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Sexual Precocity in a 16-Month-Old: B2 _; t+ \. M/ C8 R: D
Boy Induced by Indirect Topical
- Q. Q* k8 R+ [2 Q% JExposure to Testosterone
9 E  e7 T" M7 R6 G( hSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) K8 E) [/ M  o$ T7 l0 w
and Kenneth R. Rettig, MD12 q9 Z* i( M; ]" |9 `* c
Clinical Pediatrics. u- V4 j  K5 D: z7 c( J
Volume 46 Number 6( i0 v3 \  ~/ C
July 2007 540-5430 e/ ]1 ~. F! O$ K) u$ y' O
© 2007 Sage Publications9 @6 N, |$ x0 ]" w
10.1177/00099228062966517 x0 A6 ^, U& A- s; ]/ \# Z* |% a
http://clp.sagepub.com+ y; K5 H9 L4 V6 U/ t0 p, X. i! I
hosted at
( E) Y: R' _- C3 p1 ~' ihttp://online.sagepub.com& x3 W/ `) N4 k
Precocious puberty in boys, central or peripheral,/ |8 ?6 p& l2 o
is a significant concern for physicians. Central7 L  z, m2 g! ~& ~* ?8 g, Q8 C7 P
precocious puberty (CPP), which is mediated9 n7 I1 _( |; v) M) p! K* v- J( E6 e& u
through the hypothalamic pituitary gonadal axis, has7 \% j% |8 S* x0 |7 S
a higher incidence of organic central nervous system
' ^, v$ o% A6 V- Q9 b! z% K% Xlesions in boys.1,2 Virilization in boys, as manifested
; P, ?2 m: q: p2 X/ P, Jby enlargement of the penis, development of pubic
; W: D) `: ~# X" A, F/ D1 c( k) Thair, and facial acne without enlargement of testi-/ |5 ?$ h" c+ K) p
cles, suggests peripheral or pseudopuberty.1-3 We
: ~; p, r4 I- l2 Z0 q% ureport a 16-month-old boy who presented with the, C8 r/ X+ r: Q' U+ o
enlargement of the phallus and pubic hair develop-# `, z3 T% y: w
ment without testicular enlargement, which was due0 t# s1 w# @8 w7 s! c" q( j
to the unintentional exposure to androgen gel used by
. v; D9 n" Z* H- l+ F7 xthe father. The family initially concealed this infor-
! r+ R' F  b5 N1 o* \mation, resulting in an extensive work-up for this
7 j! v8 N) s4 R  K" l  ichild. Given the widespread and easy availability of/ E. q: i3 b0 u! P0 c
testosterone gel and cream, we believe this is proba-' ^( v8 N+ o* g7 l8 g6 v
bly more common than the rare case report in the4 z  I8 ]' H  s1 J6 x1 W
literature.4
. p1 B1 S! e3 KPatient Report  g9 R/ s/ [" k6 a
A 16-month-old white child was referred to the
7 x7 |- P5 |( Q3 ]# b9 p4 g2 D1 }endocrine clinic by his pediatrician with the concern6 }$ p# q- o; ^# I( ]  C: b
of early sexual development. His mother noticed* \/ g. b  A8 v1 Q& x4 q. Q3 ]
light colored pubic hair development when he was
" h. L9 M( K7 A' p4 P( u; O, i) F5 lFrom the 1Division of Pediatric Endocrinology, 2University of
5 n. j1 _; D  P+ _! C+ \3 Z; D3 @2 pSouth Alabama Medical Center, Mobile, Alabama.% I2 V; H  S* R+ e% D0 Q% i
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 |+ }9 T( [; Q7 r1 KProfessor of Pediatrics, University of South Alabama, College of! ~. M8 T) q3 v
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: ]9 n; y  m5 W" r6 m0 W1 l% `8 H
e-mail: [email protected].* G( ?! [6 y( j2 T6 l
about 6 to 7 months old, which progressively became4 h: P+ R0 r& v- F
darker. She was also concerned about the enlarge-; \! C( D7 g5 G$ \  o# S5 Z# Y4 v
ment of his penis and frequent erections. The child( I/ U$ a% K4 Z1 C* L7 n5 E
was the product of a full-term normal delivery, with
4 r5 ~' a% P8 E1 G& R5 h( o; f# a' ra birth weight of 7 lb 14 oz, and birth length of
) e& W5 m  M7 M( y: W& z; B9 w20 inches. He was breast-fed throughout the first year
' L4 E2 e' X$ Z/ S' ]5 U6 l5 }% [of life and was still receiving breast milk along with
0 B: g0 D( V) ^4 s! h+ q5 ]solid food. He had no hospitalizations or surgery,7 v# D5 R$ X4 L: k7 t3 g$ i
and his psychosocial and psychomotor development+ ^5 J9 w1 ^5 q2 Z1 y, F
was age appropriate.
  s( F8 w) l0 d% K+ I4 K7 JThe family history was remarkable for the father,+ x$ D' F1 J6 _: _6 N, H6 A8 {
who was diagnosed with hypothyroidism at age 16,
6 L) ?6 n4 w- g) p7 _$ n9 mwhich was treated with thyroxine. The father’s
2 ]3 [' I' Y3 o4 j1 gheight was 6 feet, and he went through a somewhat" O- o" k+ k  G+ I
early puberty and had stopped growing by age 14.
