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Sexual Precocity in a 16-Month-Old
+ Q  v# z) N: ^$ H: IBoy Induced by Indirect Topical
9 |5 [5 x0 H( J* n) }, F# @( c9 M) RExposure to Testosterone
, Z4 R: j2 Z  t  V9 ySamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 i& I+ {4 t+ e3 n2 ~# @and Kenneth R. Rettig, MD1
$ J) N0 K! l  e* Q7 rClinical Pediatrics0 B7 I  ]' P3 _# B( K  K, q0 Q
Volume 46 Number 6
. I! z; s& ]# `; I  T: yJuly 2007 540-543: \0 u3 D( W' B: a) Y
© 2007 Sage Publications: z+ V! _( d) T3 i1 m- j! j$ [2 u
10.1177/0009922806296651
7 h$ q( N" Y# A$ }http://clp.sagepub.com
) E7 E$ }9 ^( K5 Z4 Ehosted at8 l4 j  W9 J6 E2 Z
http://online.sagepub.com" k/ w# _5 W* U% C1 r
Precocious puberty in boys, central or peripheral,# x& z" C' T! a) g0 R, a, H- U) h
is a significant concern for physicians. Central3 X. e  b4 n2 P8 j2 i7 B
precocious puberty (CPP), which is mediated
  V; o! l* }0 z, M$ m9 Tthrough the hypothalamic pituitary gonadal axis, has: K8 \  g/ i  W: s" C
a higher incidence of organic central nervous system' L& ]) F% s; F
lesions in boys.1,2 Virilization in boys, as manifested
2 y9 y- f- @- V. F. `' X4 Vby enlargement of the penis, development of pubic
7 J4 n9 Q6 ?6 a$ B9 a" a1 o% Hhair, and facial acne without enlargement of testi-
1 J; n1 a$ q, Y. y% O$ Tcles, suggests peripheral or pseudopuberty.1-3 We
/ }; S/ S$ T- a, {+ _+ D! oreport a 16-month-old boy who presented with the  ], t5 k! D# p" {9 U
enlargement of the phallus and pubic hair develop-
) o( x' u4 @) {# l! C0 }; dment without testicular enlargement, which was due5 }7 s# V/ H: N. R8 J
to the unintentional exposure to androgen gel used by4 Z7 B, t1 ]6 S, F0 E2 T- Q# N/ b
the father. The family initially concealed this infor-2 d4 `. Y- Y, ~; }; s
mation, resulting in an extensive work-up for this* \& X' V* r' y  r, ~9 w
child. Given the widespread and easy availability of0 X' ]8 M- O# H- v  U- J
testosterone gel and cream, we believe this is proba-
5 d& |( B7 Z* k& gbly more common than the rare case report in the- G6 x' V" g! N6 O2 M# C2 q8 N
literature.4# @% L( R: U# @, O- u3 s) c& A
Patient Report
# s4 p( R6 Y* U" OA 16-month-old white child was referred to the. n. [) x- o6 A
endocrine clinic by his pediatrician with the concern
! L: ~5 Z# f* D: @of early sexual development. His mother noticed# K4 f  P7 N. H6 W0 V3 K
light colored pubic hair development when he was: D" ^/ t& _! s- F
From the 1Division of Pediatric Endocrinology, 2University of
) g$ l) R1 J1 p% KSouth Alabama Medical Center, Mobile, Alabama." a8 `$ ?! k7 `' Z. a7 Z) B* q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, m( K$ \% g& K, L: i( ?: BProfessor of Pediatrics, University of South Alabama, College of
( n4 z' D1 b' ^1 a2 v1 v, r+ G7 DMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; G0 ]7 @+ e  w) g
e-mail: [email protected].
( F2 Y* |# o" F" b  y4 _8 ]about 6 to 7 months old, which progressively became
* ~  J8 N/ J8 ~; E4 b" O+ {4 idarker. She was also concerned about the enlarge-
, j3 g6 ?% S% B' q, rment of his penis and frequent erections. The child
' o, _" L/ O- q; J5 b- u2 Kwas the product of a full-term normal delivery, with; j: Y" h2 t+ b9 R
a birth weight of 7 lb 14 oz, and birth length of& ?2 k. h6 u" X- h: v
20 inches. He was breast-fed throughout the first year
) ]7 [, j  w9 n) p2 [of life and was still receiving breast milk along with; l2 k! \! v) G: y; U
solid food. He had no hospitalizations or surgery,4 G; _- ]: x; z9 ~7 \/ N7 f- e
and his psychosocial and psychomotor development3 Q' N- L1 H# \* B
was age appropriate.
% R' S7 L. x$ eThe family history was remarkable for the father,% L/ _2 ~! V# D2 p6 s- ], \
who was diagnosed with hypothyroidism at age 16,
9 Q1 W; n- C! ~# k+ ^which was treated with thyroxine. The father’s' ]+ e' |- x$ D" o2 Q: J
height was 6 feet, and he went through a somewhat
" K! a1 p# \  _; D. X* Fearly puberty and had stopped growing by age 14.
) p' b4 j' j0 C' qThe father denied taking any other medication. The
+ A! A$ {% K2 b8 Pchild’s mother was in good health. Her menarche
  I- ?; [( D$ M6 jwas at 11 years of age, and her height was at 5 feet9 q& P8 r; w/ M+ x
5 inches. There was no other family history of pre-/ R6 E) `/ V. n" i0 E( Z
cocious sexual development in the first-degree rela-
8 A8 s7 x9 d+ f; i( W4 etives. There were no siblings.) g; y; Z( @% B- N: d! K
Physical Examination7 |0 F9 V' m, a. \5 B0 [% J
The physical examination revealed a very active,
$ x3 h- L$ Y+ g2 _4 j$ p8 X2 Rplayful, and healthy boy. The vital signs documented
6 r: N2 U. W# n) Sa blood pressure of 85/50 mm Hg, his length was
+ B" H/ d$ F1 s; u6 v; c9 Z" e90 cm (>97th percentile), and his weight was 14.4 kg% G# @5 H: ]6 r4 M! j
(also >97th percentile). The observed yearly growth
2 i8 ?7 M" ^6 O2 m0 B' A2 H8 {" a. y8 ovelocity was 30 cm (12 inches). The examination of
- o* \+ _( s/ G3 }9 y* n+ mthe neck revealed no thyroid enlargement.
