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Sexual Precocity in a 16-Month-Old' B8 p% N! z. M7 r6 u
Boy Induced by Indirect Topical
4 H/ @2 ~+ |7 ?! Z# SExposure to Testosterone
+ ]  I4 X# I8 m' M8 j- v4 sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 F5 q' W1 r1 ~
and Kenneth R. Rettig, MD1. @5 g/ q9 b5 H- l# l5 B( H
Clinical Pediatrics; i8 Y# c! A& X' z
Volume 46 Number 6
# E( ^. @5 R9 O$ G4 Z. k4 FJuly 2007 540-5439 ~( Z& Z  _, Q7 Z& _
© 2007 Sage Publications4 Y5 ~' k0 G4 g- g& \6 S
10.1177/0009922806296651+ _! E, @0 W5 J# ^* o  U
http://clp.sagepub.com. b! ~: g8 N% r
hosted at
) W6 J; Z& N3 s5 _; z$ j5 Chttp://online.sagepub.com( z; g7 _' T7 J9 ?/ g( E5 e5 ^
Precocious puberty in boys, central or peripheral,% {/ O4 X3 v; c7 q$ K
is a significant concern for physicians. Central8 @; E! Y2 r9 R3 w4 e  F# ]9 R9 K
precocious puberty (CPP), which is mediated
, m( _  W! w8 W8 r7 H; j, {1 Rthrough the hypothalamic pituitary gonadal axis, has5 X# P3 f* |7 V& `# E
a higher incidence of organic central nervous system
( G* G+ D; R" j' B4 H9 Y& wlesions in boys.1,2 Virilization in boys, as manifested
, m8 N0 f3 H+ ]1 J' w+ Bby enlargement of the penis, development of pubic
( X: I% U) A+ x; Ghair, and facial acne without enlargement of testi-9 s$ }$ z$ `# G+ d$ r  M7 |1 n
cles, suggests peripheral or pseudopuberty.1-3 We7 {/ m- K8 j/ I1 G
report a 16-month-old boy who presented with the
. J& h7 s2 }6 s& ]' N# l5 cenlargement of the phallus and pubic hair develop-
4 w' z/ w9 g+ w- Q7 }& Ument without testicular enlargement, which was due8 L! T! J3 e3 F+ }; ~
to the unintentional exposure to androgen gel used by0 v9 L( U! W! g- P. r8 u- ~" W
the father. The family initially concealed this infor-
# h/ Y, W. r: R" w& r0 _mation, resulting in an extensive work-up for this" O; `, p% X. l) f
child. Given the widespread and easy availability of: t: F; E4 h8 p* g! @) e
testosterone gel and cream, we believe this is proba-: D7 v/ C8 I! w2 f
bly more common than the rare case report in the
0 f6 a# H, `1 N. q  J' Fliterature.4; }) G2 U9 K+ x3 f! j
Patient Report* F& f! D: T" L8 `( b$ @/ w# D
A 16-month-old white child was referred to the* i1 e( w- ^# G+ `
endocrine clinic by his pediatrician with the concern
& J$ s" ]4 v" h7 E' ]- ]of early sexual development. His mother noticed
) _$ W% F- f' alight colored pubic hair development when he was
3 w, {1 C% ]1 B5 N6 aFrom the 1Division of Pediatric Endocrinology, 2University of: H" s8 s/ E" j# `" V
South Alabama Medical Center, Mobile, Alabama.0 W- m2 ~, K% ^2 ?
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 k6 x+ s5 \8 n# o: hProfessor of Pediatrics, University of South Alabama, College of
  E: s) K6 ?2 ]4 FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" z1 M/ i4 t" e* Be-mail: [email protected].. q& W- \. i% ~9 n; Y- X# w6 U
about 6 to 7 months old, which progressively became9 s4 e7 I6 `: W1 @( ]
darker. She was also concerned about the enlarge-+ P; J" C+ @6 C( s, f2 M( w
ment of his penis and frequent erections. The child, N0 ?6 N3 h( T1 ^7 E; n( N
was the product of a full-term normal delivery, with
7 b! |3 k+ \1 c$ H- fa birth weight of 7 lb 14 oz, and birth length of
) z" l  r. O- Q+ W9 K20 inches. He was breast-fed throughout the first year
& ?( M; z/ r3 c9 v9 [# H; d/ Bof life and was still receiving breast milk along with. o* x$ W1 X4 F( Y0 ~3 X1 y3 ?
solid food. He had no hospitalizations or surgery,
+ |2 w; x' c% z9 }and his psychosocial and psychomotor development4 I+ L% x  \5 i; Y. C. L
was age appropriate.0 \) ?1 ?% G# a9 o# Z  C. ?
The family history was remarkable for the father,' y; D8 b% M* O4 x" x. a
who was diagnosed with hypothyroidism at age 16,
) J# {2 ]0 ~( Y# e+ @! Mwhich was treated with thyroxine. The father’s
: v/ C7 b* t5 t4 k% y: U  uheight was 6 feet, and he went through a somewhat3 z2 Z) H9 j! z; J0 b
early puberty and had stopped growing by age 14.2 g' L7 n8 d% n0 f" ]: E/ ~
The father denied taking any other medication. The- m- @( D+ _  N/ W) e" \6 \$ s
child’s mother was in good health. Her menarche) X* @+ ~* N  u0 Z+ A8 X0 @& P
was at 11 years of age, and her height was at 5 feet0 ^; K. O& u( z- x# Y# l4 C: d
5 inches. There was no other family history of pre-4 i4 w$ p. V! m) n
cocious sexual development in the first-degree rela-
/ n2 @1 B. n+ k1 W4 W, otives. There were no siblings." U" X) N; s$ e$ Q, P
Physical Examination  }  j0 f% X2 e# G
The physical examination revealed a very active,- r% |' @' I* m
playful, and healthy boy. The vital signs documented2 B" t+ z# f0 A" Y' Q
a blood pressure of 85/50 mm Hg, his length was7 @' n; z  h" ~6 p: f# x+ S6 [
90 cm (>97th percentile), and his weight was 14.4 kg$ h+ l# }6 m! x" U0 Z6 l2 w
(also >97th percentile). The observed yearly growth
5 ~' A/ o5 O5 Pvelocity was 30 cm (12 inches). The examination of. ]/ f" _* o9 A) N& m+ x3 s  }
the neck revealed no thyroid enlargement.
