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Sexual Precocity in a 16-Month-Old
# x# D5 n- C- v8 p2 n( nBoy Induced by Indirect Topical6 Y+ {) d, o9 r: x+ `
Exposure to Testosterone3 T7 q. `4 i0 c1 J$ U" L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. B5 p- |  w0 X( E( I5 c" G: n
and Kenneth R. Rettig, MD16 N1 N0 l" F- t( [/ }$ K& I2 [
Clinical Pediatrics
8 X1 T, |1 @* Z9 u4 X( r" kVolume 46 Number 6
0 v9 ^7 ^8 F" b. K. Y' ZJuly 2007 540-5439 q+ c8 `9 G% `8 y8 m5 l+ M
© 2007 Sage Publications/ h( j7 c( I# H4 W1 E3 \
10.1177/0009922806296651
. D5 D9 h' ]5 Rhttp://clp.sagepub.com
- [& T* C1 P. s" i/ z8 r/ Q; bhosted at) p4 a0 @# i3 m5 _
http://online.sagepub.com
4 [, |  \3 G* `3 V+ i1 Q% yPrecocious puberty in boys, central or peripheral,+ B7 C1 @8 c& G! F. j2 v2 E( w
is a significant concern for physicians. Central
! j: i; d2 y9 X* f0 Jprecocious puberty (CPP), which is mediated
  c! R6 v4 J% D0 athrough the hypothalamic pituitary gonadal axis, has
! l3 Z3 F& q+ B* U! Ea higher incidence of organic central nervous system
; _& P' }  t2 R# Q9 _0 }" g. b9 z$ Tlesions in boys.1,2 Virilization in boys, as manifested
6 @; d; L) c& ^5 @8 ~; C( Hby enlargement of the penis, development of pubic8 I  a! }. G, [% h
hair, and facial acne without enlargement of testi-  O) g0 ~% ^; z  I+ z* ]) Q3 {( ^% K
cles, suggests peripheral or pseudopuberty.1-3 We
' O: N8 }4 J; Kreport a 16-month-old boy who presented with the( c) h, g5 |4 ~0 R  w2 m( S% F: R% ~
enlargement of the phallus and pubic hair develop-& E6 w/ Z0 v) f
ment without testicular enlargement, which was due
6 G' ~# G% Y+ eto the unintentional exposure to androgen gel used by
  F* T! L& g0 N) e3 W& Bthe father. The family initially concealed this infor-# V$ U; ]* G' n* s& w3 m
mation, resulting in an extensive work-up for this" U' T: ]/ {9 ~/ g0 `$ w/ M
child. Given the widespread and easy availability of
2 m, n0 L* C2 S5 ^# Mtestosterone gel and cream, we believe this is proba-  }/ K. p6 a3 _: F1 Z; f
bly more common than the rare case report in the
' I4 \( `. @& o  p9 Rliterature.4
; h$ G' k0 m9 H5 ?Patient Report
) q! d. C" q5 B* M9 ]' L; o* YA 16-month-old white child was referred to the
- f) a& X: H8 U; J8 oendocrine clinic by his pediatrician with the concern; c* A& w% W) o$ G  ~; C
of early sexual development. His mother noticed- @5 f3 i' U8 j9 b8 k6 p
light colored pubic hair development when he was
) c- @- ~6 T7 a' O" s' wFrom the 1Division of Pediatric Endocrinology, 2University of
( h/ s3 G0 U5 zSouth Alabama Medical Center, Mobile, Alabama.
8 S( k; [+ K" w3 k, @4 N3 U9 NAddress correspondence to: Samar K. Bhowmick, MD, FACE,* X0 R* P9 h' @/ M  X2 }8 D
Professor of Pediatrics, University of South Alabama, College of
8 p: W: P0 W0 ^9 r0 u; {0 oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 h" H% o4 @7 S  {% ]1 V+ _
e-mail: [email protected].
: ^# c# _# V5 L7 r# t0 [about 6 to 7 months old, which progressively became: h: e6 U+ J+ \! `6 W# {4 ^* d
darker. She was also concerned about the enlarge-
  ?3 d6 ~, s. H% [4 kment of his penis and frequent erections. The child
8 V7 Y2 h2 J, p$ H  Y# u4 h5 z! Cwas the product of a full-term normal delivery, with! U! A6 L" M' F6 D( }$ q
a birth weight of 7 lb 14 oz, and birth length of5 b$ b: j- e0 Q. K. H; b7 w
20 inches. He was breast-fed throughout the first year
# y0 ^7 n  }, S: d4 D2 ~, }of life and was still receiving breast milk along with
) ^( {8 Q: ^4 d+ ~# \, [solid food. He had no hospitalizations or surgery,- e+ _; _; a. |+ c8 v- @
and his psychosocial and psychomotor development
+ X+ A/ `# n  t3 C, \. q8 m6 `was age appropriate.
8 g) Z7 Z2 z" XThe family history was remarkable for the father,
% [4 X' f% J2 R7 s3 }who was diagnosed with hypothyroidism at age 16,
/ m% S5 [, r' i! ?which was treated with thyroxine. The father’s
: m0 |' p2 n( _5 Eheight was 6 feet, and he went through a somewhat( e" w, q8 P- r% u3 C4 a( ^
early puberty and had stopped growing by age 14./ H& w/ w% D# S; h" A
The father denied taking any other medication. The7 A- B$ l1 D* U
child’s mother was in good health. Her menarche$ Z. ^8 F6 Y! [4 c9 g1 U
was at 11 years of age, and her height was at 5 feet& h! J) P8 H2 L" i- Z7 Q; z9 @
5 inches. There was no other family history of pre-
4 c  q. B. F$ ^2 ]; i- e% Ccocious sexual development in the first-degree rela-9 E8 f7 s4 D3 w2 ]/ y& h
tives. There were no siblings.0 H9 E- J- k5 N; p" U: w
Physical Examination
. `7 ?- A7 n1 d& |* ZThe physical examination revealed a very active,
, \% p5 c5 {' W5 ]playful, and healthy boy. The vital signs documented
4 B* Y! Q: x3 _$ Ea blood pressure of 85/50 mm Hg, his length was
# u7 y# q) j8 E3 y$ t6 a9 a90 cm (>97th percentile), and his weight was 14.4 kg
4 M: J- ~6 }; s0 }(also >97th percentile). The observed yearly growth2 D1 E# }- {5 q" [: G* m* G2 r
velocity was 30 cm (12 inches). The examination of) M& M  a' j; Y: s  g4 p# q
the neck revealed no thyroid enlargement.- E* J9 ~& n+ l
The genitourinary examination was remarkable for. D: `2 p' ~" f+ R2 I! D
enlargement of the penis, with a stretched length of% ]& h' ~  p6 r+ i0 ~: J' l
8 cm and a width of 2 cm. The glans penis was very well2 Y- s' \* {" _: O4 f. Z" I
developed. The pubic hair was Tanner II, mostly around
% g- }' l0 h; a: I2 h+ u/ Q540, c' e1 Q  ^6 O5 M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" y) S  l% B& ?9 Y  K
the base of the phallus and was dark and curled. The* T% i( i" F$ N$ V% C9 r
testicular volume was prepubertal at 2 mL each.