' j8 l1 D/ G) S( r: ^The father denied taking any other medication. The
5 j5 o% g) G1 f! v+ W& wchild’s mother was in good health. Her menarche& R( M8 T- w: ?, {' K9 r$ N
was at 11 years of age, and her height was at 5 feet$ ^. q0 s5 y7 l2 ~
5 inches. There was no other family history of pre-$ r! b1 _: Y+ h0 n# B1 E, i
cocious sexual development in the first-degree rela-
% [5 M( L$ t/ q+ jtives. There were no siblings.. z+ j9 R/ @# B$ e+ \' Y9 c+ _
Physical Examination
( t" Y' f+ F8 n  J% V' eThe physical examination revealed a very active,
5 d6 P' Z6 \$ S# Bplayful, and healthy boy. The vital signs documented
+ Q7 k9 f4 k  X& W: |7 _0 }7 Ga blood pressure of 85/50 mm Hg, his length was/ G# F4 x9 c4 T$ q0 |! `
90 cm (>97th percentile), and his weight was 14.4 kg
5 ?( {0 _* c; A) j(also >97th percentile). The observed yearly growth# j& I+ I' n- X& l& c6 m) C  Y
velocity was 30 cm (12 inches). The examination of
( u3 m+ j6 q% s( K* {the neck revealed no thyroid enlargement.' U; E( P& N2 Q" W* J
The genitourinary examination was remarkable for
( w8 L$ ]2 D9 {; R( nenlargement of the penis, with a stretched length of* k' S; ^/ k. C# R4 C
8 cm and a width of 2 cm. The glans penis was very well7 @+ M9 [; b; N- v1 x
developed. The pubic hair was Tanner II, mostly around1 A3 I5 s  ?. l& @; `8 {) t; o$ b
540
/ n' R& }0 V2 nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; @* C/ a1 N% l( O' Sthe base of the phallus and was dark and curled. The4 p: C% i: F1 x$ a
testicular volume was prepubertal at 2 mL each., A2 H9 |( ?) ~( G; }
The skin was moist and smooth and somewhat
) k1 \' Y5 l0 Roily. No axillary hair was noted. There were no
# ?7 e0 _% v. m7 ~/ @abnormal skin pigmentations or café-au-lait spots.
0 w3 l/ o& C6 pNeurologic evaluation showed deep tendon reflex 2+
1 I$ U7 T/ P4 h  J0 P( Abilateral and symmetrical. There was no suggestion
1 j; i+ o* l: Q9 W7 C% [! B/ z7 P; bof papilledema.6 Z4 I) P! q' O% M
Laboratory Evaluation
& `1 H/ }. {! {, QThe bone age was consistent with 28 months by
+ I! l( }: M# ~using the standard of Greulich and Pyle at a chrono-
& G! c# z  x/ G& v$ qlogic age of 16 months (advanced).5 Chromosomal
4 U. A0 M* K& _! A: Gkaryotype was 46XY. The thyroid function test
: K. q" R6 A5 F/ F$ xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% D; }6 p3 J6 C+ m; {! z; z
lating hormone level was 1.3 µIU/mL (both normal).
' C" L  U% }* N: ~The concentrations of serum electrolytes, blood
# A  x9 w" F. o+ s  Turea nitrogen, creatinine, and calcium all were
6 q( G4 H& ~; t0 w! pwithin normal range for his age. The concentration% y+ l/ m6 B6 k: |" |
of serum 17-hydroxyprogesterone was 16 ng/dL
* w; G+ M9 g7 u. u7 L( O1 _8 ?(normal, 3 to 90 ng/dL), androstenedione was 20: ?! m3 e! [& s+ X1 T
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ v! Y: ~) U% c( m
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 N+ c: ]5 n3 y% Z5 @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ @7 ]; O5 T4 W$ F" |49ng/dL), 11-desoxycortisol (specific compound S)# i' ?0 f) R, h0 S  r+ d4 m
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 C% ]8 Z3 z6 P/ ^9 a& M8 ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% e) ?& H+ s) h" i& w4 `3 ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 ]' v+ _! T+ e  i) z
and β-human chorionic gonadotropin was less than' Q9 ?* u8 w3 L; J3 p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
! }/ {$ P" B7 D0 Dstimulating hormone and leuteinizing hormone
, [, j+ S3 z+ h2 A" j' Mconcentrations were less than 0.05 mIU/mL. m/ p8 U1 ]6 _1 `1 `! _$ Y
(prepubertal).
: a9 \3 R' S5 y2 ?  m8 hThe parents were notified about the laboratory3 z5 D# `1 O) K
results and were informed that all of the tests were
5 u* |5 `. G1 |. j$ [normal except the testosterone level was high. The
8 M1 x5 j+ c4 T9 Xfollow-up visit was arranged within a few weeks to
9 s( G* q+ U# O2 |6 L" Mobtain testicular and abdominal sonograms; how-
' t: ]  D3 w* O, `3 uever, the family did not return for 4 months.
7 K: r5 e7 C5 z0 h3 u! U5 [/ I  qPhysical examination at this time revealed that the: a# O  ?( C* R! C+ g
child had grown 2.5 cm in 4 months and had gained: W; C; i* f( Q" l
2 kg of weight. Physical examination remained
. X, ]( x: u" K" k' H! H) Uunchanged. Surprisingly, the pubic hair almost com-
# t$ I" R# u6 Spletely disappeared except for a few vellous hairs at4 R% S" o' F% |+ H8 @
the base of the phallus. Testicular volume was still 2# C8 k4 M- {) b/ n- y  ~
mL, and the size of the penis remained unchanged.+ W5 {. F9 H. X; }5 O, u; {
The mother also said that the boy was no longer hav-
) J# L( @$ M7 p; R- Wing frequent erections.) h1 A, B- q; p7 c, c7 q# O- f
Both parents were again questioned about use of" Q! |+ u6 `9 Q4 `' T% M$ m
any ointment/creams that they may have applied to0 n! S; _7 a. V
the child’s skin. This time the father admitted the3 }6 b' _/ |! ~* L
Topical Testosterone Exposure / Bhowmick et al 541
0 Z* t" @; v8 f' euse of testosterone gel twice daily that he was apply-
" {& D! q# O3 r9 }4 f3 Ting over his own shoulders, chest, and back area for
) W( \' \8 M8 _; \a year. The father also revealed he was embarrassed% ~* L" T5 R4 U1 G2 |
to disclose that he was using a testosterone gel pre-
% i6 H1 b2 ]. |: b3 {4 X  Fscribed by his family physician for decreased libido# E+ h; ]! W( x1 j  q) [$ j" y
secondary to depression.$ G$ ^* @' K7 P+ y' t7 g+ ?3 x
The child slept in the same bed with parents.
) {* k4 L! v/ e9 X* tThe father would hug the baby and hold him on his' j1 h( ^3 N+ _- n: m, U
chest for a considerable period of time, causing sig-
) @- U* [: J, Cnificant bare skin contact between baby and father.
