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Sexual Precocity in a 16-Month-Old- O, p% L6 j/ j0 J1 }
Boy Induced by Indirect Topical
0 ?9 a" w! z$ R$ o: AExposure to Testosterone
9 m0 Z: b* ~. w) T: ySamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# ~" A8 F; }/ y0 y6 o, a9 ~0 `0 kand Kenneth R. Rettig, MD1
  Q2 N% M: ^4 y1 EClinical Pediatrics
( [& S$ o  G! T" i6 z& pVolume 46 Number 6  J% M3 \5 G5 B
July 2007 540-543
) x; W5 ]  j3 U3 c2 m4 U© 2007 Sage Publications% u3 N) j) \# |" |, ]; Q$ u( h
10.1177/0009922806296651
* b) G2 J  Z; p- W% E& o+ shttp://clp.sagepub.com. _3 a, n$ Q: B3 Q( W, C6 X! A
hosted at
  P4 o6 s" q) Z8 E* a2 E2 Ohttp://online.sagepub.com& a+ `( S3 g9 }
Precocious puberty in boys, central or peripheral,
1 X: u5 {* W- S9 v, Gis a significant concern for physicians. Central
( L" Z- o3 {+ C# ^3 P% ~precocious puberty (CPP), which is mediated9 _3 ~6 R7 l, K( z( E4 d
through the hypothalamic pituitary gonadal axis, has
: U0 b6 K) X, C. |a higher incidence of organic central nervous system  Y' c$ ~. U* _, I( L% l) V
lesions in boys.1,2 Virilization in boys, as manifested- ~' P5 M" s7 n7 P5 @* i- @
by enlargement of the penis, development of pubic) \8 z0 ?: c. K# V$ o1 M9 X; [) w. ]5 q
hair, and facial acne without enlargement of testi-. ]6 X/ {7 G& }) m" e
cles, suggests peripheral or pseudopuberty.1-3 We9 ?. T8 v9 @4 M3 y  t. |. l
report a 16-month-old boy who presented with the, J: k7 A# Q- E0 V
enlargement of the phallus and pubic hair develop-; n5 p2 m8 \: D$ s0 M2 z
ment without testicular enlargement, which was due! i) E7 |* D. p
to the unintentional exposure to androgen gel used by
9 P/ x0 C/ l: v3 h, v; }9 ithe father. The family initially concealed this infor-
! p* Y) @6 f5 b' Pmation, resulting in an extensive work-up for this' N# Z- R+ b4 T: j5 @# o5 U
child. Given the widespread and easy availability of
) Z' `) T2 Y# r+ Dtestosterone gel and cream, we believe this is proba-
; i/ P7 o! B4 x# Rbly more common than the rare case report in the7 Q4 A- L5 r0 ~) Z  ~, K
literature.4
4 Z6 `6 q9 @( i% `. i- NPatient Report
; b) B$ d/ Y3 P/ kA 16-month-old white child was referred to the
7 }4 J0 C  k: g: a( _endocrine clinic by his pediatrician with the concern* u) i, h, Q+ _6 _+ ?* W! w- M% _# O
of early sexual development. His mother noticed2 V4 O% Z6 E+ @6 m) t' E0 s1 Z& `3 y4 l
light colored pubic hair development when he was
. g. ~! }3 x2 KFrom the 1Division of Pediatric Endocrinology, 2University of+ n% p; W5 W; t5 Q# L
South Alabama Medical Center, Mobile, Alabama.+ _$ g/ Z5 k7 z/ C# O+ N
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 `+ M0 _& ]6 s& q+ M! Y5 U- P% Y' k2 b& k
Professor of Pediatrics, University of South Alabama, College of
+ p# F! G$ y: \8 ], W) KMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" b. A6 e3 m  i+ U4 g2 [+ je-mail: [email protected].9 `8 Z3 ]' {. v. }! v& K
about 6 to 7 months old, which progressively became
# J0 ?3 N/ W: B1 y" T8 udarker. She was also concerned about the enlarge-
8 M( S- ~  w' L9 {ment of his penis and frequent erections. The child; M7 }& Y+ k) x! \) {
was the product of a full-term normal delivery, with
3 r+ j5 j, ^) E: F4 [) ia birth weight of 7 lb 14 oz, and birth length of  s( q1 S$ t7 ?6 ~
20 inches. He was breast-fed throughout the first year
% v# q7 R( }0 @# L# Dof life and was still receiving breast milk along with# w, c' T) f# Z$ m8 h! l
solid food. He had no hospitalizations or surgery,
. S( A% B& ?3 Q: vand his psychosocial and psychomotor development# f# B: w; I8 O" _( P- o
was age appropriate.& v. D- i2 o7 H0 X3 h
The family history was remarkable for the father,1 g9 n' Y& s9 |6 }2 [% r% D: h
who was diagnosed with hypothyroidism at age 16,
4 f% v7 D% F- ewhich was treated with thyroxine. The father’s1 H, e7 [6 [: H; V4 F( W' N( c
height was 6 feet, and he went through a somewhat; D5 j% x3 h: Z2 |0 p0 B2 [5 M' R
early puberty and had stopped growing by age 14.1 z6 J# B" l2 v3 \8 v; ]. @) o9 n
The father denied taking any other medication. The% K9 V- I: M% f1 L& f& h
child’s mother was in good health. Her menarche/ g+ T! j. U6 m. S* u, }& O
was at 11 years of age, and her height was at 5 feet, K( C, P9 i& y/ L. H3 J' n
5 inches. There was no other family history of pre-
/ v- D: Y) n& v) [. a  J4 _* \3 w. ~; I8 Lcocious sexual development in the first-degree rela-
( C3 v# F% Y9 ytives. There were no siblings.
