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Sexual Precocity in a 16-Month-Old
  l$ }5 E; J7 v6 {# EBoy Induced by Indirect Topical
' }2 `; a0 n4 O( u" k4 t3 DExposure to Testosterone
7 }4 p3 b3 h% z- k3 y: i: iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* G7 H' R! x! ?, kand Kenneth R. Rettig, MD1
. c$ ^2 |/ I; r2 K' z6 @Clinical Pediatrics/ V* Y6 E* T8 C$ q& }* l
Volume 46 Number 6
) ?4 S7 ]7 _0 t/ d" zJuly 2007 540-543
/ P* {: E9 N" L' |& D, |' o4 J© 2007 Sage Publications# Y0 P, X3 o5 `6 b
10.1177/0009922806296651
+ Y) S, A3 a- G: t. O7 Rhttp://clp.sagepub.com
4 h# m2 e# ]9 v6 J6 j) ^# y6 Chosted at* W. z* _+ E. j4 X: m/ o4 \
http://online.sagepub.com
- `* I7 Q6 G5 l( Y8 A0 Q; PPrecocious puberty in boys, central or peripheral,
! C0 z' [$ \, ]) E2 {& W) @' Jis a significant concern for physicians. Central
( }0 ~! H1 T2 F# K, tprecocious puberty (CPP), which is mediated
& z( [' t2 B1 ?. ^1 Bthrough the hypothalamic pituitary gonadal axis, has
1 n3 @0 q' s( _% O. pa higher incidence of organic central nervous system
) G4 V( F, u1 N  H4 ~: C! W! Flesions in boys.1,2 Virilization in boys, as manifested  w" h& Y5 Y: i# R# w, b
by enlargement of the penis, development of pubic
/ w/ q& j6 Q2 |$ ahair, and facial acne without enlargement of testi-
' K) R9 i( W  X0 h& v+ s! l3 T) Ccles, suggests peripheral or pseudopuberty.1-3 We3 W, ?% V5 m; k
report a 16-month-old boy who presented with the
4 @* `; B7 Y( fenlargement of the phallus and pubic hair develop-
# A$ `2 r; X- A/ J/ p# C# qment without testicular enlargement, which was due
3 f* [/ I: E2 a( h: N4 K# h1 jto the unintentional exposure to androgen gel used by. @% O, F" p/ e* y5 p! V
the father. The family initially concealed this infor-
/ S; z/ p; ?" }) O) Qmation, resulting in an extensive work-up for this
9 C3 Q4 a" m: T; L2 Z0 `* G. \child. Given the widespread and easy availability of  \0 Z& D  R& ~( s9 v. _, d
testosterone gel and cream, we believe this is proba-% u( I9 i2 H3 h0 v, R+ R! y
bly more common than the rare case report in the- F9 z5 u4 c9 j$ O5 U6 Z
literature.4
) Y6 c( w6 W: `. I5 }Patient Report6 I4 C/ f, M! `# C) j3 ?( B. S
A 16-month-old white child was referred to the
. D; A7 o7 D7 e2 o# L+ Fendocrine clinic by his pediatrician with the concern
, m! J6 k! ?6 G" S- F9 zof early sexual development. His mother noticed- u" w7 {) X8 r" |
light colored pubic hair development when he was
* a" r8 N. d; N1 TFrom the 1Division of Pediatric Endocrinology, 2University of6 n1 p: ?4 `: M% w& p4 r
South Alabama Medical Center, Mobile, Alabama., S4 G  V" L" V& p* l+ l( P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 b: h/ B( `  FProfessor of Pediatrics, University of South Alabama, College of
( s' x# u; E0 G3 u6 d/ ~1 \% LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  x: Y5 |9 f* ~) te-mail: [email protected].
" d! v! C) ~! Y( c* o9 a( `5 y0 F% Kabout 6 to 7 months old, which progressively became
8 M) S. M' g& y9 Ydarker. She was also concerned about the enlarge-
! m+ o9 x/ f4 B! [ment of his penis and frequent erections. The child6 t/ z8 q1 S  M1 ?1 o; B- m
was the product of a full-term normal delivery, with
$ C# ^4 t  f6 r& va birth weight of 7 lb 14 oz, and birth length of
" J4 z$ k- V/ s7 j9 c1 L) D20 inches. He was breast-fed throughout the first year
& ^" q4 d" ~1 R" Rof life and was still receiving breast milk along with* E4 B7 g, I9 I+ l/ A- P
solid food. He had no hospitalizations or surgery,: o/ o# `7 V) f9 j
and his psychosocial and psychomotor development
! T) Z' h9 q) e/ a' }was age appropriate.
8 S& S0 i4 p' @The family history was remarkable for the father,
# f' L$ z, }: i2 Gwho was diagnosed with hypothyroidism at age 16,
4 u1 {. ]( x. B9 zwhich was treated with thyroxine. The father’s
3 R" W2 v5 u# V+ k" m" Q: kheight was 6 feet, and he went through a somewhat! X0 |* {; [+ P% j
early puberty and had stopped growing by age 14.
! N" D( Z: _6 A3 p$ l9 x% L) lThe father denied taking any other medication. The
/ {, z% P% M+ y& v2 S* [. Y8 Uchild’s mother was in good health. Her menarche' |* h: ?0 C; p7 f8 d8 x
was at 11 years of age, and her height was at 5 feet4 |* q) Q  f" Y6 ]( Y7 F7 P6 c8 T
5 inches. There was no other family history of pre-# o- f0 m& V" |- W7 Z6 h, ?( o
cocious sexual development in the first-degree rela-
8 M0 n9 `( D/ f% Z. B5 t2 g4 Vtives. There were no siblings., f+ r3 Y0 E7 F: b: ^0 ?' Q0 N% V
Physical Examination
, ~: K4 D' M5 x+ _0 }4 f2 [: g& `  lThe physical examination revealed a very active,
) X. T" p  D4 f" y9 u& {1 B' Hplayful, and healthy boy. The vital signs documented
+ c; O! ]1 L3 }3 F. `- F# w4 ^$ ra blood pressure of 85/50 mm Hg, his length was) @) C9 _  U# |# K, R
90 cm (>97th percentile), and his weight was 14.4 kg0 n0 @8 V: P6 w# r5 C
(also >97th percentile). The observed yearly growth+ Z( {+ g. D7 s) w/ i
velocity was 30 cm (12 inches). The examination of1 T4 U% D" j6 V) y
the neck revealed no thyroid enlargement./ |' v/ m5 S8 D2 @1 O: N
The genitourinary examination was remarkable for
1 ^' s' B+ n$ k% Q6 ^6 Uenlargement of the penis, with a stretched length of
. a% ], C( X! m1 p# ^; m( z8 cm and a width of 2 cm. The glans penis was very well% B# @8 J1 e/ ]
developed. The pubic hair was Tanner II, mostly around* S, b; I# s" F
540
5 `' {; R2 J/ S, r2 v. q& Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, t4 U. g/ J2 q7 F* {0 P5 s  ^
the base of the phallus and was dark and curled. The9 \6 x. Y6 i9 l' X' I7 N( _  J
testicular volume was prepubertal at 2 mL each.
