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Sexual Precocity in a 16-Month-Old9 {& K7 R8 m5 i" x# h
Boy Induced by Indirect Topical
& _  T. M- M; V( uExposure to Testosterone
9 D3 i) x4 j3 h' J2 O1 [8 GSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% B/ O6 m/ z( a! [8 H0 m! Z- {8 t
and Kenneth R. Rettig, MD1. Q9 ^$ n- g7 w2 a6 `
Clinical Pediatrics# u  o. Y" Z4 ]# I5 v  y8 V8 S
Volume 46 Number 6  \1 D% w3 P! i0 P6 q
July 2007 540-543) g# ~4 H* `) [+ o6 I
© 2007 Sage Publications8 K: C  x0 a* e" O5 y  x
10.1177/0009922806296651
0 Y9 I: O3 _5 y' A: ^# c* Z. Mhttp://clp.sagepub.com
: a0 `' Q* v" F1 V9 Ehosted at
. S& N; F/ A5 h' d# \& R2 y. [http://online.sagepub.com- W$ O3 b% O, E
Precocious puberty in boys, central or peripheral,
% N" v& Q# k2 W/ }! T/ his a significant concern for physicians. Central
0 `$ }( T/ s, P6 k0 Pprecocious puberty (CPP), which is mediated$ P& ~! d7 b! w) ?: W
through the hypothalamic pituitary gonadal axis, has
% L3 o/ Q) P( C: S4 F1 q( Z2 Ka higher incidence of organic central nervous system
* v4 p8 _* K+ g2 J' N- ~  f; o- `# h% `/ Mlesions in boys.1,2 Virilization in boys, as manifested0 q& E/ e7 I3 L5 S: O8 G2 D+ c
by enlargement of the penis, development of pubic: A6 L% U$ i0 O* p- n5 b6 P
hair, and facial acne without enlargement of testi-( n  S1 J1 r; v* I' Q/ {  v  U9 o; f
cles, suggests peripheral or pseudopuberty.1-3 We, p6 Q- J7 ~- [
report a 16-month-old boy who presented with the, X  i0 u2 J4 k1 X- r  ^0 X& x/ |
enlargement of the phallus and pubic hair develop-8 u: h4 j- W' f+ l! n1 f4 |
ment without testicular enlargement, which was due- F% i5 @% T7 }( ?& w# p
to the unintentional exposure to androgen gel used by# D1 n2 Z9 h8 m0 T- z' W
the father. The family initially concealed this infor-7 b* }+ A. C% \( v4 N
mation, resulting in an extensive work-up for this) D5 R- a  i2 L  t' t
child. Given the widespread and easy availability of
7 `+ J2 {* M: Z! Y+ O1 ptestosterone gel and cream, we believe this is proba-
" e: O1 o6 B4 f: S8 b6 _' Wbly more common than the rare case report in the
2 J2 U7 _. [  _; c/ a9 g& L5 U: }literature.4
, Y8 ]) @- b+ C& ~6 A+ Z' r5 P% zPatient Report
. K* U# L$ F4 W" t# rA 16-month-old white child was referred to the+ S4 O9 I) t, |: F$ @
endocrine clinic by his pediatrician with the concern9 A" c+ Y7 U9 w  o
of early sexual development. His mother noticed" D, d/ }2 X5 H: J; e' L
light colored pubic hair development when he was
0 G8 H* h! E/ T$ l) N3 T3 w% NFrom the 1Division of Pediatric Endocrinology, 2University of
3 _0 J& R! o/ W( C6 D/ `South Alabama Medical Center, Mobile, Alabama.
5 X( z8 B9 [! QAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 J  q" k/ z# A5 Q
Professor of Pediatrics, University of South Alabama, College of' l5 D4 K. p4 n3 r7 C3 \4 `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% j9 y3 n4 e6 O  M4 ve-mail: [email protected].5 l! W+ |$ Z- Q' {2 D" w9 |# U
about 6 to 7 months old, which progressively became& q( @1 d  ^; ^; _$ y3 G; \& P$ O
darker. She was also concerned about the enlarge-
& X/ Z; X+ d- X0 Q7 n, h, Qment of his penis and frequent erections. The child
7 u% B" N3 u7 [# n8 R' wwas the product of a full-term normal delivery, with6 E" s+ n0 v! K2 A$ m
a birth weight of 7 lb 14 oz, and birth length of$ K: W  P1 v" p# y( L  E
20 inches. He was breast-fed throughout the first year
1 W8 {0 s9 q- ~of life and was still receiving breast milk along with1 `' f/ u- f& e5 Y" a
solid food. He had no hospitalizations or surgery,* q/ _, I7 Y. o+ U# k7 w& M7 @3 C
and his psychosocial and psychomotor development1 g3 X# Q# ~+ a& w! K/ m# p. G; o
was age appropriate.
0 }/ o6 u) w( J( aThe family history was remarkable for the father,
$ ~1 m9 `) s7 a# [: Dwho was diagnosed with hypothyroidism at age 16,7 Q% y6 [8 L/ W( |
which was treated with thyroxine. The father’s. C  W7 d4 b! }3 r2 S8 E# H
height was 6 feet, and he went through a somewhat  T3 D: y- P) f8 v6 g
early puberty and had stopped growing by age 14.
6 }  q' ]; P4 ?4 {' k' aThe father denied taking any other medication. The5 n. X) L2 ]5 P9 X; S; `
child’s mother was in good health. Her menarche
: D; j% u" k# [3 u2 C- Twas at 11 years of age, and her height was at 5 feet
8 ~( |3 B0 B1 }& o# S9 [5 inches. There was no other family history of pre-, l' r( Q* s" Q
cocious sexual development in the first-degree rela-: l+ u/ b# }0 S! J; R2 O, }9 u
tives. There were no siblings.
