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Sexual Precocity in a 16-Month-Old
5 c' d7 J" E# M+ p( H9 sBoy Induced by Indirect Topical
2 j- F! {% X: t+ m! \6 g' a- Y9 zExposure to Testosterone
6 G0 B: g3 _& h: R: O. rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- T7 S7 ^! p6 i: mand Kenneth R. Rettig, MD1
1 D" d* [" b& B) b' ~0 W  H4 p7 dClinical Pediatrics
* m2 W2 t4 o( p) I% ^$ oVolume 46 Number 6
: \. t1 V% O; m8 TJuly 2007 540-543' p+ K! C- v: E. a% K
© 2007 Sage Publications
7 _* s* g% H" O  z6 Z! |10.1177/0009922806296651+ x8 w" I, b% S
http://clp.sagepub.com, c0 O, A, ]' n) Z% w3 [" m: U$ l) ]
hosted at: X# }8 i" {# k$ A& z' s6 V* v
http://online.sagepub.com- p; ~& x% C1 F0 J- {1 y
Precocious puberty in boys, central or peripheral,
- f9 P* P. e8 D  ^( ^is a significant concern for physicians. Central
4 L1 w2 P& u, R: C- oprecocious puberty (CPP), which is mediated3 C6 m: m7 Z; _' d+ Y
through the hypothalamic pituitary gonadal axis, has
" g+ G) e& c6 _a higher incidence of organic central nervous system# ]. @$ Y8 M: \; B, j  r
lesions in boys.1,2 Virilization in boys, as manifested
9 w0 t3 F  P6 ?( \2 Qby enlargement of the penis, development of pubic. L# J  K: ~$ `' H" a
hair, and facial acne without enlargement of testi-2 T! c0 w4 I" F/ B3 ^* p$ ^
cles, suggests peripheral or pseudopuberty.1-3 We" a0 O& ]" M) t# d) X8 v& P
report a 16-month-old boy who presented with the
( ^- g+ L1 ~7 E% ]- D8 Genlargement of the phallus and pubic hair develop-
$ y8 J  x+ h: f" x8 a( |. gment without testicular enlargement, which was due$ x9 J6 k+ V) ]* F4 n; m9 Q5 h
to the unintentional exposure to androgen gel used by
, U5 A  l# Q& N+ K( B$ q9 W2 uthe father. The family initially concealed this infor-5 P5 e4 E3 Y4 M4 `; F
mation, resulting in an extensive work-up for this. t2 H: g) {& N1 A8 i2 w
child. Given the widespread and easy availability of& P4 N, O, [4 e* y" y  d! o
testosterone gel and cream, we believe this is proba-1 X1 J3 o4 i6 ~7 ~0 ^
bly more common than the rare case report in the, k1 E, {+ b" S8 a2 I6 e+ w- [1 X# X8 `
literature.44 j9 w' M4 B- J- a3 s
Patient Report
7 |  |( s# @6 Z. \5 q' P% h( x% DA 16-month-old white child was referred to the
! `( H) q0 ~! x% N2 i0 z" F1 A2 aendocrine clinic by his pediatrician with the concern0 B# j, j* A) `1 k5 }2 ?
of early sexual development. His mother noticed
- M: u# M2 B7 G9 K, }light colored pubic hair development when he was" f0 b6 o" F+ G9 E9 q. A0 n
From the 1Division of Pediatric Endocrinology, 2University of
; e3 x& g5 H# `South Alabama Medical Center, Mobile, Alabama.
' S# Z) E; p) J# U  yAddress correspondence to: Samar K. Bhowmick, MD, FACE,, L3 Y9 M2 W& R3 `( O: g+ q
Professor of Pediatrics, University of South Alabama, College of5 Q( y! X, s4 h( U9 ?- i6 u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* h) e1 W: Q) M
e-mail: [email protected].
# r. ], i' @( Gabout 6 to 7 months old, which progressively became  t+ H- w4 m0 g9 _
darker. She was also concerned about the enlarge-
6 j% C" s( N8 }# f$ }ment of his penis and frequent erections. The child
# Y/ f' o5 l5 I; E: N, S& Qwas the product of a full-term normal delivery, with  a7 T7 s' u+ n% l8 ^; ^
a birth weight of 7 lb 14 oz, and birth length of% _9 n9 r4 X8 [2 o# _4 W$ h
20 inches. He was breast-fed throughout the first year# w3 K+ r$ Q5 p* T+ a$ t2 m& h7 J
of life and was still receiving breast milk along with& I* J: F" C+ `& n* d  z& m+ I" w, \
solid food. He had no hospitalizations or surgery,4 n' E# }5 V2 Z. a# [! b' W/ A
and his psychosocial and psychomotor development& Y" P7 O% f1 p# l- |/ O' P
was age appropriate.1 i8 X2 ^/ W% W7 w2 Q; ]1 z5 C+ R
The family history was remarkable for the father,# E# e" s5 e, e9 J* z9 ?6 \
who was diagnosed with hypothyroidism at age 16,
; H0 Z" b( ?9 y" r$ Vwhich was treated with thyroxine. The father’s1 u3 N; g+ R% U# }
height was 6 feet, and he went through a somewhat
( `6 z! t) O4 s; a7 K, Gearly puberty and had stopped growing by age 14.' P' k1 q  v+ G4 P: X
The father denied taking any other medication. The
- A7 V, b" X* schild’s mother was in good health. Her menarche) e! |; r' L$ }; f$ `
was at 11 years of age, and her height was at 5 feet# @* w. F* k4 g$ n  ~% B" l0 K( B% H7 X
5 inches. There was no other family history of pre-
, N+ v* d( S# ?: ^( Y; Vcocious sexual development in the first-degree rela-
' A! R; ^+ p* h8 T  f. Qtives. There were no siblings.
