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Sexual Precocity in a 16-Month-Old
! S/ K4 m6 }4 s4 \Boy Induced by Indirect Topical
7 _5 U" p5 w: J  C" x) L* DExposure to Testosterone
) N) j5 w8 j  USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 r* R5 F* ^' L$ l  Mand Kenneth R. Rettig, MD1
+ P0 X! G+ L/ @0 y. FClinical Pediatrics
% V8 Z! Q0 {( {Volume 46 Number 6- A& [$ x2 q1 y  j# R5 y
July 2007 540-543( c& _$ E3 X& f9 X
© 2007 Sage Publications
4 t3 Q/ ~* `# P1 X10.1177/0009922806296651- ~2 C9 S3 |* B7 n- r
http://clp.sagepub.com# b3 S# n8 w! M9 W6 \9 G1 W" j1 n
hosted at
& A7 F) C$ [( ehttp://online.sagepub.com
2 V; O! l# D+ c& cPrecocious puberty in boys, central or peripheral,
( b$ \  A; A3 y; U7 B1 ris a significant concern for physicians. Central7 j% d3 `. H% B. x5 `- z
precocious puberty (CPP), which is mediated
6 r! w7 T6 j8 m8 {( \- E! l$ Dthrough the hypothalamic pituitary gonadal axis, has
. \/ H- J( P+ D7 x* y  G: W# J# m3 b9 Ia higher incidence of organic central nervous system- X  b" C1 E' v: U9 x
lesions in boys.1,2 Virilization in boys, as manifested
9 X$ T, }% t; V! r! ~# vby enlargement of the penis, development of pubic
0 s. O0 Z" X4 g# Whair, and facial acne without enlargement of testi-2 R) u/ D0 [! T6 b* \5 u+ R
cles, suggests peripheral or pseudopuberty.1-3 We/ g% Z/ @$ Y( B  P- d
report a 16-month-old boy who presented with the; X, I8 o/ R) d! K
enlargement of the phallus and pubic hair develop-3 `- L/ G4 N0 i. i; _
ment without testicular enlargement, which was due# ?  Q" F1 \# x
to the unintentional exposure to androgen gel used by
1 S: B, O: J; T+ V7 c* _8 fthe father. The family initially concealed this infor-
# X+ z' a$ U) r+ w5 Bmation, resulting in an extensive work-up for this
  }% ~! w$ y9 ~* Schild. Given the widespread and easy availability of8 E7 x- K5 U* b4 h
testosterone gel and cream, we believe this is proba-
" ]$ L! m4 I# s! N$ K% \bly more common than the rare case report in the
& m8 u% D% q4 v) ^literature.4  o* C% d* O" Y% T9 B. P
Patient Report% N  n  u* C$ Z$ u/ d1 m5 F
A 16-month-old white child was referred to the2 w! \" B- o" q2 t9 N6 L9 \
endocrine clinic by his pediatrician with the concern
9 i3 L2 Y5 n0 Y; h: L) qof early sexual development. His mother noticed
7 \; Q! H$ w7 p& u6 w7 t  hlight colored pubic hair development when he was% R. `% m$ `1 |( D: a8 o
From the 1Division of Pediatric Endocrinology, 2University of7 U" O- E) W0 ]. }8 \
South Alabama Medical Center, Mobile, Alabama.3 m. J% S. ~2 o. G
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 \  s8 w7 O1 @- H# l/ e$ u
Professor of Pediatrics, University of South Alabama, College of
  V: b9 `* b0 C7 `4 E7 KMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;: R; r2 D; ?/ ^+ n1 B
e-mail: [email protected].
" r) Y3 ]5 z* T" D8 A& habout 6 to 7 months old, which progressively became
; V3 B* d9 E5 n4 T, a" W5 Xdarker. She was also concerned about the enlarge-* h2 L3 E0 q2 E) Z
ment of his penis and frequent erections. The child
! g1 X8 b4 S0 z$ U! gwas the product of a full-term normal delivery, with
% `5 W) ^, I- g3 f5 la birth weight of 7 lb 14 oz, and birth length of
0 e2 y4 e. j* I2 n' p6 I( P2 O20 inches. He was breast-fed throughout the first year
$ k4 i& e- j4 x. f" ?' t4 F" Vof life and was still receiving breast milk along with
4 b% r9 ~6 [4 O6 E" [) H  Xsolid food. He had no hospitalizations or surgery,
5 ^# d# W3 X; e- h; band his psychosocial and psychomotor development& z$ v( S6 D( _
was age appropriate.  o) x! c' p5 c3 m7 o9 U
The family history was remarkable for the father,8 B( v5 Y! l5 n8 w% ]( ]7 d
who was diagnosed with hypothyroidism at age 16,
9 C: F, L. G/ s0 R4 a9 [  cwhich was treated with thyroxine. The father’s
% B7 w+ T* B9 l+ u' K8 y. |height was 6 feet, and he went through a somewhat1 F3 J$ `' i% y# l0 X
early puberty and had stopped growing by age 14.# P4 [: \) }+ _, D
The father denied taking any other medication. The
7 _: J, U+ t+ M( Q) {; |child’s mother was in good health. Her menarche5 K# B& D- n7 `6 }0 ~& D8 T6 N# T5 D
was at 11 years of age, and her height was at 5 feet
: D. p% e: r$ V5 f5 inches. There was no other family history of pre-. d) Q" U% v* _5 I- ]# T! }
cocious sexual development in the first-degree rela-
) r6 H! n( _7 l$ b. }- s' ?tives. There were no siblings.
