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鄉下的妹子太便宜,一次四個都要了[12P]

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Sexual Precocity in a 16-Month-Old4 y; ]0 R2 }4 P! ~6 O; j
Boy Induced by Indirect Topical& E2 {4 q' I1 y' i# m+ c
Exposure to Testosterone
5 U* h# T' o, mSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. |, |! _' u1 U9 e$ k; |+ U" tand Kenneth R. Rettig, MD1
  d% B* }4 o0 o7 @0 P. E& x* B1 NClinical Pediatrics1 w+ X6 |( `7 G5 D
Volume 46 Number 6
$ w) x; W: c7 U$ D- c9 bJuly 2007 540-543$ e% h5 W: b3 v- V7 c" U* ~7 j$ D
© 2007 Sage Publications* Y4 U9 L9 E) G, R
10.1177/00099228062966517 `, q7 v0 p& K4 h$ Q, O% W
http://clp.sagepub.com# U2 h6 X3 c- J! H$ ]
hosted at
: u/ q/ o3 m8 O/ Y# v! j  [6 zhttp://online.sagepub.com( a3 U& t; \: t1 ~! p. [0 f
Precocious puberty in boys, central or peripheral,
' r/ U. f; Q6 ~; ~; b6 a7 |0 f) dis a significant concern for physicians. Central
; h5 @5 h5 z. Zprecocious puberty (CPP), which is mediated- n. k! a: c  s% |( U% u: [
through the hypothalamic pituitary gonadal axis, has
( P8 g+ C2 `+ ^1 K8 u6 d: ]a higher incidence of organic central nervous system3 h& z" i! w& z3 L3 Y. B0 S
lesions in boys.1,2 Virilization in boys, as manifested
: N; X. B6 B" |  C2 G" P. Rby enlargement of the penis, development of pubic2 E0 _& c* N3 F/ V  w7 d
hair, and facial acne without enlargement of testi-0 T' _' f/ q9 j. S
cles, suggests peripheral or pseudopuberty.1-3 We! t. X8 s. V: ~; v' ]: R
report a 16-month-old boy who presented with the
1 s, x7 b" h3 x+ ~/ Z0 f3 Yenlargement of the phallus and pubic hair develop-
; W% ?6 g6 ?& R0 P  E' R& C; ^' Oment without testicular enlargement, which was due
" d$ n- U+ L4 h, U' z! E$ p3 Ato the unintentional exposure to androgen gel used by  V% B5 x( P2 b. T0 f
the father. The family initially concealed this infor-
/ |0 A1 Q$ `  M2 h7 umation, resulting in an extensive work-up for this0 z" L9 Y" W- X/ g# C* g$ z9 _% w. n
child. Given the widespread and easy availability of8 u1 y' V" B- ^  {, H
testosterone gel and cream, we believe this is proba-. D; W, Z; `5 J0 w
bly more common than the rare case report in the% a, n8 v* s, \2 V1 D) e
literature.45 C9 |# ~/ y3 n9 U# N( {
Patient Report; E9 H' F' X7 w
A 16-month-old white child was referred to the1 ^0 |) H3 ~! _0 l8 a1 D+ Q. p
endocrine clinic by his pediatrician with the concern) a7 l- h! X* ^6 `
of early sexual development. His mother noticed
  H2 Q/ F- H( W3 ?5 elight colored pubic hair development when he was
5 Q7 K/ n. u( _: C$ n/ hFrom the 1Division of Pediatric Endocrinology, 2University of, G3 `6 o/ ?7 L. f; J
South Alabama Medical Center, Mobile, Alabama.
+ r+ h; n. c2 L5 y% b+ ?- ZAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 g2 |( a8 |1 v2 v9 z  d" X
Professor of Pediatrics, University of South Alabama, College of
0 s, V- z2 v+ i$ K! X' ?" KMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;& ?1 x5 o& J4 G0 S
e-mail: [email protected].
4 h$ ~% p3 Z% ?  S3 K9 Vabout 6 to 7 months old, which progressively became
( `: q! _9 v; r4 @, b! ^" z9 c. Rdarker. She was also concerned about the enlarge-2 L/ s9 ?$ W0 k; K- N  a, n
ment of his penis and frequent erections. The child
) P# d; n' B2 d3 M1 g. T* R; ^was the product of a full-term normal delivery, with/ ^, v7 {! h# a# i; P
a birth weight of 7 lb 14 oz, and birth length of
1 [6 A1 I( n% S: n; u20 inches. He was breast-fed throughout the first year
5 ]2 H% d* z, A: A5 Mof life and was still receiving breast milk along with2 r  O2 f1 U7 O8 ~, U
solid food. He had no hospitalizations or surgery,/ |3 P% C; h7 W, Y
and his psychosocial and psychomotor development
# K) r1 H, o3 k* B$ m. bwas age appropriate.
: }8 ~* V" O  c' h* h" _: X8 XThe family history was remarkable for the father,% R) h& B. _( l( N" [) H0 F' l5 q
who was diagnosed with hypothyroidism at age 16,
# l8 m8 ^7 }' O$ twhich was treated with thyroxine. The father’s
7 u% Z; Y9 y4 aheight was 6 feet, and he went through a somewhat9 Q# C9 N5 t9 d" r
early puberty and had stopped growing by age 14./ B( ]5 R+ F: R8 t  _$ p3 A
The father denied taking any other medication. The- Q: v0 M; ~7 K( c1 B" N: {* B. a
child’s mother was in good health. Her menarche
/ I8 u$ k7 B% e4 i1 awas at 11 years of age, and her height was at 5 feet
) C7 z4 S/ B" |; F$ e7 ]5 inches. There was no other family history of pre-
; z$ ]0 ~. w* Q( N& Rcocious sexual development in the first-degree rela-
5 I& @% x/ V0 G0 rtives. There were no siblings.
* g! V  i/ F' I; B9 o8 ]: HPhysical Examination
4 @- U) C5 i2 EThe physical examination revealed a very active,# v/ W6 ]/ \  _. G$ N- ]5 q1 }3 g
playful, and healthy boy. The vital signs documented
! _/ I- }* s& K" g. V. W5 X& sa blood pressure of 85/50 mm Hg, his length was- A1 }2 n% n! c4 p
