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Sexual Precocity in a 16-Month-Old6 C. ?1 A" W/ l* `% R( E
Boy Induced by Indirect Topical7 F3 x* ~! A$ q( u
Exposure to Testosterone
3 I# K; ^! _& |. _8 i) f2 QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' E: L9 |0 y* j4 u4 W- }, Z; {* i1 T1 q
and Kenneth R. Rettig, MD1* `4 U. j% C" R1 p" T. l5 y& d9 q& d
Clinical Pediatrics( q! ?: B  j. l- v; u1 s( ?
Volume 46 Number 66 N3 z1 K0 Z+ G9 R. E1 n3 H
July 2007 540-543  |7 }- D& `. e  I
© 2007 Sage Publications
9 ^5 z/ I6 \/ x* x10.1177/0009922806296651+ O; ]) l6 t6 V" d
http://clp.sagepub.com. \" b3 }# r& `4 X- X' s
hosted at
  o4 B, ~1 t# D  fhttp://online.sagepub.com
8 }/ `5 P% o- j' ?! `Precocious puberty in boys, central or peripheral,
2 J; ]2 [6 W+ N. `) sis a significant concern for physicians. Central
4 W2 z- L- u; _9 k5 d; A0 P1 iprecocious puberty (CPP), which is mediated( e6 V; g9 m( K: n% T
through the hypothalamic pituitary gonadal axis, has
0 q" j5 T3 Z8 k& q9 qa higher incidence of organic central nervous system
# w; M3 H, ^( y; [$ O( slesions in boys.1,2 Virilization in boys, as manifested
1 O8 {# i" k# L( @; lby enlargement of the penis, development of pubic$ I- h- Y  A6 v) M
hair, and facial acne without enlargement of testi-
# y" ^  ~' F5 y8 h7 Vcles, suggests peripheral or pseudopuberty.1-3 We
5 r$ R  v3 R! {report a 16-month-old boy who presented with the
7 M) z# S' I7 `enlargement of the phallus and pubic hair develop-
8 N$ _! Z. x5 v  m+ Vment without testicular enlargement, which was due
# d4 y8 t* }9 |; Gto the unintentional exposure to androgen gel used by
0 u& ~4 V* A* G  y/ m2 ?, D; Hthe father. The family initially concealed this infor-0 a3 G' f7 K% V
mation, resulting in an extensive work-up for this
# b1 \# w9 E! gchild. Given the widespread and easy availability of
# b$ T# G3 h( I; f3 }1 Ttestosterone gel and cream, we believe this is proba-- d9 I) n0 s! C+ T0 @9 `- t' v
bly more common than the rare case report in the
' N: I& r* v% |, E- h0 u1 Kliterature.45 U/ E8 j: d( Q- O# L/ V4 ]
Patient Report
/ ]  s& x7 v# _7 g- l" q! YA 16-month-old white child was referred to the; f2 O, j9 P# @
endocrine clinic by his pediatrician with the concern/ D3 c# ^) x6 X* K$ d9 |1 v
of early sexual development. His mother noticed
7 `: Z1 {9 S! L: j  J3 j1 r. f% ulight colored pubic hair development when he was# J. u2 W- `4 h, b% E
From the 1Division of Pediatric Endocrinology, 2University of
8 S& Y0 k0 a! g" q3 [0 }South Alabama Medical Center, Mobile, Alabama.
5 J. J) ~4 X: k4 iAddress correspondence to: Samar K. Bhowmick, MD, FACE,
: k- k% p) p+ m6 p. OProfessor of Pediatrics, University of South Alabama, College of
0 e3 N; X/ P5 D2 Z7 ^. M/ e4 ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# F! K$ z$ C9 d- b1 ee-mail: [email protected].; k7 V/ W/ R% b) ~: D& a- Z
about 6 to 7 months old, which progressively became1 @! n* ^# f* d7 }
darker. She was also concerned about the enlarge-
' e. G% r+ h& l# H1 q. L, K  E/ c9 fment of his penis and frequent erections. The child
  C; j/ ]# |) ^" K# u6 m" p# F2 wwas the product of a full-term normal delivery, with. R4 x( v# b$ O  F: p! {( _
a birth weight of 7 lb 14 oz, and birth length of' I0 ?, U7 T# h" B' h- o
20 inches. He was breast-fed throughout the first year
. m8 Z  \9 z7 ]# a3 g7 K# pof life and was still receiving breast milk along with
; y; J. q* e& ~3 }6 l& O( h3 nsolid food. He had no hospitalizations or surgery,
0 O3 b; F7 ?5 W- [- Xand his psychosocial and psychomotor development
% I; Y  x1 k9 K3 uwas age appropriate.
( q! l) a+ L) `+ P! G9 V7 ?The family history was remarkable for the father,1 ?, {) V# Q* `' n" Z2 V" o
who was diagnosed with hypothyroidism at age 16,/ y2 ]: F8 \( ^% A$ g5 L2 `
which was treated with thyroxine. The father’s
# C: [7 ?3 o. p2 [* Hheight was 6 feet, and he went through a somewhat
1 S0 B2 b' {+ K( A/ Q9 `early puberty and had stopped growing by age 14." Y& K+ w6 c) i7 R
The father denied taking any other medication. The
! U4 R0 s- ]% ~$ r/ {% |child’s mother was in good health. Her menarche1 ]0 ?& y, Q) B  ]/ k! P4 \
was at 11 years of age, and her height was at 5 feet
! I1 A/ P$ K( J7 a  N5 inches. There was no other family history of pre-
+ l# _" \# z9 H. ]& g. n7 P& t" Jcocious sexual development in the first-degree rela-
1 `  N" [1 E& [9 O3 e0 Itives. There were no siblings.1 }% |- g0 \4 U- Z% v  I3 b+ T
Physical Examination1 E2 M7 Q' ]  y  S
The physical examination revealed a very active,$ @1 F0 ^2 Z+ v7 T0 _9 b
playful, and healthy boy. The vital signs documented- j/ w: T* m9 A3 S
a blood pressure of 85/50 mm Hg, his length was
$ Y. x- O; l! Q" U  U) P  ^90 cm (>97th percentile), and his weight was 14.4 kg
% }8 A7 ]( c, s9 Z7 r(also >97th percentile). The observed yearly growth
. W4 h0 P# k; ~7 c: h2 L1 S; {& H; Bvelocity was 30 cm (12 inches). The examination of; z* v; I1 B2 ]! p% _3 U
the neck revealed no thyroid enlargement.