, I2 j  W2 \+ h4 k. `9 y  NPhysical Examination) S# o# H" s$ Z4 D1 o3 Z% P+ g
The physical examination revealed a very active,3 k7 f* M( k" I( ~' p# ^; r) a
playful, and healthy boy. The vital signs documented
6 m) D7 K( d& ~8 `2 Ia blood pressure of 85/50 mm Hg, his length was
. Y9 d, P, U- \1 P/ p! z90 cm (>97th percentile), and his weight was 14.4 kg" K, T; _0 L6 k. X$ P
(also >97th percentile). The observed yearly growth
6 b( U' B$ i5 s6 u! M% M. p# avelocity was 30 cm (12 inches). The examination of- k* [6 z& `% j! {7 [' Y8 k2 x
the neck revealed no thyroid enlargement.4 U! _7 g, W4 s& Y
The genitourinary examination was remarkable for% e- x/ ^, s, Q! t
enlargement of the penis, with a stretched length of
0 M! ], y, X7 l5 u9 k: ~8 cm and a width of 2 cm. The glans penis was very well* y* x* S' m" B' P" f: n2 s1 {
developed. The pubic hair was Tanner II, mostly around: ?% d3 I) ~% \
540
0 j' y+ \% J; b9 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 X! X: t! K8 T! x0 ]* Ythe base of the phallus and was dark and curled. The" Q8 Q+ W1 S' }+ |  w* L
testicular volume was prepubertal at 2 mL each.
* t! H! G# L% |4 ^The skin was moist and smooth and somewhat6 a5 L$ ?& u2 z8 E! s
oily. No axillary hair was noted. There were no; t6 W+ O5 @& m: J! A$ z7 C
abnormal skin pigmentations or café-au-lait spots.
0 B5 D5 L% x7 A8 h, E( wNeurologic evaluation showed deep tendon reflex 2+
' Z9 w* b) l* U3 x* U( Ybilateral and symmetrical. There was no suggestion
$ c) Y( d$ q( Sof papilledema.8 K* g9 _" G" g# Z5 R
Laboratory Evaluation$ b2 V- l* Z; I0 \6 o) x) x
The bone age was consistent with 28 months by$ z1 S. K& N8 s3 M
using the standard of Greulich and Pyle at a chrono-( t. r8 ~* T% O* p
logic age of 16 months (advanced).5 Chromosomal! f% J$ w, c  J
karyotype was 46XY. The thyroid function test
: O( D4 `2 z2 r3 x7 a1 V" {showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ {# {4 R6 n2 X( |7 z, r
lating hormone level was 1.3 µIU/mL (both normal).
, T8 d" v0 W/ @9 K. Y( bThe concentrations of serum electrolytes, blood
* G7 |. `2 f. j& n" d# Wurea nitrogen, creatinine, and calcium all were* y" T. ^* C# E2 K3 p
within normal range for his age. The concentration
3 u8 k4 d3 c1 g% u5 ~% w: J3 Zof serum 17-hydroxyprogesterone was 16 ng/dL' [6 k. a) w+ p- s. k6 e: N
(normal, 3 to 90 ng/dL), androstenedione was 20
# B, D( i* k' C# l8 N% f6 wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ y- h3 w, U& O4 M" ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 q- Z0 U% l; d& @desoxycorticosterone was 4.3 ng/dL (normal, 7 to" B: i0 u/ t, u
49ng/dL), 11-desoxycortisol (specific compound S)8 O( k! l* D- d% t* i8 \
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 y: s4 N$ y6 k0 A. A2 i6 O" T7 i* P" N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 m5 [+ l" P& E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 Y3 B  G. u' T; v
and β-human chorionic gonadotropin was less than
' ~1 p/ U0 M; g3 J& F5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 B% l# H" u- ^, T0 bstimulating hormone and leuteinizing hormone2 T: v* q1 X, `
concentrations were less than 0.05 mIU/mL. l' n5 L$ n' `0 n$ v+ T9 x5 D5 L
(prepubertal).
! ?6 f9 P0 R3 V7 l' \The parents were notified about the laboratory3 A/ |0 T& K( k5 g5 E8 l" ?
results and were informed that all of the tests were
5 R6 Z- ]2 w  `/ G* Knormal except the testosterone level was high. The
5 o/ _5 ]1 f  U1 o" a. v  Y& Efollow-up visit was arranged within a few weeks to1 P2 ]4 g7 T8 P% j. M& w& }' r; A
obtain testicular and abdominal sonograms; how-
9 [! k7 I4 L, G7 }ever, the family did not return for 4 months.1 i! {6 b+ Q) x) S" l
Physical examination at this time revealed that the( T" t: N  F2 o) r9 Q3 a/ }4 x* s
child had grown 2.5 cm in 4 months and had gained7 \: z  l& D* ~9 p  o
2 kg of weight. Physical examination remained
/ o* l( s/ W" m0 J3 c! Wunchanged. Surprisingly, the pubic hair almost com-
3 Z- [% F- m" `( y& apletely disappeared except for a few vellous hairs at
3 ]8 p% m5 S1 o) K' o# U2 Ethe base of the phallus. Testicular volume was still 2
3 I" n5 M  k( y8 t$ amL, and the size of the penis remained unchanged.- T& }/ P% n8 I
The mother also said that the boy was no longer hav-) \1 J! a! Z( q7 k$ B
ing frequent erections.
6 K' m# \0 f+ S8 o, c  Y% V& `Both parents were again questioned about use of6 M! `/ X- S9 f3 ^6 e1 A6 N
any ointment/creams that they may have applied to% n! o; B: s6 k. q. P) v+ g2 i
the child’s skin. This time the father admitted the- C. `& x% |& Q- ]" W
Topical Testosterone Exposure / Bhowmick et al 541
4 L' h- H; E3 u4 y( T* Yuse of testosterone gel twice daily that he was apply-
( X/ |9 e# N" [* @' Y/ q4 ^; _9 y2 E* ming over his own shoulders, chest, and back area for
8 @/ I% W0 A$ j! o4 r% c. r1 za year. The father also revealed he was embarrassed! f+ x$ @' O0 l
to disclose that he was using a testosterone gel pre-' b+ i5 H3 c( F- S' Q% J
scribed by his family physician for decreased libido
& Y' f' Y; `. I  c. |2 ?. isecondary to depression.
5 c2 c. f% f  H" h8 I' s2 ?The child slept in the same bed with parents.
4 c. \5 g' |/ l( @) ~- K! R- aThe father would hug the baby and hold him on his
: z* P, @7 _  q# a$ `chest for a considerable period of time, causing sig-
/ U3 N# i) r' |; ?! }* dnificant bare skin contact between baby and father.
