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Sexual Precocity in a 16-Month-Old
+ C! R  ^# U# }- u; lBoy Induced by Indirect Topical/ y" S: o# m# Z) }3 S( a. r4 p: l
Exposure to Testosterone9 b( |- F" A( _& C9 ^. r  L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ F3 M; ^  s& i8 p: Q+ N  iand Kenneth R. Rettig, MD1
4 U% L8 @2 C6 L# _0 I* R& nClinical Pediatrics
% G3 o( ]; q% J9 r8 U! w7 x9 PVolume 46 Number 6
: P5 h4 l6 ?- h. M1 SJuly 2007 540-543& b1 ~1 b7 p4 G5 Y6 l; Q
© 2007 Sage Publications
, X" S$ N* q; Y) W* i10.1177/0009922806296651: H6 U& L& W+ P! H- W8 }
http://clp.sagepub.com/ T  d* v. s( ~; V" U/ @' I' p! y
hosted at
5 M) G! Z, A" t+ S# t9 @http://online.sagepub.com* {- G8 H7 P7 C: U/ q2 e
Precocious puberty in boys, central or peripheral,
& C  y0 {8 y7 h6 ~! j! K+ ]5 Lis a significant concern for physicians. Central
1 g& g$ N0 [6 l) Q" [precocious puberty (CPP), which is mediated
: ~/ J& t( K- X# L- n6 r8 Vthrough the hypothalamic pituitary gonadal axis, has
# e& l/ e6 k9 v1 I, sa higher incidence of organic central nervous system
% I0 U1 H: H) e3 [' z* R4 Zlesions in boys.1,2 Virilization in boys, as manifested
2 n6 M. U- r; b4 H9 ]6 {" b1 k/ sby enlargement of the penis, development of pubic/ ~2 ^3 }0 X7 [+ g8 d5 R" k
hair, and facial acne without enlargement of testi-6 V! O% I* x1 n1 r. v
cles, suggests peripheral or pseudopuberty.1-3 We
- O6 @" p% ?) V# Lreport a 16-month-old boy who presented with the
% ^0 F! E# z2 B( n8 R- I; k$ [enlargement of the phallus and pubic hair develop-2 l; e. M: ]+ z6 I, c. P* r. \" \
ment without testicular enlargement, which was due# j& U6 w( k0 q2 g' D2 X2 l; D4 w- _
to the unintentional exposure to androgen gel used by  W# X5 |5 F! p
the father. The family initially concealed this infor-
: x  K/ K" ]- m# |9 ymation, resulting in an extensive work-up for this3 C2 f+ e7 f( M- X- V; @8 y+ ^; }
child. Given the widespread and easy availability of
# Q9 `! _) ^9 ~( w3 |/ mtestosterone gel and cream, we believe this is proba-7 T9 h- [: ^; A8 N/ |9 f
bly more common than the rare case report in the
; m. L7 w8 j( E. i8 H( Zliterature.4$ @, n7 {3 P2 g0 Z9 x
Patient Report) D$ v, w) C! V1 z# m1 T  v
A 16-month-old white child was referred to the* Y1 {. f# J3 h
endocrine clinic by his pediatrician with the concern
( A" q* m& ?- n  g" p  t) I9 Yof early sexual development. His mother noticed0 r  V7 e* @) ?
light colored pubic hair development when he was
8 R8 t- C1 g) q- m" ^From the 1Division of Pediatric Endocrinology, 2University of
# L" B" D9 V1 J1 A  i5 K! DSouth Alabama Medical Center, Mobile, Alabama.' d2 Z4 X+ M! @# {' i# ?3 a
Address correspondence to: Samar K. Bhowmick, MD, FACE,# k8 [) ~% X, Q/ ]6 m, \. v
Professor of Pediatrics, University of South Alabama, College of7 Q- ^% g' h' h5 y3 N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 s  e, P) k9 d3 p" }9 b3 Ee-mail: [email protected].6 i( W: W$ C; c1 G% L2 @. K, D
about 6 to 7 months old, which progressively became( r) D% K0 I( `+ A8 L
darker. She was also concerned about the enlarge-
/ p5 {% ?. z2 f! p  m/ V" Z1 V" Wment of his penis and frequent erections. The child
9 A) v2 p8 N! wwas the product of a full-term normal delivery, with8 G& i" @, J2 g/ s; }
a birth weight of 7 lb 14 oz, and birth length of
: h$ u' f+ S! d) k20 inches. He was breast-fed throughout the first year
2 y( u6 s/ I1 P( o3 ^6 sof life and was still receiving breast milk along with/ q2 \0 P& a) q8 x- J- Z- B
solid food. He had no hospitalizations or surgery,
0 r0 o8 p" y& j1 \1 P' d. [and his psychosocial and psychomotor development
6 y/ g* g1 N# [/ I0 Iwas age appropriate.- I. y; j; w$ k* F
The family history was remarkable for the father,8 N* I2 ?! `- E* b" K
who was diagnosed with hypothyroidism at age 16,
2 t: i/ k% s7 hwhich was treated with thyroxine. The father’s
$ U. |0 V/ L: n% mheight was 6 feet, and he went through a somewhat
7 F3 X- l1 _) w# Zearly puberty and had stopped growing by age 14.* ]+ Q* q: g8 M7 [" G" d
The father denied taking any other medication. The0 z3 `/ D/ I0 u
child’s mother was in good health. Her menarche
/ ]" l  f8 ~/ _! a9 ~was at 11 years of age, and her height was at 5 feet$ k$ k1 |# z! X
5 inches. There was no other family history of pre-
- z) g+ P/ s6 K7 ~; g8 I, |6 S) ycocious sexual development in the first-degree rela-
4 e6 ^2 U" K. U) b* y& k7 Jtives. There were no siblings.
, u! \2 r4 N2 }9 Q) G6 j8 ^$ ?Physical Examination2 Y8 \: }' }: U% e. \' G
The physical examination revealed a very active,
9 T; z) `( @" l0 I/ i+ dplayful, and healthy boy. The vital signs documented7 u" q5 o3 M8 M9 f; S' W2 w
a blood pressure of 85/50 mm Hg, his length was
2 I. O: a: s, g# h1 @8 }90 cm (>97th percentile), and his weight was 14.4 kg( D1 s& a" A3 P8 V: O9 ?8 E  S" n4 a
(also >97th percentile). The observed yearly growth
; S4 X( p/ s2 r" Qvelocity was 30 cm (12 inches). The examination of
0 ^2 s4 Z' @$ z& T1 P8 ^the neck revealed no thyroid enlargement.
