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Sexual Precocity in a 16-Month-Old
" t9 a7 X7 J2 c# ]- }( W/ y# w$ k" kBoy Induced by Indirect Topical5 ]. M0 q6 A/ r6 i
Exposure to Testosterone& V3 o- w, p' E
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ z& Y+ \: b4 X/ {' k# G5 x6 _and Kenneth R. Rettig, MD1
$ X0 U/ h1 [1 L% c' M# J0 JClinical Pediatrics
; Q) o0 r8 g- k# _+ [+ pVolume 46 Number 63 U$ ?  m3 o: [$ u$ ]/ b/ f0 I
July 2007 540-543$ Z0 d' p; _: t4 y, ]# v! A
© 2007 Sage Publications3 k* T& m6 A9 ?6 E; t
10.1177/0009922806296651- n8 i5 {# x$ B3 G+ u. E% o
http://clp.sagepub.com
' q& K5 E1 t9 z( S& q9 P/ U7 L- I' |hosted at0 |- Q5 P# U* s( G
http://online.sagepub.com
$ P% x. }; Z; \. Z  p' @Precocious puberty in boys, central or peripheral,% V9 T& @& B+ s, `" [- a/ e
is a significant concern for physicians. Central
% T& M$ m$ ?1 ?- `* }/ aprecocious puberty (CPP), which is mediated7 S! P/ N: n# {: N
through the hypothalamic pituitary gonadal axis, has
! K( p2 k) W& M3 [5 [+ qa higher incidence of organic central nervous system
+ x# s. C& h( x, {: Ylesions in boys.1,2 Virilization in boys, as manifested1 }( B- S7 N+ s4 B& `- @
by enlargement of the penis, development of pubic
  X2 S! I7 H, O" X. w" t! Qhair, and facial acne without enlargement of testi-0 ~% k6 p. I; T3 H. p
cles, suggests peripheral or pseudopuberty.1-3 We# m; e5 |- k% Z7 W
report a 16-month-old boy who presented with the
& p. h9 Z* q8 r" G4 ]enlargement of the phallus and pubic hair develop-
2 d5 ?% I  F" V# Hment without testicular enlargement, which was due5 l& P1 B+ U+ d. f/ N/ p& u1 c  Z5 m
to the unintentional exposure to androgen gel used by
. b$ K' U% N% P; uthe father. The family initially concealed this infor-
1 |$ y2 t; D( O- v4 ^: [/ C5 ^( e: {mation, resulting in an extensive work-up for this# U: x$ M0 R/ J
child. Given the widespread and easy availability of$ y% s2 P; h6 {  }+ h
testosterone gel and cream, we believe this is proba-* d5 v! K5 A' L5 k
bly more common than the rare case report in the
) t$ g* C! `  l: K+ g' `7 Xliterature.4
& h3 T' S) i& Y- [0 f! {9 vPatient Report- V) ^: `4 H  Y. s
A 16-month-old white child was referred to the3 e0 N: w. j3 q
endocrine clinic by his pediatrician with the concern# Q7 n2 f7 N+ x# n, U/ o
of early sexual development. His mother noticed
' y7 M( G' o. _9 plight colored pubic hair development when he was
$ {! t1 }  `& J) o: eFrom the 1Division of Pediatric Endocrinology, 2University of
, v! c! p) @* OSouth Alabama Medical Center, Mobile, Alabama.1 o/ Q: k6 t# r8 k' G. b: b5 p# N. d
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 {7 }" B# l2 T9 }, R# U& UProfessor of Pediatrics, University of South Alabama, College of
( @3 R# t; O. J& e$ @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 f  A* ]9 P6 M7 N' d: c- me-mail: [email protected].
3 e3 s* M- ^# g- w  }- B+ Q) babout 6 to 7 months old, which progressively became: @% g! e8 l9 V9 f2 E
darker. She was also concerned about the enlarge-. F7 S% S8 S; Z4 t: W1 t
ment of his penis and frequent erections. The child" N( x( T$ e, R
was the product of a full-term normal delivery, with; `7 c1 [. }: E0 c. w
a birth weight of 7 lb 14 oz, and birth length of4 Q' I6 J/ G) x, X/ a) D' ~& H$ |
20 inches. He was breast-fed throughout the first year
1 b  E$ `: s( C. V$ B) ~. `of life and was still receiving breast milk along with1 f8 r6 W' R2 q2 ~0 O
solid food. He had no hospitalizations or surgery,2 p0 B: ?& L2 e) Z% D
and his psychosocial and psychomotor development
0 {, a. n# d$ k( h; w& G' U* N! p3 @was age appropriate., a  S" C3 I( k  M" E
The family history was remarkable for the father,+ e5 j1 W7 X1 K' m0 T1 X
who was diagnosed with hypothyroidism at age 16,
  S- A, l9 Q: |' J- _which was treated with thyroxine. The father’s7 @+ ]5 b3 T% R2 E4 X6 E
height was 6 feet, and he went through a somewhat/ k1 `: O7 n# E3 {9 j1 G
early puberty and had stopped growing by age 14.
( R; K! g- u# `* o/ j6 TThe father denied taking any other medication. The6 R6 M/ Q+ t+ B9 ?- E- F
child’s mother was in good health. Her menarche
, _6 `3 B' l  E5 t  s5 |; C9 u/ \was at 11 years of age, and her height was at 5 feet- i- ]* e4 X# X
5 inches. There was no other family history of pre-
* _% `) }9 X6 C3 c" y+ acocious sexual development in the first-degree rela-
3 C8 N! i/ L. s' A8 Otives. There were no siblings.1 H% V0 g# d, G, p
Physical Examination$ U# T: z) G2 t9 f5 n
The physical examination revealed a very active,
5 B; m8 |' T; g% Iplayful, and healthy boy. The vital signs documented
4 {: C0 z( F. X$ I1 \2 U& E9 I2 \a blood pressure of 85/50 mm Hg, his length was  N, j8 Q( Y3 e; [( M: V2 {
90 cm (>97th percentile), and his weight was 14.4 kg+ _7 m  _  h# m$ T
(also >97th percentile). The observed yearly growth
" S  p6 }+ ?! e4 ?# u  x* S. svelocity was 30 cm (12 inches). The examination of
# F/ R& r! D6 d+ j9 @the neck revealed no thyroid enlargement.% i( J* P$ H4 N  ]9 }  P
The genitourinary examination was remarkable for
0 D! M% [* W, Q" A0 k( nenlargement of the penis, with a stretched length of# F3 J8 k; z1 |/ R% a' A
8 cm and a width of 2 cm. The glans penis was very well
4 V- H' B8 T* cdeveloped. The pubic hair was Tanner II, mostly around
: Y% z5 N' U, k* q; Z540
8 b: D5 d& P/ }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; c, \" ?  R( n1 U" z! Y
the base of the phallus and was dark and curled. The+ j0 x" _. q2 V9 W6 ^) W! q  f
testicular volume was prepubertal at 2 mL each.2 v" |2 r/ B6 k: g
The skin was moist and smooth and somewhat7 g, b, D9 u0 B" _# \" K
oily. No axillary hair was noted. There were no+ I* z9 N$ t2 y' ]. a
abnormal skin pigmentations or café-au-lait spots." ^+ ]: s6 a& c; A. `* g1 m# J# H
