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Sexual Precocity in a 16-Month-Old/ O% l( W/ N( }0 |+ M8 d  V9 S' N
Boy Induced by Indirect Topical: v( ^# V& K1 K! [' j$ c  r
Exposure to Testosterone
3 [: S; L4 S; ^7 `& mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* C& F  ]+ ~4 U1 h* a( a6 C9 i
and Kenneth R. Rettig, MD1
! a: e$ I( {0 p  }) a3 yClinical Pediatrics
, U: ]: u* W3 [! ~4 f2 `5 QVolume 46 Number 61 X3 J' h6 }9 ^, f
July 2007 540-543) R, m, T5 j8 ~. G8 ?
© 2007 Sage Publications
* ]% w" y( l4 d) V8 N( N% k8 K* @10.1177/0009922806296651
- a1 e7 ]/ p, F# w( G# D0 @http://clp.sagepub.com; s& ]; ]# B6 E* X, m6 V& ^
hosted at/ D9 d( l, E1 v$ i5 S' M' e+ f' |
http://online.sagepub.com9 [2 V& |5 a( b  F9 l; j
Precocious puberty in boys, central or peripheral,
" b, o0 K8 W) V$ Bis a significant concern for physicians. Central: B! [5 |' D! N/ g* ?* @" c
precocious puberty (CPP), which is mediated
0 a) _4 L) k- z2 bthrough the hypothalamic pituitary gonadal axis, has
- _$ `  R" O" B5 |: B# X* Ha higher incidence of organic central nervous system
& \9 I6 y6 K% V0 F' blesions in boys.1,2 Virilization in boys, as manifested
1 N3 w0 u' R; y/ M$ }by enlargement of the penis, development of pubic. `% E2 M2 l: c5 f. v" B; ?, n- j4 u
hair, and facial acne without enlargement of testi-" ]) H2 p' L6 V# V
cles, suggests peripheral or pseudopuberty.1-3 We- c. J  {2 \9 }; `3 w' {
report a 16-month-old boy who presented with the
7 u) p* ^/ F5 J0 }enlargement of the phallus and pubic hair develop-3 s3 b% ?- J0 p
ment without testicular enlargement, which was due) R. w1 c8 c; I+ I, L  S
to the unintentional exposure to androgen gel used by
# h% ?. C8 E" J" E5 ]: o3 X& xthe father. The family initially concealed this infor-
- T1 y! H1 ?" Cmation, resulting in an extensive work-up for this
  R9 C$ ~3 V1 j1 y" F9 _child. Given the widespread and easy availability of
* ?% x! b" i. [9 T5 v9 U- t! ^7 utestosterone gel and cream, we believe this is proba-' E+ _- C4 P. t. F! F6 {6 q
bly more common than the rare case report in the
/ z+ D( L0 S" j$ T* D( xliterature.4
! T' ?  q( ~4 u' X, K# mPatient Report; n, D* v) }( g& z
A 16-month-old white child was referred to the
% A8 G; o9 E6 e/ u% {" ?endocrine clinic by his pediatrician with the concern
" B9 V5 p  a% t  I% kof early sexual development. His mother noticed
& L4 i2 E* Q# X& p$ a0 |2 r& alight colored pubic hair development when he was6 D! Q0 x; d, t% e1 A. U
From the 1Division of Pediatric Endocrinology, 2University of6 k$ k$ v$ ^$ r% S9 U" I
South Alabama Medical Center, Mobile, Alabama.
/ d; i. e! O# v2 P7 {Address correspondence to: Samar K. Bhowmick, MD, FACE,1 t4 F2 A5 ^3 x: W( w$ Q3 b2 @) v8 E1 H4 F
Professor of Pediatrics, University of South Alabama, College of
  m# `% t  u' ^Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( c( o, w4 O2 T3 w5 o. ~
e-mail: [email protected].
7 _1 ^  Z, [7 q! m& wabout 6 to 7 months old, which progressively became  A; u$ N$ O+ {) ^, z- U! N+ j
darker. She was also concerned about the enlarge-
+ r; i2 M3 M% c5 u% wment of his penis and frequent erections. The child2 q4 U2 N1 y0 e9 u, m9 f. X
was the product of a full-term normal delivery, with
" ]$ k3 X* C5 y  Q  ia birth weight of 7 lb 14 oz, and birth length of# p+ I3 E* z! M8 D
20 inches. He was breast-fed throughout the first year
9 A) M! H- Y2 q" l% j8 [  Yof life and was still receiving breast milk along with4 d$ Q/ [. m$ o6 P1 m( Z) T
solid food. He had no hospitalizations or surgery,7 s( n# T1 q8 X" O) M6 d6 Z6 [
and his psychosocial and psychomotor development
/ }# E, \8 c* Ywas age appropriate.
$ |1 ~4 R$ r" JThe family history was remarkable for the father,
: W$ J- \5 ]* d/ L6 gwho was diagnosed with hypothyroidism at age 16,7 ~5 y4 ]( s. E( s$ N
which was treated with thyroxine. The father’s; l/ V& l; T. X; e; @3 ?7 [
height was 6 feet, and he went through a somewhat
: q9 a4 s7 K) W, P- S0 iearly puberty and had stopped growing by age 14.
0 P" B& P+ j- \! s! k  [The father denied taking any other medication. The' H: b+ T7 D  }" R, Q: k# w9 m) N$ {9 x
child’s mother was in good health. Her menarche$ X+ m/ @" Z! i/ i0 Z9 ^/ `
was at 11 years of age, and her height was at 5 feet7 c$ z: ~; m) o" K% ~, t+ H" T6 J
5 inches. There was no other family history of pre-9 R- \( D. x% u  V7 o7 o/ P+ z4 [
cocious sexual development in the first-degree rela-
! J6 }6 B2 Y1 j3 rtives. There were no siblings.
