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Sexual Precocity in a 16-Month-Old
  p# d6 r6 Y) h5 W. B) jBoy Induced by Indirect Topical
/ m( r1 q! o! B$ N1 M% EExposure to Testosterone
- G/ J& X- p7 K7 I$ J6 _Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- }1 W- H  H. p0 W! }' v6 band Kenneth R. Rettig, MD16 Y6 r' B  ]  q& r
Clinical Pediatrics
' _, Z# {% k  G* p- ~' CVolume 46 Number 6% @' j$ a0 Q! a7 m
July 2007 540-543
* G6 B+ \/ r* o  @7 a8 H6 \! B© 2007 Sage Publications
2 o( ^1 |( r8 Q8 C3 t5 N* Z10.1177/0009922806296651
4 i- H  W; _6 |. W" hhttp://clp.sagepub.com
" J: F/ F: G  rhosted at* H0 Q. @3 ~( {3 N0 C! P0 L
http://online.sagepub.com
0 V$ r- [- H7 u: r, ^! BPrecocious puberty in boys, central or peripheral,
+ q: `) C4 ?9 ?) Q3 p$ l& Mis a significant concern for physicians. Central
. K- \1 q/ J( [3 s& j. tprecocious puberty (CPP), which is mediated
5 h5 s$ |' x6 M7 m3 Z) Kthrough the hypothalamic pituitary gonadal axis, has
. j$ y, P0 i" @a higher incidence of organic central nervous system
7 L1 s" D8 D% y& ~lesions in boys.1,2 Virilization in boys, as manifested
' r% ?/ s& Y" h1 A+ D: bby enlargement of the penis, development of pubic
! X: X3 y) b7 S  b1 chair, and facial acne without enlargement of testi-
0 D: r% q( W" g% _- P: j' Ycles, suggests peripheral or pseudopuberty.1-3 We* A& R& T: a5 }  E! c) `7 L: h" o
report a 16-month-old boy who presented with the
. I1 `7 R. Z' {enlargement of the phallus and pubic hair develop-9 v+ [$ g. O7 \& C: @1 |, i( R
ment without testicular enlargement, which was due4 ~& {6 H' A9 l3 a8 d
to the unintentional exposure to androgen gel used by" ?; L8 ]* @& }4 b) q
the father. The family initially concealed this infor-1 Z: r  s6 m2 ], W; u. j
mation, resulting in an extensive work-up for this
3 U. Y/ D: |" m" [! Lchild. Given the widespread and easy availability of
' X4 Q7 c$ ?3 Z# ntestosterone gel and cream, we believe this is proba-6 O. n. L* d/ t6 D$ y* c! @
bly more common than the rare case report in the
3 Y/ _) v2 h2 s$ {1 H  U& bliterature.4
, z% K6 u: V0 ~- {8 ~. qPatient Report
7 \( a% d6 o0 GA 16-month-old white child was referred to the
0 r4 N- W, T+ A7 U2 ]& ]endocrine clinic by his pediatrician with the concern
$ r& F7 s$ A  N1 e& }7 F4 a1 hof early sexual development. His mother noticed$ P* i/ C$ R! _
light colored pubic hair development when he was
3 ?) r" b1 T, p8 AFrom the 1Division of Pediatric Endocrinology, 2University of& E# }6 K6 ]! g4 _" `
South Alabama Medical Center, Mobile, Alabama.( C2 S( |: t: R
Address correspondence to: Samar K. Bhowmick, MD, FACE,& o! s  p0 C# f" h  b' G/ o* S7 N
Professor of Pediatrics, University of South Alabama, College of
3 S8 ^' ~$ \$ Z# J. sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ ^. j. y) b6 t0 G4 f% {0 x6 d! B
e-mail: [email protected].
6 I, Z' n7 @* I" U( {1 v: a$ jabout 6 to 7 months old, which progressively became
% ^8 F$ w9 O5 T( X% o% {darker. She was also concerned about the enlarge-8 ^3 ?- O& Q$ V- _
ment of his penis and frequent erections. The child
, K+ |$ s& ^9 d7 W* I9 e3 l; vwas the product of a full-term normal delivery, with
+ V" E* H: M: n' ]: N! \8 V5 Xa birth weight of 7 lb 14 oz, and birth length of
- R! ?% G) @5 r& U) m5 G5 a20 inches. He was breast-fed throughout the first year
8 a4 L# x' }$ oof life and was still receiving breast milk along with3 w; F9 f5 r) r2 H; B& U4 v3 z
solid food. He had no hospitalizations or surgery,& d* i9 u3 A: Y3 T
and his psychosocial and psychomotor development
( q. Y* o+ L/ B' l! Xwas age appropriate.
/ j2 W5 H0 U% L( m+ UThe family history was remarkable for the father,
, p+ ^3 H7 H1 j" q% a7 y3 k" N* X% rwho was diagnosed with hypothyroidism at age 16,
2 s" g9 I0 [) m  bwhich was treated with thyroxine. The father’s" n% r* h' L/ k2 R+ s# Y
height was 6 feet, and he went through a somewhat) S0 a4 E4 Y/ }( |# A
early puberty and had stopped growing by age 14.! _8 G8 s3 K6 x; b+ V
The father denied taking any other medication. The
# D$ x, B+ n* M; Q. s) t7 v* Nchild’s mother was in good health. Her menarche! z) B; ?, t* L5 i4 k6 z
was at 11 years of age, and her height was at 5 feet
) S& C! h3 D0 @4 L* o. ?0 T/ V5 inches. There was no other family history of pre-( U3 I/ n9 D9 Z: B, V
cocious sexual development in the first-degree rela-$ a. z/ o* `/ |. w/ }, p
tives. There were no siblings.3 y4 `  ~5 B- ]8 |
Physical Examination8 i8 t4 p6 {: O4 j, ^( f: F: @
The physical examination revealed a very active,* S0 p0 S1 v8 L3 h# C
playful, and healthy boy. The vital signs documented
) I9 \* F# c  n' ga blood pressure of 85/50 mm Hg, his length was
- \& I: u/ ?3 [8 F# p; j90 cm (>97th percentile), and his weight was 14.4 kg
9 ]; H" K; M; T/ M5 g& O' Q(also >97th percentile). The observed yearly growth
  V! ^! Z7 {) V* k. F, Nvelocity was 30 cm (12 inches). The examination of. ?! u) q8 S: B8 g! T# m) l
the neck revealed no thyroid enlargement.
