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Sexual Precocity in a 16-Month-Old  @2 [! P4 j' U
Boy Induced by Indirect Topical
3 y- _3 r' e2 D. F6 }2 YExposure to Testosterone# _( \7 p9 j5 T/ N4 W  o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; A# F6 B1 z6 ^5 l$ E2 q% eand Kenneth R. Rettig, MD1( |; m+ U, _7 N1 j1 P
Clinical Pediatrics8 J9 @, T( W5 G7 C4 u0 ]1 E) O
Volume 46 Number 6+ N9 g6 X1 V; _) C
July 2007 540-543  f( K$ _$ {, s/ v( `4 b$ p
© 2007 Sage Publications
' `5 n: y! T" I/ w( L10.1177/0009922806296651
) o: c, O* s" Q* ]0 yhttp://clp.sagepub.com
! f3 O+ I9 i, Q. shosted at5 ~/ ^) O* @+ E
http://online.sagepub.com
* X* M- {0 b0 x5 [8 YPrecocious puberty in boys, central or peripheral,
  j! s5 f" [$ l- O+ {  w+ ris a significant concern for physicians. Central
% p$ H' P. H. h% m( S0 s1 T0 Vprecocious puberty (CPP), which is mediated% u. E& F0 M8 Z& i6 l1 g
through the hypothalamic pituitary gonadal axis, has
7 Q+ w& u8 B7 M( Z1 ?a higher incidence of organic central nervous system
. o! A( y- v0 P2 i+ Glesions in boys.1,2 Virilization in boys, as manifested
" a  r  A! F; r! eby enlargement of the penis, development of pubic
/ d% {. x2 w/ r+ ]hair, and facial acne without enlargement of testi-* K( T9 A- S  J& `
cles, suggests peripheral or pseudopuberty.1-3 We' Y9 n: n; m( |1 j
report a 16-month-old boy who presented with the
" Z6 y/ b  [3 E. y; N9 X: benlargement of the phallus and pubic hair develop-
9 u: Y" ^+ l# q  S- F3 mment without testicular enlargement, which was due( B4 Z/ ~' Q  V& z3 W6 P6 H6 T
to the unintentional exposure to androgen gel used by/ v! t7 S7 ]! ?* v# s/ W, K( B6 I. l
the father. The family initially concealed this infor-
/ _. B3 R' |3 O3 V/ Jmation, resulting in an extensive work-up for this, @6 ~- c# T% P* H
child. Given the widespread and easy availability of
3 X8 P1 U& N) w, ptestosterone gel and cream, we believe this is proba-+ }8 ~% Z5 s* }0 q2 y" b4 i" t
bly more common than the rare case report in the  G9 l3 f' n* m- q2 }6 h3 s
literature.4- ~- M2 c# x% C1 g+ O
Patient Report
' h; Y3 O, E( a! V7 l. T( N' T0 U, QA 16-month-old white child was referred to the! s7 c7 X- v  u5 h) b
endocrine clinic by his pediatrician with the concern
( L2 E( g/ x- `' K: r( ^of early sexual development. His mother noticed
/ ]; \" D6 ~- L* ], H# K7 w9 E0 clight colored pubic hair development when he was
4 L. G6 |, k+ @* r  W6 A* t0 }From the 1Division of Pediatric Endocrinology, 2University of& E' d9 d9 g' O  Q1 T
South Alabama Medical Center, Mobile, Alabama.& Q0 x6 y' }8 n. G" A
Address correspondence to: Samar K. Bhowmick, MD, FACE,+ n  U/ Z$ m) H1 [, s! p' ^/ V
Professor of Pediatrics, University of South Alabama, College of
) m/ B* R- K5 D' m4 T5 zMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( G2 N7 `; W" L  x7 [
e-mail: [email protected]./ z& H9 u1 p" W7 E5 h3 Q$ t3 |
about 6 to 7 months old, which progressively became- E% ^! w$ c2 V) i. j3 F
darker. She was also concerned about the enlarge-% K7 h) z, O" f* \: y/ s, O! ^
ment of his penis and frequent erections. The child
' t( L6 b" n" `- d9 L, X; Iwas the product of a full-term normal delivery, with
  H5 w9 t" O( o. f  I' I! Xa birth weight of 7 lb 14 oz, and birth length of7 W! _  K; O" k
20 inches. He was breast-fed throughout the first year
9 G+ U% O5 T' E: |# r  m" O: U6 T, oof life and was still receiving breast milk along with
7 K& r% K( H! [% V$ N7 ?solid food. He had no hospitalizations or surgery,
3 K$ W9 f5 Q% `and his psychosocial and psychomotor development
8 f0 \8 F( ^$ Y2 ]: Z" m6 ]- Kwas age appropriate.
1 P8 y) m! m; I# L* y$ \The family history was remarkable for the father,. J  F5 B# Y4 Q$ S# r. h. [0 x  O9 m# s0 p
who was diagnosed with hypothyroidism at age 16,
% r; b4 i* u0 H9 F$ z0 |) f3 owhich was treated with thyroxine. The father’s9 E# d$ t3 B  [/ Y: A' M6 b
height was 6 feet, and he went through a somewhat+ j1 q" b! \: X, B% K
early puberty and had stopped growing by age 14.4 w7 N' J" q# Y# t# f4 |
The father denied taking any other medication. The
: T. b4 s" \" J$ Z1 Z9 lchild’s mother was in good health. Her menarche; J' I8 R- u' X3 A0 B
was at 11 years of age, and her height was at 5 feet
8 Y% `$ d7 U$ k5 inches. There was no other family history of pre-
$ a6 i+ s1 `9 {+ O  n. |- qcocious sexual development in the first-degree rela-
2 _' {- O; }3 }8 [8 ftives. There were no siblings.( @* L. v+ d# {/ Y2 w1 g
Physical Examination
8 U6 l6 O# t4 u2 p1 T/ JThe physical examination revealed a very active,
/ s0 \$ R; w; b4 y8 r# V" C# Hplayful, and healthy boy. The vital signs documented$ ~! c1 \: O) d. p0 X
a blood pressure of 85/50 mm Hg, his length was
. }. b# b% `: ?0 O; C% k- a7 o# j90 cm (>97th percentile), and his weight was 14.4 kg, i5 `- Z! `. V, G; U
(also >97th percentile). The observed yearly growth
4 {6 ~0 W/ ^, Fvelocity was 30 cm (12 inches). The examination of3 H" A0 u2 g6 P' v
the neck revealed no thyroid enlargement.# K5 P& c- M! ]0 Q$ h* I
The genitourinary examination was remarkable for
, ?9 R# Q% Y  {2 e  F% I) `5 uenlargement of the penis, with a stretched length of" _5 r! Z  x% |6 T( V* W3 H
8 cm and a width of 2 cm. The glans penis was very well5 o: X5 W7 E, v; i8 I8 ^
developed. The pubic hair was Tanner II, mostly around5 n9 d9 T# @* H& y" |4 K; ?