8 R+ {; V# G+ n- C/ w: O8 mThe skin was moist and smooth and somewhat
3 Z: o, c1 S* [2 A" Y+ k# Z" Poily. No axillary hair was noted. There were no
- {( l/ ~; [& A' q0 ]' [abnormal skin pigmentations or café-au-lait spots.
- k( r( I+ V6 S5 Z1 u. kNeurologic evaluation showed deep tendon reflex 2+" b0 _. z) i: \8 ]/ y
bilateral and symmetrical. There was no suggestion
3 W0 s6 }. R3 C4 wof papilledema.
3 s& t1 L8 C% I- Y& Q% Q' z0 t( r1 SLaboratory Evaluation
- h+ ]( v3 ?+ E: x% K- ?# KThe bone age was consistent with 28 months by
- h7 ]) a. w+ V  S) Pusing the standard of Greulich and Pyle at a chrono-- C4 f$ t6 X' ]5 d7 ], H7 ?1 U
logic age of 16 months (advanced).5 Chromosomal3 Y" s8 k+ w: S0 W1 m9 m
karyotype was 46XY. The thyroid function test* g3 T7 u, d" k7 Z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# y- e- l& l7 P& U  ~- X8 V0 A! s
lating hormone level was 1.3 µIU/mL (both normal).
* S3 O2 d) R, v( _1 RThe concentrations of serum electrolytes, blood+ h7 ^/ J: v; j1 O0 s4 S
urea nitrogen, creatinine, and calcium all were
% w4 z3 R% s  f& }within normal range for his age. The concentration: S* i5 ]# T7 c4 N2 E7 N
of serum 17-hydroxyprogesterone was 16 ng/dL: _7 c5 E1 |) ~  z' n# D3 r
(normal, 3 to 90 ng/dL), androstenedione was 205 H+ k1 q8 n5 z7 l7 R$ ?/ r" x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 V2 V, E' T( v
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," `4 y1 U# k6 s. N% [6 W: Y6 D* |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 t5 }' N+ K  R2 v3 Q, {& M49ng/dL), 11-desoxycortisol (specific compound S), y( S' l) y" F, w9 k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ h4 G2 M# ?; Z% F# ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. _9 X' g; j/ f' i' a$ b9 M' L
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& r5 r; c" e- B% h4 V
and β-human chorionic gonadotropin was less than# l9 C+ f: a+ a, T
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( \. o% j3 w+ R1 p2 O7 G) {- n/ astimulating hormone and leuteinizing hormone# A: Z* {& ?) `' q. V
concentrations were less than 0.05 mIU/mL' o& C  R1 h# R
(prepubertal).
6 Y* p7 E* A: H. WThe parents were notified about the laboratory
: c0 S) s4 _. M' Y. Aresults and were informed that all of the tests were# |! n1 f4 @& G$ c( l7 V
normal except the testosterone level was high. The
) b- r8 l1 x+ g/ n8 ofollow-up visit was arranged within a few weeks to1 O, v0 c, ^4 k9 V
obtain testicular and abdominal sonograms; how-
+ ^( \$ c4 P! A  r4 _1 E# sever, the family did not return for 4 months.
* w1 x& Y& K/ L: y0 M- {Physical examination at this time revealed that the
% j- O$ }* }% h# R2 s* [) r0 h1 p0 rchild had grown 2.5 cm in 4 months and had gained
/ k. B& D. D6 u2 kg of weight. Physical examination remained! D" H0 e* r' e4 U+ a1 v( G
unchanged. Surprisingly, the pubic hair almost com-
9 O8 i& W$ X" i$ gpletely disappeared except for a few vellous hairs at9 Y+ T  E% V2 s9 _& f) C
the base of the phallus. Testicular volume was still 2) J) m5 Z& I9 P4 ]
mL, and the size of the penis remained unchanged.. }" v; J6 L! Q. D; k
The mother also said that the boy was no longer hav-8 W) i& [0 k/ g' E0 e" V0 K2 A
ing frequent erections.
; M& C8 I5 i4 O. CBoth parents were again questioned about use of
: E+ \6 d7 [; B7 O+ \2 y$ Dany ointment/creams that they may have applied to, _3 b* H. d! @% D( E
the child’s skin. This time the father admitted the" o) I7 M) t* j( h- U% x* z/ N3 ~
Topical Testosterone Exposure / Bhowmick et al 541) G0 U; A2 `6 ]1 |
use of testosterone gel twice daily that he was apply-9 e1 `2 a$ N% U' W% W; ^+ o
ing over his own shoulders, chest, and back area for/ ?2 y2 J. `  H5 K6 X/ z. `
a year. The father also revealed he was embarrassed
: Y  T2 u: ]( g* Q6 t6 C9 `to disclose that he was using a testosterone gel pre-
7 F8 {3 T2 S! `2 }! k& Lscribed by his family physician for decreased libido( Z* a: u' E0 t1 K2 _& \
secondary to depression.
2 {8 G  \  Y1 eThe child slept in the same bed with parents.
% c3 G0 ?7 P7 L% |8 B5 CThe father would hug the baby and hold him on his
& [) B6 l8 F( l* D3 ~3 q7 Gchest for a considerable period of time, causing sig-
8 `$ g: C; J8 ~6 a- U% x2 anificant bare skin contact between baby and father.
