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Sexual Precocity in a 16-Month-Old, ]# [* o8 k7 k( V6 X& @* N
Boy Induced by Indirect Topical
: q% d! j  I5 Q: V; j# ?, {$ dExposure to Testosterone
& Q, V# C7 c; ~& S7 I/ w$ L3 FSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, x( B# t1 q( s  K" Y. @+ {; d3 J6 B4 ^
and Kenneth R. Rettig, MD1, i" v: I. X) h# P# x
Clinical Pediatrics) X( B. q# K# M
Volume 46 Number 6/ p7 L1 P# P$ X, `% ]! k3 Y. w
July 2007 540-543
# A+ c- y/ P( V" Y4 d© 2007 Sage Publications/ b. ~) A! Y% @8 \+ Y7 I0 P
10.1177/0009922806296651
6 r4 C/ m+ D4 Fhttp://clp.sagepub.com
0 y' {% I* c- F! ~- [hosted at' A) A! P% _* C9 m' P; ^: Z
http://online.sagepub.com4 K$ Q" l6 p* M. U+ o
Precocious puberty in boys, central or peripheral,* X" q7 x. O4 _1 V* {) r
is a significant concern for physicians. Central, s+ F8 r. {/ U; A1 b
precocious puberty (CPP), which is mediated# H, }, Z' g& f7 |! c# V
through the hypothalamic pituitary gonadal axis, has1 N& [2 Y2 d8 Z. E% m8 ~
a higher incidence of organic central nervous system# l" z* @" r+ Q9 q+ B  D$ v
lesions in boys.1,2 Virilization in boys, as manifested
. V9 W% r" ^% q: A0 k8 a3 ^; D$ z* Lby enlargement of the penis, development of pubic$ l- {8 \0 D. l$ y% I
hair, and facial acne without enlargement of testi-2 D- v7 G& S+ t( J% n
cles, suggests peripheral or pseudopuberty.1-3 We0 R. a5 J" c* V0 n/ U
report a 16-month-old boy who presented with the
6 x8 R& q+ K- [3 renlargement of the phallus and pubic hair develop-& n3 g  R! N; k  W
ment without testicular enlargement, which was due
: M0 e- E& F! i  s1 v8 e4 Gto the unintentional exposure to androgen gel used by6 D# y2 ?' b+ U4 w( B  k3 c
the father. The family initially concealed this infor-
$ z/ T$ ^6 r/ M+ |; wmation, resulting in an extensive work-up for this9 f, I9 ~: k0 w, f+ o7 O8 a# F
child. Given the widespread and easy availability of( V2 d2 e& D0 ^: B* D' y9 X
testosterone gel and cream, we believe this is proba-& z8 Q6 T' `& j+ P+ d" p
bly more common than the rare case report in the/ L1 u& X* D! y% N# {
literature.4: B6 O( w; _. x  e0 w& B% f8 t
Patient Report
) M7 a7 v5 p1 i, C! Q; W0 [A 16-month-old white child was referred to the; l" A( S7 l5 c, ~" I1 k; _
endocrine clinic by his pediatrician with the concern
; v" Z2 a$ F: iof early sexual development. His mother noticed
3 H! C/ |9 u5 b% N7 qlight colored pubic hair development when he was" B6 y* w; M0 N7 H: G+ k( D4 i
From the 1Division of Pediatric Endocrinology, 2University of" o; D/ @8 `/ V  L4 e1 ]
South Alabama Medical Center, Mobile, Alabama.: g! b! E% S# m0 w
Address correspondence to: Samar K. Bhowmick, MD, FACE,0 C8 d9 ?% i9 @; V" w+ ^* W( b
Professor of Pediatrics, University of South Alabama, College of: @+ C+ J; c# n, L3 l. D
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 D, y, B# w, o0 F* ke-mail: [email protected].0 b/ z8 H8 r3 g* |# `+ T# f
about 6 to 7 months old, which progressively became
3 ~" `# U" f2 ldarker. She was also concerned about the enlarge-
8 U4 S& n/ `+ a; P3 Qment of his penis and frequent erections. The child
) R" q3 S; ]0 m) i5 Ywas the product of a full-term normal delivery, with; F1 D8 I9 @- P4 d
a birth weight of 7 lb 14 oz, and birth length of
+ ~% u0 A  d8 l3 Q( c7 V! n20 inches. He was breast-fed throughout the first year8 f. U1 I0 @8 P5 C3 g- t  z) u
of life and was still receiving breast milk along with( T# p; Y) p. W, ^% R9 k5 V
solid food. He had no hospitalizations or surgery,  |$ j5 ~, t( \4 U3 {
and his psychosocial and psychomotor development
% v5 d8 V5 x1 s% i  X; ywas age appropriate.
" V3 v7 b" S* A1 P. lThe family history was remarkable for the father,
/ C) E, ]/ a. N# L( P2 A2 [6 Lwho was diagnosed with hypothyroidism at age 16,
* C. A" P7 I4 g  c- n/ x* \which was treated with thyroxine. The father’s
8 x7 y2 z1 O2 o+ H( U& fheight was 6 feet, and he went through a somewhat
2 Q+ _/ X8 Y2 O% [& s" }( Rearly puberty and had stopped growing by age 14.$ i1 N( O% D% _  W$ C' K( M/ |
The father denied taking any other medication. The
1 h, w9 e7 ^9 y5 c7 w4 lchild’s mother was in good health. Her menarche9 a) V' b' `( T
was at 11 years of age, and her height was at 5 feet
# {( P- z8 U$ X5 ^9 R" \, |  |5 inches. There was no other family history of pre-# k. X4 c% F9 Q9 u. q6 t
cocious sexual development in the first-degree rela-9 G! E1 I" Q5 o3 X& ?- {
tives. There were no siblings.
; R' T# h4 h8 J9 R9 jPhysical Examination
+ x* f* d7 a" M. N  l# dThe physical examination revealed a very active,
  |7 X, E8 |' |/ [- I- c$ R' [& }playful, and healthy boy. The vital signs documented
- y# }3 {- I6 Na blood pressure of 85/50 mm Hg, his length was
# _2 K# G  c& N9 ^1 c90 cm (>97th percentile), and his weight was 14.4 kg6 D: Y& j; _: r0 K! b
(also >97th percentile). The observed yearly growth
8 p! N, P3 P" ], o. pvelocity was 30 cm (12 inches). The examination of/ ^, u  \: O/ b. k
the neck revealed no thyroid enlargement.
