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Sexual Precocity in a 16-Month-Old
$ ]) U% r+ j! ^( FBoy Induced by Indirect Topical* A# W5 \( Z0 g9 K3 {% R0 r
Exposure to Testosterone, W4 x" `, J  Q+ I
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! b4 C& s! u. ?6 d5 \/ X7 ?, Y7 n; p
and Kenneth R. Rettig, MD1
; Y( W: k. r  C+ QClinical Pediatrics
. c3 v& j3 i- D% cVolume 46 Number 6
$ J( g0 w/ Y( [8 f6 q- kJuly 2007 540-543$ M7 Z3 i( n* R7 q
© 2007 Sage Publications
1 |# W% ^, L& ^; y  r, l10.1177/0009922806296651$ q" L* u/ ?9 i( [
http://clp.sagepub.com
) j2 Q9 @" C$ w5 h  Fhosted at
+ t9 `" p7 `3 `6 L+ Mhttp://online.sagepub.com) s. z) Q, d) |# `5 ]
Precocious puberty in boys, central or peripheral,
- o/ \. I, B, W$ W: o# i" cis a significant concern for physicians. Central& V8 B- Q% ^0 F' {# V5 D
precocious puberty (CPP), which is mediated
' c  f; Z( p% X2 |through the hypothalamic pituitary gonadal axis, has! a9 w. G' f, p3 O& v+ _
a higher incidence of organic central nervous system  X7 Q4 O7 {1 w) ^: l5 r8 P
lesions in boys.1,2 Virilization in boys, as manifested
( N  T9 j* w$ n3 N# S, z1 I' ~by enlargement of the penis, development of pubic
/ _# n' r( a2 i1 F1 [  M, Fhair, and facial acne without enlargement of testi-
6 ], q( w0 ?6 G; T* dcles, suggests peripheral or pseudopuberty.1-3 We
# z) S- |( G5 C8 F; Freport a 16-month-old boy who presented with the8 L# g& m) I, d
enlargement of the phallus and pubic hair develop-  K+ R1 K, Y  q/ n
ment without testicular enlargement, which was due* a% b) r& _, p
to the unintentional exposure to androgen gel used by; t1 [  t! o  z0 P
the father. The family initially concealed this infor-
2 P" n6 ^& X5 j: ?0 Gmation, resulting in an extensive work-up for this* ~* [. p$ x2 X0 [+ m4 ?
child. Given the widespread and easy availability of
! e6 C5 p" [/ d' U2 y# v8 ?3 `& Q) p9 mtestosterone gel and cream, we believe this is proba-  S. W7 X7 X8 W4 F/ ~' ^
bly more common than the rare case report in the
" f8 A7 v' _: k6 g9 `: ^+ \. `/ B! C" lliterature.4: \2 M( J& J% D) u! V- T: l( Q
Patient Report) t0 {+ u( C3 F+ @
A 16-month-old white child was referred to the  N# y+ Y! x: ~
endocrine clinic by his pediatrician with the concern6 ~( \( f6 i7 n- x
of early sexual development. His mother noticed- L, L$ l/ w% I7 Z6 t" ~
light colored pubic hair development when he was
5 w( Q' ^) T7 R$ WFrom the 1Division of Pediatric Endocrinology, 2University of
$ @# Q. Z& k  Y+ E( Q& R1 A( kSouth Alabama Medical Center, Mobile, Alabama.- p; |3 T. ~/ Q$ R" D8 x% g0 v. U
Address correspondence to: Samar K. Bhowmick, MD, FACE,# ]- w% @9 Q* d0 z! V
Professor of Pediatrics, University of South Alabama, College of& g& Z5 U. R$ o0 q! ?$ T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ |/ [& {, q+ G  Pe-mail: [email protected].
; M$ G# C) r0 ]" v5 babout 6 to 7 months old, which progressively became
1 R# P/ o" W  i$ Z! L, N9 Z; r1 P2 Tdarker. She was also concerned about the enlarge-
1 Z3 e- F( X: _* s- gment of his penis and frequent erections. The child
+ q7 y5 O4 K+ I' kwas the product of a full-term normal delivery, with' z4 a9 F4 N! V3 x  U
a birth weight of 7 lb 14 oz, and birth length of- D; c. y$ s. z
20 inches. He was breast-fed throughout the first year  }! Z5 ~8 L, \9 g$ g/ ~
of life and was still receiving breast milk along with
! a& W" X! U+ J+ z; Gsolid food. He had no hospitalizations or surgery,2 B+ Q- b2 R8 W2 W2 C) a$ C, a
and his psychosocial and psychomotor development! f6 ?0 F1 Y! l& z+ E4 c: f
was age appropriate.' Z  P3 @) A: C' T/ S4 E
The family history was remarkable for the father,
4 R7 u4 S- N" L  o0 k4 Cwho was diagnosed with hypothyroidism at age 16,! I% x3 H9 Z0 G: D
which was treated with thyroxine. The father’s
" ?" J9 g6 Z# M& K5 e, ?. hheight was 6 feet, and he went through a somewhat! ]9 v; n: ^  Z# a- x$ O, O$ F  `; Z5 @  X
early puberty and had stopped growing by age 14." y! R4 R( W6 [  W3 {, ?; H
The father denied taking any other medication. The  G4 @0 ]8 h7 J& U
child’s mother was in good health. Her menarche: z# B2 x3 e* q& p
was at 11 years of age, and her height was at 5 feet% W% X) L' z8 Z6 z4 L
5 inches. There was no other family history of pre-
. R6 f$ U  }, @2 }cocious sexual development in the first-degree rela-
0 t  [3 ]( D0 f/ O, }8 utives. There were no siblings.. R0 ?- s% |$ o9 w7 U4 o" @, N7 r
Physical Examination& V3 j! f$ N3 W" w
The physical examination revealed a very active,
% I) [- }/ }9 K0 U4 P8 eplayful, and healthy boy. The vital signs documented
. O& ~% ^; e8 G4 Z* ]7 J  F( A9 }a blood pressure of 85/50 mm Hg, his length was
8 U% T$ i# `! ~3 ^' h$ |9 S% S- `: Z1 Q90 cm (>97th percentile), and his weight was 14.4 kg
( g2 l6 Z* u6 X6 k$ b3 l(also >97th percentile). The observed yearly growth- ]+ T# u& G, p- I# x3 M
velocity was 30 cm (12 inches). The examination of
