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Sexual Precocity in a 16-Month-Old" R! k. D  t% r/ `6 d( k
Boy Induced by Indirect Topical) @& n" {  i4 b& m4 G/ n
Exposure to Testosterone
- v% c0 {: d% |7 q/ `1 V+ c* vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ q5 X# V# D2 D5 a: k1 I) Jand Kenneth R. Rettig, MD1
9 f" K7 ]! @0 N2 L$ xClinical Pediatrics" e5 w$ R% ?1 A7 E7 e
Volume 46 Number 6
2 X- |3 b# ]' O" h+ O$ h/ r0 F8 R, tJuly 2007 540-5434 q5 d) t9 v# o- R7 i
© 2007 Sage Publications* @  g( l. y& \  ?
10.1177/0009922806296651& {+ z( U0 K+ W: X- j
http://clp.sagepub.com7 ]- u5 I0 @* j- p6 n
hosted at4 w$ k8 N- d/ `+ p) G2 X& L. p: U3 k
http://online.sagepub.com4 E- r0 O, ^7 p, t) E3 w' A' g6 t
Precocious puberty in boys, central or peripheral,
" x/ U( R6 B# ^  w% sis a significant concern for physicians. Central% O! Y# z6 I" E6 D
precocious puberty (CPP), which is mediated" F7 J0 r8 I3 ]* q4 O5 R* W7 t# R
through the hypothalamic pituitary gonadal axis, has  E0 P$ A6 g* I
a higher incidence of organic central nervous system' a$ V# H+ }9 o& y5 f5 _
lesions in boys.1,2 Virilization in boys, as manifested9 M7 G. N' T% a; j
by enlargement of the penis, development of pubic
: K6 V% _. }5 n$ N, Hhair, and facial acne without enlargement of testi-; N; T# m' h- [7 f$ ^4 E
cles, suggests peripheral or pseudopuberty.1-3 We9 O" o  G& a% z( W9 x5 [
report a 16-month-old boy who presented with the
7 E0 t# s6 t( a, U, H3 g2 |enlargement of the phallus and pubic hair develop-; q, r" c! }! u( M
ment without testicular enlargement, which was due+ l7 _  }2 U4 ?. B3 r$ g, w: x
to the unintentional exposure to androgen gel used by
" S- `( R0 o+ vthe father. The family initially concealed this infor-5 C' N4 m: \$ h- Z
mation, resulting in an extensive work-up for this/ v  q8 E$ b& f5 u) ?1 o( ]% ?* P
child. Given the widespread and easy availability of
; H2 n8 V$ X3 @, C: E0 Rtestosterone gel and cream, we believe this is proba-7 J* T3 x& \& p: g
bly more common than the rare case report in the
+ a! _1 x& M' J# \3 |- i. |& Yliterature.4( J% x5 A5 {. g6 h& e! n
Patient Report
& B0 P3 r2 i" M+ W! w8 T; H' BA 16-month-old white child was referred to the6 u! M* y" j5 ^1 [3 B4 e
endocrine clinic by his pediatrician with the concern
% V0 i' _* g' h; E# c% }# Q" P8 i0 pof early sexual development. His mother noticed1 `) R& w+ A2 I9 e( p" V  o( r) k
light colored pubic hair development when he was
3 l; m- p2 _6 s4 u) f) E1 ?From the 1Division of Pediatric Endocrinology, 2University of& M; i( l/ P' g1 l
South Alabama Medical Center, Mobile, Alabama.2 `: k2 [+ Y) H* _( n' J9 @% W/ ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& ^, O3 N$ e1 N/ |Professor of Pediatrics, University of South Alabama, College of( e0 x% A  ?  p2 g7 P  d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 U2 F9 K, R9 l2 t% G" X; n
e-mail: [email protected].
: G& a2 w8 P5 c- K3 F& Cabout 6 to 7 months old, which progressively became7 d* u+ [" y9 \5 C$ ]% D
darker. She was also concerned about the enlarge-
# ?6 Q( J" f6 N% E! l' Y: G9 Zment of his penis and frequent erections. The child
  u; c  a( J0 ~. t+ h# E) ?$ |was the product of a full-term normal delivery, with! P& L$ F! c( r- U5 k( R" P
a birth weight of 7 lb 14 oz, and birth length of/ J& n  H% H4 E6 ~* K
20 inches. He was breast-fed throughout the first year
# g& p$ V; V% Y& Z% K" qof life and was still receiving breast milk along with+ R0 R3 Y9 O7 T' k
solid food. He had no hospitalizations or surgery,! a! a1 S' h+ _/ o( K4 E! B
and his psychosocial and psychomotor development" l8 d1 @& P/ J+ J' w+ m# {
was age appropriate.9 D9 f$ j' `0 f4 f
The family history was remarkable for the father,! N& M5 x5 D" `2 x; i4 S: Q
who was diagnosed with hypothyroidism at age 16,3 K0 X0 S1 H- T; Q  r; _
which was treated with thyroxine. The father’s
4 J0 M2 s8 W6 K* d* Oheight was 6 feet, and he went through a somewhat5 _$ c4 c- }0 a" L6 ]9 K" _- D4 Y4 @
early puberty and had stopped growing by age 14.
( C+ ]0 ^8 ]; x: \The father denied taking any other medication. The
: W& m& v6 p: l. i! r$ U  Tchild’s mother was in good health. Her menarche
3 n; ~0 @( S5 qwas at 11 years of age, and her height was at 5 feet. X3 d" {; k2 t' Q  Z7 k$ X
5 inches. There was no other family history of pre-8 D3 Y+ A7 h: {/ }( o* Y  r
cocious sexual development in the first-degree rela-
3 Z. d( H% k* F* E6 Y6 Rtives. There were no siblings.4 y' A% C3 ~2 P1 k4 B* Z
Physical Examination
: f# G! _4 d: I  |" X! W' h9 L8 ZThe physical examination revealed a very active,
* ?5 u6 }& z& u; k" f8 Xplayful, and healthy boy. The vital signs documented
- N6 L2 b3 w; H; ]/ \$ C! q2 Oa blood pressure of 85/50 mm Hg, his length was
, y( J" G# N. s8 Y: t  y% i90 cm (>97th percentile), and his weight was 14.4 kg
! G! B; h  ^. W8 I6 t% Z+ ^; {0 I- z(also >97th percentile). The observed yearly growth
: o6 s7 t3 a+ j4 ~# Bvelocity was 30 cm (12 inches). The examination of, q* l+ I& W9 l. ~2 l0 D
the neck revealed no thyroid enlargement.8 ]" t% H6 N+ c# ]
The genitourinary examination was remarkable for# o6 O( i- k1 B5 Q7 W# V4 ^
enlargement of the penis, with a stretched length of' z: w) F6 u; y, W2 Z
8 cm and a width of 2 cm. The glans penis was very well! m* _( q; B2 Y: ~6 ]* M% Z  s
developed. The pubic hair was Tanner II, mostly around
; w; P# V% g6 f0 z& ?8 V# E5403 [: Y0 ~! S. n# z; G1 L/ F0 m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" ?+ ]9 a% u# p6 Othe base of the phallus and was dark and curled. The
2 Q; F6 K, m" N- u' [. Ntesticular volume was prepubertal at 2 mL each.8 I/ Q0 T2 _- W% X8 {2 m5 j
The skin was moist and smooth and somewhat. T+ b$ r$ M' [, ?
