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Sexual Precocity in a 16-Month-Old
. v2 |" [0 L* e0 j5 M1 ^% w0 Q$ kBoy Induced by Indirect Topical$ s, Y$ ~0 p# O; P1 [
Exposure to Testosterone
5 S% \% V( M  y" |Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: y* L* H, ^. W1 m& T& C- c$ d+ A( }and Kenneth R. Rettig, MD1
, u% g9 Q4 V( K  h% RClinical Pediatrics# ^( T  [/ U- v, a( K# O9 \
Volume 46 Number 6- {0 o' ?6 r7 f+ G% |# U2 a
July 2007 540-543
8 t3 Z9 K$ o( h4 B1 {3 `, j© 2007 Sage Publications
( a- _3 B& |) q10.1177/0009922806296651
' P& ^4 [1 O& H1 S3 e/ Nhttp://clp.sagepub.com
: x5 l( w; Q, E2 h9 _  Fhosted at( [" J3 z8 b: g  a
http://online.sagepub.com3 C; _8 p9 V. F9 ^$ g
Precocious puberty in boys, central or peripheral,
# h" Y. \0 L9 l7 j+ \" s' t( Wis a significant concern for physicians. Central; P/ y: e# o- H% _; o
precocious puberty (CPP), which is mediated2 `- j- x% q8 K7 {* _/ q
through the hypothalamic pituitary gonadal axis, has' ?! a: P' e) a- x/ C: B2 |/ ]
a higher incidence of organic central nervous system3 r. h( {  Q7 A# p; Y
lesions in boys.1,2 Virilization in boys, as manifested
" A# g& Y& ]2 j4 B) T5 e- Nby enlargement of the penis, development of pubic
9 z4 h. R1 Z3 L6 W0 p9 Z" Whair, and facial acne without enlargement of testi-
) k* o9 X5 n7 i$ |. pcles, suggests peripheral or pseudopuberty.1-3 We& N" W/ u8 j: W3 Z( J
report a 16-month-old boy who presented with the: {7 ], d0 |" M* G1 X  a3 q+ l) ^5 {* H
enlargement of the phallus and pubic hair develop-  c0 V2 [* X! C" C! c
ment without testicular enlargement, which was due- V8 K  \' X0 q
to the unintentional exposure to androgen gel used by
0 R. B7 o  n2 |8 Ithe father. The family initially concealed this infor-) P  m  j# l! F( K1 E0 Z6 F% w
mation, resulting in an extensive work-up for this7 k" {2 }- S% W+ K/ {
child. Given the widespread and easy availability of
. p( b' G( k3 z# }3 Otestosterone gel and cream, we believe this is proba-
8 |+ U# a0 U9 u; n1 z. ^bly more common than the rare case report in the" t) U5 g  D9 Z9 f3 i3 `! o4 M
literature.4
& D% ~# I: l% r0 T/ c: GPatient Report6 z& q2 E, f' o; {
A 16-month-old white child was referred to the6 ?$ e4 T1 _$ a. ^) B) n
endocrine clinic by his pediatrician with the concern: R3 V; V6 T) A( \. N) t7 n2 {3 x) Q
of early sexual development. His mother noticed
  A. \8 f4 z( L* d3 Z1 Hlight colored pubic hair development when he was9 S2 C  h$ I, O( P& `/ R1 L
From the 1Division of Pediatric Endocrinology, 2University of
; @  Y- j1 t* l2 M! b- w- t: H# PSouth Alabama Medical Center, Mobile, Alabama.$ n, X: ^7 m' s9 J1 P) S! M
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 U# G. _, d; g- SProfessor of Pediatrics, University of South Alabama, College of
1 L# E! z" T! G5 a% }+ f+ {Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( U& r6 ]8 ?& t. C
e-mail: [email protected].( ~4 J9 l8 K0 ]+ {1 y4 a
about 6 to 7 months old, which progressively became8 q! X3 z" d- Q; M8 @2 V
darker. She was also concerned about the enlarge-
1 L& J; r  V8 y+ O" O! ]6 c- d" m2 Fment of his penis and frequent erections. The child
7 i4 Z" W2 b2 C5 v: D7 T6 t5 `( Dwas the product of a full-term normal delivery, with( G9 T! n) b# H2 z
a birth weight of 7 lb 14 oz, and birth length of' k+ I% G0 ~" h0 Q" B  N
20 inches. He was breast-fed throughout the first year: }& ]3 U  e4 _% O
of life and was still receiving breast milk along with
6 @& S& j1 [$ n0 K% O1 i* {solid food. He had no hospitalizations or surgery,
, {/ a: G4 ^# I. `5 u% q% V2 rand his psychosocial and psychomotor development
( \- r3 m8 R- uwas age appropriate.0 U3 @6 \4 ^0 _! F1 [
The family history was remarkable for the father,
$ P; A# f- g0 R- `; z8 `0 ~who was diagnosed with hypothyroidism at age 16,
. {/ `$ G- D8 Cwhich was treated with thyroxine. The father’s
) {2 @- M% h* g' eheight was 6 feet, and he went through a somewhat
  O% m& o  i. k  rearly puberty and had stopped growing by age 14., V( a" b, }: ]5 n8 l$ a# r
The father denied taking any other medication. The9 q% \4 g0 V$ ^! ?: s6 \1 g
child’s mother was in good health. Her menarche, k. r8 j: b5 _& k( v) n
was at 11 years of age, and her height was at 5 feet
8 X6 W+ C% Q( S, d: D& M' c5 inches. There was no other family history of pre-" l. e  `8 w0 c' ^
cocious sexual development in the first-degree rela-
  E7 I* e! _9 o5 Z* ztives. There were no siblings.2 q+ R9 R# D5 t" o- Q
Physical Examination
0 g5 Z" z" V4 W; IThe physical examination revealed a very active,6 h; Q2 ^2 m. s5 q1 w- r6 g  B
playful, and healthy boy. The vital signs documented
. H3 }  g: V3 X! j$ g! _7 ja blood pressure of 85/50 mm Hg, his length was2 h  L' {3 N8 V
90 cm (>97th percentile), and his weight was 14.4 kg
. [% k$ H* {! I(also >97th percentile). The observed yearly growth1 v. P' Z; X# g2 [
velocity was 30 cm (12 inches). The examination of
! M. [4 p  G5 t# Othe neck revealed no thyroid enlargement.5 V0 A+ ]+ p7 j! f
The genitourinary examination was remarkable for$ G; g1 `$ y8 ^% ~# g3 n
enlargement of the penis, with a stretched length of
( W& C2 A" u0 j; n+ ?/ u( c8 cm and a width of 2 cm. The glans penis was very well
8 j2 w' l' X0 v& m* _developed. The pubic hair was Tanner II, mostly around
0 U- I6 ~  d; g( `: h540
, }5 N8 P  v3 Z* H& Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 a* D  A  Q- Z$ `8 K. E2 w& D1 }
the base of the phallus and was dark and curled. The1 f) z7 f$ J: h: Q  @: o0 s
testicular volume was prepubertal at 2 mL each.& X( }) @  d5 u& \0 u
The skin was moist and smooth and somewhat7 f7 R: M7 ?" D0 n
oily. No axillary hair was noted. There were no
( M( O. q2 @% Z, Uabnormal skin pigmentations or café-au-lait spots.