5402 [) o+ j, K: w- m+ R  O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 m/ ?& s5 G# q/ Cthe base of the phallus and was dark and curled. The$ o: ^6 u3 O7 d9 T! u
testicular volume was prepubertal at 2 mL each.
; P& G6 J( Z  sThe skin was moist and smooth and somewhat; k* e( p. y# L" Q
oily. No axillary hair was noted. There were no, j! c) b' C# e6 P! K+ a- n& y
abnormal skin pigmentations or café-au-lait spots.8 z' K& k# ]# E& j) c( K
Neurologic evaluation showed deep tendon reflex 2+; [8 k) V0 Q! K6 |8 w) k
bilateral and symmetrical. There was no suggestion
/ x9 r/ q* t' w' d4 H* a" h& ^of papilledema.
1 F, ]& |: b/ U. Q( {. yLaboratory Evaluation# X  z0 s! ^: P
The bone age was consistent with 28 months by
6 u* d' O9 _& p/ G$ Yusing the standard of Greulich and Pyle at a chrono-. C7 b) s  d1 h, N4 L6 i+ U
logic age of 16 months (advanced).5 Chromosomal5 @" R" C6 C7 W% }9 M
karyotype was 46XY. The thyroid function test
* Q/ b9 e& ~! g, J( k; i9 a1 e- \8 Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
- _$ E7 \4 Y6 X, e! ]: g  Z3 J- Elating hormone level was 1.3 µIU/mL (both normal)., H  ?, l4 ?' V- i/ m$ N. Q
The concentrations of serum electrolytes, blood7 n' U! z) K/ V' O
urea nitrogen, creatinine, and calcium all were, i5 |* U6 \2 t/ s4 t9 {6 e
within normal range for his age. The concentration: W, ~# S. w( v$ V1 F7 _
of serum 17-hydroxyprogesterone was 16 ng/dL
8 q0 n+ V( B7 u9 M! V(normal, 3 to 90 ng/dL), androstenedione was 20. Y( n8 ^5 l, j9 |5 v! T
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( d7 @" \* ^- Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 r9 H* z' E* f2 H' gdesoxycorticosterone was 4.3 ng/dL (normal, 7 to+ }. q( f- o/ t/ K
49ng/dL), 11-desoxycortisol (specific compound S)
/ y/ Q1 o1 U9 |9 z3 cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# l$ b' f4 o# Q+ G( K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
* n) g! G( F+ r" ]testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' H" F6 o( \% U3 T0 l
and β-human chorionic gonadotropin was less than: P' K1 {1 x6 k: \( f, i) [
5 mIU/mL (normal <5 mIU/mL). Serum follicular) A/ B; l: v0 T, M/ q& z7 m( k
stimulating hormone and leuteinizing hormone
' X! v% V4 [% o& Oconcentrations were less than 0.05 mIU/mL
/ G& _( |$ N3 N! ~(prepubertal).
; O8 m7 R6 L. vThe parents were notified about the laboratory
  S" H# k; `& k; O1 Presults and were informed that all of the tests were0 j; C3 k( Y7 P7 S, N* I) @
normal except the testosterone level was high. The
4 G4 q' c) u; Y( W  u/ Q! G2 ~follow-up visit was arranged within a few weeks to
: M) L+ `3 h: d. robtain testicular and abdominal sonograms; how-
0 D! x, R4 N2 }0 O* p$ p5 V' |0 gever, the family did not return for 4 months.3 q; v9 n' ^! c* d6 @
Physical examination at this time revealed that the
, L- [8 M/ E9 c3 C/ \5 ichild had grown 2.5 cm in 4 months and had gained
& ^- v! b1 X. r0 T; K2 kg of weight. Physical examination remained" J. B8 F8 ]' W" ]6 _
unchanged. Surprisingly, the pubic hair almost com-; G& S; g( b$ O' e& F$ R
pletely disappeared except for a few vellous hairs at7 `/ C* E; v6 I
the base of the phallus. Testicular volume was still 2
/ f' `# F4 ^3 P5 I2 m) a0 Z5 [" ]mL, and the size of the penis remained unchanged.+ h0 F4 r( n3 J  _4 Y
The mother also said that the boy was no longer hav-6 |) b$ _3 `% n( {- \" K1 f/ n
ing frequent erections.
/ P) P+ s) L, m+ ?- L& R- e: I- iBoth parents were again questioned about use of
- k8 u" n2 }+ @$ F. Z8 d5 D5 kany ointment/creams that they may have applied to" B* @% u2 C4 z# y' w# Y
the child’s skin. This time the father admitted the, ?. U$ ^# d1 G+ u" k
Topical Testosterone Exposure / Bhowmick et al 5418 s. G( s* }( m* @  |! b
use of testosterone gel twice daily that he was apply-
6 T1 ~/ U7 Z9 p9 R8 A. jing over his own shoulders, chest, and back area for# Y7 F% V; r! ^$ H- A
a year. The father also revealed he was embarrassed
1 B. C5 }- |* A+ o9 rto disclose that he was using a testosterone gel pre-
8 y  |7 B  c- Mscribed by his family physician for decreased libido0 d: d5 @* ?$ T6 M, C" H2 P  |
secondary to depression.
) C! K- ^4 F! JThe child slept in the same bed with parents.; W6 p2 \( v/ N  y
The father would hug the baby and hold him on his* t9 I/ u  [* _( _
chest for a considerable period of time, causing sig-
( s3 J' G! O! h4 W8 d$ J0 bnificant bare skin contact between baby and father.