6 ^7 S0 ]8 n; b  J# ?# r+ o: \the neck revealed no thyroid enlargement.0 i8 P! ^' F$ q, s: W
The genitourinary examination was remarkable for1 Q& h% P0 |! Q/ A; t4 O3 ^: r
enlargement of the penis, with a stretched length of1 s+ ~1 M5 y; \4 Z; G- j9 K
8 cm and a width of 2 cm. The glans penis was very well. f6 E& I. j% i. o
developed. The pubic hair was Tanner II, mostly around
, j4 f0 B0 @$ w  T  A! B540
% K0 e1 b  q2 |+ X( c$ u, G) {! hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 n8 S3 l) o3 L2 L0 Y% M" s
the base of the phallus and was dark and curled. The
+ g4 w7 ~) C3 _# e# v+ htesticular volume was prepubertal at 2 mL each.1 x: {; P6 H9 J( D2 v
The skin was moist and smooth and somewhat
: I8 e% L9 x! w' k2 z0 A4 ooily. No axillary hair was noted. There were no
$ y, N6 n# q% p% _" Fabnormal skin pigmentations or café-au-lait spots.2 R7 p5 N" _' C: T8 N
Neurologic evaluation showed deep tendon reflex 2+
3 L2 x: N8 {0 _bilateral and symmetrical. There was no suggestion
# Y- L% |# [5 t  E7 r: r) o, t8 Gof papilledema.. B$ b1 D& c7 n+ A. M7 B
Laboratory Evaluation- T8 H& l% B- y4 s. s- \- v
The bone age was consistent with 28 months by
  n7 @4 {: M4 ^: B. zusing the standard of Greulich and Pyle at a chrono-+ W1 z0 l; S4 E
logic age of 16 months (advanced).5 Chromosomal
3 b4 n& U; Y" zkaryotype was 46XY. The thyroid function test9 N3 F3 o8 s5 ?8 ^" |, {6 c) ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) p- R* M. D( w" w  |lating hormone level was 1.3 µIU/mL (both normal)., s: W/ O3 {$ W* w
The concentrations of serum electrolytes, blood
6 I: F4 T: V% w8 H; Surea nitrogen, creatinine, and calcium all were
. s) Y# w2 l# n8 Q1 _& Q9 ?within normal range for his age. The concentration, _7 K) k$ t( [: G
of serum 17-hydroxyprogesterone was 16 ng/dL# T; N8 W- D" q" u/ u
(normal, 3 to 90 ng/dL), androstenedione was 206 O0 O/ k6 t+ i1 v8 f5 o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& t2 O" @( Y' @0 X9 Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),2 D: a6 p+ C0 |! ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* {3 g) Q  E, I! Z$ g) N7 S' R0 h
49ng/dL), 11-desoxycortisol (specific compound S)2 u4 I  b3 M- s" H1 v1 Z* `* }5 D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# R/ O- ?7 B4 P. _- }tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 g* {4 ?$ h4 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),' F/ `) I+ _( Q9 W7 J* ?3 ?
and β-human chorionic gonadotropin was less than
0 ?, y" Z4 V1 ?5 mIU/mL (normal <5 mIU/mL). Serum follicular3 h; m; E  ~4 D
stimulating hormone and leuteinizing hormone
5 h7 N$ B$ g6 u6 ]. uconcentrations were less than 0.05 mIU/mL) c3 M8 y! O: v) z; I% y6 z7 Z
(prepubertal).
9 U3 g' v# Z$ Z  pThe parents were notified about the laboratory5 d( m# @" [. v$ T  c1 H! ~
results and were informed that all of the tests were$ E# S2 \5 K) `9 Q( [; M
normal except the testosterone level was high. The
! ]* m1 O/ a, A( pfollow-up visit was arranged within a few weeks to
0 E+ S- V8 ?2 _  I2 q8 Pobtain testicular and abdominal sonograms; how-
  Q/ i' b4 K% o  ?& R; y7 T4 Wever, the family did not return for 4 months.9 [, I7 h2 I2 p3 t& m$ D; a
Physical examination at this time revealed that the
! ]# q3 Y) W6 I* C- Vchild had grown 2.5 cm in 4 months and had gained
+ a- I" {6 J/ F* o  K2 kg of weight. Physical examination remained
& m: b4 \9 u# n/ b0 r0 Ounchanged. Surprisingly, the pubic hair almost com-
- L5 @. P2 Z+ S1 s, E& fpletely disappeared except for a few vellous hairs at
5 @. [% J* I- Y3 }% d7 Uthe base of the phallus. Testicular volume was still 2) t: e, g! s# e/ m5 a5 a5 A% ?
mL, and the size of the penis remained unchanged.4 o- h1 C  w1 q$ z' {: j# c- u
The mother also said that the boy was no longer hav-3 h1 i9 x' _4 z! }0 E# Q
ing frequent erections.* x* N# r; L2 ^' ]; z
Both parents were again questioned about use of
# Z" _# U5 A3 ^9 j, n( l0 @any ointment/creams that they may have applied to, D7 G) t# j5 Q2 L, s
the child’s skin. This time the father admitted the
* O$ W. {. Z( ?8 J: y7 M$ g2 X# a: W; ~Topical Testosterone Exposure / Bhowmick et al 541
% e8 P- w5 X' r7 W* p( b; E9 u, ~use of testosterone gel twice daily that he was apply-) t; p2 |: ~: L5 F2 o1 C
ing over his own shoulders, chest, and back area for4 F# O4 {' z+ \- @
a year. The father also revealed he was embarrassed2 U8 M6 N( p5 C" p7 N6 K
to disclose that he was using a testosterone gel pre-
$ ], r& x* a' @7 Y4 M8 xscribed by his family physician for decreased libido
$ H+ X5 o& h/ O% p( S! l! Isecondary to depression.
% N& z+ I& U7 V3 RThe child slept in the same bed with parents.
# }  H/ }" O& g% N' d9 PThe father would hug the baby and hold him on his
' W( J* h7 z  ~3 Kchest for a considerable period of time, causing sig-8 U* K5 d% y. y1 O
nificant bare skin contact between baby and father.
