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Sexual Precocity in a 16-Month-Old0 n5 I0 }5 B2 {- w  v0 h
Boy Induced by Indirect Topical6 Z; X; i. m7 u
Exposure to Testosterone
8 P* ~  F+ B7 _7 Y. O2 VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 }2 y% T' Q5 N- d: u5 k5 z  T2 k$ b
and Kenneth R. Rettig, MD1! H5 o' {! I0 |7 d* D7 y' z# a& }
Clinical Pediatrics
) v+ X1 |" H. |! R2 e% H& l9 B. HVolume 46 Number 61 b" j9 s1 J4 I/ h
July 2007 540-543  s4 q; R8 h  s% O% F) N
© 2007 Sage Publications
" H6 H  w! c9 u10.1177/0009922806296651
; M5 k- Y( x0 M2 O* N* ~8 ~6 |http://clp.sagepub.com0 G! ]: K  y6 n- p) b- ^' I
hosted at
- q) Z6 u* y) n8 {$ K9 q2 Dhttp://online.sagepub.com6 \' r& k+ S6 l& M5 F; q5 b
Precocious puberty in boys, central or peripheral,
3 t+ O5 g. q6 J+ Y) k& vis a significant concern for physicians. Central
# Y5 n/ C$ o6 o9 Jprecocious puberty (CPP), which is mediated
% W+ k# v3 F$ @/ ?3 a2 e3 othrough the hypothalamic pituitary gonadal axis, has
+ q# m5 h' S, t9 e3 c$ Q# Oa higher incidence of organic central nervous system
: W6 o( z" ~9 L* _# V! plesions in boys.1,2 Virilization in boys, as manifested
2 M8 w) j+ ]0 T1 i% Z; gby enlargement of the penis, development of pubic
. u) x/ u0 c* O6 Xhair, and facial acne without enlargement of testi-7 F" C$ F4 `4 B6 O" v
cles, suggests peripheral or pseudopuberty.1-3 We
, d* _6 ^, m3 S2 W/ Rreport a 16-month-old boy who presented with the% N. [/ k( n( q
enlargement of the phallus and pubic hair develop-
6 c0 I* ~  o2 I5 Qment without testicular enlargement, which was due& g! S$ y4 F# @: w/ K" G+ F* @
to the unintentional exposure to androgen gel used by
6 m7 k, l; o1 `, n; C3 j- t  |* vthe father. The family initially concealed this infor-
) |8 c5 o4 W$ E2 Nmation, resulting in an extensive work-up for this
. w& D3 R( {. d( G' Schild. Given the widespread and easy availability of% t( F* g2 ?& @  x3 B
testosterone gel and cream, we believe this is proba-
: m& B7 N! Z5 u7 s0 H* J( D, Ebly more common than the rare case report in the
+ D+ P# b9 A( b: u" ^, W( ]) lliterature.4
8 V8 r+ T3 {: X6 c! }6 \Patient Report1 q/ \8 P2 \& b# K( d! B+ Z
A 16-month-old white child was referred to the3 L- [+ m5 X* L8 \7 X5 }+ ^7 u: |4 u
endocrine clinic by his pediatrician with the concern" E" S+ C+ ]& b0 }* e
of early sexual development. His mother noticed
7 p7 z/ C) B8 c& b4 olight colored pubic hair development when he was
) v+ `' w& }9 P6 U# W( aFrom the 1Division of Pediatric Endocrinology, 2University of
% A9 Z. C% ?4 r/ j& Q4 f( `South Alabama Medical Center, Mobile, Alabama.# S: A" G5 o5 ^; l: ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,2 ~7 K0 S1 g; h! E. N7 [# d
Professor of Pediatrics, University of South Alabama, College of1 V; U; o, c% D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! k& P, C. D1 g) J1 ~9 c
e-mail: [email protected].7 i. {* ^7 b- ~& p) q
about 6 to 7 months old, which progressively became
& M4 x! h6 K+ ]3 q! U, j6 h% Ydarker. She was also concerned about the enlarge-
% S, }8 X3 b0 x& `6 ]. ]ment of his penis and frequent erections. The child
1 ]# m8 F/ F; g- r: {was the product of a full-term normal delivery, with+ t+ j8 Y# o4 x& V/ ]: Z
a birth weight of 7 lb 14 oz, and birth length of
. _0 s0 w1 _4 o- T$ b$ j( s20 inches. He was breast-fed throughout the first year1 Y' I% A8 ^  K* p
of life and was still receiving breast milk along with
) [1 {' }% P6 o% e& I  D% d  _; asolid food. He had no hospitalizations or surgery,
% V6 v( h2 p' `7 `& t3 M  K% land his psychosocial and psychomotor development# r3 M% }% Z/ Z- |7 j3 N. C' i0 H& U
was age appropriate.# Q- T: r+ D' c! E
The family history was remarkable for the father,
( C, x1 g8 R1 i" T+ y5 e# Gwho was diagnosed with hypothyroidism at age 16,+ _$ F' ^& o- T; I5 b9 O) m
which was treated with thyroxine. The father’s! T( k" Z! b0 }; c) _! Z- q6 L
height was 6 feet, and he went through a somewhat, \; y& F& u+ k( `; W2 j
early puberty and had stopped growing by age 14.
4 V, m: p7 m0 s) I: CThe father denied taking any other medication. The
) z9 C3 x. ^4 g/ G4 [child’s mother was in good health. Her menarche& K+ a( p! ~  a1 g( D
was at 11 years of age, and her height was at 5 feet" G: x) y4 k$ f; W: T) S' g
5 inches. There was no other family history of pre-% E+ B) F- e9 e- D
cocious sexual development in the first-degree rela-* m+ F- o, n8 ~, l, I$ E8 s
tives. There were no siblings.
