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Sexual Precocity in a 16-Month-Old, C7 @( q- {1 u- B; t) x/ Y* ?
Boy Induced by Indirect Topical
: H0 {8 Q) A3 AExposure to Testosterone
& g6 p; J' v0 }+ JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 c$ e( H; z& k5 m! M# [and Kenneth R. Rettig, MD1/ e) B: W9 X3 x% x; n4 p
Clinical Pediatrics
3 l' b4 m2 X6 q+ TVolume 46 Number 6
- |" t/ t) y, gJuly 2007 540-543- p0 ~6 b4 r8 v
© 2007 Sage Publications- Y$ m5 N! f8 G! V$ ~7 g
10.1177/0009922806296651; C8 ]9 W; t5 q9 m. [
http://clp.sagepub.com
, K9 [+ d5 b! a2 i( }# shosted at0 M# O; `3 X! E) i2 S+ V3 B9 u
http://online.sagepub.com/ m7 n2 |. y2 W
Precocious puberty in boys, central or peripheral,
( {3 ?; r: c8 n% Eis a significant concern for physicians. Central. s( z0 M3 T: d* ~3 I/ {
precocious puberty (CPP), which is mediated; l2 U! u$ ^1 e* M6 f. \& G
through the hypothalamic pituitary gonadal axis, has
2 X8 K5 M+ F: z/ h. ]" ?4 s4 S# W, Sa higher incidence of organic central nervous system
! p2 y3 f2 _+ `$ K! W7 \7 Qlesions in boys.1,2 Virilization in boys, as manifested& d1 ?+ q* g% w: h
by enlargement of the penis, development of pubic
, {% L8 |" M9 o% [7 D/ xhair, and facial acne without enlargement of testi-4 z, _8 W, H3 @4 [1 @* {8 r; t, c5 }- `
cles, suggests peripheral or pseudopuberty.1-3 We
, H; j, R: y& b9 }1 e, a; v* mreport a 16-month-old boy who presented with the# |! |9 h& j0 o+ l9 y4 }5 J2 H
enlargement of the phallus and pubic hair develop-
" V* [8 m: ]7 |  Jment without testicular enlargement, which was due" m7 G* u$ f, ~8 J! _; g: T
to the unintentional exposure to androgen gel used by
, {$ m7 H1 n# {, L8 H5 g; Y3 Vthe father. The family initially concealed this infor-
8 v6 s8 |/ h/ d1 f4 Q! f6 Xmation, resulting in an extensive work-up for this6 @& g% y2 Q& M. e% G
child. Given the widespread and easy availability of, t: {0 W. o, t/ S6 R  S
testosterone gel and cream, we believe this is proba-8 C! i" Q! ^7 d% T* d
bly more common than the rare case report in the, ^8 {, C2 {  I$ `' |. ]
literature.4
1 W; [6 R- x. e- D- UPatient Report$ b" A. J# n! Z# ^
A 16-month-old white child was referred to the
3 N6 ~( y, d% J- A4 A! E/ l3 `endocrine clinic by his pediatrician with the concern2 K" R7 P& N; {
of early sexual development. His mother noticed
5 F& k. `. Q) d# y, Xlight colored pubic hair development when he was
9 ^, X) a; j  lFrom the 1Division of Pediatric Endocrinology, 2University of# x. |7 G- s2 s# S) E# ^4 w- J
South Alabama Medical Center, Mobile, Alabama.& ~5 U/ z9 x  G* H# u: V: R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# L; u+ ~* d2 y3 n6 `4 l0 iProfessor of Pediatrics, University of South Alabama, College of2 h0 C3 L* _# J+ [! q  Q/ W
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, V' ^. @+ h) I: a# l' J8 o  ue-mail: [email protected].
! A8 Q& u! J( pabout 6 to 7 months old, which progressively became
0 v& I7 I8 T! ~$ e4 ?# N. A7 i. Bdarker. She was also concerned about the enlarge-: t  w& N! ^+ \, T5 v. K
ment of his penis and frequent erections. The child
& a( q9 b. Q4 A4 Y2 Lwas the product of a full-term normal delivery, with! ~2 K$ D2 C! H- R
a birth weight of 7 lb 14 oz, and birth length of
# ?+ J) c6 I2 F, `3 g20 inches. He was breast-fed throughout the first year
5 l% [: |8 n) D+ N& _2 _  o6 Hof life and was still receiving breast milk along with! r$ Y7 c0 q- C/ ?$ U: N1 f
solid food. He had no hospitalizations or surgery,
& k) x9 H; g; K$ G3 f6 r4 mand his psychosocial and psychomotor development
: u, [" e. f- f1 x. Q3 ~/ twas age appropriate.& `( N3 K; A: V4 {3 d: G' x. d+ l
The family history was remarkable for the father,
0 F, s5 @0 E$ ^1 }& l' `4 rwho was diagnosed with hypothyroidism at age 16,
, \4 _& |0 A" H5 y) Fwhich was treated with thyroxine. The father’s
! j- ^5 j, g  E: [* i0 theight was 6 feet, and he went through a somewhat
- J% U) X4 E" g# ?" K3 U0 v# fearly puberty and had stopped growing by age 14.
  o0 a" y- P% ]: V% Q" u" k! NThe father denied taking any other medication. The% W4 {1 g) b5 T% g# t% j
child’s mother was in good health. Her menarche
8 F) n" d, S! D$ J" u/ Awas at 11 years of age, and her height was at 5 feet
1 T% U2 n, |8 f$ {5 inches. There was no other family history of pre-) F: w( a' [- v% S  p1 f* w
cocious sexual development in the first-degree rela-
4 @5 Z1 P/ B5 Dtives. There were no siblings.. |% @, \6 f, e& M1 C
Physical Examination
7 D+ j/ F9 n- |The physical examination revealed a very active,
* G' r* p( y9 i. E$ ]6 {: N/ Rplayful, and healthy boy. The vital signs documented, u* q4 X2 J# z1 S. K
a blood pressure of 85/50 mm Hg, his length was
, z5 W2 M5 D6 X% P9 P! G/ q8 v0 M- v90 cm (>97th percentile), and his weight was 14.4 kg
: H3 @: g6 B: C% J(also >97th percentile). The observed yearly growth! x1 p* ?$ B( g. c# y0 _
velocity was 30 cm (12 inches). The examination of
/ h" D0 ~* f: r! Pthe neck revealed no thyroid enlargement.- m3 r( F) N6 e  F' G! r
The genitourinary examination was remarkable for  G( N0 Z& O: u* {) J) n* K) k- z
enlargement of the penis, with a stretched length of
2 v( x5 i6 m# C8 cm and a width of 2 cm. The glans penis was very well% ~' H5 [2 u$ @0 d% [7 |% E
developed. The pubic hair was Tanner II, mostly around4 C, ]$ n# S8 e7 v
5403 @8 \% s3 P" r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- @. x$ t  v2 _0 l4 E/ Wthe base of the phallus and was dark and curled. The
& C4 T7 ^" ^/ E7 y  u7 ]% S, ?testicular volume was prepubertal at 2 mL each.9 h9 K: W( p4 O' N: s% `% G
The skin was moist and smooth and somewhat
2 c/ @/ [/ u9 S2 ]2 F3 ^oily. No axillary hair was noted. There were no
+ k3 C: D# L: F3 Mabnormal skin pigmentations or café-au-lait spots.