Neurologic evaluation showed deep tendon reflex 2+/ ]7 s8 h; f7 @( I, N9 C' Z9 w
bilateral and symmetrical. There was no suggestion
5 J" }2 p$ H/ g  |of papilledema.
; A) f! W: V2 ?6 {7 xLaboratory Evaluation
$ ^. ?$ F$ Y: QThe bone age was consistent with 28 months by
6 q7 G5 U5 i4 r7 `$ O7 N3 _using the standard of Greulich and Pyle at a chrono-
! [% L. q9 b- vlogic age of 16 months (advanced).5 Chromosomal
. ^# t. r7 U7 J( D. r1 J+ w6 Kkaryotype was 46XY. The thyroid function test, j- ?/ l: g1 ~9 A9 ^5 O# y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  k( \! ?- e- F$ v3 olating hormone level was 1.3 µIU/mL (both normal).8 U( k1 L3 o! `( w4 R1 O% E
The concentrations of serum electrolytes, blood  W( f/ q$ L/ t0 t* T
urea nitrogen, creatinine, and calcium all were
* y3 F+ a; `7 y# m% vwithin normal range for his age. The concentration
  Y5 w4 u; Y( E( p$ ~  X$ x+ c8 s) v$ Oof serum 17-hydroxyprogesterone was 16 ng/dL1 C, u6 Y) j6 a/ W- k, m9 X
(normal, 3 to 90 ng/dL), androstenedione was 20
- F! s& H6 p# nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' e5 R/ Y* a! Y3 W- T3 {# Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 J* ]! Z+ c9 D3 {' k/ Fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
, V' G" {4 `1 I9 C% z0 i49ng/dL), 11-desoxycortisol (specific compound S)
, Z7 j* g3 k- Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% ]+ Q, b8 I& p: \# u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 ~4 u* w: @8 Z2 R! i9 s2 B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( N' I4 m& P- Z# S& p  sand β-human chorionic gonadotropin was less than
% T0 ~1 m* W$ v4 S) j* f, i5 }9 V5 mIU/mL (normal <5 mIU/mL). Serum follicular
: M1 W& ?# ~9 j$ ]stimulating hormone and leuteinizing hormone! D3 y2 Q8 T0 i% W* f% y$ s$ N
concentrations were less than 0.05 mIU/mL
+ a! {3 j6 t! I. e" X7 i(prepubertal).
0 R" b5 J4 Y# _1 X( }: X! |The parents were notified about the laboratory2 {5 ?- O$ T% h# K5 t8 s) H
results and were informed that all of the tests were
& x& q/ Y0 Z( U" anormal except the testosterone level was high. The
7 _9 n2 h$ x8 E9 g1 ^5 gfollow-up visit was arranged within a few weeks to4 {- S& H! S3 j1 F- N" H( q
obtain testicular and abdominal sonograms; how-) p- J/ N" H6 }. m8 y' o! y
ever, the family did not return for 4 months.; F; z. w1 f& b5 q1 ?
Physical examination at this time revealed that the
1 t' f) h9 J1 I% _! h( a) i, xchild had grown 2.5 cm in 4 months and had gained
$ E. {7 _! [6 |9 a2 kg of weight. Physical examination remained* f4 p3 E5 c% R+ V4 z) I' T
unchanged. Surprisingly, the pubic hair almost com-# U2 J1 [% S7 s# I5 C* x$ U* D( e- ^
pletely disappeared except for a few vellous hairs at
0 y$ f8 K, ]& N! y  {2 bthe base of the phallus. Testicular volume was still 2+ ^! D. H  @4 U6 Z6 I0 l: C5 _
mL, and the size of the penis remained unchanged.+ F, Y5 D2 C; j6 k3 I3 z2 D
The mother also said that the boy was no longer hav-
# e- ?& E8 `6 j! r) v/ aing frequent erections.! T" X. G! E9 t5 A
Both parents were again questioned about use of( V' D4 C" N1 ?9 x
any ointment/creams that they may have applied to
8 R5 [$ B. J9 _& c; @4 v1 qthe child’s skin. This time the father admitted the) E. U7 y$ V  V- W3 j9 Q; J" _8 r
Topical Testosterone Exposure / Bhowmick et al 541
7 x1 R2 k- A: _  S7 e5 _use of testosterone gel twice daily that he was apply-
' I& L1 c: N& t' s/ Ying over his own shoulders, chest, and back area for: _: p/ P. q$ c& {; M
a year. The father also revealed he was embarrassed
& W# G' S" E+ X$ ^2 ito disclose that he was using a testosterone gel pre-
8 s0 r1 V+ E* ?scribed by his family physician for decreased libido6 ]" U! `, z1 Y& V
secondary to depression.; G' M0 l3 w2 B' |- h
The child slept in the same bed with parents.0 k* P. c; j( U1 _2 |1 Z
The father would hug the baby and hold him on his' N* c+ `, y% S' S5 C- B1 s6 g
chest for a considerable period of time, causing sig-
3 P6 W( ]- q5 ?3 Pnificant bare skin contact between baby and father.. y" }9 O9 a  Q0 g0 j- }. D
The father also admitted that after the phone call,* j, K. h( P7 @# Z/ U
when he learned the testosterone level in the baby
6 ]8 Z3 {4 T$ \" rwas high, he then read the product information! \3 `* `/ T  |8 t" l* l8 Z
packet and concluded that it was most likely the rea-# S, T. Z' ~6 i$ r. _! o: g
son for the child’s virilization. At that time, they
' g% C$ Z/ U+ t# k$ v) k) ^decided to put the baby in a separate bed, and the0 p0 y3 w! |9 X2 N. l0 N' w; G
father was not hugging him with bare skin and had. o* u  k) h- D- G" L$ j
been using protective clothing. A repeat testosterone
$ `' X* H; Y. W. n( D; v& Y: v: ^test was ordered, but the family did not go to the6 `/ H$ R: H9 B! _/ C4 C
laboratory to obtain the test.
