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Sexual Precocity in a 16-Month-Old
, O- L. g( D4 n; r5 RBoy Induced by Indirect Topical
. C8 |( W9 {; @6 hExposure to Testosterone
; \' l7 o5 k, Z0 _/ i1 D& q' r4 XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, K0 @# W4 d7 S& {, W. i: b
and Kenneth R. Rettig, MD12 s" v- g. b7 ?8 Y; E
Clinical Pediatrics
1 d& M; }4 m1 G: O6 f- hVolume 46 Number 6
6 k  X6 W* _5 r1 D" Q& s; {/ y) oJuly 2007 540-543  Q/ b0 b  A5 d2 `4 [  W
© 2007 Sage Publications+ P# E& T$ x6 h& N! B
10.1177/0009922806296651- _8 W& w9 ?5 ?# ^0 w$ t
http://clp.sagepub.com0 S* }( S" U( K. j' H
hosted at
9 F4 _. {0 G5 Y. j& Chttp://online.sagepub.com. h# p  S7 q8 N
Precocious puberty in boys, central or peripheral,
8 @( C9 Y0 m- N4 Tis a significant concern for physicians. Central  _, E5 J% ]; ?8 n& ]4 p
precocious puberty (CPP), which is mediated
9 u) d, r  H( A) wthrough the hypothalamic pituitary gonadal axis, has
2 [% r) O. n1 \& {% D* Qa higher incidence of organic central nervous system3 p$ m% K9 U" E8 k! E, D
lesions in boys.1,2 Virilization in boys, as manifested9 L: d0 f/ _- v) T2 U
by enlargement of the penis, development of pubic  f2 I6 }- ?1 t) w2 v$ p+ X5 e  D
hair, and facial acne without enlargement of testi-8 Q7 F6 T  w! e+ u$ x
cles, suggests peripheral or pseudopuberty.1-3 We4 W, y; o( f+ W2 J5 E; m
report a 16-month-old boy who presented with the
: n$ i% `9 f- b0 penlargement of the phallus and pubic hair develop-
! ~# F. v  [/ }1 N* P, z' ument without testicular enlargement, which was due
6 }6 U- m7 W! z# Sto the unintentional exposure to androgen gel used by
) o( f5 ~" x. M. C$ ]& |/ T% vthe father. The family initially concealed this infor-. A* |5 c+ C5 z9 |2 j2 p5 z! f
mation, resulting in an extensive work-up for this+ g. g2 z( S2 h+ `! B
child. Given the widespread and easy availability of
3 ]8 O$ w: n/ ~; M0 Dtestosterone gel and cream, we believe this is proba-
$ C2 r# \# h! v8 W( \bly more common than the rare case report in the. d1 d6 o- V1 F. e+ p( v
literature.4
4 ?; K9 O2 M0 B5 @0 k: [  ZPatient Report. ^1 V9 c! L5 J$ W4 ?4 c
A 16-month-old white child was referred to the
, O1 ~. H7 D- x  e5 Hendocrine clinic by his pediatrician with the concern
2 R. {" r5 w  `$ `' ?% g% Rof early sexual development. His mother noticed: E) ~( h. N6 b, L3 p* M& f3 e
light colored pubic hair development when he was
2 H+ A4 }8 j+ K) TFrom the 1Division of Pediatric Endocrinology, 2University of, P" \4 N% h& M. y5 D: D, v- v% \
South Alabama Medical Center, Mobile, Alabama.! B$ W2 H! n" b9 p) e4 R
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 b" C$ ^4 I3 |2 M
Professor of Pediatrics, University of South Alabama, College of# V- D7 i: i7 h7 k+ S% t" l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 R& ~( R( Y* t
e-mail: [email protected].
* S7 [9 a& O- e+ D! E& ?7 [about 6 to 7 months old, which progressively became
7 G+ S2 C. d) `. w* `8 rdarker. She was also concerned about the enlarge-
1 k1 Q; K3 h! Dment of his penis and frequent erections. The child
7 j# O8 {2 x% @5 i) `5 b$ v' bwas the product of a full-term normal delivery, with# d* A, w" F7 Z  K+ {6 V+ M
a birth weight of 7 lb 14 oz, and birth length of8 o. L7 e) U- j# A- N
20 inches. He was breast-fed throughout the first year
. Z% c+ t. ^( A5 Jof life and was still receiving breast milk along with2 R: K3 d8 A0 ?) o) p
solid food. He had no hospitalizations or surgery,
4 K2 M  [' B( j6 j+ u. D) Dand his psychosocial and psychomotor development
; h3 o% v: l  mwas age appropriate.
* \% |3 l/ L8 L& c! S9 t" cThe family history was remarkable for the father,! [. M& \% S7 Z4 \" c+ z
who was diagnosed with hypothyroidism at age 16,
* g: e0 @  x, K" U+ S  Twhich was treated with thyroxine. The father’s
# ?5 M* W$ i* i- l% Bheight was 6 feet, and he went through a somewhat0 u# `: `1 t  }! t4 J3 Y) Z- E
early puberty and had stopped growing by age 14.
+ `! l$ j  ]5 J) S: SThe father denied taking any other medication. The
- l/ i# Q# R' \child’s mother was in good health. Her menarche
6 Y! J7 U7 q7 X# ?! e/ Hwas at 11 years of age, and her height was at 5 feet/ u- g0 m& U- G4 k( M# X
5 inches. There was no other family history of pre-  q; H% t. j" G7 n5 c
cocious sexual development in the first-degree rela-% k% A. q- n1 L0 m. ~( z
tives. There were no siblings.
