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Sexual Precocity in a 16-Month-Old
$ N! l. |9 D( W" ~Boy Induced by Indirect Topical8 v) Z( c/ }. o1 }& T' E
Exposure to Testosterone
6 j& g/ f+ M& g  T) aSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ I! n9 u) f. O  l" G7 M7 H, Qand Kenneth R. Rettig, MD1
) p* z9 F: [1 |Clinical Pediatrics
) y, O* a' s1 E) J6 @* E: V6 JVolume 46 Number 66 w6 V/ E( V1 E* r( L
July 2007 540-5438 M3 B) ~# @: U6 I7 r
© 2007 Sage Publications
1 q" d2 f: [* Q$ E. W10.1177/0009922806296651
: M' J  D: S2 c0 b* U2 Ohttp://clp.sagepub.com
& k0 r  l. C0 S) T: ihosted at" b/ I4 O) _8 ^% B$ I, ?) w
http://online.sagepub.com* d/ ^7 F; O7 c+ t
Precocious puberty in boys, central or peripheral,/ ^5 E2 D: N+ ~+ ^0 f0 J, R
is a significant concern for physicians. Central
" G& ]; S2 C7 Q) dprecocious puberty (CPP), which is mediated
7 @* l2 S2 y! x- A% L) Dthrough the hypothalamic pituitary gonadal axis, has
. O# Y3 i1 U/ I4 @a higher incidence of organic central nervous system$ G+ S1 o) }( G/ B" L
lesions in boys.1,2 Virilization in boys, as manifested
& r. Q2 f2 C3 b6 r" B. n5 d4 q: oby enlargement of the penis, development of pubic1 b3 \0 }, c2 z& _6 D- {
hair, and facial acne without enlargement of testi-" w# d4 |2 O2 A) |
cles, suggests peripheral or pseudopuberty.1-3 We0 R9 [, }0 ?. I
report a 16-month-old boy who presented with the7 H: j( Y6 X2 b) f
enlargement of the phallus and pubic hair develop-# ]2 I" V/ k% D) F
ment without testicular enlargement, which was due( y3 T% _% h3 f5 Q
to the unintentional exposure to androgen gel used by) R5 X/ I( R9 P7 \
the father. The family initially concealed this infor-
# F: p) x( O- C  {9 C9 j, C  |mation, resulting in an extensive work-up for this7 k8 V& s" @8 z# V$ r
child. Given the widespread and easy availability of
7 r. ^3 o% W% f# U5 mtestosterone gel and cream, we believe this is proba-
: L* s0 e3 }7 I/ r: r8 q7 jbly more common than the rare case report in the
2 c! R9 J: H5 [- _literature.4( M! w# U. _$ d& J( q# @+ g
Patient Report
0 ]' _& Z# k# R$ ~3 r4 R% BA 16-month-old white child was referred to the
' s+ P! v$ j8 O% h: y3 {endocrine clinic by his pediatrician with the concern( O8 ~5 P0 z. o8 ^6 Y
of early sexual development. His mother noticed$ [' s' I6 H' t. w' Y+ ?
light colored pubic hair development when he was
$ B7 v, d( C$ D4 b: y. A9 `6 E- pFrom the 1Division of Pediatric Endocrinology, 2University of
! d/ v8 f3 o+ H" v/ g0 W" w9 FSouth Alabama Medical Center, Mobile, Alabama.
: m7 P% f7 _- F' \7 k4 _Address correspondence to: Samar K. Bhowmick, MD, FACE,1 s# i8 |) l. P
Professor of Pediatrics, University of South Alabama, College of% U2 Q0 V1 r: e6 u9 C$ J6 i, s9 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 Z1 a, h$ v" O. x/ n0 C
e-mail: [email protected]., c- {5 [* H8 U
about 6 to 7 months old, which progressively became
" u( ~7 T- F6 X) e0 Qdarker. She was also concerned about the enlarge-
# z) \, C. A& mment of his penis and frequent erections. The child
; s/ m  [9 {, R' _0 k) M- [was the product of a full-term normal delivery, with
8 y' v! m" c5 F1 Z' G8 \8 ua birth weight of 7 lb 14 oz, and birth length of  ]: Z) i- ]. K  E
20 inches. He was breast-fed throughout the first year
1 v1 w' Z: C% _) N  B& @% Rof life and was still receiving breast milk along with& Z* I0 I0 \, i3 T
solid food. He had no hospitalizations or surgery,
# L6 g1 X8 I7 B3 [( h& @  sand his psychosocial and psychomotor development, F* @, V" W1 m# I& K1 F5 V
was age appropriate.1 z. l5 j' s8 p: x+ |
The family history was remarkable for the father,
( F8 }" q! D9 T/ a3 q$ E3 Vwho was diagnosed with hypothyroidism at age 16,
% w& Q0 Y5 T+ S; kwhich was treated with thyroxine. The father’s' ?2 e2 Q* y% @$ i+ a1 q, K
height was 6 feet, and he went through a somewhat% r9 f% e6 B" ?! g# @4 c+ C
early puberty and had stopped growing by age 14.
) W5 I- y) M% L( h- B0 R5 I& `# XThe father denied taking any other medication. The
! y1 S; j; g, p5 {8 Qchild’s mother was in good health. Her menarche
8 I. G3 d: m$ Zwas at 11 years of age, and her height was at 5 feet
" B5 ?( ^) i1 E$ f7 I5 inches. There was no other family history of pre-
/ z. k: t3 N7 b9 \0 dcocious sexual development in the first-degree rela-
' @1 J8 `- x$ ]6 E6 P" k! G* O) \) X1 gtives. There were no siblings.3 y5 K) ?/ S) h
Physical Examination) b- P9 i! r& k' Z! _
The physical examination revealed a very active,9 z! q- [0 V$ @# H+ b: {9 c
playful, and healthy boy. The vital signs documented' d& v8 m8 ^7 K4 [4 ]3 h
a blood pressure of 85/50 mm Hg, his length was: D; P2 ^7 Q# z# k/ X
90 cm (>97th percentile), and his weight was 14.4 kg
$ ?* T& ]8 ^5 J$ O3 {(also >97th percentile). The observed yearly growth& x8 O, i9 E4 @" W( g- K5 b
velocity was 30 cm (12 inches). The examination of
/ I7 Z$ Q7 A5 f. p# ?the neck revealed no thyroid enlargement.  \; m" {& T% o, D- X
The genitourinary examination was remarkable for& F% }4 h; f! W6 v& w' A# V2 i" ]0 I
enlargement of the penis, with a stretched length of1 K  E! }; L1 W/ J- N
8 cm and a width of 2 cm. The glans penis was very well
/ V2 F! k4 A& z' u3 N0 t- x: udeveloped. The pubic hair was Tanner II, mostly around
+ S) D! B9 x9 M1 N0 ~8 j4 b540
- F% m5 F0 f( x2 Z: u% {9 ~& iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; B' i% S' y. F+ b
the base of the phallus and was dark and curled. The
, V" ~2 w8 b+ V5 g* Utesticular volume was prepubertal at 2 mL each.7 I, c2 q0 d- @1 w1 w
The skin was moist and smooth and somewhat6 W/ F2 L' i* q9 k/ w7 K$ A$ E7 L
oily. No axillary hair was noted. There were no
( o+ j# m: c* p6 C) L% yabnormal skin pigmentations or café-au-lait spots.
