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Sexual Precocity in a 16-Month-Old; D1 N0 J4 I3 r/ Y  ]6 n& Y7 y7 h( S
Boy Induced by Indirect Topical% S* }2 F5 F5 M
Exposure to Testosterone
# q& G/ ]) J6 ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 @) u% m, u/ z3 Y& `  E( Land Kenneth R. Rettig, MD1
' `2 F4 l: [: Y1 {( c$ j$ eClinical Pediatrics$ V! s/ M) ^. ^6 k
Volume 46 Number 6
2 y8 I) g. s; e( l: ]! ^" \July 2007 540-543" B/ S! _( n" Q
© 2007 Sage Publications' `7 |3 c/ h! A3 l3 ]8 \
10.1177/00099228062966513 _  s3 I- Z. Z' L
http://clp.sagepub.com
4 ^- Z6 l! {3 e: B( f7 j5 Q- m& Rhosted at4 N- V& T4 o7 O4 J$ W* ^
http://online.sagepub.com
/ |% ?. [1 A! b+ b! ^. s! iPrecocious puberty in boys, central or peripheral,# T" _$ x6 A/ d& Y7 o4 o- J. W
is a significant concern for physicians. Central
! V& [/ Z  ~* K9 s+ z( N6 nprecocious puberty (CPP), which is mediated
4 `8 s/ P; @$ v6 S5 q4 ]& Othrough the hypothalamic pituitary gonadal axis, has
! H+ p; R2 F" ^; ia higher incidence of organic central nervous system" v& d; |+ ^  J. E$ y
lesions in boys.1,2 Virilization in boys, as manifested- B) o1 L3 k  r; v( t
by enlargement of the penis, development of pubic
! d8 f2 P; {  qhair, and facial acne without enlargement of testi-  T+ E5 [- p2 J
cles, suggests peripheral or pseudopuberty.1-3 We8 V7 z! f& Q5 t" ~: J, t
report a 16-month-old boy who presented with the
7 r  c! N9 h+ }  {5 q( N6 `5 `enlargement of the phallus and pubic hair develop-
7 I5 k# |' t# wment without testicular enlargement, which was due
- V0 ^, O6 r$ `* E  K; Sto the unintentional exposure to androgen gel used by7 ]* c9 z6 B9 S2 B! p$ h/ e" X
the father. The family initially concealed this infor-. U. G! l- r% }( ^# V! D0 A
mation, resulting in an extensive work-up for this0 V7 Z2 R/ \8 w4 h
child. Given the widespread and easy availability of
) U. U: n4 @8 G# M, Ltestosterone gel and cream, we believe this is proba-
4 ~2 L: I# W- x1 J8 dbly more common than the rare case report in the% _6 l# r4 K. d# D1 ^3 h
literature.4
* R$ E4 N' E0 l' hPatient Report( B7 p+ R) ?- w& N1 u$ c% p* ~# m
A 16-month-old white child was referred to the
! p) G9 x' V4 n+ j3 A. f; L1 C# [endocrine clinic by his pediatrician with the concern4 L% Y( a( a* P
of early sexual development. His mother noticed
, c1 B  k. r1 k/ e& U' ]8 Y; vlight colored pubic hair development when he was
: K% w3 `/ g- ^! j: Z2 L. t3 jFrom the 1Division of Pediatric Endocrinology, 2University of7 z1 |1 y3 d! i9 k! P0 V2 L4 F' N
South Alabama Medical Center, Mobile, Alabama.
8 ]6 L. c. l1 W/ M9 p" w+ {8 xAddress correspondence to: Samar K. Bhowmick, MD, FACE,  w' Q' [1 [0 G0 b3 c& |: `
Professor of Pediatrics, University of South Alabama, College of$ M, a8 T' z0 F( {- Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ s% o" W. {; D8 j4 |+ C. v- K# n
e-mail: [email protected].
8 ]" t  ~6 C1 B: x, [! Labout 6 to 7 months old, which progressively became
- f% F" R( b7 p% _0 ^7 C: v+ Ndarker. She was also concerned about the enlarge-. [5 \9 F" E# |5 n+ o
ment of his penis and frequent erections. The child+ [( m. T% e; s- ]) E
was the product of a full-term normal delivery, with
  S2 i9 ]. g7 Pa birth weight of 7 lb 14 oz, and birth length of
8 I3 v- H. n! V+ h20 inches. He was breast-fed throughout the first year
. P$ ^3 V! C6 c9 F8 a! F! Yof life and was still receiving breast milk along with' F7 [) }9 K6 S% _6 U
solid food. He had no hospitalizations or surgery,
( b: @: k1 h! D1 M; Q4 T0 u& vand his psychosocial and psychomotor development0 ^9 F, |/ n! ?, q3 `' ~& h
was age appropriate.1 Z+ u* y1 [. }! i
The family history was remarkable for the father,8 G% {0 G4 f- a7 A
who was diagnosed with hypothyroidism at age 16,% F" P! P9 ]6 T9 u
which was treated with thyroxine. The father’s
) ?3 h1 W2 n6 T$ q% A5 o4 k# C2 `height was 6 feet, and he went through a somewhat
* O3 l0 ^- k  K/ ]' {early puberty and had stopped growing by age 14.
: r" h5 T' Z  w( U, U4 Q) @: ZThe father denied taking any other medication. The) h3 Y% u3 E2 w+ C* v4 _
child’s mother was in good health. Her menarche
1 ?6 {: k) O$ y( J9 m" A8 Iwas at 11 years of age, and her height was at 5 feet  g/ o8 ^, P/ ]
5 inches. There was no other family history of pre-
# h. D* I$ f3 w; Icocious sexual development in the first-degree rela-
  b, Y: l% |- `( ~( K% U% ?tives. There were no siblings.' d% N6 I5 s4 W- i! g- [1 i
Physical Examination
4 t/ M9 `- v" e1 h* m& V5 ~The physical examination revealed a very active,
8 ?! M, v" C! Y+ `" Fplayful, and healthy boy. The vital signs documented+ ^6 m+ h. z. `, I9 ?
a blood pressure of 85/50 mm Hg, his length was; l' I3 ?. U, K5 e
90 cm (>97th percentile), and his weight was 14.4 kg
. [( ]) E% W6 |% r# k7 |3 q; w(also >97th percentile). The observed yearly growth  m% @8 s$ k* J
velocity was 30 cm (12 inches). The examination of
8 G/ b4 m- y5 S, P* o. Athe neck revealed no thyroid enlargement.+ E; |: f* A; f9 W& G6 N( y
The genitourinary examination was remarkable for
: D& N$ j) r- p* I( ienlargement of the penis, with a stretched length of4 {% k) z9 H' j* z- f
8 cm and a width of 2 cm. The glans penis was very well+ s4 j: X2 ]1 V7 n
developed. The pubic hair was Tanner II, mostly around5 Y: y3 d( \; C6 I9 t+ ~
540
) O7 J, Q! H/ A: l4 F- mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. A) {4 K" J9 c1 A( p' H; B
the base of the phallus and was dark and curled. The( h+ [- U; I: Z& Y
testicular volume was prepubertal at 2 mL each.
