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Sexual Precocity in a 16-Month-Old! P0 {5 F0 F4 x
Boy Induced by Indirect Topical, C0 X& Z( `9 @$ `) l
Exposure to Testosterone# B. p" W7 u' e% M( o% D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 v5 r1 G0 W/ u
and Kenneth R. Rettig, MD1. _6 N% t/ q* T
Clinical Pediatrics' P% I3 T8 [( f, v% C
Volume 46 Number 6
/ U' m. r, R3 l+ a. jJuly 2007 540-543% f/ V6 Z! k' t; E% a4 t
© 2007 Sage Publications( H8 q% o3 t0 M. n* Q% m
10.1177/0009922806296651: L# Z1 Q' S; E6 W* f- [
http://clp.sagepub.com6 [* B, b1 o$ x9 K( c- T  E
hosted at- U6 r5 U8 p4 z, [% D
http://online.sagepub.com
' y) o; w+ \3 j; K" B$ aPrecocious puberty in boys, central or peripheral,
) A& f" [9 `- Z+ uis a significant concern for physicians. Central* ?5 s6 N: Q) o$ F
precocious puberty (CPP), which is mediated% k. j* F8 i! J
through the hypothalamic pituitary gonadal axis, has
% Q( J+ w2 e$ Ca higher incidence of organic central nervous system
. A( ^& r' C& ^' b9 Zlesions in boys.1,2 Virilization in boys, as manifested
% B3 ?) y& y# x8 s- vby enlargement of the penis, development of pubic
) R# g6 U, e& [$ {* O2 ?+ fhair, and facial acne without enlargement of testi-
6 @' W6 q9 l/ h- ?+ P+ ecles, suggests peripheral or pseudopuberty.1-3 We
$ [+ N* Q) e( t! ^8 Nreport a 16-month-old boy who presented with the
- @( ?+ S' p" H: [2 _# Lenlargement of the phallus and pubic hair develop-
6 I+ b; Y2 k9 t% F6 m! q" Ament without testicular enlargement, which was due
' ~) d0 l0 l1 u' D# yto the unintentional exposure to androgen gel used by
8 {  M  W) o! e$ [9 w2 h7 r. s1 Gthe father. The family initially concealed this infor-& i: W+ A. F& h5 I3 B6 Q' D9 W
mation, resulting in an extensive work-up for this
: N6 v8 i( e  @4 ]. s' N: g. Xchild. Given the widespread and easy availability of
' [9 g# T* z& x, S8 r% e9 ztestosterone gel and cream, we believe this is proba-
- O6 d( p/ l7 g9 T+ ^; G2 i0 `- nbly more common than the rare case report in the! O8 H8 X# z6 |* J) h. K& \* l
literature.40 s. r. `3 l& k) r$ f1 y9 x
Patient Report1 W4 k2 t$ E( q" B% V2 T
A 16-month-old white child was referred to the
3 G! f% D  q3 P% D$ _: Kendocrine clinic by his pediatrician with the concern
0 m5 ~1 t* N' Y" ?8 ~of early sexual development. His mother noticed3 c1 I! G5 f5 E4 o" g
light colored pubic hair development when he was- e6 L! }: J' W2 X
From the 1Division of Pediatric Endocrinology, 2University of8 |! j+ i' o6 F6 G. {- V& H: l
South Alabama Medical Center, Mobile, Alabama.. Y+ {3 T6 z( X
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- s+ T+ _+ p9 q$ c+ N. j1 W0 I( bProfessor of Pediatrics, University of South Alabama, College of, T: y( D- L2 F# {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 e# l* h% F/ d5 f0 R& Y( ~. }e-mail: [email protected]./ b8 m" ^8 i& E
about 6 to 7 months old, which progressively became
/ X+ y8 r# H3 g+ k+ }darker. She was also concerned about the enlarge-) J, X6 q# }; W( j& c+ u& |
ment of his penis and frequent erections. The child8 b+ L; M) q5 h, K
was the product of a full-term normal delivery, with
/ E( k& v+ z% f, R, a" ~a birth weight of 7 lb 14 oz, and birth length of" `* Z0 A2 P7 G, m8 L( Q5 }
20 inches. He was breast-fed throughout the first year3 E' t  e" G" o1 K# G
of life and was still receiving breast milk along with' W' k5 _+ z* h; u- A
solid food. He had no hospitalizations or surgery,( d, y2 }' |  P! z# V$ L4 {) H% {8 m2 U
and his psychosocial and psychomotor development
+ G& Q9 Q& Y4 swas age appropriate.
9 f: r5 e+ N4 y6 N! RThe family history was remarkable for the father,5 k' f. `1 s! U; m. y9 ?" Y
who was diagnosed with hypothyroidism at age 16,
6 _) Q$ f+ L5 W  A0 C; g/ rwhich was treated with thyroxine. The father’s
% J  ?! k6 [  h$ cheight was 6 feet, and he went through a somewhat
* }, V" B9 u$ V# ^) J0 \2 v/ oearly puberty and had stopped growing by age 14.
( A. v. C, a9 A7 Y2 JThe father denied taking any other medication. The2 G9 N+ L* \  \+ y9 ]$ [$ G; N
child’s mother was in good health. Her menarche4 G5 A7 }2 C$ x
was at 11 years of age, and her height was at 5 feet1 T! u  Z9 m% z
5 inches. There was no other family history of pre-
# g" `# |9 V0 y* C# @9 C4 Ccocious sexual development in the first-degree rela-% c9 o6 A# v4 C2 s' z  I' |
tives. There were no siblings.
. ]$ ~( x( W1 o" j, dPhysical Examination
$ Z) w8 q* Y4 \" k) a8 {5 \The physical examination revealed a very active,
8 A! S1 Z: v' [: t) @( I8 ^) Mplayful, and healthy boy. The vital signs documented
- o1 ^! s* ^0 G7 |6 z2 pa blood pressure of 85/50 mm Hg, his length was8 B- T1 }1 p* ]" t
90 cm (>97th percentile), and his weight was 14.4 kg( \% a: Y8 }4 c
(also >97th percentile). The observed yearly growth
4 [/ d$ S: v7 n$ q1 Tvelocity was 30 cm (12 inches). The examination of
+ x# |" t  x% k" _& y( R0 u! Sthe neck revealed no thyroid enlargement./ o9 g+ @; k; G/ u" e0 M: P
The genitourinary examination was remarkable for7 b" P/ m. L# `/ F; k  Z6 U+ M
enlargement of the penis, with a stretched length of
: J$ G2 O8 r( ^/ M6 J8 f8 cm and a width of 2 cm. The glans penis was very well' O5 V: y$ Q2 Q  U4 W
developed. The pubic hair was Tanner II, mostly around2 T, g; T8 R% h+ ]2 j! O
540' B' G& t( O. M  B" \7 U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ C- @) Q6 t2 ~
the base of the phallus and was dark and curled. The: E- Y( |: ?9 O. N% V
testicular volume was prepubertal at 2 mL each.
