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Sexual Precocity in a 16-Month-Old
" ?- ~' G1 j3 o1 vBoy Induced by Indirect Topical7 e$ P& h( j6 _, ~2 y* x
Exposure to Testosterone- C: X- M* T( I% n! ?
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2" ~: q' U, {. f- Q
and Kenneth R. Rettig, MD1* d6 W0 s) I+ c, T9 S
Clinical Pediatrics+ f, ^+ W' D4 K
Volume 46 Number 6
2 v! [( O- d2 R/ vJuly 2007 540-543
0 I) k; K- ~: \. f# M- a; D© 2007 Sage Publications9 W" s4 s8 Z+ j
10.1177/0009922806296651; w4 F& @, o# C3 c' g( ~  M$ j
http://clp.sagepub.com
5 U% u* {: d" ^, J& N( v5 ~# Bhosted at: s  m2 [2 @& W  ?! R
http://online.sagepub.com
3 H$ r: I$ ^8 `; \Precocious puberty in boys, central or peripheral,
) |5 t! Z: X5 t$ }is a significant concern for physicians. Central9 E7 \/ w4 E' k
precocious puberty (CPP), which is mediated
( U. J* s/ n, v# C) [4 Sthrough the hypothalamic pituitary gonadal axis, has2 T& _% {- J% r0 r0 D+ {2 t; X5 l/ G
a higher incidence of organic central nervous system
8 f. t8 R. ^9 ~* ^) Y6 Nlesions in boys.1,2 Virilization in boys, as manifested
& Z$ S' ]9 i, k- Wby enlargement of the penis, development of pubic; i) [! w! J7 ~$ ^+ v" R
hair, and facial acne without enlargement of testi-* c* c" v6 I6 G0 n
cles, suggests peripheral or pseudopuberty.1-3 We
5 `& |) s8 p$ b% J  u9 V# zreport a 16-month-old boy who presented with the
5 J% u7 p4 a0 V9 Q2 lenlargement of the phallus and pubic hair develop-0 O5 `& V8 t* A( P6 R  ^. G
ment without testicular enlargement, which was due& k1 u+ z! Y) Q5 c
to the unintentional exposure to androgen gel used by
' X7 e2 Q6 X+ w: Y  b7 z7 \the father. The family initially concealed this infor-
2 z; e5 z! q3 z9 l: c; dmation, resulting in an extensive work-up for this
0 G2 ^. A! R7 {* x9 W* l( Achild. Given the widespread and easy availability of
+ C( z% S. L* {" o5 ]testosterone gel and cream, we believe this is proba-
* D4 g2 c6 O* q+ A2 sbly more common than the rare case report in the
8 [( ?0 W. l3 [1 |literature.49 w1 W0 y/ Z4 R! u9 J2 O
Patient Report
0 W3 C/ l5 p4 L# Q+ p. [A 16-month-old white child was referred to the$ N& L' x& @' I# Y7 ~2 o+ c" q
endocrine clinic by his pediatrician with the concern% h+ w' b4 A4 |8 U
of early sexual development. His mother noticed
0 o1 v) T3 q  C: B8 X0 @0 Dlight colored pubic hair development when he was
" n6 X( }$ J1 [From the 1Division of Pediatric Endocrinology, 2University of
8 n$ A  V1 h/ G' O3 d( USouth Alabama Medical Center, Mobile, Alabama.+ L! ?8 a% ^  T  T$ ]- ]$ @
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; k  L( y4 O% }/ M+ w; NProfessor of Pediatrics, University of South Alabama, College of
' r% z8 C8 P3 f9 R' q4 c# uMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 P+ T2 L* U, t! h  e
e-mail: [email protected].. U9 G" d1 @0 l
about 6 to 7 months old, which progressively became2 c# z) V- _! S4 G8 Q! O
darker. She was also concerned about the enlarge-1 m! b7 k! D' f4 \; q5 i' b2 z
ment of his penis and frequent erections. The child- x" z; V1 m" w: E
was the product of a full-term normal delivery, with
; O8 R3 r3 n: M4 n$ `# [- ta birth weight of 7 lb 14 oz, and birth length of
# ], j; U  w$ z: R7 K20 inches. He was breast-fed throughout the first year
* u  X7 z% x+ l: Y: O9 }of life and was still receiving breast milk along with
# h6 R' y  _% {4 d% ]8 ]solid food. He had no hospitalizations or surgery,' o, H1 u. t5 Y+ I
and his psychosocial and psychomotor development
( P/ l' V/ ?1 W9 u# ~  i# pwas age appropriate.& Y/ ^% g1 N; l7 {% E4 j) R
The family history was remarkable for the father,
7 ~6 d2 R  A: p9 o3 nwho was diagnosed with hypothyroidism at age 16,. G$ ^8 _/ Q& b* }9 C
which was treated with thyroxine. The father’s3 V" g- Y# H" w: ?8 o) h8 z1 T4 m
height was 6 feet, and he went through a somewhat
4 `3 f5 P+ Q$ s# s3 @7 E9 u& r8 rearly puberty and had stopped growing by age 14.
$ Y" S+ w5 W& n+ uThe father denied taking any other medication. The
7 U5 U) @5 r, S' B- achild’s mother was in good health. Her menarche
+ u( m( q) z: D. b6 w2 ewas at 11 years of age, and her height was at 5 feet- {" s. E$ F! G
5 inches. There was no other family history of pre-* L( C4 D% a' Q: @8 O
cocious sexual development in the first-degree rela-: R# z( X0 \* z( t, {
tives. There were no siblings./ a7 r. [- a. I# n3 O! w
Physical Examination+ t# Y. _5 ?/ j
The physical examination revealed a very active,
' G$ o; C3 z% N8 l9 {7 S5 Z8 cplayful, and healthy boy. The vital signs documented
$ T: T  W" ?0 ?, P& V4 G+ Sa blood pressure of 85/50 mm Hg, his length was
. D4 u0 i* }: d; @& _& t90 cm (>97th percentile), and his weight was 14.4 kg) Q+ }$ u" J9 r" p
(also >97th percentile). The observed yearly growth
5 v1 b. v7 H6 E$ `9 V3 q$ }* Qvelocity was 30 cm (12 inches). The examination of
; [: A/ P8 |% H1 e5 fthe neck revealed no thyroid enlargement.! p6 h% q% {5 S+ @* }! D
The genitourinary examination was remarkable for2 k+ f' W  v1 |3 h4 s
enlargement of the penis, with a stretched length of
) Y. B8 ~4 I* g4 Q2 I( o" u8 cm and a width of 2 cm. The glans penis was very well
- Y1 O9 P7 T) ]  P; k+ K8 u/ \developed. The pubic hair was Tanner II, mostly around) @* j' O8 e: N5 }) E( X
540
1 F1 B6 T. a7 F/ m: N! i9 H9 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ u+ C0 I5 L  `# B) Q. M0 f
the base of the phallus and was dark and curled. The' l( n! }8 P/ T% @) D8 i
testicular volume was prepubertal at 2 mL each., _  g6 M/ _: g4 R- a/ @9 ^: P( c7 H
The skin was moist and smooth and somewhat
2 T/ Q/ A& K  G0 toily. No axillary hair was noted. There were no: w+ ?0 S1 N( R8 [
abnormal skin pigmentations or café-au-lait spots.
