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Sexual Precocity in a 16-Month-Old2 k/ M3 u; t9 j3 R" c2 a
Boy Induced by Indirect Topical5 C7 a$ t) d. b/ ~
Exposure to Testosterone0 H, }/ x# x6 c- u+ S4 u6 i. L" l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( {! i" q! I) w+ q2 u! b5 H1 k
and Kenneth R. Rettig, MD1% r  o7 b  C  {7 p/ ]% Q* T
Clinical Pediatrics
% [  q8 Z5 L! `5 b! p* O- W( c8 p; RVolume 46 Number 64 z' S5 K+ F8 v) W; U8 Z
July 2007 540-543
# m' _+ _1 C# _; n* T0 n& e+ n% B© 2007 Sage Publications
0 Y8 X, w+ m9 g1 c: |! y7 E10.1177/0009922806296651; B( `0 w$ ^* w8 h
http://clp.sagepub.com* S5 X. y/ X( C6 [% Z8 N# k
hosted at6 {' n1 u- W7 c% T
http://online.sagepub.com
7 L0 F" i3 h& Q+ |0 }( {8 ~Precocious puberty in boys, central or peripheral,
2 e4 @- r1 F9 q4 |4 lis a significant concern for physicians. Central
/ c8 H' e0 U; _7 I- L( l3 y: eprecocious puberty (CPP), which is mediated
; ]0 H' F# u) t. xthrough the hypothalamic pituitary gonadal axis, has& `, ]. U0 |5 P# P. {+ q
a higher incidence of organic central nervous system) n9 {3 l9 O) ~# `0 r; [
lesions in boys.1,2 Virilization in boys, as manifested
3 A2 N" d5 _  C2 |0 o  C7 vby enlargement of the penis, development of pubic: ~/ y8 u7 Z4 x2 }; ?! B
hair, and facial acne without enlargement of testi-
9 l# n- }2 D3 i3 e0 w+ xcles, suggests peripheral or pseudopuberty.1-3 We" a9 c& s7 p, w
report a 16-month-old boy who presented with the
( I3 k0 [5 |& {% jenlargement of the phallus and pubic hair develop-
) }6 c0 H: ~$ u' T8 m$ }" Y5 M8 [ment without testicular enlargement, which was due  Z1 e. X* E) l- f& R8 p  {6 J
to the unintentional exposure to androgen gel used by6 Q# S; A1 b- i4 i  n
the father. The family initially concealed this infor-
) s: P' h6 }4 v- a& @6 }6 B* @mation, resulting in an extensive work-up for this
+ C( z! \6 j- [5 T4 v, ~8 u: w9 Bchild. Given the widespread and easy availability of
+ F+ D8 ?" c& z7 F; xtestosterone gel and cream, we believe this is proba-9 |9 ?; M- ~" k( p, r9 _
bly more common than the rare case report in the
7 s8 S" O0 R$ a' j8 ]literature.4, @/ E; L3 c5 ?' }
Patient Report
" ]3 T4 o! \+ pA 16-month-old white child was referred to the
5 b2 d- \! q: Qendocrine clinic by his pediatrician with the concern
5 J4 B" a3 T4 k  j5 G* Pof early sexual development. His mother noticed( x/ y6 j0 Z- p6 f  U1 `, @
light colored pubic hair development when he was
  M. J: B# \5 I& z4 c% \9 p: `/ qFrom the 1Division of Pediatric Endocrinology, 2University of7 }# i* o2 s& [' h7 S, Z
South Alabama Medical Center, Mobile, Alabama.
0 }( h2 [0 i9 A$ U3 `Address correspondence to: Samar K. Bhowmick, MD, FACE,
! [( q" O# U8 w/ g* vProfessor of Pediatrics, University of South Alabama, College of( M3 F$ v. [9 j- T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# z0 i" o3 @8 c- n) re-mail: [email protected].
0 H7 `) l5 ]) W. y# s; eabout 6 to 7 months old, which progressively became4 ?) S6 ^7 j: k5 C
darker. She was also concerned about the enlarge-8 Y9 N4 Y0 G  \; B
ment of his penis and frequent erections. The child$ h5 P: {6 W+ E9 v% o
was the product of a full-term normal delivery, with& N3 T9 D2 [8 y3 W1 @2 ~& F
a birth weight of 7 lb 14 oz, and birth length of2 J$ V; P, R. a8 a( J& b& {
20 inches. He was breast-fed throughout the first year
  i9 G: ^' w# _- z: ]5 qof life and was still receiving breast milk along with" Z5 N! a3 S/ W, ]! [  U0 q# x
solid food. He had no hospitalizations or surgery,
6 d6 a2 f: H4 v4 [2 kand his psychosocial and psychomotor development3 [0 I" G$ d1 _- t; R" O3 y4 ^5 k# ~
was age appropriate.
! L; E  r: G) x& I* ?' u: LThe family history was remarkable for the father,5 A0 b2 R& s6 s4 M: k0 o: ^& Z
who was diagnosed with hypothyroidism at age 16,- p' o; S$ c) L  Y) h) @& a
which was treated with thyroxine. The father’s. V1 L9 s. }  @; T
height was 6 feet, and he went through a somewhat0 K% h1 {7 ]2 _- V' U, o( l
early puberty and had stopped growing by age 14.
, E* T7 q' [3 cThe father denied taking any other medication. The
  ?! v+ Y5 L& w( Achild’s mother was in good health. Her menarche( y  ^, q  W$ s+ U: H
was at 11 years of age, and her height was at 5 feet
5 d7 S- `2 [: w0 B5 M) r0 ^- P5 inches. There was no other family history of pre-" ~; w- l) s( B  G' S/ _
cocious sexual development in the first-degree rela-
8 V* V, U- I( {+ M2 n- S- F3 F3 Utives. There were no siblings.
* h0 `' H8 ]5 g- N# j% `( h3 F  OPhysical Examination
  ~$ m% E2 D& B. QThe physical examination revealed a very active,
7 ]$ }: ], |( e  O% E0 }playful, and healthy boy. The vital signs documented8 q% f$ B6 F2 R, Y8 [
a blood pressure of 85/50 mm Hg, his length was
% D. g* M8 `4 A% Z1 z& d90 cm (>97th percentile), and his weight was 14.4 kg
% c4 V5 z9 x2 y+ V% _$ [(also >97th percentile). The observed yearly growth
, k& u+ C) F$ z9 _2 svelocity was 30 cm (12 inches). The examination of
3 \8 H5 Y+ X0 s! _9 xthe neck revealed no thyroid enlargement.9 K9 k7 U. x4 h
The genitourinary examination was remarkable for4 z2 {1 z2 _8 f. ~5 L! u6 n
enlargement of the penis, with a stretched length of7 o" w" e( p+ \; j
8 cm and a width of 2 cm. The glans penis was very well
: \% F5 L% r  W6 p- c: t- U6 ]developed. The pubic hair was Tanner II, mostly around
9 j4 Y8 c8 J/ p: [) A4 U540/ m1 B& ~( W+ z5 A. v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 u* c: Q; F* E8 `5 h. v2 [
the base of the phallus and was dark and curled. The
1 a. |, @: y/ z& }0 stesticular volume was prepubertal at 2 mL each.
