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Sexual Precocity in a 16-Month-Old
" A+ @- B& T3 T1 UBoy Induced by Indirect Topical
; p3 G$ m8 y) j" s+ s# CExposure to Testosterone) |# k& @4 q4 f, y+ A) V
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 P1 G' S4 L) j
and Kenneth R. Rettig, MD17 ^& P- }; L9 j1 y/ k3 j9 Z# E
Clinical Pediatrics
& L1 l: D9 x* tVolume 46 Number 6
2 w- a9 H# I/ M- B/ B; SJuly 2007 540-543
2 l- G0 }/ U5 s1 k0 I6 x" O+ l; h; V- x9 l© 2007 Sage Publications
1 h/ P2 f4 H. E& Z10.1177/00099228062966518 q; O3 `3 g# Q5 f9 W, L
http://clp.sagepub.com
: |+ b- b: Z  P) X! T' Q' l" A" ~& `hosted at
% k' V4 D& f' F* p# n8 Z. ^1 Khttp://online.sagepub.com
" _* g2 _. I7 K5 pPrecocious puberty in boys, central or peripheral,4 N$ Y# U4 z9 k; y$ i# z
is a significant concern for physicians. Central
" ^* p. c! [: R: I6 j1 Oprecocious puberty (CPP), which is mediated4 o1 I  e/ L' ?
through the hypothalamic pituitary gonadal axis, has
( w3 _8 D% o6 W& O6 Ra higher incidence of organic central nervous system
, }0 e* _. G% [0 `2 ^lesions in boys.1,2 Virilization in boys, as manifested
0 X( S6 J3 I! xby enlargement of the penis, development of pubic
5 [! K# }0 \6 d8 p: [6 Q/ `- j! [hair, and facial acne without enlargement of testi-( G' a) z( K  a5 V4 E
cles, suggests peripheral or pseudopuberty.1-3 We
% \9 M/ _- `; N9 x) b/ xreport a 16-month-old boy who presented with the" c9 v& w7 {$ d' m6 c8 N
enlargement of the phallus and pubic hair develop-0 T2 v: `; j8 A  F6 K5 b( {
ment without testicular enlargement, which was due
4 O5 u! R- R% t# lto the unintentional exposure to androgen gel used by$ L+ s# b; @9 D" k* p: d
the father. The family initially concealed this infor-
% V) d5 {* e) ]" N. m$ Z$ ymation, resulting in an extensive work-up for this: `: [( V9 _. w6 T, G4 ~" ^
child. Given the widespread and easy availability of7 q# l: g5 r8 ?# t' v7 @
testosterone gel and cream, we believe this is proba-( }2 ]$ Z  f) f! x! B
bly more common than the rare case report in the
7 R2 t9 @  u1 }8 Eliterature.4
' R; _2 r$ M/ ~Patient Report8 V+ ?& P( b7 ~7 U; [; E
A 16-month-old white child was referred to the4 d) o/ L8 v& {, I7 h) O
endocrine clinic by his pediatrician with the concern
8 s" F: q1 j% L2 S4 X- f. Yof early sexual development. His mother noticed
/ x" H7 @( S, B* ylight colored pubic hair development when he was; o2 u0 x+ L8 P
From the 1Division of Pediatric Endocrinology, 2University of
; X% A- M4 j3 aSouth Alabama Medical Center, Mobile, Alabama.
( Z  m! H5 a( M) \* vAddress correspondence to: Samar K. Bhowmick, MD, FACE,4 ^  r/ D' V: ^5 i
Professor of Pediatrics, University of South Alabama, College of4 }$ h9 `- n. _7 H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ h& A& U1 ~/ m% H5 S/ K! Ae-mail: [email protected].5 }* N9 D) c6 ]  n7 e
about 6 to 7 months old, which progressively became' _: K4 T0 A% D6 ]1 c
darker. She was also concerned about the enlarge-
! k  p" H& d/ C- M: }3 _) Ument of his penis and frequent erections. The child; m2 E; V; _. \( N
was the product of a full-term normal delivery, with
! F1 }8 Z9 N, }- p% c6 g4 z( Ea birth weight of 7 lb 14 oz, and birth length of) a9 M- c1 K! i- b
20 inches. He was breast-fed throughout the first year
: B$ [& H, H5 }of life and was still receiving breast milk along with$ q1 C2 L( s; |( k' |
solid food. He had no hospitalizations or surgery,2 X' d8 t5 t3 Z& `- y& C; C
and his psychosocial and psychomotor development0 w: e3 j: y) r7 Z2 M: h1 @4 [4 G
was age appropriate.2 O3 z9 N0 ]# \6 [  T
The family history was remarkable for the father,: }( V# e2 N" O7 V: x; }* ?/ {
who was diagnosed with hypothyroidism at age 16,
: c% a3 \3 ?4 G- X9 A# ~8 rwhich was treated with thyroxine. The father’s
3 M! D# u4 Y; J* s) u& Y( M2 a$ M, Fheight was 6 feet, and he went through a somewhat
& o. W3 j: K1 D+ T) kearly puberty and had stopped growing by age 14.
4 x" Q  \; b# B8 `/ Q) k+ MThe father denied taking any other medication. The
- O( w8 E8 Q; F! E2 w* r& l- Kchild’s mother was in good health. Her menarche! n( a. Y+ U* z; ]
was at 11 years of age, and her height was at 5 feet
1 ?1 P6 _+ e/ C5 ]: m5 inches. There was no other family history of pre-7 ~) K- s6 p7 L5 ]$ D6 i; W9 ]! F
cocious sexual development in the first-degree rela-9 i/ u  P2 i* e* B
tives. There were no siblings.
5 s- ]$ j+ l0 B9 Z, nPhysical Examination+ G  N/ f5 G5 P+ ?
