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Sexual Precocity in a 16-Month-Old
- D2 }( y3 I% K; K! x" KBoy Induced by Indirect Topical
& R" y" n/ V: o" nExposure to Testosterone
. }# D7 U# Y2 A7 Z% f: f% WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ O# y+ y$ h3 X6 e# ^* r3 Y4 Q$ x
and Kenneth R. Rettig, MD1
3 C9 q( L+ F+ q8 zClinical Pediatrics% l; V- l" ]  m% X! j( p! A. l
Volume 46 Number 6
; N& i8 o3 e( vJuly 2007 540-543" ~6 t3 l3 i+ }; W" b9 W* m( [
© 2007 Sage Publications( a& S1 L, N0 L* l/ z$ l: Z! r
10.1177/0009922806296651! Y# c3 [3 t0 C0 K! Y% Q4 \
http://clp.sagepub.com! I0 s9 ]& M* x. }5 Y
hosted at  a7 {/ s; R8 ~+ L
http://online.sagepub.com! J3 h3 ]/ ?+ G: c7 l
Precocious puberty in boys, central or peripheral,9 z# z1 T& }3 |* @. U
is a significant concern for physicians. Central
4 B# k& D  ~6 x, D1 @5 A. Cprecocious puberty (CPP), which is mediated
  c  @- s9 ~+ Q5 nthrough the hypothalamic pituitary gonadal axis, has
$ p2 m2 h( G2 Q  N/ m+ m1 Ya higher incidence of organic central nervous system
& P5 M2 t+ x5 D% S( V& elesions in boys.1,2 Virilization in boys, as manifested8 |1 e7 m# g% e  P" z2 |
by enlargement of the penis, development of pubic. o) `# M' F" {5 q9 g
hair, and facial acne without enlargement of testi-& ?' o9 S: y+ W  B1 J+ |
cles, suggests peripheral or pseudopuberty.1-3 We+ N7 v3 Q' M) N* W5 B
report a 16-month-old boy who presented with the
1 Q% P4 L1 ]; q5 u- wenlargement of the phallus and pubic hair develop-4 w) @# p# b. y' L! l6 G6 `
ment without testicular enlargement, which was due/ S' V( W$ n2 v2 @+ u* Z
to the unintentional exposure to androgen gel used by1 M6 u- r% [2 _# s6 ]2 d
the father. The family initially concealed this infor-
4 r- O) Z7 m& y/ h7 tmation, resulting in an extensive work-up for this/ E' k* E% D2 s
child. Given the widespread and easy availability of1 p' [  W( G; x4 p5 G
testosterone gel and cream, we believe this is proba-
0 v1 V' h* ~- c4 W  {1 ybly more common than the rare case report in the
" z) c" j: s( o6 kliterature.4% J" O0 N( {. m1 c" c0 @
Patient Report$ z. j4 C! \; Y; [. t
A 16-month-old white child was referred to the. d) ?0 L" q. G" Z  l$ z: o# _
endocrine clinic by his pediatrician with the concern
/ O( k4 O% M7 Q! ^/ r* }of early sexual development. His mother noticed3 o" a9 r1 u# k3 `# N4 i
light colored pubic hair development when he was
% V1 g, ]5 L9 L; i. W* o' HFrom the 1Division of Pediatric Endocrinology, 2University of
! m9 w* n. i" T4 a: F5 w/ nSouth Alabama Medical Center, Mobile, Alabama.
; P& y' r2 r. l; p$ y% X. SAddress correspondence to: Samar K. Bhowmick, MD, FACE,' C0 Z3 O% {& W) ?
Professor of Pediatrics, University of South Alabama, College of* x5 a# \3 V- }! F. Q6 S* n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! U; H" i0 m. m) a; Z2 M7 ]e-mail: [email protected].
. [, P' t' I3 B0 X, Zabout 6 to 7 months old, which progressively became9 Z" M( b7 b' |% d4 b$ |
darker. She was also concerned about the enlarge-; o& {2 Z; h- d
ment of his penis and frequent erections. The child2 B9 U! V( B- x' I/ a* F
was the product of a full-term normal delivery, with! Z2 N2 t' U7 s$ j2 S
a birth weight of 7 lb 14 oz, and birth length of
; s, f" b, q) S) G20 inches. He was breast-fed throughout the first year
# X% X/ B; @/ ?! M+ mof life and was still receiving breast milk along with
" t# r4 V5 C7 n0 d; w: _1 O' h0 ?solid food. He had no hospitalizations or surgery,7 d- i1 {# d- G" x. S2 D
and his psychosocial and psychomotor development0 `1 k% Q% q4 \" g# Z
was age appropriate.0 l5 s4 W) o* D+ O$ x  R
The family history was remarkable for the father,
1 \+ v6 H. P6 L* T/ t4 h. awho was diagnosed with hypothyroidism at age 16,! f7 R; Y0 G+ c  r* `7 B* {% ^
which was treated with thyroxine. The father’s( j& G5 \# p8 u3 O& R/ `* Y
height was 6 feet, and he went through a somewhat6 a3 I* R2 H' M
early puberty and had stopped growing by age 14./ t# g: N9 d2 v1 G- o1 J
The father denied taking any other medication. The4 i0 T7 i/ X3 e7 e
child’s mother was in good health. Her menarche
+ L* m* r0 t/ U3 dwas at 11 years of age, and her height was at 5 feet
5 j: o( G7 f$ d7 p) n2 r5 inches. There was no other family history of pre-7 ~" ?) V6 C% T8 ]
cocious sexual development in the first-degree rela-2 t$ E/ I+ M6 h" [+ d, k
tives. There were no siblings.
# |( J! V+ h- d. MPhysical Examination
: s  g9 {* }3 `% z3 d( iThe physical examination revealed a very active,
9 q' K5 M% V" k5 i+ D0 qplayful, and healthy boy. The vital signs documented- o  i1 k3 {: C5 v9 B
a blood pressure of 85/50 mm Hg, his length was5 X+ b! Z! E4 J; r
90 cm (>97th percentile), and his weight was 14.4 kg7 u6 v8 b) q5 |& |- i' o. r8 f* c
(also >97th percentile). The observed yearly growth
5 _6 M% K" G0 ]9 B. Bvelocity was 30 cm (12 inches). The examination of9 `) q7 E* q4 k4 C
the neck revealed no thyroid enlargement.
