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Sexual Precocity in a 16-Month-Old
! P5 S) ^. N- g; l4 T  |2 M, j5 hBoy Induced by Indirect Topical
7 J# \4 M- M- W2 lExposure to Testosterone/ ?1 e8 b, @4 l, \' x3 ?
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. j- t- n( S+ q" ?- b6 iand Kenneth R. Rettig, MD1
6 f' t8 t% X$ p3 ]+ S0 i: h  aClinical Pediatrics- y  i& ?. M  Q
Volume 46 Number 6
" W+ L# V7 K& F. _2 U1 H, @: I6 VJuly 2007 540-543+ \* D1 s; Z6 m3 o4 x( q" t
© 2007 Sage Publications
7 J( G  ?- ]. |: R" Z$ q4 s+ [) o10.1177/0009922806296651
4 |; V3 l+ D$ g6 ]; y; f2 U6 V7 chttp://clp.sagepub.com
  v; ~& j; U2 O0 K: D) Phosted at3 u* z+ K9 @2 d) ^5 M' B" C
http://online.sagepub.com
( n# E! {$ B, ]/ ?( u" J; l' ~Precocious puberty in boys, central or peripheral,
0 y& x9 B5 ~. B; pis a significant concern for physicians. Central
: a  V" V; U0 b, c4 {+ M# Pprecocious puberty (CPP), which is mediated
7 t4 \7 g6 P3 Y' dthrough the hypothalamic pituitary gonadal axis, has
/ C8 }/ V+ o( |3 ~% ]. H! Ja higher incidence of organic central nervous system1 d/ A1 S& g+ M4 c
lesions in boys.1,2 Virilization in boys, as manifested
3 `$ `% b' h* C# ?$ gby enlargement of the penis, development of pubic3 }6 d% _+ x0 P: G& ]0 \
hair, and facial acne without enlargement of testi-
# T+ l: @# r% ]  F  g# ?+ Qcles, suggests peripheral or pseudopuberty.1-3 We
: I" V& W1 V1 ], Q, S5 Oreport a 16-month-old boy who presented with the
, {) P: G" V+ v5 g. t* henlargement of the phallus and pubic hair develop-
; ^9 s' s8 D, s4 U, H6 Sment without testicular enlargement, which was due0 S6 p  {/ A* D8 `# X( k1 Z
to the unintentional exposure to androgen gel used by
1 |' P9 V( b  Y" I& lthe father. The family initially concealed this infor-2 A0 S& i5 r4 d. B
mation, resulting in an extensive work-up for this
( o6 a; k' b5 s7 Schild. Given the widespread and easy availability of. {+ u! D# H  b. `% c
testosterone gel and cream, we believe this is proba-& A5 t# H) N) _2 O; P: V' |
bly more common than the rare case report in the5 ]( ~4 a8 Q8 n. d+ N  F
literature.4' I9 l+ @& V  Z! X/ j7 h
Patient Report
# B8 V  o0 m6 Z+ _- w8 QA 16-month-old white child was referred to the
2 p6 N- ~( |4 b* z/ G& A7 k# Dendocrine clinic by his pediatrician with the concern
8 B4 t8 y! ]; u3 f# F5 `of early sexual development. His mother noticed9 A$ U; T/ E& N& s
light colored pubic hair development when he was: I, I1 n% _! I  h0 r- S
From the 1Division of Pediatric Endocrinology, 2University of
$ P$ i' X+ e- z+ N$ z" U4 P+ HSouth Alabama Medical Center, Mobile, Alabama.0 }9 T) F# l& F% G+ X6 ^5 ]* G( P
Address correspondence to: Samar K. Bhowmick, MD, FACE,) e; S' v: ?6 h9 n
Professor of Pediatrics, University of South Alabama, College of$ ?& Z& Z  v6 J' p/ g6 `* v
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) u0 ]5 l" M) X! ~  E1 |" r% ve-mail: [email protected].
+ `7 j$ {5 M" |' v3 zabout 6 to 7 months old, which progressively became
4 O: K+ E! R/ J# [, ~# Kdarker. She was also concerned about the enlarge-- q6 _: J. a- z
ment of his penis and frequent erections. The child; W9 E) K& _) m3 P2 G6 k( q
was the product of a full-term normal delivery, with( g8 O( F3 U6 R' Q4 ]* D; N( ]; a% q
a birth weight of 7 lb 14 oz, and birth length of2 Y2 L' C; E3 Z# f+ c
20 inches. He was breast-fed throughout the first year
5 _6 n4 j/ O; Y* gof life and was still receiving breast milk along with. o& \+ @/ c, k/ z# ?4 Y9 S
solid food. He had no hospitalizations or surgery,6 G3 d% {* V3 y
and his psychosocial and psychomotor development% X0 K% Y. f! a5 u0 N' ^
was age appropriate.
4 w8 }. A; M; k  Q) {5 W. iThe family history was remarkable for the father,
8 s/ [) Q% D5 Cwho was diagnosed with hypothyroidism at age 16,' `  N; j, c/ C8 T9 U5 \* x9 S# r
which was treated with thyroxine. The father’s
* G7 t; o) }- @, Q' Z4 R% r; H2 Dheight was 6 feet, and he went through a somewhat
9 w7 A" Z, T$ K; {5 I+ J  Searly puberty and had stopped growing by age 14.
0 M4 {- A$ q6 jThe father denied taking any other medication. The: y$ A  R) E/ z
child’s mother was in good health. Her menarche
+ n( c# h' d! F2 S5 ?1 x0 xwas at 11 years of age, and her height was at 5 feet
2 k/ G5 A! g8 T" o5 inches. There was no other family history of pre-' ^3 A* P* d: T) _4 [; ~$ o
cocious sexual development in the first-degree rela-7 p" h9 V5 p+ o) V+ p
tives. There were no siblings.
