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Sexual Precocity in a 16-Month-Old+ J2 Y: e7 R& u8 ], i0 d* U
Boy Induced by Indirect Topical% r/ ^2 Y' X; _+ l! J1 G
Exposure to Testosterone
* G, R: u: j) O) m2 `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 N/ e% p% Y+ {" k" {# w
and Kenneth R. Rettig, MD1
) ~  z- B. T+ d) q) n8 R) b# l1 N$ Y& K& \Clinical Pediatrics
2 ^- g/ G/ {5 N- V" G3 k; lVolume 46 Number 6. z2 |! a0 ~$ g+ Z% `  e" y* `4 \6 t
July 2007 540-543& v; m/ H7 j6 C' V  E+ Z/ w& B" m2 a$ \
© 2007 Sage Publications
4 m/ i( b, ?* a2 I, R& P10.1177/0009922806296651
; K6 Q/ ]6 V; p: Qhttp://clp.sagepub.com% f/ d/ e' i8 u! }& Y4 \
hosted at
7 k+ x% D9 o4 z+ u5 P1 rhttp://online.sagepub.com5 K9 x8 h9 m, j3 i) U" e
Precocious puberty in boys, central or peripheral,
! B) T" s; L- ris a significant concern for physicians. Central
  i& o- @& h, H2 ^+ @+ Bprecocious puberty (CPP), which is mediated0 }/ G! R4 d( A4 b
through the hypothalamic pituitary gonadal axis, has8 u3 p! s  n# I% d! p* ^/ W
a higher incidence of organic central nervous system
4 ~; _6 N# S* O2 p  i, d9 s, Ulesions in boys.1,2 Virilization in boys, as manifested
9 b: w5 y7 r8 A/ @+ {8 e0 uby enlargement of the penis, development of pubic
; j0 h) A  ~9 e3 N) Q; Z: Mhair, and facial acne without enlargement of testi-
6 E: g, m+ J/ s7 B/ ?" Lcles, suggests peripheral or pseudopuberty.1-3 We2 |% J; U1 \& J8 e8 s7 d5 K. z
report a 16-month-old boy who presented with the
3 q% C) G" J2 q0 W* E0 p4 q! R  Nenlargement of the phallus and pubic hair develop-
2 ?3 Y0 b+ A- I' U1 bment without testicular enlargement, which was due
" s" [! E9 ]7 g+ i' Q- \to the unintentional exposure to androgen gel used by
! `/ R* V9 k" R$ j' M7 N; L9 J% fthe father. The family initially concealed this infor-7 s' L# I' w+ n" D3 v2 r
mation, resulting in an extensive work-up for this
2 Z8 `8 q4 ^6 q: M5 R7 [4 Uchild. Given the widespread and easy availability of2 r5 ~; E# o) u/ W
testosterone gel and cream, we believe this is proba-
/ |1 \2 g9 b; i3 F2 U. O$ i6 x' nbly more common than the rare case report in the* `: c9 G! v8 E/ |2 C; \# j5 L
literature.4  ], ]) E3 m7 R3 d& Z1 D/ _9 o. L, x
Patient Report
+ `- q% B. G$ T& |; \! CA 16-month-old white child was referred to the$ L+ j0 r0 U1 u: S  @2 p* c
endocrine clinic by his pediatrician with the concern# {8 F  f- a) |4 C
of early sexual development. His mother noticed& l2 Q+ a9 ]+ H3 A
light colored pubic hair development when he was4 q  }6 s+ W' ^+ N
From the 1Division of Pediatric Endocrinology, 2University of# `' p: q! W: V# d
South Alabama Medical Center, Mobile, Alabama.
. h% @+ [+ d* [# f5 O. a' c/ _Address correspondence to: Samar K. Bhowmick, MD, FACE,; |4 b0 x- u) u5 o4 P6 q& R
Professor of Pediatrics, University of South Alabama, College of
2 [+ ]- V2 k# B* r5 C5 B# [, A6 ^Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 N4 Z* }, [6 z8 y/ Be-mail: [email protected].
$ @1 e. v$ \& j  B# Tabout 6 to 7 months old, which progressively became% H: ~$ D9 m  ]3 ?6 z3 F
darker. She was also concerned about the enlarge-
- ?/ v% X' v9 V( xment of his penis and frequent erections. The child
! \& X9 i9 S+ n1 o! f) Dwas the product of a full-term normal delivery, with/ O( N. H- U6 o5 ^
a birth weight of 7 lb 14 oz, and birth length of3 q3 g+ x1 v+ i8 e
20 inches. He was breast-fed throughout the first year
* q+ R* d  u. O* N8 G% Rof life and was still receiving breast milk along with
5 W" s% }! }, i1 {3 f4 Z" Gsolid food. He had no hospitalizations or surgery,! A! J( l/ }. H+ b0 T
and his psychosocial and psychomotor development
2 j" |5 A9 Q& o) I5 F" `8 Iwas age appropriate.: T6 P: h8 g6 e) J
The family history was remarkable for the father,& C  {- I+ Q; r* J$ U
who was diagnosed with hypothyroidism at age 16,
+ t0 }! y' s1 f* Owhich was treated with thyroxine. The father’s0 ~- M6 r1 p5 c% Y/ b( b6 O
height was 6 feet, and he went through a somewhat
  F6 j1 I" M2 d7 A+ fearly puberty and had stopped growing by age 14.
