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Sexual Precocity in a 16-Month-Old
4 ?. s1 e( N: u+ M2 G2 i+ hBoy Induced by Indirect Topical/ J+ }* o$ o( K- S! x
Exposure to Testosterone+ w) x- E: M+ h$ o8 a% _8 o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( ^' }" D& F. h" `8 r' \
and Kenneth R. Rettig, MD1
9 i, t( j% V5 {Clinical Pediatrics; |0 B! Z) O" c% {4 X0 d- I/ p
Volume 46 Number 6
- N3 j. d* Y/ G9 B( o  I! H7 PJuly 2007 540-543
' h6 e$ z! |0 e1 ?, w: n© 2007 Sage Publications
8 _8 V( [+ b3 [7 U1 s10.1177/0009922806296651' F4 u2 @9 Z* J* A
http://clp.sagepub.com! }) o& d2 I- L% c1 e
hosted at- G, P+ h  E# T2 o. `; h
http://online.sagepub.com
7 S$ \: o$ {) E6 IPrecocious puberty in boys, central or peripheral,8 E# n2 I6 h( I# X$ w0 T: y
is a significant concern for physicians. Central; r# S  F7 O* I  m- k2 @
precocious puberty (CPP), which is mediated  |, a' ], T! h8 R  H9 v/ H2 \
through the hypothalamic pituitary gonadal axis, has
3 A1 j4 [  t" z  M5 w3 na higher incidence of organic central nervous system. u' ?3 L# \1 P+ ~) R) O: t
lesions in boys.1,2 Virilization in boys, as manifested
7 u+ |+ a) ~  Q5 O# S7 iby enlargement of the penis, development of pubic
; z, U9 p! F% r$ t0 T' Y, `4 M  xhair, and facial acne without enlargement of testi-0 g+ k' x1 H7 u( ~# m
cles, suggests peripheral or pseudopuberty.1-3 We
) `* \# h  X- K4 ^3 e3 {6 t, B& a2 @report a 16-month-old boy who presented with the
" x. a6 R, y& {) D7 N& Lenlargement of the phallus and pubic hair develop-# e& e; v  r+ H
ment without testicular enlargement, which was due
  J8 ]% c3 e; F$ s  U8 m! zto the unintentional exposure to androgen gel used by8 k, L" v5 Q5 {7 @: y7 j% S9 v
the father. The family initially concealed this infor-
" t7 x. ?# O+ _9 m) b7 Zmation, resulting in an extensive work-up for this
( r( o1 R4 \9 a+ T6 nchild. Given the widespread and easy availability of
" A. L9 A! Y9 [2 wtestosterone gel and cream, we believe this is proba-
8 w- A. l* O  t- p$ N7 g$ S% ~! T+ Tbly more common than the rare case report in the
' z  l' F; W/ G. Q9 t6 z6 d: uliterature.4
# l3 r, p. X* j5 t" l# M& ]& |/ r; ePatient Report7 s6 G" C8 u5 ~
A 16-month-old white child was referred to the
: T1 `; f& r* Z- h" Vendocrine clinic by his pediatrician with the concern2 w8 C- r, x, ~: |$ b
of early sexual development. His mother noticed
1 o5 L# X" O% Y$ P0 x8 V1 Y$ _0 D$ ilight colored pubic hair development when he was/ d. B6 k0 H& T; \: D7 n5 z
From the 1Division of Pediatric Endocrinology, 2University of# o/ v0 Z7 K4 {/ O' b$ Z
South Alabama Medical Center, Mobile, Alabama.
6 e( d6 ~' }; b4 g5 z  H7 z( mAddress correspondence to: Samar K. Bhowmick, MD, FACE,' l! H! e8 U; b- o; Q3 P
Professor of Pediatrics, University of South Alabama, College of
3 j) d7 f* n; \9 q& L* T+ YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' c$ k+ N0 Q& t
e-mail: [email protected].7 A  N  j! ]8 ^- b% g% }* C
about 6 to 7 months old, which progressively became0 b+ K. Z# x: X' d; i2 `
darker. She was also concerned about the enlarge-+ Y# S3 p. [+ O3 t: V  k( F! |
ment of his penis and frequent erections. The child& x4 d8 S8 ?- t& z, Y+ m) q9 c
was the product of a full-term normal delivery, with7 K3 V; A# Z/ E( G* U
a birth weight of 7 lb 14 oz, and birth length of- Y4 N9 \7 Y# r; E% j- a+ \, A8 C
20 inches. He was breast-fed throughout the first year# p3 v) U& k, O$ X7 r
of life and was still receiving breast milk along with6 a8 A- J8 |* v, _8 T- j
solid food. He had no hospitalizations or surgery,
- P4 ]+ v  L7 r0 Cand his psychosocial and psychomotor development9 V2 _. N+ A0 m
was age appropriate.
/ m) ^9 U1 |* pThe family history was remarkable for the father,
! A* h8 z+ t6 n7 |who was diagnosed with hypothyroidism at age 16,
9 e1 C8 p6 {/ b0 h4 gwhich was treated with thyroxine. The father’s4 N8 d  c! c8 q. H! E: v
height was 6 feet, and he went through a somewhat2 H) H! \5 \. `0 }! V3 G: ]
early puberty and had stopped growing by age 14.7 Z( U3 ^6 H- j% E4 [  Y
The father denied taking any other medication. The
6 n& i0 \  Z) ]) M! C% Gchild’s mother was in good health. Her menarche! {4 t0 [( `/ p" V0 y3 |% c0 x/ x
was at 11 years of age, and her height was at 5 feet
" F+ M* M6 e, W8 q3 t5 inches. There was no other family history of pre-; d9 W" A3 J& s) E9 a( |
cocious sexual development in the first-degree rela-; S9 }  j# `, h
tives. There were no siblings.
8 i% c/ G8 ~; w& X; l. tPhysical Examination
3 @" |, \( |# ?7 CThe physical examination revealed a very active,
. z( D$ S6 n9 B$ Oplayful, and healthy boy. The vital signs documented4 Z$ o8 e4 M- U2 N4 k0 f# z- q
a blood pressure of 85/50 mm Hg, his length was- U( _9 d- \3 ]% i/ V7 Q; G8 A* {
90 cm (>97th percentile), and his weight was 14.4 kg
% P" H! S8 c/ K) \/ u) T9 p(also >97th percentile). The observed yearly growth/ Z* r7 o& X' W$ P) _$ Z% c; ~
velocity was 30 cm (12 inches). The examination of+ W' A4 _/ M4 K  c8 p( C) I
the neck revealed no thyroid enlargement.
