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Sexual Precocity in a 16-Month-Old
, v2 w' N' o" Y5 K% H5 `Boy Induced by Indirect Topical
. N. _5 g7 b" b9 qExposure to Testosterone
: I9 ]8 i0 Z: g* [. T0 c& j, fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 g% L- o4 l( i1 ]) A& f( z
and Kenneth R. Rettig, MD1
4 ^4 T: q% @2 dClinical Pediatrics
; R% P! w, {$ [3 h# @Volume 46 Number 6
- a: d0 Z0 `( YJuly 2007 540-543% [& e( d( t. @1 h/ i3 o
© 2007 Sage Publications
2 n3 b2 X. D5 o# z* z+ B0 }10.1177/0009922806296651& w! i# ?& [4 q' h. |/ {7 p
http://clp.sagepub.com3 I1 P/ H7 F' U; [3 l( B' |/ O( m' {
hosted at& c- e* P# X1 W' T2 `/ {2 ]
http://online.sagepub.com1 W- c* {1 q8 N4 V/ G" [
Precocious puberty in boys, central or peripheral,
4 |7 E- Z* X1 `is a significant concern for physicians. Central
: |5 q7 J4 T" Qprecocious puberty (CPP), which is mediated
7 y- [0 c9 u2 K1 M3 p; vthrough the hypothalamic pituitary gonadal axis, has
" ?( ^. c$ R- o0 E. g2 W- o7 Ba higher incidence of organic central nervous system
- W& G, T1 N$ ilesions in boys.1,2 Virilization in boys, as manifested9 I% ?5 q0 X: l9 K
by enlargement of the penis, development of pubic
& c' @! e4 j, W) H+ ~5 z3 w' p7 rhair, and facial acne without enlargement of testi-3 V# `9 w) M# {' Z; ~
cles, suggests peripheral or pseudopuberty.1-3 We# W) W; J8 ]( [+ i
report a 16-month-old boy who presented with the
% Y% \8 s8 a8 A( Z8 Ienlargement of the phallus and pubic hair develop-' `/ g4 X% H8 B; ~. }3 ~$ t9 g) p7 T
ment without testicular enlargement, which was due
% i) ~1 U) O& p. w( t* E3 Lto the unintentional exposure to androgen gel used by
( n/ g8 X& ^8 C* U, ]4 |the father. The family initially concealed this infor-
2 T7 V+ u$ m5 G4 a; Q3 l3 \mation, resulting in an extensive work-up for this7 v+ O# {) T6 S
child. Given the widespread and easy availability of
& Z; q) p5 T0 Z+ p( o2 j! Y, g2 `testosterone gel and cream, we believe this is proba-
0 P- q' B* X) Y9 x+ D$ hbly more common than the rare case report in the
5 ?/ h6 `, M) G; V; y, k! M9 V# dliterature.4. S4 ?& |# o4 [4 ?0 X/ f
Patient Report
* R- C" }# |2 E# ~, V' jA 16-month-old white child was referred to the# M: q$ w- K/ V
endocrine clinic by his pediatrician with the concern. }  }$ M- Y$ ?+ k- c; J
of early sexual development. His mother noticed
% m6 F# [% h+ Y/ blight colored pubic hair development when he was
/ L3 E# |: ~9 j, b$ R3 J3 Z( SFrom the 1Division of Pediatric Endocrinology, 2University of  a5 z+ V5 V: q
South Alabama Medical Center, Mobile, Alabama.. s6 F# @5 T) m1 I  i4 e8 }- b
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 o- E/ d, J8 e* K9 E
Professor of Pediatrics, University of South Alabama, College of5 [5 \+ Y- I8 B8 ?7 O
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 x6 e0 k  v( K6 ]
e-mail: [email protected].
+ E2 w8 n0 N! ]8 R1 @' U1 ~* E0 _1 jabout 6 to 7 months old, which progressively became+ a& d, X' e2 l  X
darker. She was also concerned about the enlarge-
: V  _! e' ~8 Lment of his penis and frequent erections. The child
# y6 d) o" g2 w1 V. G5 C4 Z* M9 Rwas the product of a full-term normal delivery, with
) |! c; E. ?8 b7 B3 Ta birth weight of 7 lb 14 oz, and birth length of
" @. u" D2 M% y9 o9 t8 A: ~5 _  t; }20 inches. He was breast-fed throughout the first year" j* E- m9 z8 w2 H
of life and was still receiving breast milk along with
1 v1 p* @" M' H: B" O1 Wsolid food. He had no hospitalizations or surgery,9 j, K' j, G$ f0 e! v, j
and his psychosocial and psychomotor development
3 C# g2 Q1 M" |; x: N) w- v* Wwas age appropriate.# A2 f' e5 a2 d
The family history was remarkable for the father,
8 P/ {! T6 f; v1 Z; [3 }& ~5 m) Pwho was diagnosed with hypothyroidism at age 16,
* L+ J8 r; f0 o1 Nwhich was treated with thyroxine. The father’s
/ \! x& b* g, A! ?height was 6 feet, and he went through a somewhat
, y( c" K" r( {. gearly puberty and had stopped growing by age 14.% q& u, A1 L" {# T
The father denied taking any other medication. The
0 Q: U4 A/ Y. [: R; Nchild’s mother was in good health. Her menarche
: t5 [+ G) c0 S, ~! Zwas at 11 years of age, and her height was at 5 feet
$ h* {  q3 T2 `6 y3 }; x& F5 inches. There was no other family history of pre-
8 e) {; l' @2 f# d; |cocious sexual development in the first-degree rela-
, ^% ~& z$ o" L% J" d4 etives. There were no siblings.! M" r( o1 `) i, }) f" R7 H% M/ U
Physical Examination, B. T8 C& G5 I% [% |2 m
The physical examination revealed a very active,
: n, R- ~- S2 Yplayful, and healthy boy. The vital signs documented
9 ?1 g8 G( m2 R/ Va blood pressure of 85/50 mm Hg, his length was
7 o& J! P" @+ b7 _90 cm (>97th percentile), and his weight was 14.4 kg
9 K5 s" j2 q! f  o! m(also >97th percentile). The observed yearly growth
- |+ E6 `& }* q) f6 F- ~5 U# Vvelocity was 30 cm (12 inches). The examination of  k2 {1 m5 N2 n% u
the neck revealed no thyroid enlargement.