% a9 t7 A( C6 m# `3 O$ I! @' \The father denied taking any other medication. The
2 V/ ?7 F1 A7 M! i9 i' \! fchild’s mother was in good health. Her menarche
8 M. C) i* N* q' V5 mwas at 11 years of age, and her height was at 5 feet
5 I- \# W9 w7 g- |5 inches. There was no other family history of pre-! o: S8 ~7 _) i6 c/ c7 [
cocious sexual development in the first-degree rela-
! N7 h/ G) F& R( U4 q4 e3 Htives. There were no siblings.$ p+ g0 n$ [* ]
Physical Examination
1 P+ \' g& L+ AThe physical examination revealed a very active,4 n: X) _# s1 n; |
playful, and healthy boy. The vital signs documented
2 E% v+ P% E  g  v, \a blood pressure of 85/50 mm Hg, his length was8 q% k% _( ^. R$ y
90 cm (>97th percentile), and his weight was 14.4 kg& O8 O$ b( L7 Y/ R
(also >97th percentile). The observed yearly growth0 U$ ^* P) f  `( S3 p  ~* ?8 X
velocity was 30 cm (12 inches). The examination of
9 J# `- P2 Y4 X- z9 L+ wthe neck revealed no thyroid enlargement.  I) [- L1 `& q- n- \% d6 W
The genitourinary examination was remarkable for$ B; J. d  f; S* D) C
enlargement of the penis, with a stretched length of
  O: F% f1 n5 N0 Y% T! R- v( {8 cm and a width of 2 cm. The glans penis was very well  P' n0 e8 k4 v3 L  |" H4 }* j9 h
developed. The pubic hair was Tanner II, mostly around
2 D4 y0 O( A1 ?$ Z' C540( m" f. N! `8 T! R# B  ?4 p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 B% }" l( _  G& K6 _; Q
the base of the phallus and was dark and curled. The: B! E, N" a" o$ Y5 ~
testicular volume was prepubertal at 2 mL each.
- o. p  p4 H5 s/ V5 O3 [/ zThe skin was moist and smooth and somewhat* v% I6 w, n. Y6 D8 C; m
oily. No axillary hair was noted. There were no
8 y1 _( k9 \6 q5 d' P5 F( Wabnormal skin pigmentations or café-au-lait spots.1 d6 W+ n7 G" d2 S" v; P4 E
Neurologic evaluation showed deep tendon reflex 2+
- _( W# T8 U) e8 D! x4 C+ \# Nbilateral and symmetrical. There was no suggestion
" R7 M) b# ]2 _( N0 n7 O4 yof papilledema.! B$ p5 m- V  h
Laboratory Evaluation4 q0 d3 `4 Z, t# p) t
The bone age was consistent with 28 months by& g, s/ n1 W' }6 `7 \5 \  O/ K7 I
using the standard of Greulich and Pyle at a chrono-
9 C1 S9 }6 W8 \1 I5 rlogic age of 16 months (advanced).5 Chromosomal
7 F# j0 H& Q& ?( r1 N0 a6 |6 gkaryotype was 46XY. The thyroid function test. K" `1 P+ O1 {9 v( h$ P9 B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-& `$ Q: i" K7 L+ y6 T
lating hormone level was 1.3 µIU/mL (both normal).
) A$ o6 @$ S+ y& e; M' J' X$ x) `The concentrations of serum electrolytes, blood2 q8 s" u* Q, G+ `
urea nitrogen, creatinine, and calcium all were
" e& B, y) ?3 \! Xwithin normal range for his age. The concentration
7 Y) S& v* I4 _+ T4 d1 t! mof serum 17-hydroxyprogesterone was 16 ng/dL
5 ]% m! }2 }. b) C4 |3 _  G(normal, 3 to 90 ng/dL), androstenedione was 20
8 t8 e- Z5 v, g+ `3 a; @! qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
  g8 a! z+ n$ uterone was 38 ng/dL (normal, 50 to 760 ng/dL),5 `/ r! X( B% S3 P# u
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 X0 W9 U& K' W( c" u5 Y0 b# k$ N
49ng/dL), 11-desoxycortisol (specific compound S)
  V* m1 H. k, n3 l  X5 d0 }, }2 e1 dwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% J' K( D# f, L( ~+ u3 d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 p1 y. z' ~$ b$ J7 l; A8 f9 Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. i8 a( `  `. _
and β-human chorionic gonadotropin was less than9 `7 G: s& i" ^' t3 m* x6 ?0 V: n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
  B9 L9 @0 s2 |, C6 [0 e% ~% ?) z& Bstimulating hormone and leuteinizing hormone
% N1 v' ~: e" a2 Q) W- K5 Mconcentrations were less than 0.05 mIU/mL* m$ q! V, b. l! c& Z
(prepubertal).3 N4 H9 g! H/ p* K+ I
The parents were notified about the laboratory
. s7 V, \& m# y2 F, hresults and were informed that all of the tests were7 k% f; C1 n& q: x" D$ f+ C
normal except the testosterone level was high. The7 l$ j% u4 ~, o6 L
follow-up visit was arranged within a few weeks to/ {, {* G3 I/ O' i
obtain testicular and abdominal sonograms; how-
0 h' F1 q7 T& m  Xever, the family did not return for 4 months.
7 \$ o, T! n( c5 E. e: KPhysical examination at this time revealed that the6 W2 N$ N! m1 d% d/ |# Y
child had grown 2.5 cm in 4 months and had gained9 [) D# o2 c+ _+ B  @1 d5 u
2 kg of weight. Physical examination remained
! z& _4 V8 p- }" m* ounchanged. Surprisingly, the pubic hair almost com-/ h8 L, X. O% d& k! |5 R$ u
pletely disappeared except for a few vellous hairs at1 o1 x1 h  N; l# m6 B- K0 p
the base of the phallus. Testicular volume was still 2
+ m7 S" [' s) }* u7 omL, and the size of the penis remained unchanged.1 n7 c$ T, f/ F1 _
The mother also said that the boy was no longer hav-
; e) c7 u, S- F5 `! i: @  {! ?ing frequent erections.* D# K7 U+ {2 t7 S- Y
Both parents were again questioned about use of
" f$ T0 c) p- ~any ointment/creams that they may have applied to* K, d7 B2 {% M
the child’s skin. This time the father admitted the, r; V7 c# d6 V" @3 \' l: c- g
Topical Testosterone Exposure / Bhowmick et al 541
0 \5 u* r, B# Ruse of testosterone gel twice daily that he was apply-
) H% i+ M; F. }6 o" _ing over his own shoulders, chest, and back area for