. _% V" z8 v& E/ `; oThe skin was moist and smooth and somewhat! j; Q, T0 ~# i6 y; x" f$ R" X* G
oily. No axillary hair was noted. There were no8 ~7 H' Z* H( n4 @
abnormal skin pigmentations or café-au-lait spots./ Q) Z% e  I9 |5 E5 k1 H. H5 E
Neurologic evaluation showed deep tendon reflex 2+
" c8 A+ B" P- M, e7 S$ x7 X& J4 V4 Jbilateral and symmetrical. There was no suggestion
, ^. A+ q8 J5 I0 X) @of papilledema.- A) h  m2 G9 Q. Y7 L0 O
Laboratory Evaluation
7 m8 V; [9 E) ?& x0 F; ^5 k+ t6 WThe bone age was consistent with 28 months by
" h; {" X9 L1 R- b' s* Kusing the standard of Greulich and Pyle at a chrono-1 C. O! j  ]& C$ x7 t. o
logic age of 16 months (advanced).5 Chromosomal2 A) z) X: X3 [- ~
karyotype was 46XY. The thyroid function test) v) f) j; A* e( j5 ~1 E8 D8 R; ]5 }: S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 y2 g& i3 X$ e0 slating hormone level was 1.3 µIU/mL (both normal)./ A3 k1 R4 g. B4 m6 x2 o
The concentrations of serum electrolytes, blood
% C; O9 V# t% I: b+ eurea nitrogen, creatinine, and calcium all were9 B7 X8 r, R8 S& z0 T* {* a
within normal range for his age. The concentration' W+ ~- E4 c7 x
of serum 17-hydroxyprogesterone was 16 ng/dL# K, R8 C  R: R  {# O: l
(normal, 3 to 90 ng/dL), androstenedione was 20+ `; [( \9 w0 |  X1 v+ R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. D; I2 g. c0 ], ^9 e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 ]% s; A$ Q; {+ z) Z3 V4 O( s: Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 z* M: M& T2 J; O4 s9 e3 `* w% ~# k49ng/dL), 11-desoxycortisol (specific compound S)  i! [7 Y/ T" z5 P+ {- D2 m5 O9 J
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% A! X; O# N3 q, l
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* D9 {/ v0 e# S% L: g  C, \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 x9 ~- U5 S) G
and β-human chorionic gonadotropin was less than& d2 j9 R) P* U5 y$ G
5 mIU/mL (normal <5 mIU/mL). Serum follicular: x8 P" e/ t! F  H
stimulating hormone and leuteinizing hormone6 e6 S2 ?' m" Q
concentrations were less than 0.05 mIU/mL
" }6 N5 [8 L# w" X(prepubertal).8 q% l2 t6 \2 g& T/ O9 T
The parents were notified about the laboratory
# ]! X+ ~1 ?6 Qresults and were informed that all of the tests were
- R2 I1 t& W3 A! ~5 r3 d7 cnormal except the testosterone level was high. The
% a1 h) p7 N1 M( b" w: `2 C! i5 Zfollow-up visit was arranged within a few weeks to2 n( K5 N' B  o' V* F7 t
obtain testicular and abdominal sonograms; how-
6 J4 \! p, X4 C, H, G! g) ?! }ever, the family did not return for 4 months.
* k* m* Z* j; [- ?/ d% X0 LPhysical examination at this time revealed that the6 N7 {2 x) N# L! J" Y
child had grown 2.5 cm in 4 months and had gained4 ]) z9 ]2 h: e& V' |
2 kg of weight. Physical examination remained: `2 Z' S! U; I& _7 J
unchanged. Surprisingly, the pubic hair almost com-5 H2 v1 o2 B3 |2 T" W
pletely disappeared except for a few vellous hairs at, D  Q6 m, ^! ?* R' l: E2 T
the base of the phallus. Testicular volume was still 2" Z2 [$ o* x" W. P8 I
mL, and the size of the penis remained unchanged.  [5 J5 R3 r3 w0 ~- u4 x& o
The mother also said that the boy was no longer hav-
0 H5 P! V1 n0 b! H# t' _ing frequent erections.5 y+ v3 U0 J( [; K1 D
Both parents were again questioned about use of/ y2 C6 V+ Y3 }2 U9 f0 B3 H
any ointment/creams that they may have applied to
# E' b9 Q! V, Y  [0 Z7 H2 Xthe child’s skin. This time the father admitted the
1 [7 }' Q8 V4 n  v" MTopical Testosterone Exposure / Bhowmick et al 541% x$ Q0 J3 U$ b, S, D. B8 e' q% p
use of testosterone gel twice daily that he was apply-% Y; x2 s% v# H' ]# L
ing over his own shoulders, chest, and back area for
) X" W0 }4 C& R1 z; W. |a year. The father also revealed he was embarrassed+ M% Y1 ]: s# V3 B
to disclose that he was using a testosterone gel pre-
3 p3 G3 s" u- x/ {scribed by his family physician for decreased libido1 U7 f0 Q+ V$ _: `
secondary to depression.
! E4 e' h, `. N; z" |The child slept in the same bed with parents.9 O( T  A, k) Y
The father would hug the baby and hold him on his& m$ l) K$ G! l& @! V
chest for a considerable period of time, causing sig-' {! I! Y9 p9 d! Y
nificant bare skin contact between baby and father.
