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Sexual Precocity in a 16-Month-Old
, Z* a4 X7 G3 O  L, fBoy Induced by Indirect Topical. t. O, L  K0 d7 S$ U
Exposure to Testosterone
* c4 Z2 |$ Q3 n  D$ w# gSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2  O- ?! ^% V) B, e7 ]+ h
and Kenneth R. Rettig, MD1
( O/ o$ G& U' h" N" J6 h4 F# }Clinical Pediatrics
" g. J/ O7 D- B- D6 A/ mVolume 46 Number 6
0 g4 j  i3 a( r( \6 }) _July 2007 540-543
3 D! |5 u5 J: E7 s; a© 2007 Sage Publications; }2 r( ?! ]- m' L
10.1177/0009922806296651% \1 r/ Q# {/ k3 b
http://clp.sagepub.com
9 J2 {) }6 a9 yhosted at
7 y' |) P3 {3 Thttp://online.sagepub.com; Y! G2 N1 R( |4 Q) U( O2 D3 ]
Precocious puberty in boys, central or peripheral,
+ T  c$ v! g3 F- B1 P+ _- D: Lis a significant concern for physicians. Central( z6 b  `5 V" m
precocious puberty (CPP), which is mediated
  D/ N& o, J! G3 U5 Dthrough the hypothalamic pituitary gonadal axis, has
5 f4 z/ R7 P5 qa higher incidence of organic central nervous system
; ?& M* @2 M- K& r: C, Q: y) }: Llesions in boys.1,2 Virilization in boys, as manifested
. f, j) @1 o# c1 Aby enlargement of the penis, development of pubic" z: j% C: A# r6 e. o1 a* L
hair, and facial acne without enlargement of testi-0 ~- e% B3 m8 C
cles, suggests peripheral or pseudopuberty.1-3 We( y+ N& A: ]6 s1 O' g" X+ Y9 Q
report a 16-month-old boy who presented with the, L# S; ]9 @3 h. [4 g2 N3 s; o
enlargement of the phallus and pubic hair develop-" k& N8 _0 W# r( z$ ?0 o
ment without testicular enlargement, which was due2 _* m6 m; }$ S$ x8 u' |$ U
to the unintentional exposure to androgen gel used by- \: V7 b( N4 B
the father. The family initially concealed this infor-. h1 o" G  G$ X
mation, resulting in an extensive work-up for this
4 K. q' A5 L9 m' ?, r7 Ychild. Given the widespread and easy availability of
$ p# Y5 b) P6 ~1 qtestosterone gel and cream, we believe this is proba-
, d, V, Y% ?, sbly more common than the rare case report in the* C* `& h: |2 M# u( G9 {) V
literature.4' M: t9 @; s. N2 w* ]7 t
Patient Report% u9 |5 C: O! P8 P9 @
A 16-month-old white child was referred to the9 Q' m5 k* E7 G7 U
endocrine clinic by his pediatrician with the concern
' G  X  y/ x# Z& k) y$ }1 tof early sexual development. His mother noticed
% I+ F0 p- j4 z9 nlight colored pubic hair development when he was. ]; k4 c* H. ^, o1 {3 v
From the 1Division of Pediatric Endocrinology, 2University of6 \, e8 }* M7 T: A. d0 y4 X
South Alabama Medical Center, Mobile, Alabama./ c/ m# l6 S8 H, D0 K+ l
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( b0 p. s* \5 I( u! s1 g9 SProfessor of Pediatrics, University of South Alabama, College of/ f6 A1 w( J6 X  P, t
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! M( h2 X" a7 |
e-mail: [email protected].
3 x5 p+ t1 i" \6 @about 6 to 7 months old, which progressively became# S* o% y0 F% P
darker. She was also concerned about the enlarge-
* g) n6 v( W& h, v7 K* O" ~- v) ?: Jment of his penis and frequent erections. The child" q; l2 S- a7 {
was the product of a full-term normal delivery, with
& [$ o- {3 Y! o" y$ H. ?a birth weight of 7 lb 14 oz, and birth length of
2 ~0 q+ x% W) F/ i- |20 inches. He was breast-fed throughout the first year; ^1 z' `) O( p
of life and was still receiving breast milk along with
; R, M" O) A* I% l* P# g; n# Lsolid food. He had no hospitalizations or surgery,
0 h( U- N4 r$ |! Q* q$ W( q0 _and his psychosocial and psychomotor development1 g! ]0 \/ x( p8 Q
was age appropriate.3 g1 k3 b# S' r5 I0 M+ ?
The family history was remarkable for the father,
' ]+ g. T2 m. j% H: e3 v7 Zwho was diagnosed with hypothyroidism at age 16,3 l& U& H! t) B1 b8 Z3 J
which was treated with thyroxine. The father’s
' o8 T' T; }# W! {  g# j+ _0 _height was 6 feet, and he went through a somewhat& m; a6 ?3 |2 L/ R/ M
early puberty and had stopped growing by age 14.
& [8 j5 B* ?% q* |: nThe father denied taking any other medication. The0 Y1 T, \( Z) o4 I% j
child’s mother was in good health. Her menarche; F1 C7 Z. ~: Z1 x9 P, e2 ?6 E
was at 11 years of age, and her height was at 5 feet- [4 z4 e$ }! j: Q+ r" F' y( s
5 inches. There was no other family history of pre-/ b9 ]2 [( o; o& z4 h: _) x3 R
cocious sexual development in the first-degree rela-1 t& ^' C9 U. R: b2 u# ~8 z5 O" L2 z
tives. There were no siblings.