$ X5 I' s% c% _  C; X4 y2 \7 G3 K( ^/ zThe genitourinary examination was remarkable for
7 e7 m, x- `$ P* R9 @$ D  n. Eenlargement of the penis, with a stretched length of- [1 T$ R+ y( E- L
8 cm and a width of 2 cm. The glans penis was very well
/ F2 E, ?) H: _8 ideveloped. The pubic hair was Tanner II, mostly around- i. E) P% ~+ Z; ]
540- Y% Q& b9 g  D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 k% _7 P7 _3 `# q& G9 J+ _6 X# W, H
the base of the phallus and was dark and curled. The
. C3 ?+ v* R- F9 H& ~% X" Otesticular volume was prepubertal at 2 mL each.$ C7 o! k4 d/ w! p9 t" h# u
The skin was moist and smooth and somewhat
2 J3 Y0 O% P- z: E, v6 u- }oily. No axillary hair was noted. There were no
6 {* q& |3 o& rabnormal skin pigmentations or café-au-lait spots.
6 z) {) Q5 V* E: f' w% a$ gNeurologic evaluation showed deep tendon reflex 2+
# [3 U! Z& ]! G+ H1 qbilateral and symmetrical. There was no suggestion
2 t0 k% ^1 E' J* T8 L' ~of papilledema.  u" t2 G  X3 L+ e
Laboratory Evaluation1 F- v0 J. u! K! P) b8 L+ d
The bone age was consistent with 28 months by) A% r9 Q: r! L( M. I# m: Y$ ~6 `
using the standard of Greulich and Pyle at a chrono-
, l4 @) v' f# j. k( p6 Klogic age of 16 months (advanced).5 Chromosomal) G4 V% h( M$ ^! \  T
karyotype was 46XY. The thyroid function test( H% T+ z* v% r* ~- ~3 a
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
( }9 y5 K  N; r- x, }9 Xlating hormone level was 1.3 µIU/mL (both normal).
9 P! e" E( d' M. kThe concentrations of serum electrolytes, blood
; L2 G& s) V, B0 V/ M+ E* iurea nitrogen, creatinine, and calcium all were! v' J9 }0 ]% O. t/ U* ]
within normal range for his age. The concentration0 y8 k7 @5 W# k
of serum 17-hydroxyprogesterone was 16 ng/dL
# `# B1 S5 A$ ?' `(normal, 3 to 90 ng/dL), androstenedione was 20
1 k# m$ e, R5 J9 m# S9 Xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ D" R' h+ {1 \  R" E: F, ~! b7 n* ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 x5 f3 i# C, }2 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to: M+ B( R  i5 o4 \- K) s
49ng/dL), 11-desoxycortisol (specific compound S), t6 [" w8 D7 ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 h" L, x; {/ G6 K* n7 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 f  i/ ^! U0 B& I- Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* y1 t! i, D6 Z. z  ?0 [
and β-human chorionic gonadotropin was less than8 M! |. g# k1 j+ M1 }
5 mIU/mL (normal <5 mIU/mL). Serum follicular0 V! n/ E6 s' h) F1 R
stimulating hormone and leuteinizing hormone
) F/ }3 r! |1 a% X2 s+ W% Q5 r. Econcentrations were less than 0.05 mIU/mL
3 @4 v: A7 j) [(prepubertal).
% w( U6 K' c- c& HThe parents were notified about the laboratory: f0 m; `+ R3 ^9 m7 ]; f' m
results and were informed that all of the tests were/ b" o, ]3 Y  c/ @" u. t" q
normal except the testosterone level was high. The9 P- @) g: B, d& S7 x/ b/ ^
follow-up visit was arranged within a few weeks to
8 D' q' f6 @. \! g$ Jobtain testicular and abdominal sonograms; how-2 x5 @) D" u% T% @# k
ever, the family did not return for 4 months.
- [0 _1 u6 Q) a' R3 I* ~# MPhysical examination at this time revealed that the2 S8 `: E6 P6 T' b5 f% D
child had grown 2.5 cm in 4 months and had gained
. _/ w% t$ i  \: w; [2 kg of weight. Physical examination remained% ?( z% ~( I/ Y& [) {
unchanged. Surprisingly, the pubic hair almost com-
4 u) R% W" {3 ^- s5 l& Cpletely disappeared except for a few vellous hairs at
3 i( z& ?6 S; W2 a1 kthe base of the phallus. Testicular volume was still 2
7 i3 p! _9 x) c) B. a# {mL, and the size of the penis remained unchanged.
4 ~) U: d) m7 j& g9 N  J9 IThe mother also said that the boy was no longer hav-. e7 ~7 h1 S  i" S; T- N
ing frequent erections.
$ X1 }( v3 }6 H. W/ Y! x4 n% zBoth parents were again questioned about use of
& C5 s/ V- h9 H/ O" f& cany ointment/creams that they may have applied to
; X$ x5 ^4 B1 ?2 {; P! Y# z9 kthe child’s skin. This time the father admitted the
6 d2 ?1 N! W9 k, g! ^Topical Testosterone Exposure / Bhowmick et al 541
, l  Z; _5 w: G) W, g. c0 C7 v, R# G5 Juse of testosterone gel twice daily that he was apply-/ a) y( Z, C+ S8 A" K/ M
ing over his own shoulders, chest, and back area for
/ z+ \6 P/ r% o; }a year. The father also revealed he was embarrassed
3 C4 P+ u; [) M) p' j  u  _, uto disclose that he was using a testosterone gel pre-
( h' n% x3 J6 O6 Pscribed by his family physician for decreased libido
) c& M/ x0 \2 Z5 i: h8 Esecondary to depression.
# ?& j+ S# |* }; B) H% ~- {5 s3 f. ZThe child slept in the same bed with parents.6 K: f( g9 P8 Z0 ]3 f  G% r
The father would hug the baby and hold him on his0 o6 u8 T$ P% k1 j6 B
chest for a considerable period of time, causing sig-6 m" _; D+ K, @" i
nificant bare skin contact between baby and father.