0 y4 ~! b& p2 k  \1 }# T0 F" p- yThe father also admitted that after the phone call,
: x8 H/ M& u: U6 @when he learned the testosterone level in the baby& a0 E+ o* |8 }% [0 ~# ~
was high, he then read the product information
; R0 z& d) }  L+ _  mpacket and concluded that it was most likely the rea-! M# c0 K0 y. M4 N6 }3 s! e
son for the child’s virilization. At that time, they. W4 V- T8 W/ k( Q
decided to put the baby in a separate bed, and the
$ J% ?+ H, F# I+ s: A9 A! \father was not hugging him with bare skin and had
5 w8 Q1 N6 ^9 C+ Xbeen using protective clothing. A repeat testosterone7 H+ E- \' _! M  h% r
test was ordered, but the family did not go to the
( F1 t5 m0 W) J2 {! S2 ^5 y  slaboratory to obtain the test.
2 V+ E3 l9 Z2 i! k7 \- NDiscussion& U1 j0 U/ j4 }% M
Precocious puberty in boys is defined as secondary: S# t; O3 E+ K
sexual development before 9 years of age.1,4: i' r7 P$ ?; v0 E
Precocious puberty is termed as central (true) when
* N2 |; y, k. D3 Hit is caused by the premature activation of hypo-& j; n0 r' |# n4 n
thalamic pituitary gonadal axis. CPP is more com-
- H. e' J, S4 Q) tmon in girls than in boys.1,3 Most boys with CPP5 J- b$ M% z) p1 p1 y3 i) H
may have a central nervous system lesion that is
" M- P: _, G3 r0 ?% yresponsible for the early activation of the hypothal-- B2 J6 Q8 [$ c' K% R
amic pituitary gonadal axis.1-3 Thus, greater empha-
* \  l8 M$ y$ c; q: V2 z0 C3 Vsis has been given to neuroradiologic imaging in
+ ^( C9 j& ?+ b' X1 kboys with precocious puberty. In addition to viril-+ a, p/ g2 V/ ~3 [
ization, the clinical hallmark of CPP is the symmet-, [, O8 e5 e* R* y+ t" ~
rical testicular growth secondary to stimulation by1 T( t7 t, ?7 }' w" X7 ^/ z
gonadotropins.1,3. G, J+ l& J- @( X: W
Gonadotropin-independent peripheral preco-
1 X! ~) ], n& {  |cious puberty in boys also results from inappropriate
* D$ P" y' ?8 P! T8 |7 Uandrogenic stimulation from either endogenous or1 s) }( M( e) A0 c  N8 E- w) T
exogenous sources, nonpituitary gonadotropin stim-+ {2 _* @8 v2 S3 i) w
ulation, and rare activating mutations.3 Virilizing( t4 S! l* d1 P* l
congenital adrenal hyperplasia producing excessive( b1 f3 y3 I1 n& B1 Q( K& Y' h
adrenal androgens is a common cause of precocious  d, e* ^; o9 g% ]2 k  W
puberty in boys.3,4
( t6 V8 @0 Z/ h. h; i) Z1 _" Z7 bThe most common form of congenital adrenal
4 F$ u" J5 ?( G; Q/ X2 |5 x( [+ A9 C! ^hyperplasia is the 21-hydroxylase enzyme deficiency.
' l2 \& {+ W. kThe 11-β hydroxylase deficiency may also result in
, s1 h% ^; c" V! mexcessive adrenal androgen production, and rarely,
6 R- o6 k; S! ]" u7 U1 @an adrenal tumor may also cause adrenal androgen
+ F% u( N: I8 c% M: Wexcess.1,3& o7 z3 {9 g# r) D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, }8 t  F& _; ]. A# q, {5 Y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. A. F/ H! A6 e# W1 U% H5 M8 O
A unique entity of male-limited gonadotropin-! `% \! I4 \2 e9 C1 d5 d6 x
independent precocious puberty, which is also known
2 V+ k5 ?. @) F) v+ Eas testotoxicosis, may cause precocious puberty at a  ]: ^( f/ |2 {$ l/ U
very young age. The physical findings in these boys
: f1 R* Q" h! P1 i0 i5 y$ I/ |3 kwith this disorder are full pubertal development,
7 I( K. W# {/ Q# M8 ^including bilateral testicular growth, similar to boys
5 P* o4 u: w+ n! I5 X' Awith CPP. The gonadotropin levels in this disorder
/ m3 G0 D4 N; |6 ?' g7 f, {are suppressed to prepubertal levels and do not show
& c6 X& F4 t2 P$ V) y' l8 e* cpubertal response of gonadotropin after gonadotropin-. B( e7 o- \9 u1 R0 U  o, V
releasing hormone stimulation. This is a sex-linked
4 U! V$ k7 j9 s3 k1 _autosomal dominant disorder that affects only
: o  K4 {; j. _) B5 }0 m# mmales; therefore, other male members of the family& H( }! X! F+ F8 J* I" Q6 S/ E6 ]! a
may have similar precocious puberty.3
; j/ V/ Z0 \  w; e6 x" gIn our patient, physical examination was incon-4 K3 L/ R. @' \: M7 ]
sistent with true precocious puberty since his testi-
% l4 O9 f2 ?8 O" D# f6 f3 a+ r1 ncles were prepubertal in size. However, testotoxicosis9 F9 m+ t7 D, J. P. b; {
was in the differential diagnosis because his father
. X& ~/ x- U" v; ]9 q8 L) Istarted puberty somewhat early, and occasionally,2 c! J* b9 q% }; t9 P6 n9 `
testicular enlargement is not that evident in the
# X  b2 J! r2 tbeginning of this process.1 In the absence of a neg-$ M/ K& N1 y: T, _5 f
ative initial history of androgen exposure, our! E; d$ k) x) f4 F" B
biggest concern was virilizing adrenal hyperplasia,
5 l% a, I+ L1 F" {' deither 21-hydroxylase deficiency or 11-β hydroxylase
- r! Q* U+ O! _; {deficiency. Those diagnoses were excluded by find-
3 a6 L1 l8 `( V5 w  N  |, jing the normal level of adrenal steroids.7 ?$ `) @4 N, i$ y8 |5 `
The diagnosis of exogenous androgens was strongly) w) Y5 o7 R( l8 Q8 \: r* z" D/ C
suspected in a follow-up visit after 4 months because6 e8 k0 ~& q3 t' D0 e/ O0 U# d
the physical examination revealed the complete disap-& j6 u9 l$ y2 ]1 s
pearance of pubic hair, normal growth velocity, and. C, U+ H" V8 y7 r3 k, N) g
decreased erections. The father admitted using a testos-
5 b- ?2 L- i+ b) Gterone gel, which he concealed at first visit. He was9 k% l+ Z. {: _, }
using it rather frequently, twice a day. The Physicians’
2 p1 v, `6 W( uDesk Reference, or package insert of this product, gel or# P/ V, W& v; [
cream, cautions about dermal testosterone transfer to
& s" t. Y' z" W3 @: {' a& Punprotected females through direct skin exposure.
