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Sexual Precocity in a 16-Month-Old
- T6 m- Q$ X) O* v4 J& }) r4 GBoy Induced by Indirect Topical$ B0 i: L( G% w; {+ q! ~
Exposure to Testosterone$ l/ u- T) ^6 D* W/ l' l
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 a  W) ^+ n& Z5 ?  k5 k& s
and Kenneth R. Rettig, MD1
5 G' T; F' G) I& b, \) u& A, GClinical Pediatrics
' \% b7 L/ L0 u+ E2 ZVolume 46 Number 6
' q  g- |$ Q# E6 V. XJuly 2007 540-543( ^' Q0 [5 T- Z) R3 ^/ T
© 2007 Sage Publications( x& B+ ~% g: S7 ~
10.1177/00099228062966514 N. i8 `6 I7 u- O  G" |
http://clp.sagepub.com
$ B3 d, f3 y+ R1 X/ r! c6 h, ?hosted at
& {3 o' r% j0 o5 m. ^9 b" whttp://online.sagepub.com+ M. V# {# o$ m! {& ]
Precocious puberty in boys, central or peripheral,. x' _7 l4 t3 Z2 n  X, b. Q, {
is a significant concern for physicians. Central  z" o  ^; K2 g$ y1 T* d
precocious puberty (CPP), which is mediated
$ D! A2 a& z5 c9 Wthrough the hypothalamic pituitary gonadal axis, has
# W0 Q' [" x$ a# A/ a4 K; l# L, va higher incidence of organic central nervous system/ k% m& z7 H& B( A( T- m
lesions in boys.1,2 Virilization in boys, as manifested: [  g1 H/ G4 t  B8 n
by enlargement of the penis, development of pubic
2 Q- ?/ S' }8 M6 j7 Shair, and facial acne without enlargement of testi-
( c0 V  y0 l$ [, g. P2 `cles, suggests peripheral or pseudopuberty.1-3 We
) F0 f9 z% Q# |3 P+ Wreport a 16-month-old boy who presented with the3 y2 V. }# m& ^  k& X
enlargement of the phallus and pubic hair develop-* h. A1 H" K. j5 s
ment without testicular enlargement, which was due- x1 P8 [7 V/ S8 w3 R. c) g6 A
to the unintentional exposure to androgen gel used by6 a' {5 ^/ L4 M* f& `
the father. The family initially concealed this infor-
+ ^0 }$ ^8 m) Hmation, resulting in an extensive work-up for this3 Q# E1 Y" ^9 B$ z- }
child. Given the widespread and easy availability of. X* g) h1 l1 E! Z
testosterone gel and cream, we believe this is proba-1 S  S& w3 F4 s
bly more common than the rare case report in the+ l% V+ @& l7 C, M4 G
literature.4
( v, d3 X2 L( r% JPatient Report
3 d9 J7 J  n9 P/ `9 lA 16-month-old white child was referred to the9 ^4 o9 Q% g( {# }- L
endocrine clinic by his pediatrician with the concern0 S; g5 }+ I' Y; N' M( b
of early sexual development. His mother noticed
) ]8 r: {" k) Y) \' g9 D# Olight colored pubic hair development when he was
+ R! ]" A# Y4 [7 R& `# U% Z6 m1 sFrom the 1Division of Pediatric Endocrinology, 2University of
! {! p* ^( o% `South Alabama Medical Center, Mobile, Alabama.
1 j: Q) C; W/ N' k& \: ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,
* C  i" H. Q* h7 z* l. uProfessor of Pediatrics, University of South Alabama, College of
% D. F1 r  j) t% x5 C3 j5 Q  h$ A7 {Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ V* }% _$ s: U% A" n& J1 v) Y! I
e-mail: [email protected].
+ U8 @8 G3 H7 e' rabout 6 to 7 months old, which progressively became
% f3 R0 G5 H0 k$ ]# j" z; T0 i" Ldarker. She was also concerned about the enlarge-/ B# F2 ~: Z. T" M6 `, y" p& _
ment of his penis and frequent erections. The child8 Y; l3 k3 d2 J
was the product of a full-term normal delivery, with- ^9 u: n( r8 Z( {2 I0 Z* ]
a birth weight of 7 lb 14 oz, and birth length of
1 X8 E4 }% ^$ Q$ `. z20 inches. He was breast-fed throughout the first year
8 U# T" x0 R7 C% kof life and was still receiving breast milk along with
; [! P+ z0 K4 l4 N5 l, x6 Jsolid food. He had no hospitalizations or surgery,3 Y  g/ w4 q: _% [) R( A
and his psychosocial and psychomotor development
9 V  @7 l8 r) @- B  u/ `- {was age appropriate.
7 X# E! A8 j! OThe family history was remarkable for the father,
* F4 b7 C  i+ t% Y# dwho was diagnosed with hypothyroidism at age 16,1 R! p, D; b# M4 e
which was treated with thyroxine. The father’s& [2 t/ T, C  A
height was 6 feet, and he went through a somewhat: A3 m* M8 N" Q8 R$ g
early puberty and had stopped growing by age 14.
  p) S* a! l5 r! s/ W: p* uThe father denied taking any other medication. The
+ E. A* {3 |' pchild’s mother was in good health. Her menarche
2 ]) f/ f  T, Iwas at 11 years of age, and her height was at 5 feet
/ A, H- U, U  p& M5 F5 inches. There was no other family history of pre-
9 V; x" H2 ^2 }. S( @cocious sexual development in the first-degree rela-% [9 r, d. ]# A) Y
tives. There were no siblings.+ X9 V  e( a$ s) W7 H2 r' h
Physical Examination' g! R0 Q0 y; `1 ]& R
The physical examination revealed a very active,
. z6 G) }% I: c! V+ O: S. [+ Fplayful, and healthy boy. The vital signs documented: Z6 N+ }0 f$ h- @* Q
a blood pressure of 85/50 mm Hg, his length was
2 H% I3 ~/ [7 x$ m# J% w90 cm (>97th percentile), and his weight was 14.4 kg- r: f% H5 U2 f5 x' a
(also >97th percentile). The observed yearly growth
# J' p# T" {* }5 l. I0 u2 M+ \velocity was 30 cm (12 inches). The examination of
% y; D6 ^0 g9 R& E7 othe neck revealed no thyroid enlargement." n  {/ Y! W9 t3 J# \
The genitourinary examination was remarkable for
! n; |" j' D* \- ~  O' ]! @enlargement of the penis, with a stretched length of
# b, k" s. ]9 x' ]2 U* K8 cm and a width of 2 cm. The glans penis was very well, `0 D# U5 l, D
developed. The pubic hair was Tanner II, mostly around
6 [: V* R/ ~) p( \0 k' K540
; ^7 X' C  H0 B8 o# \' k- mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ G5 f/ `6 K; |, b0 N- `
the base of the phallus and was dark and curled. The* f  s, g! g* i4 ^, M2 V8 N, a! M4 U
testicular volume was prepubertal at 2 mL each.4 F. @- ]9 T0 e1 x9 s9 |: j
The skin was moist and smooth and somewhat
. M: l& A& K8 o% loily. No axillary hair was noted. There were no+ {% q  e2 T8 e* [1 m
abnormal skin pigmentations or café-au-lait spots.