- W$ {$ H$ a- q7 \The father also admitted that after the phone call,
3 C+ `! F6 V- D9 ~) \$ g- P+ N  Kwhen he learned the testosterone level in the baby" g  X$ [  G: s) j  T+ v1 d
was high, he then read the product information2 |+ S3 _5 l( A2 o& ]
packet and concluded that it was most likely the rea-( Y9 Z" j0 ~. @" Q
son for the child’s virilization. At that time, they4 S6 Z. R. D, i7 l" E7 _" ]
decided to put the baby in a separate bed, and the1 A6 y  e) l" T1 Y+ v( u  R
father was not hugging him with bare skin and had% i9 r( e7 u: n, `1 K+ a; {
been using protective clothing. A repeat testosterone
, C) i. q. j' r% o0 {5 p) vtest was ordered, but the family did not go to the
$ X# I+ D# P( n; A0 glaboratory to obtain the test.+ J0 R5 K% S" p- L4 ?' b% m
Discussion
9 y' ]) v4 W* o5 f( J% d9 ePrecocious puberty in boys is defined as secondary: e: Z3 l* @5 c
sexual development before 9 years of age.1,4$ n2 W8 c8 K' ~
Precocious puberty is termed as central (true) when6 M0 o% G) Q% J: {
it is caused by the premature activation of hypo-
* P3 L  h! l: H  kthalamic pituitary gonadal axis. CPP is more com-  F2 Z4 P0 b9 z; }' W
mon in girls than in boys.1,3 Most boys with CPP
( ]2 f$ o2 v' y) v- _. i. w! zmay have a central nervous system lesion that is
& k+ S- C( x4 S" iresponsible for the early activation of the hypothal-
! l: ?: Q$ a7 p8 {5 Jamic pituitary gonadal axis.1-3 Thus, greater empha-
/ N  L# h6 W* i6 F2 ^7 {8 G3 Wsis has been given to neuroradiologic imaging in8 R/ E* d! I' I3 b! u! N+ q
boys with precocious puberty. In addition to viril-
& N7 R" E+ Y& L/ T9 w" mization, the clinical hallmark of CPP is the symmet-
& S5 v+ j! J& x/ m! Erical testicular growth secondary to stimulation by
7 F. r7 ~0 S0 w- ygonadotropins.1,3! h- r, ~$ _2 k# O  A
Gonadotropin-independent peripheral preco-) [  x6 z+ m$ X2 E
cious puberty in boys also results from inappropriate' P: l4 e) D  ?' w  m5 O
androgenic stimulation from either endogenous or4 f$ p7 ]+ ?) e4 ]/ H1 @7 j0 [
exogenous sources, nonpituitary gonadotropin stim-; j: @/ S, Y! H. {0 L' X
ulation, and rare activating mutations.3 Virilizing+ j9 {6 ~( k0 f: L9 j
congenital adrenal hyperplasia producing excessive; t: u6 m+ ]" ?3 _* x
adrenal androgens is a common cause of precocious+ }. F, ]( j$ [: G  E
puberty in boys.3,4! i( f3 I+ D3 @0 {0 @; [# `
The most common form of congenital adrenal6 ]/ }2 S0 M  O6 c% G+ w( Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
6 K& W  R/ v: @& n; WThe 11-β hydroxylase deficiency may also result in0 l9 y# P& k' a0 z
excessive adrenal androgen production, and rarely,
8 I5 n* r7 l( Z; r: Z) s% t' _5 han adrenal tumor may also cause adrenal androgen8 x$ L( e: ~' s/ M8 U
excess.1,3
1 ^, E# {( R. n! o7 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ f; h  X3 G# [5 `. K7 U% K
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ v! }/ K4 {- |. L$ A; j3 F. i% lA unique entity of male-limited gonadotropin-
/ _; ^& H) R4 `independent precocious puberty, which is also known& ]$ M8 ]9 X# _% ]2 Q3 m8 H$ q
as testotoxicosis, may cause precocious puberty at a) V7 Q5 z6 B& Z3 [7 K% }
very young age. The physical findings in these boys0 }0 q8 E# U6 `, V( K
with this disorder are full pubertal development,
" l) Q9 L- F$ x/ l, g5 H% Jincluding bilateral testicular growth, similar to boys7 @+ X2 U% ?8 ~2 S: ]
with CPP. The gonadotropin levels in this disorder) w" G9 ?* C( q5 ^7 H/ c
are suppressed to prepubertal levels and do not show0 o  l. i0 b' O5 R# n( P
pubertal response of gonadotropin after gonadotropin-
$ g; q: V) k5 Vreleasing hormone stimulation. This is a sex-linked
' q* H; y. E* k. n$ Z; [, k5 G" gautosomal dominant disorder that affects only
8 h& j! b" |" N2 t: Wmales; therefore, other male members of the family
) f0 `5 g5 i# u% Qmay have similar precocious puberty.33 T% [' ?3 Q% K  L$ B2 S
In our patient, physical examination was incon-
$ I1 p$ u# p- Qsistent with true precocious puberty since his testi-' E$ H# s* m- U: W4 o
cles were prepubertal in size. However, testotoxicosis2 p/ r6 m0 Z2 e2 Q7 `: y
was in the differential diagnosis because his father0 q1 y! J* X! M. l2 f8 j
started puberty somewhat early, and occasionally,) U  y/ B- g2 x0 F
testicular enlargement is not that evident in the5 \% l1 D. m4 L) G$ E, E
beginning of this process.1 In the absence of a neg-) K! G. l0 q8 y9 w
ative initial history of androgen exposure, our. ]* C+ ]/ [0 @+ s0 a- c, `$ z& v$ E
biggest concern was virilizing adrenal hyperplasia,
, O  w: ^( Q( R( ?either 21-hydroxylase deficiency or 11-β hydroxylase
5 F$ s# W& O4 ^7 y8 q7 o  Ndeficiency. Those diagnoses were excluded by find-; Q0 q5 S' Q) h, z. M
ing the normal level of adrenal steroids.- K- Q# J( J' P8 q
The diagnosis of exogenous androgens was strongly# I/ x5 z4 G6 |* w3 F: [: f
suspected in a follow-up visit after 4 months because
, x# N7 s1 T1 V# [1 p% _) e+ Rthe physical examination revealed the complete disap-
( n/ t; |4 f9 Q/ f0 h4 ~# gpearance of pubic hair, normal growth velocity, and4 T: n/ U) z4 h* L7 u+ M
decreased erections. The father admitted using a testos-5 C$ ]/ l% T2 m& p* y+ K! m+ i
terone gel, which he concealed at first visit. He was
. q- b# }' `  s, `% Gusing it rather frequently, twice a day. The Physicians’. A5 \% r% p- T- y! c
Desk Reference, or package insert of this product, gel or
) X* F8 K. |& R- ?& Z. rcream, cautions about dermal testosterone transfer to
: z' ^9 I5 x+ l1 d: ~unprotected females through direct skin exposure.8 N+ I6 a) D3 [9 b. g( I! K, ?