( X; c$ @. q+ |$ ~" h( l$ w( q) sPhysical Examination; u" e8 X  _, G& H7 C/ D2 k
The physical examination revealed a very active,& i, ~* V( V5 y
playful, and healthy boy. The vital signs documented
$ A9 M0 I& ~8 |a blood pressure of 85/50 mm Hg, his length was" F0 O: u- _0 j5 f  W0 z
90 cm (>97th percentile), and his weight was 14.4 kg
6 J! @. G$ Y; e' I* u' U: p7 [+ x(also >97th percentile). The observed yearly growth6 E. G$ M9 F2 L( }4 e7 i
velocity was 30 cm (12 inches). The examination of
6 N% D* c1 @/ {9 ?4 j1 q/ z) Gthe neck revealed no thyroid enlargement.
$ T- R  x! o$ w4 I4 ~. I; qThe genitourinary examination was remarkable for( f( ]2 I& @% b* Y* e& X
enlargement of the penis, with a stretched length of
( x$ R* h/ A) R3 _1 i8 cm and a width of 2 cm. The glans penis was very well
' U" Q) u. _' |4 w1 p( @& l2 z" Kdeveloped. The pubic hair was Tanner II, mostly around
' ]" r# r% x8 ~3 z9 W8 o- x7 _540
8 N/ t6 f* @# h& y: Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- t0 v, C$ G" @" z
the base of the phallus and was dark and curled. The
5 b. c2 C3 D5 d- N+ |. _; otesticular volume was prepubertal at 2 mL each.& Q0 `% Z! b) g' X/ [$ Q# Q
The skin was moist and smooth and somewhat
. b6 E2 m. q, x) M( Ioily. No axillary hair was noted. There were no
, g2 p: x$ e) I) K; Q+ j  X+ Habnormal skin pigmentations or café-au-lait spots.: U1 r# u, \. T; x5 p. c4 c' A
Neurologic evaluation showed deep tendon reflex 2+7 u5 O& f/ m1 T$ V5 J4 V
bilateral and symmetrical. There was no suggestion% W- Y- t% O- [" W9 e7 ^5 e. {8 y8 T
of papilledema.( x3 V7 [- H' Y+ d. q3 j# _
Laboratory Evaluation0 _) a! G) I3 s. V
The bone age was consistent with 28 months by
4 m8 s5 d' a+ A! Eusing the standard of Greulich and Pyle at a chrono-" J/ d8 }5 u: |3 {! G" m! C& S
logic age of 16 months (advanced).5 Chromosomal
5 l7 n: N1 [9 j& o  B! Y0 i" ykaryotype was 46XY. The thyroid function test7 E; I' |) r; G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 o% {' b. q3 j+ r, }, C4 W1 W
lating hormone level was 1.3 µIU/mL (both normal).
9 y4 q. E. {$ E4 x6 h1 AThe concentrations of serum electrolytes, blood. s2 V* O4 v. W5 t# v
urea nitrogen, creatinine, and calcium all were
7 L/ J! ~9 l: c$ ~within normal range for his age. The concentration
: a# d' n  M' u6 _of serum 17-hydroxyprogesterone was 16 ng/dL9 u1 V. ~+ ~0 s, l: |- p
(normal, 3 to 90 ng/dL), androstenedione was 20
: R3 D5 E8 S9 P$ B7 e% gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" n! ^4 M6 J4 X1 }- d
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& `$ H) M9 M* A& f; ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 X8 ]2 o) @+ O' \
49ng/dL), 11-desoxycortisol (specific compound S)
- l5 u: H5 k5 D& ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ _7 c8 K3 k  d7 qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 x5 a( q! U7 V* j* K& V9 S
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 b, i& T. _" T6 f
and β-human chorionic gonadotropin was less than. F2 S; ?; z1 \( V) ~; w) k4 a
5 mIU/mL (normal <5 mIU/mL). Serum follicular9 X4 ~7 W/ }; b- @: C
stimulating hormone and leuteinizing hormone0 B/ v5 C: ^1 n7 O5 K7 X
concentrations were less than 0.05 mIU/mL+ D; b( E! e, U2 a( F
(prepubertal).
0 ^6 U2 A9 i  yThe parents were notified about the laboratory
0 S! a4 E$ X* y! J- jresults and were informed that all of the tests were/ Q9 D9 Y9 z+ @6 e! A% B8 _, |; R
normal except the testosterone level was high. The% w! \+ }5 p  A, _% h
follow-up visit was arranged within a few weeks to8 b4 k7 `$ a: u2 b$ X
obtain testicular and abdominal sonograms; how-. p' `& s. q2 G8 [9 q! A
ever, the family did not return for 4 months.' Z0 ?8 ^' M8 Z$ J: H6 [
Physical examination at this time revealed that the- x+ D) O7 u- Q/ Y! B
child had grown 2.5 cm in 4 months and had gained4 ?/ A0 X3 m, {* g8 Q5 K
2 kg of weight. Physical examination remained
; }2 q3 t7 y% Qunchanged. Surprisingly, the pubic hair almost com-
7 F8 R% a& }7 z# L3 q- L& m4 F$ Opletely disappeared except for a few vellous hairs at
2 d& c) t/ ?: A( D/ [& v8 L* o/ b: Ithe base of the phallus. Testicular volume was still 2
, o( G. f' t: y! C. RmL, and the size of the penis remained unchanged.
1 |  U% z& X! _: x; Y7 m2 U3 h% bThe mother also said that the boy was no longer hav-0 g; W8 A8 w( t1 P
ing frequent erections.: Q5 C! j9 k. B9 O" |
Both parents were again questioned about use of
. ]5 L" W# s7 v  s; x/ iany ointment/creams that they may have applied to
4 j+ `) ]4 p  K& J* L9 Gthe child’s skin. This time the father admitted the- v; I5 q! x  C5 O5 t2 n1 z
Topical Testosterone Exposure / Bhowmick et al 541
  ~. ~. ~: L' {) Q5 S! Cuse of testosterone gel twice daily that he was apply-
' H" x4 `9 Q: k3 }+ o+ Aing over his own shoulders, chest, and back area for
% P' V9 y# |+ S, ^2 o+ ia year. The father also revealed he was embarrassed4 ?% H$ h9 T7 B; u, o2 {5 O% M- ^& Z
to disclose that he was using a testosterone gel pre-& O2 ]- X. G/ r1 s
scribed by his family physician for decreased libido' ?2 r7 Y& p" k5 a; z6 p
secondary to depression.: `. {* L+ F0 n* w9 z
The child slept in the same bed with parents.  A) C+ \; x5 l* y# D
The father would hug the baby and hold him on his$ j0 @; ^6 ?9 ^* I2 h) n0 e; W+ w
chest for a considerable period of time, causing sig-
" m' J& X$ j( T0 f& g6 z- ]nificant bare skin contact between baby and father.