4 J8 n# J+ Q8 j0 Y- ]- lThe genitourinary examination was remarkable for+ T3 ~$ ?! a2 G0 F. q4 b
enlargement of the penis, with a stretched length of5 k7 E8 h% {( j
8 cm and a width of 2 cm. The glans penis was very well
/ x. c, H0 S$ z* T0 y" ?' Q& H. Kdeveloped. The pubic hair was Tanner II, mostly around
: m8 c; Z6 b) c* B3 ^8 f5406 ?# J1 o, A8 b5 }$ K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" V# C2 W4 L* v( [the base of the phallus and was dark and curled. The
  b/ Z0 h" ~" C: b' X/ c. xtesticular volume was prepubertal at 2 mL each.$ V1 s: @, E1 V6 r/ b
The skin was moist and smooth and somewhat
/ H$ m! M5 h6 ?. G9 boily. No axillary hair was noted. There were no& G" x3 Q& I5 h6 A4 _; H
abnormal skin pigmentations or café-au-lait spots.
( ^+ w. x# j( v  X2 vNeurologic evaluation showed deep tendon reflex 2+9 ]3 O+ U8 f1 u( |
bilateral and symmetrical. There was no suggestion3 S0 J2 ^& e8 L$ [) ?8 d1 \, z
of papilledema.
. d& x; }5 n1 U' }Laboratory Evaluation
/ }( T( ^0 u& \/ NThe bone age was consistent with 28 months by
0 G$ i3 V7 Y8 g$ u3 husing the standard of Greulich and Pyle at a chrono-
8 S+ K: P3 o+ Qlogic age of 16 months (advanced).5 Chromosomal
1 s  O* _" X! _, s  Fkaryotype was 46XY. The thyroid function test# a9 L" b/ i. v: y2 Y$ k' \( O
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 D$ X4 f7 q' ]% [* t; h3 \lating hormone level was 1.3 µIU/mL (both normal).
( c1 T* P$ S# [8 M' F4 eThe concentrations of serum electrolytes, blood
8 N# ~5 l7 a7 jurea nitrogen, creatinine, and calcium all were0 k1 s0 B6 r$ K" l
within normal range for his age. The concentration
$ V' c# h7 X# q0 \3 T/ _& Lof serum 17-hydroxyprogesterone was 16 ng/dL
* E+ Q- A% k& w* `/ K* E8 i" p) Z- r(normal, 3 to 90 ng/dL), androstenedione was 20
3 X* W; \5 M: x+ @' Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 h$ P/ q( M0 l' i! A
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. e0 P7 Y% Z' J4 J+ cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ `5 Y! Y% N7 D0 Q( O5 a: C49ng/dL), 11-desoxycortisol (specific compound S)+ G( H- F) @& Z0 F, X3 F
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: f" K5 a! x5 y9 z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 C, |: F; w5 D6 e' r8 btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% }: B# _8 h  r& A0 H4 mand β-human chorionic gonadotropin was less than
4 V# B/ U8 d6 S# N) I5 mIU/mL (normal <5 mIU/mL). Serum follicular6 A  X: l7 z$ j
stimulating hormone and leuteinizing hormone
1 R; \& T! i8 p6 lconcentrations were less than 0.05 mIU/mL+ x2 _6 d0 M* y( j; C# W; K: j
(prepubertal).% G* L0 P! q1 E! D4 b) i& q) T
The parents were notified about the laboratory
4 r4 x" @* O" _results and were informed that all of the tests were
& }7 C! u6 a8 nnormal except the testosterone level was high. The
$ ~) ]* @3 Q$ V! O) p- zfollow-up visit was arranged within a few weeks to
" ~& A# B, @) M+ e' Vobtain testicular and abdominal sonograms; how-2 r, v; M- i3 x( N
ever, the family did not return for 4 months.
8 x. z* |8 w4 ~# z# HPhysical examination at this time revealed that the7 s# l4 c' L5 a* r3 Y4 q, E5 j
child had grown 2.5 cm in 4 months and had gained
! Y4 a# V+ m" B) e4 n& k' T: \2 kg of weight. Physical examination remained
5 w; A# g! \; K4 `7 k( Eunchanged. Surprisingly, the pubic hair almost com-$ q% s9 J1 G  q2 F/ U" b- J* w' b
pletely disappeared except for a few vellous hairs at
! j# a5 }, ^# v( W! L! @& Pthe base of the phallus. Testicular volume was still 2
# e3 K' ~4 o* \$ L' n2 M+ a( q8 t" ?mL, and the size of the penis remained unchanged.3 c( Y# q) x2 \8 h5 _
The mother also said that the boy was no longer hav-7 r1 Y7 {3 h$ S5 p1 s) F. Y* Z+ L
ing frequent erections.
' k' u& E6 N; W  p! c0 p9 CBoth parents were again questioned about use of& s: D# e& c. u4 c- m8 q% R8 l- |7 W
any ointment/creams that they may have applied to
: {: `. L5 p2 G/ e, j; O. Hthe child’s skin. This time the father admitted the
7 W! I) m: D1 Y/ b5 `# O; N3 R+ |4 }Topical Testosterone Exposure / Bhowmick et al 541+ b+ X7 R5 ]. i
use of testosterone gel twice daily that he was apply-+ l/ T$ C' q, s. F
ing over his own shoulders, chest, and back area for
  V/ ?  f" z0 E" p4 _a year. The father also revealed he was embarrassed
% P* {6 h$ r' E7 n& J+ U* kto disclose that he was using a testosterone gel pre-, d- V# G$ w  i/ B
scribed by his family physician for decreased libido
3 B% p# K* t  h# J' S7 Lsecondary to depression.
) ~! P$ p; T, D! d3 `' fThe child slept in the same bed with parents.
* _+ \2 T$ R" s3 P/ B8 k; r% w- W7 nThe father would hug the baby and hold him on his  j, v% M* J, W( F3 F
chest for a considerable period of time, causing sig-$ w# `  K( I) w; t4 p# o4 ?
nificant bare skin contact between baby and father.