6 Q$ k6 J  \3 k! r- `6 F* DNeurologic evaluation showed deep tendon reflex 2+
) O; ?4 @( N  M2 W+ g, Zbilateral and symmetrical. There was no suggestion, d7 b9 w3 r9 L' \( K$ _6 o
of papilledema.# c1 V$ E7 ]3 H! `
Laboratory Evaluation  F4 C4 P3 C, ~2 o4 H
The bone age was consistent with 28 months by
5 O5 o/ Q; N& z7 V5 F4 w3 x1 d3 eusing the standard of Greulich and Pyle at a chrono-& _/ y! G6 m) A! \  X
logic age of 16 months (advanced).5 Chromosomal+ ~* m4 k3 e# n7 y* O
karyotype was 46XY. The thyroid function test! `8 S+ i' J1 Q0 }" S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 v: B& v4 C- A1 |" Flating hormone level was 1.3 µIU/mL (both normal).! A3 D( q7 j8 Q
The concentrations of serum electrolytes, blood
3 j7 K& I7 _4 r4 G6 X2 Durea nitrogen, creatinine, and calcium all were4 a5 Z! m. v6 J0 u: C+ W
within normal range for his age. The concentration& [% P1 f9 N; [% s9 h
of serum 17-hydroxyprogesterone was 16 ng/dL
, ^$ K- r3 ?2 A0 E- M7 q7 r$ J% y5 w(normal, 3 to 90 ng/dL), androstenedione was 20
2 C* v, `1 @  Q3 ]ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 d9 N9 c8 h- C" v- B+ `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" ]( D+ R# v3 l! [% @$ gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: f$ z  E' @- ~2 Z. _49ng/dL), 11-desoxycortisol (specific compound S)
' C$ K- ]1 a/ R4 G  _was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-+ e1 U, d5 t: a8 N$ }
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 b9 x+ N4 f- U0 I( N4 ^- utestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- N3 S8 a9 ?0 g2 p/ `+ sand β-human chorionic gonadotropin was less than0 F8 L- }$ K  A$ u+ O; V4 X$ @
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ p: @( y" a0 J# b$ [
stimulating hormone and leuteinizing hormone+ j/ t$ B" \6 Q6 G* S- L
concentrations were less than 0.05 mIU/mL: [# K9 Y6 D; E6 t
(prepubertal)., S' x3 a( U* f- [7 j/ Y9 m# _
The parents were notified about the laboratory
! V3 t" a1 @6 }( l' _7 N6 x. |results and were informed that all of the tests were
5 e: O! q" E2 Q7 fnormal except the testosterone level was high. The
+ m4 X; g& b) N( vfollow-up visit was arranged within a few weeks to. r3 ?2 h6 S6 p, {
obtain testicular and abdominal sonograms; how-$ p9 _( @3 P( L9 @) G- x' b
ever, the family did not return for 4 months.
2 w6 y6 h2 h# t+ a, I0 PPhysical examination at this time revealed that the& d% A1 }) g) x4 a0 \
child had grown 2.5 cm in 4 months and had gained8 F9 s/ a  g7 h7 f# w# t
2 kg of weight. Physical examination remained& o- J; ]# b. G; O# X
unchanged. Surprisingly, the pubic hair almost com-
* u) j8 y% j! g1 u1 U( spletely disappeared except for a few vellous hairs at
- Y6 b' h& p) R0 xthe base of the phallus. Testicular volume was still 2
7 k2 e5 y! E# }8 `4 K* {4 r4 K( [mL, and the size of the penis remained unchanged.
( A9 x6 b# U8 I% I/ p1 l. X% sThe mother also said that the boy was no longer hav-
2 x$ F& O- E! bing frequent erections.
. N1 [  t, ?8 Q7 e- J, gBoth parents were again questioned about use of0 ~: h: k3 r% E. u- V9 I6 v6 b/ a
any ointment/creams that they may have applied to
! W( n% o7 _4 E' g& T1 C% athe child’s skin. This time the father admitted the
4 Y  t$ Z( O& M3 E8 dTopical Testosterone Exposure / Bhowmick et al 5419 @; M: x" L  k  i7 }: X
use of testosterone gel twice daily that he was apply-6 ~5 k6 o9 q% y  s  W$ X% \% A
ing over his own shoulders, chest, and back area for5 F* t- B, K! F/ t! Q
a year. The father also revealed he was embarrassed
  s! k8 d2 ]) v7 H9 e6 G) e: {/ y8 vto disclose that he was using a testosterone gel pre-
7 M4 m  Q& P  g& bscribed by his family physician for decreased libido
- c5 {* E+ y2 r. Ksecondary to depression.
* i5 ~  Q; @9 j# n4 B3 FThe child slept in the same bed with parents.
! w7 u1 P" G9 Q, ~" ^" o# jThe father would hug the baby and hold him on his
; g* L. s5 W, a) |4 [7 _chest for a considerable period of time, causing sig-
, ~/ v1 _2 ]4 K1 c! jnificant bare skin contact between baby and father.
