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Sexual Precocity in a 16-Month-Old, j2 z9 ?3 s- U3 P) [
Boy Induced by Indirect Topical
/ x! R. D6 l) aExposure to Testosterone
* ^( p3 T3 E9 x& L2 k0 Z6 dSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: _4 I2 A+ b+ I' t* R+ Oand Kenneth R. Rettig, MD1
/ E0 p7 e1 n+ O  R; r# D1 x  }" ^Clinical Pediatrics) s5 H3 _7 m8 Z9 w
Volume 46 Number 6, b, D7 w2 Q- u4 Y
July 2007 540-543, f4 h$ D$ e& m! ?% j
© 2007 Sage Publications) w; c: c3 b! i5 P3 O: Y
10.1177/0009922806296651  y9 Z: M, ^# }1 T
http://clp.sagepub.com
5 J" h6 t& k; q. ?3 shosted at
; ?- `) e: A$ W: y5 ?/ v) C6 Ghttp://online.sagepub.com  D  R. g, f% ^; E) M' I
Precocious puberty in boys, central or peripheral,
; c1 L+ H9 k3 u4 x# o8 Q. L) Zis a significant concern for physicians. Central
4 D* l. Z5 h3 U) [0 ~precocious puberty (CPP), which is mediated. x+ L- ~  ~  L" \: E, c1 a
through the hypothalamic pituitary gonadal axis, has
+ U+ N5 H* \+ O6 t, @( Na higher incidence of organic central nervous system
0 C2 F! L! J% |0 {- ilesions in boys.1,2 Virilization in boys, as manifested
7 j8 ^. ?% ]$ I- A" P3 Rby enlargement of the penis, development of pubic) W! V, ?! [3 I
hair, and facial acne without enlargement of testi-
* {; o5 O/ y  M$ H2 E7 vcles, suggests peripheral or pseudopuberty.1-3 We. h, n" i% H7 ?! {5 `% k& g
report a 16-month-old boy who presented with the
% S- A1 d/ o- j! l5 @. g: cenlargement of the phallus and pubic hair develop-9 g# M) K# I. c3 X0 S
ment without testicular enlargement, which was due, ?/ X8 z0 s/ F2 {
to the unintentional exposure to androgen gel used by
# `& `8 `* E: ^the father. The family initially concealed this infor-
8 }$ [4 l3 Z: A4 M) qmation, resulting in an extensive work-up for this
; E8 |1 b6 f/ t6 S4 \. Tchild. Given the widespread and easy availability of
( r# X9 W; d3 Q+ v& ?6 x! X3 r' ?  rtestosterone gel and cream, we believe this is proba-8 U, h) H: R0 B* ~1 O( i' Q
bly more common than the rare case report in the1 q( g6 l$ b8 w% r0 \
literature.4
* x* }3 [! M6 \3 X  BPatient Report
2 u2 ]5 S+ K- k  w  b( IA 16-month-old white child was referred to the
, d% y7 m- I# P2 kendocrine clinic by his pediatrician with the concern
2 s$ m4 d8 h$ G; {+ Nof early sexual development. His mother noticed
7 ]. \, Z8 Z$ d) g9 ^' L6 Alight colored pubic hair development when he was2 }1 Z' I, b# D7 G
From the 1Division of Pediatric Endocrinology, 2University of
6 n) ]* X& S% B6 Y2 `9 i: A7 h0 KSouth Alabama Medical Center, Mobile, Alabama.
2 |% Y. F3 N! {! i# q& U* H4 nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 m5 B6 o4 J$ S/ m, e% Y% q- W7 ]Professor of Pediatrics, University of South Alabama, College of
# f( ~, v* n9 Y% ]+ UMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( f& V2 K# ^$ g' z0 X( S
e-mail: [email protected].
% o+ o$ {$ {, }: a' i$ zabout 6 to 7 months old, which progressively became4 i, k- o# Q# O/ S. c
darker. She was also concerned about the enlarge-
7 ?5 Q: C' |$ J- f0 g" ~ment of his penis and frequent erections. The child
7 x+ V+ U3 X: R% Awas the product of a full-term normal delivery, with
' G7 S( ]+ v. b/ b4 C) I! u" k& oa birth weight of 7 lb 14 oz, and birth length of- h, r4 v5 K% ?. s7 k" f
20 inches. He was breast-fed throughout the first year7 L6 y* Q6 a/ g! B/ |
of life and was still receiving breast milk along with! H8 g, V+ Y3 {6 V6 Y
solid food. He had no hospitalizations or surgery,
7 j2 ^! [: f# e" E9 B6 Y% V+ qand his psychosocial and psychomotor development% v, ?& x8 v* o. m- M
was age appropriate.
" z7 c2 U( {' ZThe family history was remarkable for the father,( {: l/ }& u8 b9 U6 e  [
who was diagnosed with hypothyroidism at age 16,: o% T! z% X9 {. W5 u
which was treated with thyroxine. The father’s! c' w2 K. w! p; S
height was 6 feet, and he went through a somewhat
5 z& T7 R2 g  _, B" y* yearly puberty and had stopped growing by age 14.
; Q- `! D, e2 EThe father denied taking any other medication. The7 M3 q0 \% f0 D3 b) M+ N
child’s mother was in good health. Her menarche
4 `' q' Y; o" z7 s, ~$ b; nwas at 11 years of age, and her height was at 5 feet% h$ ?+ C# a" `
5 inches. There was no other family history of pre-
8 D6 K. u5 `% \* _6 e" ^( bcocious sexual development in the first-degree rela-4 N+ H, s) W/ ]" x% r3 H
tives. There were no siblings.& I/ A# o) \9 G3 I, J8 \+ u/ |
Physical Examination
3 y! m8 I+ f( q0 [: c; p7 f+ a7 o! hThe physical examination revealed a very active,
, l3 P1 I: E& g, G, ^playful, and healthy boy. The vital signs documented4 Q1 `8 f3 ^) [) L4 \& _$ i
a blood pressure of 85/50 mm Hg, his length was0 {. U+ q& x0 n3 z& o0 q
90 cm (>97th percentile), and his weight was 14.4 kg
9 o6 F: W: f8 w1 ^# i5 {(also >97th percentile). The observed yearly growth
5 y9 r6 }- l' t# t: q( bvelocity was 30 cm (12 inches). The examination of8 o4 D9 k# X9 [" b! X* _
the neck revealed no thyroid enlargement.