) Z0 F7 H6 }3 n" r* PThe genitourinary examination was remarkable for- {0 ?0 c8 y2 Z/ s1 U
enlargement of the penis, with a stretched length of
; T5 x+ p+ m/ A1 u, d8 cm and a width of 2 cm. The glans penis was very well
9 d' ?2 A1 k1 ]% J. d7 odeveloped. The pubic hair was Tanner II, mostly around
! R3 |3 P/ z3 g4 i8 U' P5407 n( k1 n! k, i* A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ?9 u  c5 z$ G$ Q  ^  A
the base of the phallus and was dark and curled. The$ Y) L' i& H8 e( m
testicular volume was prepubertal at 2 mL each.
& ~7 [% y2 z; R% b/ R6 f9 aThe skin was moist and smooth and somewhat9 k8 B1 S2 x1 ^# G( G
oily. No axillary hair was noted. There were no
; l1 i6 g) R5 F" Y2 c# L3 H+ ~+ iabnormal skin pigmentations or café-au-lait spots.
" |0 Z7 X) T; P+ t( p- ^, D, [Neurologic evaluation showed deep tendon reflex 2+6 X; e; D, I$ B8 k0 b9 e
bilateral and symmetrical. There was no suggestion4 P& r* G, a( D: a2 R9 g( w
of papilledema.
/ O  s8 g  m3 y* @& m9 @: @9 p! ~Laboratory Evaluation
  M6 f; F* s* r+ s. _The bone age was consistent with 28 months by
9 H2 c5 H0 P3 Q5 ausing the standard of Greulich and Pyle at a chrono-
7 B+ Q7 h' P% A: tlogic age of 16 months (advanced).5 Chromosomal0 Z/ e; Z3 N  o2 {
karyotype was 46XY. The thyroid function test
4 ^4 g$ O7 K) r# ^/ {4 v$ x. E# nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 y# g3 }- n- b, k, e$ V4 l, n( O
lating hormone level was 1.3 µIU/mL (both normal).6 n/ R5 j2 ^9 Z0 s: f( z
The concentrations of serum electrolytes, blood
7 G2 `% E8 l# w4 z7 m' Qurea nitrogen, creatinine, and calcium all were) T2 O6 j- {1 J  |
within normal range for his age. The concentration
: A0 ]. [8 ~% @% e, p3 O0 p+ T' E/ Uof serum 17-hydroxyprogesterone was 16 ng/dL
+ I; c6 d) z( B* R, |+ x(normal, 3 to 90 ng/dL), androstenedione was 20
5 M3 ?3 W  w* n$ rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 h  K. g4 o' `2 _( q" A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 X1 H' f: |: y1 b: Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: h2 f: J3 M  w* l' v: I49ng/dL), 11-desoxycortisol (specific compound S)
9 P# L" h; B+ |was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 i# }$ g9 L5 z7 q* [# Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- E1 k! A7 \* O. _- Gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 E# l! [2 u) aand β-human chorionic gonadotropin was less than
1 ?4 q" V0 }' m# {( n+ [5 mIU/mL (normal <5 mIU/mL). Serum follicular
% P5 Y/ Y- E8 [* p$ K/ _stimulating hormone and leuteinizing hormone# k. O+ y& a2 C2 U. \% |) H  O
concentrations were less than 0.05 mIU/mL7 ]' u% ^- }/ {  z
(prepubertal).% S, N/ g( K6 w& s3 R% U( B3 y
The parents were notified about the laboratory! z4 E/ a( }# e2 X. u
results and were informed that all of the tests were8 E$ ?0 u3 v9 S' {  \, T
normal except the testosterone level was high. The
2 K" ?0 {6 [, }# `' y8 [* Qfollow-up visit was arranged within a few weeks to5 g8 A/ O' x4 R$ w) c) t" Q
obtain testicular and abdominal sonograms; how-1 p2 i8 F* c6 G% P8 c
ever, the family did not return for 4 months.6 `. A4 Z8 W$ L! _# S9 y+ D
Physical examination at this time revealed that the
+ e/ C9 E& ?  mchild had grown 2.5 cm in 4 months and had gained
; {5 y/ F6 D4 ~/ A2 kg of weight. Physical examination remained, u2 H' ?; n2 F
unchanged. Surprisingly, the pubic hair almost com-' E, {/ N( s+ b, x( a" ^6 ]! O& D0 r' }
pletely disappeared except for a few vellous hairs at8 i3 U7 {. r/ B8 p1 h+ u5 A
the base of the phallus. Testicular volume was still 2' V+ n( e- O* I' \5 A5 W
mL, and the size of the penis remained unchanged.. B- a; q! @' ^, `  g
The mother also said that the boy was no longer hav-6 `4 P& `7 g% z
ing frequent erections.
7 m4 _5 F5 V4 E8 B+ _1 S# E$ yBoth parents were again questioned about use of
& }) j. ]) A# B8 G* ^$ f: sany ointment/creams that they may have applied to* k/ k8 T7 u4 t8 J
the child’s skin. This time the father admitted the
5 x1 @1 S5 q7 f% Q" |1 A; gTopical Testosterone Exposure / Bhowmick et al 541
% t, R8 c* I+ R$ h0 a' T* F$ M2 Cuse of testosterone gel twice daily that he was apply-. h* x( c) r7 J/ T9 q4 Y, ?0 A# V4 V
