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Sexual Precocity in a 16-Month-Old8 h; t  \9 ^% G
Boy Induced by Indirect Topical
5 _# z! I# l# M% T8 }! jExposure to Testosterone1 c) f& ~, o# n, |; N! T
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" _0 k7 o' {0 Q2 \/ P) h) b5 e& Mand Kenneth R. Rettig, MD18 M3 p) \  _9 e- s3 J; a
Clinical Pediatrics' ^' u( C9 R0 r" Q
Volume 46 Number 6. H5 \7 l4 F, y# i0 e* {8 G
July 2007 540-543  b# `$ O: O) x: O. ?0 v- L+ O
© 2007 Sage Publications, C6 h, N9 @7 A
10.1177/0009922806296651" R$ E* e  J4 `5 I: V
http://clp.sagepub.com
; D" K7 ]0 y6 L6 bhosted at
# O2 Y4 ]' E2 H$ f% qhttp://online.sagepub.com
5 B! J) u2 a9 s  m; J6 b- qPrecocious puberty in boys, central or peripheral,
) a$ |$ C' Y  ~) e8 [0 N$ M" sis a significant concern for physicians. Central
, z9 h5 B/ C: k2 ^1 a+ y, |precocious puberty (CPP), which is mediated) s, |& }+ L; Q) [% ~
through the hypothalamic pituitary gonadal axis, has1 Y  h, w% d* j3 f- b
a higher incidence of organic central nervous system) |4 M5 h5 f) g
lesions in boys.1,2 Virilization in boys, as manifested" Q' C' `! d0 }8 L: ~/ V
by enlargement of the penis, development of pubic
3 T# P1 }' u7 I: y8 e0 yhair, and facial acne without enlargement of testi-
, ], g, a' K) L8 V, p" Scles, suggests peripheral or pseudopuberty.1-3 We- G, r- R5 x- \3 t
report a 16-month-old boy who presented with the
& p% G. d$ H4 x- O  V% N7 penlargement of the phallus and pubic hair develop-
& Q+ v; ~7 N( ^7 H+ o0 Kment without testicular enlargement, which was due
& Q5 w  S9 G$ |. r- Y1 l# kto the unintentional exposure to androgen gel used by
: T2 @& w6 i7 Q; w5 \8 l" fthe father. The family initially concealed this infor-
6 o0 t, w" U. A; c% E& Qmation, resulting in an extensive work-up for this
: E6 S, L9 w' t! ?, ~child. Given the widespread and easy availability of
( |( _$ L& f* m8 M2 y* A  ttestosterone gel and cream, we believe this is proba-, i& r2 y- [/ e
bly more common than the rare case report in the
) p2 w: x( O' [. p& D' z. u4 z- ^6 Wliterature.4
0 K9 x2 @! Z5 f) ^( O# u1 YPatient Report; X" z! V# Z& c: o. K
A 16-month-old white child was referred to the. G, x+ e0 _  ?% r8 G1 Z
endocrine clinic by his pediatrician with the concern
+ X( c2 ?5 T4 A3 j1 b+ @* uof early sexual development. His mother noticed( V/ D. P0 \% Q; F9 X3 b
light colored pubic hair development when he was
1 O% q2 f( _9 V: h+ M9 I8 _From the 1Division of Pediatric Endocrinology, 2University of
. t! d- _1 _7 [: E  k# O: _2 |) v  VSouth Alabama Medical Center, Mobile, Alabama.
, H0 `6 ?: v5 e3 vAddress correspondence to: Samar K. Bhowmick, MD, FACE," a$ ~7 {3 @/ W0 Y* L
Professor of Pediatrics, University of South Alabama, College of  U& N9 K( U! M& j6 L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ e* Q3 j. N/ @: M5 Ye-mail: [email protected].
9 I5 z* ~  H# K+ K, E) Nabout 6 to 7 months old, which progressively became! l3 s2 p- w2 q' a- {- K' }
darker. She was also concerned about the enlarge-' u' W: z$ T4 o% `# f
ment of his penis and frequent erections. The child
6 J3 q( t/ q/ Y4 c3 i( mwas the product of a full-term normal delivery, with$ |5 m% T! {) \3 _) f; k$ j( L
a birth weight of 7 lb 14 oz, and birth length of; _3 j! }4 E& K  x0 [$ ?/ |
20 inches. He was breast-fed throughout the first year; b4 z- J! h$ E2 f$ i1 |
of life and was still receiving breast milk along with( B. ?+ x" j4 N( j2 w8 g
solid food. He had no hospitalizations or surgery,
2 R1 v" z( [  Wand his psychosocial and psychomotor development# B/ {0 j# b  w% i0 z5 X3 E3 j
was age appropriate.
0 m$ b7 h/ B+ v4 w8 m* Y; jThe family history was remarkable for the father,6 Y* q8 F2 G4 x' s* ]( @
who was diagnosed with hypothyroidism at age 16,
  e0 b* f1 V/ ~7 d5 j  hwhich was treated with thyroxine. The father’s
9 @6 D) O0 I1 g: Z/ V4 P* eheight was 6 feet, and he went through a somewhat: L+ V- M& k. g7 f' f$ u! a; T& N
early puberty and had stopped growing by age 14.
0 a% c5 b+ S5 R) NThe father denied taking any other medication. The- x" S. F( o7 W  Q, y$ S# p
child’s mother was in good health. Her menarche
- ?* d. ]7 M( u  `8 Wwas at 11 years of age, and her height was at 5 feet2 C7 \1 F) h  o& N' X: S
5 inches. There was no other family history of pre-6 U$ K- d+ O# g; \( h
cocious sexual development in the first-degree rela-
. ~# ?6 V$ a3 Z0 Q8 {6 V2 V* S* g$ ltives. There were no siblings.