! K0 m9 |3 G6 Y! m+ [, _) l4 OPhysical Examination
" g- z9 E; h; M! D  n, L, ]7 c6 ^The physical examination revealed a very active,
1 g! K8 O4 ], Yplayful, and healthy boy. The vital signs documented& j  O1 i# K3 X4 @2 f5 Y
a blood pressure of 85/50 mm Hg, his length was: d4 c  s8 s; F2 k
90 cm (>97th percentile), and his weight was 14.4 kg7 {: H/ ^# q- T
(also >97th percentile). The observed yearly growth
7 H0 _8 ~# _" mvelocity was 30 cm (12 inches). The examination of
0 Q9 H& N3 F3 jthe neck revealed no thyroid enlargement.% `) L1 {8 q: g( a2 Y
The genitourinary examination was remarkable for
1 ]1 j4 r% m( x$ Denlargement of the penis, with a stretched length of
0 h/ _* Q" O" c  c8 cm and a width of 2 cm. The glans penis was very well! A  D2 R# B" t* C1 H- i) [
developed. The pubic hair was Tanner II, mostly around0 ]- u: l' w& J; F9 q% R0 i
540
# d. A. N! s+ j" G5 r; Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' ?1 C/ x' B& e9 Jthe base of the phallus and was dark and curled. The6 v. g8 Z7 U, f9 b* ]' Y- w
testicular volume was prepubertal at 2 mL each.+ R$ f9 ]* l! c' K; `& B
The skin was moist and smooth and somewhat
9 G9 t& a+ {: J! l/ L  foily. No axillary hair was noted. There were no/ f  l0 j5 B  C. @# Y  H
abnormal skin pigmentations or café-au-lait spots.1 O! o" n- A$ |$ y3 }- b
Neurologic evaluation showed deep tendon reflex 2+# e8 l6 u, x9 h0 ~5 v! d
bilateral and symmetrical. There was no suggestion7 X% c! ?9 I: E
of papilledema.1 T' q' \6 D; Z( w
Laboratory Evaluation
' c3 o- S. |& }7 @# uThe bone age was consistent with 28 months by# N/ l2 ^; [; V& e1 W
using the standard of Greulich and Pyle at a chrono-
! w' a: d( K1 b) u4 Xlogic age of 16 months (advanced).5 Chromosomal4 k  K, A3 E9 M- _
karyotype was 46XY. The thyroid function test
. o* ]5 u' g* o) W* Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- ?( Q! C8 P; j8 ?( i% a* x
lating hormone level was 1.3 µIU/mL (both normal).
: s8 W3 r' F% o% pThe concentrations of serum electrolytes, blood
0 i: q9 B$ D6 I6 I$ a8 purea nitrogen, creatinine, and calcium all were
; w3 u+ s0 j7 v, D' M2 rwithin normal range for his age. The concentration
0 @$ g, T" q0 E  I' Gof serum 17-hydroxyprogesterone was 16 ng/dL' p! V8 G# u9 m0 F& t" G
(normal, 3 to 90 ng/dL), androstenedione was 20" |) H+ P9 |; T2 [9 G
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) [/ x! `- w5 V& Z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 g! t9 ]0 w8 G% H9 l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 p- F2 K5 M: |) A( f
49ng/dL), 11-desoxycortisol (specific compound S): Y. e9 m* b$ m7 O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  [$ `* U2 U$ {- gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# o* K) l& _+ w: j, w* s
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 D8 |1 `0 j5 y% Wand β-human chorionic gonadotropin was less than6 u  l6 J+ r' {8 D
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 x7 R4 f1 Z) [" U( H8 f$ a1 @5 @+ h
stimulating hormone and leuteinizing hormone# h2 `6 R: P4 R" N! n7 _: T% Z3 e! }
concentrations were less than 0.05 mIU/mL
7 J. ~+ U: D6 d  X' v: m% [(prepubertal).
# d- h! B% f' v, s2 L! @6 Y  lThe parents were notified about the laboratory0 N: f! h% c1 h
results and were informed that all of the tests were3 D4 e) F. e( R/ k9 C+ Q  f: a
normal except the testosterone level was high. The' `( o8 ]  v. n8 k, w6 [: H5 X. m
follow-up visit was arranged within a few weeks to
6 Z4 M+ V: H* n6 P" k4 o' [1 kobtain testicular and abdominal sonograms; how-
7 K1 t- ^* v: m- ]0 ]& bever, the family did not return for 4 months.  a8 |7 U8 ^7 D( p
Physical examination at this time revealed that the* J, [1 [3 l/ E/ `2 P/ z; A" u
child had grown 2.5 cm in 4 months and had gained, G/ E4 k2 w9 W4 G; o. {$ J! s
2 kg of weight. Physical examination remained+ K% ^$ ?; ?, `  S
unchanged. Surprisingly, the pubic hair almost com-. i* m1 A) y- m* g7 y" g; m
pletely disappeared except for a few vellous hairs at0 p1 Y4 l5 ?7 |" v
the base of the phallus. Testicular volume was still 22 G4 z( ^% u& h/ ]+ Y! m  c
mL, and the size of the penis remained unchanged.
4 Z8 @4 b' P# h* K1 ^The mother also said that the boy was no longer hav-( }4 b: x, [, H' j
ing frequent erections.+ _* S5 t6 v# u" ^1 X- m1 s
Both parents were again questioned about use of4 c7 r! R& k( x; i* z5 ^" @4 l
any ointment/creams that they may have applied to
6 c7 _8 O) |) {- U1 O4 e+ Hthe child’s skin. This time the father admitted the; S4 \: s9 y( e5 K4 {& Y
Topical Testosterone Exposure / Bhowmick et al 541
! `7 h7 I- `5 _4 M6 G% p2 S' P3 f" zuse of testosterone gel twice daily that he was apply-3 G6 {0 t; @% Q  C2 |% I& g5 Y
ing over his own shoulders, chest, and back area for
/ A0 Z, x+ T& Ka year. The father also revealed he was embarrassed
5 L; }4 ^4 q0 ~1 J/ Ito disclose that he was using a testosterone gel pre-% M8 \0 G! W; x
scribed by his family physician for decreased libido
4 b( D$ R" n8 [" wsecondary to depression.