8 O% i- L" X% v( m" i5 u+ ZThe genitourinary examination was remarkable for0 ~! }- v! a: r- C5 V/ w
enlargement of the penis, with a stretched length of  L! r2 z: i8 H- E9 u* B4 g
8 cm and a width of 2 cm. The glans penis was very well
: w! D: @0 u# t$ k  [* pdeveloped. The pubic hair was Tanner II, mostly around7 T% m6 Z  ]2 W4 l0 w& k9 t4 w: D# `
5402 ?7 C0 H2 a  \# u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( A4 v0 M, O& c5 M; Vthe base of the phallus and was dark and curled. The) |# Y6 f3 [, d/ a* ~- y' G
testicular volume was prepubertal at 2 mL each.- M# d' h, g3 Q
The skin was moist and smooth and somewhat
( q" n( x* F" F4 q, i; p5 J) W( p# }oily. No axillary hair was noted. There were no
0 W3 F: P- d; u# E+ I8 m% |abnormal skin pigmentations or café-au-lait spots./ C% p0 `5 o4 K4 c: P
Neurologic evaluation showed deep tendon reflex 2+
, j7 w* e  n: y6 J0 ~bilateral and symmetrical. There was no suggestion- l, l1 W$ {) }- F
of papilledema.6 N& |! S2 H3 b( E* `( W
Laboratory Evaluation
4 J2 g8 I( z+ a( a' _The bone age was consistent with 28 months by. o- M& x) b2 }( c' T8 o
using the standard of Greulich and Pyle at a chrono-% N: p. b; s! r' j, O
logic age of 16 months (advanced).5 Chromosomal- u/ m2 J, x9 p9 Q, @7 e8 p7 H( G
karyotype was 46XY. The thyroid function test! B9 _$ O- @4 O2 a3 T( m+ q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: d5 C" Z* C# Z9 O
lating hormone level was 1.3 µIU/mL (both normal).
( F: [2 U1 [' u! F. lThe concentrations of serum electrolytes, blood. t$ N( o3 @& c3 g1 t: Z- B7 W; Z
urea nitrogen, creatinine, and calcium all were3 M% [- ^* U7 S8 }3 M- K
within normal range for his age. The concentration$ d% T: Q8 c3 p1 C, H8 @
of serum 17-hydroxyprogesterone was 16 ng/dL& ]; G  E6 R% M; }# d. l
(normal, 3 to 90 ng/dL), androstenedione was 20
$ s) K+ O, _- `ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 p* D; [% ]! R( |6 x' t3 b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" Q4 H# j1 a5 w9 G5 j! {desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 r: u+ }5 J  X7 P4 v
49ng/dL), 11-desoxycortisol (specific compound S)
6 P+ g/ ~) H7 ^( Q0 @5 Owas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- Q% U7 |0 {1 f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 N( c6 R, O2 o5 i3 g7 otestosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 F5 y/ U, \: W) A. ]
and β-human chorionic gonadotropin was less than
6 L  ~* k+ M4 e$ Z* L$ s5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 e/ J" x$ @' Q5 g& w$ [stimulating hormone and leuteinizing hormone; S* o: }1 e( R; a
concentrations were less than 0.05 mIU/mL
) C8 h/ x( l- Z+ B" {% u(prepubertal).
8 {& [$ D/ z7 I+ qThe parents were notified about the laboratory3 f- }+ j5 N# Y1 X/ K6 }0 ]
results and were informed that all of the tests were
- Y4 z  _- s8 lnormal except the testosterone level was high. The) {; O: i7 N" F: p4 [
follow-up visit was arranged within a few weeks to7 r- |: K0 k( k5 [7 B# [3 w
obtain testicular and abdominal sonograms; how-
6 y$ l7 ~% H- t8 Dever, the family did not return for 4 months.
8 F) ]5 d) _& t  CPhysical examination at this time revealed that the
7 f$ m2 p9 M2 u) _) r( Xchild had grown 2.5 cm in 4 months and had gained& \; L. r$ }  F
2 kg of weight. Physical examination remained% j* w+ S0 g: n  l
unchanged. Surprisingly, the pubic hair almost com-
' b* @" ^# C) z% j0 S' @1 Tpletely disappeared except for a few vellous hairs at( e+ O. b/ l0 ^
the base of the phallus. Testicular volume was still 2
1 F* N7 B% ^& K' n3 e$ r# ImL, and the size of the penis remained unchanged.* R! _" C3 O1 j; g& }6 g9 R
The mother also said that the boy was no longer hav-
: I! ~0 J8 H: O" p' }' iing frequent erections.
5 O: e0 C% a1 ^0 G( ^Both parents were again questioned about use of; x; s+ T( B% b
any ointment/creams that they may have applied to+ e/ z; @* k* u% z. A# B
the child’s skin. This time the father admitted the
+ R# i5 ~% X0 y& B! ], m. d& R0 uTopical Testosterone Exposure / Bhowmick et al 541  W; {0 B: {5 ?/ z- ^- L7 q
use of testosterone gel twice daily that he was apply-
9 K) M1 w, X4 k  b5 _ing over his own shoulders, chest, and back area for/ [* r- H" t1 `3 @% c9 c9 t
a year. The father also revealed he was embarrassed
+ ]- G, H8 n( k" g% p1 |2 @to disclose that he was using a testosterone gel pre-
' k9 J5 g" r/ t$ ~! dscribed by his family physician for decreased libido( c- ?& {$ V/ _2 ~: g
secondary to depression.
" n/ j6 v! b% \% `+ ?2 f5 `The child slept in the same bed with parents.) ^% F$ E/ E1 ]7 Y+ P( |6 R
The father would hug the baby and hold him on his
- x+ R  T% K+ echest for a considerable period of time, causing sig-
( x& [4 d# y0 {2 O9 W9 M' onificant bare skin contact between baby and father.
, e5 p$ `& m6 K9 D' W  K& VThe father also admitted that after the phone call,
& @! d7 g( L9 a& F+ Wwhen he learned the testosterone level in the baby2 R. b& h- x+ n2 C) J0 i
was high, he then read the product information1 i+ T4 o9 F" G" T, |
packet and concluded that it was most likely the rea-
! B( x+ e( Y- U& \! O* E+ Eson for the child’s virilization. At that time, they6 J7 ?$ |% C' ?/ h0 Q, x
decided to put the baby in a separate bed, and the
# V# x0 c/ E1 F6 s* Yfather was not hugging him with bare skin and had
$ E5 e( R. O/ G& I3 f- M- tbeen using protective clothing. A repeat testosterone
- m* F- K4 C# ~' u7 \5 htest was ordered, but the family did not go to the
  u8 d8 B+ x: N( g- Elaboratory to obtain the test.