5 @5 i9 D* p/ i8 U, A2 Y+ N# F9 bThe father also admitted that after the phone call,3 ~  W6 G/ r6 P! J- A
when he learned the testosterone level in the baby" Y; ?* r0 A2 x3 r
was high, he then read the product information" a5 q' V  D; S& m! Y' G
packet and concluded that it was most likely the rea-
1 B7 ^. b# m( p/ Kson for the child’s virilization. At that time, they
6 l# T0 E/ |" B) T! edecided to put the baby in a separate bed, and the5 d% s7 n* b/ D: y
father was not hugging him with bare skin and had
# I8 i5 Q* H+ u. P. N7 X% rbeen using protective clothing. A repeat testosterone
) S- @* Y5 d4 \# ptest was ordered, but the family did not go to the+ k: {1 I' a2 W- b
laboratory to obtain the test.4 _$ m1 {2 ?1 A) l! e* Y+ H* G9 g
Discussion' B. D' T4 _) A" Y2 y& {
Precocious puberty in boys is defined as secondary3 Q+ [. h; T  i- o" [
sexual development before 9 years of age.1,4
3 K( M$ J9 k# Y! f( [) |$ ?9 {Precocious puberty is termed as central (true) when
) M( u: U! X- s7 s& ~it is caused by the premature activation of hypo-
( u8 r3 U* w- y' _: g7 h7 G: M3 X, Rthalamic pituitary gonadal axis. CPP is more com-
. U& }/ I3 P! Tmon in girls than in boys.1,3 Most boys with CPP, f4 p5 [: C" |) ?. t7 X
may have a central nervous system lesion that is  m! x; B$ a) g5 d# [" F
responsible for the early activation of the hypothal-
4 O- x  I/ d7 `* v& ~7 r9 ^; J4 Hamic pituitary gonadal axis.1-3 Thus, greater empha-
# [# Z3 H$ y. b% Esis has been given to neuroradiologic imaging in
& y! P' ?3 C$ y& }" tboys with precocious puberty. In addition to viril-. s, t' l) j1 f) L9 y. f
ization, the clinical hallmark of CPP is the symmet-" j; d* X- T" X7 D8 r) r
rical testicular growth secondary to stimulation by2 {( w0 H# Y, x$ ^
gonadotropins.1,3' t! _$ ]% u- w9 F; z8 Q: l
Gonadotropin-independent peripheral preco-
% j$ ]$ L! C+ Hcious puberty in boys also results from inappropriate) {: c1 @2 K: @
androgenic stimulation from either endogenous or
8 m9 C- z4 |' r, {! c& xexogenous sources, nonpituitary gonadotropin stim-5 Y) X: P' M2 o7 ^2 t% z; O
ulation, and rare activating mutations.3 Virilizing
4 E/ b2 g# V( ?) ]4 qcongenital adrenal hyperplasia producing excessive
! q8 d  T3 Q9 cadrenal androgens is a common cause of precocious
$ I' b/ `- j. j% D  W+ K# t! upuberty in boys.3,4$ F4 F: X* s& f1 z
The most common form of congenital adrenal# V5 ?) c# q$ x; G( q7 @3 U
hyperplasia is the 21-hydroxylase enzyme deficiency.8 P: F) n  a; I# O; j
The 11-β hydroxylase deficiency may also result in% ^% \0 H! f' A# ^. C
excessive adrenal androgen production, and rarely,
+ j/ Z* b. z  \4 w* J8 @8 San adrenal tumor may also cause adrenal androgen
0 V6 y. ]7 a1 O* Z$ t# vexcess.1,30 [1 m# y; K' E) b0 P' o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% Z/ Z; @: v; o) l
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% L8 y9 n  W( [& a; Q- K
A unique entity of male-limited gonadotropin-
5 S- Z1 T  b! Iindependent precocious puberty, which is also known* q4 w+ w' N# p6 T6 b$ Q1 [
as testotoxicosis, may cause precocious puberty at a% F8 e. y/ j; b/ d% ~& I" h
very young age. The physical findings in these boys  I: }7 J2 j# R3 L1 G
with this disorder are full pubertal development,' ?9 h4 \" X0 u6 n6 o% i
including bilateral testicular growth, similar to boys
; |) {* _5 f; B2 g2 O' ~with CPP. The gonadotropin levels in this disorder3 f0 |; P" {, K( T, _# ]% i: V# e  P+ x
are suppressed to prepubertal levels and do not show* q: \0 z: P- n. k
pubertal response of gonadotropin after gonadotropin-5 K) Q# X, O2 [
releasing hormone stimulation. This is a sex-linked. f, p% B8 h. t/ m) X/ Z
autosomal dominant disorder that affects only
9 y6 y$ }) o8 `: \1 g7 l4 B% Tmales; therefore, other male members of the family/ m( a' [/ ?0 E. i$ h$ w
may have similar precocious puberty.3
$ @! c9 @  z: D% B& @In our patient, physical examination was incon-) U5 o, G8 o( {7 j8 L/ W
sistent with true precocious puberty since his testi-% H1 m* i3 N# l, ?  U% n4 e; i3 [
cles were prepubertal in size. However, testotoxicosis
2 q( }6 B/ b/ A* S6 Cwas in the differential diagnosis because his father
5 C5 J& [% L2 q1 tstarted puberty somewhat early, and occasionally,9 @5 `' l9 y4 W! S0 t8 b
testicular enlargement is not that evident in the
7 }: @1 u- Q1 u$ Obeginning of this process.1 In the absence of a neg-. ~# H) y5 p( g" D& T- ^$ i
ative initial history of androgen exposure, our( P7 B; H# m0 h8 C; F* ?3 A1 R
biggest concern was virilizing adrenal hyperplasia,: Y/ D6 \0 I0 e8 P9 J. e
either 21-hydroxylase deficiency or 11-β hydroxylase4 F& X6 L7 _# Y" N. z/ V
deficiency. Those diagnoses were excluded by find-
* p9 b0 Q' O5 Y, }) F: aing the normal level of adrenal steroids., d" ]; F& |' T. m% z4 ?
