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Sexual Precocity in a 16-Month-Old
+ l+ _! n' j# |; DBoy Induced by Indirect Topical
8 u; u4 n/ G( F) Y  c' T. g4 d" FExposure to Testosterone+ f6 M/ m) d! e2 c) _* \  e. h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 {! C% k- l3 k1 }5 s, a
and Kenneth R. Rettig, MD1
2 R; X3 t% J! pClinical Pediatrics. ^% w/ ?3 ]  c( Q6 U/ x
Volume 46 Number 6
3 o. d0 V+ E0 q0 L" H! `  l( \July 2007 540-543/ c# K  j" v  J. D
© 2007 Sage Publications
% G7 T  Q( W! B' k) a3 P) l10.1177/0009922806296651
7 |  m" M8 E, r* h2 vhttp://clp.sagepub.com
2 u# r& S3 Y: S; D* qhosted at" ^* E. h5 K! i/ @1 P' G! a( R& ^
http://online.sagepub.com
& ^2 m- F: M+ O' h9 oPrecocious puberty in boys, central or peripheral,
# S9 w0 e, e$ t% }is a significant concern for physicians. Central
  N% H; G* K( v  [precocious puberty (CPP), which is mediated
: t1 Y$ ]3 T% r3 C* jthrough the hypothalamic pituitary gonadal axis, has( B. I/ H1 H0 |* t# c6 M( t( g
a higher incidence of organic central nervous system# c1 T1 g4 ]) d& B
lesions in boys.1,2 Virilization in boys, as manifested
% T3 C  z% y6 d( b6 q- r( Rby enlargement of the penis, development of pubic
% O1 C$ `/ n+ Xhair, and facial acne without enlargement of testi-
+ ]) e9 j' x3 O# K9 z, s2 ucles, suggests peripheral or pseudopuberty.1-3 We
* |. ]9 G6 |& S5 V: |" O4 sreport a 16-month-old boy who presented with the
4 W4 f8 a3 m5 O: t  |- Q1 Menlargement of the phallus and pubic hair develop-
) p' G0 v, g$ T# o8 |. ement without testicular enlargement, which was due
* L% J8 T1 i3 W9 Y* T$ {to the unintentional exposure to androgen gel used by' h" s* d  G  V( q: y  h+ b
the father. The family initially concealed this infor-$ E0 c6 N' p3 C1 B% c- K; z
mation, resulting in an extensive work-up for this
, z; F3 V; T- b3 y$ e' ^child. Given the widespread and easy availability of3 N, N+ I2 X, G( \  |7 g
testosterone gel and cream, we believe this is proba-/ |4 D5 Z/ Q0 B/ E0 f1 f& T
bly more common than the rare case report in the  b; o( |% l3 J  V3 ~
literature.4
! k/ V4 v+ s, u" YPatient Report
/ C6 Z; L9 ~8 K  {A 16-month-old white child was referred to the, u& w; u- O( H) s3 U
endocrine clinic by his pediatrician with the concern
: _% t3 o6 ]3 F5 a) b4 F: `of early sexual development. His mother noticed7 f/ U$ W" y* U( N- M
light colored pubic hair development when he was, y9 E$ c; Y, a, H3 Y2 z
From the 1Division of Pediatric Endocrinology, 2University of7 x$ [( {0 f5 A8 ^9 B; ]
South Alabama Medical Center, Mobile, Alabama.
2 k+ F7 S1 L) l! }* F" F8 t& [Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 d/ K1 |8 T0 T9 _% \; o$ UProfessor of Pediatrics, University of South Alabama, College of! b+ {0 v, ?0 W2 t6 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 ~$ i5 J" w+ ^0 i
e-mail: [email protected]., q& h; Q6 }9 r' \3 e, a- e; O
about 6 to 7 months old, which progressively became3 x$ }5 E: e4 e0 h: }" }4 l8 u3 X
darker. She was also concerned about the enlarge-6 M. w! m( {( r- @" O+ X/ Y
ment of his penis and frequent erections. The child( [4 R. s4 T, [& G- F$ o" G' W0 C
was the product of a full-term normal delivery, with
$ H4 L: z4 X2 G- U" I/ ma birth weight of 7 lb 14 oz, and birth length of# N1 Z( ^  E4 g" ~! B% Q/ R
20 inches. He was breast-fed throughout the first year
% k$ c7 W0 J- Gof life and was still receiving breast milk along with3 S; C8 V- V& L* j
solid food. He had no hospitalizations or surgery,
0 s# z( n$ u: d; B6 Jand his psychosocial and psychomotor development
. U: `- v* b  D) Uwas age appropriate.
5 Z' @+ U8 B: x8 iThe family history was remarkable for the father,3 ^! ?9 w! U4 R- q8 U* j7 L6 @
who was diagnosed with hypothyroidism at age 16,. b1 b1 z1 f4 {$ s0 }8 L9 B
which was treated with thyroxine. The father’s
( U8 c# O6 p- Y2 T8 {height was 6 feet, and he went through a somewhat, v5 ]+ |+ F  H1 ]# `
early puberty and had stopped growing by age 14.+ s+ g' h2 w! L( z
The father denied taking any other medication. The- a% G* x0 [5 [
child’s mother was in good health. Her menarche1 `. z: [, h9 `( Y, J
was at 11 years of age, and her height was at 5 feet/ N& m. h3 [- \5 H7 @3 w/ Y, v
5 inches. There was no other family history of pre-
; {  F+ v5 ]0 D% Ucocious sexual development in the first-degree rela-
. A8 c5 c, n) f: d; t5 A2 ntives. There were no siblings.! `4 ?8 ~2 [7 l& k2 F
Physical Examination
# a3 w/ a5 P- M6 a( vThe physical examination revealed a very active,; w8 z( \3 q" C& |1 d4 O
playful, and healthy boy. The vital signs documented
2 q% B. M4 j/ a6 g5 ?( Ma blood pressure of 85/50 mm Hg, his length was- d& l4 j: ~. F$ p! n# F; u( M1 k% E
90 cm (>97th percentile), and his weight was 14.4 kg
% y0 ~/ ^; b: B: i  y0 q" A6 P(also >97th percentile). The observed yearly growth
8 x7 U1 n% f3 f1 f: L0 U5 `# avelocity was 30 cm (12 inches). The examination of
  f$ K# P' q4 e1 [6 Q8 Ithe neck revealed no thyroid enlargement.
