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Sexual Precocity in a 16-Month-Old
$ k5 d+ B, D4 z( g# {3 }Boy Induced by Indirect Topical( I6 ^* D. e2 u# |2 A
Exposure to Testosterone6 T0 ^& a( a8 D5 @) K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. f8 P( n# r! ]& wand Kenneth R. Rettig, MD1
# |, f5 `- E; W6 ]  m! OClinical Pediatrics
$ F! r& i6 }5 u0 n, |! vVolume 46 Number 6. I0 x  g/ E2 h$ C( g& ~1 C% }9 F  N
July 2007 540-543$ c* r3 G6 g) Q* S: X1 Y- O" J4 n8 C8 ]
© 2007 Sage Publications
2 U: ?9 y* U+ E& C) z/ \& \$ \10.1177/0009922806296651
: l2 E  k  I& B/ z: T/ ~( ahttp://clp.sagepub.com0 N/ {" ^' y$ g5 Q, d: \4 e; {. q
hosted at6 ^' k% y9 Y( Y/ u6 ]$ v& l
http://online.sagepub.com
! q( c9 S6 b) D1 A3 |) lPrecocious puberty in boys, central or peripheral,
, ?5 H) F' d" }; ?% w! n0 b) G6 G9 jis a significant concern for physicians. Central5 U% R& j3 D1 r; A; ]5 r  z
precocious puberty (CPP), which is mediated+ }9 t7 N" f2 L! _
through the hypothalamic pituitary gonadal axis, has- O' K, S! `. A
a higher incidence of organic central nervous system6 G4 O9 N# v/ t- F
lesions in boys.1,2 Virilization in boys, as manifested
& `* \; j- z% G, Oby enlargement of the penis, development of pubic6 _; d2 @5 a8 Q; J- u1 V+ t. Y$ a
hair, and facial acne without enlargement of testi-
. \1 l9 ]! r! C) z; W/ g  Bcles, suggests peripheral or pseudopuberty.1-3 We
* {6 i; V/ b7 oreport a 16-month-old boy who presented with the' v3 a! Y6 V" ?$ M2 X: P# b
enlargement of the phallus and pubic hair develop-
! m7 C7 C# }  h+ Y& z% Tment without testicular enlargement, which was due! ?1 b, v6 c! K0 T1 m
to the unintentional exposure to androgen gel used by
+ @2 n( U% w! u7 T1 _the father. The family initially concealed this infor-
( B% D$ `9 V0 J" r' U4 m  Umation, resulting in an extensive work-up for this
8 s) k2 R' o) c% J6 h. S/ Y" {child. Given the widespread and easy availability of" q: i4 X( w( a8 q+ A
testosterone gel and cream, we believe this is proba-% G% i/ K2 q. ^0 W( F( j; d# @
bly more common than the rare case report in the
2 M1 ?1 n6 c/ |0 Z' {: t3 q; Dliterature.4
4 ]: h6 ]5 |; i$ t$ {Patient Report
( m5 I+ G0 ]+ TA 16-month-old white child was referred to the
8 ^4 G1 i) \6 r3 L" E! L# sendocrine clinic by his pediatrician with the concern
" w) x8 h" O( Q8 r% i: ^) [of early sexual development. His mother noticed4 e' S2 S& `( x' F: @
light colored pubic hair development when he was5 l4 Q( ^% f: T& j5 a+ k! h8 `
From the 1Division of Pediatric Endocrinology, 2University of
3 }" g. }2 \* [) W6 sSouth Alabama Medical Center, Mobile, Alabama.
$ Q- Q; w5 R+ |) XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
) n6 W' E' s6 s. C2 h4 g3 ?Professor of Pediatrics, University of South Alabama, College of. R) v+ K% q" _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 a9 x2 y. T8 ^) O5 J* \0 O6 Ue-mail: [email protected].# l' D% t' q$ _: D
about 6 to 7 months old, which progressively became) l9 }+ y' f2 i8 H3 J. u
darker. She was also concerned about the enlarge-
1 I+ K) j8 q2 |7 @! w* Iment of his penis and frequent erections. The child& J) z. T$ p  H1 s% ]
was the product of a full-term normal delivery, with7 _# Q! \9 J9 O
a birth weight of 7 lb 14 oz, and birth length of
: Z: ^; l3 j: ?: i5 i# q20 inches. He was breast-fed throughout the first year: O0 V2 k4 e: q7 g1 h7 W
of life and was still receiving breast milk along with
( h, f2 u" ^  ], J4 Tsolid food. He had no hospitalizations or surgery,3 ]) t# i) j. z+ K! T4 a
and his psychosocial and psychomotor development
2 B* f1 k9 k$ ]' e2 P( Wwas age appropriate.7 T# E/ w$ R+ k8 O
The family history was remarkable for the father,2 R9 N! E' s" o4 x- T. O
who was diagnosed with hypothyroidism at age 16,1 t' K9 o1 d3 H
which was treated with thyroxine. The father’s
- Y) w. ]( V* Lheight was 6 feet, and he went through a somewhat! n) g7 D0 f3 @# V& S2 V' r1 |
early puberty and had stopped growing by age 14.9 P7 M/ T: D* C& `5 i" q9 d
The father denied taking any other medication. The- h6 l$ \) F' U7 o5 N/ N
child’s mother was in good health. Her menarche
8 V+ p6 @/ w$ W: K; ?was at 11 years of age, and her height was at 5 feet1 e; w/ N1 S+ K2 q% g
5 inches. There was no other family history of pre-
/ @4 E# `; O# o8 |! jcocious sexual development in the first-degree rela-
& {1 _5 j  Q8 t/ X2 }tives. There were no siblings.