  z; p/ @- m) i$ V( D7 cPhysical Examination
6 ]$ D8 u7 ~# e4 u- J4 \, _  n! l  W; XThe physical examination revealed a very active,5 F" O  U/ I' i( M9 Q
playful, and healthy boy. The vital signs documented
3 c; e  K' I# s4 H/ t8 y2 X  Qa blood pressure of 85/50 mm Hg, his length was1 ?2 h. b7 I& Q0 _/ s; N
90 cm (>97th percentile), and his weight was 14.4 kg
2 @7 H2 z' J: a' }! z" Z: G$ |(also >97th percentile). The observed yearly growth1 ^. ]7 C) }; d9 f3 y& o+ B4 y
velocity was 30 cm (12 inches). The examination of
4 L* N9 S0 I, X; uthe neck revealed no thyroid enlargement.
9 O# H: x9 h: s+ t! c* b& mThe genitourinary examination was remarkable for
/ M! V: x* w9 j8 d! p* menlargement of the penis, with a stretched length of$ i9 g; f  ]$ E9 q& b2 I& H
8 cm and a width of 2 cm. The glans penis was very well2 m& q' u: s/ M0 L
developed. The pubic hair was Tanner II, mostly around. G5 i: t8 y6 X$ }$ j+ A8 s
540% _/ {5 ^8 C; f) Y2 ^( j/ J/ v1 F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 L9 |# M8 q4 t- P, a! \# K
the base of the phallus and was dark and curled. The" Y6 L+ E+ D7 t  p3 Q7 q8 A6 g
testicular volume was prepubertal at 2 mL each.7 b* E( @5 R0 U! |+ K1 ^% M
The skin was moist and smooth and somewhat- x) N  |. \: w" F4 Y/ d
oily. No axillary hair was noted. There were no
/ O8 r( Q! |0 v9 _$ s: \abnormal skin pigmentations or café-au-lait spots./ s" S( P  u6 h
Neurologic evaluation showed deep tendon reflex 2+
7 T( H) S1 b- |8 D/ Jbilateral and symmetrical. There was no suggestion  Z$ D4 d0 _* W  \" O0 n6 m
of papilledema.
7 `2 I+ [+ C" z& DLaboratory Evaluation
* C& E9 H$ c, t) Z' Y8 ~The bone age was consistent with 28 months by! c9 T1 Z* [% ?6 z- C6 ^& S
using the standard of Greulich and Pyle at a chrono-
8 m) U" V. |3 X+ S, R, s7 I5 x2 blogic age of 16 months (advanced).5 Chromosomal' u: I+ J: |0 F1 b) J- B# k8 _8 l
karyotype was 46XY. The thyroid function test3 c) z! N; z6 W' W4 f6 ^; k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! \/ K' s2 _. k) Q% L
lating hormone level was 1.3 µIU/mL (both normal).
+ A) m- s# q+ n" C0 k3 [" \5 _5 NThe concentrations of serum electrolytes, blood
  s' y  a$ F2 K+ turea nitrogen, creatinine, and calcium all were9 B' E0 |8 u) u0 o: c( z
within normal range for his age. The concentration
8 ~7 M. z8 G% }of serum 17-hydroxyprogesterone was 16 ng/dL
  [! Z$ J: |" S% D$ n$ i(normal, 3 to 90 ng/dL), androstenedione was 20
8 `( ^: n+ \! I; x' _  Hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 T3 y6 R: J4 o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),, ~; i, J) G7 ]
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: p- W% [, D; ?8 T% K$ A7 ~
49ng/dL), 11-desoxycortisol (specific compound S)
; h3 L' R5 i6 s1 m3 H3 n. b( Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- @- W8 Z' S) N) Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 e* z: ^) |/ ^8 m; y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 c% W/ E8 \3 b4 a8 y1 \* vand β-human chorionic gonadotropin was less than: H; A5 a' w/ d1 Q$ r  i
5 mIU/mL (normal <5 mIU/mL). Serum follicular5 U: o* ?' J$ X0 a
stimulating hormone and leuteinizing hormone" q$ X+ C; P7 ^3 f
concentrations were less than 0.05 mIU/mL
3 `% T7 f( U: |; K& u1 ~(prepubertal).
& k3 E4 p7 \+ @$ {" _5 O" EThe parents were notified about the laboratory) r: K8 `0 Z5 p- M+ v8 g
results and were informed that all of the tests were
  r. _5 D+ T4 f2 U( ]" V& M2 k* b( Ynormal except the testosterone level was high. The7 N6 C1 `, `& b# @. u* F
follow-up visit was arranged within a few weeks to8 Q& u' q1 u5 T+ R( w
obtain testicular and abdominal sonograms; how-, G* @! Z) C$ _3 c
ever, the family did not return for 4 months.
% q- Y$ Q3 ]$ q. n4 B/ B) D: jPhysical examination at this time revealed that the
/ I9 ^7 q/ d/ b5 J/ j: t* cchild had grown 2.5 cm in 4 months and had gained
5 P  V- |& V0 e( b; j: j, L" i2 kg of weight. Physical examination remained! H5 k6 O9 R* S* x" \: T/ g
unchanged. Surprisingly, the pubic hair almost com-* G! y, ~6 U$ f4 T# ]+ r
pletely disappeared except for a few vellous hairs at4 T/ p3 m* o% a. `
the base of the phallus. Testicular volume was still 2
* K9 J) T  b9 m' M5 M/ V( qmL, and the size of the penis remained unchanged.6 u1 E2 G0 m- J
The mother also said that the boy was no longer hav-5 S( ^- H, R+ a( X
ing frequent erections.5 D! K9 m) H  q( J4 A' `  E3 R* p; R
Both parents were again questioned about use of
$ U1 @! \% z2 {  J. x  Gany ointment/creams that they may have applied to
# r- l) I9 S" g. ^/ j# a) Lthe child’s skin. This time the father admitted the
  @. i3 q/ Z3 dTopical Testosterone Exposure / Bhowmick et al 541
! W! w* ~7 m$ I: `0 B2 G$ J8 Xuse of testosterone gel twice daily that he was apply-
1 N9 F  C9 c5 k2 ming over his own shoulders, chest, and back area for; H2 u7 b/ k6 H8 R  s2 @3 ~
a year. The father also revealed he was embarrassed/ q5 W3 {  S' p# e  e& D
to disclose that he was using a testosterone gel pre-: |$ n! C6 V- u* o2 |, p
scribed by his family physician for decreased libido, c8 K! w. _& q! G7 i3 ~
secondary to depression." V6 Z; o/ f: {0 y/ _9 X  B
The child slept in the same bed with parents.! f; E0 f* g. k3 k1 L$ p' C
The father would hug the baby and hold him on his
6 s, Q' e  b9 B; i( i7 bchest for a considerable period of time, causing sig-7 [5 A8 \- g2 U* Z4 ~' n
nificant bare skin contact between baby and father.
