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Sexual Precocity in a 16-Month-Old3 K8 ]& y, D9 d/ ?6 [
Boy Induced by Indirect Topical
4 Z0 z7 w* h/ U+ `+ L: e% p$ MExposure to Testosterone
9 W) ]0 \! G; g4 ASamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 _& `0 ^3 {7 z; u2 _
and Kenneth R. Rettig, MD1, K8 u. a- y) s0 E0 R
Clinical Pediatrics
: l/ S1 V' s2 w3 T) Q  X' S. aVolume 46 Number 6  R* V/ b' K. L0 p- h
July 2007 540-543
% F, D' _4 c  m3 x© 2007 Sage Publications2 ?! \/ _, L0 @0 I/ T5 a$ h
10.1177/0009922806296651
0 w% y% J3 d+ C5 n8 C  zhttp://clp.sagepub.com" d. ?/ a$ H  e* Q# I
hosted at8 C1 ?' `* D, Y
http://online.sagepub.com
( X$ ~; J. }4 Q. e' ~+ M; vPrecocious puberty in boys, central or peripheral,' r2 h% F3 L& \+ ]
is a significant concern for physicians. Central
5 x2 ]/ N+ j/ W- q0 Pprecocious puberty (CPP), which is mediated
2 z% ~4 y  b7 w' othrough the hypothalamic pituitary gonadal axis, has9 x, t0 {; G! O- a1 M
a higher incidence of organic central nervous system
  B- v9 f9 @5 s! q6 l( r2 @lesions in boys.1,2 Virilization in boys, as manifested" n3 u& z& J0 Y
by enlargement of the penis, development of pubic. h+ p! X$ T& _; Z) @  V* T" G
hair, and facial acne without enlargement of testi-
% i( Z3 r# d/ C1 N$ Q' \! Vcles, suggests peripheral or pseudopuberty.1-3 We6 Q  q( T8 Y( M: u
report a 16-month-old boy who presented with the% H3 ^3 q8 K: d" I# r
enlargement of the phallus and pubic hair develop-
$ K1 e$ Q) o/ C. p6 m3 sment without testicular enlargement, which was due
/ c3 j+ ]! A/ jto the unintentional exposure to androgen gel used by/ x9 S* F. X( H8 z; G+ o( y4 {' u
the father. The family initially concealed this infor-& g# y7 c% f0 G3 `& y, C7 \! N
mation, resulting in an extensive work-up for this6 `1 E( z9 g& [' Z' x* |
child. Given the widespread and easy availability of0 _5 c; e# y9 I# C; {
testosterone gel and cream, we believe this is proba-) y/ C. s; i" v; W: R
bly more common than the rare case report in the
9 g& a) r1 U2 S& Y5 g6 s) D+ Rliterature.49 B* ^) A! c( }& v
Patient Report
8 G  V2 o- L$ l5 d& o, BA 16-month-old white child was referred to the! L, |( }0 e/ M# L' i' e
endocrine clinic by his pediatrician with the concern
( \0 {( m. d4 x3 sof early sexual development. His mother noticed
. h( ?8 `6 l9 `; ?5 w$ q' ?# \light colored pubic hair development when he was
- T5 q- v" I! c2 I; i  zFrom the 1Division of Pediatric Endocrinology, 2University of- ?9 {' p# n- x
South Alabama Medical Center, Mobile, Alabama.+ z! x" B" `4 N( p  o( r( Q. J
Address correspondence to: Samar K. Bhowmick, MD, FACE,: G4 R* O. r# u, w" `( e
Professor of Pediatrics, University of South Alabama, College of% f; u' k1 U' O) I$ q' B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ u; f- d- G1 I8 a9 I
e-mail: [email protected].
; j/ f$ f9 \7 p$ y9 y. \about 6 to 7 months old, which progressively became
/ Q/ v* r$ T8 t- P" L& ~, c0 X& kdarker. She was also concerned about the enlarge-
) X* O! h3 n0 Nment of his penis and frequent erections. The child
- x7 k6 Q/ C$ r, q3 V6 ^* Wwas the product of a full-term normal delivery, with
2 P( s0 O* e/ V! D; P2 O8 wa birth weight of 7 lb 14 oz, and birth length of+ x8 g6 u, w' j
20 inches. He was breast-fed throughout the first year( W0 b$ h$ b+ m( z" l! I& z& L& P
of life and was still receiving breast milk along with6 H# \/ ^) C/ {: K# b6 B( p  Q3 s
solid food. He had no hospitalizations or surgery,
, L( O# q5 R, g/ `/ sand his psychosocial and psychomotor development
3 w9 H5 [" e5 b7 H# [/ Ywas age appropriate.& {; ~. e2 J" w5 q* n; l' ^1 L
The family history was remarkable for the father,) J; D8 l. Y  p$ b. P( V
who was diagnosed with hypothyroidism at age 16,
& |6 l  T% D% ~which was treated with thyroxine. The father’s
# S' ?3 w! J1 o7 n, G: Hheight was 6 feet, and he went through a somewhat% h7 p2 I: G0 H2 c# ]1 H3 t5 [! O
early puberty and had stopped growing by age 14.
' Q' [# C# L( M& j1 @5 SThe father denied taking any other medication. The+ \. l9 j5 x+ H8 H- e
child’s mother was in good health. Her menarche& P' y$ _; C5 @1 z+ k
was at 11 years of age, and her height was at 5 feet' d' D6 U" B% q
5 inches. There was no other family history of pre-7 n$ H8 T6 C8 T. ~/ \6 V' ]9 h
cocious sexual development in the first-degree rela-: T- w8 _) \" ~  A2 q- _
tives. There were no siblings.
! N7 a" @$ h0 Q1 N7 ^Physical Examination
# ~. G: k. g6 @The physical examination revealed a very active,
) O: @% D# W9 Lplayful, and healthy boy. The vital signs documented. B) |% O/ e9 G+ S! F3 g  x
a blood pressure of 85/50 mm Hg, his length was' t) p" w0 m5 I$ h2 d5 W
90 cm (>97th percentile), and his weight was 14.4 kg
" C( S& H5 L- Z+ l1 Z$ q! z- V(also >97th percentile). The observed yearly growth
$ G9 G. d' \/ K; ?; _: g" o% nvelocity was 30 cm (12 inches). The examination of: [' o* A+ G7 [' c* V( l/ Z
the neck revealed no thyroid enlargement.