" v) \8 ~% ^/ ~) P( b4 ~The genitourinary examination was remarkable for
. Y' ]0 q1 H; I& ]% A. W$ eenlargement of the penis, with a stretched length of
% w# |- \4 p( [3 P" x8 cm and a width of 2 cm. The glans penis was very well
# _0 n7 K5 x/ ^" qdeveloped. The pubic hair was Tanner II, mostly around
9 X5 ?9 a7 N' t$ {- L. `540% ^. H7 U# d- i0 _; g7 w" T
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  l' Y& E7 u2 L
the base of the phallus and was dark and curled. The0 B* k, f. h( d
testicular volume was prepubertal at 2 mL each.
2 M" u( A' y/ @' e! QThe skin was moist and smooth and somewhat! e5 Z; u6 L% ?1 b
oily. No axillary hair was noted. There were no
+ `. D: _  Q, U$ a5 R8 J/ M5 Cabnormal skin pigmentations or café-au-lait spots.
/ S" E! F. V$ _; PNeurologic evaluation showed deep tendon reflex 2+3 y7 B9 m  }& w1 C7 s3 D3 r0 W$ {- ~
bilateral and symmetrical. There was no suggestion
, |  O3 |8 R, y) z! B  Fof papilledema.& l9 V2 q) a2 L$ x2 i0 R
Laboratory Evaluation* U3 y) S( y4 ~4 d. M8 e7 }' i; g# y  y
The bone age was consistent with 28 months by7 z* h; T, }+ ]6 o3 U# l' D8 R7 V4 U
using the standard of Greulich and Pyle at a chrono-
5 I; I5 `( X7 Q, K. M7 }/ c1 \" Q5 tlogic age of 16 months (advanced).5 Chromosomal9 r8 o( K1 _9 l: L/ r
karyotype was 46XY. The thyroid function test
7 [! v: Q$ y' D* {* T( K, G/ Lshowed a free T4 of 1.69 ng/dL, and thyroid stimu-! H" o' w( O: U* T) f, d
lating hormone level was 1.3 µIU/mL (both normal).- m. N# V% Y- M1 M5 R5 Q  u1 T- z/ h
The concentrations of serum electrolytes, blood5 |) Z& r, V& R
urea nitrogen, creatinine, and calcium all were
! I* E: h1 _- B" mwithin normal range for his age. The concentration0 Y* e" C  t) X' S  I* A3 S3 Y* g
of serum 17-hydroxyprogesterone was 16 ng/dL
7 N; w( t& c' H; g2 H/ Z. L(normal, 3 to 90 ng/dL), androstenedione was 208 \. O2 `0 i: {5 S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- l! N* J( t  c. B) ^0 Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; B* g. L8 T/ S1 j& n/ vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# y, I. e* l0 T* T: G# Z. r49ng/dL), 11-desoxycortisol (specific compound S); G1 j& g5 N. t' q; q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 R! o3 ]5 `8 atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 H* O5 A, S5 K& d2 [6 e1 Qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
  B! B& \" |/ P% S* Q# e. m7 ?and β-human chorionic gonadotropin was less than
( _& |, }5 ]! z( k5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 H# M3 }3 m+ ?stimulating hormone and leuteinizing hormone9 D: I& v9 S! C" A* g3 I2 F
concentrations were less than 0.05 mIU/mL& q+ D& @/ c; |
(prepubertal).  P$ y9 T& I1 m# o" U, e0 `0 x
The parents were notified about the laboratory
+ |4 j' h1 f! q/ a- o# s5 oresults and were informed that all of the tests were
8 e8 L2 a  X7 r5 B) Q$ ynormal except the testosterone level was high. The
  @2 ~9 S7 B% J' j" H; C: D6 Efollow-up visit was arranged within a few weeks to
9 u4 W7 v7 i5 T, C) _8 `obtain testicular and abdominal sonograms; how-
2 D1 f. c4 b) G3 [/ B! B/ gever, the family did not return for 4 months.
, Y' d. r" f; X9 W" ~Physical examination at this time revealed that the
, l& R. p! V/ R" Ochild had grown 2.5 cm in 4 months and had gained
  ^6 Y/ _# l5 C( @9 `2 kg of weight. Physical examination remained
! P/ ]& H5 T' v2 Lunchanged. Surprisingly, the pubic hair almost com-
$ |4 a0 _, u. O; zpletely disappeared except for a few vellous hairs at
6 y$ L5 U+ [1 I0 _) H; v( I) A' bthe base of the phallus. Testicular volume was still 26 ?; }3 J! V, i. E3 G/ T" C& W, g
mL, and the size of the penis remained unchanged.4 T- ]: h" b5 U0 x" G
The mother also said that the boy was no longer hav-# d1 n( U: O+ k
ing frequent erections.
9 Y2 a& e) Y: b+ v7 @7 t5 h5 g- F, r, eBoth parents were again questioned about use of
1 F3 T' e9 h7 x$ b2 {any ointment/creams that they may have applied to
. E- E2 }( c) W7 j5 u% F$ R: cthe child’s skin. This time the father admitted the) E+ N- \9 e6 Y& u9 X+ C! x+ ?: d! l% n( I
Topical Testosterone Exposure / Bhowmick et al 541
! }, k( b$ e& g( \use of testosterone gel twice daily that he was apply-
; p1 N6 }! h5 V& [2 _  s- I: Ming over his own shoulders, chest, and back area for
  D5 v, H) r% w( Za year. The father also revealed he was embarrassed
" t- h, X+ A  kto disclose that he was using a testosterone gel pre-$ f1 v/ ]4 M. \- m$ M/ M* L3 Z
scribed by his family physician for decreased libido  |$ g0 g" R$ k, N) ]3 l0 ?
secondary to depression.
8 z, m) v7 i" K) X- D0 w0 nThe child slept in the same bed with parents.' Q; Q' I. _! j
The father would hug the baby and hold him on his
8 \5 J( Y2 A* _- Q. ?' `0 n7 xchest for a considerable period of time, causing sig-9 U3 I) d4 ^( e) i
nificant bare skin contact between baby and father.
