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Sexual Precocity in a 16-Month-Old2 n% f, z8 w/ l2 I, W/ M
Boy Induced by Indirect Topical, M+ `( Q( u* C0 ^9 s3 e* f
Exposure to Testosterone6 W4 C# z9 y0 d3 D! t1 m- e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 `2 S; @8 \; S! O
and Kenneth R. Rettig, MD1! ]6 a) H7 W6 O0 k
Clinical Pediatrics
$ H+ ]: `5 _5 v8 VVolume 46 Number 6
# N  k# q7 ^! v! n. U+ xJuly 2007 540-543; q3 B2 V: {* ]3 i: H
© 2007 Sage Publications% P' q: x- S. `! m# H
10.1177/0009922806296651
( N: W+ C; m* e, k; m; D5 {7 Whttp://clp.sagepub.com! }1 m3 i0 \/ O% S; i9 A
hosted at& Z3 k, y# x8 D( s- M4 I6 L
http://online.sagepub.com
. C* H  z& C: R- j+ N0 sPrecocious puberty in boys, central or peripheral,
+ X3 V# q1 x- {( ?# a, Bis a significant concern for physicians. Central
2 a. h3 h: }9 q+ P! jprecocious puberty (CPP), which is mediated) Q, n3 H6 u9 O* @/ \# j! M
through the hypothalamic pituitary gonadal axis, has& @% P4 c: K% e7 D9 C
a higher incidence of organic central nervous system
  ?5 b7 [6 X7 G; n1 \! z$ Clesions in boys.1,2 Virilization in boys, as manifested3 m+ u) [$ T; d' c$ V3 B
by enlargement of the penis, development of pubic
( _+ K6 U5 h6 p$ H  Ihair, and facial acne without enlargement of testi-
6 p1 C( O. N  X/ }! n7 Acles, suggests peripheral or pseudopuberty.1-3 We! w9 [5 N9 ]4 k- D1 D1 m
report a 16-month-old boy who presented with the; t$ G5 u3 K. k0 |, e: _; @6 e( f
enlargement of the phallus and pubic hair develop-9 V% \+ A1 O+ X; q7 g2 v+ G' H; \
ment without testicular enlargement, which was due. [& ?+ n. W! h6 Y/ A( v
to the unintentional exposure to androgen gel used by
0 D  q0 L# A) I  cthe father. The family initially concealed this infor-
* n% q* i# N1 g4 ]mation, resulting in an extensive work-up for this  j8 H5 v$ t) |, X8 M
child. Given the widespread and easy availability of
5 T/ s9 j: c8 \! U) x! Wtestosterone gel and cream, we believe this is proba-4 D$ W- C; j- i! O& m9 c
bly more common than the rare case report in the4 E% ], E' J) q6 B: h
literature.4
% U4 k; |2 T$ zPatient Report
: D! a0 i" c& d0 ?+ _- f7 {/ GA 16-month-old white child was referred to the
% k; H+ w. H- E; b4 S( \4 H* O) Jendocrine clinic by his pediatrician with the concern' K9 o1 I6 s! t" y* M
of early sexual development. His mother noticed
( f& o1 z/ W2 Y/ O2 Wlight colored pubic hair development when he was
) U# e) ~( i7 ~) W( ^From the 1Division of Pediatric Endocrinology, 2University of) n8 R; N) _& ?
South Alabama Medical Center, Mobile, Alabama.
4 M, Y# K5 c3 T/ |Address correspondence to: Samar K. Bhowmick, MD, FACE,2 T- C& b# M4 B2 C/ J, y
Professor of Pediatrics, University of South Alabama, College of
* _) f- G4 N$ e8 @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. C. D! _- R: u3 [5 O: K. h$ r. We-mail: [email protected].7 f3 e. |- J4 U2 Q
about 6 to 7 months old, which progressively became! o; S& H% X, d* J4 H6 k
darker. She was also concerned about the enlarge-
2 p* Z  l$ O/ w- G8 v+ [/ Qment of his penis and frequent erections. The child# j# ^7 s; B- I
was the product of a full-term normal delivery, with1 ~) {. [+ g  K' s
a birth weight of 7 lb 14 oz, and birth length of
- i' O2 r9 i3 d$ T1 D20 inches. He was breast-fed throughout the first year
' l1 l2 p, z4 V9 i/ g& H) }% {of life and was still receiving breast milk along with
4 Z3 I. K: o( A% ]' t, b: O" tsolid food. He had no hospitalizations or surgery,. |: j" e0 p' Z
and his psychosocial and psychomotor development
  U# j* V% T2 N3 u' w+ ?. _7 S" lwas age appropriate.' Y% E6 Z# U( Q
The family history was remarkable for the father,. t; w0 P. b% x5 Q6 R( \
who was diagnosed with hypothyroidism at age 16,, g% _# e4 F$ {' A% Z1 H& K3 F1 }
which was treated with thyroxine. The father’s) _" N0 }0 Q8 Y1 }7 Q0 [
height was 6 feet, and he went through a somewhat. h/ a6 b$ A6 l( @
early puberty and had stopped growing by age 14.
; o! B) g4 b- q4 @6 a+ CThe father denied taking any other medication. The
  b5 U, Q0 }4 Q0 r' V; A- Hchild’s mother was in good health. Her menarche
) E  u9 h8 |4 X) ~6 Uwas at 11 years of age, and her height was at 5 feet
; e: k& p7 M6 w5 inches. There was no other family history of pre-: _# ]( m) q! L/ X0 q% t  H
cocious sexual development in the first-degree rela-
! t8 C2 S# s1 B( vtives. There were no siblings.8 d+ p; p0 p* N& ]6 ?/ T+ r9 _
Physical Examination2 J! c/ r* G' q( j6 B  ~
The physical examination revealed a very active,: F* c& o* z- ^8 g" ]# a
playful, and healthy boy. The vital signs documented3 h8 X! H; z8 `8 g/ h) p7 \
a blood pressure of 85/50 mm Hg, his length was$ \' F8 S3 l: O; t% T: v) \
90 cm (>97th percentile), and his weight was 14.4 kg
9 Z# i2 c4 M, X0 ?# _# \1 [(also >97th percentile). The observed yearly growth
9 f4 s: y# j1 P7 mvelocity was 30 cm (12 inches). The examination of
  e: p+ X! V  E6 e3 Y2 Qthe neck revealed no thyroid enlargement.