0 \. d6 L0 r& AThe skin was moist and smooth and somewhat
, P& ?7 l& u. c+ hoily. No axillary hair was noted. There were no
: L5 Z; V! m' @9 ~( L! Fabnormal skin pigmentations or café-au-lait spots.3 k) R& K1 q  Q: @! N* V
Neurologic evaluation showed deep tendon reflex 2+
, \; z, ~- A) F" m, Dbilateral and symmetrical. There was no suggestion; O# _% f9 T& H' c5 ^  O! Y
of papilledema.
. q% w- ^5 |5 V; k; ~Laboratory Evaluation
+ v* q1 }7 b9 U$ j4 iThe bone age was consistent with 28 months by
$ i0 z- j/ m# S7 w% D9 cusing the standard of Greulich and Pyle at a chrono-( I; W- W6 P3 E! c9 M5 I* F, E, Q
logic age of 16 months (advanced).5 Chromosomal8 G, c# H, V3 e0 N* s! p' m
karyotype was 46XY. The thyroid function test, L; c7 `% h: z9 R0 `& j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-* s% I. p3 O2 J2 H5 r! \% x
lating hormone level was 1.3 µIU/mL (both normal).
( y: |7 U: Z8 d+ f/ Y, i& c( t* ]; eThe concentrations of serum electrolytes, blood
$ _9 {, x0 b" @- @  M% U6 \urea nitrogen, creatinine, and calcium all were- I, a, p) |" y
within normal range for his age. The concentration
: n) J* e$ B0 T7 _of serum 17-hydroxyprogesterone was 16 ng/dL, Y" }$ C: l; L7 @% P' L
(normal, 3 to 90 ng/dL), androstenedione was 207 d# c3 u$ j% t6 T- f" `2 a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  B% \. J- I$ z$ k& O' E, T2 S7 }terone was 38 ng/dL (normal, 50 to 760 ng/dL),% k6 u! r# v7 g5 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 a/ G% W2 C+ B: ^6 k8 I49ng/dL), 11-desoxycortisol (specific compound S), W0 s$ u/ r$ \% s9 f1 O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. E0 N9 S9 j# {. ?+ [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& d6 n8 @1 |/ A+ i, p- I/ f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 \5 I: x$ K1 Y! w% Gand β-human chorionic gonadotropin was less than
8 I7 e: S+ F! N5 mIU/mL (normal <5 mIU/mL). Serum follicular
  e5 x" [. k0 J, o6 Gstimulating hormone and leuteinizing hormone6 v: q1 A& b  G2 ]; ~" N6 [2 N. b. t
concentrations were less than 0.05 mIU/mL. H9 W% X9 [9 f8 L
(prepubertal).
) [4 Y; x- g& g# [The parents were notified about the laboratory
3 G3 U" k# f9 |" z5 d* t3 R) K3 Vresults and were informed that all of the tests were
/ r! I0 T7 O$ R. \, Fnormal except the testosterone level was high. The/ Y2 p+ P3 k' s) o# |
follow-up visit was arranged within a few weeks to( R- m' o$ ^: Z. \8 _
obtain testicular and abdominal sonograms; how-) \" d! e# e+ u& x& S" \  s7 d
ever, the family did not return for 4 months.  K1 u1 |5 O: I, x5 R; d
Physical examination at this time revealed that the8 R# ?; P; I* C. O  e# x& ?0 ]# o( Y
child had grown 2.5 cm in 4 months and had gained
7 {( ^1 b% v$ S  O2 kg of weight. Physical examination remained' s4 {( {2 Q* o& }9 `  l/ p
unchanged. Surprisingly, the pubic hair almost com-3 {! c1 c- Q# d" i" U
pletely disappeared except for a few vellous hairs at
7 T; f4 k9 e5 G3 }, @5 u6 Tthe base of the phallus. Testicular volume was still 2
% l& }) d7 _8 z: b  _mL, and the size of the penis remained unchanged.! m8 `% z* {: `, V7 @
The mother also said that the boy was no longer hav-
9 {8 c" j# j* F3 A; ?  A' x& O, u& Iing frequent erections.
7 Q4 @+ f$ u0 KBoth parents were again questioned about use of2 Q" S0 o( X9 X
any ointment/creams that they may have applied to
. N7 m- Q$ N1 s, F) wthe child’s skin. This time the father admitted the
9 r6 G$ g4 N9 Z; e2 R) M& q+ ITopical Testosterone Exposure / Bhowmick et al 541
" ^4 }$ q1 e5 n% b! Z  F' F7 O+ X6 Ouse of testosterone gel twice daily that he was apply-$ I; U, W1 a& J
ing over his own shoulders, chest, and back area for$ N- K$ A5 Q' c* q1 n
a year. The father also revealed he was embarrassed  w, F0 D, R0 a5 a7 ^/ ?4 }
to disclose that he was using a testosterone gel pre-
4 u0 L* ]! B& p2 U2 Zscribed by his family physician for decreased libido" c0 c) e9 N8 w
secondary to depression.
5 y( x  p- w/ W- V: ^% l4 bThe child slept in the same bed with parents.
' P! t: `; t/ [) a, S) K# c8 IThe father would hug the baby and hold him on his6 u+ E/ n. `; T0 N6 S6 l/ H2 h) d- z
chest for a considerable period of time, causing sig-6 i5 P7 {  |4 [, L) P, W
nificant bare skin contact between baby and father.
