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Sexual Precocity in a 16-Month-Old# i! _7 W  D) I6 `  ~4 F3 g
Boy Induced by Indirect Topical" @( R3 v, i5 I1 i" F
Exposure to Testosterone
; V2 H4 W6 S, }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( R1 R4 U- a  D$ g
and Kenneth R. Rettig, MD1
3 K; R4 M! C  ~8 ]1 x+ bClinical Pediatrics5 e% [: a( }: x8 D/ K- G7 U
Volume 46 Number 61 ^, e# [: U% }+ l) C9 t
July 2007 540-543
% r6 l+ w: N3 `© 2007 Sage Publications
$ R  T" X) G9 G0 z10.1177/0009922806296651- H. I6 e6 G1 B: a
http://clp.sagepub.com/ R6 i, B2 @. U8 o6 s& f7 {
hosted at
" K# {$ Q* j2 b/ d1 r% j" B7 Nhttp://online.sagepub.com
8 M2 B$ C: m+ `* j2 x# IPrecocious puberty in boys, central or peripheral,9 f+ s, S  k( p- d9 ?& O8 S6 |
is a significant concern for physicians. Central
7 H7 A9 }! P2 {precocious puberty (CPP), which is mediated
4 N: c* r, v2 q( [0 b! wthrough the hypothalamic pituitary gonadal axis, has
% _% a7 Y8 U$ [5 q6 M+ G" fa higher incidence of organic central nervous system
# ?+ [8 e* s( j& L( B% z, Y' V- rlesions in boys.1,2 Virilization in boys, as manifested
2 r# E3 }' v9 X. p  Eby enlargement of the penis, development of pubic
; e' y  v) G! o6 H9 dhair, and facial acne without enlargement of testi-  ^# p! h( ^4 z1 r# e: o5 R
cles, suggests peripheral or pseudopuberty.1-3 We
# `1 t; w+ m, p9 n% g" M4 Ireport a 16-month-old boy who presented with the
0 |$ V4 J9 G: L6 Qenlargement of the phallus and pubic hair develop-4 @; J/ J- i. e5 V  M
ment without testicular enlargement, which was due* d. U1 j  c( z6 X$ Z% N; z
to the unintentional exposure to androgen gel used by
6 e! Y5 Z3 V, X) u2 M( ^4 gthe father. The family initially concealed this infor-) F, o' W" e- g& F5 m' N
mation, resulting in an extensive work-up for this* |; L+ \- q8 w0 v5 Z
child. Given the widespread and easy availability of
8 x: l9 w2 {  c. f8 T/ gtestosterone gel and cream, we believe this is proba-' T% g) l$ N" ]3 r7 t
bly more common than the rare case report in the: C; Q4 h4 W9 K0 z/ w+ a
literature.4
' j3 Z/ x$ p7 N- [! C  YPatient Report
/ b) K2 L" j; iA 16-month-old white child was referred to the
6 ]( p0 {5 Q, u9 k; S5 [: m3 D  }8 sendocrine clinic by his pediatrician with the concern! z; ?' x  o# b5 Y
of early sexual development. His mother noticed/ h9 j& h: t6 G, G2 r1 ~0 n
light colored pubic hair development when he was
: E, d1 K$ [/ hFrom the 1Division of Pediatric Endocrinology, 2University of
" ^$ X! \0 k. N8 xSouth Alabama Medical Center, Mobile, Alabama.$ n( i/ q. n2 p" O
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& s, |. T2 H! `1 WProfessor of Pediatrics, University of South Alabama, College of
9 ]3 c) Y  E: ^3 v7 o3 vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; D; J7 H4 }/ K! v, [" K, M
e-mail: [email protected].+ P. r4 P) N6 H4 t6 G$ ~' j
about 6 to 7 months old, which progressively became
! S* g& |- M4 B8 B" G& Ndarker. She was also concerned about the enlarge-
/ J# U( n/ A3 T' v; m5 ?- Sment of his penis and frequent erections. The child
+ U% C" P/ D: c  w1 w5 P) u* Wwas the product of a full-term normal delivery, with$ ~$ S! S% t4 f
a birth weight of 7 lb 14 oz, and birth length of8 G; N2 J" _- B
20 inches. He was breast-fed throughout the first year% K; O; q/ ]* s0 ~2 P9 O6 N0 d
of life and was still receiving breast milk along with
" u3 L  P% A* y9 P+ Y/ r0 lsolid food. He had no hospitalizations or surgery,
  J" t! e7 e5 B/ v3 |1 band his psychosocial and psychomotor development' \' L3 G% @5 C; N! K/ E" Y( ^
was age appropriate.  v% \( K3 W/ ~3 M
The family history was remarkable for the father,
2 P5 H, C; B) |, N4 ^0 `who was diagnosed with hypothyroidism at age 16,
5 z% C& q# p8 [% b# g# ^7 [which was treated with thyroxine. The father’s5 `# p, f4 U: s$ z' I+ m
height was 6 feet, and he went through a somewhat
+ k* d5 R7 t* S9 y- A3 Y  wearly puberty and had stopped growing by age 14.8 S5 W7 ]! j: w1 n6 r4 j- L9 M8 H9 p: K: Y
The father denied taking any other medication. The
' l  `# ~, ^# p/ X4 Cchild’s mother was in good health. Her menarche5 y+ b. ?8 \+ g3 Z; a0 J$ b. m
was at 11 years of age, and her height was at 5 feet
4 I( `3 u$ @+ y; R$ V4 A5 inches. There was no other family history of pre-
+ d* v2 Y- ~4 I$ r6 \' ecocious sexual development in the first-degree rela-3 m" ?; Q: |  _4 w9 Y$ w( c
tives. There were no siblings.