. c+ U9 O8 P8 ]2 F4 e! B6 \1 B" XThe child slept in the same bed with parents.9 f$ c6 L& ~* z
The father would hug the baby and hold him on his
# H; g: R. o/ u4 j- }chest for a considerable period of time, causing sig-0 `% M6 Q, t: [! ~, v% w# W
nificant bare skin contact between baby and father.* p2 J' I4 l1 ^- K( W' @! n
The father also admitted that after the phone call,8 D: Y3 a; c) g9 \0 }# i/ ^
when he learned the testosterone level in the baby
: k) `$ k: P( j: g' b' cwas high, he then read the product information
4 P2 {. B5 R, ]! x0 S; Bpacket and concluded that it was most likely the rea-% k. ]0 H7 R9 D: e6 x. m4 z
son for the child’s virilization. At that time, they- _$ O4 g' d9 h! p1 V; O
decided to put the baby in a separate bed, and the+ M1 G4 N: K5 g% R
father was not hugging him with bare skin and had, ^7 J" a% ?! ~
been using protective clothing. A repeat testosterone' K, E1 U& g7 b# r* y
test was ordered, but the family did not go to the9 ?1 V3 X- Q4 \3 Z; l
laboratory to obtain the test.+ B$ v: J% L+ L& X' U
Discussion
1 g" Y8 M0 ]% d! Y! l" }Precocious puberty in boys is defined as secondary( v; s9 [. z5 {5 r% C
sexual development before 9 years of age.1,4
% s/ M) w3 S) D, r' q# f* x" rPrecocious puberty is termed as central (true) when
5 K7 C4 {& A* e; J' R3 B- Eit is caused by the premature activation of hypo-& ?% [  Z- U* y6 k
thalamic pituitary gonadal axis. CPP is more com-4 h2 h% m5 y* T2 K- @  S! x
mon in girls than in boys.1,3 Most boys with CPP
( O* q) {& y7 D+ i1 J$ ^7 Y! gmay have a central nervous system lesion that is
4 N5 M# g1 @% _0 X+ G& r! s* ?4 Lresponsible for the early activation of the hypothal-
( f# K$ `  r& x) C$ damic pituitary gonadal axis.1-3 Thus, greater empha-& O  b, S6 Z' P
sis has been given to neuroradiologic imaging in
, K9 V! x8 l, m, G* H# Gboys with precocious puberty. In addition to viril-* R7 R) a8 N* B  d# k9 o
ization, the clinical hallmark of CPP is the symmet-% F# j% J  m' b1 g, ~3 L3 |
rical testicular growth secondary to stimulation by, x$ Q- O7 N/ U2 E
gonadotropins.1,35 a! i5 n- B% p$ r! p1 W0 O1 k9 l
Gonadotropin-independent peripheral preco-
; p5 N- O/ v$ w& z0 y! @; dcious puberty in boys also results from inappropriate. d" `. @2 R; H  o/ L0 K; j
androgenic stimulation from either endogenous or
, q( |9 V# K+ ]4 Fexogenous sources, nonpituitary gonadotropin stim-& _  A+ r+ y9 e8 c: S1 }$ n
ulation, and rare activating mutations.3 Virilizing
# Y7 D2 ~& Z5 b  a7 ^) X7 Icongenital adrenal hyperplasia producing excessive( R& U1 z% t7 S/ j7 W
adrenal androgens is a common cause of precocious: E: U' F9 B3 j) m9 x; R1 q/ m" G9 }
puberty in boys.3,4
  d! E  Q+ b& `* W+ pThe most common form of congenital adrenal* n9 d8 E  V; J+ o  q9 |& R8 X4 v6 E
hyperplasia is the 21-hydroxylase enzyme deficiency.) f  l& E7 ?. g3 f5 E/ O
The 11-β hydroxylase deficiency may also result in, K* B" e. H4 }0 c6 A* g# d
excessive adrenal androgen production, and rarely,
  f+ |% ?. n, b/ e$ S3 ian adrenal tumor may also cause adrenal androgen& n6 R  w6 k, B  [! u
excess.1,3
6 H3 B* g0 H1 w, p# s6 M0 p$ k% zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  M4 P' d, y: _* }* @  ?/ B+ d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. K0 I" ~( a3 m( q& a+ u5 JA unique entity of male-limited gonadotropin-, C; t; \# O7 g  ~0 e5 _$ X6 k
independent precocious puberty, which is also known/ a$ s: H, c; y- d/ T
as testotoxicosis, may cause precocious puberty at a
- n5 H" I, p8 y6 U* Y7 [; o1 yvery young age. The physical findings in these boys
1 l: d/ Q4 D! l1 ~* Mwith this disorder are full pubertal development,
6 A; H9 \. d: I7 U+ Wincluding bilateral testicular growth, similar to boys
8 m4 m' Y+ b" o" L1 d( C0 kwith CPP. The gonadotropin levels in this disorder" {: x2 u0 k; X  ^3 V
are suppressed to prepubertal levels and do not show
/ \" Q- P" A3 p' c8 e' }pubertal response of gonadotropin after gonadotropin-
( j- M7 T9 |6 n: d* `- Kreleasing hormone stimulation. This is a sex-linked
2 X6 e  v% J+ s/ C" T: kautosomal dominant disorder that affects only1 g4 @5 r  Y% x; l! d. g
males; therefore, other male members of the family1 }) S( L" }& z
may have similar precocious puberty.3" v, Y; G6 ?$ h
In our patient, physical examination was incon-) |% E+ ?+ y5 S8 V: N4 Q2 V
sistent with true precocious puberty since his testi-8 w9 _" A1 l/ G4 \! B, a6 B# j# l
cles were prepubertal in size. However, testotoxicosis7 B$ L6 w: q8 c  x/ @: f
was in the differential diagnosis because his father9 e1 |, e' Z/ C5 X6 N' w3 |
started puberty somewhat early, and occasionally,
) Q9 v: a4 y2 X& B; k$ [9 etesticular enlargement is not that evident in the/ i4 K/ x0 H: M) f8 N4 s: N+ @
beginning of this process.1 In the absence of a neg-
9 i3 H' l+ a( [  f. b# U5 _ative initial history of androgen exposure, our& F) O, D: Q% ~9 ]
biggest concern was virilizing adrenal hyperplasia,! |# Q% V7 o- y7 A
either 21-hydroxylase deficiency or 11-β hydroxylase
+ Z# i5 q( {8 _/ d+ I8 ^* Udeficiency. Those diagnoses were excluded by find-0 |* ^) Z' }, k! b: E0 U& b& [
ing the normal level of adrenal steroids.6 J- [. K; F6 Y# F
The diagnosis of exogenous androgens was strongly- w' x7 u# ?% Y! m; j) i
suspected in a follow-up visit after 4 months because& n6 i# D$ ?2 l& T8 v- \# }
the physical examination revealed the complete disap-, y7 v# W8 H# z- n$ R6 o
pearance of pubic hair, normal growth velocity, and! [" Z2 ~% U3 Q0 y8 d, \! t* B- N$ n
decreased erections. The father admitted using a testos-
2 n5 l8 V1 ?8 Z" O2 v' N. qterone gel, which he concealed at first visit. He was  e; }  E, P, o: a8 v
using it rather frequently, twice a day. The Physicians’3 `4 {; u' s# @$ o
Desk Reference, or package insert of this product, gel or
0 S, y& \  H& qcream, cautions about dermal testosterone transfer to3 R" z: T6 H: c% M) S' \/ J8 f
unprotected females through direct skin exposure.
