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Sexual Precocity in a 16-Month-Old- g/ }" W( L; u+ C% E
Boy Induced by Indirect Topical5 V7 A9 `' M' G* D: s! g- @. f3 O
Exposure to Testosterone4 u2 B( F6 x$ _* w! c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- T. D" J& ~, T6 [. H' vand Kenneth R. Rettig, MD1; @/ u2 @+ A/ ]
Clinical Pediatrics9 w* a. p( B$ G$ ~
Volume 46 Number 6
- a0 c5 k% `' N2 j3 d3 v: d4 t/ zJuly 2007 540-543  K( K4 D2 J, C) ^( `( T
© 2007 Sage Publications% |+ F% u# q7 H! A
10.1177/0009922806296651
: f5 D- K5 o6 v: W- e1 K& Mhttp://clp.sagepub.com
  F0 E+ h/ W& g3 t3 ]' e, \hosted at) R4 x/ v5 B* h7 d# [: r% Z! y
http://online.sagepub.com: g7 }$ E  d* p
Precocious puberty in boys, central or peripheral,
( g% ?1 ?: H" S0 J  r, y' r3 lis a significant concern for physicians. Central# @* m+ H# B' a/ |8 g' H
precocious puberty (CPP), which is mediated
& E: y: m- q1 K" N9 S0 lthrough the hypothalamic pituitary gonadal axis, has
# x5 d# j4 b2 Y7 N/ Na higher incidence of organic central nervous system
  E9 n2 ?; r; z" glesions in boys.1,2 Virilization in boys, as manifested6 D7 c, t+ Z8 `$ l' o& z
by enlargement of the penis, development of pubic; x8 z# s4 f9 C5 D, G, f5 t5 S: }$ v
hair, and facial acne without enlargement of testi-
0 @- s& i. c5 P  u) m1 C1 A5 Ocles, suggests peripheral or pseudopuberty.1-3 We
1 f6 r: z2 ]- nreport a 16-month-old boy who presented with the: j6 z6 ?6 N, A2 O6 W& D( [
enlargement of the phallus and pubic hair develop-
) V: o" Y1 z8 q$ H5 E# u& Ament without testicular enlargement, which was due9 f: z" [' \: e4 L! g0 a" C! E
to the unintentional exposure to androgen gel used by
4 D  E- D$ p8 Y8 i/ gthe father. The family initially concealed this infor-' Y0 t1 b% ]9 |$ E7 G# v2 L7 t
mation, resulting in an extensive work-up for this
  A# B! A$ S& W2 o; h+ J! b* N7 C6 r& achild. Given the widespread and easy availability of
9 D  U$ g  ?3 J- k8 }testosterone gel and cream, we believe this is proba-
# q9 u. A. g4 B" [+ }bly more common than the rare case report in the8 o* p. N8 B0 Z- e5 O4 \% a
literature.4! ]# ?  R% l* j  @
Patient Report
+ K; P: q# L3 j4 h1 l. U5 |$ `A 16-month-old white child was referred to the! E. J0 G7 B7 J5 l/ l. T' I
endocrine clinic by his pediatrician with the concern- @5 T4 {. y- \9 F; G$ G
of early sexual development. His mother noticed
4 Z; T/ U7 N2 O9 g8 o8 |light colored pubic hair development when he was- i7 H5 s4 l5 v$ t" ]
From the 1Division of Pediatric Endocrinology, 2University of. h' j& a/ C3 K: G, ]
South Alabama Medical Center, Mobile, Alabama.* Y( m/ o3 k% ?: p) D7 n
Address correspondence to: Samar K. Bhowmick, MD, FACE,% D* M9 V! ?) k' f; L& [$ v
Professor of Pediatrics, University of South Alabama, College of9 p% M8 F2 U3 n4 F0 N6 P5 Y
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# d* r, }2 C1 U# ]e-mail: [email protected].
' W& F$ ^# `- Dabout 6 to 7 months old, which progressively became; S6 F5 ~& q8 G( v* w
darker. She was also concerned about the enlarge-/ P' s5 R6 e" \8 m
ment of his penis and frequent erections. The child
1 }# ?1 }& N: Qwas the product of a full-term normal delivery, with
8 e0 i( t/ ]/ @a birth weight of 7 lb 14 oz, and birth length of
/ d9 L" m8 s& }20 inches. He was breast-fed throughout the first year- r2 g& `7 e  O0 y3 r4 U
of life and was still receiving breast milk along with4 p) Y8 w$ a* T! \
solid food. He had no hospitalizations or surgery,5 Y; x: k( [6 S6 \! \$ r7 f
and his psychosocial and psychomotor development5 Q* p8 p* i: O4 E
was age appropriate., Y2 t- k. i) Z' w
The family history was remarkable for the father,7 t+ m' d  _) h! O  z
who was diagnosed with hypothyroidism at age 16,% y+ @- M3 m4 `+ y
which was treated with thyroxine. The father’s/ q* j& l6 c. s+ J4 |# y4 G
height was 6 feet, and he went through a somewhat8 X  B6 X& C$ i2 m; U0 O
early puberty and had stopped growing by age 14.
* \) ~4 \% B# w; p$ ^: LThe father denied taking any other medication. The2 O) U& F1 X0 B8 o; e2 c8 J
child’s mother was in good health. Her menarche
  \8 r- T" _4 g) J- [/ b, iwas at 11 years of age, and her height was at 5 feet! y: b$ e' q+ l+ J% U/ a5 T
5 inches. There was no other family history of pre-
! {% Y! o& ]- I# p, q! k" Ccocious sexual development in the first-degree rela-+ l8 Q, u5 M, S
tives. There were no siblings.
* T/ l8 d! `/ {Physical Examination
4 N* o+ ]6 k! O- I4 ?  e! a, hThe physical examination revealed a very active,( R' u$ I- n4 [" Y$ z( o) Q
playful, and healthy boy. The vital signs documented
. b1 o, _6 w6 Ka blood pressure of 85/50 mm Hg, his length was4 x  J$ l1 G; W4 d! U  J9 E- Z
90 cm (>97th percentile), and his weight was 14.4 kg
. z# a8 Y' b! s% k! H(also >97th percentile). The observed yearly growth" x- s; {) F$ C1 {7 k; v: m3 I7 h
velocity was 30 cm (12 inches). The examination of
( }' S( M; h% `, Nthe neck revealed no thyroid enlargement.
