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Sexual Precocity in a 16-Month-Old
, c! L, z3 T2 i& J1 p* ^! WBoy Induced by Indirect Topical; A! ~. ]0 k3 O+ u% ^
Exposure to Testosterone: R, {. }" e4 a1 {
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 I0 y1 \3 k# r" S
and Kenneth R. Rettig, MD1$ c0 b3 w4 N2 ^1 ]% A3 I( V/ `
Clinical Pediatrics
) X' i1 w+ C( qVolume 46 Number 6
5 b6 K6 n0 ?: Y& h5 mJuly 2007 540-5434 |, \6 \: U* |. v2 }2 S* f9 t
© 2007 Sage Publications
$ I0 c0 v4 j6 v10.1177/0009922806296651% X, t( z4 d+ E- _+ Z8 U) f
http://clp.sagepub.com
5 x2 N, B4 S9 S, chosted at
: V3 U( c. u0 ghttp://online.sagepub.com, ]: g! [1 ^! H0 q  @/ B2 f2 c1 o
Precocious puberty in boys, central or peripheral,
# V& v7 l0 D. a. u! P  his a significant concern for physicians. Central
. C' w( \  b& N0 C+ i8 k" t2 }precocious puberty (CPP), which is mediated
! ^& Z6 m+ B5 ~5 b9 D" fthrough the hypothalamic pituitary gonadal axis, has
- a" n4 ]+ e3 c# H/ a- @6 x- ^/ Pa higher incidence of organic central nervous system' A$ R# z  ~3 Q" A2 N* A
lesions in boys.1,2 Virilization in boys, as manifested+ l' s+ ?$ a1 ]% O1 c1 K( ^
by enlargement of the penis, development of pubic; F: \5 \) m5 ~( I- T% I0 O
hair, and facial acne without enlargement of testi-
$ ^) N/ F* |( U' A3 K8 M% U" M8 Ycles, suggests peripheral or pseudopuberty.1-3 We: T, x) ^8 D: ]1 W3 y
report a 16-month-old boy who presented with the
1 f2 e8 H( r7 t# n1 ?- z* b! W8 f. [enlargement of the phallus and pubic hair develop-
- |8 a1 G3 _3 X0 Nment without testicular enlargement, which was due
( E, c- ]% T! Z2 W" s0 \to the unintentional exposure to androgen gel used by
0 x  }1 u; i- f. a8 Z3 Ethe father. The family initially concealed this infor-9 N+ @7 j) Y0 L/ I( r! v" O
mation, resulting in an extensive work-up for this
0 P1 D5 ]- l- r  w* S- Q6 {child. Given the widespread and easy availability of6 h+ E. b/ A/ W% z
testosterone gel and cream, we believe this is proba-+ o- I* n3 Y% u9 ^) r/ Z7 @
bly more common than the rare case report in the
) z+ N2 C8 ]+ n- ?literature.4
$ N2 G; v2 n: [9 ]; ?9 N( p" }Patient Report
8 z5 J; l7 r" b7 z1 |" MA 16-month-old white child was referred to the
: ?+ v5 f- t6 ]2 Fendocrine clinic by his pediatrician with the concern
, @8 W# f1 ~1 w7 j& V& Dof early sexual development. His mother noticed1 @. Z; w: W) y- q- C
light colored pubic hair development when he was8 h" {7 H0 {* m% X9 m+ i
From the 1Division of Pediatric Endocrinology, 2University of6 B) ?/ I5 Q' z1 u, Z& y0 L
South Alabama Medical Center, Mobile, Alabama.8 f, X  n$ w# k4 V8 J
Address correspondence to: Samar K. Bhowmick, MD, FACE,5 v: S2 Q8 E6 A
Professor of Pediatrics, University of South Alabama, College of
8 J. c; V8 E8 f% S* D( `. nMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 j& V1 D/ \: h' A5 Z8 ge-mail: [email protected].
/ B) G( H; m4 I  u6 D9 Q& e0 Nabout 6 to 7 months old, which progressively became& F  i( a. L0 S5 S# M( y. i
darker. She was also concerned about the enlarge-4 M# ?8 @! _% r$ x; ?1 P+ t
ment of his penis and frequent erections. The child
1 Y, h$ [! y. g6 q9 B. Twas the product of a full-term normal delivery, with
/ _8 A* k3 Y7 ^$ ha birth weight of 7 lb 14 oz, and birth length of5 L* V, N; }% j( m2 o
20 inches. He was breast-fed throughout the first year3 e4 J6 V3 m+ _( y6 S: ^$ u
of life and was still receiving breast milk along with
4 [6 y$ n0 a' K3 d# Csolid food. He had no hospitalizations or surgery,/ z& Y  B, s  j: J! |
and his psychosocial and psychomotor development" Y- h/ _2 ~) i! A) v1 c
was age appropriate.! z9 ]; Q; x! {& m0 t2 |+ i' J, q# p
The family history was remarkable for the father,% ?5 A# H! d7 X1 I! j4 n- z
who was diagnosed with hypothyroidism at age 16,4 k5 J) s% s$ a" t0 u/ |( K5 v  E
which was treated with thyroxine. The father’s" T8 P1 I6 I9 p. u
height was 6 feet, and he went through a somewhat$ X7 G# t: M/ s, i% {
early puberty and had stopped growing by age 14.( ~- g2 G  \, d) w, j9 M1 r4 I
The father denied taking any other medication. The6 T, W, B# I6 F% `, e7 ~7 p0 S
child’s mother was in good health. Her menarche6 b! x# @& l5 P3 _3 ~
was at 11 years of age, and her height was at 5 feet
8 f# s! O" `- Y4 J7 P: k5 inches. There was no other family history of pre-, Z* Y$ Y, l0 |$ p, s
cocious sexual development in the first-degree rela-, C% q  P4 E( M: w
tives. There were no siblings.$ X  `: p6 j* q- i$ V7 g5 i
Physical Examination
- H0 K( {: g' j6 c5 zThe physical examination revealed a very active,
, Z1 U8 c# [! \playful, and healthy boy. The vital signs documented/ F, g. [# d" }. z7 I# P
a blood pressure of 85/50 mm Hg, his length was5 Q" s6 J7 L4 i9 }0 p$ u. m$ E& E9 h4 a
90 cm (>97th percentile), and his weight was 14.4 kg" f7 B) u! O8 c0 F. }$ g% h
(also >97th percentile). The observed yearly growth" v* H' U2 G4 o) J
velocity was 30 cm (12 inches). The examination of3 A- N" B0 Q. H2 S9 R
the neck revealed no thyroid enlargement.