. i- y8 h1 ?3 J9 N) r, XNeurologic evaluation showed deep tendon reflex 2+
! j" K3 v) `3 M2 K3 c7 |bilateral and symmetrical. There was no suggestion
& W6 R# M" Z" v( uof papilledema.
  e( s/ a3 T1 G9 [3 nLaboratory Evaluation* e( p# o& i! u, i
The bone age was consistent with 28 months by7 u' ?% N1 e, y: m" s: u* D
using the standard of Greulich and Pyle at a chrono-
% r4 `  j8 z; ]7 J/ J3 Q3 Qlogic age of 16 months (advanced).5 Chromosomal
, f3 W& m" x; f# [3 m  Rkaryotype was 46XY. The thyroid function test( l* ]5 a  w0 I7 Z! z3 B5 k
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. z! c# H* A5 V( O8 _lating hormone level was 1.3 µIU/mL (both normal).% J8 b1 U! g* u0 a1 E2 ~
The concentrations of serum electrolytes, blood
6 q( @% ?% ^! ?& e) S" A2 W" E% lurea nitrogen, creatinine, and calcium all were
" C) j! M8 k# Awithin normal range for his age. The concentration& p( u5 f0 Z7 Z+ Q5 h1 k
of serum 17-hydroxyprogesterone was 16 ng/dL
) ~6 H9 `  D. p$ g, b(normal, 3 to 90 ng/dL), androstenedione was 20
+ H% M! Q# U9 H! }1 P4 o! E! Vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# G8 _& M- L6 H' d7 Z& o) B
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; L8 v" j: ^# a$ M% ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# s$ F2 k  f- ?! z$ j
49ng/dL), 11-desoxycortisol (specific compound S)
! w" h. e9 Y" T* N! I" awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& j! _% E. k6 h6 y- utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, F6 N; N- k) f1 c  A7 N( Z
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' c6 P2 W: v  |9 V+ `3 C( Dand β-human chorionic gonadotropin was less than4 a- S" g9 U# {. f% `0 G: O; b+ M
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ v- t% v: e9 ?+ {- K
stimulating hormone and leuteinizing hormone
# u% n* w$ D  ?7 a5 U/ v6 {; [concentrations were less than 0.05 mIU/mL! h: V# f1 ~) |7 T  ~- t
(prepubertal).
9 k( F* [6 n- G3 `The parents were notified about the laboratory
+ Z9 t" g# N& ]; c2 B/ rresults and were informed that all of the tests were8 F4 Q( ]# b- }+ N+ y5 V; @. x
normal except the testosterone level was high. The
" @& l" [/ a: v+ \5 mfollow-up visit was arranged within a few weeks to
3 M& z5 f+ g  w3 K: ]obtain testicular and abdominal sonograms; how-& Y8 Z0 a; O8 ^% [9 T
ever, the family did not return for 4 months.
  z( {; ]. d* v7 H+ ~0 b  O, DPhysical examination at this time revealed that the
8 k( w) X7 P& Schild had grown 2.5 cm in 4 months and had gained
" F2 ?% \& b( M9 ^2 kg of weight. Physical examination remained
( R8 A/ V* A& |) [" y  a3 Sunchanged. Surprisingly, the pubic hair almost com-6 A* M7 E) a6 b) A0 Z& l
pletely disappeared except for a few vellous hairs at, m( E& Y  A! M$ \0 S. L" t4 c3 q
the base of the phallus. Testicular volume was still 29 ~8 H6 `5 U; _2 i
mL, and the size of the penis remained unchanged.
% i& a9 i: y4 m% S- a9 g' [The mother also said that the boy was no longer hav-
! t. W- d. O) e9 O& I6 y6 iing frequent erections.0 E# }3 @* U; \2 w# ?  r. _
Both parents were again questioned about use of
3 u" q' Q9 F5 t) q4 s" Y. `) [$ }any ointment/creams that they may have applied to
0 e) {# g# I3 l1 k% ?8 bthe child’s skin. This time the father admitted the
  [3 d5 o; }. ]) n3 O. H9 dTopical Testosterone Exposure / Bhowmick et al 541
. v1 u( F- @/ Z* S1 yuse of testosterone gel twice daily that he was apply-
# Y$ K) x3 I0 N7 i& U8 ring over his own shoulders, chest, and back area for
2 U7 c# E5 D& P; Da year. The father also revealed he was embarrassed
  v3 ~) b' W/ tto disclose that he was using a testosterone gel pre-
  [4 z$ A; K2 `* Lscribed by his family physician for decreased libido! U. ~) b/ P$ l4 ]/ H
secondary to depression.
