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Sexual Precocity in a 16-Month-Old
0 L. S4 N7 h' z) v& vBoy Induced by Indirect Topical* @. |  P6 T1 p& i9 A! w9 s
Exposure to Testosterone0 T" u2 T, o( J/ q& e: [1 X# K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, b, P. P* R. C6 \2 s. Q
and Kenneth R. Rettig, MD10 p7 I9 O& Q3 j% @/ L* R, q
Clinical Pediatrics
  W$ g& [* j1 ?8 L8 U4 QVolume 46 Number 6! y; e2 ], b; i% ~% @0 c) H' A
July 2007 540-543
% P0 d; r7 L( C: u9 B© 2007 Sage Publications
5 {& [: F$ ^6 f0 A# C. Y- L8 F10.1177/0009922806296651
# M* _9 X! _. z6 Jhttp://clp.sagepub.com' P) ~7 S" k, B+ K
hosted at& g7 o3 W2 U# V; W0 r7 E5 H1 F
http://online.sagepub.com
% f+ a% C5 d/ N5 B3 T& Z0 N1 tPrecocious puberty in boys, central or peripheral,
3 ^  x4 n, h" }4 `6 C# O& bis a significant concern for physicians. Central
* i! L& s+ _$ ~6 Eprecocious puberty (CPP), which is mediated3 V3 v( w  t- L0 s, Y: f4 I& y1 ~
through the hypothalamic pituitary gonadal axis, has4 B! g  Q9 g& c( R  ^: G
a higher incidence of organic central nervous system
  T) {3 ]3 E1 @. \lesions in boys.1,2 Virilization in boys, as manifested
1 F% k: c( n, F2 u9 A% {/ Yby enlargement of the penis, development of pubic% r" M7 y& u% V
hair, and facial acne without enlargement of testi-
2 ?$ b/ G" P- z/ ^3 Vcles, suggests peripheral or pseudopuberty.1-3 We3 f* ?  d; W  g( L0 Y
report a 16-month-old boy who presented with the. T3 H8 ~/ N% A% p' R* a
enlargement of the phallus and pubic hair develop-4 r9 a8 P9 s& h! y* G
ment without testicular enlargement, which was due3 w( j  x; F. e+ l
to the unintentional exposure to androgen gel used by
! e  `+ T$ m+ F: v6 U  E4 @the father. The family initially concealed this infor-" b, S* g( P2 ]
mation, resulting in an extensive work-up for this  }* y3 n% f+ c, \% _/ i; _
child. Given the widespread and easy availability of
- }! o# V  i% A7 ~, y  ]9 ctestosterone gel and cream, we believe this is proba-
% |5 g6 q, Z5 ^* _, Hbly more common than the rare case report in the/ @5 c% K  x: }0 y* Y2 W# g
literature.4" g  a& X/ x5 c$ n7 v% `
Patient Report2 `# J! R1 g' W  |$ O$ g
A 16-month-old white child was referred to the6 q# B7 i9 X! N$ K  a/ J6 r
endocrine clinic by his pediatrician with the concern0 V, m7 v3 g  G6 O
of early sexual development. His mother noticed. Z3 _+ y" y$ q+ o# m9 t
light colored pubic hair development when he was" }2 `+ e! h/ D! l5 \) P0 F
From the 1Division of Pediatric Endocrinology, 2University of
( m7 u8 O( u5 _, U- ?South Alabama Medical Center, Mobile, Alabama.
9 a* `1 B/ q8 @7 W9 `1 L0 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 C1 @: y1 h3 c0 y* R* NProfessor of Pediatrics, University of South Alabama, College of
9 J+ P8 m+ m1 R5 d- LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ F7 F5 ]% H  B5 o/ }8 I1 ?* \e-mail: [email protected].0 i- p: f5 ?, k
about 6 to 7 months old, which progressively became
) ?: B; p" ], i$ {darker. She was also concerned about the enlarge-
+ N! }; r/ z+ N9 Xment of his penis and frequent erections. The child' }  B' x; e* O
was the product of a full-term normal delivery, with  y3 T8 r- \4 P2 ^, G# v' m
a birth weight of 7 lb 14 oz, and birth length of
2 z+ o9 _  n* Y1 V, ?: o: J20 inches. He was breast-fed throughout the first year
: g  p9 }# N9 t  N3 `of life and was still receiving breast milk along with
& x' L0 P! i4 a! y& @solid food. He had no hospitalizations or surgery,/ E0 \# z, Q. m  e3 k8 W5 I, a2 D
and his psychosocial and psychomotor development, P# ?# q4 o% [
was age appropriate.
+ I& [4 a$ P, v* S5 ~* B7 TThe family history was remarkable for the father,
6 R/ f) f  D: A8 l3 lwho was diagnosed with hypothyroidism at age 16,
- e( S, ]% w+ b3 Ewhich was treated with thyroxine. The father’s
4 z, J! M) f+ k( Q6 M$ q% A* y$ pheight was 6 feet, and he went through a somewhat5 j& h! D' I+ ^3 j% u" Z
early puberty and had stopped growing by age 14.
( L7 {5 i$ p/ ~" ?1 H7 `, HThe father denied taking any other medication. The% H' H* M4 M5 h. N
child’s mother was in good health. Her menarche0 O+ |8 s! F+ H- S3 x3 a
was at 11 years of age, and her height was at 5 feet
2 {: @# M3 m5 {& y( ]* Q, w5 inches. There was no other family history of pre-7 M2 o, t0 H0 B2 i: M+ [
cocious sexual development in the first-degree rela-
1 t* m% D+ t3 j% Utives. There were no siblings.2 v& x: w: ~" u) u% B
Physical Examination
* {9 Z3 _# A  q9 ~6 F/ i7 gThe physical examination revealed a very active,
7 Y- ^' i: g3 Q0 p# Dplayful, and healthy boy. The vital signs documented& X* i/ z! w4 J0 X4 z
a blood pressure of 85/50 mm Hg, his length was
2 m; |# j! W- Y  c90 cm (>97th percentile), and his weight was 14.4 kg8 Y/ Z5 k& r1 s5 C8 {) n- _. D5 W' O
(also >97th percentile). The observed yearly growth
) j, W3 s9 _- S2 Lvelocity was 30 cm (12 inches). The examination of+ N' d. q  z8 A
the neck revealed no thyroid enlargement.
