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Sexual Precocity in a 16-Month-Old
. i# Y; P' o0 a! BBoy Induced by Indirect Topical
1 R5 t( h9 O- l, pExposure to Testosterone9 W( F% n5 U) V" u
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! `; Q# r* ^0 p  n3 m/ m
and Kenneth R. Rettig, MD1
# c6 a4 g) `: S3 @6 ]* XClinical Pediatrics* R0 u5 I6 p2 W1 _! C, o
Volume 46 Number 6  ~( c- s7 L+ s# M# x# {& }. f
July 2007 540-543, u! I. W1 q4 `8 |2 w; o
© 2007 Sage Publications6 V: h: B* w, _+ J7 f0 T7 k
10.1177/0009922806296651, j4 u8 T* G6 c: }- U
http://clp.sagepub.com- a$ y, L6 F. l9 _
hosted at1 f; U" {* d% L/ n; k
http://online.sagepub.com
0 R1 B) v7 X. V7 h7 p: yPrecocious puberty in boys, central or peripheral,& ^* {6 }1 D5 M5 W
is a significant concern for physicians. Central
7 l- Z2 @. [! D( m8 Y2 x5 I' Mprecocious puberty (CPP), which is mediated
' c  Q! V2 \9 k' L$ ]7 qthrough the hypothalamic pituitary gonadal axis, has$ C& |4 ~2 L, m" |. \, Z
a higher incidence of organic central nervous system2 g7 R% |0 r9 q5 U( i
lesions in boys.1,2 Virilization in boys, as manifested! a7 ?0 A, s5 R% Y: C  g+ }% e
by enlargement of the penis, development of pubic, Q' A" j- A0 I5 y: J$ M' R( M9 X
hair, and facial acne without enlargement of testi-
$ {/ v3 t& T$ w$ ~9 P6 dcles, suggests peripheral or pseudopuberty.1-3 We: p0 {; H0 m( Z% \
report a 16-month-old boy who presented with the7 P# |! u; p+ K, V0 Q
enlargement of the phallus and pubic hair develop-
% T# L0 S7 i9 r7 q* x0 Yment without testicular enlargement, which was due
% |0 o& f* p, z+ Vto the unintentional exposure to androgen gel used by
2 O: {6 S7 _  T. Wthe father. The family initially concealed this infor-
" J& f/ u% t# v$ E0 O: omation, resulting in an extensive work-up for this
! t+ y. R: X8 M- bchild. Given the widespread and easy availability of" i/ X* U5 N5 v7 Y& E8 y
testosterone gel and cream, we believe this is proba-5 V( i/ n& o, N) F' v: E, h6 v
bly more common than the rare case report in the/ A' J- s& {3 r! e/ a' X
literature.4/ b: @' @' Q* i
Patient Report
; Y* L5 X- v$ M0 i5 ZA 16-month-old white child was referred to the
  W' u/ G" g, Z/ P/ V! l) C& hendocrine clinic by his pediatrician with the concern; Q( @0 F3 O! t4 Y  z) w+ }
of early sexual development. His mother noticed
1 L: \6 C, p" u$ v# m( [light colored pubic hair development when he was7 u0 D& A1 O( `& h9 Q
From the 1Division of Pediatric Endocrinology, 2University of
) f2 l2 d! ]) ~  {6 B, n. W& lSouth Alabama Medical Center, Mobile, Alabama.4 \9 y" \+ }: D0 Q+ p, v- z0 L
Address correspondence to: Samar K. Bhowmick, MD, FACE,: F: _; p! d8 d+ f9 Z
Professor of Pediatrics, University of South Alabama, College of
1 u! l* I  a2 f- }+ Z; ]  FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) c9 @; x, v6 V- N' E' X0 De-mail: [email protected].& }2 p$ O' N5 E7 u/ [5 a
about 6 to 7 months old, which progressively became
" M2 ?: ^5 P( a- x6 E: ]darker. She was also concerned about the enlarge-0 ]; s# b  K+ Q# H- _
ment of his penis and frequent erections. The child( I- E* i1 ~  F" {7 n7 [1 }# c
was the product of a full-term normal delivery, with7 o; i- x. T4 r# j3 Z4 k
a birth weight of 7 lb 14 oz, and birth length of; f4 _( W/ H0 r# f& ^+ j3 t
20 inches. He was breast-fed throughout the first year4 f5 J" o3 N2 P2 j, n6 Z$ b) k- ~* t
of life and was still receiving breast milk along with7 |5 r/ _  c$ M; q9 u8 k! u/ N8 u
solid food. He had no hospitalizations or surgery,. G6 D( B, e$ Q9 q- `. X
and his psychosocial and psychomotor development
1 B5 Z6 P5 m% nwas age appropriate.4 a; d5 K, O& }$ A( S
The family history was remarkable for the father,' S3 Z5 l! C4 W/ E
who was diagnosed with hypothyroidism at age 16,4 \$ I) p/ j5 I8 P. W8 M
which was treated with thyroxine. The father’s/ }( K" i/ p9 G5 @$ _
height was 6 feet, and he went through a somewhat
1 J' G/ G1 A: L+ l. K# mearly puberty and had stopped growing by age 14.0 _% h, v$ M# d5 O( y- q
The father denied taking any other medication. The8 S. m9 I. X8 b
child’s mother was in good health. Her menarche
5 S+ S* \' ^5 O+ o+ T- fwas at 11 years of age, and her height was at 5 feet
9 p7 A5 m3 `* D5 inches. There was no other family history of pre-/ ^6 p4 w0 R9 u$ o! t
cocious sexual development in the first-degree rela-# s' k# R4 q1 @) f
tives. There were no siblings.
