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Sexual Precocity in a 16-Month-Old. H  d" z( O( r) L% O- g, Z
Boy Induced by Indirect Topical' j5 I3 O  B0 F/ X
Exposure to Testosterone/ [7 c0 d8 y! w8 G) K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, D- ^& A+ S2 w9 t( Qand Kenneth R. Rettig, MD1
8 v) Q; z# C7 @  t! w4 iClinical Pediatrics
' Z3 C6 G: x8 t6 X% fVolume 46 Number 60 @8 }2 Z% J0 T6 Y
July 2007 540-543" {5 n5 [) o) u! ^
© 2007 Sage Publications
; @! W$ C! ^5 O% h2 y: B1 a10.1177/0009922806296651
; ?1 `% m' ]# w! q. ?http://clp.sagepub.com
% l4 r. n0 a. P7 k; |, z, ghosted at
6 Z1 m# ~) D! Vhttp://online.sagepub.com, h% U& i& ~8 Q
Precocious puberty in boys, central or peripheral,
& W' v2 f3 ~9 S, g, m+ P8 ^is a significant concern for physicians. Central
! e9 z/ q. m: N$ N$ W+ Y6 v* L  Vprecocious puberty (CPP), which is mediated% C& Y& n: V9 ]( B. p. _1 f
through the hypothalamic pituitary gonadal axis, has9 x* H" i$ a0 u% a* N! s# K
a higher incidence of organic central nervous system6 @  K( f5 @: Z- N
lesions in boys.1,2 Virilization in boys, as manifested: w( l8 ]9 R4 m: H- X+ \( D& t
by enlargement of the penis, development of pubic
- N$ h9 W, @( Q3 {hair, and facial acne without enlargement of testi-
: X  H. T9 o: N: n% @, Xcles, suggests peripheral or pseudopuberty.1-3 We
2 l# u4 P3 s( |! ureport a 16-month-old boy who presented with the
* Q: i  O/ e: xenlargement of the phallus and pubic hair develop-
8 w  f1 m3 j( C: ament without testicular enlargement, which was due% q1 ~; b2 w' m  c
to the unintentional exposure to androgen gel used by
+ t; S  z! f& I& k) pthe father. The family initially concealed this infor-9 N8 n. x1 k- u$ m9 k
mation, resulting in an extensive work-up for this' s" z6 S( Z) r- ?
child. Given the widespread and easy availability of/ y3 R* V' r4 T8 Y6 Q
testosterone gel and cream, we believe this is proba-, @- l) m$ L+ [' }5 Y; H( P: S& H
bly more common than the rare case report in the
' h7 H4 ]1 O; C3 M  L3 {  t& Zliterature.4# @/ _6 `1 y0 @9 K0 O
Patient Report
) A; u, n% J# @5 pA 16-month-old white child was referred to the# Z4 H/ {- ~4 T
endocrine clinic by his pediatrician with the concern7 [, S  }' B7 u2 k9 V
of early sexual development. His mother noticed, o$ A+ z9 Z5 ?8 H2 g
light colored pubic hair development when he was
6 H9 ^# D/ A( T. \From the 1Division of Pediatric Endocrinology, 2University of! ?! N+ E5 X9 X% {+ g4 g
South Alabama Medical Center, Mobile, Alabama.
. }8 M" `: \" B0 ^6 u. wAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. j# e. Z* c9 V& g8 e; l9 C" XProfessor of Pediatrics, University of South Alabama, College of6 J( d4 M: X* A1 |0 i  \3 r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 N. c3 U1 x5 r9 K# e- w
e-mail: [email protected]./ I+ a' ]5 u! o" P
about 6 to 7 months old, which progressively became
: ^/ m( K! o$ L( \darker. She was also concerned about the enlarge-0 r/ i/ ~: H  Q$ q  f* _, ^. R
ment of his penis and frequent erections. The child
5 M, X3 N+ Q. _( c: n* Y( v/ r/ L" Cwas the product of a full-term normal delivery, with* G. ]9 u1 h. m6 {
a birth weight of 7 lb 14 oz, and birth length of4 C, I/ c/ Z( P1 _$ ^
20 inches. He was breast-fed throughout the first year9 c9 d4 P- x6 W0 j% q
of life and was still receiving breast milk along with
- T! t  k- c3 N! Zsolid food. He had no hospitalizations or surgery,) k3 P4 }& A. g( w4 F- v
and his psychosocial and psychomotor development
& v+ I( Q$ D3 D- q' s: f- qwas age appropriate.
2 T- e9 H! i- t) ~The family history was remarkable for the father,
( R! L( a, l- m) Q& {+ T0 I5 e$ @2 @who was diagnosed with hypothyroidism at age 16,9 ~3 c( ~4 |& a, E  ^; V, [
which was treated with thyroxine. The father’s
( e7 o& y" |. T2 |' theight was 6 feet, and he went through a somewhat
( L# H: N, q* o  q3 Searly puberty and had stopped growing by age 14.  U8 j3 _6 N/ e/ g: m5 F( A
The father denied taking any other medication. The9 b. L* x7 Q% ?, A/ S
child’s mother was in good health. Her menarche
/ x/ `& }5 b7 h' ~- e3 _was at 11 years of age, and her height was at 5 feet
0 T/ _" e( `& J! U5 inches. There was no other family history of pre-
7 Y- p; V* e3 X  L. D5 J& P* pcocious sexual development in the first-degree rela-4 f& _7 S, ~- Y0 L! q/ T2 K) `! S
tives. There were no siblings.9 D* I  s8 Y7 ?+ `" l9 S3 i, v
Physical Examination
- t2 e9 a, m* q6 c  S) eThe physical examination revealed a very active,' ]$ P- N' M. L4 r4 y
playful, and healthy boy. The vital signs documented3 X5 ]2 J$ x8 A, b9 W2 i$ Z
a blood pressure of 85/50 mm Hg, his length was/ N- m6 P1 n2 T9 Y1 T& o! L8 x
90 cm (>97th percentile), and his weight was 14.4 kg
( S# \2 [; j# K; M7 l6 [/ ~(also >97th percentile). The observed yearly growth- U, D0 w1 }8 t* ]9 W
velocity was 30 cm (12 inches). The examination of: S' {; H, u4 G* M
the neck revealed no thyroid enlargement.