; U# W2 ?6 R4 s3 vDiscussion
: ^3 D9 C7 }8 Z6 r# iPrecocious puberty in boys is defined as secondary" P6 @# K! I: `: {% J5 ^
sexual development before 9 years of age.1,4
9 c) Y7 [  [& q* jPrecocious puberty is termed as central (true) when* H$ q$ n/ [5 N7 e, \
it is caused by the premature activation of hypo-0 k: z0 d9 p% ?2 E/ d
thalamic pituitary gonadal axis. CPP is more com-
% ]9 N) o: m1 a  Q; @mon in girls than in boys.1,3 Most boys with CPP
) V9 R! U$ i) j" l2 ~may have a central nervous system lesion that is1 W1 `/ b; o2 |
responsible for the early activation of the hypothal-# X4 B8 `& A+ R' z0 P: J) y9 T
amic pituitary gonadal axis.1-3 Thus, greater empha-7 G9 w1 Z2 ^6 D& w* @( R7 \  Z
sis has been given to neuroradiologic imaging in
, p# T- h3 u* s/ rboys with precocious puberty. In addition to viril-( N: N0 M7 t0 P% p' ^6 g5 n% V
ization, the clinical hallmark of CPP is the symmet-+ h  V* g' X% y0 H( d2 o! E3 M. L
rical testicular growth secondary to stimulation by
. H, V! ^! t, \% O* K7 K" \gonadotropins.1,3
4 n6 t/ B# g( i% g  N  oGonadotropin-independent peripheral preco-
" z. z0 B) R2 r3 Z, o4 Z/ W( J* Ocious puberty in boys also results from inappropriate* e- M" I7 }6 W2 {/ A0 N) q7 t
androgenic stimulation from either endogenous or( a2 T  l* K, x" D" |  [' f& M3 a
exogenous sources, nonpituitary gonadotropin stim-! d7 v0 D; s' |7 Z: D: T9 D% E+ Y
ulation, and rare activating mutations.3 Virilizing! Y% d4 C+ Y5 E3 g3 d
congenital adrenal hyperplasia producing excessive8 ]$ N8 G3 B1 ?- [
adrenal androgens is a common cause of precocious
( L0 B" ?& ~/ q- V0 d/ m  t5 Spuberty in boys.3,4
" d9 \$ U; \8 ~0 U$ z# E5 L' [2 TThe most common form of congenital adrenal
/ l3 U: d" p$ p# C8 O7 G$ Y6 C$ [5 Z+ x# Whyperplasia is the 21-hydroxylase enzyme deficiency.5 Q  B1 @0 x" D0 C
The 11-β hydroxylase deficiency may also result in; H; B) |3 H$ Z) C  @& B
excessive adrenal androgen production, and rarely,
! U6 s" F5 `- ]3 N! Nan adrenal tumor may also cause adrenal androgen
" F4 R' y( N1 V, c2 Cexcess.1,34 }- n; c9 e' ?0 J2 [' J1 G% e. O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# o) A$ n0 ?9 _1 S  V) d. `8 ^( _542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 }1 z$ A$ F  o5 CA unique entity of male-limited gonadotropin-
6 a' q" x7 @0 ~independent precocious puberty, which is also known5 A% _" G* e4 ^, c+ N% ^
as testotoxicosis, may cause precocious puberty at a
1 p+ q: g# z/ ?( m% J* u2 kvery young age. The physical findings in these boys2 B; l) a. ]" o! s; y
with this disorder are full pubertal development,
( F5 m$ r. h0 R4 [including bilateral testicular growth, similar to boys
, S2 ^' x. g1 x* Ywith CPP. The gonadotropin levels in this disorder
: Y& l" _: M% O; \are suppressed to prepubertal levels and do not show
0 G% C0 j1 n6 T) ?pubertal response of gonadotropin after gonadotropin-5 [0 e' m9 e6 t) }* K. E& F* q: m
releasing hormone stimulation. This is a sex-linked, [, L& w: l! Z" s" I6 ^
autosomal dominant disorder that affects only
9 a- p' b6 S3 q. t0 ~' j) Omales; therefore, other male members of the family  Q1 n+ ^5 d1 g1 v0 E9 N, m7 m
may have similar precocious puberty.3& q4 |" Z. l4 p* I: h
In our patient, physical examination was incon-4 F2 J* W8 [( P" v2 a" H2 O% F
sistent with true precocious puberty since his testi-
% r" K# G) q0 |6 S/ ]( Vcles were prepubertal in size. However, testotoxicosis
' ?# M( U2 L; C0 Uwas in the differential diagnosis because his father
/ w7 y# I2 S. \" Y* `started puberty somewhat early, and occasionally,5 ]# T9 C' u- C6 l# h2 v
testicular enlargement is not that evident in the) i9 @9 c) ^2 c
beginning of this process.1 In the absence of a neg-
) m+ I2 v, A0 o: iative initial history of androgen exposure, our5 j( W2 i* w# h
biggest concern was virilizing adrenal hyperplasia,
0 i( |  J9 z7 H! q# Ieither 21-hydroxylase deficiency or 11-β hydroxylase' g0 g& v8 g& P; N
deficiency. Those diagnoses were excluded by find-6 O3 p$ F$ U7 a! B1 X9 w5 M
ing the normal level of adrenal steroids.
  N* ]# Y) @( z) [6 ^* p, ?The diagnosis of exogenous androgens was strongly
5 `- L6 ~# b( O# X6 o$ [1 osuspected in a follow-up visit after 4 months because+ V) T! G1 [5 M1 e# ]0 s
the physical examination revealed the complete disap-
# u  }: r# E' ?$ {pearance of pubic hair, normal growth velocity, and* H, Q! }2 \# _4 O  X
decreased erections. The father admitted using a testos-
) q: Z! @& ?6 i1 z7 oterone gel, which he concealed at first visit. He was' Y, C( d8 `% v( l$ Z
using it rather frequently, twice a day. The Physicians’
! f( y, K7 Y' }3 B0 W  @$ XDesk Reference, or package insert of this product, gel or
) N0 c, m9 v5 X/ a# |7 |/ l8 Mcream, cautions about dermal testosterone transfer to" K4 _9 M+ i& G1 I- M% i4 c7 `
unprotected females through direct skin exposure.
