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Sexual Precocity in a 16-Month-Old" C+ q5 q* a) O, p& V8 r3 s- ?% L
Boy Induced by Indirect Topical
5 N: s3 Z4 r6 c1 O9 x5 w+ dExposure to Testosterone
* y7 R1 K# h% G1 ]$ e, wSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! ~: \" L+ |1 z" g
and Kenneth R. Rettig, MD1
" P5 v7 X- s6 p! @' vClinical Pediatrics! l& n) N- `7 b, `1 }* r- [! n
Volume 46 Number 6
6 H& h: r& J" W9 j  Y/ ]9 n: sJuly 2007 540-543" X! @4 R5 z6 M8 x
© 2007 Sage Publications
: o$ p" R( X' l+ l- R. r& M10.1177/0009922806296651% h  l3 Y! o' X7 {( c
http://clp.sagepub.com
3 g5 ?% o4 D& o: D+ E+ khosted at
9 K# {3 K2 n  s: Q* \http://online.sagepub.com. I* I+ }/ Z( k7 t+ k( p8 |' |, t; @
Precocious puberty in boys, central or peripheral,
9 s+ l5 ?, e* A$ Bis a significant concern for physicians. Central" F0 n$ ?; @% X4 Z  s
precocious puberty (CPP), which is mediated
4 r- U% Z, \7 Y  Ithrough the hypothalamic pituitary gonadal axis, has
8 a# p3 p& d0 L9 r: D' C  Q" C1 ~: Za higher incidence of organic central nervous system% {3 t1 o! ^2 N: P5 F
lesions in boys.1,2 Virilization in boys, as manifested" _' w4 }  H; g' D* ^
by enlargement of the penis, development of pubic
! f# Y4 }! `, }! qhair, and facial acne without enlargement of testi-
* w6 F/ Y9 D. m/ ecles, suggests peripheral or pseudopuberty.1-3 We
8 f( h0 Y- _) ]6 O' n$ Areport a 16-month-old boy who presented with the5 Q% ?* I. I& `. [" P- }: X; r
enlargement of the phallus and pubic hair develop-  c7 k% m2 h* m9 F) J1 O# Y9 z: z
ment without testicular enlargement, which was due, w/ \" k. P, I# q" v
to the unintentional exposure to androgen gel used by
# H# ^9 s- \: u! L( ~9 q% Sthe father. The family initially concealed this infor-" H) g" i8 t4 a2 m
mation, resulting in an extensive work-up for this5 y, \% Y- l- N4 [8 i
child. Given the widespread and easy availability of
/ o. o2 d# S! C! V1 j8 N" h8 u2 itestosterone gel and cream, we believe this is proba-. h3 c; B2 H1 z5 z- l3 \  k
bly more common than the rare case report in the
! g" W# ~' M2 V8 M# u5 xliterature.4
% V1 U% r/ |) B0 d" EPatient Report
. M+ |1 g* I" _; M8 b, f& R" {5 MA 16-month-old white child was referred to the
1 v" V- X; F' G+ H" v  M% D, ]endocrine clinic by his pediatrician with the concern
' `( G4 ]* d7 T' \5 V3 k! e, I- c' hof early sexual development. His mother noticed) b$ P, ^- Q6 z, F! Z
light colored pubic hair development when he was
2 H' O. V6 _' v/ tFrom the 1Division of Pediatric Endocrinology, 2University of) N* V+ Z; r& q% x' r% x( ^
South Alabama Medical Center, Mobile, Alabama.
, Z' Y( J0 K1 n9 X' xAddress correspondence to: Samar K. Bhowmick, MD, FACE,3 t; L- K5 p! @6 I
Professor of Pediatrics, University of South Alabama, College of2 `3 y) X& M1 W  [# e1 n) W, w8 G+ c) C
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 `! G2 K; l" f5 Be-mail: [email protected].1 N7 i6 u) q7 {2 R0 k6 n- z
about 6 to 7 months old, which progressively became
1 x1 `) c0 {( i* N  P! m9 Tdarker. She was also concerned about the enlarge-
$ ]! t+ v4 k6 nment of his penis and frequent erections. The child7 s: J. s& P8 U) l! W9 M/ O1 ]9 r
was the product of a full-term normal delivery, with+ U& P  u2 [: j+ d
a birth weight of 7 lb 14 oz, and birth length of
5 n, u9 p% T. X  g; q20 inches. He was breast-fed throughout the first year( Y$ r: E' x  G1 m7 z! F4 N4 i% o
of life and was still receiving breast milk along with) ^7 k" Q; q+ B
solid food. He had no hospitalizations or surgery,: G8 q/ e! L! U5 x
and his psychosocial and psychomotor development
* H- W! l; d3 t7 |  k4 dwas age appropriate./ v- h. R! }/ \  F1 B
The family history was remarkable for the father,) ?  [  f  d7 g4 D+ t
who was diagnosed with hypothyroidism at age 16,
1 W/ n6 j$ |) F1 |which was treated with thyroxine. The father’s
4 H5 p9 [8 t. C4 lheight was 6 feet, and he went through a somewhat+ N, S& h& e6 T2 l
early puberty and had stopped growing by age 14./ w2 {0 V# J% x, E
The father denied taking any other medication. The; E% P. `; l, n2 ]( V$ g/ O  I& y, l- j
child’s mother was in good health. Her menarche( @: g, a0 w) _* R$ p2 `6 v. L4 X
was at 11 years of age, and her height was at 5 feet7 G' v6 s; F" ?4 H
5 inches. There was no other family history of pre-# b( }- n' x9 R2 I$ P" j
cocious sexual development in the first-degree rela-
/ `" j9 O8 G, ?; O& ktives. There were no siblings./ V9 ~% ?* x$ V
Physical Examination  H2 [) z8 ~' O4 [* c7 L
The physical examination revealed a very active,5 Q. Y/ r1 L/ l4 [2 \* U3 {. z
playful, and healthy boy. The vital signs documented; w3 j; M, g$ P7 R% h! I6 a3 g, x
a blood pressure of 85/50 mm Hg, his length was
. [: ?# t3 r: e! U' s4 A" b5 l90 cm (>97th percentile), and his weight was 14.4 kg# {* z' S8 ]4 c$ s: x+ H4 H+ H
(also >97th percentile). The observed yearly growth! i  v& E9 A6 r& K3 L
velocity was 30 cm (12 inches). The examination of( x8 {% }& J2 V8 q
the neck revealed no thyroid enlargement.0 o2 t; s; u! F) q* _8 q9 _' D0 G
The genitourinary examination was remarkable for5 j8 |' R  @  q. B( I
enlargement of the penis, with a stretched length of
2 [6 k# ]( k+ K8 cm and a width of 2 cm. The glans penis was very well
9 n9 \% a$ ~% a) F3 O2 Vdeveloped. The pubic hair was Tanner II, mostly around
/ i0 K! M! E$ f5 M$ X, n7 c540( j( Z; v! @4 F* P/ h5 H6 @) r+ v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- q) ^0 Y; X' i9 d) W( k0 ^4 A3 nthe base of the phallus and was dark and curled. The
& i$ t) [6 e7 l1 w! ntesticular volume was prepubertal at 2 mL each.8 V. u. P8 c: K" J" ^