; h- W- }* z1 u# g1 k9 \8 LThe skin was moist and smooth and somewhat
4 e0 X$ O2 D( U2 H4 G) ^% ?/ ~; F& Joily. No axillary hair was noted. There were no
" f6 e1 w% I6 K) Mabnormal skin pigmentations or café-au-lait spots.
# t2 S. T6 A6 h  Q% b) f) jNeurologic evaluation showed deep tendon reflex 2+
1 }1 c& X! t# l7 k! y. c3 Vbilateral and symmetrical. There was no suggestion4 }" Y7 q( Y( |" h. G& K9 y: o0 i% K: }# V
of papilledema.
  n7 c4 q0 ]  Y# }% a1 W3 e* p( }Laboratory Evaluation4 I+ B5 J' D+ O7 J, ], B, Y
The bone age was consistent with 28 months by4 r6 E* M0 H7 H$ R8 F
using the standard of Greulich and Pyle at a chrono-) s) _. n$ |5 |: M7 Z' J
logic age of 16 months (advanced).5 Chromosomal3 L$ V  E" o3 k4 c% |
karyotype was 46XY. The thyroid function test1 n5 Y# e: L" U( X$ T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 F% ~; K1 P$ r" _+ T5 Jlating hormone level was 1.3 µIU/mL (both normal).$ ]% \+ s7 ^4 h1 ^6 @
The concentrations of serum electrolytes, blood! ?; s4 N/ w8 \) C& m! U: Q& y: s, Y
urea nitrogen, creatinine, and calcium all were1 [5 n" u$ }8 ?* S, K! Q
within normal range for his age. The concentration1 }1 ^1 L& y* U) [; ?5 L
of serum 17-hydroxyprogesterone was 16 ng/dL1 Z5 M$ {) B3 r. s
(normal, 3 to 90 ng/dL), androstenedione was 20
  V+ K8 m6 K3 n( c2 t. W4 t0 vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 C. y" S3 v, ]: j3 t4 eterone was 38 ng/dL (normal, 50 to 760 ng/dL),: _* D) ~3 u/ b1 h
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! }0 u/ Z1 b0 x1 v: Z8 R9 h$ D49ng/dL), 11-desoxycortisol (specific compound S)6 \+ T4 \6 r, ]( t" ?0 D( u) W
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 @$ V  S. |# q4 K) ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. e, e2 z" ]( f4 e9 Q' I6 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),# H& _7 y8 ?5 N. B; G& d
and β-human chorionic gonadotropin was less than
: d3 x" q. W- \2 }5 R! D! f+ h# y5 mIU/mL (normal <5 mIU/mL). Serum follicular& H6 i, `# n. f+ f/ W3 i6 Y% e
stimulating hormone and leuteinizing hormone
9 A  Y( I& ?; U9 |' Y4 n+ qconcentrations were less than 0.05 mIU/mL" m( D9 m/ }9 H% d# Q
(prepubertal).
, A- n% p! S. q( J: T* t! qThe parents were notified about the laboratory! ?# n  U7 R6 d1 w/ P% C/ r
results and were informed that all of the tests were6 ~2 ?7 |+ k  c
normal except the testosterone level was high. The
- w3 z, V% f4 j) a# V1 V) Y; }9 lfollow-up visit was arranged within a few weeks to
# v) C! P% u/ ^7 wobtain testicular and abdominal sonograms; how-  o5 Q4 `9 |6 {: v, ]8 e
ever, the family did not return for 4 months.
4 L" _+ `1 I1 A3 V, z% mPhysical examination at this time revealed that the
3 h; d' i) z* x. t# k* |/ z. Fchild had grown 2.5 cm in 4 months and had gained1 v  @" Q& A  M6 P) u$ W& r
2 kg of weight. Physical examination remained/ a# Y3 F. y$ f6 M5 _4 {
unchanged. Surprisingly, the pubic hair almost com-5 K; G, @# E: V8 q
pletely disappeared except for a few vellous hairs at
9 |9 b! y% O: [( y5 B, s% jthe base of the phallus. Testicular volume was still 2
9 g, o$ X- u. U1 n# X) `mL, and the size of the penis remained unchanged., r  D* u+ T8 \5 P
The mother also said that the boy was no longer hav-/ K% H& a# Y  j* d: X6 t, L
ing frequent erections.
, X# \: f4 `# c6 @! [* i# O: KBoth parents were again questioned about use of
/ `  T/ S  O! c  S% L' ^any ointment/creams that they may have applied to
% N( m2 d; \6 p; Bthe child’s skin. This time the father admitted the
, i5 N1 O7 c! ]% r0 LTopical Testosterone Exposure / Bhowmick et al 541, {# h8 N. L$ j) t* Q$ l- n
use of testosterone gel twice daily that he was apply-" K! f" F" E4 f7 K2 o* u% m  i
ing over his own shoulders, chest, and back area for
& S$ B  k% F; `2 oa year. The father also revealed he was embarrassed, a8 w0 O2 l8 R3 |* v
to disclose that he was using a testosterone gel pre-
# g- r& I) Y' A( m, A+ Escribed by his family physician for decreased libido
. ]. [3 j4 M7 h3 |0 v8 Ysecondary to depression.2 Z- C9 w7 H$ y; j, `% F; ?
The child slept in the same bed with parents.
& G) c7 c, ~2 X- m! \The father would hug the baby and hold him on his
) |0 T" x# ~0 q$ |+ f0 p7 achest for a considerable period of time, causing sig-7 a1 w0 H' c3 D6 ]& E5 W8 ~0 b
nificant bare skin contact between baby and father.
