showed deep tendon reflex 2+) u2 X! g# u% r- ^' S
bilateral and symmetrical. There was no suggestion
5 h3 o: N: E- W* `+ Y7 aof papilledema.3 L5 L, X- H) X3 Y! T
Laboratory Evaluation
! K$ {6 H! n& DThe bone age was consistent with 28 months by
1 E) p; N4 ]3 T0 B: R+ ousing the standard of Greulich and Pyle at a chrono-
- b. ^% D+ \/ l. H5 u- Z! zlogic age of 16 months (advanced).5 Chromosomal& i! o7 f- f0 X7 o( f
karyotype was 46XY. The thyroid function test
! q1 _+ F! |4 sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 e" m2 U2 U, C9 e" |0 xlating hormone level was 1.3 µIU/mL (both normal).( R: j4 Z3 u- [8 h4 g
The concentrations of serum electrolytes, blood& ]/ d; R" q) t
urea nitrogen, creatinine, and calcium all were
1 O) m) S  b3 C$ P8 awithin normal range for his age. The concentration
2 b) g  J" H0 l: yof serum 17-hydroxyprogesterone was 16 ng/dL
0 }. p! Z! K* e/ [$ M(normal, 3 to 90 ng/dL), androstenedione was 20
4 ?. P1 n+ O' M# K/ \( _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ w) s3 S, _. Y* V6 l
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 d1 q2 W/ M, r7 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
& C, D; b5 r6 L2 z4 ~  T49ng/dL), 11-desoxycortisol (specific compound S)7 b4 Z9 E+ Z( `3 r
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 u6 d! B$ X9 q  l/ `9 g( ?" @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 T$ a, w$ H6 a+ Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ d, p+ e: |# [and β-human chorionic gonadotropin was less than
  z6 c5 K2 m5 S# b- N2 B5 mIU/mL (normal <5 mIU/mL). Serum follicular% A6 w; {; k, s* ~+ x7 F$ e
stimulating hormone and leuteinizing hormone
+ {& c7 ?% R1 u, @) E- \concentrations were less than 0.05 mIU/mL
" ~* q5 Y5 C2 C# D. i6 @(prepubertal).
4 V3 ^) t' x+ H8 ]) {The parents were notified about the laboratory
+ S. E( R2 e- _+ t9 T" qresults and were informed that all of the tests were
: i  l6 Q/ P% C* A' ~3 W! fnormal except the testosterone level was high. The4 {# Y5 h5 ^6 G7 {' x5 T; N# N
follow-up visit was arranged within a few weeks to' c6 x' w1 m+ S/ n2 A
obtain testicular and abdominal sonograms; how-
: m  J- r5 c3 a  I# N, c5 Vever, the family did not return for 4 months./ e% J: S( b6 |& y6 d: l# z4 ^
Physical examination at this time revealed that the5 r& j  b; U  x+ n
child had grown 2.5 cm in 4 months and had gained
6 O( c7 T. Y5 O2 Y7 v2 a2 A2 kg of weight. Physical examination remained
7 H5 r& O. `5 B, B  junchanged. Surprisingly, the pubic hair almost com-
& B8 d; ~  Y( G1 lpletely disappeared except for a few vellous hairs at+ ~) J: E8 I6 E
the base of the phallus. Testicular volume was still 2
5 P  g& u& m, W9 Z" l/ JmL, and the size of the penis remained unchanged.8 o7 q. U& N: N, F8 t7 C1 [
The mother also said that the boy was no longer hav-  v4 i: s* ^9 o% Z+ n6 O+ y
ing frequent erections.  T, V# i. M9 m- \
Both parents were again questioned about use of
8 _9 b" B: s/ u  Cany ointment/creams that they may have applied to: O1 k# M0 [3 A2 L1 o2 [1 `
the child’s skin. This time the father admitted the
' |9 ?2 k+ P0 X$ }3 I& i( TTopical Testosterone Exposure / Bhowmick et al 541
8 f2 z2 r' g% r3 Xuse of testosterone gel twice daily that he was apply-
8 B: U. Y' C: X0 Cing over his own shoulders, chest, and back area for5 D% x  Y3 O, r2 |$ H
a year. The father also revealed he was embarrassed* C& o+ m, |$ q# t. Z2 h
to disclose that he was using a testosterone gel pre-
2 |1 l; Y' {* Qscribed by his family physician for decreased libido+ d3 m3 g* w" o% L+ T
secondary to depression.2 M9 m1 d, U0 T" q3 r8 p
The child slept in the same bed with parents.
