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Sexual Precocity in a 16-Month-Old6 n6 j6 z& O1 ~: G0 Q6 h& ~
Boy Induced by Indirect Topical0 R, m! r7 m) Z' Y$ W  F
Exposure to Testosterone
+ u* @7 i! Y9 C1 l9 u( B/ {2 {8 [Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 {+ F" H0 P" b6 W  T
and Kenneth R. Rettig, MD1$ j* C4 [+ ?* A# @7 Q
Clinical Pediatrics
( S; u% r8 J" J1 L/ pVolume 46 Number 6
6 p4 H: o, r9 B/ ^. oJuly 2007 540-543
) d2 v. |9 H4 W, n# P1 ]8 o© 2007 Sage Publications
0 h% T8 u: T# E) i5 J9 ~10.1177/0009922806296651
, @! y% w! o5 n/ R! shttp://clp.sagepub.com7 o7 O6 y. H# X" ?1 b+ n- b( {
hosted at
1 z% g) ^* Y: o: Uhttp://online.sagepub.com5 ^$ [) e! j2 r' v" r: S
Precocious puberty in boys, central or peripheral,: c$ K8 O5 \' G. T; p2 H9 S
is a significant concern for physicians. Central1 ?7 Q$ U# Q3 u& _' M+ W( C
precocious puberty (CPP), which is mediated
+ T2 |8 v) z" f( c: ethrough the hypothalamic pituitary gonadal axis, has
  y# Y# Y9 Z! ]* r- Y9 R/ Ka higher incidence of organic central nervous system
' l5 E5 N4 p5 ?* h% alesions in boys.1,2 Virilization in boys, as manifested
$ m3 [" D2 q2 [9 uby enlargement of the penis, development of pubic
8 q0 t% ?( m6 |% C3 i/ Nhair, and facial acne without enlargement of testi-
: U' Q( H) T, B' @$ @% H( e* Ccles, suggests peripheral or pseudopuberty.1-3 We3 L% ~6 c% Q1 x9 L) @1 v  ^. Y! H1 ^
report a 16-month-old boy who presented with the
+ u* t$ x$ _% \2 R" S# Q/ {enlargement of the phallus and pubic hair develop-4 Z1 B4 l% p9 E$ `" R$ [, m
ment without testicular enlargement, which was due) N2 B3 z  K6 |% f7 J3 W+ D8 d5 h7 }
to the unintentional exposure to androgen gel used by1 N/ ~/ Y$ Y5 P% _
the father. The family initially concealed this infor-
1 w* u9 i6 Q4 `( Xmation, resulting in an extensive work-up for this
. k1 l* C& d0 L8 `child. Given the widespread and easy availability of
  U" f8 |& _7 Ptestosterone gel and cream, we believe this is proba-5 a" s# ?) V+ u6 {- [
bly more common than the rare case report in the" f4 r7 [$ j* Q' H+ \
literature.4
  D6 O6 E, u* Q+ W, u) X# R! HPatient Report( I" U9 i$ U# w0 j" A5 s% M
A 16-month-old white child was referred to the
) i0 [  b1 o; `; a, Uendocrine clinic by his pediatrician with the concern0 X! `; |4 N( v: M0 q2 w) T  e1 t
of early sexual development. His mother noticed
. {: X5 h8 V7 T  S5 ]! slight colored pubic hair development when he was
- _* ?) Q0 u% R; s3 X5 b  Y4 PFrom the 1Division of Pediatric Endocrinology, 2University of
  D4 w( p8 a3 |- ]% {; e' z* E% m9 WSouth Alabama Medical Center, Mobile, Alabama.9 j) {% G% ^+ d
Address correspondence to: Samar K. Bhowmick, MD, FACE,$ e. x% u1 _! y) J
Professor of Pediatrics, University of South Alabama, College of
5 T6 D/ e9 k9 OMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ w3 n2 n5 b) }& z, S
e-mail: [email protected].
8 ?: `. O) E+ Z! P4 Dabout 6 to 7 months old, which progressively became
* n5 v8 ~6 H% m2 k# n8 r8 bdarker. She was also concerned about the enlarge-' F7 @& O+ U  P) r% c5 X
ment of his penis and frequent erections. The child+ g8 W6 c9 o3 E9 k' z8 x6 x2 F
was the product of a full-term normal delivery, with- Y% Y1 ]; B6 b. X, t
a birth weight of 7 lb 14 oz, and birth length of  h7 I! s! d* A0 g8 F( I* j
20 inches. He was breast-fed throughout the first year; u9 K" t8 S+ Y  @; b9 d# \
of life and was still receiving breast milk along with& P: I/ O9 t; N
solid food. He had no hospitalizations or surgery,
% ^$ g- t2 ], K8 I* Q) Nand his psychosocial and psychomotor development) {* c3 B# a' i2 N) a2 T
was age appropriate.
7 U/ B* R8 e4 H! P! i+ E+ DThe family history was remarkable for the father,
5 W/ W4 t. k4 r) L: Vwho was diagnosed with hypothyroidism at age 16,9 q2 e! X+ E, @3 ^7 Q
which was treated with thyroxine. The father’s
8 p- ?4 I+ e6 n5 m9 F6 \height was 6 feet, and he went through a somewhat
: d* a- i& O7 |5 Y/ r/ ^+ oearly puberty and had stopped growing by age 14.
( l* D1 S, j% ^$ UThe father denied taking any other medication. The9 q" j- W- z' P5 v
child’s mother was in good health. Her menarche
: S. A- g; g  w' O0 rwas at 11 years of age, and her height was at 5 feet
. \( m- @# `( |5 inches. There was no other family history of pre-
- b7 H0 y* I0 J! V* rcocious sexual development in the first-degree rela-$ `, K$ P9 f) p% X
tives. There were no siblings.
$ t8 Y$ Y. o% Y' H1 @  Z6 }Physical Examination
/ w8 @4 U8 q, K8 y9 Q& pThe physical examination revealed a very active,
( a9 ^* R5 O: z8 Kplayful, and healthy boy. The vital signs documented
5 b$ b8 n( a8 z3 @' i( u0 Ka blood pressure of 85/50 mm Hg, his length was; ?2 J5 ~4 K0 s' }( ]) w6 x4 g
90 cm (>97th percentile), and his weight was 14.4 kg
5 F3 o; G0 p" g7 m+ d8 ]8 d(also >97th percentile). The observed yearly growth
! W. [# {7 F) F: Q3 Y8 ovelocity was 30 cm (12 inches). The examination of
+ \( j0 W$ E% m; l; r% sthe neck revealed no thyroid enlargement.