The diagnosis of exogenous androgens was strongly
# a6 G5 n4 i3 }- n# z& gsuspected in a follow-up visit after 4 months because
# a/ J1 d8 a' G* b2 ]$ M! @; Dthe physical examination revealed the complete disap-$ w6 c( ?  X/ N% @, x
pearance of pubic hair, normal growth velocity, and- \2 _+ H0 p6 i2 @" F
decreased erections. The father admitted using a testos-
! Y. Y+ g7 Q' uterone gel, which he concealed at first visit. He was- b- O2 s1 ?* N1 W( A
using it rather frequently, twice a day. The Physicians’3 }( }% K2 s  A; `
Desk Reference, or package insert of this product, gel or
- J) F5 V4 w9 i' lcream, cautions about dermal testosterone transfer to4 n5 B  S  ]. A: t1 U' a
unprotected females through direct skin exposure.; r! E5 c8 U1 \9 }' Q
Serum testosterone level was found to be 2 times the8 ]6 Q% h# T1 z/ ^
baseline value in those females who were exposed to  b7 V9 P) \3 y+ |4 F, @9 W
even 15 minutes of direct skin contact with their male1 \( a1 N7 n. b: M# c
partners.6 However, when a shirt covered the applica-
( ?7 x5 x, q& F$ E  Gtion site, this testosterone transfer was prevented.
0 {* ]; s# v  u3 C, r7 ^. xOur patient’s testosterone level was 60 ng/mL,
: \6 Q( i; s' lwhich was clearly high. Some studies suggest that5 t4 c' m$ c. m; [8 E3 M
dermal conversion of testosterone to dihydrotestos-: K' D3 c( j( _& r7 h
terone, which is a more potent metabolite, is more) t$ X" Y! E* `* S2 s) c" q
active in young children exposed to testosterone" k  q8 c! b8 T& l2 c3 O- X" [
exogenously7; however, we did not measure a dihy-
; _& t' A$ I! i& t: f+ V4 Edrotestosterone level in our patient. In addition to, E1 c0 z$ N/ C- ]0 T$ o# d
virilization, exposure to exogenous testosterone in
; \1 e5 E/ H" w1 d- bchildren results in an increase in growth velocity and
9 F) N1 h0 R1 C1 U3 t* wadvanced bone age, as seen in our patient./ Q! e. O2 o6 R2 p3 Y! B
The long-term effect of androgen exposure during) o, w0 ~; \8 L! Q. r+ C
early childhood on pubertal development and final
" E/ U! n* ^9 q1 h5 gadult height are not fully known and always remain1 x5 @8 j! \# c1 L
a concern. Children treated with short-term testos-6 P5 Z* X* d+ S. G, ~% u% ^5 _
terone injection or topical androgen may exhibit some+ L9 G( T, d5 C! W
acceleration of the skeletal maturation; however, after2 v# Z9 W" ?* V: |" i
cessation of treatment, the rate of bone maturation
, N2 F* }4 h5 cdecelerates and gradually returns to normal.8,9% Y! |  m2 H' @' J' D2 M; r
There are conflicting reports and controversy$ o( a* z  i& o. }
over the effect of early androgen exposure on adult
; m0 @5 f6 W! @8 _  J* l, m# }penile length.10,11 Some reports suggest subnormal4 S+ s5 l0 A3 g
adult penile length, apparently because of downreg-
! \; v+ F. Y" R9 ~# Zulation of androgen receptor number.10,12 However,! K; H# p3 p8 p9 }/ ~- _
Sutherland et al13 did not find a correlation between1 u. {  _! u  ?' T2 r
childhood testosterone exposure and reduced adult, d+ J+ o) W6 F' J2 R2 J. Z
penile length in clinical studies.
% E) M% C# C" X" F0 FNonetheless, we do not believe our patient is. \" J3 ~6 ?: {+ t- o5 @; U
going to experience any of the untoward effects from
& b, U+ E& I; qtestosterone exposure as mentioned earlier because  ~) U! v$ @- U" S* L
the exposure was not for a prolonged period of time.
, w  C1 n% X3 K  w/ g" fAlthough the bone age was advanced at the time of
1 ^- S) L9 x' k0 K& @1 q& k% Mdiagnosis, the child had a normal growth velocity at5 S, W5 A( F! @
the follow-up visit. It is hoped that his final adult& \8 f9 s2 C5 E6 I9 y
height will not be affected.
6 h. ]* o6 c; `Although rarely reported, the widespread avail-0 X: s$ h  y# D: g3 a# C9 ~! O1 H1 x
ability of androgen products in our society may
- M& c$ B5 H: `$ iindeed cause more virilization in male or female
* R/ A" a4 m0 T/ Ichildren than one would realize. Exposure to andro-& N$ E9 [$ T% P9 s. O" M
gen products must be considered and specific ques-
- J2 `; Z4 }8 S+ Y$ n4 ?  {tioning about the use of a testosterone product or
2 _. L7 K$ l" `  X. J; Xgel should be asked of the family members during) b" `6 u3 \5 W) P1 f2 ^
the evaluation of any children who present with vir-
0 [. K  I% a! j) ?ilization or peripheral precocious puberty. The diag-- h4 ~! U# ]) ~- F. J( i5 G
nosis can be established by just a few tests and by) H+ C9 ?% q5 r) ^
appropriate history. The inability to obtain such a
7 t" U' J, y+ L' ^" r) ehistory, or failure to ask the specific questions, may
4 V; F* P+ N: u! M6 C4 Yresult in extensive, unnecessary, and expensive
( E7 m" P& R4 Y) H- U" V7 v) L7 Rinvestigation. The primary care physician should be
: R* A' y! ^% G9 L$ baware of this fact, because most of these children
& H! Z. w! r, C- f  w$ Rmay initially present in their practice. The Physicians’
* W; V8 V% u* K! w/ w, xDesk Reference and package insert should also put a
5 C1 [. [0 P3 {$ |warning about the virilizing effect on a male or: K: G( K( h; _" o
female child who might come in contact with some-/ o2 W- M% m/ C  n  U
one using any of these products.# O( u4 t1 ]9 N8 a& ^6 L1 f; ^
References! I& a: Q8 c1 [4 ?
1. Styne DM. The testes: disorder of sexual differentiation+ s, o% d+ b8 r; T) P/ C
and puberty in the male. In: Sperling MA, ed. Pediatric
8 x$ u$ \: L& _% T! O- N! R- aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: X5 v; E6 q; E1 u. K$ ^
2002: 565-628.