' y3 ^+ g% F: q9 `: k9 |/ t) G6 bThe father would hug the baby and hold him on his8 ~/ O- C4 B" {
chest for a considerable period of time, causing sig-' B- F1 {1 G9 ^, ^0 ^) ]0 \
nificant bare skin contact between baby and father.7 \0 I& i- j' M; @
The father also admitted that after the phone call,
. I1 O% ^# N* X: U  f$ n; Wwhen he learned the testosterone level in the baby
+ L7 ^& K4 E7 s* mwas high, he then read the product information. W4 q1 K9 z4 E2 c
packet and concluded that it was most likely the rea-5 R8 @; I, ]  N, B" v, T
son for the child’s virilization. At that time, they# T' z) t# r" v% F
decided to put the baby in a separate bed, and the
2 g; K  U+ Z/ ifather was not hugging him with bare skin and had. I  ~' I4 @! Z" `3 t' y- F( ]
been using protective clothing. A repeat testosterone. Y/ q4 n; Q6 x% p
test was ordered, but the family did not go to the% ^7 G. q- z( M4 [
laboratory to obtain the test.8 I1 S, I0 {9 q! F  t" _
Discussion8 ^. S* K$ e! m
Precocious puberty in boys is defined as secondary
3 L2 I- x. |. S$ f1 h6 |1 o& H* Z: _sexual development before 9 years of age.1,45 _# \" s6 l0 U
Precocious puberty is termed as central (true) when" z/ t4 L% u( k+ `  w
it is caused by the premature activation of hypo-" q! v9 P/ n  ]: ]: o% p; a
thalamic pituitary gonadal axis. CPP is more com-
! F% F8 j1 O: w6 D& T" ymon in girls than in boys.1,3 Most boys with CPP
- p( L' Y8 B- O1 [, vmay have a central nervous system lesion that is% H% e0 _% k' r) S6 j  v
responsible for the early activation of the hypothal-
& I; H$ V; j# ~% v" _' L$ eamic pituitary gonadal axis.1-3 Thus, greater empha-
( _# p' z7 q; I" ?9 N# ssis has been given to neuroradiologic imaging in
/ \. K+ }9 w' |5 }& oboys with precocious puberty. In addition to viril-
3 n2 j+ x+ R8 S9 r, p& S9 l$ Oization, the clinical hallmark of CPP is the symmet-( U  @, B9 H( j0 h
rical testicular growth secondary to stimulation by
: F: f* G" c  Mgonadotropins.1,3
4 T% }, p! \+ b; OGonadotropin-independent peripheral preco-
3 b. f5 S9 N7 x6 K3 `. D! pcious puberty in boys also results from inappropriate  i! i" i. i7 }3 ^$ P
androgenic stimulation from either endogenous or
+ A/ V! g# f! Hexogenous sources, nonpituitary gonadotropin stim-! I0 R, J9 M8 G" w
ulation, and rare activating mutations.3 Virilizing
. y3 T7 h/ v1 O* wcongenital adrenal hyperplasia producing excessive1 {% e: ~9 T. P% M. ]; l4 @. k' f
adrenal androgens is a common cause of precocious+ l9 h0 ^8 k% ^! x$ j+ b
puberty in boys.3,42 ^# c; l, \8 I) `
The most common form of congenital adrenal. W! z. ~  r. _4 ?
hyperplasia is the 21-hydroxylase enzyme deficiency.( M- U0 a' S1 A+ P  f3 B9 l4 s: B
The 11-β hydroxylase deficiency may also result in9 Z( y9 D9 A8 q8 e
excessive adrenal androgen production, and rarely,
5 j' I, ?" R5 {an adrenal tumor may also cause adrenal androgen
! a+ {0 S8 A# p1 o* ?excess.1,3
; v4 V3 ~+ d1 J/ [8 `, t% W( ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, d5 T; u& `$ b7 B% }
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 T9 @+ ?/ B, f  v1 E' sA unique entity of male-limited gonadotropin-. j; P# E" |  u0 r; z
independent precocious puberty, which is also known$ Q& s% m3 b1 f* g$ @- d2 e; G
as testotoxicosis, may cause precocious puberty at a8 N; Y# M# |2 o# b% b5 U( u9 }1 v
very young age. The physical findings in these boys
! U0 r/ I: {6 g3 T/ e6 U) iwith this disorder are full pubertal development,  N  V/ V  `1 r4 ]/ b7 \- N
including bilateral testicular growth, similar to boys0 L' O  Z: `0 S6 c5 ?7 v6 _) l
with CPP. The gonadotropin levels in this disorder5 ^, A  J/ l* V6 n+ f. z
are suppressed to prepubertal levels and do not show
0 `  F6 ^# y7 spubertal response of gonadotropin after gonadotropin-: _: z5 l6 t" h7 D- g8 d/ G5 j, ?