# Z. E+ I& q4 g9 K! G: M, `3 `0 E1 _Serum testosterone level was found to be 2 times the
; h  Q) B' @7 z5 F$ sbaseline value in those females who were exposed to9 X( _& B& f) x# x: u3 B% @
even 15 minutes of direct skin contact with their male5 I/ j- g% ~8 Z  Y
partners.6 However, when a shirt covered the applica-9 h5 @6 h- |3 R2 Q7 R- X( E$ }
tion site, this testosterone transfer was prevented.
; _& j* X) C$ ~+ b- ^( f  ]Our patient’s testosterone level was 60 ng/mL,8 s* b8 K* Q# V6 r& M% s
which was clearly high. Some studies suggest that
0 e5 ^1 J$ a. m% ~9 C! ddermal conversion of testosterone to dihydrotestos-
! B# t; V# J: \' Q  V* eterone, which is a more potent metabolite, is more* [. V+ U- k  ]) r+ V; \! x) D
active in young children exposed to testosterone& A& q% {- Y  v; ]# H
exogenously7; however, we did not measure a dihy-% M+ f/ Y# N- i8 n9 A$ V( e
drotestosterone level in our patient. In addition to4 U& H0 w2 Q- I( _0 Z# V3 [
virilization, exposure to exogenous testosterone in& ~: _/ G2 c! Z( _' E/ @
children results in an increase in growth velocity and
( R( s5 I' [! d+ Y& s0 \* ]/ ^advanced bone age, as seen in our patient.
+ V6 H1 ]+ u& Z" nThe long-term effect of androgen exposure during* J, ]. A. L" }
early childhood on pubertal development and final5 L+ G! i4 ?, d4 y
adult height are not fully known and always remain4 O+ c( l. Y# j1 ?
a concern. Children treated with short-term testos-+ R  d) v7 ?1 L
terone injection or topical androgen may exhibit some( m, c9 Q3 ]) p3 \* I
acceleration of the skeletal maturation; however, after
5 N7 s# K# h8 N3 y1 Hcessation of treatment, the rate of bone maturation
8 y* t2 r* |0 a0 ?' a2 ^decelerates and gradually returns to normal.8,9. C: M, F; F; W! q/ U2 K
There are conflicting reports and controversy' B, _0 D+ v8 M9 g" n6 q
over the effect of early androgen exposure on adult8 T# P" \7 k: C1 i
penile length.10,11 Some reports suggest subnormal3 B0 @! I. J1 F* o  j3 ?8 a
adult penile length, apparently because of downreg-
4 e0 N- E1 T$ I3 X3 Kulation of androgen receptor number.10,12 However,6 i0 S/ A4 T3 K
Sutherland et al13 did not find a correlation between( R; p( r; D% C
childhood testosterone exposure and reduced adult
% Q0 U9 g8 q2 m6 G9 d6 ypenile length in clinical studies.# m  G. |* ]4 ?/ ]% I
Nonetheless, we do not believe our patient is! W  w! x: ^- r: N, p2 t; l
going to experience any of the untoward effects from' I( E/ O7 Y) H' H
testosterone exposure as mentioned earlier because6 M/ @: q& r$ s7 n' z' q6 \  e- [
the exposure was not for a prolonged period of time.
! Q2 A: U9 Q$ V0 UAlthough the bone age was advanced at the time of
1 J7 J. ^) x& c! h" N  X  u+ ?diagnosis, the child had a normal growth velocity at( g- o6 L2 d; Y, ]! A9 |% H9 t: ?
the follow-up visit. It is hoped that his final adult
2 V8 ]) }; u4 k5 kheight will not be affected.( {6 S( O: P0 S+ r1 Y" w
Although rarely reported, the widespread avail-+ c/ Y6 q' G2 G3 l/ A; Z
ability of androgen products in our society may6 u/ B) [; K  z$ I1 E& v
indeed cause more virilization in male or female& d# e5 H+ ~* l) [) f/ Z+ m- a& ]
children than one would realize. Exposure to andro-
4 a4 k; [. k, r( _! X. `2 T  Lgen products must be considered and specific ques-( V1 A. }$ E( g. V' Q; H7 [! O
tioning about the use of a testosterone product or
& s* q" ]; {1 w) Pgel should be asked of the family members during
# |) ]4 g% c5 p, W7 `9 c# b/ ithe evaluation of any children who present with vir-; Y% j2 p! Q$ S! y) F+ _
ilization or peripheral precocious puberty. The diag-
' Z" ]+ U2 o/ k3 w" S( Mnosis can be established by just a few tests and by1 b/ w, J/ C0 u: K$ O  f
appropriate history. The inability to obtain such a) f) F; P, E* ~4 c, a& b
history, or failure to ask the specific questions, may% {7 s0 T7 K& ~* K( F9 c
result in extensive, unnecessary, and expensive
/ J5 ^$ D' k5 Zinvestigation. The primary care physician should be4 n3 o- Z  w" B+ z/ W3 D. K
aware of this fact, because most of these children1 A6 U- u. A4 d: `
may initially present in their practice. The Physicians’
! \# v* I- f9 `3 v) `Desk Reference and package insert should also put a) y& T  b4 q* b5 ?3 ]3 Z8 b
warning about the virilizing effect on a male or$ D; b6 f  ^1 w, ^
female child who might come in contact with some-  r: [7 `* j$ H6 A. b1 }" G: J. a
one using any of these products.4 Z" _- K% _, P
References
  |0 G5 w) A2 _1. Styne DM. The testes: disorder of sexual differentiation- L5 Q; r0 z( n, w! P+ K
and puberty in the male. In: Sperling MA, ed. Pediatric+ k* E0 v* g( f. W, ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: s. J4 I, X4 H2002: 565-628.7 D. Z/ j# g! R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% q$ `# e( q* e3 _( H! B% dpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old/ q/ H' m" G) e* L% z
