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Sexual Precocity in a 16-Month-Old) k: ]7 h) j' {! d; P
Boy Induced by Indirect Topical8 k" |4 Z7 o5 e2 a
Exposure to Testosterone
) Z1 X: E: j  P! l2 ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 b# n: Z' j$ Z& i4 C4 z9 q5 k
and Kenneth R. Rettig, MD1
0 n% N4 m3 @# w0 U0 d3 l) X. PClinical Pediatrics
3 q; O* y; R0 }: w' ]) ~6 gVolume 46 Number 6
0 B9 F9 e* w+ \5 b; VJuly 2007 540-543
9 l/ [8 g  k/ n5 k+ z© 2007 Sage Publications8 y) ~9 q8 u8 @" F- o
10.1177/0009922806296651, n, W. X6 f0 x$ s" m
http://clp.sagepub.com
2 x! Y. N% k- c! ?2 h: k. Phosted at5 F0 i. h1 H, A/ ]* l+ [7 y
http://online.sagepub.com
' \( }: j% v; k1 yPrecocious puberty in boys, central or peripheral,
4 i. K! G7 G. ?6 W$ T0 N' v# ?is a significant concern for physicians. Central
4 O( u  s, h% y+ pprecocious puberty (CPP), which is mediated
/ x/ q9 s1 B5 V8 O2 ~, jthrough the hypothalamic pituitary gonadal axis, has
! |; ~$ h6 M( C. j; Za higher incidence of organic central nervous system
8 j% r2 l& J2 Q* J/ z0 Hlesions in boys.1,2 Virilization in boys, as manifested9 N8 a  Y* D. p0 x$ V$ l- u
by enlargement of the penis, development of pubic
3 q' A2 }% j6 k- N) w' c  ahair, and facial acne without enlargement of testi-
. C3 P  q  k: x& Dcles, suggests peripheral or pseudopuberty.1-3 We8 v% l! \3 ?( _5 Q3 h8 U# b: D
report a 16-month-old boy who presented with the
: i. m1 c. W7 v* [) ^enlargement of the phallus and pubic hair develop-7 z) d& n5 @7 @& q6 ^: c- J4 p
ment without testicular enlargement, which was due
1 w- {7 ]' R9 Jto the unintentional exposure to androgen gel used by5 V0 E/ H7 \( K; Y0 _
the father. The family initially concealed this infor-
1 m! a3 ]. g6 P) B+ P! cmation, resulting in an extensive work-up for this
7 H- [- K9 c% J0 r  p8 L" d. C( H) Ychild. Given the widespread and easy availability of4 {6 l4 G$ k. P2 T" k5 J& W2 u
testosterone gel and cream, we believe this is proba-3 p; I/ r, N2 n4 g) m. L
bly more common than the rare case report in the
3 P+ D5 W+ V" r8 {literature.4
0 s. q# u$ c- Y3 d8 R7 [Patient Report- O7 ]: s/ }$ c" t& x
A 16-month-old white child was referred to the
# |  ^7 K6 ?9 }& Wendocrine clinic by his pediatrician with the concern
, {6 f$ Z0 I5 t( b) q% E; Kof early sexual development. His mother noticed) F+ \' y5 v$ V& d. |
light colored pubic hair development when he was  Q" J% q  x& O% z
From the 1Division of Pediatric Endocrinology, 2University of. J4 G5 G6 f' S# z+ D
South Alabama Medical Center, Mobile, Alabama.& ^1 R5 _$ m$ A# H/ |% W8 x  R3 g
Address correspondence to: Samar K. Bhowmick, MD, FACE,6 J/ x- f2 c. w
Professor of Pediatrics, University of South Alabama, College of% D) O' [' T2 S: n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ i1 k2 J4 D6 v6 d: F* Ne-mail: [email protected].# k% n1 j, K) b+ D" z. x' h
about 6 to 7 months old, which progressively became7 o- E" k3 H8 j% J
darker. She was also concerned about the enlarge-
8 ?1 U& S( ^  |2 Y) `" K. {ment of his penis and frequent erections. The child
$ q" Z9 i" k! |was the product of a full-term normal delivery, with
4 q) u$ ]$ Q9 ia birth weight of 7 lb 14 oz, and birth length of2 x6 I5 _; ?. d/ m: R% @( x5 m
20 inches. He was breast-fed throughout the first year; N/ s, D& _: @2 z$ v
of life and was still receiving breast milk along with
( P: r1 s" P9 E4 N. @; L) f! p3 Gsolid food. He had no hospitalizations or surgery,
8 U- o) r! B( hand his psychosocial and psychomotor development; I5 ~, A3 G2 k. F7 v
was age appropriate.: K# ~2 m/ v6 u, k% o8 D0 ?2 D
The family history was remarkable for the father,8 Z2 U5 t, P  Y4 w: F
who was diagnosed with hypothyroidism at age 16,
8 S! N1 f! F. y6 R: T" N- D8 {which was treated with thyroxine. The father’s
- j: {8 O2 D, |" Wheight was 6 feet, and he went through a somewhat
7 X6 ^+ k5 f2 Q; b0 N9 w* rearly puberty and had stopped growing by age 14.
4 k& ~) N. d  y& [: VThe father denied taking any other medication. The
% {. q+ b' ^& J" g) Zchild’s mother was in good health. Her menarche, M* O, F8 K9 N0 G+ s6 A
was at 11 years of age, and her height was at 5 feet$ Z( c, W0 t* O9 U# [
5 inches. There was no other family history of pre-2 v; D' F, a4 ?+ j
cocious sexual development in the first-degree rela-
5 T$ f  c+ Z+ T; K2 ntives. There were no siblings.
: h. l2 u# U* B! J! V1 NPhysical Examination* J$ x, n& n- E% E- `2 c
The physical examination revealed a very active,
  i/ W; u/ X; Z( m5 B7 Jplayful, and healthy boy. The vital signs documented1 s5 L9 b: d' C: H! q2 U
a blood pressure of 85/50 mm Hg, his length was6 c' f/ R8 P' M- z8 _4 C/ Y7 W
90 cm (>97th percentile), and his weight was 14.4 kg
* F6 W8 B5 Z8 q1 Y, I1 Y7 K! F(also >97th percentile). The observed yearly growth5 l& H0 k4 f1 e/ ?. R* ~
velocity was 30 cm (12 inches). The examination of" e& r. e8 K( W
the neck revealed no thyroid enlargement.7 u  e, Q: I" J1 Z% Y! X2 H
The genitourinary examination was remarkable for" Y, D. ?: O. x" k
enlargement of the penis, with a stretched length of! U$ p5 S% w- P& k# c
8 cm and a width of 2 cm. The glans penis was very well
* [4 h/ Q( u9 ?) n/ N$ @' fdeveloped. The pubic hair was Tanner II, mostly around
! p& U( A) m5 D: \* q. {540& Y% T6 |5 X$ E  P5 t0 A4 k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 H. P  Y  M8 f  h4 athe base of the phallus and was dark and curled. The
% S" r  y: k- O* |' J9 q7 h) j1 Etesticular volume was prepubertal at 2 mL each.