1 l2 V: ]/ A" r) [  c8 V. n0 ^The genitourinary examination was remarkable for
2 Z; T; n" z( ]. @3 J6 }6 G- cenlargement of the penis, with a stretched length of: J# W: @. s* r3 T- H1 h5 \$ H9 `
8 cm and a width of 2 cm. The glans penis was very well1 \1 u4 }/ F) c; d2 D8 e* [8 T
developed. The pubic hair was Tanner II, mostly around
0 F. z3 x2 r9 m- x7 C) T540
7 V+ C! m" z0 Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 _. `; [- U% h- B6 t4 f( e  D: x. ^% I+ [4 |
the base of the phallus and was dark and curled. The
* A( C8 ?6 K! H. F6 C# etesticular volume was prepubertal at 2 mL each.
5 ]3 V9 ?6 e0 B. wThe skin was moist and smooth and somewhat7 c/ t8 U4 {9 [
oily. No axillary hair was noted. There were no
6 R9 x' I  P0 N$ Y2 kabnormal skin pigmentations or café-au-lait spots.# [! z% A: k/ X7 g5 V
Neurologic evaluation showed deep tendon reflex 2+* _7 `' K3 B# Y% w' [8 t( t. z
bilateral and symmetrical. There was no suggestion
* ]6 r0 F8 e7 [5 d" c, k7 iof papilledema.8 ]- Y: S1 x: {/ ^! A- p! s* }1 M
Laboratory Evaluation
/ ?7 k; I7 U, q$ AThe bone age was consistent with 28 months by" f6 x/ W$ h; M6 O
using the standard of Greulich and Pyle at a chrono-6 x# i7 }5 T& n8 D" \" F
logic age of 16 months (advanced).5 Chromosomal
# v9 q5 E/ V' }9 r- okaryotype was 46XY. The thyroid function test
; d8 }/ T6 |! z5 z6 J' Y, _: O- C. \showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 ^$ Y; e  |, r5 ^' I' Q9 j
lating hormone level was 1.3 µIU/mL (both normal).: F/ u+ U2 A' x2 L3 v* e
The concentrations of serum electrolytes, blood
: ~. }- u5 R: R# xurea nitrogen, creatinine, and calcium all were: j2 C( {5 ~5 h% l7 @9 r1 |8 ?
within normal range for his age. The concentration
* X  v- i0 o- cof serum 17-hydroxyprogesterone was 16 ng/dL6 n. w0 s) W# A, }) }0 _
(normal, 3 to 90 ng/dL), androstenedione was 205 i9 K) m* _. m( _# l7 ]
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 C5 k& y$ v$ o+ @: H$ b* }terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ y2 A6 k: [3 d4 P9 U1 R3 m0 }desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 L% l0 d2 n2 q. L49ng/dL), 11-desoxycortisol (specific compound S)
. }. _' R+ }6 X: Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 ^4 W$ z  I- U7 ~2 Z% a7 }( g1 t7 E9 i/ stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ G* }9 Y' Y' A& E, `3 ?6 C
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ E( Y. R1 X' t7 \
and β-human chorionic gonadotropin was less than2 g+ O' t5 Q5 o6 C" t, b0 G
5 mIU/mL (normal <5 mIU/mL). Serum follicular
" j9 i' q+ r* L+ U- q; e. m: nstimulating hormone and leuteinizing hormone3 V6 p6 {1 K2 {1 R4 v
concentrations were less than 0.05 mIU/mL
$ X" ~2 N' [5 X" X+ k$ Z+ o' ?(prepubertal).' ?) C) x7 c1 b, d/ {2 q5 E8 q
The parents were notified about the laboratory/ F  f& {$ n) R9 \+ M2 [/ w, c( j9 ~% E' b
results and were informed that all of the tests were
0 ?9 N/ x+ _5 f: dnormal except the testosterone level was high. The
) k8 a4 ?& m' h) kfollow-up visit was arranged within a few weeks to
3 Z5 H! e( A- q+ Pobtain testicular and abdominal sonograms; how-+ C& ]8 g* h+ l. q: M. B$ G
ever, the family did not return for 4 months.
& ^5 u/ s, p& E6 h4 V3 dPhysical examination at this time revealed that the
1 T; m) `* T: y: {/ y/ Schild had grown 2.5 cm in 4 months and had gained7 }9 F0 }3 _- V
2 kg of weight. Physical examination remained1 N  F- O4 p. _& l& u8 Z2 v- H
unchanged. Surprisingly, the pubic hair almost com-
, C5 U" B4 Y7 ?4 H* H8 ?/ A9 m' `pletely disappeared except for a few vellous hairs at
, q: f5 n+ f7 [" `! Uthe base of the phallus. Testicular volume was still 2
# }% V. W. \4 N4 Q! d4 g) ]! g4 GmL, and the size of the penis remained unchanged.+ F7 C% ^7 A& `. V! ~& Z6 I4 |7 \
The mother also said that the boy was no longer hav-
+ m9 Q$ M4 `. N( [1 \9 d" V2 ~6 ]. Bing frequent erections.
. k6 _% N# H5 K4 m) CBoth parents were again questioned about use of, V( u% E8 x! V1 A
any ointment/creams that they may have applied to1 G6 I8 w% H" k  m7 L9 o
the child’s skin. This time the father admitted the
4 L! F" \- ~' |- \Topical Testosterone Exposure / Bhowmick et al 541
$ t9 O' P" h9 G" Fuse of testosterone gel twice daily that he was apply-( \5 O6 N) b5 o* K. _7 U
ing over his own shoulders, chest, and back area for5 n& v4 g* `+ i9 {' \! w$ L
a year. The father also revealed he was embarrassed/ X$ ~  O+ Z9 o$ ]" |5 {
to disclose that he was using a testosterone gel pre-
0 {- H: X( C# `$ _! R& Y! n" Bscribed by his family physician for decreased libido
& r8 |( m$ O3 R# f- |& @, Jsecondary to depression.
5 n( A' Y/ p% m. ~The child slept in the same bed with parents.
1 y! H0 s4 {& X/ A$ rThe father would hug the baby and hold him on his
+ K6 D4 b7 z. w6 m0 D: Mchest for a considerable period of time, causing sig-
/ e" w( z# g0 ^, c7 w0 z' w& Onificant bare skin contact between baby and father.