) a* c' ~5 X! R9 D2 uPhysical Examination
/ o: {) j7 n) i. B1 Z! K( _The physical examination revealed a very active,* q4 k/ u4 w. j: S: q. `* x$ [" V8 d
playful, and healthy boy. The vital signs documented! V2 g2 @# ~  f+ k! j
a blood pressure of 85/50 mm Hg, his length was- e: `4 J# c8 V/ b: Z/ [" @
90 cm (>97th percentile), and his weight was 14.4 kg
: n. @1 V  }6 y( q1 S5 F: M1 |(also >97th percentile). The observed yearly growth) N8 r9 r/ |8 S
velocity was 30 cm (12 inches). The examination of) n+ E9 G% J/ H; ^- t( B: w6 O
the neck revealed no thyroid enlargement.  k" Q" Y& B2 ^- f
The genitourinary examination was remarkable for
( A  T( F0 E7 Fenlargement of the penis, with a stretched length of
8 @4 Z4 R: w# b, d9 e  o8 cm and a width of 2 cm. The glans penis was very well8 }$ s( a/ K+ ]8 y* ^
developed. The pubic hair was Tanner II, mostly around
8 V6 f4 R+ ^" O7 q# l" d$ w540
0 g2 O% A: C% `/ I5 ^: rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* |, S/ D% ~: d* ^. A
the base of the phallus and was dark and curled. The
6 E2 b2 I3 @0 F, r# O2 ^9 l4 g8 Y7 Ttesticular volume was prepubertal at 2 mL each.
$ X0 \% F9 }+ D+ H. i9 MThe skin was moist and smooth and somewhat
4 i( U! z, i  x% u. g7 ~+ ioily. No axillary hair was noted. There were no/ ^% d& z/ y5 y+ d) S+ d
abnormal skin pigmentations or café-au-lait spots.
! y6 X' y$ _7 H0 _& q3 D/ U& i! dNeurologic evaluation showed deep tendon reflex 2+: k( b+ B. N5 \, x) ^! ~8 W
bilateral and symmetrical. There was no suggestion4 M' m' j9 n& \
of papilledema.# z" ]0 x' X2 g9 n; R5 ~8 w1 f
Laboratory Evaluation
( P$ x" d# X( v. G0 sThe bone age was consistent with 28 months by) L# t# L: K3 @( @. U/ |" T& |
using the standard of Greulich and Pyle at a chrono-. t! }2 n/ ]2 ^1 n8 _1 z) G
logic age of 16 months (advanced).5 Chromosomal
% y0 y0 f+ o, B$ s' t2 ]karyotype was 46XY. The thyroid function test, b* L: _+ F$ P, B+ E/ u4 J) g2 O5 X
showed a free T4 of 1.69 ng/dL, and thyroid stimu-7 E5 e' C+ [+ [' Q, K
lating hormone level was 1.3 µIU/mL (both normal).
  I, E6 e; x) F% j6 e  v5 W0 ^4 FThe concentrations of serum electrolytes, blood
1 O' \' s) @: o+ k+ h! g! vurea nitrogen, creatinine, and calcium all were
: n" X# I+ O- g' uwithin normal range for his age. The concentration$ Y2 Q1 @9 u- ^4 b
of serum 17-hydroxyprogesterone was 16 ng/dL3 F/ o3 ^2 y; b6 I' |4 K; Z
(normal, 3 to 90 ng/dL), androstenedione was 20
  A6 j" _! N$ ^/ Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ x8 q& X2 r8 s/ z* J
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ v/ U& A  Q' O1 A' ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 U' b3 f( A- f' O. P3 Y
49ng/dL), 11-desoxycortisol (specific compound S)
9 T, m0 W. h% o. c+ P: Nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
; k' H: V+ q$ ]- k2 Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 u5 [' g' B: b- D5 K7 z% i; L9 Q( Ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" ]" r# b5 G0 `& Xand β-human chorionic gonadotropin was less than
) S. M2 O! C# _5 mIU/mL (normal <5 mIU/mL). Serum follicular) j" R% `0 X- [: G  G
stimulating hormone and leuteinizing hormone% ^. q& R8 p0 B( z/ ^' w
concentrations were less than 0.05 mIU/mL( E: E  ^& F% s" J
(prepubertal).& I- ^5 Y/ Q" k8 s" |8 T% ]
The parents were notified about the laboratory
3 f- g8 a% Y8 O' j9 t5 L* J, rresults and were informed that all of the tests were. r' }0 Y* ~4 j+ i+ u$ U
normal except the testosterone level was high. The
# g: }2 C/ F. b. g9 S0 m2 ?follow-up visit was arranged within a few weeks to4 B+ t) B' L% l4 a* B3 f1 s
obtain testicular and abdominal sonograms; how-4 z* k$ j3 S$ l! w* }+ ?3 C: T
ever, the family did not return for 4 months., Q+ K+ n6 _0 O& q
Physical examination at this time revealed that the- |5 {7 m* @1 f6 T
child had grown 2.5 cm in 4 months and had gained- ]3 b0 }- `  P, K. b+ J) X
2 kg of weight. Physical examination remained
& Q( R3 @- y0 A# Bunchanged. Surprisingly, the pubic hair almost com-3 C# ~. ?, {2 J" {) d' a2 j- H7 S
pletely disappeared except for a few vellous hairs at
- z( I3 L+ ~3 B7 z, \- ?the base of the phallus. Testicular volume was still 23 z* |0 m  _* a$ |0 q' C7 \5 x
mL, and the size of the penis remained unchanged.
! R3 Y: `0 R* b- @The mother also said that the boy was no longer hav-
$ k9 ?4 M1 L* X1 n! y4 I; ~5 King frequent erections.) a# P$ [2 m' G, @; x
Both parents were again questioned about use of  E; f0 b9 U8 I( n7 \
any ointment/creams that they may have applied to
$ N- ^( i: f+ ?" f. x, Bthe child’s skin. This time the father admitted the
$ J5 J7 @# h7 L# YTopical Testosterone Exposure / Bhowmick et al 541
" P6 g: c7 R# A4 X' Kuse of testosterone gel twice daily that he was apply-
. T# E# P2 H3 i# w9 S. J" Sing over his own shoulders, chest, and back area for% I% j" B- a; W9 {: |2 ]3 i
a year. The father also revealed he was embarrassed# q/ `, ]+ j, ]" U6 J
to disclose that he was using a testosterone gel pre-$ X7 _  U/ c/ N5 Q# K  X
scribed by his family physician for decreased libido
6 c# u' S. |. m. ^. qsecondary to depression.9 J% J! b7 s/ h; N
The child slept in the same bed with parents.5 F. `5 K5 Q0 \
The father would hug the baby and hold him on his
, v* S! R) Z/ J: mchest for a considerable period of time, causing sig-
, t3 ~, W8 s4 F! p5 N+ jnificant bare skin contact between baby and father.. e" b, z. w7 h3 p2 b6 [+ e, S
The father also admitted that after the phone call,
; }& H4 r! g3 Z' Y  n/ uwhen he learned the testosterone level in the baby* K# Q0 q$ l: j( A
was high, he then read the product information& r" h* a. `8 B5 E0 q7 W3 c% H
packet and concluded that it was most likely the rea-1 T$ B* t6 n  n9 q; J/ ~6 h( q& M
son for the child’s virilization. At that time, they2 h$ A2 r4 u$ |, R6 u8 K
decided to put the baby in a separate bed, and the
* R5 j* B' s) o. a8 g! Nfather was not hugging him with bare skin and had# q3 M/ s+ K) }  v5 r
been using protective clothing. A repeat testosterone
5 _( V8 H3 p! z, qtest was ordered, but the family did not go to the& l7 Z( q6 _1 R8 z$ U4 i1 D' D
laboratory to obtain the test.