, }% e9 K! W% E% n' p4 _The genitourinary examination was remarkable for2 I3 {! X1 C. ^. y7 P
enlargement of the penis, with a stretched length of1 W$ @7 x9 J! G$ p- {
8 cm and a width of 2 cm. The glans penis was very well' T* D' Z) `& B& U
developed. The pubic hair was Tanner II, mostly around* c% U- k0 K3 F  ~& H* i8 f
540
+ ^/ K! u* |" v" e2 _  Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  i. ]" l7 @% n! E  ^/ x6 U6 Ythe base of the phallus and was dark and curled. The
3 e8 h2 a0 U- t: Y* `testicular volume was prepubertal at 2 mL each.
( f+ P4 w% S" W$ S" O9 {The skin was moist and smooth and somewhat
/ E) t* @% _; G" Voily. No axillary hair was noted. There were no
& j9 z. q' [: w4 A2 X* _/ A. ^abnormal skin pigmentations or café-au-lait spots.& D' F8 |$ M0 V5 W- d9 a3 r
Neurologic evaluation showed deep tendon reflex 2+" h5 e" V4 w' o
bilateral and symmetrical. There was no suggestion: d: p+ _5 o$ |: n5 ]; `2 [
of papilledema.
0 H/ Y2 w( F' ]: g* |! F0 G5 H; ]Laboratory Evaluation
8 g1 h, c1 v9 ?* ^  ^The bone age was consistent with 28 months by
! x& |7 M2 F1 {0 o2 c, P$ eusing the standard of Greulich and Pyle at a chrono-6 U; O3 F. w  q6 Y/ K/ H8 P3 Z
logic age of 16 months (advanced).5 Chromosomal  N6 S" e! o  Q3 L0 a
karyotype was 46XY. The thyroid function test% L# n$ P8 N- w- d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 N2 R( \0 y$ f3 K
lating hormone level was 1.3 µIU/mL (both normal).
1 \/ A" q( K+ t6 g. R; b, eThe concentrations of serum electrolytes, blood8 O/ R! g$ t+ i4 V4 o4 I# M
urea nitrogen, creatinine, and calcium all were
9 K8 W# A' @+ c) K& Hwithin normal range for his age. The concentration
# }# o: i( p7 ^; M( O8 Z4 Gof serum 17-hydroxyprogesterone was 16 ng/dL
! \- m5 G8 x: @9 O7 Z: @(normal, 3 to 90 ng/dL), androstenedione was 20, U. R" H* N' p1 {- {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& f, z: L) ]: A4 r& l, j4 j
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& G3 ]; S. @8 f; {+ N/ o2 i) odesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 A( U/ f0 N! \  b8 j) N
49ng/dL), 11-desoxycortisol (specific compound S), J5 }. R6 g9 ~/ J0 ^9 G: H% ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" U# b4 U+ |5 `. K. M( \  |
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( x" w3 d/ R  ^( L5 V$ N$ {/ [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," b7 Q8 s. ]" J5 }
and β-human chorionic gonadotropin was less than
9 h! u' a" R1 C8 k; P1 E; T9 |5 mIU/mL (normal <5 mIU/mL). Serum follicular: ^6 L' H. H- J$ W
stimulating hormone and leuteinizing hormone* |6 @" g2 J; w
concentrations were less than 0.05 mIU/mL0 c) b( p% P1 i# K, I
(prepubertal).
1 ^2 |3 Q4 |8 O- I7 v+ n% VThe parents were notified about the laboratory
4 u' }8 G  o" [+ V) G# iresults and were informed that all of the tests were
, g5 |2 K, c6 P; B7 N& c& w# ynormal except the testosterone level was high. The
1 B! S9 ~- K  a3 F& Sfollow-up visit was arranged within a few weeks to% m  E4 d3 k4 r
obtain testicular and abdominal sonograms; how-/ e" Q' h/ Q( j% w4 m$ k* E- Q
ever, the family did not return for 4 months.
) L* D/ H* v4 n8 UPhysical examination at this time revealed that the- g2 G3 I6 h% m0 h8 G& L
child had grown 2.5 cm in 4 months and had gained
# }, ?0 W, ?0 G, Z2 kg of weight. Physical examination remained
% E* Y% X, @9 t/ cunchanged. Surprisingly, the pubic hair almost com-
9 h( x- A' K  z5 C% Upletely disappeared except for a few vellous hairs at
& c; n; l& d3 h9 ^9 R! nthe base of the phallus. Testicular volume was still 2+ ^/ K3 H* Q9 i9 _3 N0 r
mL, and the size of the penis remained unchanged.( ^' h9 M( i( I
The mother also said that the boy was no longer hav-
% j: V8 J  }; i. t& S1 l: \  Ping frequent erections.
, j0 p! P) y7 q4 s8 ^Both parents were again questioned about use of
0 c% }2 J5 `, q: J6 o( Zany ointment/creams that they may have applied to
0 {. y; `) o2 }  K. ]the child’s skin. This time the father admitted the, a* ?. d. o+ s+ M3 @
Topical Testosterone Exposure / Bhowmick et al 541* s4 @- L, o/ _, T
use of testosterone gel twice daily that he was apply-
! R9 o4 e. I$ s1 ?, k1 A$ ~3 Ging over his own shoulders, chest, and back area for& \( ~- l$ H8 h' X  \
a year. The father also revealed he was embarrassed; S1 I# {0 v3 I, j$ ~, ?( I& L
to disclose that he was using a testosterone gel pre-
$ R' F9 D! u$ r  ^" x  tscribed by his family physician for decreased libido
" P0 ^2 o* e6 a/ T; G2 dsecondary to depression.
: v5 ^. u$ q3 V2 tThe child slept in the same bed with parents.
