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Sexual Precocity in a 16-Month-Old
  D& O2 s. s) {4 h% gBoy Induced by Indirect Topical2 `1 U0 _) F. w" y$ E
Exposure to Testosterone! Q$ W0 D7 r) @( O5 D' k* j3 X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" w! v. c' `& h7 U: C* p% Hand Kenneth R. Rettig, MD1
; a, g+ a% g. rClinical Pediatrics
" [& X1 M+ |" L( Q8 m  @Volume 46 Number 6
$ D; E0 m# z9 PJuly 2007 540-543
7 B1 p" j$ e- p© 2007 Sage Publications5 N& J" f$ V) [. _
10.1177/0009922806296651
* |6 X  Q9 Q- A7 F- Whttp://clp.sagepub.com
6 V- O8 q; d! [: T9 qhosted at1 C$ C7 B& S2 G/ U# @
http://online.sagepub.com
, X+ T' a: `, e3 n  I' JPrecocious puberty in boys, central or peripheral,
% g/ p3 s. H# E% F- {! Wis a significant concern for physicians. Central
, u8 e5 U. s9 E1 _1 w9 zprecocious puberty (CPP), which is mediated
" H9 @! h& l0 `1 pthrough the hypothalamic pituitary gonadal axis, has* P, P7 j+ |" x; g
a higher incidence of organic central nervous system: ]) X" F. e- A- v
lesions in boys.1,2 Virilization in boys, as manifested3 R, b- B' f0 T: T4 t' _6 T
by enlargement of the penis, development of pubic
1 q! f+ G8 p! V: s" e6 d  t+ Q/ @( zhair, and facial acne without enlargement of testi-; z$ W- S$ p0 R  }) R' P* R3 p
cles, suggests peripheral or pseudopuberty.1-3 We
6 R5 H+ Z/ ^! p( N7 G  G- G) Xreport a 16-month-old boy who presented with the
5 M8 t# m/ @4 Q7 lenlargement of the phallus and pubic hair develop-
  |# S# D1 Q$ G2 Sment without testicular enlargement, which was due
" {8 h  l' s( Z# Hto the unintentional exposure to androgen gel used by
% c3 N& X! k  v8 g# Rthe father. The family initially concealed this infor-" J- b0 t# Q( [9 g' @7 t, t0 g& m" R
mation, resulting in an extensive work-up for this
) }% b7 z- {. x3 x7 `0 uchild. Given the widespread and easy availability of' x8 q/ I' N& F2 U4 i
testosterone gel and cream, we believe this is proba-" d9 Q% d4 E$ u- p' W& H
bly more common than the rare case report in the
- I- A" v! q  X8 Sliterature.4, }/ V" w/ K* ?. ^3 ~) w
Patient Report6 y& `- h- p& x$ b
A 16-month-old white child was referred to the) A" }* E( ~% }$ c% U$ t
endocrine clinic by his pediatrician with the concern
; W3 M+ C. @7 M: ~/ o! N& Tof early sexual development. His mother noticed
5 u; ^* z. i% D( J% dlight colored pubic hair development when he was
' Q! y) m, h8 k' x) ~From the 1Division of Pediatric Endocrinology, 2University of9 \3 M# ~# `1 @3 D& N. k
South Alabama Medical Center, Mobile, Alabama.
; n+ u9 f+ C7 Z5 LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
$ s8 ^' y% X4 I  y6 J* pProfessor of Pediatrics, University of South Alabama, College of' v2 M  ^, i1 ]3 p* u5 @, c: F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 H0 H4 P) @( _: z7 Be-mail: [email protected].
+ b0 i& u% B6 o8 M& \about 6 to 7 months old, which progressively became
  H1 h# A  j6 K' M* ]0 ]' a, Ndarker. She was also concerned about the enlarge-
+ w2 {4 V, W  t5 o/ b" `2 w7 Gment of his penis and frequent erections. The child6 e. }' W& b- v# J+ _0 @; N) @/ p
was the product of a full-term normal delivery, with" z5 J: R5 z" c* {
a birth weight of 7 lb 14 oz, and birth length of7 M- b  E2 W6 k' _/ Q
20 inches. He was breast-fed throughout the first year
7 C1 r9 v7 F  [5 w6 I! D8 |of life and was still receiving breast milk along with  ^# M8 f* I  N
solid food. He had no hospitalizations or surgery,
1 g- ?, D; A/ A3 ]- X* H$ mand his psychosocial and psychomotor development
5 A( C: _5 y' F4 n' e" w' Zwas age appropriate.
0 N8 H: q* B2 W9 B/ f  }+ ^The family history was remarkable for the father,
% i" }1 ]; z! ?: ^- Xwho was diagnosed with hypothyroidism at age 16,
7 M1 v. {; b8 b& lwhich was treated with thyroxine. The father’s
% |. x: j- m4 ?& U, Dheight was 6 feet, and he went through a somewhat
3 Y+ S' y9 p) `2 Uearly puberty and had stopped growing by age 14./ N" e9 n0 R, G; m/ h" R7 j
The father denied taking any other medication. The$ N$ X' \) J; i; `
child’s mother was in good health. Her menarche
* X( y, T% Q) j- z# p& Awas at 11 years of age, and her height was at 5 feet
( b* _! F) P& C" q# G; a5 inches. There was no other family history of pre-
8 A/ n9 J1 K; g5 L/ v0 L" Gcocious sexual development in the first-degree rela-# X+ r# j& N4 F% e* a. l. R
tives. There were no siblings.
5 X+ t2 O6 }) r2 n7 y4 H- X1 r- B( QPhysical Examination
5 Q8 y* o& }0 i0 T7 O% z+ MThe physical examination revealed a very active,2 D8 \1 ^1 O4 g$ F: t4 D- Z. k
playful, and healthy boy. The vital signs documented
% ?5 v# b: U" \$ j& Ta blood pressure of 85/50 mm Hg, his length was
3 l$ q/ x9 m$ q& |9 @90 cm (>97th percentile), and his weight was 14.4 kg
4 \0 R: Q+ O6 y0 |6 A(also >97th percentile). The observed yearly growth
6 c* a8 V/ e! k, x7 B' W) u$ Xvelocity was 30 cm (12 inches). The examination of! h6 s3 U  E! W1 U+ e4 A# K4 T/ j
the neck revealed no thyroid enlargement.