Serum testosterone level was found to be 2 times the5 T+ j5 q+ l( i& @1 ?( g8 P
baseline value in those females who were exposed to
: a% O+ P+ ]) c7 N; weven 15 minutes of direct skin contact with their male7 h# e4 }% ]  U& Q' U- ]+ ~! ^" W
partners.6 However, when a shirt covered the applica-
+ {8 t- T2 ]" J( C8 \* btion site, this testosterone transfer was prevented.& U1 X$ I5 g- ]" B6 G4 B
Our patient’s testosterone level was 60 ng/mL,2 b& ~3 [2 [7 U) N
which was clearly high. Some studies suggest that
# ~6 M7 ]0 c& z6 o5 ~. adermal conversion of testosterone to dihydrotestos-
7 ^& v* `2 q# ?0 @  I/ yterone, which is a more potent metabolite, is more
% ^1 j+ D. z. c+ z0 _% k, A2 sactive in young children exposed to testosterone
' r2 R; v9 P# O& V4 d* Nexogenously7; however, we did not measure a dihy-1 E( T* e* W) z
drotestosterone level in our patient. In addition to
7 A9 M) L6 E) g6 rvirilization, exposure to exogenous testosterone in
% j" p3 z/ O; n- Z6 N) s, Ychildren results in an increase in growth velocity and
2 p* F, E" Q1 \  |advanced bone age, as seen in our patient.
1 G, I% c( U6 v1 VThe long-term effect of androgen exposure during6 n$ L+ P, \2 ?: r
early childhood on pubertal development and final
6 y* F! B+ T+ q/ z2 }adult height are not fully known and always remain. w; z  I8 j. [* \7 }$ ~
a concern. Children treated with short-term testos-
: l$ J5 z+ G* j& u, jterone injection or topical androgen may exhibit some0 d# w/ _+ R# O
acceleration of the skeletal maturation; however, after, s5 E6 }$ Y) `- y. t
cessation of treatment, the rate of bone maturation
( e( k* r! k6 L) y1 sdecelerates and gradually returns to normal.8,9
* W: T' r! Q3 I* S) U$ kThere are conflicting reports and controversy
# O; H$ H( Z4 O& Kover the effect of early androgen exposure on adult# U3 K( G$ A3 X
penile length.10,11 Some reports suggest subnormal
$ Q4 V7 c  Y* V8 q( s- radult penile length, apparently because of downreg-
6 J( u3 L2 X& [1 P) N' v& sulation of androgen receptor number.10,12 However,* k8 H. r$ A. o( F
Sutherland et al13 did not find a correlation between" }' u* }% f5 m% c+ c/ N* P1 I
childhood testosterone exposure and reduced adult. h& K4 s. u1 m; t) L  t
penile length in clinical studies.# N+ |6 v0 Y7 H: x' R" c
Nonetheless, we do not believe our patient is
$ ~" R4 g: k1 ?9 F% y! qgoing to experience any of the untoward effects from
* B( F8 [, _' Otestosterone exposure as mentioned earlier because
! r9 s& b; t. U! I% a: \* ithe exposure was not for a prolonged period of time.  j' p: R, u) Z) L, V. i
Although the bone age was advanced at the time of
1 G: u* }( ?7 R* G4 C8 Odiagnosis, the child had a normal growth velocity at
; k3 o  _2 a+ ?+ J7 W* m' zthe follow-up visit. It is hoped that his final adult
0 Q- m8 i+ ]7 q, Z6 qheight will not be affected.6 e* D3 g) T8 p
Although rarely reported, the widespread avail-
# @- D; _! Z, z8 n& Wability of androgen products in our society may" U( @4 f" p" ~1 s# Z4 Q
indeed cause more virilization in male or female' n/ M0 D4 K3 y
children than one would realize. Exposure to andro-  L, \0 G0 C' v& }9 _! B" f( E
gen products must be considered and specific ques-, c- U* C/ n1 V4 W& \
tioning about the use of a testosterone product or% e) B& _* Y' B% W0 l. ]) ~" z
gel should be asked of the family members during8 W/ a  m! E) _, @% D: I6 C5 ~8 h
the evaluation of any children who present with vir-
' k) R1 P. V, b  y: A  Z. T  {/ tilization or peripheral precocious puberty. The diag-
) ?3 _% C9 U* w, K$ Knosis can be established by just a few tests and by8 }) y, k- ?8 D& c# i6 d
appropriate history. The inability to obtain such a: W: K3 k' ]+ }, |& Y
history, or failure to ask the specific questions, may- w9 e4 [+ M+ B  J$ F
result in extensive, unnecessary, and expensive
$ c1 x& f5 g2 d  y/ v* B9 Minvestigation. The primary care physician should be5 p  a' L& H0 n. T: ]
aware of this fact, because most of these children7 L' D- ^2 m$ ?" V" M; {
may initially present in their practice. The Physicians’
6 t9 `  S9 m  D, j. W. zDesk Reference and package insert should also put a. H. [6 I# y: p) Z  B
warning about the virilizing effect on a male or0 _9 F  V( e$ H  J3 c
female child who might come in contact with some-( _( s* T) t) }0 G3 B
one using any of these products.
/ @( \+ B; G8 f1 F3 mReferences
. B! c+ L; ^. P& K1. Styne DM. The testes: disorder of sexual differentiation
. _, Z$ ^9 e* ^6 Q" a& }4 [# t  B+ ~% tand puberty in the male. In: Sperling MA, ed. Pediatric
4 j) |" m, `1 v; M- r. SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- F- I. N) e6 L! ]7 y7 d  S) [
2002: 565-628.