5 ^$ p+ v- |5 {* z& Y  V5 c! O: \The genitourinary examination was remarkable for/ s+ |. _1 u" j  ^
enlargement of the penis, with a stretched length of# A: L) w; u' e" d# s; u
8 cm and a width of 2 cm. The glans penis was very well
7 Q) h$ O. R4 M" q* J5 @developed. The pubic hair was Tanner II, mostly around
; F. s- n! G3 X5 ^540. M" |2 i( ^3 D1 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 O; c/ A+ [% }9 A0 N( n  D( @. N
the base of the phallus and was dark and curled. The% V+ ~4 R* `! b4 z
testicular volume was prepubertal at 2 mL each.
& b, w. @+ m1 b1 tThe skin was moist and smooth and somewhat2 C' O- e/ a4 o" m) X' Y$ ]
oily. No axillary hair was noted. There were no. Z2 M& @+ Z1 o, N, n
abnormal skin pigmentations or café-au-lait spots.
) V/ U$ [+ i8 M3 e- u( s; Y) K) ~, eNeurologic evaluation showed deep tendon reflex 2+4 L  `  `$ k* M5 o6 w
bilateral and symmetrical. There was no suggestion
, e  I% o9 L% @; u# ?of papilledema.
0 ~* y" L. }* u$ FLaboratory Evaluation
  E: V# A: M0 t/ _! u# N9 VThe bone age was consistent with 28 months by
& ~  Y+ y: ^4 G' Y4 Z: V  Zusing the standard of Greulich and Pyle at a chrono-; [$ W& I1 |5 P. y
logic age of 16 months (advanced).5 Chromosomal* f. i: O2 U4 M
karyotype was 46XY. The thyroid function test/ k# ]% Y3 w! s# \; }
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 m+ j' B/ {+ @- l$ V& e
lating hormone level was 1.3 µIU/mL (both normal).9 P! ~! q' }+ [& C, O; _' _
The concentrations of serum electrolytes, blood
+ |7 K1 [! i5 C$ L7 ]' _/ R) |3 Aurea nitrogen, creatinine, and calcium all were% i1 \! O6 O% z
within normal range for his age. The concentration7 n6 v" \5 A7 {& D4 O3 X/ V/ f: t
of serum 17-hydroxyprogesterone was 16 ng/dL& Z* K- k: j# n+ u! y
(normal, 3 to 90 ng/dL), androstenedione was 20
  f0 ~% ?; z8 |8 _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 Y& O$ Z% A  _8 S
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
: D. d2 y+ p" j- L! z  idesoxycorticosterone was 4.3 ng/dL (normal, 7 to- L6 ~" S& }1 I+ s
49ng/dL), 11-desoxycortisol (specific compound S)7 G9 w; z: T6 b9 V5 e
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. e- T& }. A! T6 R9 v0 ?  G$ atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 ~# j7 g1 e2 g" o( ~
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  h! Q+ R2 }: J# F, |/ Eand β-human chorionic gonadotropin was less than8 H( v  c. l/ d1 p2 E/ s
5 mIU/mL (normal <5 mIU/mL). Serum follicular% I; {: ]5 j8 O5 o! K, v
stimulating hormone and leuteinizing hormone
/ b* ?9 ?$ [4 D, ~concentrations were less than 0.05 mIU/mL$ N. c2 _0 t! p; j' w, U, Y
(prepubertal).
$ j, O# c. T% t5 O8 U- F( QThe parents were notified about the laboratory/ d. j# S( m  o2 ?! ^
results and were informed that all of the tests were  g2 H3 a; K+ ^5 ^0 @
normal except the testosterone level was high. The
5 z# H" ?% ~3 i! a6 v. |- Vfollow-up visit was arranged within a few weeks to2 ~+ M7 C4 f- R0 ?' @7 P
obtain testicular and abdominal sonograms; how-
, `& ?0 T7 a% v  I6 Q& ^ever, the family did not return for 4 months.
/ M) F- ^1 s7 K' zPhysical examination at this time revealed that the" `  o" O3 k, ^6 f1 p# m9 Y
child had grown 2.5 cm in 4 months and had gained
" T7 M+ C( s3 M' t3 E9 S2 kg of weight. Physical examination remained- T  J! P) m$ b5 `) Z
unchanged. Surprisingly, the pubic hair almost com-2 `  Q; T0 _$ X& o; {
pletely disappeared except for a few vellous hairs at
. ?- c8 T- M( H# ~& ethe base of the phallus. Testicular volume was still 2+ V0 m( V# }9 S6 Y/ P$ ?- g+ o
mL, and the size of the penis remained unchanged.$ E  B% G, A7 d: ]: h  l+ X
The mother also said that the boy was no longer hav-
8 a" q9 N3 c( L4 \ing frequent erections.) f, t  m( [3 b3 u' x4 T4 A
Both parents were again questioned about use of
$ N0 y) |7 P6 L0 [7 h3 k, [, fany ointment/creams that they may have applied to
& w: l/ E. N( [/ E% J; ]% ?the child’s skin. This time the father admitted the% k/ }* a7 a9 U4 W! n7 M
Topical Testosterone Exposure / Bhowmick et al 541
' w9 w0 S9 T5 guse of testosterone gel twice daily that he was apply-* U! A2 u) R5 Q/ m% G
ing over his own shoulders, chest, and back area for) F/ @0 t. w- K: R2 `
a year. The father also revealed he was embarrassed
4 c% \# X) q% R7 oto disclose that he was using a testosterone gel pre-* ^$ {0 w" h) J& ^1 y' M
scribed by his family physician for decreased libido* U3 z# T9 s: Q9 M5 J
secondary to depression.. p) H" ?5 L. h+ L" a! P4 |$ K  j6 o
The child slept in the same bed with parents.' \- V3 U" t( D+ F. W
The father would hug the baby and hold him on his7 p4 i+ M% T0 B+ s; A: I: Y
chest for a considerable period of time, causing sig-% z' ?6 Z! ?& v: T
nificant bare skin contact between baby and father.