% f/ c( W2 h0 w, l1 O1 y; N6 KThe father also admitted that after the phone call,2 L! ^1 }2 `9 f0 U
when he learned the testosterone level in the baby
5 w1 m; C& D" f& k8 B! Awas high, he then read the product information  i3 C: a' F* F$ K+ w' J+ b& G9 t
packet and concluded that it was most likely the rea-: X3 K& E  X% d$ A
son for the child’s virilization. At that time, they
- z/ l. y" Y. B* b( u1 @4 b4 t+ J: Cdecided to put the baby in a separate bed, and the# s% h* w- f5 r
father was not hugging him with bare skin and had
2 h* }" ]( R- C: H& Z- sbeen using protective clothing. A repeat testosterone
5 }4 |/ d. k& ?$ {& stest was ordered, but the family did not go to the
2 s( Q5 E/ {* \0 q6 Blaboratory to obtain the test.
7 X3 Y& W9 J, J% H( ADiscussion
* V- r  f: |" ZPrecocious puberty in boys is defined as secondary6 ~6 S4 p/ Q" O$ U, ?
sexual development before 9 years of age.1,4- C9 K  v) l' S$ b
Precocious puberty is termed as central (true) when9 |( `$ E* `4 e% z; Q- l
it is caused by the premature activation of hypo-
  q9 S' M$ C3 Hthalamic pituitary gonadal axis. CPP is more com-' d+ f. |1 P) k, i" \/ k2 A6 P
mon in girls than in boys.1,3 Most boys with CPP
+ D6 R3 b0 B& E, vmay have a central nervous system lesion that is1 b4 Z; L, {/ l* y( M! F
responsible for the early activation of the hypothal-2 C; r7 d/ L. C; Z7 q, ]" J
amic pituitary gonadal axis.1-3 Thus, greater empha-+ g) f; q- j- \4 n4 }- e/ h7 T6 \
sis has been given to neuroradiologic imaging in1 ^& g1 I) ?6 S0 o. r7 f
boys with precocious puberty. In addition to viril-5 t: A5 o" o1 a
ization, the clinical hallmark of CPP is the symmet-
+ z! ?* X$ T6 U+ w& {8 E7 Hrical testicular growth secondary to stimulation by/ n" p/ S+ ?* J" }7 Q' e1 M
gonadotropins.1,3
) B* i. ]5 v8 G7 v' s0 \Gonadotropin-independent peripheral preco-/ k0 s6 Z1 i& {4 _- c9 b1 S4 Y& Y" i
cious puberty in boys also results from inappropriate
# w" A- J  r& qandrogenic stimulation from either endogenous or
& }2 h( l) e6 }9 e* m# Zexogenous sources, nonpituitary gonadotropin stim-; u# q! Z  I& }3 G3 m
ulation, and rare activating mutations.3 Virilizing
& p6 ?  h, t) |/ ccongenital adrenal hyperplasia producing excessive
9 \. i4 \# w: `% vadrenal androgens is a common cause of precocious) D! z" |# I6 ~7 E. b5 F
puberty in boys.3,4( w8 I: u5 w& n. U: Y' n: j1 _4 O6 J
The most common form of congenital adrenal# }; ?6 z8 D% \7 f1 m$ {1 Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
0 U8 V( h% k+ M, u" [The 11-β hydroxylase deficiency may also result in
+ H  h& t# ]$ ?4 Eexcessive adrenal androgen production, and rarely,
& b$ u) r* ]( ]# L. K5 y2 Can adrenal tumor may also cause adrenal androgen" t: o* H8 Y6 R
excess.1,3
: Q! G6 g5 e- @' \+ \" j, M1 t- dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# r3 w$ G: Q, H" f7 [6 T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) A7 n2 A$ n3 x2 g* `9 k: r
A unique entity of male-limited gonadotropin-
3 G4 [2 O8 M& Q2 L. y7 E# V2 {3 \4 Rindependent precocious puberty, which is also known
1 B2 b  m3 e1 |) v7 e" P2 n: T( _& Pas testotoxicosis, may cause precocious puberty at a1 c4 w7 Y/ ^5 D# s
very young age. The physical findings in these boys  D/ B- V, W: D9 K- ~/ @1 e2 n
with this disorder are full pubertal development,+ b' x6 R0 l) Y0 o4 ~* R4 T
including bilateral testicular growth, similar to boys" s8 f- C0 y$ a0 @9 B; P  f; \
with CPP. The gonadotropin levels in this disorder
4 `3 b( B& H* s3 `9 y) k: @are suppressed to prepubertal levels and do not show
8 B* A4 @1 v) c* r, Lpubertal response of gonadotropin after gonadotropin-/ u* R! f* M- p/ o5 V6 d
releasing hormone stimulation. This is a sex-linked
( C1 x; n1 u- j$ j3 H7 Nautosomal dominant disorder that affects only; o7 S; ~3 Y4 g2 t
males; therefore, other male members of the family
* K  N, A4 ~8 Y* ~6 Dmay have similar precocious puberty.3
2 K1 E' i5 g% r, o& B! X9 e1 BIn our patient, physical examination was incon-- A5 a; F# b/ @# J
sistent with true precocious puberty since his testi-
  {) G0 w* H( ]& M) y7 A2 U, {cles were prepubertal in size. However, testotoxicosis
. V2 z4 e: b1 u- w& T; {' S9 qwas in the differential diagnosis because his father
5 U1 E& {+ S$ ~, Z; G3 bstarted puberty somewhat early, and occasionally,
+ Q) r$ T1 q4 I0 _testicular enlargement is not that evident in the
6 N' X1 I" P1 t& o" i  vbeginning of this process.1 In the absence of a neg-7 ]( R" m! P. w6 j
ative initial history of androgen exposure, our
9 W, q% ^% k! p5 |; H& Wbiggest concern was virilizing adrenal hyperplasia,! W& a: E9 u2 r8 U' ?5 p# v
either 21-hydroxylase deficiency or 11-β hydroxylase" E4 W7 F7 G  x
deficiency. Those diagnoses were excluded by find-
2 o3 }+ n' C; p1 m& @1 Eing the normal level of adrenal steroids.
/ T' _2 I- e5 m/ w3 [The diagnosis of exogenous androgens was strongly
# h3 ?( E4 ^" n* Bsuspected in a follow-up visit after 4 months because
( x& Q. p5 b# {$ `- j0 O. Tthe physical examination revealed the complete disap-# g6 h/ i$ y0 P+ ]" Q/ {  u
pearance of pubic hair, normal growth velocity, and
; [( Q) f6 C' M7 s% j' a- u# Bdecreased erections. The father admitted using a testos-% D, v7 {( g3 Q
terone gel, which he concealed at first visit. He was
7 E7 `$ d( k# ?- }$ rusing it rather frequently, twice a day. The Physicians’
+ ]) h. l( Q: f6 l! E! WDesk Reference, or package insert of this product, gel or5 |$ A1 d, o/ D6 j) h3 }
cream, cautions about dermal testosterone transfer to9 N; w9 R4 o9 e! s  k$ O
unprotected females through direct skin exposure.