# W9 O, U% W, bThe genitourinary examination was remarkable for+ k% G) d0 D. g( g8 N7 o4 z
enlargement of the penis, with a stretched length of) o4 d9 J4 I! G
8 cm and a width of 2 cm. The glans penis was very well* i* h& H* @3 W, j: ^
developed. The pubic hair was Tanner II, mostly around; _; J3 T" d) y  |0 w
5406 v' z& e1 F& P- ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 x$ l) [! u. u$ ~& g* _the base of the phallus and was dark and curled. The
. O) J3 B  j- O0 h7 [# ~testicular volume was prepubertal at 2 mL each.
0 ~" I; `$ W* e% j. e9 G1 r8 OThe skin was moist and smooth and somewhat
# T3 Y1 ~; W1 o  ^* ~oily. No axillary hair was noted. There were no
- _! B" ?; ~3 t* Habnormal skin pigmentations or café-au-lait spots.- r7 N% M9 H$ Q8 U! n
Neurologic evaluation showed deep tendon reflex 2+
* x7 _" O9 n9 e' Y$ |; J% ibilateral and symmetrical. There was no suggestion
$ W" ~' z5 T( mof papilledema.
1 k' O1 M3 u* n% K/ H% Y0 SLaboratory Evaluation2 }8 Y8 [. `$ T# _% A$ S+ h- F
The bone age was consistent with 28 months by) n; R( G! c! P7 R( `
using the standard of Greulich and Pyle at a chrono-: C3 t/ k9 B9 E+ a/ k& D( i
logic age of 16 months (advanced).5 Chromosomal4 i8 T9 a3 C6 {. H3 M" s
karyotype was 46XY. The thyroid function test- I; ~3 }5 z+ N; q& j& Z) q" E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% @. d, [. Y2 l. v  Wlating hormone level was 1.3 µIU/mL (both normal).
7 A/ a* L, W$ V1 A6 GThe concentrations of serum electrolytes, blood
% t+ ^7 F, y" [, ?6 wurea nitrogen, creatinine, and calcium all were
- {5 E% c+ R6 ]within normal range for his age. The concentration1 T/ s* r/ ?* E4 s
of serum 17-hydroxyprogesterone was 16 ng/dL
  k; e5 D  L  n) ?. `! K( m(normal, 3 to 90 ng/dL), androstenedione was 20
( |( ~) t* S6 ~! `/ \5 bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) v- E1 v/ V* O4 l4 T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 w4 z. u' w! e6 [/ Jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 S* \$ j& c3 A, ^8 k* i0 Y" S
49ng/dL), 11-desoxycortisol (specific compound S)
& q3 k7 c% I9 j9 M2 P- c6 o7 Dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 v1 H5 z) l7 @5 A: C1 t# Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 k, I6 Z" n  K% u* ^+ rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! N+ v" n/ E  W3 l- m7 Aand β-human chorionic gonadotropin was less than( q  \  T, F# n1 p
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 A" q0 ]( ]! o4 w$ I8 a# K
stimulating hormone and leuteinizing hormone
8 m" i0 Y( d3 U/ J2 b* d$ B# Kconcentrations were less than 0.05 mIU/mL
0 @, a9 q( ^, w$ Y(prepubertal).
1 m3 J; G9 j; l5 L1 R0 e) oThe parents were notified about the laboratory
; k& k1 g: |2 z4 O/ Z4 u7 y4 Vresults and were informed that all of the tests were
7 q- r$ n1 C* Y1 [) ]/ inormal except the testosterone level was high. The
7 g* \- p$ o7 O. i# Q  Y9 q4 Qfollow-up visit was arranged within a few weeks to+ C* l2 a5 V; h4 _% O6 O3 l
obtain testicular and abdominal sonograms; how-8 L# v. H* O+ N
ever, the family did not return for 4 months.
/ s: A" @' ^' j' [: [/ \Physical examination at this time revealed that the
+ B5 _& A1 f; q% E5 achild had grown 2.5 cm in 4 months and had gained& ]  H- C0 Z6 Z( ?8 O# L/ E  I" N
2 kg of weight. Physical examination remained/ O. T# ^# d; S3 g
unchanged. Surprisingly, the pubic hair almost com-! I# B; q1 j0 z
pletely disappeared except for a few vellous hairs at
2 F3 F# V9 N# D  I4 Fthe base of the phallus. Testicular volume was still 29 g# Z$ d+ R  r+ D. A( _, C
mL, and the size of the penis remained unchanged., |3 q, K; ?' x- }
The mother also said that the boy was no longer hav-
+ ?! X7 s1 t% d2 bing frequent erections., L  z5 M2 a% [/ v; F4 v) p) m# k0 G; k  q
Both parents were again questioned about use of
( j7 b. H  s, v( d& b, g/ _) }' N3 dany ointment/creams that they may have applied to
4 s5 O1 Y* X8 L) Y2 u& Tthe child’s skin. This time the father admitted the
' f- c, p- Y, _& [" q( U0 gTopical Testosterone Exposure / Bhowmick et al 5416 J% Y1 g1 r) s* @& e1 \( G& s: p% c
use of testosterone gel twice daily that he was apply-1 k, ]  i7 `1 w6 C& `: g
ing over his own shoulders, chest, and back area for9 M9 T* [6 r' z& J# }8 X& e1 J" H
a year. The father also revealed he was embarrassed
% \" P. y  r6 R' i. _* dto disclose that he was using a testosterone gel pre-
+ U! f/ g; @/ _- b* S' bscribed by his family physician for decreased libido9 D! z8 X' s+ y7 d: c2 I
secondary to depression.
; R3 V+ h: P) W5 u0 tThe child slept in the same bed with parents.