4 Y$ t3 p, v! I0 s  o. P; N1 L, g% uSerum testosterone level was found to be 2 times the4 Q  v( {) w, s7 @  D6 S
baseline value in those females who were exposed to
/ D$ L! j& o, Z$ keven 15 minutes of direct skin contact with their male! w: m! v; u" }6 p: N
partners.6 However, when a shirt covered the applica-
( ~/ m% K* ~; W5 htion site, this testosterone transfer was prevented.& l' j. O" ^& ]# U, B8 D
Our patient’s testosterone level was 60 ng/mL,
! j( L- z. g+ l- H6 ?" `) @which was clearly high. Some studies suggest that
: H" k- O7 Q* G( Xdermal conversion of testosterone to dihydrotestos-
% s$ `2 ^7 A+ Kterone, which is a more potent metabolite, is more$ b" D- E9 u9 j/ j2 g7 F3 q
active in young children exposed to testosterone
- z7 Z9 S( M" r# sexogenously7; however, we did not measure a dihy-
# C$ ^& s. x/ `# j( [drotestosterone level in our patient. In addition to
: V3 |1 K" t2 W- X" R9 bvirilization, exposure to exogenous testosterone in$ p/ d  ~9 B2 [8 i6 w: O8 B' o
children results in an increase in growth velocity and
( m2 l: e. H+ xadvanced bone age, as seen in our patient.
2 d$ `7 J0 A: NThe long-term effect of androgen exposure during2 ^) w; l% x8 m- l* ?/ s. K7 E
early childhood on pubertal development and final2 V  f" U2 b6 ^& V& ~5 \6 l; V
adult height are not fully known and always remain2 @9 A6 M5 T$ C8 |
a concern. Children treated with short-term testos-
$ V0 A3 Z* h" p# oterone injection or topical androgen may exhibit some/ b3 Z; Q# A+ y4 D5 U# K0 U4 @- L
acceleration of the skeletal maturation; however, after* v4 K8 }. M$ V8 m( F
cessation of treatment, the rate of bone maturation  k  g+ \: q  \; t. s# d
decelerates and gradually returns to normal.8,9
/ I9 P2 d$ v2 a& fThere are conflicting reports and controversy4 n1 {  g  ^0 ^) \4 I' ~% g
over the effect of early androgen exposure on adult
6 s! N" G- I4 Q* `penile length.10,11 Some reports suggest subnormal' R) v2 m7 Z6 d( b# j/ B
adult penile length, apparently because of downreg-
; O# H, u+ Z2 o4 I  ?+ ?4 }. nulation of androgen receptor number.10,12 However,
( u! H" [0 w  E1 T- sSutherland et al13 did not find a correlation between& v) T  h. A0 o; R# v: J
childhood testosterone exposure and reduced adult
2 O- ^, x5 t/ `, K+ b7 ppenile length in clinical studies.
( U) J+ o& o7 @) t/ }2 SNonetheless, we do not believe our patient is
/ Y5 k" |4 A0 }going to experience any of the untoward effects from
: \( v& O$ ^. c4 ftestosterone exposure as mentioned earlier because
% p7 E, j6 w8 Y4 ^3 Gthe exposure was not for a prolonged period of time.% @: x+ W! @+ F3 Z4 K
Although the bone age was advanced at the time of5 ^0 F4 m! J* v( g- E
diagnosis, the child had a normal growth velocity at
! N& [. `% A/ Y" c5 Y/ nthe follow-up visit. It is hoped that his final adult
6 ]5 X$ m7 {7 @6 mheight will not be affected.5 c' a' o& S; p3 u& {
Although rarely reported, the widespread avail-) v# F" V# O2 O% Y& C
ability of androgen products in our society may
% o. M; s: |8 z5 s' n0 g" Bindeed cause more virilization in male or female* N" x6 K8 d: u. B% K
children than one would realize. Exposure to andro-
5 u2 j( v- m8 E& \! G0 N% Sgen products must be considered and specific ques-
% @3 A* T8 o! Ftioning about the use of a testosterone product or/ {2 T5 K8 I% S$ c- I) i
gel should be asked of the family members during4 }' B6 D3 \3 Q3 ?4 h
the evaluation of any children who present with vir-
3 k# M; S  J- S, o+ z' bilization or peripheral precocious puberty. The diag-3 e. C' U1 h& I) ]& v
nosis can be established by just a few tests and by
7 V& @# s4 }3 M5 r+ B* ?7 ^: o( A, O& nappropriate history. The inability to obtain such a
( Y2 R/ L6 l' L, Q/ y6 Y6 k0 k/ }history, or failure to ask the specific questions, may4 U" I! i2 |/ L+ i# n/ Y
result in extensive, unnecessary, and expensive
% \/ Y5 N1 l/ A2 iinvestigation. The primary care physician should be
2 g5 I  p% i2 {: N2 W8 z4 Zaware of this fact, because most of these children( n9 Z' H+ t4 m. ?
may initially present in their practice. The Physicians’
4 t% k$ F7 y$ z# n( K4 N( iDesk Reference and package insert should also put a- J' |2 U! E" m
warning about the virilizing effect on a male or2 i, d3 ?6 @% c) U2 ]6 R
female child who might come in contact with some-
: d" _8 u# _% F* k( W& u1 h" sone using any of these products.
" Q4 ~9 R" Q$ M2 N( A* OReferences
: D- W+ Z. C; x  Q& H1. Styne DM. The testes: disorder of sexual differentiation5 y: h; l: |7 j: K  q
and puberty in the male. In: Sperling MA, ed. Pediatric0 Q8 ^3 L: }; A; ^5 M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 G) K9 a; c! f3 \( j; ]) U9 ~2002: 565-628.
