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Sexual Precocity in a 16-Month-Old
1 ?- Z! Q+ B6 C; n9 j( J( w6 uBoy Induced by Indirect Topical$ |) i, w* d3 i9 j
Exposure to Testosterone6 h) B0 R4 ]. \" f- l2 u0 A+ n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) H) s& n6 i& H, A  a7 |5 J
and Kenneth R. Rettig, MD1* Q' p$ D2 c  ]0 S5 e
Clinical Pediatrics2 Z& m+ M3 J; p' N: L0 z
Volume 46 Number 69 `) h5 g1 b5 q; z/ b1 `* E5 k4 y: T
July 2007 540-543+ D% W4 c1 b9 D5 I
© 2007 Sage Publications
2 N; S+ P4 E( m6 ?7 O6 |10.1177/0009922806296651
( M0 v1 D$ ?1 zhttp://clp.sagepub.com% \. y( I! v' T1 i
hosted at' H3 u3 |* E2 A; Z  ]
http://online.sagepub.com
" X2 T* A# V  M% @3 ?1 \2 UPrecocious puberty in boys, central or peripheral,3 d2 e( B: u# X. u! Z( M# y9 e
is a significant concern for physicians. Central8 @. j6 s% L' i. @( G( ~9 j$ I
precocious puberty (CPP), which is mediated& J5 \- A% C  m, u/ Y: O$ T& u# O' p
through the hypothalamic pituitary gonadal axis, has5 s2 D( ^% ^/ g& d% x
a higher incidence of organic central nervous system$ l5 e$ Y( I( H
lesions in boys.1,2 Virilization in boys, as manifested9 A# T# c5 P+ a) B' G3 q( w5 r
by enlargement of the penis, development of pubic
' D& r9 g% l9 C: G: T) uhair, and facial acne without enlargement of testi-0 I3 M# L3 H4 w8 F
cles, suggests peripheral or pseudopuberty.1-3 We% S$ x/ T$ ]& |9 Y; [
report a 16-month-old boy who presented with the
& P. P) O5 v+ U# }enlargement of the phallus and pubic hair develop-
; ]1 Q; K; K) v; iment without testicular enlargement, which was due/ y, k, N3 m4 E0 h$ d$ y
to the unintentional exposure to androgen gel used by2 s4 K4 ?4 }  L0 w8 `
the father. The family initially concealed this infor-9 f9 F! g! j- ~; v  L
mation, resulting in an extensive work-up for this2 U) E3 a( S1 C1 C6 L5 O0 N. C: |
child. Given the widespread and easy availability of& G* l5 C/ c! F# }
testosterone gel and cream, we believe this is proba-
4 e5 ~8 R9 V; Q% hbly more common than the rare case report in the
. p+ g1 Y9 w+ Q  a  `literature.4
9 M$ H' I& _! [3 _4 HPatient Report* P5 n1 I3 R' D3 j% }+ }# b
A 16-month-old white child was referred to the
3 U/ I+ X8 M: p3 e- b* e# }1 o1 cendocrine clinic by his pediatrician with the concern" F3 {1 g  C; R7 m/ n
of early sexual development. His mother noticed
# P; Y+ {" h6 b; b$ r) tlight colored pubic hair development when he was4 w  Q. h1 R# m- m$ S
From the 1Division of Pediatric Endocrinology, 2University of
" j( x0 {7 n/ x' [# fSouth Alabama Medical Center, Mobile, Alabama.
0 j& l  G9 l8 J, P1 XAddress correspondence to: Samar K. Bhowmick, MD, FACE,  I: `  U0 n( v+ y, m7 p9 W2 U0 q) ]1 \
Professor of Pediatrics, University of South Alabama, College of! z5 C0 \8 T5 B) F# k! T. y* [9 g* c3 N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% R9 e9 \8 i- k$ _/ ^- O4 h" J
e-mail: [email protected].
8 m2 r* s0 F0 V2 I. F. Sabout 6 to 7 months old, which progressively became
, p9 c2 i/ V0 a% p. {- Gdarker. She was also concerned about the enlarge-
! u# Z4 W5 w% ]: ~; k/ H! {ment of his penis and frequent erections. The child
- T* [' V, g& t) Fwas the product of a full-term normal delivery, with2 X$ I. d5 {+ [- ^1 t+ X
a birth weight of 7 lb 14 oz, and birth length of
9 N( X3 a: H8 S$ a! ~20 inches. He was breast-fed throughout the first year. n7 [' _- }- S0 i0 J8 G! s2 R
of life and was still receiving breast milk along with9 h: C" e& L! y; ]4 d  o" n
solid food. He had no hospitalizations or surgery,
* u; T6 ]4 W8 l+ {4 D9 g' ?and his psychosocial and psychomotor development
* r) F% m4 p' }9 ^  s. Zwas age appropriate.
! ~9 l0 u2 H0 J1 _  |' Q0 G3 ZThe family history was remarkable for the father,! F9 r& e0 D9 ]2 o5 q6 h+ q  z! Y
who was diagnosed with hypothyroidism at age 16,
: `9 T' ~1 C4 }7 A" N/ j( n6 m3 jwhich was treated with thyroxine. The father’s: g% c. f( u1 W$ u( d& ?
height was 6 feet, and he went through a somewhat
9 v& n# ]* i: q: b4 N: p# R" ]early puberty and had stopped growing by age 14.
: e/ D) h3 h( [' y: [2 ~1 `The father denied taking any other medication. The/ n$ p6 ^) i3 {+ V$ X
child’s mother was in good health. Her menarche& m- k4 {6 ~3 d
was at 11 years of age, and her height was at 5 feet
  e0 ?& c6 `, ?* p1 p- `5 inches. There was no other family history of pre-
! o0 _& a, I7 d6 V8 u, Zcocious sexual development in the first-degree rela-. m2 {# v- H6 {# Y. D. w) h" E
tives. There were no siblings.* d* m$ R& q- ~4 w
Physical Examination: K2 E) Q3 z2 k2 k
The physical examination revealed a very active,
+ P: ?6 J; T( Iplayful, and healthy boy. The vital signs documented+ U! k! Q, H& R8 w" ~
a blood pressure of 85/50 mm Hg, his length was
: ?+ ]  f  R2 D" O  ~7 W. v6 m90 cm (>97th percentile), and his weight was 14.4 kg
1 Y  N* G2 k! _(also >97th percentile). The observed yearly growth
- J0 V% g, y5 i4 x( uvelocity was 30 cm (12 inches). The examination of
0 {$ k. u# f9 k) J% q2 ^the neck revealed no thyroid enlargement.