# o, [* L$ C1 ^: u& H  M2 T0 ^The genitourinary examination was remarkable for& Q5 |% x) K7 m( y8 q& U
enlargement of the penis, with a stretched length of
1 z4 h: p$ `6 i' k7 ?8 cm and a width of 2 cm. The glans penis was very well
" M( i( q0 f8 \. _; e) Qdeveloped. The pubic hair was Tanner II, mostly around. |+ M" F; m- D9 _0 f4 d
5408 C  s1 i! u' F+ r1 g0 i5 K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ z; U" A1 v' o: M
the base of the phallus and was dark and curled. The
1 ^( r, }: l2 f# N7 V/ X9 Y) x5 Htesticular volume was prepubertal at 2 mL each.: C1 f3 F2 m* n! O+ |. `2 L4 e. y
The skin was moist and smooth and somewhat; q. ~+ c5 b( H- W  m- t( u
oily. No axillary hair was noted. There were no+ ^. M) p" r: T6 o3 l
abnormal skin pigmentations or café-au-lait spots.
- J9 q4 K5 v: K; pNeurologic evaluation showed deep tendon reflex 2+7 X5 o% a) f& \3 _0 ?8 v+ ~/ I
bilateral and symmetrical. There was no suggestion
) g- n# I/ L& i9 z+ Rof papilledema.
2 v& H6 w5 C+ `+ TLaboratory Evaluation
# x, ]- K. O2 ~5 IThe bone age was consistent with 28 months by
" b  i9 V$ t3 L% p' H  iusing the standard of Greulich and Pyle at a chrono-
2 f5 `6 L1 F6 x, v9 [8 elogic age of 16 months (advanced).5 Chromosomal4 Y# ]# p# p! a. u
karyotype was 46XY. The thyroid function test
% N# i! s& I2 h4 Z! \) _showed a free T4 of 1.69 ng/dL, and thyroid stimu-' K9 [( I1 q1 J7 F
lating hormone level was 1.3 µIU/mL (both normal).
* ^$ \6 {/ w9 j. v7 J7 d4 iThe concentrations of serum electrolytes, blood' Y; y9 g9 ~9 |: G8 W9 g% {4 D) p
urea nitrogen, creatinine, and calcium all were
* m6 T1 b7 \5 B/ F' f" Y, i& B9 p4 ^, \, fwithin normal range for his age. The concentration5 x8 k0 }3 `8 Q0 m( }  u0 o7 l9 i& B
of serum 17-hydroxyprogesterone was 16 ng/dL
/ U! t2 Q. O4 w- J: q$ u(normal, 3 to 90 ng/dL), androstenedione was 204 J, _. M& r: V4 i# L
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; K8 W, G% W; O; [$ |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" M: j3 ?. }2 J% Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
) B2 w! w- Y  C( @6 r& k49ng/dL), 11-desoxycortisol (specific compound S)
8 n1 z: P6 ~$ a' [was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 p: \# x3 d) Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 |; k/ K* W  T# P  W9 _7 ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ p7 ]0 e6 U9 }- {0 R0 F6 m  _and β-human chorionic gonadotropin was less than
- f& Z' C5 f% S7 ^& s9 r5 mIU/mL (normal <5 mIU/mL). Serum follicular, X5 R" `+ N0 l
stimulating hormone and leuteinizing hormone
0 K: w0 @/ N$ b: |- \  ?concentrations were less than 0.05 mIU/mL
, _  p0 I  o' G6 |3 D6 k' [8 H$ J(prepubertal).
7 I& j, H4 ]5 o$ q& XThe parents were notified about the laboratory
7 |* w9 f2 H8 k$ Rresults and were informed that all of the tests were( D. Y4 L* R2 r% ]2 n  A7 [9 T8 Y
normal except the testosterone level was high. The& @( d( n) t8 R4 s
follow-up visit was arranged within a few weeks to
/ J: u. i( J4 o6 q/ e7 x' i! pobtain testicular and abdominal sonograms; how-" V) V' c3 L* L& z( b+ K
ever, the family did not return for 4 months.4 B0 r0 f2 g0 n1 B$ I  H/ I" ]# L
Physical examination at this time revealed that the# Y( v% [# i# V" i+ M1 O1 q. C: @7 d* I
child had grown 2.5 cm in 4 months and had gained& K7 b. j  C' e+ d
2 kg of weight. Physical examination remained5 Z" E: Q% `3 L0 d, N4 t% p
unchanged. Surprisingly, the pubic hair almost com-
7 [2 j" ^- t/ B  @1 K- opletely disappeared except for a few vellous hairs at+ A# H* R' [; T4 K, n" B
the base of the phallus. Testicular volume was still 2
# c9 Q% W4 C* lmL, and the size of the penis remained unchanged.
) J$ W, _% [4 B" iThe mother also said that the boy was no longer hav-" B& j/ ]: H8 ^7 R8 ~$ [
ing frequent erections.
1 r, y7 U5 s# x; V4 w( bBoth parents were again questioned about use of8 X, f5 L' k( o! _# l* Y
any ointment/creams that they may have applied to8 k1 H7 r" R. m
the child’s skin. This time the father admitted the) Z/ a4 j$ {, v+ j
Topical Testosterone Exposure / Bhowmick et al 541
  U; o% a: }& T$ e6 ~use of testosterone gel twice daily that he was apply-3 ^$ ?( k; ~4 J3 t$ D& Y5 b8 }
ing over his own shoulders, chest, and back area for  C& k8 P1 Z1 m" {; f6 a
a year. The father also revealed he was embarrassed
& x9 d1 ~4 j  N7 K( ato disclose that he was using a testosterone gel pre-
4 |0 P0 r" M! escribed by his family physician for decreased libido, d, X6 o. X& z5 m. ^* a. I
secondary to depression.
% T  l/ A' t/ |The child slept in the same bed with parents.