( ~5 {. F; A1 k) u! V% XPhysical Examination
+ N2 {, \% t% a2 wThe physical examination revealed a very active,
" c% b1 K7 f4 \, |; `: c" @playful, and healthy boy. The vital signs documented
: G% r3 Y, u# A5 Z4 k" i" W: Ya blood pressure of 85/50 mm Hg, his length was# Q: c- ^# M* g8 q! C2 T
90 cm (>97th percentile), and his weight was 14.4 kg
) ^; Z. {1 `- t+ P2 t& v(also >97th percentile). The observed yearly growth
0 }! I4 [  u# Q, e2 ~/ y# j; @velocity was 30 cm (12 inches). The examination of
8 |2 Z2 X/ M* m( J; p0 f8 e0 jthe neck revealed no thyroid enlargement.& R5 y, f( ~6 ]5 C
The genitourinary examination was remarkable for7 A% N1 y, d# J- v2 X* P
enlargement of the penis, with a stretched length of# ^# q( \; u  W/ g' Q
8 cm and a width of 2 cm. The glans penis was very well8 x4 @$ E& `- M: W2 g0 ^8 k
developed. The pubic hair was Tanner II, mostly around
0 g) _3 d! X4 A- A5 L$ l540! A6 x. [% `/ o. Y% d$ J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) F6 T7 n+ i2 G4 v0 B; xthe base of the phallus and was dark and curled. The# l0 \+ w0 R6 m% m. z4 g9 d
testicular volume was prepubertal at 2 mL each.( g+ \+ M& R. t: d# U5 p; ]# x
The skin was moist and smooth and somewhat9 v3 g3 [7 P! D; m; r2 A7 {
oily. No axillary hair was noted. There were no
* a# k# D% d9 \0 o( X$ f6 rabnormal skin pigmentations or café-au-lait spots.
) R2 {3 b' l2 _) z! o& mNeurologic evaluation showed deep tendon reflex 2+; k+ n+ ~% X: f, l5 u( ~
bilateral and symmetrical. There was no suggestion$ r: ~$ g  Z8 a2 k
of papilledema.3 }2 W1 W6 S' D. Z4 Z, X& _
Laboratory Evaluation5 j8 V: y4 u% e( h+ z4 ?# O
The bone age was consistent with 28 months by' a7 ^6 @9 y  O
using the standard of Greulich and Pyle at a chrono-
/ T- }- _! |8 o. |logic age of 16 months (advanced).5 Chromosomal
7 k5 P( H9 E  ~% y/ l# t' B# Ekaryotype was 46XY. The thyroid function test
& T, q, N2 x1 F0 E2 D. h$ ?5 V, vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
. l, G5 C! r! o9 Z4 k9 mlating hormone level was 1.3 µIU/mL (both normal).$ M$ u4 O9 N  k: @5 z" G0 N
The concentrations of serum electrolytes, blood( h- X1 j/ D' r( ]
urea nitrogen, creatinine, and calcium all were9 M. B! M& z- A
within normal range for his age. The concentration
7 p% J' V1 c$ S2 Y' K0 i" ^0 ~! B* }of serum 17-hydroxyprogesterone was 16 ng/dL, i8 {! ?! o/ h& t; ]4 a) ?
(normal, 3 to 90 ng/dL), androstenedione was 20
/ F9 t% t0 i# ]2 V) P. X2 A0 Bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 @. M( N% i, i  d2 ^; t0 a
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& r0 j: ~4 v  ^3 Q/ ^8 i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to! ]! o; M5 z% Y
49ng/dL), 11-desoxycortisol (specific compound S)) D8 b) o: H. `7 h5 @( {, p3 p; N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 V( q9 z5 v! T9 K8 a: |' f, \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 p& c. w! ^7 M2 O4 Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) P0 @" G. |+ Iand β-human chorionic gonadotropin was less than
1 T: d1 ?2 r1 Q5 mIU/mL (normal <5 mIU/mL). Serum follicular
" \% [. _: A8 Z/ c* \stimulating hormone and leuteinizing hormone
. }. a" ]8 }" C2 a0 q2 Vconcentrations were less than 0.05 mIU/mL
! C  C% d# p" B% K% g5 \# V' c- n/ L(prepubertal).$ B. d" M( T- H3 }0 x! p+ W
The parents were notified about the laboratory7 F( `8 S% P9 P6 v5 h" m/ R9 Q( p( T0 V
results and were informed that all of the tests were
' d' u$ Y# t3 B+ ]# ?* Nnormal except the testosterone level was high. The# B1 D5 Q; o/ C6 n. F& j$ S% p* S! m
follow-up visit was arranged within a few weeks to4 W* F! p% X, A  z7 J
obtain testicular and abdominal sonograms; how-3 W, @4 X, P3 P( J0 t
ever, the family did not return for 4 months.
" _% Z. O) t! h7 s- A6 B3 wPhysical examination at this time revealed that the+ w# p0 K& j4 k
child had grown 2.5 cm in 4 months and had gained
5 e: c3 T5 z% ^( l2 kg of weight. Physical examination remained
3 i$ X0 x( |+ d) z+ bunchanged. Surprisingly, the pubic hair almost com-
2 x. s$ T4 Y! V" y0 Xpletely disappeared except for a few vellous hairs at# a% w( r: \9 I9 ]" t8 P1 X$ o8 M
the base of the phallus. Testicular volume was still 2
$ G  u! i9 [! X( E9 LmL, and the size of the penis remained unchanged.
4 w8 a( z1 b1 J, ]The mother also said that the boy was no longer hav-
& r; y, r" n/ v( ling frequent erections.
$ }2 V! t. A1 n. [Both parents were again questioned about use of
) D1 e, a' M. h& w3 D* aany ointment/creams that they may have applied to
) |1 p& M% x! M: Z0 Zthe child’s skin. This time the father admitted the
$ S' [1 {5 h: D0 ]3 q4 t4 tTopical Testosterone Exposure / Bhowmick et al 541
* q3 _& O$ }8 P7 Z3 q# duse of testosterone gel twice daily that he was apply-( x: I# \6 b$ q( I, j! [
ing over his own shoulders, chest, and back area for- b! M+ T4 |& W$ R# i
a year. The father also revealed he was embarrassed1 M9 \5 L' M9 C& l. J; q9 }
to disclose that he was using a testosterone gel pre-
9 D4 V1 Y5 ^0 j  K; W  t+ Tscribed by his family physician for decreased libido
0 ]6 }3 c$ x* Y! y4 W) vsecondary to depression.