6 @. w. ~. V+ \4 @4 r( i" y- SThe father also admitted that after the phone call,/ }0 k' F6 [$ _" |1 d
when he learned the testosterone level in the baby
& P# k/ z( G. Jwas high, he then read the product information
" {+ W! Z7 N$ w0 G5 W& O( ?packet and concluded that it was most likely the rea-. o) ^5 Y; @/ a7 q. T. K
son for the child’s virilization. At that time, they5 B& I% T* ?- N2 G
decided to put the baby in a separate bed, and the2 @+ o/ c8 `2 p" Q  Z/ a8 O
father was not hugging him with bare skin and had
; t8 \7 h0 a$ c) g- r6 Xbeen using protective clothing. A repeat testosterone
! B& ~% ]# l& A  D9 D/ D/ y0 Htest was ordered, but the family did not go to the
" i- Y& Y8 {( v& y) e( a4 ylaboratory to obtain the test.
3 s$ q' Y" l; D4 v+ n( IDiscussion3 t, ^2 _0 |, I" v) I. ?
Precocious puberty in boys is defined as secondary& O; ^/ ?& T" @
sexual development before 9 years of age.1,4
- [$ p' G7 o$ S/ T. `; SPrecocious puberty is termed as central (true) when
. H; J. j9 i; q6 W9 b3 q+ N0 p" e( oit is caused by the premature activation of hypo-
; k! A/ `8 t4 ^! F" }thalamic pituitary gonadal axis. CPP is more com-
4 {- k& F7 E8 nmon in girls than in boys.1,3 Most boys with CPP
! d2 G3 Y6 r1 \: p$ |. n0 {may have a central nervous system lesion that is- }8 e, X) i7 ^, ]" u
responsible for the early activation of the hypothal-
2 h7 N9 P5 ^" K& R+ v. }( Gamic pituitary gonadal axis.1-3 Thus, greater empha-
9 Q4 i, Z' O$ r, c: L; gsis has been given to neuroradiologic imaging in! Q& ]& o$ H& T+ U4 T8 j8 H
boys with precocious puberty. In addition to viril-' f6 b0 P8 l8 K4 @7 f& S
ization, the clinical hallmark of CPP is the symmet-
1 F7 ]; z) W, ^) vrical testicular growth secondary to stimulation by7 l- N6 D3 j9 z/ f! u1 s
gonadotropins.1,3
3 t& y2 B- E8 \" w6 f7 |! l% A' W8 {Gonadotropin-independent peripheral preco-/ h6 z* Z: q4 F8 V9 ^7 E1 ^  f
cious puberty in boys also results from inappropriate
% q  t- Y% {$ Y8 ^) G5 H. A8 candrogenic stimulation from either endogenous or3 |3 k! R, d8 g2 Q. R
exogenous sources, nonpituitary gonadotropin stim-
, U# {0 t5 h8 {& u* K; v: j$ b2 Mulation, and rare activating mutations.3 Virilizing
$ O8 _5 J3 g! Y1 @+ ~, G/ C: Dcongenital adrenal hyperplasia producing excessive
0 n& R! u/ n7 i; yadrenal androgens is a common cause of precocious
2 S2 \3 d( Z& Y0 m" Xpuberty in boys.3,4% X7 X9 E' n) y$ h; z* V
The most common form of congenital adrenal
7 B1 _# k  ?9 A, e  O5 {hyperplasia is the 21-hydroxylase enzyme deficiency.
5 K" Z; V( E3 h) z/ f# oThe 11-β hydroxylase deficiency may also result in
" U  d/ t- v7 r5 uexcessive adrenal androgen production, and rarely,2 i& P% m) z8 V+ j
an adrenal tumor may also cause adrenal androgen2 h  Z2 w1 J5 H' g
excess.1,3
! O& P+ B" c& ]- F' u+ U9 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 n0 p& I& Z; C6 |
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ Q5 G3 \  M# [* ?A unique entity of male-limited gonadotropin-
+ |/ K  [/ [* ~4 T6 ~. n' Nindependent precocious puberty, which is also known
$ \4 d3 G9 T: Z8 ]9 fas testotoxicosis, may cause precocious puberty at a
- w* a* \  ], q0 K( R6 g7 jvery young age. The physical findings in these boys- b8 ~4 X7 b6 S( a
with this disorder are full pubertal development,/ N8 Z# I! J' O% G& K1 o' G
including bilateral testicular growth, similar to boys3 {! w  s. D: B; J. p& ]" A5 U8 v% @
with CPP. The gonadotropin levels in this disorder
$ \9 [2 e: W/ a! P# l! Hare suppressed to prepubertal levels and do not show
4 l8 t1 p6 @9 O$ ]pubertal response of gonadotropin after gonadotropin-
' j1 E+ r  a% _/ u* j" b& Greleasing hormone stimulation. This is a sex-linked( |: I" o: C7 ?7 I
autosomal dominant disorder that affects only
. L4 J% V3 W/ ~) n& H4 H. smales; therefore, other male members of the family  E9 ?9 n% r/ |
may have similar precocious puberty.3# k6 g7 t4 L% v
In our patient, physical examination was incon-# H% G- ^% N3 }( `5 V5 R4 N' B
sistent with true precocious puberty since his testi-. y7 r  L- p8 u9 S
cles were prepubertal in size. However, testotoxicosis0 X8 ~1 i4 t6 j2 T& s5 p
was in the differential diagnosis because his father$ G$ f+ i" H. K1 r; W. E
started puberty somewhat early, and occasionally,9 l$ `# C. Y% d& {
testicular enlargement is not that evident in the
, P) W! u9 f0 t2 nbeginning of this process.1 In the absence of a neg-
9 Q4 Q! o  ^- F' K, J, `+ F! zative initial history of androgen exposure, our" f3 a  T9 K* b; w9 W  y6 G
biggest concern was virilizing adrenal hyperplasia,
, E9 Q5 k; Y6 h3 T( Seither 21-hydroxylase deficiency or 11-β hydroxylase$ e+ s% Q6 V2 z3 X0 }% h
deficiency. Those diagnoses were excluded by find-
% ^3 p1 {: U/ J! b/ Aing the normal level of adrenal steroids.. l' K5 O" u- v& F+ n* B- M( O
The diagnosis of exogenous androgens was strongly( F: a4 C/ p8 f5 \- z1 n; h5 K
suspected in a follow-up visit after 4 months because. P% j+ Y" C! A: Y2 i
the physical examination revealed the complete disap-+ u  f! E+ z4 N; h: j/ H2 {9 J
pearance of pubic hair, normal growth velocity, and