7 H( _- a7 A; [6 ~4 W2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( `3 u/ e) i2 H- m, M/ E+ p. D- R
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
* f1 W' `& j$ ]+ o5 VBoy Induced by Indirect Topical
, p3 W+ Y/ r; A3 sExposure to Testosterone
  W4 m' W. U. H9 E! HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
  A1 w# T& \4 S8 x$ pand Kenneth R. Rettig, MD1
! W% x  `- l  O- K! \9 ]2 `Clinical Pediatrics! I+ `, n7 k+ U* u
Volume 46 Number 6
6 R: k( `8 o/ p: uJuly 2007 540-543
% e. K9 g* {. G/ ~1 i5 C© 2007 Sage Publications) y% |+ o2 |1 e* b4 x5 z
10.1177/0009922806296651  g1 d) Y$ r1 i/ |, ~
http://clp.sagepub.com4 l- k$ Q- Y$ g: \! n2 k( Q) L
hosted at
7 L# r5 k) B5 m! X- J% g6 u- _! qhttp://online.sagepub.com+ V) k; ]% K, f% G) s
Precocious puberty in boys, central or peripheral,% |- `- d7 y  \
is a significant concern for physicians. Central
5 b. |3 N; K; D$ kprecocious puberty (CPP), which is mediated7 z) G, U( R9 i+ s" J' F  T  r) C
through the hypothalamic pituitary gonadal axis, has
% E) M' b' k+ T8 R) Q2 J: Y2 G* Y! Ha higher incidence of organic central nervous system" y, U- m+ N- i( ^" L- |* F: P
lesions in boys.1,2 Virilization in boys, as manifested4 K; L3 G: a6 P8 Y
by enlargement of the penis, development of pubic2 v- \6 e. x& N0 p. J
hair, and facial acne without enlargement of testi-1 w5 M6 F7 Y# D! L% x9 w7 x* b
cles, suggests peripheral or pseudopuberty.1-3 We
' @0 @, o! l+ U* i9 [! Jreport a 16-month-old boy who presented with the% ]: h. f3 f4 w
enlargement of the phallus and pubic hair develop-
& A% |- Z5 d; ]+ w: T2 ]: Kment without testicular enlargement, which was due
6 r# Y# K. ~! _9 b+ |to the unintentional exposure to androgen gel used by, X* w2 a) ]0 J$ K' C* D* P( H
the father. The family initially concealed this infor-8 g: q4 [& C, y2 ~
mation, resulting in an extensive work-up for this
5 E$ d3 l( F. H# O7 B3 M2 B- |child. Given the widespread and easy availability of# K) k6 Q& ~7 Y( q0 c' ]. k
testosterone gel and cream, we believe this is proba-/ k2 |' |; S$ v6 y! a9 _! B9 E+ t, Q
bly more common than the rare case report in the
. P' ^: _& z* m$ ]9 q( E$ g3 T5 ]literature.4
; {" S4 T8 e9 L4 ^  m  DPatient Report( a" @" h8 [: {  ~3 N
A 16-month-old white child was referred to the
) g' `6 S: S) O7 Nendocrine clinic by his pediatrician with the concern
, ^1 s' Y( H' D/ Hof early sexual development. His mother noticed; Z4 p8 r* n2 z" z' x- l
light colored pubic hair development when he was
% A/ {. U2 e  R( \8 I' EFrom the 1Division of Pediatric Endocrinology, 2University of6 W7 f6 P, W) F4 B
South Alabama Medical Center, Mobile, Alabama.( m, p3 ?$ m* L( e" D- L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 U# D/ k2 X& S; }Professor of Pediatrics, University of South Alabama, College of
/ h$ m  `" y  B( R) x, m' SMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 O' q, r0 D0 s- o: |7 h
e-mail: [email protected].
+ y; H( s- Q, v8 ~( {about 6 to 7 months old, which progressively became
3 k. X7 x+ d3 |6 i6 Edarker. She was also concerned about the enlarge-0 z' ]) R4 R# S; q5 ?+ m
ment of his penis and frequent erections. The child
5 q( u7 ]; t  y* i' t+ ]was the product of a full-term normal delivery, with
5 E5 k) [2 I/ Z% @, E0 a: ua birth weight of 7 lb 14 oz, and birth length of4 _( q& L. {; m' r+ E
20 inches. He was breast-fed throughout the first year7 [3 _3 S2 C- k) o
of life and was still receiving breast milk along with
4 i8 {  ^3 z1 i8 H* Z7 ]solid food. He had no hospitalizations or surgery,+ I( {# _  J( |! Q* D6 k
and his psychosocial and psychomotor development
8 D. G6 v$ z! w  rwas age appropriate.1 `+ Y0 ]. U. z7 J# u. {3 y
The family history was remarkable for the father,
2 y' G" ~& Z( Y: ^8 dwho was diagnosed with hypothyroidism at age 16,
3 Z8 m$ m. D4 [% e, Kwhich was treated with thyroxine. The father’s
+ A3 k- l# X- L4 M6 U5 g9 t, y: pheight was 6 feet, and he went through a somewhat* _1 Q6 g- r3 Q8 Y% Y) |2 h* f
early puberty and had stopped growing by age 14.
+ N3 Z# z& @: {( o3 H8 i# d' I, K) }The father denied taking any other medication. The7 R+ r+ V& Q" L- q3 X! c
child’s mother was in good health. Her menarche
4 \- h1 |* d- Q/ Awas at 11 years of age, and her height was at 5 feet1 E0 q/ X7 q" j" T
5 inches. There was no other family history of pre-3 b% n( A  F0 e% r; y4 b; x" ?3 [