! J- `. w& k" l. f, S- H* F2 VThe genitourinary examination was remarkable for6 ^6 @$ D  J2 U" V
enlargement of the penis, with a stretched length of+ T( r- f0 J/ r! L
8 cm and a width of 2 cm. The glans penis was very well9 O+ y# u: E, A. `# s& C
developed. The pubic hair was Tanner II, mostly around# q( w4 \$ l, z0 v; Z& s' @
540
7 j" T3 w. Y. F; X. K5 Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% X( ^/ |. R+ p" {9 v7 i! Qthe base of the phallus and was dark and curled. The9 ]3 I  P6 E+ n/ l
testicular volume was prepubertal at 2 mL each.
5 l/ Y6 @0 K* _* }/ b/ s( jThe skin was moist and smooth and somewhat  `: a  \1 l1 z% V; J5 X7 `  o
oily. No axillary hair was noted. There were no4 W, t8 j$ Y2 {  @" E( |
abnormal skin pigmentations or café-au-lait spots.
1 w1 _; }2 q5 X6 j7 T6 P* ~Neurologic evaluation showed deep tendon reflex 2+: A7 Y$ g: o7 j! T- W! }1 q# a
bilateral and symmetrical. There was no suggestion1 `/ J6 G  h+ F$ N2 _( {
of papilledema.7 g) ]& M" `3 w7 {, n1 c
Laboratory Evaluation
! v7 ~. Y" j6 J3 t: _; wThe bone age was consistent with 28 months by1 }1 p" f0 ~3 e: M; W; \) _$ h
using the standard of Greulich and Pyle at a chrono-8 i8 c/ b1 B& k/ C) k) b
logic age of 16 months (advanced).5 Chromosomal( ]6 r2 j2 T2 \. v4 L  s& [& `
karyotype was 46XY. The thyroid function test
" `4 S: h" q) O) Wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 g3 `# l& J: \
lating hormone level was 1.3 µIU/mL (both normal).
, o3 V0 L5 m4 v% O: HThe concentrations of serum electrolytes, blood5 F! y9 U2 C! P
urea nitrogen, creatinine, and calcium all were& m. e- m4 O3 V: y# S# D4 t1 `
within normal range for his age. The concentration# r2 {" O( \# {8 m6 q
of serum 17-hydroxyprogesterone was 16 ng/dL
) `7 y! i$ x! Q(normal, 3 to 90 ng/dL), androstenedione was 20
3 B. q) \$ Y* ^5 h# Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 W, |* P1 X8 u: j0 J' V6 E4 |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),# S2 D0 U( o  C5 j4 U- @8 a
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( Q. ^, |% a+ h% V* m
49ng/dL), 11-desoxycortisol (specific compound S)
4 [; R/ b0 n/ q; a3 ]1 \( awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 C) Z0 U$ E) Y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' d) A, v( Z4 \' V2 u' F+ Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 C! r3 B4 D3 f$ C8 W3 G+ ]and β-human chorionic gonadotropin was less than
  e- @  V3 f; n$ _7 F: K5 mIU/mL (normal <5 mIU/mL). Serum follicular! d7 \& y+ {3 i- j/ k  ?8 S
stimulating hormone and leuteinizing hormone
0 ~$ v/ {! j6 b1 Uconcentrations were less than 0.05 mIU/mL( d9 u8 H) I* Q* x) o2 U
(prepubertal).
- r/ W, n! F$ NThe parents were notified about the laboratory% m# _; d8 h+ S6 a7 d! S2 d( V
results and were informed that all of the tests were9 S* b5 F; h, N7 w6 _; v7 S% K
normal except the testosterone level was high. The
. R& C% g8 @9 P3 Z, f% Jfollow-up visit was arranged within a few weeks to3 r$ a# T; p! x7 E5 q: \: g; Z
obtain testicular and abdominal sonograms; how-
0 B5 Q# |8 R8 t4 r+ ]$ |ever, the family did not return for 4 months.
) H& a+ S/ ~% N) ~Physical examination at this time revealed that the
; ~1 N6 _: n1 `: k9 S$ _' `child had grown 2.5 cm in 4 months and had gained3 _5 U8 l% q& V$ y
2 kg of weight. Physical examination remained1 ^5 n9 N# S0 @9 y# m7 \
unchanged. Surprisingly, the pubic hair almost com-
3 \0 b# j7 s2 ~" K+ W9 Q( m2 ypletely disappeared except for a few vellous hairs at  e% v9 i1 ~6 v  ~- q
the base of the phallus. Testicular volume was still 2- i& Z$ O* \: h8 z& R
mL, and the size of the penis remained unchanged.2 r" {3 f) Z$ s% r  {- F- ^
The mother also said that the boy was no longer hav-$ q) l% l( k6 I! K
ing frequent erections.
& U- a4 z% _/ v& G, uBoth parents were again questioned about use of) d; m: N" d; ~  r
any ointment/creams that they may have applied to
" y0 T$ Q+ m- P9 ~the child’s skin. This time the father admitted the! O% ~3 k4 w: j, H( q; Y/ L
Topical Testosterone Exposure / Bhowmick et al 541! d, c, f( i! _3 N( k+ O
use of testosterone gel twice daily that he was apply-
6 a( I; n2 q2 p( k' t& Iing over his own shoulders, chest, and back area for$ H+ H+ y' v. T" Z8 H
a year. The father also revealed he was embarrassed
1 `% O. A7 U- A1 B5 `& Tto disclose that he was using a testosterone gel pre-
$ T. u* t( P4 y, i# Yscribed by his family physician for decreased libido
1 u' K1 i0 I( y, j0 V) J4 usecondary to depression.