+ r! O: A( g/ x8 z" ~The father also admitted that after the phone call,
) M" V& Y. O) l% N/ Cwhen he learned the testosterone level in the baby
! e& P: [; X7 |# K7 K+ Z$ s+ owas high, he then read the product information* s2 m( O' Q5 q( v$ O
packet and concluded that it was most likely the rea-# O) w% ?) z7 F; ~. w' k8 J) [& z! P
son for the child’s virilization. At that time, they2 G5 d1 n1 A/ `" L" P+ E  R% j
decided to put the baby in a separate bed, and the
- x1 w) W7 T- Q% {& D- p  Rfather was not hugging him with bare skin and had( J$ g% v7 c8 V/ }$ c
been using protective clothing. A repeat testosterone5 P' E  m  ?; z0 l- y+ R$ u! Y1 z
test was ordered, but the family did not go to the
! h! m, f' {) claboratory to obtain the test.4 s  p( b6 ?% E% w, j
Discussion8 U9 E+ F- ?1 b/ M: p
Precocious puberty in boys is defined as secondary+ N  M/ b2 v' u- a* Z
sexual development before 9 years of age.1,4
" p' I# G2 D( e( tPrecocious puberty is termed as central (true) when
1 q  G  W2 ?% |( K$ Git is caused by the premature activation of hypo-6 `1 k$ i9 Z# @) ^1 H
thalamic pituitary gonadal axis. CPP is more com-; e9 |( {7 }6 l+ ~/ h
mon in girls than in boys.1,3 Most boys with CPP
4 T+ z# w/ R. V. K' qmay have a central nervous system lesion that is  W2 W' x3 ^3 p, C. U0 s; Y- M
responsible for the early activation of the hypothal-
: \6 Q9 Y# h0 p1 D/ [; Hamic pituitary gonadal axis.1-3 Thus, greater empha-, `$ z3 O" b7 i+ D8 O8 F2 q
sis has been given to neuroradiologic imaging in1 `3 O2 |4 f3 x9 q+ q
boys with precocious puberty. In addition to viril-* t. X& o5 A- k- d* j
ization, the clinical hallmark of CPP is the symmet-
! J% M& Y: P  Z7 Grical testicular growth secondary to stimulation by
# U& V& Q( \9 v# j6 ]1 zgonadotropins.1,3$ c' o5 {6 F- S+ t2 n5 X" T) k
Gonadotropin-independent peripheral preco-" B2 Q" ?9 _; n/ |4 Z' j# |3 |
cious puberty in boys also results from inappropriate
3 W. `9 @3 o3 M/ ]8 Candrogenic stimulation from either endogenous or% o) M; Y. j2 T0 T; p$ a
exogenous sources, nonpituitary gonadotropin stim-! q9 P. Q7 o0 V  j- r5 I  U" k9 h
ulation, and rare activating mutations.3 Virilizing8 E0 F" k' ^! T' I# J; F
congenital adrenal hyperplasia producing excessive
. M$ n- D4 `8 Tadrenal androgens is a common cause of precocious4 C5 o% u. j, \
puberty in boys.3,44 ?  j% A$ ]) V# T+ ?
The most common form of congenital adrenal
4 D4 G! D* m3 s  e& c1 x4 Xhyperplasia is the 21-hydroxylase enzyme deficiency.! u* Y! {" n: W' r
The 11-β hydroxylase deficiency may also result in
! P6 q& ~5 L+ T# `+ k0 T0 m2 yexcessive adrenal androgen production, and rarely,
1 J2 {( x5 y8 L8 `) zan adrenal tumor may also cause adrenal androgen1 I3 g* W4 F( b- `; R
excess.1,36 o( M% O+ V. m- n. j* w6 f' ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 R; o3 Y9 S  m6 y/ x5 ?
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ W) }; e$ E, W8 i" q2 ~A unique entity of male-limited gonadotropin-6 v' z1 a8 n' e# p7 n  `
independent precocious puberty, which is also known) A" t6 m% U0 Z- ]+ n5 P2 `
as testotoxicosis, may cause precocious puberty at a2 r! I+ R/ G6 |
very young age. The physical findings in these boys/ \+ @0 y' z! A8 _; G1 q# K
with this disorder are full pubertal development,* i& c0 V3 ~- a
including bilateral testicular growth, similar to boys/ T5 ]+ u! H) h' M: \7 R2 A
with CPP. The gonadotropin levels in this disorder- `% A* u+ c, X3 ?, k5 m4 I0 ?
are suppressed to prepubertal levels and do not show& t& P+ H. [& w# M( a( O
pubertal response of gonadotropin after gonadotropin-" E; ~3 {4 k$ u8 ]$ h/ K/ J, d
releasing hormone stimulation. This is a sex-linked
; Y5 L# N# h2 S2 D- r' Gautosomal dominant disorder that affects only
6 c$ e/ w" y7 q, u& |+ O: ?) Qmales; therefore, other male members of the family
( M1 G! V- m' K& t, B2 Nmay have similar precocious puberty.3
  N2 a4 ?7 ?& RIn our patient, physical examination was incon-
3 c3 V6 E  Q  j" m9 ~! Vsistent with true precocious puberty since his testi-, X( A; I/ o! [4 Z0 T% y
cles were prepubertal in size. However, testotoxicosis0 _, V( R- I- U+ P
was in the differential diagnosis because his father
( m3 G# ?" {: u; y6 S. i% Ustarted puberty somewhat early, and occasionally,
+ Y- f& W0 ~& g6 l- r0 atesticular enlargement is not that evident in the  N3 V. H4 S2 ^& a) V" ?- M- R
beginning of this process.1 In the absence of a neg-
0 H, U5 x9 w" w! v& N- ~+ Sative initial history of androgen exposure, our
) h/ f2 A9 e! X6 h' L8 U% Jbiggest concern was virilizing adrenal hyperplasia,
7 n$ g0 H/ [# d0 p3 e, e. X( @either 21-hydroxylase deficiency or 11-β hydroxylase( X& z% n: V8 g. ^# \