8 i% q4 }$ n% |0 n* @The father also admitted that after the phone call,1 k( @* r- ]8 h3 ^
when he learned the testosterone level in the baby' @8 O1 [% K$ y0 ^0 r3 b
was high, he then read the product information
5 J' A3 V; E; e4 n% O8 U/ ^packet and concluded that it was most likely the rea-0 v7 T- j$ ^( K3 o# B. T
son for the child’s virilization. At that time, they. E8 s7 O9 a$ B" c
decided to put the baby in a separate bed, and the
+ n4 n+ J( E/ s" y8 z" tfather was not hugging him with bare skin and had4 g) y+ \0 m3 o, h8 \9 M6 U
been using protective clothing. A repeat testosterone& m* [8 B* G# l& T; v
test was ordered, but the family did not go to the; @! W( j0 \5 @, v: r
laboratory to obtain the test.
3 D; b3 L2 @  _" F2 e( UDiscussion; O; _0 P3 L  Y, I7 f) F& t7 Y
Precocious puberty in boys is defined as secondary
& H$ h( w4 `/ [& s7 G4 bsexual development before 9 years of age.1,4- S9 a' O3 p4 W. k, W
Precocious puberty is termed as central (true) when
- D+ S( L# o. w7 q5 x2 o. t0 a4 X; zit is caused by the premature activation of hypo-
4 M" K" F  w9 K, p& @thalamic pituitary gonadal axis. CPP is more com-
9 `/ N) z3 Z7 n/ l! k# Vmon in girls than in boys.1,3 Most boys with CPP7 A! i! Z& B0 Y6 T/ _" I% |
may have a central nervous system lesion that is
6 i3 c" p& {; R% X7 Y: Nresponsible for the early activation of the hypothal-
1 {8 q3 ^" e" }* t* T9 pamic pituitary gonadal axis.1-3 Thus, greater empha-8 B) _- f0 F; D0 j
sis has been given to neuroradiologic imaging in
+ l8 D1 J6 \& u; h0 }% _, ~- wboys with precocious puberty. In addition to viril-% l- q3 A% l. b9 E2 J) `9 x
ization, the clinical hallmark of CPP is the symmet-
4 ~) f* t$ ?! Q1 G' Orical testicular growth secondary to stimulation by- q' S3 V5 |, H: m
gonadotropins.1,3( y. Q6 M  v6 D6 f
Gonadotropin-independent peripheral preco-. U1 E3 T3 g2 n2 _
cious puberty in boys also results from inappropriate) K9 U7 j5 ]+ t& T( R
androgenic stimulation from either endogenous or
3 A$ F  _. @+ ]2 I- o7 X2 ?exogenous sources, nonpituitary gonadotropin stim-
0 u; y( ]+ ]$ r6 N9 S) |5 N4 j, Dulation, and rare activating mutations.3 Virilizing. w+ p! R: L: h9 B
congenital adrenal hyperplasia producing excessive
1 ]# R% O6 S- i4 @) O# Tadrenal androgens is a common cause of precocious, n. \" A3 i. i# t
puberty in boys.3,4
! r# J4 m  W7 `- W% T0 `The most common form of congenital adrenal
9 y. K8 e9 F' D! z5 N; ?; {- [hyperplasia is the 21-hydroxylase enzyme deficiency.
# N, ]9 N* S# oThe 11-β hydroxylase deficiency may also result in; d& l' _! j5 c4 ]
excessive adrenal androgen production, and rarely,
0 O9 o3 D+ g  J$ o/ tan adrenal tumor may also cause adrenal androgen9 b5 \- y8 d" p( a# w  }
excess.1,3/ ]. Z% S$ M; ?* K* E/ y, s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# Y' a* M8 {/ T" T$ S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 y5 z8 I0 B) Z, JA unique entity of male-limited gonadotropin-
  v5 _" _9 X3 f. `independent precocious puberty, which is also known
5 F8 @' j' J( D( c) q+ t- Qas testotoxicosis, may cause precocious puberty at a7 A; C" g/ M2 q& e5 h: L  I
very young age. The physical findings in these boys0 \* v) e7 f' a
with this disorder are full pubertal development,
! C% i  W5 Q8 @) p3 F! Rincluding bilateral testicular growth, similar to boys
- X: @4 C. b: X/ i) l' }$ u9 {+ G9 Nwith CPP. The gonadotropin levels in this disorder' s% P0 y5 S2 Z4 A
are suppressed to prepubertal levels and do not show! W% G, n( L  V# F
pubertal response of gonadotropin after gonadotropin-
6 L! G7 Q$ L% p+ Q4 Hreleasing hormone stimulation. This is a sex-linked
$ W) S$ Z3 V7 f: ?" ]autosomal dominant disorder that affects only
  R$ l* f& Q, mmales; therefore, other male members of the family
3 Z  L+ ~% C: m1 Imay have similar precocious puberty.3( F& U* [# C( B- s
In our patient, physical examination was incon-
# l1 E) K* O, O2 K0 e1 v- asistent with true precocious puberty since his testi-
# b# S2 F1 e6 @: B) m5 v. Pcles were prepubertal in size. However, testotoxicosis4 m( _0 w! J8 v1 F2 \4 E
was in the differential diagnosis because his father
1 K1 y+ w( i. }started puberty somewhat early, and occasionally,
: c" L, w% k2 D% I- Ftesticular enlargement is not that evident in the+ c) J4 X. E8 }9 s
beginning of this process.1 In the absence of a neg-
0 L, ~2 a5 ?6 l' Qative initial history of androgen exposure, our. l9 g% ^* s- k& l
biggest concern was virilizing adrenal hyperplasia,
/ {9 f+ U  K$ f" v- feither 21-hydroxylase deficiency or 11-β hydroxylase% G' t+ T* I( Q8 j
deficiency. Those diagnoses were excluded by find-2 H$ S; e) z# ~. w2 N4 P0 H+ z5 q
ing the normal level of adrenal steroids.6 ?. U1 ]9 J! x5 e+ I" {
The diagnosis of exogenous androgens was strongly% ^* b/ l2 ^% F0 P5 s: i" X
suspected in a follow-up visit after 4 months because
* y- @2 m: ~6 V7 h3 s2 i4 d4 i* v- Xthe physical examination revealed the complete disap-
3 U4 J' H8 o7 }1 k2 ?5 Ppearance of pubic hair, normal growth velocity, and7 `* O* F5 V5 h7 J6 s  B
decreased erections. The father admitted using a testos-
( K; V( M3 |! Hterone gel, which he concealed at first visit. He was
/ w& R) w! X: e4 cusing it rather frequently, twice a day. The Physicians’
$ B; m# J! v4 A- o8 tDesk Reference, or package insert of this product, gel or
8 X$ `6 i- ~+ l. hcream, cautions about dermal testosterone transfer to% W+ t+ c0 j+ D7 v  F
unprotected females through direct skin exposure.! A# ^# h/ Z. U4 V8 b, h' W! Z& @% F
Serum testosterone level was found to be 2 times the* `5 Y3 [" l  v1 }! l
baseline value in those females who were exposed to# t% {. l" B1 b+ Z% i3 K5 `- i