+ I4 K4 i  w& @# A, _0 e% b! _2 ~The father also admitted that after the phone call,
7 y0 t( u  ]5 P; |6 z- L* jwhen he learned the testosterone level in the baby. p/ p# n) b9 }/ p" u
was high, he then read the product information+ y- Q- x1 H  C
packet and concluded that it was most likely the rea-" N; B+ O& {/ l) d2 D
son for the child’s virilization. At that time, they
& h) i7 j5 Y' |) x( G' F0 S: Ndecided to put the baby in a separate bed, and the; B) y) O% ?4 H2 o( ?9 Z9 q
father was not hugging him with bare skin and had
9 T% B! p+ X( j2 jbeen using protective clothing. A repeat testosterone
) {+ O$ K" R4 U' Q; mtest was ordered, but the family did not go to the0 E- E: i. L) Q7 ?# f! z
laboratory to obtain the test.
* ?( M2 N% _3 [Discussion
5 u$ J  x+ C. vPrecocious puberty in boys is defined as secondary
, Z: v- G6 m' z2 g. Rsexual development before 9 years of age.1,4
4 O( y( i) s. @% ]. m3 p2 I% G; zPrecocious puberty is termed as central (true) when
& F/ k% B6 t" i* B2 Tit is caused by the premature activation of hypo-
; r  x8 z9 D! D- tthalamic pituitary gonadal axis. CPP is more com-
( ^4 q4 s# t/ E9 s2 `) imon in girls than in boys.1,3 Most boys with CPP  `$ r  N2 i! b5 p* \3 J
may have a central nervous system lesion that is' \, q2 C  `( r; U1 p. b  N$ p9 Q
responsible for the early activation of the hypothal-
& Y% I' V2 P$ A4 W% E$ {/ ]' \* oamic pituitary gonadal axis.1-3 Thus, greater empha-, T6 b3 ]$ Z. P0 g2 u& i, K, r. {% O
sis has been given to neuroradiologic imaging in
; b7 A0 w: }! z' U/ I* t: Hboys with precocious puberty. In addition to viril-4 Q5 O5 Z- }5 S/ h& g( a) R: r1 J
ization, the clinical hallmark of CPP is the symmet-
# {; ]) |8 b3 R# z% ?+ Qrical testicular growth secondary to stimulation by& w/ q3 O- u' l# ~, O9 n
gonadotropins.1,3
9 M2 p7 T* k$ w+ ~8 V3 SGonadotropin-independent peripheral preco-
! L& j5 `! _/ O+ Zcious puberty in boys also results from inappropriate
6 w4 h5 [0 j. Z6 U6 qandrogenic stimulation from either endogenous or
7 q: t5 v% t! q4 D" \" l* @exogenous sources, nonpituitary gonadotropin stim-
1 W$ U# Y5 M9 Iulation, and rare activating mutations.3 Virilizing- e$ |: d& b3 H0 E  B; M! i: n- Q
congenital adrenal hyperplasia producing excessive
0 g6 E! C5 l. }+ \! _( Cadrenal androgens is a common cause of precocious- i* ~( p; s2 U
puberty in boys.3,4
* r) _9 a) B) |) YThe most common form of congenital adrenal1 X5 M) j1 R. n! p/ D& T! P
hyperplasia is the 21-hydroxylase enzyme deficiency.; U: r- e; {* [  Q3 F+ O
The 11-β hydroxylase deficiency may also result in
8 M7 h$ ]7 q9 c" Uexcessive adrenal androgen production, and rarely,; Q) s7 h! W! j9 o
an adrenal tumor may also cause adrenal androgen$ {# `2 i5 k. G; u* J1 a
excess.1,3
) H7 B5 v9 h2 d( \& kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 \$ }- j" b/ g; V542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 F+ j( `+ Q  S' W. y2 G' k  nA unique entity of male-limited gonadotropin-" \) y- f: Q7 x. V) u8 s
independent precocious puberty, which is also known
' i: w) G/ P9 E% T; ^as testotoxicosis, may cause precocious puberty at a, n; h9 `) R, @# v: o  _- Q
very young age. The physical findings in these boys1 v1 `+ h# V8 M% r2 z. d
with this disorder are full pubertal development,
1 d# v% v2 L, c4 U/ J7 u- m( yincluding bilateral testicular growth, similar to boys) _7 n; U. E/ V+ O: H  j
with CPP. The gonadotropin levels in this disorder& t& A) k! x: ]
are suppressed to prepubertal levels and do not show
% u! L3 w) j7 X2 i; U+ f! J1 H! Wpubertal response of gonadotropin after gonadotropin-
1 W4 e% T2 L; }  Z# kreleasing hormone stimulation. This is a sex-linked
. T, ^* m3 k+ J& ~% |! v0 ^% Pautosomal dominant disorder that affects only0 m" K1 M+ K2 p
males; therefore, other male members of the family; q; C5 G0 [; m% `  O: b7 G
may have similar precocious puberty.3
. ^$ H4 c; Q' |) u3 HIn our patient, physical examination was incon-6 r' n; N' I3 \. ~6 n2 t
sistent with true precocious puberty since his testi-
. u+ p9 ^4 U4 m8 `9 A0 L9 xcles were prepubertal in size. However, testotoxicosis
+ X  Y7 ^$ U& Y% c7 O) r8 R( X) dwas in the differential diagnosis because his father
0 ?) t* |/ j) o& l8 Cstarted puberty somewhat early, and occasionally,
7 l  m; p3 w$ ctesticular enlargement is not that evident in the" ~1 D3 }+ ~8 B7 r/ A1 \" q/ ?' `
beginning of this process.1 In the absence of a neg-
/ o8 F1 o2 i+ }/ r  Rative initial history of androgen exposure, our
' I! n; M. R7 t, k+ @9 Y* Ybiggest concern was virilizing adrenal hyperplasia,
. m% h) m/ ^: m- b" ieither 21-hydroxylase deficiency or 11-β hydroxylase
: @$ m- {5 P. }* udeficiency. Those diagnoses were excluded by find-
- S5 D/ X% F2 B8 _8 i. v9 Jing the normal level of adrenal steroids.1 J5 @0 e2 b1 K& F, m# p+ w2 K
The diagnosis of exogenous androgens was strongly  }5 h0 ^1 F* S( x* E. ]7 a) L) A* L
suspected in a follow-up visit after 4 months because
$ {% h: b6 ~; r' ~" M, N, Z' m  zthe physical examination revealed the complete disap-
8 \+ _% c  y' y8 U" X' `* C6 Zpearance of pubic hair, normal growth velocity, and+ p" B/ y/ \# M$ A& S$ w5 J
decreased erections. The father admitted using a testos-
- ]* M4 b; W+ I9 nterone gel, which he concealed at first visit. He was' e* x7 ?" H( G- O4 l
using it rather frequently, twice a day. The Physicians’8 g1 d" u4 }& a$ D9 N
Desk Reference, or package insert of this product, gel or