0 r( s6 g2 g5 RNeurologic evaluation showed deep tendon reflex 2+
- I- j2 l- ^+ L- u# X$ Y: D3 \% @bilateral and symmetrical. There was no suggestion
9 l( q! Y0 ]/ r' ^of papilledema.& q* a; q- \$ s" q, c% S
Laboratory Evaluation
! I+ t- e+ ~3 r; \The bone age was consistent with 28 months by& r7 H& v* ?9 ]/ ^
using the standard of Greulich and Pyle at a chrono-! w1 W, d% N) E  @( T1 d  ^3 K' [
logic age of 16 months (advanced).5 Chromosomal* p. c& Q! j7 I2 o8 l# x
karyotype was 46XY. The thyroid function test
1 O# W( d* {5 w+ T/ h# w1 dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 ^' e# l$ q, s; Q; I& h7 B: f
lating hormone level was 1.3 µIU/mL (both normal).
0 R" t; \% W3 E" s. aThe concentrations of serum electrolytes, blood2 s) X; N8 z2 ]7 X+ t
urea nitrogen, creatinine, and calcium all were
( X3 b) u0 k7 \, G( V& mwithin normal range for his age. The concentration
8 b% g# D" N. t& u3 |+ N; P7 ]of serum 17-hydroxyprogesterone was 16 ng/dL; w- [+ M8 k: }
(normal, 3 to 90 ng/dL), androstenedione was 20
  u) h: V4 _! j& _( @+ f6 D" g" Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 D! e% S+ v4 F1 V& w! t% Y- Qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
! g$ Q+ ^2 e& \  Xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
  l2 S7 d! @5 U1 {% I# d% M49ng/dL), 11-desoxycortisol (specific compound S): K0 T- Z( O' l& ]2 ^# o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ g0 n% G. x* y' [; a5 C" qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* ]; B+ e& t. L& d6 c( X/ dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ f# X4 c3 H- g9 c. {% `4 F% n$ O
and β-human chorionic gonadotropin was less than2 G$ t. G) C* P) e/ |9 |
5 mIU/mL (normal <5 mIU/mL). Serum follicular/ [3 `1 F- @- [3 ]2 a# Z
stimulating hormone and leuteinizing hormone
- n- U% n  l0 i; N4 N0 x& Yconcentrations were less than 0.05 mIU/mL
; y+ i9 r; D3 }5 Q: E(prepubertal)./ g+ N9 X0 R& \* ^7 f6 }$ R
The parents were notified about the laboratory1 U. K. p7 Y8 s) L3 J( f
results and were informed that all of the tests were
0 \0 d5 P. x* d0 Z: [7 B7 ~normal except the testosterone level was high. The
2 Z/ u' a  a% U8 k# {' Ffollow-up visit was arranged within a few weeks to: d- Q+ Z: j6 R! O
obtain testicular and abdominal sonograms; how-5 Z5 r3 ~: _# ]
ever, the family did not return for 4 months.
. b  @8 d' u$ g$ k" U0 B- WPhysical examination at this time revealed that the; M% e! A- M, F; J8 }2 i
child had grown 2.5 cm in 4 months and had gained& k; {$ p4 w* @" ?' k4 n+ E
2 kg of weight. Physical examination remained
3 Z" Q1 \; Q1 T  e' F6 cunchanged. Surprisingly, the pubic hair almost com-: M$ u. o2 |  y9 P( L
pletely disappeared except for a few vellous hairs at
) _1 Y9 x# E3 L" x8 a9 lthe base of the phallus. Testicular volume was still 2
0 b! M  p8 B4 ^mL, and the size of the penis remained unchanged.1 {! F/ p9 O% `$ o( s4 @' Q0 R
The mother also said that the boy was no longer hav-
- R& \  j6 W% T6 B3 ?! Aing frequent erections.
9 b) h# Z: l6 L* R8 h' c  sBoth parents were again questioned about use of) K4 d0 z9 \3 N/ [( w, W
any ointment/creams that they may have applied to
' N& E4 f4 G* b/ V& B% Wthe child’s skin. This time the father admitted the- W9 D1 x0 ]$ U: E0 ~* x
Topical Testosterone Exposure / Bhowmick et al 541( b+ s! R& M  s7 w
use of testosterone gel twice daily that he was apply-
+ a$ `# D; l8 C; xing over his own shoulders, chest, and back area for: i2 q8 d0 P2 X3 F* u3 _
a year. The father also revealed he was embarrassed! @$ }" |( P0 X; c8 y8 C, y
to disclose that he was using a testosterone gel pre-& t7 `2 z% E9 _4 c8 U/ I- T
scribed by his family physician for decreased libido
) b( Q) o( Q  j$ b0 |3 W- wsecondary to depression.
- T. ]) n: a) u$ H- x" w& ]The child slept in the same bed with parents.