) P3 l$ n; T9 t7 m( }& zThe genitourinary examination was remarkable for
  b0 m; w4 |. y1 s9 E3 n; Q$ Zenlargement of the penis, with a stretched length of0 a- a7 A1 r, p3 U% ~6 ]
8 cm and a width of 2 cm. The glans penis was very well
0 |( O- U2 p2 q% ?1 n: Udeveloped. The pubic hair was Tanner II, mostly around
% G+ z; f, R2 _- X540: c! k1 j- C6 r/ J) ]+ _
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( y4 r$ r' {. z6 @9 d! E
the base of the phallus and was dark and curled. The3 z- Y- T( |6 _) `5 s9 ?
testicular volume was prepubertal at 2 mL each.
0 ]8 x: e. I3 x' vThe skin was moist and smooth and somewhat
' w) C1 [1 T9 m! [1 Ioily. No axillary hair was noted. There were no
8 E( y) Z0 k! A! ^) M0 s, j- B- Sabnormal skin pigmentations or café-au-lait spots.
! w$ S" ~3 h+ D$ `  `" QNeurologic evaluation showed deep tendon reflex 2+( d. a) y5 p6 I
bilateral and symmetrical. There was no suggestion
0 ^9 X& E+ M9 ?( lof papilledema.
3 x! r3 Y2 d; G1 F5 zLaboratory Evaluation
: ?5 V/ ]; Z, v9 tThe bone age was consistent with 28 months by$ t: {. g, g* W# F( ]. }+ i, S
using the standard of Greulich and Pyle at a chrono-2 w7 t* i  \9 i5 M5 R7 v- Z) H
logic age of 16 months (advanced).5 Chromosomal
% z, K; P4 |  r4 ]6 M3 \1 M& dkaryotype was 46XY. The thyroid function test
6 ]) T' K9 v" z, _. K* x( y0 zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 u* q( m! E2 l* b% }. k: dlating hormone level was 1.3 µIU/mL (both normal).' r2 d5 K8 ~7 R& |! Y
The concentrations of serum electrolytes, blood& J( n1 I" R) J6 x  D
urea nitrogen, creatinine, and calcium all were/ W& Z. q# k1 ]  _; f* a: Z* S
within normal range for his age. The concentration
2 d; k8 x# v( Q( _of serum 17-hydroxyprogesterone was 16 ng/dL9 ?. l( Z. r0 l  p3 E, q' e. g
(normal, 3 to 90 ng/dL), androstenedione was 20" J) b$ b* z2 y+ s( K8 {  P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ K6 P% L, K9 Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 a. e9 Y9 [' b! s9 A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 e; ]8 M. r5 `* d
49ng/dL), 11-desoxycortisol (specific compound S): ~' C9 ?5 V4 @) R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 L' h- s( {  Z" k5 k
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" ?! U1 C, V. H% ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 Y5 n3 `, @. S/ I0 z
and β-human chorionic gonadotropin was less than  n( Q' o* m; D  \1 o
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# A0 @  V7 r3 ]7 `; h6 n1 e* [stimulating hormone and leuteinizing hormone
: i! O% n: H* _: L- n# @; C' uconcentrations were less than 0.05 mIU/mL
$ `1 S, t$ M) J+ E" t+ i- y( J(prepubertal).$ f$ n- T+ V7 K9 X( o: H
The parents were notified about the laboratory8 t$ x/ F6 h" N! ^* E8 a* d0 K& Q' R
results and were informed that all of the tests were/ D3 B* U8 y( M
normal except the testosterone level was high. The
' T- x/ ~- `1 U0 v9 X- h* h) k( R  n0 zfollow-up visit was arranged within a few weeks to
+ J) f! F( c5 }& v) V+ dobtain testicular and abdominal sonograms; how-
* g) \/ c7 Q  oever, the family did not return for 4 months.
4 |0 b" [1 [$ f. `  Z! F2 nPhysical examination at this time revealed that the
$ D2 |3 C. c3 G4 D4 Tchild had grown 2.5 cm in 4 months and had gained
7 x* g! O& N7 C$ m! ~2 d2 kg of weight. Physical examination remained/ E/ ~5 g( Y8 K
unchanged. Surprisingly, the pubic hair almost com-
' X6 G. M3 c8 V1 I, k) G8 kpletely disappeared except for a few vellous hairs at& i6 q4 o" ^" D) k9 r
the base of the phallus. Testicular volume was still 2
# E" f6 {0 T  cmL, and the size of the penis remained unchanged.
- C2 P0 c- u5 K) U+ MThe mother also said that the boy was no longer hav-( a, w* r+ c) o) ~8 @7 A$ K1 Q! s
ing frequent erections.
+ T9 u2 L1 X# @3 S7 @/ W9 SBoth parents were again questioned about use of; ~9 f1 U. Q6 A# {5 ]8 _' P) r
any ointment/creams that they may have applied to+ y( w+ q) f! L" r$ C9 i1 \
the child’s skin. This time the father admitted the- ~! \: p5 J) M7 Y6 n7 i, r0 _
Topical Testosterone Exposure / Bhowmick et al 5413 p! b4 n4 t$ X' Q8 T2 ], e
use of testosterone gel twice daily that he was apply-. b4 T3 R' j7 i; E! P: B0 s
ing over his own shoulders, chest, and back area for
- V& E% @& H! P4 A, `( ha year. The father also revealed he was embarrassed! q# X5 h( C) c! h
to disclose that he was using a testosterone gel pre-% t! [# Y( i! M
scribed by his family physician for decreased libido) u9 L! k. W0 y9 X
secondary to depression.8 b* v* H: a- _3 k, c
The child slept in the same bed with parents.