/ E4 ~6 e( A( W# T( IThe genitourinary examination was remarkable for' v5 W8 _+ v" K$ ]# c7 k2 O
enlargement of the penis, with a stretched length of! j2 K5 K0 g5 T8 z
8 cm and a width of 2 cm. The glans penis was very well
9 c4 |" h  [$ Q6 ?# H6 Mdeveloped. The pubic hair was Tanner II, mostly around% V9 I; E4 _& z0 \8 B
540! u) F6 O5 U" g2 ]/ ~' u! v) j
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ X8 J/ I9 ]* Z; [
the base of the phallus and was dark and curled. The( J. {5 J0 a( h4 C) c
testicular volume was prepubertal at 2 mL each.
; x: d7 ?: s! c0 IThe skin was moist and smooth and somewhat7 c3 v% `! h; |" q
oily. No axillary hair was noted. There were no# R2 m5 f' h6 g4 X$ a
abnormal skin pigmentations or café-au-lait spots.
/ h) t" m: k. T+ e# u' Q0 _, `7 @" ~Neurologic evaluation showed deep tendon reflex 2+8 r0 O- H  O: ^, L+ A
bilateral and symmetrical. There was no suggestion
& E! f- _  l( E. a# zof papilledema.
' Z, F" V  P$ X  |$ ALaboratory Evaluation
- s9 G8 f5 J- ]+ Y8 h( U% @The bone age was consistent with 28 months by
3 l  ?& L  o$ I( y8 @+ Z  Yusing the standard of Greulich and Pyle at a chrono-
# \* _4 J" K8 L* C: A2 N0 b: y/ w# elogic age of 16 months (advanced).5 Chromosomal
8 {+ e* n* Y9 Y+ A" ?( g7 Rkaryotype was 46XY. The thyroid function test
! d- V6 L( X* M3 g5 cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 n( R7 S# X1 i6 K+ ^lating hormone level was 1.3 µIU/mL (both normal).
8 n  I) y+ j; s! ?3 u4 _The concentrations of serum electrolytes, blood
1 {  }( M! @3 ~9 j, J! I" [urea nitrogen, creatinine, and calcium all were
1 r! P5 @/ _0 T3 Z1 J7 owithin normal range for his age. The concentration
& p$ c0 Z8 Y" oof serum 17-hydroxyprogesterone was 16 ng/dL
0 T5 T. Q! D* J2 u2 w" y0 Y  B(normal, 3 to 90 ng/dL), androstenedione was 209 O7 T; o4 r; C$ k/ j
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% P( r2 I% D3 [8 g0 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
* A1 F& D) n$ B, p5 }' i7 Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 M( W9 W+ x) _! K& s49ng/dL), 11-desoxycortisol (specific compound S)
! W9 |3 l4 S/ ], gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) q, D+ C3 O4 O  q6 {2 ?tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% E" e5 l3 H4 \2 p. _. |testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* V' ]1 D5 ?* ^) wand β-human chorionic gonadotropin was less than
1 Y9 X. z% T/ M( r5 mIU/mL (normal <5 mIU/mL). Serum follicular5 N7 l" ]- |' s. d
stimulating hormone and leuteinizing hormone
) a3 k" z( T! _+ B3 \3 u0 hconcentrations were less than 0.05 mIU/mL1 T% J2 m% p5 U$ H5 @2 j, V
(prepubertal).
: ?8 a1 F& f! @  K$ ]% B* CThe parents were notified about the laboratory* A, s  P" i. q- ~5 \" O7 ]
results and were informed that all of the tests were
6 ~* L' |3 @( pnormal except the testosterone level was high. The
- t7 Y4 U' m$ d1 v7 i  G' B7 R' ?follow-up visit was arranged within a few weeks to. m/ n% `/ v  V3 `3 N8 B* B
obtain testicular and abdominal sonograms; how-2 c" ~* j  I2 F3 V* X. d
ever, the family did not return for 4 months.
! _; `& w& J9 \7 B' zPhysical examination at this time revealed that the
0 H* l( y; ?' G! t, W( x$ cchild had grown 2.5 cm in 4 months and had gained
" U5 E6 F; W" R2 i# Y4 g  ]+ C: }: ~2 kg of weight. Physical examination remained
. p( z8 E, B% i0 gunchanged. Surprisingly, the pubic hair almost com-
  l) e: M' C8 G, D7 jpletely disappeared except for a few vellous hairs at
0 t/ z/ G+ k0 tthe base of the phallus. Testicular volume was still 2# P. U, h. @% k1 |
mL, and the size of the penis remained unchanged.
9 v, R) M, r9 U# R- M: cThe mother also said that the boy was no longer hav-
1 d/ c  R7 }) `* Y+ n$ hing frequent erections.$ `* \) I) _7 T1 B' I9 v: E
Both parents were again questioned about use of6 U# Z5 o! b  C. j" [- y7 r
any ointment/creams that they may have applied to4 y4 f1 I; b; `: y  o( Z* R
the child’s skin. This time the father admitted the% X$ f# e1 o: P; @( V1 g3 l) Z/ {
Topical Testosterone Exposure / Bhowmick et al 541! [5 ~0 Z4 Q" \/ E
use of testosterone gel twice daily that he was apply-5 X$ u1 {  ^4 J3 S/ w- L5 A6 n
ing over his own shoulders, chest, and back area for& g  C4 x- _/ }# I
a year. The father also revealed he was embarrassed
8 ?' a; w4 A5 u" e3 z* A4 Rto disclose that he was using a testosterone gel pre-/ v* x1 I# _: s" `0 V
scribed by his family physician for decreased libido) B, L) r0 @" z, S& H
secondary to depression.3 R! o( B5 Q; e6 F. H7 O6 K! j# T; O
The child slept in the same bed with parents.
! ?" m( [- W+ E4 S# F2 tThe father would hug the baby and hold him on his1 s+ I0 G+ A" N8 u& F9 h
chest for a considerable period of time, causing sig-/ s& Z9 [/ Y' d: L4 p
nificant bare skin contact between baby and father.