* |9 W) ^' X6 S9 V' dThe child slept in the same bed with parents.: y) W& L9 c( d5 S* i3 r
The father would hug the baby and hold him on his
0 H, V3 h5 Z  `$ C; d2 h; U% R* u2 Zchest for a considerable period of time, causing sig-
3 V0 k- @; U( ~) _nificant bare skin contact between baby and father.8 t1 p. G( d$ J$ S; ?: G9 Z) F
The father also admitted that after the phone call,' [$ v( V. {3 x7 @3 O; y% i7 k- ?
when he learned the testosterone level in the baby
% V7 |; O9 v3 xwas high, he then read the product information1 P* O3 \+ ~2 a7 ~! O
packet and concluded that it was most likely the rea-
& ~) x% \1 u5 j7 h2 O0 j, qson for the child’s virilization. At that time, they: b5 h, j/ `/ c, }% Y: e
decided to put the baby in a separate bed, and the& p: C6 {8 `& Y( ^+ _/ Y' t: [
father was not hugging him with bare skin and had
' p0 x' s8 ^5 H2 q) Ibeen using protective clothing. A repeat testosterone
+ V. H% o0 e! stest was ordered, but the family did not go to the
2 T9 k7 r+ B, O; a0 P9 B5 Z1 ]laboratory to obtain the test.
; M# {/ {4 w& @4 c. X; uDiscussion1 b- H3 D. s9 S, Y( L$ v
Precocious puberty in boys is defined as secondary
: W, r3 U! Z9 }, U) z0 c8 @( esexual development before 9 years of age.1,4
* G( z/ a- A% zPrecocious puberty is termed as central (true) when+ B: l) y8 `; B" K  a
it is caused by the premature activation of hypo-- T: {8 y% j& e9 F: A' T# N6 l
thalamic pituitary gonadal axis. CPP is more com-$ l: y! ~" E, T# ?
mon in girls than in boys.1,3 Most boys with CPP- @9 Q- F5 H. `8 p1 l( B8 d% |
may have a central nervous system lesion that is
/ g( b! g2 w! d5 F7 dresponsible for the early activation of the hypothal-* ~0 a$ Y* Q% D+ s. E9 h3 v% u# G
amic pituitary gonadal axis.1-3 Thus, greater empha-& _/ m* L& c  X1 S6 I
sis has been given to neuroradiologic imaging in/ }: ]5 G( F/ c- j, z- {' O
boys with precocious puberty. In addition to viril-4 @9 H" q5 m8 S$ \
ization, the clinical hallmark of CPP is the symmet-
+ ^/ ?& q$ f" m9 J  irical testicular growth secondary to stimulation by; m* i( H7 x  r+ m
gonadotropins.1,3+ _' {( h! u8 u. u4 A! V7 n
Gonadotropin-independent peripheral preco-" J' T' ~/ i+ u2 S* B. h$ j2 k
cious puberty in boys also results from inappropriate  P" n9 K1 y# i  }: I
androgenic stimulation from either endogenous or
! j' W! T' E' t" Z6 gexogenous sources, nonpituitary gonadotropin stim-$ O" p& x. u7 v1 A; q
ulation, and rare activating mutations.3 Virilizing
3 s  H' \* ^/ N. Xcongenital adrenal hyperplasia producing excessive
3 G3 E- z& i8 o9 q; Q% e" }; yadrenal androgens is a common cause of precocious" K3 x5 f/ q9 _  m9 F7 V; @
puberty in boys.3,4# v1 E9 k3 R- p/ G
The most common form of congenital adrenal
# Y/ S' `( {) \7 a1 F% W. Ihyperplasia is the 21-hydroxylase enzyme deficiency.
7 i, e' e5 E3 F$ QThe 11-β hydroxylase deficiency may also result in
4 G+ M0 G5 K" W5 zexcessive adrenal androgen production, and rarely,5 `/ e& e4 y$ C7 ~- T
an adrenal tumor may also cause adrenal androgen
9 O$ Y# m5 r$ b9 `excess.1,3& W3 V3 K( B4 A1 j& s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, b" X* F6 n" J' U542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! \' b: q# p# N( X; aA unique entity of male-limited gonadotropin-# e1 v7 I6 b0 b/ V( Q, L: k2 d; B
independent precocious puberty, which is also known8 Y  s  y, l6 T
as testotoxicosis, may cause precocious puberty at a
" F6 x& L7 e8 O- uvery young age. The physical findings in these boys
' S8 }% I+ C6 R- ^* v1 Q& Ywith this disorder are full pubertal development,' `2 F8 {/ }$ ]* y0 C
including bilateral testicular growth, similar to boys
% w# C# e' `7 E/ o# ]  h+ Gwith CPP. The gonadotropin levels in this disorder. g# i9 h1 |+ l4 h+ ?
are suppressed to prepubertal levels and do not show- P' v( E, W3 h3 H
pubertal response of gonadotropin after gonadotropin-
  z' R2 Q+ }; M5 ]: Y) Y9 ^- Ireleasing hormone stimulation. This is a sex-linked1 H  u, t$ }) H
autosomal dominant disorder that affects only
( B; u% B9 b: k$ J3 rmales; therefore, other male members of the family
8 R4 t5 O* B* f% U1 t0 w( m! f% ~8 @may have similar precocious puberty.3
/ a& S. ]' |; rIn our patient, physical examination was incon-
1 K6 t& Z, b+ E1 ?& s0 M4 j$ Ksistent with true precocious puberty since his testi-
' f( Q  i. W# g7 M4 L/ bcles were prepubertal in size. However, testotoxicosis
0 i7 i/ N" ?1 O  M- V6 kwas in the differential diagnosis because his father; T" }. @! n& T1 A6 k7 i* W
started puberty somewhat early, and occasionally,
6 J, Z4 Q1 m, }- b9 `; `' Y. ltesticular enlargement is not that evident in the
/ [) x6 v+ X8 H2 _3 n( D( N2 pbeginning of this process.1 In the absence of a neg-
# B1 e( h0 N/ w' Y  @! }0 a' Xative initial history of androgen exposure, our% f) D  ~6 Z! |+ F+ r, [
biggest concern was virilizing adrenal hyperplasia,) m! n5 q( E# M7 M. D/ p* j4 g
either 21-hydroxylase deficiency or 11-β hydroxylase9 |5 W, h& T9 a8 h
deficiency. Those diagnoses were excluded by find-9 B, j- ?+ ?3 q: b) d
ing the normal level of adrenal steroids.# R$ y+ U$ i# z6 M! p
The diagnosis of exogenous androgens was strongly& V8 p  P5 r! X3 [9 K$ ^
suspected in a follow-up visit after 4 months because
( r3 }" w- ?' Z' b- X9 dthe physical examination revealed the complete disap-
3 c4 o4 A4 m8 e7 d2 vpearance of pubic hair, normal growth velocity, and
: u. j! F; J" @3 p& P" @  _decreased erections. The father admitted using a testos-5 P# y" r% m. q! y2 v
terone gel, which he concealed at first visit. He was
/ t% `9 Q+ }- E* Z3 k0 busing it rather frequently, twice a day. The Physicians’
: |1 R' T' Q$ k# X6 [# ~$ fDesk Reference, or package insert of this product, gel or6 s; _! j- F( h" [2 R7 t
cream, cautions about dermal testosterone transfer to+ S+ x4 ^) F2 b# e& l9 q4 t, U9 E6 y
unprotected females through direct skin exposure.
