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Sexual Precocity in a 16-Month-Old- [6 R. Y3 ^5 h
Boy Induced by Indirect Topical
% `+ O- G/ j/ J: ?Exposure to Testosterone
2 \& f* m3 r8 X6 PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 w0 D; t! ], U7 x; z
and Kenneth R. Rettig, MD1; o; k, D% _* m/ t; T6 K; T
Clinical Pediatrics6 v. I' o( I4 ^" z7 T/ R5 x4 B+ H. P
Volume 46 Number 6
5 }1 q6 }- e" ?9 H" `+ pJuly 2007 540-543( L- h* @$ w" L5 H  V
© 2007 Sage Publications
8 [) w3 W( r6 ]. a10.1177/0009922806296651. S0 U4 d' q1 x! u5 Q2 \
http://clp.sagepub.com
1 s3 \6 v" z9 I; Y2 \+ |7 f. Qhosted at
& ~: L# h) `$ x/ m4 zhttp://online.sagepub.com) K% d! L! l- u9 G+ S
Precocious puberty in boys, central or peripheral,
; G% _; O! K6 T- D- pis a significant concern for physicians. Central
" ~5 M6 ]" q( D+ bprecocious puberty (CPP), which is mediated. n& F( I% G* R# Q; V
through the hypothalamic pituitary gonadal axis, has9 t, ^6 A: T; }
a higher incidence of organic central nervous system7 h, i+ R# J3 F8 l
lesions in boys.1,2 Virilization in boys, as manifested, j+ c; ?7 x/ _
by enlargement of the penis, development of pubic3 q$ S7 n3 Q, A2 ]1 X' {
hair, and facial acne without enlargement of testi-! J1 {) G" ~+ H6 ^8 w
cles, suggests peripheral or pseudopuberty.1-3 We8 D4 H2 P+ Y) {6 q* ]1 G
report a 16-month-old boy who presented with the
) }  U% W' N% n1 [0 `enlargement of the phallus and pubic hair develop-0 f$ n2 e. W" ?5 {3 q: w
ment without testicular enlargement, which was due
9 ?  Z4 }3 j  V4 r! Mto the unintentional exposure to androgen gel used by! H' U; n3 G) \" `# b/ A  U  ~( q
the father. The family initially concealed this infor-
% |9 Z% P; @5 J5 ?3 S* B, k5 vmation, resulting in an extensive work-up for this5 O1 v5 I  y: R! N7 p8 T# q
child. Given the widespread and easy availability of) N( V( d$ J7 H3 R; a& i
testosterone gel and cream, we believe this is proba-
0 w% o: T6 H. g0 ~# P6 ?: ^. D% J2 rbly more common than the rare case report in the5 i" ~$ @3 \/ I" j! W  K& E* |0 M
literature.40 Z4 k' c$ i9 G. ~" F% g. H
Patient Report( ]5 m7 U; |/ h9 e: B
A 16-month-old white child was referred to the
+ I0 w0 M, u1 L& Dendocrine clinic by his pediatrician with the concern
: ~8 t+ K* v. B8 d( ?of early sexual development. His mother noticed( G- x% F0 R6 U
light colored pubic hair development when he was( V* ~4 y4 ~+ b4 z
From the 1Division of Pediatric Endocrinology, 2University of8 Y7 _, b  K- r- F) `, \5 c' H$ \
South Alabama Medical Center, Mobile, Alabama.
, G1 `! C2 u+ Z" @) x7 VAddress correspondence to: Samar K. Bhowmick, MD, FACE,0 q1 ?; S7 z1 ~) W1 X
Professor of Pediatrics, University of South Alabama, College of
4 r) S9 t2 M7 D' bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 O9 d: }$ T% e4 h7 o9 e9 Ae-mail: [email protected].
0 [! ^" R: n; v& O& \# ^about 6 to 7 months old, which progressively became
5 X0 y* `" _( ^$ P9 f% Pdarker. She was also concerned about the enlarge-
' j. n: z" {3 p' A) Mment of his penis and frequent erections. The child2 `- S! C/ z4 q1 i
was the product of a full-term normal delivery, with/ T- V8 ^7 I1 G  j3 |0 s1 u& o
a birth weight of 7 lb 14 oz, and birth length of" C0 X$ T% P0 `/ c3 l
20 inches. He was breast-fed throughout the first year
% e2 N: G" B! V, P! `+ Aof life and was still receiving breast milk along with
) v- _; B- R. `5 p9 G2 X0 i# Q7 _solid food. He had no hospitalizations or surgery,1 u/ D$ h; S" ~! |# H1 e' n# ?
and his psychosocial and psychomotor development. H, a6 l# _3 E5 c1 }: L; C& Z
was age appropriate.5 P: q6 [0 O7 o/ @4 R3 ^
The family history was remarkable for the father,$ E" z; Z% [" Q- Q
who was diagnosed with hypothyroidism at age 16,  }9 q6 s$ r) [, [6 z8 J' a
which was treated with thyroxine. The father’s% `% b( |5 k+ G) W! F
height was 6 feet, and he went through a somewhat3 p3 {7 H: b( i; |5 \5 s, P) H" y
early puberty and had stopped growing by age 14." s  E  ]0 S  _
The father denied taking any other medication. The
/ O1 Z, t! A/ d9 v7 n% o/ G6 e  nchild’s mother was in good health. Her menarche
& W) v9 Q8 @/ y2 A# d9 ywas at 11 years of age, and her height was at 5 feet
4 n* M. b! q" m0 r2 h5 inches. There was no other family history of pre-9 G) V0 J5 L. J2 K& ?6 H' g
cocious sexual development in the first-degree rela-' j+ F' u6 _/ G
tives. There were no siblings.
* K( N  e/ X0 ^4 u- q2 FPhysical Examination
8 W+ v4 n/ c* Y: I% U4 ^The physical examination revealed a very active,
! H* L0 j' D" m8 w: Dplayful, and healthy boy. The vital signs documented
/ \7 Z1 G) e) g" `) f3 u& d$ fa blood pressure of 85/50 mm Hg, his length was" \$ p6 A1 c( w) _+ W" P/ \) q
90 cm (>97th percentile), and his weight was 14.4 kg
( U* M* x/ c' o(also >97th percentile). The observed yearly growth
4 s0 Q' W) A* j7 H0 ^' Nvelocity was 30 cm (12 inches). The examination of
$ P$ c: H% L2 |4 s- l) Rthe neck revealed no thyroid enlargement.