" ^/ J# B- I* F% M5 `4 `5 H/ VThe skin was moist and smooth and somewhat
  r6 f2 s$ G7 t) I$ o  A: |- ~4 k1 Ooily. No axillary hair was noted. There were no0 x+ h% d1 S, ~- u. ?2 @6 }7 P
abnormal skin pigmentations or café-au-lait spots.+ X, `( e1 \3 J' j# w
Neurologic evaluation showed deep tendon reflex 2+
+ P5 i8 q0 o9 M* y( c  Kbilateral and symmetrical. There was no suggestion$ Z/ b7 D7 ^/ H8 U
of papilledema.: X# C" a* m2 a6 H7 }  |
Laboratory Evaluation
; w8 Y. r; o; X) bThe bone age was consistent with 28 months by
' a4 A7 P5 T# |0 _0 b' e1 z7 v7 kusing the standard of Greulich and Pyle at a chrono-+ y& o& t$ I: z+ ~+ L- E
logic age of 16 months (advanced).5 Chromosomal
, Y" w( W) t1 C3 d( ?( g1 Okaryotype was 46XY. The thyroid function test. g) V+ `1 |3 Z/ b; e! N5 `+ U
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ x: ^4 s( n$ O# }8 \- g/ k, D: olating hormone level was 1.3 µIU/mL (both normal)./ v; ?3 k, N- o# ~
The concentrations of serum electrolytes, blood
- W/ Z8 A* l9 M' z. u% U6 ]1 S' r1 {urea nitrogen, creatinine, and calcium all were
! }( o3 v* d/ B8 b* E, Iwithin normal range for his age. The concentration
- Y$ Y, O" d: B. c& eof serum 17-hydroxyprogesterone was 16 ng/dL) E' q3 [$ B4 j% v
(normal, 3 to 90 ng/dL), androstenedione was 20& J6 q. x9 \2 Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ h' b% B: H/ H# w; q) k0 Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
- z/ H% P) m7 g+ W5 odesoxycorticosterone was 4.3 ng/dL (normal, 7 to) L! M7 h7 o  U
49ng/dL), 11-desoxycortisol (specific compound S)! ]/ G4 w# j* j6 {$ |' t
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- Q5 k" u% E6 C9 r. y+ K3 q
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 y& F- P  i' `, q3 Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 K- V) K8 ^( Dand β-human chorionic gonadotropin was less than+ ^! A1 ]7 E' @
5 mIU/mL (normal <5 mIU/mL). Serum follicular
. i  C! `5 ~- V- h. w' Qstimulating hormone and leuteinizing hormone
: |$ x3 E% L' ~$ a' |1 O8 x; rconcentrations were less than 0.05 mIU/mL- Z% ?( o3 h1 j7 s% S  V
(prepubertal).# u( i4 }% G. l: k
The parents were notified about the laboratory
* j& R9 {+ m$ j! {  K' bresults and were informed that all of the tests were0 N3 `" P, D: ?$ f+ Y
normal except the testosterone level was high. The4 I+ h# u8 c% c) U: l
follow-up visit was arranged within a few weeks to
  I2 S$ E6 @# i6 ]/ robtain testicular and abdominal sonograms; how-
5 R1 }7 H% H5 Q/ _ever, the family did not return for 4 months.6 Y& a- y- u2 w8 y( J; s4 ]' P
Physical examination at this time revealed that the
6 l8 j& h6 m  Mchild had grown 2.5 cm in 4 months and had gained
  @* Q9 i  v7 y, G) V% ]" ]( e) @2 kg of weight. Physical examination remained& L" \% @2 [6 Z
unchanged. Surprisingly, the pubic hair almost com-
8 e& s5 S+ ]' X, u$ F8 Cpletely disappeared except for a few vellous hairs at
6 w9 S0 }# b% ~the base of the phallus. Testicular volume was still 2* h; q$ z2 s7 M  W" h, Y
mL, and the size of the penis remained unchanged.
) ?: w+ I% F" |7 @, [) \8 r" _The mother also said that the boy was no longer hav-6 {3 y4 r8 H9 x# V, J0 v/ E
ing frequent erections.' `' A5 g/ z$ F  z+ N8 q; z2 U% A/ y2 [
Both parents were again questioned about use of, u1 a+ N3 p9 n8 j3 K; q
any ointment/creams that they may have applied to
* ?! `) Y5 }! K  R1 M: }the child’s skin. This time the father admitted the
( O% A. d2 z2 ]# ?4 pTopical Testosterone Exposure / Bhowmick et al 541) ]  B) V; ^4 x, z" j
use of testosterone gel twice daily that he was apply-: w7 r/ Y7 {5 `: w" N
ing over his own shoulders, chest, and back area for
7 R- G5 J6 D! E( t, G7 Da year. The father also revealed he was embarrassed
4 j/ W" D+ I$ W. o; j, zto disclose that he was using a testosterone gel pre-
+ Y) v6 j, t1 kscribed by his family physician for decreased libido' i9 }, T8 ]3 a6 v4 B, @
secondary to depression." I1 [! i3 h* S9 i
The child slept in the same bed with parents.
' ]% t8 H# D) F: @& q& KThe father would hug the baby and hold him on his) L% k) Y; c+ J' P5 Z' q
chest for a considerable period of time, causing sig-
& Y4 ]! p2 `$ I+ D0 S. D+ Enificant bare skin contact between baby and father.