! l/ \! |+ A( d' J, ZThe child slept in the same bed with parents.1 w9 }4 \9 i* r2 ^7 v. }
The father would hug the baby and hold him on his' R1 i: L: n. O
chest for a considerable period of time, causing sig-
  @. k& Z* Q% y, D% v$ I9 l5 nnificant bare skin contact between baby and father.# M4 u/ n7 S( L- s+ a! G. c
The father also admitted that after the phone call,3 a% d2 E; W4 D% J' K( C& V8 D- R
when he learned the testosterone level in the baby
% [( k* V  k# m: Awas high, he then read the product information9 T8 C, ^( k# z7 @( Q/ Q# f
packet and concluded that it was most likely the rea-/ O. R  I4 G  Y7 x. {. r
son for the child’s virilization. At that time, they
& T& \' w: j. I& Qdecided to put the baby in a separate bed, and the
* K; ^0 X, c! ]" e% F& vfather was not hugging him with bare skin and had
0 S; H/ M4 H7 \5 e' B) a. e0 {been using protective clothing. A repeat testosterone' I) N# T, D5 m% T* Y& }9 }# M
test was ordered, but the family did not go to the9 K$ `% J0 ]' c
laboratory to obtain the test.
6 E  S- w& m4 C7 D$ k9 kDiscussion2 T& o4 w# h* P
Precocious puberty in boys is defined as secondary- {$ C7 \+ W9 F4 L% o
sexual development before 9 years of age.1,4
5 Y6 r6 L! |8 w6 n7 z; K4 I" l" [Precocious puberty is termed as central (true) when/ h/ A9 S; W8 ~! Q
it is caused by the premature activation of hypo-9 D/ L0 m  K& ^* c& I6 V
thalamic pituitary gonadal axis. CPP is more com-5 y: \! l4 C$ M
mon in girls than in boys.1,3 Most boys with CPP- ~; B& i9 X( T4 `- @# D
may have a central nervous system lesion that is
7 N7 Q8 |  T! E( i! R. Cresponsible for the early activation of the hypothal-
  g) |$ d! B  a# Famic pituitary gonadal axis.1-3 Thus, greater empha-
/ F9 U$ Q) U# n& C/ W4 G2 Esis has been given to neuroradiologic imaging in  V' l( S6 v7 a
boys with precocious puberty. In addition to viril-2 ]- C) L3 v. M8 _0 D
ization, the clinical hallmark of CPP is the symmet-
7 c- o* w" {8 N1 h2 zrical testicular growth secondary to stimulation by. v7 F; m( e9 g: D
gonadotropins.1,3  t6 m6 K: v, y) O
Gonadotropin-independent peripheral preco-
: S. H- ]; B; w5 @8 x7 xcious puberty in boys also results from inappropriate
( i0 n( j2 H3 U8 F" f7 g9 dandrogenic stimulation from either endogenous or9 W. G5 L( E2 p5 t+ G
exogenous sources, nonpituitary gonadotropin stim-
; T- q3 _% j2 e/ w5 e8 {; lulation, and rare activating mutations.3 Virilizing. z) {8 _; u4 K% h) U
congenital adrenal hyperplasia producing excessive( e+ B, e8 |3 `, Q
adrenal androgens is a common cause of precocious
9 r7 a& S) A8 hpuberty in boys.3,4$ A% ?+ K2 j% `9 k: f# {& t. e6 h
The most common form of congenital adrenal; v& R" n# x, U" }5 I% ?. m
hyperplasia is the 21-hydroxylase enzyme deficiency.
- v- Y3 a% k+ U. S! c9 \The 11-β hydroxylase deficiency may also result in
  D3 ~7 {7 f  f4 l7 O' Jexcessive adrenal androgen production, and rarely,
, w$ K9 k& Y1 d# ?5 aan adrenal tumor may also cause adrenal androgen
; c5 _# x0 ]% {: m5 Yexcess.1,3, Z' ^% w# Y/ D. T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% A: e  \) W8 j6 g6 r542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 N  R: w8 N) R+ H- `A unique entity of male-limited gonadotropin-* [1 T5 S4 L  B- r- H; V/ K' Z! q
independent precocious puberty, which is also known
& Z/ Q: W( e4 C5 z6 l$ zas testotoxicosis, may cause precocious puberty at a
6 ~# F: T: h: i8 }" |very young age. The physical findings in these boys
' k5 K' P! r7 W4 b" kwith this disorder are full pubertal development,8 u. x5 k4 p/ i, J" I
including bilateral testicular growth, similar to boys4 |4 d, _. |6 h# M8 B
with CPP. The gonadotropin levels in this disorder
9 G# A, J& X3 C( l$ n. M. f& |0 U- Xare suppressed to prepubertal levels and do not show9 F! f; Z: c2 ?. z
pubertal response of gonadotropin after gonadotropin-
! x7 `( }/ L0 s, Sreleasing hormone stimulation. This is a sex-linked
. |+ Q$ Z% J$ s* e; Tautosomal dominant disorder that affects only
; N; g2 }# n0 d- H( ~males; therefore, other male members of the family: l& _6 R, X6 c* |5 s+ _
may have similar precocious puberty.3
! p7 e9 T1 N' k: u. K. D: x( u4 s- cIn our patient, physical examination was incon-) N0 s& g; V/ X
sistent with true precocious puberty since his testi-! k: a! {. b/ |2 X; c' s
cles were prepubertal in size. However, testotoxicosis* i# h3 q6 i* H) D
was in the differential diagnosis because his father' Y( g3 _4 b  i. A8 z8 W( f) x, J; M
started puberty somewhat early, and occasionally,# w6 S* f  R$ @/ a5 _( M: Z0 {% d
testicular enlargement is not that evident in the+ r) v2 }8 ^) p9 o  I) m4 c
beginning of this process.1 In the absence of a neg-
) O. W' q3 n* w0 r6 |ative initial history of androgen exposure, our3 m  _* Q. s# ]3 T
biggest concern was virilizing adrenal hyperplasia,& U; [- y" R! O& X+ t4 j
either 21-hydroxylase deficiency or 11-β hydroxylase
; t0 h$ ]. l4 u: B( Y5 S5 t* ndeficiency. Those diagnoses were excluded by find-
7 K5 D: f7 \% [" B" Fing the normal level of adrenal steroids.
6 I9 I% Z  R7 n% EThe diagnosis of exogenous androgens was strongly5 D: F* v' q+ _* U
suspected in a follow-up visit after 4 months because7 }( i' W# F% z' G2 y& u) d) R
the physical examination revealed the complete disap-0 J/ J- k+ G* q$ x% N
pearance of pubic hair, normal growth velocity, and4 u! @0 `) X2 z/ O
decreased erections. The father admitted using a testos-
% M/ }+ V; [8 z# R1 p, tterone gel, which he concealed at first visit. He was
  Q9 E+ g* K- O0 \4 @; @using it rather frequently, twice a day. The Physicians’
( @5 C. r  b. \/ g) r5 |Desk Reference, or package insert of this product, gel or1 X0 q  f) ^2 |' ]; Y
cream, cautions about dermal testosterone transfer to, a5 r. N. s% T' Z# H* I, ^2 q
unprotected females through direct skin exposure.5 `1 w/ y- w  x3 F
Serum testosterone level was found to be 2 times the
( b$ Y8 P1 X* K$ g! bbaseline value in those females who were exposed to7 I/ Y! V: t# S. M$ N) s! W
even 15 minutes of direct skin contact with their male2 o* T; |7 C8 y9 V
partners.6 However, when a shirt covered the applica-1 o/ W- F% o; Z* k6 ~+ K# u3 n+ }
tion site, this testosterone transfer was prevented.