; V& M" g  R1 O5 J7 @5 F3 n/ xThe father also admitted that after the phone call,/ g1 S* r: X3 F1 J% ^
when he learned the testosterone level in the baby
3 m- Q0 O/ _) W+ f& [was high, he then read the product information
9 Z& O$ B2 T' s0 t! H2 u/ j" spacket and concluded that it was most likely the rea-5 j7 B. n5 v$ F. c  G
son for the child’s virilization. At that time, they
- o8 `4 s  c4 a1 b* ldecided to put the baby in a separate bed, and the
5 {$ ^8 u/ G3 h$ _3 pfather was not hugging him with bare skin and had4 @5 ^, S( g* ]( ^3 ]' x
been using protective clothing. A repeat testosterone/ X0 V+ @3 ~7 t5 ]1 D
test was ordered, but the family did not go to the
8 }% A6 l3 [2 h* r. n6 c( V, z% k6 n) glaboratory to obtain the test.1 I6 F' h7 e. P: }
Discussion. p* N$ g! P) s9 ^  ?
Precocious puberty in boys is defined as secondary( D0 D! X( i) G/ [7 g8 |
sexual development before 9 years of age.1,4
5 P0 r- d  D, j; kPrecocious puberty is termed as central (true) when
4 a2 h  K) ]$ i3 S) Hit is caused by the premature activation of hypo-9 a4 k' S5 k+ [) m5 \" q
thalamic pituitary gonadal axis. CPP is more com-; |; O9 L4 ^. u, W- T3 {1 l
mon in girls than in boys.1,3 Most boys with CPP
' }3 Q3 @  n( ?- \, ?) L& h- gmay have a central nervous system lesion that is9 @, C! L( S# T9 Z" Z) A# _
responsible for the early activation of the hypothal-
1 u# v, l! J* v) j9 y# \) S  H# `5 T; `$ Gamic pituitary gonadal axis.1-3 Thus, greater empha-
7 O3 q" x2 r" \5 u; Wsis has been given to neuroradiologic imaging in& O) f' V: b- {
boys with precocious puberty. In addition to viril-6 O; v/ ]. ^# G* B1 T
ization, the clinical hallmark of CPP is the symmet-
" w9 B6 |( ]( \' p2 u. B% ^% Vrical testicular growth secondary to stimulation by. v! h, j7 K  W, u4 N
gonadotropins.1,3
3 |9 A1 M1 T& c) g" ^0 G2 eGonadotropin-independent peripheral preco-
7 _% Q' x; w1 U$ ~# g2 Hcious puberty in boys also results from inappropriate& a6 L! S0 y/ P& x
androgenic stimulation from either endogenous or
6 H, u: R/ R* z8 g# dexogenous sources, nonpituitary gonadotropin stim-
  r% Y, Y6 f$ e1 J* ~) A% _ulation, and rare activating mutations.3 Virilizing
4 M* c4 Q) F% U7 T! Ocongenital adrenal hyperplasia producing excessive
( ~/ R& m- w+ i, ]9 N) a8 P- g  Dadrenal androgens is a common cause of precocious  i1 R# B0 }" u5 }3 C  K
puberty in boys.3,4
! _) ?0 I# h* `! V! B/ SThe most common form of congenital adrenal+ x) F: x" y  C5 N6 g$ }
hyperplasia is the 21-hydroxylase enzyme deficiency.* C7 X9 ]4 _1 S7 e
The 11-β hydroxylase deficiency may also result in
9 C9 z0 ]* w4 Q$ y" H/ vexcessive adrenal androgen production, and rarely,
8 |2 E2 ~) C+ {* ban adrenal tumor may also cause adrenal androgen
$ F- w" H( F7 u4 texcess.1,34 L( j$ ~  ]. n- P) u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 `8 h" G: P3 }
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: h. }' e( s2 k
A unique entity of male-limited gonadotropin-4 e$ j- ^$ Q( U& g/ O, I
independent precocious puberty, which is also known" N1 E  O$ e6 p- J/ Y6 i
as testotoxicosis, may cause precocious puberty at a" z6 \5 X( p/ G$ Q+ I
very young age. The physical findings in these boys
2 r' \7 w* I% b) U( @% j$ _" Fwith this disorder are full pubertal development,1 f8 P( T" W) S) g- `+ W1 _- i3 ~
including bilateral testicular growth, similar to boys
% }; U  n4 G9 e* v# X& Bwith CPP. The gonadotropin levels in this disorder8 d0 ?0 ~. Y. e5 j: c; R
are suppressed to prepubertal levels and do not show# M! r7 o/ k; C9 d& v! }0 R) M
pubertal response of gonadotropin after gonadotropin-
2 Z' C  O; x: h, }4 {  ~releasing hormone stimulation. This is a sex-linked7 S4 n/ Y( `! J* _( V: x
autosomal dominant disorder that affects only
2 g( l! G' u# \males; therefore, other male members of the family# C9 U. j0 P# c5 {: X' M( e
may have similar precocious puberty.37 [1 c3 h, @+ ]% n) c+ y
In our patient, physical examination was incon-5 P. L; C7 W6 z! j* A, x
sistent with true precocious puberty since his testi-
2 x' \/ `% |2 U, T8 gcles were prepubertal in size. However, testotoxicosis
6 G6 N" @) i2 Bwas in the differential diagnosis because his father
2 q; R# E4 q2 Dstarted puberty somewhat early, and occasionally,, V# h) G4 A( ^+ E
testicular enlargement is not that evident in the" W, k- k: y+ k7 O8 u6 _' ]4 A, B
beginning of this process.1 In the absence of a neg-
2 ?, Q$ b1 h& Q  J9 `& q+ xative initial history of androgen exposure, our
0 y/ z0 t- n/ vbiggest concern was virilizing adrenal hyperplasia,
9 K$ W7 I6 A2 g( Y: M5 W; Veither 21-hydroxylase deficiency or 11-β hydroxylase
$ f9 ^9 s% s7 O7 z9 wdeficiency. Those diagnoses were excluded by find-
$ i# p; m3 S: I% ~ing the normal level of adrenal steroids.3 Y+ [2 V3 O( o: e0 b3 h
The diagnosis of exogenous androgens was strongly
( T$ \" Z8 z  E9 c4 ssuspected in a follow-up visit after 4 months because
$ }0 B% l5 @+ Mthe physical examination revealed the complete disap-
8 W9 L6 C! z( Jpearance of pubic hair, normal growth velocity, and9 l3 W2 C: I2 t3 {
decreased erections. The father admitted using a testos-
  x4 u& q" |& d. \" _* Bterone gel, which he concealed at first visit. He was7 t' h7 ?0 D: E' R: m' ?8 ]3 N9 o
using it rather frequently, twice a day. The Physicians’
" c' u+ C, h* N- _. XDesk Reference, or package insert of this product, gel or/ o' _$ V- \4 _) G1 L# e
cream, cautions about dermal testosterone transfer to" K2 U, L& Q' a( s0 Y) S+ d
unprotected females through direct skin exposure.' E8 R! z0 f  Y# @; j+ a8 t7 t1 H
Serum testosterone level was found to be 2 times the4 n5 [9 w9 N( R2 X: N
baseline value in those females who were exposed to
0 B. F5 ?+ A+ v- X0 feven 15 minutes of direct skin contact with their male+ P) Y, O: D: A3 @5 A' F
partners.6 However, when a shirt covered the applica-2 Y0 _5 M3 I0 E3 e! |7 a, {
tion site, this testosterone transfer was prevented.