Boy Induced by Indirect Topical
+ q( @4 l2 C2 ^* K7 j- N5 \4 GExposure to Testosterone8 q/ `/ b. p; s, D8 v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: w: R8 g" I" m9 G2 dand Kenneth R. Rettig, MD1
' e% P) u" T; q6 [Clinical Pediatrics6 y9 Z# T' B+ S9 S9 A- f
Volume 46 Number 6
/ O& n9 V: I  x4 l! B+ r- O6 xJuly 2007 540-5432 E5 V) c6 M# Z3 s$ U# g
© 2007 Sage Publications
; L3 U! h! Z8 N6 U+ D$ e9 j10.1177/0009922806296651
7 S6 B$ g8 U) j8 ]/ X# V& e8 T5 Ehttp://clp.sagepub.com
3 e) E) c/ W- f  R" ?: Ihosted at
8 H0 ?; y, w9 D4 w- q. {( \http://online.sagepub.com
! y6 n7 Y# t$ u" U- Z' J2 `Precocious puberty in boys, central or peripheral,
7 W5 [4 D6 j% H/ b8 Vis a significant concern for physicians. Central
9 L2 z" m8 t; x! I# N, Dprecocious puberty (CPP), which is mediated0 L: Q4 w6 O1 Z2 L0 T5 i
through the hypothalamic pituitary gonadal axis, has
4 ^/ `( y/ k: _a higher incidence of organic central nervous system5 b/ f' ~" d7 T
lesions in boys.1,2 Virilization in boys, as manifested2 E( q- r7 i& j
by enlargement of the penis, development of pubic
  O; u% q- Z, yhair, and facial acne without enlargement of testi-1 w# E* A4 B- M1 D
cles, suggests peripheral or pseudopuberty.1-3 We
2 X; e$ ?* \% P6 J( sreport a 16-month-old boy who presented with the
9 D. ~6 J9 {1 B: N4 P( d, N4 Cenlargement of the phallus and pubic hair develop-% y! E" K2 @9 D9 T" _: B9 k
ment without testicular enlargement, which was due
$ w3 P8 E' e- j7 q, `9 c) wto the unintentional exposure to androgen gel used by
8 D# \6 Q, W  y7 |; s; gthe father. The family initially concealed this infor-" L5 @" Q; o' e% b4 X' l+ J
mation, resulting in an extensive work-up for this
. _+ d) g. G- Q2 ~child. Given the widespread and easy availability of+ }# K0 k8 h4 r% x5 y( U1 Z& k; f% D
testosterone gel and cream, we believe this is proba-( W* g) h! d+ B# ~
bly more common than the rare case report in the2 _% l+ L" K: s$ `* e. B; b$ Z
literature.49 @  i" p6 [1 z$ w4 l
Patient Report# Z4 t" M/ Y& C0 C! k) m
A 16-month-old white child was referred to the2 O, ~# {# o4 h& \- |
endocrine clinic by his pediatrician with the concern
0 e/ _( Z( ^+ E6 d3 j* @& ]of early sexual development. His mother noticed
( S$ @: Q7 Q1 s$ n( K8 z8 Jlight colored pubic hair development when he was7 s7 I3 x* K7 W" v- S7 B
From the 1Division of Pediatric Endocrinology, 2University of" y( J3 F5 Y4 W6 U' c: ^" ^4 W- r
South Alabama Medical Center, Mobile, Alabama.
. E5 @- Z, [# Z5 o9 t' lAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 a4 [8 H/ b$ o- k/ i; @( RProfessor of Pediatrics, University of South Alabama, College of  W, Z- v! a7 w2 s" x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* T9 v3 v2 R8 b6 v, B8 B
e-mail: [email protected].7 e* t6 h  k! `9 w7 J9 {$ l
about 6 to 7 months old, which progressively became* u, e# r; a( i9 w- [2 j5 T" p9 j3 M
darker. She was also concerned about the enlarge-$ b4 b. t7 [/ V. Q3 c5 R
ment of his penis and frequent erections. The child
# c; [  I  s6 y/ G/ ^2 cwas the product of a full-term normal delivery, with
( l8 Z1 \' F. ?) s5 Ta birth weight of 7 lb 14 oz, and birth length of
' H0 p$ I; b7 m% W  l3 M" V20 inches. He was breast-fed throughout the first year( P$ H8 `6 g# Q; e: O- K# P0 Z
of life and was still receiving breast milk along with
: V. j0 t3 A( G# B, Z* _solid food. He had no hospitalizations or surgery,
- }: X5 m. k& tand his psychosocial and psychomotor development
, }6 G5 n4 \' \6 Q$ uwas age appropriate.! ?# ~8 [; g9 c2 P
The family history was remarkable for the father,
  ?4 q5 a6 ~+ [9 rwho was diagnosed with hypothyroidism at age 16,
* N1 E  N1 h3 Uwhich was treated with thyroxine. The father’s% |) ^& ?& ^2 u
height was 6 feet, and he went through a somewhat
0 n# Q+ W% Q% ?% g; oearly puberty and had stopped growing by age 14./ u0 p  q( ], v: I  y4 f8 ^
The father denied taking any other medication. The; g  F: m, D; |) W
child’s mother was in good health. Her menarche, W8 Y; I, \/ @( ], R4 m
was at 11 years of age, and her height was at 5 feet
! b, j/ C3 [- A' ^4 N0 ?5 inches. There was no other family history of pre-, o( f7 j6 u( ]) Z8 @; n; X
cocious sexual development in the first-degree rela-% B$ Z3 U! r7 ?- Z$ W
tives. There were no siblings.6 ^9 T7 `1 l$ ]
Physical Examination
' e; \1 ~% t. R2 Z# P- gThe physical examination revealed a very active,
5 q8 u' |8 ^# k% k1 Lplayful, and healthy boy. The vital signs documented
& b" k7 U+ K- q+ K( m; _8 Y0 Ta blood pressure of 85/50 mm Hg, his length was" j8 Y9 N$ H2 Q% O
90 cm (>97th percentile), and his weight was 14.4 kg$ k# O  s$ J6 c$ o1 I# u+ L
(also >97th percentile). The observed yearly growth" w' `" Y9 l3 u* O
velocity was 30 cm (12 inches). The examination of( f: K( D) M/ }$ f, n% h. \
the neck revealed no thyroid enlargement.