; W8 C% X6 G1 X- |4 ^+ SThe father also admitted that after the phone call,
1 o  Z) `7 V& _1 Dwhen he learned the testosterone level in the baby
5 f- b" q9 ?8 b2 U, Awas high, he then read the product information9 x  A9 W( ?* p: E7 Z  _( J
packet and concluded that it was most likely the rea-7 j/ \$ C1 i& h# Y& |4 [7 x" P% z" w
son for the child’s virilization. At that time, they
9 D/ |9 K, y+ q" w% _& J* J2 ldecided to put the baby in a separate bed, and the
5 }/ ?6 O" X# C5 Nfather was not hugging him with bare skin and had) ~* I- q* _! f3 T4 u+ t, u
been using protective clothing. A repeat testosterone
! }) c; R! e1 }" s) p: T/ ^test was ordered, but the family did not go to the7 H5 S' }5 v/ G: W
laboratory to obtain the test.1 p3 Z' m5 D5 Q; _$ |6 X3 [: H3 d
Discussion1 s. c9 |) y) R* l. }6 n" g1 W* Z) q) C
Precocious puberty in boys is defined as secondary3 m2 `  M" h0 ]4 v# x: l+ k& B
sexual development before 9 years of age.1,4
# u4 F" f: q& L) sPrecocious puberty is termed as central (true) when
( t/ G2 y! p7 m: ^3 hit is caused by the premature activation of hypo-& ]0 x, `) X. Q3 |) @; B2 T
thalamic pituitary gonadal axis. CPP is more com-
0 }. s3 t4 b& E) s7 T# X% vmon in girls than in boys.1,3 Most boys with CPP5 R0 H" A4 [' ?( q
may have a central nervous system lesion that is
, P+ G/ d+ d; Z! B4 ^& x8 i& Cresponsible for the early activation of the hypothal-# _8 i3 _1 S5 D+ U( Y/ M6 F
amic pituitary gonadal axis.1-3 Thus, greater empha-$ j* Q5 Q8 J% C$ ?
sis has been given to neuroradiologic imaging in
* ]% E# j# i5 s$ {- `  ~/ pboys with precocious puberty. In addition to viril-/ y# k/ |  Q+ x- m+ u5 V
ization, the clinical hallmark of CPP is the symmet-' h7 M/ X- |. K  R( E& o
rical testicular growth secondary to stimulation by$ Z& w# n" Q% O2 S7 f
gonadotropins.1,3# j( t$ Z: C3 }% ?- L; r
Gonadotropin-independent peripheral preco-
& ^0 {) g- X' ^0 I( xcious puberty in boys also results from inappropriate
3 ]9 P: Y( s. e6 C; \. O4 iandrogenic stimulation from either endogenous or/ |! M8 x0 r" h$ v
exogenous sources, nonpituitary gonadotropin stim-+ i1 o9 A4 `3 j: O5 V+ t
ulation, and rare activating mutations.3 Virilizing
; R# S0 q1 C3 Econgenital adrenal hyperplasia producing excessive
) T8 d; b% p+ ]5 |# Vadrenal androgens is a common cause of precocious
- E: Z/ b  _. `1 npuberty in boys.3,4" l, h9 D& ^/ {: T: \7 B/ Y
The most common form of congenital adrenal3 o9 C6 O  a* t; p" h( {% P
hyperplasia is the 21-hydroxylase enzyme deficiency.
; i) ]- g% X5 i  g. ~( O4 Q% mThe 11-β hydroxylase deficiency may also result in: U4 }$ D; L1 c
excessive adrenal androgen production, and rarely,
! d/ V7 i. f6 x  A# `! Ean adrenal tumor may also cause adrenal androgen3 t0 x* J! F; N: p
excess.1,3% B# G  ]) W6 m1 o4 i  n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 U( q$ }( b: V- |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) x3 g  Y8 z  O. K. W8 a( g6 HA unique entity of male-limited gonadotropin-
- F, e3 G  o+ Q! W3 }/ sindependent precocious puberty, which is also known
+ v6 ]" R" \  [/ pas testotoxicosis, may cause precocious puberty at a/ k0 f: V+ J5 z& P1 {; s
very young age. The physical findings in these boys% V5 B7 k( O% O2 H2 e; E$ b
with this disorder are full pubertal development,( S$ |9 W% ~# ?  b, t! D" X
including bilateral testicular growth, similar to boys: @# ^/ _3 i' c! N" q5 j8 {
with CPP. The gonadotropin levels in this disorder* C( C: l3 Z" O# v' ]
are suppressed to prepubertal levels and do not show
# _2 C: s* W9 d  I' Q& b' spubertal response of gonadotropin after gonadotropin-& S, u/ D& N. c+ j' ^: A: a
releasing hormone stimulation. This is a sex-linked
/ w" t, q+ K; v& Z& ~autosomal dominant disorder that affects only( x- _1 d4 _- E
males; therefore, other male members of the family2 V* F% h5 C: N3 u1 L/ t0 u
may have similar precocious puberty.3) V' ?8 s: E1 g3 ]* b
In our patient, physical examination was incon-6 ?- Z( d& p1 I6 l' E! u
sistent with true precocious puberty since his testi-6 Q! N0 ?% S% `2 U. L  X
cles were prepubertal in size. However, testotoxicosis, l! P* g! B7 y* Z  X  K
was in the differential diagnosis because his father
% W4 v+ z; v& X3 w" U' N* K4 `* z2 sstarted puberty somewhat early, and occasionally,
4 J0 v: O  L4 @- S; b- ktesticular enlargement is not that evident in the
8 j; B' E( I( I7 w  obeginning of this process.1 In the absence of a neg-  M/ s- T  J0 D2 I8 M; y& A  ]
ative initial history of androgen exposure, our
3 _6 q9 B$ t- Ibiggest concern was virilizing adrenal hyperplasia,
$ t5 V1 ]% M& r6 q( S/ neither 21-hydroxylase deficiency or 11-β hydroxylase9 J, w+ X$ I" n2 |
deficiency. Those diagnoses were excluded by find-
' T/ q, e; t9 W9 ring the normal level of adrenal steroids.: Q4 t- {# b, t* W  |1 X6 V+ a* O
The diagnosis of exogenous androgens was strongly
5 f" {) z: [. ?+ u5 {. |; Zsuspected in a follow-up visit after 4 months because
' o# H" a! i$ f, y9 [* U" sthe physical examination revealed the complete disap-
' M) a6 Z: k; c$ q) C3 K1 {pearance of pubic hair, normal growth velocity, and  E" V( l: b. `. P) Y* H
decreased erections. The father admitted using a testos-
2 G" f, i% g) j  [4 nterone gel, which he concealed at first visit. He was9 e# ^/ Z; h+ X6 m; t1 T" e& g' `
using it rather frequently, twice a day. The Physicians’
2 l  o2 L( A5 ?7 Q! K+ vDesk Reference, or package insert of this product, gel or& _4 `% D7 |3 E+ o( [; T' {
cream, cautions about dermal testosterone transfer to8 m, T) h0 Z* h6 H
unprotected females through direct skin exposure.' W. U: r, F) q8 [" ?