: {; ]# s+ O2 h- c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 i6 D4 l( f' Z  l+ p4 O1 k4 b
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 k$ c2 ^" ~4 I, @; Y* o" ^
Boy Induced by Indirect Topical
5 k8 w- q8 N( b: `. R3 D5 [8 IExposure to Testosterone
3 _5 G2 P9 ^6 c* X1 }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 _& b- z) m% s8 l
and Kenneth R. Rettig, MD14 Y' V  Y- |8 T# _
Clinical Pediatrics7 {; o* r. W' W7 X, N+ o
Volume 46 Number 6
4 U: N: R2 h! JJuly 2007 540-543
* g- @8 i4 N" t3 V/ j  U* Y© 2007 Sage Publications
, @4 b: l' v- H6 I* Z& q) A10.1177/0009922806296651
3 h9 F% U% Y$ ^3 B# |6 A( J/ bhttp://clp.sagepub.com% V; x- u3 d- G) J
hosted at
* }) b' V) s7 Nhttp://online.sagepub.com
  _. C6 c2 c1 MPrecocious puberty in boys, central or peripheral,
3 K4 n* K. E; B# T- q8 {$ T+ P" ois a significant concern for physicians. Central# u1 ~; ]% O3 `7 ^
precocious puberty (CPP), which is mediated
: I% {" K: m& v, p0 x: U8 F5 m. Gthrough the hypothalamic pituitary gonadal axis, has
% W# G$ |/ Z6 K2 q  k; k) @. Ea higher incidence of organic central nervous system; z4 V# V6 [  p6 t. x. R
lesions in boys.1,2 Virilization in boys, as manifested
9 i" b' P) ~+ R3 v! pby enlargement of the penis, development of pubic& o& {: m1 U( C9 J# u9 x
hair, and facial acne without enlargement of testi-
+ \6 ?4 M5 f) ?! V; m! Y9 Gcles, suggests peripheral or pseudopuberty.1-3 We
; G/ `2 m6 z( ~3 {' S3 ureport a 16-month-old boy who presented with the3 A  M+ O9 O1 F% ^" R
enlargement of the phallus and pubic hair develop-$ P: w% f; v& l. S% j
ment without testicular enlargement, which was due
4 R, i2 N3 J! i  Q0 c6 b6 o; Oto the unintentional exposure to androgen gel used by* K1 l- Z# S1 `! C/ D6 j
the father. The family initially concealed this infor-
0 M5 A% ~# S1 ?8 `1 amation, resulting in an extensive work-up for this
* _- A6 y3 ^, Q, ]2 p! o9 A  bchild. Given the widespread and easy availability of$ `+ A, V3 u7 D
testosterone gel and cream, we believe this is proba-
! \$ o7 \$ Q! b, E$ qbly more common than the rare case report in the  Q6 w5 e; D8 E& y) E: y
literature.4& A, `# U$ s, R0 Y
Patient Report
7 s/ u4 d+ _; Z- ?6 Y" aA 16-month-old white child was referred to the1 f# y0 Y& `- V
endocrine clinic by his pediatrician with the concern9 D9 i- N0 R; V- ?2 X0 K
of early sexual development. His mother noticed6 i- o6 D' G# i# X. q' q& r
light colored pubic hair development when he was
2 D9 Z. G! P7 y7 c# C, W/ q" ]From the 1Division of Pediatric Endocrinology, 2University of
1 K1 o* e1 @, a7 x  ASouth Alabama Medical Center, Mobile, Alabama.# A) T& Q2 |7 c, O3 i
Address correspondence to: Samar K. Bhowmick, MD, FACE,& p  J6 Z1 @+ `, a) b+ d4 p6 R
Professor of Pediatrics, University of South Alabama, College of) I- U* ^: f4 W# u1 H4 m; l6 G2 k
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 n( a3 p( l" y) Ge-mail: [email protected].
% i, D9 E* p3 G. c- F- @; Eabout 6 to 7 months old, which progressively became
/ W/ q/ \5 r8 V0 c' x6 zdarker. She was also concerned about the enlarge-% S+ F& a9 ~1 N$ W3 }* a
ment of his penis and frequent erections. The child
3 n' O  }1 L3 f- ]$ ^" B$ M! xwas the product of a full-term normal delivery, with7 ]$ E6 _. \) X# G* W. I1 D
a birth weight of 7 lb 14 oz, and birth length of
# N  h% V4 s) |# {20 inches. He was breast-fed throughout the first year
/ A- v6 Z( H" n$ ^8 a4 j" c& Vof life and was still receiving breast milk along with
$ Y8 H. k0 b' t# h. V/ Vsolid food. He had no hospitalizations or surgery,! w) o) j5 M: o0 }& ~
and his psychosocial and psychomotor development
/ n8 D; }+ Q' ?0 R% T  v, p" Xwas age appropriate.2 z5 t# |6 z( ]$ E% V: |8 Z6 O  }
The family history was remarkable for the father,6 o: ~- o1 Q2 G" j8 R, N( i
who was diagnosed with hypothyroidism at age 16,5 @* q+ ], P% T/ @) m- H  _8 m
which was treated with thyroxine. The father’s
. f5 H0 g; o8 O2 @, Iheight was 6 feet, and he went through a somewhat
& k1 H1 ?) d5 B+ I0 K; O3 }, Fearly puberty and had stopped growing by age 14.& y$ s5 m7 C6 J5 q
The father denied taking any other medication. The
" z' V2 m- m4 N/ |: o1 t9 Y$ Bchild’s mother was in good health. Her menarche; m7 ]5 g4 R1 X/ v/ V
was at 11 years of age, and her height was at 5 feet
& f" i/ w+ h6 A4 B" M9 r; S5 inches. There was no other family history of pre-
9 k( `; D% q2 ?/ lcocious sexual development in the first-degree rela-
7 b. k$ ]% T; Y- [  H; I8 A$ A9 Z- rtives. There were no siblings.) N8 x% W+ a0 `7 H' X$ g& G" ^' I
Physical Examination
! O6 v, i: {% e& u" {2 q4 wThe physical examination revealed a very active,
$ v5 ?* }% B$ F3 A4 T) N3 kplayful, and healthy boy. The vital signs documented5 ^7 B0 v  d1 d2 N0 V4 B0 r5 b
a blood pressure of 85/50 mm Hg, his length was7 G: F2 P) T+ V, u: i6 @2 G( s
90 cm (>97th percentile), and his weight was 14.4 kg
" O2 u' \: S1 k) ?+ i& m(also >97th percentile). The observed yearly growth
0 y. u/ |" Q+ ]1 m9 wvelocity was 30 cm (12 inches). The examination of
1 b/ K: I! @$ d( b0 C6 a6 |- `  \the neck revealed no thyroid enlargement.