  Z% z4 X3 I( s2 }" p' b  ZPhysical Examination
. x0 R3 U1 c" ]! P% q7 Z' N$ _# W# nThe physical examination revealed a very active,
$ K3 S( D- b/ o. {8 w3 J3 nplayful, and healthy boy. The vital signs documented
+ ~, N4 d) u. g: m, D2 X  Ja blood pressure of 85/50 mm Hg, his length was
, G; d, e' |. e: |# K90 cm (>97th percentile), and his weight was 14.4 kg
" U4 e" `1 }" M8 O) h(also >97th percentile). The observed yearly growth3 h. T1 \3 a! O& ]" ~1 Z* w$ m
velocity was 30 cm (12 inches). The examination of! P8 w" {& E/ D% g6 B& h
the neck revealed no thyroid enlargement.6 q5 w8 O: j* h: T
The genitourinary examination was remarkable for
" y( {# ]6 X2 Z1 F9 oenlargement of the penis, with a stretched length of4 `9 {: N+ {! V1 A$ u  @- i, C
8 cm and a width of 2 cm. The glans penis was very well
; R2 ]6 w  O7 @- W% \5 qdeveloped. The pubic hair was Tanner II, mostly around/ D0 ]0 X% O9 B+ _! ~' t5 E
540
+ p- w& Z7 N1 B; bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 q9 M! e( Z/ H. k
the base of the phallus and was dark and curled. The* ~. U9 W. r$ q
testicular volume was prepubertal at 2 mL each.
9 h7 w! i) w* \* ~The skin was moist and smooth and somewhat
) S" }/ G0 p7 P/ B: \. ]* poily. No axillary hair was noted. There were no
9 m- Y$ J) B. aabnormal skin pigmentations or café-au-lait spots.
& @  X+ V) v$ ^  C7 e7 |4 ~Neurologic evaluation showed deep tendon reflex 2+
6 ~/ }- U2 R$ u4 H2 M& Ibilateral and symmetrical. There was no suggestion& |' ^4 J; f# k* n! {
of papilledema.) q4 a! g, n2 K& b3 ?" N1 i
Laboratory Evaluation
$ y0 V) t) s5 ?/ m" ^/ AThe bone age was consistent with 28 months by1 ?# u' Z0 d6 A% @- x( w8 Y
using the standard of Greulich and Pyle at a chrono-
; M; i+ E) }2 x1 B% o4 s" r4 e, llogic age of 16 months (advanced).5 Chromosomal
" t" N  \1 @4 n. {6 N" Bkaryotype was 46XY. The thyroid function test
8 u4 M; f' t: p/ ]4 ^/ }! t( Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
; v* A" T) ?8 Y5 }% s# Llating hormone level was 1.3 µIU/mL (both normal).
; E# a! `5 l2 `1 r4 NThe concentrations of serum electrolytes, blood# y* T( Q+ G9 c7 W. K" F
urea nitrogen, creatinine, and calcium all were! d0 Z: H/ n9 A: [7 D
within normal range for his age. The concentration6 ^1 {$ _% y* C' o5 X: r. @
of serum 17-hydroxyprogesterone was 16 ng/dL' u' P& b' r, B. m
(normal, 3 to 90 ng/dL), androstenedione was 20  }: r" X, U7 t/ o( e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 H& ^  t1 k7 N; F" n5 b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 _$ i  Z" q7 sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to$ k) C% V3 B) ?8 J2 @+ G
49ng/dL), 11-desoxycortisol (specific compound S)0 f. W* h% p9 u; j3 _. S4 A3 o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" X5 S$ N( t8 P: h- x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: R9 ~- ~" v6 o: M# t. m& Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# e2 l- M, `- B! dand β-human chorionic gonadotropin was less than& C; D- {/ T( q' ~) Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 Q# _$ X$ e& o" I5 istimulating hormone and leuteinizing hormone, Z( n3 U+ S2 M- ^4 l5 ~3 g. J
concentrations were less than 0.05 mIU/mL
6 f) X: W2 W  z/ E' W% X* ]4 ](prepubertal).
' W9 K' p7 ~# Z" d( CThe parents were notified about the laboratory
+ [2 B7 A5 Q5 h0 ~8 [4 bresults and were informed that all of the tests were
9 x+ ~1 f5 E6 {5 v- N5 s$ m) lnormal except the testosterone level was high. The
  H: J5 \4 V) yfollow-up visit was arranged within a few weeks to
/ Q: Q8 }) g6 K' \& h( M" J0 l% Jobtain testicular and abdominal sonograms; how-/ u: c* B& R: B, ~( ~
ever, the family did not return for 4 months.) D0 F  R& i5 T2 ?
Physical examination at this time revealed that the
) t4 y1 q) s5 V& X+ Tchild had grown 2.5 cm in 4 months and had gained8 Q* H1 y0 O# @& }  F; [/ u
2 kg of weight. Physical examination remained7 V6 {! x! J, ~2 K8 t7 a2 U& X
unchanged. Surprisingly, the pubic hair almost com-4 U- O. P3 a+ L$ k5 k2 F
pletely disappeared except for a few vellous hairs at
" S- U$ s8 L2 X" @% ythe base of the phallus. Testicular volume was still 21 @" E$ u& D0 @# g3 t
mL, and the size of the penis remained unchanged." v$ k( h3 h( }$ z3 K  b4 g
The mother also said that the boy was no longer hav-
7 J" e/ Z, v, C, ying frequent erections.# n0 l. C, Z5 g
Both parents were again questioned about use of
2 s' y  F9 R9 J& M7 `: l" Fany ointment/creams that they may have applied to+ }5 w/ _; e/ n' H8 |" h( Y
the child’s skin. This time the father admitted the
: ?( G% c# ~1 G0 C: rTopical Testosterone Exposure / Bhowmick et al 541
; G5 L, `1 X7 m7 ^/ Y  L$ o$ W1 vuse of testosterone gel twice daily that he was apply-
- z) ^$ m% L5 j0 Ping over his own shoulders, chest, and back area for2 k9 h: R& d+ h, Q# w3 h
a year. The father also revealed he was embarrassed9 B) P% n; f, `! T$ C3 Z
to disclose that he was using a testosterone gel pre-
; I# g, A  N; p- X1 y1 Q% B0 U: Oscribed by his family physician for decreased libido
6 ^/ S: o2 c6 H  Ssecondary to depression.9 R/ }. O& _, H0 f. T' v5 N" j