9 {8 S6 `4 Y9 Q$ N  w3 t) X8 j: c* x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: x1 B4 f8 [( ^% f1 E; h! g
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
2 j- }$ {* h3 ^5 p7 i  R2 RBoy Induced by Indirect Topical' U& x5 B. [2 A* b# y
Exposure to Testosterone
  P( a! `  d: R( f9 }6 p9 iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 b+ D8 H3 [% f% W: _
and Kenneth R. Rettig, MD1; c( D- u, I4 C2 f. X$ @- U) `  v3 j
Clinical Pediatrics
) ^( c" D4 \9 j0 K- ~8 CVolume 46 Number 6
" Q. |; u" j* g4 g8 p' ]July 2007 540-5438 k9 n( z0 A8 N$ C8 D! Y" a, ]
© 2007 Sage Publications* W3 k& U$ m8 k. \' p; u6 Y2 Y( A
10.1177/0009922806296651
/ W/ A+ g4 d6 q4 e5 I' [http://clp.sagepub.com: `; t5 p6 T5 f1 x# T& M, g0 e
hosted at
* o7 E1 e+ |9 }% W) chttp://online.sagepub.com1 w  y, ?: P2 ?3 Z$ B
Precocious puberty in boys, central or peripheral,, Y, L! e/ S* ?
is a significant concern for physicians. Central4 x6 k/ r* G7 k9 S" F
precocious puberty (CPP), which is mediated
2 F& y% o" q- M% {* N( h) M. _through the hypothalamic pituitary gonadal axis, has' ?" f4 O: y8 }; \2 [
a higher incidence of organic central nervous system3 R. e5 s5 E! X
lesions in boys.1,2 Virilization in boys, as manifested5 P: Q  g' ^; X% I# r5 M" x+ `: D( g
by enlargement of the penis, development of pubic
$ _& ^+ t3 t) O3 j0 L8 y& jhair, and facial acne without enlargement of testi-
6 A% J7 m7 `- ]) Ccles, suggests peripheral or pseudopuberty.1-3 We, |5 b, X/ \1 Z/ M/ a
report a 16-month-old boy who presented with the3 @& N3 p* u) j% G
enlargement of the phallus and pubic hair develop-
' h6 g# B% W+ @: @. k) ]3 p2 oment without testicular enlargement, which was due
" j) c6 z1 c. [/ qto the unintentional exposure to androgen gel used by3 b0 M" m2 {; Y
the father. The family initially concealed this infor-
# J% `7 u9 y, E! |mation, resulting in an extensive work-up for this- B+ p. U/ h' b+ e+ u* e6 P
child. Given the widespread and easy availability of
) k  g3 L) M* R1 V8 W3 utestosterone gel and cream, we believe this is proba-5 p$ w3 M: w) h! w! \. X" M
bly more common than the rare case report in the
1 @8 ^! ^) |- t9 e7 Xliterature.4
3 T9 S* W! c9 }% U' ~& i; @Patient Report
7 o) ?% K' [$ I. iA 16-month-old white child was referred to the* R" a+ ^' E1 M* ^* J8 M
endocrine clinic by his pediatrician with the concern
  u2 Y, Z) K5 g$ {* Y! Oof early sexual development. His mother noticed% d* ~8 j6 Z# }1 O. L& t
light colored pubic hair development when he was0 K% B% z/ Z# Q
From the 1Division of Pediatric Endocrinology, 2University of
0 I( `! f- P+ nSouth Alabama Medical Center, Mobile, Alabama.. e9 W9 @0 {( x2 q7 Q3 d
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ a" S1 Z, \& W; q
Professor of Pediatrics, University of South Alabama, College of! w# f5 \: _1 Z, I5 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" A' N9 q  F# \; ]( me-mail: [email protected]." k# o( \6 U- _4 v2 O/ z
about 6 to 7 months old, which progressively became
! H3 Q# {2 |0 F# H9 udarker. She was also concerned about the enlarge-
$ s5 D7 N( J; M5 q. v; Vment of his penis and frequent erections. The child' z* o) [' o; w4 m5 n# l$ R
was the product of a full-term normal delivery, with
& A! E: K# O" P0 G* ~a birth weight of 7 lb 14 oz, and birth length of! c3 N7 t; f& k* _; R
20 inches. He was breast-fed throughout the first year
! i4 g' L1 e& q/ n; }. x: s8 hof life and was still receiving breast milk along with' C, f; {& h3 n1 a  H) L0 M$ {
solid food. He had no hospitalizations or surgery,% _8 b! q; b8 E  @5 F6 i
and his psychosocial and psychomotor development/ n$ _- X# o: f
was age appropriate.5 B/ u: v2 h% s- e3 r- N
The family history was remarkable for the father,
# a6 V. E+ Z) A5 n& rwho was diagnosed with hypothyroidism at age 16,
% b: G1 k3 X6 B( w! x, Y& x5 nwhich was treated with thyroxine. The father’s7 u/ u% U- j1 F0 U. N
height was 6 feet, and he went through a somewhat9 C% U) }* L8 _% {% G! T
early puberty and had stopped growing by age 14.+ u! A6 D, P  M, H
The father denied taking any other medication. The
7 r' [) }( j1 `' o+ m1 N6 @' schild’s mother was in good health. Her menarche
9 q& x0 D7 C5 K4 \# ^was at 11 years of age, and her height was at 5 feet9 L- t9 r  W1 |- ~) l
5 inches. There was no other family history of pre-
& c- X7 U3 p$ k" J0 M/ f, }6 Scocious sexual development in the first-degree rela-
4 F  o" |/ C% ?tives. There were no siblings.
( R6 U$ G- b; L. L* W) rPhysical Examination
" m. z/ l2 I( _7 {! P# OThe physical examination revealed a very active,
* {$ h" Q  [$ I6 gplayful, and healthy boy. The vital signs documented# r4 x% R# k8 T4 z9 d
a blood pressure of 85/50 mm Hg, his length was
7 X- j- g8 c! J1 [90 cm (>97th percentile), and his weight was 14.4 kg3 c& U1 `( D( L# O
(also >97th percentile). The observed yearly growth6 I4 x. s* {% T2 _& C8 s, q, Y: m3 l
velocity was 30 cm (12 inches). The examination of! D% P3 W7 P! f9 d' V
the neck revealed no thyroid enlargement.( j4 B5 h" \7 a: h# {% B5 [
The genitourinary examination was remarkable for( |) }6 w. q0 L+ x2 H) `$ W/ y
enlargement of the penis, with a stretched length of
: }* F- D  \5 ~: W$ x8 x. @8 cm and a width of 2 cm. The glans penis was very well
1 y. G$ g2 _, {: z: i* Odeveloped. The pubic hair was Tanner II, mostly around& ^! Z' I. p/ G( E6 @
540; s* K7 q3 b9 I6 C% R0 Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 o  E& X( e+ U5 g! y4 H, @7 {4 nthe base of the phallus and was dark and curled. The- j# h5 G' ?. ?' ~
testicular volume was prepubertal at 2 mL each.