. G- e4 e) s. G: ~& mPhysical Examination
- @( w- w  _) ?/ VThe physical examination revealed a very active,- \* U* Y% x6 }+ V( N' i
playful, and healthy boy. The vital signs documented, x, y- ~9 ^" z2 S, d$ r
a blood pressure of 85/50 mm Hg, his length was
8 n, F8 T1 x  z0 _90 cm (>97th percentile), and his weight was 14.4 kg
  Q0 z2 F, \5 q, g(also >97th percentile). The observed yearly growth
. {4 S! }& Z; w$ `* K( ?velocity was 30 cm (12 inches). The examination of
# X! @6 d0 t; v; r4 bthe neck revealed no thyroid enlargement.  o& A" r. X% L# a# g) v1 j
The genitourinary examination was remarkable for& Z0 m9 U( t; T& B/ Y
enlargement of the penis, with a stretched length of$ T: Z6 `$ C" V, F" n. }+ ^
8 cm and a width of 2 cm. The glans penis was very well
0 X4 f8 ?  d: d9 Q9 Adeveloped. The pubic hair was Tanner II, mostly around5 L5 k+ ~3 D4 }; O/ _6 U
540
9 I4 x% o2 c+ Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 [. Z8 Y1 z( F7 ^; ^' }
the base of the phallus and was dark and curled. The
- F! s3 o- H7 H- t0 G3 ^5 gtesticular volume was prepubertal at 2 mL each.
' v6 y# n6 C2 w' lThe skin was moist and smooth and somewhat; S5 k# N4 Z+ w: ~+ i
oily. No axillary hair was noted. There were no
- H* {4 P3 H6 ?! f5 g- Q7 mabnormal skin pigmentations or café-au-lait spots.
! B* V2 ?0 |' r8 M7 j1 Q' Y+ YNeurologic evaluation showed deep tendon reflex 2+. N0 Z  F8 X( i( R" X
bilateral and symmetrical. There was no suggestion
' V; _' J: X' W( Z  C, X* t  fof papilledema.+ Z1 U6 c# c$ G0 _; N! S9 A. H
Laboratory Evaluation! T! W9 I' m/ U: a& K+ Y
The bone age was consistent with 28 months by5 K; v- p/ m0 s9 J- f" y
using the standard of Greulich and Pyle at a chrono-
+ d6 C3 H, s) m  C1 L; Z9 Flogic age of 16 months (advanced).5 Chromosomal
6 z6 s; k" ~5 f. B! ]/ nkaryotype was 46XY. The thyroid function test# m% x+ N: G: U: V8 s3 b
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 d2 u' W2 X# plating hormone level was 1.3 µIU/mL (both normal).
6 S( v: q$ J( ], IThe concentrations of serum electrolytes, blood" D8 s- F0 I/ O; `* W7 T! w) E
urea nitrogen, creatinine, and calcium all were7 F3 @; q6 ?6 b* E
within normal range for his age. The concentration
. q7 A; g; ^9 E5 f" }of serum 17-hydroxyprogesterone was 16 ng/dL' S. P4 c+ _# P$ G3 f% ^6 B, ?" y
(normal, 3 to 90 ng/dL), androstenedione was 20/ _* K: M1 `7 G  ^0 K& X! I9 k) M+ u
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 }2 A; D) ]  [% n8 }
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# m6 X: P$ S5 h) tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to- ?  L- d: M$ @5 H2 H  g
49ng/dL), 11-desoxycortisol (specific compound S)
/ _+ t/ j" r% N+ K. p% K2 uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 M5 d# m8 T3 j( \. vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% H7 W9 p, y1 V/ [testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ m2 u. `+ b! |" f8 @& w: v4 Uand β-human chorionic gonadotropin was less than4 x" W0 x" G! y3 f
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ c* i, F/ k5 v! b
stimulating hormone and leuteinizing hormone
/ l( f1 L, P4 Q: s3 xconcentrations were less than 0.05 mIU/mL
( j! o. X" }/ P4 p7 M(prepubertal).
7 d" a% @1 r1 p$ w' Q7 x, y! CThe parents were notified about the laboratory
* V8 n7 Y, T4 G' o; }results and were informed that all of the tests were- x  R) p; h/ ^. g( F) F9 t* @
normal except the testosterone level was high. The( g( q0 ?0 ?- V! N$ ~
follow-up visit was arranged within a few weeks to
" W) R0 v6 e) ~' P% H+ Robtain testicular and abdominal sonograms; how-8 c+ `: a: B1 c1 t5 D" L! i, P
ever, the family did not return for 4 months.
9 V* A: v. j& _* c! R/ |' {0 l' TPhysical examination at this time revealed that the
9 N$ I) ~. V$ s+ V& pchild had grown 2.5 cm in 4 months and had gained' @6 ]. U# L' J& e: J0 A, K
2 kg of weight. Physical examination remained' _; S0 R1 [' L# w, t  O" }
unchanged. Surprisingly, the pubic hair almost com-9 _5 v0 f# Q$ e- U' x; B0 w: j- U
pletely disappeared except for a few vellous hairs at7 D% f0 \* e+ G/ v$ H
the base of the phallus. Testicular volume was still 2
1 [: R# n, R) W6 g! VmL, and the size of the penis remained unchanged.
9 f: d- V* ^' u( W* Q$ y& g/ [The mother also said that the boy was no longer hav-1 e+ x8 |( ]" b/ P
ing frequent erections.
8 X" W( w. a' R- A; s1 B- WBoth parents were again questioned about use of& q, Z( P7 z; e2 O
any ointment/creams that they may have applied to
% C7 x' |2 ~0 [6 R2 p6 {! Z9 Nthe child’s skin. This time the father admitted the4 H1 h* L5 u/ @& H8 j
Topical Testosterone Exposure / Bhowmick et al 541! A% ?; f9 q- M5 C% y$ Y
use of testosterone gel twice daily that he was apply-: r; D* R$ d( K7 A+ e4 `! L# {
ing over his own shoulders, chest, and back area for
* l% H" p; s/ j' n: ha year. The father also revealed he was embarrassed( z* y7 c. X' q& r6 h
to disclose that he was using a testosterone gel pre-9 y7 h+ V3 _8 u6 Y6 @  u6 L
scribed by his family physician for decreased libido
4 C& ?7 v: i7 P  a9 C- @# Rsecondary to depression.
% R+ n: r4 x* s* c  w; U* ^% yThe child slept in the same bed with parents.