2 h& X# g9 y( ]- {$ VThe genitourinary examination was remarkable for
$ d8 k/ C. _7 ?9 w* B4 `$ lenlargement of the penis, with a stretched length of8 k/ R' `7 ?1 i, {. s9 Q" E, T( m7 r
8 cm and a width of 2 cm. The glans penis was very well
8 P* J" T1 n. G+ v, Zdeveloped. The pubic hair was Tanner II, mostly around" y* e% W" `; X
540
& S- P! R! y- n9 U4 V! l* W7 }- {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ U+ W4 J/ N9 z$ X! R
the base of the phallus and was dark and curled. The  C" W1 r+ d7 p# C& S  L
testicular volume was prepubertal at 2 mL each.  f4 ]. f1 n0 _
The skin was moist and smooth and somewhat; b' H2 `6 N" o( g* a" O* W
oily. No axillary hair was noted. There were no
# ]8 G) {: q4 s" _; x9 U1 rabnormal skin pigmentations or café-au-lait spots.
" F# \4 O, n( A8 JNeurologic evaluation showed deep tendon reflex 2+. Y* _+ u& s5 S, t
bilateral and symmetrical. There was no suggestion* f! p% f8 s  r0 _+ i
of papilledema.7 T( w  W+ I" u* j8 t+ x: b
Laboratory Evaluation. _4 l8 \( D* \' O" Z: y: P
The bone age was consistent with 28 months by7 P. }, H2 K3 Q4 j5 ^3 h/ U
using the standard of Greulich and Pyle at a chrono-
$ W7 H0 S( j2 @7 E6 w1 l$ ylogic age of 16 months (advanced).5 Chromosomal& f3 f7 M+ r- ]
karyotype was 46XY. The thyroid function test3 G, g0 _) N0 e, g$ |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! K2 K% F' L9 s# Z5 J. |2 ^% x4 W
lating hormone level was 1.3 µIU/mL (both normal).
8 k! @9 W4 H9 t" oThe concentrations of serum electrolytes, blood
) A# G1 D5 J7 Surea nitrogen, creatinine, and calcium all were
( R4 L) K1 k% Hwithin normal range for his age. The concentration
; U9 \7 t6 f! M4 C7 T; Vof serum 17-hydroxyprogesterone was 16 ng/dL3 E3 _$ S4 D- U/ G$ L1 ?* D/ Y2 b! w9 Y
(normal, 3 to 90 ng/dL), androstenedione was 205 w) F. Z  }/ z6 q4 D4 U; Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' G# w3 o, y4 p/ v- R, Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),; k$ C% F* A+ \* L: Y( M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' H% o! f% D' @( e9 O
49ng/dL), 11-desoxycortisol (specific compound S)
7 U# O- D% R. q. {& Twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 G' e) Y/ S- w4 [8 z6 C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 h9 M* A, \" l  j+ Z" M' o4 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ U( M& Y7 w8 {and β-human chorionic gonadotropin was less than5 t8 M' b* A/ O9 l* b+ x( f
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* l- p$ j& t! Y$ o! dstimulating hormone and leuteinizing hormone
4 L  \. ^: G! e$ |% \concentrations were less than 0.05 mIU/mL
* W5 L# m. d/ @* U7 c0 D# s(prepubertal).9 {' t& W5 U7 `* |: }6 P4 g; P9 X6 a
The parents were notified about the laboratory! n6 C' X- U! ~
results and were informed that all of the tests were0 ~2 c" L+ u+ ~" x1 v6 n: d/ g
normal except the testosterone level was high. The+ @  [$ Q* b! n4 r, v4 _
follow-up visit was arranged within a few weeks to
# w. I1 f$ Q) t+ P' Q4 A# `# Z, |obtain testicular and abdominal sonograms; how-
/ |9 r7 n. G0 kever, the family did not return for 4 months.' x$ G1 R$ R5 _" R  P
Physical examination at this time revealed that the
% b3 J# P& q# s* \5 Z! lchild had grown 2.5 cm in 4 months and had gained* e+ a  `+ A" Y+ V' p$ H0 u. W
2 kg of weight. Physical examination remained: s# l& `2 k# I( E
unchanged. Surprisingly, the pubic hair almost com-
" r% E5 G" T' C4 Ppletely disappeared except for a few vellous hairs at
- m* {  H$ M/ {9 Dthe base of the phallus. Testicular volume was still 2
1 [$ U. F  w. F( m1 Y6 ]" `* BmL, and the size of the penis remained unchanged.
& j# y8 [# i! t& _7 ?The mother also said that the boy was no longer hav-
' J) u' }: I( V; B# ^( [5 O! k! ring frequent erections.
  X& d! k, M- x5 z; CBoth parents were again questioned about use of* x9 Y7 k  ?1 J& p# d" d
any ointment/creams that they may have applied to
! I. K3 q/ j6 v( }% S$ D- _the child’s skin. This time the father admitted the
# w% r6 U& `  r0 K! L. |4 hTopical Testosterone Exposure / Bhowmick et al 5411 D; \! u0 s% Z$ s5 {6 ]
use of testosterone gel twice daily that he was apply-
9 i2 U1 V% g2 v7 xing over his own shoulders, chest, and back area for4 N# `) I9 n' I, [
a year. The father also revealed he was embarrassed4 V  g4 N% F! k) h: a
to disclose that he was using a testosterone gel pre-- g& L6 U, F( T  G) y" t
scribed by his family physician for decreased libido6 E1 y1 G4 s! x: `. H* f& k
secondary to depression., ?* b) }6 }. B
The child slept in the same bed with parents.
3 N( W2 U$ x$ Q( XThe father would hug the baby and hold him on his2 P. B8 p6 c/ z1 |1 E, g6 {+ J) O7 R
chest for a considerable period of time, causing sig-. ]/ h, C' O* Z  b4 p
nificant bare skin contact between baby and father.