1 ]5 Q: C: w4 v' KThe father also admitted that after the phone call,; E7 z3 T6 \7 p9 Z' t5 b
when he learned the testosterone level in the baby! {' M6 c3 h& R4 \* D& t; X* l9 f8 w
was high, he then read the product information
$ \; z5 K: S, d8 a$ i7 n6 p% _packet and concluded that it was most likely the rea-
5 z- i. [" G# x) Y; fson for the child’s virilization. At that time, they
9 k) K: ^; i. W: b* t* _& r3 Kdecided to put the baby in a separate bed, and the. J- Y, Q" z. S8 S* ]) H6 ]  f
father was not hugging him with bare skin and had8 X8 _0 [. h& {5 S) g
been using protective clothing. A repeat testosterone# n1 j/ }2 C5 a1 ^* H2 A
test was ordered, but the family did not go to the0 s4 G& j& F7 y+ d5 E& G) y
laboratory to obtain the test.5 L0 O, w  s+ l: q& [
Discussion
/ \5 O+ j+ ^! z8 oPrecocious puberty in boys is defined as secondary  K/ g& M8 v+ h3 g; q
sexual development before 9 years of age.1,41 c: h' i; A. i6 |* u; h
Precocious puberty is termed as central (true) when/ I* \* `/ z& Q% E, F0 `3 L
it is caused by the premature activation of hypo-
1 m- G" I! w2 h) nthalamic pituitary gonadal axis. CPP is more com-
7 d" V% }5 g! i! t( p% hmon in girls than in boys.1,3 Most boys with CPP) Y. O, {+ s5 p; K( ~# J
may have a central nervous system lesion that is
7 u# Y5 ^' s/ h' |# `responsible for the early activation of the hypothal-; ~$ k- C" Z2 w9 d- Q& ~7 U# g! c- ^
amic pituitary gonadal axis.1-3 Thus, greater empha-0 Z# W/ Z! p6 a9 l- p' q
sis has been given to neuroradiologic imaging in8 _7 \, u2 P% d& n
boys with precocious puberty. In addition to viril-, O1 I0 Q# m4 i! M/ l- u6 s
ization, the clinical hallmark of CPP is the symmet-
8 V* c% g% C. m4 Crical testicular growth secondary to stimulation by' t6 _6 T( h. M7 n
gonadotropins.1,3
5 v* l1 ^( e: {Gonadotropin-independent peripheral preco-, Y  _7 a) J" W
cious puberty in boys also results from inappropriate% j" R# R( T1 C! {2 P  `' d+ q1 q  q5 f
androgenic stimulation from either endogenous or1 z, Y0 a) v* x! y" s  s* a6 J
exogenous sources, nonpituitary gonadotropin stim-
9 n6 D8 E- s0 q6 E9 Mulation, and rare activating mutations.3 Virilizing  e2 |/ M+ ?9 {$ b
congenital adrenal hyperplasia producing excessive
' Q9 Y! w; [! W/ b3 \adrenal androgens is a common cause of precocious
! j  C" U5 _3 Z' W. J& S) p% A4 kpuberty in boys.3,41 w7 J# c( p5 |  Z
The most common form of congenital adrenal
( Y" d, ]1 {( X2 w7 Uhyperplasia is the 21-hydroxylase enzyme deficiency.6 p8 ?# k+ k# D* o( ~: m& F
The 11-β hydroxylase deficiency may also result in
8 a0 J7 X, c6 x! gexcessive adrenal androgen production, and rarely,
6 }; e* k; w- S- T4 ~& van adrenal tumor may also cause adrenal androgen8 W: c, Z, E4 m, n! t. I% y2 d* q
excess.1,37 ^$ q9 W: m( G2 H2 g  R1 N- g# d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 U; e, v+ S: E6 w542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 ]' s( t0 S4 F: I  Q
A unique entity of male-limited gonadotropin-
1 M, `* O1 c. N- _, i) sindependent precocious puberty, which is also known* Q. O9 I9 I, a" ?1 f2 N
as testotoxicosis, may cause precocious puberty at a: l' g. A- _: r  P
very young age. The physical findings in these boys; ]7 {2 ~# w  |5 B, f  j
with this disorder are full pubertal development,1 b( K' w% D2 o" u: N* C0 N! X$ r1 P
including bilateral testicular growth, similar to boys" o' H  p) O5 A
with CPP. The gonadotropin levels in this disorder' K: P- [, g/ [3 J: w. _
are suppressed to prepubertal levels and do not show
* O; i% X& s$ rpubertal response of gonadotropin after gonadotropin-7 e9 _* K  @$ h( M' Q
releasing hormone stimulation. This is a sex-linked* |" w& T4 u2 b
autosomal dominant disorder that affects only
- r" A& v# a) m' e' q9 wmales; therefore, other male members of the family
2 k5 w2 A5 q/ l  U# d% B, Vmay have similar precocious puberty.3( I  @4 \. G2 N. D# x5 O+ ~% ^
In our patient, physical examination was incon-# g& O0 f% E: P$ D
sistent with true precocious puberty since his testi-9 |' D2 m3 h& T
cles were prepubertal in size. However, testotoxicosis
9 O3 @1 O6 ^8 r6 c) Y  xwas in the differential diagnosis because his father$ k% n! s2 S1 S7 f
started puberty somewhat early, and occasionally,4 M1 v+ N9 y1 T  O1 J! g$ |' q
testicular enlargement is not that evident in the6 S* D7 ]! Y4 k8 S
beginning of this process.1 In the absence of a neg-
7 A; e1 ~) H4 sative initial history of androgen exposure, our
7 u; ^% \) L7 i8 L& rbiggest concern was virilizing adrenal hyperplasia,
, y' S. T- X6 V, h5 p1 K, l2 l7 eeither 21-hydroxylase deficiency or 11-β hydroxylase- ]. ?4 I) H- |% x: p; X) m# f2 B
deficiency. Those diagnoses were excluded by find-
8 l' N; g( f* @; s) f# h1 U2 Ting the normal level of adrenal steroids.
5 \8 r  \2 m( K; JThe diagnosis of exogenous androgens was strongly
8 A' L/ g1 Y9 \2 v7 l( G0 q# D4 ysuspected in a follow-up visit after 4 months because
# V7 ?" p% K% e; E8 G) u5 M$ p0 b0 M7 c# Ithe physical examination revealed the complete disap-
- d$ j5 g* T: X+ Vpearance of pubic hair, normal growth velocity, and& Z+ v  F! f: Q5 N$ g/ y
decreased erections. The father admitted using a testos-  c) e% d% o7 z  X$ w5 Y
terone gel, which he concealed at first visit. He was
1 J; a/ |: I; g  i1 ^. M+ busing it rather frequently, twice a day. The Physicians’
" b. E8 U7 O! K! w2 x. ]3 FDesk Reference, or package insert of this product, gel or
, P7 K+ ~5 D# g  \" I( ucream, cautions about dermal testosterone transfer to
, N1 K  O3 ^& {unprotected females through direct skin exposure.