deficiency. Those diagnoses were excluded by find-
1 N+ s% T; I4 k: Oing the normal level of adrenal steroids.
6 \" M4 K7 H" `& h6 A, XThe diagnosis of exogenous androgens was strongly
- y( \4 x3 [  ~5 {" _suspected in a follow-up visit after 4 months because
- ^  {) Y% P/ o4 B# B8 Gthe physical examination revealed the complete disap-
$ e; _; E+ H, b+ H: \pearance of pubic hair, normal growth velocity, and
. J& g/ Z% [! d8 z$ Rdecreased erections. The father admitted using a testos-
( V2 B2 U# d2 L: b! R: n$ Oterone gel, which he concealed at first visit. He was
7 D# [( A( j( n- N7 d+ Tusing it rather frequently, twice a day. The Physicians’+ L, K- ]  y, |9 ^% B
Desk Reference, or package insert of this product, gel or
$ V& V& \4 D0 Pcream, cautions about dermal testosterone transfer to
8 Q3 T# @/ L/ p  Ounprotected females through direct skin exposure.
, q& R/ G! l8 \' [+ \7 _* Z% _- ZSerum testosterone level was found to be 2 times the
: b( ^( H7 ^& q  dbaseline value in those females who were exposed to
% m) e1 b9 b: S; Meven 15 minutes of direct skin contact with their male( u; P8 o$ |2 s: t
partners.6 However, when a shirt covered the applica-  P6 g* f' Q& s8 a( I
tion site, this testosterone transfer was prevented.
6 x, S6 o. {8 \& ~; iOur patient’s testosterone level was 60 ng/mL,- n6 o0 m7 F  D( y* v* V: M
which was clearly high. Some studies suggest that
, M1 C/ \( r2 _% Xdermal conversion of testosterone to dihydrotestos-
3 {* l& u4 B4 Q2 A5 hterone, which is a more potent metabolite, is more
8 H* z% [/ V0 [. y% |. Nactive in young children exposed to testosterone
) o- ?/ `  j, E) uexogenously7; however, we did not measure a dihy-, Z  G" l+ S& ?' s: k
drotestosterone level in our patient. In addition to
7 H7 N3 s2 v+ l# I* T2 g" Fvirilization, exposure to exogenous testosterone in
4 q) C! s" l6 N. qchildren results in an increase in growth velocity and
( }7 o( o- z9 ?$ Y$ n) y& {advanced bone age, as seen in our patient.+ |( h8 T; ^% F7 a
The long-term effect of androgen exposure during$ P4 m+ {3 H. K
early childhood on pubertal development and final
8 l" @: w' Y: H5 Wadult height are not fully known and always remain* W" k* O, E4 z" N
a concern. Children treated with short-term testos-& i! A8 E# L0 P; Y$ [9 P
terone injection or topical androgen may exhibit some
1 \# l) R; r- i" ^acceleration of the skeletal maturation; however, after# m0 I* E$ c2 Y7 M
cessation of treatment, the rate of bone maturation
# M6 p: j- }% V- wdecelerates and gradually returns to normal.8,9
# ?# k' q3 D& S; s4 `& |There are conflicting reports and controversy
, G- t# Y3 @* L# l. g7 C& Pover the effect of early androgen exposure on adult& C2 h) @& V* c! @
penile length.10,11 Some reports suggest subnormal
# V" G9 d) Y( V% Yadult penile length, apparently because of downreg-
4 p, g8 U9 b1 J+ Aulation of androgen receptor number.10,12 However,- U& }" b3 Y, z
Sutherland et al13 did not find a correlation between; ]+ Q( H; `2 j& [
childhood testosterone exposure and reduced adult
. ~2 B0 y; J9 Ppenile length in clinical studies.
2 M9 M" ?  H7 E/ D! o+ j# S' cNonetheless, we do not believe our patient is# h  d# i+ L/ P! d9 O
going to experience any of the untoward effects from% I5 h# K2 R9 F) n/ ^' E6 q  g
testosterone exposure as mentioned earlier because
* r/ Y4 X5 D0 r. J: f0 nthe exposure was not for a prolonged period of time., P* L+ u2 |0 t5 K! ?1 D. y
Although the bone age was advanced at the time of
6 [: v4 |" w; V/ n) Hdiagnosis, the child had a normal growth velocity at& v- ^4 W" t3 }& |# z# W/ h
the follow-up visit. It is hoped that his final adult- b  y- S9 g% A
height will not be affected.% H6 ^2 a4 G3 @% T, c4 p
Although rarely reported, the widespread avail-
+ G1 S9 }( Y7 @5 aability of androgen products in our society may
4 d+ ~1 E! |7 w2 l/ X! rindeed cause more virilization in male or female
  _* Q$ |6 E4 Z* h, K# A/ g+ R' Tchildren than one would realize. Exposure to andro-$ l# U4 {5 R' n5 g
gen products must be considered and specific ques-
1 c1 ]% y' I' n# i' w& ftioning about the use of a testosterone product or  `1 I* D' x5 x
gel should be asked of the family members during1 Y# ?  I6 t4 y4 u: c
the evaluation of any children who present with vir-; d) i5 U* ]- B5 ~$ q
ilization or peripheral precocious puberty. The diag-
$ b% V3 l$ z4 N# ^nosis can be established by just a few tests and by
8 k% B) L, ^" iappropriate history. The inability to obtain such a; Q) y$ i% J3 B
history, or failure to ask the specific questions, may3 ~1 S4 W; q: r- W& d6 B1 h$ C
result in extensive, unnecessary, and expensive
- e+ }: j1 Q& |' y& }8 Z' W8 o" yinvestigation. The primary care physician should be& z+ B$ C& D, g( N3 l! }6 r8 y
aware of this fact, because most of these children( w, l( y1 q) Z/ ]4 H
may initially present in their practice. The Physicians’8 l. v% F1 M; h
Desk Reference and package insert should also put a
$ c" n4 Q- |0 {. y/ X& t: `warning about the virilizing effect on a male or& S+ Y; y; {; b4 `
female child who might come in contact with some-3 u4 J) ~1 y( e
one using any of these products.: m, i% r& R9 M1 y
References
# e% |/ C' }( C3 Q1. Styne DM. The testes: disorder of sexual differentiation% E0 p& j+ `; [
and puberty in the male. In: Sperling MA, ed. Pediatric
7 D" B" G% \3 u8 N! ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& c& B7 M$ O0 X+ U
2002: 565-628.$ h. ~  j. {9 G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; }( [+ O. S4 h9 Q