% Q1 D* R6 Y$ M& VDiscussion6 H' V& O" [$ u1 r6 [
Precocious puberty in boys is defined as secondary0 a4 l& u/ Q0 U4 o0 a
sexual development before 9 years of age.1,4( Q9 Q- z- H; r; P
Precocious puberty is termed as central (true) when
7 |$ P! H. ^, p& S* X1 v, E) d3 ~it is caused by the premature activation of hypo-
, x. A0 t% d# J( ~* sthalamic pituitary gonadal axis. CPP is more com-
# G- t0 v& O( \mon in girls than in boys.1,3 Most boys with CPP
: |; h$ Z# f1 N5 C3 nmay have a central nervous system lesion that is8 c8 G- x2 q4 u6 M
responsible for the early activation of the hypothal-: F2 @5 t- Y# d4 P% D/ H* y9 g
amic pituitary gonadal axis.1-3 Thus, greater empha-9 P' j. ?7 W3 x' s  V% U
sis has been given to neuroradiologic imaging in
" H! M/ y- n) U" t8 ]boys with precocious puberty. In addition to viril-
0 P8 m, `. V# j+ N* u& g  wization, the clinical hallmark of CPP is the symmet-  c' @1 @/ L1 F# E6 C
rical testicular growth secondary to stimulation by) x) W& v9 Z# A/ ?/ |
gonadotropins.1,35 T% e3 i$ o6 {! M: P8 X4 I  P
Gonadotropin-independent peripheral preco-0 g3 O7 @. v; L6 J
cious puberty in boys also results from inappropriate
1 d: k2 ?+ }2 {androgenic stimulation from either endogenous or% B) v' b# J8 W. d) ]4 L
exogenous sources, nonpituitary gonadotropin stim-
8 B) B5 Q/ b7 b+ vulation, and rare activating mutations.3 Virilizing3 [8 p# x, O& e% ?  a
congenital adrenal hyperplasia producing excessive8 a; D9 j" T# V) r/ Q" F" i
adrenal androgens is a common cause of precocious3 f$ ?* X% `5 f* J3 {
puberty in boys.3,4- F' A# t7 R$ V8 X0 g
The most common form of congenital adrenal- n/ r: d- i7 h! I) L2 j4 P
hyperplasia is the 21-hydroxylase enzyme deficiency.. S& z; }* |9 W: j+ y6 g/ t
The 11-β hydroxylase deficiency may also result in5 Y9 t/ _, g/ e
excessive adrenal androgen production, and rarely,
9 k. |5 }# G; K& w( K. `an adrenal tumor may also cause adrenal androgen" `. R+ I4 f( _! R, M
excess.1,3* J* Y/ F4 {4 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( _; i, v3 l' S% F542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) m. j/ Q$ f$ A5 f( BA unique entity of male-limited gonadotropin-7 k1 K/ y1 E& T# c
independent precocious puberty, which is also known
$ S, m1 |' E! U3 u! f& w! Ras testotoxicosis, may cause precocious puberty at a& g4 @' `( X. L6 k" ?' y
very young age. The physical findings in these boys
7 N. O' Q7 W( b; rwith this disorder are full pubertal development,
" ?7 Z4 `- u8 o: k/ vincluding bilateral testicular growth, similar to boys+ G9 q* ]7 [* G3 D; {
with CPP. The gonadotropin levels in this disorder
  |0 t' F' W8 G+ ^: ~7 W/ Vare suppressed to prepubertal levels and do not show
  x+ P% Y3 p( L. y5 A; Y; }, t  Xpubertal response of gonadotropin after gonadotropin-
9 J; j  C4 W% k4 F6 b. P0 Kreleasing hormone stimulation. This is a sex-linked/ h+ u( t0 t3 m: F4 h0 F  C
autosomal dominant disorder that affects only/ R* Q1 @1 B, q; `
males; therefore, other male members of the family2 m, M5 _6 N* i8 }
may have similar precocious puberty.3
' @' d7 [% x  b& ]- tIn our patient, physical examination was incon-
% K" S* c3 R& ?: T3 ~sistent with true precocious puberty since his testi-$ C4 `: c5 }6 u' p% O. N. a
cles were prepubertal in size. However, testotoxicosis
* a. E- O* z4 H2 |4 v. A! f( \9 l" P4 Gwas in the differential diagnosis because his father
2 V6 ^6 a- L- @! }0 nstarted puberty somewhat early, and occasionally,
$ [' Z# i6 Q3 W3 q8 Y8 U# \( \7 Ctesticular enlargement is not that evident in the% U! j3 G2 R3 G
beginning of this process.1 In the absence of a neg-
. H# F* X7 u) C& @ative initial history of androgen exposure, our: o% {( V0 ]' b2 v1 Q
biggest concern was virilizing adrenal hyperplasia,
% x4 ?7 r2 h# l- U8 ^# ieither 21-hydroxylase deficiency or 11-β hydroxylase8 R) `4 u& \- `3 l- W1 i
deficiency. Those diagnoses were excluded by find-  |+ r" `* T1 t$ B0 i/ p
ing the normal level of adrenal steroids.6 e  \, N6 y$ N  n& V( E
The diagnosis of exogenous androgens was strongly8 [, C3 n7 l. B4 L0 R& A
suspected in a follow-up visit after 4 months because5 j8 t& r' \: |% G
the physical examination revealed the complete disap-
% M$ y1 v; R1 F9 f+ H7 r' F/ Fpearance of pubic hair, normal growth velocity, and  H/ x$ ?3 s7 |! z! R2 m9 D
decreased erections. The father admitted using a testos-
* Y$ ~/ D0 R" Aterone gel, which he concealed at first visit. He was
' R% p8 K8 h9 s. E: n8 d6 ausing it rather frequently, twice a day. The Physicians’
# Y/ e" m, P7 D1 v2 MDesk Reference, or package insert of this product, gel or
1 l/ ]) p# J- N- H% r1 N; icream, cautions about dermal testosterone transfer to2 C" e. X9 ?) V; w5 n+ h8 L
unprotected females through direct skin exposure.