1 Q9 }$ J  n) n( p6 `" P. }! K# O* _The father also admitted that after the phone call,
# v. `: n5 F- k, d( L5 r! |  rwhen he learned the testosterone level in the baby4 u) V* T# |; t, v
was high, he then read the product information/ k" [! c. h& m! w0 o( P: R
packet and concluded that it was most likely the rea-3 v: }; p& J) g! M
son for the child’s virilization. At that time, they3 B9 i- }6 T  h
decided to put the baby in a separate bed, and the
( K9 }3 a$ m- b# u2 I8 u! j3 sfather was not hugging him with bare skin and had
6 `' Q' f5 o: n# o5 N; ^: ybeen using protective clothing. A repeat testosterone
4 j5 D* y2 _) }0 @test was ordered, but the family did not go to the- Z1 E3 j6 n1 x; E' b; x4 H7 P
laboratory to obtain the test.
2 \: J( p+ l/ h; q4 {8 J- BDiscussion
+ m: s6 ^9 E) V; r+ |# O8 _9 r. MPrecocious puberty in boys is defined as secondary- I8 x$ X/ ^' E" a: K$ Z% v' k
sexual development before 9 years of age.1,4+ v, A! ?  _7 s1 d
Precocious puberty is termed as central (true) when3 r# g8 W- d9 Q0 X# c; w% S+ l1 j
it is caused by the premature activation of hypo-; S+ b& W- E& C7 T, ^8 z! C* |+ V
thalamic pituitary gonadal axis. CPP is more com-1 x* H% ]' ^5 s- ^
mon in girls than in boys.1,3 Most boys with CPP
! v- W* j: l0 @9 A+ C& k' n/ W! bmay have a central nervous system lesion that is
1 T2 T! i- B! R- tresponsible for the early activation of the hypothal-
+ h' h! q1 Q/ \) W% Samic pituitary gonadal axis.1-3 Thus, greater empha-
/ w3 o" S( v4 ]: Usis has been given to neuroradiologic imaging in
7 C3 q1 X) F  h& xboys with precocious puberty. In addition to viril-
" |# ]& P0 v1 l; {% oization, the clinical hallmark of CPP is the symmet-
" D# q! V- j) [rical testicular growth secondary to stimulation by5 Y9 [/ i  m; a: e
gonadotropins.1,3$ B2 [# k1 u& E$ A8 \. L4 ~
Gonadotropin-independent peripheral preco-
( F' _; ]- t& X2 ~5 f1 A7 N3 E7 bcious puberty in boys also results from inappropriate
, \: {8 W' [8 g, Bandrogenic stimulation from either endogenous or* {7 K7 V: [6 ]& x# g- Z' B2 y, s  G
exogenous sources, nonpituitary gonadotropin stim-# p+ L, i9 a: }% N$ y
ulation, and rare activating mutations.3 Virilizing1 }8 _" `7 x; \0 @& `
congenital adrenal hyperplasia producing excessive+ \2 \# Q- z4 J+ P. X
adrenal androgens is a common cause of precocious
2 U2 Y1 z# @8 ^7 X+ D) b) ?* [. _* @puberty in boys.3,4
7 \( R0 E9 |* h" FThe most common form of congenital adrenal9 N  c& O' r" |9 N& m* ?* K% Q5 q
hyperplasia is the 21-hydroxylase enzyme deficiency.
  I6 f4 f0 C  g) dThe 11-β hydroxylase deficiency may also result in
7 z) K$ t6 X' p' [- K8 gexcessive adrenal androgen production, and rarely,: p$ H3 t/ G3 f! u. n0 x
an adrenal tumor may also cause adrenal androgen
8 H* o$ l4 T* O. \( D% {  ~# Iexcess.1,3; O: t7 L* @" @6 t) b% K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& [0 O- I& L" E  o
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 N/ b$ L1 ?- V4 S8 C& S- WA unique entity of male-limited gonadotropin-
, k2 ^! \- i& {& }( jindependent precocious puberty, which is also known/ U9 b0 n  q) N8 r* [' A$ r0 q
as testotoxicosis, may cause precocious puberty at a+ |) {/ a3 ~' b& j3 U; o
very young age. The physical findings in these boys- T2 x, C% a5 H6 M, I8 W
with this disorder are full pubertal development,
1 N. l; x! Y# b% R* v# Vincluding bilateral testicular growth, similar to boys
; i  x; U" \: K+ H3 a# e0 d: t- u+ Gwith CPP. The gonadotropin levels in this disorder& a1 H3 {6 e# ?! ]# }
are suppressed to prepubertal levels and do not show* Z" D: G$ o( N: b' S1 \8 t9 o
pubertal response of gonadotropin after gonadotropin-
& [  K! S& @+ N- k) B* creleasing hormone stimulation. This is a sex-linked
7 g- @5 z4 X4 e5 m7 E# F; V2 lautosomal dominant disorder that affects only
5 j  i- y, J7 ?! m% r9 zmales; therefore, other male members of the family. A( t- K4 H$ h, c  i$ s  _% l
may have similar precocious puberty.3% i* f/ i5 z) u* d2 L* Y. b
In our patient, physical examination was incon-
0 q5 G1 m# g4 N1 h- ~* P& i# ?+ [( vsistent with true precocious puberty since his testi-
4 _+ W/ m9 X7 j2 o( r0 A3 Bcles were prepubertal in size. However, testotoxicosis  }% N( ]) }, y( x
was in the differential diagnosis because his father
4 t" ^$ v- y, g2 w7 g7 ~! I7 @started puberty somewhat early, and occasionally,
; b! j- e* k, u+ j) t+ {$ ftesticular enlargement is not that evident in the
. |' u$ P+ m8 n, Wbeginning of this process.1 In the absence of a neg-
$ u7 r# M* s% bative initial history of androgen exposure, our- v7 |& }% x( R7 C# y3 E
biggest concern was virilizing adrenal hyperplasia,
* g1 l7 v; |9 ]4 x1 B' ^* _either 21-hydroxylase deficiency or 11-β hydroxylase
  Q5 ?8 F& p* f$ I3 Rdeficiency. Those diagnoses were excluded by find-
$ v. _9 I" ~& F, n- Ping the normal level of adrenal steroids.