/ \6 q% R, M0 u9 n2 v8 W/ d* qThe father also admitted that after the phone call,6 ~% }! m9 M) `
when he learned the testosterone level in the baby
( b/ A6 h+ b8 J# P% awas high, he then read the product information
6 R  |* J+ Y; {  Z5 z9 E7 x$ U9 Rpacket and concluded that it was most likely the rea-
* O- F: B& M: F2 Xson for the child’s virilization. At that time, they
+ y; w- B; C4 R2 J5 ^* m  P9 bdecided to put the baby in a separate bed, and the3 x0 H; _# m1 m: Z: ]$ b4 O
father was not hugging him with bare skin and had
- u  y$ e8 o( J- Obeen using protective clothing. A repeat testosterone+ g& J$ d  K6 Q" F$ f& W
test was ordered, but the family did not go to the
! y! U: K6 T$ a$ Y* ]) n$ Slaboratory to obtain the test.
- H1 q3 N" U1 MDiscussion
; z3 c/ ?# y- ~7 b1 hPrecocious puberty in boys is defined as secondary
" A8 j( t& |' V2 w0 S$ @sexual development before 9 years of age.1,4& [$ n" }! x: D, w; @0 m
Precocious puberty is termed as central (true) when
5 ]) x1 R( @2 I. c% Yit is caused by the premature activation of hypo-0 c9 ?5 P; y6 s& b! I
thalamic pituitary gonadal axis. CPP is more com-4 r- W) D. O, q0 d2 h# [; X
mon in girls than in boys.1,3 Most boys with CPP8 n7 Z5 t9 j: p! o8 M
may have a central nervous system lesion that is
" \0 r: o4 r9 \5 qresponsible for the early activation of the hypothal-6 z6 V; `- K$ e
amic pituitary gonadal axis.1-3 Thus, greater empha-* p0 c9 b: J0 [) @* j6 W
sis has been given to neuroradiologic imaging in- Q/ J3 p5 l1 L; A
boys with precocious puberty. In addition to viril-
7 T3 m6 G, D8 @+ d. M6 f0 Jization, the clinical hallmark of CPP is the symmet-5 r, t% M0 K, a) ~6 l
rical testicular growth secondary to stimulation by  Q2 z! h  I( W8 H4 U
gonadotropins.1,3, B7 ~+ @  n9 L5 |- l
Gonadotropin-independent peripheral preco-
1 Y2 C+ j0 p! f- Q) o; k# b! ncious puberty in boys also results from inappropriate
; x: O8 n' D. B% `0 \androgenic stimulation from either endogenous or& N; r/ T1 p- t+ h% s0 ?3 A9 R$ D
exogenous sources, nonpituitary gonadotropin stim-9 \8 w* w3 I" ]+ U
ulation, and rare activating mutations.3 Virilizing/ |9 P3 b- _: L8 m) ?- W
congenital adrenal hyperplasia producing excessive
* J3 d7 u# Y; U! w: wadrenal androgens is a common cause of precocious4 V) M8 c  D! w/ l' r, z
puberty in boys.3,4! Z( U8 N; a: W  Z8 Q5 l
The most common form of congenital adrenal
- [0 q; O7 f7 ^, u8 ]1 s( vhyperplasia is the 21-hydroxylase enzyme deficiency.
: P: r2 z  ^4 nThe 11-β hydroxylase deficiency may also result in7 o9 ?5 j9 J8 k
excessive adrenal androgen production, and rarely,, t# P: F1 F( S; s  T) `/ S
an adrenal tumor may also cause adrenal androgen
0 A& c8 u1 Q3 |; a! d3 n' aexcess.1,3
1 p7 V2 N4 `' fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 E7 K! D& k7 Q: S# a  d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 V. x+ Q8 d! ?4 o9 F! ZA unique entity of male-limited gonadotropin-5 N0 p4 Q* T' t2 m# f; B
independent precocious puberty, which is also known& H8 y( k! H4 p4 o5 R. b
as testotoxicosis, may cause precocious puberty at a" s$ v6 m* {" u
very young age. The physical findings in these boys
  a/ q, V. Q0 C- o; X8 j: i, `% Ywith this disorder are full pubertal development,
7 }4 h* C& m9 cincluding bilateral testicular growth, similar to boys
6 g2 h8 y6 q" Y8 }" `9 `6 q8 Y8 P1 ewith CPP. The gonadotropin levels in this disorder1 v# }5 F( @+ v: c
are suppressed to prepubertal levels and do not show- ~$ a+ m! l6 V9 U
pubertal response of gonadotropin after gonadotropin-
  s( l8 E. i# C3 @releasing hormone stimulation. This is a sex-linked
. g/ J0 i) t/ _+ r9 B# uautosomal dominant disorder that affects only
& G" h# J3 a! [" J4 Umales; therefore, other male members of the family( A. D5 ]  G2 t4 y* ?$ r! ]
may have similar precocious puberty.3
) S* k: y* u, b- d0 fIn our patient, physical examination was incon-
4 l" ~# A. E1 K/ L* Fsistent with true precocious puberty since his testi-' m+ ]$ i3 X8 N/ j# t
cles were prepubertal in size. However, testotoxicosis* _( C/ L$ `' `' N5 v) s$ X
was in the differential diagnosis because his father
4 |- P2 ?9 Z3 V  Y" Q- u. ]started puberty somewhat early, and occasionally,2 U9 b+ t7 X  c
testicular enlargement is not that evident in the
0 S; E; A/ [4 L# _" Cbeginning of this process.1 In the absence of a neg-( F7 ^. J. f7 K: G( W5 s0 \2 `* S
ative initial history of androgen exposure, our
5 }2 @* z7 {* }' n( g! gbiggest concern was virilizing adrenal hyperplasia,6 |# s8 f1 E+ w5 G
either 21-hydroxylase deficiency or 11-β hydroxylase1 F9 t! [, m" z/ @% s; S
deficiency. Those diagnoses were excluded by find-8 S: e5 m2 t7 C5 w0 w
ing the normal level of adrenal steroids.