" z% [6 @- Z8 M9 P3 x, v1 NThe genitourinary examination was remarkable for
* l4 W$ m3 Y* C" Q( fenlargement of the penis, with a stretched length of
$ U5 M$ |) ?/ }' m5 b0 K; N8 cm and a width of 2 cm. The glans penis was very well/ ^3 ~" C0 m1 v7 u1 {& V* S
developed. The pubic hair was Tanner II, mostly around1 a/ T7 N- U) P+ }
5400 s+ Z& g# O- w  r4 J2 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& e( T1 z3 G( Fthe base of the phallus and was dark and curled. The0 E) l  s, }3 {8 C4 j: G, ?+ D
testicular volume was prepubertal at 2 mL each.
1 Y$ T; M1 ?' @6 K  E& SThe skin was moist and smooth and somewhat
& l3 s+ t1 a$ R8 P+ {0 t. f$ Goily. No axillary hair was noted. There were no
( r# u5 s& a) B1 Uabnormal skin pigmentations or café-au-lait spots.5 K- }7 R8 J2 q3 I8 f, V" J
Neurologic evaluation showed deep tendon reflex 2+
8 V; ]7 p) D$ J: u1 G; y  Ubilateral and symmetrical. There was no suggestion
  c) y2 V& D6 K9 ]" dof papilledema.+ K- w' p. j+ G6 Z9 q
Laboratory Evaluation
. S% q- J/ c" BThe bone age was consistent with 28 months by3 \! ]! ]% T4 d3 W) \
using the standard of Greulich and Pyle at a chrono-) ~8 S/ ~0 Y6 t: M* y/ R( P
logic age of 16 months (advanced).5 Chromosomal1 b3 W# A9 _0 b
karyotype was 46XY. The thyroid function test3 I% q3 s4 r- }. |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, B3 d# r8 x% ?% ~8 Olating hormone level was 1.3 µIU/mL (both normal).
' L1 S) @, x- `& vThe concentrations of serum electrolytes, blood
. x/ z5 j1 h8 `( L" qurea nitrogen, creatinine, and calcium all were2 |* I$ K/ g4 y* G0 }" e% F
within normal range for his age. The concentration
6 ^; d6 y( \( y, R  Kof serum 17-hydroxyprogesterone was 16 ng/dL
0 \, C6 P$ m8 Z# {" z" g- ^(normal, 3 to 90 ng/dL), androstenedione was 20
& h8 e. b0 f0 v3 h4 g7 s6 \2 @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ L/ l8 q/ \: Y) I; ^5 x/ l0 _5 N1 tterone was 38 ng/dL (normal, 50 to 760 ng/dL),- N) p) h' |1 f* h6 W& B: e: D8 F
desoxycorticosterone was 4.3 ng/dL (normal, 7 to8 e' x9 i& D+ G5 _7 e
49ng/dL), 11-desoxycortisol (specific compound S)
0 k* \2 w" g. k$ o4 ?$ Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 K8 c5 T$ O  ]6 N+ P. [* u3 xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 C+ t+ W8 `* R; K5 b6 O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! w2 a' D' x9 Y5 E& j7 J% V- Q" H* m+ A) T
and β-human chorionic gonadotropin was less than7 ]6 m4 K3 \2 O: H
5 mIU/mL (normal <5 mIU/mL). Serum follicular) H- w& x. F( I6 k4 I6 s! B  ?2 O
stimulating hormone and leuteinizing hormone1 W1 G( E& }) y7 \% a/ d' d
concentrations were less than 0.05 mIU/mL& y& F1 y7 c1 T2 X, {, x, a
(prepubertal).
" H, R' Z) Z3 }The parents were notified about the laboratory3 g2 n1 \& m! [3 u# C* ^% I* f; I6 O
results and were informed that all of the tests were
9 q6 S  K) N9 ]6 q4 cnormal except the testosterone level was high. The; X! d( o8 A- \/ }7 {; M( Q
follow-up visit was arranged within a few weeks to
( U  l. N, U  Nobtain testicular and abdominal sonograms; how-2 x% K( {4 @$ ?/ C! i! r) I( _
ever, the family did not return for 4 months.
* q4 v1 \8 I9 u/ L3 w* f$ b* T- H2 RPhysical examination at this time revealed that the1 P3 l* i, N! h: [
child had grown 2.5 cm in 4 months and had gained; }! ]- u; A6 _
2 kg of weight. Physical examination remained' D# B) S9 w+ u8 y
unchanged. Surprisingly, the pubic hair almost com-
7 u- T( }* k$ }; t9 a+ ^pletely disappeared except for a few vellous hairs at
' ], P& c/ o% M8 q9 lthe base of the phallus. Testicular volume was still 2( G. i" V0 c' u5 @- |; I
mL, and the size of the penis remained unchanged.
# `6 L' w, t8 z* b1 k6 b. ^; ?The mother also said that the boy was no longer hav-
: B& @4 a1 |4 E/ D8 N7 ~* ying frequent erections.( |4 n8 }9 \/ g% w0 ~5 S6 Y! s
Both parents were again questioned about use of
( p1 j6 ?# G: K" t" _! ^" p( xany ointment/creams that they may have applied to! J. {1 X9 w6 ~; A3 D
the child’s skin. This time the father admitted the
# \4 j; G+ x3 M, e% j$ HTopical Testosterone Exposure / Bhowmick et al 541
  {. ?6 V* A# P0 Z7 z$ W2 Ouse of testosterone gel twice daily that he was apply-
7 z1 T% ^$ f( w- z2 ning over his own shoulders, chest, and back area for9 P, l, P/ D0 P" T
a year. The father also revealed he was embarrassed  _2 P1 |& l3 ~  h4 c9 {2 e  [! h1 A
to disclose that he was using a testosterone gel pre-% J6 E3 N' d6 _
scribed by his family physician for decreased libido! G" u, Z6 ~- Z  r! g
secondary to depression.
. r* p$ |9 X: iThe child slept in the same bed with parents.
4 }9 k: z. u) AThe father would hug the baby and hold him on his
9 A( u: }0 n* F: K; ychest for a considerable period of time, causing sig-
2 g" p& e" h/ s+ O' s0 ~nificant bare skin contact between baby and father.