The physical examination revealed a very active,
* C% E* M5 ^: c. aplayful, and healthy boy. The vital signs documented& G; T3 g# B5 f# J
a blood pressure of 85/50 mm Hg, his length was8 O1 B! M1 |0 f+ _
90 cm (>97th percentile), and his weight was 14.4 kg( h5 Q5 S# h2 O; T4 p4 g2 f
(also >97th percentile). The observed yearly growth% H  {8 n! C) Q# I' N# J/ O
velocity was 30 cm (12 inches). The examination of
% O- f: b; t; L' ^5 l9 ]the neck revealed no thyroid enlargement./ g$ L( g* x3 W2 n
The genitourinary examination was remarkable for
0 V# @# X8 {  k5 a! Z1 Venlargement of the penis, with a stretched length of
  t* l# R. n% O3 ~5 O6 U8 cm and a width of 2 cm. The glans penis was very well( X! Y" R4 n3 g
developed. The pubic hair was Tanner II, mostly around
; z& i/ F* s0 N6 K+ w5407 V# v5 D7 L8 P. `; o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. o( T' ~! y% H/ E6 I7 L
the base of the phallus and was dark and curled. The
* R+ y7 {( T- ]) n: s/ Gtesticular volume was prepubertal at 2 mL each.9 [+ B7 {: @" L9 y) n0 G
The skin was moist and smooth and somewhat
& r0 J) T$ G$ E6 z2 toily. No axillary hair was noted. There were no
/ {4 {8 c- m* ]! babnormal skin pigmentations or café-au-lait spots.
! E, |+ g$ @/ n1 _5 HNeurologic evaluation showed deep tendon reflex 2+! F& l% O4 e1 N" {  Q. X5 E
bilateral and symmetrical. There was no suggestion
5 A2 F' ~, R3 k& `5 W2 a# I9 n) ~# Wof papilledema.
3 M6 N4 @# @& K1 A8 A9 QLaboratory Evaluation
* n' k  b4 p5 X. y4 C$ xThe bone age was consistent with 28 months by. N( T4 f% J5 h4 T) u  U
using the standard of Greulich and Pyle at a chrono-
4 v. d! F% Z2 L- ~- ^logic age of 16 months (advanced).5 Chromosomal& w5 N& V7 L+ z8 k  [: x
karyotype was 46XY. The thyroid function test) {; F: ]: v; g! ?, W. s( K* o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" g3 }0 ^. h0 g2 Y, {
lating hormone level was 1.3 µIU/mL (both normal)./ b; J, q" V. K& X1 b& ~+ [
The concentrations of serum electrolytes, blood
! a& E1 B% m: v5 A/ {2 K" C7 a3 V: ]urea nitrogen, creatinine, and calcium all were8 I) b. r' t1 ?+ S3 l
within normal range for his age. The concentration
# C" o5 v7 C& F$ g$ _of serum 17-hydroxyprogesterone was 16 ng/dL: _5 D: ]8 U' x5 e
(normal, 3 to 90 ng/dL), androstenedione was 20
) J7 P2 c$ x' P0 T, t( Ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 M0 L1 ^6 U# w7 Y' z6 a0 ^5 k/ mterone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 s+ h8 B( g5 T" l0 T% Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
. R' U! x; R. ^7 ?/ Y49ng/dL), 11-desoxycortisol (specific compound S)  H+ h8 |4 N; J8 u' C# d
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 c) u+ |  l0 h6 N0 |4 [) c
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 Z+ a5 A! X7 q7 y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 F" x5 o+ F8 c4 p8 R) H* E( v. C
and β-human chorionic gonadotropin was less than
8 a4 M2 r1 N& d/ {5 mIU/mL (normal <5 mIU/mL). Serum follicular
% L* y. H9 G# g: l$ w7 Y8 hstimulating hormone and leuteinizing hormone+ b6 _- D2 S3 n) L, ?+ S3 n
concentrations were less than 0.05 mIU/mL
# j7 g& o- }2 p8 F(prepubertal).
  ?" W  h2 X+ S8 j3 ^The parents were notified about the laboratory
0 f6 W) A! A% J4 ^* S$ D& Iresults and were informed that all of the tests were
% S/ V% G2 U6 E: F6 y& unormal except the testosterone level was high. The" f, ]5 |4 `$ N1 \% }
follow-up visit was arranged within a few weeks to
5 b9 f. o5 u: M9 X& _obtain testicular and abdominal sonograms; how-
$ w1 U$ o6 _9 {2 O& Zever, the family did not return for 4 months.4 e4 z! d) {3 }) p7 E& v5 n+ _0 C
Physical examination at this time revealed that the5 C$ }. {+ F7 d5 g& A
child had grown 2.5 cm in 4 months and had gained
& k) F2 r1 O# r, ?+ @( r; G2 kg of weight. Physical examination remained4 ]: ~7 n+ b' k: z/ K. m! ^$ U
unchanged. Surprisingly, the pubic hair almost com-
+ U( s) ]9 Q- j$ l- o' w. Ipletely disappeared except for a few vellous hairs at
( Q4 T" K2 L2 J7 H( A( _  h( mthe base of the phallus. Testicular volume was still 2
! r" H+ L8 S0 T+ @5 `' wmL, and the size of the penis remained unchanged.1 K6 o/ C* Z' {9 o7 G( r" J( d3 a' f9 @# ^
The mother also said that the boy was no longer hav-4 S& r5 z4 ]# h- v$ y  L' W7 O2 c" @
ing frequent erections.8 l2 [: l6 @% y! `  Z$ F  J  C) L
Both parents were again questioned about use of
; d% v% v# \! K  Yany ointment/creams that they may have applied to6 w" F$ {5 h$ i' J* p+ b
the child’s skin. This time the father admitted the
' W4 y2 D' c0 W! T! \2 sTopical Testosterone Exposure / Bhowmick et al 541
( V/ L3 {# s2 {use of testosterone gel twice daily that he was apply-
0 k0 |7 [' a* x5 O+ T3 v! ?ing over his own shoulders, chest, and back area for2 v2 b0 d! \0 B& ?