Serum testosterone level was found to be 2 times the" `& O' y1 D2 }8 E. h# V
baseline value in those females who were exposed to
1 X' x, y2 O8 k, I3 D, n1 Eeven 15 minutes of direct skin contact with their male% t6 }% F% i9 i7 z, _9 ^
partners.6 However, when a shirt covered the applica-
! _. U8 J/ j1 w- G' Y5 r- F' Qtion site, this testosterone transfer was prevented./ E1 k$ }, l5 ^3 G2 W2 V
Our patient’s testosterone level was 60 ng/mL,  z3 b6 E8 H9 e( }, z9 X
which was clearly high. Some studies suggest that. d5 v. s; @, a: `6 {
dermal conversion of testosterone to dihydrotestos-
+ S* U! p0 R4 `7 F7 Z1 mterone, which is a more potent metabolite, is more
5 d0 ^, z& y7 d. i( J' o+ ?active in young children exposed to testosterone
, r6 E& d+ `% rexogenously7; however, we did not measure a dihy-+ z2 l- w  Y+ E* ]) j
drotestosterone level in our patient. In addition to
4 N# x9 z' S8 q. s- O, F/ Pvirilization, exposure to exogenous testosterone in
* f; x! B1 z6 D' `5 [4 I* Vchildren results in an increase in growth velocity and
6 _" K9 N7 f0 Kadvanced bone age, as seen in our patient.2 j0 W8 _1 m" M3 L9 `
The long-term effect of androgen exposure during! S& p+ a* ~1 \6 `% S& f
early childhood on pubertal development and final  K% j; L0 O9 z) w( U* L
adult height are not fully known and always remain1 b6 ^5 i' O% k& C0 [0 p0 E
a concern. Children treated with short-term testos-
  `& G* o: _# S2 R+ gterone injection or topical androgen may exhibit some
6 E  }$ g  ?4 {acceleration of the skeletal maturation; however, after
! D' o6 j7 y" ~9 ^. Q/ x$ T1 K6 Xcessation of treatment, the rate of bone maturation
8 I9 K/ u  R0 h- Z/ K% _% C* ~, Zdecelerates and gradually returns to normal.8,9
  h( Y9 F' w- p, e% g% xThere are conflicting reports and controversy
! T5 y! R0 r  B; O5 Z- C$ n: vover the effect of early androgen exposure on adult
7 r! c$ Z5 C. a+ M+ \- h% ~6 Xpenile length.10,11 Some reports suggest subnormal
+ U8 O* }' x( Y- e  m  ]adult penile length, apparently because of downreg-
9 F! g8 Y5 ^7 {ulation of androgen receptor number.10,12 However,  N  v8 h4 l! \& }( R7 e8 ?3 n- V
Sutherland et al13 did not find a correlation between* e# I& I) p% ~7 F7 }
childhood testosterone exposure and reduced adult
6 D: R# Y6 K0 j' T& j! ]  {' Kpenile length in clinical studies.
1 x4 v  U% N% S4 Z; x/ ~5 {Nonetheless, we do not believe our patient is
+ c& i9 G2 P$ _3 Y; _$ ?going to experience any of the untoward effects from4 O2 i* m: J) g, }* d
testosterone exposure as mentioned earlier because8 r# ~/ Z( o! J2 k: M5 G' w
the exposure was not for a prolonged period of time.7 _' K" O6 J8 M: L, c/ g* p6 P4 s
Although the bone age was advanced at the time of
7 z9 W  x3 c* y# O& Ydiagnosis, the child had a normal growth velocity at9 W5 W7 q% m" L
the follow-up visit. It is hoped that his final adult8 y; ~/ ~( E0 g% t
height will not be affected.
, Z  a7 N5 q9 ZAlthough rarely reported, the widespread avail-5 _1 f) h+ E  E1 E; }
ability of androgen products in our society may+ _9 @  e) N; a2 s9 Q3 F& t( `
indeed cause more virilization in male or female) ^; z4 m2 Q/ t' P4 y! k
children than one would realize. Exposure to andro-, z7 K- m- u9 U' F( ~
gen products must be considered and specific ques-
& r  F6 g( e1 g6 ?' otioning about the use of a testosterone product or1 ]7 O# x0 y2 c9 A* G8 x  D
gel should be asked of the family members during( K8 G" p! V. Y, g' ]7 |  v: D
the evaluation of any children who present with vir-
4 m) J$ W9 \; V# O5 `3 xilization or peripheral precocious puberty. The diag-1 o1 \) ?5 _! G$ W/ E7 X  A
nosis can be established by just a few tests and by. X% M' O" ]. L- i# P7 D
appropriate history. The inability to obtain such a
7 a0 O$ t1 q4 rhistory, or failure to ask the specific questions, may
! J2 s, w7 h) |' _# g4 @result in extensive, unnecessary, and expensive; G2 n! c  v4 v0 p
investigation. The primary care physician should be
& a0 H/ c3 Z; y+ r' }5 e0 G8 Caware of this fact, because most of these children2 `+ x% ]1 [, p
may initially present in their practice. The Physicians’
0 b$ t2 u6 f5 PDesk Reference and package insert should also put a  H4 W8 T  C2 l  W0 W9 @+ C
warning about the virilizing effect on a male or) n4 H  g( d# H4 F" _# |
female child who might come in contact with some-
1 j! ?" D; z9 t! l, N- h2 C3 Q5 u1 Qone using any of these products.6 R8 D& t+ S1 ^# ~% P
References% Y' Z4 z( Z( E$ Z% B; c$ G' x
1. Styne DM. The testes: disorder of sexual differentiation
: M% R6 {8 G0 ~3 `3 K* P' xand puberty in the male. In: Sperling MA, ed. Pediatric
5 {% j; K0 l- k1 P2 c2 W' WEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ L) j# \& G8 V* i& ]: O  S
2002: 565-628.; i' n& O$ w4 q6 I
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' b! t7 \7 @! N& F! _# \9 |, t" c
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
" X. W$ R+ o7 `/ R2 {( S# rBoy Induced by Indirect Topical
( E: E+ c7 ^* d, c# |Exposure to Testosterone
. u9 d7 Y9 x. m- \5 C9 D* USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* N! K9 _; g8 h: l! I: D/ c
and Kenneth R. Rettig, MD1# Z1 G2 g- `0 T4 D9 i  I! l+ t
Clinical Pediatrics
& u3 |, D- X3 ]Volume 46 Number 6
; P6 r! b" t( j' H0 {8 B: CJuly 2007 540-5438 Q* F3 J( w7 C
© 2007 Sage Publications7 ?- y  w! V7 y4 R7 f& I4 ^8 ]6 h
10.1177/0009922806296651# C1 p( w7 e, C: S. g9 X. j  N! y3 B2 ?