  ~+ T8 i. T! ]8 b2 {0 R& A+ ?The father would hug the baby and hold him on his9 V9 J* e8 F) t" N
chest for a considerable period of time, causing sig-- v( F8 T% y0 F2 I: _2 D; R
nificant bare skin contact between baby and father.5 ^0 x' j5 h) |$ C  M, t5 @3 a
The father also admitted that after the phone call,; C/ ~* j& W/ ?  t* {" b
when he learned the testosterone level in the baby) L/ M$ |, V- f. b) n
was high, he then read the product information
/ b2 a$ l0 P4 p" Hpacket and concluded that it was most likely the rea-
& V  W. o* c+ r/ B( I- Xson for the child’s virilization. At that time, they
  Y, z# [; D/ |decided to put the baby in a separate bed, and the
$ D- x/ n" l: h( X+ Zfather was not hugging him with bare skin and had
: \. T" U- s1 @0 }0 w1 N: |/ kbeen using protective clothing. A repeat testosterone
4 P/ S( V. k1 u0 a& @4 dtest was ordered, but the family did not go to the
; e3 j- S( [; Dlaboratory to obtain the test.
( f; ?! s: f7 _7 t$ N2 P: rDiscussion
. o* X  }( d1 Y  B2 ZPrecocious puberty in boys is defined as secondary9 [: J, l* Y( ?' X
sexual development before 9 years of age.1,4
$ Q- c2 B3 Q, s# kPrecocious puberty is termed as central (true) when
0 K4 @6 K6 @" ]% G' K( i! r: G1 _it is caused by the premature activation of hypo-
& C2 j& j0 _1 h# J  n4 V$ A; sthalamic pituitary gonadal axis. CPP is more com-
6 U$ C' q+ j, F* B  h0 ?mon in girls than in boys.1,3 Most boys with CPP
, V1 t, U! |+ V' c3 m3 ]  jmay have a central nervous system lesion that is
; [- g! u4 @* I* G# H# Aresponsible for the early activation of the hypothal-
1 Q) [3 T9 u4 q$ a  qamic pituitary gonadal axis.1-3 Thus, greater empha-
0 I4 z# |9 q) C# v$ c& R7 t+ Bsis has been given to neuroradiologic imaging in0 C# {: D$ H; y. [9 o) q
boys with precocious puberty. In addition to viril-% r) |- z% K  g* ^6 {
ization, the clinical hallmark of CPP is the symmet-6 H8 S: X$ u* J8 K% O
rical testicular growth secondary to stimulation by- {8 Y/ r3 K% z: z5 Q, K
gonadotropins.1,3- M2 n; P" h8 I! R* w6 s
Gonadotropin-independent peripheral preco-+ K: G& z% h5 z- b0 s
cious puberty in boys also results from inappropriate
- c, y4 z( b6 S, Q8 r( oandrogenic stimulation from either endogenous or
+ q8 ]( B$ @# {exogenous sources, nonpituitary gonadotropin stim-0 u# H; r7 D7 S- \6 p! ~7 Q3 |
ulation, and rare activating mutations.3 Virilizing
) E1 _' U; v- U4 Y( M& _' Gcongenital adrenal hyperplasia producing excessive9 _0 }& n/ z# h+ F
adrenal androgens is a common cause of precocious6 G0 e2 s3 L; V8 i+ |. ^) a# @
puberty in boys.3,4! e3 Y: H+ S6 Q
The most common form of congenital adrenal
5 h. Y( R) K$ W/ ~hyperplasia is the 21-hydroxylase enzyme deficiency.; {9 u+ j4 n" S( K( O
The 11-β hydroxylase deficiency may also result in
  e# g( |5 B. Rexcessive adrenal androgen production, and rarely,, }0 Q# l" ~* b, V
an adrenal tumor may also cause adrenal androgen5 Z2 X+ i% ]3 D# B  ^6 }3 Y# e5 D$ f
excess.1,3
; f; o# }" s3 {8 M% Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 L' E; r" `9 Y3 J( L
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" y1 J' i; o' hA unique entity of male-limited gonadotropin-2 S0 F* r5 ^) F: S
independent precocious puberty, which is also known
' Y2 b* U2 p1 ?- Las testotoxicosis, may cause precocious puberty at a4 x9 ]0 }& h5 i8 l: D6 [
very young age. The physical findings in these boys
3 S" _* @8 E+ D& awith this disorder are full pubertal development,
* P' @1 _) C: [/ vincluding bilateral testicular growth, similar to boys
) J# ^6 C% Q8 Z5 o( I5 Qwith CPP. The gonadotropin levels in this disorder1 C% G, _- F% o0 P; D0 O
are suppressed to prepubertal levels and do not show
5 Y# l' _+ s/ c1 upubertal response of gonadotropin after gonadotropin-+ u% @. {* p1 I7 _+ n+ g
releasing hormone stimulation. This is a sex-linked
5 v. o, U& J9 n2 \* m3 S3 Tautosomal dominant disorder that affects only
" w# A3 Z0 I) Q' s: x$ U4 Cmales; therefore, other male members of the family
3 k. S5 u  Y; r( l1 @may have similar precocious puberty.3+ o- Z' a0 K- S( R7 D. c
In our patient, physical examination was incon-, l! K8 e! J& v4 {* G/ `& |. p! t& W9 L& w# S
sistent with true precocious puberty since his testi-
% `5 i0 F8 D' A# |2 q; {) Hcles were prepubertal in size. However, testotoxicosis0 p3 ?  U# L  F9 Y
was in the differential diagnosis because his father
* I% |) _; p" ?8 _3 mstarted puberty somewhat early, and occasionally,4 H# Z" {( x( }
testicular enlargement is not that evident in the
0 K2 ]  }. g# q% \$ p$ `- u4 g) \beginning of this process.1 In the absence of a neg-
1 p# i! h$ d* k5 j0 T& p- Z9 Hative initial history of androgen exposure, our
; L' d; }, m; Y0 G; G7 xbiggest concern was virilizing adrenal hyperplasia,
) U, q$ F9 H6 ^either 21-hydroxylase deficiency or 11-β hydroxylase
* d8 v8 j' S" C. @# W0 G, ?deficiency. Those diagnoses were excluded by find-
- c% R- v% J7 R) iing the normal level of adrenal steroids.
% I" o  H" E2 W6 W8 k/ \- Z( GThe diagnosis of exogenous androgens was strongly: `7 v) U9 R  G# I$ A
suspected in a follow-up visit after 4 months because6 R, }# [9 t& R5 U! G* _
the physical examination revealed the complete disap-' K1 H; ]5 E, B; j+ A2 {- z
pearance of pubic hair, normal growth velocity, and
; d: M2 b* B+ b! T$ adecreased erections. The father admitted using a testos-2 e, ~# r5 C* v2 I  H& s5 }/ D: n
terone gel, which he concealed at first visit. He was5 H' a3 x# Q) y
using it rather frequently, twice a day. The Physicians’
0 I4 Z2 G- v+ h: `  W% O' HDesk Reference, or package insert of this product, gel or
& q" ~. _2 c3 T9 E$ jcream, cautions about dermal testosterone transfer to7 V) h2 a% u# l" X9 \) k- ^
unprotected females through direct skin exposure.