6 ]. W1 Q' U% _. y- X# YThe father also admitted that after the phone call,
' l$ ^+ c; g1 e# C: M- Swhen he learned the testosterone level in the baby# o; W3 l0 Y% N6 M: W' J* M2 |. F" X
was high, he then read the product information; I! v( d! d: z, ]" k% Z
packet and concluded that it was most likely the rea-
- n. c; m! w% yson for the child’s virilization. At that time, they
% e: ]1 a! c4 s; @9 c. {" Zdecided to put the baby in a separate bed, and the
6 }! ^$ ~# l" ~; a- i* u3 Ffather was not hugging him with bare skin and had
2 p/ |4 o% |7 `' J3 bbeen using protective clothing. A repeat testosterone- W+ K% K" K6 w5 b; i% Y, r+ M+ V
test was ordered, but the family did not go to the
$ E) w. M+ h: M1 ~! B7 xlaboratory to obtain the test.
2 V  G" U" W: n$ E0 |Discussion+ L5 T+ g# V  ^* P. Q# j
Precocious puberty in boys is defined as secondary
' [7 W9 \  N8 Usexual development before 9 years of age.1,4
: q5 p8 q+ A3 |- |0 I6 J0 A3 F4 DPrecocious puberty is termed as central (true) when
$ W3 l" U) C0 Iit is caused by the premature activation of hypo-
+ f+ }! j# z2 \% ~2 J# Vthalamic pituitary gonadal axis. CPP is more com-
) i3 m2 ]- s2 O; p& v9 L, D0 {mon in girls than in boys.1,3 Most boys with CPP
, D$ E1 @" K6 J( I; Ymay have a central nervous system lesion that is1 @5 D. F( z( D& D; j* q
responsible for the early activation of the hypothal-
9 t- h% k; ~8 Camic pituitary gonadal axis.1-3 Thus, greater empha-- W- C9 o& x- s( z6 t/ F- ]8 X
sis has been given to neuroradiologic imaging in
! P, ~( t2 O9 a. O6 {/ R6 uboys with precocious puberty. In addition to viril-' R# F+ p1 Y4 j# L7 `8 F9 ?0 m- a
ization, the clinical hallmark of CPP is the symmet-4 u4 a2 @" s5 [" U! O1 _
rical testicular growth secondary to stimulation by  I5 c2 D3 o4 h, [% S, B. I
gonadotropins.1,3
/ h6 P) c: C) U  d- jGonadotropin-independent peripheral preco-# a% H6 D: o9 P% ?$ [" M% a
cious puberty in boys also results from inappropriate' C% F8 O: @) A. e0 E
androgenic stimulation from either endogenous or
+ d2 A+ ?1 S0 o5 o$ Qexogenous sources, nonpituitary gonadotropin stim-
1 X& ]8 ]1 f1 V  A: V7 Z5 o' Zulation, and rare activating mutations.3 Virilizing
& s! s+ u, x- Qcongenital adrenal hyperplasia producing excessive$ ~$ ?0 ~6 L/ E1 [( w: `
adrenal androgens is a common cause of precocious
1 R) q% k& G9 t( k+ }- ?  p2 rpuberty in boys.3,4  R6 x+ Z7 n( X9 \' _: _3 w) _
The most common form of congenital adrenal
9 n6 p6 E( M7 u  d- ~, Qhyperplasia is the 21-hydroxylase enzyme deficiency.
$ s$ p3 y+ i8 I6 k3 @6 b4 U/ cThe 11-β hydroxylase deficiency may also result in
2 T  j/ _1 ]' `excessive adrenal androgen production, and rarely,# `" W: B5 {! T) o" S! X" m* t1 ?
an adrenal tumor may also cause adrenal androgen: Z) ^! B  }$ p
excess.1,31 _. u; V  v- Q' h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 H3 I% T! e: G7 `# B: h: [. [) T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: ?$ w6 D; P9 W( T$ RA unique entity of male-limited gonadotropin-: W( ^; D  K" a: G
independent precocious puberty, which is also known
3 J, L8 H/ Z5 Q8 Y3 Uas testotoxicosis, may cause precocious puberty at a$ p$ y" }4 z2 r; F( ]
very young age. The physical findings in these boys3 D+ N4 M+ d% u2 z" k
with this disorder are full pubertal development,4 j* c2 ]2 N$ |  {' S% R
including bilateral testicular growth, similar to boys
- ^) P' g$ V# f" |' ~' Uwith CPP. The gonadotropin levels in this disorder! W6 u$ p* B* ?) A
are suppressed to prepubertal levels and do not show
- x: q0 ?  U* S7 k: j2 C3 gpubertal response of gonadotropin after gonadotropin-
( B4 @! H8 z: W$ C* U1 o7 mreleasing hormone stimulation. This is a sex-linked
: r: R9 a5 @( U" z; ]. K  `5 |autosomal dominant disorder that affects only* F7 F& p8 p; O, s
males; therefore, other male members of the family
# _, D% _0 L  amay have similar precocious puberty.3
) }& L& `$ }6 J/ kIn our patient, physical examination was incon-- n5 S$ T8 `$ D
sistent with true precocious puberty since his testi-
0 m: E: c, T3 ^" F/ n- C& H& C) @cles were prepubertal in size. However, testotoxicosis+ g6 A( H  B" i! U8 x
was in the differential diagnosis because his father
+ R3 z9 y6 O+ h: T$ Cstarted puberty somewhat early, and occasionally,$ ]! P: d' a7 W2 F+ `
testicular enlargement is not that evident in the
3 i, s3 F. B- I6 rbeginning of this process.1 In the absence of a neg-4 X0 o8 ^# n: r, M! N; @* ~
ative initial history of androgen exposure, our. H1 U4 S. g0 u+ ~  X, u* R" S
biggest concern was virilizing adrenal hyperplasia,; J( F( U6 n+ t6 G1 i" W
either 21-hydroxylase deficiency or 11-β hydroxylase
. z" L1 F% q1 ?0 b3 Rdeficiency. Those diagnoses were excluded by find-8 {. }7 T5 k0 F: E
ing the normal level of adrenal steroids.7 D9 d! L& r3 z4 [: D" t5 Y
The diagnosis of exogenous androgens was strongly
; s; e; F. N& m; esuspected in a follow-up visit after 4 months because
3 N# W# b" |* I2 U2 Y3 u$ W4 {the physical examination revealed the complete disap-
, f% H) a" o/ z, w( Spearance of pubic hair, normal growth velocity, and
! [1 x, t2 U, z) m9 ~decreased erections. The father admitted using a testos-: g/ P: m, x4 h1 p; [, |4 X
terone gel, which he concealed at first visit. He was# U$ k$ I! t5 H& h. o
using it rather frequently, twice a day. The Physicians’1 Y* e* y$ E7 |
Desk Reference, or package insert of this product, gel or
9 _( G& V7 P! q- |$ k6 ycream, cautions about dermal testosterone transfer to
% r, e. X7 ~9 Lunprotected females through direct skin exposure.2 t+ l0 s2 d+ |. A" m8 Q+ F  Q
Serum testosterone level was found to be 2 times the  I/ H0 `6 G$ g6 t
baseline value in those females who were exposed to2 s9 _0 u/ a. L) y  q" v9 G
even 15 minutes of direct skin contact with their male
) a, k8 \, B7 k  Apartners.6 However, when a shirt covered the applica-
( d) p: ~/ _# V; J- qtion site, this testosterone transfer was prevented.: I7 [) Z7 l( j, g3 i0 O: b& }/ R
Our patient’s testosterone level was 60 ng/mL,% a3 ]# f( X, b, b3 c
which was clearly high. Some studies suggest that
! Y" e  z( Z: q0 h( Pdermal conversion of testosterone to dihydrotestos-; T: W7 i7 D+ U1 E, K$ H) C
terone, which is a more potent metabolite, is more
/ c4 K, [' S0 \% j" O/ p% ?& g8 b0 I5 Nactive in young children exposed to testosterone: z- N& ^, b( a- {9 ~
exogenously7; however, we did not measure a dihy-1 ^/ B0 _5 x4 v7 D' e" c
drotestosterone level in our patient. In addition to; x: N' ]0 X6 H5 R* n6 f
virilization, exposure to exogenous testosterone in
3 G7 q# z7 t) ]" R- Vchildren results in an increase in growth velocity and
+ s0 m; D# [3 }7 n( Padvanced bone age, as seen in our patient.