; c% t. s# ^( A# C) HSerum testosterone level was found to be 2 times the
/ g8 X8 e1 Q; B* W. v) _+ t* W6 Cbaseline value in those females who were exposed to$ l  R# A/ y$ [4 Y+ L, ~
even 15 minutes of direct skin contact with their male
0 h; p! b! X" ^& y; [partners.6 However, when a shirt covered the applica-
' L% K* W; f6 Z& [6 Mtion site, this testosterone transfer was prevented.
( [+ @! L7 ?! ]$ Q; m) U( XOur patient’s testosterone level was 60 ng/mL,& `1 w5 L! x% P) x2 p
which was clearly high. Some studies suggest that
2 |& ~* _8 ]2 b+ y! ~( D* @dermal conversion of testosterone to dihydrotestos-" e# S8 Z1 H: v( l( N% P: V$ g
terone, which is a more potent metabolite, is more
9 _2 O! P4 u; l, B- s3 R! Nactive in young children exposed to testosterone% }3 @) s% S4 l! y7 ]' J8 l
exogenously7; however, we did not measure a dihy-
5 A  {# b8 c: k5 X- l' E* N7 Q9 `drotestosterone level in our patient. In addition to
5 \$ k' |3 C: N( D, ]$ zvirilization, exposure to exogenous testosterone in+ h7 i. h* ?( C
children results in an increase in growth velocity and1 S, b9 c% H% Y
advanced bone age, as seen in our patient.
# t1 Z8 F* e+ {: G* OThe long-term effect of androgen exposure during
! a7 b' R. J. k- r" Uearly childhood on pubertal development and final
- A3 }  o. B4 I- ladult height are not fully known and always remain
/ R, |6 n4 s6 W: Q' x1 va concern. Children treated with short-term testos-8 Y/ I( O9 ~: Y/ ]
terone injection or topical androgen may exhibit some) e4 {$ f, `+ ]! F+ O* f, d$ k
acceleration of the skeletal maturation; however, after
9 a) _* z7 `6 d2 x! ncessation of treatment, the rate of bone maturation
) @* p. }& p$ h" }decelerates and gradually returns to normal.8,9$ I5 p0 p- v  h) g% y
There are conflicting reports and controversy! P+ g+ z0 y1 c3 |0 z
over the effect of early androgen exposure on adult2 x& `1 |) D9 h) g" ~7 {
penile length.10,11 Some reports suggest subnormal5 C% a0 c  M1 @4 n1 z
adult penile length, apparently because of downreg-
: _0 z' O% B3 l) Pulation of androgen receptor number.10,12 However,4 @* S5 L9 p' @( ~7 g: j7 g& h
Sutherland et al13 did not find a correlation between
3 u4 ~3 _" g/ r# e( P! Wchildhood testosterone exposure and reduced adult; U3 w. C1 H- ^7 h* c" T- x
penile length in clinical studies.
" \& I# ~* H3 E# v' {) P5 jNonetheless, we do not believe our patient is
7 [; q2 P- u& g; h( I: w( l# T6 Ngoing to experience any of the untoward effects from5 B8 I# N( J' O; z4 f$ y  b( v1 ^
testosterone exposure as mentioned earlier because
+ T9 A5 p; k4 {2 s% Athe exposure was not for a prolonged period of time.; a9 [3 I7 ?/ L  R6 h
Although the bone age was advanced at the time of' Q* r& T# j( D
diagnosis, the child had a normal growth velocity at
' u* G5 ~  _0 a7 U" W. F1 P8 Gthe follow-up visit. It is hoped that his final adult
( W0 j$ t5 i+ v; H$ z' ~height will not be affected., y" A: }$ K3 V! m5 Y; |
Although rarely reported, the widespread avail-
* T3 D7 C3 ~+ ]4 |6 sability of androgen products in our society may
9 z$ m  ~" ]% d  ?9 e; n' ^indeed cause more virilization in male or female5 Y, a# K* r& s6 O
children than one would realize. Exposure to andro-
8 s' [  p* X! e/ i+ n, @gen products must be considered and specific ques-7 t& ^* e  P- B7 i: q! Z
tioning about the use of a testosterone product or
8 {# T  R& P0 R! I: T! xgel should be asked of the family members during
3 y) q! o$ W$ D" [. Hthe evaluation of any children who present with vir-
  i  ]; U6 I" d, k/ u9 pilization or peripheral precocious puberty. The diag-, X  ?* i: E" ~6 P" G
nosis can be established by just a few tests and by
, b# n* f* d$ Q% ]. L+ rappropriate history. The inability to obtain such a
4 c$ T6 e* r* {; o& yhistory, or failure to ask the specific questions, may
9 K; ^- k' H+ \3 B8 W% Wresult in extensive, unnecessary, and expensive1 l' m) r6 p+ x4 W: K; O
investigation. The primary care physician should be
6 y4 C6 F+ K  a+ [5 U/ a7 s5 G5 haware of this fact, because most of these children+ d- a% R  Y" e* ^  M
may initially present in their practice. The Physicians’
: S% z+ j- D  d% w; mDesk Reference and package insert should also put a
* Y0 d5 W. p6 L* y+ T4 S0 qwarning about the virilizing effect on a male or
8 x" z6 K' G+ h9 ?1 A$ O2 ffemale child who might come in contact with some-
4 B& y! i+ Y: Y+ I6 [! |! U0 ~one using any of these products.
9 s2 A& x  ^  m( d  {References: ?, p" c" J' z
1. Styne DM. The testes: disorder of sexual differentiation
# L& K( w, N' H  S( Xand puberty in the male. In: Sperling MA, ed. Pediatric
  X/ u# a5 h5 G* z# kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- o2 b) g7 E8 v% T( o/ n/ j7 N
2002: 565-628.