The child slept in the same bed with parents.2 H% J* ~( a, T1 s$ T- r' ]4 J
The father would hug the baby and hold him on his
0 ?& n0 c% I( C" t3 o% jchest for a considerable period of time, causing sig-! f6 q8 i' U. u* N' Q( \
nificant bare skin contact between baby and father.2 I) Q& W" X, A1 c% o6 \
The father also admitted that after the phone call,3 H1 L) Z0 K0 x
when he learned the testosterone level in the baby
1 k$ w/ B: {& u/ \) ~4 M5 mwas high, he then read the product information
8 t# e9 e6 R4 L  kpacket and concluded that it was most likely the rea-* d% x9 [4 s6 Y
son for the child’s virilization. At that time, they
! p7 E1 P  {! s, S# N9 |decided to put the baby in a separate bed, and the3 O: J# w0 {8 w; W6 u/ q
father was not hugging him with bare skin and had3 q8 O/ z9 C1 r) L6 o2 @
been using protective clothing. A repeat testosterone* ^" [6 G7 e2 r0 d1 P  K( `( W
test was ordered, but the family did not go to the  O! k( f$ f0 e6 Q0 e  ?& H7 O# t
laboratory to obtain the test./ W8 }% q% |' j
Discussion8 A+ I7 A2 h- @4 ~9 g9 H) ]9 D
Precocious puberty in boys is defined as secondary* U( ~. A+ b. m. h( o
sexual development before 9 years of age.1,4  A; v7 m; C" l; |3 x; {* M
Precocious puberty is termed as central (true) when
1 h& o7 ~) c! M3 j. r5 l# Rit is caused by the premature activation of hypo-
% [! L; z# b+ c8 Z. \thalamic pituitary gonadal axis. CPP is more com-
! Q6 |/ `6 e4 _) d5 qmon in girls than in boys.1,3 Most boys with CPP
4 e) Z6 k3 x* [may have a central nervous system lesion that is
. V1 w3 J  R6 a$ _4 mresponsible for the early activation of the hypothal-. c. x8 b& m6 G  O& }) S. E
amic pituitary gonadal axis.1-3 Thus, greater empha-* S- S! T% r; K! c2 h# I
sis has been given to neuroradiologic imaging in: ]! ^( W' V1 }" B
boys with precocious puberty. In addition to viril-9 w- @5 _! }  G! r# l! M
ization, the clinical hallmark of CPP is the symmet-. G& `7 G7 _' ]+ R, i
rical testicular growth secondary to stimulation by
( b2 G' v7 t# c2 ^. U4 Y) N4 ]5 igonadotropins.1,3
# c" x6 s) X: bGonadotropin-independent peripheral preco-& \8 T) u. U& H% e1 ^
cious puberty in boys also results from inappropriate* H9 q7 Q6 V4 ~( @. G+ J
androgenic stimulation from either endogenous or
7 ^. B0 W! G( y5 X+ ~exogenous sources, nonpituitary gonadotropin stim-. a0 h/ ?. B" S. c& I3 r2 S
ulation, and rare activating mutations.3 Virilizing% V8 ~$ F: q' h
congenital adrenal hyperplasia producing excessive2 ?' M, j" G7 J) S7 l  B* O) o
adrenal androgens is a common cause of precocious: W# K3 x6 N9 Y
puberty in boys.3,4
0 ?# u1 a" G' ]The most common form of congenital adrenal+ n# v: e; O3 s" C6 m+ k  g6 E
hyperplasia is the 21-hydroxylase enzyme deficiency.( e+ e" d6 a3 p" n% o* n; J
The 11-β hydroxylase deficiency may also result in. a" B7 Y' _* |. M$ Y- T3 _; o4 Y
excessive adrenal androgen production, and rarely,
  a0 j! s- D6 A. y) q) aan adrenal tumor may also cause adrenal androgen
5 |5 X- z3 {' e4 `  B+ N# b0 I2 |excess.1,3
) Y5 w3 l# S' ?; Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 ]& D5 e! b2 j& y, g0 J4 I  ?542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 n3 Y' `  a' n& i% j6 sA unique entity of male-limited gonadotropin-8 T' g4 ]. I/ d2 I2 u. ]3 g
independent precocious puberty, which is also known3 m" \7 z+ u% ^6 X4 j% F
as testotoxicosis, may cause precocious puberty at a# _  F( S# k2 e* ]
very young age. The physical findings in these boys% D& a: v, S+ e; w' n6 y6 K2 Y# A
with this disorder are full pubertal development,+ ]+ N9 H6 x$ U  T* G
including bilateral testicular growth, similar to boys
0 v) b9 o0 l* u0 ?6 {, }& dwith CPP. The gonadotropin levels in this disorder
5 t5 H: H/ [& G. a# Q% Fare suppressed to prepubertal levels and do not show5 r( K/ `' l+ g) N# e6 b/ B0 D8 w' X7 K4 [
pubertal response of gonadotropin after gonadotropin-" V2 ]" ]& d" M3 M* p% e" z
releasing hormone stimulation. This is a sex-linked
) o! q# _: l  h7 z3 Z& fautosomal dominant disorder that affects only4 v3 p  ^* @, g; k' O& k+ _; c
males; therefore, other male members of the family7 w- _7 {1 Q1 Y2 ?" j" F6 S
may have similar precocious puberty.3
5 }9 z' A4 l/ X- ^3 X, D7 hIn our patient, physical examination was incon-% U* A" h$ \5 Z* l8 L. e% Y
sistent with true precocious puberty since his testi-! s% ~; C. v7 q
cles were prepubertal in size. However, testotoxicosis
% s0 G; z1 x, N; swas in the differential diagnosis because his father
, ^" \' B" d3 Cstarted puberty somewhat early, and occasionally,
; y& D% Q7 `- Atesticular enlargement is not that evident in the
' X' i; m$ V; _4 E6 mbeginning of this process.1 In the absence of a neg-6 B* H& Q& B1 x  d3 i
ative initial history of androgen exposure, our# {  Q- B8 U1 j2 p8 t9 I* I! K
biggest concern was virilizing adrenal hyperplasia,9 T' f2 s) C2 ]; p& W, q
either 21-hydroxylase deficiency or 11-β hydroxylase
. {, p; M) L: \deficiency. Those diagnoses were excluded by find-
; S. N: Z7 H2 g, R/ [7 G: p1 _ing the normal level of adrenal steroids.