. p; `7 d  W3 k' ZThe father also admitted that after the phone call,
4 N! H; E0 [% O# G' ~0 r7 ywhen he learned the testosterone level in the baby5 Q; W/ s8 d% g- J7 s
was high, he then read the product information: b1 x( N' E! S. O6 Y- q' B' \
packet and concluded that it was most likely the rea-; N$ ]+ e7 w1 L% Z& `: H
son for the child’s virilization. At that time, they8 l2 {7 K6 d0 Y5 M5 y
decided to put the baby in a separate bed, and the
& x+ w0 j. B) O5 s* J& ^father was not hugging him with bare skin and had8 |. M' A: ?1 g' X8 w
been using protective clothing. A repeat testosterone
- G. B$ H2 p0 j' w) Atest was ordered, but the family did not go to the5 g6 h! P% b; z- v
laboratory to obtain the test.
( K' V! Q" O* f5 RDiscussion
$ Y  g, g* s/ K9 f& N" e% b% nPrecocious puberty in boys is defined as secondary
# h' E4 w9 |& t& y8 G! u" z1 k' Gsexual development before 9 years of age.1,4
6 v: }* S' I8 F" ^; g2 E" t) }Precocious puberty is termed as central (true) when
7 e+ v3 @7 a" _$ Bit is caused by the premature activation of hypo-1 s0 G" }6 T9 j- k$ `6 s7 Q( P9 j
thalamic pituitary gonadal axis. CPP is more com-) J5 G7 c; S+ r3 V) ]
mon in girls than in boys.1,3 Most boys with CPP
$ X! k' f, K1 P5 {0 C+ m0 Omay have a central nervous system lesion that is
& I3 t) M. x: D; @$ Oresponsible for the early activation of the hypothal-5 l# y- f1 R  |+ v
amic pituitary gonadal axis.1-3 Thus, greater empha-
6 u% E. h6 ?4 asis has been given to neuroradiologic imaging in
- ^2 B7 W: B. R$ K& hboys with precocious puberty. In addition to viril-5 k5 O8 U3 ]5 Z- z
ization, the clinical hallmark of CPP is the symmet-$ O7 V2 c8 ~+ A7 r" a
rical testicular growth secondary to stimulation by  l5 n% z- K& k0 ~, C& x
gonadotropins.1,3
+ S( x% W1 Q1 C- lGonadotropin-independent peripheral preco-3 o) v. ^* @9 g- X
cious puberty in boys also results from inappropriate$ D, u: l) f1 F. m1 `! y/ z$ \; i
androgenic stimulation from either endogenous or
4 P. A7 B& {2 X2 W7 U* fexogenous sources, nonpituitary gonadotropin stim-
* i& y2 X/ v' v/ yulation, and rare activating mutations.3 Virilizing
' i& {2 M2 s  m& Jcongenital adrenal hyperplasia producing excessive0 w; @' t+ m' O4 r3 j) }
adrenal androgens is a common cause of precocious
: C4 [3 ]0 r4 kpuberty in boys.3,4# B8 F: X1 p  y- z$ W
The most common form of congenital adrenal# T$ T. y" \+ C5 b3 P" x
hyperplasia is the 21-hydroxylase enzyme deficiency.. f$ {$ f5 z# q6 @: `3 T* V4 |
The 11-β hydroxylase deficiency may also result in* y1 z  T9 {4 M. X
excessive adrenal androgen production, and rarely,6 C8 [+ Q# M/ ~3 w
an adrenal tumor may also cause adrenal androgen# @3 b" B) L0 Y7 P0 O
excess.1,3
2 N2 f! |; I2 |) Z% fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 A+ j+ B( _. T2 b7 W3 t542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 b( ?' J) Q9 v2 E/ \A unique entity of male-limited gonadotropin-7 Z& d3 P4 s' s8 @
independent precocious puberty, which is also known
5 ]: k+ ~5 g' {7 L& |. H  ?$ Zas testotoxicosis, may cause precocious puberty at a4 B; F9 y* d+ u( j
very young age. The physical findings in these boys
0 o$ {" c: x" V$ n+ Bwith this disorder are full pubertal development,
$ l3 _8 B5 p7 D. c% k$ rincluding bilateral testicular growth, similar to boys
& Z: R4 @# y1 V- n$ O/ Kwith CPP. The gonadotropin levels in this disorder
; h# H  D9 S6 D8 q. G& {6 y. Ware suppressed to prepubertal levels and do not show
9 E' p4 s( P8 X6 [& Spubertal response of gonadotropin after gonadotropin-  N% r" i+ l. U( N- X
releasing hormone stimulation. This is a sex-linked7 K% Y& g6 y' u9 b7 u
autosomal dominant disorder that affects only
6 T7 K3 h& s  Q& zmales; therefore, other male members of the family  U9 y. K7 r$ N2 l. w8 f
may have similar precocious puberty.35 }/ x, ~& Q$ z% f# |
In our patient, physical examination was incon-6 P; g+ G5 b1 ?) O5 K5 n
sistent with true precocious puberty since his testi-
* c& I9 k7 z- ecles were prepubertal in size. However, testotoxicosis
( V8 z# D  }7 I' h3 ]  q" awas in the differential diagnosis because his father
. b) d) _. J1 X9 [started puberty somewhat early, and occasionally,
" a0 W/ v+ @- ?0 B4 o: ?( Qtesticular enlargement is not that evident in the
( V" I- F. z* y0 i3 Mbeginning of this process.1 In the absence of a neg-6 Y3 e+ ~' F7 \0 `2 T
ative initial history of androgen exposure, our7 t, e7 O7 _/ H' N2 a. @6 S8 a' W) E
biggest concern was virilizing adrenal hyperplasia,
: O* ~& c3 s" J  Ieither 21-hydroxylase deficiency or 11-β hydroxylase
7 `0 W2 ^! Z! K. d$ F. a4 q& sdeficiency. Those diagnoses were excluded by find-0 t8 f3 B" [3 ^+ ~! f& p
ing the normal level of adrenal steroids.5 h- i# r5 r8 R8 L
The diagnosis of exogenous androgens was strongly5 A- V& Y; `) k4 t: y( b2 N! l
suspected in a follow-up visit after 4 months because9 s: i$ d' D* C0 w6 V
the physical examination revealed the complete disap-# I& s% G5 U! I. ]) {+ G
pearance of pubic hair, normal growth velocity, and
- i1 T7 B+ }# Y$ L6 }! ^& B" i& fdecreased erections. The father admitted using a testos-( y, A0 s. ?7 O$ u( [
terone gel, which he concealed at first visit. He was
8 |" x' v  [- }2 `' J( eusing it rather frequently, twice a day. The Physicians’9 \" Q" C4 q" L2 _# d$ f
Desk Reference, or package insert of this product, gel or/ F, q* \# e: o9 ~
cream, cautions about dermal testosterone transfer to# U+ V8 D7 V) g! z" x! G
unprotected females through direct skin exposure.