- \' ^! v6 q" \6 z& D7 S7 G5 {The genitourinary examination was remarkable for3 X0 @# u! w4 u7 y( `1 ]& |, w
enlargement of the penis, with a stretched length of( ]. q3 F1 @0 u3 F- @
8 cm and a width of 2 cm. The glans penis was very well
3 A: _8 Y8 _# J) q) b: L: N3 x/ Kdeveloped. The pubic hair was Tanner II, mostly around, K# M$ d, q* O" t7 g: A& L
540
1 t# P6 _$ M  O  r; I- f" H, Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ c  J; E- O& Y
the base of the phallus and was dark and curled. The
+ K4 P5 J, h& d0 O. c4 a5 ~testicular volume was prepubertal at 2 mL each.7 l7 z/ D3 g7 M9 H$ k8 C/ @+ T3 V9 u' X
The skin was moist and smooth and somewhat
! G% g1 Q% e1 hoily. No axillary hair was noted. There were no/ K+ H6 P2 c8 |8 s3 Y: x1 Y$ W' Y( o
abnormal skin pigmentations or café-au-lait spots.3 S0 d! `( t! k! F
Neurologic evaluation showed deep tendon reflex 2+# k0 z2 j' K: h9 f0 K
bilateral and symmetrical. There was no suggestion5 a8 O- j+ c2 g
of papilledema.2 R2 T* @7 K+ k9 w" C5 h" [( J
Laboratory Evaluation  [2 S  I, U4 I1 E+ \
The bone age was consistent with 28 months by& e" J+ _: Z1 ^5 S1 I
using the standard of Greulich and Pyle at a chrono-6 |) r, }3 {, a0 H3 F6 N
logic age of 16 months (advanced).5 Chromosomal
: l* q1 r* X, O# L  Ikaryotype was 46XY. The thyroid function test
- x$ R) X& D- x, C/ l3 \showed a free T4 of 1.69 ng/dL, and thyroid stimu-, W. S/ Y. @% v* V4 N
lating hormone level was 1.3 µIU/mL (both normal).: w4 c  U1 f% {: X! F* r
The concentrations of serum electrolytes, blood2 g7 U( T# I/ P) H
urea nitrogen, creatinine, and calcium all were# D9 |& n5 I! h* z
within normal range for his age. The concentration
" {3 a6 U# S) J! dof serum 17-hydroxyprogesterone was 16 ng/dL
& g8 J- o; Q, h2 T* ]: A0 A(normal, 3 to 90 ng/dL), androstenedione was 20
8 I8 b/ T' N3 J7 L% @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 N+ D, D  D( t6 G7 t  xterone was 38 ng/dL (normal, 50 to 760 ng/dL),; j6 L! B& o7 G# D0 j: N3 W
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# F0 \8 M1 s: v49ng/dL), 11-desoxycortisol (specific compound S)
) q" e6 r; q( \- Twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 R; }7 m; x( x: l  S3 q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 m+ k' z" c! htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),* M2 T# P% d7 @# \9 R
and β-human chorionic gonadotropin was less than! T7 A& I& v: a3 O6 y
5 mIU/mL (normal <5 mIU/mL). Serum follicular  X8 P! q! ^  x$ J0 o
stimulating hormone and leuteinizing hormone% X' F2 ?4 Q5 n/ d
concentrations were less than 0.05 mIU/mL5 p9 T: g  r" W# I& n: B
(prepubertal).
& B5 c9 G" d+ M- yThe parents were notified about the laboratory
5 |) K; f5 m+ i9 xresults and were informed that all of the tests were9 L% r+ E# A, Z) i% Z
normal except the testosterone level was high. The
9 I5 Q( Q; O4 C$ R1 n( efollow-up visit was arranged within a few weeks to+ N7 k' `! W: R7 r: [
obtain testicular and abdominal sonograms; how-
; q: c: t; j6 r8 a$ A3 Zever, the family did not return for 4 months." Y, }5 W5 @3 F
Physical examination at this time revealed that the( n8 }6 Z- d; C* @9 l
child had grown 2.5 cm in 4 months and had gained& x) T' }( t9 }+ m4 V
2 kg of weight. Physical examination remained
6 U4 m. `* @* Vunchanged. Surprisingly, the pubic hair almost com-( [% h1 D9 r+ l: c( N3 }0 b
pletely disappeared except for a few vellous hairs at+ z, f7 x$ K$ {$ [# I# z
the base of the phallus. Testicular volume was still 2( U+ |0 H/ J+ |- h
mL, and the size of the penis remained unchanged.
, X- u8 w. X8 |1 w- l* p' m1 ]/ eThe mother also said that the boy was no longer hav-
2 u1 W9 e- f/ m1 s7 Xing frequent erections.
. {& L- v/ i  e* c4 ~3 E$ X5 BBoth parents were again questioned about use of
- [! ?- ?5 p: v6 }* H& z; Iany ointment/creams that they may have applied to
4 p& i  o6 i) R1 hthe child’s skin. This time the father admitted the
8 {( j- g, }. c% ]8 s8 u# nTopical Testosterone Exposure / Bhowmick et al 5414 K% d$ z7 y4 F8 I
use of testosterone gel twice daily that he was apply-
6 n3 ?+ O" I7 x% d4 f: {ing over his own shoulders, chest, and back area for( E- H4 {) H0 b; ^2 z
a year. The father also revealed he was embarrassed
$ {: f5 W( D" O. Cto disclose that he was using a testosterone gel pre-
' t0 }) l" R; n' }* Rscribed by his family physician for decreased libido- h% Z" x8 b5 v! C+ f
secondary to depression.9 c/ |$ ]; @8 [0 y+ j4 Y2 i6 ?4 c
The child slept in the same bed with parents.! b& e" {3 F/ G( |
The father would hug the baby and hold him on his
: S) {  j2 n' k- A3 Z0 h0 achest for a considerable period of time, causing sig-
) U2 k3 c) y$ z6 I% Onificant bare skin contact between baby and father.