6 s: ]/ s, K, H1 SThe genitourinary examination was remarkable for, M8 w5 p6 t  r* u4 V
enlargement of the penis, with a stretched length of
1 {, ]; R, F( t# o# O8 cm and a width of 2 cm. The glans penis was very well3 n2 Y" ~% f' r" i
developed. The pubic hair was Tanner II, mostly around2 K" K7 w, |) {# v  b) L
540
5 i- l' g5 f! h# Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ T- d+ N4 g! u; ~1 f% u: f1 dthe base of the phallus and was dark and curled. The& r6 N& G8 f  m- P1 E+ t- w" o) k
testicular volume was prepubertal at 2 mL each.& t+ X' \# n0 V% g, I
The skin was moist and smooth and somewhat
( h+ R6 L, X9 k) ?oily. No axillary hair was noted. There were no5 T" B" a2 A$ C7 ^4 P. W
abnormal skin pigmentations or café-au-lait spots.& R8 q7 `: l$ I) @6 v
Neurologic evaluation showed deep tendon reflex 2+
  r; n; v5 l8 p( Q7 o# s1 R( G5 q$ {bilateral and symmetrical. There was no suggestion
" x6 Q- _% O9 |! gof papilledema.
' T- X, p6 K2 \5 j) V( h2 G0 x- v( @Laboratory Evaluation1 W* O  {! ^7 j9 c8 q6 @
The bone age was consistent with 28 months by
1 Q" B' f# C2 \! l* n# O- a7 {using the standard of Greulich and Pyle at a chrono-; Z  Z+ f0 o' Y" @  y9 H+ A
logic age of 16 months (advanced).5 Chromosomal
+ Q7 p& X" H. vkaryotype was 46XY. The thyroid function test
  i- p8 L5 ]' G1 }/ x, k6 M) }showed a free T4 of 1.69 ng/dL, and thyroid stimu-( M$ k! l/ N! K5 }4 ^
lating hormone level was 1.3 µIU/mL (both normal).* `4 Z5 J/ X* T* k! T( F
The concentrations of serum electrolytes, blood" x; V9 B0 ?7 c. w
urea nitrogen, creatinine, and calcium all were
4 z) r* S. w& M0 R; [, `( Cwithin normal range for his age. The concentration7 [0 ?8 u9 r% w/ C& k
of serum 17-hydroxyprogesterone was 16 ng/dL
& S& a% W; `. c2 t5 p5 w. S(normal, 3 to 90 ng/dL), androstenedione was 20
* _* m. Y3 @+ ]& C4 `2 @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 N( H7 u$ o) J: K1 O0 J$ _# K, J; g) [terone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 V1 t' A1 G+ y4 T  V" Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
; ]6 Y# g( X9 D* v$ f) j  \0 `49ng/dL), 11-desoxycortisol (specific compound S)! D" G- }4 v  J) q8 L( N0 v" k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. i  B3 O1 r" x" h# M/ F; o! h! Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 O' z2 C# m8 O6 H, I, J% J7 z) [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 p* f4 T; H5 hand β-human chorionic gonadotropin was less than
0 G3 r0 O; Z: p- X9 B5 mIU/mL (normal <5 mIU/mL). Serum follicular2 P" I- {) Z) |! @
stimulating hormone and leuteinizing hormone1 Y- f8 l" R1 O$ r
concentrations were less than 0.05 mIU/mL# ?: j, q2 X1 M6 m! B+ k* }: v& k6 ]
(prepubertal).. K; o$ k* _" C5 }; \# L9 u
The parents were notified about the laboratory) x) t2 ?1 O; z+ @. u! \* V2 h3 f
results and were informed that all of the tests were
3 p# y; N: ?2 c7 @8 I( d% }+ Wnormal except the testosterone level was high. The2 |5 V) e1 E, [$ M2 k' I! Q
follow-up visit was arranged within a few weeks to
; ~# K; L" C0 Iobtain testicular and abdominal sonograms; how-0 K7 f! A( }9 {1 |' d! O  }
ever, the family did not return for 4 months.* ]# R' D9 t7 v3 @
Physical examination at this time revealed that the8 `, J1 h# n1 a. T$ K: r8 I0 _
child had grown 2.5 cm in 4 months and had gained; e( S3 E( b1 a
2 kg of weight. Physical examination remained
6 J% [3 d. U5 ^6 [& uunchanged. Surprisingly, the pubic hair almost com-
2 m% Y+ |7 C1 ]& b1 ~0 J5 m  Z. V  _pletely disappeared except for a few vellous hairs at
5 N) f# H6 Z2 t8 J9 Dthe base of the phallus. Testicular volume was still 29 H' ]8 e! |; i& q5 b
mL, and the size of the penis remained unchanged.
6 f" q2 N; b2 A/ @. {+ _7 W. f. JThe mother also said that the boy was no longer hav-4 B1 G& K2 G, b- d
ing frequent erections.
$ I3 t% K: v5 l; }) ?! oBoth parents were again questioned about use of
9 W9 u% s" L$ s+ o# H9 s% qany ointment/creams that they may have applied to- I; p  G7 {* Z
the child’s skin. This time the father admitted the7 o4 `# J! S5 B% S- r" @* m0 }7 P
Topical Testosterone Exposure / Bhowmick et al 541
, a+ _! I# E0 ?% w4 ?: ause of testosterone gel twice daily that he was apply-
6 E' E" c- ]# s5 _. g! \$ Y$ qing over his own shoulders, chest, and back area for
/ o- L- g7 N- A/ _9 u% oa year. The father also revealed he was embarrassed# c* E& K7 k/ h
to disclose that he was using a testosterone gel pre-
& K2 S% C/ O3 k2 j% zscribed by his family physician for decreased libido
$ f$ B+ z  x. Psecondary to depression.
+ q1 Q& V0 x& L" f- AThe child slept in the same bed with parents.
$ _/ r! ~& U8 y) J. z/ G; fThe father would hug the baby and hold him on his9 G7 ^: T, T, D3 T0 V
chest for a considerable period of time, causing sig-# H: a- y) S5 {0 z! g2 N
nificant bare skin contact between baby and father.