# P- I/ P4 V- ^Serum testosterone level was found to be 2 times the6 Q+ i. s0 `4 t  _, V  P
baseline value in those females who were exposed to1 R9 O: q% A, b- C& F, z" @
even 15 minutes of direct skin contact with their male! e/ u+ @, E3 N
partners.6 However, when a shirt covered the applica-: J3 W' ?/ k8 r6 h- i
tion site, this testosterone transfer was prevented.8 w) k5 j  Z2 }
Our patient’s testosterone level was 60 ng/mL,
' z% t* x, J/ ~: r! q* Mwhich was clearly high. Some studies suggest that
( u/ y" B& U3 ^7 Gdermal conversion of testosterone to dihydrotestos-% _! Z5 m7 ~+ v& |$ J
terone, which is a more potent metabolite, is more* z+ R9 u9 W: [: ~; V
active in young children exposed to testosterone6 P2 U) b; `/ }. @4 J
exogenously7; however, we did not measure a dihy-( j' }1 e( `# f$ N
drotestosterone level in our patient. In addition to
" W/ a$ G2 u+ \7 q, q0 n5 S; K3 |virilization, exposure to exogenous testosterone in
; S4 M, |) B' h7 E2 ~" \2 Q: [3 Schildren results in an increase in growth velocity and2 w( h4 H4 }2 Y6 ~+ c
advanced bone age, as seen in our patient.! o8 G+ N7 C+ D
The long-term effect of androgen exposure during, F4 \' z6 ?& ?
early childhood on pubertal development and final+ {* J5 j0 [* p0 p2 ]
adult height are not fully known and always remain
1 c3 j8 d0 P  ^9 a/ n- G( a2 na concern. Children treated with short-term testos-' }# w/ B, z* H0 U3 \- m; \: v
terone injection or topical androgen may exhibit some  a5 k* l& F$ Q* P+ j6 h) o
acceleration of the skeletal maturation; however, after
" ]7 N0 U6 n( E; ocessation of treatment, the rate of bone maturation
9 p& K+ b3 W2 Y5 u8 @/ `7 ?decelerates and gradually returns to normal.8,9: m$ I: X$ U1 G3 D' \& F
There are conflicting reports and controversy7 A( z9 B: c$ n6 J+ x2 c2 X" k3 D
over the effect of early androgen exposure on adult4 B6 d- j: b% {& O+ V: y
penile length.10,11 Some reports suggest subnormal
0 m2 M4 y  _3 R; @$ c- d4 x7 [7 wadult penile length, apparently because of downreg-
; B5 N) M1 W+ e9 J" n6 r3 g& Zulation of androgen receptor number.10,12 However,
7 k& W+ O3 b7 U& C  vSutherland et al13 did not find a correlation between. u! b! w( i7 ~% v9 c5 Z
childhood testosterone exposure and reduced adult9 l0 n0 |) d8 v6 F) o+ P1 x
penile length in clinical studies.
$ T; z1 J- \9 ?) y/ O7 BNonetheless, we do not believe our patient is( r7 b- }; }9 T# Y3 ]& b8 b
going to experience any of the untoward effects from8 [  w3 T5 x: `
testosterone exposure as mentioned earlier because  p: t5 d0 j- w4 L+ a
the exposure was not for a prolonged period of time.
# C3 {  }: Z. }# iAlthough the bone age was advanced at the time of- S; ~5 L  ~3 u  m
diagnosis, the child had a normal growth velocity at
" l6 {( f  ?4 m  [& h2 R2 othe follow-up visit. It is hoped that his final adult
. N% s( D# j3 k. `& J' A+ d  qheight will not be affected.
0 n0 [+ _* q& Q  D: W$ E" Q1 _Although rarely reported, the widespread avail-" @& @8 a4 d1 Z+ k  s8 U7 b6 d. n
ability of androgen products in our society may* g4 i) H% U& ^$ {9 d
indeed cause more virilization in male or female
9 u) N' ~6 P* d" |+ U/ o# Dchildren than one would realize. Exposure to andro-
' d# b0 |4 @; h3 v- {/ @8 B5 t: Ygen products must be considered and specific ques-
1 X/ Y. {' i) F6 y7 R* _. P- \  ltioning about the use of a testosterone product or
) e3 }- P) V0 U' S9 B$ r  W# V  M3 ]gel should be asked of the family members during1 U: y2 e6 F+ }  r
the evaluation of any children who present with vir-
5 v7 S( V: Q# R3 m$ L' |: X' ], lilization or peripheral precocious puberty. The diag-7 F, F# \. v7 O% ^3 J) }
nosis can be established by just a few tests and by% m) |( C- F- `- Y; Y, s: M+ x- j
appropriate history. The inability to obtain such a
2 i! r$ t2 x) G- d& H0 mhistory, or failure to ask the specific questions, may
) O3 ^5 z! p  V3 i6 g9 P2 \result in extensive, unnecessary, and expensive
3 r) B! K* H. y8 k# V0 ]. r. Kinvestigation. The primary care physician should be* z4 L) t' ^4 m) f4 o! k6 c" p
aware of this fact, because most of these children
3 {0 n- g9 z3 k6 i: Tmay initially present in their practice. The Physicians’% Y% B- r+ {. q$ n* u8 r, W
Desk Reference and package insert should also put a8 _3 b; f5 p" u& ~& D8 y1 @
warning about the virilizing effect on a male or
; h7 c" s0 C7 L: x4 t/ T+ K9 V3 Pfemale child who might come in contact with some-
, M& ^* i6 H3 U0 C. D! ]one using any of these products.; L2 @# f" |0 s6 m0 _4 m& @
References/ R1 s# z) P8 ]9 K$ T6 T0 q
1. Styne DM. The testes: disorder of sexual differentiation5 N9 a) x7 G  B$ w9 K6 L
and puberty in the male. In: Sperling MA, ed. Pediatric2 b/ _7 x- j4 V, r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' u. Y. l5 \5 d2 C
2002: 565-628.