% [8 p- \$ a& e/ U/ @! _% OThe father also admitted that after the phone call,
5 e; f; _1 v1 [' C& U2 P2 _7 ^when he learned the testosterone level in the baby( P; i5 @' v5 h. p# e
was high, he then read the product information! x1 Z, r1 \  f, f) m' N
packet and concluded that it was most likely the rea-
' L/ G( ^  P. `8 T/ bson for the child’s virilization. At that time, they
* W9 k2 q; r' ~3 d8 K& adecided to put the baby in a separate bed, and the
+ t+ `, w/ W8 S; k! T6 A- Tfather was not hugging him with bare skin and had
% {( h9 z* ~2 hbeen using protective clothing. A repeat testosterone! A( \! y4 e& @6 {
test was ordered, but the family did not go to the
9 v; f3 @  Z' C9 M0 s; k% E/ Elaboratory to obtain the test.0 ^1 b, e9 S1 u' D% ?: P; K8 D
Discussion  i$ `( V' b; |" Y" z/ f
Precocious puberty in boys is defined as secondary) h! O% J4 E0 Y  a% O
sexual development before 9 years of age.1,4
! K/ Z: x' J6 {7 }8 ~7 rPrecocious puberty is termed as central (true) when
' b- d" J; i+ e0 Z4 Tit is caused by the premature activation of hypo-
4 y% S) z) j  C3 ]: _thalamic pituitary gonadal axis. CPP is more com-
7 _* D. `; q+ m: v, j; _* r7 Vmon in girls than in boys.1,3 Most boys with CPP
0 Y6 v/ ?3 P9 B, \+ B; G( a' H7 Omay have a central nervous system lesion that is+ o5 t5 c/ E9 H8 h$ `' J! f
responsible for the early activation of the hypothal-
8 j3 q  n* K* ]2 L4 |& k- |( ~* samic pituitary gonadal axis.1-3 Thus, greater empha-2 [8 T) |7 Z* ]# j
sis has been given to neuroradiologic imaging in
1 {2 T# C  U8 g7 z* @boys with precocious puberty. In addition to viril-
- K% t# v9 j: h# j8 N- I. _ization, the clinical hallmark of CPP is the symmet-) {9 X# I* t* R. c: \0 s3 l
rical testicular growth secondary to stimulation by
, {7 a7 n8 ?! ~4 L- |gonadotropins.1,3. l3 E6 ?1 ~; [% b* j) e! \
Gonadotropin-independent peripheral preco-9 q) u8 k. u4 U% x
cious puberty in boys also results from inappropriate
+ a3 I% Z  |/ Q6 F' N/ `androgenic stimulation from either endogenous or$ B# b( D2 B1 s* H
exogenous sources, nonpituitary gonadotropin stim-" ?+ H# K9 {4 H3 Q
ulation, and rare activating mutations.3 Virilizing" P, z. f+ ^. m3 N; W5 [
congenital adrenal hyperplasia producing excessive
0 J# R) k' e$ y8 p1 h' M/ W8 Padrenal androgens is a common cause of precocious9 X) d2 z3 H& f" \/ u  i/ E9 [
puberty in boys.3,4
3 k7 i$ E" F# R% L+ J$ ?9 JThe most common form of congenital adrenal
: A+ m1 S1 o4 S6 A; Shyperplasia is the 21-hydroxylase enzyme deficiency.
+ |7 ]$ T. e# H! e) ]! p/ kThe 11-β hydroxylase deficiency may also result in# E* W! A  \7 b& V
excessive adrenal androgen production, and rarely,
3 [7 t4 X' N+ f5 ~! P2 c) p( {" ran adrenal tumor may also cause adrenal androgen
- T- r8 ~$ q, u/ zexcess.1,3/ N7 K( D6 e5 L) Q" H* e- m5 e: T" Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ c# f, D" M! J. r7 _5 b
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' U* h$ v& L* i4 f% m
A unique entity of male-limited gonadotropin-
0 U) y7 x2 Z  n+ t& {) m# Windependent precocious puberty, which is also known  F6 o% Y" [! ^  }
as testotoxicosis, may cause precocious puberty at a
! x% {2 K5 I  p# U! {$ }very young age. The physical findings in these boys
" }. x  m! Z! t, C) n  G$ |with this disorder are full pubertal development,
8 h' a. C. S. [" b7 k3 k1 Aincluding bilateral testicular growth, similar to boys
, r- W/ ^4 V7 ^$ C/ B3 }& _% b( gwith CPP. The gonadotropin levels in this disorder
; ~+ j, d7 x# ]+ k+ `. D: R, r3 pare suppressed to prepubertal levels and do not show
  m! J6 K" u6 B, F& M& `pubertal response of gonadotropin after gonadotropin-& U& D8 L: j/ e0 j
releasing hormone stimulation. This is a sex-linked0 }; A/ ]. z! _
autosomal dominant disorder that affects only! u, v. E' g* e  O* X
males; therefore, other male members of the family( Q3 w" y2 p3 x$ x7 B& G3 X, S( _
may have similar precocious puberty.37 {9 x0 S  k, |( `( i7 r1 G0 y
In our patient, physical examination was incon-, D7 ^& Y, y7 b- K' s
sistent with true precocious puberty since his testi-
5 K- q/ c! l9 E) h, |cles were prepubertal in size. However, testotoxicosis. z7 z! R8 T# @- c  `
was in the differential diagnosis because his father
# f  d$ |! T/ I# O: Y8 istarted puberty somewhat early, and occasionally,
& Y6 C' ]) ?) `$ }/ @testicular enlargement is not that evident in the# a$ l: u) {5 ]7 a0 i1 P
beginning of this process.1 In the absence of a neg-$ H5 F$ P. X6 p7 a" }+ A
ative initial history of androgen exposure, our' R3 X* C$ `$ V
biggest concern was virilizing adrenal hyperplasia,- M: ], @0 K* x" M3 l2 p
either 21-hydroxylase deficiency or 11-β hydroxylase9 r- U: B' ^& E" M
deficiency. Those diagnoses were excluded by find-
6 n1 }" q! L, Y+ }ing the normal level of adrenal steroids.0 y- |- {( ^" [, k  Y) s
The diagnosis of exogenous androgens was strongly; G& b: x3 O3 Z8 [
suspected in a follow-up visit after 4 months because