7 \1 l2 |# h6 z$ p" [% pThe father would hug the baby and hold him on his9 A3 i3 F/ g* [) Y+ O
chest for a considerable period of time, causing sig-
3 D6 _& P+ R+ h1 Z2 [) ^* M% ]  Vnificant bare skin contact between baby and father.* X3 g, P9 n, `
The father also admitted that after the phone call,
: r& |, t- `9 b! m6 ~8 C: L. S/ cwhen he learned the testosterone level in the baby
) G$ q6 p$ K; f5 {( R. o, pwas high, he then read the product information1 H, ]& c% u* p1 |9 M8 S1 b" B
packet and concluded that it was most likely the rea-
3 z  v4 G, [& N& G8 E- U. nson for the child’s virilization. At that time, they
9 T3 O! @3 p8 [: E: R3 E/ sdecided to put the baby in a separate bed, and the
+ Q! Y, \# m% W) I/ |father was not hugging him with bare skin and had
, l) t* N6 `5 p2 u6 q, |0 G- nbeen using protective clothing. A repeat testosterone- ^. c& I: b0 K
test was ordered, but the family did not go to the& f; N6 {9 a7 U% t8 D0 o
laboratory to obtain the test.+ @4 e% l  c' J
Discussion& i" o" B# a; t  ?. x& G
Precocious puberty in boys is defined as secondary
; V, O6 p% @  S, I) \sexual development before 9 years of age.1,4
" |7 \+ ], h& N- G/ |Precocious puberty is termed as central (true) when/ _+ u! r- ]4 e# |% {$ p6 ?) S
it is caused by the premature activation of hypo-
+ x8 r' N, z  J; G1 _7 S/ K5 pthalamic pituitary gonadal axis. CPP is more com-9 a, a. x' N& _2 t/ v
mon in girls than in boys.1,3 Most boys with CPP4 K" q2 N8 m0 W
may have a central nervous system lesion that is! U- `6 I8 z& F' }- G( ^
responsible for the early activation of the hypothal-
0 q) S" c9 y0 Mamic pituitary gonadal axis.1-3 Thus, greater empha-" I/ v. h) {3 o. h  l
sis has been given to neuroradiologic imaging in
8 i& D! l; d: Cboys with precocious puberty. In addition to viril-
. e/ V1 j$ y3 s- Eization, the clinical hallmark of CPP is the symmet-: \; x' |: J& {- m4 s2 v2 f
rical testicular growth secondary to stimulation by& `, W- ]4 V/ k) z
gonadotropins.1,3: k( I3 P& S6 f( ]% x* Q
Gonadotropin-independent peripheral preco-7 f5 i5 g; v- V* G6 Q* v
cious puberty in boys also results from inappropriate
- V& O% q2 g' b  ^% P" j0 D: Kandrogenic stimulation from either endogenous or0 v, o; I8 ^: G5 X0 F
exogenous sources, nonpituitary gonadotropin stim-
+ ?7 Q- F( J) Mulation, and rare activating mutations.3 Virilizing/ X) g1 Q% {- B( [7 L. u
congenital adrenal hyperplasia producing excessive3 o2 P) ~- r5 H& i
adrenal androgens is a common cause of precocious( K1 ^7 T0 V- [3 P
puberty in boys.3,4
) b8 V# N7 w0 n. w( J9 DThe most common form of congenital adrenal
: _6 r$ A% r* m! X' c' N7 dhyperplasia is the 21-hydroxylase enzyme deficiency.7 }" J9 E' ]+ I
The 11-β hydroxylase deficiency may also result in
# V* u" ?+ a% `: ^" b+ Mexcessive adrenal androgen production, and rarely,
" O0 X: ^) M1 F" }/ L' w* |4 ~an adrenal tumor may also cause adrenal androgen% l( F: E: i! j: h4 W( D1 `7 c6 f# ^
excess.1,3; ^' U7 v- k: E; L1 z' I8 i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ I7 r3 O: G& |" ^) K
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 Y& W" b- L  p0 nA unique entity of male-limited gonadotropin-# `$ A' j: i$ o4 W: F2 B
independent precocious puberty, which is also known1 @( Y+ d8 Y4 G  i" [
as testotoxicosis, may cause precocious puberty at a0 _- o- J, N5 c$ A
very young age. The physical findings in these boys
; Q* F: l5 E" f+ }) g3 \with this disorder are full pubertal development,% k: [, E8 P$ E) S
including bilateral testicular growth, similar to boys9 T/ a& y8 I& D8 q
with CPP. The gonadotropin levels in this disorder/ m3 s0 o# F$ e8 T+ W0 c
are suppressed to prepubertal levels and do not show
& s; J. c* O6 r+ Ppubertal response of gonadotropin after gonadotropin-
3 _( \, T1 _- @. A' z4 Ereleasing hormone stimulation. This is a sex-linked, z" v9 ]0 @/ q" Y3 T8 Y
autosomal dominant disorder that affects only/ i! M  h5 A% I4 G9 f: A3 k: C) b( F
males; therefore, other male members of the family
6 S* R3 K# e. R0 n0 }+ |! K" ^' Amay have similar precocious puberty.3
. R4 S$ }) y; V$ kIn our patient, physical examination was incon-: j8 h: ~- P( B' Z& X/ Z
sistent with true precocious puberty since his testi-
0 k- `5 F, _* N& hcles were prepubertal in size. However, testotoxicosis
3 K4 \: q# m% k5 E1 Qwas in the differential diagnosis because his father
$ U" g( ~7 q. m, jstarted puberty somewhat early, and occasionally,
" u6 g4 m, ^! P2 r& f4 m& Z6 \testicular enlargement is not that evident in the
# ~( w1 U$ |0 X/ B  D7 ibeginning of this process.1 In the absence of a neg-
3 {9 X4 q8 V+ [/ ^) Z( {8 ?ative initial history of androgen exposure, our7 x8 J9 t8 K  [2 x, J+ A# ?
biggest concern was virilizing adrenal hyperplasia,' p  c/ A7 I+ B1 _
either 21-hydroxylase deficiency or 11-β hydroxylase
) E! F$ `9 e. Udeficiency. Those diagnoses were excluded by find-' Q4 P8 H1 u. J# ]1 G: q
ing the normal level of adrenal steroids.' @, d3 |) O9 B; _& D$ w
The diagnosis of exogenous androgens was strongly
8 `, V) G8 L& t2 F* y$ Esuspected in a follow-up visit after 4 months because
+ D3 j! H+ `4 D. l9 X( d1 {2 Ythe physical examination revealed the complete disap-4 T8 `# }3 N; D) v* I
pearance of pubic hair, normal growth velocity, and
+ q, \. M) a; ~4 s6 h. pdecreased erections. The father admitted using a testos-
3 d7 m: Y3 V) E' `1 ?/ t- Z/ gterone gel, which he concealed at first visit. He was7 W; t! A7 K7 n: k
using it rather frequently, twice a day. The Physicians’4 {  e, o& k9 W( s
Desk Reference, or package insert of this product, gel or1 V! V5 S/ S% ~- a
cream, cautions about dermal testosterone transfer to6 f& g8 Y: O  |: y- O
unprotected females through direct skin exposure.