( k, [3 [  Y& h: rDiscussion8 k+ e+ C, s" A' {. t3 r7 o0 P
Precocious puberty in boys is defined as secondary; V( _; ]% T2 s
sexual development before 9 years of age.1,4
! Y, w. W0 h" g8 cPrecocious puberty is termed as central (true) when) r# ~7 D& x4 @1 n
it is caused by the premature activation of hypo-, ^7 B; z: Y4 q7 H3 x" X/ z: _
thalamic pituitary gonadal axis. CPP is more com-7 Q& @0 n) B% H4 ~$ P* D- k
mon in girls than in boys.1,3 Most boys with CPP
; s- e" i& ~9 r" g+ imay have a central nervous system lesion that is
2 l# B9 p4 g+ D2 hresponsible for the early activation of the hypothal-
2 i( S+ i0 w" I/ p  f# Y, W, Iamic pituitary gonadal axis.1-3 Thus, greater empha-
4 N2 `9 A1 D2 g0 L+ ~; Y* }6 Qsis has been given to neuroradiologic imaging in
5 m5 j9 ]* ]7 V* y8 J( Yboys with precocious puberty. In addition to viril-! C. P" D  g9 _- F  e* J
ization, the clinical hallmark of CPP is the symmet-
$ `5 J6 y- `( c; [( ?% Drical testicular growth secondary to stimulation by
+ R' q6 o0 M+ O1 Z  g7 L) ]gonadotropins.1,3/ D/ z4 A& e) `3 {: O: [6 t3 B
Gonadotropin-independent peripheral preco-
7 L# @6 R+ J8 L" }' M3 x! y) ^cious puberty in boys also results from inappropriate
1 J# a+ l: u4 r: ?' b  J6 `* X1 ^3 |androgenic stimulation from either endogenous or! B* d+ E: P- _6 ~  v/ p1 x
exogenous sources, nonpituitary gonadotropin stim-" b, h# d  ^( S' h4 ^/ A
ulation, and rare activating mutations.3 Virilizing
# ~% Q# C) \9 u- g& P+ ?congenital adrenal hyperplasia producing excessive8 w% C- d2 e! ~4 P$ h
adrenal androgens is a common cause of precocious2 V/ V& q3 D& u
puberty in boys.3,4/ b) X0 }8 F1 z8 I. h/ @8 a
The most common form of congenital adrenal/ ?" [8 z2 I! Q7 @
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ d$ F1 c# Q3 r. _The 11-β hydroxylase deficiency may also result in3 }5 N9 H: e5 D. [% h: t. {! e& w
excessive adrenal androgen production, and rarely,
4 @1 j2 `2 j) c$ Y( k* n! Wan adrenal tumor may also cause adrenal androgen  ^, F# U! v/ ?' v9 P# ^
excess.1,3, `: V- k0 y8 E  \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# p2 l* D" b( V4 Y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; U8 ~: a$ {0 o9 d8 ?2 Z/ X9 R
A unique entity of male-limited gonadotropin-2 ]! D, y: R7 p9 o/ h8 S
independent precocious puberty, which is also known
- E$ j  q$ ~5 T: i2 T+ S1 Gas testotoxicosis, may cause precocious puberty at a
% X$ R0 F* x/ N+ }3 k) x9 S3 N$ bvery young age. The physical findings in these boys
" Y8 s5 j# k% a( q# Xwith this disorder are full pubertal development,& ?6 b3 {; j. M' H$ G( `8 |- D
including bilateral testicular growth, similar to boys+ k- f9 E( U, m' o
with CPP. The gonadotropin levels in this disorder9 k! Q. g7 n- J/ g; M  I1 C! x
are suppressed to prepubertal levels and do not show
( G$ `' Y- V% z0 F5 B/ \, ]pubertal response of gonadotropin after gonadotropin-9 _, t2 u5 ^! z3 K
releasing hormone stimulation. This is a sex-linked
* U) k9 _( w( l9 S3 U, yautosomal dominant disorder that affects only9 m2 N0 K0 T4 {7 N3 U) w6 y0 L
males; therefore, other male members of the family9 ?$ ~8 o/ A+ a8 J5 w
may have similar precocious puberty.3# n* E! G/ q! \
In our patient, physical examination was incon-
& a" s! U: c+ Esistent with true precocious puberty since his testi-4 r3 T% E/ B# w* X! i/ D9 _
cles were prepubertal in size. However, testotoxicosis
* P, F9 ?, W0 O; Q1 ^3 rwas in the differential diagnosis because his father4 a8 Q0 U- P% x% N- B
started puberty somewhat early, and occasionally,
* n# q" @) {' g1 P! b! xtesticular enlargement is not that evident in the
$ F! n! \: r5 z: G5 Hbeginning of this process.1 In the absence of a neg-6 X8 y# W& A- w8 X5 Q+ D
ative initial history of androgen exposure, our
( I9 i+ F$ ~" _+ b; t$ D  nbiggest concern was virilizing adrenal hyperplasia,* ~1 o2 p5 }. l& V
either 21-hydroxylase deficiency or 11-β hydroxylase
% m0 f0 O7 e+ m5 e- S+ Fdeficiency. Those diagnoses were excluded by find-0 }8 P) }4 m8 }# m
ing the normal level of adrenal steroids.2 n2 N5 v: a6 A% L4 v
The diagnosis of exogenous androgens was strongly3 Q* Z! J" I: [7 c& H- e4 q
suspected in a follow-up visit after 4 months because
" L2 r' J8 j0 v  t- G% W7 V  kthe physical examination revealed the complete disap-
/ ?9 ^; L: M% J6 ?- ?7 m' ipearance of pubic hair, normal growth velocity, and! n+ u3 z' m9 f1 j$ }; l8 E
decreased erections. The father admitted using a testos-
/ U; Z, i( \& x$ t7 T9 z* s2 I6 Oterone gel, which he concealed at first visit. He was
* C8 i$ l% d+ _+ m" Ousing it rather frequently, twice a day. The Physicians’& Q5 b3 Y9 x  m. m; y8 c
Desk Reference, or package insert of this product, gel or
. C5 ]. {" B" \; \! x0 S! e* T( Wcream, cautions about dermal testosterone transfer to
/ n/ X5 r* U( U1 L) ~unprotected females through direct skin exposure.* K3 ~! [* S; t) P' q
Serum testosterone level was found to be 2 times the: P, ?4 u, o0 j; C
baseline value in those females who were exposed to
/ p& g( Q. \, W1 J$ w% H5 w% G: qeven 15 minutes of direct skin contact with their male& C6 a, Y7 @" Q% y  W/ a8 j6 W
partners.6 However, when a shirt covered the applica-
4 l7 w! u% ?1 H! d4 Gtion site, this testosterone transfer was prevented.