1 C: H% @$ H: f' x* C* qPhysical Examination5 Q, \/ b" ~; p
The physical examination revealed a very active,
; p- E. [# w! r3 e+ u/ ^1 [! d2 ~playful, and healthy boy. The vital signs documented, ^3 H9 W  F8 Z
a blood pressure of 85/50 mm Hg, his length was
9 C# b0 k8 U; H0 L90 cm (>97th percentile), and his weight was 14.4 kg7 k' l% Y4 E: t- [3 b0 K; x4 b
(also >97th percentile). The observed yearly growth9 \& r6 x0 T1 o. b# e1 `; @1 D% a
velocity was 30 cm (12 inches). The examination of
8 P8 w$ Z8 G& `! `! U5 ithe neck revealed no thyroid enlargement.( N! E3 j7 @2 e& m# _% Q1 I
The genitourinary examination was remarkable for+ x5 U- x, k' ]/ }- }
enlargement of the penis, with a stretched length of
$ l  b( M/ L2 k) t, w) j" m' _8 cm and a width of 2 cm. The glans penis was very well5 \' j( p% ?4 Z* q2 B
developed. The pubic hair was Tanner II, mostly around
# }1 X# b/ W% X: Y# A2 q# \" i540
3 ]6 L+ B3 t5 J4 E, aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& u5 s* w5 t& x6 T9 Nthe base of the phallus and was dark and curled. The
5 s5 v( |/ T5 Ftesticular volume was prepubertal at 2 mL each.
) j! B- h: r. y. N- j3 rThe skin was moist and smooth and somewhat
) y7 Y5 P( H1 h, c5 `5 U& l/ `oily. No axillary hair was noted. There were no
( G) R, A) Y4 _+ K' `abnormal skin pigmentations or café-au-lait spots.
+ M% Z: ]$ R1 m' g2 P; kNeurologic evaluation showed deep tendon reflex 2+5 ?) k, L/ Y  e+ y" D0 C: a7 B
bilateral and symmetrical. There was no suggestion* g$ Y* `0 D' @2 {' L. O9 A2 N9 ~
of papilledema.# p* }$ I$ L, K! B: Z4 s  U
Laboratory Evaluation
+ c! P+ ?2 C& x) l' iThe bone age was consistent with 28 months by
1 j$ [8 ?% v8 X8 Wusing the standard of Greulich and Pyle at a chrono-
: P  y# N5 v( z7 t/ llogic age of 16 months (advanced).5 Chromosomal. G3 F9 n5 U, f; Z) w
karyotype was 46XY. The thyroid function test, M, z; V) _  p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 e0 n6 `; P" f5 b% c: i  I; E
lating hormone level was 1.3 µIU/mL (both normal).
6 \+ B, R; P  A9 T4 ]& C& J. pThe concentrations of serum electrolytes, blood* U5 S' t- e9 T' F
urea nitrogen, creatinine, and calcium all were( Z2 R( |& p+ `1 g" J/ F
within normal range for his age. The concentration2 A% {" a) [; y5 t: {% }" X, V
of serum 17-hydroxyprogesterone was 16 ng/dL% D* B* m: F% e- U7 ^
(normal, 3 to 90 ng/dL), androstenedione was 20
+ D8 j  J3 p4 ^& O3 ?3 Bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, h: I$ `# e( `: ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! u0 V4 E  W, d, kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 }: X; b8 i+ V; y& C) Z
49ng/dL), 11-desoxycortisol (specific compound S)
7 ]1 h8 p( X. z+ H4 Ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 O: Y/ ]$ D" [" L& M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 f0 H, ~! R- K- p, Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; v# m0 U/ C, I0 ^9 D. D& W4 Xand β-human chorionic gonadotropin was less than
8 P$ j3 e) O. n$ @6 b- T, m7 l- \5 mIU/mL (normal <5 mIU/mL). Serum follicular
# M9 \/ z6 ^& h, a, n1 i- Jstimulating hormone and leuteinizing hormone
& Y- W1 F0 t7 ?. P, ^7 t1 Qconcentrations were less than 0.05 mIU/mL
' U9 E1 ^2 U  u. L2 }(prepubertal).9 b1 s& J/ \0 U# Y. ]
The parents were notified about the laboratory
6 ~: g$ z* B  U# Lresults and were informed that all of the tests were
3 V* y% H4 [% P6 x" x9 ]normal except the testosterone level was high. The
* m- q# n5 E+ C8 T: {% Kfollow-up visit was arranged within a few weeks to5 ^; z4 B& X) N' z1 b
obtain testicular and abdominal sonograms; how-5 ]1 `# b% S8 y7 J0 c1 H
ever, the family did not return for 4 months.& E; f; f* T& U) a. _- m
Physical examination at this time revealed that the
$ J$ ^3 d" I$ e0 ^' |child had grown 2.5 cm in 4 months and had gained
' W+ G, t7 y+ n2 kg of weight. Physical examination remained
  ~: b3 j# D9 k' ~5 w9 h" Zunchanged. Surprisingly, the pubic hair almost com-
. L! z2 c* {0 rpletely disappeared except for a few vellous hairs at
' G2 n) {* ~* ^  Q$ F: d- Ythe base of the phallus. Testicular volume was still 23 Y. Y6 @% N3 l) o8 K
mL, and the size of the penis remained unchanged.# f$ J; D$ f2 ?% m3 L5 k! Q
The mother also said that the boy was no longer hav-! W0 a$ y( C) _# Z
ing frequent erections.2 ^) I( _$ f8 \7 Q. \) ~
Both parents were again questioned about use of! H& T& ]" p* Z8 O$ b" F6 ^. k
any ointment/creams that they may have applied to
, v9 x. a# [1 X# R/ i' ithe child’s skin. This time the father admitted the
8 i5 ^+ _9 C" gTopical Testosterone Exposure / Bhowmick et al 5415 v2 j, j$ O/ @" U
use of testosterone gel twice daily that he was apply-0 _4 o' i3 x* Z- f7 y
ing over his own shoulders, chest, and back area for
$ _; q7 l8 S6 \+ Va year. The father also revealed he was embarrassed
3 g. U1 @$ h9 }8 ?) k! \to disclose that he was using a testosterone gel pre-
4 `# b7 ?% R8 }( f3 n7 ]. z& @scribed by his family physician for decreased libido1 R% C3 D; t9 k; l. `: I- c
secondary to depression.7 X4 `2 y4 K. ^3 H) ^9 _, i
The child slept in the same bed with parents.
9 S1 a. t) g: W% cThe father would hug the baby and hold him on his# h+ p5 m4 w# M: D. d4 {( \- e
chest for a considerable period of time, causing sig-7 S1 x5 X" @0 `
nificant bare skin contact between baby and father.9 I9 d+ Z& a: u0 d' W& u
The father also admitted that after the phone call,
8 j% z0 A6 E) ewhen he learned the testosterone level in the baby
: X7 N; A* D# O: Hwas high, he then read the product information
4 Y; q. \0 l  q6 {& O( upacket and concluded that it was most likely the rea-& e) J: Q5 D3 U: k- Y
son for the child’s virilization. At that time, they* A# o: Z8 ]$ \* m
decided to put the baby in a separate bed, and the, z/ K: Q2 k9 x2 m4 V
father was not hugging him with bare skin and had
+ e* G4 ?+ i" u* Zbeen using protective clothing. A repeat testosterone0 w1 i# u. P0 N* S% |! `/ r
test was ordered, but the family did not go to the
( w0 O: R) t# f% |% ilaboratory to obtain the test.