; N1 t5 R' d% q' iSerum testosterone level was found to be 2 times the
. z+ j4 u6 V: v+ \baseline value in those females who were exposed to
7 Q/ y; @5 k4 f& ~# @even 15 minutes of direct skin contact with their male) J. k: ~4 V# E) `3 c2 v
partners.6 However, when a shirt covered the applica-( J2 n% X3 a7 g' R" `2 g! k
tion site, this testosterone transfer was prevented.( P# m; B2 e2 Q8 v# l. S
Our patient’s testosterone level was 60 ng/mL,5 l4 j; c" H) O, O
which was clearly high. Some studies suggest that
6 d0 t+ Y' E6 Tdermal conversion of testosterone to dihydrotestos-
& {4 R0 b" h' K( m% r' _0 Tterone, which is a more potent metabolite, is more5 i- Y( w' P+ g1 Z5 J/ I
active in young children exposed to testosterone0 Z) y4 ?: f5 U+ ?; B
exogenously7; however, we did not measure a dihy-
. w( G2 n, q* R( S1 ^drotestosterone level in our patient. In addition to, z+ C2 R4 Z" J6 Q, @, [1 r: v8 O
virilization, exposure to exogenous testosterone in
( u3 d7 m- b/ x3 }9 G% `children results in an increase in growth velocity and
) W. ^7 z* R3 E6 A0 ?2 C$ R6 madvanced bone age, as seen in our patient.
3 m& I2 r7 u  H0 @The long-term effect of androgen exposure during) y1 N& K+ Q: T1 W# @& N' T: [
early childhood on pubertal development and final4 h% R- z) M  u7 k7 s
adult height are not fully known and always remain, I" x  a( l% R3 v+ q  k' G! f7 A2 a6 O
a concern. Children treated with short-term testos-! w! D7 W1 P. j0 ^2 b7 F% a7 X: |3 H
terone injection or topical androgen may exhibit some
) O8 _+ a- J  E5 e# U& B1 i1 Bacceleration of the skeletal maturation; however, after
( i: O0 M1 {. ccessation of treatment, the rate of bone maturation
, q1 L% W: y% d0 Edecelerates and gradually returns to normal.8,9( B% m" g$ y) i% @
There are conflicting reports and controversy
) Q* u8 R% N5 G9 k; P( ?' \; dover the effect of early androgen exposure on adult/ Y% O6 |- z5 f0 R+ q& z
penile length.10,11 Some reports suggest subnormal# f- K; f/ ~# a( D' W3 f; p8 H! i
adult penile length, apparently because of downreg-  e( w* @+ w; T1 h
ulation of androgen receptor number.10,12 However,, q" Y5 h' j8 C5 t  W5 r4 L
Sutherland et al13 did not find a correlation between
5 b- Q6 l3 I; z* }# Ichildhood testosterone exposure and reduced adult  s& g: L: Y5 B+ Z+ Q# p" ^' S
penile length in clinical studies.
+ W' m2 ]' {) }  SNonetheless, we do not believe our patient is
( N; b$ o" u) f- l6 {, Igoing to experience any of the untoward effects from2 p% v, Q0 z; o$ q' s& D
testosterone exposure as mentioned earlier because" h& V7 B2 k, R# v' N4 C
the exposure was not for a prolonged period of time.5 D$ i8 ^* T: H
Although the bone age was advanced at the time of
; I- C8 G( k& f% Z4 Rdiagnosis, the child had a normal growth velocity at
8 M+ a4 p( A* C& d2 I: Vthe follow-up visit. It is hoped that his final adult
! Y: d+ i$ i' @height will not be affected./ ?, q" _7 R5 c0 M1 c4 h
Although rarely reported, the widespread avail-, w9 A. ^/ }+ s# E6 _, q3 N3 S' H
ability of androgen products in our society may
( F% q) @) X, V. c( Hindeed cause more virilization in male or female
0 U/ J$ k+ x; X; q4 M3 O8 ?4 |children than one would realize. Exposure to andro-# {4 {+ q; O$ N0 Z5 @
gen products must be considered and specific ques-* V" }. W3 |" P  L  k# k( `
tioning about the use of a testosterone product or2 s; e, i0 h+ z5 K/ M% v
gel should be asked of the family members during
* I) L  B9 r5 c& U( Ythe evaluation of any children who present with vir-9 P2 E+ H  c8 ^1 U2 A3 _' @. A" X
ilization or peripheral precocious puberty. The diag-
9 f" P2 |8 n1 f- i' f( i9 @nosis can be established by just a few tests and by
8 {. u. t1 a' gappropriate history. The inability to obtain such a/ m8 m$ n7 a2 X3 n1 b' `8 _* [
history, or failure to ask the specific questions, may
3 w$ x3 d8 x! D1 Tresult in extensive, unnecessary, and expensive
& z- {  a+ ~  V" Qinvestigation. The primary care physician should be
5 g. _% o& v, h- }  Baware of this fact, because most of these children
  x" r5 g0 o, b( I4 Ymay initially present in their practice. The Physicians’
1 y# a8 G# T. A2 p8 u- `Desk Reference and package insert should also put a
1 }( u& _4 H) j4 iwarning about the virilizing effect on a male or
/ y" {) H$ F6 v2 k3 e0 ]. P# Ifemale child who might come in contact with some-
" V5 ?2 o* K0 F9 Vone using any of these products.5 t0 Y2 L2 W& g4 D) C- h
References
; e3 W' Q" S9 M4 S1. Styne DM. The testes: disorder of sexual differentiation  G' Q' e  V: y3 n  |8 Y