% r4 T" b+ e4 X3 m: RPhysical Examination7 k! U! q; M( \8 x0 g( B$ @
The physical examination revealed a very active,
1 s, O: X6 ?  d( E" Aplayful, and healthy boy. The vital signs documented
& O* T2 G8 l) b+ T  i; ma blood pressure of 85/50 mm Hg, his length was
+ A- k! k0 X* n  H7 p90 cm (>97th percentile), and his weight was 14.4 kg. [$ r6 [3 O% F1 g" ?5 X$ U; M" X1 D
(also >97th percentile). The observed yearly growth
4 j/ s; B( l- b" c2 d! Ovelocity was 30 cm (12 inches). The examination of
) W; x. g+ b% M' a" u( a" A" ^5 @" cthe neck revealed no thyroid enlargement.  {4 |) O: `/ \
The genitourinary examination was remarkable for
- o8 e: i; b0 {" M0 Penlargement of the penis, with a stretched length of# j# c0 I+ `  L: g1 G0 W8 j
8 cm and a width of 2 cm. The glans penis was very well- w5 C8 r9 R- @3 {, p$ f
developed. The pubic hair was Tanner II, mostly around$ b( Q8 x3 ]5 M; I
5400 l7 x1 t9 {- X! S3 I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 H; k! B! O! C* Zthe base of the phallus and was dark and curled. The8 R8 g* z5 y. y# a( J0 F0 ]
testicular volume was prepubertal at 2 mL each./ t1 s  k% J6 F( `" e" M1 Q, W
The skin was moist and smooth and somewhat
( @* ?1 b8 g- P2 L! e1 s0 ioily. No axillary hair was noted. There were no
: }2 ^. w* p5 O4 g0 z; rabnormal skin pigmentations or café-au-lait spots.
( ]3 S8 g7 u/ f% ?9 W6 Y5 k4 K6 }( YNeurologic evaluation showed deep tendon reflex 2+
: M  x, L( P! Vbilateral and symmetrical. There was no suggestion% B) [1 l& m6 _
of papilledema.
0 G6 z; w1 w* ]Laboratory Evaluation8 J- y6 z! E  C% _+ N
The bone age was consistent with 28 months by& x! c/ h' Q+ @* [
using the standard of Greulich and Pyle at a chrono-
2 J" `' r  t) [% D4 S. clogic age of 16 months (advanced).5 Chromosomal$ F' i9 K  `( E4 [% i" C  B
karyotype was 46XY. The thyroid function test
& l( p9 }+ }7 g, P: ^/ X  Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
* m- w6 v2 l9 p2 clating hormone level was 1.3 µIU/mL (both normal).# ?+ X# ?1 Z6 }$ l* j0 m* S+ {" c/ M
The concentrations of serum electrolytes, blood
* h; b. E4 [3 Y4 c8 s3 c3 nurea nitrogen, creatinine, and calcium all were) o/ \1 t6 u2 \1 a* G
within normal range for his age. The concentration2 }; K7 Y& P9 q# g+ j
of serum 17-hydroxyprogesterone was 16 ng/dL$ \' a% @6 \( j  C
(normal, 3 to 90 ng/dL), androstenedione was 20
! n/ Q4 O2 y' K4 c4 a- dng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 M& z% Q. r% W$ L: y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 Z  \9 _5 J' B- P5 h) }, k' ]
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: k3 ?4 G( Q" J
49ng/dL), 11-desoxycortisol (specific compound S)! u5 v* _2 ~7 ]& o* T+ W5 y, x: y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- z* X3 ]' ]3 q% U1 U, a, B
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total- D. Y4 `: N$ ^  C0 z
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 [3 B. u8 M; Uand β-human chorionic gonadotropin was less than
# p' B9 k* u6 H2 d6 z0 [5 mIU/mL (normal <5 mIU/mL). Serum follicular
: p8 a& P- E5 `" q" hstimulating hormone and leuteinizing hormone
. Z* d0 S! k& T. X, f! i: Gconcentrations were less than 0.05 mIU/mL% H5 s6 d5 T( S7 x( D, u3 @
(prepubertal).( Q1 k3 ?/ B+ T4 Z/ m, F" r; P/ r% f
The parents were notified about the laboratory
% t0 p; [4 V1 P4 u# N8 H. Sresults and were informed that all of the tests were/ s& p6 \" X% l, `
normal except the testosterone level was high. The. O0 i* U# J: [+ T6 a, M0 P
follow-up visit was arranged within a few weeks to
/ S. G& k/ J5 z* M4 I0 z5 n( L) lobtain testicular and abdominal sonograms; how-
, \- Q* i, k0 F2 n' cever, the family did not return for 4 months.
4 W' C6 J% E. E5 q' M( ?1 wPhysical examination at this time revealed that the
' g4 [# I# v# Z% Q' Achild had grown 2.5 cm in 4 months and had gained
: J/ M, y) z4 m7 z1 [2 kg of weight. Physical examination remained* C. D  s9 {: H! {
unchanged. Surprisingly, the pubic hair almost com-- R2 z- w  R9 P
pletely disappeared except for a few vellous hairs at5 l+ K' w, V0 N! J0 e5 F
the base of the phallus. Testicular volume was still 21 |& M( L$ e; ^5 Y& d
mL, and the size of the penis remained unchanged.& k1 ~- r$ h1 X( G) [* L! e& U$ f
The mother also said that the boy was no longer hav-
; H) `6 Y  B& r& p/ V8 bing frequent erections.6 C7 B; T" l6 o3 t3 J
Both parents were again questioned about use of3 X0 ^( Z3 N. Z- ?) r& J
any ointment/creams that they may have applied to
$ {. _) m; s- mthe child’s skin. This time the father admitted the6 y7 B: v" }5 s
Topical Testosterone Exposure / Bhowmick et al 541
, h5 W$ J7 v9 X$ z- s+ z* |. f8 X' \use of testosterone gel twice daily that he was apply-, u# u9 }( e7 O8 g( Q
ing over his own shoulders, chest, and back area for
3 O, H4 a5 y5 ~- X6 ea year. The father also revealed he was embarrassed  f1 N5 I8 j3 l8 ]* R1 Q
to disclose that he was using a testosterone gel pre-
. L3 T' `: c$ K9 }' Qscribed by his family physician for decreased libido
" }" i5 W" V9 T4 W0 Ksecondary to depression.  A' d0 g; |+ h9 Z
The child slept in the same bed with parents.
/ ~# `$ m- j2 r3 l7 ~The father would hug the baby and hold him on his! L$ s8 B9 R# @: h, \2 L1 B. q# \$ g
chest for a considerable period of time, causing sig-
, E2 v: w' m. w& r" Xnificant bare skin contact between baby and father.