/ i7 Z$ b! S% i0 Icream, cautions about dermal testosterone transfer to7 c' D6 H  _" j1 i  |3 j
unprotected females through direct skin exposure.3 t0 v5 G+ a$ l, I
Serum testosterone level was found to be 2 times the
. e8 @& s$ f# [1 [8 N  `4 r8 L5 Rbaseline value in those females who were exposed to
; \! c, B$ R) w" B# K! {even 15 minutes of direct skin contact with their male# ]8 K) _% z% u) A7 G8 p
partners.6 However, when a shirt covered the applica-
& S) N0 v  w+ I0 u% M1 ution site, this testosterone transfer was prevented.. L" @& @+ f( D2 `% z
Our patient’s testosterone level was 60 ng/mL,
$ u0 f" S7 ?+ j, l! a9 z/ ]which was clearly high. Some studies suggest that
5 A7 U5 `# J& X7 \8 Idermal conversion of testosterone to dihydrotestos-
3 e5 a8 X: J9 U! X6 |terone, which is a more potent metabolite, is more
" O3 D" G( e( pactive in young children exposed to testosterone1 V! B0 w' V8 f7 r
exogenously7; however, we did not measure a dihy-) K' n6 q: s: ?3 Q$ F
drotestosterone level in our patient. In addition to
  m' U. o7 N/ Q7 t' X: C3 A2 e% |: l- \virilization, exposure to exogenous testosterone in
" l4 T  Z; W, I, @children results in an increase in growth velocity and
1 b; I  x8 G, h/ nadvanced bone age, as seen in our patient.
; N: y) @2 O: v' r. iThe long-term effect of androgen exposure during
# L- c0 \, y$ t" w4 x* U' ^, R' a' Searly childhood on pubertal development and final
! o: i7 }2 T( U+ E! D9 ~adult height are not fully known and always remain
* y6 D  Y  q" xa concern. Children treated with short-term testos-
: s8 V0 G0 \: ]# g( ~terone injection or topical androgen may exhibit some
" E9 u) G$ x3 l) ~0 E% u! R- U7 lacceleration of the skeletal maturation; however, after
. w( w9 e, F( c  ?cessation of treatment, the rate of bone maturation
! p0 p2 Y) K4 v2 j  G8 \) d4 odecelerates and gradually returns to normal.8,90 O( u4 N% W( R+ p4 k5 ~( Q
There are conflicting reports and controversy- v" U$ _& s+ `8 |( d% |7 q3 k
over the effect of early androgen exposure on adult  d7 z/ X! W9 D! M+ m! y
penile length.10,11 Some reports suggest subnormal! ]7 }) l% U! T/ S8 C
adult penile length, apparently because of downreg-; V/ x6 g' p, t  `/ l1 T4 e
ulation of androgen receptor number.10,12 However,
. f" h6 o; ]  q- WSutherland et al13 did not find a correlation between
9 y8 K8 N7 j: j8 Q6 Q' n" Nchildhood testosterone exposure and reduced adult
7 U$ T- D8 L' H- Lpenile length in clinical studies.
' B. {# S0 H* Z* F" @0 BNonetheless, we do not believe our patient is) y2 o; Q# F1 X) x. x# F
going to experience any of the untoward effects from1 z  w2 c" J- Q
testosterone exposure as mentioned earlier because
$ a2 v8 W7 ?; O- a5 Jthe exposure was not for a prolonged period of time.
& R# h2 t1 [2 \8 t; vAlthough the bone age was advanced at the time of2 S. u' g  l+ K# ]+ b. J
diagnosis, the child had a normal growth velocity at8 f& G2 k9 ]) q5 \4 ?" E$ R7 L# J
the follow-up visit. It is hoped that his final adult
6 I- t# R% D' T7 r( N  b3 v2 u( Yheight will not be affected." q! L6 M! o! G/ k, |# S
Although rarely reported, the widespread avail-
2 d$ g1 l/ x/ E* G) U- Jability of androgen products in our society may
% B7 I8 Y8 l. l! J9 Iindeed cause more virilization in male or female
: M3 s2 K* N1 z0 zchildren than one would realize. Exposure to andro-
7 ?, a! j" G/ s1 }+ S$ j( Fgen products must be considered and specific ques-4 E3 y2 T& @7 `# P: h  ^4 N- h# E
tioning about the use of a testosterone product or
, D4 J8 C: ]. i" y1 Q- j/ ]gel should be asked of the family members during
( [5 t8 G. g5 |  _- ~6 rthe evaluation of any children who present with vir-. W1 u4 ^& v( Y0 K
ilization or peripheral precocious puberty. The diag-
, J1 D/ G6 U4 ]5 }nosis can be established by just a few tests and by
7 K: w$ s5 e0 g3 F, @+ pappropriate history. The inability to obtain such a
7 u5 q% b' }5 |0 Q; e: r: ~history, or failure to ask the specific questions, may
& N' \$ f% R; V. ~5 y  B8 X% {result in extensive, unnecessary, and expensive& l1 g( @, h  V1 O9 T
investigation. The primary care physician should be
1 t. i) \0 [4 g8 qaware of this fact, because most of these children( w  ?2 x7 u; ]
may initially present in their practice. The Physicians’
8 e+ o6 O. W/ o7 L$ e$ |Desk Reference and package insert should also put a
4 q; m% {2 G7 a5 z% Wwarning about the virilizing effect on a male or5 ?1 ~9 E6 j2 @9 p* D$ m
female child who might come in contact with some-
4 C2 H. b1 O/ None using any of these products.
9 |, c& `1 s6 k4 L  JReferences  S7 k* X4 N+ H  X0 ]+ ^& A
1. Styne DM. The testes: disorder of sexual differentiation6 E8 X6 d8 N; w9 i4 {
and puberty in the male. In: Sperling MA, ed. Pediatric$ y/ x1 I3 o. F. E7 Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 B8 Y4 W! f& B- U8 J% @% m
2002: 565-628.* L' M5 C8 K' N# }0 ^7 V: U8 v
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% Z% ^, T3 C' l* S: H8 Wpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old- j! `+ y% _' c, h
Boy Induced by Indirect Topical
6 ~7 [4 _: f6 _! s- V% C' U: l+ GExposure to Testosterone# K& `5 t1 P; y/ O+ d& e4 Z1 n. F  [" I
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 K3 K7 l( b! W! W, rand Kenneth R. Rettig, MD1- v' X0 h1 A$ g) n. a. |9 ~! W; v
Clinical Pediatrics
3 M; v- f# I- K) TVolume 46 Number 65 q  ?: O5 y$ _/ l' l6 T
July 2007 540-543# Z2 ~- s; `; w8 b; r3 S
© 2007 Sage Publications- s( S: ]" s) F$ j/ f
10.1177/0009922806296651( I' a; \0 X! ?