; X& A2 U7 Y) q# n  mThe genitourinary examination was remarkable for+ C. }/ W: W/ U5 D6 J1 g6 j/ S) J# @
enlargement of the penis, with a stretched length of
: a  ?# H$ B9 h4 L3 Y- Q$ F8 cm and a width of 2 cm. The glans penis was very well
2 z' |. \2 d+ s" y: Ndeveloped. The pubic hair was Tanner II, mostly around) l/ h1 t- y# \& {( k0 S
540
" Y' U! E7 z" X4 j' y; D# Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  U  L& U( a$ B2 W; V0 o. a1 X0 g
the base of the phallus and was dark and curled. The
4 n. f& l( }1 c( ?! Ctesticular volume was prepubertal at 2 mL each.
  [" j( ]2 R  u& _, M$ fThe skin was moist and smooth and somewhat7 V. D& U/ T, N% T+ q
oily. No axillary hair was noted. There were no
8 R  e; j9 |% i3 Dabnormal skin pigmentations or café-au-lait spots.9 }0 ~4 l% z! M
Neurologic evaluation showed deep tendon reflex 2+
6 ], C5 L& |# ?$ }' l$ Dbilateral and symmetrical. There was no suggestion
7 k$ S: D2 T3 l, B: mof papilledema.
9 _6 }9 m) }- Z7 _# HLaboratory Evaluation
8 L- z+ l+ a7 O( ^The bone age was consistent with 28 months by: q) _# _( m' j; z' `
using the standard of Greulich and Pyle at a chrono-
# r4 C+ q0 k4 n# K9 `logic age of 16 months (advanced).5 Chromosomal4 N- J6 l. w3 u& L
karyotype was 46XY. The thyroid function test
  x5 x1 @* l: V8 K. i7 |1 Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 g. V+ l; }. m; ]- O; ~lating hormone level was 1.3 µIU/mL (both normal).
  g7 Z* H7 @* w# r: F9 S9 ?The concentrations of serum electrolytes, blood5 _% b* v# Y8 F
urea nitrogen, creatinine, and calcium all were* y7 X7 }5 o4 U4 T8 r6 W
within normal range for his age. The concentration/ @) p$ o3 I/ Z, J8 T
of serum 17-hydroxyprogesterone was 16 ng/dL
! m- \& P) W/ y; Q5 B(normal, 3 to 90 ng/dL), androstenedione was 20
  u) V0 o& c' H: B, i! ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 K) z  p  H" {% X) M; e1 Rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
( x7 K' c* |0 q9 e& ?desoxycorticosterone was 4.3 ng/dL (normal, 7 to
* g; ~' [- d7 I1 t) Q49ng/dL), 11-desoxycortisol (specific compound S)
  G+ t; v! @5 M- k4 N5 _6 _; Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, H0 p) G5 }* d% s; C& p* Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ W4 g0 h: E0 B8 K
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 i: F' d7 |7 ~0 \8 ?: @8 i* U4 D6 band β-human chorionic gonadotropin was less than
/ I9 T; [7 t# H+ q) R, o9 |5 mIU/mL (normal <5 mIU/mL). Serum follicular
" l7 @6 a! p/ j" H1 b5 w' c+ X0 mstimulating hormone and leuteinizing hormone
$ M, Q. ]- ~# r  Rconcentrations were less than 0.05 mIU/mL7 H+ v- U' f" g+ S9 Y7 P
(prepubertal).
6 Q7 \2 \- s/ ?. m9 v4 [1 j$ p3 qThe parents were notified about the laboratory/ i, h7 d2 b. I/ `, k$ x- w
results and were informed that all of the tests were
8 j% f6 I/ {2 Q2 mnormal except the testosterone level was high. The( r9 `# x, z" _1 {. I) C
follow-up visit was arranged within a few weeks to7 w; n/ b+ N8 ]
obtain testicular and abdominal sonograms; how-
- @0 F2 x2 M: ]/ h  Sever, the family did not return for 4 months.
' `( \- ]6 S, H- M$ p" U  s/ ^Physical examination at this time revealed that the5 J( C) g( @- h  f% d3 |/ y
child had grown 2.5 cm in 4 months and had gained
' L5 B' N, H& ]% t* L( X2 kg of weight. Physical examination remained
: q9 Q# D, o+ K( S5 s' Q( L8 junchanged. Surprisingly, the pubic hair almost com-( s, J- W6 v* C- |$ e- I  b: o
pletely disappeared except for a few vellous hairs at( x2 s& p5 S' t
the base of the phallus. Testicular volume was still 2
( S1 x0 @# z$ t- nmL, and the size of the penis remained unchanged.9 k& h  x0 v+ q# D2 q
The mother also said that the boy was no longer hav-
# k, T  h  H6 W+ Y( L. R4 hing frequent erections./ X- ?" f: e6 W% J
Both parents were again questioned about use of' x3 \) Q* C1 \* M. R: ^
any ointment/creams that they may have applied to
" H8 R, p+ V& \- c- ~+ Gthe child’s skin. This time the father admitted the
: ?) ~2 E8 y" x4 JTopical Testosterone Exposure / Bhowmick et al 541
  G9 \9 M% g1 l3 ~use of testosterone gel twice daily that he was apply-
+ R$ J0 E+ D3 ^3 u) a( |ing over his own shoulders, chest, and back area for
+ \! N1 j& x3 w, w6 f* d0 d1 ^3 ha year. The father also revealed he was embarrassed  P9 ^; W$ h. s9 r2 m
to disclose that he was using a testosterone gel pre-
8 p% t9 d! n( ^7 g. r# q" Dscribed by his family physician for decreased libido
' t; n7 _/ i8 d( F8 \  n: m' M# T1 xsecondary to depression.
  u# c0 |0 V4 X  r9 m/ f: |The child slept in the same bed with parents.
4 `3 E; U4 v; h: }: W: Q) {0 FThe father would hug the baby and hold him on his
% J; X# {0 z' w9 M( |. X9 _chest for a considerable period of time, causing sig-
* y/ v6 H! o- ]nificant bare skin contact between baby and father.