' m/ E7 @0 ]+ t, rThe father also admitted that after the phone call,
- }3 ~+ g5 \; j/ p3 E; `when he learned the testosterone level in the baby
* i- }2 c) t  u8 c% F' m! p- _was high, he then read the product information
, h+ [5 b. c% h. x4 e1 g2 P, npacket and concluded that it was most likely the rea-
1 [* q% c; z4 u# |, Z0 Hson for the child’s virilization. At that time, they
& [; |3 S! ^( a6 y4 L( xdecided to put the baby in a separate bed, and the
9 U' h$ M# c6 q! X/ t. Cfather was not hugging him with bare skin and had
7 r: a& P3 m' Ebeen using protective clothing. A repeat testosterone: X, P' Y9 O7 ?# F+ }
test was ordered, but the family did not go to the
3 y% ?4 U+ j6 n9 rlaboratory to obtain the test.$ h, Y" T  @/ x' X
Discussion
4 W& M1 U6 S( R4 U& B  f, c9 aPrecocious puberty in boys is defined as secondary* O  X' v$ X7 U+ b4 Y' H
sexual development before 9 years of age.1,43 \! r# j% J7 H0 j* ?! A. j
Precocious puberty is termed as central (true) when
2 ]  @5 U6 a$ Z' v0 {- @it is caused by the premature activation of hypo-. P5 Q4 K$ W2 V) v  A
thalamic pituitary gonadal axis. CPP is more com-
: Y& O/ k  W# P, i$ k0 P8 {mon in girls than in boys.1,3 Most boys with CPP
  K, @, a) q" Bmay have a central nervous system lesion that is
- L. E7 E/ h! Xresponsible for the early activation of the hypothal-
1 Y  T2 o# T0 pamic pituitary gonadal axis.1-3 Thus, greater empha-
7 P" w, L& _0 J- d% e+ Q. usis has been given to neuroradiologic imaging in
6 s$ i0 A8 f1 l, x) Wboys with precocious puberty. In addition to viril-
# ?: G$ J: M$ N* ]3 g& sization, the clinical hallmark of CPP is the symmet-) j( `" Z5 Q# t: `) G
rical testicular growth secondary to stimulation by7 {8 Y3 t' b  f! {6 U) @+ C6 O3 A+ S
gonadotropins.1,3
+ Q- E+ }7 E( [0 O& y  {Gonadotropin-independent peripheral preco-* V& `+ N5 h/ z& N5 Y- `
cious puberty in boys also results from inappropriate
) W; Z5 H* j* |" b) k" randrogenic stimulation from either endogenous or9 k/ G1 q$ R1 u' I' W( z3 w
exogenous sources, nonpituitary gonadotropin stim-/ u0 B+ `+ B$ c6 F& R
ulation, and rare activating mutations.3 Virilizing5 \) n* s$ l& a7 {
congenital adrenal hyperplasia producing excessive
) y+ K% ?6 ?2 \" h7 @+ madrenal androgens is a common cause of precocious5 |) K( V; B: K  Q9 o/ e: Z5 x
puberty in boys.3,4: x7 m& g% r& c  n/ W  g. w, l
The most common form of congenital adrenal
5 D, s7 Q; t; e8 _, ihyperplasia is the 21-hydroxylase enzyme deficiency.
' o) u' X' S/ eThe 11-β hydroxylase deficiency may also result in0 |! h' e. R, v5 I6 k
excessive adrenal androgen production, and rarely,1 H; E3 {) f/ O8 D" `9 E6 s
an adrenal tumor may also cause adrenal androgen+ j+ W* n8 M, u  L, A9 J
excess.1,3* m9 m" P" n9 ]/ @+ a6 w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; Y+ b$ F) ]& m$ f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) n  }' r- @0 ]/ l/ g, oA unique entity of male-limited gonadotropin-1 `- T3 i# g1 d( v+ ~
independent precocious puberty, which is also known
) t' ]/ m- B7 A# U& J4 Gas testotoxicosis, may cause precocious puberty at a0 h; \9 ~. N# B, Q* ]. ]7 e. A
very young age. The physical findings in these boys8 y/ [1 [% c) {& m
with this disorder are full pubertal development,. M% q& m: S! n8 D
including bilateral testicular growth, similar to boys; M4 ~9 T  Q6 d9 ?# k. P: ~
with CPP. The gonadotropin levels in this disorder
/ {. a# m  N% @1 r, zare suppressed to prepubertal levels and do not show
, {5 y1 i5 e! dpubertal response of gonadotropin after gonadotropin-7 Q- W7 w+ O) l8 o" z8 g8 t! O
releasing hormone stimulation. This is a sex-linked6 o" _' \% f6 \0 B
autosomal dominant disorder that affects only
( q8 l. i* X9 H9 X) m- @males; therefore, other male members of the family
8 b8 z# P+ p8 X- T( Z4 Xmay have similar precocious puberty.3
5 x: `8 }! C$ }In our patient, physical examination was incon-
6 }8 _' C7 P. `7 W- Gsistent with true precocious puberty since his testi-
; L5 P2 L6 u7 v8 @" @cles were prepubertal in size. However, testotoxicosis2 x  l8 _/ `- {3 m% @/ Z/ b
was in the differential diagnosis because his father
9 f% j$ T6 k) R$ wstarted puberty somewhat early, and occasionally,4 b  V: N3 C" u! n: G1 S
testicular enlargement is not that evident in the
/ p3 o  B0 R1 Y; y0 j8 d7 xbeginning of this process.1 In the absence of a neg-
9 m' E  v# M# v2 y1 @( wative initial history of androgen exposure, our8 @# r" T1 P! e6 Y0 }" E
biggest concern was virilizing adrenal hyperplasia,
1 h7 j; f9 f  y, b  P1 U$ H& oeither 21-hydroxylase deficiency or 11-β hydroxylase
6 I( B" Q/ A" |3 H2 {; jdeficiency. Those diagnoses were excluded by find-& h6 g6 r) m5 A! g% k- `
ing the normal level of adrenal steroids.
1 G" }# S. o. A0 R, b" Z* Y: EThe diagnosis of exogenous androgens was strongly
' z/ x( Q8 N5 `# w7 k/ L3 n# y/ Nsuspected in a follow-up visit after 4 months because3 r% V$ k! e) [6 }! v6 `1 z3 a9 `" v
the physical examination revealed the complete disap-
8 [+ \$ p# ?: `3 Ypearance of pubic hair, normal growth velocity, and
/ X$ q) V; f6 ldecreased erections. The father admitted using a testos-
8 A* d" [1 N: J( t; q' @* `9 I8 hterone gel, which he concealed at first visit. He was
8 \4 C& e) s: {' g+ rusing it rather frequently, twice a day. The Physicians’: U. F! Z; e9 P- V3 y
Desk Reference, or package insert of this product, gel or
7 c; P- N: y( g* Q/ q2 scream, cautions about dermal testosterone transfer to6 c7 c4 L8 l/ Q
unprotected females through direct skin exposure.