) s0 B+ ~% ^, zdecreased erections. The father admitted using a testos-4 e  O$ _0 P# y0 c5 M
terone gel, which he concealed at first visit. He was
7 g' j( `# {7 @  \7 b4 Kusing it rather frequently, twice a day. The Physicians’
( }4 s2 t: B( r/ iDesk Reference, or package insert of this product, gel or
7 t$ b  s  A5 Y+ M4 y8 L! Ocream, cautions about dermal testosterone transfer to: T5 W( _" O+ n; c: _5 P
unprotected females through direct skin exposure.- S* v' J! y. x( v3 F' x
Serum testosterone level was found to be 2 times the
9 M% T2 f# V+ H& ^baseline value in those females who were exposed to
. |7 @; l& o' K1 q% \even 15 minutes of direct skin contact with their male
) A) r' x* w/ [8 a: npartners.6 However, when a shirt covered the applica-
! D  {5 f" R# @7 ^  otion site, this testosterone transfer was prevented.! [, C" K" F$ `% E( _
Our patient’s testosterone level was 60 ng/mL,/ G2 Z8 U( z. ~" J# U2 b3 c) c
which was clearly high. Some studies suggest that' W4 O6 K- {! W4 r( L" H
dermal conversion of testosterone to dihydrotestos-  e& {3 j8 |+ T& y4 e  B$ D
terone, which is a more potent metabolite, is more
  m( O0 m) ^" `active in young children exposed to testosterone
5 i, u5 l+ ?) _( \3 Lexogenously7; however, we did not measure a dihy-+ L! O6 z2 c1 z8 d# Y! a, w
drotestosterone level in our patient. In addition to
/ Z: N, K" }* V: r( Uvirilization, exposure to exogenous testosterone in
& _( [7 L- r+ @7 @. I  G+ Z  P8 r) P4 tchildren results in an increase in growth velocity and
9 O/ q- {4 n" Hadvanced bone age, as seen in our patient.
5 T7 d8 b. J2 D: a: L! r* FThe long-term effect of androgen exposure during- d% @! q. ]8 S! L3 e" s
early childhood on pubertal development and final
% }4 Z2 v& F; J; @adult height are not fully known and always remain
+ Q: r% M7 F! s# ea concern. Children treated with short-term testos-: O' {- b1 t! n6 T( K# D/ `  O
terone injection or topical androgen may exhibit some
6 i+ D7 Q7 {$ w4 E! Bacceleration of the skeletal maturation; however, after5 o+ ~5 b6 Y- I* `
cessation of treatment, the rate of bone maturation
0 x0 }& M" a% v+ u* Q6 vdecelerates and gradually returns to normal.8,9, ]# \. \0 {  N9 Y
There are conflicting reports and controversy
3 r# \" K- C0 |' h. W7 pover the effect of early androgen exposure on adult9 W) ]6 q2 q. k+ K& @+ a
penile length.10,11 Some reports suggest subnormal. X# T0 a5 S3 ~! D% D: u
adult penile length, apparently because of downreg-
& r* s  p$ Z+ ]- Nulation of androgen receptor number.10,12 However,
% Z* c) G9 b3 f+ G- eSutherland et al13 did not find a correlation between( W8 t. J9 Q. p
childhood testosterone exposure and reduced adult8 x6 ?( Z. D7 h1 x! U0 Y% N
penile length in clinical studies.) a  z- a) L; f+ x; V: o- j
Nonetheless, we do not believe our patient is
( m) s/ |" c: E; ]8 G9 Q- C; qgoing to experience any of the untoward effects from% ^. w6 m9 H& X! o$ P5 B' J" ]; q
testosterone exposure as mentioned earlier because
# z& A3 ]3 ?; ]. |2 {the exposure was not for a prolonged period of time.5 b+ R* z, }2 d. `
Although the bone age was advanced at the time of
' [/ h  U* ], w: T/ J. K$ U. }diagnosis, the child had a normal growth velocity at) E- Q/ y' Q+ i# \
the follow-up visit. It is hoped that his final adult
7 M( s! |; v0 S& ?" \$ {! b# vheight will not be affected.) y1 J2 x, a, M  @4 ]4 M
Although rarely reported, the widespread avail-
5 s% ~4 [; P* q- b- aability of androgen products in our society may
' C. W' _) S5 @4 x2 U9 ^indeed cause more virilization in male or female
/ d( I. x+ a# |' L4 B( }children than one would realize. Exposure to andro-! i9 ^- f7 @6 A& C5 |' [" d1 p! t1 H
gen products must be considered and specific ques-
9 R5 {3 o# u7 Ytioning about the use of a testosterone product or
- M& E1 u- R5 x+ |gel should be asked of the family members during3 U. Y. ~  `9 S7 ?! G& w+ }, b6 Q
the evaluation of any children who present with vir-
' ~& C7 X$ l0 D0 K: U; _& b6 ?ilization or peripheral precocious puberty. The diag-. H) D) G+ s. i% Z, w" O
nosis can be established by just a few tests and by4 c3 a5 I, O& }: D
appropriate history. The inability to obtain such a8 u& F3 H$ m6 u4 A& K/ r* k
history, or failure to ask the specific questions, may" b8 H/ R7 N: b
result in extensive, unnecessary, and expensive1 K) l( _! N: c0 ^. j& ]
investigation. The primary care physician should be% K5 A& |( q! H- k9 a3 U, G; Y/ b
aware of this fact, because most of these children8 O$ H0 I# K5 [# n0 d
may initially present in their practice. The Physicians’! ?! U# v6 e. Y" s* U! A& O
Desk Reference and package insert should also put a
9 Y. m( u% p: g, |1 p/ n* [warning about the virilizing effect on a male or
* M+ e3 y$ e. r; X: O% V+ ]9 rfemale child who might come in contact with some-' y- `! M2 Q4 e' k
one using any of these products.
  N! A1 d- Y; x9 H  L( Y0 H( _References2 ^* D; Z8 F2 C4 `
1. Styne DM. The testes: disorder of sexual differentiation
% z5 F5 c: h+ K% J1 ?: v& S9 Dand puberty in the male. In: Sperling MA, ed. Pediatric- x3 A* g+ q  D  u! ?" W
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ W$ N- f1 z- l: E0 L2002: 565-628.