) }8 |; ?  }1 d9 b6 T5 ~, e9 dPhysical Examination
0 z( g1 O# f- j) y1 n( f6 |The physical examination revealed a very active,2 t; \* x" _# z1 z1 T. J1 _1 A, o
playful, and healthy boy. The vital signs documented
) j( e9 W, _2 O& Oa blood pressure of 85/50 mm Hg, his length was! n% L6 x7 [5 U9 D; a
90 cm (>97th percentile), and his weight was 14.4 kg
/ w  H$ K2 `- b( F/ I  O(also >97th percentile). The observed yearly growth
3 p( x8 j& m$ a4 C. nvelocity was 30 cm (12 inches). The examination of7 m" h* S! g3 X1 x
the neck revealed no thyroid enlargement.- B+ m" R$ G7 Y
The genitourinary examination was remarkable for- U2 s3 a( p+ ~  M8 ~4 b) ~$ F
enlargement of the penis, with a stretched length of; W" g9 L- t7 N3 t/ G
8 cm and a width of 2 cm. The glans penis was very well
3 N& x0 U4 C1 u& Udeveloped. The pubic hair was Tanner II, mostly around$ u4 Y6 |$ r6 V
540
) Z8 @7 b& I1 m) K8 G2 A5 [: Y* `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* ]8 r2 p7 l7 R% x6 Y8 w. K
the base of the phallus and was dark and curled. The
8 j2 ~/ e' b. q  ctesticular volume was prepubertal at 2 mL each.
) v* C+ i0 m2 u- \The skin was moist and smooth and somewhat; ]( J0 G- ]( a/ i; J- G
oily. No axillary hair was noted. There were no
: K# A0 ~( G) x, R+ v, qabnormal skin pigmentations or café-au-lait spots.8 o7 y- \% v5 R* u+ w9 ^+ k: z% i- |" W
Neurologic evaluation showed deep tendon reflex 2+
/ t7 b$ |0 O' a2 Q2 `bilateral and symmetrical. There was no suggestion% l4 e! n$ ^& w/ w
of papilledema.$ ]4 Y, y6 S. J  y8 y8 n
Laboratory Evaluation
7 U0 P% |1 g1 \. h: qThe bone age was consistent with 28 months by, C3 }6 |" q: y2 L4 C7 s
using the standard of Greulich and Pyle at a chrono-. l+ x3 k+ E" B( l! [
logic age of 16 months (advanced).5 Chromosomal9 D4 M' Q6 x1 k! s2 U
karyotype was 46XY. The thyroid function test
% o4 L# u( C; }showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 L$ d3 u" N  ^' s" l; ]" k
lating hormone level was 1.3 µIU/mL (both normal).* z1 p3 e6 {  i) T% Z' n% n
The concentrations of serum electrolytes, blood
. Q2 ?( l4 e/ @3 lurea nitrogen, creatinine, and calcium all were% e( v, T0 [% E! t# s% m
within normal range for his age. The concentration
, l7 H2 E+ v/ Hof serum 17-hydroxyprogesterone was 16 ng/dL. Q3 l' y2 }2 \2 J
(normal, 3 to 90 ng/dL), androstenedione was 20
! S3 g: e4 j# K  v- `5 W* |- F! D. vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
+ _- N& H1 R4 D; i  W1 }/ z+ bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' c9 r! k7 l( n& _4 @desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 m9 i) |- G/ a# @0 ^0 d( {49ng/dL), 11-desoxycortisol (specific compound S). N6 u. |+ B* q% i$ y, g9 A3 T# t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" x6 [- G; W: t! c5 B# ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- h: i8 r7 M; e/ z* Y* M" u+ Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) |1 ?1 o6 t+ n7 ~6 `6 T, V* [and β-human chorionic gonadotropin was less than" U3 C; ^* z) h, D9 f; ^; ~6 [/ s1 k
5 mIU/mL (normal <5 mIU/mL). Serum follicular
. Y1 Q, |& K. ?' i6 astimulating hormone and leuteinizing hormone
  |, k2 N1 s6 o5 V+ _  _concentrations were less than 0.05 mIU/mL
) W/ ~- F- v( `# B5 W0 ]8 l% U(prepubertal).0 b% ?' c) }" `9 p8 ~
The parents were notified about the laboratory0 x$ l  F$ y% I8 m# x* T
results and were informed that all of the tests were# h$ z9 ]. K; r( I/ F3 w
normal except the testosterone level was high. The
$ g2 X2 Z$ W1 Q$ x4 vfollow-up visit was arranged within a few weeks to- G7 s( w3 `& |) k8 [8 l, [
obtain testicular and abdominal sonograms; how-
  v. [( b& V6 b& _+ M& F0 w: Dever, the family did not return for 4 months.0 d% D5 T9 t5 N) x. y! S7 n
Physical examination at this time revealed that the% d: L6 D- b7 R% t# l
child had grown 2.5 cm in 4 months and had gained) L4 O; [" Y! m5 B; L
2 kg of weight. Physical examination remained0 y$ {, K, _# b2 d- F/ Z
unchanged. Surprisingly, the pubic hair almost com-5 S7 o1 M5 s6 i
pletely disappeared except for a few vellous hairs at
, s8 E, Q9 C: Jthe base of the phallus. Testicular volume was still 2
( H9 N' C( ?/ {' P# G. b. hmL, and the size of the penis remained unchanged.4 r) {" ]7 D1 {; [/ |
The mother also said that the boy was no longer hav-
: A+ Q- x! D& R8 ~  \ing frequent erections.8 t& w$ Q; P0 x7 m, h- E. [0 k: I% T
Both parents were again questioned about use of6 k9 t" ]+ e4 t" p! _
any ointment/creams that they may have applied to5 ^3 H# d5 k  m/ C$ d
the child’s skin. This time the father admitted the# a: H! ~" u6 K5 [0 ~1 |( C" k
Topical Testosterone Exposure / Bhowmick et al 541
; N' t* O5 f5 Zuse of testosterone gel twice daily that he was apply-$ P9 u& ]. I7 w% {
ing over his own shoulders, chest, and back area for
3 {/ d9 m- i0 C  Aa year. The father also revealed he was embarrassed
- n& [+ b, e0 d4 ato disclose that he was using a testosterone gel pre-6 s3 g0 r- ?. g4 B4 w
scribed by his family physician for decreased libido
% V* _: \6 ?  W8 y: b! U4 i& R+ X/ `secondary to depression.
. A5 O& B" U3 e3 M% IThe child slept in the same bed with parents.