9 J" ~, d: f  V  V0 uThe father also admitted that after the phone call,
& J/ `: Q) g0 P# u9 F; V* [when he learned the testosterone level in the baby
: [" w0 u+ h  ~) ^3 V7 v+ h8 rwas high, he then read the product information3 z. L- r2 ?1 G, _  l% R8 o0 Y* x
packet and concluded that it was most likely the rea-
7 B; Y- o! b; d( g) z" s) Oson for the child’s virilization. At that time, they
/ f5 m5 I6 V2 {% \  k- Jdecided to put the baby in a separate bed, and the9 i3 |* i0 t) g/ m) H4 {
father was not hugging him with bare skin and had
3 ]8 R* _3 Y9 \: D# e9 n# ]! Bbeen using protective clothing. A repeat testosterone
5 k5 r) v% Q: stest was ordered, but the family did not go to the! Z: n* w& x' e: `* E8 d1 h9 Y
laboratory to obtain the test., C- H* p% \& @& |9 b4 `( D
Discussion  P: ~- ?9 B  h& h( k" ~
Precocious puberty in boys is defined as secondary0 \& b' [7 [7 K. ?/ ]. s
sexual development before 9 years of age.1,41 y/ ], v7 y3 _' C2 b- i3 z
Precocious puberty is termed as central (true) when
: t* n5 {; ~0 P; V& fit is caused by the premature activation of hypo-9 `5 Q' e9 M5 r. e
thalamic pituitary gonadal axis. CPP is more com-2 d2 {/ R- ^7 l9 D3 q
mon in girls than in boys.1,3 Most boys with CPP
, `8 P+ J: J5 imay have a central nervous system lesion that is0 u, ?9 f& B, O; e+ K: R
responsible for the early activation of the hypothal-
) o" ~! k) j  [amic pituitary gonadal axis.1-3 Thus, greater empha-& {& R4 |( [4 X; P3 V
sis has been given to neuroradiologic imaging in
4 {' U" O5 O# B" w( iboys with precocious puberty. In addition to viril-
0 V# q- ?  Y6 x: bization, the clinical hallmark of CPP is the symmet-
8 G5 K& c3 L' r9 Y3 k; G& V7 brical testicular growth secondary to stimulation by
/ |) ]5 J+ l) u. X) w# ^8 |gonadotropins.1,38 l! L! I$ A% @5 a9 b% I
Gonadotropin-independent peripheral preco-
0 Y, @) f5 H. M5 D% M1 lcious puberty in boys also results from inappropriate% d- X- g8 a; L$ g8 H# P
androgenic stimulation from either endogenous or
0 D9 f( f% h2 s9 Z) sexogenous sources, nonpituitary gonadotropin stim-6 J5 F. |) B: c' [* V% J6 {; C
ulation, and rare activating mutations.3 Virilizing' b8 N" p$ `- C# N  L# f- [
congenital adrenal hyperplasia producing excessive6 L  D: Y, |5 O9 O' V
adrenal androgens is a common cause of precocious5 Z0 ]& r: C: q& w) W
puberty in boys.3,4
' d! V% u$ b6 z/ Y, K5 nThe most common form of congenital adrenal5 `% V% @  ~3 r4 s+ o4 ^/ _: l
hyperplasia is the 21-hydroxylase enzyme deficiency." s# F' `8 p& l2 u- e
The 11-β hydroxylase deficiency may also result in
7 e* Y/ F4 w9 y3 Hexcessive adrenal androgen production, and rarely,& R7 I) O, M, _. b- {9 |
an adrenal tumor may also cause adrenal androgen
5 U1 R7 q; n# s3 Fexcess.1,3
( A% j4 x) @& O0 O  ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 s; D" V1 \% P' n* ~542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 R, [2 E, B( N2 Z6 G
A unique entity of male-limited gonadotropin-
& |3 f8 S& Y2 v2 Dindependent precocious puberty, which is also known
2 }: m3 b, U' b* J2 k$ u$ k. sas testotoxicosis, may cause precocious puberty at a2 }( [$ W% r) H7 |+ X0 h
very young age. The physical findings in these boys
9 }/ e; H$ l5 n# qwith this disorder are full pubertal development,$ \2 {" g& d" M- Z/ ~/ J
including bilateral testicular growth, similar to boys/ J2 I+ \: w5 l' A1 [7 F
with CPP. The gonadotropin levels in this disorder3 x2 f8 {6 ~$ w+ Y! E5 @8 `5 _, F
are suppressed to prepubertal levels and do not show* `. U( u7 j4 G9 i8 O
pubertal response of gonadotropin after gonadotropin-# ^5 `( x1 `6 ~* _
releasing hormone stimulation. This is a sex-linked6 Z! Q9 S9 Q( H! s) z3 e6 K
autosomal dominant disorder that affects only: {) ]5 Q  \6 z2 h* Q! T
males; therefore, other male members of the family
) j6 v3 y' _6 }7 V; l3 Qmay have similar precocious puberty.3
1 G0 _/ U0 G' X* f+ @6 cIn our patient, physical examination was incon-6 `- ~. J  c. Z/ ~. ~3 V
sistent with true precocious puberty since his testi-
1 u& S# C3 ?0 A  b$ Jcles were prepubertal in size. However, testotoxicosis, @5 d0 `0 R% v5 |, M2 W
was in the differential diagnosis because his father
8 H/ I; A/ E! p7 ~0 {started puberty somewhat early, and occasionally,7 X/ g7 Q: k) c8 W' s' F
testicular enlargement is not that evident in the: u/ u, ~6 m5 u
beginning of this process.1 In the absence of a neg-1 \% K  i0 i% e: K- S/ N
ative initial history of androgen exposure, our
5 f: {8 v  |2 I+ L* M# _0 wbiggest concern was virilizing adrenal hyperplasia,$ F$ |' |, u) g8 s0 m
either 21-hydroxylase deficiency or 11-β hydroxylase( k7 V  {; v* p( V4 y
deficiency. Those diagnoses were excluded by find-" _2 M1 x& l8 |5 y/ f' K) `
ing the normal level of adrenal steroids.