7 H7 `- U8 K' P5 f+ mThe genitourinary examination was remarkable for% c& _8 p5 s/ o+ q2 V
enlargement of the penis, with a stretched length of) |- B; k- t( `6 ^1 ^" J+ \. F" J* e
8 cm and a width of 2 cm. The glans penis was very well
9 t$ p7 u  ^, v! q7 Edeveloped. The pubic hair was Tanner II, mostly around
: H& y+ z1 q0 ?" r/ A540- A8 v6 S8 M5 t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 Z) P& ~# V" |" B6 O7 l' Q4 |
the base of the phallus and was dark and curled. The1 `3 f1 z0 s  c8 p2 z0 _
testicular volume was prepubertal at 2 mL each.( j% U0 H: B/ E4 R# i6 _
The skin was moist and smooth and somewhat
* _/ n4 ]* y! N1 X8 woily. No axillary hair was noted. There were no
6 V- D* I1 N) b, ]& wabnormal skin pigmentations or café-au-lait spots.* u( e) |' |* x2 U/ Y! I! ^
Neurologic evaluation showed deep tendon reflex 2+
/ K0 R+ G: f$ K( nbilateral and symmetrical. There was no suggestion0 [+ y0 X( a" t) d! {3 n! }
of papilledema.6 ^. ?" X& [8 T* ~& w
Laboratory Evaluation3 Y( S' B( Z( }" A: F) U
The bone age was consistent with 28 months by8 X- q' p7 l8 a
using the standard of Greulich and Pyle at a chrono-8 }; `8 V6 N' V- v8 q- U0 N# R
logic age of 16 months (advanced).5 Chromosomal
1 Y' x( _$ Q( O8 Y1 Akaryotype was 46XY. The thyroid function test% K( c- s$ T0 o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& K2 S: e) d, M- e( T
lating hormone level was 1.3 µIU/mL (both normal).: J- A8 G1 z/ s
The concentrations of serum electrolytes, blood
/ Q- U/ |" x; d/ Furea nitrogen, creatinine, and calcium all were- c" R1 Q; h+ A% ^
within normal range for his age. The concentration
3 T/ ~+ j, {% r4 Iof serum 17-hydroxyprogesterone was 16 ng/dL$ |# A7 _; A& E) X8 o9 x
(normal, 3 to 90 ng/dL), androstenedione was 20
+ I$ b  X1 T: Dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 G! E- b: p/ C" X2 N5 @# j
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) O" s! B, D2 B# M3 }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 K& Q0 ]+ `) m% Q49ng/dL), 11-desoxycortisol (specific compound S)  I- a& j& }. g9 [8 W8 ^' D) ]( D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" D# q! a" R7 A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' M* l0 |; D/ S. d
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' e2 O  S' a$ O8 X. f4 u; T9 P) A
and β-human chorionic gonadotropin was less than6 K( n$ \9 g% n) n4 `3 }+ V  v
5 mIU/mL (normal <5 mIU/mL). Serum follicular2 J+ x" K9 T( B7 R9 }  ?4 x" i
stimulating hormone and leuteinizing hormone
/ @: J% r: c, u$ m. fconcentrations were less than 0.05 mIU/mL8 M5 h" n) D8 \9 Z2 i5 n
(prepubertal).+ s8 t# W; Q# K, k# X
The parents were notified about the laboratory9 z2 X# D' V" e0 B
results and were informed that all of the tests were9 V" n7 {2 |" g: i( Y7 y, T7 ~
normal except the testosterone level was high. The
% W: \5 e5 U6 q$ U; |7 y' mfollow-up visit was arranged within a few weeks to
1 ^0 r0 y% |( [) r' B7 T- lobtain testicular and abdominal sonograms; how-
+ Q( ?. p# \$ d% {! c) {) gever, the family did not return for 4 months.
5 @" ~, Z% \; }9 iPhysical examination at this time revealed that the: _! k9 v: }% @
child had grown 2.5 cm in 4 months and had gained
; R$ Y, I* [9 ^+ L6 j& ^" @1 ~2 kg of weight. Physical examination remained7 C4 }" Z8 r. z- W
unchanged. Surprisingly, the pubic hair almost com-
2 H+ j, [" y  b! E: Q; L0 epletely disappeared except for a few vellous hairs at
" O* Y( K, |) A; t( n3 ~the base of the phallus. Testicular volume was still 2
) z+ X8 R. O" y) M' _# BmL, and the size of the penis remained unchanged.
/ g) L2 v; L4 VThe mother also said that the boy was no longer hav-
+ t+ I  Z4 A& ]; \8 T2 L. |ing frequent erections.& s  K% Y; J( s6 ?, V1 o; `
Both parents were again questioned about use of- p/ w3 ], m- s0 y
any ointment/creams that they may have applied to
2 C0 g; J& W- @8 p- ^/ \the child’s skin. This time the father admitted the
+ `. m% t! u8 i; g$ f) PTopical Testosterone Exposure / Bhowmick et al 541
8 d3 K; O, L# Quse of testosterone gel twice daily that he was apply-
; g' ~6 X7 H" C: x0 W! i+ g3 B) j4 _ing over his own shoulders, chest, and back area for# G* S$ z" X, k
a year. The father also revealed he was embarrassed
0 H$ O# L. C3 Y6 S: @to disclose that he was using a testosterone gel pre-2 _/ l, s4 _1 u1 ~( Q$ L. w0 a
scribed by his family physician for decreased libido
: E/ m- s! s1 N0 }! J+ |7 nsecondary to depression.
" z$ Q6 U% S; f+ ?' ~8 KThe child slept in the same bed with parents.$ j: R( |" |3 _, P; A+ ^* G5 W
The father would hug the baby and hold him on his, v6 I. h. f7 L! }; m. d- W1 z
chest for a considerable period of time, causing sig-
/ v, i4 K( ~" {7 _. ]9 }6 v6 }6 nnificant bare skin contact between baby and father.0 G: |* k7 O$ `0 N$ I- _4 q: a
The father also admitted that after the phone call,
) {' P' G' b; m+ U( f* c& Zwhen he learned the testosterone level in the baby
! p7 r* D9 k+ y- e) l8 fwas high, he then read the product information
1 T* Q7 R; p2 I9 z& M/ F' Zpacket and concluded that it was most likely the rea-! K( B/ v5 o3 o/ P
son for the child’s virilization. At that time, they
. v+ i$ f# ~6 b' T  o# Zdecided to put the baby in a separate bed, and the
5 S: L( j0 d8 U' S$ Ofather was not hugging him with bare skin and had
% b) J$ R9 c0 pbeen using protective clothing. A repeat testosterone
# s) G/ E) U5 V# Wtest was ordered, but the family did not go to the
. F% H1 g5 O5 c# v& t, o4 C, vlaboratory to obtain the test.