cocious sexual development in the first-degree rela-
9 V( z% f+ y* |6 \6 ^tives. There were no siblings.
1 B, n; U! i5 \7 E3 TPhysical Examination
: }' }0 n$ {% @5 w& H$ [The physical examination revealed a very active,
1 @. i/ [0 G' J1 F5 t  Q! Qplayful, and healthy boy. The vital signs documented
* v, K& v) U) ^  wa blood pressure of 85/50 mm Hg, his length was0 [& t1 Z) f6 O8 W
90 cm (>97th percentile), and his weight was 14.4 kg
- R& D6 v  v* Q. @(also >97th percentile). The observed yearly growth: k: D2 x) w9 U
velocity was 30 cm (12 inches). The examination of, S' Q3 e+ e/ e" w
the neck revealed no thyroid enlargement.  |" C+ ~7 E8 [% O% [8 H% y6 j
The genitourinary examination was remarkable for
: ]6 x* L9 e1 Q1 denlargement of the penis, with a stretched length of2 M& }$ `* m1 u8 q+ W, p# k$ {, h
8 cm and a width of 2 cm. The glans penis was very well
" P! F+ E4 ?1 edeveloped. The pubic hair was Tanner II, mostly around! J  k3 k: {0 Z7 b% b$ r
540& f& F6 i- d$ a/ N$ ^  i3 [5 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" x+ K" ~% S3 X  c( ^the base of the phallus and was dark and curled. The
# i5 C) O( s8 V  ^' s( n7 mtesticular volume was prepubertal at 2 mL each.' ]: e6 ~6 J) m- v6 K
The skin was moist and smooth and somewhat
: x* _( `! B( ^, C. \oily. No axillary hair was noted. There were no
6 C; O4 ^7 `3 D" ]* x7 Z% V- `abnormal skin pigmentations or café-au-lait spots.
. K+ d: \" J3 G1 p+ p4 u9 NNeurologic evaluation showed deep tendon reflex 2+
3 b, F! e  x3 Y' a! cbilateral and symmetrical. There was no suggestion$ c$ p; i( V8 U/ t: k
of papilledema.
  A/ A  d! Q6 l  q/ I- OLaboratory Evaluation
7 b  k4 K: s3 K+ UThe bone age was consistent with 28 months by* p' z4 U1 a  ^  L, o  T: b
using the standard of Greulich and Pyle at a chrono-
' Q/ H3 s1 O  K) F- T9 H& a, l! Ylogic age of 16 months (advanced).5 Chromosomal
3 i9 H5 ?3 G9 Dkaryotype was 46XY. The thyroid function test
4 x6 W! p7 H# E, H$ O. p& Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 w2 m% g4 c) ~8 ~0 mlating hormone level was 1.3 µIU/mL (both normal).
+ E4 Z) b2 M, S4 ~. `3 _; VThe concentrations of serum electrolytes, blood! I1 y2 s2 v  k, C- `6 K' M# c/ M
urea nitrogen, creatinine, and calcium all were5 T9 Q- m, I$ Z
within normal range for his age. The concentration1 t" W2 F# _& e) A4 Y* _
of serum 17-hydroxyprogesterone was 16 ng/dL: V2 A! V; r5 E. t( F
(normal, 3 to 90 ng/dL), androstenedione was 20: U# ?" \. G- o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 Z' l/ t/ I6 K
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# t, w2 k/ I( ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to5 X/ Q7 t: e  d7 Q0 Q$ b
49ng/dL), 11-desoxycortisol (specific compound S)
6 F! V& }; T$ y- `& z% f! Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( n1 W4 x0 [/ @6 k' I0 e0 `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. h; f- B, m4 g$ u  l6 H! M& ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL)," {! s1 y6 H7 j9 K% m; V9 G2 [
and β-human chorionic gonadotropin was less than
5 V' F" ~9 L. x; a+ I' M4 Q5 K) z5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ M. p- @" s. p0 {6 [- Q* mstimulating hormone and leuteinizing hormone# A0 G- K" q6 F0 e( g* r
concentrations were less than 0.05 mIU/mL
" J& n! P/ e" @* o# @(prepubertal).+ {+ M$ W9 M4 D& c, s
The parents were notified about the laboratory' ^8 \- R( n" H! e9 B; U" l
results and were informed that all of the tests were! M* p; \6 n' G& J( ]4 |- i' M
normal except the testosterone level was high. The
8 R; e! J* [" d' w/ h) O3 Xfollow-up visit was arranged within a few weeks to
; a* q  c2 V3 C# z$ wobtain testicular and abdominal sonograms; how-
' z" x2 A  `! W; L1 iever, the family did not return for 4 months.1 M; R* K# E* C$ I" g$ e
Physical examination at this time revealed that the
& s  S! a4 q4 Y. xchild had grown 2.5 cm in 4 months and had gained" U" f5 L5 z1 g! V6 q
2 kg of weight. Physical examination remained1 U3 h* j( S, q; X" ?+ x6 z
unchanged. Surprisingly, the pubic hair almost com-
( a( P  [! X8 A5 Gpletely disappeared except for a few vellous hairs at
5 S! f+ A* A1 U0 B; N9 _the base of the phallus. Testicular volume was still 2
1 N, @2 l! X4 `9 C: VmL, and the size of the penis remained unchanged.
& |- \! n( k- k" w9 F1 D& K2 N( ZThe mother also said that the boy was no longer hav-
) p" A/ K( [  q" }- N4 sing frequent erections.
$ p  y. d& W: |+ w2 [) XBoth parents were again questioned about use of
6 D2 G2 k0 B; z6 z7 W* A( f. Nany ointment/creams that they may have applied to
- N, d0 L  j  x& ?# [0 ?. qthe child’s skin. This time the father admitted the! x: g- V3 L9 n1 P
Topical Testosterone Exposure / Bhowmick et al 541
' b3 K& U# J3 Y# R6 Tuse of testosterone gel twice daily that he was apply-
2 t3 z( r7 I7 O6 B& _$ z7 p3 Ning over his own shoulders, chest, and back area for
# q7 }& R& T1 `8 N( \8 Ra year. The father also revealed he was embarrassed  A$ r4 _& ~. a% }  Z0 w
to disclose that he was using a testosterone gel pre-
7 w: H( ?1 X4 f' m  w& Kscribed by his family physician for decreased libido
5 {1 s* l) @% _0 x% a+ i+ Wsecondary to depression.7 Q8 A( v1 S2 |, [
The child slept in the same bed with parents.