: K$ f( d7 Q" K5 VThe skin was moist and smooth and somewhat
1 K8 ?. H& Y2 D' Q* E$ D  V- Yoily. No axillary hair was noted. There were no
; V& Z  x2 s9 Z; R: ^) o1 }2 ]) N/ Qabnormal skin pigmentations or café-au-lait spots.. F  W' T+ _& i' `% V
Neurologic evaluation showed deep tendon reflex 2+2 M" {$ M8 C% `8 g# _
bilateral and symmetrical. There was no suggestion
( E1 j  j5 y/ d2 q5 G( Lof papilledema.
8 T) H3 C, D( V) lLaboratory Evaluation
5 Q7 I3 g, F* f! ~4 D1 YThe bone age was consistent with 28 months by
7 H3 g2 o* o  r+ \using the standard of Greulich and Pyle at a chrono-: u+ i" R7 N$ O% w7 ^
logic age of 16 months (advanced).5 Chromosomal: W  y( i7 N& B& K% y$ I
karyotype was 46XY. The thyroid function test
5 ]  q9 R* |' w5 P% [, Vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-0 ]( [# c, W+ m6 P$ c
lating hormone level was 1.3 µIU/mL (both normal).; L" J4 ]) D, g" i( V1 y: @
The concentrations of serum electrolytes, blood
# ^. ^. z9 u. ^/ Xurea nitrogen, creatinine, and calcium all were3 M/ m+ k, q, S
within normal range for his age. The concentration3 y% l6 X; }2 J  r& x( A
of serum 17-hydroxyprogesterone was 16 ng/dL
& p- b. J6 y; q9 Q: C: l& B(normal, 3 to 90 ng/dL), androstenedione was 206 _) l) v' d0 w8 @7 X
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- E8 t+ }1 v+ K; @0 Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( ^3 U' I- b% C0 o6 N1 M' {desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ k% B: G8 j) C
49ng/dL), 11-desoxycortisol (specific compound S)
7 `1 V- u1 H7 X) v" q  bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! t$ c# C& x" l. ^tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 q/ N, {( D" V* z! {4 x% ]6 |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 U: w+ ]% o  v- n: R3 }and β-human chorionic gonadotropin was less than) B- B( m+ Q2 S
5 mIU/mL (normal <5 mIU/mL). Serum follicular- E6 B3 d: C9 e; C1 Z
stimulating hormone and leuteinizing hormone
' N! p' Y" c% g. ^  ~& n8 `concentrations were less than 0.05 mIU/mL
/ I/ k4 [1 ]7 b! X! [0 t(prepubertal).
# V4 h, l, `' i7 U* e7 ]The parents were notified about the laboratory2 G( ~, e9 X9 t2 L) _% d5 q
results and were informed that all of the tests were
# o3 X7 @: j! |* g1 V3 P8 W, n" p5 Znormal except the testosterone level was high. The% \2 c0 H# l& P2 Z% Y/ |
follow-up visit was arranged within a few weeks to
( B; ~9 p2 P$ v3 `  V) p9 r+ V, f' F/ Robtain testicular and abdominal sonograms; how-6 C9 w3 x* _5 v/ Q  e8 S) N
ever, the family did not return for 4 months.) b+ l1 Z0 s& o( Q+ z7 W
Physical examination at this time revealed that the% }) ]9 ?5 ~% j
child had grown 2.5 cm in 4 months and had gained, a+ t* G. p9 q# |
2 kg of weight. Physical examination remained
1 T6 [2 `2 f. ~4 S) T4 E& H' Nunchanged. Surprisingly, the pubic hair almost com-! f2 }# C  ~8 [4 C- V' s5 o4 p
pletely disappeared except for a few vellous hairs at
+ T2 P( s1 U4 B. Y3 i- P; Pthe base of the phallus. Testicular volume was still 2. u6 ?; u2 c( u( \) l: }- s
mL, and the size of the penis remained unchanged.
( D4 C* O2 f/ L2 R) }( fThe mother also said that the boy was no longer hav-7 X* Y9 L% J: a) z: a, x& f
ing frequent erections.; |  u: D; P; z0 R, B5 Y+ `: Z4 E
Both parents were again questioned about use of
4 p$ z. N; a5 q' c, k8 {any ointment/creams that they may have applied to/ Z% ^6 N# }! [" O# Z( W8 B
the child’s skin. This time the father admitted the5 I. ^. V% K% g" H0 c
Topical Testosterone Exposure / Bhowmick et al 5418 U5 c! O1 g, G$ D$ ~4 U
use of testosterone gel twice daily that he was apply-2 f+ F% J' @1 a9 g4 W' Z. S
ing over his own shoulders, chest, and back area for4 f- ]; }( i+ e! e* k  O) X
a year. The father also revealed he was embarrassed8 P  u" ~; q  D$ Z0 C1 x; P9 b+ C
to disclose that he was using a testosterone gel pre-6 w/ b4 T4 ?8 c- Z1 T/ H8 c" S2 k
scribed by his family physician for decreased libido
9 H, ?' a1 a% G: Esecondary to depression.6 T, R, p9 n+ a- S8 r
The child slept in the same bed with parents.