9 m3 ?/ f/ n5 b! x7 O9 e7 u$ T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious, {5 q" V* Y6 `; u, t
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old; R9 k9 k  L* D9 j. A2 [+ G
Boy Induced by Indirect Topical
% \( {  i/ P" s4 f0 k9 \Exposure to Testosterone' }: I- M. p# v( I  ]! u4 l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& W* k. Q  C8 G) ?and Kenneth R. Rettig, MD1& ]! x3 [& F/ G2 f7 y
Clinical Pediatrics  E7 `' X: Y. {6 O4 G9 g9 i
Volume 46 Number 6) F" L, R* L; a( Y* u
July 2007 540-5436 A% o+ n: a0 G0 v2 K
© 2007 Sage Publications
3 b$ x: Q& e/ \( K& o  S& B8 t10.1177/0009922806296651& }' q) d& r. f' v& V! ]- c
http://clp.sagepub.com
# a. c4 M9 k/ X1 }+ ^8 i: n9 E, U* Lhosted at! F! ?/ _/ o# r. _1 {: K
http://online.sagepub.com
, V  s+ G  g1 Q2 Y1 h4 y8 VPrecocious puberty in boys, central or peripheral,
; N( [& J6 H' m# _/ Y) O/ ]is a significant concern for physicians. Central( f$ H& |/ ?: W( ~. a
precocious puberty (CPP), which is mediated
) `' M+ E1 M2 x$ N/ E; B) rthrough the hypothalamic pituitary gonadal axis, has
; L0 j& r3 T& y9 _! oa higher incidence of organic central nervous system6 x* R; D  z$ D: N1 W( |9 D
lesions in boys.1,2 Virilization in boys, as manifested
7 m+ `# B2 O) {8 Iby enlargement of the penis, development of pubic
. r) p+ Q7 h# P/ u3 q9 h, X9 Vhair, and facial acne without enlargement of testi-
) W! G2 ?. n, k: v! ?4 mcles, suggests peripheral or pseudopuberty.1-3 We* a) x  @9 J% R. o; }4 U% i
report a 16-month-old boy who presented with the
0 c2 ~' @& Q' T. lenlargement of the phallus and pubic hair develop-
3 ~- c% F3 G; yment without testicular enlargement, which was due
! k- p) g8 M- D. ]% g% ito the unintentional exposure to androgen gel used by
* U8 v7 t  L( K3 H( l5 q1 m6 jthe father. The family initially concealed this infor-6 c# p" q% j$ `
mation, resulting in an extensive work-up for this4 U; V- ]3 X) ^$ F$ Z. h' P
child. Given the widespread and easy availability of! ]  X1 q, _5 ^
testosterone gel and cream, we believe this is proba-7 B1 h; m7 K7 D" [- k% ?6 B
bly more common than the rare case report in the7 [9 X9 ~7 }* ]3 u9 k, h" k
literature.4  O6 z! o7 X: c9 X
Patient Report
) `8 A$ ^7 O7 HA 16-month-old white child was referred to the
8 J. P4 g) Q2 |2 x! Q9 N0 fendocrine clinic by his pediatrician with the concern: q# f; X0 n  ?) i. H
of early sexual development. His mother noticed* o# P# v: R* {+ J- _
light colored pubic hair development when he was
" \% f, f( R* Z$ GFrom the 1Division of Pediatric Endocrinology, 2University of. z# f0 P, e: b
South Alabama Medical Center, Mobile, Alabama.
0 Z2 Y, f. v4 E. U7 hAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& l8 n  G9 I7 _1 N# fProfessor of Pediatrics, University of South Alabama, College of1 M. M8 W- j) J! T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 P' f& @: F  J$ t* Ve-mail: [email protected].
: e2 ~9 Y0 Q4 N  H6 |9 l, @about 6 to 7 months old, which progressively became8 @9 w& R" q+ b# U
darker. She was also concerned about the enlarge-
, h& V1 c$ t5 l$ {. Rment of his penis and frequent erections. The child1 u3 n+ T: X6 k. d! N3 E) b
was the product of a full-term normal delivery, with
8 K+ N5 t3 r6 [( t8 Qa birth weight of 7 lb 14 oz, and birth length of
2 b( {+ ]5 ~! k5 _20 inches. He was breast-fed throughout the first year
& X7 ~6 |0 ^+ d7 a+ ]9 x" gof life and was still receiving breast milk along with
$ k! p# V/ E" K. N$ ~$ |solid food. He had no hospitalizations or surgery,
$ ~; D6 j/ G) B/ B: ~$ W# v- iand his psychosocial and psychomotor development
- A5 y" ]. U% \" \was age appropriate.
  ~  x4 l' {2 Q0 L1 \$ J3 AThe family history was remarkable for the father,
6 N  j0 |3 s0 o) m% A2 R. Z7 k1 K( Xwho was diagnosed with hypothyroidism at age 16,+ p7 X  I$ @# P! {  D
which was treated with thyroxine. The father’s
+ a/ }2 t) |+ x. E8 P, J6 a# X6 Y/ [height was 6 feet, and he went through a somewhat
2 z6 Y: ~+ y+ W" \" v3 J" nearly puberty and had stopped growing by age 14.
- G+ T; |# H" b  S% AThe father denied taking any other medication. The
* A6 n5 ]+ B4 M4 o6 ]2 y% u- Xchild’s mother was in good health. Her menarche
$ T1 N% c" d- r2 xwas at 11 years of age, and her height was at 5 feet
5 ^# U" C5 D! u2 y9 m' _5 inches. There was no other family history of pre-
1 j- v# s* {( O$ `) B, e. xcocious sexual development in the first-degree rela-
  a7 j1 ^2 Z, {! ^& r7 Ktives. There were no siblings.- @0 r, R: X5 B# w0 n! ~7 _- [# f
Physical Examination
' Y3 m# }4 R. \* n# Z1 q2 z" IThe physical examination revealed a very active,5 e8 E5 F; I  T" z( e7 }
playful, and healthy boy. The vital signs documented
$ m  H+ J$ i) D* K9 q5 ]$ u/ Y+ h* a" Aa blood pressure of 85/50 mm Hg, his length was; l) _; e& _5 G- f0 x3 D9 Z
90 cm (>97th percentile), and his weight was 14.4 kg
3 e4 {$ K) l5 [) z(also >97th percentile). The observed yearly growth
/ X$ q& y. i: |: y! `. @velocity was 30 cm (12 inches). The examination of$ t2 R) X) q/ ^. d" e; F
the neck revealed no thyroid enlargement.6 U7 Y3 a$ n5 k* M7 e4 E" y, W; @
The genitourinary examination was remarkable for0 ?2 m* J+ _  Y# c& g
enlargement of the penis, with a stretched length of: V( x- M8 y. ?