0 G7 V5 ]! W) D& f8 D( rNeurologic evaluation showed deep tendon reflex 2+
8 \0 U/ G+ H5 Ybilateral and symmetrical. There was no suggestion. [; S$ {% R( G# O; H0 T
of papilledema.2 p# r! K/ v! X4 m
Laboratory Evaluation
) W. s' _# f( Z+ w9 B- LThe bone age was consistent with 28 months by
, e* @3 C6 v) u! |9 j& uusing the standard of Greulich and Pyle at a chrono-
# ^6 F4 |. w9 @( `logic age of 16 months (advanced).5 Chromosomal
" n- N# x+ }! F4 B* c: v; ^5 Pkaryotype was 46XY. The thyroid function test: x& s1 [% m7 A1 i. A: F
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
  O, A# ?- b1 V% \$ C, Nlating hormone level was 1.3 µIU/mL (both normal).' j; ]! N( a  J. U# T* `" _, d- Y
The concentrations of serum electrolytes, blood
/ s/ L- g- {% H! }. g+ }! z  Z$ Lurea nitrogen, creatinine, and calcium all were1 O  O) \4 @* B8 [) @% e
within normal range for his age. The concentration( z1 w$ P$ o# K! x1 w5 L% }
of serum 17-hydroxyprogesterone was 16 ng/dL
" a( A  g& K7 C- o6 Z% [(normal, 3 to 90 ng/dL), androstenedione was 20
8 A$ w+ @4 e4 v# }" ]ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ \5 Q1 i; J, E" k
terone was 38 ng/dL (normal, 50 to 760 ng/dL),. F+ h, z2 U3 ?2 [+ w  S
desoxycorticosterone was 4.3 ng/dL (normal, 7 to% x7 Q( R6 a: |+ q8 t7 _
49ng/dL), 11-desoxycortisol (specific compound S)) H0 U) }4 j. E3 C; Z0 T$ S- i
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-2 Q& q3 `+ Y: P( L7 g+ D
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: C- {1 j; w$ S: B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) s$ V, Z$ T; L8 R! [$ M
and β-human chorionic gonadotropin was less than# m! T3 b5 X  }1 x6 N% J% E3 F8 E: L
5 mIU/mL (normal <5 mIU/mL). Serum follicular% \! U1 g- `9 n4 d# |* S2 \/ ?7 z6 V& M
stimulating hormone and leuteinizing hormone
* c3 }" W8 x% o3 t6 P" b/ qconcentrations were less than 0.05 mIU/mL$ N- f- k0 B/ d. f/ G8 V% c
(prepubertal).. n6 N: a2 M8 P$ y" Q: Z. _
The parents were notified about the laboratory" `4 z- [; ~/ W, m0 h1 t, w
results and were informed that all of the tests were
' a/ w- g" `' i& Y  S6 X! Rnormal except the testosterone level was high. The4 g# w# x0 `" c0 j+ W
follow-up visit was arranged within a few weeks to
0 c, q/ q1 M  G6 u8 Cobtain testicular and abdominal sonograms; how-
& p+ J( ]3 t, n1 o0 S2 Kever, the family did not return for 4 months.
' s% {6 q, {. {% _8 @- r2 dPhysical examination at this time revealed that the6 b8 m% _9 {& M5 J# U' b
child had grown 2.5 cm in 4 months and had gained5 f  Q3 b4 N% P' J
2 kg of weight. Physical examination remained( C0 o& P5 i/ K" K2 Q( X* I' ~- V
unchanged. Surprisingly, the pubic hair almost com-3 W5 G+ M& j5 _) F; X' d
pletely disappeared except for a few vellous hairs at
# }  q5 G: p0 |$ h  Vthe base of the phallus. Testicular volume was still 2
! ]# Q' P. A; b2 X1 dmL, and the size of the penis remained unchanged.
; b1 U7 b0 H- @% ]) _& t4 aThe mother also said that the boy was no longer hav-
& o8 G: O, _3 P* E8 X% }ing frequent erections.
) z  R: e0 V. v/ p- zBoth parents were again questioned about use of
+ H) p, r5 o' F' r5 s& qany ointment/creams that they may have applied to# }* D2 [" }% ~/ D7 A
the child’s skin. This time the father admitted the$ m7 a: h1 G( S
Topical Testosterone Exposure / Bhowmick et al 541
+ }$ [" p( z6 i  o7 Nuse of testosterone gel twice daily that he was apply-2 R/ ]' n+ d* @" j7 C( i
ing over his own shoulders, chest, and back area for
. f! M3 |7 i1 o5 I1 ba year. The father also revealed he was embarrassed
  _( v/ X5 u9 z) b* i; gto disclose that he was using a testosterone gel pre-
& G0 p& T0 B6 A- ]4 T" A3 ^, Dscribed by his family physician for decreased libido- U# w$ S; Y, y. h# O
secondary to depression.0 Z. `% t1 Y2 F8 r
The child slept in the same bed with parents.