% k! T# G- R# e* @- R: d5 ]Our patient’s testosterone level was 60 ng/mL,! E$ D5 o. n" Q$ m" o# A
which was clearly high. Some studies suggest that% a0 g: b' c3 S, `
dermal conversion of testosterone to dihydrotestos-5 r* y( E* `/ O& O/ L
terone, which is a more potent metabolite, is more1 a7 p1 U; B, N# Y
active in young children exposed to testosterone
. x- V. V+ y. G, _* rexogenously7; however, we did not measure a dihy-9 ^6 l. u* `) S2 |
drotestosterone level in our patient. In addition to
5 ~* I# Y* a8 A8 ]( |# Pvirilization, exposure to exogenous testosterone in
. j* y( R" M  o9 f1 l6 P$ W0 ochildren results in an increase in growth velocity and$ l1 r: n4 q0 Y
advanced bone age, as seen in our patient.# [* j5 X9 R, \3 G( u1 c  z
The long-term effect of androgen exposure during
  T( Z7 B4 n  z2 A  D2 g2 jearly childhood on pubertal development and final
% t6 b2 Y8 W( @' @3 M, C* b9 V4 `: padult height are not fully known and always remain' t& w5 x4 u" ?$ s
a concern. Children treated with short-term testos-8 a9 Y% J1 ^. p9 ^/ S) a2 T
terone injection or topical androgen may exhibit some4 F! X' ^# L: t& @
acceleration of the skeletal maturation; however, after
3 o+ U7 K+ e3 q# }cessation of treatment, the rate of bone maturation7 a" i- ?7 y2 T- n& @! U
decelerates and gradually returns to normal.8,92 C# O6 c( r) L6 H
There are conflicting reports and controversy
: U/ f* S  I9 eover the effect of early androgen exposure on adult0 b. J# `8 O5 E* g+ L
penile length.10,11 Some reports suggest subnormal
# p( X$ K9 v* T0 C1 x7 c+ q. ladult penile length, apparently because of downreg-
# U9 I6 x7 a# M  X) ^' Rulation of androgen receptor number.10,12 However,/ N$ X) h! v  O3 ?2 Q' T
Sutherland et al13 did not find a correlation between
* O. W0 {0 k  L- h& y; E7 O( Bchildhood testosterone exposure and reduced adult) `% w9 l8 }- R4 y, y. E3 @
penile length in clinical studies.
% z9 a9 a- F4 g5 oNonetheless, we do not believe our patient is
. P. P+ v- x1 }! f$ B9 H  ?: F, ugoing to experience any of the untoward effects from
9 n1 {1 C6 A. X. X: S3 ^2 ytestosterone exposure as mentioned earlier because
0 u+ P0 o5 n; Y+ o5 g- F) uthe exposure was not for a prolonged period of time.( c. H) X5 P$ ~2 U. ^$ V
Although the bone age was advanced at the time of
! Z) [, m. `# _9 J( V+ ^( {diagnosis, the child had a normal growth velocity at' ^9 z* k* \" t( I
the follow-up visit. It is hoped that his final adult
$ [/ h( M2 m" H9 `2 I) E& t- b" nheight will not be affected.
0 g" Q+ s. }- n, t/ }& }Although rarely reported, the widespread avail-
6 G. o3 z% G( ^4 _4 k9 `ability of androgen products in our society may4 _2 l/ }  g; c. O; K# I# A( ?
indeed cause more virilization in male or female! U; W) t1 F$ F% F
children than one would realize. Exposure to andro-+ X* X8 I! G6 u  Z
gen products must be considered and specific ques-5 q1 q$ o& t6 Z* H  a5 f4 @& R
tioning about the use of a testosterone product or
. M: x9 K7 X2 R4 b7 xgel should be asked of the family members during; ?* O& ]& [/ J( Y  N9 m5 E% b$ S
the evaluation of any children who present with vir-# v( F* m; @7 `0 h
ilization or peripheral precocious puberty. The diag-$ }' v# J- u0 u0 b
nosis can be established by just a few tests and by: U( J) K9 B9 H2 o- Z/ d
appropriate history. The inability to obtain such a
) c8 u& t$ O: ^* T8 s* S# G* ~6 whistory, or failure to ask the specific questions, may
( h/ v$ D& r: ]- X% g; U) {4 t# Bresult in extensive, unnecessary, and expensive7 [6 o; Q& T: n# [2 S; v/ @7 p
investigation. The primary care physician should be
/ g- E, @# x4 t2 b) Uaware of this fact, because most of these children
$ A) q: @+ x( v: [5 c  M2 P7 y3 cmay initially present in their practice. The Physicians’' [8 ~* J3 [0 m# k, @/ [( g
Desk Reference and package insert should also put a
! n% ^, _  t& i, X+ r0 n2 Zwarning about the virilizing effect on a male or. r' }7 r1 y& j# @
female child who might come in contact with some-
+ C3 J- }5 G% |. }! Qone using any of these products.' G* T6 S. q4 f: W3 @5 l
References
8 }/ Q5 r% q: a/ |1 F2 t1. Styne DM. The testes: disorder of sexual differentiation* r$ b5 o& p* o6 O$ o8 o
and puberty in the male. In: Sperling MA, ed. Pediatric
0 F& S$ r& Z1 t* ]6 B+ cEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, f  _% h7 \6 }) f
2002: 565-628.$ N, Y  d" N/ I) A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* f1 t' d' o$ [7 O  B
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: j  d& R- ?$ m7 m9 q% v) z
Boy Induced by Indirect Topical
9 ]; B2 G4 ^5 ^- OExposure to Testosterone
3 i, q) F. L  kSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: `. d2 l# b; \: R' ~1 }
