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Sexual Precocity in a 16-Month-Old
, E6 K5 c2 \& J: c) @" {# k5 q, pBoy Induced by Indirect Topical5 E6 X& o) C( R3 b
Exposure to Testosterone
9 o+ L% L5 u8 y1 QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ T. q/ a/ ?6 V
and Kenneth R. Rettig, MD1% c( \+ R' h/ P$ x5 y) l+ H
Clinical Pediatrics
, y; _5 {0 O1 f2 s/ C) [% _Volume 46 Number 6* i5 e7 }( q6 |$ N7 I% k7 i$ J
July 2007 540-543
" F4 z9 a% Q, x© 2007 Sage Publications" Y9 i3 B9 W  e+ L4 f4 a
10.1177/00099228062966518 L; @/ F+ g4 S+ z7 z
http://clp.sagepub.com. \5 f: X/ }0 ~% h  R- d
hosted at
$ H5 [  l5 p9 |http://online.sagepub.com
7 b* m7 u; ^$ `Precocious puberty in boys, central or peripheral,
: G* d( w4 F7 ]5 ^is a significant concern for physicians. Central
( X% e0 G# }+ B6 A! o; Kprecocious puberty (CPP), which is mediated, H% E: O0 {# R4 J# F+ M! W6 ~+ P
through the hypothalamic pituitary gonadal axis, has  t) y- t, J+ i3 y8 M7 p$ B  m
a higher incidence of organic central nervous system
1 G1 v) e7 j/ Mlesions in boys.1,2 Virilization in boys, as manifested; {, c9 M' A, W  E% f9 f
by enlargement of the penis, development of pubic
& D* w8 h( ^- i+ {- e! X! Fhair, and facial acne without enlargement of testi-4 c& b; z$ K0 j: N, D- ]
cles, suggests peripheral or pseudopuberty.1-3 We- `) K7 ?! ^' [2 u9 g, v& T
report a 16-month-old boy who presented with the
7 ~/ ^9 E: Y* s7 G, l0 eenlargement of the phallus and pubic hair develop-& L+ @; ?1 K% T& J: ^3 }' h
ment without testicular enlargement, which was due- d8 d/ y; M/ M9 R% r8 P. [' p0 H
to the unintentional exposure to androgen gel used by
2 D$ K( e4 `# D! ?the father. The family initially concealed this infor-2 B3 p. W" K  G% q$ Z/ {' [1 z  C2 P
mation, resulting in an extensive work-up for this$ |. S% T3 I7 R
child. Given the widespread and easy availability of
; e8 B! p1 T/ Qtestosterone gel and cream, we believe this is proba-
. K8 A0 L$ B- o4 ~: Pbly more common than the rare case report in the
$ a! G. @) S& l9 ^8 {( r8 x3 ~0 v) pliterature.4
( \4 D& u; |9 I' pPatient Report, Q, b- a+ m" H; _+ m
A 16-month-old white child was referred to the1 T/ @! k! t* z5 t) d/ R, [
endocrine clinic by his pediatrician with the concern7 W0 {, h  {$ h$ z1 t
of early sexual development. His mother noticed
' z, `' X- V- Q1 plight colored pubic hair development when he was
) e5 t6 L7 W4 w! UFrom the 1Division of Pediatric Endocrinology, 2University of- m4 ]$ c2 r- I% z% H$ |
South Alabama Medical Center, Mobile, Alabama." F" I% J3 {" u! c
Address correspondence to: Samar K. Bhowmick, MD, FACE,
! k0 `# S; b4 J* [  p5 Y0 L1 cProfessor of Pediatrics, University of South Alabama, College of* f; u. V+ n+ f1 k+ H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" k3 @$ C8 K3 h- p" d5 r7 l
e-mail: [email protected].
2 o. G) P- w  e9 Z9 B, dabout 6 to 7 months old, which progressively became
) f: N5 k8 B) i) l& wdarker. She was also concerned about the enlarge-
! t2 I7 f- o3 [, _- \; ]ment of his penis and frequent erections. The child
: Y7 I0 f7 f6 V; l" Owas the product of a full-term normal delivery, with
7 G" l+ i) `! s) ia birth weight of 7 lb 14 oz, and birth length of$ ~1 U  g& y% v. L9 l4 N
20 inches. He was breast-fed throughout the first year
. r4 Y! o. `. x6 x8 `5 qof life and was still receiving breast milk along with8 J& Q; d% E4 P+ I, b1 p
solid food. He had no hospitalizations or surgery,
, r: }- @' L6 u  J+ T5 Land his psychosocial and psychomotor development  o( Y7 R1 [6 a4 s
was age appropriate./ h% ?. ]0 r, V& P% o. h5 _/ r
The family history was remarkable for the father,. P5 l3 Z! W' _- C
who was diagnosed with hypothyroidism at age 16,
: B# G' M7 Y! `  k) vwhich was treated with thyroxine. The father’s7 V5 s% z$ i' S' S  k
height was 6 feet, and he went through a somewhat: U" X" s6 H9 Y8 X/ C
early puberty and had stopped growing by age 14.: y) S5 W0 Z. a: z
The father denied taking any other medication. The# @1 a0 c$ t% n
child’s mother was in good health. Her menarche; n) R* ?# d" k$ |) \7 |
was at 11 years of age, and her height was at 5 feet. p; Q% y" U  |& I% W7 \3 s& w: o
5 inches. There was no other family history of pre-
7 C- x; w7 V6 Mcocious sexual development in the first-degree rela-; y/ ]1 u7 K6 g6 m
tives. There were no siblings.1 l2 i2 H- m+ w& H5 L& s
Physical Examination
1 e( R5 a% _) c8 QThe physical examination revealed a very active,  n! d4 i6 s) I
playful, and healthy boy. The vital signs documented
9 G: [. d* m) f1 k% j7 }a blood pressure of 85/50 mm Hg, his length was
0 c, y- n" K2 |0 ], w: y) L9 J90 cm (>97th percentile), and his weight was 14.4 kg( I8 v# D9 e/ H. R
(also >97th percentile). The observed yearly growth
. J- ?. `6 s. n/ V/ zvelocity was 30 cm (12 inches). The examination of' [6 J+ |4 i1 q0 M
the neck revealed no thyroid enlargement.$ j- y" R( f  t( N) O' J* T
The genitourinary examination was remarkable for% d# x# x: F  L( U
enlargement of the penis, with a stretched length of
# F$ J% d* ~7 h+ u8 cm and a width of 2 cm. The glans penis was very well
. P$ S/ b" E  `# g$ V' j5 `developed. The pubic hair was Tanner II, mostly around1 I+ m/ n/ \9 B5 B" Q* s6 T
5404 t' q( ^, a7 A# W1 B: Q( [( r  v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, b: _6 h# j4 Z% C8 Q5 L
the base of the phallus and was dark and curled. The
' o: t$ m) A" J  P' qtesticular volume was prepubertal at 2 mL each.2 s' {* ~2 _8 t/ i
The skin was moist and smooth and somewhat" J+ O, v% i7 w/ o3 i4 f
oily. No axillary hair was noted. There were no' n& p: t+ p' W  T# h
abnormal skin pigmentations or café-au-lait spots.