even 15 minutes of direct skin contact with their male. R% `2 y$ k2 x
partners.6 However, when a shirt covered the applica-
# E" J! v4 ~, ^2 w4 X1 ption site, this testosterone transfer was prevented.
' K) [4 `. g# W- {' @0 k8 f' ?Our patient’s testosterone level was 60 ng/mL,* Q4 {3 V) v' }; D6 \' o9 C
which was clearly high. Some studies suggest that: M7 R' U& t  s
dermal conversion of testosterone to dihydrotestos-8 G7 x' H8 ?, p# @( d+ I/ r. o
terone, which is a more potent metabolite, is more
" n! `" X: x& J) P. factive in young children exposed to testosterone
* z0 n7 ]& W! e  e9 Sexogenously7; however, we did not measure a dihy-
, r/ \& Y' v/ \' R+ O2 y  Cdrotestosterone level in our patient. In addition to
# l8 u3 n  S4 R$ i5 lvirilization, exposure to exogenous testosterone in
, X, s0 b3 d% k1 M" _4 ichildren results in an increase in growth velocity and
# W) D9 T  f: p; x6 Iadvanced bone age, as seen in our patient.
+ Y7 A9 k$ y6 r3 QThe long-term effect of androgen exposure during
( b- q6 J( ]6 |5 oearly childhood on pubertal development and final( p, {1 ~4 Z  o+ \! [3 _
adult height are not fully known and always remain
$ S8 I  C: n: z: \7 N  Da concern. Children treated with short-term testos-8 Q* z' w( Z( R
terone injection or topical androgen may exhibit some
" v$ y. O( b2 S' V5 X1 r5 Gacceleration of the skeletal maturation; however, after1 I% ~1 S: s( G* e4 t* M" l
cessation of treatment, the rate of bone maturation
# \* q' [7 a: d" l# a% Udecelerates and gradually returns to normal.8,9
. x. k7 R! p" K+ e6 ~There are conflicting reports and controversy" k, W/ l5 e& x* N+ y$ V- T
over the effect of early androgen exposure on adult) r2 J! y4 g% K! i5 f. U) j  O
penile length.10,11 Some reports suggest subnormal
3 M+ p6 S0 W9 s7 ^( Z- R' xadult penile length, apparently because of downreg-
1 x, r, h" F0 f+ v% }ulation of androgen receptor number.10,12 However,1 H" h9 }6 q$ q  C. R2 S  ]7 J; w
Sutherland et al13 did not find a correlation between
# M2 R2 j5 v3 ]9 k3 G" j0 Schildhood testosterone exposure and reduced adult3 d  q8 @: G6 H, c* m; B
penile length in clinical studies.
* O% k* Y3 B1 z' e1 A- P; GNonetheless, we do not believe our patient is
3 R$ F$ v7 Z& L) |. z8 i% w% Ngoing to experience any of the untoward effects from- K1 p% S& g5 N# {  Y$ h
testosterone exposure as mentioned earlier because
- k8 t5 V1 U( F* rthe exposure was not for a prolonged period of time.! D+ d. h, q- ]) _- q  e+ ^3 m  Y9 N
Although the bone age was advanced at the time of
+ e  Z( p; o8 @diagnosis, the child had a normal growth velocity at0 E3 X) j! r' S' o( y
the follow-up visit. It is hoped that his final adult
8 h# K: U8 l$ ~3 cheight will not be affected.
; i# X& i! _' z# K0 X/ eAlthough rarely reported, the widespread avail-0 V; O! P* ~3 n. n
ability of androgen products in our society may
$ l- `3 d# U  E. H$ ^indeed cause more virilization in male or female) e! q! P) ?# _( r
children than one would realize. Exposure to andro-
/ s. S$ Q3 F7 t% V/ u0 \7 G% L) ^/ [gen products must be considered and specific ques-
1 P! ?0 n- D$ E. |& etioning about the use of a testosterone product or* U( m0 }( b: i# K5 A( B# ]' ?! D
gel should be asked of the family members during
3 A" e% \: E( ?& o6 a! N; e5 Qthe evaluation of any children who present with vir-
5 \# G& @( m/ b* v" f& W( |1 Dilization or peripheral precocious puberty. The diag-
8 P. ^4 Q1 B! g& r% b) A8 Nnosis can be established by just a few tests and by
7 W$ ]- V# w) X$ T0 p" Sappropriate history. The inability to obtain such a- A, O% s0 }; Y6 _1 }- J2 v
history, or failure to ask the specific questions, may$ t3 ^2 N3 Q7 a: A0 W# o
result in extensive, unnecessary, and expensive
7 G! B5 J: Q1 Y! d9 g) |investigation. The primary care physician should be
. h0 e" O* Z) L8 i2 d* }aware of this fact, because most of these children
( d9 m2 e: c+ n; vmay initially present in their practice. The Physicians’1 O' k3 M1 N" _9 [- C; ~
Desk Reference and package insert should also put a
% S2 U9 G0 t) Lwarning about the virilizing effect on a male or, U0 @6 a+ l; {3 R7 F4 R" r
female child who might come in contact with some-
1 c/ r* J4 v9 O, pone using any of these products.% l) W* ]6 c, ]( Z0 {, E4 Z& h# D
References+ c- g( Q; D% O2 D3 C# F1 `" W
1. Styne DM. The testes: disorder of sexual differentiation
$ H  Y9 U" a# o3 _and puberty in the male. In: Sperling MA, ed. Pediatric5 Y/ O0 g4 X1 q# D
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# X4 ?' V0 O$ ^9 R. l2002: 565-628.