' ~! ~- B0 f  c+ A0 a+ \Serum testosterone level was found to be 2 times the7 j% x8 U9 h% M6 I; z+ o
baseline value in those females who were exposed to- }/ `  v% k- w0 w
even 15 minutes of direct skin contact with their male; [5 Y/ F$ X2 N$ g, ]  j( ^
partners.6 However, when a shirt covered the applica-# z  I9 b2 g0 K2 `1 D- b8 X
tion site, this testosterone transfer was prevented.! O  c- l5 v* @* r
Our patient’s testosterone level was 60 ng/mL,- G+ z! j8 I5 L) L# U
which was clearly high. Some studies suggest that  L! e, H7 h, p5 R) i; K
dermal conversion of testosterone to dihydrotestos-
5 W( U4 _* f1 s+ G; Z: j5 Fterone, which is a more potent metabolite, is more) @9 A, d5 W6 E* n# Z6 j
active in young children exposed to testosterone
+ _+ @4 c  |2 E+ m% Texogenously7; however, we did not measure a dihy-1 Q1 ~: Q3 `2 {+ j- v
drotestosterone level in our patient. In addition to
- b0 }: I  T. U; R* Y- n" s* vvirilization, exposure to exogenous testosterone in
1 Z' S* E% w9 B8 J8 [* ^- }; [children results in an increase in growth velocity and" K7 d! G$ W$ ^. r7 U& O4 Z
advanced bone age, as seen in our patient.
" i! _- n+ q' A7 P: {6 \3 @+ o% l6 RThe long-term effect of androgen exposure during2 o# W' [5 ^4 |! c0 _! J
early childhood on pubertal development and final
: \- J9 _( ^6 T2 Ladult height are not fully known and always remain
5 b9 l- y+ q- X' l8 d4 Za concern. Children treated with short-term testos-! Q- d; m+ _( d" b( n
terone injection or topical androgen may exhibit some# x/ c: j! i+ q; g! X6 |
acceleration of the skeletal maturation; however, after
" T8 h+ K& T4 fcessation of treatment, the rate of bone maturation. x3 u; i6 F2 X. s3 e  w. E
decelerates and gradually returns to normal.8,9* W4 ]' ~& [2 T/ y, I: E
There are conflicting reports and controversy: c2 i* w5 V# t7 p
over the effect of early androgen exposure on adult
3 E5 N# L1 q7 F- _& u% b  jpenile length.10,11 Some reports suggest subnormal
1 K" V% s, u: F' v% b* dadult penile length, apparently because of downreg-
7 Q, d5 q: A' S( E0 o& q) E2 U$ j4 xulation of androgen receptor number.10,12 However,$ r7 Y) B  C; M  n- j+ t) @
Sutherland et al13 did not find a correlation between
" j  V: _4 |8 K( uchildhood testosterone exposure and reduced adult
3 Z1 ]( [. u  b  v% V& |3 Hpenile length in clinical studies.- {$ U6 [5 |0 g9 g% g2 L, c
Nonetheless, we do not believe our patient is
, J% g1 o4 K* J) a- y2 C3 Fgoing to experience any of the untoward effects from5 H" [+ x3 {" D9 g2 @; b; g
testosterone exposure as mentioned earlier because
( g) q0 Y; B' Fthe exposure was not for a prolonged period of time.# h6 D7 X1 ]5 {% U) T
Although the bone age was advanced at the time of. x5 N0 ~) }# k, C/ m; T; P
diagnosis, the child had a normal growth velocity at. t9 {! E& h6 _/ U" [+ ^, H2 T
the follow-up visit. It is hoped that his final adult& K8 g# Z! ~  N5 C1 Z
height will not be affected.1 v- S9 @# i" f& P0 ~$ w/ M
Although rarely reported, the widespread avail-+ ?. `3 a$ @$ m& @
ability of androgen products in our society may
) A3 N8 b" O$ X( G+ X9 P0 U; Hindeed cause more virilization in male or female  \1 J3 L2 n5 J3 w" _
children than one would realize. Exposure to andro-
. {& W  d+ _- h+ D5 g8 g, [5 Agen products must be considered and specific ques-
; M% g7 ^( T% j, w# e2 q2 wtioning about the use of a testosterone product or
! n9 x5 G2 k$ y4 f7 n7 l  ygel should be asked of the family members during1 J4 t- x1 L% w8 w( y
the evaluation of any children who present with vir-  r; S% u4 F* ^& K; H: s. U
ilization or peripheral precocious puberty. The diag-) K3 N( t6 F3 R! b' A, `, I
nosis can be established by just a few tests and by
6 Y# F3 R/ e" j& z  Y& Wappropriate history. The inability to obtain such a+ d! D0 O( \# i/ `
history, or failure to ask the specific questions, may2 J* B* j0 d+ l0 z2 t
result in extensive, unnecessary, and expensive7 C6 D# \1 E( \. j
investigation. The primary care physician should be
6 X$ X% i$ V) i9 y. Uaware of this fact, because most of these children
7 Z6 Q' {; L+ u3 umay initially present in their practice. The Physicians’
* W0 ]! l! F- Y% [0 L4 F2 W4 U2 U  IDesk Reference and package insert should also put a
  _6 Q% n& t7 t& {' [5 uwarning about the virilizing effect on a male or
2 b$ \* R  I6 Y& y" q6 jfemale child who might come in contact with some-
; {+ ?8 l  z& Y, g+ G( Uone using any of these products.$ D, y( o& _; @" V$ s8 D/ Y8 m3 L
References' g; [% D6 P' e7 B9 i
1. Styne DM. The testes: disorder of sexual differentiation
3 w* ~+ J3 t5 v: o% gand puberty in the male. In: Sperling MA, ed. Pediatric
; B5 z0 H0 {9 C3 ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) u6 y7 @5 O/ q
2002: 565-628.