/ {2 d& [+ D8 h: `! c5 ^& JSerum testosterone level was found to be 2 times the
' B4 v1 S) C3 o3 j: l( Fbaseline value in those females who were exposed to% ~8 [: N8 E1 K) K7 @. ~; g
even 15 minutes of direct skin contact with their male1 h& t* |% U5 a$ `
partners.6 However, when a shirt covered the applica-
" ]/ v6 Y& b' \5 p: a$ ~tion site, this testosterone transfer was prevented.  F, J  X2 C# h; C
Our patient’s testosterone level was 60 ng/mL,! o; {2 x" c7 w/ j6 i/ C
which was clearly high. Some studies suggest that
- m, r- c5 N" F0 m6 W3 Wdermal conversion of testosterone to dihydrotestos-
5 z3 k9 I5 C# U1 }: }' fterone, which is a more potent metabolite, is more$ F# e  M) i+ C& n  w" M
active in young children exposed to testosterone
3 Z! t! _) |) K, f1 i$ oexogenously7; however, we did not measure a dihy-
$ u" w- h* f6 D: F4 a; P4 u- ~drotestosterone level in our patient. In addition to
; O9 U  R( E; H. ^4 o0 Lvirilization, exposure to exogenous testosterone in- P  T# }# {& Z! D7 v1 r- Z- D
children results in an increase in growth velocity and
6 U0 e7 e  b1 |' F4 k* `advanced bone age, as seen in our patient.
* k( G: ~3 b4 w! ^  }$ EThe long-term effect of androgen exposure during% }; C7 b- g6 r1 t* k# H- i
early childhood on pubertal development and final" o- U+ Z  B8 G" {0 q  y
adult height are not fully known and always remain
& z4 [3 S/ F$ F1 x" y3 Aa concern. Children treated with short-term testos-
* c- w. q4 Z" Iterone injection or topical androgen may exhibit some0 g* g  E& O7 Y+ P' @
acceleration of the skeletal maturation; however, after
8 H# U# H5 ?' n* U, tcessation of treatment, the rate of bone maturation* ~5 A9 q, M8 F3 [. N+ }
decelerates and gradually returns to normal.8,92 m; _9 R! d4 y6 w
There are conflicting reports and controversy
& Z2 i4 Q1 v+ x0 [* Qover the effect of early androgen exposure on adult
) ^4 `( A% X8 s7 @penile length.10,11 Some reports suggest subnormal5 n* r- f' Y9 i4 E; H
adult penile length, apparently because of downreg-
4 n( t3 E% |$ T+ S, {ulation of androgen receptor number.10,12 However,* I! n$ k& l4 a. c( J, W% j) `$ M
Sutherland et al13 did not find a correlation between5 Z( O! w$ k* c0 F1 a
childhood testosterone exposure and reduced adult# O+ w0 i4 c7 q6 f6 b: \1 i
penile length in clinical studies.
( l2 @. m/ ~( `- _( N0 |Nonetheless, we do not believe our patient is
& F. }/ k3 I) Y  H+ ?going to experience any of the untoward effects from  a- O/ }) M" L% l
testosterone exposure as mentioned earlier because
- V' ]( w/ h- M, athe exposure was not for a prolonged period of time.) B' V$ Y! E8 g$ W: o" }8 B
Although the bone age was advanced at the time of
4 O9 z1 v! u) v8 n. c( t9 \% Idiagnosis, the child had a normal growth velocity at+ u# |, A  y! m% w
the follow-up visit. It is hoped that his final adult* M9 T4 U) X) C; B+ E  f7 ?
height will not be affected.- c# Y/ i& A# y3 D- z6 z# a  J( l9 C  T. i3 y
Although rarely reported, the widespread avail-
% w( d/ r+ \, D; Wability of androgen products in our society may4 R. p2 s* ?  {0 Z5 N
indeed cause more virilization in male or female" C! l) O# J) _- B
children than one would realize. Exposure to andro-* E7 a+ e( z5 i3 _! b0 m
gen products must be considered and specific ques-
- h; k7 W4 r! @' _tioning about the use of a testosterone product or6 c& o& G) N( G8 X  B
gel should be asked of the family members during: }" Z+ ^  X( i: T5 L
the evaluation of any children who present with vir-
% X! t2 o0 Z3 j8 G. s3 Zilization or peripheral precocious puberty. The diag-
/ o' g+ l" R) G2 D4 ^6 Jnosis can be established by just a few tests and by
* x- ~' a+ T# n  Bappropriate history. The inability to obtain such a0 o' f1 o% ^$ V5 r/ Y
history, or failure to ask the specific questions, may
" t$ j, R$ U" a" nresult in extensive, unnecessary, and expensive
; Q4 w7 O  ^1 M- l+ Z! X! f$ binvestigation. The primary care physician should be
  z& `" R$ N/ E; B% a2 B4 |aware of this fact, because most of these children
: B" |: y9 N& N7 d6 f8 Smay initially present in their practice. The Physicians’' _2 ?$ O# t. ^( A' P
Desk Reference and package insert should also put a: E' V* G# J2 d- y2 F# o) t5 i+ x
warning about the virilizing effect on a male or
& W  J* q) f# efemale child who might come in contact with some-
5 @: L6 n7 G* T$ L. rone using any of these products.