$ K2 y+ Z3 h0 E6 f3 }8 p: `Discussion
4 V" G  }0 q  s$ u* k8 D# T7 b! dPrecocious puberty in boys is defined as secondary$ w1 s' C9 v& A3 h1 G3 j
sexual development before 9 years of age.1,4' m- g* C. r2 A1 j. \
Precocious puberty is termed as central (true) when
% Y( f- R9 I2 r- m* s% Wit is caused by the premature activation of hypo-
) O7 b, g6 w, I6 \: mthalamic pituitary gonadal axis. CPP is more com-
2 i# |' X/ K4 ~5 H2 fmon in girls than in boys.1,3 Most boys with CPP. S$ K' _. Z2 Z: j5 ?
may have a central nervous system lesion that is; q* j, b6 `! c& l' p! y- J
responsible for the early activation of the hypothal-: u! R1 f9 L4 k" e0 b/ _9 w2 O. K3 c8 a
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ Y3 D" a& a. P( t1 Nsis has been given to neuroradiologic imaging in- `6 S+ _8 i! S
boys with precocious puberty. In addition to viril-7 P0 p' e2 M) r5 ]1 Q
ization, the clinical hallmark of CPP is the symmet-
/ L% S6 B! s: w0 p) j7 xrical testicular growth secondary to stimulation by
9 i" q. t* n6 T+ Bgonadotropins.1,3
! Q. q1 h" @# kGonadotropin-independent peripheral preco-. L& d, u: |) q+ e
cious puberty in boys also results from inappropriate
( |# I6 n+ }* ]0 }androgenic stimulation from either endogenous or
9 k3 E; W/ q) H2 E( A8 l) y( `exogenous sources, nonpituitary gonadotropin stim-
3 D+ n+ ~) R+ q* q; Eulation, and rare activating mutations.3 Virilizing
0 ~" o0 O/ y7 Z# s* ?1 _, mcongenital adrenal hyperplasia producing excessive7 ?' H7 L% @2 Y+ {8 t
adrenal androgens is a common cause of precocious; e( A# N9 {- ]/ d! h' ^7 G8 S+ q
puberty in boys.3,44 x* P4 Z* A: {6 p2 r
The most common form of congenital adrenal3 p( O! k% [' U5 z- V. l
hyperplasia is the 21-hydroxylase enzyme deficiency.
. m6 p3 r9 h( hThe 11-β hydroxylase deficiency may also result in
( b# c+ X8 y1 z$ U$ w3 k; Z# Iexcessive adrenal androgen production, and rarely,8 e+ z8 I4 `! l3 e
an adrenal tumor may also cause adrenal androgen5 V& G. `  s2 l# G
excess.1,38 [+ _& z! Y! i% U  O. O' \! S+ o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 o; G' `, p, e) J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* h2 t' ^) k% Z% W
A unique entity of male-limited gonadotropin-, ~/ W$ c' `5 r( }; J4 w
independent precocious puberty, which is also known
1 I2 n# E: j. [, D; v% s& Kas testotoxicosis, may cause precocious puberty at a$ ^# ~7 q  x1 o7 J3 D& g
very young age. The physical findings in these boys
% }( a7 X9 r( t" [$ V! h1 gwith this disorder are full pubertal development,  D8 o0 e2 c- ?' G! L! t- k
including bilateral testicular growth, similar to boys  w" c2 O1 E5 \7 F# ]/ F' y
with CPP. The gonadotropin levels in this disorder
! N- d  s! |! H0 u3 l9 lare suppressed to prepubertal levels and do not show
4 i7 g  f) B! c* F) Dpubertal response of gonadotropin after gonadotropin-
1 P& i* R/ ~- _. ~: `) j- I2 p* Yreleasing hormone stimulation. This is a sex-linked
& l5 o+ k0 H6 a6 a. zautosomal dominant disorder that affects only
. O+ z8 n% K6 i3 Q  V* X  Qmales; therefore, other male members of the family) e7 m1 z0 T$ y% ~! ~  ?: m& Y
may have similar precocious puberty.3, P1 C6 O7 V  ]  a) T; i" `" e
In our patient, physical examination was incon-: v0 i  u) Q2 T% Z& P+ k) o
sistent with true precocious puberty since his testi-
2 |& D2 z$ O* ]cles were prepubertal in size. However, testotoxicosis
: t2 z8 a; F2 s7 y' owas in the differential diagnosis because his father
" ^. i8 b9 J- _* x  G) @5 lstarted puberty somewhat early, and occasionally,
4 q/ ]. G" L& ?  y) @5 xtesticular enlargement is not that evident in the
5 F# i' f- k' B9 v1 c: v* C2 fbeginning of this process.1 In the absence of a neg-
7 B1 B) y% N" R* J7 kative initial history of androgen exposure, our
7 `1 {+ f% _9 |& h# V0 T0 ?biggest concern was virilizing adrenal hyperplasia,
3 J' u4 l1 i% M8 }either 21-hydroxylase deficiency or 11-β hydroxylase
' n: w( o; O8 V& }3 Ldeficiency. Those diagnoses were excluded by find-
! v4 C" s8 q9 C+ t& I+ B3 Jing the normal level of adrenal steroids.
7 l0 P- |2 ^5 `' z" c0 BThe diagnosis of exogenous androgens was strongly
/ Q1 r/ v( _$ L2 I1 Tsuspected in a follow-up visit after 4 months because
6 X. K% D, p* l# p2 [+ ?9 k1 O& n5 [the physical examination revealed the complete disap-
( H  l/ j/ O8 O3 B: b& A+ ppearance of pubic hair, normal growth velocity, and
3 C6 g% o, p/ g1 z5 Xdecreased erections. The father admitted using a testos-
6 L& B4 T7 a- C, a. l4 v$ ?terone gel, which he concealed at first visit. He was7 Y! y; A* }) X, U
using it rather frequently, twice a day. The Physicians’
& q/ y( o' g& g3 g8 @Desk Reference, or package insert of this product, gel or  V  m# T; m" g( @3 d. w
cream, cautions about dermal testosterone transfer to# s  }- Q# l& ?$ ?2 z1 z
unprotected females through direct skin exposure.