1 L& ?2 R: L1 T; aThe father also admitted that after the phone call,
5 c5 [6 i4 u* B7 k5 r* t2 C  uwhen he learned the testosterone level in the baby  |# T) W1 K- y" M
was high, he then read the product information  M; N8 {2 O6 O# F
packet and concluded that it was most likely the rea-
# v6 s- c8 ?2 N  fson for the child’s virilization. At that time, they; g  v2 J& M% S
decided to put the baby in a separate bed, and the6 f; T' I' y' f/ ?* O+ r
father was not hugging him with bare skin and had3 i- R$ |, O$ m+ s/ N: o. x
been using protective clothing. A repeat testosterone
  F0 D7 R8 D# Ktest was ordered, but the family did not go to the3 h; \- C8 x$ _( ~' `! ?& d
laboratory to obtain the test.4 ~5 \! U5 H/ K9 Z
Discussion
( U  ?! h: J' uPrecocious puberty in boys is defined as secondary
' m( _2 o- |, ]+ s; fsexual development before 9 years of age.1,45 c! P( F4 _- i" m- ~
Precocious puberty is termed as central (true) when8 }( k% c" r- ~( G+ P9 B
it is caused by the premature activation of hypo-/ F; C/ M+ m: w/ J& h8 Y/ I6 r/ u8 y$ a
thalamic pituitary gonadal axis. CPP is more com-& N0 o6 t5 n+ g! }% {& j: v
mon in girls than in boys.1,3 Most boys with CPP
# y/ W5 \- P2 v' I3 Wmay have a central nervous system lesion that is9 j1 ]8 N0 o9 ?
responsible for the early activation of the hypothal-7 }  Q6 F' o7 {. B! c
amic pituitary gonadal axis.1-3 Thus, greater empha-7 w8 Q; U0 y  E/ E2 g8 [4 k3 \: B
sis has been given to neuroradiologic imaging in3 K2 f6 y5 m& J3 N' k9 Y& h' v+ R
boys with precocious puberty. In addition to viril-4 M3 F3 N4 n) s, ]9 g( T% n
ization, the clinical hallmark of CPP is the symmet-
1 l; p# v9 o6 m3 e  l- C' Nrical testicular growth secondary to stimulation by
: d" [, O# K7 D# f$ pgonadotropins.1,3* ]& y  L5 U. o0 ^8 S
Gonadotropin-independent peripheral preco-, j7 J# B- U! s
cious puberty in boys also results from inappropriate0 S: q" x5 W7 J2 u
androgenic stimulation from either endogenous or
) C5 v- a) z$ }9 c- D7 B( F# ]5 Bexogenous sources, nonpituitary gonadotropin stim-: X. S0 B. X' x4 S6 H6 P
ulation, and rare activating mutations.3 Virilizing
* x3 O/ b; [2 k4 ~( l9 J& ncongenital adrenal hyperplasia producing excessive1 |& S: b  V7 W5 N$ y* r
adrenal androgens is a common cause of precocious0 G3 r$ i4 u& \5 q0 o( l+ H! Q% ]3 |
puberty in boys.3,48 Y0 w9 w2 H* P0 l0 f
The most common form of congenital adrenal
4 Z+ o* z3 }  z. n9 B8 Thyperplasia is the 21-hydroxylase enzyme deficiency.
% @; a; o( S, dThe 11-β hydroxylase deficiency may also result in' z. l" g8 b6 \9 N1 g
excessive adrenal androgen production, and rarely,& b6 I4 h: n8 D' n2 |
an adrenal tumor may also cause adrenal androgen+ Z" C1 f2 ?3 u  }) j6 [
excess.1,34 m6 x! T* I8 G- p( L& y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& n; o3 F$ O3 H$ c
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 H6 \0 \! R2 v5 U$ ~A unique entity of male-limited gonadotropin-
8 p$ q$ e9 k2 l8 R% x  hindependent precocious puberty, which is also known
$ [5 l4 ~% b; M& m& j2 h! yas testotoxicosis, may cause precocious puberty at a
( N" {* \3 k/ a. T  e8 Wvery young age. The physical findings in these boys- g* _7 f; e' _3 G% A8 z
with this disorder are full pubertal development,
; h/ a# x5 K: a8 }1 Eincluding bilateral testicular growth, similar to boys
, ~# ]2 r$ U6 v% Y& g* M, U" kwith CPP. The gonadotropin levels in this disorder% i5 g. u% x1 c
are suppressed to prepubertal levels and do not show
, |7 L! f: Y$ qpubertal response of gonadotropin after gonadotropin-1 d6 j6 {" y1 a5 P! Z: ~* b# F% {
releasing hormone stimulation. This is a sex-linked
* T5 n& O, I  x9 S; Pautosomal dominant disorder that affects only; {+ s: F9 a& S% n* o: A
males; therefore, other male members of the family+ i$ D" B8 e7 U- Z
may have similar precocious puberty.3- N* W- }; Y0 H
In our patient, physical examination was incon-
% K# q& ~1 b) p/ P/ g2 |) v7 lsistent with true precocious puberty since his testi-3 {3 Y6 \, z5 X) K! }0 ?) n
cles were prepubertal in size. However, testotoxicosis
7 D# f- C" R* P0 p+ K/ g6 Dwas in the differential diagnosis because his father
  N  D# [% C6 @+ n& u2 S. F. w2 Estarted puberty somewhat early, and occasionally,
2 j' g* r6 O3 Ltesticular enlargement is not that evident in the
9 b' [, S  K+ b! _, _, G6 ^$ P% }/ mbeginning of this process.1 In the absence of a neg-( Z: T7 D* Y& l& \  |% ~5 V7 J
ative initial history of androgen exposure, our3 r% d' ?) M; a5 j/ I
biggest concern was virilizing adrenal hyperplasia,
1 I. w9 C0 E# [6 {2 M. ^either 21-hydroxylase deficiency or 11-β hydroxylase
% z6 U5 g: m) p  Z- Ldeficiency. Those diagnoses were excluded by find-
/ c: H* B6 A$ T+ @4 j! Ming the normal level of adrenal steroids.6 A0 A9 b  I# \9 ~8 c' [
The diagnosis of exogenous androgens was strongly
9 K; V( v( d5 Xsuspected in a follow-up visit after 4 months because
1 c5 |$ P3 h, wthe physical examination revealed the complete disap-
  S! {9 I8 J5 g6 rpearance of pubic hair, normal growth velocity, and
2 m/ L- O& V# b* Kdecreased erections. The father admitted using a testos-' h: P( y* e9 q0 }  e; _
terone gel, which he concealed at first visit. He was1 {$ H% v/ g7 \3 }- I9 y' V: A( Y
using it rather frequently, twice a day. The Physicians’4 B7 b) O3 N) W% w. a' F! c- b- X
Desk Reference, or package insert of this product, gel or5 I* A0 l& z  m4 u7 {
cream, cautions about dermal testosterone transfer to" l; r: r2 p+ ]) I: U
unprotected females through direct skin exposure.