6 E2 a) v8 T3 X- D5 p* U! ~$ [Serum testosterone level was found to be 2 times the
% |* D# n2 X. tbaseline value in those females who were exposed to2 F& j% n1 c* U% }% H: a# P$ s) d+ P+ n
even 15 minutes of direct skin contact with their male
9 d; k( I9 ^$ \' \1 R/ j; d$ }partners.6 However, when a shirt covered the applica-
& s0 Y+ n: Q1 P% ]7 z( @7 Ption site, this testosterone transfer was prevented.6 V3 U% _; {' J# C, @6 q. `" h7 A
Our patient’s testosterone level was 60 ng/mL,
" w% H2 T% B5 l: J' y! v1 mwhich was clearly high. Some studies suggest that& B1 Z1 P  V- |" D( }% ]/ A
dermal conversion of testosterone to dihydrotestos-
" r8 L* x) j- U" t) Hterone, which is a more potent metabolite, is more$ @9 G! L4 p4 L$ ~  T$ ?
active in young children exposed to testosterone& c0 b; {7 Y; m( j8 Y" y
exogenously7; however, we did not measure a dihy-
0 N. K' d' ~* P/ qdrotestosterone level in our patient. In addition to
2 R* _. e/ ^0 S' G2 |1 ~4 B6 \: |virilization, exposure to exogenous testosterone in
$ Y  t. L6 F0 {: Gchildren results in an increase in growth velocity and. a; Y( ~; e: Y/ e% v3 ^! M
advanced bone age, as seen in our patient.& B( j2 u/ ?& w
The long-term effect of androgen exposure during/ ~1 Y3 ~' l" h* K+ G
early childhood on pubertal development and final
. K( _# {8 j- t" fadult height are not fully known and always remain
6 w/ r! x4 n5 j5 [. W8 Z  da concern. Children treated with short-term testos-6 M$ M9 f% @% A2 s' b+ Y& |
terone injection or topical androgen may exhibit some' d) e( r4 D7 z/ R1 t5 D
acceleration of the skeletal maturation; however, after
4 _! W6 W2 B- W3 qcessation of treatment, the rate of bone maturation! \& E! C$ C' A  m
decelerates and gradually returns to normal.8,9
9 ^: B' p$ a7 g, r2 q( V& M! gThere are conflicting reports and controversy' u- l. k1 v7 N3 T1 r9 l
over the effect of early androgen exposure on adult& K6 M8 P: L; H2 x" p+ J( a
penile length.10,11 Some reports suggest subnormal
2 b: h" `8 C. l& H) qadult penile length, apparently because of downreg-' i' ]! ^3 n9 W3 E- T/ N
ulation of androgen receptor number.10,12 However,
0 ?* X8 a; g3 u( H6 s- ISutherland et al13 did not find a correlation between( h; z) M9 \- h" a. G  [" Y
childhood testosterone exposure and reduced adult
) |" B5 O% h0 i  w( q) R7 kpenile length in clinical studies.
2 E/ {) P5 W' Y0 s  |8 J2 R0 eNonetheless, we do not believe our patient is0 t" J' q! L% q; d% ^- x9 b6 ~
going to experience any of the untoward effects from& W/ n5 l7 |1 l& D6 B6 x4 @
testosterone exposure as mentioned earlier because4 Z/ n) ^5 q7 ?! E: q, S
the exposure was not for a prolonged period of time.$ L+ O2 W" @$ t. Q) {
Although the bone age was advanced at the time of# h% u& f* V7 B8 |8 l5 v
diagnosis, the child had a normal growth velocity at' f0 M, Z6 `, w& d+ `
the follow-up visit. It is hoped that his final adult* Y, Z2 P7 }  z. A, y. l7 D
height will not be affected.
) r6 V- d# z- {0 K2 jAlthough rarely reported, the widespread avail-
- d* h$ P* ?; C% Oability of androgen products in our society may
: l6 d- w6 Q+ d5 Z6 X- }# Y3 gindeed cause more virilization in male or female2 h$ P) ~* c6 T' r9 t* u
children than one would realize. Exposure to andro-# Q9 L% m' q" n  O. R  F8 G! J
gen products must be considered and specific ques-& U: f& S1 k7 R! D) k
tioning about the use of a testosterone product or: O: D/ y* Z- J* v/ U/ \# B# ~' B9 ~& i
gel should be asked of the family members during! E" u6 F- @) F4 m0 B  a
the evaluation of any children who present with vir-5 a8 w8 }; j  [; x9 B9 Q- e
ilization or peripheral precocious puberty. The diag-) m' [- }- u6 z+ `& p/ Y' p
nosis can be established by just a few tests and by6 w( t$ _5 N4 R0 j7 R
appropriate history. The inability to obtain such a
6 x6 |8 h9 n. v% E2 P$ zhistory, or failure to ask the specific questions, may* D/ `& ~7 ?9 n# ?  X) t
result in extensive, unnecessary, and expensive0 P1 [! m+ v* p  m/ s
investigation. The primary care physician should be; p! c7 p) |3 j
aware of this fact, because most of these children
4 ^6 b8 u- C+ r& rmay initially present in their practice. The Physicians’! j) r+ ^- v) q9 a" J, F# s
Desk Reference and package insert should also put a
. v1 E9 \: D: M) `3 j5 w8 k  Dwarning about the virilizing effect on a male or
/ a, e+ H" x2 U8 ?' A' [+ zfemale child who might come in contact with some-0 g6 H# W' n) y; e
one using any of these products.% V0 C: x* a( U, P3 V
References! e, e/ Q$ Q/ X& \
1. Styne DM. The testes: disorder of sexual differentiation
1 h) w! s) D+ G" S7 ^0 dand puberty in the male. In: Sperling MA, ed. Pediatric! \* C# `& G  |3 S/ \& K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" y2 k) s* D2 f: \0 K7 T7 g: A2002: 565-628.