. n3 w" T5 B* V- O7 FSerum testosterone level was found to be 2 times the
7 O* e. `" @  Q# m' D" W- k8 C7 q6 P- zbaseline value in those females who were exposed to
! ^. F3 q1 N9 [, y1 s  Veven 15 minutes of direct skin contact with their male
9 s3 V& d# C7 J8 npartners.6 However, when a shirt covered the applica-! V+ [/ k3 d, Z3 A( }2 x% L4 Y
tion site, this testosterone transfer was prevented.
: h! v7 b+ r' {Our patient’s testosterone level was 60 ng/mL,; F% I/ J+ i$ s2 r# Q. S" r! `
which was clearly high. Some studies suggest that. I( G1 m. f) ^( r  t
dermal conversion of testosterone to dihydrotestos-
) x+ @  ^8 C2 Wterone, which is a more potent metabolite, is more. H0 h2 S$ P7 V9 ?! q( K
active in young children exposed to testosterone: B* H, u) N* A9 c
exogenously7; however, we did not measure a dihy-
! p8 x. p' D3 L, K, `drotestosterone level in our patient. In addition to
1 Z7 I. y$ h5 ^- w' x( B% I9 Dvirilization, exposure to exogenous testosterone in
+ J# M/ T7 A* L. ~: h1 h$ Wchildren results in an increase in growth velocity and# S8 x% y; ?# I+ i& y1 l
advanced bone age, as seen in our patient.
5 H! D. K' P0 }: TThe long-term effect of androgen exposure during9 ]9 Z$ C/ L( W+ u7 f5 _* R& H
early childhood on pubertal development and final
9 H" K$ N- g* \, E/ R* vadult height are not fully known and always remain4 [0 w! E/ T+ X# H- Z7 l2 d
a concern. Children treated with short-term testos-
! w0 b7 N6 T" v9 K( j# m' Bterone injection or topical androgen may exhibit some
( x' r. H* F' J+ lacceleration of the skeletal maturation; however, after
4 Q+ J4 Y$ a4 O5 X8 T9 E( Q- P9 dcessation of treatment, the rate of bone maturation
& `6 J; I: L$ G" O: f9 \decelerates and gradually returns to normal.8,9
) F# D' E$ {: X0 @+ s9 J* t# P3 }/ SThere are conflicting reports and controversy( z( y5 K3 r' [5 _) _* Z, r
over the effect of early androgen exposure on adult9 Q$ P6 L. l$ s/ q, e* b% ?
penile length.10,11 Some reports suggest subnormal) E+ [  w* t9 U* d8 r) H) ]
adult penile length, apparently because of downreg-
; W4 m1 F& n; b3 X0 U' ]9 eulation of androgen receptor number.10,12 However,
4 y) T1 H3 k4 G- pSutherland et al13 did not find a correlation between' L% C$ n, \' L2 F/ U
childhood testosterone exposure and reduced adult  R. i' R/ i  X( e6 M0 k
penile length in clinical studies.1 S* Q- Q3 u* O5 r1 h" d) N
Nonetheless, we do not believe our patient is
' u# D- w- K4 o/ _going to experience any of the untoward effects from
; K  Z4 W: T( n9 V, m* stestosterone exposure as mentioned earlier because7 z5 ~( _2 y2 g; m$ d) r% C/ m
the exposure was not for a prolonged period of time.
2 _" F9 d; L% {  K% N, C7 U: B- g% mAlthough the bone age was advanced at the time of
: ~- d& U6 u7 u, \diagnosis, the child had a normal growth velocity at
7 V) b5 V* {% F; Sthe follow-up visit. It is hoped that his final adult
/ W3 F0 B( E- R' L( W9 H% W6 kheight will not be affected." ?. p5 e3 {2 m  r; E5 L
Although rarely reported, the widespread avail-- V- A+ q( a  U
ability of androgen products in our society may
6 U5 z. D! F8 O% ~7 X- o* Z  Dindeed cause more virilization in male or female  V# o0 T2 _7 |, _" e0 k( ]- H
children than one would realize. Exposure to andro-& D5 u) v# Z# }1 \
gen products must be considered and specific ques-
1 U' D. h9 S& ]- Vtioning about the use of a testosterone product or1 |& A. Y+ z2 {
gel should be asked of the family members during
6 ?, [# C7 \5 G1 C. [" _7 tthe evaluation of any children who present with vir-
- k- h* R+ Y4 A0 Vilization or peripheral precocious puberty. The diag-
8 i/ `) I& N- [4 g) Bnosis can be established by just a few tests and by: W4 O. r" }# X. p" q, O( I" ?
appropriate history. The inability to obtain such a
5 [( _- e& W9 X* d; [" G2 Jhistory, or failure to ask the specific questions, may, r7 E  w) J8 E  ]& `; e; h( m
result in extensive, unnecessary, and expensive5 t, h# h& S/ V% _' @% @# x
investigation. The primary care physician should be+ K2 T1 s  y7 M3 K- i' n
aware of this fact, because most of these children
- v0 @1 o2 x8 O$ smay initially present in their practice. The Physicians’; X2 l: A0 G  P
Desk Reference and package insert should also put a
# z" V! n0 q$ [( z  |2 qwarning about the virilizing effect on a male or
( b+ \+ ]3 q: ~female child who might come in contact with some-
! K/ r) N( Q% D; L5 g- jone using any of these products." r' Q+ H) C, A5 m+ x* f' T
References
: u, E& @) c1 w0 j( h7 t6 K; B1. Styne DM. The testes: disorder of sexual differentiation, |. ~* A/ c3 S$ G/ u
and puberty in the male. In: Sperling MA, ed. Pediatric
7 w/ M5 |1 i( Y& _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;7 H1 ]& d( B& W" S  d( E
2002: 565-628.