! L. T: n8 c8 ^1 d5 a! |' HThe father would hug the baby and hold him on his
0 R3 Z0 O6 q+ z( ^7 \( `6 K/ b6 qchest for a considerable period of time, causing sig-
3 t/ _% P2 A9 G: o0 B# h( I8 T+ L' ]nificant bare skin contact between baby and father.; q7 R" v7 y: T8 U% Y2 a% D
The father also admitted that after the phone call,
% p5 H6 O/ F8 ]$ Rwhen he learned the testosterone level in the baby, Y. x4 D# @8 \* }
was high, he then read the product information
% Q* X# s0 K9 e/ K1 U9 ~, apacket and concluded that it was most likely the rea-
& A, y3 e' W0 P' j6 I; I+ f+ Json for the child’s virilization. At that time, they
% H+ F" p& ^$ I, ddecided to put the baby in a separate bed, and the
' C* @- [2 o4 E) N/ }7 w" v/ z0 |father was not hugging him with bare skin and had
1 ^3 K( E' `" U2 G4 Vbeen using protective clothing. A repeat testosterone0 M& ^9 [1 ~' E; @  Z% _/ C4 g4 H9 I
test was ordered, but the family did not go to the7 e9 _; c( ^  n- V0 M) ?
laboratory to obtain the test./ s( F; F2 m0 q& y( y  ?
Discussion0 e9 @0 @) T4 ?( ^/ A; C, T' o( `
Precocious puberty in boys is defined as secondary
! o9 _$ k+ w0 o* K9 ^4 d/ lsexual development before 9 years of age.1,4# T4 E6 k# l- V' p6 i0 \6 S
Precocious puberty is termed as central (true) when( X9 q8 ^7 g% z0 e) \
it is caused by the premature activation of hypo-
, h+ j2 b* f( T3 othalamic pituitary gonadal axis. CPP is more com-7 l0 q3 B( k: P1 d3 {$ G. b
mon in girls than in boys.1,3 Most boys with CPP
3 [; H& p7 A# K7 F# C2 Nmay have a central nervous system lesion that is2 ^" M2 i$ t; y
responsible for the early activation of the hypothal-5 s  R# c8 Y0 T, u( x
amic pituitary gonadal axis.1-3 Thus, greater empha-/ V# C( z, @" E, J& s
sis has been given to neuroradiologic imaging in" g* i! _2 c/ J6 B, U
boys with precocious puberty. In addition to viril-
9 u. s# @2 i; V3 B# Kization, the clinical hallmark of CPP is the symmet-% w! w/ v5 x6 X. m6 T6 p$ b
rical testicular growth secondary to stimulation by! E1 S, P* q2 f4 p6 L" a
gonadotropins.1,3
6 m; ^+ }2 _# U8 d% KGonadotropin-independent peripheral preco-' w6 x9 M: x6 a
cious puberty in boys also results from inappropriate7 b- a  i) ^- v1 c" |8 r+ l
androgenic stimulation from either endogenous or* H$ A5 Y9 H+ c1 D
exogenous sources, nonpituitary gonadotropin stim-$ F) g  x% s3 Z) {+ d* {
ulation, and rare activating mutations.3 Virilizing
; |0 |+ D2 b3 @, N$ c% S/ [0 H3 acongenital adrenal hyperplasia producing excessive
; @5 a5 ?; A+ }$ `) b& r" p& ~5 s4 Nadrenal androgens is a common cause of precocious
- ?) ?) `5 j" i; Qpuberty in boys.3,4
, c" L5 q# d/ e4 W: ]! V* XThe most common form of congenital adrenal+ A# `6 y) _9 [. G  i  B7 J
hyperplasia is the 21-hydroxylase enzyme deficiency.
+ G' c1 D1 [0 [" {The 11-β hydroxylase deficiency may also result in3 h" H9 ]9 n- Z) |& x
excessive adrenal androgen production, and rarely,
) U; `$ {2 w) k* Z! J6 uan adrenal tumor may also cause adrenal androgen
+ Y  x3 f& ]3 V& }$ Q8 `excess.1,3* Y0 B! u/ Z$ O( M$ w  r+ j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) I4 L& Y5 R7 m
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 {. `# \" i! _" R3 L/ S7 \
A unique entity of male-limited gonadotropin-$ L: j9 ~2 I) P
independent precocious puberty, which is also known
9 n3 v- b  `6 L* G: @as testotoxicosis, may cause precocious puberty at a
9 e* D! W6 N6 p* _  k% ]  Cvery young age. The physical findings in these boys
6 z! L# {" @& W' z3 X0 uwith this disorder are full pubertal development,4 R* ?0 i1 E& j" E" V5 r
including bilateral testicular growth, similar to boys/ e  J4 D( ]4 O
with CPP. The gonadotropin levels in this disorder2 A6 a+ O* R' _) I, H
are suppressed to prepubertal levels and do not show
0 R- V9 i# E3 e7 d, z: M' o% e- Wpubertal response of gonadotropin after gonadotropin-9 ~5 m6 U0 s8 Z! P7 S0 `* R$ I; z
releasing hormone stimulation. This is a sex-linked8 Q* |% Q) ?2 L" E
autosomal dominant disorder that affects only
" M" ?9 ~+ b1 G4 ]+ kmales; therefore, other male members of the family8 n& r/ m) V  c+ f
may have similar precocious puberty.3
4 m- n- y) ~' W$ b9 f5 W& NIn our patient, physical examination was incon-
) F3 q9 ~$ ~" \% d, csistent with true precocious puberty since his testi-
% \3 P1 S1 X5 W5 i0 zcles were prepubertal in size. However, testotoxicosis
3 B4 ~1 N! B2 D8 Vwas in the differential diagnosis because his father) m8 v) q4 C% Y4 I$ r# Z
started puberty somewhat early, and occasionally,
9 J5 T6 q) X! b( b7 Utesticular enlargement is not that evident in the
. m8 X% F  K7 w. x  `beginning of this process.1 In the absence of a neg-; s& E; C% \( _+ d1 U2 p! h
ative initial history of androgen exposure, our
9 J! o! D- r2 p  S' Q  r2 xbiggest concern was virilizing adrenal hyperplasia,
/ t# S. N- i& ^3 x0 u! xeither 21-hydroxylase deficiency or 11-β hydroxylase
% b  M& P4 G' v4 o- L) b% `3 l- mdeficiency. Those diagnoses were excluded by find-
5 ^! D) }1 s5 d9 s7 k! _  ~( _ing the normal level of adrenal steroids.