and Kenneth R. Rettig, MD12 d2 y: U" i/ ]8 h7 k
Clinical Pediatrics
6 ]# U1 c$ k% m( [+ @" j, bVolume 46 Number 69 w' a& N! S; v" T' c! J2 T
July 2007 540-543# r3 S3 T9 S# V5 G% ^, z
© 2007 Sage Publications4 S7 K: o  c2 i# d) \# \7 g% [
10.1177/0009922806296651
, c% E6 H. [' \( mhttp://clp.sagepub.com. g# d% `/ l6 f5 c# u7 J8 p- t
hosted at, g$ L) L2 U; F' H( Q4 y
http://online.sagepub.com
+ j" n% t" L# V. K9 R5 n5 P4 dPrecocious puberty in boys, central or peripheral,
- z+ M& L8 U7 S9 x7 \5 ]is a significant concern for physicians. Central
" k* o$ j1 Z) Uprecocious puberty (CPP), which is mediated
( y0 U# |4 @( l2 X1 ?through the hypothalamic pituitary gonadal axis, has
( h% E. I' p: [% Y6 ha higher incidence of organic central nervous system2 k- _( ~$ \2 Z& P. p! V" ?" E
lesions in boys.1,2 Virilization in boys, as manifested
; }+ i0 v! K* i, }1 yby enlargement of the penis, development of pubic
2 u* H9 o4 w( t% X- I1 Qhair, and facial acne without enlargement of testi-
( Z& R7 ~0 U8 C1 H% C( m! m2 Ucles, suggests peripheral or pseudopuberty.1-3 We
* l/ S( n4 z% F8 O9 Z9 }& w# Ereport a 16-month-old boy who presented with the$ O9 N% J) k, C4 y; ]  \
enlargement of the phallus and pubic hair develop-. i: V( {3 \) g" i: H+ m
ment without testicular enlargement, which was due
# \! k; {& h/ _to the unintentional exposure to androgen gel used by
8 F' C. o3 W. m# i. W1 Lthe father. The family initially concealed this infor-% F0 O# v; M, S) @; o
mation, resulting in an extensive work-up for this4 I' s: a4 F: T* A& b1 K0 q2 |
child. Given the widespread and easy availability of
% q0 q$ E! V+ q6 M/ ~. w& E" s7 h6 Ltestosterone gel and cream, we believe this is proba-
* |+ _  a, C8 C2 N, T, V1 _3 {- w. vbly more common than the rare case report in the
& }5 [  H1 T8 Wliterature.4( b! j5 E) o: B% Y2 Y  l
Patient Report
+ ~/ j6 ~' D# |A 16-month-old white child was referred to the
1 ~- i0 G( ]0 Yendocrine clinic by his pediatrician with the concern! _* ^8 ]3 `$ x# v
of early sexual development. His mother noticed) K, b% ^" E6 l  R8 f' t& o3 {. `
light colored pubic hair development when he was' H0 P* t) _7 K* |6 L
From the 1Division of Pediatric Endocrinology, 2University of  E* G8 |" u2 N7 y0 Y9 p# r
South Alabama Medical Center, Mobile, Alabama.' k" X  j4 }2 K; d
Address correspondence to: Samar K. Bhowmick, MD, FACE,: N' u2 C" q/ O
Professor of Pediatrics, University of South Alabama, College of
3 I& B( @4 X6 N3 q, LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  Y+ ?$ }: Z% l1 E
e-mail: [email protected].
( b1 t+ D8 {$ T4 _8 n9 Oabout 6 to 7 months old, which progressively became7 O# d) v2 B" j& [2 W
darker. She was also concerned about the enlarge-6 C6 S4 b" D+ y! ]
ment of his penis and frequent erections. The child$ i! @5 x1 V& \
was the product of a full-term normal delivery, with
# Q6 \7 p) V7 d' v& k1 X% |$ O4 Ra birth weight of 7 lb 14 oz, and birth length of) U5 v- |$ g3 v+ a1 L: U( G
20 inches. He was breast-fed throughout the first year% g& F$ }8 O* i3 n! b7 t' }
of life and was still receiving breast milk along with  `$ z) o$ u. f2 s" M" L1 ?
solid food. He had no hospitalizations or surgery,7 `2 E$ S% K- h  M* |+ h
and his psychosocial and psychomotor development
! B8 V1 d& {" P" T4 o$ {# Zwas age appropriate.9 [. T/ [) y6 i. t) f1 x
The family history was remarkable for the father,
  d; U1 Q# d: ]* lwho was diagnosed with hypothyroidism at age 16,6 g. p) U* B6 g' Q5 U7 V. x5 c! M/ I
which was treated with thyroxine. The father’s6 p+ _, F5 R) f/ N) Q
height was 6 feet, and he went through a somewhat, a4 w6 j9 e- |% K- ?: E5 K9 l
early puberty and had stopped growing by age 14.
7 E" }. T, u! b7 Y& s% `# [The father denied taking any other medication. The
: ?5 K; _; W* ^& g+ @) T+ Pchild’s mother was in good health. Her menarche' ~; G# L  X" n
was at 11 years of age, and her height was at 5 feet, s- o. a, m' B7 L% n6 R1 o9 Y# ^
5 inches. There was no other family history of pre-
- t& Y/ \% p' |( d: i* ycocious sexual development in the first-degree rela-
' ^$ x8 b3 |  U6 A2 }  J6 Dtives. There were no siblings.
% V- Z) J0 h5 S0 \% W4 k9 }Physical Examination) Q" ?5 m* y1 |% V' P! I- K( V- \# P
The physical examination revealed a very active,  q: F4 l! F' P
playful, and healthy boy. The vital signs documented8 H1 {. T( U7 p$ k
a blood pressure of 85/50 mm Hg, his length was, `: y! t1 |8 e8 ?. M
90 cm (>97th percentile), and his weight was 14.4 kg5 T" y3 t, {) p6 k, Q+ e1 O
(also >97th percentile). The observed yearly growth/ R7 t6 j) _9 ?, k
velocity was 30 cm (12 inches). The examination of* D$ S8 K) \. B" V& j# o
the neck revealed no thyroid enlargement.