( }- [4 }$ ^- ^. ~5 JThe long-term effect of androgen exposure during7 u$ k% G' B! a) Y( |* G, I
early childhood on pubertal development and final
2 R- T! W2 y# Z; e+ C: Jadult height are not fully known and always remain' v% U$ U" \( k1 e1 V0 ?4 P- l4 f
a concern. Children treated with short-term testos-  c: J% X9 q+ z9 q  B/ w; D
terone injection or topical androgen may exhibit some, I4 G. s4 e  d, d8 V6 _" D
acceleration of the skeletal maturation; however, after$ Z& A' t+ i0 N, B$ [$ |$ C
cessation of treatment, the rate of bone maturation
$ }! ]$ I0 ?8 S$ ldecelerates and gradually returns to normal.8,94 I3 m7 X+ \4 P7 S6 _6 j$ u
There are conflicting reports and controversy
0 F1 h6 _& l' {$ K- v5 n, M& Z5 xover the effect of early androgen exposure on adult0 K8 l( A, H# C5 d6 G
penile length.10,11 Some reports suggest subnormal% V: @' p+ t9 Z' d# X
adult penile length, apparently because of downreg-
& t9 U# f1 P5 K' H6 C) qulation of androgen receptor number.10,12 However,: [% ]: l1 P% l
Sutherland et al13 did not find a correlation between
8 n1 I0 B# B: w$ t; ?1 ]) t4 ^  zchildhood testosterone exposure and reduced adult
7 m. _; n3 D/ J; Qpenile length in clinical studies.
( U2 o2 u' L  kNonetheless, we do not believe our patient is
. c# v& ]( l- U; s  M( v& G4 v1 Sgoing to experience any of the untoward effects from
( i' R% h# P4 K: G' |testosterone exposure as mentioned earlier because; C3 W; T) b% i" E7 t  W2 _( Z% b
the exposure was not for a prolonged period of time.
) S  S$ \9 w  p% fAlthough the bone age was advanced at the time of$ B) J( X/ H8 k# W
diagnosis, the child had a normal growth velocity at
. _* k6 c% U' athe follow-up visit. It is hoped that his final adult
* ?* a7 Z" l7 b. i% i! Q7 Theight will not be affected.
" k8 i) x4 A8 E: o5 s4 NAlthough rarely reported, the widespread avail-1 H1 H; K) _0 r5 b
ability of androgen products in our society may4 R! B1 e' }: r% A5 q
indeed cause more virilization in male or female( K$ B8 {+ T* c# W2 t
children than one would realize. Exposure to andro-9 x+ ^! o/ E) m5 I& g5 n" x/ ^
gen products must be considered and specific ques-
$ W# w0 I! i' ationing about the use of a testosterone product or, Y2 a5 R; K# H  J+ m1 N7 y: I
gel should be asked of the family members during
# e+ O  D. T0 E! Y  Y: e2 j1 ^. R6 Ythe evaluation of any children who present with vir-/ q9 s2 M. z! O# K/ s$ T4 P% c' M
ilization or peripheral precocious puberty. The diag-5 F/ K" o6 m: @/ n) O
nosis can be established by just a few tests and by
+ |" \( W4 F% X6 z8 y1 }  t* A) T! xappropriate history. The inability to obtain such a8 l2 P5 _7 L1 E! C3 i. N1 q
history, or failure to ask the specific questions, may
9 L! }+ N! n4 K4 t( @6 Xresult in extensive, unnecessary, and expensive1 y! n" T' j+ p; V! J* g
investigation. The primary care physician should be6 P' r) R) k" u) e$ i
aware of this fact, because most of these children
- p- m* V) a: |may initially present in their practice. The Physicians’0 F# W) c8 T, r  ~, Y! l0 h
Desk Reference and package insert should also put a& E, k$ v- N/ S! P" B2 N, W  }1 }
warning about the virilizing effect on a male or; T3 j# B1 M' k# X3 P" G$ \* L9 {8 g
female child who might come in contact with some-$ P1 |( a* o: L# y5 K
one using any of these products.
9 P( `! ]! |7 ZReferences0 l7 S- C2 ^- w, A
1. Styne DM. The testes: disorder of sexual differentiation
- ]: c  {1 ^/ h) p7 b; W! c0 t3 land puberty in the male. In: Sperling MA, ed. Pediatric
4 `. t( k) K' l& x( I- aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 T# _9 \7 B5 Y9 I  o2002: 565-628.