( R* W1 J2 E1 `' L* p7 M0 I: bOur patient’s testosterone level was 60 ng/mL,
% B' B8 d3 n$ @2 Q- s2 p5 ~4 z. z3 Awhich was clearly high. Some studies suggest that
& N5 A( q. G' Adermal conversion of testosterone to dihydrotestos-
2 f: ?4 H  I7 A7 \terone, which is a more potent metabolite, is more
; g, V( z3 L3 }; u4 Yactive in young children exposed to testosterone+ U0 ]$ P7 i! u( X
exogenously7; however, we did not measure a dihy-
+ l% u/ Q% C' s( P, A3 udrotestosterone level in our patient. In addition to& G; Z2 E# O7 M" w2 Q( c
virilization, exposure to exogenous testosterone in
* G$ {; U% Y( v  c6 F1 Mchildren results in an increase in growth velocity and
, [) l7 u9 A, ^2 n3 M. a/ d. T" badvanced bone age, as seen in our patient." r5 @$ t2 S( E, J/ R7 A4 Y
The long-term effect of androgen exposure during! y: A6 G# S7 e/ `4 W
early childhood on pubertal development and final6 P) F* \( T! L7 I5 x) ~
adult height are not fully known and always remain# w/ z& ~2 D1 B
a concern. Children treated with short-term testos-
7 F  T: I0 e9 ]1 Fterone injection or topical androgen may exhibit some
% v  |. J2 C8 Q9 g  c  k( [acceleration of the skeletal maturation; however, after) z: |- O; k  P- L
cessation of treatment, the rate of bone maturation7 R6 |; q" q) i; _# h: q
decelerates and gradually returns to normal.8,99 b/ L; K0 g( D! D
There are conflicting reports and controversy0 Z, {' R" h5 N) T! Z
over the effect of early androgen exposure on adult$ l3 K1 m3 W7 R, ^
penile length.10,11 Some reports suggest subnormal
" Z5 G2 u0 i" n- _# Jadult penile length, apparently because of downreg-
# p: B7 q$ A% r! V9 w; bulation of androgen receptor number.10,12 However,
# n" F) j+ t; K$ {3 ~Sutherland et al13 did not find a correlation between% S3 v# q. k' p: B, U
childhood testosterone exposure and reduced adult
1 i' e7 w/ n; W; o' V  J# ^) d/ [penile length in clinical studies.' P- h: j, z- x% T; j
Nonetheless, we do not believe our patient is9 n# F# }$ k" ]
going to experience any of the untoward effects from
. `% Q4 c! |6 L! m( Otestosterone exposure as mentioned earlier because9 e$ A1 Z, ?) H/ l, ~+ a1 @, g2 @
the exposure was not for a prolonged period of time.
* m' l9 D/ t: AAlthough the bone age was advanced at the time of
/ Q! q  O8 c" w$ E5 Xdiagnosis, the child had a normal growth velocity at" ~& J6 X1 x$ m- h2 R9 P1 x  Z
the follow-up visit. It is hoped that his final adult
7 a- L% z7 A3 e7 E% O$ x  v7 dheight will not be affected.& C9 L+ u+ y- B- N$ @
Although rarely reported, the widespread avail-* O( N1 {# ~8 Q; L" f% W! q( `8 z$ k
ability of androgen products in our society may% x5 n+ |5 h1 I  s) e' E
indeed cause more virilization in male or female
1 f% B5 ]6 T, B. L, }children than one would realize. Exposure to andro-
+ g5 n2 l. J; G& h' y$ hgen products must be considered and specific ques-0 i% p. Z# f/ L) v  |( s4 F+ j
tioning about the use of a testosterone product or6 y9 X3 [" m" y$ S
gel should be asked of the family members during# Y: D; r6 l7 R) H1 R
the evaluation of any children who present with vir-6 `7 v: C" `) l! y6 k2 [( I% X" F9 l1 F% a+ J
ilization or peripheral precocious puberty. The diag-
# X* ]$ V* {. H1 O6 Mnosis can be established by just a few tests and by6 r1 N5 I. d9 h3 j
appropriate history. The inability to obtain such a
- N! n) k6 i- [history, or failure to ask the specific questions, may! _% b7 i  s; N, n: M
result in extensive, unnecessary, and expensive
7 Y& k3 X- {6 y- T8 R" R9 G, Zinvestigation. The primary care physician should be8 S- X  Q$ K+ _) N' q
aware of this fact, because most of these children
# @% [0 E  |( i/ q8 e9 R+ Rmay initially present in their practice. The Physicians’
8 V( y% L4 B0 wDesk Reference and package insert should also put a3 O% r! D9 a( `& E) I" S1 N
warning about the virilizing effect on a male or. C. X% V. @1 P* G  U# o3 E! q
female child who might come in contact with some-
0 l5 [# x/ V/ Q8 m( K6 N' [6 y! jone using any of these products.$ g$ J5 q  |& c$ D4 g" {
References
: u+ p+ q2 A, q" F1. Styne DM. The testes: disorder of sexual differentiation5 Y4 V! S4 q$ g
and puberty in the male. In: Sperling MA, ed. Pediatric, Y: L( [1 c1 G5 U! o. ^5 l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
, ]$ z( d- _: W3 t" s. ?$ d2002: 565-628.9 j2 ?6 l0 N8 {: n