0 F. \7 s1 O/ W3 _' @a year. The father also revealed he was embarrassed
! \& X) c7 ~+ e( t+ D2 Jto disclose that he was using a testosterone gel pre-2 R. j+ ^) E/ M- ]
scribed by his family physician for decreased libido4 b- |' `8 ~" R. k7 E% @( e% z: ^
secondary to depression./ [$ [6 |( j" r2 _& q
The child slept in the same bed with parents./ @3 L3 j8 Q7 x
The father would hug the baby and hold him on his
5 @5 H/ B5 k0 g* \& u  A# _. Schest for a considerable period of time, causing sig-- |* b" }: q* F3 n# j2 d% v
nificant bare skin contact between baby and father.7 J; }5 r& J, z* b( }
The father also admitted that after the phone call,, X* M1 ~) I; K3 _6 n
when he learned the testosterone level in the baby% r: m* c0 s& B4 D
was high, he then read the product information% a0 r3 K# g0 @$ D0 d$ t% u
packet and concluded that it was most likely the rea-4 H) ]" w  u! n) ?: W* F& y- h
son for the child’s virilization. At that time, they* h: G, P& B2 @9 W
decided to put the baby in a separate bed, and the4 j+ c3 z# U9 b. d
father was not hugging him with bare skin and had
. m$ y; V& B4 J1 A( Q! c; e  f" o6 ]been using protective clothing. A repeat testosterone
% F8 y$ c, c, [; f  d7 Y) Btest was ordered, but the family did not go to the
: z, s- Z7 G  c4 h6 B4 Vlaboratory to obtain the test.' U; C7 I7 X# x! S' q- `  I" j
Discussion
2 ~  x) d1 v' K7 l6 u3 m* z2 XPrecocious puberty in boys is defined as secondary% L! Q2 e% f' X) X+ E% ~
sexual development before 9 years of age.1,4
* f3 F& K( R/ ~5 h) C2 `Precocious puberty is termed as central (true) when
* Y! l+ f2 w% j* ]. x, W0 bit is caused by the premature activation of hypo-/ V& W' }  @* Q: q- |! U
thalamic pituitary gonadal axis. CPP is more com-
) ^/ |% S$ a: C2 c2 tmon in girls than in boys.1,3 Most boys with CPP9 f" x8 ]3 n- K7 e
may have a central nervous system lesion that is2 I* f6 K) A% A) E3 g
responsible for the early activation of the hypothal-* Q& }6 e# n) [  Z9 J# ^* d1 P
amic pituitary gonadal axis.1-3 Thus, greater empha-
( _" ?/ U- F2 Z9 _5 ssis has been given to neuroradiologic imaging in4 S7 A' r0 a7 C" s: z
boys with precocious puberty. In addition to viril-
  t. n7 s( q6 W- G' [. pization, the clinical hallmark of CPP is the symmet-
# e( x" g( J' I$ k1 Krical testicular growth secondary to stimulation by0 W) z% s1 c/ U4 A: z9 u, q! k4 K
gonadotropins.1,3
% Q$ |# V- p, SGonadotropin-independent peripheral preco-
4 q0 `6 {+ ^3 G/ Ccious puberty in boys also results from inappropriate/ F5 k7 J7 R1 s6 g' W2 k' a
androgenic stimulation from either endogenous or( \0 s8 @- V3 T& ^) m
exogenous sources, nonpituitary gonadotropin stim-
0 I, e. c$ v: m2 c) Bulation, and rare activating mutations.3 Virilizing
! I/ }3 O0 V1 N6 ycongenital adrenal hyperplasia producing excessive4 d, L$ j5 }, Z# \
adrenal androgens is a common cause of precocious& [1 U# e7 _) [' J
puberty in boys.3,4
8 F3 n5 B2 [* |- k* iThe most common form of congenital adrenal
! l5 a) C  h* D5 p( ]) \hyperplasia is the 21-hydroxylase enzyme deficiency.( v. T8 j( S# A- Q/ {
The 11-β hydroxylase deficiency may also result in
' L: Q& A# r' gexcessive adrenal androgen production, and rarely,
7 r* O3 T- F- B% l3 ]/ w! wan adrenal tumor may also cause adrenal androgen2 Q$ a( v0 x) P" g. u& W
excess.1,3
" h7 k+ `: R  o# Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& ?# H  A& F+ p+ R8 `3 q% Z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  A( y$ i1 p0 o
A unique entity of male-limited gonadotropin-
! I- `( W' j- D- a$ A# k: K! Gindependent precocious puberty, which is also known
/ M9 i  @) u7 ?0 oas testotoxicosis, may cause precocious puberty at a7 y+ z$ {) O2 o0 w3 b, C2 \4 O
very young age. The physical findings in these boys! H2 m( u# E& s" b8 W; P
with this disorder are full pubertal development,+ E& |1 o8 q! K! F% x  Q0 N2 W
including bilateral testicular growth, similar to boys
& ]8 T# i2 ?7 D% t) \; kwith CPP. The gonadotropin levels in this disorder+ I9 i8 k% N2 x5 [
are suppressed to prepubertal levels and do not show
7 K: X+ E5 n) ?/ P  S+ {8 |pubertal response of gonadotropin after gonadotropin-
) w$ K. B7 K3 V9 C7 Z' jreleasing hormone stimulation. This is a sex-linked
% \2 U' P' L$ ]# K8 eautosomal dominant disorder that affects only: ]1 o; B8 c3 D- }* X
males; therefore, other male members of the family
& ]& A) Q( O* p6 R( [- U/ W5 Y) Wmay have similar precocious puberty.35 k' J# n4 Y* c& P, M5 B
In our patient, physical examination was incon-' s; O% B0 `) Y, f* q
sistent with true precocious puberty since his testi-
5 d. u8 P# ~4 Icles were prepubertal in size. However, testotoxicosis- n, ?$ d( ^# S. l* k
was in the differential diagnosis because his father" q- m' H% B& ]: ?6 [
started puberty somewhat early, and occasionally,
. K6 I# M. A: r- ?testicular enlargement is not that evident in the
, @1 s& f! {8 L# w0 Ibeginning of this process.1 In the absence of a neg-
0 |' q0 O+ ~* i3 W3 X' Lative initial history of androgen exposure, our
$ a' u$ E4 E, u% S3 Y5 s! P! }biggest concern was virilizing adrenal hyperplasia,+ r  l, z1 g3 `0 h
either 21-hydroxylase deficiency or 11-β hydroxylase5 p( a! w$ u3 k' ^: }: w
deficiency. Those diagnoses were excluded by find-
$ J5 K( j1 n2 J  H5 Ging the normal level of adrenal steroids.