90 cm (>97th percentile), and his weight was 14.4 kg1 X/ X* ~0 {( l$ y- I
(also >97th percentile). The observed yearly growth0 K9 e  Q# s- e8 a# Z
velocity was 30 cm (12 inches). The examination of
1 M6 F) n. J$ y) K5 E( e. ~the neck revealed no thyroid enlargement.
. T. E, J6 Q/ w0 Y1 e  I8 o* k0 H& m9 SThe genitourinary examination was remarkable for: g9 x7 @8 j0 a2 b* n
enlargement of the penis, with a stretched length of
2 K6 E$ L+ V1 ]  o2 q; s& _7 h; k8 cm and a width of 2 cm. The glans penis was very well
  r% H% s5 t' _$ Mdeveloped. The pubic hair was Tanner II, mostly around
) y3 P6 ~. j: Y540( _5 j  m% y/ R0 A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; }: R8 u$ d( Sthe base of the phallus and was dark and curled. The$ @6 ~5 }4 e. f. `9 F1 A
testicular volume was prepubertal at 2 mL each.
% i# Z# u- i: k! g" v0 Z* IThe skin was moist and smooth and somewhat
' R. l. i; l* I, coily. No axillary hair was noted. There were no
: S2 O! E6 f/ Aabnormal skin pigmentations or café-au-lait spots., X' u/ S" k  _( G
Neurologic evaluation showed deep tendon reflex 2+* ]' u& v) H, f9 C
bilateral and symmetrical. There was no suggestion, o4 Y. n! L# u1 ]1 v9 \4 p: @
of papilledema." n1 \! n- B3 W4 e" W' V
Laboratory Evaluation. x, `5 R) X' Z
The bone age was consistent with 28 months by
: c* Y4 g7 \( M: U/ q' Busing the standard of Greulich and Pyle at a chrono-
5 S) k2 b8 ]# l# V  blogic age of 16 months (advanced).5 Chromosomal
* r! q5 E; ]4 r  a, Okaryotype was 46XY. The thyroid function test% Y; V$ F- F: |$ ~# `, {$ \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: t) G7 M2 O; l0 l* e4 e
lating hormone level was 1.3 µIU/mL (both normal).7 R5 _( A  J5 w
The concentrations of serum electrolytes, blood4 e  @8 V! c; z# X
urea nitrogen, creatinine, and calcium all were' P6 n  J1 [7 Q; G# _" f
within normal range for his age. The concentration/ p$ X( {: ^" _: @) Z8 ~* U
of serum 17-hydroxyprogesterone was 16 ng/dL: {- T5 l2 O- I
(normal, 3 to 90 ng/dL), androstenedione was 20
* X1 b0 n" d( S9 c3 K: yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) r: l6 X8 p3 V, ^/ Z. oterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 U1 ]: L. M9 W2 n
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 d" j1 }6 W- F8 t# W8 l6 d9 L' P
49ng/dL), 11-desoxycortisol (specific compound S): `% h2 V2 o# C; e! ]% f
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' U  t$ m4 u3 N# w) z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 Q% M! @# v4 {( A( B3 u7 |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 i' l, Q$ ]: R5 Uand β-human chorionic gonadotropin was less than
( b" ^/ |4 U5 l' i: k3 ^5 mIU/mL (normal <5 mIU/mL). Serum follicular. k* N8 C* \% d8 @
stimulating hormone and leuteinizing hormone
; M- t- i8 q: Kconcentrations were less than 0.05 mIU/mL
  `, i: c. v1 q* j1 y, u(prepubertal).
6 Q# a, F* f5 VThe parents were notified about the laboratory* M) @6 v% {0 Q2 v
results and were informed that all of the tests were
3 H& {* J( K0 }  H$ q5 S8 Q5 b5 x3 onormal except the testosterone level was high. The% i( `) I* R& e8 n! L4 p2 ?
follow-up visit was arranged within a few weeks to
9 {) H. b4 D$ t- Aobtain testicular and abdominal sonograms; how-
0 h  _# \7 r9 ^) \ever, the family did not return for 4 months.- ^, K. m8 A: S
Physical examination at this time revealed that the$ P0 h+ y4 p4 ^# D! ^$ r
child had grown 2.5 cm in 4 months and had gained* M0 ?# O0 U6 X6 m+ I9 l2 ]! Z1 \
2 kg of weight. Physical examination remained
2 _2 H) z$ i) A- @( junchanged. Surprisingly, the pubic hair almost com-
. g. o% {) d! |9 I7 Qpletely disappeared except for a few vellous hairs at
: p# F; V% \- M9 bthe base of the phallus. Testicular volume was still 2
3 `! o! n+ A/ y, j3 emL, and the size of the penis remained unchanged.- t; l9 Y5 ~& c. ~) s9 J. b
The mother also said that the boy was no longer hav-4 h# o  ~( }5 H
ing frequent erections./ g. x( ^# D( M/ [( x# f
Both parents were again questioned about use of" k3 B5 o0 X* {, e+ l9 T
any ointment/creams that they may have applied to# D2 M* d: t6 y! t% @) C
the child’s skin. This time the father admitted the
4 i9 r/ J4 q7 \7 tTopical Testosterone Exposure / Bhowmick et al 5410 C/ O8 I# A6 M, c
use of testosterone gel twice daily that he was apply-; Y) s$ P: g9 I0 @6 z- o  @
ing over his own shoulders, chest, and back area for+ S% Y. {; z) z% @
a year. The father also revealed he was embarrassed
6 h( ?- z, I5 P1 h/ n8 eto disclose that he was using a testosterone gel pre-6 T3 l. X0 ^, H& Y! |2 n
scribed by his family physician for decreased libido
* ?& z/ S1 K" R0 ^5 }secondary to depression.1 H9 i; Q5 U% K, Y% k, ]
The child slept in the same bed with parents.# U+ {$ M1 F. k" @
The father would hug the baby and hold him on his# t! b- m" i5 _