0 Z6 n0 h2 t; hDiscussion
. J* b1 l% _2 q& w+ Z' e# TPrecocious puberty in boys is defined as secondary$ u: m! ]6 g+ P+ M" Z
sexual development before 9 years of age.1,4) M7 [$ K+ R" J
Precocious puberty is termed as central (true) when
) j. h* V. y( T' E- \it is caused by the premature activation of hypo-
, b' d: _6 U/ V, @! F; b$ E7 N/ m( Vthalamic pituitary gonadal axis. CPP is more com-0 |7 J2 W/ c& b4 j( I# q! I7 n
mon in girls than in boys.1,3 Most boys with CPP5 K1 w1 q$ x0 O# S! K
may have a central nervous system lesion that is" y. _5 P' y7 L6 o' t
responsible for the early activation of the hypothal-+ ]5 o9 D$ L$ G& W; E) z7 s: L3 j
amic pituitary gonadal axis.1-3 Thus, greater empha-
: L6 E6 d9 `5 _1 S8 o1 gsis has been given to neuroradiologic imaging in2 J- I' z& G4 N
boys with precocious puberty. In addition to viril-- A) O2 c/ m- }: K- H& \  l7 `
ization, the clinical hallmark of CPP is the symmet-
0 d, h. S, j3 crical testicular growth secondary to stimulation by' I! [2 V6 U0 z" z2 `) n
gonadotropins.1,3( M: v' u* W" J( A
Gonadotropin-independent peripheral preco-, a4 |% s( a/ }; e3 p6 u
cious puberty in boys also results from inappropriate7 }2 I2 t0 i; h: m* ]& j
androgenic stimulation from either endogenous or1 K" `- F* [- V8 V8 x; {7 ~
exogenous sources, nonpituitary gonadotropin stim-9 o. W" u' w- a' m* o" U$ |
ulation, and rare activating mutations.3 Virilizing( @) \3 y; N5 B' {" o
congenital adrenal hyperplasia producing excessive
7 F2 V9 T; q& e' A$ ]' @adrenal androgens is a common cause of precocious' W, k; @% E  E0 H0 M+ u
puberty in boys.3,4/ p. }' G1 Z7 T2 z* m+ \% ~! n
The most common form of congenital adrenal# s0 v! `# C" M! t2 v
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 F9 D& K& o6 d3 B4 `! r* sThe 11-β hydroxylase deficiency may also result in; L0 @5 H; Q, E$ D7 |: n
excessive adrenal androgen production, and rarely,3 @& m+ p+ k; W( D5 G7 ~' M' W$ ~
an adrenal tumor may also cause adrenal androgen
5 Z) Q" h' h3 d$ s7 ~excess.1,3
4 r6 N6 ?9 }  Y$ q/ r; mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; a8 L( C, }$ ?* v! r4 H% c4 h542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 X' @1 ^- |* o6 b7 s
A unique entity of male-limited gonadotropin-6 n! t. O3 X/ _9 l/ K2 U5 }& R
independent precocious puberty, which is also known
7 R% K$ }% z5 ^7 X6 o* vas testotoxicosis, may cause precocious puberty at a2 ~' }! k$ ^1 u) j. m
very young age. The physical findings in these boys
' v5 N: h' S$ G6 _: V% n. awith this disorder are full pubertal development,6 L. q& E; U) [
including bilateral testicular growth, similar to boys9 s7 z) R" O# j! I2 w: j
with CPP. The gonadotropin levels in this disorder
- y/ F* i1 ]$ r, f1 X( }) }( |are suppressed to prepubertal levels and do not show
5 h( O" H' D, \; b/ Wpubertal response of gonadotropin after gonadotropin-
. u' m  O, S; p8 s; Qreleasing hormone stimulation. This is a sex-linked3 v9 ~5 Q3 F1 B
autosomal dominant disorder that affects only, A; G, m' j7 M: @
males; therefore, other male members of the family
8 G- c3 S9 W7 G& c- Jmay have similar precocious puberty.3
! c' I5 `& u1 N+ jIn our patient, physical examination was incon-
' `9 {. _$ [, n$ f4 |sistent with true precocious puberty since his testi-  c4 }8 w$ G, g5 I3 O
cles were prepubertal in size. However, testotoxicosis& ?; |# B; |. |6 p# ^; x5 G
was in the differential diagnosis because his father8 \1 c( y# G  C# Z& B5 J
started puberty somewhat early, and occasionally,
% ?  n/ w1 v& F% }2 A2 [5 S+ atesticular enlargement is not that evident in the
0 i/ z& D/ B4 f" B8 a6 ]9 N* Rbeginning of this process.1 In the absence of a neg-
6 t+ t, ?% i* s# W7 k- V9 y, C. rative initial history of androgen exposure, our
$ _1 g$ j+ i, G# t2 Gbiggest concern was virilizing adrenal hyperplasia,
( K0 M2 Q1 r: t9 A# [' c% Z0 ueither 21-hydroxylase deficiency or 11-β hydroxylase) G) C8 m  F1 h- h! B4 O" Y
deficiency. Those diagnoses were excluded by find-
+ C. A* l! l' `$ i, j- F' ting the normal level of adrenal steroids.5 O( t9 q- z' i% @7 }) x! C( b6 m
The diagnosis of exogenous androgens was strongly
( Q( c" w$ w% m1 b; K! C0 osuspected in a follow-up visit after 4 months because$ a) `( W7 b2 K
the physical examination revealed the complete disap-
; A) x& U: f/ _pearance of pubic hair, normal growth velocity, and
5 d4 T. m" z/ f8 |9 |0 \$ ldecreased erections. The father admitted using a testos-  q: o8 n# x$ u) \* g$ B& C) n
terone gel, which he concealed at first visit. He was6 g/ O4 u) n- A% K  Z& H7 V
using it rather frequently, twice a day. The Physicians’( e- H. \6 v" D; ]6 g* d
Desk Reference, or package insert of this product, gel or
# s5 P& I+ [" i. k+ ~. S- r# N7 y  O: }cream, cautions about dermal testosterone transfer to, l% B% i# F( d: A4 y  d: G  M6 Z( P$ T% d
unprotected females through direct skin exposure.