, n2 _4 {: _8 e: [) o- w2 i. RThe child slept in the same bed with parents.9 b  {  n7 c' y1 c9 U& Y! F2 X3 y
The father would hug the baby and hold him on his
9 \, F0 O5 b$ Q9 T& Rchest for a considerable period of time, causing sig-. }2 D& ^5 d% f1 G# x: k
nificant bare skin contact between baby and father.9 L, K; A# f* |7 S) P: Y6 ?4 n
The father also admitted that after the phone call,( f. G- v4 U& Z) {  W9 S
when he learned the testosterone level in the baby+ i) j9 l4 m1 v/ [3 o$ ]# b
was high, he then read the product information
/ {9 ]2 N4 M; K, u! \3 z# C5 K2 O% ^5 epacket and concluded that it was most likely the rea-
  s# I  {5 \3 }" A1 a: [' D8 Tson for the child’s virilization. At that time, they/ u- n2 q3 U  y, Z' M& z2 u1 I$ o
decided to put the baby in a separate bed, and the
; E, p: @. O: U- o6 @; jfather was not hugging him with bare skin and had" w# e# K& v9 ^8 O$ W
been using protective clothing. A repeat testosterone: R2 P0 _( c3 S5 U/ a
test was ordered, but the family did not go to the# C: X# J/ Q/ v
laboratory to obtain the test.3 N) @/ Q- v7 S( U8 j# G1 I' |
Discussion
1 A+ ]1 [) m  J6 S" B1 }Precocious puberty in boys is defined as secondary
  m0 a3 p% ^, ksexual development before 9 years of age.1,47 P7 |0 E* J6 x1 k) m" \( o
Precocious puberty is termed as central (true) when
& [2 w+ [; [7 L. ~6 ~& Xit is caused by the premature activation of hypo-
7 M1 @9 A4 t  b2 ^3 M: K+ v) Zthalamic pituitary gonadal axis. CPP is more com-
: H- l" h( _# M3 V, Mmon in girls than in boys.1,3 Most boys with CPP0 A* D* n1 U$ h/ A
may have a central nervous system lesion that is
# r) w' Y. a  ~2 Kresponsible for the early activation of the hypothal-* ?3 a8 E3 P1 J6 p1 L0 U/ E
amic pituitary gonadal axis.1-3 Thus, greater empha-
" n/ Y2 G3 T( C& a/ N! ^, n' ksis has been given to neuroradiologic imaging in
: K% {) r; a0 y0 Gboys with precocious puberty. In addition to viril-
; v) \6 W/ A/ y! S6 L$ d2 Tization, the clinical hallmark of CPP is the symmet-
8 w( n$ d% y- M5 |4 d( q3 x3 b+ vrical testicular growth secondary to stimulation by
0 i: C6 G: |( R: y2 ogonadotropins.1,3' O. b% }3 t5 ]' l
Gonadotropin-independent peripheral preco-
7 y% b5 q" {& I" _" b% Icious puberty in boys also results from inappropriate- ^7 u3 V- ]8 }! @& [1 X/ T
androgenic stimulation from either endogenous or
( Q3 ^) ^5 E9 M) ?exogenous sources, nonpituitary gonadotropin stim-5 d% o+ |8 V1 _( S3 X0 w7 D
ulation, and rare activating mutations.3 Virilizing) c1 w( U: `$ t, @/ r5 K
congenital adrenal hyperplasia producing excessive, S& U. Z+ d& h5 b% ]9 T3 p' P3 o, t
adrenal androgens is a common cause of precocious% N. E' j7 u# w( h
puberty in boys.3,4( F0 {9 U* f; e" P( U" B& t
The most common form of congenital adrenal
- r$ X0 e* l  j1 r) T8 Yhyperplasia is the 21-hydroxylase enzyme deficiency., {3 l, e' B* d; A
The 11-β hydroxylase deficiency may also result in
% U5 A4 W9 B5 |3 h6 kexcessive adrenal androgen production, and rarely,
+ m( |* j* C& E. M# c. ban adrenal tumor may also cause adrenal androgen
# ]2 X7 ^, h, V  y9 Fexcess.1,3( ?) s# x) h( y- q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 N5 U3 o- `: w, `
542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 v+ r0 F. s$ q, F. R1 V
A unique entity of male-limited gonadotropin-# e4 n# e9 M# D
independent precocious puberty, which is also known) Z8 E2 j8 I: R1 ?% J8 e
as testotoxicosis, may cause precocious puberty at a8 D( g8 P+ I1 i
very young age. The physical findings in these boys$ V6 ?1 B+ [/ Z5 w2 q" x
with this disorder are full pubertal development,
2 z3 p( r4 v% \7 P7 d& Z7 lincluding bilateral testicular growth, similar to boys0 f+ D2 o7 S, O5 [0 D7 n5 K
with CPP. The gonadotropin levels in this disorder
; F4 O6 X7 i9 K  T! Ware suppressed to prepubertal levels and do not show
: z7 n% r+ t8 {pubertal response of gonadotropin after gonadotropin-
/ u7 m0 p; r5 ?) X# a$ Rreleasing hormone stimulation. This is a sex-linked  P9 B0 w7 j0 c! ~0 |! Z# h4 t* s
autosomal dominant disorder that affects only6 c$ U8 V4 F4 h: H& v
males; therefore, other male members of the family  B7 \4 x% y8 x* X
may have similar precocious puberty.3
) f& r- A: f. Z# g" X& }In our patient, physical examination was incon-
* G/ U1 ~+ V2 o' x% |; U. T6 isistent with true precocious puberty since his testi-
- T3 f4 W+ y+ x3 ]1 Acles were prepubertal in size. However, testotoxicosis
7 ?1 T" l  I: _& J" I9 }was in the differential diagnosis because his father
0 H7 r/ R: U! c- d# t$ \1 Vstarted puberty somewhat early, and occasionally,
# j3 p" @3 u3 I' B! v% G! w. ]( ]testicular enlargement is not that evident in the% W) }0 A' s  d8 C# b5 U% X
beginning of this process.1 In the absence of a neg-# c1 _! D( W, {  c
ative initial history of androgen exposure, our. Y# O9 Q, U8 y0 e
biggest concern was virilizing adrenal hyperplasia,8 P+ w9 u5 S. U6 h% V  o0 a+ m
either 21-hydroxylase deficiency or 11-β hydroxylase
/ i: M. Z+ b5 R; ]deficiency. Those diagnoses were excluded by find-
, e5 b( y! m4 b/ `ing the normal level of adrenal steroids.
  l1 I* d; ]9 ]- `* w. }9 ]& \/ \The diagnosis of exogenous androgens was strongly) {$ T" ~7 m- |6 F
suspected in a follow-up visit after 4 months because
  p5 _5 p0 R& O7 _+ U, l, v0 bthe physical examination revealed the complete disap-$ Z, M& |2 I. P# O0 ~
pearance of pubic hair, normal growth velocity, and+ P% x. S( Z# t8 [8 l5 z! k/ X
decreased erections. The father admitted using a testos-
0 ?, D8 D" ]8 X3 Q2 w5 o" ~terone gel, which he concealed at first visit. He was
3 m1 ?( I9 a3 K4 xusing it rather frequently, twice a day. The Physicians’+ Z2 u. k+ J4 D
Desk Reference, or package insert of this product, gel or  _& L( b8 D. S) {
cream, cautions about dermal testosterone transfer to/ T5 d0 m" h: g% x; r5 w
unprotected females through direct skin exposure.; m5 m! s2 R! ^  W
Serum testosterone level was found to be 2 times the' U" O# }+ n2 X% O3 v' X, @
baseline value in those females who were exposed to
; Z7 @; w- |5 q1 Neven 15 minutes of direct skin contact with their male6 U& b! B' u& y" R
partners.6 However, when a shirt covered the applica-
4 e; S! q- o9 P5 }tion site, this testosterone transfer was prevented.