5 E+ K0 v& Q+ `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 h& M# ~% Y$ x1 ]0 Q
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
' C. j2 e# M( p( P1 v& B0 B2 |  b* OBoy Induced by Indirect Topical% t6 {9 \/ g8 Z
Exposure to Testosterone( _; @' A3 }% l( [- h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" _6 J9 j* V+ cand Kenneth R. Rettig, MD1+ U2 w! N4 N6 ~, h
Clinical Pediatrics
, K6 i) x5 }. \' c+ DVolume 46 Number 6
3 m6 p, a, V/ H% nJuly 2007 540-543
( v7 A, K% k0 T© 2007 Sage Publications/ D- J: u  V! O) y; J" {
10.1177/0009922806296651; t3 P& G+ w% o3 P
http://clp.sagepub.com
5 b0 q6 R$ A+ f3 ^6 hhosted at
. G2 i( |) y' |. w. N7 _8 o2 \& f$ thttp://online.sagepub.com/ n* S4 N/ ?9 |2 o0 |
Precocious puberty in boys, central or peripheral,8 u5 ]; ?4 ~" n, g3 @6 I
is a significant concern for physicians. Central8 d- x3 \' f7 k4 @$ s/ G: X3 V7 c
precocious puberty (CPP), which is mediated
# X5 \+ O! a: Pthrough the hypothalamic pituitary gonadal axis, has
$ I3 r7 S( m( h( B1 ^( |a higher incidence of organic central nervous system
! |, |+ D( |0 llesions in boys.1,2 Virilization in boys, as manifested
  J8 m9 q$ d) L$ v7 x# }0 i0 vby enlargement of the penis, development of pubic4 E6 `+ [( K% P$ I' J: k! w: S3 X
hair, and facial acne without enlargement of testi-
/ l0 b' l7 A; F4 tcles, suggests peripheral or pseudopuberty.1-3 We+ o+ o  m: Y2 c- \6 g
report a 16-month-old boy who presented with the$ W8 b3 x1 c2 C( }7 A
enlargement of the phallus and pubic hair develop-, Q! |6 y; s/ L1 S2 W
ment without testicular enlargement, which was due
# z9 p7 ~; }9 Y' r. H+ f: \6 Mto the unintentional exposure to androgen gel used by
: P6 Q- ?1 d/ D$ V8 u  _% S9 Ythe father. The family initially concealed this infor-1 ?" G5 J4 f. Q6 f6 j2 K5 S3 D
mation, resulting in an extensive work-up for this
1 \1 U7 l& m* k2 C5 i0 u# dchild. Given the widespread and easy availability of! l: R, W" G0 a% O5 x4 N* S1 m- f
testosterone gel and cream, we believe this is proba-
$ X; K0 m- Y6 w- jbly more common than the rare case report in the
$ Q" J: e+ Q9 g) l/ B5 [" S' Gliterature.48 s7 ^" J$ V0 x" ^: a5 ~! K) A  j
Patient Report- D1 \/ L! Z0 N2 g, q
A 16-month-old white child was referred to the/ ~( g) a; D& U" h9 c
endocrine clinic by his pediatrician with the concern
2 \& {# ]* D& p9 R1 \of early sexual development. His mother noticed( E" q# h' Z3 {2 B3 h: z: B# ^
light colored pubic hair development when he was3 F* P/ Z. J. p6 l
From the 1Division of Pediatric Endocrinology, 2University of
+ x7 q! V7 E" T* OSouth Alabama Medical Center, Mobile, Alabama." H1 x' L4 |/ {' K' Y) J
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 o( M1 R5 _8 m  S6 IProfessor of Pediatrics, University of South Alabama, College of# n! T/ ?9 }; f) G* u( Y: {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  w# c. |: J! de-mail: [email protected].
2 d1 h% h" J4 ]# A& u9 G! Xabout 6 to 7 months old, which progressively became
# K- G+ j3 G' w$ u4 B7 W" ~darker. She was also concerned about the enlarge-% A4 X+ G; ~$ V4 d' u
ment of his penis and frequent erections. The child
( }+ A, P3 o! o; E: M& k: Qwas the product of a full-term normal delivery, with1 p# }- k$ j, I* K( J8 a
a birth weight of 7 lb 14 oz, and birth length of, B# F7 g2 r8 {
20 inches. He was breast-fed throughout the first year
5 g5 T; T2 h3 Y1 ]& W3 ^of life and was still receiving breast milk along with
5 Z; @+ q7 B. s4 P9 l- _. t2 nsolid food. He had no hospitalizations or surgery,
4 U1 O  n8 i- v% Nand his psychosocial and psychomotor development6 e$ t( E1 K0 G# m6 E2 x- J- M
was age appropriate.
+ ~& Q% U1 {( S# SThe family history was remarkable for the father,
2 M7 e0 c( {) r  m! nwho was diagnosed with hypothyroidism at age 16,( a& G6 o+ k( l2 J7 A
which was treated with thyroxine. The father’s
' h7 n; F! y  a* Z& d" q$ D! S0 d7 s0 \' Lheight was 6 feet, and he went through a somewhat1 e4 Q0 U, m0 |
early puberty and had stopped growing by age 14.# r* r+ t3 L7 q/ U
The father denied taking any other medication. The
+ v" }; Q& z$ x- fchild’s mother was in good health. Her menarche! ^; T, o, f- y6 t. v2 w
was at 11 years of age, and her height was at 5 feet1 |* ~5 d$ X. D  i+ I1 k2 R0 N
5 inches. There was no other family history of pre-
! u( b5 i0 v5 z' `) _' J9 }2 D" @" h! ycocious sexual development in the first-degree rela-
; K/ E% d) E" j. ltives. There were no siblings.
/ W& i% S7 |, W7 B4 P" X: f& QPhysical Examination
& F! _$ h8 Z/ \( h! _; _( r  TThe physical examination revealed a very active,
) z, j7 P. o3 x* J- jplayful, and healthy boy. The vital signs documented' D% h" j) p. P; D8 Y# N+ _
a blood pressure of 85/50 mm Hg, his length was
2 O6 J( H- ^3 k) {1 d7 Y* n90 cm (>97th percentile), and his weight was 14.4 kg
$ p! c  ~. @* m- i* ?( G(also >97th percentile). The observed yearly growth
1 Z* v8 p+ Q% Lvelocity was 30 cm (12 inches). The examination of
1 ?2 P/ }; g6 Y) I0 zthe neck revealed no thyroid enlargement.1 g( [3 Z$ i2 T6 d1 {' T. W
The genitourinary examination was remarkable for
/ ~' a  _2 e; [6 H- C$ X0 Y. y0 eenlargement of the penis, with a stretched length of
' T. R: i9 t- @; i; M0 P1 c8 cm and a width of 2 cm. The glans penis was very well
' n  C1 I* {7 C! H" K; V& ldeveloped. The pubic hair was Tanner II, mostly around
% o) h9 ?* k2 X; `6 @  e/ {) q540) D* E8 L& x" O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# c" D0 R6 R3 j) A9 ~& k
the base of the phallus and was dark and curled. The0 z8 u3 _/ S% d; l4 }- y
testicular volume was prepubertal at 2 mL each.