8 S  h: l' Q: t: J. K. D+ _, VSerum testosterone level was found to be 2 times the. z- d0 z9 |( e0 {' h
baseline value in those females who were exposed to
2 B) g6 W1 r% D! Z) \even 15 minutes of direct skin contact with their male1 m8 ?/ k3 z6 s4 \8 o2 G- {
partners.6 However, when a shirt covered the applica-" A5 F. l$ V8 K/ f, s$ J1 M1 h
tion site, this testosterone transfer was prevented.0 c$ |& ~2 l1 i+ b
Our patient’s testosterone level was 60 ng/mL,
' D" M7 G7 d0 S/ z- p3 mwhich was clearly high. Some studies suggest that
+ t* m% V# l2 U' t: K# Mdermal conversion of testosterone to dihydrotestos-
% R5 v" ~$ K+ I& v# i' eterone, which is a more potent metabolite, is more
& Q& d8 x3 I: ~- _active in young children exposed to testosterone/ N0 {" ^  @  ?" J
exogenously7; however, we did not measure a dihy-
7 J; M, W! Z* R, odrotestosterone level in our patient. In addition to( R) I( J! Q- B9 \* F* L
virilization, exposure to exogenous testosterone in! C7 l9 Y% U! o$ q2 B! |  @
children results in an increase in growth velocity and3 O4 i2 i* U' @8 d+ n
advanced bone age, as seen in our patient.
' `: }4 {$ Y# r, {: @" ~4 P& FThe long-term effect of androgen exposure during  Y$ b2 }4 @  F
early childhood on pubertal development and final  M, t3 F+ R- b: q* ^" X
adult height are not fully known and always remain
' G: V4 u* _8 J* w# Pa concern. Children treated with short-term testos-3 L7 N. P2 D3 p; @2 G' b
terone injection or topical androgen may exhibit some0 h9 u  t% B8 ~/ x: b
acceleration of the skeletal maturation; however, after
/ j3 Y0 B" N6 D- N$ g! W8 \cessation of treatment, the rate of bone maturation- ^; e8 L$ k  U0 u5 M0 l
decelerates and gradually returns to normal.8,9
0 e; ?0 v& o3 `! fThere are conflicting reports and controversy
* g* a' m5 h! X3 _8 E4 I- p1 Nover the effect of early androgen exposure on adult
; H! q: L2 }* K' {# g; k+ @penile length.10,11 Some reports suggest subnormal
5 y2 I) S+ z4 ?adult penile length, apparently because of downreg-* k! F+ U! M& R- Z7 n) o) ~
ulation of androgen receptor number.10,12 However,$ n4 H& p! q% c( y8 R
Sutherland et al13 did not find a correlation between
) `3 Q* g! }! l5 B2 e) _, i: lchildhood testosterone exposure and reduced adult
; m( X8 R; o6 C+ y/ M6 @5 xpenile length in clinical studies.
$ ^& X8 B/ ~: |8 P" \* yNonetheless, we do not believe our patient is" F9 m( \2 w4 t" P+ m; ^0 L
going to experience any of the untoward effects from% K% F' d& e/ l4 i) g, z
testosterone exposure as mentioned earlier because8 Q1 P+ H. l# \
the exposure was not for a prolonged period of time.# _  V( ~/ e2 k) U! c3 G1 V! O
Although the bone age was advanced at the time of
! N* b7 D# [( x* K- k- Xdiagnosis, the child had a normal growth velocity at/ i/ N0 ^- f) I& v" G
the follow-up visit. It is hoped that his final adult
; ], q  _) G2 x' l" U+ n/ B5 o0 iheight will not be affected.; `% Z3 r- H; T9 t
Although rarely reported, the widespread avail-
4 l5 Q  T: i* D" \. ^ability of androgen products in our society may- g- F9 Q% T- [. u
indeed cause more virilization in male or female
; v( H% \! Z* Dchildren than one would realize. Exposure to andro-
5 h6 l0 g3 q8 H8 qgen products must be considered and specific ques-' r/ A% k8 P5 t( ^4 F$ b' V
tioning about the use of a testosterone product or
) ~! ?% Q, u# jgel should be asked of the family members during
: [6 s" r5 G/ y, R4 o; _the evaluation of any children who present with vir-
% f7 c. M9 o, N; jilization or peripheral precocious puberty. The diag-
/ J) `0 e! E6 `8 `nosis can be established by just a few tests and by
6 ?# R0 s9 z3 u# v2 |+ gappropriate history. The inability to obtain such a
9 {1 t) @1 y# A) thistory, or failure to ask the specific questions, may' k- D9 y$ {% _5 W0 o" Q% w: S
result in extensive, unnecessary, and expensive
/ O8 }* J2 T: B: l$ m# X! n. F- Xinvestigation. The primary care physician should be. f" s* e, E9 E' P6 `7 S% L
aware of this fact, because most of these children% `- V' R- g4 N! m+ U8 l
may initially present in their practice. The Physicians’7 D4 r& p% _$ Q
Desk Reference and package insert should also put a
& W& ]2 j9 c( zwarning about the virilizing effect on a male or. o: Y7 ^0 f; u$ O% J* d. n
female child who might come in contact with some-
! ]2 e5 p# E3 f. S0 o$ [. yone using any of these products.
, F' t( E, f- dReferences/ l: @6 r1 b' n8 x3 |' W
1. Styne DM. The testes: disorder of sexual differentiation
0 \- ~) r9 z  P* M1 L# ]; n3 V/ H0 @and puberty in the male. In: Sperling MA, ed. Pediatric
* U: U5 _6 _: T  U  h6 IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! f4 b/ z( t0 \; c2 u2002: 565-628.