" m% V6 v# ?$ H) V- G9 YThe father would hug the baby and hold him on his
( P  Z7 c; ~( V) s' x4 rchest for a considerable period of time, causing sig-" Z' z* P$ G6 G" L. `1 W, P/ h
nificant bare skin contact between baby and father.) T! H# p) L/ J; \3 _" N$ `
The father also admitted that after the phone call,
4 R- R0 Z' R& w. I' s4 z. b  T) {7 Y4 Zwhen he learned the testosterone level in the baby; j# y3 B9 |) _4 V! B4 L$ y
was high, he then read the product information
" m9 M$ ]; z5 X8 q/ ]4 {packet and concluded that it was most likely the rea-
* H3 I# }9 E4 ?, O$ m/ fson for the child’s virilization. At that time, they0 Y/ i$ p, X7 j; z4 L$ C& Y
decided to put the baby in a separate bed, and the6 Z' ^$ w; p3 p( H8 S  c; t& f
father was not hugging him with bare skin and had
$ C+ Z+ D5 U2 I! rbeen using protective clothing. A repeat testosterone1 A- z; Q/ F. K( @
test was ordered, but the family did not go to the
9 ^. ~* N8 ^, w0 t( p/ @  a2 A% {laboratory to obtain the test.4 U+ I) F1 i- x; ^' n& Y
Discussion& o! w$ Q) X: z8 s% [% F
Precocious puberty in boys is defined as secondary* ~- T3 H8 y  Y/ H
sexual development before 9 years of age.1,4
/ N8 ]# i  |# F; w. r+ Z: NPrecocious puberty is termed as central (true) when
2 h2 o# w6 W# jit is caused by the premature activation of hypo-2 I  J1 h; }/ L8 ]* D; \
thalamic pituitary gonadal axis. CPP is more com-: j2 E% e- X0 A6 i, a8 Q. k4 a" \; m
mon in girls than in boys.1,3 Most boys with CPP
2 W( _( n- d) v( `6 @! Y6 b7 t- pmay have a central nervous system lesion that is# l5 B) D! `8 m
responsible for the early activation of the hypothal-1 P) g8 @# Y5 L8 D3 N
amic pituitary gonadal axis.1-3 Thus, greater empha-; X2 {; |' y* X" R( @
sis has been given to neuroradiologic imaging in
8 ]. ]9 f) l# E( a1 W/ d# cboys with precocious puberty. In addition to viril-
' e+ e) W+ b( r7 x. a/ @( }3 Gization, the clinical hallmark of CPP is the symmet-/ Z7 H% C9 _, c( ^2 M: }
rical testicular growth secondary to stimulation by! L" b* V/ ~4 n2 ]. v2 Z% a
gonadotropins.1,31 E9 K8 o1 o* [1 w- P2 }
Gonadotropin-independent peripheral preco-
/ b3 ?3 v& M; V5 [! |# Hcious puberty in boys also results from inappropriate! e$ I9 f- E% a+ m  V: U
androgenic stimulation from either endogenous or+ L, {: J* g& ~. c9 D
exogenous sources, nonpituitary gonadotropin stim-
+ g. [- R3 H; l6 _# h# N4 aulation, and rare activating mutations.3 Virilizing
7 H) m2 d; X5 M& fcongenital adrenal hyperplasia producing excessive5 v/ o8 f' `( @3 `  m/ O6 @. A
adrenal androgens is a common cause of precocious
& u4 L4 b" ]4 Y; O$ k( mpuberty in boys.3,4. t6 p5 g  {! Z
The most common form of congenital adrenal
! Y# J$ h2 e- \+ Zhyperplasia is the 21-hydroxylase enzyme deficiency.
- P2 c, R7 h0 p/ W8 G& xThe 11-β hydroxylase deficiency may also result in* F6 ~: o. x* I5 _
excessive adrenal androgen production, and rarely,) b% s# b% l7 N  S7 ^, f1 q% s( x, q
an adrenal tumor may also cause adrenal androgen( T, e! i% Q: P+ I
excess.1,3, S8 Q8 ^# t% s' p. {. Q/ p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& S: ^- M! @: M/ j! [6 {542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 M/ X( B% ]4 A) h) L4 [8 J
A unique entity of male-limited gonadotropin-2 u! b: s0 }% V
independent precocious puberty, which is also known
+ U8 X. [; t) fas testotoxicosis, may cause precocious puberty at a
' Z* g: B! G+ S0 Jvery young age. The physical findings in these boys
. L, B/ p+ `% s5 Ywith this disorder are full pubertal development,
( M$ n; t- W3 r6 `4 R+ qincluding bilateral testicular growth, similar to boys$ ?* e* M( b+ \- {8 x
with CPP. The gonadotropin levels in this disorder- I- ]( O% \! c# s! [( _2 ^
are suppressed to prepubertal levels and do not show) q5 D  u- N; n; X. f2 O% [
pubertal response of gonadotropin after gonadotropin-0 A% t( s- m" e: d% g: ~9 ]
releasing hormone stimulation. This is a sex-linked9 ^6 D9 {( V) v  n& n: I( F
autosomal dominant disorder that affects only5 @8 V: p0 G4 i+ L4 J" b+ Y
males; therefore, other male members of the family) Z( ~2 u7 {2 p. U
may have similar precocious puberty.3
1 P: W* O4 j5 V+ [In our patient, physical examination was incon-
4 v- l: d& Z# G0 h1 Osistent with true precocious puberty since his testi-
( m% M: ~: B- F+ C0 g* `/ zcles were prepubertal in size. However, testotoxicosis
) h# l' W: `5 ]was in the differential diagnosis because his father' q* M& t6 ?5 l8 F& `
started puberty somewhat early, and occasionally,
7 ], N, j/ M& d* btesticular enlargement is not that evident in the
* C' X( k/ J# p8 r: C9 fbeginning of this process.1 In the absence of a neg-
0 Y1 ~1 K+ B" e; c2 `. [ative initial history of androgen exposure, our
/ C. R$ H0 f; B3 bbiggest concern was virilizing adrenal hyperplasia,
& [! {' g$ t4 s4 F0 Seither 21-hydroxylase deficiency or 11-β hydroxylase; c+ N+ y! H# n7 Z; V
deficiency. Those diagnoses were excluded by find-; V  F) L: J6 O) j: K" J
ing the normal level of adrenal steroids.