0 u9 `2 ]; C$ {( y# r% GThe father also admitted that after the phone call,
7 v8 j5 N% e% I2 t& Pwhen he learned the testosterone level in the baby
9 i# R7 ]  y/ b3 gwas high, he then read the product information/ r; p4 i. `. J# J
packet and concluded that it was most likely the rea-
$ W; d& I2 d$ k* Qson for the child’s virilization. At that time, they
$ M: r4 G: D* ^/ M3 n/ Rdecided to put the baby in a separate bed, and the0 a9 A& P; l2 G- [' U; G5 V$ }
father was not hugging him with bare skin and had
9 g0 [3 N" k  y+ a+ Z$ Q: Cbeen using protective clothing. A repeat testosterone. U, q+ A4 K( o) @0 {9 }/ [
test was ordered, but the family did not go to the
; O4 t, _7 [1 s0 q8 ]laboratory to obtain the test.8 ^5 x( p& a: F) c; _
Discussion
& k- T' C3 ~- R9 O8 MPrecocious puberty in boys is defined as secondary
) ~/ J: b3 ~$ k4 Y9 ~sexual development before 9 years of age.1,4* ~( \2 i6 G" m6 p1 O/ x
Precocious puberty is termed as central (true) when2 p; B; H, p1 C& f( y! E& X
it is caused by the premature activation of hypo-
3 `) M0 x% I7 k5 i2 _4 ?8 Rthalamic pituitary gonadal axis. CPP is more com-
: Q: [* t3 D* e4 lmon in girls than in boys.1,3 Most boys with CPP
) @; a4 K2 V) ], S: v4 R* _may have a central nervous system lesion that is
$ ^# G# p% b6 ?  K$ nresponsible for the early activation of the hypothal-
2 V$ R( m+ B4 n; B! ]7 k; W* |amic pituitary gonadal axis.1-3 Thus, greater empha-
9 E$ E. ]7 L2 ^3 s$ U- o) Qsis has been given to neuroradiologic imaging in
! a  |" D8 m4 \7 O8 u( }# wboys with precocious puberty. In addition to viril-
% p; D0 b9 q& F7 ], P" a6 Lization, the clinical hallmark of CPP is the symmet-* u, t  I7 n, \$ K" b% q9 E
rical testicular growth secondary to stimulation by
4 r/ {1 y8 t2 m' @# x( W" L7 Wgonadotropins.1,37 T7 d! X9 b+ m2 V
Gonadotropin-independent peripheral preco-4 N* D0 R- G9 B
cious puberty in boys also results from inappropriate
! C: h3 G8 l8 K; H5 x+ D" o4 I4 Randrogenic stimulation from either endogenous or
. X- ~) k) B: w, jexogenous sources, nonpituitary gonadotropin stim-& i; u# ?/ f* k9 i0 M- f+ Y5 `6 U
ulation, and rare activating mutations.3 Virilizing
) E) a9 W* m* F6 Q; n  mcongenital adrenal hyperplasia producing excessive% Y' }/ B6 }$ Y
adrenal androgens is a common cause of precocious
: o8 }  {8 D" `8 h( e6 k1 {! v- Opuberty in boys.3,4
, f7 }" z5 s6 b9 C9 L: {9 o" QThe most common form of congenital adrenal
. ]( a) w6 U% V' K) ohyperplasia is the 21-hydroxylase enzyme deficiency.
9 X  T5 Z- _+ G; s( _0 vThe 11-β hydroxylase deficiency may also result in) m  B# c3 Z" l
excessive adrenal androgen production, and rarely,
6 k6 l) h! E; D2 Y, i% Man adrenal tumor may also cause adrenal androgen
$ c/ M0 {0 a1 u4 c8 A! v* i' Zexcess.1,3
* C8 D0 o: z, iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  l7 z- B7 |5 _6 b5 M$ e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, i  V! K/ V+ A9 `  y" jA unique entity of male-limited gonadotropin-' m6 {& R4 h1 u- |7 L+ f9 \
independent precocious puberty, which is also known9 u; b. Y$ p0 A( h, M1 s
as testotoxicosis, may cause precocious puberty at a: P0 h3 f3 M2 Y* c2 S# p: J4 z
very young age. The physical findings in these boys$ I3 x% H7 h' O# K7 L- \
with this disorder are full pubertal development,
3 O* E: R% U5 h; {including bilateral testicular growth, similar to boys4 d& d3 ]: B: G/ [( {. ~4 W
with CPP. The gonadotropin levels in this disorder
* i# @7 {6 s$ g0 ?* }/ bare suppressed to prepubertal levels and do not show6 [/ X) W, ^& Z9 M
pubertal response of gonadotropin after gonadotropin-/ y  _- b2 _+ P; ]
releasing hormone stimulation. This is a sex-linked' \9 J. }1 N, p! ]4 \9 i/ ?2 k
autosomal dominant disorder that affects only
* M* v+ a" b2 V# M; j7 Zmales; therefore, other male members of the family6 L5 W5 R* Y* t6 D7 A2 ]! U
may have similar precocious puberty.38 O/ H4 Y) q9 ^
In our patient, physical examination was incon-8 F" c5 B+ C$ |
sistent with true precocious puberty since his testi-* `2 n: E% |8 H
cles were prepubertal in size. However, testotoxicosis
' d/ f5 `( ]; b  |) r- Ywas in the differential diagnosis because his father
' |) ^5 Y, I" q1 `: bstarted puberty somewhat early, and occasionally,8 R$ \6 v3 V5 ]  q2 ~* u
testicular enlargement is not that evident in the" ?, a( }) l3 i4 `3 N- _* |
beginning of this process.1 In the absence of a neg-
7 i) o5 t9 |9 d2 r: C7 ?ative initial history of androgen exposure, our
2 b6 s2 F: x4 o# W1 V0 [: ^biggest concern was virilizing adrenal hyperplasia," t# z, u) r( ?5 e/ x
either 21-hydroxylase deficiency or 11-β hydroxylase
) w+ B$ K9 O- q+ h$ j% fdeficiency. Those diagnoses were excluded by find-
/ {& \0 h" x( R' j0 h# iing the normal level of adrenal steroids.