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) T( B* J6 g3 j/ Q; P" V
Boy Induced by Indirect Topical# P: D1 [/ u* ?4 j2 j
Exposure to Testosterone" k( U0 ~- I* t! }# g$ k9 n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 \* o% ~& J# ~3 j: Y$ zand Kenneth R. Rettig, MD1
* c3 I0 I  P! _$ ]Clinical Pediatrics
2 Q( a6 O9 c+ QVolume 46 Number 6" [# G  C% i+ S* O2 V
July 2007 540-543) g8 [4 ~4 {6 k* ^2 G; H/ a; q
© 2007 Sage Publications
6 H! |8 A; T1 o, K+ a6 I0 }* n10.1177/0009922806296651
! l; G) S( u$ K: Nhttp://clp.sagepub.com
7 O% H; v& @0 p4 }5 q4 n) i8 B) chosted at
' v1 Y+ |" O7 |' X: k7 lhttp://online.sagepub.com5 B# s+ E, W% [- F- r
Precocious puberty in boys, central or peripheral,
) n' o8 Y! W+ Z; N* a% his a significant concern for physicians. Central0 T; \/ y" l7 V: s! T
precocious puberty (CPP), which is mediated0 A5 a+ b1 Z  T  w) j5 x# m( b
through the hypothalamic pituitary gonadal axis, has
  ~0 B3 t. ^3 c! e* N- Ba higher incidence of organic central nervous system
1 F, B' c. ~0 R& j- mlesions in boys.1,2 Virilization in boys, as manifested; Z+ U  D2 d% ^" a1 p
by enlargement of the penis, development of pubic) w4 _0 z; c+ X: N2 o. ^
hair, and facial acne without enlargement of testi-
9 K! p0 v% m" @( x  Xcles, suggests peripheral or pseudopuberty.1-3 We+ h/ `0 p- n) [2 g7 G4 G/ C$ i, r
report a 16-month-old boy who presented with the
; L* S( l, K; f) D$ _" senlargement of the phallus and pubic hair develop-7 x/ i  D: w' t4 B/ Y
ment without testicular enlargement, which was due1 y/ L" U# o" N( _, V0 t3 U3 M
to the unintentional exposure to androgen gel used by
0 M1 p6 q4 f% E3 vthe father. The family initially concealed this infor-/ D3 P! _! U( H' ^5 Z; \7 Z% y" |
mation, resulting in an extensive work-up for this
' P6 M5 y2 M# o6 \% k2 a' J- c1 pchild. Given the widespread and easy availability of5 H) J; r- J: a
testosterone gel and cream, we believe this is proba-! n7 i8 x, G' p* J; V  m* c( _% x
bly more common than the rare case report in the
3 g& n8 u/ W# k+ R& y; `' _literature.4
8 ^! x0 U2 y5 @1 e6 R  P) x# F8 SPatient Report
  v8 V% M9 `" Y* g9 [A 16-month-old white child was referred to the
6 K5 ^0 m" Z% [6 S( g  ~0 q/ kendocrine clinic by his pediatrician with the concern
5 a& D0 k8 n: V8 R, S; C5 Y  b! uof early sexual development. His mother noticed! e2 M) C1 ?2 R+ }* A, s; Z
light colored pubic hair development when he was
8 T1 R2 T' C/ j' _- KFrom the 1Division of Pediatric Endocrinology, 2University of
* \  j" `1 k2 u; u% m( u9 f0 tSouth Alabama Medical Center, Mobile, Alabama.
8 |% \! A  g7 I5 a5 e8 n- M, LAddress correspondence to: Samar K. Bhowmick, MD, FACE,
% K7 n8 g% w  B& ], sProfessor of Pediatrics, University of South Alabama, College of
5 x- p0 S( H7 S6 XMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ m' e2 Z, L3 x" ?4 x. j. I
e-mail: [email protected].
2 R3 Q% D8 W5 b7 i) ^2 Eabout 6 to 7 months old, which progressively became
/ `; y" H0 }( l/ w5 S9 z5 ndarker. She was also concerned about the enlarge-
* d( c1 s  q" P* J' jment of his penis and frequent erections. The child8 p" e7 ]/ B# p: e1 I4 Y
was the product of a full-term normal delivery, with  P  S4 k# k7 k/ r; }
a birth weight of 7 lb 14 oz, and birth length of
& _  ]: t+ Q) C, n4 ^. V2 `20 inches. He was breast-fed throughout the first year& |  G# S+ J5 h8 c8 r- L' r
of life and was still receiving breast milk along with2 N; i8 P2 i, }0 k0 R5 m& P% c
solid food. He had no hospitalizations or surgery,
! E2 X0 N8 h4 \8 w, [7 }and his psychosocial and psychomotor development
3 r; \8 U& Y; `was age appropriate.
% d9 N$ Y! d# f7 l6 a0 YThe family history was remarkable for the father,
% X! ~6 Z# I* q! X# i9 V. z1 cwho was diagnosed with hypothyroidism at age 16,
9 D2 Y4 W% o7 A& R0 i# U  `" Qwhich was treated with thyroxine. The father’s  `) t) {/ W4 d  P: X
height was 6 feet, and he went through a somewhat) V3 y' b; T/ ^% f! ~0 w; W
early puberty and had stopped growing by age 14.( J8 H5 `' A/ @; n; H8 `
The father denied taking any other medication. The5 s+ P% I" l% A9 Y2 L! \( @7 o
child’s mother was in good health. Her menarche) N5 S2 C1 e8 C/ V" k. i" `1 j
was at 11 years of age, and her height was at 5 feet
7 X# H" `' n2 Z5 inches. There was no other family history of pre-7 L: z. H  Z; C  F
cocious sexual development in the first-degree rela-
. e8 ?0 ~9 ?* H1 etives. There were no siblings.& y( V* [( T( E% O0 q) J3 e
Physical Examination
( f4 {; b: w9 C' W6 G9 DThe physical examination revealed a very active,9 g0 q0 p, U( Z: U
playful, and healthy boy. The vital signs documented; ]7 t( W  u) c
a blood pressure of 85/50 mm Hg, his length was( P. m( Q5 N% x: {
90 cm (>97th percentile), and his weight was 14.4 kg
) N7 F, N# k6 ~$ W(also >97th percentile). The observed yearly growth2 u" H6 u' ~$ [9 R4 p
velocity was 30 cm (12 inches). The examination of5 i* t( V5 M" C5 ]( Q
the neck revealed no thyroid enlargement.  V7 {) X5 B6 J( v7 y- U/ S; v
The genitourinary examination was remarkable for. }, M9 r% H  E+ [/ O$ V! ~& j
enlargement of the penis, with a stretched length of
& G, c/ N& E. }# E/ n8 cm and a width of 2 cm. The glans penis was very well
# W! g; f# ]( C+ O5 Gdeveloped. The pubic hair was Tanner II, mostly around8 v  f, O8 f6 ?5 h  F
5406 H. P, D2 d- n# G, O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, k- \+ U  X! |& p% G4 Zthe base of the phallus and was dark and curled. The) O, Z+ y2 j4 g
testicular volume was prepubertal at 2 mL each.