9 U6 \' `: H7 S1 e- KThe genitourinary examination was remarkable for
2 M5 P/ R  j3 N+ `  R9 B  Wenlargement of the penis, with a stretched length of* W& E1 Z! C2 p& k& E3 b3 n
8 cm and a width of 2 cm. The glans penis was very well+ N3 o. P2 ^' T
developed. The pubic hair was Tanner II, mostly around% v% T. E6 f3 \
540
5 ?+ A& ^2 E+ U: ~" t  @* yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 b. w; @1 k8 _+ M; [9 }4 [the base of the phallus and was dark and curled. The
* V" j" m- I8 u3 e- E6 _4 Ttesticular volume was prepubertal at 2 mL each.
4 D. |/ |; W  `! Q! O- MThe skin was moist and smooth and somewhat! S) u2 o8 C  e5 S
oily. No axillary hair was noted. There were no' X; N+ p# G: {0 N: j
abnormal skin pigmentations or café-au-lait spots.+ w0 Y, W9 G3 H) u% h1 H# f& N
Neurologic evaluation showed deep tendon reflex 2+7 l6 \, u- O3 }3 }
bilateral and symmetrical. There was no suggestion
) X4 v/ Q. b9 T5 ]6 h+ x% j- t8 Xof papilledema.
3 }- u# G  w/ j+ lLaboratory Evaluation
: V: o6 m  R! i3 [; A  \$ DThe bone age was consistent with 28 months by# G" a: l1 e" O! W" a
using the standard of Greulich and Pyle at a chrono-
) \- g" R) A' Z' s- Mlogic age of 16 months (advanced).5 Chromosomal
3 b3 o( K: f+ }7 s: X6 u  Gkaryotype was 46XY. The thyroid function test
# v4 Z# I" W3 M# ^5 Z( Vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
# [  R2 C6 W" y$ V9 `lating hormone level was 1.3 µIU/mL (both normal).
$ _# N3 ?6 h! K) r5 Y6 k' IThe concentrations of serum electrolytes, blood
! u; _3 U1 I& S  l# \: q/ F1 k( Yurea nitrogen, creatinine, and calcium all were# f; K: k7 b$ a
within normal range for his age. The concentration2 i1 K, `% [, m4 P4 q5 X3 j, q
of serum 17-hydroxyprogesterone was 16 ng/dL9 _2 ~- m7 A, ?+ }5 J
(normal, 3 to 90 ng/dL), androstenedione was 204 l) g7 k& x+ M" [+ }% l
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 J) W* e3 S, |# S. `. U/ _" Uterone was 38 ng/dL (normal, 50 to 760 ng/dL),  R3 e, @, [2 d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to; U6 I. v6 H4 h
49ng/dL), 11-desoxycortisol (specific compound S)
' m% c$ r" L, q- r* L$ Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
* C" d: p8 h! T, ]  Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 y: O, T; A! J# I! Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 X: K: H" y' n- }6 F
and β-human chorionic gonadotropin was less than; ~% m! I5 {$ `; m
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 f0 T$ V3 N" qstimulating hormone and leuteinizing hormone! N' J# W; |; Y4 U6 h# R
concentrations were less than 0.05 mIU/mL
8 M3 U1 j) q8 M1 R; H8 k(prepubertal).8 c0 G* W; U8 Q# b* T! [
The parents were notified about the laboratory+ f4 s! K& B- \5 W  k3 X3 G0 y# B7 L
results and were informed that all of the tests were
+ J, m2 M3 L5 [4 knormal except the testosterone level was high. The
- ^; l9 ]3 y6 u: i" qfollow-up visit was arranged within a few weeks to
$ N$ I5 y  Y! K$ uobtain testicular and abdominal sonograms; how-9 b  U+ `& L1 y; b  e+ z
ever, the family did not return for 4 months.+ w# G7 Q0 w6 O- K5 f8 \% s
Physical examination at this time revealed that the8 j# j' g# x* |- L7 B
child had grown 2.5 cm in 4 months and had gained
# k2 y! |/ U8 \  F: p/ w7 I6 [2 kg of weight. Physical examination remained. _& `4 I, M$ h- t: Z/ x- }
unchanged. Surprisingly, the pubic hair almost com-2 j% v& ]; T3 b
pletely disappeared except for a few vellous hairs at
5 x2 O3 |  M1 [% C& `1 f& x# M5 {the base of the phallus. Testicular volume was still 2
1 [' ^; N+ ?' ?2 t7 w% ]% GmL, and the size of the penis remained unchanged.3 s# E8 G( h, Y
The mother also said that the boy was no longer hav-
4 H. ^# S* O" I+ T8 ning frequent erections.
. F' X" C8 t7 I5 s/ C" d- F! d5 VBoth parents were again questioned about use of" x7 y3 \3 Y5 w, _3 J8 s
any ointment/creams that they may have applied to$ a- }* |0 U% c, x2 r
the child’s skin. This time the father admitted the- S  ?6 q/ x0 k7 t
Topical Testosterone Exposure / Bhowmick et al 5419 x2 w2 [  U; r0 \; n4 q: J
use of testosterone gel twice daily that he was apply-" r+ _5 y; l; ]5 W( R) n6 D
ing over his own shoulders, chest, and back area for# ^6 R, D) f1 U) s( r$ C
a year. The father also revealed he was embarrassed
: I5 r- O6 Q' [0 Kto disclose that he was using a testosterone gel pre-, V" |8 f: h9 v% k$ Y7 W
scribed by his family physician for decreased libido
7 d) h, ?9 y, I  M. h5 F0 esecondary to depression.
3 k' _4 V1 P0 JThe child slept in the same bed with parents.
4 @# S" y5 D, }  M" g0 W* QThe father would hug the baby and hold him on his7 ^' B0 h8 `  i3 l
chest for a considerable period of time, causing sig-
( S9 I4 y' L, Lnificant bare skin contact between baby and father.
. _$ P% d0 n0 c$ bThe father also admitted that after the phone call,
( ]( j: V: {2 {2 A8 w3 T1 v+ d9 `when he learned the testosterone level in the baby
8 e- W$ ?- {, z& ?) W/ c5 {1 {was high, he then read the product information
, r' g9 c+ a9 F# C4 p2 Z( b' R# apacket and concluded that it was most likely the rea-
3 W4 F! {5 B- \6 T$ R' Y; r3 tson for the child’s virilization. At that time, they
1 N0 ?) `2 V- M% l' n* u0 P- m0 `decided to put the baby in a separate bed, and the+ D  B5 j* t( w$ G
father was not hugging him with bare skin and had
0 `9 b7 O0 Y- w2 {  }been using protective clothing. A repeat testosterone0 R* R" ]+ s. }0 m+ ]
test was ordered, but the family did not go to the6 O2 _. R" `! e' S' b
laboratory to obtain the test.