. e, f5 v1 M1 P2 y7 ^. \, H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 f* p1 \$ _+ V) [% H- O5 p! |  apuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 e8 e4 c  A/ d1 U7 Y' H
Boy Induced by Indirect Topical' q2 v3 x  G. }" U. [. R. w
Exposure to Testosterone
. t% {$ Q8 K" C) C1 z4 K, nSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2$ J% ~! R# L, F+ _$ X5 F( V
and Kenneth R. Rettig, MD1
7 ^0 N* b% s. Z0 LClinical Pediatrics" f( p- ~) x! L; M
Volume 46 Number 6
( m4 L' J" h# [5 I4 y& t; UJuly 2007 540-543
+ |( R" C+ n  @  ?, g" G© 2007 Sage Publications9 h  `: N/ V, L' f
10.1177/00099228062966510 E5 \" [4 R; o& J3 I5 `& H& {( V
http://clp.sagepub.com
! j) a4 A. A5 h7 h( v2 R2 x  Thosted at
4 @" P; u5 M- z& rhttp://online.sagepub.com5 }' r$ V1 j6 ^! @  N8 \
Precocious puberty in boys, central or peripheral,
  ~5 l! x5 V; W4 _is a significant concern for physicians. Central. B. p- G7 h4 Z. ?+ l
precocious puberty (CPP), which is mediated
7 @7 B& C/ V9 S/ V  b( l6 vthrough the hypothalamic pituitary gonadal axis, has4 c  Y: p4 \; m" a6 c$ |
a higher incidence of organic central nervous system2 s7 ?7 r$ X  j* b) t
lesions in boys.1,2 Virilization in boys, as manifested. h5 Y0 z; `& Z
by enlargement of the penis, development of pubic
" s' @! W3 \. R( n* W2 [% P. xhair, and facial acne without enlargement of testi-
- D- N$ z" d& i  Z7 l: ^cles, suggests peripheral or pseudopuberty.1-3 We; J7 F$ J8 g/ q
report a 16-month-old boy who presented with the
& n  p! M' {( l) b8 U6 Oenlargement of the phallus and pubic hair develop-3 x1 e0 _) ~( `
ment without testicular enlargement, which was due
  N9 `2 Z. F7 W/ q! s! Y) v, ato the unintentional exposure to androgen gel used by
( J2 M) |$ G5 N" pthe father. The family initially concealed this infor-# I* c* x) v1 J) s! r5 p8 n* r
mation, resulting in an extensive work-up for this
2 ?4 X8 M% N" Y. c+ X' ochild. Given the widespread and easy availability of3 \5 ^2 U, ]/ ?; I5 L& t) D7 O
testosterone gel and cream, we believe this is proba-7 ]$ m: ~7 }; Z  I
bly more common than the rare case report in the8 s2 s/ ?" a+ D6 V5 H4 l9 S
literature.4
5 n! x+ ~+ \+ _Patient Report% }6 K- `* L3 W9 S- D# l9 a
A 16-month-old white child was referred to the
, O. I3 ]6 d" j0 Zendocrine clinic by his pediatrician with the concern
6 L  p+ C3 S7 ~1 Xof early sexual development. His mother noticed( f$ M) u1 h* c% U+ e
light colored pubic hair development when he was' f3 q1 e* @, n  J' `6 g! q
From the 1Division of Pediatric Endocrinology, 2University of
7 U) W! O, u( \- T' }3 V& aSouth Alabama Medical Center, Mobile, Alabama.
# S9 v5 U, q9 d" N8 hAddress correspondence to: Samar K. Bhowmick, MD, FACE,
9 Y1 M: ?" L% u8 G4 P  d6 }Professor of Pediatrics, University of South Alabama, College of+ b! d' U2 G- `* L5 q  ]  F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" D7 x" B9 [+ L  @e-mail: [email protected].- W' k  N! ~. d% y' U) M
about 6 to 7 months old, which progressively became
! g, M7 `& G" t# q" e! j2 Udarker. She was also concerned about the enlarge-
- \- I7 B# E0 z3 t  c0 Sment of his penis and frequent erections. The child* }% \8 J" t- j) Q0 I! s5 j
was the product of a full-term normal delivery, with" @9 \! H- R6 w0 H. `) {
a birth weight of 7 lb 14 oz, and birth length of3 q9 `! i/ W$ I9 _9 v- Y3 N- {) O
20 inches. He was breast-fed throughout the first year2 C, |; m. g+ J6 @& [! M. R
of life and was still receiving breast milk along with3 L/ @+ `( ~6 L% }" k
solid food. He had no hospitalizations or surgery,4 X! O# M* Q7 K1 a  Z9 l( s$ M
and his psychosocial and psychomotor development
% L5 ^( v; w/ K- ^2 Jwas age appropriate.- M% z7 C  d# }$ W5 z% x/ V
The family history was remarkable for the father,
6 R( b! y2 ]" e, m1 q4 rwho was diagnosed with hypothyroidism at age 16,* h: |& F# h$ S; r
which was treated with thyroxine. The father’s
( Z& j( E! l  V9 lheight was 6 feet, and he went through a somewhat! [  `) `/ v8 N# c! I5 m1 q& k, |! K
early puberty and had stopped growing by age 14.+ A9 T" D2 k6 f) Y2 S' [9 e# x- P
The father denied taking any other medication. The5 l: I3 c, A& ~9 N7 c$ i/ `
child’s mother was in good health. Her menarche# G" g+ q+ H& M
was at 11 years of age, and her height was at 5 feet
+ b6 a! X2 E8 i' w9 V  Q5 inches. There was no other family history of pre-9 j. A; ~! l8 [4 ?0 ~% s5 x/ @6 E
cocious sexual development in the first-degree rela-
& T$ `- ]* k! S! u* R" ?tives. There were no siblings.  ~3 z3 j& Z+ x: k( V
Physical Examination2 Z: L3 l3 J4 q+ B
The physical examination revealed a very active,
7 @5 U7 ?7 D$ d9 s- k& X* w- G' Splayful, and healthy boy. The vital signs documented
: y% \, U' q$ E1 H+ r& Sa blood pressure of 85/50 mm Hg, his length was
: J2 K* z/ b1 F& ]* j( {90 cm (>97th percentile), and his weight was 14.4 kg4 E- u. M7 x( W( C  r9 o* }9 x2 @
(also >97th percentile). The observed yearly growth% ?# s( B- X8 t/ B3 |7 [* e6 `
velocity was 30 cm (12 inches). The examination of
' k6 S: P/ h% C" Y# Gthe neck revealed no thyroid enlargement.  s, b& _( P( K- k6 ^: u
The genitourinary examination was remarkable for
' Z. X; f$ e9 J. }- Q  @/ ^4 penlargement of the penis, with a stretched length of
4 J- {( K& b) K; k) v2 r/ n+ |5 }8 cm and a width of 2 cm. The glans penis was very well2 L. l' g9 A- H" Y; a7 `+ L8 D- E
developed. The pubic hair was Tanner II, mostly around
0 v  z9 t# H  d3 \+ {0 b6 x6 N540) P0 l/ Q  n$ h, Y1 m7 Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 Q4 r2 m$ Y. ^' m! S
the base of the phallus and was dark and curled. The$ J( J( {3 ~" s' I1 t" [- f* H' V- ]
testicular volume was prepubertal at 2 mL each.