( o; ~. \! ?  S! vThe father also admitted that after the phone call,
! W* G) ?1 m: i# Iwhen he learned the testosterone level in the baby& ]% d6 H) l' J  H6 p( e4 q  `
was high, he then read the product information8 L3 Z7 m% Y( I7 Z! _2 t  I3 R
packet and concluded that it was most likely the rea-
* x" a& w7 n3 hson for the child’s virilization. At that time, they; L% E- L1 p! g" c" [8 A" g3 X9 M
decided to put the baby in a separate bed, and the
1 I4 H8 y( b+ K- K+ `; ?' m9 Xfather was not hugging him with bare skin and had
+ F+ n( k! m: q# g2 g9 O; \been using protective clothing. A repeat testosterone
+ m! M4 j& B! z2 W5 Jtest was ordered, but the family did not go to the: A  h: o% @2 o' J1 O( G/ O
laboratory to obtain the test.
% v: \- _, R* g, A6 ]. z4 `Discussion) R9 _  _& o  p! I2 {! y3 }
Precocious puberty in boys is defined as secondary9 d3 X" }, I5 D5 v2 v' E3 q
sexual development before 9 years of age.1,4! F8 p- T! @6 k4 Y0 K0 N
Precocious puberty is termed as central (true) when/ a" g. Z  B2 {8 S) ?
it is caused by the premature activation of hypo-4 i8 k; k2 b7 h6 X
thalamic pituitary gonadal axis. CPP is more com-1 ]+ p  X; m/ I* c: j
mon in girls than in boys.1,3 Most boys with CPP- g' s& b+ U# l& }' X
may have a central nervous system lesion that is. R/ r9 ?2 _5 P, j, n; w/ E! G, l
responsible for the early activation of the hypothal-
  V& h. i6 _- b0 Vamic pituitary gonadal axis.1-3 Thus, greater empha-
) K/ z9 U! N' V3 O  N8 F+ k3 Jsis has been given to neuroradiologic imaging in
# w3 @  I. E( R  q. b1 uboys with precocious puberty. In addition to viril-
, u* W' B; r: b: Dization, the clinical hallmark of CPP is the symmet-
8 @4 [2 d! E0 [# |: _rical testicular growth secondary to stimulation by
7 T6 X' ~- ^" O0 e; L  fgonadotropins.1,3+ A) h& u0 i9 `7 W& R8 b
Gonadotropin-independent peripheral preco-
7 [; h* }3 v) [' tcious puberty in boys also results from inappropriate: C" [! t9 N. @( d
androgenic stimulation from either endogenous or" r) u/ [. ]8 c9 R' Y
exogenous sources, nonpituitary gonadotropin stim-
8 x7 Y, J7 Y" [0 V/ x/ T9 A' s& a- Eulation, and rare activating mutations.3 Virilizing7 x. E7 s4 @' D5 E  Y; A  N0 z
congenital adrenal hyperplasia producing excessive
3 q6 _( Y. ^# j: f! G% u- Y7 S" oadrenal androgens is a common cause of precocious* s0 L' ]% ^6 v
puberty in boys.3,48 N0 [; b( [4 V
The most common form of congenital adrenal
0 V( W$ [8 ~8 Y1 {) f. o% K0 f! G8 khyperplasia is the 21-hydroxylase enzyme deficiency.% \7 h; `: I1 I2 L  t" z3 [! l% v3 S
The 11-β hydroxylase deficiency may also result in
/ K) q/ f1 \3 O4 n" Gexcessive adrenal androgen production, and rarely,
9 }% ]# O, l6 o3 g/ h' Nan adrenal tumor may also cause adrenal androgen* Q, w! S/ n% [: j* e
excess.1,3
  n' I( S9 L7 C2 s  c+ V* Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 y' F& F9 |5 L/ r( G0 `0 g
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) m* d; i  f! w6 g/ t" J- x4 p( \
A unique entity of male-limited gonadotropin-
0 [6 t+ C3 o- J, E5 Xindependent precocious puberty, which is also known2 B) p- P+ J' k$ D' z- h1 X  j
as testotoxicosis, may cause precocious puberty at a
2 B! ^9 ~$ T: _  d0 N  }. Lvery young age. The physical findings in these boys$ r) r$ D- J: M; D# g
with this disorder are full pubertal development,! }6 ?/ S" c7 }0 P% j  p
including bilateral testicular growth, similar to boys3 ~3 {% B& ?  J# N
with CPP. The gonadotropin levels in this disorder
6 i+ O/ R- r$ m2 j" z0 Zare suppressed to prepubertal levels and do not show7 |+ _( G8 O7 y  Q
pubertal response of gonadotropin after gonadotropin-
. s, w. M. m0 I. p' j) F2 |" l7 |releasing hormone stimulation. This is a sex-linked5 J1 {( u* U4 \; u; n' K! g& R
autosomal dominant disorder that affects only
, O& n, t: t0 }6 C* i$ ?  @males; therefore, other male members of the family
7 @$ k/ H9 ~& \5 W$ y4 Zmay have similar precocious puberty.3. S, G, O1 Q% M# P: a
In our patient, physical examination was incon-. L6 K5 |: T: I
sistent with true precocious puberty since his testi-
0 Z7 e+ x7 {% ^! R( [; ^  Vcles were prepubertal in size. However, testotoxicosis6 Z* G( V- h5 d( r. ~
was in the differential diagnosis because his father
; Y- z* C4 l0 I7 Nstarted puberty somewhat early, and occasionally,1 X( j1 D! g1 J: P
testicular enlargement is not that evident in the
- z) g2 g3 I) ]- r; _% \! X5 ]! ?beginning of this process.1 In the absence of a neg-
; v5 {3 q) G. w) I6 Dative initial history of androgen exposure, our
/ e6 O  h; h& j) k! n" O6 [: Gbiggest concern was virilizing adrenal hyperplasia,
/ h( Q- U# C7 ?) Y& A. L2 }0 I3 neither 21-hydroxylase deficiency or 11-β hydroxylase# D0 _/ E; t  U/ L
deficiency. Those diagnoses were excluded by find-8 s" V& I/ `& W5 `3 y3 {
ing the normal level of adrenal steroids./ P, m! y; ]3 [/ K0 n+ l8 Z2 P
The diagnosis of exogenous androgens was strongly( C, E. M4 h$ u( L' E) _' ]
suspected in a follow-up visit after 4 months because* Y/ a  @# ?/ `, {* a9 U
the physical examination revealed the complete disap-
9 h3 T/ ?' ?  j. }pearance of pubic hair, normal growth velocity, and2 G* o# l) }% }7 W8 S- w
decreased erections. The father admitted using a testos-+ j$ K( t/ V& ?4 T: o# I9 M
terone gel, which he concealed at first visit. He was1 o2 H4 K; P; M. A
using it rather frequently, twice a day. The Physicians’
' G; V9 h- D! A9 ~& w2 R0 vDesk Reference, or package insert of this product, gel or. Z# j' M  O% A7 z& t  B
cream, cautions about dermal testosterone transfer to! Z- m2 ]3 w( T- `" _
unprotected females through direct skin exposure.