* l$ P8 K: b4 @! ?' G5 \6 i5 e' I, A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' T0 H6 u5 S$ {! M. Upuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ N! I, S9 o. z4 W* uBoy Induced by Indirect Topical
+ C7 [' M3 Q! `3 P5 aExposure to Testosterone
! `7 q% T) M3 b3 x" jSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 K7 C4 G' p/ D, H# B0 ]# \
and Kenneth R. Rettig, MD1
! z" h6 p9 W3 t4 L1 fClinical Pediatrics
( E' w0 h# Y9 i2 d  F% {' z3 O+ nVolume 46 Number 62 j" Y  Z& w0 r* D2 B  M, j
July 2007 540-543
3 j% B$ \- g. _6 h1 B6 m© 2007 Sage Publications
- V% r) l' E3 n, \: `' o10.1177/0009922806296651* P6 G: m; H: G4 f) g# @
http://clp.sagepub.com
1 w* b# o3 S/ ?; F( d! mhosted at
/ U5 i# L" k" R5 g( ghttp://online.sagepub.com; v' \4 r7 ?/ K- C6 i4 {$ y
Precocious puberty in boys, central or peripheral,
( A$ V9 ^8 _4 [9 a0 A4 kis a significant concern for physicians. Central
7 e+ ?3 ^! [4 \3 Z: P% Mprecocious puberty (CPP), which is mediated
+ M  h# `* M( X8 A# ]5 o' ^- P6 U5 B5 G9 |through the hypothalamic pituitary gonadal axis, has
4 h2 J6 p) H9 ?a higher incidence of organic central nervous system+ p$ `0 s+ C1 q9 G& [) m
lesions in boys.1,2 Virilization in boys, as manifested( p$ ~- o; Y( V4 b( _
by enlargement of the penis, development of pubic
$ u9 }) z6 E+ V2 q9 h6 Ahair, and facial acne without enlargement of testi-* f) d, F2 O3 W8 Y% c
cles, suggests peripheral or pseudopuberty.1-3 We
# v# b# B$ A' t6 l2 _% oreport a 16-month-old boy who presented with the" u% D/ O; f3 x, }! {1 C4 e8 J
enlargement of the phallus and pubic hair develop-( G/ `  N0 v8 P
ment without testicular enlargement, which was due/ Y! f, [* n4 k0 C
to the unintentional exposure to androgen gel used by1 G: q7 J1 d4 V2 h6 I
the father. The family initially concealed this infor-
0 v/ i) r7 B- \' ^3 m$ Rmation, resulting in an extensive work-up for this
4 R  K' |0 [/ y8 F7 F4 h! pchild. Given the widespread and easy availability of
% ~) |3 `! J8 a1 @  ?- ztestosterone gel and cream, we believe this is proba-' Q6 q4 |3 f! \  g0 A
bly more common than the rare case report in the: Z8 }- i1 `2 y+ |4 U
literature.4
$ F6 a+ w# W# `' OPatient Report) H/ \+ b  D! L  c0 ~$ [4 ^
A 16-month-old white child was referred to the
; f9 a; Y* g- [5 `7 aendocrine clinic by his pediatrician with the concern
" w: Y( r, d$ s/ J- P# l+ Yof early sexual development. His mother noticed6 n; J, u& \1 D$ ?. E% T! V
light colored pubic hair development when he was- j5 a' a! S& ]* ~/ A* x% h5 D
From the 1Division of Pediatric Endocrinology, 2University of
: Q1 \& o# B9 o" FSouth Alabama Medical Center, Mobile, Alabama.
8 H) c  d5 Z) y' T0 QAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 D- b" |0 p: t* _" {/ y2 VProfessor of Pediatrics, University of South Alabama, College of  k% K" o$ T! N& m+ R; Q/ s, ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, T* h- L! ^  u( q5 {e-mail: [email protected].
% G9 y$ l! a* Y+ c8 Z0 |about 6 to 7 months old, which progressively became
; ?4 U7 ^: u1 s2 F: Ldarker. She was also concerned about the enlarge-7 c$ F3 p# M) s% j) b  i# p
ment of his penis and frequent erections. The child
! v: r$ L  q' o/ a3 g. @  Uwas the product of a full-term normal delivery, with3 y& P# V/ S2 w# D) [( Q
a birth weight of 7 lb 14 oz, and birth length of
0 q7 h5 u9 t; l  w  P& J" C20 inches. He was breast-fed throughout the first year6 c9 L; Y  a9 e  V' i( ^
of life and was still receiving breast milk along with
0 I! P! e& K* v9 _solid food. He had no hospitalizations or surgery,
, r( L" K  {. Q0 ]* v5 p8 C0 gand his psychosocial and psychomotor development. Y5 h+ L- J" {6 D  ]
was age appropriate.
: }' F, g( N1 I6 m: eThe family history was remarkable for the father,' j" ~& U  `' g/ b3 F! B
who was diagnosed with hypothyroidism at age 16,$ i4 t" T7 k! E6 X! v) `2 ?
which was treated with thyroxine. The father’s: i6 l4 @' Y. M# L& b
height was 6 feet, and he went through a somewhat/ X& k  U9 H9 c: Z1 ?
early puberty and had stopped growing by age 14.. s3 F% z" m  w0 B( r, l$ d
The father denied taking any other medication. The* P+ a; ~- R2 \9 j8 P
child’s mother was in good health. Her menarche7 L% H8 r! V# B7 y: E
was at 11 years of age, and her height was at 5 feet
& g) Q) ?; U7 C) O& \: {5 inches. There was no other family history of pre-
+ d* h+ @8 q1 ], Bcocious sexual development in the first-degree rela-
5 I7 Q/ m' J: @! ?tives. There were no siblings.
( q* p9 c$ [0 d) [$ s  tPhysical Examination3 l5 F( d4 R3 M8 q. J' p. H. C
The physical examination revealed a very active,
5 }/ Q. C9 v4 X2 }playful, and healthy boy. The vital signs documented
! K$ P1 [" x: S6 l3 aa blood pressure of 85/50 mm Hg, his length was: F% l3 m+ a! ?% x. h2 T
90 cm (>97th percentile), and his weight was 14.4 kg3 z- z$ H% h  p$ D- U9 o/ V% i6 `
(also >97th percentile). The observed yearly growth% H7 l3 }( P3 |$ V" t
velocity was 30 cm (12 inches). The examination of8 c; j9 p7 t: ?, s; q$ d) {5 C
the neck revealed no thyroid enlargement.