. Z) r5 n8 N0 ?0 n. ZThe genitourinary examination was remarkable for
* C* i3 {6 b$ i# uenlargement of the penis, with a stretched length of
' d* g* u; T3 s& W; [8 cm and a width of 2 cm. The glans penis was very well6 c0 H$ k! ~- ]) t" N
developed. The pubic hair was Tanner II, mostly around
- @! ~( L+ @: [% ], f$ G540
6 O# y3 v, g  o7 b8 w- ~: Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& S1 F7 g) p! `
the base of the phallus and was dark and curled. The
6 e4 c( u5 }: D4 gtesticular volume was prepubertal at 2 mL each.
- z. a4 h8 \6 p  g1 D8 d) V! KThe skin was moist and smooth and somewhat2 ^7 H: ^: F- N% j5 X# c$ E
oily. No axillary hair was noted. There were no
" i/ i! L) F8 g$ Z& A9 [, sabnormal skin pigmentations or café-au-lait spots.6 X1 e1 a9 e% I" D
Neurologic evaluation showed deep tendon reflex 2+
7 [8 n5 p' K1 H4 ^( `bilateral and symmetrical. There was no suggestion# B3 M3 ^+ d" ?* [
of papilledema.
1 w3 o- d0 I! g3 d7 _* i: [$ g$ lLaboratory Evaluation. m4 I: }9 }9 \: `# @0 N" i
The bone age was consistent with 28 months by
" h3 n# m$ `  j) s' _using the standard of Greulich and Pyle at a chrono-
2 I6 {$ ^+ U1 t. Ilogic age of 16 months (advanced).5 Chromosomal5 @+ F" \1 x, ]  }1 X& B) t( a" r; [
karyotype was 46XY. The thyroid function test6 M* I3 x6 p* r5 ]5 T/ l
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 d7 Y" n# P: m1 ^) I
lating hormone level was 1.3 µIU/mL (both normal).2 y. p/ O3 h! D# A; W
The concentrations of serum electrolytes, blood! Q/ n2 O" t1 V; @2 Q' w0 C
urea nitrogen, creatinine, and calcium all were
# W: ^5 s, O. W; ^. |. Dwithin normal range for his age. The concentration
! R- ?: Y  X  x! G2 p4 V$ Cof serum 17-hydroxyprogesterone was 16 ng/dL
/ B$ a$ @3 N2 F2 Y4 b' _3 a(normal, 3 to 90 ng/dL), androstenedione was 20- F& a4 L1 T" e& |3 k. i1 Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ O0 [3 N& [1 |) q! r/ Q  jterone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 ~& U5 M: H7 A# odesoxycorticosterone was 4.3 ng/dL (normal, 7 to8 G2 x# w9 D: q( L& m: }
49ng/dL), 11-desoxycortisol (specific compound S)
, z1 y' T' ?9 Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  G" A0 T: o# I7 U1 {tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 u- `# i+ g, i- B# H; a. W  X  K$ atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* R# f. y$ }. V4 c8 c4 k) _
and β-human chorionic gonadotropin was less than: A4 e( @3 R! [8 A0 ^6 P3 L* P
5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 ]  g& ~9 ~- ^! pstimulating hormone and leuteinizing hormone
2 F5 p4 V* m# [% a; _4 s; F0 pconcentrations were less than 0.05 mIU/mL
  d8 `& G. q+ X; t0 }(prepubertal).
- A5 i* z& Y' O- J1 w7 V9 aThe parents were notified about the laboratory
4 P- K. p( S# i8 v9 a2 F! ]' U1 Aresults and were informed that all of the tests were
9 W5 D8 p- r4 W2 N' @2 `normal except the testosterone level was high. The
  r* V2 h! b. K2 G& ~) \follow-up visit was arranged within a few weeks to
  x% P  Q# Q( m& V6 Yobtain testicular and abdominal sonograms; how-
* q! |8 N" Q  ~; ]. {" _; b$ xever, the family did not return for 4 months., s6 l8 t( s+ |5 c5 B
Physical examination at this time revealed that the7 u* L. ^4 w4 \& ~6 e
child had grown 2.5 cm in 4 months and had gained# k! K8 f7 N& H" z$ k, X
2 kg of weight. Physical examination remained
1 C) L/ }, p2 f3 K6 kunchanged. Surprisingly, the pubic hair almost com-
3 z- G# l  }% q0 g: Q+ h; Ipletely disappeared except for a few vellous hairs at  Q, a5 `$ _! m1 P2 A
the base of the phallus. Testicular volume was still 2
' D4 _& Y, I  ?+ R: u1 wmL, and the size of the penis remained unchanged.2 Q1 G0 n. x" U3 B, j
The mother also said that the boy was no longer hav-; k! L+ D$ T9 Q$ j; q$ H
ing frequent erections.$ |4 v" X. j- V- d- g# f4 T
Both parents were again questioned about use of
9 a; m4 ^# f4 X2 R9 P- m! {any ointment/creams that they may have applied to2 o7 B. K0 z' Q5 H- J7 D. U
the child’s skin. This time the father admitted the
& U; b. D$ K( r1 Z" BTopical Testosterone Exposure / Bhowmick et al 541
4 D4 L' A( I4 F. @8 s: R* puse of testosterone gel twice daily that he was apply-2 {9 y' x* |- h" p( o
ing over his own shoulders, chest, and back area for8 Q8 c' i' n3 ?( W& |) s$ b
a year. The father also revealed he was embarrassed3 N7 `( s' L1 W4 ^# R
to disclose that he was using a testosterone gel pre-8 Q* u# R1 Y) n5 R
scribed by his family physician for decreased libido# r/ w+ Y1 K: S* v2 T/ `1 G. {
secondary to depression.
( t" Y0 `7 {) R3 i6 q% B1 E8 lThe child slept in the same bed with parents.
. v7 @5 c: S& S+ \' zThe father would hug the baby and hold him on his# o' M3 }" h) {: T" u5 b+ P
chest for a considerable period of time, causing sig-
- U9 o. z8 ~" u8 g: P8 I. Mnificant bare skin contact between baby and father.