6 E: b5 q. N; h3 R- w8 @Neurologic evaluation showed deep tendon reflex 2+
1 Y4 y3 C% ~4 r- P0 N, Q# Gbilateral and symmetrical. There was no suggestion& ]( }; V  q# B% x3 C6 u
of papilledema.
3 W8 G6 i  ^0 y6 tLaboratory Evaluation
4 k, C0 H0 `5 C/ o/ LThe bone age was consistent with 28 months by1 Y# ]* k/ [- g9 `; r
using the standard of Greulich and Pyle at a chrono-% r4 v4 @- ?. z  O: y3 G5 e- Q
logic age of 16 months (advanced).5 Chromosomal" g4 S* G; |: l& e+ p0 f
karyotype was 46XY. The thyroid function test
/ G3 o4 a+ p4 Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  B% }, f* k4 Zlating hormone level was 1.3 µIU/mL (both normal).% P% [+ r9 P8 C; F/ ]+ X: m/ r1 J
The concentrations of serum electrolytes, blood
  k' b" Z8 P8 E* D  B6 i: y# A  t; y% |urea nitrogen, creatinine, and calcium all were; f! \9 D! r' Z2 y% A
within normal range for his age. The concentration
- C" A- t; z6 U1 ^of serum 17-hydroxyprogesterone was 16 ng/dL
, ?# M/ \2 r6 f5 c  Q7 F1 Z(normal, 3 to 90 ng/dL), androstenedione was 20$ M, i' g9 y/ \6 k! c$ C( H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" [/ z, t. n3 c6 n2 Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( p! V2 _, V0 e+ R! S7 bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
. t" \$ h' f* S4 x49ng/dL), 11-desoxycortisol (specific compound S)5 r8 ]6 Y6 O: J5 W
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# F7 ^7 _9 v/ S. D1 K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! A$ B( i, F2 A' C+ K  y- }testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 q4 y+ y" F, ~0 C+ tand β-human chorionic gonadotropin was less than; H/ d- X: `% y% L) p  P6 ^7 k
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ n7 m3 d2 n, e& n. o/ V
stimulating hormone and leuteinizing hormone
0 }" }4 W) O" E) d$ gconcentrations were less than 0.05 mIU/mL; O0 G, |9 V5 t) E  L% o2 U! u% Y
(prepubertal).( K# R6 d! h7 b# c
The parents were notified about the laboratory
' d0 \! y1 d# v( o+ Z2 _results and were informed that all of the tests were% J: k9 R1 K9 i( M! o
normal except the testosterone level was high. The
- `+ P: E0 D# v% X% h, k, N2 Dfollow-up visit was arranged within a few weeks to3 D) v* T9 v  i  [% X' \( M6 k
obtain testicular and abdominal sonograms; how-
& A9 w1 z* f9 d9 r$ j9 Bever, the family did not return for 4 months.- _" h; N3 P# Q* {! ?5 R
Physical examination at this time revealed that the4 ^8 @+ ^$ j& w& }- C
child had grown 2.5 cm in 4 months and had gained% P( w$ h  t  W( ]
2 kg of weight. Physical examination remained
9 ?$ K: z/ n6 G: n( M8 ?* f. Punchanged. Surprisingly, the pubic hair almost com-- ?; e( A7 M% o' c+ l  J
pletely disappeared except for a few vellous hairs at2 V' t, L$ S$ ^
the base of the phallus. Testicular volume was still 2
# {1 w: m! n) \' B0 P, k2 CmL, and the size of the penis remained unchanged./ q( C. [6 P  M- v0 R5 b
The mother also said that the boy was no longer hav-
# n9 Z% s, q& S& c4 |4 F' Sing frequent erections.9 c+ Y# o, r2 i  F0 V% i7 E
Both parents were again questioned about use of. J# }8 I( \% S$ S
any ointment/creams that they may have applied to
$ d- q) Q" z9 r3 A+ s8 ethe child’s skin. This time the father admitted the
& ~# x9 @+ M# A( |) LTopical Testosterone Exposure / Bhowmick et al 541
( i: W2 G5 |' w. ^use of testosterone gel twice daily that he was apply-* f4 s* m7 I- y9 I& F+ K1 @! u
ing over his own shoulders, chest, and back area for" h- M1 u) D8 w2 O& l7 ?+ u
a year. The father also revealed he was embarrassed# l% x$ v6 V) z8 i
to disclose that he was using a testosterone gel pre-
7 ?" M+ x2 x- p# o* ]scribed by his family physician for decreased libido2 t5 i; c. H$ T& |
secondary to depression.
6 ]% b" I$ b4 W$ Y( X. a/ T# Q. y& xThe child slept in the same bed with parents.
: l" P; `# L; y. BThe father would hug the baby and hold him on his- q$ d$ A- _4 K: j& Y' u
chest for a considerable period of time, causing sig-
" M& h% C( O" F. _: Pnificant bare skin contact between baby and father.& ?# J6 b/ r& X% i0 E, p5 y
The father also admitted that after the phone call,
  t+ @5 }9 u( O. S$ o% awhen he learned the testosterone level in the baby* `8 v5 I2 e& q, e0 I6 Y  A. T2 x
was high, he then read the product information
5 {% R- B* a$ C8 c: O# Z1 tpacket and concluded that it was most likely the rea-. M9 R$ P- j1 `6 T
son for the child’s virilization. At that time, they
% D8 C$ i& v! q0 [) rdecided to put the baby in a separate bed, and the+ g/ Y+ U) |: F& F: @8 J
father was not hugging him with bare skin and had
# \/ L7 f2 U7 h; N+ A  `9 C: G) }$ P! Z5 nbeen using protective clothing. A repeat testosterone
. i7 _, r) w7 j" itest was ordered, but the family did not go to the: b, V% g( Q  ?* j0 w9 L: L' p
laboratory to obtain the test.