5 x$ o" A- f+ M* ?Our patient’s testosterone level was 60 ng/mL,; C; i2 `% T/ y# a8 L' A$ M
which was clearly high. Some studies suggest that
0 ]( x/ q+ e8 `! U: s" i, Ndermal conversion of testosterone to dihydrotestos-
. n4 x2 b0 D+ }1 n2 r, L" Iterone, which is a more potent metabolite, is more- V7 m& l' E# Y3 I" W
active in young children exposed to testosterone
# ^0 L/ l! b" m7 z& |* T  ~9 f3 Cexogenously7; however, we did not measure a dihy-
$ G- O% Y  @9 ~: u8 Ddrotestosterone level in our patient. In addition to6 S. E/ x9 |! {
virilization, exposure to exogenous testosterone in/ A+ E# n( Y* c3 H
children results in an increase in growth velocity and1 F' ^2 X3 }2 ^2 ]0 M/ V- E  k
advanced bone age, as seen in our patient.7 S( B8 z+ I$ `& V* k
The long-term effect of androgen exposure during
% w* P  c! d# f! Yearly childhood on pubertal development and final& `! E# ~0 t: S" `0 F1 H2 G
adult height are not fully known and always remain
0 l( G( @1 r8 v0 g  J$ va concern. Children treated with short-term testos-
/ r: ^% ~1 [; H( Gterone injection or topical androgen may exhibit some
0 M$ y* K& Y3 m1 K; G3 x- jacceleration of the skeletal maturation; however, after" W" y8 e3 L. ?3 t3 O
cessation of treatment, the rate of bone maturation
( S6 B, q, N+ h1 p" m( k5 q+ Jdecelerates and gradually returns to normal.8,9! b) b) {* [; K2 ^- R' a4 y
There are conflicting reports and controversy
7 B' z6 g: p, fover the effect of early androgen exposure on adult' h$ W+ C. n/ R8 t
penile length.10,11 Some reports suggest subnormal
- z+ ~7 Y' a3 d( A2 `' padult penile length, apparently because of downreg-
0 P* W5 T* [3 y) F1 Z5 p: T' Oulation of androgen receptor number.10,12 However,5 Z) H% H' p) @9 L
Sutherland et al13 did not find a correlation between
% f7 i$ Q# A+ `childhood testosterone exposure and reduced adult# L- Z4 K7 L" D6 g! }2 w
penile length in clinical studies.
( t6 Z1 v! v2 Y1 J/ ~/ TNonetheless, we do not believe our patient is* {9 X+ ?; N, ^" w
going to experience any of the untoward effects from8 K$ d4 V( J, w5 m; h' ^
testosterone exposure as mentioned earlier because
" ^9 ?3 _7 [% m* l; J9 cthe exposure was not for a prolonged period of time.
# o; d& g/ e* @Although the bone age was advanced at the time of
$ o  T- z5 i8 S8 N" R" m" d& f5 vdiagnosis, the child had a normal growth velocity at- j; V; {, o% i' p0 Y# o  ]/ L/ e& [
the follow-up visit. It is hoped that his final adult
- l7 O7 |7 j; U3 r* {- R3 F  Uheight will not be affected.
6 i* W6 r$ ]& n* ?! QAlthough rarely reported, the widespread avail-
; d0 m8 g* L. Xability of androgen products in our society may7 L; A8 \+ t1 z$ n- a; s$ c8 l  {/ q
indeed cause more virilization in male or female! O( t7 |& @$ K( c& E+ Y1 F/ U( ]
children than one would realize. Exposure to andro-
0 H  G! J1 C& n. |$ Ngen products must be considered and specific ques-, d) \! V3 W( H$ w: \
tioning about the use of a testosterone product or
6 d# n3 e  P1 o% c+ L$ P  K* N% tgel should be asked of the family members during
; q4 u5 G6 k5 Y* a/ Tthe evaluation of any children who present with vir-" _, V' ~' J& v7 P$ f. ]" x
ilization or peripheral precocious puberty. The diag-; t; @" L5 ~4 `
nosis can be established by just a few tests and by
# ]7 b) W; i8 h, mappropriate history. The inability to obtain such a) g5 p& S2 s! O- F" L  |+ O
history, or failure to ask the specific questions, may
9 @5 i" \6 B1 \) _+ }; H9 Sresult in extensive, unnecessary, and expensive( V* r* Q& E0 c% O2 _: {# m
investigation. The primary care physician should be
) I. Q0 F. G$ a3 S4 m& baware of this fact, because most of these children1 q4 `0 U! j. J6 e' }6 a3 S
may initially present in their practice. The Physicians’# s; r; ~& y4 w) g9 z' C
Desk Reference and package insert should also put a
. u# j. Q8 O+ Z. G$ ?! cwarning about the virilizing effect on a male or. z: k" f' U) d& B% w" u
female child who might come in contact with some-
3 G. Z* ?1 K  X: ]9 n% K  {one using any of these products.6 ]! {- v# N$ |+ L% @
References
' x# G: u6 x; C& u# w& d* M1. Styne DM. The testes: disorder of sexual differentiation6 B# d4 w# Y5 B
and puberty in the male. In: Sperling MA, ed. Pediatric
* l3 c2 T) A+ x8 m8 Q, MEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 Q! i1 L* a5 J2002: 565-628.