oily. No axillary hair was noted. There were no( L; Y0 l0 A; X# N
abnormal skin pigmentations or café-au-lait spots.
; ^; L) b* q- R$ eNeurologic evaluation showed deep tendon reflex 2+
3 u) r/ u2 y) R( S& F. N) Y  G0 Ibilateral and symmetrical. There was no suggestion* u  p! {3 \" h, q
of papilledema.; ]$ X7 x) ?! p+ k1 ?: h4 e/ z
Laboratory Evaluation# z( z, O2 ]* B* z' E; X
The bone age was consistent with 28 months by' V5 l$ L7 f# R9 M) J
using the standard of Greulich and Pyle at a chrono-% M2 G7 v& g1 M2 ]& m& c* I
logic age of 16 months (advanced).5 Chromosomal
( i% G2 k3 C6 E1 r: q5 @4 okaryotype was 46XY. The thyroid function test
2 z( r* y' E( L/ Z; l1 fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-+ J6 g1 ]& S& X" Q, O8 _* l
lating hormone level was 1.3 µIU/mL (both normal).
. Y( r$ X5 k, [, U& eThe concentrations of serum electrolytes, blood. @" W$ M: s6 x, W$ A
urea nitrogen, creatinine, and calcium all were& u  @6 L* I( M& ^6 g5 K
within normal range for his age. The concentration$ @5 f$ S1 H# a. m* Q
of serum 17-hydroxyprogesterone was 16 ng/dL
$ P# Y: D6 j9 ?# C(normal, 3 to 90 ng/dL), androstenedione was 20; K& q2 p+ \6 d2 J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 i0 d" R1 @6 v/ }' @$ T
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ v2 O6 S& E, O3 M$ O# C/ Hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to% ]& @, E5 l5 ?- X. A, s8 |
49ng/dL), 11-desoxycortisol (specific compound S)( W; O$ w% }% D
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# S% e6 h% ~: G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 v8 H+ ~+ I; i7 E/ {  Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. V8 e! T! u. k" H
and β-human chorionic gonadotropin was less than2 l3 ^! }# ^. p! ]' V! @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" D: y* d# A( T+ d/ istimulating hormone and leuteinizing hormone
* I' K. L$ r2 G* {concentrations were less than 0.05 mIU/mL& {( M: G4 Z+ x; R5 }! S" r
(prepubertal).
. A9 ?8 c  w* R  dThe parents were notified about the laboratory
! J' n; ]) I2 r6 j. U% @results and were informed that all of the tests were7 U2 C' n. c- z) W4 z
normal except the testosterone level was high. The
  k: G# d) k- u. `* Gfollow-up visit was arranged within a few weeks to
- R7 p* `1 j' y% u! f1 k% K0 L/ uobtain testicular and abdominal sonograms; how-
8 P! d4 o0 h$ I0 j1 hever, the family did not return for 4 months.! r8 a3 t- r* b2 v' H, k- z4 R& m. @
Physical examination at this time revealed that the
- [; O1 I3 x' A+ D% }2 Y- tchild had grown 2.5 cm in 4 months and had gained
! R6 ?% r( B8 G* t# ~2 kg of weight. Physical examination remained
5 @+ f3 e" O! c2 _! V  ~unchanged. Surprisingly, the pubic hair almost com-
1 d+ N; [. ]. ]$ ^1 d5 f4 ~% fpletely disappeared except for a few vellous hairs at
, B" _7 U5 i2 A3 v8 q+ E% M  Hthe base of the phallus. Testicular volume was still 29 T  K8 P, U: X0 o; w
mL, and the size of the penis remained unchanged.- @1 g6 y/ J. z( T+ g0 g9 |
The mother also said that the boy was no longer hav-
* l7 \+ Z* C4 D2 p4 ~- Ming frequent erections.! V% m1 \; `# Y
Both parents were again questioned about use of+ @" Z5 S% y5 ?) r- D8 W/ q5 y
any ointment/creams that they may have applied to* b6 e- n+ l2 [9 W* `
the child’s skin. This time the father admitted the
8 G/ w, E, ]5 M3 vTopical Testosterone Exposure / Bhowmick et al 5419 W! W1 o7 n% Y: f( i4 H
use of testosterone gel twice daily that he was apply-
2 j5 A! w, B$ Ying over his own shoulders, chest, and back area for
% r8 E+ P  G+ ~2 K  F3 ma year. The father also revealed he was embarrassed2 O4 \3 T. C8 t" q" }$ P, @
to disclose that he was using a testosterone gel pre-8 _/ q3 [. K, K$ @( G% V
scribed by his family physician for decreased libido
/ t) e+ m# Z% q, o. [9 Ksecondary to depression.4 w7 i- N0 \9 f  \% X: Y7 w3 r4 i
The child slept in the same bed with parents.. Y4 A; I9 K2 x
The father would hug the baby and hold him on his5 n! Y6 S2 h- \, Y. K  q
chest for a considerable period of time, causing sig-! W  T( B( t4 r& v
nificant bare skin contact between baby and father." ?$ r. N; Z% v/ P3 k3 e& N
The father also admitted that after the phone call,
$ W9 m! H, B0 Hwhen he learned the testosterone level in the baby
. r$ R$ u. \! J' E6 w2 T' p) {, bwas high, he then read the product information
) }) o* I7 J/ Ypacket and concluded that it was most likely the rea-% j8 P; d' T  t4 _' Q
son for the child’s virilization. At that time, they
' }: G' k9 w$ L/ z$ G' a4 J1 ydecided to put the baby in a separate bed, and the3 _9 r( B$ S2 B# }! M2 x
father was not hugging him with bare skin and had
+ x# U, g  r- {2 c7 Dbeen using protective clothing. A repeat testosterone0 N+ ~9 G7 e( ?