( [% M1 Q8 `$ X( l6 u% `The diagnosis of exogenous androgens was strongly$ \. A6 y6 B  v( W: p3 l. y0 C2 @
suspected in a follow-up visit after 4 months because
4 ~; a. e4 P, O) ~the physical examination revealed the complete disap-9 \& y8 b  S: |6 I' \
pearance of pubic hair, normal growth velocity, and7 [: z, v: b5 M
decreased erections. The father admitted using a testos-* O  a* ~$ t1 n  H  u
terone gel, which he concealed at first visit. He was4 E* k, E+ v9 ]9 B5 |
using it rather frequently, twice a day. The Physicians’
, x5 I1 L# {) A/ r, s" ]4 ~Desk Reference, or package insert of this product, gel or& b6 u; e) _" {" l; d
cream, cautions about dermal testosterone transfer to6 @  {  l# Q* Q; q
unprotected females through direct skin exposure.
" o8 Y$ J9 E! U1 ESerum testosterone level was found to be 2 times the6 p2 T& h$ Z- M9 X7 v! j; \( F& O
baseline value in those females who were exposed to" o9 U6 u9 L) ^' }4 |* }* `
even 15 minutes of direct skin contact with their male9 T. }* O0 a4 d  I" \4 A. K9 T! Q
partners.6 However, when a shirt covered the applica-
- ]# u1 M0 K2 u8 Q2 ction site, this testosterone transfer was prevented.. c2 {8 o6 S  ], c& ^' c6 Z
Our patient’s testosterone level was 60 ng/mL,
2 p; o5 {) K- X+ z5 u$ Awhich was clearly high. Some studies suggest that
$ V& l4 W9 }% u  ?! A( ~dermal conversion of testosterone to dihydrotestos-
! X, J- _( }2 t4 V# }0 wterone, which is a more potent metabolite, is more& y* V9 ~1 d) ~1 F$ Y
active in young children exposed to testosterone- K; A. o: I( Q0 ?* W; n! x4 _3 c7 {
exogenously7; however, we did not measure a dihy-
! N/ L# E4 a2 }+ qdrotestosterone level in our patient. In addition to7 y  K2 n3 X+ z
virilization, exposure to exogenous testosterone in5 K; ^: e" Q0 Q, u% F& D# F0 f
children results in an increase in growth velocity and
' f1 X4 h; k6 x2 Cadvanced bone age, as seen in our patient.) @8 I( ?1 q; Q1 t4 l) Q4 O
The long-term effect of androgen exposure during
3 ?, Q6 j4 w% v2 Eearly childhood on pubertal development and final
; Y7 k' c5 e. Vadult height are not fully known and always remain
+ j$ o, v3 F$ j9 u6 H7 Ha concern. Children treated with short-term testos-
5 Q$ X+ r7 \6 [3 g4 H+ h6 Gterone injection or topical androgen may exhibit some& q) g1 p  y) w& U
acceleration of the skeletal maturation; however, after
, Q6 h2 S% C: E; y; Scessation of treatment, the rate of bone maturation
* o' l2 T: _3 n" a7 g  b) \decelerates and gradually returns to normal.8,9% b" L" T1 e! _4 K  [$ c. J  Z3 u
There are conflicting reports and controversy
+ @) T3 G3 h8 Q( `over the effect of early androgen exposure on adult6 ?- N, m; k6 X$ ~
penile length.10,11 Some reports suggest subnormal) I# P2 f0 O" p" ?  d( R, M
adult penile length, apparently because of downreg-
; J0 ?! I- E. R, t  r' Wulation of androgen receptor number.10,12 However,
' _* F; _: j$ c6 dSutherland et al13 did not find a correlation between. C! {2 S" e9 c
childhood testosterone exposure and reduced adult# z, f) [* T: \" A% w* u+ H
penile length in clinical studies.6 P, d5 I8 e7 P( v- a- x
Nonetheless, we do not believe our patient is( I' g' c9 Z$ W- c, x  [, E
going to experience any of the untoward effects from! a3 }; o! h4 t+ @9 ^3 s# {$ ?
testosterone exposure as mentioned earlier because
" L  G7 j0 ?. T. {. r1 w  kthe exposure was not for a prolonged period of time.
' w4 ]3 z+ ]2 sAlthough the bone age was advanced at the time of
: W. E) V) g9 n' b( D. z) Ndiagnosis, the child had a normal growth velocity at3 v1 K, P" P2 H" \0 W5 L" W% K" F* S5 h, y
the follow-up visit. It is hoped that his final adult, _8 z/ O' Z' s4 M, I4 `
height will not be affected.
7 Z4 w( S/ ?0 b; Y% `Although rarely reported, the widespread avail-% D7 q5 `5 q) ]/ m
ability of androgen products in our society may. y: i9 E& G' c. U! Y. V" D
indeed cause more virilization in male or female
+ X8 H3 S) }* L6 c) kchildren than one would realize. Exposure to andro-: t' D7 x' w7 t+ h+ j3 @" y  o
gen products must be considered and specific ques-; M8 A1 ~- |* P
tioning about the use of a testosterone product or
: C/ u, r$ A" e2 o6 C( w. I6 B4 Ugel should be asked of the family members during
0 {* h) A" [; W7 u  W! \the evaluation of any children who present with vir-
. {" Q/ o1 {* v! H& q/ e+ Nilization or peripheral precocious puberty. The diag-
4 n: F, d# Q* [nosis can be established by just a few tests and by
8 u. `: p: J- F9 Tappropriate history. The inability to obtain such a9 G! b; D# N0 y0 k& u' z! }
history, or failure to ask the specific questions, may$ B7 l! p. e' N1 N% {: Z' u
result in extensive, unnecessary, and expensive8 \, V3 r, s4 D6 q$ N; b. Z
investigation. The primary care physician should be
+ ~) f/ V& a2 y1 vaware of this fact, because most of these children
* V" E6 H1 s! v: p6 N% Tmay initially present in their practice. The Physicians’
' m: r. V3 {+ c& X, o$ O# ]/ ?$ _Desk Reference and package insert should also put a
( B; r0 P6 G0 w& B  v4 ewarning about the virilizing effect on a male or9 b& @0 f' g! a( Q" J
female child who might come in contact with some-/ b' O% p5 A) A' i- Y
one using any of these products./ J6 Q- D$ A% [3 S
References
( O" B% J6 c/ h* x1. Styne DM. The testes: disorder of sexual differentiation
  k( T# W2 Q# a, t7 Y7 Xand puberty in the male. In: Sperling MA, ed. Pediatric8 }3 X7 e4 [: j" G6 S. |5 f
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& X2 J, K2 D$ L# ~  P6 c2002: 565-628.( s( M7 E: j6 g