( |8 L3 N  n* l" _6 YThe father also admitted that after the phone call,
- X' w+ k" Y3 k! J$ h5 rwhen he learned the testosterone level in the baby& i" ~: M) m9 x1 z4 E' h# i
was high, he then read the product information2 o# I' ~5 s# p2 D4 M# `) s3 a$ `) O
packet and concluded that it was most likely the rea-
. Z) B5 d2 T* mson for the child’s virilization. At that time, they
, H* b- p/ }6 S5 rdecided to put the baby in a separate bed, and the
$ X8 m; T% _' \) ]father was not hugging him with bare skin and had
& ~0 A1 {# c! k! b2 t' p( Pbeen using protective clothing. A repeat testosterone1 H/ A* `. ], ?  u# a3 d% s0 L
test was ordered, but the family did not go to the
; p6 V% |7 \% [: ^3 A& n1 xlaboratory to obtain the test.
  @( Y( v" |! s* f7 n; b1 g) ~/ eDiscussion7 d, r$ j8 H& e& i* i! w/ x
Precocious puberty in boys is defined as secondary9 ~+ }  D, X% U2 ~* x" T" M
sexual development before 9 years of age.1,4( o; l7 h+ K* r: |5 r5 x
Precocious puberty is termed as central (true) when- U3 J0 P$ e, j. W. g5 _. ?4 a
it is caused by the premature activation of hypo-
4 s- ?& g3 K4 C* z5 nthalamic pituitary gonadal axis. CPP is more com-
4 P( i: b" p1 A, g, H; z% @) xmon in girls than in boys.1,3 Most boys with CPP
0 H8 F' Z4 ^/ T& P  t8 I6 D7 Xmay have a central nervous system lesion that is
8 ]4 K) Z, P# E3 Dresponsible for the early activation of the hypothal-2 Q, @+ U; }. _, D  g( q3 G+ L
amic pituitary gonadal axis.1-3 Thus, greater empha-1 K8 X1 Q9 ^( ?2 Y+ D8 V. u
sis has been given to neuroradiologic imaging in7 ?) ]* t2 {2 k, `
boys with precocious puberty. In addition to viril-! z: y% V  G- i6 _% ~* @. g
ization, the clinical hallmark of CPP is the symmet-
/ o& }+ a; S$ n, a+ F' n  Brical testicular growth secondary to stimulation by
+ M, s; v+ ?! f$ ]" a2 F7 q5 Kgonadotropins.1,34 N: P9 q3 H; p
Gonadotropin-independent peripheral preco-/ V7 \# c1 J& S0 I+ K* {
cious puberty in boys also results from inappropriate
7 r5 r( o. [4 ^, w* Y6 h5 g4 o1 `: y2 Gandrogenic stimulation from either endogenous or
7 x- D6 _# c" Q( [; {exogenous sources, nonpituitary gonadotropin stim-0 j% J5 d# |' O# w7 c
ulation, and rare activating mutations.3 Virilizing& \1 a; t( t/ A2 U
congenital adrenal hyperplasia producing excessive
/ e5 ]# [; |8 E# \adrenal androgens is a common cause of precocious
: y  L$ S4 s: ~5 upuberty in boys.3,4
& d5 m7 J/ L0 h# S* |, n) sThe most common form of congenital adrenal
3 ^8 H9 T4 Z* j; |hyperplasia is the 21-hydroxylase enzyme deficiency.
. g, W7 y+ J- F. w  i; K& OThe 11-β hydroxylase deficiency may also result in
  z3 m3 [& B4 B- kexcessive adrenal androgen production, and rarely,0 a# T- @' T# {
an adrenal tumor may also cause adrenal androgen. c4 C; h% {$ J  p% v/ `" v5 l
excess.1,3
% V1 D# j+ q1 }: Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& I8 i! @) o) H& Y; Q3 K2 }8 ~$ a( w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% i, T5 S0 i: |+ F$ a. ]
A unique entity of male-limited gonadotropin-+ X! D  v- j/ D5 c0 N" W& q& T
independent precocious puberty, which is also known
1 m  H! `0 K' Z1 a9 {. has testotoxicosis, may cause precocious puberty at a
# o; A" `) U2 h9 a: Zvery young age. The physical findings in these boys
  C$ ]5 f* r' n  Q$ f9 e- Swith this disorder are full pubertal development,
8 F3 ]  [" C& [- Z6 Lincluding bilateral testicular growth, similar to boys
+ V5 w. G5 P+ [7 a% Awith CPP. The gonadotropin levels in this disorder
" R& x. s! X9 P) ?+ e# Nare suppressed to prepubertal levels and do not show1 r1 H& j! c3 i
pubertal response of gonadotropin after gonadotropin-
3 k" s& ^" i' `* r6 j7 c/ x9 f* mreleasing hormone stimulation. This is a sex-linked2 g5 R$ \2 ^' Y# _/ z* e) F
autosomal dominant disorder that affects only
  A8 v# @/ [) E1 O3 hmales; therefore, other male members of the family" C! n' P; M9 D" d/ W9 U
may have similar precocious puberty.3, d( i- ^- F; R5 `- R& _
In our patient, physical examination was incon-$ ^5 e4 m8 p9 `5 N9 w
sistent with true precocious puberty since his testi-8 x  o" Z3 ?0 E* r8 A, ^& q
cles were prepubertal in size. However, testotoxicosis
( S8 G1 g* B. a& q$ Dwas in the differential diagnosis because his father
+ u4 ^0 Z0 l3 k. Wstarted puberty somewhat early, and occasionally,6 @* M! A# D  ~9 _* j
testicular enlargement is not that evident in the
# z& k& C  r8 J1 a9 p, s3 O5 S7 E7 tbeginning of this process.1 In the absence of a neg-
& y% k5 W& D" `. W# J7 G) h/ c7 }ative initial history of androgen exposure, our
+ @/ ^: O  L9 [$ j; V; mbiggest concern was virilizing adrenal hyperplasia,
) t/ N) }* E. |either 21-hydroxylase deficiency or 11-β hydroxylase
3 k% F* q1 H5 x( |deficiency. Those diagnoses were excluded by find-
& S# s# m, A: Ling the normal level of adrenal steroids.