a year. The father also revealed he was embarrassed
9 F( @8 c: x" y* Uto disclose that he was using a testosterone gel pre-2 h9 M9 \+ ?! b& w5 y& {
scribed by his family physician for decreased libido: }* `/ }: |+ x$ M: x# O1 J: Y8 s
secondary to depression.: B, v; K# K, [8 k0 b1 x
The child slept in the same bed with parents.3 A: k6 G5 P( e/ T* @1 {* i
The father would hug the baby and hold him on his
6 P4 t$ d0 e$ uchest for a considerable period of time, causing sig-) c; C* S. S0 l  M% l
nificant bare skin contact between baby and father.  i2 V6 q! a8 S2 g7 ?2 b
The father also admitted that after the phone call,: _& H0 [% W5 M  \6 J
when he learned the testosterone level in the baby5 N8 m8 R- m$ k7 s' s5 K
was high, he then read the product information
( `/ c4 A+ q2 w$ t! P" S* Hpacket and concluded that it was most likely the rea-9 x9 P5 \$ [$ K8 |; L5 [
son for the child’s virilization. At that time, they5 z& O! N2 G4 T+ l8 y; S# N$ e7 O
decided to put the baby in a separate bed, and the0 M  s$ e1 N7 @) G; b# t) _+ e5 n
father was not hugging him with bare skin and had: L& L9 o3 {, B
been using protective clothing. A repeat testosterone) b0 b: g1 h) q
test was ordered, but the family did not go to the$ I/ d" ?2 q$ k( T
laboratory to obtain the test.% f7 _, s$ z* u5 x
Discussion* M" ^2 ?6 z4 U* E' u6 [2 t9 s
Precocious puberty in boys is defined as secondary
7 F; y0 u; Z  U2 Ksexual development before 9 years of age.1,40 H3 H% e( G3 q1 y9 s! b
Precocious puberty is termed as central (true) when/ }; h: B# i9 C* P4 t
it is caused by the premature activation of hypo-
0 K' I# h7 D# |6 ]7 ]: W0 dthalamic pituitary gonadal axis. CPP is more com-2 e/ X+ F1 [% @/ \
mon in girls than in boys.1,3 Most boys with CPP6 |+ F' Z& M! b
may have a central nervous system lesion that is
- ~0 \# @- W4 N0 S: Wresponsible for the early activation of the hypothal-, f, l) G' e6 G: ?; D* U% T' h
amic pituitary gonadal axis.1-3 Thus, greater empha-$ j7 }( C# t# z0 ~- O9 w4 E
sis has been given to neuroradiologic imaging in$ b/ G/ }3 ^( [0 N3 K1 U  L
boys with precocious puberty. In addition to viril-
; l# e9 [( ~* W. ^# M1 Cization, the clinical hallmark of CPP is the symmet-
" Y! ]6 X, l! R7 Zrical testicular growth secondary to stimulation by, F% X$ h& r- I8 _2 U! R7 m
gonadotropins.1,3
% J( ]  Y, a/ I& h; {; QGonadotropin-independent peripheral preco-3 M  x  M' Y0 l) }1 }  \
cious puberty in boys also results from inappropriate
' v) I7 d! J: E7 W  candrogenic stimulation from either endogenous or2 X! Z. ]' o! A" J7 S
exogenous sources, nonpituitary gonadotropin stim-4 ]  ~0 G+ Y' e7 @1 I  N% Q1 D$ _
ulation, and rare activating mutations.3 Virilizing9 ]8 u+ W3 Q+ [) `. }
congenital adrenal hyperplasia producing excessive7 A) e& o3 v) q' O  L/ w" w9 `% i
adrenal androgens is a common cause of precocious
3 r1 x" t0 p' {  J( Epuberty in boys.3,4
. |$ I# s- {: x7 E. h3 p) r( n- BThe most common form of congenital adrenal
! P1 ^5 p+ e# t) h4 j' s6 ahyperplasia is the 21-hydroxylase enzyme deficiency.8 V  {# H  G% Y0 V0 k' p
The 11-β hydroxylase deficiency may also result in, z! _. j( l1 h. U: h+ q7 c2 X( ]
excessive adrenal androgen production, and rarely,, f. ?( U4 @1 R2 X
an adrenal tumor may also cause adrenal androgen
3 K5 C* N; S: C6 M/ }excess.1,3
7 k' k* I- |( u! v- e# Y5 {, uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. p' w7 @6 z  x; J2 I% \
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 [3 `2 T/ c! g. gA unique entity of male-limited gonadotropin-6 H- G  z# K+ _
independent precocious puberty, which is also known, a9 x6 w5 K" z% Q8 I3 F
as testotoxicosis, may cause precocious puberty at a9 e% |: G1 v$ C4 x) e
very young age. The physical findings in these boys
0 I! U. L! ^1 ^1 d2 v( bwith this disorder are full pubertal development,
. s+ H, Z$ I: ~: D) k" ?including bilateral testicular growth, similar to boys
  ]8 s  [( F* j* Y- A: u: lwith CPP. The gonadotropin levels in this disorder: t! Y" C7 w7 J
are suppressed to prepubertal levels and do not show
5 j, m! t1 @) @! A; P5 O9 Dpubertal response of gonadotropin after gonadotropin-
0 T1 Y) V% S1 k: l1 nreleasing hormone stimulation. This is a sex-linked! c& {/ R$ o* t5 A, P; U. E
autosomal dominant disorder that affects only7 d/ `2 z; C, A; s+ t, Q
males; therefore, other male members of the family+ H( F1 h# [0 Z  E
may have similar precocious puberty.3
1 M" m( b# U. B9 TIn our patient, physical examination was incon-% Q8 g. R# }& I) o
sistent with true precocious puberty since his testi-* m3 T4 q3 @* R+ B6 d( d. b  Y3 s
cles were prepubertal in size. However, testotoxicosis
% b* L0 F- i6 c" Wwas in the differential diagnosis because his father
) J2 o, e/ J- k6 Gstarted puberty somewhat early, and occasionally,- M* {1 ^; a) c. C& h. p
testicular enlargement is not that evident in the
" X* |* R* u- i+ G: s* I* Ubeginning of this process.1 In the absence of a neg-0 {) t$ B: k# V" `0 ]
ative initial history of androgen exposure, our
7 B5 Z6 Y8 s8 K% ]* ^biggest concern was virilizing adrenal hyperplasia,
6 z/ K* X1 w% e. K% V. Y/ aeither 21-hydroxylase deficiency or 11-β hydroxylase( r+ p( C' Y" A8 a8 B" a
deficiency. Those diagnoses were excluded by find-* s7 Q& E- E6 l2 p8 j1 E
ing the normal level of adrenal steroids.
% q7 t4 J! Y" d, R5 ]. E3 xThe diagnosis of exogenous androgens was strongly
$ H; l% F" s) f7 k! O5 jsuspected in a follow-up visit after 4 months because6 ]7 m" O. F/ ]- T" ~
the physical examination revealed the complete disap-
; o" i7 C1 m# N8 h! Z1 mpearance of pubic hair, normal growth velocity, and
! n. S$ O' a8 [. Kdecreased erections. The father admitted using a testos-
& K+ w+ f% Z0 K, t  n2 D0 K* pterone gel, which he concealed at first visit. He was
- X9 ~2 r# y0 A0 Z6 G; R5 t' Eusing it rather frequently, twice a day. The Physicians’
/ I3 G  A0 \) W1 z- ZDesk Reference, or package insert of this product, gel or# }) [0 E8 }- @4 a! L" I
cream, cautions about dermal testosterone transfer to
, w* V" y+ {/ u) c1 w" xunprotected females through direct skin exposure.