/ M" g. x- h5 G% @8 [The father also admitted that after the phone call,
0 T! r: J/ e& b  _) J6 [$ Cwhen he learned the testosterone level in the baby, w" l3 a' n" g1 x( @  |& ~
was high, he then read the product information* Z* i$ \0 Q( f4 ~
packet and concluded that it was most likely the rea-0 o5 l& P1 U/ x$ x" d4 B
son for the child’s virilization. At that time, they! F5 \& k* L, p4 u$ n3 L9 }
decided to put the baby in a separate bed, and the6 V' r5 R6 N7 H" |. d" c
father was not hugging him with bare skin and had4 Q3 t# J  H' N/ i+ j& d
been using protective clothing. A repeat testosterone
) T2 U1 e& g  e1 J. Wtest was ordered, but the family did not go to the
: O+ H3 u6 i/ }  `1 Wlaboratory to obtain the test.
/ S$ d& i5 \/ c9 UDiscussion; f; v6 x6 j- p4 |1 `! X
Precocious puberty in boys is defined as secondary8 n7 S9 @4 J" |1 a" G2 f+ R
sexual development before 9 years of age.1,4* k& j! P' T$ F& j( y6 J) \
Precocious puberty is termed as central (true) when
, Q* P7 {! o# @$ g9 n9 H. ^( tit is caused by the premature activation of hypo-8 s0 B. H% u. p
thalamic pituitary gonadal axis. CPP is more com-
6 H9 ]  [4 e3 W; zmon in girls than in boys.1,3 Most boys with CPP# b& d$ x% _8 X% c: }: ?0 q
may have a central nervous system lesion that is
) c# n0 R8 o+ y( [responsible for the early activation of the hypothal-
4 k$ j7 O0 T; c) W( T" Camic pituitary gonadal axis.1-3 Thus, greater empha-5 o3 D' x4 p& t$ y4 N
sis has been given to neuroradiologic imaging in
! r1 ~& v1 P; @: _, y  Cboys with precocious puberty. In addition to viril-
0 r& {; \/ _. p6 }1 A( Cization, the clinical hallmark of CPP is the symmet-
/ Z: Q. w3 J+ C: Trical testicular growth secondary to stimulation by( e$ I9 r1 R8 I
gonadotropins.1,34 _% ^, |$ c5 B9 M
Gonadotropin-independent peripheral preco-
. Y2 w( Z2 A( T/ G7 f8 e# m  M2 \cious puberty in boys also results from inappropriate9 \; s8 g1 [: b2 W# o' L" M
androgenic stimulation from either endogenous or. C+ Q+ K3 f5 h" {1 @( }
exogenous sources, nonpituitary gonadotropin stim-" `2 Y( Y5 b4 w( s- W+ P9 l+ Y
ulation, and rare activating mutations.3 Virilizing
. H$ K8 q! A. k  p+ @% Q3 \congenital adrenal hyperplasia producing excessive
8 G- n3 Q* [( c  N: l% |! h7 hadrenal androgens is a common cause of precocious6 o* C& g0 ~/ D/ k+ v# x
puberty in boys.3,4; [; y8 \. S. M) T2 H# F. G, p% i
The most common form of congenital adrenal
) _# u  }. L2 M( dhyperplasia is the 21-hydroxylase enzyme deficiency.# D- e4 h1 ?  O1 M2 V, J' k
The 11-β hydroxylase deficiency may also result in* D/ q$ @$ @" \3 \
excessive adrenal androgen production, and rarely,0 q6 y- i9 h& X7 z
an adrenal tumor may also cause adrenal androgen
! r. N2 r; n' z# j9 N! _excess.1,3
5 w* P( w& h' Z* M$ Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  R/ a. L( C8 @* r4 ?7 |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ ^1 I1 Q4 i- cA unique entity of male-limited gonadotropin-! t% }9 W! |1 R/ \4 j
independent precocious puberty, which is also known
8 K0 l; P& t/ O) d; X( r0 Ias testotoxicosis, may cause precocious puberty at a
& z+ ^' z+ O. F/ b6 `$ w/ mvery young age. The physical findings in these boys. o1 k" a( d* _: J; B
with this disorder are full pubertal development,3 c( e1 p9 @! J; W3 n7 w! W+ s
including bilateral testicular growth, similar to boys
0 x- u- Y$ T! E3 r9 W0 ^! _( K+ ]; [1 hwith CPP. The gonadotropin levels in this disorder
$ ~0 M; T! I3 tare suppressed to prepubertal levels and do not show
- ^+ Z& Y0 A7 m. a$ t7 Gpubertal response of gonadotropin after gonadotropin-
/ E) K9 ?- |6 ], y1 y2 l+ Freleasing hormone stimulation. This is a sex-linked
0 I7 N! L) O- k, K0 Lautosomal dominant disorder that affects only+ N) D$ R$ B0 r4 p1 R6 l# J
males; therefore, other male members of the family
- ?6 `2 X( [4 {# Nmay have similar precocious puberty.3
, s* g9 e- @8 oIn our patient, physical examination was incon-: k& Z* z# n8 w0 d7 ~2 n5 `/ I
sistent with true precocious puberty since his testi-! w0 [2 @/ ^) x- r1 [- S2 ~
cles were prepubertal in size. However, testotoxicosis
+ E' F' U/ _) e0 Y% ]. ywas in the differential diagnosis because his father, [- D  s$ m9 p4 N8 m: x- s8 M4 K
started puberty somewhat early, and occasionally,; |: u' P0 l, r# v8 }4 l( f5 X. a
testicular enlargement is not that evident in the7 o0 h; E( u0 b. d+ E+ U: ~+ S% y
beginning of this process.1 In the absence of a neg-
) _; I3 h. ~' w3 r# Zative initial history of androgen exposure, our
, @& t2 P% s8 ?7 A; xbiggest concern was virilizing adrenal hyperplasia,
8 n; ]1 m7 o$ c' t7 c: h$ heither 21-hydroxylase deficiency or 11-β hydroxylase
; m3 r8 M/ l% J! `/ T4 Adeficiency. Those diagnoses were excluded by find-
. d! `3 o3 c& v. ?. X! G& F/ hing the normal level of adrenal steroids.