$ [- k6 |6 a' A3 L5 w. v1 W: ?) DSerum testosterone level was found to be 2 times the
( I  f" v( t& ?9 Zbaseline value in those females who were exposed to
0 K& t  x1 F1 [5 m% c+ e7 L' K& heven 15 minutes of direct skin contact with their male
" q9 o- p% C2 R0 `7 epartners.6 However, when a shirt covered the applica-9 `" w+ h3 K# p# _. q
tion site, this testosterone transfer was prevented.
  J; s4 k6 _5 ^" L# r! KOur patient’s testosterone level was 60 ng/mL,
% M" ?% \1 ?1 w8 U: T( _which was clearly high. Some studies suggest that% g1 y$ l" p% e3 Q
dermal conversion of testosterone to dihydrotestos-
9 C* V1 N% R4 Pterone, which is a more potent metabolite, is more
$ [; d) B8 u$ i- x: ^( E+ J! cactive in young children exposed to testosterone5 ~; s( h6 ^7 ?. t9 ^# H7 t: b
exogenously7; however, we did not measure a dihy-
. J3 {! Q1 [6 {1 o& t/ c5 Xdrotestosterone level in our patient. In addition to2 p4 W! ]. Z" V' F% T# n/ b0 P8 p
virilization, exposure to exogenous testosterone in: ]# n, m0 V" \) E; ?$ M
children results in an increase in growth velocity and
5 X% }; U2 L- n  Q, d& j4 G- qadvanced bone age, as seen in our patient.
2 g. T" X2 x' E& WThe long-term effect of androgen exposure during" J. P$ R7 y& `9 L
early childhood on pubertal development and final
- Y2 Q5 D- v/ ~8 _! b; @adult height are not fully known and always remain9 t7 U- U8 {9 J. L2 |# m
a concern. Children treated with short-term testos-
, T/ [' d8 Z. c& E) Xterone injection or topical androgen may exhibit some3 x/ J& z0 ]7 C+ _1 W0 h
acceleration of the skeletal maturation; however, after
9 e1 f$ e3 A5 Dcessation of treatment, the rate of bone maturation! e( P( [( a. T! w/ D7 w4 Z
decelerates and gradually returns to normal.8,9+ A/ D( a3 U2 j' j% R' x4 @
There are conflicting reports and controversy. T. I  e! X# Y1 n
over the effect of early androgen exposure on adult) O( V: Z9 V, ]: |" X
penile length.10,11 Some reports suggest subnormal: {  L+ E$ W' ~
adult penile length, apparently because of downreg-( z( H7 k0 g/ C; Y4 y
ulation of androgen receptor number.10,12 However,
. }' c/ _0 @3 k8 p7 dSutherland et al13 did not find a correlation between
* m4 n9 n: w2 E" k: y- q2 zchildhood testosterone exposure and reduced adult
: k% [% O7 \+ v: w1 ^penile length in clinical studies.
9 e7 e$ ~# k6 cNonetheless, we do not believe our patient is7 Y- l; u% O  L# f, H* Z% U
going to experience any of the untoward effects from
. N- h2 \- T# I: }# stestosterone exposure as mentioned earlier because
. E+ q9 R8 @) q+ |& @) A! }* Othe exposure was not for a prolonged period of time.
, [- I; J& P( E& X8 r  [, xAlthough the bone age was advanced at the time of
. q5 s' v9 t. ^/ \& Vdiagnosis, the child had a normal growth velocity at
( f' H* a4 C* {, e1 K3 a9 d1 D" dthe follow-up visit. It is hoped that his final adult" Y, N' M; e& R5 t3 ]
height will not be affected.
" t: n1 [! j) h! g& C( rAlthough rarely reported, the widespread avail-5 M. `) R8 r, O* [9 W( S
ability of androgen products in our society may$ P7 r6 M0 x6 Z& J7 v
indeed cause more virilization in male or female
4 O9 U% F. Y6 l3 w$ r, a& n; _0 r" _5 @children than one would realize. Exposure to andro-
; J# k! F) P  c) C) c) Ugen products must be considered and specific ques-; M0 d$ ]3 P5 U+ c1 K4 a
tioning about the use of a testosterone product or
* j' H6 a$ C& V0 Y% T5 ngel should be asked of the family members during$ A( i( I% \) E3 b
the evaluation of any children who present with vir-9 m# Z! P' D. Q$ ?7 @
ilization or peripheral precocious puberty. The diag-
& Y- @) D  E( l# z; S, j% ]nosis can be established by just a few tests and by
0 @9 x3 _3 e: d" b( H, p! G) ~appropriate history. The inability to obtain such a( x! \, T! I6 b5 X; `& O* S; n" b
history, or failure to ask the specific questions, may
6 ]0 k. h- |, ~result in extensive, unnecessary, and expensive1 l6 _, g$ x" ~5 F; Z! R9 o
investigation. The primary care physician should be. q$ D) m" w4 k( s" i
aware of this fact, because most of these children; \. ^% k$ {! }: U0 J  m
may initially present in their practice. The Physicians’* T- ~& f* N# S% o0 X
Desk Reference and package insert should also put a
" H* \- j! v, z6 ]! L% w8 cwarning about the virilizing effect on a male or
! v( `0 z7 A- N+ r4 P: Q! g# ofemale child who might come in contact with some-) A0 t, _1 V# W- \' c, a
one using any of these products.