5 w, _* E$ y, gthe physical examination revealed the complete disap-
' i# u4 P! @+ G9 U$ h' H0 x# c. X% mpearance of pubic hair, normal growth velocity, and! \, a8 o5 z) U  p' S" t3 h
decreased erections. The father admitted using a testos-
" _7 M* ^" t8 ]- u3 S% _; {# Pterone gel, which he concealed at first visit. He was; @9 n2 i- H- o1 Q$ b  D0 @8 ?3 G& ^
using it rather frequently, twice a day. The Physicians’0 C9 k2 s8 A6 u4 m; O
Desk Reference, or package insert of this product, gel or# i0 q4 F# _6 v# ]9 T4 c
cream, cautions about dermal testosterone transfer to
$ h- A2 @3 i  K  F! S3 aunprotected females through direct skin exposure.( X) t# y. T9 ?0 J
Serum testosterone level was found to be 2 times the
' @, {6 K$ K) \5 s. Jbaseline value in those females who were exposed to
4 X2 A8 e1 [6 R4 t( `  jeven 15 minutes of direct skin contact with their male7 E; v6 [3 U3 u/ j, p- b
partners.6 However, when a shirt covered the applica-
+ D, W  z) a8 r. K, R8 ^tion site, this testosterone transfer was prevented.4 z( ~" y) a4 I& H
Our patient’s testosterone level was 60 ng/mL,
/ R9 H. q# j5 c( [which was clearly high. Some studies suggest that, k% f) i2 ]( Z2 ^2 x  |8 g
dermal conversion of testosterone to dihydrotestos-: r' |  t: _  X, t# c
terone, which is a more potent metabolite, is more6 Z5 G: g; ^5 N: t
active in young children exposed to testosterone
4 \2 H' n! T) kexogenously7; however, we did not measure a dihy-0 |) o1 w& T5 W- m* w
drotestosterone level in our patient. In addition to, @- @5 Q5 D0 \& V
virilization, exposure to exogenous testosterone in
, b* C9 Q+ c9 ^; S3 ~' b  R5 @9 xchildren results in an increase in growth velocity and
& i) u: u2 @# q' X3 B7 l0 ~advanced bone age, as seen in our patient.' `) `1 M& p: p; M* E
The long-term effect of androgen exposure during+ V/ i: @8 e. a7 k6 i
early childhood on pubertal development and final/ e9 g6 o0 P' P$ @" i& d7 \" ^, K
adult height are not fully known and always remain
  }1 O/ _+ M' ^: ]0 Xa concern. Children treated with short-term testos-
7 b! \6 ~' n! m% C- O2 K* \terone injection or topical androgen may exhibit some4 Q3 d3 Y$ B4 l5 d: }3 V6 n
acceleration of the skeletal maturation; however, after
% R2 y; @; j% e6 zcessation of treatment, the rate of bone maturation: }+ f2 n3 R5 F9 s6 l: c) Y5 y
decelerates and gradually returns to normal.8,9, |2 v) l" r2 U; [  I& @
There are conflicting reports and controversy+ \8 m; X9 c4 @  R4 X8 s6 a
over the effect of early androgen exposure on adult7 [3 }4 Z3 ]. ^+ J# p: o
penile length.10,11 Some reports suggest subnormal' n' _. K2 p  n0 T& O; P' X1 r
adult penile length, apparently because of downreg-
+ z* j% ?$ _4 _: A$ U7 S$ p  V2 Yulation of androgen receptor number.10,12 However,
* R% Q  [$ K2 `. a5 bSutherland et al13 did not find a correlation between
( K; U2 B$ ~; n. h. n; Y+ ]* ~childhood testosterone exposure and reduced adult8 }+ [# t9 C8 r. t  P
penile length in clinical studies.4 f: Z( H- i' E1 {: j+ j
Nonetheless, we do not believe our patient is
6 |% ?7 N- y2 n6 e# }going to experience any of the untoward effects from1 ^( }0 G3 J  @5 u
testosterone exposure as mentioned earlier because7 g5 r. P+ H, Q, N* E# z: ]
the exposure was not for a prolonged period of time.* F2 o# ]; T) p; p4 l: b
Although the bone age was advanced at the time of/ f; p$ M; q: V  \
diagnosis, the child had a normal growth velocity at& _. M1 O$ W1 I- u4 @
the follow-up visit. It is hoped that his final adult
4 l* r4 b$ q- g6 z8 C- A- Iheight will not be affected./ o# _3 y7 U' p; b) g
Although rarely reported, the widespread avail-# o; j" d) ~( V" V
ability of androgen products in our society may
" \% t; G' t- w. i4 W, K4 z; Jindeed cause more virilization in male or female5 k- j- B: {; ~' f) ?* @+ b- P
children than one would realize. Exposure to andro-, I1 v7 S' ?6 \
gen products must be considered and specific ques-1 ?) Y+ c2 R3 n' q. K8 K
tioning about the use of a testosterone product or
; c; K6 D5 f2 ]7 x% agel should be asked of the family members during
/ m$ D1 a0 J4 B$ i2 Pthe evaluation of any children who present with vir-
( ~: [3 B% s2 N1 z4 X% q1 kilization or peripheral precocious puberty. The diag-4 ~2 m8 q! l+ A+ v
nosis can be established by just a few tests and by
  H+ h1 P) j% ?  e$ u1 _appropriate history. The inability to obtain such a
& A7 Z" ]3 g3 B% f1 Vhistory, or failure to ask the specific questions, may
1 x" \7 d8 ?6 r' mresult in extensive, unnecessary, and expensive
% q6 }: X9 w4 \( n; Iinvestigation. The primary care physician should be$ z9 b  ]$ P) ~
aware of this fact, because most of these children
8 [8 Y" q2 N7 @9 W8 a& Q; S( bmay initially present in their practice. The Physicians’
9 v2 W- T$ p; }Desk Reference and package insert should also put a
5 q9 N9 y' E5 F5 Y4 T) A  Q  h' hwarning about the virilizing effect on a male or