' e9 ~: Y' D0 Q" b1 s4 \The genitourinary examination was remarkable for* j  s! u* |' O6 s2 r$ z
enlargement of the penis, with a stretched length of
6 v- e0 a  m/ c8 cm and a width of 2 cm. The glans penis was very well: u% _8 e/ ~6 ]
developed. The pubic hair was Tanner II, mostly around$ P" ]8 C9 N/ c% v1 f: \5 V9 d
5404 H6 S* _) G; n3 q2 E( P& r& a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 X+ Z$ M7 m/ `, G0 q% F( }the base of the phallus and was dark and curled. The
, v6 C! f5 i9 L; q7 H0 l- F7 @testicular volume was prepubertal at 2 mL each.' b( Q2 }! {1 E$ W9 _
The skin was moist and smooth and somewhat( Z; x+ ^: ^! c) y5 G
oily. No axillary hair was noted. There were no  p: @( g6 n; X4 ?1 g
abnormal skin pigmentations or café-au-lait spots.
3 I4 t0 o, U- s7 ?) O, z/ YNeurologic evaluation showed deep tendon reflex 2+2 x7 r) l6 X( f+ v
bilateral and symmetrical. There was no suggestion& W4 y) e, ~/ L. f3 }8 E& L# ~1 Z
of papilledema.& T/ R; W+ }1 s, t
Laboratory Evaluation
( T3 q0 a6 J; a* y/ d6 u0 HThe bone age was consistent with 28 months by
9 \3 M9 Q3 E* o$ t2 dusing the standard of Greulich and Pyle at a chrono-
: m6 ]- }# [6 W4 X, x! h7 Hlogic age of 16 months (advanced).5 Chromosomal4 w5 \. D% C" X4 L/ q
karyotype was 46XY. The thyroid function test
' G9 m2 Z1 N# R" b, @; F9 r- Wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-/ \/ J% {- U# d7 Z
lating hormone level was 1.3 µIU/mL (both normal).
, t. M2 [) \! p! N" {* w! L$ Q. v& `# [The concentrations of serum electrolytes, blood3 M7 L: I/ D  ?0 S
urea nitrogen, creatinine, and calcium all were. d4 W% H8 a8 Y, w
within normal range for his age. The concentration5 W0 V  i, C1 K/ O' R, g+ v
of serum 17-hydroxyprogesterone was 16 ng/dL, j/ O2 A! B- x- `5 I2 v/ m& [' O
(normal, 3 to 90 ng/dL), androstenedione was 20
  _+ G. |2 X+ ^  Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! B7 x) m8 E/ ]' W+ D' @1 W* q% Tterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 G2 G1 x( F8 v. L  U2 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 f8 t1 r% n- I3 i& D+ y) x
49ng/dL), 11-desoxycortisol (specific compound S)
" A0 o5 M$ \! z( t* u$ M# g' Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; i# X" x& P& |% rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& V7 K3 J8 S& J% B/ c2 s% s9 i
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," X2 l2 v$ m2 V0 N/ r
and β-human chorionic gonadotropin was less than& ]2 E9 J: J; \, \. T5 U1 h) }
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 l' i9 s; H; r& z: l
stimulating hormone and leuteinizing hormone
+ y! z; u2 ]; Lconcentrations were less than 0.05 mIU/mL( W2 Y0 j$ s! [  M( x+ A; c0 r4 A- Z
(prepubertal).
# p; V: o# \  x6 z2 k" `5 sThe parents were notified about the laboratory( Z2 e" p2 B& X3 e
results and were informed that all of the tests were8 K( }$ V; o8 A) ^0 P5 f
normal except the testosterone level was high. The
1 @4 U* U) ^8 u& Qfollow-up visit was arranged within a few weeks to
( t8 {. y( K3 q2 I  J' xobtain testicular and abdominal sonograms; how-
! j) p: {  y$ t3 o: O' Lever, the family did not return for 4 months.
: ~; r$ A2 L% Z. jPhysical examination at this time revealed that the
2 ^  Q1 A2 ?7 A6 Kchild had grown 2.5 cm in 4 months and had gained3 i2 H1 n5 b4 e2 J- v! s" L" s- s
2 kg of weight. Physical examination remained
* ~) l' y  u! Q' L4 Xunchanged. Surprisingly, the pubic hair almost com-
; U4 Q6 E4 U* [2 E0 i5 @pletely disappeared except for a few vellous hairs at) y" H% z' I$ Q
the base of the phallus. Testicular volume was still 2( L& ~1 ^( O+ a% y: Q+ @; T
mL, and the size of the penis remained unchanged.- q6 K% \/ ^5 V6 y, x/ \
The mother also said that the boy was no longer hav-. C7 d* j% i; Y! |1 ]+ U
ing frequent erections." z! u. @# |8 ]. l
Both parents were again questioned about use of
$ A8 X% O% E: q' @any ointment/creams that they may have applied to# j/ a2 C) k& E, g
the child’s skin. This time the father admitted the$ v4 ]& e! Q% d# Y  {' h) r/ Z
Topical Testosterone Exposure / Bhowmick et al 541; c5 N* R; u, t3 B& y' o2 a
use of testosterone gel twice daily that he was apply-: ^$ K# w4 o6 S9 R- C2 I8 J  G
ing over his own shoulders, chest, and back area for
3 Z: a, C6 U! F- P  G7 o9 q* T, ~a year. The father also revealed he was embarrassed
$ q% ~& R- v" R4 K) r$ }to disclose that he was using a testosterone gel pre-- [5 L+ g* Q/ p' c$ i
scribed by his family physician for decreased libido
9 I) T* S+ _' q% Vsecondary to depression.5 |- |5 j: x7 @) W; A
The child slept in the same bed with parents.