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 P4 {+ F1 P& ~
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old* ~6 x" m# ]6 ^8 F
Boy Induced by Indirect Topical% G; C3 H9 l7 ?: c1 s& u
Exposure to Testosterone' V9 \. _3 X* d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; F' B' B6 _; n' u: L! U4 ~3 _
and Kenneth R. Rettig, MD1+ J) U- Q" L  G. n6 z
Clinical Pediatrics: @- }, e! u5 h% V. s
Volume 46 Number 6' Y0 _# a0 T7 Y! i# q
July 2007 540-5435 I' V# o* u5 n& n1 [) v
© 2007 Sage Publications$ @  K5 V" A. }$ _3 m. B8 `! B4 g
10.1177/0009922806296651# ~0 k7 N* k3 y- }: F; Z+ i
http://clp.sagepub.com0 B4 P& A8 q) i" {/ h) S# m
hosted at
- u1 ]  |0 f" O) m( B) Jhttp://online.sagepub.com5 y  ]. z: M% ]' |2 m: C! F
Precocious puberty in boys, central or peripheral,
' ?0 N7 Y+ m+ {. Tis a significant concern for physicians. Central
  M4 [4 |4 m: S  R8 tprecocious puberty (CPP), which is mediated' {. \. [" j+ A) F, O1 c: B$ B
through the hypothalamic pituitary gonadal axis, has
3 A: ]& z2 V: I. f6 U$ ~a higher incidence of organic central nervous system9 j% b6 F: q; B% W1 R( v
lesions in boys.1,2 Virilization in boys, as manifested0 c- W/ B; H8 o, V/ y  N+ Y1 Q8 R
by enlargement of the penis, development of pubic
* s/ T; }: k* S# @' F8 U+ dhair, and facial acne without enlargement of testi-
% f7 S! `" {# d- ~% p. B) x3 z7 scles, suggests peripheral or pseudopuberty.1-3 We- F2 U+ x+ f& r) b& M
report a 16-month-old boy who presented with the0 j4 K3 u9 r& T7 O- {( v
enlargement of the phallus and pubic hair develop-- N) \& }2 ]) V, f
ment without testicular enlargement, which was due' k0 k6 a  n* m8 t7 ?) l
to the unintentional exposure to androgen gel used by
; t& X8 p' I7 Qthe father. The family initially concealed this infor-0 z3 l) @+ b, ~' a6 S
mation, resulting in an extensive work-up for this# v5 @6 _: e, n) F) A
child. Given the widespread and easy availability of
& m; i: {0 ~3 i% ^! ~1 T  K8 ptestosterone gel and cream, we believe this is proba-; l# @: X- w4 W" ^& y
bly more common than the rare case report in the6 q- j1 X+ s/ J  [) o; S
literature.4
# j) I' f  P7 x2 C6 y  e4 U) H# xPatient Report
2 L4 t% k+ [% l  y/ c: |5 s  ?A 16-month-old white child was referred to the! O% E7 F9 o) w& `  p; i& x
endocrine clinic by his pediatrician with the concern
2 ?& A+ B' M5 [$ d! lof early sexual development. His mother noticed
3 }* M8 @. X6 a7 t( i; k4 Z4 [light colored pubic hair development when he was
$ _4 K% H- i/ a& G% B: wFrom the 1Division of Pediatric Endocrinology, 2University of
" j$ {* f3 Q3 _# ^- sSouth Alabama Medical Center, Mobile, Alabama.( D6 U$ ?! A" P: n/ t7 k
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( P& B7 E6 s6 mProfessor of Pediatrics, University of South Alabama, College of3 Z* b/ \4 B- U" G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# G4 l- k' T. @2 S( B# K+ B( L
e-mail: [email protected].
* s( c: {1 Q9 O* yabout 6 to 7 months old, which progressively became
( X- ?1 g: u) ?- c3 @* Vdarker. She was also concerned about the enlarge-
# U2 [) B- O2 u) R0 bment of his penis and frequent erections. The child3 \0 [3 e+ X4 w: {% B& P+ v
was the product of a full-term normal delivery, with# ^) j  d- [' Y1 B
a birth weight of 7 lb 14 oz, and birth length of
. X* C5 D5 W$ z20 inches. He was breast-fed throughout the first year
0 d6 x& H$ u+ [of life and was still receiving breast milk along with( D  O7 I- t- n9 ~
solid food. He had no hospitalizations or surgery,
  O& P5 x  Z8 `$ Jand his psychosocial and psychomotor development
6 w$ a$ J) u1 ?( swas age appropriate.
, Z  z- H. X0 L! r: ?7 P& l# }The family history was remarkable for the father,1 m! U3 p  `: B0 b9 t, U: @
who was diagnosed with hypothyroidism at age 16,
# C8 S& F7 C" Z3 ~% |which was treated with thyroxine. The father’s, a& E8 z' ]9 o& f
height was 6 feet, and he went through a somewhat" D; H5 S+ W# i
early puberty and had stopped growing by age 14.
4 D, D& t4 W4 ^# |9 r' q4 fThe father denied taking any other medication. The% r7 N: j1 ^- R
child’s mother was in good health. Her menarche
7 `, ]2 l( t  c+ {/ g7 x* Uwas at 11 years of age, and her height was at 5 feet
) |+ u) `2 F- Q" Z3 p5 inches. There was no other family history of pre-
6 p: [1 p5 u; i: ]5 f0 e! @cocious sexual development in the first-degree rela-
& m- [. b! W* w. F( btives. There were no siblings.