- O% I. i$ K6 M& N0 K( CThe diagnosis of exogenous androgens was strongly
3 l% y3 y1 g# x2 G0 h1 ~suspected in a follow-up visit after 4 months because- n, I8 o; c/ [6 G/ S
the physical examination revealed the complete disap-7 z* w4 y, ^1 e2 V) K0 f4 c% i
pearance of pubic hair, normal growth velocity, and
2 Z: u. |/ O) G, u9 ^2 U+ t, |decreased erections. The father admitted using a testos-0 ], P8 J! J- c- R0 U/ E6 \$ r
terone gel, which he concealed at first visit. He was- c; }5 Y$ _4 v* \3 E2 Q% G
using it rather frequently, twice a day. The Physicians’' R1 n5 A% U+ g; C) x6 x
Desk Reference, or package insert of this product, gel or" `, B( ^: x; w
cream, cautions about dermal testosterone transfer to# r% ?+ Z- L. {
unprotected females through direct skin exposure.
' N( N( [) [! eSerum testosterone level was found to be 2 times the
" H/ e1 ^1 x: b- C6 M7 M) V4 {baseline value in those females who were exposed to9 [9 `' Q$ {5 v9 p) N
even 15 minutes of direct skin contact with their male* Y7 Y" w4 l" ?. C
partners.6 However, when a shirt covered the applica-
$ X$ H7 y1 q& d7 Etion site, this testosterone transfer was prevented.' Y) w* M& o: I2 B
Our patient’s testosterone level was 60 ng/mL,
, x1 @, N$ i" |3 \! n5 [( Lwhich was clearly high. Some studies suggest that& ?; u8 s( H8 a9 U7 o- J6 o
dermal conversion of testosterone to dihydrotestos-
/ {' S7 o% R0 W1 k9 tterone, which is a more potent metabolite, is more
, h6 K% C" l: Y' aactive in young children exposed to testosterone
) r2 _& z" [8 r0 a. Y* cexogenously7; however, we did not measure a dihy-
: y; x/ P9 G/ t1 R8 S1 ?7 R; ~drotestosterone level in our patient. In addition to
! R, x6 n/ {; o$ a) yvirilization, exposure to exogenous testosterone in' M$ Z+ H( x& U& v" F% b
children results in an increase in growth velocity and
, @, i& h1 Y6 Y: b4 p  |advanced bone age, as seen in our patient.# ~7 T1 Z" X' M+ W7 g) u) n5 S6 k' _  E
The long-term effect of androgen exposure during
" i% v1 x' m" v0 ?$ R+ B( ^5 Jearly childhood on pubertal development and final
# j( R9 y: ?8 z% ?3 {adult height are not fully known and always remain
9 O2 p1 e) {( e0 Ya concern. Children treated with short-term testos-
" h3 A: m" w5 `2 r' z, U  N) Wterone injection or topical androgen may exhibit some% {+ ^( Z% U  g' _
acceleration of the skeletal maturation; however, after
5 N+ G  G8 F( ?8 P; y) F# Ocessation of treatment, the rate of bone maturation
; q2 ?, J' C. a' R6 `: h3 }decelerates and gradually returns to normal.8,9
! K& T4 E- z- q: cThere are conflicting reports and controversy6 A. `3 s9 P; A6 U5 {; l0 |8 A
over the effect of early androgen exposure on adult
0 u: i+ q; J5 A" U- Ppenile length.10,11 Some reports suggest subnormal; L/ N  `: ?3 H" ]: j' U: U# W
adult penile length, apparently because of downreg-7 b4 G  k* |% R1 @  h
ulation of androgen receptor number.10,12 However,
4 i; |: J& S& N8 {) X- ]! F2 FSutherland et al13 did not find a correlation between3 D# E, N0 ]: R' Q
childhood testosterone exposure and reduced adult
) p6 z' _# u- U) apenile length in clinical studies.6 D0 S3 Y* a  b5 q4 [
Nonetheless, we do not believe our patient is
+ \$ T: n6 ]1 s! p" ~% `7 O- Q5 X( sgoing to experience any of the untoward effects from4 k) N1 D5 L5 t/ w- O$ w
testosterone exposure as mentioned earlier because5 s+ V  h7 j! w
the exposure was not for a prolonged period of time.  Z# @7 |! J* r6 m
Although the bone age was advanced at the time of' J/ @2 w7 v( F+ _6 `) S
diagnosis, the child had a normal growth velocity at0 s2 I+ F* _) j2 b! D6 t! P2 Y
the follow-up visit. It is hoped that his final adult$ z/ x' x9 _- X* `
height will not be affected.+ h' ]+ a1 N' N4 A" ^
Although rarely reported, the widespread avail-5 k+ ~9 x5 P: z+ x4 }
ability of androgen products in our society may" `  {, K8 w/ T" b
indeed cause more virilization in male or female
% _1 u, C$ [" K0 |' jchildren than one would realize. Exposure to andro-
( M; A" @  v8 V. a2 L  ^+ h! qgen products must be considered and specific ques-2 o7 L/ [; s5 X, m) ]& d' \! b
tioning about the use of a testosterone product or+ Z1 r7 v2 e( C/ q: K
gel should be asked of the family members during
! ?/ C+ g: h- B7 d; P- D; ?the evaluation of any children who present with vir-
. c8 [" {, R* v7 }& [* K  Silization or peripheral precocious puberty. The diag-
' e# f- w& E( N3 p% V8 _nosis can be established by just a few tests and by
, z' s# ^0 p2 |+ ?appropriate history. The inability to obtain such a
6 |$ a7 n0 Q3 K- \, S" Ehistory, or failure to ask the specific questions, may( H. N4 t: |) U- W  `% k4 g: t
result in extensive, unnecessary, and expensive
  [/ }: _1 B9 i. _. Tinvestigation. The primary care physician should be' B+ w8 _7 H/ K3 a$ ^
aware of this fact, because most of these children3 l4 Z; ?8 K( v% m# }
may initially present in their practice. The Physicians’5 [6 I. D0 a- t% z6 H
Desk Reference and package insert should also put a# A1 l3 m7 ~' R9 `: `9 J4 R' d
warning about the virilizing effect on a male or5 \  A( s% ]. S) V
female child who might come in contact with some-
% ~& @; K2 s# R3 A/ {- H0 \one using any of these products.