" Z. b) a6 Z- q% @The genitourinary examination was remarkable for2 a3 k% B0 {' [9 K0 i3 S3 l
enlargement of the penis, with a stretched length of) w* s8 `/ N* G2 P; ]
8 cm and a width of 2 cm. The glans penis was very well
4 h) e; Z. _5 v" u: K2 Pdeveloped. The pubic hair was Tanner II, mostly around
; u( o4 w( K1 D* F% r/ V8 Z3 ]% ]5407 n& H8 |! E3 O* |6 {. h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 e8 Y2 Z, q7 p9 u( p0 mthe base of the phallus and was dark and curled. The
- v+ g) W# F/ ?; q7 w' H; y) C. Y4 m- m8 ftesticular volume was prepubertal at 2 mL each.$ E& q3 d8 f8 f" }0 J6 f
The skin was moist and smooth and somewhat' J* B  t) k2 y  z+ L
oily. No axillary hair was noted. There were no4 m/ Q1 h" g4 c# S7 S( R
abnormal skin pigmentations or café-au-lait spots.* G" W4 g3 }7 ?: x7 ?$ o5 C
Neurologic evaluation showed deep tendon reflex 2+& ^0 E0 a+ E* ?& E, O8 ~9 {
bilateral and symmetrical. There was no suggestion
/ h+ b2 @4 ]! Q5 `- F# X: o4 yof papilledema.& u2 p& q+ |: ?  |# v* P( Q
Laboratory Evaluation- d" J/ J5 e/ s8 F4 @7 {! p
The bone age was consistent with 28 months by
6 A! w2 u" W0 _" D, Nusing the standard of Greulich and Pyle at a chrono-
) K, N# P9 ~' Nlogic age of 16 months (advanced).5 Chromosomal
8 }( N. o! p$ P2 ^7 h/ |karyotype was 46XY. The thyroid function test
' Y/ F  w- c* G# Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
# x& @, B. ]4 g8 m; x) x  vlating hormone level was 1.3 µIU/mL (both normal).( u4 i$ @2 }# l1 u, M& z
The concentrations of serum electrolytes, blood2 `1 n# d! P. Z1 F3 u
urea nitrogen, creatinine, and calcium all were
6 Z% A* d- \# |; a5 r  j# {within normal range for his age. The concentration
) |* Z) N- X) G  I( U( q2 t; Gof serum 17-hydroxyprogesterone was 16 ng/dL6 {$ s; L2 d0 J* Q' ?
(normal, 3 to 90 ng/dL), androstenedione was 207 X7 i, H, Q! ?$ X  z% I
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ w0 N3 f6 x( I
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ u, g7 O7 `& g0 b" Z9 p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to7 @7 i- R1 K- X3 g! l2 f3 m7 D1 G0 @
49ng/dL), 11-desoxycortisol (specific compound S)
) A( p4 j% L5 F8 U& ^: B3 Ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. r0 K$ Q  d2 Y$ p1 V) p1 M/ o
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' V" s, S4 b$ d% K' S# Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 j1 l, i0 y+ M- a! \and β-human chorionic gonadotropin was less than
1 w8 M8 G2 g! l" ~" e& Z$ [5 mIU/mL (normal <5 mIU/mL). Serum follicular" R1 b; ~4 G7 ]( ~6 ?# V* k( O
stimulating hormone and leuteinizing hormone8 k( w8 |6 z# }  k3 {% f
concentrations were less than 0.05 mIU/mL
* W/ L+ y, P& ?3 S9 X2 m% h(prepubertal).( `" T8 d% x2 j8 ]) v2 w
The parents were notified about the laboratory
! B) J( z  q% i, Oresults and were informed that all of the tests were6 L& D6 X1 h' E" u
normal except the testosterone level was high. The
3 b' c  [9 p' E. G1 P, G* {( y: cfollow-up visit was arranged within a few weeks to) h/ s8 i- H4 M" V$ ?( c* C1 c* N* E
obtain testicular and abdominal sonograms; how-
9 G+ g6 i# E. [ever, the family did not return for 4 months.' O  i8 w0 W( \* S' Z% V, a* z
Physical examination at this time revealed that the
! D  B" n! A" q9 ~7 J# b* Zchild had grown 2.5 cm in 4 months and had gained
8 c; \9 U, T9 f: H8 l* W+ R2 kg of weight. Physical examination remained
: H/ ?, E/ o0 @, S. [4 E# u9 Qunchanged. Surprisingly, the pubic hair almost com-  ?/ W* ~+ P5 S, v$ z8 P* @& g0 p
pletely disappeared except for a few vellous hairs at
+ m& @8 p9 Y! f) n$ ?) M8 _: q( `/ xthe base of the phallus. Testicular volume was still 2
7 W" U' R, l2 U2 ~' U# ?' p* HmL, and the size of the penis remained unchanged.* Q1 m, v  ~- |% h4 e
The mother also said that the boy was no longer hav-
' N. h- j/ Y; ~7 c% H- D. D% g0 h. Ging frequent erections.
( V, T& T( y& x3 ^4 G/ q% cBoth parents were again questioned about use of
! o' H6 |8 C8 n4 b7 Q+ @. J- r1 nany ointment/creams that they may have applied to
6 u  O4 ]) e8 u- E2 a& x3 g" n& othe child’s skin. This time the father admitted the
2 ~9 Q0 a: P: {+ V6 {; ZTopical Testosterone Exposure / Bhowmick et al 5419 W6 t9 {0 x- `; ]; ?+ G, @
use of testosterone gel twice daily that he was apply-' B6 t2 ~9 K% @% g+ g
ing over his own shoulders, chest, and back area for" o: }/ g7 z# [; m1 ]. Z
a year. The father also revealed he was embarrassed) q) y! b4 W& g  K% r: q6 U& s. U% @
to disclose that he was using a testosterone gel pre-& s) P- L. o/ A( @8 |' I
scribed by his family physician for decreased libido1 P& ~1 R, n6 C: _) y1 @+ ]
secondary to depression.
; f6 m; U. {' z& I$ P* |! ~, ZThe child slept in the same bed with parents.