5 L9 {3 }; r$ Q; nOur patient’s testosterone level was 60 ng/mL,' X& W+ U- K* ^. D$ U3 x2 h
which was clearly high. Some studies suggest that# k6 j; w7 }. ]" ?2 S
dermal conversion of testosterone to dihydrotestos-" a$ Z  S5 R5 F# I* k* b* S" b
terone, which is a more potent metabolite, is more
. L- v& q, C9 j, Q/ a3 u3 Factive in young children exposed to testosterone, e$ f. ]; x/ D7 ]. S# ?3 h# p: W
exogenously7; however, we did not measure a dihy-
* _* `2 ~+ ~9 N* p; @! |  g( Qdrotestosterone level in our patient. In addition to
% c9 Q3 X" w, \: mvirilization, exposure to exogenous testosterone in/ n( B' g/ z' g( V, G/ Z
children results in an increase in growth velocity and
$ N0 H6 P  o! K* c: a1 |# Z6 v$ Ladvanced bone age, as seen in our patient.
' d6 U! G7 T! C3 I  sThe long-term effect of androgen exposure during
+ ?- w7 q9 k' g) W. T0 v+ \" |- Cearly childhood on pubertal development and final
8 r) V$ Q# W6 o$ z0 wadult height are not fully known and always remain  W2 Z! {6 S0 i% W( B- t# v# P% P) v0 |
a concern. Children treated with short-term testos-' x3 c  S( r% j$ B7 A! w+ d
terone injection or topical androgen may exhibit some, R: W  }' k0 J  F' K" J- k
acceleration of the skeletal maturation; however, after1 d9 s! M3 }! Y5 ]% g. \5 A
cessation of treatment, the rate of bone maturation, W7 o4 c1 \8 z  M. H
decelerates and gradually returns to normal.8,9
) ^% j$ u8 `# \5 a3 m1 f. k3 g2 wThere are conflicting reports and controversy' Z0 F1 }  |; J. f& Z% |3 Q5 o+ }
over the effect of early androgen exposure on adult' m. v. }4 q* `; u5 j! e& j( a
penile length.10,11 Some reports suggest subnormal
$ j3 m9 a- f5 D4 k/ U: w( v: a7 Fadult penile length, apparently because of downreg-
+ Y' ^3 k1 p$ z' s( Uulation of androgen receptor number.10,12 However,
* o! r0 J( G' LSutherland et al13 did not find a correlation between
+ B0 k3 ]0 H- b3 Y4 K: N4 o; V5 i) achildhood testosterone exposure and reduced adult
9 }$ U- M& i; r1 _7 \' [% x* tpenile length in clinical studies.
, W- X* k  J8 x; W+ |+ MNonetheless, we do not believe our patient is5 Y; z2 Y; m8 u/ T' O# ~9 i
going to experience any of the untoward effects from  r! O2 o3 b! J7 j2 S% l' v* N& P
testosterone exposure as mentioned earlier because
9 t6 Q- r7 t8 V8 A; ]  \8 V# qthe exposure was not for a prolonged period of time.9 n8 _7 f* M' B5 q" x" f) Y8 F
Although the bone age was advanced at the time of2 `) p' R/ }3 s( g- A0 w1 z7 `7 \! ?% d
diagnosis, the child had a normal growth velocity at
9 |1 r- R8 m5 hthe follow-up visit. It is hoped that his final adult
; t, p, _: i! [height will not be affected.* N" k6 Q' K0 w( v+ ?* F; u
Although rarely reported, the widespread avail-
* \# C7 M1 c) H# P: \; u! Pability of androgen products in our society may; b" T  g. m7 s3 W8 t
indeed cause more virilization in male or female+ H! f/ F: O; Z, Z5 y$ u
children than one would realize. Exposure to andro-) E/ j1 A5 _* K7 G( E- y6 p' B8 V
gen products must be considered and specific ques-6 A& E9 ?* f+ o3 @3 z. l" Y$ c
tioning about the use of a testosterone product or2 [' ]/ L( c5 a+ k2 v3 U
gel should be asked of the family members during
. n& l! \1 j, t0 S9 R, j, dthe evaluation of any children who present with vir-
3 j' x1 E- w/ R; V' K) H- n0 G: T8 a! ]6 cilization or peripheral precocious puberty. The diag-& J) k8 ^1 d7 F' N8 K
nosis can be established by just a few tests and by
% [6 @3 K$ z+ s, y( nappropriate history. The inability to obtain such a& W% a. `% x* \2 I2 N4 z
history, or failure to ask the specific questions, may1 ]" ?  n. R8 C
result in extensive, unnecessary, and expensive1 ~- F& `6 i" W, ^- P8 w
investigation. The primary care physician should be0 i+ e: v( b9 ^1 e% a1 `* [
aware of this fact, because most of these children6 K; V" \2 |7 p5 T6 O, M4 g
may initially present in their practice. The Physicians’5 P% R# N: {& O. @0 w& I+ N
Desk Reference and package insert should also put a
) `$ l3 W# p; W3 W" y3 v0 y% c+ Zwarning about the virilizing effect on a male or
# V* a, P; ~- C2 W3 X2 h$ @9 vfemale child who might come in contact with some-
: i8 [) K% I' {0 h2 Fone using any of these products., T4 _3 Y+ w2 o: |; o
References
1 w1 F7 Q& e0 N/ L1 L$ m1. Styne DM. The testes: disorder of sexual differentiation
2 M4 Q3 c% Z. S( s& j' o# X0 Wand puberty in the male. In: Sperling MA, ed. Pediatric6 b% R! c# i$ s* h! Y# f3 p
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ @( ]$ l! P5 M: h" D5 X2002: 565-628.