0 U; W8 {# [' v. f4 ]0 h) mPhysical Examination/ X1 }- {* p) o# j/ }# f
The physical examination revealed a very active,. ]4 y" F+ q8 U/ W) G
playful, and healthy boy. The vital signs documented
+ E. ^" _4 b/ ^2 H, w! K) Za blood pressure of 85/50 mm Hg, his length was& y$ ?; y2 q0 x: u
90 cm (>97th percentile), and his weight was 14.4 kg. g5 G& V- G% n. l5 g( T  J- R
(also >97th percentile). The observed yearly growth$ d- F2 M" \  ^$ z% t
velocity was 30 cm (12 inches). The examination of7 q- n0 B: ~3 V( E- R! J
the neck revealed no thyroid enlargement.* E, d0 I0 D. r- r/ y) M2 F/ r
The genitourinary examination was remarkable for2 `4 V1 H* _9 c' W9 x
enlargement of the penis, with a stretched length of9 o! W- z' ^9 X- d4 m
8 cm and a width of 2 cm. The glans penis was very well0 _/ `  u' w, Q- V
developed. The pubic hair was Tanner II, mostly around
6 ?( n- D4 ?. k3 p- A$ M( a) v540
$ ^- u0 U7 d  Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' J2 _" c  {: Zthe base of the phallus and was dark and curled. The
% _  I; d! N$ e- Xtesticular volume was prepubertal at 2 mL each.
1 L5 L& G" N6 ]( d4 C& ~. GThe skin was moist and smooth and somewhat
5 a8 g, E2 }! p" r% U/ joily. No axillary hair was noted. There were no7 }" Q6 Z2 D5 ?$ c# K$ l
abnormal skin pigmentations or café-au-lait spots.
4 O! D! k9 X/ a4 \) P; H! q, YNeurologic evaluation showed deep tendon reflex 2+7 Q) a9 r3 F2 g8 U) @
bilateral and symmetrical. There was no suggestion
9 s" C& h# |: |1 n1 }; Tof papilledema." H9 R3 y% R! \' J. I1 q6 ?
Laboratory Evaluation
( K6 K! `2 q2 f6 J8 ^& M! \3 z  f7 bThe bone age was consistent with 28 months by' m" Z* ]9 i/ t( ~: V. y, l; E
using the standard of Greulich and Pyle at a chrono-
6 c/ s' b. ^7 \! R' _" U" j" V  g% _logic age of 16 months (advanced).5 Chromosomal5 B8 {* J5 M5 B* ]9 s, F1 _
karyotype was 46XY. The thyroid function test  ?3 ]6 {0 X6 ^
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; t/ X- V' }- S: Z& U4 ~8 r
lating hormone level was 1.3 µIU/mL (both normal).1 x$ T8 u& r# C1 w) \% L/ y8 l
The concentrations of serum electrolytes, blood
* u5 g1 c2 u1 v4 H3 h7 a# _- Hurea nitrogen, creatinine, and calcium all were; X/ H: a  g  n+ ^5 B- k
within normal range for his age. The concentration
5 a6 E: h$ i  }5 g9 C# Jof serum 17-hydroxyprogesterone was 16 ng/dL# z  Q, S  Y+ R5 f) ~
(normal, 3 to 90 ng/dL), androstenedione was 20+ ^3 C8 Y: K( K6 J- r
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ J% a+ f$ I# f) |  N! r
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 c0 Z" D# i* f3 R8 _* l: j0 \8 R  sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  I4 u: X6 m) O! T5 H49ng/dL), 11-desoxycortisol (specific compound S)
6 q4 Y0 s0 M% r9 Q+ k$ Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  Q/ N3 |; L9 @3 K- s, Y& Jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 T, j& o' `9 E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 u2 W6 ^) U$ h, i1 O! Aand β-human chorionic gonadotropin was less than2 L3 p; ~& R% m  r8 l7 A
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 o7 k+ ~5 ?: `! Y) A" U& bstimulating hormone and leuteinizing hormone
$ C; {1 N. {. e  e$ e* Tconcentrations were less than 0.05 mIU/mL
0 p, Z* c6 H1 s% c- D. w3 o* T(prepubertal).
7 C4 l; R6 u6 J4 W) N( fThe parents were notified about the laboratory$ y9 a1 |! |2 Y% q
results and were informed that all of the tests were1 a0 O1 S6 ~4 l3 I- \; U1 @2 c
normal except the testosterone level was high. The. J) Z5 L1 K8 a5 J8 E( K5 n5 B" P
follow-up visit was arranged within a few weeks to
5 e4 ]0 r* _5 `& B/ Bobtain testicular and abdominal sonograms; how-
. I+ r1 v2 D3 h6 R! \+ Hever, the family did not return for 4 months.
9 H  C6 c# g" l8 v7 V' PPhysical examination at this time revealed that the
& {, u9 N0 Y1 q' W1 Q1 echild had grown 2.5 cm in 4 months and had gained0 `2 V+ |/ S# u) U5 i* R
2 kg of weight. Physical examination remained  Q) `9 i8 C! m& P7 o  V; ~6 P
unchanged. Surprisingly, the pubic hair almost com-4 U. y2 ^* j$ v! o/ R: G
pletely disappeared except for a few vellous hairs at; x& S( [) R( n( s: o+ w4 E
the base of the phallus. Testicular volume was still 2
  I* X: z- j. GmL, and the size of the penis remained unchanged.; _3 _( [) T  D" f5 K
The mother also said that the boy was no longer hav-
6 }3 e7 L& w; V* b5 x# B; Jing frequent erections.+ ~+ r; L2 L; x. r* u8 O
Both parents were again questioned about use of
; c& L1 ?: O3 ~* b+ z2 rany ointment/creams that they may have applied to
% ]; V4 e4 e1 t# c" U( C% V( fthe child’s skin. This time the father admitted the
0 c4 j8 [; n$ I; \Topical Testosterone Exposure / Bhowmick et al 5418 }. [  ~2 D! o8 X8 V
use of testosterone gel twice daily that he was apply-
+ y) P9 N+ X+ e6 l$ n" Zing over his own shoulders, chest, and back area for
2 m) K# x" _- ^' `: ma year. The father also revealed he was embarrassed
; i& f9 k7 L! ?to disclose that he was using a testosterone gel pre-, D; A( p% ?3 Y
scribed by his family physician for decreased libido
$ ?9 y/ A( R8 ^+ }- zsecondary to depression.
. |, J. J5 N: u! ^8 ]5 ?The child slept in the same bed with parents.. \/ k% ~9 v6 o
The father would hug the baby and hold him on his5 R$ Q* B* d* s2 R9 M
chest for a considerable period of time, causing sig-
9 ]9 S$ R7 e" E- cnificant bare skin contact between baby and father.