4 j  v" S1 @$ i( Y$ m; _& M8 F2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 ]' j9 R, b2 n, A9 q, g6 r8 ^5 |' G
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old1 t( C2 v* P% ^$ W9 {
Boy Induced by Indirect Topical
- @$ X9 I8 C" K. SExposure to Testosterone
% }. l0 S8 \9 Q+ V- A/ @$ CSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 Y( i* c* y: G% f2 p( H. ?6 Eand Kenneth R. Rettig, MD1
* n; |- e- o1 \# X1 cClinical Pediatrics  }7 j1 g5 V! J+ b0 @
Volume 46 Number 6
7 `" r1 q) U$ b! \& M  f. N6 ZJuly 2007 540-543
$ e& M# W/ V, U5 X8 y2 R8 t© 2007 Sage Publications
( f+ O$ c, m7 ^" J3 X' E10.1177/0009922806296651& n( o- h$ b$ {
http://clp.sagepub.com" c& y: E' u" u+ p4 E
hosted at
: _) y- t4 [' z" ghttp://online.sagepub.com$ w+ L( u* g8 e1 u
Precocious puberty in boys, central or peripheral,
' U" O! Q' h  Q; T: V2 Q$ f5 `5 _is a significant concern for physicians. Central
) Q2 u" m7 q/ H: z, Rprecocious puberty (CPP), which is mediated
# v7 F3 m! j! h7 Gthrough the hypothalamic pituitary gonadal axis, has  }# B1 `' E0 G& T6 r; c
a higher incidence of organic central nervous system  F1 @; H$ S2 I. ?
lesions in boys.1,2 Virilization in boys, as manifested
: m0 u8 e0 M7 \) a% W0 O/ _" uby enlargement of the penis, development of pubic
% @# H- Q0 ~0 ?7 Ohair, and facial acne without enlargement of testi-
" r" [. J4 U# ^3 M0 Z' Z  ocles, suggests peripheral or pseudopuberty.1-3 We
* n& k0 O/ D! ^report a 16-month-old boy who presented with the
1 b; g9 m# i& x1 x4 u5 a, B3 penlargement of the phallus and pubic hair develop-7 B  ?" K5 X, D' w
ment without testicular enlargement, which was due
/ r) q" E( w; Zto the unintentional exposure to androgen gel used by* X, d2 y( \* |2 }7 a+ i
the father. The family initially concealed this infor-
, ], H! O' J$ B$ vmation, resulting in an extensive work-up for this
2 z6 i# B* z- n9 achild. Given the widespread and easy availability of
* N; b* J/ n* s) I3 d; j8 w" Ntestosterone gel and cream, we believe this is proba-
7 k9 {! D) V: N  y# ^; ]9 Xbly more common than the rare case report in the
4 G9 S' B4 ]& W- Q- ~, Zliterature.4$ I2 L" N$ l# M; E' d, D+ L+ ?
Patient Report/ L0 V/ {+ E) C9 V
A 16-month-old white child was referred to the
: X9 E4 ?" E$ \% A9 f* Iendocrine clinic by his pediatrician with the concern2 ]! M* r6 u( F6 g& N
of early sexual development. His mother noticed
; O4 L) h, n8 c0 }; f8 Ulight colored pubic hair development when he was5 A1 }: H5 X5 |0 N) F1 t
From the 1Division of Pediatric Endocrinology, 2University of
, x7 p, X" E+ `6 T' C5 kSouth Alabama Medical Center, Mobile, Alabama./ C2 M. m+ p* T: w; e
Address correspondence to: Samar K. Bhowmick, MD, FACE,4 O5 G# L. P* U  A0 A' Z, k; N
Professor of Pediatrics, University of South Alabama, College of* J% J4 k; f2 I! L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 J% d& R! B3 v: K3 h- ~! Ie-mail: [email protected].* [0 e0 T( h0 V/ v( v0 S
about 6 to 7 months old, which progressively became. V2 r- s7 _2 S# Y. j) D: F
darker. She was also concerned about the enlarge-
% y$ q- y& _4 Q% s$ V1 J9 dment of his penis and frequent erections. The child
  ]; r5 m* X( zwas the product of a full-term normal delivery, with% Z! E  j: k, M0 }# ?$ Q: N
a birth weight of 7 lb 14 oz, and birth length of
3 e2 P& E& ]( F6 J& Y20 inches. He was breast-fed throughout the first year* }7 S& s( v% f5 x* p$ [  }
of life and was still receiving breast milk along with  C$ R1 p: v2 z  ]6 z* e+ |
solid food. He had no hospitalizations or surgery,
/ j- X7 R( A0 B, f' ^. Land his psychosocial and psychomotor development* c/ G, u3 D+ D8 W
was age appropriate.! S0 ], R; B9 o5 O: }" f& ]2 `5 h$ M
The family history was remarkable for the father,
2 ]0 ~. e2 U: B% Wwho was diagnosed with hypothyroidism at age 16,
6 Y8 L2 Z* s; E% X/ vwhich was treated with thyroxine. The father’s
( U% @% a4 i: P6 h6 T  jheight was 6 feet, and he went through a somewhat
  Z) Z% o0 S) A, ?- e! E) f6 N& _( oearly puberty and had stopped growing by age 14.
/ B* s$ Y4 @1 }7 @' {7 M, JThe father denied taking any other medication. The$ t) t+ T. }3 Q) T' V" }( T
child’s mother was in good health. Her menarche0 N, M  S: @& p- b+ H2 d
was at 11 years of age, and her height was at 5 feet
6 ^0 u: b& O  ]5 inches. There was no other family history of pre-
. q( c4 M7 t3 O0 [cocious sexual development in the first-degree rela-4 Z9 _5 U& o' ~, S* _3 G6 v9 N9 [
tives. There were no siblings.; f4 U6 a- E' |/ K4 k! P. ]  K
Physical Examination
% b3 s2 P8 t) iThe physical examination revealed a very active,9 }) z: W+ t  \
playful, and healthy boy. The vital signs documented$ V, G, z7 K. w7 P
a blood pressure of 85/50 mm Hg, his length was. Q" G  M4 Z+ d7 _3 u& C
90 cm (>97th percentile), and his weight was 14.4 kg4 u; X" T9 z2 Y$ f/ \7 o7 f( v
(also >97th percentile). The observed yearly growth
' F; z+ H" B# X8 Z% r1 Bvelocity was 30 cm (12 inches). The examination of
4 e3 ~: J/ T7 P' J  w! gthe neck revealed no thyroid enlargement.