; ]2 v: o4 {3 i& X4 r% HThe genitourinary examination was remarkable for2 Q, h$ V& d1 J( l( x
enlargement of the penis, with a stretched length of4 s  V) }/ t9 }, `
8 cm and a width of 2 cm. The glans penis was very well
/ z6 ~. J9 y. [! Vdeveloped. The pubic hair was Tanner II, mostly around  R9 I9 J7 G: P* t
540
6 k. O0 ^; n4 \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  E, a7 Q' x% Q; Sthe base of the phallus and was dark and curled. The% U- |* k' m: Q9 h! L
testicular volume was prepubertal at 2 mL each.
& h$ }1 _# i# w! L- CThe skin was moist and smooth and somewhat
. {9 I* e/ @( Z  K, Yoily. No axillary hair was noted. There were no
8 O/ E" b5 J# |4 z% c4 F- H; l3 iabnormal skin pigmentations or café-au-lait spots.6 S3 T- z! X0 _
Neurologic evaluation showed deep tendon reflex 2+
9 ^& I1 T% v9 I* Vbilateral and symmetrical. There was no suggestion
, h  P, }9 |/ ]+ bof papilledema.: d9 w0 A- }2 P2 Z7 l
Laboratory Evaluation5 a. y6 q* T+ R  s: ~- k
The bone age was consistent with 28 months by
  B' Z) g7 \- v+ ^  s' ]+ Uusing the standard of Greulich and Pyle at a chrono-
2 s& h2 S8 u, @% p( blogic age of 16 months (advanced).5 Chromosomal
3 T4 T$ ]9 ?7 lkaryotype was 46XY. The thyroid function test
' H" i9 z% x$ [) }7 p& n% y1 ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 L. T4 |4 h" P+ w3 }: x
lating hormone level was 1.3 µIU/mL (both normal).
# C. r1 h5 Z/ J& N  n+ MThe concentrations of serum electrolytes, blood* Q8 p  N2 K7 s! H
urea nitrogen, creatinine, and calcium all were/ @8 x' I4 y2 Y3 A( D9 F) d& K9 @
within normal range for his age. The concentration
! C6 f' \$ {+ I2 W8 S) l, n2 Yof serum 17-hydroxyprogesterone was 16 ng/dL
' e$ C& x( Y! G(normal, 3 to 90 ng/dL), androstenedione was 20
6 @% w/ D) R& y: G* V- Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 u8 p" Z7 E! U! W  b7 }) N. l% aterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 i% Z! o7 ?6 J! l2 v" C  ]/ u
desoxycorticosterone was 4.3 ng/dL (normal, 7 to9 _+ B7 W3 J; C
49ng/dL), 11-desoxycortisol (specific compound S)- {3 A& V7 |1 F( s; A
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% H" A: L: n/ W9 k% s7 m+ ?  @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; N. x1 P- |9 Ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. v* o/ C8 |# I8 y7 f" o+ W" r/ |8 z
and β-human chorionic gonadotropin was less than
9 _  k8 N- G' t$ b' n5 mIU/mL (normal <5 mIU/mL). Serum follicular
: H0 p# X8 Y2 H  _- ^1 fstimulating hormone and leuteinizing hormone0 U, \4 E7 a1 @3 s& o: b" j3 U1 r
concentrations were less than 0.05 mIU/mL
+ a! \' @' l) W7 H1 S: \(prepubertal).9 n. t' D) g% @3 g6 O, X: `
The parents were notified about the laboratory9 q& S6 [( \$ X$ R) a* }; E+ e* j
results and were informed that all of the tests were, S6 L% t- D6 C8 c4 L8 B' L
normal except the testosterone level was high. The
2 p7 X2 |5 k, ?- ?& [8 p' s3 P) }" pfollow-up visit was arranged within a few weeks to
! a0 V" A& X$ V4 Q2 cobtain testicular and abdominal sonograms; how-/ S6 X5 J+ F3 H5 y) s" w" N) Y5 {
ever, the family did not return for 4 months.$ U9 B- X( ~7 a6 p: F. a) C
Physical examination at this time revealed that the. |/ s6 S8 G- e3 N  X5 _1 s* t
child had grown 2.5 cm in 4 months and had gained, O0 E! }/ X( `- t
2 kg of weight. Physical examination remained2 s& |; q! a" d% r# w
unchanged. Surprisingly, the pubic hair almost com-0 c& Z; K* p% w6 s# L
pletely disappeared except for a few vellous hairs at0 t, @. N2 Q- g
the base of the phallus. Testicular volume was still 2
9 @9 A/ U$ E: \. O4 f" B; G/ D8 l4 i" mmL, and the size of the penis remained unchanged.! N/ `% |9 s0 t) w; y' f
The mother also said that the boy was no longer hav-1 t" n5 L& i9 B  X: F) X
ing frequent erections.
+ g6 G4 O6 b& Q* n( O/ N7 kBoth parents were again questioned about use of3 \* v* v6 ?6 K/ M/ s7 z
any ointment/creams that they may have applied to
% s5 _; Z: U. t+ R& W/ O; gthe child’s skin. This time the father admitted the( B6 M% o, O6 r! [, v$ s
Topical Testosterone Exposure / Bhowmick et al 541$ ^! T' V0 P; G7 ^9 q$ U
use of testosterone gel twice daily that he was apply-
1 e  |" M& ^( [& |ing over his own shoulders, chest, and back area for
* }% [- w" K9 Pa year. The father also revealed he was embarrassed
% x( w3 c  g# g" }- l( b: m% ^1 R9 c/ Kto disclose that he was using a testosterone gel pre-
/ z" S: N# f3 l1 S- R  |( y! [scribed by his family physician for decreased libido1 }/ Q: V5 c3 G; u; n# \
secondary to depression.: Z! f) U$ k( s0 q$ S- J
The child slept in the same bed with parents.
7 n. E7 T5 F. i  `! Z8 U' rThe father would hug the baby and hold him on his
; j- }) K5 J- u. W! Rchest for a considerable period of time, causing sig-$ n: J# a; S4 `& Q; o, B- N
nificant bare skin contact between baby and father.3 Q  l3 B% t+ m- p4 n) X5 i7 {
The father also admitted that after the phone call,& u  F# [$ \, }! J' _2 f5 e- x/ Z* I. M" y
when he learned the testosterone level in the baby# Q$ I) H0 M5 F6 [- x. t* c
was high, he then read the product information; Q3 N3 p( O$ \3 @/ [/ H% @1 \
packet and concluded that it was most likely the rea-
* k9 K4 M$ q9 [+ Yson for the child’s virilization. At that time, they
' r" v+ \! ~4 J. t. \decided to put the baby in a separate bed, and the$ I: z( w# H& W( N$ Z3 I7 I
father was not hugging him with bare skin and had
& G5 J# e/ U% h) ^2 G# ]. Fbeen using protective clothing. A repeat testosterone$ W, f: S8 E8 r0 r1 \4 L6 P  x5 T
test was ordered, but the family did not go to the$ ]6 D" }/ t5 Y4 e4 g# I" I2 _
laboratory to obtain the test.