* F: R* r( }- R. dThe father would hug the baby and hold him on his
, ]5 Y/ }5 U$ n. ], K" lchest for a considerable period of time, causing sig-
% G$ n$ b& ]1 H. k* H" vnificant bare skin contact between baby and father.+ b. N+ [0 c9 {+ p2 w
The father also admitted that after the phone call,
; B* I! v; M' I9 X5 L  V- qwhen he learned the testosterone level in the baby
+ i3 i6 q2 H: h# S: P$ {' R% w" D1 s* Iwas high, he then read the product information
4 y8 {. p2 \7 K4 ~5 N1 _' y" gpacket and concluded that it was most likely the rea-" {: P- j- P  F0 y6 M, _, p+ V- I2 F
son for the child’s virilization. At that time, they' W1 Z* ]1 k& g5 v. t$ F6 Q
decided to put the baby in a separate bed, and the2 n! |4 D8 v. _; I
father was not hugging him with bare skin and had
: k. g% r' m) H+ W# q8 Q- kbeen using protective clothing. A repeat testosterone' w9 W7 G# r- S- l5 }7 e5 I6 O
test was ordered, but the family did not go to the
  h# I+ n! F' g  B/ v  dlaboratory to obtain the test.) y% X: z! z/ U: G- {6 b7 }
Discussion
4 n- F# x( }  B6 NPrecocious puberty in boys is defined as secondary
, ]8 s3 h0 ^9 \2 t6 W% n2 csexual development before 9 years of age.1,4
6 {* D" r7 L" f; gPrecocious puberty is termed as central (true) when! P; F% K" {& D7 H* ?! q
it is caused by the premature activation of hypo-/ h* h( y, A: n( m( R4 C; b: f2 ~
thalamic pituitary gonadal axis. CPP is more com-( ?! k+ H2 V( _! P* }( K4 e
mon in girls than in boys.1,3 Most boys with CPP
2 ^: A! x5 J* pmay have a central nervous system lesion that is* {' V& a5 k* \, y+ |# D
responsible for the early activation of the hypothal-
7 ^( }, W& b* k, `: @amic pituitary gonadal axis.1-3 Thus, greater empha-2 R$ n* U3 }7 \8 T  `
sis has been given to neuroradiologic imaging in
0 o4 A6 H' r! dboys with precocious puberty. In addition to viril-
! H% x2 W: _& ^/ x5 x& Q. r0 C. ^ization, the clinical hallmark of CPP is the symmet-! g- Q& C' l" g! U/ ^3 i' i
rical testicular growth secondary to stimulation by
% ]3 _! a7 {- f9 D7 Igonadotropins.1,3
3 v( _: Q+ d& B, W% nGonadotropin-independent peripheral preco-
" K4 Y: d1 t7 A8 T% `6 }cious puberty in boys also results from inappropriate
6 s6 D/ r6 \: c8 @( g' Candrogenic stimulation from either endogenous or
  Y. |  E& s( d$ q! z( K0 I0 C$ kexogenous sources, nonpituitary gonadotropin stim-- G& G/ G/ l2 D; |. ]$ U( @
ulation, and rare activating mutations.3 Virilizing
, t! v& ]$ N6 l2 ]congenital adrenal hyperplasia producing excessive
; ^' W$ a! r" v' jadrenal androgens is a common cause of precocious- t: S  @5 o9 J0 |* p, x4 K
puberty in boys.3,42 f, K, r. m) m
The most common form of congenital adrenal
4 B. q9 b7 b2 p& U. t: thyperplasia is the 21-hydroxylase enzyme deficiency.. f7 D& V- z+ C6 ~
The 11-β hydroxylase deficiency may also result in6 c  }( x$ ]  l
excessive adrenal androgen production, and rarely,2 w5 ~! |+ k4 I- G4 W( d
an adrenal tumor may also cause adrenal androgen
. x5 P5 u' V8 }excess.1,3
( q1 X& N3 J- }: |2 g: l0 b0 b  rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* e! X# n9 x& C7 q2 R) U* Y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: P8 }, E: r+ }& EA unique entity of male-limited gonadotropin-
7 Y' b3 H5 H. pindependent precocious puberty, which is also known
0 L. k1 v( o2 b9 B5 xas testotoxicosis, may cause precocious puberty at a6 \+ n7 E9 T' g* I# z
very young age. The physical findings in these boys! N9 r% l+ e- V1 @  F0 O* w
with this disorder are full pubertal development,
) e! X1 m4 N. m0 ~- D! _+ Sincluding bilateral testicular growth, similar to boys% j8 Z7 a4 e" S
with CPP. The gonadotropin levels in this disorder! R2 `# |$ V' {8 f: \: O) Y
are suppressed to prepubertal levels and do not show
2 c* X3 k( }/ N/ _6 d# K; x" spubertal response of gonadotropin after gonadotropin-
" |; t0 \: s: I" p. _releasing hormone stimulation. This is a sex-linked
: G  P  R6 v- j8 @- {) A9 z7 Pautosomal dominant disorder that affects only# X" i2 D1 k2 e, k* n; F! o' @
males; therefore, other male members of the family
' d, v) y/ Q! B- @* i* k/ P3 dmay have similar precocious puberty.3  {; k" p! T2 x
In our patient, physical examination was incon-
" e4 d& D  ]; @sistent with true precocious puberty since his testi-- F& _! {4 p6 m  E
cles were prepubertal in size. However, testotoxicosis+ O: f6 \1 Y" L7 Q- V- E) ]3 R+ b% [
was in the differential diagnosis because his father
$ ?9 D! b1 |9 K2 J6 Ustarted puberty somewhat early, and occasionally,% U8 k- p9 @* Y) r. ]+ h
testicular enlargement is not that evident in the5 X) e. R& |! n
beginning of this process.1 In the absence of a neg-$ A' P  g4 r. a( T2 P' c% q: t
ative initial history of androgen exposure, our% @' J9 B5 a- R; `+ k
biggest concern was virilizing adrenal hyperplasia,
5 S! U; G  l- d! ]: A' Peither 21-hydroxylase deficiency or 11-β hydroxylase# b+ O, e9 a: \/ l9 o
deficiency. Those diagnoses were excluded by find-
9 \( E9 d+ y% cing the normal level of adrenal steroids.. Q6 Y4 b. N5 Z6 y
The diagnosis of exogenous androgens was strongly
) @7 K, n) ~4 w: `1 Wsuspected in a follow-up visit after 4 months because! O' D1 ]5 X9 h
the physical examination revealed the complete disap-7 j+ V% |$ d. u% N
pearance of pubic hair, normal growth velocity, and" H' `2 o. q, v; D2 w$ D: V3 \2 a
decreased erections. The father admitted using a testos-
( y+ N4 B! S5 Tterone gel, which he concealed at first visit. He was3 c& d6 f& W& r5 I( ^5 q
using it rather frequently, twice a day. The Physicians’5 I( r* s7 @7 p/ X8 m
Desk Reference, or package insert of this product, gel or
; u0 Q0 E% {. ^& d& ~5 m1 Jcream, cautions about dermal testosterone transfer to
) R" h; V: C* W5 {# {4 Dunprotected females through direct skin exposure.