/ N' E1 n! H8 a4 w  ^3 ^The diagnosis of exogenous androgens was strongly( s' L9 i( ]5 z& j9 L7 R7 {  h
suspected in a follow-up visit after 4 months because" \7 O" W7 U, i. I
the physical examination revealed the complete disap-
) D& y, ~- X0 R7 |8 B3 D' cpearance of pubic hair, normal growth velocity, and
6 B2 h$ Y' m0 K2 E" M& fdecreased erections. The father admitted using a testos-/ i) ]; c  |- c
terone gel, which he concealed at first visit. He was
8 R+ ^' P: r- `( V9 Y1 f$ P5 Kusing it rather frequently, twice a day. The Physicians’
! u2 P  ^8 h7 A$ r% L' k) BDesk Reference, or package insert of this product, gel or! d- s) x+ ?* ^8 J5 c2 e( y: F
cream, cautions about dermal testosterone transfer to  C1 s( w$ v/ B
unprotected females through direct skin exposure.. ?2 y9 q6 S$ C$ \7 L' K
Serum testosterone level was found to be 2 times the
! P) y2 M$ o0 y" V# n) Ubaseline value in those females who were exposed to" `: [. l8 X4 d; r- D5 f
even 15 minutes of direct skin contact with their male1 Y- g: u- i1 }# N; Y( ?& |1 Z% j
partners.6 However, when a shirt covered the applica-4 z( ^: N1 }+ C& F8 f: N
tion site, this testosterone transfer was prevented.4 F! w1 d, j, W2 p- ?
Our patient’s testosterone level was 60 ng/mL,
" d# g, E: s' _% T6 H% Xwhich was clearly high. Some studies suggest that
# |1 ]. z7 l. b5 U' C$ gdermal conversion of testosterone to dihydrotestos-, @& p3 T  Y6 s7 k/ A
terone, which is a more potent metabolite, is more0 f7 i4 A" W# j% Y( }# G
active in young children exposed to testosterone2 n8 O. [+ }+ B- P4 N* p
exogenously7; however, we did not measure a dihy-' C9 s% F2 b* G6 S. ^8 D
drotestosterone level in our patient. In addition to
; l' e5 h! k1 D5 s8 Jvirilization, exposure to exogenous testosterone in6 a$ \% e! [+ C' ]* M
children results in an increase in growth velocity and
$ n  v6 I/ Y' E7 g7 }advanced bone age, as seen in our patient.
& S* }: d+ c* _* m' oThe long-term effect of androgen exposure during' k9 S/ F; P& R
early childhood on pubertal development and final' j7 F3 V; [2 k& `
adult height are not fully known and always remain6 O+ O$ E4 y8 E$ y
a concern. Children treated with short-term testos-3 R/ R; i! W9 D, t, j
terone injection or topical androgen may exhibit some
* m0 K. T/ V! `  g! }acceleration of the skeletal maturation; however, after! U' K  L- N4 E* v1 o
cessation of treatment, the rate of bone maturation$ j6 ?# v6 L3 t1 _9 u7 u' b
decelerates and gradually returns to normal.8,9% u# y+ R3 v; d
There are conflicting reports and controversy
1 n, ~  N( U+ |+ ]) X4 Qover the effect of early androgen exposure on adult1 U# c3 z7 t- u/ u" z
penile length.10,11 Some reports suggest subnormal
) e, f6 s: ~. R4 Qadult penile length, apparently because of downreg-/ A8 G5 f) J) a9 R, w1 I
ulation of androgen receptor number.10,12 However,3 d  y3 L, k; P* c
Sutherland et al13 did not find a correlation between
5 W# M: ~  d) _  R! ~$ b1 H! G5 Ochildhood testosterone exposure and reduced adult
- o' G, I; Q  Q7 m; v6 a2 `penile length in clinical studies.
' J0 h5 l/ {' m* z# LNonetheless, we do not believe our patient is
: ^! F3 N' v$ K$ |- Ygoing to experience any of the untoward effects from: x5 @$ t" E% G) U5 h+ r; w: q
testosterone exposure as mentioned earlier because
) ~6 Q( i. D0 rthe exposure was not for a prolonged period of time.* F9 o) ]1 i3 L2 D3 y5 h
Although the bone age was advanced at the time of
8 r; A$ k5 O/ W5 ldiagnosis, the child had a normal growth velocity at
$ x7 z4 k1 u2 r0 g, vthe follow-up visit. It is hoped that his final adult
5 |% W5 s. @' E+ o( E, H: lheight will not be affected.
8 L) O5 W# R$ J/ X$ q# QAlthough rarely reported, the widespread avail-
7 A7 _/ U! G9 L4 X4 e3 N- m' R. g2 v, r# {ability of androgen products in our society may
5 k  S: Z5 i' o- S( F) a. oindeed cause more virilization in male or female( D! |+ ~0 c$ ?1 a% d' t" ?- i
children than one would realize. Exposure to andro-
$ x+ U! Y+ _0 o$ Vgen products must be considered and specific ques-
2 T; l$ g0 \" }tioning about the use of a testosterone product or6 g" H' @" p$ B0 p' o, Q1 g
gel should be asked of the family members during$ H) F1 k' ]6 y$ C
the evaluation of any children who present with vir-
& \: H5 y0 o5 p. M+ t7 Wilization or peripheral precocious puberty. The diag-) r' t1 B! A6 a2 r5 W% U
nosis can be established by just a few tests and by
4 [" r* ?( d3 ?appropriate history. The inability to obtain such a
- m$ X- H4 {+ @# Xhistory, or failure to ask the specific questions, may4 [' I2 w3 |7 M" A5 s; v
result in extensive, unnecessary, and expensive* [/ u; X9 N8 c# v. |  u$ H
investigation. The primary care physician should be
5 D! G8 S& D2 ~! Waware of this fact, because most of these children
8 ^0 ?8 h2 B5 p3 R  ]5 dmay initially present in their practice. The Physicians’
' F- S% H, F7 [; p8 l1 BDesk Reference and package insert should also put a
2 P5 V$ e0 ~  a; d4 X% dwarning about the virilizing effect on a male or
. f. {; u4 l1 ~female child who might come in contact with some-
9 x5 W4 t9 k/ W% S+ P. Qone using any of these products.4 o8 R. @/ P" a2 z
References# w% [, {" n# U8 b
1. Styne DM. The testes: disorder of sexual differentiation