6 q) w- G* t) I5 J/ l& K. V% e+ ZThe diagnosis of exogenous androgens was strongly. h+ S' J5 [) v3 T7 `' t
suspected in a follow-up visit after 4 months because
' g3 @; W1 ~) Lthe physical examination revealed the complete disap-& E' k  q: o4 N* o- z5 ~! E
pearance of pubic hair, normal growth velocity, and% ^: U0 l! H8 R  d) x$ \# ]
decreased erections. The father admitted using a testos-% \/ D2 g' b% T" \
terone gel, which he concealed at first visit. He was
! t/ k# X5 E% x. L6 o9 x, Ousing it rather frequently, twice a day. The Physicians’- {* B  I( m, L7 `1 q% n' e( H2 E
Desk Reference, or package insert of this product, gel or# U" [0 q/ j& p: J1 [/ T4 ^
cream, cautions about dermal testosterone transfer to2 y( A8 L1 m( [0 k. a9 E0 T
unprotected females through direct skin exposure.* [4 Q) u$ n+ q4 j# S" w
Serum testosterone level was found to be 2 times the# X# I0 G  c/ s8 ]7 `
baseline value in those females who were exposed to$ O4 |) J" w& X2 [+ f& L- e0 T4 [4 K8 X
even 15 minutes of direct skin contact with their male
0 a4 u, \; v: Lpartners.6 However, when a shirt covered the applica-8 k# q) |9 d3 |& T  ]
tion site, this testosterone transfer was prevented.
( G& O( t; p+ [3 i7 Y& cOur patient’s testosterone level was 60 ng/mL,
& `; ^7 B3 h5 ^( a' ~which was clearly high. Some studies suggest that* J. O; \4 d, r: ~( @
dermal conversion of testosterone to dihydrotestos-
" i' q2 h5 c" z0 h$ \terone, which is a more potent metabolite, is more) [" O, J4 a: K9 M; s
active in young children exposed to testosterone8 H$ M2 n* q3 Y
exogenously7; however, we did not measure a dihy-
. }# G4 l; B. Y6 F. Adrotestosterone level in our patient. In addition to0 x7 [! t+ s/ E6 b" d
virilization, exposure to exogenous testosterone in
  r1 H1 Y. b' rchildren results in an increase in growth velocity and
0 X7 I! \; v: v( \. ~: Jadvanced bone age, as seen in our patient.
6 k1 h8 x! g$ |, h# A8 kThe long-term effect of androgen exposure during
1 d6 z, e5 `% w" p5 T: z, M1 pearly childhood on pubertal development and final
& D) S6 u# a" Yadult height are not fully known and always remain" x/ o# a# Y+ V5 q& p3 d6 `  U6 s
a concern. Children treated with short-term testos-
7 q( O* S1 {  g3 x( nterone injection or topical androgen may exhibit some8 l6 h  B, S+ y9 ?" K1 i6 E
acceleration of the skeletal maturation; however, after
9 ]! [# X$ m, b+ G) w' G* xcessation of treatment, the rate of bone maturation
& o3 I- l+ R3 c( v$ X/ Odecelerates and gradually returns to normal.8,9
( \, j* {6 f8 y, k0 gThere are conflicting reports and controversy
) k3 a- W6 l9 Q  y+ @( `% q; d% c* mover the effect of early androgen exposure on adult- m8 u" V8 z& }8 z7 N8 x. C
penile length.10,11 Some reports suggest subnormal/ `1 t  x4 v! I
adult penile length, apparently because of downreg-! \' z5 o. S! i, d* A
ulation of androgen receptor number.10,12 However,
$ G- A2 Y7 h5 _6 t) n) k& USutherland et al13 did not find a correlation between+ U, Q3 E% ]. X
childhood testosterone exposure and reduced adult
3 y5 s+ \5 H/ \2 W/ ?) ?; s, O0 Gpenile length in clinical studies.& M: q& ^" a1 U& }, W& Q
Nonetheless, we do not believe our patient is
( `' d* P6 }, n$ X4 lgoing to experience any of the untoward effects from
* ~' V1 l+ c% R0 n, Ctestosterone exposure as mentioned earlier because
* \# S  K/ x5 k2 z. Athe exposure was not for a prolonged period of time.
) G4 ~3 [! K% k/ tAlthough the bone age was advanced at the time of' A) X% U) x* F$ T0 G& w
diagnosis, the child had a normal growth velocity at  }  s) l# C& v$ d9 C4 k
the follow-up visit. It is hoped that his final adult% p7 q% k" A. a1 m  g, r, ^
height will not be affected.9 s  _* H6 b7 O1 v- z
Although rarely reported, the widespread avail-
5 q4 X# v5 t& Fability of androgen products in our society may3 A# t9 L8 p) S- _; M
indeed cause more virilization in male or female' g6 u% l, r9 {+ ^6 z
children than one would realize. Exposure to andro-3 }5 _# |$ H% _6 {
gen products must be considered and specific ques-
$ _- n% s7 i  |( ]+ n0 btioning about the use of a testosterone product or+ o8 |& t) ]4 Q% A8 b$ N4 [+ ~+ Z
gel should be asked of the family members during
- R; b0 f# n% _; wthe evaluation of any children who present with vir-
5 n; S. R- c& V+ l3 W. W- ]ilization or peripheral precocious puberty. The diag-
. h; G' u( a- @/ jnosis can be established by just a few tests and by5 G7 c5 U7 D. X# [. N+ s
appropriate history. The inability to obtain such a
5 Z/ Q/ |! R  \3 i% whistory, or failure to ask the specific questions, may
7 @8 @2 A3 P; {- ~result in extensive, unnecessary, and expensive
' Z4 \: W2 @' l) Tinvestigation. The primary care physician should be( I" d: A% T0 [$ E1 U( r
aware of this fact, because most of these children
% [. D6 E; o* Z4 s0 imay initially present in their practice. The Physicians’
6 e. S% Q9 ?3 {+ q* \Desk Reference and package insert should also put a; x+ _8 ?3 |4 Y' K, R/ n
warning about the virilizing effect on a male or
. T5 K% F8 s% n/ S- \female child who might come in contact with some-
( ~- o% a# r4 R+ I' fone using any of these products.