; ~; h/ U0 @: }0 B# l  ~Discussion9 w: v) V) x, I3 F  I% f6 O! @
Precocious puberty in boys is defined as secondary
, d# _) {# {; B/ ?sexual development before 9 years of age.1,4& `. b4 y: S9 M8 r: X( x  P8 @
Precocious puberty is termed as central (true) when" v  N# F' x. f
it is caused by the premature activation of hypo-
" j8 m4 y1 S2 w% G2 C& z+ Pthalamic pituitary gonadal axis. CPP is more com-2 P7 n: ?0 _  q1 m0 @2 ?) }
mon in girls than in boys.1,3 Most boys with CPP, G7 E' M4 A$ D6 k, n  X
may have a central nervous system lesion that is; b1 G+ y. H4 U) X* B
responsible for the early activation of the hypothal-/ |+ e. s' {$ S/ q( ?0 k
amic pituitary gonadal axis.1-3 Thus, greater empha-1 H9 y6 X1 V/ \! @' G( |1 R7 @* f
sis has been given to neuroradiologic imaging in
7 k$ J! d' N0 e' Vboys with precocious puberty. In addition to viril-
! W4 D# C" q/ Q; Q: k) n# }8 I8 Q" Rization, the clinical hallmark of CPP is the symmet-
+ D$ `8 ?* E4 Y1 trical testicular growth secondary to stimulation by! r! {9 @5 x+ Z: q& G3 a  e$ o3 f, a
gonadotropins.1,3
7 |/ h1 z) L) cGonadotropin-independent peripheral preco-/ `& I& o; l  a7 J5 x
cious puberty in boys also results from inappropriate# m" n; Z( |) Q/ s1 K+ }% K3 |+ c
androgenic stimulation from either endogenous or
* l& O7 @+ L! c/ s8 G3 \0 Dexogenous sources, nonpituitary gonadotropin stim-
/ y8 o) h5 f4 X7 J; Qulation, and rare activating mutations.3 Virilizing! O; e1 ?/ d: u5 X; g, {) k) {
congenital adrenal hyperplasia producing excessive) m5 r. x0 S/ g* L
adrenal androgens is a common cause of precocious
5 E! p, y2 e8 c* `0 Opuberty in boys.3,4
9 Y+ M" j& N  oThe most common form of congenital adrenal
: ]' @& H/ _# X3 {hyperplasia is the 21-hydroxylase enzyme deficiency.
3 k$ [4 _4 U1 @' G3 C; cThe 11-β hydroxylase deficiency may also result in
4 c: e( [- \* H2 ^) {; r5 x' b# ~excessive adrenal androgen production, and rarely,2 m8 S( h/ |: l( a
an adrenal tumor may also cause adrenal androgen
) N# Q7 z7 y& cexcess.1,3
8 @, D! c& f5 ]+ K9 F; f6 k+ pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ q0 M! S7 Q, R6 q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 ?3 R+ {- f( m' g7 V4 {- J% nA unique entity of male-limited gonadotropin-
+ |5 @  u! t! l" _! [3 y( uindependent precocious puberty, which is also known
- [: D. A: L# W0 R4 Sas testotoxicosis, may cause precocious puberty at a6 p' J& k/ I. @& Z- W  V& Q; D
very young age. The physical findings in these boys7 B/ Q' Y8 G( p, D
with this disorder are full pubertal development,
9 I, x. P5 s) Dincluding bilateral testicular growth, similar to boys
3 u: Q0 j" o% B" }) z+ p6 xwith CPP. The gonadotropin levels in this disorder
6 ?; C+ M' b4 t4 care suppressed to prepubertal levels and do not show
4 F1 X+ f1 d) x3 {: D0 Wpubertal response of gonadotropin after gonadotropin-3 U* w! F, h' U/ X
releasing hormone stimulation. This is a sex-linked# ?1 p! |: ~4 S6 W5 w
autosomal dominant disorder that affects only
% R1 f" z$ R& `- ^" f! }males; therefore, other male members of the family( W$ d" @! T0 M" i% q, [/ `: p+ e
may have similar precocious puberty.3
2 U$ z+ T" ?" EIn our patient, physical examination was incon-
2 M/ E5 o* X, \) q; H/ Ssistent with true precocious puberty since his testi-
2 U9 H8 F7 [; j5 Q4 {0 D! j/ Qcles were prepubertal in size. However, testotoxicosis
9 `: p2 ?7 V4 M. W" Fwas in the differential diagnosis because his father4 m( Z7 ^* t7 m4 M; s
started puberty somewhat early, and occasionally,. ^3 z( Z, Z! k6 G8 Z# F
testicular enlargement is not that evident in the9 e7 a3 }7 H; S8 W5 I3 @9 d. {
beginning of this process.1 In the absence of a neg-3 b6 `. p. y3 h3 F$ V" U" A7 d# v7 g
ative initial history of androgen exposure, our, J0 z$ X0 u$ Z( ^# G1 _" x
biggest concern was virilizing adrenal hyperplasia,$ y0 _  j! J/ E
either 21-hydroxylase deficiency or 11-β hydroxylase
1 a7 X( C# x9 ~) [2 D: |deficiency. Those diagnoses were excluded by find-8 c* D- ]  D5 O" g3 _
ing the normal level of adrenal steroids.. C3 M6 |9 A2 F0 b
The diagnosis of exogenous androgens was strongly( `2 N8 d& r% D! U- E
suspected in a follow-up visit after 4 months because" n1 S/ C, v- E9 I* P& O7 M
the physical examination revealed the complete disap-2 ~4 q$ c  y6 G! m- ~
pearance of pubic hair, normal growth velocity, and
% l' [/ Y' {* n: Ndecreased erections. The father admitted using a testos-
6 B% v* H; h4 g% s. D- Uterone gel, which he concealed at first visit. He was
1 `3 U5 J  O8 H* _% Cusing it rather frequently, twice a day. The Physicians’( J  D" h% V. j0 D1 `4 m- p
Desk Reference, or package insert of this product, gel or
  @+ ]3 V4 G9 [/ |! y( O8 Acream, cautions about dermal testosterone transfer to* K% h% _. T2 n. C, o, i
unprotected females through direct skin exposure.