3 N1 I1 ?4 e: k1 N! `and puberty in the male. In: Sperling MA, ed. Pediatric" N. b3 p. H- {  G- e. i
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! Q. d9 n0 D* ?! a0 ^2002: 565-628.- F$ B" s6 t: Y. K$ H
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
# X9 G+ {0 ]. d6 O- vpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
; J0 ~+ i: \) T) kBoy Induced by Indirect Topical
. l7 H+ P. [$ o/ n0 F; J' LExposure to Testosterone; V; u. M8 Y4 m$ }. {' x( X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ i0 n6 s, x5 j0 f( O7 X- O  kand Kenneth R. Rettig, MD1. c- z2 @' C9 U; t: M
Clinical Pediatrics& o# I( {$ ^; K5 |
Volume 46 Number 6& T/ ]4 S2 M8 d8 \* K5 ^- W
July 2007 540-543
5 x6 r. N) M7 u7 Z1 B: x© 2007 Sage Publications
; V1 y2 C9 `# i3 ]3 z( [$ l10.1177/0009922806296651( T5 P  d( ?6 I& v
http://clp.sagepub.com
3 L- S* T: h- }. P+ bhosted at
, S* y, B" |$ d0 y1 V# zhttp://online.sagepub.com
" q8 {2 L8 `3 n0 n, E5 m% `Precocious puberty in boys, central or peripheral,2 P; _2 _8 e, r
is a significant concern for physicians. Central& A) Q5 M. ^  T. D6 T$ u8 L2 l) ^
precocious puberty (CPP), which is mediated5 Y% a! K) }( R& ^/ ], U
through the hypothalamic pituitary gonadal axis, has0 m  q& ]  C4 m8 v0 \' m: G; g+ k
a higher incidence of organic central nervous system
( {3 r5 Q' O# L8 Q$ Z0 V3 J8 e) flesions in boys.1,2 Virilization in boys, as manifested4 ]6 q4 P' h! d. \$ w; u  s5 g! w
by enlargement of the penis, development of pubic# L" `6 H9 j2 a: k2 U
hair, and facial acne without enlargement of testi-  u2 A4 m6 h: V
cles, suggests peripheral or pseudopuberty.1-3 We# I2 j1 H* L6 ~& V3 A9 E( o
report a 16-month-old boy who presented with the( h! c: _" Y; o2 @& L7 w2 `
enlargement of the phallus and pubic hair develop-' _4 F) G; f6 X0 q- a$ g
ment without testicular enlargement, which was due  r/ B' u1 x5 I' E
to the unintentional exposure to androgen gel used by* w1 c) w3 ^( V) g
the father. The family initially concealed this infor-
6 d; g' e1 _4 q5 c$ L% smation, resulting in an extensive work-up for this
- h; O% y  `9 |) W$ i- R; Y9 mchild. Given the widespread and easy availability of, y0 d1 j7 h( r- O: Q/ v
testosterone gel and cream, we believe this is proba-" D* ]1 x- D/ p3 r9 R
bly more common than the rare case report in the
. W% D# v* H/ sliterature.4& u( {1 m+ a) l0 `) K: G
Patient Report
$ Q2 t  p2 |2 M; O5 o6 ]A 16-month-old white child was referred to the
. m' ~0 J7 J7 P/ Cendocrine clinic by his pediatrician with the concern
7 T7 E4 M' L8 d7 n7 }1 H6 aof early sexual development. His mother noticed
5 m. t1 M; l  `) `! Rlight colored pubic hair development when he was
- T9 z, [1 }# P1 s8 Q8 MFrom the 1Division of Pediatric Endocrinology, 2University of# b) O) O1 N0 I
South Alabama Medical Center, Mobile, Alabama.0 \# Q) H' z/ n! p
Address correspondence to: Samar K. Bhowmick, MD, FACE,
+ y" s( b( r' O1 eProfessor of Pediatrics, University of South Alabama, College of2 t+ q6 T6 [( \& ?) x% X; S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 T6 A& X& z' X! h9 ~: l0 k( ?1 je-mail: [email protected].
4 v; x. J: A6 B! c: |about 6 to 7 months old, which progressively became
3 V% D4 R$ p) d% c. Odarker. She was also concerned about the enlarge-
* \7 n: q* n2 S& k1 K( i7 s8 X* K' Oment of his penis and frequent erections. The child' I' i' N/ y- ^
was the product of a full-term normal delivery, with) {0 Y4 }5 {% L6 Z) R( ~! q0 B
a birth weight of 7 lb 14 oz, and birth length of
) K) M% ~9 d7 j20 inches. He was breast-fed throughout the first year4 L; c1 V# l( z# d: i4 e- F1 i( j
of life and was still receiving breast milk along with
9 ~2 C+ V- _- |( f. x# Tsolid food. He had no hospitalizations or surgery,
8 |: P( R- k4 X: Y$ ]0 j; |6 Dand his psychosocial and psychomotor development
* r! r. X5 O9 [  v" a/ q. r! Zwas age appropriate.
# A5 O' d$ n& VThe family history was remarkable for the father,
. v  T- s8 j7 A+ d1 y0 `- Awho was diagnosed with hypothyroidism at age 16,
/ P: t( |0 I/ ^7 U( g5 Swhich was treated with thyroxine. The father’s
% m: m2 K0 T0 ]" \+ _height was 6 feet, and he went through a somewhat
' K( u3 ~' r% k, q& b+ `* P% y" c& {; Tearly puberty and had stopped growing by age 14.  ?! ^* m6 l' \. k5 A( B$ K+ f
The father denied taking any other medication. The
; P; z5 z; B5 S4 a* q' Qchild’s mother was in good health. Her menarche
/ u/ W2 ]: d5 m+ v6 O9 G8 ]was at 11 years of age, and her height was at 5 feet1 f! Q6 h& F) t
5 inches. There was no other family history of pre-0 n; e6 Y2 m& ]; I0 ?
cocious sexual development in the first-degree rela-
1 `1 H, G6 W3 {+ Gtives. There were no siblings.7 ]; |8 H1 c& g  N
Physical Examination/ V) D5 f9 K" J" d- o
The physical examination revealed a very active,
2 t+ p; A4 U9 F8 T9 v" |$ \playful, and healthy boy. The vital signs documented
/ ~& ]# m- R4 k: ?3 oa blood pressure of 85/50 mm Hg, his length was
& f' i5 R$ t# w4 d! j90 cm (>97th percentile), and his weight was 14.4 kg: d% u5 g0 k* R
(also >97th percentile). The observed yearly growth
3 w/ D) g0 @- Y# _7 }  N6 |& uvelocity was 30 cm (12 inches). The examination of8 l& d& }2 g  ~% ^9 O; x
the neck revealed no thyroid enlargement.