3 [# O" p# [, ZThe skin was moist and smooth and somewhat8 T+ |) ]/ J, U( y. I
oily. No axillary hair was noted. There were no$ w! D( `: q2 Y& h' l
abnormal skin pigmentations or café-au-lait spots.4 i0 k; K% v# H7 i+ d
Neurologic evaluation showed deep tendon reflex 2+7 Y( A  U5 C5 K& w) x
bilateral and symmetrical. There was no suggestion
- i% g! W1 w  P1 l0 }7 Wof papilledema.
. J2 l" D# X% l7 U% @) sLaboratory Evaluation9 u  H! @' P; U" d* s
The bone age was consistent with 28 months by
" S. j4 c/ d" ^8 ]) }2 b! musing the standard of Greulich and Pyle at a chrono-3 _" `& J/ E% g( d* g
logic age of 16 months (advanced).5 Chromosomal
8 h0 |" ~; D- p( k% vkaryotype was 46XY. The thyroid function test
8 _- a8 o& `& sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-- r8 i$ W  w. f
lating hormone level was 1.3 µIU/mL (both normal).) u1 Q4 s4 u2 \# w6 m% p
The concentrations of serum electrolytes, blood/ @1 Y& O- }( ~) a& e- Y4 f
urea nitrogen, creatinine, and calcium all were) A& A# s5 j. r/ h
within normal range for his age. The concentration: ]9 K% U: c# ^* T4 C# d1 D
of serum 17-hydroxyprogesterone was 16 ng/dL. o4 U9 _. j2 X7 ^2 f
(normal, 3 to 90 ng/dL), androstenedione was 203 k. ~$ {3 c) Q4 O& B
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, {6 a7 _& ^& b3 H2 L2 e* \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% v. @+ a, T6 Q0 F2 M. Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 y) z  U% x, q4 _' B* Y49ng/dL), 11-desoxycortisol (specific compound S)2 v8 c1 q4 J/ H7 C& K) O8 G& Z+ J( M8 [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 c( d$ Y+ K+ n  s9 g/ `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 v2 @3 G9 x. E( p& z& p
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% n8 s$ l& n( {( t! `
and β-human chorionic gonadotropin was less than2 d6 l8 {& ~% p0 n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
& l* X$ C$ B3 a1 M  M. qstimulating hormone and leuteinizing hormone
! l: h" Q* s) hconcentrations were less than 0.05 mIU/mL
" r" ]; t& [( N9 n8 d$ a(prepubertal).. x* e$ \7 F, Z4 [. }( }! Q
The parents were notified about the laboratory
  n" a+ p, p7 \8 ]) W# [2 w3 P! x1 |results and were informed that all of the tests were) {7 Z0 N% ~9 n- v. V" }3 l8 X/ O
normal except the testosterone level was high. The3 I) e0 P6 |/ V$ f5 s' S
follow-up visit was arranged within a few weeks to
, n9 i$ P: X6 `  gobtain testicular and abdominal sonograms; how-# z+ g  r, c4 l/ G' F
ever, the family did not return for 4 months.
2 i; [  F- ^$ W2 mPhysical examination at this time revealed that the: u7 [+ K. ?, p: G
child had grown 2.5 cm in 4 months and had gained
, K  X; V- d: e- N6 B2 kg of weight. Physical examination remained; [  L/ F# C0 J( l# p, a5 \# l
unchanged. Surprisingly, the pubic hair almost com-+ ?+ J5 S; G" R
pletely disappeared except for a few vellous hairs at3 u7 f) h3 |" e! l9 b7 x
the base of the phallus. Testicular volume was still 2$ t0 N7 {9 W& t  _9 k) g
mL, and the size of the penis remained unchanged.
) i  R' R" y) @" h. mThe mother also said that the boy was no longer hav-3 M2 u$ ?; R% Z
ing frequent erections.0 N1 m9 u$ W2 i/ q' J
Both parents were again questioned about use of
7 B; j2 Z' H7 Rany ointment/creams that they may have applied to
5 _! m2 k, o- J. y  u$ {the child’s skin. This time the father admitted the$ @8 ^8 J, d! M
Topical Testosterone Exposure / Bhowmick et al 541' \$ e# }1 ?' c+ N6 T& x8 M
use of testosterone gel twice daily that he was apply-+ _4 F2 y- v) N- h, u+ ?8 j/ [! C( s
ing over his own shoulders, chest, and back area for8 C4 M6 X; x' d5 Z8 m; R$ x
a year. The father also revealed he was embarrassed
" t, o0 ]( }) c$ m4 ~! N, w2 Uto disclose that he was using a testosterone gel pre-2 N9 p' u' C: X7 P" a0 e
scribed by his family physician for decreased libido
: q" n4 g$ o0 O/ h: Q1 x; Gsecondary to depression.
& b3 O7 {* @* [, W1 I- UThe child slept in the same bed with parents.
+ I8 n+ Y* T" \' IThe father would hug the baby and hold him on his
* K1 t0 P" \2 Y1 V; ]( R6 tchest for a considerable period of time, causing sig-& E+ I: s, i! h8 @$ C
nificant bare skin contact between baby and father.( q$ X! N7 j1 @
The father also admitted that after the phone call,! J$ t( E! ]' S9 @
when he learned the testosterone level in the baby3 x0 r" z7 C0 T
was high, he then read the product information5 ^8 q: t2 t- [
packet and concluded that it was most likely the rea-
4 K5 @3 `: @3 H+ z" X  ~2 mson for the child’s virilization. At that time, they
: }! G/ Y5 [" g7 A! Q( pdecided to put the baby in a separate bed, and the
! s2 h; ~( R0 H  \' e  zfather was not hugging him with bare skin and had
" v0 f6 a  h# N9 sbeen using protective clothing. A repeat testosterone1 ^$ q, o2 `6 P0 `7 n% a0 F/ _, \
test was ordered, but the family did not go to the5 N( Q! B$ U4 \( J% }
laboratory to obtain the test.