6 h5 V3 ]7 A& `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" _; w* u: E5 L9 t- y0 }0 e
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old3 t. [4 s) n9 Q/ P9 A
Boy Induced by Indirect Topical
; i" ~# g& M$ ZExposure to Testosterone
. `3 k' U# p& Y8 \* cSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 Z' v1 C- H$ Z4 P% _+ dand Kenneth R. Rettig, MD1
. ^; Z8 n4 |' o, ]0 i: h3 cClinical Pediatrics
; x: U) Z3 m% N& q: I4 VVolume 46 Number 6
- |$ t$ {# E, X4 N7 N5 p( W8 l$ MJuly 2007 540-543* i. C7 E* P0 H$ D1 w$ _% X
© 2007 Sage Publications5 O$ ~' u1 h6 R; u6 e1 f$ }
10.1177/00099228062966510 [( J8 J: O# |2 g( Y' L9 ^
http://clp.sagepub.com
" F& b! W% S4 v) a" C  |* S8 _& [hosted at5 w: _9 t( ?7 q% o% H- G
http://online.sagepub.com, P6 \7 R) l" V& ]% n' [! N7 G
Precocious puberty in boys, central or peripheral,: ]' K, h; x% q' s2 z
is a significant concern for physicians. Central; h1 \2 c3 t2 c. s
precocious puberty (CPP), which is mediated
1 K" r) h& ^$ {  bthrough the hypothalamic pituitary gonadal axis, has/ v8 T6 D& s) v1 k& k: K( K
a higher incidence of organic central nervous system) e$ E$ n5 I; W/ H
lesions in boys.1,2 Virilization in boys, as manifested
' m, M6 S9 O) G4 {by enlargement of the penis, development of pubic
# ^7 o  ^6 M: ?hair, and facial acne without enlargement of testi-+ g2 j# |1 h0 D6 x% p, |4 J
cles, suggests peripheral or pseudopuberty.1-3 We7 {; ]) @* N- b: l8 _
report a 16-month-old boy who presented with the$ _6 ^+ R1 n2 U
enlargement of the phallus and pubic hair develop-; [  y' s( m' b
ment without testicular enlargement, which was due
, N+ \% g- S1 ]to the unintentional exposure to androgen gel used by2 M  K! P3 ~9 {: C. ^1 n' f
the father. The family initially concealed this infor-
$ y) a4 m0 w/ o. H. a& h" d* @mation, resulting in an extensive work-up for this
% O8 z# {1 `9 m% M( Z6 _child. Given the widespread and easy availability of7 {+ h8 e% a' O! B! {
testosterone gel and cream, we believe this is proba-) z. o3 I! n" |, a) S, H
bly more common than the rare case report in the
1 V' ?! l! r. t  b7 p- a( L/ }literature.4& E9 L, t3 `+ E6 T& H5 \
Patient Report2 G9 f4 K, z# |& t
A 16-month-old white child was referred to the
8 Y. @  `# U9 e, n6 [- U* Lendocrine clinic by his pediatrician with the concern
2 c1 y0 z. D" s- I" Z. gof early sexual development. His mother noticed
# r, p& ~# s. t+ X" T7 E% T2 flight colored pubic hair development when he was
- {+ i3 _1 M; k0 |From the 1Division of Pediatric Endocrinology, 2University of
" o! F: X" E1 W2 H* y' J0 WSouth Alabama Medical Center, Mobile, Alabama.
% C$ [* V1 `% U" ]5 }' [Address correspondence to: Samar K. Bhowmick, MD, FACE,
; A4 L* f3 n8 x6 E; L7 F( GProfessor of Pediatrics, University of South Alabama, College of
- I1 ^3 J" i  A3 tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ O! E$ e# m3 r. d4 O
e-mail: [email protected].( r/ j9 a6 ^5 `- L% a
about 6 to 7 months old, which progressively became) k1 }3 Q8 }' U3 n# V
darker. She was also concerned about the enlarge-" {7 \# k  t3 T1 R& f
ment of his penis and frequent erections. The child9 m4 W0 n: q* J* j! @2 f0 k
was the product of a full-term normal delivery, with8 ~- P, ~8 [6 \* U
a birth weight of 7 lb 14 oz, and birth length of
' h! z7 C. h3 B; K2 z( s20 inches. He was breast-fed throughout the first year
' \) f6 A- ?( L/ h0 B. _of life and was still receiving breast milk along with; A- v9 ?/ M- Q9 z! Z- G
solid food. He had no hospitalizations or surgery,
5 x6 W! L2 w4 V) u8 sand his psychosocial and psychomotor development/ u+ ?3 u% `4 o$ u6 |! i' c
was age appropriate.
( o! s% x1 J" p  O2 v: nThe family history was remarkable for the father,
3 C2 C/ w( y/ L2 d" }3 Ewho was diagnosed with hypothyroidism at age 16,
6 k/ `& W5 e9 {4 g0 x( b( Kwhich was treated with thyroxine. The father’s
6 a3 M% e2 y4 ^4 E7 `  t0 G, yheight was 6 feet, and he went through a somewhat7 D: q: x$ G4 Q/ R2 k6 I6 W2 b6 ~
early puberty and had stopped growing by age 14.
# p1 W  l# y2 c1 w# O0 ~( QThe father denied taking any other medication. The
- M6 T& C: Z# {, K( K( K1 K1 Ochild’s mother was in good health. Her menarche
* v5 I1 D+ \7 [4 k& {  Owas at 11 years of age, and her height was at 5 feet5 O; P, P: G! i
5 inches. There was no other family history of pre-
, v5 e" [" V( D2 u/ w' |# @6 Jcocious sexual development in the first-degree rela-  ~/ h  H/ C  o; U) g" p
tives. There were no siblings.3 a. j# k; Z/ n$ l& x% G9 H
Physical Examination3 e1 Y; j& s" |& ]1 i! W1 U- N
The physical examination revealed a very active,# I, C& Y/ N: X
playful, and healthy boy. The vital signs documented
$ H7 o+ Q! ]7 M) R5 P- sa blood pressure of 85/50 mm Hg, his length was
* g9 M0 R1 Y; \* a; q& E9 Z90 cm (>97th percentile), and his weight was 14.4 kg
" K; t  U7 O0 n! c/ G8 S(also >97th percentile). The observed yearly growth
- B# u/ `. y" }: kvelocity was 30 cm (12 inches). The examination of
) `+ d0 ~9 j: E6 Lthe neck revealed no thyroid enlargement./ j7 ~0 r# j. w. k
The genitourinary examination was remarkable for4 O- Z+ H- S  R2 ^7 q* |
enlargement of the penis, with a stretched length of; E# X; N( W. U- {- y, q
8 cm and a width of 2 cm. The glans penis was very well
! u9 }$ k0 B0 F9 e' K7 P0 udeveloped. The pubic hair was Tanner II, mostly around5 j1 ?; m7 P& P, u  n4 P( y7 V
540
" z2 {1 s4 t$ J# Y. _: x! ?1 ]" Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% l1 D5 |2 k1 B. B' x
the base of the phallus and was dark and curled. The/ z/ D- Y9 c, A& l  f; p
testicular volume was prepubertal at 2 mL each.9 b5 U! R* Z7 t% ?