# D& A# Y6 E) J0 |+ t0 T$ N0 g% Z8 kSerum testosterone level was found to be 2 times the: O2 C5 l: Q- S- Y+ d
baseline value in those females who were exposed to" ^) `$ C+ d/ I8 Z$ Z4 Y' W
even 15 minutes of direct skin contact with their male
" K$ \% o4 t8 Y" I' w  p0 Spartners.6 However, when a shirt covered the applica-, ^1 Y4 X! r" O" ]
tion site, this testosterone transfer was prevented.& L: F8 }0 v& w4 V. C$ P
Our patient’s testosterone level was 60 ng/mL,. r; m$ n$ s; \! W: X7 m
which was clearly high. Some studies suggest that
3 H% i% Z$ S1 hdermal conversion of testosterone to dihydrotestos-
8 v" Q" p; [5 z, _3 b7 F$ Hterone, which is a more potent metabolite, is more; V9 c) `7 y6 d7 w; l+ J  N: u
active in young children exposed to testosterone0 W- ]# P) `8 J% z  ], x
exogenously7; however, we did not measure a dihy-
$ ^% }5 |- Q; c% ]$ wdrotestosterone level in our patient. In addition to
6 o7 n6 u/ q0 g+ ]! Jvirilization, exposure to exogenous testosterone in
( `  w% s5 [: P8 tchildren results in an increase in growth velocity and- U" E5 z, t/ o$ w, f) Q3 A- b
advanced bone age, as seen in our patient.3 p; E/ W. [9 W. S- Q6 t
The long-term effect of androgen exposure during: q9 U' V, @+ Y! e* {3 e
early childhood on pubertal development and final
0 u/ X5 q: d( G: T" jadult height are not fully known and always remain
. L+ ?' v, C- R4 m* x) Ba concern. Children treated with short-term testos-) Y( a) Y$ x, h5 a* _' P6 D" Y
terone injection or topical androgen may exhibit some
) @2 _8 R* v, W* Y0 pacceleration of the skeletal maturation; however, after( `3 O. u3 ^% @5 q% s6 k* b7 v
cessation of treatment, the rate of bone maturation
4 n* W6 H1 ]6 H" Mdecelerates and gradually returns to normal.8,9- R( [5 o2 q* H/ Q+ _
There are conflicting reports and controversy
) C. X1 y9 @# L" q! Mover the effect of early androgen exposure on adult, k. ^( k" n3 p9 Y
penile length.10,11 Some reports suggest subnormal
" a% K- S5 Y! g! H1 A+ Jadult penile length, apparently because of downreg-# h* H2 C6 ^4 m+ }; M6 ^5 _
ulation of androgen receptor number.10,12 However,
3 f2 c( R. W; K6 ]% @Sutherland et al13 did not find a correlation between
, ~' Y6 R, |* Y% X1 Bchildhood testosterone exposure and reduced adult
9 a- N* O5 T5 L( W7 V$ c/ L- K0 gpenile length in clinical studies.0 _6 P+ \2 M6 L' A
Nonetheless, we do not believe our patient is
8 p. _% j4 K( r+ a+ E$ ~) Qgoing to experience any of the untoward effects from0 m5 H7 Z; b5 G+ {0 ]- e& Q
testosterone exposure as mentioned earlier because) R( x1 h- }. \  g: @0 T, Z6 i
the exposure was not for a prolonged period of time.+ `) u4 L; W! y: Z4 z  P( ~* W
Although the bone age was advanced at the time of
: C7 H6 R" g' U# f3 Ddiagnosis, the child had a normal growth velocity at
! O) x( C" C( q' p  u! S. rthe follow-up visit. It is hoped that his final adult, r6 ^, u9 T1 e% L: ~" U! x
height will not be affected.
% t" x; B, ?: ]' N) q$ v* ?Although rarely reported, the widespread avail-
: P/ U% S" M* cability of androgen products in our society may
* f5 t- ]1 Q( qindeed cause more virilization in male or female
; a8 M: h8 g8 ^5 G2 d* b3 achildren than one would realize. Exposure to andro-6 p$ `! M' \8 Q; M7 e% _; l8 \1 U# a
gen products must be considered and specific ques-; r; X! W5 M" {( _: A
tioning about the use of a testosterone product or$ G) C8 ^$ {2 S& w. K
gel should be asked of the family members during6 ]( T' g! v: ^8 q! w* {
the evaluation of any children who present with vir-
2 `  M! A/ @! F3 r$ b0 |  D& E! @2 Zilization or peripheral precocious puberty. The diag-
3 n" P7 R8 [* Snosis can be established by just a few tests and by6 P" D& [9 X4 q
appropriate history. The inability to obtain such a$ B$ {6 m3 d& a. Q9 ~1 V
history, or failure to ask the specific questions, may
- U! U4 m9 C+ P$ E% I6 f# @result in extensive, unnecessary, and expensive5 t1 j: f9 O3 g7 d
investigation. The primary care physician should be- q  K5 F% J. u
aware of this fact, because most of these children4 d5 X0 T# ~2 e/ P( h8 K
may initially present in their practice. The Physicians’
8 j2 _- P. ?9 W7 [Desk Reference and package insert should also put a
% K8 ^+ n5 z' X6 O3 ^& F5 @warning about the virilizing effect on a male or
5 `3 T) e1 |$ _$ J- M# Xfemale child who might come in contact with some-& {$ `6 J+ r; u9 D, r
one using any of these products.
& S8 L# a  d" E6 EReferences8 s8 m/ O- D/ m) U, S7 p
1. Styne DM. The testes: disorder of sexual differentiation
" @- d  T; ]$ _3 Fand puberty in the male. In: Sperling MA, ed. Pediatric
, L4 V0 W6 b8 F2 i6 ~3 X  [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
( m0 x* W8 g, ?8 J2002: 565-628.