6 w! A" n# ?1 N: y( o/ Y) qReferences6 v. `" R' X( r' [0 R/ ]% s' Y9 Y
1. Styne DM. The testes: disorder of sexual differentiation. L  _7 M+ A  f8 z8 k. I1 L1 E
and puberty in the male. In: Sperling MA, ed. Pediatric3 Q' T& Y" q4 D# z: {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: y0 }1 f5 H! `+ D
2002: 565-628.: k. }+ Q4 f% [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) K' {9 E7 N( X0 X2 c
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
( l. h* L( h7 P" D8 O9 O& YBoy Induced by Indirect Topical
) L& ?- |* J7 ^& l# p3 cExposure to Testosterone
# O* D; |! i& t* |7 Q0 E2 aSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' D  i2 `8 t2 m, \" a
and Kenneth R. Rettig, MD1
$ Y9 A3 S7 H3 y3 {) k. j, HClinical Pediatrics" M, `+ N0 {! X
Volume 46 Number 69 c4 `  a  e9 h% Y* R
July 2007 540-543* N$ {6 m: }3 @! V1 \$ M
© 2007 Sage Publications
2 L/ c% w: S& y8 o10.1177/0009922806296651/ |+ i( t+ J) W; X
http://clp.sagepub.com) N7 k! d: m' v! p3 y
hosted at
4 h) M& O1 P3 }2 x8 J# m: Dhttp://online.sagepub.com
* r' @+ b( q' z/ o; E9 I2 @0 K' w0 QPrecocious puberty in boys, central or peripheral,
# M' k, x1 `- c% P5 i" O4 v; w& Ais a significant concern for physicians. Central; V& V0 U4 @$ C8 p  N& e* N
precocious puberty (CPP), which is mediated- `/ X- W5 r1 W9 D' Y
through the hypothalamic pituitary gonadal axis, has
# T3 D2 n: N! H6 Va higher incidence of organic central nervous system5 X& z1 k- g% }6 d: j) x4 s+ V
lesions in boys.1,2 Virilization in boys, as manifested; \! k" d! U# s' m0 x' N: a
by enlargement of the penis, development of pubic( Z) ~+ Y  M! S# b
hair, and facial acne without enlargement of testi-& |4 B- h" Y+ @6 P
cles, suggests peripheral or pseudopuberty.1-3 We" L+ E8 D7 G4 t: y7 ~
report a 16-month-old boy who presented with the4 T. z) C" U  f& }6 d- f
enlargement of the phallus and pubic hair develop-
: J2 l; o; ~: xment without testicular enlargement, which was due; R* Q2 @* R# f) Y& I7 C; e" J
to the unintentional exposure to androgen gel used by5 P% t& O. P) ~* `& ]  _$ v
the father. The family initially concealed this infor-, V  @  w% X# k: V6 D0 y  a& J
mation, resulting in an extensive work-up for this
5 ?% P# C& n4 R7 mchild. Given the widespread and easy availability of
+ M4 Q4 l2 v: N' I: ~! y& l5 a" ftestosterone gel and cream, we believe this is proba-9 F- t/ `: Q5 W) w& [: p
bly more common than the rare case report in the
8 g3 v5 b* @, O& j" |5 M/ Sliterature.4
! b3 m( ~* m5 s* E. VPatient Report0 G6 {8 [2 ^! y7 Q
A 16-month-old white child was referred to the8 v4 }0 C8 N$ I' q% X
endocrine clinic by his pediatrician with the concern
7 I1 G2 o1 Q4 C$ j( M+ Nof early sexual development. His mother noticed! b" C  U1 t9 ^1 C7 c
light colored pubic hair development when he was+ F# u( {; T. f" O# F
From the 1Division of Pediatric Endocrinology, 2University of9 c7 H& ]2 ?+ _
South Alabama Medical Center, Mobile, Alabama.7 r* M1 R; S5 t8 }' e& R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 `6 e- |5 N+ mProfessor of Pediatrics, University of South Alabama, College of
8 x: k9 l/ `3 E. O5 W* U3 ?+ SMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- Q& |9 ]' k, b3 V: k& O' Oe-mail: [email protected].2 g' c( I3 _1 F/ {
about 6 to 7 months old, which progressively became
  n/ q' E/ |) y$ A& I$ l+ P' l: h! Udarker. She was also concerned about the enlarge-) ?' E& p! r! A1 n2 {: e
ment of his penis and frequent erections. The child
0 a. N1 C* r' {2 t" I! Ywas the product of a full-term normal delivery, with
- ^9 k! c+ m" k$ i4 d4 d* C0 w- sa birth weight of 7 lb 14 oz, and birth length of8 _- V1 M5 n0 X8 l* c  G
20 inches. He was breast-fed throughout the first year9 h! w" _4 A! D: s0 Y4 k
of life and was still receiving breast milk along with
. t, S7 B$ {# u& `, Z" v; W* gsolid food. He had no hospitalizations or surgery,1 g2 F" |% x, D4 o( E
and his psychosocial and psychomotor development) i# P1 T! H. `" v
was age appropriate.2 u+ P" l$ p6 s5 C7 s6 u5 {
The family history was remarkable for the father,) Y7 @; j( _9 ]4 |) v! R0 `
who was diagnosed with hypothyroidism at age 16,
) Y/ m! a# x7 R; zwhich was treated with thyroxine. The father’s
# I$ r+ }+ @7 K: h4 `height was 6 feet, and he went through a somewhat
( x, \0 a2 `; searly puberty and had stopped growing by age 14.# G# U+ y) P( t0 X! Q" X2 e0 f
The father denied taking any other medication. The6 O, l  v6 [! ^- [# s) p
child’s mother was in good health. Her menarche+ ~5 }! o0 `: n) ^( E* G: ~% t# n
was at 11 years of age, and her height was at 5 feet
* h( |1 F$ Q1 r( e+ a5 inches. There was no other family history of pre-
% _! F( R  {9 u/ _cocious sexual development in the first-degree rela-0 ~& X9 c  p: F" X
tives. There were no siblings.
0 @0 C5 Q/ Y& i, RPhysical Examination8 l7 F& ~9 ^6 O' i7 F# X  U
The physical examination revealed a very active,
, r3 F6 a4 d) [- v+ s- J- N( Gplayful, and healthy boy. The vital signs documented
' Y- T; l; }6 l3 ^! M3 k# ^a blood pressure of 85/50 mm Hg, his length was
0 T) d+ u$ B3 h. z90 cm (>97th percentile), and his weight was 14.4 kg
7 \9 y4 H( H4 b6 n: a6 {3 `( n2 h(also >97th percentile). The observed yearly growth
6 n4 K# c; J, t: @0 r  uvelocity was 30 cm (12 inches). The examination of1 Y3 t2 |9 J2 ?& ?
the neck revealed no thyroid enlargement.