) u, Z9 [0 c9 g2 MSerum testosterone level was found to be 2 times the3 p. c1 J- |/ i* t% q- o
baseline value in those females who were exposed to) O/ C& A0 ^6 C  x" I
even 15 minutes of direct skin contact with their male
0 F7 L% Y+ w. |9 \1 ~* Vpartners.6 However, when a shirt covered the applica-  C! b3 b# n" b
tion site, this testosterone transfer was prevented.
$ j' M! E/ j' |Our patient’s testosterone level was 60 ng/mL,. l; O) r5 L( W4 C9 u
which was clearly high. Some studies suggest that
. j3 i2 c+ E! x5 A, b/ G2 i, p' Udermal conversion of testosterone to dihydrotestos-
" [6 j5 I6 C# }* ^1 rterone, which is a more potent metabolite, is more
8 R' h4 v5 Q6 s- k# Vactive in young children exposed to testosterone8 J! U/ f) W, {2 A/ u
exogenously7; however, we did not measure a dihy-
' [( m8 Q9 o. F6 C6 f* d0 ?' hdrotestosterone level in our patient. In addition to
5 B  O8 i- W; L. ?) Lvirilization, exposure to exogenous testosterone in* j" j* v4 E6 N7 T5 B
children results in an increase in growth velocity and7 |, ?* B% Z' b: U6 z1 H
advanced bone age, as seen in our patient.! |5 c9 n. z, a
The long-term effect of androgen exposure during4 R7 Q; s& o4 e& {; B% r
early childhood on pubertal development and final! z) s0 Z" v  m* w7 ~0 p$ a
adult height are not fully known and always remain
5 R" F' Z. n3 h+ w& ?& Ia concern. Children treated with short-term testos-! J0 I8 }9 B; S( \& N( a0 X  b( X
terone injection or topical androgen may exhibit some( r$ q6 A4 x; U
acceleration of the skeletal maturation; however, after
7 S- w/ |: p; m# @% \4 Ecessation of treatment, the rate of bone maturation5 U5 P$ U2 N! i
decelerates and gradually returns to normal.8,9
# u7 N+ l" f- g- n% T: h1 VThere are conflicting reports and controversy
. u8 v0 q; ^1 k. gover the effect of early androgen exposure on adult
& s8 B  {/ c6 D8 t- t! \penile length.10,11 Some reports suggest subnormal
1 T. J  C4 E- o4 l, Oadult penile length, apparently because of downreg-
& r+ J9 g- T0 E2 Q  s3 sulation of androgen receptor number.10,12 However,
7 e) H" ]( W" ?3 |7 C( ^Sutherland et al13 did not find a correlation between
2 O+ x) \) i: V2 X1 f0 U2 cchildhood testosterone exposure and reduced adult" v8 G1 P. t+ Y- a! r  B1 Y; r
penile length in clinical studies.
. X7 m+ D. G6 U% e6 zNonetheless, we do not believe our patient is# x9 Z- w: S) v8 l3 N; ]3 }
going to experience any of the untoward effects from
0 Q, {5 q4 z% K/ L* r- A" dtestosterone exposure as mentioned earlier because
% s3 R8 I0 H% O5 \) B2 A6 Ythe exposure was not for a prolonged period of time.
* M  C( K% ?) H  ^Although the bone age was advanced at the time of$ y4 z. W7 }& h! L4 E) Y( y$ c; V
diagnosis, the child had a normal growth velocity at# b0 x" a! I. S$ S
the follow-up visit. It is hoped that his final adult
% T$ P- Y1 V+ h, O1 w. mheight will not be affected., F% y) X) a% {) {1 D1 v
Although rarely reported, the widespread avail-6 ]& k# Z* ^" B4 D9 |2 E, j( S
ability of androgen products in our society may
, V8 F% _+ r( i8 s) W) Z! a; jindeed cause more virilization in male or female
0 r& {( b7 N3 Q; Q! C0 [children than one would realize. Exposure to andro-7 d0 Y: m: \2 P( j+ p
gen products must be considered and specific ques-# }' L* x3 ]2 n  M- j
tioning about the use of a testosterone product or
* ]- y  J5 c5 X& o. C+ Ogel should be asked of the family members during
+ l4 n6 _1 U+ [$ _the evaluation of any children who present with vir-
( i% x" x: `" ~ilization or peripheral precocious puberty. The diag-
  J! h2 P5 |* Q" ~; knosis can be established by just a few tests and by' n  N: l0 v3 l4 Z5 o
appropriate history. The inability to obtain such a8 g/ T+ M7 S/ H( o" V. W; k5 u( {
history, or failure to ask the specific questions, may
0 p2 f$ `0 Y: ?) `' bresult in extensive, unnecessary, and expensive+ U, F' L' I3 T6 i* W2 j& i
investigation. The primary care physician should be
3 b& c8 c7 `  I2 Naware of this fact, because most of these children
$ B& j0 A- m/ }! Q. H% S9 vmay initially present in their practice. The Physicians’
8 Z1 c) e* G$ t% T" X3 x& U- ?Desk Reference and package insert should also put a) p/ ~5 N6 u4 g. A* _
warning about the virilizing effect on a male or8 m" F6 I7 Q3 V; T$ p! ?% J9 M
female child who might come in contact with some-6 J+ {# \+ h2 i
one using any of these products.# |3 {( {2 b/ F
References
5 ~6 z! ]  B! ~1. Styne DM. The testes: disorder of sexual differentiation- z  I! V$ t; ^3 ~& q
and puberty in the male. In: Sperling MA, ed. Pediatric7 t) o/ f4 [. i9 T5 m0 s8 ~- z8 w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ c6 w+ a! F5 v2002: 565-628.5 u7 v3 Y/ n% Y" ?