& Z) @3 v8 S" K7 e8 E$ U& N6 H: uThe diagnosis of exogenous androgens was strongly" Y) Z$ p' x+ S+ r5 |
suspected in a follow-up visit after 4 months because  ^, e6 _* |% t2 {
the physical examination revealed the complete disap-$ A) M3 U7 t/ a8 r! u
pearance of pubic hair, normal growth velocity, and
. J2 `; P9 f' E0 y2 K6 t8 A1 p" Ndecreased erections. The father admitted using a testos-* r1 z( M$ Y8 Z4 P
terone gel, which he concealed at first visit. He was
0 m( B5 |8 q" S; o! B9 v$ xusing it rather frequently, twice a day. The Physicians’
4 g9 ^( Y) h8 I% h5 pDesk Reference, or package insert of this product, gel or7 z6 L% n/ ?" q$ B* ?% z2 k
cream, cautions about dermal testosterone transfer to
1 [* Q. a2 b9 Y/ s- j( j- s! wunprotected females through direct skin exposure.
6 _& k; V4 r" p5 v" Z% TSerum testosterone level was found to be 2 times the, O; I' Y3 h& ^8 Z5 U
baseline value in those females who were exposed to% e% a/ k0 x* R7 O; y) F  q
even 15 minutes of direct skin contact with their male4 R3 Y: k! l: o, E* z
partners.6 However, when a shirt covered the applica-. P& s* H) S' P0 w- c4 V
tion site, this testosterone transfer was prevented.
  F* V/ y7 V$ A) v, bOur patient’s testosterone level was 60 ng/mL,) S- V% _9 Y7 |, e3 y9 W9 a3 R
which was clearly high. Some studies suggest that
3 b. r7 y* x/ Q/ r; {dermal conversion of testosterone to dihydrotestos-
( W6 |/ f" C6 F/ k, S9 Gterone, which is a more potent metabolite, is more
8 v: T; T, k1 k8 x) I7 t* ^  ~7 tactive in young children exposed to testosterone
2 l" h& C9 k$ U% N; _exogenously7; however, we did not measure a dihy-& P7 v9 {* g' b2 K/ O
drotestosterone level in our patient. In addition to. A: O  A& k/ f
virilization, exposure to exogenous testosterone in
  c2 U6 R3 j/ C6 @8 gchildren results in an increase in growth velocity and
# d3 T8 _) i* e8 g+ I9 C! Qadvanced bone age, as seen in our patient.
' t7 ?* L- @, l5 i5 }7 G, ^The long-term effect of androgen exposure during
) y1 S: l* f1 `; Hearly childhood on pubertal development and final& G: c; W9 Y7 u- r" B& x  w
adult height are not fully known and always remain, d+ V9 B) F3 |' {
a concern. Children treated with short-term testos-3 a5 c; D( R) g2 n% X4 M
terone injection or topical androgen may exhibit some
1 M; V$ R$ ]+ r; z  d5 Bacceleration of the skeletal maturation; however, after- \' n! J8 R$ h) f
cessation of treatment, the rate of bone maturation
% _. ?0 v/ X9 n) b" Sdecelerates and gradually returns to normal.8,9( Z. m4 ~2 H" i" i; p
There are conflicting reports and controversy* \7 I* h( |% S
over the effect of early androgen exposure on adult- K8 r) A: z' I. u
penile length.10,11 Some reports suggest subnormal
: Y5 I/ x+ a6 [5 H$ gadult penile length, apparently because of downreg-! c3 G5 h6 K; {2 N+ U3 P
ulation of androgen receptor number.10,12 However,+ Z7 j; i8 [1 h( G
Sutherland et al13 did not find a correlation between$ d: ]( T! P" V& X5 d
childhood testosterone exposure and reduced adult
1 Y1 K: `* ~% v  openile length in clinical studies.
/ i. t/ P3 m/ a* \; o, L; ZNonetheless, we do not believe our patient is3 O2 E* t* g8 e. f7 {
going to experience any of the untoward effects from5 V# U/ p9 I: \# E" T
testosterone exposure as mentioned earlier because
0 ^: ~! I6 A6 p" f( j$ l2 b# |. xthe exposure was not for a prolonged period of time.
6 G; _5 J. C9 o8 W% dAlthough the bone age was advanced at the time of4 v" G! D4 N) h
diagnosis, the child had a normal growth velocity at8 a# U8 A) _8 S7 [) u! \
the follow-up visit. It is hoped that his final adult
' G$ B4 o1 v0 `height will not be affected.
# W7 {! Z  D$ C8 I' O9 h8 ^Although rarely reported, the widespread avail-
* ~1 n# G1 R9 I( Sability of androgen products in our society may
: a% Z8 B/ G; _( [: x% |% pindeed cause more virilization in male or female
- d9 N4 P9 O7 H4 _6 L; Rchildren than one would realize. Exposure to andro-
9 ?1 Q* W( a% H( Ogen products must be considered and specific ques-
  Y( P; _  K5 D/ z9 r& G: y9 stioning about the use of a testosterone product or
3 y  {: R3 }9 [' Vgel should be asked of the family members during
* X" \, `, c7 K4 h/ \; A) Pthe evaluation of any children who present with vir-3 c7 a2 }- L6 Y3 G  a
ilization or peripheral precocious puberty. The diag-* R' ]+ O' l. o1 M* @7 W1 x
nosis can be established by just a few tests and by, N% U( y, ~- i+ Y7 t6 F
appropriate history. The inability to obtain such a  j6 }5 {' A& C5 [" V. K' D  y. W! e
history, or failure to ask the specific questions, may
* |% b% r2 \% \result in extensive, unnecessary, and expensive  {! ^+ `9 q  Q5 V. X
investigation. The primary care physician should be& z' E0 z& d4 J9 ~: S" M* {
aware of this fact, because most of these children: l8 n& r& |+ A# s$ w9 I9 Q, u, Y
may initially present in their practice. The Physicians’  C# j& _4 o/ D. R$ h( T" k- \% ]* Q& i
Desk Reference and package insert should also put a" ?, M) N; X+ h! Y& f7 V
warning about the virilizing effect on a male or
* w8 D9 D0 V, zfemale child who might come in contact with some-
& Z7 O; Q0 I$ y: c4 M9 Gone using any of these products.
, G" E" ^3 R8 I) oReferences# W; ~4 E- p+ A% ]. D
1. Styne DM. The testes: disorder of sexual differentiation. T( D" g0 I1 v1 C( L1 f8 a6 X9 j
and puberty in the male. In: Sperling MA, ed. Pediatric
+ d9 u6 B* F, ^# Y6 G5 [% j+ HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 s& J$ k$ Z, @2002: 565-628.