1 S# M2 ]% G; A# ^The diagnosis of exogenous androgens was strongly& U- p7 O6 o" N
suspected in a follow-up visit after 4 months because7 K' j6 a/ k/ t% m+ _
the physical examination revealed the complete disap-/ ^3 o8 l4 x$ ?& `. w' N& e
pearance of pubic hair, normal growth velocity, and7 v9 t+ E! x9 P8 P
decreased erections. The father admitted using a testos-; B, a% R, @; G8 J" U
terone gel, which he concealed at first visit. He was
7 U! @& u, `3 p3 l# _: zusing it rather frequently, twice a day. The Physicians’
4 l) |6 y: M/ F) D2 \Desk Reference, or package insert of this product, gel or3 p# ^" u. X; y! H* U
cream, cautions about dermal testosterone transfer to/ A" ^/ C: ?; b* Y
unprotected females through direct skin exposure.) O0 t; Q/ k* [9 U2 w% E
Serum testosterone level was found to be 2 times the( ~) y3 J. y; _7 w& D
baseline value in those females who were exposed to
7 F8 P7 \8 Y) heven 15 minutes of direct skin contact with their male; i2 w9 L2 H/ ]$ |. H
partners.6 However, when a shirt covered the applica-1 L# K7 ~+ w. X* A" y. c8 e: w
tion site, this testosterone transfer was prevented.
# h) w- f8 v$ h; o/ mOur patient’s testosterone level was 60 ng/mL,. ~" A7 P* C! {2 O( k9 Z# g
which was clearly high. Some studies suggest that- z& R1 e: G2 j
dermal conversion of testosterone to dihydrotestos-3 X) ~, e: l) H1 m! ^$ K! O  A
terone, which is a more potent metabolite, is more0 M. c, L+ n7 Y6 k$ F+ s
active in young children exposed to testosterone8 i. X5 e& P8 V5 F
exogenously7; however, we did not measure a dihy-6 v8 c" v+ b/ n8 R, K' p
drotestosterone level in our patient. In addition to9 u9 F0 [, D& C) l! A1 }# G
virilization, exposure to exogenous testosterone in
- o6 B5 n% f; Y9 [% t/ _) b. tchildren results in an increase in growth velocity and+ s, W0 A; ]. a9 T' ]- j; c
advanced bone age, as seen in our patient.
5 V& p# v; s' e4 t' x' X; O, M' ~) e$ wThe long-term effect of androgen exposure during
5 v) j7 \7 J# X/ ]2 @3 |early childhood on pubertal development and final3 C: b2 H. F0 X! a
adult height are not fully known and always remain
- O; m  {0 {' O, q' S/ r/ Ia concern. Children treated with short-term testos-0 `* b6 b/ z/ k/ K
terone injection or topical androgen may exhibit some  W* X, U" Y6 w0 B
acceleration of the skeletal maturation; however, after
& T! v+ [, F( S- u" ^cessation of treatment, the rate of bone maturation
0 W; f6 _# r8 p; w7 W) s* U2 z- Tdecelerates and gradually returns to normal.8,9/ Y- k( ~0 S) B5 \
There are conflicting reports and controversy. E: R6 q4 W+ @: S) |! P, _
over the effect of early androgen exposure on adult
  @0 `* l4 e7 r, Xpenile length.10,11 Some reports suggest subnormal
! G" o; z0 P* G/ R* e1 P' L& ?! J! u# cadult penile length, apparently because of downreg-2 Z* F/ t! t4 f" @/ A
ulation of androgen receptor number.10,12 However,
0 i; [. z' }) C: ySutherland et al13 did not find a correlation between
0 ?8 [$ z) Y; W4 D2 [, ichildhood testosterone exposure and reduced adult
1 \; z/ B/ k7 f7 |penile length in clinical studies.8 w2 J: T" D7 R, o# B. b+ Z. S
Nonetheless, we do not believe our patient is$ e+ L" \9 B% z# M: \9 P( M
going to experience any of the untoward effects from$ ~4 r9 J& u' r5 I& J" g
testosterone exposure as mentioned earlier because
7 N) p/ m& i1 {+ |( Pthe exposure was not for a prolonged period of time.
* Y: C9 `# z: F1 T, R" WAlthough the bone age was advanced at the time of
9 o0 y( R5 a) V% adiagnosis, the child had a normal growth velocity at+ j9 T) L$ j; c) [1 w
the follow-up visit. It is hoped that his final adult
0 G( T5 l& l" S% D7 R* \height will not be affected.7 ]. r" D' G6 u3 j+ D6 b
Although rarely reported, the widespread avail-
$ K, X: I* ]* C) ]; R9 uability of androgen products in our society may
+ {8 t6 k2 L! d; L" d5 bindeed cause more virilization in male or female
0 }! q- z& [  E: Z. B( nchildren than one would realize. Exposure to andro-
, I8 w% q6 W$ W5 P! Ugen products must be considered and specific ques-, D  s  Q  i; \4 F/ h$ [! `
tioning about the use of a testosterone product or
  [" S2 N: |- T$ o4 X8 M5 Zgel should be asked of the family members during  K% ?6 B% O) t" S
the evaluation of any children who present with vir-
. d7 i9 l5 e9 l. Iilization or peripheral precocious puberty. The diag-
1 G( k+ @5 ~; ]nosis can be established by just a few tests and by
1 l1 f7 R; Z4 ~) ]- D# @appropriate history. The inability to obtain such a( H, K1 X% w# B  Q# ^: D/ f
history, or failure to ask the specific questions, may7 S* a9 E, D2 A/ M' ]5 K
result in extensive, unnecessary, and expensive5 s' a* }; V) }' y* p' ^6 K, L) ~# s
investigation. The primary care physician should be$ f0 }) n. H$ T7 e( G
aware of this fact, because most of these children
6 I; K( }: U  \6 N2 R: Z7 q! Q# ~may initially present in their practice. The Physicians’
* f+ }: d. S2 V3 F. Z8 ]Desk Reference and package insert should also put a& J. S$ o( Q4 _  h: A8 P& v0 d
warning about the virilizing effect on a male or0 i" J9 B2 n+ A9 _. O4 [
female child who might come in contact with some-
! c% w2 ~) Y8 Z+ G; D* Y, Z  X) e' F% aone using any of these products.