) j' S+ @0 M0 q9 u$ D( SSerum testosterone level was found to be 2 times the
9 i7 }, u6 X+ d% o8 C- z3 ?baseline value in those females who were exposed to( Q; C) V! d4 W3 D  K
even 15 minutes of direct skin contact with their male$ d+ B+ e0 \  }9 R. |$ D
partners.6 However, when a shirt covered the applica-. d* f9 U% t6 g7 d# C6 H& A
tion site, this testosterone transfer was prevented.0 f9 b; t4 L  W4 k3 v: [$ x
Our patient’s testosterone level was 60 ng/mL,
8 E  t4 m+ d( h: Wwhich was clearly high. Some studies suggest that7 o9 t4 r4 o, {2 W3 n5 V2 v
dermal conversion of testosterone to dihydrotestos-9 ]5 g; m8 s/ V4 p
terone, which is a more potent metabolite, is more
; ^/ W% ^- ]% A1 h* Mactive in young children exposed to testosterone7 }5 a9 M8 l6 a6 H: P) x
exogenously7; however, we did not measure a dihy-. [$ s* y  d3 `2 I' t7 v3 \* [0 ]
drotestosterone level in our patient. In addition to7 q% E  D. _/ [  i( m
virilization, exposure to exogenous testosterone in! O! ?/ Z" D; q1 d2 u( J
children results in an increase in growth velocity and! D& q& l" o( u* i8 [
advanced bone age, as seen in our patient./ E3 e/ O  A& o8 B9 h
The long-term effect of androgen exposure during
+ d; v5 F. ~6 S1 U0 A4 L8 d9 Searly childhood on pubertal development and final5 x( t5 w1 U$ l2 c! u
adult height are not fully known and always remain
' y" N) F7 m  \; _% _0 Sa concern. Children treated with short-term testos-
' j. H) T, |4 {9 z9 z9 ]' E' Cterone injection or topical androgen may exhibit some
+ P2 L! t8 T; I. }3 Iacceleration of the skeletal maturation; however, after
* P" C' D* v9 w# c3 zcessation of treatment, the rate of bone maturation
# j2 C, R) R- [1 P0 C! T2 g$ odecelerates and gradually returns to normal.8,95 U4 e+ t+ M$ V( Q" m
There are conflicting reports and controversy
+ i, r% w1 J3 X1 \) Wover the effect of early androgen exposure on adult: g$ T9 Z/ ]& m1 X/ _! ?
penile length.10,11 Some reports suggest subnormal( W8 Q5 [: d! g+ o
adult penile length, apparently because of downreg-
# P/ P! c9 K2 _, r! g8 G/ Iulation of androgen receptor number.10,12 However,
) W0 Q& H* i2 k* @: R, WSutherland et al13 did not find a correlation between' S, R8 \6 e" Q( g" Z
childhood testosterone exposure and reduced adult
/ Z$ ~3 @' l+ E; Cpenile length in clinical studies.( [) b; P  Y5 t
Nonetheless, we do not believe our patient is
  i9 Z9 s+ X$ A! `0 f6 Tgoing to experience any of the untoward effects from
% ?+ ^, y$ i3 f4 ?, r$ p0 ?testosterone exposure as mentioned earlier because+ R6 P- w+ N. D8 {6 [
the exposure was not for a prolonged period of time.* m1 I& d! |* ?
Although the bone age was advanced at the time of
$ l; l7 e7 t: G: b2 l1 e6 |# ~& zdiagnosis, the child had a normal growth velocity at
4 O/ K5 ]4 |. `9 s! z$ V) jthe follow-up visit. It is hoped that his final adult
! i- x) L9 H8 U" Z/ ?- @( H& lheight will not be affected.* o! O- Q3 ~' t& d+ ~2 @0 n
Although rarely reported, the widespread avail-
3 m* J3 e" S& `8 _* Jability of androgen products in our society may
8 h- o6 \! _- R# dindeed cause more virilization in male or female
* G2 e1 v  v* @5 o) Z" schildren than one would realize. Exposure to andro-! |/ ^8 @+ i# Z7 V7 ^; B* u
gen products must be considered and specific ques-
; K) q6 ?) ]# s- W7 I# v3 l( ttioning about the use of a testosterone product or
1 I  y; W4 k4 g& @/ zgel should be asked of the family members during
& C( J& O6 @/ c% x$ p: Hthe evaluation of any children who present with vir-* G: ?( t) [. c# c8 Y! H2 Q
ilization or peripheral precocious puberty. The diag-% _( C) r- [2 a* c( J
nosis can be established by just a few tests and by. G2 t  Q& k, @, G/ d
appropriate history. The inability to obtain such a
* a5 m' B: z5 e/ vhistory, or failure to ask the specific questions, may2 U% L! [4 Y/ Q" t
result in extensive, unnecessary, and expensive" a7 ^& z1 n0 S
investigation. The primary care physician should be4 P' Q$ \: T! K: ^, P
aware of this fact, because most of these children  v8 m0 @; g( x6 N5 _
may initially present in their practice. The Physicians’: a% J* U. S2 j! T8 i0 U
Desk Reference and package insert should also put a
# b5 K8 L5 W0 _warning about the virilizing effect on a male or/ |2 ]4 K' X- U
female child who might come in contact with some-! }6 R6 \( t0 a8 u/ i- f' z# \
one using any of these products.