% A: M! F, d8 P! ]. k9 XThe father would hug the baby and hold him on his
- c* ?" g7 |! L& M4 achest for a considerable period of time, causing sig-' A- Y5 {9 }1 y" p7 {
nificant bare skin contact between baby and father.- Z7 i+ T: G9 v3 h+ ^" W
The father also admitted that after the phone call,+ s* t' B* C* x( D  D& q+ \
when he learned the testosterone level in the baby
0 V3 ^  Q! H! _# K) _was high, he then read the product information- H' F: L/ [1 m' p4 g% i
packet and concluded that it was most likely the rea-0 w3 p: {& B3 K1 b; M
son for the child’s virilization. At that time, they
! E0 T- T' J: ndecided to put the baby in a separate bed, and the
& e, f& l& S$ Lfather was not hugging him with bare skin and had* ^% l  b- X. a4 M* p% F2 l
been using protective clothing. A repeat testosterone
/ y* H: o, p1 S5 D( ftest was ordered, but the family did not go to the
9 P$ Z# \# w9 C0 ~' ^: c2 ]7 elaboratory to obtain the test.
$ j/ o: d7 X3 i' T8 ~4 ]Discussion
8 U! c* ?2 [  M* x2 y3 T4 _Precocious puberty in boys is defined as secondary, [( g$ l* ?$ ?9 O6 G4 ^5 f5 d% Q6 [
sexual development before 9 years of age.1,4: s$ k; [  [& K$ x
Precocious puberty is termed as central (true) when4 r! u8 S& _0 G0 i* V' @/ c
it is caused by the premature activation of hypo-
9 H" @7 j  G5 z/ i4 K1 h8 ~1 Nthalamic pituitary gonadal axis. CPP is more com-& ~: w1 Z; s% d* F
mon in girls than in boys.1,3 Most boys with CPP% Y' O8 N! F" p3 a
may have a central nervous system lesion that is
; R. c; m) o( u3 `9 V! Uresponsible for the early activation of the hypothal-
' @# q8 U$ J- h) P6 t+ ^% G+ ]amic pituitary gonadal axis.1-3 Thus, greater empha-+ t  A& }+ c, w1 f$ `, \
sis has been given to neuroradiologic imaging in1 ^  {8 u  y4 g
boys with precocious puberty. In addition to viril-
1 E4 w2 B3 b3 _: |* F& Qization, the clinical hallmark of CPP is the symmet-* E1 Y4 R: c3 d: E  n
rical testicular growth secondary to stimulation by( E9 v6 E( G9 T8 O1 L
gonadotropins.1,30 C: t7 n' K4 C" q
Gonadotropin-independent peripheral preco-( O4 y; O" l* S3 Z% V6 }% E
cious puberty in boys also results from inappropriate  @  `+ y- p' t- K) s$ k
androgenic stimulation from either endogenous or% s- M6 m; H! l  V
exogenous sources, nonpituitary gonadotropin stim-
5 I0 V$ l0 d+ N& n) o( |3 Rulation, and rare activating mutations.3 Virilizing: M: z! D9 r! m1 |5 `3 \
congenital adrenal hyperplasia producing excessive
  _# Y% R# S) X( ]! s. x6 x" vadrenal androgens is a common cause of precocious" [% ^, C! _2 |% x7 P: @
puberty in boys.3,4
# K6 b) V. L, M4 EThe most common form of congenital adrenal) X+ U& v9 `+ t% c
hyperplasia is the 21-hydroxylase enzyme deficiency.
% W$ |! V% l3 t2 N. ]/ k9 N0 HThe 11-β hydroxylase deficiency may also result in
& n5 N6 z" Q$ K6 p, W) I; ]( oexcessive adrenal androgen production, and rarely,& ^; u# F# ]: l. q
an adrenal tumor may also cause adrenal androgen4 O! h/ f7 L! }8 E% c" c* W6 f( ^# F# b0 M
excess.1,3
% _! }$ @8 c$ X* qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ P5 [! b( s* v/ S542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 w  t% K8 b1 t( d# I; K+ g/ A/ j
A unique entity of male-limited gonadotropin-5 ]0 I. L. d5 P; H) i: v
independent precocious puberty, which is also known
1 ^# K5 p* H: J5 R) u) F' has testotoxicosis, may cause precocious puberty at a7 |( ]! [' T' H8 e$ _
very young age. The physical findings in these boys$ u7 W' t) C$ T& q# a8 |  V
with this disorder are full pubertal development,
4 R% h' y, @: y0 X& Rincluding bilateral testicular growth, similar to boys
, e# ^1 q* u8 ^+ V( z, p1 ~3 ^with CPP. The gonadotropin levels in this disorder$ W8 y/ }* h: {$ O1 I  c& P( H
are suppressed to prepubertal levels and do not show
/ I0 @5 y4 L) Jpubertal response of gonadotropin after gonadotropin-) @; {. Y% o9 [& M$ A2 W  ^
releasing hormone stimulation. This is a sex-linked1 D. l3 x4 l- [
autosomal dominant disorder that affects only
; Z( m0 ~) L3 b# L: R" p2 imales; therefore, other male members of the family
& L4 D% [0 [) w+ M) Xmay have similar precocious puberty.35 i0 G7 C  O0 t% ]- e/ S5 p/ p
In our patient, physical examination was incon-
. h) s$ s6 A/ e2 usistent with true precocious puberty since his testi-
3 J3 S, Y1 T9 q' F9 \cles were prepubertal in size. However, testotoxicosis
1 F( S7 ~5 S4 L- H( g' rwas in the differential diagnosis because his father
7 i2 O5 a9 I, {. m# O( C1 S* Tstarted puberty somewhat early, and occasionally,% S4 F1 g3 v' Y4 |8 K
testicular enlargement is not that evident in the
/ l* f4 t: c& D2 xbeginning of this process.1 In the absence of a neg-3 k$ t7 X" V% V
ative initial history of androgen exposure, our, Z7 @4 Q: s! D5 ]& O+ E; S) H- F
biggest concern was virilizing adrenal hyperplasia,1 b: ^: Z! ^: q% Z* i
either 21-hydroxylase deficiency or 11-β hydroxylase
3 [4 ~/ U. ~4 Rdeficiency. Those diagnoses were excluded by find-( O9 U% Y' v8 ~; V6 V7 z
ing the normal level of adrenal steroids.
* [9 |$ y0 K/ \" f9 A6 S; a' W0 [0 q' tThe diagnosis of exogenous androgens was strongly1 M4 |+ N1 ]2 O# ~1 K
suspected in a follow-up visit after 4 months because
/ U6 O8 O0 W0 o- z3 J7 lthe physical examination revealed the complete disap-) O" ]9 G9 c& p$ ~1 u6 Y7 C* J
pearance of pubic hair, normal growth velocity, and
2 P1 y' l5 G$ R; C  H8 B( O5 ldecreased erections. The father admitted using a testos-
8 l  K- C2 ^# ~! m7 o9 @7 D1 ^terone gel, which he concealed at first visit. He was
1 E8 M" }$ B7 qusing it rather frequently, twice a day. The Physicians’
& W3 S9 |: s8 X0 a$ s/ qDesk Reference, or package insert of this product, gel or
2 l( E6 ^+ m- |% N5 K5 Ncream, cautions about dermal testosterone transfer to
- E. [  ~; e; s+ W5 V; t2 Z! U8 xunprotected females through direct skin exposure.