4 ^0 j3 j0 `" D( C  N# S2 r$ u$ F/ s! IPhysical Examination
; d3 O/ t7 f. w; yThe physical examination revealed a very active," q( o( J$ ~! }: E+ S( {8 C
playful, and healthy boy. The vital signs documented
8 H- O) N* y/ `. z9 L- v# W  s, ma blood pressure of 85/50 mm Hg, his length was
. [  ?2 q# s, l4 U5 [" t: v7 A90 cm (>97th percentile), and his weight was 14.4 kg
# Q2 a% x3 e5 ~: k(also >97th percentile). The observed yearly growth9 L8 w$ r+ [1 |% e' H4 e+ |
velocity was 30 cm (12 inches). The examination of$ u' f4 r1 e& x; e0 w
the neck revealed no thyroid enlargement.6 K" S$ u1 r$ @$ Q
The genitourinary examination was remarkable for# P; P7 E3 ~4 H. q; C
enlargement of the penis, with a stretched length of* `6 ^4 A6 k% n$ T9 ?! H
8 cm and a width of 2 cm. The glans penis was very well5 y' C+ n3 A( l1 e7 J8 [* X
developed. The pubic hair was Tanner II, mostly around1 G9 k8 P/ F2 @
540
: }: @$ Q+ U( z* Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" S9 e, j9 ]/ \
the base of the phallus and was dark and curled. The9 w' ?, ^7 Y/ ~0 I! a2 D. T/ J
testicular volume was prepubertal at 2 mL each.8 F6 X. Q* y+ n$ Y% U
The skin was moist and smooth and somewhat& F1 x% Z, d; @8 U- u
oily. No axillary hair was noted. There were no+ ?7 n0 p! @( H5 u# g4 |! W
abnormal skin pigmentations or café-au-lait spots.
- X" P0 B; I( J( k6 INeurologic evaluation showed deep tendon reflex 2+
4 B; I3 [) ]9 `bilateral and symmetrical. There was no suggestion
0 h: O  G- {1 t: }6 c2 t4 hof papilledema.8 G" m/ K7 L: s- s6 w, }2 l' S
Laboratory Evaluation
( P+ O- i8 i5 A$ i2 i/ {# RThe bone age was consistent with 28 months by
; ]& V* r6 g- n# K) {* G4 t  lusing the standard of Greulich and Pyle at a chrono-
7 g$ A; R& W* U# @logic age of 16 months (advanced).5 Chromosomal
) G; ]- }3 ?5 |3 C& _" }. okaryotype was 46XY. The thyroid function test/ V" y! f) U* p% L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) F) N2 W% `" d3 flating hormone level was 1.3 µIU/mL (both normal).
% y7 f) T/ i1 ]2 t  N! ?The concentrations of serum electrolytes, blood
% @; T8 c# C9 N+ Curea nitrogen, creatinine, and calcium all were8 s% w/ q: f. D% @
within normal range for his age. The concentration. d5 O" a, X! S5 f6 U7 v5 c
of serum 17-hydroxyprogesterone was 16 ng/dL! i( u, E9 O; D: O# M- D/ p# ~# b
(normal, 3 to 90 ng/dL), androstenedione was 20
, P) g: B: [/ X" Bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 Y$ s3 E1 p! z. ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ c& H, Y! _$ E: a; y5 D( Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to( [& A  s' \/ P5 |& T3 t
49ng/dL), 11-desoxycortisol (specific compound S)) `  G2 m6 H0 b1 i
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 r% ~2 M. O/ I. b6 Y2 Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 f: o& k! B4 S0 V9 v- O* dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ S( Y$ y' [3 z  D# Eand β-human chorionic gonadotropin was less than
! T% ]  I; j6 g4 I9 }9 S4 `) _5 mIU/mL (normal <5 mIU/mL). Serum follicular
- p0 K# B/ w: B1 l' v. \0 Zstimulating hormone and leuteinizing hormone5 h7 W5 e9 ^0 N. P
concentrations were less than 0.05 mIU/mL
+ j% s" o9 A: A0 |(prepubertal).
" N* F9 p7 G- _6 i8 t6 _The parents were notified about the laboratory
# I; P& l+ D! W# E1 d1 H( u6 \) cresults and were informed that all of the tests were9 Z5 F/ ^3 ]/ K' Z
normal except the testosterone level was high. The5 x7 g% k. O" g5 k1 z$ E: z6 M' U
follow-up visit was arranged within a few weeks to4 V' Q" |6 X( K: B5 T1 ~9 u
obtain testicular and abdominal sonograms; how-& u# j; _% l: Z, c# ^9 \
ever, the family did not return for 4 months.
! b( P) ^4 r1 v3 SPhysical examination at this time revealed that the  I! @' |- V9 m9 T8 c1 z/ p
child had grown 2.5 cm in 4 months and had gained3 M) h% l3 n5 K, q3 |4 n
2 kg of weight. Physical examination remained
1 t, n( h$ {! H6 R& }unchanged. Surprisingly, the pubic hair almost com-7 n" H$ e6 u  `% X4 _- g$ d
pletely disappeared except for a few vellous hairs at% `* y# I7 t6 F. k4 Y& q7 G: q
the base of the phallus. Testicular volume was still 2
7 a: g% N4 [& `* @% u3 l, t0 H, RmL, and the size of the penis remained unchanged.
: x+ ^/ Z; Z; f$ i- [* m. f& A2 CThe mother also said that the boy was no longer hav-6 y) E; Q* o2 \# s) G% ^9 ?8 C* j
ing frequent erections.
% J: ^! n) Y! I- Q9 O' X9 \Both parents were again questioned about use of( [; i) Y( M7 f3 b* ?/ O# G
any ointment/creams that they may have applied to
) q3 X! u$ r! d5 P" |the child’s skin. This time the father admitted the
5 c# ]$ r, r/ k) k: pTopical Testosterone Exposure / Bhowmick et al 541* c' q3 `, G6 d1 u
use of testosterone gel twice daily that he was apply-" J0 ^- U* f- L0 y; B% V+ m
ing over his own shoulders, chest, and back area for
6 P- i% ]# q4 c# Q( |- La year. The father also revealed he was embarrassed
4 q; I1 o: J% ^to disclose that he was using a testosterone gel pre-8 _  R6 s2 G" p! U% Z! h
scribed by his family physician for decreased libido
: h+ {) ~. |5 P5 Ysecondary to depression.
1 {  K/ c  A9 ~- u( k& z3 NThe child slept in the same bed with parents.
5 j- N& d4 D* I6 f1 ?( [/ ^The father would hug the baby and hold him on his
/ |/ [- x- n1 K2 K0 S7 qchest for a considerable period of time, causing sig-: }; l) n% w/ U- N7 G* u% ~
nificant bare skin contact between baby and father.