$ T* q) C8 o6 YThe diagnosis of exogenous androgens was strongly
1 X0 m  O4 E+ x$ X" E( msuspected in a follow-up visit after 4 months because
% Q# V9 b' j9 u3 _the physical examination revealed the complete disap-$ v6 \/ Y2 c6 ^! h
pearance of pubic hair, normal growth velocity, and- A- W4 e" L0 o1 E  R
decreased erections. The father admitted using a testos-
/ @6 ^; p2 A1 G3 w4 jterone gel, which he concealed at first visit. He was
! j  M8 E' b' E# nusing it rather frequently, twice a day. The Physicians’8 w& b' h6 U: |1 d) M' X  {
Desk Reference, or package insert of this product, gel or
8 \( R& j/ K& I! `( q% Vcream, cautions about dermal testosterone transfer to1 u8 J; S7 |. [
unprotected females through direct skin exposure.
# U! \, L- e; q1 NSerum testosterone level was found to be 2 times the) s  U! }3 y* p5 d, ~" O6 S5 _2 W
baseline value in those females who were exposed to
! N) n9 X6 k7 A5 t2 ceven 15 minutes of direct skin contact with their male
! Z+ V+ ~* u; L$ Y* ^2 v! r4 `0 j$ Upartners.6 However, when a shirt covered the applica-& G3 y/ @6 F6 n5 o' Q9 d& h
tion site, this testosterone transfer was prevented.
9 p* m3 z0 D8 S8 WOur patient’s testosterone level was 60 ng/mL,7 v3 A% [8 E" }2 z/ V
which was clearly high. Some studies suggest that
7 _5 C/ K) u% q% k# s1 |6 Ydermal conversion of testosterone to dihydrotestos-2 }0 C6 V! g" L3 R5 s; q
terone, which is a more potent metabolite, is more7 J0 q; h! f  ~/ a  k
active in young children exposed to testosterone
* e8 t( N9 ~" x" J' j' rexogenously7; however, we did not measure a dihy-: D/ A: a7 A0 O6 t4 h
drotestosterone level in our patient. In addition to
  \% T; Q1 @% i1 F3 svirilization, exposure to exogenous testosterone in9 V' g- l$ e8 Z5 V: U9 |8 M
children results in an increase in growth velocity and
/ a3 x3 G* a& ], yadvanced bone age, as seen in our patient., G$ t% s. R3 b" E2 A, m+ m6 ^: D+ N
The long-term effect of androgen exposure during
  A3 I! P3 o$ C/ I$ Jearly childhood on pubertal development and final
3 \8 V3 z" s& p9 ~( e) S" w+ Ladult height are not fully known and always remain$ s9 k% E; X, P
a concern. Children treated with short-term testos-
, z& E  Y: J5 E+ rterone injection or topical androgen may exhibit some
! `% i) u' x% y6 H  M0 Pacceleration of the skeletal maturation; however, after. R+ Z! A% ?" Y: a& q; ~
cessation of treatment, the rate of bone maturation
" }, K: M. i$ _; k# ?decelerates and gradually returns to normal.8,9
, Q* {7 Y5 q8 F: `- H. \There are conflicting reports and controversy  r6 D) {0 w7 y1 G& q% J
over the effect of early androgen exposure on adult4 Z$ @# U+ V: [
penile length.10,11 Some reports suggest subnormal" C$ d# [# @4 B6 |2 k8 u# a) h5 I: O+ o
adult penile length, apparently because of downreg-
4 l5 D7 w+ A5 t/ E, e3 a/ x+ b8 i, f% kulation of androgen receptor number.10,12 However,- y, g" X; w1 t2 n3 K
Sutherland et al13 did not find a correlation between
3 i5 |/ j! h6 d/ b6 Gchildhood testosterone exposure and reduced adult4 O/ x( D" S* o8 N$ O: H* @7 s% O
penile length in clinical studies.; z) U4 N! O- q( L; h
Nonetheless, we do not believe our patient is" t" f$ U. C6 h& l, ^
going to experience any of the untoward effects from
% j3 |7 A( s, Z! _8 b7 _4 _2 |testosterone exposure as mentioned earlier because" L) D1 f! ?! \- c- @/ G9 x
the exposure was not for a prolonged period of time.
6 s; B* i2 o. {. T+ fAlthough the bone age was advanced at the time of
+ B& A& ^4 Z) N8 q, K) B! bdiagnosis, the child had a normal growth velocity at
. n) X2 f4 W/ q9 @. W- |the follow-up visit. It is hoped that his final adult# n  M  I' {  y$ q9 M' s2 q
height will not be affected.
) D% y' s7 B* A- NAlthough rarely reported, the widespread avail-
& _0 K2 J1 n' a. m; z% Iability of androgen products in our society may
( `, z1 N, D* P: j+ y& v: Windeed cause more virilization in male or female! P  ~' s- ^5 S- D
children than one would realize. Exposure to andro-3 P( V& ]0 y, v& b
gen products must be considered and specific ques-
7 [! @1 y9 K& l( R0 ltioning about the use of a testosterone product or
* ~6 h4 D  q% E2 M; j/ Q% Y2 t! Lgel should be asked of the family members during) B9 _" i5 s+ Y. T
the evaluation of any children who present with vir-
1 Y6 z' \- ^/ Ailization or peripheral precocious puberty. The diag-0 \' u8 l1 {$ ]
nosis can be established by just a few tests and by! }' P9 Q) I* Z0 r: b% c5 W
appropriate history. The inability to obtain such a8 Y: `( q: i; Q9 e  h2 `) f
history, or failure to ask the specific questions, may
' u: ?: O4 C6 r$ }0 Z# Qresult in extensive, unnecessary, and expensive
* ~$ T( M- N3 I0 i( Dinvestigation. The primary care physician should be1 u+ _. _0 R8 X- q
aware of this fact, because most of these children
+ O- Y0 N( A- P% [$ [may initially present in their practice. The Physicians’
# B: k) D5 k/ BDesk Reference and package insert should also put a
5 _3 v" e3 u* \4 r2 [4 U1 A) W1 |warning about the virilizing effect on a male or* W+ L. l3 U, }5 R1 b
female child who might come in contact with some-
* d3 v& `1 p* H+ G" [2 ?7 none using any of these products.: h$ f4 o9 X, B4 F
References
4 U! k& c/ c7 k1. Styne DM. The testes: disorder of sexual differentiation) q1 e& o/ n. k$ C' r% q2 T
and puberty in the male. In: Sperling MA, ed. Pediatric. R& x% W% @! ]3 k/ C# J. ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 x  ?. f, o0 r0 s) v2002: 565-628.