" q+ M4 D/ S  }! s3 M  PSerum testosterone level was found to be 2 times the4 o: |% ~: l& ?, w# R5 _
baseline value in those females who were exposed to$ Z: n& B: W# F. c2 w# Y/ T
even 15 minutes of direct skin contact with their male. j* G7 m0 H7 D# i1 K) B
partners.6 However, when a shirt covered the applica-# F, m, ?! Q% N0 ]) I7 \' Q. r# B
tion site, this testosterone transfer was prevented.
/ ?  d/ L+ \2 M, I+ n8 ?: a; `! ~Our patient’s testosterone level was 60 ng/mL,6 S2 j/ h8 L! o+ m2 q
which was clearly high. Some studies suggest that
1 U! _0 R4 m1 [8 ?1 _$ zdermal conversion of testosterone to dihydrotestos-
1 L6 n- [& o+ S6 [' Vterone, which is a more potent metabolite, is more
1 m2 T8 {/ m3 E: F9 Wactive in young children exposed to testosterone! `6 {, h7 S3 n( ]1 W( y# s1 o  b
exogenously7; however, we did not measure a dihy-
/ u9 `: B- D+ ]0 ndrotestosterone level in our patient. In addition to
1 I$ o3 v7 l7 Y1 f' h9 @virilization, exposure to exogenous testosterone in
! i) ~3 E+ X- N3 g* g# l/ A9 @children results in an increase in growth velocity and& f( D% c. b1 C+ m  e" M
advanced bone age, as seen in our patient.
' r$ P( q& C" ~The long-term effect of androgen exposure during- T& r; s( k. X1 o% D9 X0 J
early childhood on pubertal development and final
# X7 Z7 ]) [; g5 b* o6 ^+ Cadult height are not fully known and always remain
, n; M4 u& Q2 Q+ {  w0 D' @% Ea concern. Children treated with short-term testos-
3 L1 l. x; ^6 f. K3 Cterone injection or topical androgen may exhibit some
' P% Y, [, e* d' d+ x- B- c. Vacceleration of the skeletal maturation; however, after
7 A7 s" j! t7 r) v! Kcessation of treatment, the rate of bone maturation- a! U1 W% `3 \4 U: k0 X0 s  o  Q
decelerates and gradually returns to normal.8,94 g; S4 M4 x' N1 W" e$ U  ~+ ~
There are conflicting reports and controversy
( `& K' h- ~# b5 d) |6 R% u% Cover the effect of early androgen exposure on adult
, ]6 f) ?  R, m7 Gpenile length.10,11 Some reports suggest subnormal
0 j3 z0 z8 r, b: |adult penile length, apparently because of downreg-
: G' H% d' n6 m+ z* Yulation of androgen receptor number.10,12 However,
% |* V" X* Z) gSutherland et al13 did not find a correlation between# D* c$ P" r2 l$ B
childhood testosterone exposure and reduced adult
+ X: r$ g8 l( Qpenile length in clinical studies.
8 o0 `8 n& g( h% b/ N' DNonetheless, we do not believe our patient is
) u! k5 O# j3 u! ?) Bgoing to experience any of the untoward effects from
# t' A& o+ C' v8 V( E, ]( ctestosterone exposure as mentioned earlier because
/ o8 S5 [& y: rthe exposure was not for a prolonged period of time.
$ W- M; D# u8 ]. k: E5 sAlthough the bone age was advanced at the time of1 s. A3 l* P7 k$ ~: n
diagnosis, the child had a normal growth velocity at
+ W( i0 ]# A! F2 Mthe follow-up visit. It is hoped that his final adult
. w4 o5 G; d/ Xheight will not be affected.
* T5 a& _6 C3 U+ m/ s& |! lAlthough rarely reported, the widespread avail-' @, ~$ Z* W2 D5 U
ability of androgen products in our society may3 R% Y1 k7 f, q% t
indeed cause more virilization in male or female) m6 K, f" N' S& @# y
children than one would realize. Exposure to andro-
$ {7 R7 a) k) T: j9 N- r7 Ygen products must be considered and specific ques-
* E/ y& Z1 o0 v* b' jtioning about the use of a testosterone product or
4 k& p8 X/ r& ~. k. }; W6 Ngel should be asked of the family members during# W( C- `) S3 h4 A" {; J9 x8 {
the evaluation of any children who present with vir-1 s( ], i& B7 r- I4 F
ilization or peripheral precocious puberty. The diag-) T! o2 P. D( s& c
nosis can be established by just a few tests and by
3 ~3 K- |: `5 s; r0 I- S2 W# I2 E( Q' mappropriate history. The inability to obtain such a
) o  t+ K3 P/ r" E* |! Q8 d& Nhistory, or failure to ask the specific questions, may$ i( P% z% _8 z: L( F0 l3 |3 \
result in extensive, unnecessary, and expensive1 q" f0 I8 g3 @5 o" D
investigation. The primary care physician should be
9 S$ i, ~7 ?) }7 f. j, R% S4 Paware of this fact, because most of these children
: w+ ^8 V8 Y) I+ i7 R" b! s% U, Fmay initially present in their practice. The Physicians’  T1 @3 R# B" f( I$ X; [/ M3 ^
Desk Reference and package insert should also put a# |. r6 e9 Q+ }0 c
warning about the virilizing effect on a male or
9 A9 a' ?; u# v. w6 vfemale child who might come in contact with some-. [2 |5 L+ `2 K6 t( j, l2 \* g. m
one using any of these products.