8 `; N. l" ^: e) O" }The father would hug the baby and hold him on his
- I4 s. A4 U8 J; n1 v9 U; C; ]chest for a considerable period of time, causing sig-
6 |1 Y/ X) J8 b# S, u/ [nificant bare skin contact between baby and father.7 C$ n8 |" A( J' P
The father also admitted that after the phone call,
- }  O4 Q- }* D7 n' ^3 u' M& swhen he learned the testosterone level in the baby
. b2 i  U9 h+ Hwas high, he then read the product information
/ ]6 V: m9 z  \! s- k$ ^packet and concluded that it was most likely the rea-4 ^2 q) |6 r$ O6 I0 W: W
son for the child’s virilization. At that time, they5 l3 f* U6 d" x2 h
decided to put the baby in a separate bed, and the" B7 u3 l, E! L9 h7 D' m, I4 W2 Y
father was not hugging him with bare skin and had1 U" p" ]% i* E) X* @
been using protective clothing. A repeat testosterone+ S# q& a( I- o6 w* R. X! m5 @8 T, d
test was ordered, but the family did not go to the
4 W% @8 B) L" g+ Y% v6 v3 r6 Tlaboratory to obtain the test.
- s4 f" Z& m' D9 P& LDiscussion* h0 H& q( l, o5 R
Precocious puberty in boys is defined as secondary/ z) L3 H8 ]  v7 }
sexual development before 9 years of age.1,4
4 L4 b& S0 }8 u5 kPrecocious puberty is termed as central (true) when
- \( N7 F9 u3 [it is caused by the premature activation of hypo-% X4 e$ \! c9 p0 I7 b# M
thalamic pituitary gonadal axis. CPP is more com-
% D1 g6 U3 b/ q1 s, }mon in girls than in boys.1,3 Most boys with CPP- c/ a+ G4 F. h1 x0 q1 }! T/ y
may have a central nervous system lesion that is+ X, E+ ?8 H: U2 l% E
responsible for the early activation of the hypothal-; @! Y( {5 r: j: ]  x( i
amic pituitary gonadal axis.1-3 Thus, greater empha-% H$ _, d7 G& S6 h( t1 |+ b, H
sis has been given to neuroradiologic imaging in6 l- `+ \/ s, u$ Y
boys with precocious puberty. In addition to viril-2 a; i4 c; I( O4 y0 [9 z- H: P
ization, the clinical hallmark of CPP is the symmet-: ?4 O/ y# U! a1 _; G% Y7 q8 x5 [
rical testicular growth secondary to stimulation by
# R: @2 `6 e, p- r- R% agonadotropins.1,3
5 a( i8 u# {( `: SGonadotropin-independent peripheral preco-
7 B  d4 ^( v6 s* Q1 R) lcious puberty in boys also results from inappropriate
8 L3 U4 J5 w, N9 Y# y6 tandrogenic stimulation from either endogenous or2 U* Q" g5 M+ o( Y# m
exogenous sources, nonpituitary gonadotropin stim-
+ I  j1 H0 l. O! ^1 qulation, and rare activating mutations.3 Virilizing8 b' e3 S. t, z1 z3 ?3 w
congenital adrenal hyperplasia producing excessive( G, ?6 `4 N# h
adrenal androgens is a common cause of precocious- c& Q* d) [( Z6 G& Q6 U6 s- M
puberty in boys.3,4
0 K8 B- {- `: |% d, ?, y/ Z$ k8 |The most common form of congenital adrenal
2 j9 I1 F  m# F9 q/ x4 E; ~$ Vhyperplasia is the 21-hydroxylase enzyme deficiency.  j1 j7 Q% ?/ y/ D0 b; i, ^$ O
The 11-β hydroxylase deficiency may also result in& v" Y& D) T" n: I1 Y& K7 e
excessive adrenal androgen production, and rarely,
  f8 Z% v) l7 e( k( |6 zan adrenal tumor may also cause adrenal androgen
2 w" k  a5 y5 \& V3 k' _" d( Cexcess.1,36 x  n. N: L7 {/ R, |5 y" z: S5 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 `& [1 a% v$ Q+ o
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' a2 P! L4 j! d
A unique entity of male-limited gonadotropin-/ s; k7 u1 i6 t! n
independent precocious puberty, which is also known
( S6 X! a. q) s/ j2 T+ M+ G0 ias testotoxicosis, may cause precocious puberty at a  h% J* O3 V+ E+ B6 Z( t6 W- p  h
very young age. The physical findings in these boys! K3 b4 v+ i( b1 D) u
with this disorder are full pubertal development,
9 i# a- e1 q+ W2 dincluding bilateral testicular growth, similar to boys
2 K4 b; `; S9 b$ G0 r5 x9 O# A- b( Kwith CPP. The gonadotropin levels in this disorder0 T% U0 q8 m7 u+ g
are suppressed to prepubertal levels and do not show
) R; K$ \: ~- n- h8 Vpubertal response of gonadotropin after gonadotropin-
2 M& W4 L2 q% kreleasing hormone stimulation. This is a sex-linked
. u7 K3 N' o- u% W' \* Xautosomal dominant disorder that affects only
& ?( ?9 s7 [/ j( L0 G# ^males; therefore, other male members of the family
, N% W. [- |0 Q5 n& B/ [( zmay have similar precocious puberty.3
+ R8 i& [9 |, gIn our patient, physical examination was incon-/ w7 A% w) b( t* A6 |% }* n$ o
sistent with true precocious puberty since his testi-+ y( i$ J+ m) K6 p0 K0 b$ w4 G
cles were prepubertal in size. However, testotoxicosis# w" M1 s  y8 K; @& e
was in the differential diagnosis because his father
) C$ h( t+ G% `1 C" |+ n/ Jstarted puberty somewhat early, and occasionally,- G- k) a5 w6 ?; z
testicular enlargement is not that evident in the7 Y; F  y3 {. l: X
beginning of this process.1 In the absence of a neg-- {* ], S2 B' }/ z* q; ?( q; _
ative initial history of androgen exposure, our
& T7 o4 I. s/ hbiggest concern was virilizing adrenal hyperplasia,, E6 F5 {. l  c9 l
either 21-hydroxylase deficiency or 11-β hydroxylase1 T) a# E5 Y0 x+ q) K, n( G4 r. [; L
deficiency. Those diagnoses were excluded by find-
/ \' W) G; F0 x8 }: X, ying the normal level of adrenal steroids.& c: A4 U) b: V8 i
The diagnosis of exogenous androgens was strongly0 T8 j$ H) J! Q4 T5 X! z, O, s
suspected in a follow-up visit after 4 months because
: [4 t- y: Q0 h/ x$ k3 pthe physical examination revealed the complete disap-
2 V" z* C) j; D4 q+ B! xpearance of pubic hair, normal growth velocity, and4 }( }, N8 v9 V
decreased erections. The father admitted using a testos-+ a& x; f' l2 F% m1 }2 I( L# G
terone gel, which he concealed at first visit. He was3 f5 _1 Y* w& ?  b
using it rather frequently, twice a day. The Physicians’# w1 g6 |- a, C5 b9 z" |
Desk Reference, or package insert of this product, gel or
' L4 g* I8 n6 g+ M( d8 Wcream, cautions about dermal testosterone transfer to5 \* C% a' `% n
unprotected females through direct skin exposure.