  s! u& h- p# R! fThe diagnosis of exogenous androgens was strongly1 ~+ t/ z0 X9 ~; \/ s, ~! t
suspected in a follow-up visit after 4 months because
7 s# Z# O5 L& h2 L+ b. cthe physical examination revealed the complete disap-
5 [' M: S" Q3 ?/ Ypearance of pubic hair, normal growth velocity, and# v  @$ b8 u# [0 l; q2 P5 V* C5 O
decreased erections. The father admitted using a testos-
6 R/ k1 e! P! ~4 i# B6 nterone gel, which he concealed at first visit. He was
& O5 A! U0 a5 i* Jusing it rather frequently, twice a day. The Physicians’- l( y3 {- I+ ~# p/ F8 J% ^+ x9 V
Desk Reference, or package insert of this product, gel or
7 O: d% ~) R( rcream, cautions about dermal testosterone transfer to
3 Y9 g& \& o' b5 W% f+ e5 U; Uunprotected females through direct skin exposure.
" E8 G/ r6 N+ N" t; ~Serum testosterone level was found to be 2 times the
# E8 C  V) G: ^$ Rbaseline value in those females who were exposed to/ u+ l+ N( H+ F; B; U2 w
even 15 minutes of direct skin contact with their male& G% k: B$ b1 u( G% v2 U
partners.6 However, when a shirt covered the applica-
/ s3 V# @, P+ E" _tion site, this testosterone transfer was prevented.
$ R3 @! k' P" J. \% K4 g  b8 OOur patient’s testosterone level was 60 ng/mL,' d5 w" y* c% r  h7 ]/ Z" }
which was clearly high. Some studies suggest that
5 n0 `% R0 U. Gdermal conversion of testosterone to dihydrotestos-
& j8 F) W4 X/ {, Y0 k: l$ b6 _terone, which is a more potent metabolite, is more# b4 [9 P1 t. y! R. R; ?" M
active in young children exposed to testosterone
, p; W/ d* i. j4 Q; fexogenously7; however, we did not measure a dihy-! N' t+ T. |9 w* @( s. l2 S
drotestosterone level in our patient. In addition to/ s& O) c# l/ i$ q& K$ ?( ~2 K( x
virilization, exposure to exogenous testosterone in
0 k$ S, j! D4 }children results in an increase in growth velocity and
: i* z7 ?1 i3 {: s6 H8 Padvanced bone age, as seen in our patient., V& {7 a% }4 f1 n: O+ }  t3 e
The long-term effect of androgen exposure during) U7 d+ e- w" r1 |$ l" P2 I
early childhood on pubertal development and final% f, J2 r9 k$ l. A' K0 n
adult height are not fully known and always remain# e% [& _% c8 H. R9 ]* w  H  O
a concern. Children treated with short-term testos-
+ n+ M5 p1 A( a$ C1 o# C& @, Zterone injection or topical androgen may exhibit some
. @5 p1 y/ N* e0 E  vacceleration of the skeletal maturation; however, after; M4 p5 ^2 @" ?- N
cessation of treatment, the rate of bone maturation
  \3 n& g3 n0 g+ m4 Zdecelerates and gradually returns to normal.8,9
, h  `- W, @6 K0 E5 r1 c5 mThere are conflicting reports and controversy
$ l5 F9 ?3 Q, ?over the effect of early androgen exposure on adult
: [5 ?- ?1 g- l2 w/ Ipenile length.10,11 Some reports suggest subnormal+ D7 ^, o# G% V
adult penile length, apparently because of downreg-! x& W' n* c3 [8 p
ulation of androgen receptor number.10,12 However,8 ^4 d% e- p& k+ u# S
Sutherland et al13 did not find a correlation between# n/ ~, ~/ O  r1 r% y3 M. V
childhood testosterone exposure and reduced adult
- h# y( j1 u' I% k- R' {penile length in clinical studies.
6 F% `2 w0 r# f& V& W8 Z" fNonetheless, we do not believe our patient is
- y# b4 A! t$ _  Hgoing to experience any of the untoward effects from
! d) l- O7 \3 [6 z/ U: J9 P" R3 Etestosterone exposure as mentioned earlier because
& M$ b9 \: I8 l% N8 O0 Othe exposure was not for a prolonged period of time.( c- H# ^5 T) u/ X
Although the bone age was advanced at the time of% l1 g9 J2 ~  O7 E
diagnosis, the child had a normal growth velocity at
4 a" q' |7 b2 o$ V: ythe follow-up visit. It is hoped that his final adult
. o- H" Y+ s4 L+ b' W. Yheight will not be affected.
( h, N: k5 w+ |8 |/ a& aAlthough rarely reported, the widespread avail-
: a1 ?9 p9 n" x- C* u" x5 o9 [# c4 yability of androgen products in our society may: D5 v+ n. r( j8 Z/ Y, {
indeed cause more virilization in male or female& W; z4 l) _: R7 j+ r3 n6 R
children than one would realize. Exposure to andro-5 Z3 L% Y; j: z8 \$ l4 T: l
gen products must be considered and specific ques-5 P' L7 w7 S9 H2 v
tioning about the use of a testosterone product or' O: q" h$ K2 _! M  ~1 |' h
gel should be asked of the family members during
* {) u7 F9 a1 B9 ithe evaluation of any children who present with vir-* l# K3 ^% k$ n/ \$ W. D
ilization or peripheral precocious puberty. The diag-: W4 Y5 S7 c# k
nosis can be established by just a few tests and by
0 Y' U1 s: a  m" |. u( Bappropriate history. The inability to obtain such a+ l* V" X+ q% s5 k2 t$ u) f# ?
history, or failure to ask the specific questions, may4 `: V: o) d6 r1 E! L! I5 _1 q7 J+ P
result in extensive, unnecessary, and expensive6 I1 w- W3 e, s6 `2 h
investigation. The primary care physician should be
: j* I, w, l4 E3 _6 b, {2 Iaware of this fact, because most of these children
, D" W7 r  G- g+ @9 }& R# O9 p9 pmay initially present in their practice. The Physicians’. X9 u: c1 L6 F# p, J9 @
Desk Reference and package insert should also put a) y/ Y6 v, M; e, |: k
warning about the virilizing effect on a male or8 o: d. ]5 X& c" P5 U
female child who might come in contact with some-" n) o# ^4 P5 Q# f  Y3 v
one using any of these products.