4 u& N1 x: p9 g- k8 F$ l2 v' wThe father also admitted that after the phone call,
: k% a* u' Y6 D9 Dwhen he learned the testosterone level in the baby8 O9 s- |$ n8 h9 Y' ?5 U% ]
was high, he then read the product information' j' ^  Y- V" o2 l& M: _8 d
packet and concluded that it was most likely the rea-
4 K# Y+ G4 U+ T# E$ `" l" f5 Ison for the child’s virilization. At that time, they$ I2 ~& O" ^  ~+ |/ k
decided to put the baby in a separate bed, and the  [) {' w/ |* j, I- z, M) j
father was not hugging him with bare skin and had
! Z$ l# P" {+ L! Rbeen using protective clothing. A repeat testosterone
. a$ R/ h: v! o& K) @( ntest was ordered, but the family did not go to the
7 k$ L2 F& p+ u* t0 dlaboratory to obtain the test.7 V; K) `) G/ B' z. n* O
Discussion
% y( d) d: j' ]  \: c6 x4 vPrecocious puberty in boys is defined as secondary% V2 F1 M8 K( Y
sexual development before 9 years of age.1,4
' N& l  {" J8 `/ F) ^Precocious puberty is termed as central (true) when
% F9 g" V7 O9 a: }it is caused by the premature activation of hypo-& W- P* r+ b7 E
thalamic pituitary gonadal axis. CPP is more com-8 r0 d" q5 J6 F3 z1 G6 g' t  H3 J8 U
mon in girls than in boys.1,3 Most boys with CPP# P+ H: ~& M4 i
may have a central nervous system lesion that is
; D! ~8 ^3 @3 E  Bresponsible for the early activation of the hypothal-
' e4 @9 _5 Q6 j" H) p0 z* Pamic pituitary gonadal axis.1-3 Thus, greater empha-
# w7 F5 f( E9 ksis has been given to neuroradiologic imaging in$ t/ N6 |8 \+ F. i' i' q
boys with precocious puberty. In addition to viril-
/ w+ z! U7 k( P0 ?' T8 @- Oization, the clinical hallmark of CPP is the symmet-
) ~$ A4 g# x" D. u& |; W  Xrical testicular growth secondary to stimulation by
/ ~' i0 G+ i: h! D; _gonadotropins.1,3
: @% M1 ?$ \& p, f& y  r& I& VGonadotropin-independent peripheral preco-" y/ R. A# f. K+ s% X
cious puberty in boys also results from inappropriate6 a3 C" d; h& A- V6 K) j! \+ ^
androgenic stimulation from either endogenous or
2 ^: p" |! a" e' H( ?1 P, pexogenous sources, nonpituitary gonadotropin stim-, w9 h8 E. c8 p! @  ^0 s
ulation, and rare activating mutations.3 Virilizing
* C( p1 k' B5 w/ c# H1 fcongenital adrenal hyperplasia producing excessive/ W# i6 W$ u$ e; K5 ~& Z) w! `
adrenal androgens is a common cause of precocious
# `5 s: o; h. N3 Npuberty in boys.3,4) D- P/ V% y! x+ R) [  v
The most common form of congenital adrenal8 V( u5 N3 s8 R( h
hyperplasia is the 21-hydroxylase enzyme deficiency./ @, k8 _  T& }8 u
The 11-β hydroxylase deficiency may also result in
$ q  I9 l; S! J& @excessive adrenal androgen production, and rarely,
2 _2 K( F/ k. B: X( Can adrenal tumor may also cause adrenal androgen$ s% c) h' R/ u" z, b, {
excess.1,3
: Y* K4 E3 `) t5 D* i5 l  S: Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% _' t; ~, S& A/ F3 _4 E542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# x/ B) ^/ y6 w" h, _! cA unique entity of male-limited gonadotropin-" l% n0 k7 ^- x( W$ V
independent precocious puberty, which is also known
2 m; Z8 N8 a: O' T" ~8 B/ Ias testotoxicosis, may cause precocious puberty at a
" \" ?. _( A* R, s2 _5 f+ `very young age. The physical findings in these boys8 y+ K* X$ X+ u7 ]6 l
with this disorder are full pubertal development,
, G9 f3 n- H& a4 fincluding bilateral testicular growth, similar to boys- \# P+ C& q( A" B
with CPP. The gonadotropin levels in this disorder
$ `& _6 T8 X, i  c" ^are suppressed to prepubertal levels and do not show1 i" V  J+ R) R# I9 h4 R6 m
pubertal response of gonadotropin after gonadotropin-
, G# G. d; i0 g9 Rreleasing hormone stimulation. This is a sex-linked2 h0 F5 }% W. b6 E1 N
autosomal dominant disorder that affects only+ ?/ a) [3 s* f3 g' X* W
males; therefore, other male members of the family% P  A# {5 Y  ~4 s( c. l; U! K6 w
may have similar precocious puberty.3
, s% k1 N5 h7 aIn our patient, physical examination was incon-
3 A% j$ K( T6 ^& Xsistent with true precocious puberty since his testi-+ s" L' y- S6 Y2 d
cles were prepubertal in size. However, testotoxicosis0 r& d$ P5 A9 Y2 J# I  H
was in the differential diagnosis because his father
& I& v- c. a) Q4 m# i& f1 G! Zstarted puberty somewhat early, and occasionally,& r3 U# w8 S. k2 W9 x4 l
testicular enlargement is not that evident in the
3 Z8 F" X" [6 a. E& Dbeginning of this process.1 In the absence of a neg-/ \& q9 Z  T5 z" q$ R
ative initial history of androgen exposure, our
( r: {) \" P: k6 `1 j0 obiggest concern was virilizing adrenal hyperplasia,
0 `2 g# N7 `: g3 d$ x, heither 21-hydroxylase deficiency or 11-β hydroxylase
' r! ?- S* j* j/ Y; @5 K) Odeficiency. Those diagnoses were excluded by find-2 U4 e& G& {0 D, Y8 o' Z! `
ing the normal level of adrenal steroids.5 T" U6 v' n* I
The diagnosis of exogenous androgens was strongly) r1 B$ I# V' n- [
suspected in a follow-up visit after 4 months because: u2 L( f, F: H* T* L
the physical examination revealed the complete disap-; c2 y1 m% x$ y7 H$ P% c- Z' q
pearance of pubic hair, normal growth velocity, and1 k0 C: N' a8 [* }1 D
decreased erections. The father admitted using a testos-' Y3 x, W, R- D- o" L5 K
terone gel, which he concealed at first visit. He was' e; L9 J+ v5 e
using it rather frequently, twice a day. The Physicians’, x* |6 W. n9 `9 Q4 e/ K' X/ ?: C) H
Desk Reference, or package insert of this product, gel or- `. v* n% H. t! T
cream, cautions about dermal testosterone transfer to; e4 `! c  q' I2 ~) Y" n/ C4 h; g
unprotected females through direct skin exposure.