; @5 a3 a; r- I; V" z" @Serum testosterone level was found to be 2 times the8 K5 c1 _/ C3 g3 [/ j8 y* U
baseline value in those females who were exposed to
# o. Y8 u; ^. L# W5 A1 ]7 t7 Feven 15 minutes of direct skin contact with their male
$ f2 ]9 o& U+ ~, X4 o; I/ m( j: Npartners.6 However, when a shirt covered the applica-4 D% v8 ~5 U: R* a7 _' E& f2 S
tion site, this testosterone transfer was prevented.2 Z5 k: y) J' [" d9 y1 a( V1 X
Our patient’s testosterone level was 60 ng/mL,
* E, y+ Y+ j' p4 d% L: lwhich was clearly high. Some studies suggest that
9 p5 \! q2 K) z8 X1 ]5 _* s( ]dermal conversion of testosterone to dihydrotestos-
5 t- a# g2 D1 p# t! Yterone, which is a more potent metabolite, is more/ E% C6 l! }! [, \$ a+ u$ c
active in young children exposed to testosterone) W. b- A3 l+ u- c" A
exogenously7; however, we did not measure a dihy-
9 S3 f  R+ q9 W; `$ L3 gdrotestosterone level in our patient. In addition to
, U) I  f9 O: V: bvirilization, exposure to exogenous testosterone in
! v9 I6 W- U3 ^0 nchildren results in an increase in growth velocity and
( X) ~1 q1 O5 ^5 S5 iadvanced bone age, as seen in our patient.
( u& [0 f# K9 P6 VThe long-term effect of androgen exposure during2 @: `* ^- D# \
early childhood on pubertal development and final
6 g2 b% I1 V3 z: s$ ~5 Nadult height are not fully known and always remain' k- [/ d* b3 q1 X
a concern. Children treated with short-term testos-
& z, A; w. T7 T' g5 t+ n8 T" ~terone injection or topical androgen may exhibit some- z4 P/ u2 @% H0 y" O$ c2 f% ^
acceleration of the skeletal maturation; however, after2 Q: ?1 a" D; i0 d
cessation of treatment, the rate of bone maturation
" R  S% V* }! W' W6 P9 Pdecelerates and gradually returns to normal.8,94 B' n0 U% J  ~
There are conflicting reports and controversy
# k( e" l# v: sover the effect of early androgen exposure on adult( u8 x6 R4 M2 R) U
penile length.10,11 Some reports suggest subnormal% e, y, ]' j! z- i  l9 H/ m
adult penile length, apparently because of downreg-
/ Y4 E6 Z# Y5 o' \0 z1 B4 T  uulation of androgen receptor number.10,12 However,
9 b& z- N' z/ W5 dSutherland et al13 did not find a correlation between) {4 B# v$ Z' @2 I+ c3 S7 }& O
childhood testosterone exposure and reduced adult1 Q2 r! X& Z- W5 s4 l/ z
penile length in clinical studies.: @( D2 r- U9 z  l$ L5 e
Nonetheless, we do not believe our patient is- |; y! n" n* \: M0 E
going to experience any of the untoward effects from
  z6 I% k! A. b. h1 m/ X7 l. N8 Ptestosterone exposure as mentioned earlier because9 T  {) e6 a* ^, l4 ^
the exposure was not for a prolonged period of time.! i$ l; N- ^/ u3 ~& Y( w/ R- z
Although the bone age was advanced at the time of
( @6 ^. T/ Z! }" Fdiagnosis, the child had a normal growth velocity at* x3 L) C( E8 Y8 ^& S" Q/ J; y
the follow-up visit. It is hoped that his final adult
2 Q0 J; N8 o) D* P, Y! xheight will not be affected.
" ^! B3 ?( [9 y! \+ g0 dAlthough rarely reported, the widespread avail-- `0 M$ B! C6 E1 i
ability of androgen products in our society may4 l6 Y. o# J- ?9 `7 u
indeed cause more virilization in male or female, G+ c$ A" S& L( X  |
children than one would realize. Exposure to andro-0 Y  O* W* |) j
gen products must be considered and specific ques-
- ?& q9 G: k1 p8 F) ~6 Wtioning about the use of a testosterone product or0 X) Z' b. t. q8 J/ g1 T
gel should be asked of the family members during. F6 G" e9 F4 `( O2 A# Q/ }& F
the evaluation of any children who present with vir-
& K  D7 O2 v' S+ l6 Q4 ?ilization or peripheral precocious puberty. The diag-, I- i! L, J2 X2 f; y
nosis can be established by just a few tests and by
. K7 Z& P" K2 w0 U0 vappropriate history. The inability to obtain such a# Y& l- W5 c0 n6 b; ~; k" f! z
history, or failure to ask the specific questions, may
( U& G2 N0 Z% o. i4 uresult in extensive, unnecessary, and expensive8 H/ a, r) B# I
investigation. The primary care physician should be1 M2 O( {8 f" p9 ]
aware of this fact, because most of these children+ ?, u. p( b/ I  M! e2 }; U
may initially present in their practice. The Physicians’$ i0 c, z) z0 o2 T" r$ b9 t' F
Desk Reference and package insert should also put a
9 L& H, U3 u( T  ~$ y* a. N- ywarning about the virilizing effect on a male or# y/ T; \/ D* D% j+ p
female child who might come in contact with some-# B* m6 X  U4 e: ~
one using any of these products.