+ S$ V5 c& }5 I! b7 X- d; {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& i, K2 h6 w* c7 v1 S1 cpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old, n! Z- [+ H. d: O# u5 R, D
Boy Induced by Indirect Topical
" N7 v# ?8 B+ v% _+ rExposure to Testosterone8 ~' c  K' y$ q! z' G6 N( N
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: _' x# Y# o3 X! a+ cand Kenneth R. Rettig, MD1, X% w+ J' `: Z5 g9 j/ O) A
Clinical Pediatrics
; w! T% H; C) ^  c/ l8 d. r: OVolume 46 Number 60 K( J, [4 c, l: o) T4 s1 X4 l
July 2007 540-543  I, X9 H/ B. v! P; L. s
© 2007 Sage Publications+ ]+ M* S# R& V
10.1177/0009922806296651
1 N( n7 @) r5 o! W. Jhttp://clp.sagepub.com2 e" y5 o1 i! Q- ?6 Y
hosted at
5 N1 b& i4 U! \4 ?4 C0 Ehttp://online.sagepub.com
& i2 h! E* B' W- ZPrecocious puberty in boys, central or peripheral,
3 @0 ?% \4 r* @% Lis a significant concern for physicians. Central
! a, D# R8 K9 e5 V1 Zprecocious puberty (CPP), which is mediated
/ V  m+ \6 U' o" f$ m" Q( cthrough the hypothalamic pituitary gonadal axis, has: o! i# l: @1 D$ W
a higher incidence of organic central nervous system, `9 z# l. U3 P5 U# V8 Y7 Y
lesions in boys.1,2 Virilization in boys, as manifested* e" U7 m' h( P9 _
by enlargement of the penis, development of pubic9 s1 W! s& x8 i  H7 h' G9 S7 ?
hair, and facial acne without enlargement of testi-% \0 E$ X8 r& ^0 G
cles, suggests peripheral or pseudopuberty.1-3 We
; H8 M* u; O6 _6 l# [) ]report a 16-month-old boy who presented with the/ h* m' N8 b/ W6 t. A$ D$ J
enlargement of the phallus and pubic hair develop-
& F( N- Z) x# r- I' kment without testicular enlargement, which was due5 M/ f  t' A, {* I
to the unintentional exposure to androgen gel used by
1 |: W0 ]$ D9 Ythe father. The family initially concealed this infor-+ |8 _# V6 D- q
mation, resulting in an extensive work-up for this2 A6 o' J4 V- X, B
child. Given the widespread and easy availability of& c; L! k$ M$ w/ J! d
testosterone gel and cream, we believe this is proba-9 v0 o" a' t, W. E+ c1 `; W
bly more common than the rare case report in the7 u. ^' \6 s" U2 C3 q% {+ ^: S  s
literature.4+ i5 X& k' {$ E* h( e, X
Patient Report
3 U  D  a7 |3 g* x4 nA 16-month-old white child was referred to the
, X7 x8 u9 s" |) T; Q2 \; }( c/ \# x" I2 iendocrine clinic by his pediatrician with the concern
9 r; t. N9 p% R* T& I8 s1 H$ \of early sexual development. His mother noticed
  j- d% B! V5 ~) M  q6 M- R! w# Nlight colored pubic hair development when he was
* z+ n* L( c# o( q" L! w* YFrom the 1Division of Pediatric Endocrinology, 2University of
$ J; @0 x) O% t$ B( r  _( w$ SSouth Alabama Medical Center, Mobile, Alabama.% m/ u6 a5 p+ @- F. m
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 G) C! F! T/ }  \: @  tProfessor of Pediatrics, University of South Alabama, College of
4 ~3 C9 y$ ], V9 F; S  ^: ?/ u% qMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- J- ~, B2 t7 b. t. x6 v; F. K
e-mail: [email protected].- J# o" \# k. E( j7 }* Y
about 6 to 7 months old, which progressively became7 ^/ M/ x' q' i4 p$ t0 h3 N
darker. She was also concerned about the enlarge-* v8 }# c4 Z( c% b3 O  F
ment of his penis and frequent erections. The child
% ^( ?/ Z" _' Y; ^was the product of a full-term normal delivery, with: y5 M2 s6 K( B; i" K( s) M
a birth weight of 7 lb 14 oz, and birth length of
: f3 t! Y" T) u20 inches. He was breast-fed throughout the first year3 P4 Q9 c& b2 S; r! l. j
of life and was still receiving breast milk along with8 f# q5 R6 A; _5 u
solid food. He had no hospitalizations or surgery,
- {6 D+ w" q' |5 Y3 m' {& l( S' Iand his psychosocial and psychomotor development
- W/ b. y2 I4 Pwas age appropriate.
3 b$ v2 O, [1 E. `$ \9 q8 k, }The family history was remarkable for the father,# Q  w( j& _* ~
who was diagnosed with hypothyroidism at age 16,8 q- [/ s6 X' s& W% z. ^' @
which was treated with thyroxine. The father’s
/ I, y9 p9 u6 i! o" {3 Y% |' ?height was 6 feet, and he went through a somewhat( f) D0 I+ ^! k- }7 S7 N
early puberty and had stopped growing by age 14.! r/ i. v2 c) Y6 j* H) _
The father denied taking any other medication. The
" h* }: R9 X2 m5 d% mchild’s mother was in good health. Her menarche% c6 f* m& ~5 o0 w; D3 F4 y/ B; _
was at 11 years of age, and her height was at 5 feet1 |5 K5 E6 S. `2 z$ S6 x! M% p
5 inches. There was no other family history of pre-
) m4 q. s" _. Q& tcocious sexual development in the first-degree rela-0 l% }" j: B% H# o/ ~6 A  g3 U
tives. There were no siblings.
$ _9 s3 m% ^; s+ `2 r: T" SPhysical Examination* J: }) q2 l) y
The physical examination revealed a very active,' o7 b; r9 X& X+ L! t5 |% b% n
playful, and healthy boy. The vital signs documented
  p/ C; ~; d' H2 }a blood pressure of 85/50 mm Hg, his length was
4 [# [  p1 F% j( V90 cm (>97th percentile), and his weight was 14.4 kg" l1 y  ?( v- d
(also >97th percentile). The observed yearly growth
/ `! G) u. N) }8 ?' ]! Nvelocity was 30 cm (12 inches). The examination of9 B( g  w: O: A& W# X) w0 o
the neck revealed no thyroid enlargement.