2 n; ?& ?3 c- E3 Y' Y  iThe father also admitted that after the phone call,
8 h8 _6 Q. q0 Z' W% H& n, bwhen he learned the testosterone level in the baby
4 `" t' V; R5 n3 q. T# Xwas high, he then read the product information: T( m3 q* }" k  N' h1 p* J5 h1 K2 N
packet and concluded that it was most likely the rea-& @$ V5 t5 e1 X6 {5 e
son for the child’s virilization. At that time, they
5 [1 k3 _2 R; v' vdecided to put the baby in a separate bed, and the
7 H# W8 V* Y7 m' E& @& Ofather was not hugging him with bare skin and had
8 v# n4 {- S  K. ^been using protective clothing. A repeat testosterone
* `" K- E/ v  i. K9 \) htest was ordered, but the family did not go to the* Q- j5 A3 F" M5 D) E9 o# M* J
laboratory to obtain the test.; m$ U7 _, m+ s- l
Discussion
  r# m$ b2 V* k5 z6 w5 RPrecocious puberty in boys is defined as secondary
% K: v+ ]! y0 Y1 _0 Fsexual development before 9 years of age.1,4
0 N( E1 j7 }: V" L1 v* YPrecocious puberty is termed as central (true) when( m9 [3 K6 _, X1 Y0 b) S" _
it is caused by the premature activation of hypo-
, D/ C8 p4 P) W5 z" Z! d' T# |! kthalamic pituitary gonadal axis. CPP is more com-
7 b" Q1 v" F: Jmon in girls than in boys.1,3 Most boys with CPP3 }4 Z" z9 D( q! A, E7 [" V! W9 [( e, ^+ P
may have a central nervous system lesion that is  l3 S7 G" X4 x# Z1 N) n8 x- s( U
responsible for the early activation of the hypothal-
9 v  v# R. ]% T% t$ K3 ramic pituitary gonadal axis.1-3 Thus, greater empha-4 ?, I4 h, z- V/ @" v5 L
sis has been given to neuroradiologic imaging in
( p5 v& @: w8 V% z2 M% Y+ Tboys with precocious puberty. In addition to viril-
0 N+ s& O6 g5 r3 Uization, the clinical hallmark of CPP is the symmet-
1 L7 {' S' J% c! U+ C' c" {% Qrical testicular growth secondary to stimulation by- F+ t' n5 N9 K9 @
gonadotropins.1,3" I& o$ ]% U. m
Gonadotropin-independent peripheral preco-! T5 T3 }$ q" R" a2 H# f
cious puberty in boys also results from inappropriate
, y" }  {; d  t) r$ bandrogenic stimulation from either endogenous or
3 y% M- V& V* d8 sexogenous sources, nonpituitary gonadotropin stim-
; b3 }3 b# s# Q8 M" c" c- xulation, and rare activating mutations.3 Virilizing5 d5 F& R) D( {/ J1 ^
congenital adrenal hyperplasia producing excessive! X' y" Y+ ^3 N9 m
adrenal androgens is a common cause of precocious
1 C( X* I8 D9 Q& _$ ppuberty in boys.3,4
" U, s- p- B8 ~+ z3 d: UThe most common form of congenital adrenal
8 g. Z/ ^4 P! t% U# m7 I4 d6 Jhyperplasia is the 21-hydroxylase enzyme deficiency., d1 |5 M# Q) ]$ ]4 n5 p& u" B7 r
The 11-β hydroxylase deficiency may also result in6 p3 \- v8 ^2 z" l$ p
excessive adrenal androgen production, and rarely,
' m8 y  `: G9 R2 Z- T! lan adrenal tumor may also cause adrenal androgen# a* {& f- x4 ]' r' C
excess.1,3
3 t5 B0 e5 B( `! Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 k7 a) B9 ~" p+ q- V542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% N+ P0 T" w+ X& H3 B& c: ]6 j" bA unique entity of male-limited gonadotropin-8 X4 W+ u. C( m8 ^0 l/ o9 N
independent precocious puberty, which is also known
' t6 K# N1 v" ]& V- yas testotoxicosis, may cause precocious puberty at a  k  w$ [/ \4 ], j; }  D- W
very young age. The physical findings in these boys
: l( E3 N# P  _/ g3 \with this disorder are full pubertal development,
: a+ u! D$ ]' a2 o8 H2 r6 C% P2 t8 Zincluding bilateral testicular growth, similar to boys* m; q% `5 ?1 D7 j7 A8 f
with CPP. The gonadotropin levels in this disorder1 O: E$ H+ T( I" O
are suppressed to prepubertal levels and do not show( [) w6 @: W" v* L+ l% q
pubertal response of gonadotropin after gonadotropin-& C4 Y, ^3 _5 X
releasing hormone stimulation. This is a sex-linked
- \& L7 Q3 c" c) ]: ?autosomal dominant disorder that affects only, C+ x6 \, S$ \% w3 k/ T7 j9 @
males; therefore, other male members of the family9 n$ O: o' C, }6 C; n1 x7 ?