  n+ p" G1 I) H2 N( bSerum testosterone level was found to be 2 times the
+ |8 c/ J: j/ S, K4 ^% X- }baseline value in those females who were exposed to
  P6 N# D$ R( I/ ^even 15 minutes of direct skin contact with their male
! j, J0 r( }! rpartners.6 However, when a shirt covered the applica-/ K- U$ c1 i* u5 V" u0 S4 L
tion site, this testosterone transfer was prevented.6 H7 E! f/ z# T# m( Y7 S
Our patient’s testosterone level was 60 ng/mL,0 p0 Z+ U( {0 Z; L8 Z, x
which was clearly high. Some studies suggest that
' N/ K6 f8 S+ A8 U9 Ndermal conversion of testosterone to dihydrotestos-
  E1 U$ `  `8 h: X9 U- `& [4 T3 kterone, which is a more potent metabolite, is more
' O3 |. j6 G9 |& q- N5 |active in young children exposed to testosterone  y5 `8 C+ `. D
exogenously7; however, we did not measure a dihy-
. b+ \" i1 H; s' tdrotestosterone level in our patient. In addition to0 W9 i0 N! x$ f9 q9 Q0 l+ f& o1 x
virilization, exposure to exogenous testosterone in5 M8 e3 b5 S: v  c
children results in an increase in growth velocity and, S/ Y. E9 M  V
advanced bone age, as seen in our patient.
/ e  m$ y2 _7 |" K; yThe long-term effect of androgen exposure during
: E1 k. w# D6 k6 W; T+ d: F1 {early childhood on pubertal development and final+ f' m# Y! @8 \+ M/ K4 v3 k, G
adult height are not fully known and always remain
! I: _6 u/ [& C/ R' Ha concern. Children treated with short-term testos-5 o5 u, v$ t1 \
terone injection or topical androgen may exhibit some1 z8 U: o/ S0 {2 t- C5 R: z, m
acceleration of the skeletal maturation; however, after
& d2 A" Z  \3 r$ P7 g3 c: y% Ecessation of treatment, the rate of bone maturation
0 r. X0 r' r% vdecelerates and gradually returns to normal.8,9( ~; ]3 M! |6 P: [/ t2 J. l
There are conflicting reports and controversy
( R; h8 A4 K0 B+ u9 F1 Fover the effect of early androgen exposure on adult! w1 R; ^& U' N' n, U
penile length.10,11 Some reports suggest subnormal
. E' C0 z4 T' x8 cadult penile length, apparently because of downreg-  S' F& [; O) R1 ?0 }2 q% O
ulation of androgen receptor number.10,12 However,
. A! _0 F8 u4 ?8 |Sutherland et al13 did not find a correlation between% D: D3 L9 e" d% D9 u; |
childhood testosterone exposure and reduced adult* I- g* k; t: P* l5 i
penile length in clinical studies.
1 P, `3 j7 y8 s" X! p/ G  ANonetheless, we do not believe our patient is
7 L% g/ o6 \4 L# E6 y# Ngoing to experience any of the untoward effects from
) x: a( a' D3 r/ |  T2 Btestosterone exposure as mentioned earlier because4 c3 p. w/ P( N
the exposure was not for a prolonged period of time.
/ ^  C' ~3 E0 j1 P+ V% @; Z" yAlthough the bone age was advanced at the time of
- k5 j2 s" h+ ?8 q4 W; Odiagnosis, the child had a normal growth velocity at
& [% t; [, n& u1 ]the follow-up visit. It is hoped that his final adult+ o  O; B# \2 C' ]
height will not be affected.. L0 v$ |: r6 K! Z* y) y
Although rarely reported, the widespread avail-
- s) u- j! l# v5 H  k7 p3 `7 x- Pability of androgen products in our society may
3 z! R1 {0 a  c! Oindeed cause more virilization in male or female
- U+ u7 [. }/ \) Q5 z8 t2 r* {# nchildren than one would realize. Exposure to andro-
1 ]* l. N$ i6 b0 A0 T% Q0 A. Cgen products must be considered and specific ques-
4 O8 l3 k8 P" t9 a# Itioning about the use of a testosterone product or
- \, U3 V! q; [0 N2 H  rgel should be asked of the family members during9 Y" K- Z: V4 v8 Z- w' g5 w. i9 t6 g
the evaluation of any children who present with vir-
. S9 o* g+ b! i$ X2 gilization or peripheral precocious puberty. The diag-, h0 O4 g: r/ P
nosis can be established by just a few tests and by7 n5 F+ N/ c& W* d. A7 z. ~2 B
appropriate history. The inability to obtain such a6 q6 h( _! n* S8 p" o! Y
history, or failure to ask the specific questions, may
1 n& I+ @" ]) K6 V& p  Q- Iresult in extensive, unnecessary, and expensive
5 D( Z, t0 V/ Q. Xinvestigation. The primary care physician should be
( U! F& |9 J* G3 l0 daware of this fact, because most of these children: s* M7 ^) N; Z6 Y3 Q& Q; g
may initially present in their practice. The Physicians’" S7 `# P  {4 h
Desk Reference and package insert should also put a
3 i0 o- d+ V9 {$ a# E3 ?+ }warning about the virilizing effect on a male or; J% k' ^, e  I8 f0 O; t
female child who might come in contact with some-
! p8 [, |5 \$ Xone using any of these products.
+ Z2 E1 m4 @' R: x- x2 \( oReferences7 I2 Z8 [* ]- t2 |7 S
1. Styne DM. The testes: disorder of sexual differentiation
: n' x4 F8 D5 O4 f5 ?  cand puberty in the male. In: Sperling MA, ed. Pediatric
2 I. R6 m* y3 w! \/ ]) \0 R8 jEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. ?' t' t7 |& e
2002: 565-628.