. g7 |/ X- v0 P6 X. D" cfemale child who might come in contact with some-
8 U( B; M: ~0 u5 w# Q! none using any of these products.# F( x; q) b: E9 @3 e  [
References
1 y. s1 t7 [0 N' Y9 o1 d/ X" }; J1. Styne DM. The testes: disorder of sexual differentiation, o$ I- t9 A9 f* s& ^
and puberty in the male. In: Sperling MA, ed. Pediatric
0 F: I! W5 p% E* u5 u2 ~* gEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- I% I3 m9 f7 P  B# j
2002: 565-628.( D- d: A$ d2 n+ O$ i! i5 `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: D0 Q6 }( P+ j; Z& W0 U. _
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old3 P+ r9 k- z8 C- U0 f$ m% a# I9 K
Boy Induced by Indirect Topical
6 ^0 B* c  K1 `' o! rExposure to Testosterone
5 V4 s+ O( _" O9 iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: f/ `0 R' @3 i; rand Kenneth R. Rettig, MD1! Y9 W4 ]" U4 Q+ p5 D4 t
Clinical Pediatrics
  [; o1 Z: ]* k$ eVolume 46 Number 6( U6 Q& v% q1 x+ C( h( ^1 R
July 2007 540-5430 ?* V5 e: e, W3 F6 ~; C4 ]
© 2007 Sage Publications+ B5 F4 h# V* p
10.1177/0009922806296651: H# F  ^$ O7 F1 s  k
http://clp.sagepub.com
3 O' E0 `. A# i: j9 Z# @4 p  S- N1 mhosted at
$ g, _* r/ y/ I/ B$ Thttp://online.sagepub.com# ?8 u& h' K# u) V/ k' M* N# P
Precocious puberty in boys, central or peripheral,
# S# T( B/ S$ I) S7 V. F" kis a significant concern for physicians. Central! W) k$ J7 Z  q2 q' \8 j
precocious puberty (CPP), which is mediated; ?6 K2 T6 c4 `* d* M* k5 X( W' v
through the hypothalamic pituitary gonadal axis, has: T1 {2 D0 M' _! U  R
a higher incidence of organic central nervous system
/ Z: r+ |) ^2 c* O' n: t, K& ?3 V" slesions in boys.1,2 Virilization in boys, as manifested' ^6 f% T6 Z: D
by enlargement of the penis, development of pubic
. z2 E2 O2 {; _( S* hhair, and facial acne without enlargement of testi-  J; t% O; r# F0 w" R% T  `6 ]
cles, suggests peripheral or pseudopuberty.1-3 We. [5 l3 c! N# W! D
report a 16-month-old boy who presented with the9 O& u7 t; m: O( e
enlargement of the phallus and pubic hair develop-4 y9 ^. R( G9 _1 ^! D: J* w6 c
ment without testicular enlargement, which was due' d7 j9 M8 U$ Q7 z
to the unintentional exposure to androgen gel used by
. o% y, ^" I% d4 ?the father. The family initially concealed this infor-
5 N' L$ y0 h& F4 ]( O9 pmation, resulting in an extensive work-up for this
0 a6 n' ?3 k5 G8 b5 A# M+ Gchild. Given the widespread and easy availability of
. ]$ d8 x& Q( C. L' Utestosterone gel and cream, we believe this is proba-
8 {& Z! W/ h# tbly more common than the rare case report in the( ~& U; ^$ Z4 G; H' t9 V( {! b
literature.4
" z* b& E  r% fPatient Report
/ ?& P4 v! R; c8 i" e% v- CA 16-month-old white child was referred to the8 y6 `% O% J0 }
endocrine clinic by his pediatrician with the concern* D; V0 }2 R3 L0 _7 F, s
of early sexual development. His mother noticed) ?' p! C+ ^; q, e" a) Y
light colored pubic hair development when he was3 N+ ?" z: s0 U, R. Y
From the 1Division of Pediatric Endocrinology, 2University of0 T3 f: a7 N) Y
South Alabama Medical Center, Mobile, Alabama.
0 H5 @# a& X% r9 D' {6 n$ {Address correspondence to: Samar K. Bhowmick, MD, FACE,# h+ L' M( G9 [5 r
Professor of Pediatrics, University of South Alabama, College of
0 N8 k3 i" k3 H9 J2 k8 \Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' a; r! l& [0 n2 R% J
e-mail: [email protected].) V& C7 i. `+ N
about 6 to 7 months old, which progressively became! M' ?& [7 R+ E% W
darker. She was also concerned about the enlarge-
9 Z/ \% y' V+ i! E2 e' z% Y/ qment of his penis and frequent erections. The child) p  s9 y0 M4 ^9 c: |
was the product of a full-term normal delivery, with
5 m% L3 @/ z: Y2 |7 \- Y  a( g9 Ua birth weight of 7 lb 14 oz, and birth length of
4 P) m, S3 e+ ?: w1 v# q20 inches. He was breast-fed throughout the first year) J" _  p# V- c0 \- ~6 |  h  U
of life and was still receiving breast milk along with2 _, Y- ^6 V- t0 c4 Q+ c# \- g7 d6 \
solid food. He had no hospitalizations or surgery," C. P7 c: F& D4 Z& ]
and his psychosocial and psychomotor development8 i: ]+ \1 c, i! _8 U. l/ |! P
was age appropriate.$ t: s/ J+ x7 `# w0 N
The family history was remarkable for the father,
3 |! i# l$ d  E4 ]  j# @" gwho was diagnosed with hypothyroidism at age 16,
7 H( V; m8 F; s. i' V" ewhich was treated with thyroxine. The father’s
% E6 E6 M: l7 M/ mheight was 6 feet, and he went through a somewhat
' B5 P5 K; ]$ _4 s# ~0 J8 bearly puberty and had stopped growing by age 14.
3 f3 ?4 }0 D/ P# L; @2 jThe father denied taking any other medication. The; X+ _8 n. p( I  b1 `
child’s mother was in good health. Her menarche
$ n4 a; ?7 ^; W1 }2 A" uwas at 11 years of age, and her height was at 5 feet6 Z* C: P/ @# b9 p0 k* I8 b( l* B) U
5 inches. There was no other family history of pre-
& E( U! P* B" n* q, x( Z# W: {: Icocious sexual development in the first-degree rela-3 _. h( q, ]9 y5 v# l% a
tives. There were no siblings.