) G2 S$ G0 z$ f$ x5 E  B# qThe father would hug the baby and hold him on his
, W! k1 h5 n; Tchest for a considerable period of time, causing sig-, E7 ?9 k$ E- W0 P: q; o
nificant bare skin contact between baby and father.! ^6 c6 Q  W$ E, {
The father also admitted that after the phone call,
; T5 F1 A1 X: s% c/ Z+ N0 b2 mwhen he learned the testosterone level in the baby+ s$ ?! C* Y3 t# [1 @. t
was high, he then read the product information# t5 {0 e$ t% f  V0 m$ R8 _
packet and concluded that it was most likely the rea-5 G- Y8 G+ S3 p  B
son for the child’s virilization. At that time, they
* b7 H8 ~) u/ ~# [decided to put the baby in a separate bed, and the
# U4 f+ A5 P4 F5 ofather was not hugging him with bare skin and had
/ P: ?: y, f$ j' |# z" z: Pbeen using protective clothing. A repeat testosterone
' m* G' B# f0 m1 |! `test was ordered, but the family did not go to the
+ r1 b1 N/ |$ p! @& [- ]laboratory to obtain the test.- P# A1 @$ ~5 [+ K
Discussion
8 D+ q' n" D' E/ E$ ^Precocious puberty in boys is defined as secondary8 F" t7 {) i5 [- {; @9 w7 h3 h
sexual development before 9 years of age.1,4
1 e9 J' O4 s8 |Precocious puberty is termed as central (true) when
1 [* U% B  i1 G( zit is caused by the premature activation of hypo-9 l8 R3 P, I/ S% U, L5 s
thalamic pituitary gonadal axis. CPP is more com-! h9 ^8 b: L$ E$ N
mon in girls than in boys.1,3 Most boys with CPP( z- |; [/ [4 H; \$ K/ g* a( ^
may have a central nervous system lesion that is+ A) D; k8 R3 o; T& J. P% H+ ~
responsible for the early activation of the hypothal-! E% J9 ^: i9 N0 r% c
amic pituitary gonadal axis.1-3 Thus, greater empha-: S$ Q: i5 q! j+ T* C
sis has been given to neuroradiologic imaging in
8 t3 c5 O5 X* ^( aboys with precocious puberty. In addition to viril-
+ g3 D. Q0 ]2 B: Xization, the clinical hallmark of CPP is the symmet-
9 z4 M" |, ]1 W) K) o! Orical testicular growth secondary to stimulation by+ l# e. m! O1 b' C2 w: {
gonadotropins.1,3. ~  j' {/ b7 F* b* J5 }
Gonadotropin-independent peripheral preco-
5 i8 B0 z6 d$ n( ^- m  Kcious puberty in boys also results from inappropriate0 s- t- ]/ n( j% M
androgenic stimulation from either endogenous or
" `) P# h6 f8 n& C) P' [+ _; D: qexogenous sources, nonpituitary gonadotropin stim-
! ?) T' m6 Y/ M! h: ^8 Fulation, and rare activating mutations.3 Virilizing
* |( g& T5 w. }2 k- @2 Xcongenital adrenal hyperplasia producing excessive) C! o( P4 `6 r' H4 ]
adrenal androgens is a common cause of precocious- X' i7 _6 R2 n0 d
puberty in boys.3,43 K, |, d( i7 B5 Z$ v
The most common form of congenital adrenal
8 r% r: ^5 }+ a/ Ahyperplasia is the 21-hydroxylase enzyme deficiency.
2 C* Q! F8 \. nThe 11-β hydroxylase deficiency may also result in
! K4 ?2 C1 v  s6 h" O# k9 P! vexcessive adrenal androgen production, and rarely,
4 ^4 l( H, b: u9 s$ z4 i& ean adrenal tumor may also cause adrenal androgen
, R" [+ L& R/ \excess.1,3" g" f" |* m) y7 \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' {6 n6 N' l' h3 Y! p' y$ c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ k, t4 m/ n) G7 g: E/ X
A unique entity of male-limited gonadotropin-
- U: n8 O4 D: D0 P' R: d- I5 U  P- M! Qindependent precocious puberty, which is also known
8 w3 {$ a; V& W: u# Ias testotoxicosis, may cause precocious puberty at a4 C& n: v1 F+ Y# h" }# Z
very young age. The physical findings in these boys
5 s9 D' B6 v1 h) j1 kwith this disorder are full pubertal development,
, C: w  |  a1 Oincluding bilateral testicular growth, similar to boys
8 `8 W5 i; T$ p4 O; Y; S3 f5 h, M7 jwith CPP. The gonadotropin levels in this disorder
" S* l) @8 v* t# h1 k/ sare suppressed to prepubertal levels and do not show
* z4 a4 J8 C9 c% M9 @" I; E5 hpubertal response of gonadotropin after gonadotropin-! L5 {5 O4 C+ E' c
releasing hormone stimulation. This is a sex-linked
+ ?9 u5 n) s2 o7 {autosomal dominant disorder that affects only- }7 m! U3 N) y' h: i
males; therefore, other male members of the family
  S* l$ O3 N' p$ b( \2 Kmay have similar precocious puberty.3
3 ^8 }+ c$ n! L" Y6 J; JIn our patient, physical examination was incon-
# G" R# V# `5 Z. P' L+ P0 B) C' ^sistent with true precocious puberty since his testi-) B! D7 Z3 n( Z$ r/ `& m$ H
cles were prepubertal in size. However, testotoxicosis4 X, o1 f: P# t$ w: T8 ?! P9 n' f) M
was in the differential diagnosis because his father
: y/ `- p4 r0 S  Q9 Estarted puberty somewhat early, and occasionally,
3 O/ x* b* s0 o% ^5 S; F+ utesticular enlargement is not that evident in the
, X. H& Y3 y9 ^% K1 C5 ^$ w* |beginning of this process.1 In the absence of a neg-
* x0 [* q( n' L/ {1 n' h: _- vative initial history of androgen exposure, our
! u1 C4 V7 o9 n6 `biggest concern was virilizing adrenal hyperplasia,) c: e+ a9 H5 F
either 21-hydroxylase deficiency or 11-β hydroxylase