releasing hormone stimulation. This is a sex-linked  A  P& d& P6 |! T
autosomal dominant disorder that affects only" G# ?4 P) U6 d1 a* ^# R
males; therefore, other male members of the family& l) |1 L% ?, x. A3 G2 ~
may have similar precocious puberty.3/ g# Q- w, i2 Y4 Q! u7 _
In our patient, physical examination was incon-
4 M2 O4 b& |9 `0 B: b8 a( q0 {- Esistent with true precocious puberty since his testi-
. _5 e3 F  Y; q+ Kcles were prepubertal in size. However, testotoxicosis0 P  ?8 }6 ?# q7 N
was in the differential diagnosis because his father3 \7 j+ i: l. `' c* O
started puberty somewhat early, and occasionally,2 Y, ]- Q" D6 |5 S% i$ b
testicular enlargement is not that evident in the
9 h) p" J- {# `' x/ ^beginning of this process.1 In the absence of a neg-6 Z) d1 Y/ h* p  j% s8 B, K/ b, ]: v0 S
ative initial history of androgen exposure, our
3 v2 S1 G: g$ x8 g) Ubiggest concern was virilizing adrenal hyperplasia,# H; n! U7 C: X% I6 q. R
either 21-hydroxylase deficiency or 11-β hydroxylase+ F* M3 l  m# H" n& q0 y" U: }
deficiency. Those diagnoses were excluded by find-
, R# y" h6 N+ d6 C1 Cing the normal level of adrenal steroids.
/ m0 U! t6 D; k" Q$ M$ l. h' S$ wThe diagnosis of exogenous androgens was strongly
6 z- l+ [- d% z2 }suspected in a follow-up visit after 4 months because5 X  ^" G/ _6 c1 ^7 q- P4 s
the physical examination revealed the complete disap-
: M6 I) H3 R, l1 |pearance of pubic hair, normal growth velocity, and
& ~3 F% d% [3 V' [1 q2 ~; z8 C3 {decreased erections. The father admitted using a testos-
: ]1 j' |+ `" M) ^. j: k$ n6 t9 S! tterone gel, which he concealed at first visit. He was
, n! L  A1 f9 wusing it rather frequently, twice a day. The Physicians’
* E& Q. Y- [/ h) B9 L" _Desk Reference, or package insert of this product, gel or) ^. ?5 p8 l- |( N$ x
cream, cautions about dermal testosterone transfer to. n+ t0 j: D. q6 x
unprotected females through direct skin exposure.
7 [9 Q* o' }) v9 p8 iSerum testosterone level was found to be 2 times the( h2 p3 N, E4 z0 w* G, k2 L3 @
baseline value in those females who were exposed to
5 T7 t8 ]9 [% K' x+ Ieven 15 minutes of direct skin contact with their male6 Q2 }1 g; T" Q0 ~* W
partners.6 However, when a shirt covered the applica-
) i6 m8 f; P3 Q" z. P7 M4 d) Ftion site, this testosterone transfer was prevented.6 i& o0 p' e8 H! m/ R) r8 I) q$ T
Our patient’s testosterone level was 60 ng/mL,) K* ~8 T& F$ D6 P! I- |. D8 @
which was clearly high. Some studies suggest that
1 p  v4 G) v/ Vdermal conversion of testosterone to dihydrotestos-1 h. g& O# K7 N  j- ]2 a
terone, which is a more potent metabolite, is more
+ z, Z  U$ w* R! N3 c; Factive in young children exposed to testosterone0 r0 t( \  V6 [) s3 c
exogenously7; however, we did not measure a dihy-
' P' L, F3 v3 e) k. l' Kdrotestosterone level in our patient. In addition to9 K/ M& D( L& _
virilization, exposure to exogenous testosterone in6 f2 o. ^2 h' @' w4 c( k
children results in an increase in growth velocity and7 v2 k% A/ d% y9 E+ H2 F  T
advanced bone age, as seen in our patient.& y- o0 c9 `- B2 G  H6 i5 B
The long-term effect of androgen exposure during
' v! g6 ]3 x  b/ {4 _. Mearly childhood on pubertal development and final
4 T7 c1 M8 f; t, _( Oadult height are not fully known and always remain
  X3 A* x/ z) p0 e5 r2 {a concern. Children treated with short-term testos-
, Z- K4 N6 i0 z0 g4 {terone injection or topical androgen may exhibit some