* Z! S% {5 j- T- I$ Z3 {9 NPhysical Examination9 @* ]6 F2 c' S% C1 J
The physical examination revealed a very active,
& e1 Z0 h9 u5 g' kplayful, and healthy boy. The vital signs documented
4 S* `4 m+ e: H$ D, J* g* fa blood pressure of 85/50 mm Hg, his length was
% j2 G  t9 {, e$ S90 cm (>97th percentile), and his weight was 14.4 kg( @+ {  `. U! _# Y2 J, Z# ?8 l) w! c
(also >97th percentile). The observed yearly growth
  i: q# Z* l4 Mvelocity was 30 cm (12 inches). The examination of
- e' R& H. M. D. {the neck revealed no thyroid enlargement.8 i# D- F  @% v+ R# b
The genitourinary examination was remarkable for& O5 _& C: W% e* R
enlargement of the penis, with a stretched length of
: p1 N1 a; w4 z- R7 z6 r, _8 cm and a width of 2 cm. The glans penis was very well
* V6 \9 O' a8 Q. u% v& w: A# t0 M" Ddeveloped. The pubic hair was Tanner II, mostly around8 ^8 k8 H- F9 k0 f2 c$ V
540
: M  [  u; @1 D/ v4 _) Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ v: S1 J% H8 m6 n$ i
the base of the phallus and was dark and curled. The! ^' {1 D- {2 L* r
testicular volume was prepubertal at 2 mL each.
, q. j8 c9 x$ I8 L6 P) m0 oThe skin was moist and smooth and somewhat0 b6 g: u9 t  b7 ?, a8 x) o/ `- P
oily. No axillary hair was noted. There were no
* v; _- W% `3 t5 }6 ?abnormal skin pigmentations or café-au-lait spots.
% [' t. _) p5 g, G' |Neurologic evaluation showed deep tendon reflex 2+3 \9 s& d7 ?( L3 D; ]
bilateral and symmetrical. There was no suggestion
- v1 L" p% t# n+ a* P  |of papilledema.$ i( d1 O- `7 h
Laboratory Evaluation. e: U- l1 T1 C  _; Q3 \
The bone age was consistent with 28 months by
2 n" g# r( _6 ?using the standard of Greulich and Pyle at a chrono-
& A" m# p2 C/ a% B8 vlogic age of 16 months (advanced).5 Chromosomal  u4 N; H1 y( @2 f' d7 `" r
karyotype was 46XY. The thyroid function test3 @/ b9 @) G) K8 Y3 U8 S
showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 I7 `* F$ ~% g- G+ T
lating hormone level was 1.3 µIU/mL (both normal).$ _* q. x, E; a( f( {/ x7 x! X; F
The concentrations of serum electrolytes, blood' {" `, s* s" z$ Z# d
urea nitrogen, creatinine, and calcium all were: b/ r3 O' M3 \  T
within normal range for his age. The concentration; w0 u. L/ s4 u
of serum 17-hydroxyprogesterone was 16 ng/dL, d4 w+ R, M) b8 O# L
(normal, 3 to 90 ng/dL), androstenedione was 20; `5 d; l9 R& z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! r3 q0 x2 e  F; \terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ W2 l- Q6 @" w- p' Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ d9 n9 X/ t% g$ i6 U49ng/dL), 11-desoxycortisol (specific compound S)
( L2 W3 z% \9 x4 f/ R: m& jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! k$ K# V+ ?8 ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& S1 B9 O$ D0 X. H' btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# q4 C% I1 Y9 ~and β-human chorionic gonadotropin was less than
  R+ r- W6 h1 |- y- c9 L5 mIU/mL (normal <5 mIU/mL). Serum follicular; y5 p7 U, o- a
stimulating hormone and leuteinizing hormone7 e% G# a$ I  U& _2 s- B% Y
concentrations were less than 0.05 mIU/mL
! r9 c% n* k" _  k(prepubertal).
! n3 t& J6 L: ~' Y  \( kThe parents were notified about the laboratory! U8 C2 ~# y3 M' d9 C
results and were informed that all of the tests were5 V$ |1 y2 k( T0 L
normal except the testosterone level was high. The
% w6 R1 Z. A$ j; Ifollow-up visit was arranged within a few weeks to2 B& [# L7 @2 N7 @7 b! j' S/ K9 r9 O
obtain testicular and abdominal sonograms; how-, D& ^: J3 M' b+ M5 g" p
ever, the family did not return for 4 months.
0 _5 b& k5 G  v8 mPhysical examination at this time revealed that the
% D) O5 t& }/ p9 Y9 Bchild had grown 2.5 cm in 4 months and had gained
/ \& ~7 {% s% I3 `% ^- x" r2 kg of weight. Physical examination remained
( o, G/ |0 z+ Iunchanged. Surprisingly, the pubic hair almost com-" A6 P$ |) y9 ]# o6 S
pletely disappeared except for a few vellous hairs at
% b: v" U4 \7 Nthe base of the phallus. Testicular volume was still 2; }+ w, y" i! Z1 s2 l
mL, and the size of the penis remained unchanged.
( j! ?7 d2 ~7 y9 H% M4 b1 oThe mother also said that the boy was no longer hav-
+ O3 e: R4 P; M; T, |5 j+ ving frequent erections.; _3 _4 ]: f$ Q, m9 ~) T
Both parents were again questioned about use of5 ?1 {' k; y+ r- A7 J, O) B$ B  W
any ointment/creams that they may have applied to) y1 l0 v2 ^. b% ]5 |, P2 f
the child’s skin. This time the father admitted the( o, T7 a9 J& x5 D1 n& z
Topical Testosterone Exposure / Bhowmick et al 541, @& b8 |# |, n( ]
use of testosterone gel twice daily that he was apply-: b0 t0 q5 f7 ]6 Z7 A* ~* }/ \
ing over his own shoulders, chest, and back area for: |1 z* \- B+ [" P1 G) k! Y, B
a year. The father also revealed he was embarrassed
3 w9 u. ]9 u. Y( q6 w% K. lto disclose that he was using a testosterone gel pre-
; j, P/ v; ~$ p: D+ tscribed by his family physician for decreased libido
" x0 [; q1 {; y+ m# xsecondary to depression.
, z; M  @. V" QThe child slept in the same bed with parents.- W0 |: H. r# c5 S- p8 j( L
The father would hug the baby and hold him on his
6 s6 }& w; K) X7 p' ~1 dchest for a considerable period of time, causing sig-: M' s, d* |/ T+ e5 x3 }
nificant bare skin contact between baby and father.