& V; y& @7 x- RThe father also admitted that after the phone call,
. p- z- M. W4 e; W. {! L- A. b& R7 Twhen he learned the testosterone level in the baby
1 G) K4 f, d2 `) \' ywas high, he then read the product information5 x0 x. i$ v5 v, C8 T
packet and concluded that it was most likely the rea-
; O* m- k/ n# _4 ason for the child’s virilization. At that time, they
- u5 o" h. z' U4 y& `  e6 _decided to put the baby in a separate bed, and the
3 `8 F! s- j! j6 K* H- dfather was not hugging him with bare skin and had( R! N) p: I4 {# h: l
been using protective clothing. A repeat testosterone
7 A& ]+ h& q$ Ftest was ordered, but the family did not go to the2 D: y" A7 o+ k: |' V/ G% N8 t
laboratory to obtain the test.
6 e3 [# \, d) s; u" Y: SDiscussion
0 p; E, I1 O6 s! S/ T" d' PPrecocious puberty in boys is defined as secondary
3 r3 Q' c" r8 N4 L% r3 Usexual development before 9 years of age.1,4
6 a7 X) i! a8 `( F: i6 h. B6 T5 NPrecocious puberty is termed as central (true) when, z" z$ z, s9 @3 F+ P. C
it is caused by the premature activation of hypo-. h2 A+ Y4 @: K' y( c% C
thalamic pituitary gonadal axis. CPP is more com-5 c+ l2 P% \$ o0 q
mon in girls than in boys.1,3 Most boys with CPP
$ Z- j+ z$ Q, a# Q9 o$ }may have a central nervous system lesion that is6 R$ j' D2 [6 o9 Y; _
responsible for the early activation of the hypothal-$ z# S+ O3 Q0 b# P% z
amic pituitary gonadal axis.1-3 Thus, greater empha-: }. K& u+ d" O4 a+ E3 T1 X
sis has been given to neuroradiologic imaging in
9 f8 m/ r& E2 o( v! t6 r& p: y% Qboys with precocious puberty. In addition to viril-
* b  q: t* N6 Z' kization, the clinical hallmark of CPP is the symmet-2 ^" V3 \+ G0 o' M' O
rical testicular growth secondary to stimulation by
" R0 x* I9 l+ K4 fgonadotropins.1,3; m" d) f1 O4 M6 X0 B. K+ E
Gonadotropin-independent peripheral preco-0 [  b3 G  K* p6 I( W2 I1 Q
cious puberty in boys also results from inappropriate
3 j& S5 @& R/ E3 c$ Sandrogenic stimulation from either endogenous or
) j% e* R6 q( Aexogenous sources, nonpituitary gonadotropin stim-
  @2 q- K1 W9 O; eulation, and rare activating mutations.3 Virilizing! @, l/ h% D  B
congenital adrenal hyperplasia producing excessive
3 |0 P2 [8 s4 h2 p1 d3 kadrenal androgens is a common cause of precocious1 D4 c1 m& r1 P
puberty in boys.3,4% B* X6 M' V9 @8 |4 ?
The most common form of congenital adrenal
+ y& Z6 w) N( Ihyperplasia is the 21-hydroxylase enzyme deficiency.
/ d: P  F1 h  R+ IThe 11-β hydroxylase deficiency may also result in
" Q. w* X$ _4 ]. @' Z1 eexcessive adrenal androgen production, and rarely,8 f5 W" T4 \- v/ t2 ?
an adrenal tumor may also cause adrenal androgen
# p1 h# [, Z9 Gexcess.1,38 n+ k7 p) k4 k- }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: o6 p5 k5 e8 ]' X$ o6 T% }542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 |3 o% |. b& }: a+ g2 P8 ^0 ~
A unique entity of male-limited gonadotropin-3 m2 v4 C& V2 ]
independent precocious puberty, which is also known$ D5 E) s+ S' ^: ]" S
as testotoxicosis, may cause precocious puberty at a
% }, q" @4 A; I! f; R: p* hvery young age. The physical findings in these boys2 {' s* G4 E5 `
with this disorder are full pubertal development,  X( {# [0 @- N
including bilateral testicular growth, similar to boys
* [" s( A3 Y3 D; ^with CPP. The gonadotropin levels in this disorder
4 m# T8 c! R" j' W. t% z' [9 Y5 jare suppressed to prepubertal levels and do not show
" u9 h. _& K1 b( c2 cpubertal response of gonadotropin after gonadotropin-
8 l! u8 i& E- U5 h- n; T0 `releasing hormone stimulation. This is a sex-linked7 p5 @& y5 ?' N5 l, s( X
autosomal dominant disorder that affects only+ k) I( \0 a2 k) r" g, Y# _
males; therefore, other male members of the family
9 T$ e# u7 U: r& hmay have similar precocious puberty.3
% ~/ s, i% E2 @" p1 lIn our patient, physical examination was incon-
$ x1 q: N6 a: M# Z( ]# Ssistent with true precocious puberty since his testi-
9 |% T( g: y$ y; C& T- X! P. hcles were prepubertal in size. However, testotoxicosis# x/ X5 q  `  V% L0 S2 F  P
was in the differential diagnosis because his father' H0 J1 `. l5 u" n. u
started puberty somewhat early, and occasionally,
. J. E* q$ t6 M( M8 \testicular enlargement is not that evident in the2 x. X& p* i" L9 m5 G- W. r1 ?% e
beginning of this process.1 In the absence of a neg-6 H; d, o3 L) H' Q
ative initial history of androgen exposure, our  k, q  e0 K* ^1 ]. ^  B% S- N
biggest concern was virilizing adrenal hyperplasia,
0 F$ m7 i( p% q$ {either 21-hydroxylase deficiency or 11-β hydroxylase( F1 q  }- L! v7 L' p" C: n3 V
deficiency. Those diagnoses were excluded by find-: E) a$ {7 _5 f/ G/ X0 C  ~5 e
ing the normal level of adrenal steroids.