/ M( U$ X. v! e" \3 Q! r" T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; E+ D% s7 V- V3 p2 p7 |0 S
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
& y  v6 Z# \6 w0 G8 G! IBoy Induced by Indirect Topical+ Z+ C* l! ]- n8 [' X( d- ]
Exposure to Testosterone# n) h9 G8 z0 R" ^+ U7 k7 V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 D& R0 w) ?  j1 i8 a- q% Uand Kenneth R. Rettig, MD1/ E- X- j/ `5 @$ j/ O$ i
Clinical Pediatrics
; N! C% i/ }  Q: N& e3 W, iVolume 46 Number 6
8 ]0 \" z: C' ^% Q2 W% K% ~July 2007 540-5434 t8 d9 A' G# ]8 Z' b. ]
© 2007 Sage Publications
( F5 d4 ?, G9 l  q2 |10.1177/0009922806296651/ x# N9 R1 l/ Z7 [4 D) t0 l$ k
http://clp.sagepub.com. P/ @! e# u1 z1 q$ t' M+ b5 p
hosted at
7 ]  D3 Q! q7 P: j8 k; Q" shttp://online.sagepub.com- M6 {) x9 z* N- T- l
Precocious puberty in boys, central or peripheral,
; n8 x/ R" N8 y4 ?1 \, V2 ~( Lis a significant concern for physicians. Central9 {  B( D( g, K) U+ [( s
precocious puberty (CPP), which is mediated
( R/ i, Q" G: f$ C6 {/ b5 dthrough the hypothalamic pituitary gonadal axis, has
; P" N) t$ t9 T/ }% C6 M3 Ca higher incidence of organic central nervous system
. |( ]" S  e: K/ o, W$ Klesions in boys.1,2 Virilization in boys, as manifested  X1 _8 J0 i9 o' U( A# A: ^
by enlargement of the penis, development of pubic
  G- j4 A' v; `6 Ghair, and facial acne without enlargement of testi-# i# i8 ~0 g6 u  t. T/ y
cles, suggests peripheral or pseudopuberty.1-3 We
- E2 h, B  K% N% \: f, Lreport a 16-month-old boy who presented with the+ N/ h* i# S' j- h5 h/ l% u& C
enlargement of the phallus and pubic hair develop-3 g  H9 L& u4 {% n. T! q. c: C
ment without testicular enlargement, which was due) ~5 c4 x. {8 _  e4 A
to the unintentional exposure to androgen gel used by6 s7 u8 c5 L, O) ~1 b* R' y+ G( }
the father. The family initially concealed this infor-
( F2 j& Z; B0 Pmation, resulting in an extensive work-up for this
% Q6 ~0 e7 N# n- ]% mchild. Given the widespread and easy availability of
& r0 h6 \: F% E. Vtestosterone gel and cream, we believe this is proba-
( u% s) f( [, s" S8 I6 S& Qbly more common than the rare case report in the! ~9 V; O! E1 e( G* G
literature.42 g8 h1 Z( ?7 k
Patient Report% K* n  h+ `# {. [
A 16-month-old white child was referred to the
) i9 |* ?  ?/ ?! V) fendocrine clinic by his pediatrician with the concern  d9 F, I$ R9 y* D: x  g+ m9 d
of early sexual development. His mother noticed/ @! i4 {7 v0 ]9 L" u" W
light colored pubic hair development when he was
' f" S. H  H( l" I0 F: YFrom the 1Division of Pediatric Endocrinology, 2University of3 r0 x0 M9 w+ U4 p& p* j" |. N: J
South Alabama Medical Center, Mobile, Alabama.
/ y$ o1 f8 @/ S& h5 \! vAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 U8 B* I  f' b. [' {- _Professor of Pediatrics, University of South Alabama, College of
6 U% h9 M- j) k: CMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. V, T4 G: N, b, R1 \e-mail: [email protected].
  D- r+ @1 ]! A  o3 U: \about 6 to 7 months old, which progressively became
* {3 t1 U" K1 P$ i' K2 Mdarker. She was also concerned about the enlarge-
) i' F0 C: f; jment of his penis and frequent erections. The child
$ R3 ~' k5 Q8 n6 m* X* F: ]was the product of a full-term normal delivery, with
( b. j0 t7 R1 Ka birth weight of 7 lb 14 oz, and birth length of
2 M8 U7 l+ q9 C; x20 inches. He was breast-fed throughout the first year9 I: u; ~4 y  v7 R* s" z$ x
of life and was still receiving breast milk along with( [5 l: S! j# o  L& ?/ q
solid food. He had no hospitalizations or surgery,
: G$ n" L  W% S. K9 i. `and his psychosocial and psychomotor development
( q, E( }: O- E& M. Gwas age appropriate.4 w) i" `9 _0 m. F
The family history was remarkable for the father,
+ O; s" P4 l: G8 |who was diagnosed with hypothyroidism at age 16,) p9 ]7 z7 ]( P
which was treated with thyroxine. The father’s
7 j& P' i# E( \$ bheight was 6 feet, and he went through a somewhat- z9 x  D) D7 C8 x# Z7 r
early puberty and had stopped growing by age 14.
4 g2 g+ E0 m$ n" xThe father denied taking any other medication. The( o. F. ^4 ^+ c" B, L5 H
child’s mother was in good health. Her menarche5 t- d9 }- H$ K2 @' P
was at 11 years of age, and her height was at 5 feet5 H, K0 g& I. ?  h$ R9 F3 |/ P+ x  n
5 inches. There was no other family history of pre-! P9 N% s# u  O1 s
cocious sexual development in the first-degree rela-! e7 F7 W1 n/ n( Q) O% Z( s" ^4 X" `
tives. There were no siblings.) V7 Q6 l7 Q  a5 ]1 W# j0 G
Physical Examination
  y2 D; ^7 l! v* V4 j3 nThe physical examination revealed a very active,
) Q  P! f0 m+ S+ d" qplayful, and healthy boy. The vital signs documented8 R6 R$ z3 O+ A% u* n  s" Z
a blood pressure of 85/50 mm Hg, his length was
! p; D- F) q# O6 H$ q% s! m90 cm (>97th percentile), and his weight was 14.4 kg
" s9 ^! Z1 i' L% H0 Z+ Q(also >97th percentile). The observed yearly growth9 i; K4 o" D: P
velocity was 30 cm (12 inches). The examination of
" z+ A# t1 L0 w+ ^the neck revealed no thyroid enlargement.% J7 c! |/ [7 ]7 b/ E
The genitourinary examination was remarkable for
1 _# ~' t8 @1 ^( R# H; Penlargement of the penis, with a stretched length of
2 `. o5 e* B! }9 ^7 m2 T, k8 cm and a width of 2 cm. The glans penis was very well, ^, }/ ]5 P4 N4 }
developed. The pubic hair was Tanner II, mostly around
7 Z! ~8 @" g& u- ^540' }! f( x' E: x$ D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 A! R0 i% e9 ithe base of the phallus and was dark and curled. The