3 C8 j  u/ m. V  n6 |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! p9 i7 J: u, C: ^3 ~
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
) `9 i) S8 F8 S8 T) F  J7 ABoy Induced by Indirect Topical
8 ^- u' g& R7 m7 ?2 v3 C. pExposure to Testosterone& K9 P9 ?/ ^2 d% A
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- K8 c% S9 a+ ^' T- {% Mand Kenneth R. Rettig, MD1$ d( z# M3 i4 b/ O7 @
Clinical Pediatrics2 \$ C0 w/ Z# ?# T0 Q" X
Volume 46 Number 68 \  I# b+ C0 ]/ g1 G& ~
July 2007 540-543
6 ~2 [; U0 b' ~! n© 2007 Sage Publications
2 T* P, U1 {* j$ D' M10.1177/0009922806296651
7 U- r7 \* H9 B2 X5 rhttp://clp.sagepub.com' Z8 X6 A  g2 A$ N: v8 T/ m
hosted at
5 L  D$ E6 b1 C6 I. K4 Vhttp://online.sagepub.com, g' p/ @- S: b1 A8 C  a
Precocious puberty in boys, central or peripheral,5 y1 b) i; C; B+ A2 j
is a significant concern for physicians. Central
- Z1 S8 Q( O. r; [# Jprecocious puberty (CPP), which is mediated( m* `6 v1 @$ q) {/ S% v
through the hypothalamic pituitary gonadal axis, has: y1 P$ y- W; b: d' J
a higher incidence of organic central nervous system
0 X+ _5 b6 U( [# Glesions in boys.1,2 Virilization in boys, as manifested% [) D  P( f5 H) k& R
by enlargement of the penis, development of pubic* V$ A" I* o# k7 F2 C
hair, and facial acne without enlargement of testi-
7 E' v9 C' s! l! J  _cles, suggests peripheral or pseudopuberty.1-3 We
7 N3 L' K! C& I3 u2 ?* ^report a 16-month-old boy who presented with the
+ T0 W3 p3 O! U; D, s! q7 Lenlargement of the phallus and pubic hair develop-5 j7 H# O) P, A6 \
ment without testicular enlargement, which was due4 q$ d# |* r& ?# K8 L! m2 \3 k2 `' i
to the unintentional exposure to androgen gel used by
1 l* k6 j2 _/ T0 ^# }1 x% ]the father. The family initially concealed this infor-2 E$ e) j6 _' I; C5 y6 b
mation, resulting in an extensive work-up for this8 I4 d8 D. M* M
child. Given the widespread and easy availability of+ ?3 \% z# U# }# y
testosterone gel and cream, we believe this is proba-# `6 o/ X& |! k% Y/ K
bly more common than the rare case report in the0 K$ J& x: p' {- U" W2 T* m
literature.4
3 X2 ^3 ]; w; C1 }) L: OPatient Report3 m% N( g3 I* Y1 {$ o2 Y- n
A 16-month-old white child was referred to the
. _! O( t% t0 K1 Rendocrine clinic by his pediatrician with the concern$ J3 E9 Q4 V' q$ @! A
of early sexual development. His mother noticed
6 C- C" t% e5 \/ wlight colored pubic hair development when he was& ?, g/ o# ]4 l7 t* @
From the 1Division of Pediatric Endocrinology, 2University of* G: d* J7 g0 m2 s
South Alabama Medical Center, Mobile, Alabama.7 A$ I8 {- q+ j
Address correspondence to: Samar K. Bhowmick, MD, FACE,
& N7 D$ Z9 Z5 F2 l' uProfessor of Pediatrics, University of South Alabama, College of9 p+ A5 q: e2 U1 D1 v  k
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ D( k1 a+ H/ j+ q  w+ le-mail: [email protected].+ e2 [* [0 b  i/ {
about 6 to 7 months old, which progressively became
* {$ m' p% ], l6 Idarker. She was also concerned about the enlarge-( g$ f; x2 h: Q, f
ment of his penis and frequent erections. The child
  L- \7 H/ r# m# |& t0 p% o+ Kwas the product of a full-term normal delivery, with6 L6 T  E2 d9 T6 z- v/ E
a birth weight of 7 lb 14 oz, and birth length of
8 l, q& T+ Y$ p3 h, P" E20 inches. He was breast-fed throughout the first year
3 p# i$ g  l. iof life and was still receiving breast milk along with
* V) u9 D1 r/ U- K* ~solid food. He had no hospitalizations or surgery,
9 _. l3 [, P- \. N5 F" Kand his psychosocial and psychomotor development
, f' x* \; b! v& iwas age appropriate.
; Y* ^; l9 K" ~- k0 }* a4 J+ i" tThe family history was remarkable for the father,& E$ ]6 ^; N( R
who was diagnosed with hypothyroidism at age 16,0 K, E6 m8 m. R$ p  P2 E6 E: a
which was treated with thyroxine. The father’s
1 B. }* E$ R- K3 n6 U# ]* a/ H$ Y' Uheight was 6 feet, and he went through a somewhat
% k/ V* E  x$ I# s5 P7 d7 a; bearly puberty and had stopped growing by age 14.6 I" z8 ^& [4 D* O
The father denied taking any other medication. The$ M# R- H& ^' i+ L$ z9 t6 A
child’s mother was in good health. Her menarche6 _8 M% U" A( U; V4 r* [
was at 11 years of age, and her height was at 5 feet
$ G( b% d7 h" e) a. H& O5 inches. There was no other family history of pre-6 K7 N6 l) k1 A: t3 o
cocious sexual development in the first-degree rela-
+ ]+ [  b6 G9 ntives. There were no siblings.