; _4 p. `0 P4 ~! Z. \deficiency. Those diagnoses were excluded by find-# _5 a) t" E% C5 x$ o
ing the normal level of adrenal steroids.  X; S) v+ j+ Y/ F. c  o
The diagnosis of exogenous androgens was strongly1 a- g6 E; O3 {) K( G
suspected in a follow-up visit after 4 months because; Y) ?* W; V3 t3 \- H
the physical examination revealed the complete disap-( m1 ?1 K2 z+ ]- Z
pearance of pubic hair, normal growth velocity, and
5 Z9 n" O% d/ A, S5 L, }decreased erections. The father admitted using a testos-
$ z& S, c4 E' I5 z, ~terone gel, which he concealed at first visit. He was5 q. _; P3 @$ }' C5 N/ S
using it rather frequently, twice a day. The Physicians’
0 H& r- E; ]( a# ]# J2 S: JDesk Reference, or package insert of this product, gel or" |: p, }& M6 P/ a
cream, cautions about dermal testosterone transfer to
7 }  ~0 i% c6 D: m. ~, z: }1 Runprotected females through direct skin exposure.6 j! K" y( t/ A# |
Serum testosterone level was found to be 2 times the
% @& j  Q0 ~! ^2 {( L- S0 R, ?baseline value in those females who were exposed to: `6 W8 M( |: [( d! h
even 15 minutes of direct skin contact with their male3 u% s3 {* n7 @3 L1 Q7 F
partners.6 However, when a shirt covered the applica-
2 W3 C( E. }; y4 u3 ition site, this testosterone transfer was prevented.+ Y7 ]2 X+ B! o$ Q" Z' i/ N8 l
Our patient’s testosterone level was 60 ng/mL,
% t5 }9 o# z7 m: bwhich was clearly high. Some studies suggest that
/ Z! u/ x- s( u5 h3 I9 `9 v$ gdermal conversion of testosterone to dihydrotestos-. @3 b% v# g' a1 ?" t
terone, which is a more potent metabolite, is more
( }% d6 h" i) Y6 Mactive in young children exposed to testosterone8 e5 X1 E$ w+ b. o( s: Q, p+ l8 B
exogenously7; however, we did not measure a dihy-
. q% Q) r( O  o1 C# I5 x, gdrotestosterone level in our patient. In addition to: U; W+ m% Q, E! g/ K
virilization, exposure to exogenous testosterone in
4 q: U# k9 t% z( _9 Jchildren results in an increase in growth velocity and
2 [1 R8 S% g) E3 I' ladvanced bone age, as seen in our patient.
; \2 G; `- x$ ~. V6 D0 E: YThe long-term effect of androgen exposure during
& D5 A8 n/ w, ^8 \4 a& }) nearly childhood on pubertal development and final) }9 h( N: F, v0 P
adult height are not fully known and always remain
, j0 R, o7 S1 _) t& b5 na concern. Children treated with short-term testos-/ R; J% I5 y$ t/ f0 s
terone injection or topical androgen may exhibit some) I) k/ T( n2 r
acceleration of the skeletal maturation; however, after- ~1 d, `8 \* d
cessation of treatment, the rate of bone maturation
0 y6 b! Y0 w; |% odecelerates and gradually returns to normal.8,9# V/ I' H! A$ E% L. U$ a. b
There are conflicting reports and controversy/ [1 X9 i" t  ?$ z
over the effect of early androgen exposure on adult, ]6 g% F; `+ E' u) F# G2 L
penile length.10,11 Some reports suggest subnormal  A! ^4 s: A+ f' n' J- g* g
adult penile length, apparently because of downreg-
* N3 Q6 `* y2 I* o- vulation of androgen receptor number.10,12 However,
; V/ X) r+ @- B: I: R; p7 iSutherland et al13 did not find a correlation between* |# b7 X. @+ X# a" ~" d, l: y9 C
childhood testosterone exposure and reduced adult! e+ s: X- V9 m
penile length in clinical studies.
+ h0 D0 [) b4 x( r. A* T( hNonetheless, we do not believe our patient is
8 n  r* n$ b4 k5 ]( y# R% kgoing to experience any of the untoward effects from. v# r3 h' C8 q" L  S- t) l' ?
testosterone exposure as mentioned earlier because0 g7 E9 C5 g: K% _% ^# c* o. `
the exposure was not for a prolonged period of time.% J  {! A  R! P+ f
Although the bone age was advanced at the time of6 C, T& y& r# N, [" S
diagnosis, the child had a normal growth velocity at
7 m0 P- m' z1 Mthe follow-up visit. It is hoped that his final adult
* `% a" S! K8 d3 e" pheight will not be affected.% b% h+ q. J7 ~9 I  J2 C
Although rarely reported, the widespread avail-
/ y1 E, v, P& S4 T- C: rability of androgen products in our society may
8 j& ]( M4 s, a+ Lindeed cause more virilization in male or female+ v, L( |* |8 F- v* B& _
children than one would realize. Exposure to andro-
) b9 m" y9 Y/ Jgen products must be considered and specific ques-
8 g  p2 O! j# [) t# ctioning about the use of a testosterone product or; ?  Y; ~" f9 a* ^; R4 p
gel should be asked of the family members during
& x7 W7 J* Z7 R% rthe evaluation of any children who present with vir-
; ^9 z+ z& M# ]- N' g  Q) xilization or peripheral precocious puberty. The diag-
+ h8 p) t0 l6 \5 i' l8 Z: vnosis can be established by just a few tests and by
! r5 ~3 Z; P, u5 V) |/ T% V, U. D8 ~  u2 Nappropriate history. The inability to obtain such a
2 R, J, l* y- x  hhistory, or failure to ask the specific questions, may' R& ?! y1 T' Y1 H! @
result in extensive, unnecessary, and expensive