# e2 k1 S3 S7 m* Q/ h- K$ V/ v1 eThe diagnosis of exogenous androgens was strongly
3 l6 r7 _: [+ P7 E' ]8 P8 Ksuspected in a follow-up visit after 4 months because
! s0 w' w$ S. F9 Cthe physical examination revealed the complete disap-5 W0 i2 D9 G  U) R" h. ?
pearance of pubic hair, normal growth velocity, and8 Y% R7 d1 o$ \
decreased erections. The father admitted using a testos-' u( N- P) ^; M  \  r
terone gel, which he concealed at first visit. He was+ z2 |6 g4 R8 b
using it rather frequently, twice a day. The Physicians’5 n2 b& E. N* G" _* K6 G! z: Y* M
Desk Reference, or package insert of this product, gel or- y1 A" N/ ^, g7 w" K0 i# X; y
cream, cautions about dermal testosterone transfer to: [5 _. n* d% B* X$ T
unprotected females through direct skin exposure.1 x$ s8 V' S! C
Serum testosterone level was found to be 2 times the% o  Y% V& Y/ `% t# K: `( f' e% D1 D
baseline value in those females who were exposed to
2 `1 d  l3 o  W( Veven 15 minutes of direct skin contact with their male- L: Z! l% {0 U& J- d: Q4 U
partners.6 However, when a shirt covered the applica-
) ], X: f* l/ ?8 Q/ qtion site, this testosterone transfer was prevented.' }; s  g( J3 i. \7 c9 U7 ?
Our patient’s testosterone level was 60 ng/mL,+ o/ }) N0 d! k6 v7 V8 S: }0 t
which was clearly high. Some studies suggest that
& d' u! Q& Q: S3 bdermal conversion of testosterone to dihydrotestos-
# M5 B5 O' k4 tterone, which is a more potent metabolite, is more
* ~9 G. M' P' H* }2 g  K  I; kactive in young children exposed to testosterone
6 {: @& H$ K  l( J7 p2 V- gexogenously7; however, we did not measure a dihy-/ A5 H( v* ~  o; @
drotestosterone level in our patient. In addition to8 E0 w4 q2 e/ D& X: e
virilization, exposure to exogenous testosterone in
" L8 Y/ q* ^% L, w. y2 Hchildren results in an increase in growth velocity and
  G7 i* H, ]+ s8 ]advanced bone age, as seen in our patient.
$ b/ N; A3 I/ I; \The long-term effect of androgen exposure during" E2 x# t. f" z0 \- f8 T* _
early childhood on pubertal development and final
; f* ?2 ]4 U7 V- z# Fadult height are not fully known and always remain
9 |1 L! X. t9 `0 A' b. ^a concern. Children treated with short-term testos-. Y; T" n$ r9 j6 R5 ^
terone injection or topical androgen may exhibit some5 V( E) g# W' ?% U7 V' |/ K) k" D
acceleration of the skeletal maturation; however, after
) p( g" {6 W. D: e) R' F; ~* o; vcessation of treatment, the rate of bone maturation: q0 e0 S. k4 g: N# r) I$ ?
decelerates and gradually returns to normal.8,9
2 V, G! R: b- M9 ?( {  R9 F$ mThere are conflicting reports and controversy+ \1 H& s" M& u) ^% h( {
over the effect of early androgen exposure on adult0 b: u* }! h8 c; z
penile length.10,11 Some reports suggest subnormal
4 Z  q3 Y# u: H% z  e& t$ G  |adult penile length, apparently because of downreg-
9 @$ m. V4 \& ^ulation of androgen receptor number.10,12 However,
. U# A5 G+ r) y0 g& B& }3 Z0 |Sutherland et al13 did not find a correlation between- H( Y/ D' C$ \- x  g/ L" S& q
childhood testosterone exposure and reduced adult6 v8 [- D" e( ^6 i$ @$ i
penile length in clinical studies.! J# S2 B* V% |( v1 w, H* n
Nonetheless, we do not believe our patient is" j2 W" z! l+ H! Z
going to experience any of the untoward effects from0 r/ n0 H, Q# i
testosterone exposure as mentioned earlier because
& U$ y8 e, x0 D) H* othe exposure was not for a prolonged period of time.1 ]. k& Y  x5 |. c
Although the bone age was advanced at the time of
# m  g( M9 h8 X* vdiagnosis, the child had a normal growth velocity at7 Y+ |5 H7 S4 J  t6 }3 C7 z: R# T
the follow-up visit. It is hoped that his final adult  V7 ]# i) i+ k/ x
height will not be affected.( s$ M9 J7 y! }! |' e2 \
Although rarely reported, the widespread avail-3 C% h0 D2 L$ U- K5 g( e" ]
ability of androgen products in our society may# d3 d) p6 R' U2 {6 _! V( d1 Y
indeed cause more virilization in male or female
' e# N) ?# `( c  j% u  @2 wchildren than one would realize. Exposure to andro-- p) i  d6 _0 N" ]
gen products must be considered and specific ques-
/ G6 Q; E7 ~" I) `8 w: ~tioning about the use of a testosterone product or- q4 M$ }2 C4 s; f& |9 d* G7 U- U( p
gel should be asked of the family members during
0 b! }5 o5 _6 l; Uthe evaluation of any children who present with vir-
; Y, {$ V1 a; y( b+ ~' \1 Jilization or peripheral precocious puberty. The diag-: t3 @( f! w* m: q
nosis can be established by just a few tests and by+ y, e, z5 N9 Z: q' \7 m: }
appropriate history. The inability to obtain such a
- W7 D% {% c: x& y! H7 [1 Lhistory, or failure to ask the specific questions, may% p; e, Q7 l8 H8 _: v9 h
result in extensive, unnecessary, and expensive; O: O3 z9 Z) R4 @
investigation. The primary care physician should be