The skin was moist and smooth and somewhat' L7 p1 |% B. w: o) O0 \+ A
oily. No axillary hair was noted. There were no7 [2 m- n, R( D# \
abnormal skin pigmentations or café-au-lait spots.. m% s7 O$ \; ~4 C' W
Neurologic evaluation showed deep tendon reflex 2+
1 J" `1 [# {' c. y  \bilateral and symmetrical. There was no suggestion
6 X5 j3 i) v6 b2 eof papilledema.
! o" i9 ~0 s# r: B: LLaboratory Evaluation6 X; s, V; q( Y4 {: |
The bone age was consistent with 28 months by
1 A0 x% F( a3 _7 A8 Ousing the standard of Greulich and Pyle at a chrono-: e! }" d1 b8 \2 V2 \) c
logic age of 16 months (advanced).5 Chromosomal+ ]+ C5 k& ]& p9 r  X9 B* `
karyotype was 46XY. The thyroid function test
2 b. T$ F3 G6 K$ r5 ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 o/ l& h$ A' p) S" N( slating hormone level was 1.3 µIU/mL (both normal).  X# E9 Z2 ~& {, Z* ^1 }
The concentrations of serum electrolytes, blood
$ G. k4 `" y2 \5 Y( B# }urea nitrogen, creatinine, and calcium all were
8 J' D% v( }- _  T' swithin normal range for his age. The concentration' ?$ A) f. r  z; J* p+ y
of serum 17-hydroxyprogesterone was 16 ng/dL5 z0 ~9 C: c- B! I) ?3 F, Y, }
(normal, 3 to 90 ng/dL), androstenedione was 204 k$ ^4 S3 l3 K4 y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ U( j0 ^- m5 K9 a' Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 T. }4 n# C4 P0 G& y. M. rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to; u) u+ L  j+ T  m8 ?. F
49ng/dL), 11-desoxycortisol (specific compound S); p) @& m* [* t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 s0 T0 R0 m  ?: |5 C; q) jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total6 [' J, ]/ }% L, |7 M( V) N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 O9 C# `% ^( B. D  Wand β-human chorionic gonadotropin was less than# i) j5 K" ]: k6 h
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 j3 h3 |2 Q" Y7 f1 w+ Wstimulating hormone and leuteinizing hormone5 k; P, v5 L* T: \
concentrations were less than 0.05 mIU/mL
7 N- P& l6 ~  _- \2 P# O+ X! R(prepubertal).9 N8 c  J% ?! J6 w: a6 {
The parents were notified about the laboratory
) A/ ^/ M0 |- s* H& C+ vresults and were informed that all of the tests were
3 y6 I* N; x- l% V3 ^6 bnormal except the testosterone level was high. The
- e- P; v6 q1 J1 \6 c6 ofollow-up visit was arranged within a few weeks to# }% x. Z/ |9 o- H) K6 y$ Q/ |
obtain testicular and abdominal sonograms; how-6 l% K2 {. V2 {) U% l
ever, the family did not return for 4 months.; k& z8 s8 r9 m( w: D, {% W9 D
Physical examination at this time revealed that the- o/ K9 ?" A# O, T) a
child had grown 2.5 cm in 4 months and had gained" ]- U7 _' \' g4 {' f
2 kg of weight. Physical examination remained
6 F0 `6 H/ _5 l7 C5 K7 uunchanged. Surprisingly, the pubic hair almost com-% y, B5 f; S3 y" O* d
pletely disappeared except for a few vellous hairs at- R7 A' y6 s( q3 o- I
the base of the phallus. Testicular volume was still 2; H" ?% b& A1 R# q, O
mL, and the size of the penis remained unchanged.
# I$ z3 f; e; t$ d4 YThe mother also said that the boy was no longer hav-
4 p& @. v' u8 {) A# Eing frequent erections.$ ~3 R$ ?3 z8 R* s1 }' V2 H) A
Both parents were again questioned about use of
9 y- Y; O# f8 Eany ointment/creams that they may have applied to7 i. o3 N$ U7 I' N2 g/ {" O
the child’s skin. This time the father admitted the0 F" Q/ e4 j6 ~& r# m
Topical Testosterone Exposure / Bhowmick et al 541( J2 P* b6 I; O" n6 k# h+ g! b; W, s
use of testosterone gel twice daily that he was apply-. d% k. ^- n, n- ~' Y2 h' Z
ing over his own shoulders, chest, and back area for) @5 _( d; m3 F/ R. P) E6 N; N
a year. The father also revealed he was embarrassed% A& T( S% c* @' D. d# K% t
to disclose that he was using a testosterone gel pre-
4 ^3 Q( }6 o% H9 xscribed by his family physician for decreased libido8 X: ?% }/ G, h4 f5 S
secondary to depression.
# c1 j/ o1 P1 I) z- v1 m/ gThe child slept in the same bed with parents.5 h: i  f7 w: }7 l6 V
The father would hug the baby and hold him on his
( z' a0 y2 c, a- schest for a considerable period of time, causing sig-
/ a  ]& F* r' y- l: r/ F% T: Onificant bare skin contact between baby and father.