" G( _2 p5 ]4 E- s* yThe father would hug the baby and hold him on his6 G; c3 u: @+ n3 @7 |( K, L7 U
chest for a considerable period of time, causing sig-; \5 Y: ?' j5 _0 n2 e* L
nificant bare skin contact between baby and father.7 x# |9 F, `4 c. h" j$ k
The father also admitted that after the phone call,
3 e7 Q( E& M" L: e# P  h+ V+ j5 t  Bwhen he learned the testosterone level in the baby( V* g0 o! Q5 S; q" M: c$ C+ b: E1 a
was high, he then read the product information/ I; L" A9 `4 n0 `
packet and concluded that it was most likely the rea-
  {9 L, U! U* J9 ~3 R0 Oson for the child’s virilization. At that time, they
8 j5 f8 g" k* g$ ddecided to put the baby in a separate bed, and the
2 R; z5 H0 O  e) f8 X: Wfather was not hugging him with bare skin and had& [, l* y1 I, ]0 k
been using protective clothing. A repeat testosterone- m6 x6 k+ E! c0 B4 q. E
test was ordered, but the family did not go to the# _0 l$ h" Q& q- l# F/ U
laboratory to obtain the test.( |' f& c) L4 ?" p9 |4 G* y2 f
Discussion
# ~6 a: s9 u# l' OPrecocious puberty in boys is defined as secondary
+ P3 f0 Y4 q9 ?5 c7 P; H* ^sexual development before 9 years of age.1,4
$ p5 ~( K* h' O8 t. B/ j+ \0 A' WPrecocious puberty is termed as central (true) when
( Z8 b( Y" \; q2 F" B( tit is caused by the premature activation of hypo-
0 {) H5 f. Y. Y6 Qthalamic pituitary gonadal axis. CPP is more com-
! |; {! j4 E' o0 k1 Y2 pmon in girls than in boys.1,3 Most boys with CPP3 o* O( k. Y  o/ W7 u
may have a central nervous system lesion that is
, M6 ?; Y) z) }8 q: z5 Sresponsible for the early activation of the hypothal-
4 Q: T( `" w+ O6 `  \) Uamic pituitary gonadal axis.1-3 Thus, greater empha-
: u0 J) \% T; ~1 l5 o/ \sis has been given to neuroradiologic imaging in
4 @5 U; K  a; Rboys with precocious puberty. In addition to viril-) o6 z7 x' ~) L% K4 s  R4 H% {& V
ization, the clinical hallmark of CPP is the symmet-
; G4 ?9 C; ]& w! p/ D& O9 X; @rical testicular growth secondary to stimulation by
7 ^  R% Y) K8 B* n! E% `gonadotropins.1,31 Y5 p& b5 ]9 g1 t8 E1 O& n! V
Gonadotropin-independent peripheral preco-: y$ t; j( [5 {8 J# T0 q( j) Z/ i9 Z
cious puberty in boys also results from inappropriate
# s$ o" j. K' w4 Gandrogenic stimulation from either endogenous or5 }4 d9 ~: b6 D. `: S$ r: u, V# @' W/ Z
exogenous sources, nonpituitary gonadotropin stim-
) t6 I5 P4 F0 l$ L' X& A9 Uulation, and rare activating mutations.3 Virilizing+ w/ j5 U% M0 ~
congenital adrenal hyperplasia producing excessive! c1 R  q* g2 g% ]: Q
adrenal androgens is a common cause of precocious
4 Q  B- S: C  u5 Ypuberty in boys.3,4( `8 N) t% C' M) M* A, K! x
The most common form of congenital adrenal5 h' H: u% f. R& |, f4 p/ H, K+ B
hyperplasia is the 21-hydroxylase enzyme deficiency.
* j) r- N8 s6 b1 M* qThe 11-β hydroxylase deficiency may also result in1 L7 O0 h  W! [3 K
excessive adrenal androgen production, and rarely,
9 Q1 M: W6 P2 _+ h0 Aan adrenal tumor may also cause adrenal androgen& j! E5 X+ ?& P2 I+ g7 J* v+ Y# F/ {
excess.1,3
' I' E5 {. E: T. A- tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) Q: n% F# X: Z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* v+ D6 ]" W0 r1 S* pA unique entity of male-limited gonadotropin-  B0 E, O6 P/ R7 p% E0 O
independent precocious puberty, which is also known, N) S2 r0 L- I' y( h: S
as testotoxicosis, may cause precocious puberty at a
# E; L8 Y7 i4 M. G6 Avery young age. The physical findings in these boys
7 b. e1 v3 V  i( {: }- Awith this disorder are full pubertal development,. D" \" }! P* t1 K# s5 G
including bilateral testicular growth, similar to boys  T* o. M8 Y/ S, S$ S; b5 {
with CPP. The gonadotropin levels in this disorder9 p# }: y" h2 N( `* M: U
are suppressed to prepubertal levels and do not show
( T! ^" O  z0 jpubertal response of gonadotropin after gonadotropin-8 V& f0 D8 h. o$ {! ?" O4 N0 D
releasing hormone stimulation. This is a sex-linked* n4 M& C% W6 O; V1 m% s& Z
autosomal dominant disorder that affects only
* D! g/ a: c/ h# H1 W7 Q1 emales; therefore, other male members of the family. E6 W8 X  A# \
may have similar precocious puberty.3' M+ u' P& p; g* T" P) |
In our patient, physical examination was incon-- z( L" v2 a& w- q9 l
sistent with true precocious puberty since his testi-
/ P' L- B/ o6 G# J  E! Ycles were prepubertal in size. However, testotoxicosis
- i* B+ j1 S# M6 ~9 L; swas in the differential diagnosis because his father
: v* ^( S1 Q* j' l4 j  ustarted puberty somewhat early, and occasionally,' d( S" E' y. o/ p9 I2 y9 {
testicular enlargement is not that evident in the( r$ x1 Q, D; ?. a9 N
beginning of this process.1 In the absence of a neg-: Y$ @1 X/ F4 J
ative initial history of androgen exposure, our
# O4 A& G) N/ B/ h1 y4 v5 wbiggest concern was virilizing adrenal hyperplasia,
7 A" e: y2 N. Ueither 21-hydroxylase deficiency or 11-β hydroxylase8 x% A2 V6 A4 C: ]
deficiency. Those diagnoses were excluded by find-" y) w  k0 v# y- U  l
ing the normal level of adrenal steroids.