8 i! s& k! z; y" _9 X& e3 fThe father would hug the baby and hold him on his
; y3 R) G" K* S! `- Q1 V* Fchest for a considerable period of time, causing sig-% H! R8 d4 k% x# y
nificant bare skin contact between baby and father.
  o) o# p( B! H. V" t2 QThe father also admitted that after the phone call,  _% w3 v- }/ v2 H7 @
when he learned the testosterone level in the baby
5 f( F; R! n0 G5 _* cwas high, he then read the product information
  D. V6 h/ ^) I0 B# }( apacket and concluded that it was most likely the rea-$ F7 }5 t5 _/ C0 Z0 l( e
son for the child’s virilization. At that time, they
+ ]6 V6 x! A2 ^* P5 gdecided to put the baby in a separate bed, and the8 b1 m% L9 X- b
father was not hugging him with bare skin and had2 ^" m; v6 ^/ [  \) |- A: c
been using protective clothing. A repeat testosterone0 M. X1 ~: C. I5 _# W. m! F- B9 t
test was ordered, but the family did not go to the
& R) V; `5 ?1 {; O8 Tlaboratory to obtain the test.
2 Q! T3 Q7 b! F% wDiscussion
7 m0 O6 p* M0 m7 \4 K7 h# u7 kPrecocious puberty in boys is defined as secondary
* ]) O* @% B( Gsexual development before 9 years of age.1,48 h- C  q3 e6 g" t6 G+ ]
Precocious puberty is termed as central (true) when
  n" M1 ?6 I( {/ ~6 o( b% dit is caused by the premature activation of hypo-3 E/ s  u' z4 x5 |' _; W$ q$ d2 j
thalamic pituitary gonadal axis. CPP is more com-
) R" I5 \6 [4 g: ^mon in girls than in boys.1,3 Most boys with CPP3 D0 x9 ?: }' C4 P' p
may have a central nervous system lesion that is* W! X1 j9 }: b' X$ ?
responsible for the early activation of the hypothal-. ^5 Q! @- f" ]  k) Y8 q
amic pituitary gonadal axis.1-3 Thus, greater empha-; F) C4 e2 S/ m  b; Y
sis has been given to neuroradiologic imaging in
9 n+ n. ]- Y8 |boys with precocious puberty. In addition to viril-
! a; Z. t! M+ h! g9 wization, the clinical hallmark of CPP is the symmet-7 ~+ _( C5 L; U7 y/ T5 A8 `
rical testicular growth secondary to stimulation by
3 w1 r/ {. l. A$ T4 r% ~6 P5 Mgonadotropins.1,32 I7 q1 Z+ p6 B2 B& O
Gonadotropin-independent peripheral preco-7 g& F# J# b4 f, ?* `1 p
cious puberty in boys also results from inappropriate* g' e- k) o1 T- k
androgenic stimulation from either endogenous or- w1 k2 F. ?: e. ]. \2 W
exogenous sources, nonpituitary gonadotropin stim-
( a6 V7 A" h2 d) G! kulation, and rare activating mutations.3 Virilizing
8 t3 T# [  L  x5 Bcongenital adrenal hyperplasia producing excessive
4 ~% s4 }' G  \' |adrenal androgens is a common cause of precocious
  W$ h  Z+ A2 U5 B, b2 m: vpuberty in boys.3,4
' x& k2 ~  i5 L/ [The most common form of congenital adrenal  H3 m. s) }, i" N
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 X6 A9 O, h: ^The 11-β hydroxylase deficiency may also result in: a6 A, n3 U, e
excessive adrenal androgen production, and rarely,) G; \6 V8 \4 l1 T
an adrenal tumor may also cause adrenal androgen
" d3 Y; g2 _- A) y+ d: i8 Fexcess.1,34 {, A7 t" F  w0 Z. P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; I6 M5 f: w" F9 U/ S" m( r2 a
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 W& d) l- [+ {5 N
A unique entity of male-limited gonadotropin-0 Z8 N* r5 A7 w2 i" P
independent precocious puberty, which is also known
& I) C! O# v" x6 yas testotoxicosis, may cause precocious puberty at a
0 ~) b0 A; R# U0 c  h: d7 tvery young age. The physical findings in these boys
2 M( ]9 ]' v' @+ p' twith this disorder are full pubertal development,
$ b) G* ]% b" R& R1 e, K2 b3 ]including bilateral testicular growth, similar to boys
  y" `: G9 W# S2 k3 c4 ~1 \$ ~) U3 jwith CPP. The gonadotropin levels in this disorder% F+ {" V- r5 {4 _# F
are suppressed to prepubertal levels and do not show4 u  V  ~+ _0 s; L1 \6 N1 X* m
pubertal response of gonadotropin after gonadotropin-3 C6 S0 r6 @, U, }3 G
releasing hormone stimulation. This is a sex-linked/ j0 b. Z& I6 g" T8 O1 p) n
autosomal dominant disorder that affects only; J) F3 h1 [2 O5 D  N
males; therefore, other male members of the family
0 M1 g& _) L) \: F" u/ k3 imay have similar precocious puberty.3
; _, j/ H: [/ U6 D; S7 f% C& OIn our patient, physical examination was incon-
' @0 ]+ O. B! K' Y  Vsistent with true precocious puberty since his testi-) A) x6 Q% u; Z  B8 p
cles were prepubertal in size. However, testotoxicosis
% W( y8 h+ Y( B6 t  d$ Fwas in the differential diagnosis because his father% E2 Z4 b7 Z: q8 D8 v
started puberty somewhat early, and occasionally,
+ J/ b0 N, W. P( _testicular enlargement is not that evident in the( H9 M- @$ K9 M! ^
beginning of this process.1 In the absence of a neg-
4 j9 B* W$ d: d1 i: H9 lative initial history of androgen exposure, our
1 r  {, r- a( c* z$ I/ bbiggest concern was virilizing adrenal hyperplasia,/ I. [7 S: ^1 Q9 ^5 u+ j/ ~2 q9 M% M
either 21-hydroxylase deficiency or 11-β hydroxylase
/ P( J) z0 W6 N; j4 Fdeficiency. Those diagnoses were excluded by find-9 Z* @8 d" M* j( J" H) z; @& {; @
ing the normal level of adrenal steroids.( V# i6 j+ l, o0 o
The diagnosis of exogenous androgens was strongly
  v6 r8 W. f$ L# asuspected in a follow-up visit after 4 months because
( S$ n" G: V1 K# m3 e& h( E  Wthe physical examination revealed the complete disap-
% ~% o) M8 F) Y2 ?1 jpearance of pubic hair, normal growth velocity, and1 V( Q1 o! d' K$ K7 G7 c+ T0 E$ g
decreased erections. The father admitted using a testos-# o% t( F) E6 u- N+ T
terone gel, which he concealed at first visit. He was
9 N# f6 {0 d" ^) N3 O- K) Husing it rather frequently, twice a day. The Physicians’+ W. p* I; r" H9 |7 B7 l
Desk Reference, or package insert of this product, gel or
3 ?0 L7 g, Q9 D  A" Ccream, cautions about dermal testosterone transfer to( g. T) O2 R! r
unprotected females through direct skin exposure.