/ F6 t7 d1 t9 Z9 [% [The genitourinary examination was remarkable for
% K0 Z2 G* M5 S* W) aenlargement of the penis, with a stretched length of6 m( v* @& q1 B, |' y$ R5 K  p
8 cm and a width of 2 cm. The glans penis was very well
& T% r+ I: K! ?6 F& @developed. The pubic hair was Tanner II, mostly around
# S! o# `8 s- m- P0 Z5406 {0 O* p& e5 V% ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& Q9 K  s7 X( n, c' Z( @% D' Sthe base of the phallus and was dark and curled. The3 Y# D3 y1 A4 R( h) A
testicular volume was prepubertal at 2 mL each.
) Q- I5 D2 Y8 \: j% XThe skin was moist and smooth and somewhat
3 Y) v% K- w0 a9 Uoily. No axillary hair was noted. There were no
) E# b9 b- H/ Z  p4 L% k5 jabnormal skin pigmentations or café-au-lait spots.. [1 p( R( c7 v4 e
Neurologic evaluation showed deep tendon reflex 2+- r4 I: s  @# Q, H. J# w. m0 y
bilateral and symmetrical. There was no suggestion% [( ]/ b9 o& L
of papilledema.
) t& `$ z) p% q3 r! `Laboratory Evaluation1 O1 V+ ]" |: N8 |
The bone age was consistent with 28 months by# N) c6 ]$ a7 I1 r  U
using the standard of Greulich and Pyle at a chrono-- s1 S; Q% Q; t0 A& K6 W4 P4 {
logic age of 16 months (advanced).5 Chromosomal6 A% f. ]& Z; m' I  S0 M2 H/ ?! r5 M1 h
karyotype was 46XY. The thyroid function test
* P& M# G3 g) L( C3 o; R, O7 u( bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
% W) j; Z; c, K7 M- P+ u2 Hlating hormone level was 1.3 µIU/mL (both normal).
6 N: B% _  c; Y; j" f4 a. t+ wThe concentrations of serum electrolytes, blood
4 V: a  T" R2 s3 c/ o) curea nitrogen, creatinine, and calcium all were
6 A7 U+ J% E2 o0 Qwithin normal range for his age. The concentration  X2 i4 y# v* I; v1 [' A" L' J
of serum 17-hydroxyprogesterone was 16 ng/dL
" i2 w! R( ]. Q. ^4 P9 e( F(normal, 3 to 90 ng/dL), androstenedione was 20: ~" R) M- F* p( x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 x, H* W% Z/ [/ qterone was 38 ng/dL (normal, 50 to 760 ng/dL),/ ^+ L4 z* _3 Y0 M" z7 W
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 j# ]6 O; s  e" ?; S! ]
49ng/dL), 11-desoxycortisol (specific compound S)& Z; o  B  J0 G; Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% B) k' H) U# Wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; ]0 m- O# n3 O$ N, j  A: M% gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),0 l! F+ Z$ d: a1 W# e1 g' K% m3 C1 R
and β-human chorionic gonadotropin was less than7 t& B: _7 J. J9 D8 \. ?& d  H
5 mIU/mL (normal <5 mIU/mL). Serum follicular% v( h/ O/ V( @9 a/ M1 x$ n
stimulating hormone and leuteinizing hormone; }+ \/ f$ ~7 g& U- V4 j
concentrations were less than 0.05 mIU/mL4 P1 t6 a5 m- O- e2 x
(prepubertal).2 D- ]- q& y# q% R# C3 y) {
The parents were notified about the laboratory
2 U; ~2 |+ j6 Q5 Jresults and were informed that all of the tests were
  |. _" ~1 n5 ?0 pnormal except the testosterone level was high. The1 c0 V! N3 v0 o5 S5 r  T
follow-up visit was arranged within a few weeks to
3 L" ?3 ?* B  O7 ^) wobtain testicular and abdominal sonograms; how-
2 Q% {9 p& K# k* xever, the family did not return for 4 months.+ T; @$ p/ P+ P4 s  L% I
Physical examination at this time revealed that the
6 c* X3 }2 v/ j$ z% Q8 D0 {child had grown 2.5 cm in 4 months and had gained
8 P/ p2 e& e; P/ X2 kg of weight. Physical examination remained
" _, K# \' J" T4 Vunchanged. Surprisingly, the pubic hair almost com-
2 [# r( \% p! k3 vpletely disappeared except for a few vellous hairs at
6 V' ~; ?3 l- d3 K& _! tthe base of the phallus. Testicular volume was still 2
6 t3 z$ f) c% J) g; ^mL, and the size of the penis remained unchanged.
% \+ o" z) I! [' R. }The mother also said that the boy was no longer hav-
) B3 Z( e2 @' V3 G/ J5 Fing frequent erections.! o( H. Q7 t# Q' D6 M$ o
Both parents were again questioned about use of3 _) J% W% [- p: z2 @% o* p
any ointment/creams that they may have applied to
' O% S2 U) Q- `9 ]the child’s skin. This time the father admitted the
2 h/ Y6 j/ K  U  U$ a) A; W2 lTopical Testosterone Exposure / Bhowmick et al 541
5 ]; P: G, Y7 f9 C6 Q# buse of testosterone gel twice daily that he was apply-
1 l+ V- s) q; Ring over his own shoulders, chest, and back area for
! g2 D8 L' N: Ta year. The father also revealed he was embarrassed, n9 Z) p  B1 F* R* a$ N6 Y
to disclose that he was using a testosterone gel pre-
4 X0 ]% K3 V  M& m+ T8 Oscribed by his family physician for decreased libido: o7 Y. k8 C4 \* ^/ Y% y8 P
secondary to depression.