4 t! Q) X& T1 l# H0 t+ H+ ^Physical Examination
; r+ N2 c% [2 j  C  e% X$ BThe physical examination revealed a very active,5 x; t( O6 Z: d5 a. o" D
playful, and healthy boy. The vital signs documented
7 I: U: e6 X7 H. b' }a blood pressure of 85/50 mm Hg, his length was
) {' d& G" O9 d; `+ q. `0 l9 |8 i90 cm (>97th percentile), and his weight was 14.4 kg
1 C5 C- W3 l% J; m2 _. H# t(also >97th percentile). The observed yearly growth
& t, p9 O& z: F( W9 J6 {( \7 zvelocity was 30 cm (12 inches). The examination of
0 |# m8 }9 T# a! E3 mthe neck revealed no thyroid enlargement.6 d, r2 ~9 }) f) s* ~
The genitourinary examination was remarkable for2 I4 p& Q& @# u% K5 ^
enlargement of the penis, with a stretched length of
# n; U" u2 K4 o8 cm and a width of 2 cm. The glans penis was very well+ N2 m- A) F" y# i5 C" x* b
developed. The pubic hair was Tanner II, mostly around
# s0 {% p6 t& z* |6 k, J3 T9 t5409 F; D1 a8 i4 ~5 `1 l5 g  G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 v" n  z+ }, a0 T/ X8 c! r$ k' A
the base of the phallus and was dark and curled. The' x, M# K8 P4 ?3 M' j6 B8 r% D& S
testicular volume was prepubertal at 2 mL each.: e+ S& l  L+ o& V
The skin was moist and smooth and somewhat
5 }) q0 H9 }7 I8 F/ B$ @8 _4 Yoily. No axillary hair was noted. There were no' F1 S! |3 V' `# t2 Y
abnormal skin pigmentations or café-au-lait spots.1 U+ H2 |; O7 W
Neurologic evaluation showed deep tendon reflex 2+3 k" T0 ^0 N' \
bilateral and symmetrical. There was no suggestion
8 h" W" z9 A$ _, e, [of papilledema.
3 I7 J0 q" {: z$ V2 l- G- H1 xLaboratory Evaluation4 t( I0 p2 A3 i, b1 R! t
The bone age was consistent with 28 months by( R8 q7 ]1 V! G, ^  J; Y+ {! p
using the standard of Greulich and Pyle at a chrono-( S. u' y$ L' L' T  W# C
logic age of 16 months (advanced).5 Chromosomal. `; I, I. y0 p, a0 P
karyotype was 46XY. The thyroid function test
4 K. n8 ~* P1 }. Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! ?/ C, k4 {2 W+ L8 k6 Klating hormone level was 1.3 µIU/mL (both normal).
4 b& e( @- Y- G- NThe concentrations of serum electrolytes, blood
( e7 L3 }+ M, P+ S% L- Curea nitrogen, creatinine, and calcium all were& j/ o* [! I4 p
within normal range for his age. The concentration, G: e- r# S! @) u+ ~( b5 L
of serum 17-hydroxyprogesterone was 16 ng/dL
* v- d  m. I5 |5 M3 F(normal, 3 to 90 ng/dL), androstenedione was 20' q8 d: [' {) F0 e( x1 i4 n6 O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ f* Y9 Y5 b, ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( ~5 t4 _  M1 r) x! E( t  S6 ?2 Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 u) ~- V3 v' x4 ?- z6 ^/ A
49ng/dL), 11-desoxycortisol (specific compound S)
) z; e) i3 O- o; `3 v6 Q% |was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# Z3 B% h0 R# v+ A% [7 D" Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! l! \* z* H* K6 stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) I0 [: V9 g9 A" ~7 m$ h' h/ Kand β-human chorionic gonadotropin was less than8 M/ R: g, b$ w
5 mIU/mL (normal <5 mIU/mL). Serum follicular  l) G: ]5 V! M1 x; p
stimulating hormone and leuteinizing hormone: b# R( w9 \5 E+ g6 B/ b
concentrations were less than 0.05 mIU/mL
; x, \* d! `! i$ f- C(prepubertal).
: @9 r: A3 Y3 D  U) F0 A- e8 E/ yThe parents were notified about the laboratory% O/ q2 r# Y  A/ N8 V8 h
results and were informed that all of the tests were) J; D1 b( @4 _1 U% u. ~
normal except the testosterone level was high. The
( M& v  t3 z; D2 yfollow-up visit was arranged within a few weeks to
+ ~1 j: h' K8 Qobtain testicular and abdominal sonograms; how-1 G; Y, ?, x" L+ Y4 q2 p: G. h. m7 _
ever, the family did not return for 4 months.. a; Q- B7 q9 L) l  A# C, @
Physical examination at this time revealed that the
! {+ X/ Z% e) \' K4 P# {child had grown 2.5 cm in 4 months and had gained
) I- S6 z2 n# E2 kg of weight. Physical examination remained4 z5 T# z; p7 G! ^
unchanged. Surprisingly, the pubic hair almost com-
3 h. X# f9 o: p2 |pletely disappeared except for a few vellous hairs at
( N; B2 d5 O: }& c# S1 V/ T3 ^$ A& Vthe base of the phallus. Testicular volume was still 2
* q: t, P9 q. f$ N2 i: p! W; Y; mmL, and the size of the penis remained unchanged.1 o' F! J6 o$ b# i; M& j  i  N: A* V
The mother also said that the boy was no longer hav-3 H3 b5 Z; `; X  D; e
ing frequent erections.
  p- h$ i7 t. K* P$ h7 }  r& Y* W* f! WBoth parents were again questioned about use of
, Q" {: G8 }6 |any ointment/creams that they may have applied to. H; n3 I  e6 B) ~+ ^2 o3 I
the child’s skin. This time the father admitted the8 B# P1 q0 H, h/ q
Topical Testosterone Exposure / Bhowmick et al 541. y9 G# M+ F7 k$ m' y
use of testosterone gel twice daily that he was apply-
/ v: O+ I* z8 _6 h- P! j6 a7 O" g7 Bing over his own shoulders, chest, and back area for& @0 s, O4 A4 b& G4 @
a year. The father also revealed he was embarrassed: s9 M: p1 f* K8 O
to disclose that he was using a testosterone gel pre-( F6 i+ V  Y. O" J% f; O5 A
scribed by his family physician for decreased libido- J1 m7 d; g; H1 Y1 B, e
secondary to depression.- E4 `% Y; j) u/ X7 f" y4 h
The child slept in the same bed with parents.
- D. h! V! I* [: D0 FThe father would hug the baby and hold him on his2 T4 C. Z8 x6 ^3 l4 |
chest for a considerable period of time, causing sig-
) ?# V5 h  E6 ~( dnificant bare skin contact between baby and father.