! I8 M( W; z* s9 ~, O/ K8 S- aReferences
( V7 `: y+ S" Z4 [: M1. Styne DM. The testes: disorder of sexual differentiation
' I. {/ ?8 e1 {- Kand puberty in the male. In: Sperling MA, ed. Pediatric; R5 Z% z. ]0 l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% _" I- F; S6 Q/ i- [- D
2002: 565-628.! T" B& ]$ B: U) B8 W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 ]: l" k% w+ H" O: ]puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old  r3 _) B; s2 z* f+ P+ h, n
Boy Induced by Indirect Topical
. {. o5 z4 F0 G* I3 x: yExposure to Testosterone
1 c9 O* T6 d# iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: g" ^0 C- \+ D% L
and Kenneth R. Rettig, MD13 l8 J' ]) L+ E
Clinical Pediatrics) C/ y9 x  @) N' I- ]+ r
Volume 46 Number 6
) [; J! W" V% u  D0 K8 E& cJuly 2007 540-543/ U8 t; n( O- t+ B/ D) W
© 2007 Sage Publications/ D& v7 s4 |1 A# m9 F
10.1177/0009922806296651
6 U8 C- E, D: k% [9 X, f* n7 ]http://clp.sagepub.com
  d! ?) C+ j  Z5 P6 p+ Zhosted at. r1 e; M* r& J0 N* E8 V5 [& X- \2 E! ?
http://online.sagepub.com$ y7 d0 J; W$ B3 X# B
Precocious puberty in boys, central or peripheral,9 L; Q3 V6 k+ w& c
is a significant concern for physicians. Central
& k9 f  K. }. E( y; O3 O+ Bprecocious puberty (CPP), which is mediated
7 j8 C( F+ A- g* `5 O; D0 jthrough the hypothalamic pituitary gonadal axis, has9 J2 \: R0 W$ z3 m
a higher incidence of organic central nervous system
) C/ R: l& s$ z# r$ B( X. I, Xlesions in boys.1,2 Virilization in boys, as manifested
' ~2 f/ D3 y. F5 a  Y9 eby enlargement of the penis, development of pubic
; b# c# p3 z! O4 u0 xhair, and facial acne without enlargement of testi-! S: i! L; A! T8 R
cles, suggests peripheral or pseudopuberty.1-3 We
8 Q( Z5 j" [: D( H( areport a 16-month-old boy who presented with the' x& K4 t3 `, U
enlargement of the phallus and pubic hair develop-) O+ E! e5 N6 M; N
ment without testicular enlargement, which was due7 X0 d( f5 d) C
to the unintentional exposure to androgen gel used by
+ u8 ?2 Q* m& V8 z: T/ ^the father. The family initially concealed this infor-
# e" G2 r9 f7 a" v& n5 `3 _, V9 u' m  xmation, resulting in an extensive work-up for this
9 I' z! {$ [& w, Cchild. Given the widespread and easy availability of) s6 \% G2 d$ W$ N5 Y
testosterone gel and cream, we believe this is proba-7 f$ F" m: E5 U3 C# I/ S
bly more common than the rare case report in the
0 S" j8 ^( f$ i3 T- O' ?; `6 J2 ^- Iliterature.4
  P# H/ b" u1 W' O; X4 x3 u( s7 {Patient Report( |4 u+ M5 Y' K& @! N: ^0 X2 ]
A 16-month-old white child was referred to the
/ m0 R  U0 ]; i5 Dendocrine clinic by his pediatrician with the concern
& }+ k- r- `) xof early sexual development. His mother noticed
) b- Q+ u* g2 h- Nlight colored pubic hair development when he was, J+ D  t) u; o8 g% A$ @  l
From the 1Division of Pediatric Endocrinology, 2University of
: I, k* n) W2 p' G% GSouth Alabama Medical Center, Mobile, Alabama.
$ y9 |5 v& P* w: C0 P# {. ?# HAddress correspondence to: Samar K. Bhowmick, MD, FACE,
, z, {" Z2 N  X6 uProfessor of Pediatrics, University of South Alabama, College of
% D; m0 Z3 F6 kMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; W' o- j# c' |6 u: b, C
e-mail: [email protected].
9 e  n. Q" m, x( @7 E  tabout 6 to 7 months old, which progressively became
; w% _0 {! q& g8 r& Z" o' ddarker. She was also concerned about the enlarge-4 L- L7 T- C8 L" M3 d, F! @: q: C
ment of his penis and frequent erections. The child, L5 S8 O& E9 W! ]" d( G# N
was the product of a full-term normal delivery, with
1 R' f6 W$ ]( s$ H! y* o6 ^2 Za birth weight of 7 lb 14 oz, and birth length of" Q4 l- q8 r; e" _5 l
20 inches. He was breast-fed throughout the first year+ `" J, s/ R+ X1 }% H0 Y
of life and was still receiving breast milk along with
- l7 h9 ?% e! X/ lsolid food. He had no hospitalizations or surgery,+ ?$ e& b! X. _4 G9 k) M0 ~0 x
and his psychosocial and psychomotor development% b; ]6 C# l, ~9 Y* M0 a* ~
was age appropriate.
" |+ D. j6 Y. C* I% k. n) UThe family history was remarkable for the father,- w4 h5 m) H: f" ^  a8 O
who was diagnosed with hypothyroidism at age 16,
" Y, n$ C+ I" a: V+ qwhich was treated with thyroxine. The father’s0 K5 ?, M  l' g2 |
height was 6 feet, and he went through a somewhat: b5 B3 A( ^5 |+ p3 A  x3 [, c# Z
early puberty and had stopped growing by age 14.; G1 ~/ r9 E# `
The father denied taking any other medication. The* x! d* R! m2 h( @
child’s mother was in good health. Her menarche
% D3 u5 `9 e/ P& {7 F! t/ Rwas at 11 years of age, and her height was at 5 feet
- k& P/ Y, S; u% `& r* [1 ?5 inches. There was no other family history of pre-$ l: j3 }( z, b' @2 X
cocious sexual development in the first-degree rela-+ T/ E, d5 \7 @5 y
tives. There were no siblings.  Z" ^5 Y5 p$ u+ ]
Physical Examination! p" Q0 O" U" {2 R# f, x
The physical examination revealed a very active,
- L( }2 p* w  v5 L: _; wplayful, and healthy boy. The vital signs documented0 Y0 _/ f- v+ a8 k5 e0 [) H
a blood pressure of 85/50 mm Hg, his length was
1 S% v- ^2 d, \; v& `( L8 I90 cm (>97th percentile), and his weight was 14.4 kg& b9 ]6 R) I  W: n: T4 f2 V# F
(also >97th percentile). The observed yearly growth7 ^; [( v( x% b' O& c( V
velocity was 30 cm (12 inches). The examination of. V# n* ?7 N% n/ \- Y8 l
the neck revealed no thyroid enlargement.& m( o( \! V% q/ w+ w+ d: {
The genitourinary examination was remarkable for
0 ?, ]+ }3 G- }, v' Kenlargement of the penis, with a stretched length of
0 D% r0 v- p" S0 @( R& m8 cm and a width of 2 cm. The glans penis was very well
' r) z2 x* u7 y7 x( M6 {developed. The pubic hair was Tanner II, mostly around
/ a/ v/ x9 r. G: I% y& x' s7 A540$ \, ]6 N! O1 O* a7 d& J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% |- _, ^7 @9 S, e; ^3 ~+ uthe base of the phallus and was dark and curled. The  L( v2 u2 U' o' X4 A3 N
testicular volume was prepubertal at 2 mL each.