5 I6 |/ e! r% O; B6 x* LReferences9 N4 T% `  L+ O/ Y- G9 D
1. Styne DM. The testes: disorder of sexual differentiation% J" J' h9 F0 x0 U' `
and puberty in the male. In: Sperling MA, ed. Pediatric
$ {/ ?6 k2 y2 j8 \0 [" SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; K& t' E: @6 k, f' h0 ?2002: 565-628." _' f$ l8 T; }$ F8 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" O9 u% h% S$ O0 h
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old& }; [( m  l/ h4 G5 _& _3 q
Boy Induced by Indirect Topical
; F+ x3 o# ], P$ j- n% I: |6 @Exposure to Testosterone/ o5 e! {4 g$ g; O& s( S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 q* q! l+ V" E& y8 k2 N. O
and Kenneth R. Rettig, MD1% ~1 ~- t$ @# |8 O: B/ ~
Clinical Pediatrics: j# k5 _( F) X0 a9 x/ p( @- O" N
Volume 46 Number 6
7 M# E# p9 i! T  fJuly 2007 540-543
/ {- p6 v' I! R! G" e© 2007 Sage Publications# h" x" D: B# S, r. X
10.1177/0009922806296651! q6 W/ A3 t" r
http://clp.sagepub.com
6 w" W- E% U0 _hosted at
) V6 t2 m- z: R( n4 u9 y9 l: N% w- thttp://online.sagepub.com' b, R* w# Z9 |* T6 I7 I+ t
Precocious puberty in boys, central or peripheral,
% t) F3 k7 n! bis a significant concern for physicians. Central9 ?. w( I% f4 \% Y# U# v
precocious puberty (CPP), which is mediated( J, J  q' I2 X: V6 @8 b! ]
through the hypothalamic pituitary gonadal axis, has
6 M. i& |6 @& Ra higher incidence of organic central nervous system: Q: B3 a% X! `9 J8 e- y) r
lesions in boys.1,2 Virilization in boys, as manifested
8 N; t+ k% r2 Bby enlargement of the penis, development of pubic
3 m- I7 M9 O1 b& H) R+ Shair, and facial acne without enlargement of testi-
7 l( w' X$ F+ s) y; W" ~0 q8 O$ u: ccles, suggests peripheral or pseudopuberty.1-3 We3 a: J' d, D% s- t% V' B$ W
report a 16-month-old boy who presented with the8 x* j" @2 O& J' C5 `
enlargement of the phallus and pubic hair develop-
% r2 a" K8 X8 d1 v' ]8 wment without testicular enlargement, which was due! q' o3 o. d/ y- X
to the unintentional exposure to androgen gel used by
! j$ h: E- t. W- ~) V$ p* f1 ~the father. The family initially concealed this infor-6 m4 m, z9 Z+ D0 N: S
mation, resulting in an extensive work-up for this
; c! }* i. |; B* x$ T- V) l& wchild. Given the widespread and easy availability of, e! t/ R: r6 E$ Z) X5 z
testosterone gel and cream, we believe this is proba-3 A; j& F1 t+ e
bly more common than the rare case report in the: o) I: F8 N: [/ f
literature.4
5 ^8 Y+ v, T) ePatient Report
( ^& E  u6 w# vA 16-month-old white child was referred to the
; M$ Q7 h6 m! L! y+ ~endocrine clinic by his pediatrician with the concern
, H# P, n# f# h( T2 q8 {of early sexual development. His mother noticed1 Z5 `# g* a/ T$ b) @* L
light colored pubic hair development when he was5 w5 `( q) @( p4 `
From the 1Division of Pediatric Endocrinology, 2University of: E7 m) j$ w( n/ Y. T
South Alabama Medical Center, Mobile, Alabama.0 _* X9 O# s) ~; m1 J" E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 Z  D+ @4 L4 c, Y4 _8 Q2 }Professor of Pediatrics, University of South Alabama, College of4 O& W6 k+ u; n) E9 A
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 n" z3 c& B! E( \! x1 Ge-mail: [email protected].' W; ^0 p7 G  V1 J% Q) [3 p
about 6 to 7 months old, which progressively became
. \, F% t7 I% N- ~7 h/ X' H/ n4 Kdarker. She was also concerned about the enlarge-+ Z6 p" G/ q- J; T0 P% D
ment of his penis and frequent erections. The child
" _* @0 `  k7 |: u1 Pwas the product of a full-term normal delivery, with
7 o, S+ j4 Z8 G' [8 s2 xa birth weight of 7 lb 14 oz, and birth length of
4 [  E( p9 V9 I20 inches. He was breast-fed throughout the first year
. w5 U* }. q: B* L9 f$ y% iof life and was still receiving breast milk along with+ s- q: J  B5 U: P$ R
solid food. He had no hospitalizations or surgery,
! R/ d- K8 {7 Y+ y& d7 vand his psychosocial and psychomotor development
4 ]/ ^" G$ ?: J: X0 cwas age appropriate.- J! n; `. J. w+ e9 H
The family history was remarkable for the father,
1 g: W  }. X8 s/ r7 r( p+ g& P% Cwho was diagnosed with hypothyroidism at age 16,: J! k3 Z& L. r- p5 ]
which was treated with thyroxine. The father’s4 u! S9 a* w% p4 Y4 y
height was 6 feet, and he went through a somewhat
2 H7 c* W0 O0 @& P. o" i) f2 d9 t* Fearly puberty and had stopped growing by age 14.
1 C  b2 k/ d2 |6 g  z  P2 h; J# GThe father denied taking any other medication. The
3 A5 K7 H3 I; u' Y- B" bchild’s mother was in good health. Her menarche
" I* V; l- V: Owas at 11 years of age, and her height was at 5 feet# z! Y& t+ S9 ?, d5 l5 K
5 inches. There was no other family history of pre-
4 Z4 ?7 l! s# Z$ E" v3 Jcocious sexual development in the first-degree rela-; e! G8 C7 i2 J+ j9 U$ I& O/ M
tives. There were no siblings.7 x0 f3 i0 O# z" z% h
Physical Examination3 v# {9 z) k! n5 G: D& G7 L( w
The physical examination revealed a very active,
' a( _+ T+ j/ lplayful, and healthy boy. The vital signs documented' g8 Q* d' }& p
a blood pressure of 85/50 mm Hg, his length was6 ]3 I8 h9 J& t0 [/ b* z
90 cm (>97th percentile), and his weight was 14.4 kg4 O' H. J7 H4 H# \& i
(also >97th percentile). The observed yearly growth9 Z1 v3 U+ A' N3 V
velocity was 30 cm (12 inches). The examination of
1 ^! b3 r- m' Y: w) L' U/ Mthe neck revealed no thyroid enlargement.8 o/ G; j& A  O4 N
The genitourinary examination was remarkable for
" m- Q; S6 l; x' M0 Q/ qenlargement of the penis, with a stretched length of6 c& N, J/ n/ o+ k7 e- t6 n
8 cm and a width of 2 cm. The glans penis was very well' m+ {! K$ Z1 U4 ]" q. K3 }( j: ^
developed. The pubic hair was Tanner II, mostly around
% b. x% r0 [" J( M540
8 @  ~0 J& R/ Q% n# Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 l1 n$ ~+ y! m6 J: {( Tthe base of the phallus and was dark and curled. The% f  }7 i& v  p
testicular volume was prepubertal at 2 mL each.