2 A6 {* G" c) A* [/ xSerum testosterone level was found to be 2 times the3 q; l6 E1 t  ]* }, _
baseline value in those females who were exposed to
! ?, y( l( f3 \: c8 G1 Beven 15 minutes of direct skin contact with their male% n+ z, ^1 F7 y" Q8 R2 U5 a
partners.6 However, when a shirt covered the applica-; @4 S4 U+ A9 D
tion site, this testosterone transfer was prevented.
! @: r, i7 i( K+ r% TOur patient’s testosterone level was 60 ng/mL,0 X3 K, k& t% X2 g1 }
which was clearly high. Some studies suggest that
5 ?5 A" }- f8 P; d* Cdermal conversion of testosterone to dihydrotestos-
5 I* u5 f- Y& |3 dterone, which is a more potent metabolite, is more; Q/ M- h: n4 R/ e# E! N) I, G
active in young children exposed to testosterone( \3 ~. ?0 O5 w7 @& g
exogenously7; however, we did not measure a dihy-0 ^! J; C* ?+ C  w6 {
drotestosterone level in our patient. In addition to
/ T) h5 j1 ~4 dvirilization, exposure to exogenous testosterone in$ V, z+ w" v* q& R0 G# p
children results in an increase in growth velocity and
. E7 q' u0 ?( h; L4 q2 w! uadvanced bone age, as seen in our patient.( Q2 ?* i$ T" H1 `+ C4 o
The long-term effect of androgen exposure during% R2 h7 ~" K3 T7 X, t) p
early childhood on pubertal development and final7 X& T7 J6 _* G0 v
adult height are not fully known and always remain
6 `3 o* B' m1 K% o3 }+ R1 n. k/ ya concern. Children treated with short-term testos-
' N( L* @% R+ m5 h' P0 Xterone injection or topical androgen may exhibit some% n& r0 ]. c" t* K8 S3 W& Y' H/ [2 o
acceleration of the skeletal maturation; however, after/ x# P" D  ^# }: T4 D
cessation of treatment, the rate of bone maturation4 b4 T1 |; }+ t; ]% c& k& G. l
decelerates and gradually returns to normal.8,9( n) l$ S9 j2 W! r; S0 l
There are conflicting reports and controversy
6 c8 B& t7 Y4 i" F3 pover the effect of early androgen exposure on adult
: l: a6 e" `2 ?/ Dpenile length.10,11 Some reports suggest subnormal
7 \' J* R, E7 A8 G: \0 ?" madult penile length, apparently because of downreg-
* ~; e' {8 N; W8 I) Eulation of androgen receptor number.10,12 However,
3 h; u# x( \  Z% y4 Y5 W, o- ?Sutherland et al13 did not find a correlation between
4 Q# L8 M" y9 f8 u4 Pchildhood testosterone exposure and reduced adult" }! o. f9 z. U' Z1 e
penile length in clinical studies.
  u' S& ~* P9 ]4 V4 ?$ ~5 M9 cNonetheless, we do not believe our patient is
$ i, u! N. c5 [going to experience any of the untoward effects from- {1 {2 v" }& ?! t& h( T
testosterone exposure as mentioned earlier because
5 W  Q5 g' s" X+ e8 K9 v8 Pthe exposure was not for a prolonged period of time.
5 i; [: i& X/ e9 e/ dAlthough the bone age was advanced at the time of
+ F6 G$ }  d/ y5 N! jdiagnosis, the child had a normal growth velocity at! k' \# O# ]6 H2 ^. O5 ^, M
the follow-up visit. It is hoped that his final adult% m1 N6 C7 X9 M8 L: \# l* T, k
height will not be affected.
7 f) i7 C- x: i% P2 @2 }0 tAlthough rarely reported, the widespread avail-1 F5 D( J* f4 m6 k" h: y% B1 o
ability of androgen products in our society may
( u! r. M# \8 I  d) W% e1 u. xindeed cause more virilization in male or female
+ E- F" `+ O( a1 mchildren than one would realize. Exposure to andro-
# \! M: }9 C  I" K9 J" j' Rgen products must be considered and specific ques-! J/ K. f' e0 K# b
tioning about the use of a testosterone product or
2 |  {& y; _1 D4 bgel should be asked of the family members during; @1 Q/ u: L. j- e
the evaluation of any children who present with vir-6 m$ A9 ~0 ^- Q8 c4 G
ilization or peripheral precocious puberty. The diag-1 c) E5 r  u- q- C" `. A% E
nosis can be established by just a few tests and by$ Q9 @' o" t  m: d+ F
appropriate history. The inability to obtain such a
" V% j- ~. y+ O* L/ K; ~5 m% ihistory, or failure to ask the specific questions, may
# b  d. I+ o- ]result in extensive, unnecessary, and expensive, `) w6 `+ x* P% x. k$ l) w5 c. X
investigation. The primary care physician should be
, c/ ^9 N! F. \' s" a. V  r6 u. Baware of this fact, because most of these children
* B! V' v( b% L6 Z7 r1 }; {# d8 ymay initially present in their practice. The Physicians’! X4 @# D+ X0 B
Desk Reference and package insert should also put a$ J8 n5 k  e2 I5 R( x& Z- e0 H& ^) T
warning about the virilizing effect on a male or
  U5 M) d5 H/ p4 O6 {7 Nfemale child who might come in contact with some-
+ e+ f$ ~" O8 c  J3 |one using any of these products.