8 a- r! I1 |  e' N8 f3 TThe father also admitted that after the phone call,
. K& |/ r( f9 q, `8 z: q$ P4 _, G. awhen he learned the testosterone level in the baby7 K4 A2 Q: ~' i; j2 W& n: F+ [7 M
was high, he then read the product information
/ u" I: ]* I; k1 dpacket and concluded that it was most likely the rea-
6 q1 `3 t% p- ^$ Z. f6 Z) Wson for the child’s virilization. At that time, they2 }* V3 Z6 Z3 C8 d
decided to put the baby in a separate bed, and the' F. w' G$ x* K* v8 e$ ^+ U/ Y: ?6 h
father was not hugging him with bare skin and had, D8 c* ~- q+ }, z1 M
been using protective clothing. A repeat testosterone
3 |' s% h: O( z) D: Ltest was ordered, but the family did not go to the
# A9 q3 N' L$ `8 a! ~2 H0 hlaboratory to obtain the test.7 Z9 n! t! [1 f
Discussion
9 W+ g; X0 t7 DPrecocious puberty in boys is defined as secondary
8 E6 t1 T% s9 D+ ^- Y) q9 d- o. s4 Z' Ssexual development before 9 years of age.1,4& l! G6 m& m# w9 L/ E  v) B
Precocious puberty is termed as central (true) when9 h* i; D$ G" [* a2 j
it is caused by the premature activation of hypo-
4 }3 o# o5 d5 j  H# ]thalamic pituitary gonadal axis. CPP is more com-# U  _3 a4 m1 S$ H0 N$ g4 b$ A
mon in girls than in boys.1,3 Most boys with CPP/ p) M$ {( K: K
may have a central nervous system lesion that is
+ A+ I: P1 V# X" uresponsible for the early activation of the hypothal-) ]. S! z$ r0 Q- u
amic pituitary gonadal axis.1-3 Thus, greater empha-' K; C; V" F+ k; @/ F$ [9 [
sis has been given to neuroradiologic imaging in
+ v5 }% X& F# S, b) C. Lboys with precocious puberty. In addition to viril-
. N* W1 b8 t) f2 s" M% iization, the clinical hallmark of CPP is the symmet-
4 Z( G# K1 ]# `# x1 vrical testicular growth secondary to stimulation by- b- J: |  E; Q, z/ O6 {
gonadotropins.1,34 b6 J$ I3 f7 H0 a- p
Gonadotropin-independent peripheral preco-
/ u  `  `$ n! ?; Gcious puberty in boys also results from inappropriate: K; T0 M* T5 z( E) X
androgenic stimulation from either endogenous or( d6 H* s0 y4 Q- g( A( E, @
exogenous sources, nonpituitary gonadotropin stim-' U. b$ D4 F3 W# b7 P
ulation, and rare activating mutations.3 Virilizing
  i! l# b, L; J& f2 k* {8 mcongenital adrenal hyperplasia producing excessive
9 L& }" T! n5 b- \. `* O2 Fadrenal androgens is a common cause of precocious( r$ a5 v- u8 A4 h
puberty in boys.3,4
. |* d! P) f7 y3 D; {The most common form of congenital adrenal
+ Y& x; d  X+ l0 E+ ^0 d  w% V6 vhyperplasia is the 21-hydroxylase enzyme deficiency.* o) b6 }- Y: d: V8 c, n. ?& ^- ^
The 11-β hydroxylase deficiency may also result in& p& n. j( {( X' k. o
excessive adrenal androgen production, and rarely,
, S8 v2 s: |3 k( ]) f5 wan adrenal tumor may also cause adrenal androgen- {6 q+ w: i; d& q3 q" V( t
excess.1,3
, I: f1 s6 j. z. G. m9 Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& ?2 }# I% e& G) h" F* x- @8 O# H
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 ^, M) u( e, eA unique entity of male-limited gonadotropin-8 O, _/ B* t$ f. f" U0 }+ n
independent precocious puberty, which is also known" i" O: Q# y& Q0 @
as testotoxicosis, may cause precocious puberty at a
  D$ |$ H% \; w( W; ?, Vvery young age. The physical findings in these boys0 t2 y9 z$ G7 \- q) ~
with this disorder are full pubertal development,
. h+ u) o. T2 K8 M4 I( D8 k: s2 rincluding bilateral testicular growth, similar to boys
: [. i9 q/ Y) ?8 A5 x* n% b0 c7 bwith CPP. The gonadotropin levels in this disorder- m+ [3 D( o" p% u9 }; |
are suppressed to prepubertal levels and do not show2 n5 X( L3 \: s6 b
pubertal response of gonadotropin after gonadotropin-: m& c8 ~2 z% D1 [
releasing hormone stimulation. This is a sex-linked
5 G* [( S6 U2 d' C, o5 jautosomal dominant disorder that affects only6 j2 m1 k' f* J! e
males; therefore, other male members of the family2 f0 @3 v( v! s6 g3 l/ P* a
may have similar precocious puberty.3
. Q% t/ c9 w" ?1 C. F; }3 b: Q+ [In our patient, physical examination was incon-" J* v5 b% ]/ U/ D
sistent with true precocious puberty since his testi-
/ s$ f  i$ W/ P# {, Ccles were prepubertal in size. However, testotoxicosis3 m. ^8 a; K9 Q) }
was in the differential diagnosis because his father; k0 s: g" p+ U( c* U( Q, E
started puberty somewhat early, and occasionally,6 C7 k% T6 S6 y8 B6 K6 z+ F& F5 K
testicular enlargement is not that evident in the5 h' [0 Y0 N, u, k' h4 W( G! G! n
beginning of this process.1 In the absence of a neg-( \6 ]9 n: m. D$ ~  W! s
ative initial history of androgen exposure, our
- m, `8 `4 |0 Z( t0 k* O2 D$ ~biggest concern was virilizing adrenal hyperplasia,
: o" k$ s* n  u6 Xeither 21-hydroxylase deficiency or 11-β hydroxylase
2 J2 z- G: d# d9 R* t5 g; |/ Adeficiency. Those diagnoses were excluded by find-
: F9 T8 e6 u8 oing the normal level of adrenal steroids.. E3 d" w' c; }1 Y" a
The diagnosis of exogenous androgens was strongly
- e. k# v# W* B- ssuspected in a follow-up visit after 4 months because! u- t* y8 ^/ ?, B( h