http://clp.sagepub.com& B' C& j9 ]. b
hosted at
' r% G% d  I! Vhttp://online.sagepub.com/ J9 Q1 G' D8 J7 y+ _/ p
Precocious puberty in boys, central or peripheral,
3 `) s- T7 d7 h. wis a significant concern for physicians. Central9 I1 H# G: ^- |3 M! X- l
precocious puberty (CPP), which is mediated1 y7 X% R4 {4 x1 [) h, e
through the hypothalamic pituitary gonadal axis, has) h9 t1 t: ^2 m4 {9 Z- O7 w! A
a higher incidence of organic central nervous system
1 q9 d2 \* }" C1 z, Wlesions in boys.1,2 Virilization in boys, as manifested
. L2 S# I& y8 {" T7 f# K5 t+ Yby enlargement of the penis, development of pubic
8 t1 U* A2 s( u7 F# W/ \. M, khair, and facial acne without enlargement of testi-
2 a1 n" U! E5 r9 t# S* s3 `; Dcles, suggests peripheral or pseudopuberty.1-3 We# n* L+ ~3 }/ p9 N+ x
report a 16-month-old boy who presented with the
* }1 L1 `7 a4 Q: Senlargement of the phallus and pubic hair develop-7 \. a9 x  Q. C9 Y9 M% }
ment without testicular enlargement, which was due  e2 ?# M: M* j; h3 F0 G
to the unintentional exposure to androgen gel used by
7 c& \; e1 r. }3 w6 L* [: c, _the father. The family initially concealed this infor-
( Y6 B, n4 j4 @* }2 B" ?9 [: Lmation, resulting in an extensive work-up for this4 c5 g4 f1 X8 U! P1 z
child. Given the widespread and easy availability of
  C+ u( e  g& Y  a$ t* q' Wtestosterone gel and cream, we believe this is proba-
$ T( d# s6 P. q* D: k7 xbly more common than the rare case report in the
+ \3 b0 {! T9 \( Y& a% i0 J7 |literature.42 {' H6 A. k" P) S' P9 `" z/ B# A# X) j
Patient Report
1 D7 G" O4 m' w2 CA 16-month-old white child was referred to the, S# T' O/ ?4 M/ v6 r
endocrine clinic by his pediatrician with the concern" [/ Y2 ]9 ?: G+ K5 Y* |! q) m% Y$ y
of early sexual development. His mother noticed
7 q2 K! L: f4 c9 h8 H, jlight colored pubic hair development when he was
' _- o% e) ?; N6 `4 \; HFrom the 1Division of Pediatric Endocrinology, 2University of& Q- L$ z0 y: \1 V5 P" U+ C4 d
South Alabama Medical Center, Mobile, Alabama.$ }! {- b" {% S* Y! U5 s: F
Address correspondence to: Samar K. Bhowmick, MD, FACE,% `' V1 Z  ^" J- x# u1 j4 q' K- B) |' G
Professor of Pediatrics, University of South Alabama, College of1 H% Y/ m3 q1 a& i5 [9 b* X
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 @7 W) d  k6 \/ @2 J1 ae-mail: [email protected].* L2 p" O( P$ V1 `0 i9 \- B
about 6 to 7 months old, which progressively became* D4 z7 p3 h2 H: t
darker. She was also concerned about the enlarge-5 T5 D* N, k# |2 ~! l% Q6 y% U
ment of his penis and frequent erections. The child6 q) D& q' N9 N( o% |
was the product of a full-term normal delivery, with
- c5 a6 u' z1 |0 n5 ca birth weight of 7 lb 14 oz, and birth length of
  A5 ^+ U6 i+ P. C( L20 inches. He was breast-fed throughout the first year% n+ S- M0 P# B/ C2 F, b0 @
of life and was still receiving breast milk along with2 x; S) k6 n+ y; y) D8 v
solid food. He had no hospitalizations or surgery,
# H; R# ~/ M+ c1 x, Aand his psychosocial and psychomotor development5 i5 g  z- A2 w- f1 v
was age appropriate.
' Y' c2 {& J) e! @5 A, LThe family history was remarkable for the father,7 N- O2 s+ j) f9 d# U2 u
who was diagnosed with hypothyroidism at age 16,3 b% b9 G2 H7 i6 y5 Q$ a
which was treated with thyroxine. The father’s
+ P. z' n7 j# A* m! B# y% Dheight was 6 feet, and he went through a somewhat
1 a9 ~6 `* Y; J6 J+ i4 `1 G. zearly puberty and had stopped growing by age 14.* ^0 _+ K3 J1 U. m5 X# X
The father denied taking any other medication. The
# O$ P8 e4 {, n* C6 P+ `child’s mother was in good health. Her menarche
7 X% e% C0 V: T9 Xwas at 11 years of age, and her height was at 5 feet
2 o: J8 p) L% g8 d5 inches. There was no other family history of pre-
" U( i( m. O1 Q! i0 C; zcocious sexual development in the first-degree rela-7 p7 V; Q; y4 p1 K2 I5 f7 d" g# C, ?