test was ordered, but the family did not go to the
0 c) s& g9 L" k: G; |laboratory to obtain the test.) s8 \1 e, H6 y! K. h
Discussion
+ z" v$ S3 `) r! tPrecocious puberty in boys is defined as secondary. A% n0 f3 @" E8 ?4 d3 s* y
sexual development before 9 years of age.1,4
1 ~% ^# G! r+ q0 T$ NPrecocious puberty is termed as central (true) when
* W! x; p$ B$ x+ e3 c7 d1 ?0 ]: R) Mit is caused by the premature activation of hypo-! r6 g/ S9 C  Y. I+ r2 c- D
thalamic pituitary gonadal axis. CPP is more com-
+ c  {# [! t) v+ @# ~0 o; jmon in girls than in boys.1,3 Most boys with CPP
0 L2 W! C8 [6 U5 X! j1 P9 e* Hmay have a central nervous system lesion that is( ~2 Q8 [. N/ ^- J5 W5 M" M2 ^
responsible for the early activation of the hypothal-
, C- B# {# \8 F( }8 [4 b# ~amic pituitary gonadal axis.1-3 Thus, greater empha-* K' m! s7 F0 R7 I% i! l# L) d
sis has been given to neuroradiologic imaging in/ b; z1 ^" F& q$ ^
boys with precocious puberty. In addition to viril-" J: _. y- _# p- l! o$ M3 u4 [6 v
ization, the clinical hallmark of CPP is the symmet-
- `% O# d5 P; n7 ^; h6 Grical testicular growth secondary to stimulation by
9 N# z2 A) j* w4 M7 C+ ngonadotropins.1,3
5 ^, v0 ^, O3 e7 n3 r, nGonadotropin-independent peripheral preco-, H: x6 {( _6 ~0 s: |$ Q
cious puberty in boys also results from inappropriate* L2 G: c6 T+ E. G
androgenic stimulation from either endogenous or, U) ?9 ]- p" K7 u
exogenous sources, nonpituitary gonadotropin stim-$ w% p/ T% N1 q2 m* b! j
ulation, and rare activating mutations.3 Virilizing
+ M# \0 y3 S$ rcongenital adrenal hyperplasia producing excessive
0 ?) |8 S: {( R  f: i1 d) }adrenal androgens is a common cause of precocious
* p7 X  k  Z- P$ A' e# _) epuberty in boys.3,4. Y" i( M* U7 j9 ~, {) N+ P
The most common form of congenital adrenal/ W# n+ ]- p# d( z. w3 \0 v& b) y
hyperplasia is the 21-hydroxylase enzyme deficiency.* r" r: ?3 A  G8 g- i
The 11-β hydroxylase deficiency may also result in3 R9 r8 B( {- q7 V1 ?5 [$ i) M
excessive adrenal androgen production, and rarely,
  \$ y% a3 k4 {an adrenal tumor may also cause adrenal androgen
& u$ L: `/ \8 O6 Lexcess.1,31 \/ r9 [( E, ^  x% \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 [- A# p# Z4 K- i4 f$ G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 y, t# I' w! ?9 c$ `9 ]1 QA unique entity of male-limited gonadotropin-
' }" J6 D9 w! _/ `independent precocious puberty, which is also known
+ U+ D' X& v& las testotoxicosis, may cause precocious puberty at a
- K4 F( ^& _8 H' J' f; dvery young age. The physical findings in these boys
: q' M6 n3 e2 d, O) n: uwith this disorder are full pubertal development,
: a. q+ p" c3 U0 g" @9 M4 T  Cincluding bilateral testicular growth, similar to boys) d8 z4 Z2 M: w- J6 q# s
with CPP. The gonadotropin levels in this disorder! d2 v7 v$ q  M8 h/ p/ G
are suppressed to prepubertal levels and do not show
; {% v$ o" J; M$ Z" V# x. O8 ipubertal response of gonadotropin after gonadotropin-
4 b6 @* ?! j1 h4 ?releasing hormone stimulation. This is a sex-linked
- w5 w; C! b3 k" c1 }! xautosomal dominant disorder that affects only
: U/ G+ ]* f5 f" `6 `' {males; therefore, other male members of the family
$ q1 o9 X+ l! i! A0 k8 t4 O" {may have similar precocious puberty.3/ k7 f2 T5 \9 g- t
In our patient, physical examination was incon-
7 {+ S0 L6 W& n7 z8 Xsistent with true precocious puberty since his testi-
- E' _+ j  Q4 {; M* |5 Ycles were prepubertal in size. However, testotoxicosis
, ?& m5 X+ b& `2 R' r2 ewas in the differential diagnosis because his father! Z; s$ H. |; _8 k6 F" _- q: P
started puberty somewhat early, and occasionally,
9 a3 ]/ o# K3 l8 Y. W2 p) z. mtesticular enlargement is not that evident in the
! f+ R  E9 x8 K/ t6 Ibeginning of this process.1 In the absence of a neg-; t$ b- ?) Z% A! i
ative initial history of androgen exposure, our5 s& |* ?. W$ ]
biggest concern was virilizing adrenal hyperplasia,
1 C! k7 S% ^6 m- _% I8 e! l. Qeither 21-hydroxylase deficiency or 11-β hydroxylase
% }" x- c5 w( n/ kdeficiency. Those diagnoses were excluded by find-( K$ ^* ~8 y+ ]0 {' A: \* N
ing the normal level of adrenal steroids.$ P% f& j, P7 t
The diagnosis of exogenous androgens was strongly! _, {) }: ]2 z9 j
suspected in a follow-up visit after 4 months because; N. O; e) |. V  c" R9 m! D
the physical examination revealed the complete disap-, l& Y% q- ?9 H% X; j9 X
pearance of pubic hair, normal growth velocity, and
: }6 l3 M% ?8 Z4 D: i" b0 `decreased erections. The father admitted using a testos-5 _  W4 {: J* W! k- ^# g
terone gel, which he concealed at first visit. He was& W& Y9 L; {( l- M
using it rather frequently, twice a day. The Physicians’
7 E3 n( D; E/ z6 ]6 A9 yDesk Reference, or package insert of this product, gel or
* M2 S  g, k8 U! h# w4 |$ p" Q* @cream, cautions about dermal testosterone transfer to4 q% a  R% o  A) ?; P! i
unprotected females through direct skin exposure.