3 T8 N! Q3 A2 J/ [/ W! E' p  |$ H+ o. WDiscussion
2 e: [6 F2 C- |/ DPrecocious puberty in boys is defined as secondary
) F5 F- ]4 ?; }! z/ Y; ^4 N; s) J' Zsexual development before 9 years of age.1,41 @* X9 s/ {+ W' t6 p4 N$ `; T- _
Precocious puberty is termed as central (true) when
7 O8 |& n2 M/ D4 `it is caused by the premature activation of hypo-
5 v- L* K3 J+ D+ x6 a# h  S1 Othalamic pituitary gonadal axis. CPP is more com-3 g* x2 H% c) |; v: u8 h" ~
mon in girls than in boys.1,3 Most boys with CPP
- V+ F7 o/ |6 o# smay have a central nervous system lesion that is0 K7 ^4 g" B. A* N  B- I
responsible for the early activation of the hypothal-
. F6 W/ N& z# T7 ^$ Bamic pituitary gonadal axis.1-3 Thus, greater empha-- G+ M( o: k( y+ [
sis has been given to neuroradiologic imaging in
! I: y% m4 f# ?3 ^; r$ \, d2 {boys with precocious puberty. In addition to viril-# @+ F4 a7 \. M, G* M  E1 {3 @8 k
ization, the clinical hallmark of CPP is the symmet-* i2 l$ Z# m8 w4 O. u% m+ Q
rical testicular growth secondary to stimulation by  F; w# h. j3 l
gonadotropins.1,39 y" d0 g( ]. o! ?+ K1 I
Gonadotropin-independent peripheral preco-
* q- c4 r: N* u. ?cious puberty in boys also results from inappropriate, B+ A$ z! a1 U" R2 r4 ?6 x
androgenic stimulation from either endogenous or
" x, k( X1 W  g/ cexogenous sources, nonpituitary gonadotropin stim-0 [3 m( E% f! j+ S- i
ulation, and rare activating mutations.3 Virilizing
, t! z# k# J/ a/ L; z6 \8 hcongenital adrenal hyperplasia producing excessive
, Z, d! Z6 ~; Dadrenal androgens is a common cause of precocious
# _, y: @9 j, J2 \& S& Z& w, Mpuberty in boys.3,40 J5 k6 C6 S2 F: s3 ]
The most common form of congenital adrenal
1 E  L* ^) ]6 f3 H' }) k" Lhyperplasia is the 21-hydroxylase enzyme deficiency.
% Y# k  _- u4 nThe 11-β hydroxylase deficiency may also result in& O) F. R0 @: w" {2 A: B  N
excessive adrenal androgen production, and rarely,# J3 N& G- m* J$ T4 y
an adrenal tumor may also cause adrenal androgen, Z' k- S  S2 n0 q
excess.1,3
4 {! H0 y' i/ F$ L; tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 O) ^) k+ O. C) v1 F& X9 T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- M- H5 a; ?' f7 E/ A1 W2 b8 \
A unique entity of male-limited gonadotropin-0 \8 x' q3 y. ^! m4 f6 G# o& ~
independent precocious puberty, which is also known
- @6 `- r0 a  O8 j9 Fas testotoxicosis, may cause precocious puberty at a
6 L# Y& \, C9 x+ k- q# hvery young age. The physical findings in these boys
5 o, i4 F$ ?. w- ~with this disorder are full pubertal development,
  h( z% w  g1 h& @. r2 P  ~including bilateral testicular growth, similar to boys, |: x  a- k; `" y) z2 p/ ^/ w
with CPP. The gonadotropin levels in this disorder
/ \& M4 G& j* Z' z: ]are suppressed to prepubertal levels and do not show
( E- Q- T! y% e1 j. I. y  t2 ^2 Epubertal response of gonadotropin after gonadotropin-+ F( L5 b5 u, b
releasing hormone stimulation. This is a sex-linked
9 \  x1 n, ?: S7 D  P) ^autosomal dominant disorder that affects only: H1 c' r' x1 C6 z: @* [6 d
males; therefore, other male members of the family# p6 j2 ~' {: K8 n: n# n
may have similar precocious puberty.3
/ i, Z' P4 W, l; N8 bIn our patient, physical examination was incon-, T, }7 X' J+ e7 N9 z
sistent with true precocious puberty since his testi-
8 L" d- }1 l. A- L3 ecles were prepubertal in size. However, testotoxicosis
) u+ |+ [0 E8 q/ l( Kwas in the differential diagnosis because his father
+ Q& }( p, ]- k4 {4 ~started puberty somewhat early, and occasionally,/ B, i# |' P8 S' F* f
testicular enlargement is not that evident in the
2 Q  t! a5 Z6 p! _beginning of this process.1 In the absence of a neg-
# T4 X' T3 d7 `6 X( eative initial history of androgen exposure, our
5 M; q5 z6 F/ `biggest concern was virilizing adrenal hyperplasia,5 F4 ]+ G3 @' f% X& `6 M
either 21-hydroxylase deficiency or 11-β hydroxylase
6 S; u2 v7 m  ydeficiency. Those diagnoses were excluded by find-
# C! S- e- D* A+ \ing the normal level of adrenal steroids.
! U1 O6 i1 V$ o+ T# B" gThe diagnosis of exogenous androgens was strongly
2 Q7 N3 K, j. u% V- ^2 d% ususpected in a follow-up visit after 4 months because
# h5 G) C5 _" Q8 a) k1 g, I4 ~, Gthe physical examination revealed the complete disap-& h& ]9 K  u( p
pearance of pubic hair, normal growth velocity, and4 V9 ?: [. ~/ N0 V9 |
decreased erections. The father admitted using a testos-; `" F6 Y! H; f& i
terone gel, which he concealed at first visit. He was
9 L: H3 ~- y& m7 B1 lusing it rather frequently, twice a day. The Physicians’
" x% h3 n3 v! ^" w9 e: c1 @Desk Reference, or package insert of this product, gel or
% o7 W; P8 F+ a. q& O4 i% d/ ucream, cautions about dermal testosterone transfer to: j1 c& Q* E* |6 P( t. b4 Y
unprotected females through direct skin exposure., Y' Y5 R, h( ~. f6 n0 {/ Y# D
Serum testosterone level was found to be 2 times the
3 K) x3 k4 H0 pbaseline value in those females who were exposed to
& s6 X/ d+ k) \5 j& jeven 15 minutes of direct skin contact with their male
' W# A9 Q: h  s! r3 j7 {5 Xpartners.6 However, when a shirt covered the applica-8 X2 W( Q7 n7 v4 ]* m
tion site, this testosterone transfer was prevented.