The skin was moist and smooth and somewhat
5 E# e" @8 B, ~- B; Y% b" Z7 Y& Toily. No axillary hair was noted. There were no
1 A5 T9 I) K- ~abnormal skin pigmentations or café-au-lait spots.
' y; J# x3 Q( lNeurologic evaluation showed deep tendon reflex 2+
! }. H4 |) W  Z* kbilateral and symmetrical. There was no suggestion" h- j8 `; j' R$ N
of papilledema.4 C+ `) o! _: H! O! Y2 r
Laboratory Evaluation
* ?9 Z! m* D; d7 l9 BThe bone age was consistent with 28 months by
: w  O5 Q! q5 Ausing the standard of Greulich and Pyle at a chrono-
! j6 {  K3 G9 Jlogic age of 16 months (advanced).5 Chromosomal
& z0 [( j$ C# N- @  }karyotype was 46XY. The thyroid function test
' J( G6 u+ E! Y4 c+ D" tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" G: N* j* \" I+ M! X3 R
lating hormone level was 1.3 µIU/mL (both normal).2 n; Y* ~1 M2 X. J7 r
The concentrations of serum electrolytes, blood9 t% Y8 X- T, `
urea nitrogen, creatinine, and calcium all were
4 D3 }2 G. ?4 g% b5 kwithin normal range for his age. The concentration
3 {# _" ?8 T, M" L  E+ K3 vof serum 17-hydroxyprogesterone was 16 ng/dL
& t, r& M5 [/ d+ U/ k(normal, 3 to 90 ng/dL), androstenedione was 20
  [# D+ w7 B+ n0 P. Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& w7 F5 s; i4 Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
# i. a0 ^" F7 I6 Bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 V: ]- F6 ~" a* T49ng/dL), 11-desoxycortisol (specific compound S)
2 o) W9 l" d" u6 U+ ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 F" t$ Q( w! R4 C) |4 |; Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ m3 s6 f! i, L6 }6 i6 n
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 S8 r" I. X& W+ @% A; m: P$ l' q
and β-human chorionic gonadotropin was less than; }1 r! M+ g* V# j
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ \' ?- J8 K- W9 S+ n" w9 i
stimulating hormone and leuteinizing hormone* X8 E3 K1 j0 D3 u! t: _/ }
concentrations were less than 0.05 mIU/mL
0 N, V4 Q, |- I; a" ]8 D' A(prepubertal).
3 i- w- R  [$ c1 _! g7 l: iThe parents were notified about the laboratory8 ]9 X6 p/ o" b7 G9 {9 e
results and were informed that all of the tests were" ?" n8 x) H$ {6 B
normal except the testosterone level was high. The
8 T2 v) v0 C4 B0 E! X; ^9 {# Sfollow-up visit was arranged within a few weeks to
$ N1 Q0 h. \" W: bobtain testicular and abdominal sonograms; how-
' \/ C3 A( P* v; y9 Q# b) Never, the family did not return for 4 months.
0 Q* d* c* q3 b% J' O% yPhysical examination at this time revealed that the9 Z% \' Y0 I! L1 z; X& j: \3 O
child had grown 2.5 cm in 4 months and had gained! r. b% [4 n  M8 B
2 kg of weight. Physical examination remained
4 t! O7 q* f4 W9 M  Bunchanged. Surprisingly, the pubic hair almost com-( ], @% S& W6 h. B, a* R8 x5 @, E
pletely disappeared except for a few vellous hairs at5 z! X7 b; E/ J2 B0 Y* H1 p  v
the base of the phallus. Testicular volume was still 2
! O: X6 i/ R9 k3 B% A  z3 c; bmL, and the size of the penis remained unchanged.2 |) E. [5 x: ^; D9 d' V! e
The mother also said that the boy was no longer hav-4 `& {5 Y( f3 G3 @. L1 X
ing frequent erections.
- F$ ?7 p9 o! ^% W' b) hBoth parents were again questioned about use of
' s! `( M* Y  J1 Yany ointment/creams that they may have applied to  q, Q. c0 P3 b8 N5 t
the child’s skin. This time the father admitted the7 o% E: P( ]0 K! Q, P$ A. H  s
Topical Testosterone Exposure / Bhowmick et al 541: j5 A5 @8 @" ?& w: Q5 {
use of testosterone gel twice daily that he was apply-+ b7 Z: d, n% X4 s
ing over his own shoulders, chest, and back area for5 a6 v9 G8 u+ o+ c% Q
a year. The father also revealed he was embarrassed5 A6 U' n4 z, y9 H8 T7 b
to disclose that he was using a testosterone gel pre-
, q# ~! F4 z' {4 @$ c# Y/ \5 lscribed by his family physician for decreased libido
4 r- o" t( {# D# R- ]2 n0 Ysecondary to depression.