! y( R$ V2 D3 h! j( X" yThe genitourinary examination was remarkable for4 y. V( m% }7 \- `( j/ s# q
enlargement of the penis, with a stretched length of# j# F! }3 E. V
8 cm and a width of 2 cm. The glans penis was very well
/ \8 _4 K+ n5 X! a  Ddeveloped. The pubic hair was Tanner II, mostly around7 }% r* M  C' C( ~* |1 w% w2 M
540- s& p5 [" b- K' Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* y$ @( ]. n/ j$ B5 ~
the base of the phallus and was dark and curled. The' O% X) W2 |  O; r
testicular volume was prepubertal at 2 mL each.% p- Y. d9 B' `4 \! J3 B" E% r! p
The skin was moist and smooth and somewhat) C! N3 B$ h% A7 u; s& i
oily. No axillary hair was noted. There were no( {; z, R  Y; x2 C8 N. c
abnormal skin pigmentations or café-au-lait spots.; @" h+ ~) ]& {
Neurologic evaluation showed deep tendon reflex 2+7 m' P+ f0 A. V/ w* N
bilateral and symmetrical. There was no suggestion
8 ^3 n" [$ @3 ?of papilledema.5 k6 Z! y# M% B6 q/ }6 V
Laboratory Evaluation
/ p, Z% T# }( e5 |* ?' d8 l" lThe bone age was consistent with 28 months by! p; I; n1 E, o" T$ c) V
using the standard of Greulich and Pyle at a chrono-! Q# r7 Y, P& u/ K. R( G3 a9 Y6 m, {
logic age of 16 months (advanced).5 Chromosomal* V! S4 m9 j9 Q  V
karyotype was 46XY. The thyroid function test
8 {2 C5 J- J, kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 Q1 q$ D" {( T! x5 W
lating hormone level was 1.3 µIU/mL (both normal).' x# R. y) `- R+ R( W6 y
The concentrations of serum electrolytes, blood" a, J  a: l1 ?, A8 \
urea nitrogen, creatinine, and calcium all were
2 p. w1 L* c$ s4 X/ {within normal range for his age. The concentration
# ?0 Y. |; _* J+ p: |6 j1 Tof serum 17-hydroxyprogesterone was 16 ng/dL4 F. s& j! V6 q, @
(normal, 3 to 90 ng/dL), androstenedione was 205 A9 _: T2 S3 b8 X9 n7 j4 H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 X$ z' X3 z8 w* Y* _# S6 c' Y; t" Wterone was 38 ng/dL (normal, 50 to 760 ng/dL),2 R- A# A# \+ c( J# a6 V' \( Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 y2 x1 I- D: B' H( J0 a1 _* I& k49ng/dL), 11-desoxycortisol (specific compound S)
0 S2 b) b! ^0 i- ]$ A, x( Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 O' M+ t0 T( T+ |
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
; `0 m& x; h  Gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 @, L/ Z6 T7 Q& n; _: w  }, @and β-human chorionic gonadotropin was less than% I: h  v$ {, x* S4 u7 f
5 mIU/mL (normal <5 mIU/mL). Serum follicular: t6 `3 P! A& y0 p5 X
stimulating hormone and leuteinizing hormone2 @+ M0 p& T$ r) ^. s1 \* q- L
concentrations were less than 0.05 mIU/mL
( I1 P7 p- L1 ^9 e(prepubertal).
8 U! ^3 ]% O. ~The parents were notified about the laboratory6 N- y" I8 z/ }  i
results and were informed that all of the tests were
4 k; l' B; e3 y' Hnormal except the testosterone level was high. The3 f8 r- Y* L- |1 q3 B: q# I+ G
follow-up visit was arranged within a few weeks to
3 P! d: w$ R% T! [8 o5 iobtain testicular and abdominal sonograms; how-" L8 ~: M! Z3 R" o2 y' e) y
ever, the family did not return for 4 months.: J& v1 h$ z5 G
Physical examination at this time revealed that the2 B5 r( O1 Q, n: Q7 P
child had grown 2.5 cm in 4 months and had gained9 a! T; N! G& o, R
2 kg of weight. Physical examination remained8 G' B+ w" `- A7 q; v" k
unchanged. Surprisingly, the pubic hair almost com-
' K" ]& J  y. S9 {! Gpletely disappeared except for a few vellous hairs at4 N  N9 v  w; E8 z% h1 P
the base of the phallus. Testicular volume was still 2
" j. l* I/ X! N2 t/ ~2 d8 G9 YmL, and the size of the penis remained unchanged.) W# }8 L$ K) g2 w
The mother also said that the boy was no longer hav-& o! g( `( ~$ w; e( _6 k8 O
ing frequent erections.