6 b# B7 D  F% @; K  n" ^* ADiscussion
4 k) g' B/ F6 D/ \; t$ u5 j3 w) IPrecocious puberty in boys is defined as secondary
6 i! F1 m! B$ h, e  v7 ksexual development before 9 years of age.1,48 C# y9 r1 C) u, z, Y
Precocious puberty is termed as central (true) when) R# ^. g( I2 \9 c# |
it is caused by the premature activation of hypo-$ Z; t  c2 {! m
thalamic pituitary gonadal axis. CPP is more com-
. k* {( C( z3 ~( r: v2 X/ u0 qmon in girls than in boys.1,3 Most boys with CPP
2 {/ I* h; K* a& O) m# g$ Y! Wmay have a central nervous system lesion that is) u& m  N2 Y. C% B0 l/ ?# w
responsible for the early activation of the hypothal-7 ~# H# x7 T+ `$ s2 n
amic pituitary gonadal axis.1-3 Thus, greater empha-9 d7 [, n7 U% E- b4 d( k' o
sis has been given to neuroradiologic imaging in
  w$ e! H) q6 _/ O5 M. |+ K% Lboys with precocious puberty. In addition to viril-) ]1 `3 @0 Q, [5 {" W8 t3 |% t4 J
ization, the clinical hallmark of CPP is the symmet-+ X  r* g4 z. N4 S, P& B- f
rical testicular growth secondary to stimulation by4 `5 p# u1 a# J# E; B+ Y
gonadotropins.1,3  \4 M# h% q6 g1 f/ |
Gonadotropin-independent peripheral preco-6 D& `( y) C' ~8 b
cious puberty in boys also results from inappropriate
$ h2 a) [) S8 r' w% }androgenic stimulation from either endogenous or
2 y" r3 J$ X6 p3 u/ T4 \exogenous sources, nonpituitary gonadotropin stim-
7 o$ m' s3 K, j" [ulation, and rare activating mutations.3 Virilizing+ Q% I" b1 ?- b1 V3 }- H
congenital adrenal hyperplasia producing excessive- h1 N' v# l& B/ M
adrenal androgens is a common cause of precocious# E! U+ }, W9 Z9 C/ B
puberty in boys.3,4
8 R+ H, d1 k2 _$ o  M; A7 OThe most common form of congenital adrenal
4 m" |) J  G6 X5 O8 r0 u( H8 Mhyperplasia is the 21-hydroxylase enzyme deficiency.
+ o& J4 ?) U' I# Q9 ^* ZThe 11-β hydroxylase deficiency may also result in; j$ j& L! r: I" P7 l* d
excessive adrenal androgen production, and rarely,( e1 t. ^! z2 f: R  E; i
an adrenal tumor may also cause adrenal androgen: E6 d; V9 |  E- h
excess.1,3" v5 H+ b( S0 u6 o5 R* ?( [0 d$ p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' |' B  q  t; L0 g6 a+ \2 g6 n. J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! a) [! H2 D- m9 gA unique entity of male-limited gonadotropin-
! ^( h: d' _& L# r! Cindependent precocious puberty, which is also known5 D& g1 \0 [% r) p
as testotoxicosis, may cause precocious puberty at a, x; T/ W; H1 O: o
very young age. The physical findings in these boys2 H0 ]! p3 L+ P8 K4 f
with this disorder are full pubertal development,9 W. \' ~+ R" V( Y, H+ g
including bilateral testicular growth, similar to boys: L2 |. Z  p* u8 ?3 r
with CPP. The gonadotropin levels in this disorder& |3 {" J$ w! r1 @% Y2 H2 k; Y
are suppressed to prepubertal levels and do not show' ]: g3 z5 b8 D, A
pubertal response of gonadotropin after gonadotropin-
/ [8 n2 B6 q2 k7 vreleasing hormone stimulation. This is a sex-linked
, e) d2 f4 \. s  t% g9 `( ^autosomal dominant disorder that affects only! E, g6 B, I  |5 Q) R6 Q7 r# ?: t
males; therefore, other male members of the family. M  {. Q& T( K8 z+ p
may have similar precocious puberty.3
+ H/ c, g0 s3 ]5 W; U+ t/ @7 eIn our patient, physical examination was incon-
4 w! K8 r- @5 g. V( h1 a$ ~sistent with true precocious puberty since his testi-
# f: O, G, M& v' c$ P7 l9 r3 Wcles were prepubertal in size. However, testotoxicosis
8 X# n  z& _5 `0 l6 V4 M+ Pwas in the differential diagnosis because his father( m& C6 J  M7 g! w
started puberty somewhat early, and occasionally,8 Q, q( f" A/ S0 n5 G
testicular enlargement is not that evident in the) l- J" M$ |# i
beginning of this process.1 In the absence of a neg-2 C" ]9 m2 J/ \1 p6 w
ative initial history of androgen exposure, our
/ v9 B$ v- g1 M' U6 G8 P, jbiggest concern was virilizing adrenal hyperplasia,, _8 k% r  l3 G5 S, ?  L
either 21-hydroxylase deficiency or 11-β hydroxylase, D% d* M' Q' \9 J( v* i
deficiency. Those diagnoses were excluded by find-
/ c: _+ D7 J$ n" L* xing the normal level of adrenal steroids.; p, G6 i+ N$ S# I) n- ^- d+ J
The diagnosis of exogenous androgens was strongly3 G+ e. N5 [: T; J! y- a
suspected in a follow-up visit after 4 months because2 k( K/ Q# I6 j; b
the physical examination revealed the complete disap-# k3 D, ?6 a' `1 P0 o
pearance of pubic hair, normal growth velocity, and9 G3 e7 J$ F7 y  b9 I1 y$ I
decreased erections. The father admitted using a testos-
5 h" j' Z& y4 K9 cterone gel, which he concealed at first visit. He was1 a/ w  I* _& H* K$ O1 H
using it rather frequently, twice a day. The Physicians’
  ^. F7 d' v/ J2 C+ JDesk Reference, or package insert of this product, gel or  e: w. W5 [7 `/ P; ^$ a
cream, cautions about dermal testosterone transfer to0 o  y& v/ W. q6 ?1 e
unprotected females through direct skin exposure.9 u. g( T4 s# Q# I
Serum testosterone level was found to be 2 times the% ~! Z* w2 Y1 ?3 h( f) e- u0 M: o