may have similar precocious puberty.3
& t% [6 w, P$ c; J- SIn our patient, physical examination was incon-7 N6 i+ C8 {/ \
sistent with true precocious puberty since his testi-& g1 F6 _* ]  \& k* d3 D6 f6 z( }
cles were prepubertal in size. However, testotoxicosis
+ R) E, o: |/ t: }! p4 nwas in the differential diagnosis because his father
0 u; c! j+ }/ y0 M2 J) ?6 W* Fstarted puberty somewhat early, and occasionally,
3 C* G( k3 a7 x9 p! u" }3 ~/ h* t/ a6 ltesticular enlargement is not that evident in the% E" {: E5 ~. A9 B2 o
beginning of this process.1 In the absence of a neg-* Z& f; M8 X' Z2 a! B* L2 s6 b
ative initial history of androgen exposure, our3 h3 n$ l' j7 |' P( A
biggest concern was virilizing adrenal hyperplasia,# {; n7 ~3 q" J' x9 q5 L* C8 ]
either 21-hydroxylase deficiency or 11-β hydroxylase
/ b9 M9 h2 t" j& `0 t- `deficiency. Those diagnoses were excluded by find-
3 Q) K8 |9 |7 ?- U! qing the normal level of adrenal steroids.8 Q1 v1 A. |- J$ c
The diagnosis of exogenous androgens was strongly
2 k& j- t4 Q6 d& V/ S$ dsuspected in a follow-up visit after 4 months because/ E/ Z' L1 ]% ~
the physical examination revealed the complete disap-" q* g2 v* \! ~- F: M+ ?( N! B
pearance of pubic hair, normal growth velocity, and3 I4 y9 x6 _8 s, M) y* U5 ^
decreased erections. The father admitted using a testos-7 X7 {/ h" m* I# R! J* n
terone gel, which he concealed at first visit. He was
2 U7 F, r6 _* Q' Uusing it rather frequently, twice a day. The Physicians’; Z$ Y0 c* D! q0 |9 O+ I
Desk Reference, or package insert of this product, gel or
/ v4 `! U/ U4 u, C/ p/ Lcream, cautions about dermal testosterone transfer to
! m9 `! Q* V' ?- x  Dunprotected females through direct skin exposure." @2 G7 e( d' o) |; Y
Serum testosterone level was found to be 2 times the
5 [' N# m% }' t# A9 ?3 xbaseline value in those females who were exposed to3 n1 Z! z( g: d
even 15 minutes of direct skin contact with their male
- \0 K  a' M7 i0 k# tpartners.6 However, when a shirt covered the applica-
" p9 F  J; P8 ction site, this testosterone transfer was prevented.5 c% |  Y" n, U, `4 K$ K" i( S
Our patient’s testosterone level was 60 ng/mL,' w1 {3 l" b  S7 k, \$ J
which was clearly high. Some studies suggest that( n3 \4 S/ B. m9 @2 u4 ~
dermal conversion of testosterone to dihydrotestos-
. x% P( N  B* b# W" ?2 Oterone, which is a more potent metabolite, is more& J3 v" V: t1 t, z- i+ C7 t2 I, g
active in young children exposed to testosterone
9 s( M- x& c) x: }) jexogenously7; however, we did not measure a dihy-
) o9 Y. ~" z# i, G! N- f# \) udrotestosterone level in our patient. In addition to8 T" o2 i$ q( I/ a: @3 u
virilization, exposure to exogenous testosterone in5 j9 O& V7 w6 {% Z
children results in an increase in growth velocity and( F  s$ n6 w: U7 m
advanced bone age, as seen in our patient." L- v7 K: }- [0 n1 i- v6 q1 P5 v
The long-term effect of androgen exposure during
. j  @6 z1 Q) }: `- I4 ^* ~  cearly childhood on pubertal development and final7 Q& b0 i3 T1 n
adult height are not fully known and always remain
9 v. z# M# L" C. H& F. q7 a* Ra concern. Children treated with short-term testos-; W, n- _6 \& {' \
terone injection or topical androgen may exhibit some
3 X  @: Z4 [% k; ~8 B) x  bacceleration of the skeletal maturation; however, after
- L4 F: ?! A- X' N9 H# bcessation of treatment, the rate of bone maturation( w" \8 @% L$ ?# B2 |, K- U/ p
decelerates and gradually returns to normal.8,9& y( t3 x7 M, u3 `2 X
There are conflicting reports and controversy
0 _, H$ ^+ X, b3 {over the effect of early androgen exposure on adult
! N0 ?' F" }# z# i' k3 |penile length.10,11 Some reports suggest subnormal
* u( m) s  N) X# J. C* G0 _( vadult penile length, apparently because of downreg-3 i. n2 J# H3 c' N& U
ulation of androgen receptor number.10,12 However,
) f+ ^7 c" k" L4 oSutherland et al13 did not find a correlation between" U' k1 _) h. [3 F% y. J
childhood testosterone exposure and reduced adult  V# D6 g# O; }2 ~6 R; k
penile length in clinical studies.
: d- y+ G  F2 w" ?5 k1 U  dNonetheless, we do not believe our patient is7 u( E: A9 y$ F9 i
going to experience any of the untoward effects from
/ Z$ P+ Z6 N% n! {- @9 a+ ]testosterone exposure as mentioned earlier because
& Z, M3 L; V0 z" ?7 J% ythe exposure was not for a prolonged period of time.6 M; w0 J) ^- V- D
Although the bone age was advanced at the time of. f; m! ]4 D" r, b* L  P
diagnosis, the child had a normal growth velocity at
# K, h% g4 d0 ^0 r! J$ _+ d# I* [the follow-up visit. It is hoped that his final adult
1 t. k  u# ~* yheight will not be affected.$ q3 g& X& W' h, |4 Y
Although rarely reported, the widespread avail-+ K: R; y2 K, q
ability of androgen products in our society may
- `* ?' w, |2 K9 Hindeed cause more virilization in male or female
  @: ]/ m$ b' o$ `. B- @* ?8 I" [. Qchildren than one would realize. Exposure to andro-
. r9 C) H2 w" T8 Lgen products must be considered and specific ques-
' X/ C, a: `& e6 Mtioning about the use of a testosterone product or0 j4 Y. Z. H5 G! q
gel should be asked of the family members during
* H8 [& v. x% J; ~the evaluation of any children who present with vir-7 l7 S( h1 U; Y
ilization or peripheral precocious puberty. The diag-( j8 N- L; J$ E/ `
nosis can be established by just a few tests and by
2 P; v0 I7 W% \9 A; M* xappropriate history. The inability to obtain such a# p8 w! @& n2 z; ^% p* I
history, or failure to ask the specific questions, may
6 W! x& T4 s5 ^result in extensive, unnecessary, and expensive
/ Z* p) d7 T# M/ l% Z1 X( x, \# Oinvestigation. The primary care physician should be
& w6 d2 J8 \( Y# L7 _aware of this fact, because most of these children
4 V8 d% s* O+ P% L8 L% M2 L  u3 _may initially present in their practice. The Physicians’
! b( ~" D. ^: ~7 q, [, r8 A7 t: wDesk Reference and package insert should also put a
8 K6 o) ~) R2 b$ ?: V$ r( zwarning about the virilizing effect on a male or% z' k, i# X4 j
female child who might come in contact with some-/ w. p3 c' w4 \
one using any of these products.
1 K* S6 B: p% f. [References5 I8 r. r1 w9 u; X3 [& K+ ]2 c% r
1. Styne DM. The testes: disorder of sexual differentiation
0 r+ P( ^/ s' J( Pand puberty in the male. In: Sperling MA, ed. Pediatric; g1 G/ |) d1 V8 T3 [/ d# A
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 ]4 Z8 ?) e& `& B5 `: g2002: 565-628.