/ ]/ |7 y5 T+ k3 W9 n% l3 VThe child slept in the same bed with parents.$ C8 g2 ?7 s  ^5 k. L
The father would hug the baby and hold him on his. ]$ C) e6 i- W; o
chest for a considerable period of time, causing sig-
3 L  _2 ]& j) r  c# f: D; ?nificant bare skin contact between baby and father.+ ^& r# a. i) L  z. p
The father also admitted that after the phone call,
! j" c8 d" b% n4 \5 T5 Y2 B, zwhen he learned the testosterone level in the baby" d: L* L/ L) ]
was high, he then read the product information
0 `* j+ @- z' K& I0 Hpacket and concluded that it was most likely the rea-
& P) S# Y: w8 _$ T7 ason for the child’s virilization. At that time, they; l* V* N: b; P& f- V9 R
decided to put the baby in a separate bed, and the
1 k- |2 @% h; J# Ifather was not hugging him with bare skin and had, l0 [% b, x) ^& H
been using protective clothing. A repeat testosterone) ~6 N  w+ I+ B
test was ordered, but the family did not go to the
* X9 d6 L9 }0 s3 Zlaboratory to obtain the test.6 N. b( L3 a1 S  ^
Discussion! c& n0 R' p6 ?! r$ C. [( w
Precocious puberty in boys is defined as secondary( R: h& |( K; o4 I  U" X8 R8 K* o
sexual development before 9 years of age.1,4
4 l$ v9 k9 U' @/ a$ uPrecocious puberty is termed as central (true) when
, z# t7 a5 l: Xit is caused by the premature activation of hypo-
7 [& s% \2 u8 Zthalamic pituitary gonadal axis. CPP is more com-
. l/ u* B' F( g9 x, umon in girls than in boys.1,3 Most boys with CPP5 G" }# c4 \3 ]9 Q
may have a central nervous system lesion that is, B; J- m! R8 a  [
responsible for the early activation of the hypothal-
3 u# U8 U' X+ |7 L  s) n4 Z) _2 e" @amic pituitary gonadal axis.1-3 Thus, greater empha-% v! }) k3 d6 E' I9 ?
sis has been given to neuroradiologic imaging in- L" e. v/ y! e1 _
boys with precocious puberty. In addition to viril-
" A; N/ A2 r  ~# _& zization, the clinical hallmark of CPP is the symmet-+ U. b* Z6 X7 u" _1 @9 M7 Y
rical testicular growth secondary to stimulation by% O2 Z9 Q# U3 e1 n0 R" K* O
gonadotropins.1,3% N3 E4 G( ]( O& i2 J# g2 w( i* J, W
Gonadotropin-independent peripheral preco-
' \6 }6 E! _1 C! \3 u; ~cious puberty in boys also results from inappropriate
* H( \  T* Z# G) n- d; vandrogenic stimulation from either endogenous or: N0 V7 I$ L- q9 f( x: D
exogenous sources, nonpituitary gonadotropin stim-, Z2 y. M; U% \* r$ ~' p* I8 W
ulation, and rare activating mutations.3 Virilizing
( }$ A7 F6 A7 T, T1 U  S2 ^0 rcongenital adrenal hyperplasia producing excessive
: g; n2 E9 W+ E  s' E8 d8 Uadrenal androgens is a common cause of precocious- j1 p/ U" r# i. E$ ^# E# }7 V
puberty in boys.3,4
2 z6 Z: m' l! B* ^The most common form of congenital adrenal
) j& }* H3 L9 G& E  I! f. l9 ^hyperplasia is the 21-hydroxylase enzyme deficiency.
6 U9 f: e: C. Y* hThe 11-β hydroxylase deficiency may also result in
( L  e! w6 s' W; i9 ~excessive adrenal androgen production, and rarely,
( |7 G  ?% L& C  P6 s- M4 t" Z# zan adrenal tumor may also cause adrenal androgen1 g/ G; j  o9 t/ b9 H3 R
excess.1,35 T3 h* b1 E# B# @4 e9 W- @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; G  n2 N* x7 t9 q542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 W" K- B" b8 z7 u
A unique entity of male-limited gonadotropin-# p0 e3 P2 V4 F* N, S& v' w3 r# O
independent precocious puberty, which is also known8 o/ g& v* @' O, x! O
as testotoxicosis, may cause precocious puberty at a
' f+ P" y  s+ P( Avery young age. The physical findings in these boys# `0 O4 O* K: x3 }8 [, _! C
with this disorder are full pubertal development,
" R3 g2 k; o4 Bincluding bilateral testicular growth, similar to boys
% U3 ~0 @( e% Y9 U7 ewith CPP. The gonadotropin levels in this disorder$ E- L7 s$ ^$ V# u! |# H# t  C
are suppressed to prepubertal levels and do not show0 z2 W# j4 g, W. e+ G; w7 Q: r
pubertal response of gonadotropin after gonadotropin-
# @* C6 C- S$ r, ?$ @releasing hormone stimulation. This is a sex-linked7 y( t/ X9 a" w* x
autosomal dominant disorder that affects only
2 u$ ?0 ~9 d% F+ c  C7 J  z( g0 bmales; therefore, other male members of the family5 v5 P; _  N( z, ^" I
may have similar precocious puberty.3
9 F* R2 \$ \4 p9 B7 F2 Q8 kIn our patient, physical examination was incon-$ {; K7 x8 v0 x
sistent with true precocious puberty since his testi-
$ X: H5 R* A  q; B% E- g) mcles were prepubertal in size. However, testotoxicosis2 a8 X# C7 J7 L- {# e/ x
was in the differential diagnosis because his father% {5 w. X3 X5 w
started puberty somewhat early, and occasionally,
* w, K5 J8 l/ A* z$ Q& Ltesticular enlargement is not that evident in the
8 X! V' e* A" T; b7 U( @beginning of this process.1 In the absence of a neg-
8 z  y6 j% P0 ?& l3 m0 Pative initial history of androgen exposure, our
0 ]( `7 k1 r% P$ Cbiggest concern was virilizing adrenal hyperplasia,, W, e& y; }4 M9 A- i: {$ S7 l
either 21-hydroxylase deficiency or 11-β hydroxylase
" P  R) Z' Q$ ~deficiency. Those diagnoses were excluded by find-4 R% ^/ o: \7 q. S3 v7 ?7 i, ]2 V3 P
ing the normal level of adrenal steroids.
! B$ w) X) R8 b9 K, cThe diagnosis of exogenous androgens was strongly0 u" f2 u) q) p& A) Q: n
suspected in a follow-up visit after 4 months because% y% p5 V4 R9 ^6 ~. Z/ f/ `
the physical examination revealed the complete disap-9 j% ^+ b% h+ n1 e% X
pearance of pubic hair, normal growth velocity, and
' Z  A  [6 s6 Y  t/ ^decreased erections. The father admitted using a testos-
1 I9 [6 M6 n" z% e$ g+ V( Lterone gel, which he concealed at first visit. He was6 w! r  i, F/ Q  M& Q
using it rather frequently, twice a day. The Physicians’
0 L/ Y7 T/ Z7 {+ V+ R; WDesk Reference, or package insert of this product, gel or
4 R! _) I& {6 }( p4 [* icream, cautions about dermal testosterone transfer to
" T6 U3 \0 {$ i8 t$ y7 Dunprotected females through direct skin exposure.