7 q+ G( b' `9 S0 o! k6 ?1 PThe father also admitted that after the phone call,
/ x5 q9 @) P3 [when he learned the testosterone level in the baby0 `; S0 B" g9 R( n$ f+ f
was high, he then read the product information
( m% v* d- ^' \; x- o0 G$ spacket and concluded that it was most likely the rea-
7 ~0 C$ ^  ^9 \son for the child’s virilization. At that time, they
0 R5 t/ V$ o" s2 idecided to put the baby in a separate bed, and the* r; H( L, I/ o
father was not hugging him with bare skin and had
; x: P: }# v1 ~% e" n+ u% Fbeen using protective clothing. A repeat testosterone. `. ~; z# s! y( v1 \; b
test was ordered, but the family did not go to the
1 k& i( C; N8 `( y, f& ?laboratory to obtain the test.; s  ^- b" S2 w7 m$ B. b$ }/ v5 C9 M: [
Discussion
' R) R8 b0 r" g( C2 e! yPrecocious puberty in boys is defined as secondary
/ h6 {5 E/ r+ t4 F! K/ `sexual development before 9 years of age.1,4# v3 W: |0 F' B/ r
Precocious puberty is termed as central (true) when
# {6 R) k. _, \- cit is caused by the premature activation of hypo-: F% W. S6 i" |6 q3 T! X
thalamic pituitary gonadal axis. CPP is more com-* ~6 y8 J9 H2 Y5 _0 J, D
mon in girls than in boys.1,3 Most boys with CPP0 [* E4 n4 L, U/ G% V$ ?
may have a central nervous system lesion that is
. C9 l& ~2 L0 `" S2 a2 I7 Kresponsible for the early activation of the hypothal-
0 A' X3 S4 I/ u; k. B) ?# L0 A9 ramic pituitary gonadal axis.1-3 Thus, greater empha-+ v7 v) ?) G4 o; p
sis has been given to neuroradiologic imaging in
3 B9 C6 _. ?& R8 K6 L) b) yboys with precocious puberty. In addition to viril-
: {7 Q1 v4 m% T' U' Eization, the clinical hallmark of CPP is the symmet-
4 W; K, _' E5 T. c" |rical testicular growth secondary to stimulation by1 s. M* T' w4 m- F6 W
gonadotropins.1,3
2 Z% B! ]+ A4 t" O" R# t: {Gonadotropin-independent peripheral preco-
  A2 g: r. y9 a2 w% I7 U! Q) L! `cious puberty in boys also results from inappropriate
5 V* Z* e8 B+ e% b7 zandrogenic stimulation from either endogenous or; [6 B6 O9 h/ I1 K
exogenous sources, nonpituitary gonadotropin stim-% |8 P7 s: K7 Y
ulation, and rare activating mutations.3 Virilizing
/ ?7 K# @8 ?- B: p% n: `+ Y+ }! Acongenital adrenal hyperplasia producing excessive
) b/ A9 b  e2 Qadrenal androgens is a common cause of precocious3 n) J1 M: l7 @
puberty in boys.3,47 A1 Z7 O+ v) u- \9 E1 X
The most common form of congenital adrenal
$ y8 ^% B, R6 B8 hhyperplasia is the 21-hydroxylase enzyme deficiency.
/ P  o  o6 j0 a5 y: c2 HThe 11-β hydroxylase deficiency may also result in5 d+ k  L4 U$ M8 Q6 A( S4 M8 j
excessive adrenal androgen production, and rarely,; H3 B! ], X* t0 t' u
an adrenal tumor may also cause adrenal androgen
: p9 w& P+ h, O8 o: W$ M; g5 T* y6 Fexcess.1,3
1 ~9 q# X. ^: T: ^* ~at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& u5 g! X" |3 _; C6 s- O+ z5 c
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# J, s* z( c1 _' E4 B8 y" y9 {- k1 hA unique entity of male-limited gonadotropin-
6 G" D! n8 x2 \0 V/ Sindependent precocious puberty, which is also known6 X8 e3 f+ t* I6 s  a2 T0 E
as testotoxicosis, may cause precocious puberty at a4 m4 E' C" ?6 O9 l
very young age. The physical findings in these boys
' Z& {, g1 R* ^! J1 p+ k3 uwith this disorder are full pubertal development,2 T" }7 q, ~- ~6 R
including bilateral testicular growth, similar to boys5 D& J, Z9 g6 Y" B& H, b
with CPP. The gonadotropin levels in this disorder
) I& v, U$ U5 f9 W  Oare suppressed to prepubertal levels and do not show
0 S" S3 y; o0 L: z- v1 vpubertal response of gonadotropin after gonadotropin-8 {3 a2 l1 U$ ?( H0 m' v* }
releasing hormone stimulation. This is a sex-linked4 c5 G: R; x  g7 z' S( k
autosomal dominant disorder that affects only
6 y" _8 {/ v; n  m- X3 Smales; therefore, other male members of the family
/ H' X1 s# L* H4 Qmay have similar precocious puberty.36 \0 d" \1 {0 C3 Z  ]
In our patient, physical examination was incon-0 h4 d0 d  E5 o! @2 C% d
sistent with true precocious puberty since his testi-
% J7 g/ j9 o& o- k9 tcles were prepubertal in size. However, testotoxicosis( r  c: e' p$ }
was in the differential diagnosis because his father, q6 E/ s( O0 Z4 {) d: |
started puberty somewhat early, and occasionally,$ X  h1 ^$ b" z$ E4 ?: |
testicular enlargement is not that evident in the
7 c. T/ m# s+ I+ D2 ?- ~: Pbeginning of this process.1 In the absence of a neg-
9 w( u) P2 j/ Q% T' P! F$ fative initial history of androgen exposure, our! ]% @, n3 K% X1 M5 z5 j4 q
biggest concern was virilizing adrenal hyperplasia,
" V/ _+ ]. e/ c# S& veither 21-hydroxylase deficiency or 11-β hydroxylase9 Z0 @3 W* n7 m0 a* B
deficiency. Those diagnoses were excluded by find-
' d0 S- j3 G; g/ iing the normal level of adrenal steroids.