8 cm and a width of 2 cm. The glans penis was very well1 b# j; d  T" S& j+ a6 L2 f
developed. The pubic hair was Tanner II, mostly around
3 i/ B  q5 R2 q. u2 A540
  |1 z( n: [" U' M* E$ Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" M" a0 ?9 o; L5 r$ K
the base of the phallus and was dark and curled. The1 V2 N+ K; A1 Y; c' g5 G% N- O
testicular volume was prepubertal at 2 mL each.* Y& X0 K1 o: T3 U, {
The skin was moist and smooth and somewhat2 ?7 S0 o9 F4 u3 B/ T2 d" @1 N2 P" x2 J
oily. No axillary hair was noted. There were no( R- m- r6 g: J0 j1 h3 F1 ]9 R  J
abnormal skin pigmentations or café-au-lait spots.
/ `. Y  v! Y: E! sNeurologic evaluation showed deep tendon reflex 2+
7 s' A+ l7 u; Z/ Obilateral and symmetrical. There was no suggestion3 x; c! [; x' j- a7 j. H  P% C7 S
of papilledema.
$ N: @& R9 a9 L* i- {& Z1 HLaboratory Evaluation# m/ O& P, ]* b/ ?7 ?# p
The bone age was consistent with 28 months by) i6 [- L& Z% n& B' n4 Z* [
using the standard of Greulich and Pyle at a chrono-
( s  W& p/ Q  Y5 I; J) P& blogic age of 16 months (advanced).5 Chromosomal
5 w$ S% R6 _: L# e- ~% zkaryotype was 46XY. The thyroid function test+ z4 Q, W& S$ c- d5 C8 G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 H  h$ O* f3 l1 o( E; hlating hormone level was 1.3 µIU/mL (both normal)./ c8 t7 _0 I& z: ?- f6 A1 j
The concentrations of serum electrolytes, blood
: \5 @' `( C8 C) H8 F* B3 vurea nitrogen, creatinine, and calcium all were8 L0 ~: r3 p# U& t; h1 Q
within normal range for his age. The concentration
0 p7 y; h7 |+ T% |: oof serum 17-hydroxyprogesterone was 16 ng/dL7 q7 K* }. i5 u4 {: ]- F
(normal, 3 to 90 ng/dL), androstenedione was 20
! \. O" Q" U2 W' @& s1 Q. ~ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  ?$ l3 p& n: w1 T  oterone was 38 ng/dL (normal, 50 to 760 ng/dL),. k6 G$ }9 f* i7 \3 i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# d5 \+ q/ H) O7 @
49ng/dL), 11-desoxycortisol (specific compound S)
# K" k6 Z, a; w) Z( `was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 z" V2 ]! @9 q) f- a1 P9 l- U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" T/ o& I2 j% m% f! ?# ^
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 z! X# J! u  G+ y% m! ]1 O* S7 band β-human chorionic gonadotropin was less than
8 o6 \" @5 |; N" z5 mIU/mL (normal <5 mIU/mL). Serum follicular1 B9 X4 \; i5 L+ q! d1 q
stimulating hormone and leuteinizing hormone
' g: Z- o* n+ H: T  yconcentrations were less than 0.05 mIU/mL! E: S$ ]: S- ~. M
(prepubertal).
$ q# [) }/ T, }! E9 o/ Y/ J9 iThe parents were notified about the laboratory
0 m) A9 }( r( F: Q/ S8 D8 w2 d% Uresults and were informed that all of the tests were
9 P3 v: l" M/ c) s& R; ?- j8 P( nnormal except the testosterone level was high. The& z6 M: ]/ m4 c, a9 |
follow-up visit was arranged within a few weeks to
4 @3 _2 J; A& h; k' r( lobtain testicular and abdominal sonograms; how-* O9 J7 G5 `0 J
ever, the family did not return for 4 months.
" I' p6 ~2 ?' O/ B, g# aPhysical examination at this time revealed that the
# P4 J5 O$ [* p2 |child had grown 2.5 cm in 4 months and had gained
" Y! M. ~( q# C. u0 _2 kg of weight. Physical examination remained9 h# s1 o. O* D& Q, p' B
unchanged. Surprisingly, the pubic hair almost com-! s# {" a4 x' j# ?0 T  ~
pletely disappeared except for a few vellous hairs at8 s9 ?% j, j1 n3 ~' `7 e6 h. U
the base of the phallus. Testicular volume was still 2
/ [* g- s% a0 s$ Y0 T0 O" SmL, and the size of the penis remained unchanged.) Q0 G- f+ i7 E* Y1 v) s: _
The mother also said that the boy was no longer hav-
+ t4 `! m. q4 Y6 ?  r6 D4 A* e7 Sing frequent erections.
- f& H# r, Q" W, ^6 }Both parents were again questioned about use of
: a! W# F3 \+ Z1 J2 B+ Lany ointment/creams that they may have applied to! i. a2 p9 ]  r2 Q+ j6 m3 }8 U
the child’s skin. This time the father admitted the; y* t; ^" l* V
Topical Testosterone Exposure / Bhowmick et al 541% C+ Q/ B9 z/ m% r! |: s0 [
use of testosterone gel twice daily that he was apply-- ^' ^7 y! F  Z8 D" p* u: M" d
ing over his own shoulders, chest, and back area for. e$ q5 U# S9 u4 _  Z1 D2 K1 n; e  D0 ^
a year. The father also revealed he was embarrassed9 {0 }3 C7 H! c; n* y7 ~/ e
to disclose that he was using a testosterone gel pre-% `1 f. G% N$ W: b. ?" @
scribed by his family physician for decreased libido
4 s: M! y+ u* d( N( }! G2 G' Hsecondary to depression.