! S* m' n; v/ C- ^5 S% _Neurologic evaluation showed deep tendon reflex 2+4 w; g' t6 {+ [  v7 Q& m
bilateral and symmetrical. There was no suggestion
4 _- `& Y; l, \& Q" a8 [of papilledema.
& h2 H: H  ~" q8 T& ELaboratory Evaluation  u- T: K7 b5 r1 H$ @
The bone age was consistent with 28 months by
/ J2 ^8 o  @6 o; A/ m# iusing the standard of Greulich and Pyle at a chrono-
4 T9 J, P2 Y  N8 s9 r" Elogic age of 16 months (advanced).5 Chromosomal: {: r" |' k% ]/ \% ?
karyotype was 46XY. The thyroid function test% s" e4 q/ ^# x- Y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 h) @$ D$ m& T
lating hormone level was 1.3 µIU/mL (both normal).2 s, n9 U6 W/ d# R. y
The concentrations of serum electrolytes, blood! Q  q) d; G2 J; b) @7 L
urea nitrogen, creatinine, and calcium all were# j7 @# D1 ]) x7 O
within normal range for his age. The concentration
1 @  a' w1 j  q3 Gof serum 17-hydroxyprogesterone was 16 ng/dL
2 ?: v) s2 z7 h1 I, `) R(normal, 3 to 90 ng/dL), androstenedione was 20% Q5 K% c# Q( l0 I1 ~7 w7 v
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 Z2 E. N* U& u6 `+ A2 V9 pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: }5 k0 C! S7 [2 R8 K8 Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
9 o9 _* W3 ~: Q- P$ r6 C  f49ng/dL), 11-desoxycortisol (specific compound S)
0 Y0 y% C# B8 N4 i. z' e% nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 m- |& I3 P3 |. E# s% F  z7 rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! ]- h9 x3 w/ ~# n- X6 Q9 Htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ G* F0 k: S2 ]+ i  P! uand β-human chorionic gonadotropin was less than! C7 Y) h. D" B
5 mIU/mL (normal <5 mIU/mL). Serum follicular% U- A* x* a7 u
stimulating hormone and leuteinizing hormone
7 \5 W/ m* Z2 Vconcentrations were less than 0.05 mIU/mL% N, Y! x3 J9 `+ O* ?0 o
(prepubertal).
9 T* k+ a% e- P9 ~' m3 oThe parents were notified about the laboratory
" n8 m9 ?' K' |8 {results and were informed that all of the tests were
2 `; t$ `; a2 r# S& c0 snormal except the testosterone level was high. The
/ V  u( n* q; M& M2 g, qfollow-up visit was arranged within a few weeks to% i! ~& E& b, s# Y/ e
obtain testicular and abdominal sonograms; how-* x  J2 i4 {9 k" C
ever, the family did not return for 4 months.
3 W' i0 q% N8 u2 g& S% D+ ]4 bPhysical examination at this time revealed that the& I& G' P( a% Q* f1 I7 u
child had grown 2.5 cm in 4 months and had gained& A8 f. ]% Q, H. `5 Z
2 kg of weight. Physical examination remained
" S' t# \- t; P5 tunchanged. Surprisingly, the pubic hair almost com-
/ K2 H$ i  u" K- Dpletely disappeared except for a few vellous hairs at
3 j& t9 ~) U2 k8 D" w& Q' p9 dthe base of the phallus. Testicular volume was still 27 U7 t, z( g& ]5 o3 Z8 h
mL, and the size of the penis remained unchanged.9 h) r5 \- Q) F4 A. G  n  P
The mother also said that the boy was no longer hav-# r$ ~. Z4 w) W
ing frequent erections.
: M5 j' z4 y4 z$ c- T. q2 W" nBoth parents were again questioned about use of
; ^3 A- J0 S- S+ ]/ p8 gany ointment/creams that they may have applied to
( c: J2 r3 ?: ?4 V, Y) ythe child’s skin. This time the father admitted the  j6 v* t% n4 D3 b
Topical Testosterone Exposure / Bhowmick et al 541
$ I2 U" O6 o/ C6 duse of testosterone gel twice daily that he was apply-
& Q1 i& L- D. t7 ring over his own shoulders, chest, and back area for
& s. U1 G/ F  Y; o6 g2 Wa year. The father also revealed he was embarrassed7 x" Q( h- ~. q
to disclose that he was using a testosterone gel pre-
* [7 l* G# E% Z& H" T, xscribed by his family physician for decreased libido
, F2 ]) u* D( D( I7 ?secondary to depression.
4 X. m6 t% C5 K+ }The child slept in the same bed with parents." \2 Z& f, x/ ^! N( Z7 m  Z3 A
The father would hug the baby and hold him on his
6 J, ]) i  R/ v. `: r! f+ _chest for a considerable period of time, causing sig-, Q; p% {+ _2 T2 g- ^
nificant bare skin contact between baby and father.