3 H( W6 Y! y. ]( @The skin was moist and smooth and somewhat* g/ z5 m; c  [( o
oily. No axillary hair was noted. There were no; X0 O/ j  a0 J& T- g) Y6 T
abnormal skin pigmentations or café-au-lait spots.' @% U. n% `- N$ a( C
Neurologic evaluation showed deep tendon reflex 2+
+ C# h4 x: K; s; Jbilateral and symmetrical. There was no suggestion
- ?9 r$ s* M. a7 g2 \of papilledema.
+ v0 u: o' {8 mLaboratory Evaluation# X% b; o/ Z/ y4 f& I/ g
The bone age was consistent with 28 months by; }2 B4 z; v) Y/ U; O' h: i
using the standard of Greulich and Pyle at a chrono-5 A+ s3 S* _' i3 V4 M5 s1 X- t
logic age of 16 months (advanced).5 Chromosomal
( ?6 N2 s* l: ~& kkaryotype was 46XY. The thyroid function test
# d2 H, V1 ?# p4 m9 }' E) u3 Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ H2 \0 _, k; o, d  I1 @3 klating hormone level was 1.3 µIU/mL (both normal).8 C, r# \& I: L5 i" I
The concentrations of serum electrolytes, blood: S" Z, r& j$ x. ^; ^4 q
urea nitrogen, creatinine, and calcium all were* z! o% E+ u$ V& I
within normal range for his age. The concentration! N! _5 [' D" z2 [
of serum 17-hydroxyprogesterone was 16 ng/dL
" q6 X, e6 r: W' j2 G. W9 h$ G5 m* N& h(normal, 3 to 90 ng/dL), androstenedione was 20. h; M, L6 U6 H% b, A- N9 R  F
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 N7 N7 ^5 x$ H* v% h2 |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( J3 x1 g* r; idesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 U% p' G4 S: z0 k1 f5 ?
49ng/dL), 11-desoxycortisol (specific compound S)
+ K! D4 `. A- b0 o0 ?' ?, Z& `was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 L3 v) `* L: ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ p2 a- l, @* D9 X6 Wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 s9 k0 I0 W" U' p( N
and β-human chorionic gonadotropin was less than
9 Q2 z$ w3 i6 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 X+ c' ?" Q+ Z* E; i$ r3 Fstimulating hormone and leuteinizing hormone
% E* Y1 T: u( y8 y3 @$ C5 i9 J8 Jconcentrations were less than 0.05 mIU/mL' [+ h; I4 s/ D7 }% J
(prepubertal).
( S8 n% |4 X( t5 ~+ `1 X# @: VThe parents were notified about the laboratory( t4 ~8 ^. u  H
results and were informed that all of the tests were, _) c! N) u$ R# F
normal except the testosterone level was high. The
; o) ]9 e  R% _) T9 v1 F! ]5 A  q5 Yfollow-up visit was arranged within a few weeks to
2 w8 a) \8 c9 O0 b: Lobtain testicular and abdominal sonograms; how-6 `; b' P2 \; O* P& q- S6 ~' T& [
ever, the family did not return for 4 months.
, d; h6 B( o1 M( ~& h) ?8 uPhysical examination at this time revealed that the( m5 }4 O- J- D/ {- z5 l1 `0 z
child had grown 2.5 cm in 4 months and had gained
8 `+ q1 p# q5 r: j1 p2 kg of weight. Physical examination remained
9 N1 r- y: x- H& @  y! L. iunchanged. Surprisingly, the pubic hair almost com-
; ^3 F9 c# h/ V% f0 ^pletely disappeared except for a few vellous hairs at
' c0 l0 n, r0 L8 T6 b+ v) sthe base of the phallus. Testicular volume was still 2
+ {3 c1 \) \7 D4 @" ]; u1 C; nmL, and the size of the penis remained unchanged.4 o/ d. h' e: G0 k: I% R  E
The mother also said that the boy was no longer hav-
; W/ l! T0 C, \3 D; s+ k8 M1 jing frequent erections.
3 H; Y! [1 Q, o( P2 c3 [Both parents were again questioned about use of- x: H& y% f9 u3 B  ]  m* w
any ointment/creams that they may have applied to
0 A  o% X  H- A) t& Ethe child’s skin. This time the father admitted the
5 ~" P; ^1 t$ ?- n" w$ H3 a2 gTopical Testosterone Exposure / Bhowmick et al 541
: x% G/ u! C( }; _. P+ Huse of testosterone gel twice daily that he was apply-  m  }7 }' e6 l- A+ `
ing over his own shoulders, chest, and back area for
1 k) S: a: ~( w2 ga year. The father also revealed he was embarrassed
- Y3 t7 s( t6 s5 Y& Zto disclose that he was using a testosterone gel pre-
; N9 F+ D, @* k3 E" `) b5 z" escribed by his family physician for decreased libido
  t, r& ^/ y& i1 Q0 D7 i4 j$ ]secondary to depression.) R  k* r* y* Y
The child slept in the same bed with parents.