7 U. m" z& u9 q5 E) |testicular volume was prepubertal at 2 mL each.
0 e2 r; d) L6 W/ Y) t. M% ~1 aThe skin was moist and smooth and somewhat
" l! B9 ~  R6 Q. r* ^( a, Zoily. No axillary hair was noted. There were no
/ j1 H3 N6 v; }4 @$ ]% h8 Pabnormal skin pigmentations or café-au-lait spots.+ L6 X3 U& b% L4 k' x2 b
Neurologic evaluation showed deep tendon reflex 2+) I$ e0 h- m/ }, k
bilateral and symmetrical. There was no suggestion" E: ?9 A) Q2 K6 n! p  \) v
of papilledema.
+ r; x" V& b: W! q0 b( nLaboratory Evaluation
( a, E6 t2 p( |The bone age was consistent with 28 months by. k# ^/ v: Z) M3 C
using the standard of Greulich and Pyle at a chrono-4 O& G. r& }7 f* U# x
logic age of 16 months (advanced).5 Chromosomal( M" g- B+ H9 G2 S7 N5 x  A0 S
karyotype was 46XY. The thyroid function test# V; z' V- h5 C& o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 v$ u6 p4 b, q- V' ?2 c
lating hormone level was 1.3 µIU/mL (both normal).
* Z8 \7 Q0 H& \5 e( a9 g3 [+ S, Y. x0 GThe concentrations of serum electrolytes, blood
/ j+ |, S6 g% Z! `0 E! m, d) xurea nitrogen, creatinine, and calcium all were2 [5 I6 `0 q3 V2 d: x; j- M
within normal range for his age. The concentration
2 m/ e: Q0 {  u5 `5 A( vof serum 17-hydroxyprogesterone was 16 ng/dL% C( w* c( t/ Q* D4 L# c0 g
(normal, 3 to 90 ng/dL), androstenedione was 20$ N( A6 ^9 r; H3 o* R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 T% ~6 `- q" S3 t" Eterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 d2 d/ M/ P  E2 N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: H5 i) M# N% K9 H49ng/dL), 11-desoxycortisol (specific compound S)
- h3 j! v7 Y2 U9 _& o+ F" Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-  S( _7 ]( `- M  U7 s/ m
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 F) I- ?* f8 g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; h) i. o  `8 V) Y- Mand β-human chorionic gonadotropin was less than
8 C) Z: t3 V1 X5 mIU/mL (normal <5 mIU/mL). Serum follicular: Z4 e) d- A2 B3 w3 @6 o4 v
stimulating hormone and leuteinizing hormone
% C9 B! b* k8 B  qconcentrations were less than 0.05 mIU/mL
; d5 `( \" {! q7 B( s% R+ K(prepubertal).* y4 z+ \( v! t$ v, d. Y
The parents were notified about the laboratory. W- K! [8 \% u7 T4 C! l
results and were informed that all of the tests were
8 `( m* a! k- ]$ Hnormal except the testosterone level was high. The7 i: d- [: y; Q' G( z
follow-up visit was arranged within a few weeks to
9 n; N4 H* ^6 i) r2 r; @7 B# t% A7 zobtain testicular and abdominal sonograms; how-
* J  g2 D5 T9 E( Y( c6 a% G7 dever, the family did not return for 4 months.
+ C* v$ E  e3 N% }Physical examination at this time revealed that the) t8 r3 h4 C& E4 C) v+ Y5 q
child had grown 2.5 cm in 4 months and had gained
, s9 @! f, ]1 X) W7 I0 J* g) z2 kg of weight. Physical examination remained
- w3 y4 H( N* junchanged. Surprisingly, the pubic hair almost com-
7 t$ I" b4 Y; D5 C( Bpletely disappeared except for a few vellous hairs at1 O( C, N% M" Q# @* F  m
the base of the phallus. Testicular volume was still 2
: x+ O, G+ d/ M3 S! KmL, and the size of the penis remained unchanged." n, t1 H1 a( d  y( D* E8 x" D; `
The mother also said that the boy was no longer hav-
9 c$ [  b/ P3 j2 sing frequent erections.- y3 I1 ~1 ~" v3 \
Both parents were again questioned about use of
+ z* r# R8 t- Z6 Tany ointment/creams that they may have applied to
6 z; t0 Y, P& I/ }5 dthe child’s skin. This time the father admitted the3 s: k5 w  o( V$ k
Topical Testosterone Exposure / Bhowmick et al 541
; r4 u6 A9 B; ouse of testosterone gel twice daily that he was apply-
  M, H) D, o8 K. Qing over his own shoulders, chest, and back area for
4 N8 m' P6 z) ]% H% g. O1 V4 za year. The father also revealed he was embarrassed
8 v: t$ ?; ?/ t' kto disclose that he was using a testosterone gel pre-7 w; }3 \' Y% l; s5 b: ?6 p' s2 u5 M
scribed by his family physician for decreased libido  K2 t9 M! z; I/ U
secondary to depression.9 t7 B1 i, F- ]
The child slept in the same bed with parents.
- }4 L: l- S- ^The father would hug the baby and hold him on his$ L; L7 I+ I' I( m* j
chest for a considerable period of time, causing sig-  {/ K* J5 z5 U3 P1 J/ V
nificant bare skin contact between baby and father.# @+ y8 R$ T9 w# d# f2 ?! l( w( @% i
The father also admitted that after the phone call,
9 C" s2 I0 |2 c4 q% xwhen he learned the testosterone level in the baby, h' m  d8 P' v! g$ A
was high, he then read the product information
8 [( }! n4 X/ k$ O/ x9 P6 Ppacket and concluded that it was most likely the rea-
5 d( t2 C4 \+ S+ Z& dson for the child’s virilization. At that time, they9 z: c; E; [1 W: V3 F
decided to put the baby in a separate bed, and the: F8 z, U: J6 r2 C- k* T- {
father was not hugging him with bare skin and had
+ t, V. }# L: Mbeen using protective clothing. A repeat testosterone
, j% `, }1 |9 @; T! E' U4 `test was ordered, but the family did not go to the
* e$ K' D5 u6 Wlaboratory to obtain the test.