3 E9 G" H2 k  |# M1 x" k* b' gOur patient’s testosterone level was 60 ng/mL,
: X7 X, J, i. H# Q8 swhich was clearly high. Some studies suggest that, Q' j8 W0 ?* u) r, s
dermal conversion of testosterone to dihydrotestos-
5 t: `% \2 C) q0 o: gterone, which is a more potent metabolite, is more
7 Q+ r5 X3 @! B* p3 N; d  Zactive in young children exposed to testosterone  `/ w# j, j' P. ^6 K* v6 I
exogenously7; however, we did not measure a dihy-
, a4 {# ?: `8 [9 I1 `: rdrotestosterone level in our patient. In addition to" Q4 o# k& X3 N! q$ @
virilization, exposure to exogenous testosterone in/ ~2 }7 z; u  ]0 q% M: r% u* C" Y; {: h
children results in an increase in growth velocity and
" ]8 J4 ~2 ]' W) r% Madvanced bone age, as seen in our patient.
  [, c) T0 {: @/ i7 a+ k8 H7 X5 TThe long-term effect of androgen exposure during
! t( z+ ^: ?& w7 y2 @) y' v3 U' w/ Nearly childhood on pubertal development and final+ V" }4 ]* J5 v( T! S
adult height are not fully known and always remain
5 O  `7 H0 l0 n$ l2 {a concern. Children treated with short-term testos-
( S! N" P* F. Q# ?9 b, ?terone injection or topical androgen may exhibit some
2 \: g" x) A# G/ S$ E1 u3 V) K" }+ i2 tacceleration of the skeletal maturation; however, after
- \* I- H/ }9 W: Ncessation of treatment, the rate of bone maturation! {: p1 k. X$ E* W! |% e
decelerates and gradually returns to normal.8,9$ _7 L. E% V6 m$ m% r2 z
There are conflicting reports and controversy" b7 J% w% M3 U% y, Q
over the effect of early androgen exposure on adult
) v2 y9 l3 X5 m' H; d; e3 ^) g  Ipenile length.10,11 Some reports suggest subnormal  U, t- L5 y- l) U
adult penile length, apparently because of downreg-
2 ~2 t% ~$ Z2 P8 a( z/ Kulation of androgen receptor number.10,12 However,
; _/ N: k' ~9 x( A3 ASutherland et al13 did not find a correlation between2 S/ N% ?" n: }+ ^5 s" o
childhood testosterone exposure and reduced adult( d/ o3 x- o8 C$ c
penile length in clinical studies.4 k' l/ T! q- g' s: E* N
Nonetheless, we do not believe our patient is
$ _4 G# M% _/ e& ~' ?* y5 {9 Zgoing to experience any of the untoward effects from
# @0 c+ ]0 V) m: ~) W, [3 k9 n3 ?testosterone exposure as mentioned earlier because
' j/ M- p' x' v) Sthe exposure was not for a prolonged period of time.
5 K2 w2 D( L* w1 ?3 O3 v; T9 H9 vAlthough the bone age was advanced at the time of
1 a3 F( T- A3 S1 N/ O) c4 }0 Idiagnosis, the child had a normal growth velocity at
4 W% `0 ~$ k, X4 `/ F; D% Lthe follow-up visit. It is hoped that his final adult7 K+ _# X* [! @* h: P$ X5 h
height will not be affected.4 R) X' L+ [% r
Although rarely reported, the widespread avail-
: }1 Z1 X8 B/ X) q; `( p5 z, Vability of androgen products in our society may8 j1 {( X2 Y' x
indeed cause more virilization in male or female' K# o5 v& G* Q/ _0 g- m; c, d
children than one would realize. Exposure to andro-
) b9 _  U7 ?% {# C  c% `gen products must be considered and specific ques-9 a: ]% D/ [( W5 ?: P
tioning about the use of a testosterone product or, _+ ^2 [' o/ ]9 ~3 Z% Z
gel should be asked of the family members during# K% C9 |, u# O1 Y; y
the evaluation of any children who present with vir-
9 u+ {) D+ @9 h0 e4 Bilization or peripheral precocious puberty. The diag-
% I# }( r6 k, w' fnosis can be established by just a few tests and by
) H1 _6 u& _4 i% lappropriate history. The inability to obtain such a
; j& R/ C; N  B! r# ~" Uhistory, or failure to ask the specific questions, may8 K% y0 J9 P1 y. R
result in extensive, unnecessary, and expensive+ Y8 n  O9 |  x
investigation. The primary care physician should be- E+ z( ]7 j2 V/ |0 T
aware of this fact, because most of these children
6 A: C* b2 b9 ^* Y* W$ Qmay initially present in their practice. The Physicians’6 L: ~4 H$ t( I* m6 Y5 e: F
Desk Reference and package insert should also put a' z/ g0 J1 e- y
warning about the virilizing effect on a male or& }! x6 G1 ~2 M+ W. @- G
female child who might come in contact with some-
1 d" j3 o5 r+ F  Ione using any of these products./ W0 y+ d% K' d0 F- o
References7 N1 W1 A5 l" Y2 K, b! d/ P. A0 ^
1. Styne DM. The testes: disorder of sexual differentiation
7 t7 B0 r# ~/ F& M" Nand puberty in the male. In: Sperling MA, ed. Pediatric: S$ ]6 f% X9 @7 Q4 `* I- H, Y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 K! W" D5 x( V7 q4 v8 E2002: 565-628.