the physical examination revealed the complete disap-
; d; C! @' a( Y- Qpearance of pubic hair, normal growth velocity, and
) p, p: d1 M3 K8 J& ?( _decreased erections. The father admitted using a testos-* P9 }& S7 V# R2 @
terone gel, which he concealed at first visit. He was) A; r3 [$ ?. ~0 ^" ]( q
using it rather frequently, twice a day. The Physicians’0 P7 {, \: Y6 j% X4 Z
Desk Reference, or package insert of this product, gel or; n9 E3 V1 e: M) K
cream, cautions about dermal testosterone transfer to7 d+ U1 U5 u2 r
unprotected females through direct skin exposure.6 p" \) d  k' L! {
Serum testosterone level was found to be 2 times the5 t6 h# Q) t8 |/ W3 H# ~9 t
baseline value in those females who were exposed to- _' C/ T$ ]3 i0 R0 R
even 15 minutes of direct skin contact with their male
. B3 Y  }  L9 y. {7 S) y  hpartners.6 However, when a shirt covered the applica-
. I4 q! ]) U' b: P% I. o% @& m% u5 Etion site, this testosterone transfer was prevented.: t, n1 S: h, A) a; u
Our patient’s testosterone level was 60 ng/mL,
' |& Y7 s* L$ a* m+ T4 |which was clearly high. Some studies suggest that
( R9 F) D1 a$ t6 K" `( c' S$ bdermal conversion of testosterone to dihydrotestos-" ]1 X3 E2 Y5 P5 _2 a
terone, which is a more potent metabolite, is more
2 q( t1 h$ v" X; g& Aactive in young children exposed to testosterone
8 k2 E1 \1 N* Y# O. R1 Xexogenously7; however, we did not measure a dihy-$ g% {  ~% j& l! T3 |
drotestosterone level in our patient. In addition to
$ Y8 Q0 @' p6 \$ y; y7 Q% }virilization, exposure to exogenous testosterone in
: b6 ^' X7 B5 D1 Y' r3 c, N4 {$ bchildren results in an increase in growth velocity and
& ~/ i' J4 G' r* \8 S4 m7 L3 ^advanced bone age, as seen in our patient.3 `; v6 y* I7 H  Q' o
The long-term effect of androgen exposure during
8 O5 \+ y6 h) dearly childhood on pubertal development and final" b, S; ]" p& Z5 V2 ]( i7 r
adult height are not fully known and always remain
2 a$ ]. v/ Z# Q, d7 S/ t1 p9 ta concern. Children treated with short-term testos-
8 O. G$ f. h9 ?! Yterone injection or topical androgen may exhibit some
6 y. t. ?5 J. j$ Qacceleration of the skeletal maturation; however, after* p- `. R% U, A+ @1 Q- M; K3 b, o, T
cessation of treatment, the rate of bone maturation6 j& H6 t3 `% J* r9 @
decelerates and gradually returns to normal.8,9$ P' L8 J1 ~6 U$ t; J* Q
There are conflicting reports and controversy! Z$ S: p0 `7 w: @- K' Z
over the effect of early androgen exposure on adult
  i2 f  b# `/ w' ?+ s# upenile length.10,11 Some reports suggest subnormal
. K8 P% f- ~2 ^adult penile length, apparently because of downreg-
* J5 q8 G. _$ f) tulation of androgen receptor number.10,12 However,: S) {- N* z7 c
Sutherland et al13 did not find a correlation between
3 W9 Y/ A9 X* g7 _childhood testosterone exposure and reduced adult
2 n& d" G' z, N0 i' W0 o; upenile length in clinical studies.( m7 \1 D$ ~( l# V3 k$ H
Nonetheless, we do not believe our patient is
2 W/ W+ ]4 L! x8 L( @3 }4 Ngoing to experience any of the untoward effects from! v0 ^: O/ K  ?5 q! y# q) ~
testosterone exposure as mentioned earlier because
$ e  m, \: D1 \1 c/ e- L5 nthe exposure was not for a prolonged period of time.8 b2 S. F! B: }9 m' ^# ]8 [1 s0 I  x
Although the bone age was advanced at the time of( a7 `. F; @" `% @9 H
diagnosis, the child had a normal growth velocity at
! F6 t3 j7 {' u& R: Hthe follow-up visit. It is hoped that his final adult
' y* T6 B! |9 B, {. t# ?2 Jheight will not be affected.: w! J4 w! M$ l/ A( z
Although rarely reported, the widespread avail-
- u# s7 M5 s+ g7 w: e* z6 Bability of androgen products in our society may( D2 m4 [% q( ~8 |# {: l4 A
indeed cause more virilization in male or female$ R% \- {  ^: X( D
children than one would realize. Exposure to andro-3 e# [( [) S' {8 _* P' Y6 C% v
gen products must be considered and specific ques-
5 t7 j, }  j+ Stioning about the use of a testosterone product or9 `4 V! t! v# B: ^3 }  X
gel should be asked of the family members during
& D& P' U: G2 \% Dthe evaluation of any children who present with vir-
& h2 [6 a( T& L4 Jilization or peripheral precocious puberty. The diag-
( M# K  _+ @1 O/ _! E6 A3 @# O8 l% x7 Jnosis can be established by just a few tests and by
6 A, O4 D  N2 D1 s9 U2 wappropriate history. The inability to obtain such a
; t. H1 G) p7 T- T7 rhistory, or failure to ask the specific questions, may" F; \$ H/ `4 H( A0 I2 D+ S
result in extensive, unnecessary, and expensive) ~7 Y  J* x) E7 e8 j% |
investigation. The primary care physician should be
2 O4 b! i& L& v# z1 eaware of this fact, because most of these children
  F8 `0 P# T1 w" Q0 y8 m' W8 ^" Imay initially present in their practice. The Physicians’
1 ?4 n5 m" i7 g+ @) z- YDesk Reference and package insert should also put a5 r, F0 K2 d' ?' K
warning about the virilizing effect on a male or
# ^; F9 P: x. Z) I4 v' e+ tfemale child who might come in contact with some-
2 [8 h  P8 I2 }3 c% y, j) c) Rone using any of these products.