and puberty in the male. In: Sperling MA, ed. Pediatric6 a7 @  T+ C& O& [6 O1 _( ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! R4 X$ l* i* Q7 x2002: 565-628." ?% f+ x; \; f4 n$ I
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 N; \& c8 w) W  D
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
: I" A6 {2 R* J1 C4 A, {Boy Induced by Indirect Topical
) E, r0 l4 c. \! d* lExposure to Testosterone
9 w9 j  D7 V# DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ u( P5 k7 {* Q0 L" L
and Kenneth R. Rettig, MD17 f4 Z7 v% z" [6 e' a. M$ b
Clinical Pediatrics
1 k/ I: D0 m2 E8 oVolume 46 Number 60 Q8 i2 |7 K  x' R5 c
July 2007 540-543
) ]* Q! c; Z: V% G$ p© 2007 Sage Publications4 V# G- S  C) J9 K- `# m
10.1177/0009922806296651/ \. I3 H2 P& J$ O! P
http://clp.sagepub.com& r1 X+ c8 y( F7 s1 ~5 j
hosted at$ q6 }( Z( f) y" `& D
http://online.sagepub.com
* t( q2 B  A/ o5 BPrecocious puberty in boys, central or peripheral,* h9 D$ ~5 u" i3 [6 @4 X* t
is a significant concern for physicians. Central) n9 X& K& Z! j" t3 A: g$ p! D4 ^
precocious puberty (CPP), which is mediated
% T+ S1 K9 ^- y* g' l' Cthrough the hypothalamic pituitary gonadal axis, has" B3 E& {& C1 }; z) i' ^% h1 x% w( d
a higher incidence of organic central nervous system5 b; }, z9 x' w; h1 k8 u- A
lesions in boys.1,2 Virilization in boys, as manifested# L! G( Y+ v: j/ q' B+ M! `
by enlargement of the penis, development of pubic! m: }" N7 t- @. s
hair, and facial acne without enlargement of testi-
: @( }0 H" d4 o2 c0 @/ Dcles, suggests peripheral or pseudopuberty.1-3 We) U* x. g+ s/ G, r, |' _  K' Y
report a 16-month-old boy who presented with the7 B5 S' u5 }) W6 u
enlargement of the phallus and pubic hair develop-
3 `! s- v& W$ k1 R# [) `ment without testicular enlargement, which was due
. _3 l1 A0 N9 h5 }+ I0 t: Oto the unintentional exposure to androgen gel used by
6 i+ ]( g# |7 A+ @' Ythe father. The family initially concealed this infor-
8 E6 P/ c" h; k, e9 r$ D6 K5 Zmation, resulting in an extensive work-up for this
5 a% B( T/ f0 {& |6 R' Rchild. Given the widespread and easy availability of3 Z# K4 f# F& \- @2 R# |( f# j- @
testosterone gel and cream, we believe this is proba-& F  ?6 H6 J( ^2 s! R
bly more common than the rare case report in the6 A& }/ @3 \' U. p
literature.4
- y" W8 u4 n! GPatient Report2 \& k+ r/ G# z; v; f
A 16-month-old white child was referred to the1 f( S! [+ t- U1 m* n: {, z
endocrine clinic by his pediatrician with the concern
* \* {$ W- M$ U. vof early sexual development. His mother noticed9 V) ]  G6 B/ @; r4 o, F% \. r! D
light colored pubic hair development when he was5 ]8 C/ \1 K7 F0 e, p3 p- l
From the 1Division of Pediatric Endocrinology, 2University of5 q" h! M/ U4 z2 Y8 V( z
South Alabama Medical Center, Mobile, Alabama.
# S/ g0 R6 d8 J2 xAddress correspondence to: Samar K. Bhowmick, MD, FACE,! T# t, I% J. ?! O. p7 F0 }; G0 _0 Y
Professor of Pediatrics, University of South Alabama, College of
- _7 c9 R6 t: j( e+ d+ e" d6 cMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( w8 ?1 e8 W5 x- u3 r  z
e-mail: [email protected].
2 H7 W4 x$ `: [" Zabout 6 to 7 months old, which progressively became
9 {. o% ~; R, t$ w' Pdarker. She was also concerned about the enlarge-
8 U% r: n+ b( x* T9 z, r& wment of his penis and frequent erections. The child
8 K  |  d+ q. i" Gwas the product of a full-term normal delivery, with: b' n& F) W1 S$ z! @; j
a birth weight of 7 lb 14 oz, and birth length of
- r$ e4 m" G: F' d; l% c20 inches. He was breast-fed throughout the first year
# _- X( S) T+ u9 gof life and was still receiving breast milk along with
8 n3 W. {7 S6 @9 |* ?) c5 hsolid food. He had no hospitalizations or surgery,/ c  ^6 h* p1 W% s
and his psychosocial and psychomotor development
  q8 p: b, R) s7 Q4 }was age appropriate.; k3 U; w1 p) m% D
The family history was remarkable for the father,
4 R3 L& B9 u; g& B3 _who was diagnosed with hypothyroidism at age 16,
7 [4 T1 m6 {1 p* D: ^which was treated with thyroxine. The father’s
, F4 @/ Y- m6 C3 f3 c) qheight was 6 feet, and he went through a somewhat; b! A( O- j6 u
early puberty and had stopped growing by age 14.6 k* E0 ~2 J1 `8 z" \' z7 G
The father denied taking any other medication. The: S, y* T8 X, q: S+ ?
child’s mother was in good health. Her menarche
2 l  a: }( C% i! o1 owas at 11 years of age, and her height was at 5 feet
) x5 n1 q3 E' m9 S. {0 s% W, P# _5 inches. There was no other family history of pre-, g  N% F5 P! s# e8 V
cocious sexual development in the first-degree rela-
* C7 ?# d- \4 q' v% |tives. There were no siblings.