+ }% J/ V/ f1 f  _* }  I/ s1 z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# \  K7 D6 R/ ?$ b5 o7 ipuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
1 F+ }) \" {5 ^# Z2 T  [! b& _Boy Induced by Indirect Topical
9 ?% t$ h9 Z" Z, j7 cExposure to Testosterone
4 j/ p8 k0 @/ S" E* [3 rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; {) N5 M2 v6 F' n1 K. x3 @and Kenneth R. Rettig, MD1( ?# v$ d' N2 Y# d4 M6 S4 b+ o
Clinical Pediatrics
7 A# e$ |2 X# I+ bVolume 46 Number 62 g8 \: ^& w( o
July 2007 540-543
1 p3 I+ U2 h# V3 n2 f© 2007 Sage Publications
5 w. M1 k3 c" {6 R2 L$ _+ y10.1177/0009922806296651# s& W- B7 _* U. S
http://clp.sagepub.com2 D& p7 U% J+ E6 r2 E
hosted at. _  v+ T% _4 e. l6 _. W! k  @, V
http://online.sagepub.com/ D' F& @/ y5 Z7 J7 |! c7 `+ g6 B
Precocious puberty in boys, central or peripheral,# e) A4 T: R* R+ W* Z/ ^
is a significant concern for physicians. Central
9 }; a# B8 L; i% W# J& t- aprecocious puberty (CPP), which is mediated
# b* ]( N; M% r& ~- Tthrough the hypothalamic pituitary gonadal axis, has
9 E+ V  z: S& pa higher incidence of organic central nervous system
/ B1 F) ]$ S7 j* a  i; xlesions in boys.1,2 Virilization in boys, as manifested
$ v  ]) w0 k( f7 N0 i' ~- [by enlargement of the penis, development of pubic& w9 i3 F- y6 x9 E& b2 ]' p1 i: H
hair, and facial acne without enlargement of testi-
+ a1 y! g1 _5 e0 K6 kcles, suggests peripheral or pseudopuberty.1-3 We
% d2 H! ?5 e# w0 y2 z: ?report a 16-month-old boy who presented with the
, w$ v3 X  Z/ u1 ^; F$ `8 y6 {2 F1 kenlargement of the phallus and pubic hair develop-! J3 }) S0 v/ j( o6 e- z  P
ment without testicular enlargement, which was due' E! n5 ]8 P6 C3 V- u/ k  W
to the unintentional exposure to androgen gel used by
8 U% ]# j: h6 b, a6 N- H8 jthe father. The family initially concealed this infor-% o2 @1 L& b' ~
mation, resulting in an extensive work-up for this$ T# m2 B( E/ z/ A2 ]' V
child. Given the widespread and easy availability of
3 [6 z; _% R# L& o+ Gtestosterone gel and cream, we believe this is proba-# I6 D* Z; H: c9 K/ G6 o
bly more common than the rare case report in the# P0 Q5 E0 U  c
literature.4
; Q, \( ^+ e/ [5 j) `2 F. K7 QPatient Report
3 x4 y& t4 _* G3 G, K( bA 16-month-old white child was referred to the
2 R: l1 T1 N' ]- Mendocrine clinic by his pediatrician with the concern
! _/ _" k% y, hof early sexual development. His mother noticed* E, q1 G7 }5 |  H
light colored pubic hair development when he was% @! s# G9 h6 Y) c
From the 1Division of Pediatric Endocrinology, 2University of8 L( B# Z' W2 q/ K9 M
South Alabama Medical Center, Mobile, Alabama., ?6 }! g& o% L# T
Address correspondence to: Samar K. Bhowmick, MD, FACE,  t0 k; H. ]% i. [! r
Professor of Pediatrics, University of South Alabama, College of  `# Y+ |8 A9 L7 f* l' m( V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  X  Z$ V! V  G: a* z* u/ U. q. \3 V$ e" |e-mail: [email protected].% X: i9 L: q# Q4 {- F
about 6 to 7 months old, which progressively became
! s+ }/ A# Z9 _! ^( ldarker. She was also concerned about the enlarge-
  u0 [1 N  T5 ~5 w* f( u6 [+ Mment of his penis and frequent erections. The child: F) e  \: O8 c) }
was the product of a full-term normal delivery, with1 N7 u; Z, ~6 L9 \
a birth weight of 7 lb 14 oz, and birth length of
5 \% z" f' T3 y4 e20 inches. He was breast-fed throughout the first year
9 ~" x) T1 z5 f( J. `7 @: U, K5 _of life and was still receiving breast milk along with7 G( B/ v0 ~  T
solid food. He had no hospitalizations or surgery,
) ?0 z: |% k+ @2 H1 \- u, K7 {and his psychosocial and psychomotor development) F) Q$ Q( l7 z
was age appropriate.
! B; }3 ~1 V. Q' f: X" \The family history was remarkable for the father,- [2 c; n- i9 e  q% {
who was diagnosed with hypothyroidism at age 16,
* H' [+ w% Z/ `) G" S6 L3 N) X4 ^  ewhich was treated with thyroxine. The father’s( c3 R- h9 J7 `0 E( \
height was 6 feet, and he went through a somewhat9 H4 N/ J- ?% c. Z6 N/ J
early puberty and had stopped growing by age 14.6 r6 X! I/ x- v: r3 s& g7 T
The father denied taking any other medication. The6 R/ l+ F. t) z/ N; f$ H
child’s mother was in good health. Her menarche8 [! m, u' ]* o4 d' Z( \( F
was at 11 years of age, and her height was at 5 feet, c. F* V# |) J1 `4 x/ F# P
5 inches. There was no other family history of pre-7 k: }( j0 N6 K
cocious sexual development in the first-degree rela-
6 n4 f7 K8 f- e% R6 a5 ztives. There were no siblings.