& w3 U: A2 z% G' _6 m" n5 OThe father also admitted that after the phone call,
6 S$ t" ~# b( u( R" ]5 O7 ^when he learned the testosterone level in the baby
* Q" A- n! P1 w/ f. X  i% q; Swas high, he then read the product information
+ {( R" [" f: ^; G3 Qpacket and concluded that it was most likely the rea-4 r& @' b) e) N3 G  E
son for the child’s virilization. At that time, they0 p( `. P6 @9 _4 G  t4 h! K
decided to put the baby in a separate bed, and the
" R3 l- {* g" Q: b1 Hfather was not hugging him with bare skin and had
% L8 z1 L* }+ m6 Gbeen using protective clothing. A repeat testosterone
+ U2 q! _, B" s/ Utest was ordered, but the family did not go to the' I1 m# N% H1 d) J
laboratory to obtain the test.
  w6 s" M" i2 f3 E0 u; T' pDiscussion; D/ Y8 V# `( z, |$ L' ~
Precocious puberty in boys is defined as secondary
( F7 X/ V/ |, z# P6 Rsexual development before 9 years of age.1,4
) U; c8 \* Z. T! b2 GPrecocious puberty is termed as central (true) when+ R& R! o! d3 e7 j
it is caused by the premature activation of hypo-
2 d4 U$ [. T$ Q2 `. E- Mthalamic pituitary gonadal axis. CPP is more com-
+ E6 R$ o% h5 ?6 R3 X  q4 x% E$ Pmon in girls than in boys.1,3 Most boys with CPP
" U0 n1 V6 M: h. ^. rmay have a central nervous system lesion that is
, Y/ |. Z/ x+ ~: k# S2 ]responsible for the early activation of the hypothal-
% C1 p4 w0 W2 |8 D  R) e" p( |9 samic pituitary gonadal axis.1-3 Thus, greater empha-7 b) h, C2 e  ]3 @
sis has been given to neuroradiologic imaging in5 @" U0 ^2 \1 q8 ^8 f* L0 v
boys with precocious puberty. In addition to viril-4 p* z# i! ^/ i: ]
ization, the clinical hallmark of CPP is the symmet-
2 @) K# S/ N; w! y0 Nrical testicular growth secondary to stimulation by
3 u6 T; E: R/ J' O+ k! Mgonadotropins.1,3
4 T; h7 E$ [0 h$ e. UGonadotropin-independent peripheral preco-
. z4 U' y0 I  o0 R7 jcious puberty in boys also results from inappropriate
5 r; x# C+ C1 W6 ^- xandrogenic stimulation from either endogenous or' _/ v6 v3 x: N" Y4 X
exogenous sources, nonpituitary gonadotropin stim-
6 ^& n, I3 ]" N( m' aulation, and rare activating mutations.3 Virilizing
. r; a9 j* |3 J. @' H* d2 A' }congenital adrenal hyperplasia producing excessive8 u/ F2 |5 x) q2 V' c/ y
adrenal androgens is a common cause of precocious0 r/ Q  S4 r+ P3 o& g
puberty in boys.3,4
7 H: u/ S: I2 P  {- I3 T) }  T) }The most common form of congenital adrenal% V1 |9 Y- V) d- i, ^- ?+ M7 ~9 w
hyperplasia is the 21-hydroxylase enzyme deficiency.0 V( r$ e7 z2 a/ U! S, w+ A1 m' C
The 11-β hydroxylase deficiency may also result in' ?3 D- Q$ @( j( ]4 P: ~- }
excessive adrenal androgen production, and rarely,+ B2 b# A! m- [. u; ^
an adrenal tumor may also cause adrenal androgen
* q3 l9 z; G$ N6 b# b0 s% pexcess.1,3) b& U  k, h. a$ y8 m# Q$ W3 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ K) `( r/ D5 g* W2 U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 N" Z$ t; s2 A+ p! U0 P' u; \/ G" mA unique entity of male-limited gonadotropin-
+ h- g8 N/ }) t0 Jindependent precocious puberty, which is also known
9 X) y8 f( n" Q: v2 ]as testotoxicosis, may cause precocious puberty at a
' x; k4 f+ \" Q  g! W, Cvery young age. The physical findings in these boys
: @: X3 z, A7 mwith this disorder are full pubertal development,: A& B& w: |  V/ O+ T
including bilateral testicular growth, similar to boys9 d& w0 w& ^7 Q
with CPP. The gonadotropin levels in this disorder5 X* {5 r( l% g/ [
are suppressed to prepubertal levels and do not show
; C2 W1 I( B" @1 g# y. {/ @6 M) ipubertal response of gonadotropin after gonadotropin-
# }% Z: q* c+ ^8 d, @9 F1 c1 ~0 G# wreleasing hormone stimulation. This is a sex-linked
6 o$ P) M4 ~, F& Q6 m. J( q# ]! pautosomal dominant disorder that affects only
% D( ?0 H" S7 {+ x# h9 N6 D% emales; therefore, other male members of the family6 |2 h& j, T+ |& ^1 U* k5 ?# [( z5 a
may have similar precocious puberty.3
8 M' n. A- D: T5 L+ v1 ZIn our patient, physical examination was incon-, ]' z# Y- l% E" `8 y
sistent with true precocious puberty since his testi-; Q! Y' P# s. n3 A' ?" f/ _
cles were prepubertal in size. However, testotoxicosis2 T1 o& h( G. q- n' Q; L" J
was in the differential diagnosis because his father
, c. X: l& U8 Q( ^( N9 M3 k! m6 H4 m- Istarted puberty somewhat early, and occasionally,7 h# g5 ~% X0 B: W, L+ H
testicular enlargement is not that evident in the
4 \" D( \  `4 N- \beginning of this process.1 In the absence of a neg-% g  K! P$ A( P6 l/ H3 c8 B
ative initial history of androgen exposure, our4 f, G% `+ [7 j
biggest concern was virilizing adrenal hyperplasia,
* L; v: L$ Z( U$ Veither 21-hydroxylase deficiency or 11-β hydroxylase9 S" I6 D' D: [4 \; N: t
deficiency. Those diagnoses were excluded by find-& [! z0 {0 q. d' k9 N# s, B
ing the normal level of adrenal steroids.5 R/ \! Y* q" }  d
The diagnosis of exogenous androgens was strongly' T9 l/ k/ v5 E) `
suspected in a follow-up visit after 4 months because
( j* y# ^% {: d' [the physical examination revealed the complete disap-' F6 v& ]' [' K* m- i7 r& q9 D! J
pearance of pubic hair, normal growth velocity, and
* c# v& ^8 ]4 M/ c- S6 Q8 Adecreased erections. The father admitted using a testos-, K  X7 s+ e; Z0 ]) H% Y0 v7 K7 H
terone gel, which he concealed at first visit. He was
1 U3 O' n7 p& F6 ?2 W7 Xusing it rather frequently, twice a day. The Physicians’  J9 G7 X4 G( ]9 l
Desk Reference, or package insert of this product, gel or1 p# R4 G4 Q' H& x
cream, cautions about dermal testosterone transfer to
( d5 p" E' Y' ]unprotected females through direct skin exposure.- z7 H" e9 w( t) p  ~& a! `$ t+ I- Z
Serum testosterone level was found to be 2 times the; V  T; S& U8 F' q- J# R
baseline value in those females who were exposed to' r  r1 @2 o. O$ p" j& Q
even 15 minutes of direct skin contact with their male2 z- |- r3 z6 v
partners.6 However, when a shirt covered the applica-
0 c( ~! H  W  j  H- t6 |* Ation site, this testosterone transfer was prevented.