. L! ?( [5 ^" FPhysical Examination
0 v  C, M' E: Q, LThe physical examination revealed a very active,4 Q" ]5 K7 I5 \2 o0 t, h; d
playful, and healthy boy. The vital signs documented* L. ^# m! V' e  s' x3 T
a blood pressure of 85/50 mm Hg, his length was
: r! R" X0 @5 r) h" {! [90 cm (>97th percentile), and his weight was 14.4 kg
2 j, u6 {4 b+ Y& V* n(also >97th percentile). The observed yearly growth7 d/ X3 o- X' o, U. S# ]
velocity was 30 cm (12 inches). The examination of0 e# H8 L8 x5 k; z2 h2 b
the neck revealed no thyroid enlargement.- T- Y  W! ^' n
The genitourinary examination was remarkable for
0 @* w" @$ `* \! J* R4 Venlargement of the penis, with a stretched length of
" e( U) l. X, Q8 cm and a width of 2 cm. The glans penis was very well
0 [- o! ~! s4 H6 B( W* L9 sdeveloped. The pubic hair was Tanner II, mostly around& j  i' i3 t4 s! c: M
540; v! O) N+ i+ Q2 i) @1 _- }0 u" ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" e0 A5 I* ?# _4 |$ e1 z0 E: dthe base of the phallus and was dark and curled. The
; [2 P$ M9 P/ C) i* ~9 W- E& ctesticular volume was prepubertal at 2 mL each.+ |0 }9 b8 |! D
The skin was moist and smooth and somewhat
4 w, A/ v1 b" R( C+ I& P5 ^oily. No axillary hair was noted. There were no  W# j: v9 `" ~- F1 Z" d
abnormal skin pigmentations or café-au-lait spots.
+ E' N( t4 D6 r8 j7 `Neurologic evaluation showed deep tendon reflex 2+
1 v0 i. y5 V' `/ {, z" Wbilateral and symmetrical. There was no suggestion4 o3 g2 I) i; |1 l: j
of papilledema.. d/ h' }9 ]  }- H" c0 x# J- _
Laboratory Evaluation9 I6 _6 Y0 O# u' ?) }
The bone age was consistent with 28 months by. j( H+ s+ B5 Z
using the standard of Greulich and Pyle at a chrono-
, G8 T: \3 @) t, k7 _/ E4 Jlogic age of 16 months (advanced).5 Chromosomal2 X4 A7 K6 C" t7 O
karyotype was 46XY. The thyroid function test
6 n6 A4 N6 B& q! y* Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: {# y- @$ T5 N; l. g# b" R
lating hormone level was 1.3 µIU/mL (both normal).
* |8 R6 F  r# c* C2 W3 Y3 gThe concentrations of serum electrolytes, blood
0 ]8 }- D8 D" Z0 furea nitrogen, creatinine, and calcium all were1 `4 s% x3 }8 a( d7 e
within normal range for his age. The concentration2 c) h0 q/ }- {2 S, Y' W6 p1 A) A& x
of serum 17-hydroxyprogesterone was 16 ng/dL' [& \) m% s- m0 |8 v$ e( W
(normal, 3 to 90 ng/dL), androstenedione was 200 Y' u4 o$ k% e* S; ~# g& i6 {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ h. n( v, X9 ~1 o: X6 ], c
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( o7 y0 V, t4 q. {desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 [' B+ }. ^* r; W# g
49ng/dL), 11-desoxycortisol (specific compound S)
! S# {  J+ p# s0 j) v9 ?) n7 Y5 ]7 uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ P0 I5 W5 O6 F$ T, h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 {& c0 c9 G, X; G4 G9 T) l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),- ]' P3 b( P* ~! T6 j
and β-human chorionic gonadotropin was less than
& v# K1 i+ D9 S) F5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 i! p7 R9 F6 a$ R+ z5 f* lstimulating hormone and leuteinizing hormone1 e6 l! i# _, q, d3 M6 a
concentrations were less than 0.05 mIU/mL! L" X* ~4 L! a+ n' \
(prepubertal).
( t7 ?: u. t8 \1 ]" fThe parents were notified about the laboratory7 P& G9 z9 M/ |1 U( R5 ]
results and were informed that all of the tests were
. p2 F0 y" Y- \, w! Q2 |/ L8 {% Snormal except the testosterone level was high. The* @  Y$ @  v. W5 x# n
follow-up visit was arranged within a few weeks to
, s$ ]; @$ \: O6 T* p8 Pobtain testicular and abdominal sonograms; how-( v- F& k8 ^& f8 V( i! m) H5 a
ever, the family did not return for 4 months.
( N+ J- D; `6 G6 p* OPhysical examination at this time revealed that the
: [& p7 O/ h5 lchild had grown 2.5 cm in 4 months and had gained
, S$ o$ y1 u+ l9 e5 F2 kg of weight. Physical examination remained
1 z. U) f% V* l2 l$ S& Junchanged. Surprisingly, the pubic hair almost com-
; R$ T& z' E0 D9 Y9 r' X$ [: [) fpletely disappeared except for a few vellous hairs at, L" c* B7 \- o* |' d
the base of the phallus. Testicular volume was still 2
+ X) b( P* ^& v; V# _# TmL, and the size of the penis remained unchanged.
8 h$ H/ y. u1 k+ [' kThe mother also said that the boy was no longer hav-
' h  O+ ~: @( ]- b# {, p) ^ing frequent erections.4 p' D3 s2 X& _/ F
Both parents were again questioned about use of
& x* J1 N; O- E6 d2 X+ uany ointment/creams that they may have applied to
; t1 _& E3 w2 V% o- U; @the child’s skin. This time the father admitted the1 t( v1 e5 n0 ~3 [5 d5 n
Topical Testosterone Exposure / Bhowmick et al 5415 s/ X* f! |; S) v
use of testosterone gel twice daily that he was apply-5 q  D. r( K, G, a' |* l% {- S9 Q$ M
ing over his own shoulders, chest, and back area for
/ l  y. `, F" ?( J4 Ba year. The father also revealed he was embarrassed/ [! B3 ~( [& B
to disclose that he was using a testosterone gel pre-
( j4 p" n! F+ g0 T7 U8 Q0 Lscribed by his family physician for decreased libido0 H& j% Q6 P! r& J) n2 `- c% t+ v
secondary to depression.
& T- {; h4 ^, G) |The child slept in the same bed with parents.; Z! n7 d7 k8 n
The father would hug the baby and hold him on his2 m- q5 S" w2 d0 j2 ]
chest for a considerable period of time, causing sig-7 o- x9 H1 i$ f: z+ N. C; @/ u
nificant bare skin contact between baby and father.