9 J- i/ s, s8 j- BReferences" y7 w; g$ ]( c$ h9 Y3 d9 ?
1. Styne DM. The testes: disorder of sexual differentiation4 u- v% f+ m! r9 P0 s4 \" p# m
and puberty in the male. In: Sperling MA, ed. Pediatric
# {! h) J; k8 K, R9 i4 GEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% Z: o9 C9 w$ a# H" V$ d  r, ?2002: 565-628.. `: O' B( Q  X; H+ A# Y+ _9 R3 t
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
" `2 u6 h2 B0 ?; o! Y% G. O9 x  e0 Q  v4 Kpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
5 g  D2 m  V: Z  XBoy Induced by Indirect Topical) w6 q. ~2 }' S" G, ]8 A
Exposure to Testosterone
& P; p+ c; @  w8 T* i7 G4 j, ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 M/ y  N$ N! C$ M- \4 o
and Kenneth R. Rettig, MD1! E& G( X/ u+ ?# r5 r' o0 M
Clinical Pediatrics: [$ k1 f* R$ G5 g. I- S
Volume 46 Number 6
+ K  y, g- j  Q  J, ?- _5 jJuly 2007 540-543
# C* _4 e$ a  i/ N6 l5 ~5 Y& Q© 2007 Sage Publications
+ X( B! ]" y' _2 e6 Q! V  [' e10.1177/0009922806296651
) r4 N+ X' \- u1 W8 r+ Ehttp://clp.sagepub.com, ]' s) I- O1 _0 y
hosted at  H( ~/ }4 y% e0 b3 z0 Y! r) z
http://online.sagepub.com* o3 c0 V7 N8 X- ]- S( o+ p
Precocious puberty in boys, central or peripheral,, h. \- x( j# q/ _, f$ @5 o5 D
is a significant concern for physicians. Central
& h) u# W1 y8 D5 mprecocious puberty (CPP), which is mediated
: t! k! A4 M# I2 s, Lthrough the hypothalamic pituitary gonadal axis, has' I. ?6 o- N# u& z
a higher incidence of organic central nervous system
; z1 {* I4 F) J5 ^9 i! I- L; H, ylesions in boys.1,2 Virilization in boys, as manifested
, V1 t% @" e- F3 p/ M$ Sby enlargement of the penis, development of pubic
; L* H! n9 O* v: r6 mhair, and facial acne without enlargement of testi-+ G7 T+ Q5 m  o) {; j, _2 r, g
cles, suggests peripheral or pseudopuberty.1-3 We, d9 c( m" x+ S" Z# V/ _) b
report a 16-month-old boy who presented with the4 R2 Y" x) L' D6 R& ]
enlargement of the phallus and pubic hair develop-! d5 i; {8 C! d. G
ment without testicular enlargement, which was due
. X* J. X" T% Y! C* ~2 U7 N3 R: Yto the unintentional exposure to androgen gel used by" I' x) E$ [( E
the father. The family initially concealed this infor-
; h* t+ k  D, Z1 k: Q+ i' B% |mation, resulting in an extensive work-up for this% E+ _# U# ]4 ]9 {  i
child. Given the widespread and easy availability of
; |, W% `# d! {: y7 \testosterone gel and cream, we believe this is proba-
  s) ~6 r" W. y: ~( E/ mbly more common than the rare case report in the3 q; Q. j: y( O6 v! {' \+ E
literature.4
. n! u& n/ q+ [$ P" Z5 z4 `Patient Report
& E8 a% k5 y+ e: [$ W- aA 16-month-old white child was referred to the" O: I( a$ l: T
endocrine clinic by his pediatrician with the concern6 |+ F, O, L& E; ~) r9 c+ o
of early sexual development. His mother noticed
; v. Y( l) P6 w* Rlight colored pubic hair development when he was
; [; q. M$ O) L: r" B0 P0 _8 ~7 Q* }From the 1Division of Pediatric Endocrinology, 2University of
( u3 E, G/ E$ N0 ?4 TSouth Alabama Medical Center, Mobile, Alabama., t5 T: G! L0 ?
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 R$ r& r& m/ d# I! j0 Z' RProfessor of Pediatrics, University of South Alabama, College of4 R/ F1 `$ f5 R6 z" U( b
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ Y1 ~0 O% _' m2 I7 s, @e-mail: [email protected].: _  x" }- }+ T4 a
about 6 to 7 months old, which progressively became
* z0 I. z( N7 I4 W9 S+ ]5 Hdarker. She was also concerned about the enlarge-; J4 u# f+ J% u# H+ _' S3 v  M
ment of his penis and frequent erections. The child  Q; O' w3 f6 o: ]( D0 y2 [
was the product of a full-term normal delivery, with8 v* I3 e4 {* S
a birth weight of 7 lb 14 oz, and birth length of4 s( A( O# i  K- p) a) D
20 inches. He was breast-fed throughout the first year
/ I7 S2 @5 a8 ~  O& D/ b+ K/ Dof life and was still receiving breast milk along with
2 {1 _2 q6 P7 c8 Y0 A7 Usolid food. He had no hospitalizations or surgery,
: [" p3 c4 V2 l9 |1 p6 f- Rand his psychosocial and psychomotor development
) h. G# {7 t9 r  P; fwas age appropriate.
$ l% ]$ i% K% [The family history was remarkable for the father,2 x) \7 W# L' w" w0 n6 h$ ^
who was diagnosed with hypothyroidism at age 16,& N" C; i- U  g& l8 o2 Q# F8 v
which was treated with thyroxine. The father’s$ L6 ]3 |5 d  ~- e6 ?7 i: J, S' ?! i, T
height was 6 feet, and he went through a somewhat
% C/ c) r0 x  Q  m6 {  Aearly puberty and had stopped growing by age 14.
3 m+ o* A* I  L) y# IThe father denied taking any other medication. The3 Y2 Z  j/ s  \) q$ b! i
child’s mother was in good health. Her menarche
, G( k& m8 f* }' i, P  [was at 11 years of age, and her height was at 5 feet$ d5 x" C' F4 j" W! I& Q; F
5 inches. There was no other family history of pre-+ v% }8 L0 p+ U- r4 L$ Y
cocious sexual development in the first-degree rela-  V/ U) A/ |  T2 K  I
tives. There were no siblings.