chest for a considerable period of time, causing sig-
" q$ x4 N# b+ ~/ hnificant bare skin contact between baby and father.7 x/ j3 w6 }8 [3 x+ A
The father also admitted that after the phone call,
1 y9 ?. h, M, @when he learned the testosterone level in the baby! H6 _4 Q: b3 v3 a2 T
was high, he then read the product information
, ^6 Q, R% q/ z- Spacket and concluded that it was most likely the rea-; w9 r4 R( V: y
son for the child’s virilization. At that time, they
/ Y, J  v) D8 M+ U# [/ _3 Fdecided to put the baby in a separate bed, and the
5 H1 f# p, u2 X, p% d4 Pfather was not hugging him with bare skin and had
+ q% ?1 z& [  K" z8 U8 dbeen using protective clothing. A repeat testosterone  t1 i0 q9 n  z3 x0 h+ W# R( U% n6 Y3 v
test was ordered, but the family did not go to the. S7 M& d! m/ k
laboratory to obtain the test.& Z6 k1 ?: R& Z8 ]
Discussion
7 \- P0 M! V/ |) [  M$ w; v  U& tPrecocious puberty in boys is defined as secondary
5 x% q" P% j5 _/ O: a0 g7 `sexual development before 9 years of age.1,4! k& }* L" u( t$ t3 u0 [5 v2 O
Precocious puberty is termed as central (true) when& T- \8 F6 w, Z1 B7 P% ~
it is caused by the premature activation of hypo-* I6 x5 H. @* ]' n( G
thalamic pituitary gonadal axis. CPP is more com-
9 ~9 l" V# ~) o+ Fmon in girls than in boys.1,3 Most boys with CPP
) L$ {' ^( ^9 j& Mmay have a central nervous system lesion that is7 ^) W' p- P: @
responsible for the early activation of the hypothal-
# O$ d' T& J# k& ?) @8 b7 hamic pituitary gonadal axis.1-3 Thus, greater empha-
3 e, a5 K$ o  b' }0 ]  M! qsis has been given to neuroradiologic imaging in
: u( w0 \' a; l% c- k) Z. U- Iboys with precocious puberty. In addition to viril-
5 F6 g5 J% c) A% U6 C% \ization, the clinical hallmark of CPP is the symmet-. Z; F: r0 k+ Q+ Z% M3 A
rical testicular growth secondary to stimulation by
2 A6 Q' ]5 E+ j! W- @gonadotropins.1,3
1 ?$ @5 r! X% m" X# Y* JGonadotropin-independent peripheral preco-
  h; R1 o8 x7 @  r* |' Pcious puberty in boys also results from inappropriate
# K3 P: R5 y+ [androgenic stimulation from either endogenous or
; ~$ X# P5 m4 A7 L, B/ p; jexogenous sources, nonpituitary gonadotropin stim-
. w. h0 T& z0 _ulation, and rare activating mutations.3 Virilizing1 [. M& ]* n) D
congenital adrenal hyperplasia producing excessive9 q) t7 S. K! J+ L6 j
adrenal androgens is a common cause of precocious
6 n. O1 i9 L( b: R8 q8 [1 Upuberty in boys.3,4
3 ?% v; t) c6 F  {8 nThe most common form of congenital adrenal/ V3 S, f! k! T  q
hyperplasia is the 21-hydroxylase enzyme deficiency.
1 W4 c8 e; P/ @2 ~1 C+ ]' NThe 11-β hydroxylase deficiency may also result in
4 H  E5 f( {: X, l6 Z; u- kexcessive adrenal androgen production, and rarely,
- n! \3 C" w1 M( D" w0 E5 Can adrenal tumor may also cause adrenal androgen
- U2 p/ _3 D7 texcess.1,3
$ r9 I/ Q# ~( w  o. Zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* N, E( U6 x- @& S+ U; {; z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" \) P$ l! v( f4 x  j1 M3 AA unique entity of male-limited gonadotropin-6 E6 {! k9 L% l
independent precocious puberty, which is also known
/ M! M" z; a% Eas testotoxicosis, may cause precocious puberty at a
% i! o$ l% _8 l2 }/ J: C( ?$ \very young age. The physical findings in these boys
; }, V7 D5 I3 ~1 Kwith this disorder are full pubertal development,
5 S* [1 I# r: {5 {including bilateral testicular growth, similar to boys
- z- d% a" A  p5 jwith CPP. The gonadotropin levels in this disorder$ W9 {3 z! G, V4 _- b' R( e
are suppressed to prepubertal levels and do not show5 l% l, j/ t1 Y
pubertal response of gonadotropin after gonadotropin-
3 W) ^  V8 I( K1 nreleasing hormone stimulation. This is a sex-linked" {; ?3 m  r5 c! Y0 r
autosomal dominant disorder that affects only
1 u- `6 s6 X5 A0 n# dmales; therefore, other male members of the family
6 W4 `+ m0 j. E- ?) ]+ R: Tmay have similar precocious puberty.3$ ]( l7 u8 l; d) u9 Z# N
In our patient, physical examination was incon-4 {8 x/ Z; U/ _" l$ F) T/ i! ?+ a
sistent with true precocious puberty since his testi-- {9 y" j3 P; f# K5 x
cles were prepubertal in size. However, testotoxicosis4 e1 Z8 J2 \1 q4 @
was in the differential diagnosis because his father
( [" w; E7 `- l- t2 Ustarted puberty somewhat early, and occasionally,
- _' H& c, P/ v6 X) t5 F. otesticular enlargement is not that evident in the3 e, N" ]1 l: T' |2 ~% o. V
beginning of this process.1 In the absence of a neg-
5 b! H8 E: r/ |" c7 ~ative initial history of androgen exposure, our! X8 y6 R; V2 ?7 n) Y
biggest concern was virilizing adrenal hyperplasia,0 f% `8 |$ M) A
either 21-hydroxylase deficiency or 11-β hydroxylase
" _& P5 }0 ~0 i$ cdeficiency. Those diagnoses were excluded by find-5 {5 p0 m+ F* {, l
ing the normal level of adrenal steroids.