ing over his own shoulders, chest, and back area for
7 b5 a' y4 q$ N" y* ka year. The father also revealed he was embarrassed
4 }& [1 H& ^: Ito disclose that he was using a testosterone gel pre-
! S( r0 }5 g( Jscribed by his family physician for decreased libido
# T0 k, a+ [- r2 O& B, [secondary to depression.
7 g3 k, k7 _+ J9 O. L2 tThe child slept in the same bed with parents.% c/ ~# I: Q, p5 q
The father would hug the baby and hold him on his
! M& G9 w# s) S  q) I$ hchest for a considerable period of time, causing sig-, F% `  ^: ?, N. x+ X# D
nificant bare skin contact between baby and father.. H/ V9 w& s8 [  ^+ ~, A0 Q$ {
The father also admitted that after the phone call,
6 h6 h7 a2 G3 ^9 G3 s3 @# Pwhen he learned the testosterone level in the baby& U6 D% d( k2 D% w# y9 Q9 k
was high, he then read the product information0 R7 c8 i" ?& U* R/ s
packet and concluded that it was most likely the rea-
. B# V7 v. [& ason for the child’s virilization. At that time, they- O  _: S/ I4 T! D
decided to put the baby in a separate bed, and the! {6 m' b% E7 ]1 A+ x
father was not hugging him with bare skin and had& p7 k2 o* M5 Q9 g
been using protective clothing. A repeat testosterone
4 \& B. A. \# _test was ordered, but the family did not go to the  L& p/ F# N& L" p- U0 ^
laboratory to obtain the test.& J4 c; E" k& `" g2 k
Discussion
( Z0 b+ {0 y( N7 vPrecocious puberty in boys is defined as secondary
* \8 b/ @/ ]0 J, t8 ]4 f7 Rsexual development before 9 years of age.1,4
) d) y0 S3 k: C2 cPrecocious puberty is termed as central (true) when
# g* ^' l( {8 Z3 Pit is caused by the premature activation of hypo-. k% I; C8 l' H2 V; M, Y
thalamic pituitary gonadal axis. CPP is more com-! n" X/ E8 v/ g! O7 E3 e1 s
mon in girls than in boys.1,3 Most boys with CPP
( i9 H, s! V9 T; k% h8 cmay have a central nervous system lesion that is
/ }6 H7 `+ L1 L/ k" |7 kresponsible for the early activation of the hypothal-
1 x# {0 y! m5 mamic pituitary gonadal axis.1-3 Thus, greater empha-
6 k4 x1 ], q7 }* `: e$ jsis has been given to neuroradiologic imaging in
0 [9 P- M& w9 {2 O6 q2 Pboys with precocious puberty. In addition to viril-( B: @' N! N: C0 a" E% X1 }
ization, the clinical hallmark of CPP is the symmet-! d4 U9 U, g" s8 A
rical testicular growth secondary to stimulation by0 A% a7 V1 }9 |' Y- N
gonadotropins.1,34 x: W# T' Q/ L) h% u
Gonadotropin-independent peripheral preco-  j* r9 |5 i6 u# L
cious puberty in boys also results from inappropriate
) w6 x1 a" n$ xandrogenic stimulation from either endogenous or) \: @' `5 E) o; j
exogenous sources, nonpituitary gonadotropin stim-
; o7 f; u4 F$ g1 Tulation, and rare activating mutations.3 Virilizing
9 `; e# l6 I% Hcongenital adrenal hyperplasia producing excessive
. i! }: o* m" b) z9 a$ G, ~2 G! |adrenal androgens is a common cause of precocious
4 `( s2 R2 E$ M; U3 E# R1 kpuberty in boys.3,4+ z  Y1 [9 @% {
The most common form of congenital adrenal
3 T" e7 Y' K/ c. {. y& v; w/ ^hyperplasia is the 21-hydroxylase enzyme deficiency.
, R9 H1 o5 c' X, B( l& PThe 11-β hydroxylase deficiency may also result in
: F+ Q3 C2 `4 p5 qexcessive adrenal androgen production, and rarely,. a8 @  ]. |& u$ j
an adrenal tumor may also cause adrenal androgen
' f, L& ?* Q' h$ n+ u* jexcess.1,3
& X& V2 X7 e" A9 U# S8 Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* n' r6 x$ p, X3 c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, y  u* g4 Z% T" y* v  Z0 rA unique entity of male-limited gonadotropin-; |7 F) x. c9 H( {/ l
independent precocious puberty, which is also known
# j: p) j6 G9 O5 i! h! ^7 aas testotoxicosis, may cause precocious puberty at a* x' g/ M: `8 u- R" s
very young age. The physical findings in these boys4 i8 C9 M+ x, e; c, L- l; N
with this disorder are full pubertal development,
- Q" s5 [5 _6 G# d  G$ Iincluding bilateral testicular growth, similar to boys8 O5 z% q$ b& U; W
with CPP. The gonadotropin levels in this disorder
# d* P- l6 Z# R# O. _% a9 Care suppressed to prepubertal levels and do not show$ W0 E& r1 J; Q. s7 S- z' ]
pubertal response of gonadotropin after gonadotropin-- L- t9 D- Z$ n( N2 x" U$ r- N0 f+ q
releasing hormone stimulation. This is a sex-linked
. |* l6 ~2 l! B/ ^; t8 O1 bautosomal dominant disorder that affects only
! u. |  R1 A  q. B- fmales; therefore, other male members of the family$ X/ b6 p; {* {2 r! n: @
may have similar precocious puberty.37 G/ s/ q. o* V$ k% W4 x9 f( R
In our patient, physical examination was incon-
, p5 I8 d$ E5 G6 x* Ksistent with true precocious puberty since his testi-
: R# r% Z7 t% l9 n' }- l7 d. fcles were prepubertal in size. However, testotoxicosis0 j4 F: d0 Z/ b3 I- d
was in the differential diagnosis because his father  B/ n- E+ c# n1 |. H1 U0 O' Z! K
started puberty somewhat early, and occasionally,
, {3 \4 @- |- N9 dtesticular enlargement is not that evident in the; @' d5 Q; ^9 m! H; M2 e2 G  B
beginning of this process.1 In the absence of a neg-5 g; r* g8 B* l6 f; D, }
ative initial history of androgen exposure, our( n5 N& ]8 r* \( H3 [
biggest concern was virilizing adrenal hyperplasia,  E# E" a3 P. j! r5 E
either 21-hydroxylase deficiency or 11-β hydroxylase! X9 d. F: j8 w  N# R( G1 c- U$ W
deficiency. Those diagnoses were excluded by find-9 b) E9 Y- i5 d2 G: {
ing the normal level of adrenal steroids.8 ?1 q- k- w1 m' S1 m. v5 Z
The diagnosis of exogenous androgens was strongly. ]) v9 ~% n" z0 j( R  L/ n  k' n
suspected in a follow-up visit after 4 months because/ Q& c0 x& [3 o, Q: N
the physical examination revealed the complete disap-
/ l! P/ N  G& z1 ~% {& x+ U" Ipearance of pubic hair, normal growth velocity, and# G" G4 f9 @: k! m$ g
decreased erections. The father admitted using a testos-
( ]1 [7 Q6 q- w2 r+ H. g+ ^terone gel, which he concealed at first visit. He was
" ]/ T' |7 d5 r" n& F) Husing it rather frequently, twice a day. The Physicians’
* e$ L+ s$ F7 ~- K% n5 XDesk Reference, or package insert of this product, gel or, Y4 c) |6 c9 p
cream, cautions about dermal testosterone transfer to1 a- A; L% Z0 B) h. a# k" d
unprotected females through direct skin exposure.4 Y7 F- p2 k% r. B  s
Serum testosterone level was found to be 2 times the
2 K! W" h& I. V* f) L6 y9 [baseline value in those females who were exposed to9 k9 d; W6 E; E0 S: z7 {$ g4 q$ C; F
even 15 minutes of direct skin contact with their male; m' a1 z% x4 ?