2 w6 J7 B3 c4 v8 X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- n' c: z% D9 ]9 j. O4 fpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old& A8 t! K8 r. H6 \
Boy Induced by Indirect Topical6 c4 j4 C3 D5 v: K. L: B
Exposure to Testosterone! S3 z; ^2 X. K; \- y
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( q: u! {& @6 }: k# N9 e( j% }5 T# Z
and Kenneth R. Rettig, MD1* P# [5 A/ z) K/ G9 e/ {
Clinical Pediatrics, O6 [9 [- |# K7 b
Volume 46 Number 66 p3 n% q' f/ D$ |- a
July 2007 540-543, [& r% \+ n; l8 }+ c
© 2007 Sage Publications
  @- w0 Z4 H! e6 P9 L* \$ U10.1177/0009922806296651
9 ]9 `+ _- M5 {3 k) {http://clp.sagepub.com
* a9 @7 }& d! Ahosted at" |- n# ?3 O+ n4 ^# k; s) k( X) [
http://online.sagepub.com
2 l+ c; H9 u) U5 LPrecocious puberty in boys, central or peripheral,. N* F! v4 V$ Z8 o  D5 v
is a significant concern for physicians. Central
+ q3 s/ y" [4 u( {2 J' V5 Qprecocious puberty (CPP), which is mediated' ?9 t, M- h; j
through the hypothalamic pituitary gonadal axis, has, v2 O  U7 p* ?. V0 F# H
a higher incidence of organic central nervous system
, l( `4 Y7 H. O% n. ~! s3 N/ @& rlesions in boys.1,2 Virilization in boys, as manifested
; d6 T. l' Y. J9 x/ S# O# B5 Vby enlargement of the penis, development of pubic! n" o9 y* G: r: D! K: A
hair, and facial acne without enlargement of testi-' l5 h2 k: d8 B. G" [( l, ^
cles, suggests peripheral or pseudopuberty.1-3 We
1 y* R; S; t& \6 g# Xreport a 16-month-old boy who presented with the3 M2 _& _/ t3 q9 T; Q' s4 Y
enlargement of the phallus and pubic hair develop-: H) T4 J6 r: W3 p
ment without testicular enlargement, which was due
! t$ k; U0 v8 \" ~9 ^to the unintentional exposure to androgen gel used by; R" j8 y- l. t& B/ N
the father. The family initially concealed this infor-
9 G0 @- N+ x: X; U5 S, h  |mation, resulting in an extensive work-up for this& k# C: m2 _6 c, d
child. Given the widespread and easy availability of
# k- R% E, x' c3 ltestosterone gel and cream, we believe this is proba-2 `, ~/ @' T* X) v0 p# H/ J) w
bly more common than the rare case report in the& l( U% s$ w% |8 ]4 q/ [( o$ a
literature.4" W9 t# E8 E, p$ ~& j' A& V# a, m" s
Patient Report
! A/ J3 D" ^) S5 q" \" b9 H; xA 16-month-old white child was referred to the2 D! o* ~; s7 ^; G) w+ h/ v/ Q" d3 A
endocrine clinic by his pediatrician with the concern
0 ^9 N9 X. q  S6 E3 t$ vof early sexual development. His mother noticed0 ~; v+ P" M4 M' z) _
light colored pubic hair development when he was' R9 e$ P( F9 q, f- I
From the 1Division of Pediatric Endocrinology, 2University of
$ y2 S: `6 w* x" h3 @# U( ~South Alabama Medical Center, Mobile, Alabama.
# ~. o8 a7 G2 FAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 W1 w0 _+ _) Z2 j& G: r' n2 W
Professor of Pediatrics, University of South Alabama, College of
: B" I$ X# @8 r+ x% K( A. V0 cMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;$ J$ D; u3 J/ [, w$ b# G! f' N
e-mail: [email protected].2 O( |; k7 j" r# r
about 6 to 7 months old, which progressively became, P+ d& a2 ]) M3 a
darker. She was also concerned about the enlarge-
- `) U8 P8 V1 P. Y* @  T" Ement of his penis and frequent erections. The child
: A8 ]: q9 h6 S+ k* P/ i: p) {was the product of a full-term normal delivery, with
+ P9 k% ?& e/ Y% A% ~! {) }! |, Ia birth weight of 7 lb 14 oz, and birth length of
; s, w$ W. q5 E7 ?20 inches. He was breast-fed throughout the first year
7 l- N* T! y/ M& G9 ?( rof life and was still receiving breast milk along with
. R2 k( P* }* r  [8 q6 E+ Xsolid food. He had no hospitalizations or surgery,
/ m5 d3 e/ |# _1 w) W7 F% Pand his psychosocial and psychomotor development
2 U8 V4 }& l  mwas age appropriate.
6 r" C/ t. V. `8 W4 w& k! `The family history was remarkable for the father,
( _- y0 l8 U# z% nwho was diagnosed with hypothyroidism at age 16,4 R7 z' Y" U+ X
which was treated with thyroxine. The father’s& v5 @- N2 C4 B! j% W; P( ]! ~! w
height was 6 feet, and he went through a somewhat& z$ m8 J: g, W% ~% f0 u0 |
early puberty and had stopped growing by age 14.