7 U6 ^7 I' b, U! ?The genitourinary examination was remarkable for
+ T( e) X; ?5 u7 H. Tenlargement of the penis, with a stretched length of, D3 q% u" ~& e2 e% J
8 cm and a width of 2 cm. The glans penis was very well
, d; C/ j2 m, B) E9 _$ q5 @$ `developed. The pubic hair was Tanner II, mostly around
! m- F* j* L* D540
8 q& W) ]; k: o+ O% Q2 J; lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* k$ M) v* q+ }. R% h7 Z( ]
the base of the phallus and was dark and curled. The
8 o9 Y! I, [) U" N" qtesticular volume was prepubertal at 2 mL each.
0 D1 F4 m+ N( _+ n8 P: GThe skin was moist and smooth and somewhat9 D8 k8 q+ V( w3 j5 ~' v
oily. No axillary hair was noted. There were no& B% D$ H. u0 d! N0 m' k
abnormal skin pigmentations or café-au-lait spots.
( J5 l1 Y$ e, w' T; x  ?Neurologic evaluation showed deep tendon reflex 2++ t; |4 v1 E8 P) i; O4 b' U# n! }1 V
bilateral and symmetrical. There was no suggestion  S2 N% I  u" U( T; A
of papilledema.
( P$ B( h8 L4 GLaboratory Evaluation
$ H: C1 X7 H$ \1 m; M* wThe bone age was consistent with 28 months by
0 S6 v4 j  f4 j6 v: v$ X1 V9 Wusing the standard of Greulich and Pyle at a chrono-& i' E* \) N$ f, X7 E
logic age of 16 months (advanced).5 Chromosomal' i9 \! H6 O# u" a# K
karyotype was 46XY. The thyroid function test
) {& d. ~2 P; k; E( L" c6 d% T; @showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 q- i4 F" X/ F, r7 Z' Elating hormone level was 1.3 µIU/mL (both normal).( A' ^% C; b/ U$ g9 ~; A
The concentrations of serum electrolytes, blood; Y# L2 `$ {2 D: U: \
urea nitrogen, creatinine, and calcium all were
2 X" B1 W% `7 A! f) T" l+ Y4 r! Pwithin normal range for his age. The concentration! X* p+ D  ?! i
of serum 17-hydroxyprogesterone was 16 ng/dL
7 P% P5 c7 s7 _1 ^# r; L- p(normal, 3 to 90 ng/dL), androstenedione was 200 _, o1 [% @  M/ o8 p. F& x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" J+ C8 ?" s2 D: Y7 ?6 C
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 L) x$ c/ J, P4 n) K& _5 \8 M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) {4 S& p0 U! S2 i49ng/dL), 11-desoxycortisol (specific compound S)
/ M& t2 x' g+ e. A9 u' o, swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 K) R$ V3 H( ~# \# r) _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 P" _: c/ z: G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 `' I$ O, K8 S' Z
and β-human chorionic gonadotropin was less than
& g" S  k; B3 w# y* E5 mIU/mL (normal <5 mIU/mL). Serum follicular& Z2 A$ F4 i7 O( K& q5 E
stimulating hormone and leuteinizing hormone
  {+ b, V. U- [- a# \concentrations were less than 0.05 mIU/mL
! i2 T- D- {" @2 o$ R% e(prepubertal)." Z: V# m+ J* M/ `, m) ?
The parents were notified about the laboratory
2 Z- Z* c" `) x2 `8 `results and were informed that all of the tests were* Y9 N; b9 f( o
normal except the testosterone level was high. The
2 t! z# o: F1 s* Zfollow-up visit was arranged within a few weeks to
: r5 n( y# g2 g. w/ U  o. Q- @obtain testicular and abdominal sonograms; how-' d' x6 c  E& R5 ~* b" j
ever, the family did not return for 4 months.
, o8 E8 h  U% QPhysical examination at this time revealed that the
: v" h7 E' v1 echild had grown 2.5 cm in 4 months and had gained
% D9 i  m  {/ r) T; X% e9 \9 E0 W2 kg of weight. Physical examination remained8 n4 z6 m2 t( i) D
unchanged. Surprisingly, the pubic hair almost com-" l; y- ]4 ~& W: r, H- f# ?
pletely disappeared except for a few vellous hairs at
, b. L% ^2 [1 \) W  L" H" fthe base of the phallus. Testicular volume was still 2
) T% X/ a; i3 d, c/ GmL, and the size of the penis remained unchanged.
8 i  G& X- f. T6 F' A. tThe mother also said that the boy was no longer hav-
! u" A' E% L9 b/ L# m: `0 j( R+ Fing frequent erections.! n/ n) a! D) x
Both parents were again questioned about use of
, X9 v) r) M# f, k  v2 |any ointment/creams that they may have applied to4 r- R+ g7 o# O* M) [- c
the child’s skin. This time the father admitted the
2 Y# z8 {7 ^4 o! R$ E& q, u9 ETopical Testosterone Exposure / Bhowmick et al 541: R* C  d7 a" ?! v% E) R
use of testosterone gel twice daily that he was apply-
) H% T" V4 a1 o4 V4 F7 Xing over his own shoulders, chest, and back area for
/ W& D. h# f- d0 ]: Z6 s; ?  A+ Ja year. The father also revealed he was embarrassed
8 h8 L6 B7 h/ l7 W# pto disclose that he was using a testosterone gel pre-, K) E3 M) U; J1 U& P
scribed by his family physician for decreased libido
" O& T' J' t8 w/ f4 I0 ~secondary to depression.% Q* L" ~2 z, D/ C
The child slept in the same bed with parents.