$ U1 F: F& n+ A: V" t; p4 q7 D1 TPhysical Examination2 ~0 B0 w5 V8 m' S- g8 p" o
The physical examination revealed a very active,
. P4 b- f% u- A! Nplayful, and healthy boy. The vital signs documented
0 t3 ^4 H8 b7 L7 V$ V! aa blood pressure of 85/50 mm Hg, his length was
0 v& G; z8 Z" S+ o  K$ C90 cm (>97th percentile), and his weight was 14.4 kg7 E, Q2 Y4 ^! j! I
(also >97th percentile). The observed yearly growth8 q. r6 Y8 I& T; C
velocity was 30 cm (12 inches). The examination of
- p; E9 Y' ^. ~) Kthe neck revealed no thyroid enlargement.: E" [3 _& z' k$ t6 x: G8 ?. Z
The genitourinary examination was remarkable for- m% C: C  X6 }
enlargement of the penis, with a stretched length of) ]2 C8 _3 s$ i" C
8 cm and a width of 2 cm. The glans penis was very well( S! I; e) ^" c: H0 K4 y1 S
developed. The pubic hair was Tanner II, mostly around/ D" {, z4 a( p- b- r! d
5402 g' x# k9 }6 O" j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
/ D# v0 v/ P, r% _* ~the base of the phallus and was dark and curled. The7 X; {$ g+ x0 ], I4 V0 T
testicular volume was prepubertal at 2 mL each.
, \6 }3 m: e) p% w) O1 C1 ?1 D1 LThe skin was moist and smooth and somewhat
- a: L2 R% G# N" X4 s7 M7 qoily. No axillary hair was noted. There were no3 H7 u* I7 D. @% o; A2 L
abnormal skin pigmentations or café-au-lait spots.% V$ [! q" r/ d. k$ S
Neurologic evaluation showed deep tendon reflex 2+- H- H7 ^' k& z4 V6 o; z8 f) S: }
bilateral and symmetrical. There was no suggestion
: T6 Y! z1 V+ b( Yof papilledema.  F( t# R( u4 \( z$ k
Laboratory Evaluation0 E- P* \0 y. Z) P
The bone age was consistent with 28 months by& u3 H6 O$ E& o& y# E! ^
using the standard of Greulich and Pyle at a chrono-! ^- e% R3 Z7 p4 m7 N7 c
logic age of 16 months (advanced).5 Chromosomal
# j  f& e! `' ^9 O7 D2 \0 Ukaryotype was 46XY. The thyroid function test5 g! u  i4 d, Y1 B: v/ F. b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 }0 v: P+ j5 [& T$ z% G& X
lating hormone level was 1.3 µIU/mL (both normal).. l+ j! h6 ?. |/ b7 d" v/ B/ e
The concentrations of serum electrolytes, blood
4 \: ?3 F0 X# ~' t  Z5 {! U( Q! ?3 Hurea nitrogen, creatinine, and calcium all were* ?* S' Y) |6 G) |* g/ p5 D
within normal range for his age. The concentration# ^9 ~$ y5 j' o9 i9 R2 S/ m
of serum 17-hydroxyprogesterone was 16 ng/dL6 W; ]. Z5 f/ F% X8 O' t5 ~; |* |
(normal, 3 to 90 ng/dL), androstenedione was 20+ Q- o$ a( E+ B( h* X$ V
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 T, u' ^* o* P
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 u9 F9 X( L$ N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 G: v' @( O+ ]7 _3 X/ H49ng/dL), 11-desoxycortisol (specific compound S)% a4 j' z# I7 T* f( b
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: R2 A: n& h! _) |. O( ~6 U3 g  q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ U8 D4 k7 i; a4 V
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ S, F7 E1 k4 o+ R) p% ^, k# x9 Vand β-human chorionic gonadotropin was less than
$ u0 l6 `% l5 l5 H, j% H5 V! ?% Y5 mIU/mL (normal <5 mIU/mL). Serum follicular! p% L2 H, s: P# i5 g( j/ s
stimulating hormone and leuteinizing hormone
) M. I. Y9 L5 r4 zconcentrations were less than 0.05 mIU/mL8 G& }2 X, M/ R1 m# O6 _. [
(prepubertal).
, a1 W' t1 \: X1 MThe parents were notified about the laboratory
! u8 q& z, G% A$ zresults and were informed that all of the tests were
1 f* u) }* a' ?+ G; M" V  R7 T9 ]6 e* |normal except the testosterone level was high. The
; ?) l2 k& J: s. P% ^/ ?% C- Rfollow-up visit was arranged within a few weeks to
: ]/ b" [; h4 o% Xobtain testicular and abdominal sonograms; how-
* g7 J4 u7 M8 _2 [# g) _: xever, the family did not return for 4 months.$ l  b# Q  H1 p$ T, N
Physical examination at this time revealed that the$ M2 ]; D* ^: Z
child had grown 2.5 cm in 4 months and had gained
& p) O( w3 I; ]3 H2 kg of weight. Physical examination remained6 a: w; p2 t5 x" ^' b. u
unchanged. Surprisingly, the pubic hair almost com-# o1 z* ]# Z8 B7 n, x; p
pletely disappeared except for a few vellous hairs at
4 c2 w3 i( B% x0 D& g& k, zthe base of the phallus. Testicular volume was still 2  P/ y; Y1 {. ]/ L2 @
mL, and the size of the penis remained unchanged.
9 ?- Z# T9 @6 `5 \  W. H5 i$ pThe mother also said that the boy was no longer hav-
' `( e4 ]2 J8 v6 a8 Ning frequent erections.
0 v- h, o2 a. c- BBoth parents were again questioned about use of
' E* r4 a% a5 e' ?3 Hany ointment/creams that they may have applied to
3 P8 `8 h; O* o9 V& d8 d3 x  {the child’s skin. This time the father admitted the: [% C+ [: G; u: J
Topical Testosterone Exposure / Bhowmick et al 541( Y  ?3 j/ W' o" w( n: M
use of testosterone gel twice daily that he was apply-
. d. ^$ }, y" Q/ @0 H8 Z4 a) Eing over his own shoulders, chest, and back area for
. k" P) U! `7 a: ba year. The father also revealed he was embarrassed
7 l) u% V- k9 k" A+ T* P( Rto disclose that he was using a testosterone gel pre-7 `% ^% A% m% O0 r8 r
scribed by his family physician for decreased libido
* r: `/ m9 y6 K) ]0 R% \" csecondary to depression.
& Y% Y3 ]6 N2 o7 d( ~8 JThe child slept in the same bed with parents., o) ^. ~; r9 y. W
The father would hug the baby and hold him on his
4 C: H" l5 z: P3 T# f( Gchest for a considerable period of time, causing sig-& \. K5 D, n4 h. y
nificant bare skin contact between baby and father.