9 B! m1 M8 @; L) G7 UThe child slept in the same bed with parents.
5 ^4 F8 U4 h" iThe father would hug the baby and hold him on his
; t7 u( f$ N7 V0 ~; h. Bchest for a considerable period of time, causing sig-
8 U9 g* ~* s" q  i% B) j, |5 Mnificant bare skin contact between baby and father.* n4 c) }, q3 l9 p$ Q8 J! ~% n
The father also admitted that after the phone call,
1 t! V0 ?* i' K9 p* C2 Bwhen he learned the testosterone level in the baby
; [* c$ ]8 P% p  M: f1 i, Mwas high, he then read the product information
# ?5 K2 s4 ^8 B% g; |packet and concluded that it was most likely the rea-% s5 V) c& w( Z) G& ?" D
son for the child’s virilization. At that time, they
* N: O& H$ J8 P  Mdecided to put the baby in a separate bed, and the1 ~9 x& R% J/ N5 }* x  D
father was not hugging him with bare skin and had/ i  p. h6 }7 B6 c" N8 h3 O
been using protective clothing. A repeat testosterone
) n& `0 l! X/ mtest was ordered, but the family did not go to the2 i6 s6 U' \3 T4 S/ ]
laboratory to obtain the test.. B2 q# R# i& |$ O7 y. t, c
Discussion: F+ {2 c. C( \  K
Precocious puberty in boys is defined as secondary
/ O7 j3 H2 N# U0 c7 e! ]" B$ [sexual development before 9 years of age.1,4
/ \: X) R2 y$ Z* N+ \0 t# HPrecocious puberty is termed as central (true) when$ ~  G4 X: Q( [/ n. H5 ?
it is caused by the premature activation of hypo-
1 U: V9 ?# n3 M: N% s1 i+ uthalamic pituitary gonadal axis. CPP is more com-! c( a9 u! n5 n2 \
mon in girls than in boys.1,3 Most boys with CPP
+ P/ K) X* Z" a. t& i8 a8 Lmay have a central nervous system lesion that is9 H- t& ~! B5 Y( @' t% ]
responsible for the early activation of the hypothal-
- F4 M$ E" ~- C, L* X2 y+ M: Ramic pituitary gonadal axis.1-3 Thus, greater empha-
9 q5 O: q2 w' ~# q+ Msis has been given to neuroradiologic imaging in
) b4 x- k/ i6 |0 W- Nboys with precocious puberty. In addition to viril-
" B4 \: b) Z* e. t: Z0 \ization, the clinical hallmark of CPP is the symmet-
/ }1 ?  B$ }- @0 Z" G3 rrical testicular growth secondary to stimulation by
/ w: \& M& u! I! s" h( E( m" C/ M. Fgonadotropins.1,3* n5 R5 j+ d8 v. G9 r$ a0 P
Gonadotropin-independent peripheral preco-+ |& Y1 D: H& Z: ^! v0 c
cious puberty in boys also results from inappropriate$ I! `; \$ k4 e! C0 ~* ]
androgenic stimulation from either endogenous or
! f9 I$ Z3 `" \7 z4 {" texogenous sources, nonpituitary gonadotropin stim-& D* ?5 r# n) S
ulation, and rare activating mutations.3 Virilizing
$ E3 O# x4 _0 K  Lcongenital adrenal hyperplasia producing excessive# \. _' E8 \1 W( x; Z
adrenal androgens is a common cause of precocious
" y* i. m6 R) dpuberty in boys.3,4
. E& z# ^5 r8 F1 X( vThe most common form of congenital adrenal1 O* q- _5 g/ x* K- S
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 L7 K$ ~$ g4 x! mThe 11-β hydroxylase deficiency may also result in
. i6 H0 Q) K$ O+ L) i" N8 |% T  I1 l3 \excessive adrenal androgen production, and rarely,, }6 Y* I( ?# ]# V  ?5 W+ a
an adrenal tumor may also cause adrenal androgen
% |9 ~9 {6 ?: ?, Dexcess.1,3' r3 W8 z; K8 d" L. q- z" w" Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( q& d: m4 D4 ?; M0 [% Y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 j6 }9 ^0 F* A! aA unique entity of male-limited gonadotropin-& h& T2 q5 P: V* R1 S3 f
independent precocious puberty, which is also known
) R: _! N. G* z& p5 {" bas testotoxicosis, may cause precocious puberty at a/ }5 s: ~5 n, a
very young age. The physical findings in these boys( ]+ }# V# Z- ?; S2 ?% Z6 O1 N& `
with this disorder are full pubertal development,
. K/ G( f- O; _including bilateral testicular growth, similar to boys% Y$ ^& k4 Z" ?% G1 _3 n
with CPP. The gonadotropin levels in this disorder
2 p8 K1 \7 T! ?" `. `: hare suppressed to prepubertal levels and do not show
5 u" O5 N' E1 T# Ipubertal response of gonadotropin after gonadotropin-5 k& Z2 P/ I% @. {9 J/ M) T0 i6 n
releasing hormone stimulation. This is a sex-linked0 u' w. K2 i4 `! O
autosomal dominant disorder that affects only
! a: @9 p$ G- E5 X8 n( k# Lmales; therefore, other male members of the family! x' y% Z9 Z% b* L/ Y
may have similar precocious puberty.3* ~# p! a) s1 a3 o" J' ?1 A- H
In our patient, physical examination was incon-& Q1 u! I+ J, I* j
sistent with true precocious puberty since his testi-* `! m6 ^- W4 E! ^  |
cles were prepubertal in size. However, testotoxicosis
6 M/ ?! L6 T  f! J8 x" xwas in the differential diagnosis because his father
3 w; A' {. r* k7 l3 R. _started puberty somewhat early, and occasionally,
/ n1 c5 z# Y* z7 H, `' z2 Z, ~+ A& Ntesticular enlargement is not that evident in the
8 q( B% h5 _- D- N1 ^  obeginning of this process.1 In the absence of a neg-
/ X8 X3 e, Y1 x2 c6 Dative initial history of androgen exposure, our6 [5 G, [6 H$ ~) S$ ^
biggest concern was virilizing adrenal hyperplasia,
+ x- p6 g: {+ S' Q$ O) l1 Weither 21-hydroxylase deficiency or 11-β hydroxylase
; z6 }! A$ P# P0 I7 j( E; V7 ?deficiency. Those diagnoses were excluded by find-
; G; P6 j# T( @" ting the normal level of adrenal steroids.; a( }; e2 M9 E9 X# q
The diagnosis of exogenous androgens was strongly
, v& t2 y. }% C7 Ssuspected in a follow-up visit after 4 months because
5 U; L7 ^5 W: Y% A" a, k9 _" X5 ~) sthe physical examination revealed the complete disap-
. i- _9 ~  x# Q0 G9 Y6 c3 {pearance of pubic hair, normal growth velocity, and
$ A: r7 |# r$ G9 H% gdecreased erections. The father admitted using a testos-
! n. t' J: M0 Gterone gel, which he concealed at first visit. He was1 F, _' j" Q9 C% w5 [
using it rather frequently, twice a day. The Physicians’, z! t0 n3 X7 n: I" A1 F+ j7 l  u
Desk Reference, or package insert of this product, gel or/ Y* w9 q' q! `' ~* ^# ]
cream, cautions about dermal testosterone transfer to" h7 Z4 H) u8 T) y( q
unprotected females through direct skin exposure.# L3 f1 c3 k6 t4 ]+ ~; ?' I8 J
Serum testosterone level was found to be 2 times the
1 T8 R* x# Q* g# H+ |baseline value in those females who were exposed to
! g9 Y" ]% I( B6 p4 Q/ t0 G* \4 e& Meven 15 minutes of direct skin contact with their male
9 l  j4 B/ N! Xpartners.6 However, when a shirt covered the applica-
4 c4 o/ f& _. ttion site, this testosterone transfer was prevented.1 ]3 w$ ?6 l" i% g3 ]( O' l
Our patient’s testosterone level was 60 ng/mL,
/ d) w2 K- a8 k0 U: e/ C' Mwhich was clearly high. Some studies suggest that
1 Q$ n' c6 e, \+ K8 }  ydermal conversion of testosterone to dihydrotestos-, n( g; T. @' x3 x
terone, which is a more potent metabolite, is more
' j1 h2 ]7 q- _! g% I3 Factive in young children exposed to testosterone0 j1 l: @* Z6 p
exogenously7; however, we did not measure a dihy-
; i& ~! n8 y* t6 `1 d  D. Udrotestosterone level in our patient. In addition to% }0 _1 K! z: z0 T, s1 v
virilization, exposure to exogenous testosterone in% D5 E( G4 o; e7 \0 k4 `. P
children results in an increase in growth velocity and
1 ^. I" b# o5 |5 \" c( j. ]advanced bone age, as seen in our patient.