& i) e0 C5 B% o7 q3 Q3 tSerum testosterone level was found to be 2 times the
+ W5 b; X6 X5 F& rbaseline value in those females who were exposed to
$ T, M6 j; }' L. |$ e* y: peven 15 minutes of direct skin contact with their male
/ Z8 T- L/ C5 zpartners.6 However, when a shirt covered the applica-
2 D% c. r7 ^2 ^) @. m, `tion site, this testosterone transfer was prevented.% [4 `, \, l/ F5 l$ \: q+ O3 ~# ^
Our patient’s testosterone level was 60 ng/mL,
  q+ d4 l' |, b. j4 v0 }' vwhich was clearly high. Some studies suggest that
& K4 S' N4 P6 P/ ?5 v! \" Y6 j2 J; fdermal conversion of testosterone to dihydrotestos-
3 L& p0 K7 m" ^( \( U' j4 z) z  dterone, which is a more potent metabolite, is more, g/ I0 t2 B$ r" {4 v- v  a
active in young children exposed to testosterone
3 |- i4 L; v. L: |$ mexogenously7; however, we did not measure a dihy-
7 `$ O* a; j6 r1 J( a" ^5 Xdrotestosterone level in our patient. In addition to; O; k; y1 l4 y9 ]0 l1 z6 I, q
virilization, exposure to exogenous testosterone in
8 ~# f, q* D1 A: _9 {children results in an increase in growth velocity and3 O& P7 z' M- f- \8 A
advanced bone age, as seen in our patient.
1 o- q( z% {' J; a. ^The long-term effect of androgen exposure during
. T: _+ ~* r* A( z" F5 Z- Mearly childhood on pubertal development and final& o# h& ?+ |7 n( J6 `
adult height are not fully known and always remain9 a. J7 ~4 x2 {8 ~% h
a concern. Children treated with short-term testos-
' l+ d2 p5 I, Eterone injection or topical androgen may exhibit some+ M  E" Q, y, o( ]# I
acceleration of the skeletal maturation; however, after: M8 N) G2 f! I, q1 N! v
cessation of treatment, the rate of bone maturation
8 b: X- q) z. |. ]& hdecelerates and gradually returns to normal.8,9
) N) O# n+ N6 i9 gThere are conflicting reports and controversy& G) Z, w% Q* V* U
over the effect of early androgen exposure on adult' @# ?3 q; y; x0 x5 O+ G
penile length.10,11 Some reports suggest subnormal6 J, v, h$ {# t
adult penile length, apparently because of downreg-+ y+ k  ]. g% U$ `2 c4 N: b  z7 \
ulation of androgen receptor number.10,12 However,
: K. A: ?1 i3 L" u: i5 @# [Sutherland et al13 did not find a correlation between# P- x- z! |. j* f' [! a% {
childhood testosterone exposure and reduced adult
6 D$ f9 d) v* G% h8 Qpenile length in clinical studies.
  i& y' R  Z: a( \5 K$ R  v% t1 c8 bNonetheless, we do not believe our patient is
9 B4 {5 n2 Q" X9 p5 u7 H$ jgoing to experience any of the untoward effects from1 U7 k5 v5 T9 P  k( k0 C
testosterone exposure as mentioned earlier because
8 v# P+ z6 k8 u' r  `! othe exposure was not for a prolonged period of time.
5 `6 t! m( [: w, KAlthough the bone age was advanced at the time of
/ Z! Q7 y( s' Gdiagnosis, the child had a normal growth velocity at: U" S2 o3 u, e
the follow-up visit. It is hoped that his final adult
( n% N; T0 g9 mheight will not be affected.% @2 W; d8 z- C3 @
Although rarely reported, the widespread avail-
8 D, B$ |' z6 lability of androgen products in our society may* }# I, @" Z- j2 p
indeed cause more virilization in male or female: J1 }. |* ^  b& a+ b# f6 |; R* I% r
children than one would realize. Exposure to andro-: k, L* a! n. l* X) G" b. ^' @
gen products must be considered and specific ques-% I9 k$ J5 h. d7 ]# @
tioning about the use of a testosterone product or+ b% r/ K% Y+ h  X. @% v
gel should be asked of the family members during
9 _6 e9 m5 C  u+ I. w  E# {* wthe evaluation of any children who present with vir-
2 ]- F. h) [1 p. p7 iilization or peripheral precocious puberty. The diag-
9 x3 V% M% s7 n4 X+ P% A4 h0 gnosis can be established by just a few tests and by
& T2 l  I8 X- ?. N8 x# cappropriate history. The inability to obtain such a
9 \4 Q2 K3 u, m: A& y1 whistory, or failure to ask the specific questions, may
6 Z3 t, a; l) \: _* presult in extensive, unnecessary, and expensive
0 h& V8 a. m, Pinvestigation. The primary care physician should be
* k0 f0 L: [# }  N7 Iaware of this fact, because most of these children% q$ K* R, s; z/ _' h
may initially present in their practice. The Physicians’6 f3 A. G" H1 Z* e  c9 L
Desk Reference and package insert should also put a0 T8 k$ H. Y) Y! ^
warning about the virilizing effect on a male or' g6 I6 |& m5 ^4 n% C) _
female child who might come in contact with some-( _: {$ s5 _( f% x: Y3 X
one using any of these products.