  U4 x8 J4 H# }) k# [+ l' dPhysical Examination1 J  b# n- O& I2 d
The physical examination revealed a very active,
2 o* W" S) v- v; j+ I6 q& m  gplayful, and healthy boy. The vital signs documented* l) x6 V; w! M
a blood pressure of 85/50 mm Hg, his length was
3 D0 e; ?( q7 e) x90 cm (>97th percentile), and his weight was 14.4 kg
% f! \# l4 z% t8 K7 |(also >97th percentile). The observed yearly growth# r: J' S9 B. ?4 N
velocity was 30 cm (12 inches). The examination of
+ x+ E! l# K7 [9 s3 K( B  Ithe neck revealed no thyroid enlargement., }& }7 R* p; M3 F- s- e
The genitourinary examination was remarkable for
% E( ?/ s) M& m$ J, ~+ p: Oenlargement of the penis, with a stretched length of+ V! O+ g- r# u9 L1 C
8 cm and a width of 2 cm. The glans penis was very well; E2 G5 X* \2 y  I
developed. The pubic hair was Tanner II, mostly around
" T" ?, p" C/ h( ?. k9 t/ R540
* g0 B* o1 x# d$ v6 h8 w/ \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# E' ~  t+ \$ |. M6 k$ vthe base of the phallus and was dark and curled. The
! f/ Q. O. V+ Y. f9 c/ vtesticular volume was prepubertal at 2 mL each.' |0 R6 Q" y9 {& B+ }5 C! n, s
The skin was moist and smooth and somewhat
6 i7 ^; C( G3 H6 |2 E8 X2 u. yoily. No axillary hair was noted. There were no9 W# i( o! j3 G% e
abnormal skin pigmentations or café-au-lait spots.
! f% S, v# u6 o5 q& h$ t. B" jNeurologic evaluation showed deep tendon reflex 2+
. R* |9 W, D) [" @bilateral and symmetrical. There was no suggestion5 _" Z- X& S8 d8 K" j. N; |
of papilledema.1 Y' s6 O7 _- ~
Laboratory Evaluation
0 q! g0 L% o1 U% M7 I; {$ m: l! fThe bone age was consistent with 28 months by5 B2 ?! R. C) q
using the standard of Greulich and Pyle at a chrono-: o. s& L  P  G. ?) u  D' v
logic age of 16 months (advanced).5 Chromosomal; j# E5 j' o& ~8 ~& |: o$ K
karyotype was 46XY. The thyroid function test
& M: V- z: P; l& b$ \showed a free T4 of 1.69 ng/dL, and thyroid stimu-- `/ X+ [5 V! w3 U! c9 a0 s5 V: k
lating hormone level was 1.3 µIU/mL (both normal).
/ G  r2 P- T5 ?! a4 gThe concentrations of serum electrolytes, blood8 b; t% G) b5 N6 D- |
urea nitrogen, creatinine, and calcium all were) P! M* h; ^% p/ m/ n% V: X9 j
within normal range for his age. The concentration
% d7 d- c- d+ J) xof serum 17-hydroxyprogesterone was 16 ng/dL- [0 w$ q  Y8 @( ^, P
(normal, 3 to 90 ng/dL), androstenedione was 20& z6 M  ?, W( K
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 t5 B- h/ J; n( i
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 D5 ^$ s. x# Y5 ?/ Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
) m9 ]% g4 [+ \: p1 G49ng/dL), 11-desoxycortisol (specific compound S)
6 g% U* U$ E* m5 a3 n! u5 s8 Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. Q8 E2 s6 G- f5 }. Btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 c! n- Z7 B2 c3 u) G' o+ {$ L) u) z
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( H, ]' ]+ y0 B; y# U" N" D1 ]$ Yand β-human chorionic gonadotropin was less than
2 V1 `* a! ~# d0 T: ]9 K' f3 x5 mIU/mL (normal <5 mIU/mL). Serum follicular% Y4 T; T6 ], H* r( n
stimulating hormone and leuteinizing hormone
- k& A4 s- S' D" j( A' @$ ?( Lconcentrations were less than 0.05 mIU/mL
. |# `: V$ \: U  B6 f$ V9 e: h(prepubertal).1 q1 f6 D; W' k! F
The parents were notified about the laboratory) \: X) m, `* u$ P% o5 ~& M5 d
results and were informed that all of the tests were1 S1 b; W4 U; X1 A0 a, I
normal except the testosterone level was high. The* V* S  v/ x+ a! O% V
follow-up visit was arranged within a few weeks to
" i2 l) A; A6 V, f/ |+ @obtain testicular and abdominal sonograms; how-
# T6 K/ L; b% Qever, the family did not return for 4 months.
; T! ~0 G' [) JPhysical examination at this time revealed that the& a, B' o% i4 ~: q* i1 j
child had grown 2.5 cm in 4 months and had gained0 E/ k5 l2 A& S+ L, e8 h# T
2 kg of weight. Physical examination remained
% C' O/ a" j! D! P* U) \: `$ f% sunchanged. Surprisingly, the pubic hair almost com-3 @* B2 a( {) F- @
pletely disappeared except for a few vellous hairs at3 q2 O# Y( `' \7 Z
the base of the phallus. Testicular volume was still 2) g- \2 Y% [4 ?
mL, and the size of the penis remained unchanged.& ?& r: S$ g7 \+ q- O0 Q/ B. K8 E
The mother also said that the boy was no longer hav-$ b7 W! h& w: {* H4 N- k' V
ing frequent erections.
' j( A7 k/ C4 u0 E% U  M! `Both parents were again questioned about use of5 n- A7 a8 u6 @1 [
any ointment/creams that they may have applied to, E( _8 v* k- D4 \& ^+ `/ ?0 m6 M
the child’s skin. This time the father admitted the8 S7 B9 N. O7 x
Topical Testosterone Exposure / Bhowmick et al 541
) p3 m& V: C8 ause of testosterone gel twice daily that he was apply-
9 z9 M/ l6 p% ^/ e7 Oing over his own shoulders, chest, and back area for% ~# E* U. B- _7 J, M% Q1 o
a year. The father also revealed he was embarrassed
; v$ Q* L1 b. A( |to disclose that he was using a testosterone gel pre-
7 n& A# A6 |( sscribed by his family physician for decreased libido
0 d% @0 {# a; a# H% Asecondary to depression.  n: X' ]* f* B% E; w) m
The child slept in the same bed with parents.
  I& k% u" l$ c9 r. b6 gThe father would hug the baby and hold him on his8 ]! z5 ?& [: m9 D
chest for a considerable period of time, causing sig-
( C. G. q! c; [) tnificant bare skin contact between baby and father.