4 f9 [) _5 Z; {' t9 R" FReferences
( B9 b# D$ M2 h0 Y1 S: R+ ~1. Styne DM. The testes: disorder of sexual differentiation
! r5 X7 }: ^% n( n# x, k1 kand puberty in the male. In: Sperling MA, ed. Pediatric3 i- u; I# p3 R9 L4 E( F
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% c/ e9 O/ D. M2002: 565-628.* R( N9 B0 t4 R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 S. K/ P! W% Q& L
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old: T% w; H& V9 n5 c6 Q7 j
Boy Induced by Indirect Topical/ g# o: w% \, d
Exposure to Testosterone
9 N: q( l( y  O0 [) T: R: ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 ]( B0 x* ]4 Dand Kenneth R. Rettig, MD15 u$ [  u# J: v" p" f% v
Clinical Pediatrics0 p8 B& `$ E" |- v3 o
Volume 46 Number 6
& }! X6 b% }  W- G7 q6 V  EJuly 2007 540-543
5 t& A( a7 r: }+ _5 s( W! E© 2007 Sage Publications( I* ]1 A0 X" ]
10.1177/0009922806296651
1 l  j$ Q7 z! A% S% Mhttp://clp.sagepub.com1 L% ]* s8 u: R& W2 I2 T" P
hosted at
8 x. V, [, w: p# r! r" v0 ohttp://online.sagepub.com: g3 E! S# a- i( n
Precocious puberty in boys, central or peripheral,
3 V8 {& F7 Y0 I; A, o& Ois a significant concern for physicians. Central4 s, |/ U+ G: B+ o. O" A, d
precocious puberty (CPP), which is mediated  w) Q- u2 R9 \' m9 t* C
through the hypothalamic pituitary gonadal axis, has
+ W2 v2 Y7 C* e- M: ]a higher incidence of organic central nervous system% y2 ^' E& t+ g
lesions in boys.1,2 Virilization in boys, as manifested
. f& [& ^" X( _7 S4 z  \9 ^by enlargement of the penis, development of pubic% y! \; u3 Q- `  U3 {# m
hair, and facial acne without enlargement of testi-
% @3 L% y' E) `cles, suggests peripheral or pseudopuberty.1-3 We
7 V, a$ Z' K0 k$ `" q& d. Ireport a 16-month-old boy who presented with the: _& E( q- z* L9 N. c  G
enlargement of the phallus and pubic hair develop-
2 i* t) G9 d8 i% }ment without testicular enlargement, which was due9 w# _3 ^5 t2 x6 g, ^; B
to the unintentional exposure to androgen gel used by8 O/ y0 }. O( G! v* [: t
the father. The family initially concealed this infor-/ @4 }5 [) P8 v3 y7 D5 e9 B- J( i
mation, resulting in an extensive work-up for this
/ Y6 Y# |3 F' c  ]child. Given the widespread and easy availability of
- L( ^; P$ q$ x& v& ztestosterone gel and cream, we believe this is proba-+ J8 @0 Z) h0 N1 }2 M: s' L# p
bly more common than the rare case report in the
# l; Z8 Y: X# Zliterature.4# B+ _; O( e% H- x  v
Patient Report
$ k" J& ^' G$ VA 16-month-old white child was referred to the, r2 n( u, m) G2 V. S8 `4 n( U' |3 v
endocrine clinic by his pediatrician with the concern
3 w, d, A" ?, \! H. d+ Z1 Hof early sexual development. His mother noticed* E' z% w9 n8 z  c. S9 l! ]
light colored pubic hair development when he was* K+ j- n, r+ j, h3 l
From the 1Division of Pediatric Endocrinology, 2University of8 V- o3 m/ ^3 E/ e5 |
South Alabama Medical Center, Mobile, Alabama.: Y+ o* O1 c2 W  @- |* G7 z( q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* n( @- V% C' {) n! P& p0 F& OProfessor of Pediatrics, University of South Alabama, College of
' ^) @( M& C! |% }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" ~) e, A; m% T8 ie-mail: [email protected].% l" n1 e, t8 R+ y: X
about 6 to 7 months old, which progressively became- K# I- @5 K- k/ ~& S2 k0 ^
darker. She was also concerned about the enlarge-
1 n% I9 _5 k' |6 C) Z6 v2 kment of his penis and frequent erections. The child; Q( |; l* j9 z; B
was the product of a full-term normal delivery, with- d$ m, o  K) F: f' B
a birth weight of 7 lb 14 oz, and birth length of/ s+ ~% L6 v& c8 ^9 x4 T% L
20 inches. He was breast-fed throughout the first year
; f) [& {) q3 ~+ x6 Mof life and was still receiving breast milk along with
0 ]: x) U' I1 s: J: ]% Nsolid food. He had no hospitalizations or surgery,
. Z' c# w( G1 f  Q: G' band his psychosocial and psychomotor development
; a9 ~" E  M! s! S/ I: ]/ jwas age appropriate." k5 W5 A/ q: l, ]( _( ?
The family history was remarkable for the father,
1 f' V. n4 f* Z! C) T) @, uwho was diagnosed with hypothyroidism at age 16,
" E4 W: M- W8 [: w  ywhich was treated with thyroxine. The father’s
  u& j5 ~5 m; F) Aheight was 6 feet, and he went through a somewhat
# \! P8 F! I( Iearly puberty and had stopped growing by age 14.* _: V6 H# |9 A. _
The father denied taking any other medication. The1 J! {2 J% y( n. f/ M! E( o$ Y& h3 n+ q
child’s mother was in good health. Her menarche" i0 a" }* U! g/ O; S/ H& t( K) U
was at 11 years of age, and her height was at 5 feet: u  ]+ F8 z- M( T4 h
5 inches. There was no other family history of pre-
- a0 Z& _* n0 \" E3 _cocious sexual development in the first-degree rela-
* H; h% V" H' }tives. There were no siblings.
% Z' n  ?  \- Z0 a' MPhysical Examination: q+ a% _/ y! Y; J5 O! r( V
The physical examination revealed a very active,
! P& R) D5 c# r- B  q1 |* eplayful, and healthy boy. The vital signs documented
$ u* f" u+ M/ i' ?# Q8 }$ U0 W: ~1 Ea blood pressure of 85/50 mm Hg, his length was
5 T. x& T) {& P- p$ `  x' `3 Y8 ?90 cm (>97th percentile), and his weight was 14.4 kg
# Q) J7 F5 ?2 N. s(also >97th percentile). The observed yearly growth
2 u+ k% z9 r0 h/ |) g  J- Qvelocity was 30 cm (12 inches). The examination of
0 H, G1 v' m# o4 x! t2 Zthe neck revealed no thyroid enlargement.  \' x# l* F) k
The genitourinary examination was remarkable for; |+ V" l6 Q& t& E1 ?. m
enlargement of the penis, with a stretched length of/ S2 A& v, Y2 j) X) A, J  b
8 cm and a width of 2 cm. The glans penis was very well
9 |4 F4 x; T6 c) G4 ?) A% ]developed. The pubic hair was Tanner II, mostly around
2 t! f$ W5 m' D, b540
2 [2 j) B* R( f* K6 I6 Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( O3 N( L- H* bthe base of the phallus and was dark and curled. The) V+ I# U2 O* }6 K) \1 P
testicular volume was prepubertal at 2 mL each.