( K. k* O! F; GOur patient’s testosterone level was 60 ng/mL,
9 ?- w' l, t8 Xwhich was clearly high. Some studies suggest that
& L. M+ b# |- l& g! p6 _# s9 ydermal conversion of testosterone to dihydrotestos-
" W2 H& N0 k6 aterone, which is a more potent metabolite, is more- O) q, O. O& e& w. C7 H  _6 M8 \$ F
active in young children exposed to testosterone
$ {/ T$ }, ?+ R. d* Uexogenously7; however, we did not measure a dihy-- {' E2 U6 y( E9 C2 {
drotestosterone level in our patient. In addition to
0 s1 n' G- p9 C% R" _1 k$ \$ |virilization, exposure to exogenous testosterone in
# E+ q  Y  x! F8 z" R  schildren results in an increase in growth velocity and
; H; @5 x) v& M$ z, T3 a" Fadvanced bone age, as seen in our patient.6 y. h2 [; N. A6 _2 X
The long-term effect of androgen exposure during; w% R! @( c6 J. |+ F3 T
early childhood on pubertal development and final* n9 D9 w/ t4 e1 q9 k
adult height are not fully known and always remain& a  U' O! J" [' B* t3 x
a concern. Children treated with short-term testos-
* c9 S4 T, \1 H* wterone injection or topical androgen may exhibit some
. z5 X  o$ U% X5 @0 f2 @0 eacceleration of the skeletal maturation; however, after
/ j. F6 d. x- N2 a* bcessation of treatment, the rate of bone maturation
( G5 w& u8 ?7 L9 _& q2 ~+ e9 L6 u* v) gdecelerates and gradually returns to normal.8,9
5 n& X2 \: Y; |! }' Q. m) r! X% FThere are conflicting reports and controversy
6 b, ]* _2 ]& r' r! r2 Q3 _; iover the effect of early androgen exposure on adult
% j4 b4 B9 g; O" X! }penile length.10,11 Some reports suggest subnormal% a6 R, {7 D1 [* P2 ^9 e: o
adult penile length, apparently because of downreg-
( z! P/ I8 j9 }) Fulation of androgen receptor number.10,12 However,
0 B: _6 u! D, T& M& oSutherland et al13 did not find a correlation between
% G( d: R+ U& D# q6 a; v2 zchildhood testosterone exposure and reduced adult( T, @* d# K' ^- e6 g
penile length in clinical studies.
: r: j! ~" s  s1 e8 iNonetheless, we do not believe our patient is# s/ |! E0 r4 k2 ?* l- I
going to experience any of the untoward effects from+ g- T  U. H* h+ D
testosterone exposure as mentioned earlier because- d4 R2 N7 y' U/ \4 b+ L
the exposure was not for a prolonged period of time.  u# H% L% c& P6 t  l' s! Y' \
Although the bone age was advanced at the time of
  r8 h5 Q# \7 k+ O/ K* Cdiagnosis, the child had a normal growth velocity at
4 O1 \$ R1 b6 b0 v6 H; E8 uthe follow-up visit. It is hoped that his final adult4 Z( ~3 d. T. t% k
height will not be affected.
# C/ I2 X% e, c: y( f/ }Although rarely reported, the widespread avail-. R2 b0 `" \3 k# a4 b6 ~$ w
ability of androgen products in our society may
  {" X0 j; g" pindeed cause more virilization in male or female4 S- k/ T* \% {6 v9 a& {  O" u
children than one would realize. Exposure to andro-$ g$ B% ?) X" p  Y) Q
gen products must be considered and specific ques-
" l% I# M# n  R. v& F& o% m+ ztioning about the use of a testosterone product or- _& ?4 l! y, I; T2 J
gel should be asked of the family members during- m9 [" u7 V4 h5 A2 s3 K1 O
the evaluation of any children who present with vir-' K* {  w" v" ~4 ]8 U) {
ilization or peripheral precocious puberty. The diag-
- K% y; h3 O) Q2 A. E9 f1 Z4 Unosis can be established by just a few tests and by0 b' [$ }2 e9 c1 N1 @' y
appropriate history. The inability to obtain such a( i1 J; d4 q, r- g
history, or failure to ask the specific questions, may
: Z7 P/ j  c1 v+ r/ i- Fresult in extensive, unnecessary, and expensive$ `( C- c; M/ ~) {# @# ~7 R
investigation. The primary care physician should be
( [2 `0 G& d; g5 B0 V$ y& Taware of this fact, because most of these children# A: v2 F" r' E$ i: ^
may initially present in their practice. The Physicians’
+ n6 C6 ^& ?" y. J4 z7 E" }7 M* o" `: fDesk Reference and package insert should also put a! |3 y! @; A* \3 X% x
warning about the virilizing effect on a male or8 y# h. v! p5 c5 I! a/ S
female child who might come in contact with some-4 Z5 `! J7 a7 C( d8 \  }
one using any of these products.