; n% ]$ _* k) c8 B6 K1 F/ W2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: c* C4 j( ~- e% I4 m6 G, L) m/ Jpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
/ H; g4 C8 G& R: w" ~! CBoy Induced by Indirect Topical( r$ Z, Q! ^6 R4 S/ r9 B- j
Exposure to Testosterone) X) }( Q% ]+ o9 Z2 d" i! A7 o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 R' y) l- {# U# D
and Kenneth R. Rettig, MD1- \! a) P3 z/ i8 L- B  M
Clinical Pediatrics3 d8 p. [- G, [- k  I/ Y4 ?3 A: |
Volume 46 Number 6
* ~5 a3 I& I8 R5 a3 eJuly 2007 540-543
* M* `4 \) x, \# j+ ^# a% @" H© 2007 Sage Publications0 N- ?. b% u& [
10.1177/0009922806296651
/ b3 x$ R9 a8 E+ ]$ M; s! phttp://clp.sagepub.com
$ O& A+ _' J( Q( @8 Ghosted at
4 V% r  M; @1 K1 phttp://online.sagepub.com! }9 y- x; f. {* L3 Q
Precocious puberty in boys, central or peripheral,6 ?3 A9 }1 ~- W' g- @
is a significant concern for physicians. Central* T& Y% A( Q' p
precocious puberty (CPP), which is mediated
, g$ D0 p8 y- h( ^8 q) v* Qthrough the hypothalamic pituitary gonadal axis, has
5 P5 Q- Z) B  @! N" O+ }* }* xa higher incidence of organic central nervous system
$ b' b" t) D# @; G/ M9 n; D$ P/ `lesions in boys.1,2 Virilization in boys, as manifested) M$ e: [* J& L" G9 D- ?. {
by enlargement of the penis, development of pubic# U0 U1 c$ ]+ `  Q/ Y# H
hair, and facial acne without enlargement of testi-7 l1 p, C+ t1 t
cles, suggests peripheral or pseudopuberty.1-3 We) l/ A( d% Y& t8 B
report a 16-month-old boy who presented with the
+ R% h$ g. S' t' K( G0 m: Ienlargement of the phallus and pubic hair develop-
; t6 ?/ x4 T  z' Wment without testicular enlargement, which was due- V* N4 x/ t7 m/ J" V' j- M, a
to the unintentional exposure to androgen gel used by8 X& j0 w1 H0 E2 g
the father. The family initially concealed this infor-! W" q* e& L* k2 }1 x' s
mation, resulting in an extensive work-up for this/ r9 G$ e- O' O
child. Given the widespread and easy availability of7 \; J4 ~% [# ~- g( G9 {
testosterone gel and cream, we believe this is proba-% \! T7 j0 F3 K9 n
bly more common than the rare case report in the7 w. c( A5 k, l4 T% s
literature.4
2 l. U7 N3 G, P! ?; u+ pPatient Report
$ Q$ v) j3 p2 ?$ K" l! |& KA 16-month-old white child was referred to the
4 H* ^4 q& z' }7 ]4 Q" Kendocrine clinic by his pediatrician with the concern7 B8 R( v  H4 {- F" Y# ?) \
of early sexual development. His mother noticed% p6 I) o9 |5 @
light colored pubic hair development when he was7 ~3 f3 {  b5 b7 \, g8 I
From the 1Division of Pediatric Endocrinology, 2University of5 M+ t) I) H" q( O! x
South Alabama Medical Center, Mobile, Alabama.6 M7 o' D/ {2 v8 S3 k  `+ X+ T/ P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 l3 V! k, Q* i$ [Professor of Pediatrics, University of South Alabama, College of% l, v5 I. n1 u/ O' @2 g' B4 Q
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% G& a1 b) I* G
e-mail: [email protected].! A4 `) |, A. R, D9 K
about 6 to 7 months old, which progressively became
. D, y4 O9 _! o1 wdarker. She was also concerned about the enlarge-
; s# P, M2 v) s5 x( u& J8 Bment of his penis and frequent erections. The child  `  w* q/ g* C3 x/ W+ G
was the product of a full-term normal delivery, with
0 H8 \7 f) _) q, J- T4 S# @a birth weight of 7 lb 14 oz, and birth length of
/ K+ S2 {+ q! O8 `. F3 [20 inches. He was breast-fed throughout the first year
) i$ A# v: G8 d8 j/ T/ M. u9 Iof life and was still receiving breast milk along with/ z# x/ z3 i# K) b
solid food. He had no hospitalizations or surgery,3 X2 U8 o' D" [
and his psychosocial and psychomotor development4 l" C. R  v( I, J( R: Z, c9 {
was age appropriate.  r. ?! z4 O: q& ~+ p/ @
The family history was remarkable for the father,9 S& Q, L, r. g$ ~- i
who was diagnosed with hypothyroidism at age 16,# U) z1 q0 C. V7 H" o2 F
which was treated with thyroxine. The father’s' E( [+ o$ Z  |3 a3 Q
height was 6 feet, and he went through a somewhat
6 X+ g) b, h. m% o7 Dearly puberty and had stopped growing by age 14.7 z  \( r; f# C* o- i
The father denied taking any other medication. The
, N6 m. c9 _4 _3 Y& e; s2 h7 h, ochild’s mother was in good health. Her menarche
0 z. W/ [( O  e) hwas at 11 years of age, and her height was at 5 feet
# S2 J' p! A8 B# b* m5 inches. There was no other family history of pre-
' g6 |: o. y# `! dcocious sexual development in the first-degree rela-) C% ]. _& r8 \
tives. There were no siblings.: I; p9 l* \* x5 X; n
Physical Examination( M5 x: e: j- i' j, z
The physical examination revealed a very active,
5 @9 u9 g9 b9 S: _' J0 Rplayful, and healthy boy. The vital signs documented
* m1 [7 W  \$ Na blood pressure of 85/50 mm Hg, his length was
( R3 y8 i$ `* K' M* e% B* c( r90 cm (>97th percentile), and his weight was 14.4 kg
' u8 @4 J3 \* l3 e) n, ]& @3 j(also >97th percentile). The observed yearly growth
4 K# Y& i: ^7 m3 z7 mvelocity was 30 cm (12 inches). The examination of
& ?6 U/ v/ I1 tthe neck revealed no thyroid enlargement.% p2 _8 E: K2 g% x3 L, ~2 D0 Z+ x
The genitourinary examination was remarkable for
' m  h: t! c) M' Q* }+ Y% Uenlargement of the penis, with a stretched length of6 a# T6 y' ?; H5 D% \
8 cm and a width of 2 cm. The glans penis was very well
$ W5 B* n6 n5 O; Bdeveloped. The pubic hair was Tanner II, mostly around) i+ ~( Y8 a& o% r+ W
540& P# u4 {1 m( O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ \6 D$ R& w9 |( O" z: |
the base of the phallus and was dark and curled. The
. I  n. w) _8 otesticular volume was prepubertal at 2 mL each.