( Z4 G0 E6 k* r) j, Naware of this fact, because most of these children9 o5 l: R, R% p4 Y2 y
may initially present in their practice. The Physicians’1 E/ N) w$ j/ W& v: r3 c  p
Desk Reference and package insert should also put a
8 u' E7 c3 U( e/ Zwarning about the virilizing effect on a male or" s% P3 k) q  g: i! e, u
female child who might come in contact with some-
2 Z5 {1 Q! D6 e- Kone using any of these products.) }6 Z* E  \9 B: \5 ^- M8 r
References
/ d* m  A2 ?% N0 l0 e1. Styne DM. The testes: disorder of sexual differentiation
9 Y) o, c6 s7 l0 _$ i7 M. I% iand puberty in the male. In: Sperling MA, ed. Pediatric
, Q' N7 s" A$ k0 uEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* Z* z5 x# Y5 J/ t0 i9 R( p
2002: 565-628.. y( ^6 o$ k1 n; n( F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. S8 c. ~& F8 `
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
$ B( m: i% M+ i4 R. c; UBoy Induced by Indirect Topical$ `4 B- a5 d6 O& j4 v) t( P
Exposure to Testosterone) d' ?& }' b; i/ X" M6 J
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 g' Y/ Z, s, m8 [- {; j! Qand Kenneth R. Rettig, MD1
$ n$ X' Q: m, y4 s- L$ hClinical Pediatrics, z) p6 o0 C  b7 a) H5 q2 s
Volume 46 Number 6
# }' @0 [+ o2 ^& Q& j7 o0 aJuly 2007 540-5434 T+ u/ j: W& t4 [+ V' f
© 2007 Sage Publications
2 d! q7 Y* D2 ?) _10.1177/0009922806296651
7 x$ f5 C$ W, |5 q  B1 F' ahttp://clp.sagepub.com; S% `- I/ V& V' n! ^& R
hosted at% y6 u! t5 m+ \+ l1 n
http://online.sagepub.com  s) j- p! S1 M& O0 @% v
Precocious puberty in boys, central or peripheral,
. A" B4 ^+ `/ G+ n  ?' iis a significant concern for physicians. Central" D# t; x- k9 ?0 P# M2 k0 ?# ~: G; a
precocious puberty (CPP), which is mediated
9 k" }7 }  q& j" V7 ]5 ythrough the hypothalamic pituitary gonadal axis, has0 Y: C( x6 x+ p% t( D' n* N9 G5 O! i
a higher incidence of organic central nervous system
' F9 z' ]6 {8 {' P( Q6 A7 K8 G4 p( Ulesions in boys.1,2 Virilization in boys, as manifested
" ~1 N! Z; y, E: \1 k+ o0 @by enlargement of the penis, development of pubic' j$ ~! y* R  Z4 i
hair, and facial acne without enlargement of testi-7 D% O& m- H. f, ~/ d, s0 V, m. C$ {7 K
cles, suggests peripheral or pseudopuberty.1-3 We
1 ~# o: j3 _6 y. j6 hreport a 16-month-old boy who presented with the& Z/ l1 ?; y  C7 A; i( [( m
enlargement of the phallus and pubic hair develop-1 A' B! v! }; l% t. n0 ]
ment without testicular enlargement, which was due7 F2 Y  o! f+ `6 i- q# ?
to the unintentional exposure to androgen gel used by. u' F1 l3 w4 f$ V$ @1 f/ a2 V! s
the father. The family initially concealed this infor-
/ e; l- J+ `1 Emation, resulting in an extensive work-up for this
" ~% C% V( m) v( ]3 rchild. Given the widespread and easy availability of7 z" v* X/ b6 S7 n: @- s& X7 ?% h
testosterone gel and cream, we believe this is proba-3 `+ F" J0 a; w0 m  {0 O+ G
bly more common than the rare case report in the# U4 |& p# z. X1 H+ `% W/ s
literature.4
, T& \6 Q9 v4 s4 cPatient Report
; h4 L+ ?* B1 dA 16-month-old white child was referred to the
+ X# B2 f' Y9 y- z% oendocrine clinic by his pediatrician with the concern
7 b" p: j/ w8 b1 wof early sexual development. His mother noticed
- F6 ]1 M8 E# Z. f! d/ E$ \; @light colored pubic hair development when he was* w" m2 G% C) z0 `; {: Y
From the 1Division of Pediatric Endocrinology, 2University of
  Q. E3 y! O: w: W& FSouth Alabama Medical Center, Mobile, Alabama.
, v0 X9 [( A4 I& ^Address correspondence to: Samar K. Bhowmick, MD, FACE,1 h3 q& y1 S. x& N4 @1 V9 j
Professor of Pediatrics, University of South Alabama, College of
7 {, ~( ?& R0 z0 l! g) FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 w( i. _% T3 |( l6 O+ i
e-mail: [email protected]." C) [/ C6 O! x! N, Q2 N1 q2 K
about 6 to 7 months old, which progressively became/ L- E, Q! V. A  a0 g8 `" P
darker. She was also concerned about the enlarge-
5 |/ I: b$ ~9 a# sment of his penis and frequent erections. The child2 G% T3 `% c5 P4 b3 b& z
was the product of a full-term normal delivery, with+ E. p* w% n8 j$ E4 R0 d# j
a birth weight of 7 lb 14 oz, and birth length of
& ^  d0 w. z/ T+ w- A20 inches. He was breast-fed throughout the first year
- o. V; D/ s7 tof life and was still receiving breast milk along with1 s+ i% Y  g$ a* M
solid food. He had no hospitalizations or surgery,
- x4 ^3 _  s- o6 Band his psychosocial and psychomotor development
' S7 |9 a1 k1 @# \( ^was age appropriate.
) f! O0 K, U. ?% Y# QThe family history was remarkable for the father,
+ V2 j% L/ G6 T8 [' c* twho was diagnosed with hypothyroidism at age 16,. ]/ J3 X, r) ?. \
which was treated with thyroxine. The father’s
# I# ~% Z7 E; X& ]# s( m8 Y4 ?height was 6 feet, and he went through a somewhat- k. u% s5 ?+ ?" a. ?; T$ O
early puberty and had stopped growing by age 14.