& s- z, l! J' q+ y3 H- zThe father also admitted that after the phone call,7 K! n  h1 {# {. r3 w6 L
when he learned the testosterone level in the baby
5 V5 _2 C+ V6 {: Y: v, gwas high, he then read the product information
2 O: _' n+ Y, R$ Q( W. i; C# dpacket and concluded that it was most likely the rea-
; P' i: P0 g2 e( c7 U) b. }+ v; y# ason for the child’s virilization. At that time, they
  ~4 u. M* }9 B9 \decided to put the baby in a separate bed, and the
: @6 N9 r+ `* l, afather was not hugging him with bare skin and had- C1 f7 u7 P( b- B& k
been using protective clothing. A repeat testosterone
: m7 c# u+ M' ztest was ordered, but the family did not go to the
2 W5 k# T6 T% T! t' a3 C5 nlaboratory to obtain the test.
3 i0 I% ^# {* ^Discussion* I* r, W3 {/ X- S1 }! R/ q
Precocious puberty in boys is defined as secondary& ~# E3 |% u1 s$ A8 Y" `/ v; \  l+ t
sexual development before 9 years of age.1,4
8 S5 ?& X4 @! l- R9 C, [( y4 OPrecocious puberty is termed as central (true) when
6 a' J' J+ i# k! a0 @& |. Kit is caused by the premature activation of hypo-/ v: a7 S6 v+ i  J! f
thalamic pituitary gonadal axis. CPP is more com-) o0 ]) _9 {5 g2 C2 \. B
mon in girls than in boys.1,3 Most boys with CPP! _+ {6 o8 v0 f
may have a central nervous system lesion that is
+ R$ `7 J& ~4 t8 \" Xresponsible for the early activation of the hypothal-
  c) t$ G. s& c- Namic pituitary gonadal axis.1-3 Thus, greater empha-, G" }& c8 ^! F6 \& H% d
sis has been given to neuroradiologic imaging in+ J* v: ]& M7 `4 M' X. y) D) v
boys with precocious puberty. In addition to viril-3 J2 ~8 ~, E# ~+ u$ n2 B7 T
ization, the clinical hallmark of CPP is the symmet-
! u6 m8 U6 \% J! jrical testicular growth secondary to stimulation by
" d5 h" i8 S# Z  I/ D- x6 Cgonadotropins.1,3) C' E0 V# ?. I' ~! m$ c
Gonadotropin-independent peripheral preco-
* d$ ~- j* h) }1 ?! ?( rcious puberty in boys also results from inappropriate# J7 _3 T% Q  ]8 l
androgenic stimulation from either endogenous or
) }' f' s6 y9 }) nexogenous sources, nonpituitary gonadotropin stim-
3 ?% D+ Q' D& ?+ F* ]2 A5 julation, and rare activating mutations.3 Virilizing' `2 Y  m1 Z. P, r4 B/ m1 I) X
congenital adrenal hyperplasia producing excessive7 ^$ i8 x0 B! N  O. b: ?8 x! L1 J5 M
adrenal androgens is a common cause of precocious
5 r# O+ ]/ j8 C5 w' }  F+ |, jpuberty in boys.3,43 T% q- g: g4 a3 u% S6 m8 @4 I
The most common form of congenital adrenal1 H0 q! n. d+ R3 D, x
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 [, v8 B+ M* Z! N! C& I8 ]The 11-β hydroxylase deficiency may also result in
6 E3 r3 g6 j  _4 T1 Y; W; \excessive adrenal androgen production, and rarely,0 r  W& c. }8 N0 P
an adrenal tumor may also cause adrenal androgen2 S9 a. T& ?  h! R' T& W
excess.1,3
& ]3 {& ^  W. A$ ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  h  ~) J, c' l& L+ I4 P$ `( u$ O3 ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% Y, G: |! ~$ s' L5 P0 f
A unique entity of male-limited gonadotropin-
* l, N% y3 p/ m) r5 z% J: _independent precocious puberty, which is also known
. U) n1 W. W6 E) s( T6 zas testotoxicosis, may cause precocious puberty at a
8 W5 K2 }/ _9 @/ fvery young age. The physical findings in these boys  W, U0 g1 L; z  J; A9 U3 I1 h7 f
with this disorder are full pubertal development,
' t: B; L; ~# G& _" O# Hincluding bilateral testicular growth, similar to boys$ `  _* ^. s! ]# ^% n. F
with CPP. The gonadotropin levels in this disorder
2 H( O, X( Z0 _* Ware suppressed to prepubertal levels and do not show3 l4 T  J! ~- }7 d* r7 C
pubertal response of gonadotropin after gonadotropin-
% s! P& u6 I+ F8 _! n1 b( Vreleasing hormone stimulation. This is a sex-linked
: Z* H0 q7 x; W' }2 o* Jautosomal dominant disorder that affects only
3 C& j- ?  i4 @' J8 ?! Z1 X; T7 e) J1 U  Rmales; therefore, other male members of the family
: h1 d3 X( j+ Y' y% a  A0 [+ m6 bmay have similar precocious puberty.3
2 D: b9 T5 _( P) c% @4 d2 KIn our patient, physical examination was incon-- H1 t+ A6 @) ^; s5 j+ \# f' Y
sistent with true precocious puberty since his testi-
/ J' ~2 T9 u4 L& ?- Wcles were prepubertal in size. However, testotoxicosis" v3 O! o! a+ N# @/ G3 f
was in the differential diagnosis because his father+ G. h8 n: Q/ h5 G( e7 f
started puberty somewhat early, and occasionally,
& G: O" T' w  f( ^testicular enlargement is not that evident in the
9 w8 g1 J# w- V! B( Ybeginning of this process.1 In the absence of a neg-
+ v- \9 X/ i. r- T3 [& ^( _ative initial history of androgen exposure, our
: p) Q3 N. Q- Bbiggest concern was virilizing adrenal hyperplasia,
8 s3 X  H) B) L4 s/ k* @- ueither 21-hydroxylase deficiency or 11-β hydroxylase; [9 C* R2 I8 S( h; i3 z
deficiency. Those diagnoses were excluded by find-
) K, d& y# W1 v# b& A3 v; U3 ring the normal level of adrenal steroids.% C6 B  D" n" t' v
The diagnosis of exogenous androgens was strongly
  p( b' L4 x# ^4 {suspected in a follow-up visit after 4 months because
! ^7 E- T$ E3 Q7 C+ ]the physical examination revealed the complete disap-) ^7 l4 W  g" G' D) k6 {! s
pearance of pubic hair, normal growth velocity, and- C3 C& S' [) W, A! q5 }( A# G
decreased erections. The father admitted using a testos-0 p+ \! A/ w2 }' j5 j
terone gel, which he concealed at first visit. He was
: |" f7 S7 _( L8 ~+ Fusing it rather frequently, twice a day. The Physicians’