- T$ f" g( d% x; ?9 `; X0 ZThe diagnosis of exogenous androgens was strongly* k4 P8 @  u; z# ^
suspected in a follow-up visit after 4 months because
% _  D3 \1 ?9 r- y4 dthe physical examination revealed the complete disap-# V+ h; Z: n8 `* B" Y! j0 n( o
pearance of pubic hair, normal growth velocity, and( v, i& M6 P8 e+ n' H! w2 N! Q# I
decreased erections. The father admitted using a testos-1 I, j8 T: X) X  M& f5 b" p6 k
terone gel, which he concealed at first visit. He was
' N) ^6 x$ C0 W2 m; k) Musing it rather frequently, twice a day. The Physicians’! Q' L5 m6 ^- X1 k) M3 H
Desk Reference, or package insert of this product, gel or; N1 I3 |) N) M& M" P' L) L
cream, cautions about dermal testosterone transfer to# ]- v: v& }0 W0 l6 V+ @/ B' G' r( Q
unprotected females through direct skin exposure.7 X$ g3 X& F( S+ \2 X. I6 J; p
Serum testosterone level was found to be 2 times the. F* _4 f! P# w7 T7 q. K1 a
baseline value in those females who were exposed to/ X" l1 @1 @3 Z+ k/ o) B' I0 a
even 15 minutes of direct skin contact with their male
( Q. o7 _9 |$ M3 U7 U' kpartners.6 However, when a shirt covered the applica-/ q: j6 E* i" p# o/ G
tion site, this testosterone transfer was prevented.
: e2 w- D4 t% G0 n- _% r7 _Our patient’s testosterone level was 60 ng/mL,
  G& a; {1 D# b7 a3 {which was clearly high. Some studies suggest that
6 {8 f7 z# z+ r, m6 odermal conversion of testosterone to dihydrotestos-, n8 C2 Z" k" g9 A
terone, which is a more potent metabolite, is more% j5 O9 N+ j+ E( m5 b
active in young children exposed to testosterone3 F. F4 o; J8 `5 Z
exogenously7; however, we did not measure a dihy-6 k2 w% _0 `6 K6 S
drotestosterone level in our patient. In addition to
2 ]: }0 F4 I' D  ]. _3 h2 xvirilization, exposure to exogenous testosterone in
+ i% z7 ]7 M: echildren results in an increase in growth velocity and
2 N8 T, ^) A4 x0 s! Jadvanced bone age, as seen in our patient.) W: H9 Z* J6 ~3 n
The long-term effect of androgen exposure during! F# r4 e6 ^3 E5 V
early childhood on pubertal development and final
# A& W% Q" P* [2 }9 U, Padult height are not fully known and always remain
, t! {! _0 ~; L) s' f9 S" Fa concern. Children treated with short-term testos-9 l8 z8 M2 f) p" L) b1 n/ ~
terone injection or topical androgen may exhibit some
( k3 X+ b5 J2 M3 T# }- Lacceleration of the skeletal maturation; however, after* z+ f! B1 S3 l( Y8 j
cessation of treatment, the rate of bone maturation+ r- Q& Q- _( S3 C
decelerates and gradually returns to normal.8,9
; U9 d; R5 r' @$ e( z& UThere are conflicting reports and controversy
/ ^% a- z1 o% D$ y1 Gover the effect of early androgen exposure on adult9 x/ u5 V; s/ D* c1 p
penile length.10,11 Some reports suggest subnormal+ z+ A' R) I% R% O; a# M
adult penile length, apparently because of downreg-
0 L4 {4 u4 Q" C$ q2 _( m" nulation of androgen receptor number.10,12 However,
' l" X0 S- W+ F" \2 ]# k" i3 ESutherland et al13 did not find a correlation between; X  {" ]" X. q1 g. i% O5 |4 x$ q/ H
childhood testosterone exposure and reduced adult/ o/ q2 F0 O; U( j
penile length in clinical studies.: U/ y: s6 Y, K# y/ z! J
Nonetheless, we do not believe our patient is
4 j* Z" V) B, i; v5 zgoing to experience any of the untoward effects from) g% @' j+ W  u0 \8 S+ {
testosterone exposure as mentioned earlier because' R+ X6 ?' _$ h* ]* S7 E
the exposure was not for a prolonged period of time.
) p* y9 |( o- O6 bAlthough the bone age was advanced at the time of
# O5 B) q0 z7 F) _" `diagnosis, the child had a normal growth velocity at$ ?2 t% s2 l2 Z3 s* C
the follow-up visit. It is hoped that his final adult
  U$ b3 t/ I9 B2 A% eheight will not be affected.
% |2 l, ~5 D2 O: G- w% j" J) l- I2 wAlthough rarely reported, the widespread avail-
) d' R& u* \9 d% Cability of androgen products in our society may2 n5 [/ i! I0 y( f+ R1 l
indeed cause more virilization in male or female7 t, i7 p" E; q& A# G# g2 ?5 `
children than one would realize. Exposure to andro-
2 ~- R; ^" k- Tgen products must be considered and specific ques-
- ?4 ~, u* D- g9 ], Z3 @2 ntioning about the use of a testosterone product or1 H9 P$ ]9 c5 }' y$ X0 p
gel should be asked of the family members during
2 b! N$ c+ Y: w: q% C7 I- k4 l9 ithe evaluation of any children who present with vir-2 \( T& v) n: A2 l# T7 x
ilization or peripheral precocious puberty. The diag-
2 X: s8 o. Y  p+ J+ c' \7 F* j( ynosis can be established by just a few tests and by! t" o, B5 b0 r& t
appropriate history. The inability to obtain such a% n4 l' q( I# ?$ Q! I* C: P
history, or failure to ask the specific questions, may
/ e3 f2 W+ v% {+ i* T6 Tresult in extensive, unnecessary, and expensive
7 [# Y' t0 w" U- U/ einvestigation. The primary care physician should be
) F$ r7 c3 t& Vaware of this fact, because most of these children
6 p$ w) W2 W$ Rmay initially present in their practice. The Physicians’
8 A% P7 \: q5 y3 V5 j  w! ADesk Reference and package insert should also put a4 h/ z8 R/ C* C" w% o
warning about the virilizing effect on a male or
+ F8 ?$ m$ i7 D9 X0 j: J( Q# [- _female child who might come in contact with some-: ~. V  x' |- H. p2 t
one using any of these products.- p$ h  k6 B6 ?1 u
References& c* v* f+ D2 y; @8 N8 e1 M/ a
1. Styne DM. The testes: disorder of sexual differentiation
6 Y: q3 Q* x/ C. s" Yand puberty in the male. In: Sperling MA, ed. Pediatric
; v& k- W# C) G; i3 rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 E1 x6 m" f0 M2002: 565-628.) ^3 `6 [* G; p- [" ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% }7 t) }8 W/ n+ jpuberty in children with tumours of the suprasellar pineal
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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!

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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
累計簽到:11 天
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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

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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?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層
: `8 u5 O3 Y. j: b
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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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