! H$ R0 s4 B- Y' W2 V  BSerum testosterone level was found to be 2 times the! _8 P$ [5 q& N/ V( ]% ]; g
baseline value in those females who were exposed to' A9 C2 i# a3 d' N
even 15 minutes of direct skin contact with their male# \# O/ v. s& h. b. x% ^
partners.6 However, when a shirt covered the applica-
. d: D; W- W- V2 |7 Qtion site, this testosterone transfer was prevented.
/ W7 z" e9 l2 Q. c/ c2 nOur patient’s testosterone level was 60 ng/mL,
4 X3 w/ `8 @) U. H( bwhich was clearly high. Some studies suggest that
% B1 Q6 m5 J+ \% M3 H7 y& M0 w! adermal conversion of testosterone to dihydrotestos-
% u: o6 O4 J# A1 Vterone, which is a more potent metabolite, is more
  g' Y2 ]; E  A# O$ @active in young children exposed to testosterone. W- c5 p  d) I; c# V: E
exogenously7; however, we did not measure a dihy-$ ]2 s& ]% I$ V- o! J
drotestosterone level in our patient. In addition to
2 c7 p9 e) Z& }virilization, exposure to exogenous testosterone in
' C5 {1 ?, J1 h7 L4 M& cchildren results in an increase in growth velocity and) D& p& |, e. k  X  i) n# f* @: v
advanced bone age, as seen in our patient.; g# g) U: T6 L9 N: B
The long-term effect of androgen exposure during' ~0 X/ C+ y) X8 E# K  F
early childhood on pubertal development and final
! d3 @" I* M0 Kadult height are not fully known and always remain
: d/ z) P+ b, u: _* c$ ya concern. Children treated with short-term testos-/ T! n/ j. e6 e" \! V8 R
terone injection or topical androgen may exhibit some$ S, e* u9 K9 O9 v+ O' c
acceleration of the skeletal maturation; however, after4 d5 R' |9 P4 ]& k/ A1 `% p- g
cessation of treatment, the rate of bone maturation8 X! f' g: o8 t9 a
decelerates and gradually returns to normal.8,9
3 R; k( {$ ]6 M6 @) `& b/ ^* A! yThere are conflicting reports and controversy
4 V3 {! ?" @6 R* a, nover the effect of early androgen exposure on adult* W7 C5 t( @- _5 s* h+ U% P
penile length.10,11 Some reports suggest subnormal
* n. ~8 m$ J1 badult penile length, apparently because of downreg-
+ N* h5 Z& ~, a2 }ulation of androgen receptor number.10,12 However,
1 D" I% J. T. j& @Sutherland et al13 did not find a correlation between5 g  d' q! R' u, B- r8 j  A( m
childhood testosterone exposure and reduced adult
3 {6 |  m2 N: X8 l4 z1 Epenile length in clinical studies.
& `+ B2 P/ m4 q& q9 S& |3 ANonetheless, we do not believe our patient is
1 x% @% O' ^" {4 f, Sgoing to experience any of the untoward effects from2 a% e( R, a; E4 S0 I/ Z5 J
testosterone exposure as mentioned earlier because4 W- x& ]* q: a/ E6 b& S* F
the exposure was not for a prolonged period of time.
. i8 D3 O0 h6 eAlthough the bone age was advanced at the time of6 F# o; p4 Q. s* u2 x' N
diagnosis, the child had a normal growth velocity at
2 R& y& r" S$ M  B/ rthe follow-up visit. It is hoped that his final adult
) r  J2 W/ a6 o' w2 q( D& zheight will not be affected.- H  Q8 `8 S  y1 t3 }6 M. k+ q
Although rarely reported, the widespread avail-) n3 a4 z2 V- \
ability of androgen products in our society may
8 o4 P! I% W# N9 i3 Q) x2 Findeed cause more virilization in male or female7 k' n: r5 a3 q" {7 {1 P
children than one would realize. Exposure to andro-
( \+ _) S2 E& {3 W* l: H7 a$ Vgen products must be considered and specific ques-  Z* X! G5 `' [" d% t  ^
tioning about the use of a testosterone product or
# `8 Z1 b7 p) k8 k. Qgel should be asked of the family members during1 z. }9 r9 g% ^# Q" i! z3 _! V
the evaluation of any children who present with vir-; J7 M* G  q4 n3 B/ ~
ilization or peripheral precocious puberty. The diag-: d" G1 |4 N0 q. A' K& x# |, T
nosis can be established by just a few tests and by0 N' A' ^8 p; G1 {2 N. I& q: K# P
appropriate history. The inability to obtain such a
! X4 c8 D4 K3 j8 d7 i& Ihistory, or failure to ask the specific questions, may9 |1 U3 S# U  D% l9 G
result in extensive, unnecessary, and expensive
& E0 S7 _4 z5 y* x$ J0 kinvestigation. The primary care physician should be
4 J: i6 w* K) j( n  @aware of this fact, because most of these children8 b9 k5 b" _  E) A1 Z/ L
may initially present in their practice. The Physicians’
: l) {+ Y# y; h4 X1 jDesk Reference and package insert should also put a
/ R7 Z8 I/ G+ _) }! r% E  x9 \warning about the virilizing effect on a male or
# }* H8 A9 n& M" rfemale child who might come in contact with some-4 e7 p" a: u9 q& p; z7 \9 B
one using any of these products.2 M% M  p* C5 I
References$ Z4 |- k: ^! I& p" ]
1. Styne DM. The testes: disorder of sexual differentiation
3 w0 G. B- c- ~; s5 Sand puberty in the male. In: Sperling MA, ed. Pediatric# P0 `$ m, i: n- n6 X! p: X' m" B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* b& Q) e: U$ T
2002: 565-628.