1 S/ s6 {- j! [+ aacceleration of the skeletal maturation; however, after
  v3 s! E; F) A+ W0 Tcessation of treatment, the rate of bone maturation
' h! g* |0 i! l4 p3 ]9 Q# D( Fdecelerates and gradually returns to normal.8,96 f4 R, c  D0 n- R$ I- Z, P6 l
There are conflicting reports and controversy& F% u. z( l& `9 X) E
over the effect of early androgen exposure on adult' s% v$ e$ X, C3 b1 q( t
penile length.10,11 Some reports suggest subnormal
. Q- U# g$ j: s4 |adult penile length, apparently because of downreg-/ e: ?! O. D, i
ulation of androgen receptor number.10,12 However," n( j3 b* S; G
Sutherland et al13 did not find a correlation between6 U5 X" \2 h9 Q4 l) O' [" L
childhood testosterone exposure and reduced adult/ Y$ W6 H* u6 I& @  L8 r
penile length in clinical studies.+ E8 e- S% w# I& e. h! x0 t
Nonetheless, we do not believe our patient is3 X1 j. r6 R- n4 V0 j& U" r
going to experience any of the untoward effects from
3 D( j) @  Y( q5 H  ltestosterone exposure as mentioned earlier because* w; B6 O% h. J4 K
the exposure was not for a prolonged period of time.
% O! L: S6 Z4 a2 L- ^2 @% _Although the bone age was advanced at the time of
( H3 F' E6 \% t$ D8 n( A: ^+ jdiagnosis, the child had a normal growth velocity at: N: _1 A" b, D8 Y4 u: {( Y
the follow-up visit. It is hoped that his final adult3 \0 r& G) n5 x5 n. @$ e
height will not be affected.
7 o2 S- }( U' b3 H% L8 EAlthough rarely reported, the widespread avail-
5 O3 W& A  v! {# G; rability of androgen products in our society may) c2 h2 c3 w* [% Y
indeed cause more virilization in male or female; Z8 O$ }0 W; K) A
children than one would realize. Exposure to andro-
0 v) ~/ x( s7 Q4 H  A1 D1 bgen products must be considered and specific ques-
' v; N% E$ A$ htioning about the use of a testosterone product or& e* n! K5 p! {8 x. x% ~
gel should be asked of the family members during/ U9 u( C1 @& v# |6 X1 E6 V
the evaluation of any children who present with vir-
! _. F) {4 y3 r  H5 O% X8 g: silization or peripheral precocious puberty. The diag-4 k9 X$ Y6 J, n- w9 O. z, @
nosis can be established by just a few tests and by
# @$ A3 C3 G& Vappropriate history. The inability to obtain such a% a9 y" L3 [" U, L9 W$ P  A& a
history, or failure to ask the specific questions, may( k& ~1 l* z5 c. H
result in extensive, unnecessary, and expensive
  l" J6 u, N" L2 f9 C7 y$ M% vinvestigation. The primary care physician should be. ~( L) _& M! f: O/ b6 E
aware of this fact, because most of these children
- U) G9 I8 I2 T2 Fmay initially present in their practice. The Physicians’  d4 g3 t8 `  t) ?3 v) h
Desk Reference and package insert should also put a8 R4 g/ e7 Y* O& v% k6 r" c
warning about the virilizing effect on a male or  Q. q. M6 r! G
female child who might come in contact with some-
8 Q, A; e: y) e( Jone using any of these products.7 Y5 x8 _8 R2 m& c9 @; t
References4 ^9 X) r. Q/ i# ?% m
1. Styne DM. The testes: disorder of sexual differentiation1 B8 l' q0 x7 {- |1 ?, G
and puberty in the male. In: Sperling MA, ed. Pediatric- E  E5 K+ b, x: m! p
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' b! [. \- u' R, P7 m( ?- Y2002: 565-628.1 }  R5 s; k. b' e+ U
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 n) [8 G7 i. R7 D8 ^
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
2 ]3 h: Z/ Y! C" W' y# H
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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