tives. There were no siblings.# i4 }3 z$ R$ S  K
Physical Examination! u. N! d: b9 A; t$ i! u4 B0 @
The physical examination revealed a very active,
% B) `% K" c( r3 B/ {playful, and healthy boy. The vital signs documented
7 f3 ~. I# B' ^5 Q: l; ^$ qa blood pressure of 85/50 mm Hg, his length was
; a5 ~! M) B/ D+ J! S7 H! B! w5 i90 cm (>97th percentile), and his weight was 14.4 kg8 W# K; p5 [/ {6 w
(also >97th percentile). The observed yearly growth
, r7 \+ D2 v% g) V( Avelocity was 30 cm (12 inches). The examination of$ p( X* e6 @9 Q& e
the neck revealed no thyroid enlargement.: w1 C% Q, [3 U& F
The genitourinary examination was remarkable for$ P+ ~& y% _# U, P" Y
enlargement of the penis, with a stretched length of: i: H3 i. {2 h. K' A4 s6 \
8 cm and a width of 2 cm. The glans penis was very well; U9 i' {# p- w& B
developed. The pubic hair was Tanner II, mostly around
, d3 Z3 N/ N, {8 C% ?- Y540
/ A8 P' c' t/ x8 `% [1 Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! h& M' @9 ~( v. ^9 E& B
the base of the phallus and was dark and curled. The) a7 l7 d& C; |" n$ w) C! Z8 u
testicular volume was prepubertal at 2 mL each.
8 `5 y$ g2 G( ?6 f) x" XThe skin was moist and smooth and somewhat1 d: M+ C2 W7 ~/ J5 w& D$ |
oily. No axillary hair was noted. There were no
, ~7 A4 K5 x% {  c0 p1 Wabnormal skin pigmentations or café-au-lait spots.
: r- x2 {  L# s8 yNeurologic evaluation showed deep tendon reflex 2+: u7 t( r. Z+ z# E
bilateral and symmetrical. There was no suggestion
$ ^/ `9 `8 W2 |8 F* N/ Z( F5 g4 Kof papilledema.! @/ i0 P; Q$ `, [
Laboratory Evaluation6 b/ d( P. K0 d
The bone age was consistent with 28 months by
% r" u( U9 F! [% H. d* Iusing the standard of Greulich and Pyle at a chrono-
# I) D* Z. B  i0 }, Q4 Tlogic age of 16 months (advanced).5 Chromosomal
# x2 _$ W! S( [% Hkaryotype was 46XY. The thyroid function test/ d9 O1 Q8 e- L5 F
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 P' O1 Y; j- h, r. J0 `
lating hormone level was 1.3 µIU/mL (both normal).8 Q, _9 t+ _9 Q
The concentrations of serum electrolytes, blood/ c) u; Y9 R1 |3 m, r
urea nitrogen, creatinine, and calcium all were& Z: c6 w- B1 \" }
within normal range for his age. The concentration
$ F* I1 t! I1 [* p" x4 |& g5 Gof serum 17-hydroxyprogesterone was 16 ng/dL
6 a. F. B/ E1 N% ](normal, 3 to 90 ng/dL), androstenedione was 20
" v2 }% Q, e4 ]9 X+ u8 _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' z. C# X, M. z% A+ bterone was 38 ng/dL (normal, 50 to 760 ng/dL),  X1 E! h0 s, i2 m' r* {
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" L5 ^/ I% S. G+ [6 u/ y49ng/dL), 11-desoxycortisol (specific compound S)
/ o9 J. E# Z1 p7 j% awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 ?6 |. E, Q# K  n. h/ ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& ~) u/ @+ X  C, m
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) n- X' L2 I& b% S+ z2 m3 h
and β-human chorionic gonadotropin was less than* y  k! H8 ]3 n6 N+ _
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 X- l+ Z2 a2 s$ Kstimulating hormone and leuteinizing hormone' L: T2 z3 ]' L1 u  j
concentrations were less than 0.05 mIU/mL
& W6 w" D! k. l( ?2 H(prepubertal).
3 `5 r8 j4 r& zThe parents were notified about the laboratory4 I9 E. j: p% ~6 [+ s
results and were informed that all of the tests were6 `' p1 L/ U! G1 V
normal except the testosterone level was high. The
7 D0 I; a1 D# F& M& kfollow-up visit was arranged within a few weeks to
7 _' |) i+ b& B( h, V8 C1 t& n1 ~obtain testicular and abdominal sonograms; how-
, S- ]" o' b0 L1 Vever, the family did not return for 4 months.
; s' N  u4 Q' a" L0 _1 m4 G# oPhysical examination at this time revealed that the/ m8 W0 D3 _% _
child had grown 2.5 cm in 4 months and had gained
8 F- T0 h# ?# v* [& z9 y7 k9 a2 kg of weight. Physical examination remained
7 b: D. R% N6 ^/ h' Q1 Y9 Qunchanged. Surprisingly, the pubic hair almost com-
7 @# @* y& j* p6 v7 npletely disappeared except for a few vellous hairs at/ {' |& k* }) j
the base of the phallus. Testicular volume was still 2, Q( z3 o) l5 B, t7 c
mL, and the size of the penis remained unchanged.
$ A0 E& ^7 F; r4 PThe mother also said that the boy was no longer hav-
0 B' x- c6 `5 t; r3 ving frequent erections.
- ^' |) z& m+ A5 xBoth parents were again questioned about use of
* S5 V5 o( Z3 E# N1 t5 q, Many ointment/creams that they may have applied to
* |+ L% v3 n8 d. F7 Lthe child’s skin. This time the father admitted the5 R: j* t9 b3 v! Y( E; d
Topical Testosterone Exposure / Bhowmick et al 541
+ ^, l. M' k+ p7 ~& S  Zuse of testosterone gel twice daily that he was apply-
7 w+ E- m/ p! ^+ `/ U8 u' cing over his own shoulders, chest, and back area for
* O; b* a& }1 |, Ha year. The father also revealed he was embarrassed9 T3 a9 D# S; [3 k( s
to disclose that he was using a testosterone gel pre-
! {! J* C  X& r! S3 fscribed by his family physician for decreased libido0 N/ W/ H7 H4 o, K( _
secondary to depression.