1 E+ `  u, C6 V0 w8 u8 rSerum testosterone level was found to be 2 times the
' Q- A$ s9 _1 t3 ]8 A' B7 c0 Dbaseline value in those females who were exposed to0 F, F5 y% U. n) J
even 15 minutes of direct skin contact with their male0 @* p1 e6 j6 R* L3 S* p  U  n
partners.6 However, when a shirt covered the applica-
+ i: T7 t) d) P+ h" e; s2 _tion site, this testosterone transfer was prevented." \, I- s6 a1 S: }% S
Our patient’s testosterone level was 60 ng/mL,
) S  Q& H1 V, j2 w- lwhich was clearly high. Some studies suggest that
( E. C8 P7 L" m0 Gdermal conversion of testosterone to dihydrotestos-
8 H+ \2 \6 q+ w3 K, qterone, which is a more potent metabolite, is more
# N8 X" ]  _' V. D3 gactive in young children exposed to testosterone
, u% _# x' R* w1 K  w. Wexogenously7; however, we did not measure a dihy-
3 n$ F# h/ J& O( o3 F8 ~drotestosterone level in our patient. In addition to
& A( s* f: A6 n/ y1 k- ovirilization, exposure to exogenous testosterone in& e: @5 W8 L+ y& P9 k6 }
children results in an increase in growth velocity and8 e" ^' y$ R+ _
advanced bone age, as seen in our patient.
( z! O" e. z  b0 [The long-term effect of androgen exposure during& y# ?% ]+ H5 V" w
early childhood on pubertal development and final9 }4 x$ ~, o. W( g4 P0 r+ b4 I
adult height are not fully known and always remain) y0 i+ M/ I( b2 q5 a8 [
a concern. Children treated with short-term testos-3 Z! F) u8 l/ b- X; Y
terone injection or topical androgen may exhibit some9 L2 j+ r9 F( t0 z4 M
acceleration of the skeletal maturation; however, after
& i/ C3 M% J% ^# ~4 ]4 s) wcessation of treatment, the rate of bone maturation, Y: l* Z; L6 I# t
decelerates and gradually returns to normal.8,91 H0 r; x3 y. |. J$ F) X- o: N+ P2 @
There are conflicting reports and controversy
2 |) C0 Q" ^) z( A- D7 T) Y6 Gover the effect of early androgen exposure on adult* [6 z0 W; i" p+ y& Y$ M* g
penile length.10,11 Some reports suggest subnormal" H6 B* [' Y! @- K. K
adult penile length, apparently because of downreg-2 ^- N6 T# U/ i# S- ~" z
ulation of androgen receptor number.10,12 However,) P- }; O" G3 ~7 ^6 h3 V
Sutherland et al13 did not find a correlation between
: i9 X1 X5 H/ B8 [1 h# Schildhood testosterone exposure and reduced adult1 _0 n1 a$ T% k- G/ X2 b3 ?
penile length in clinical studies.
% Q8 Y2 r/ Z2 d& x0 ?: vNonetheless, we do not believe our patient is
% e6 U+ Y6 G2 t3 E% M! R' \going to experience any of the untoward effects from
$ ~# T6 E& l5 ^/ z9 S" Otestosterone exposure as mentioned earlier because, C. E+ S3 Z4 c, g
the exposure was not for a prolonged period of time.% F( x% }( C' b- y+ k1 }1 F  B7 s
Although the bone age was advanced at the time of
/ ]8 P. b% Y) a8 fdiagnosis, the child had a normal growth velocity at1 k7 c3 g8 x: Z5 }7 p  b' T9 s
the follow-up visit. It is hoped that his final adult
. G7 J- P4 C+ fheight will not be affected.( C$ v, |. K8 j$ Q
Although rarely reported, the widespread avail-0 {+ x5 z7 v; S* b# x
ability of androgen products in our society may$ ~3 O/ x' `( M* p5 v/ V
indeed cause more virilization in male or female; e0 p9 t5 J  g# g5 c
children than one would realize. Exposure to andro-2 k' v5 l5 x) U3 Z0 L" g2 H
gen products must be considered and specific ques-" ^& E0 T5 Z2 t2 S( D
tioning about the use of a testosterone product or( P5 f( J: ?1 m# k( h
gel should be asked of the family members during# e( @: ^6 A# [/ }
the evaluation of any children who present with vir-
: G. K( }* A' Gilization or peripheral precocious puberty. The diag-
0 R5 v- k2 I( X' L0 p# _6 q2 _: v0 unosis can be established by just a few tests and by4 j* g" a8 s6 g- n, {2 j
appropriate history. The inability to obtain such a
* Z3 X& J$ V- K2 o$ q" H- S; T+ U" _history, or failure to ask the specific questions, may9 r3 Z. i9 ]% }0 Z- M1 r
result in extensive, unnecessary, and expensive
. u0 `3 V; ~# j& t" Uinvestigation. The primary care physician should be
0 J. V8 Z0 ^" v2 Z+ zaware of this fact, because most of these children
0 Z! G0 \- f% Smay initially present in their practice. The Physicians’, [7 h/ j9 l# t
Desk Reference and package insert should also put a
5 j3 Y1 U# G8 U. a3 F6 |' v3 owarning about the virilizing effect on a male or
; t% b+ G% r) p1 qfemale child who might come in contact with some-/ l- f- {3 i, y* }# f+ b
one using any of these products.4 B1 e5 q2 F& A9 B
References
% \6 k3 D6 l$ W2 b# F) ~: X% C- W0 U! Y2 D+ b1. Styne DM. The testes: disorder of sexual differentiation
6 Z1 L! R$ S" i) K5 hand puberty in the male. In: Sperling MA, ed. Pediatric8 l: v% D: R2 o) [  z- H! A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) \) u' ]& N- T2002: 565-628.