# s. b" u$ c4 H0 t! I! VThe father denied taking any other medication. The2 a2 M" g" ^. Y. P" V! e
child’s mother was in good health. Her menarche
( G7 b. V" x/ [1 ~  m" Ywas at 11 years of age, and her height was at 5 feet+ ]2 {" R: ]0 V9 S* a" Z0 \
5 inches. There was no other family history of pre-, d: M9 b7 Z' P  r' q4 y! ^
cocious sexual development in the first-degree rela-2 U' j4 f/ T  k+ G$ [7 B, o
tives. There were no siblings.1 y, Y, S9 t" H% ?+ U/ G9 J
Physical Examination1 |7 b8 M$ s- X' Y
The physical examination revealed a very active,0 T2 U# {- H4 |& _
playful, and healthy boy. The vital signs documented* `. z$ |( h7 e+ E8 n
a blood pressure of 85/50 mm Hg, his length was. y1 l  y" q8 O
90 cm (>97th percentile), and his weight was 14.4 kg6 C$ _: Y7 N- m9 k8 Q
(also >97th percentile). The observed yearly growth
4 c  w/ A- S% I! }) n# T5 U3 Tvelocity was 30 cm (12 inches). The examination of( T1 l: t# M3 w% q
the neck revealed no thyroid enlargement.. ]( d/ d% Q" N! e8 P8 Y/ ]
The genitourinary examination was remarkable for
: d" z* W9 _( n& J& jenlargement of the penis, with a stretched length of
. E3 i/ P$ A; N, n; J3 [8 cm and a width of 2 cm. The glans penis was very well
! ?) `: ]9 i# h7 Jdeveloped. The pubic hair was Tanner II, mostly around
3 w- o+ |5 A3 k8 G6 q540
5 T: m& [) t( mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# j& h- b4 @& f9 M
the base of the phallus and was dark and curled. The
/ a! H/ [+ P; K; u% c4 z3 U* M+ A  rtesticular volume was prepubertal at 2 mL each.+ m3 J: r$ g2 |
The skin was moist and smooth and somewhat
; S% I; h2 x% e, E* `oily. No axillary hair was noted. There were no( Q3 H: b$ U7 u% j0 `' a" ~
abnormal skin pigmentations or café-au-lait spots.5 ~% h& _  r$ [$ |# b
Neurologic evaluation showed deep tendon reflex 2+  p! A! I7 p4 f  G. Z
bilateral and symmetrical. There was no suggestion
( J! E0 I6 w: x. w; Y5 cof papilledema.- `4 B+ J0 J* f; X: ]
Laboratory Evaluation& t: K* K  @, G* \0 ]- @6 u
The bone age was consistent with 28 months by
% }) r1 p; M0 S" fusing the standard of Greulich and Pyle at a chrono-7 M6 s" f7 ?9 Z$ Z2 j4 K
logic age of 16 months (advanced).5 Chromosomal
' B# S% ^* H$ d2 Mkaryotype was 46XY. The thyroid function test
. J! ]" j3 s* h5 M8 \4 u: Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-4 A8 @! }) N2 Y- J
lating hormone level was 1.3 µIU/mL (both normal).; x& x$ z1 y9 ^
The concentrations of serum electrolytes, blood
8 d; r( q9 M' h" p  Furea nitrogen, creatinine, and calcium all were+ Q7 F! O0 J  t8 I. j/ c) F
within normal range for his age. The concentration* z2 n' C6 ^. I; t
of serum 17-hydroxyprogesterone was 16 ng/dL
3 i5 v8 }0 c9 {- g2 g4 e( c(normal, 3 to 90 ng/dL), androstenedione was 20
8 {1 e2 V% T9 C" Z9 H0 a+ cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# w0 @7 ]0 |2 t' ]- y* dterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ J. _, g; x  }: m8 F0 A
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" ^! v, I7 `8 h2 z
49ng/dL), 11-desoxycortisol (specific compound S)1 l2 _) m7 n- ?/ \& A2 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  R6 e$ Y& j* G& s# Atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 d4 K, @. k) }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ N, o9 H) k, b" n7 c) [and β-human chorionic gonadotropin was less than
# E4 @' Y1 r' p5 V8 U& ]5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 e* _; u: g  w- wstimulating hormone and leuteinizing hormone) l6 Z5 E6 }- p: E
concentrations were less than 0.05 mIU/mL
8 L: D5 J, o1 U( m# G4 z7 r(prepubertal).+ u6 F% ^4 N, k6 Q
The parents were notified about the laboratory
2 N4 b% d4 f' ]9 R$ t$ }& \results and were informed that all of the tests were
! a/ p8 K( W' v* l8 j2 D* o. @normal except the testosterone level was high. The; K( d+ G  g& V5 `8 d
follow-up visit was arranged within a few weeks to
5 c5 S/ d" V8 x9 kobtain testicular and abdominal sonograms; how-" C4 f8 @1 w$ `. F: k8 I5 ]" `
ever, the family did not return for 4 months.
: G4 `6 y7 I& i5 W- f8 _# |6 CPhysical examination at this time revealed that the$ {; q# ~8 u0 [
child had grown 2.5 cm in 4 months and had gained
) a' q& P; _( \; u; {% M2 kg of weight. Physical examination remained
& h, w6 X8 Y$ c: G  n2 runchanged. Surprisingly, the pubic hair almost com-
6 j9 y# X+ Z7 @; T; y' {pletely disappeared except for a few vellous hairs at2 M" A) D' `$ n4 k/ R
the base of the phallus. Testicular volume was still 2/ f! m* G: G' E& }7 ]8 d* c. L+ r
mL, and the size of the penis remained unchanged.
) m1 J: I( k0 T( |# xThe mother also said that the boy was no longer hav-
# u; G+ f' T; U9 v  d8 ~! jing frequent erections.
3 G5 }/ y7 y- R0 G( aBoth parents were again questioned about use of
7 Q7 f1 m& J! v9 U7 cany ointment/creams that they may have applied to4 \9 u* @9 J6 g
the child’s skin. This time the father admitted the
' V& J& ^2 L% g, ?: ]Topical Testosterone Exposure / Bhowmick et al 5416 W, ?6 \6 B/ Z2 E' h; S
use of testosterone gel twice daily that he was apply-8 P( k7 C5 b5 b1 E! `! k7 m$ h