+ L" a- ]6 [. m! `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) b  z4 W/ w- W+ c8 g' r4 q4 k5 a' `puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: m) Q6 e" D2 r& s
Boy Induced by Indirect Topical
& i: Y5 _; ]/ K# d% e  IExposure to Testosterone/ O7 i8 M6 n1 J4 R" T/ K3 R
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, L8 G4 t2 W9 D1 Z2 f) c) t; r0 m: Q
and Kenneth R. Rettig, MD15 [9 _+ D5 b3 r" V* _6 x
Clinical Pediatrics5 D3 [3 _8 m2 c( y0 g
Volume 46 Number 6
! t- M. r& N. ?6 b" gJuly 2007 540-5432 J( y: y# h2 c9 p8 R
© 2007 Sage Publications
: n$ I3 [% d$ w, o10.1177/0009922806296651
0 F' z( y9 ^1 T% X. y1 w# uhttp://clp.sagepub.com# R) c( H7 m' _" Q9 g+ K
hosted at
; h- h* ^0 N, R$ C2 G6 O7 ghttp://online.sagepub.com' _1 N9 c7 |# i; }" c& @
Precocious puberty in boys, central or peripheral,
  g" z' O- W# l. d8 uis a significant concern for physicians. Central
9 X3 o. [; l9 Rprecocious puberty (CPP), which is mediated
: d$ Z4 R) m# zthrough the hypothalamic pituitary gonadal axis, has& o$ M$ T- ?3 w, m7 W# {7 D- |
a higher incidence of organic central nervous system
- G2 `$ V$ v" D- m7 g6 i4 j3 slesions in boys.1,2 Virilization in boys, as manifested- t4 A( E: ?% |
by enlargement of the penis, development of pubic3 \& z: r8 M2 J4 d& ]8 G
hair, and facial acne without enlargement of testi-
% Y7 o- D. l- V: fcles, suggests peripheral or pseudopuberty.1-3 We
) V# q( h. a1 f: `- i& z! Xreport a 16-month-old boy who presented with the
  T  R& x! H4 henlargement of the phallus and pubic hair develop-$ B' O& h+ ^" M" P8 G, N9 Y8 D
ment without testicular enlargement, which was due
0 j# r2 C3 x( z8 @to the unintentional exposure to androgen gel used by, t( U, J9 M) E) X* r
the father. The family initially concealed this infor-$ L0 r5 ]' X9 x3 ]: e
mation, resulting in an extensive work-up for this, l  n' g1 d( m0 W7 A6 a
child. Given the widespread and easy availability of* m5 h% i& m0 ?; p
testosterone gel and cream, we believe this is proba-
1 L  U' R5 e* n" ]bly more common than the rare case report in the% J/ [1 v4 a  O3 S* `
literature.48 Y/ A' v! g  x( t) M& K
Patient Report, E8 ]  y& W  X1 J" G+ O
A 16-month-old white child was referred to the; H% F9 h2 q3 X6 I/ Q
endocrine clinic by his pediatrician with the concern3 i) ^7 y, a( f
of early sexual development. His mother noticed
" O. W# V. R9 R- E7 Clight colored pubic hair development when he was& G3 x0 [  w5 @1 c
From the 1Division of Pediatric Endocrinology, 2University of
; L" h& D/ t/ Z/ f4 N( k+ RSouth Alabama Medical Center, Mobile, Alabama.; ]" b6 J  O" Z! |, x" h7 V$ _
Address correspondence to: Samar K. Bhowmick, MD, FACE,: U) f9 c( F; Q8 P( C' s
Professor of Pediatrics, University of South Alabama, College of4 u( @9 e2 }* F$ p( y: B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, X: T* l: X9 E  `; H8 b0 t
e-mail: [email protected]., K- |4 @' `& e
about 6 to 7 months old, which progressively became
: Q: t  N* L2 N: edarker. She was also concerned about the enlarge-5 m( ?2 |/ I9 j4 E  I) Z2 F
ment of his penis and frequent erections. The child9 g: {# z; c; Z7 [( i
was the product of a full-term normal delivery, with+ X" t: U2 d0 J. H; [
a birth weight of 7 lb 14 oz, and birth length of5 w. I7 ^: ~' J1 p( o1 t& @" V
20 inches. He was breast-fed throughout the first year0 ^% J  A' T- W9 @! |& S
of life and was still receiving breast milk along with
9 j4 `6 Z' t- L6 Lsolid food. He had no hospitalizations or surgery,
( X6 r" {( U) iand his psychosocial and psychomotor development
: W8 j- r  Z0 u2 j- M% Bwas age appropriate.
+ a' T4 M' s' ?2 i1 g( w9 LThe family history was remarkable for the father,
% n2 B5 z  o6 Iwho was diagnosed with hypothyroidism at age 16,) L' j: ~% G7 W' r( p* N  x) R
which was treated with thyroxine. The father’s
4 \4 D3 p: o, ~2 ^1 @* F# ]: k; Hheight was 6 feet, and he went through a somewhat
& K# k0 I* M9 Q, q. ^" n- searly puberty and had stopped growing by age 14.
' p1 ]) {5 K- o, FThe father denied taking any other medication. The
' M3 V; Q9 |- m. k+ Z# |7 R- wchild’s mother was in good health. Her menarche7 b" @- @* r& G' J2 z! s1 j
was at 11 years of age, and her height was at 5 feet* K' ]. a  t, Q
5 inches. There was no other family history of pre-
) G! Q% M+ ~$ y% `2 P/ Ccocious sexual development in the first-degree rela-% F+ B7 c( k; E( g9 N. B
tives. There were no siblings.
& W! o  l  O1 o' n% SPhysical Examination3 x& s1 M$ ^0 Y. \
The physical examination revealed a very active,3 G" G2 t% `! ?1 s, U
playful, and healthy boy. The vital signs documented! y5 Q5 e+ z- @2 [" p: b
a blood pressure of 85/50 mm Hg, his length was
- P% B/ X7 ^; x' n$ f90 cm (>97th percentile), and his weight was 14.4 kg; p1 m  @8 F( M
(also >97th percentile). The observed yearly growth3 @! G( b1 D# J+ t- E* f% H2 ]
velocity was 30 cm (12 inches). The examination of( r% ]+ F- c4 B7 H. c- {1 \
the neck revealed no thyroid enlargement.