$ |% c1 j6 a+ ~The child slept in the same bed with parents.( E0 U/ S/ p/ T. N2 ~
The father would hug the baby and hold him on his( s9 Z1 p* ~. I  e/ u' L. a
chest for a considerable period of time, causing sig-0 b) G" R, N0 e
nificant bare skin contact between baby and father.- c: W7 w  K* \4 Z8 y, w; D
The father also admitted that after the phone call,
" j/ d. D" E2 I' A" ~8 qwhen he learned the testosterone level in the baby1 C/ `) o! p& E" T9 s& h( J
was high, he then read the product information
( P  _7 j# C0 w: w. z6 ]packet and concluded that it was most likely the rea-3 [/ `/ @# X" h: X* E  {
son for the child’s virilization. At that time, they& k- [% g8 _9 y4 q" s  I  G
decided to put the baby in a separate bed, and the
3 z8 K+ d6 f$ J# V4 |father was not hugging him with bare skin and had
5 X4 {$ a% U, \# A: f2 q  n2 V  Lbeen using protective clothing. A repeat testosterone
1 n: B& U3 W: l1 s, V8 f: g2 ztest was ordered, but the family did not go to the
% b- W( l& M2 B9 t, n+ llaboratory to obtain the test.8 J/ a: p- S3 G( o6 }7 L' `, a. [
Discussion* W; V6 i2 Z% k7 F6 Y/ k
Precocious puberty in boys is defined as secondary
5 p. q1 ~! {: q+ fsexual development before 9 years of age.1,4
0 O! E  G+ H6 H" `Precocious puberty is termed as central (true) when, r/ F" U: a( W8 Y8 m
it is caused by the premature activation of hypo-! U  f9 \8 k: t3 r' W
thalamic pituitary gonadal axis. CPP is more com-
& k- r& I2 M. t! }) S, ]! Xmon in girls than in boys.1,3 Most boys with CPP0 X/ D8 N( [; Y, {) _
may have a central nervous system lesion that is5 g1 K% k, t2 D0 m8 R
responsible for the early activation of the hypothal-' r% C7 @+ ]. P
amic pituitary gonadal axis.1-3 Thus, greater empha-
  \5 A7 T* r/ {- q, z) }; Ksis has been given to neuroradiologic imaging in7 l% F$ X' z" B# A
boys with precocious puberty. In addition to viril-3 V! s9 N6 L3 l
ization, the clinical hallmark of CPP is the symmet-
5 ~7 }* K' a# M: m1 arical testicular growth secondary to stimulation by* P! B  k  A4 _. O  Y5 ]
gonadotropins.1,3' B0 o/ u8 S$ d9 Z' t$ f5 B$ e
Gonadotropin-independent peripheral preco-
/ W8 J! q' K* P7 i% ^3 q, I) l; lcious puberty in boys also results from inappropriate
6 `5 H" `3 i, R$ E# z& B" _6 Candrogenic stimulation from either endogenous or
9 G: W) r5 A0 W/ k; \0 O' N( j# Kexogenous sources, nonpituitary gonadotropin stim-
% h" ?+ t2 Y- _* v- Eulation, and rare activating mutations.3 Virilizing
5 W7 F. v( q3 O0 |; g) {' lcongenital adrenal hyperplasia producing excessive
, v2 N- f. t- a# uadrenal androgens is a common cause of precocious- g9 C  V- z: h0 ?% W4 d
puberty in boys.3,4  [& n( p/ y& l& E
The most common form of congenital adrenal0 r3 |6 t# u: w$ F0 H
hyperplasia is the 21-hydroxylase enzyme deficiency., e. j$ W7 h, B! ], O" E  @0 C
The 11-β hydroxylase deficiency may also result in
+ ]8 y- Z9 l. _( }1 Dexcessive adrenal androgen production, and rarely,; o. O% b. q! c7 p
an adrenal tumor may also cause adrenal androgen
4 ^8 X7 [. R! P) p' j7 `excess.1,3  O. W) ?; L5 S8 G" X* A& {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ u' e% \% \. Y: x! K( W
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, L: g9 c( h; F5 T" W
A unique entity of male-limited gonadotropin-
7 c$ C2 g* b1 r7 e: \8 q1 n# Xindependent precocious puberty, which is also known- l2 L- r' A: y# }( n* i- S5 X0 l
as testotoxicosis, may cause precocious puberty at a4 r  Z7 i  ?7 E  n/ g/ N; h
very young age. The physical findings in these boys+ E/ e$ `+ |( ~' n
with this disorder are full pubertal development,0 {$ q4 T% W1 T" Z4 q8 k
including bilateral testicular growth, similar to boys  E1 }8 _- g6 t
with CPP. The gonadotropin levels in this disorder- Y# a$ K, l$ S1 \: v3 y
are suppressed to prepubertal levels and do not show
" ^% V( e) f. G1 F* K" ~( a3 _pubertal response of gonadotropin after gonadotropin-
0 F3 i# N; Q' B. ~8 a7 K1 areleasing hormone stimulation. This is a sex-linked# j! Z, E1 {: Y
autosomal dominant disorder that affects only
) u  u: D" B; p' ^males; therefore, other male members of the family
3 e' Y7 O0 g. Y! gmay have similar precocious puberty.3
# X* E$ K; X" PIn our patient, physical examination was incon-
7 P3 u$ h2 C! C) n( d7 ksistent with true precocious puberty since his testi-
  T9 v5 W* u0 [cles were prepubertal in size. However, testotoxicosis6 ^6 ]6 o" C# R4 q0 s+ L
was in the differential diagnosis because his father
5 O1 u2 Z9 w  |, U0 `$ Sstarted puberty somewhat early, and occasionally,
2 E7 l& D1 X- H8 U9 H9 p/ L( etesticular enlargement is not that evident in the
- j- M, [, }0 Q" e- Ybeginning of this process.1 In the absence of a neg-4 s* f& I! [* a3 C$ j
ative initial history of androgen exposure, our
) V/ q2 W1 R" E( X% jbiggest concern was virilizing adrenal hyperplasia,- c4 C, B- I% ~  t( W6 k0 b