7 j6 e3 v# U7 _The father would hug the baby and hold him on his3 O) e" s+ Y: Q
chest for a considerable period of time, causing sig-
6 U, _1 A; q' U! Bnificant bare skin contact between baby and father.
0 w# G$ ~" I2 HThe father also admitted that after the phone call,
  ?- t8 d6 `; Z. F7 |when he learned the testosterone level in the baby5 Z4 U7 Q5 T; W
was high, he then read the product information- T, C# G4 y8 R
packet and concluded that it was most likely the rea-
; k, {8 ~+ Z; x( T5 ?son for the child’s virilization. At that time, they
8 O9 t" X1 |* R" J5 v( m) D9 Y! ydecided to put the baby in a separate bed, and the
! _8 r8 v7 d5 W3 j2 K: M0 k: Y% Ffather was not hugging him with bare skin and had9 }# f+ r9 b1 I- m5 @+ F
been using protective clothing. A repeat testosterone
. ~) _4 _# a, h1 Gtest was ordered, but the family did not go to the+ i7 D! O( [, Q. p. q7 k
laboratory to obtain the test.
  A: m  y) X7 C& }0 [  wDiscussion
, d) t7 C9 g+ m/ BPrecocious puberty in boys is defined as secondary
' q) p+ `! k  U+ t2 psexual development before 9 years of age.1,4
9 `& F, p. U0 N# ]' c5 OPrecocious puberty is termed as central (true) when
) A+ q- V. F8 A, Bit is caused by the premature activation of hypo-1 j/ q0 }& _$ R3 s: O, [4 g
thalamic pituitary gonadal axis. CPP is more com-" M  K0 z, v1 s) L2 Q7 ~
mon in girls than in boys.1,3 Most boys with CPP
  `7 q; R- v: F# U0 K7 R3 gmay have a central nervous system lesion that is9 H4 |# g# F6 h' S/ D" U6 M
responsible for the early activation of the hypothal-
' A, X. D5 i# damic pituitary gonadal axis.1-3 Thus, greater empha-8 L; \$ \" d4 a5 L5 r* F& m$ _
sis has been given to neuroradiologic imaging in1 q) C4 }8 q% h9 R6 t& V
boys with precocious puberty. In addition to viril-
& J" `6 Y  J* b5 sization, the clinical hallmark of CPP is the symmet-& i/ u& z' `8 C: Q$ _
rical testicular growth secondary to stimulation by
( f  u% V5 d3 J' G! ~0 x9 `' _5 xgonadotropins.1,3
7 n( j6 w. H, ?3 c" MGonadotropin-independent peripheral preco-
8 [* [) K/ E; T  u, X5 T) Jcious puberty in boys also results from inappropriate
9 L# p* |0 S( dandrogenic stimulation from either endogenous or4 Z+ d8 E  K, d' u. W, X( [- A
exogenous sources, nonpituitary gonadotropin stim-
3 G" P) z- [/ U" F* `+ h/ s- lulation, and rare activating mutations.3 Virilizing
( j+ I, n1 V2 t: w' j$ `- fcongenital adrenal hyperplasia producing excessive
/ J) I. K! M+ t3 M& b2 ^1 dadrenal androgens is a common cause of precocious
+ n" q, d  c6 B$ upuberty in boys.3,4" {2 W( a- f1 h/ V4 n9 y  Z- C
The most common form of congenital adrenal/ _( m4 ]: Y8 ?2 d. ?* D
hyperplasia is the 21-hydroxylase enzyme deficiency.
, [' f: F- B. \% {- C3 xThe 11-β hydroxylase deficiency may also result in. H& O. n, S. ], T. y) F
excessive adrenal androgen production, and rarely,
( R8 W, @9 k1 E' }an adrenal tumor may also cause adrenal androgen
: Y- a% |4 ?, _: nexcess.1,3* z: [0 l7 X$ B6 v# R; {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% ]9 Q( W- e% T0 Z1 h! E5 Q3 I2 _) T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 s; v5 E8 g! ~* n' N# N% @% b1 aA unique entity of male-limited gonadotropin-
- h( r0 t; Q' W0 G1 L/ g5 oindependent precocious puberty, which is also known
" n) j% W+ F2 T% V) R: D& z& yas testotoxicosis, may cause precocious puberty at a
+ n% I$ o& M. {( a  Y& C) Rvery young age. The physical findings in these boys
! N; w# e9 _: S5 F5 s4 \with this disorder are full pubertal development,# M+ k5 I/ A6 R" I
including bilateral testicular growth, similar to boys) S- M# E0 ?: p
with CPP. The gonadotropin levels in this disorder
- V; G! A+ L! w& ~are suppressed to prepubertal levels and do not show
5 h' w0 F0 B7 ypubertal response of gonadotropin after gonadotropin-8 |- a' ?- r4 d
releasing hormone stimulation. This is a sex-linked
0 W7 T/ i' J) x4 x$ h( o; yautosomal dominant disorder that affects only; C( d3 K/ H  ?
males; therefore, other male members of the family
  A# n, E$ j9 x& O2 R- d; _: |may have similar precocious puberty.3
/ W! \& ]5 E, T) r% R6 k" ~In our patient, physical examination was incon-. H, p) i# I- P& P" F+ Y; m
sistent with true precocious puberty since his testi-& i2 m( |' ]+ u  o9 ~6 v1 ]  @" H
cles were prepubertal in size. However, testotoxicosis4 q; h, T& j' M7 L
was in the differential diagnosis because his father
9 b8 s, C+ r3 f$ [* b$ Y! Astarted puberty somewhat early, and occasionally," H0 n. o, G! x" Q$ ^6 b
testicular enlargement is not that evident in the
1 o9 {- N( `' }8 G, H% S( wbeginning of this process.1 In the absence of a neg-: u$ y, Y9 K; W$ w: ^
ative initial history of androgen exposure, our
7 y6 d/ B& M0 B6 m2 o  Jbiggest concern was virilizing adrenal hyperplasia,7 g8 G1 o8 Y( n% N- w8 Z
either 21-hydroxylase deficiency or 11-β hydroxylase
5 ]2 t: o- s; vdeficiency. Those diagnoses were excluded by find-: E. x; W8 i8 {; n& `
ing the normal level of adrenal steroids.