- L! V8 r/ Q' X  |2 S' gDesk Reference, or package insert of this product, gel or6 Z8 J9 d* B" w5 g% D5 m" x  H' {6 m
cream, cautions about dermal testosterone transfer to
$ B% O( F% p' V! ^. F8 Y3 S* punprotected females through direct skin exposure.1 F0 L# M* t5 X) \, {  f; E
Serum testosterone level was found to be 2 times the
6 z: d. d! t( O$ |& P( tbaseline value in those females who were exposed to4 z1 z$ \$ _2 y1 M' ~/ ]" P
even 15 minutes of direct skin contact with their male* ^" a6 T. F2 T5 r6 H" m0 U. d( @4 d
partners.6 However, when a shirt covered the applica-+ h6 j% e& M0 I% C
tion site, this testosterone transfer was prevented.5 Y( _" }1 Z: \' D  n
Our patient’s testosterone level was 60 ng/mL,
2 A$ _7 a. s3 p& Q: o$ q0 h; z# [6 }2 kwhich was clearly high. Some studies suggest that
  L, B+ Z+ V; V6 t" [3 o, adermal conversion of testosterone to dihydrotestos-
( X6 {1 b1 Q! `* _3 u# A6 l: Jterone, which is a more potent metabolite, is more
7 P4 |# @! a/ _2 Vactive in young children exposed to testosterone& J$ H) W; ^# a* P7 l
exogenously7; however, we did not measure a dihy-; P$ u# L9 F1 r+ Q! _+ v
drotestosterone level in our patient. In addition to
: P1 s: Z5 ]' W  L+ lvirilization, exposure to exogenous testosterone in
/ p" a8 ^/ z4 Xchildren results in an increase in growth velocity and, x* J; u' {% z6 j
advanced bone age, as seen in our patient.& H. v3 a0 L5 B% R3 ~/ o! n, t
The long-term effect of androgen exposure during# `0 y. {. L; F& I/ F7 @
early childhood on pubertal development and final
. ~' Y* c5 X; s$ R+ b; Cadult height are not fully known and always remain- F" O# k+ X* K. Z1 a
a concern. Children treated with short-term testos-# T$ r/ I. ?. e; U7 V2 [% A( h4 J9 u' [
terone injection or topical androgen may exhibit some
1 M8 a. x5 A% @) `0 o, a9 qacceleration of the skeletal maturation; however, after8 Q: `/ v3 R2 j9 Q
cessation of treatment, the rate of bone maturation  f7 z6 B7 E1 q- @1 G
decelerates and gradually returns to normal.8,9; o" H; [9 g$ g4 `
There are conflicting reports and controversy
& B$ M9 P' k  k+ ]7 q5 e( oover the effect of early androgen exposure on adult( x' h& k% U' p0 y4 w; Y' @
penile length.10,11 Some reports suggest subnormal
) e7 K5 ?  ^, `, j0 madult penile length, apparently because of downreg-
8 }9 ~+ B# j+ T- [0 h: ~' Lulation of androgen receptor number.10,12 However,
, C* ^. y5 N. l/ q. I5 u' ZSutherland et al13 did not find a correlation between
- G1 d, f  j! I; h4 G6 }  }childhood testosterone exposure and reduced adult
6 J: V2 \* f$ J: }5 j2 }4 Upenile length in clinical studies.4 E, d6 I1 r6 R; |- F: p/ c3 m  f
Nonetheless, we do not believe our patient is: N5 B. A. T6 @4 ?7 R8 [" T
going to experience any of the untoward effects from
& s/ [/ X: X3 I7 l# @9 X1 {testosterone exposure as mentioned earlier because$ w# h9 V7 c& `7 y; N
the exposure was not for a prolonged period of time.8 ~1 k' K" A) h. g
Although the bone age was advanced at the time of  B8 t9 P! r1 C8 X
diagnosis, the child had a normal growth velocity at1 I, A# @) v' I* |: L7 X( U
the follow-up visit. It is hoped that his final adult
1 k1 m1 H6 `0 Wheight will not be affected.) V% Q. f: H" o7 N* I
Although rarely reported, the widespread avail-
3 ?9 I6 P$ q3 C  O) \+ t- e0 ~/ vability of androgen products in our society may
2 ^2 o' e% ~) Z( j  c- }indeed cause more virilization in male or female- M& c- P. X! U$ X2 `
children than one would realize. Exposure to andro-
6 U& c5 V& |3 Z9 n4 q$ D6 }1 ]gen products must be considered and specific ques-
* V5 n* `3 T  ^% E) m6 O& A! W$ Ttioning about the use of a testosterone product or: h+ H, Y+ `, @  \) a) c# A
gel should be asked of the family members during
( g& L3 c; X6 _/ bthe evaluation of any children who present with vir-
: E- S" u  U- v8 L4 K& y# \% x) bilization or peripheral precocious puberty. The diag-
* H  E0 C7 O6 G3 Znosis can be established by just a few tests and by% j* O9 K: O; D9 y; }0 e6 f
appropriate history. The inability to obtain such a
3 h* L, r/ n* S/ b. R! r/ a3 Xhistory, or failure to ask the specific questions, may8 G/ h/ o# G* _, l4 B0 ~% L7 T
result in extensive, unnecessary, and expensive
5 x$ D- m+ ]; Z3 ]investigation. The primary care physician should be9 x) e8 L8 Q. I5 z6 A  g( l9 l7 W
aware of this fact, because most of these children- z6 d) T( U6 t+ i' |8 _
may initially present in their practice. The Physicians’8 k. }3 }6 ], d  ^; Y; A
Desk Reference and package insert should also put a
' i" c1 g! ^- Z- e" @+ Lwarning about the virilizing effect on a male or- G* ^/ o' K8 x) o: ]: D" x
female child who might come in contact with some-$ b! g* M( v" ~: \3 }
one using any of these products." J) a7 b" V' l- x2 V( k
References4 a, ]$ C) `- v6 N' ^
1. Styne DM. The testes: disorder of sexual differentiation1 {/ e' h! v8 s8 W8 V# `
and puberty in the male. In: Sperling MA, ed. Pediatric
7 Z: ~' Q, y9 M9 b1 f! [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. G  Q6 E3 r/ `, s" x
2002: 565-628.- @( `; X  f* j4 Y2 x, y* s8 _
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! j: w; C) \0 O- i2 apuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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
$ e( ~! p7 U/ ^  L
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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