ing over his own shoulders, chest, and back area for! q% B8 i  o; b
a year. The father also revealed he was embarrassed
2 {' k- c& I2 F5 l6 i  uto disclose that he was using a testosterone gel pre-
% I$ e5 x; N* Z7 X+ t0 mscribed by his family physician for decreased libido
7 T- t5 j% D" @9 @5 w# ~5 Hsecondary to depression.
0 P) A1 l) }7 D2 G& y7 aThe child slept in the same bed with parents.
& Z% K" A' W8 q% N6 n2 d7 RThe father would hug the baby and hold him on his
; r* b) n$ D5 o( n5 }- ^chest for a considerable period of time, causing sig-. r1 T9 K% ^: p; I! [* X
nificant bare skin contact between baby and father.; }& n3 W, G. Z6 h
The father also admitted that after the phone call,: ?1 d9 O) r7 y; ~( i  ?8 X$ h
when he learned the testosterone level in the baby; B/ A( y# ~( I  k+ l) _* v
was high, he then read the product information
* h* u* l  p! S8 W* j/ J  f+ F) `% Lpacket and concluded that it was most likely the rea-
& {1 x: j8 T: }0 E: |5 D% Uson for the child’s virilization. At that time, they
  h3 Y3 H+ W. @! |. B4 [1 Q6 s# Tdecided to put the baby in a separate bed, and the
* y: Q7 s0 h7 {8 z8 P; G6 afather was not hugging him with bare skin and had, x6 s1 J+ ]: w: F& @/ u9 g  t
been using protective clothing. A repeat testosterone. K* o, A$ F# _. t* K
test was ordered, but the family did not go to the0 `7 n% i, r2 h
laboratory to obtain the test.. L: K9 ]( ?6 U, s% h; h0 w! T
Discussion9 d6 ^/ l. `7 }3 Y/ \
Precocious puberty in boys is defined as secondary
/ ]/ o! Y4 g( ^sexual development before 9 years of age.1,41 C+ Q4 |* [+ e- _: J3 l
Precocious puberty is termed as central (true) when
. G6 l, o+ T; k% ~. |it is caused by the premature activation of hypo-& N9 @1 Z; e& w. I* i
thalamic pituitary gonadal axis. CPP is more com-  w+ b9 G9 ]8 p( w" O
mon in girls than in boys.1,3 Most boys with CPP( H! o5 r) o, y, ?
may have a central nervous system lesion that is5 k9 V1 D' h4 D' D0 @
responsible for the early activation of the hypothal-
6 d4 t- l$ ^$ T5 J1 ^: eamic pituitary gonadal axis.1-3 Thus, greater empha-
1 s! J8 \5 D' d; a- o: v- G4 msis has been given to neuroradiologic imaging in5 @* V) s9 Q/ i* I/ S$ |6 Y) _+ o( _* ]; \
boys with precocious puberty. In addition to viril-
( P3 k" }( p: u# M' J# pization, the clinical hallmark of CPP is the symmet-
  n/ ^; g$ k; prical testicular growth secondary to stimulation by
. u  _) D* U) \- P$ V+ pgonadotropins.1,3
- E" G( R9 a1 q2 \8 k$ K$ nGonadotropin-independent peripheral preco-  J8 C) @# k5 ~% R5 S  j
cious puberty in boys also results from inappropriate, v" A& X. ?) Z1 h( Y0 t
androgenic stimulation from either endogenous or  w% U! r$ G) l* r) S
exogenous sources, nonpituitary gonadotropin stim-
5 I* ]7 C: D/ A( h* a8 H/ ~# k$ c5 [' mulation, and rare activating mutations.3 Virilizing1 L- m) [& }% h) d9 R: q5 H
congenital adrenal hyperplasia producing excessive% s# m( z2 g0 l
adrenal androgens is a common cause of precocious; }$ x5 @: j! Z, C
puberty in boys.3,4
. c5 t2 W3 u4 C: }( B# L+ |8 A- ?The most common form of congenital adrenal; V7 u# U; o. u
hyperplasia is the 21-hydroxylase enzyme deficiency.! P8 ^  F6 n5 R  s, f. C
The 11-β hydroxylase deficiency may also result in! O/ e! a% D# G! j6 H5 T6 r
excessive adrenal androgen production, and rarely,# }( |. O! N% i
an adrenal tumor may also cause adrenal androgen
$ R' D7 C7 x1 C9 Y  \% K! kexcess.1,37 t! Y* p& u# N0 ]% ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  ?: @" h; S8 E) c
542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 p% J, ^1 ?# y& M
A unique entity of male-limited gonadotropin-
, g! Y- a" _: @9 i! o& ?independent precocious puberty, which is also known
- t" }) x& J+ V, \' m" Q) yas testotoxicosis, may cause precocious puberty at a
5 F9 u$ n- n1 G/ S' w& Wvery young age. The physical findings in these boys
. q9 i$ e, q. X: _( Y" Rwith this disorder are full pubertal development,
/ K: w" M4 _  m) yincluding bilateral testicular growth, similar to boys
# v& H5 b8 Q9 d/ Cwith CPP. The gonadotropin levels in this disorder
# v0 o5 D: z, w& K# @are suppressed to prepubertal levels and do not show% j8 E/ G9 X" i( Q$ v( t5 T
pubertal response of gonadotropin after gonadotropin-4 i* ?# R3 k/ z$ Q$ i$ P. `
releasing hormone stimulation. This is a sex-linked
. m. i4 u" N5 {" ]! B9 Lautosomal dominant disorder that affects only
3 }( f( u! B( J) {$ ymales; therefore, other male members of the family0 D3 b4 D% }3 @
may have similar precocious puberty.38 N3 x: q, u6 |7 r- ]- Z9 e
In our patient, physical examination was incon-
) z# a5 C4 n% ^sistent with true precocious puberty since his testi-
; I" O; x# v- \% qcles were prepubertal in size. However, testotoxicosis
" n7 c) ?9 r2 g* H% F- j0 Uwas in the differential diagnosis because his father
' z3 X1 t% i% F* j7 {' Zstarted puberty somewhat early, and occasionally,
) ^: U, C& `( k2 x  ztesticular enlargement is not that evident in the; G( V% J: i3 y
beginning of this process.1 In the absence of a neg-8 O. B7 p) A$ o7 I
ative initial history of androgen exposure, our0 K3 i2 u9 }  M
biggest concern was virilizing adrenal hyperplasia,1 P0 D, j2 L8 V" H6 S" v
either 21-hydroxylase deficiency or 11-β hydroxylase
8 H3 [/ ?' b' H2 Tdeficiency. Those diagnoses were excluded by find-7 h  u) w9 g* D$ P, b5 g  B4 v; b
ing the normal level of adrenal steroids.$ p: b& c3 o, v5 T: V+ z3 w+ u
The diagnosis of exogenous androgens was strongly
& u" `7 n, g! I, Q9 \suspected in a follow-up visit after 4 months because2 n' u  c0 r- b; V3 a) s& {5 ?5 W
the physical examination revealed the complete disap-
8 n- c# H# s  U, s& Y/ rpearance of pubic hair, normal growth velocity, and
' |% Q. q  E( g3 g" Y  j9 i* q% Udecreased erections. The father admitted using a testos-" J8 g2 D4 F, m) f& F0 x& s& H% X
terone gel, which he concealed at first visit. He was
. u6 a) _4 n. k8 @' N0 ausing it rather frequently, twice a day. The Physicians’$ l( L  x( r" }1 L. T9 r) X
Desk Reference, or package insert of this product, gel or' c4 v  T8 Q4 F* A
cream, cautions about dermal testosterone transfer to
, S8 O( x- T  w5 Wunprotected females through direct skin exposure.  t3 T) P" }) f7 O# H
Serum testosterone level was found to be 2 times the
% w# I" G- N" o; ]baseline value in those females who were exposed to
4 V, \5 c2 }% Eeven 15 minutes of direct skin contact with their male
9 q7 J* U* S, g# m% epartners.6 However, when a shirt covered the applica-; T% R' v6 D& x' k. x
tion site, this testosterone transfer was prevented.