partners.6 However, when a shirt covered the applica-+ V9 e/ ]8 O0 f1 M1 S
tion site, this testosterone transfer was prevented./ C. p5 y3 q* @* L" o8 H) @
Our patient’s testosterone level was 60 ng/mL,
5 o1 H  ?& p: m1 ^which was clearly high. Some studies suggest that* d5 }  a2 x) C
dermal conversion of testosterone to dihydrotestos-# A* K: g5 O' H7 f
terone, which is a more potent metabolite, is more9 t0 Z5 v& ?$ X6 u8 e  K0 K0 N
active in young children exposed to testosterone
8 a. c4 v" C* {: T" o' X- }exogenously7; however, we did not measure a dihy-
+ R( M! J  Q7 {4 v2 _drotestosterone level in our patient. In addition to
) O3 n. R7 y9 `1 M! O! E6 ~virilization, exposure to exogenous testosterone in
: X( C# @- K# n0 y) \; Wchildren results in an increase in growth velocity and
  w8 `( g5 t# k. V+ J2 n: hadvanced bone age, as seen in our patient.
! t! k  b7 M$ jThe long-term effect of androgen exposure during
! |9 R  @5 g8 r6 p: jearly childhood on pubertal development and final5 B/ I3 i( O+ j, h' }9 \
adult height are not fully known and always remain* U  I% ?, a0 p1 a
a concern. Children treated with short-term testos-
' u/ e( A& N3 \! u& }  A8 mterone injection or topical androgen may exhibit some' N+ c. c+ {% S; t" v* n" h
acceleration of the skeletal maturation; however, after
2 t8 J) a9 G. f5 Q9 D+ C! ?cessation of treatment, the rate of bone maturation5 j, h+ P# K; i% ]8 D& L
decelerates and gradually returns to normal.8,9
* f# T3 S: A0 c9 ~) C$ uThere are conflicting reports and controversy) F! g0 r0 Q5 g  U6 s+ s4 K! Y+ A' s
over the effect of early androgen exposure on adult
1 }8 W. ?, }2 l7 ~0 a9 l& @penile length.10,11 Some reports suggest subnormal
! u1 Z6 W% }( _$ V3 c0 ]2 h! @) ladult penile length, apparently because of downreg-
1 @+ I; W5 s0 _! h( Culation of androgen receptor number.10,12 However,
6 t% J8 v' t* L1 E; x1 X  [Sutherland et al13 did not find a correlation between( B2 ~$ K/ {$ q0 y: T. C" F9 b, k
childhood testosterone exposure and reduced adult9 @+ Q; m% f0 l) x% S
penile length in clinical studies.! ^- e2 c4 U. N
Nonetheless, we do not believe our patient is
& S3 f3 o; S4 vgoing to experience any of the untoward effects from
& X* s8 o7 Y  P# }. O0 etestosterone exposure as mentioned earlier because
; U% G9 m2 b1 m/ J& p/ T# Bthe exposure was not for a prolonged period of time.* y0 X' d# A! m) R  B# I5 G
Although the bone age was advanced at the time of2 D- i0 ^0 f/ D1 n% d% n2 N
diagnosis, the child had a normal growth velocity at
$ m7 O  @8 l7 S7 o% Sthe follow-up visit. It is hoped that his final adult$ L  w3 W! o3 Y# ^
height will not be affected.
5 |; M6 F( H! r9 V3 p% D" |Although rarely reported, the widespread avail-6 |/ i$ T+ \( |9 U
ability of androgen products in our society may
7 u2 F! V" |  ~  a0 G0 ?, ^( `  Windeed cause more virilization in male or female0 ?3 }# e& F% E4 a4 i* s
children than one would realize. Exposure to andro-& ^9 g( N, m1 @7 D, M5 ~  l! e, F
gen products must be considered and specific ques-
. a! i  i2 F. x" B' w. Ptioning about the use of a testosterone product or
+ o1 R5 R6 C- b6 p, Q* k3 egel should be asked of the family members during
- G( P2 K4 p; b& w8 @- d5 hthe evaluation of any children who present with vir-
$ p( ?, F$ o, zilization or peripheral precocious puberty. The diag-
+ n5 S0 l" n: Y. X$ o3 W' L/ Qnosis can be established by just a few tests and by+ {1 s" E% N0 F* X9 ]8 ~9 b# P
appropriate history. The inability to obtain such a
. v" K" E! @5 k! o( Ihistory, or failure to ask the specific questions, may- ~( \9 ~& [1 r9 k( v) ^& X; [
result in extensive, unnecessary, and expensive
6 F9 Q) K' q4 c4 ]investigation. The primary care physician should be
( j5 ^, ?0 h+ |3 R* H4 m- Waware of this fact, because most of these children9 F5 r  `% h& l- R: H
may initially present in their practice. The Physicians’
% G: G' S" P' y6 qDesk Reference and package insert should also put a* R$ e, x% }; w
warning about the virilizing effect on a male or
3 k' I$ H0 H: W  X5 J: j8 wfemale child who might come in contact with some-3 E9 s) G1 C" n. i
one using any of these products.
% m2 V& b( n& t* l- {2 [( QReferences
$ O6 Z5 Y) D# P5 `7 N1. Styne DM. The testes: disorder of sexual differentiation
& U8 E' {; w! ~9 r( \: V, |/ yand puberty in the male. In: Sperling MA, ed. Pediatric* M  S) k/ Z+ ^. X! i- O
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) S9 W+ L" o6 z4 w1 g2 z
2002: 565-628.