; g5 Q8 x) p: s8 zThe father also admitted that after the phone call,
& f2 E7 h4 }, l+ B3 kwhen he learned the testosterone level in the baby2 W; d, Z% ?, ^  w  D- Z
was high, he then read the product information
3 C5 ^5 f& N1 q" b$ @  Qpacket and concluded that it was most likely the rea-
( g& {* Z7 m) r5 h3 Kson for the child’s virilization. At that time, they. C' y' k% r, z
decided to put the baby in a separate bed, and the, E+ [3 H0 l5 Y, S
father was not hugging him with bare skin and had: ?( h& Z  ^* d6 O% X$ x2 r
been using protective clothing. A repeat testosterone
( w2 [( q, g8 M$ `0 R4 Utest was ordered, but the family did not go to the
% J: C5 q0 C7 v5 c* w" ]* Claboratory to obtain the test.( B+ ~& U8 d3 D; ~8 x& K+ f
Discussion7 {# g! n! L- a" e
Precocious puberty in boys is defined as secondary: A6 o/ S0 p$ w$ P
sexual development before 9 years of age.1,4
# ~1 Y' L- R' f* `& k0 pPrecocious puberty is termed as central (true) when
" ?9 X+ O! y" ?* h& Tit is caused by the premature activation of hypo-. x# _# B; b( ~
thalamic pituitary gonadal axis. CPP is more com-
3 _) E/ a. w* u/ _mon in girls than in boys.1,3 Most boys with CPP
. G  K0 U( w2 U$ Omay have a central nervous system lesion that is# n- C3 I' a( |. P
responsible for the early activation of the hypothal-) ~2 ^7 I6 @4 i6 U( y9 z
amic pituitary gonadal axis.1-3 Thus, greater empha-0 u* t  P* u" w* K
sis has been given to neuroradiologic imaging in& Z- M8 ^5 I! t$ S
boys with precocious puberty. In addition to viril-
% g2 |& j8 I' ^7 t' p5 U) p4 N0 I, Zization, the clinical hallmark of CPP is the symmet-3 O% ~4 \. y, B) w
rical testicular growth secondary to stimulation by' m/ X5 G5 X" Q, w: H6 D3 S
gonadotropins.1,3' ?9 n2 K- p( m
Gonadotropin-independent peripheral preco-; Y* n0 m/ x9 A( f# e
cious puberty in boys also results from inappropriate
$ U' y) q, L2 n' p" pandrogenic stimulation from either endogenous or
' {1 c! t2 ^1 O3 w* u, lexogenous sources, nonpituitary gonadotropin stim-! U/ |, M" V' z4 B+ b9 {. u
ulation, and rare activating mutations.3 Virilizing( @; a7 M* ^5 Y: `7 ]
congenital adrenal hyperplasia producing excessive* S" B% O8 Q3 O5 T
adrenal androgens is a common cause of precocious( s- v. c. i( t- s3 F) I
puberty in boys.3,4
$ Z# j( b3 f# V, I8 S  qThe most common form of congenital adrenal& B' C6 P' H) [
hyperplasia is the 21-hydroxylase enzyme deficiency.2 w$ N, i5 h/ b; C* ?3 H
The 11-β hydroxylase deficiency may also result in- N  L' m4 F: {: D
excessive adrenal androgen production, and rarely,/ j; k" D( l& \* q, y! e. F
an adrenal tumor may also cause adrenal androgen0 x8 a& T+ b2 B9 y6 h+ I5 r" f
excess.1,3
9 B9 P) Y6 T  u. Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# u4 B6 a  W* N1 i5 I1 m. P542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 s( T& B7 B  a: p& \
A unique entity of male-limited gonadotropin-
2 B5 s* n$ ~$ u6 |independent precocious puberty, which is also known) @0 H7 C2 `7 C, T7 \
as testotoxicosis, may cause precocious puberty at a6 z$ d$ A% \9 ?% |0 b9 A
very young age. The physical findings in these boys
* S2 [# c5 F: [9 i! `1 y4 X( qwith this disorder are full pubertal development,
% \& B9 w) X6 oincluding bilateral testicular growth, similar to boys9 Y% B6 ~& E! o1 W, t* y1 S. n
with CPP. The gonadotropin levels in this disorder: l1 r; P$ i; _: o2 g
are suppressed to prepubertal levels and do not show
# j3 [" a9 u# ]3 Y8 Wpubertal response of gonadotropin after gonadotropin-
& X, }2 E" ?. q  Z6 m7 J, p/ nreleasing hormone stimulation. This is a sex-linked
# j5 x3 p4 Z" u5 [( R) Iautosomal dominant disorder that affects only
2 G' C# Z. G: p4 }4 c, ymales; therefore, other male members of the family
' k+ S8 L9 l- s8 M- Z+ @1 o, {5 Ymay have similar precocious puberty.31 A- z) y  k, r6 p+ p7 L
In our patient, physical examination was incon-4 z0 u9 C: x/ ?5 b! Y1 f
sistent with true precocious puberty since his testi-8 n9 h* g! |+ M* t+ I+ I
cles were prepubertal in size. However, testotoxicosis
0 g6 L6 q6 d1 lwas in the differential diagnosis because his father1 z! _7 P# \, `( C* u' E6 f3 ~! ?
started puberty somewhat early, and occasionally,
) t0 I% [/ \0 ]; Dtesticular enlargement is not that evident in the5 k, c  D; n# e* Z0 ]
beginning of this process.1 In the absence of a neg-5 t( @' K1 ~$ V  N  k
ative initial history of androgen exposure, our# l" q2 P: t, T/ f/ I4 z
biggest concern was virilizing adrenal hyperplasia,* Q# R& |3 E9 x, F$ f  _2 \5 r, y
either 21-hydroxylase deficiency or 11-β hydroxylase
7 s, P+ n: I. c- L" |deficiency. Those diagnoses were excluded by find-5 S7 m  c, Q1 @! Z; ^" Q5 E) E
ing the normal level of adrenal steroids.# L5 J" @" V5 B' D2 g: l2 ]
The diagnosis of exogenous androgens was strongly
4 t2 r* e2 N* G2 O5 v  E5 vsuspected in a follow-up visit after 4 months because
9 w6 F7 j+ [4 h2 Athe physical examination revealed the complete disap-
0 H# p% [& q/ _- x% ?pearance of pubic hair, normal growth velocity, and1 j- M2 ~% T5 ^, ]4 B
decreased erections. The father admitted using a testos-
" I. C7 ~9 C" ?: j+ O* f6 Rterone gel, which he concealed at first visit. He was* d. p' z. I* J" R' Y' ]. V. M
using it rather frequently, twice a day. The Physicians’
# [3 E; n0 p) I6 H9 UDesk Reference, or package insert of this product, gel or
* F; h" e9 Q7 X1 J: m) r9 Jcream, cautions about dermal testosterone transfer to
( k0 Q) p6 M; |/ t: Y/ F. D$ E: Bunprotected females through direct skin exposure.: f; r2 U+ r. v
Serum testosterone level was found to be 2 times the
' D1 W. M! I7 S5 b2 d% |baseline value in those females who were exposed to
& b: o' J% C) r# D9 [. Keven 15 minutes of direct skin contact with their male
+ R# I" ^& U5 c5 ~partners.6 However, when a shirt covered the applica-, T+ L% }* @2 U
tion site, this testosterone transfer was prevented.