; B; G' J, o* Q- L& j3 j, MThe genitourinary examination was remarkable for
' q4 g: ]- k; O. Y* j. l! Nenlargement of the penis, with a stretched length of' g: [/ o8 c$ U* L0 c9 D& b: h
8 cm and a width of 2 cm. The glans penis was very well2 u1 k+ g: M7 H( d; i
developed. The pubic hair was Tanner II, mostly around: d4 t( z+ H+ d2 e9 b1 @( M( Y9 t
540
7 K& w; A  T) `; R, W2 oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 ~* v/ a" f4 G$ \1 n( Z
the base of the phallus and was dark and curled. The
. j0 f) ^2 d! t6 t, Htesticular volume was prepubertal at 2 mL each.0 V- n8 t$ D6 J" q8 y; f
The skin was moist and smooth and somewhat
' Q# E& e( p4 M# I2 m, Aoily. No axillary hair was noted. There were no1 ?. v; t; V: `' z3 }$ Q% u
abnormal skin pigmentations or café-au-lait spots., u4 }0 ~  `, _5 ?5 U
Neurologic evaluation showed deep tendon reflex 2+# A- ?& K- X2 v
bilateral and symmetrical. There was no suggestion
: m) j, C; M8 O8 _+ L+ r" C6 gof papilledema." m. O) @2 c% u, ?
Laboratory Evaluation+ {; A! d% p3 r) Z
The bone age was consistent with 28 months by" ~, h+ n7 P& V9 y6 n% D" ]
using the standard of Greulich and Pyle at a chrono-
( _% M/ a* ?/ jlogic age of 16 months (advanced).5 Chromosomal
7 S5 j! Q% j& z6 c3 y3 zkaryotype was 46XY. The thyroid function test
9 F6 c9 [- W3 R# c7 x2 f: tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-) p' P9 j  {! i$ ?6 V
lating hormone level was 1.3 µIU/mL (both normal).
$ H% m& A+ X& D& a; f: A1 oThe concentrations of serum electrolytes, blood/ H& Q3 |; x2 b9 b0 D  @
urea nitrogen, creatinine, and calcium all were
( k6 B* h- U% M' a. l6 k, Gwithin normal range for his age. The concentration" E& h$ z5 U, ?$ H: _9 I
of serum 17-hydroxyprogesterone was 16 ng/dL' Q; X% {+ h8 V1 s/ f2 |
(normal, 3 to 90 ng/dL), androstenedione was 206 y6 D8 {8 Z! a( M) F# H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" A9 |* g1 D' V2 A6 n
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ y2 [5 A$ [6 ?8 _" v* {desoxycorticosterone was 4.3 ng/dL (normal, 7 to
, j! s) H3 l, F7 G! D+ [# [2 v. j( g1 }49ng/dL), 11-desoxycortisol (specific compound S)# p& ]6 v  ?8 i% M& c
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  Z1 S; E) V. }8 A2 ~" O3 |tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 L) A# `( P$ |+ P4 O6 i4 \) X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) [9 x4 G& I3 Q. _# k* f3 M3 ^) q1 }and β-human chorionic gonadotropin was less than
) A& ^. \& r4 U: u* k9 |5 mIU/mL (normal <5 mIU/mL). Serum follicular
' o/ x5 |9 m0 n: d/ h' Fstimulating hormone and leuteinizing hormone
7 Z& R( u# ^% E2 Q. O" U/ \$ S4 qconcentrations were less than 0.05 mIU/mL
, M: A) g5 O3 n! E! s) X(prepubertal).
4 A, C) E4 g. {- W6 vThe parents were notified about the laboratory+ @1 o5 V8 C6 f) P& M- x# b
results and were informed that all of the tests were
6 o; H& a5 i( fnormal except the testosterone level was high. The
& C* j* P: x, A2 {9 z5 \; u1 gfollow-up visit was arranged within a few weeks to9 a" k. j: H- f1 ^0 D! _8 a7 [
obtain testicular and abdominal sonograms; how-; T1 z" \! U+ O& p
ever, the family did not return for 4 months.2 O. T0 ^) h" [/ B. a6 a
Physical examination at this time revealed that the
9 C7 G. v2 g( ^, Zchild had grown 2.5 cm in 4 months and had gained
0 A7 D9 H5 g* q+ n  ?4 U5 K2 kg of weight. Physical examination remained
9 x" G1 q( O) j) j8 [# ~/ Runchanged. Surprisingly, the pubic hair almost com-3 P& L9 K+ ]8 M+ R& ]4 }
pletely disappeared except for a few vellous hairs at
: Q9 t  U9 Z% j, n- K0 G$ J3 F# @the base of the phallus. Testicular volume was still 2$ ~1 N4 C/ p9 U! j
mL, and the size of the penis remained unchanged.
$ d3 ]3 j: X) t. n+ w" CThe mother also said that the boy was no longer hav-
$ `% D- ?) Z8 K# s' K) W; F% a9 zing frequent erections.* [5 {3 Z9 q$ @/ P# E0 {, ]3 f
Both parents were again questioned about use of
' v/ o6 U$ \2 J' m$ }' ?any ointment/creams that they may have applied to
: X7 g) c, ]( b( e) Bthe child’s skin. This time the father admitted the
; j0 B7 x, m) Z9 ~, q; N  i8 kTopical Testosterone Exposure / Bhowmick et al 541
- v/ s- G  W' F6 o$ ^use of testosterone gel twice daily that he was apply-
3 z" Z$ O' y/ `% }8 Wing over his own shoulders, chest, and back area for
/ f9 \' {& E- M) Q# g& {7 `a year. The father also revealed he was embarrassed
3 ]  |3 |- i) I) ~' ?  kto disclose that he was using a testosterone gel pre-' Y3 \+ Y$ U7 Y" _
scribed by his family physician for decreased libido
1 c" Y2 y1 Y: e" N% N* m% D8 l, fsecondary to depression.