4 L2 H) a1 Q  A. }( y( i# J2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# k% `5 J) T/ V1 Z) f3 v' u8 Xpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 h. h+ \4 N" v! vBoy Induced by Indirect Topical
6 e9 L% C* c  C& c$ p. FExposure to Testosterone% V+ a2 e, n8 M) f1 k
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, M( [1 R6 p+ D, nand Kenneth R. Rettig, MD1
+ ?* J" V' d% w5 ^Clinical Pediatrics4 S( P4 ?( D7 m
Volume 46 Number 6
9 l+ c/ A  \5 w7 e, AJuly 2007 540-5435 y! T5 b5 B  t- `/ o
© 2007 Sage Publications
0 i% N. X6 ?8 g% s10.1177/0009922806296651
% f3 h# W  L5 i- J4 z. Qhttp://clp.sagepub.com0 V( B8 w7 k3 g' w1 M: b
hosted at
( p* @( _: Z) q. |7 ~7 Thttp://online.sagepub.com* u% F, F, f( ~" k6 U2 x" j% r- O2 X
Precocious puberty in boys, central or peripheral,
9 J1 U* @/ j/ b1 j' Ris a significant concern for physicians. Central/ @6 ?6 s1 i, @. z/ W3 w/ F
precocious puberty (CPP), which is mediated3 t7 `& ]$ y" P, R+ ~- |
through the hypothalamic pituitary gonadal axis, has, G, T' z" y9 `0 w
a higher incidence of organic central nervous system
* r" ?1 J- g7 L% \8 L! X& x1 jlesions in boys.1,2 Virilization in boys, as manifested
7 z' y/ e; g# `0 ?by enlargement of the penis, development of pubic
4 D3 `/ p0 Q, [. Qhair, and facial acne without enlargement of testi-
- E! F( r& A* }% o4 z6 p4 gcles, suggests peripheral or pseudopuberty.1-3 We
3 l' K+ v7 j5 ?  Freport a 16-month-old boy who presented with the
' t* T4 A# G* ?$ S2 Q+ c6 ]8 nenlargement of the phallus and pubic hair develop-. t- ^  `) ~" ^- r/ {- Q+ b2 {/ t9 C
ment without testicular enlargement, which was due
5 P$ f' C- n1 Oto the unintentional exposure to androgen gel used by
/ f) t! H' H- l( ~the father. The family initially concealed this infor-( b9 ^) \& t3 p1 l4 Z% V  n4 ^
mation, resulting in an extensive work-up for this$ G. z. p7 K6 j
child. Given the widespread and easy availability of
  H- Y6 z% `& r9 M+ d6 Atestosterone gel and cream, we believe this is proba-
" P: Y) w- {3 A. t$ k8 P0 P" Sbly more common than the rare case report in the
" O& J" G3 Z1 m* V- `) \literature.47 m9 F' F% Y) Y' ~7 h0 f' N
Patient Report# ]' n. c6 o6 B7 b5 C
A 16-month-old white child was referred to the
- V1 K8 Y! ?4 G- g% Q& vendocrine clinic by his pediatrician with the concern
: F. P. V4 T  x; V% B: n* M/ nof early sexual development. His mother noticed
+ Q: h  i6 e8 [3 z$ h3 ulight colored pubic hair development when he was
7 Q* \0 Y% ~4 gFrom the 1Division of Pediatric Endocrinology, 2University of
4 j# l/ u* O6 v$ ]South Alabama Medical Center, Mobile, Alabama.$ }. p) Q+ X" L6 f/ R7 }) W
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 p2 n1 F6 f+ m/ x7 gProfessor of Pediatrics, University of South Alabama, College of+ M. M+ G4 }) ?  i
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& w* e7 w2 B! `$ t4 n& w
e-mail: [email protected].8 F( a' D+ z1 I# B9 u
about 6 to 7 months old, which progressively became: N% H  R0 N/ n" \3 M+ u
darker. She was also concerned about the enlarge-
6 ?" y1 p* ?9 w6 E- [. {9 ]; t: bment of his penis and frequent erections. The child$ r6 u7 ?# F9 r" ~% q9 P
was the product of a full-term normal delivery, with
0 F$ o3 f3 s2 W' K, i6 V3 o, \a birth weight of 7 lb 14 oz, and birth length of' w2 t1 g& L) B- p+ ?& K
20 inches. He was breast-fed throughout the first year( W6 U+ V; Z2 A; U5 S& o7 V
of life and was still receiving breast milk along with
# x2 q) @: \+ V$ N: u9 E8 s3 tsolid food. He had no hospitalizations or surgery,; B# q, e; ?( y: F  a9 s1 H" d
and his psychosocial and psychomotor development
# y' v6 k% j! t7 owas age appropriate.
* Q7 K" F* `; F' z" a, s- zThe family history was remarkable for the father,( [. n9 f. \6 Y7 \, h; {2 m
who was diagnosed with hypothyroidism at age 16,
$ s! m* Q" T4 l: {" \which was treated with thyroxine. The father’s
' i' @( B8 M0 H# x. kheight was 6 feet, and he went through a somewhat
! R+ b3 d' h& T! E. kearly puberty and had stopped growing by age 14.