! A( U- C9 S; ^1 x0 \( ?2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& a0 \# }" B  M) o" zpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 }2 P( v" g; ^
Boy Induced by Indirect Topical) e8 o+ I1 @) H# o* |: N
Exposure to Testosterone
( V! U3 s4 K+ q* H. M8 y( vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 a0 H( I8 U# v2 v3 y6 F
and Kenneth R. Rettig, MD1
- d; k9 @/ b- ?$ V6 ~- TClinical Pediatrics% u- b7 O1 r( d# S4 j6 V" T- s
Volume 46 Number 6
0 J' L& [3 W$ ?: j+ l' L. [July 2007 540-543. R( M" D% |- J8 j% e0 F0 I
© 2007 Sage Publications2 }$ C+ N7 r1 @7 h
10.1177/0009922806296651* K8 [9 w9 J# ]: F
http://clp.sagepub.com6 \# N2 m6 \- X
hosted at
0 V' A0 O/ k) h: r8 r; S6 ^% w. lhttp://online.sagepub.com
3 \& }" h6 y/ ?  R3 O' n6 v0 VPrecocious puberty in boys, central or peripheral,4 G1 s, K& A/ T6 [1 w6 O
is a significant concern for physicians. Central
5 s- A) [- Y0 x1 V4 S1 x: C( [- B: R& pprecocious puberty (CPP), which is mediated3 M" B1 \' G" ]: _: i/ Q
through the hypothalamic pituitary gonadal axis, has
" H$ b7 p, j6 \' w3 @( J0 ^a higher incidence of organic central nervous system
' ?5 o1 M) O' ~, b( Elesions in boys.1,2 Virilization in boys, as manifested  F2 u/ K2 k" Y/ S, K9 X
by enlargement of the penis, development of pubic
+ Q. T$ S. Z+ I* Z$ C. Rhair, and facial acne without enlargement of testi-
5 z  o6 ]7 U2 s! v* Scles, suggests peripheral or pseudopuberty.1-3 We0 M, z# S5 }  M8 C
report a 16-month-old boy who presented with the
  m. W% i5 ]+ D; Cenlargement of the phallus and pubic hair develop-
; l( w8 z* i) m# |' N) e, r% P3 C/ Bment without testicular enlargement, which was due; G- U/ v0 K% z. d/ `6 r5 B
to the unintentional exposure to androgen gel used by
4 k& g8 c1 R. D5 h1 u, U) Mthe father. The family initially concealed this infor-
+ D5 m' e- C& @4 A  w$ Xmation, resulting in an extensive work-up for this
+ e/ m' O  k1 v) Uchild. Given the widespread and easy availability of
3 l( J+ i8 ]" w, I. i+ \  }testosterone gel and cream, we believe this is proba-
0 X# S: H* r; M. pbly more common than the rare case report in the
4 H" ^& _6 I: j# T6 O: I% a. i% Kliterature.4& C: d: V5 W( r
Patient Report9 c+ o& x# I7 y5 _. q: P# j: k2 ^
A 16-month-old white child was referred to the
6 K7 F- \' Z, `. c4 X+ pendocrine clinic by his pediatrician with the concern) H% O- ~' M! z
of early sexual development. His mother noticed
6 H$ }! h  m2 Q6 Glight colored pubic hair development when he was
6 e9 {/ r+ y# H# lFrom the 1Division of Pediatric Endocrinology, 2University of
( Z) y5 W* t+ Y; l8 g; X% rSouth Alabama Medical Center, Mobile, Alabama." E$ Z8 k, N3 Y& ]* a6 @" {# {! F
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 @  [+ D4 T# w& J
Professor of Pediatrics, University of South Alabama, College of
: g! r' ?5 A: `, |/ q! d; rMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 T! ?3 ^6 q7 E, e: l  B$ _e-mail: [email protected].
+ F  n# s, c8 k' v8 Zabout 6 to 7 months old, which progressively became
: V& u2 y" Y0 \darker. She was also concerned about the enlarge-
5 Z: K+ M; f. B) ~7 wment of his penis and frequent erections. The child
2 g4 u" o3 F. q& Y3 B. lwas the product of a full-term normal delivery, with1 F7 r4 Y9 T- x6 P1 L  N( e
a birth weight of 7 lb 14 oz, and birth length of
7 W* d  ]9 s+ b# }: O) v20 inches. He was breast-fed throughout the first year
, r( T2 W( Y# Gof life and was still receiving breast milk along with
9 s  t( M( K8 ~) J9 f0 j6 dsolid food. He had no hospitalizations or surgery,
3 R- ^% f. b: \and his psychosocial and psychomotor development& {5 ]2 Q2 R& s$ S2 [* _7 H
was age appropriate.
& A% f! B- ~$ W: H( jThe family history was remarkable for the father,
$ Y8 t* }4 {; z% A( O6 R& Q' Z: lwho was diagnosed with hypothyroidism at age 16,
) k- t2 I1 f3 I5 k/ k: m' hwhich was treated with thyroxine. The father’s" M# i, S6 u6 N! {1 Z  d; F
height was 6 feet, and he went through a somewhat
" k. q/ p( j; Q6 o) kearly puberty and had stopped growing by age 14., r' J1 l) P. |6 H' ?
The father denied taking any other medication. The
  \$ q3 v/ _/ T& Jchild’s mother was in good health. Her menarche5 w% }% {: Z! S% d4 t- K
was at 11 years of age, and her height was at 5 feet
2 o$ S1 L+ g6 f  D: J5 inches. There was no other family history of pre-- }# v2 I& E  F6 S6 G9 @2 {
cocious sexual development in the first-degree rela-
4 {4 Q+ |0 N" V! D4 ztives. There were no siblings.
4 z* V$ [) P, B& r$ Q( X) ?6 T. VPhysical Examination' m% U5 {# F1 D* y) e! @! [
The physical examination revealed a very active,9 O4 T4 f3 m- i# o
playful, and healthy boy. The vital signs documented
* g3 N( o6 A, ]  F6 ua blood pressure of 85/50 mm Hg, his length was
) N) w* `$ a: E, F% W+ Z# R3 s90 cm (>97th percentile), and his weight was 14.4 kg- F. E0 i# k. \' N6 e
(also >97th percentile). The observed yearly growth1 |8 Z9 S% N1 d  a
velocity was 30 cm (12 inches). The examination of
+ a4 L# D% z! M2 zthe neck revealed no thyroid enlargement.