% X& u3 C$ m% iThe skin was moist and smooth and somewhat
% |; Z: X2 k( S) qoily. No axillary hair was noted. There were no
5 q; E; }5 [3 V  |+ W, Q% qabnormal skin pigmentations or café-au-lait spots.
7 I2 F7 T* w% f( j3 V7 ZNeurologic evaluation showed deep tendon reflex 2+
) T+ ^' Z1 e4 R* e% mbilateral and symmetrical. There was no suggestion" ~3 _- @+ X4 u' `: E5 q4 k4 J
of papilledema.- O) H- A5 o1 A2 n- U( r: u
Laboratory Evaluation
  l' C4 B9 K8 ^# gThe bone age was consistent with 28 months by" [, {8 v9 v, _. P
using the standard of Greulich and Pyle at a chrono-
7 q* q( U/ v- ^4 A+ Flogic age of 16 months (advanced).5 Chromosomal
) T8 \9 a6 f1 z( z+ K) t5 \  N4 u9 hkaryotype was 46XY. The thyroid function test
- U$ c9 R  Q. M8 Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
  H, y* `% p; c* \- `+ alating hormone level was 1.3 µIU/mL (both normal).5 Z4 D% @. x" D2 ?( O4 W
The concentrations of serum electrolytes, blood/ ~, x3 {' X4 ]/ B; d* N' i
urea nitrogen, creatinine, and calcium all were
0 M% C6 t/ w. p6 c' Z, `% d' m7 jwithin normal range for his age. The concentration7 D# u% |+ w! X" m
of serum 17-hydroxyprogesterone was 16 ng/dL* q  ^/ ]& L/ }8 r% b. q* J
(normal, 3 to 90 ng/dL), androstenedione was 20
- n6 u9 S. Z# j& b$ q1 ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ C1 r: u( {, y/ @  vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ A) c) k1 S9 m& Y  r! tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" A# C$ D$ g5 C3 D& j! o+ b
49ng/dL), 11-desoxycortisol (specific compound S)
$ @7 s2 P- b: D- Twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) h9 X. I; n! F: X/ z) ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- B$ r! V2 i' h1 Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL)," f% o3 Y: t; ?0 A0 b0 S! `" R
and β-human chorionic gonadotropin was less than
) s. K' v7 N% ~  T8 }  u% ]0 K5 ?5 S5 mIU/mL (normal <5 mIU/mL). Serum follicular& S6 M4 f6 b$ x6 p/ f( }  b
stimulating hormone and leuteinizing hormone' c4 D; T, P2 q# h6 q2 Y. J; q7 V
concentrations were less than 0.05 mIU/mL9 X8 k% g* U+ [) ^. ~
(prepubertal).
% c. D9 Z1 R. ~" q. z- iThe parents were notified about the laboratory+ M, T; i/ O  \. g
results and were informed that all of the tests were
/ o9 e- X8 A5 p4 d6 Y; u6 e! g9 qnormal except the testosterone level was high. The6 \/ N4 L3 M3 S
follow-up visit was arranged within a few weeks to
8 C/ X) `* n/ L% ~obtain testicular and abdominal sonograms; how-
6 @4 v( s& |2 J9 u( r9 ^0 Bever, the family did not return for 4 months.3 x- b' c- [9 y" ]% `; V* _
Physical examination at this time revealed that the) L1 q* L! b4 s7 ]: n0 G  V
child had grown 2.5 cm in 4 months and had gained& a# V( M% T, g- v8 k) B
2 kg of weight. Physical examination remained5 a" h/ H7 g* |8 z
unchanged. Surprisingly, the pubic hair almost com-
( G* R" v# r; h! Fpletely disappeared except for a few vellous hairs at5 M' u7 O1 e+ A; m' a
the base of the phallus. Testicular volume was still 2
2 x1 \; v5 y2 \7 s" OmL, and the size of the penis remained unchanged.
6 a1 z* v( k, y2 S) rThe mother also said that the boy was no longer hav-
1 S( l  A3 d5 C$ _ing frequent erections.  J# Q, F9 B+ b; `6 ]9 N3 V
Both parents were again questioned about use of
1 G& J% ]; U+ A( u( Oany ointment/creams that they may have applied to
8 p) j( B; w3 U6 e  T$ E0 N) Ithe child’s skin. This time the father admitted the. |- i1 O2 P8 s5 x
Topical Testosterone Exposure / Bhowmick et al 541. M5 G9 O. n( H/ l- K3 s( L
use of testosterone gel twice daily that he was apply-
/ k( a8 c3 c4 q1 [ing over his own shoulders, chest, and back area for5 ^' |. X: a  R/ W6 @1 p% l% e3 i
a year. The father also revealed he was embarrassed0 u) M- k: D2 X( Z* |1 I
to disclose that he was using a testosterone gel pre-
4 ^3 T8 c4 ~- E* a$ w. @7 x( Yscribed by his family physician for decreased libido
9 n) V1 F4 }& esecondary to depression.$ L3 K" {3 M  b1 L2 t9 L0 y3 n
The child slept in the same bed with parents.
7 J( S; G7 H  TThe father would hug the baby and hold him on his
# o6 w* W5 C- U8 m$ t" pchest for a considerable period of time, causing sig-4 a3 y/ P# d3 {3 r' F
nificant bare skin contact between baby and father.