4 h0 F  V" ^7 V3 e: ?6 x  L. @The skin was moist and smooth and somewhat
  s" f2 s- L0 \* }8 d4 ioily. No axillary hair was noted. There were no/ P9 ]  _. S) u
abnormal skin pigmentations or café-au-lait spots.) v8 x4 U' F3 O4 o. f+ ]4 C3 {
Neurologic evaluation showed deep tendon reflex 2+
' F+ z% l2 F. T2 Kbilateral and symmetrical. There was no suggestion9 @  _) Y5 x+ G& [
of papilledema.- Q/ F# L! x! P3 l
Laboratory Evaluation1 s6 v" m* c8 J+ d; F
The bone age was consistent with 28 months by
+ v6 c. ?- `$ F* A' K9 Husing the standard of Greulich and Pyle at a chrono-. z2 S9 M/ D; E' t$ S
logic age of 16 months (advanced).5 Chromosomal, i/ D$ W9 J$ N6 X
karyotype was 46XY. The thyroid function test# H/ G& V9 @' X0 \( J% _
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. G, D, k$ w9 m. ?4 D1 klating hormone level was 1.3 µIU/mL (both normal).. i  q- V" n9 I5 u3 {2 d7 V
The concentrations of serum electrolytes, blood
* a8 L* _! Z/ g% L3 N, P4 E8 [urea nitrogen, creatinine, and calcium all were
. c. a4 ^" ]) b4 j3 Jwithin normal range for his age. The concentration3 R" a9 T+ w  v4 a9 [
of serum 17-hydroxyprogesterone was 16 ng/dL# S- X0 B, [$ t/ H( V4 K$ `# v. X: L
(normal, 3 to 90 ng/dL), androstenedione was 201 k, W5 j4 d# R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; Y, K$ Q. ?& g( h1 ~+ ~" g
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 a7 H- Y0 J7 s" X$ Q+ g' V6 zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# V* Q$ h7 ]* L$ N  w; t: v6 s9 W* p49ng/dL), 11-desoxycortisol (specific compound S)' o' e- j  \0 K$ u- {! q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% |# d9 S4 R9 O" R" _8 d# c# N4 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
3 O  K# S" U8 f9 ~& F2 u3 P: t0 R  ~testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( f5 o# [# O/ r: h( _and β-human chorionic gonadotropin was less than
+ @( ]5 O' Y% r5 e( I; J6 @5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 ^9 x; x. J! L, c$ j6 x5 v4 N, Y/ Nstimulating hormone and leuteinizing hormone& Y" Y# s- c8 q3 O8 N4 {
concentrations were less than 0.05 mIU/mL
5 ]+ J5 ~$ ^+ ~: F7 H* U6 R(prepubertal).4 Z3 P  [  Q) f# X' p$ ]6 t
The parents were notified about the laboratory: c8 p- ~- B8 P$ H- [. W7 ]
results and were informed that all of the tests were# N# C0 a9 K, `, r3 [; q
normal except the testosterone level was high. The3 H% |' h8 k$ ^$ z* a" t
follow-up visit was arranged within a few weeks to8 V7 E% K/ i3 b3 j0 `
obtain testicular and abdominal sonograms; how-( I0 H+ N3 [' J7 p
ever, the family did not return for 4 months.: M! [8 X# A0 O# @4 [6 w
Physical examination at this time revealed that the
) @, |5 |, l) \; r# s* r( Ichild had grown 2.5 cm in 4 months and had gained
- _* u2 s" r" l, _2 kg of weight. Physical examination remained
* p: j# m, }/ Zunchanged. Surprisingly, the pubic hair almost com-
' o, p- A0 y/ v5 hpletely disappeared except for a few vellous hairs at
; R" r6 y8 o+ I/ R4 j+ d& Othe base of the phallus. Testicular volume was still 2' @+ y, k0 G+ C' x- e
mL, and the size of the penis remained unchanged.1 b$ F6 i1 H# y0 Y
The mother also said that the boy was no longer hav-  t$ H. i) G  Y4 c6 g6 O0 {- c
ing frequent erections.! \5 j0 x: s) C2 o8 V( Y
Both parents were again questioned about use of* G3 z( _3 K" r: l4 N
any ointment/creams that they may have applied to- s$ ]9 f/ K5 E# i2 E
the child’s skin. This time the father admitted the
* B9 U( P8 s! JTopical Testosterone Exposure / Bhowmick et al 541( W0 M4 W8 z8 H) J7 E& o$ g0 _" s: s
use of testosterone gel twice daily that he was apply-, _' N  w0 ?* a+ |# W3 W& V  v
ing over his own shoulders, chest, and back area for/ i/ e' {* x9 ^; e( i
a year. The father also revealed he was embarrassed/ I* R* H, G) c; L6 ^6 j4 U
to disclose that he was using a testosterone gel pre-; c  y) d% h/ Z) Y  R6 j: S
scribed by his family physician for decreased libido
6 M$ \( T" S0 f7 `# Rsecondary to depression.
2 x- S: O1 R( x8 a" ^, x) IThe child slept in the same bed with parents.
9 D9 Q$ N& ~9 L  `The father would hug the baby and hold him on his
& M3 k5 a! X0 i7 C/ e- ~) ichest for a considerable period of time, causing sig-* n* u" g3 |& Z: L
nificant bare skin contact between baby and father.