$ T9 f6 ?8 d6 }! ~/ I# e" I: ^The diagnosis of exogenous androgens was strongly
  Y' c+ G$ H5 ksuspected in a follow-up visit after 4 months because/ C$ T4 ?* @4 G
the physical examination revealed the complete disap-
; T( P* i/ F0 F, V& ]$ Y% cpearance of pubic hair, normal growth velocity, and# @' O5 d6 t! X5 M5 p
decreased erections. The father admitted using a testos-- m& B# `. f; K6 }
terone gel, which he concealed at first visit. He was
) n7 X* E* G, l4 J$ b: H5 d8 O4 m7 f1 Wusing it rather frequently, twice a day. The Physicians’! K( I" k% S2 O6 C! f
Desk Reference, or package insert of this product, gel or
( d2 W8 O" |2 U# Ccream, cautions about dermal testosterone transfer to
1 J0 t, Y8 U8 a/ lunprotected females through direct skin exposure.2 B+ T0 |" h1 ?9 A& l; q4 g6 D
Serum testosterone level was found to be 2 times the
- `  L) x  U, Bbaseline value in those females who were exposed to
' L; n- @3 G7 K$ q0 p. Q5 Teven 15 minutes of direct skin contact with their male
9 I! e  A# O, F; b, F2 y  u/ E, bpartners.6 However, when a shirt covered the applica-
  p" {2 N7 |& T, S2 dtion site, this testosterone transfer was prevented.  ?  C% x4 @9 Y$ ]8 W; {% l1 z8 c. A
Our patient’s testosterone level was 60 ng/mL,
0 q& c; R; E6 r' a" Jwhich was clearly high. Some studies suggest that% b# y2 Q/ g% ?* r' y2 c2 D
dermal conversion of testosterone to dihydrotestos-
" F  l8 P+ Y: \; q; A) [terone, which is a more potent metabolite, is more; N. `/ {& J5 h/ s3 N& }, J
active in young children exposed to testosterone3 n* s# p' _/ B. f* |1 y+ G
exogenously7; however, we did not measure a dihy-
! r5 n& I, y& V" i6 Qdrotestosterone level in our patient. In addition to! N3 W: N8 F: C3 F& j
virilization, exposure to exogenous testosterone in
# I: l* V, g# i1 ychildren results in an increase in growth velocity and- u5 l" M- i4 m7 `9 X* F
advanced bone age, as seen in our patient.; P* q+ ]8 P" t3 l% ?) b
The long-term effect of androgen exposure during
- ?' ~! O) ~" l4 p# Vearly childhood on pubertal development and final
4 E$ ]- Q/ e& Kadult height are not fully known and always remain0 f' h5 z: A) n) `; q, j5 j; [$ [$ N
a concern. Children treated with short-term testos-$ ]$ T" Z6 G6 _# \' j" j! F
terone injection or topical androgen may exhibit some
1 Z* J! {) r% A9 zacceleration of the skeletal maturation; however, after
1 J3 b0 S8 \7 G/ hcessation of treatment, the rate of bone maturation; w/ i1 j: ?; r- i
decelerates and gradually returns to normal.8,9
0 n0 J# k" N# |) T& |There are conflicting reports and controversy' T2 A. i3 a- w9 e4 p8 R8 s' Q
over the effect of early androgen exposure on adult) ?& W4 \9 f# z, k
penile length.10,11 Some reports suggest subnormal
( `4 _# }) l! L; Nadult penile length, apparently because of downreg-$ `, Z  T! j3 g! M9 v' ]. ^* U
ulation of androgen receptor number.10,12 However,1 w5 [5 D9 G, w( ]. k' Z3 J
Sutherland et al13 did not find a correlation between9 W* @$ g9 Y* b
childhood testosterone exposure and reduced adult
# Q, Z- E. b3 z0 [penile length in clinical studies.
0 `" e, j1 Y2 GNonetheless, we do not believe our patient is
. s- K) @; t5 Q! Z2 wgoing to experience any of the untoward effects from
: _. o, `1 d# u4 g8 [testosterone exposure as mentioned earlier because5 ]& a- p0 P5 \6 }9 u2 U. z2 n
the exposure was not for a prolonged period of time.
- h" b* G8 h, p5 }Although the bone age was advanced at the time of& i9 E  H( k* {: g2 N0 L
diagnosis, the child had a normal growth velocity at
7 X! T6 [5 b& m0 Hthe follow-up visit. It is hoped that his final adult
) `" T( Q# S, E6 k" p. E( A) l% Nheight will not be affected.- i3 z! F; q8 @( E4 G" q
Although rarely reported, the widespread avail-
1 }* |+ k! Q. zability of androgen products in our society may
& W* }+ G9 r9 {9 L! ~0 Zindeed cause more virilization in male or female( l# h- @' b" @
children than one would realize. Exposure to andro-
$ n# U$ v& b' k- S/ u' a4 hgen products must be considered and specific ques-" }, J$ w$ u5 }! V# A, R
tioning about the use of a testosterone product or- g4 K$ k/ y9 D. t) V2 u
gel should be asked of the family members during
0 d: {! J  E- k8 n% Xthe evaluation of any children who present with vir-
! u/ C2 @0 K; v" c8 E3 }7 o# Nilization or peripheral precocious puberty. The diag-3 G9 |! l6 c& H$ P' N- c/ A' Q! j* e
nosis can be established by just a few tests and by( s2 \+ Z7 g) G5 \
appropriate history. The inability to obtain such a4 J8 r5 L; q# x9 M9 v% P- D
history, or failure to ask the specific questions, may
' `; y7 q: R( ~8 uresult in extensive, unnecessary, and expensive
1 {6 \& y; q& m( `* Winvestigation. The primary care physician should be
# O9 g  I* J: N8 S- Eaware of this fact, because most of these children
5 Z5 N: [) z& _" N( N( u9 K# bmay initially present in their practice. The Physicians’7 p1 c( g* d, n. i% S+ N% c
Desk Reference and package insert should also put a  O4 M+ f9 B& y7 X& s
warning about the virilizing effect on a male or0 p/ p7 D2 K: v3 s3 H
female child who might come in contact with some-5 }4 M+ Q6 a4 ]
one using any of these products.