; [, ~2 L& y% r" g1 zSerum testosterone level was found to be 2 times the
+ X- p+ B- u& `5 obaseline value in those females who were exposed to
, e: O5 D6 h/ s0 U7 f7 i0 Qeven 15 minutes of direct skin contact with their male' H  p3 _' J; R; c
partners.6 However, when a shirt covered the applica-
; a+ m& r( Q/ S6 Q1 S7 R& ^tion site, this testosterone transfer was prevented.! ]  k& r% e  X$ ?& D/ B$ k% w
Our patient’s testosterone level was 60 ng/mL,
3 ]  Y2 \1 j" U( R7 kwhich was clearly high. Some studies suggest that5 f. `1 O) P  ]. R0 x
dermal conversion of testosterone to dihydrotestos-
* `. s' C7 C; n" D/ o9 Kterone, which is a more potent metabolite, is more. W1 Y" R$ x2 e. [
active in young children exposed to testosterone: X' K& t' u6 f
exogenously7; however, we did not measure a dihy-6 H5 P! N- Y/ P* `- ~
drotestosterone level in our patient. In addition to
9 E3 E* x# J6 bvirilization, exposure to exogenous testosterone in
, `7 Y* B4 r3 U0 F) qchildren results in an increase in growth velocity and, f. j7 V8 J  P* V+ m) u
advanced bone age, as seen in our patient.- z6 Y* \9 n. \
The long-term effect of androgen exposure during
4 Z3 D+ k8 b* n) G7 Wearly childhood on pubertal development and final
7 ]" Z9 G2 A3 z# O! m# T4 wadult height are not fully known and always remain
/ @3 G) r* ^! v2 Qa concern. Children treated with short-term testos-$ M' D; D$ \  M9 P5 F" L
terone injection or topical androgen may exhibit some
& U2 u7 V9 i, T8 w3 P: ]acceleration of the skeletal maturation; however, after
) l1 w" `! z7 Xcessation of treatment, the rate of bone maturation5 y) }" i* T9 _
decelerates and gradually returns to normal.8,91 k% P4 @/ I4 Y& g: X- d& ^
There are conflicting reports and controversy6 T% y( a  U& x, K0 X8 i: `9 D$ O
over the effect of early androgen exposure on adult
3 X/ [, N7 Z* ~2 [. \0 a) N$ N. Spenile length.10,11 Some reports suggest subnormal* V7 f, H+ D( p4 `2 F3 a9 ]% s: C: Y- @
adult penile length, apparently because of downreg-9 d" y- W. p- o4 c" B4 n/ Y
ulation of androgen receptor number.10,12 However,4 J% o, c- Q* ^
Sutherland et al13 did not find a correlation between
, v( u2 Z/ w" X) Gchildhood testosterone exposure and reduced adult
# v) g3 |! s# d9 S, v8 Ypenile length in clinical studies.
% w4 ?. \+ b, q( c0 mNonetheless, we do not believe our patient is
6 o3 b( Z. {- N0 C$ \going to experience any of the untoward effects from
0 Q6 q% ]  O3 L8 z" B" Etestosterone exposure as mentioned earlier because* y! ?7 Z9 _9 n; b
the exposure was not for a prolonged period of time.5 v1 R3 R' q9 [' Z
Although the bone age was advanced at the time of
! \5 t) x; [- r& X$ W- ?4 Tdiagnosis, the child had a normal growth velocity at
3 L3 W" u+ t) I6 Cthe follow-up visit. It is hoped that his final adult
% A/ k/ r" d1 C) C& @height will not be affected.
  W, A( N* C( b" s* cAlthough rarely reported, the widespread avail-* o3 R* A: T" T& W9 G
ability of androgen products in our society may
& D3 s: x: A1 N2 y# ~indeed cause more virilization in male or female
, T) @+ B/ o" u  cchildren than one would realize. Exposure to andro-
  F) b& l1 a& x8 n) j8 Y. dgen products must be considered and specific ques-0 d3 p$ k" q. \. [, {  D1 d9 m
tioning about the use of a testosterone product or" e1 b$ ]+ `! @0 d, @8 l3 p
gel should be asked of the family members during
5 C7 k+ b7 J( W5 M5 Uthe evaluation of any children who present with vir-# I! n7 @. Y- N( n% A
ilization or peripheral precocious puberty. The diag-
: I1 Z$ Z4 C. h* y/ [4 H2 a) \3 gnosis can be established by just a few tests and by3 }8 g* _0 w% L  C  M
appropriate history. The inability to obtain such a
; r4 E9 {0 Y1 shistory, or failure to ask the specific questions, may
0 x: a" h' R* |  }/ lresult in extensive, unnecessary, and expensive( @4 ^/ r4 T! z" }4 h
investigation. The primary care physician should be
6 I, \" t0 b* V9 [+ b! M; P9 Daware of this fact, because most of these children
3 q( P5 s  Y" b% Z$ M, h6 Y, Jmay initially present in their practice. The Physicians’
5 u& t4 u- ?/ z" LDesk Reference and package insert should also put a
$ L: w) [* N) y; q2 z( Hwarning about the virilizing effect on a male or  G$ V8 C1 a4 O: j/ J
female child who might come in contact with some-
! L1 h9 N1 g& c3 a7 Mone using any of these products.: G' [, J7 w/ l( W: L+ }0 s
References1 B9 j7 |3 X* E& b+ }/ M( }. B
1. Styne DM. The testes: disorder of sexual differentiation
5 ?4 V) _5 \# t: j2 ?# y6 p5 gand puberty in the male. In: Sperling MA, ed. Pediatric( J7 f1 }3 W) |4 ]' D9 N, P- T$ w- J% M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 V2 Z3 p/ E1 }( V) @3 L
2002: 565-628.