' L4 E8 |# A( k5 `( a, n, W5 _1 W1 nThe skin was moist and smooth and somewhat
! n9 M' t' S3 B( k" Eoily. No axillary hair was noted. There were no
: N: U) [: t$ k3 m$ |! q6 F+ [* @abnormal skin pigmentations or café-au-lait spots.
8 [0 e, |  V6 NNeurologic evaluation showed deep tendon reflex 2+
1 R3 P& o: w7 D, I& T( @& {- obilateral and symmetrical. There was no suggestion
' g( h$ S# S4 f: |5 C* {of papilledema.
/ n+ @# }8 q: ]0 W& v+ eLaboratory Evaluation, J* M' ~; G+ A3 ~: B+ I+ a
The bone age was consistent with 28 months by
* J( ^, @1 B2 R1 `$ x6 \using the standard of Greulich and Pyle at a chrono-
) k5 B! @  Q- r# Plogic age of 16 months (advanced).5 Chromosomal- O! m* q  n$ q, s
karyotype was 46XY. The thyroid function test; N' N$ O3 w9 m
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, n2 t4 h0 O+ g7 m
lating hormone level was 1.3 µIU/mL (both normal).
# {+ T: a9 d- `6 f5 MThe concentrations of serum electrolytes, blood
3 }; r9 y" l, c; G  Z  w. F9 [urea nitrogen, creatinine, and calcium all were1 k# X, \+ D# F9 o2 U% I$ v6 \
within normal range for his age. The concentration" h' L( h6 G! p/ R  g; Q
of serum 17-hydroxyprogesterone was 16 ng/dL8 E' i+ Q* G1 ]- ]7 _$ O
(normal, 3 to 90 ng/dL), androstenedione was 208 L4 D" d( L  P' a% Q' I7 c
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( q9 l5 u9 W+ ?" b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- @- n+ j3 N: l. t3 w2 \desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 ?& F) \. u6 |! U2 h49ng/dL), 11-desoxycortisol (specific compound S)
5 W( R/ W9 i5 W! _) {3 twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 x, Q- f2 y8 ?. V! v: c1 Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 z+ l, ^, q0 p4 V0 C0 p; q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! e6 _5 `! q, q$ U7 F6 H+ G4 j. jand β-human chorionic gonadotropin was less than. L+ U6 n: G+ g/ \
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# E  W. \# k8 Y+ tstimulating hormone and leuteinizing hormone. W  D2 `9 \5 D# g. Q  e
concentrations were less than 0.05 mIU/mL2 O  C0 K: ?& d# J
(prepubertal).
0 R9 Z6 ^' B9 ^8 g; P  Q: FThe parents were notified about the laboratory
: Q% g( s: p+ j6 w  a2 _results and were informed that all of the tests were
  ?. Q& {4 x  W8 qnormal except the testosterone level was high. The
( k, X% S" l* v* B7 nfollow-up visit was arranged within a few weeks to& |( W; H$ z1 c7 g9 l
obtain testicular and abdominal sonograms; how-
  R2 U0 e- i- \4 S' z; ]1 W& hever, the family did not return for 4 months.# ~  k6 J; m# B* g- Y# @
Physical examination at this time revealed that the. H: P. \* T$ Z3 D& w
child had grown 2.5 cm in 4 months and had gained
; W. y5 I3 `: I" T& ^- B2 kg of weight. Physical examination remained
  m; Y4 J) P; u- c/ r4 b) _unchanged. Surprisingly, the pubic hair almost com-+ P3 [; r7 T: M
pletely disappeared except for a few vellous hairs at# h! }; `; Y+ n2 m1 M* J# j' e
the base of the phallus. Testicular volume was still 2- _, s0 c  ~1 i0 C' Y' ^& g
mL, and the size of the penis remained unchanged.
! `! ^2 i+ t( J" U5 s" q* CThe mother also said that the boy was no longer hav-
- v4 n+ U: a  M* s+ aing frequent erections.
  m! c) A: o5 O7 D1 P3 |4 H' LBoth parents were again questioned about use of. Q4 O/ l6 I0 O( l& w
any ointment/creams that they may have applied to
+ A5 m! V' h% B; z: U3 s7 H5 d1 Ithe child’s skin. This time the father admitted the
6 O% z% M$ `! H- v7 T$ @+ ITopical Testosterone Exposure / Bhowmick et al 541
7 L% N- ?* X. d$ P1 V0 z, ~6 v, Yuse of testosterone gel twice daily that he was apply-9 g) [* |! h& K, q$ c
ing over his own shoulders, chest, and back area for
1 j7 f) B  r8 |  Z" z0 c4 {a year. The father also revealed he was embarrassed" c. o. A2 H* d5 ^) ~$ e& @! D  r
to disclose that he was using a testosterone gel pre-
. T9 V* h! F, ^: kscribed by his family physician for decreased libido7 G. s0 o+ F) }( `% p
secondary to depression.6 a5 K5 u: g& U, q* p
The child slept in the same bed with parents.