" H2 \$ [/ W; ^, c" A* LReferences
, W& l( t( W6 b& y+ B5 d+ ~. l* l1. Styne DM. The testes: disorder of sexual differentiation
1 [# A4 Q: z- K! f# W6 x# Xand puberty in the male. In: Sperling MA, ed. Pediatric
( m$ \. w) j8 P$ \! e- B  BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 |- I3 O5 D/ e- O
2002: 565-628.9 \/ q1 `" ]# Q0 w2 v1 r$ Y  d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% C* K8 K- x7 ~puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
- y4 g$ }# _* G/ b1 |Boy Induced by Indirect Topical: P! e$ {' v% A
Exposure to Testosterone2 O- ~7 G: }- V- ?+ h  h6 L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 P8 \/ j1 I1 X2 s! qand Kenneth R. Rettig, MD1/ o7 E  k+ q& I/ s+ T* h2 J8 Y& a
Clinical Pediatrics' g% w. F2 h' X5 b6 ?! I! X# O6 j% Y$ o
Volume 46 Number 67 T- M# ^5 t8 |& ?7 y. O6 f
July 2007 540-543
1 H" g4 N2 ^) I' t+ V+ x3 `2 Z© 2007 Sage Publications
( T7 g0 {4 o, L3 w0 I( N8 S  _( {) `10.1177/0009922806296651; w$ }( T  \/ c
http://clp.sagepub.com8 L& O' Z# Y9 E' |7 ]* J* E- ?2 [/ h
hosted at
/ u( J+ q! v, N" {: A; W/ E. ]: c8 Mhttp://online.sagepub.com: L/ A) B% q8 v6 D, \
Precocious puberty in boys, central or peripheral,
/ g! z. M7 U3 Q3 O+ jis a significant concern for physicians. Central
0 H6 g3 n& }( ?6 p  V- i. Gprecocious puberty (CPP), which is mediated
1 i" b! p8 v# J# x  `/ I" G0 Y3 @+ rthrough the hypothalamic pituitary gonadal axis, has: d8 h. Q, `# |8 s- E3 |6 y& a( ^5 {
a higher incidence of organic central nervous system$ x7 w" C; G+ Z; V8 c
lesions in boys.1,2 Virilization in boys, as manifested# a% N2 P- j1 |5 `
by enlargement of the penis, development of pubic
+ D4 V. {2 Q2 o3 |hair, and facial acne without enlargement of testi-% U. k3 n& ?/ ^3 O& x6 \) F
cles, suggests peripheral or pseudopuberty.1-3 We
" n, h1 w" ?# O* g& G" b& vreport a 16-month-old boy who presented with the
; h" m. f, ?2 y! q, M; Genlargement of the phallus and pubic hair develop-
' E2 T# @4 O! I( cment without testicular enlargement, which was due
: [: P1 K2 ]' b! V1 Kto the unintentional exposure to androgen gel used by
) E! u9 O# q. I& O( `the father. The family initially concealed this infor-  e# d4 N) ]4 Y9 X& Q; `
mation, resulting in an extensive work-up for this2 W" v1 A/ o9 x6 o  ]* V& o
child. Given the widespread and easy availability of
2 D' }$ J/ k( Ttestosterone gel and cream, we believe this is proba-
2 B4 @' ^" m( U( s" dbly more common than the rare case report in the3 b0 S7 o; L* w
literature.46 Z/ `+ u8 W# P6 t8 l. U2 }- N
Patient Report6 ~% X2 }8 D2 G3 y0 L7 {
A 16-month-old white child was referred to the
4 U) Q4 }3 q# D- R5 \endocrine clinic by his pediatrician with the concern2 _1 I3 f" I2 O3 E  E$ H6 M
of early sexual development. His mother noticed" X) y% V5 A4 [' p6 z$ Y' v5 `
light colored pubic hair development when he was
3 Q: E9 [$ ^3 j/ W, U( eFrom the 1Division of Pediatric Endocrinology, 2University of
0 y& s  C' Z, c& `South Alabama Medical Center, Mobile, Alabama.5 d' B# R1 _" r+ k
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 f; X4 X& j. m* [. b3 lProfessor of Pediatrics, University of South Alabama, College of% w% X. \# }$ K$ O2 o
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 W# `& I: l% v# i* M9 W( f
e-mail: [email protected].2 q: O, R% N2 {5 R( v, p4 H- c* c
about 6 to 7 months old, which progressively became
6 q, k4 I; U8 F9 }* U& Z% s$ wdarker. She was also concerned about the enlarge-& n8 C, x& v& d2 W6 _
ment of his penis and frequent erections. The child
; S5 o& ]% ]) d/ {was the product of a full-term normal delivery, with$ R9 F6 T3 V( V5 \8 A. O
a birth weight of 7 lb 14 oz, and birth length of
/ I, a% m8 M* y% s% i! k20 inches. He was breast-fed throughout the first year9 U$ t. S& c  J  p$ P4 {1 y
of life and was still receiving breast milk along with
; ^8 k' n* H% U) o! W4 a' y$ |solid food. He had no hospitalizations or surgery,
9 `4 v  t4 q1 N$ [0 a  O5 land his psychosocial and psychomotor development
- @9 l1 p  [" ]was age appropriate." }6 g- d  [" c2 u$ d$ X1 X
The family history was remarkable for the father,6 y* |  X7 c# ^( s3 Y
who was diagnosed with hypothyroidism at age 16,& ~) R2 K0 @. C* T+ s
which was treated with thyroxine. The father’s
; Z; h2 U3 }5 U% @height was 6 feet, and he went through a somewhat: i2 p7 ~. x: ?3 I: \* a8 v% ]6 \
early puberty and had stopped growing by age 14.
# Z6 w  d( o, O( q3 F6 bThe father denied taking any other medication. The
4 }( h7 W  {% z2 Y0 A, e3 ]: schild’s mother was in good health. Her menarche
8 Q1 n4 _+ @$ D1 N6 J2 mwas at 11 years of age, and her height was at 5 feet' Z. R4 R* p$ |5 _
5 inches. There was no other family history of pre-1 Y7 O& B0 {6 H' p# Y  `
cocious sexual development in the first-degree rela-
' M' J7 q( k. D  g' R# ]: ltives. There were no siblings.