$ Y) y( V, j; RThe father also admitted that after the phone call,- k" w3 @( S6 a: {) q' C; S" Y+ x
when he learned the testosterone level in the baby
# G0 s) X+ X# c  i8 M. rwas high, he then read the product information$ J6 l! G8 L- q
packet and concluded that it was most likely the rea-: ^% l  c8 O  z
son for the child’s virilization. At that time, they; ^) e8 |/ V) ?& |- C
decided to put the baby in a separate bed, and the8 M) Z2 ^# ^6 w4 y
father was not hugging him with bare skin and had
: U4 K6 Q. \  M$ s1 L1 x" {. ubeen using protective clothing. A repeat testosterone
4 _& U$ ^! f! e( Z; {test was ordered, but the family did not go to the: H  B! S! \; G" o7 c* J
laboratory to obtain the test.' I: ~  a# h1 p
Discussion" E+ @3 o# H& _6 E( g
Precocious puberty in boys is defined as secondary( e% `2 h, L5 ]
sexual development before 9 years of age.1,48 g" k6 m7 ?9 |  d$ ~& U0 a* ?5 k
Precocious puberty is termed as central (true) when
: \! J/ o, l9 E) }) x8 Wit is caused by the premature activation of hypo-
9 W2 t8 B. ]) ?5 T: jthalamic pituitary gonadal axis. CPP is more com-
% _9 c3 a0 ^% f4 u4 B2 Lmon in girls than in boys.1,3 Most boys with CPP
# ~2 o6 M& H3 _8 X  A" lmay have a central nervous system lesion that is
1 s, q5 _$ C1 y4 ^) i& wresponsible for the early activation of the hypothal-
$ d$ a) {  s- p/ Q- g* O! kamic pituitary gonadal axis.1-3 Thus, greater empha-/ S  W" }" T' @- `8 C; m
sis has been given to neuroradiologic imaging in  @5 i7 j6 v0 L- T# P
boys with precocious puberty. In addition to viril-( m# ?* J) s: A3 W9 v. I: i
ization, the clinical hallmark of CPP is the symmet-0 g- x* t8 u2 B6 {9 N! Q
rical testicular growth secondary to stimulation by
: n; c8 H7 ?0 j* S! N5 Tgonadotropins.1,35 A* @7 s. d9 l4 K/ E4 t) ~! i
Gonadotropin-independent peripheral preco-
  r% Q# I$ X" i" f" a' E+ X/ e5 ]$ p% Wcious puberty in boys also results from inappropriate- \) I, d6 ?5 s( k
androgenic stimulation from either endogenous or
6 u% J/ u/ m! l! f0 }exogenous sources, nonpituitary gonadotropin stim-
# c8 H6 D4 j' \8 pulation, and rare activating mutations.3 Virilizing+ G! t) W, O8 L3 I7 h
congenital adrenal hyperplasia producing excessive
8 }$ J& l7 N4 k& ^$ [1 F' `adrenal androgens is a common cause of precocious- _* b/ l' Z- s+ B$ V, Z
puberty in boys.3,4; G. b! U7 I& m1 }8 e
The most common form of congenital adrenal/ S$ d9 ]- @" Z( \: Q6 ^
hyperplasia is the 21-hydroxylase enzyme deficiency.
. Z; _/ `7 O  M- G. jThe 11-β hydroxylase deficiency may also result in
+ a! C; V7 F3 M) t0 k- T: Q% Zexcessive adrenal androgen production, and rarely,
+ z  u7 r  c  S, nan adrenal tumor may also cause adrenal androgen2 T1 I: Y) M4 q  v8 F$ Y+ S
excess.1,3+ o1 p/ ~$ _4 L7 P9 p  n, J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) i  T/ r: u3 ~  `
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ K! o; l+ h% @) h/ r
A unique entity of male-limited gonadotropin-
9 |& n3 _8 r! d/ j# |; Y! lindependent precocious puberty, which is also known
- n5 Z9 v6 T: k/ Oas testotoxicosis, may cause precocious puberty at a. Z$ W7 ^, T% Y  b
very young age. The physical findings in these boys  @8 I; O4 _3 m6 T" q  N
with this disorder are full pubertal development,
3 h  g+ _2 e$ b" r/ x& l4 sincluding bilateral testicular growth, similar to boys3 G2 `: L  w: G% e4 I  C3 H( s+ w
with CPP. The gonadotropin levels in this disorder
. @$ n  G4 `! g$ ]  Yare suppressed to prepubertal levels and do not show
) \2 K3 o1 T/ C- j' ]( W0 f% Ppubertal response of gonadotropin after gonadotropin-
! ?7 W3 x6 W% f# V+ Areleasing hormone stimulation. This is a sex-linked
  Q8 |5 i( ^1 W+ X  n( K+ X3 {, eautosomal dominant disorder that affects only
+ P0 |/ P" J+ p% c' }, ~  T+ Ymales; therefore, other male members of the family) d& y7 m& W, p
may have similar precocious puberty.39 r- ?1 t* }' K8 q# l) J
In our patient, physical examination was incon-
8 O$ P1 x/ C' s1 T* Isistent with true precocious puberty since his testi-
8 e" |  S1 y  t8 Kcles were prepubertal in size. However, testotoxicosis4 _5 V2 k/ Z% c# s% v% |
was in the differential diagnosis because his father
& w/ o9 r7 t# l  x2 j4 u2 `6 lstarted puberty somewhat early, and occasionally,) D; V4 M3 H3 U' f
testicular enlargement is not that evident in the3 h4 ]0 {9 z8 _5 d$ s) ~7 X* V7 l2 `# ]
beginning of this process.1 In the absence of a neg-% A2 a9 A( n. h1 D* K: t
ative initial history of androgen exposure, our  f( T& t$ {$ c  m6 r
biggest concern was virilizing adrenal hyperplasia,
; U( k7 U# a7 o8 s  b1 Keither 21-hydroxylase deficiency or 11-β hydroxylase
3 {. L! E( `. W( _9 y3 _+ C7 l4 ideficiency. Those diagnoses were excluded by find-1 d/ R1 k0 V' V: f) l. O8 |& A
ing the normal level of adrenal steroids.