+ z' P* j  X' b1 j7 a5 V) Q# S+ ZThe father would hug the baby and hold him on his+ r( M- R+ i3 J! O) k" [
chest for a considerable period of time, causing sig-5 V& [  v; H+ I4 X
nificant bare skin contact between baby and father.1 P1 E. f* m  r5 i) f& |
The father also admitted that after the phone call,
1 c8 S$ F6 ^" q5 Qwhen he learned the testosterone level in the baby
/ s, l/ N5 \5 n4 p6 K" B$ x* cwas high, he then read the product information" O" |) z7 L% K/ y; l& ?2 h& d2 j
packet and concluded that it was most likely the rea-$ o* Q9 s4 Q  _4 A( t+ B" [2 I
son for the child’s virilization. At that time, they: }0 w; }2 |* B  o( t
decided to put the baby in a separate bed, and the/ ]9 e$ g4 d) j2 m4 G
father was not hugging him with bare skin and had2 U$ s8 F/ n% S: a# R# ^3 H
been using protective clothing. A repeat testosterone5 c2 `1 ~4 K2 Y7 ~
test was ordered, but the family did not go to the
$ y0 x, d7 _1 R- N4 I2 Q5 \laboratory to obtain the test.' L! V8 l0 Q( K/ X& U/ f9 B
Discussion; D! o( r1 P. e6 [4 r& S
Precocious puberty in boys is defined as secondary
5 W8 ?: G& R( r9 Dsexual development before 9 years of age.1,4
0 ?3 [4 c) G+ }- A1 Z9 p5 u5 [5 gPrecocious puberty is termed as central (true) when" y6 I3 o5 q3 B4 y# k, v& y+ G1 U
it is caused by the premature activation of hypo-
/ @5 A$ W6 c7 f6 t$ p6 s& f# ?thalamic pituitary gonadal axis. CPP is more com-
  S# k% Z6 ~9 C6 v$ j6 q8 J: cmon in girls than in boys.1,3 Most boys with CPP3 I& }& K+ v8 @' F; x8 F
may have a central nervous system lesion that is! u- B& c$ \: }1 F, s
responsible for the early activation of the hypothal-, A/ o% r" m2 J2 Y
amic pituitary gonadal axis.1-3 Thus, greater empha-
- y( ^* K* b+ v7 C: G& S, K2 hsis has been given to neuroradiologic imaging in
: X0 m4 m3 w4 m1 ?1 u+ C; `, zboys with precocious puberty. In addition to viril-
8 w  P: W. n& e& Zization, the clinical hallmark of CPP is the symmet-4 ]9 ?9 Q0 D, w$ D- A- o
rical testicular growth secondary to stimulation by
# y" A0 C. ]7 q9 q8 i! rgonadotropins.1,3( X9 Z- u- G0 x3 C
Gonadotropin-independent peripheral preco-
. m' d/ b8 I' z' M# H0 r0 Tcious puberty in boys also results from inappropriate
* m' R% Q; Z! E: Q* Yandrogenic stimulation from either endogenous or
# U7 R0 ~7 f/ ?% Y1 H7 v" ~7 nexogenous sources, nonpituitary gonadotropin stim-
* L) `! t! K- V0 ]& Tulation, and rare activating mutations.3 Virilizing
9 T+ w) R. s# K3 F* Kcongenital adrenal hyperplasia producing excessive
7 n( K9 J& \" Q: |! A8 aadrenal androgens is a common cause of precocious
0 ^1 G8 p& H1 Q6 K6 Ppuberty in boys.3,4+ \( ^+ R/ x% Y4 l. o
The most common form of congenital adrenal+ s6 ~, l& V1 N3 p6 b
hyperplasia is the 21-hydroxylase enzyme deficiency.4 S* P( ^" |% J2 W% Q  W* @1 Q
The 11-β hydroxylase deficiency may also result in1 P7 c8 u- y2 v4 R
excessive adrenal androgen production, and rarely,
1 @$ W8 A; v  W2 p8 {5 Aan adrenal tumor may also cause adrenal androgen
" D2 b3 ^/ j+ d7 v5 ^* oexcess.1,3- p" N( h/ `2 D# A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) C. l# H4 S4 ]3 ^7 v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, ?& m; e0 {$ C# |) I: ZA unique entity of male-limited gonadotropin-( [- M; I7 ~" ], M+ F( ?
independent precocious puberty, which is also known' f3 L% w7 S0 ]# o
as testotoxicosis, may cause precocious puberty at a3 ]7 h# ]  J1 s9 C8 |
very young age. The physical findings in these boys
+ N. M# h2 y, pwith this disorder are full pubertal development,
7 [) p& |( Y% Sincluding bilateral testicular growth, similar to boys
* u8 L1 K6 K' F& q+ c( Fwith CPP. The gonadotropin levels in this disorder
6 ?2 j) R/ s! V# P1 F: ?1 qare suppressed to prepubertal levels and do not show
* s) k" j. e- o3 Npubertal response of gonadotropin after gonadotropin-" I4 u. |' I2 D' I/ i* V
releasing hormone stimulation. This is a sex-linked
) I9 R7 N: Z  B' R* D/ `autosomal dominant disorder that affects only# J9 q, l5 r2 ?
males; therefore, other male members of the family
1 y3 H# {/ G( k" \, e5 S/ Xmay have similar precocious puberty.3" T! A3 E% ~2 @( X
In our patient, physical examination was incon-
0 X" n9 f& o$ y8 Esistent with true precocious puberty since his testi-, ?& I/ \5 H$ b0 V1 R/ d
cles were prepubertal in size. However, testotoxicosis7 B9 Y5 x/ Q1 ]7 y/ u, r
was in the differential diagnosis because his father
6 j4 b) ^+ ~+ k( T+ y7 O6 Istarted puberty somewhat early, and occasionally,; S7 e/ B; {9 ~' S6 G
testicular enlargement is not that evident in the2 n& b5 y  m! x; b
beginning of this process.1 In the absence of a neg-
; _7 K% q. M' x% p! u( \) Cative initial history of androgen exposure, our
" Q$ U# }2 a/ h4 q/ }biggest concern was virilizing adrenal hyperplasia,, l: _! e* q0 p4 g
either 21-hydroxylase deficiency or 11-β hydroxylase
4 d0 J6 F- S: Rdeficiency. Those diagnoses were excluded by find-
) \( T/ s6 j& u8 Ving the normal level of adrenal steroids.. y' \8 d& ]6 q/ l3 V
The diagnosis of exogenous androgens was strongly
, C" A( C1 n: ~+ ~9 T. h9 Xsuspected in a follow-up visit after 4 months because% J' s! ~6 E1 t6 y! W/ f/ |
the physical examination revealed the complete disap-; j! C7 ?, p/ Q3 @% A
pearance of pubic hair, normal growth velocity, and
; L- i( u3 e3 mdecreased erections. The father admitted using a testos-+ _; s' B# d2 Y* O- o
terone gel, which he concealed at first visit. He was; p: n' q6 u- y' c6 y- P
using it rather frequently, twice a day. The Physicians’1 v- y3 e6 b- R) T7 l6 |' P
Desk Reference, or package insert of this product, gel or/ @" X# f% I2 B: U% n4 \
cream, cautions about dermal testosterone transfer to2 \. R0 u/ C  Q5 g4 H: \- D$ e
unprotected females through direct skin exposure.- W8 @' f  a* a3 c5 n
Serum testosterone level was found to be 2 times the* r7 j& G6 l; k6 J7 }; ]/ N4 o
baseline value in those females who were exposed to
& ^/ A! I4 {4 leven 15 minutes of direct skin contact with their male5 Q+ l0 z/ Z" R. G4 w
partners.6 However, when a shirt covered the applica-
9 h6 r% G: c$ K) ?tion site, this testosterone transfer was prevented.0 w# D6 L; X' j) @, @" f: `
Our patient’s testosterone level was 60 ng/mL,
5 ^' j& G: r* E" ewhich was clearly high. Some studies suggest that
. }4 y: ^: D4 T6 B9 adermal conversion of testosterone to dihydrotestos-
% J+ ~) q( c  z; Nterone, which is a more potent metabolite, is more
3 I2 T/ }# W9 h- c3 S; L" Xactive in young children exposed to testosterone
8 A5 A' I4 S# l) D2 z! ~exogenously7; however, we did not measure a dihy-
$ y& c  l) r) |0 c& s) O) w) _+ Ldrotestosterone level in our patient. In addition to* m* k8 g" {6 q: K' N, G" a
virilization, exposure to exogenous testosterone in
/ ^$ Y0 V8 y5 `8 Y$ w8 echildren results in an increase in growth velocity and
" S4 W6 T; ]8 |% Z- o: B7 Jadvanced bone age, as seen in our patient.