. E! o! W1 e: X( zSerum testosterone level was found to be 2 times the
$ z9 U6 Z; q* S. m+ E; [2 Sbaseline value in those females who were exposed to0 C+ }1 A$ x& Y3 m9 A+ w0 h2 l
even 15 minutes of direct skin contact with their male
( k1 s4 j; z5 b: \) b. Bpartners.6 However, when a shirt covered the applica-
8 L, X& s0 g5 Otion site, this testosterone transfer was prevented.
( [) V3 h8 y, i9 e$ ~: l% V6 X$ I! UOur patient’s testosterone level was 60 ng/mL,( z+ L% D) E& A1 \" W
which was clearly high. Some studies suggest that1 Z2 p* z- q" z1 R8 T+ a
dermal conversion of testosterone to dihydrotestos-* y3 H; H2 o5 j: I; Z* ]
terone, which is a more potent metabolite, is more
0 X: T& f9 s" N# jactive in young children exposed to testosterone
, ]$ S3 @: m( t. `exogenously7; however, we did not measure a dihy-3 x, X- N  i. r8 [
drotestosterone level in our patient. In addition to
6 V# v* i5 o* K" k; N( Hvirilization, exposure to exogenous testosterone in
9 W* |% t5 ]4 P# {3 a1 V: [children results in an increase in growth velocity and
, m5 f2 B/ y& V; ]3 F: u+ }advanced bone age, as seen in our patient.
/ E7 L5 V- e. ?# u& u( n1 T  f2 PThe long-term effect of androgen exposure during
- H  A. m" ^; I( h6 V( J" Nearly childhood on pubertal development and final
8 D) S" K6 X- U% O5 Nadult height are not fully known and always remain
0 d1 _' C$ O1 B( G; g$ Ja concern. Children treated with short-term testos-
+ j+ D2 {  t6 Jterone injection or topical androgen may exhibit some
5 A' r* X9 @4 ~5 ]9 g* x; a* n% oacceleration of the skeletal maturation; however, after
; f/ ]: |  A# K9 e. c" K5 W2 V, lcessation of treatment, the rate of bone maturation
6 K" G! }4 n# O# Bdecelerates and gradually returns to normal.8,9! M: s5 b& L" W) Q8 v, f
There are conflicting reports and controversy1 v) c7 V3 g' l2 `9 u
over the effect of early androgen exposure on adult
) D" a0 k; d6 x- h+ upenile length.10,11 Some reports suggest subnormal" O1 x; m- k% [3 ]
adult penile length, apparently because of downreg-: n. Y( _9 g! \2 p8 l& y
ulation of androgen receptor number.10,12 However,
6 _$ Q) s. X0 ~+ C" X3 B/ uSutherland et al13 did not find a correlation between
  {2 V+ m2 M6 g1 T1 A( }* Q# R  H6 Zchildhood testosterone exposure and reduced adult8 ~+ q: L' B' z
penile length in clinical studies.
4 h% ?& G% u& V+ QNonetheless, we do not believe our patient is2 k) i# m5 l  \6 e% I0 o
going to experience any of the untoward effects from
! F8 c  s: Z/ k/ h' Z5 Mtestosterone exposure as mentioned earlier because
1 C9 C" D+ a. ]the exposure was not for a prolonged period of time.
6 e& G4 K, w* Q' h9 X3 C7 ~Although the bone age was advanced at the time of
& {0 Q0 ?3 n6 z% Cdiagnosis, the child had a normal growth velocity at
# A. G7 P8 x9 N4 b* R" @9 j) Bthe follow-up visit. It is hoped that his final adult( N) u% u8 J8 F2 Z
height will not be affected.
5 C' S  n  Y. `" |Although rarely reported, the widespread avail-9 M6 N4 Q! ~9 i5 S0 Y: B, d/ Q
ability of androgen products in our society may# |4 {+ u  i. [; o7 X$ a
indeed cause more virilization in male or female
: A7 `9 ^1 J$ I1 v1 uchildren than one would realize. Exposure to andro-
5 h5 S- D9 j+ ]. v$ bgen products must be considered and specific ques-% F8 k1 R% \7 x% K& {  ~! t
tioning about the use of a testosterone product or
& t: c. |+ D; O& c& dgel should be asked of the family members during
- o/ }: W% l* R4 e7 Q7 {the evaluation of any children who present with vir-( T& I7 r# E* s; E4 @: M
ilization or peripheral precocious puberty. The diag-
, d# c9 T1 `) J( znosis can be established by just a few tests and by* V& D$ E+ ]2 w% {2 e7 H( U! O2 k
appropriate history. The inability to obtain such a
" Y+ v) P0 X# `& Thistory, or failure to ask the specific questions, may
" H9 n1 R) s/ Q6 O- n$ Gresult in extensive, unnecessary, and expensive
4 \! X, `/ a% Q8 |7 Yinvestigation. The primary care physician should be
+ [) Z1 H* ?1 U. u9 zaware of this fact, because most of these children
8 j8 p; V1 |8 U3 Cmay initially present in their practice. The Physicians’
' D* k* |7 s$ I' a" r* h& ~Desk Reference and package insert should also put a: z# ~3 a) S2 c. [: M
warning about the virilizing effect on a male or
2 m0 s( Z, q' D' e' Q/ H6 ?( Cfemale child who might come in contact with some-
( `/ U9 k: v8 F( @one using any of these products.; z$ V& j4 W3 w* }* E- I
References
) w. j' Z9 }5 X* j3 F1. Styne DM. The testes: disorder of sexual differentiation* h  J6 R& t0 M/ f$ A* a
and puberty in the male. In: Sperling MA, ed. Pediatric0 w% `; }  q- n9 |6 A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;9 T5 v* A4 M) F/ @* B0 V- p
2002: 565-628.