5 u# ~/ c' n' Y2 W, P! ?2 F0 D. j: DReferences
2 A$ |9 ^  x- m8 a1. Styne DM. The testes: disorder of sexual differentiation0 t) Z  {8 _4 g  K$ @: U. F- `
and puberty in the male. In: Sperling MA, ed. Pediatric
. {5 V/ S2 K  Z, }  UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# `" |# ]- y) u! W3 a
2002: 565-628.. L2 I! |& i0 M# N
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 a3 `6 m9 b# [% Rpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
) i/ r; x- ?. a  yBoy Induced by Indirect Topical3 n8 L, w2 b; T5 Q8 G! m- ?
Exposure to Testosterone) C/ e. R( `8 D! W- k5 v4 K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; Z" H# f6 K  D8 \. `8 \6 F/ M9 {and Kenneth R. Rettig, MD1
% @" D8 b6 V; j% `2 b, k! r5 qClinical Pediatrics! i- p6 Z7 D/ R
Volume 46 Number 68 @$ @  W8 j2 e! V
July 2007 540-543
4 c) e6 r3 r) G+ |+ c  t© 2007 Sage Publications- P# F( @9 P- V* @
10.1177/0009922806296651
8 w0 A/ V# [- whttp://clp.sagepub.com
5 v% {! H5 H% @* o5 U* x$ x) k2 Shosted at; u% d9 i  E1 E8 n) x
http://online.sagepub.com% h4 x' {! B' j5 o1 H9 }/ g/ m
Precocious puberty in boys, central or peripheral,
7 i+ m, Y8 Z: U, {9 \2 ]5 jis a significant concern for physicians. Central
& k7 X" H. c7 r5 a$ qprecocious puberty (CPP), which is mediated% D0 q4 m) E4 w6 O$ x
through the hypothalamic pituitary gonadal axis, has( M( ?7 C* h2 G' g  R; s2 R
a higher incidence of organic central nervous system' v; l7 k! U" y8 }, W1 a
lesions in boys.1,2 Virilization in boys, as manifested! v3 k# G. B9 S& {
by enlargement of the penis, development of pubic& `* g2 x4 t# g3 x. C
hair, and facial acne without enlargement of testi-
" J9 O- B9 J& \1 p+ \* l% Bcles, suggests peripheral or pseudopuberty.1-3 We
5 o0 I6 p( L+ g% F3 z! ^report a 16-month-old boy who presented with the/ T& g  B- _3 y8 `! H; I/ V9 {- _
enlargement of the phallus and pubic hair develop-  X2 S* f9 x8 _8 |) q& U
ment without testicular enlargement, which was due/ i1 u3 u+ ~  i9 d) T' ?
to the unintentional exposure to androgen gel used by! _  E: T5 v+ ?! J; @8 V
the father. The family initially concealed this infor-
  J5 I$ l# b# w* z( `6 Z& {6 ?mation, resulting in an extensive work-up for this; U: p5 D9 c2 U. U3 `
child. Given the widespread and easy availability of* s& R' u6 Y/ h# i! i
testosterone gel and cream, we believe this is proba-& l2 [% ?" f1 {# h
bly more common than the rare case report in the/ [" l, R2 ~) ?$ w' J
literature.4
2 r' f  T8 q( _# ~' q: ]Patient Report, Z6 s1 M0 t  T/ n8 O% a
A 16-month-old white child was referred to the- p; r* \- e8 w0 }
endocrine clinic by his pediatrician with the concern
, e$ V8 C0 @7 z9 j# Aof early sexual development. His mother noticed0 |2 w# L" h( e- n4 i& x
light colored pubic hair development when he was
/ A5 U! r, A/ l7 s" G0 @$ g8 j% rFrom the 1Division of Pediatric Endocrinology, 2University of
2 o8 w, R2 \, y& L6 Y7 \3 zSouth Alabama Medical Center, Mobile, Alabama.3 }; O. a! c- z, |
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 X3 n; _2 N/ h0 I! W
Professor of Pediatrics, University of South Alabama, College of
7 b7 C& |5 t( Z- l: _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) Y' s9 h2 r( u9 ^3 r
e-mail: [email protected]./ W2 t0 ^  E& V& g( I( z
about 6 to 7 months old, which progressively became8 A; ?* ]: \0 e! b
darker. She was also concerned about the enlarge-/ ^/ S" w; ]4 P6 m6 `
ment of his penis and frequent erections. The child% h2 h1 c- O: o5 A# n3 j5 D
was the product of a full-term normal delivery, with# C' R, ]% B) M/ [1 {7 c# [0 M! V
a birth weight of 7 lb 14 oz, and birth length of
1 w% _' O$ E: v7 F7 \7 F20 inches. He was breast-fed throughout the first year" @$ o# P; k5 B( T) `
of life and was still receiving breast milk along with
6 X1 e* W& P' J& qsolid food. He had no hospitalizations or surgery,6 Z6 o* \; M; t" ~! r" l
and his psychosocial and psychomotor development
$ A$ B6 T" v8 l) `8 gwas age appropriate.
' u# T  d- E9 k# u8 O, _9 ~The family history was remarkable for the father,
7 t9 B, C8 Q! N7 m* H4 Awho was diagnosed with hypothyroidism at age 16,
/ H$ b6 s  [( G5 y# Swhich was treated with thyroxine. The father’s
2 _: n6 ~, h0 A6 dheight was 6 feet, and he went through a somewhat+ ~' C* `. [/ l$ b0 c
early puberty and had stopped growing by age 14.
+ n' u- r1 Y4 K( e6 PThe father denied taking any other medication. The
% Y$ H( e. L( f# Lchild’s mother was in good health. Her menarche
' E( B$ ~) O' }3 ^was at 11 years of age, and her height was at 5 feet
/ o- d: \$ n" w0 O4 O: m. T5 inches. There was no other family history of pre-
( k  K9 |* A/ }; x0 n3 Q% S3 _! }0 Xcocious sexual development in the first-degree rela-
4 J+ h5 l: t$ L5 d( Ptives. There were no siblings.
% y8 Y+ y/ w( W3 i" N$ DPhysical Examination0 d% \+ m2 O/ ?) v% z) C% ?