' @3 n2 s1 x4 O4 F# ]investigation. The primary care physician should be
* Q1 ]& Q9 A2 kaware of this fact, because most of these children0 a% X& Z( K" j% X  U4 g$ a9 w/ U
may initially present in their practice. The Physicians’/ k6 Z9 R9 E4 i+ d  J) M, h0 C, I4 p
Desk Reference and package insert should also put a8 a% U: ^; R5 @* k! i$ w
warning about the virilizing effect on a male or
# g' _; J  W* J, v5 yfemale child who might come in contact with some-3 G  R' ~: V; `7 W
one using any of these products.3 A  R' @# ]2 A; ^! V+ n6 j! d- C
References
$ h8 J) a0 G" D# g2 s. C( a1. Styne DM. The testes: disorder of sexual differentiation
. B9 K" `. H2 Tand puberty in the male. In: Sperling MA, ed. Pediatric
2 J" V% Q( f) l5 ?6 DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ V5 N* v) o! k5 i" |6 I2 I2002: 565-628.6 O  S4 v3 _; m$ d1 {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% A" @- p& S& X' b* [3 a
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old) ~) \" c% \* ^3 i/ r' G
Boy Induced by Indirect Topical
8 k' k0 l. j$ _7 IExposure to Testosterone, d5 X  k% N& t, B+ b% T- C6 ]5 _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& \/ N) f- J5 z: E. Tand Kenneth R. Rettig, MD12 w' u3 N5 [' r1 a8 a
Clinical Pediatrics# w1 X5 [+ X9 w' S
Volume 46 Number 6/ g6 M: k0 e# s# l6 g- t9 h
July 2007 540-543
4 }% _( r' ~5 P© 2007 Sage Publications
8 O5 Z+ S3 i8 g0 B& `10.1177/0009922806296651
/ `% m4 x5 v+ K1 s9 Hhttp://clp.sagepub.com
/ |" h1 n2 V2 V7 ]hosted at
  m& i- r! x+ A; P, |- Ahttp://online.sagepub.com
  r& k/ U( a& |% B! W6 y9 HPrecocious puberty in boys, central or peripheral,
' \* R  T5 {. m6 k# Cis a significant concern for physicians. Central
4 e/ @' o$ z1 q3 r( qprecocious puberty (CPP), which is mediated
1 a# {' n  t% k8 Z$ C4 s* pthrough the hypothalamic pituitary gonadal axis, has
, G% q1 i# q, R9 @" i0 W7 ja higher incidence of organic central nervous system
. f' a$ q/ `- Xlesions in boys.1,2 Virilization in boys, as manifested
6 d9 w" r2 h! sby enlargement of the penis, development of pubic
( X- Z9 f) y* J6 E$ [/ X5 G" [1 M% xhair, and facial acne without enlargement of testi-8 Y% y: a/ B. O3 P* w
cles, suggests peripheral or pseudopuberty.1-3 We9 T% h5 Q: h& c  Y' J: Y& J
report a 16-month-old boy who presented with the
0 ?" k( F3 V! ]* @& @: o1 Kenlargement of the phallus and pubic hair develop-2 n) f7 D- ]6 o7 M0 e
ment without testicular enlargement, which was due- F2 e4 p8 |* ~0 [. T# O8 {
to the unintentional exposure to androgen gel used by
" |# B; ?* U1 uthe father. The family initially concealed this infor-
1 {2 k1 a! |, A6 C. ymation, resulting in an extensive work-up for this
4 z. C8 r& e4 k# d2 |child. Given the widespread and easy availability of
/ U5 h/ {' I1 G2 Wtestosterone gel and cream, we believe this is proba-  v3 S0 e' q/ z# o: N/ J, M4 t
bly more common than the rare case report in the
$ V2 g* d0 c5 m6 cliterature.4. X* g$ V7 i! h& z/ G2 V/ r  e
Patient Report
6 I: _" z& J, e6 e% k& TA 16-month-old white child was referred to the/ H0 t: {) ]' D  y4 t4 ^
endocrine clinic by his pediatrician with the concern
+ t! h8 E; m: o2 A2 N3 ~$ V8 F" o* Eof early sexual development. His mother noticed! \; [2 H& K4 T4 G, z# O. j
light colored pubic hair development when he was1 n$ L) c$ j2 D8 Q% k' X6 i
From the 1Division of Pediatric Endocrinology, 2University of1 v. i, B& o( S# S* ^% r+ R
South Alabama Medical Center, Mobile, Alabama.9 S$ O# C2 s% t" C7 q
Address correspondence to: Samar K. Bhowmick, MD, FACE,' Q8 q7 \( m% r- z- T
Professor of Pediatrics, University of South Alabama, College of0 M& g  R7 n# O% x1 E: H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 h. ^8 u6 |6 {: I. U0 r
e-mail: [email protected].  L7 v- A7 f; Q) X+ W
about 6 to 7 months old, which progressively became; W3 e* \! F, [
darker. She was also concerned about the enlarge-5 }+ w% W% s' R
ment of his penis and frequent erections. The child' D( U% _% u' `0 t3 ?
was the product of a full-term normal delivery, with
0 h- C$ @5 ?) [: S# a, }: `a birth weight of 7 lb 14 oz, and birth length of
+ ^6 ^+ t! v+ i% H& @! s20 inches. He was breast-fed throughout the first year* k0 F, K3 K2 k$ O) B! `1 ^) r
of life and was still receiving breast milk along with
6 A9 L, |: `! i) S9 w0 csolid food. He had no hospitalizations or surgery,9 `2 @% a3 K$ I! L' H2 Z1 t
and his psychosocial and psychomotor development7 `/ w5 X' F7 E4 u
was age appropriate.- [' T# E9 G$ R) Y4 F/ a- |9 O
The family history was remarkable for the father,
+ Z1 X4 q9 x* m" A2 f/ d/ lwho was diagnosed with hypothyroidism at age 16,' @  Q: R8 t. ]$ \) U5 V
which was treated with thyroxine. The father’s+ f: |+ ~( O5 [& y( H6 }( l
height was 6 feet, and he went through a somewhat
  E  s+ Y  F7 N2 O% @9 tearly puberty and had stopped growing by age 14.