8 E# u" G# O" o, S1 y( hPhysical Examination0 {, Q, G" a, L
The physical examination revealed a very active,
: d* A1 @+ z3 l' b' Tplayful, and healthy boy. The vital signs documented
  b. T" t* _( F8 A8 da blood pressure of 85/50 mm Hg, his length was1 s9 [/ _- q8 _8 x9 T$ F1 j
90 cm (>97th percentile), and his weight was 14.4 kg
% n1 S3 V* G& {% A5 s+ T(also >97th percentile). The observed yearly growth# D; }$ K; F: N- C+ x; x
velocity was 30 cm (12 inches). The examination of' ]5 I$ X" H! F/ ~* x& ?* z* K
the neck revealed no thyroid enlargement.( `$ [1 k- L& I
The genitourinary examination was remarkable for3 p. n! C: L- v% u0 v
enlargement of the penis, with a stretched length of4 h' ?$ d3 ~8 z5 C0 {
8 cm and a width of 2 cm. The glans penis was very well) j- t% r% p, {' J! A) b
developed. The pubic hair was Tanner II, mostly around( V- F3 `* I" A, w4 {1 C0 k3 g" n
540
9 y3 `( g3 a: dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& l, Q: e& q/ @) F: l- B. lthe base of the phallus and was dark and curled. The
2 U* ?8 i- K: P( S( H5 u) n' i/ Gtesticular volume was prepubertal at 2 mL each.2 N  |; G: z) A0 ]+ s: L% N! d& ?: I
The skin was moist and smooth and somewhat8 c* B$ P( ]( t# R" j7 q/ g( D
oily. No axillary hair was noted. There were no
! d$ O3 g% i) X0 p8 Q( p" [abnormal skin pigmentations or café-au-lait spots.
* W* _" T5 L% oNeurologic evaluation showed deep tendon reflex 2+
# l. f0 f  z0 K2 H: J0 Pbilateral and symmetrical. There was no suggestion
" d/ u$ Y. A# U! j6 Zof papilledema.( L8 ?& ^! C  X4 e8 n9 Y2 n
Laboratory Evaluation
+ ~0 U" D* B5 L- w7 zThe bone age was consistent with 28 months by3 A. P+ b% K# Z5 o) g. j' n) I! r6 Y
using the standard of Greulich and Pyle at a chrono-- Y5 R4 T* S" F$ }
logic age of 16 months (advanced).5 Chromosomal
9 ]0 e3 P0 F5 \7 wkaryotype was 46XY. The thyroid function test
, Z" t# R/ J( r* B2 }% x9 ]showed a free T4 of 1.69 ng/dL, and thyroid stimu-
! L2 L/ G1 N; g, \1 N8 R1 Alating hormone level was 1.3 µIU/mL (both normal).- z7 s0 i  o! w( d6 N
The concentrations of serum electrolytes, blood
$ y3 k. }7 S. A. V. v! r) Y  l; Murea nitrogen, creatinine, and calcium all were+ i" t1 }, S  x" h2 I
within normal range for his age. The concentration
  |) |* X0 u% f7 d- _. ^of serum 17-hydroxyprogesterone was 16 ng/dL
, w5 k2 I" [0 s2 y7 @(normal, 3 to 90 ng/dL), androstenedione was 20
2 e! v! Q, r. D+ M3 m. a7 @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 c9 C4 r1 ]5 I. x/ Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, X* x) V/ v& h5 k' Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 Z) @) I" a, Y4 v  j  Z49ng/dL), 11-desoxycortisol (specific compound S)
4 M5 W5 o# a6 `. M( H2 vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 B- l* l2 Z; L% Q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: n4 U' F0 A: o+ Y# P' w
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),- V8 S& |/ n% v) f/ X+ _
and β-human chorionic gonadotropin was less than
$ ^% c% D$ U" R2 _- [/ H/ r& |. t5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 h/ p/ b2 C, o/ ]9 s7 Fstimulating hormone and leuteinizing hormone+ j. D% f$ R, h9 L* o. w0 J- R
concentrations were less than 0.05 mIU/mL8 t! [# a/ z- \4 B/ d
(prepubertal).
1 i5 N6 @, P6 K/ Q6 H- O5 CThe parents were notified about the laboratory! A8 b: l6 p( {# W/ n6 s6 ^3 m, a
results and were informed that all of the tests were7 P, I. k; D- E; B5 p8 \
normal except the testosterone level was high. The0 u: d( T# Z6 }) Q4 [! ^
follow-up visit was arranged within a few weeks to
/ n# R8 u- T' ^2 {& ^% i# `obtain testicular and abdominal sonograms; how-. h' \/ o' F! c9 S6 Z* x2 j4 _
ever, the family did not return for 4 months.  W& `; r1 X6 E: o" z' E- t6 V+ I
Physical examination at this time revealed that the
& S1 Y  {' l; y0 \/ {child had grown 2.5 cm in 4 months and had gained6 R! [$ |3 B, K  ^+ f
2 kg of weight. Physical examination remained
4 e8 A! {% J) _# g+ junchanged. Surprisingly, the pubic hair almost com-5 S; W- s8 T  x5 y7 Z9 O( D5 [
pletely disappeared except for a few vellous hairs at/ e! C0 s( B  f2 W; K1 F
the base of the phallus. Testicular volume was still 2, T2 L) }* ]& q7 g
mL, and the size of the penis remained unchanged.# R- ]- U; o. A
The mother also said that the boy was no longer hav-1 Y! D$ s3 R$ H+ y4 N  p) [8 G
ing frequent erections.
& r: c  s: q, X6 `# E7 B. qBoth parents were again questioned about use of4 @+ o# D2 s) X" z# E; M% N
any ointment/creams that they may have applied to" m/ Y8 O+ @" k& N& M+ A( e4 `4 a: t
the child’s skin. This time the father admitted the
4 |+ s8 u* O- |1 nTopical Testosterone Exposure / Bhowmick et al 541" P0 [  @' \! ~7 ]
use of testosterone gel twice daily that he was apply-" \# P8 q5 e7 x8 e) n. @
ing over his own shoulders, chest, and back area for
/ Z% N$ ^0 g& K/ la year. The father also revealed he was embarrassed) H9 H" @% K' ~9 ~. o. U
to disclose that he was using a testosterone gel pre-
/ U  o1 Q. t* t6 _. kscribed by his family physician for decreased libido
' S5 r" L/ l% F" i) c; M1 s8 Ksecondary to depression.
9 T: b, M8 G0 i, JThe child slept in the same bed with parents.
$ ]# o7 U: L; OThe father would hug the baby and hold him on his5 r$ V7 u* h4 u6 y% f
chest for a considerable period of time, causing sig-/ u: v* b" A  h+ B5 d
nificant bare skin contact between baby and father.
  d1 h2 z/ w$ r! j8 ?0 U: W. SThe father also admitted that after the phone call,& k* V: @/ I& T& W& i- r
when he learned the testosterone level in the baby; T# H5 o. n5 J' Y! X
was high, he then read the product information
' A. L% |/ I. n" [; rpacket and concluded that it was most likely the rea-
/ y0 z+ z1 o/ d" `8 k3 Eson for the child’s virilization. At that time, they
( _& q7 k# w8 P* bdecided to put the baby in a separate bed, and the( f9 N& o# M+ H" D' c. Z2 O* B
father was not hugging him with bare skin and had
; z5 q1 F& [2 b/ a8 Hbeen using protective clothing. A repeat testosterone
+ x; a5 x* y  R) E1 E0 @0 htest was ordered, but the family did not go to the' \! ^8 n* }; E7 O' H( {, @
laboratory to obtain the test.