The physical examination revealed a very active,
3 y# Z9 M- Z" O  H1 y. F5 |4 T0 T) ]playful, and healthy boy. The vital signs documented9 S: d' R7 f5 `
a blood pressure of 85/50 mm Hg, his length was
; x0 o' Z$ ~9 e+ `. C90 cm (>97th percentile), and his weight was 14.4 kg
9 S+ U( E* A) v7 G% k3 B(also >97th percentile). The observed yearly growth3 _2 A1 q( `- a
velocity was 30 cm (12 inches). The examination of
% }! S) S% N# u, [; N& B/ pthe neck revealed no thyroid enlargement.( J8 I& C5 A0 K# [6 M6 l
The genitourinary examination was remarkable for
1 k! @8 [9 j+ v' F+ benlargement of the penis, with a stretched length of
  t, D1 }( ^1 e! m7 l/ z- j* v8 cm and a width of 2 cm. The glans penis was very well
! C- I2 s3 t% A  z# V1 R/ s7 Ideveloped. The pubic hair was Tanner II, mostly around
- E! G! a  y9 f% S& `& V+ h5406 ^  S3 ?$ ?+ q1 n. o* B
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' r( b% a- R3 G7 h4 r3 @the base of the phallus and was dark and curled. The; ~0 w; X$ r6 J, h7 ^  K
testicular volume was prepubertal at 2 mL each.# ^" w( A1 ~( V8 x2 G0 |
The skin was moist and smooth and somewhat1 b1 j, b" W. N9 G7 U
oily. No axillary hair was noted. There were no: j4 t- v  y/ x
abnormal skin pigmentations or café-au-lait spots.7 k1 c% d' [; a: p; I
Neurologic evaluation showed deep tendon reflex 2+
6 A' Z4 ^+ a& m% H1 H# [# t; }bilateral and symmetrical. There was no suggestion
6 q. N; M4 N% Z# U- @( i" @1 vof papilledema.# q, p. j! D* f; c% d
Laboratory Evaluation
: r3 h: S, D( ]: y7 mThe bone age was consistent with 28 months by" s, g3 P- S: x$ N4 U
using the standard of Greulich and Pyle at a chrono-  }7 x$ R3 a6 D0 A: N# b
logic age of 16 months (advanced).5 Chromosomal' W+ c  ?* y' G- |
karyotype was 46XY. The thyroid function test7 }& y6 F: g, y
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 f8 z$ D& G' w2 V5 K
lating hormone level was 1.3 µIU/mL (both normal).
$ I; h% O  U. W; p& bThe concentrations of serum electrolytes, blood
. F) O1 I6 P! s& Xurea nitrogen, creatinine, and calcium all were
9 b! x" \9 V6 ?within normal range for his age. The concentration
+ c( |; k4 j. O. hof serum 17-hydroxyprogesterone was 16 ng/dL
8 Q  M  M- x" s* C8 ~( n( z(normal, 3 to 90 ng/dL), androstenedione was 20
0 U7 J1 A5 u3 n) k1 mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 ]& c( ?! Y- E% G8 p5 [
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 }# T! W$ K, s1 _, i8 M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 m  E/ p) C  N6 x49ng/dL), 11-desoxycortisol (specific compound S)! H+ B" g7 K7 r$ H; r7 {$ W3 x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 ?* ?' r: P9 ?$ }3 Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ j. t# g$ a5 `4 U5 ?; g9 ^testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% u$ b7 B( ^* h
and β-human chorionic gonadotropin was less than2 w2 R8 ?3 Z1 f/ s3 j5 L
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ O; x) f' {) t
stimulating hormone and leuteinizing hormone; @+ p2 |! s: M% }$ Y2 b
concentrations were less than 0.05 mIU/mL
/ S! V$ o' Y: c(prepubertal).
- P% r4 }& E& eThe parents were notified about the laboratory; ~  k% G' ^+ E0 j
results and were informed that all of the tests were
1 V$ ~) ~5 D  z- \# E5 N: q2 G, Gnormal except the testosterone level was high. The( e) |8 I; H4 u" q6 `
follow-up visit was arranged within a few weeks to
+ h+ T0 L6 ~0 Nobtain testicular and abdominal sonograms; how-
$ Z6 r/ W' L( e: Pever, the family did not return for 4 months.0 M. b0 O. W- G- G; @
Physical examination at this time revealed that the
/ ?5 l% X6 h, Tchild had grown 2.5 cm in 4 months and had gained6 K) X4 o# ~  E+ j# _9 n
2 kg of weight. Physical examination remained" a. p; A9 s3 X0 q6 o" F) i
unchanged. Surprisingly, the pubic hair almost com-. {$ l4 I- t1 S% s  F
pletely disappeared except for a few vellous hairs at
' e$ f2 z9 c9 ]" U' Z+ jthe base of the phallus. Testicular volume was still 2- v1 B+ `5 _0 v) h
mL, and the size of the penis remained unchanged.8 o* j# ?( P7 C: O
The mother also said that the boy was no longer hav-
/ G) ]; z+ ]+ M9 d3 x2 ?" Y1 F5 o' ~ing frequent erections." f7 M7 j+ z: J! Y7 m  i1 y
Both parents were again questioned about use of5 a7 o+ V2 X) {: L
any ointment/creams that they may have applied to" G0 S( j( @& q
the child’s skin. This time the father admitted the
9 m6 i: ~: g' ?; KTopical Testosterone Exposure / Bhowmick et al 541
; R6 W* |) I* i% v; u3 Muse of testosterone gel twice daily that he was apply-( c# i: @* Z" u
ing over his own shoulders, chest, and back area for
( {0 H6 J( w9 z+ s) V% D; t' X) La year. The father also revealed he was embarrassed, h( X+ v' R5 }& J6 p( F
to disclose that he was using a testosterone gel pre-" e8 q# }* R3 `) `& D: Z* R
scribed by his family physician for decreased libido
- m" @) i4 y3 `- \  o/ m6 Qsecondary to depression.
! J2 v9 K8 q/ A: rThe child slept in the same bed with parents.