, C0 B$ K; T/ V' x8 ?- vReferences
' _$ Q; x* b  L1. Styne DM. The testes: disorder of sexual differentiation3 r6 U& |) {, V; S
and puberty in the male. In: Sperling MA, ed. Pediatric
9 B9 R7 Z9 `5 w5 dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& Z: L( W0 g5 [( ~
2002: 565-628.1 n; g* l* [2 [0 Y( a4 k" ~" T
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 y& ~" ^9 ^2 E. `+ v; C
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old9 a7 _" C0 y' L4 U# Y* E$ p* r
Boy Induced by Indirect Topical6 f* e/ u: a' E% R5 @( z1 W
Exposure to Testosterone, `' N0 X: Y; T" p* T0 ?8 G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ E2 C$ h9 G  E) W3 L' X1 c1 Tand Kenneth R. Rettig, MD1
7 F: ~5 Q& @5 [/ X% ~' D3 d* qClinical Pediatrics' U' B/ A* G% @" L; i
Volume 46 Number 60 k, T" b5 h8 K0 f
July 2007 540-543/ [% V0 d7 i+ u8 E
© 2007 Sage Publications
& E5 t' h: o" M% X5 Q4 Q' F10.1177/0009922806296651* E# P  Y/ }- ?
http://clp.sagepub.com7 z# D* }' I4 t# _6 _
hosted at
( ^$ j, m" {6 E3 E9 {2 ~  fhttp://online.sagepub.com" T" f) p$ f! M8 p6 F- X/ l. Z
Precocious puberty in boys, central or peripheral,
2 @5 u% u1 t/ f6 b+ w% [is a significant concern for physicians. Central
3 A9 }$ h3 f+ xprecocious puberty (CPP), which is mediated" \6 i. d- e, ]1 E
through the hypothalamic pituitary gonadal axis, has
. t' r; t2 T! e+ [a higher incidence of organic central nervous system
. L) p: T* K  q) Xlesions in boys.1,2 Virilization in boys, as manifested
) s$ ?; v( o1 Pby enlargement of the penis, development of pubic: ?% o- u( f+ X; j" J# R
hair, and facial acne without enlargement of testi-
$ i" t' i5 Q9 |  z0 Qcles, suggests peripheral or pseudopuberty.1-3 We+ {: [* [! ~" t
report a 16-month-old boy who presented with the
! F8 ]9 Z; T) P$ @% P1 ]# renlargement of the phallus and pubic hair develop-
2 x; C2 e, {! l" C1 W; o1 @ment without testicular enlargement, which was due
2 h4 J+ T5 u, a  uto the unintentional exposure to androgen gel used by
5 E2 p+ ~% w6 `, J5 [' vthe father. The family initially concealed this infor-
1 q1 o) B3 }& x8 j1 e; omation, resulting in an extensive work-up for this# |9 j! i2 J) C3 Y0 L4 x' B/ |
child. Given the widespread and easy availability of
# ~; [, w" N4 Y4 x9 Ltestosterone gel and cream, we believe this is proba-" i2 ~2 j3 d! s# C# t1 ]  T
bly more common than the rare case report in the
5 Z3 q8 G& n2 n" _literature.4
7 U% t; V5 P; w) E" dPatient Report
( V' P4 [! ^- bA 16-month-old white child was referred to the, q% A  A" I/ e" y  Z
endocrine clinic by his pediatrician with the concern
9 c! k$ g) ^( [* rof early sexual development. His mother noticed! Z: G$ A. u2 Q- B2 a5 C
light colored pubic hair development when he was
. @8 Q$ g7 {: j  @8 ^" j- V& |+ N2 [From the 1Division of Pediatric Endocrinology, 2University of3 @: z1 Y2 w% z: k$ X& G1 B6 m
South Alabama Medical Center, Mobile, Alabama.
' j! [6 y/ K5 G  ~! nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' F% T% M$ s0 k, F% k2 m) iProfessor of Pediatrics, University of South Alabama, College of) c; z8 M& Y( L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;  Y0 {  S, R/ y& R$ S
e-mail: [email protected].
2 O- c8 y3 m$ S4 tabout 6 to 7 months old, which progressively became
! j2 x+ J8 S$ {0 kdarker. She was also concerned about the enlarge-0 \& q) M; ]( G& t
ment of his penis and frequent erections. The child6 q( L1 k& n; `+ d% c! G7 a% d; i& p6 @
was the product of a full-term normal delivery, with
' `2 W+ l' j  Y0 [a birth weight of 7 lb 14 oz, and birth length of" `; }8 l4 k# K) o& M! O
20 inches. He was breast-fed throughout the first year6 Y$ G. \* b2 g0 P$ {1 B8 @
of life and was still receiving breast milk along with
: G& a% z+ I" I0 dsolid food. He had no hospitalizations or surgery,$ F; ?  \6 u/ _" _" i# g6 X
and his psychosocial and psychomotor development1 L' I4 {6 v% f
was age appropriate.
0 v$ O1 }+ B5 m) h* O+ `& R) DThe family history was remarkable for the father,
/ J. ?# [: c/ h% \+ Dwho was diagnosed with hypothyroidism at age 16,
) |5 W) O1 O& Pwhich was treated with thyroxine. The father’s
: t4 O4 e( {/ [/ ~! U, Wheight was 6 feet, and he went through a somewhat; K9 }1 G, S5 Q3 }
early puberty and had stopped growing by age 14.
# m$ x9 l/ s, _9 r% V" s# d1 ZThe father denied taking any other medication. The8 t% B5 v( F' c/ F2 I2 N( p- V9 n: Z& l4 D
child’s mother was in good health. Her menarche
3 u# \/ [, B3 |7 r( L9 vwas at 11 years of age, and her height was at 5 feet9 |% [; |4 P5 k  a* B6 T$ @
5 inches. There was no other family history of pre-
  m0 W! s5 B+ ^2 scocious sexual development in the first-degree rela-
" v" Y, O/ h  ^4 O1 \tives. There were no siblings.5 u/ f9 B) h6 d: n' v; k( {2 r
Physical Examination, d; U5 I% K4 G& p  v
The physical examination revealed a very active,
  z5 O7 e, @, _+ A9 H% p  _' l$ qplayful, and healthy boy. The vital signs documented
6 J0 b1 ^9 R) Y! y% S0 M% v3 }a blood pressure of 85/50 mm Hg, his length was
$ n6 M) n" S* q( x/ \+ F$ \90 cm (>97th percentile), and his weight was 14.4 kg
$ U- m9 K; Z! w1 c9 m7 v! ?(also >97th percentile). The observed yearly growth/ Y- D8 V, ?0 k$ I! B& n
velocity was 30 cm (12 inches). The examination of3 {) Z/ S+ c- H
the neck revealed no thyroid enlargement.+ [5 r0 F. p* N9 O  H& ]& R
The genitourinary examination was remarkable for
2 A2 t$ o! E9 M, h/ z( Eenlargement of the penis, with a stretched length of  l8 ?5 F8 f& {
8 cm and a width of 2 cm. The glans penis was very well
6 L$ k3 a- t/ Edeveloped. The pubic hair was Tanner II, mostly around$ G3 @* o- \8 |1 W: @" O( ^' j
540: z& l5 r/ f+ q8 U/ B' T: k: \+ H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; O) C2 |, ]" M) O. _2 r- }
the base of the phallus and was dark and curled. The; _: d% D0 j" D
testicular volume was prepubertal at 2 mL each.