& W3 U# I5 g3 E4 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( V. }/ C' j+ y  W/ T" j) h8 e; E
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) j% h& T4 W' c5 c: Y3 I0 k$ D
Boy Induced by Indirect Topical
% @7 D8 u/ |0 R, s  R$ b  H: l+ X* ^% v. `Exposure to Testosterone
0 `7 i$ k+ G8 |Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) y# E, V' ]4 C. q) h7 R& L" Z. \$ k
and Kenneth R. Rettig, MD1
' v8 {' [8 a) v: iClinical Pediatrics
: k$ A3 J4 w" {Volume 46 Number 6
( e9 n4 A) {0 @" X4 M1 rJuly 2007 540-543' v6 @. f5 \5 M' T7 |" ?: ^
© 2007 Sage Publications5 d" e( W$ E" v$ k
10.1177/0009922806296651
# A( O- i4 q' r8 g; p* {% Fhttp://clp.sagepub.com; Z) K1 f, j: R
hosted at
4 P" ]: @9 ]! C% Vhttp://online.sagepub.com. j# Q* Y, S6 q2 d9 ]6 B
Precocious puberty in boys, central or peripheral,9 v& q5 X1 H: e7 d, ^
is a significant concern for physicians. Central: v5 D* ^8 M' u
precocious puberty (CPP), which is mediated5 G( e/ p! a2 F! ?* z; D" K7 N
through the hypothalamic pituitary gonadal axis, has
6 [0 y* _0 c0 z/ I/ V4 ca higher incidence of organic central nervous system4 Y' v% Y7 E/ t* D- W' m
lesions in boys.1,2 Virilization in boys, as manifested2 _% a# ~% z3 `' |3 d1 h5 Z5 b
by enlargement of the penis, development of pubic% S" G+ U9 u& x5 D1 o& J5 R# A
hair, and facial acne without enlargement of testi-4 @9 k% l% m, ^( y5 e) ]% o; @
cles, suggests peripheral or pseudopuberty.1-3 We
2 h' D& D$ q+ D6 i" a& u* x/ Preport a 16-month-old boy who presented with the
0 j1 i" A: R; [  D- {2 @* ~2 v  Denlargement of the phallus and pubic hair develop-8 `1 I6 C) J- p8 K
ment without testicular enlargement, which was due9 n$ o9 d  E" U
to the unintentional exposure to androgen gel used by
) c4 D. h8 S% l+ i2 }- Lthe father. The family initially concealed this infor-8 C7 |0 X. |: U( C
mation, resulting in an extensive work-up for this
1 p+ @" }+ N; j* [child. Given the widespread and easy availability of$ ?9 L# f, f6 k" F5 D
testosterone gel and cream, we believe this is proba-; [3 D1 J4 v9 Z1 d
bly more common than the rare case report in the
5 u% z' W' `% e6 hliterature.4& L" N7 b" u, Y9 t9 w2 I
Patient Report
& v4 d' O4 V8 Y9 F; KA 16-month-old white child was referred to the1 A6 q, Q/ u1 A2 K
endocrine clinic by his pediatrician with the concern+ @" ^: G: A% A; {
of early sexual development. His mother noticed9 {; o- b1 d1 [) t7 M
light colored pubic hair development when he was9 K- g9 j* B0 ?6 B% y
From the 1Division of Pediatric Endocrinology, 2University of% S: w% t% r" d
South Alabama Medical Center, Mobile, Alabama.+ t! r! e. b7 Y; K  c
Address correspondence to: Samar K. Bhowmick, MD, FACE,
  r, A9 x- I( {# WProfessor of Pediatrics, University of South Alabama, College of
0 q9 w' R' e$ WMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- T, O7 G8 w. ^; T4 U/ J% b7 `e-mail: [email protected].
5 C" l' h& c* C. _; K4 n  oabout 6 to 7 months old, which progressively became) Z0 a, D$ G4 }) |2 o: y
darker. She was also concerned about the enlarge-( v: R0 @: S# h# |0 h1 B8 P) F* w! R
ment of his penis and frequent erections. The child
& C+ l8 Z" J, S+ P5 }5 J2 Hwas the product of a full-term normal delivery, with
8 H# n5 u5 u9 ~5 g- _) j9 [a birth weight of 7 lb 14 oz, and birth length of
) z7 y: p, m4 A, a, z1 ~20 inches. He was breast-fed throughout the first year
% y" L& t! \' s, J2 ?& }# xof life and was still receiving breast milk along with
5 y3 \8 k( ^! y/ Fsolid food. He had no hospitalizations or surgery,
2 y% p+ M& {3 R" ]& ?and his psychosocial and psychomotor development2 u! C4 s; C& N9 H8 }, T
was age appropriate.
" R! C, M! C8 e& }The family history was remarkable for the father,
" z* K8 q! C  b0 }5 B2 ~2 Y$ {& P% Swho was diagnosed with hypothyroidism at age 16,
: i% U/ K: ]7 f% L4 z+ ?which was treated with thyroxine. The father’s9 ]7 m, w- G  X- J& x3 y6 T$ \
height was 6 feet, and he went through a somewhat5 e; p: i" ?0 d. j
early puberty and had stopped growing by age 14." V4 D6 }& ^4 t- X' e8 c
The father denied taking any other medication. The3 G4 b) e1 N# |
child’s mother was in good health. Her menarche
; n% [! t& v  ]0 awas at 11 years of age, and her height was at 5 feet0 p! ^; J; Y, u8 p3 `3 u
5 inches. There was no other family history of pre-
+ k- `. S& c8 n$ Y: I+ {7 icocious sexual development in the first-degree rela-8 H4 g% w& q. P, L9 F* V
tives. There were no siblings.