( o% N, u5 l2 H* W. I5 cThe father denied taking any other medication. The
3 K7 F" Z, J  O. Mchild’s mother was in good health. Her menarche
7 F# I! W" o! K  \. q+ M8 T$ r5 p5 Gwas at 11 years of age, and her height was at 5 feet
+ z9 z5 t. x& Z" Z* F" ?' L5 inches. There was no other family history of pre-
$ c/ ]7 g, P" icocious sexual development in the first-degree rela-
- ~8 q4 J8 \- F9 U7 {' t8 ]tives. There were no siblings., t+ A$ E' y' ~9 w
Physical Examination5 U; f2 H2 V0 H8 M
The physical examination revealed a very active,8 b# h* W- F, e" y0 J
playful, and healthy boy. The vital signs documented' `1 B4 |+ y9 P' t
a blood pressure of 85/50 mm Hg, his length was
- \7 L9 h' y, c90 cm (>97th percentile), and his weight was 14.4 kg
* \2 |( G  N# N(also >97th percentile). The observed yearly growth- W& Q1 R+ Y+ ~& m6 u# n
velocity was 30 cm (12 inches). The examination of1 F3 y4 ]4 N3 x3 n4 z' R
the neck revealed no thyroid enlargement.0 G' ?5 r& N. R( ^: ^: s$ b, S
The genitourinary examination was remarkable for
4 _  m; @+ U0 k! V8 nenlargement of the penis, with a stretched length of2 Z/ M8 r/ ]8 ?- t1 p2 s
8 cm and a width of 2 cm. The glans penis was very well
% _1 z# F% j7 G4 e9 }' H1 S4 u  [1 T' z. xdeveloped. The pubic hair was Tanner II, mostly around
) U4 g& `. P8 v* W5 X540
% x1 ?5 O" j7 F# B! kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" \' s! A- v: q* V$ Z
the base of the phallus and was dark and curled. The3 X7 G! G  F+ E- l
testicular volume was prepubertal at 2 mL each.4 g4 Y' n# i" v, N/ ]' R1 R
The skin was moist and smooth and somewhat
- w. e' v9 f$ D5 X- R! d% A: uoily. No axillary hair was noted. There were no
( F# [; m" ?+ u' habnormal skin pigmentations or café-au-lait spots.
% ~& P, x* P$ J0 E# H, [5 GNeurologic evaluation showed deep tendon reflex 2+6 X1 l+ \) K- ?
bilateral and symmetrical. There was no suggestion9 }0 O) f  r! h; O
of papilledema.
( @5 b7 \' d% X( x$ |* ~/ sLaboratory Evaluation
, Z4 E6 T  y/ {, M5 r; J& FThe bone age was consistent with 28 months by
4 F9 U* {2 N1 w, ?/ L! A3 ]3 O: Busing the standard of Greulich and Pyle at a chrono-
8 B8 G( L1 f6 i" Z) hlogic age of 16 months (advanced).5 Chromosomal/ l. E, n6 U! C5 `
karyotype was 46XY. The thyroid function test1 Z% Q  q/ Y* h3 Y' ~. _" A
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ }/ [  t& X# M6 Tlating hormone level was 1.3 µIU/mL (both normal).; N- ^7 m) Q- p9 V& p
The concentrations of serum electrolytes, blood5 d; t4 E* Z4 J& d9 V  V$ g! V# }
urea nitrogen, creatinine, and calcium all were5 `8 G; J0 w/ g
within normal range for his age. The concentration
! F/ Y+ c& ^8 [4 vof serum 17-hydroxyprogesterone was 16 ng/dL
4 ~7 C; y3 U7 h! `, I) w+ H(normal, 3 to 90 ng/dL), androstenedione was 20' j8 I: x8 F$ G7 a- E) {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; A/ z9 }$ h0 |  r3 E; Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ A  G; X) U! k8 C6 E
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# ?; v1 P, e! r; C4 Q% D8 E
49ng/dL), 11-desoxycortisol (specific compound S)
0 W2 j3 a6 s- Z+ W/ m8 @9 Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% n/ P# x6 I7 etisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total- [; c) f. z4 L) k+ [. T& n( a  O
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! ^5 u, o5 \( Z* ~# B6 C6 b) _7 ?and β-human chorionic gonadotropin was less than) C$ p3 k) e( Y" b1 D- j
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ M6 ?* N* i7 @; q
stimulating hormone and leuteinizing hormone. n) q9 E4 v  L7 t4 {
concentrations were less than 0.05 mIU/mL
& J; \8 D+ f4 P(prepubertal).
' S8 S9 y( X. w( Z1 I1 {. dThe parents were notified about the laboratory, W' ?+ ~5 q9 f5 ^
results and were informed that all of the tests were; z! Z! I2 }+ _/ f2 W$ N5 S" v
normal except the testosterone level was high. The' q8 e7 h: s! H  |( [* ]
follow-up visit was arranged within a few weeks to5 K" K8 S; P+ `) c8 D; _1 A
obtain testicular and abdominal sonograms; how-
7 Z1 T* J7 V" pever, the family did not return for 4 months.
6 P3 g; I0 I1 ~# C+ K( r9 LPhysical examination at this time revealed that the8 E1 R. i& Q) F9 W
child had grown 2.5 cm in 4 months and had gained
+ }9 M" d: {- r) r7 L2 kg of weight. Physical examination remained
& m- e) u, }8 Y* junchanged. Surprisingly, the pubic hair almost com-
( y! V; h6 V- T. Jpletely disappeared except for a few vellous hairs at1 j( }) i4 K2 a) P+ K6 P. c8 p
the base of the phallus. Testicular volume was still 2  f- {; a5 ]! ?4 u
mL, and the size of the penis remained unchanged.! z) c/ N3 U. a% L
The mother also said that the boy was no longer hav-$ v( W# C$ \2 V; ]. {7 O1 y
ing frequent erections.
& M/ R9 x3 k) T( z4 tBoth parents were again questioned about use of
2 f' ]: j) }: q1 Lany ointment/creams that they may have applied to( Z* N/ k* L4 f, B, ]
the child’s skin. This time the father admitted the1 A1 z/ z3 D5 o5 y
Topical Testosterone Exposure / Bhowmick et al 5417 v3 r8 g& V. x! E; k/ I, G
use of testosterone gel twice daily that he was apply-/ U) ?. N% r7 {5 j) e! [: w# l
ing over his own shoulders, chest, and back area for
) ]1 c2 f4 B3 ]a year. The father also revealed he was embarrassed
5 f# X$ G  t6 ato disclose that he was using a testosterone gel pre-
' m" Z! ^+ u$ L. T) ]# L+ }( Lscribed by his family physician for decreased libido3 E0 b4 d* }2 l4 e5 V
secondary to depression.4 t8 V$ ^( X  e5 z5 O
The child slept in the same bed with parents.
! J- Q1 L( v+ @3 p* Y$ s- c' [: ^The father would hug the baby and hold him on his; N7 H5 w1 e% T
chest for a considerable period of time, causing sig-
, V$ t' E7 g2 {1 y$ C  bnificant bare skin contact between baby and father.