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 S5 u5 z$ \2 Q8 Opuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
! m) }3 d/ t% e' m: dBoy Induced by Indirect Topical
" V" q& D" b( fExposure to Testosterone
+ ?* P- @9 {# U( J5 R1 E4 vSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) |+ V1 R0 [; A4 w' z1 }1 h
and Kenneth R. Rettig, MD11 u; Q& ^8 s1 m+ |; t
Clinical Pediatrics: e1 V) i% F  u! w8 Z. u6 w: _7 m
Volume 46 Number 6
% F' `+ q8 N* i5 IJuly 2007 540-5439 z6 U$ X! \8 X) ^
© 2007 Sage Publications# ~! T1 R* W* }3 ]' P/ ~, o4 u
10.1177/0009922806296651
0 p! r5 W) C1 s) h# Ohttp://clp.sagepub.com
: d) v" [7 ^+ F5 Q- ]4 \+ y8 d& dhosted at
6 J3 _: q- g. l& g4 o- Z- W8 }http://online.sagepub.com
' T) k3 U* |- Q3 y9 SPrecocious puberty in boys, central or peripheral,
. e! x: t* m7 C6 W7 B  c( iis a significant concern for physicians. Central
' _. y6 P) U* L4 i  w. I- j2 kprecocious puberty (CPP), which is mediated9 ?7 t8 n' q" ~, q, h  \
through the hypothalamic pituitary gonadal axis, has+ G* \  i3 T: h* L7 T
a higher incidence of organic central nervous system2 H7 Q( I$ {. x: I6 p6 K4 @
lesions in boys.1,2 Virilization in boys, as manifested
: j4 J# i. H3 X$ U# j6 fby enlargement of the penis, development of pubic1 l, T% w9 r% B- T  g
hair, and facial acne without enlargement of testi-5 t! w) p# U( x0 i# r
cles, suggests peripheral or pseudopuberty.1-3 We3 w4 O" x- W9 K8 \
report a 16-month-old boy who presented with the
' J1 W# b+ e8 _" j! D  ^enlargement of the phallus and pubic hair develop-: Z  g1 d$ C8 _3 \$ \9 f# {7 ]. I
ment without testicular enlargement, which was due: x( I2 ?" d! _: G3 ?; K
to the unintentional exposure to androgen gel used by" a6 }. M4 B8 s9 G
the father. The family initially concealed this infor-& B1 ?' h, `: L
mation, resulting in an extensive work-up for this; ]1 q. ]9 Y; {3 K9 ^8 @
child. Given the widespread and easy availability of& l2 [' q& T' i0 S6 c; N
testosterone gel and cream, we believe this is proba-7 M/ c! k1 Q, [1 C! C+ {8 J2 Y
bly more common than the rare case report in the
# p* |; m+ m' \& B  j+ \literature.4  H; d' B6 f# C! C( J/ I( S$ m5 ?
Patient Report
4 M" R/ c' s, B+ \% A" @- b! R" QA 16-month-old white child was referred to the
) m2 {3 f  R- \3 sendocrine clinic by his pediatrician with the concern
- t3 P* O& m/ U) f- Sof early sexual development. His mother noticed- ]7 I+ n- F0 G, l% E7 Y
light colored pubic hair development when he was
9 H; E0 f; ^8 r; i: f3 g9 H/ Q: R* }  ZFrom the 1Division of Pediatric Endocrinology, 2University of
3 c4 x+ M1 J# u9 o  A/ c# [South Alabama Medical Center, Mobile, Alabama.+ A2 Z" j3 u- G: \3 ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' s( P) D' X% W% V3 uProfessor of Pediatrics, University of South Alabama, College of
4 y. l! W7 H) ]0 g/ R+ ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# I+ u, p7 A/ C# x6 be-mail: [email protected].& p: t' v4 d# u4 s7 V
about 6 to 7 months old, which progressively became5 w  C  F# C* |6 c1 E. T1 L+ K
darker. She was also concerned about the enlarge-
  `! l$ |9 Y0 P& Z2 h+ wment of his penis and frequent erections. The child3 B# f' Y* W( ^: P" ^& {
was the product of a full-term normal delivery, with  e& \/ ]; p9 ]( o5 f( K
a birth weight of 7 lb 14 oz, and birth length of
2 {7 f! C3 A# e1 z20 inches. He was breast-fed throughout the first year
; n% Q* N- @* h6 E% E0 e( Z1 ?; K; Xof life and was still receiving breast milk along with
. H- i0 n2 B, F: ?, R" z* asolid food. He had no hospitalizations or surgery,' {9 X6 |) y$ p' s! Q2 n
and his psychosocial and psychomotor development2 r. u/ _# ^* [) O, N, z2 [: N
was age appropriate.) R. M# X. K" I" i: l' l, ]: a
The family history was remarkable for the father,
# F: p6 a! m- [( Bwho was diagnosed with hypothyroidism at age 16,9 [# ]! o) {  d0 R& o! y9 k
which was treated with thyroxine. The father’s8 B! @0 _! o0 m  u* G
height was 6 feet, and he went through a somewhat
. d) ?/ w6 L7 E4 n- j5 vearly puberty and had stopped growing by age 14.6 f, K6 c- I8 t& S4 A6 u! A' F
The father denied taking any other medication. The" o4 ~4 Z: q5 w+ ~
child’s mother was in good health. Her menarche
- L& u3 ~0 V6 W7 U/ p/ z) Mwas at 11 years of age, and her height was at 5 feet" }" W# b2 a6 Z' e
5 inches. There was no other family history of pre-
1 i: V: @) G, E+ P# Kcocious sexual development in the first-degree rela-
2 U6 ^# k. i6 M, h1 H  Ztives. There were no siblings.. m2 ?; ^3 O; g1 d
Physical Examination& Y; V9 _3 A5 t8 D( j$ t
The physical examination revealed a very active,
# c' Y; s" q. ]  E/ q- kplayful, and healthy boy. The vital signs documented2 z" I4 O# K/ k( H5 D3 l
a blood pressure of 85/50 mm Hg, his length was% L% n/ _( ^, D% v* S* _& a
90 cm (>97th percentile), and his weight was 14.4 kg7 d7 Q4 Y- T8 T
(also >97th percentile). The observed yearly growth) @$ r% K- i& q4 _& q0 L- f
velocity was 30 cm (12 inches). The examination of- ~5 }- G. i- d2 Q2 [
the neck revealed no thyroid enlargement.- ~' Q# @8 ?* p( f' J
The genitourinary examination was remarkable for8 b: b; ]0 f* m0 @! d
enlargement of the penis, with a stretched length of& \  I4 d! a" I+ @
8 cm and a width of 2 cm. The glans penis was very well1 G2 k4 f3 B* `1 A& R5 A9 Z) m3 j
developed. The pubic hair was Tanner II, mostly around
, A  F. s6 l' o+ n540/ k3 z0 L2 a6 m7 ?& U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' ?4 E& R2 P* i0 ?( |the base of the phallus and was dark and curled. The8 x" x, f/ D/ U, l/ h" a
testicular volume was prepubertal at 2 mL each.