0 g! D+ C4 e. Z& m* X1 Y6 d  C2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! i* v( j/ t5 g# Y
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old2 J* {4 p/ G4 w+ C* C/ [: Z
Boy Induced by Indirect Topical# \3 V, @' c$ E* D6 t5 S
Exposure to Testosterone
4 z3 o4 w3 L# r$ V: m1 ?, ~% ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. |+ v9 j4 j2 i3 X0 v. r/ `
and Kenneth R. Rettig, MD1* Z& w# [3 N1 Z2 r) J, Y, _. n
Clinical Pediatrics, z" r; I, l8 a% Q( O/ S+ B3 \
Volume 46 Number 6, G1 k$ h# s: Q
July 2007 540-543) i3 X5 _! r* P/ U& V1 o9 f2 d7 q, l
© 2007 Sage Publications
7 x1 c8 N7 W0 ]) |10.1177/0009922806296651; F/ @: W' ~/ p( h, K! u
http://clp.sagepub.com  x+ M1 J. {; U: W& ]  ?/ G
hosted at
& W) g; Z# K0 O* A: Zhttp://online.sagepub.com
9 \  ?3 T6 T5 A" J2 A/ _/ V  x" CPrecocious puberty in boys, central or peripheral,1 V2 _& T( J- R; }; o* @
is a significant concern for physicians. Central" }7 g1 G! `5 ~" b
precocious puberty (CPP), which is mediated
' Y9 a/ E$ {6 X& e3 Athrough the hypothalamic pituitary gonadal axis, has* t5 X  W( ^4 u+ K* a$ s/ i* ^
a higher incidence of organic central nervous system
4 w  `( q. a  r  a% r. u+ plesions in boys.1,2 Virilization in boys, as manifested
7 \! A9 D- {  k* hby enlargement of the penis, development of pubic
% Y6 m1 }* N( S2 k9 M0 ahair, and facial acne without enlargement of testi-8 o" `1 X+ j/ |8 e& X/ a
cles, suggests peripheral or pseudopuberty.1-3 We/ R- Y9 @$ r& g- [
report a 16-month-old boy who presented with the
' `0 C/ V" U& p% Jenlargement of the phallus and pubic hair develop-9 `9 G0 k  `  i7 H: f7 S3 N. K
ment without testicular enlargement, which was due% x2 D0 _& {- Z9 |
to the unintentional exposure to androgen gel used by
4 o* b1 h8 i; ~/ I' l! }the father. The family initially concealed this infor-: b2 H. U, s  @$ Q9 c1 w
mation, resulting in an extensive work-up for this
( ?0 v$ W+ f: z  d* O; qchild. Given the widespread and easy availability of
, b* O! C, r' Ktestosterone gel and cream, we believe this is proba-# q; T2 p" i$ y1 q$ c% m
bly more common than the rare case report in the
) K  M3 b  `* G+ K' j) fliterature.4
$ [5 e4 t9 Y7 B& k- C3 GPatient Report8 X/ f* l6 v! C  C4 b1 e
A 16-month-old white child was referred to the& Z& \+ f9 D, H/ ?$ X: X
endocrine clinic by his pediatrician with the concern
, R% a& W$ Q) b) f( ]) x" [of early sexual development. His mother noticed
' X4 Z) @* c" N$ @# zlight colored pubic hair development when he was
: a) F0 T$ R) L: IFrom the 1Division of Pediatric Endocrinology, 2University of
/ h* x$ ]2 h( X7 S6 ISouth Alabama Medical Center, Mobile, Alabama.
- i7 b/ P" V( l6 O; @; ?& f) kAddress correspondence to: Samar K. Bhowmick, MD, FACE,
( z+ \0 p1 E; M$ Q/ c4 Q) I: I$ sProfessor of Pediatrics, University of South Alabama, College of+ `! N/ b5 \" Z. p. f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% ^) Y7 A* J! r' Y4 k+ p2 me-mail: [email protected].$ K; B! w4 Q% w$ |
about 6 to 7 months old, which progressively became
) {" E$ v0 j6 s: B' n6 ~$ @7 Pdarker. She was also concerned about the enlarge-
1 D7 K, t( Z" ~/ u- g- yment of his penis and frequent erections. The child3 I% @0 n3 r5 C. h; a1 E! Z" u
was the product of a full-term normal delivery, with! [# r( Z0 q% {9 v5 X
a birth weight of 7 lb 14 oz, and birth length of
4 j) l1 Y5 x6 p2 W20 inches. He was breast-fed throughout the first year
2 ?* j. }4 ]9 b, o& S! E7 Dof life and was still receiving breast milk along with
& K* \+ i# E* p6 G+ @+ i- Wsolid food. He had no hospitalizations or surgery,; w# d7 t) {' ^" }8 P
and his psychosocial and psychomotor development& K$ ?! X( C6 s2 B% Y$ Y9 r
was age appropriate.
  p. @( ^1 O, K+ P4 fThe family history was remarkable for the father,; [; b* D9 H% I& z' G' B. l, o
who was diagnosed with hypothyroidism at age 16,. \4 w/ p3 n7 j5 d/ b4 K: ^6 B5 I$ ^
which was treated with thyroxine. The father’s
9 Q" P( p2 N% h: V  t6 h. pheight was 6 feet, and he went through a somewhat
' [4 L; [5 R4 }1 v# q/ searly puberty and had stopped growing by age 14.) X. |, x8 \/ _" ?: j
The father denied taking any other medication. The
4 x% ^+ h( j# B. n& j3 Uchild’s mother was in good health. Her menarche
0 A$ Y# A% f' F5 s8 }9 Mwas at 11 years of age, and her height was at 5 feet
8 l/ F3 L! ?3 W( r5 inches. There was no other family history of pre-) I1 p9 ^# ~) K0 `' p
cocious sexual development in the first-degree rela-9 M. a9 I1 C8 n8 ~
tives. There were no siblings.