! ?7 E8 l# \3 i$ v6 W. nThe diagnosis of exogenous androgens was strongly) k2 S/ ?* r. M- G
suspected in a follow-up visit after 4 months because  O. }9 E( ]4 v6 F) g) P  S
the physical examination revealed the complete disap-
, R8 Z) f% T: e( N' Npearance of pubic hair, normal growth velocity, and
* l  K7 k- h5 P. Sdecreased erections. The father admitted using a testos-
7 V; G* `1 P8 V. x' Z& {, jterone gel, which he concealed at first visit. He was
# n1 o; s  W# r( x. _8 c& `8 w; M; }using it rather frequently, twice a day. The Physicians’
; X8 m$ ?- h$ q8 R  ]  h4 Q- UDesk Reference, or package insert of this product, gel or
/ Z  p  g0 ]8 I4 g# icream, cautions about dermal testosterone transfer to& d1 T3 X2 n- {$ m
unprotected females through direct skin exposure.- r2 r$ R6 ~6 v1 |8 @2 k
Serum testosterone level was found to be 2 times the
; I& W* y! H& bbaseline value in those females who were exposed to( T5 r! f5 Q$ W0 q# E& U
even 15 minutes of direct skin contact with their male7 w( M) j5 J# _5 _. i8 n
partners.6 However, when a shirt covered the applica-
0 |# S$ Z5 ~# @/ J/ ption site, this testosterone transfer was prevented.
9 _4 u1 J: I. Z7 e( KOur patient’s testosterone level was 60 ng/mL,
4 F% F+ Q' S3 _( ?8 l! Y+ ?& W" Lwhich was clearly high. Some studies suggest that
4 X* L; x- ?4 w8 Adermal conversion of testosterone to dihydrotestos-& J0 S& F! q# L) C) i
terone, which is a more potent metabolite, is more6 J8 j0 P# T+ m# {' y4 G6 S
active in young children exposed to testosterone( N( g3 S! Z, u
exogenously7; however, we did not measure a dihy-) q9 K- J; T' A$ l
drotestosterone level in our patient. In addition to3 ]! m1 ^9 v" C- q* K1 J1 F7 H
virilization, exposure to exogenous testosterone in
* N' p/ Q* K  C+ q, j; Dchildren results in an increase in growth velocity and
$ j4 W1 Z5 @, b5 j- Uadvanced bone age, as seen in our patient.4 k, ]5 n  r( I: A
The long-term effect of androgen exposure during
$ V' l1 u2 p4 t9 i" ^+ Oearly childhood on pubertal development and final0 @$ Y: m6 [- F- @* Q; l. E# v
adult height are not fully known and always remain0 {( U6 w" @& ]3 k" r3 c; A
a concern. Children treated with short-term testos-0 g# g3 a/ p; \% |5 ~, @
terone injection or topical androgen may exhibit some  _4 n- t. W# `  E9 \" @: N
acceleration of the skeletal maturation; however, after5 @1 n! v( i2 [
cessation of treatment, the rate of bone maturation7 e+ \3 V* U1 W( H( D' _
decelerates and gradually returns to normal.8,9% i0 _! t$ \4 f2 ?3 q% t# q
There are conflicting reports and controversy5 h" q! K. |) J$ f6 P+ i
over the effect of early androgen exposure on adult
; B1 k9 i- Q; U. |  @penile length.10,11 Some reports suggest subnormal* ?! q9 O( E( H. ~" ]0 N4 w' [" |& o
adult penile length, apparently because of downreg-
3 n/ k6 G% O! [- n; K8 W6 Culation of androgen receptor number.10,12 However,- ~! W' t4 j  ~( n
Sutherland et al13 did not find a correlation between& v& q, N$ z8 l0 V1 }" [
childhood testosterone exposure and reduced adult
3 ]: p) W1 l& vpenile length in clinical studies.: D' Q3 s1 _3 @8 o7 t+ M+ T
Nonetheless, we do not believe our patient is
: z2 U4 m) B7 J- m6 c$ Q4 |going to experience any of the untoward effects from
$ K, D* q) s, x( Rtestosterone exposure as mentioned earlier because9 x/ f2 ?: A3 w1 C0 [2 o7 _& o
the exposure was not for a prolonged period of time.
; z& _$ H8 @' z' O4 M3 C& QAlthough the bone age was advanced at the time of# E  Q, x. ~5 j( V# m7 Z0 P2 H% m
diagnosis, the child had a normal growth velocity at
% u1 q0 |6 e5 |4 j) lthe follow-up visit. It is hoped that his final adult
+ }5 o6 z9 D( Y! ?8 t3 wheight will not be affected.
0 E& B3 Y2 F! q# xAlthough rarely reported, the widespread avail-
1 U3 c1 [+ X2 xability of androgen products in our society may
$ i) f: H* W7 T4 `indeed cause more virilization in male or female$ n! E4 u5 j1 I6 R5 b
children than one would realize. Exposure to andro-+ [8 ^5 V0 i% S# o
gen products must be considered and specific ques-* |( D& q9 }: [( h9 }3 ~! ?
tioning about the use of a testosterone product or- e! e% L7 B' }* v- J1 K
gel should be asked of the family members during
- V' Y; z3 m3 w9 [9 A. [$ O. `the evaluation of any children who present with vir-
1 S6 y0 C- i3 ]- y! rilization or peripheral precocious puberty. The diag-/ E! s+ j; l2 H; M  X
nosis can be established by just a few tests and by
3 ~6 x& Y/ R7 d/ k# Oappropriate history. The inability to obtain such a0 z! g5 S% [/ D/ m! J2 ^, p8 b
history, or failure to ask the specific questions, may
9 l3 j& v: q: W0 o) Nresult in extensive, unnecessary, and expensive
4 [9 r  a, A( d9 Y5 finvestigation. The primary care physician should be
4 ~/ E/ @2 [) Q8 E. y/ Aaware of this fact, because most of these children, d$ g5 V; ]5 k1 M8 T5 L+ g
may initially present in their practice. The Physicians’
. e* e; Q8 x4 ?2 }& QDesk Reference and package insert should also put a" O8 N  W' @. G4 c
warning about the virilizing effect on a male or
* u" v0 S8 ~5 [female child who might come in contact with some-* X2 n# b0 Y9 O% A* g2 V! ^
one using any of these products.7 T/ R/ I, n. _/ ]
References, r! n9 w! O% y
1. Styne DM. The testes: disorder of sexual differentiation
5 Y% g; f0 w0 F$ q0 x. j8 b0 Gand puberty in the male. In: Sperling MA, ed. Pediatric
" _- L4 e$ j0 B* HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 C8 E1 o! |3 n- [; _0 z$ o! s
2002: 565-628.& K& J2 M/ v$ O4 \" }- |
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" E0 y( }- W" U. e; H% Y) J3 o
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
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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

8 H+ ~5 w2 `/ [/ B7 i' D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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