7 W$ Q. W7 @# k! V- }6 v# wReferences$ _0 Z9 `! h1 R% {5 `; L$ |3 X" ~
1. Styne DM. The testes: disorder of sexual differentiation% \# ^" [) h. M( K
and puberty in the male. In: Sperling MA, ed. Pediatric
6 X' m2 l% T/ x8 O4 SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" K0 w, k8 B4 H' V* f# i( {* L
2002: 565-628.* L# N  ?3 A7 k/ _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# h$ e4 z% ]  n% Ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* E' g" A: f; m5 B7 Y8 {
Boy Induced by Indirect Topical' P3 n9 B$ H2 X1 f! v: T
Exposure to Testosterone
0 N! |, u9 U. T( y# k; c! w1 DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ ^+ b$ y0 o4 U7 h
and Kenneth R. Rettig, MD1
9 s* h; N' |$ z+ _0 \" XClinical Pediatrics
$ t9 m$ n# @: ?5 K; s$ sVolume 46 Number 62 @! B9 K' G& z% [
July 2007 540-543
$ n) D. u- a2 m; V+ B; f3 M/ L© 2007 Sage Publications
# ?2 b) ^4 ^- [9 M6 ]10.1177/0009922806296651
4 |1 u" ]0 L  L- phttp://clp.sagepub.com
- D/ }2 u3 v. i% f1 E& [hosted at
. P0 |2 S" ~* U* A$ d( Khttp://online.sagepub.com9 R( c+ n5 R- L; B0 p
Precocious puberty in boys, central or peripheral,5 j, q+ Y& ~  J- K
is a significant concern for physicians. Central
& g3 c/ p( }/ I( C, K4 `precocious puberty (CPP), which is mediated
& I9 S3 l& f# I* P  Q# ^through the hypothalamic pituitary gonadal axis, has
0 P- k* P6 u' U/ ]1 F0 ma higher incidence of organic central nervous system4 i! R+ X, K% n6 Z
lesions in boys.1,2 Virilization in boys, as manifested
$ Z' x) l9 M6 z8 M4 g- |by enlargement of the penis, development of pubic6 I' K7 v% s, T3 s9 B  R
hair, and facial acne without enlargement of testi-
7 H; v- R7 m( c7 N9 P0 F+ ]cles, suggests peripheral or pseudopuberty.1-3 We) d/ {3 D  f( r8 X, A
report a 16-month-old boy who presented with the# L% l( X/ }2 b6 v; v/ |
enlargement of the phallus and pubic hair develop-6 j5 D5 [, p& T6 W: m
ment without testicular enlargement, which was due
5 j6 r: e/ M3 _to the unintentional exposure to androgen gel used by% D0 U9 t3 h3 ?0 ^) @: b
the father. The family initially concealed this infor-  U  w5 u0 S  A: \+ Q
mation, resulting in an extensive work-up for this
# ~, O! C* ]! a  j) T5 bchild. Given the widespread and easy availability of
" z2 `- C& d' k7 ]5 M+ Otestosterone gel and cream, we believe this is proba-  i7 h  v. x& k3 y* x/ L& V
bly more common than the rare case report in the
* q+ T; z- v9 s6 U6 p+ pliterature.40 S- S1 L/ k! w
Patient Report* Y0 @' t) k7 @1 a. A$ |: {
A 16-month-old white child was referred to the
- T1 ]# Z1 f- G6 ~4 E! x8 {! J; |. }/ fendocrine clinic by his pediatrician with the concern/ D3 W: {! k8 G# }; X; X* U
of early sexual development. His mother noticed8 S: x: L% b9 {
light colored pubic hair development when he was
( N" x* M2 q8 n; [2 r" MFrom the 1Division of Pediatric Endocrinology, 2University of, t8 x+ X; z+ E% Y. p. \) k4 U. ]
South Alabama Medical Center, Mobile, Alabama.8 |3 b  X7 Y) m4 F9 e& {; r
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( w$ a, \; `, I8 `9 eProfessor of Pediatrics, University of South Alabama, College of" [  k7 S+ u8 b9 g* e4 @# n, H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 T, z. e( e, L9 b1 m6 ~e-mail: [email protected].
# `) L% W5 W8 e3 T3 ]8 q6 Habout 6 to 7 months old, which progressively became5 i" a, z5 p! S! W1 i; z. L
darker. She was also concerned about the enlarge-
' n' A6 [8 P( y3 J1 V' m9 \ment of his penis and frequent erections. The child
+ a2 ?% _; R' C7 e0 \/ M2 C9 Owas the product of a full-term normal delivery, with7 N  i: |; _3 r, Y/ L. f
a birth weight of 7 lb 14 oz, and birth length of8 {3 c2 q4 q" [' j) K/ f; |9 b
20 inches. He was breast-fed throughout the first year5 |$ L2 w* a7 P9 U# F% G: F
of life and was still receiving breast milk along with
1 |7 S7 ^' C' d+ {* q2 c9 isolid food. He had no hospitalizations or surgery,
9 e) ^8 t7 t8 ]- c* Yand his psychosocial and psychomotor development% h0 g9 E  W4 s; Z5 r
was age appropriate.3 X- j( u- m& I+ f- R6 S) ?; ^* }
The family history was remarkable for the father,6 p5 i8 I% r; h/ s5 O0 F: x; h
who was diagnosed with hypothyroidism at age 16,  G- a- m" s/ r
which was treated with thyroxine. The father’s
5 I! E0 X/ K& g! D% s% N8 Hheight was 6 feet, and he went through a somewhat
+ E5 W* c) M  T9 mearly puberty and had stopped growing by age 14.
, u' X$ i# M  m9 f0 e, @, lThe father denied taking any other medication. The
+ U9 ?& M' N5 B1 C0 a* k" E2 ^child’s mother was in good health. Her menarche, K2 P/ f! o! g
was at 11 years of age, and her height was at 5 feet
1 X' t2 ~' y4 s$ K) C8 N4 i5 inches. There was no other family history of pre-8 o' N, L, M; c2 \" U+ R9 `9 E
cocious sexual development in the first-degree rela-
5 V4 a% B' Z/ z& Q( k6 n# Atives. There were no siblings.# K" V# H, q  |, X1 }2 m0 o
Physical Examination% U5 e- w9 N7 r. M& i
The physical examination revealed a very active,
5 x! o% U1 w+ I! M$ lplayful, and healthy boy. The vital signs documented7 L" v' v' T" R
a blood pressure of 85/50 mm Hg, his length was' H% V/ J9 z; W, t) I* y
90 cm (>97th percentile), and his weight was 14.4 kg
- ]" K0 o* R2 U- }* i  }(also >97th percentile). The observed yearly growth
0 k  [5 u0 W5 @: zvelocity was 30 cm (12 inches). The examination of' e0 N+ Y- n8 u2 c1 m
the neck revealed no thyroid enlargement.# I( L. l6 b7 n- D# e) t8 S6 X
The genitourinary examination was remarkable for
( b; [1 }  x# Q6 i  @( penlargement of the penis, with a stretched length of
4 t4 o9 x' q$ |4 L5 e" C) n- h8 cm and a width of 2 cm. The glans penis was very well' |- s9 X. q% p; a! Z/ T. J5 \1 L
developed. The pubic hair was Tanner II, mostly around
( V, Z9 H  Z% r540, g' x* r# W  F2 K# @; C" U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( G6 g3 K% ^5 ^
the base of the phallus and was dark and curled. The' ^$ c3 ^5 T& s( q4 s/ K
testicular volume was prepubertal at 2 mL each.