9 [# l& \  M  ~9 g8 eReferences
! k8 P+ R* M# ]2 S3 Q8 }: W1. Styne DM. The testes: disorder of sexual differentiation3 }' K1 q; r- V# O
and puberty in the male. In: Sperling MA, ed. Pediatric
2 Z; c  L, i& GEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. W" Y9 k; ]& n7 f$ |: t2002: 565-628.
4 ?: y# b; [  @5 L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 d% ?+ K8 b  h$ h, C' Z" Epuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old/ M0 F* c2 h! ]3 h1 H, u
Boy Induced by Indirect Topical3 M& \8 V8 _% A' l- B
Exposure to Testosterone. g1 R& @1 t+ j, V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 a* }/ G* n, Rand Kenneth R. Rettig, MD1
2 U' p' l  X/ M& X' j$ G2 hClinical Pediatrics
  T" t& g1 f& E. q) c- Y5 F$ tVolume 46 Number 62 f+ W6 T+ g0 j: Y& X" o
July 2007 540-543' ]. A+ m) P0 s6 F
© 2007 Sage Publications. t6 B3 O- ]/ d8 h( k) m$ m8 H
10.1177/0009922806296651) g) q* i- s" m; Y9 u3 Y+ g
http://clp.sagepub.com0 k7 A4 {  A0 j- v; ?3 @* w: ~
hosted at
3 g$ T8 B/ c; d5 fhttp://online.sagepub.com# E0 D- a$ O& z. {: E% }, }, A4 |
Precocious puberty in boys, central or peripheral,& ]$ E# G* M* ?8 X; r
is a significant concern for physicians. Central4 ~% @8 B7 c9 J
precocious puberty (CPP), which is mediated# G  q% J% ]0 g, G! v% Y
through the hypothalamic pituitary gonadal axis, has
& c; v# E: J9 H7 c: Wa higher incidence of organic central nervous system
' \1 B- |1 T; {8 c5 G4 ~, wlesions in boys.1,2 Virilization in boys, as manifested
8 p" T: M* |/ T7 ^1 A" C: vby enlargement of the penis, development of pubic2 }( ^& H9 H+ R5 ^
hair, and facial acne without enlargement of testi-
, i! P# _# q8 P' _4 A2 Q0 A+ jcles, suggests peripheral or pseudopuberty.1-3 We8 s/ q9 r  ~4 v/ W6 a
report a 16-month-old boy who presented with the2 }5 _: q; G) [0 r( U
enlargement of the phallus and pubic hair develop-
* k6 I5 f! }2 Dment without testicular enlargement, which was due
4 J0 r- d9 ~6 ^" e* ^" Cto the unintentional exposure to androgen gel used by
& p* s$ a8 t$ D0 k0 j8 ^- Tthe father. The family initially concealed this infor-8 i  e* o! t' B5 T
mation, resulting in an extensive work-up for this0 F$ P% b* F  s  B2 U9 R2 M' j
child. Given the widespread and easy availability of
6 R( x$ n0 ~1 k, ~' |0 H7 Mtestosterone gel and cream, we believe this is proba-& R# @) f( s4 _: k& T8 W/ @
bly more common than the rare case report in the: r) a5 U! W% O  H
literature.4
+ Q0 y3 A& ]* j% hPatient Report
3 T) Z" K; o& PA 16-month-old white child was referred to the
3 H' k/ i/ [0 i& C' U' J$ a& ?endocrine clinic by his pediatrician with the concern
/ i4 d* U+ k1 w3 O( g% _of early sexual development. His mother noticed
% T- _7 z+ c  R" f$ D9 ]# rlight colored pubic hair development when he was5 m" D; R3 J% H
From the 1Division of Pediatric Endocrinology, 2University of
: [$ f4 y" r& V1 c3 e- D5 DSouth Alabama Medical Center, Mobile, Alabama.+ R! P0 I4 O$ r: G: K5 b1 ]$ `
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# f5 [* l7 z! i- \  n" h; iProfessor of Pediatrics, University of South Alabama, College of
9 |* O  w" J6 m6 I1 d! WMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 }) C  Z4 g3 V  N: o# y9 P
e-mail: [email protected].7 s$ S4 G# m4 l) H# E. V/ W
about 6 to 7 months old, which progressively became% q+ y. V* v/ C
darker. She was also concerned about the enlarge-
! s- Z7 B% K' m3 kment of his penis and frequent erections. The child
# b3 R. {$ {6 Bwas the product of a full-term normal delivery, with# w( C4 m, N  D. U; h* e
a birth weight of 7 lb 14 oz, and birth length of4 x# Y4 D- M) S4 U& v5 b+ j
20 inches. He was breast-fed throughout the first year: c- l0 z0 G$ G! E0 g
of life and was still receiving breast milk along with
! o/ O% H/ i9 C8 W+ K) ]3 Vsolid food. He had no hospitalizations or surgery,; ^. K' n1 M6 s6 t7 U9 h
and his psychosocial and psychomotor development7 ~6 x, j! i: [- I, q
was age appropriate.1 l# |8 W; v% j0 S" `! w
The family history was remarkable for the father,1 \2 n4 ~) b, `2 f2 k+ @9 \. i: b
who was diagnosed with hypothyroidism at age 16,2 ?' Y, Q5 I& @7 C3 @+ {
which was treated with thyroxine. The father’s
- Q. v2 @  k9 u( f6 R" {height was 6 feet, and he went through a somewhat) \% [- m) A' i
early puberty and had stopped growing by age 14.( o" s3 e$ V( j: W4 r* j# _" Y; Y
The father denied taking any other medication. The4 z+ C- x/ A; k# j4 q8 S4 n
child’s mother was in good health. Her menarche3 O+ i: a" n. M8 Z8 `
was at 11 years of age, and her height was at 5 feet
# `! Q9 r8 B# B+ A# g6 L5 inches. There was no other family history of pre-0 o8 x  U2 H) u% ]" ^
cocious sexual development in the first-degree rela-
( X; d; N4 V; ~# itives. There were no siblings.