% a' l% z/ V! q# l8 T4 nBoth parents were again questioned about use of
% l  C/ F7 u9 ^9 p' l" rany ointment/creams that they may have applied to
0 p, y' K6 [* `! ^8 ~the child’s skin. This time the father admitted the
: J+ r8 K1 ^/ j. {4 VTopical Testosterone Exposure / Bhowmick et al 541. l5 |6 U6 A- m3 r# z& _7 H; G
use of testosterone gel twice daily that he was apply-; @6 C( K" v$ R+ {4 t+ t! ^
ing over his own shoulders, chest, and back area for
: `1 D: T9 T; z0 b; `. l( g. pa year. The father also revealed he was embarrassed
: s- v6 \& G0 Mto disclose that he was using a testosterone gel pre-
$ W+ C2 j- V% T  |9 J5 }scribed by his family physician for decreased libido1 b& V1 \; V+ }* ~$ S
secondary to depression.: r, m$ |3 j# f3 r8 N# L! \
The child slept in the same bed with parents.. U5 x2 N' K# G$ ~
The father would hug the baby and hold him on his
1 T- u9 H$ J& c7 r3 h! v6 |chest for a considerable period of time, causing sig-
* _5 d) Z5 e- r  qnificant bare skin contact between baby and father.. {7 c* U4 O5 B- A4 u
The father also admitted that after the phone call,
" N$ @' X7 S, b4 o8 swhen he learned the testosterone level in the baby5 U, E& ^' l' a# O
was high, he then read the product information/ S/ V0 O  Q$ ~0 k
packet and concluded that it was most likely the rea-
0 Q3 ^  U; ]4 [0 i8 G% `son for the child’s virilization. At that time, they5 w  C7 v' X% H- [7 C0 l  p3 |
decided to put the baby in a separate bed, and the+ J- w6 N. s) x2 h9 W, U
father was not hugging him with bare skin and had
$ w, l9 A9 M$ x7 fbeen using protective clothing. A repeat testosterone# `' ~4 U5 q( B
test was ordered, but the family did not go to the7 M2 @  p7 P5 L' F9 v9 c2 @
laboratory to obtain the test.3 v7 F3 C8 k( R  m  S
Discussion
7 u" {7 t) B5 J  RPrecocious puberty in boys is defined as secondary
1 o# ?" \# K; u0 csexual development before 9 years of age.1,46 @4 o# J8 [( l0 `% X$ Z$ c
Precocious puberty is termed as central (true) when, [7 `, A" X( N% ^% l
it is caused by the premature activation of hypo-, i! M* a( [3 ], `# O
thalamic pituitary gonadal axis. CPP is more com-
7 }  J3 v4 O# I4 {+ ]$ ?! Cmon in girls than in boys.1,3 Most boys with CPP
& w. A( C: N4 F0 a: x# V6 Z* rmay have a central nervous system lesion that is& R" q' [: ~( P4 G# x
responsible for the early activation of the hypothal-
) P* {( R: J5 N$ N# j) t' oamic pituitary gonadal axis.1-3 Thus, greater empha-' A, r4 L  d0 `4 t. S
sis has been given to neuroradiologic imaging in" w2 x& u, y$ w( {: M
boys with precocious puberty. In addition to viril-
, ]* J$ ^" n7 E! Z, s/ J4 _ization, the clinical hallmark of CPP is the symmet-" k: z6 X# a6 n+ K
rical testicular growth secondary to stimulation by4 n/ G2 E: ]% v/ f, h  P- g
gonadotropins.1,3. O" ]8 m4 F) v1 u; C3 Z# l
Gonadotropin-independent peripheral preco-1 Q/ ?: N* M3 J
cious puberty in boys also results from inappropriate. W3 E: v5 \/ t$ }5 U
androgenic stimulation from either endogenous or3 R8 c: }2 W( h8 Q3 A# s  s
exogenous sources, nonpituitary gonadotropin stim-
" T. h! C* L! k6 }4 o6 o: ]ulation, and rare activating mutations.3 Virilizing9 d( Q, l' j. l# i- C) {  u
congenital adrenal hyperplasia producing excessive+ f! ~6 T2 ?  r* r2 Z) }
adrenal androgens is a common cause of precocious
, `# F8 `4 i, P9 {- C  Xpuberty in boys.3,4+ d7 F5 q) d1 i8 T+ |
The most common form of congenital adrenal
" P3 j. ^' H- ]' B4 nhyperplasia is the 21-hydroxylase enzyme deficiency.8 D! k! L6 I4 Z7 a1 `% {+ W) u' J
The 11-β hydroxylase deficiency may also result in7 m$ Q" [, e) Y2 S/ J2 f
excessive adrenal androgen production, and rarely,( U: C3 Z4 Y" S
an adrenal tumor may also cause adrenal androgen. o+ H4 t/ h' L2 H( Z" d$ k
excess.1,37 o1 E3 X8 Y9 d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" q6 m! _* B3 o6 [% F& `' A
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6 F  n% Q' B/ D( W1 a9 I* FA unique entity of male-limited gonadotropin-
2 N) Y+ Q6 f: {independent precocious puberty, which is also known
6 d) M' {! C1 K# t8 C. q+ Gas testotoxicosis, may cause precocious puberty at a
5 s" I, S" x5 i. @very young age. The physical findings in these boys* p+ J( l: v9 M' _
with this disorder are full pubertal development,- Q5 B+ t( ?" |1 B1 l
including bilateral testicular growth, similar to boys. x* q# B: e# {/ m2 b% Q0 `
with CPP. The gonadotropin levels in this disorder
5 ]( v" ^0 ~# T# S1 pare suppressed to prepubertal levels and do not show! w0 V$ F0 X# }4 j9 c% w
pubertal response of gonadotropin after gonadotropin-
, ~; X# C5 P8 Y1 z, Greleasing hormone stimulation. This is a sex-linked* P$ S6 g8 p$ k& p' k% y3 N
autosomal dominant disorder that affects only
: G4 G" d( ?% V" hmales; therefore, other male members of the family7 H4 j! E* |; j3 ]
may have similar precocious puberty.3
2 y% ]$ K0 _1 Y+ U- C- zIn our patient, physical examination was incon-
( |8 \* k: E" D; {) H7 W- psistent with true precocious puberty since his testi-
# P% q- A1 b$ {, ^+ U7 s/ Ucles were prepubertal in size. However, testotoxicosis
7 V. P! p/ Y) ^- Q) n7 A3 G; s. T9 awas in the differential diagnosis because his father# t  e; p7 m- S4 |0 u
started puberty somewhat early, and occasionally,/ x3 U7 e* Z( e' @* X
testicular enlargement is not that evident in the$ n$ M+ u/ X: r; r& H
beginning of this process.1 In the absence of a neg-
0 l6 R; t  ?0 Sative initial history of androgen exposure, our
- H/ Z2 X5 m$ T: Zbiggest concern was virilizing adrenal hyperplasia," v5 H5 F& `* z* f" u# O
either 21-hydroxylase deficiency or 11-β hydroxylase
% j& }' s8 I6 G1 `4 j; xdeficiency. Those diagnoses were excluded by find-
& A6 @( Z8 c4 `9 K* Ying the normal level of adrenal steroids.) o5 J) l# H/ }
The diagnosis of exogenous androgens was strongly
3 f+ z' u+ b* i" w) Zsuspected in a follow-up visit after 4 months because5 f0 `* {5 J/ E
the physical examination revealed the complete disap-
  _4 F) x0 N% |6 R4 W" Tpearance of pubic hair, normal growth velocity, and: j/ `- q1 F& J$ K
decreased erections. The father admitted using a testos-* b5 V/ @' i4 `' F0 V( w# y
terone gel, which he concealed at first visit. He was8 v  y% ?6 P" ~2 e4 }) X
using it rather frequently, twice a day. The Physicians’
3 i3 q3 [# X0 Q6 k' W4 u2 s8 Q" u: jDesk Reference, or package insert of this product, gel or- v6 c1 j6 D4 A2 m8 C
cream, cautions about dermal testosterone transfer to. l, N; z3 p7 w' M
unprotected females through direct skin exposure.