- y  ]5 h% v9 oThe skin was moist and smooth and somewhat
: A+ W3 c7 |' ]& G) V4 v. p# moily. No axillary hair was noted. There were no
  ^$ s) F2 |6 Y+ S& u. P, W+ e  \. Rabnormal skin pigmentations or café-au-lait spots.
- l1 ]1 ?/ w5 A) ]# V6 B* Y# ANeurologic evaluation showed deep tendon reflex 2+, s& d) v, J5 x; E. o6 V  t& F; g
bilateral and symmetrical. There was no suggestion( s1 w8 p9 m0 P5 S
of papilledema.
% ]* }; ^6 j# a7 a5 a: uLaboratory Evaluation) t0 u: G7 _# w' E% |, n
The bone age was consistent with 28 months by
( r8 D: O, ?5 cusing the standard of Greulich and Pyle at a chrono-
7 g1 C0 t) v" D* A6 i* ^logic age of 16 months (advanced).5 Chromosomal: v  {' o6 m7 @/ k% U6 U
karyotype was 46XY. The thyroid function test
" d) n9 p% b& i& f. l7 z- ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. |: c- Z- c/ n( G& hlating hormone level was 1.3 µIU/mL (both normal).5 C* E- Z. }$ a# F6 Q6 j
The concentrations of serum electrolytes, blood
/ O& V/ T2 a0 G, E7 curea nitrogen, creatinine, and calcium all were
/ j- R! @: L# {  p0 X0 ?within normal range for his age. The concentration7 ]; `5 K. W8 B# ]( f" L: h1 O
of serum 17-hydroxyprogesterone was 16 ng/dL
8 [1 R) M, B0 j+ u9 n  C8 K5 g(normal, 3 to 90 ng/dL), androstenedione was 20
! ]+ e- z/ ]# f) t, q4 Jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; ]; r) G1 @9 Y2 `* h8 o) x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, b8 o3 ^, {9 A1 C% ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 N' @2 |2 s; q6 N; o
49ng/dL), 11-desoxycortisol (specific compound S)( Z6 |" J3 o. t4 {  e; _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 W5 _' N7 a3 Q' i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% u4 I) @: L% Y3 r# n' u
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),. F; c  [. i) d5 s3 V: ^2 O
and β-human chorionic gonadotropin was less than% C' u4 |) m8 d* w4 f  P9 ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ _6 g7 x' N9 b* |stimulating hormone and leuteinizing hormone
  _: v* ^( H0 Y) j0 kconcentrations were less than 0.05 mIU/mL
- ?) @* ?  ^# d/ \1 m(prepubertal).0 C% V9 X! F' i
The parents were notified about the laboratory
' ]$ A8 J# `! _7 H: ^: q* aresults and were informed that all of the tests were4 V+ t4 I1 I4 m, l" c/ v2 A
normal except the testosterone level was high. The
( o- M1 N! G# Xfollow-up visit was arranged within a few weeks to
3 L% T: c5 e5 t0 s, ]" j( _3 Qobtain testicular and abdominal sonograms; how-( t* r/ l% M3 Y/ z
ever, the family did not return for 4 months.  K9 r6 n* D) l) E
Physical examination at this time revealed that the
# V7 I4 E- T2 F" u( uchild had grown 2.5 cm in 4 months and had gained! P, r6 p1 A5 l3 ]' U8 U8 w
2 kg of weight. Physical examination remained
+ K4 l. K/ \# m% Z) @unchanged. Surprisingly, the pubic hair almost com-
' n  [% t2 J( Z: ypletely disappeared except for a few vellous hairs at
7 _1 T4 S6 c. J( v/ [the base of the phallus. Testicular volume was still 2
0 M; t- e. O* b6 t1 u8 bmL, and the size of the penis remained unchanged.
1 k- [5 T  x  b2 e4 ]. RThe mother also said that the boy was no longer hav-
  r- O: T) H/ R+ l4 g' H1 z; _ing frequent erections.+ F+ N" X) K) p
Both parents were again questioned about use of
$ i% z! j# J' f4 _3 I/ e$ sany ointment/creams that they may have applied to
5 ~- `0 o6 |9 I3 d- }/ _! X, athe child’s skin. This time the father admitted the
/ a3 B" K1 X9 c8 J& l+ UTopical Testosterone Exposure / Bhowmick et al 541
) V( W9 ?0 C  N6 ~3 ?use of testosterone gel twice daily that he was apply-' C! D' D0 x: S3 Q4 Y6 t5 j+ `
ing over his own shoulders, chest, and back area for' u3 ?" {7 P9 r" F& F' y
a year. The father also revealed he was embarrassed
0 H- ^( o4 ]: M" {0 p- R8 sto disclose that he was using a testosterone gel pre-
  |7 m( {- `) q1 R# {+ T( v* Z0 lscribed by his family physician for decreased libido
2 Z' K- g" X; y- osecondary to depression.
$ P8 ?: d/ _) S0 pThe child slept in the same bed with parents.$ n/ [, j+ o/ Q) P  x
The father would hug the baby and hold him on his4 }4 `! @" V( T
chest for a considerable period of time, causing sig-
+ N* Q& m- ]/ G' A/ mnificant bare skin contact between baby and father.9 R; s5 c, y0 ~2 J/ [' R5 m
The father also admitted that after the phone call,
( p. C+ ?7 u* c) H  V6 Y, swhen he learned the testosterone level in the baby1 o# @0 v+ m# U
was high, he then read the product information4 U2 G6 M4 O4 i
packet and concluded that it was most likely the rea-
' U% c( [% I" U5 B. X7 K* oson for the child’s virilization. At that time, they
: W4 o+ v/ U- w7 R; n3 x7 Idecided to put the baby in a separate bed, and the
  K. E6 A& h& M- i4 @% V/ _/ bfather was not hugging him with bare skin and had5 X8 l5 c/ a" W- x! A" p
been using protective clothing. A repeat testosterone" c" W% k& |6 r. D. v6 ~- k' e
test was ordered, but the family did not go to the  N+ Z; q" X: X9 K9 X
laboratory to obtain the test.