- V# [# }; S% i- wPhysical Examination
! t3 m, S5 j$ }$ u: [" NThe physical examination revealed a very active,
2 ]3 S8 D& I* S# aplayful, and healthy boy. The vital signs documented
. R1 X- \- M, a) u# P9 ea blood pressure of 85/50 mm Hg, his length was6 c3 s; A2 h2 S
90 cm (>97th percentile), and his weight was 14.4 kg
, i  S4 ]0 Q$ Z(also >97th percentile). The observed yearly growth9 |" }. }3 }# S' c* V4 h5 h1 n
velocity was 30 cm (12 inches). The examination of
! J8 I8 b- M8 K$ \# j  n/ Xthe neck revealed no thyroid enlargement.& x( D( B4 Z$ a+ w9 P: B. c6 d
The genitourinary examination was remarkable for
. T8 J4 B1 y6 B6 X3 _& Q4 Zenlargement of the penis, with a stretched length of1 h3 w; v1 N9 C
8 cm and a width of 2 cm. The glans penis was very well
% C" G8 a- H4 Q; ^9 j4 x3 bdeveloped. The pubic hair was Tanner II, mostly around( u! K; j* J) Y& |5 b8 N9 r2 }, g' {. U
540. U; d( q5 u; ]  x/ `6 |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' @9 h9 h/ v+ q- f
the base of the phallus and was dark and curled. The4 j* f5 F4 M" P
testicular volume was prepubertal at 2 mL each.# }6 _" P% u9 N3 N; m
The skin was moist and smooth and somewhat3 j7 ^( V% V  S, O
oily. No axillary hair was noted. There were no
& c2 S% u9 `0 x1 Q0 Y1 Wabnormal skin pigmentations or café-au-lait spots.+ G. t! J0 U# C# Q( ^& L1 h
Neurologic evaluation showed deep tendon reflex 2+- z. [) P, D8 [$ e
bilateral and symmetrical. There was no suggestion" U; K. o7 ^# W& d/ }
of papilledema.. ]+ ^+ I1 W! r4 p( s- }, W
Laboratory Evaluation8 G/ c9 n: V: M$ U: w4 }
The bone age was consistent with 28 months by
7 X3 n. R, V; j/ Vusing the standard of Greulich and Pyle at a chrono-
8 U" F3 ]  T. V& n, xlogic age of 16 months (advanced).5 Chromosomal% Z9 L) r6 C& k5 _
karyotype was 46XY. The thyroid function test
- G0 _  E4 v0 m0 j3 Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-$ l& N! U: O" b. {8 d
lating hormone level was 1.3 µIU/mL (both normal).
; v, ]+ g5 D6 s; c; ZThe concentrations of serum electrolytes, blood
" V7 T: h* R. i7 v) o5 X! y* |urea nitrogen, creatinine, and calcium all were
# o1 }+ M5 ]# S- U& kwithin normal range for his age. The concentration
; s6 @4 ~5 ~2 ?4 [! B$ I, Sof serum 17-hydroxyprogesterone was 16 ng/dL3 I' r8 ~  ?. {0 W( L
(normal, 3 to 90 ng/dL), androstenedione was 20
$ Y1 \, ]8 |# E1 K% gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 ~* C" b6 n' b! j  U3 J
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: E+ f) l9 R$ s; [7 C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 F7 C5 O+ e9 T3 C# V9 `49ng/dL), 11-desoxycortisol (specific compound S)$ I7 W* f5 t6 j+ m  ~- z+ g" }4 V
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- A# [; L4 Z1 d; C) f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 d5 a: }' \% \" w% H- ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 c. B( l# M& z' a9 z. ~' ?* U% tand β-human chorionic gonadotropin was less than8 c4 p, x- y" n6 ?$ t  {& ^6 O
5 mIU/mL (normal <5 mIU/mL). Serum follicular' E% C, n0 s* X, {! v* v, C1 Z
stimulating hormone and leuteinizing hormone
/ p) D- m8 V; M& d5 oconcentrations were less than 0.05 mIU/mL
/ Y! s3 b( b) T) C+ n% V(prepubertal).
- L8 k3 L; c5 y5 kThe parents were notified about the laboratory
, `) I7 d8 ]* tresults and were informed that all of the tests were
; y5 [3 r: a* A% W- k- J* d, q3 tnormal except the testosterone level was high. The
: L- z$ m0 y" afollow-up visit was arranged within a few weeks to. Z2 c3 N2 Z$ p* }" e; l+ Y$ O
obtain testicular and abdominal sonograms; how-2 @. C4 s- \  C3 y$ d( \
ever, the family did not return for 4 months.
/ V5 E0 D: L, y  ~$ T6 y% mPhysical examination at this time revealed that the
( h! W0 Q. A$ Q, V( |" Q: schild had grown 2.5 cm in 4 months and had gained& P( _0 V1 F% }' H; M$ s* c; [
2 kg of weight. Physical examination remained: A5 V9 }& g! m) P4 S. [
unchanged. Surprisingly, the pubic hair almost com-+ U5 W1 |. V5 i) w( X, u
pletely disappeared except for a few vellous hairs at. b& j) C+ L# m. ~5 k
the base of the phallus. Testicular volume was still 2/ M+ ^+ z5 K6 H. N7 F2 n
mL, and the size of the penis remained unchanged.& w% Y5 ^2 A# O6 t! ?6 j- r; j
The mother also said that the boy was no longer hav-& Y, r: b8 E! W$ W- T' y1 k
ing frequent erections.
. R) c: K) s$ e- ?6 R0 r* }  QBoth parents were again questioned about use of( l6 u5 {5 \5 W7 _- Z
any ointment/creams that they may have applied to2 E5 b* P/ M' I% w
the child’s skin. This time the father admitted the$ ~! b' [, s  u
Topical Testosterone Exposure / Bhowmick et al 541
' v' `' T/ @! l; G  ause of testosterone gel twice daily that he was apply-
# `$ ?- x- D2 h# ~- x0 ]# [5 ging over his own shoulders, chest, and back area for# {' E/ Y8 R  r9 z: c: D6 d( m
a year. The father also revealed he was embarrassed  I3 k) B) c/ S# X" p. `* ?
to disclose that he was using a testosterone gel pre-1 ^/ Q& S! U- ?: I+ G) X+ M$ ^+ I
scribed by his family physician for decreased libido
' S3 u8 {  H& Zsecondary to depression.; L# w0 C9 D# m
The child slept in the same bed with parents.
7 D! T6 }% k) t9 W# K. s. ^- ?The father would hug the baby and hold him on his3 `# Q1 B5 h9 _
chest for a considerable period of time, causing sig-9 C& a$ D6 b! F7 M/ E% M
nificant bare skin contact between baby and father.