$ G  t- W6 b; K% P2 I% o5 UThe skin was moist and smooth and somewhat7 T- x9 t$ F4 U: J7 k& {
oily. No axillary hair was noted. There were no
1 @* c7 j! j& E3 b6 k6 j  `5 b  a6 Aabnormal skin pigmentations or café-au-lait spots.9 z6 x( y& p* @* ~
Neurologic evaluation showed deep tendon reflex 2+
$ T4 W0 `1 r$ a7 }' ~. k" u8 Mbilateral and symmetrical. There was no suggestion
/ `6 R/ {7 y" {, [: f' t7 C# lof papilledema.
+ I& {1 C* p. s1 j& j2 w5 K2 l" @Laboratory Evaluation
5 A6 |% P0 z) X5 y+ \The bone age was consistent with 28 months by
/ l* E6 P9 |* f! Z+ }7 ausing the standard of Greulich and Pyle at a chrono-# o' b  Q. P3 X. x% M  n0 {% |
logic age of 16 months (advanced).5 Chromosomal! M! o  Z5 L3 d# Z" S+ I) d( r
karyotype was 46XY. The thyroid function test0 n) K$ R3 {& h3 t2 g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-( U1 t/ M7 z4 {1 Q2 a! }1 E( X+ M
lating hormone level was 1.3 µIU/mL (both normal).
. g. g' \2 l5 W( E0 oThe concentrations of serum electrolytes, blood& x/ B$ P- h9 h( b3 f/ q* H6 j
urea nitrogen, creatinine, and calcium all were
9 g7 q. V1 h: Awithin normal range for his age. The concentration% \# O! C# ~. f, k
of serum 17-hydroxyprogesterone was 16 ng/dL4 ]3 Z$ B5 T1 Z) d" T: H
(normal, 3 to 90 ng/dL), androstenedione was 20
3 {% y. Z/ j7 @1 A& i6 bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 E4 a3 T1 e# h
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
$ ?1 l$ j# {  r* p1 ~' Hdesoxycorticosterone was 4.3 ng/dL (normal, 7 to% \. F$ A( X+ T+ r: n, Y2 q6 C; r
49ng/dL), 11-desoxycortisol (specific compound S)7 B, J+ D/ a, e  w% U3 p: w- T
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) Q7 E5 t, S/ w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, E' t8 ]! K4 t/ [, R+ B3 H7 }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 _' T* J$ S& h& d* I% H( h7 P
and β-human chorionic gonadotropin was less than
- M! u; g0 r+ O" t% ~6 z' q5 @5 mIU/mL (normal <5 mIU/mL). Serum follicular* [8 l2 V: X  G4 @
stimulating hormone and leuteinizing hormone
. o- y( y3 r- D1 ?. Aconcentrations were less than 0.05 mIU/mL6 W9 T' W' Y* Y+ v& g2 c- O
(prepubertal).. d0 H& ]- J/ H. I4 l
The parents were notified about the laboratory, M. f) ^/ G: p" W
results and were informed that all of the tests were6 e* w3 i! @) a6 v6 T: b6 `. q
normal except the testosterone level was high. The3 g" d/ t" l& F7 x2 X: Z
follow-up visit was arranged within a few weeks to% A6 U' w0 k0 V& x7 |8 V* R9 y
obtain testicular and abdominal sonograms; how-8 u! r( z$ Q4 z5 q" L; T
ever, the family did not return for 4 months.
1 s9 w" a0 V5 @3 j# @% gPhysical examination at this time revealed that the
3 p  i1 I- g1 _! ?% Pchild had grown 2.5 cm in 4 months and had gained
0 c, o2 i7 G- M' S1 d! N( P2 kg of weight. Physical examination remained
% l" R) x) f" [' Tunchanged. Surprisingly, the pubic hair almost com-
' ]: n4 q* F' ?/ Q* Qpletely disappeared except for a few vellous hairs at
& G0 U0 T/ v4 Z7 b& N# ~6 ^) fthe base of the phallus. Testicular volume was still 2
- O3 v7 H4 e9 `; ~' U  ~mL, and the size of the penis remained unchanged.' g# p7 [3 |7 ^8 a
The mother also said that the boy was no longer hav-
( ^. e  k: p4 Q# s2 Ning frequent erections.6 M& U$ }3 ~( b. t/ S/ p  t1 u3 O
Both parents were again questioned about use of! g' q; j0 R2 k' Q" s* j/ Y# q
any ointment/creams that they may have applied to4 g* n2 b5 k! C3 c8 [! q$ r. j# {
the child’s skin. This time the father admitted the( T& R; G) V! G& H
Topical Testosterone Exposure / Bhowmick et al 5412 D- E( i. D/ V( T% A& r; D  n
use of testosterone gel twice daily that he was apply-
; y" b4 _9 S% j+ q! Xing over his own shoulders, chest, and back area for
; X0 |$ H0 k% r0 {* Aa year. The father also revealed he was embarrassed
; E7 t, O! b  }" Pto disclose that he was using a testosterone gel pre-+ `3 w! g# U9 i& y2 D
scribed by his family physician for decreased libido
( q( {7 \: B+ a* B2 s( [, ]secondary to depression.
& n7 x3 u2 u: a+ d4 FThe child slept in the same bed with parents.
: N3 }& P& w) V% ~" }0 w% u0 \The father would hug the baby and hold him on his
2 x( k) O7 |! ychest for a considerable period of time, causing sig-; ?# E  \) ^- s* E1 E( @
nificant bare skin contact between baby and father.