% [# E, `) D$ J6 D/ T4 |! x. MThe father denied taking any other medication. The
4 q3 A$ {5 S$ q4 ]. Schild’s mother was in good health. Her menarche7 d6 V! h3 A& b
was at 11 years of age, and her height was at 5 feet- B" h8 |9 s2 n5 Z, j
5 inches. There was no other family history of pre-
+ N  k3 R" M6 v, X: R9 jcocious sexual development in the first-degree rela-: A, O7 T9 @4 i* d. I1 U  j
tives. There were no siblings.# A: h  q! P9 n. X( Q) U7 s1 R
Physical Examination
, S" ?" t5 ^+ K% ]! J, T# }The physical examination revealed a very active,) }2 F1 f; ], W) K; E# D& T
playful, and healthy boy. The vital signs documented: I( w9 b1 r; K$ c" i: h
a blood pressure of 85/50 mm Hg, his length was8 }. z4 p8 s$ h% m. |
90 cm (>97th percentile), and his weight was 14.4 kg
; H2 v  K. ~) W  E% {(also >97th percentile). The observed yearly growth) E4 P7 e+ C1 }7 u
velocity was 30 cm (12 inches). The examination of% P, l- ^: s6 q0 S/ C7 ]
the neck revealed no thyroid enlargement." Q: @/ y2 F5 `4 ]5 B! J" y
The genitourinary examination was remarkable for
8 M$ @4 V9 C- E* f; c3 l3 Venlargement of the penis, with a stretched length of
7 I5 X5 \& {$ u8 cm and a width of 2 cm. The glans penis was very well2 O' E% n; k7 i' ]+ A- K3 s
developed. The pubic hair was Tanner II, mostly around" |7 z  p, V5 l0 D/ @* p: H
540
+ ]# o- ^+ K) ~: B- l+ nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* G  l1 v0 J" }2 M$ J/ L2 X- C( R' jthe base of the phallus and was dark and curled. The6 j8 F) T, ^+ g' G  A0 ?* _2 C
testicular volume was prepubertal at 2 mL each.! m0 X9 t7 V* O1 `1 ~
The skin was moist and smooth and somewhat
0 q0 w' R. F7 }) |oily. No axillary hair was noted. There were no
) V- Q6 @7 V9 B. p% yabnormal skin pigmentations or café-au-lait spots.# U/ w( ~; b6 Q1 \; W5 `/ Q2 m
Neurologic evaluation showed deep tendon reflex 2+
8 n6 H0 x; O) rbilateral and symmetrical. There was no suggestion
; `2 `' I" H; u5 V% v8 qof papilledema.  i5 S- _. e3 W; u: D' x
Laboratory Evaluation; \1 H1 `& w" J. b; f
The bone age was consistent with 28 months by
0 {' s# j2 ^, {using the standard of Greulich and Pyle at a chrono-' H% ?! E  D: P
logic age of 16 months (advanced).5 Chromosomal6 R% M/ a4 g5 R/ ]" \
karyotype was 46XY. The thyroid function test
! }) x" p4 `3 h0 j) qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: u# D  j9 i) j
lating hormone level was 1.3 µIU/mL (both normal).. y. o0 n- ~2 G  {7 y1 @
The concentrations of serum electrolytes, blood
2 M8 V4 L: i! ]4 N) b% @  ]! Zurea nitrogen, creatinine, and calcium all were0 B0 e& ^. }; O& T
within normal range for his age. The concentration
2 t: _# |) X# i" Sof serum 17-hydroxyprogesterone was 16 ng/dL
: y" y. u7 o' d4 E3 L$ x' G6 Y(normal, 3 to 90 ng/dL), androstenedione was 20
4 P- m) f" ?8 s. ?" \( m9 ]ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 H/ N7 ?  v6 X- p% c: a. o
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 z4 r7 s! u# edesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 {) q% R! f2 J9 i& m; K! F$ ]) e
49ng/dL), 11-desoxycortisol (specific compound S)
  D& l8 E" ~8 b" J+ Nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. Z9 `! `9 _! a, Q1 A" ]tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ ^5 L4 B8 G& q) e: X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! }' J" m7 {/ e/ {
and β-human chorionic gonadotropin was less than
. I) H/ ?9 ~* }  B4 Z. a" P5 mIU/mL (normal <5 mIU/mL). Serum follicular
" d2 P( x" t* @0 D9 Y- istimulating hormone and leuteinizing hormone- g" D0 k6 Y" L7 }# J! N0 S
concentrations were less than 0.05 mIU/mL
3 L# Y! c8 I+ Q' V(prepubertal).
1 s0 d' s# z( fThe parents were notified about the laboratory; x" h8 \4 X6 H# L" a' M& O; @) C9 X* |( N& |
results and were informed that all of the tests were! ^1 m% q. H2 F, R+ I6 g# p
normal except the testosterone level was high. The8 T* k4 v" W6 l
follow-up visit was arranged within a few weeks to
3 G0 U' `% w/ aobtain testicular and abdominal sonograms; how-
' V- b% I* X0 v8 Tever, the family did not return for 4 months.
" @5 y1 c& Y/ jPhysical examination at this time revealed that the8 L5 c2 [) Q  m
child had grown 2.5 cm in 4 months and had gained9 g2 j* d$ G. \& b- Y* D! M
2 kg of weight. Physical examination remained
' B% f: M) i/ S# ~' punchanged. Surprisingly, the pubic hair almost com-2 `% Y, j8 J7 @0 R* K! ?
pletely disappeared except for a few vellous hairs at' s1 `9 S5 @$ ~
the base of the phallus. Testicular volume was still 2: e) t# [* ?  a; `
mL, and the size of the penis remained unchanged.* i! l+ L8 y6 A' R3 _% H6 `
The mother also said that the boy was no longer hav-. q" y; H' |* k
ing frequent erections.
1 ^# d8 \# b4 lBoth parents were again questioned about use of
' c5 |  G' n% ], u" tany ointment/creams that they may have applied to$ n9 d" e. ]9 F
the child’s skin. This time the father admitted the
2 m/ R. C  Y1 S; s  |! K) gTopical Testosterone Exposure / Bhowmick et al 541  ^& |: o* ~4 `! w9 o
use of testosterone gel twice daily that he was apply-
' e" q6 a* ^+ l! P7 t3 a/ d% ^5 ding over his own shoulders, chest, and back area for/ k7 ]" Z3 I6 k9 C: j8 m# M
a year. The father also revealed he was embarrassed1 y7 o  j% y. s1 v
to disclose that he was using a testosterone gel pre-- K3 u" U: x# F
scribed by his family physician for decreased libido
( j7 }3 K9 T" Csecondary to depression./ V. q: `. o9 d- W# ]! a) T0 x
The child slept in the same bed with parents.
- o: E9 E& T, k! GThe father would hug the baby and hold him on his+ U! y' a: S) Q, S, M$ _
chest for a considerable period of time, causing sig-
" ]$ }' W+ J. g- c& _nificant bare skin contact between baby and father.