( B+ C( N4 p7 `- M7 @Physical Examination
6 M3 t6 U3 P7 qThe physical examination revealed a very active,7 x* }$ H6 S- O
playful, and healthy boy. The vital signs documented
$ q/ m0 ^8 J$ \5 B/ X/ `a blood pressure of 85/50 mm Hg, his length was
$ ]8 \/ P& C2 s& g$ z% T90 cm (>97th percentile), and his weight was 14.4 kg# J. S; i9 m6 X) _* Z0 S6 ~- P
(also >97th percentile). The observed yearly growth6 V( K, p% H2 F( H: d& j
velocity was 30 cm (12 inches). The examination of% B3 D2 A+ h: |7 x
the neck revealed no thyroid enlargement.& h0 G+ f6 E" [7 _/ p
The genitourinary examination was remarkable for
5 e  Z8 w! P/ p- a4 menlargement of the penis, with a stretched length of4 b% S3 r: S. t3 g$ w  o
8 cm and a width of 2 cm. The glans penis was very well& r6 _7 A: t) x5 k6 y* ?
developed. The pubic hair was Tanner II, mostly around  G" z% |+ P/ J) c
5409 {$ l2 Z# _; [* i( t6 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, p: |' c! q  N4 v3 R) ethe base of the phallus and was dark and curled. The; F  G7 e% x  t+ i
testicular volume was prepubertal at 2 mL each.
1 J1 G) Q2 ?5 J( hThe skin was moist and smooth and somewhat8 |8 G" N, x, Y/ [& e8 a- H2 o' X
oily. No axillary hair was noted. There were no# [+ ]9 K1 @' E2 M' h: F! p
abnormal skin pigmentations or café-au-lait spots.
5 [, Q6 `$ g+ G# {% gNeurologic evaluation showed deep tendon reflex 2+( X0 `; v8 Q$ a" Y# c  a' I; g5 c2 i
bilateral and symmetrical. There was no suggestion( |: o, |( A7 |! G8 B8 [- N1 v) F  h
of papilledema.
. B0 X" l3 `- r1 p  e7 ~1 kLaboratory Evaluation
: F, J/ Z9 {! k# EThe bone age was consistent with 28 months by7 r4 K4 ^0 D6 I" P* a- U
using the standard of Greulich and Pyle at a chrono-
2 d1 f% n. [7 |  p- d) ~) mlogic age of 16 months (advanced).5 Chromosomal
5 W7 B1 x( W2 A* ikaryotype was 46XY. The thyroid function test
6 B* I' x; b! X( N* kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 L) X8 |- X: z% Flating hormone level was 1.3 µIU/mL (both normal).' v3 k: x. p/ k; q, x8 \
The concentrations of serum electrolytes, blood
1 A6 K5 X+ W" o; Eurea nitrogen, creatinine, and calcium all were6 c$ J0 G6 R. {7 m
within normal range for his age. The concentration
) b3 O2 h$ O# }6 e6 x( H& Wof serum 17-hydroxyprogesterone was 16 ng/dL
5 t$ i6 e4 w: H- Q! F* D9 u4 P(normal, 3 to 90 ng/dL), androstenedione was 20' z" k$ n$ i- k' W8 C  O/ R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' r8 }* f& ~! M# }  O* e- N! \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 J) b, r* G$ P8 g7 b% fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# _) h8 O# I# F, t5 y& n49ng/dL), 11-desoxycortisol (specific compound S)1 V7 F0 Q0 s8 T* v$ y; ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) j* {7 m. I( a  ~$ w2 a) Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total) a5 B5 {# ?* g5 N5 W
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 `: z) x9 R  F
and β-human chorionic gonadotropin was less than- r# g' t8 d; @, {1 i
5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 }( a$ X  G4 ?! z& ]5 Hstimulating hormone and leuteinizing hormone5 W1 W. \* i3 a- m1 l
concentrations were less than 0.05 mIU/mL, z; m/ b+ l# f# n3 V: A
(prepubertal).0 r, R# k. r! g" t$ R) d( m
The parents were notified about the laboratory1 h5 g+ b! G+ i% O
results and were informed that all of the tests were
# k; K; r+ E$ Q* Rnormal except the testosterone level was high. The2 P- Z! D& p) Y3 b- R
follow-up visit was arranged within a few weeks to) E# m$ _7 w7 h" B- E
obtain testicular and abdominal sonograms; how-
9 F  l' I1 v5 h9 y, oever, the family did not return for 4 months.6 ~+ e1 m. R& A* K  D
Physical examination at this time revealed that the
% @: m# x1 i, y9 ychild had grown 2.5 cm in 4 months and had gained
3 m: ^  R4 [8 s( Y  F2 kg of weight. Physical examination remained: p( O0 K2 f, {9 \% `3 C! \5 w
unchanged. Surprisingly, the pubic hair almost com-; |6 y% h% O4 B. U  V
pletely disappeared except for a few vellous hairs at
* r- E3 A. O# _0 L, g4 Ethe base of the phallus. Testicular volume was still 2( B) c) h. B+ d7 {7 B. f* g
mL, and the size of the penis remained unchanged.* }- j0 {. O4 S2 W; l7 A
The mother also said that the boy was no longer hav-
! p# \6 c4 _1 Cing frequent erections.6 ?/ S/ J7 n" n& v1 e+ H: ^0 G
Both parents were again questioned about use of
  f. n" \; K$ n& R' {3 P, e& Lany ointment/creams that they may have applied to
+ O+ \, s# m, `8 Dthe child’s skin. This time the father admitted the/ m0 L* ]. o; B9 w6 W/ Q
Topical Testosterone Exposure / Bhowmick et al 5418 v1 l" N, W" u  B: \
use of testosterone gel twice daily that he was apply-
& C+ \; ?( E4 g5 xing over his own shoulders, chest, and back area for
- x% B% o1 j( f2 a  g: ^' x( d$ ea year. The father also revealed he was embarrassed2 c- S0 a, I! n* u
to disclose that he was using a testosterone gel pre-" n% ~' h, C# r) T
scribed by his family physician for decreased libido
( T, z9 \8 d/ u  Zsecondary to depression.
, L( a; ~4 z+ R2 S5 o* nThe child slept in the same bed with parents.
8 {- b* p; W6 x0 P8 ~  oThe father would hug the baby and hold him on his, X3 U1 D- f$ X' J
chest for a considerable period of time, causing sig-
" k0 ?, C: F5 {nificant bare skin contact between baby and father.