3 y& R. Z6 o% a/ PThe father also admitted that after the phone call,
, b. r. P0 b/ u6 @& Xwhen he learned the testosterone level in the baby
- @. G7 q! ~; C6 B; jwas high, he then read the product information
: ~# _+ L* ^$ q" z" h' b! i+ Tpacket and concluded that it was most likely the rea-- z2 i2 y4 H  ~6 [: s- B. B- `  ?
son for the child’s virilization. At that time, they& H" `! _7 J$ r$ T3 w
decided to put the baby in a separate bed, and the/ t8 f) n" A* h' j9 v. ~; L6 E' i
father was not hugging him with bare skin and had
# ^+ u5 H7 o' V; Z7 {( hbeen using protective clothing. A repeat testosterone
" }" G' p! ]/ u; q# etest was ordered, but the family did not go to the+ \/ y2 E2 X  L& D9 |+ j
laboratory to obtain the test.
# k0 K8 p' c/ ^Discussion/ W  q  U! U( `+ C" ?
Precocious puberty in boys is defined as secondary! T4 G( t* j6 m$ {. ?2 h
sexual development before 9 years of age.1,46 }( n2 r  S, q% B, A% Y2 }; o; ?
Precocious puberty is termed as central (true) when$ I/ L- Z) |: z/ \! U
it is caused by the premature activation of hypo-$ m1 Y/ ]$ h% u) ~3 n5 w1 B
thalamic pituitary gonadal axis. CPP is more com-
3 X- N" G# o+ h8 v0 ~mon in girls than in boys.1,3 Most boys with CPP
+ n/ x6 N# _2 v3 D% q$ omay have a central nervous system lesion that is
+ G+ U! G, M$ kresponsible for the early activation of the hypothal-7 O" a% h8 Z. e& a( M
amic pituitary gonadal axis.1-3 Thus, greater empha-6 |. Z2 [5 {" w* [& J3 v. F/ N/ S
sis has been given to neuroradiologic imaging in8 t- b& W% h. J6 u
boys with precocious puberty. In addition to viril-. @4 c7 D+ J- ]9 }1 g
ization, the clinical hallmark of CPP is the symmet-
; K- N5 ^$ b" D" ]rical testicular growth secondary to stimulation by
: Z, O! k4 M  F7 K) v4 Ygonadotropins.1,3
% y6 R5 J) D" }Gonadotropin-independent peripheral preco-# o, |( N# n& p& Q
cious puberty in boys also results from inappropriate4 ]8 t; |1 a6 C9 K1 U) ?, [
androgenic stimulation from either endogenous or
, j1 v* D3 F1 q8 r8 x4 sexogenous sources, nonpituitary gonadotropin stim-
& K2 u% U' F% I2 J8 n, i. Iulation, and rare activating mutations.3 Virilizing
6 j$ H$ e, \+ Y4 ncongenital adrenal hyperplasia producing excessive
. {; t  H8 }) }* v$ Yadrenal androgens is a common cause of precocious
3 c; O7 j  b9 W& l1 Tpuberty in boys.3,4  H) y8 \; O. A
The most common form of congenital adrenal6 Z; Z; D- h6 _/ Q" M+ ]
hyperplasia is the 21-hydroxylase enzyme deficiency.! e8 W, G5 ~) A' m: I% f! c! G
The 11-β hydroxylase deficiency may also result in
+ i; X* `1 C+ f3 e, U! S& jexcessive adrenal androgen production, and rarely,
" H: @  i, o4 K4 qan adrenal tumor may also cause adrenal androgen
( L+ j" Q  x: G1 Fexcess.1,37 C8 K$ o- q- B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ ~3 L9 `! q$ v! u542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; J! G/ b4 y6 j0 B6 H2 ?. P9 m
A unique entity of male-limited gonadotropin-
% H; C. `- `' n0 c3 aindependent precocious puberty, which is also known
; P( @; \- t/ {as testotoxicosis, may cause precocious puberty at a& l* |" e* a* q. s3 H( d/ t" Z& c
very young age. The physical findings in these boys
( D4 `6 s- c" @3 f$ C" `2 x8 lwith this disorder are full pubertal development,. H5 J6 ~7 G0 I) H+ `
including bilateral testicular growth, similar to boys  K0 F0 @& P+ T. E; `4 y, I/ q
with CPP. The gonadotropin levels in this disorder
* l& A9 F% c4 V' a( Gare suppressed to prepubertal levels and do not show+ }& V" W' s/ k  k! ?" t7 L; D2 j/ ^8 j
pubertal response of gonadotropin after gonadotropin-
% z( t3 _4 Y. ureleasing hormone stimulation. This is a sex-linked
2 k9 L% D" ~/ l5 N! I% lautosomal dominant disorder that affects only) C6 M: A& u* T3 J
males; therefore, other male members of the family) ?9 y2 d" \/ l* E, c& i% Z
may have similar precocious puberty.3
0 f* S6 I9 ?8 tIn our patient, physical examination was incon-
4 s. w( O) D, J4 N% }3 Xsistent with true precocious puberty since his testi-
) C, T, P# s: d1 F5 B  m2 ?4 }5 Gcles were prepubertal in size. However, testotoxicosis8 ?! W3 G6 @% T' _. S" q7 ?8 K4 I* ]
was in the differential diagnosis because his father
2 c: `1 E- G$ y! V& T1 F- L' F" f  _( estarted puberty somewhat early, and occasionally,
) J1 g4 v; ~0 @  A; v3 l6 ktesticular enlargement is not that evident in the
( y2 E& w1 I! R- [' {" Jbeginning of this process.1 In the absence of a neg-
# @  I1 P* m' v, Bative initial history of androgen exposure, our1 n: y; W- x/ [3 {; L6 F
biggest concern was virilizing adrenal hyperplasia,. ~& h) U( l( x, e
either 21-hydroxylase deficiency or 11-β hydroxylase. w0 t4 v! W' J4 L. T; Y2 j& `; }
deficiency. Those diagnoses were excluded by find-
5 h! `4 Z# |" z4 {1 l  J( K, L2 J& Ling the normal level of adrenal steroids.
  N" k5 G" {" y* W1 nThe diagnosis of exogenous androgens was strongly
* F2 S, F7 z" I7 ?suspected in a follow-up visit after 4 months because
* x- h/ T0 z  F1 Q, |. _the physical examination revealed the complete disap-9 Z* n9 k& {: M5 U+ H8 ~- o
pearance of pubic hair, normal growth velocity, and* F% K3 N' H; N% R# N* `6 x
decreased erections. The father admitted using a testos-; a1 S% Q( _, h& K" ~- v
terone gel, which he concealed at first visit. He was
# Q1 C  e8 S* W  l9 Husing it rather frequently, twice a day. The Physicians’- D3 u9 N3 q% l0 i6 h
Desk Reference, or package insert of this product, gel or
- d$ V  U, _- M. y* g3 y: Hcream, cautions about dermal testosterone transfer to) R6 J2 {, ^$ f5 Q6 y* g" A
unprotected females through direct skin exposure.