1 g% ^4 J9 G9 IThe father also admitted that after the phone call,
7 _; [/ }! F! y" ?when he learned the testosterone level in the baby
5 q6 h, E6 M" X- M' P  o4 C0 fwas high, he then read the product information
& E% v% F5 H0 mpacket and concluded that it was most likely the rea-3 f( M. e& j1 p$ @- K* p
son for the child’s virilization. At that time, they$ d" C9 R6 H0 p
decided to put the baby in a separate bed, and the0 A( N! w, [# y5 L2 ^  G& g
father was not hugging him with bare skin and had
# j. W6 P! `) {" E( |; z% m% wbeen using protective clothing. A repeat testosterone  V0 y8 z6 G8 L
test was ordered, but the family did not go to the: O. n, @$ W+ c1 o( A- S& t1 B
laboratory to obtain the test., H. M' i* K# h, l7 z' S
Discussion
1 e. ~' V2 ]  h2 u' h+ I+ n" HPrecocious puberty in boys is defined as secondary7 R: u4 I7 H, c! j% D3 g* N
sexual development before 9 years of age.1,4
8 M% t& N2 |) i' K& w9 J( dPrecocious puberty is termed as central (true) when0 {7 j7 d$ {' \5 m3 b& k
it is caused by the premature activation of hypo-
) I2 f. l( h- ^* k0 m! V7 o3 w2 Tthalamic pituitary gonadal axis. CPP is more com-
# N- I- Z% w4 Nmon in girls than in boys.1,3 Most boys with CPP* _% o) V4 e) r1 v* V5 ?
may have a central nervous system lesion that is8 w- O; Z$ W2 B* c9 l5 u
responsible for the early activation of the hypothal-) Z' ]# M9 X2 H+ ?1 F1 \
amic pituitary gonadal axis.1-3 Thus, greater empha-
# n2 g% r/ h8 E- R4 Z, vsis has been given to neuroradiologic imaging in
. A! M, @! i2 X* d* c! xboys with precocious puberty. In addition to viril-
' W$ W1 a1 ]' ]: j7 c* zization, the clinical hallmark of CPP is the symmet-' `' G$ P- m; S5 S& H7 g* K
rical testicular growth secondary to stimulation by
5 o  v# ~7 h" E5 }  pgonadotropins.1,3
, o% s4 c8 U7 k1 k/ Z9 _+ PGonadotropin-independent peripheral preco-
# R: c% ?, d* r- Bcious puberty in boys also results from inappropriate
6 J* B% t# x! i: Z" ]( C) _3 n% }androgenic stimulation from either endogenous or3 W2 l: H* g$ z' l
exogenous sources, nonpituitary gonadotropin stim-. S/ Z% b2 v+ p% @9 }' [( j/ r& p
ulation, and rare activating mutations.3 Virilizing
/ t0 m- r: y$ L. |congenital adrenal hyperplasia producing excessive+ l; U6 N) `$ {: o% @
adrenal androgens is a common cause of precocious
2 L  T8 s' U5 |5 W, J8 q* C5 npuberty in boys.3,4# U$ f: x4 P& s( y
The most common form of congenital adrenal! A4 z* |; ]3 K6 T
hyperplasia is the 21-hydroxylase enzyme deficiency.
" Q# O! M! C, z9 E, i, fThe 11-β hydroxylase deficiency may also result in' e) {( D9 m8 O* O/ f
excessive adrenal androgen production, and rarely,
7 v* ~% N/ a/ y$ T2 ~  S2 C0 ban adrenal tumor may also cause adrenal androgen3 n( b! Z  U( d) I4 i, |" w& s) t
excess.1,3
1 u$ \% F4 ~, U4 _- M! Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 E7 t3 p4 g! K! H+ t
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
' ?' L& h4 X/ u( _; O- rA unique entity of male-limited gonadotropin-% B' K& G  L$ }9 E+ y) e- p& b
independent precocious puberty, which is also known
0 v+ O. _' e" H* a# G. d! }+ ias testotoxicosis, may cause precocious puberty at a1 Q) `0 ]8 E+ J. |
very young age. The physical findings in these boys% L6 g" o8 \. ^0 k% K9 z4 x
with this disorder are full pubertal development,. N) K/ _, _% b( B
including bilateral testicular growth, similar to boys* |# X4 I( C/ w) c6 a- M
with CPP. The gonadotropin levels in this disorder
2 `" ?+ c, a& o1 Xare suppressed to prepubertal levels and do not show% W: o' N6 ^2 G2 Z$ [5 r
pubertal response of gonadotropin after gonadotropin-3 J- u3 D2 R# B6 I
releasing hormone stimulation. This is a sex-linked
3 `: f" ]9 B( Z( Z( H& jautosomal dominant disorder that affects only& D8 C  a# L  c# U3 \
males; therefore, other male members of the family5 c+ j  O* g* ?) v9 r
may have similar precocious puberty.3
: i9 i% o0 L; x1 _$ Y. O& SIn our patient, physical examination was incon-; G% L1 s$ ~, k" G* @: U4 |9 W
sistent with true precocious puberty since his testi-
4 m$ [, l0 d1 Q- m0 h" g8 \( qcles were prepubertal in size. However, testotoxicosis, I0 D$ ^" L+ s- |( p5 \
was in the differential diagnosis because his father" a" M* I. ~" d' Z5 k9 g
started puberty somewhat early, and occasionally,: Z' ]2 a% m' w! C2 C; Z1 T
testicular enlargement is not that evident in the
% |' r$ d- o' w: ~# K4 ]4 d# Fbeginning of this process.1 In the absence of a neg-$ F4 ?2 ]; ^" ~5 Y
ative initial history of androgen exposure, our
  e* q. q5 E9 E( h  d4 n5 y2 Ybiggest concern was virilizing adrenal hyperplasia,
/ C2 W# f8 K1 p0 Weither 21-hydroxylase deficiency or 11-β hydroxylase' ]& S1 K2 j) @8 L
deficiency. Those diagnoses were excluded by find-
) t0 t: J& I3 M2 `" Ving the normal level of adrenal steroids.; ~& d8 o$ C; s9 L( Q
The diagnosis of exogenous androgens was strongly
2 y  R3 I6 W# V% fsuspected in a follow-up visit after 4 months because- [. k3 N" M& D/ t% |( o8 `
the physical examination revealed the complete disap-! v3 \$ b& n* q
pearance of pubic hair, normal growth velocity, and5 I# V+ F! z2 N6 W# s0 ?