+ V( a' ]3 Y  T2 n* uReferences: E. [. z0 y% h' n3 J8 e# o6 [. I
1. Styne DM. The testes: disorder of sexual differentiation
5 r0 @/ n" Z2 e: U# c# a( C$ i2 sand puberty in the male. In: Sperling MA, ed. Pediatric
9 @8 J' G$ j5 p5 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& E% Q3 P; U4 G2 q
2002: 565-628." l$ J$ o  W) M* a
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 y. U! U0 y" D2 x8 O) _2 P9 c2 Dpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old% X- |; \, n' i- }6 b
Boy Induced by Indirect Topical
$ K. B: {% D- T+ I" F& yExposure to Testosterone+ r( t) |2 H( [- F
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 O- Q) K. o' W/ I( C/ _/ j" s1 M8 F
and Kenneth R. Rettig, MD1
  t3 I+ j' C# f  u& ~, O& QClinical Pediatrics5 o: H1 w8 x" N2 h" L! P' t
Volume 46 Number 6
, W$ H" y6 Z$ y/ w2 h- mJuly 2007 540-5433 {; _! [, N! X6 m: \: c: T$ {' M$ U
© 2007 Sage Publications
0 u, F; V3 ^% n& R10.1177/00099228062966511 b* d. F0 L5 m( ]1 t
http://clp.sagepub.com
. x" t" [& ~. S- G, {: G$ bhosted at, b  w+ t2 p$ G6 s( A( W8 n2 b
http://online.sagepub.com/ w; B7 J/ ^% n& o/ W2 K& E- h+ _
Precocious puberty in boys, central or peripheral,6 n0 G; k; \: w
is a significant concern for physicians. Central0 y8 C1 H4 b5 d( R1 U4 \- S, C
precocious puberty (CPP), which is mediated
4 }8 e% O6 n; P+ O% g0 W: p5 pthrough the hypothalamic pituitary gonadal axis, has; K& c% }8 r/ @6 y! |8 s2 K
a higher incidence of organic central nervous system: \+ _- s. g+ H2 v; N7 V' C
lesions in boys.1,2 Virilization in boys, as manifested
4 W& _0 Q: M, t" D2 zby enlargement of the penis, development of pubic
( j5 G8 a( y4 X6 P. qhair, and facial acne without enlargement of testi-
1 ~& ^% v1 \* [+ ]& e; ucles, suggests peripheral or pseudopuberty.1-3 We
' h8 w% j1 A: T- xreport a 16-month-old boy who presented with the
. v" l% n, V8 K- [1 ienlargement of the phallus and pubic hair develop-0 F! O( b$ x* f$ }
ment without testicular enlargement, which was due) P: D' d; [9 v4 F
to the unintentional exposure to androgen gel used by' D  B2 f  ]' X0 K- V6 D% V2 U
the father. The family initially concealed this infor-
1 P8 I/ i7 \0 Z& jmation, resulting in an extensive work-up for this* V2 W9 U/ d- K3 A+ |' v7 H' E
child. Given the widespread and easy availability of& X# ?. Y* x2 A7 ?8 @. X9 @9 D
testosterone gel and cream, we believe this is proba-
1 Q5 }. r# E* W* C; }  y# Ibly more common than the rare case report in the* m3 P1 I9 i5 r3 Y0 S
literature.4
4 K9 {( ?/ z1 f" B) pPatient Report$ p+ H4 I0 p; C2 T
A 16-month-old white child was referred to the
- h' a: m: E* D" g! C/ Mendocrine clinic by his pediatrician with the concern
* k  Q3 [: ~6 i2 h4 @of early sexual development. His mother noticed5 h8 O  b$ {- |- ?5 \
light colored pubic hair development when he was# d+ H0 V" Q( D3 t7 r
From the 1Division of Pediatric Endocrinology, 2University of& s0 {$ v% G( ~  F# h* [
South Alabama Medical Center, Mobile, Alabama.
1 F2 B1 L3 R! z6 P5 I8 F1 ?5 ~Address correspondence to: Samar K. Bhowmick, MD, FACE,
: s$ i; o0 X! ]6 Q7 O" K+ [' EProfessor of Pediatrics, University of South Alabama, College of+ T& p2 Q' X; E( O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  b8 i- w% @1 T+ j( F* o; S  A+ Pe-mail: [email protected].
  B+ P# `) C' A+ Vabout 6 to 7 months old, which progressively became
/ t* B6 @( L3 G. F3 s5 |+ sdarker. She was also concerned about the enlarge-  m/ a) u  F+ Z, r8 K
ment of his penis and frequent erections. The child$ g2 @8 }* O  x
was the product of a full-term normal delivery, with4 V9 f9 |1 B3 A/ e6 [
a birth weight of 7 lb 14 oz, and birth length of. I. N5 [  ~( o, f# {2 o. R3 J
20 inches. He was breast-fed throughout the first year2 e3 k& ^! K3 l  s6 _% E
of life and was still receiving breast milk along with
$ H! r( N+ |/ d7 J- ]2 r% Xsolid food. He had no hospitalizations or surgery,
; B+ g+ B% D/ H5 W" W  u1 Wand his psychosocial and psychomotor development5 D, i- Y; i* c4 M  j$ o
was age appropriate./ l/ O0 T! d- J/ u3 u) ~6 ]9 Y( B
The family history was remarkable for the father,
, b* G, p0 g7 b2 v$ awho was diagnosed with hypothyroidism at age 16,
0 @7 i8 y0 A. [) @4 ?8 n- pwhich was treated with thyroxine. The father’s' ]( Z& Y+ R2 ?' ]+ v4 _
height was 6 feet, and he went through a somewhat9 ~7 ]) y) }. v6 F
early puberty and had stopped growing by age 14.. D# c/ l, F' O$ C% ]; {3 W! ^
The father denied taking any other medication. The  n# Z- `: U* p
child’s mother was in good health. Her menarche) h- ?! x/ _0 |
was at 11 years of age, and her height was at 5 feet
+ L$ |$ k2 V% t( @8 V0 Q5 inches. There was no other family history of pre-* n! e" h0 U& A1 Y4 _8 n3 w