8 |) x8 L4 g+ B. X) F- s  i1 M# EDiscussion9 W  t8 E8 u1 [
Precocious puberty in boys is defined as secondary
! A% U: Z) ]3 f7 P0 b  wsexual development before 9 years of age.1,4% M' l2 ~: q% i3 p/ w( E/ w& c) D, t" I
Precocious puberty is termed as central (true) when4 j" ?- y  ?7 x% V
it is caused by the premature activation of hypo-
2 W2 a1 X. [0 J2 q$ ~: Hthalamic pituitary gonadal axis. CPP is more com-
9 P; Y6 o1 y, B% S8 Jmon in girls than in boys.1,3 Most boys with CPP
) Z! s9 [* _+ x. {+ X( ]2 Cmay have a central nervous system lesion that is6 Q  ?* p2 [: W3 t/ }
responsible for the early activation of the hypothal-6 C0 F+ ?% R4 w* F) m
amic pituitary gonadal axis.1-3 Thus, greater empha-
. G' i" ~: a) ]2 C+ H( h; tsis has been given to neuroradiologic imaging in$ p, [9 `7 x& B( b
boys with precocious puberty. In addition to viril-! h+ z# [$ J5 u- s# J) b
ization, the clinical hallmark of CPP is the symmet-3 H  c! K# P6 I' Y7 x5 v5 y
rical testicular growth secondary to stimulation by
( d6 M0 e' J7 O! Igonadotropins.1,3/ Z7 N& b" z6 \1 a
Gonadotropin-independent peripheral preco-2 K' E3 f% |  }: g( f
cious puberty in boys also results from inappropriate6 q2 ~! E- m0 d% ^5 \  n& n
androgenic stimulation from either endogenous or& t) P- l' D! {; m3 [& l1 ~  L( H
exogenous sources, nonpituitary gonadotropin stim-2 c" }, E# }. B- `2 k5 b1 ?) G( U- k
ulation, and rare activating mutations.3 Virilizing
- {" ?6 ]( H( ~. V: i9 ycongenital adrenal hyperplasia producing excessive! P* ?8 N  A& Q$ }' Y  }  d
adrenal androgens is a common cause of precocious; S7 n! j3 d6 m- S1 ?
puberty in boys.3,4' R5 I0 O% J9 X4 m* J) X$ k! t
The most common form of congenital adrenal
0 g6 S( A4 J/ J/ Z* R& v+ C! g7 fhyperplasia is the 21-hydroxylase enzyme deficiency./ Y! r+ J' r5 G$ g! n$ @/ d
The 11-β hydroxylase deficiency may also result in$ a1 O# ~0 p3 Y& c8 a# T) s
excessive adrenal androgen production, and rarely,
" P; ]! e- p( H+ @- u  N5 [an adrenal tumor may also cause adrenal androgen; s) Y; O  \/ l) [% q9 C3 |3 d! R
excess.1,3$ F4 L' Y2 ]/ u8 q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 W8 I( x% q6 u8 A# [2 i
542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 u4 J! \( Y+ p2 C2 B
A unique entity of male-limited gonadotropin-
2 h+ O7 S" G  _0 H  k/ K6 b7 l5 hindependent precocious puberty, which is also known
3 J0 t; ~/ c* K/ i* z0 jas testotoxicosis, may cause precocious puberty at a' Q  T' b) b4 t) g0 A; v$ J0 Q/ U
very young age. The physical findings in these boys
  ?7 f$ m, j6 V9 g9 Ywith this disorder are full pubertal development,$ T) Q4 S+ U2 g1 a
including bilateral testicular growth, similar to boys
( V3 \0 |+ l0 J: G; \+ `with CPP. The gonadotropin levels in this disorder
5 G* ]8 ~9 u! E) Y/ B2 w0 mare suppressed to prepubertal levels and do not show
# ^9 Q1 `( T0 e4 j* `& }pubertal response of gonadotropin after gonadotropin-
6 k/ X3 w7 X* e. m: v! G" Wreleasing hormone stimulation. This is a sex-linked/ s& x% H! J( E* p" A% P$ I8 z
autosomal dominant disorder that affects only
" R$ z& _% w3 Q" i, y* imales; therefore, other male members of the family
% B: j( F6 i: V- _may have similar precocious puberty.3
% ^/ U, Z; X* p& N1 [. T  RIn our patient, physical examination was incon-  u4 i% d) K& G" h1 `2 d
sistent with true precocious puberty since his testi-  b4 g! n& A, ^
cles were prepubertal in size. However, testotoxicosis" \) i$ j  ^! M+ y% d' f2 U: a6 w) i
was in the differential diagnosis because his father
7 b# p  u! q! Q4 Hstarted puberty somewhat early, and occasionally,
1 u- k+ e! v( p" v- mtesticular enlargement is not that evident in the
- S' T) N  m3 Abeginning of this process.1 In the absence of a neg-- ~+ o- U/ b% R
ative initial history of androgen exposure, our; W& p5 h6 l4 c. a/ _
biggest concern was virilizing adrenal hyperplasia,4 G* F3 H3 W% X( k7 D6 r( W+ \! K0 \9 {
either 21-hydroxylase deficiency or 11-β hydroxylase
+ ^1 }) e. U+ y0 }deficiency. Those diagnoses were excluded by find-6 F0 z9 }) {. N) Q) {0 F
ing the normal level of adrenal steroids./ q8 O- i  Y$ N2 `6 o
The diagnosis of exogenous androgens was strongly# _0 e' m; c: u/ |! \) A2 y
suspected in a follow-up visit after 4 months because
/ d' E3 T2 o6 P8 O# ^the physical examination revealed the complete disap-- a% `& e; @+ q* L5 P" v
pearance of pubic hair, normal growth velocity, and
2 i4 ]9 p# v0 ^: \decreased erections. The father admitted using a testos-8 @/ P+ ^: U* c9 N* G- }0 R  ~" {
terone gel, which he concealed at first visit. He was& S$ j7 v) c2 X. S+ j
using it rather frequently, twice a day. The Physicians’
+ S; E9 ?* @8 O% @/ F: W: Z% c; ODesk Reference, or package insert of this product, gel or+ K. J6 L! a% O$ R! v, J
cream, cautions about dermal testosterone transfer to7 B  L" j3 U- q% h$ W  g
unprotected females through direct skin exposure.