( Z0 M0 _( L$ m1 t! c' I7 |  RThe father also admitted that after the phone call,
3 {! b- r/ x) [+ o/ Y2 Y2 x3 uwhen he learned the testosterone level in the baby
0 E, v! |% m8 R5 O/ d: rwas high, he then read the product information
& x2 |" `  u2 |9 G9 M' F& cpacket and concluded that it was most likely the rea-
8 n. @7 c# v( H- q1 lson for the child’s virilization. At that time, they1 W4 b. g+ ?3 `
decided to put the baby in a separate bed, and the8 q8 z6 y+ d- X# y+ |% F8 \
father was not hugging him with bare skin and had
* H  I; W' q) T1 p( Y  vbeen using protective clothing. A repeat testosterone2 v$ b) E2 l& l3 X1 A& _
test was ordered, but the family did not go to the
7 y0 W: c& y7 P2 E$ Jlaboratory to obtain the test.
# F: Z  E1 e3 X3 LDiscussion
" U: a$ m3 u% p  ePrecocious puberty in boys is defined as secondary
" X1 e- {( j) Z' H0 Y& X& usexual development before 9 years of age.1,4
9 e8 Q& h! n) C  v' M2 q" ?: UPrecocious puberty is termed as central (true) when
) p9 e- Y3 J7 l( m  }' p  Fit is caused by the premature activation of hypo-4 P+ |, N3 |# _' V
thalamic pituitary gonadal axis. CPP is more com-5 l( a8 y! a  s! z4 X3 N+ X
mon in girls than in boys.1,3 Most boys with CPP: C; s2 a1 n$ p8 W) F
may have a central nervous system lesion that is
& t4 v- y, v7 v' Gresponsible for the early activation of the hypothal-
8 [: [" T! e5 q/ vamic pituitary gonadal axis.1-3 Thus, greater empha-
$ \% }2 k/ r& h$ o# ~sis has been given to neuroradiologic imaging in
* s7 |, w- p5 h$ I& D' Oboys with precocious puberty. In addition to viril-" E9 _0 \8 ?# v$ ]( A' x& x
ization, the clinical hallmark of CPP is the symmet-
8 }3 K3 D3 Z4 ^* I0 arical testicular growth secondary to stimulation by
! x: K$ D+ ?' ]* _+ Q: R2 Y5 x# pgonadotropins.1,3
8 j/ l4 J/ T2 j7 X; ?) F5 yGonadotropin-independent peripheral preco-8 A( x2 L: L7 U- V5 L
cious puberty in boys also results from inappropriate
( c7 y4 I' j& H2 ?androgenic stimulation from either endogenous or9 W4 F2 x$ K  V2 |- _0 O% O/ Q
exogenous sources, nonpituitary gonadotropin stim-) F& x) `# m. |6 f5 X
ulation, and rare activating mutations.3 Virilizing9 |% [  \8 f* L+ E) e+ `! P
congenital adrenal hyperplasia producing excessive7 t+ X" ?2 S2 P
adrenal androgens is a common cause of precocious
% s" z1 @  o% D1 U$ rpuberty in boys.3,4
# C' Z6 @( g0 \; ?" w7 y3 _  tThe most common form of congenital adrenal
, V, x5 D, g7 A4 x  J) M2 j4 Z4 _hyperplasia is the 21-hydroxylase enzyme deficiency.. P) x6 P$ |6 m) h( |6 ?. p' }: t
The 11-β hydroxylase deficiency may also result in, a5 r/ U! W+ E" L
excessive adrenal androgen production, and rarely,
! Y4 K2 C/ a* p. }' V9 K6 `an adrenal tumor may also cause adrenal androgen) L1 Z0 L5 G1 N) x/ m) F
excess.1,3
2 `8 n1 o1 k4 b( C+ h4 H& dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& m) Y* Q7 H; m9 v7 C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& w- ?% r/ Y/ a0 q  g( d/ u( i1 eA unique entity of male-limited gonadotropin-1 ^* i* S5 ?- ]$ Y  G& L
independent precocious puberty, which is also known
; l" U3 Y7 e; p5 _& X: Tas testotoxicosis, may cause precocious puberty at a2 ?- e) c& v8 p' D: F: w9 ]
very young age. The physical findings in these boys
! Z! x* g, l: G) e* g" A* ~with this disorder are full pubertal development,0 {1 K; a& g) E; L7 ~
including bilateral testicular growth, similar to boys; \  Y. L. S1 s
with CPP. The gonadotropin levels in this disorder
( {" b. ?3 z$ d' E6 t  S' hare suppressed to prepubertal levels and do not show$ T1 a  I) l1 S
pubertal response of gonadotropin after gonadotropin-5 {! |7 k/ _3 W6 c5 ~9 h) K
releasing hormone stimulation. This is a sex-linked$ ~; }8 X" {; T' m
autosomal dominant disorder that affects only
. s6 B1 z+ s& G& P; y/ Umales; therefore, other male members of the family$ B6 R0 d! S% g3 p4 M5 A& v* T
may have similar precocious puberty.3
2 i+ A; @) p4 kIn our patient, physical examination was incon-
! P- F2 O& H" ]9 ^. t, u& L/ L! fsistent with true precocious puberty since his testi-0 s/ j1 _4 P& [; z& ^
cles were prepubertal in size. However, testotoxicosis
1 K. R8 U; n0 F$ j' C; _& M5 Swas in the differential diagnosis because his father
" c8 ?9 I& ]  w3 F& M# dstarted puberty somewhat early, and occasionally,
9 z. V, h6 v! b/ \  i# m) {, j0 B8 Utesticular enlargement is not that evident in the
, p2 k; H! E" T  o8 P: Q, qbeginning of this process.1 In the absence of a neg-# v; ^+ Y" [! B' [! }( y8 E
ative initial history of androgen exposure, our
% b* Z7 I1 `# K0 `$ X7 [5 K7 nbiggest concern was virilizing adrenal hyperplasia,6 @4 s: T2 i$ S+ K: w
either 21-hydroxylase deficiency or 11-β hydroxylase! B/ H4 R( w+ ?; y. U
deficiency. Those diagnoses were excluded by find-
1 @! v% }+ s3 Q' L2 ring the normal level of adrenal steroids.- z! O0 u; n" Z8 @
The diagnosis of exogenous androgens was strongly
( L. e: F5 v; q, asuspected in a follow-up visit after 4 months because, k6 x# i. G) Q( H
the physical examination revealed the complete disap-$ c" a" \8 y# x, h# Z
pearance of pubic hair, normal growth velocity, and
* U/ S5 o( n' c$ g3 f( ~decreased erections. The father admitted using a testos-
& A3 c, S" ]0 jterone gel, which he concealed at first visit. He was
4 d% p* e! {, A0 ?/ e/ jusing it rather frequently, twice a day. The Physicians’7 r0 Y* T/ h2 W+ P; g- k
Desk Reference, or package insert of this product, gel or( D: c$ Z. }9 H. R
cream, cautions about dermal testosterone transfer to
! z( ?: X2 }; s. Punprotected females through direct skin exposure.