1 ^: @3 y! [0 ]7 v& k3 H1 R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious  x" _7 ]% v0 s8 C$ b6 A
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* _' G: ?% W0 l
Boy Induced by Indirect Topical
) J  O6 H9 Q! K8 ^( `Exposure to Testosterone/ V9 e! `5 d4 T; T* z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 u6 q. U! i: ?' [8 fand Kenneth R. Rettig, MD1
: ?/ }  m) S3 x3 R  FClinical Pediatrics$ C9 G2 j3 s0 M: Z! T2 W
Volume 46 Number 6+ ~0 i% z/ ^; ~& l
July 2007 540-543
: Z, k+ S0 O2 H© 2007 Sage Publications3 l5 J# j( K* q" J3 y+ n
10.1177/0009922806296651
4 _3 s; E5 D: K) F, `( C7 Qhttp://clp.sagepub.com
: x7 B& n6 d7 @( j; }hosted at# s3 \* ~  j$ z1 q  U9 }% }
http://online.sagepub.com
. Y1 R3 k9 _# N1 d# uPrecocious puberty in boys, central or peripheral,
0 `0 E$ Y( h  Y8 `4 S: X( E2 P4 Pis a significant concern for physicians. Central
2 u% c% y1 w. l$ W( Wprecocious puberty (CPP), which is mediated
5 B/ e. @- Q2 O" x* ^* Gthrough the hypothalamic pituitary gonadal axis, has1 `8 g. M6 M5 f7 [9 a% C
a higher incidence of organic central nervous system
7 B  ~9 j: [" U/ Zlesions in boys.1,2 Virilization in boys, as manifested
/ |$ V4 U( ]( F4 v6 X3 |8 Eby enlargement of the penis, development of pubic
; b2 h2 v7 I' K6 K1 n4 ?! Yhair, and facial acne without enlargement of testi-; x6 y. k  d5 {4 \* i
cles, suggests peripheral or pseudopuberty.1-3 We
) {$ x) g' d7 C& |report a 16-month-old boy who presented with the3 t" K* S8 D* [: _8 A
enlargement of the phallus and pubic hair develop-
3 i+ ?& \; @/ A  Y- G! U, }ment without testicular enlargement, which was due, Q1 G' d- o2 k4 D( @
to the unintentional exposure to androgen gel used by
5 I8 m1 h3 Z6 Vthe father. The family initially concealed this infor-# H8 h7 Q$ l, s
mation, resulting in an extensive work-up for this: d. P, d% Y; A* S: P7 k
child. Given the widespread and easy availability of
" }' F0 z3 b% \' O3 H: A2 _, ftestosterone gel and cream, we believe this is proba-. Z3 b( \! }! r8 ^+ |
bly more common than the rare case report in the
2 R9 _) G9 g4 p/ g# }  j% f& vliterature.4+ M! p+ o# e$ N. H
Patient Report5 b) F4 I  ^; ~' c
A 16-month-old white child was referred to the
- S7 X/ c5 D0 [" {+ c; _endocrine clinic by his pediatrician with the concern3 ], J. K4 b% k$ [! a
of early sexual development. His mother noticed4 o$ h+ T4 b  O- M, B
light colored pubic hair development when he was- ^8 s# E: r+ B& p. k# q
From the 1Division of Pediatric Endocrinology, 2University of
9 B. V& j8 j" YSouth Alabama Medical Center, Mobile, Alabama.% m2 o$ A' C2 f' P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( ^% |% P+ ?. @Professor of Pediatrics, University of South Alabama, College of
7 n( e" z# R, A; I* @1 E5 ]* ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% n% ^, p; p0 @7 l" t& g! ^e-mail: [email protected].
+ X! @, r+ n' T. _$ r& L) aabout 6 to 7 months old, which progressively became
7 }, F, m: }( Z0 `( Odarker. She was also concerned about the enlarge-: A8 U' h3 Q8 l; V) c
ment of his penis and frequent erections. The child: s' h4 x0 ?& e: M9 }" ^* ]2 M2 X& k
was the product of a full-term normal delivery, with6 x0 B7 W" h; e# Y8 c5 R
a birth weight of 7 lb 14 oz, and birth length of
3 k0 Y/ U* c3 o% t% s2 D' M: p% P20 inches. He was breast-fed throughout the first year7 q( A$ |2 W! O4 _& ?. t" B3 P8 E
of life and was still receiving breast milk along with5 m6 p. r  U) w& b; }# a
solid food. He had no hospitalizations or surgery,
' L7 C0 d0 @, S  Mand his psychosocial and psychomotor development) N0 R" p5 [8 r1 R2 E+ ^! b! \0 p
was age appropriate.
( W: F) }8 Y5 j3 I9 w% P8 iThe family history was remarkable for the father,
; {. L8 m! r& ~! z" M* U2 twho was diagnosed with hypothyroidism at age 16,5 L$ R9 R0 B" A$ Q. b
which was treated with thyroxine. The father’s: |' c  k0 q$ P& @
height was 6 feet, and he went through a somewhat
! u) x8 P4 s( q0 h6 Searly puberty and had stopped growing by age 14.
, R5 q5 o" W- {+ J+ zThe father denied taking any other medication. The3 u0 H# K6 `1 x( p6 D4 f
child’s mother was in good health. Her menarche5 ^1 D+ V6 y6 {# }5 |
was at 11 years of age, and her height was at 5 feet
! s/ A" N4 d  b9 c7 G5 inches. There was no other family history of pre-) Z8 J! `4 z  H1 m1 c1 o7 m
cocious sexual development in the first-degree rela-
& ^" E3 A  @8 m) k  w) t5 Q2 ?: U/ Rtives. There were no siblings.; _2 X& m4 T8 I0 J2 g( ?