# W2 R& `5 g& N: [Physical Examination
  Y& Z8 F  x+ N: x/ wThe physical examination revealed a very active,8 A+ V! f2 h- Z" H2 P7 Z
playful, and healthy boy. The vital signs documented
3 ~, v9 Q3 Z- W6 A3 S6 va blood pressure of 85/50 mm Hg, his length was3 X; p/ D# T% v! w* r/ R
90 cm (>97th percentile), and his weight was 14.4 kg
* X$ ?7 s( v% s) g(also >97th percentile). The observed yearly growth1 |; [; B- @) S2 c
velocity was 30 cm (12 inches). The examination of- \9 l# t  ~( J: h+ i1 w6 a3 v+ ~
the neck revealed no thyroid enlargement.% ?3 D# m3 I- \
The genitourinary examination was remarkable for3 m) ?5 C, X) F* U* P1 S7 ^
enlargement of the penis, with a stretched length of8 r% Z/ e9 G( k5 c$ T
8 cm and a width of 2 cm. The glans penis was very well& `0 S* w0 l9 U2 Y
developed. The pubic hair was Tanner II, mostly around& n1 h3 ]3 L! v" J# b# U
540. o- [: Z+ ]" P& W# c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% U1 D% H$ y) S. s! V# B
the base of the phallus and was dark and curled. The
  X" k- k4 L. Z5 A0 y7 m( w  Q. |! Ptesticular volume was prepubertal at 2 mL each.* g/ L, u7 t5 y
The skin was moist and smooth and somewhat
* h' P5 f% g$ S. K. b; `oily. No axillary hair was noted. There were no
' g( n$ |/ `+ i& p; \9 `abnormal skin pigmentations or café-au-lait spots.( d- H' L3 I, Q! B
Neurologic evaluation showed deep tendon reflex 2+
9 ]3 M6 p5 _) a/ h) \8 f- b: nbilateral and symmetrical. There was no suggestion
7 m: y$ i. F  D# I, p2 wof papilledema.6 l6 ^% y5 e, n" U
Laboratory Evaluation
4 s$ [; r# M- M( |! Z; U% E) B+ C4 O6 rThe bone age was consistent with 28 months by3 x+ ~5 ^4 D# M9 E
using the standard of Greulich and Pyle at a chrono-: L) x. F  K4 D. j$ z& C% r
logic age of 16 months (advanced).5 Chromosomal
+ e/ O4 a9 g' f- E! Akaryotype was 46XY. The thyroid function test% k# Z' h! Y3 Z* q; G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 a- I( `9 ~1 a+ e' R1 ~, N5 i7 z" ?
lating hormone level was 1.3 µIU/mL (both normal).
9 L- Z8 ]% K0 H1 y9 G' t/ yThe concentrations of serum electrolytes, blood) d" a: w7 A. g
urea nitrogen, creatinine, and calcium all were) `& c% r3 l7 @/ Z( M  m
within normal range for his age. The concentration
9 t+ a) A0 Z2 G5 e/ I) b% F6 |of serum 17-hydroxyprogesterone was 16 ng/dL4 o9 j, Y8 f" B- D
(normal, 3 to 90 ng/dL), androstenedione was 20! i8 |7 W% l8 {1 `( \2 }
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( g( i& f7 y) T! E7 H' \( ~+ ^  fterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 l% @) ~3 G; g8 s' J
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" R) {2 q/ |3 g  P$ U! p! ]
49ng/dL), 11-desoxycortisol (specific compound S)
- y5 @0 b. @* j% D1 S2 Rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 B8 D, y$ w/ S1 O& e$ K2 b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# r0 s1 u% U7 \+ ^4 Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 _( |9 x$ U% }# `3 U' @
and β-human chorionic gonadotropin was less than9 P9 o0 A. z* m0 Z
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 X0 _& q8 a9 S" Wstimulating hormone and leuteinizing hormone5 u/ k, A4 _, D& p0 `5 I$ O' e
concentrations were less than 0.05 mIU/mL% d8 \2 k' v  \+ f; o
(prepubertal).+ D. i, m, A. Y6 ], W/ N$ }3 s, }, S
The parents were notified about the laboratory
) C1 g7 A6 u' t6 }: z  lresults and were informed that all of the tests were
; v) W7 V5 M* ^) @normal except the testosterone level was high. The4 _1 J6 X3 r, f4 K2 r1 D
follow-up visit was arranged within a few weeks to8 n# B$ `/ t7 n! m0 M0 o
obtain testicular and abdominal sonograms; how-
, _* V" W) r* h; a( @! W! ~ever, the family did not return for 4 months.
1 G+ W9 p5 m% ^2 ]6 o% oPhysical examination at this time revealed that the3 Z! U2 y9 H2 ]; f. X
child had grown 2.5 cm in 4 months and had gained
: w* R6 S: b0 g3 v; Q2 w% u+ _2 kg of weight. Physical examination remained
7 ^* j7 G1 ~  m. t, l& hunchanged. Surprisingly, the pubic hair almost com-& e. C9 p$ r  D
pletely disappeared except for a few vellous hairs at
$ V+ V2 m1 _4 m4 f0 h2 [, {2 x3 Rthe base of the phallus. Testicular volume was still 2
8 s3 z. R2 h1 NmL, and the size of the penis remained unchanged.
5 v2 ]$ b' J8 X. v( c! i0 i& {3 o; a4 {( dThe mother also said that the boy was no longer hav-9 z! o' A( F3 `: v: n
ing frequent erections.
. V: ]& n# i3 K* \5 k' rBoth parents were again questioned about use of- o( A$ G" i8 O9 U! e
any ointment/creams that they may have applied to# J( \4 C2 G0 G
the child’s skin. This time the father admitted the5 n1 H+ h, A- m# F$ W! g0 Y
Topical Testosterone Exposure / Bhowmick et al 541
" ^/ M$ z6 p: h6 Vuse of testosterone gel twice daily that he was apply-
2 i* x$ N9 ~9 u8 t% G! Fing over his own shoulders, chest, and back area for
* y$ G* Q1 U9 [- ~  {: {a year. The father also revealed he was embarrassed& _3 L; h- |: |( ^1 e: `
to disclose that he was using a testosterone gel pre-* p( o/ x! b$ u( m( C. ?) \8 Y3 j7 Z
scribed by his family physician for decreased libido
: D- }* ?* j8 ^9 i6 Hsecondary to depression." ]) o# R; ?2 x, i# d' Z: a& p5 C% N
The child slept in the same bed with parents.6 V; {8 n7 I( x( D0 m- L" i0 R
The father would hug the baby and hold him on his6 ]' r, W5 J0 ^  K" ~
chest for a considerable period of time, causing sig-5 M! }1 p6 Z( D1 U
nificant bare skin contact between baby and father.