! B6 f8 L% b  A0 a& }+ D* n6 EThe skin was moist and smooth and somewhat) c4 o. g+ d7 ?
oily. No axillary hair was noted. There were no% e, N6 ]! Q8 I/ z- ~3 m
abnormal skin pigmentations or café-au-lait spots.3 p6 Z4 z( }$ ?
Neurologic evaluation showed deep tendon reflex 2+
7 s  d9 U* @# \) T5 |bilateral and symmetrical. There was no suggestion
/ ?) h* Z: C. G$ D; W/ r% xof papilledema.
6 u* N$ k; m+ ]0 c' B4 ~: BLaboratory Evaluation& e* t. d1 L' r/ F
The bone age was consistent with 28 months by
# a/ x( a2 z% \" m' Y8 W7 Iusing the standard of Greulich and Pyle at a chrono-" x1 D9 Y8 N* L3 Y: Q+ v9 _
logic age of 16 months (advanced).5 Chromosomal$ y$ _: [' [4 k+ A. Z
karyotype was 46XY. The thyroid function test
0 Q6 e1 u! c/ {. r  h) h/ l; v5 y/ R' ashowed a free T4 of 1.69 ng/dL, and thyroid stimu-- t% z- u" b  d# k0 W- D1 i8 D
lating hormone level was 1.3 µIU/mL (both normal).' P5 E; O# Z9 E1 g! O9 {( f& G" a7 ]
The concentrations of serum electrolytes, blood4 ]5 j4 e  D8 d; `, m
urea nitrogen, creatinine, and calcium all were
( }2 w, |1 q9 `/ Awithin normal range for his age. The concentration6 {# p+ Y- Y# A3 n$ k
of serum 17-hydroxyprogesterone was 16 ng/dL+ M, D' [+ S" K# \# U1 |3 V
(normal, 3 to 90 ng/dL), androstenedione was 20% d- n$ ^/ v. F  m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  d6 H% z/ ?& U% dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& V( r* q( I" |desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 \' k) W& n; S, T
49ng/dL), 11-desoxycortisol (specific compound S)5 ?) `% {: }6 `% j) i1 x# [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 r6 R, F8 ~1 w3 a2 s0 u: t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* w8 {, f: u5 ], C, I5 Z$ }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),- \4 y$ P, p/ l
and β-human chorionic gonadotropin was less than
7 {2 ]% ~9 X7 i5 mIU/mL (normal <5 mIU/mL). Serum follicular* o* K4 {- s2 @* b
stimulating hormone and leuteinizing hormone' B2 o2 Q  y4 j# S' w
concentrations were less than 0.05 mIU/mL
3 |: j3 P4 ~$ s$ e: X; |(prepubertal).; u0 v' ]; X( G" r: j1 O: V
The parents were notified about the laboratory4 \, l' [7 H* R, G, {+ B
results and were informed that all of the tests were6 I6 ]; s  ], g+ e" b/ }: J
normal except the testosterone level was high. The! g+ H4 Z/ W1 a  @# Z
follow-up visit was arranged within a few weeks to# V4 K2 \5 d. ?
obtain testicular and abdominal sonograms; how-
' C7 I# L' I. ]1 ?, J2 _* bever, the family did not return for 4 months.# N* n4 d$ f& e# ^! Q9 a# w
Physical examination at this time revealed that the) C- w5 k, T  J2 z3 e
child had grown 2.5 cm in 4 months and had gained
) h9 f+ x9 n# {2 c/ E: c. d2 kg of weight. Physical examination remained
  u: c7 h- V8 k* E  }7 M$ yunchanged. Surprisingly, the pubic hair almost com-) j9 \" q4 v8 l) p0 K* h
pletely disappeared except for a few vellous hairs at
* c% J* B5 N' i1 Tthe base of the phallus. Testicular volume was still 2
) B$ p! M$ U2 G, r2 nmL, and the size of the penis remained unchanged.4 Y! {% L2 w5 E. K9 g
The mother also said that the boy was no longer hav-! y2 q. M9 O" B7 z
ing frequent erections.
$ k8 e3 w( i$ y8 nBoth parents were again questioned about use of, [7 o" N( Q) T$ d2 Q# E" D: `
any ointment/creams that they may have applied to
2 \5 p; I2 @0 H% q% G* g! fthe child’s skin. This time the father admitted the
4 A) O8 W0 i) X& h  \$ aTopical Testosterone Exposure / Bhowmick et al 5410 v2 t' v( M8 G/ q% a/ w6 R
use of testosterone gel twice daily that he was apply-
$ Z; v5 z, Q% t! Z" ^) \% i. [/ Bing over his own shoulders, chest, and back area for. j, D/ z; B/ ?( T6 y9 y
a year. The father also revealed he was embarrassed+ L3 \+ l6 r  m3 z. b4 v
to disclose that he was using a testosterone gel pre-7 X& q9 A1 _6 m8 k; q* T
scribed by his family physician for decreased libido9 e) c& s6 l1 G
secondary to depression./ c- F6 h# G: j$ |) h  V
The child slept in the same bed with parents.
. {+ i' A8 T1 y9 ~+ r1 lThe father would hug the baby and hold him on his0 [( t0 }% i  Z$ h$ Q- u* K
chest for a considerable period of time, causing sig-
/ w2 I2 u2 b, |3 M+ y* Qnificant bare skin contact between baby and father.