. `; u7 J* o9 r! {4 x- e" M- D* AThe genitourinary examination was remarkable for
( J- @3 |1 c; Jenlargement of the penis, with a stretched length of, e; r3 U) b$ S9 ]3 h0 @- P
8 cm and a width of 2 cm. The glans penis was very well6 `% ~1 y7 w# M5 @; w8 }
developed. The pubic hair was Tanner II, mostly around, q0 t7 ]# {) ^: [
540$ [1 B5 P8 ~! ^2 `8 ]/ D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! E9 ~) H# g, T( xthe base of the phallus and was dark and curled. The* o' M( \3 k% E' S
testicular volume was prepubertal at 2 mL each.
4 d; E/ y2 N5 j5 f$ r6 @The skin was moist and smooth and somewhat% p! O% u) H1 x3 A5 t
oily. No axillary hair was noted. There were no# G" @3 ]9 c8 @3 X. g
abnormal skin pigmentations or café-au-lait spots.- _7 T' k) a# k- d( i6 X
Neurologic evaluation showed deep tendon reflex 2+
+ Y7 n& y. C' ~bilateral and symmetrical. There was no suggestion
/ L/ J2 z& X7 R& A' \1 Rof papilledema.8 ~& T- w; o, F3 Z7 S1 W* @+ i+ y
Laboratory Evaluation# Z5 C) |) [" k2 q+ Z
The bone age was consistent with 28 months by: t" X6 E, R$ @* q' B, O
using the standard of Greulich and Pyle at a chrono-
1 @  x& [/ _/ d* Z2 e) m/ rlogic age of 16 months (advanced).5 Chromosomal
. T7 `4 D2 g; }; X1 Fkaryotype was 46XY. The thyroid function test2 m. V8 g5 k" }' v, I7 ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-% `$ U" R# T! `2 q4 `
lating hormone level was 1.3 µIU/mL (both normal).8 X7 }- O0 X* }& W
The concentrations of serum electrolytes, blood1 Q: ~* |& Y6 z5 y5 W
urea nitrogen, creatinine, and calcium all were: a" a; M' T. |5 O1 Z; J
within normal range for his age. The concentration8 ~2 B, z% }) g( a
of serum 17-hydroxyprogesterone was 16 ng/dL
) G, D' e5 n3 P$ g5 p5 t& B(normal, 3 to 90 ng/dL), androstenedione was 20
  F+ G# r9 j2 b/ ?8 Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# ?1 S! F7 M" z% M  E" I" Mterone was 38 ng/dL (normal, 50 to 760 ng/dL),, Q% S- m8 q, [/ o" C1 N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* O; G, u. ~4 t6 L. l! s' a" g  s& v
49ng/dL), 11-desoxycortisol (specific compound S)+ r9 E' A/ D  v! a
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 _2 \) ~$ s* t6 x* u- d- r' a
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 V8 G- v# T# H! K. @1 C& Q2 ?: n
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! M" q; ~8 t, a2 H( X
and β-human chorionic gonadotropin was less than
/ Q: g+ {) W- P0 G5 mIU/mL (normal <5 mIU/mL). Serum follicular! S) f" W* s0 t2 t
stimulating hormone and leuteinizing hormone
  V1 \8 v2 @1 v+ f3 P( W% }concentrations were less than 0.05 mIU/mL
9 l/ F2 b( q; \(prepubertal).9 d! Y( ]7 @2 P, H; F
The parents were notified about the laboratory$ _9 x  `9 _  u6 P, F, W% g
results and were informed that all of the tests were
! i; {# Q: C) ]' B; g& F1 ynormal except the testosterone level was high. The* f) v% [- G1 e! G: C+ u
follow-up visit was arranged within a few weeks to
5 s. }* t& q" hobtain testicular and abdominal sonograms; how-- m' S3 J7 a2 g) M* f% g& @
ever, the family did not return for 4 months.
1 C) h/ ]! E7 k8 RPhysical examination at this time revealed that the9 X& X' W, I- V3 e3 r8 x, f% Q
child had grown 2.5 cm in 4 months and had gained/ `1 x( L* }) m/ g0 L
2 kg of weight. Physical examination remained
- q8 V" x" h7 B) vunchanged. Surprisingly, the pubic hair almost com-
& T+ ~, G$ D4 U0 I7 F/ @pletely disappeared except for a few vellous hairs at( Q! a. X* Y3 I% p% ~1 W  r
the base of the phallus. Testicular volume was still 2
* }0 H, Z" X0 B2 @' v& _8 L6 VmL, and the size of the penis remained unchanged.
5 I0 `/ E$ V; m5 n& c' xThe mother also said that the boy was no longer hav-
' d7 @* |! S! K4 c% X+ ving frequent erections.3 s! H' T5 q" |$ r
Both parents were again questioned about use of! O$ s9 c% T+ b! Q
any ointment/creams that they may have applied to
$ G5 d9 i& ]! l+ R9 T# ^% H/ Othe child’s skin. This time the father admitted the+ E( V0 W: s: z9 o. \" C  q
Topical Testosterone Exposure / Bhowmick et al 541
; ?9 ~8 Y+ {! b) J/ m. Duse of testosterone gel twice daily that he was apply-
: b5 P. x2 r) U1 T1 f: King over his own shoulders, chest, and back area for
% d/ \5 _5 @; Ja year. The father also revealed he was embarrassed" [# Y$ I+ H) q' {4 j' B1 v# B  T, ~
to disclose that he was using a testosterone gel pre-
8 h" I/ W1 x+ g' ^/ L* ?& m1 Hscribed by his family physician for decreased libido
! k9 f* M9 O* T# r/ x) Csecondary to depression.