. |. ^# i& n9 N$ `4 IThe father also admitted that after the phone call,
: a8 J5 F( R) M5 Ewhen he learned the testosterone level in the baby
& |3 M3 e' a! K8 H  ~# @was high, he then read the product information' r5 f% M7 a+ {# \' p2 ?: \$ U: Z
packet and concluded that it was most likely the rea-
- R2 {# R) [% e  ~& Z8 m, ?& ason for the child’s virilization. At that time, they- s- m0 z, i8 u1 [
decided to put the baby in a separate bed, and the
# O% O  F% U; P: e9 cfather was not hugging him with bare skin and had4 a* G, t. @" y4 W( l
been using protective clothing. A repeat testosterone. H$ M8 U) v3 z% g: Q& @
test was ordered, but the family did not go to the
9 T5 |1 c! I8 N( U" q" u, W4 Q8 |* Alaboratory to obtain the test.) @6 p, K' g% C) p6 U8 y
Discussion
! v9 ?) d1 G" X) T: PPrecocious puberty in boys is defined as secondary
+ k" T: ~* z, Asexual development before 9 years of age.1,4/ H" f) N- o# g* @; |
Precocious puberty is termed as central (true) when
' M, l8 c7 a" ^8 r1 O" q9 Sit is caused by the premature activation of hypo-+ d/ U8 H" ]6 y, o8 D4 K: _, \+ M
thalamic pituitary gonadal axis. CPP is more com-
2 ?+ F! e0 U2 w( e( I$ Fmon in girls than in boys.1,3 Most boys with CPP/ w; u) y% f2 `/ Z4 C! Y
may have a central nervous system lesion that is/ H0 T+ B( h3 o  p
responsible for the early activation of the hypothal-2 j& M$ M" s+ ~' X0 {, c
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 M5 u; D( Z1 W4 i6 `sis has been given to neuroradiologic imaging in2 C5 Y7 s( {0 V# d9 |
boys with precocious puberty. In addition to viril-
7 K( L0 E2 a7 X! b/ ?ization, the clinical hallmark of CPP is the symmet-8 M- o" m! P8 G- x) D; g: [, P
rical testicular growth secondary to stimulation by0 _& F& a7 d7 [) e& z+ b& w% n
gonadotropins.1,3
! Q# q( Z0 l+ ~Gonadotropin-independent peripheral preco-
* o% e  G) E0 i/ B1 h4 N' ^  Wcious puberty in boys also results from inappropriate
. W5 N1 O% ~$ h6 w' q) zandrogenic stimulation from either endogenous or
( A1 j' x1 _+ Dexogenous sources, nonpituitary gonadotropin stim-
1 T3 B3 ~* P  `5 E9 sulation, and rare activating mutations.3 Virilizing6 w  [3 t5 b+ k  u
congenital adrenal hyperplasia producing excessive
  D) \* J$ W: Q  Zadrenal androgens is a common cause of precocious, w1 L- p+ R" g+ g/ d& B7 f3 y
puberty in boys.3,40 p) }1 p6 |! Z: r( C
The most common form of congenital adrenal
7 ?" b6 p6 b$ f* e/ i- @hyperplasia is the 21-hydroxylase enzyme deficiency., {/ N; @# r3 ~! T+ S
The 11-β hydroxylase deficiency may also result in
- u7 q, ?& C* texcessive adrenal androgen production, and rarely,
/ r2 q! i6 L( [& V  han adrenal tumor may also cause adrenal androgen
4 G+ o& F7 d8 N* w6 X9 D% O: aexcess.1,3
/ W- ~. L/ k8 zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, B  q4 j, w; u0 t7 h" V" |( r542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" X4 F) [1 N) c3 C7 f1 T- w# A$ SA unique entity of male-limited gonadotropin-* b: i4 q- Z! |  p
independent precocious puberty, which is also known7 F  T; ?* q" a( C
as testotoxicosis, may cause precocious puberty at a  Q$ I% c1 n# E' i" q
very young age. The physical findings in these boys! `1 B" T% d5 a, A
with this disorder are full pubertal development,! P8 d+ @( U. Y' o2 p) V% ?
including bilateral testicular growth, similar to boys" e/ s! v8 ?) f+ W, Y8 o
with CPP. The gonadotropin levels in this disorder
* X: v  o' ^) ^( z9 b+ M; Yare suppressed to prepubertal levels and do not show1 w# N& A( R$ R2 F
pubertal response of gonadotropin after gonadotropin-6 ~, N6 `4 A7 ]3 |
releasing hormone stimulation. This is a sex-linked
* n# v' ?2 k  a/ |% c' r) e* u- tautosomal dominant disorder that affects only
9 @# d1 C; p% k0 jmales; therefore, other male members of the family
1 B  |# G' q0 J' d, U5 P% Xmay have similar precocious puberty.3
  X, B% s' N6 e7 d; M) GIn our patient, physical examination was incon-
) Y8 ~) n9 Q, k  ~# g6 z4 Ksistent with true precocious puberty since his testi-
* g& c, ^) T  P$ P7 x! Pcles were prepubertal in size. However, testotoxicosis' D$ K0 N) |& Z9 v% r
was in the differential diagnosis because his father
3 v! S8 d$ K8 F1 D% rstarted puberty somewhat early, and occasionally,: R. C2 i% [6 i2 q1 L- d& h
testicular enlargement is not that evident in the% }8 m( b$ ~" ?, C* N
beginning of this process.1 In the absence of a neg-
" n5 f& y6 i0 F1 Aative initial history of androgen exposure, our
' M8 g9 [: l" _biggest concern was virilizing adrenal hyperplasia,2 H3 W' @, s" \2 ?
either 21-hydroxylase deficiency or 11-β hydroxylase  M( W4 |3 M  |+ U, `) r5 `
deficiency. Those diagnoses were excluded by find-0 q# k6 A: l4 }
ing the normal level of adrenal steroids.- f1 d3 d$ P  p/ k' K) c
The diagnosis of exogenous androgens was strongly( \) d) ]" G6 W8 E
suspected in a follow-up visit after 4 months because5 ^2 z- a5 ^. i: [6 y3 j
the physical examination revealed the complete disap-
/ g9 l: K# @( C5 v3 @& }5 j7 \# t4 apearance of pubic hair, normal growth velocity, and+ `6 x, K3 m1 K$ F$ D
decreased erections. The father admitted using a testos-  A/ s4 U6 M* @  F) w
terone gel, which he concealed at first visit. He was
9 s* V5 a. M8 A  p8 g2 m& A2 S- Busing it rather frequently, twice a day. The Physicians’
! y5 L8 Z4 J2 w5 c+ G2 p4 n" o+ _  CDesk Reference, or package insert of this product, gel or3 H5 v2 b) }" ^  |1 s1 j
cream, cautions about dermal testosterone transfer to5 N* P' P+ j+ z% \6 ~1 e3 ?