4 z6 w7 p# T# B0 O) r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ I# S& M; R/ Y1 @  v7 D
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old, b, Z9 h. D; X& f0 v2 @
Boy Induced by Indirect Topical
7 h2 k. w4 T. bExposure to Testosterone0 X; m. b# A0 t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, B# C: k, Z0 q9 Jand Kenneth R. Rettig, MD1
) B6 c! u, G* P! m: vClinical Pediatrics
% \+ Q) ?9 [1 T4 A: l0 @Volume 46 Number 6( w8 b# D5 h9 }( v
July 2007 540-543
7 o2 g; |1 J5 Z" e0 |3 o© 2007 Sage Publications
" q: Q( n1 i0 @* c10.1177/0009922806296651, m; N( ~0 q) T4 G: P
http://clp.sagepub.com% j  W# n3 ^3 I
hosted at
+ B9 E9 w  z" Zhttp://online.sagepub.com+ D" P8 h$ A7 V* b7 W" H
Precocious puberty in boys, central or peripheral,' Q% _- I, v8 X( B( V2 b
is a significant concern for physicians. Central. ^! B4 `" a; |/ k+ c2 x: g7 h
precocious puberty (CPP), which is mediated
: [9 e# c% z# Rthrough the hypothalamic pituitary gonadal axis, has
2 U& |, H5 J0 g2 k9 ca higher incidence of organic central nervous system: [* @/ A9 g  ]' @$ J) L/ f' L9 D
lesions in boys.1,2 Virilization in boys, as manifested
7 P0 s# F, j$ Lby enlargement of the penis, development of pubic
- V  ~" Q3 B( n# s" _hair, and facial acne without enlargement of testi-# f8 S% q: S" w( z( U& L) C
cles, suggests peripheral or pseudopuberty.1-3 We
* B7 v  r( H  p* hreport a 16-month-old boy who presented with the
9 f1 ~  _2 l! ]$ Y" X. P5 henlargement of the phallus and pubic hair develop-) Q/ d+ Q; ]: `* ]" E% w% i
ment without testicular enlargement, which was due
2 t7 ?7 C! R% _* l; o! m, Oto the unintentional exposure to androgen gel used by
0 b1 v5 j9 ^+ P4 M# F+ |* ~the father. The family initially concealed this infor-
3 b0 _7 q4 v- y7 nmation, resulting in an extensive work-up for this: G4 R" G# X- Q6 s9 ^
child. Given the widespread and easy availability of6 A2 E# Q8 U1 c9 e2 n& Q. I/ a
testosterone gel and cream, we believe this is proba-+ V( N% j) U6 k0 [0 C3 P
bly more common than the rare case report in the
2 o9 \6 _! G2 e% z/ E4 Kliterature.4
9 S2 Y$ y( y1 M+ PPatient Report3 m& x& ?. @, k. {/ j
A 16-month-old white child was referred to the  K+ P! C* a0 A6 ~
endocrine clinic by his pediatrician with the concern
/ L: B; l) `4 l, g, xof early sexual development. His mother noticed5 {5 O# k  }$ u4 ^
light colored pubic hair development when he was
" c4 i( C4 W! U3 Q2 H( ?7 D( X) BFrom the 1Division of Pediatric Endocrinology, 2University of) G+ c. G' L1 H: W. F5 y; ?! }
South Alabama Medical Center, Mobile, Alabama.8 s: C8 J  j* n$ K% r
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 J( E7 T7 g8 P
Professor of Pediatrics, University of South Alabama, College of
# d) r/ m0 f& c5 J/ C1 LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# x8 j3 y3 F. d0 U6 A& V$ H! F
e-mail: [email protected].
) [9 v" A6 `* g+ ~/ x7 t# D! cabout 6 to 7 months old, which progressively became" l) V. ^! [- W( s0 ^
darker. She was also concerned about the enlarge-
6 i  n5 W* U- j, ]5 y, ]0 c, fment of his penis and frequent erections. The child! i0 E5 c7 H$ ]  f  @1 Y- [
was the product of a full-term normal delivery, with
$ W7 v) J# z- E! y& va birth weight of 7 lb 14 oz, and birth length of
; b: ?" b# B" p# q3 U. E0 E20 inches. He was breast-fed throughout the first year" g, m8 U3 p3 J8 s1 f0 x. I
of life and was still receiving breast milk along with
  f- X4 w% x0 ^. v4 D& nsolid food. He had no hospitalizations or surgery,
% d- G& M- A$ O2 q8 ]5 jand his psychosocial and psychomotor development5 \6 O- z9 z( y9 d5 m! v
was age appropriate.
$ l! D$ @  R0 Y  n6 L' GThe family history was remarkable for the father,  ?( O, m6 h+ _$ q6 |4 x* G+ ^' w
who was diagnosed with hypothyroidism at age 16,9 a& b& T0 m5 Z' b- ]7 P3 P, G
which was treated with thyroxine. The father’s2 f8 G! u" c+ q/ ?
height was 6 feet, and he went through a somewhat- L* e; m- Q" w( T& P4 I! O
early puberty and had stopped growing by age 14.
' S/ c) _3 K0 ^The father denied taking any other medication. The
! n7 j3 \, g& wchild’s mother was in good health. Her menarche
* N3 M6 c$ B' F9 I- B5 Qwas at 11 years of age, and her height was at 5 feet6 s4 G5 ^8 v/ _2 ~6 m
5 inches. There was no other family history of pre-( |5 [+ n3 y7 `: ~. n$ h# ^
cocious sexual development in the first-degree rela-( b  Z8 r1 @% J) s% r: Y3 \6 X
tives. There were no siblings.3 f3 ]$ ?, @" w7 d5 T, Q6 e
Physical Examination
1 o4 c  E# f2 D2 J" L/ x9 |7 `  kThe physical examination revealed a very active,
+ c8 t5 a# V" c; z. v$ Oplayful, and healthy boy. The vital signs documented
& W9 O; g9 J/ d) S6 {, z' q; T7 Ga blood pressure of 85/50 mm Hg, his length was
$ N( L- I  J4 y1 G90 cm (>97th percentile), and his weight was 14.4 kg( p7 @% m- j( N) [  l
(also >97th percentile). The observed yearly growth
$ J* X1 p/ k1 g6 Hvelocity was 30 cm (12 inches). The examination of
0 `! I. H0 ?, [" mthe neck revealed no thyroid enlargement.