; h& B. y1 q6 _4 L+ v* k  ?/ cThe long-term effect of androgen exposure during( _6 n/ b' C4 x' H  j3 r/ \/ @- |" c
early childhood on pubertal development and final
6 y& s* Y% w! D% p7 p5 Q3 iadult height are not fully known and always remain0 Q2 F6 f* K/ Y" R
a concern. Children treated with short-term testos-
* H) C! \# c3 ^terone injection or topical androgen may exhibit some
5 @! j! s+ ]- Z& `) r0 [& wacceleration of the skeletal maturation; however, after
+ o5 g( W8 L# G! O, ?9 Vcessation of treatment, the rate of bone maturation
+ E/ X# N* F+ K0 E2 n& [5 c. idecelerates and gradually returns to normal.8,93 o  u; k# \9 s- l. d+ t
There are conflicting reports and controversy
4 ?, X7 @3 J2 c. J3 O6 Z9 Kover the effect of early androgen exposure on adult
" L' F3 n9 F/ {/ ]; Wpenile length.10,11 Some reports suggest subnormal' c" E( c9 e( Q' l
adult penile length, apparently because of downreg-  t, f/ l2 T* Q, {% d
ulation of androgen receptor number.10,12 However,2 k/ B3 ~+ M2 N2 y
Sutherland et al13 did not find a correlation between
9 q/ S. X% W+ x3 I% n2 R& m/ z( uchildhood testosterone exposure and reduced adult. [3 V7 m7 {4 _! X
penile length in clinical studies.+ C; f9 `2 l8 v2 q; m! m
Nonetheless, we do not believe our patient is
' q9 c, b# ]9 Z  g, T: G5 agoing to experience any of the untoward effects from
8 T, e/ ]- W. w; z2 W& Itestosterone exposure as mentioned earlier because
9 Q9 F9 B0 H1 Q% Z2 Sthe exposure was not for a prolonged period of time.
9 a' b; O2 T3 }( G3 a+ _Although the bone age was advanced at the time of7 h: Y0 Y2 @) E; U
diagnosis, the child had a normal growth velocity at  o. @* M8 ?! i: V3 ?# ?
the follow-up visit. It is hoped that his final adult, x. U% o+ T1 E3 _. V: o
height will not be affected.
0 J) |6 @$ h3 B5 AAlthough rarely reported, the widespread avail-
3 @* L' v$ i2 V( s0 r' lability of androgen products in our society may
# d3 u7 A( B6 R$ ^9 z0 ]- e- i' Windeed cause more virilization in male or female
0 B! w( S6 a  ]children than one would realize. Exposure to andro-
2 w9 U5 s0 U6 I+ G8 Sgen products must be considered and specific ques-
9 R  w; c6 `% F$ c- [" Y* gtioning about the use of a testosterone product or
) h2 u& F) a7 y8 Cgel should be asked of the family members during
  \3 T' P1 O0 `+ I. _  u% k( \% \the evaluation of any children who present with vir-! f* p& P- n# c/ h: V) J
ilization or peripheral precocious puberty. The diag-/ I5 P0 s$ ~2 R5 S& S& \& K3 Z
nosis can be established by just a few tests and by  r7 S9 d7 z% m6 @, `  v# |! ^
appropriate history. The inability to obtain such a0 r, c% e3 }- Y3 D
history, or failure to ask the specific questions, may
" U& m! w# c5 I8 ^; oresult in extensive, unnecessary, and expensive$ I6 x3 K( W3 Q$ L: C! ?: _
investigation. The primary care physician should be- Z" q4 i  h: L) f" k  y
aware of this fact, because most of these children) c2 I9 S8 G8 ?& m7 I
may initially present in their practice. The Physicians’
; w, t+ `" l$ Q. ODesk Reference and package insert should also put a
' r2 ^& b  ]2 c; g) O) W2 nwarning about the virilizing effect on a male or
5 p0 g  q7 ]5 E! A7 hfemale child who might come in contact with some-% Q' B9 b6 D; e- O- G/ s: D
one using any of these products.. ?" ]+ g! D+ v* u  ^8 o  S
References- b3 b" J# b/ @3 h( c) t
1. Styne DM. The testes: disorder of sexual differentiation& k+ |$ s- Y, R" D, @* r
and puberty in the male. In: Sperling MA, ed. Pediatric( ~0 O/ S+ U0 A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 s& ^2 D. _6 S% M' t4 A
2002: 565-628.
% ], }' t4 [: [! S- Y5 S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) B9 ]) M8 E* D4 F- b
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
& L5 K- [4 }  {4 H! E, A
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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