4 v. z* a0 \1 d$ _The skin was moist and smooth and somewhat
% j0 W5 w) `0 xoily. No axillary hair was noted. There were no: [, `: ~3 K" u
abnormal skin pigmentations or café-au-lait spots.+ b2 x# C/ o: _" s& j
Neurologic evaluation showed deep tendon reflex 2+/ S# p; v3 [9 @) ^- z- h1 J* g
bilateral and symmetrical. There was no suggestion, C2 V; ^6 m* d$ a  m; U1 g  ?
of papilledema.
4 g4 c8 r2 I% B* [% ULaboratory Evaluation
7 ]- ^( R  F5 t. _The bone age was consistent with 28 months by
6 ?0 ^! w: |9 o* Pusing the standard of Greulich and Pyle at a chrono-/ a' Y  H' I6 Q
logic age of 16 months (advanced).5 Chromosomal0 C) {9 P$ s2 U! Z
karyotype was 46XY. The thyroid function test) U9 {0 k7 b. c, }) m; C/ Z; h: L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: \# |4 S9 F1 `1 U" J9 V6 ?
lating hormone level was 1.3 µIU/mL (both normal).
3 s3 b; w5 s4 p, s/ s1 o; zThe concentrations of serum electrolytes, blood: Q+ F* s) _8 S' R- s' Q  l5 h
urea nitrogen, creatinine, and calcium all were
" w) g; |4 b3 F3 A* w) x6 Twithin normal range for his age. The concentration
. p$ j5 u; e4 F8 j- P* X" aof serum 17-hydroxyprogesterone was 16 ng/dL( v. N2 x& k# o7 ?
(normal, 3 to 90 ng/dL), androstenedione was 20: h1 O: A2 V4 f# y7 x3 d/ J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; a# X: s: {/ y$ @) L! o% g$ \* Jterone was 38 ng/dL (normal, 50 to 760 ng/dL),; h  @* z! i. K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
& C$ w1 T6 m. H# E49ng/dL), 11-desoxycortisol (specific compound S): z9 V# W8 [: R8 X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 r- W( T( ]. |% z( q8 `
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 G( d+ l+ n6 _! @) ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ o5 u+ h, q) I, h$ Z9 _$ vand β-human chorionic gonadotropin was less than- t4 o& h+ P' R
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  @8 I, H, F8 l" f5 tstimulating hormone and leuteinizing hormone
7 l& V7 L! X& _0 l/ u: w1 Z3 uconcentrations were less than 0.05 mIU/mL
8 G$ F( |2 ]  J) N(prepubertal).
  K; U+ R5 E* ^: C' K. ~The parents were notified about the laboratory: i( ~$ b6 M# ^1 G! C& e
results and were informed that all of the tests were
+ K$ ^2 M) x+ Ynormal except the testosterone level was high. The0 B- D; W1 D2 f& s/ y. |
follow-up visit was arranged within a few weeks to8 x. Z- X- z4 o5 M2 |
obtain testicular and abdominal sonograms; how-8 d6 C- T, I& a- W. I( G' c! _* d
ever, the family did not return for 4 months.
3 x0 y- h% e1 ]3 VPhysical examination at this time revealed that the
, W: O5 m% _3 n* S$ `) ~child had grown 2.5 cm in 4 months and had gained! D# }% A! Y* a8 D$ ?- f
2 kg of weight. Physical examination remained
0 L7 l# w# g$ r3 C& p0 f6 G! ^unchanged. Surprisingly, the pubic hair almost com-
2 {/ j/ _; F7 l7 J) M8 q, ~pletely disappeared except for a few vellous hairs at
6 H5 z! ~  D4 V1 Q( R3 H* Q6 ]1 pthe base of the phallus. Testicular volume was still 2
4 ]  K8 E/ u4 o, |! H$ D0 d% lmL, and the size of the penis remained unchanged.
" N  A# g5 N$ K3 KThe mother also said that the boy was no longer hav-
0 \  V. [$ r$ e2 E$ T  iing frequent erections.
+ Z; d2 m8 j2 _+ MBoth parents were again questioned about use of& G4 x( G: F3 c5 z( u
any ointment/creams that they may have applied to/ I# x6 B+ Y! b; g# I
the child’s skin. This time the father admitted the* q  `  S' z/ h* c  d- ~
Topical Testosterone Exposure / Bhowmick et al 541
0 c4 ~: W+ `2 H1 X: [  X4 x! \use of testosterone gel twice daily that he was apply-; W* {+ [( ~2 F. W! [
ing over his own shoulders, chest, and back area for/ n: s+ o- L) _! W0 x  P% F/ j
a year. The father also revealed he was embarrassed6 B9 D! a) N% Y6 X6 o$ L% P
to disclose that he was using a testosterone gel pre-
/ t  s2 h0 c, e- Tscribed by his family physician for decreased libido0 w8 g2 N; s  I8 U+ S. d' ~% H
secondary to depression.
% b+ F6 @- t2 p9 L# dThe child slept in the same bed with parents.7 `* k9 P; O7 I. B+ V% c& ~' G2 c
The father would hug the baby and hold him on his
/ V& @2 I2 t' g+ I4 qchest for a considerable period of time, causing sig-
8 j0 K# V4 V7 Fnificant bare skin contact between baby and father.