8 C3 p# q& g6 s" m; vThe genitourinary examination was remarkable for
* U5 z8 i* M( _, B/ Nenlargement of the penis, with a stretched length of- X1 N/ x2 X$ J' H# S
8 cm and a width of 2 cm. The glans penis was very well
: p0 L5 W% T; _6 g) p$ pdeveloped. The pubic hair was Tanner II, mostly around  X/ p# a+ M3 L
5406 @7 D, K! ^7 `( z2 _% {' D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; v. S2 o" n9 ]2 a  w3 b2 c+ q* N8 Bthe base of the phallus and was dark and curled. The
3 O( H7 @( F# H1 {: p% Q: ^testicular volume was prepubertal at 2 mL each.. e; [, e- L- m" K+ S' l# G% p; v
The skin was moist and smooth and somewhat8 b: I: i8 k" F- Y$ M5 Q
oily. No axillary hair was noted. There were no
2 v$ B6 |/ y9 \+ S9 o* U& v5 fabnormal skin pigmentations or café-au-lait spots.
! j6 G* G2 W; o  PNeurologic evaluation showed deep tendon reflex 2+: x; ~+ [0 M: d2 o" X3 Y: F
bilateral and symmetrical. There was no suggestion+ v+ B( N/ [& w& ]0 b
of papilledema.
7 N  I: c% Y; o: k$ yLaboratory Evaluation3 D$ I& O2 @! r3 f) K* c, G
The bone age was consistent with 28 months by* p. b7 m& u* {- r; T
using the standard of Greulich and Pyle at a chrono-3 g6 A+ M7 _6 [) y- w$ U
logic age of 16 months (advanced).5 Chromosomal
. Q% W7 Y5 W9 s! Skaryotype was 46XY. The thyroid function test
* `6 Y# T: j8 ]6 Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-9 n' i$ C* M8 N3 n: ?
lating hormone level was 1.3 µIU/mL (both normal).- r1 R) x9 E: j5 Z  [  f
The concentrations of serum electrolytes, blood
7 b- M! J7 D  E# eurea nitrogen, creatinine, and calcium all were8 A7 X  u: }4 @5 s6 a& f: {: e8 z5 u
within normal range for his age. The concentration( w; ^; I7 q) R$ `0 R8 r
of serum 17-hydroxyprogesterone was 16 ng/dL
& {3 ?! x  l) ?; ](normal, 3 to 90 ng/dL), androstenedione was 20
  m$ v+ Y# U% v* y2 E3 w: x; Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, C2 X* m% Q6 `6 [& E$ Xterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& |4 s3 Z8 Y# c9 }" l; X8 |" w. wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to6 B; h: |( w1 `5 o; C1 N$ F! e
49ng/dL), 11-desoxycortisol (specific compound S)8 o6 x9 D/ \1 ^5 n* j" @6 W
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 n  h! S8 Q4 u6 Jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 x+ v  ^3 B! a8 q' I. Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 w# F" e7 W* D; l, ?9 Zand β-human chorionic gonadotropin was less than' u6 f/ l: t2 t' n: T
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# n( O: k. v1 G! x/ astimulating hormone and leuteinizing hormone( k9 v  \1 I  q. I# ~$ Z0 t* h
concentrations were less than 0.05 mIU/mL
8 Y9 x) D; s: ?3 W9 S$ n(prepubertal).
: L% X) N& H- C( ~The parents were notified about the laboratory
1 F0 E7 Q4 B* U0 Bresults and were informed that all of the tests were8 Q6 ?' R4 N! ~& `) d$ S
normal except the testosterone level was high. The
) d1 T% w0 V2 l3 j- O+ Wfollow-up visit was arranged within a few weeks to
. j; A+ o: S) X9 A5 [! fobtain testicular and abdominal sonograms; how-
! h6 c% Z: v" ^$ f1 Bever, the family did not return for 4 months.
$ d) q( D' H  `) J4 ]1 APhysical examination at this time revealed that the' t, `1 G0 Q( M) {
child had grown 2.5 cm in 4 months and had gained
2 ~6 y; F* P- z0 t6 r3 \2 kg of weight. Physical examination remained+ W/ Z+ i8 _  K) y
unchanged. Surprisingly, the pubic hair almost com-; V: R8 P* w  }7 n; f* U8 y
pletely disappeared except for a few vellous hairs at+ o9 s; s. h& ^
the base of the phallus. Testicular volume was still 2
# @% H% L$ M8 s  R: J1 s4 [mL, and the size of the penis remained unchanged.9 _+ [* W8 n  f0 c  }
The mother also said that the boy was no longer hav-0 D8 d6 G# G# S) A4 U# N4 V) P
ing frequent erections.
8 R* N  a' {. Z8 m, }' F3 i& qBoth parents were again questioned about use of
2 i, d- ]0 M$ q8 w' T* \( v4 Many ointment/creams that they may have applied to6 F5 I6 F. }# Z& K' X5 L2 P% ]
the child’s skin. This time the father admitted the
/ H  W( P( b- n2 oTopical Testosterone Exposure / Bhowmick et al 541  E% C* @3 b9 L+ H* f, _& [6 E; A5 U5 {
use of testosterone gel twice daily that he was apply-; D. S) y9 y4 l; Z
ing over his own shoulders, chest, and back area for7 `2 V" @$ m' R: L/ @) I0 q
a year. The father also revealed he was embarrassed
) J( @% R0 m4 l8 b1 o8 l6 R3 jto disclose that he was using a testosterone gel pre-
) x' U/ v9 m# A0 k1 escribed by his family physician for decreased libido1 K# V. n; j+ q7 M- W9 P( Q7 _
secondary to depression.
  V4 o( G  `) D8 q- o! K; K4 k+ U- oThe child slept in the same bed with parents.4 ?0 W& J" l8 m( j; A5 y' I! g0 ~
The father would hug the baby and hold him on his
2 b. [9 O! F2 mchest for a considerable period of time, causing sig-
$ A! {+ k( s1 E1 L1 y8 e1 Snificant bare skin contact between baby and father./ b# e: q0 E: K! \* z
The father also admitted that after the phone call,
) u  ?0 Z7 {4 V. A/ ewhen he learned the testosterone level in the baby, N, z% f' g0 F4 v+ @& m- Q+ y
was high, he then read the product information
. |0 X$ K" F" M" I4 o9 F; apacket and concluded that it was most likely the rea-  s; B, A/ Z2 m, V! h
son for the child’s virilization. At that time, they' e3 c& p7 b' k! D" Z; Z
decided to put the baby in a separate bed, and the
7 s8 k2 B/ d& I9 b6 m! Mfather was not hugging him with bare skin and had
5 p$ Q3 r( J$ M8 ibeen using protective clothing. A repeat testosterone5 i- D0 T. H, ?7 a" J3 U- e
test was ordered, but the family did not go to the
% i) k" {* q) r  x/ D- ]6 U) rlaboratory to obtain the test.