% r3 N* c% h! z0 `- a$ O% TDiscussion- J9 Y% P. t- H& |: t
Precocious puberty in boys is defined as secondary8 s! X9 r" k0 T3 z8 r( G" a
sexual development before 9 years of age.1,4
" `' z. S, z. E) o/ rPrecocious puberty is termed as central (true) when0 O: f7 N# F, i* q3 Q" q$ d8 d
it is caused by the premature activation of hypo-
/ c/ ?" [$ W# B* G% p9 nthalamic pituitary gonadal axis. CPP is more com-
7 t4 e9 ~) ]6 c9 T7 e& _; omon in girls than in boys.1,3 Most boys with CPP
. {, o# s4 q  a# r9 l) p, S# Jmay have a central nervous system lesion that is
) B/ P& W# \2 s1 Q3 g2 I4 ?6 Jresponsible for the early activation of the hypothal-% v4 C; P& a2 d) i+ A: W2 A5 G4 u
amic pituitary gonadal axis.1-3 Thus, greater empha-
  b8 \$ o$ L% s0 o. I7 Tsis has been given to neuroradiologic imaging in
2 `* @$ `: @% w" j: lboys with precocious puberty. In addition to viril-, j0 k$ Q( g" Q' j/ q8 g/ o0 Z/ {
ization, the clinical hallmark of CPP is the symmet-* X" D: t4 x; Q: B9 R5 Y" A# P
rical testicular growth secondary to stimulation by+ D% C! h! d* V, z! O
gonadotropins.1,38 M- X) P- {6 G9 i& g: z5 `; f
Gonadotropin-independent peripheral preco-
; W) t3 M/ R4 e  R$ b. Jcious puberty in boys also results from inappropriate
7 R7 r2 L4 F/ X+ a, Uandrogenic stimulation from either endogenous or1 V- B2 ^( Y3 K6 a1 \1 H
exogenous sources, nonpituitary gonadotropin stim-
5 z- E9 B, N. n9 @ulation, and rare activating mutations.3 Virilizing  t2 s' _" e/ r# s# i! i4 p
congenital adrenal hyperplasia producing excessive( l1 S* k3 z$ o0 Y& `4 E& v
adrenal androgens is a common cause of precocious* D/ @3 y. y3 k6 _8 T
puberty in boys.3,4
8 G  H; X/ X' h- d: w+ m( {The most common form of congenital adrenal/ u% r" }5 M, s* X- m
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 C/ ~1 l# z7 @. m/ r. E! Z6 j- ~The 11-β hydroxylase deficiency may also result in* M9 |7 }2 X4 @# R5 d" p
excessive adrenal androgen production, and rarely,0 M. x/ D9 _' x( [# z6 A
an adrenal tumor may also cause adrenal androgen
: E: W  l1 Z" h. \, r! ]! yexcess.1,3: w0 t6 S8 G5 m7 m0 D8 ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ l& d' u# h  t  \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( P0 F/ |- r; ~- z  C: aA unique entity of male-limited gonadotropin-' |" m" p0 U5 ?+ s
independent precocious puberty, which is also known8 ^$ i- S# Q6 D, b- O3 o# [
as testotoxicosis, may cause precocious puberty at a9 d2 w) `+ @- B% N
very young age. The physical findings in these boys
+ r: k1 B# P; D; cwith this disorder are full pubertal development,0 h. `% [  g" ?9 \) ~0 W: q1 T
including bilateral testicular growth, similar to boys
+ m0 B  Q7 h5 g6 a0 ^$ J! P$ Q* `with CPP. The gonadotropin levels in this disorder
" E5 n  e( j) b- m- d% Lare suppressed to prepubertal levels and do not show
4 B5 ?2 Y6 P& t( _5 b+ j: R1 ]pubertal response of gonadotropin after gonadotropin-
  P0 T* `" X5 }$ A, x+ a0 }releasing hormone stimulation. This is a sex-linked/ b. H% j$ {9 [6 Q
autosomal dominant disorder that affects only
' a- K' \* F5 c: m8 o2 emales; therefore, other male members of the family* L7 t# ]3 M0 b9 D
may have similar precocious puberty.3' F2 E5 t* X! |- ]/ @" a! L* r' R
In our patient, physical examination was incon-! [) A$ }% S- f% i
sistent with true precocious puberty since his testi-
5 P/ K9 ]4 D9 ccles were prepubertal in size. However, testotoxicosis) p* g6 g+ N  ?/ w' f0 I/ D! ~
was in the differential diagnosis because his father" j; y# l+ H$ F( ~* T. x, W2 N3 ~
started puberty somewhat early, and occasionally,
  ~/ g4 d+ m; o! A% \) M, d2 Itesticular enlargement is not that evident in the
# {' z' `5 i0 |! w) [8 Jbeginning of this process.1 In the absence of a neg-% |3 Z) {0 J; d$ f7 g8 k
ative initial history of androgen exposure, our
- P* ^& l( T1 S* abiggest concern was virilizing adrenal hyperplasia,
- I& E) b9 o5 \( S( leither 21-hydroxylase deficiency or 11-β hydroxylase  s' Y& u" ]# G7 u
deficiency. Those diagnoses were excluded by find-1 l$ e8 o/ s6 F  U
ing the normal level of adrenal steroids./ W7 q/ Z' l4 C0 {- E; t7 U; D
The diagnosis of exogenous androgens was strongly
) e: p* [7 {- R! o" e; tsuspected in a follow-up visit after 4 months because7 K* e2 @4 j7 ~/ p2 c' W* d
the physical examination revealed the complete disap-# [3 x( H& d* j' m& C* e
pearance of pubic hair, normal growth velocity, and
: V7 ?' @7 a5 U; q8 |2 H: x+ l; Mdecreased erections. The father admitted using a testos-4 s1 w) D9 C% X+ h% J) H
terone gel, which he concealed at first visit. He was
7 b1 U7 g9 h' v# B; D& Ausing it rather frequently, twice a day. The Physicians’
/ o8 [& k4 m* z# \Desk Reference, or package insert of this product, gel or9 k. N/ R; B9 E. _! ^! l
cream, cautions about dermal testosterone transfer to
& C6 H. j/ C4 L# Cunprotected females through direct skin exposure.: z. B8 v# x1 D% w# J. v
Serum testosterone level was found to be 2 times the4 i# ~3 i. S* P3 a
baseline value in those females who were exposed to8 l: h9 z. C+ Z- x9 ?