& F2 Z" x. X- X5 e' KSerum testosterone level was found to be 2 times the8 K* [4 B8 p7 Z2 b6 f
baseline value in those females who were exposed to. @  W% O4 D( {% V. |( J2 _
even 15 minutes of direct skin contact with their male
0 u* X, M6 r) {: Lpartners.6 However, when a shirt covered the applica-. v3 [3 `& i+ P9 P  |/ @& Z
tion site, this testosterone transfer was prevented.+ K6 B7 C% ]3 ]- J1 O
Our patient’s testosterone level was 60 ng/mL,
  |9 g! w$ U. {which was clearly high. Some studies suggest that! L4 V4 {( c: M9 l# O7 u7 d: u
dermal conversion of testosterone to dihydrotestos-6 r. m# q3 L2 y$ J4 l8 J$ b. S
terone, which is a more potent metabolite, is more
5 @# K. k- `& u- o* l/ `, Hactive in young children exposed to testosterone
+ V( h& M1 j# N4 l+ Lexogenously7; however, we did not measure a dihy-
& I" N$ b, x5 Q. K; x6 Z9 T% ^drotestosterone level in our patient. In addition to
& ^( [$ [* Z- H* D8 Dvirilization, exposure to exogenous testosterone in
% E( M+ h$ Q2 k) o% cchildren results in an increase in growth velocity and3 o8 I! ]- Z. g
advanced bone age, as seen in our patient.1 b& Q/ o$ x; x9 b1 x. ]/ E8 O
The long-term effect of androgen exposure during
: Y+ o9 b1 K* \; w, tearly childhood on pubertal development and final
; Y# A- q% v! h* C6 Zadult height are not fully known and always remain
% C* h2 k' g4 D5 Ea concern. Children treated with short-term testos-
$ }; }  a* s5 j# Jterone injection or topical androgen may exhibit some! |8 t) q* u. A% H; U! T4 I/ c7 l# }
acceleration of the skeletal maturation; however, after
# h# c3 t; f. u3 j# _" x/ Mcessation of treatment, the rate of bone maturation7 v) z, R" a3 D; L# I  y" a
decelerates and gradually returns to normal.8,9; d  j2 c2 W4 x; k/ O
There are conflicting reports and controversy2 K$ L+ X( c" X! n: @/ z/ N9 p
over the effect of early androgen exposure on adult
1 z' O7 V) O- |! x! Ypenile length.10,11 Some reports suggest subnormal
" Q6 I7 h) B2 J5 d5 g" |7 zadult penile length, apparently because of downreg-
5 r* N4 |0 V, P2 M8 R; L0 sulation of androgen receptor number.10,12 However,5 a' m# Q8 ^+ r# z
Sutherland et al13 did not find a correlation between
6 @' f9 L7 d2 G( M. y* E3 z. @" Schildhood testosterone exposure and reduced adult
9 Y, `7 b7 h" N9 Gpenile length in clinical studies.
8 h* M/ i& Y9 M+ P* A& {+ T; L! zNonetheless, we do not believe our patient is+ B8 l. h( K; B" N0 f
going to experience any of the untoward effects from
8 a: y& c1 C( z- e4 xtestosterone exposure as mentioned earlier because
6 x8 z1 e& Z5 O6 h6 lthe exposure was not for a prolonged period of time.
% \' F9 }0 X) f- L% vAlthough the bone age was advanced at the time of
) k; I% t. K' D9 x$ ^: xdiagnosis, the child had a normal growth velocity at" m/ H% x) H3 D8 U2 P# d+ ^
the follow-up visit. It is hoped that his final adult
% s: g. I1 C) ^3 N! Eheight will not be affected." ?4 H- C$ d: X
Although rarely reported, the widespread avail-
( T9 {7 p! v9 a+ P4 Kability of androgen products in our society may7 K% k3 Z% t! B  J8 c2 ?
indeed cause more virilization in male or female
7 b* j* D+ k* S" k, z1 g7 ochildren than one would realize. Exposure to andro-
8 c* j$ Q6 X9 Wgen products must be considered and specific ques-
- Z0 n  U- j5 T, `4 ]1 Ktioning about the use of a testosterone product or
) F  B# e! S0 @! p6 V1 {% A- Jgel should be asked of the family members during
2 g+ k' g9 s- U7 ^  S* bthe evaluation of any children who present with vir-
2 E/ J! h2 e- W, Z5 Iilization or peripheral precocious puberty. The diag-: Q' _9 s7 k, v' o
nosis can be established by just a few tests and by
+ A& x+ C+ A& wappropriate history. The inability to obtain such a# k' l  {( L% ^9 g  u# R2 n% D
history, or failure to ask the specific questions, may& q  K/ ^1 z# M1 o  A
result in extensive, unnecessary, and expensive8 o* J# T0 r0 g! h1 W
investigation. The primary care physician should be
% ]( Y4 G) }/ O$ Caware of this fact, because most of these children
- o4 _, f  j( K* O# ?& h; Hmay initially present in their practice. The Physicians’; L$ I& ~! s; |* ~4 z8 v
Desk Reference and package insert should also put a
6 Q/ C, j. v& s, Lwarning about the virilizing effect on a male or
3 v6 A/ T) e3 p7 Q5 }6 j6 Afemale child who might come in contact with some-
/ Z; r" u% |7 T4 n) Oone using any of these products.' V6 _- z7 {8 R
References
2 ]& A/ \! j1 {; j" u" `/ G1. Styne DM. The testes: disorder of sexual differentiation
* d8 S8 m) Q9 D0 E, D" q2 u  c: @and puberty in the male. In: Sperling MA, ed. Pediatric