; T& n/ G, k3 J1 XThe father denied taking any other medication. The) U& q- I  K( o8 `' j
child’s mother was in good health. Her menarche
0 }7 F5 B( J: h: G7 Ywas at 11 years of age, and her height was at 5 feet% i6 `# f! i, U' V+ f
5 inches. There was no other family history of pre-
% c& Z1 Q# q' n2 S/ Jcocious sexual development in the first-degree rela-
+ {$ G  g+ p8 h9 f+ gtives. There were no siblings.4 M# U- z' w3 E" i
Physical Examination  |6 G6 W2 ^& r% t/ M4 A
The physical examination revealed a very active,7 V5 H/ m6 L* {1 ?/ _2 c
playful, and healthy boy. The vital signs documented1 B3 U5 n) W# ]0 Z; v; y
a blood pressure of 85/50 mm Hg, his length was
3 L5 h$ ~0 O: |9 T- l7 Y90 cm (>97th percentile), and his weight was 14.4 kg
" f6 c. j- u' z/ Z6 Z' Z" U(also >97th percentile). The observed yearly growth
) p! m; E/ V- u% kvelocity was 30 cm (12 inches). The examination of# w7 p9 J4 K8 _' f% h& D: x
the neck revealed no thyroid enlargement.0 D  {1 I* q3 r
The genitourinary examination was remarkable for6 R6 x( f9 F" F+ I6 [0 F6 {
enlargement of the penis, with a stretched length of$ D- [! ~! Y9 V
8 cm and a width of 2 cm. The glans penis was very well
2 c' ~* E. w6 L5 f( J- ^) Udeveloped. The pubic hair was Tanner II, mostly around
- G& s2 n# j5 e4 H" N9 z5404 X/ g4 W; q# u3 V8 ?, Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 D  @$ p# u! T6 Q$ g$ E. v8 W3 zthe base of the phallus and was dark and curled. The* }3 M8 d* a! N" s. U
testicular volume was prepubertal at 2 mL each./ d' R+ F7 H- a! z
The skin was moist and smooth and somewhat
* [8 \/ {: b. M# b9 z0 Woily. No axillary hair was noted. There were no% y: }0 J7 G* x) ]+ w( P
abnormal skin pigmentations or café-au-lait spots.4 `8 J- q1 S2 o" |$ G' b3 a
Neurologic evaluation showed deep tendon reflex 2+0 b! d4 Q. i( C8 o, I9 J
bilateral and symmetrical. There was no suggestion$ e; s2 n' L4 v# A. ~& j
of papilledema.7 w( v/ M% ^% T; B2 I
Laboratory Evaluation
7 Z$ k; ~0 m4 S/ _/ W4 oThe bone age was consistent with 28 months by
- o: X! t  D. X5 U+ ~using the standard of Greulich and Pyle at a chrono-& `: B) ~: P4 t8 \5 N
logic age of 16 months (advanced).5 Chromosomal
5 D) s; _9 K4 P; w1 |4 ^5 hkaryotype was 46XY. The thyroid function test! i5 E3 o- E6 K/ K" @
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" [1 m2 C! Q0 t% q' ulating hormone level was 1.3 µIU/mL (both normal).
, ?9 i# Z9 K$ [6 i* [. h9 A, f+ qThe concentrations of serum electrolytes, blood6 U: }0 s) Y3 f; n
urea nitrogen, creatinine, and calcium all were: X% j. @0 c4 L  g: X2 q" ~
within normal range for his age. The concentration1 j. F9 F! E& w" |+ b& p- w
of serum 17-hydroxyprogesterone was 16 ng/dL( \. Y- L9 ?/ @, h
(normal, 3 to 90 ng/dL), androstenedione was 20
3 a& P4 T. d& E: z0 K" X( Ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ _5 ^0 R# A5 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 Z" [  A/ k, E3 h% r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
& g6 g# V  w: M5 K49ng/dL), 11-desoxycortisol (specific compound S)
% u( c, E( b" `' s" r7 p' Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' X4 @1 v& A- y3 S% I% W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 B$ T) d+ b0 ^testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 Q4 H$ m( [( }; p2 N6 X; Q
and β-human chorionic gonadotropin was less than- J+ F$ w, J/ |0 v4 h5 p
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 ~8 L6 _6 x. U2 ?& S2 Y9 Y6 K* ~( h
stimulating hormone and leuteinizing hormone
! N( ]% Z/ k3 s% V# ]  Kconcentrations were less than 0.05 mIU/mL/ l6 g- E; J+ h6 E! z  a1 p3 t
(prepubertal).
$ s1 I% L6 H4 U3 ]) Z5 Q- W) pThe parents were notified about the laboratory
( q5 h% q8 z$ n# cresults and were informed that all of the tests were0 l% Z# n7 W1 M
normal except the testosterone level was high. The3 ^* I1 B% U$ c* K) N# W3 s
follow-up visit was arranged within a few weeks to
1 k9 p: E. {9 Y. q  @/ b; Aobtain testicular and abdominal sonograms; how-  R4 ^5 E8 l- v: S3 U% _
ever, the family did not return for 4 months.0 |" _2 l5 V3 w$ v
Physical examination at this time revealed that the
6 _: ~" S' V/ O9 E5 Nchild had grown 2.5 cm in 4 months and had gained
) V8 Z" \" k$ }+ ?2 kg of weight. Physical examination remained
8 p# e; P% D0 P7 z# |+ ^+ _. runchanged. Surprisingly, the pubic hair almost com-4 b8 o1 F# y4 p
pletely disappeared except for a few vellous hairs at
: Y* g/ Q- T, H" @4 fthe base of the phallus. Testicular volume was still 2
8 c" ?! h% E3 s/ X$ _- D* _mL, and the size of the penis remained unchanged.
$ L" T9 g; q3 w! Z3 ]) f6 z) i0 N7 xThe mother also said that the boy was no longer hav-6 p- e5 e% x/ O8 R7 q; u
ing frequent erections., r8 {7 U6 a% u9 L
Both parents were again questioned about use of  e4 o) V7 l0 e& p* h, @! Y
any ointment/creams that they may have applied to6 R) l9 |/ q( e# j  x* R
the child’s skin. This time the father admitted the
( d- e! D* B5 T  qTopical Testosterone Exposure / Bhowmick et al 541
) ?( o2 M  u2 V9 q# nuse of testosterone gel twice daily that he was apply-0 D  |; l; I: i* P
ing over his own shoulders, chest, and back area for
5 |6 L( ^2 f. h5 `a year. The father also revealed he was embarrassed& @, p- _& F. y) X
to disclose that he was using a testosterone gel pre-; S8 g/ l6 c6 s2 b5 f' N
scribed by his family physician for decreased libido
( e  k$ `! ^+ N0 usecondary to depression.& P8 {' H( U1 `0 p2 I
The child slept in the same bed with parents.* Z5 r7 |8 Y) V6 J1 {8 s
The father would hug the baby and hold him on his0 I6 g7 @* l, B' y
chest for a considerable period of time, causing sig-3 ?1 d2 X, m: i; ?' L; n1 U
nificant bare skin contact between baby and father.