. Q, n# ~8 \  G+ u' s. I' B; `The father would hug the baby and hold him on his
+ `7 f! M- z  L( C: E6 y/ Tchest for a considerable period of time, causing sig-, N: w, j4 B0 d, g2 u% L
nificant bare skin contact between baby and father., u. e% a+ p4 s
The father also admitted that after the phone call,- p( o$ ?: H0 E3 f# ?8 S
when he learned the testosterone level in the baby2 ]& U! G% P% L
was high, he then read the product information
7 [# r- T0 o# apacket and concluded that it was most likely the rea-/ d! v# D/ `' r% r% @4 d6 v4 T
son for the child’s virilization. At that time, they/ w9 p0 M4 k. I9 {  ]. n
decided to put the baby in a separate bed, and the6 O" V9 g2 f; \" `
father was not hugging him with bare skin and had4 k' n# n' n$ M% W
been using protective clothing. A repeat testosterone
0 B$ R( O! @9 j9 \+ g/ `6 `# Ctest was ordered, but the family did not go to the0 O2 {. n; x' C  U& ~2 L2 |& H
laboratory to obtain the test.
" [7 k0 H% h  U/ M7 ~Discussion" C4 K9 T3 n" {( _# x7 n- @# O  M
Precocious puberty in boys is defined as secondary3 f. J) w3 M; m# c; ~  D
sexual development before 9 years of age.1,4
) G) t# A+ T, r5 n7 S9 uPrecocious puberty is termed as central (true) when/ Y) B& {- j7 n0 C; W9 l3 F7 s3 x8 K8 C
it is caused by the premature activation of hypo-
+ @: s8 B& B+ r  O+ g" rthalamic pituitary gonadal axis. CPP is more com-
% t/ X& M. Z! kmon in girls than in boys.1,3 Most boys with CPP: U+ r  j: j1 y+ A* a- e  U
may have a central nervous system lesion that is- P1 C+ e: [/ d
responsible for the early activation of the hypothal-
* b$ ]% @5 a( s/ s2 C* }, c$ ^amic pituitary gonadal axis.1-3 Thus, greater empha-/ K# a  U: U$ R: x# b: a
sis has been given to neuroradiologic imaging in2 Y( f2 K- n  ~
boys with precocious puberty. In addition to viril-
/ n& G5 u% L  S! a- m4 fization, the clinical hallmark of CPP is the symmet-
5 ^/ I" g1 G! E& c) H, \rical testicular growth secondary to stimulation by
& @  R+ ?( E. ^! X2 Ggonadotropins.1,3' d3 c9 f. J$ m7 E; z/ F/ \; Q
Gonadotropin-independent peripheral preco-
; A  h7 V# c! e% @) t/ |( c- H- a7 {cious puberty in boys also results from inappropriate
1 l" o" T8 h5 C- D/ Yandrogenic stimulation from either endogenous or
( P: S2 y6 |; Bexogenous sources, nonpituitary gonadotropin stim-( q$ l; B) H9 p# @7 m5 y$ K$ `% C
ulation, and rare activating mutations.3 Virilizing
: c( F- I9 a1 d- t) rcongenital adrenal hyperplasia producing excessive
. j6 R" l$ }0 w0 o( Sadrenal androgens is a common cause of precocious
7 `5 U# o1 K5 W3 f5 S+ v* k+ vpuberty in boys.3,45 F5 v% j8 v, U8 \* S: L. V7 z7 Y5 p" m
The most common form of congenital adrenal
- P( Z. l4 g' t9 `hyperplasia is the 21-hydroxylase enzyme deficiency.
% e6 k! f% m7 `6 B  F  LThe 11-β hydroxylase deficiency may also result in9 P$ v" _* C5 u$ M
excessive adrenal androgen production, and rarely,
- h+ y( @* v3 T  f6 n( N$ oan adrenal tumor may also cause adrenal androgen
% b! M( d: F* e0 \( i$ M0 a" |excess.1,3
; B. p1 o6 V* e$ o( uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 c# x6 N$ o6 q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* L6 y  z- \7 G* l% ]$ `A unique entity of male-limited gonadotropin-# @% [7 }. T: b. e+ g6 c
independent precocious puberty, which is also known
2 t4 U0 h9 B* d8 r- h! Q" Sas testotoxicosis, may cause precocious puberty at a7 n" F9 e! N- b$ y
very young age. The physical findings in these boys" p% L0 t0 @& g4 o+ O2 G4 `( A
with this disorder are full pubertal development,. z" r0 J4 b8 e6 V9 B) X0 C. e
including bilateral testicular growth, similar to boys! i2 S6 Q9 {$ w( g1 e/ s) X) {
with CPP. The gonadotropin levels in this disorder% U2 L1 y6 v! O) m! n% {* U7 ]
are suppressed to prepubertal levels and do not show& I$ R% j6 W: |0 ?
pubertal response of gonadotropin after gonadotropin-7 l: Y6 T+ p5 A: Q. r
releasing hormone stimulation. This is a sex-linked& m( a! z; s, h& h, n
autosomal dominant disorder that affects only
, _! V  @. i, a. A# X& z& zmales; therefore, other male members of the family4 L- m6 W8 @( S; s1 `
may have similar precocious puberty.3- N2 g  P- I6 G5 J
In our patient, physical examination was incon-
2 D8 e- ^  s+ s6 I: y6 Rsistent with true precocious puberty since his testi-6 S% `) @. W* J" f% E0 {
cles were prepubertal in size. However, testotoxicosis
( J) t+ [# ?, Y  d9 c, Z2 pwas in the differential diagnosis because his father4 u& a7 `$ Q- x: L' O) H2 W! t
started puberty somewhat early, and occasionally,7 [6 p/ i' H" l8 b! I" U( @# T) H' I
testicular enlargement is not that evident in the
: P8 b: [4 i- x; @2 D1 \, ?beginning of this process.1 In the absence of a neg-
! {9 T; X' @% o8 Native initial history of androgen exposure, our
) t3 G  B/ x! d7 m* Qbiggest concern was virilizing adrenal hyperplasia,7 ?1 {  Q5 ?3 b, P" n" V: K& o
either 21-hydroxylase deficiency or 11-β hydroxylase
4 y  W4 }" C- J( a6 c& Mdeficiency. Those diagnoses were excluded by find-" w7 i0 Y& P/ Z" ?
ing the normal level of adrenal steroids.