7 H' s- B1 e  `! D. @. lThe father also admitted that after the phone call,. G6 {4 d& _4 `( V1 l
when he learned the testosterone level in the baby
% o6 a) S- N( k! `was high, he then read the product information% I0 E7 K+ e- Y. n
packet and concluded that it was most likely the rea-) v; D4 s! K* g- n
son for the child’s virilization. At that time, they
# J+ p2 w. a! Ndecided to put the baby in a separate bed, and the4 r& p' F1 L% z2 c# s: Y' y
father was not hugging him with bare skin and had
0 U1 N5 V) a, p! I7 j  {1 R4 ]been using protective clothing. A repeat testosterone
$ O& _, u: W! R% a0 D; etest was ordered, but the family did not go to the: X1 x# p8 H0 U
laboratory to obtain the test.2 U/ e: Z% o/ f! R) B+ ]
Discussion
+ @  H  N5 r) g& K: ]Precocious puberty in boys is defined as secondary9 |9 e; J/ S- ?
sexual development before 9 years of age.1,4
; W7 C( [( [+ |' Z0 q5 V- FPrecocious puberty is termed as central (true) when  F+ q) b, v* U0 z: G- t: G# R) ^6 }  [
it is caused by the premature activation of hypo-
; E, ?/ n1 u: a/ G# |; wthalamic pituitary gonadal axis. CPP is more com-5 S) u. J0 E. U7 s$ p% @& [1 x
mon in girls than in boys.1,3 Most boys with CPP
  v  c# ?( }/ d0 D: A' q6 P& c7 Pmay have a central nervous system lesion that is! c6 m  H( b/ v: m
responsible for the early activation of the hypothal-0 q' _- y" S% L$ [! ~9 Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 h4 ]) V+ b& b- y' {sis has been given to neuroradiologic imaging in
* n$ X, M. B+ `  u/ s/ H7 q) U0 Vboys with precocious puberty. In addition to viril-
* ?5 W( w) l1 Fization, the clinical hallmark of CPP is the symmet-
& {* O6 Q. _( @. ]3 |4 E  I/ Trical testicular growth secondary to stimulation by/ R, _& a+ l. s
gonadotropins.1,3
) y" V% ?5 j/ }1 h& xGonadotropin-independent peripheral preco-3 F* K( A4 V1 V
cious puberty in boys also results from inappropriate
$ _3 s( T  v# o% o4 M+ T9 aandrogenic stimulation from either endogenous or6 {# ]" s( P- V+ [7 w' \
exogenous sources, nonpituitary gonadotropin stim-
# a  K8 s6 R; U" `) _* Gulation, and rare activating mutations.3 Virilizing
4 z% g, W- f4 a9 h; dcongenital adrenal hyperplasia producing excessive
- C. A! G/ G8 E2 I& H$ r# Xadrenal androgens is a common cause of precocious/ s$ b5 A* F, r7 @
puberty in boys.3,4
% E6 T# S8 v& ^4 FThe most common form of congenital adrenal
& Z8 N; j4 N* C) Vhyperplasia is the 21-hydroxylase enzyme deficiency.) i) e* L  c* f) A5 ~* B
The 11-β hydroxylase deficiency may also result in7 P! K  u/ C  O
excessive adrenal androgen production, and rarely,& X$ K" U7 S/ }- b' g  D& b
an adrenal tumor may also cause adrenal androgen
: ], _9 x4 u( {( S% Dexcess.1,3$ ]; k( [1 Q+ v' ]+ y! a
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ y. @4 V# |0 E# c# U/ u1 p
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 [0 N5 f% A8 v. S, S7 ^* A
A unique entity of male-limited gonadotropin-
' z- f- n6 |/ M5 ^; G# xindependent precocious puberty, which is also known# j; w# A- e0 ?5 ^3 V3 \
as testotoxicosis, may cause precocious puberty at a2 q/ d' P, K* m9 m4 s# u+ Q
very young age. The physical findings in these boys
% h$ m; P7 ^8 S1 j3 n& w# F( ~with this disorder are full pubertal development,% M" r  \; V" B: V" I  \1 Z, t. p# I
including bilateral testicular growth, similar to boys
5 O/ K5 P5 P, w. Ywith CPP. The gonadotropin levels in this disorder
( v4 q: f, j  b* X" l3 U- I' y4 nare suppressed to prepubertal levels and do not show
: E2 [- s4 o: Cpubertal response of gonadotropin after gonadotropin-4 {# H, W8 M+ n
releasing hormone stimulation. This is a sex-linked/ k0 _1 `6 o2 r7 |4 z
autosomal dominant disorder that affects only& O. L1 r4 q! W% h9 d6 U5 R+ Q$ Z
males; therefore, other male members of the family
9 P2 E/ s; V+ [4 H; H0 Y& zmay have similar precocious puberty.3( p  W! e8 p3 m* L7 Z. J
In our patient, physical examination was incon-1 B+ d' \. k$ ]/ m; m
sistent with true precocious puberty since his testi-0 Z9 E9 R$ N) U8 j
cles were prepubertal in size. However, testotoxicosis$ o* U1 m' t) j( m+ h
was in the differential diagnosis because his father
( {% @) _, n4 }4 D  h' Rstarted puberty somewhat early, and occasionally,
- h0 B1 }4 W1 _) {testicular enlargement is not that evident in the( d% v# v' |' s) p& R5 E
beginning of this process.1 In the absence of a neg-
/ B: R# W5 _0 P1 w/ ]ative initial history of androgen exposure, our! B3 K2 \5 v& e, U
biggest concern was virilizing adrenal hyperplasia,$ g3 L) _# j8 }0 O! M0 p! w+ M# @) s
either 21-hydroxylase deficiency or 11-β hydroxylase
2 w. E2 y7 ~$ ]9 Z; }deficiency. Those diagnoses were excluded by find-! `& j$ }7 X8 G: @0 ?
ing the normal level of adrenal steroids.
2 @" `" Z" K, }: L. k% O: A' {The diagnosis of exogenous androgens was strongly/ y3 K# q: \" C$ {1 T
suspected in a follow-up visit after 4 months because
3 t3 ^/ Z# a3 `) N% ]! _: pthe physical examination revealed the complete disap-" @" s, t. @' Y) f9 o, N' T. e
pearance of pubic hair, normal growth velocity, and
1 X* H# }: _( D+ c1 }decreased erections. The father admitted using a testos-9 C( [/ k; C* q, c7 q" }
terone gel, which he concealed at first visit. He was. c- x( {$ E2 a: m/ J- n' v) K
using it rather frequently, twice a day. The Physicians’% r6 W1 f: R$ ~/ I( r8 V9 f
Desk Reference, or package insert of this product, gel or
/ a4 X( [& F5 {# T  _0 \% C5 X( Lcream, cautions about dermal testosterone transfer to
! J4 _( ~; O$ l( X. [: @: ~8 Lunprotected females through direct skin exposure.