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 I) ~9 k+ V/ c# B9 M, D& Npuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" u$ R# {' i: D0 K5 ^0 qBoy Induced by Indirect Topical
. a. j9 `" C" L0 X* N/ L( zExposure to Testosterone
# G6 s# _) f: |4 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) L( _& I6 H# B9 ^+ j" M6 `
and Kenneth R. Rettig, MD17 I+ j3 i5 c6 ^: Y# l, Y" w3 e
Clinical Pediatrics( y" X2 C$ l# c" ~1 u- D3 w1 o
Volume 46 Number 6* N8 y7 A5 `; _9 I& H
July 2007 540-543  l+ Q% L7 ]9 s( s$ [( ]5 `- K( I% g, ]
© 2007 Sage Publications1 J3 e( z3 H4 K
10.1177/00099228062966518 A. L* p+ x" ?. Z! O
http://clp.sagepub.com
& w% U) p9 s6 V( N2 dhosted at# i8 i* V; L% ?1 H" u  m* w5 ]9 ~4 Y
http://online.sagepub.com4 u2 |" {) y# z+ p4 h' U
Precocious puberty in boys, central or peripheral,6 k, N' F& D+ Z7 ~
is a significant concern for physicians. Central
: g9 k2 A# m* r2 \( Y  R5 p9 C6 Hprecocious puberty (CPP), which is mediated7 p& n6 x- p! S: b% p/ _9 a2 r
through the hypothalamic pituitary gonadal axis, has+ W' H$ |; F8 ]5 R6 h
a higher incidence of organic central nervous system
" c6 G8 m+ x0 d5 @: q4 [/ P4 blesions in boys.1,2 Virilization in boys, as manifested
6 v7 W# S3 W8 B: ~4 Y. q2 p% ]by enlargement of the penis, development of pubic* @7 e5 |; a6 u
hair, and facial acne without enlargement of testi-' i* E* V- E' T1 |( r% ]
cles, suggests peripheral or pseudopuberty.1-3 We3 H4 H8 Q5 h( K
report a 16-month-old boy who presented with the. C- s! q% o) g  g$ R. A7 n
enlargement of the phallus and pubic hair develop-6 f6 H8 j6 J3 |* r- D. r9 F: p" M( y
ment without testicular enlargement, which was due
- A0 ?# Z% d( l! @1 Q4 lto the unintentional exposure to androgen gel used by
' h/ d' E$ p' {6 n: g7 H. Uthe father. The family initially concealed this infor-& L: R7 L$ f. j6 |7 _
mation, resulting in an extensive work-up for this
! w1 d8 D+ Z; Y9 `# Q  i' t+ rchild. Given the widespread and easy availability of
% q, _+ g0 Y0 U+ n4 h8 b( {. Gtestosterone gel and cream, we believe this is proba-1 [* o) p" q! r; ]# W
bly more common than the rare case report in the  l$ D6 ]/ P# D5 g8 @
literature.4
4 q( ~4 s, R' N+ ?% fPatient Report2 r0 C0 ?( g3 o6 f
A 16-month-old white child was referred to the% x" f. t, S% p4 @
endocrine clinic by his pediatrician with the concern8 w8 i% Y3 E- y6 t* R& H/ i+ C( @
of early sexual development. His mother noticed
! v& ~$ i2 N/ a5 b$ _* L4 mlight colored pubic hair development when he was; \0 h$ c# u- l$ x& [% W
From the 1Division of Pediatric Endocrinology, 2University of
' W* m# m& M2 d$ NSouth Alabama Medical Center, Mobile, Alabama.
$ O& {1 F  m8 Z- w  s! K5 H0 QAddress correspondence to: Samar K. Bhowmick, MD, FACE,: q" b! c1 Z0 A. I0 e6 f7 [
Professor of Pediatrics, University of South Alabama, College of. a: o6 X1 w7 m6 s" H3 m3 z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) a  e6 R# j9 m. d' K- U5 S+ j4 b2 J0 G5 \- e
e-mail: [email protected].
3 k8 c/ J! X. X9 d7 S1 `4 mabout 6 to 7 months old, which progressively became+ C# i7 m  H) d" j5 F" E
darker. She was also concerned about the enlarge-
, _+ S5 L8 D" k# a6 L. Vment of his penis and frequent erections. The child+ f' H' o  C6 E
was the product of a full-term normal delivery, with. D+ x' ~* {) u  }+ @
a birth weight of 7 lb 14 oz, and birth length of
: f# I8 m4 t8 I& G3 M$ l) ~20 inches. He was breast-fed throughout the first year9 k; `0 j0 d0 ]
of life and was still receiving breast milk along with/ ~# Q1 S: q: n8 [
solid food. He had no hospitalizations or surgery,
! W/ q8 U* `8 l: ^and his psychosocial and psychomotor development
( M3 S" x- o8 R: ^was age appropriate.
8 h4 u7 e' h& q1 o) ^3 }The family history was remarkable for the father,
$ F9 x2 s" w6 Ewho was diagnosed with hypothyroidism at age 16,1 _7 n- a; w1 O5 i( G( |
which was treated with thyroxine. The father’s' \, p- d- t/ G- e; n0 j$ K
height was 6 feet, and he went through a somewhat
: }9 P: Y6 w6 ]1 D& {- u3 V$ nearly puberty and had stopped growing by age 14.3 o+ D0 ~, ~3 {# N* L! [
The father denied taking any other medication. The$ G/ a$ u& K  f- a! u
child’s mother was in good health. Her menarche; Y/ ~5 k& b' Q3 t. L$ O
was at 11 years of age, and her height was at 5 feet
* L4 e; {, ^7 V  b3 N# G' f, G; N* f5 inches. There was no other family history of pre-8 A2 l/ u) f2 I+ e( o
cocious sexual development in the first-degree rela-& N; o6 D( v6 I& N
tives. There were no siblings.4 Z" Q2 o" ~, j  B
Physical Examination1 W+ Y. R: r7 r# @
The physical examination revealed a very active,# k% o- w+ D. U  ~
playful, and healthy boy. The vital signs documented
: K# r; W0 G7 h$ Sa blood pressure of 85/50 mm Hg, his length was
0 |5 q7 o, H: \5 x90 cm (>97th percentile), and his weight was 14.4 kg
6 [* ]/ J- I+ L# i( s4 c8 x: `(also >97th percentile). The observed yearly growth  K; g  M4 U2 J
velocity was 30 cm (12 inches). The examination of2 `  T! g" _  l! {
the neck revealed no thyroid enlargement.+ H) K! {+ |! _1 _" B9 |+ ?% O, c
The genitourinary examination was remarkable for8 Z3 m8 `( q' J0 W& ]; D; _
enlargement of the penis, with a stretched length of
' X) V" c6 {" y5 x8 cm and a width of 2 cm. The glans penis was very well
% U/ ^; n6 {& ]: G( K- Hdeveloped. The pubic hair was Tanner II, mostly around
& J) v0 ^) A, D7 O6 v1 F0 Q# ?5404 b3 k& P1 C8 w: g* b' s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. d; P" `/ F; O5 Ethe base of the phallus and was dark and curled. The  _: S, G, Q6 x2 h
testicular volume was prepubertal at 2 mL each.