, W) \. _5 t/ W/ NPhysical Examination; R  j' U, F/ [
The physical examination revealed a very active,6 J! W% Y1 u1 S3 J+ R, _
playful, and healthy boy. The vital signs documented6 O  A) w, |  P! u% E0 m2 r
a blood pressure of 85/50 mm Hg, his length was
( {  I  m2 n; T$ Y/ [+ w$ O90 cm (>97th percentile), and his weight was 14.4 kg2 z* \7 S5 p: s7 E2 q& ]5 c
(also >97th percentile). The observed yearly growth5 J1 P, R. [4 s8 ?) X: `* D0 m
velocity was 30 cm (12 inches). The examination of
) b2 M( U# n. D" s: c! s0 Kthe neck revealed no thyroid enlargement.: l( x$ b8 n, d6 `
The genitourinary examination was remarkable for
! B6 ~) R, `8 i3 }# J6 uenlargement of the penis, with a stretched length of
/ S0 [* Q: q/ T2 {8 cm and a width of 2 cm. The glans penis was very well
- ?# m/ a) q: r/ Z3 q: Fdeveloped. The pubic hair was Tanner II, mostly around; ~4 F( e; v3 Q* W7 t0 h+ x1 b
540/ i% \* K) C9 n/ U# h, x; _: I& \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ u! ?# z) P# \the base of the phallus and was dark and curled. The
) q: [) A) Z: m( b2 D1 Wtesticular volume was prepubertal at 2 mL each.
/ Z3 c. t/ W  o$ c$ }The skin was moist and smooth and somewhat
9 {* {* b4 w6 n9 I. g$ i! voily. No axillary hair was noted. There were no
- N0 G( K9 Q! v( }8 `abnormal skin pigmentations or café-au-lait spots.
4 w+ O9 b/ ^8 o' X- wNeurologic evaluation showed deep tendon reflex 2+
. M# v8 b) ^% ]4 |bilateral and symmetrical. There was no suggestion. @' u% d/ E2 j
of papilledema.! F9 g7 H9 s& o- e/ _
Laboratory Evaluation
& M% w# Z, [, D1 {8 bThe bone age was consistent with 28 months by  L6 I- ?" Y+ b% O( \
using the standard of Greulich and Pyle at a chrono-
7 N2 t  Q; d+ Z( @logic age of 16 months (advanced).5 Chromosomal) R3 t$ C) E1 }5 F
karyotype was 46XY. The thyroid function test
& ~  F8 D- `$ n4 Z, [$ Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-
% x: W. A" I7 \/ ilating hormone level was 1.3 µIU/mL (both normal).! Z" c2 L; @. l; f  D7 t9 Y3 f: G/ A
The concentrations of serum electrolytes, blood) v: O- i4 K% w
urea nitrogen, creatinine, and calcium all were
& |; p9 K5 J( h8 C( Z+ H% M- m  ?within normal range for his age. The concentration: D. }2 i9 l* y
of serum 17-hydroxyprogesterone was 16 ng/dL
3 ]& R0 ~4 p& _+ k; S: E2 z5 X(normal, 3 to 90 ng/dL), androstenedione was 20
" F2 Y' `) e) x5 Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 @7 b1 Q" H5 L2 t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; P* k& t& A, @* Q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ X9 ]7 e  h2 M" ^3 y49ng/dL), 11-desoxycortisol (specific compound S); a& I$ c) {# B" |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 o0 a- a" Q" f1 _3 gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ w! m7 s4 |! c( Y' o& e* gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 P( y' Z; I, z- f
and β-human chorionic gonadotropin was less than4 d1 S  U0 w7 g
5 mIU/mL (normal <5 mIU/mL). Serum follicular" f. B" g* G* X3 w, a, @& A
stimulating hormone and leuteinizing hormone* U3 Y+ L5 c$ m4 y" k5 K$ b$ @! ~
concentrations were less than 0.05 mIU/mL& {" r9 X" _2 l& O
(prepubertal).
- d: u# g& Z, nThe parents were notified about the laboratory+ q' w2 Q' D6 s4 _; n& Z- Y
results and were informed that all of the tests were
& ?1 L8 V* w; l6 F9 onormal except the testosterone level was high. The* _( v! o( h. t1 c. c, Z* [
follow-up visit was arranged within a few weeks to( }# m+ E. Z* N7 D( `9 o
obtain testicular and abdominal sonograms; how-
" y0 P. z% f7 {& ^+ J& i4 o/ k( Z. Uever, the family did not return for 4 months.
  y& d, h+ \  Y! |1 w& o  mPhysical examination at this time revealed that the
6 c% \% Q* Q' n6 pchild had grown 2.5 cm in 4 months and had gained2 ]7 `4 H& c5 ^
2 kg of weight. Physical examination remained
' Z& T. D$ P* t% s& Junchanged. Surprisingly, the pubic hair almost com-
, v8 [' b1 }& k- t/ vpletely disappeared except for a few vellous hairs at
7 `8 l( u$ B2 V9 cthe base of the phallus. Testicular volume was still 2
" {  U/ }7 Q; Y* R8 rmL, and the size of the penis remained unchanged.+ w' D' V9 ^( S/ x  V" ^# B+ U
The mother also said that the boy was no longer hav-0 y/ R- z" v7 K6 T' |0 Q, I
ing frequent erections.8 D! @) n* a3 Q) m3 r
Both parents were again questioned about use of% w: X3 @1 f2 T' R1 b( |0 Z* K
any ointment/creams that they may have applied to
5 ^' p1 f9 [2 q3 u- zthe child’s skin. This time the father admitted the
. g* E2 \& z/ D1 S' C7 v- QTopical Testosterone Exposure / Bhowmick et al 541( G) A7 m, v: y
use of testosterone gel twice daily that he was apply-
9 t: Z0 W4 o- x6 D: c, bing over his own shoulders, chest, and back area for1 R' E, f9 G& M& S" I9 G
a year. The father also revealed he was embarrassed- \4 M* P. f; ~' h5 L. f
to disclose that he was using a testosterone gel pre-
* \& |: v9 j5 M; Vscribed by his family physician for decreased libido5 l* Q/ W% i# {, Z
secondary to depression.& d7 Y! a" A0 ^8 L! {6 a
The child slept in the same bed with parents.6 k) n7 Z* t. T1 h( Q  c, w
The father would hug the baby and hold him on his. u5 F% v( O! w5 q7 O$ ?* U
chest for a considerable period of time, causing sig-2 T1 b! u/ M) k0 Y" H" b' [! k
nificant bare skin contact between baby and father.