8 U' R  G0 s: t  rReferences) A+ ?  |6 L$ K6 X' @) N
1. Styne DM. The testes: disorder of sexual differentiation
' n: A7 n9 [6 Y  l  k7 I  Kand puberty in the male. In: Sperling MA, ed. Pediatric
1 a2 B) ^1 L# \9 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% K0 ^0 @, t3 I! x9 S) [
2002: 565-628.; |/ v5 r, W7 U' A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' M2 ^1 I) i5 ^/ \- }3 b5 l; apuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
; ^5 |* F+ {* \7 _Boy Induced by Indirect Topical" O" R. X* M  O
Exposure to Testosterone
) Q2 p9 p) N  \. ^Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ H% ~5 ]# N" e- P. g/ D0 Dand Kenneth R. Rettig, MD1
7 K$ J4 K( l5 E) s, U  {Clinical Pediatrics
8 u' l; Q1 u7 TVolume 46 Number 69 Q9 }' m7 E5 F! F6 P  V& }7 m
July 2007 540-543
) G! M! G- Z4 {2 m; W© 2007 Sage Publications
& @" L& I* x( F) W5 h10.1177/0009922806296651
5 |! D. U7 u& Y$ o! e4 F9 `8 v' Fhttp://clp.sagepub.com+ P- z6 _# o2 u. Y3 H: ?2 ]
hosted at( k* Z+ y! ?0 M' V; R
http://online.sagepub.com
! U* s% r: x. C# d( {1 ]) w8 r; {; JPrecocious puberty in boys, central or peripheral,) A+ T0 m! l: U( j
is a significant concern for physicians. Central" c3 B, ~/ `* M4 ^
precocious puberty (CPP), which is mediated
3 O6 q$ b3 ?! n- {* hthrough the hypothalamic pituitary gonadal axis, has7 q; ~; W- d2 d: b: f3 G+ Y
a higher incidence of organic central nervous system
2 l, W; S2 i  n1 ilesions in boys.1,2 Virilization in boys, as manifested
" X9 S0 I0 k, Y  a, eby enlargement of the penis, development of pubic
, e) c: T& K. ~5 uhair, and facial acne without enlargement of testi-) F4 u3 e% K  F
cles, suggests peripheral or pseudopuberty.1-3 We- u0 c2 j$ g( H8 S9 ?
report a 16-month-old boy who presented with the5 Y. `4 O/ B" Q* s1 A  V
enlargement of the phallus and pubic hair develop-
2 g$ B2 P  }7 o5 {ment without testicular enlargement, which was due
& a- X# r) \3 fto the unintentional exposure to androgen gel used by6 C$ ~7 H6 L; P/ r% `" R& ^% O
the father. The family initially concealed this infor-: a. x0 f& {1 H8 F6 ~
mation, resulting in an extensive work-up for this
( H' A6 a3 o! K' }# Qchild. Given the widespread and easy availability of
& E' O5 z; ]' i' i5 [testosterone gel and cream, we believe this is proba-
  j  G2 s7 h* mbly more common than the rare case report in the+ r* c1 b# o( d( L
literature.43 z! L/ [& U( G" w  E
Patient Report; `7 n( F( {6 s. Q7 t
A 16-month-old white child was referred to the
0 X+ X/ Q( p* i+ xendocrine clinic by his pediatrician with the concern$ f* E" p% i3 J) x
of early sexual development. His mother noticed$ d0 Z7 @2 N# V: q, R/ Z
light colored pubic hair development when he was' n6 E( E& H/ _
From the 1Division of Pediatric Endocrinology, 2University of' A( ^8 n* n2 U+ L9 M
South Alabama Medical Center, Mobile, Alabama.& J/ g3 P" q5 \- X  F
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# X" A+ B6 m. W3 f0 ]Professor of Pediatrics, University of South Alabama, College of
$ \* p( ~/ _* K  \Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;% s, m" |8 W3 g
e-mail: [email protected].2 l" D: v" L4 M! i% v( s% R
about 6 to 7 months old, which progressively became
8 x; J, C; ]" I0 F) Udarker. She was also concerned about the enlarge-
. s9 t. o1 [# I/ c# L& ^# _, }8 tment of his penis and frequent erections. The child
  K  G) x# _! H3 @6 bwas the product of a full-term normal delivery, with* w/ X% Y! N2 s6 |: c* P( Z% ~# @0 ~
a birth weight of 7 lb 14 oz, and birth length of/ x7 F- A: J+ |
20 inches. He was breast-fed throughout the first year( ^% a5 ~6 h  z5 _7 z, Y! V
of life and was still receiving breast milk along with; [0 ~# ~) m2 q" E
solid food. He had no hospitalizations or surgery,
! f& v* X8 ^  i8 N# W" A1 Yand his psychosocial and psychomotor development9 z- F1 {( m0 U% O/ g. d
was age appropriate.
5 C6 ^+ ?3 I1 l0 Z% o# B5 m9 M* eThe family history was remarkable for the father,
* U. D2 D/ I- R+ T1 v7 Y7 h* lwho was diagnosed with hypothyroidism at age 16,
) X/ |; T' d4 R( S" [" q: f% lwhich was treated with thyroxine. The father’s
+ G% }( L' S; }' X2 R1 Gheight was 6 feet, and he went through a somewhat$ w) @, N/ V$ {: C8 l- S
early puberty and had stopped growing by age 14.. L6 l6 f& e. [4 a6 t- M3 _- f
The father denied taking any other medication. The# _/ X7 s; J7 b- d& u
child’s mother was in good health. Her menarche0 K- _% |% ?! |6 t
was at 11 years of age, and her height was at 5 feet
1 c' K! z6 @3 b8 }8 e! u7 l, E; T  B5 inches. There was no other family history of pre-
3 h# `; t; y7 L/ k; E) |cocious sexual development in the first-degree rela-. A+ D1 I, d) ~9 d+ J- d
tives. There were no siblings.
. m1 d2 ~6 t1 E% SPhysical Examination
7 t* {+ ^1 M" R, y  m2 KThe physical examination revealed a very active,
5 K$ r$ ~# n3 F' C. jplayful, and healthy boy. The vital signs documented2 b& D4 z+ ~1 ?
a blood pressure of 85/50 mm Hg, his length was
. R' n9 Z& m0 r0 d) N90 cm (>97th percentile), and his weight was 14.4 kg
# F5 _# W$ M/ ]/ I: A(also >97th percentile). The observed yearly growth! ]' N) ^/ \4 U! T: H
velocity was 30 cm (12 inches). The examination of
% c3 V6 w- |# n. z) Lthe neck revealed no thyroid enlargement.