even 15 minutes of direct skin contact with their male' F5 \  C, O, H6 a- M7 K
partners.6 However, when a shirt covered the applica-: B; {3 N, [8 F* [7 x. \+ p
tion site, this testosterone transfer was prevented., W( A1 A: U% ~6 S5 y* a
Our patient’s testosterone level was 60 ng/mL,) ^* [3 J% c1 c1 s# O* a2 l
which was clearly high. Some studies suggest that: i! z1 `9 y1 m
dermal conversion of testosterone to dihydrotestos-) k4 p  n. X' f  @. @
terone, which is a more potent metabolite, is more
# \! n* h" C* Z/ x! Bactive in young children exposed to testosterone
8 D$ D9 @) T$ U1 I! j* fexogenously7; however, we did not measure a dihy-
/ Z8 n$ K2 ~: [9 hdrotestosterone level in our patient. In addition to
5 C* k3 I# y, j: n+ q% Fvirilization, exposure to exogenous testosterone in
5 d% J* M) b; a: Q, h; E  H) ?5 |# uchildren results in an increase in growth velocity and- e) b" E2 h% P7 x# ?
advanced bone age, as seen in our patient.5 j# R# G/ @/ Y' Z4 L
The long-term effect of androgen exposure during
$ T+ ~3 K' v* S% i: F. T. wearly childhood on pubertal development and final
* N" b0 i. k6 C# R4 f* B' A6 x+ cadult height are not fully known and always remain
" f" Q$ W" I8 M* Ya concern. Children treated with short-term testos-/ a4 V4 }" V8 R7 [9 |2 D  a
terone injection or topical androgen may exhibit some2 m  c9 B2 f1 D8 \7 B
acceleration of the skeletal maturation; however, after
; S2 \/ I5 S8 u: p, H4 hcessation of treatment, the rate of bone maturation
) }* U8 D9 F2 T) Z; edecelerates and gradually returns to normal.8,9
' _( ^' K+ k9 P  a+ IThere are conflicting reports and controversy/ W  D0 F/ e. |) T
over the effect of early androgen exposure on adult
2 a# R, s8 r+ J# T! qpenile length.10,11 Some reports suggest subnormal1 {- ~7 ~6 _3 ~  i: d9 V  t, [
adult penile length, apparently because of downreg-
1 [4 b# Q% J! i+ Z  Vulation of androgen receptor number.10,12 However,
+ l! u! X9 Q3 J4 w0 N3 F7 N0 ESutherland et al13 did not find a correlation between2 V( g) i$ \7 {& E
childhood testosterone exposure and reduced adult
7 v* Y' q; a5 I1 y- C" {. V+ ypenile length in clinical studies.
3 K8 {# j1 _6 ]Nonetheless, we do not believe our patient is
' o2 _! q: E- u, Zgoing to experience any of the untoward effects from( O( J- `$ Q# {" m% ~% N. E# P
testosterone exposure as mentioned earlier because  j% I: P' N* K8 ]1 w8 H2 }; K  }- z( b
the exposure was not for a prolonged period of time.' J: B- R/ L4 Z, E2 h5 k) {
Although the bone age was advanced at the time of
4 i( i. W. n% P8 cdiagnosis, the child had a normal growth velocity at  ]3 D8 Q0 B7 M& B
the follow-up visit. It is hoped that his final adult
/ r7 T5 ^+ y% J+ l  g8 z# l, Rheight will not be affected.& F2 E& Y$ k4 U& Z- x; R! U
Although rarely reported, the widespread avail-' a. y& v+ P; q, K7 C% I
ability of androgen products in our society may: k% y7 Z, a( V- q  f& v
indeed cause more virilization in male or female
. z( f3 M2 Q, \) p$ E6 c8 R' Uchildren than one would realize. Exposure to andro-
- s& e) x: j9 ?0 fgen products must be considered and specific ques-
; f9 s8 d& ~, C, \tioning about the use of a testosterone product or- B4 K& U% t& S( b1 q  Y8 g/ K$ K. x
gel should be asked of the family members during3 e6 M8 V1 F! |5 ~' t" l
the evaluation of any children who present with vir-3 O; m  n# Q& m2 q/ s4 ^% F
ilization or peripheral precocious puberty. The diag-, k. @4 y5 G7 l# e
nosis can be established by just a few tests and by
! }- @" c$ k" n0 v- Aappropriate history. The inability to obtain such a  |+ H' T, r7 n3 G& H) Z/ h3 |3 p% O
history, or failure to ask the specific questions, may
! n- l, `8 r2 v7 C6 Vresult in extensive, unnecessary, and expensive) b2 P2 q7 `6 J9 H* Q
investigation. The primary care physician should be1 l+ O; o9 |/ f* k9 Z% }+ n$ D
aware of this fact, because most of these children, ~, C- |7 H: X  j& O* s
may initially present in their practice. The Physicians’
7 j: i: N2 c: Z, RDesk Reference and package insert should also put a7 i! ^1 G8 Y7 |& P3 J1 L' F9 m: }
warning about the virilizing effect on a male or+ M$ S/ v' t6 P$ n7 R& p. i
female child who might come in contact with some-
7 ^, n2 b0 i$ O0 F' None using any of these products.
  D  e, \* c! b: KReferences- N4 V, e- P! Q6 x
1. Styne DM. The testes: disorder of sexual differentiation# O' {! J- S* M0 L3 Q" h( N( Y  u
and puberty in the male. In: Sperling MA, ed. Pediatric
4 D# Z$ ~' s! [' a$ Z& \1 UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 i* E# X3 `7 N) y/ f0 t) \+ D5 H
2002: 565-628.! m2 i' A5 ~- G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# E' _# Y9 ?' npuberty 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
) @3 l/ i, q* _3 J" G
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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