- M* X. m7 W1 [# a. g, L2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 Y* k3 ?& p0 v$ G
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old% O2 Z! |4 [* E' G* r
Boy Induced by Indirect Topical
$ A9 D" k  ?: D, E4 h$ |4 ^& mExposure to Testosterone
$ \+ f, x. e3 a3 C# g9 b  H- p5 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2, r( n5 ^+ o5 r: C
and Kenneth R. Rettig, MD14 @3 v# J8 c! G' a
Clinical Pediatrics* }  h( X$ a8 c6 [# C% t
Volume 46 Number 6" I: R# H8 a5 A: ~" H
July 2007 540-543
8 W5 S5 ]' J, v$ h5 f* X/ z© 2007 Sage Publications
! X" |) i# t6 p6 n( f10.1177/0009922806296651' t( Q, `, l7 P' T9 t' }/ \1 ~( c; i( n
http://clp.sagepub.com
) I( Q( O# N5 S7 O2 o7 p' [hosted at
- }; t3 T4 Q6 }0 ]- A7 L) ahttp://online.sagepub.com% i9 q% o! D  {, _$ V
Precocious puberty in boys, central or peripheral,
; i7 ]/ N- V! R5 wis a significant concern for physicians. Central, ^3 o* M. G! \$ \4 o  S  {
precocious puberty (CPP), which is mediated
" _/ r! v8 X% [9 ~; q, Lthrough the hypothalamic pituitary gonadal axis, has
7 s8 J- r& \7 _5 `a higher incidence of organic central nervous system& P  `$ y5 q7 `6 y1 g
lesions in boys.1,2 Virilization in boys, as manifested* ]# a& N9 K! i4 T: W" p# v
by enlargement of the penis, development of pubic- U$ w2 k; J. ]1 I! {1 \2 K. ^
hair, and facial acne without enlargement of testi-" [, A1 b3 G: p9 l* a
cles, suggests peripheral or pseudopuberty.1-3 We8 O: A! H( W8 ^9 s" p  M& n6 ?
report a 16-month-old boy who presented with the
: p% |8 @5 Y, S* _: a$ D+ Zenlargement of the phallus and pubic hair develop-5 O; W' W6 b" \* p( s' L
ment without testicular enlargement, which was due
, y! n( _% {( p# n. Z" dto the unintentional exposure to androgen gel used by6 a" e) f7 h4 E1 D2 v1 i; ]
the father. The family initially concealed this infor-+ T0 n7 N) g( f4 T; w* e! M. k
mation, resulting in an extensive work-up for this, q( K9 Z, h0 L7 L$ |5 S8 M# Y  s4 j# X$ C
child. Given the widespread and easy availability of- [4 @( Z% n) ^1 h
testosterone gel and cream, we believe this is proba-2 b* n, ?7 r$ d5 Y% `
bly more common than the rare case report in the
- q, @3 b9 ^9 t. D4 I  r) B* Z. }literature.4
) C1 ^2 Z; t: ]3 o. ?, \! ZPatient Report, a) n( S4 j: l8 m
A 16-month-old white child was referred to the+ _! \7 j! N( Y7 y4 q; n. `
endocrine clinic by his pediatrician with the concern
6 _9 p" |7 W5 [% ~% J) q/ P- j+ Sof early sexual development. His mother noticed
. V- E) j/ K0 _9 Slight colored pubic hair development when he was5 a6 K9 u/ G9 e, a
From the 1Division of Pediatric Endocrinology, 2University of
; F0 J* ~: w/ Z2 B5 k2 cSouth Alabama Medical Center, Mobile, Alabama.2 n, c1 a2 |5 D& A  m* ^4 S
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 v+ E- c8 [0 X$ B9 cProfessor of Pediatrics, University of South Alabama, College of9 |8 D4 B# ~1 {/ h, Y- G+ _4 r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* A& d; O& e; k$ |* _( s3 Ae-mail: [email protected].
4 `2 Y$ u' N4 o& E% c4 nabout 6 to 7 months old, which progressively became" N' X5 `/ q: f( w
darker. She was also concerned about the enlarge-
9 Y0 R  R! j1 ?( S7 N; ]* a4 ement of his penis and frequent erections. The child! N' {. a" L" Q# W* c
was the product of a full-term normal delivery, with
, C# S7 H( ^; k# E- ba birth weight of 7 lb 14 oz, and birth length of
/ v) ?/ }& I. Q" b9 {; t, _3 D20 inches. He was breast-fed throughout the first year) u$ F0 K2 g3 d1 O  Q" ]
of life and was still receiving breast milk along with% t' {2 @" G, q/ K- B
solid food. He had no hospitalizations or surgery,. h8 i7 y1 l5 g3 O
and his psychosocial and psychomotor development2 q, v# z; H/ w
was age appropriate.
* O! X0 q" t5 d5 Y9 [4 N6 H# I- s5 ]The family history was remarkable for the father,
8 [2 g6 R& K) y$ _, a2 |) o5 iwho was diagnosed with hypothyroidism at age 16,
5 d3 n. N+ X% U' h* R+ Uwhich was treated with thyroxine. The father’s! o! o6 \  Y" N* L+ i9 k
height was 6 feet, and he went through a somewhat
/ ]8 E+ c* ]) p" Bearly puberty and had stopped growing by age 14.. `% F; \" o% k. x
The father denied taking any other medication. The
; s: i, R( j+ j& }child’s mother was in good health. Her menarche
. t# Z) k$ {) v* @4 l9 ?; Mwas at 11 years of age, and her height was at 5 feet7 T8 T4 v. @4 S" A
5 inches. There was no other family history of pre-" S& x7 b% s) }- E5 z
cocious sexual development in the first-degree rela-
  j: X, y& B1 j6 `2 T: ntives. There were no siblings.
7 |8 |! E! m1 qPhysical Examination2 h' d8 U' l7 }4 L  X7 W/ q
The physical examination revealed a very active,
9 ?+ V- B7 F3 L0 |; _% O0 g  Aplayful, and healthy boy. The vital signs documented
- s+ T3 c/ t! Z& o/ ua blood pressure of 85/50 mm Hg, his length was4 f3 G& B4 L/ T0 W
90 cm (>97th percentile), and his weight was 14.4 kg2 S3 a5 R/ Y  ~8 N
(also >97th percentile). The observed yearly growth! x, u* B+ C: T' i* r) [3 h( A
velocity was 30 cm (12 inches). The examination of* N- k: D2 y2 Z" d9 G. p& l) R5 v( c
the neck revealed no thyroid enlargement.