* F. w, K! l! ?0 {' \References# {; x. u6 B; _) C  I. Y, t
1. Styne DM. The testes: disorder of sexual differentiation
5 S6 @& ~) y: N+ A3 S$ y4 T+ @and puberty in the male. In: Sperling MA, ed. Pediatric' a1 _7 Y+ M/ r: ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; I+ k3 C; G: E1 q# j! y
2002: 565-628.6 H: [! p6 Z# G/ P9 `, h7 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ }2 [0 o! P! H- S  rpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
& L+ D+ t( K1 o. E: s1 G8 s9 K6 ]Boy Induced by Indirect Topical
6 z0 g( J# F0 S# `& NExposure to Testosterone5 ?( ^2 h# S& h3 C
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# N; |) g2 R6 g* B6 O% {and Kenneth R. Rettig, MD13 a; u& ~8 t, ^4 W( {
Clinical Pediatrics
) A: D+ L2 d- G' j, y9 V( g) O! MVolume 46 Number 64 v  F; R) P) G9 K
July 2007 540-543
$ r) W, q2 T$ {, w  Z© 2007 Sage Publications6 Q5 Q( H# A3 k+ ^
10.1177/0009922806296651, g4 `* p% l" d0 t/ S; J- B2 z
http://clp.sagepub.com
1 O; S" d% J7 F/ Z' I* V# d4 `1 Qhosted at
# G. Y) ^, K& d0 yhttp://online.sagepub.com7 r/ _  s; W8 b1 e
Precocious puberty in boys, central or peripheral,+ s- W3 V4 g) A1 [8 y
is a significant concern for physicians. Central
% V* t- a" \: a  u1 Rprecocious puberty (CPP), which is mediated9 z+ W' a. ~* q+ s# u2 G* N4 O
through the hypothalamic pituitary gonadal axis, has
3 k/ v8 D) X/ x) S, n: O+ \' H& ya higher incidence of organic central nervous system1 j0 k2 B4 p8 J/ h* a
lesions in boys.1,2 Virilization in boys, as manifested
, F5 _0 {  ?0 }7 sby enlargement of the penis, development of pubic
3 r: w$ D3 q! w3 L2 ]3 Ehair, and facial acne without enlargement of testi-: j8 Z% i' E5 T
cles, suggests peripheral or pseudopuberty.1-3 We
: X1 Y7 E! c4 ~" j+ hreport a 16-month-old boy who presented with the
# G" r3 r3 E/ E0 h6 c# w4 yenlargement of the phallus and pubic hair develop-
# G; D- g$ v( A2 q9 _ment without testicular enlargement, which was due
  k! A8 Y' }! Sto the unintentional exposure to androgen gel used by: O4 G. U% K& n! F5 H& B& K4 u
the father. The family initially concealed this infor-
/ e$ a: L: @- N- A' T4 e) }2 L) `mation, resulting in an extensive work-up for this: S' r2 n3 ]8 Y4 Q1 J
child. Given the widespread and easy availability of# _0 d" }& H' u' [) a* ^
testosterone gel and cream, we believe this is proba-; C4 B" D; W3 ^/ b8 a
bly more common than the rare case report in the
5 v$ f; M+ ]' U; p* ?+ b5 bliterature.4
6 O/ J4 W' j+ bPatient Report
" @! u% {4 Q+ ]$ |: XA 16-month-old white child was referred to the
' b! i+ a* \+ E4 Wendocrine clinic by his pediatrician with the concern
3 e0 E: W4 g/ K- v  n$ Qof early sexual development. His mother noticed
7 Z3 D% l' E* h' O' L/ ?' z" flight colored pubic hair development when he was5 x5 \/ e' g9 \/ S- b3 h
From the 1Division of Pediatric Endocrinology, 2University of- S0 i- j/ C8 y
South Alabama Medical Center, Mobile, Alabama., A8 |$ c& T: E/ ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,3 j2 B& q" a6 w
Professor of Pediatrics, University of South Alabama, College of8 ]' |9 z) ^# P. t6 E% K  _: |' L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* ~; x# ?, \2 _/ e: O8 r* ae-mail: [email protected].& D; z" M; @0 z
about 6 to 7 months old, which progressively became$ A5 J. A5 [8 N% V. Y! j) \! w8 j
darker. She was also concerned about the enlarge-
2 Z4 D* U5 E. jment of his penis and frequent erections. The child
1 t/ X( n% O" \% s, d6 j& I% {  vwas the product of a full-term normal delivery, with
, r% E9 a! @/ t8 k5 A  ca birth weight of 7 lb 14 oz, and birth length of
& ^; u/ J! {. N$ @20 inches. He was breast-fed throughout the first year
  d# c  E, [! M: v4 u' x4 Qof life and was still receiving breast milk along with
& w7 ]3 r: ^+ ^, T( Nsolid food. He had no hospitalizations or surgery,4 ?) a1 _1 P1 d8 w/ ~  I
and his psychosocial and psychomotor development7 l# f' E( U! R) `( S
was age appropriate.5 s2 E: [9 l% x0 p' M
The family history was remarkable for the father,! u. Q& d$ c8 G# j# W
who was diagnosed with hypothyroidism at age 16,) d# E( Q2 G8 B( O) i* F: N" J4 r
which was treated with thyroxine. The father’s" a6 b/ f' L# w/ {# N% M" h4 G
height was 6 feet, and he went through a somewhat" H4 V5 o* T4 v7 F$ L
early puberty and had stopped growing by age 14.
: ]' n4 V: e  v9 u% |The father denied taking any other medication. The
6 W: h+ m# U% _: Hchild’s mother was in good health. Her menarche
0 h2 e9 ^8 e9 W5 Z1 c* {7 Cwas at 11 years of age, and her height was at 5 feet& U4 P3 @0 h6 k4 [) b! T- {
5 inches. There was no other family history of pre-
6 q2 t: u/ s( L/ M9 W: L% \  `  Vcocious sexual development in the first-degree rela-; J6 p1 E5 B- }6 v% `0 r
tives. There were no siblings.
3 ?9 t0 t9 L$ @: K" VPhysical Examination; e, ^! _, u6 q% |
The physical examination revealed a very active,
" d6 h; A! F' G7 {playful, and healthy boy. The vital signs documented
) L( y) m* I* \( X3 Z# Da blood pressure of 85/50 mm Hg, his length was
, Z* H5 p: A1 E8 ]5 F" F90 cm (>97th percentile), and his weight was 14.4 kg1 Y/ B! i3 {, e- W0 |
(also >97th percentile). The observed yearly growth
8 N6 F4 a7 j8 B9 h% Ivelocity was 30 cm (12 inches). The examination of; Q5 B) R! _+ c9 k  o* u
the neck revealed no thyroid enlargement.