4 X4 p: w. S4 V5 UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 ^9 L3 O% Q6 }2002: 565-628.
1 h; z9 A2 Q! ]- S$ G( h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 w3 U7 ^/ v1 @# Vpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' O* E* u( k2 ]4 [# `; E7 l' MBoy Induced by Indirect Topical: O3 c# c3 Z( v
Exposure to Testosterone# j' a3 G5 Q) W, W$ @, O: G: u, |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& E% `6 h  A3 Y" U5 a7 P
and Kenneth R. Rettig, MD1
9 n5 P5 X  ~( ]9 g; \9 Z4 A# L8 W; VClinical Pediatrics! T% [, s" e6 @7 F5 m, i
Volume 46 Number 6( s$ b% Z6 i) O  I
July 2007 540-5431 P) K' U5 _# t/ R$ \) z/ q0 Z- ~2 G: @
© 2007 Sage Publications' }: N8 @/ x0 C6 M8 c* r  T
10.1177/00099228062966511 C9 w6 S% T5 D' W2 E8 g; w
http://clp.sagepub.com- s2 }; U/ W6 U4 R. k
hosted at& B. w- c' I, g, A+ J* g% S) o/ o
http://online.sagepub.com
( {/ n( [5 X, ~9 e8 TPrecocious puberty in boys, central or peripheral,. q/ ?# h& B! h" K  O
is a significant concern for physicians. Central
1 C2 E7 Q3 Y" W6 ^precocious puberty (CPP), which is mediated
! @% j; N2 Q. c9 L" d# V  ]through the hypothalamic pituitary gonadal axis, has2 d9 s- b: [( I. \1 ]3 M
a higher incidence of organic central nervous system
+ V  C# L" c- ?& glesions in boys.1,2 Virilization in boys, as manifested
" f3 f2 D2 P, T  b" [/ C: Oby enlargement of the penis, development of pubic5 N: M+ f2 a* z/ G/ e3 D) m  F( M5 i
hair, and facial acne without enlargement of testi-2 E5 q2 {* r8 Y9 o& z; W
cles, suggests peripheral or pseudopuberty.1-3 We
5 ~& f, K% _" Treport a 16-month-old boy who presented with the
& d  }& h1 D/ p4 t9 ~& B& U; senlargement of the phallus and pubic hair develop-
6 J$ T% j# H. W' dment without testicular enlargement, which was due  J: x6 N7 ~. T. x6 \& c
to the unintentional exposure to androgen gel used by" r! N$ r- z2 F' G
the father. The family initially concealed this infor-& b. H. Q4 i& j2 z$ W
mation, resulting in an extensive work-up for this% G9 J( A% P4 c+ O- ^% M
child. Given the widespread and easy availability of
# p, t8 s9 V/ p) I; x# s& N' _% ctestosterone gel and cream, we believe this is proba-7 H# ~. R! u$ z
bly more common than the rare case report in the. B' v) t* y: B8 ~6 J
literature.42 ]. \/ m. E/ C
Patient Report6 X# X' I9 q2 b. ]  g
A 16-month-old white child was referred to the
! ^* @* j0 ]  I# V0 Tendocrine clinic by his pediatrician with the concern
' o$ }! d) `2 o. ?2 iof early sexual development. His mother noticed
  k3 ?: o1 c6 T5 W& u$ Qlight colored pubic hair development when he was
# {! o8 Q6 q5 a- {2 v2 R3 EFrom the 1Division of Pediatric Endocrinology, 2University of
' T/ @; L2 L& `( o5 z- ^8 OSouth Alabama Medical Center, Mobile, Alabama.
' V. ^9 p2 U4 F& YAddress correspondence to: Samar K. Bhowmick, MD, FACE,
1 _, K' E+ r3 m# W: _Professor of Pediatrics, University of South Alabama, College of5 N, X! t6 l1 O. a" e- c
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ r. k  d7 p2 M8 s
e-mail: [email protected].
) w& A" [9 A) i% b; z) D3 Qabout 6 to 7 months old, which progressively became7 p7 `5 _5 _+ ~) h- H
darker. She was also concerned about the enlarge-
& Y2 D3 o# I0 p, [: u, }. r. M+ g8 kment of his penis and frequent erections. The child
  x: v# i& i. j: N7 j! X/ R% owas the product of a full-term normal delivery, with  k) N9 m$ ^- j% O. r
a birth weight of 7 lb 14 oz, and birth length of
  }* a# V+ W- w2 u8 F& k20 inches. He was breast-fed throughout the first year
( U8 O. {7 s3 B8 v7 a/ Cof life and was still receiving breast milk along with2 |5 p1 \/ p/ S' L
solid food. He had no hospitalizations or surgery,, O- q7 Q0 |. L' G8 v  ^& d% n
and his psychosocial and psychomotor development  w2 z6 R! o# W9 R
was age appropriate.
3 T8 g; _' B! XThe family history was remarkable for the father,: T' U% ?& f& c# l
who was diagnosed with hypothyroidism at age 16,5 D/ x2 `- u! c; O
which was treated with thyroxine. The father’s
  T; `! |% }6 Iheight was 6 feet, and he went through a somewhat) z( c. o" W4 _0 E$ N' N5 D2 @
early puberty and had stopped growing by age 14.2 q! @; ?* ]8 t8 \  u
The father denied taking any other medication. The" d) j" Y, X% \+ N& n2 Q! T
child’s mother was in good health. Her menarche$ t8 s1 u! Y! z/ O: r3 ^. {7 o
was at 11 years of age, and her height was at 5 feet
9 j" p: j/ b6 Q$ b( N. [+ t5 inches. There was no other family history of pre-
* A* {/ J- C, t3 S# B& T! ~2 u0 |cocious sexual development in the first-degree rela-
9 d  x+ @+ w) e- O% x) S4 Atives. There were no siblings.