: Z. L, p7 u" I5 U/ ]The long-term effect of androgen exposure during
( B0 i& m2 E" y3 O4 {, M4 ]early childhood on pubertal development and final
! @$ x5 J" ~2 N" N- Ladult height are not fully known and always remain
5 W/ S% {- A8 u& Ya concern. Children treated with short-term testos-
" K$ ~$ m0 W3 O1 k  rterone injection or topical androgen may exhibit some; W: R: L! u. H  t3 n- n& k
acceleration of the skeletal maturation; however, after1 ~3 b" y; d, j
cessation of treatment, the rate of bone maturation: U) m, J+ Z& {. u, U
decelerates and gradually returns to normal.8,9: H0 e' a$ G6 A) v1 u
There are conflicting reports and controversy
7 i% x* C' s1 v9 `' Yover the effect of early androgen exposure on adult$ D( U1 a: q6 F
penile length.10,11 Some reports suggest subnormal* S0 o" C( Z) ~  ]( v2 H$ a
adult penile length, apparently because of downreg-
- H' J7 n, k% l7 yulation of androgen receptor number.10,12 However,! G! H) }- N! ^- ]9 z! \9 E& ~9 Y
Sutherland et al13 did not find a correlation between. b0 s! F/ T# v" h# J
childhood testosterone exposure and reduced adult
8 H" U) b& Y- h5 Npenile length in clinical studies.7 n) P2 K+ X7 D  w; O: k
Nonetheless, we do not believe our patient is
3 o4 D$ G; I  V0 rgoing to experience any of the untoward effects from; W$ F0 a+ W8 |& }/ T
testosterone exposure as mentioned earlier because" A( `- H% ~$ M9 B2 p
the exposure was not for a prolonged period of time.
9 P/ J2 N0 j4 c" lAlthough the bone age was advanced at the time of
' F3 C; q/ U4 d$ r5 c% cdiagnosis, the child had a normal growth velocity at* ]0 ?( ^5 b$ G9 Q7 f4 V
the follow-up visit. It is hoped that his final adult
0 D2 |( `+ w4 j  O2 v( V% Gheight will not be affected.
. m- p' Y- I3 B6 W, xAlthough rarely reported, the widespread avail-$ P7 B7 R. Y+ p/ a  j3 w& n
ability of androgen products in our society may. M, X0 x+ E3 l& ?5 S
indeed cause more virilization in male or female
0 U0 @/ e3 v+ E3 mchildren than one would realize. Exposure to andro-! Q& L, M7 y4 \% {% X: X
gen products must be considered and specific ques-
: s3 R" R1 q; |; T6 c; N% ]/ V& Dtioning about the use of a testosterone product or
1 n1 W* k( T$ a4 H1 L9 J5 Hgel should be asked of the family members during3 L3 l# i" a; s& `: r! D% C
the evaluation of any children who present with vir-
( A7 [) V: j4 G" T2 y. [9 Zilization or peripheral precocious puberty. The diag-
: N; h& X9 A$ F0 h/ }9 {) pnosis can be established by just a few tests and by
7 l$ p) h' I) E4 ]appropriate history. The inability to obtain such a
& b' \( G6 H8 i$ K; ~8 e& @' Whistory, or failure to ask the specific questions, may
# z1 @& |7 ^' q  Eresult in extensive, unnecessary, and expensive& a' b0 R( e4 G4 Q
investigation. The primary care physician should be2 u, E$ `9 M4 m. [
aware of this fact, because most of these children  |( c, D3 m1 l% a- T) E
may initially present in their practice. The Physicians’
9 ~7 u9 {& m8 _+ O* s- j1 C: p, R: |5 JDesk Reference and package insert should also put a
$ b/ x- V' c7 [8 pwarning about the virilizing effect on a male or, r- @* O( G4 H6 i7 W
female child who might come in contact with some-
3 j7 r0 Q  f0 n7 _* mone using any of these products." F! z4 a# _$ n3 A  J2 v& H
References3 X1 c; E  G) z8 Z2 F. e$ A' B$ ~, ~
1. Styne DM. The testes: disorder of sexual differentiation
/ l* w+ j& O0 J/ t7 h, kand puberty in the male. In: Sperling MA, ed. Pediatric
6 @0 j( h! m2 K9 H4 M( {2 N  |Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 c7 b# G1 i' ~7 B9 N" k" l2002: 565-628.. H2 o+ I( o) {8 `8 M( R, W! b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! c+ ], F6 x0 o9 Q6 V% i* K, {' W5 spuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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

, |' a$ e  j* r) o4 V3 r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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