& G* _8 a7 v1 E$ i) iThe child slept in the same bed with parents.% y, Q) u; X. @
The father would hug the baby and hold him on his6 k9 ^* z5 `& t# {
chest for a considerable period of time, causing sig-
$ Q3 k- c( G8 F2 Nnificant bare skin contact between baby and father.9 W. L; s6 a/ t" z6 {# p& o- V' o
The father also admitted that after the phone call,
! j- A( p7 _' B4 J6 F8 n0 s! wwhen he learned the testosterone level in the baby8 L; y) n8 \$ _: B
was high, he then read the product information3 O4 \( n3 y" r$ O5 u2 q' \$ l, x
packet and concluded that it was most likely the rea-
& V6 V! H, T8 H  o2 P! yson for the child’s virilization. At that time, they
  F$ x' G6 F5 Bdecided to put the baby in a separate bed, and the" b! P; }( W! \0 c0 {. u) e
father was not hugging him with bare skin and had
0 W; e& I' Q5 }" rbeen using protective clothing. A repeat testosterone
$ h% r/ @0 V7 x3 wtest was ordered, but the family did not go to the- v8 c" e8 P$ J2 t$ F* b& A8 c/ \
laboratory to obtain the test.
0 ]6 i7 ~) c1 g: p: JDiscussion1 S3 h: [; }2 S' K8 [5 z  u& [$ i
Precocious puberty in boys is defined as secondary
. U  z! C3 o4 y% C7 k* J) L9 C2 Ssexual development before 9 years of age.1,44 j( R1 u. l) T, j
Precocious puberty is termed as central (true) when% v* T, j3 n2 N6 w( W" r
it is caused by the premature activation of hypo-
# a  G1 H6 {9 H( Q9 Uthalamic pituitary gonadal axis. CPP is more com-
, P& S3 ^5 N, {mon in girls than in boys.1,3 Most boys with CPP/ i+ T, ~% ~6 d( x' Q
may have a central nervous system lesion that is5 Q3 Y. B/ p: {  M
responsible for the early activation of the hypothal-0 o7 s" z+ T7 w1 d2 h* M, U6 l
amic pituitary gonadal axis.1-3 Thus, greater empha-, C! c* g7 c& G3 |9 @! ~) r
sis has been given to neuroradiologic imaging in
% ]7 y* V  t# j, W  wboys with precocious puberty. In addition to viril-! C- H! N" T. t+ n" w* H" I. q
ization, the clinical hallmark of CPP is the symmet-, i6 }% G$ r7 U$ [/ S5 S
rical testicular growth secondary to stimulation by
+ `5 N: M+ f5 Z2 w6 E* n* ?gonadotropins.1,3
# g6 c/ A2 u( ?" H, W' j6 `/ y8 iGonadotropin-independent peripheral preco-
% T/ F% Z4 V% X: _$ R0 r+ Qcious puberty in boys also results from inappropriate8 F" k, ]5 x, v0 E2 N
androgenic stimulation from either endogenous or
3 \6 \/ t, v3 g  C1 V+ sexogenous sources, nonpituitary gonadotropin stim-
' c, P9 \( g# \+ Hulation, and rare activating mutations.3 Virilizing
" r' r' w$ F# z' }) B$ Mcongenital adrenal hyperplasia producing excessive
2 P1 K( M0 c) W. m6 Dadrenal androgens is a common cause of precocious
4 W2 p9 X* e# p* z& g( |* Qpuberty in boys.3,4
9 \4 b1 H7 H6 u* p) h0 MThe most common form of congenital adrenal* g! L: P/ p4 \6 U$ c7 V, {  A
hyperplasia is the 21-hydroxylase enzyme deficiency.
. o" w; X5 V8 p' b. p; c$ J- XThe 11-β hydroxylase deficiency may also result in
4 Q' e6 }' _8 ^% Y" p4 y4 ^6 e/ Eexcessive adrenal androgen production, and rarely,
$ u' F2 B. O$ c& ]an adrenal tumor may also cause adrenal androgen) J8 l. Y' s/ V' S
excess.1,3( x3 r6 P3 g# f- l; `$ c8 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 U# R7 p2 k, z; |0 J+ Z+ l
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* _5 M( ^, C1 Q8 l0 Y
A unique entity of male-limited gonadotropin-
' m4 w2 }( {' C/ ?) Pindependent precocious puberty, which is also known
0 t+ G+ I! z# O8 Aas testotoxicosis, may cause precocious puberty at a% I2 U3 l% o, ^) ?. h
very young age. The physical findings in these boys
  S& s: t( A3 hwith this disorder are full pubertal development,& J7 B/ K, [9 @' }' |
including bilateral testicular growth, similar to boys' G' u/ H# N# o8 j/ ]
with CPP. The gonadotropin levels in this disorder
% e# b. ~) J/ jare suppressed to prepubertal levels and do not show) d$ l0 c0 Z$ J* N) T, P, l) z
pubertal response of gonadotropin after gonadotropin-8 W( U' t1 C% A! b
releasing hormone stimulation. This is a sex-linked' |1 j" s; r% P! J5 Q0 ^$ q3 Q. s
autosomal dominant disorder that affects only+ ~# ~1 `) M( O" N7 r* @+ b
males; therefore, other male members of the family
5 b9 g1 \" m9 ^, }5 }' A- V- n0 Umay have similar precocious puberty.3' @7 M7 k- f$ R/ p% e/ D
In our patient, physical examination was incon-
& A9 u3 l2 l" t, b( i1 C; {% Asistent with true precocious puberty since his testi-, H, c) P* M* m. P. K# V
cles were prepubertal in size. However, testotoxicosis# h% z! {/ K6 n! F; `+ N: p0 z
was in the differential diagnosis because his father
: z/ `2 R5 x7 M% F9 v+ ?. h/ [started puberty somewhat early, and occasionally,& f/ y3 d% ?4 G$ b: l) P
testicular enlargement is not that evident in the
$ }, Z4 L6 {: k- p" p7 Mbeginning of this process.1 In the absence of a neg-; A) q  h4 e4 E  s
ative initial history of androgen exposure, our7 z1 e( S. I. e/ u
biggest concern was virilizing adrenal hyperplasia,
: O0 A2 Y) ~: ^/ G9 _either 21-hydroxylase deficiency or 11-β hydroxylase8 y) n" X0 @5 V9 Y) E
deficiency. Those diagnoses were excluded by find-
" j" q7 z. l3 w: U9 \" Ping the normal level of adrenal steroids.