& d8 a0 p* p3 D8 v. W8 H7 cThe father also admitted that after the phone call,$ ?' s% u& a! z1 h$ y
when he learned the testosterone level in the baby- h! [8 a7 v: L  x
was high, he then read the product information
$ a; j( W' ^, \7 }" E% H9 |. y% Vpacket and concluded that it was most likely the rea-, ?) D0 J; V- S- b+ r; {2 B! x
son for the child’s virilization. At that time, they
. |6 Z5 a9 `  v  p% Cdecided to put the baby in a separate bed, and the
: c! \# c; `  C& C. d; f; dfather was not hugging him with bare skin and had: `% X6 j$ G; k2 b) Q
been using protective clothing. A repeat testosterone0 O& A; A8 a+ B
test was ordered, but the family did not go to the
1 j+ s+ X& _  glaboratory to obtain the test.
; v1 B& R* J/ ^Discussion. h/ U4 X: r+ Q
Precocious puberty in boys is defined as secondary; b) }1 F6 W6 Q& H) @( t. X
sexual development before 9 years of age.1,4
6 I7 L# P! Z6 Z6 E- M5 qPrecocious puberty is termed as central (true) when
/ l" x( f( H4 {2 sit is caused by the premature activation of hypo-  V& W, p2 c, f- j
thalamic pituitary gonadal axis. CPP is more com-
( {- D8 ?7 F1 X1 Rmon in girls than in boys.1,3 Most boys with CPP# y7 q3 g- R! f) w
may have a central nervous system lesion that is2 h# _* I1 Z' U: f
responsible for the early activation of the hypothal-: Y" c& v" U* e
amic pituitary gonadal axis.1-3 Thus, greater empha-
5 r& t7 t( q+ |8 J' S7 s: l0 j4 d& z* ?( [4 Msis has been given to neuroradiologic imaging in# y( A# Y% r' }, I
boys with precocious puberty. In addition to viril-* ?. Q' R  D+ Z' t
ization, the clinical hallmark of CPP is the symmet-8 `6 O: y/ c5 s
rical testicular growth secondary to stimulation by
+ B" e0 M. t- I0 I. z7 |0 ^gonadotropins.1,3
4 M) O& }* Q. X* y$ m  fGonadotropin-independent peripheral preco-5 N: Q/ t8 o- t* n" S0 Z: J. T% z
cious puberty in boys also results from inappropriate, h: j+ c3 I" q2 L
androgenic stimulation from either endogenous or, j7 U( S: Q( x
exogenous sources, nonpituitary gonadotropin stim-
/ K% C) S3 l9 n% xulation, and rare activating mutations.3 Virilizing4 V! t" k8 n( ?3 _$ }1 a
congenital adrenal hyperplasia producing excessive
+ @( m1 Z8 K4 k9 Vadrenal androgens is a common cause of precocious
, ]( d. m- h* l  ppuberty in boys.3,41 Z- Y( n4 i6 i! k( S% L& V/ s
The most common form of congenital adrenal
& X* e7 a7 r9 \1 o& ~9 Chyperplasia is the 21-hydroxylase enzyme deficiency., F2 U4 Y& R4 h# G
The 11-β hydroxylase deficiency may also result in
- p3 c: C2 [- t. hexcessive adrenal androgen production, and rarely,3 S' d* E( W0 v! A0 Z9 k
an adrenal tumor may also cause adrenal androgen* d9 d  s' @  m
excess.1,3: M) v* j& q9 ~5 z8 Y2 O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! {$ q/ h1 B) i( @' ]& \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* x& F0 m* @& o! z# T* V" T" sA unique entity of male-limited gonadotropin-
! o' T/ ?+ q$ U* Y: pindependent precocious puberty, which is also known
  }8 e; k' U; f! P8 Aas testotoxicosis, may cause precocious puberty at a5 U: S5 x+ L& N8 }' }8 R# x5 P+ }) F
very young age. The physical findings in these boys( t. g5 S; P6 O8 \
with this disorder are full pubertal development,/ K3 V! |6 {0 B# Y! W
including bilateral testicular growth, similar to boys, Y1 C( |7 O  Z/ L9 B1 b1 D
with CPP. The gonadotropin levels in this disorder( }2 ?3 P& ^* T& r* t
are suppressed to prepubertal levels and do not show
% u2 [& ]  q) v3 X- Q* opubertal response of gonadotropin after gonadotropin-, E/ D' {+ N* K6 \  _. @
releasing hormone stimulation. This is a sex-linked
! w7 c9 _! o! j, c, Q1 d7 Yautosomal dominant disorder that affects only# a- c0 }$ R; Z0 X$ J0 F. O5 F" R, c6 w
males; therefore, other male members of the family6 x' l' M2 x, o$ b2 ^% ]9 O/ W
may have similar precocious puberty.3
! J3 G2 l+ P7 d. n) i8 rIn our patient, physical examination was incon-
+ l! a/ t- C: g8 \sistent with true precocious puberty since his testi-: R  u) E6 \/ }/ q* W9 U1 X
cles were prepubertal in size. However, testotoxicosis4 a3 ~3 T7 M- z* f
was in the differential diagnosis because his father
) ~$ {7 ]! I, P+ {) ystarted puberty somewhat early, and occasionally,
+ o, N7 a& x* o3 X" x  H% y1 Rtesticular enlargement is not that evident in the
# q) k+ s* L5 `+ ~( S5 p9 {$ q8 ^beginning of this process.1 In the absence of a neg-
! H. F* @8 o/ D4 q5 J4 {, i9 m: Pative initial history of androgen exposure, our
2 T: @  |4 p2 L$ i  N8 t  kbiggest concern was virilizing adrenal hyperplasia,, u* u. }5 p! ]% s- v4 R
either 21-hydroxylase deficiency or 11-β hydroxylase
1 I( h1 H8 l  G5 w3 W8 udeficiency. Those diagnoses were excluded by find-
) q% ?; Y8 E$ D) ^- Ming the normal level of adrenal steroids.5 r- p+ q# y3 T/ y) w
The diagnosis of exogenous androgens was strongly
6 ]$ q0 X& ]! w& s  ^2 \suspected in a follow-up visit after 4 months because5 W$ [& N; w7 ?7 D2 I4 A9 T; {1 G
the physical examination revealed the complete disap-
0 `7 \$ P7 ?5 T4 {) B2 q- xpearance of pubic hair, normal growth velocity, and3 b' n) P. i9 r! }" }* X3 C
decreased erections. The father admitted using a testos-
5 ?+ L3 G. ~& _  J7 Y6 Vterone gel, which he concealed at first visit. He was
; W% G/ i$ ?, [" @3 m3 C4 ]using it rather frequently, twice a day. The Physicians’& z" ~# V4 l# a7 G+ Z
Desk Reference, or package insert of this product, gel or2 J1 h. |! S: f  `( u
cream, cautions about dermal testosterone transfer to2 Q) S, `3 C. B3 M
unprotected females through direct skin exposure.