1 a) Z, Q4 h4 _- E/ A, v9 WDiscussion2 J# n/ i3 ~5 x" |* g
Precocious puberty in boys is defined as secondary
* M  x2 R' o5 Y2 h9 a8 _) tsexual development before 9 years of age.1,4/ \) Q7 c' y' O; V/ f2 B
Precocious puberty is termed as central (true) when8 O  }# |* b( t& Z
it is caused by the premature activation of hypo-9 u1 ~2 j7 X/ C
thalamic pituitary gonadal axis. CPP is more com-
4 y& [1 q  I9 m+ qmon in girls than in boys.1,3 Most boys with CPP2 a5 Y9 f. D1 ^/ e* h8 x& H- L
may have a central nervous system lesion that is
/ H- ]9 |/ S6 ~  p* K( p0 Y+ h) Dresponsible for the early activation of the hypothal-3 @: s. k  H, L4 h' X+ n
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ N8 L+ G- w0 `4 o' N3 `! D/ P( isis has been given to neuroradiologic imaging in
2 U& l/ L4 L5 R0 U8 G# pboys with precocious puberty. In addition to viril-; v" X/ h) X- w# o* m: a
ization, the clinical hallmark of CPP is the symmet-. G7 ?) K- {, W2 ?
rical testicular growth secondary to stimulation by  A/ p3 J4 F, R  v8 H
gonadotropins.1,3& o# m2 i7 ]' |; E8 \  ]
Gonadotropin-independent peripheral preco-6 X) x, V; r, P2 q$ z% i; Y4 M0 W- Z
cious puberty in boys also results from inappropriate0 o, L4 i( A! Q4 E
androgenic stimulation from either endogenous or5 ^+ W9 c! J) g$ l: n$ j8 s
exogenous sources, nonpituitary gonadotropin stim-6 U: u+ {5 ]5 F: p
ulation, and rare activating mutations.3 Virilizing
& L8 H1 ^) J. k/ ]: R% D7 R9 ~0 Scongenital adrenal hyperplasia producing excessive
) @4 O% a' H6 `# S7 `adrenal androgens is a common cause of precocious1 X  F$ K# h! `$ d. c# j6 p
puberty in boys.3,4# a. E2 M0 l3 e! T1 Y' U( r
The most common form of congenital adrenal
# e* O/ ^# N+ k+ R5 Uhyperplasia is the 21-hydroxylase enzyme deficiency.
8 R4 w0 M- t4 L6 |+ R( H! FThe 11-β hydroxylase deficiency may also result in) @4 _  O6 W5 t# m  b
excessive adrenal androgen production, and rarely,
; q! A1 `* {  i+ T8 v3 Wan adrenal tumor may also cause adrenal androgen
8 b5 w2 L# b( C+ X' A4 R6 a" B8 [excess.1,3
4 ?2 s* X  R( L, d) }at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 i( C6 s. E8 S' ?5 J+ L1 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! |# I! W, e0 c9 e" }A unique entity of male-limited gonadotropin-
8 G$ c# ]$ M9 |7 L( K( ]1 U3 Z6 X2 mindependent precocious puberty, which is also known
1 M3 A# |/ }- Y" mas testotoxicosis, may cause precocious puberty at a4 c9 J7 B/ }2 _, j7 a5 e* w1 z
very young age. The physical findings in these boys4 A- Z( V' j" K3 `
with this disorder are full pubertal development,
( P: l0 M" J9 A0 ~) R; R% \$ wincluding bilateral testicular growth, similar to boys
3 M, N- o# h9 C$ jwith CPP. The gonadotropin levels in this disorder8 N0 u+ s* q. O" ?
are suppressed to prepubertal levels and do not show
3 u- @$ t+ Z6 \pubertal response of gonadotropin after gonadotropin-0 b2 {5 l+ Z: j0 l& ?
releasing hormone stimulation. This is a sex-linked* D0 C8 ]8 d; i6 V: D  \5 F1 r
autosomal dominant disorder that affects only, y  D- `. `& v
males; therefore, other male members of the family3 G: ?# j& J( [2 G2 X% c! U
may have similar precocious puberty.3
& @: t) L: ^& ?  W  |; {& FIn our patient, physical examination was incon-
5 L8 B' ?3 `- Z1 tsistent with true precocious puberty since his testi-
# |3 L0 ]8 P0 E% Dcles were prepubertal in size. However, testotoxicosis; ^( h- F  @9 i7 }, _
was in the differential diagnosis because his father
& ?8 L. U7 K! d4 y/ }& Vstarted puberty somewhat early, and occasionally,: V8 A, V+ q6 |6 e2 y1 }2 q
testicular enlargement is not that evident in the
' ~4 N4 p5 T3 b( o$ W5 xbeginning of this process.1 In the absence of a neg-
7 x% R$ p1 y4 J3 w* n- i3 rative initial history of androgen exposure, our% E: v( z4 b+ {" {! ~
biggest concern was virilizing adrenal hyperplasia,3 W) S/ M& a1 \/ Y+ f
either 21-hydroxylase deficiency or 11-β hydroxylase
  C7 [) m6 d' M( b+ kdeficiency. Those diagnoses were excluded by find-, ^: W9 P/ O  e+ i9 O. S4 }, g: a- L! \
ing the normal level of adrenal steroids.