3 S! V- I; N! F; Q/ X. r: e  VThe genitourinary examination was remarkable for, c. _( x# {9 m+ S1 n0 ?6 |! C$ v# N
enlargement of the penis, with a stretched length of+ a3 T7 r0 g' v
8 cm and a width of 2 cm. The glans penis was very well" V5 b& |; H6 {- r/ R& V
developed. The pubic hair was Tanner II, mostly around! \6 G  g8 D1 c; g/ z4 w9 {: Q) }0 |/ }
540
- Q; @& B* d' N; G, v& e" z1 pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- S# C$ _5 V+ \" a9 w* e
the base of the phallus and was dark and curled. The
1 ?8 s. y; \0 F# b- P, ktesticular volume was prepubertal at 2 mL each.
" `$ a% O1 @" Z' Z% }/ O) O: xThe skin was moist and smooth and somewhat
/ Z' k9 V3 `7 k+ d. M6 a" Toily. No axillary hair was noted. There were no; E2 R( J0 D# O( e9 g& j
abnormal skin pigmentations or café-au-lait spots.2 `$ W4 _% n' x, R; f0 L$ t
Neurologic evaluation showed deep tendon reflex 2+
/ d5 C6 ]8 t( L. E5 ]bilateral and symmetrical. There was no suggestion1 @. ]" N, ^5 c$ K
of papilledema.+ J, z: T7 V. c5 P" G: a; x
Laboratory Evaluation  s2 K- }/ c) W6 w/ P
The bone age was consistent with 28 months by/ F; _4 N) ], _& z5 \  W' U/ L
using the standard of Greulich and Pyle at a chrono-
' L' N& A5 z1 u1 v8 _" mlogic age of 16 months (advanced).5 Chromosomal5 \7 n6 F; q, }$ v# I; `% h: p
karyotype was 46XY. The thyroid function test- U! |0 M' G6 T+ o" E" T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-5 h* a# u+ x+ e( h/ e
lating hormone level was 1.3 µIU/mL (both normal).0 M& H9 _( f$ {* S; A
The concentrations of serum electrolytes, blood" R, Q: z  {) y* r1 B$ ?
urea nitrogen, creatinine, and calcium all were
- y' _' A4 o. Z! n5 gwithin normal range for his age. The concentration9 z, u; j7 Z* F$ b3 B8 T
of serum 17-hydroxyprogesterone was 16 ng/dL
" J7 G8 O  v1 Y7 ?$ a(normal, 3 to 90 ng/dL), androstenedione was 20: m5 M: @: E- E* o: G0 H/ o7 p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ o& h5 m# u! o7 |* vterone was 38 ng/dL (normal, 50 to 760 ng/dL),( y3 G0 v8 g  I0 S0 y  u
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! n8 z2 f0 ?8 }& F49ng/dL), 11-desoxycortisol (specific compound S)# m( v* A  L& e$ h1 x9 z* ~6 E) j1 ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 {' \) g1 Z& f! p$ @- C9 R; xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 J0 e0 n" ?- z2 F; ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 ^  B# z% B4 U, N* J
and β-human chorionic gonadotropin was less than8 m& T) L9 |& [  d
5 mIU/mL (normal <5 mIU/mL). Serum follicular2 j5 J+ f1 s7 d  K; F/ W/ D
stimulating hormone and leuteinizing hormone' k8 ]9 ~5 q4 n$ x0 C. |
concentrations were less than 0.05 mIU/mL
. q3 k) x. z" O) s+ p' |9 R' J(prepubertal).8 X9 w4 b2 F  r8 R# \, Y- D  ]
The parents were notified about the laboratory
3 S7 b3 ?8 J" D) E0 a+ h0 R$ x1 P* hresults and were informed that all of the tests were
( _, a( N1 _: f) ?# M% wnormal except the testosterone level was high. The3 ~+ y5 M2 \3 @% H! P7 O
follow-up visit was arranged within a few weeks to
+ L% b- {8 ]9 b& @0 p" yobtain testicular and abdominal sonograms; how-8 h: E& W& y# M- Y6 V' ~# i6 y
ever, the family did not return for 4 months.; v1 J# |/ \$ z* ~0 g# U
Physical examination at this time revealed that the
7 g6 @3 n9 \7 I7 rchild had grown 2.5 cm in 4 months and had gained. c6 \1 I$ _: Q( @7 D' Q
2 kg of weight. Physical examination remained1 H9 B" l# m2 q' O; r
unchanged. Surprisingly, the pubic hair almost com-: N7 }+ H/ q& y2 i
pletely disappeared except for a few vellous hairs at
) q) p/ L. Q& J$ Vthe base of the phallus. Testicular volume was still 2" a) z  c" Q- U4 N' ^
mL, and the size of the penis remained unchanged.
5 }  o  c( s5 K' R1 x1 t& SThe mother also said that the boy was no longer hav-- c$ L5 F: \0 X2 L1 C0 u; C
ing frequent erections.
+ `5 k# b! z7 ?Both parents were again questioned about use of3 Q+ b" J) F6 G
any ointment/creams that they may have applied to
/ M% U5 r( r: o/ l. Bthe child’s skin. This time the father admitted the
4 _  I0 E8 o( Y2 P$ k, OTopical Testosterone Exposure / Bhowmick et al 541) M" |2 w+ [- S6 ?- A, S& Q6 s
use of testosterone gel twice daily that he was apply-
9 ^; t+ v: A$ w/ k0 |3 Ning over his own shoulders, chest, and back area for3 ]& R% U( M4 z
a year. The father also revealed he was embarrassed
; r# ~+ x" i' Eto disclose that he was using a testosterone gel pre-
5 i" A2 v2 A/ bscribed by his family physician for decreased libido- k2 `; L( f1 @  Z& b' p
secondary to depression.
( W4 F: ~- r- SThe child slept in the same bed with parents.7 b0 a$ K# i5 O9 b2 Z0 H. @% B
The father would hug the baby and hold him on his* u0 K+ N% f$ t( j( Q
chest for a considerable period of time, causing sig-
% a2 v) _8 r) |9 z  _nificant bare skin contact between baby and father.