/ t" e( A' [- ~/ B4 d; P) O& `The father also admitted that after the phone call,
5 u; m" I% t8 K5 Qwhen he learned the testosterone level in the baby
" W9 V; B. ~7 [was high, he then read the product information
- p3 C2 V7 w) [$ l7 apacket and concluded that it was most likely the rea-7 j, h' r$ R# q. N5 U, y1 w
son for the child’s virilization. At that time, they) |8 Q  }# p4 [5 p2 p  a% n; Q" X/ x
decided to put the baby in a separate bed, and the
7 c) ?! e  e7 ~3 k* tfather was not hugging him with bare skin and had
3 @: E( |& g7 a! [: p" G( Bbeen using protective clothing. A repeat testosterone
& [4 k( [! K9 H8 |" o' Btest was ordered, but the family did not go to the
' a; h5 }& ?) B+ ?laboratory to obtain the test.  I9 B' A2 K5 Z+ @# ]8 Y5 o
Discussion* |$ G6 g9 H' s8 \6 C& G
Precocious puberty in boys is defined as secondary# n4 r) R8 l0 u) J" P- U
sexual development before 9 years of age.1,4" y2 M" H! j) r6 S9 s, b! Y% i
Precocious puberty is termed as central (true) when
6 J  o$ N4 U* N% R8 nit is caused by the premature activation of hypo-9 g* a( V" [' v% B
thalamic pituitary gonadal axis. CPP is more com-
* T0 W: n' _) ?, n' o: Nmon in girls than in boys.1,3 Most boys with CPP, m3 R3 f. c& E% ^- P$ h  a
may have a central nervous system lesion that is; l0 W, w# r9 n! ^
responsible for the early activation of the hypothal-
, `. A( @8 u9 j$ B7 a2 ramic pituitary gonadal axis.1-3 Thus, greater empha-/ \  j+ D6 L! H0 P. a( ]& F* G
sis has been given to neuroradiologic imaging in
. e/ v1 d: U/ Oboys with precocious puberty. In addition to viril-* ]' K' `0 n  _3 ~, d& }; A% u, G
ization, the clinical hallmark of CPP is the symmet-
# P6 F1 r' H/ E" @- |rical testicular growth secondary to stimulation by" l7 i; R; d; N# N5 }2 j" M9 Y
gonadotropins.1,3
$ G; n7 M4 _# d6 e, HGonadotropin-independent peripheral preco-% m) O+ _( Z& v% M
cious puberty in boys also results from inappropriate6 J7 j9 D$ W6 D
androgenic stimulation from either endogenous or: R! W0 h1 J' Q& A7 O: I
exogenous sources, nonpituitary gonadotropin stim-
2 A+ ^% \9 q6 X$ H( ?ulation, and rare activating mutations.3 Virilizing
9 i& }. r3 `$ m& x8 C" Rcongenital adrenal hyperplasia producing excessive, y8 h7 U/ C/ _4 i3 h; B' H7 E
adrenal androgens is a common cause of precocious' b3 D# C' O9 c% g2 I
puberty in boys.3,4
. {( Y% M- e# N7 ^The most common form of congenital adrenal
, R3 W" E9 L( x) A- }7 k5 R( w. @hyperplasia is the 21-hydroxylase enzyme deficiency.
1 T) u7 c6 B: N( k. G: tThe 11-β hydroxylase deficiency may also result in; Q7 g* E8 W0 N( D: r/ o3 \# j
excessive adrenal androgen production, and rarely,3 @) T4 }1 Y1 t5 d2 M1 c. E
an adrenal tumor may also cause adrenal androgen
: f0 F+ J' O" [: K6 Q( z2 ~excess.1,3
) C! X) D. t  k+ g: ]9 U0 ~# Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ o2 o! H" h6 G3 G$ i( b2 n  W/ y2 L7 _
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 G# q. R1 a/ |# U: hA unique entity of male-limited gonadotropin-
& n( m7 E1 Z9 C+ ^  aindependent precocious puberty, which is also known6 H4 M* n/ }) H: r
as testotoxicosis, may cause precocious puberty at a. l3 D( ?7 {+ K3 e
very young age. The physical findings in these boys: w, U' ?" q* a7 w( [% z
with this disorder are full pubertal development,& J( S" _" r0 {" X* K" o, q
including bilateral testicular growth, similar to boys. N8 K4 @9 c9 A$ @* p8 f
with CPP. The gonadotropin levels in this disorder
  c( H3 J7 l+ Pare suppressed to prepubertal levels and do not show
: g2 U7 ~- r  L8 Z' u$ \pubertal response of gonadotropin after gonadotropin-
, @& T# |0 p8 `1 u2 _9 X$ c! oreleasing hormone stimulation. This is a sex-linked' c. Y: L* L( d- A; y8 m
autosomal dominant disorder that affects only2 h4 n# r6 p2 c$ O. b, v& P. ?
males; therefore, other male members of the family
9 B- U- o4 Z8 O( _* c5 Wmay have similar precocious puberty.3
" @2 f) @) _# S  U4 GIn our patient, physical examination was incon-
- {2 C+ @# a7 ~' M+ H+ Dsistent with true precocious puberty since his testi-+ X0 r! R' X6 a7 N
cles were prepubertal in size. However, testotoxicosis2 u2 e9 {, Q/ P* q
was in the differential diagnosis because his father6 U9 e5 }& k0 M
started puberty somewhat early, and occasionally,
( R7 O2 F# j. q( ]0 atesticular enlargement is not that evident in the
8 M/ h# x( D* obeginning of this process.1 In the absence of a neg-
) T' y* ?# f- P' hative initial history of androgen exposure, our
' M- ^; R4 A6 I* z+ H7 }biggest concern was virilizing adrenal hyperplasia,
0 X+ v& r# t; }5 H* |. Yeither 21-hydroxylase deficiency or 11-β hydroxylase
1 P+ U1 _- g/ |) \' K7 vdeficiency. Those diagnoses were excluded by find-3 h6 x3 F; L6 O+ P& p9 A. B
ing the normal level of adrenal steroids.! M1 h! v. ?+ z
The diagnosis of exogenous androgens was strongly
6 N# }8 Y/ a3 I& C$ Asuspected in a follow-up visit after 4 months because
) M% n' i& R0 y. t' w8 Qthe physical examination revealed the complete disap-% g2 b' e1 w' p9 G* H
pearance of pubic hair, normal growth velocity, and. E  Q! W7 u  j/ ^0 N
decreased erections. The father admitted using a testos-8 U& X; j0 b* L. C3 B& l3 p  ?