# ~0 j+ \" {+ z. g1 `: E  rThe skin was moist and smooth and somewhat4 e5 J; K& j2 r9 B
oily. No axillary hair was noted. There were no5 N9 X2 Y  \% r+ A1 Y
abnormal skin pigmentations or café-au-lait spots.  N; r# ~, P1 ?; r& q8 Y
Neurologic evaluation showed deep tendon reflex 2+
" a8 n& [" _4 I4 Y# jbilateral and symmetrical. There was no suggestion
; c8 k1 M0 `$ F* Q5 Y) R' d! ?of papilledema.( P  u6 E7 D+ p. q+ T
Laboratory Evaluation2 Q. B4 N1 t2 a9 Q4 f# R( K
The bone age was consistent with 28 months by
: ~2 [3 i8 {% V) v* }using the standard of Greulich and Pyle at a chrono-# w. T6 D8 Q+ r9 ]  ^1 I) L
logic age of 16 months (advanced).5 Chromosomal
1 w9 F2 y1 A. p/ H) Q' P2 q( l0 ~+ ]+ Akaryotype was 46XY. The thyroid function test; r6 u0 f/ j1 M  p$ L# t
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ ^% w; j. N% o; _& K% A2 H
lating hormone level was 1.3 µIU/mL (both normal).
: @: }* \2 a) E, H) k' \The concentrations of serum electrolytes, blood
+ m% q0 [% L* H/ turea nitrogen, creatinine, and calcium all were' ~( U$ ~# `2 [
within normal range for his age. The concentration
% f6 Q" d2 S" D+ I. E9 yof serum 17-hydroxyprogesterone was 16 ng/dL
- Y9 L' d$ s' E/ c  d(normal, 3 to 90 ng/dL), androstenedione was 20
, Q4 H+ I3 m- i6 }; ~9 zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 W9 C! b  Q& x1 K; V% wterone was 38 ng/dL (normal, 50 to 760 ng/dL),4 v8 v' Y) }! U& w! Q5 _3 ~. w3 @. i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ t4 c* j% L  G* b49ng/dL), 11-desoxycortisol (specific compound S)7 H: ]: Y+ E3 @. m5 G/ _1 S
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( W0 ~) Y! t1 W, H- M# D; A
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' x. Y3 o2 s  c: T  G. g8 [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 p* i/ g/ H& y  Fand β-human chorionic gonadotropin was less than3 b$ }4 U- }& d# u* I* ^, C
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ K1 u! ?) D( e/ d! P1 A+ t! O
stimulating hormone and leuteinizing hormone
' {+ U$ y! P' V4 |6 b, m4 w: Aconcentrations were less than 0.05 mIU/mL( G5 s% N0 B9 w1 T  C) ?$ q) G
(prepubertal).! r$ g& e" x# w, ~. H
The parents were notified about the laboratory5 \8 O# R1 V1 }  k$ P$ e
results and were informed that all of the tests were+ [( R5 G+ G) f# m2 O
normal except the testosterone level was high. The
/ Q) z2 O# s" R7 z( F* [7 p: M. Cfollow-up visit was arranged within a few weeks to/ h0 R/ w7 l) M" L
obtain testicular and abdominal sonograms; how-
: O" F5 v8 D" s) L3 x5 y2 |% }+ mever, the family did not return for 4 months.
9 p: g* H  E: o  F2 Q: A) n: PPhysical examination at this time revealed that the
7 Z& I6 J1 c( E* n& y3 O  mchild had grown 2.5 cm in 4 months and had gained
3 i9 E' \5 V6 L+ i2 kg of weight. Physical examination remained
5 y( o. x* H! U* g9 tunchanged. Surprisingly, the pubic hair almost com-
9 ^. I# D& s0 f- f2 T9 J# M' `pletely disappeared except for a few vellous hairs at' O9 b, W7 Z! C
the base of the phallus. Testicular volume was still 2" f7 \; l4 X/ O! G6 N( ~' h
mL, and the size of the penis remained unchanged.! ~3 J" g. R! I: F+ a2 X
The mother also said that the boy was no longer hav-
5 v8 o( {2 {7 O9 E; y- ming frequent erections.
. K" d6 u) J6 U# s( RBoth parents were again questioned about use of
) L: E( `: u0 J5 }. N6 i+ R- @, @any ointment/creams that they may have applied to
0 A9 ]& i8 p) W* Rthe child’s skin. This time the father admitted the
. ~7 p! {$ M7 |" C/ E  N, U4 hTopical Testosterone Exposure / Bhowmick et al 541
3 w$ ]6 w( W0 C3 U4 Puse of testosterone gel twice daily that he was apply-
' T2 a0 R$ [4 d' [ing over his own shoulders, chest, and back area for
, ~* B4 W7 L7 ?& z2 sa year. The father also revealed he was embarrassed% r' _& S' F- X! f7 o& ?
to disclose that he was using a testosterone gel pre-
% g/ U  E1 C( ^; ]2 R3 S4 k2 _' Fscribed by his family physician for decreased libido0 v& o" T- D+ |9 ]
secondary to depression.