cocious sexual development in the first-degree rela-
3 V; Z7 H) J& q% ktives. There were no siblings.
/ T# f! j2 ], S& _  {: HPhysical Examination( e, t( m/ ^. f( s- y" A
The physical examination revealed a very active,
4 \: c5 I3 S7 Rplayful, and healthy boy. The vital signs documented
% V% G6 D8 u2 n# `- ~a blood pressure of 85/50 mm Hg, his length was2 r; n* F7 i0 q
90 cm (>97th percentile), and his weight was 14.4 kg
  f& {$ [* }- ~$ q5 a% r: ](also >97th percentile). The observed yearly growth
- J* h- k/ L* y, R' S# \& o' w( ivelocity was 30 cm (12 inches). The examination of/ Z5 X5 M4 s  |+ z+ s
the neck revealed no thyroid enlargement.& F9 K  w$ T2 j  q
The genitourinary examination was remarkable for
+ E! R5 f, B' W$ W* |+ Menlargement of the penis, with a stretched length of
) \, O- _5 h9 Y  I! X! g# J8 cm and a width of 2 cm. The glans penis was very well7 ]) }+ a. _* {4 l  R. g
developed. The pubic hair was Tanner II, mostly around
) A  I1 k  T: L' g  y& d: b. t' v9 i540% }, X3 z; R: A6 C* U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! e& D7 J) ^0 ]4 othe base of the phallus and was dark and curled. The* C5 K* y" g# p6 W: [0 D0 Y  O5 K* `* ~
testicular volume was prepubertal at 2 mL each.2 N% o7 L( Y+ j7 r9 k0 r
The skin was moist and smooth and somewhat8 L# d& T. ~" ?  C
oily. No axillary hair was noted. There were no
$ d% a  U3 s2 {6 @5 qabnormal skin pigmentations or café-au-lait spots.5 J0 f* }4 H+ T- Y
Neurologic evaluation showed deep tendon reflex 2+: p% J# p0 q! p0 }$ M
bilateral and symmetrical. There was no suggestion
) Y7 ?2 _( S& V1 s6 xof papilledema.2 m; |& W2 n+ z. D8 b
Laboratory Evaluation: F/ O4 W  l3 b6 ~, w
The bone age was consistent with 28 months by
' w5 V7 h2 b" t; c! A4 musing the standard of Greulich and Pyle at a chrono-
9 T8 S% d* ~$ t: w) z& }* I: Jlogic age of 16 months (advanced).5 Chromosomal
2 C3 L7 k6 V, y0 k" g/ `karyotype was 46XY. The thyroid function test" e" b- t9 R2 G% |; J& y( B
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: l2 S0 A1 S2 Z+ o3 clating hormone level was 1.3 µIU/mL (both normal).5 X' a- H( b& K7 s+ h+ @
The concentrations of serum electrolytes, blood
2 e% o; [* v' ?, ]2 ourea nitrogen, creatinine, and calcium all were
$ p) |; m9 b# h8 t8 E3 Fwithin normal range for his age. The concentration
3 o9 f( g; |( @: o8 a, o  s9 kof serum 17-hydroxyprogesterone was 16 ng/dL1 q' m: s$ o0 v* @4 ~
(normal, 3 to 90 ng/dL), androstenedione was 20+ d. f5 h6 ~3 P, F8 e+ i$ ?: U4 x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ \3 t6 q( \. ]2 \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 d, U7 C& Y; R0 Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
; l7 @' N, J& x: g- o49ng/dL), 11-desoxycortisol (specific compound S)
& u6 l4 `/ Q: I/ Lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 R  O3 O+ L- T! n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" U' ?+ k- K5 [0 @
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 _3 L: B/ f+ o: ?
and β-human chorionic gonadotropin was less than
8 Y$ N6 ], T' ?7 c) d5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 X! h' ~: c4 A, G! zstimulating hormone and leuteinizing hormone
% J8 ?7 ~1 m0 C& y' cconcentrations were less than 0.05 mIU/mL
; d* p# `$ U; F( H7 t1 \/ `(prepubertal).
( i1 D: j7 P2 [1 {The parents were notified about the laboratory! X# j: O( B% L
results and were informed that all of the tests were
  c7 K9 u, U" U0 m4 r, Tnormal except the testosterone level was high. The
4 }/ F( X6 m$ }, }- }follow-up visit was arranged within a few weeks to8 \( v; c0 N& e  C
obtain testicular and abdominal sonograms; how-
( a" X0 _! h3 L* Cever, the family did not return for 4 months.( w: @5 h7 X; A% h3 W9 u+ v# d& n
Physical examination at this time revealed that the! Q' {+ ]1 _& b9 R0 Z
child had grown 2.5 cm in 4 months and had gained* J( }0 W% I( G
2 kg of weight. Physical examination remained( l7 Y" S% j5 U$ z# Q! I
unchanged. Surprisingly, the pubic hair almost com-
. R& q" ]4 I( d4 c5 C( f; ipletely disappeared except for a few vellous hairs at
1 e# o. B( q! athe base of the phallus. Testicular volume was still 2
5 Q* c5 H) i# B) MmL, and the size of the penis remained unchanged.
( m; b4 [3 |' `/ L7 VThe mother also said that the boy was no longer hav-
, ^7 V, M/ O7 W. @5 Z" Sing frequent erections.
! v2 ?1 X+ @, U4 _Both parents were again questioned about use of6 Y6 f7 s" V/ p  x
any ointment/creams that they may have applied to
) F2 h" i" P# N0 L0 ~) K3 g/ ithe child’s skin. This time the father admitted the
0 _. i9 [4 s6 ~5 R/ g) KTopical Testosterone Exposure / Bhowmick et al 541% c% p4 C* t- e1 T! Z& g" _
use of testosterone gel twice daily that he was apply-! Q0 \/ a' b1 ]
ing over his own shoulders, chest, and back area for
  X! y& }9 X8 e1 La year. The father also revealed he was embarrassed" Z2 @, f" }& ]# s# P% Q8 n) W. ^
to disclose that he was using a testosterone gel pre-, b0 ^, b2 C: L5 |
scribed by his family physician for decreased libido
% Q9 k# K! l% Z1 P% |* Q7 Zsecondary to depression.5 z: |* R$ F: n4 U, s) v# w- o
The child slept in the same bed with parents.
" V! ~' F; ^3 O0 K9 sThe father would hug the baby and hold him on his
5 j# Q) S1 [. [. L! y& e8 ~chest for a considerable period of time, causing sig-
2 f- @- @: Y4 s% S$ ^7 Bnificant bare skin contact between baby and father.