0 N0 @9 q, L, l, M% r  cThe diagnosis of exogenous androgens was strongly
) X7 A: i8 l+ D; Fsuspected in a follow-up visit after 4 months because
1 F, x0 R8 L, s8 [the physical examination revealed the complete disap-: y* F$ d( @/ q0 V; c! H
pearance of pubic hair, normal growth velocity, and; w& j7 g4 ?' B/ \
decreased erections. The father admitted using a testos-- D9 @6 _# s# x( I
terone gel, which he concealed at first visit. He was
, J! F& }2 w- u, ]/ vusing it rather frequently, twice a day. The Physicians’
" V4 }# F1 T- DDesk Reference, or package insert of this product, gel or9 i2 D" V) p( m( M$ Y( Y& Y9 U
cream, cautions about dermal testosterone transfer to
2 ?# O% a1 r* Zunprotected females through direct skin exposure.) m. @7 N# @7 f0 j
Serum testosterone level was found to be 2 times the9 N: J' R# h! s( R& \6 e
baseline value in those females who were exposed to' ]+ T2 [( w; h3 I5 Y8 ]. }
even 15 minutes of direct skin contact with their male
+ _+ w" j4 h/ O; I. _( Wpartners.6 However, when a shirt covered the applica-% X! F0 a  \2 Y1 Z9 G/ Z
tion site, this testosterone transfer was prevented.2 `' p4 }8 j9 P4 g
Our patient’s testosterone level was 60 ng/mL,, _( t5 u6 {2 q5 l0 K( e' O  I
which was clearly high. Some studies suggest that7 U! K5 m' b# b
dermal conversion of testosterone to dihydrotestos-/ I6 U9 m, v( z0 x6 O& |: a: X
terone, which is a more potent metabolite, is more6 V3 g6 W# Y5 j' g" Y' E
active in young children exposed to testosterone
: J1 l& ?, |7 h9 j9 @& }exogenously7; however, we did not measure a dihy-
9 W% I$ u: @" O$ H' W6 v1 ddrotestosterone level in our patient. In addition to3 j. U! X) W3 X" b/ E
virilization, exposure to exogenous testosterone in
0 J) |6 ]/ ~% z% Y7 |children results in an increase in growth velocity and
2 ^# E% h4 i: Y- b* J3 Vadvanced bone age, as seen in our patient.5 d  N6 m" d9 ~8 c+ A
The long-term effect of androgen exposure during, T, L% l  b/ R$ P1 _
early childhood on pubertal development and final
! g6 }$ _* O9 aadult height are not fully known and always remain
. |2 G& u4 o. s2 |6 d* R6 {a concern. Children treated with short-term testos-: F$ H4 q) S" l7 @
terone injection or topical androgen may exhibit some  w4 z/ ~: c6 f: V/ v
acceleration of the skeletal maturation; however, after
7 h7 e+ Z1 c7 v8 f7 @. I9 ?cessation of treatment, the rate of bone maturation
/ S! w5 A4 K( z* gdecelerates and gradually returns to normal.8,91 L4 G) G7 u& ]: X7 s: j' r/ I
There are conflicting reports and controversy
; b* J0 P( o/ p! ^  |: Yover the effect of early androgen exposure on adult7 W: w& d2 f% P3 a$ u3 }0 M
penile length.10,11 Some reports suggest subnormal3 K, G0 I+ k8 i- q9 q! k3 |
adult penile length, apparently because of downreg-
: e6 I/ E: Y8 A! b3 @# Q! W& Y1 ?ulation of androgen receptor number.10,12 However,
  I! Q" k* }  b/ A& ^3 VSutherland et al13 did not find a correlation between
. q6 s. k" m$ H' u/ wchildhood testosterone exposure and reduced adult+ y+ p8 I9 Z3 C/ \9 r
penile length in clinical studies.$ k0 v* b/ n4 r& u4 ~0 J
Nonetheless, we do not believe our patient is
1 A  \6 p& c  _/ vgoing to experience any of the untoward effects from
- {3 h/ R, Z& B7 F: j$ \' d% y% jtestosterone exposure as mentioned earlier because+ ?2 d1 t  N0 R" x0 w$ X& L
the exposure was not for a prolonged period of time.
+ C- m, a5 U9 h& W7 Z( vAlthough the bone age was advanced at the time of
5 W3 |' R0 l. O1 ~8 J0 vdiagnosis, the child had a normal growth velocity at2 \$ B1 |4 e, P2 M; [9 K* j
the follow-up visit. It is hoped that his final adult$ j# Q# h, A0 ~& H, M+ o9 c
height will not be affected." g% t/ h1 \, F6 B
Although rarely reported, the widespread avail-9 v$ Z8 c- G: k1 h  U
ability of androgen products in our society may
* s( [4 ^$ u- z2 jindeed cause more virilization in male or female6 ?/ V, [. [) F% F$ G* S! W
children than one would realize. Exposure to andro-  q9 g$ X* I* `5 b9 _
gen products must be considered and specific ques-, e' [6 I8 `  O, s, d# j+ g& ^! o
tioning about the use of a testosterone product or
* l: B+ Q. A  W* L4 _! \& Jgel should be asked of the family members during6 ]) @  q, x8 _7 F
the evaluation of any children who present with vir-
5 ?. L0 T, u% X0 G4 G/ b7 z+ Kilization or peripheral precocious puberty. The diag-9 n" M& ~: c; z2 j, N
nosis can be established by just a few tests and by
; J' e8 K3 b6 B! `5 r, P  kappropriate history. The inability to obtain such a& P- a6 o6 p) M4 t- O8 {. h2 U
history, or failure to ask the specific questions, may
, s7 N: K; R5 G3 oresult in extensive, unnecessary, and expensive
8 t7 @( v& ^# Z! s: ?investigation. The primary care physician should be
3 \& }0 @5 n3 c9 Zaware of this fact, because most of these children
6 `* V- G! ]9 o' t, amay initially present in their practice. The Physicians’
) C# z( V* X6 V$ x+ ~$ v" TDesk Reference and package insert should also put a$ x: I# j% L' X! y1 u+ N
warning about the virilizing effect on a male or; c4 H3 B: p  {+ T9 U6 l' A
female child who might come in contact with some-& E8 v$ E1 z( `# l+ ?( L) i4 X7 F
one using any of these products.
' k8 y" o, w( s: N+ }% L' }! cReferences
" |0 D  x6 O! u( `% H4 B1. Styne DM. The testes: disorder of sexual differentiation
; U, q: ]3 c- _8 {& r, cand puberty in the male. In: Sperling MA, ed. Pediatric* T  u( C. t7 [4 Q! n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 e: H+ I: \  s1 e# G, z- N) o( d8 I
2002: 565-628.
" z: r5 q+ J0 I( `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 |! x- c. ^, Y$ z: {# Apuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
5 ~  L5 P% f- J, R  @$ v
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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