+ Y# C7 ~% k# I. tThe diagnosis of exogenous androgens was strongly) p* n" ]! X! T' P
suspected in a follow-up visit after 4 months because, n+ m3 }- N4 A" d( O* e! i" ^
the physical examination revealed the complete disap-- G7 j- H" L6 T  m" M6 b7 D/ C
pearance of pubic hair, normal growth velocity, and
! I' B" w4 p+ d& @' udecreased erections. The father admitted using a testos-
# D) ^+ [' `; O/ N* qterone gel, which he concealed at first visit. He was
6 p: U/ K/ T0 S# V7 F1 dusing it rather frequently, twice a day. The Physicians’
' i2 b8 V1 r5 R& x2 ?8 LDesk Reference, or package insert of this product, gel or
! U, _7 f% B: R6 i. r- r4 |cream, cautions about dermal testosterone transfer to
* B- v1 ]( J% U/ x! sunprotected females through direct skin exposure.; m  Z9 W  E$ |+ J$ N
Serum testosterone level was found to be 2 times the/ \* M' p9 Q. ?/ p. ^! V" M* H
baseline value in those females who were exposed to6 D8 i' ]0 n5 \5 h% t1 R
even 15 minutes of direct skin contact with their male
% P& O- {6 ]0 ~" b, e( Dpartners.6 However, when a shirt covered the applica-1 }/ t( l# K0 h' H1 U/ t% p
tion site, this testosterone transfer was prevented.7 x( O5 m0 `3 \  J
Our patient’s testosterone level was 60 ng/mL,
, Y6 t/ H% B: s/ G" s. Rwhich was clearly high. Some studies suggest that' V+ E! D) w5 o, |6 y
dermal conversion of testosterone to dihydrotestos-/ f  z8 Y+ o9 F3 T
terone, which is a more potent metabolite, is more
$ {2 y# q% Q# W& I) `2 kactive in young children exposed to testosterone
9 l! c+ ^" w2 _. J/ W; [exogenously7; however, we did not measure a dihy-( [& k* l2 ?( n) e- l+ [" v
drotestosterone level in our patient. In addition to& h% U# T6 h9 y& e9 o( f
virilization, exposure to exogenous testosterone in
& U) a. V$ \: `, J! y+ [children results in an increase in growth velocity and
' V, w- U/ o; |* r7 x6 Zadvanced bone age, as seen in our patient.  ?' P" B! m2 {1 q3 X
The long-term effect of androgen exposure during$ S3 y2 r& t1 L1 _: t( _- @
early childhood on pubertal development and final
# z" |4 @1 ?( @2 S; Gadult height are not fully known and always remain
9 r+ t3 G. ]0 o0 G  Aa concern. Children treated with short-term testos-* ?' a4 z5 C) i- I
terone injection or topical androgen may exhibit some; b  o, p, C) M5 [
acceleration of the skeletal maturation; however, after
: X& q/ ]5 I* w, ocessation of treatment, the rate of bone maturation2 }9 d' @& ]" f- S
decelerates and gradually returns to normal.8,9! ~) T* j0 b- }
There are conflicting reports and controversy  ^4 U" e2 w2 R! g9 e
over the effect of early androgen exposure on adult/ l, _& G9 G8 t. N( _
penile length.10,11 Some reports suggest subnormal
6 V. T" h9 I" qadult penile length, apparently because of downreg-
4 @1 ^4 ~8 ]% Vulation of androgen receptor number.10,12 However,2 B, O* G$ E- m8 O- j' M
Sutherland et al13 did not find a correlation between3 R1 s; F1 D$ G0 g# X' a
childhood testosterone exposure and reduced adult5 G! o$ X7 B$ [6 t9 T
penile length in clinical studies.) M& n+ f& T. S8 O' B$ A0 N
Nonetheless, we do not believe our patient is, Z" z2 N3 n4 u) o# Q! [
going to experience any of the untoward effects from
# j2 \9 k- F6 R3 `testosterone exposure as mentioned earlier because5 H' s/ A4 B: K6 R# Z+ A6 w$ s
the exposure was not for a prolonged period of time.
  \' S8 b& R; }) x" e( zAlthough the bone age was advanced at the time of( _( F' ]% S6 \; ~% {) q
diagnosis, the child had a normal growth velocity at3 `2 G* h; ?" X9 h" x3 d# C
the follow-up visit. It is hoped that his final adult# D$ F1 S+ F6 p1 ?4 G# D4 Z
height will not be affected.& p7 `; f: {, g7 R8 Y
Although rarely reported, the widespread avail-9 z0 J/ Z0 K! t( D
ability of androgen products in our society may
3 P- j% F: @- T# iindeed cause more virilization in male or female% n* N+ a/ i/ y, g% D! P& X1 B
children than one would realize. Exposure to andro-
. x2 G2 B  x$ t, I, n7 u* Y- Qgen products must be considered and specific ques-- ^  C8 y% D# H. F) O$ W
tioning about the use of a testosterone product or
! Z; C% \+ S& _7 d5 O' tgel should be asked of the family members during2 r# c$ G0 t; z; V8 X' k; P' L$ f; q& y
the evaluation of any children who present with vir-6 E8 H' E# H8 A: m6 ~- r: [
ilization or peripheral precocious puberty. The diag-& ]. v3 q% J! v" K, z1 q, ~
nosis can be established by just a few tests and by
9 S5 L' h! Y. ]6 }+ ?- }. yappropriate history. The inability to obtain such a: t. ?" r$ O5 e* L
history, or failure to ask the specific questions, may' x% F% W; D9 H/ h7 x2 Y
result in extensive, unnecessary, and expensive
9 X  q+ H) Q, m6 Y) ainvestigation. The primary care physician should be
8 f' J) |5 ~6 |& z! f0 Yaware of this fact, because most of these children
8 v2 _, K1 R- ?may initially present in their practice. The Physicians’; }9 ]# A( c' O& Z" j% `
Desk Reference and package insert should also put a; W' C5 C  N( ]8 R3 X+ ~
warning about the virilizing effect on a male or/ x4 d1 J- z! N- N/ H$ C6 ^
female child who might come in contact with some-# c% ~. w! @7 c2 A
one using any of these products.4 {) W, r# C1 j$ M8 f1 z  W
References
) l  m! D' U. C1. Styne DM. The testes: disorder of sexual differentiation
0 P: ~4 f* @! T' f: M1 @and puberty in the male. In: Sperling MA, ed. Pediatric
1 i$ @9 U; r2 J; _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) [: B+ v6 h' m& O2002: 565-628.