( r+ E" k* x) @, M, f& _The father would hug the baby and hold him on his* w" O8 W7 ~: G; {( m
chest for a considerable period of time, causing sig-
6 y5 A$ P3 C( k/ }/ ~nificant bare skin contact between baby and father.+ U6 v- u) a- f7 \' b
The father also admitted that after the phone call,) l0 F% ]% p! {) V% O2 r% H" j* k
when he learned the testosterone level in the baby- A/ E: ]( K% D2 F  l( D0 ~$ ]
was high, he then read the product information
2 j- t' \! K; V0 x& y- A9 ^packet and concluded that it was most likely the rea-9 \6 x" V- n( ]& t8 Z) G. m: X
son for the child’s virilization. At that time, they, J: l% u6 p( f; O/ ]' A9 |
decided to put the baby in a separate bed, and the
: B" j. f+ ?1 `9 @9 [father was not hugging him with bare skin and had
& V5 Z) f4 b2 L- [) n; g, S" X& jbeen using protective clothing. A repeat testosterone2 _( i9 X$ W5 e2 u! O' L# a, X2 @' y
test was ordered, but the family did not go to the2 R9 }; I8 \; W4 c
laboratory to obtain the test.' `, J9 I/ e( G4 k6 v* e
Discussion
( }" K0 |: s5 V7 \* \Precocious puberty in boys is defined as secondary
! I6 y5 _, X0 psexual development before 9 years of age.1,4
( F& X! w; V9 HPrecocious puberty is termed as central (true) when: z. o# `, M( m# H% ?. h- g
it is caused by the premature activation of hypo-
) ?1 ^' z/ L2 A. A& B) {5 ]% Kthalamic pituitary gonadal axis. CPP is more com-, M, i9 v! Q% A" A5 E0 P0 r
mon in girls than in boys.1,3 Most boys with CPP+ t( l2 _* e  F$ |* S' O' x
may have a central nervous system lesion that is  S; Y3 I8 {1 K: ^3 g2 \& z; u
responsible for the early activation of the hypothal-
7 o  f7 ~" Z3 c( q0 d7 y$ ^amic pituitary gonadal axis.1-3 Thus, greater empha-
: C! r" K3 x  }6 a, K7 ^; fsis has been given to neuroradiologic imaging in, B5 Y8 B1 T0 ^6 ?2 z) [$ T% T3 I& Q' W
boys with precocious puberty. In addition to viril-
/ u4 ?1 o2 k. R1 ~# p  ?ization, the clinical hallmark of CPP is the symmet-8 _# V0 h, P. Y9 \1 M/ ?! @
rical testicular growth secondary to stimulation by
5 N: m( ~' e7 t" t; ngonadotropins.1,3
% @, [, |7 |' FGonadotropin-independent peripheral preco-
" x  O4 R6 z  S1 y6 t1 t, [- z. Dcious puberty in boys also results from inappropriate
% e$ k$ N( R* n0 k" V* pandrogenic stimulation from either endogenous or/ x+ W3 T3 D2 C
exogenous sources, nonpituitary gonadotropin stim-
" E- g& ~. h7 T: E8 eulation, and rare activating mutations.3 Virilizing
: K. t8 i2 p8 q1 {6 gcongenital adrenal hyperplasia producing excessive
! ~: G; {  _* }adrenal androgens is a common cause of precocious
/ C. E4 R$ I8 u% r% Vpuberty in boys.3,4
# V( ~0 F& P4 B  r  T; O/ u. iThe most common form of congenital adrenal
  ?4 H# \9 O2 Rhyperplasia is the 21-hydroxylase enzyme deficiency.( L% }, ]" r  X  I6 d  B  p
The 11-β hydroxylase deficiency may also result in
7 ]% O; J  s' P0 C4 o. w5 pexcessive adrenal androgen production, and rarely," M9 c' Q7 y- m# [; n* V8 H# }
an adrenal tumor may also cause adrenal androgen  {0 k* H7 k$ d4 B% O6 ~' u
excess.1,3( v" I) }: i2 u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ t! i& h% c6 M/ b
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 m& n8 U) j8 Q( MA unique entity of male-limited gonadotropin-
: t( I( Z; y$ ?0 r( N3 ~) ?independent precocious puberty, which is also known5 \( {* E5 l- l
as testotoxicosis, may cause precocious puberty at a
- T) f  B4 J. y& F7 i7 _5 o3 @very young age. The physical findings in these boys
! N' b. Y+ l: P+ p1 Hwith this disorder are full pubertal development,) X3 {* C: V2 j7 r) M
including bilateral testicular growth, similar to boys! z& Z9 @4 B( U, A& D+ g1 Y
with CPP. The gonadotropin levels in this disorder: z* h" G6 D4 y4 [, Q7 a
are suppressed to prepubertal levels and do not show" m% X! c4 Z& x' k; J
pubertal response of gonadotropin after gonadotropin-0 W. `8 ^6 l1 ~$ i+ J8 {' P7 L/ @  B
releasing hormone stimulation. This is a sex-linked
: u: ?2 u  R) u" ~$ X& pautosomal dominant disorder that affects only( I& T" ]: W! G" w9 g5 |
males; therefore, other male members of the family
% q4 [$ s' v% `$ Z. \( tmay have similar precocious puberty.3' t- F4 D9 E1 ~1 i3 p' q/ I9 o6 I
In our patient, physical examination was incon-
6 @+ |/ j3 }/ A+ S( l* i' {5 xsistent with true precocious puberty since his testi-* C3 a( d: D0 i9 e. {3 `1 k3 l
cles were prepubertal in size. However, testotoxicosis
7 G. H9 ]1 X3 C' h0 P) wwas in the differential diagnosis because his father' i2 C8 E) p8 K$ n  [+ E8 a
started puberty somewhat early, and occasionally,
2 Y# d  |! |0 S- t% a, ptesticular enlargement is not that evident in the8 W! p+ M8 w! A) r/ h, L5 S
beginning of this process.1 In the absence of a neg-/ J2 x8 m- K+ L6 T: N
ative initial history of androgen exposure, our8 P/ R+ g0 V% X+ F
biggest concern was virilizing adrenal hyperplasia,
/ w" }% C& \% J6 F9 T  ~4 ^either 21-hydroxylase deficiency or 11-β hydroxylase, I6 x4 @+ c" H- m$ n