  ?, _( [5 h! Y( v* p+ TThe father also admitted that after the phone call,
# _5 y/ ~" r- q* p* @when he learned the testosterone level in the baby& ^6 U$ v% B8 t: N
was high, he then read the product information
: J7 {! z( y7 ]( g- l) I' d0 g/ qpacket and concluded that it was most likely the rea-7 Q, u+ E3 f; i* M
son for the child’s virilization. At that time, they
2 T! r- k* s. _3 `decided to put the baby in a separate bed, and the) L  S1 |  N: [! a) k
father was not hugging him with bare skin and had/ p  e- J4 t+ }5 A
been using protective clothing. A repeat testosterone+ l) C* S7 P, B7 J0 o- x
test was ordered, but the family did not go to the
! W3 O5 t, O1 i; s# P; ulaboratory to obtain the test.- u2 M0 I2 P3 ^1 x4 _, j  l
Discussion
7 ?; W. `8 b# g" |Precocious puberty in boys is defined as secondary
9 Q* V- d) }6 n, F# xsexual development before 9 years of age.1,4
: K/ S/ \+ V" Y9 {  y& P1 VPrecocious puberty is termed as central (true) when
- z+ w' H5 `4 }1 m( ]) zit is caused by the premature activation of hypo-- K; Y' Z7 K3 P  N
thalamic pituitary gonadal axis. CPP is more com-
7 h. k* v& ^; Umon in girls than in boys.1,3 Most boys with CPP
4 s# m2 ^3 F: H/ \4 Zmay have a central nervous system lesion that is7 e) L) k  U! m; ?; M
responsible for the early activation of the hypothal-/ P+ O( f4 _/ ?' S) R
amic pituitary gonadal axis.1-3 Thus, greater empha-8 T" x4 o: i+ x; \+ M4 M& @9 M
sis has been given to neuroradiologic imaging in2 N. `- P0 j! h, g* m
boys with precocious puberty. In addition to viril-
; Q) R4 n  c' {! cization, the clinical hallmark of CPP is the symmet-
, W0 @3 A8 u0 C$ J) X; {rical testicular growth secondary to stimulation by
# K8 h: Y, O! K) |" X; W+ c# Zgonadotropins.1,3
$ u( K- k+ j+ p) G1 oGonadotropin-independent peripheral preco-
% O& M6 f* U- D4 P# B# y+ Pcious puberty in boys also results from inappropriate
- n6 A! ~7 G4 E$ q/ J( n. `- U4 Zandrogenic stimulation from either endogenous or. s% {! ]" ?6 W) P6 p+ G
exogenous sources, nonpituitary gonadotropin stim-0 T& ]$ J: j5 [2 h/ p6 p2 y1 C
ulation, and rare activating mutations.3 Virilizing6 D9 m1 `( x* U7 L8 M$ |' k
congenital adrenal hyperplasia producing excessive1 A$ B& E  d" \6 f9 t8 ?
adrenal androgens is a common cause of precocious
3 X2 t% r7 F( n: R+ Kpuberty in boys.3,4
. s& Z+ q  y- A# Q3 j2 @% pThe most common form of congenital adrenal
6 R$ G9 ]& `' r: {$ Ghyperplasia is the 21-hydroxylase enzyme deficiency.
- G' Y* j3 g1 G2 p# B7 E; H5 j: IThe 11-β hydroxylase deficiency may also result in1 J8 _" J3 b) x/ \# f/ E  K6 c2 W
excessive adrenal androgen production, and rarely,
6 v: Y; ?% }1 Y2 M1 I3 ?6 E( e: d+ Oan adrenal tumor may also cause adrenal androgen
: b) n, z; `$ M7 Rexcess.1,3! _0 T: a4 n) q$ N  {4 {* ]4 }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ m$ ]+ d: o( Y( }
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- M: F1 d+ h) P; O
A unique entity of male-limited gonadotropin-# J( \4 s0 O: K6 A
independent precocious puberty, which is also known
. H0 _' }2 X5 o: C4 ?9 O) _as testotoxicosis, may cause precocious puberty at a
. u% M  h$ O( |0 p* qvery young age. The physical findings in these boys
: ]* M' `1 j: o: _* N4 Y& ?with this disorder are full pubertal development,
7 a8 I! m  b) K! p8 Xincluding bilateral testicular growth, similar to boys- m2 d( I# K" ~! c4 D: A9 B
with CPP. The gonadotropin levels in this disorder
1 j6 [; I' F8 L  uare suppressed to prepubertal levels and do not show! X/ Y1 J+ ~. z+ O
pubertal response of gonadotropin after gonadotropin-
# O; l/ i( q1 S( c  xreleasing hormone stimulation. This is a sex-linked, b: v+ L2 o" y7 m* W2 t. X
autosomal dominant disorder that affects only1 `9 j3 G- d) d- F* J4 Y
males; therefore, other male members of the family
8 n# u5 d9 u3 s4 f7 rmay have similar precocious puberty.3
3 u. [" J* C  ?7 oIn our patient, physical examination was incon-+ m" [6 K7 O5 a3 L& ?
sistent with true precocious puberty since his testi-- y- B3 c3 ~0 ]- z7 w+ {
cles were prepubertal in size. However, testotoxicosis! X; ~) |4 p* ]! K" c
was in the differential diagnosis because his father
, M" W' b( i3 K+ P- h+ `1 xstarted puberty somewhat early, and occasionally,6 I* g  s6 n5 h; L0 e3 W' I* m6 j) S
testicular enlargement is not that evident in the
5 d9 u; l9 ^3 w; C6 t# B* s' D- {beginning of this process.1 In the absence of a neg-8 `) b: [, j& P, S& A
ative initial history of androgen exposure, our
0 T8 K8 }- U1 t  p9 N- T/ u1 Mbiggest concern was virilizing adrenal hyperplasia,
( U) ?0 B, b6 r* o$ Peither 21-hydroxylase deficiency or 11-β hydroxylase2 D, \  b) B' w3 h+ {1 p
deficiency. Those diagnoses were excluded by find-
6 j" _( X0 I2 e: Xing the normal level of adrenal steroids.