6 L: Q* N( Z5 H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ h8 F3 u, t; P7 m4 U# u( v; b+ S
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ E' M$ u# f6 ]- XBoy Induced by Indirect Topical
/ N8 b  f+ a2 o) N6 _' fExposure to Testosterone( n+ ^  W! P. a; w* x4 j1 Z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 x! p9 ^) q1 r  v5 S% rand Kenneth R. Rettig, MD1
" B, u, p* m- x) w/ W& _Clinical Pediatrics0 h4 X  @! A( h: c# \% o' S) G
Volume 46 Number 67 P' F  I2 C  @, z+ g! Z
July 2007 540-543
7 w& }7 b3 c& j' c' T' h# t6 q8 X$ j- ]© 2007 Sage Publications4 {, Z6 }4 H& G4 h
10.1177/00099228062966518 \& A# @+ t  D. c% R6 W, w, Q
http://clp.sagepub.com
% L7 n4 P! Z! Y1 `  o, thosted at
7 H1 A: y% J' zhttp://online.sagepub.com- C( H5 E7 Q3 Z; f& `7 H! B
Precocious puberty in boys, central or peripheral,
( |2 p% }" D% c4 u) Y$ gis a significant concern for physicians. Central5 d0 e% N+ V6 h: @0 o
precocious puberty (CPP), which is mediated
/ v$ K+ p8 d. E: Y0 i7 vthrough the hypothalamic pituitary gonadal axis, has% W: R! s" {3 [: K1 E
a higher incidence of organic central nervous system
5 j- \; J0 V5 M5 p- ?lesions in boys.1,2 Virilization in boys, as manifested
& u- A2 c) G3 mby enlargement of the penis, development of pubic1 U" C( d+ z- }' c1 F9 l
hair, and facial acne without enlargement of testi-
0 m$ l8 m9 i! d) `# Ecles, suggests peripheral or pseudopuberty.1-3 We5 a- B8 X9 u! w$ H$ S9 Z5 w6 ~
report a 16-month-old boy who presented with the
; q- W) U& H$ n; ?: s' oenlargement of the phallus and pubic hair develop-
& }( I3 Z; a/ \" l" Yment without testicular enlargement, which was due2 Y" H: Q# f  b( b" O
to the unintentional exposure to androgen gel used by8 C) U8 L, L! a' I, W3 W) s
the father. The family initially concealed this infor-
1 N: ^, ~6 v4 a; @' n* g9 |mation, resulting in an extensive work-up for this  {! V9 R: O/ @4 N( Z
child. Given the widespread and easy availability of
( k- q+ C) U" G8 a0 C( a# ptestosterone gel and cream, we believe this is proba-6 R4 K* j4 X  k. S
bly more common than the rare case report in the
0 `: K' ]$ ~* h6 p: M* Wliterature.4* b4 B9 f. J3 }, {- }1 J
Patient Report2 k; m: R& w, n0 J
A 16-month-old white child was referred to the1 V7 {! P6 I  l/ I' q6 @; [+ G* G
endocrine clinic by his pediatrician with the concern
6 K9 i3 s* b; xof early sexual development. His mother noticed
2 n9 w  B& n5 ]: S8 S. xlight colored pubic hair development when he was' K0 E4 H: L7 k4 q4 l" z
From the 1Division of Pediatric Endocrinology, 2University of
: @0 d) h6 F( e7 P+ i/ ASouth Alabama Medical Center, Mobile, Alabama.
0 R1 x( ]8 _) q7 tAddress correspondence to: Samar K. Bhowmick, MD, FACE,
- M4 {% r! B1 V+ W% E( pProfessor of Pediatrics, University of South Alabama, College of; X& G1 {  O' j; d: P( Z' W
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
( r9 x& I  ~: h, De-mail: [email protected]., v# z- H4 @% \6 l( h
about 6 to 7 months old, which progressively became8 l( G7 V& X+ {2 Q. V2 n4 X3 x. K
darker. She was also concerned about the enlarge-: w$ p0 E0 `  m# H+ c1 t* l  H+ l
ment of his penis and frequent erections. The child$ T2 M. |% l1 C) N6 L$ I3 T
was the product of a full-term normal delivery, with& t# o$ c' j7 |8 ?: D9 H* ^3 s
a birth weight of 7 lb 14 oz, and birth length of
0 Q6 S) q3 c7 u, O) k' _20 inches. He was breast-fed throughout the first year
. b1 u+ I9 _6 l0 r4 I$ |& Dof life and was still receiving breast milk along with
6 T8 k; M( g% X4 b9 U& @5 A! Nsolid food. He had no hospitalizations or surgery,. q$ z7 @  v/ h4 ]' |- z
and his psychosocial and psychomotor development+ _" U  N' q/ M, ^. g4 ?4 L
was age appropriate.
0 ]& u6 S. M1 h& n+ e% j! m' Y) IThe family history was remarkable for the father,3 L7 z, S" @( `
who was diagnosed with hypothyroidism at age 16,) q$ Q& Y$ V7 Q' `7 C8 j
which was treated with thyroxine. The father’s7 A, j. D' v, [
height was 6 feet, and he went through a somewhat7 X& _+ ]+ D: [: }  D2 N* x4 Q
early puberty and had stopped growing by age 14.
! l6 Z, g4 d9 i9 f$ _& p  pThe father denied taking any other medication. The
3 |5 P- m6 X) R# h+ Lchild’s mother was in good health. Her menarche, W! H/ A% W, Z7 v4 j$ O
was at 11 years of age, and her height was at 5 feet3 o, y; q6 ]$ N4 Y  f- G8 |
5 inches. There was no other family history of pre-) i& d5 J1 V& \( b
cocious sexual development in the first-degree rela-1 \3 d, Y  Y" I; S/ P, H
tives. There were no siblings.