+ ^2 ^" A; }; C: k  O: BThe skin was moist and smooth and somewhat5 Z( [0 l2 O6 N# P) `+ C
oily. No axillary hair was noted. There were no! h# V5 X+ u, T/ N4 _: \! F7 n
abnormal skin pigmentations or café-au-lait spots.
6 z8 j* o. ^+ u; z; V) VNeurologic evaluation showed deep tendon reflex 2+
0 t9 F  r, V6 C, B9 G# O7 [7 ]bilateral and symmetrical. There was no suggestion
9 w/ t' n, a- }) A0 f# Xof papilledema.9 I: P5 ?. O9 Z% E) ], m( w3 A& F+ y  e
Laboratory Evaluation
1 Z/ c) p" ^: \/ j6 PThe bone age was consistent with 28 months by4 |( Y! w/ Z' u% u2 e0 i
using the standard of Greulich and Pyle at a chrono-" g! G  p' r( v9 ]! X6 i5 z% |
logic age of 16 months (advanced).5 Chromosomal& _) ]4 G( K4 O* p3 d) a
karyotype was 46XY. The thyroid function test$ F9 `" O5 {! g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 A6 n2 h' V7 s+ E2 N
lating hormone level was 1.3 µIU/mL (both normal).* _8 Q0 n" P. {' T; _
The concentrations of serum electrolytes, blood
; B( N+ N; [4 S; ]+ r* ourea nitrogen, creatinine, and calcium all were( B. T# ~( w  _/ I  ?
within normal range for his age. The concentration
0 R; o" E) \* r1 K+ }/ o8 Jof serum 17-hydroxyprogesterone was 16 ng/dL: r5 M, ?2 F6 U1 ~/ f
(normal, 3 to 90 ng/dL), androstenedione was 20- l$ O4 }' k/ l, G5 k- b+ Q, S+ _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 T* \! I% A- G0 `; y+ o! u& k7 W  qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
. j/ p) A2 Q9 _" Z7 g& f3 Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# b% l' m: g9 l3 \* C( h) b49ng/dL), 11-desoxycortisol (specific compound S)% l9 x5 V, |/ E0 P( H5 r# _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" }5 T; u& I  U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( o/ l, K% O# n% ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" g" Q1 W3 B. K% V3 f! gand β-human chorionic gonadotropin was less than
5 b$ T6 n8 K& t2 d' T5 mIU/mL (normal <5 mIU/mL). Serum follicular
; ~! x) u& ~4 V! X+ S1 ystimulating hormone and leuteinizing hormone  c/ t: D; ~9 Z
concentrations were less than 0.05 mIU/mL
3 @9 {5 Q$ X9 S$ ^(prepubertal).
4 ^, ]* w; c! R, Q+ iThe parents were notified about the laboratory3 j/ i2 Y% ~( I( t. J  d2 S
results and were informed that all of the tests were- q" m; k% K1 y% f+ J# N: s0 ~
normal except the testosterone level was high. The
( C* W' M) c! }$ c$ dfollow-up visit was arranged within a few weeks to+ ~. T3 P6 q( @+ R7 w4 N8 z+ W
obtain testicular and abdominal sonograms; how-, |$ `/ c% J/ k/ m% ^; V
ever, the family did not return for 4 months.
6 t/ C. n2 S( r8 w; s3 r; zPhysical examination at this time revealed that the
$ _$ J! @1 C6 w1 L* Q- Lchild had grown 2.5 cm in 4 months and had gained$ c* ~3 m4 ?* [. c
2 kg of weight. Physical examination remained6 w7 f0 {" c- I
unchanged. Surprisingly, the pubic hair almost com-
1 {* H. c/ j1 ^pletely disappeared except for a few vellous hairs at
( r3 K4 b7 h* C: p6 f5 k. [- U5 ~the base of the phallus. Testicular volume was still 2
% L& A2 C( b" m, p( F+ i1 dmL, and the size of the penis remained unchanged.2 ]  G$ @5 G& ~* x* i: Z
The mother also said that the boy was no longer hav-
- H8 C: q6 r, J/ q1 Ting frequent erections.) p  i# s. E) f' o5 A) |
Both parents were again questioned about use of* N7 B3 v9 x; y5 r
any ointment/creams that they may have applied to3 Y* W5 e3 ~# c
the child’s skin. This time the father admitted the' p- f: q  b  M% c' J' g
Topical Testosterone Exposure / Bhowmick et al 541
. R% U0 I/ e9 g; `use of testosterone gel twice daily that he was apply-
$ p" x  c: P$ O9 ], ning over his own shoulders, chest, and back area for
8 l. p1 d; ^0 Q# a0 @8 O; a' Na year. The father also revealed he was embarrassed
6 W  M3 F0 q# z" @to disclose that he was using a testosterone gel pre-
. p* }4 x8 }( L8 _+ xscribed by his family physician for decreased libido
! N9 K' y( \1 w+ D% v; n4 p" {, P" Ysecondary to depression.
8 b7 @% N, D* n- ?The child slept in the same bed with parents.