6 o+ j- x, [% a, f4 WThe father also admitted that after the phone call,0 ^3 [# C, A& ^! r( K( ~" I
when he learned the testosterone level in the baby4 [# \: f( j% n0 R& T( Z9 \
was high, he then read the product information  d/ l1 g6 N8 ~* g! Y, `3 p
packet and concluded that it was most likely the rea-
$ g, x( R+ m9 l8 G( v- ^son for the child’s virilization. At that time, they
0 I3 q5 q$ w6 Pdecided to put the baby in a separate bed, and the
( k5 y+ p+ z% v# o6 a; E8 }; R& [father was not hugging him with bare skin and had
* A; K; S8 V9 d) w9 H2 }8 sbeen using protective clothing. A repeat testosterone
0 P/ e7 w) L# i6 Ktest was ordered, but the family did not go to the! ?9 o& C2 k8 q- H- z; [# @. E+ |
laboratory to obtain the test.* f1 M1 h4 Y: r
Discussion
% j7 T4 ^! K7 ^* @: n8 u0 s, v; XPrecocious puberty in boys is defined as secondary
. z" Z! T. p' k& Y* Usexual development before 9 years of age.1,4
: A5 s- M( P) E  gPrecocious puberty is termed as central (true) when1 c5 K$ ^* I+ }
it is caused by the premature activation of hypo-$ p/ y7 O2 R5 C( b5 @, e
thalamic pituitary gonadal axis. CPP is more com-
6 Y2 U/ a% v8 b& P: P, C4 [  v  Omon in girls than in boys.1,3 Most boys with CPP
. c3 y  x1 t/ umay have a central nervous system lesion that is
, \* q  I+ j/ Tresponsible for the early activation of the hypothal-, a  U0 e! A: S2 D6 r% `
amic pituitary gonadal axis.1-3 Thus, greater empha-$ I7 z: c2 t2 Z1 W  ]
sis has been given to neuroradiologic imaging in/ l6 W% L3 I2 t3 d
boys with precocious puberty. In addition to viril-# y% j5 _# [& i# |
ization, the clinical hallmark of CPP is the symmet-. `! \- }6 ?$ c+ _
rical testicular growth secondary to stimulation by
3 Z5 H& y; d. Q' [0 jgonadotropins.1,3; g& K8 |8 P: d$ Z
Gonadotropin-independent peripheral preco-- b1 W, ~3 I. M" Y0 H
cious puberty in boys also results from inappropriate  `( U) c7 J+ u6 x; e9 ]
androgenic stimulation from either endogenous or& f6 b- z" X5 m$ R
exogenous sources, nonpituitary gonadotropin stim-# p% Y4 s$ @, u! X6 k
ulation, and rare activating mutations.3 Virilizing
6 |; v/ z( O6 f! |3 Fcongenital adrenal hyperplasia producing excessive% F) T5 o( H4 i
adrenal androgens is a common cause of precocious8 D6 L7 Q+ U1 d  E* C8 w( H; v
puberty in boys.3,46 n* o( O2 a. \' V2 t- N1 _  a* a
The most common form of congenital adrenal
- k& j7 L( q. f+ Y1 j% M& v! }hyperplasia is the 21-hydroxylase enzyme deficiency.( r/ P& ]1 L, C" B& H; }7 Z
The 11-β hydroxylase deficiency may also result in
5 y  _, a; l1 \, k9 U: W' S( S2 u9 bexcessive adrenal androgen production, and rarely,
, U( V' S) a  \$ Lan adrenal tumor may also cause adrenal androgen) z4 f! u. F* P- W2 R
excess.1,3! W5 G0 v# o, X0 s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 Z% e( d8 `4 g0 g, f542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& W( q- o. Y* o" l
A unique entity of male-limited gonadotropin-! p8 _  O1 T6 w
independent precocious puberty, which is also known
& q* ^, a6 E2 [# ]2 H# b% vas testotoxicosis, may cause precocious puberty at a) ~7 ~, A) C" _7 d3 X/ e) K: L
very young age. The physical findings in these boys
* s3 n8 e! F6 f- Hwith this disorder are full pubertal development,
2 U: m+ I  X5 ]including bilateral testicular growth, similar to boys6 X! t8 |3 b3 T( R( c9 Q( K
with CPP. The gonadotropin levels in this disorder1 l! t* P; p# g! t3 ^0 X4 Y& n
are suppressed to prepubertal levels and do not show  a: h, {' J3 \
pubertal response of gonadotropin after gonadotropin-
- F1 Y& G# q0 dreleasing hormone stimulation. This is a sex-linked) l* |6 {( F* I' E9 i
autosomal dominant disorder that affects only. y3 j# {0 O" S$ T9 ]* k$ ~
males; therefore, other male members of the family
  i, _! F0 T; @: g) Pmay have similar precocious puberty.3- G% y0 _, o; z! l" f6 I
In our patient, physical examination was incon-. v9 o0 `! n. h' z1 e7 c1 c5 d+ y1 [0 D
sistent with true precocious puberty since his testi-
& @: [; ~  m% J: t* Zcles were prepubertal in size. However, testotoxicosis- H( a) U* H6 ~2 h
was in the differential diagnosis because his father3 t+ s/ X1 M. z* U/ T
started puberty somewhat early, and occasionally,% M  I3 o) N* W+ D
testicular enlargement is not that evident in the
% G1 c1 [- `& ?3 k' ibeginning of this process.1 In the absence of a neg-- E# ?2 o7 p7 r+ D6 q$ e$ I
ative initial history of androgen exposure, our
: Q& f  E/ t/ P; G  |biggest concern was virilizing adrenal hyperplasia,2 v( Y8 F1 y" |5 a( R) c
either 21-hydroxylase deficiency or 11-β hydroxylase3 R5 j4 Y& D6 A% y' W/ i* O
deficiency. Those diagnoses were excluded by find-3 f. s* I. R2 l$ x# R, Q
ing the normal level of adrenal steroids.- L3 y9 Q0 u: t$ X& e
The diagnosis of exogenous androgens was strongly" d4 E( |& C/ t4 Q
suspected in a follow-up visit after 4 months because7 V! g7 C* e$ y& E* n
the physical examination revealed the complete disap-" d, O7 Y3 M: w' X0 p
pearance of pubic hair, normal growth velocity, and
: a7 H' S2 q2 e0 W. ndecreased erections. The father admitted using a testos-
$ o4 j  {  B& _; n+ N" W# J3 kterone gel, which he concealed at first visit. He was
+ [" H7 c, c* H& v# d- ~using it rather frequently, twice a day. The Physicians’
5 v& k0 `0 j2 {& u% g1 UDesk Reference, or package insert of this product, gel or, [1 w& n  |8 R2 `+ R
cream, cautions about dermal testosterone transfer to4 @6 y& M, h) I! W
unprotected females through direct skin exposure.! U" @; Q- N  q" Z( I9 h
Serum testosterone level was found to be 2 times the. i& E6 J% y: z/ s  j3 }" `
baseline value in those females who were exposed to9 e6 F) w8 \  }5 o+ ^
even 15 minutes of direct skin contact with their male1 i5 K. ~1 o: s
partners.6 However, when a shirt covered the applica-
6 I* e  T  k& E& j$ G- s9 D" Ution site, this testosterone transfer was prevented.( G/ h) H  Z# m3 h* M7 f
Our patient’s testosterone level was 60 ng/mL,
) p. X) ~7 y9 m  Q4 Twhich was clearly high. Some studies suggest that
6 k5 g, W/ @( p  idermal conversion of testosterone to dihydrotestos-, ?: v0 u% O7 k
terone, which is a more potent metabolite, is more
8 r& I7 s5 x6 _" ractive in young children exposed to testosterone& N) {/ j! B$ G/ m! f
exogenously7; however, we did not measure a dihy-) i$ z5 m  h. h' t; v/ A
drotestosterone level in our patient. In addition to
. H3 @9 ?% F& c, m0 h/ ^virilization, exposure to exogenous testosterone in" f5 |- |% u- F) b
children results in an increase in growth velocity and
0 y" k! g, M% B2 ?6 `3 f$ m8 o: Tadvanced bone age, as seen in our patient.