" z) V& d# A' `& G" j0 E+ W% Z7 AThe father would hug the baby and hold him on his
$ L( |) B  e7 Tchest for a considerable period of time, causing sig-
2 L1 K  L$ f0 R$ z8 I/ Inificant bare skin contact between baby and father.
& ^0 x3 L& j/ X+ `The father also admitted that after the phone call,
' Y, Q% Q* R$ m: R6 s. K- b2 nwhen he learned the testosterone level in the baby* g" ~* d& z; n& w' F2 x$ V# `
was high, he then read the product information( R  M4 c/ `- G* c
packet and concluded that it was most likely the rea-3 M; @6 V6 ^! V) A/ n7 J  V  X
son for the child’s virilization. At that time, they7 q! R' z( O' l$ V, \9 G
decided to put the baby in a separate bed, and the4 q9 e0 S/ F2 {7 Q! N- f% s
father was not hugging him with bare skin and had
0 r' r) b  Y: \# r  F2 F. Dbeen using protective clothing. A repeat testosterone
" o+ g# q6 @+ }2 I/ g1 ktest was ordered, but the family did not go to the
( Y0 p0 {1 Q  h! J$ A( j7 D* ?( jlaboratory to obtain the test.8 T2 a* j3 A1 B" z' `5 S. Y& \
Discussion) O+ G& `. }" t
Precocious puberty in boys is defined as secondary, N# Q# A4 d  ?  h
sexual development before 9 years of age.1,4
# e* e* y5 Y6 ^- \1 mPrecocious puberty is termed as central (true) when
9 y  c4 E3 y& s7 Uit is caused by the premature activation of hypo-
8 w! b( E8 {% A8 R3 i8 Cthalamic pituitary gonadal axis. CPP is more com-
- p# \' R0 N6 B2 k+ Fmon in girls than in boys.1,3 Most boys with CPP; w7 m/ K& F. w3 e2 v
may have a central nervous system lesion that is8 u! _0 S# C( B- n% }
responsible for the early activation of the hypothal-
% u5 F# s; L: I2 V) U+ G& _6 Ramic pituitary gonadal axis.1-3 Thus, greater empha-$ U; h' R3 X! d0 x* B" d
sis has been given to neuroradiologic imaging in3 L8 \9 P. \; T+ T. l! q5 B6 v
boys with precocious puberty. In addition to viril-
: P6 P2 ^' t1 C2 Y3 w# h% F1 Oization, the clinical hallmark of CPP is the symmet-; k. p- K0 G. P: v9 A- p
rical testicular growth secondary to stimulation by
/ Y2 k; `" V7 Q" D3 k  Q/ ?3 pgonadotropins.1,3$ I7 a, W- a6 e! C# P3 n
Gonadotropin-independent peripheral preco-
! K) M7 ]# L& @) g$ D1 ycious puberty in boys also results from inappropriate4 M4 b; z' X- u; M1 m  T
androgenic stimulation from either endogenous or3 R0 M9 }/ @1 ?8 U
exogenous sources, nonpituitary gonadotropin stim-
1 R7 d' g+ o  g3 u; n& ?ulation, and rare activating mutations.3 Virilizing* y1 ?4 t; ^- W
congenital adrenal hyperplasia producing excessive$ n# s! _6 i8 J/ {, j- h
adrenal androgens is a common cause of precocious
' z& L! J# n' L9 {puberty in boys.3,4
: o2 ]* j  `9 n: e2 k8 D; x5 D! ~% dThe most common form of congenital adrenal
9 `! e* ~) R) P: S( vhyperplasia is the 21-hydroxylase enzyme deficiency.
+ [* I6 k/ I' d5 @' Y& b3 eThe 11-β hydroxylase deficiency may also result in
0 e  s9 Y2 p5 F+ ^excessive adrenal androgen production, and rarely,$ l& w" A/ ^; J8 l+ N
an adrenal tumor may also cause adrenal androgen
2 ~* u6 D, K2 ?4 p) i3 X, ^excess.1,3
1 ?' ?9 B/ g, E- G5 z3 A0 ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 x9 y# a2 O  a7 x6 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 s% f, I& H! G, u( D' N4 t! nA unique entity of male-limited gonadotropin-; ?8 ^- O: `2 V' W1 Z8 ^% V
independent precocious puberty, which is also known
  k- u) l( W; l( _/ |3 pas testotoxicosis, may cause precocious puberty at a
, q% n7 k+ X: B8 Nvery young age. The physical findings in these boys; G, R0 c- P& }+ J. S
with this disorder are full pubertal development,
% k6 B) t  L8 O% l8 I! G9 xincluding bilateral testicular growth, similar to boys
. J/ C' g" I( @( _( H4 L; Swith CPP. The gonadotropin levels in this disorder5 U8 T9 v1 q" h" G4 b5 h
are suppressed to prepubertal levels and do not show; p% |' {' r7 E4 Z) j% h1 n
pubertal response of gonadotropin after gonadotropin-/ J4 f2 _* E6 M" Z" r; ]6 s; k% t) C
releasing hormone stimulation. This is a sex-linked
+ Y$ ]$ U' `) ]3 Z9 A6 cautosomal dominant disorder that affects only, m8 z) {, N( a5 Z
males; therefore, other male members of the family
4 d6 K6 ?4 [0 K. L2 Q% Z; }may have similar precocious puberty.3
3 _: _, O7 k" ]. A! M% XIn our patient, physical examination was incon-
- f! p1 F  P' s/ D3 ^2 @* x! Zsistent with true precocious puberty since his testi-7 J0 D$ \5 W& [' S) z" b- `
cles were prepubertal in size. However, testotoxicosis
2 b( f7 Y8 k0 C6 P: R2 f1 f* @4 Bwas in the differential diagnosis because his father
; o% A/ H* Z, y+ P/ E* C: Istarted puberty somewhat early, and occasionally,/ a" x9 u) O0 T, X4 X
testicular enlargement is not that evident in the# D- P$ G$ O" @
beginning of this process.1 In the absence of a neg-
; i- Q" ]" A- I0 @2 j5 Aative initial history of androgen exposure, our
0 }9 Z! `9 v1 U9 S6 w3 m( ebiggest concern was virilizing adrenal hyperplasia,
0 v( r. h# _( A. Reither 21-hydroxylase deficiency or 11-β hydroxylase7 O* G5 _# _& Z6 y" D3 H& L. w
deficiency. Those diagnoses were excluded by find-
" v% S! @! }' `$ z3 h* t1 G/ Ving the normal level of adrenal steroids., ^) y5 c3 w0 T# a
The diagnosis of exogenous androgens was strongly
3 c9 D7 S. c# q; }& E& lsuspected in a follow-up visit after 4 months because5 D7 T" I* y1 [$ j
the physical examination revealed the complete disap-& \0 n% f* n$ e- l! G/ ?( ~  h
pearance of pubic hair, normal growth velocity, and
0 Q$ J2 d4 j8 H2 Q& l- g# vdecreased erections. The father admitted using a testos-
  {; d2 D/ G& k% V$ P# O( x# }$ ^/ eterone gel, which he concealed at first visit. He was
" G2 D  |+ X8 c) a/ V3 R% \4 qusing it rather frequently, twice a day. The Physicians’; P8 |( u0 |# F; T  O
Desk Reference, or package insert of this product, gel or3 |( [6 h$ E: z/ t% C
cream, cautions about dermal testosterone transfer to2 A6 ?& z1 t7 w8 T: l1 G) e7 i
unprotected females through direct skin exposure.