+ [8 _$ @3 l/ @7 K0 k8 w  |; QThe child slept in the same bed with parents., t0 F4 a5 @% b5 ?9 N; G7 a; Y/ j* ]
The father would hug the baby and hold him on his
/ R1 `3 r+ R/ |) g3 E$ c8 ?chest for a considerable period of time, causing sig-
+ J: J0 X  G( r: z  H5 Onificant bare skin contact between baby and father.7 w4 r' z; k& x, g5 }1 M
The father also admitted that after the phone call,, h% y0 G8 K7 Q  r
when he learned the testosterone level in the baby
: P% ~+ w0 M$ A- M0 Vwas high, he then read the product information
0 o' k& G- `6 h. |: ppacket and concluded that it was most likely the rea-
7 q& P, t. r( f8 g, A9 Nson for the child’s virilization. At that time, they  t- w. Y- I* b5 M# J
decided to put the baby in a separate bed, and the$ S' R+ P8 ?% Z9 @- W. ~+ K, h) b
father was not hugging him with bare skin and had& F/ v/ T" r% i; `, I) |& f9 L8 h
been using protective clothing. A repeat testosterone
. b1 r7 e$ Y6 j. V8 \test was ordered, but the family did not go to the5 D  f7 s. D! y8 h: ]# B
laboratory to obtain the test.3 F! j0 c; J: }( d3 b% J9 `
Discussion
9 v! i% U0 c! k6 d7 A2 NPrecocious puberty in boys is defined as secondary
! r: P( k# C. Z% d  g* g( l3 n5 P- _sexual development before 9 years of age.1,4( m8 Y" N1 e+ h! R; b8 U
Precocious puberty is termed as central (true) when
& C/ Y0 E0 r8 [% Pit is caused by the premature activation of hypo-. A3 a  I2 e+ H6 e$ J
thalamic pituitary gonadal axis. CPP is more com-* j% K/ R* M7 s& q* H5 Z: a, s& i3 h
mon in girls than in boys.1,3 Most boys with CPP6 O$ i1 B4 v) h+ M6 p
may have a central nervous system lesion that is3 \2 Y5 A. @+ b; f6 F
responsible for the early activation of the hypothal-9 }9 D: b. j8 I: p& u0 P0 J
amic pituitary gonadal axis.1-3 Thus, greater empha-7 a6 U# c3 @, S" X: j7 m. e
sis has been given to neuroradiologic imaging in
/ p  H% P4 c: ], ^- e$ oboys with precocious puberty. In addition to viril-
5 L, O7 _( p# z5 vization, the clinical hallmark of CPP is the symmet-
' F8 [+ j. F1 k) m& Q# ]rical testicular growth secondary to stimulation by- ]+ G! p8 h0 `9 P, i0 e) J
gonadotropins.1,3: t' u8 ~/ s& Z& J
Gonadotropin-independent peripheral preco-
  G- }& W; L0 O9 fcious puberty in boys also results from inappropriate
" k! B- c  ^+ d/ s# Y- N& ], ~androgenic stimulation from either endogenous or; B: F/ X( _& [5 ?5 Q
exogenous sources, nonpituitary gonadotropin stim-; N* h, n% S6 Z1 g" V$ \
ulation, and rare activating mutations.3 Virilizing0 c. p; F  D3 W6 l+ }
congenital adrenal hyperplasia producing excessive* o0 s- A3 w; g
adrenal androgens is a common cause of precocious
8 D% S% t% o9 ?- hpuberty in boys.3,4
6 w, `, S' R0 W* pThe most common form of congenital adrenal# m, e: U) p6 j  K+ @
hyperplasia is the 21-hydroxylase enzyme deficiency.4 ]* m4 P0 d) M# ^0 ?4 A  d. p+ g
The 11-β hydroxylase deficiency may also result in
8 |1 o7 A9 t# r! dexcessive adrenal androgen production, and rarely,
& l& R/ L# k, uan adrenal tumor may also cause adrenal androgen: ~, T% r% |0 N1 g' d
excess.1,38 V* ]5 {) D" ]3 p) b& Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* _7 z" D& z5 J, j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! L8 r5 r: k6 \: q5 ]
A unique entity of male-limited gonadotropin-! ?) z3 Y* Q9 Q/ {& X! E6 r
independent precocious puberty, which is also known- @" p4 ]7 D6 E; q
as testotoxicosis, may cause precocious puberty at a
, L( }& N/ Z0 |* c% }& Bvery young age. The physical findings in these boys
: J' l7 S' q; Y. qwith this disorder are full pubertal development,# X$ x0 S% H5 ~" F
including bilateral testicular growth, similar to boys
) j, t, D% p* |5 s% \with CPP. The gonadotropin levels in this disorder' p4 d% L% V" A# @
are suppressed to prepubertal levels and do not show" o! i& P/ d; C# f
pubertal response of gonadotropin after gonadotropin-% C6 d/ A' _$ Z+ m
releasing hormone stimulation. This is a sex-linked
2 G% o! \$ x. d: w3 ~0 Yautosomal dominant disorder that affects only+ h; P3 u; ^( M* N; p1 }: {# y0 i
males; therefore, other male members of the family
. e" \; n. M# z. tmay have similar precocious puberty.3- V3 w7 I( B. G, l2 e' V  ]
In our patient, physical examination was incon-* }  C2 Z, v$ G# _, q5 t: i# h
sistent with true precocious puberty since his testi-
7 F  @: Q; u# M$ `& gcles were prepubertal in size. However, testotoxicosis
" H; J; O- g+ t/ ~0 {' X7 S5 Xwas in the differential diagnosis because his father7 K0 |1 F9 v4 S% }4 r9 K  v7 F
started puberty somewhat early, and occasionally,
# o: V* @% b9 U0 W+ c! X3 C# F3 rtesticular enlargement is not that evident in the8 O9 R) ~' @) E5 p8 y) T
beginning of this process.1 In the absence of a neg-% Z) R2 D6 L( Q) [' h$ h$ f
ative initial history of androgen exposure, our; _; d# o& B  d
biggest concern was virilizing adrenal hyperplasia,
5 v. c% z. g& P( X- \1 leither 21-hydroxylase deficiency or 11-β hydroxylase8 G, c$ [$ f5 Y5 [; g- l2 ~
deficiency. Those diagnoses were excluded by find-: c1 q* e) |0 W" s6 [
ing the normal level of adrenal steroids.