Physical Examination
, C# _1 W& W: F" h) kThe physical examination revealed a very active,- r/ U( Y9 c3 w
playful, and healthy boy. The vital signs documented3 P; y3 A7 y, P, R4 G  A
a blood pressure of 85/50 mm Hg, his length was1 _# O7 A1 Z8 ]- u" v2 ]
90 cm (>97th percentile), and his weight was 14.4 kg1 _9 H: w) O9 C2 F
(also >97th percentile). The observed yearly growth: {+ i: b2 D/ d
velocity was 30 cm (12 inches). The examination of. o7 v- p4 Z) `% x! ~; W3 N
the neck revealed no thyroid enlargement.# w* c3 K8 b5 i) R# y
The genitourinary examination was remarkable for
8 _" i4 B, {, t/ v4 M1 _enlargement of the penis, with a stretched length of
1 g2 o# }' q+ e8 d/ y8 cm and a width of 2 cm. The glans penis was very well& e4 J! Q0 ^& @5 t4 ^
developed. The pubic hair was Tanner II, mostly around
" T, V, r4 w- p2 k* q4 a1 n* P' ]540
/ E7 \4 }& k, vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 g! O3 v% }# H, }the base of the phallus and was dark and curled. The- V+ n1 Q* o- G; s: r
testicular volume was prepubertal at 2 mL each.+ y! k  M% {! k5 x- a
The skin was moist and smooth and somewhat
8 I! [7 g! j& j/ P4 w( H/ t, F7 ?  ?oily. No axillary hair was noted. There were no* G) y. @# I' d
abnormal skin pigmentations or café-au-lait spots., q5 O' q. d7 I* b2 C
Neurologic evaluation showed deep tendon reflex 2+
* @- |+ j+ X' K: ibilateral and symmetrical. There was no suggestion
/ r3 |3 Q+ T' Iof papilledema.
* }  b; N2 p0 H, N4 KLaboratory Evaluation
1 C# x7 }! y& u5 Q& \% DThe bone age was consistent with 28 months by
+ B6 ]' i# ^0 T- Vusing the standard of Greulich and Pyle at a chrono-$ S" C* ~$ Z3 v  e" n
logic age of 16 months (advanced).5 Chromosomal' [& x$ P# D5 o4 v# V
karyotype was 46XY. The thyroid function test
8 n% E: P4 X1 R, zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-0 Y# B0 Z: l: @; K9 v
lating hormone level was 1.3 µIU/mL (both normal).
, r' K2 D+ L" m+ oThe concentrations of serum electrolytes, blood
( ~; R6 F6 i5 J9 ]( D" G: {5 Rurea nitrogen, creatinine, and calcium all were/ B/ A7 \1 i" h! ^
within normal range for his age. The concentration8 u( _; p. O" M  Y2 H
of serum 17-hydroxyprogesterone was 16 ng/dL
, t( \. j6 D: \: A8 U0 n4 q  c8 U(normal, 3 to 90 ng/dL), androstenedione was 20
, s. I6 p! N9 |4 ?9 L% K  ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; E$ @3 p) a/ |- B: nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; _0 l' |2 ^# P: }3 y; |" e% [( }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 B  s) x3 t3 @) F1 ^& |" V% G49ng/dL), 11-desoxycortisol (specific compound S)  C, I# I8 b: P3 O- y4 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 l1 U% m# K9 F' M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 u* c  r7 z' r( @6 x: w& H! k
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 @* f$ L0 K9 C& F1 q6 U
and β-human chorionic gonadotropin was less than
1 Y/ S8 f' c( e, `2 l+ f5 mIU/mL (normal <5 mIU/mL). Serum follicular
. G: X2 N4 B3 d. Zstimulating hormone and leuteinizing hormone$ Q; c- a8 w3 E" S& X
concentrations were less than 0.05 mIU/mL& I& z3 U0 F) e. A
(prepubertal).4 Y0 N9 E1 z$ l1 E# D( a2 Y$ Z  t
The parents were notified about the laboratory! h, G. z, {2 w  k% S
results and were informed that all of the tests were7 J# [( B) X- H  y" \' V
normal except the testosterone level was high. The
8 S7 i8 F. Z. k% I  x4 y/ O/ h' afollow-up visit was arranged within a few weeks to1 I4 P! w0 }8 O1 c
obtain testicular and abdominal sonograms; how-
3 C+ s& J, W# u4 V# m4 hever, the family did not return for 4 months.( \# O$ r) y# Y  s4 ]
Physical examination at this time revealed that the
% O- \' J! T! B; ~, i$ x" Mchild had grown 2.5 cm in 4 months and had gained  O2 x+ s+ ]& M5 S. \9 `* L
2 kg of weight. Physical examination remained' B# ~8 R" m% q6 r# a+ ~
unchanged. Surprisingly, the pubic hair almost com-8 s, j0 W1 m% @
pletely disappeared except for a few vellous hairs at$ R- r$ c' Z; i  m/ d) M1 ^8 T' B: W, Y
the base of the phallus. Testicular volume was still 25 ?1 ]8 @, O; H. ~- {/ ~' ~
mL, and the size of the penis remained unchanged., y$ @* X$ q6 `# P: g  e
The mother also said that the boy was no longer hav-
+ z$ F7 u8 U0 E, ?ing frequent erections.5 v2 W; F. p& c: q
Both parents were again questioned about use of9 h+ W7 i& ^- H
any ointment/creams that they may have applied to+ t  P! ?( ?2 r4 i1 X+ v0 U6 V
the child’s skin. This time the father admitted the
0 c5 c6 P/ O, V$ A+ Z7 E" QTopical Testosterone Exposure / Bhowmick et al 541; |: D1 ~" I9 A- q! T
use of testosterone gel twice daily that he was apply-9 `9 Z& N, c5 @1 l3 l* ^
ing over his own shoulders, chest, and back area for
$ W7 C6 V, j" Z+ F, E9 wa year. The father also revealed he was embarrassed* a5 v5 [4 F  `2 t' k. [
to disclose that he was using a testosterone gel pre-
$ b  O+ ]- r. s( sscribed by his family physician for decreased libido
+ y" h$ \, j/ Usecondary to depression.: V7 z! d, d; X% H; c
The child slept in the same bed with parents.7 j: e9 _+ |- a1 [
The father would hug the baby and hold him on his
: H8 r9 y6 Z6 |: V$ v7 x$ v1 ~chest for a considerable period of time, causing sig-5 V) u( u& b+ S8 |# E0 A
nificant bare skin contact between baby and father.% ^$ ~! d- D) @/ }) h
The father also admitted that after the phone call,* L8 J1 p+ _+ T: G# y! x  L: f
when he learned the testosterone level in the baby( b3 z$ N* a( J- g
was high, he then read the product information, E. z5 g4 ]. a3 V+ I, n( s8 m  ^+ X. M- Q
packet and concluded that it was most likely the rea-
$ K# B0 v+ D4 V4 H8 zson for the child’s virilization. At that time, they) {& B4 L8 ]5 f3 q1 @3 u, j
decided to put the baby in a separate bed, and the
, B3 e4 b, a; p( ^father was not hugging him with bare skin and had
1 Q; b9 z( V+ ebeen using protective clothing. A repeat testosterone
& l# i6 J. M+ X; j3 m: Mtest was ordered, but the family did not go to the
" y; i6 J5 X- [- S9 Olaboratory to obtain the test.