2 w3 r( U2 G& ]# [' E$ G6 ~The father also admitted that after the phone call,& q& S. y+ f) @+ J
when he learned the testosterone level in the baby  F3 F0 U+ R9 \( g
was high, he then read the product information
( [/ d& t) a$ ]1 O' f- m. F. O) Fpacket and concluded that it was most likely the rea-. I3 c. N& q* G# M. ]$ \
son for the child’s virilization. At that time, they/ t5 l1 X( R- @  U9 I
decided to put the baby in a separate bed, and the
( V# A) w- ^$ f( v" m- R1 B4 \+ Hfather was not hugging him with bare skin and had- l4 }( {  Y3 B7 |- G
been using protective clothing. A repeat testosterone
$ p# u$ w0 P0 R! x( p  M. Q/ t& @test was ordered, but the family did not go to the1 p& _% r$ T$ y
laboratory to obtain the test.3 J! I. {8 J$ g
Discussion
  u9 o8 r7 ?9 E; q; Y6 a5 }Precocious puberty in boys is defined as secondary: r+ l* L' I# n9 Q) S+ n7 q
sexual development before 9 years of age.1,4
3 {, z9 l" N) qPrecocious puberty is termed as central (true) when
+ @" S4 U( Q, O6 y2 E6 ^it is caused by the premature activation of hypo-4 }0 K  y, k3 _6 t! d
thalamic pituitary gonadal axis. CPP is more com-8 ^3 U, Z7 O; F3 R* i0 W
mon in girls than in boys.1,3 Most boys with CPP
+ ^: J. p( I7 \' [' kmay have a central nervous system lesion that is
- h) R$ {/ G' B2 Xresponsible for the early activation of the hypothal-3 e8 E5 Z; u0 k+ G) b
amic pituitary gonadal axis.1-3 Thus, greater empha-: c7 a) k# H6 U& T. v8 q
sis has been given to neuroradiologic imaging in
( [: _5 O) D! i9 @+ x& Yboys with precocious puberty. In addition to viril-4 f) l5 K* b3 G* N8 P* w! ^$ K
ization, the clinical hallmark of CPP is the symmet-' h$ {7 w6 S7 _1 r& Z1 C
rical testicular growth secondary to stimulation by
4 Z. }- F$ D3 Bgonadotropins.1,3
- v% {4 ]/ K6 Z, v% UGonadotropin-independent peripheral preco-8 H5 D) Z. ?  m! A  v% l$ |% E' D
cious puberty in boys also results from inappropriate( c+ @* n% y  U6 ]- G6 k
androgenic stimulation from either endogenous or
  b" G; T$ i, _& cexogenous sources, nonpituitary gonadotropin stim-
: g0 x7 p, g0 S7 julation, and rare activating mutations.3 Virilizing, h. h0 M7 s( e1 ~
congenital adrenal hyperplasia producing excessive
3 A$ [$ u0 e- ?( Wadrenal androgens is a common cause of precocious$ G! [- L# g# v/ E( p- m% _
puberty in boys.3,4
4 L  P+ \$ t; }/ R/ O( o( x$ aThe most common form of congenital adrenal
  |4 M, S$ t& X" V+ z' M0 C0 O1 I1 Bhyperplasia is the 21-hydroxylase enzyme deficiency.
& |* l$ `0 y7 v* L- s8 @The 11-β hydroxylase deficiency may also result in5 Y- g0 E% E- Z$ h
excessive adrenal androgen production, and rarely,  j3 V, R% J/ I) k' P% E# g
an adrenal tumor may also cause adrenal androgen
( E8 S" P8 X+ P) @- Qexcess.1,32 v7 x) ]! A4 K4 K1 A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' ~' ]0 n1 p+ W4 g2 V5 J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 D0 u4 l/ g; _% X9 c0 XA unique entity of male-limited gonadotropin-
- F+ M# A4 p  X7 L& Y# f& kindependent precocious puberty, which is also known! S1 J( `" F$ J6 V6 s
as testotoxicosis, may cause precocious puberty at a
9 R8 @3 `* @  u) n$ I! ?' s( Avery young age. The physical findings in these boys! U1 u( F: r' }
with this disorder are full pubertal development,
3 H/ w; R( U% F( r0 @, mincluding bilateral testicular growth, similar to boys2 q1 y, l* K! l: O! w3 Z
with CPP. The gonadotropin levels in this disorder
" }' J+ o7 |4 J9 ~6 Gare suppressed to prepubertal levels and do not show/ w% V0 @8 U5 G: c5 x" W
pubertal response of gonadotropin after gonadotropin-3 H5 B1 D0 q' F& M. G
releasing hormone stimulation. This is a sex-linked3 R2 w7 q' X3 f  \) P4 s
autosomal dominant disorder that affects only
& i0 Y# j) O! o) @0 o9 ?males; therefore, other male members of the family0 m" t# D: \% M2 s$ ]6 h
may have similar precocious puberty.3$ @; X- d( @5 E3 C8 Q9 I; }
In our patient, physical examination was incon-% F# o# h4 M. `7 w  q/ ?( T
sistent with true precocious puberty since his testi-
0 s1 v  w: N4 L, ?) Z# f% ocles were prepubertal in size. However, testotoxicosis
$ T  C8 i. ]' q* m9 r+ @7 bwas in the differential diagnosis because his father# d+ K2 n  ]2 J1 L6 j, h- a
started puberty somewhat early, and occasionally,1 G& }% e, M! P  ~6 {, @
testicular enlargement is not that evident in the1 y* N, n1 ]  q* o0 D
beginning of this process.1 In the absence of a neg-. ?5 K4 ~' a* J( S8 w
ative initial history of androgen exposure, our
% ]4 S. V. m) m+ p5 J# A0 w  Q" W9 S9 Mbiggest concern was virilizing adrenal hyperplasia,% k. F  M' K  B6 r4 }
either 21-hydroxylase deficiency or 11-β hydroxylase
5 ]7 K+ {7 l2 Wdeficiency. Those diagnoses were excluded by find-
; x* q& K: P9 |ing the normal level of adrenal steroids.0 R/ _- O6 X5 l2 K( l! P9 D
The diagnosis of exogenous androgens was strongly1 u  _* R# x9 j+ S& x
suspected in a follow-up visit after 4 months because
) w! b. Z& q  g2 P/ \! qthe physical examination revealed the complete disap-
3 ?" E! R& O$ {4 i9 q0 `pearance of pubic hair, normal growth velocity, and
7 K9 Z; J" m3 w; Gdecreased erections. The father admitted using a testos-0 D) V4 |$ b  ~4 J# c
terone gel, which he concealed at first visit. He was5 ~8 b8 M) Z( B3 U/ @2 b; G; p
using it rather frequently, twice a day. The Physicians’4 s$ R8 ?: p- ~3 Q: p
Desk Reference, or package insert of this product, gel or+ H7 u+ o7 F9 c; K
cream, cautions about dermal testosterone transfer to
  q6 Y/ h/ L( }8 [& Ounprotected females through direct skin exposure.+ ]+ C: k8 n, Q3 E# U/ b+ p5 G
Serum testosterone level was found to be 2 times the8 U' b& N6 V$ G" a5 n6 i) ?: S! F
baseline value in those females who were exposed to+ w9 Y$ ^# }' M9 ]5 P3 @- e! t* J
even 15 minutes of direct skin contact with their male
* c3 h; [) a" X& b/ |  qpartners.6 However, when a shirt covered the applica-; V$ j3 |0 |5 i' ~- R
tion site, this testosterone transfer was prevented.