baseline value in those females who were exposed to
* j' l  M2 a2 @, oeven 15 minutes of direct skin contact with their male
' d- g; J6 E; w! J( d/ \) {partners.6 However, when a shirt covered the applica-) m( P1 J( U6 w0 D! F3 g# y
tion site, this testosterone transfer was prevented.1 o# P( y; ^5 D! E5 |% T
Our patient’s testosterone level was 60 ng/mL,
; |4 m6 g/ }# ^- f$ Kwhich was clearly high. Some studies suggest that
9 ~9 }1 T8 f0 O3 F' Ndermal conversion of testosterone to dihydrotestos-
0 N5 C( x- `7 oterone, which is a more potent metabolite, is more
" r6 r) V( o1 G( X6 D3 _active in young children exposed to testosterone2 i" R7 E0 ]/ p2 A) Z! Z
exogenously7; however, we did not measure a dihy-$ A$ t+ B8 u% u) R. d) M
drotestosterone level in our patient. In addition to$ `* f9 k, S: ~  N: R5 r  I
virilization, exposure to exogenous testosterone in
; B, W  ]2 o  r* Z- _children results in an increase in growth velocity and: R/ ?7 M3 |& [* Y$ K2 M) c
advanced bone age, as seen in our patient.# {: R/ o; a7 @4 R5 E/ p
The long-term effect of androgen exposure during# {: I0 u+ T) y; y3 R  Q
early childhood on pubertal development and final
3 L# P" R: ?/ o9 w2 c0 M) Q8 Dadult height are not fully known and always remain
) @, B$ E7 P) N5 ^) q: D$ {a concern. Children treated with short-term testos-
$ r, ]1 `) C1 j2 ?3 ~* H/ Qterone injection or topical androgen may exhibit some
! ~8 A! R6 B" b5 P: v! H; g8 M$ N6 yacceleration of the skeletal maturation; however, after# x$ e4 F( n% Q& i0 R
cessation of treatment, the rate of bone maturation
' n+ V: Y/ H  p# B0 Gdecelerates and gradually returns to normal.8,9+ [: D8 I9 t4 S2 Q6 M
There are conflicting reports and controversy# \1 s' p4 @& N4 ^6 G* k. d
over the effect of early androgen exposure on adult- o: R) n) a5 b" ^, B$ L
penile length.10,11 Some reports suggest subnormal" G5 L5 T2 K* h% X
adult penile length, apparently because of downreg-
4 c+ M8 Z  b( U7 ]ulation of androgen receptor number.10,12 However,
; H; e9 e3 U0 JSutherland et al13 did not find a correlation between
4 O, A% Z; X7 R) r& Q' \childhood testosterone exposure and reduced adult
, K9 y1 K" P0 F& q# openile length in clinical studies.% y. ^& e9 m3 O) U+ z8 E. ^
Nonetheless, we do not believe our patient is
% a2 B2 A) y: l4 i2 h+ Y$ Hgoing to experience any of the untoward effects from) @( x0 d! e) x  l  O. \
testosterone exposure as mentioned earlier because
) t' f* ^# c) K0 V$ X- }8 U' Xthe exposure was not for a prolonged period of time.
9 f# ~! r3 @5 w. A- L+ W& c0 j0 RAlthough the bone age was advanced at the time of
0 l  l' y5 d" L0 g0 y0 }' wdiagnosis, the child had a normal growth velocity at
2 h* E# ~* G+ j) _/ }# U( mthe follow-up visit. It is hoped that his final adult
, T& l8 ?. @- b" Dheight will not be affected.; u% O3 ]! N! |; ~6 ?4 Q  e* n
Although rarely reported, the widespread avail-
) ^+ c3 E( W$ J& q  Kability of androgen products in our society may, D: N, L5 E3 j, n9 O  j
indeed cause more virilization in male or female; k, s8 f9 ]$ M# {
children than one would realize. Exposure to andro-( p7 u4 v% r! C
gen products must be considered and specific ques-
* M5 ]$ R4 E! e  @tioning about the use of a testosterone product or
: I7 I" {6 u! v$ i5 ^( ugel should be asked of the family members during
0 i8 H0 V& Y& J! t+ dthe evaluation of any children who present with vir-8 n0 d" N" c7 W- `( D7 G& ~
ilization or peripheral precocious puberty. The diag-: A/ Y$ x8 s0 @  c3 s/ ^7 T2 m
nosis can be established by just a few tests and by
* @; y+ }/ d) [6 }5 rappropriate history. The inability to obtain such a/ R6 q4 \& N# i/ y* _4 k& H. f
history, or failure to ask the specific questions, may
# x) ^8 y# D  E* p: |5 z0 O- hresult in extensive, unnecessary, and expensive
; T4 @5 h4 k" N% n% I. w2 w0 ?investigation. The primary care physician should be
5 O6 G) l6 }1 X7 Naware of this fact, because most of these children$ n9 ^, r# `0 P4 r) ~! ]1 v5 i8 D
may initially present in their practice. The Physicians’! j, F0 B% U* Q4 ]
Desk Reference and package insert should also put a2 o; D* B2 ?+ p
warning about the virilizing effect on a male or
! M8 n' L; }+ i. G: i9 vfemale child who might come in contact with some-, b" g3 `! D* @. R( ^8 `* \
one using any of these products.
- s' B/ R5 j' q! V: A0 l$ dReferences' }  Q6 }+ H1 y
1. Styne DM. The testes: disorder of sexual differentiation7 K" o# Z3 F/ M) d
and puberty in the male. In: Sperling MA, ed. Pediatric+ A( {- `, m) M% h3 A& X3 ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 M7 r' H( B& E% Q, ~- }4 H8 c2002: 565-628.9 U, Y6 h7 i2 m; q8 b5 `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 O4 M) g7 t$ C2 Apuberty 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

+ _, t6 E$ a9 r. E) D/ `2 U/ 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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