" n& z' |& \% S: U6 q/ j2 W! NThe diagnosis of exogenous androgens was strongly0 K$ z* o( s3 h! x3 Z' x* y
suspected in a follow-up visit after 4 months because1 c6 L9 H' |* w- L- w
the physical examination revealed the complete disap-0 L3 r7 ^+ A. Y" C
pearance of pubic hair, normal growth velocity, and3 e% r0 ]# r* ?. [
decreased erections. The father admitted using a testos-
  Z6 E7 Z; |, p) l& I, Q; ~terone gel, which he concealed at first visit. He was
2 `& Y6 q; x8 t! dusing it rather frequently, twice a day. The Physicians’
$ [' \7 x7 }: j+ qDesk Reference, or package insert of this product, gel or, a' V' O' }% M4 L
cream, cautions about dermal testosterone transfer to9 j6 d" p$ G) T0 I3 |9 q& Q( C. Q
unprotected females through direct skin exposure.6 b. u& d) j! R6 A8 E6 A
Serum testosterone level was found to be 2 times the+ n+ r9 E3 g  r$ N6 p2 X
baseline value in those females who were exposed to5 }5 b/ ^: ~2 N" w/ ]
even 15 minutes of direct skin contact with their male
8 C- B( j, n/ L4 r) N; Mpartners.6 However, when a shirt covered the applica-
3 c6 I: R6 ^% k$ T/ G7 Ytion site, this testosterone transfer was prevented.$ Z; e; E/ @! O6 ?+ P8 K" r4 R+ ~
Our patient’s testosterone level was 60 ng/mL,
; d% L# M4 [4 F& q6 G) F9 u; qwhich was clearly high. Some studies suggest that: N, k) N& R% X0 E% v& k$ o1 [, w
dermal conversion of testosterone to dihydrotestos-
- @' d# d# s! I5 @2 A8 |& Nterone, which is a more potent metabolite, is more
% e: n5 i% w9 ?active in young children exposed to testosterone
" M: q5 K. T5 y' Z: P+ qexogenously7; however, we did not measure a dihy-. Z- l( O! g" [
drotestosterone level in our patient. In addition to2 P- c& o- L( {3 |9 z, X
virilization, exposure to exogenous testosterone in6 U9 f3 Y8 Z( v- X2 T
children results in an increase in growth velocity and
9 N; ?" ~- O1 g6 Z$ {advanced bone age, as seen in our patient.- s7 h( w+ l: Y
The long-term effect of androgen exposure during5 o1 d: ^! f% ?: g& A" {- ?
early childhood on pubertal development and final2 t/ o6 [. \$ b& M, O. ]" p
adult height are not fully known and always remain3 a. M) C# b. Y
a concern. Children treated with short-term testos-
6 f2 D8 r1 w, J: jterone injection or topical androgen may exhibit some
$ X( k' m& v3 [* A9 ?. a, a9 G0 D& v; h  Hacceleration of the skeletal maturation; however, after
- G4 W% N6 L* t4 ycessation of treatment, the rate of bone maturation
% E) j3 M$ s1 Y, Z% `; \decelerates and gradually returns to normal.8,94 C& ?  M) s8 y  g/ y9 k: L
There are conflicting reports and controversy
$ F' g3 [: k( u' d9 X; d& u. ]) P- Cover the effect of early androgen exposure on adult" }6 O) X: ?8 v$ X% C
penile length.10,11 Some reports suggest subnormal; c5 N+ |9 w: ]
adult penile length, apparently because of downreg-( T1 _' f8 F, h) ]: w- ]6 H7 d
ulation of androgen receptor number.10,12 However,
( }$ L% A* U+ z/ WSutherland et al13 did not find a correlation between% X2 S; p+ B5 l  [) Y
childhood testosterone exposure and reduced adult
6 a& z! N- @0 L" ^+ ]penile length in clinical studies.- F9 S5 ]  }! M& v' K
Nonetheless, we do not believe our patient is4 g$ ]( D- w" e5 _. w& s
going to experience any of the untoward effects from
% e# [0 k* n3 O7 I! Q7 ?/ atestosterone exposure as mentioned earlier because
% e, j; y( w) |) d" Zthe exposure was not for a prolonged period of time.
" H3 T" c& r  E9 E4 u4 U7 cAlthough the bone age was advanced at the time of
0 r6 o. m- I5 }5 S/ Idiagnosis, the child had a normal growth velocity at* d4 Z2 ~3 u! j+ z  ~1 I0 f+ I9 ?
the follow-up visit. It is hoped that his final adult" u! N: l0 w) Y5 p4 O
height will not be affected.. r$ Q# i" }: L( y
Although rarely reported, the widespread avail-
$ p5 a# z0 ]- G7 Iability of androgen products in our society may# n, L" Z2 c5 H# V% }
indeed cause more virilization in male or female
( T6 P9 T5 p0 O- c. O3 lchildren than one would realize. Exposure to andro-
' `+ D# j: m0 U. c3 j) fgen products must be considered and specific ques-
+ d+ m3 p  V& `/ x! n, }2 X0 }tioning about the use of a testosterone product or
1 T: Y  G* _+ Zgel should be asked of the family members during
* f9 j' t8 N) S+ b3 athe evaluation of any children who present with vir-
6 Z2 A( l+ x. e" [( x3 dilization or peripheral precocious puberty. The diag-7 I' ~# D! [) ^+ K) [* k- w/ \
nosis can be established by just a few tests and by5 K0 ^6 U3 @+ U9 d0 C
appropriate history. The inability to obtain such a# G* A: Y9 _; f
history, or failure to ask the specific questions, may
( v3 C# C! z6 P- E: x$ p, Mresult in extensive, unnecessary, and expensive
6 x- Y" ?4 _5 U# f" Z- uinvestigation. The primary care physician should be" H, ]5 v8 H5 \! ~1 B
aware of this fact, because most of these children; ]+ t8 s7 z) x4 K+ c
may initially present in their practice. The Physicians’
  l& e% D* N1 H9 XDesk Reference and package insert should also put a
( I1 O% }% b* Q) T4 Q$ H8 }warning about the virilizing effect on a male or9 I7 l3 w' @+ C
female child who might come in contact with some-3 B! b, H, ?  s$ z0 o
one using any of these products.
5 c* ^0 D. t& R2 n, bReferences
. M" U" K# b5 x: W$ f" @1. Styne DM. The testes: disorder of sexual differentiation. Z. F: G6 w9 h
and puberty in the male. In: Sperling MA, ed. Pediatric! c. m5 N/ G% `: E
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" M/ ]+ y( X6 U+ B8 E4 P2002: 565-628.5 k' H5 [) `% X5 H7 `) ^& _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& `% U, r# r% C5 s0 f: Ppuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

* K. G, C6 ]% C, y& Z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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