/ j8 V' c( n! R9 ^6 W* ]% N  a; xThe long-term effect of androgen exposure during
' [& |2 D' @$ ^' l$ B! xearly childhood on pubertal development and final$ P3 |& O" c0 h3 D6 F. G
adult height are not fully known and always remain
. `' @  [, s, [7 U5 ~8 Sa concern. Children treated with short-term testos-7 C9 N- R8 v+ j/ J% p0 \
terone injection or topical androgen may exhibit some* @2 w0 C$ |5 W
acceleration of the skeletal maturation; however, after
. t: T7 R0 z# {* a" q5 Ucessation of treatment, the rate of bone maturation0 p1 h8 c# c# B6 [4 @) t
decelerates and gradually returns to normal.8,9% S( c5 L' `% L0 y
There are conflicting reports and controversy
& y7 K  k7 o/ A9 K6 S$ N+ Uover the effect of early androgen exposure on adult
3 O* |# b$ P/ c0 m( kpenile length.10,11 Some reports suggest subnormal) ^2 {& `" Y& N/ J% B
adult penile length, apparently because of downreg-6 l! o4 g# ]; s# {; j
ulation of androgen receptor number.10,12 However,& A0 e0 i2 V5 ?
Sutherland et al13 did not find a correlation between2 L0 Y; @  {7 s& k
childhood testosterone exposure and reduced adult1 q6 P# J; I8 t$ j
penile length in clinical studies.
" A( [9 E0 G& v7 zNonetheless, we do not believe our patient is
( r  k6 v3 \' C( r* Fgoing to experience any of the untoward effects from" D" G8 Y& i9 b2 `0 F' k  c
testosterone exposure as mentioned earlier because; V/ c$ u2 g2 o! o' v! A, v# l
the exposure was not for a prolonged period of time.( R# ?6 o' u) s" P+ v' R  A/ h
Although the bone age was advanced at the time of
( J7 u( g, R) W9 l; jdiagnosis, the child had a normal growth velocity at) E/ R0 Y+ q3 m3 B. k' D
the follow-up visit. It is hoped that his final adult+ |0 n" ]% _/ n- x' j8 y
height will not be affected.
2 |. {3 u4 Q" F! A! t5 S* FAlthough rarely reported, the widespread avail-( P( ^: g7 X3 r& f2 a% ]' O5 x
ability of androgen products in our society may8 ^. l) |2 @$ K0 `1 m  c+ D* }
indeed cause more virilization in male or female; r% t( `$ t$ v6 A/ i
children than one would realize. Exposure to andro-7 n* U* ?( f0 F2 E2 l2 [
gen products must be considered and specific ques-" P/ X8 I# ^0 d, a6 h
tioning about the use of a testosterone product or
1 y4 \0 J1 C9 z! \- w6 t% Z0 N  Rgel should be asked of the family members during- O! P! X; {+ V6 G9 A. Z
the evaluation of any children who present with vir-
1 h3 l$ P1 d2 h' _% x, Q; Filization or peripheral precocious puberty. The diag-8 r" Y, h  P: _0 |
nosis can be established by just a few tests and by
. {+ p3 j& K4 W) K$ a' c6 yappropriate history. The inability to obtain such a
# L% m7 {, N+ K5 }2 thistory, or failure to ask the specific questions, may
1 L# Q& B1 p$ C7 u4 q% a% presult in extensive, unnecessary, and expensive# i; I1 g/ b! A: X- b/ c' h
investigation. The primary care physician should be
$ W( {, @+ x4 l! O# iaware of this fact, because most of these children( P( m2 ]2 J( P/ B, B
may initially present in their practice. The Physicians’
2 I' {' ~$ d/ ?9 cDesk Reference and package insert should also put a9 u5 a) d  D7 c/ j; g# Q
warning about the virilizing effect on a male or
' I" m, t2 A, j6 g! X9 wfemale child who might come in contact with some-
! I& l4 k+ F" \6 S3 Cone using any of these products.: \# c$ h% e. W* {6 A0 i6 u
References* Z# z- o6 w( N5 ]
1. Styne DM. The testes: disorder of sexual differentiation9 q  N( P5 e4 u, U% J" j) x- x
and puberty in the male. In: Sperling MA, ed. Pediatric* Z1 k5 Y: C/ Y+ r6 d6 c4 c$ K
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 Y5 c+ O. v5 \4 {  e
2002: 565-628.
% l& |; q* G3 B7 a3 [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 k2 ]  V$ j, \" t8 m" mpuberty in children with tumours of the suprasellar pineal
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發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

! t6 X2 y0 b# i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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