either 21-hydroxylase deficiency or 11-β hydroxylase
# T. Z* U. n6 Y, R8 Xdeficiency. Those diagnoses were excluded by find-
3 T0 p! o* b2 c4 x% E( ?: ~" Jing the normal level of adrenal steroids.
) n2 Q* M/ e* ^8 z7 l% cThe diagnosis of exogenous androgens was strongly
2 t( F3 T3 T$ y8 ^- Msuspected in a follow-up visit after 4 months because' x4 c4 u  V; a
the physical examination revealed the complete disap-
8 F& i6 A( @/ c( I1 V( lpearance of pubic hair, normal growth velocity, and8 p) C# k3 A7 S, c9 U
decreased erections. The father admitted using a testos-' D: T' E% Y# A1 M% @/ i
terone gel, which he concealed at first visit. He was7 A) K3 @, [9 N
using it rather frequently, twice a day. The Physicians’" T% w  m, |# r
Desk Reference, or package insert of this product, gel or" i3 C0 f: |! ]
cream, cautions about dermal testosterone transfer to/ g* K/ C( c8 D" E2 s
unprotected females through direct skin exposure.1 T+ T% v5 ~1 M+ d$ I* g' s
Serum testosterone level was found to be 2 times the
" G5 ~/ m% A, R  n# mbaseline value in those females who were exposed to
3 v4 l' F& M% {9 b# e  R* Eeven 15 minutes of direct skin contact with their male9 U9 [% ~) _  E+ i  R
partners.6 However, when a shirt covered the applica-
- x8 ~, r0 i2 J3 Ktion site, this testosterone transfer was prevented.- `3 S8 @& J$ a! |! Y
Our patient’s testosterone level was 60 ng/mL,6 I, t' K5 f; M: H
which was clearly high. Some studies suggest that  e0 D  |+ n) g$ L3 ]+ c) @
dermal conversion of testosterone to dihydrotestos-
: H/ P0 o9 q! D( s9 U, Oterone, which is a more potent metabolite, is more6 K* t2 u: y7 \  W- B& Y
active in young children exposed to testosterone
" m) h4 R# W6 H; \exogenously7; however, we did not measure a dihy-: R  j! ^% f. v7 E, b* W
drotestosterone level in our patient. In addition to
% k% R$ j9 }- A- T, c" I8 h1 Xvirilization, exposure to exogenous testosterone in
! p" C# S! c0 v6 [1 j  q& Uchildren results in an increase in growth velocity and5 P, `+ j1 N; G: z
advanced bone age, as seen in our patient.
8 z* A& Z$ l2 |" hThe long-term effect of androgen exposure during
2 f+ _- O, }" y" t: r4 R9 gearly childhood on pubertal development and final. T0 v4 u3 ~; E- W
adult height are not fully known and always remain+ n6 Z, D! n* l  F( ^! U3 u
a concern. Children treated with short-term testos-
. I9 j: c/ a: U& Hterone injection or topical androgen may exhibit some
' l# {# n. r7 o8 s2 {acceleration of the skeletal maturation; however, after9 A: H) r. \5 I) o/ B* C: J
cessation of treatment, the rate of bone maturation7 k& p% ~. @2 ]; p2 v* G
decelerates and gradually returns to normal.8,9; E) p; M. E% w/ a1 d* k
There are conflicting reports and controversy
; r! F& ?; {; j/ y5 Xover the effect of early androgen exposure on adult
) F* k! O) P2 H! d& L/ gpenile length.10,11 Some reports suggest subnormal
& M2 T& C3 f- z4 l4 E2 }& Nadult penile length, apparently because of downreg-
# r; ~7 Q7 U3 ]: i# wulation of androgen receptor number.10,12 However,
& s4 }3 Z4 m* Q$ ESutherland et al13 did not find a correlation between+ E$ Z$ q  k* B5 P& ]& [% B
childhood testosterone exposure and reduced adult  n$ C( K3 L: j
penile length in clinical studies.
, {. i* X+ |, ANonetheless, we do not believe our patient is
" b# _$ ?2 U; z$ N& Tgoing to experience any of the untoward effects from
3 f$ \# e3 [- i# p! qtestosterone exposure as mentioned earlier because9 x/ G8 g! _+ K. \& C9 A5 W' N
the exposure was not for a prolonged period of time.
/ [- v1 q+ J4 W$ q& hAlthough the bone age was advanced at the time of' |* y  q2 |& h0 l  e
diagnosis, the child had a normal growth velocity at
- y+ \  O- P/ C5 P* k4 ~the follow-up visit. It is hoped that his final adult7 j2 [5 L; w# }8 J' ~
height will not be affected.
3 E. s# X" V; C! |4 w9 QAlthough rarely reported, the widespread avail-
% i1 F. L0 f- F( W1 h' }ability of androgen products in our society may6 x5 z7 ^! V' K% O
indeed cause more virilization in male or female% G9 Z$ C; P1 I& w
children than one would realize. Exposure to andro-
% t, S, \- E6 F9 \! ~  kgen products must be considered and specific ques-
, h0 V+ m! }* V6 h! [tioning about the use of a testosterone product or4 d" H, p1 _1 F6 C+ D
gel should be asked of the family members during
6 E9 P' X  X( K+ C9 V" {/ ~* _2 t' gthe evaluation of any children who present with vir-9 T8 R1 @! N* |* ]& S
ilization or peripheral precocious puberty. The diag-$ i) Q8 n, r) y
nosis can be established by just a few tests and by
# V! b" }  T1 g; z" U0 {appropriate history. The inability to obtain such a) ^) X' ~+ e' t; J4 p) i4 a  N
history, or failure to ask the specific questions, may
- R% m' W& y! z, g3 k/ oresult in extensive, unnecessary, and expensive
& p! X  R! A* D2 c6 A. D+ E  Ginvestigation. The primary care physician should be
8 }! n9 O5 Y+ X5 D! Haware of this fact, because most of these children9 S# H* J# Y4 ^6 L  T/ [
may initially present in their practice. The Physicians’
7 a- c0 M* F' G/ |3 ?4 B2 b7 [4 JDesk Reference and package insert should also put a
, o2 m$ o. D1 `( k* y* w  Xwarning about the virilizing effect on a male or! q, X: f% j: v. j* _8 Z# k
female child who might come in contact with some-0 X  v- C' G- s  X/ z$ X# [
one using any of these products.% s6 s$ C7 `& E, P4 @" x. b
References# a, R& i2 e; K2 C* x" j5 q
1. Styne DM. The testes: disorder of sexual differentiation' X9 j( e0 M  h6 n$ m
and puberty in the male. In: Sperling MA, ed. Pediatric
8 w& f0 `8 s: {: r3 ^$ rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% g. u- L2 G, z
2002: 565-628.
4 s( ]- m! j; n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 [7 l. ?4 K( a  T& Npuberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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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
; W9 d, v6 t2 }; {7 s* 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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