' ~3 \8 f) ]+ F9 s  hThe genitourinary examination was remarkable for6 R; ~9 A( y6 n& q+ S8 |! m
enlargement of the penis, with a stretched length of6 d! [# a1 ^6 D* V+ K$ V
8 cm and a width of 2 cm. The glans penis was very well
0 q! ?( y' ~0 d% V/ j4 O6 u0 wdeveloped. The pubic hair was Tanner II, mostly around) h. e6 h2 T9 [$ H$ G3 F5 K
540
- a7 ?! W6 i9 C1 }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; T' K# A6 i/ u( M% ~the base of the phallus and was dark and curled. The
  `- u% M9 @  M6 ]4 H* Z5 qtesticular volume was prepubertal at 2 mL each.
9 T! f0 Z1 K4 ]The skin was moist and smooth and somewhat6 D; J; E: U7 I. |. Q
oily. No axillary hair was noted. There were no
2 b1 c( N/ |9 a3 ^9 Aabnormal skin pigmentations or café-au-lait spots.
0 _4 ^+ l1 o2 L! v4 dNeurologic evaluation showed deep tendon reflex 2+
' K0 M1 j4 W! x" Nbilateral and symmetrical. There was no suggestion( [6 |0 {" D' @6 l& T: q/ Q1 m2 q! |
of papilledema.2 F; K$ W% n: ^# q) Y
Laboratory Evaluation
# Y* [$ t! r& U7 e* x; GThe bone age was consistent with 28 months by/ u' ?9 H4 D9 R7 Y' t% |
using the standard of Greulich and Pyle at a chrono-# q3 A5 u1 o9 c/ k/ k( @& R
logic age of 16 months (advanced).5 Chromosomal+ ]- o. M1 v" ]7 O# t
karyotype was 46XY. The thyroid function test
2 }/ J# m; i. }, O/ I9 h# U  qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( r5 t6 w" P. \- m; s# o; \lating hormone level was 1.3 µIU/mL (both normal).& Z6 n$ z& X; R+ a" W9 Y
The concentrations of serum electrolytes, blood
0 p- a5 }5 N* ]urea nitrogen, creatinine, and calcium all were8 a8 F; i3 V( |, R
within normal range for his age. The concentration' ^- q( `, R8 ?# s; ~
of serum 17-hydroxyprogesterone was 16 ng/dL( D( S, Q" s0 \/ c8 ?
(normal, 3 to 90 ng/dL), androstenedione was 20
  `- }, D, U* ]) f6 ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-. \9 B, a& k. U) x" h( n% E
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," L% q! Z% [! I% E7 @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
  o# {) k. x# |0 w0 z49ng/dL), 11-desoxycortisol (specific compound S)" v+ t0 ~. @9 k5 T9 z* \! a' B; p
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 c5 w! _  }: D$ e4 \5 k3 b2 |1 ?. atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% o7 h  w; T+ x5 h5 E5 L- `
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ s4 J% e0 s4 v& v* S
and β-human chorionic gonadotropin was less than
6 K& U) C2 t, i! Z) y9 R' G1 \5 mIU/mL (normal <5 mIU/mL). Serum follicular
) U* ?9 v1 |$ R2 k4 d- ostimulating hormone and leuteinizing hormone& M1 m+ k3 L+ j4 K' O
concentrations were less than 0.05 mIU/mL
9 m" `% |$ r/ G8 t1 Z9 v) q(prepubertal).# K0 ~" R8 Z: w- j! u
The parents were notified about the laboratory
  |1 f  {7 @% x8 Hresults and were informed that all of the tests were
+ t0 h* J0 L" ]0 k$ ]normal except the testosterone level was high. The7 P2 n- M+ ^& v; J, g% U
follow-up visit was arranged within a few weeks to$ [# @+ \$ H/ @' J( V
obtain testicular and abdominal sonograms; how-
3 o+ `' g* s. I& I3 r/ g& D# Fever, the family did not return for 4 months.# z, W1 C  n% ?! V( r
Physical examination at this time revealed that the- X6 l& k  z5 R9 i' B% s
child had grown 2.5 cm in 4 months and had gained( k" R" Y5 ]  ]. X8 `$ X! l" j0 t
2 kg of weight. Physical examination remained
  z1 G1 A1 j& x2 L; A3 Z0 U) Yunchanged. Surprisingly, the pubic hair almost com-
0 S- S* n6 Y, \( z* rpletely disappeared except for a few vellous hairs at3 [* W" k- r- _1 ?9 W" Q
the base of the phallus. Testicular volume was still 28 v* {8 h( K2 d% s" y2 a# k% f
mL, and the size of the penis remained unchanged.
1 z# \0 M1 \' eThe mother also said that the boy was no longer hav-6 y/ n/ P$ K0 `
ing frequent erections.5 [, S1 W# z) E1 _& N
Both parents were again questioned about use of0 a4 |: D3 D" k4 b: U4 B
any ointment/creams that they may have applied to
: `  I( P* s# S, f1 J- F9 s6 Zthe child’s skin. This time the father admitted the
' ~3 |+ T9 K/ j. _9 m4 i- uTopical Testosterone Exposure / Bhowmick et al 541
& Z, Y, V! B( ^( I5 Luse of testosterone gel twice daily that he was apply-
9 f; s. Y! N. ~% r$ ^ing over his own shoulders, chest, and back area for4 j4 ?5 f( ^/ D% |& ^6 `
a year. The father also revealed he was embarrassed  T, h4 n5 s* A  x8 R0 D; @2 P+ e
to disclose that he was using a testosterone gel pre-
0 o/ Y$ j  Q4 d% N& ^. ascribed by his family physician for decreased libido: f8 ?" T: R8 f3 Y6 X8 k2 w! e
secondary to depression.+ J/ y( V) x- ~* ^9 o! X( a3 \2 c
The child slept in the same bed with parents.