9 W! {( G& S1 ~9 U9 w' dPhysical Examination
3 F' |: x# E/ _The physical examination revealed a very active,  z8 m3 F: y* ]) j
playful, and healthy boy. The vital signs documented5 n; R$ C* Z" A& j9 l7 k* P5 L8 |) W
a blood pressure of 85/50 mm Hg, his length was
; c* g0 j9 L/ R90 cm (>97th percentile), and his weight was 14.4 kg
3 b/ V- T! Z7 p3 |: m& i; K(also >97th percentile). The observed yearly growth. D; _2 a8 |" G1 f) k8 n
velocity was 30 cm (12 inches). The examination of/ ~7 T' h; E6 B: f
the neck revealed no thyroid enlargement.2 S9 w4 S( g) @
The genitourinary examination was remarkable for+ \9 q9 Q5 q4 M0 ~  L6 Z9 \
enlargement of the penis, with a stretched length of
' r/ y" g. E) H' \, G8 cm and a width of 2 cm. The glans penis was very well! C" u& V* e) Q/ X  r
developed. The pubic hair was Tanner II, mostly around
( I9 E2 s$ e+ u7 Y5400 c1 ^8 X" Q5 t( P% u: }) e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# {) z- x. g( V/ c8 tthe base of the phallus and was dark and curled. The
1 B6 m% W- {! C9 p( a0 {testicular volume was prepubertal at 2 mL each.
+ l+ s$ `% d/ W7 Q1 oThe skin was moist and smooth and somewhat7 |7 O" e6 y8 [. G( L1 C: n
oily. No axillary hair was noted. There were no( Y0 b6 M2 p& L, {" P6 n5 h; n& s0 L
abnormal skin pigmentations or café-au-lait spots.  H# T; B0 _( k: N% s( Z0 P1 E
Neurologic evaluation showed deep tendon reflex 2+; k" r  A  k) `6 V$ o$ J0 ]. S
bilateral and symmetrical. There was no suggestion
/ P: B$ T3 R0 E/ i& vof papilledema.
, V. |* B+ T5 X' m; nLaboratory Evaluation
6 O: _! G& E1 H1 J9 V1 l5 WThe bone age was consistent with 28 months by$ ]7 B1 W! f5 C+ ?/ m/ ]
using the standard of Greulich and Pyle at a chrono-- ~# N( J4 `3 x( n+ ^# _1 f9 l
logic age of 16 months (advanced).5 Chromosomal9 w+ Y' c. Z: s1 U( G. \( |
karyotype was 46XY. The thyroid function test
1 E: l  t  L  Z& k; K0 h8 r! s  sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 x8 _* {5 L# M; f. D! h/ j# R% Q$ C
lating hormone level was 1.3 µIU/mL (both normal).
3 x. ^& r& F1 k" |1 I: uThe concentrations of serum electrolytes, blood4 c: R' ?- t* g( @. p: A
urea nitrogen, creatinine, and calcium all were
2 G- \0 O  b: M. U' ewithin normal range for his age. The concentration
' K/ {$ N+ Y$ `/ y; K9 Tof serum 17-hydroxyprogesterone was 16 ng/dL
4 V- ~, A4 ^  R$ W' t+ u(normal, 3 to 90 ng/dL), androstenedione was 20# G$ s# O5 y5 W& ]6 ^5 E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 w/ _/ N! C0 |+ Q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% v+ [. q) _( b$ X3 @* F! w( R. Vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: h& n6 @& w. s49ng/dL), 11-desoxycortisol (specific compound S)
; T8 A/ i8 Q8 L, N( S% Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  i1 J7 E3 O, M2 ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# ~2 m  L7 I9 _% G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; H3 Q! b1 C9 r* pand β-human chorionic gonadotropin was less than1 N& W/ \- i) p: p* i$ O2 H4 h, }
5 mIU/mL (normal <5 mIU/mL). Serum follicular  ?/ f, C: w. K9 M3 I
stimulating hormone and leuteinizing hormone
+ u' _  Q" E( z" L2 r; Oconcentrations were less than 0.05 mIU/mL
/ P) t. V0 `5 i; k- }4 _0 o$ _8 D(prepubertal).
, f( T& X, e, f! _7 c& RThe parents were notified about the laboratory
  z9 }" x6 @4 Presults and were informed that all of the tests were
% U7 g  _! P- k! W  p5 k. v' Enormal except the testosterone level was high. The
" P5 D0 W( a/ q/ d  Yfollow-up visit was arranged within a few weeks to# h% u% s8 k7 A& @$ D/ _0 E/ o! p  x4 s
obtain testicular and abdominal sonograms; how-
1 S. ~0 ]5 ~2 Y6 e  u% H1 G8 Q0 Vever, the family did not return for 4 months.: }# q& |' r4 G4 M- q& z
Physical examination at this time revealed that the, X7 ^+ A. q% a/ A
child had grown 2.5 cm in 4 months and had gained% M% W, |( s/ n
2 kg of weight. Physical examination remained
9 N0 `7 h- _# y* ?( b0 e7 T: o! |unchanged. Surprisingly, the pubic hair almost com-
4 d6 l1 i5 u' N9 m& A2 Ipletely disappeared except for a few vellous hairs at
7 Q( R2 X( E1 H* a) ?the base of the phallus. Testicular volume was still 2& x* x% D# y3 K1 L
mL, and the size of the penis remained unchanged.. {) ?# p  [" c) R9 g1 m
The mother also said that the boy was no longer hav-) w! c0 R* P6 m; [  V$ k# {8 W2 y
ing frequent erections.6 E! B. x# m+ ?6 z' z( ~& _6 Q
Both parents were again questioned about use of2 e9 r1 e7 X& Y- @
any ointment/creams that they may have applied to% X( \. G; E$ Z' r2 w3 C, S
the child’s skin. This time the father admitted the
6 Q9 x3 M) y" G# gTopical Testosterone Exposure / Bhowmick et al 541/ G+ z; j/ n! z; S: C) }
use of testosterone gel twice daily that he was apply-8 N+ ^  G, n$ ~: P  a+ k. L, \
ing over his own shoulders, chest, and back area for
- v( L; N) O/ h6 f2 c0 Ja year. The father also revealed he was embarrassed# u$ \9 l& n- f+ X9 S* t7 e
to disclose that he was using a testosterone gel pre-# C& h3 Y# x5 w+ K( q
scribed by his family physician for decreased libido* S% A. L7 a( `: h4 ^* B) h) e
secondary to depression.
, c7 e2 [5 w3 f8 k5 RThe child slept in the same bed with parents.
4 M) _1 ]6 R, F/ PThe father would hug the baby and hold him on his- s0 k" o; o2 j* V
chest for a considerable period of time, causing sig-
1 c7 G( {8 O  p+ Y& G. L2 enificant bare skin contact between baby and father.