0 v% j" ]5 H6 ?5 ^  r4 rPhysical Examination
$ b' }; o5 @) q6 G. J) zThe physical examination revealed a very active,% w- [8 K: n- n8 p8 R5 A
playful, and healthy boy. The vital signs documented
6 F# D  \; ]: `, \8 |- [& J& fa blood pressure of 85/50 mm Hg, his length was  f7 ]1 s7 T+ a" Q
90 cm (>97th percentile), and his weight was 14.4 kg
1 i) f. N- u- I; _1 z7 M* t(also >97th percentile). The observed yearly growth
) P2 w# \; K" c3 {: D' q6 \velocity was 30 cm (12 inches). The examination of( y4 o5 b! n) V9 g3 M( Y! y
the neck revealed no thyroid enlargement.: q1 N# u8 [, s# E
The genitourinary examination was remarkable for7 @. J6 R& E" O8 d7 O2 {
enlargement of the penis, with a stretched length of
7 ^4 S- k" \1 K( C! y  \8 cm and a width of 2 cm. The glans penis was very well  h$ A  O8 E) D, h$ s' [" x  k
developed. The pubic hair was Tanner II, mostly around4 x- i& e0 f) a1 \- V
540/ H; h3 H  g9 Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( [4 T# q0 d5 X; ~
the base of the phallus and was dark and curled. The
& m/ M4 O3 F: g+ B  I! Htesticular volume was prepubertal at 2 mL each.3 w: x0 E2 ]' S5 U7 O% w
The skin was moist and smooth and somewhat
! O* N6 w. p. M+ b. V! i2 Uoily. No axillary hair was noted. There were no8 z8 |6 r3 R6 o* T5 N9 X
abnormal skin pigmentations or café-au-lait spots.7 h- [0 h& j+ q
Neurologic evaluation showed deep tendon reflex 2+4 U& ?$ H8 K* y- x3 V6 I
bilateral and symmetrical. There was no suggestion; N: W1 R! K0 Y, ]0 i8 M7 X7 P7 L
of papilledema.
/ L% h* Q3 c" c# I4 v2 R7 ?Laboratory Evaluation4 L9 r5 e' d1 y. }6 T9 U. L* v; f  e
The bone age was consistent with 28 months by
3 y  x4 v3 Z4 W3 rusing the standard of Greulich and Pyle at a chrono-' N6 k  Z; K* Q) m% H
logic age of 16 months (advanced).5 Chromosomal- S! o% T& F+ S; @
karyotype was 46XY. The thyroid function test
' Q, ~) e1 D: @& v) F' Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 h& R2 z3 H) ]
lating hormone level was 1.3 µIU/mL (both normal).
* x/ G& _9 L, Y/ G# o! \* s8 vThe concentrations of serum electrolytes, blood$ s6 z& p+ ]0 @  D0 a4 G
urea nitrogen, creatinine, and calcium all were6 K, p+ f- T1 s
within normal range for his age. The concentration& E) f# a0 d. r8 i) o2 x. Z9 u
of serum 17-hydroxyprogesterone was 16 ng/dL  i- M% O' v' `, R) l( O
(normal, 3 to 90 ng/dL), androstenedione was 20
1 M4 Y2 e' ?/ R  X  i9 o" Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ ^. u" h8 h" J  ]/ Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),% r7 d( |1 S( ^1 v% ?& U3 R: C4 B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 ^; p) v3 m0 C1 c5 K( G49ng/dL), 11-desoxycortisol (specific compound S)8 A$ p4 w) F& O  Z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! l8 j. z7 B4 U. j8 K9 k1 n' C9 z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; B& h* _: t+ E- |$ ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 J3 N, J' U+ B* P$ I7 ]! L0 ^" }and β-human chorionic gonadotropin was less than
5 [3 G# g8 u2 `4 J8 A  }4 r5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ n4 ?% E, u, U2 o5 Fstimulating hormone and leuteinizing hormone: l" g' `+ ~) l) \# k: f, ?* z5 B
concentrations were less than 0.05 mIU/mL+ l" R2 T' P" y, F. p4 B
(prepubertal).
8 F  A/ H# }# {( y. t; gThe parents were notified about the laboratory
: u% Z% }0 _' M3 l! L6 q# Gresults and were informed that all of the tests were0 d' r) u, y9 }8 Z
normal except the testosterone level was high. The
8 Z8 `1 x& l# W6 ifollow-up visit was arranged within a few weeks to  @$ T0 X% S$ ^7 P8 n+ n. Q0 s
obtain testicular and abdominal sonograms; how-+ ~6 \0 {/ H) i# Y
ever, the family did not return for 4 months.
0 ?5 O2 ^. y/ Q# Q* Y0 EPhysical examination at this time revealed that the
, g$ c' P/ J- S& t, Qchild had grown 2.5 cm in 4 months and had gained
4 \0 Q: _" B8 C. [2 kg of weight. Physical examination remained, }/ @- |7 H1 R# G9 ~8 Q
unchanged. Surprisingly, the pubic hair almost com-
) `- K8 `8 }% j2 H% f! E# Rpletely disappeared except for a few vellous hairs at' @4 Q2 D& s4 J5 H
the base of the phallus. Testicular volume was still 2; A+ V, V4 b3 h' X: p7 E; Y
mL, and the size of the penis remained unchanged.
$ y  m9 i7 S: P  `/ e: u1 LThe mother also said that the boy was no longer hav-8 |1 U0 a7 a# Q8 I4 E* F
ing frequent erections.% s7 w7 j; D, H
Both parents were again questioned about use of" S, C5 N! I" U% Y' ]
any ointment/creams that they may have applied to2 t! Z/ B/ x7 [% ^: Q6 w
the child’s skin. This time the father admitted the# ^% b* {' ], e8 A
Topical Testosterone Exposure / Bhowmick et al 541
( J% i- e% @6 z% Iuse of testosterone gel twice daily that he was apply-7 b, [. P: g' B" }: G4 l
ing over his own shoulders, chest, and back area for
& P% I' U5 w7 i) X3 |& oa year. The father also revealed he was embarrassed3 o5 q5 C) K3 S$ x
to disclose that he was using a testosterone gel pre-- m9 B0 a) t# H0 {6 A3 _  I3 b' `
scribed by his family physician for decreased libido
3 o% P. x8 X5 n, i/ }, f/ [secondary to depression.8 q/ c+ T$ o9 L, e9 B4 D" s! E
The child slept in the same bed with parents.
: r/ S  \8 X" Y: S# _The father would hug the baby and hold him on his
% |5 M& s5 R) h% Wchest for a considerable period of time, causing sig-
+ j5 g; N8 k; _! i: Knificant bare skin contact between baby and father.