2 @' j6 Y2 L/ K. p! q5 ZThe father also admitted that after the phone call,7 l9 ~& C- h! A8 G
when he learned the testosterone level in the baby% F1 w0 [2 N/ K% k- Y
was high, he then read the product information
& r6 X  _$ Y8 v2 P4 Epacket and concluded that it was most likely the rea-
$ A! i& z; ~# S0 w# ^; Mson for the child’s virilization. At that time, they
$ e9 X) V3 f4 n" _3 f" Kdecided to put the baby in a separate bed, and the  v) n7 w4 R* `- Q3 L
father was not hugging him with bare skin and had! W. N4 N5 E3 Q  l1 J# @  E3 c- O
been using protective clothing. A repeat testosterone
3 a3 x! B, A3 u) mtest was ordered, but the family did not go to the
* m3 g, a6 V7 q) E% Z6 n$ B5 [laboratory to obtain the test.0 s# y) B- H! D
Discussion* q9 F7 E0 _( r7 O& m* }/ d3 g6 p
Precocious puberty in boys is defined as secondary  y( x6 y) e4 j
sexual development before 9 years of age.1,4
. ^$ ]3 ~; Z' pPrecocious puberty is termed as central (true) when
8 V/ e2 D, ~, n6 X7 hit is caused by the premature activation of hypo-  S: H( z0 J6 _5 Z; h! A
thalamic pituitary gonadal axis. CPP is more com-
7 m! C; V1 f' p( Gmon in girls than in boys.1,3 Most boys with CPP
( {5 {3 U5 z/ ?3 q6 [3 Ymay have a central nervous system lesion that is
# R& w! d' [9 Presponsible for the early activation of the hypothal-
  J# _& W1 |1 U8 Namic pituitary gonadal axis.1-3 Thus, greater empha-
2 w0 P3 B" N; H) m/ ?: ]( @5 e- wsis has been given to neuroradiologic imaging in
) r8 s) e+ v: d5 x6 gboys with precocious puberty. In addition to viril-1 H2 Z$ j! S0 a
ization, the clinical hallmark of CPP is the symmet-
$ g4 O2 a  Q2 `* crical testicular growth secondary to stimulation by
5 M9 A/ w" U) h" ~" ]gonadotropins.1,3
* F4 `* g) _: i5 h+ h% UGonadotropin-independent peripheral preco-+ C" l( y. u2 z% A/ }
cious puberty in boys also results from inappropriate
9 n7 |  L3 I8 w! Fandrogenic stimulation from either endogenous or: K: J! U! i; O3 n/ W' o
exogenous sources, nonpituitary gonadotropin stim-9 k' G5 j/ o7 }. y' N
ulation, and rare activating mutations.3 Virilizing! o, C5 j" p* \7 _: T" D
congenital adrenal hyperplasia producing excessive
; T5 V2 N! X# {: Nadrenal androgens is a common cause of precocious$ r" n! ~- [, w0 g& G/ ]
puberty in boys.3,48 {& h6 `6 }) l3 R+ e  b
The most common form of congenital adrenal$ `5 l8 S; l# N! z. X+ s
hyperplasia is the 21-hydroxylase enzyme deficiency.
2 K, P- }% P" H5 R  B1 }' o( P; ~The 11-β hydroxylase deficiency may also result in
) a# I  t6 u0 Fexcessive adrenal androgen production, and rarely,
# k, p3 l, ~8 B( ~, F/ Gan adrenal tumor may also cause adrenal androgen" {7 y7 A7 y! f% q0 s
excess.1,3! C1 r3 q" H) |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 l* {' N+ v  u9 c& f- o: E% \3 C542 Clinical Pediatrics / Vol. 46, No. 6, July 2007  a! X3 i* ^& T
A unique entity of male-limited gonadotropin-9 V$ d' E/ z( U  `
independent precocious puberty, which is also known
) ~4 \$ k. b9 @7 m: ?as testotoxicosis, may cause precocious puberty at a. b5 C3 l. j3 _* T( ~, k0 b( c
very young age. The physical findings in these boys
5 U7 M1 N; `4 g  l8 K" \0 L8 Z; S: S8 Kwith this disorder are full pubertal development,$ g4 V9 C3 d0 j$ B
including bilateral testicular growth, similar to boys
9 R( a( n- s6 \6 R% {: X0 Bwith CPP. The gonadotropin levels in this disorder$ h6 q/ M7 w" k% ^) w
are suppressed to prepubertal levels and do not show  R; G* o, v, ?  m
pubertal response of gonadotropin after gonadotropin-
2 i& y- f* ~( y8 F( H$ [; T* _9 t7 I/ Creleasing hormone stimulation. This is a sex-linked
- ]" K- j: \7 f2 Uautosomal dominant disorder that affects only
2 i7 f+ v9 V# j0 l5 cmales; therefore, other male members of the family, L. E; b9 j( Y6 n+ o# C* f
may have similar precocious puberty.3% x- n/ T0 W- {5 _
In our patient, physical examination was incon-
) q- ]8 H8 r7 }( R4 h# Wsistent with true precocious puberty since his testi-% N, z2 J6 y5 E0 Z+ V. C; k" O
cles were prepubertal in size. However, testotoxicosis
" \# i% w+ Y3 Y6 ?was in the differential diagnosis because his father. t- U. L/ _) a( M% e; ]; t% _) j8 V
started puberty somewhat early, and occasionally,
4 X9 u! w% i5 a8 ^! p' }testicular enlargement is not that evident in the
8 M+ d: _, D+ X" p) Qbeginning of this process.1 In the absence of a neg-8 r# j5 M; s1 t6 Q, m
ative initial history of androgen exposure, our
3 V4 D& |3 @( W$ s. nbiggest concern was virilizing adrenal hyperplasia,4 d  o+ s7 q9 Q8 `0 ]
either 21-hydroxylase deficiency or 11-β hydroxylase
: Y9 h0 f, Y# L8 n: h+ h" n+ {deficiency. Those diagnoses were excluded by find-% ?! q' [7 \  F8 s; r6 r9 _
ing the normal level of adrenal steroids.' ]# @" X3 h  R7 U% j
The diagnosis of exogenous androgens was strongly
5 H) d$ ]" d. g6 i. H, S$ |suspected in a follow-up visit after 4 months because
3 W9 G' Z0 Q6 K# @the physical examination revealed the complete disap-
! x' ^7 P9 [% `: O. N( _pearance of pubic hair, normal growth velocity, and3 c" i  n! n1 {) T
decreased erections. The father admitted using a testos-- `7 @: U7 H5 X; M3 S& m' h9 p
terone gel, which he concealed at first visit. He was
$ i/ v+ w# h/ v! V' `: susing it rather frequently, twice a day. The Physicians’
* @4 r6 Z2 {" M0 `' k1 [+ IDesk Reference, or package insert of this product, gel or
% b. U1 r" K( O. J9 X( h1 r+ b: dcream, cautions about dermal testosterone transfer to, q3 `. e6 p5 q
unprotected females through direct skin exposure.