2 p: U! u0 W; D2 R0 ~  A' nThe father also admitted that after the phone call,
4 d0 D; j% X# ewhen he learned the testosterone level in the baby7 v% j6 Q, m6 J7 n
was high, he then read the product information
2 _$ Q5 u8 Z/ Bpacket and concluded that it was most likely the rea-& r. U* V! A8 [" z
son for the child’s virilization. At that time, they+ N) [& Z7 e, J! S# B
decided to put the baby in a separate bed, and the
% E; W" c+ g1 A+ G% efather was not hugging him with bare skin and had5 G* L; z+ J% ?4 `
been using protective clothing. A repeat testosterone4 {9 x: m: z6 C. U
test was ordered, but the family did not go to the
4 ]: m8 Z. u" Vlaboratory to obtain the test.
! s2 o6 j, }) j1 ZDiscussion# I1 B2 L; x0 ]6 [$ ~6 L
Precocious puberty in boys is defined as secondary
$ T6 d0 _$ y% x- wsexual development before 9 years of age.1,43 `+ Y  M) C; X( b
Precocious puberty is termed as central (true) when. E2 t, T  a3 }
it is caused by the premature activation of hypo-
1 j- }$ B+ @2 G8 E+ gthalamic pituitary gonadal axis. CPP is more com-( }% m1 `( B- @& M# a& A: F
mon in girls than in boys.1,3 Most boys with CPP
; `$ E- U) T6 r3 m/ m/ y. Pmay have a central nervous system lesion that is& W) V8 L( F* M, y8 ~+ t8 z$ b( M
responsible for the early activation of the hypothal-
; n' H- w; p' o  K% J! {amic pituitary gonadal axis.1-3 Thus, greater empha-
- a/ h# @' u, O' I# a0 hsis has been given to neuroradiologic imaging in, ^, J2 l7 Q; M, k9 k# Z* k
boys with precocious puberty. In addition to viril-& l3 i% Y1 x* ^- W6 ~
ization, the clinical hallmark of CPP is the symmet-& H9 }# {5 n0 n7 C6 T
rical testicular growth secondary to stimulation by
3 V& k6 t. d* U' j- p; Lgonadotropins.1,39 n- j& G' m7 V. i
Gonadotropin-independent peripheral preco-
4 ~& I4 q7 J* [  l! \cious puberty in boys also results from inappropriate# U% I. N& D" n: h! }
androgenic stimulation from either endogenous or" n. d! u# h# e
exogenous sources, nonpituitary gonadotropin stim-
6 z; q/ d! y) y4 [ulation, and rare activating mutations.3 Virilizing
" y2 @# E% t  ucongenital adrenal hyperplasia producing excessive" D! m. W+ w1 v* e
adrenal androgens is a common cause of precocious+ R# h+ X. x( g* U/ z5 N$ J" r
puberty in boys.3,4
+ Z& s8 B; @4 S1 Z% W; |! v7 jThe most common form of congenital adrenal( |  ~3 ~8 o3 s5 G
hyperplasia is the 21-hydroxylase enzyme deficiency.
  F( J+ p3 z+ J0 T+ zThe 11-β hydroxylase deficiency may also result in' r0 {( F7 h) e+ M$ ~& U
excessive adrenal androgen production, and rarely,* x. C1 }+ ?8 E2 u! r0 _: Z7 \
an adrenal tumor may also cause adrenal androgen, M+ Z3 {" p: e$ C
excess.1,3% g+ v8 w" a3 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 i" V. s- }. ^. M5 [' ~$ W542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 t# l5 q( ^4 \- Q6 S3 H4 X6 }
A unique entity of male-limited gonadotropin-4 I8 E' R8 I& l" \. X& c3 W
independent precocious puberty, which is also known- K% x- l# D- N  l
as testotoxicosis, may cause precocious puberty at a5 d+ k+ s( {7 y$ S, U+ j( h8 t" [
very young age. The physical findings in these boys
8 x0 x( ^' M* `9 nwith this disorder are full pubertal development,3 E1 p+ i- s( }0 H- L2 v/ T9 A: G
including bilateral testicular growth, similar to boys1 P  n  t! p$ |, X' X, z  r
with CPP. The gonadotropin levels in this disorder
" p) x' {8 D# v3 G4 ^2 R8 sare suppressed to prepubertal levels and do not show
* }3 N. G; V; {4 h, ^pubertal response of gonadotropin after gonadotropin-9 C9 |/ Q# e8 m! L" n
releasing hormone stimulation. This is a sex-linked
2 K. b/ J* I3 ^( p/ j( Uautosomal dominant disorder that affects only$ }; R% G' q: D+ Q& z8 u7 k
males; therefore, other male members of the family: F. x& C" t1 u3 l, t
may have similar precocious puberty.3
" T7 v1 @  P) X6 U' b/ YIn our patient, physical examination was incon-, \$ x) A  ~) \: y. ]1 G( ]5 {1 V
sistent with true precocious puberty since his testi-
9 y$ z5 ]+ s  b* O: S: S0 `4 scles were prepubertal in size. However, testotoxicosis
% F% ]: X$ O% R- U- wwas in the differential diagnosis because his father" i0 p/ B0 n. C, I8 l
started puberty somewhat early, and occasionally,
! G. V3 D2 r. Z/ q* v' Mtesticular enlargement is not that evident in the
( }, F6 z. m" {1 [beginning of this process.1 In the absence of a neg-2 n1 d. ^6 d% h$ o. W% u( j
ative initial history of androgen exposure, our
& ~# ^- r+ N3 \biggest concern was virilizing adrenal hyperplasia,
8 f& K3 m& D2 C7 B% P& Beither 21-hydroxylase deficiency or 11-β hydroxylase/ l4 d& F7 e4 h3 `7 N
deficiency. Those diagnoses were excluded by find-- J; k, g6 X8 H. l% [  I& |
ing the normal level of adrenal steroids.
3 o- l" Z) [$ ZThe diagnosis of exogenous androgens was strongly
# k1 j$ q6 e8 d4 p6 gsuspected in a follow-up visit after 4 months because
4 I7 Z, ]. @, W* D0 G- Z' T+ Sthe physical examination revealed the complete disap-  |) F6 \3 {4 T+ J! j/ l
pearance of pubic hair, normal growth velocity, and3 _: ^; o; Q' k4 r$ L
decreased erections. The father admitted using a testos-4 @% ^+ d, E. x: H0 c1 t$ P/ p7 b
terone gel, which he concealed at first visit. He was# [& \6 X4 p. q. ?8 ^
using it rather frequently, twice a day. The Physicians’" B$ I8 B* ~: Q$ l3 D
Desk Reference, or package insert of this product, gel or/ D; y, X; V1 v. S& B. e
cream, cautions about dermal testosterone transfer to: @3 C7 }( G# e; f9 {, L
unprotected females through direct skin exposure.