3 R% V8 G2 ^  J3 ?- f# }1 _The father also admitted that after the phone call,
! E+ o4 V2 u- R- ]8 Jwhen he learned the testosterone level in the baby6 r7 a( z/ v# D" R9 D
was high, he then read the product information  A6 r, ?( x$ V* L1 A) Q0 j: \; D) B
packet and concluded that it was most likely the rea-  O7 s6 n+ a1 V5 S0 O& j. {0 @
son for the child’s virilization. At that time, they3 O+ v+ l4 F) X/ Y; p) ^) g
decided to put the baby in a separate bed, and the
# X$ i2 d$ Y8 sfather was not hugging him with bare skin and had
! [4 \9 d/ z8 b, {; _been using protective clothing. A repeat testosterone2 L( x3 @0 ?0 w+ {0 c
test was ordered, but the family did not go to the4 l2 e0 Z3 Z: G) q& M+ a+ @8 c- n, V
laboratory to obtain the test.: _1 @+ d% c2 K( D
Discussion0 T( a% N2 z2 _; n" l
Precocious puberty in boys is defined as secondary4 V8 S  t1 [6 w! @& B
sexual development before 9 years of age.1,4
5 D3 h+ a& |; @Precocious puberty is termed as central (true) when
7 d' d- D# I9 x  t/ l6 kit is caused by the premature activation of hypo-
) {+ |& a  C6 |" H# }thalamic pituitary gonadal axis. CPP is more com-
$ y- o) o. }2 a- q  G( qmon in girls than in boys.1,3 Most boys with CPP
, }/ i8 |& ^% K6 u0 {may have a central nervous system lesion that is
3 G8 e6 i8 {2 Y' {" nresponsible for the early activation of the hypothal-. c; x! U8 c4 M  C
amic pituitary gonadal axis.1-3 Thus, greater empha-
* W2 \- s) d; z) T1 Asis has been given to neuroradiologic imaging in1 X6 `) ?1 E4 t9 J+ L0 o; P
boys with precocious puberty. In addition to viril-2 T5 F3 r, u! S# o  h5 o2 u
ization, the clinical hallmark of CPP is the symmet-: D2 m5 {4 d7 K2 t1 i/ z( ?
rical testicular growth secondary to stimulation by
6 V% u' V- C/ A8 t' r& {gonadotropins.1,3& L0 p) I0 j- w: J5 x% l5 m( A* t
Gonadotropin-independent peripheral preco-
+ h6 e0 B9 s) [: Q& vcious puberty in boys also results from inappropriate
7 e( u+ _$ y, \# T! A8 ?7 a# ?androgenic stimulation from either endogenous or
  f2 ^0 [  W) j& J5 P3 `, _/ Wexogenous sources, nonpituitary gonadotropin stim-$ b9 N3 Q  l( B6 b$ R9 e
ulation, and rare activating mutations.3 Virilizing
# F9 t$ B( ~  |congenital adrenal hyperplasia producing excessive# F) D: C0 N9 e9 m1 Z2 v/ W
adrenal androgens is a common cause of precocious
: U) e  S0 J6 X% d3 x+ u1 r9 _puberty in boys.3,4
3 U: L& V. V' CThe most common form of congenital adrenal
( P3 [2 E6 i  V1 p$ hhyperplasia is the 21-hydroxylase enzyme deficiency.
+ u4 n2 ^2 L: I& j3 Z2 O  LThe 11-β hydroxylase deficiency may also result in
- B, b; |) X, [3 F# [+ N5 `( Kexcessive adrenal androgen production, and rarely,( Q5 z; D/ X3 X( k
an adrenal tumor may also cause adrenal androgen
* W" y  V7 i' h$ ~( ?2 H, j" _$ Zexcess.1,3
4 y* I. J- Q4 K/ S# Q( N9 |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* n  c! w1 L+ k4 ^, @542 Clinical Pediatrics / Vol. 46, No. 6, July 2007# H( l. C& s. ?7 a3 V* m% K
A unique entity of male-limited gonadotropin-( b' F# @& [* ]( l% x( f2 c, d
independent precocious puberty, which is also known
: a" N  P; c# _$ ^as testotoxicosis, may cause precocious puberty at a
4 f, u% g' e. ]) ]3 O: ~very young age. The physical findings in these boys
6 R! O$ W$ G' z7 z7 \" ?with this disorder are full pubertal development,% g  \8 Z' |5 Q* K( M6 ?2 n
including bilateral testicular growth, similar to boys" e  |% b# n) {! k6 }) T
with CPP. The gonadotropin levels in this disorder% T% w8 r$ h# d: A/ @) P" M4 G
are suppressed to prepubertal levels and do not show
) e0 x. H0 y; i2 ?& q# w2 Y* spubertal response of gonadotropin after gonadotropin-
, i1 A, a: v7 v& ?3 m. Q7 xreleasing hormone stimulation. This is a sex-linked- S+ X2 Q& e; K) P9 N
autosomal dominant disorder that affects only
8 m6 y) s* W+ i6 @8 \0 p# Dmales; therefore, other male members of the family
  j% T1 t& m. Z& a' e) ?may have similar precocious puberty.3
/ P- j0 n9 w8 h1 JIn our patient, physical examination was incon-, y4 M% I: k) p7 ]
sistent with true precocious puberty since his testi-& d$ U! ]' i7 h2 e
cles were prepubertal in size. However, testotoxicosis0 I0 f5 B" t5 p3 U
was in the differential diagnosis because his father+ `4 ]4 Q  g% k6 e' J
started puberty somewhat early, and occasionally,
/ F0 g2 G: U( J$ b0 Y+ v" @testicular enlargement is not that evident in the
2 o$ [. e( u, F/ e" n. S# Z* Z: pbeginning of this process.1 In the absence of a neg-
$ e* Q' @, s4 d: f5 I9 m$ F6 l$ S: dative initial history of androgen exposure, our
- a% y  \. S3 Z5 b% h4 Nbiggest concern was virilizing adrenal hyperplasia,
" h  z& V; ]' \* C4 L0 G) {; Leither 21-hydroxylase deficiency or 11-β hydroxylase, p6 R( @% ]$ k
deficiency. Those diagnoses were excluded by find-
  b. c2 @5 x) e2 M0 y" C9 b: o5 cing the normal level of adrenal steroids.