4 u3 {) {* n# oReferences1 A; L8 P. T, {' p' I
1. Styne DM. The testes: disorder of sexual differentiation
( ~7 D' V$ M: O4 w- R; [and puberty in the male. In: Sperling MA, ed. Pediatric
) X* s- W3 C' k+ o. m% k9 {& @2 BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ X% Z5 N% p6 p
2002: 565-628.) W) n& G; [8 }) _' u3 h' `
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ P: p% G( d% `4 n4 \+ f$ ^puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 h6 f, b; G) H5 p
Boy Induced by Indirect Topical1 E1 ?" v% k$ P
Exposure to Testosterone6 T/ L1 G! ?% ^2 c- D  O
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 U1 t; q- s5 K: B+ D, J* o+ X
and Kenneth R. Rettig, MD16 n: b+ P" J$ ^$ s6 V
Clinical Pediatrics
7 M# |% k' h( I8 [. eVolume 46 Number 6
# s! T, d2 u; F* r0 h: U3 hJuly 2007 540-543
! }% }( V1 p9 ?3 f& l3 L© 2007 Sage Publications
) _4 h9 F7 }1 L8 ?9 Q10.1177/0009922806296651
1 x; {2 w, S, H* I/ Bhttp://clp.sagepub.com. n. L; }8 h4 K6 l% o! z2 F
hosted at
% s) V8 B) w/ A' Z6 v+ r/ Xhttp://online.sagepub.com
: h0 r- `7 |, E1 l. XPrecocious puberty in boys, central or peripheral,
' ?$ @5 G9 L  G8 ]! o( L% G, N( u) Qis a significant concern for physicians. Central
, G# X; s) s& b, R& e: [precocious puberty (CPP), which is mediated
' C- b) u0 u* w: K+ n6 }/ S9 Dthrough the hypothalamic pituitary gonadal axis, has6 `3 J0 d6 x4 R) V, f" m$ G
a higher incidence of organic central nervous system# [6 E) _7 S0 r# P4 l
lesions in boys.1,2 Virilization in boys, as manifested" U  ~" a' |9 z& ]# u
by enlargement of the penis, development of pubic! K2 e0 J5 U1 s' N8 ~4 n
hair, and facial acne without enlargement of testi-
: ^- K- S* |7 Q3 {; ccles, suggests peripheral or pseudopuberty.1-3 We8 T1 _* x$ c; b
report a 16-month-old boy who presented with the
6 I0 C# m$ J9 T3 o8 T0 [1 Cenlargement of the phallus and pubic hair develop-0 y6 S6 X3 V$ U5 a0 N
ment without testicular enlargement, which was due
: A6 O) P; X5 H1 p4 C% J: c7 O/ _to the unintentional exposure to androgen gel used by: t* l$ B" D! z: l" l3 n3 |+ }/ D* P
the father. The family initially concealed this infor-
1 |9 h0 |, f" [  k1 C* pmation, resulting in an extensive work-up for this/ E- D8 [$ M, n' h  L
child. Given the widespread and easy availability of/ N! H4 @9 w2 [- D  ^4 B% R
testosterone gel and cream, we believe this is proba-
0 J8 G$ y! X0 g2 W8 h3 w! Ybly more common than the rare case report in the, i7 t, q1 n5 F  ?
literature.4
/ f, d9 d+ ]3 GPatient Report
. s! n) ^- G5 f( Q) Y6 j8 J( }A 16-month-old white child was referred to the
; W; A& {1 c3 N( [, T$ M( \endocrine clinic by his pediatrician with the concern
" Y6 D3 x1 f3 G4 y7 ^of early sexual development. His mother noticed
5 r6 }4 K8 F- w0 Y' G6 Klight colored pubic hair development when he was
/ ^* ?. i% u- k+ gFrom the 1Division of Pediatric Endocrinology, 2University of
! Q% o. V" ?0 F% r3 |0 G* n  m/ [! tSouth Alabama Medical Center, Mobile, Alabama.
7 C: ]3 O: [* L; d; |# d$ A0 Q. }Address correspondence to: Samar K. Bhowmick, MD, FACE,1 @- x4 e" }1 L, `
Professor of Pediatrics, University of South Alabama, College of$ K. W" J5 y- y8 i
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ A4 a/ @0 w% q; A. b8 q$ P9 {
e-mail: [email protected].
1 v8 R+ J0 o4 d4 Jabout 6 to 7 months old, which progressively became
3 [- o  M# t. ~darker. She was also concerned about the enlarge-
& @; k' I1 q) D& [, lment of his penis and frequent erections. The child* R3 u  Z2 w- G. T8 I
was the product of a full-term normal delivery, with
! p1 S' v6 Z, p0 m' [$ J) wa birth weight of 7 lb 14 oz, and birth length of
3 v  B: B) u  m7 ]) _! o20 inches. He was breast-fed throughout the first year+ Q$ }, p0 b" G( h1 |, o1 q
of life and was still receiving breast milk along with& l. x! ^! ]. F9 V; W; R& a
solid food. He had no hospitalizations or surgery,
& h" A0 m) b( \' S8 t1 e3 A! }and his psychosocial and psychomotor development3 k" L$ ^# D' Q& \9 y
was age appropriate.6 C$ i- z) k( u* j! `! c4 j
The family history was remarkable for the father,7 c- C3 @  C; h& `+ F
who was diagnosed with hypothyroidism at age 16,; M% E/ N. |3 E) U/ w" l, a5 ^
which was treated with thyroxine. The father’s" l& B2 e! z; A& V+ @  p2 X6 g
height was 6 feet, and he went through a somewhat" o7 s- T* m* R% _. u' f# a# o
early puberty and had stopped growing by age 14.
; ~6 t2 g" n8 M( ^6 B$ pThe father denied taking any other medication. The
5 T6 Y3 |5 P- O- K. j- Pchild’s mother was in good health. Her menarche
' i' e2 v0 L! A* Vwas at 11 years of age, and her height was at 5 feet) Z# h. ?, O9 o* e
5 inches. There was no other family history of pre-
, r5 u/ r( x3 \( n% W5 X& G, a" ncocious sexual development in the first-degree rela-
* i) X1 Y) `% u0 n9 Ptives. There were no siblings.