1 p+ Q& S$ q8 b3 }' o3 ?1 D2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ m0 D+ C, A8 S' b7 V9 N9 o9 v
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
; h( Z1 G! {  E! S8 VBoy Induced by Indirect Topical) }$ y/ o8 @- e- G
Exposure to Testosterone
3 {8 ?0 e2 ?7 O; Y, y1 xSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, }, W6 A" s* }9 z) Z4 b
and Kenneth R. Rettig, MD1
1 b) M9 `1 t- m$ LClinical Pediatrics9 E6 K9 O! v# p6 e5 @0 t9 o
Volume 46 Number 6
; u' J4 R# d1 q# @% @% A; `' _1 oJuly 2007 540-543% j+ g- Z1 ?# a( S
© 2007 Sage Publications
3 o  @) J* ?- i7 C10.1177/00099228062966514 v5 W1 c* J$ t  k5 I
http://clp.sagepub.com
0 y& t; w( w. C. H+ N7 }hosted at5 V2 y0 H1 ]& N3 Y( j, M
http://online.sagepub.com
3 w8 f( D8 c2 [( jPrecocious puberty in boys, central or peripheral,
" P4 N* n3 V3 E# y/ Ris a significant concern for physicians. Central
. p. d- B9 d+ O( Q8 a. y1 Rprecocious puberty (CPP), which is mediated! ~0 m2 ^( e+ N' o7 @
through the hypothalamic pituitary gonadal axis, has
3 U, W' {& ]* f9 E2 m6 L& Ba higher incidence of organic central nervous system& ^7 N7 X$ E% e+ y$ W' p
lesions in boys.1,2 Virilization in boys, as manifested
: x/ B- H! x4 i. Z) C0 c- |by enlargement of the penis, development of pubic6 z* d1 k7 e* a& P. [  o# S1 T
hair, and facial acne without enlargement of testi-  J8 `: n! T2 r
cles, suggests peripheral or pseudopuberty.1-3 We$ S: [: X7 _$ t: A1 u
report a 16-month-old boy who presented with the
# o( L: L) _2 d/ cenlargement of the phallus and pubic hair develop-' u; Z( ^" w# W+ P* v/ O( A
ment without testicular enlargement, which was due
+ l+ x6 z' M1 Y0 t; G' y1 sto the unintentional exposure to androgen gel used by
7 q* \( u2 Q: @' |the father. The family initially concealed this infor-
* H9 d5 f- X: u. }mation, resulting in an extensive work-up for this+ @+ _0 T" o; j4 S4 K2 K8 ^
child. Given the widespread and easy availability of
9 j9 g* b+ ]) W8 S, x9 X! F6 Wtestosterone gel and cream, we believe this is proba-: l2 f& d+ v! c
bly more common than the rare case report in the
4 Y6 p9 Q+ W3 g. s3 h. bliterature.4
& @+ @: t' a3 ]& v7 LPatient Report
$ C6 n3 n7 v& _( b9 CA 16-month-old white child was referred to the
" I) p" l3 Y; `) c/ ~( lendocrine clinic by his pediatrician with the concern
, }+ ]9 R/ {3 q1 I9 h; f3 uof early sexual development. His mother noticed: g/ e/ `% C3 L6 |
light colored pubic hair development when he was# u$ R* K6 ^" A8 d7 {; j
From the 1Division of Pediatric Endocrinology, 2University of/ `4 x5 t6 v% p4 _7 |
South Alabama Medical Center, Mobile, Alabama.
' d  Y  \* |# ^$ Y5 c% e2 X8 ]. ^Address correspondence to: Samar K. Bhowmick, MD, FACE,$ J( r. O) c$ c" b# e# q
Professor of Pediatrics, University of South Alabama, College of
" a- B8 M! ?2 S1 d5 @/ n2 fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* s8 m# n6 Z5 k" {
e-mail: [email protected].
9 i) Z1 T- m( H( Babout 6 to 7 months old, which progressively became
8 }0 s  I$ d2 `2 X" U/ Z0 H+ {  |darker. She was also concerned about the enlarge-2 D+ ?2 ]. n; z% p& K2 G, M6 S
ment of his penis and frequent erections. The child/ r4 y9 W. {3 x& F, {
was the product of a full-term normal delivery, with: E( T/ c' B2 X" _& v# @% G
a birth weight of 7 lb 14 oz, and birth length of1 v' u5 B4 y6 P
20 inches. He was breast-fed throughout the first year- R( H& R! S8 [% V) V" ]
of life and was still receiving breast milk along with; g3 y# H7 T: C7 S2 N. \
solid food. He had no hospitalizations or surgery,
2 A! c9 F' {2 F1 v! Y! j% f% [5 D& Qand his psychosocial and psychomotor development
$ w3 w6 m2 l* d' v9 pwas age appropriate.* Q6 n& r2 D$ t- Q9 i8 T
The family history was remarkable for the father,
4 a# }/ m: f5 O( _) Cwho was diagnosed with hypothyroidism at age 16,0 X0 P. e3 ]' U& F+ h( a# K7 l2 K2 F" v
which was treated with thyroxine. The father’s, K" {2 z/ {, z- N" m! X$ @) g/ r
height was 6 feet, and he went through a somewhat0 e% n: u' F2 `
early puberty and had stopped growing by age 14.
5 M' J. ^! s: e' {$ F  M/ PThe father denied taking any other medication. The
- d, m3 T1 Y2 L2 \9 j* \. dchild’s mother was in good health. Her menarche- G8 K7 ]6 u; {8 J* [0 t, {6 Z+ N/ h
was at 11 years of age, and her height was at 5 feet5 l9 |- U  N+ H. K! G
5 inches. There was no other family history of pre-1 p9 t+ C$ t! w( U! J) j( J# j
cocious sexual development in the first-degree rela-/ ]9 s! M8 W/ N$ q
tives. There were no siblings.