http://clp.sagepub.com
1 D+ V+ Y: E9 B5 |" ]: t% M$ ?hosted at
# ^8 U9 v7 g5 |http://online.sagepub.com. v2 W& {8 C& q) n' n) j1 j
Precocious puberty in boys, central or peripheral,& ?7 e8 H) }8 n4 e3 I
is a significant concern for physicians. Central
" ^: h* K+ ~' ]- z4 d) A3 `7 Aprecocious puberty (CPP), which is mediated
, A# {) z" M' j' x2 cthrough the hypothalamic pituitary gonadal axis, has2 j* a, d9 @" D4 F. q
a higher incidence of organic central nervous system
/ p/ p+ K1 ?# _- S1 ]2 Tlesions in boys.1,2 Virilization in boys, as manifested  d, P4 D  X( i1 R
by enlargement of the penis, development of pubic  P/ `9 d9 _. W# Q' U
hair, and facial acne without enlargement of testi-4 j. U% C2 Y  G2 p
cles, suggests peripheral or pseudopuberty.1-3 We6 r4 v! {5 T0 g- p( p
report a 16-month-old boy who presented with the
$ O/ _6 k- h8 G1 Menlargement of the phallus and pubic hair develop-
1 [. E0 e1 ~5 x/ |1 ]( z7 x8 kment without testicular enlargement, which was due
) \# m  \8 m1 H7 J9 c: R. ?4 ^3 z: Q% ^to the unintentional exposure to androgen gel used by
& ?  v& {, D7 E: _, W4 uthe father. The family initially concealed this infor-
& q) D' s# ?, V9 r  U+ {2 L4 x) q' Smation, resulting in an extensive work-up for this! x) n* o" }3 B. {
child. Given the widespread and easy availability of
( v. x* s% @( A9 vtestosterone gel and cream, we believe this is proba-
" o( @! e+ O5 dbly more common than the rare case report in the
4 x: k% P& c! e$ [literature.4
8 F. c9 a9 s- uPatient Report) S  A' Y+ ]5 C6 F
A 16-month-old white child was referred to the: s2 n# G* ]8 Z6 A' |; K8 ^+ ?3 W* a
endocrine clinic by his pediatrician with the concern0 i% X" o3 ^5 ]' }6 c
of early sexual development. His mother noticed0 M4 g) d+ B4 J# d/ e7 C
light colored pubic hair development when he was
# d7 J8 C" G. g3 L0 e/ bFrom the 1Division of Pediatric Endocrinology, 2University of
- v0 I$ n+ x! rSouth Alabama Medical Center, Mobile, Alabama.
  {3 @6 x- z9 RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 `# l! v/ h$ S( `. yProfessor of Pediatrics, University of South Alabama, College of" a4 \, T' @; W; {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* ~( l4 i1 p) je-mail: [email protected].4 b0 t& W+ L1 _" r7 H
about 6 to 7 months old, which progressively became2 D' x/ {1 ]) W! l' D* c
darker. She was also concerned about the enlarge-
& K" i' P4 g! [; sment of his penis and frequent erections. The child9 I; ^' O8 x# I/ G% G: J3 z+ n
was the product of a full-term normal delivery, with4 g- t- D1 i& f2 T  M" T' {2 A  O
a birth weight of 7 lb 14 oz, and birth length of
" c$ U( S8 P4 i6 ]20 inches. He was breast-fed throughout the first year) x3 q+ K: Y+ y- n! A0 q9 E% Y+ Z
of life and was still receiving breast milk along with
; N0 F6 Y4 I; b: }8 Q  J; V! esolid food. He had no hospitalizations or surgery,
! @2 s1 N) ?6 t' k6 j/ W; y1 iand his psychosocial and psychomotor development
9 r1 x3 @5 {6 F: ~: @was age appropriate.
; B4 h7 C- [8 o# }- {The family history was remarkable for the father,
8 B! z: R+ [) swho was diagnosed with hypothyroidism at age 16,
9 A6 C5 z$ G$ q, X- l+ G0 I0 j* _which was treated with thyroxine. The father’s
9 b, C9 \2 r' m/ z0 sheight was 6 feet, and he went through a somewhat
* Z# |3 i# m2 g' N/ `* Yearly puberty and had stopped growing by age 14.: M# }: g/ c1 K6 @: L
The father denied taking any other medication. The
6 k8 e. D$ f' e" r6 e- Y, schild’s mother was in good health. Her menarche5 ]) V$ }3 {# R7 Z
was at 11 years of age, and her height was at 5 feet. J3 a( N& U* i$ {) o* T
5 inches. There was no other family history of pre-
. C* ^4 H3 W" K% y: ]# d; Q( ncocious sexual development in the first-degree rela-
) W# i3 H7 [# }6 Y8 R6 y4 w; c  N% Dtives. There were no siblings.