" G# J; i0 u- V6 u5 E! T  U- M8 }Physical Examination
8 h) |# _) h9 v, B) ^+ sThe physical examination revealed a very active,
. \/ F" Z' D# v  Nplayful, and healthy boy. The vital signs documented
4 @' d# C3 d7 l3 P8 L# la blood pressure of 85/50 mm Hg, his length was
/ s( A& ?( x3 S* `8 k$ \$ {90 cm (>97th percentile), and his weight was 14.4 kg
+ A( b3 m" p' c; ]$ O8 H3 d# E(also >97th percentile). The observed yearly growth8 D# E7 {( y  R. V
velocity was 30 cm (12 inches). The examination of" z' a6 x+ C/ G5 h: S9 u' z* i
the neck revealed no thyroid enlargement.) {+ v4 ]& [" y( p
The genitourinary examination was remarkable for
2 D: r+ v" u- cenlargement of the penis, with a stretched length of) K* I: ?6 X; S. o2 W3 ?& N9 U- L
8 cm and a width of 2 cm. The glans penis was very well+ o& A" ?* ]0 h- \  k3 z6 M
developed. The pubic hair was Tanner II, mostly around8 D0 W1 m1 ]( B. x: b
540
3 o; T. _3 K: f/ B' Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 h# r' |- F: ~8 ]5 j) l. V. u7 i
the base of the phallus and was dark and curled. The
5 [0 C0 v! L9 r8 g* V7 @: ttesticular volume was prepubertal at 2 mL each.0 g$ l8 d9 E- X2 |
The skin was moist and smooth and somewhat# I; i. V2 }0 V  v, r
oily. No axillary hair was noted. There were no
% F  x* A% [5 C& Y, W5 A" E  [7 mabnormal skin pigmentations or café-au-lait spots.
/ s4 h. F* g; _- d$ p% Y& `3 PNeurologic evaluation showed deep tendon reflex 2+
' `3 s2 e! d9 @: P- |bilateral and symmetrical. There was no suggestion) D5 S1 D# o4 R$ d, J
of papilledema.
5 U7 D1 b6 F: E, _& J( SLaboratory Evaluation3 s0 B; x, l5 D! o# I  c6 E
The bone age was consistent with 28 months by* D: K" N: F6 z& G& Z
using the standard of Greulich and Pyle at a chrono-5 s5 M2 W+ L& P% ]8 \# b7 j8 N
logic age of 16 months (advanced).5 Chromosomal
" G# G+ k7 X; O$ l9 Z/ `karyotype was 46XY. The thyroid function test
6 ~" o) I& j+ Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 f( v! M) `3 Y% Q0 R
lating hormone level was 1.3 µIU/mL (both normal)./ S0 ^8 N9 @: t6 T' f% Z9 g
The concentrations of serum electrolytes, blood
6 p7 |3 c9 X) Eurea nitrogen, creatinine, and calcium all were
3 ]# v4 O6 W1 Y9 I5 V& g0 Nwithin normal range for his age. The concentration
. x! `/ J8 q: x+ |of serum 17-hydroxyprogesterone was 16 ng/dL
. M& ^! x2 x& f(normal, 3 to 90 ng/dL), androstenedione was 20& M# v- v, d8 Y: O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ P; |7 l! I) f, Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),
* k& W9 r/ ~( _6 jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to' m& D; `) u' u; Z, v
49ng/dL), 11-desoxycortisol (specific compound S)
; c; g9 t" m, \" g  H1 B# k& kwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 D9 ?% O; f& w- |- ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ z7 V* g  H# `" [. {# O2 ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),( k( {1 q3 x* ]! [
and β-human chorionic gonadotropin was less than6 q) u8 q& v, ?( O' C8 {8 n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 ~8 c3 F4 [) Lstimulating hormone and leuteinizing hormone/ e" O2 i4 K1 g3 x9 x' F8 \0 [0 v
concentrations were less than 0.05 mIU/mL
( R  r5 O( E5 f7 |  t(prepubertal).2 l# M5 N$ S8 x4 L4 O# r* B; g  s0 `
The parents were notified about the laboratory
9 `3 w. j% A, a5 f" Q4 ^results and were informed that all of the tests were
3 b7 Z3 h; l2 m" W% c4 ?7 H) Tnormal except the testosterone level was high. The
, |4 T  V2 s) w0 o! f& x1 mfollow-up visit was arranged within a few weeks to
5 ?& y5 z4 a' ?3 k6 [obtain testicular and abdominal sonograms; how-
$ q2 r& ]% @' d5 p- p/ _ever, the family did not return for 4 months.
6 F9 v6 `4 u, B7 z8 APhysical examination at this time revealed that the9 m/ l- L" s/ n
child had grown 2.5 cm in 4 months and had gained
9 J0 k1 c* f/ w0 }0 p  U0 Y$ c5 ?2 kg of weight. Physical examination remained$ {0 O, J( H2 Q  B4 C1 S
unchanged. Surprisingly, the pubic hair almost com-
# s6 ~3 `6 H1 a7 {8 ]1 Bpletely disappeared except for a few vellous hairs at: G9 X) ?/ z' g0 x. i" g5 S9 a
the base of the phallus. Testicular volume was still 2
3 ?9 D0 [: q7 p6 \mL, and the size of the penis remained unchanged.* N( G3 w& ^# i. T: Y( `9 q1 B
The mother also said that the boy was no longer hav-
; n8 |3 J/ a; u: S4 sing frequent erections.
/ }" }' j8 f1 l: y. D2 [6 sBoth parents were again questioned about use of
0 c. d- J: s$ c9 \% r5 Y' Uany ointment/creams that they may have applied to/ F, J9 B7 ?+ Q8 ]
the child’s skin. This time the father admitted the; o2 L9 L2 A  s* W
Topical Testosterone Exposure / Bhowmick et al 541
$ b8 D# X0 W. i, y* }use of testosterone gel twice daily that he was apply-5 x2 B" |6 a5 @8 ^0 t2 c
ing over his own shoulders, chest, and back area for9 [) w! e( ]+ K4 N$ k9 X' {. y
a year. The father also revealed he was embarrassed" C2 D1 o; m% b( a( j3 J3 T
to disclose that he was using a testosterone gel pre-
' U: L( I+ \* f# _, t% \) }scribed by his family physician for decreased libido8 j( A$ l& z# y0 ~6 |) K
secondary to depression.& l3 J8 U/ ^/ Z" n' ]
The child slept in the same bed with parents.0 A& F8 ]( y. f+ j) R9 Z( F$ J1 _
The father would hug the baby and hold him on his
0 M: `1 ?. J9 w! E# T8 r  tchest for a considerable period of time, causing sig-
/ ^, o, ]" c# X$ ~- `6 z. Gnificant bare skin contact between baby and father.