* n% U; j! A/ W  }( [The father also admitted that after the phone call,- v. R/ u8 O' z+ {0 N" n
when he learned the testosterone level in the baby9 z3 ]; {# l# a( R/ I
was high, he then read the product information" h( g9 D- B5 ^& o- y7 w5 P6 B
packet and concluded that it was most likely the rea-
' a8 K0 h0 A+ h1 \4 _- T0 ]# Rson for the child’s virilization. At that time, they
/ z) L' N8 G: n% Q' ddecided to put the baby in a separate bed, and the5 B5 q) T7 L7 H. F4 s( C; J
father was not hugging him with bare skin and had
( ]" T. g; J( U( z7 H# ~been using protective clothing. A repeat testosterone! M4 `* @6 v% D$ W/ j# K
test was ordered, but the family did not go to the
0 K1 D8 s* Z4 ]' {" |- }% R6 N5 v2 elaboratory to obtain the test.! h! e- o, D5 E% q0 a7 l! T# I
Discussion3 b2 a. \6 w4 K% W' t1 {
Precocious puberty in boys is defined as secondary
/ r1 l& u5 o9 B/ j( ^$ Ssexual development before 9 years of age.1,4
5 D! A2 j+ o+ ]: b  n4 kPrecocious puberty is termed as central (true) when4 i0 ~( h* \7 ^2 h
it is caused by the premature activation of hypo-: ], K% p- u% b4 e/ k
thalamic pituitary gonadal axis. CPP is more com-! c& g9 R8 s" \9 F8 O! |4 \0 y
mon in girls than in boys.1,3 Most boys with CPP+ d7 @) s2 F4 B8 h" h, d$ l
may have a central nervous system lesion that is
$ N9 B) m+ X0 v2 B* U* G+ Dresponsible for the early activation of the hypothal-
$ q* Y2 P* O9 x5 f. L) vamic pituitary gonadal axis.1-3 Thus, greater empha-
( Q6 c% \: x$ I2 vsis has been given to neuroradiologic imaging in( T' K9 o9 t# z6 s( H6 t
boys with precocious puberty. In addition to viril-% t" j, B/ B& s0 ^. O/ ?" X, E
ization, the clinical hallmark of CPP is the symmet-
# b: H2 a; P" @2 N: Hrical testicular growth secondary to stimulation by! u8 _  q; Z- Z5 e$ _  w% ~0 V- {; T
gonadotropins.1,3/ O+ e/ y/ b+ u" g
Gonadotropin-independent peripheral preco-1 f* w* j- U6 R$ h
cious puberty in boys also results from inappropriate
8 g$ {3 E) g& y" R1 H- d( \! v: A. Wandrogenic stimulation from either endogenous or
. _" z6 W& W. E& y) h. ~& iexogenous sources, nonpituitary gonadotropin stim-7 G! ~9 a1 t- ~' o* m6 Z8 Q9 W
ulation, and rare activating mutations.3 Virilizing
( e3 _6 o; ?# v4 N7 j* c. P  bcongenital adrenal hyperplasia producing excessive
+ t( ~: ~; T0 P' f$ A) qadrenal androgens is a common cause of precocious
! ]# i8 A, P, ppuberty in boys.3,4
4 J) u/ E" H4 N$ {- m& sThe most common form of congenital adrenal
/ S# U& a/ E* K: Fhyperplasia is the 21-hydroxylase enzyme deficiency.
0 D1 i8 P3 G+ n. `The 11-β hydroxylase deficiency may also result in" t4 Y# z; c2 J5 E: g% n$ e" I
excessive adrenal androgen production, and rarely,
! u2 S9 [% d( p0 s5 |an adrenal tumor may also cause adrenal androgen. B1 `  W. }, ]9 t
excess.1,3
2 K; u% y& g, k+ N3 Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% h5 k% L: ]1 H( O, c; P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 K, g" y: U2 h% E" m! t! n# IA unique entity of male-limited gonadotropin-
! g9 D; x: j7 T- O+ q; r! Qindependent precocious puberty, which is also known
" V4 p1 F9 x- N5 {as testotoxicosis, may cause precocious puberty at a
3 ]6 G7 }; j  ]: G3 k1 Gvery young age. The physical findings in these boys; k( A" r! c1 Z# X7 n
with this disorder are full pubertal development,5 B0 P# l2 c$ a$ `9 i
including bilateral testicular growth, similar to boys; W0 [9 l* u- X& W* A' d
with CPP. The gonadotropin levels in this disorder$ ]) L7 y; W8 u; a/ O
are suppressed to prepubertal levels and do not show1 N! m* K( @: H, j2 ^
pubertal response of gonadotropin after gonadotropin-
: R' {8 D9 Z; B$ W# E) a: O2 ^6 dreleasing hormone stimulation. This is a sex-linked
: P' b4 u) N! N0 O$ ]  lautosomal dominant disorder that affects only- D: y' ~  W0 V
males; therefore, other male members of the family& L  z7 K" o3 r6 Y; G9 |$ e8 A
may have similar precocious puberty.3
% V- Q. N. ~- g7 E: z: wIn our patient, physical examination was incon-
* c9 e! |4 }6 X( a1 k% g- J4 Gsistent with true precocious puberty since his testi-
9 i+ X: c4 V" d! X2 lcles were prepubertal in size. However, testotoxicosis
1 _$ Y) N9 v- |" |was in the differential diagnosis because his father+ M( g& _# x5 x4 x
started puberty somewhat early, and occasionally,
1 q5 a1 ]( T9 htesticular enlargement is not that evident in the
/ m, S7 V: p& a5 [beginning of this process.1 In the absence of a neg-" t& J/ G& I* n- x
ative initial history of androgen exposure, our
3 K4 x3 g, o) J6 T0 T4 f, w) G) cbiggest concern was virilizing adrenal hyperplasia,+ B2 g: X- q# V" ^
either 21-hydroxylase deficiency or 11-β hydroxylase) R) N% v; P; F) c/ U
deficiency. Those diagnoses were excluded by find-
# h6 V* P( D$ [: g" M, o2 {, qing the normal level of adrenal steroids.. R7 Y- {6 o1 ^
The diagnosis of exogenous androgens was strongly
5 m2 `4 ^/ q3 z( csuspected in a follow-up visit after 4 months because
2 Z: ~7 X/ `( t2 O% |4 ?7 `& m7 Ithe physical examination revealed the complete disap-6 P6 U0 n, r0 N7 C# f6 ~) F% q
pearance of pubic hair, normal growth velocity, and/ R% G! c  n# z" E- b; Z, W
decreased erections. The father admitted using a testos-8 r2 ~4 A9 S' y" s
terone gel, which he concealed at first visit. He was
3 ?4 n: S% S8 S3 `2 i$ Jusing it rather frequently, twice a day. The Physicians’
5 u8 d. c6 f9 S! p- gDesk Reference, or package insert of this product, gel or. u; O, j4 ]2 P8 c' e' h5 \- y