( }% T% h: y! J- ]The diagnosis of exogenous androgens was strongly' q# H# o& L* N. g
suspected in a follow-up visit after 4 months because% b  R2 ?3 n7 O8 Z
the physical examination revealed the complete disap-$ p. V8 S% ?8 q) p2 l# P
pearance of pubic hair, normal growth velocity, and
7 k7 q5 P& F& F9 w" K# Gdecreased erections. The father admitted using a testos-
, b4 S& ]) q+ Q4 D$ Vterone gel, which he concealed at first visit. He was9 h, j  L* l' ^" h; k' ~$ V
using it rather frequently, twice a day. The Physicians’5 S7 ~% G+ n/ B6 q
Desk Reference, or package insert of this product, gel or2 X( x; F/ I: X# E6 J
cream, cautions about dermal testosterone transfer to
% M; b8 M+ }1 t; ~3 aunprotected females through direct skin exposure.  Z7 T2 f7 S7 S+ s( ]5 @8 k7 A
Serum testosterone level was found to be 2 times the
( s, K+ ]: u6 j$ l5 j1 C* m- Ubaseline value in those females who were exposed to
4 U* S1 _8 l3 s% {* g* _even 15 minutes of direct skin contact with their male4 d/ C4 ~, ]0 {/ j2 S
partners.6 However, when a shirt covered the applica-
& J: n: m/ {% U8 ^& Qtion site, this testosterone transfer was prevented., G8 ]; h8 r$ k2 [6 U5 l
Our patient’s testosterone level was 60 ng/mL,: |5 m4 X9 d% M& U: |+ |$ V' ~
which was clearly high. Some studies suggest that
$ `/ U5 f% J8 q- B$ Z  jdermal conversion of testosterone to dihydrotestos-
. Y' O8 X6 f$ u: }' e/ \# Xterone, which is a more potent metabolite, is more% X+ ^, [! G0 |
active in young children exposed to testosterone. A; E* g) B2 U! O' h. H
exogenously7; however, we did not measure a dihy-
& v$ c6 r" Y$ O5 g# u) wdrotestosterone level in our patient. In addition to
2 s/ U2 Q( e( }virilization, exposure to exogenous testosterone in
6 P+ u- \. R. ]! Q0 ~children results in an increase in growth velocity and
+ v) w0 M6 w: m% }5 w  ladvanced bone age, as seen in our patient./ G! \: I, k( e3 m$ X3 Y" O
The long-term effect of androgen exposure during/ d4 ^( x  z5 B( n, f- h# c
early childhood on pubertal development and final
* ]  u: E2 \9 q- hadult height are not fully known and always remain) D. D5 n& ~- p' K- Q, A
a concern. Children treated with short-term testos-2 c: ~( }$ l4 R( S: `
terone injection or topical androgen may exhibit some
7 k) a8 Q% {6 I8 yacceleration of the skeletal maturation; however, after
/ k, d3 o- h/ u' t( scessation of treatment, the rate of bone maturation* H. z5 {( |8 Q2 _  U# X; a
decelerates and gradually returns to normal.8,9
3 X. M. n5 {* m9 \& c1 U( x- `There are conflicting reports and controversy
4 h1 E2 r& [/ Q5 v/ ~over the effect of early androgen exposure on adult$ ~5 g/ T0 O7 Z& P1 W
penile length.10,11 Some reports suggest subnormal+ [4 w" H) S- g) b6 l) A. u- `
adult penile length, apparently because of downreg-0 P- _4 c1 q+ l6 |7 D: F
ulation of androgen receptor number.10,12 However,  ?" B5 G1 ?# g5 K4 M! V
Sutherland et al13 did not find a correlation between$ b- B0 y% ?6 W
childhood testosterone exposure and reduced adult) w; v2 j  G+ i, U" U8 j
penile length in clinical studies.! F+ A, T; K+ U7 C( F  {
Nonetheless, we do not believe our patient is6 \7 j3 b" A. I! [" E, x+ ]
going to experience any of the untoward effects from: y" S$ V# p% x5 K+ t
testosterone exposure as mentioned earlier because
2 s! x" |% H* C1 u" M5 rthe exposure was not for a prolonged period of time.
1 b6 h" y1 ?/ O: V+ W! G) {' h" vAlthough the bone age was advanced at the time of
* C+ L! X7 Q0 B4 e8 }6 o& Ldiagnosis, the child had a normal growth velocity at! C4 K7 H% q3 C
the follow-up visit. It is hoped that his final adult0 }: e- @8 E5 k3 L, A' K% N2 d
height will not be affected.
$ \! h/ ?7 Z( W7 c* TAlthough rarely reported, the widespread avail-
; f* P) `- w8 [5 g9 Aability of androgen products in our society may
! H3 n% B. u, O' Cindeed cause more virilization in male or female% J8 S: S& N7 K$ ?: B
children than one would realize. Exposure to andro-4 R9 s2 _2 ]7 d& a% h+ s5 `* Q
gen products must be considered and specific ques-
" X( l. \' i. v$ P" H. F2 ntioning about the use of a testosterone product or$ V3 k& [0 {' ^/ v! F& C- x
gel should be asked of the family members during: w7 ?  T& |* c) t+ a
the evaluation of any children who present with vir-
5 ?4 p6 q9 p9 V( y8 c& P: yilization or peripheral precocious puberty. The diag-
& D# M$ U8 o6 M. [2 cnosis can be established by just a few tests and by9 L  r# b7 h. _# L
appropriate history. The inability to obtain such a7 q: a) j& @) q) J( Z
history, or failure to ask the specific questions, may- s2 `4 K; a0 K9 l: P% u
result in extensive, unnecessary, and expensive5 B" U" q& X% F
investigation. The primary care physician should be7 `2 g& P7 W: |! t
aware of this fact, because most of these children& J) ^% }4 b& Y+ a
may initially present in their practice. The Physicians’
! f- H! k$ v. Y) CDesk Reference and package insert should also put a' }/ J- A* G4 R1 b1 C; T
warning about the virilizing effect on a male or) Z& L0 _/ I% o* v& A$ I
female child who might come in contact with some-( E- N& ~  d9 O+ a
one using any of these products.) @& I0 J& B# ~, q0 q
References
: f, a/ }! ]; E1. Styne DM. The testes: disorder of sexual differentiation2 ]& H4 a' a9 j* S. S1 W, C
and puberty in the male. In: Sperling MA, ed. Pediatric
2 M8 S" b3 K. E$ I" NEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;, D( k- |* {* ^4 @% C8 ]4 v4 h; {+ I0 F
2002: 565-628.8 z1 @; ~: E* _1 ]- T: X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  `6 }9 A7 U+ @7 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

) v5 M5 k- i* ~7 {6 w+ [& H: n0 h2 T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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