3 L8 d+ z8 t  h, r) SPhysical Examination
( z* L& i- B- R4 f. @The physical examination revealed a very active,+ Q/ _6 W. V9 B
playful, and healthy boy. The vital signs documented
' ^9 D* }% G# k: `2 }0 {6 [4 ca blood pressure of 85/50 mm Hg, his length was  |( S4 t# H  f+ Y- p, ]
90 cm (>97th percentile), and his weight was 14.4 kg/ G- l' c; M, T- h- `
(also >97th percentile). The observed yearly growth& R6 f- g& c) N' \. Y
velocity was 30 cm (12 inches). The examination of
+ m+ g% {9 O5 Z3 |4 k  Kthe neck revealed no thyroid enlargement.( M5 [$ Q7 s: e4 ^  K/ O1 `
The genitourinary examination was remarkable for
% X, T, u! ]- N/ ienlargement of the penis, with a stretched length of
2 o6 f4 Y8 R! g1 A# r8 T. G0 @8 cm and a width of 2 cm. The glans penis was very well
- s; b4 W: \  f9 r2 H7 H$ o2 tdeveloped. The pubic hair was Tanner II, mostly around
/ P* A4 p8 }. P0 t  _3 T* M) u540
" H# t) ^( k3 t( d/ }7 P7 v" Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 {4 t, Z6 t/ W2 W
the base of the phallus and was dark and curled. The
' y2 w1 J( r* g1 r" {testicular volume was prepubertal at 2 mL each.$ B- h) L7 l  f. R+ e: ]9 ^
The skin was moist and smooth and somewhat
- Y: v( M; L# z9 G& \- a$ ~oily. No axillary hair was noted. There were no
0 o+ ^. _$ v4 ~* i, x4 A4 l: r# gabnormal skin pigmentations or café-au-lait spots.- @- e: V! @$ q% g8 b6 p
Neurologic evaluation showed deep tendon reflex 2+( j/ X$ v2 j# X8 q4 I$ j  S& ^
bilateral and symmetrical. There was no suggestion4 t( J9 ]- _% @' _( u
of papilledema.
3 @) V( c. W1 nLaboratory Evaluation( O# {8 d; h4 W: A6 Y
The bone age was consistent with 28 months by3 ]/ @& u% ^* g" Z
using the standard of Greulich and Pyle at a chrono-
. E. |( v3 a0 {, Jlogic age of 16 months (advanced).5 Chromosomal9 L6 h, f' P6 V4 u, i- Q
karyotype was 46XY. The thyroid function test0 N# F' s9 r/ |  O' c# y( X+ {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% b( A+ y) w: ?& H/ w" a1 ~lating hormone level was 1.3 µIU/mL (both normal).
& D2 e2 K  ?* E, j3 U! r9 j7 U* kThe concentrations of serum electrolytes, blood; H2 z$ s" B8 ?* q- N
urea nitrogen, creatinine, and calcium all were8 \5 E. B, h4 N# T* S2 V4 I/ }
within normal range for his age. The concentration: x! n) e$ W6 K! e6 z1 f+ A
of serum 17-hydroxyprogesterone was 16 ng/dL
$ O7 Y5 \2 |5 a(normal, 3 to 90 ng/dL), androstenedione was 20
  k8 m; j# c9 L' Y; Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- X8 x+ \; ]& L  q" ~, R
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* _& {7 \2 l+ v/ U
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) P* l8 q! K2 q7 Z49ng/dL), 11-desoxycortisol (specific compound S)% m  @/ C- `  h1 P
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-; }% O8 T2 ?; k$ \/ h2 q4 q2 s$ w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 g4 r- _, y/ R0 f# A5 N& E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 H9 A9 ~4 S% m( dand β-human chorionic gonadotropin was less than1 o" O. C3 V9 H3 R
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 r& v9 l2 c* d9 b% k/ r' P" Istimulating hormone and leuteinizing hormone9 _* o4 s5 q: X9 O
concentrations were less than 0.05 mIU/mL0 b1 ?5 T7 j$ k# P$ x
(prepubertal).
( b, R7 b# h8 l* o, E6 oThe parents were notified about the laboratory0 N- j' S* o, D5 H  ?
results and were informed that all of the tests were
) i# E# n+ i  f* |6 ^; h3 Knormal except the testosterone level was high. The
' F1 S; K0 p, u" @follow-up visit was arranged within a few weeks to  h2 }2 W, E% V5 ^( r' o
obtain testicular and abdominal sonograms; how-
  n9 u" j7 |7 e! g! d4 uever, the family did not return for 4 months.
3 t9 c  N' p, s4 o" j9 a0 e% T. rPhysical examination at this time revealed that the! e# M. Q! t$ J3 s9 L. Q  W
child had grown 2.5 cm in 4 months and had gained
- R, j) Z0 N4 Q& F2 kg of weight. Physical examination remained: Q4 n& f! N5 d0 _0 v9 q
unchanged. Surprisingly, the pubic hair almost com-
, U: M2 p) _9 `5 t3 Zpletely disappeared except for a few vellous hairs at) L5 W7 k; f' q6 D$ N
the base of the phallus. Testicular volume was still 28 B- e' a, w% r5 ]; T4 ?
mL, and the size of the penis remained unchanged.
; f5 t+ g7 @7 y$ L2 O4 FThe mother also said that the boy was no longer hav-) Y& J  ~2 |2 k, y! c0 y& G# }
ing frequent erections.
7 n1 M5 T' }% LBoth parents were again questioned about use of0 o9 E. O/ G' R1 d( T8 h: g, u
any ointment/creams that they may have applied to
  D9 @8 r+ X3 c7 R( l- _the child’s skin. This time the father admitted the
7 W) v8 V! ?$ U8 a" S; ]1 mTopical Testosterone Exposure / Bhowmick et al 5414 z+ x3 `3 _- J
use of testosterone gel twice daily that he was apply-
7 b- Y+ p+ w9 [  @ing over his own shoulders, chest, and back area for( L3 X7 M) t4 T
a year. The father also revealed he was embarrassed
  x9 n+ M1 T( O  U- B% jto disclose that he was using a testosterone gel pre-
4 z/ I; g1 g& T5 E& fscribed by his family physician for decreased libido8 b! v2 J1 m& y& [
secondary to depression., Q5 x3 n# J( d
The child slept in the same bed with parents.2 v( X/ w' w# G4 c
The father would hug the baby and hold him on his
9 P1 G; G* v/ ~) ?chest for a considerable period of time, causing sig-1 I  f4 P) [: D6 r
nificant bare skin contact between baby and father.