. g) i. B5 I$ {& L8 o* Z& n" |The diagnosis of exogenous androgens was strongly
# x  @7 B1 t3 \$ j- esuspected in a follow-up visit after 4 months because' h3 i! R0 ~: e, k
the physical examination revealed the complete disap-6 J( K8 ?' O! l2 @0 }
pearance of pubic hair, normal growth velocity, and
" t/ ]8 r/ {" w6 ldecreased erections. The father admitted using a testos-/ R! M* ~' r* G) ~$ J0 }: }7 z: _) _
terone gel, which he concealed at first visit. He was
; p6 W3 N4 z4 ^6 n8 ^9 w# Iusing it rather frequently, twice a day. The Physicians’+ R% B4 l  H4 j5 _4 C% I: _
Desk Reference, or package insert of this product, gel or( T2 B  W9 L  G
cream, cautions about dermal testosterone transfer to
0 `+ J1 m4 c7 U( Tunprotected females through direct skin exposure.( r( }- z$ J0 g% n6 `- [5 ?
Serum testosterone level was found to be 2 times the
9 ?- _/ Y* E2 k: K$ B7 ]baseline value in those females who were exposed to
# S+ m8 i3 P( t" @0 Meven 15 minutes of direct skin contact with their male
8 s; X5 [) U/ |5 E4 |" q) Fpartners.6 However, when a shirt covered the applica-$ o; O* k. F& {- ?
tion site, this testosterone transfer was prevented.
! b- _& ], v4 X) G$ w4 L) cOur patient’s testosterone level was 60 ng/mL,9 X1 ?8 E+ \  T8 E  [. `# z/ p
which was clearly high. Some studies suggest that
9 k  ~  _! b, r. M) |) _1 Z  `dermal conversion of testosterone to dihydrotestos-8 v; @* g3 h  G3 A" L
terone, which is a more potent metabolite, is more
; o( Z: ]4 a- l3 \) I5 b* Vactive in young children exposed to testosterone7 U  J( L( k! c/ S
exogenously7; however, we did not measure a dihy-# G# }% A0 J4 e
drotestosterone level in our patient. In addition to
) e. w4 C" A: q2 v4 @( {6 q# Q, @virilization, exposure to exogenous testosterone in
$ k( _3 D: B# H* m& b% \2 c3 ?children results in an increase in growth velocity and
; v% `% T; M3 {  N2 aadvanced bone age, as seen in our patient.
: m$ [+ X4 B4 A3 A6 i+ ]/ \The long-term effect of androgen exposure during- G" ]" Q1 ^/ q0 a  n- J
early childhood on pubertal development and final9 Z. V! |) f/ U& T5 U
adult height are not fully known and always remain* m- ^: D9 e, r4 F( w3 S
a concern. Children treated with short-term testos-
, d; X/ L$ t7 @1 ?; @+ g# J9 sterone injection or topical androgen may exhibit some& i# M0 a$ q# G  E1 @$ O$ F
acceleration of the skeletal maturation; however, after
3 K! `& l, L; N; Ccessation of treatment, the rate of bone maturation
3 l# a2 Y9 }' T5 M$ Ldecelerates and gradually returns to normal.8,9
. v1 z( P5 B& n) X5 wThere are conflicting reports and controversy; X* n1 {4 @' Q4 k" q! Q
over the effect of early androgen exposure on adult( p5 Y/ f0 P9 m) v+ W0 a# g6 P
penile length.10,11 Some reports suggest subnormal9 T' j0 D7 @1 i5 D* Y8 P
adult penile length, apparently because of downreg-  k$ E* [' ]% @2 Q
ulation of androgen receptor number.10,12 However,6 y5 D1 m7 T* z2 N4 ^, \: C
Sutherland et al13 did not find a correlation between
8 N. O# }0 F/ lchildhood testosterone exposure and reduced adult
' q' t4 V( k1 T, u: h- upenile length in clinical studies.4 t7 u# Y+ v# N5 K, u. H/ D2 B) R
Nonetheless, we do not believe our patient is5 d) k1 V4 ^2 h. @# E  y* a
going to experience any of the untoward effects from8 P7 q. P1 N8 t; O; I. L
testosterone exposure as mentioned earlier because( t- v: w0 b& p/ }' R
the exposure was not for a prolonged period of time.0 H* \' t3 j* f2 P6 Z
Although the bone age was advanced at the time of
7 Q. w0 Q/ r  g  a) R6 Y0 q0 Idiagnosis, the child had a normal growth velocity at, p5 L7 J/ {3 C. g1 j9 s) {8 \  t
the follow-up visit. It is hoped that his final adult4 \& c$ Q; `9 E
height will not be affected.* N6 F& G, C3 O/ H7 D* W  B
Although rarely reported, the widespread avail-
: t- \) L6 w2 R* D# Z" V; G: D0 dability of androgen products in our society may$ |" e7 c+ [+ E9 E
indeed cause more virilization in male or female
5 e/ c. ]8 T' V9 }+ ]children than one would realize. Exposure to andro-
, A0 A  m$ d) T! ]! qgen products must be considered and specific ques-
) f/ G. T! C! A( ]tioning about the use of a testosterone product or& g# H$ p5 |8 x4 g. }# i' S1 V
gel should be asked of the family members during- f! U: G3 x. q/ y! V
the evaluation of any children who present with vir-
9 C+ g; b* [7 w  \9 `( `ilization or peripheral precocious puberty. The diag-* l! n1 C: T1 ]. J
nosis can be established by just a few tests and by
) j1 y8 D. N9 Q0 Mappropriate history. The inability to obtain such a
. n& ~6 I# _8 w! Thistory, or failure to ask the specific questions, may
4 o- V% d; X. L8 o3 ]result in extensive, unnecessary, and expensive
4 p. ~+ C4 V- [5 e. V" t: Kinvestigation. The primary care physician should be
5 ?% z# |: ?1 _  X: w3 @aware of this fact, because most of these children
0 z5 v, \. `8 x& w0 Jmay initially present in their practice. The Physicians’/ T$ Z. J" P  E% j9 o6 W/ d# @
Desk Reference and package insert should also put a
( g9 O% h9 S3 ?0 z  Owarning about the virilizing effect on a male or8 I" l, Z: z* X
female child who might come in contact with some-
$ g) Z% N0 E1 F, e* ione using any of these products.
9 k3 _5 Z4 U1 h4 Y; e4 d2 |4 {+ {% YReferences- e) v( H3 j  ]( Z- Q
1. Styne DM. The testes: disorder of sexual differentiation
7 K- b. }8 V6 U+ wand puberty in the male. In: Sperling MA, ed. Pediatric1 w, U9 w; y" A. l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 l! \. B% ?5 c3 Y2002: 565-628.
0 j; W+ R& g8 S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% u% o1 V% H4 c0 f( R
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
9 o/ K& `  e! c
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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