0 _, |* j& I; q' fThe father would hug the baby and hold him on his) x  z# w: q9 ]( O: n) Y
chest for a considerable period of time, causing sig-1 ~' [3 y3 W% G, H
nificant bare skin contact between baby and father.1 ~7 c2 s1 O' @7 g7 o# P
The father also admitted that after the phone call,9 i' r8 L) G2 P
when he learned the testosterone level in the baby
' y! R3 X) L% F- p( ~. n2 U; c0 S& ^was high, he then read the product information
  U) l  w  P3 @" U' z1 J7 vpacket and concluded that it was most likely the rea-
$ p; O, b+ o; j) X# pson for the child’s virilization. At that time, they( O4 H8 t3 D: S6 o8 O( I  b' N
decided to put the baby in a separate bed, and the
" l2 I1 O; N6 f0 h2 Ffather was not hugging him with bare skin and had
/ ^2 L( ~: v: O; V' u# qbeen using protective clothing. A repeat testosterone
' q6 Q6 B! l& r( z' ?& qtest was ordered, but the family did not go to the
' o! g; {9 R. {- j2 H2 tlaboratory to obtain the test.; Y5 P+ R4 l3 l$ B
Discussion+ z( L4 _! g6 i
Precocious puberty in boys is defined as secondary! G6 a$ I% k& x2 q
sexual development before 9 years of age.1,4
+ _' q5 ?; C' x+ v1 uPrecocious puberty is termed as central (true) when
  B2 P  O6 _+ P1 F  f4 Jit is caused by the premature activation of hypo-2 h; B9 B7 |: g7 p. h8 a! `) W
thalamic pituitary gonadal axis. CPP is more com-4 }- z$ o; k5 J- i4 g0 H0 n2 ^9 m
mon in girls than in boys.1,3 Most boys with CPP
4 f' @4 \7 O6 S  J1 zmay have a central nervous system lesion that is. U8 @. l) Z0 |4 ]. t9 e1 }5 j3 s
responsible for the early activation of the hypothal-
8 n: V% E4 @1 h0 n, [  ^amic pituitary gonadal axis.1-3 Thus, greater empha-& l/ m/ z. w, ?
sis has been given to neuroradiologic imaging in8 v9 t: l6 B1 W, w5 b+ ~( d8 u1 k
boys with precocious puberty. In addition to viril-
$ r  \9 A1 t. o* C4 R2 k4 nization, the clinical hallmark of CPP is the symmet-
5 X$ o7 u0 ]' T6 a7 X3 v6 w( irical testicular growth secondary to stimulation by8 ^3 X% J  X2 t, p+ W5 s9 P
gonadotropins.1,3
! c& k! Z7 Q. o' [  m0 HGonadotropin-independent peripheral preco-( X# ^' s+ E4 e; Y1 \
cious puberty in boys also results from inappropriate
$ q, J4 Z! E7 i2 Fandrogenic stimulation from either endogenous or
# c9 E) @1 D, [8 e! `* O" U$ mexogenous sources, nonpituitary gonadotropin stim-
4 O  @5 @- d& J8 j: \ulation, and rare activating mutations.3 Virilizing
2 h# w( [; C5 `congenital adrenal hyperplasia producing excessive
' w0 g0 O9 U' C/ Jadrenal androgens is a common cause of precocious
3 b1 v8 b2 x5 B: ?! R1 v, D- X" `puberty in boys.3,4  }; E7 k& r& K  k- j1 F5 A# G9 M
The most common form of congenital adrenal8 N0 ^- m" w  I0 b( p; W
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 D% N6 v+ ^' k+ y! UThe 11-β hydroxylase deficiency may also result in3 C6 U7 o1 q% z$ t+ |5 H; c
excessive adrenal androgen production, and rarely,
4 S1 A( P& M0 B; Dan adrenal tumor may also cause adrenal androgen; v( M6 j, F5 ^7 l8 ~1 X
excess.1,3
1 O) F1 @( U) y) O+ J- a) Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 v+ t/ M& H) \4 |) y8 Y: K9 }; Y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) m; r4 P' q4 e1 \A unique entity of male-limited gonadotropin-
/ V; h+ A% o* h, \+ }independent precocious puberty, which is also known2 [; b* G+ h0 H- P' q
as testotoxicosis, may cause precocious puberty at a& q' F, j. ?8 f5 q% x
very young age. The physical findings in these boys
3 i8 |: Q* V7 H' c$ Kwith this disorder are full pubertal development,* y, G- K3 B: I+ M
including bilateral testicular growth, similar to boys5 ^9 s8 {8 E2 Z! |. q2 `+ K1 v
with CPP. The gonadotropin levels in this disorder2 K$ u9 \9 [% r3 R8 f
are suppressed to prepubertal levels and do not show
5 u! c4 d5 |) Q9 Y- a$ q0 p% ]pubertal response of gonadotropin after gonadotropin-
/ e. u" W# R0 o  n; Kreleasing hormone stimulation. This is a sex-linked. ]5 ]7 O7 Z9 i5 J! y2 }% U4 a
autosomal dominant disorder that affects only& V+ S6 i. V3 b% \1 j/ h
males; therefore, other male members of the family: a) a( N5 B/ H: B+ h
may have similar precocious puberty.3
* Q8 Y- ~; `. u# Q- h1 n) ~In our patient, physical examination was incon-7 v1 Y; X+ v8 y" R, d  [' g; A1 \
sistent with true precocious puberty since his testi-
! H% @* L+ d% N( _7 m% xcles were prepubertal in size. However, testotoxicosis
) s& n# q) k! Q- {was in the differential diagnosis because his father
' M3 |* A3 b5 I6 S) P* B* t7 Nstarted puberty somewhat early, and occasionally,3 D5 H+ u: w9 E4 V# }- z1 R
testicular enlargement is not that evident in the
& Z% u# l/ f4 \4 B. d$ @! S) ubeginning of this process.1 In the absence of a neg-7 o! R& J( `" S5 s. Q: D+ y  W
ative initial history of androgen exposure, our
/ b4 W1 X8 N4 z% Abiggest concern was virilizing adrenal hyperplasia,/ t' ~/ X5 \3 _, x
either 21-hydroxylase deficiency or 11-β hydroxylase
! M# _3 M% F! i5 r" R8 f  y2 _deficiency. Those diagnoses were excluded by find-/ l" w1 q! O/ G' s, A4 I
ing the normal level of adrenal steroids.