cream, cautions about dermal testosterone transfer to/ B; g( \6 Z+ @
unprotected females through direct skin exposure.9 t* ^1 v9 z9 w9 P3 Z: f  X
Serum testosterone level was found to be 2 times the8 O3 @5 m. X& g: [5 L
baseline value in those females who were exposed to
8 i* z0 f; V8 Deven 15 minutes of direct skin contact with their male
0 K4 j  v: t5 W6 P& J  Opartners.6 However, when a shirt covered the applica-
8 X+ B2 H  B! d. f$ Z9 o* Etion site, this testosterone transfer was prevented.
! o! _1 ^  E- t# vOur patient’s testosterone level was 60 ng/mL," n3 D2 R% O0 z+ Z( n- u$ N
which was clearly high. Some studies suggest that4 |& x7 D- v! M
dermal conversion of testosterone to dihydrotestos-+ e; f, H0 v  |
terone, which is a more potent metabolite, is more
8 B0 G: Q; g+ a6 j( k8 [- Xactive in young children exposed to testosterone& y4 f, ~; f, F$ R8 D9 \2 m
exogenously7; however, we did not measure a dihy-5 y# O' \2 t6 u
drotestosterone level in our patient. In addition to* p* x# l) {' z) J! U+ \4 o5 r$ G
virilization, exposure to exogenous testosterone in5 w$ M" B7 _1 ]) |
children results in an increase in growth velocity and
9 g( S8 Q' j# xadvanced bone age, as seen in our patient.
& \3 m2 ~# c: GThe long-term effect of androgen exposure during
+ W2 k) _- a: Dearly childhood on pubertal development and final
$ W0 v2 c2 v8 x1 zadult height are not fully known and always remain
% [! B+ b$ F8 @0 P! r3 ^; o& Ka concern. Children treated with short-term testos-; |3 S( Y5 Q- ?
terone injection or topical androgen may exhibit some
' U( D( J) g- sacceleration of the skeletal maturation; however, after! X$ ?7 @. `) }$ i2 r2 i9 @
cessation of treatment, the rate of bone maturation! E$ b# J' |  D# g
decelerates and gradually returns to normal.8,9
- ]! e/ K5 k) C& @  vThere are conflicting reports and controversy- L+ V8 n9 o+ z3 V. v
over the effect of early androgen exposure on adult
+ z& Y' W4 U( C* P& J, upenile length.10,11 Some reports suggest subnormal
6 F  o2 C. v6 }$ c+ B( @/ j1 _- x6 Qadult penile length, apparently because of downreg-. s- l& C$ T' @1 O. e1 |
ulation of androgen receptor number.10,12 However,$ a1 C# o( v. D! u, A6 o
Sutherland et al13 did not find a correlation between
* t9 F2 u( l& b; u: r9 ?; U/ Lchildhood testosterone exposure and reduced adult
! b, T) M0 e: r2 X- |- X4 V& epenile length in clinical studies.! T) r% v8 W: I; {8 A5 ^
Nonetheless, we do not believe our patient is, g- u4 Z% K# u1 r0 D
going to experience any of the untoward effects from/ F/ d$ X$ l) n. H5 m  Q5 M$ m% l
testosterone exposure as mentioned earlier because
) P5 i' Y. v; M, p% _3 ^# Q& Othe exposure was not for a prolonged period of time.. N* T4 f9 n6 Z* ~; @& j
Although the bone age was advanced at the time of
) R  z* W$ E; m0 C; _4 O/ e, Vdiagnosis, the child had a normal growth velocity at+ w- C' P- l9 j/ ~) Q
the follow-up visit. It is hoped that his final adult
: B: U; H$ t' r* C$ v5 ]height will not be affected.
8 D, ^- [1 k, H. k8 j% WAlthough rarely reported, the widespread avail-
+ K0 b/ l4 q, Z; W: s4 I; p9 u! v. kability of androgen products in our society may
3 p0 X% U% d- ~* _/ Kindeed cause more virilization in male or female* [  X" j. I+ k1 A
children than one would realize. Exposure to andro-0 k6 l" h) }* }5 l8 j% C
gen products must be considered and specific ques-
0 {% n1 n& |# D9 S! E' E  ationing about the use of a testosterone product or8 N; H  ?8 }: K! }  w/ y
gel should be asked of the family members during
/ u9 E0 Y" A# v. Mthe evaluation of any children who present with vir-
* h7 l4 p: F0 P8 O+ Yilization or peripheral precocious puberty. The diag-
' m. s, D" L5 B/ {" fnosis can be established by just a few tests and by! X' ~% w6 ]: d7 l+ z+ }
appropriate history. The inability to obtain such a9 b5 c9 M( k. X8 y
history, or failure to ask the specific questions, may* H  f, ~5 s+ W) n% C, F) \5 s
result in extensive, unnecessary, and expensive
# D- w3 H( T/ W6 T2 f- [investigation. The primary care physician should be
- q+ r3 |# [3 C) F5 j; Daware of this fact, because most of these children! a# I. y) Z* m
may initially present in their practice. The Physicians’: d/ T& r) Y' ]3 o" ?0 @1 s) L
Desk Reference and package insert should also put a
& ~4 j  f6 p; P' cwarning about the virilizing effect on a male or
' l7 Z& B* t' d( x$ \) x% m* hfemale child who might come in contact with some-5 E( P7 g% d$ i5 c+ \" B
one using any of these products.
7 w# w) @- O) \9 CReferences. t) Z; O! B9 o# @
1. Styne DM. The testes: disorder of sexual differentiation; m- f# h- D! u) s
and puberty in the male. In: Sperling MA, ed. Pediatric. {- @+ X/ M. g' V/ T0 p+ U
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 [/ U9 ^9 ~. u. z
2002: 565-628.
, a. |. |: [- J1 f9 ^0 V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 D1 [: R9 ^& U  i" s: D# Q5 Opuberty 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
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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
& f) j, f7 e0 M2 E  X$ a6 _
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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