3 \7 f! a4 Q  [) P. E8 r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ s+ d" @+ T1 q: I4 o! l2 t3 [
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' |# Z: \1 K/ Z! ?, c: K# }; T, DBoy Induced by Indirect Topical
) |! p8 E. L6 X2 Q0 ~2 QExposure to Testosterone% m$ b4 w$ \9 T5 M$ t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ h8 v! B1 I+ O5 v. B( ?- q4 ?
and Kenneth R. Rettig, MD1! |6 i* n: @' o; I. _8 f# ^0 u3 N
Clinical Pediatrics# V- M) `- T- q
Volume 46 Number 6) a' a) ?* ~. n0 L6 I
July 2007 540-543
$ l: l' O! D% C) x© 2007 Sage Publications, K  d6 Y) E, Z( _2 n; Q% I
10.1177/0009922806296651
. c9 r( u7 V* {: Ghttp://clp.sagepub.com
" g% C( ?/ _7 m% b: p$ G7 qhosted at0 N, m' s; @; Y& `* J
http://online.sagepub.com0 z. ?6 d# q4 i
Precocious puberty in boys, central or peripheral,
. L6 l7 H) r7 Q, v! A- E2 {) Sis a significant concern for physicians. Central6 h5 M7 i5 l. o7 s3 g
precocious puberty (CPP), which is mediated
2 I- I/ ?9 `! ], \' u4 a' [through the hypothalamic pituitary gonadal axis, has
+ z8 H) _% `1 k% v( w, y2 ?6 h2 ~a higher incidence of organic central nervous system
. |! c2 {* W& v# b! R) ylesions in boys.1,2 Virilization in boys, as manifested, s  I+ ^! G. r; f. r
by enlargement of the penis, development of pubic* V2 n8 G  W, M
hair, and facial acne without enlargement of testi-4 H$ N; y0 ^; c6 Y
cles, suggests peripheral or pseudopuberty.1-3 We/ x/ i8 }' ~2 e5 h# s; ?
report a 16-month-old boy who presented with the8 s! ^7 ~  ^% V6 b
enlargement of the phallus and pubic hair develop-" Y# Z+ ^/ P9 ]8 g% Z, y1 I
ment without testicular enlargement, which was due
' b1 k6 [$ f- r; K% b  f+ eto the unintentional exposure to androgen gel used by
9 |8 P/ L$ c4 M- L' n1 xthe father. The family initially concealed this infor-$ L" m) t1 U/ s7 |3 x9 }' Z( [
mation, resulting in an extensive work-up for this$ v( }$ J, _( @; ?4 A
child. Given the widespread and easy availability of
, S2 U/ q+ L# P: r4 u  h+ @testosterone gel and cream, we believe this is proba-
4 N  _" Q4 Q- ?3 s) wbly more common than the rare case report in the3 `' g) S7 t$ V  [; o7 u* A
literature.4
+ h4 R! `; Z/ f6 }& C% K  K4 RPatient Report
, X; |. ?( @) [/ a# ^A 16-month-old white child was referred to the
9 f) X" g: q, x% D0 i0 ?endocrine clinic by his pediatrician with the concern; H8 h6 f/ D& z1 T0 R' t7 m! v
of early sexual development. His mother noticed7 Y& d4 h+ R$ v+ t
light colored pubic hair development when he was8 [* O) w3 q9 t5 V
From the 1Division of Pediatric Endocrinology, 2University of
7 G; @8 G/ I; s8 bSouth Alabama Medical Center, Mobile, Alabama.% U- P: ~$ A1 t! F* D
Address correspondence to: Samar K. Bhowmick, MD, FACE,+ P  z" z7 M7 I  i
Professor of Pediatrics, University of South Alabama, College of
  Y, W  X0 {4 ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 ?: e$ f9 }% w) `1 R0 k
e-mail: [email protected].1 e) {0 N" I/ M% S+ M! ?0 A0 _$ x
about 6 to 7 months old, which progressively became. R7 s$ C" t& q4 |; g5 Y
darker. She was also concerned about the enlarge-( s# |+ V. _3 ?- v) M% H5 w
ment of his penis and frequent erections. The child0 O# g, v, J0 l; I# Q, o! I
was the product of a full-term normal delivery, with
, _) d7 Z5 ]4 G3 Wa birth weight of 7 lb 14 oz, and birth length of, Y- p+ E5 Y2 a. e1 `  m$ T
20 inches. He was breast-fed throughout the first year
. A8 ~9 _  ]1 ~5 Qof life and was still receiving breast milk along with4 Q# }  j; k/ h/ h
solid food. He had no hospitalizations or surgery,, T6 @. V$ O, D& V; I
and his psychosocial and psychomotor development
" a- z" |6 D$ L4 M. iwas age appropriate.
: R# L9 ~9 B, A3 v4 v- J3 l$ h9 PThe family history was remarkable for the father,
* I* M0 p2 D3 i9 Swho was diagnosed with hypothyroidism at age 16,1 J; T7 N9 J) u. |$ i7 T, w
which was treated with thyroxine. The father’s
* w2 N( G% x/ ^* A/ ?! Wheight was 6 feet, and he went through a somewhat
  ?" ^: L$ B6 J, u8 v; Q: \early puberty and had stopped growing by age 14.9 ?, E+ K# \: Y2 z' p2 G) r6 u7 g
The father denied taking any other medication. The
; a2 r: m# K9 R, ychild’s mother was in good health. Her menarche
! o5 x7 h9 h( p5 l- _was at 11 years of age, and her height was at 5 feet
& M  a( f! `$ i4 V; ^' p9 t5 inches. There was no other family history of pre-
  X0 J& }' ?% P& I. P" e9 w5 Scocious sexual development in the first-degree rela-/ ?1 k  ]; S& s* F. K
tives. There were no siblings.& Q, t" @8 h( l: w  H2 R
Physical Examination
6 T: |- `1 h- @5 G/ L0 ]The physical examination revealed a very active,; i( S6 ?: L8 K+ f
playful, and healthy boy. The vital signs documented  [, E, z+ l( ]9 T. Z- [  ^
a blood pressure of 85/50 mm Hg, his length was$ f" B# a% [8 t4 h0 w7 z- X1 U
90 cm (>97th percentile), and his weight was 14.4 kg
1 ?- b1 O! H$ p(also >97th percentile). The observed yearly growth
' H: [* B! d* R' H* ]9 |% Vvelocity was 30 cm (12 inches). The examination of
$ M; x! F+ J, O# p  \the neck revealed no thyroid enlargement.2 c* q5 b$ S1 W: Z0 m9 f8 d
The genitourinary examination was remarkable for
$ }8 x6 |* i1 R1 Q' ~enlargement of the penis, with a stretched length of
' ?2 }1 @6 m; X( `! b8 cm and a width of 2 cm. The glans penis was very well
# e, j7 j& D  ideveloped. The pubic hair was Tanner II, mostly around+ s5 C7 |! ]. b
540
, a1 ]: _: ~4 v5 X0 B1 @! }% Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; N, L* |! t5 S) rthe base of the phallus and was dark and curled. The$ q$ M" }  ^6 i( r% h
testicular volume was prepubertal at 2 mL each.