; |9 K8 `/ p8 G" @# N- t8 WDiscussion
0 ?' R) ?/ ^' {& l4 ~% C( MPrecocious puberty in boys is defined as secondary
2 w, r8 f7 J, |sexual development before 9 years of age.1,4$ Z- c' y! {/ b! Q8 a
Precocious puberty is termed as central (true) when9 v* ?. K3 Q0 a' D1 ?
it is caused by the premature activation of hypo-. L. v& ]- M: y( L3 E( |3 u
thalamic pituitary gonadal axis. CPP is more com-
- n5 `! c3 {# y9 y& vmon in girls than in boys.1,3 Most boys with CPP& H1 S; s; |2 t; S
may have a central nervous system lesion that is
, e1 b3 b# l; ]& O  O3 aresponsible for the early activation of the hypothal-
& X  H" A4 R$ N, @# i2 |amic pituitary gonadal axis.1-3 Thus, greater empha-' C' g# R$ Q8 d8 N+ U  i7 Y
sis has been given to neuroradiologic imaging in: ^+ n' E) H  n4 [! Y+ G0 W
boys with precocious puberty. In addition to viril-1 j5 F; W! ]6 N' h( n* H* C+ I
ization, the clinical hallmark of CPP is the symmet-
; A! j/ N3 E9 [  U) m. D0 D) vrical testicular growth secondary to stimulation by% w* K; B+ a3 L6 z6 o5 H' {
gonadotropins.1,3" d0 u9 y; J, i' h
Gonadotropin-independent peripheral preco-! z. a# ]" p  Z8 C: f
cious puberty in boys also results from inappropriate' h$ g( m% Q+ E& a) F
androgenic stimulation from either endogenous or
3 h3 q3 J& e- Q5 E- Lexogenous sources, nonpituitary gonadotropin stim-) S" N4 ?- P; B; {9 P
ulation, and rare activating mutations.3 Virilizing
' Y; a0 N: V3 @0 e# u  rcongenital adrenal hyperplasia producing excessive3 h2 X2 _5 ?2 b3 r. |
adrenal androgens is a common cause of precocious
2 V0 T( e0 x% Q$ R) x. L  Apuberty in boys.3,4, _% i4 k& b) r$ q5 m  }
The most common form of congenital adrenal
7 W/ x! m; W6 e7 L  Xhyperplasia is the 21-hydroxylase enzyme deficiency.& O( _% E" w0 |( g# \- L( k
The 11-β hydroxylase deficiency may also result in
$ m: l5 w, P0 ^! q1 Wexcessive adrenal androgen production, and rarely,) K/ @8 O3 \# ]- J' \) |+ {. n: i
an adrenal tumor may also cause adrenal androgen
% U) j% x3 q. ~5 Y3 `excess.1,3
" ^4 o# Z: k7 J4 C7 ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. }- ?# o1 H  U, i4 f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; u, a) f8 g0 U6 D  d6 C  pA unique entity of male-limited gonadotropin-
& \5 X  K, Z$ r6 B6 oindependent precocious puberty, which is also known
( ~6 ~( Z+ {/ L: S- Kas testotoxicosis, may cause precocious puberty at a
5 s0 h2 P, o9 R' B) g6 _$ Every young age. The physical findings in these boys3 X! N  W& ^/ \! P, Y% O/ |0 ?9 {
with this disorder are full pubertal development,, I; x7 n  K5 \; ^
including bilateral testicular growth, similar to boys) B# s/ H! q* `4 G: H
with CPP. The gonadotropin levels in this disorder
7 W  r! W- R& ?4 m) v/ ~are suppressed to prepubertal levels and do not show7 G9 }; Q* S6 R
pubertal response of gonadotropin after gonadotropin-! v. m( {0 S, E+ |! _4 O4 S* m
releasing hormone stimulation. This is a sex-linked; \9 E- |1 ^; ]
autosomal dominant disorder that affects only
4 i5 Z3 y5 D) l( lmales; therefore, other male members of the family/ [2 o+ _% f( e* m
may have similar precocious puberty.3' x. n4 s# F" ^$ P. @* Y2 p
In our patient, physical examination was incon-% C( p( y' |; f! G( G
sistent with true precocious puberty since his testi-) {7 U! W+ v1 D
cles were prepubertal in size. However, testotoxicosis
5 F! }( ^( `! c$ m' ?, Cwas in the differential diagnosis because his father9 W& b2 z; V9 m' j+ F3 f# x/ v7 u0 S
started puberty somewhat early, and occasionally,
- ~/ d' W  R7 p6 qtesticular enlargement is not that evident in the
2 A9 I, h& T5 Q4 l+ I2 I+ G% Sbeginning of this process.1 In the absence of a neg-
7 w4 j  G" z0 a/ Oative initial history of androgen exposure, our
6 M# k! p0 d4 l; d/ X9 M. ~5 Wbiggest concern was virilizing adrenal hyperplasia,  d. ^' z9 W3 i# f
either 21-hydroxylase deficiency or 11-β hydroxylase
# H/ D; S$ l& x' W1 Ydeficiency. Those diagnoses were excluded by find-8 }$ r' P( E% z# `3 ~8 m2 b
ing the normal level of adrenal steroids.; b7 _4 _4 ]& v" W( W0 @- O) F. q
The diagnosis of exogenous androgens was strongly
+ r* a6 e' n9 z7 y% L/ ^: isuspected in a follow-up visit after 4 months because
% Q$ x5 e9 D& s/ Fthe physical examination revealed the complete disap-
6 M4 u  H6 W2 o/ r2 a1 Bpearance of pubic hair, normal growth velocity, and
, W. N9 g4 g  J& [7 o. V! {" kdecreased erections. The father admitted using a testos-  t* I* p( Y: F( P( R
terone gel, which he concealed at first visit. He was
5 ?! t3 Y. P- ^using it rather frequently, twice a day. The Physicians’
) _- i" |( f7 z' f. I6 |3 gDesk Reference, or package insert of this product, gel or1 f9 H8 v# U" {0 n2 g7 B& W
cream, cautions about dermal testosterone transfer to
9 d) L9 a+ V, @$ V! |unprotected females through direct skin exposure.  X9 d4 @5 k( g2 I3 e+ R1 z
Serum testosterone level was found to be 2 times the: q" B1 e' ~; o5 S* P* v  u7 x
baseline value in those females who were exposed to& |9 P9 O% z+ u! o1 _! S  i4 C
even 15 minutes of direct skin contact with their male
( v) g8 A9 z! m5 B) C: Npartners.6 However, when a shirt covered the applica-
6 W% s% |, k" E) z( ~& ^4 c3 ?tion site, this testosterone transfer was prevented.  F: s, ]. a- [0 m) @5 a
Our patient’s testosterone level was 60 ng/mL,
, U& z: a7 N5 Awhich was clearly high. Some studies suggest that
, ~2 O+ _6 _* o5 a- Jdermal conversion of testosterone to dihydrotestos-& i7 p+ o) W) M1 H5 m
terone, which is a more potent metabolite, is more
+ a7 S1 r) q1 w5 Cactive in young children exposed to testosterone
* l% b3 n2 W2 ~2 {4 ]3 |4 eexogenously7; however, we did not measure a dihy-
7 ]* v% F/ F6 C) \2 q8 s4 B7 {$ f) \. ~drotestosterone level in our patient. In addition to! Q# I* r, q4 y" X; e
virilization, exposure to exogenous testosterone in
$ Q' m/ K) [2 Q, b- Rchildren results in an increase in growth velocity and0 a1 c+ {+ Y7 u3 R- E
advanced bone age, as seen in our patient.