8 s; \8 l( L) L' T0 T) qThe child slept in the same bed with parents.! R4 |5 M& G* K9 D( L; Y
The father would hug the baby and hold him on his; ?( c) \( ~) Y' d! v$ K5 }
chest for a considerable period of time, causing sig-
& O5 ]" [$ t8 |1 k3 Q. cnificant bare skin contact between baby and father." t5 e" }$ w& i. ~8 o0 W
The father also admitted that after the phone call,6 z. @, ^  }( x. b- f+ j
when he learned the testosterone level in the baby9 ^# \& e8 i. Y
was high, he then read the product information
7 L& ^4 z) P6 b# L1 e% spacket and concluded that it was most likely the rea-
7 P, E: L$ |0 Y3 {son for the child’s virilization. At that time, they' V% ~: J; r( t$ D+ t' N# W3 U
decided to put the baby in a separate bed, and the
3 B! J  j( f# Ifather was not hugging him with bare skin and had6 p9 u6 L; J1 y% K' J7 D! B
been using protective clothing. A repeat testosterone
  T" a& Q: Z* Z) g$ K& ctest was ordered, but the family did not go to the
4 I' Z- G0 d4 a9 T( blaboratory to obtain the test.: N0 a' @, O: W2 V1 z: O' |9 m) u
Discussion
4 ~, J% Y: V. {: u+ F9 rPrecocious puberty in boys is defined as secondary+ \6 K' `* z( E, I4 {* Q2 s
sexual development before 9 years of age.1,4
* D$ q# R! d; _9 z8 k2 QPrecocious puberty is termed as central (true) when
8 q# l+ g% A& p; A7 ~8 Sit is caused by the premature activation of hypo-
  ]9 A$ P) k; ethalamic pituitary gonadal axis. CPP is more com-1 k4 T5 L1 I( [  T5 A4 i
mon in girls than in boys.1,3 Most boys with CPP2 i) J4 S  w* ]" [8 z
may have a central nervous system lesion that is' ^7 d+ b* a- e: K+ y4 L
responsible for the early activation of the hypothal-2 j1 W- s7 T) {$ ?  t; E( f* O
amic pituitary gonadal axis.1-3 Thus, greater empha-! L/ _* I$ K3 W' R1 l2 e4 [# Q0 `
sis has been given to neuroradiologic imaging in5 H( g1 m# v- I1 \
boys with precocious puberty. In addition to viril-
; P' ?2 T* v+ m$ i; r, k# Q' wization, the clinical hallmark of CPP is the symmet-* k% J7 w& z, \6 ~5 h* }& K6 \
rical testicular growth secondary to stimulation by
. G: {6 k' T: n; V8 C$ m. ~gonadotropins.1,3* ?/ H9 v% E( m
Gonadotropin-independent peripheral preco-
9 i# c2 E$ K( l  C9 U' icious puberty in boys also results from inappropriate, c& ~5 H" f" ~( N6 Z: E
androgenic stimulation from either endogenous or. g1 n3 T: o1 O* t' Q
exogenous sources, nonpituitary gonadotropin stim-
$ w9 T+ W0 Z" d) fulation, and rare activating mutations.3 Virilizing2 e- U8 h! e7 f8 L' W
congenital adrenal hyperplasia producing excessive/ E5 z* S# G1 _  M$ u3 C& M
adrenal androgens is a common cause of precocious/ A& C3 L3 W9 }5 K9 ?
puberty in boys.3,4
$ F7 U- b& q1 _- C+ y( EThe most common form of congenital adrenal
6 F1 c* n* [3 k* T1 _hyperplasia is the 21-hydroxylase enzyme deficiency.# z9 ?' a( ?2 T5 E, L- D
The 11-β hydroxylase deficiency may also result in
- \9 K$ R( b8 @  R) ^excessive adrenal androgen production, and rarely,! `# s" x! R- S2 S
an adrenal tumor may also cause adrenal androgen
- a% C4 g4 N0 R( h8 m6 k7 Lexcess.1,3; Z' R, }" U, O5 D1 F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% U! U  f4 u$ ^9 e% @; C5 y4 W542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ I3 A( f" A1 \* eA unique entity of male-limited gonadotropin-
0 o/ q* O5 ^. u9 }& s/ tindependent precocious puberty, which is also known
4 f3 w! j) N2 Q# R# u$ s: @' g3 bas testotoxicosis, may cause precocious puberty at a
& z$ L8 U* S$ f+ ]very young age. The physical findings in these boys, F& w  n: ?5 @& G) B. j. C( _: h
with this disorder are full pubertal development,4 g  C' T4 f% [! }
including bilateral testicular growth, similar to boys
2 F& U0 B+ \% c- h% Vwith CPP. The gonadotropin levels in this disorder
& ^9 t0 \  ^) |: [' u5 m; ~are suppressed to prepubertal levels and do not show& k" T! {2 y* G* m/ \
pubertal response of gonadotropin after gonadotropin-
6 l) c+ E. x6 M) f. z$ ^: }* |releasing hormone stimulation. This is a sex-linked  R- v0 [+ R( L' K
autosomal dominant disorder that affects only+ d2 W  W1 x0 J2 ~1 `$ V) Q/ |( c
males; therefore, other male members of the family' g1 `1 }, X8 i* k7 M( b. E
may have similar precocious puberty.3
) U/ l0 k: m, |+ [In our patient, physical examination was incon-
4 ~3 `2 Q; j. asistent with true precocious puberty since his testi-# G  Q- Z( ?$ ?  Z1 E
cles were prepubertal in size. However, testotoxicosis
$ s& U$ q2 S& g0 D* twas in the differential diagnosis because his father1 ^- g8 r% R0 ]8 u+ Z: z3 ~4 d, U
started puberty somewhat early, and occasionally,) f) j0 e7 i0 D. D  h
testicular enlargement is not that evident in the
1 Q# c4 O) B/ P) F) z. |beginning of this process.1 In the absence of a neg-5 N3 j7 O; ]  s+ T! u+ S
ative initial history of androgen exposure, our
) |1 j5 J( T0 n+ cbiggest concern was virilizing adrenal hyperplasia,
$ d! x' N  b' {9 keither 21-hydroxylase deficiency or 11-β hydroxylase
9 V$ |+ B, D$ Q' }: {5 Jdeficiency. Those diagnoses were excluded by find-
$ Y; E6 O$ ~" M5 X: ?/ ging the normal level of adrenal steroids.
. t8 i- S+ x2 o* o' cThe diagnosis of exogenous androgens was strongly
( K0 C6 v2 b$ f: w$ V8 d  n; lsuspected in a follow-up visit after 4 months because# R8 n. c# Q7 [  V
the physical examination revealed the complete disap-
" E2 s' ^& g& x- @# K0 Lpearance of pubic hair, normal growth velocity, and
9 s7 _! [( F0 @. w+ D5 o1 @decreased erections. The father admitted using a testos-7 N, \8 j" c1 l' P8 u3 V3 d' [
terone gel, which he concealed at first visit. He was; }3 k  Q  Y  t+ v( M4 c
using it rather frequently, twice a day. The Physicians’3 P* ?/ J# D0 U
Desk Reference, or package insert of this product, gel or
' m  b- T/ }# ?" jcream, cautions about dermal testosterone transfer to
/ Y; R/ Z; s, ?' d4 Gunprotected females through direct skin exposure.