) h4 O+ _  r6 Y3 ?The father would hug the baby and hold him on his
1 Q, c* g! L/ V8 }. `' {chest for a considerable period of time, causing sig-
  @; q9 n+ {# @) R. J% rnificant bare skin contact between baby and father.9 Q/ w; V; D9 h
The father also admitted that after the phone call,
: g- {- O( [) V( r. r9 iwhen he learned the testosterone level in the baby. u+ x. q' e! o8 \
was high, he then read the product information
% K" {% r& `* @% T9 ipacket and concluded that it was most likely the rea-
: H# Q, h+ t0 L6 O5 ~* ]( zson for the child’s virilization. At that time, they* q7 g7 V4 e# x, Y
decided to put the baby in a separate bed, and the
( R3 j0 A# d, G; i3 g4 R$ Mfather was not hugging him with bare skin and had
# B4 c: _* }$ e( _9 I% J4 k4 ~been using protective clothing. A repeat testosterone
4 Y1 P3 r4 I9 t$ k# z: ]test was ordered, but the family did not go to the
( a; j) F+ {; Z" {5 B5 P7 }) r3 ]laboratory to obtain the test." q8 @: p7 @$ D+ e5 i. M( ?0 H
Discussion2 ~; q' U2 S% k& c+ V; G4 j
Precocious puberty in boys is defined as secondary5 t& W# B$ W) w$ y7 x# {
sexual development before 9 years of age.1,4( f2 N2 L, A( L' g( @* y- C
Precocious puberty is termed as central (true) when5 p! q) x7 v# K5 L
it is caused by the premature activation of hypo-# e  _: Y8 f/ S+ T( O
thalamic pituitary gonadal axis. CPP is more com-: |2 y) Q& \! T+ q2 c4 q8 h+ t+ B6 Q: X
mon in girls than in boys.1,3 Most boys with CPP& Y, u' T0 `1 ]5 f( [  Y- p& B
may have a central nervous system lesion that is
5 u- {; ]' v( G- E" tresponsible for the early activation of the hypothal-# H; t# y- m5 S1 s0 e. ]4 M
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 e/ o" Q4 D7 `* t* Lsis has been given to neuroradiologic imaging in
6 P, p3 j' U2 r) m/ z5 J7 ]# g  Iboys with precocious puberty. In addition to viril-% }4 r: v& x. k) p5 O- c+ @& h  Q
ization, the clinical hallmark of CPP is the symmet-
0 C" y6 P: W8 ]8 {+ ~; srical testicular growth secondary to stimulation by
: ^* I( H# V- C$ dgonadotropins.1,3
9 j5 j. \' g5 ]" q  wGonadotropin-independent peripheral preco-
5 b8 e$ B" U/ h, E+ K, |2 scious puberty in boys also results from inappropriate
4 I8 K) {# `5 Z: V  ]8 randrogenic stimulation from either endogenous or
# ^& u  B% b% V: c2 i+ y; Texogenous sources, nonpituitary gonadotropin stim-6 d# F) g8 R9 ~: X; A- q, U
ulation, and rare activating mutations.3 Virilizing
% i$ G0 C! D$ r9 S' @9 F7 Gcongenital adrenal hyperplasia producing excessive9 S+ o% Y% ~' D! ~+ R  o& L) X
adrenal androgens is a common cause of precocious  e2 ^9 h4 h9 O
puberty in boys.3,4
0 ]4 ^! k8 ~; d& CThe most common form of congenital adrenal+ E8 T5 y5 D! k7 B3 A& |
hyperplasia is the 21-hydroxylase enzyme deficiency.0 N  J+ r" i9 a+ }& m8 r9 w0 H
The 11-β hydroxylase deficiency may also result in
/ V7 k5 \6 Z' M# [. b3 K( @" `: Vexcessive adrenal androgen production, and rarely,% A$ {& T! }9 T' C
an adrenal tumor may also cause adrenal androgen( F- Y3 F  h! ^7 i( [# S0 E
excess.1,3
! b0 _" j/ W' Y) }$ P1 jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- T: H6 a& N: C- T, ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: r+ x! w8 {' n' ~& r0 U
A unique entity of male-limited gonadotropin-. O6 m  L6 q0 t4 S# T: j
independent precocious puberty, which is also known
- _( }) f8 m' |9 v2 ^* s: \, Las testotoxicosis, may cause precocious puberty at a$ L) @" T+ q; `( h8 R7 \! q: l
very young age. The physical findings in these boys( u9 D( ]% D$ C0 \
with this disorder are full pubertal development,# j0 I# }4 F. V! x/ b
including bilateral testicular growth, similar to boys
  i8 ]- U' p- Z5 B0 vwith CPP. The gonadotropin levels in this disorder8 g+ z3 Q+ A7 x. c1 E+ a9 G* {
are suppressed to prepubertal levels and do not show
, F0 z) ~, O  U+ I1 Ypubertal response of gonadotropin after gonadotropin-
4 h8 J' @" r# M6 T3 k7 Vreleasing hormone stimulation. This is a sex-linked
; |1 x6 a, S! n5 Y9 nautosomal dominant disorder that affects only% j; Y; r1 \3 m% ]
males; therefore, other male members of the family4 x( \& ^. c9 `0 ?0 A, |
may have similar precocious puberty.3
9 h+ p% f/ x2 g) KIn our patient, physical examination was incon-" T+ |. A' D1 Z2 P7 M( }$ k
sistent with true precocious puberty since his testi-* ]) y& [+ f; f$ S
cles were prepubertal in size. However, testotoxicosis3 G8 |9 @$ R7 d, ?3 q( t7 K
was in the differential diagnosis because his father) w( n! D# {2 ^: _0 F' f3 b' \
started puberty somewhat early, and occasionally,$ a0 F4 P% J- c1 G
testicular enlargement is not that evident in the& m* G6 Y: U  r) b
beginning of this process.1 In the absence of a neg-
+ Y* }2 y( U- M1 Rative initial history of androgen exposure, our
* j8 ^/ y+ A! ]2 }6 D. B' x! D# J3 wbiggest concern was virilizing adrenal hyperplasia,
% C* e$ E1 B1 [; I7 i5 oeither 21-hydroxylase deficiency or 11-β hydroxylase6 J9 b# {" X  q, @% g
deficiency. Those diagnoses were excluded by find-7 j( I/ O, k: O3 x6 ~; {
ing the normal level of adrenal steroids.
0 V! D. a  I, kThe diagnosis of exogenous androgens was strongly# K- [: i( X7 L* h" L0 P2 @. V
suspected in a follow-up visit after 4 months because: O% P' j+ q; `1 B- y9 }
the physical examination revealed the complete disap-
  C* B% h  M  Z5 N; J2 Lpearance of pubic hair, normal growth velocity, and
% F1 ]) c' @6 t+ O: B! p) I4 zdecreased erections. The father admitted using a testos-
5 H9 U$ e$ W( [terone gel, which he concealed at first visit. He was
0 t/ h1 X; g; w! }7 U+ x# A/ ousing it rather frequently, twice a day. The Physicians’
7 T' v/ W* D8 p+ N5 IDesk Reference, or package insert of this product, gel or
2 ^$ _# }% N8 }1 O, O8 E% r. G# zcream, cautions about dermal testosterone transfer to0 B* R7 U3 |" C
unprotected females through direct skin exposure.