: `$ D# r: P) A! uThe father also admitted that after the phone call,+ x1 h& x2 ~2 A. T% v
when he learned the testosterone level in the baby9 H) ~8 z0 {9 F
was high, he then read the product information
; Y  c0 m. r( [3 Wpacket and concluded that it was most likely the rea-
# a/ M2 q; R4 F' H3 N, B2 Nson for the child’s virilization. At that time, they
* L/ N% a, y- _  {- a3 Sdecided to put the baby in a separate bed, and the/ m# o$ g( ~" D* q
father was not hugging him with bare skin and had
* L( n* e0 T& K, f* ^been using protective clothing. A repeat testosterone
# I, p8 ^' y$ f- P) H9 D* B8 @test was ordered, but the family did not go to the: U2 E; R: K: }, ]+ U7 `; \$ ]8 N: n
laboratory to obtain the test.$ {# J' T# n' j; m
Discussion
. d2 u1 U# @( u  C. ~" EPrecocious puberty in boys is defined as secondary
$ n7 ]0 F$ U" O2 ]sexual development before 9 years of age.1,4+ _' @( M1 ]" Z% a5 U
Precocious puberty is termed as central (true) when5 Z$ F  [8 o9 A( J
it is caused by the premature activation of hypo-
6 N  Y6 F1 k: P9 d  S4 Ythalamic pituitary gonadal axis. CPP is more com-
5 V) Z/ x& y  x3 ?- K2 k& W( m1 t* Fmon in girls than in boys.1,3 Most boys with CPP
0 M. |5 A' j) Qmay have a central nervous system lesion that is8 l9 Q3 t  ^7 i* e; j5 I
responsible for the early activation of the hypothal-
4 Y! S7 n0 M2 Y, L) wamic pituitary gonadal axis.1-3 Thus, greater empha-9 }% F. c6 [( H* V  Z# T; v
sis has been given to neuroradiologic imaging in
" l* {% O. g. h; O$ P; jboys with precocious puberty. In addition to viril-& E) ?' t% o, _
ization, the clinical hallmark of CPP is the symmet-! {. G/ U; h1 f& \8 v. O  {! d* v
rical testicular growth secondary to stimulation by
, Q# P' N- w& i9 Jgonadotropins.1,3% S& C, j0 l* L% `
Gonadotropin-independent peripheral preco-7 a/ j' ^' b9 P
cious puberty in boys also results from inappropriate! a3 x: f% L! `. i
androgenic stimulation from either endogenous or
& d5 D$ E+ W) h: xexogenous sources, nonpituitary gonadotropin stim-9 \2 e2 f$ D  ^- x
ulation, and rare activating mutations.3 Virilizing
8 K1 O9 i! ]2 @$ e0 ]% {: w. hcongenital adrenal hyperplasia producing excessive
: _% A1 w5 q: j. Z- U" o9 zadrenal androgens is a common cause of precocious+ ?0 T2 c6 {- ^! {/ v
puberty in boys.3,4
+ @- n& h, w2 ]* u5 OThe most common form of congenital adrenal
4 d: {9 A& g+ rhyperplasia is the 21-hydroxylase enzyme deficiency.- U: c3 k0 J4 F3 W. {
The 11-β hydroxylase deficiency may also result in# m4 ^- C6 y/ ]* W
excessive adrenal androgen production, and rarely,* Q# S* B% ~6 C4 |) u' G1 `
an adrenal tumor may also cause adrenal androgen
; ?% a% o) U: ~8 E4 M, \excess.1,36 U  }1 c6 O  s7 w* E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) n. `# U7 T7 X% K! O8 n' `542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) p- [# f; o. TA unique entity of male-limited gonadotropin-
6 c- ^3 Z; p9 l9 findependent precocious puberty, which is also known9 a& a1 D9 v+ `( A3 M3 ]" C3 Z
as testotoxicosis, may cause precocious puberty at a$ {- x5 \- ?) ?5 Q- V/ q0 I* I, \
very young age. The physical findings in these boys
0 E/ n" |- |1 O/ P/ \! Bwith this disorder are full pubertal development,
, o: H. o( n. b) q5 k/ A0 W8 Lincluding bilateral testicular growth, similar to boys
& l2 o* X3 a1 f. gwith CPP. The gonadotropin levels in this disorder
. Q9 G' H& r9 J6 E: `, B* {% pare suppressed to prepubertal levels and do not show
) q9 @; g' d% i: c6 C5 S) Tpubertal response of gonadotropin after gonadotropin-8 k1 ?; I( R/ D. ?5 c3 ?' b# m; [
releasing hormone stimulation. This is a sex-linked
! m8 \: ]! `7 c; C& t4 yautosomal dominant disorder that affects only* k5 P1 T! U7 |$ b
males; therefore, other male members of the family
% b9 x/ `. w( g# i* T% @0 Gmay have similar precocious puberty.38 ]5 \% ]- W) o3 B0 ~# Y5 o
In our patient, physical examination was incon-
) i- c7 r$ ^1 n& jsistent with true precocious puberty since his testi-/ z5 w8 y- ^+ ]; k& t
cles were prepubertal in size. However, testotoxicosis7 B9 b+ @' b3 N) K& n- m6 v4 ~
was in the differential diagnosis because his father
4 K: q! ^, Y4 D( [started puberty somewhat early, and occasionally,
# L' W! g2 s8 m7 k" stesticular enlargement is not that evident in the# i+ _8 e! @- |! O7 z/ R6 u
beginning of this process.1 In the absence of a neg-
. H/ z( S' f" M8 C& k8 Kative initial history of androgen exposure, our! H0 Z4 X1 U2 l, ]
biggest concern was virilizing adrenal hyperplasia,4 r. E% ^% Y  O* }
either 21-hydroxylase deficiency or 11-β hydroxylase
; P# q( f& J' t; \( l" X( Rdeficiency. Those diagnoses were excluded by find-; |$ u* a# N$ T. t# ~: h/ y/ }
ing the normal level of adrenal steroids.