" w" H5 y! s5 [4 Q! z3 _  sThe genitourinary examination was remarkable for8 R- O& V+ L  A7 ^% _
enlargement of the penis, with a stretched length of
- Q! z! U( k% k1 o4 `' g8 cm and a width of 2 cm. The glans penis was very well: [% W# M& i3 I2 m% s% f2 c
developed. The pubic hair was Tanner II, mostly around
) _& i7 e+ F; t# R$ ?* S540
8 b* E, ?! Y! h/ y$ |at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# g& _- s, t7 N  y, r2 q
the base of the phallus and was dark and curled. The
% L) {- r; \$ P# ^$ N' ]testicular volume was prepubertal at 2 mL each.
# |0 A6 f' J0 }The skin was moist and smooth and somewhat
# o& K, s& a4 g4 k3 Doily. No axillary hair was noted. There were no9 q6 P, m/ b2 ?1 w/ @6 O9 |: J
abnormal skin pigmentations or café-au-lait spots.. C4 P+ i  l  ?7 ^1 Y
Neurologic evaluation showed deep tendon reflex 2+8 ~% ~& D% ~1 ^8 h9 l1 |
bilateral and symmetrical. There was no suggestion
9 w) m3 B. Q* A0 F+ ~' Y+ ?$ Cof papilledema.9 t. H2 n$ d  M9 f, c# i+ P
Laboratory Evaluation3 g/ y+ Y0 Q3 R! M( d
The bone age was consistent with 28 months by
1 E2 i+ u# H& E% b2 i$ r( m5 Uusing the standard of Greulich and Pyle at a chrono-9 v& e) }7 m$ R! z
logic age of 16 months (advanced).5 Chromosomal
! N$ j4 _& Q, C: _  l. E' u( @# ^karyotype was 46XY. The thyroid function test
" k* a  L) i. L8 nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 u, l4 T: L0 G0 Rlating hormone level was 1.3 µIU/mL (both normal).5 J; }! `: v/ s; Q! R# H5 @
The concentrations of serum electrolytes, blood: t& Q5 l( Z8 {0 ]9 F: Z. y9 a
urea nitrogen, creatinine, and calcium all were
$ i: A" o' l) L" r( f; s4 ~" Jwithin normal range for his age. The concentration
  g# g7 H& o: q  x% {of serum 17-hydroxyprogesterone was 16 ng/dL
1 a0 }: ?9 Y5 G1 ?- `5 c3 G5 j(normal, 3 to 90 ng/dL), androstenedione was 20/ o# {  V2 ~9 ?. M+ \8 ^
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: [, \9 p5 U; N) Y$ ~7 ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- e4 I8 ?6 a) q' _, t2 z& C/ T8 Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 J% t+ i1 f2 _! {( j0 U
49ng/dL), 11-desoxycortisol (specific compound S); p' J. n( c5 e7 a% ]
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 V8 X" E4 }) t! m# o5 [' u* ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ y. `" Z6 z! G4 w( H3 g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 s" x/ L% g/ V  n- w4 Pand β-human chorionic gonadotropin was less than* R) E1 B1 n- C
5 mIU/mL (normal <5 mIU/mL). Serum follicular' }3 Y; P" e+ S( U
stimulating hormone and leuteinizing hormone2 q9 w9 j# }/ J) V7 N' O4 \
concentrations were less than 0.05 mIU/mL
: Z* B% T5 W1 c; `5 a(prepubertal).+ c0 ^" \3 j* |; I6 o8 h
The parents were notified about the laboratory
; ~+ k! Y8 H! ?2 }/ M$ Qresults and were informed that all of the tests were
; w% p9 u: a' }+ ~normal except the testosterone level was high. The
: W7 z. s) W1 O: H9 \' l2 S  j" Tfollow-up visit was arranged within a few weeks to
& i+ p% O7 W3 }/ c/ Lobtain testicular and abdominal sonograms; how-: F- K" i/ o' T( ~" }/ Y
ever, the family did not return for 4 months.* p) D% v5 c$ q
Physical examination at this time revealed that the, G1 m0 t/ }8 k; P
child had grown 2.5 cm in 4 months and had gained
% ?. Q4 G& f$ K) B2 kg of weight. Physical examination remained1 V0 Q: d- Q) ~7 C
unchanged. Surprisingly, the pubic hair almost com-  {' `# N$ F3 P
pletely disappeared except for a few vellous hairs at
! d4 k  G$ I" }( ~! A  D% r( vthe base of the phallus. Testicular volume was still 2
! p, j1 e- [4 n  N# n$ pmL, and the size of the penis remained unchanged.: J3 V/ h/ P5 N8 o9 v% J5 ~
The mother also said that the boy was no longer hav-& h  M: x/ f1 h9 Z8 f9 x& i
ing frequent erections.  M/ Z6 ]$ r- S- n
Both parents were again questioned about use of1 m. J4 c, {! F# p# [
any ointment/creams that they may have applied to
& o  p* Q# Z/ athe child’s skin. This time the father admitted the
: J  C# @6 u9 X% L' NTopical Testosterone Exposure / Bhowmick et al 541/ c- a6 O6 G0 U5 z! ~. b4 s1 @
use of testosterone gel twice daily that he was apply-) ]8 M4 {- G0 Y, F. M) h+ t- \
ing over his own shoulders, chest, and back area for
0 x# n4 R+ r' [, W0 U- Ba year. The father also revealed he was embarrassed' K" @) {; I3 V2 p: Y% m
to disclose that he was using a testosterone gel pre-# T# [  a  }9 M9 v
scribed by his family physician for decreased libido
, b2 s, y! e4 R0 T, p( _secondary to depression./ E7 H5 u; L6 V
The child slept in the same bed with parents.. _. |7 b' `& A6 m% H& x6 B2 k/ C
The father would hug the baby and hold him on his, A* G+ q6 V# d/ i5 v* |
chest for a considerable period of time, causing sig-
) z  o) z4 s$ f+ u2 l5 f! Dnificant bare skin contact between baby and father.