& _$ m# p7 F& L8 J  N% M  t/ GThe diagnosis of exogenous androgens was strongly; I  d2 h* s2 R/ v
suspected in a follow-up visit after 4 months because& j( Y! I" z# k5 X/ e4 _6 [$ }
the physical examination revealed the complete disap-
2 \* C9 X) T+ o4 F5 {! @pearance of pubic hair, normal growth velocity, and3 v: l6 K; \) u9 I; `0 s5 \5 O
decreased erections. The father admitted using a testos-
- `5 @' F% Y5 g+ V/ Nterone gel, which he concealed at first visit. He was
& N) b8 _7 T# L9 I) @" Yusing it rather frequently, twice a day. The Physicians’
. Z. H$ C9 B; w! HDesk Reference, or package insert of this product, gel or
6 K: _! Z! I, F+ x, @cream, cautions about dermal testosterone transfer to9 U, @( Y5 n5 d
unprotected females through direct skin exposure.* H! e, {1 O/ z( s/ R
Serum testosterone level was found to be 2 times the
: `0 \! n3 W( s# z3 Ybaseline value in those females who were exposed to/ k, U1 X' S! ^- c
even 15 minutes of direct skin contact with their male6 b( h/ ]" N; c% q
partners.6 However, when a shirt covered the applica-. x' x! b1 v7 g4 B( T& G
tion site, this testosterone transfer was prevented.; V7 n, A$ ]) c
Our patient’s testosterone level was 60 ng/mL,
9 c5 E& N! ~/ }, g, A, G5 Swhich was clearly high. Some studies suggest that
8 k5 \9 h; B0 L. p; t! {5 Rdermal conversion of testosterone to dihydrotestos-% D& A, \2 n5 R0 j; V9 L
terone, which is a more potent metabolite, is more6 B& l7 x; y, w& c* L& x4 |
active in young children exposed to testosterone: T( L4 y3 k, [; X0 `) u
exogenously7; however, we did not measure a dihy-% k; N4 r: X$ q" p) d
drotestosterone level in our patient. In addition to# u  U+ p' j- V0 W% {
virilization, exposure to exogenous testosterone in; w( D! @0 N$ S( w
children results in an increase in growth velocity and" ]7 \. O4 j: l& L- ?7 |4 q% ~- f
advanced bone age, as seen in our patient.
  X- B3 B5 O. g& ]- DThe long-term effect of androgen exposure during
3 ^! x7 R! n$ J# B7 P! P: j# E; Rearly childhood on pubertal development and final
" I/ z- R' t8 }% D% Y' wadult height are not fully known and always remain8 u3 ~* P) E! J2 J- ~
a concern. Children treated with short-term testos-
9 |& }! f5 }/ u. iterone injection or topical androgen may exhibit some
$ M( O" ]. Z# X8 U/ Z/ R" B- I, K! wacceleration of the skeletal maturation; however, after, ?% b) r! X0 Q8 N, ~. S
cessation of treatment, the rate of bone maturation
: u( t; D& X! l, K2 Gdecelerates and gradually returns to normal.8,9
* n3 j* n  ~0 S$ ]  Z& ?There are conflicting reports and controversy& z) X2 s/ `1 k, F6 B+ v$ I
over the effect of early androgen exposure on adult& c, I, T. Y, g/ j2 B/ y
penile length.10,11 Some reports suggest subnormal& f+ {4 J' P% h0 C  ?, ^2 Q
adult penile length, apparently because of downreg-
' {; r1 x, P, {' b9 L; Fulation of androgen receptor number.10,12 However,
7 U& n! j: n5 }, ~7 }3 z! R0 tSutherland et al13 did not find a correlation between
* \( N5 A* o: K9 ]childhood testosterone exposure and reduced adult
7 U- g. ?0 i6 I# S4 Z! K$ s$ Qpenile length in clinical studies.: A9 D4 N) l; Z# Q
Nonetheless, we do not believe our patient is
" y  W4 F8 B9 a8 s2 _4 ]& L; {2 x- Vgoing to experience any of the untoward effects from
5 y! c( a* F$ S5 Btestosterone exposure as mentioned earlier because
+ G( I2 U  ]# X" s1 x  Q; ?the exposure was not for a prolonged period of time.( J& m9 P. l  ^5 w
Although the bone age was advanced at the time of0 c) g, F8 q: V" t9 f
diagnosis, the child had a normal growth velocity at, X- N- L2 y  n: m% e0 w
the follow-up visit. It is hoped that his final adult9 W* w! m  e* y7 a0 g  ]& R
height will not be affected.* q& Z+ B% S, n. p
Although rarely reported, the widespread avail-' p: D9 j% K; J
ability of androgen products in our society may
' {3 L  t7 e- Q4 o8 B4 q/ L/ L- Qindeed cause more virilization in male or female
# ~' {, o; ~* Y& ychildren than one would realize. Exposure to andro-
+ I' o( H+ N9 \( y1 \( P& K! E  kgen products must be considered and specific ques-
( K! G: s/ m* H) E( @" C; x* ?tioning about the use of a testosterone product or5 i" s! q  M' T& R2 {
gel should be asked of the family members during
. @7 t! o; i8 z4 S. Hthe evaluation of any children who present with vir-5 A% F( s5 f% h$ I8 r
ilization or peripheral precocious puberty. The diag-
4 ]/ A4 I$ |' Hnosis can be established by just a few tests and by
/ b- n+ ?/ o: ~5 {& ^  _- }appropriate history. The inability to obtain such a
' @4 d1 W/ @4 Z) rhistory, or failure to ask the specific questions, may
# e% {! g+ X6 H" q( P/ U" x/ y+ f8 @result in extensive, unnecessary, and expensive
" Q( A3 u% @/ _: M, Q; C/ zinvestigation. The primary care physician should be) g, h6 A1 w. d0 u/ V. }
aware of this fact, because most of these children6 \2 o, f( Q8 X1 j
may initially present in their practice. The Physicians’
* D+ d# P% w2 uDesk Reference and package insert should also put a
! \  ^, Z+ r2 A- k$ Uwarning about the virilizing effect on a male or! c1 a; f& Y$ b
female child who might come in contact with some-! Y  Y: p5 ~' A9 ?+ f0 [- _) f
one using any of these products.
+ C0 g( l$ N2 a  OReferences$ G3 _. Z6 i) Z  S% u' P
1. Styne DM. The testes: disorder of sexual differentiation
' ]( L# O: K5 y. G5 [8 Pand puberty in the male. In: Sperling MA, ed. Pediatric+ g4 Y/ [. Q8 U/ r( z) ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  _# n& T8 _- Y2 O+ B2 A) l: w
2002: 565-628.
5 \- m* ~1 u7 a5 ]  L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: ?7 N. b2 g, ?puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
8 c( c% @2 e8 c
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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