/ s" b8 V/ Y* X( HSerum testosterone level was found to be 2 times the
) q/ s# ~; W9 X& @$ x  ^! l: Qbaseline value in those females who were exposed to
9 C& \/ e, u, t8 J: @even 15 minutes of direct skin contact with their male
  r! |! J& s* l1 B$ i2 |partners.6 However, when a shirt covered the applica-
5 P7 J; e5 H0 a* gtion site, this testosterone transfer was prevented.1 i( Q! K: p* p( Y9 i
Our patient’s testosterone level was 60 ng/mL,+ W* V* r9 R. J/ _% {1 L
which was clearly high. Some studies suggest that4 P+ K' V+ Y& {2 X
dermal conversion of testosterone to dihydrotestos-1 T+ g, t4 ~; L4 Q' [' q5 W3 d" ?+ d/ g
terone, which is a more potent metabolite, is more
) o, U1 Z& {! _1 L" C4 Z  `- _# I  jactive in young children exposed to testosterone) n7 c# w( }  u6 L: w
exogenously7; however, we did not measure a dihy-
+ s6 M. N% Y2 ddrotestosterone level in our patient. In addition to
. v" }+ i$ r9 T  a! V( Cvirilization, exposure to exogenous testosterone in
! |: ^" r; `( t6 i- b; gchildren results in an increase in growth velocity and3 X8 c8 ]% H0 R  {3 b( T7 B# Y
advanced bone age, as seen in our patient.
! o  B, a1 l, u/ |, k* zThe long-term effect of androgen exposure during9 V; ~4 b( n; q6 ]+ u  `2 E' T) r
early childhood on pubertal development and final  Q  Q. Y' a( A0 [) y
adult height are not fully known and always remain
3 @) q$ }& }3 ~* }a concern. Children treated with short-term testos-8 w2 ^7 {. m# C7 G9 s+ A; {% g
terone injection or topical androgen may exhibit some: |+ V: i5 l" f+ y* T8 d
acceleration of the skeletal maturation; however, after/ z6 H* M+ r! \% G
cessation of treatment, the rate of bone maturation
9 h7 a" l* m' Sdecelerates and gradually returns to normal.8,9
3 g% w; B, b. G- ?There are conflicting reports and controversy. _3 Y) @- o* ~8 [6 J2 q
over the effect of early androgen exposure on adult
" y% }$ n+ c2 tpenile length.10,11 Some reports suggest subnormal
! T" d* O; l( _/ V# |% Zadult penile length, apparently because of downreg-
+ S- u6 K6 ?" Q! rulation of androgen receptor number.10,12 However,/ O  @$ @6 o+ V5 V, u6 S1 w0 D2 O
Sutherland et al13 did not find a correlation between
( }1 ?+ b4 b; e% S! g! p4 ^childhood testosterone exposure and reduced adult
. ]5 ^: b% c7 E* ^4 N6 B" _0 bpenile length in clinical studies.6 f  c* @" d& c; A  w
Nonetheless, we do not believe our patient is$ O8 e6 {7 u1 ?0 _
going to experience any of the untoward effects from3 v% Q/ k' J' F; g& c$ P
testosterone exposure as mentioned earlier because
) D0 g( L7 |  O$ A/ Y/ uthe exposure was not for a prolonged period of time.
) T; m0 c  c8 {. [Although the bone age was advanced at the time of
8 X9 e4 v- G7 i- }3 A* S: Cdiagnosis, the child had a normal growth velocity at
8 L: N# d! Q; J' i9 q% r: @. }the follow-up visit. It is hoped that his final adult9 c# [2 ^9 X0 B1 y
height will not be affected.
* \1 D# z( w3 T; r( iAlthough rarely reported, the widespread avail-
6 O/ P) E2 K1 }9 G' G# xability of androgen products in our society may3 u; h  p6 I% r" O- b/ l
indeed cause more virilization in male or female
$ f; ~; F. C8 z3 Fchildren than one would realize. Exposure to andro-
/ ^, a7 E3 M& @gen products must be considered and specific ques-# f( d0 M7 J( P' P; B& S" D8 Y: n' [2 p
tioning about the use of a testosterone product or& e$ _  D( _5 ^: T; v$ W
gel should be asked of the family members during
" Q, R( d" {* a+ ^0 j* G) ~' g' `1 N% sthe evaluation of any children who present with vir-
# c) R3 p" G4 K& q& jilization or peripheral precocious puberty. The diag-# h1 q4 q+ i8 L" K% B
nosis can be established by just a few tests and by; H3 z) A8 F5 O( r+ N) Y( Y$ m
appropriate history. The inability to obtain such a
* F8 M7 l' p3 v7 K, i5 nhistory, or failure to ask the specific questions, may* R: U5 K; |% s
result in extensive, unnecessary, and expensive
6 |9 l4 Y  y! G: s' ^investigation. The primary care physician should be; d% {8 u5 |! _6 }; w$ J! h' Q% e" z
aware of this fact, because most of these children+ m4 M8 Z' e5 H3 u, [7 v& J$ L
may initially present in their practice. The Physicians’# t) D) b, \3 Q, T
Desk Reference and package insert should also put a
- [* }  H1 z' N, W+ q3 i3 I) }warning about the virilizing effect on a male or1 G/ L7 i  j3 B# e5 _) n/ i7 T
female child who might come in contact with some-* O, K- I9 S5 u6 u
one using any of these products.
0 Q; b  D6 Y9 b* C! F7 PReferences( E# F+ @, Q/ m0 F- P( r+ ~+ J
1. Styne DM. The testes: disorder of sexual differentiation
( r7 H7 f  Z. C8 ?! s+ v) ~6 Y7 I. {/ Rand puberty in the male. In: Sperling MA, ed. Pediatric
7 P1 B& u! Z- B0 e) _Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 A4 \" h7 q4 O. B# m8 ]& @2002: 565-628.
' d( O4 W. Q1 N2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 O/ @6 E7 Y' F; n1 d6 @' k
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
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!
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
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?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
% }& g% C8 f; Q( w) X: H9 {2 @
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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