" l; [5 Q( ?1 {5 `' v1 g! Z% zSerum testosterone level was found to be 2 times the' g. r* T. z  x. Z
baseline value in those females who were exposed to5 _; K$ X$ L" k  x7 W
even 15 minutes of direct skin contact with their male9 _! v3 Y9 W! V
partners.6 However, when a shirt covered the applica-
; g, {9 V5 Z5 m0 ltion site, this testosterone transfer was prevented.' E; L5 l: }9 w8 j9 v' k7 e
Our patient’s testosterone level was 60 ng/mL,
+ L3 a4 V1 O: C& z8 D; T, awhich was clearly high. Some studies suggest that2 o/ W- l. s% @
dermal conversion of testosterone to dihydrotestos-0 `8 A/ s6 }+ D6 \5 j( ~
terone, which is a more potent metabolite, is more
7 x' _3 S- x8 v9 ?4 H* a8 Zactive in young children exposed to testosterone- l- |8 p/ m3 C7 V& x1 r# e
exogenously7; however, we did not measure a dihy-
( t2 {0 c; N7 z2 M; ~- e3 o( x9 Odrotestosterone level in our patient. In addition to
0 i6 O* L1 }/ s- G  e) c+ [virilization, exposure to exogenous testosterone in
3 n  h' g0 V. K/ schildren results in an increase in growth velocity and# @! A* ^+ o+ e: o
advanced bone age, as seen in our patient.
% _( ?3 \" Z6 W' H9 PThe long-term effect of androgen exposure during/ [$ V* J/ B" P. P: s/ P
early childhood on pubertal development and final
; K$ \( C$ u% ^( g8 Q$ Qadult height are not fully known and always remain
5 r" r/ a8 Q4 f# _  a- K; q! Pa concern. Children treated with short-term testos-) E* |1 n- T% {  X' o, P/ u
terone injection or topical androgen may exhibit some& y" |& }" {5 A( }' U3 r* R( S, a
acceleration of the skeletal maturation; however, after; D+ j* _: |8 M6 ~% U" s' H
cessation of treatment, the rate of bone maturation5 P, f, J2 x2 ?4 {/ Q9 J
decelerates and gradually returns to normal.8,94 m% @( q2 H( T$ k
There are conflicting reports and controversy
; ~6 \/ a9 L0 g6 B3 ?2 Wover the effect of early androgen exposure on adult
* m; j$ n% ^0 \' Zpenile length.10,11 Some reports suggest subnormal/ N: Q: ~, l, q/ o
adult penile length, apparently because of downreg-% Y2 R4 U: x% F4 f3 e. W7 n
ulation of androgen receptor number.10,12 However,& x. ?! t& ^/ T7 s7 \
Sutherland et al13 did not find a correlation between
$ d9 z, Z# q5 i, uchildhood testosterone exposure and reduced adult0 ^1 i! h3 O$ H0 L! i: _0 E' ]
penile length in clinical studies.
1 s8 C/ r  p. G* T" p! U# uNonetheless, we do not believe our patient is
+ [0 d. b* P- F/ s" w  t& _going to experience any of the untoward effects from3 _4 Z1 l4 w7 j* u* l# @
testosterone exposure as mentioned earlier because3 l4 f7 W4 H; M( [6 B: M, h/ k
the exposure was not for a prolonged period of time.- @' L" ?  g" d" n" H: `
Although the bone age was advanced at the time of6 l$ D( |7 {* N4 w) o4 I
diagnosis, the child had a normal growth velocity at
: Z9 c: z" y% d0 E  _' d+ rthe follow-up visit. It is hoped that his final adult
2 Q% Q. i8 _0 @8 m6 ^height will not be affected.
& j  F/ F$ J; Z! WAlthough rarely reported, the widespread avail-
  o* {' l4 c. oability of androgen products in our society may
, A: Y) ~  F9 ]1 x8 _, \8 P0 Mindeed cause more virilization in male or female% s& J' m7 z4 _$ g3 m! \- t* Q
children than one would realize. Exposure to andro-2 [$ p! q( ~2 r& z
gen products must be considered and specific ques-
0 r" K" f$ t! V- Y) {2 T( V' stioning about the use of a testosterone product or
7 I2 O" T$ s% G$ x2 }& Q: }1 G; _gel should be asked of the family members during
: n  C$ T3 g1 @7 Fthe evaluation of any children who present with vir-
: c* M0 b% g- \: uilization or peripheral precocious puberty. The diag-3 v8 K& X+ ]& t/ i- C
nosis can be established by just a few tests and by
( ~) v  p  U! d1 `& Uappropriate history. The inability to obtain such a
# A0 h1 O( p- Bhistory, or failure to ask the specific questions, may2 J# c# K2 Z2 _
result in extensive, unnecessary, and expensive% e) U/ d) h: q( a
investigation. The primary care physician should be1 ~0 ~' X% q; c4 {, v* p+ M
aware of this fact, because most of these children
' j- X8 _5 P3 _# ]/ Mmay initially present in their practice. The Physicians’
, T" C' P3 z/ UDesk Reference and package insert should also put a# m# w# v2 u. ?  K
warning about the virilizing effect on a male or9 e: _  C/ Z4 A$ @: K' s  T
female child who might come in contact with some-
# @5 E0 o0 l" a7 s! b/ O0 R% K- Qone using any of these products.. Y5 l$ C6 P* Z( j, O2 e, {/ z  k
References; o) @' |  @3 `# _
1. Styne DM. The testes: disorder of sexual differentiation
1 y, `' \2 G/ f5 E9 x: H+ yand puberty in the male. In: Sperling MA, ed. Pediatric
* |; D% w" g+ ~% i& M( eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- t. b1 w# U( f! K+ {; B+ c2 ?( z
2002: 565-628.
5 l  j* A2 O( Q0 V0 b& u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* ^! s1 }8 \! |+ Opuberty 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
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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
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- v. j$ a4 I6 F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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