& i- T, K6 d, w) A1 m$ r  _The father also admitted that after the phone call,
7 T6 |+ c* J1 v8 h* gwhen he learned the testosterone level in the baby/ X1 @  }; x, f& z) \
was high, he then read the product information
  t& X, a! X! U( k, [2 X' t# zpacket and concluded that it was most likely the rea-
7 {: n8 L: A: t  `6 n! z- vson for the child’s virilization. At that time, they" B. Z0 ~; E- F; k
decided to put the baby in a separate bed, and the
( c; r! z# }- B$ S  Ifather was not hugging him with bare skin and had& H" ]. P; F2 [; X& |
been using protective clothing. A repeat testosterone; G( `  T6 Z, _; H, ?' k
test was ordered, but the family did not go to the) ]4 ?% g" X! X/ a! \, c5 U1 ~
laboratory to obtain the test.. H$ F  g& ~6 m( O# U
Discussion: f5 l4 ~: N7 ~2 D9 c$ i4 G
Precocious puberty in boys is defined as secondary
7 {' S5 F+ X+ U* msexual development before 9 years of age.1,4- Q( ]1 t& v7 S; q/ z( E) T
Precocious puberty is termed as central (true) when
; z$ A5 w+ P9 r, c3 f8 Wit is caused by the premature activation of hypo-+ N1 f9 F# ^( w3 @9 K# {; Q
thalamic pituitary gonadal axis. CPP is more com-
; o/ W& r3 t3 x) `mon in girls than in boys.1,3 Most boys with CPP
% T2 X! N. R' y0 jmay have a central nervous system lesion that is
0 J5 T1 {8 Q2 G5 l) L. m- kresponsible for the early activation of the hypothal-# a' Q3 h! U  F% U/ q
amic pituitary gonadal axis.1-3 Thus, greater empha-
) p- _9 @# [6 V: j$ W% U- ^sis has been given to neuroradiologic imaging in
3 [! p% y9 g1 D3 Mboys with precocious puberty. In addition to viril-
1 l* K3 D6 h8 M; j: f- |$ i/ yization, the clinical hallmark of CPP is the symmet-
- [3 ~$ p/ S- }9 crical testicular growth secondary to stimulation by4 L% t# m6 i4 q* b
gonadotropins.1,3
' S6 {. e. n7 t" mGonadotropin-independent peripheral preco-4 ^8 I8 z; b# [7 }
cious puberty in boys also results from inappropriate
$ B. ~: w% i; eandrogenic stimulation from either endogenous or
+ e0 n- v; r( u2 \; I! r" v& lexogenous sources, nonpituitary gonadotropin stim-0 `' F* b* {3 m/ V* l$ A
ulation, and rare activating mutations.3 Virilizing* d: C/ o( I/ U& H6 T
congenital adrenal hyperplasia producing excessive( _  c  z+ v5 R' P  z: T
adrenal androgens is a common cause of precocious
# J; c& z" |5 O9 T$ `: @- Opuberty in boys.3,42 T+ X1 f& b, u2 c. A8 t- ~
The most common form of congenital adrenal* ^  p* z; g3 p. N
hyperplasia is the 21-hydroxylase enzyme deficiency.! E' B- E2 R* F' I
The 11-β hydroxylase deficiency may also result in
8 ~: x0 y$ D, X2 o5 h- \excessive adrenal androgen production, and rarely,6 o" P# p+ [' B/ U; A) W1 M
an adrenal tumor may also cause adrenal androgen
  a/ j! y4 j. {+ [( }0 Mexcess.1,3
! S% \9 O( n1 w1 ]( s8 o* bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* s( O* k3 k' ^: S" m. s542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ [5 ]. O( D1 q
A unique entity of male-limited gonadotropin-
! W' g8 O2 g/ V* qindependent precocious puberty, which is also known
  ]. B: U* c" I; o* Gas testotoxicosis, may cause precocious puberty at a7 i$ E- P9 i0 q' ^  O- J# ]' d, B
very young age. The physical findings in these boys0 P8 t. B! |& X1 }
with this disorder are full pubertal development,2 p  j1 \  ^( f; k4 `8 w/ G7 P0 C
including bilateral testicular growth, similar to boys
' k/ k+ o2 Z3 Lwith CPP. The gonadotropin levels in this disorder
, w4 j5 F2 n3 w: A1 [4 aare suppressed to prepubertal levels and do not show+ _" q% V# {' u8 n; ^- M
pubertal response of gonadotropin after gonadotropin-
4 i4 e* x! d3 [releasing hormone stimulation. This is a sex-linked
$ n' f) u# r0 W6 l4 o' Pautosomal dominant disorder that affects only/ X' U( e: T/ p4 _9 I
males; therefore, other male members of the family5 |+ l: h; @& `# R
may have similar precocious puberty.3
7 }- E* p  U2 i6 e! A. SIn our patient, physical examination was incon-
& F4 c  P4 v2 e  z4 lsistent with true precocious puberty since his testi-$ M6 |3 e, h) Q: m* V% Y: M' ^
cles were prepubertal in size. However, testotoxicosis
' p4 s  f" c( n' C; \/ Bwas in the differential diagnosis because his father, w9 e" a2 |3 S& H; ?5 h2 N6 Q
started puberty somewhat early, and occasionally,0 l$ q) H5 J5 o
testicular enlargement is not that evident in the! ~) P$ M* X/ `+ G+ t2 l
beginning of this process.1 In the absence of a neg-" H! z8 k9 c! u7 G5 A% J' v
ative initial history of androgen exposure, our% q; n1 V* H4 ^; ^5 `6 w7 s1 N
biggest concern was virilizing adrenal hyperplasia,/ s( W9 m+ g1 j2 W5 w
either 21-hydroxylase deficiency or 11-β hydroxylase
; a* {2 t, Y* j0 V$ P, sdeficiency. Those diagnoses were excluded by find-- G8 N% z: ~% W' }& K# h
ing the normal level of adrenal steroids.: X+ ^1 W0 u; H/ r/ }
The diagnosis of exogenous androgens was strongly
2 v- G, k% Q# g9 y" y1 {3 \$ Ususpected in a follow-up visit after 4 months because
# E, b' _! ]; ^the physical examination revealed the complete disap-
) N# X) w. V$ L: z0 u0 C7 Epearance of pubic hair, normal growth velocity, and8 a  |! j3 a4 V* ~: ^. w+ J6 Y
decreased erections. The father admitted using a testos-" m7 c1 i; c4 p6 d, P( _3 D& S* U
terone gel, which he concealed at first visit. He was