" b5 R' M6 e  X3 CThe diagnosis of exogenous androgens was strongly! X4 m* b5 j" I
suspected in a follow-up visit after 4 months because
1 x$ w4 X" U4 C5 l# u$ [- ]4 zthe physical examination revealed the complete disap-
  |) K0 C6 x! W4 g7 S% s9 hpearance of pubic hair, normal growth velocity, and
7 w! p  a1 E+ R; mdecreased erections. The father admitted using a testos-4 D- B( z0 q2 r* @
terone gel, which he concealed at first visit. He was
* j2 J& f, L' j, V/ M/ S! B4 E. \using it rather frequently, twice a day. The Physicians’
; P3 S9 j5 b2 }# a( N$ }+ p# TDesk Reference, or package insert of this product, gel or
: Q9 W6 e# S* C  a0 P2 Wcream, cautions about dermal testosterone transfer to! n  _' L# \4 @5 ^  Z$ p: t" l
unprotected females through direct skin exposure.
( F- T+ E  Q; }5 kSerum testosterone level was found to be 2 times the' I& i* E. @& B- H# q: t
baseline value in those females who were exposed to5 R2 a1 x, N2 w% |, ~
even 15 minutes of direct skin contact with their male* o% |7 ~7 ^( i; N) ]
partners.6 However, when a shirt covered the applica-. l' P3 h) G7 S% P
tion site, this testosterone transfer was prevented.
: o9 w. u! t& W1 v0 f- D* L1 @' N+ nOur patient’s testosterone level was 60 ng/mL,
4 ^3 K' l' o2 ?4 n* }! Z- iwhich was clearly high. Some studies suggest that) u2 S7 Q2 n0 h7 T, W& F1 j
dermal conversion of testosterone to dihydrotestos-7 O+ W* n! s4 O% f
terone, which is a more potent metabolite, is more
9 ^7 b$ G: z* _' \active in young children exposed to testosterone; x- J% f- i" A7 d: e
exogenously7; however, we did not measure a dihy-1 v  C" s; Z+ [- j0 W. w/ R# Y; o  z
drotestosterone level in our patient. In addition to6 h8 b' K9 ~5 @
virilization, exposure to exogenous testosterone in
& l7 c  z4 U% `4 N( o% tchildren results in an increase in growth velocity and8 `: q3 l2 W8 s3 u! s
advanced bone age, as seen in our patient.3 Z1 u! u+ M$ I9 T5 l( |6 }$ c
The long-term effect of androgen exposure during
" Y0 b# T4 h( D* l/ g" K9 H9 q0 Wearly childhood on pubertal development and final
) n' t  U- k$ T2 }& vadult height are not fully known and always remain" p7 N7 j" y% i4 u; N
a concern. Children treated with short-term testos-4 K# s  @* n& @
terone injection or topical androgen may exhibit some
3 Y& b) L8 d& [# y# kacceleration of the skeletal maturation; however, after
5 e, Z: g7 }5 z7 O2 {1 a& x, zcessation of treatment, the rate of bone maturation
; d" y7 H. k: J7 A. H) Tdecelerates and gradually returns to normal.8,94 |+ A# l0 n+ x, I. h2 c
There are conflicting reports and controversy
  I# P$ S3 H4 X- ]/ Yover the effect of early androgen exposure on adult- j+ W5 B5 o" `6 z. o, L. V9 |5 i
penile length.10,11 Some reports suggest subnormal; M% u# y! `! I1 j
adult penile length, apparently because of downreg-6 k. X* q+ Q% L3 y4 D* f
ulation of androgen receptor number.10,12 However,5 m- O; J, z/ ~, r: }2 v* {
Sutherland et al13 did not find a correlation between& e% |) Y5 ^& n9 L! {8 l, w
childhood testosterone exposure and reduced adult
5 H+ s; V5 @  c' Y7 ~penile length in clinical studies.
' }. q8 v% [) m' U' uNonetheless, we do not believe our patient is, ~  G( W4 h( U; h
going to experience any of the untoward effects from( P' c, M4 w' D- {
testosterone exposure as mentioned earlier because
" P4 U' ?9 x& H  O, Y( Uthe exposure was not for a prolonged period of time.
, F" W2 x4 ^6 B6 _9 |- R) CAlthough the bone age was advanced at the time of
1 B( M. E% M$ y6 o$ idiagnosis, the child had a normal growth velocity at
3 F8 m% l0 e4 `the follow-up visit. It is hoped that his final adult# [9 R2 `; Q7 s+ r
height will not be affected.) X8 ]2 Z, h4 c5 _! R  p8 h
Although rarely reported, the widespread avail-
1 N3 n4 v3 W1 [* i2 v5 y4 e7 d$ rability of androgen products in our society may; I1 G7 O# A! T% {' y0 o
indeed cause more virilization in male or female: Y3 y1 p" K" b5 @. Q6 n
children than one would realize. Exposure to andro-8 f& y1 ?+ R" ~1 c
gen products must be considered and specific ques-8 P; ~  x2 ]" m, ?: _
tioning about the use of a testosterone product or
2 u  [5 c+ |+ ^; sgel should be asked of the family members during
- T( u) m7 @6 A; X: ~, O5 uthe evaluation of any children who present with vir-9 A/ h  ^9 A" z! t3 u
ilization or peripheral precocious puberty. The diag-
4 k; ~& J4 E* Vnosis can be established by just a few tests and by$ h% w$ l$ g2 V# H! W6 p% ^
appropriate history. The inability to obtain such a( P0 B8 X8 ?" l! j, I$ @' q
history, or failure to ask the specific questions, may/ y4 g# J4 x8 S0 {/ Y# N& L
result in extensive, unnecessary, and expensive
. E; u5 D0 s1 h- jinvestigation. The primary care physician should be- B6 Q" k  Q; o
aware of this fact, because most of these children2 B" ?0 ~& g$ @" p" \5 ]. B' i
may initially present in their practice. The Physicians’& K' e( W# }0 i
Desk Reference and package insert should also put a( T) l6 }" ~" N, D8 a$ D0 f# x. q
warning about the virilizing effect on a male or  o( ^$ b& Y7 h; J" Q* N
female child who might come in contact with some-
2 ]$ P3 w, k2 Xone using any of these products.
+ [, Y, Q& [; q4 M# gReferences" k0 B: i1 z, V% J6 M
1. Styne DM. The testes: disorder of sexual differentiation
/ R' S( Z7 r7 M5 O6 L# d3 U; u$ `and puberty in the male. In: Sperling MA, ed. Pediatric
/ P) ?2 N2 b0 _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 M9 Y% L, |% C0 m' u) p2002: 565-628.5 _+ K2 g, l8 T& [2 [. }: e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" K" F  x+ x2 N& {: R
puberty 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
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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

$ `! N$ \. q3 C) f" \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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