8 O. |* Z& v: V9 T5 G. L( P/ RThe father also admitted that after the phone call,. }2 U; q& ^$ o6 U; z
when he learned the testosterone level in the baby
; D# G8 x  x# \& M% g- D" Jwas high, he then read the product information
4 |. A# |+ |8 M9 \packet and concluded that it was most likely the rea-
7 M* f6 V. P5 Z4 _; @, L3 l/ D! ison for the child’s virilization. At that time, they
4 J) R9 a2 i8 [9 Z; G3 t4 qdecided to put the baby in a separate bed, and the
  |% u5 R' n  Z2 V1 Bfather was not hugging him with bare skin and had
* ]4 r3 y) O- d0 x: u; {, ^5 obeen using protective clothing. A repeat testosterone7 w( }, ~( `5 m, W" |) T1 Q
test was ordered, but the family did not go to the
% @* ?( F' r( J; ^# W; g/ g3 Mlaboratory to obtain the test.1 |, o) e0 X- D1 H; O+ o& I
Discussion
# J7 W+ a  L2 e6 o7 wPrecocious puberty in boys is defined as secondary
' V/ k, y2 Z, asexual development before 9 years of age.1,4
, u' Z5 {; W% W% ]" A2 HPrecocious puberty is termed as central (true) when
" O" l1 y/ k2 t1 A% v/ ]it is caused by the premature activation of hypo-* I% g. @  ?. c# B0 \& O/ P
thalamic pituitary gonadal axis. CPP is more com-
0 [9 P, h( O* F- f3 R6 j0 tmon in girls than in boys.1,3 Most boys with CPP* ~2 e) T! Z' U& ]4 E8 T
may have a central nervous system lesion that is2 X( u- l' o; v- l
responsible for the early activation of the hypothal-4 y8 |; a- P; e3 n7 v
amic pituitary gonadal axis.1-3 Thus, greater empha-+ f. F: j6 v/ Y2 i. H
sis has been given to neuroradiologic imaging in
* R) }6 t* ~+ g$ V& [boys with precocious puberty. In addition to viril-* x1 t9 n$ i8 X. ?+ N# ^
ization, the clinical hallmark of CPP is the symmet-
# ~  V! s& @- I6 ^0 A9 Zrical testicular growth secondary to stimulation by
. B' Y( \* v% Lgonadotropins.1,3
' J" X  W. k% qGonadotropin-independent peripheral preco-* W. ^+ {) ]  y2 p9 {9 C# G0 A% Y
cious puberty in boys also results from inappropriate8 F- C% S) Q) f+ z
androgenic stimulation from either endogenous or
- P( ?* \- B$ H/ s6 d! R' Lexogenous sources, nonpituitary gonadotropin stim-
: B: A9 W. k& i! q+ i/ G- zulation, and rare activating mutations.3 Virilizing
8 j7 x3 _5 H! r6 o- _+ jcongenital adrenal hyperplasia producing excessive
' A: W% C. b$ b; F9 Badrenal androgens is a common cause of precocious- P% y0 z, ]6 {- ~  q, `9 o. T3 ?, B0 R7 M
puberty in boys.3,4( W1 E& P6 \2 W8 O0 v' M/ `. |
The most common form of congenital adrenal* ]- J7 b( S+ P8 o
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 I. k. K4 b2 w# P0 ?- AThe 11-β hydroxylase deficiency may also result in
- R# j* Z* r. p+ Q7 Xexcessive adrenal androgen production, and rarely,
; U, A8 E7 L8 A3 L- f$ Kan adrenal tumor may also cause adrenal androgen2 k( i, [7 V) ~) C8 l8 _0 n# c
excess.1,3) z1 P& x1 ^$ |9 Z7 K) H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ X" j% g# m+ l9 u2 A542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 Y" O# Y- k- M
A unique entity of male-limited gonadotropin-1 p# {: K5 _" X7 e% R
independent precocious puberty, which is also known9 i* D8 r( r6 }) d( i
as testotoxicosis, may cause precocious puberty at a, n3 F- ]% `8 j' W7 t7 v# J
very young age. The physical findings in these boys
" p* j& `: E" B9 }* {with this disorder are full pubertal development,
) x. g  w  g/ O% ^* vincluding bilateral testicular growth, similar to boys
% h2 }6 o0 E! Z; fwith CPP. The gonadotropin levels in this disorder$ S- X, z3 {* H$ H4 h7 [/ _
are suppressed to prepubertal levels and do not show, l4 g1 v1 e  A
pubertal response of gonadotropin after gonadotropin-
5 ?; S. r, r7 J* i& q/ C6 Creleasing hormone stimulation. This is a sex-linked
* k* t2 w" Q$ u7 C$ M/ z( k5 `- Oautosomal dominant disorder that affects only
7 K" R% z1 p- l0 K( ~5 I' fmales; therefore, other male members of the family
! z7 `! v1 |# {% a7 ymay have similar precocious puberty.3
$ N: J* p( j. |' G, {In our patient, physical examination was incon-/ q4 T$ ]2 A" J' s  F( [9 |& U$ K
sistent with true precocious puberty since his testi-5 ]& p- n+ {/ o+ v1 U
cles were prepubertal in size. However, testotoxicosis4 S, Q9 z+ z" w! P! W4 E9 J! H
was in the differential diagnosis because his father
! c& T8 [  ]1 @2 M) [/ s! Xstarted puberty somewhat early, and occasionally,
: s4 M( h% L/ K+ G3 \" }$ `testicular enlargement is not that evident in the9 a- `. i1 Y$ L& L, Q7 [* h
beginning of this process.1 In the absence of a neg-
4 Q+ U. {, r( ^1 I* ?ative initial history of androgen exposure, our
% c" \/ p* \$ Pbiggest concern was virilizing adrenal hyperplasia,
. o8 m" A, L& l' }5 reither 21-hydroxylase deficiency or 11-β hydroxylase
4 h8 G; {$ A/ s( Z' |8 Cdeficiency. Those diagnoses were excluded by find-+ g8 P3 ?: b% G2 ?, `  ~8 E
ing the normal level of adrenal steroids.! M( J# u% Z& C, ^5 e8 F( A8 ?, S
The diagnosis of exogenous androgens was strongly, T& C1 q3 N, U
suspected in a follow-up visit after 4 months because) x/ u$ g1 l: F- c8 z6 X5 V
the physical examination revealed the complete disap-
7 l0 i8 `& G8 d. T' P: A' Ppearance of pubic hair, normal growth velocity, and" G# n' V; y# K- F% w
decreased erections. The father admitted using a testos-5 X- ]! H1 A9 F2 q. w- x: a
terone gel, which he concealed at first visit. He was
# A9 n, J* w, Y- w* Xusing it rather frequently, twice a day. The Physicians’
1 j3 T3 E) Z5 EDesk Reference, or package insert of this product, gel or. q" D- J+ D) K, j) F2 j
cream, cautions about dermal testosterone transfer to
( \9 f' J1 m1 @% l- punprotected females through direct skin exposure.