0 s/ ]5 }3 r% w( W5 \. |- e4 r/ s8 aThe father also admitted that after the phone call,
" V6 {! Y# M$ j0 ~8 hwhen he learned the testosterone level in the baby
( m# J! g3 L+ G- mwas high, he then read the product information
0 W7 E5 e: U6 [" `- _  upacket and concluded that it was most likely the rea-
' R/ o9 ], _  Q% I- b$ [! `son for the child’s virilization. At that time, they
& A! l1 y: l+ \" ^- fdecided to put the baby in a separate bed, and the
& k! D5 ]5 C3 F0 S. Vfather was not hugging him with bare skin and had
4 C" _  o8 L) b2 rbeen using protective clothing. A repeat testosterone
) s! ?* H% P/ j+ n1 ~, Ytest was ordered, but the family did not go to the
% E. ^: Z) j" n7 ilaboratory to obtain the test.& B! t" U' J& ~( a5 o& a
Discussion
7 r5 g) d2 B1 h' qPrecocious puberty in boys is defined as secondary: }9 c. Y8 c& R/ K) y9 [
sexual development before 9 years of age.1,4, l! l, _$ M- z* o: R/ H- `- {- B
Precocious puberty is termed as central (true) when6 [$ F- C: J* ]; b
it is caused by the premature activation of hypo-7 o1 L6 V# {% @. y9 k% l6 y6 Y
thalamic pituitary gonadal axis. CPP is more com-! c4 d& x3 }7 A4 o; H5 {8 G; e
mon in girls than in boys.1,3 Most boys with CPP
7 H/ ]) R7 e* |1 x3 ]9 N$ u) \- ?may have a central nervous system lesion that is
" ~4 y! J9 X" Oresponsible for the early activation of the hypothal-
; l- x6 y* b3 K/ Famic pituitary gonadal axis.1-3 Thus, greater empha-
+ E  n) E9 P- b4 @2 ]- Ysis has been given to neuroradiologic imaging in
7 X8 [  Y2 g1 R' A* tboys with precocious puberty. In addition to viril-
7 m/ o9 Q) r7 Tization, the clinical hallmark of CPP is the symmet-: v# e  G+ c" y5 e) j
rical testicular growth secondary to stimulation by
; e& a5 W+ s! C; fgonadotropins.1,3
& k3 c. {' H7 u5 A! oGonadotropin-independent peripheral preco-/ ]0 B, Y8 [9 s. _- f) M6 V, w
cious puberty in boys also results from inappropriate
6 @% o- A2 {& h# w) d: V, Y0 Z) x# Wandrogenic stimulation from either endogenous or
# J- j5 ^5 ^5 ?* V3 F- }exogenous sources, nonpituitary gonadotropin stim-. d1 N" V& P' }. M; j5 }+ V: l
ulation, and rare activating mutations.3 Virilizing0 V$ o6 E; N8 C: F% e; U6 |
congenital adrenal hyperplasia producing excessive
! H8 O4 \  s& t! \* Oadrenal androgens is a common cause of precocious' S% _/ y% W6 _1 h; J
puberty in boys.3,4" L6 t7 P8 G$ E) v
The most common form of congenital adrenal
4 [- J4 c1 |4 v1 p5 ]hyperplasia is the 21-hydroxylase enzyme deficiency.6 K+ ~8 i/ H8 i. [3 n' v, i
The 11-β hydroxylase deficiency may also result in/ }! r% [1 O  R7 U
excessive adrenal androgen production, and rarely," Q# t3 ?% L" @, W) Y! q
an adrenal tumor may also cause adrenal androgen- W) Q6 C% w7 F# S# @9 w
excess.1,3
7 ^# c  j8 o  Y$ k& }. t% }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( E, R0 U0 H$ o# P542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* U. q, o0 P; l$ c) U/ f5 YA unique entity of male-limited gonadotropin-
& k9 ~: i1 [, R2 n& Cindependent precocious puberty, which is also known: @4 v4 E) B$ m- d
as testotoxicosis, may cause precocious puberty at a
# o- h2 E5 e( {  W, overy young age. The physical findings in these boys) z+ f9 S& K2 C# L! z2 d+ l5 z
with this disorder are full pubertal development,: A$ t) f  p% K5 r
including bilateral testicular growth, similar to boys$ a; C: e% _2 |* M! m
with CPP. The gonadotropin levels in this disorder
4 K3 ~$ E, x/ G5 o3 Z' z7 Q4 Rare suppressed to prepubertal levels and do not show' W3 H9 }  F" X; C: @; v* \! V" x0 J( o
pubertal response of gonadotropin after gonadotropin-
3 x# i1 m9 x7 R+ w0 Lreleasing hormone stimulation. This is a sex-linked
) @9 u# d( r  ~; s2 {1 lautosomal dominant disorder that affects only6 g$ w/ `4 l( ?8 w
males; therefore, other male members of the family) T8 R3 m/ q5 |6 I3 ]( z  k( B# @
may have similar precocious puberty.3
% ~1 Z+ I" a- Z: U' ZIn our patient, physical examination was incon-
( Y3 M# @/ i. y" h1 ~9 G0 N& Ksistent with true precocious puberty since his testi-
' N- B4 c' z$ d0 ucles were prepubertal in size. However, testotoxicosis: [) ~0 e3 h( z8 O; M5 K
was in the differential diagnosis because his father+ z& K: J7 b  U- {5 S; R
started puberty somewhat early, and occasionally,! f! p4 Z; T" w+ H$ i! g1 C- r& J8 c
testicular enlargement is not that evident in the& [  v9 D: e: W5 W
beginning of this process.1 In the absence of a neg-' u' c  p0 }, u& I& B
ative initial history of androgen exposure, our
$ @. a2 z2 {0 n1 B( W, Rbiggest concern was virilizing adrenal hyperplasia,6 \4 U' C) H, d$ B* f9 I0 b6 G