- q8 L% I! M4 o5 v6 K4 UThe diagnosis of exogenous androgens was strongly
4 I* S1 J/ ?+ i  N( D: hsuspected in a follow-up visit after 4 months because
1 }7 k/ ^# L4 Y; ]) q1 ythe physical examination revealed the complete disap-3 U! ~% j- I) Z- A, B
pearance of pubic hair, normal growth velocity, and
' u/ I' t+ \% W) Q2 p, _- p8 Y( Ddecreased erections. The father admitted using a testos-
0 x0 X( u% D/ Nterone gel, which he concealed at first visit. He was7 ~# V- A& ^1 E
using it rather frequently, twice a day. The Physicians’, X7 X: [& R; V6 B* y; s
Desk Reference, or package insert of this product, gel or+ Z! \9 W4 z) a. c( w  _
cream, cautions about dermal testosterone transfer to3 S  W4 _$ b& w; y' N5 M. z6 Q
unprotected females through direct skin exposure.
. C" U. |2 k" ^6 ?* I/ Y6 |* N$ eSerum testosterone level was found to be 2 times the, k1 j: K% x% e% O* j* J, e# F4 {
baseline value in those females who were exposed to& {8 H0 E" J  p9 Q0 V
even 15 minutes of direct skin contact with their male# S# p! ]" {8 r7 K! _
partners.6 However, when a shirt covered the applica-) Q7 V1 c2 l" V* B8 O% M' T
tion site, this testosterone transfer was prevented.
: s* S: i- P! l3 R% W- u  }: a6 h: oOur patient’s testosterone level was 60 ng/mL,
! f, t0 J" e6 p: r4 c2 N* Jwhich was clearly high. Some studies suggest that5 t+ ]% E/ G4 v0 K0 u
dermal conversion of testosterone to dihydrotestos-9 F3 |6 K# P: Y
terone, which is a more potent metabolite, is more
9 i5 K; ?9 @) B5 n8 gactive in young children exposed to testosterone# r: Z/ D7 R2 J0 W3 j8 p* I7 ?# ?
exogenously7; however, we did not measure a dihy-: M" I8 @  I% j, S: j! V
drotestosterone level in our patient. In addition to& I) B  y5 c& S( {4 f8 p* U
virilization, exposure to exogenous testosterone in7 U3 p# s! g) X
children results in an increase in growth velocity and9 }( n, J/ t9 U
advanced bone age, as seen in our patient.
4 Y. f" J. |; BThe long-term effect of androgen exposure during, B: B& C, z) T8 ]
early childhood on pubertal development and final- \# p! F3 a) Y$ K  \# h4 k) Q
adult height are not fully known and always remain/ [$ }' u8 D# s: {( W) Y# z4 q
a concern. Children treated with short-term testos-
$ ?& a7 E# L% G- o, _terone injection or topical androgen may exhibit some
2 z0 g5 g2 p# g+ w( z) Cacceleration of the skeletal maturation; however, after% Q4 ]2 a9 e! U
cessation of treatment, the rate of bone maturation8 o3 L8 S9 k" E  }
decelerates and gradually returns to normal.8,9
( u0 X4 ^" a* i4 iThere are conflicting reports and controversy
$ B0 g* B' a, w, mover the effect of early androgen exposure on adult# {8 ~* L$ |! T" g  L: L. g
penile length.10,11 Some reports suggest subnormal5 ]7 _' O* y* X5 \
adult penile length, apparently because of downreg-- E- A7 u% Z" h+ A5 ~8 n: }
ulation of androgen receptor number.10,12 However,
7 E5 c' h  R4 WSutherland et al13 did not find a correlation between# a! ^. f$ N) I5 X
childhood testosterone exposure and reduced adult& T$ H. l" W, L) s5 c9 c: f4 T0 w) B
penile length in clinical studies.
+ \; i* U) d" y% i  k, g9 _Nonetheless, we do not believe our patient is
2 p; O6 Z  q5 n+ _; h! agoing to experience any of the untoward effects from
( g9 M# L  j6 ~  ?testosterone exposure as mentioned earlier because
2 f% d& @9 N3 |5 P% O/ Rthe exposure was not for a prolonged period of time.
( R* j7 i- D% w  K( v2 sAlthough the bone age was advanced at the time of, w& Q7 j+ W) |: F
diagnosis, the child had a normal growth velocity at
  o( a! z' C4 C4 S1 }' Nthe follow-up visit. It is hoped that his final adult
" Z2 R0 r6 A' m/ a! }height will not be affected.- O3 L/ x4 {' g
Although rarely reported, the widespread avail-$ }6 }( }& M4 Z: z
ability of androgen products in our society may
! O+ I+ m2 T  C" o  q- [! o6 E* d6 v% jindeed cause more virilization in male or female
5 f9 J+ d# h5 Z8 x/ Lchildren than one would realize. Exposure to andro-0 V# ~! F0 z0 R
gen products must be considered and specific ques-
9 @( R/ E! j3 L$ ytioning about the use of a testosterone product or
7 K/ K+ m* ?8 \5 `+ r" j# Hgel should be asked of the family members during9 v- j6 ]3 Z8 d# f$ ^$ z
the evaluation of any children who present with vir-# J2 ]/ T/ I5 h! O
ilization or peripheral precocious puberty. The diag-
4 K3 C! P* I1 J$ Znosis can be established by just a few tests and by
4 i/ r7 y2 u4 q6 F" J; Kappropriate history. The inability to obtain such a
; X/ e' v7 A; g% w: D1 a$ k  @history, or failure to ask the specific questions, may
1 D, F0 h) V, m. Kresult in extensive, unnecessary, and expensive
- k4 x" G1 p% h8 pinvestigation. The primary care physician should be
  Q- t8 E) q% V2 Zaware of this fact, because most of these children
: `% e4 X- S: K8 }: `7 k+ Hmay initially present in their practice. The Physicians’
! ?, g& T9 [/ ]Desk Reference and package insert should also put a1 `% Z0 Q9 U7 ~
warning about the virilizing effect on a male or
9 U) t, ]' i: k. y. p1 Nfemale child who might come in contact with some-* o. [$ K5 P7 |* _7 K! T
one using any of these products.; H7 J6 a) l/ W0 a% {; ~
References
# E4 {/ v9 C4 x6 o7 e1. Styne DM. The testes: disorder of sexual differentiation
( @$ D# O5 b! oand puberty in the male. In: Sperling MA, ed. Pediatric# L8 o2 ^. T8 D  n- `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# R  B( b3 u# V  I- ]2002: 565-628.