# o; Y5 B" z8 o; h7 \  a3 @The genitourinary examination was remarkable for
, @0 \$ s# ^/ \- X! r  L$ _* Uenlargement of the penis, with a stretched length of
: f% H5 `" j( L9 ]8 cm and a width of 2 cm. The glans penis was very well  H  h) `6 i% V9 C7 W6 s
developed. The pubic hair was Tanner II, mostly around
$ h# d6 N& e8 J% G540
6 \& Y( M1 n; h  E1 E  x* Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! U  g' v5 c8 E7 sthe base of the phallus and was dark and curled. The. f# W9 p) W0 j. m5 J
testicular volume was prepubertal at 2 mL each.: @7 T0 l4 r$ I! d" |6 Z5 V1 p
The skin was moist and smooth and somewhat3 U! s3 s) I5 a/ w, c
oily. No axillary hair was noted. There were no
& N, g7 _1 [% m+ s! Q# ^" p. l8 p) Babnormal skin pigmentations or café-au-lait spots.
  s* M$ G. N/ T% L, l" M2 D) E& G" t9 nNeurologic evaluation showed deep tendon reflex 2+
1 G$ N# [! g/ e% \* B  ]" Q* D+ Jbilateral and symmetrical. There was no suggestion' ~- X% z( H8 H$ b; Z& x, h+ V
of papilledema.
4 l5 o6 t: Z0 x1 m$ F  ?Laboratory Evaluation; X% G7 o2 X+ k  F# k
The bone age was consistent with 28 months by
8 d# ~: s9 h7 Q) x$ o2 B4 ~; R+ Y( eusing the standard of Greulich and Pyle at a chrono-
! G7 j, Q3 i: b% n1 slogic age of 16 months (advanced).5 Chromosomal# b8 W: ^  p/ L+ f$ Z: _0 J
karyotype was 46XY. The thyroid function test
$ R; g% a% y3 R' R- ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 R7 ?6 o; s# u: y4 slating hormone level was 1.3 µIU/mL (both normal).0 o, ^. s- ~/ K% F, w
The concentrations of serum electrolytes, blood
6 c3 I, {7 a) R4 kurea nitrogen, creatinine, and calcium all were
4 D  M5 T6 z% N1 ]$ w8 g2 h* hwithin normal range for his age. The concentration# B9 u; @, {; Y, T: p/ E
of serum 17-hydroxyprogesterone was 16 ng/dL. o: k% H% m' A0 ^. R
(normal, 3 to 90 ng/dL), androstenedione was 20
; g# l! Y4 l8 x8 Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( i, L8 {3 v4 X1 p* pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
  z& n( H; t1 b0 P4 t! W) r$ \0 Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to5 c6 h/ O2 ], I! K  m8 Q" x
49ng/dL), 11-desoxycortisol (specific compound S)" ?1 d5 ~3 L  v' E3 Q) v( B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  t4 |3 r1 k8 q  l* ?" |, v% Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 C* X* N; {4 W) U  ^+ r1 F
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ z. ?. w0 g0 Q' h' h2 R. S6 u
and β-human chorionic gonadotropin was less than+ H5 D2 L) h3 f8 @- k/ ]5 ?* {
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ {3 M4 N3 {& q' o
stimulating hormone and leuteinizing hormone1 n4 i: d5 Q; G8 `& t
concentrations were less than 0.05 mIU/mL) ?' S' h+ V' k1 W  y$ V
(prepubertal).0 x9 h% s  r3 b. c0 O! J
The parents were notified about the laboratory
* o, u" F7 ?( r( k* gresults and were informed that all of the tests were1 l; A2 J/ {+ V% H. R* L4 A
normal except the testosterone level was high. The  I5 O8 e4 }4 V; i0 @2 j9 R
follow-up visit was arranged within a few weeks to# j( K* B5 a$ l+ P4 {& {# H1 V
obtain testicular and abdominal sonograms; how-* t2 R, q2 ?1 y" k
ever, the family did not return for 4 months.
( j  {! z& y: X4 L+ XPhysical examination at this time revealed that the) n5 P& t$ {/ G8 E: {
child had grown 2.5 cm in 4 months and had gained3 `. j1 l& P; G% G+ ?
2 kg of weight. Physical examination remained
7 f5 u( |# I& w3 junchanged. Surprisingly, the pubic hair almost com-
; ]) \: ~, k$ Kpletely disappeared except for a few vellous hairs at
+ T. j: N4 E" G" y- U0 uthe base of the phallus. Testicular volume was still 2' R& F: H& r/ @; v/ t0 }4 d, S6 K
mL, and the size of the penis remained unchanged.1 N! m2 e3 p& P/ i( ?& f& p8 r
The mother also said that the boy was no longer hav-. Z$ N( h+ c3 s( \: ~1 E5 n
ing frequent erections.# ]1 ~7 ]2 E, c
Both parents were again questioned about use of
( k' P- B6 b) o  Q+ v5 Pany ointment/creams that they may have applied to3 p5 Z. `" b  y0 s- O0 W
the child’s skin. This time the father admitted the' U) ~# u; N# g' c: c& @8 |! z+ u9 o
Topical Testosterone Exposure / Bhowmick et al 541
" |( G: F: w" |) ~use of testosterone gel twice daily that he was apply-* ^3 M+ s0 m9 `+ H  S7 p2 P
ing over his own shoulders, chest, and back area for, a+ E# K5 ^, M* M, \1 e
a year. The father also revealed he was embarrassed
$ f7 p3 f( C8 N% kto disclose that he was using a testosterone gel pre-
7 j& o4 H% T9 Kscribed by his family physician for decreased libido/ l% w5 I# s$ D. H5 Y' L, ?
secondary to depression.
" B" t: v* a  ~! K6 Y: |0 m: qThe child slept in the same bed with parents.