& r9 j! X% l' CThe genitourinary examination was remarkable for4 k+ M' u. @6 b7 k6 P% g
enlargement of the penis, with a stretched length of  X& s" d# Z6 m9 q9 f
8 cm and a width of 2 cm. The glans penis was very well
! {6 B/ A# l; X6 c3 sdeveloped. The pubic hair was Tanner II, mostly around
! {& U7 s2 M3 G% X/ x  ?1 k3 L, R! `540
% V5 M8 q9 I1 s0 k$ yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 u- [0 x5 d6 R, t* S- m
the base of the phallus and was dark and curled. The1 u" n1 I3 ~; k: U% Y
testicular volume was prepubertal at 2 mL each.
# ?0 o! i+ Z7 D; \6 H7 iThe skin was moist and smooth and somewhat# f0 N- j1 E9 b- W: d& }+ ~, o: B
oily. No axillary hair was noted. There were no2 F: w( q9 l% y) q* \1 _
abnormal skin pigmentations or café-au-lait spots.* |5 f+ m8 L8 Z( I
Neurologic evaluation showed deep tendon reflex 2+/ K2 z* v; y6 V! D3 Y+ \
bilateral and symmetrical. There was no suggestion
; W4 a0 y; [# G- [0 u! yof papilledema.
+ t  W7 D9 H: T$ I  Y# B2 dLaboratory Evaluation
7 h9 g2 b% N& h+ oThe bone age was consistent with 28 months by4 [) e+ `: P. N0 f. _
using the standard of Greulich and Pyle at a chrono-
9 j  g- ^& N) P# B0 c: Llogic age of 16 months (advanced).5 Chromosomal( S: \( c  E- N8 ~& d! Z
karyotype was 46XY. The thyroid function test8 b5 g$ Q& U8 S) `2 |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. ]" |; l  ~7 C6 j5 U" P
lating hormone level was 1.3 µIU/mL (both normal).
0 I1 a4 D; N' x1 v$ [The concentrations of serum electrolytes, blood* s1 O1 T' K3 ]5 @
urea nitrogen, creatinine, and calcium all were
1 {9 Y7 b) S: E, rwithin normal range for his age. The concentration
1 p1 _/ S, g$ Y4 n, B1 Aof serum 17-hydroxyprogesterone was 16 ng/dL
2 q& ~9 c. `. ~9 u7 w( o4 ^(normal, 3 to 90 ng/dL), androstenedione was 20
0 U2 m' |4 f. [7 v, z! c0 png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* m, x0 J2 h: Z7 j7 v2 M
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 h: Q+ d* p2 R! v0 y4 pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 C8 a$ l0 E! @% \, h49ng/dL), 11-desoxycortisol (specific compound S)
7 G+ \- b4 j$ Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  _& m- Q  a) L- N  [( d( S: btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 N. j* W. W/ `0 D( rtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),  Q6 j5 o3 h4 }% |
and β-human chorionic gonadotropin was less than' U1 R7 R7 P0 _! v( u) W, A5 ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular' o2 S; ~0 P# d9 C- \) h
stimulating hormone and leuteinizing hormone( ~5 T+ {& `5 X8 R. C
concentrations were less than 0.05 mIU/mL
' R/ R+ ]9 e9 d/ R4 E(prepubertal).& H7 k5 _# Q, Q/ h. m; s8 d" T, e9 n3 L
The parents were notified about the laboratory
1 V5 ?2 H) r. _6 T2 S8 P! Aresults and were informed that all of the tests were5 j$ ~2 ^+ f9 `# S
normal except the testosterone level was high. The
8 y/ q8 R! o$ b, @- o6 f3 l) ]% \- Nfollow-up visit was arranged within a few weeks to
" ^6 K- [# C4 H7 c/ u/ ^& T. ^% sobtain testicular and abdominal sonograms; how-3 ?7 _! u- i1 x2 E$ l
ever, the family did not return for 4 months.
0 j# f9 G0 N9 r3 R/ w! {Physical examination at this time revealed that the! b- c! p/ F. N" e
child had grown 2.5 cm in 4 months and had gained! V+ i5 q7 g  r( [* R
2 kg of weight. Physical examination remained
  K, i  X9 t  ]. @, P3 cunchanged. Surprisingly, the pubic hair almost com-6 X8 N5 k" Y0 E1 E% c. |2 D% g
pletely disappeared except for a few vellous hairs at
; i4 q8 z; o6 K3 O  ?the base of the phallus. Testicular volume was still 2
5 d2 ^0 b$ y, c3 O' k! x$ M2 jmL, and the size of the penis remained unchanged." x0 ]7 P. Y3 D, r3 h" H
The mother also said that the boy was no longer hav-; N9 H! _$ y5 e. ^2 M9 e9 p' q3 t
ing frequent erections.
4 v( E+ O8 n& `9 {Both parents were again questioned about use of: `6 U$ g! N% e& Z3 b" E1 G6 R
any ointment/creams that they may have applied to3 b4 H  L1 [. H2 |, X  f
the child’s skin. This time the father admitted the7 `; }+ X' {8 i+ Y2 ?* |
Topical Testosterone Exposure / Bhowmick et al 541
& t( B* \* x' g/ p4 {use of testosterone gel twice daily that he was apply-" W7 v; y9 T  U8 i. C9 J  V  s9 h
ing over his own shoulders, chest, and back area for
) A3 @2 C$ R9 L  I5 p# `- fa year. The father also revealed he was embarrassed  M: x( R7 P6 C" F8 H) Z/ ~
to disclose that he was using a testosterone gel pre-" q# g: O3 U$ w
scribed by his family physician for decreased libido
% x# |# Y$ H8 hsecondary to depression.7 Q1 S2 J2 S3 E5 e) y7 F$ Q
The child slept in the same bed with parents.  A: H1 a/ a8 \6 Q6 E; G
The father would hug the baby and hold him on his* X* H7 P" l! [# ?3 x" k
chest for a considerable period of time, causing sig-1 H7 |" U1 Q5 j$ d* u) U- S
nificant bare skin contact between baby and father.( C  d7 ?- G- P2 E* y5 x! D0 S
The father also admitted that after the phone call,( h' I# J; I5 [& s1 j* t9 L
when he learned the testosterone level in the baby
* P& u1 s, ^! a2 J' cwas high, he then read the product information
2 J  B. O- r  tpacket and concluded that it was most likely the rea-
& u* v$ m- k! ^1 json for the child’s virilization. At that time, they
4 T/ {  B0 [% P' W  ~# O& zdecided to put the baby in a separate bed, and the) W% s$ U" w$ p* y+ z; ^0 V
father was not hugging him with bare skin and had" ~! U, m/ ?- y0 D& F% D: B
been using protective clothing. A repeat testosterone
1 o1 G0 L8 j/ E+ Ptest was ordered, but the family did not go to the
  |! F$ ?  i) f* S7 ^0 M5 vlaboratory to obtain the test.