+ i; i! N8 f, G4 k% S+ D8 h  ~8 WDiscussion
  E6 {( r* L3 W$ q- G: i/ L& VPrecocious puberty in boys is defined as secondary
% |) J  k. _# z+ x4 H# S$ F/ Z3 Tsexual development before 9 years of age.1,4
+ m8 E' V& @4 |  B/ [8 dPrecocious puberty is termed as central (true) when- O8 ~+ Q% g# X2 W2 ]
it is caused by the premature activation of hypo-
2 l' F" Y: L' _' w8 F( o. sthalamic pituitary gonadal axis. CPP is more com-
( E! O3 y6 F. h  U6 bmon in girls than in boys.1,3 Most boys with CPP
, M: E& `) d1 |2 g% M, q: T8 gmay have a central nervous system lesion that is
1 i, @1 T# A: @responsible for the early activation of the hypothal-
) G# h0 E3 o$ Hamic pituitary gonadal axis.1-3 Thus, greater empha-- }* u9 Y4 h( S" C1 }/ a
sis has been given to neuroradiologic imaging in1 r2 t3 l6 @2 i: E) X  P
boys with precocious puberty. In addition to viril-7 _" A) p) K, B+ C4 ~
ization, the clinical hallmark of CPP is the symmet-
8 e. V9 z9 w. `( A0 Xrical testicular growth secondary to stimulation by
6 O* ~7 @( Q0 b6 V1 F/ Fgonadotropins.1,3
4 s  a3 D" _0 kGonadotropin-independent peripheral preco-4 c# z7 e8 `- L/ [9 X9 s
cious puberty in boys also results from inappropriate; M4 z' q8 m7 @$ h+ q2 A
androgenic stimulation from either endogenous or
& r" Z- u) \9 `5 y' x( ^& Zexogenous sources, nonpituitary gonadotropin stim-- S4 P; e2 J3 F: ]2 O
ulation, and rare activating mutations.3 Virilizing
* V' ?+ Y) d& l0 gcongenital adrenal hyperplasia producing excessive
. o8 B5 a8 Q) A# Dadrenal androgens is a common cause of precocious
3 r5 a# g* {' T. |& J0 x- ypuberty in boys.3,48 N4 m' j- g/ `% R5 Q/ s
The most common form of congenital adrenal7 l) C( z! s2 N; |) G
hyperplasia is the 21-hydroxylase enzyme deficiency.
  v* z. A$ j: D$ O( uThe 11-β hydroxylase deficiency may also result in
8 v( N' ~/ R+ l2 [5 Texcessive adrenal androgen production, and rarely,# x" H7 d7 z# _5 ?
an adrenal tumor may also cause adrenal androgen
- Y6 T( S4 C/ p0 \. s" L7 Fexcess.1,3
% P* j) K0 W8 ~  w5 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 d  p" |) Y/ X6 u( A3 m4 _542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 I0 y: b/ k5 ~" \
A unique entity of male-limited gonadotropin-5 ]/ [# A9 f! Y; m
independent precocious puberty, which is also known
+ u- }8 y$ d' \" c3 qas testotoxicosis, may cause precocious puberty at a
2 N& j3 p) h, z/ R$ c5 P  u5 uvery young age. The physical findings in these boys
+ @- I" K  ^% u  v, j! e; P7 j- t( qwith this disorder are full pubertal development,
5 ], `6 C+ }6 {3 }9 Wincluding bilateral testicular growth, similar to boys
5 j% u" i0 k5 \( \with CPP. The gonadotropin levels in this disorder; |( A/ j. W- Q% p& \; L  l
are suppressed to prepubertal levels and do not show
6 I: `8 C8 J" D( I1 Z3 dpubertal response of gonadotropin after gonadotropin-
& H7 a) x* g. ?releasing hormone stimulation. This is a sex-linked
% ~6 j# c( E8 h8 U/ A  uautosomal dominant disorder that affects only9 {) `  J  K3 O/ t/ P+ @
males; therefore, other male members of the family/ R5 C$ ?1 u6 x0 ?& \: l
may have similar precocious puberty.3
1 r5 [! A. h' M2 z4 w% ^In our patient, physical examination was incon-( J5 b. }/ ~- v! J$ K* `. B$ `
sistent with true precocious puberty since his testi-, q- a$ ]6 x: t" Y0 d
cles were prepubertal in size. However, testotoxicosis
, o7 T8 s3 k3 p2 h/ L1 Pwas in the differential diagnosis because his father! S! S8 {2 @+ r$ ^
started puberty somewhat early, and occasionally,' j) j1 C! c7 D4 N& [9 ]4 o
testicular enlargement is not that evident in the
  F5 j' K5 u2 m# l- C1 \beginning of this process.1 In the absence of a neg-
& E+ S* X& t1 X" V4 gative initial history of androgen exposure, our
& r: M% T( W8 Y3 J' o# K2 h+ f" }biggest concern was virilizing adrenal hyperplasia,
0 v# g. O3 F# w1 |4 M" Ueither 21-hydroxylase deficiency or 11-β hydroxylase2 w/ t3 w, }& A& ]$ ^6 e& R. ?
deficiency. Those diagnoses were excluded by find-, J, y) Z1 ~- }' O( V
ing the normal level of adrenal steroids.; X. V! g. l& ?! I6 A2 {3 w
The diagnosis of exogenous androgens was strongly
' L6 D5 a$ A  esuspected in a follow-up visit after 4 months because
% ^0 M, T7 m' a8 {1 @% gthe physical examination revealed the complete disap-
4 A, S" |) ^8 Tpearance of pubic hair, normal growth velocity, and
/ q7 u' P( _& A9 i! vdecreased erections. The father admitted using a testos-  q. l4 Q0 H- V' t) y( i, n- H
terone gel, which he concealed at first visit. He was
  @$ x1 x5 D# i: p7 R% w3 C! ]using it rather frequently, twice a day. The Physicians’
1 {% `+ b4 c) M- lDesk Reference, or package insert of this product, gel or1 L, L4 Z: l3 q3 j' t
cream, cautions about dermal testosterone transfer to
( i& N  k5 ?; `3 b! O# Zunprotected females through direct skin exposure.