2 S1 _; U( w* o/ S9 a% O, jThe skin was moist and smooth and somewhat9 Y7 I, L9 Z9 @
oily. No axillary hair was noted. There were no
- K# `+ A% m1 n/ o& v4 Habnormal skin pigmentations or café-au-lait spots.
$ }# u; P2 [& UNeurologic evaluation showed deep tendon reflex 2+
( T7 C& _2 f$ p, G! I! Mbilateral and symmetrical. There was no suggestion' u3 {4 w: D7 p' Z5 B8 ]8 l% E! L
of papilledema.
6 |& s# P3 H6 G$ A8 G" w# E- L( GLaboratory Evaluation! I+ H7 }: E1 X" d8 }8 a( f
The bone age was consistent with 28 months by
: {9 O2 |2 ~: z) ^using the standard of Greulich and Pyle at a chrono-
' ~9 V# X3 c  r6 d2 u  m+ x6 r: _logic age of 16 months (advanced).5 Chromosomal( L% ^, @& g; [) ]7 H! ^
karyotype was 46XY. The thyroid function test
" ^2 D: o' \, W7 _! g5 ~9 ?showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# |) P( O3 V1 p; I% Rlating hormone level was 1.3 µIU/mL (both normal).0 R  j$ y% Y+ G; l( U
The concentrations of serum electrolytes, blood
3 f) l# ^6 Y  [, _urea nitrogen, creatinine, and calcium all were0 b3 z2 N3 S, A  a
within normal range for his age. The concentration9 k, T" U8 @/ H
of serum 17-hydroxyprogesterone was 16 ng/dL! |" L& x( m3 S6 o
(normal, 3 to 90 ng/dL), androstenedione was 205 F/ l) @" Z6 M/ F9 n  Y  o  o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, |) t* \" n0 d6 y2 a6 u/ U# mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
* B! G8 o) v: x6 ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to  v- s! y+ ~( N
49ng/dL), 11-desoxycortisol (specific compound S)
" a8 a! g2 P- n* w% u1 S" G0 [: fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: g) ?9 Q) q# `7 Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: B6 |% J$ G' m: `5 U9 D) }testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," n6 B% T0 ~4 q  u* C
and β-human chorionic gonadotropin was less than0 d' v! u9 W" i
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; w* X: c# d5 G' zstimulating hormone and leuteinizing hormone
# U, e& a* v; X- f# y" I  \& sconcentrations were less than 0.05 mIU/mL
8 _1 z$ c( o" L) X- _% r(prepubertal).* p& O! P- S+ p6 X
The parents were notified about the laboratory. s, ]; n' I/ @# j, `/ U
results and were informed that all of the tests were
! ?, ?5 C3 Z6 ~) ?& j& b: }6 mnormal except the testosterone level was high. The
# O( S# U- \9 X% }4 i8 h' T: K' Ffollow-up visit was arranged within a few weeks to8 Z& e) y: p3 I3 ?4 q
obtain testicular and abdominal sonograms; how-6 a! ~1 k) `: ?3 m
ever, the family did not return for 4 months.9 S" o0 u+ k; k/ y/ V0 @
Physical examination at this time revealed that the. x$ H5 z& w0 d2 k& ^- g" e
child had grown 2.5 cm in 4 months and had gained
+ k7 y1 y0 O0 [& @) W: x0 L2 kg of weight. Physical examination remained
. F. U; `0 z( c) J. Iunchanged. Surprisingly, the pubic hair almost com-. P/ f! E. d: K3 R9 u3 P6 d2 \) t
pletely disappeared except for a few vellous hairs at9 u& X9 ^5 u/ _* r# N
the base of the phallus. Testicular volume was still 2
- v7 V5 H2 s& A$ f6 T# K$ UmL, and the size of the penis remained unchanged.7 Y- n& a- L: s( Y' i
The mother also said that the boy was no longer hav-4 U, B& m9 T) i' Z9 u( Z9 |
ing frequent erections.
* w( ^# v1 y: m/ a3 @Both parents were again questioned about use of# H# `! b! g9 a% }6 S
any ointment/creams that they may have applied to7 W- R0 k/ l; Z& [6 ^
the child’s skin. This time the father admitted the
  J9 U$ Q- L  X  OTopical Testosterone Exposure / Bhowmick et al 541+ O  @  [% V+ p2 A) L
use of testosterone gel twice daily that he was apply-
. b. s8 J* y1 q; jing over his own shoulders, chest, and back area for( T/ [, ?5 S( Z, b7 g; e0 y1 |' @
a year. The father also revealed he was embarrassed
) D6 Y4 }% N. Pto disclose that he was using a testosterone gel pre-
; A% ^3 S! X- E5 M1 a( bscribed by his family physician for decreased libido' m8 d) R( K& @( d4 w* I
secondary to depression.