$ R6 v, }# {6 c6 `. wSerum testosterone level was found to be 2 times the
$ X( a/ h# _/ e  _6 u9 s2 Ebaseline value in those females who were exposed to
1 D/ L8 R7 D# X: ~3 M) @5 Heven 15 minutes of direct skin contact with their male
- j! e6 G; t; Xpartners.6 However, when a shirt covered the applica-
/ A9 o# q+ l( M1 o( h7 vtion site, this testosterone transfer was prevented.
& a/ b+ z* V5 l$ Z- l5 ^& }% D! i9 ~' oOur patient’s testosterone level was 60 ng/mL,$ J( T& |! \1 o) R4 u/ T
which was clearly high. Some studies suggest that
# C6 B5 M  X5 G; c5 Cdermal conversion of testosterone to dihydrotestos-
& B; _' q6 f. T2 \terone, which is a more potent metabolite, is more' x* r8 F  \1 g
active in young children exposed to testosterone, _  l+ b) N5 u8 O* n
exogenously7; however, we did not measure a dihy-/ `" U  R& g' r: }) o
drotestosterone level in our patient. In addition to' {8 ?# p, j  O1 y# _
virilization, exposure to exogenous testosterone in
2 V: L9 \+ B+ n+ K: q% Ochildren results in an increase in growth velocity and
4 i# k" u+ C8 _% Madvanced bone age, as seen in our patient.
6 Z* p1 r! c) [/ U' p+ xThe long-term effect of androgen exposure during
4 A2 ^2 G* T4 o- h! ^7 Cearly childhood on pubertal development and final; |$ B- o& c! b  `
adult height are not fully known and always remain
( f, K! L3 W) k0 L7 r4 v1 Ia concern. Children treated with short-term testos-: L. u0 i, L+ s. s& [. ~8 Q
terone injection or topical androgen may exhibit some
. ^/ `+ W9 F) x% _' x7 Vacceleration of the skeletal maturation; however, after% H& ~! f# P$ s9 Q2 n5 @- K
cessation of treatment, the rate of bone maturation& C; N+ R, X" {4 [1 M, r- r
decelerates and gradually returns to normal.8,9
4 Z, D1 t& }1 k& AThere are conflicting reports and controversy4 t" e+ w1 b2 g
over the effect of early androgen exposure on adult
1 s  G; j3 ~0 D3 y( E. Fpenile length.10,11 Some reports suggest subnormal& c7 w8 S) T  Y! B& O4 C, R9 ~- O, k
adult penile length, apparently because of downreg-: J5 s; l( z, k6 Y  \
ulation of androgen receptor number.10,12 However,7 ~7 }* G, S$ o3 J: Q# N+ a
Sutherland et al13 did not find a correlation between6 C# R: w1 j* I# b( W2 Y
childhood testosterone exposure and reduced adult. ]( x6 o1 R5 V8 U% O% ?
penile length in clinical studies.' n8 ^) Q6 s0 Y( S
Nonetheless, we do not believe our patient is
; y: {; ?2 k6 `+ v, zgoing to experience any of the untoward effects from2 N6 ?2 x6 ^& g& b
testosterone exposure as mentioned earlier because
1 Z: [2 u) f* D2 [the exposure was not for a prolonged period of time.9 W4 a7 E4 u! p7 J2 ~
Although the bone age was advanced at the time of
& P% u2 x% o+ X+ z; ldiagnosis, the child had a normal growth velocity at: H- K" i* h5 V- e, |2 ^8 G
the follow-up visit. It is hoped that his final adult( J' M  V" T' W/ N3 K! E0 r, _
height will not be affected.% u- I: X  c5 ?* C/ {! H
Although rarely reported, the widespread avail-; I  k9 Y# _' O( o
ability of androgen products in our society may
2 z3 @( k7 o1 q+ S' qindeed cause more virilization in male or female) O7 K+ I# z, l' ]
children than one would realize. Exposure to andro-
5 R7 E- n, O' \gen products must be considered and specific ques-; P$ t9 z" z! F4 [8 P& i
tioning about the use of a testosterone product or
5 q; B! D/ w0 {! _2 c4 I) j9 tgel should be asked of the family members during- P6 b5 @) o! K6 c+ Q- i5 W
the evaluation of any children who present with vir-6 z! s( P5 C. c# s2 R' y3 a
ilization or peripheral precocious puberty. The diag-- K% p# R7 u4 ^5 Q2 r* D! y/ t
nosis can be established by just a few tests and by
. d! U$ q/ t3 jappropriate history. The inability to obtain such a) _# s4 o0 h. `# g  V( f5 u- W
history, or failure to ask the specific questions, may) _# L  c0 s7 w) h5 q5 w
result in extensive, unnecessary, and expensive
6 m. h8 m  M$ Y7 ~2 H) i9 e) hinvestigation. The primary care physician should be) n; Z( K0 r7 `1 X
aware of this fact, because most of these children
0 D- W; x* n$ J3 Q5 g/ g% y# M& G& C3 Bmay initially present in their practice. The Physicians’
' G& C. ~; J8 X; ^Desk Reference and package insert should also put a( h# s" w) x" j1 P
warning about the virilizing effect on a male or
" l! P$ s$ u2 B9 w( [7 _female child who might come in contact with some-
0 M  N% v- V" L7 P; h, Wone using any of these products./ n; {5 M) w" L6 O
References
5 \; O' X3 d1 }& f4 q' U1. Styne DM. The testes: disorder of sexual differentiation5 i& u9 h! M+ ~2 k, F: _3 R' J% N
and puberty in the male. In: Sperling MA, ed. Pediatric* ^/ z6 \; ~3 G. X
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 v! ]: v5 ^# I2002: 565-628.
. d( Y, _* L9 `0 ~6 N1 O* M2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 E2 a, m, M; r* D2 M. _, z, R
puberty in children with tumours of the suprasellar pineal
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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!

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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!
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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

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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
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4个什么样的?
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

5 L/ I- ?& C# p$ s* Y: s精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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