: l/ Z" P! K9 z; \: p! q( k, KPhysical Examination2 ?  o" s# d6 L9 s1 D7 t
The physical examination revealed a very active,
! r4 R& T3 v& zplayful, and healthy boy. The vital signs documented
: Z* S! Q$ G& G7 W( y5 A* Na blood pressure of 85/50 mm Hg, his length was
* C2 T* K8 n2 F. H* X& u: q# A; t90 cm (>97th percentile), and his weight was 14.4 kg
5 T! |( [9 x4 {7 V7 x(also >97th percentile). The observed yearly growth* F& _* y& E, q7 ~/ t
velocity was 30 cm (12 inches). The examination of) H& ^. m* W; N) Q$ U
the neck revealed no thyroid enlargement.  x9 D4 q% M! q! q
The genitourinary examination was remarkable for
% v7 I+ x; h6 w3 t  Renlargement of the penis, with a stretched length of7 F  M+ s5 q2 M; E+ N4 n
8 cm and a width of 2 cm. The glans penis was very well
0 B! _3 r) U  N% D: c8 C+ L1 L5 p$ t# edeveloped. The pubic hair was Tanner II, mostly around
% u" I" P( P" q* k540
' `7 p2 s4 P, z( Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ x3 O! m, P6 M9 A4 W) R
the base of the phallus and was dark and curled. The
! O# m0 x* `. X6 D% Wtesticular volume was prepubertal at 2 mL each.+ M# P  P# g; x3 h. ]
The skin was moist and smooth and somewhat
( J: \- L; E) Y  Y; t7 i1 Aoily. No axillary hair was noted. There were no
: ~$ C7 [8 _- z8 R5 {9 t& Vabnormal skin pigmentations or café-au-lait spots.
) {1 J4 {& m1 MNeurologic evaluation showed deep tendon reflex 2+
& `  ], y8 g& ]- Jbilateral and symmetrical. There was no suggestion$ f" g/ J! k$ D5 h* D1 }  V* X# b
of papilledema.
2 P  }% w- A" GLaboratory Evaluation) v3 {, N  h. c9 Y8 A
The bone age was consistent with 28 months by
6 ~! |% M8 ?' d; I4 Fusing the standard of Greulich and Pyle at a chrono-. W" c/ u. V% ]( c; J0 K5 Q
logic age of 16 months (advanced).5 Chromosomal  ?4 W3 j. |1 Z# Y$ ^0 D
karyotype was 46XY. The thyroid function test
9 |" P) n: D8 |: M0 Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
* Z- w" ]8 l& e0 \* Zlating hormone level was 1.3 µIU/mL (both normal).1 V: {7 r8 S7 X
The concentrations of serum electrolytes, blood
5 L* F2 e6 f8 E/ U5 Q6 Wurea nitrogen, creatinine, and calcium all were
1 @9 O7 j) E6 D- o  Dwithin normal range for his age. The concentration( u2 f9 V& I8 N
of serum 17-hydroxyprogesterone was 16 ng/dL
% ~  Z& x* `3 O4 d& J(normal, 3 to 90 ng/dL), androstenedione was 20
2 Z2 E/ x/ P+ {- [ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 ?8 x  z+ p7 L0 F
terone was 38 ng/dL (normal, 50 to 760 ng/dL),+ V: E, H$ A/ H5 r3 o  @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to% |. Q7 R& ?; s* Q  y
49ng/dL), 11-desoxycortisol (specific compound S)( s/ q- S1 y# ]: m) ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 h, H( K5 S. v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; y( r( T! P1 n; z6 s( b0 o7 Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# Z( g( B2 x  I, d6 J% j, oand β-human chorionic gonadotropin was less than5 ?, e  ]% E. i$ |) B, t# C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  k' T% s7 i: C& V9 ^stimulating hormone and leuteinizing hormone5 `! Y+ Z" Z  `  Z1 E" x1 @
concentrations were less than 0.05 mIU/mL
6 P, q/ P  I8 y" H(prepubertal).
# e9 ?/ k! K/ q$ o3 o+ R, R, qThe parents were notified about the laboratory4 m+ L: c; Q# f: `* d, X9 a( V
results and were informed that all of the tests were
+ N. v( o2 E1 m1 ~& qnormal except the testosterone level was high. The7 o/ d! \2 Q! z" x2 B7 J/ G
follow-up visit was arranged within a few weeks to
: E1 w# {$ X! Vobtain testicular and abdominal sonograms; how-. ]+ k$ _# u- v2 ]
ever, the family did not return for 4 months.
* \+ F, y3 P; _3 E  s8 z* uPhysical examination at this time revealed that the8 _1 W( a7 i+ K3 y# R
child had grown 2.5 cm in 4 months and had gained6 Q8 F, d( g$ A: J3 r6 @0 D- ?( [8 w, x2 E
2 kg of weight. Physical examination remained
, ]+ g: N7 g- G1 B+ z7 s  _unchanged. Surprisingly, the pubic hair almost com-
6 Y2 \- a. i+ o" Xpletely disappeared except for a few vellous hairs at
# K& D7 }7 k$ K" _3 b1 R# Y9 {the base of the phallus. Testicular volume was still 2
5 t% H: @! [% C& J% _8 i/ a* SmL, and the size of the penis remained unchanged.+ z+ {# Q! m: ]- {: @