) ^% \1 C5 N* B% O0 `) |The diagnosis of exogenous androgens was strongly9 g5 c: _2 P8 c; v
suspected in a follow-up visit after 4 months because
2 J8 O4 L. q/ F+ ~5 W. Wthe physical examination revealed the complete disap-
9 Q# o" G- `2 _, C) V6 Tpearance of pubic hair, normal growth velocity, and) P: b) T# O/ {% ~
decreased erections. The father admitted using a testos-
* _' Y; g/ E8 }9 Uterone gel, which he concealed at first visit. He was4 ^! V( I$ x) w" o* }* C* X
using it rather frequently, twice a day. The Physicians’- W5 j1 f! R" J5 f, P; Y
Desk Reference, or package insert of this product, gel or
& r& s% l7 s5 ^& ecream, cautions about dermal testosterone transfer to8 B1 u/ m6 @. l2 O; y8 l# P
unprotected females through direct skin exposure.# b# s. v& ]: a" W4 P1 X& r
Serum testosterone level was found to be 2 times the/ q, v, ~9 o5 E3 D* u% M
baseline value in those females who were exposed to
* ~* W: q# x! A, D+ |8 D- f; meven 15 minutes of direct skin contact with their male
5 F/ `, ]7 T" K& Fpartners.6 However, when a shirt covered the applica-
0 v! s( N5 `3 s& {4 j+ gtion site, this testosterone transfer was prevented.
, A7 G( ~* [1 p) c4 b+ J4 q  `Our patient’s testosterone level was 60 ng/mL,1 E2 F9 d3 {5 a9 d" c
which was clearly high. Some studies suggest that
! b: }2 B) h$ U) m0 ^0 bdermal conversion of testosterone to dihydrotestos-5 K* L' o8 Q/ x. E
terone, which is a more potent metabolite, is more3 Y2 P' ?  M# {- p
active in young children exposed to testosterone
2 T; Q$ E$ T% R3 Nexogenously7; however, we did not measure a dihy-
% n3 m  W% i# r+ k3 N' rdrotestosterone level in our patient. In addition to
2 m' z( s0 T0 @( o2 kvirilization, exposure to exogenous testosterone in- b/ B$ z0 p9 W; J
children results in an increase in growth velocity and
- S' r. E6 e* h9 g1 L+ Eadvanced bone age, as seen in our patient.3 e9 s! |5 N7 H( B. G" k
The long-term effect of androgen exposure during
7 W/ U- {" |' M% Y3 h' Oearly childhood on pubertal development and final; i( \9 A. h1 u5 d) T
adult height are not fully known and always remain! X9 a* B1 T8 _. e
a concern. Children treated with short-term testos-
1 N' `% ~0 r* w6 J, f$ T" l6 q( Nterone injection or topical androgen may exhibit some
  n( \  R& ?+ j! ]* Vacceleration of the skeletal maturation; however, after! _, d0 d4 O9 g0 B1 I* i: r3 H" z
cessation of treatment, the rate of bone maturation7 T. }  O  n$ d" G2 N) }; u
decelerates and gradually returns to normal.8,9
! _  |$ b+ X+ h2 K/ W- z0 D$ xThere are conflicting reports and controversy, i" n) h1 n/ ~8 T2 q
over the effect of early androgen exposure on adult  A$ z( M, H, }( \6 W
penile length.10,11 Some reports suggest subnormal* ^' R5 y. f5 r! Q4 N/ U
adult penile length, apparently because of downreg-# X2 W4 B$ e: K. a* Z7 \
ulation of androgen receptor number.10,12 However,2 B, y. f6 @$ k1 V0 V  D6 x2 q
Sutherland et al13 did not find a correlation between
0 v1 s2 v; x7 ^. G, hchildhood testosterone exposure and reduced adult4 I8 N/ F' f* }* b, @
penile length in clinical studies.; e2 m7 z0 E0 a! P* n: O
Nonetheless, we do not believe our patient is
; K$ Y1 r2 R& M- u; h  Bgoing to experience any of the untoward effects from! g9 {* q) r# A! I6 k6 E& R' `8 E
testosterone exposure as mentioned earlier because
% K/ A+ ]" a& r- fthe exposure was not for a prolonged period of time.: q( |9 d- k5 S9 i
Although the bone age was advanced at the time of9 R/ P. U% J* B+ [% `$ m/ ^6 V
diagnosis, the child had a normal growth velocity at
8 V' l5 N. F  G( \the follow-up visit. It is hoped that his final adult+ f5 V( F* j3 p6 Q" F; p7 s& Y/ c7 @
height will not be affected.
8 c6 k( U! O+ F" G9 E, A. i' G! HAlthough rarely reported, the widespread avail-4 H: s: N0 r. ~% w, z
ability of androgen products in our society may' u! Z' [( [4 h, x  S' M* F
indeed cause more virilization in male or female
' [: u3 ~% x: W( echildren than one would realize. Exposure to andro-
& @' @, S! v  ~gen products must be considered and specific ques-
5 Y' s& {, |, V' d. J6 ^# ~/ Z5 rtioning about the use of a testosterone product or
6 p- I; |# t% lgel should be asked of the family members during( t. M2 g; e0 i
the evaluation of any children who present with vir-2 h: v: y1 R9 D; F7 Q% d6 w6 y
ilization or peripheral precocious puberty. The diag-
4 v: c& b$ J) X9 J; f+ P* O& _' u) ^" anosis can be established by just a few tests and by
7 ]* A" h" [# D/ x) Oappropriate history. The inability to obtain such a# M3 e" M$ P. m2 P7 \1 e/ p
history, or failure to ask the specific questions, may
1 o1 N8 `# h4 z" A- M9 n+ lresult in extensive, unnecessary, and expensive- U4 L8 h! j$ Z; V7 Z
investigation. The primary care physician should be7 k( {% Q: R( L1 _7 m
aware of this fact, because most of these children% l1 y8 [. ?, o2 S1 X! u  Y/ r
may initially present in their practice. The Physicians’  O- D5 F! ]! I6 N& e+ [  O) U  \
Desk Reference and package insert should also put a4 G5 y) T7 A6 Z+ m# g& U1 ^* }3 P0 t
warning about the virilizing effect on a male or
# K) G( \# i: r/ c1 ]& y$ _female child who might come in contact with some-
! ~7 c$ ?+ j8 D* v5 Cone using any of these products.7 ^; }6 W* r1 L$ s$ Z
References
7 Y" X& b& a  _6 J( J) i1. Styne DM. The testes: disorder of sexual differentiation
  M! c1 ?, D" ^/ k2 w2 i# b0 uand puberty in the male. In: Sperling MA, ed. Pediatric9 F5 S& J9 z6 J
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ H! e6 c7 `. u: r! K9 |7 `, T4 G2002: 565-628.
, g" t- `1 _5 n/ g/ F" P2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 [  ~) u. c1 A; G/ ~7 @
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
$ I; F0 a& r2 _0 o, G7 d! _
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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