: H& J7 v6 m7 y' v3 eThe diagnosis of exogenous androgens was strongly0 s4 e' N$ f* c: V& U' _+ J
suspected in a follow-up visit after 4 months because
" c/ a4 O! f5 t3 P4 l# Ethe physical examination revealed the complete disap-& V7 t' X0 @7 J/ q" J; q
pearance of pubic hair, normal growth velocity, and
# v# w( @" {% R# Q; Odecreased erections. The father admitted using a testos-
5 I8 ~" E3 {8 m' Q3 U6 o0 v6 [* [terone gel, which he concealed at first visit. He was
' j% y3 D2 Y3 A8 I4 Rusing it rather frequently, twice a day. The Physicians’/ c# F( [$ @1 S( C. A: w
Desk Reference, or package insert of this product, gel or
# I0 ^. Q& C$ W: bcream, cautions about dermal testosterone transfer to
  r# i: I# ^/ q' |  gunprotected females through direct skin exposure.1 V3 M9 q* i* h$ S' ]. \' u* [
Serum testosterone level was found to be 2 times the6 N1 h& i9 |8 Q% u  o$ H2 p( g& }
baseline value in those females who were exposed to
! V6 m- C; W2 Reven 15 minutes of direct skin contact with their male
% [$ ?$ a/ R3 P- {. bpartners.6 However, when a shirt covered the applica-
! }2 O* p2 H: @! c5 `/ H8 X  l3 Etion site, this testosterone transfer was prevented.! s# `* S$ y; |6 E
Our patient’s testosterone level was 60 ng/mL,
* Y* L/ @- `+ ^3 \' E* Q7 J' @which was clearly high. Some studies suggest that0 ]2 \% l" k" j  {+ u
dermal conversion of testosterone to dihydrotestos-
! F) E" B+ O- D0 Tterone, which is a more potent metabolite, is more6 ^! ^7 j; g& k: p& v
active in young children exposed to testosterone
- J: x' V* I, dexogenously7; however, we did not measure a dihy-. r' a; o( @9 v# h) W" C
drotestosterone level in our patient. In addition to
; b7 L3 c7 d! c0 ?virilization, exposure to exogenous testosterone in
" y. P* g( A5 `children results in an increase in growth velocity and
) O7 @' o; ?$ f. i+ }1 Eadvanced bone age, as seen in our patient.. U- W" T7 Q& [/ |6 C4 I
The long-term effect of androgen exposure during
; B0 \* w+ P: B; o1 f2 ~* m1 ]  l+ }early childhood on pubertal development and final' \& a9 S6 k, O: ~: o. W  {& x
adult height are not fully known and always remain# ^9 K! F3 _; N7 ^  E
a concern. Children treated with short-term testos-' ?. z: Y) f% }" E/ W7 R& E* F
terone injection or topical androgen may exhibit some
% t+ E% F. `- c4 Z4 Y; Gacceleration of the skeletal maturation; however, after
. P9 o+ Q# Y3 Q/ I- Icessation of treatment, the rate of bone maturation! S+ m$ Y: l" T4 Q
decelerates and gradually returns to normal.8,9
/ N$ [0 Q5 G8 ~& wThere are conflicting reports and controversy3 Z5 o2 g$ M4 `/ |8 r" `4 L
over the effect of early androgen exposure on adult
# H( D5 z' K2 z+ Q/ H2 a3 A  \penile length.10,11 Some reports suggest subnormal9 \6 P( X7 x5 f# v1 \; n; ~: X
adult penile length, apparently because of downreg-8 L* s6 g! w' g4 X
ulation of androgen receptor number.10,12 However,$ K5 x# r* X9 |7 [) v9 R/ K
Sutherland et al13 did not find a correlation between
4 j0 o2 P! [) b7 p1 [childhood testosterone exposure and reduced adult
1 `7 _8 `5 t, V- ipenile length in clinical studies.4 Y$ }9 I  ~2 s" J
Nonetheless, we do not believe our patient is
& I5 X& Z9 o* F) t9 \going to experience any of the untoward effects from1 Q9 g# E  ~6 d3 s, ~" l+ ]# Y0 J6 M7 i
testosterone exposure as mentioned earlier because0 w  V. z& [) l8 x3 Y
the exposure was not for a prolonged period of time.+ P' q! Z% b1 |, Q
Although the bone age was advanced at the time of( {+ B/ f# @* O2 `0 z0 a
diagnosis, the child had a normal growth velocity at
9 i6 M+ y: c+ A7 S- L* t. t6 Ythe follow-up visit. It is hoped that his final adult
, p5 F( @3 |, \. Oheight will not be affected./ u: Y+ @5 }0 w, |0 ^
Although rarely reported, the widespread avail-4 Z, p( ^5 V2 c* K6 s4 k0 C- k
ability of androgen products in our society may
8 c: B# M+ ~0 q5 f% c! n4 Qindeed cause more virilization in male or female+ f0 m; a3 y0 d% D+ A. b+ r9 C1 v
children than one would realize. Exposure to andro-' F2 q, a0 d' P6 d
gen products must be considered and specific ques-2 X( E; P, a0 u  ]8 {' h
tioning about the use of a testosterone product or; [. {! M& K* b# T  t4 h
gel should be asked of the family members during
9 D. Z9 D$ z( n$ P1 n1 cthe evaluation of any children who present with vir-
. p8 E5 }3 L8 A' z2 W! H7 `ilization or peripheral precocious puberty. The diag-8 ?/ `3 G; W& [& p
nosis can be established by just a few tests and by
: c+ \* V2 ~# Z! c) {appropriate history. The inability to obtain such a, X* \* B' m5 i7 g1 T/ _
history, or failure to ask the specific questions, may& _" T0 y% r5 o7 _1 W4 g4 s
result in extensive, unnecessary, and expensive/ L7 t- Y: B+ j2 u% y( H
investigation. The primary care physician should be
4 t) s9 \( O  h! a$ Yaware of this fact, because most of these children5 J* O9 O' ~: S0 _; ^% T0 c, ~: `
may initially present in their practice. The Physicians’$ S/ C4 }" ~) S0 E; b( G! M
Desk Reference and package insert should also put a
$ Z( A, i. O) M: c$ q" Cwarning about the virilizing effect on a male or8 _' ]! Z. ^7 m, Y2 r# o4 B, Q
female child who might come in contact with some-
( @4 I: Z6 y# V" }7 u9 bone using any of these products.
7 P: k1 ?  M) H. s! dReferences
7 I5 h2 ?' [" P. c% Z: n1. Styne DM. The testes: disorder of sexual differentiation
* Y/ i1 A" X9 z/ d! land puberty in the male. In: Sperling MA, ed. Pediatric
  @+ }# ^+ o0 V+ d+ GEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. s  K% z' p  u3 g9 m
2002: 565-628.
. Q( E2 f$ Z7 A, Z* B( D. Y9 \, K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! p& \+ ]5 R2 G0 P; w6 epuberty 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
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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
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

2 S5 B- G9 z; r. w* l3 t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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