* g$ T. a8 r# u) i! `4 S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 ~' B7 K, {' M) b, m
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
# I1 M% u4 o- {5 TBoy Induced by Indirect Topical& b7 w/ w/ U' o) g: T7 b5 a
Exposure to Testosterone
5 \. l9 d* I0 i3 ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 L% Y# M5 o. C3 g
and Kenneth R. Rettig, MD15 j4 z5 p2 j7 Q7 v$ k  I
Clinical Pediatrics/ K5 t6 k+ ?. p2 p, S
Volume 46 Number 6
$ _, s2 _' K" I3 G; gJuly 2007 540-5434 g0 q3 ?/ C0 R- g$ x2 M4 Z+ M. S
© 2007 Sage Publications
7 _/ K+ j* Y& l. p10.1177/0009922806296651) d4 N# h% R- H6 ]) G6 `7 }. e* ]
http://clp.sagepub.com7 ~! Y" ]# p) m' y( Q- W
hosted at
9 \  }3 h' N3 A0 h- t2 uhttp://online.sagepub.com8 Q6 w) o: K( g3 q8 k; R7 a; `- H1 u
Precocious puberty in boys, central or peripheral,) [9 ~4 \: H4 g9 m* |4 [
is a significant concern for physicians. Central
5 y8 Q0 e5 [' k! f% ~. q$ |; a* Aprecocious puberty (CPP), which is mediated
# z5 `9 h+ M* R9 j& Q: Athrough the hypothalamic pituitary gonadal axis, has
. n, ^9 F1 A2 a& f7 `6 K; R- g3 [a higher incidence of organic central nervous system% S# p8 ?0 G9 u( D
lesions in boys.1,2 Virilization in boys, as manifested
$ V3 l4 ?6 \! K- w0 _7 pby enlargement of the penis, development of pubic
  o+ k! M7 f7 P4 Phair, and facial acne without enlargement of testi-0 C! m1 W" z  ?) Q3 E# \4 ]( S
cles, suggests peripheral or pseudopuberty.1-3 We
' X) k! G7 @! u3 t' qreport a 16-month-old boy who presented with the: k9 ^2 @$ H5 f9 n* [
enlargement of the phallus and pubic hair develop-( @% m9 ~& n$ S) K9 e+ @- ?) a
ment without testicular enlargement, which was due, A" }: ~; R! V; x$ W0 m/ U2 i9 V5 n
to the unintentional exposure to androgen gel used by
) I$ m5 Y! [- S, d: Uthe father. The family initially concealed this infor-
; p% H/ R8 p  n* y! a, B0 Vmation, resulting in an extensive work-up for this
$ t1 p5 L" e4 N8 xchild. Given the widespread and easy availability of/ N9 |" H6 i5 z7 k6 x' ]- X
testosterone gel and cream, we believe this is proba-7 L" E9 F. B9 _) S2 u1 K
bly more common than the rare case report in the. F6 S& L' T5 ?$ U1 _
literature.4
. R5 \6 v  A7 l5 E3 V$ GPatient Report
3 v6 Y$ l0 D" o6 gA 16-month-old white child was referred to the
; m- H, l8 v  d! `% Mendocrine clinic by his pediatrician with the concern
( C& T& _& w" _9 Qof early sexual development. His mother noticed# K8 e4 V, W' w# b4 _6 P
light colored pubic hair development when he was
6 j4 ?9 a0 i( M- `5 b$ w7 gFrom the 1Division of Pediatric Endocrinology, 2University of
4 h8 {5 o5 ~; S* y' YSouth Alabama Medical Center, Mobile, Alabama.
3 r0 r' ?" J3 j4 D9 eAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 N2 Q* a! z: ^& O4 q
Professor of Pediatrics, University of South Alabama, College of
; B3 O, J- j+ V/ \/ sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 l& o  f4 K5 o. z1 I* B2 W
e-mail: [email protected].
1 P3 h' r) k! q& ]& l* Dabout 6 to 7 months old, which progressively became
; d8 }7 k8 h$ A6 gdarker. She was also concerned about the enlarge-
: h* E8 @+ r2 B7 Cment of his penis and frequent erections. The child
6 @9 x" d! C/ xwas the product of a full-term normal delivery, with
: m) R% i' h* W& Ga birth weight of 7 lb 14 oz, and birth length of# t) u1 {! s: s
20 inches. He was breast-fed throughout the first year3 d5 \% E4 P! F7 l" T
of life and was still receiving breast milk along with1 r7 m# x: n. C0 _2 Z
solid food. He had no hospitalizations or surgery,
# L" Z- r$ K  P5 A6 O0 ?1 {and his psychosocial and psychomotor development
9 Z3 Q% N9 c* f3 e7 K" y2 |was age appropriate.
- ]( X5 }( [$ n$ F0 mThe family history was remarkable for the father,
3 i' l" B! T$ U3 J9 V$ rwho was diagnosed with hypothyroidism at age 16,
9 k, f, ?( `* j& ?5 Ywhich was treated with thyroxine. The father’s
, C0 e1 O3 t8 Gheight was 6 feet, and he went through a somewhat2 d- Y% q2 E5 ?% w+ m) v4 @& d8 A0 j
early puberty and had stopped growing by age 14.