' A4 b  k- x5 I2 Z3 \8 n' T) R" EOur patient’s testosterone level was 60 ng/mL,
, V# n7 z! K3 E* Mwhich was clearly high. Some studies suggest that
( v7 y& h* j* X# odermal conversion of testosterone to dihydrotestos-
6 t/ @5 Y5 K( x  Wterone, which is a more potent metabolite, is more
+ X0 ]( K- T# {) Z% s1 ?active in young children exposed to testosterone
1 m, B$ Y8 Z4 k$ p2 m# A; D" vexogenously7; however, we did not measure a dihy-, K- |: X  C0 H7 I, i# R% e! V( u2 A
drotestosterone level in our patient. In addition to
8 W/ b+ {5 N7 ?7 r6 N9 Cvirilization, exposure to exogenous testosterone in
. q  s6 x* }3 U! p% ychildren results in an increase in growth velocity and* O% E+ r8 f0 R* r
advanced bone age, as seen in our patient.
# ^2 O9 T8 v+ @0 u; C0 D/ T- nThe long-term effect of androgen exposure during
& {; h& V6 Z7 u( [  v+ N. searly childhood on pubertal development and final) W5 \9 p7 r3 }  L- Q' Z5 q5 ]
adult height are not fully known and always remain
: ]4 w; c6 s# f& _4 S: ya concern. Children treated with short-term testos-
8 h& b3 i% ~$ y, r6 U( k9 j5 a6 J2 ~terone injection or topical androgen may exhibit some) ?4 |  ~# z: O
acceleration of the skeletal maturation; however, after0 @' f$ Y3 _  o+ e! m
cessation of treatment, the rate of bone maturation% M, ]* E7 J* Z9 K( G) S
decelerates and gradually returns to normal.8,9
3 u  a' M6 n9 h+ F9 PThere are conflicting reports and controversy7 @0 D. p' I( A1 u( Z+ r
over the effect of early androgen exposure on adult
3 g& d" I3 ~$ ypenile length.10,11 Some reports suggest subnormal
  A  o( B; a% f7 xadult penile length, apparently because of downreg-0 ]1 X2 n# _* `, F
ulation of androgen receptor number.10,12 However," n! m/ d; z0 X7 L' A/ a
Sutherland et al13 did not find a correlation between& Y  k$ G( A% z' T7 P6 j$ M+ K- {
childhood testosterone exposure and reduced adult2 M7 a& k2 E: j0 M0 e- W
penile length in clinical studies.9 h8 q$ f2 H) m( K: y
Nonetheless, we do not believe our patient is
; e: V0 B$ Z8 {) J* `5 Dgoing to experience any of the untoward effects from
$ B8 I+ x5 B8 Y/ Dtestosterone exposure as mentioned earlier because
! P- S- I# j7 ~) R2 L: Pthe exposure was not for a prolonged period of time.# I0 `2 `! l& T8 i1 M6 K: A- `3 R1 d  X
Although the bone age was advanced at the time of
! X6 }, ~' O  c- d" f- Jdiagnosis, the child had a normal growth velocity at6 G6 U+ ^9 s7 K; n
the follow-up visit. It is hoped that his final adult
) c$ ~- K% h! U9 p' X: |height will not be affected.
% f& e' p4 V" F: w( o$ b* f6 T" EAlthough rarely reported, the widespread avail-' P! E$ y+ s+ t, H( s/ E; C
ability of androgen products in our society may
4 \. H2 `- l' S" a, L9 I. t' @- |indeed cause more virilization in male or female
* E1 ], `8 n* echildren than one would realize. Exposure to andro-
: ^! _& j* D) E) J) D- M( Qgen products must be considered and specific ques-
4 |8 R0 x3 n! O( i) |# ~8 z, ttioning about the use of a testosterone product or
3 W& m. }3 s* T, y+ Agel should be asked of the family members during
: P: ?- Y/ u) m- L8 z1 ithe evaluation of any children who present with vir-" p4 J$ u' H; [1 M- t7 r
ilization or peripheral precocious puberty. The diag-1 J% m; w9 `! ~' k' s
nosis can be established by just a few tests and by
7 v( M/ k8 A7 D' Gappropriate history. The inability to obtain such a* J, V$ f' t4 C, R
history, or failure to ask the specific questions, may- q  ?8 Q, `6 Q6 I
result in extensive, unnecessary, and expensive
( |6 H9 W# D/ e6 qinvestigation. The primary care physician should be& c  v9 t+ \4 B: Y* Z  R* V; g, B; B+ |
aware of this fact, because most of these children4 K# m2 _" ?4 Z- N6 E% [' s
may initially present in their practice. The Physicians’8 C( B2 o& f: s
Desk Reference and package insert should also put a" G' b* h" V$ ]
warning about the virilizing effect on a male or# X& Q2 z4 H$ _6 m6 x$ ?
female child who might come in contact with some-
0 D- K8 m$ i) h, ~* Y, Aone using any of these products.
' b+ F, h' a! \5 t5 @" ^0 C6 bReferences
4 S: A9 u- s% u1. Styne DM. The testes: disorder of sexual differentiation) E- L* A- F' ?6 t1 b
and puberty in the male. In: Sperling MA, ed. Pediatric2 B7 |% j2 I- c$ ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( T& k- Z/ v9 t  t) x
2002: 565-628.: s. V, d6 c7 S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! y6 @0 [# Y1 r: D( P6 b$ c
puberty in children with tumours of the suprasellar pineal
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VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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

* f. x0 L$ Y& _7 H4 w+ w( F; i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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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