# W: y- l' \& w0 F5 b* kDiscussion8 e1 D- Z' b: v9 H7 M: A5 B9 t
Precocious puberty in boys is defined as secondary0 k+ W- a& Y1 J6 B% G8 a( K, f
sexual development before 9 years of age.1,4% z  }0 R# b/ l
Precocious puberty is termed as central (true) when
' e  H/ [  j' y3 [3 eit is caused by the premature activation of hypo-( s1 K+ y. m9 V
thalamic pituitary gonadal axis. CPP is more com-
* l' H5 j, O* }! hmon in girls than in boys.1,3 Most boys with CPP/ w. S" d" ~' [4 E/ W1 c1 s
may have a central nervous system lesion that is. j* w! U4 q" i3 J
responsible for the early activation of the hypothal-, v; E3 {+ x6 G) b- W1 [
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ Q0 h3 _" p# a( e% _0 V4 Psis has been given to neuroradiologic imaging in
; _( A% b3 m) ~- e$ v, W- ^% Lboys with precocious puberty. In addition to viril-
$ |3 f1 U- O) d" J( jization, the clinical hallmark of CPP is the symmet-
  Z( o  F$ F" f( p9 [* Irical testicular growth secondary to stimulation by
& s2 q$ R: V! xgonadotropins.1,3$ t" M3 H8 }1 X9 S. i$ O1 u! w
Gonadotropin-independent peripheral preco-
6 g5 O. `1 k+ b6 icious puberty in boys also results from inappropriate/ U0 I% U% q" S5 @
androgenic stimulation from either endogenous or/ H, a& K8 `- P" N5 ~. e7 I
exogenous sources, nonpituitary gonadotropin stim-3 Y- {& p. W( p% {. ]2 q
ulation, and rare activating mutations.3 Virilizing
5 z1 ^, I6 ]8 G" j& Bcongenital adrenal hyperplasia producing excessive8 l5 Y* J/ j  B2 y7 I8 J5 b
adrenal androgens is a common cause of precocious2 U$ |6 L/ y- E. r* Q' o
puberty in boys.3,4
4 n3 G% _% M8 f' KThe most common form of congenital adrenal
: m9 P1 P. c, n% yhyperplasia is the 21-hydroxylase enzyme deficiency.. D3 n7 S: \# E7 g0 o3 Y: b7 g
The 11-β hydroxylase deficiency may also result in" a' K3 B) k* c
excessive adrenal androgen production, and rarely,+ _1 J% w0 \4 m" Q
an adrenal tumor may also cause adrenal androgen
: o6 ~& ^0 E: P2 e- \excess.1,30 ]1 s- f5 {5 ]: Z# }4 b3 o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 R+ F  }- `  E& L" h
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" o# K- G# z- |* a% d- p- S# K
A unique entity of male-limited gonadotropin-6 D! ~; a' C5 l& p+ ~0 a6 I" H
independent precocious puberty, which is also known; i: T# I2 C  ~  h: N0 c& Y% ?+ P
as testotoxicosis, may cause precocious puberty at a
* t+ T: x2 R* ]$ [' @very young age. The physical findings in these boys
& i# k$ ^& ^/ S( k- P8 cwith this disorder are full pubertal development,
, i3 I& j" O+ A9 J: t- v- ^* C' Y# Dincluding bilateral testicular growth, similar to boys$ b$ ]7 j& C  ]9 S4 {5 u
with CPP. The gonadotropin levels in this disorder
% W9 k7 n3 m# P7 @+ Q2 n" lare suppressed to prepubertal levels and do not show
8 |! X3 m: I9 t. g6 Gpubertal response of gonadotropin after gonadotropin-3 g+ M, t# g" |( H' r3 H: |: x
releasing hormone stimulation. This is a sex-linked
  p4 |& U5 P' d' U* J3 Aautosomal dominant disorder that affects only1 K( B, J- z3 z( I
males; therefore, other male members of the family
* X. f+ K, O7 G9 Vmay have similar precocious puberty.3
9 F1 a' t/ z7 R/ V  wIn our patient, physical examination was incon-5 }0 o7 }4 \. f2 }- Z1 N( ]
sistent with true precocious puberty since his testi-
$ u& e  e8 ~, h6 [( T* tcles were prepubertal in size. However, testotoxicosis; c9 ]2 Q& S, d1 ?
was in the differential diagnosis because his father
9 R* S9 q5 r5 x  @/ Q& ]started puberty somewhat early, and occasionally,
* h! S4 @# s0 a9 ?( ltesticular enlargement is not that evident in the
* a0 t% L) p) W& s& }beginning of this process.1 In the absence of a neg-& p' i( x" z% b1 r1 m3 ~% o
ative initial history of androgen exposure, our3 \' [: {9 ~' t" {2 v; A
biggest concern was virilizing adrenal hyperplasia,
- L/ G* b2 Z1 y8 R8 w2 ~, heither 21-hydroxylase deficiency or 11-β hydroxylase
% @/ [8 @/ l) L' \* F5 y# ^deficiency. Those diagnoses were excluded by find-
. s0 g2 f9 d! Z& ~ing the normal level of adrenal steroids.0 P- E# D6 a) C1 z' R& U. y1 K6 b" r
The diagnosis of exogenous androgens was strongly
6 B) x! `( X% F% Q9 q) R, Hsuspected in a follow-up visit after 4 months because6 t- }4 V! M$ |) v6 V6 G+ u3 @
the physical examination revealed the complete disap-
+ `& ~, U9 |% |5 ]# wpearance of pubic hair, normal growth velocity, and. A, u2 P8 Y7 W! e+ V, U. H* e3 K2 \, d
decreased erections. The father admitted using a testos-- F$ s9 o: X6 f
terone gel, which he concealed at first visit. He was
% d* F: r/ D# e9 o; A( F5 Wusing it rather frequently, twice a day. The Physicians’- R0 c/ f9 o7 F8 l& ]" ~
Desk Reference, or package insert of this product, gel or) U) T% l/ ]! O, P
cream, cautions about dermal testosterone transfer to
- q1 b9 X$ E9 ~/ q1 c2 _$ v* _4 k/ gunprotected females through direct skin exposure.. Q& F! `6 m3 b9 N
Serum testosterone level was found to be 2 times the* Q/ E: ^8 b, b3 C4 z  t
baseline value in those females who were exposed to
! e' l( G# I) b! Heven 15 minutes of direct skin contact with their male
# O# J; U$ ^6 G* p. F" |! _partners.6 However, when a shirt covered the applica-
2 h: N. ^1 U  D/ ?4 x9 ption site, this testosterone transfer was prevented.