" F) L. q  l  R: F0 |/ C2 YThe father would hug the baby and hold him on his+ C# R1 {8 B9 m5 m! U
chest for a considerable period of time, causing sig-. }) B* I2 b, I9 O. O
nificant bare skin contact between baby and father./ ]8 L/ W8 y7 F; p6 H, {
The father also admitted that after the phone call,
" A5 |; D2 K: V1 Mwhen he learned the testosterone level in the baby$ m% W' o. n1 }. B9 j7 K
was high, he then read the product information0 E+ B+ j$ ]* {# T! F4 Z
packet and concluded that it was most likely the rea-0 @' ]' k. X/ l
son for the child’s virilization. At that time, they* G, n- t0 B6 y% i# C) P2 Z: H4 c  f
decided to put the baby in a separate bed, and the% N+ z% }8 v5 ~" s  u1 H1 D" }9 P
father was not hugging him with bare skin and had$ L4 @6 k, E; K
been using protective clothing. A repeat testosterone4 s1 ^3 E- ~% O( c# o, t3 \. L
test was ordered, but the family did not go to the  y# ^8 t' g: n' [
laboratory to obtain the test.
: D6 }: f* K# K2 g3 h7 P0 tDiscussion
# N3 Q0 C! }+ X/ y8 kPrecocious puberty in boys is defined as secondary/ ?7 y# ^  o0 O3 C0 \# Q3 y' D
sexual development before 9 years of age.1,4. e0 I1 ?% \8 @
Precocious puberty is termed as central (true) when3 [; N; p' P' E. Z" ]7 ?
it is caused by the premature activation of hypo-
! x5 ?+ j- j0 @" A1 jthalamic pituitary gonadal axis. CPP is more com-; w& h) H$ y, C0 i
mon in girls than in boys.1,3 Most boys with CPP
, s4 e& M3 P/ ^0 H7 G  Emay have a central nervous system lesion that is
, n# A5 ~4 q+ e( xresponsible for the early activation of the hypothal-
! e* Q3 j* q) f% ~% E* Tamic pituitary gonadal axis.1-3 Thus, greater empha-  }; k. ?. h7 q6 O
sis has been given to neuroradiologic imaging in6 C$ |& B1 }' K1 P- f' M
boys with precocious puberty. In addition to viril-: {9 h7 q- B+ P. [3 C" m% |6 f
ization, the clinical hallmark of CPP is the symmet-% _' b' Q0 Q! I3 y% B
rical testicular growth secondary to stimulation by
- N" H3 a5 P1 K" }gonadotropins.1,3
  S$ z% E& X' ?) s; P( f& BGonadotropin-independent peripheral preco-% N. t: A; q( b, l
cious puberty in boys also results from inappropriate
: N2 F+ G) l. aandrogenic stimulation from either endogenous or5 ~% x! E4 @4 B+ Z
exogenous sources, nonpituitary gonadotropin stim-1 O+ g  _& ~( z
ulation, and rare activating mutations.3 Virilizing
# H; w% O) @! X  ~7 h0 Hcongenital adrenal hyperplasia producing excessive" N% f6 ?$ M8 r. ^
adrenal androgens is a common cause of precocious
6 O( B  q* c+ gpuberty in boys.3,4
/ @& H& l2 m; T' EThe most common form of congenital adrenal3 ?+ B$ n7 ~( `; P: l3 s3 J7 l
hyperplasia is the 21-hydroxylase enzyme deficiency.1 Q4 m) ^! s: q, y' x
The 11-β hydroxylase deficiency may also result in4 Q5 [2 o$ f) ?5 l$ L
excessive adrenal androgen production, and rarely,0 z4 ~6 P: f8 S1 c
an adrenal tumor may also cause adrenal androgen( M+ j3 {. u: z( L
excess.1,3& O: `+ W$ q# T8 R$ H% V+ t* [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# D& W7 W' x# j; a
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' d! [, x# E" qA unique entity of male-limited gonadotropin-
( d3 P+ z. a% H9 Y; k3 Y; W. Rindependent precocious puberty, which is also known
( N  A( ^. B$ N8 `5 E" m9 las testotoxicosis, may cause precocious puberty at a
* o4 O2 P" H& i! y9 R( c6 w2 zvery young age. The physical findings in these boys" \% j% S( V) R7 R
with this disorder are full pubertal development,
- a) I0 d. G. L4 [! Wincluding bilateral testicular growth, similar to boys
9 o3 y0 j. n) h) e6 Xwith CPP. The gonadotropin levels in this disorder
9 }% n: E  f, q/ `) _( eare suppressed to prepubertal levels and do not show
* N2 ]! v2 m4 L# z1 _! fpubertal response of gonadotropin after gonadotropin-# a6 C; `% h0 U5 M, I9 E
releasing hormone stimulation. This is a sex-linked
# b" `# G, f& q& }2 zautosomal dominant disorder that affects only
( \) ^. @  m3 o" W. x# k- Rmales; therefore, other male members of the family
1 O, ~5 m4 B* ]" B9 w; {2 ]may have similar precocious puberty.3
9 D. Q* T$ H4 b/ F! bIn our patient, physical examination was incon-2 ~6 z+ t; i% [2 b1 c% z0 i5 g! S
sistent with true precocious puberty since his testi-/ b! N5 D2 |9 P8 x. o% b9 _
cles were prepubertal in size. However, testotoxicosis
& R* n( Q" E7 c! R( s* uwas in the differential diagnosis because his father# p2 S9 z7 {2 s9 a3 o
started puberty somewhat early, and occasionally,
: [0 ?5 q$ L8 ?+ Qtesticular enlargement is not that evident in the* _. D; \7 W* ^+ ]. e5 k; s
beginning of this process.1 In the absence of a neg-  y5 j8 F9 T4 b2 {4 W" O
ative initial history of androgen exposure, our: I, i$ f) i1 r( ?9 J8 [% z) |
biggest concern was virilizing adrenal hyperplasia,4 `) w3 f9 w$ g- d! q  j
either 21-hydroxylase deficiency or 11-β hydroxylase
! [, c: T/ o. T9 Mdeficiency. Those diagnoses were excluded by find-$ u  ^4 Q; {. |
ing the normal level of adrenal steroids./ ?6 q" Y2 {+ D' C, F/ s+ K
The diagnosis of exogenous androgens was strongly2 j1 b' d8 U8 }# f3 s0 G, }% L7 |
suspected in a follow-up visit after 4 months because  h* H4 o$ z1 f/ o$ h1 Z- F- ?
the physical examination revealed the complete disap-
& p/ b/ l1 l, Npearance of pubic hair, normal growth velocity, and0 E8 o; t2 B2 X
decreased erections. The father admitted using a testos-# r1 ]; a- P6 D% S5 ?! U' m  O9 C
terone gel, which he concealed at first visit. He was2 l( t$ S: y1 m& L: B  w
using it rather frequently, twice a day. The Physicians’' ?$ J0 M# o0 U7 q7 q' q
Desk Reference, or package insert of this product, gel or
5 y( u4 N6 y& V8 x: e" W5 ^cream, cautions about dermal testosterone transfer to
: Z# }, W7 P8 S& x  cunprotected females through direct skin exposure.