2 C7 Z1 V& p  K7 \, tThe father also admitted that after the phone call,, d( R. z. p$ w, H% V) D
when he learned the testosterone level in the baby5 q" J5 w9 E2 x) F
was high, he then read the product information! J. Y" f: v6 F! @  i  `7 q! C
packet and concluded that it was most likely the rea-, _, B% i+ S3 i. W
son for the child’s virilization. At that time, they
/ ^3 f! v& a# z4 Y9 V% |decided to put the baby in a separate bed, and the3 L) X! D0 g, P6 d. f9 D. `, z: p
father was not hugging him with bare skin and had0 O- l; Z% g% r! G5 l
been using protective clothing. A repeat testosterone
5 s3 J, D; |: l/ b% qtest was ordered, but the family did not go to the) o) E4 [5 ^7 A  X& J
laboratory to obtain the test.- P  q4 F; c* t- ^3 r; z
Discussion; S) v1 X- A& f! S7 n% S+ [& w& n6 Y
Precocious puberty in boys is defined as secondary+ ?& N( Q6 Q( t2 m2 G/ P
sexual development before 9 years of age.1,4( N+ q6 f% f" d8 w
Precocious puberty is termed as central (true) when, F' i' C( ~  q+ L! H
it is caused by the premature activation of hypo-
* [( o( S: d' h0 k- Kthalamic pituitary gonadal axis. CPP is more com-
6 D2 b# N/ P3 h6 @6 Z" [mon in girls than in boys.1,3 Most boys with CPP, u2 w) ^- u* M+ b4 M+ ?! j
may have a central nervous system lesion that is
; C- Z/ h) [7 ]* e( h/ {6 ^: h1 ?responsible for the early activation of the hypothal-
3 ^4 F5 a* f$ t. {5 d# }amic pituitary gonadal axis.1-3 Thus, greater empha-
! U; T% s9 E$ [sis has been given to neuroradiologic imaging in( o5 H) B/ A, j, e$ f& m
boys with precocious puberty. In addition to viril-
' K& m& x9 s. O/ @ization, the clinical hallmark of CPP is the symmet-
- Y4 A) }/ e6 R  Erical testicular growth secondary to stimulation by
( h( ]& P7 a; k/ T) M, |6 \gonadotropins.1,3
6 d( w) l: U- p/ K, L* `5 Z6 F  bGonadotropin-independent peripheral preco-
2 z3 Q* G7 q- }, O. U: f* ?cious puberty in boys also results from inappropriate: w4 ]: E" O1 E9 S7 r
androgenic stimulation from either endogenous or
# u, Y5 X1 O3 W: }3 d6 j- ^8 F0 Kexogenous sources, nonpituitary gonadotropin stim-
  K! L$ f: ?( s3 {( Q0 Yulation, and rare activating mutations.3 Virilizing0 r) Y8 A& O8 ^7 x4 W! p$ n
congenital adrenal hyperplasia producing excessive
; w8 X5 R1 h$ V. }& M: t! Gadrenal androgens is a common cause of precocious. E, L& x6 m! @7 o  B
puberty in boys.3,49 s$ T- X% X5 C3 b% k
The most common form of congenital adrenal
3 e7 D+ L+ r, m6 I* Jhyperplasia is the 21-hydroxylase enzyme deficiency.
2 J9 g3 @. r" SThe 11-β hydroxylase deficiency may also result in. _3 @0 d+ B. H: m1 a: ]
excessive adrenal androgen production, and rarely,
' L6 Q9 Y1 T' S# I* Q* Zan adrenal tumor may also cause adrenal androgen( \. N, t- W! z$ X: |
excess.1,3
, i" C( t! U# k; V6 e3 J; M) w# \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" k$ n' h7 H( R6 F542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 k* \" o  ^. ]  U8 M! [
A unique entity of male-limited gonadotropin-
6 {' O, u7 K: Jindependent precocious puberty, which is also known
! \6 M+ ^' K" k7 I9 c% pas testotoxicosis, may cause precocious puberty at a
. d& j" s0 @6 r9 Vvery young age. The physical findings in these boys  I' m, c2 \* \: ?- d3 {
with this disorder are full pubertal development,: h/ R* B: H# h$ l( N" X
including bilateral testicular growth, similar to boys" w. G  A2 U( h) {& Q4 G( l
with CPP. The gonadotropin levels in this disorder
8 p8 a: V6 X. B1 o6 K) y' k1 a& @are suppressed to prepubertal levels and do not show- z5 }7 L, d- t  J. Z5 y
pubertal response of gonadotropin after gonadotropin-. x9 H2 n$ @* L9 D- f8 ~
releasing hormone stimulation. This is a sex-linked
; J9 i0 L1 w# j% h7 M: u6 Qautosomal dominant disorder that affects only
) K2 o% @$ @5 m( J( M7 Ymales; therefore, other male members of the family7 j6 T' M, n, ~( m" N, i1 ]
may have similar precocious puberty.38 c3 K8 G$ h- N* y
In our patient, physical examination was incon-
& y. s  q' W1 w5 f4 U7 P& K$ Ssistent with true precocious puberty since his testi-
6 r+ s9 b) S4 q/ @2 c" u* M9 Zcles were prepubertal in size. However, testotoxicosis
+ r" X- ^- ^+ T7 T9 Q1 g# |5 p8 |. Owas in the differential diagnosis because his father+ o0 Z8 X; x; L) j
started puberty somewhat early, and occasionally,8 t# u( F/ N. {; H( |/ t( F2 g
testicular enlargement is not that evident in the8 l, i3 l7 B: t
beginning of this process.1 In the absence of a neg-
) T" Y9 C/ ~$ f- B8 ^! i* mative initial history of androgen exposure, our
( t. C( K7 t: K8 J0 kbiggest concern was virilizing adrenal hyperplasia,
4 J7 T1 T4 y% S- P( e& i$ X8 a# ueither 21-hydroxylase deficiency or 11-β hydroxylase4 o  r8 X; b6 i* q6 ]/ x/ b
deficiency. Those diagnoses were excluded by find-
& n) m5 I8 a5 l. Y4 M. }) cing the normal level of adrenal steroids.
  y* H! Q8 t5 S# i5 _; v- }The diagnosis of exogenous androgens was strongly' l, |. _- G* g0 \
suspected in a follow-up visit after 4 months because
- o* m- m( W$ p  Ethe physical examination revealed the complete disap-* q) e, S3 y: {, ]
pearance of pubic hair, normal growth velocity, and
" ]/ z+ E7 O& _6 C! @; \decreased erections. The father admitted using a testos-
: X  \2 ?7 f* @" c5 q# A& aterone gel, which he concealed at first visit. He was  p: ?( _! f0 q& u* K+ b' T) t( i
using it rather frequently, twice a day. The Physicians’4 x: d2 Q4 V8 n0 Z$ z. i: Q
Desk Reference, or package insert of this product, gel or1 A7 G; J/ |0 Q; m! O' n9 l! ~+ R5 J
cream, cautions about dermal testosterone transfer to- n% T& W$ w4 U  p1 n
unprotected females through direct skin exposure.) e% s6 j9 _+ }' E/ M7 H1 Z
Serum testosterone level was found to be 2 times the* ?, Z0 |7 v4 K( x  A( n* r! ^0 Z
baseline value in those females who were exposed to
# l. S# U! s4 ^even 15 minutes of direct skin contact with their male
% ~! G$ U& Q7 q  S! B* tpartners.6 However, when a shirt covered the applica-; @7 g7 q1 u+ p& u
tion site, this testosterone transfer was prevented.