4 \. l1 h% z3 ?% N+ ?% z$ }The father also admitted that after the phone call,. A/ x$ U) w& I9 n4 a4 z
when he learned the testosterone level in the baby- s2 y+ |$ V/ }4 X6 c
was high, he then read the product information* I; j& n$ z+ [) t* Y- p" g
packet and concluded that it was most likely the rea-2 n" ]* F1 k2 c: N9 G
son for the child’s virilization. At that time, they3 d! \  W& A! c2 l  q. S0 s9 @
decided to put the baby in a separate bed, and the
' h' I& T$ d* z' N5 A2 v2 J, cfather was not hugging him with bare skin and had. s5 l- I2 H" ^, I) O! z
been using protective clothing. A repeat testosterone6 S$ v- o: U7 ~, |) t
test was ordered, but the family did not go to the+ I+ [5 Y/ w" `( c8 u1 S
laboratory to obtain the test.
1 s6 Z. o; M$ J6 B6 tDiscussion
* v" f1 \4 }3 ]/ h5 w7 }Precocious puberty in boys is defined as secondary
" p) Q1 O3 H! t6 }  p  M1 \sexual development before 9 years of age.1,41 }0 N2 g2 Q7 ]: Z* E
Precocious puberty is termed as central (true) when2 v- Z' C& Y3 W$ l$ q! g4 J
it is caused by the premature activation of hypo-$ F. K: V8 R8 {" |7 _9 G4 u
thalamic pituitary gonadal axis. CPP is more com-
. \+ m7 K! Z* y) g) {mon in girls than in boys.1,3 Most boys with CPP
; w4 u9 m( G% U8 z  j3 Q9 i% [* Tmay have a central nervous system lesion that is4 x1 M7 i: I8 [/ x: @
responsible for the early activation of the hypothal-
. \* s$ G" ?, X. H$ Mamic pituitary gonadal axis.1-3 Thus, greater empha-
" s9 r& W1 W1 k( u% u8 Csis has been given to neuroradiologic imaging in
0 K8 t/ G, r) @6 ^' y/ aboys with precocious puberty. In addition to viril-
8 _' H  F; U. Z9 tization, the clinical hallmark of CPP is the symmet-
3 ~0 ~5 d# W  G/ U/ |3 ^rical testicular growth secondary to stimulation by% u8 K' o7 S9 P: {* E8 K0 y5 q/ ]- s
gonadotropins.1,3
1 f" d. {# X7 u9 eGonadotropin-independent peripheral preco-
$ h5 h& M7 M- O3 L* ^cious puberty in boys also results from inappropriate
0 r0 x$ c5 [0 H! @4 J) d6 uandrogenic stimulation from either endogenous or2 K' A3 W' a2 {) s# D& b7 x4 [+ `
exogenous sources, nonpituitary gonadotropin stim-
1 _5 z* e5 n+ u( |& Culation, and rare activating mutations.3 Virilizing! R1 b  h: G5 I4 g6 t, A( C& \
congenital adrenal hyperplasia producing excessive
$ C( O. e( m9 `1 X' o7 V* }7 c6 {adrenal androgens is a common cause of precocious% W% |, ~6 Q/ v8 ?/ s: `# @9 z
puberty in boys.3,4, S1 ~2 O- `8 N; o3 v
The most common form of congenital adrenal8 l6 {9 r5 \$ ^8 F& K8 W4 Y
hyperplasia is the 21-hydroxylase enzyme deficiency.
, f0 z! }- f3 u6 W1 k! i4 mThe 11-β hydroxylase deficiency may also result in
' C. d: R- Q  G) Y8 cexcessive adrenal androgen production, and rarely,
* i; `& h- ~9 g$ T" X1 m  l" ~an adrenal tumor may also cause adrenal androgen- d5 H$ F3 |8 s6 B
excess.1,3
1 r  }8 Z& ^5 w6 J3 Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 e( M! p) k% `. A2 D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ _$ b. R; A  C1 U. AA unique entity of male-limited gonadotropin-
' X( ~# V7 L) i. R( ?# Xindependent precocious puberty, which is also known/ v* L$ ~/ p1 w
as testotoxicosis, may cause precocious puberty at a
* b; M3 q. E/ M9 Z* x' q' tvery young age. The physical findings in these boys7 p2 t5 q  q2 P2 s* a3 S' p
with this disorder are full pubertal development,
) [+ f8 I8 s9 y( }* C- u$ F# Tincluding bilateral testicular growth, similar to boys
) B& F. y- U- L( h+ Gwith CPP. The gonadotropin levels in this disorder3 X! H3 P; t  s4 M4 C: T
are suppressed to prepubertal levels and do not show- ?* b; d- u+ c6 W; t7 ~7 m/ w
pubertal response of gonadotropin after gonadotropin-
* i# @# S+ o9 N0 W$ J/ z4 q2 g8 Qreleasing hormone stimulation. This is a sex-linked
# D6 Z7 s! p) rautosomal dominant disorder that affects only( U2 l& Z; C) X1 G2 Y
males; therefore, other male members of the family7 [; p$ G! k3 G7 d$ {
may have similar precocious puberty.3) U2 l0 z7 u, Q: ?: n: J) O
In our patient, physical examination was incon-
9 U; j! E# w4 w+ _- ^, ^: }sistent with true precocious puberty since his testi-
* ?* C, s1 _2 M. C# Icles were prepubertal in size. However, testotoxicosis
2 K3 W) a) Z! u8 x, Y- Uwas in the differential diagnosis because his father
) H1 j0 q% F! V- v* t" [/ [started puberty somewhat early, and occasionally,
8 R% M3 C, r) ktesticular enlargement is not that evident in the
. r% U  U, K4 e2 {beginning of this process.1 In the absence of a neg-& F; M  ^" T. W# a/ r) @
ative initial history of androgen exposure, our
$ n0 [5 d- p: Q2 O2 Jbiggest concern was virilizing adrenal hyperplasia,
" v0 @0 M9 {7 v. heither 21-hydroxylase deficiency or 11-β hydroxylase* f& l# H* V& f
deficiency. Those diagnoses were excluded by find-, \; t) _1 @  W! u
ing the normal level of adrenal steroids./ d8 s; E6 j) S* R2 j! b
The diagnosis of exogenous androgens was strongly
3 Z4 C& @0 V; Q5 O: Isuspected in a follow-up visit after 4 months because
  B, d/ z5 }6 Y/ H7 s2 Jthe physical examination revealed the complete disap-# X- \* o4 Q; S, L1 k( T
pearance of pubic hair, normal growth velocity, and4 r) w( d: T7 P: U
decreased erections. The father admitted using a testos-
( J* G* D) A8 e  }0 [: O7 l: Uterone gel, which he concealed at first visit. He was
' s  ~3 h* Z/ N: xusing it rather frequently, twice a day. The Physicians’. ]2 M5 L" K& `) r
Desk Reference, or package insert of this product, gel or
" h5 V; {# L9 g+ H3 t2 L0 _cream, cautions about dermal testosterone transfer to
/ o1 h8 j$ S0 K! R4 lunprotected females through direct skin exposure.