terone gel, which he concealed at first visit. He was
2 H+ R. l/ k5 O1 p' ^using it rather frequently, twice a day. The Physicians’
3 Z8 i! [  q, T$ k' W9 q$ g% h* FDesk Reference, or package insert of this product, gel or
) i( h- A) I, Q9 |cream, cautions about dermal testosterone transfer to% a8 w: ^& _& n' f& N) q3 f: N6 \% l
unprotected females through direct skin exposure.7 S8 B& p! b' s. o  f) |
Serum testosterone level was found to be 2 times the3 t. X% U1 ]6 z% l$ W' U
baseline value in those females who were exposed to
5 i* n! s' v, F8 x1 feven 15 minutes of direct skin contact with their male3 P. t! {, e! G" Z# ?0 a. l" E
partners.6 However, when a shirt covered the applica-
7 u" f9 Q" f- [4 Ction site, this testosterone transfer was prevented.7 E2 p0 [% ~' o8 E# m6 _1 A" n9 Y
Our patient’s testosterone level was 60 ng/mL,
; K8 U' z$ j2 N, rwhich was clearly high. Some studies suggest that; p8 `0 B4 X: x0 J8 f) H( ~& u- [4 G
dermal conversion of testosterone to dihydrotestos-
7 U( j0 \- y% o: c4 gterone, which is a more potent metabolite, is more, B  L5 ?* }+ b. X) d
active in young children exposed to testosterone/ ]* |( u& g2 @! f# h5 V* A
exogenously7; however, we did not measure a dihy-+ T% o0 g5 l& x: c9 I! Z
drotestosterone level in our patient. In addition to3 C/ c2 f( L9 |8 i  t9 r! L
virilization, exposure to exogenous testosterone in3 F. P3 y1 ^. N5 u5 u
children results in an increase in growth velocity and
7 v$ W5 J6 c5 b2 [2 ~5 y$ p" c5 uadvanced bone age, as seen in our patient.: K; c3 a5 {9 d
The long-term effect of androgen exposure during5 V, r7 }+ d8 n" b# v
early childhood on pubertal development and final
; ^% d. o$ b9 sadult height are not fully known and always remain
9 ?; c& j. l! N9 w% d  ?a concern. Children treated with short-term testos-* [, k- ^0 x1 o, T5 h6 j
terone injection or topical androgen may exhibit some
9 V8 I! G3 E8 n) zacceleration of the skeletal maturation; however, after
/ |; T6 g5 Z$ T. [, F! `cessation of treatment, the rate of bone maturation
0 Y' H1 f# ?) _decelerates and gradually returns to normal.8,9
1 R- O) v, }  @1 U: z3 OThere are conflicting reports and controversy6 F: l5 Q7 Y( \4 `9 y
over the effect of early androgen exposure on adult; s7 Z# N, [& ?/ Z  K$ i! Z) g; p
penile length.10,11 Some reports suggest subnormal
& A9 _! o6 h# f4 jadult penile length, apparently because of downreg-
$ p, ?3 O" u; Q  M6 S7 Dulation of androgen receptor number.10,12 However,
: w' f, I, j  [$ ~Sutherland et al13 did not find a correlation between9 i+ ~5 S3 {- Q! n8 @+ c% p
childhood testosterone exposure and reduced adult
8 A$ J: |' O& }3 O% l4 J& [penile length in clinical studies.) k, T! t, O! E' Q) @5 l2 ^
Nonetheless, we do not believe our patient is' P2 X- w3 {% y4 S$ B
going to experience any of the untoward effects from& z; K0 z# ]0 ?# {/ i+ y: b4 {
testosterone exposure as mentioned earlier because4 h7 \* K; m9 Z4 ]" |1 G
the exposure was not for a prolonged period of time.
# a+ {- N; c$ U8 m* |- zAlthough the bone age was advanced at the time of8 o! H- D$ i2 z3 o
diagnosis, the child had a normal growth velocity at
& L  f' \$ r" sthe follow-up visit. It is hoped that his final adult
, a6 \4 `( T& ~3 K1 G# t. I9 w6 yheight will not be affected.
0 c  R2 ?, e/ V$ E$ }$ h0 RAlthough rarely reported, the widespread avail-
5 p% G$ F2 y; A+ t5 M8 uability of androgen products in our society may
5 k1 ^4 X' d5 w3 ]7 kindeed cause more virilization in male or female7 p8 }4 v# z& F) p% g. \
children than one would realize. Exposure to andro-) t) _* s/ G" M! h+ t( N4 H
gen products must be considered and specific ques-  u2 ^1 u* p( x9 A8 }
tioning about the use of a testosterone product or- u. a' M' s6 A0 k% _
gel should be asked of the family members during
5 g9 R& h) C1 o) X9 Fthe evaluation of any children who present with vir-
9 }' p( J$ e7 Gilization or peripheral precocious puberty. The diag-
( g% s2 A* C) \nosis can be established by just a few tests and by
+ b  i9 o. n" }) J+ Q& s6 q. c  `appropriate history. The inability to obtain such a3 u, n# j% h" l7 q' {4 e( Q. g
history, or failure to ask the specific questions, may# h- Q* c, S: R
result in extensive, unnecessary, and expensive* S$ p" y% g* v6 F% \
investigation. The primary care physician should be
6 K/ x7 w! z: q  {0 I7 Aaware of this fact, because most of these children
0 m" P6 W) t. K: A6 E! _8 Q( amay initially present in their practice. The Physicians’+ z% O3 p  _) G/ F6 }
Desk Reference and package insert should also put a
% C1 t' U- \; Owarning about the virilizing effect on a male or
  `* u$ N2 [# b  {7 z& hfemale child who might come in contact with some-
( g2 A! S8 j# u8 C) K/ S4 Yone using any of these products.1 ?0 @% ~6 A. S- }4 d9 p; s4 N5 `
References+ i8 W2 h8 Q1 }% O5 X& ^, Q+ x$ r
1. Styne DM. The testes: disorder of sexual differentiation
9 F, X8 F2 J4 K3 D8 r+ Yand puberty in the male. In: Sperling MA, ed. Pediatric8 I' M% L" @3 d3 g3 S
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 \% s, j5 u" g
2002: 565-628.
( g3 P0 \  m/ F, u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. v; D7 t  B/ S) ?1 g( S3 u+ zpuberty in children with tumours of the suprasellar pineal
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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
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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

' H5 V# W7 _5 G! H9 R% R4 {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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