4 F  L! Y" U5 {3 `* iThe father denied taking any other medication. The
2 r' Q. V9 O+ _9 zchild’s mother was in good health. Her menarche
# [) X: L4 p' k2 e/ Twas at 11 years of age, and her height was at 5 feet% [( S4 _9 |, S" {
5 inches. There was no other family history of pre-
5 S4 n2 M3 V2 N; h' ^/ zcocious sexual development in the first-degree rela-% u' L* a/ l- H
tives. There were no siblings.* G  `& c( p8 q+ ^; C
Physical Examination4 L$ p9 y( H2 f' K4 c! o  Y
The physical examination revealed a very active,
5 N+ {9 X8 P3 j$ _' vplayful, and healthy boy. The vital signs documented. C4 Y% U* p( D
a blood pressure of 85/50 mm Hg, his length was: X1 z! }/ ~' j' m$ Q9 {, C- Q: I
90 cm (>97th percentile), and his weight was 14.4 kg, B/ [- g1 d$ J8 k' `
(also >97th percentile). The observed yearly growth) M% j7 W* E, O
velocity was 30 cm (12 inches). The examination of8 p$ i9 @$ ^. c' G! x4 U& s, z
the neck revealed no thyroid enlargement.4 n$ G! [# J' A' Q/ b$ M- X
The genitourinary examination was remarkable for, G% A3 ^0 b% y0 l: n
enlargement of the penis, with a stretched length of. g" H. l' w; j. t3 q
8 cm and a width of 2 cm. The glans penis was very well9 e- z' ]3 U2 X% ?  }9 x
developed. The pubic hair was Tanner II, mostly around
4 X9 ]8 ?8 B& o3 L540
+ ~* R: W; F' l/ `* Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 {. y0 U$ V$ a2 L; a* }
the base of the phallus and was dark and curled. The
! z- R) x7 c, Z. wtesticular volume was prepubertal at 2 mL each.6 w7 f: ~  J4 h0 r4 ~
The skin was moist and smooth and somewhat
8 v% ]: l2 w4 [' K3 A- Loily. No axillary hair was noted. There were no" ]  t/ _5 a* F6 j/ s4 g
abnormal skin pigmentations or café-au-lait spots.. D! |) c. ~6 Q6 B' G! C) y: _
Neurologic evaluation showed deep tendon reflex 2+
! G1 y. r% K3 Tbilateral and symmetrical. There was no suggestion$ b% `0 H! Z! P" L
of papilledema.  `9 i9 v. n* J3 c' L( ^8 a
Laboratory Evaluation
/ b) V: q5 Z- P8 ~The bone age was consistent with 28 months by
0 \. @- d8 ~2 W' a  ^using the standard of Greulich and Pyle at a chrono-( R" k$ M  k/ K' l# E  a$ F* t
logic age of 16 months (advanced).5 Chromosomal0 y0 |5 p8 ~4 ?& b
karyotype was 46XY. The thyroid function test# @/ _/ ?  K7 C/ g; \4 o4 L: V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 u  s; j( _0 p- @$ d4 I9 mlating hormone level was 1.3 µIU/mL (both normal).  r% G( y! J6 u
The concentrations of serum electrolytes, blood
* X% j  i8 P# W. f# p. Zurea nitrogen, creatinine, and calcium all were
; k3 H/ o. e) s! Awithin normal range for his age. The concentration
7 @7 Q( h3 J7 ~0 @of serum 17-hydroxyprogesterone was 16 ng/dL# a' U3 p+ g6 B: [- v/ d0 b' d
(normal, 3 to 90 ng/dL), androstenedione was 20
9 S. x: ]# [5 mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, o: {0 _8 F7 @' M& H
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
  Z- o$ i. h( g$ u& `% ], a1 g  Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to
) ^0 F& w% y1 v2 i+ e- D; z, H# M49ng/dL), 11-desoxycortisol (specific compound S)- I0 T+ R6 A( T9 L  Y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# c2 L- R" d& S- o/ }( O' W$ I( |tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 [5 [* C+ B) V/ p2 Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 H- f1 |2 c' A' E$ w
and β-human chorionic gonadotropin was less than6 ^- X$ w4 F/ L$ o) G4 b
5 mIU/mL (normal <5 mIU/mL). Serum follicular0 l' E4 g( K! l* n
stimulating hormone and leuteinizing hormone5 @) h$ H  R) m, ]& ?' |) ^* h
concentrations were less than 0.05 mIU/mL
: a9 W' j9 `  e" W& @$ z(prepubertal).( {5 P1 [# Q: t' _
The parents were notified about the laboratory
% Z( W+ x' S( B& U* I$ J- Rresults and were informed that all of the tests were
4 O6 N* L5 W1 C+ V4 }normal except the testosterone level was high. The1 r" J" P4 e  A) J+ t( A9 O
follow-up visit was arranged within a few weeks to+ V2 ?) n1 F! B, h7 j
obtain testicular and abdominal sonograms; how-/ a: x' q" c" b
ever, the family did not return for 4 months.! l2 x7 F- q# a, t7 g
Physical examination at this time revealed that the
6 q  N/ \8 D+ Kchild had grown 2.5 cm in 4 months and had gained4 R) @; y- E( C2 w" c
2 kg of weight. Physical examination remained
0 m4 k8 B6 r$ G' K; lunchanged. Surprisingly, the pubic hair almost com-
2 H% m# K. X0 v! V% z# W5 Hpletely disappeared except for a few vellous hairs at
$ x* [3 T5 W$ b1 ]. R" d' t) kthe base of the phallus. Testicular volume was still 2
& s8 n, T) q; d5 d3 ]mL, and the size of the penis remained unchanged.1 }( Q% n$ r% X
The mother also said that the boy was no longer hav-0 w. }- k/ S/ D! M5 k3 G
ing frequent erections.6 @# \6 X! K" y! m
Both parents were again questioned about use of& f: u6 B/ z9 t9 a
any ointment/creams that they may have applied to
5 c9 X; o: D4 q7 O' e3 K3 b. Othe child’s skin. This time the father admitted the- `1 R6 ?, L3 ]8 {
Topical Testosterone Exposure / Bhowmick et al 541
4 A7 n5 S5 V9 Z$ Vuse of testosterone gel twice daily that he was apply-
# I8 A0 _1 Q# Z  {$ y  L( [: Z4 {ing over his own shoulders, chest, and back area for1 ?% k$ t% G; f4 ], E$ M# |
a year. The father also revealed he was embarrassed6 l3 k2 R) ?9 c6 d5 M4 \1 Q
to disclose that he was using a testosterone gel pre-
. O" Y' y: o& u; G- ?scribed by his family physician for decreased libido
: F" E* V3 t" S$ @8 D: X) Asecondary to depression.- @& L! S; T8 c' E2 P
The child slept in the same bed with parents.
. w2 e# h! Y0 x0 I% NThe father would hug the baby and hold him on his
3 l4 ~( a( f5 L" E" P- Tchest for a considerable period of time, causing sig-5 o2 \7 G( D: |+ F5 D1 I  N* X# ?" G6 U
nificant bare skin contact between baby and father.