* m& G, J. v' kThe diagnosis of exogenous androgens was strongly9 s& F7 x$ d, Q; h  D  Y$ N
suspected in a follow-up visit after 4 months because
7 J/ r/ F- t! j. s5 jthe physical examination revealed the complete disap-
7 B5 d! u" W! A  z* [" Hpearance of pubic hair, normal growth velocity, and; y- ~- k% b- s2 c- ^! G3 C
decreased erections. The father admitted using a testos-
4 P5 b( F: f7 x- O+ o& v. u9 ]terone gel, which he concealed at first visit. He was- K: e* p, ?  p3 d) W
using it rather frequently, twice a day. The Physicians’
5 j+ [: v! ~* z3 o% B; t) \: m: dDesk Reference, or package insert of this product, gel or
  H2 W9 i1 h. L% E7 Xcream, cautions about dermal testosterone transfer to
( l% v0 G# d3 _7 R- R/ \unprotected females through direct skin exposure.& d. w1 H' E$ H& j/ A  o* g5 c( R
Serum testosterone level was found to be 2 times the+ ~8 G- ~( b0 k- ?% p/ v3 e) W
baseline value in those females who were exposed to
7 L1 \5 I7 N: f! @  W3 M& eeven 15 minutes of direct skin contact with their male
' c/ @9 y* e1 B, \partners.6 However, when a shirt covered the applica-
5 F4 r" j% }% {( M$ F5 L0 Ltion site, this testosterone transfer was prevented.
' w/ c% D; i- Y# S& tOur patient’s testosterone level was 60 ng/mL,
) C: w; O. g( Z6 v/ Z. Xwhich was clearly high. Some studies suggest that
+ F: [6 x6 ]- |dermal conversion of testosterone to dihydrotestos-
$ Y1 a8 l) J/ r) E- f+ Z" tterone, which is a more potent metabolite, is more  p; u* ]2 j5 `* G# F' W: ~
active in young children exposed to testosterone
0 ~# G1 j3 x8 V; p: iexogenously7; however, we did not measure a dihy-
( K9 X8 c" h  [0 `/ Ldrotestosterone level in our patient. In addition to
; ?' J$ e. p2 x; ~: cvirilization, exposure to exogenous testosterone in) E& t9 u' S; _- l
children results in an increase in growth velocity and6 t7 {' R  F" Z; O! W
advanced bone age, as seen in our patient.
$ v$ ~) f) p7 i* Z! JThe long-term effect of androgen exposure during# v4 T& ]6 r" }
early childhood on pubertal development and final2 i0 L  c+ x8 ~6 z8 }
adult height are not fully known and always remain  Z8 D! ^( i$ G: W1 s
a concern. Children treated with short-term testos-
) t) {" Q0 E) H* v, B8 M2 dterone injection or topical androgen may exhibit some3 a7 [* L, {1 G4 L
acceleration of the skeletal maturation; however, after
: x+ _5 P5 Z  g9 J7 H2 e: mcessation of treatment, the rate of bone maturation4 {  \$ @. |3 Y; _$ \* Y3 Q& `
decelerates and gradually returns to normal.8,98 ~# j# H7 s4 I) b4 S6 e
There are conflicting reports and controversy
$ ~& Z- Q" t& D% F# oover the effect of early androgen exposure on adult( }! J% Q* {; ~+ S4 N1 S$ u
penile length.10,11 Some reports suggest subnormal0 U# u* D2 W! C  f# T) p5 Y
adult penile length, apparently because of downreg-
0 a6 \# P6 }! d6 |9 L9 K% }ulation of androgen receptor number.10,12 However,
# Q& X1 d9 p6 P/ m+ O/ u" PSutherland et al13 did not find a correlation between% R3 H* ]. m% V
childhood testosterone exposure and reduced adult
$ W1 `* v& \' S2 s5 P9 v, lpenile length in clinical studies.
0 f1 n/ _7 Z- gNonetheless, we do not believe our patient is
: u+ t& n: K" Ogoing to experience any of the untoward effects from) X% Q3 a; P) P, w" {) m: t
testosterone exposure as mentioned earlier because7 |9 z5 f5 H4 \1 b3 e# h" b
the exposure was not for a prolonged period of time.
) h% W0 l% o. h3 y! b, ]) \4 {Although the bone age was advanced at the time of! H2 E% y+ ^$ `/ `$ X. D; V' K
diagnosis, the child had a normal growth velocity at4 F, ?( |# w9 x9 _4 k
the follow-up visit. It is hoped that his final adult
1 B% t5 q7 j) Q' b1 H7 wheight will not be affected.
. s% C' s8 A- @- IAlthough rarely reported, the widespread avail-) y& A, j1 `3 _& y; c
ability of androgen products in our society may
) L* K1 S% \% Y* l, i  aindeed cause more virilization in male or female5 M  ?) B% U: G
children than one would realize. Exposure to andro-( B; }' t/ Z2 y/ x2 f" W
gen products must be considered and specific ques-
( [* O5 a7 _: b" Q+ i2 e; P' itioning about the use of a testosterone product or" B$ F! J* q8 Q' S' p
gel should be asked of the family members during7 y9 }: B2 N2 Z5 w) k) e
the evaluation of any children who present with vir-
& r' l( W; @7 P0 bilization or peripheral precocious puberty. The diag-1 A" F8 c$ p5 X$ |
nosis can be established by just a few tests and by: A: u! P' L+ D7 d( g( ~% F
appropriate history. The inability to obtain such a
9 j0 j9 Q2 a, c. g: A- [history, or failure to ask the specific questions, may: I* h$ \# `& Z: E$ c' l) C/ H
result in extensive, unnecessary, and expensive  H: G; k% K7 ~. S7 D( m
investigation. The primary care physician should be
: ]! C5 L' P2 u) M: R9 _aware of this fact, because most of these children/ H1 t) d2 G5 i& u% u
may initially present in their practice. The Physicians’
: }- P' f4 J( A$ q- k& HDesk Reference and package insert should also put a0 F  Y7 P$ c+ C) t9 I  h
warning about the virilizing effect on a male or9 M# J# z$ U( f  T$ ~
female child who might come in contact with some-% n/ a8 a* B8 D, J
one using any of these products.
; }$ @7 O+ X; q6 w: ]References
0 Q: P2 }+ L' m8 r1 d1. Styne DM. The testes: disorder of sexual differentiation$ A8 u3 ]5 t7 t$ U- M' D  E; T* K
and puberty in the male. In: Sperling MA, ed. Pediatric
- I# D% R0 q6 m7 q1 j* f, L# q0 kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 \' u4 M% q0 D! s
2002: 565-628.
& G5 [/ y. F: u1 ]! R6 j, O2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ {5 d$ [3 ~, @6 E3 x. u
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
% r* s+ E* m4 T; O
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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