$ A: v+ ^  A) z% U8 e0 s5 t% uThe skin was moist and smooth and somewhat
# J0 G# w! |( c% Voily. No axillary hair was noted. There were no2 `0 ^( V$ M/ }1 J
abnormal skin pigmentations or café-au-lait spots.% D4 a) R) R, h+ R8 p2 C* q& L
Neurologic evaluation showed deep tendon reflex 2+
0 r+ w. H  C0 }  @bilateral and symmetrical. There was no suggestion  Q. M9 _  Y0 z! {( p+ D; U& ?
of papilledema.# a9 S. w5 [/ W! S# c
Laboratory Evaluation  e  B8 w  M* _) K/ r) F7 b
The bone age was consistent with 28 months by& h  H2 v* f  S/ q
using the standard of Greulich and Pyle at a chrono-
( x1 \* v, @0 m$ {% ylogic age of 16 months (advanced).5 Chromosomal
/ h) @, a4 Q7 |7 J$ |" j1 ykaryotype was 46XY. The thyroid function test
, o, x' Z, ~% U1 d" Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
; V. q" I* R$ {) V0 |lating hormone level was 1.3 µIU/mL (both normal).0 r1 A; J7 y; g4 ~4 s& O4 X" Z
The concentrations of serum electrolytes, blood
" `1 V" e, u! t, Burea nitrogen, creatinine, and calcium all were( h3 h& p' J* k4 k
within normal range for his age. The concentration: `6 ~1 K) ?6 J1 j$ D  O/ ~: u
of serum 17-hydroxyprogesterone was 16 ng/dL
) B5 ?2 L2 X1 {  h( [(normal, 3 to 90 ng/dL), androstenedione was 20
( L/ P( V& W+ @; y2 I# J2 r- Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. z/ Y' |) t. v  F$ t; @
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& M2 x' ?, U9 ^3 ~/ {& T( X" h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ e- i% ?* L, [- A/ I- j- ?/ W4 K49ng/dL), 11-desoxycortisol (specific compound S)9 _5 J$ \0 D* g/ T$ L! v
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ W, z4 {, d! H0 W/ Mtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ i, R0 e) H2 b! t" X' |0 j# t
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 Z5 e# v- |$ r1 `2 ^8 ?and β-human chorionic gonadotropin was less than
, m9 _9 w: n' n: ~9 r5 mIU/mL (normal <5 mIU/mL). Serum follicular0 u, M5 |+ [1 y
stimulating hormone and leuteinizing hormone4 A0 K: h2 {) c+ ?8 i  d
concentrations were less than 0.05 mIU/mL
* C: n& f- z! I9 j- I9 v2 @(prepubertal).8 A% E+ k, \) b! m! A: I
The parents were notified about the laboratory
3 h" o% q. Q/ Iresults and were informed that all of the tests were1 l: ~. |# @( R4 q+ G; m1 K
normal except the testosterone level was high. The
- S, d) \, p; z: |follow-up visit was arranged within a few weeks to
6 a" d7 i5 K: }obtain testicular and abdominal sonograms; how-
) A# v3 w  m3 F+ [ever, the family did not return for 4 months.: \, y' F& \9 l' H3 Y$ W* F- ^
Physical examination at this time revealed that the! L5 Y& l3 m: q+ O4 n3 A
child had grown 2.5 cm in 4 months and had gained; X* f/ N. L/ ]3 p$ L# s3 v
2 kg of weight. Physical examination remained
% N, ~/ U% k5 ?* ~/ {. t- d( Wunchanged. Surprisingly, the pubic hair almost com-
9 {/ O6 X" {/ z7 r9 lpletely disappeared except for a few vellous hairs at
$ [' S% F' b- e2 Qthe base of the phallus. Testicular volume was still 2  P8 Z8 o# r8 u+ l  A5 M" D
mL, and the size of the penis remained unchanged.
2 Q- L9 g1 Q5 ]9 Q; I' HThe mother also said that the boy was no longer hav-
# i$ X$ S. Y2 ~! E* ?2 a, e2 |ing frequent erections.% |. @7 z7 i; f2 s5 V
Both parents were again questioned about use of: D; S" S. K$ Y' o
any ointment/creams that they may have applied to
" q) O4 A& T0 z. W7 `the child’s skin. This time the father admitted the
0 b1 A, B. i9 z; o7 b9 X+ tTopical Testosterone Exposure / Bhowmick et al 541- o1 `% H2 r; f# L2 r
use of testosterone gel twice daily that he was apply-+ V" M6 [- K  Z4 b& W
ing over his own shoulders, chest, and back area for# P& P; M2 m% J6 @0 u% {4 x
a year. The father also revealed he was embarrassed$ \, U9 ~# [$ J' P
to disclose that he was using a testosterone gel pre-
! i" B3 S$ D7 t3 kscribed by his family physician for decreased libido* F3 ]$ V  ]' d( }( w. x
secondary to depression.
+ b0 [& S: p  b0 Y4 o, K  \The child slept in the same bed with parents.
; O+ `. n2 s5 ~The father would hug the baby and hold him on his/ s% W* u& a. y2 N" n$ ~
chest for a considerable period of time, causing sig-9 w9 \3 f8 r. ]; E
nificant bare skin contact between baby and father.