* `/ g. f& g& V  `# ^3 ?  S, ]The father would hug the baby and hold him on his6 I1 p8 }, D8 w
chest for a considerable period of time, causing sig-  B* T- P8 {; w7 k7 c
nificant bare skin contact between baby and father.- X* J1 ^9 s/ d5 o
The father also admitted that after the phone call,7 h6 w, O' y" @& ^/ s# A- E+ m
when he learned the testosterone level in the baby
9 ?8 z& K. G; Y6 B  Twas high, he then read the product information
4 o; ]- d0 o7 l8 Z$ |packet and concluded that it was most likely the rea-2 L% A/ p1 P  S8 h# Y) k
son for the child’s virilization. At that time, they
" I6 p2 V) o) g2 Idecided to put the baby in a separate bed, and the0 w9 I1 b% x/ c% o* E7 P
father was not hugging him with bare skin and had
4 k/ f0 k& S; E7 J' Pbeen using protective clothing. A repeat testosterone
0 g, l% }1 A$ k% {( t+ j) Wtest was ordered, but the family did not go to the, V: Q5 X; K5 d! n- L. O
laboratory to obtain the test.
$ [* C! x1 x# T: K4 Z" N+ ?Discussion
5 P4 x& U; t/ PPrecocious puberty in boys is defined as secondary! p- L- _- [0 O
sexual development before 9 years of age.1,4: f: X2 `7 P+ I! |( d( l
Precocious puberty is termed as central (true) when2 {/ O! [8 l6 e2 u
it is caused by the premature activation of hypo-
3 B3 D- E; h. I& n6 p+ mthalamic pituitary gonadal axis. CPP is more com-
0 O) ~9 k& }9 g- Emon in girls than in boys.1,3 Most boys with CPP& t7 h9 X1 c2 F. N  \" O+ `7 c
may have a central nervous system lesion that is
+ |4 Q5 p  W. z$ d0 ~responsible for the early activation of the hypothal-3 b2 N5 c* s1 v
amic pituitary gonadal axis.1-3 Thus, greater empha-
0 P3 C6 @' i- I1 Nsis has been given to neuroradiologic imaging in- e9 ~& Q2 v! _7 b, |; X
boys with precocious puberty. In addition to viril-
2 y4 h$ N4 r0 n6 A7 O: Q7 tization, the clinical hallmark of CPP is the symmet-
3 @& i( s& \- ?% Wrical testicular growth secondary to stimulation by
0 ]) l% k5 q9 q3 T4 Y4 q% rgonadotropins.1,3
2 X. z7 t/ r& P0 G) }Gonadotropin-independent peripheral preco-
; s; T+ w! g( B: _' dcious puberty in boys also results from inappropriate( t0 Y/ B7 G! n" k  Y& p
androgenic stimulation from either endogenous or8 L1 I$ q3 @5 k, K6 [
exogenous sources, nonpituitary gonadotropin stim-6 X8 r" n# b/ R  ]6 Q
ulation, and rare activating mutations.3 Virilizing
4 S0 y% W. g9 H9 b/ y. bcongenital adrenal hyperplasia producing excessive. E- T+ w$ c* O0 F3 l
adrenal androgens is a common cause of precocious
' S; M( u& N% T# h9 C( N" \* |puberty in boys.3,4: r) k5 L( n0 M, D
The most common form of congenital adrenal5 {) `  Q' |* P: I
hyperplasia is the 21-hydroxylase enzyme deficiency.
7 C, E' O3 g( q9 n+ G( uThe 11-β hydroxylase deficiency may also result in
& _/ T' L" `) g. q5 e2 P4 V/ _excessive adrenal androgen production, and rarely,
2 D" n" K, r) w6 G: o8 t5 C5 w6 `an adrenal tumor may also cause adrenal androgen
8 J8 B- g4 u3 v  c; d. eexcess.1,39 i  ^* h9 e5 e7 I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. G! Y  ?- r1 r* ~# a% c
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( v8 O' n0 u$ qA unique entity of male-limited gonadotropin-
# x9 u4 f; d  K9 y! iindependent precocious puberty, which is also known1 s2 z& k6 [0 c5 Z- Q
as testotoxicosis, may cause precocious puberty at a
; i% j" A" n5 z" B3 rvery young age. The physical findings in these boys, |  A/ A7 D. K7 J
with this disorder are full pubertal development,
2 F) D; i5 |/ J( a+ x- Uincluding bilateral testicular growth, similar to boys
8 Z; |1 v' K( I9 t/ x! W8 F+ y+ Kwith CPP. The gonadotropin levels in this disorder# m) B3 \5 ]0 Q% h0 \# u
are suppressed to prepubertal levels and do not show# O) C" Z. V5 `! K
pubertal response of gonadotropin after gonadotropin-6 E4 c) @# y) h0 \5 H- S  e
releasing hormone stimulation. This is a sex-linked
9 O% U9 g9 b, C, D0 uautosomal dominant disorder that affects only
7 v0 z" H/ i  F' gmales; therefore, other male members of the family) E8 `2 t( `& u; b* ^3 t
may have similar precocious puberty.3  x: ?6 U0 n! J
In our patient, physical examination was incon-
7 d; q' B# i5 m" ^% Dsistent with true precocious puberty since his testi-
( H+ ]3 M* I' ?& J1 O/ pcles were prepubertal in size. However, testotoxicosis$ E/ Q1 o: ]/ Y; {$ m
was in the differential diagnosis because his father0 X7 {% R1 ?' s
started puberty somewhat early, and occasionally,
! O$ g" Q8 j- ^7 `0 ^1 a/ Wtesticular enlargement is not that evident in the
) V0 x! ~8 H* R/ g0 C  ^" Xbeginning of this process.1 In the absence of a neg-
& t1 A1 T: O5 W2 m: z6 y, Y6 }ative initial history of androgen exposure, our- F( H0 S$ Y9 v4 n& W
biggest concern was virilizing adrenal hyperplasia," O5 Y7 Q! B4 N
either 21-hydroxylase deficiency or 11-β hydroxylase
  K; m# n1 x0 H8 ?# edeficiency. Those diagnoses were excluded by find-# M  M1 r: F$ U$ b" H
ing the normal level of adrenal steroids.