+ R, n  [: D: `' F. ]) k7 tThe long-term effect of androgen exposure during
. S; j1 f$ u4 r# F  {early childhood on pubertal development and final2 }6 O7 ]8 N* [) x
adult height are not fully known and always remain
& q8 r/ B  D4 O' g! c- Ha concern. Children treated with short-term testos-
# E# b  a: W6 U7 W# }' p+ Wterone injection or topical androgen may exhibit some
: |6 A' D4 T4 }. W+ m1 v4 oacceleration of the skeletal maturation; however, after4 q) j) m  P8 F* x+ Z( p: e( b
cessation of treatment, the rate of bone maturation
7 b" z2 j/ \4 o* K% O2 ydecelerates and gradually returns to normal.8,9
+ b. h& s% x+ ^There are conflicting reports and controversy5 n2 Q+ B) }9 G0 q
over the effect of early androgen exposure on adult1 H9 ^- l8 ?3 m, q' b
penile length.10,11 Some reports suggest subnormal9 j2 R/ F4 e! o
adult penile length, apparently because of downreg-" R1 t% d3 R7 w( T: G. Z2 t! d. s+ `
ulation of androgen receptor number.10,12 However,0 X/ X+ h; ]1 E
Sutherland et al13 did not find a correlation between
, R$ K* c8 A( |) ^childhood testosterone exposure and reduced adult
6 c( c8 \' S/ v2 l' f  C6 Q4 |penile length in clinical studies.  ]6 Z+ |# T- g) Q3 I2 A8 i9 S) ?" ]
Nonetheless, we do not believe our patient is& H' g# Y/ e# I# D
going to experience any of the untoward effects from
* s. n" s( g& Mtestosterone exposure as mentioned earlier because, g9 n. }$ X; R2 Z, ?9 i
the exposure was not for a prolonged period of time.) @& H' [4 [3 Y+ {4 b5 c8 r- ]
Although the bone age was advanced at the time of
7 J1 {/ B* G$ I' z  l* ydiagnosis, the child had a normal growth velocity at- ?6 z! b, q. J: E
the follow-up visit. It is hoped that his final adult
9 ~$ b$ d2 {. `  \6 s2 Nheight will not be affected.$ ^6 H: o& Y) n" [6 t7 r
Although rarely reported, the widespread avail-; S' u% u7 y, d6 O
ability of androgen products in our society may
: k$ W3 T8 B' X% H/ qindeed cause more virilization in male or female
) Z) S0 g9 g' N* cchildren than one would realize. Exposure to andro-3 e5 J% a; p0 x& D  h  F- i
gen products must be considered and specific ques-
" |/ ^2 J' }1 c0 ^+ qtioning about the use of a testosterone product or8 Q. Y" `7 m8 W( Y1 q3 V6 \: y3 S2 A
gel should be asked of the family members during- i% D$ a1 A: E- W
the evaluation of any children who present with vir-
9 U; S7 u" ], h  c4 }ilization or peripheral precocious puberty. The diag-
9 Y* U, m% H" @nosis can be established by just a few tests and by
" T4 b. ^1 @+ uappropriate history. The inability to obtain such a3 b4 s5 k4 @$ b6 q/ s
history, or failure to ask the specific questions, may
& w4 k" R) B; L, j: nresult in extensive, unnecessary, and expensive
0 U1 ?  o# X# i# G3 z0 }7 B* z! Dinvestigation. The primary care physician should be# Q4 A3 t5 H! e: c5 v, O0 s
aware of this fact, because most of these children6 d* K" N9 d8 M$ }7 x% \1 q
may initially present in their practice. The Physicians’
4 P" l. T, E' ?# d) G4 I; i$ _# oDesk Reference and package insert should also put a
8 p% d5 ]- X( i! ]! T" xwarning about the virilizing effect on a male or7 i; i3 V; ~3 r+ C
female child who might come in contact with some-
7 O7 o, x2 T4 g9 F; K7 B5 P3 oone using any of these products.
3 W5 r2 b4 e( }& E6 ~6 `' I  LReferences0 i  w) O5 v8 }% H, X" I. {* O/ E1 E$ ]
1. Styne DM. The testes: disorder of sexual differentiation- ]: b8 v8 o& H% w; x1 v( J
and puberty in the male. In: Sperling MA, ed. Pediatric: H7 C- v* Q8 Y- c# l% x
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 z* i2 k  X. s5 I( c% c) c
2002: 565-628.
. i& ^* ]: X- s% l1 p( U" G% ^5 R% u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 d/ l# j) c" w0 h) \$ b. r+ e
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
  |1 u& Y" o+ Y$ O! N
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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