1 H5 L7 M3 b# \" m. t) W# gSerum testosterone level was found to be 2 times the: ]' ?: J7 M5 _- P; w% b1 M% K& a
baseline value in those females who were exposed to
; g- Q0 D9 z6 n: Reven 15 minutes of direct skin contact with their male$ ~7 d' S/ a; O3 `/ [- P
partners.6 However, when a shirt covered the applica-
+ Y5 W$ m- p1 w$ \tion site, this testosterone transfer was prevented.$ ]! O( T" l) S- I9 A, q  S2 R( S
Our patient’s testosterone level was 60 ng/mL,. A, o, `- Z! \- c/ ]0 E; x& v
which was clearly high. Some studies suggest that  B3 ~  W& ?  M1 b
dermal conversion of testosterone to dihydrotestos-- r9 a& E* ^! `0 y4 l
terone, which is a more potent metabolite, is more
% c2 k9 ?! a7 _& L& S2 ]8 Zactive in young children exposed to testosterone0 }. V  R7 B0 b! b
exogenously7; however, we did not measure a dihy-7 M5 O, r# ?9 O0 Y& Z; z  ?- v
drotestosterone level in our patient. In addition to! _2 D" p6 J$ J6 j$ L( i
virilization, exposure to exogenous testosterone in
. D* C" M8 t8 i3 k4 E8 nchildren results in an increase in growth velocity and/ u( B8 o* C& G& F% n
advanced bone age, as seen in our patient.3 N% r9 M! q- y) ?
The long-term effect of androgen exposure during
& _- x" o$ y" D2 }5 q3 fearly childhood on pubertal development and final7 F  \, i3 y' P$ ]
adult height are not fully known and always remain
0 o: t  r, Y2 d3 i- Na concern. Children treated with short-term testos-; ^8 Z* J5 k( `6 p# ~0 G0 T
terone injection or topical androgen may exhibit some  @3 F+ b& X3 l. s( P- o$ Z7 b# Z
acceleration of the skeletal maturation; however, after4 a: U9 @' c7 [5 n- h
cessation of treatment, the rate of bone maturation
" o/ k! t# D! U) @decelerates and gradually returns to normal.8,9
2 x+ e3 |6 R8 A" g3 wThere are conflicting reports and controversy3 [* q- Y9 f$ W: g0 _
over the effect of early androgen exposure on adult
9 r$ L$ ~  @; ]3 W. Npenile length.10,11 Some reports suggest subnormal
/ Q+ D, K: a3 [. ^6 Y1 R) dadult penile length, apparently because of downreg-
+ z  Z7 [; x  w0 Z: @' W/ Xulation of androgen receptor number.10,12 However,/ I! w. `7 k' _
Sutherland et al13 did not find a correlation between
7 t- c9 ^( H5 K1 G- {/ gchildhood testosterone exposure and reduced adult
# Q7 i" @- b9 Xpenile length in clinical studies.1 f  A! H9 n- I% t. i
Nonetheless, we do not believe our patient is" r$ t  E0 l7 p
going to experience any of the untoward effects from; @6 U- ]+ @3 ]/ r/ J, Y6 V, H* W: d/ b
testosterone exposure as mentioned earlier because; K# p" Q4 V5 s- `$ j6 |3 @- U
the exposure was not for a prolonged period of time.
- Q7 }6 ]2 m, u( _' g+ z% q2 KAlthough the bone age was advanced at the time of
+ p  O6 D" v; d( ]* F; Ddiagnosis, the child had a normal growth velocity at
9 U! u+ o/ C/ b+ ]( Cthe follow-up visit. It is hoped that his final adult5 y; }! A0 F/ @+ v2 a4 ?* O
height will not be affected.0 N( a* p$ A5 G. |
Although rarely reported, the widespread avail-- Y" G( X2 @& ~2 z0 q
ability of androgen products in our society may
# V1 c2 Z5 D7 P4 }5 b/ rindeed cause more virilization in male or female
- p" P- ~# k" T% X. [children than one would realize. Exposure to andro-
. X; \; {+ t. l3 i0 Q3 mgen products must be considered and specific ques-
# b8 v) D" n8 p: Z* U2 utioning about the use of a testosterone product or5 @( K8 j( K& t- _1 G' s
gel should be asked of the family members during
( u5 V. U* r9 |- l2 Z6 Gthe evaluation of any children who present with vir-+ b6 ?& [. H/ S; q, W8 K
ilization or peripheral precocious puberty. The diag-9 T, R' ~' l- H7 r+ d/ E0 T5 X5 e' @
nosis can be established by just a few tests and by
& U; Y/ g! V) v% ^7 N. c1 }appropriate history. The inability to obtain such a
/ w' X9 g8 U3 p% r" Z  }$ Q, `history, or failure to ask the specific questions, may% I, s3 |- ^$ Z$ Y" _6 M
result in extensive, unnecessary, and expensive& c( ]/ V9 f+ m! F: x& t
investigation. The primary care physician should be
+ e3 C7 K, T) ?aware of this fact, because most of these children) g5 y1 e8 l6 h# d- S
may initially present in their practice. The Physicians’
  X9 r+ E  b% h% K; UDesk Reference and package insert should also put a
6 @! u7 S3 H# A) Twarning about the virilizing effect on a male or
; R. X/ z+ n; L$ r5 Jfemale child who might come in contact with some-
) X7 s) C+ y7 j8 L# \0 `one using any of these products.
3 o+ V; G4 E1 I. d$ JReferences) g* W- Y4 y' i1 d, `# i
1. Styne DM. The testes: disorder of sexual differentiation5 X* Q$ u1 H2 P0 C
and puberty in the male. In: Sperling MA, ed. Pediatric
) I# d5 U+ A8 U; L4 c* A0 mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 ]1 K' V$ z5 l$ R) U9 X6 @2002: 565-628.
+ Q* [' `! k& f* D& p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ R' E6 u. o7 O4 y  z* [) A$ p
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

3 I" s8 {6 y* x6 U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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