- K$ g. \3 q2 d* B8 tSerum testosterone level was found to be 2 times the% S9 ]9 l! t6 F
baseline value in those females who were exposed to
. n1 D% u8 K# W4 R8 Z! c5 @; z) Xeven 15 minutes of direct skin contact with their male6 Z8 z: H# v0 O! q, p& H2 i
partners.6 However, when a shirt covered the applica-* w# A' c$ z+ j; z/ |
tion site, this testosterone transfer was prevented.
- _* d8 k+ t( _Our patient’s testosterone level was 60 ng/mL,
7 k# E7 ^- Z9 d$ k6 ^. u5 t$ L% R+ Xwhich was clearly high. Some studies suggest that- [0 [' u1 y8 L6 Y& g
dermal conversion of testosterone to dihydrotestos-
! D  I" n2 N* t# p* Bterone, which is a more potent metabolite, is more
- N- c/ P2 v$ C' L7 V! D" jactive in young children exposed to testosterone
: Q8 Z) N: p+ l) M% U: f! e1 W) jexogenously7; however, we did not measure a dihy-+ c0 H( M' ]# i1 f; l. ?! ^
drotestosterone level in our patient. In addition to
5 Y4 n- l. X9 P( Yvirilization, exposure to exogenous testosterone in
9 p7 t1 w4 j* h9 Bchildren results in an increase in growth velocity and: f" T( ]# O7 |% n  T" |+ f
advanced bone age, as seen in our patient.
/ d9 P6 [: T% ^6 ]% f$ @7 kThe long-term effect of androgen exposure during
: y- p3 F) o. u) G- [- Aearly childhood on pubertal development and final
. `% H: s( H2 l/ gadult height are not fully known and always remain0 `! {/ ~# t! Y% v1 b: l6 I; ^
a concern. Children treated with short-term testos-3 [( b- D( {/ F, _) Q: I) G
terone injection or topical androgen may exhibit some
$ j* s" {3 r. r0 T8 i! iacceleration of the skeletal maturation; however, after
( G% y; ?4 n& q9 y0 G$ o! S+ vcessation of treatment, the rate of bone maturation
* ]# u# [" I* m& U* e+ Q* |5 [decelerates and gradually returns to normal.8,9
# f& @* U' Z& ]7 O( a5 k8 @& HThere are conflicting reports and controversy
6 `2 S5 f# m8 iover the effect of early androgen exposure on adult
; Y- F# X7 P$ `, w2 Ppenile length.10,11 Some reports suggest subnormal
) V) M- s! _6 oadult penile length, apparently because of downreg-
6 z, ^" F6 g' D, Iulation of androgen receptor number.10,12 However,1 d$ G3 h: I1 V" r, r
Sutherland et al13 did not find a correlation between
9 b- m6 Z) g# W2 \childhood testosterone exposure and reduced adult
0 H8 e$ S# B0 X: zpenile length in clinical studies.
: g& F) F6 b* u% B4 o( mNonetheless, we do not believe our patient is
! n* s3 M9 N+ y' ~9 b! rgoing to experience any of the untoward effects from
: `, `9 [; j3 K+ ~9 |testosterone exposure as mentioned earlier because1 T1 ?# T1 L9 d
the exposure was not for a prolonged period of time.
; z: [3 N# z1 ~: kAlthough the bone age was advanced at the time of
6 o0 u  X8 ^: M4 Odiagnosis, the child had a normal growth velocity at0 g9 j5 i, c6 y, M, J7 u
the follow-up visit. It is hoped that his final adult
3 I& u% M8 U5 _" ?, [height will not be affected.; f* s, ~) |" T. }: Z
Although rarely reported, the widespread avail-4 ~, a1 {6 q, r
ability of androgen products in our society may
* c( [" j* z5 L: Sindeed cause more virilization in male or female5 D; b- ]1 g1 O9 j0 S. y
children than one would realize. Exposure to andro-( Y4 s  f6 S2 O- l! Z
gen products must be considered and specific ques-# j- X9 s& @9 E7 z* i/ {( s
tioning about the use of a testosterone product or
) C: z4 b- }4 t6 u5 j# i% Qgel should be asked of the family members during. ~' c0 _7 O( t# O' j; X# C& U
the evaluation of any children who present with vir-
+ x6 X* Z: {6 cilization or peripheral precocious puberty. The diag-
+ ?2 S1 @8 D* a& ~: _8 N7 gnosis can be established by just a few tests and by3 ]0 ?% P9 w4 G7 q! R
appropriate history. The inability to obtain such a. s9 T9 D8 ^9 h
history, or failure to ask the specific questions, may
3 t( Z! z, L$ m- }$ Z& ^' O5 cresult in extensive, unnecessary, and expensive
* n8 q/ T) s/ G* z+ m1 kinvestigation. The primary care physician should be) l, a- U( a& ~  X* h- j
aware of this fact, because most of these children% s" J4 n5 g* C
may initially present in their practice. The Physicians’
2 Z$ {& o+ z- |4 V$ f5 }8 ZDesk Reference and package insert should also put a' }+ {' |% W* V6 L  C( W  }  Q
warning about the virilizing effect on a male or
) {: _6 _+ N) q9 r/ ~4 ?" Cfemale child who might come in contact with some-
' D5 A4 N% w1 b7 Q  J8 None using any of these products.
0 V8 \* S% W% e3 N& s) e3 o- a3 a8 \References
! c+ `% r1 F, Y& O1. Styne DM. The testes: disorder of sexual differentiation4 I7 _5 J; g+ {7 P
and puberty in the male. In: Sperling MA, ed. Pediatric
' |) v$ e9 N, T3 F3 t' W( UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 S0 l) k$ ~2 S) r( R
2002: 565-628.
! B. _% _7 y" N% g2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 r2 V7 V) Z" P# `/ M3 _# `
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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
  ^5 o: L& |2 ^$ s' w/ z
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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