5 L2 k. r3 q, `3 Q- [, c: g5 M0 XThe diagnosis of exogenous androgens was strongly
+ X6 M5 |! T; ~& Gsuspected in a follow-up visit after 4 months because
8 j; @% v7 Y* j$ X5 I, fthe physical examination revealed the complete disap-; I$ ?, W& m0 D2 ]5 i. r
pearance of pubic hair, normal growth velocity, and& i- s' k2 ?; n
decreased erections. The father admitted using a testos-* M6 B6 X6 V, N% {: S' t, ^% p
terone gel, which he concealed at first visit. He was
8 w1 A/ x+ Q1 ]9 {using it rather frequently, twice a day. The Physicians’
3 \% G7 H$ }3 R! KDesk Reference, or package insert of this product, gel or" g$ z4 A( P3 p4 O) d# g
cream, cautions about dermal testosterone transfer to4 ]( O' }" T- j4 }) q
unprotected females through direct skin exposure.0 u. H' O* ^2 @$ [4 k: E! }# [
Serum testosterone level was found to be 2 times the
/ N& K0 t7 F: [) Qbaseline value in those females who were exposed to6 f. K( y7 {. k* m* i6 j
even 15 minutes of direct skin contact with their male
  V" W1 D$ N& |$ Tpartners.6 However, when a shirt covered the applica-  v# k& m1 M' v  e1 M$ M& U, ^8 J/ ?
tion site, this testosterone transfer was prevented.
- g) M' P# k2 W: X  @% |. aOur patient’s testosterone level was 60 ng/mL,8 Z; l( Q& `2 U$ K% M& V+ X2 [
which was clearly high. Some studies suggest that
  |7 }1 x7 @- c$ d  t) adermal conversion of testosterone to dihydrotestos-' g0 l( d* M1 p$ x, R, {# o
terone, which is a more potent metabolite, is more4 T- O5 C; A* V' }, W% K% ~
active in young children exposed to testosterone3 x; Y) C. L: x
exogenously7; however, we did not measure a dihy-0 D8 i% u* |8 A& ]# ^
drotestosterone level in our patient. In addition to
; [5 i" W7 k0 H, L0 c# ovirilization, exposure to exogenous testosterone in
0 i2 v0 h1 P$ b: Vchildren results in an increase in growth velocity and
9 \) R2 {; _5 k, B/ Kadvanced bone age, as seen in our patient.; G2 R. \$ O0 ^! k! X$ s$ T1 E
The long-term effect of androgen exposure during: a- }! h9 _; L& D, D
early childhood on pubertal development and final
: u" s& c1 ~/ @- W7 kadult height are not fully known and always remain3 H2 b! a5 l2 e8 s2 N* i. {4 j
a concern. Children treated with short-term testos-  C: [. s; D( h
terone injection or topical androgen may exhibit some
  e  S: D) B( Q* H' }acceleration of the skeletal maturation; however, after
7 b% W( A) q1 b1 @; U6 dcessation of treatment, the rate of bone maturation
4 H2 d6 v/ ?9 S# V2 d) cdecelerates and gradually returns to normal.8,9
8 u6 Y" b: }9 P% t' l# K) iThere are conflicting reports and controversy
7 ]( x, p; N0 U3 lover the effect of early androgen exposure on adult4 b+ `( T1 I* ^9 s6 ^
penile length.10,11 Some reports suggest subnormal2 h6 {- s; ]7 o( |; a
adult penile length, apparently because of downreg-% w( m( B) [5 T4 u% h4 m# O; o& x
ulation of androgen receptor number.10,12 However,
, Z  p) \2 h8 l! G' JSutherland et al13 did not find a correlation between! z! H% e3 M$ e6 F8 f1 T+ S
childhood testosterone exposure and reduced adult# n- r- m: W  e7 g  I
penile length in clinical studies.
6 W% }- B# i, w. l( V  {Nonetheless, we do not believe our patient is
$ V; q% y6 M/ q1 s7 q9 }) Mgoing to experience any of the untoward effects from
3 B6 a) t" f3 T- I, F+ Vtestosterone exposure as mentioned earlier because) r# s5 z/ ]4 t7 u
the exposure was not for a prolonged period of time.9 a1 F" H* K7 w7 \
Although the bone age was advanced at the time of
: Q! c0 m  _+ d8 b% {diagnosis, the child had a normal growth velocity at
& X4 w: O6 m. k, j2 ^9 l* jthe follow-up visit. It is hoped that his final adult: P) g& R- D3 ^+ R" O: {$ c
height will not be affected./ p% C! z8 e' G- v
Although rarely reported, the widespread avail-# M, ^* i6 @6 h- T
ability of androgen products in our society may
8 Y! G. ^4 s  i) j0 p( Mindeed cause more virilization in male or female4 p- w1 k$ W& c7 Q- ?$ P) g
children than one would realize. Exposure to andro-
6 K% a; R8 I3 L1 xgen products must be considered and specific ques-
: l& F( [* s1 c: Q3 wtioning about the use of a testosterone product or
& a0 E9 g/ o. T- S4 l5 vgel should be asked of the family members during
5 b6 K# ]1 E/ b% i: H' Vthe evaluation of any children who present with vir-
0 U% C) f1 Q4 i$ m% j" ]* u: Gilization or peripheral precocious puberty. The diag-0 c  z1 O" W- k% L) G% e$ T! S
nosis can be established by just a few tests and by
& k# n" H. _. s. ^1 ~appropriate history. The inability to obtain such a
- ~5 `0 g9 q) D/ shistory, or failure to ask the specific questions, may- L& h% q/ T- P
result in extensive, unnecessary, and expensive! r# r5 C: r( l3 ~8 P% K
investigation. The primary care physician should be
0 X; @+ `9 ~( v3 A" h* iaware of this fact, because most of these children
1 F- k0 Y( _6 _0 v. [* o' kmay initially present in their practice. The Physicians’
) q/ m% F' P6 Z& W1 |5 f$ tDesk Reference and package insert should also put a( {' F4 B0 D& C+ X3 o9 o2 @) E
warning about the virilizing effect on a male or
! F* I- o8 b# c# Ofemale child who might come in contact with some-
. }* O; H0 W( q* {* P: b* Bone using any of these products.
+ \& ^6 }7 W- ^5 M4 ^  n0 ?  BReferences
; H: q9 ]  @2 c# A7 Y1. Styne DM. The testes: disorder of sexual differentiation
: K" V7 z7 _% _$ Pand puberty in the male. In: Sperling MA, ed. Pediatric
+ z( n* ^+ r, \Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ a9 d  U0 B9 q' S) ?4 ^. ?1 y
2002: 565-628.8 @3 x; t( ]! A( i8 w! C* t( e! j3 {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 d7 @: L4 O! }, `puberty in children with tumours of the suprasellar pineal
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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
. X' ^0 m  m4 X4 w8 S
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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