" g% X, F4 y4 l# ^' TSerum testosterone level was found to be 2 times the
+ v0 _6 C" g( ~9 T+ `) k9 O5 E3 ?baseline value in those females who were exposed to
7 ~$ T% [- @% Eeven 15 minutes of direct skin contact with their male
) {. |* |! V1 w5 M* l9 X6 Hpartners.6 However, when a shirt covered the applica-
1 ?0 N; b; l. ^" ltion site, this testosterone transfer was prevented.
4 [4 U# |) t9 m4 V: vOur patient’s testosterone level was 60 ng/mL,6 q. e6 |. Z' q+ Y1 V5 L& _
which was clearly high. Some studies suggest that- @* y7 g8 C6 }1 l: m/ I
dermal conversion of testosterone to dihydrotestos-3 k- h; u6 q8 a- e- ^4 X
terone, which is a more potent metabolite, is more
9 I6 x, M5 k) U- hactive in young children exposed to testosterone- m$ M4 W8 n6 a( v' ]
exogenously7; however, we did not measure a dihy-/ N' e( @9 j1 J# I! b! h2 z
drotestosterone level in our patient. In addition to
' R  ?! Z9 Q# C9 ^+ V- w' vvirilization, exposure to exogenous testosterone in7 l1 i& O' X1 T; ?: e! I7 D
children results in an increase in growth velocity and
3 c- n8 W% G: Y# P; ]advanced bone age, as seen in our patient.
- K" V# e) d4 V9 e/ Q1 c, yThe long-term effect of androgen exposure during% E$ n. ]& h- J0 Q
early childhood on pubertal development and final
/ Y3 t" e0 @* R$ ~4 K% l8 \: Aadult height are not fully known and always remain+ q5 {* c- U0 e- p( m
a concern. Children treated with short-term testos-2 r3 x' r. b: `3 a/ I7 k4 ^% R
terone injection or topical androgen may exhibit some
" e! q2 |* S$ ^; U, uacceleration of the skeletal maturation; however, after
4 H  v: M6 \' h0 V3 D. I9 j5 I# Qcessation of treatment, the rate of bone maturation) A: w5 ]6 N2 T9 Z
decelerates and gradually returns to normal.8,9
, k4 u( M3 a7 f- s7 j8 V# w# u! bThere are conflicting reports and controversy
: Q+ r: U4 g) Q/ d5 }- D2 J  _0 T, Vover the effect of early androgen exposure on adult* w9 {! Z! V4 t0 k
penile length.10,11 Some reports suggest subnormal# n! U+ J. J: u5 E! I: p2 V
adult penile length, apparently because of downreg-
3 d' f9 }5 i  y5 N1 e. A; _1 q: k- Qulation of androgen receptor number.10,12 However,3 d8 k# q7 g& Q6 Y" o
Sutherland et al13 did not find a correlation between- c) |$ {' u/ K3 z7 n  `5 q
childhood testosterone exposure and reduced adult
* L$ x% G3 n1 H3 _( wpenile length in clinical studies.* }  t! {+ Y: V; [
Nonetheless, we do not believe our patient is
1 C: t# O  v5 Rgoing to experience any of the untoward effects from0 i0 e- i& ^* K. V& a
testosterone exposure as mentioned earlier because
* t$ q4 Y( s% ]) _* O6 ^$ Cthe exposure was not for a prolonged period of time.
4 y. U7 ~- F! B* |) UAlthough the bone age was advanced at the time of
$ s! V- {9 [$ @0 I! idiagnosis, the child had a normal growth velocity at
5 z( _7 @- v  j9 n; c; H! s. Dthe follow-up visit. It is hoped that his final adult
: k8 X/ q: M4 u0 Q, z6 G; Pheight will not be affected.8 h' p" [" G- a) @- u: b
Although rarely reported, the widespread avail-& D8 o$ ~6 ~% p
ability of androgen products in our society may1 A+ C/ N; F- g, K: Z
indeed cause more virilization in male or female+ j: e8 L' P! w; H9 S. A
children than one would realize. Exposure to andro-
! R* H, u+ H2 h3 w  Ggen products must be considered and specific ques-2 a4 N/ r, K  A
tioning about the use of a testosterone product or/ O( h4 e7 \9 j0 B5 O
gel should be asked of the family members during
5 _- o; T$ j6 F2 j: R9 U: b; dthe evaluation of any children who present with vir-5 H# u) X3 L% I% }4 [( K7 `. O
ilization or peripheral precocious puberty. The diag-
# j! w. K1 V7 Mnosis can be established by just a few tests and by
+ k0 J% W- I5 R$ [appropriate history. The inability to obtain such a; L$ a; @; O( H  g+ O( Y8 y- [% }
history, or failure to ask the specific questions, may
0 a- m! }* F  F/ D6 X' U/ A/ U6 ~result in extensive, unnecessary, and expensive
2 |/ d0 w2 P1 M$ d4 Ainvestigation. The primary care physician should be3 s) M; Z/ A3 L0 R# l1 d! i
aware of this fact, because most of these children
& \( g4 H& s) }; k2 _may initially present in their practice. The Physicians’
# U* c; [( ^8 G3 t# O7 {Desk Reference and package insert should also put a6 t; P2 o2 e* k0 v  M  H' w& H* ^
warning about the virilizing effect on a male or
7 ]5 q. V! K& t5 f8 U+ L" pfemale child who might come in contact with some-" o" t# t, e/ i- o* }3 Y: D! ~
one using any of these products.$ G, Q# m& N2 w  E7 M
References/ ~+ p9 G5 @& e4 V2 u  u3 y2 D) r
1. Styne DM. The testes: disorder of sexual differentiation
* p! e* t: x$ u5 X* z+ h; N& s, oand puberty in the male. In: Sperling MA, ed. Pediatric6 M; V& v. K; E! C3 P. C+ q: ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: K0 P5 r( l2 R4 i5 V  C2002: 565-628.
' c8 L- q) W7 K4 Z" X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 U7 E8 e) q7 R
puberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

! j3 [. n# n) z0 c5 N$ H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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