either 21-hydroxylase deficiency or 11-β hydroxylase
6 ~0 V3 x! D& ideficiency. Those diagnoses were excluded by find-
# o7 _4 g+ P5 u4 n3 Qing the normal level of adrenal steroids.
% Q5 c( k& W; ~" J" [2 yThe diagnosis of exogenous androgens was strongly
5 O1 j1 z" v3 psuspected in a follow-up visit after 4 months because
$ V- z( ]! {! h  h! z* H; `the physical examination revealed the complete disap-- T& g5 R, R! W
pearance of pubic hair, normal growth velocity, and
2 j6 Y+ x/ `8 o4 P4 l6 mdecreased erections. The father admitted using a testos-( \8 k5 i2 a) Q* |6 |
terone gel, which he concealed at first visit. He was
# P) m1 Q6 k  q) o# ^& {2 Gusing it rather frequently, twice a day. The Physicians’2 f! d3 T2 Z" p3 o% B
Desk Reference, or package insert of this product, gel or
/ k/ Y0 t1 n2 i% Z& ~cream, cautions about dermal testosterone transfer to
7 Z7 [# _% t3 Cunprotected females through direct skin exposure.- c2 Y( x* U' l9 @. X1 W( Y  }
Serum testosterone level was found to be 2 times the$ @9 C% K4 o# R: i
baseline value in those females who were exposed to
- g; {8 E' Z, @" W/ q: z1 o$ a' `even 15 minutes of direct skin contact with their male! c" n. G; A  x' ^- T$ D) G1 v$ K
partners.6 However, when a shirt covered the applica-8 p0 @# z" X7 {- D
tion site, this testosterone transfer was prevented.) @. |1 [. ~4 o; E! C/ h
Our patient’s testosterone level was 60 ng/mL,
: I% ^' [/ ^- e/ e$ G$ H+ Twhich was clearly high. Some studies suggest that
6 q( e1 W5 j- X, mdermal conversion of testosterone to dihydrotestos-$ o7 t: q' `; Y3 Y: l! E
terone, which is a more potent metabolite, is more
  }- W8 m. h! K- B: lactive in young children exposed to testosterone
6 H# G( C  ~4 a" y) k* u; t; l' ]exogenously7; however, we did not measure a dihy-* J( `+ V$ c6 @( L3 h' @7 d& I; d
drotestosterone level in our patient. In addition to# ^) `. Z" W0 f0 A( w# s! |: M
virilization, exposure to exogenous testosterone in7 Y3 k% S' t8 O  D4 H7 Q
children results in an increase in growth velocity and
; X; \  M& L9 K/ |2 hadvanced bone age, as seen in our patient.
0 G# H% E: b; e6 A5 BThe long-term effect of androgen exposure during5 Q) c$ `  V5 T. e& S& _* @! \, D1 F
early childhood on pubertal development and final. v; B# `9 S9 b+ N) b
adult height are not fully known and always remain
' V; c8 M0 |( _: Q# i2 J% {a concern. Children treated with short-term testos-
% Q8 ^' M) F0 c' S0 l9 dterone injection or topical androgen may exhibit some
3 ]6 T. g" N: }. tacceleration of the skeletal maturation; however, after% u: [' g1 `; C: s8 @
cessation of treatment, the rate of bone maturation
, Q- j3 a- m5 |decelerates and gradually returns to normal.8,9
# ?' G% \( X6 T5 G5 Q1 tThere are conflicting reports and controversy) P0 ?9 K+ W( |  E4 C/ h
over the effect of early androgen exposure on adult
7 d8 @/ G9 J* y) P) U: fpenile length.10,11 Some reports suggest subnormal$ Y2 d, n4 X. N) @
adult penile length, apparently because of downreg-
- p- r. B8 ]( d" s+ Q1 L9 ?ulation of androgen receptor number.10,12 However,) j1 v  N2 O  @$ i. f  V0 |; B
Sutherland et al13 did not find a correlation between
; L5 K5 r( B: L% a3 O5 uchildhood testosterone exposure and reduced adult
  C; u, R$ u9 b" J7 i5 Npenile length in clinical studies.. l& @+ `0 Q) \
Nonetheless, we do not believe our patient is
  G# Y& n! w' c6 R+ g: t- ]going to experience any of the untoward effects from
, K2 p; ]1 ]% m: r, V% ftestosterone exposure as mentioned earlier because3 N4 p) @- m) G3 B# i
the exposure was not for a prolonged period of time.+ ?- k( o" w: n3 k* F
Although the bone age was advanced at the time of0 c* k" r$ v- g# d, v) q
diagnosis, the child had a normal growth velocity at
3 R  k& }" l& g7 ^* b& i7 e; [the follow-up visit. It is hoped that his final adult
% J0 W* f$ z, u3 w, |height will not be affected.
0 O: M  k/ C: P7 ~& p8 m: s* ?Although rarely reported, the widespread avail-+ Q8 j; R( r/ h
ability of androgen products in our society may
$ B# P5 S, W* Y* ?, b5 hindeed cause more virilization in male or female
9 Y( d% C- D5 l( {' ^) Q, Q, Zchildren than one would realize. Exposure to andro-
5 U+ O8 a' O% v; `7 ~9 f2 R1 f$ Cgen products must be considered and specific ques-
' N; S" F6 l3 q) Htioning about the use of a testosterone product or
( Y  W) r7 Z/ D; kgel should be asked of the family members during2 b8 q1 l1 R) Y) U4 F& n
the evaluation of any children who present with vir-) V6 D- t5 P, o
ilization or peripheral precocious puberty. The diag-0 R# H( }, M# Z2 h
nosis can be established by just a few tests and by
& W2 J2 t5 m5 W" Vappropriate history. The inability to obtain such a# P* g: ?! b. @: i, \4 y' x
history, or failure to ask the specific questions, may
* P- P) G8 [& ~# G1 G1 O: b  bresult in extensive, unnecessary, and expensive
: d$ E; A' G: @4 e& G, [investigation. The primary care physician should be  m, w5 N6 J5 V: V! V
aware of this fact, because most of these children. ^: l: A7 y3 S9 N( D5 e" A
may initially present in their practice. The Physicians’8 N6 G  P- r: C+ v- L" B# b
Desk Reference and package insert should also put a; j& f. U, U- y- r
warning about the virilizing effect on a male or6 E6 T# c5 E: @* |( I. h$ l+ X
female child who might come in contact with some-
. |) @* x( c7 H/ Q5 Y3 s/ V- {one using any of these products.) K$ J  ?, U& O) {  k: {: o
References
* L: Z0 I. J$ |  X, H+ R1. Styne DM. The testes: disorder of sexual differentiation$ \3 m! r1 F/ q
and puberty in the male. In: Sperling MA, ed. Pediatric/ e5 S1 K) e! G
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) s  E* z- W; M8 K' E) |/ k2002: 565-628.$ T0 C/ R* b4 A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 t0 [7 H& j0 Z* Z
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
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
, {, s! u  F$ O. c
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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