: |2 T( j5 a' Q3 DDiscussion
$ E9 d4 o. \) j- x2 vPrecocious puberty in boys is defined as secondary2 K! }6 g6 }8 r; @" J) J# K) s% [
sexual development before 9 years of age.1,4
+ f: u# x, P- F6 b% x( t& _Precocious puberty is termed as central (true) when% x. d# d8 _8 `5 m9 M# T" s: S
it is caused by the premature activation of hypo-, f1 w0 B9 f4 e. R
thalamic pituitary gonadal axis. CPP is more com-
( i. B2 G! A- u" }. R1 \$ Z5 Imon in girls than in boys.1,3 Most boys with CPP% O4 L% ^! B' }  e+ a
may have a central nervous system lesion that is! M4 s7 L4 u% }' g
responsible for the early activation of the hypothal-. o3 ^4 j3 Q3 E% U
amic pituitary gonadal axis.1-3 Thus, greater empha-
( l/ }8 J3 n# @1 Hsis has been given to neuroradiologic imaging in' I7 N' A7 Z% A- i# h9 @* b
boys with precocious puberty. In addition to viril-( s$ X+ Z5 d6 @8 P
ization, the clinical hallmark of CPP is the symmet-6 Q) @! v* K$ b8 t2 _7 h' C* I
rical testicular growth secondary to stimulation by
! e/ I  j0 ]) d+ O% ogonadotropins.1,3. V* }. ~" T% z( Y& P6 m+ c
Gonadotropin-independent peripheral preco-
: D& j% R% ]/ T* }cious puberty in boys also results from inappropriate
2 N- f3 ]; h  R9 Dandrogenic stimulation from either endogenous or% m& a( a8 D9 s) W1 f
exogenous sources, nonpituitary gonadotropin stim-5 G5 a9 q5 q* Y+ j* v+ o8 q+ }
ulation, and rare activating mutations.3 Virilizing
7 m3 M0 c$ h3 r- A& Z5 gcongenital adrenal hyperplasia producing excessive
4 V  ]3 G" A  Z$ c) t$ M/ tadrenal androgens is a common cause of precocious
, l& y/ X* s0 p% n- @2 ~puberty in boys.3,4
5 }4 r9 K6 @  y7 `The most common form of congenital adrenal1 i7 @6 j$ y. l  ~* y6 D) B1 {% b
hyperplasia is the 21-hydroxylase enzyme deficiency.' t. _( y- T0 h' \2 r% a6 u
The 11-β hydroxylase deficiency may also result in4 A* E/ i7 ^) }, c% X
excessive adrenal androgen production, and rarely,- J, ~. |& h) q
an adrenal tumor may also cause adrenal androgen6 |% c' o, _6 V7 ~+ u0 A8 \
excess.1,3
8 O+ |5 V  @$ _/ E. i( W5 e, w, Bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 t& H* N) E1 R5 O0 t1 b542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 a& _) j6 l5 B) h/ SA unique entity of male-limited gonadotropin-: q" n, t7 k2 X$ @: ?9 Y
independent precocious puberty, which is also known
# v, e3 b6 o2 s% v" X: J+ M* _' Ias testotoxicosis, may cause precocious puberty at a
: W% r  e' ]+ H, |; B3 O, _very young age. The physical findings in these boys; I4 P" [6 P( b+ \
with this disorder are full pubertal development,
( E- U& M% O4 E3 Oincluding bilateral testicular growth, similar to boys- g( S6 ], M4 x" @8 @3 p
with CPP. The gonadotropin levels in this disorder$ c1 O7 i  d7 a6 u8 A
are suppressed to prepubertal levels and do not show% v( ]3 C# i( [  x/ L+ |2 m
pubertal response of gonadotropin after gonadotropin-4 y4 ~8 r  W  M* W
releasing hormone stimulation. This is a sex-linked" _1 U7 D8 I4 k# {& j
autosomal dominant disorder that affects only8 \: k+ i; J- R' L% T( b- d
males; therefore, other male members of the family+ }3 L: O8 |. W; n: v
may have similar precocious puberty.3" `( k# Y7 Z3 T( F7 K: |- o
In our patient, physical examination was incon-
+ S  x! q: L7 Jsistent with true precocious puberty since his testi-
, w4 G& @1 @- T2 O+ S# Hcles were prepubertal in size. However, testotoxicosis
5 U, p! {3 z) s/ j3 Cwas in the differential diagnosis because his father
5 k( v3 M. `, y3 Z& [started puberty somewhat early, and occasionally,! z- N) F- {5 Q9 O4 X' R2 x
testicular enlargement is not that evident in the' f" G: s, l1 ^! w  j& @: d& z
beginning of this process.1 In the absence of a neg-6 i1 N( t% a& u! O$ O4 G
ative initial history of androgen exposure, our
, h1 U4 H- W# O4 Qbiggest concern was virilizing adrenal hyperplasia,4 s# q; \' V' L9 U1 e# F
either 21-hydroxylase deficiency or 11-β hydroxylase
: C9 L8 ^2 o* F3 _deficiency. Those diagnoses were excluded by find-
0 F8 J' S: }5 |6 K; w& V% y" F& ling the normal level of adrenal steroids.2 G$ s0 v& A7 Z8 u$ L; j9 h% Y
The diagnosis of exogenous androgens was strongly3 s6 A8 Z2 D2 a  V$ _: z
suspected in a follow-up visit after 4 months because
. e+ y2 X1 w9 x$ e% ^; {* [$ sthe physical examination revealed the complete disap-- U- f% E# {+ K  J: P! C
pearance of pubic hair, normal growth velocity, and
( @- A' f5 r0 Y1 o, J, r2 M) Cdecreased erections. The father admitted using a testos-
  G* z. P+ ?2 n6 m% u# C: B4 oterone gel, which he concealed at first visit. He was
! X9 P5 j: S3 A" rusing it rather frequently, twice a day. The Physicians’
! N( P: k) {0 T, lDesk Reference, or package insert of this product, gel or5 R) f* u& K7 n% N: W$ E& M
cream, cautions about dermal testosterone transfer to- G( X% p6 S# p: H
unprotected females through direct skin exposure.
  l6 @5 I4 Y" r$ g4 k8 p: ZSerum testosterone level was found to be 2 times the3 P: n& _4 q  o5 f- e$ p
baseline value in those females who were exposed to
) c6 `+ G1 E$ N/ Y# L% W/ Xeven 15 minutes of direct skin contact with their male
. F! F4 g5 P8 ?partners.6 However, when a shirt covered the applica-
8 |' i' Z. c; [1 g& ktion site, this testosterone transfer was prevented.