$ {5 M& c' O9 B8 V' H3 ^6 @8 QSerum testosterone level was found to be 2 times the1 h2 G/ R  s, {* p; U; M9 i
baseline value in those females who were exposed to
( e! Z' [+ X  d4 {even 15 minutes of direct skin contact with their male
9 P( f7 D2 ?- X4 t' Q, ^partners.6 However, when a shirt covered the applica-
! F: e( T( a* r2 W" w. s6 Otion site, this testosterone transfer was prevented.0 f9 z* N4 r1 L# f% ^6 `
Our patient’s testosterone level was 60 ng/mL,4 j8 c2 c6 h( X, c! ^9 f
which was clearly high. Some studies suggest that1 k* Y, Z- i- i, j/ x
dermal conversion of testosterone to dihydrotestos-
6 a; T( l4 O) |8 y. Z) N; pterone, which is a more potent metabolite, is more
# W) d6 O& j# n( z+ kactive in young children exposed to testosterone6 U; P& f$ e1 w# s5 }1 P
exogenously7; however, we did not measure a dihy-& x% ?. Q+ K2 E+ q) f5 `2 Z: a
drotestosterone level in our patient. In addition to
1 J( M6 _8 ^* `4 vvirilization, exposure to exogenous testosterone in
1 [$ C  d. d  i9 _5 F( Bchildren results in an increase in growth velocity and
8 X4 w% m& |9 q! V6 hadvanced bone age, as seen in our patient.! h- ~" \" r6 R
The long-term effect of androgen exposure during
+ P5 ~( N: V( hearly childhood on pubertal development and final2 K" J( ~4 T4 e# [
adult height are not fully known and always remain" |% g) v$ H6 s4 Q/ `4 [7 W
a concern. Children treated with short-term testos-
$ B# t" j' \/ b) ~# F2 D+ vterone injection or topical androgen may exhibit some& ~5 L  q( b0 E! E2 a3 |& x6 {
acceleration of the skeletal maturation; however, after
. E, r0 w/ }# o7 Fcessation of treatment, the rate of bone maturation
7 R" F) K/ Z. \1 Cdecelerates and gradually returns to normal.8,9
: G# f. m$ \7 t2 T/ y4 _% ^1 oThere are conflicting reports and controversy
6 e) ?' F( ?! e& oover the effect of early androgen exposure on adult
( q- w+ ~" k5 @8 D) ppenile length.10,11 Some reports suggest subnormal
8 \' Z+ u0 _- R, qadult penile length, apparently because of downreg-" W( b% D; L3 t# B; A- z4 P9 W5 M
ulation of androgen receptor number.10,12 However,( u. M& g. u, Y3 ~1 r4 h" F
Sutherland et al13 did not find a correlation between
$ J. @9 g7 }; tchildhood testosterone exposure and reduced adult" e- r0 |( Q, ]# g, [
penile length in clinical studies.
% X# u  n/ N8 q3 SNonetheless, we do not believe our patient is
, Q6 x3 V$ d  `: u# J) Jgoing to experience any of the untoward effects from
. I; E! y  x3 m" B! w. X% |testosterone exposure as mentioned earlier because
1 C. W* K. Z, e, I# T0 P2 hthe exposure was not for a prolonged period of time.
* N6 `2 W- J. ?4 w/ f, sAlthough the bone age was advanced at the time of/ ^1 M" s0 u$ @- ?& {7 b3 y4 Q
diagnosis, the child had a normal growth velocity at
( }( H$ p) o( ]" e: m& S9 W, Bthe follow-up visit. It is hoped that his final adult# H, v% w/ a$ O
height will not be affected.6 x6 t& r, N/ n; K8 t$ ~
Although rarely reported, the widespread avail-0 J% D- D  A( z$ n
ability of androgen products in our society may
4 O' P- Q8 [  y0 M8 p. `% Zindeed cause more virilization in male or female
7 b, p, A8 c4 O6 l1 I7 ychildren than one would realize. Exposure to andro-
" U! s8 {  x6 Z$ `, zgen products must be considered and specific ques-
9 [8 B& j: H2 L" xtioning about the use of a testosterone product or+ q8 Z# o# J9 B: p7 C
gel should be asked of the family members during% y1 v, E4 Q' f" k/ @9 p8 G* e* p5 [
the evaluation of any children who present with vir-
) w  }1 M: x6 j) l5 d2 lilization or peripheral precocious puberty. The diag-
  @  s' G' M# y0 lnosis can be established by just a few tests and by8 N. \* J0 y4 b; {. @: M1 @
appropriate history. The inability to obtain such a
# N6 e+ _6 ~: I& i( y; h7 vhistory, or failure to ask the specific questions, may6 L# }3 Q/ l: N0 o
result in extensive, unnecessary, and expensive
" ~5 @/ [% Z' C( h  L5 Jinvestigation. The primary care physician should be
" G0 S+ _, y$ N# U/ v, Paware of this fact, because most of these children
- s" {! P& A2 q) w" d: ^  a' Dmay initially present in their practice. The Physicians’
* q% K. ?6 i$ k+ k* k* qDesk Reference and package insert should also put a. Z, [, [& h% a4 F
warning about the virilizing effect on a male or( A5 b- b! z2 i6 v  }+ y
female child who might come in contact with some-  q7 f% r" Y' B, I7 t5 c9 P
one using any of these products.) M5 V! A9 p: R" E
References
* C* e1 K8 Z/ S# Y$ q! e( b1. Styne DM. The testes: disorder of sexual differentiation4 q, V, Q) |: x5 [9 B. ^* [
and puberty in the male. In: Sperling MA, ed. Pediatric0 [: _& o' l0 A" s; m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% }# l3 G: k+ @9 ]
2002: 565-628.
6 \" i0 k" w1 i9 \5 t2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ I' _1 G, b4 {8 qpuberty 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

/ V) P4 L. P1 N! M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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