0 g/ G& Q5 ]$ IThe diagnosis of exogenous androgens was strongly2 z- w4 F0 X9 A/ M
suspected in a follow-up visit after 4 months because
7 C; _3 o$ ]5 M8 b' Ethe physical examination revealed the complete disap-
. ?, X) T7 L1 \* t% c2 u( k* J  Ppearance of pubic hair, normal growth velocity, and
- c1 A, W; ~! m7 i3 e$ {decreased erections. The father admitted using a testos-& B8 p- ^4 H% Q1 R: m
terone gel, which he concealed at first visit. He was
5 t( e$ s. n3 r& b! u4 @8 W" K% iusing it rather frequently, twice a day. The Physicians’
; v8 B+ z& M: [$ {Desk Reference, or package insert of this product, gel or. j4 D5 H1 S! a2 g  L
cream, cautions about dermal testosterone transfer to. J4 \8 ~  T5 J2 v0 r
unprotected females through direct skin exposure.* ~" C# b3 L6 f, v9 D! B0 z
Serum testosterone level was found to be 2 times the% T8 D4 u) Z$ [: H- [
baseline value in those females who were exposed to, w, J" N+ }6 u7 W; U
even 15 minutes of direct skin contact with their male
7 m( Z; u& w/ E9 g5 h9 n/ Apartners.6 However, when a shirt covered the applica-9 [  Q  S# H5 U( D9 A7 k
tion site, this testosterone transfer was prevented.) \! V0 `# `) X5 Y
Our patient’s testosterone level was 60 ng/mL,2 |3 G% F: Q7 V, s
which was clearly high. Some studies suggest that) X2 X2 ]9 H8 N$ q0 V
dermal conversion of testosterone to dihydrotestos-
% g, ^/ i4 a( t! e2 ^! l+ ?6 pterone, which is a more potent metabolite, is more0 ?* F+ \- ]) P- a# @! F% x. Y
active in young children exposed to testosterone
8 L: @4 F7 V- ]* z& R$ T- oexogenously7; however, we did not measure a dihy-
" @  H, \3 K8 s: s" g9 ndrotestosterone level in our patient. In addition to
) r1 }. N. s$ B8 h) X0 Uvirilization, exposure to exogenous testosterone in
/ k* g" F8 @( z! T2 {children results in an increase in growth velocity and
6 P, _% B& B5 A. I3 r$ h2 J) A+ Yadvanced bone age, as seen in our patient.
( p9 t2 s) v1 f9 D$ tThe long-term effect of androgen exposure during+ I% f1 w; x0 r0 ^* I
early childhood on pubertal development and final# w6 w0 ?$ a& @# h6 T5 S; X
adult height are not fully known and always remain" y' E# y1 L1 Y: {5 _) ]+ H1 B
a concern. Children treated with short-term testos-
# t1 m* k4 e: T/ l/ `/ B& p$ l- D& d1 Vterone injection or topical androgen may exhibit some# I3 [- P6 C1 ?" T- E6 `
acceleration of the skeletal maturation; however, after0 S- u3 a# `: O# n" v
cessation of treatment, the rate of bone maturation5 ?( {4 ^8 p% D6 a& X
decelerates and gradually returns to normal.8,9- t2 x$ }- y" v& V, c
There are conflicting reports and controversy
( O. C4 d2 a& C/ f9 x/ G1 Z% M8 pover the effect of early androgen exposure on adult
5 g) B1 Q" t3 R8 A+ N$ M6 l5 ypenile length.10,11 Some reports suggest subnormal8 P; ]! L/ u: p7 m' C6 k3 r
adult penile length, apparently because of downreg-5 j# W9 H5 O- P
ulation of androgen receptor number.10,12 However,& D9 Y4 {- K& K: \" [% H9 T# t
Sutherland et al13 did not find a correlation between9 ?% g7 o) F2 {; X6 K; t: K7 B
childhood testosterone exposure and reduced adult
2 z/ D3 h/ L6 x4 U& Upenile length in clinical studies.
, b6 q+ x% X. I( q: Z  w7 gNonetheless, we do not believe our patient is6 z6 n& V, X' R# _+ `
going to experience any of the untoward effects from
; P' e( W$ U( P. {testosterone exposure as mentioned earlier because2 S7 |* u/ j& g  a! f
the exposure was not for a prolonged period of time.
) T+ ?. U' p2 _  b3 OAlthough the bone age was advanced at the time of
# |, T' {: W* ?! \diagnosis, the child had a normal growth velocity at* S2 U2 Q, j) e0 D2 \' x6 j
the follow-up visit. It is hoped that his final adult1 K6 h* t0 v% s" c+ B
height will not be affected.
$ R2 {! q/ m; vAlthough rarely reported, the widespread avail-- F* W' j6 Y# e: J2 y/ [
ability of androgen products in our society may( w+ U  ]3 T3 e& C" B
indeed cause more virilization in male or female- f/ ?+ s+ D+ e; \8 D9 j
children than one would realize. Exposure to andro-0 M3 V# E0 c4 O; {7 A, I2 [! T
gen products must be considered and specific ques-5 F3 F3 [" ~# u. e/ A4 H
tioning about the use of a testosterone product or) }( t: k: @8 R" N
gel should be asked of the family members during$ }# L; V1 m% B' b: G2 p
the evaluation of any children who present with vir-. i' v8 K, C! N# D6 o# }
ilization or peripheral precocious puberty. The diag-2 i7 d% ]+ |7 w" R( ~8 k
nosis can be established by just a few tests and by  u! b+ o+ I1 E; ?# @9 h$ `
appropriate history. The inability to obtain such a
% Z1 p* b- E/ F3 E$ |; Phistory, or failure to ask the specific questions, may
2 n  O$ z# x2 Y. @8 mresult in extensive, unnecessary, and expensive# Y. y* `  W" ~  `6 a
investigation. The primary care physician should be
3 _( N. U  _8 v% i! {8 \5 faware of this fact, because most of these children5 P4 k1 t6 P) H4 m6 B1 `5 J: f
may initially present in their practice. The Physicians’2 ~5 O, v+ A" E3 A  P5 T; Q2 R9 b
Desk Reference and package insert should also put a
* y' w' ~5 J# _' a% O% k- ~5 y' vwarning about the virilizing effect on a male or
8 i( g; N2 E& }% afemale child who might come in contact with some-
% R9 w& e& q, ?" f6 A0 B8 uone using any of these products.! q( _0 J5 {% ~5 n$ S0 M% q
References5 E+ F4 c; Q4 R! N( C+ h
1. Styne DM. The testes: disorder of sexual differentiation8 T. F9 ]" T! W) Y+ w
and puberty in the male. In: Sperling MA, ed. Pediatric) Z& o$ }) U  a7 ^  t  w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: X& j1 j( ~+ o+ s
2002: 565-628.
7 x6 J) p: Y" c2 K. [6 d* S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: Q/ ]* k$ t6 U7 r' @* m+ G
puberty in children with tumours of the suprasellar pineal
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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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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層

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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!
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