) S# Y  @6 c, NOur patient’s testosterone level was 60 ng/mL,
" t& z  i6 s8 Xwhich was clearly high. Some studies suggest that
# m+ J8 @- @9 B% J$ r% w) h. u  Udermal conversion of testosterone to dihydrotestos-- I. g* Z" w! W/ e
terone, which is a more potent metabolite, is more
' S* U7 P* U/ q6 L# G# Dactive in young children exposed to testosterone
7 L; L# D6 i. _9 @* X: }7 i( sexogenously7; however, we did not measure a dihy-9 ?8 f, N; z4 G- |7 N" z
drotestosterone level in our patient. In addition to
' b8 b# _: D) R4 k- cvirilization, exposure to exogenous testosterone in" s) G1 U0 l! [) F
children results in an increase in growth velocity and- z. c0 ^/ Q7 [: w
advanced bone age, as seen in our patient.
; m9 g' ^# X9 n5 {The long-term effect of androgen exposure during
- a  V# Z& ]. I2 k% b6 x2 s$ g' y6 Uearly childhood on pubertal development and final
! G; u) }9 e! y# jadult height are not fully known and always remain+ N7 F$ S1 T: r4 c* A0 u! L
a concern. Children treated with short-term testos-
5 Q6 v4 a) H7 Q; K) k3 kterone injection or topical androgen may exhibit some
" F& t- K! c: ?) h4 j2 ~4 {acceleration of the skeletal maturation; however, after: ?8 G, ^. `+ P# u0 \% _0 ~
cessation of treatment, the rate of bone maturation
& F# y* a  l8 E+ J6 D! \, {decelerates and gradually returns to normal.8,97 [+ j* Z0 k6 q
There are conflicting reports and controversy- K# p8 p, X* H  ], S( @  J
over the effect of early androgen exposure on adult+ W2 e3 E6 H$ Q( \8 ^$ M4 y
penile length.10,11 Some reports suggest subnormal" F  p1 M3 Y: q9 r
adult penile length, apparently because of downreg-
$ t$ ^8 K0 e* ^  D" Nulation of androgen receptor number.10,12 However,; P6 C% H& K+ L( e, p
Sutherland et al13 did not find a correlation between, y! J9 ~- H9 K2 |! @$ _) ~. |8 \% L
childhood testosterone exposure and reduced adult6 S9 V6 I1 m: T% a7 e" p
penile length in clinical studies.$ H+ X7 Z& x4 Y5 Y. T; o% ~$ x& W; u
Nonetheless, we do not believe our patient is+ x, i9 a- W/ z" k
going to experience any of the untoward effects from
% [4 f( u# |- S: C% qtestosterone exposure as mentioned earlier because& M: j2 W# w# S( _
the exposure was not for a prolonged period of time.
6 L; q2 C) U( I, k& wAlthough the bone age was advanced at the time of8 h" L$ B$ k5 x; z
diagnosis, the child had a normal growth velocity at
" K2 Q8 @1 a( `# Wthe follow-up visit. It is hoped that his final adult% v& t0 _8 s, g3 U6 ^, c
height will not be affected.
' `( J# J. |0 E  O) e  G. A% V5 MAlthough rarely reported, the widespread avail-% V& \' T$ {" i- M
ability of androgen products in our society may9 W, |. ]! W1 s3 A; T3 B( y
indeed cause more virilization in male or female
% z- s  z; U: {3 E8 d% G3 \2 xchildren than one would realize. Exposure to andro-) |$ C% ?2 ^8 {4 m
gen products must be considered and specific ques-
+ ^! O4 ?& r$ d1 z" B5 Ytioning about the use of a testosterone product or& U+ R1 f1 }  @' ?, \& C
gel should be asked of the family members during" L$ `8 m; N, `6 f# C
the evaluation of any children who present with vir-$ B' {9 N% C) t3 }
ilization or peripheral precocious puberty. The diag-# s& K  w& Z5 h# {: m; Q' v6 u$ f
nosis can be established by just a few tests and by9 x0 O+ z; G3 `! b
appropriate history. The inability to obtain such a7 ]8 c; H7 K% i  `8 e; S  b4 _
history, or failure to ask the specific questions, may4 J" \2 O6 U* p
result in extensive, unnecessary, and expensive
( @, K0 g- o1 L2 Finvestigation. The primary care physician should be& r( j! y% t; z
aware of this fact, because most of these children
. X2 C5 M1 h. T& u' S" Xmay initially present in their practice. The Physicians’
6 ]1 [6 n; z1 QDesk Reference and package insert should also put a
% D( R& v9 h1 Hwarning about the virilizing effect on a male or$ z* h8 o; d6 u7 j/ V6 f1 n" t
female child who might come in contact with some-
* _+ e: g* ^2 g+ b2 W$ {one using any of these products.
2 v3 C( l" `$ K6 X# K4 NReferences
1 T# o6 y6 {, Y1 c. F+ T1. Styne DM. The testes: disorder of sexual differentiation
' L) R4 _+ k2 \* ^and puberty in the male. In: Sperling MA, ed. Pediatric% P3 R8 y4 j6 e, q9 G) H- k1 \
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: F2 A6 F% J8 D$ a+ h# p% j
2002: 565-628.
1 i/ w7 ]8 w7 p/ n; d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ ?  b' [  |& O) a5 G  O3 ?! Vpuberty in children with tumours of the suprasellar pineal
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!
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!
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
9 p. ^+ Q' h9 P8 O# g
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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