# P, G  f* K+ z0 ~2 k2 t3 g! T& C2 oSerum testosterone level was found to be 2 times the3 _' Y) m8 r: M0 Z/ z# b
baseline value in those females who were exposed to' o' T5 @7 Q6 ~! k. O1 c# t! \: L
even 15 minutes of direct skin contact with their male
4 F8 y7 M+ e0 l( X/ L  W( _- zpartners.6 However, when a shirt covered the applica-
  M  ]/ O) y% E2 m( g; stion site, this testosterone transfer was prevented.
3 i" j7 r1 @( i9 ?  rOur patient’s testosterone level was 60 ng/mL,
+ A+ A6 o6 f3 I' `which was clearly high. Some studies suggest that
" U& f! K& t; m' Tdermal conversion of testosterone to dihydrotestos-
8 p) k& P  _8 e0 }& h# Zterone, which is a more potent metabolite, is more
9 u1 T7 N( ~8 K3 Tactive in young children exposed to testosterone
, r$ K7 r; E, z- o. hexogenously7; however, we did not measure a dihy-5 ?( C3 _( L2 C3 G- Z
drotestosterone level in our patient. In addition to
: K  x  _& x2 m0 P: {( @( ^4 ivirilization, exposure to exogenous testosterone in
2 Z. Z- i7 D/ ?children results in an increase in growth velocity and
6 {( k, e/ u! A+ A% U4 b/ k7 }advanced bone age, as seen in our patient.
, L9 |& r$ V1 L. W; _The long-term effect of androgen exposure during
) R2 M( D) F( n2 A4 T# a: `! z6 Oearly childhood on pubertal development and final
. S4 |5 b  W7 A9 q/ Qadult height are not fully known and always remain- F8 E3 V$ C; E; [; j$ t! a2 N  b7 H
a concern. Children treated with short-term testos-
8 \' y2 S& m" Z' c  Mterone injection or topical androgen may exhibit some' c& l! M8 v/ N7 A6 L
acceleration of the skeletal maturation; however, after3 D2 _, D2 e' l. z0 y
cessation of treatment, the rate of bone maturation
5 ]- x- K" d& v7 C0 H% `9 }: ~7 z) Rdecelerates and gradually returns to normal.8,9+ \3 ~- m8 w/ U; r* b
There are conflicting reports and controversy( I7 B- ^4 \9 l/ p8 ^0 z! o
over the effect of early androgen exposure on adult# D# ]' |  o$ r
penile length.10,11 Some reports suggest subnormal
' o  G! Q9 W; v/ d1 gadult penile length, apparently because of downreg-
  P0 g, [5 e1 Dulation of androgen receptor number.10,12 However,
* _9 O' M0 X8 j2 ?: \Sutherland et al13 did not find a correlation between
2 _/ i  k4 @+ ^. O8 q* P, _" @childhood testosterone exposure and reduced adult
6 e+ z; T. K; L$ Dpenile length in clinical studies.: `0 p' N" _2 K2 {0 U( H( U4 P0 |* D
Nonetheless, we do not believe our patient is
* f4 u; a# W) F9 Ygoing to experience any of the untoward effects from
1 w+ A! p' v; B7 I7 gtestosterone exposure as mentioned earlier because
! W& t8 b6 @6 g! n" k8 O" v) Rthe exposure was not for a prolonged period of time.; t) T% `+ Z, j$ O! K" ]+ o
Although the bone age was advanced at the time of0 [' T& ~" ~+ I- Z
diagnosis, the child had a normal growth velocity at+ X% |; t' O/ Z  R+ x  J
the follow-up visit. It is hoped that his final adult
6 [) P! C5 i3 l3 c' d& W1 I7 L5 c( uheight will not be affected.+ W' j5 W1 K$ M7 [
Although rarely reported, the widespread avail-5 ?6 _/ @, ^9 F2 t$ c5 e& F+ k
ability of androgen products in our society may  a' Z; z4 B, _+ @) I
indeed cause more virilization in male or female. K3 u( r3 O  }
children than one would realize. Exposure to andro-7 R  w6 B. A( c# x- N# {2 V- p% {
gen products must be considered and specific ques-
* G7 q1 f3 h2 y4 u" O) i! |) Ationing about the use of a testosterone product or. H; J/ V" z6 ~3 V
gel should be asked of the family members during
3 q- D. T$ b; dthe evaluation of any children who present with vir-+ j2 |. j, ~% i* c* @
ilization or peripheral precocious puberty. The diag-
, \3 l; ~- y' D9 d, r  O& ]nosis can be established by just a few tests and by
/ q# E8 C& R! L9 R' j$ vappropriate history. The inability to obtain such a: n& g0 e4 i4 J" R3 Y% W- P- Z
history, or failure to ask the specific questions, may( i* @4 I" W* l1 I5 o
result in extensive, unnecessary, and expensive
& k1 P5 i. X9 d6 v- |investigation. The primary care physician should be
7 _  w+ C9 q4 `8 L  ~3 Haware of this fact, because most of these children
* }! k4 H3 j; H' cmay initially present in their practice. The Physicians’) @0 C' d2 j  k- n
Desk Reference and package insert should also put a$ h( Q* r5 W' E3 D$ A" y
warning about the virilizing effect on a male or
6 d( f, ?) H1 W4 nfemale child who might come in contact with some-/ a: q( T$ X5 X  Y# v$ D
one using any of these products.
! z7 a! J( W( G3 k5 ]References! M! M' _9 `9 O2 v' Y: T
1. Styne DM. The testes: disorder of sexual differentiation/ M5 G6 l1 {! l! A& c5 O; u$ ]
and puberty in the male. In: Sperling MA, ed. Pediatric
: Y" y/ p- Z8 Q" SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 }, R9 U- t9 O& h
2002: 565-628.. B, W% q9 X3 p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 c+ ~( E! @/ K; gpuberty 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
# N# L6 H% S3 u5 c4 z! ?/ ^
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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