. y" ]/ t( k7 Y/ t8 T  d/ D' T! CThe father also admitted that after the phone call,$ x* M9 {% `8 G9 e
when he learned the testosterone level in the baby/ J! S# I8 L- N
was high, he then read the product information/ |  x% d) L8 N  I
packet and concluded that it was most likely the rea-
6 c& [3 b9 k7 U  V+ i! ?son for the child’s virilization. At that time, they
5 m- Q2 T" f/ o4 c/ \decided to put the baby in a separate bed, and the* |" N  s# J" B' E1 C* S' M/ v9 u
father was not hugging him with bare skin and had/ j2 f; ^( }: a9 l
been using protective clothing. A repeat testosterone
. C0 ^% u& @" n/ \, J. \3 Y( {test was ordered, but the family did not go to the
5 B1 Z/ h6 ?: l' M8 Ulaboratory to obtain the test.
2 U! ?' Q+ X( e, [( UDiscussion9 _6 R3 k) C# G
Precocious puberty in boys is defined as secondary; Y( ?9 ~) l- g7 [; l% @; E- i. ^5 T! g
sexual development before 9 years of age.1,4
9 s- b% _: H! K+ B1 y5 T* j) l& C# \Precocious puberty is termed as central (true) when/ E* W  I1 q9 y9 ], k
it is caused by the premature activation of hypo-7 E: }$ ?2 i3 v9 K
thalamic pituitary gonadal axis. CPP is more com-
& l/ T  f2 e# {  Jmon in girls than in boys.1,3 Most boys with CPP9 l' f. g, |& Z* Y1 w
may have a central nervous system lesion that is
8 [- ~3 V! l( k* f6 I9 L% eresponsible for the early activation of the hypothal-
* V* I+ ^2 c. O+ Q% vamic pituitary gonadal axis.1-3 Thus, greater empha-( m7 ~3 H& u$ l, N1 K% {/ ]- q
sis has been given to neuroradiologic imaging in
9 b9 B% v6 \4 f- Jboys with precocious puberty. In addition to viril-
/ p& z& c/ H% W6 i: ?0 ]( Gization, the clinical hallmark of CPP is the symmet-/ q; P( l) K, v, k4 n0 Y
rical testicular growth secondary to stimulation by
) F$ i1 y1 A1 U0 Ngonadotropins.1,3
% ^, d. x- g, D) BGonadotropin-independent peripheral preco-
. s( M: w1 F5 P' Z3 Z9 J9 W3 N& Ycious puberty in boys also results from inappropriate
7 }! r% p6 |1 H1 nandrogenic stimulation from either endogenous or0 ?/ h" w5 G, i* ]# |$ K
exogenous sources, nonpituitary gonadotropin stim-
' c* b) i5 X9 K: p5 t9 julation, and rare activating mutations.3 Virilizing# @) n  S- C; i9 P& B- W# v
congenital adrenal hyperplasia producing excessive
# t' j2 r; C; Wadrenal androgens is a common cause of precocious# I/ ~8 k( T: H& F3 ~
puberty in boys.3,4, c3 l( N6 _2 V' `0 u
The most common form of congenital adrenal% h, e/ v: x: q0 R) \
hyperplasia is the 21-hydroxylase enzyme deficiency.
" Z' x+ ^+ P% o2 ^1 F  g4 RThe 11-β hydroxylase deficiency may also result in/ g, g  K6 F/ ^- j2 R( `
excessive adrenal androgen production, and rarely,: G) c" f) S+ C- T" \* V5 F# X
an adrenal tumor may also cause adrenal androgen
* q& h- v$ \" D) @. mexcess.1,31 O: y8 l  a( x, ]- c# ^! G( X' k. |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 }4 ^9 G; M5 O  l3 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- m3 S; O- ?* J, O# P/ g' ?
A unique entity of male-limited gonadotropin-
( F0 P. I: i5 z' Q5 @independent precocious puberty, which is also known
' G$ p: m7 j. S  f7 u4 `as testotoxicosis, may cause precocious puberty at a
' C) v9 P1 n& b. t: j$ ^, Lvery young age. The physical findings in these boys; I" U8 t" g; _
with this disorder are full pubertal development,8 p1 e8 ?/ S+ |/ A/ |
including bilateral testicular growth, similar to boys
6 E* m1 f. k, {4 `1 `+ m( d# }with CPP. The gonadotropin levels in this disorder" h& K& a& |6 f9 U
are suppressed to prepubertal levels and do not show; r5 w. E$ u6 R3 D
pubertal response of gonadotropin after gonadotropin-) `3 P3 Z, w3 O
releasing hormone stimulation. This is a sex-linked
0 I" Q. k  }) K* zautosomal dominant disorder that affects only1 v  Q, v7 h" v
males; therefore, other male members of the family% Y# D5 [8 l6 o+ x+ x0 p  A) T
may have similar precocious puberty.3: ~, b  z2 k0 R
In our patient, physical examination was incon-/ a7 o% f; B+ f. b; h* \+ q
sistent with true precocious puberty since his testi-
2 |. S5 L0 F  x/ `! Gcles were prepubertal in size. However, testotoxicosis5 G2 p; u% a) y
was in the differential diagnosis because his father
  q( e% K5 V" B- X1 ystarted puberty somewhat early, and occasionally,
' p- e; y/ Q! O  v# @  Q$ f+ V8 H. `testicular enlargement is not that evident in the
1 w5 E* i* |) e' Lbeginning of this process.1 In the absence of a neg-8 ?- s0 P; C. V1 j/ ~* A& T
ative initial history of androgen exposure, our
4 |$ V* ?3 s, V% H# j. X8 @9 }biggest concern was virilizing adrenal hyperplasia,
/ H7 Y! `# q" z1 M5 \; Heither 21-hydroxylase deficiency or 11-β hydroxylase( R' Q; Y) z( T* I- j