6 J% V( z  g1 s  Y1 tThe child slept in the same bed with parents.7 V  u. e2 T: b) C- J( {7 n% [8 c
The father would hug the baby and hold him on his
3 {7 S. g  W7 ]# Y5 ychest for a considerable period of time, causing sig-
/ P' T: T, k1 T# o( C$ R" pnificant bare skin contact between baby and father.5 _7 i1 O, o" n
The father also admitted that after the phone call,
9 g" `# T7 ?: Z5 Wwhen he learned the testosterone level in the baby) q) i8 Z, `+ e4 P2 w- x
was high, he then read the product information5 J  q. m/ M* i3 a
packet and concluded that it was most likely the rea-0 t5 V$ q* g9 w8 _( Z
son for the child’s virilization. At that time, they' C( b0 d9 ]/ c  ^8 r$ C# R$ H0 m
decided to put the baby in a separate bed, and the
) s: H8 m/ o5 X/ C; w1 `7 Vfather was not hugging him with bare skin and had
* c$ ~& l$ y& N1 }" Z/ o7 g1 f$ ybeen using protective clothing. A repeat testosterone% q5 y, `* A4 R3 I, Y
test was ordered, but the family did not go to the
/ e' K' ~3 P- nlaboratory to obtain the test." O. c. P3 }+ T
Discussion& g' C& l, U8 e) r6 U
Precocious puberty in boys is defined as secondary
& ^5 ~! |7 G, G2 dsexual development before 9 years of age.1,40 q0 |) a$ v) Q; N9 x
Precocious puberty is termed as central (true) when" `  W8 q! i3 Q4 w  R$ ]
it is caused by the premature activation of hypo-
- C# x( J; h: Y0 ~: ]thalamic pituitary gonadal axis. CPP is more com-# f" ~/ m* f; |" ]0 b2 I
mon in girls than in boys.1,3 Most boys with CPP7 Y* }; O0 @- K( b9 S2 j
may have a central nervous system lesion that is
! A! Z+ d" o4 m7 Gresponsible for the early activation of the hypothal-; ?; m7 H: m7 K9 b( E1 |+ F
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ M, t! [9 A1 S: Csis has been given to neuroradiologic imaging in0 v! J0 l" |2 K" y; q  N! M
boys with precocious puberty. In addition to viril-
1 P! L) @. v: o! J0 B- \4 E. oization, the clinical hallmark of CPP is the symmet-
! Q5 M( V" _" a% F- A: Frical testicular growth secondary to stimulation by1 N& ~2 _" V; ^) r( [8 t
gonadotropins.1,3
( {' w+ [1 T2 l; I; e# @3 U0 sGonadotropin-independent peripheral preco-
+ h% m8 P5 i8 C& A& S, u8 @cious puberty in boys also results from inappropriate' J3 @, I9 g- I( Q1 e8 r
androgenic stimulation from either endogenous or4 F+ O/ r7 g1 h
exogenous sources, nonpituitary gonadotropin stim-
& F  B: S4 N  dulation, and rare activating mutations.3 Virilizing  _. a8 s. q7 P1 B
congenital adrenal hyperplasia producing excessive
0 {$ G% U. f3 W! w0 Iadrenal androgens is a common cause of precocious$ F! y  y4 ?# g! s0 Y% V
puberty in boys.3,4- L7 c# |' \" {( A3 M0 u
The most common form of congenital adrenal. s; y2 D# [* d4 W" l% e
hyperplasia is the 21-hydroxylase enzyme deficiency.6 J5 ]" t  t, Q' j- T/ P
The 11-β hydroxylase deficiency may also result in/ a. X2 t* W5 B2 _+ N9 ^1 ^# e0 y4 @
excessive adrenal androgen production, and rarely,, p8 p) ^7 w2 L1 I5 x' O
an adrenal tumor may also cause adrenal androgen
. J5 F2 `9 O. _0 ?- v1 k# Uexcess.1,3) {- }. e0 n& O3 e7 [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% j" X7 z# x; g4 h' ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 o! \8 U8 e: o* \& `: [A unique entity of male-limited gonadotropin-
# `! B5 e5 ~" Dindependent precocious puberty, which is also known0 C. [5 L9 O% c8 D$ T+ e* m
as testotoxicosis, may cause precocious puberty at a/ }: @5 [: N4 Q7 F- {
very young age. The physical findings in these boys7 Y: u2 w* y$ c4 g8 R) ?
with this disorder are full pubertal development,: @$ M2 d; Z3 {: O  ?  f. ]0 S
including bilateral testicular growth, similar to boys/ A0 Y& n; [7 A! T- q. U
with CPP. The gonadotropin levels in this disorder% R' \, o# @8 [6 l$ [7 l
are suppressed to prepubertal levels and do not show% Q. W, Z( s! G9 ^  p. b$ ~/ t7 a
pubertal response of gonadotropin after gonadotropin-. Z3 Z6 H; [& B! ^, @$ j: |0 F7 F
releasing hormone stimulation. This is a sex-linked
- [, W6 R9 K0 H- o$ N) d+ hautosomal dominant disorder that affects only
4 Z9 t; o' s7 N$ V1 t) [males; therefore, other male members of the family
& T, L& U+ p7 A2 s& n$ hmay have similar precocious puberty.3" J" M/ |) l4 A2 U
In our patient, physical examination was incon-" f9 [: N5 N5 b* B1 q2 R
sistent with true precocious puberty since his testi-
: {1 F* B7 t, @  L5 @cles were prepubertal in size. However, testotoxicosis+ l* X9 B" \3 A/ o
was in the differential diagnosis because his father
, X- H7 z7 G* }( b- N/ Lstarted puberty somewhat early, and occasionally,
! [3 X/ r  `% _testicular enlargement is not that evident in the
7 l! ]' G5 X" g8 a* x9 H* }, P( Pbeginning of this process.1 In the absence of a neg-% s4 _/ j1 W8 ]! z/ e) P+ V1 q
ative initial history of androgen exposure, our
; _% M) Q& ?* _5 X8 gbiggest concern was virilizing adrenal hyperplasia,, S0 W* I: `4 p# |' n
either 21-hydroxylase deficiency or 11-β hydroxylase+ a3 y2 O+ c7 u" w' g4 p$ w4 W
deficiency. Those diagnoses were excluded by find-! L5 o) F3 N3 h
ing the normal level of adrenal steroids.