decreased erections. The father admitted using a testos-( b4 m" Y' T. C5 i. a* J
terone gel, which he concealed at first visit. He was3 o1 U- C3 M  Y5 ^
using it rather frequently, twice a day. The Physicians’
- L7 J3 x, J" S# }Desk Reference, or package insert of this product, gel or
. j( x! v# q  {+ tcream, cautions about dermal testosterone transfer to
3 H3 C+ N3 A2 munprotected females through direct skin exposure.: m% m8 i" J; u( r$ K
Serum testosterone level was found to be 2 times the7 o' J" i* k0 I1 O, i4 U( Y/ M
baseline value in those females who were exposed to
! s; X- T2 C7 u9 R7 C- Reven 15 minutes of direct skin contact with their male
0 T$ n* m1 J. s: E; n6 j. R; W- h7 S6 Ypartners.6 However, when a shirt covered the applica-
" a9 j0 j% c( Otion site, this testosterone transfer was prevented.& B! e0 B( D+ E2 j/ K- i" j  O2 f$ I6 F! m
Our patient’s testosterone level was 60 ng/mL,
9 L% o5 ^. y/ @8 \1 Jwhich was clearly high. Some studies suggest that
1 M  t7 E/ b0 T0 u; j: h. ]dermal conversion of testosterone to dihydrotestos-
6 C9 Y8 q3 M! _" d; \% Uterone, which is a more potent metabolite, is more2 R# a( d! t; m4 j+ d
active in young children exposed to testosterone" l/ P+ }& q5 o5 q; v5 L: x4 h* o
exogenously7; however, we did not measure a dihy-
7 h8 @3 a, f, A! R2 Rdrotestosterone level in our patient. In addition to' J' e& ~, `% O( {2 q; ?) I
virilization, exposure to exogenous testosterone in, K% X6 \( s# e
children results in an increase in growth velocity and/ o* v- o8 `" {9 j
advanced bone age, as seen in our patient.
9 }- Y- O: R/ u4 FThe long-term effect of androgen exposure during
$ X1 F+ J( q6 i& [0 Y1 aearly childhood on pubertal development and final' M7 H: \+ S/ y, _: _. |0 K# y$ O
adult height are not fully known and always remain
5 u0 o! U4 b% R# m9 F( a+ h$ u  aa concern. Children treated with short-term testos-
8 J1 ~& y: T: F) r6 I; ]& N) vterone injection or topical androgen may exhibit some2 v  |4 Q1 d0 I9 w; m
acceleration of the skeletal maturation; however, after
* S) D/ z( e# Acessation of treatment, the rate of bone maturation
' `$ m$ Y/ c& s7 ]5 Adecelerates and gradually returns to normal.8,9: u% T! L% a' s" @2 ?* ?, I
There are conflicting reports and controversy
1 c2 ~, G2 f0 l; @5 v" E: Mover the effect of early androgen exposure on adult
# a7 R; @6 {( @  W7 Ppenile length.10,11 Some reports suggest subnormal8 Y$ R8 d4 n* F- l" a" z
adult penile length, apparently because of downreg-- K3 s6 J6 e6 m9 L# j- }: R
ulation of androgen receptor number.10,12 However,6 W! G$ r- a0 d: k; {+ c
Sutherland et al13 did not find a correlation between; {. i1 [# y% `5 l/ C
childhood testosterone exposure and reduced adult. t' P3 a% a' F
penile length in clinical studies.5 Q8 {% L& t( F. ~1 Q
Nonetheless, we do not believe our patient is0 p8 k* ^7 R8 N  V( F0 k2 ]+ t8 e
going to experience any of the untoward effects from
) k- Z; h6 M5 z1 \4 b, Etestosterone exposure as mentioned earlier because- Y0 ~9 Z0 B& ~% K! o2 a* v! O9 O
the exposure was not for a prolonged period of time.7 H1 n1 S. A9 Q5 ^4 R2 M
Although the bone age was advanced at the time of& _/ k1 f$ @* }1 n' ]9 z
diagnosis, the child had a normal growth velocity at
8 j/ P1 j0 Q8 \$ y7 othe follow-up visit. It is hoped that his final adult
% ~! Y$ m' _# K& `  X# Wheight will not be affected.
- U  t1 l. L* e# z% kAlthough rarely reported, the widespread avail-0 ~& O' C0 \5 j$ k% x0 V
ability of androgen products in our society may3 u. |- X) g( W; n$ u" M- B
indeed cause more virilization in male or female7 t* y! a& @7 E$ Z9 K3 ~4 P3 h, x
children than one would realize. Exposure to andro-3 i  ~; ?* E4 u# ~; Y* j
gen products must be considered and specific ques-
5 ?1 z  W6 {/ M* ptioning about the use of a testosterone product or
( A" m( }: K# Z5 Sgel should be asked of the family members during
7 h, v& k( b  n, L1 Q8 Sthe evaluation of any children who present with vir-- t$ _  ]1 \+ z: s* T3 X
ilization or peripheral precocious puberty. The diag-1 A# Y0 G& n- K, o  Y1 S( N6 U
nosis can be established by just a few tests and by
) @4 G* R9 b" K- R& kappropriate history. The inability to obtain such a
7 f- ]; C' e/ T2 _/ e! nhistory, or failure to ask the specific questions, may2 N( A( n6 l& I6 k, [$ X* S, U7 r8 P
result in extensive, unnecessary, and expensive
/ u! L9 [& ^9 ?  ?$ V/ h2 Dinvestigation. The primary care physician should be- U( }2 b0 P6 g9 E- _6 Q
aware of this fact, because most of these children; G, M$ E  o2 j* }; n0 ~
may initially present in their practice. The Physicians’. A7 l) Q, v$ {# v# N  M2 F
Desk Reference and package insert should also put a
# q& s* P) @3 e4 ~9 Z, t( b5 Jwarning about the virilizing effect on a male or
! W8 Q4 I9 l! ^female child who might come in contact with some-
, \, I8 ]  g. ]0 H2 vone using any of these products.  \) @7 w8 h: [2 h4 ^, Y
References
9 q9 T# A+ `% p+ `1. Styne DM. The testes: disorder of sexual differentiation
: q6 K/ a% N8 Xand puberty in the male. In: Sperling MA, ed. Pediatric; Q" I9 \6 i6 H1 d2 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( U5 m- F7 t9 F& I7 E
2002: 565-628.
1 N1 i3 F- r$ D9 b+ X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ z3 N0 l  k) `4 F+ h3 s3 h& b5 I
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
! n2 B, N' M% L, E% h8 w
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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