$ ]4 W5 `' F. p- J! SSerum testosterone level was found to be 2 times the+ [' b- c& D$ y8 G
baseline value in those females who were exposed to
% w- q3 e# \1 ^4 V; l: ~% }3 eeven 15 minutes of direct skin contact with their male
$ ^9 R% Z5 k. Ppartners.6 However, when a shirt covered the applica-4 P$ B8 u/ X0 i* t
tion site, this testosterone transfer was prevented.% J# c4 B7 k3 c% c, l2 s
Our patient’s testosterone level was 60 ng/mL," m5 e7 i8 R! G9 G! ?/ J5 v
which was clearly high. Some studies suggest that! S$ Y, W( r) k' C8 \: V
dermal conversion of testosterone to dihydrotestos-0 R" W: p9 P4 ]
terone, which is a more potent metabolite, is more' s* y% b" C0 H& u" d
active in young children exposed to testosterone
6 V. Z  z) G7 x1 ]exogenously7; however, we did not measure a dihy-& p* B) \- e" p
drotestosterone level in our patient. In addition to
' N5 ^, L1 h, T2 |6 S: Wvirilization, exposure to exogenous testosterone in+ Q; i, s/ G  C1 B; H
children results in an increase in growth velocity and
3 D1 l% n0 C, h& ~9 ^( {advanced bone age, as seen in our patient.
) ~. s/ p% \& ?The long-term effect of androgen exposure during
% l  J( E4 J- f" S1 v* y; A& ^early childhood on pubertal development and final5 ?! J; [- P" B
adult height are not fully known and always remain, S+ v) G7 V; [& W* a
a concern. Children treated with short-term testos-* i- h6 i- s. O! G
terone injection or topical androgen may exhibit some+ p3 ~) w0 D0 t* B
acceleration of the skeletal maturation; however, after8 d! j% H4 {+ }" E! C8 }, I2 _. N
cessation of treatment, the rate of bone maturation
# Z: H- w' K! P7 Kdecelerates and gradually returns to normal.8,9
  \) X( h1 ~* }* IThere are conflicting reports and controversy$ I$ B) j) M6 _5 p+ R
over the effect of early androgen exposure on adult0 r+ s; `. k1 X) L& I
penile length.10,11 Some reports suggest subnormal! K- m; E8 o) `4 M3 b, l
adult penile length, apparently because of downreg-
( e' r3 P5 q( X1 c& lulation of androgen receptor number.10,12 However,. X/ X% a7 |5 ^
Sutherland et al13 did not find a correlation between
( h: ~& |. l9 b5 achildhood testosterone exposure and reduced adult' R5 I4 ~- R" o! g( n- t3 H9 G
penile length in clinical studies.) V1 W3 J+ ^( ^/ Z1 t2 F
Nonetheless, we do not believe our patient is
" o6 t8 h; ]; X" g7 d* N  O1 @, _: {going to experience any of the untoward effects from
% v! E1 G3 x) k  ^+ Ztestosterone exposure as mentioned earlier because& J) D* Q: [# h  m9 ?' d% V
the exposure was not for a prolonged period of time.
1 M( I* L3 k+ E# u- J/ xAlthough the bone age was advanced at the time of
4 t- X1 }  E) Sdiagnosis, the child had a normal growth velocity at
( E( g  r! x# ~$ v5 w8 D' M* Jthe follow-up visit. It is hoped that his final adult
7 f9 U6 k3 J" w4 f( g- _height will not be affected.
% w$ S8 M  x& u5 \Although rarely reported, the widespread avail-
0 k9 C2 N8 U7 t2 I/ hability of androgen products in our society may" \1 ]: N  ?- Z$ P9 B1 {& n
indeed cause more virilization in male or female
) x' n2 k: |! cchildren than one would realize. Exposure to andro-) y0 f, ^# ]8 g# F5 X  R
gen products must be considered and specific ques-
4 A# C0 O4 ?  x. ytioning about the use of a testosterone product or
  q9 S( I" f/ u8 Rgel should be asked of the family members during
/ I8 h, j" |& u; J' lthe evaluation of any children who present with vir-% r9 ?! ^8 n! L
ilization or peripheral precocious puberty. The diag-6 P9 G9 _9 D7 L& r4 [2 y0 T
nosis can be established by just a few tests and by6 t# L& y  b8 G2 K! |2 \; U3 j, `
appropriate history. The inability to obtain such a# \5 `  l  q3 K- J$ \2 y
history, or failure to ask the specific questions, may$ a; P6 B* x" g
result in extensive, unnecessary, and expensive0 D5 P  w/ ]; \" Y- X) g
investigation. The primary care physician should be/ w5 b! T1 v( v
aware of this fact, because most of these children
& n- o1 z2 ]$ \( p/ _/ c1 `may initially present in their practice. The Physicians’
$ c- O3 a2 n; P+ g2 Q4 ?Desk Reference and package insert should also put a' ?5 W: |; B' Z. }! j
warning about the virilizing effect on a male or0 g( R6 t/ @6 y1 ]1 _
female child who might come in contact with some-
* h! U) o0 A) J8 T; ]one using any of these products.
0 H2 C  M; g1 R6 {$ v4 cReferences
# s$ R% E8 W  ^. j+ x; m7 l1. Styne DM. The testes: disorder of sexual differentiation7 G% b# L# k% s2 p4 t. r: Q
and puberty in the male. In: Sperling MA, ed. Pediatric0 u) }  i! v0 b% e' e! k, z# ?7 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' M7 g$ w5 D4 i3 F/ ^, {
2002: 565-628.
, [6 f2 M* r. g" m) B+ y8 J7 a4 a2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
  U: o  d$ V5 ?+ @  Y2 y8 ?. d! Npuberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

# J; A% c1 u; H/ K# O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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