# w- B2 q6 U: VThe diagnosis of exogenous androgens was strongly
& G% J4 a: B/ r- k$ X. O5 ^: v& asuspected in a follow-up visit after 4 months because
# k. K. |& @+ Tthe physical examination revealed the complete disap-
; C, y! h' f. G  g1 Z, ppearance of pubic hair, normal growth velocity, and; u4 B6 E- }: K- N! |5 d
decreased erections. The father admitted using a testos-, T1 B- }4 j! d" u+ w- }2 P
terone gel, which he concealed at first visit. He was3 P+ q, {' q3 Q; t* I; R
using it rather frequently, twice a day. The Physicians’  D; l/ H' D, |
Desk Reference, or package insert of this product, gel or
; p6 x2 @/ U1 l- d6 V4 Y5 Q  z" Ucream, cautions about dermal testosterone transfer to
1 F2 l0 d2 D, j/ ~unprotected females through direct skin exposure.- s9 p. x: R' L; q1 B! b
Serum testosterone level was found to be 2 times the- x( \+ [" N6 {- n* c
baseline value in those females who were exposed to
4 s" B/ W6 o3 Meven 15 minutes of direct skin contact with their male6 S/ J. V/ ]7 V8 U  w+ B3 f: Q
partners.6 However, when a shirt covered the applica-
$ x. J# a7 c- S7 Ction site, this testosterone transfer was prevented.+ J4 S3 C3 f' [/ ]1 D
Our patient’s testosterone level was 60 ng/mL,: \! w+ s$ T0 b5 b. k9 b4 @& w
which was clearly high. Some studies suggest that
. B1 z3 g9 p& A' ^: Ydermal conversion of testosterone to dihydrotestos-+ i! a; F5 K) g7 W' S3 y
terone, which is a more potent metabolite, is more
: E7 B$ Q: c- R/ yactive in young children exposed to testosterone
; Z/ d$ `( X3 E6 P+ z6 h+ Vexogenously7; however, we did not measure a dihy-
* b! \2 S8 _1 m1 {! @, c8 v$ adrotestosterone level in our patient. In addition to
3 C& o1 G8 l# N2 }' h/ t3 {virilization, exposure to exogenous testosterone in0 u- l) w) H; ?1 h
children results in an increase in growth velocity and
9 j% T8 e* o" j3 `) Dadvanced bone age, as seen in our patient.% ^: }) {+ i( K+ |; I- X! J
The long-term effect of androgen exposure during
$ N  I6 {. ~5 W9 \/ n4 searly childhood on pubertal development and final' v1 Y; y) f8 h4 F$ z% j; f
adult height are not fully known and always remain
! R/ O( V5 a6 M& f* K8 {6 ^a concern. Children treated with short-term testos-
0 C  T4 P. r% |terone injection or topical androgen may exhibit some
1 _# [  h: D( a% M; facceleration of the skeletal maturation; however, after) A. Y% x; \' {2 b0 X
cessation of treatment, the rate of bone maturation
: W: k- ^1 D+ ]# \0 tdecelerates and gradually returns to normal.8,9
( g0 M) G- s( @- nThere are conflicting reports and controversy9 z$ F. {! A, T4 W' ~% @8 ^2 u8 L8 q
over the effect of early androgen exposure on adult/ ~. b; _( Q0 y7 m4 a' Z+ `
penile length.10,11 Some reports suggest subnormal
( @7 n8 m5 z9 v7 }% n+ Z* Nadult penile length, apparently because of downreg-2 z3 e3 D% |7 P, Z% {" ~# r
ulation of androgen receptor number.10,12 However,+ I8 F- H9 W4 ~0 S: q  _" @3 t
Sutherland et al13 did not find a correlation between! b8 l% F! q( M) y4 |/ s
childhood testosterone exposure and reduced adult
. `1 w$ S! W7 {" n% q& T' [- Upenile length in clinical studies.
5 A% v' ?4 c5 P; iNonetheless, we do not believe our patient is) b9 p  S4 A, D) ?  i
going to experience any of the untoward effects from% y2 Z* r. @$ Z4 ~% J
testosterone exposure as mentioned earlier because
) F0 R) B. Y( m, G0 ]" Q) xthe exposure was not for a prolonged period of time.
6 L! j4 W. f3 }0 [# QAlthough the bone age was advanced at the time of0 g7 a: L  l0 d! K& E
diagnosis, the child had a normal growth velocity at
% S7 O4 Q6 k$ L' Bthe follow-up visit. It is hoped that his final adult
& T4 K$ }0 l' |  dheight will not be affected.
& ]* f1 x, K9 U; `: J7 ^& iAlthough rarely reported, the widespread avail-& V7 A! }, t0 \8 V
ability of androgen products in our society may
& w0 `0 r6 q$ t% t* N& I/ F9 o2 lindeed cause more virilization in male or female" M  b# Q% z3 Q
children than one would realize. Exposure to andro-
" Q: t1 }& `# R1 `  ]' o1 P6 ngen products must be considered and specific ques-
+ `  d: x! `; l" [, P4 N9 |tioning about the use of a testosterone product or
, T$ y+ v, C) Hgel should be asked of the family members during9 j  m& a* t" L1 s0 E* A: f
the evaluation of any children who present with vir-
) s: K3 O; D  J' p; j3 z7 Pilization or peripheral precocious puberty. The diag-. L: \5 W+ M4 I5 [/ [' [' J! w
nosis can be established by just a few tests and by
' x  n: E' b$ p1 j+ v  bappropriate history. The inability to obtain such a7 C: `7 Z5 }1 B
history, or failure to ask the specific questions, may
6 A$ q* ?5 e  x2 {. {result in extensive, unnecessary, and expensive
2 C: X& N9 q# O% q  Y- }6 E) Hinvestigation. The primary care physician should be
1 f9 S* Q* I' e0 daware of this fact, because most of these children
2 C2 h. M3 s1 |" a/ vmay initially present in their practice. The Physicians’; M0 `2 O5 _! S  `
Desk Reference and package insert should also put a0 r, p5 U1 q1 T2 [
warning about the virilizing effect on a male or
7 N$ }( l: U# m$ {female child who might come in contact with some-
0 d2 J- F1 R; i, d% [7 Wone using any of these products.: K) ]& [6 M9 d8 y2 I9 a
References. l7 H9 }/ Y1 ?# B7 [7 d
1. Styne DM. The testes: disorder of sexual differentiation8 [" M& x$ [% a+ J  Q9 d
and puberty in the male. In: Sperling MA, ed. Pediatric
: Z5 z4 [, ]% S; R* VEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 A3 ~$ f% @! ]& N0 H0 `0 U) Q# Z2002: 565-628.$ |) M  w- _, l/ Y7 \1 }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious  E" l. y7 h' E" Y
puberty in children with tumours of the suprasellar pineal
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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!

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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!
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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

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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

* ?: t/ _' E$ y; F& q4 ^精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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