9 a( W9 d: v! ?2 e- [5 gThe child slept in the same bed with parents.4 j  ]; a- _+ C0 w
The father would hug the baby and hold him on his
  C8 y) d  ?3 X/ n% O1 Mchest for a considerable period of time, causing sig-
0 i/ w* {* x& E0 C. o( M. G0 Nnificant bare skin contact between baby and father.' B! K- e% b9 b7 Z
The father also admitted that after the phone call,  U! L1 ^- S# \* H. n5 ~
when he learned the testosterone level in the baby% V4 `, t# l6 a) e
was high, he then read the product information
9 G4 I: Q( b. g0 o( Z; {8 qpacket and concluded that it was most likely the rea-3 Q% F" I4 n1 W/ A1 g
son for the child’s virilization. At that time, they
" C5 |( s- H, Z$ K% v4 \* A0 L- Ddecided to put the baby in a separate bed, and the
+ n6 O. w; }5 ?( i" s6 A$ g% kfather was not hugging him with bare skin and had
( Y+ h0 A! J7 d4 |been using protective clothing. A repeat testosterone
) h; N6 j8 C- ^3 _4 [2 P. Ktest was ordered, but the family did not go to the
& e$ }$ f) w4 Slaboratory to obtain the test.
; ^5 a- X) \& B: m  l: b4 SDiscussion
/ X$ X: t; O& b! H3 ]% G4 X' W" uPrecocious puberty in boys is defined as secondary0 ~' p3 m( x! K3 `6 _& L' q
sexual development before 9 years of age.1,4
. ~6 \: |7 A9 r+ yPrecocious puberty is termed as central (true) when
9 e7 Z3 Y8 g1 K- o5 g  cit is caused by the premature activation of hypo-7 j: q0 K8 B- }, R% C+ f
thalamic pituitary gonadal axis. CPP is more com-
1 r/ n% J% }6 P& X% l" Jmon in girls than in boys.1,3 Most boys with CPP
/ @4 X" o! `1 _# R3 bmay have a central nervous system lesion that is
) ^0 h) U0 l/ [1 T& Fresponsible for the early activation of the hypothal-0 F( z7 X8 @# Q3 ^, M
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ ~6 O4 a, u  e4 g" U. I- Fsis has been given to neuroradiologic imaging in
, q" ]7 W  ^  F/ t* U/ |+ S. G7 Wboys with precocious puberty. In addition to viril-
- H4 v6 I7 R1 l- @" T2 t3 ^ization, the clinical hallmark of CPP is the symmet-* J. R$ d' e: R, ~* Y: o2 Z
rical testicular growth secondary to stimulation by) }; g' i$ H$ Y
gonadotropins.1,3
$ J; ~0 D* K4 q- I$ Z& LGonadotropin-independent peripheral preco-
3 ]+ a" @0 y" y! F7 u3 i* g' {7 l: ucious puberty in boys also results from inappropriate
! n) W, p8 v6 N4 W: J% ^- f& `androgenic stimulation from either endogenous or1 B, I+ q9 f) l, O9 Q: C
exogenous sources, nonpituitary gonadotropin stim-, ~1 r0 {  k" N! |$ V. h! V$ j8 y
ulation, and rare activating mutations.3 Virilizing9 \" R' E( `0 g: r
congenital adrenal hyperplasia producing excessive: L( ?0 Q! M( [
adrenal androgens is a common cause of precocious
2 i8 v+ g4 C0 G1 u# n! n( E1 N% Lpuberty in boys.3,4, [/ }  o/ \+ h2 Q4 @, L
The most common form of congenital adrenal, X5 d% T: G' T  f' g( @4 v/ @
hyperplasia is the 21-hydroxylase enzyme deficiency.  I- B6 [$ E7 R$ e
The 11-β hydroxylase deficiency may also result in
3 ^5 ]# m$ y* Vexcessive adrenal androgen production, and rarely,
% e7 Y9 @! X* [8 E( Ban adrenal tumor may also cause adrenal androgen
2 C" c# `  w- R: U: o5 R- ~1 rexcess.1,3  [! E/ F2 b# u4 E: u8 h& C* [0 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) n$ d7 ~: t) D" L  J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( G$ X& N% F+ ~9 z# M* Q
A unique entity of male-limited gonadotropin-
& [! I& d. L2 F3 r2 tindependent precocious puberty, which is also known3 D( K4 E6 x, k7 V* L; w
as testotoxicosis, may cause precocious puberty at a
8 E+ x; Q! P8 avery young age. The physical findings in these boys
  A& \4 j1 b. \: X& C1 z; xwith this disorder are full pubertal development,
; g2 b; K6 F5 @# gincluding bilateral testicular growth, similar to boys
+ N2 U4 l/ u. z4 q* J: I0 Jwith CPP. The gonadotropin levels in this disorder/ s4 D2 c& w# Z' o$ p  H
are suppressed to prepubertal levels and do not show  o4 p% S. |3 K* U
pubertal response of gonadotropin after gonadotropin-# x9 @0 \  t1 R9 u/ x4 p/ _
releasing hormone stimulation. This is a sex-linked+ d* L$ \' Y5 V, y- p4 A. R
autosomal dominant disorder that affects only
5 t3 y' x; \/ Kmales; therefore, other male members of the family
9 A# @7 P4 j/ e- C5 P- k" B) O+ Smay have similar precocious puberty.34 g* T7 q& x" p: g! g) K
In our patient, physical examination was incon-& Q- F5 k9 q6 v+ [1 s
sistent with true precocious puberty since his testi-
' @' W9 [& n& `+ U$ @7 \cles were prepubertal in size. However, testotoxicosis
1 u% F( j" f8 J$ v9 R; y7 R4 kwas in the differential diagnosis because his father- ]+ N' x" W! o% l
started puberty somewhat early, and occasionally,
% S0 c' M* G! c* ftesticular enlargement is not that evident in the! O5 ~' C+ R( U2 @' ^
beginning of this process.1 In the absence of a neg-6 k3 \* A8 v  J; J2 ^1 f
ative initial history of androgen exposure, our
7 X" I% X) G$ ?4 U" Z% r. Ibiggest concern was virilizing adrenal hyperplasia,$ ^0 v4 d5 A% d' ?( D: u7 O: T
either 21-hydroxylase deficiency or 11-β hydroxylase
3 S0 ?: {: `0 Y( o8 }! Jdeficiency. Those diagnoses were excluded by find-8 L  h  K5 g! Z
ing the normal level of adrenal steroids.