3 g5 T8 V; m4 n9 }Serum testosterone level was found to be 2 times the0 ^. K+ |# ^0 e& T8 o8 _& h
baseline value in those females who were exposed to
* `: ^7 m7 X, i  v+ m: e: Y) k3 xeven 15 minutes of direct skin contact with their male
6 a1 B4 T" t9 m5 Q! }0 xpartners.6 However, when a shirt covered the applica-# \# C& g& u0 H' e. j4 V" _
tion site, this testosterone transfer was prevented.
; @- X4 c8 C( K2 BOur patient’s testosterone level was 60 ng/mL,
* ~6 K7 o' N1 a# R5 F8 d0 O2 b. R7 xwhich was clearly high. Some studies suggest that" p; n+ y# Q( O: f+ {' e
dermal conversion of testosterone to dihydrotestos-
' ?  Q; G0 V1 [0 Yterone, which is a more potent metabolite, is more
3 D+ {% f! A) w7 Z% H+ qactive in young children exposed to testosterone5 B/ d$ l$ H4 }8 _
exogenously7; however, we did not measure a dihy-/ ?1 z- h2 o5 w
drotestosterone level in our patient. In addition to
; R9 [! F) z* h6 hvirilization, exposure to exogenous testosterone in: C& T( O: b4 r% r% |! c. |
children results in an increase in growth velocity and6 K6 R  U0 A/ @# H6 q4 I6 ]" w
advanced bone age, as seen in our patient.
/ X0 F* K! f5 b3 s* {. {  O* cThe long-term effect of androgen exposure during
, B9 a, Q) R' p$ E+ P) b3 ~early childhood on pubertal development and final
$ O, ?$ y  J! hadult height are not fully known and always remain7 H7 N" }2 }1 U" z6 j9 T: s! U- z
a concern. Children treated with short-term testos-
% i( K# m' T$ F: a' g3 K# Y: yterone injection or topical androgen may exhibit some
  \' ^$ F5 z; jacceleration of the skeletal maturation; however, after
1 s9 U8 s9 }" h. G3 v3 W! Lcessation of treatment, the rate of bone maturation' m6 |3 ^0 u  C4 Z6 ]& [
decelerates and gradually returns to normal.8,9
& I" ]8 l# l$ M7 W* wThere are conflicting reports and controversy
7 t2 x' Y$ e, Dover the effect of early androgen exposure on adult
% ^' ]$ J/ o0 H0 d2 lpenile length.10,11 Some reports suggest subnormal
3 i4 y* \- z8 J! s& Vadult penile length, apparently because of downreg-0 F( Q+ L# v% t; R& a9 U6 j
ulation of androgen receptor number.10,12 However,4 k/ s! l# n* \6 R+ `
Sutherland et al13 did not find a correlation between. z: h2 X' ^: u! v* I. @
childhood testosterone exposure and reduced adult
8 Q% R2 {/ y: k! K: tpenile length in clinical studies.
6 S( ?# L  [& }& x/ P* PNonetheless, we do not believe our patient is
( @! q! f/ G" h0 qgoing to experience any of the untoward effects from4 |& Z' I3 M# b* p4 s* u
testosterone exposure as mentioned earlier because: A3 Q! L) @% C# c
the exposure was not for a prolonged period of time.
2 w  z# Z" {/ g' U9 ^Although the bone age was advanced at the time of
; p8 R7 ^6 g: D. {diagnosis, the child had a normal growth velocity at
* v# I. U# d3 e( O. `% Xthe follow-up visit. It is hoped that his final adult
6 m3 B/ Y, L" g# pheight will not be affected.* q8 t4 B# V. p* B4 {. p
Although rarely reported, the widespread avail-
  G6 l: P, X" |5 U, z( P# Q9 T0 Bability of androgen products in our society may, s; ^2 ~% a/ @% g; U* S
indeed cause more virilization in male or female
) V, r) Q# m: @children than one would realize. Exposure to andro-
# g3 C$ a. ?% `0 ^gen products must be considered and specific ques-
( o: h: F/ K, Z3 R1 R8 K% _5 Ttioning about the use of a testosterone product or
6 X1 E; F& O6 E, kgel should be asked of the family members during+ |/ w) b; D7 x$ G: x/ y
the evaluation of any children who present with vir-! t+ T* }7 H: x+ r8 Q( L# Y. V  ?; E
ilization or peripheral precocious puberty. The diag-' O; l# x) z# v5 s1 O6 N0 g. Z/ O
nosis can be established by just a few tests and by
6 {# o8 m2 |2 E" q% Yappropriate history. The inability to obtain such a" R: a% `; f& Z, u  I
history, or failure to ask the specific questions, may0 E" |7 f' s% M7 L
result in extensive, unnecessary, and expensive; }" Q" y: z* V& U* V
investigation. The primary care physician should be4 F! j) c% L$ n2 I1 \
aware of this fact, because most of these children' F" A  p' E8 L4 {* }: D) r) l: ~
may initially present in their practice. The Physicians’
+ Z2 J1 u8 x% KDesk Reference and package insert should also put a) R, O4 ~8 ~& D: e, J
warning about the virilizing effect on a male or. J4 [1 n7 f1 g/ b. B/ C
female child who might come in contact with some-
' |9 ~2 @+ _5 o7 done using any of these products.
, w: b: h, V4 }- i( }References
9 i/ {1 u9 g+ `8 _, Y! V: i1. Styne DM. The testes: disorder of sexual differentiation" p4 H2 t9 F8 T1 c/ g& _: B
and puberty in the male. In: Sperling MA, ed. Pediatric( ~8 R- L& g  _' `# t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;6 P8 ?. a! {+ U
2002: 565-628.  K( o7 @4 _! m- x5 U& w
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 y" A& v  X+ h( @" r9 }3 Mpuberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

5 Q. A( f9 C1 j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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