; J( _+ a+ L) E; gSerum testosterone level was found to be 2 times the! F! w% z3 L- f5 K5 t6 g: b5 S  {, b
baseline value in those females who were exposed to, S5 s; B" A5 L- N) D
even 15 minutes of direct skin contact with their male( P% B) ^, z" n( n5 u! I
partners.6 However, when a shirt covered the applica-
$ R9 _7 N' d; J' r' ]! }1 n$ Ytion site, this testosterone transfer was prevented.
3 D, j  E6 x# U( A- f8 N) SOur patient’s testosterone level was 60 ng/mL,
$ i: e" [+ k" M% G) W+ twhich was clearly high. Some studies suggest that
7 X! o0 `+ I" @" Fdermal conversion of testosterone to dihydrotestos-0 {, P0 }6 I9 M( V% F; _3 ]
terone, which is a more potent metabolite, is more
/ {7 O. x) W$ j/ [, y) Q# p' V' Zactive in young children exposed to testosterone$ O. h/ k$ v1 y( Q
exogenously7; however, we did not measure a dihy-
% r* h/ z& c) b( j" }+ S' Jdrotestosterone level in our patient. In addition to( N7 ~- d' s2 o; r' D& i
virilization, exposure to exogenous testosterone in
' `, Z, N/ L* z7 E: Achildren results in an increase in growth velocity and
) n+ Q6 t4 X- G; p9 Gadvanced bone age, as seen in our patient.
8 F) Z' c" ?. A+ v2 zThe long-term effect of androgen exposure during
. Y. I. b2 D# H; c3 e, j, g' x! q% K; Gearly childhood on pubertal development and final
. h/ O' y% }/ p* }! \: ~4 N( g' Radult height are not fully known and always remain+ G- k5 p" L, r/ t* p$ u& E  M
a concern. Children treated with short-term testos-
6 @: M* {) t/ E) N( t  cterone injection or topical androgen may exhibit some
. q6 {3 E7 m8 `* X+ _& b4 tacceleration of the skeletal maturation; however, after
' c: Y* |$ B) I) H- N6 r+ ]  ocessation of treatment, the rate of bone maturation
- S. c) e- W0 l2 ?7 O" sdecelerates and gradually returns to normal.8,9& h5 V5 t. Y! |. ]! o
There are conflicting reports and controversy5 ]; R( ^" w% _- u$ h. E
over the effect of early androgen exposure on adult2 r6 [( G7 j+ @0 W" X0 G$ A
penile length.10,11 Some reports suggest subnormal
/ p) o# c8 F; {6 n/ z; a% Hadult penile length, apparently because of downreg-
/ q- C; U& |4 a2 Oulation of androgen receptor number.10,12 However,
5 E9 s. t: Y- Y5 u1 M+ ASutherland et al13 did not find a correlation between0 r( Z$ }5 ]4 \9 \. `4 o. ~
childhood testosterone exposure and reduced adult7 u2 ~% R- n$ a6 }5 W
penile length in clinical studies.7 c1 [1 D' |5 v! W, _
Nonetheless, we do not believe our patient is# g& V" D3 l% z+ W/ D' a
going to experience any of the untoward effects from+ E# e- n* ^( b3 `
testosterone exposure as mentioned earlier because
3 ]0 v" U, D" y+ r, s# w# q& Vthe exposure was not for a prolonged period of time." P0 P) E, E  j5 _: }
Although the bone age was advanced at the time of
2 Z* z+ X% M: A9 y3 q- zdiagnosis, the child had a normal growth velocity at
7 S+ K! O' w7 ?( Bthe follow-up visit. It is hoped that his final adult& W/ C; G: F2 D4 i" L/ G# T0 n
height will not be affected.
1 y4 L! s% r* _9 EAlthough rarely reported, the widespread avail-7 z6 R' k# S$ x! T3 d; O
ability of androgen products in our society may- \+ I1 g# m1 S+ s, W
indeed cause more virilization in male or female" T' d( e0 `3 \" @5 w( c  E2 r
children than one would realize. Exposure to andro-
( \1 h! w3 V: _& |! \gen products must be considered and specific ques-
6 g# [' Z: e$ f% Otioning about the use of a testosterone product or4 F, B3 H5 j9 _% R
gel should be asked of the family members during
# r/ r- r  Q4 l9 f$ n8 B+ Fthe evaluation of any children who present with vir-0 }! D( Q& @( h) j  q/ @2 ?' v9 J
ilization or peripheral precocious puberty. The diag-4 T! I# z  d4 h. L
nosis can be established by just a few tests and by2 O# |8 _4 I! t  L0 s% c
appropriate history. The inability to obtain such a- t: y- A% v# }# u1 G8 c
history, or failure to ask the specific questions, may( y; j% ^9 T- v# Q% k/ K: y, X* I
result in extensive, unnecessary, and expensive# m% B  Q. |" }4 }, V% H% b+ a
investigation. The primary care physician should be% D, r. `: b/ L- i0 Q3 a
aware of this fact, because most of these children( }/ T, h5 T2 k; A; Q* X$ ~% y
may initially present in their practice. The Physicians’( u3 x8 w- A$ }+ b  U) C5 x) i& D
Desk Reference and package insert should also put a
- Z( Y7 s- ^. g( l6 z- |warning about the virilizing effect on a male or
+ z$ u$ U7 n' j& q  C* W8 U. M0 T" Lfemale child who might come in contact with some-
+ H, A% o2 K1 n, u: @one using any of these products.% e7 s5 Q3 R' h& A
References" k' ^. e1 P; \* d3 s5 A5 ^( `5 H
1. Styne DM. The testes: disorder of sexual differentiation
% _& I2 q; E. Z8 t. Mand puberty in the male. In: Sperling MA, ed. Pediatric+ Q+ y2 r( j" I: |  q5 S# a
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 |( X! S* I1 f$ a
2002: 565-628.
4 p5 {4 A/ H% |' \& T4 i4 h2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) F0 U0 ~! n; b  n0 ]puberty in children with tumours of the suprasellar pineal
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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!

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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
累計簽到:11 天
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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

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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?
累計簽到:3 天
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發表於 2025-1-19 02:41:05 | 顯示全部樓層

3 F$ I* G+ q8 l/ T* t; x" N+ H精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!

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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!
 分享同時學會感恩,一句感謝的話語,就是最大的支持!  歡迎交流討論
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