/ h$ r4 y5 t+ D' k8 Q' [- ?' {Our patient’s testosterone level was 60 ng/mL,
" R4 s6 Q1 H" nwhich was clearly high. Some studies suggest that' ]: R- o. V: {3 ^
dermal conversion of testosterone to dihydrotestos-2 R8 J' w. B- G% a/ a
terone, which is a more potent metabolite, is more+ ]( y0 Z% I. C4 r* b1 X
active in young children exposed to testosterone& A% F# N/ Y7 w) ^9 @7 d
exogenously7; however, we did not measure a dihy-
: r. Z9 `/ S" S+ Q1 K4 U( M3 Edrotestosterone level in our patient. In addition to
- M  n# _6 \, Q( Ovirilization, exposure to exogenous testosterone in
% y4 V7 K' H' nchildren results in an increase in growth velocity and) y9 h) p2 L- r2 g: h
advanced bone age, as seen in our patient.
; v" _5 \# }7 O2 o- j9 xThe long-term effect of androgen exposure during
3 S- ]& T; t5 learly childhood on pubertal development and final
1 w: D$ C7 k/ R+ W1 Kadult height are not fully known and always remain/ B% ~" D/ W$ g+ ], i
a concern. Children treated with short-term testos-
6 U9 [3 `$ Z) z/ p1 j( }terone injection or topical androgen may exhibit some
9 V8 `( g  ?1 e( g- \; [acceleration of the skeletal maturation; however, after1 L# I, @; t+ [) f8 ]! m
cessation of treatment, the rate of bone maturation" c8 `7 w2 S! ]! K
decelerates and gradually returns to normal.8,99 n2 W4 M' o8 N2 Y
There are conflicting reports and controversy
) q6 L* `8 J* I. R5 I9 q" `2 _0 `over the effect of early androgen exposure on adult; o. {! n2 d) Y' p, {2 p0 a1 B
penile length.10,11 Some reports suggest subnormal3 v& `$ H0 n) a9 ~
adult penile length, apparently because of downreg-+ A- }/ R/ t$ C$ ~) e
ulation of androgen receptor number.10,12 However,
! Y' p4 b9 D; R6 }8 [6 a# eSutherland et al13 did not find a correlation between
* y6 }5 n0 q; I& U" u6 Nchildhood testosterone exposure and reduced adult
' u5 M5 v2 d1 ?penile length in clinical studies.
; q; @0 n  w  s$ {' z: lNonetheless, we do not believe our patient is
; P) t/ z- ], Q) sgoing to experience any of the untoward effects from. B( V: ]! e5 @% ?& o& Q* `2 e
testosterone exposure as mentioned earlier because5 N- C& Q- T' Q4 D+ Q* s" C9 I& Y0 A
the exposure was not for a prolonged period of time.% |9 p4 }* ~/ v2 F. _" f# n/ @
Although the bone age was advanced at the time of
! g1 H0 r, Q  R! p3 Cdiagnosis, the child had a normal growth velocity at9 ^" b) e, C5 H+ u# M# ?0 G( L2 l) v9 m
the follow-up visit. It is hoped that his final adult, W# J, [4 G3 r' H; S0 {$ r' P
height will not be affected.
' f4 ~% v3 @8 m3 V/ ~( RAlthough rarely reported, the widespread avail-6 P( D, V+ N! w  c6 x' _
ability of androgen products in our society may
  e2 P' D8 z+ K4 f# Lindeed cause more virilization in male or female
" {2 @. n' M' @$ A9 }" P; [* o* Achildren than one would realize. Exposure to andro-9 N& d: X  R% B1 h" P* b
gen products must be considered and specific ques-2 A$ b1 E. v3 s8 Q: t
tioning about the use of a testosterone product or
* \+ o' K4 b' k2 @" r2 L8 Hgel should be asked of the family members during5 y2 l& ]/ |! T: y
the evaluation of any children who present with vir-
* u/ s( D0 L! e! x$ t, ^( m  C* Y. Gilization or peripheral precocious puberty. The diag-
! v; ^0 o3 |* U# D: g0 u, Lnosis can be established by just a few tests and by
3 [; w( x2 x$ ]9 A( Lappropriate history. The inability to obtain such a% u3 K; {! G5 `( X( O
history, or failure to ask the specific questions, may/ `: f9 x5 I+ D  n8 Z/ T/ }* f- Z% q
result in extensive, unnecessary, and expensive
# Q  L& @/ `, \: k0 e0 C* R" e/ p  linvestigation. The primary care physician should be( {, Y  R# N* ~+ c
aware of this fact, because most of these children8 Y! P- B0 r( u
may initially present in their practice. The Physicians’1 c  [. ^  `9 P' p# g/ \; Q
Desk Reference and package insert should also put a
% d& R8 G6 ]& h/ Jwarning about the virilizing effect on a male or1 [2 ~3 f! e2 C9 U, @
female child who might come in contact with some-1 ~# A; r4 v1 g( F) q! H
one using any of these products.
" S% c/ b5 [$ r& ^( XReferences7 F% r$ A: K4 Q) h
1. Styne DM. The testes: disorder of sexual differentiation" J6 d3 [5 E3 S4 ^& M
and puberty in the male. In: Sperling MA, ed. Pediatric8 C- o5 Q& M6 F# e8 v$ l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 o) ?# J$ N' j. J! g% Z. l2002: 565-628.
( W9 ]3 ]$ {' a9 m8 B, K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 D: g7 B1 b+ D, fpuberty 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

. D8 l. y. {) ~; t- ~. H; 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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