- f4 ^: y7 }7 P3 Q+ H0 jOur patient’s testosterone level was 60 ng/mL,
2 @9 j( v/ A" s: _. nwhich was clearly high. Some studies suggest that
; a* j; ]. ?$ V: m3 wdermal conversion of testosterone to dihydrotestos-1 o$ e+ Z: M6 a+ b
terone, which is a more potent metabolite, is more, _. k0 [' r. K; F
active in young children exposed to testosterone: @: f( Q0 D7 ^0 I2 L  J" [
exogenously7; however, we did not measure a dihy-
: d0 S) R" @( y+ R( y: v% y* A' @drotestosterone level in our patient. In addition to
& n7 G5 e& z8 T* d- D, V1 I3 a3 @virilization, exposure to exogenous testosterone in
% ~8 c$ Y  g! p9 p8 m- \- g: Lchildren results in an increase in growth velocity and
, R4 R6 W# F9 Eadvanced bone age, as seen in our patient.
8 ~% i3 d5 I; V) J7 I1 [2 rThe long-term effect of androgen exposure during
/ b/ R2 S: G* u- f& P: u3 Mearly childhood on pubertal development and final& c( [$ s1 _' d4 ?
adult height are not fully known and always remain
+ u; L0 J/ f1 W+ i, |a concern. Children treated with short-term testos-
8 }  J  o) m' `* t' A8 S, @9 D& Vterone injection or topical androgen may exhibit some
; I) l- K( I* K: u1 c5 R$ c* Eacceleration of the skeletal maturation; however, after" [: G; u; G4 f1 e) J$ {5 g, S
cessation of treatment, the rate of bone maturation4 R7 i1 E9 c% I" {' L2 S
decelerates and gradually returns to normal.8,9$ x% z! @" b' U( b* A& \
There are conflicting reports and controversy
+ v9 F4 J) `, E5 @! {) a; ]over the effect of early androgen exposure on adult1 B+ u* T$ r( a# j* U
penile length.10,11 Some reports suggest subnormal
# q) f+ S3 C$ A/ u5 _' M" wadult penile length, apparently because of downreg-
8 N6 p. i& \# `# R( Rulation of androgen receptor number.10,12 However,
* T3 @4 |+ c8 t3 D; C* uSutherland et al13 did not find a correlation between
/ J! Y" D$ ]1 k+ O- A6 `2 schildhood testosterone exposure and reduced adult* \. q/ o! \. H
penile length in clinical studies.! N8 a/ Y8 ~" s+ U# j9 b
Nonetheless, we do not believe our patient is1 Q  {6 q; S) ^; J+ N5 ^
going to experience any of the untoward effects from+ d: v7 `0 X7 b+ c3 E6 r2 c3 U4 g
testosterone exposure as mentioned earlier because* q+ b& @' e9 Z& p1 e
the exposure was not for a prolonged period of time.) H4 d) p. j- J' d4 b' F/ U, B
Although the bone age was advanced at the time of! i  c+ H5 j5 ~, W  L2 n  j% B
diagnosis, the child had a normal growth velocity at
/ J/ z+ B4 e% Q5 d3 W" p( e' Jthe follow-up visit. It is hoped that his final adult
0 R, D+ E8 A. a( f6 K8 qheight will not be affected.
, M! _4 \1 R# t6 {Although rarely reported, the widespread avail-
# C6 V: s) X1 B% S* J3 H& M  y- hability of androgen products in our society may
8 w/ _6 D" q$ O2 P2 r. rindeed cause more virilization in male or female* T0 |) c6 ~% d) Z4 @* l
children than one would realize. Exposure to andro-
% w' y2 r' k6 F  b# Qgen products must be considered and specific ques-! O, z- e. {( r1 h) _6 w3 P
tioning about the use of a testosterone product or0 `5 z0 a/ n! M1 k, e  r! K, v
gel should be asked of the family members during
1 [) s1 f! L( K+ q. C% d- [/ Fthe evaluation of any children who present with vir-
- c  [: q( n( d* o1 zilization or peripheral precocious puberty. The diag-1 y- K/ M4 k+ p8 @) `* X$ K
nosis can be established by just a few tests and by
1 |" u2 u% |# V/ C$ G) rappropriate history. The inability to obtain such a
$ X) z! B! ]& \0 j1 A$ Ehistory, or failure to ask the specific questions, may% Q3 x8 T$ z4 _/ N& k3 N
result in extensive, unnecessary, and expensive
) ]+ V( p& c" D7 @, iinvestigation. The primary care physician should be
8 ^2 g* C* n7 I& R" r' Qaware of this fact, because most of these children
% t5 J4 I, z& ^) r9 C5 i  H& h: @may initially present in their practice. The Physicians’8 d' s0 X4 z& F. e
Desk Reference and package insert should also put a
8 P: |% P, K4 `9 V$ b0 B8 twarning about the virilizing effect on a male or$ t5 I# \, |. m/ @- `5 i
female child who might come in contact with some-
" L4 {2 z) \% G8 Y% h8 N6 [* ?; Aone using any of these products.
2 i' l# ~8 D) v" m& C7 WReferences' a# n! s1 A. k8 ^% L2 }: @
1. Styne DM. The testes: disorder of sexual differentiation3 f+ E! V) n) W* a$ F9 |
and puberty in the male. In: Sperling MA, ed. Pediatric- |1 X) b9 d/ S( U& l4 c( G6 G: H& [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 v4 V1 e/ _* P
2002: 565-628.
4 B+ e  Y" B& h5 M( O1 A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 k+ E9 c4 d* }9 u/ Tpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
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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
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

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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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