7 ~" ?. h- S; B3 c+ AThe father also admitted that after the phone call,
. W* [3 d- T% c8 B1 u+ ]9 Gwhen he learned the testosterone level in the baby
1 D4 b7 }, H1 e6 Z) ]was high, he then read the product information6 t/ ~8 X2 r7 V, P- \
packet and concluded that it was most likely the rea-
* j, Q. u2 |* U0 L0 C) n6 Y- Lson for the child’s virilization. At that time, they
& y; m9 d) |7 w  J5 t) pdecided to put the baby in a separate bed, and the& o$ c' x; M- I5 d- U5 Q& N
father was not hugging him with bare skin and had
: t7 F/ F' t1 l9 N3 \6 fbeen using protective clothing. A repeat testosterone
# M. L6 ?1 H) y8 w9 V& Y  _test was ordered, but the family did not go to the
# q: C" C* k* K) f: ]8 b, blaboratory to obtain the test.# }# e( g$ O( g) X
Discussion; Y8 L0 d/ G/ R: b
Precocious puberty in boys is defined as secondary+ F  ~. a  Z# M. A2 z- y9 Y
sexual development before 9 years of age.1,4' G' T6 g9 D  q; `: ]
Precocious puberty is termed as central (true) when
- [' [2 Q' Z: F4 h0 [7 H% ^# e& Z4 kit is caused by the premature activation of hypo-3 ~% w$ x+ ^6 f  C9 K0 V/ x
thalamic pituitary gonadal axis. CPP is more com-" T* [6 x. \8 [& U
mon in girls than in boys.1,3 Most boys with CPP8 x) B/ w/ x3 F4 M. b5 w
may have a central nervous system lesion that is( ?- j5 X! R5 M$ P
responsible for the early activation of the hypothal-
5 f: @8 B7 |5 q" a: H& x# [amic pituitary gonadal axis.1-3 Thus, greater empha-
. X( N8 \0 i3 l1 X( z2 Zsis has been given to neuroradiologic imaging in
9 }* j+ d- _$ c9 g1 n: R* o$ o: t* Sboys with precocious puberty. In addition to viril-( ^$ Z# N, u' l" {* c: K  E
ization, the clinical hallmark of CPP is the symmet-
' H1 V. h+ b* k+ j" N! p) N& brical testicular growth secondary to stimulation by
" U- `  P0 A+ y+ h, N- Y6 V0 r% r% [gonadotropins.1,3
2 V8 S! N; l2 vGonadotropin-independent peripheral preco-$ m8 c1 T% k1 z
cious puberty in boys also results from inappropriate$ i, z; W+ `- \4 \2 M, T
androgenic stimulation from either endogenous or' L+ h* A! e; j! A, P1 k: U; q
exogenous sources, nonpituitary gonadotropin stim-" r  Z/ [6 E: J7 v
ulation, and rare activating mutations.3 Virilizing3 s+ R  j- t7 Y, z- `4 v$ i
congenital adrenal hyperplasia producing excessive2 v9 t$ p+ N3 K! x
adrenal androgens is a common cause of precocious0 |; _9 |* c& q2 n$ N- j
puberty in boys.3,4
3 o7 B$ \% z9 C2 n1 `The most common form of congenital adrenal9 A: l- `, Y: L) Q" h% q6 Z. g2 z* e* Z
hyperplasia is the 21-hydroxylase enzyme deficiency.
" D! v& i2 q5 _The 11-β hydroxylase deficiency may also result in3 ~2 k( }& e9 j
excessive adrenal androgen production, and rarely,
! w5 d. Z1 ]' q. L1 ]an adrenal tumor may also cause adrenal androgen
8 _- X' m+ G9 Nexcess.1,3
5 Q# Y" g! A, H$ I9 h5 Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  c" d  H4 h9 z! |$ t! h4 H8 ?
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' C' h, Z) P, r. x0 B
A unique entity of male-limited gonadotropin-
. A* g$ g% y# C+ U& G1 k0 \independent precocious puberty, which is also known
7 C; Z7 n+ p( d) }: ras testotoxicosis, may cause precocious puberty at a, V1 Q! O5 V) P- f" Y) Z! u
very young age. The physical findings in these boys
% t( r3 o1 x# Z( h: uwith this disorder are full pubertal development,
$ Q; |$ B, j- b( sincluding bilateral testicular growth, similar to boys
$ o. S6 c9 Y0 A0 T! a) Iwith CPP. The gonadotropin levels in this disorder
' k8 y2 t" ?5 F& L: J: Iare suppressed to prepubertal levels and do not show  }1 V/ K- d" `
pubertal response of gonadotropin after gonadotropin-
( ]3 |- k1 s: b6 Vreleasing hormone stimulation. This is a sex-linked
" F. d/ ?6 W6 k# F+ eautosomal dominant disorder that affects only+ L& O+ a! N- Z: g* {
males; therefore, other male members of the family9 D5 E8 E! X  n
may have similar precocious puberty.3
1 |* s) H, C  ^7 HIn our patient, physical examination was incon-3 A: [2 w3 f# u) m/ V
sistent with true precocious puberty since his testi-
  ^& ?9 ~% J" q6 j) _6 w" i8 ]) ]' J6 Scles were prepubertal in size. However, testotoxicosis0 Z0 P' P) @* r4 \
was in the differential diagnosis because his father
8 `3 j! A& v0 e- A! |# ?  X: Wstarted puberty somewhat early, and occasionally,
/ [" H7 c; n4 A& C% x" ntesticular enlargement is not that evident in the2 B! |. p  v( Z% v
beginning of this process.1 In the absence of a neg-
/ r# C0 i8 h$ F2 k) Pative initial history of androgen exposure, our$ V1 G+ l: D, x8 [+ t
biggest concern was virilizing adrenal hyperplasia,
! l. N% ]: [" ?7 Eeither 21-hydroxylase deficiency or 11-β hydroxylase
" q* k; I5 _8 ddeficiency. Those diagnoses were excluded by find-
% {$ y9 t6 v3 Y3 n* \$ P% E+ king the normal level of adrenal steroids.( ~4 W; h" H5 D+ ?+ U
The diagnosis of exogenous androgens was strongly" \4 S6 H- _8 d7 q8 Y5 P
suspected in a follow-up visit after 4 months because/ H$ t2 z/ l( B% v  @( e& Y( }
the physical examination revealed the complete disap-
; h% M9 q* V( @) R" _pearance of pubic hair, normal growth velocity, and( x& v; t  }8 x
decreased erections. The father admitted using a testos-9 T# M5 J: M2 z* ]& r2 \
terone gel, which he concealed at first visit. He was3 Y) j' H& n$ ^
using it rather frequently, twice a day. The Physicians’+ [( c5 m" f7 g7 B& z& z
Desk Reference, or package insert of this product, gel or
  ]& w9 {( k: d, s2 w: a+ Ycream, cautions about dermal testosterone transfer to
/ R9 V0 S* W. D( ]0 y  `unprotected females through direct skin exposure.