" e, N7 E, S) o" Q! ]" H) v5 v: _0 {The diagnosis of exogenous androgens was strongly$ K5 X0 O8 W0 K- C# U
suspected in a follow-up visit after 4 months because
5 A: O3 ^* k' R+ G) r, G1 D1 vthe physical examination revealed the complete disap-
' u; e" V# @+ D  Q% t9 C5 b- n$ Epearance of pubic hair, normal growth velocity, and* ^7 X' }0 r5 i; x, O' _
decreased erections. The father admitted using a testos-
- M+ ?1 Z# j$ ~: L; m0 _terone gel, which he concealed at first visit. He was
3 l% v+ h  \4 ]6 k# S) rusing it rather frequently, twice a day. The Physicians’
8 R  q7 O1 a- _+ Q2 zDesk Reference, or package insert of this product, gel or
5 @$ w* ]: l0 a( u% wcream, cautions about dermal testosterone transfer to! z9 g' W6 K$ F, e5 @% o- h
unprotected females through direct skin exposure.% K: L- l3 x; L3 A1 g3 g
Serum testosterone level was found to be 2 times the
; i) m- R8 W) |$ }$ ^baseline value in those females who were exposed to- Z5 Q' g7 B9 n
even 15 minutes of direct skin contact with their male
6 _; t) o5 q- u5 B6 ~partners.6 However, when a shirt covered the applica-# _; @8 ?! m; S, r. ^- I( I0 f
tion site, this testosterone transfer was prevented.+ a5 s% ]# z. H9 I" I+ g
Our patient’s testosterone level was 60 ng/mL,
# V+ Z8 z- V( D, j% _  j: hwhich was clearly high. Some studies suggest that9 a2 X6 \" v8 d) }
dermal conversion of testosterone to dihydrotestos-& K- G1 V0 }0 X) \7 t; y
terone, which is a more potent metabolite, is more# W- F+ L3 y( n* B
active in young children exposed to testosterone% q! E  |' i. e+ K
exogenously7; however, we did not measure a dihy-
1 A) D) h: G! E+ V' v* B  e" Idrotestosterone level in our patient. In addition to! S9 j/ b+ u6 j6 l% B5 q" X
virilization, exposure to exogenous testosterone in! m- z- B1 s# q' c3 Y& T5 a
children results in an increase in growth velocity and
) f* ?0 C! L4 u6 }) |( L' sadvanced bone age, as seen in our patient.( _0 d: N3 [8 r4 y& n- Y! u
The long-term effect of androgen exposure during; a% u% V6 H5 H/ M# p
early childhood on pubertal development and final8 N1 r) H; x( H1 S" h: @+ _
adult height are not fully known and always remain
- E, Y3 N* |% Sa concern. Children treated with short-term testos-
6 ?8 g9 ~% a3 D1 u5 i: J0 |terone injection or topical androgen may exhibit some3 _+ d* F0 X# B! h3 m3 F
acceleration of the skeletal maturation; however, after: ^5 ~8 z/ b* D' n" y( V
cessation of treatment, the rate of bone maturation
6 T- P0 S# D/ X6 Kdecelerates and gradually returns to normal.8,9' b4 f" u+ j! T! a: m
There are conflicting reports and controversy; [) m4 v' P9 k1 K' Y
over the effect of early androgen exposure on adult
' \) R2 q  `& z+ O( S+ `penile length.10,11 Some reports suggest subnormal
# c# o2 D5 u0 Radult penile length, apparently because of downreg-
  m& F0 {7 @7 A* g' \ulation of androgen receptor number.10,12 However," t# ?3 k. H, m" d
Sutherland et al13 did not find a correlation between% {; F- M: ?( K$ u' M/ `
childhood testosterone exposure and reduced adult) H, C$ |4 u' K8 f+ S7 x
penile length in clinical studies." u$ i# q3 V6 p. s. k
Nonetheless, we do not believe our patient is
5 F& Z& F( y. ogoing to experience any of the untoward effects from
( `% `  A* h6 Q  j3 x) ?9 vtestosterone exposure as mentioned earlier because7 _: J- [6 g7 h% @  S
the exposure was not for a prolonged period of time.% x3 Z6 s; U+ z( y/ t' l/ r
Although the bone age was advanced at the time of
8 @5 P: n  ^4 k3 idiagnosis, the child had a normal growth velocity at4 c# B) y* `( g& w% q
the follow-up visit. It is hoped that his final adult- l6 _  q: N$ d
height will not be affected.
7 i# s* r$ P3 _) tAlthough rarely reported, the widespread avail-) U/ r/ h" l+ k1 W1 c6 h
ability of androgen products in our society may
* `7 H4 A0 Q( f, R- X% Aindeed cause more virilization in male or female
# p4 w7 \5 P0 g' ]* Z/ \children than one would realize. Exposure to andro-* L4 s8 U$ a# m8 E
gen products must be considered and specific ques-
. l  Y; r! K( p- Z9 z$ w; v& d; x* ftioning about the use of a testosterone product or
1 }8 P; m- k  H% s9 d& w9 pgel should be asked of the family members during0 g# J8 Y" h/ s' z
the evaluation of any children who present with vir-) L$ J, v+ \1 `7 K0 ]' U9 G# [6 V
ilization or peripheral precocious puberty. The diag-9 v% [, _( {% R, n8 L
nosis can be established by just a few tests and by+ V5 Z4 z, ^3 f, k
appropriate history. The inability to obtain such a$ D, x8 h3 o) ?& j* d
history, or failure to ask the specific questions, may
/ _  M3 f0 C, E" Y. n+ l$ b% m! M% Hresult in extensive, unnecessary, and expensive
3 F" d6 [' Y) y# W- i" }6 jinvestigation. The primary care physician should be) k# c. m5 R. ]0 _
aware of this fact, because most of these children
1 a  B8 g! C$ X4 ?# \+ G! tmay initially present in their practice. The Physicians’" Z! e) q8 o% ?3 w2 v$ ]
Desk Reference and package insert should also put a
$ ~! P* g# j5 S& B# o0 Zwarning about the virilizing effect on a male or
7 B- }9 f% |  w; h7 a$ v! ]female child who might come in contact with some-2 W# [) N! c9 j4 @6 k
one using any of these products.3 m& ?8 d+ {; c5 O3 w! N
References
/ J, O1 g# L4 {0 `1. Styne DM. The testes: disorder of sexual differentiation
5 R3 Y! ?6 h9 ?: F) uand puberty in the male. In: Sperling MA, ed. Pediatric7 ], {- ~0 L; ^6 a6 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;  ]2 \4 C4 E) B8 y3 G
2002: 565-628.  E5 N% e+ T2 y; Y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 k4 L; V' o& E$ Y8 \% mpuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

! [" p$ k6 o6 s3 z9 @% y$ o' f+ \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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