- b9 F  X  k/ V" w% yOur patient’s testosterone level was 60 ng/mL,
# _5 S- e# N+ B; v, o9 Y) Swhich was clearly high. Some studies suggest that
" A0 |/ M$ J2 L8 hdermal conversion of testosterone to dihydrotestos-) L  I% m6 e; r5 B, L; ~$ a+ s
terone, which is a more potent metabolite, is more
4 b" }9 E4 E) h# A6 j8 \1 hactive in young children exposed to testosterone
5 R5 R" L. x0 K  `1 ?1 @4 v( |* Wexogenously7; however, we did not measure a dihy-
7 i( g8 z& ~* E& u2 R& i+ \drotestosterone level in our patient. In addition to
: b3 [) |) o! O% [5 T4 ]# ovirilization, exposure to exogenous testosterone in
5 s2 k* p* v* I; c$ A  mchildren results in an increase in growth velocity and
' _5 H4 j0 [& u3 i9 W) fadvanced bone age, as seen in our patient.
$ {# ^3 e( N+ ^- v9 ^9 H' q& n( mThe long-term effect of androgen exposure during# h* B# w3 J: n+ ?/ q) \6 S
early childhood on pubertal development and final
& e, G( k  v; l3 I; fadult height are not fully known and always remain
+ B  W: V" a8 G1 [0 e) c* z, ~- Ua concern. Children treated with short-term testos-6 b1 L0 u& a  l
terone injection or topical androgen may exhibit some
& _! t* W7 U4 i- v  Y& I0 a$ L& [; Q" [& Macceleration of the skeletal maturation; however, after
9 A  ~1 i" ~5 p( B( R! O8 I- icessation of treatment, the rate of bone maturation5 A3 Q( B, o3 ^
decelerates and gradually returns to normal.8,9
: n. d* K4 D6 }3 g5 w7 x5 \$ uThere are conflicting reports and controversy1 S% o# t8 b& q( J; i" R
over the effect of early androgen exposure on adult
8 N+ Q% F1 i6 G6 N- i$ H3 M6 Bpenile length.10,11 Some reports suggest subnormal
; ^2 [) Q5 {0 [/ Hadult penile length, apparently because of downreg-
) C0 @! b0 |( Z; `8 l8 ~0 E- o; w# Julation of androgen receptor number.10,12 However,
5 H/ D& P& A2 C4 j6 FSutherland et al13 did not find a correlation between( E3 G0 R6 n4 }! G7 t
childhood testosterone exposure and reduced adult4 M$ L8 X4 z6 j& w' V$ c& [
penile length in clinical studies.
2 k& A  N5 d/ B4 J' b% o4 bNonetheless, we do not believe our patient is% t0 B# k8 I, H5 \) |
going to experience any of the untoward effects from
3 Y+ m( p) }/ {; W  B3 Itestosterone exposure as mentioned earlier because
" h& q( q( v+ X  u5 p3 Y3 ~8 m& Fthe exposure was not for a prolonged period of time.
% F  \% W; E" x# |" O" JAlthough the bone age was advanced at the time of& `( @! F/ l4 b& j0 P3 q7 U
diagnosis, the child had a normal growth velocity at
4 d5 n' \# b/ `+ v( i( rthe follow-up visit. It is hoped that his final adult4 ]9 c# U& i- C! _; l& n2 s: ]
height will not be affected.! S; V+ A9 h1 c; ]9 O& L
Although rarely reported, the widespread avail-
) F: \1 B. q) X" {ability of androgen products in our society may
  S1 E" T3 X; P- b2 J/ d+ b4 yindeed cause more virilization in male or female
0 Q2 U: p! j5 Echildren than one would realize. Exposure to andro-
& Z$ l# _5 q2 Q: j0 Xgen products must be considered and specific ques-4 m# v! \$ G( L) \% [  l
tioning about the use of a testosterone product or
8 I6 y3 b5 Z3 H9 {gel should be asked of the family members during
' F. @+ w$ [3 e% }2 F6 Rthe evaluation of any children who present with vir-( }! U8 h6 H; B/ Z, C7 t
ilization or peripheral precocious puberty. The diag-
* f5 O% H6 K) T# T; ]3 t, r5 bnosis can be established by just a few tests and by
" ~+ O! v6 e% H, J3 u) F7 k2 mappropriate history. The inability to obtain such a) Z& g( u& X% K5 \6 X/ O+ e
history, or failure to ask the specific questions, may! z( h0 x- H" I
result in extensive, unnecessary, and expensive- r, \5 Z- z: z3 \
investigation. The primary care physician should be, J7 k$ b# f6 R( y
aware of this fact, because most of these children4 }/ v. `8 z  A# E0 U* W, L
may initially present in their practice. The Physicians’
- m& C, A+ r" B5 ^Desk Reference and package insert should also put a
6 Z( V: o' j  Wwarning about the virilizing effect on a male or
1 W/ K6 c7 w/ ]/ X! k: I" c% y. C8 @female child who might come in contact with some-0 A9 n# C, p7 {' y% U2 v) Z! i  z
one using any of these products.
) p/ }4 Y% ?1 o/ U- u6 @; ~* |- f3 cReferences
3 `/ e) \( B. `6 }0 M1. Styne DM. The testes: disorder of sexual differentiation- Y$ c/ G' o+ h7 L( I# M
and puberty in the male. In: Sperling MA, ed. Pediatric
/ {) Q. g4 t% \, ?% F4 dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 Z* V& E( @0 E
2002: 565-628.  `+ K8 P. M$ X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; X: m8 h8 g( C9 K4 ?6 o# Y2 p. u
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

+ ^4 l+ q1 k1 r" x1 Y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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