The mother also said that the boy was no longer hav-
6 G; ^( V- v; O* _( T+ a+ H% b3 ping frequent erections.
3 b8 _( a( i* G0 n# tBoth parents were again questioned about use of' E4 c) ~. @( }$ U
any ointment/creams that they may have applied to
( `0 Y( |* j0 e, a- l5 |' Z1 _the child’s skin. This time the father admitted the
! r0 E7 Q2 [: @Topical Testosterone Exposure / Bhowmick et al 5411 i$ j8 F2 ~$ z4 V; Y
use of testosterone gel twice daily that he was apply-
- t6 B& u6 H6 H4 {1 E; Uing over his own shoulders, chest, and back area for
8 v0 }, ~7 y' A8 W. z# sa year. The father also revealed he was embarrassed5 ?; p  ~3 _  u
to disclose that he was using a testosterone gel pre-
3 O1 J' C: U3 Y$ h! M) U( `' n' escribed by his family physician for decreased libido
- W1 }" D. i/ T! ^1 c) q$ Csecondary to depression.2 v% r  N" p5 r
The child slept in the same bed with parents.6 n0 _* z- v& }; p5 H8 B+ g+ G
The father would hug the baby and hold him on his. g: I% W8 H* v0 Z7 L' v5 a5 U
chest for a considerable period of time, causing sig-
) c. x7 x6 P, ~7 xnificant bare skin contact between baby and father.) X- t9 h8 D( a* F" ?( @- l$ O
The father also admitted that after the phone call,
1 j' R3 o8 t# u5 n1 \' L+ W) Ewhen he learned the testosterone level in the baby
9 b% N' X) [" P. i% iwas high, he then read the product information
! S* l5 O7 p1 q! q8 a6 xpacket and concluded that it was most likely the rea-
/ {" u1 o0 C) F. V! D; Json for the child’s virilization. At that time, they/ l2 K7 W( e, Q( n4 R( q
decided to put the baby in a separate bed, and the2 Z6 H4 U. r1 ~% a  Z
father was not hugging him with bare skin and had! {& Y& R/ L$ z6 l7 Y3 t$ E2 ]
been using protective clothing. A repeat testosterone
4 e: g& e0 k! v' d0 J  \; Y* Ztest was ordered, but the family did not go to the
' S# v9 N. ^. D% l3 R& s7 k# rlaboratory to obtain the test.) ^6 y( h) X. b0 Q
Discussion2 d% I1 ?+ I) _- K
Precocious puberty in boys is defined as secondary$ G* q7 Q! M; _
sexual development before 9 years of age.1,4
4 k3 c; [0 Z' c2 J& ]' \Precocious puberty is termed as central (true) when
; x# w. \' v* a- ?6 c0 ^* ?. }it is caused by the premature activation of hypo-
, A8 L6 _5 q' |4 ~thalamic pituitary gonadal axis. CPP is more com-; _0 _- _: ?: F# A9 J* u( J
mon in girls than in boys.1,3 Most boys with CPP- T. D  n3 z( I
may have a central nervous system lesion that is: P0 ~$ }2 p, p( `7 p0 e
responsible for the early activation of the hypothal-
+ C3 x3 \; _: G9 \. Xamic pituitary gonadal axis.1-3 Thus, greater empha-$ [2 ]4 X. B# [$ J. ~3 q3 G
sis has been given to neuroradiologic imaging in
; y! j% N6 t- u; }) p5 Nboys with precocious puberty. In addition to viril-
) J2 h: B: E  r. y; Bization, the clinical hallmark of CPP is the symmet-
5 n0 ?- M" l, k  v7 `+ rrical testicular growth secondary to stimulation by
5 D' S; B6 s  h6 Lgonadotropins.1,3
6 x7 h3 v) Z& q2 |$ [' z) j/ G+ HGonadotropin-independent peripheral preco-
/ L- M* v1 d: x! S; e1 hcious puberty in boys also results from inappropriate
5 m$ ?1 G4 ~* X4 K. s8 xandrogenic stimulation from either endogenous or
1 n- _5 Y" Q# Gexogenous sources, nonpituitary gonadotropin stim-
3 V7 R7 }, J4 q8 `# Wulation, and rare activating mutations.3 Virilizing
9 X+ |, M( h# _. M5 Y, pcongenital adrenal hyperplasia producing excessive0 O% g& n2 @4 N* [
adrenal androgens is a common cause of precocious' b1 A5 Z/ e4 g' r
puberty in boys.3,4
* N2 \& y" a) m/ J+ XThe most common form of congenital adrenal( m5 p3 Y  G' U- x6 z+ Z
hyperplasia is the 21-hydroxylase enzyme deficiency.. h5 ?0 O, P0 Z2 I7 e! K" ]. H$ K* z( T
The 11-β hydroxylase deficiency may also result in
/ Y! ]# e' m% |+ R" Yexcessive adrenal androgen production, and rarely,
. A1 H# x' Q& k" {) G3 Gan adrenal tumor may also cause adrenal androgen
# N; _9 |, {: X. `) m! k5 ~* sexcess.1,3
4 }" R7 P5 @; ?5 E7 z7 m5 ^; Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) E$ B) m* |/ T( ]8 S. E7 V0 V
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 E, {/ d6 z. t4 ?: @; e' m
A unique entity of male-limited gonadotropin-# y5 B6 e8 v7 `2 W* `
independent precocious puberty, which is also known6 E% \* }; g& L) ?7 z8 e
as testotoxicosis, may cause precocious puberty at a
1 U1 {3 |( Q! R9 o' @# k9 B3 rvery young age. The physical findings in these boys3 V% {; I4 l  {% J# D% E9 I( R
with this disorder are full pubertal development,1 Q; b5 }$ g6 E  ~
including bilateral testicular growth, similar to boys( A4 h6 g, q  B0 i+ Z2 W
with CPP. The gonadotropin levels in this disorder9 c% Z5 I$ I4 I' q
are suppressed to prepubertal levels and do not show
. b7 z3 H! x( X3 hpubertal response of gonadotropin after gonadotropin-% _' x7 E; S0 ~% c7 t% i* l9 d
releasing hormone stimulation. This is a sex-linked1 Y% r. Z3 a  u5 {1 Y
autosomal dominant disorder that affects only/ k& ?( y$ ?6 a0 ~7 F& i$ w. c
males; therefore, other male members of the family# B5 v& @' `/ c6 {' k$ ~
may have similar precocious puberty.3
' H% w% p" A, z: zIn our patient, physical examination was incon-( G3 J6 j. c' T2 ^5 y
sistent with true precocious puberty since his testi-, c3 u( v; N% E3 U' y( n- W  [
cles were prepubertal in size. However, testotoxicosis3 A1 y0 I; c" ~/ [* H0 A3 V6 g
was in the differential diagnosis because his father
7 B% s5 _( G/ ?8 Cstarted puberty somewhat early, and occasionally,9 f9 C) B  y) g) G( o1 p- S' V
testicular enlargement is not that evident in the8 T1 q8 a5 Q: V, c5 B
beginning of this process.1 In the absence of a neg-
, q2 c( p0 b1 ~/ {$ Iative initial history of androgen exposure, our
/ f' d! y( x( h1 u( O7 n- F* Sbiggest concern was virilizing adrenal hyperplasia,
3 h% c; c/ o6 S  q; C/ k4 b$ Leither 21-hydroxylase deficiency or 11-β hydroxylase
$ ~6 O( U2 G! I: B7 Vdeficiency. Those diagnoses were excluded by find-9 Y6 C' W; {: T2 f7 G2 G
ing the normal level of adrenal steroids.
- L# H- Q0 A( X! h( Z" _# JThe diagnosis of exogenous androgens was strongly+ X& z: Q; w% |0 ~
suspected in a follow-up visit after 4 months because8 J! V/ V0 n' I! n# Z
the physical examination revealed the complete disap-% h( ?; r& `. v3 a+ t& [3 V3 O
pearance of pubic hair, normal growth velocity, and
# Q! }% [- P/ p, y* mdecreased erections. The father admitted using a testos-
% F* O0 v- R$ L1 cterone gel, which he concealed at first visit. He was0 S1 ^0 r0 O! {4 `% Z& Y
using it rather frequently, twice a day. The Physicians’6 }  _. j1 B$ ?