9 O' P  T! }7 Y- C/ m3 Xusing it rather frequently, twice a day. The Physicians’+ @& B- i2 h3 e  j( C4 U& N7 O
Desk Reference, or package insert of this product, gel or
& n& S6 g8 e& `cream, cautions about dermal testosterone transfer to
8 G; Y3 V2 d) v& Yunprotected females through direct skin exposure.4 Z; S9 g3 e* O8 u7 b0 m) W
Serum testosterone level was found to be 2 times the
$ F+ T: Y4 m4 J- K! ]( G6 Fbaseline value in those females who were exposed to
+ z3 J; e. B9 a: x+ C4 s( Veven 15 minutes of direct skin contact with their male+ B! H9 m( C1 g$ M
partners.6 However, when a shirt covered the applica-$ R6 F' Q# a* G4 h/ S2 v
tion site, this testosterone transfer was prevented.6 Q% Y$ T) n4 t. G, h( e
Our patient’s testosterone level was 60 ng/mL,; n: X% q( ]' w
which was clearly high. Some studies suggest that
, d4 O% z" b9 q/ E& qdermal conversion of testosterone to dihydrotestos-
: r# K7 G$ P7 t, [+ Sterone, which is a more potent metabolite, is more
1 Z3 H# R9 r4 t  Q1 g- ~active in young children exposed to testosterone, g" b' Y$ j. k5 E* ~; N
exogenously7; however, we did not measure a dihy-* J7 ^- q6 O1 N
drotestosterone level in our patient. In addition to6 a5 b0 m5 C  X0 c
virilization, exposure to exogenous testosterone in
9 G$ b1 }6 }/ E* ^& u  fchildren results in an increase in growth velocity and
" y0 A& B5 a) s# o- c! g7 madvanced bone age, as seen in our patient.. B( x9 E! e6 n; O/ p
The long-term effect of androgen exposure during+ P' D$ F$ S0 i
early childhood on pubertal development and final
( l7 Q3 n# t/ Kadult height are not fully known and always remain2 k+ B, N# Y1 c3 y
a concern. Children treated with short-term testos-
  J2 P9 `) g  M0 c1 Cterone injection or topical androgen may exhibit some1 n4 l) }4 |9 L- u
acceleration of the skeletal maturation; however, after) {% N* X) [2 `' }
cessation of treatment, the rate of bone maturation; t2 k/ }5 b! D
decelerates and gradually returns to normal.8,96 t* G1 k/ s& [3 |
There are conflicting reports and controversy
% g8 ]4 r3 p% w* J- \over the effect of early androgen exposure on adult* F- @- M8 \* |7 y/ D
penile length.10,11 Some reports suggest subnormal
& B. f' ^" y: q% f# padult penile length, apparently because of downreg-1 N. d  L" s9 H) b
ulation of androgen receptor number.10,12 However,& `6 M& t1 ^1 g+ K7 _
Sutherland et al13 did not find a correlation between
  o, @. C2 Q9 C; xchildhood testosterone exposure and reduced adult6 {. P& D# ~! J& ?
penile length in clinical studies.
  z( V0 z6 `4 p; N/ s7 \' ?$ bNonetheless, we do not believe our patient is
$ S9 q1 ~$ d! pgoing to experience any of the untoward effects from, j) S. I& ~6 B% X0 F' J# g8 i
testosterone exposure as mentioned earlier because
1 a$ D- w# h- `the exposure was not for a prolonged period of time.
$ R9 A/ `7 N/ [7 p7 `8 J! `Although the bone age was advanced at the time of5 ]' Z! D! ~1 ]# F% O
diagnosis, the child had a normal growth velocity at2 W  r- b, a/ {& B5 j; m
the follow-up visit. It is hoped that his final adult( K- F0 t, y) V) D* R
height will not be affected.
8 Y5 k' h# Q- T5 z# gAlthough rarely reported, the widespread avail-
( e3 Q, D! L' c, Z; Q% dability of androgen products in our society may
9 |/ m* B: X/ \2 U) X+ ?. Mindeed cause more virilization in male or female
  w. @, O1 i  M& [: Wchildren than one would realize. Exposure to andro-
+ B! Z$ z4 q. Mgen products must be considered and specific ques-( w' x. W3 }5 ]* m: Z: t# b* G
tioning about the use of a testosterone product or6 l& S# ?" X; I/ P5 D
gel should be asked of the family members during7 `# n- U+ ~3 v* {/ R3 Z+ H/ C
the evaluation of any children who present with vir-+ G$ Q0 `. ^9 C/ t( ?  z  L
ilization or peripheral precocious puberty. The diag-1 C. u8 Q$ T+ {& s
nosis can be established by just a few tests and by# U8 f: t- J# q$ k* O
appropriate history. The inability to obtain such a
9 Q& h/ I6 J8 c$ Lhistory, or failure to ask the specific questions, may
3 ?$ ?# l8 a3 Y, Z( xresult in extensive, unnecessary, and expensive6 t5 t6 X" I! Y. a
investigation. The primary care physician should be* i$ a, u2 f9 b  {8 i5 ~
aware of this fact, because most of these children
' A5 N/ j! S% l$ ^may initially present in their practice. The Physicians’! [5 Y" X* N- A) j* y5 U
Desk Reference and package insert should also put a  w, z, F# ~: \' H
warning about the virilizing effect on a male or) b* Z! L8 k% t
female child who might come in contact with some-9 T1 }0 x$ t6 m# d1 K
one using any of these products.
+ @% ^" R- X, ^& `1 {1 D) {, bReferences
" @; r" M  H. {8 t' w: H1. Styne DM. The testes: disorder of sexual differentiation: w# f; o' L# Q" \8 ]) ^5 K
and puberty in the male. In: Sperling MA, ed. Pediatric
, D, G* Z2 F, R, Q/ K! }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 X+ i' M, ]4 ^% P0 j: U9 z2002: 565-628." }1 Q3 ?6 F& @/ v1 M* X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) i8 R+ Q" |/ |) x% I6 d1 K* Zpuberty in children with tumours of the suprasellar pineal
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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

9 [; `0 U& g/ U5 N, a1 a, y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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