+ N/ I/ V1 V% L% |Serum testosterone level was found to be 2 times the
+ o& Q6 ?  d5 A6 ~- T- tbaseline value in those females who were exposed to
% r0 T7 i( P' ]) [* c5 V8 weven 15 minutes of direct skin contact with their male
4 l" A8 F) E( }5 }. Jpartners.6 However, when a shirt covered the applica-
+ k  H/ B9 g( g2 ttion site, this testosterone transfer was prevented.2 N5 \- f' p" s' J5 Q
Our patient’s testosterone level was 60 ng/mL,$ Z/ _+ a. N" y* z# t) _2 K8 g
which was clearly high. Some studies suggest that: C' D' S5 w6 Y' S
dermal conversion of testosterone to dihydrotestos-
+ E% q+ ?6 ?  q3 n8 ~. P- L: Vterone, which is a more potent metabolite, is more3 ~% L" v! N% H" F3 U9 d2 R
active in young children exposed to testosterone# I+ u2 Y5 l9 b  K8 ]! g5 R2 P' S
exogenously7; however, we did not measure a dihy-! D9 i+ a* E# q: t9 C
drotestosterone level in our patient. In addition to
* B9 Y8 m- x+ t1 h' Bvirilization, exposure to exogenous testosterone in
1 H: o* z7 y! J1 M1 b- @children results in an increase in growth velocity and
% V. J; T- W( Oadvanced bone age, as seen in our patient.
% J( U& S( h1 e& X* Z7 PThe long-term effect of androgen exposure during
6 s- w. F  A$ b* q8 `early childhood on pubertal development and final- Q  \% `" h: e
adult height are not fully known and always remain
) F( h: W6 k6 n' o5 u$ L( Q4 F% ua concern. Children treated with short-term testos-
' D  E. |7 F! s7 `& @7 Kterone injection or topical androgen may exhibit some$ Z2 v+ b2 E* M1 J/ ^
acceleration of the skeletal maturation; however, after& o; J* k- a* Q5 M8 h; s; l' G% L
cessation of treatment, the rate of bone maturation
; O# \" v* R& b6 _) Adecelerates and gradually returns to normal.8,9/ T0 O- y9 y% ~6 |" y; d
There are conflicting reports and controversy$ g0 K! ]+ P* r- K
over the effect of early androgen exposure on adult
/ H% `) `  p# V6 j+ R- a; S; jpenile length.10,11 Some reports suggest subnormal
7 d) M% _: a+ [/ v1 X3 b0 uadult penile length, apparently because of downreg-
. P5 t/ ?4 `5 a, z# Z& |ulation of androgen receptor number.10,12 However,+ H& H6 U7 \4 J  x5 J2 p2 P' Q
Sutherland et al13 did not find a correlation between2 E8 _, u; O5 f9 {
childhood testosterone exposure and reduced adult, T& U# U4 T. M+ U
penile length in clinical studies.3 v: G1 o* N! n+ O
Nonetheless, we do not believe our patient is
/ Z- i) V. b5 \' `1 r! agoing to experience any of the untoward effects from
; n; A) i$ s2 q) ltestosterone exposure as mentioned earlier because
6 p$ R3 X' P: Y7 [1 {, Rthe exposure was not for a prolonged period of time.+ w: K- T+ t  H2 Y% `7 o* N; A9 a
Although the bone age was advanced at the time of
: T1 L, I2 L% P/ X0 Q- Fdiagnosis, the child had a normal growth velocity at& X8 g) x# w1 D
the follow-up visit. It is hoped that his final adult) n! Z9 k# Z: M& m" P6 n
height will not be affected.
8 l+ ]5 n9 `  W! nAlthough rarely reported, the widespread avail-; a2 V  j. g- ^  _4 w( P8 x; a
ability of androgen products in our society may4 v  [, b0 w9 @7 m9 S& M
indeed cause more virilization in male or female+ A) M! w' V; T6 d
children than one would realize. Exposure to andro-7 U  t  v/ u7 u
gen products must be considered and specific ques-) Z  F1 n0 q7 y# J  M7 K
tioning about the use of a testosterone product or) X# W9 i3 j, _
gel should be asked of the family members during# A% V7 ^6 i1 i. O, z; M
the evaluation of any children who present with vir-
( A0 _6 P- g- d, o+ |5 ]/ u# tilization or peripheral precocious puberty. The diag-
8 b) m- ]7 F2 g& Jnosis can be established by just a few tests and by
$ J" d/ X+ Y" b, J3 }! Jappropriate history. The inability to obtain such a
! T/ x# A. n8 P- V3 fhistory, or failure to ask the specific questions, may. @, u  [7 W1 e9 ]7 J6 `0 p
result in extensive, unnecessary, and expensive/ N7 Y7 ~8 q- ~6 d! v
investigation. The primary care physician should be
3 R; y3 \, `' xaware of this fact, because most of these children6 D' a9 B' t- p( Z$ [
may initially present in their practice. The Physicians’
1 \: V6 ^! @4 t# o9 `$ J1 g3 EDesk Reference and package insert should also put a
* z7 B8 }  G- R6 O9 ]warning about the virilizing effect on a male or
4 B1 f$ M: F, @/ _6 M( tfemale child who might come in contact with some-
2 L# n$ Q$ \# Z6 E7 i1 l/ Qone using any of these products.
% [) ?, C. Z1 g8 _References
0 x5 e4 S9 h/ S7 x1. Styne DM. The testes: disorder of sexual differentiation- G, K0 M+ W; K. z) K
and puberty in the male. In: Sperling MA, ed. Pediatric
, y  F) y$ R/ ~$ q" T' O( v  oEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" W) C" B. S! F. q# f, p# V9 `( z2002: 565-628.
3 X! o# a% Y8 b# `* t5 A" v" o2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 j1 R2 N2 m8 R' h! g  H0 G3 r; f
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

+ I( B$ \) I8 s& O# B) ?4 D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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