# U" _- T6 j& R; J) ~1 JThe father also admitted that after the phone call,# f9 r6 }! s5 v6 _; C% D) M/ o. M/ W  }
when he learned the testosterone level in the baby8 [- ~" L/ ]0 E7 p2 P
was high, he then read the product information
: O2 U) K& K) P3 Z$ n2 Ppacket and concluded that it was most likely the rea-
% [  M$ b  e9 O. [- mson for the child’s virilization. At that time, they) N, U( f! h0 e: Q
decided to put the baby in a separate bed, and the8 O( D) Z8 Q; j, J2 s
father was not hugging him with bare skin and had
2 m; y  w; o6 H9 d$ C: [0 K2 zbeen using protective clothing. A repeat testosterone' U  u9 s1 Q( u+ ]3 @5 h+ c
test was ordered, but the family did not go to the, F* ]1 o0 K: l9 y5 ?7 x1 d) G% A
laboratory to obtain the test.: B: @9 m; g3 m
Discussion
; ^  J* g& l' G- s. bPrecocious puberty in boys is defined as secondary0 X# C+ f6 u4 O' |
sexual development before 9 years of age.1,4
. ^" ?$ v# q7 EPrecocious puberty is termed as central (true) when( S0 l7 _% G8 _+ o
it is caused by the premature activation of hypo-% h% @( A, ~' r, T5 n$ C# k; O$ D
thalamic pituitary gonadal axis. CPP is more com-
$ R" Q. e, _7 ?% H  H1 Z& H' lmon in girls than in boys.1,3 Most boys with CPP) D0 n0 U. {% ]4 F1 P: M
may have a central nervous system lesion that is  o& ?/ q/ \3 n+ O" U
responsible for the early activation of the hypothal-7 G" O( J. {) w/ W2 F
amic pituitary gonadal axis.1-3 Thus, greater empha-
0 F2 G: ?1 h: I! fsis has been given to neuroradiologic imaging in
3 W: F# z) L7 q; r+ Jboys with precocious puberty. In addition to viril-7 ~& r6 q2 A" D( m( E
ization, the clinical hallmark of CPP is the symmet-
6 F, K0 e4 v& L- ^! B! K- y1 q6 c6 ~5 grical testicular growth secondary to stimulation by! f6 _5 b, g- {( f1 D; [
gonadotropins.1,3+ \/ N* E8 K. E8 b" z2 V/ D! x
Gonadotropin-independent peripheral preco-
  f: l& T, _* A$ {0 l) {cious puberty in boys also results from inappropriate: G4 A8 ~5 l6 S. V$ x! U' L) a
androgenic stimulation from either endogenous or. f& u- g5 f; o% J1 Z  R& [
exogenous sources, nonpituitary gonadotropin stim-
4 h: J8 K; h) t* h4 Z& `) x; rulation, and rare activating mutations.3 Virilizing* h. V4 W/ }( }: x1 h- Q! x( V
congenital adrenal hyperplasia producing excessive% u  ^6 Q6 {4 g" d# e
adrenal androgens is a common cause of precocious
/ E3 }0 [- ^9 Q" N# O/ G, mpuberty in boys.3,4
3 f  g$ U1 w+ z1 L/ L& H) IThe most common form of congenital adrenal
) n" s, a9 {3 b; p) k; ihyperplasia is the 21-hydroxylase enzyme deficiency.$ u9 V0 M" z' V9 ]+ O. W6 f6 ]3 W
The 11-β hydroxylase deficiency may also result in  `, y; v3 K0 |- ^$ Q
excessive adrenal androgen production, and rarely,. X, i. t; ?6 _7 x# }# @6 d
an adrenal tumor may also cause adrenal androgen6 L  ~9 o! J% a! u0 i
excess.1,3
" V) V$ h3 T0 h3 m8 Z, a0 ]% a5 g; ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 B- o$ H, O- m* l
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! ]$ Q7 j- o& M6 h- l2 o
A unique entity of male-limited gonadotropin-
; S; M/ @1 i+ I8 ~0 M9 d. p4 P  D. Bindependent precocious puberty, which is also known' ^3 G* M9 `. Y" C* I$ @
as testotoxicosis, may cause precocious puberty at a
% O7 [) e/ A! Qvery young age. The physical findings in these boys9 }+ B  ?" x# w( ?$ z
with this disorder are full pubertal development,
1 J% i, ~0 Y1 E2 V0 X8 v: Jincluding bilateral testicular growth, similar to boys3 K5 y* }- @5 S. M* w
with CPP. The gonadotropin levels in this disorder
0 D! ]4 Z' `; l2 Zare suppressed to prepubertal levels and do not show
8 [! ^: {* F3 t6 G' W7 dpubertal response of gonadotropin after gonadotropin-
* M; M) U& Z/ T5 m7 m; hreleasing hormone stimulation. This is a sex-linked
: o. V7 ^" V9 b. V0 b/ Z4 y' q' Wautosomal dominant disorder that affects only* W2 i& i: Z) K; E: H: `
males; therefore, other male members of the family7 v, p) r$ T: l) U
may have similar precocious puberty.3
8 P1 z; v3 N8 j3 k/ L4 n/ YIn our patient, physical examination was incon-" W! f2 y/ j' q3 N0 U
sistent with true precocious puberty since his testi-/ J( O; B& [9 M; D, k
cles were prepubertal in size. However, testotoxicosis
7 W( q- E; }: p9 {* ^' Ywas in the differential diagnosis because his father
- Z: O0 e) [' R& z5 Sstarted puberty somewhat early, and occasionally,9 G( A9 {& K/ y( _: X1 |8 `$ y
testicular enlargement is not that evident in the2 g9 ]9 l/ `- y
beginning of this process.1 In the absence of a neg-
7 E0 e& O/ ]( g$ r' kative initial history of androgen exposure, our3 k9 b! j6 `* p* M% P' k; o3 L
biggest concern was virilizing adrenal hyperplasia,
& y7 U, V7 B; L4 A3 L. aeither 21-hydroxylase deficiency or 11-β hydroxylase
2 \: s' |2 C" H7 q3 l& x- M6 ndeficiency. Those diagnoses were excluded by find-
& U5 N$ y$ z  @, P+ A. t* Oing the normal level of adrenal steroids.