% o: ]9 v$ d2 b/ o6 S% x0 Y  JSerum testosterone level was found to be 2 times the9 h! u$ r$ g; S7 ^
baseline value in those females who were exposed to4 T9 V$ h, w3 e: _" ~7 F' N: O: ?9 p
even 15 minutes of direct skin contact with their male
3 o) ?( ~) P# E. Upartners.6 However, when a shirt covered the applica-- `$ J( O# r8 r) R
tion site, this testosterone transfer was prevented.
6 ]2 c2 ?  v) ^: K4 z4 WOur patient’s testosterone level was 60 ng/mL,
. X: I8 c, p; [6 [- N- F0 h: Swhich was clearly high. Some studies suggest that
" Y) [/ O) I1 j; fdermal conversion of testosterone to dihydrotestos-
1 b- J+ `  [+ pterone, which is a more potent metabolite, is more+ R, ^0 X6 E: \
active in young children exposed to testosterone* j1 t3 b' Z1 j' F- X" s$ \- L
exogenously7; however, we did not measure a dihy-5 ]% ^: I3 k( {
drotestosterone level in our patient. In addition to4 n  L2 m* B# `3 T8 C
virilization, exposure to exogenous testosterone in
& p* L/ V" B3 d1 v4 e" Fchildren results in an increase in growth velocity and
# |2 ^) G4 Y1 ]) g7 N  [' \8 d8 jadvanced bone age, as seen in our patient.
1 U7 q; I/ \" }: P+ Y2 U$ ~8 D1 v) EThe long-term effect of androgen exposure during
; g7 p; Z' Q; A5 H) t4 aearly childhood on pubertal development and final- V! z* A0 r0 E2 ~" H, s( L
adult height are not fully known and always remain
1 v" z* b' s& B- Aa concern. Children treated with short-term testos-8 K+ v9 `) m7 S
terone injection or topical androgen may exhibit some
4 O1 l* f' v( V) {/ qacceleration of the skeletal maturation; however, after7 T5 N8 t* A7 z% C5 \, ^. A
cessation of treatment, the rate of bone maturation
0 u/ e( A6 K2 _6 A# A) b- Sdecelerates and gradually returns to normal.8,9( [; Q2 E2 M* {, D
There are conflicting reports and controversy- `0 l" V& a. k9 l8 {9 r! x# T
over the effect of early androgen exposure on adult6 n/ d0 d$ i* N& g+ B7 D/ A$ M
penile length.10,11 Some reports suggest subnormal
- g, L" A$ G( G7 d( X4 oadult penile length, apparently because of downreg-
, {' m4 t$ i! @: X, g. hulation of androgen receptor number.10,12 However,
) Z0 ^- A3 A% q+ TSutherland et al13 did not find a correlation between
) k: z& K7 ?: ]+ Nchildhood testosterone exposure and reduced adult5 e" E; N# R+ s7 @0 w$ t2 @/ |: p
penile length in clinical studies.& k; C( U1 B  N7 i& H
Nonetheless, we do not believe our patient is+ L4 W3 {& z. v' l
going to experience any of the untoward effects from9 b9 Y. [4 O; R1 ?+ _1 @
testosterone exposure as mentioned earlier because
% }' d+ W, g2 i  dthe exposure was not for a prolonged period of time.
& O/ ~! a/ W8 C$ ]6 O+ h( q* w# ?9 iAlthough the bone age was advanced at the time of0 r" Q3 U/ q7 d$ w7 v" q/ \; \) q
diagnosis, the child had a normal growth velocity at
# Q8 U, p6 \9 F8 Q3 Mthe follow-up visit. It is hoped that his final adult
# W6 D1 @5 ?6 N* c5 zheight will not be affected.0 Q+ }0 G' w5 j+ I! E/ W; g
Although rarely reported, the widespread avail-1 i% V4 l8 P3 a- R, M
ability of androgen products in our society may/ j0 ~3 u! ^" X- u! J5 u0 k& s: [# ~
indeed cause more virilization in male or female
4 U* Z$ t9 n" Kchildren than one would realize. Exposure to andro-8 `4 D2 x; ]4 x; p1 n* E& K- k
gen products must be considered and specific ques-
8 a3 H+ O/ p3 z9 O. Ptioning about the use of a testosterone product or
* g/ `: h  u/ N- a4 z1 hgel should be asked of the family members during
. J& E- w+ @  o/ B4 M/ Hthe evaluation of any children who present with vir-' b& u5 B! D  ^( X
ilization or peripheral precocious puberty. The diag-
& o4 d$ K4 o1 U' B; e1 }' wnosis can be established by just a few tests and by
. Y2 h; S: @$ S: r- nappropriate history. The inability to obtain such a! R6 O& J# ~. M, V& Z8 |
history, or failure to ask the specific questions, may; a8 O. z/ n5 p3 S
result in extensive, unnecessary, and expensive$ w# {5 E. J1 i4 H
investigation. The primary care physician should be! K& c7 Y! J, m7 T: E
aware of this fact, because most of these children) m% R+ g( U1 j! A
may initially present in their practice. The Physicians’
9 X. j+ z. D0 e, e5 T8 C9 TDesk Reference and package insert should also put a
/ M/ O" a" m& t/ p) A, Y* ^warning about the virilizing effect on a male or5 L& r% e9 D% T2 i0 X+ p- {
female child who might come in contact with some-
; o) b* z' e6 j% z: Jone using any of these products.
7 g8 u& Q# e1 l- Q2 g: t  R/ pReferences/ m) m# O6 }  P6 S  n
1. Styne DM. The testes: disorder of sexual differentiation
3 t/ q/ c( D7 A1 Land puberty in the male. In: Sperling MA, ed. Pediatric
, w5 d6 s+ |' J  C2 n% ]3 ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 e+ ], A& C6 ^
2002: 565-628.' u/ \! W% f% |, _, r
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 B2 Y5 n2 f( h  u; y) R
puberty in children with tumours of the suprasellar pineal
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

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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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