deficiency. Those diagnoses were excluded by find-
# @& i2 K3 D+ e$ x% M2 {. eing the normal level of adrenal steroids.
4 i8 t6 f9 B0 ?5 ]The diagnosis of exogenous androgens was strongly; i9 Z4 \4 v9 o' ^: {( G0 ~9 d( _
suspected in a follow-up visit after 4 months because
  J5 _2 @2 S) @1 L' g4 Y! M$ D/ uthe physical examination revealed the complete disap-& Q0 {& M9 u# k4 P( g
pearance of pubic hair, normal growth velocity, and
1 q( @& m. b/ Y3 W' ~$ ^decreased erections. The father admitted using a testos-
$ l% Q' Z. i- O5 F# b! Zterone gel, which he concealed at first visit. He was
+ @8 y8 L- P% j' J, @using it rather frequently, twice a day. The Physicians’; b4 J, @' M; o& |' r1 b
Desk Reference, or package insert of this product, gel or
" m# n9 C( }) O/ l1 y: T. g- jcream, cautions about dermal testosterone transfer to
& d0 L- u9 a8 r! o+ }unprotected females through direct skin exposure.' y5 `. O6 ^! c0 d
Serum testosterone level was found to be 2 times the
. V+ }2 M. O7 `. A7 C0 W: K5 Abaseline value in those females who were exposed to% V/ o7 N3 n% L3 o! I* q; X8 t4 `# Y% M
even 15 minutes of direct skin contact with their male8 v) m. o8 k) O
partners.6 However, when a shirt covered the applica-  B$ i/ b1 Q# W5 |" Y# @# L# F
tion site, this testosterone transfer was prevented.& n' u1 b3 E1 H6 U1 o2 S
Our patient’s testosterone level was 60 ng/mL,
: W* U# z& h8 q8 X% z- ^which was clearly high. Some studies suggest that
+ g) e' h2 F: u: b9 q: Zdermal conversion of testosterone to dihydrotestos-" d$ ]/ e1 q# [  }8 h8 n
terone, which is a more potent metabolite, is more4 g3 f; @* i' g$ n$ e2 a4 Z
active in young children exposed to testosterone
6 a& a6 s  Q2 Z) L" \exogenously7; however, we did not measure a dihy-# n7 }" ^0 `7 x' b$ M+ V* k# F5 ^
drotestosterone level in our patient. In addition to' `# O: n9 S% S9 A
virilization, exposure to exogenous testosterone in  w* g1 g' i5 w( ^& D( O; o7 q
children results in an increase in growth velocity and
. N: v0 Y- N3 S1 w. Tadvanced bone age, as seen in our patient.
$ @7 u; X6 K1 x& Y! s1 _; c% G6 f6 dThe long-term effect of androgen exposure during
* K6 ?# [! z. T; Y  D" {6 [early childhood on pubertal development and final
% H2 v, S9 r  w) _# u  G9 gadult height are not fully known and always remain
( _6 T& U3 y3 s$ E6 p* Pa concern. Children treated with short-term testos-) B. [8 d# }, _7 ?% `0 A7 g
terone injection or topical androgen may exhibit some
  a" R9 S5 [7 c% Wacceleration of the skeletal maturation; however, after4 G1 n! j" d4 J8 h- E7 F; N
cessation of treatment, the rate of bone maturation
) L2 K6 {1 |% u& e9 D- v1 l9 Hdecelerates and gradually returns to normal.8,97 {$ P2 `  R8 t- L4 B( h. v
There are conflicting reports and controversy
5 F1 q) O2 m( w: Dover the effect of early androgen exposure on adult
. J5 |2 B, A6 I( x4 ^penile length.10,11 Some reports suggest subnormal
8 H3 X, o" \- }9 l8 C, I' P$ Cadult penile length, apparently because of downreg-. L4 A8 O2 s, D
ulation of androgen receptor number.10,12 However,
) S# o5 L% I' U7 YSutherland et al13 did not find a correlation between! b7 ^7 w3 _# e( Y: Z0 _
childhood testosterone exposure and reduced adult
& J& v  Y# b9 A4 ~penile length in clinical studies.
% i3 H8 t6 \$ U4 Q3 s- c8 pNonetheless, we do not believe our patient is% Z* o2 _- n2 O/ v7 U. Z
going to experience any of the untoward effects from
3 m7 @+ ]" h' ?testosterone exposure as mentioned earlier because
  `; C1 K/ V% ^the exposure was not for a prolonged period of time.
0 }! @; ?/ \' l. T& M. @+ D; TAlthough the bone age was advanced at the time of  m% N& M+ J/ @, t% D5 W
diagnosis, the child had a normal growth velocity at  N8 d1 [# S3 Q! `! ^0 V1 Q
the follow-up visit. It is hoped that his final adult3 }+ D  C6 e+ |% N6 l8 ]- a
height will not be affected.$ D& |, E: v3 z' V( w; |* U9 ]
Although rarely reported, the widespread avail-/ m/ {& H' |+ \! n5 l0 N
ability of androgen products in our society may$ l7 K6 _% t: D7 ?9 o
indeed cause more virilization in male or female: L% j1 H) d' s: q+ O
children than one would realize. Exposure to andro-
. T6 k( S" H$ O5 a5 ogen products must be considered and specific ques-0 E$ V- e+ q4 d) R9 b. i& |
tioning about the use of a testosterone product or
! G2 i, s3 Y" [4 f& @7 \gel should be asked of the family members during
' A. d" |8 L" O; I. Z' Vthe evaluation of any children who present with vir-
1 D" ^. b3 x3 c0 i! V1 j# Gilization or peripheral precocious puberty. The diag-. S9 n7 x6 h6 D2 K! G
nosis can be established by just a few tests and by
, s6 O( h! P: Q6 H0 y0 S: p" F: yappropriate history. The inability to obtain such a
! v- s9 P7 N* G, ?5 Y/ F" o" Vhistory, or failure to ask the specific questions, may
$ G$ x, x& K- _- Vresult in extensive, unnecessary, and expensive7 x: a$ q4 A% h
investigation. The primary care physician should be
# ~0 y, T6 e5 \1 S; w' uaware of this fact, because most of these children( w. N# a7 A* f" k3 X
may initially present in their practice. The Physicians’
" p: {1 v. v% C7 VDesk Reference and package insert should also put a
8 q/ \0 l8 W! ^6 S/ pwarning about the virilizing effect on a male or
9 Q* ?( U" i5 H% Y$ J5 g; B4 zfemale child who might come in contact with some-
; K2 q, M8 r( \& w! g  C+ i. d* ~9 jone using any of these products.
6 r: y1 s) O$ NReferences; ?: c1 C* D+ n- |8 o- ^+ a$ y) ~, c
1. Styne DM. The testes: disorder of sexual differentiation. A  g: u' ]' h9 [2 U" s& P$ F
and puberty in the male. In: Sperling MA, ed. Pediatric: p- N6 s! M0 U/ o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 e+ b5 E) [, s; e
2002: 565-628.( `% a/ @/ ?3 K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 w& x, ~4 @$ a) ^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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

; {1 C' W$ B' t) l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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