# r  m/ p- i+ G: Q9 u, GThe diagnosis of exogenous androgens was strongly+ b- |' t5 B7 \8 g
suspected in a follow-up visit after 4 months because
) N* ?: V: B+ E& B- K8 E/ ?2 ^the physical examination revealed the complete disap-
/ e# w: z" C" z+ Tpearance of pubic hair, normal growth velocity, and
  J. w6 ~; {( ~  Z5 Zdecreased erections. The father admitted using a testos-3 E* G5 B# i0 h, B1 t
terone gel, which he concealed at first visit. He was& ^& d+ ?3 k5 M
using it rather frequently, twice a day. The Physicians’
2 @" T1 j2 O2 `: o4 f& i9 nDesk Reference, or package insert of this product, gel or2 v! q, S: k( o# _. Z+ r6 o
cream, cautions about dermal testosterone transfer to. G5 `0 ?! R% @
unprotected females through direct skin exposure.
! N7 d9 q/ o8 U5 G( V2 }Serum testosterone level was found to be 2 times the
4 E; {. O$ @" S% k: u, h; lbaseline value in those females who were exposed to
# h5 z2 l" O( q4 \* ^; Neven 15 minutes of direct skin contact with their male+ F% R2 v+ f$ N: j
partners.6 However, when a shirt covered the applica-
  U* P' U, Q0 V% Ntion site, this testosterone transfer was prevented.
6 }2 S! ]/ O. J7 h& G6 z, FOur patient’s testosterone level was 60 ng/mL,* |0 d9 ~. X5 _( `
which was clearly high. Some studies suggest that# g/ s+ N8 |7 t2 C
dermal conversion of testosterone to dihydrotestos-
% R- {5 ]: b' tterone, which is a more potent metabolite, is more
; w" q( a& f; [* \, Oactive in young children exposed to testosterone1 m! a# ]- C4 D7 e+ |% h
exogenously7; however, we did not measure a dihy-
- J$ g) P4 |3 q+ X# vdrotestosterone level in our patient. In addition to
# f; i2 T3 E" I+ G  \6 U( Z4 h; Tvirilization, exposure to exogenous testosterone in
1 i, \  n( B" J8 l& E0 z# L0 {children results in an increase in growth velocity and
( `! ~! T: z  b& m7 jadvanced bone age, as seen in our patient.1 E4 C; d( F9 t% s  S7 X
The long-term effect of androgen exposure during0 c$ x3 Q) r( r& ?, P4 o, M2 a8 g
early childhood on pubertal development and final
1 t; s5 M2 f1 A' H- Oadult height are not fully known and always remain
6 q* j" ?6 v# ta concern. Children treated with short-term testos-
; o& F$ Y9 ?  s% X* d5 f& }terone injection or topical androgen may exhibit some- e) `; }) v+ E
acceleration of the skeletal maturation; however, after
5 I0 W. J. l- Zcessation of treatment, the rate of bone maturation) W9 b$ v( q3 v
decelerates and gradually returns to normal.8,9
" k2 D, v! E, a; ?& \There are conflicting reports and controversy
) F1 `( U/ G2 x* U5 y. _9 {8 Zover the effect of early androgen exposure on adult/ s* d9 h, k$ d+ }3 z/ {4 t- }
penile length.10,11 Some reports suggest subnormal+ a- s8 p  w2 x' l5 c/ U- e
adult penile length, apparently because of downreg-
# ?7 V# n# U( U9 \# T, _; F* g, n# v/ aulation of androgen receptor number.10,12 However,
7 p, s+ o4 L% l2 uSutherland et al13 did not find a correlation between
* v6 y# a$ w* g; wchildhood testosterone exposure and reduced adult" `2 k# c; s, Z- @/ m8 M
penile length in clinical studies.
: v$ ]+ P+ C+ x+ l7 sNonetheless, we do not believe our patient is" e) j3 g4 v  E4 @# F5 k8 G& U
going to experience any of the untoward effects from
! g5 i2 A: ?0 L! Dtestosterone exposure as mentioned earlier because4 ?7 `7 F: z. ?& N% k
the exposure was not for a prolonged period of time.
; Y4 T, H, h1 g6 y/ v; b9 q+ ~Although the bone age was advanced at the time of  h5 ~) q6 b& M/ {5 f- e2 o& a
diagnosis, the child had a normal growth velocity at
; f2 a- r" ]9 Qthe follow-up visit. It is hoped that his final adult! V* o* \# ?% Y6 V
height will not be affected.
# t# x# s( n' B) }" FAlthough rarely reported, the widespread avail-7 ~- l7 n. B. a. L( B0 U- Z( g1 s
ability of androgen products in our society may
  h2 V8 e  c/ Gindeed cause more virilization in male or female) ^0 H% J8 G4 N+ A: ?
children than one would realize. Exposure to andro-
5 s1 d( D3 B# c% r+ B5 N; Lgen products must be considered and specific ques-. \( U  n: Z1 G: x
tioning about the use of a testosterone product or
) J( T0 T: a, K8 ~3 |1 X. D) Egel should be asked of the family members during
1 o6 y% k4 x) @+ A& N3 }the evaluation of any children who present with vir-
# T) {) w. e8 v, @6 M* \ilization or peripheral precocious puberty. The diag-
/ b% R. Y: e( K" L8 f9 B8 Enosis can be established by just a few tests and by) G1 |6 y2 Z, W
appropriate history. The inability to obtain such a
; [# U7 v3 k8 [( z& D/ zhistory, or failure to ask the specific questions, may
1 r$ L5 Z& D: h0 Mresult in extensive, unnecessary, and expensive
( g2 o9 v8 c3 f+ f& h8 U2 uinvestigation. The primary care physician should be$ \2 E  W( K/ z
aware of this fact, because most of these children. D. |( {" l! O3 K
may initially present in their practice. The Physicians’
1 Z1 ^0 O0 e- W  x0 N" l7 UDesk Reference and package insert should also put a4 w! f8 H& N$ E) [. ^5 N
warning about the virilizing effect on a male or8 c. ?1 b7 N. S
female child who might come in contact with some-
2 @5 J! y  s- H  e8 s: n+ \one using any of these products.
/ b- ]& r7 w8 f+ g$ nReferences5 T) H) e3 j0 {! E9 a, w
1. Styne DM. The testes: disorder of sexual differentiation
( _% u- N& o, u2 F; _and puberty in the male. In: Sperling MA, ed. Pediatric
; k9 M$ I9 Q3 U; b3 X, }. HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' z3 h% ~" r: g, U; I9 I) X
2002: 565-628.
. \8 B6 m4 G2 q% V# [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ F# C' g; R. K9 ~  r7 v# q* h3 @# j
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
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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
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

$ V! o; v6 i7 d, o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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