unprotected females through direct skin exposure.; z' i4 \; |- [( d
Serum testosterone level was found to be 2 times the) T* c& I6 c, d( w. {. S
baseline value in those females who were exposed to  \* N: I. B: u2 w
even 15 minutes of direct skin contact with their male9 w' @7 b$ R: v* k" g! q
partners.6 However, when a shirt covered the applica-
9 i" Z! O9 i1 s) @9 @. ~tion site, this testosterone transfer was prevented.6 a* q  G7 `$ i
Our patient’s testosterone level was 60 ng/mL,
+ z) G0 [4 d5 g. Z: H% W9 _  _) hwhich was clearly high. Some studies suggest that
8 r1 G* s$ p9 {+ \  ?' I- wdermal conversion of testosterone to dihydrotestos-) l7 @' N* u4 H( Q+ f6 p  ^! T
terone, which is a more potent metabolite, is more
* C4 s& N7 [0 |; R' E6 lactive in young children exposed to testosterone5 g, Z  {/ Q9 p
exogenously7; however, we did not measure a dihy-: O) M6 G: k. u$ U' t5 L
drotestosterone level in our patient. In addition to
3 g5 Z# I2 H  N$ H) ]  Gvirilization, exposure to exogenous testosterone in
9 k, Z# X" @8 Z6 F4 Rchildren results in an increase in growth velocity and+ {; \- c+ b* r5 X( x3 C# `& a
advanced bone age, as seen in our patient.* V% O% d. F5 u! Z3 C7 {, k: O& j
The long-term effect of androgen exposure during, @! P# ~& m5 f2 L
early childhood on pubertal development and final
9 {* j& d, J( x2 n7 e* nadult height are not fully known and always remain
  v/ a8 X( A+ b( ba concern. Children treated with short-term testos-
' s1 y  V) b; K; aterone injection or topical androgen may exhibit some. H( h% t! K! R. z
acceleration of the skeletal maturation; however, after) o; C' q4 @1 t6 X2 {, V# N; F
cessation of treatment, the rate of bone maturation
1 D% M7 I0 W1 M6 }' p* f. Hdecelerates and gradually returns to normal.8,9
6 c0 K/ g3 F0 ]& C; a- M, _There are conflicting reports and controversy6 O. o3 C3 W, \) t* f
over the effect of early androgen exposure on adult
$ J9 F( a+ e8 h1 I- S/ kpenile length.10,11 Some reports suggest subnormal7 Z/ H# |3 x# b% q) k3 H' U
adult penile length, apparently because of downreg-$ E. t3 W' Q# R4 m7 z
ulation of androgen receptor number.10,12 However,
$ {0 Q6 x, l; [9 ]6 r' ]* K' ySutherland et al13 did not find a correlation between
4 P. B. y4 ^! C+ ^1 H5 [( jchildhood testosterone exposure and reduced adult
7 X: T9 ^1 c6 N6 G" mpenile length in clinical studies.
$ j) _- o' e/ XNonetheless, we do not believe our patient is; t' O3 p2 r3 ^. H* X: R& L
going to experience any of the untoward effects from. q2 F* E, M# [2 g! d
testosterone exposure as mentioned earlier because/ L- r6 t. s0 @: y) M0 l
the exposure was not for a prolonged period of time.& J# R1 ^0 [2 `6 I- a+ j. I+ ^6 ?# _/ e
Although the bone age was advanced at the time of
0 M0 Y" N0 s) r4 _; Ediagnosis, the child had a normal growth velocity at4 P' ~: |! u6 F/ P: S
the follow-up visit. It is hoped that his final adult
! ~8 e/ d9 B, T4 [* F8 v* F# iheight will not be affected.
* f) ^% X' @( N9 k7 s# T, H% QAlthough rarely reported, the widespread avail-- {  ^3 ~, Q2 c$ m& ]1 ?# q
ability of androgen products in our society may: O9 ]3 b2 h* _4 D
indeed cause more virilization in male or female
/ a1 N6 s' b8 k1 K  x9 bchildren than one would realize. Exposure to andro-5 @3 V# b* g# ^6 Q1 P
gen products must be considered and specific ques-3 I0 P1 j% S& Q% L; A' J
tioning about the use of a testosterone product or
' \: Q9 n- K7 mgel should be asked of the family members during
* y5 O+ o) E2 r7 Q" m! _: fthe evaluation of any children who present with vir-
% y3 N/ ?9 Y& J, h: V# k6 U7 Qilization or peripheral precocious puberty. The diag-
0 f  l0 s- u/ K& x5 jnosis can be established by just a few tests and by. b" h# Q% g7 x# @/ y
appropriate history. The inability to obtain such a: d8 f5 Z6 M+ j- y. `2 \
history, or failure to ask the specific questions, may
1 {% J, m0 F$ k2 L5 y- l$ f+ I) rresult in extensive, unnecessary, and expensive
. s) O% v: N6 G$ Einvestigation. The primary care physician should be
; m; Q2 R" S" Y) H- l( z0 H- ~aware of this fact, because most of these children
; [+ f, R  n: [7 wmay initially present in their practice. The Physicians’+ x2 f# R+ C$ u, X: O
Desk Reference and package insert should also put a
( r, q7 q. J) c: |warning about the virilizing effect on a male or
+ X) ^  G! f; w- W4 p8 {6 ~female child who might come in contact with some-4 U! W* M1 j3 A3 N" a, y: s6 D
one using any of these products.
9 e! C3 f7 r4 R  r3 f  L% tReferences
( v) o# O, w9 T5 X- ?1. Styne DM. The testes: disorder of sexual differentiation
8 ?# W# ]# e1 g2 n( m* ^and puberty in the male. In: Sperling MA, ed. Pediatric
, g3 ]. l" s# [( mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 F. D% ^0 w2 U0 A
2002: 565-628.
; j! b% W0 ?8 z8 T2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 k" y+ }! T. T% [$ ^, Apuberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

4 S. {- c; d4 f6 o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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