4 q2 d% C' s3 i" ^9 ~0 XSerum testosterone level was found to be 2 times the3 [* `& v$ q, ~5 M
baseline value in those females who were exposed to6 E0 w! o/ M& C. _  L
even 15 minutes of direct skin contact with their male
; x2 ^" ^( {4 w' J9 ]& p2 hpartners.6 However, when a shirt covered the applica-0 q) S. ^, P, m+ @0 q% ]* [) V8 g
tion site, this testosterone transfer was prevented.3 A8 R* {/ o4 R$ b9 L- f; ]
Our patient’s testosterone level was 60 ng/mL,6 L. S6 H4 `! @/ b7 D6 d+ H% t
which was clearly high. Some studies suggest that
8 V* k( I( y4 u, ~% M3 K4 m: m2 S2 ^dermal conversion of testosterone to dihydrotestos-
' m/ D) T: Y* @3 _terone, which is a more potent metabolite, is more
  r+ j8 w1 t$ Y& ~active in young children exposed to testosterone# O6 x) `! j1 ~1 d2 r% j
exogenously7; however, we did not measure a dihy-
3 G" c3 g2 j1 h  u3 K6 y! @; Rdrotestosterone level in our patient. In addition to
4 k8 H7 O5 s4 @; T* X- Kvirilization, exposure to exogenous testosterone in
. z! O  P2 B0 p- z7 v* {/ Y! Ochildren results in an increase in growth velocity and
$ E% F" h5 ?- Yadvanced bone age, as seen in our patient.9 Y# y8 h; y1 N4 l
The long-term effect of androgen exposure during
7 N" [9 c" v; c% V- @6 {. e* Rearly childhood on pubertal development and final
  L: B2 Y) Z, @7 Y! Z- \* N. [adult height are not fully known and always remain! J% `0 i1 @5 D0 n1 P4 ]% b. r
a concern. Children treated with short-term testos-6 X4 j, g7 v' S! \. W3 |- p
terone injection or topical androgen may exhibit some! `3 H' K. W% @2 |, U5 ]  Y  F; \
acceleration of the skeletal maturation; however, after2 M: A! W% y3 _" C
cessation of treatment, the rate of bone maturation
2 g. D6 R7 f. Q9 K  ]2 Q4 {/ Ndecelerates and gradually returns to normal.8,9
) |$ @5 }+ X, PThere are conflicting reports and controversy7 i  A4 I5 x1 a. G
over the effect of early androgen exposure on adult
& j( n3 \3 v) p: ~4 b3 Kpenile length.10,11 Some reports suggest subnormal
* c4 X8 O- _  v6 H& q2 Q0 Fadult penile length, apparently because of downreg-4 {) w; d5 Y$ B, C4 d8 }
ulation of androgen receptor number.10,12 However,5 ~! U  W" M" T8 g5 ~, H& k- d
Sutherland et al13 did not find a correlation between
& V( m# q4 k* ~6 k* ?  `0 a0 g2 ~childhood testosterone exposure and reduced adult% k1 `6 Q. N2 l5 S) j
penile length in clinical studies.9 l% F/ A3 ]! o& W: ?
Nonetheless, we do not believe our patient is
7 G# Q$ }* y, X& r" B( q, V" Ygoing to experience any of the untoward effects from
- k# o7 l, P! Ttestosterone exposure as mentioned earlier because
9 {  J% }9 g0 ?7 e1 R% ^( Ythe exposure was not for a prolonged period of time.
+ d# y4 V/ V  f0 i6 fAlthough the bone age was advanced at the time of
$ F; r. X9 j* {! m' o8 u6 ^diagnosis, the child had a normal growth velocity at
/ Q, s5 a: S- I3 z6 E+ wthe follow-up visit. It is hoped that his final adult0 {/ m& [. x! Y9 z& _: j4 ]* c) f
height will not be affected.
5 ~5 i$ f# `, s3 q' EAlthough rarely reported, the widespread avail-* a$ [9 r4 G2 g$ Z+ A0 J' q
ability of androgen products in our society may
- `' n. P0 V/ \+ z( V1 v. r2 oindeed cause more virilization in male or female' Y0 r8 z0 S! `3 F' S% l
children than one would realize. Exposure to andro-) i  E* L9 z- s
gen products must be considered and specific ques-
. |- r- Z8 w# ~' t% Qtioning about the use of a testosterone product or
" {& i2 d) X& Cgel should be asked of the family members during
3 _2 i# v  T; V) g8 I, kthe evaluation of any children who present with vir-# S. g7 [8 R( h5 t
ilization or peripheral precocious puberty. The diag-! |- e# P4 H. e: V
nosis can be established by just a few tests and by
' g0 l% i) p( z- g8 @! Xappropriate history. The inability to obtain such a, c9 ?- b/ ]7 j8 O' {6 F
history, or failure to ask the specific questions, may
  O9 x( F# h3 h6 u; O) l, qresult in extensive, unnecessary, and expensive( J0 R6 M9 R$ Y4 `" A
investigation. The primary care physician should be$ C7 N9 p" [, K% o
aware of this fact, because most of these children7 N) k9 F) h3 N* p6 N2 h
may initially present in their practice. The Physicians’9 x3 r+ M( \% G5 U( g+ W
Desk Reference and package insert should also put a
5 C) T, b+ a' w  G; t- j% {0 wwarning about the virilizing effect on a male or# o5 G$ f4 v- }$ t' [- v" l! P" ^' Y
female child who might come in contact with some-
6 V7 c! y% j  gone using any of these products.5 w, [+ l3 w. ^2 H4 P
References
( k5 r, V* f. c' |7 {5 e* h0 h1. Styne DM. The testes: disorder of sexual differentiation
* ^# q* V7 D% A( wand puberty in the male. In: Sperling MA, ed. Pediatric; e4 f3 @# h- d# b' z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# n- G/ m. M" n1 t3 E* m* Y2002: 565-628.
3 r# p- g( u! n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* I, y5 P$ l* B
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
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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
% S( w3 {  F' H% V
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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