Desk Reference, or package insert of this product, gel or
( D9 p# h; O, p9 R6 zcream, cautions about dermal testosterone transfer to* X2 ]9 O$ Z  h; t6 C+ x! z2 F
unprotected females through direct skin exposure.8 W  W& B, K% @/ ~8 {; f
Serum testosterone level was found to be 2 times the3 S+ \2 }4 @$ M% g3 }; H5 h  {: E* Z
baseline value in those females who were exposed to8 C. Z9 V3 I5 d: |+ E
even 15 minutes of direct skin contact with their male. R& U4 p& F( I$ w# n& s2 X% U. U
partners.6 However, when a shirt covered the applica-0 t! i3 y! p7 `9 ^
tion site, this testosterone transfer was prevented.
$ ^% S$ ?5 t3 X* K/ d+ {Our patient’s testosterone level was 60 ng/mL,# I3 C3 E3 N$ q
which was clearly high. Some studies suggest that7 j/ _/ Q5 I" i# r& I+ d
dermal conversion of testosterone to dihydrotestos-9 H* m$ ]1 M% O: B: T
terone, which is a more potent metabolite, is more
9 t5 K) r) n4 X0 c2 x% @active in young children exposed to testosterone9 {* w1 ^# ]* P' k
exogenously7; however, we did not measure a dihy-
! q, D4 _. h4 T* T9 Edrotestosterone level in our patient. In addition to
3 v4 W& d7 c$ U8 ?virilization, exposure to exogenous testosterone in
8 }6 Z0 Q  S' O7 [7 gchildren results in an increase in growth velocity and" L  l3 i1 Q6 p" ~: i
advanced bone age, as seen in our patient.
$ Q6 }, d2 S0 ^1 fThe long-term effect of androgen exposure during
  Y, q% [3 T# Q; |1 R- L3 ^2 [. g) iearly childhood on pubertal development and final
5 k! L$ m! A( r( b% g: X  |$ wadult height are not fully known and always remain3 X+ `; Y- ]# K" l$ Q6 L
a concern. Children treated with short-term testos-
1 ~3 J& l) Q4 sterone injection or topical androgen may exhibit some: o; \  x7 G# V: X, o2 }  \  R5 G
acceleration of the skeletal maturation; however, after1 R7 I/ u% {2 n
cessation of treatment, the rate of bone maturation0 T" |' Y. ?( l0 p
decelerates and gradually returns to normal.8,9$ C1 ^; u, K. S2 Q8 w
There are conflicting reports and controversy
3 X6 b4 w5 _- j5 f. sover the effect of early androgen exposure on adult' D, v8 z- k# J% D2 Z
penile length.10,11 Some reports suggest subnormal
* g7 Z; m# s8 c9 D8 s- q$ R3 M) a$ madult penile length, apparently because of downreg-; Q. S$ _: o# Z
ulation of androgen receptor number.10,12 However,& k! P$ u2 _. t  Q! j
Sutherland et al13 did not find a correlation between1 a% l1 |' o/ y3 M) t0 V8 T
childhood testosterone exposure and reduced adult2 G* D5 ]: s: M4 @. s
penile length in clinical studies.
9 y5 `* ^' B+ V% }- R) U$ SNonetheless, we do not believe our patient is
  T$ q% x# F% j/ w4 n4 N  @4 Hgoing to experience any of the untoward effects from: s2 u6 V  h" l
testosterone exposure as mentioned earlier because% @. C- ~6 S0 ]4 G
the exposure was not for a prolonged period of time.) F+ m0 V+ a6 R3 ^5 F! A
Although the bone age was advanced at the time of
4 a# z; M0 p. m& ddiagnosis, the child had a normal growth velocity at$ ~, w  A+ T% G, D. g$ |
the follow-up visit. It is hoped that his final adult
6 P( \) ~5 S4 b1 l7 |* ^/ V( Q$ \) mheight will not be affected.$ d, A9 P- t' c# g, D9 M
Although rarely reported, the widespread avail-
9 |5 h6 f4 ~- Pability of androgen products in our society may) l0 O3 l) W) s! B& N
indeed cause more virilization in male or female* B5 @! a2 @7 c* r
children than one would realize. Exposure to andro-
0 r6 f( ^6 Z# M/ X2 F" [gen products must be considered and specific ques-- w. Q) b! k: B7 Q; r, t
tioning about the use of a testosterone product or0 ]! e- ~: w+ E
gel should be asked of the family members during7 b3 n6 i' h5 F! ~3 H& Z" q1 h9 B! ^
the evaluation of any children who present with vir-
- k5 S) P1 s/ y6 G" ]' L) x% _ilization or peripheral precocious puberty. The diag-3 o6 a! K3 V% y; \; `5 R
nosis can be established by just a few tests and by
; r8 n  Q$ p1 S$ X9 }# Q9 Xappropriate history. The inability to obtain such a: ^3 r: @, P# S
history, or failure to ask the specific questions, may
2 |+ V/ T* `/ K0 w/ yresult in extensive, unnecessary, and expensive# `- k/ ^  K/ O7 \& }: q# a
investigation. The primary care physician should be6 M. m6 A, _; e
aware of this fact, because most of these children7 y0 p" F" J- h1 ^
may initially present in their practice. The Physicians’% `: R9 Z. n  `2 E7 f
Desk Reference and package insert should also put a' k, ~, h! W. D# ?$ U
warning about the virilizing effect on a male or
/ f: a0 B" p4 Z) k: J' M, S8 Ufemale child who might come in contact with some-
0 C& s1 c& b( `( r4 |# |& ]! lone using any of these products.0 E; \' X( B! G& p" D
References
; V8 \6 V3 Q% r1. Styne DM. The testes: disorder of sexual differentiation) |( A0 C# W5 I* h; J) D
and puberty in the male. In: Sperling MA, ed. Pediatric
8 _: i# V. ?! E4 iEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 }0 w! v5 T" `, o2 ^% m
2002: 565-628.1 u* K3 F+ w  b1 r" Y8 D1 H7 y1 a9 s+ ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: y! K1 o7 d! W. ~! j: D( `; o
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
( j6 {4 b  w4 L0 U3 Z1 P
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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