deficiency. Those diagnoses were excluded by find-
0 Q6 g! R) n+ T" W3 j4 _ing the normal level of adrenal steroids.
* \  p% ]4 j# V* i  V/ RThe diagnosis of exogenous androgens was strongly3 [0 T1 u% t$ ]3 E7 g3 e9 s+ J- L% g* q3 v
suspected in a follow-up visit after 4 months because
( I, J3 M( G) Kthe physical examination revealed the complete disap-
( X8 g$ }* I; ^4 t: z% }pearance of pubic hair, normal growth velocity, and0 W8 _' e& z9 s/ @* O
decreased erections. The father admitted using a testos-) C' }$ b0 m9 E4 s- o
terone gel, which he concealed at first visit. He was
- e7 H+ w0 h4 v8 C* gusing it rather frequently, twice a day. The Physicians’- q# x( ?) V' e9 K) C5 G& j6 _' _
Desk Reference, or package insert of this product, gel or
! Q* I) r; S/ D& I+ U& [cream, cautions about dermal testosterone transfer to
" y) B5 f1 `8 m' z' i8 A( {$ Eunprotected females through direct skin exposure.9 s6 C/ K4 }7 x
Serum testosterone level was found to be 2 times the; Q4 l2 X) k: u3 s8 D3 R) a
baseline value in those females who were exposed to
5 Z: g5 c4 Y4 ?, a$ F6 Reven 15 minutes of direct skin contact with their male2 I- C0 m7 z' [0 c* h; m/ q
partners.6 However, when a shirt covered the applica-
. a* B' ]7 B+ Z, n" n  I+ X# r1 qtion site, this testosterone transfer was prevented.- C; L; t- B/ o$ u) f( n
Our patient’s testosterone level was 60 ng/mL,, C( A, [7 J3 z) {# Q- i
which was clearly high. Some studies suggest that
* k/ s; y! M/ B- _4 |1 _dermal conversion of testosterone to dihydrotestos-
. z6 m. o# h6 R' D) v0 lterone, which is a more potent metabolite, is more  D% @/ o' x& C7 w7 D: h3 m4 q9 ]
active in young children exposed to testosterone, p" b8 k& T' |+ J- S
exogenously7; however, we did not measure a dihy-3 v: N- D( u) U
drotestosterone level in our patient. In addition to
" u6 T) v. {3 ~; O8 c9 @9 \virilization, exposure to exogenous testosterone in9 v, Y. f% t& P8 F- F
children results in an increase in growth velocity and
8 x# ?1 H  p  ?, W6 D; iadvanced bone age, as seen in our patient.+ n& Z& V% H+ G+ n+ b# F: D  j
The long-term effect of androgen exposure during5 T8 I! k# d2 |/ f8 [6 d1 f' f
early childhood on pubertal development and final
' a$ V' f" l$ N: V0 k3 nadult height are not fully known and always remain; k& ~, Z! D0 h3 A
a concern. Children treated with short-term testos-9 J& W: Z5 e( i& n4 c- a0 I
terone injection or topical androgen may exhibit some. t6 U! @+ U% e$ a: J6 b& C
acceleration of the skeletal maturation; however, after: f# c- k+ s6 I7 n
cessation of treatment, the rate of bone maturation
3 p. R* l3 K8 e6 \decelerates and gradually returns to normal.8,91 _, i) y9 N# G8 N6 N8 W4 u
There are conflicting reports and controversy9 b& @3 S* `: x2 M3 T+ i  [
over the effect of early androgen exposure on adult* }) G; j0 E$ u" o: M' G5 q" r
penile length.10,11 Some reports suggest subnormal6 |5 c4 {8 [4 D" Z: S: Y8 s3 X
adult penile length, apparently because of downreg-
2 {0 B. F4 j* Uulation of androgen receptor number.10,12 However,
) ?3 G- Z. U! v" K) H  hSutherland et al13 did not find a correlation between2 G& b( U% Y# Y5 ?, ^) T8 s, e
childhood testosterone exposure and reduced adult* b. P. v1 x: Z4 l. Y2 h4 G
penile length in clinical studies.
, t/ Z# L2 m, q4 q" b/ `Nonetheless, we do not believe our patient is
) A" U8 q0 T9 P' Qgoing to experience any of the untoward effects from
- b2 H: y9 ~: ^+ B1 \5 Ltestosterone exposure as mentioned earlier because
  t. z% x- Q; v5 Zthe exposure was not for a prolonged period of time.
: r' d$ H' ~) A! N7 U3 l! v( NAlthough the bone age was advanced at the time of
9 L# r9 X/ w% R! }& |6 I+ udiagnosis, the child had a normal growth velocity at& U1 s( _( D# q0 a
the follow-up visit. It is hoped that his final adult2 H& M' Y+ n! h: C
height will not be affected.. s& h( \& M: t
Although rarely reported, the widespread avail-
8 b5 _; D3 l+ y7 ^+ T' i' K  Kability of androgen products in our society may
7 y6 E/ c' v  e% u* kindeed cause more virilization in male or female
: q2 V+ z5 h7 D1 O- p: s9 nchildren than one would realize. Exposure to andro-
* u) P1 @: r7 I6 e( @6 C# J+ Ugen products must be considered and specific ques-
: _/ M5 g& E8 w5 M$ e( Ctioning about the use of a testosterone product or2 _. s1 n) I9 K" i  R, @
gel should be asked of the family members during- l" i& X* }/ h1 P' g
the evaluation of any children who present with vir-
  G; P+ t9 I; q4 Y9 Nilization or peripheral precocious puberty. The diag-
8 S! A+ R$ r3 ^- U* Enosis can be established by just a few tests and by
6 Y, w! x5 v' @! E1 @, `appropriate history. The inability to obtain such a& A; y/ P. i; Y1 s
history, or failure to ask the specific questions, may
3 T' M  C9 B4 j$ f3 o5 _result in extensive, unnecessary, and expensive7 k9 D8 r/ {# y+ Q
investigation. The primary care physician should be0 F' j" [, w& L2 w( l; B
aware of this fact, because most of these children' l$ k- N7 u6 E  z. d0 }. x
may initially present in their practice. The Physicians’3 ]/ M: \9 N4 \2 \" f( k5 t
Desk Reference and package insert should also put a
7 d6 L5 \4 f4 N1 Hwarning about the virilizing effect on a male or9 s4 H+ Y4 t* |: [% ?- \! U; w
female child who might come in contact with some-2 S' X$ q$ U, V# P) g8 y! k
one using any of these products.
3 E9 P# p: M; D" t# e( NReferences! g) S3 F3 n9 c/ d" B, G0 C1 y" a
1. Styne DM. The testes: disorder of sexual differentiation  Z$ v6 z1 W: p' C7 V
and puberty in the male. In: Sperling MA, ed. Pediatric
0 p! v: Q4 a9 L  _' P' }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; {. v$ D" x* `. p9 y9 P2002: 565-628.
& @  G- k! [/ X2 [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! z' B& H! c# X+ g. S  L
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
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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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