. d( b2 q+ l2 B0 O' iSerum testosterone level was found to be 2 times the
: W- D3 N. x& t' C  Ubaseline value in those females who were exposed to& z3 B. C! U' b. x. K7 h% X
even 15 minutes of direct skin contact with their male6 Q) [3 z- d1 x$ M" \, `0 M
partners.6 However, when a shirt covered the applica-
$ f. L- z( N0 y& F$ ]4 R$ P7 _tion site, this testosterone transfer was prevented.
7 E% |0 w% p, ^* f( qOur patient’s testosterone level was 60 ng/mL,
6 Q/ }6 A) i5 }  E- k7 ?which was clearly high. Some studies suggest that$ ]: n8 E* m+ }5 Z
dermal conversion of testosterone to dihydrotestos-
' f  U: L+ j) |1 x3 vterone, which is a more potent metabolite, is more
3 c* V& C$ _1 M. A& K, }active in young children exposed to testosterone
- {& a6 T9 ~) ], H! a7 q+ ]exogenously7; however, we did not measure a dihy-4 I4 v$ z( R5 ~/ R& Q3 Z( y2 w
drotestosterone level in our patient. In addition to" g( T- w$ {- k, v% V1 `) N* d
virilization, exposure to exogenous testosterone in
9 O$ h# F% ^2 g( ^- W) y/ Cchildren results in an increase in growth velocity and% c; Z% \: ^0 x" Z5 _3 x
advanced bone age, as seen in our patient.
% {9 @* U3 c% f, UThe long-term effect of androgen exposure during, A* v: f/ }& d$ {: |- F
early childhood on pubertal development and final# }1 t; |4 K$ [" I
adult height are not fully known and always remain
/ Z" _  e3 {! g5 V: ba concern. Children treated with short-term testos-/ x1 }6 E: ?6 E. t* V6 @- y
terone injection or topical androgen may exhibit some% H; Z9 N; f9 R3 q3 V7 m
acceleration of the skeletal maturation; however, after
& i5 R4 z0 O9 u, t4 |, P4 scessation of treatment, the rate of bone maturation# i. `+ G) C2 J
decelerates and gradually returns to normal.8,9+ U, [4 f5 I8 U3 R2 J! H- ~
There are conflicting reports and controversy
7 O" u4 ^( Y# R) [; r& k% Vover the effect of early androgen exposure on adult4 P3 l+ |- W( M
penile length.10,11 Some reports suggest subnormal: A; q0 G7 j# O$ d, C
adult penile length, apparently because of downreg-6 I; C/ E" H- y; W# R
ulation of androgen receptor number.10,12 However,7 |  D# ^0 c5 G
Sutherland et al13 did not find a correlation between; u# `5 e; w0 j
childhood testosterone exposure and reduced adult4 \$ u, E0 d( J- K4 A
penile length in clinical studies.2 v) L) Y0 z  T) F5 @3 S
Nonetheless, we do not believe our patient is; e, [# U, A6 S' k( H" w4 e. C
going to experience any of the untoward effects from) V; `1 A# ]6 N, K8 x4 N
testosterone exposure as mentioned earlier because
' s" W! t: h! }the exposure was not for a prolonged period of time." ~0 a: u4 {# \0 S7 g) m+ _. D
Although the bone age was advanced at the time of; O6 [; e& l' {) x) K9 N7 }, a
diagnosis, the child had a normal growth velocity at
3 m5 Z$ ?6 t3 kthe follow-up visit. It is hoped that his final adult* }/ X! E" `+ A' d
height will not be affected.
# M1 y9 F" A6 _) [  KAlthough rarely reported, the widespread avail-
. M, @8 s  ~% aability of androgen products in our society may
. p" I& B2 D" K7 e% z4 y/ w# d% q! tindeed cause more virilization in male or female' R- U2 K3 V/ z1 B/ j' u; [
children than one would realize. Exposure to andro-
/ _7 K; [. {& k9 U/ j: [7 d- |gen products must be considered and specific ques-: I: g; }4 L% V# |* n/ @
tioning about the use of a testosterone product or
5 F* h: ^  i* [( s/ `gel should be asked of the family members during
6 m; y" ~1 Z. k% Mthe evaluation of any children who present with vir-
3 R5 E: c, B3 i( v6 |ilization or peripheral precocious puberty. The diag-2 u2 b! N7 f- `7 b; e6 ~
nosis can be established by just a few tests and by
; j) T$ Y  ]/ W7 a0 N" ]. ^appropriate history. The inability to obtain such a3 J$ ^" n# q" @, X! S- l
history, or failure to ask the specific questions, may
% Y6 ?9 y9 R' v( Q3 f; Vresult in extensive, unnecessary, and expensive' a; @0 G# j/ }) z( \  _
investigation. The primary care physician should be& W- Q/ l; P5 m
aware of this fact, because most of these children
- ^  u0 B) K/ P9 bmay initially present in their practice. The Physicians’
9 ?7 M$ P6 o; z. w4 s' M3 h  _/ LDesk Reference and package insert should also put a, [! _* f. m, |- @/ x+ K
warning about the virilizing effect on a male or
$ G: t8 D$ v  {% n- \- T" Z. zfemale child who might come in contact with some-. h: b8 p; j% K; \' `
one using any of these products.
$ H( h* ?8 w1 s7 n; x2 FReferences: u* z% U$ i/ Q: M4 Y
1. Styne DM. The testes: disorder of sexual differentiation
: @1 x$ ]! g6 p: L1 Yand puberty in the male. In: Sperling MA, ed. Pediatric+ |2 O4 h" X4 |) ^4 E8 E
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" l+ ?* Z6 F; \1 q) W" ~
2002: 565-628.
$ y: }, T9 x( {) o' T- M1 h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ u; g9 Y& D; D$ ~: fpuberty in children with tumours of the suprasellar pineal
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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
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
! l2 @, j' Y: d7 I# \( q$ B! g
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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