' W4 H5 v5 R* ~# |9 O0 c1 EOur patient’s testosterone level was 60 ng/mL,
( E) x. e8 i4 x/ ywhich was clearly high. Some studies suggest that
0 G) V' u/ l# X( b. Kdermal conversion of testosterone to dihydrotestos-1 v( [9 [1 s( X9 V
terone, which is a more potent metabolite, is more; R) t) e( r& |& s
active in young children exposed to testosterone
5 x# n' |' i7 X, ]1 _4 x9 \) A1 oexogenously7; however, we did not measure a dihy-
9 W5 ^2 }6 g! p1 H& \$ \drotestosterone level in our patient. In addition to! h, m1 ]: l8 U
virilization, exposure to exogenous testosterone in1 B  b' E1 y2 x: {9 ]/ K
children results in an increase in growth velocity and
. j) R3 q$ o# C  Q! l* fadvanced bone age, as seen in our patient.
, v, H- W8 B! d" ~The long-term effect of androgen exposure during) ]% l( y* a2 N6 \9 \  S
early childhood on pubertal development and final
1 y" r$ x0 h+ w4 oadult height are not fully known and always remain
  }8 M4 g0 \, ?3 z+ m1 w" ?a concern. Children treated with short-term testos-
5 A7 x) {4 d1 V1 tterone injection or topical androgen may exhibit some9 w- B' E  h3 T$ x
acceleration of the skeletal maturation; however, after* _5 \6 [, y+ ]$ e$ Z  f+ W0 c" \
cessation of treatment, the rate of bone maturation2 U4 r" a$ t. W
decelerates and gradually returns to normal.8,9
. i/ `" R0 c  o1 z* S% g5 y& C4 TThere are conflicting reports and controversy
" Y3 C3 M+ F8 R. o3 \* {9 A3 Fover the effect of early androgen exposure on adult. h" u2 c" y9 n/ K: k+ p& {
penile length.10,11 Some reports suggest subnormal. |# i& [/ K2 S0 S" G
adult penile length, apparently because of downreg-* n3 x: c- S- p3 j
ulation of androgen receptor number.10,12 However,1 a+ {+ o: W0 s8 D* R
Sutherland et al13 did not find a correlation between
: d/ J( |' Y" s1 J7 C2 cchildhood testosterone exposure and reduced adult
6 F4 e8 [" ]% q- N  ipenile length in clinical studies.
7 m. O) D1 ^4 q" U& TNonetheless, we do not believe our patient is/ \- v* Y) @! e* X5 h) s
going to experience any of the untoward effects from
3 a! }# y4 C; |testosterone exposure as mentioned earlier because
* f  K. V7 t# D% ^the exposure was not for a prolonged period of time.9 m" u7 Q8 [# W8 `7 J, E
Although the bone age was advanced at the time of8 `7 Q" a5 [" |" v5 N2 y3 ]
diagnosis, the child had a normal growth velocity at3 b0 |, C. x4 K) r  G# |! i: O+ _
the follow-up visit. It is hoped that his final adult
/ ^% h/ ~; |2 y( ~height will not be affected.
4 `2 K; M" A/ EAlthough rarely reported, the widespread avail-1 J0 x/ d! h( @4 D0 v/ c& F
ability of androgen products in our society may8 L9 ]# K4 `: }! h: U
indeed cause more virilization in male or female
7 h+ b* \& i0 q! f! Uchildren than one would realize. Exposure to andro-
2 H) E3 h2 M+ Q0 G; g0 ^% ?gen products must be considered and specific ques-
- E0 F9 ?" J0 g6 q9 S# r5 \& I0 [tioning about the use of a testosterone product or, K( o8 F3 C8 Z3 f
gel should be asked of the family members during
% I9 B6 ~3 S0 X0 [8 Athe evaluation of any children who present with vir-( h9 D  F/ L" k; e5 A- I
ilization or peripheral precocious puberty. The diag-
- S4 p# x0 k" M! H& v4 M- onosis can be established by just a few tests and by
5 ]0 H( M( L7 W1 ~; z! B* @' Eappropriate history. The inability to obtain such a  Y, \; I1 {+ n* q
history, or failure to ask the specific questions, may; S7 z% c. x4 u' k( J6 Y3 ^! w
result in extensive, unnecessary, and expensive9 D6 X3 v7 @* z. Y. B" ~2 r& G
investigation. The primary care physician should be
6 T, E3 E) R$ a2 A, t- Jaware of this fact, because most of these children
" M" F- G" w8 c  q/ ?+ s8 D6 Amay initially present in their practice. The Physicians’
7 m' J% A2 u4 G) t) h+ UDesk Reference and package insert should also put a8 Y$ q) V# [( K$ e1 j/ _
warning about the virilizing effect on a male or& x' T4 i) {$ z7 K1 ^$ s8 v/ `% B
female child who might come in contact with some-
0 g( W8 c% ?2 ~1 K" none using any of these products.0 Z5 B4 _- \% h  q  f
References  D4 f2 ^( b$ i" A$ s1 L  [! j
1. Styne DM. The testes: disorder of sexual differentiation9 K/ a; J, U- o: o/ V1 M
and puberty in the male. In: Sperling MA, ed. Pediatric
# C) ?) H: T: U9 AEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) P  u% W* s( l& q2002: 565-628.8 j) Y# U6 l* ]6 \- d/ T- \5 j) N
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ ^  L0 V7 _3 |
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

7 ^7 N# }* p1 I* F0 ~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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