9 q( [2 h8 u$ w+ C; }# _3 FSerum testosterone level was found to be 2 times the
8 I0 `( a2 ^( }4 V$ G8 Bbaseline value in those females who were exposed to
& R8 x2 J! B6 }5 veven 15 minutes of direct skin contact with their male
, @! \0 q# g4 B  N3 F5 F5 spartners.6 However, when a shirt covered the applica-
! }3 |8 K+ R* ~; F. A; s/ a& ?: vtion site, this testosterone transfer was prevented.0 w* F7 k! @3 |& |/ @! _( ]6 I
Our patient’s testosterone level was 60 ng/mL,  {6 j7 `  @+ m$ n
which was clearly high. Some studies suggest that
& @" O" j- Y- H+ q7 Y# I, Gdermal conversion of testosterone to dihydrotestos-
4 r1 I3 Q7 ~8 k0 D" j( Pterone, which is a more potent metabolite, is more
- X- X( |- l9 |9 ^& Zactive in young children exposed to testosterone
! c& R% }% Y' z( I! {# pexogenously7; however, we did not measure a dihy-
: F8 A) j( [% X, I  J" ydrotestosterone level in our patient. In addition to
1 A4 M! m% `0 m' F9 f" Z# i( kvirilization, exposure to exogenous testosterone in
* D/ g/ j! A- C" M% ]children results in an increase in growth velocity and; {, p7 J/ d1 ^6 a  n: i& c
advanced bone age, as seen in our patient.
$ g# x' x2 ~! Q; F9 r# eThe long-term effect of androgen exposure during
" e7 a" [) [! u, e3 F8 Xearly childhood on pubertal development and final
# l5 ^( r7 `( r6 j( I7 E+ gadult height are not fully known and always remain8 R$ e" \9 Y3 L5 X4 y
a concern. Children treated with short-term testos-
3 F; ]+ Y& P* V: W+ d% X! uterone injection or topical androgen may exhibit some
; [# a/ f8 Z- `( @acceleration of the skeletal maturation; however, after" Z! p6 X( S9 B- d9 ~
cessation of treatment, the rate of bone maturation
8 q. {5 H1 Y% S2 idecelerates and gradually returns to normal.8,99 e1 {- H1 L. _
There are conflicting reports and controversy3 I5 u+ |0 E6 o5 b
over the effect of early androgen exposure on adult6 f0 ^' J6 q' n5 h
penile length.10,11 Some reports suggest subnormal
' ?/ w/ z9 E9 vadult penile length, apparently because of downreg-" Q; z  ~' u, \- V; N- }1 l' O: p
ulation of androgen receptor number.10,12 However,7 N( A! Q4 }9 P. V
Sutherland et al13 did not find a correlation between+ v+ j. }0 W. m/ Y, @* i$ b2 l
childhood testosterone exposure and reduced adult9 F6 o1 |3 u( t9 J
penile length in clinical studies.) d  b5 \" j! e  D
Nonetheless, we do not believe our patient is7 [% V0 V/ A5 C, v- L2 P
going to experience any of the untoward effects from
  ]8 Z% D! R0 [' B: O7 b& z# H& Jtestosterone exposure as mentioned earlier because6 ~9 X* {- s1 D5 g
the exposure was not for a prolonged period of time.
- ~0 v: u) ^5 ^4 `" z( c# RAlthough the bone age was advanced at the time of
6 L7 }1 W9 ~. S/ U* W% _, Fdiagnosis, the child had a normal growth velocity at
, M+ N. P" h  t2 c% p; qthe follow-up visit. It is hoped that his final adult7 k8 L; y* Q* Q' W# m! O% W/ x
height will not be affected.
  H" L* I% L* S5 p# aAlthough rarely reported, the widespread avail-
$ @# Q1 c' C# j5 {" |7 M3 xability of androgen products in our society may# R2 F- A$ @- |! O) h0 E5 L+ d7 d! d
indeed cause more virilization in male or female
, ^  g/ w. O8 V7 z; a: X2 ~children than one would realize. Exposure to andro-0 q8 ~: K) |6 X; X% \8 g
gen products must be considered and specific ques-3 z* Y  i( i; ~; U* p. A
tioning about the use of a testosterone product or* c- d. z6 ]7 T. @
gel should be asked of the family members during
' k6 O; E2 E/ F7 V) Cthe evaluation of any children who present with vir-. b9 J0 M5 T. v" V( @4 p
ilization or peripheral precocious puberty. The diag-
$ L7 z5 U0 z: i9 f! x+ @1 _* Pnosis can be established by just a few tests and by
% v) G$ o: y# G3 ~0 ^. {( i' U* l1 Uappropriate history. The inability to obtain such a
$ X2 U7 s% R* A3 ]  Lhistory, or failure to ask the specific questions, may/ C6 D& n: a. B, @8 T
result in extensive, unnecessary, and expensive1 `3 {+ ]' N, c- {1 }, h" K
investigation. The primary care physician should be
7 g& g; V( M# {. [6 taware of this fact, because most of these children
) e  `3 O! ]4 ~# p$ I+ }may initially present in their practice. The Physicians’
. C1 Q; A! i( }1 b0 o! bDesk Reference and package insert should also put a) Y" |8 ]7 @" P
warning about the virilizing effect on a male or) q2 m  f9 V9 ?* [- ?$ \& l
female child who might come in contact with some-* n, \1 A; y, f! D1 ?
one using any of these products.
! ^; B+ z, H8 y9 x) z0 jReferences
+ x0 E2 w2 B; }1. Styne DM. The testes: disorder of sexual differentiation' W, r( _. [" g/ U
and puberty in the male. In: Sperling MA, ed. Pediatric
8 s, s3 h- z9 v, h* B# ], M2 kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 v& b2 I' w! J" j/ Q6 M2002: 565-628.& @% e3 H- v, J: ?; W- c
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 W3 G4 x/ I# z5 v+ U5 J8 jpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
- a5 U8 L- Z- Y/ k( O9 B
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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